Split (1)

train · 26.9k rows

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20,134	140,670	27505	Discharge summary	report	Admission Date: [2115-4-25] Discharge Date: [2115-5-2] Date of Birth: [2042-5-24] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: "gas pain" not relieved by Maalox Major Surgical or Invasive Procedure: thoracic graft antegrade deployment x2 from subclavian to celiac [2115-4-26] cholecystectomy [2115-4-26] History of Present Illness: 72 yo male with epigastric pain chronically over 2 years. Had acute onset gas pain and did not resolve with meds. Went to PCP and was sent to Er at OSh. CTA revealed Type B aortic dissection. Transferred to [Hospital1 18] on esmolol drip for surgical evaluation in stable condition. Past Medical History: HTN "borderline" GERD anxiety Social History: lives alone pipe smoker occasional ETOH Family History: negative Physical Exam: afebrile HR 67 117/71 RR 16 98% 2L NAD, anxious MMM, EOMI no neck masses or OLAD RRR with distant sounds CTAB abd soft, mild mid-abd pain , no rebound warm extrems with palp. 2+ DP gossly neurologically intact Pertinent Results: [2115-5-2] 03:04AM BLOOD WBC-19.5* RBC-3.33* Hgb-10.5* Hct-31.3* MCV-94 MCH-31.6 MCHC-33.6 RDW-14.8 Plt Ct-294 [2115-4-25] 02:15AM BLOOD WBC-14.4* RBC-3.78* Hgb-12.4* Hct-34.0* MCV-90 MCH-32.7* MCHC-36.3* RDW-14.4 Plt Ct-189 [2115-4-25] 02:15AM BLOOD Neuts-78.6* Lymphs-14.8* Monos-6.5 Eos-0.1 Baso-0.1 [2115-5-2] 03:04AM BLOOD Plt Ct-294 [2115-5-2] 03:04AM BLOOD PT-13.7* PTT-22.2 INR(PT)-1.2* [2115-4-25] 02:15AM BLOOD PT-12.2 PTT-19.2* INR(PT)-1.0 [2115-5-2] 03:04AM BLOOD Fibrino-793* [2115-5-2] 03:04AM BLOOD Glucose-110* UreaN-24* Creat-0.7 Na-139 K-3.5 Cl-103 HCO3-25 AnGap-15 [2115-5-1] 03:38AM BLOOD ALT-61* AST-28 AlkPhos-125* Amylase-23 TotBili-0.7 [2115-4-26] 03:01AM BLOOD Lipase-33 [2115-5-2] 03:04AM BLOOD Calcium-7.5* Phos-4.0 Mg-2.2 Brief Hospital Course: Admitted on [2115-4-25] with above described pain and Ct scan results. Nipride and nicardipine drips also started in CSRU. He had increasing abdominal pain on HD #1 in his LUQ, but no chest pain as described at admission. Taken urgently for torso CTA. This showed extension of dissection to right iliac, with decreasing true lumen, and increasing false lumen, as well occlusion of celiac artery. Please refer to fianl report. He had increasing WBC and abd pain, so he was taken urgently to the OR with the cardiac and vascular surgery teams. Two thoracic stent-grafts were deployed antegrade through the aorta via sternotomy (please refer to op note). Cholecystectomy was also performed for gangrenous cholecystitis. On POD #1 he c/o bilat leg weakness. He had been extubated. MRI showed no evidence of epidural hematoma. Spinal drainage cath remained in place. Neurology was consulted also. Levophed was also started to help titrate up BP. Some movement returned in left leg, but no movement in right leg on POD #2. Chest tubes were also removed on POD #2. He required additional pulmonary toilet for poor aeration of LLL and probable mucous plugging. He recovered some strength in his right leg on POD #4 and was also being treated for a UTI. He remained on a nicardipine drip. Lumbar drain removed on [4-30]. His WBC rose to 20K on [5-1]. This was thought to be possible from ? of a gangrenous spleen. Bedside swallowing evaluation done on [5-1] due to ? aspiration risk. At approx. 3:55 AM on [5-2], the patient suffered an asystolic cardiac arrest and could not be resuscitated with ACLS protocols despite continuing attempts to revive him. He was pronounced expired at 4:17 AM by Dr. [Last Name (STitle) ]. Dr. [Last Name (STitle) 1290] notified throughout arrest. Medications on Admission: zoloft prilosec Discharge Disposition: Expired Discharge Diagnosis: s/p thoracic stent-grafts placed antegrade/cholecystectomy cardiac arrest HTN GERD anxiety Discharge Condition: expired Completed by:[2115-5-17]	[ "V64.41", "575.0", "427.31", "427.5", "441.03", "557.0", "305.1", "336.1", "530.81", "794.8", "997.09", "599.0" ]	icd9cm	[ [ [] ] ]	[ "96.04", "51.22", "99.07", "99.04", "99.62", "99.60", "39.73", "99.05", "03.90" ]	icd9pcs	[ [ [] ] ]	3862, 3871	1994, 3796	354, 470	4005, 4043	1176, 1971		913, 923				3892, 3984		3822, 3839													938, 1157																												281, 316											498, 786															808, 840	856, 897
41,463	156,801	7260	Discharge summary	report	Admission Date: [2178-10-15] Discharge Date: [2178-10-23] Service: CARDIOTHORACIC Allergies: Tetanus Attending:[First Name3 (LF) 922] Chief Complaint: Dyspnea on exertion/Lightheadedness Major Surgical or Invasive Procedure: [2178-10-15] - CABGx2 (Left internal mammary->Left anterior descending artery, Vein graft->Right coronary artery); AVR(21mm [Doctor Last Name ] Pericardial Tissue Valve) History of Present Illness: 85 y/o female with history of aortic stenosis followed by serial echocardiograms. Her most recent echo revealed severe aortic stenosis. A cardiac catheterization was performed which revealed two vessel disease. She is admitted today for elective surgical management of her coronary artery and valve disease. Past Medical History: AS/CAD s/p AVR/CABGx2 [2178-10-15] Hypercholesterolemia HTN First degree AV Block Basal cell skin cancer Left leg bursitis Removal of thyroid adenoma Social History: Retired. 45 pack-year history of smoking quitting 20 years ago. Lives with daughter. Drinks 1 alcoholic beverage monthly. Family History: None Physical Exam: On exam, heart rate is 80. Respiratory rate is 16. Blood pressure is 140/88. She is 5'3" tall and weighing 149 lbs. She is in no distress today in the office. Skin is unremarkable and full. Pupils are equally round and reactive to light. Her oropharynx is benign. EOMs are intact. Neck is supple with full range of motion and well-healed scar. No JVD was appreciated. Lungs are clear bilaterally. Heart is regular rate and rhythm with a grade IV/VI systolic ejection murmur, which transmits bilaterally to both carotids. Abdomen is soft, nontender, and nondistended with positive bowel sounds. Extremities are warm and well perfused without any peripheral edema or varicosities noted. She is neurologically grossly intact with a nonfocal examination, moving all extremities, and alert and oriented x3. She has 1+ bilateral femoral and DP pulses, 2+ bilateral radial pulses, and nonpalpable PTs. Pertinent Results: [2178-10-15] ECHO PRE-BYPASS: The left atrium is mildly dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is severe aortic valve stenosis (area <0.8cm2). No aortic regurgitation is seen. The mitral valve appears structurally normal with mild calcifications and mild to moderate mitral regurgitation. There is no pericardial effusion. POST-BYPASS The new aortic valve is in normal position, stable and demonstrates appropriate gradients. Preserved biventricular function is preserved. The remainder of the exam is unchanged. ECHO [2178-10-19] The left atrium is dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. Prominent pectinate muscles, but no mass/thrombus is seen in the left atrium or left atrial appendage. Mild spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). The right atrial appendage ejection velocity is depressed (<0.2m/s). No thrombus is seen in the right atrial appendage No atrial septal defect is seen by 2D or color Doppler. There is symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). There are complex (>4mm, non-mobile) atheroma in the descending thoracic aorta. A well-seated bioprosthetic aortic valve prosthesis is present, the leaflets appear to move normally. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Impression: Spontaneous echo contrast with depressed LAA ejection velocity, but no thrombus in the left atrium or left atrial appendage. Well seated aortic valve bioprosthesis. Mild mitral regurgitation. Aortic atherosclerosis. Lower Extremity Ultrasound [2178-10-19] No DVT in left or right lower extremities. [Name (NI) 26852],[Known firstname ] [Medical Record Number 26853] F 85 [2092-11-16] Radiology Report CHEST (PA & LAT) Study Date of [2178-10-22] 9:28 AM [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] FA6A [2178-10-22] SCHED CHEST (PA & LAT) Clip # [Clip Number (Radiology) 26854] Reason: evaluate for effusion [Hospital 93] MEDICAL CONDITION: 85 year old woman with s/p mvr cabg REASON FOR THIS EXAMINATION: evaluate for effusion Provisional Findings Impression: IPf [Doctor First Name ] [2178-10-22] 1:20 PM 1. Worsening left lower lung atelectasis with associated small left pleural effusion. Small discoid atelectasis in the right lung base. Stable postoperative mediastinal widening. Preliminary Report !! PFI !! 1. Worsening left lower lung atelectasis with associated small left pleural effusion. Small discoid atelectasis in the right lung base. Stable postoperative mediastinal widening. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5785] PFI entered: [Doctor First Name ] [2178-10-22] 1:20 PM [2178-10-22] 05:55AM BLOOD WBC-9.1 RBC-3.44* Hgb-10.5* Hct-29.7* MCV-86 MCH-30.7 MCHC-35.5* RDW-14.0 Plt Ct-287 [2178-10-23] 05:30AM BLOOD PT-27.3* INR(PT)-2.7* [2178-10-22] 05:55AM BLOOD Glucose-101 UreaN-27* Creat-1.0 Na-140 K-3.3 Cl-98 HCO3-33* AnGap-12 Brief Hospital Course: Ms. [Name (NI) ] was admitted to the [Hospital1 18] on [2178-10-15] for surgical management of her aortic valve and coronary artery disease. She was taken to the operating room where she underwent coronary artery bypass grafting to two vessels and an aortic valve replacement using 21mm [Doctor Last Name ] Pericardial Valve. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. She developed atrial fibrillation and was started on amiodarone. On postoperative day one, Ms. [Name (NI) ] [Last Name (Titles) 5058] neurologically intact and was extubated. She did well initially however needed to be reintubated later on postoperative day one for volume overload. The Electrophysiology service was consulted for bradycardia. An ECHO was performed which showed no thrombus in the left atrium or left atrial appendage, a well seated aortic valve bioprosthesis, mild mitral regurgitation and aortic atherosclerosis. Heparin and coumadin were started for anticoagulation. Cardioversion was performed however she reverted back into atrial flutter shortly thereafter. She was again extubated on [2178-10-20] without incident. On [2178-10-21] she was transferred to the step down unit for further recovery. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She was gently diuresed towards her preoperative weight. She underwent a speech and swallow consult as she had some mild mental status changes postoperatively but she was found to be successfully swallowing on exam. Her mental status also cleared. She continued to make steady progress and was discharged to rehab on postoperative day 8 in stable condition. She will follow-up with Dr. [Last Name (STitle) 914], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Atenolol 50', Lipitor 40', ASA 325', Norvasc 5' Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Warfarin 1 mg Tablet Sig: [Name8 (MD) ] MD [First Name (Titles) ] [Last Name (Titles) ] INR 2.0-2.5 Tablets PO DAILY (Daily) as needed for atrial flutter: [Last Name (Titles) 18303] INR is 2.0-2.5 for atrial flutter/fibrillation. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. Tablet(s) 12. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Titrate dose for INR of [2-14].5. Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Location (un) 1110] Discharge Diagnosis: CAD/AS s/p CABGx2/AVR [2178-10-15] CAD/AS s/p CABGx2/AVR [2178-10-15] Elevated lipids, HTN, Basal Cell Ca, Bursitis L LE, Tonsillectomy, Adenoidectomy, Appendectomy, thyroidadenoma, PUD(H.pylori) 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. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 914] in 1 month. Please follow-up with Dr. [First Name (STitle) ] in [2-15] weeks. Please follow-up with Dr. [Last Name (STitle) ] in [2-16] weeks. [Telephone/Fax (1) 3393] Completed by:[2178-10-23]	[ "518.81", "424.1", "427.32", "427.31", "518.4", "458.29", "414.01", "272.0", "V10.83", "401.9", "E878.2" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.15", "35.21", "96.71", "96.04", "36.11" ]	icd9pcs	[ [ [] ] ]	9179, 9266	5867, 7743	258, 438	9515, 9522	2043, 4618	10300, 10575	1107, 1113		7841, 9156	4658, 4694	9287, 9494		7769, 7818			9546, 10277										1128, 2024																												183, 220	4726, 5844										466, 775															797, 952	968, 1091
46,425	147,345	46272	Discharge summary	report	Admission Date: [2190-2-13] Discharge Date: [2190-2-15] Service: MEDICINE Allergies: Codeine / Flagyl Attending:[First Name3 (LF) 45] Chief Complaint: STEMI Major Surgical or Invasive Procedure: coronary catheterization History of Present Illness: The patient is a 89y/o F with a PMH of hypertension admitted with inferior and inferior lateral STEMI. The patient awoke at 5AM with a mid-sternal chest pressure. She initially thought the pain was secondary to indigestion. Over the course of the day her pain persisted and began radiating to the back, the severity remained unchanged. This pm she called her brother as she became concerned that her pain was not improving. He was initially not home so she waited another 30 minutes until he returned home and took her to the BIDNH ED. The patient denies any prior episoded of chest pain and shortness of breath. She reports that she just returned from a 4 week trip in [State 4565] during which she was walking over 2 miles daily with no symptoms. . On arrival to BIDNH the patient had continued chest pressure. Initial vitals T 97.7, HR 97, BP 179/91, RR 17, O2 99% on RA. ECG demonstrated inferior ST elevations and anterior ST depressions concerning for posterior MI. She was given NTG SL, Metoprolol 5mg IV, Eptifibatide bolus plus gtt, Heparin gtt, Clopidogrel 600mg and ASA 325mg. She was transferred to [Hospital1 18] for emergent cardiac catheterization. . The patient was transferred directly to the cardiac cath lab. Initial cath was attempted through R radial artery however catheter was unable to be threaded through the subclavian so R femoral access was obtained. She was found to have a right dominant coronary system. The PDA had a 90% stenosis in its mid portion. The distal continuation of the RCA was totally occluded and there was staining of the distal posterolateral branch. She underwent PCI with a BMS to the distal PLSA. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Hypertension Bilateral cataract surgery Osteoporosis Social History: The patient lives independently. She has a brother who lives in the same building complex. Her daughter and grandchildren all live near by. -Tobacco history: None -ETOH: 1 glass of wine daily -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T 96.5, HR 62, BP 129/63, RR 18, O2 98% on RA GENERAL: elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with flat JVP 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. R groin with sheath in place, no hematoma or bruit R radial artery with compression bandage, no hematoma, pulse 2+ SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP/PT dopplerable Left: Carotid 2+ Femoral 2+ DP/PT dopplerable Pertinent Results: Cardiac catheterization [2190-2-13] - Right dominant system. LMCA normal. LAD gave rise to a large septum branch that ran within the mycocardium to the apex. The LAD ran on the lateral anterior wall and has a beaded 80-90% calcified stenosis. There was a very small diagonal branch that had a 80% stenosis in its origin. The LCx was a smaller vessel with a 60-70% stenosis in its origin. RCA - the proximal mid and distal RCA was ectatic with lumen irregularities. The PDA had a 90% stenosis in its mid portion. The distal continuation of the RCA was totally occluded and there was staining of the distal posterolateral branch. EKG: [2190-2-13] 17:38 NSR 96bpm, nl axis, nl intervals, q III, STE II, III, AVF, STD I, AVL, V1-V2 [2190-2-14] 12:29AM BLOOD WBC-10.1 RBC-4.12* Hgb-12.0 Hct-36.6 MCV-89 MCH-29.1 MCHC-32.7 RDW-13.0 Plt Ct-193 [2190-2-14] 12:29AM BLOOD PT-11.6 PTT-30.5 INR(PT)-1.0 [2190-2-14] 12:29AM BLOOD Glucose-98 UreaN-16 Creat-1.1 Na-140 K-4.9 Cl-108 HCO3-24 AnGap-13 [2190-2-14] 12:29AM BLOOD CK(CPK)-3314* [2190-2-14] 12:29AM BLOOD CK-MB-493* MB Indx-14.9* [2190-2-14] 12:29AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.0 Brief Hospital Course: INFEROLATERAL STEMI - Patient went to cardiac catheterization and a bare metal stent was placed in her postero-lateral segmental artery. She remained hemodynamically stable and chest pain free after this procedure. It is noted that patient has evidence of multivessel disease with 80-90% stenosis of LAD, 60-70% stenosis of LCx. She was continued on Aspirin 325, Clopidogrel 75 daily, Atorvastatin 80 mg, Metoprolol Succinate 25 mg and Lisinopril 5 mg prior to discharge. A trans-thoracic echo was performed which showed a depressed EF of 40-45% and mild regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior and inferolateral walls. Moderate MR was also noted. Patient has follow up with Cardiology in [Location (un) 620] for further management. HYPERTENSION: started metoprolol and restarted lisinopril at lower dose given low blood pressures. HYPERLIPIDEMIA: LDLc not at goal of 120. Continued on Atorvastatin 80 mg daily. LFTs with mild AST elevation (likely in setting of STEMI), all others normal. Follow up LFTs should be deferred in the outpatient. OSTEOPOROSIS: continued calcium and vitamin D ABNORMAL UA: Patient had low grade fever without focal signs of infection. A UA was sent which showed wbcs, however multiple UAs showed contaminated specimens. Since patient did not have symptoms, she was not treated. Medications on Admission: Vitamin D Lisinopril 10mg daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: ST elevation Myocardial Infarction Coronary Artery Disease Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted because you were having chest pain and found to have a heart attack. A cardiac catheterization was performed and you had a stent placed in one of your coronary arteries. You tolerated this procedure well. We started several new medications that are listed below. You should follow up with your primary care and cardiologist. Your new medications include: START: Plavix 75 mg daily (You should take this medication for 12 months) Aspirin 325 mg daily (You should take this medication for 1 month, then decrease to 162 mg daily indefinitely) Atorvastatin 80 mg daily Metoprolol Succinate 25 mg daily DECREASE: Lisinopril to 5 mg daily from 10 mg daily You should call your primary care doctor or go to the emergency room if you experience chest pain, shortness of breath, palpitations, lightheadedness or anything that is concerning to you. Followup Instructions: You have the following appointments scheduled: 1. Primary Care, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3649], Monday, [2-22], 2:00 pm Phone Number: [Telephone/Fax (1) 3070] 2. Cardiology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Tuesday, [2191-3-16]:00 AM Phone # [Telephone/Fax (1) 4105] Plan to arrive at 10:30 at the [Hospital3 628] Main Entrance and register at the front desk. You will be directed to the Dr. [Name (NI) 98376] office. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [Doctor First Name 63**]	[ "429.9", "414.01", "410.31", "401.9", "414.2", "733.00", "424.0" ]	icd9cm	[ [ [] ] ]	[ "36.06", "00.45", "00.40", "00.66", "88.55", "88.52", "37.22", "99.20" ]	icd9pcs	[ [ [] ] ]	7222, 7228	5096, 6478	228, 254	7340, 7340	3908, 5073	8369, 9035	2795, 2910		6561, 7199		7249, 7319		6504, 6538			7485, 8346										2925, 3889																												183, 190											282, 2471												7354, 7461			2493, 2548	2564, 2779
27,979	184,561	45273	Discharge summary	report	Admission Date: [2175-12-22] Discharge Date: [2176-1-3] Date of Birth: [2109-7-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5552] Chief Complaint: Hemoptysis, ?pneumonia Major Surgical or Invasive Procedure: Rigid Bronchoscopy Attempted bronchial artery embolization Stereotactic Brain Biopsy History of Present Illness: History of Present Illness: 66 yo male with h/o htn, glucose intolerance, recent dx of NSCLC who presents as a transfer from [Hospital3 ] for rigid bronchoscopy and possible embolization for hemoptysis. . Briefly, he began coughing up small amounts of bright red blood roughly three month ago. He started noticing streaks of blood in his sputum which progressed to about nickel-sized bits of blood. He was then referred for a CAT scan of his chest which revealed a large right upper lobe spiculated mass suspicious for malignancy. He has a history of COPD; however, has not been severely affected by this and it does not seem to impede on his daily activites. He has a 100-pack-year history of smoking and has quit 10 years ago, and lost 25 lbs recently. . He was then referred for PET scan which was positive. Subsequent bronch on [2175-12-15] at [Hospital1 18] revealed path consistent with NSCLC. He tolerated the procedure well, and then on [2175-12-19] he began to develop more hemoptysis. He decided to drive himself to the [Hospital3 ] ED, where he presented in respiratory distress and was promptly intubated for airway protection. He became hypotensive in the setting of intubation and sedation, and was started on Neosynephrine. . He was awaiting transfer to [Hospital1 18], and had imaging that showed the mass and a RLL consolidation. He spiked a fever on [2175-12-21], and was started on vancomycin and levofloxacin. He had a left IJ central line placed. His neosynephrine was changed to Levophed. His levofloxacin was changed to pip/tazo. His blood, urine, and sputum were cultured with no growth at the time of discharge. There was a question of adrenal insufficiency, and he was on decadron. His [Last Name (un) 104] stim was showed a good response, so he was stopped today. . On arrival, he was sedated and intubated, without communicating any complaints. . Review of Systems: Significant weight loss per records. Past Medical History: Past Medical History: Hypertension Hyperlipidemia Glucose intolerance NSCLC (dx [2175-12-15] via bronch) AAA s/p repair GERD Social History: Social History (per old records): He lives alone and is not married. He is retired and used to work in the camera department at the Lechmere store. He occasionally uses alcohol. He has a 100-pack-year history of smoking but quit 10 years ago. He has no history of asbestos exposure. Family History: Family History (per old records): He has a father who died at the age of 61 from a massive stroke. His mother died at the age of 90 with lung cancer. His brother recently died at the age of 58 from sudden death. He has a sister who is 66 years old and has ovarian cancer and he has another brother who is living and otherwise healthy. Physical Exam: PHYSICAL EXAM~ Vs- 96.3 130/80 60 14 100% AC 500x16 PEEP 5 50% Gen- Intubated, sedated. Heent- Anicteric, pupils 1.5mm, reactive. Neck- supple, no LAD appreciated. Cor- Regular, brady, no murmur appreciated Chest- Decreased BS right base, ronchi left side, no wheeze Abd- Obese, midline surgical scar well-healed, decreased bowel sounds Ext- mild clubbing, trace edema bilaterally Neuro- sedated, spontaneously moving all extremities, not responding to commands Skin- No rashes Pertinent Results: RADIOLOGY: CT Chest ([12-23]): FINDINGS: The right upper lobe mass has grown from 2.8 x 4.2 cm to 4.3 x 5.7 cm, 2:14, with progressive invasion of mediastinal fat, up to the trachea, esophagus, and normal calibre, superior vena cava, and new occlusion of the right upper lobe bronchus, 2:18, 22. The right upper lobe pulmonary artery is more severely encased by the tumor and significantly narrowed but not occluded. New right upper lobe posterior segment consolidation and extensive ground glass involving most of the anterior segment of right upper lobe might represent post-obstruction pneumonia. Lingular atelectasis has significantly progressed, although no endobronchial lesion is demonstrated, 3:33. New bilateral moderate nonhemorrhagic layering pleural effusion is accompanied by considerable bilateral relaxation atelectasis. Heart size is normal, and there is no pericardial effusion. The imaged portion of the upper abdomen demonstrates normal liver, spleen, adrenals, tail of the pancreas and upper portion of the kidney. There are no bone lesions suspicious for malignancy. IMPRESSION: 1. Significant interval progression of the right upper lobe tumor size, mediastinal, occlusion of the right upper lobe bronchus obstruction and most likely obstructive pneumonia, conceivably hemorrhage. 2. New moderate, bibasilar pleural effusion and severe relaxation atelectasis. 4. Mediastinal lymphadenopathy, not significantly changed. 5. Coronary calcifications. 6. Emphysema. . CT Head ([12-23]): There is a roughly 2.2 x 2.0 cm area of hypodensity (Hounsfield units 21) in the right medial cerebellum. This area did not demonstrate FDG avidity on the recent PET CT. On the current study, although it is difficult to fully evaluate, there may be an 8-mm ring-enhancing nodule in the central portion of this larger lesion. For example, please series 6, image 7. No other areas concerning for enhancing lesions are identified within the brain. There is no hydrocephalus. There is no definite mass effect on the fourth ventricle. The major vascular structures appear unremarkable. Note is made of calcifications within the cavernous carotid arteries bilaterally. No osseous lesions are identified. IMPRESSION: 1. Hypodensity in the medial right cerebellum, incompletely evaluated. An MRI of the brain with gadolinium may be valuable in further characterization. . Brain MRI ([12-24]): IMPRESSION: 1. 0.9 x 0.9 x 0.7 cm enhancing lesion in the right cerebellar hemisphere, with some perilesional edema, mild mass effect on the adjacent portion of the fourth ventricle, representing metastatic focus. 2. Increased signal in the internal auditory canals especially the left internal auditory canal on the post-contrast sequence (series 9, image 8) may partly be related to enhancement. Hence, leptomeningeal enhancement cannot be excluded based on this appearance. To correlate with LP if necessary and attention to be paid to this on future followup scans. 3. Significant amount of fluid versus mucosal thickening involving bilateral mastoid air cells. . Bronchial Artery Embolization ([12-25]): IMPRESSION: Thoracic aortogram demonstrates a diffusely enlarged and tortuous aorta. A selective right bronchial-intercostal arteriogram showed no abnormal blush or extravasation. Several attempts were made to advance a microcatheter into this artery, but were unsuccessful Brief Hospital Course: Mr. [Known lastname 6330] was a 66-year-old man with a recent diagnosis of NSCLC with mediastinal lymphadenopathy, who presented with hemoptysis and respiratory failure, underwent bronchoscopy with cauterization, was successfully extubated, and underwent unsuccessful attempt at bronchial artery embolization [2175-12-25] due to tortuous aorta. . # Respiratory failure: Patient was previously intubated for airwary protection at OSH in setting of hemoptysis assumed to be from his known large lung mass. He was transferred to [Hospital1 18] and underwent rigid bronchoscopy. [Last Name (un) ] showed significant amounts of clot in R bronchial tree, and he underwent removal of some clots and cauterization of bleeding areas. He was extubated [12-23]. He was found to have a RUL PNA on CT scan [12-23], which was thought to be post-obstructive, and he was started on broad spectrum antibiotics (Vanco/Zosyn). He continued to have quarter size amount of hemoptysis with subjective SOB requiring a NRB. On [12-25], IR tried bronchial artery embolization which was unsuccessful secondary to his tortuous aorta. He received Spiriva and Albuteral nebs prn. He was transferred out of the ICU ot OMED where he continued to improve clinically, requiring no supplemental oxygen by discharge. . # NSCLC/Hemoptysis: CT Chest showed that the right upper lobe mass has grown from 2.8 x 4.2 cm on [2175-11-1] to 4.3 x 5.7. The right upper lobe pulmonary artery was more severely encased by the tumor and significantly narrowed but not occluded. Rigid [Last Name (un) 1066] showed significant amounts of clot in R bronchial tree, and he underwent removal of some clots and cauterization of bleeding areas. IR attempted bronchial artery embolization which was unsuccessful secondary to his tortuous aorta. Radiation oncology was consulted and recommended the patient be transferred from MICU to [Hospital Unit Name 153] for XRT after brain biopsy. The patient underwent palliative XRT initially but after his brain biopsy came back negative for malignancy by preliminary report, he had definitive XRT. He received one cycle of carboplatin/paclitaxil during this admission. . # Post-obstructive pneumonia: CT chest showed RUL PNA, which was likely post-obstructive. WBC peaked at 17.0, and he was febrile at OSH. BAL Culture had sparse growth of oropharyngeal flora. Blood culture with NGTD. He was given a 12-day course of vancomycin and piperacillin-tazobactam for broad coverage of post-obstructive vs. hospital aquired pneumonia. . # Mental status changes, likely brain metastasis: Patient was awake, alert, oriented, but initially complained of visual hallucinations and had R eye ptosis with increased lacrimation. CT head on [12-23] showed 2.2 x 2.0 cm area of hypodensity in the right medial cerebellum which did not demonstrate FDG avidity on the recent PET CT. A follow up Brain MRI showed 0.9 x 0.9 x 0.7 cm enhancing lesion in the right cerebellar hemisphere, representing a metastatic focus. Leptomeningeal enhancement of L internal auditory canal could not be excluded. Neurosurgery was consulted, and the patient underwent a stereotactic brain biopsy on [12-27] which was negative for malignancy by preliminary report. . # Hypotension->Hypertension: Patient was hypotensive at time of transfer, requiring levophed, however his blood pressure improved with cessation of sedation and extubation. He was not found to be adrenally insufficient at the outside hospital. His CVP transduced upon admission was 4. It was felt less likely that the patient had a sepsis from his pneumonia, and blood Cx showed NGTD. Since extubation, patient has become hypertensive with SBP 190-200. He was started on captopril for tighter blood pressure control, but by discharge he was restarted on lisinopril. Amlodipine was held, however, and was to be added back by PCP when appropriate Medications on Admission: Medications on transfer to [Hospital1 18]: Vancomycin 1g q12 Zosyn 4.5 q8 Fentanyl drip Midazolam drip Levophed drip Lansoprazole . Allergies: NKDA Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary diagnosis: non-small-cell lung cancer Secondary diagnoses: hypertension, hyperlipidemia, gastroesophageal reflux disease Discharge Condition: Stable. Discharge Instructions: You were transferred from an outside hospital to [Hospital1 18] on [2175-12-22] with hemoptysis (coughing up blood). The hemoptysis was most likely due to your recently diagnosed lung cancer. You were intubated for airway protection but was extubated shortly after after your symptoms improved. You underwent radiation to the chest to control the bleeding. You also underwent a biopsy of a mass in a part of your brain called cerebellum. The biopsy did not show any cancer involvement, by preliminary report. You will receive chemotherapy and radiation as outpatient. Please follow up with Dr. [Last Name (STitle) ] (primary oncologist) and Dr. [First Name (STitle) 13014] (radiation oncologist) as instructed below. Your medications have been changed. Please take the new medications as instructed and do not take any old medication that is not on the discharge medication list. If you cough up blood again, develop shortness of breathness, fevers, chills, chest pain, or any other symptom that concerns you, please call your doctor or go to the nearest Emergency Room. Followup Instructions: Please go to the following appointments: * Radiation oncology: 8 am, Friday, [2176-1-5], [Hospital Ward Name 332] Basement Radiation Therapy Department, [Hospital1 1170], [Location (un) 86], MA. * Dr. [Last Name (STitle) ]: 10 am, Tuesday, [2176-1-9], [Hospital ] clinic, [Hospital Ward Name 23] Building [Location (un) ], [Hospital1 827], [Location (un) 86], MA. [Telephone/Fax (1) 6568].	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4,655	125,328	10897	Discharge summary	report	Admission Date: [2202-4-22] Discharge Date: [2202-6-2] Date of Birth: [2163-8-26] Sex: F Service: SURGERY Allergies: Codeine Attending:[First Name3 (LF) 1481] Chief Complaint: Transferred to the medical service for ongoing fevers, pancytopenia, psych issues Major Surgical or Invasive Procedure: Percutaneous needle aspiration of abdominal wall fluid x 3 Diagnositic paracentesis x 2 EGD x 3 History of Present Illness: Pt is a 38yo F with hx of ESRD secondary to Lithium toxicity, bipolar disorder, s/p renal tx failed due to PTLD (treated with rituxan), being transferred to medical service from surgical service for management of fever. The pt was admitted on [2202-4-9] to [Hospital3 ] with fever thought to be ? line infxn vs. infected abdominal fluid collection. However, fluid sterile. Discharged on keflex. Readmitted on [4-17] to [Hospital3 ] with fever. Cxs with VRE. Started on linezolid/zosyn, transferred to [Hospital1 18] transplant service on [4-22] for further management. . Active issues here have been mania (psych involved), GIB (GI did EGD showing friable antrum as likely source, bxs consistent with chemical gastritis, but not neoplasm), fever of unclear source, and abdominal fluid collections. Regarding her fluid collections, on admission here an abd CT showed fluid collection which was aspirated and found to be sterile. Liver service was consulted for possible ascites, although liver felt that fluid was more likely related to renal failure vs. PTLD. Regarding fever, all Cx data has been neg to date. Zosyn d/c'd on [4-24] and linezolid alone continued. ID consulted [4-27] for persistent fever. Repeat Abd CT on [4-27] with 9x5cm fluid collection, different from pigtailed lesion. ID switched pt to daptomycin on [4-29], linezolid d/c'd. Transplant surgery will not consider placing permanent access until the fevers resolve. Pt transferred to medical service for further management. Past Medical History: ESRD secondary to Lithium Toxicity S/P Cadaveric Renal Transplant [2196] with rejection and allograft nephrectomy [2196], now on HD Small Bowel Perforation S/P Small Bowel Resection in [2196] Post Transplant Lymphoproliferative Disorder Hypertension Hyperlipidemia Hyperprolactinemia Hypothyroidism Bipolar Disorder Appendicitis S/P Appendectomy h/o MRSA h/o VRE Social History: No smoking, occasional alcohol, no drug use. Family History: non-contributory Physical Exam: Temp 99.1 BP 104/78 Pulse 107 Resp 18 O2 sat 100 RA Gen - Alert, anxious, no acute distress HEENT - extraocular motions intact, anicteric, MMM Neck - no JVD, no cervical lymphadenopathy Chest - Clear to auscultation on anterior exam CV - Normal S1/S2, RRR, +SEM Abd - Soft, mild diffuse tenderness, nondistended, normoactive bowel sounds, ventral hernia, dressings at former drain sites in place Extr - No edema. 2+ DP pulses bilaterally Pertinent Results: ABD CT [2202-4-22]: 1. Multiple peripherally enhancing fluid collection within the mid abdomen and pelvis. 2. Ascites. 3. Atrophic kidneys. 4. Filling defect in the right greater saphenous [Last Name (LF) 5703], [First Name3 (LF) ] be due to prior surgery. 5. Complex linear lucency in the left supracondylar region, clinical correlation is requested. this may represent a motion artifact, however fracture is a consideration if patient is symptomatic at that locale. Admission: [2202-4-22] 07:30PM BLOOD WBC-6.8# RBC-2.83* Hgb-9.3* Hct-27.6* MCV-97# MCH-32.9* MCHC-33.8 RDW-20.3* Plt Ct-106# [2202-4-22] 07:30PM BLOOD PT-13.7 PTT-33.1 INR(PT)-1.2* [2202-4-22] 07:30PM BLOOD Glucose-81 UreaN-46* Creat-5.7* Na-139 K-3.9 Cl-101 HCO3-22 AnGap-20 [2202-4-23] 04:50AM BLOOD ALT-8 AST-28 AlkPhos-142* Amylase-174* TotBili-0.6 Discharge: [2202-6-2] 05:22AM BLOOD WBC-4.5 RBC-2.48* Hgb-8.0* Hct-23.6* MCV-95 MCH-32.2* MCHC-33.8 RDW-19.2* Plt Ct-113* [2202-6-2] 05:22AM BLOOD Plt Ct-113* [2202-6-2] 05:22AM BLOOD Glucose-85 UreaN-66* Creat-5.5# Na-133 K-4.1 Cl-96 HCO3-27 AnGap-14 [2202-6-1] 07:00AM BLOOD CK(CPK)-26 [2202-6-2] 05:22AM BLOOD Calcium-8.7 Phos-4.6 Mg-2.3 Operative report: PREOPERATIVE DIAGNOSES: 1. Stomach mass with gastrointestinal bleeding. 2. Incisional hernia. SURGICAL PROCEDURE: Laparotomy, lysis of adhesions, drainage of intra-abdominal fluid collections, subtotal gastrectomy and repair of incisional hernia with mesh. Pathology report: Preliminary diagnosis: Distal gastrectomy specimen: 1. Diffuse and focally polypoid severe surface-foveolar zone hyperplasia: a. The entire mucosa is involved, but the antrum has more prominent changes than the corpus. b. Focal superficial erosion (slide G). c. Marked epithelial regenerative changes; focal accumulations of macrophages in the lamina propria. 2. Focal and mild chronic inactive gastritis. 3. Areas of serosal granulation tissue and fibrosis (consistent with adhesions). 4. No mucosal or mural neoplastic infiltrates identified. 5. Proximal margin: Corpus. 6. Distal margin: Duodenum. 7. Multiple hemorrhagic lymph nodes with a "depleted" appearance; see note. [2202-5-19] 5:15 pm SEROLOGY/BLOOD FINAL REPORT [2202-5-21] HELICOBACTER PYLORI ANTIBODY TEST (Final [2202-5-21]): POSITIVE BY EIA. (Reference Range-Negative). [2202-5-27] 10:30 am SEROLOGY/BLOOD FINAL REPORT [2202-5-28] HELICOBACTER PYLORI ANTIBODY TEST (Final [2202-5-28]): NEGATIVE BY EIA. (Reference Range-Negative). [2202-5-21] 1:37 pm SWAB PERITONEAL FLUID. FINAL REPORT [2202-5-27] GRAM STAIN (Final [2202-5-21]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Final [2202-5-24]): A swab is not the optimal specimen collection to evaluate body fluids. NO GROWTH. ANAEROBIC CULTURE (Final [2202-5-27]): NO GROWTH. All blood cultures without evidence of bacteria Chest X-ray [2202-5-21]: IMPRESSION: 1. Right middle lobe atelectasis. 2. ET tube, right IJ line, NG tube, double-lumen catheter in appropriate position. Brief Hospital Course: 38 year old female with hx of ESRD secondary to Lithium toxicity, bipolar disorder, s/p renal tx failed due to PTLD, being transferred to medical service from surgical service for management of fever and GI bleeding (as well as pancytopenia, psych issues). Initially, this patient was on the Transplant service, followed as consult service by psychiatry and then by the GI service as well. The pt was admitted on [2202-4-9] to [Hospital ] with fever thought to be question of line infxn vs. infected abdominal fluid collection. However, the fluid was sterile. She was discharged on Keflex. Readmitted on [4-17] to [Hospital3 ] with fever. Cxs with VRE. Started on linezolid/[Hospital 35453] transferred to [Hospital1 18] transplant service on [4-22] for further management. The patient was finally transferred to the general surgical service under Dr [Last Name (STitle) ] for her surgery (and ultimately discharged from his service to rehab). Active issues during this admission have been mania (psych involved), GIB (GI did EGD showing friable antrum as likely source, bxs consistent with chemical gastritis, but not neoplasm, ultimately had gastrectomy), fever of unclear source, and abdominal fluid collections. Below is a summary of her hospital admission. . On admission, [Hospital ] [Known lastname 35454] medical issues were as follows: # FEVER: Etiology remains unclear since she is still spiking . Still intermittent fevers. Positive sources thus far is VRE bacteremia from OSH cx and PNA. Infected abd fluid also a possibility although previous aspirate is sterile. She was on a linezolid course, for a total of 14 days, day 1 [5-7], last day [2202-5-20]. AFB cultures, Cryto Ag, Parvo b19 IgM and HHV6 negative. Her cultures on this admission have all been negative, with multiple blood cultures. she is being discharged on daptomycin and will have received a total of 4 weeks once it is completed. . # ESRD: Dialysis MWF but temporary access pulled because of low grade fevers. Dialysis through tunnelled line qMWF. CT scan [4-22] demonstrated a filling defect in the right greater saphenous [Last Name (LF) 5703], [First Name3 (LF) ] be due to prior surgery. Line was placed [5-3]. Her doses were renally dosed. She continued HD throughout this admission, which was uneventful. She had no new renal issues. . # ABD FLUID COLLECTION: unclear etiology: [2-19] to renal failure vs. PTLD vs. adhesions. Not likely associated with liver dz per hepatology. Cultures have been sterile on CT guided aspirate on [4-23] and [4-28]. A repeat ABD CT on [4-30] shows unchanged ascites that are less dense. Also mid abd pigtail catheter with resolving small amt of fluid. -- [4-23] and [4-28]: Cultures of fluid collection have been sterile on CT guided aspirate. Cytology also neg for malignancy. -- [5-4]: Ascites fluid negative by cell count and culture. -- [5-9]: CT torso showed reaccumulation of fluid collection, not communicating with known ascites. -- [5-12]: Reaspirate fluid collection and ascites sterile by gram stain and culture. Cytology negative for malignancy. Flow cytometry neg. . # GI BLEED: EGD on [4-29] shows diffuse erythema and congestion in stomach and mucosa is friable. No sign of malignancy. H pylori was initially positive, and then found to be negative prior to discharge. . # ANEMIA: likely multifactorial with renal dz and GI bleed contributing. Pt with erythroid dyspoesis on BM bx in [1-24]. Relevance of this unclear, as on note from [2-24] seem unimpressed with findings. Heme-Onc followed platelet count and did not have new recommendations from their perspective. . # THROMBOCYTOPENIA: low but relatively stable for the Pt. HIT negative. Megakaryocytic clustering on BM bx. Once again, relevance of this unclear. low but relatively stable for the Pt. Likely also consumptive now in setting of GIB. Also possibly from valproic acid but will continue valproic acid since she's chronically on it. HIT negative prior to discharge. Megakaryocytic clustering on previous BM bx. . # PTLD: cont home leucovorin - h/o PTLD of transplanted kidney in [2196] diagnosed by EGD/Colonoscopy bx. She was on treated Rituxan and IVIG at that time. Low suspicion for PTLD at this time per Dr. [First Name (STitle) ] who follows her at clinic. . # HYPOTHYROID: continued Synthroid during this admission. # BIPOLAR: psych following, will cont olanzapine, cont divalproex and lamotrigine for mood stabilization. # FEN: regular diet at time of admission and time of discharge. The patient was given TPN after her surgery for approximately 10 days. This was stopped 2 days prior to discharge. Her nutrition labs were adequate. # PPx: holding heparin, not tolerating boots, cont PPI # Full code . ================================ ================================ ================================ Transferred to general surgery [5-21] for further management of the stomach mass with persistent GI bleeding, since no diagnosis could be made endoscopically along with the continued bleeding and possibility of malignancy, exploration was thought to be the best approach. She underwent a laparotomy, lysis of adhesions, drainage of intra-abdominal fluid collections, subtotal gastrectomy and repair of incisional hernia with mesh. She received a unit of blood and also several units of platelets because of a low platelet count. She had no intra-operative complications, post-operatively she was NPO with intravenous hydration and Dilaudid PCA. Her M-W-F dialysis schedule continued. POD 7, diet advanced, continued with intermittent fever spikes to max 102.2. POD 8, +flatus and bowel movement, repeat H.pylori negative, tolerating a regular diet, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] removed. POD 10, pain well controlled with oral Dilaudid, TPN stopped, tolerating a regular-renal diet; continues with daily low grade temps without clear etiology, Daptomycin to continue until [6-16] which would total 4 weeks of treatment. Thrombocytopenia improved with platelets 113k at time of discharge. Discharged to rehabilitation facility in stable condition on [6-2], to continue with hemodialysis, CK and CBC to be checked while on Daptomycin with each dialysis treatment. Final pathology revealed hyperplasia. Of note, the patient continued to have low-grade temperatures during this admission, with an unclear etiology. She was followed by infectious diseases (Dr [First Name4 (NamePattern1) 4850] [Last Name (NamePattern1) ]); however, the patient's family did not want ID input, and hence, their involvement was minimal. They recommended to continue Daptomycin for a total of 4 weeks (end date of [2202-6-16]); prior to stopping the Daptomycin, Dr [First Name (STitle) ] recommended to obtain a CT scan and ensure there are no clots (if they are present, Daptomycin should be continued for a total of 6 weeks). The patient's PCP should order and follow this imaging study. She was discharged to a rehabilitation facility in good condition on [2202-6-2] with her central line and dialysis catheter, the central line was to be removed in [1-19] days if her oral intake remained adequate, she was to continue her current dialysis schedule of M-W-F; she was to follow-up with her PCP [Last Name (NamePattern4) ] 1 week and Dr. [Last Name (STitle) ] in 2 weeks. Medications on Admission: Medications on xfer: Divalproex 750 mg QD Lamictal 75 mg QD leucovorin 20 mg TID sevelamer 800 mg tID linezolid 600 mg q12 protonix 40 mg q 12 olanzapine 5 mg qam, 10 mg qhs heparin 5000 U TID Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): Apply to buttocks and vaginal area. 2. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) mL Injection ASDIR (AS DIRECTED): To be administered during dialysis. 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QAM (once a day (in the morning)): Hold for sedation. 6. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)): Hold for sedation. 7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for pain. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for anxiety. 14. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q48H (every 48 hours) for 2 weeks: To be administered at dialysis Last dose 5/30. 15. Blood draws Sig: CBC and CK level M-W-F with each dialysis treatment for 3 weeks: Monitor CBC and CK level while on Daptomycin with every dialysis session. 16. CT scan Sig: CT scan chest once for 1 weeks: CT scan chest to rule out clot along HD line, If no clot, Daptomycin can be d/c after [6-16] If clot,continue 2 more weeks of Daptomycin . 17. Blood glucose level Sig: Monitor blood glucose level before breakfast and dinner twice a day: Regular Insulin Sliding Scale 0-60 mg/dL [1-19] amp D50 61-120 mg/dL 0 units 121-140 mg/dL 2 units 141-160 mg/dL 4 units 161-180 mg/dL 6 units 181-200 mg/dL 8 units 201-220 mg/dL 10 units 221-240 mg/dL 12 units > 241 mg/dL Notify MD. 18. Chemistry panel Sig: Chemistry panel once a week: Start [6-4] Na+,K+,CL,CO2,BUN,Creatinine,Glucose,Mg+,Ca+,Phosph., Albumin. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: PRIMARY: Fever GI bleed Gastritis Secondary: ESRD S/P Cadaveric Renal Transplant [2196] with rejection, currenly on hemodialysis Post Transplant Lymphoproliferative Disorder Hypertension Hyperlipidemia Hyperprolactinemia Hypothyroidism Bipolar Disorder Thrombocytopenia Anemia h/o MRSA h/o VRE Discharge Condition: Hemodynamically stable Discharge Instructions: Please take all medication as prescribed. Keep all appointments listed below. If you have chest pain or shortness of breath, get medical attention imediately. If you have any of the following, you need to call your doctor or go to the emergency room: * Increased or persistent pain not relieved by pain medication * Fevers > 101.5 for 24 hours * Nausea, vomiting, diarrhea, or abdominal distention * Inability to pass gas or stool * If incision develops redness or drainage * Shortness of breath or chest pain * If dialysis catheter develops leakage or falls out * Any other symptoms concering to you You may shower and wash incision with soap and water, pat dry No swimming or tub baths Avoid lifting more than 10lbs and abdominal stretching for 4 weeks Followup Instructions: Please follow up with your PCP [Name Initial (PRE) 176] 1-2 weeks regarding duration of Daptomycin PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Telephone/Fax (1) 22245] or with the [Hospital ] clinic in [1-19] weeks, call [Telephone/Fax (1) 457] for an appointment Follow-up with Dr. [Last Name (STitle) ] in [1-19] weeks, call [Telephone/Fax (1) 2981] for an appointment Completed by:[2202-6-2]	[ "789.5", "996.81", "568.0", "780.6", "552.21", "585.6", "286.7", "535.11", "238.79", "403.91", "041.86", "296.40", "244.9", "284.8", "211.1", "E878.0", "211.2" ]	icd9cm	[ [ [] ] ]	[ "99.04", "99.15", "88.67", "39.95", "38.95", "45.13", "45.16", "00.14", "54.59", "53.61", "88.72", "43.7", "54.91", "99.05" ]	icd9pcs	[ [ [] ] ]	16509, 16588	6399, 13876	348, 446	16931, 16956	2982, 6376	17764, 18206	2489, 2508		14119, 16486		16609, 16910		13902, 14096			16980, 17741										2523, 2963																												227, 310											474, 2011															2033, 2411	2427, 2473
49,141	119,832	53548	Discharge summary	report	Admission Date: [2128-3-15] Discharge Date: [2128-4-3] Date of Birth: [2089-2-16] Sex: F Service: MEDICINE Allergies: Codeine / Meperidine / Adhesive Attending:[First Name3 (LF) 1377] Chief Complaint: Transfer from [Hospital1 1474] for Liver Failure Management Major Surgical or Invasive Procedure: [2128-3-23] Central line placement History of Present Illness: 39 year old female with h/o gastric bypass who presented to [Hospital1 1474] on [2128-3-10] with increasing ascites, sequelae of liver failure, and rising creatinine with concern for HRS and acute liver failure. Per her family, she has been ill for at least 6 months with development of peripheral edema, abdominal distension, and weight gain (40lbs last yr, 20lbs last month). Also has had intermittent chills but no fever or rigors. She has had some nausea and vomiting, but no diarrhea. Also has had recent development of [Location (un) 2452] urine and myalgias. She presented with acute creatinine increase from baseline 0.9 to 3.9. Bili was 4.2 (4.0 direct) on admission to [Hospital1 1474]. AST 70 and ALT 24. Tp 6 but Alb 1.8. AP 145. WBC initially 13.6. Plts 148. Folate level 7. CA125 was elevated at 101.3 and ammonia up at 56. She had a diagnostic paracentesis which was consistent with SBP although culture was negative. Blood cultures grew strep pneumo in [3-7] bottles. She was started on ceftriaxone and her creatinine improved. Viral heptatitis serologies were normal and [Doctor First Name ] also negative. Her LFTs worsened and her bili trended up to around 10 and her mental status worsened. She had a repeat paracentesis which was no longer consistent with SBP. Also given 2 units PRBCs for Hct of 20.3. At that point she was transferred to [Hospital1 18]. On arrival to [Hospital1 18], initial VS 98.8, BP 137/77, HR 113, RR 20, Sats 99% on RA. She was found to be encephalopathic and unable to recount much history. She was not oriented at all. She denied any pain including abdominal pain. Denied SOB, cough, nausea. Says she needs to have a bowel movement. Able to tell husbands name but not his number - did give okay to contact him. Unable to elicit further history due to mental status. Past Medical History: Prior Gastric Bypass ([2120]) DMII (resolved with bypass) ? blood disorder (? Thalassemia) chronic HA anxiety/panic attacks s/p Cholecystectomy ([2120]) s/p hernia repair Social History: Married with three living kids (one lives with current husband, 2 live with prior husband). No IVDU history. Smoked 1ppd x 15yrs. She endorses alcohol use in past but says none recently although unable to mention time of last drink on admission. She is very confused during this conversation so unclear how much to trust information. Family History: Father with vague report of liver disease Physical Exam: Admission Physical Exam: VS - 98.8, BP 137/77, HR 113, RR 20, Sats 99% on RA. GENERAL - A&O x 1 (self). Cannot name where she is, month, presidents, or what is going on. HEENT - Icteric slcera, + Angular cheilitis, + glossitis, MMM HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored ABDOMEN - distended [2-5], + shifting dullness, nontender, no HSM, BS normoactive EXTREMITIES - WWP, 2+ DP pulses, mild non-pitting edema b/l LE SKIN - + spider angiomas scattered on chest, intermittent bruising at sites of old IVs NEURO - A&C x 1, + asterixis, very confused and unable to talk in complete sentences without drifting off, somewhat unsteady on feet. . Discharge Physical Exam GENERAL - Obtunded, jaundiced SKIN - CVL in place with some serous drainage around line HEART - Heart sounds absent LUNGS - Breath sounds absent NEURO - Does not follow commands, does not engage or interact, eyes do not track. Does not respond to painful stimulus. Pertinent Results: [Hospital1 1474] Labs: Per PCP [Name Initial (PRE) 3726]: SPEP negative, heps serols neg, [Doctor First Name ], ceruloplasmin, CA125 elevated Ascites: [2128-3-11] WBC 2292 (97%Polys, 2%lymphs, 1%other), gluc 87, TP 0.9, Alb 0.4, LDH 50 Ascites: [2128-3-13] WBC 657 (23% polys, 11%lymphs, 66%monos) Serum HCG negative AMA Ab neg, [Doctor First Name ] neg, ceruloplasmin 23 HepBsAg neg, HepBsAb neg, HCV Ab neg TSH 5.1, Free T4 1.27 Ferritin 37 CA [Telephone/Fax (1) 110065] Ascites culture [2128-3-11] final neg, gram stain [10-28] WBC, no orgs Ascites culture [2128-3-13] prelim neg, gram stain [10-28] WBC, no orgs Blood cx set 1 [2128-3-10] 1/2 bottles strep pneumo Blood cx set 2 [2128-3-10] 2/2 bottles strep pneumo, [Last Name (un) 36] to bactrim, erythromycin, vancomycin, levaquin, PCN, and ceftriaxone Admission Labs: [2128-3-15] 10:06PM WBC-10.3 RBC-2.98* HGB-9.1* HCT-27.0* MCV-91 MCH-30.5 MCHC-33.5 RDW-19.4* [2128-3-15] 10:06PM NEUTS-74.5* LYMPHS-19.8 MONOS-3.6 EOS-1.4 BASOS-0.6 [2128-3-15] 10:06PM PLT COUNT-123* [2128-3-15] 10:06PM PT-22.6* PTT-48.3* INR(PT)-2.2* [2128-3-15] 10:06PM ALBUMIN-4.7 CALCIUM-10.4* PHOSPHATE-2.1* MAGNESIUM-1.5* [2128-3-15] 10:06PM ALT(SGPT)-23 AST(SGOT)-80* LD(LDH)-139 ALK PHOS-64 TOT BILI-10.2* DIR BILI-4.4* INDIR BIL-5.8 [2128-3-15] 10:06PM GLUCOSE-83 UREA N-4* CREAT-1.0 SODIUM-149* POTASSIUM-3.2* CHLORIDE-109* TOTAL CO2-26 ANION GAP-17 [2128-3-15] 10:10PM [Doctor First Name ]-NEGATIVE [2128-3-15] 10:10PM Smooth-POSITIVE * Titer 1:20 Other Pertinent Labs: [2128-3-27] 04:30AM BLOOD WBC-5.8 RBC-2.59* Hgb-8.0* Hct-26.8* MCV-103* MCH-30.8 MCHC-29.9* RDW-22.1* Plt Ct-104* [2128-3-27] 04:30AM BLOOD PT-28.9* PTT-70.2* INR(PT)-2.8* [2128-3-27] 04:30AM BLOOD Glucose-103* UreaN-15 Creat-1.0 Na-136 K-3.8 Cl-113* HCO3-15* AnGap-12 [2128-3-22] 06:15AM BLOOD ALT-33 AST-113* LD(LDH)-264* AlkPhos-28* TotBili-15.5* [2128-3-27] 04:30AM BLOOD ALT-32 AST-89* LD(LDH)-186 AlkPhos-49 TotBili-12.5* [2128-3-27] 04:30AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.5* [2128-3-16] 11:10AM BLOOD VitB12-GREATER TH Folate-6.2 [2128-3-18] 07:00AM BLOOD Osmolal-304 [2128-3-18] 07:00AM BLOOD TSH-4.1 [2128-3-18] 07:00AM BLOOD Free T4-1.5 [2128-3-16] 11:10AM BLOOD AFP-2.0 [2128-3-16] 11:10AM BLOOD IgG-877 [2128-3-24] 11:49AM BLOOD Type-[Last Name (un) ] pO2-46* pCO2-34* pH-7.36 calTCO2-20* Base XS--5 Studies: [2128-3-16] CXR: No previous images. The heart is normal in size and there is no vascular congestion. No evidence of acute focal pneumonia. Mild atelectatic changes at the bases with possible small effusions. [2128-3-17] TTE: No valvular vegetation or abscess seen. Normal regional and global biventricular systolic function. No pathologic valvular abnormality seen. [2128-3-18] RUQ U/S: 1. Very limited exam due to the patient's body habitus. Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. Splenomegaly. 3. Trace of ascites. 4. Patent portal veins, which demonstrate appropriate direction of flow. [2128-3-18] CT Head: No acute intracranial process. No fractures identified. [2128-3-19] ECG: Sinus rhythm with extensive baseline artifact which obscures visualization of P waves. Diffuse non-specific ST-T wave chages. No previous tracing available for comparison. [2128-3-24] CXR: As compared to the previous radiograph, there is no relevant change. The right internal jugular vein catheter is in unchanged position. The NG tube that has been newly inserted shows a normal course, the tip is not included on the image. Low lung volumes, no evidence of complications, notably no pneumothorax. Brief Hospital Course: 39 year old female with h/o gastric bypass who was transferred from [Hospital1 1474] with alcoholic hepatitis, cirrhosis, and encephalopathy. #. Alcoholic hepatitis and cirrhosis: She was admitted to [Hospital1 1474] with acute liver failure as well as multiple infections and acute kidney injury. Her bilirubin trended up at the OSH and therefore she was transferred to [Hospital1 18]. On admission here, she underwent a comprehensive workup for the etiology of her liver disease. It was ultimately felt to be likely alcoholic hepatitis with cirrhosis, although her alcohol use history was not apparent on admission. Her family later admitted to her drinking about a bottle of wine per night in the last several months to years. Her labs were not consistent with viral or autoimmune hepatitis. Her bilirubin continued to rise to a peak of 15.5 with elevated INR to 2.8. She also had a workup for potential malignancy due to elevated CA125 at the OSH but OSH CT abd/pelvis was unrevealing. RUQ ultrasound here showed splenomegaly, fatty infiltration of the liver, and patent portal veins. She had paracentesis twice at OSH prior to admission which was consistent with SBP. Ultimately, her liver failed to show signs of improvement and her mental status worsened to the point she was completely obtunded and not responsive despite aggressive lactulose treatment and initiation of nutrition. Steroids were not initiated due to her multiple ongoing infections, including strep pneumo bacteremia, SBP, and UTI. She was transferred to the MICU and her care focus was shifted to comfort. She passed away on [2128-4-3]. #. SBP: On admission to OSH, she had a paracentesis consistent with SBP with >[2116] PMNs on initial tap. She was started on ceftriaxone and underwent repeat paracentesis two days later with improvement in her cell count (WBC 657, 23% PMNs). She was continued on ceftriaxone and given daily albumin. Final peritoneal fluid cultures were negative. She was continued on ceftriaxone initially here, but was eventually transitioned to cefepime due to enterobacter UTI sensitivities. She completed a 2 week course of cefepime. It was not felt that she had enough ascites to retap during her admission here. #. Strep pneumo bacteremia: Blood cultures from admission to [Hospital1 1474] grew strep pneumo sensitive to ceftriaxone. She was treated with a 14 day course of ceftriaxone (which was then transitioned to cefepime given UTI culture). Repeat blood cultures here were negative. Also underwent TTE which showed no signs of endocarditis. #. Altered mental status/toxic metabolic encephalopathy: She was admitted with altered mental status initially felt to be related to hepatic encephalopathy. CT head was unremarkable. She was oriented x 1 upon arrival to [Hospital1 18] and her mental status progressively deteriorated during her stay despite frequent bowel movements and lactulose administration. She was also treated with rifaximin. When her alcohol use history became apparent, she was given high dose thiamine and B-complex vitamins as well. As her mental status deteriorated, there was some concern for Wernicke's encephalopathy as her gait became more ataxic and she did appear to be confabulating at times. Also likely to have had multiplep vitamin deficiencies given her history of gastric bypass and alcoholism. In the first few days of admission she was agitated and at times violent requiring prn haldol and ativan and multiple code purples were called. Her mental status declined and eventually she was obtunded and did not get out of bed or respond to questions. This was ultimately felt to be from a combination of hepatic encephalopathy, Wernicke's, electrolyte abnormalities, delirum from multiple infections, and potentially anoxic injury from her sepsis on admission. The reversible causes of toxic metabolic encephalopathy were treated but she continued to be obtunded and not responsive. Ultimately it was decided to make her comfort measures only and she passed away. #. Anemia: She had macrocytic anemia on presentation, felt to be potentially related to malnutrition given her h/o gastric bypass and alcohol use. She then developed BRBPR requiring a total of 4 units of blood (had also been given 2 units at OSH). Rectal exam revealed gross bright red blood per rectum and hemorrhoids. She ultimately lost all IV access due to her substantial skin breakdown and peripheral edema, and was transferred to the MICU for central line placement for blood administration and consideration of EGD/colonoscopy. Given her mental status, she would have needed to be intubated for these procedures and her hematocrit subsequently remained stable so EGD/colonscopy was deferred. #. Hypernatremia: She had hypernatremia to 152 throughout the first week of admission despite aggressive free water replacement. It was felt to be related to her nutritional state on admission and total body free water deficit despite profound peripheral edema. Her sodium was eventually corrected but did not improve her mental status. #. UTI: She had a urine culture sent on admission that eventually grew Enterobacter sensitive to cefepime but resistant to ceftriaxone. She was then switched to cefepime and completed a 10 day course without improvement in her mental status. Repeat urine culture was negative for infection. #. Thrombocytopenia: She had stable thrombocytopenia throughout this admission felt to be related to her underlying liver disease. Although INR was elevated, it was not felt that she was developing DIC. #. Goals of care: Multiple family meetings were held during her hospitalization to discuss her prognosis and care. As her mental status continued to deteriorate despite aggressive treatment of her liver disease and infections, it was felt that her prognosis was very poor. She was transferred to the MICU for central line placement and tube feed initiation, but did not improve despite these measures. Her husband and HCP [Name (NI) ] was actively involved in all medical decisions. Her sister also flew in from [Name (NI) 6607]. Her children were able to visit prior to her death as well. Social work was consulted, and she was placed on inpatient hospice for the last 6 days of her stay. She was made comfort measures only and symptoms were managed with ativan and morphine as needed. She passed away on [2128-4-3]. Medications on Admission: Ferrous Sulfate 325mg Qd Lactuose 30mg [Hospital1 ] Mag Oxide 400mg [Hospital1 ] Pantoprazole 40mg Qd Tramadol 50mg [Hospital1 ] CTX 2g Daily (start [2128-3-12]) Albumin 25mg IV TID Nicotine Patch 14mg daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379]	[ "455.8", "311", "038.2", "285.9", "567.23", "276.0", "291.1", "584.9", "V49.87", "570", "995.92", "V85.24", "293.0", "300.00", "287.5", "599.0", "572.4", "V15.82", "V49.86", "278.00", "275.3", "572.2", "571.2", "V45.86", "789.59", "571.1" ]	icd9cm	[ [ [] ] ]	[ "38.97", "96.6" ]	icd9pcs	[ [ [] ] ]	14601, 14610	7845, 14295	355, 395	14661, 14670	3943, 4810	14726, 14858	2863, 2906		14569, 14578		14631, 14640		14321, 14546			14694, 14703										2946, 3924																												252, 317											423, 2290		7237, 7822					4826, 5545		5567, 7228						2312, 2492	2508, 2847
18,431	146,702	52569	Discharge summary	report	Admission Date: [2103-12-13] Discharge Date: [2103-12-28] Service: MEDICINE Allergies: Lipitor Attending:[First Name3 (LF) 2160] Chief Complaint: Shortness of breath, requiring NRB Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: [Age over 90 ] male with h/o CAD, HTN, CHF presented with gradually increasing SOB/DOE over past few months and for the past week has worsened to the point where he could not put on his socks/ADL's. At baseline, he walks about 1 block before getting short of breath. In addition, he notes that for the past few weeks, he has been experiencing some chest pressure, which is worse when lying flat. He saw his cardiologist in the week before admission, noted to have CHF on CXR, PCP called him to increase his Lasix dose from 60 [Hospital1 ] to 80 [Hospital1 ]; however, he was noted to have no significant increase in urine output. On the morning of admission, he saw his PCP and was sent to ED. . ED COURSE: He was given 40mg IV lasix to which he did not respond. He was subsequently given 100mg IV lasix, to which he had good urine output. . ROS: +orthopnea, no sick contacts, no fever, chills, nausea, vomiting. He does note an occasional mild non-productive cough. He denies any large, salty meals, no palpitations, no pleuritic chest pain, no lightheadedness, dizziness. Past Medical History: CAD s/p CABG [11] y ago HTN DMII DMII nephropathy TURP rectal bleeding Social History: no tob/ ETOH or IVDU Patient never married, no children. He lived with his brother in an apartment until recently when his brother died. [Name2 (NI) ] does have 2 friends who help him at home with meds, etc. Family History: not elicted Physical Exam: In the ICU on admission: VS- 95.4 127/75 48-69 24 99%NRB GEN- lying in bed, breathing slightly labored using abd muscles HEENT- MMM, PERRL, conjunctivae normal, sclerae anicteric NECK- JVP at 8cm CV- bradycardic, regular, III/VI systolic murmur at LLSB CHEST- sternum separated, poor airflow, rare rhonchi and crackles ABD- +BS, soft, NT, ND EXT- 1+ pitting edema 1/4 up tibia bilaterally NEURO- oriented X 3 SKIN- seborheic keratosis, no rashes MSK- deferred Pertinent Results: [2103-12-26] 06:45AM BLOOD WBC-9.7 RBC-3.38* Hgb-10.3* Hct-31.2* MCV-92 MCH-30.4 MCHC-33.0 RDW-15.8* Plt Ct-349 [2103-12-25] 07:10AM BLOOD WBC-8.4 RBC-3.50* Hgb-10.4* Hct-32.2* MCV-92 MCH-29.7 MCHC-32.3 RDW-15.8* Plt Ct-338 [2103-12-15] 06:38PM BLOOD Neuts-84.6* Lymphs-8.5* Monos-6.5 Eos-0.4 Baso-0.1 [2103-12-13] 01:00PM BLOOD Neuts-79.9* Lymphs-12.7* Monos-6.9 Eos-0.3 Baso-0.2 [2103-12-25] 11:00AM BLOOD PT-13.9* PTT-61.1* INR(PT)-1.2* [2103-12-20] 07:25AM BLOOD PT-14.1* PTT-34.9 INR(PT)-1.2* [2103-12-26] 06:45AM BLOOD Glucose-62* UreaN-111* Creat-3.1* Na-144 K-4.4 Cl-106 HCO3-22 AnGap-20 [2103-12-22] 06:55AM BLOOD Glucose-119* UreaN-131* Creat-3.5* Na-138 K-3.8 Cl-95* HCO3-29 AnGap-18 [2103-12-15] 06:38PM BLOOD Glucose-159* UreaN-87* Creat-3.6* Na-140 K-4.5 Cl-102 HCO3-24 AnGap-19 [2103-12-13] 01:00PM BLOOD Glucose-209* UreaN-80* Creat-3.2* Na-140 K-4.8 Cl-103 HCO3-23 AnGap-19 [2103-12-14] 04:45AM BLOOD CK(CPK)-67 [2103-12-13] 01:00PM BLOOD CK-MB-NotDone proBNP-[Numeric Identifier ]* [2103-12-13] 01:00PM BLOOD cTropnT-0.28* [2103-12-13] 06:47PM BLOOD CK-MB-13* MB Indx-16.0* cTropnT-0.30* [2103-12-14] 04:45AM BLOOD CK-MB-12* MB Indx-17.9* cTropnT-0.34* [2103-12-26] 06:45AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.3 [2103-12-14] 04:45AM BLOOD Albumin-4.2 Calcium-9.8 Phos-4.8* Mg-2.6 Iron-45 Cholest-161 [2103-12-14] 04:45AM BLOOD calTIBC-273 VitB12-1026* Folate-GREATER TH Ferritn-155 TRF-210 [2103-12-14] 04:45AM BLOOD Triglyc-94 HDL-52 CHOL/HD-3.1 LDLcalc-90 [2103-12-22] 06:55AM BLOOD Osmolal-338* [2103-12-25] 07:10AM BLOOD Osmolal-332* Pleural fluid: [2103-12-25] 01:54PM pH-7.54* Comment-PLEURAL FL [2103-12-25] 12:58PM PLEURAL WBC-125* RBC-950* Polys-17* Lymphs-19* Monos-2* Meso-14* Macro-48* [2103-12-25] 12:58PM PLEURAL TotProt-1.6 Glucose-190 LD(LDH)-93 [2103-12-25] 12:58 pm PLEURAL FLUID GRAM STAIN (Final [2103-12-26]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Pending): Pleural fluid cytology - pending [2103-12-14] 01:44AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.010 [2103-12-14] 01:44AM URINE Blood-LGE Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2103-12-14] 01:44AM URINE RBC-89* WBC-2 Bacteri-NONE Yeast-NONE Epi-0 [2103-12-14] 01:44AM URINE CastHy-2* [2103-12-16] 08:14PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.015 [2103-12-16] 08:14PM URINE Blood-LGE Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [2103-12-16] 08:14PM URINE RBC-0-2 WBC-[4-8] Bacteri-FEW Yeast-NONE Epi-0 [2103-12-16] 08:14PM URINE AmorphX-OCC [2103-12-23] 09:12AM URINE Hours-RANDOM Creat-54 Na-36 [2103-12-22] 10:29AM URINE Hours-RANDOM UreaN-415 [2103-12-22] 10:29AM URINE Osmolal-352 [2103-12-16] 8:14 pm URINE FINAL REPORT [2103-12-18] URINE CULTURE (Final [2103-12-18]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Trimethoprim/Sulfa sensitivity testing confirmed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ECHO: Conclusions: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is mild regional left ventricular systolic dysfunction with mid antero-septal hypokinesis. The right ventricular cavity is mildly dilated. Right ventricular systolic function is borderline normal. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload and superimposed conduction delay. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2102-3-31], the severity of mitral and tricuspid regurgitation has increased. The degree of pulmonbary hypertension detected has also increased. Overall regional LVEF may appear better, however, intrinsic forward EF may be reduced secondary to valvular regurgitation. CHEST, PA AND LATERAL: Bilateral pleural effusions likely slightly worse when compared to the previous exam. There is an increased retrocardiac left lower lobe collapse. There are increased perihilar interstitial opacities consistent with slight worsening in CHF. There is unfolding of the aorta with wall calcifications. The cardiac contour remains enlarged. IMPRESSION: 1. Slight worsening of interstitial pulmonary edema. 2. Slight increase in size of bilateral pleural effusions with left lower lobe atelectasis. Approved: FRI [2103-12-14] 3:21 PM Cardiology Report ECG Study Date of [2103-12-16] 4:15:42 PM Since the previous tracing of [2103-12-13] there is a regular supraventricular rhythm. This is possibly sinus with first degree A-V block, although a junctional rhythm cannot be entirely excluded. Other than rhythm, there is no significant change compared to the previous tracing of [2103-12-13]. TRACING #1 Read by: [Last Name (LF) ],[First Name3 (LF) ] B. Intervals Axes Rate PR QRS QT/QTc P QRS T 66 0 148 434/447 0 98 116 CT CHEST WITHOUT IV CONTRAST: There are moderate-sized bilateral pleural effusions, left greater than right. There is associated atelectasis of the left lower lobe. The combination of the left- sided pleural effusion and left lower lobe atelectasis apparntly accounts for the retrocardiac opacity seen on chest x- ray. The patient is status post median sternotomy with no evidence of sternal wires. There are extensive atherosclerotic coronary artery and aortic wall calcifications. There are dense calcifications involving the mitral annulus. The airways are patent down the segmental bronchi. There is no significant intrathoracic lymphadenopathy. Imaging of the upper abdomen shows multiple cystic renal lesions, which appear unchanged dating back to [2101-6-4], compatible with multiple hyperdense renal cysts. The adrenal glands are nodular and prominent, without evidence of focal mass. There are tiny gallstones. A small amount of fluid is seen anterior to the liver. IMPRESSION: Moderate-sized bilateral pleural effusions. Left lower lobe collapse. The combination of the pleural fluid and left lower lobe collapse account for the retrocardiac left lower lobe opacity on chest x-ray. Approved: MON [2103-12-17] 9:40 PM CXR: IMPRESSION: 1. Improved CHF with resolving perihilar haziness. 2. Slight improvement in left lower lobe opacity, corresponding to a combination of atelectasis and effusion on recent CT. 3. Slight decrease in small right pleural effusion. Approved: [Doctor First Name ] [2103-12-20] 4:07 PM CXR: History of shortness of breath. There is cardiomegaly with pulmonary vascular engorgement and probable small left pleural effusion consistent with CHF. In addition, there is opacity at the left base obscuring the left hemidiaphragm likely due to a combination of atelectasis/consolidation in the left lower lobe and left pleural effusion. IMPRESSION: CHF with atelectasis/consolidation left lower lobe and left pleural effusion. The left basilar opacity is possibly slightly increased since yesterday's film of [2103-12-23]. Approved: MON [2103-12-24] 9:56 PM Brief Hospital Course: CHF (systiolic and diastolic) exacerbation was felt to be the mostly likely cause of his progressive dyspnea given radiographic findings, elevated BNP, and physical exam. The CHF may have been triggered by the bradycardia/junctional escape rhythm seen on EKG. NSTEMI Also had a Non-STEMI with elevated troponins. Started initially on heparin gtt for one night; given his DNR/DNI status, he preferred noninvasive medical management only. Repeat echo revealed worsening MR [First Name (Titles) ] [Last Name (Titles) ], and it was felt that a large component of his symtpoms of failure were due to poor forward flow. He was started on an ACEI for afterload reduction and he was gently diuresed daily. Chest CT was obtained to further evaluate retrocardiac opacification for malignancy, pneumonia. CT revealed atelectasis and pleural effusions. It was decided not to tap the effusions in the ICU given his clinical improvement. New atrial flutter: was noted with a slow rate in the 60s ventricular and 150's atrial. This is new compared to EKGs in [2102]. Cardiology/EP felt that he would not benefit from pacer at this time, and nothing active to do for the atrial flutter. Specifically EP recs: "no pacer at this point but could consider if clinically improves. Age and comorbidities make BiV not indicated. Could have EPS for flutter but too sick for this now and would likely necessitate pacer". After stabilization of CHF and MI the patient was tranferred to the floor from the ICU. Due to overdiuresis, the BUN went upto >130. After few IVF boluses and holding lasix, BUN decreased. Patients renal function was almost at baseline for him. Low dose lasix was restarted. The continuing need for lasix and the dose should be determined by PCP in response to his symptoms. # UTI: Patient had a foley catheter in for the first few days of admission. He developed a burning sensation with urination, urine culture revealed E.coli and he was started on ciprofloxacin for 7 day course for complicated UTI. # Pleural effusions: 2 days prior to discharge, the patient developed dyspnea requiring oxygen. Not much improvement with nebs. CXR showed a large left pleural effusion and retrocardiac infiltrate. Given the concern that this could have been a parapneumonic effusion, thoracentesis was performed. Pleural fluid was serous yellow in colour and a transudate suggestive of CHF or renal failure. 1300 ml of fluid was drained and cytology was sent for and pending at discharge. #Pneumonia, bacterial - ciprofloxacin (for UTI) was changed to levofloxacin to complete the 14 day course. With Rx of pneumonia and thoracentesis, hypoxia and dyspnea both resolved. . # DM: Patient had hx of diabetes, type II on prandin at home. After initial insulin, started on home regimen. . # Acute on chronic renal failure: Has CKD from diabetes. Baseline creatinine 3.5 in 11/[2102]. All meds were dosed renally. Due to overdiuresis, the BUN went upto >130. After few IVF boluses and holding lasix, BUN decreased. Patient's renal function was almost at baseline for him. Low dose lasix was restarted. As stated above, the continuing need for lasix and the dose should be determined by PCP in response to his symptoms. . # Anemia: HCT baseline is ~30. Likely [3-8] chronic renal disease. He is normocytic. Iron studies, B12, folate were normal suggesting anemia of chronic disease (most likey renal disease) . # GERD: continued PPI . # CODE: dnr/dni To be discharged to [Hospital3 ]. Medications on Admission: ASA 325 QD Procardia 90 CR QD Protonix 40 QD Nitro PRN Cozaar 100 mg QD Lasix 80 [Hospital1 ] Metoprolol 25 [Hospital1 ] Lisinopril 5 mg QD Prandin 2mg Qbreakfast, 1mg Qdinner Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Repaglinide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Repaglinide 0.5 mg Tablet Sig: Two (2) Tablet PO DINNER (Dinner). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 12. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 10 days. 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Congestive heart failure (systolic and diastolic) Coronary artery disease Non ST-elevation MI Atrial flutter Acute on chronic renal failure Pneumonia, bacterial Urinary tract infection (E.Coli) Discharge Condition: Stable Discharge Instructions: The doctor at the rehab will take care of your further medical needs. Please make a follow up appointment with your primary doctor in next 10 days. Your medications have been changed. Please refer to the details attached. Return to the emergency room or call your doctor if you notice increasing shortness of breath, cougf, fever, chest pain or any other symtpoms concerning to you. Followup Instructions: Make a follow up appointment with your doctor [First Name8 (NamePattern2) ] [Last Name (Titles) 58] [Telephone/Fax (1) 3329] in the 7 to 10 days. [Last Name (LF) ],[First Name3 (LF) ] D. [Telephone/Fax (1) 3329]. (to follow cytology results of pleural fluid)	[ "511.9", "425.4", "530.81", "599.0", "357.2", "416.8", "799.02", "583.81", "410.71", "403.91", "041.4", "V45.81", "424.0", "482.9", "250.40", "369.4", "428.43", "427.32", "584.9", "285.29", "250.60" ]	icd9cm	[ [ [] ] ]	[ "34.91", "88.73" ]	icd9pcs	[ [ [] ] ]	15974, 16045	11030, 14533	252, 268	16283, 16292	2241, 4300	16727, 17014	1731, 1744		14768, 15951		16066, 16262		14559, 14745			16316, 16704										1759, 1770																												178, 214											296, 1385										1784, 2222					1407, 1484	1500, 1715		4332, 11007
54,961	157,953	45430	Discharge summary	report	Admission Date: [2165-8-9] Discharge Date: [2165-8-16] Date of Birth: [2101-11-3] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4679] Chief Complaint: Esophageal Cancer Major Surgical or Invasive Procedure: [2165-8-9]: 1. [First Name9 (NamePattern2) 12351] [Doctor Last Name ] esophagectomy. 2. Buttressing of intrathoracic anastomosis with pericardial fat. [2165-8-16]: Right thoracentesis. History of Present Illness: The patient is a 63-year-old male with a locally advanced esophageal cancer who has undergone chemoradiation therapy and is admitted following minimal invasive esophagectomy. Past Medical History: Adenocarcinoma of the esophagus, Dx [3-27] after a long course of progressive dysphagia, weight loss. The patient initially was diagnosed with GERD and Barrett's, then on [2165-4-1] an EGD showed a malignant intrinsic 5 mm stricture that was 20 mm long and appeared at 29 cm from the incisors was seen in the lower third of the esophagus. Pathology showed Adenocarcinoma at least intramucosal, submucosa not present. PET scan showed 4cm segment of mid to distal esophagus. No nodal involvement identified. No evidence of distant metastatic disease. On [2165-4-17], he underwent a bronchoscopy which showed esophageal cancer with no tracheal wall involvement on endobronchial ultrasound. - His first cycle of chemotherapy with cisplatin on [2165-4-29] 75 mg/m2 D1 and 5-FU 1000 mg/m2 D1-D3 was complicated by a diffuse erythematous skin rash of unclear etiology that resolved with discontinuation of 5-FU and anti-emetics - Received over 2500 cGy of radiotherapy. - Port-a-cath and J tube placed. Other Past Medical History: GERD Barrett's Esophagus hyperlipidemia hypertension Social History: He is a single, retired Police at [Company 2318]. He has more than 50ppy history of smoking. He rarely drink alcohol. He is active with his family and has been able to keep up with his 2 twin nieces. Family History: His mother died at 70s-80s with colon cancer, father died at age 62 with throat cancer. He was a heavy smoker. His sister has breast cancer in the 60s. Another sister has skin cancers. He has total 7 siblings. Physical Exam: VS: T 97.7, HR 101, BP 141/64, RR 22 O2 sats 95% on room air. Physical Exam: Gen: pleasant in NAD Lungs: clear t/o, diminished RLL CV: RRR S1, S2, no MRG or JVD Abd: soft, NT, jtube intact with edema, incision sites C/D/I Ext: warm, no edema Pertinent Results: [2165-8-15] 06:15AM BLOOD WBC-7.0 RBC-3.06* Hgb-9.9* Hct-28.5* MCV-93 MCH-32.3* MCHC-34.7 RDW-14.2 Plt Ct-242 [2165-8-9] 05:13PM BLOOD WBC-13.5* RBC-3.14* Hgb-10.2# Hct-29.5 MCV-94 MCH-32.5* MCHC-34.6 RDW-15.1 Plt Ct-210 [2165-8-15] 06:15AM BLOOD Glucose-123* UreaN-19 Creat-0.6 Na-138 K-3.8 Cl-103 HCO3-29 AnGap-10 [2165-8-15] 06:15AM BLOOD Calcium-7.8* Phos-4.1 Mg-2.2 [2165-8-15] Barium swallow: no leak [2165-8-15] CXR Impression: Right hydropneumothorax is small-to-moderate, has increased from prior study. Left pleural effusion is unchanged. Left lower lobe retrocardiac opacity has improved consistent with improved atelectasis. Cardiomediastinal silhouette is unchanged. Right subclavian catheter tip is at the cavoatrial junction. Brief Hospital Course: Mr. [Known lastname ] was admitted to the SICU intubated following his successful [First Name9 (NamePattern2) 12351] [Doctor Last Name ] esophagectomy with Buttressing of intrathoracic anastomosis with pericardial fat. He was successfully extubated the following day. Respiratory: aggressive nebs, pulmonary toilet, chest PT he titrated off oxygen with saturations of 91%. His chest tube was removed POD 6 following barium swallow which revealed no leak. On CXR he had an accumlating right pleural effusion, which our interventional pulmonologist performed right thoracentesis for 400cc serous fluid, which was sent off to lab on [2165-8-16]. His right JP drain was also removed [2165-8-15] following his negative esophagus study. Cardiac: hemodynamically stable in sinus rhythm throughout. GI: bowel regime and PPI were continued Nutrition: Replete was started [2165-8-10] and titrated to Goal at 105ml x 18 hrs. On [2165-8-15] the Esophagus study was negative for leak, he was started on a full liquid diet, and the tube feeds were decreased to 100 mL x 15 hours on discharge. Given that he had 2 cases of isosource 1.5 at home that he tolerated well preoperatively he was discharged home on 90ml/hr over 12 hours as discussed with our dietician. Renal: The patient's renal function remained within normal limits. His foley was removed on [2165-8-15]. He voided without difficulty. His electrolytes were repleted as needed. ID: Vanc/cefepime/Flagyl started [8-11] for concern for PNA and infiltrate seen on CXR. WBC elevated to 15 normalized following start of antibiotics. He remained afebrile and completed a 6 day course of antibiotics. Pain: Bupivacaine/Dilaudid Epidural was managed by the acute pain service. Once removed on POD 6 he was converted to PO pain medication with good control. Disposition: He was seen by physical therapy and deemed safe for home. He was discharged on [2165-8-16] as cleared by Dr. [First Name (STitle) ] and will follow-up with Dr.[First Name (STitle) ] as an outpatient to discuss pathology results. Medications on Admission: Prevacid 30 mg daily, amlodipine 5 mg daily, lipitor 10 mg daily, ativan 1 mg prn, ondansetron 8 mg prn Discharge Medications: 1. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] once a day. Disp:30 Tablet,Rapid Dissolve, DR(s) Refills:2 2. Amlodipine 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 3. Lipitor 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Last Name (STitle) ]: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:500 ML(s) Refills:0 5. tube feedings isosource 1.5 tube feedings for nutritional support following esophactomy for esophageal cancer at 90 ml/hr from 8pm to 8am. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Esophageal Cancer Hypertension Hyperlipidemia right pleural effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[Name (NI) 5067] office [Telephone/Fax (1) 2348] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or chest pain -Incision develops drainage -If J-tube falls out, call immediately [Telephone/Fax (1) 2348] -Keep right chest tube dressing on and cover site with a bandaid until healed. -You may shower. No tub bathing or swimming until incision healed. Followup Instructions: Follow-up with Dr. [First Name (STitle) ] [0-0-] Date/Time:[2165-8-29] 9:30 on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center [Location (un) 24]. Chest X-Ray [Location (un) 861] Radiology 30 minutes before your appointment. You will also see Dr. [Last Name (STitle) ] at 10am following your appointment with Dr. [First Name (STitle) ] in the same area on [2165-8-29]. Completed by:[2165-8-16]	[ "272.4", "196.1", "401.9", "511.89", "458.29", "530.85", "305.1", "531.90", "786.09", "518.0", "151.0", "V55.4", "V87.41", "V15.3", "530.81" ]	icd9cm	[ [ [] ] ]	[ "96.71", "03.90", "54.21", "50.14", "34.91", "42.52", "96.6", "42.42" ]	icd9pcs	[ [ [] ] ]	6338, 6396	3388, 5493	338, 541	6509, 6509	2592, 3365	7088, 7549	2103, 2314		5647, 6315		6417, 6488		5519, 5624			6660, 7065										2406, 2573																												281, 300											569, 746												6524, 6636			1811, 1865	1881, 2087
76,479	162,404	49732	Discharge summary	report	Admission Date: [2179-7-30] Discharge Date: [2179-8-2] Date of Birth: [2124-6-21] Sex: F Service: MEDICINE Allergies: Tetracycline / Dilaudid (PF) / Pravastatin Attending:[First Name3 (LF) 1436] Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 54-year-old woman with a history of complex Crohn's disease status post multiple enterocutaneous fistulas, colostomy and recurrent Crohn's disease complications, atrial fibrillation and nonsustained ventricular tachycardia presented to ED with CC of N/V x1 day with general malaise. No CP or SOB. ? AMS with poor medical compliance. On BB, CCB and Dig. Hypotension in the 70's HR in the 40s. Bolused IVF. Gpt atropine. EKG showed brady carid rhythm either junctional or afib. K was 6.6. Dig was 10. Dig toxicity. Got 400mg of Digibind. And peripheral dopamine. Decided to hold off on central line given high INR. Prior to transfer BP is 100 systolic HR is 50. MS is clear. Of note she was recently admitted to the colorectal service on [6-22]. During that admission her digoxin levels were noted to be 2.5 and her digoxin was held. Three days later her Digoxin level was 0.8. She was discharged on POD 8 on her original dose of 250mcg QD. Past Medical History: - Crohn's Disease (diagnosed [2167]) c/b fistulas, sigmoidectomy, SBOs - Atrial fibrillation since [2173] ---> DCCV x3 at [Hospital1 ] ---> Cardioversion [5-19] at [Hospital1 18] - Nonsustained Ventricular Tachycardia - Benign Multinodular Goiter (followed by Dr. [Last Name (STitle) ] - s/p Cervical cancer - GERD - Paraspinal cyst (followed by Dr. [Last Name (STitle) 575] - Pulmonary lesions - Mediastinal mass (stable on MRI) - Portal vein clot - Arthritis - Anxiety Social History: - Married, living with her family in [Location (un) 47] - Previously worked as physical therapist - Tobacco: Smoked intermittently in college, but no recent use - EtOH: Denies - Illicit Drug Use: Nil. Family History: - Father: UC, esophageal cancer --- Paternal aunt with [Name (NI) 4522] - Mother: Basal & squamous cell carcinoma - Grandmother developed afib at 80 years of age - Maternal grandmother: lung cancer - [Name (NI) ] diagnosed with IBD at age 14 Physical Exam: Admission Physical: VS: 57 113/45 95% ra GENERAL: NAD. Oriented x3 but intermittently confused on exam HEENT: NCAT. NECK: Supple CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR S1S2 LUNGS: CTA BL ABDOMEN: Soft. Healing midline laparotmy inscison. No evidence erythema, warmth or purulence. EXTREMITIES: 1+ PE to knees bilaterally SKIN: No stasis dermatitis Discharge Physical Exam: General Appearance: Well nourished, Overweight / Obese Head, Ears, Nose, Throat: Normocephalic Cardiovascular: RRR, S1/S2 normal (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Bowel sounds present, Tender: peri-wound tenderness, Obese, Ostomy site c/d/i Extremities: Right lower extremity edema: 1+, Left lower extremity edema: 1+ Skin: Not assessed Neurologic: Attentive, Follows simple commands, Moves all for extremities spontaneously. Pertinent Results: CBC: [2179-7-30] 05:00PM BLOOD WBC-11.8* RBC-3.51* Hgb-10.1* Hct-32.9* MCV-94 MCH-28.7 MCHC-30.7* RDW-15.0 Plt Ct-648* [2179-8-2] 07:00AM BLOOD WBC-7.9 RBC-3.15* Hgb-9.1* Hct-29.2* MCV-93 MCH-28.9 MCHC-31.2 RDW-15.1 Plt Ct-495* INR: [2179-7-30] 05:00PM BLOOD PT-49.9* PTT-45.7* INR(PT)-4.9* [2179-7-31] 11:20AM BLOOD PT-61.8* PTT-39.0* INR(PT)-6.2* [2179-8-2] 07:00AM BLOOD PT-30.8* PTT-35.3 INR(PT)-3.0* BMP: [2179-7-30] 05:00PM BLOOD Glucose-100 UreaN-31* Creat-1.4* Na-138 K-6.6* Cl-99 HCO3-28 AnGap-18 [2179-8-2] 07:00AM BLOOD Glucose-74 UreaN-11 Creat-0.9 Na-141 K-4.4 Cl-105 HCO3-28 AnGap-12 LFT: [2179-7-30] 05:00PM BLOOD ALT-27 AST-29 AlkPhos-221* TotBili-0.2 [2179-7-31] 05:14AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.4* [2179-8-2] 07:00AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0 DIG LEVEL [2179-7-30] 05:00PM BLOOD Digoxin-GREATER TH [2179-8-1] 05:06AM BLOOD Digoxin-4.6* IMAGING: [2179-7-30] CXR: FINDINGS: The cardiac, mediastinal and hilar contours appear unchanged. There is similar to somewhat increased moderate relative elevation of the right hemidiaphragm. There is no pleural effusion or pneumothorax. Pulmonary vascularity is minimally prominent and indistinct suggesting slight congestion. [2179-7-31] ABD X-Ray: There is paucity of the bowel loops gas pattern. There is only a small length of nondilated air-filed small bowel loop in the left lower quadrant. Degenerative changes are in the lumbar spine. There are no pathologic intraabdominal calcifications. Brief Hospital Course: ASSESSMENT AND PLAN: 55 [Last Name (un) 9232] with extensive medical history initially presenintg to the ED with AMS, Abdominal pain nausea and vomiting found to have digitalis toxicity. # Digoxin toxicity/Hypotension and bradycardia: Secondary to cardiac glycoside toxicity. Also has been confused about medications and there for there may be some component of BB and CCB toxicity. This is less likely however bc glucagon had little effect on her status. She received digibind in the ED for symptomatic bradycardia and her electrolye and electrophysiologic abnormalities resolved. She was transferred to the ICU on dopamine, but it was weaned down overnight and then stopped on HD #1. She was monitored in the ICU and her bradycardia also resolved. Given her digoxin toxicity, it was decided that she should not be restarted on digoxin in the future. When she had stabilized, she was restarted on her metoprolol at half dose of 50mg PO BID. She became bradycardic to the 50's after her first dose, but then on repeat later in the afternoon on HD #2 her heart rate was persistently in the 60-80s. On HD #3 her diltiazem ER was added back at half dose - 180mg PO Daily. Her blood pressures and heart rate were stable and it was felt she was safe to be discharged on half dose metoprolol and diltiazem and her lisinopril could be restarted in the outpatient setting. She should not be restarted on her digoxin. . # Nausea and vommiting: This is likley secondary to dig toxicity. Surgery is following and dose not feel this is an acute surgical issue. It improved as she was treated for her digoxin toxicity. . # Hyperkalemia: Digoxin poisoning causes na+/K+- ATP-ase failure resulting in apparent hyperkalemia. Theoretically her K shoudl begin to normalize once digibind takes effect. As a result she may in fact turn out to be total body potassium deplete given recent diarrhea. As her digoxin toxicity was treated her K+ trended from 6.6-4.2. It remained stable in the 4 range thereafter. # Supratherapeutic INR: Likley secondary to poor adherence to medication regimen. She has no apparent bleeding. Discussed with attending who would like her to get 1mg of PO vitamin K. Her INR peaked at 6.2 and then started trending down thereafter. We held her coumadin throughout the length of her stay. On the day of discharge her INR was 3.0. She will have her INR repeated on [2179-8-3] and will be restarted per Dr. [First Name (STitle) ]. . # Abdominal Pain: Patient with persistent abdominal pain around surgical site. Abdominal X-ray was unrevealing. On our exam, the pain was around the suture sites. Most likely from incision and wound healing. Surgery also evaluated her abdomen and was not concerned for complication from her surgery. We controlled her pain effectively with oxycodone 5-10mg PO Q4-6H:PRN. She was sent home with a prescriprion of oxycodone. She will follow up with her PCP for further management of her pain. # AMS: Likley secondary to digioxin toxicity. Could also be delirium in the setting of as of yet undeclared infection or poly pharmacy. Also considered head bleed given supratherapeutic INR and possibility she may have fallen while confused at home. Her confusion resolved with treatment of her digitalis toxicity. . # [Last Name (un) ]: Likley pre renal in setting poor Po intake and high ostomy out put. Will add on urine lytes to confirm and trend. Her lisinopril was held and urine lytes were unrevealing. Her creatinine improved to 1.1 on hospital day 1. She was not restarted on her lisinopril because her BP was controlled with metoprolol and diltiazem and given admission for hypotension, we wanted to only add on medications one at a time. She will need this restarted in the outpatient setting as per her primary care physician. . # Afib: Patient has very difficult to control Afib. There has been some discussion in the past with regards to starting dofetilide however she may not be the best candidate for the drug given this presentation. She was treated for her digitalis toxicity and all her rate control medications were initially held. We spoke with EP and Dr. [Last Name (STitle) ] who felt she could be rate controlled with metoprolol and diltiazem for now and he would discuss further management concerning dofetilide or AV nodal ablation in the outpatient setting. Once her bradycardia resolved she was given metoprolol 50mg PO BID (half her home dose). Her first dose caused some bradycardia, but she tolerated her second dose well. In addition, once stable on the metoprolol, she was given half her diltiazem dose, which she also tolerated well. She will be discharged off her digoxin with no plan to restart. Her metoprolol and diltiazem will be halved for now and can be increased in the outpatient setting if needed. # DM: Held metformin and continued ISS. Metformin was restarted at the time of discharge . # S/P completion colectomy and end ileostomy on [2179-6-21] for enterocutaneous fistulae from active disease in her old colostomy: Colorectal surgery is following and did not make many recommendations. Given her hospital stay, we spoke with Dr. [Last Name (STitle) 1120] who felt she did not need to see her in [Hospital ] clinic on [2179-8-3]. The wound ostomy nurses would be in contact with her regarding her next visit. . # Leukocytosis: Afebrile and no signs of infection. She appears hemoconcentrated with simultaneous elevations in all of her cell lines. Her WBC resolved with monitoring. TRANSITIONAL ISSUES: - Need to follow up INR and restart coumadin when between [3-12] - Need to restart lisinopril when indicated - Consider increase nodal agents if needed back to home doses - Will need to follow up and continue evaluate abdominal pain - She will follow up with Dr. [Last Name (STitle) ] regarding further management of her a-fib - Follow up with wound ostomy nurse regarding further post-op care Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientAtriuswebOMR. 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [Hospital1 ] 2. Calcium 500 + D NF (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit Oral Daily 3. FoLIC Acid 400 mcg PO DAILY 4. Loperamide 2 mg PO BID:PRN loose stools 5. Glargine 36 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 6. Metoprolol Tartrate 100 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. Acetaminophen 1000 mg PO Q6H:PRN pain Do not exceed 3gm per day 9. Cyanocobalamin 1000 mcg PO DAILY 10. Digoxin 0.25 mg PO DAILY 11. Ferrous Sulfate 325 mg PO DAILY 12. Lisinopril 20 mg PO DAILY 13. Lorazepam 2 mg PO TID:PRN anxiety 14. MetFORMIN (Glucophage) 500 mg PO BID 15. Simvastatin 10 mg PO DAILY 16. Warfarin 4 mg PO DAILY16 17. Diltiazem Extended-Release 360 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain Do not exceed 3gm per day 2. Cyanocobalamin 1000 mcg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [Hospital1 ] 5. FoLIC Acid 400 mcg PO DAILY 6. Glargine 36 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 7. Loperamide 2 mg PO BID 8. Lorazepam 2 mg PO TID hold for oversedation or rr<10 9. Metoprolol Tartrate 50 mg PO BID Hold for HR<60, SBP<100 RX Lopressor 50 mg 1 Tablet(s) by mouth twice a day Disp #30 Tablet Refills:1 10. Diltiazem Extended-Release 180 mg PO DAILY Hold for SBP<100, HR<60 RX Cardizem CD 180 mg 1 Capsule(s) by mouth Daily Disp #30 Tablet Refills:2 11. Omeprazole 20 mg PO DAILY 12. Simvastatin 10 mg PO DAILY 13. Calcium 500 + D NF (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit Oral Daily 14. MetFORMIN (Glucophage) 500 mg PO BID 15. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN abdominal pain Hold for Sedation, RR<10 RX oxycodone 5 mg [2-8] Tablet(s) by mouth every four (4) hours Disp #20 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary Diagnosis: Digoxin toxicity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [Hospital1 69] for digoxin toxicity. You were given medicine that binds up all the digoxin in your system. We watched you closely in the ICU and you improved significantly. You also started to have severe abdominal pain that is likely from your surgery. Your pain has been well controlled with oxycodone. We will send you home with some pain medicine. As your heart rate improved we restarted your diltiazem and metoprolol at half dose. We are currently holding your lisinopril. You should NEVER restart digoxin. You INR was also elevated, but is currently coming down. You should not take your coumadin until instructed to do so by Dr. [First Name (STitle) ]. We will repeat you INR test on [2179-8-3]. It was a pleasure taking care of you. If you have any questions, you should be sure to call Dr. [First Name (STitle) ] with further questions. We also discussed your care with Dr. [Last Name (STitle) 1120] and she said that you can skip the post-op appointment on [2179-8-3] and the wound ostomy care nurse will contact you when your next appointment is. It is very IMPORTANT that you remain well HYDRATED. The following changes were made to your medications: The following medications were STOPPED: Digoxin 0.25mcg Lisinopril 20mg by mouth Daily coumadin 4mg by mouth Daily The Following medications were CHANGED: Diltiazem ER 360mg Daily ---> Diltiazem ER 180mg by mouth Daily Metoprolol tartrate 100mg Twice a day ---> Metoprolol tartrate 50mg by mouth twice a day Followup Instructions: Name:[Hospital 197] Clinic Appointment When: Friday [8-6] at 1:40pm Location: [Hospital ] MEDICAL GROUP Address: [Hospital1 ] [Location (un) ], [Location (un) ],[Numeric Identifier 66490] Phone: [Telephone/Fax (1) 12295] Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 88517], MD When: Friday [8-6] at 2:15pm Location: [Hospital ] MEDICAL GROUP Address: [Hospital1 ] [Location (un) ], [Location (un) ],[Numeric Identifier 66490] Phone: [Telephone/Fax (1) 12295] Department: CARDIAC SERVICES When: FRIDAY [2179-8-13] at 12:40 PM With: [Name6 (MD) 251] [Last Name (NamePattern4) 677], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: DIGESTIVE DISEASE CENTER When: MONDAY [2179-8-23] at 10:30 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6925],MD [Telephone/Fax (1) 463] Building: [First Name8 (NamePattern2) ] [Hospital Ward Name 1950] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 3202] Campus: EAST Best Parking: Main Garage Department: ENDO SUITES When: MONDAY [2179-8-23*] at 10:30 AM	[ "787.01", "458.8", "530.81", "V44.2", "241.1", "427.89", "V10.41", "584.9", "555.9", "427.31", "250.00", "V12.51", "780.97", "790.92", "276.7", "E942.1", "789.09" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12934, 12983	4964, 10494	322, 329	13063, 13063	3401, 4941	14773, 16103	2065, 2317		11838, 12911		13004, 13004		10945, 11815			13214, 14750										2332, 2713																			10515, 10919									263, 284											357, 1304								13023, 13042				13078, 13190			1326, 1826	1842, 2049				2738, 3382
8,259	123,628	20680+57186	Discharge summary	report+addendum	Admission Date: [2200-4-27] Discharge Date: [2200-5-2] Date of Birth: [2173-1-6] Sex: F Service: Inpatient [Hospital1 139] Medicine HISTORY OF PRESENT ILLNESS: Patient is a 27-year-old female with past medical history significant for depression status post recent hospitalization and for cerebral palsy, who presents after an overdose of Tylenol and Tylenol PM. Per report, the patient took approximately 30 tablets of Tylenol PM and 15 tablets of regular Tylenol on the night prior to admission. The patient's father last saw the patient at approximately 11 p.m. at which time she was doing well. He found her the next morning at 7 a.m. to be lethargic with nausea and vomiting. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5613], M.D. [MD Number(2) 5614] Dictated By:[Name8 (MD) 4993] MEDQUIST36 D: [2200-5-2] 16:35 T: [2200-5-6] 07:28 JOB#: [Job Number 55228] Name: [Known lastname ], [Known firstname 194] Unit No: [Numeric Identifier 10327] Admission Date: [2200-4-27] Discharge Date: [2200-5-2] Date of Birth: [2173-1-6] Sex: F Service: Inpatient [Hospital1 ] Medicine This is a continuation of the previous dictation. HISTORY OF PRESENT ILLNESS: The father noted that the patient had left a suicide note for him. She was taken to an outside hospital and had a Tylenol level of 282 at 1:51 p.m. The patient was given charcoal and Mucomyst x2, but then she proceeded to vomit it up. At the outside hospital, her ALT was 52, AST 57, and INR of 1.2. She was transferred to the [Hospital1 8] MICU for further management. On admission, the patient was very lethargic and somewhat delirious and protecting her airway. PAST MEDICAL HISTORY: 1. Cerebral palsy with spastic diplegia leading to muscle tightness status post multiple surgeries. The patient is able to ambulate without assistance. 2. Depression with a recent hospital admission. She started seeing a psychiatrist and was started on antidepressants approximately two weeks ago. She says she has been depressed for approximately three months. 3. Anxiety. 4. No prior history of suicide attempts. 5. No history of sexual or physical abuse. MEDICATIONS AT HOME: 1. Zoloft. 2. Klonopin. SOCIAL HISTORY: The patient works as a unit secretary for [Hospital6 5557]. She lives with two roommates that recently moved to live her older brother and father since [4-10]. The patient denies any history of illicit drug use, alcohol use, or smoking. She has a B.A. in Psychology from [State 10328]. FAMILY HISTORY: Her mother died from malignant melanoma in [2193]. PHYSICAL EXAM ON ADMISSION: Blood pressure 133/100, heart rate 82, respiratory rate 26, and oxygen saturation of 97% on 2 liters by O2. Temperature 99.0. In general, the patient is following some commands and able to answer yes and no questions. She is very sedated and difficult to understand. The patient is a thin female. HEENT examination: Pupils are equal, round, and reactive to light. Mucous membranes are moist. Cardiovascular examination: Regular rate and rhythm. Chest was clear to auscultation, but poor patient effort. Abdominal examination: Soft, nontender, and nondistended with no masses and positive bowel sounds. Extremities: Warm with no lower extremity edema. Neurologic examination: Difficult to determine secondary to patient's mental status. Pupils are equal, round, and reactive to light. Face is symmetric. She wiggles her toes to commands and squeezes hands to commands. LABORATORIES ON ADMISSION: Notable for an INR of 1.4. Potassium of 1.3. Blood sugar of 140. ALT is 210, AST is 209. Serum Tylenol level 194. Serum tox screen is negative and urine tox screen is negative. Chest x-ray is negative for pneumonia. EKG shows sinus rhythm with a prolonged QTc of 467. She also has a biphasic T in V2. HOSPITAL COURSE: 1. Tylenol overdose: The patient was transferred from an outside hospital to the MICU with Tylenol and Benadryl overdoses. It is estimated that patient took at least 15 grams of Tylenol and at the time of presentation, her Tylenol level was within the toxic range. Toxicology and Liver consults were called upon admission to the MICU. The rise in transaminases and INR early were concerning, but it was felt that the patient came to treatment early. She was started N-acetylcysteine 3.5 grams IV q.4h. The patient then had a second peak in her LFTs from Tylenol toxicity with peak ALT of 3,912, AST 3,326, and INR of 1.9. As per the Liver service, it is possible to develop a second peak in the LFTs following Tylenol overdose. During this time, her mental status remained clear without asterixis. Within 24 hours, her LFTs and INRs quickly improved and at the time of discharge, her INR was 1.2. She never met Kings College criteria to suggest the need for liver transplant. The patient never developed renal failure or hypoglycemia. She received greater than 17 total doses of N-acetylcysteine IV. 2. Mental status: On admission, the patient was extremely lethargic. She was felt to be protecting her airway, however, and did not require intubation. It was felt that the lethargy was most likely secondary to Benadryl, from the Tylenol PM overdose, and from Ativan, which was given at the outside hospital. Her mental status returned to baseline in the MICU within one day of admission and her mental status remained clear throughout the remainder of the hospitalization. 3. Psychiatric: On admission, Psych was consulted. As per their recommendations, she was placed on one-to-one sitters at all times. She was also taken off all her home psychiatric medications including Zoloft and Klonopin. Psychiatry planned for inpatient psychiatric admission following resolution of her medical issues. 4. Prolonged QTc: The patient had a prolonged Q-T on admission presumably from Benadryl overdose. He was initially followed with daily EKGs and telemetry. The patient's Q-T normalized, and she had no events on telemetry. Telemetry was stopped prior to discharge. 5. Nausea: The patient was nauseous on admission, which was due to Tylenol overdose. She was treated symptomatically with Zofran and metoclopramide. At the time of discharge, the patient was no longer nauseous. 6. Pericarditis: The patient was noted to have diffuse ST elevations on EKG. The patient, however, never developed any chest pains or shortness of breath. Cardiology was curbsided and they agreed with the diagnosis of asymptomatic pericarditis. An echocardiogram was obtained to rule out any pericardial effusion and there was no effusion seen on echocardiogram. Since the patient was asymptomatic, there was no need for further intervention. DISCHARGE CONDITION: Hemodynamically stable. Ambulating. INR normalized. LFTs returning to normal. DISCHARGE STATUS: Patient is discharged to an inpatient psychiatric facility. DISCHARGE DIAGNOSES: 1. Tylenol overdose with ensuing liver dysfunction. 2. Benadryl overdose. 3. Prolonged Q-T from Benadryl overdose. 4. Depression. 5. Suicidal intention. 6. Asymptomatic pericarditis. DISCHARGE MEDICATIONS: 1. Docusate 100 mg p.o. b.i.d. 2. Senna 8.6 mg p.o. b.i.d. 3. Metoclopramide 10 mg p.o. q.6h. prn nausea. FOLLOWUP: 1. The patient is asked to followup with her primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 10329] in [1-31] weeks. 2. The patient is asked to followup with her psychiatrist following discharge from the inpatient psychiatric facility. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 661], M.D. [MD Number(2) 1515] Dictated By:[Name8 (MD) 1433] MEDQUIST36 D: [2200-5-2] 16:44 T: [2200-5-6] 08:07 JOB#: [Job Number 10330]	[ "E950.4", "311", "276.5", "423.9", "E950.0", "965.4", "799.4", "963.0", "343.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]				6861, 7022			2668, 2738	7043, 7227	7250, 7899					3990, 5106								2307, 2332																																											1328, 1802										3664, 3973		5122, 6839		3440, 3649	1824, 2286	2349, 2651
20,581	111,832	5460	Discharge summary	report	Admission Date: [2162-6-9] Discharge Date: [2162-6-29] Date of Birth: [2109-9-4] Sex: M Service: CARDIOTHORACIC Allergies: Erythromycin Ethylsuccinate Attending:[Last Name (NamePattern1) 1561] Chief Complaint: 52 yr old male w/ tracheobronchial malacia w/ stent placement in [2162-5-24]. Now admitted on [2162-6-9] for tracheobronchoplasty and right upper lobe wedge volume reduction. Major Surgical or Invasive Procedure: Awake bronchcoscopy, right thoracotomy tracheobronchoplasty and right upper lobe wedge resection for volume reduction. History of Present Illness: 52 yr old male w/ PMHX significant for COPD, tobacco history with tracheobronchomalacia. Admitted for tracheoplasty w/ marlex mesh. Past Medical History: Chronic Obstructive Pulmonary Disease, recurrent bronchitis infections, Gastric Esophogeal reflux disease, Hypercholesterolemia, s/p Left arm levator repair, trachealbronchomalacia. Social History: LIves on [Location (un) ] w/ his wife. [Name (NI) 1403] in a hotel and part-time as actor. + smoker 30 years 1ppd, quit [2156]. Family History: Uncle- emphysema [Name2 (NI) ] history of lung cancer Physical Exam: Well appearing slightly obses male in NAD HEENT: PERRL, EOMI, No cervical or supraclavicular lymphadenopathy. Resp: CTA bilat, equal but diminished. Chest: symmnetrical Heart: RRR S1, S2, no murmur ABD: soft, NT, ND, +BS Extrem: no C/C/E Neuro: Alert and oriented x 3. no focal neurologic deficits. Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2162-6-27] 04:33AM 10.9 4.27* 12.2* 36.4* 85 28.7 33.6 13.4 310 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2162-6-27] 04:33AM 310 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2162-6-27] 04:33AM 94 16 0.9 137 3.9 97 30* 14 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2162-6-27] 04:33AM 9.2 5.1* 2.1 RADIOLOGY Preliminary Report CHEST (PA & LAT) [2162-6-28] 10:02 PM CHEST (PA & LAT) Reason: ?PTX [Hospital 93] MEDICAL CONDITION: 52 year old man with s/p trachoplasty and right lung bleb resection NOW WITH H-VALVE REASON FOR THIS EXAMINATION: ?PTX HISTORY: Post-tracheoplasty and right bleb resection. ? PTX. PA AND LATERAL CHEST (THREE RADIOGRAPHS): This examination is essentially unchanged from study done 11 hours earlier on same day. Right chest tube, a portion of which may lie within the minor fissure. Small right apical PTX and possible _____small basal PTX. Extensive right subcutaneous emphysema. Bilateral upper lobe emphysema with associated vascular attenuation. Heart normal size without vascular congestion and I doubt the presence of consolidation. There are minor pleural changes and probable atelectasis in the right lung. IMPRESSION: No short interval change. Small right PTX. Severe upper lobe emphysema. DR. [First Name (STitle) ] M. [Doctor Last Name ] Brief Hospital Course: Pt was admitted on [2162-6-9] for tracheoplasty and right lung volume reduction. Operative course was uneventful. Pain was managed by epidural. Placed on imperic levoflox. POD#[1-24]: Bronch post op w/o evidence of malacia. Chest tubes w/ persistant air leak on SXN. POD#3: pt developed increasing SQ air in chest, face, neck. Persistant large air leak from chest tube -kept to SXN. Diet and activity progressed, cont'd encouragement for pul hygiene. POD#[4-27]: cont'd air leak but resolving SQ air. Epidural d/c'd and started on PCA. POD#6: pleuradesis w/ doxycycline. POD#[7-31]: peristant but diminished air leak. started on benzodiazepines for anxiety r/t prolonged hospital stay d/t persistant air leak. Chest tube remains to SXN. Progressing w/ ambulation and pul hygiene. POD#10; Chest tube placed to water seal w/o adverse effects but w/ small intermittant air leak. POD#11: worsening SQ air with chest tube on water seal-placed back to SXN. POD#[1-4] no change in air leak. Moderate bilateral LE edema d/t dependent positioning of lower extremities. Started on aldactone (already on lasix) and [Male First Name (un) ] stockings. Repeat doxycycline pleuradesis by interventional pulmonology w/ conscious sedation d/t pain. and Bronchcoscopy d/t tenacious green secretions- sputum C+S sent. Chest tube back to water seal w/ small intermittant persistant air leak. POD14-18-Chest tube in place to water seal w/intermittent air leak, afebrile, ambulation ad lib. POD#19- Pleurovac replaced w/ Heimlick valve w/ sputum trap connected for small amount of drainage. CXRY post Heimlick valve placement showed unchanged/slight improvement. POD#20- Pt discharged to home in stable condition w/ chest tube and Heimlick valve in placed to be managed by [Location 22108] and wife. [Name (NI) 22109] provided to patient for self and VNA. VNA referral for pulmonary rehab. Appt w/ [Last Name (NamePattern4) 22110], MD; [7-6]/at 12 noon. Medications on Admission: Flovent 110", protonix 40', speriva', albuterol prn Discharge Medications: 1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 1 Refills:1 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 1 Refills:0 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:1 1 Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 11. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO bid () as needed for abundant secretions. Disp:60 Tablet Sustained Release(s) Refills:1 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). Disp:120 Tablet(s) Refills:0 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:0 14. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once a day for 10 days. Disp:10 10 Refills:0 15. Hydromorphone HCl 2 mg Tablet Sig: [1-24] Tablet PO every four (4) hours as needed for pain: take 30 minutes prior to percocet for pain . Disp:60 Tablet(s) Refills:0 16. Ativan 1 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. Disp:60 Tablet(s) Refills:0 17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 14 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: tracheoplasty, right lung volume reduction, doxycycline pleuradesis x2 Discharge Condition: good Discharge Instructions: Call Dr.[Name (NI) 1816] office for: fever, redness or drainage at incision site, chest pain, shortness of breath. Resume medications as taken prior to hospitalization except for strovent and spiriva- Call Dr.[Name (NI) 6005] office on instructions for these inhalers. Resume inhalers on medication list. Take new pain medication as directed. Dilaudid 1mg 30 minutes before taking percocet. YOu may shower by covering chest tube and valve area w/ saran/cling wrap around abdomen. No tub baths. Refer to Heimlick Valve instruction sheet for care of Heimlick valve Empty collection cup at Heimlick valve as needed. Speak to [Location 22108] for Pulmonary REhab resources and phone numbers. Followup Instructions: Call Dr.[Name (NI) 1816] office for appointment in 1 week. [Telephone/Fax (1) 170].[7-6] at 12noon. Call Dr.[Name (NI) 6005] office for when your next appointment with him should be. Completed by:[2162-6-29]	[ "998.4", "E849.7", "E878.8", "518.0", "300.01", "512.1", "530.81", "492.0", "041.89", "519.1" ]	icd9cm	[ [ [] ] ]	[ "98.15", "32.29", "33.48", "33.22", "31.79", "96.05", "33.24", "34.92" ]	icd9pcs	[ [ [] ] ]	7256, 7317	3044, 5020	483, 603	7431, 7437	1537, 2124	8186, 8418	1144, 1203		5122, 7233	2161, 2246	7338, 7410		5046, 5099			7461, 8163										1218, 1518																												261, 445	2275, 3021										631, 764															786, 969	985, 1128
21,202	190,599	30430	Discharge summary	report	Admission Date: [2143-3-31] Discharge Date: [2143-5-31] Date of Birth: [2090-7-16] Sex: M Service: MEDICINE Allergies: Cefepime Attending:[First Name3 (LF) 3913] Chief Complaint: Dyspnea on Exertion, Fatigue, Low grade fever Major Surgical or Invasive Procedure: R-CVL by IR Pericardiocentesis Bone marrow biopsies x4 R neck biopsy L PICC line placement diagnostic thorocentesis by IP bronchoscopy x2 History of Present Illness: Mr. [Known lastname 47367] is a 52 year old man with no major medical problems who presented to the emergency room with shortness of breath and worsening dyspnea on exertion. For the past month, he has noticed increased bruising, and for the past week, he has noticed nosebleeds at night and bleeding gums, as well as ulcerations on his tongue. He developed progressive dyspnea on exertion, which prompted an admission to [Hospital ] Hospital, at which time his hematocrit was noted to be 16. He received 4 units of pRBC's and his bone marrow was aspirated (results pending). He was discharged home and told his bone marrow results would be available on Tuesday. The day prior to admission at [Hospital1 18], he complained of worsened dyspnea and band-like chest pain across his chest, at which time his wife insisted that he come to [Hospital1 18]. . He denies recent weight loss, but has noticed a low-grade temperature over the past week, along with night sweats, chills, and diffuse abdominal pain (no associated nausea, vomiting, diarrhea). He has had a headache which responds to ibuprofen. During his hospitalization at [Hospital ] Hospital, he developed a rash after receiving a blood transfusion. He has also noticed a non-tender ulceration on his penis, which developed within the last week. His wife notes that his color has improved dramatically since receiving the blood transfusions. Past Medical History: s/p multiple back surgeries, including cervical spinal fusion s/p basal cell carcinoma removal Nephrolithiasis Hypercholesterolemia Had cardiac cath in [2134] (per report, was "clean", after failing multiple thallium stress tests) Chronic numbness and neuropathic pain of left upper extremity/chest Social History: Lives in [Location 14840] with his wife. They have three children (ages 24, 22, and 18). He works as a technician for [Company 22957], with some exposure to lead; crawls around office buildings and below houses and may have had asbestos exposure. + tobacco history (1 ppd x "many" years, not currently). Social EtOH, no drugs. Sexually active with one partner, wife, no extramarital sexual exposures. No previous STD's. Family History: Mother died suddenly in her 70's, father died of cancer, unknown type (with visible tumors across his body). One sister with thyroid cancer, brother with diabetes, sister with [Name (NI) 5895] Disease. Physical Exam: Vitals: T 97.9, BP 122/72, HR 67, RR 18, Sat 94% on 2L (documented, but when seen he was off oxygen) Gen: Pale appearing, no acute distress HEENT: EOMI, PERRL, ?petechiae on uvula Neck: Supple, no thyromegaly Nodes: No cervical, supraclavicular or subclavicular lympahdenopathy appreciated; shottly inguinal lymphadenopathy L>R Heart: RRR, normal S1/S2, no m/r/g Lungs: Clear to auscultation bilaterally Abd: Soft, non-tender, non-distended, normal bowel sounds; no hepatosplenomegaly appreciated Back: No spinal tenderness, no costovertebral angle tenderness GU: Painless chancre on left side of penis, between shaft and head of penis, draining purulent material Ext: No clubbing/cyanosis/edema Neuro: A&O x 3 Pertinent Results: . CXR [3-31]: CHEST, TWO VIEWS: No prior for comparisons. Cardiac, mediastinal, and hilar contours are within normal limits. Linear atelectasis is seen at the left lung base. Mild blunting of the left costophrenic angle is also seen. Right costophrenic angle appears clear. Splenic shadow is not well identified. No pneumothorax. No fractures are seen. IMPRESSION: Linear atelectasis left lung base and probable tiny left pleural effusion. . CXR [4-1]: Comparison with the previous study done on [2143-3-31]. Minimally increased streaky density at the left base appears more confluent than on the earlier study. The heart and mediastinal structures are unremarkable in appearance as before. The bony thorax is grossly intact. IMPRESSION: Minimally increased density at the left base which may represent evolving pneumonia. Follow up recommended. Brief Hospital Course: Mr. [Known lastname 47367] is a 52 year old male with no major past medical history who presented with dyspnea on exertion, fatigue, and easy bruisability, and was found to be pancytopenic. He was intially admitted to the general medicine team. The morning after admission the pt triggered for a drop in SaO2 to 83% RA. He came up to 95% on 4L. CXR showed possible LLL PNA. The pt was started on cefepime. As his peripheral smear showed blasts, he was then transferred to the BMT service. On the day of admission to the BMT service ([2143-4-3]) he complained of chest pain and had diffuse ST elevations on EKG. Stat ECHO showed a pericardial effusion although he had no pulsus paradoxus. He was dgiven oxygen and transferred to the cath lab for urgent pericardiocentesis. They removed over 300mL of fluid and those cultures were negative. He then recovered in the MICU. His pericardial drain was removed the next day. He was then transferred back to the BMT service. # pericardial effusion/tamponade: As described above, ECHO showed these results. He underwent a pericardiocentesis to drain the fluid and it did not reacumulate based on several surveillence ECHOs. # pleural effusion: left sided. This was thought to be related to malignancy and to his initially pericardial effusion. The pleural effusion persisted throughout admission. He had a diagnostic thorocentesis by IP which removed 30ml of bloody fluid. No infectious source was found in the fluid. # AML: (M7). He was intially given 7+3 idarubicin and cytarabine chemotherapy to induce remission with the plan to have a donor allo transplant. His day 14 bone marrow showed continued hypercellular marrow. He was reinduced with HIDAC on [4-22]. His counts continued to remain very low for an extended period of time. His course was complicated by febrile neutropenia. He was started on cefepime but developed a rash. This was biopsied by dermatology and found to be a drug rash. He was switched to aztreonam and continued to spike temps. More antibiotics were added including vancomycin, levofloxacin and several different antifungals including caspofungin, micafungin, voriconazole, posaconazole, ambisome. He had several reactions to these antifungals including rash (likely with caspofungin and micafungin) and elevated LFTs. As his counts returned, a repeat bone marrow preliminarily showed a sick marrow but no obvious evidence of leukemia. The antibiotics were pealed back and he was discharged on voriconazole alone (see details below). He also developed mucositis which required morphine PCA and TPN for malnutrition. On the day of discharge, he was told that a bone marrow donor was likely found. # suspected fungal pneumonia: He continued to spike temperatures on several antibiotics. All of his cultures were negative. His chest CT and xrays showed patchy infiltrates. A beta glucan retured at 161; galactomanin was negative. Pulmonary and ID were following as consult teams. THe patient had a BAL which was negative except for 3 colonies of yeast among large amounts of oral flora. The yeast was thought to be contamination per pathology. Given the elevated beta glucan and the fact that he defervesced on antifungal therapy, it was thought that he likely had a fungal infection and was discharged on voriconazole. #) Elevated LFTs: This was attributed to his antifungal therapies. He seemed to have elevations with posaconazole and ambisome the most. He was sent out on voriconazole. He had two MRIs of the liver (one while still neutropenic and one after his counts recovered) to rule out obvious fungal infections in the liver; both were negative. He should have his LFTs monitored closely as an outpatient while on voriconazole. # Chest Pain: He has a history of cervical spinal fusion surgery and chronic left-sided chest pain. He was intially ruled out for AMI with negative cardiac enzymes and had a negative CTA to rule out PE. His chest pain persisted throughout admission and moved around his chest, was pleuritic in nature. This was thought to be related to resolving pleural effusions as well as a suspected fungal pneumonia especially after his counts returned. # Penile ulceration. No history of extramarital affairs, no previous STD's. Differential included primary syphilis, lymphogranulosum venereum (although very rare), skin ulceration secondary to trauma and worsened by neutropenia. This last diagnosis was likely the cause. All infectious test were negative (RPR, GC/chlamydia). He was treated with a course of ciprofloxacin and azithromycin and the ulcer healed. # renal lesion: Incidentally found on chest CT initially and a renal ultrasound also could not characterize it will. Radiology felt it might appear to be a papillary RCC, but recommended a renal MRI to fully evaluate. This needs to be followed up as an outpatient. Follow up: -Monitor LFTs -Follow up final bone marrow results -Follow up donor information -Renal MRI to evaluate renal lesion Medications on Admission: Meds: Multivitamin Lipitor 20mg daily . Discharged from [Location (un) ] on the following: Augmentin 875-125mg daily Ciprofloxacin 500mg [Hospital1 ] Folate 1mg daily Discharge Medications: 1. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp:60 Tablet(s) Refills:0 2. MS Contin 15 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO every twelve (12) hours. Disp:60 Tablet Sustained Release(s) Refills:0 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 4. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO Q3-4H (Every 3 to 4 Hours) as needed. Disp:30 Tablet(s) Refills:0 5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for nausea or insomnia. Disp:30 Tablet(s) Refills:0 6. PICC line care PICC line care per CCS protocol 7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. Disp:30 Tablet(s) Refills:0 9. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ensure Plus Liquid Sig: One (1) PO four times a day. Disp:120 Refills:0 Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary diagnosis: AML s/p 2 cycles of 7+3 induction and HIDAC reinduction pericardial effusion/tamponade febrile neutropenia suspected fungal pneumonia pleural effusion penile ulceration abnormal LFTs malnutrition Discharge Condition: vital signs stable. Oxygen saturation above 92% on RA. Tolerating oral intake. Discharge Instructions: You were admitted with AML and have received chemotherapy. You white blood cell counts have returned. Your course was complicated by fevers and a suspected fungal infection in your lungs. You are being sent out on voriconazole antifungal medication to take twice a day. Please discuss with Dr. [Last Name (STitle) ] when you should stop taking this medication. You will likely need another CAT scan of your chest to evaluate the pneumonia. You have also been given pain medications to take. You should take 30mg of MS contin twice a day and hydromorphone for breakthrough pain. As your pain improves, you should decrease the MS contin to 15mg twice a day- please speak to your doctor about tapering this down. Do not drive while on this medication. Pain medications can cause constipation. You are being given some suggestions to help control constipation: docusate stool softner, senna or bisacodyl as laxatives. You should NOT take your lipitor (atorvastatin) because your liver enzymes are elevated and this medication can interact with the liver. You should notify your physician or go to the emergency room if you have fevers >101, chills, shortness of breath, chest pain, nausea or vomiting, lightheadedness, bleeding in the gums or blood in the urine or stool or black or tarry stools or any other symptoms which are concerning to you. Followup Instructions: Please follow up Monday on the 7 [Hospital Ward Name 1826] outpatient clinic at 10:30AM. Dr. [Last Name (STitle) ] will see you on Monday in 7 [Hospital Ward Name 1826] and schedule your next appointment at that time. Completed by:[2143-6-2]	[ "288.00", "117.9", "484.7", "263.9", "593.9", "528.00", "707.14", "607.89", "794.8", "E930.5", "420.90", "197.2", "780.6", "693.0", "205.00" ]	icd9cm	[ [ [] ] ]	[ "34.91", "33.24", "41.31", "38.93", "37.21", "37.0", "99.04", "99.05", "99.15", "99.25", "86.11" ]	icd9pcs	[ [ [] ] ]	10781, 10833	4527, 9397	315, 455	11092, 11173	3645, 4504	12573, 12834	2691, 2898		9751, 10758		10854, 10854		9551, 9728			11197, 12550										2913, 3626										9408, 9525																		230, 277											483, 1903								10873, 11071							1925, 2229	2245, 2675
70,858	124,813	50620	Discharge summary	report	Admission Date: [2118-6-10] Discharge Date: [2118-6-13] Date of Birth: [2061-8-12] Sex: F Service: MEDICINE Allergies: Nsaids Attending:[First Name3 (LF) 348] Chief Complaint: ETOH withdrawal Major Surgical or Invasive Procedure: Central line placement of right internal jugular vein History of Present Illness: Mr. [Known firstname ] [Last Name (NamePattern1) 105353] is a 56 year old woman, patient of Dr. [Last Name (STitle) ], with Hepatitis C, chronic pancreatitis, and depression p/w epigastric pain radiating to her back. She was in her prior state of health until today when she started with nausea, vomit, abdominal pain and tremors, so she was concerned about "DTs" and came to the emergency room. She had been drinking a pint of vodka daily for >1 month until around 2 AM she wooke up bilous vomiting (non-bloody) and with epigastric pain radiating towards her back, similar to the one she always has with her pancreatitis. She also noted chills, and lightheadedness. She tried taking POs, but vomited the fluid immediately. She has also been having watery diarrhea, without any blood during the last days. She tried treating her symptoms with alcohol this AM without improvement. . In the ER her initial VS were: T 98.9 F, HR 92 BPM, BP 165/118 mmHg, RR 18 X', SpO2 99%. She was very anxious and tremolous that ER could not get an IV. She was very ill-appearing, ronchi in bases, RUQ pain, warm extremities. She underwent RIJ placement without complications in subsequent CXR. her initial labs were significant for Lactate of 5.4 that imrpoved to 2.3 with hydration. Her CBC was at her baseline without any leukocytosis, her BMP7 was significant for glucose of 156 and a gap of 17 with bicarbonate of 28. Her AST & ALT were slighlty elevated (108 and 55) respectively with a ratio of 1.9, alk phos 133, TB 1.1, amylase 387, lipase 130, and there was negative tox screeen. She received a total of 3 L NS for hydration, thiamine, folic acid, MVI, and a total of 30 mg of IV valium for alcohol withdrawal. She received a total of 992 143/65 97% RA. Past Medical History: 1. Historical diagnosis of Bipolar D/O though due to patient's long history of alcohol dependence it is unclear at this time if she has a substance induced mood disorder vs primary psychiatric disorder 2. s/p multiple breast lumpectomies. 3. Chronic pancreatitis s/p ERCP with sphincterotomy and stent placement at [Hospital1 2177] [8-15]; Multiple pancreatitis attacks in the past. Treatment at [Hospital1 112]. 4. s/p CCY 5. h/o L4 compression fracture with LBP 6. Alcohol dependence 7. Hepatitis C: afp [5-17] 8.0, no previous treatment 8. Ectopic pregnancy with surgical correction, received blood transfusion 9. TAB 10. h/o head trauma/skin laceration with 2 wk hospitalization following domestic abuse incident with former partner. 11. Benzodiazepine dependence and h/o overdose 12. h/o overdose on ultram in suicide attempt 13. Chronic LBP 15. Sleep disorder 16. HTN 17. H/o Stealing narcotics for which she was incarcerated and failing narcotic testing in [Company 191] recently. Psych: psychiatrist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1617] @ [Hospital3 ] [Telephone/Fax (1) 62327] 18. Ankle fracture - injured [January 2117], s/p surgery . 19. Bipolar disorder with anxiety, depression. Followed at NWH. Social History: Lives by herself in [Location (un) ], on disability. Boyfriend is former alcoholic but now clean for > 20 yrs. + long history of EtOH and polysubstance abuse, but reports only using EtOH at this point. Current smoker + [2-12] pack cigarettes per day x 30 years. Denies current IV drug use, cocaine, marijuana, heroin. Family History: Sister and father- alcoholic Mother - HTN, died of unclear reasons (pt cited possible seizure?) Sister newly diagnosed with cancer of unclear etiology (had neck mass?) Physical Exam: VITAL SIGNS - Temp 98.3 F, BP 161/96 mmHg, HR 74 BPM, RR 105 X', O2-sat 99% RA GENERAL - well-appearing woman in NAD, african american, comfortable, appropriate, jaundiced (skin, mouth, conjuntiva), tremors in both arms and hands at baseline HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, dry MM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - mild biasliary crackles, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - midl HSM, no pain while pressing with stethoscope, increased bowel sounds EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [6-15] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait 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: [2118-6-12] 05:40AM BLOOD WBC-4.3 RBC-3.25* Hgb-10.8* Hct-31.4* MCV-97 MCH-33.1* MCHC-34.2 RDW-14.5 Plt Ct-118* [2118-6-12] 05:40AM BLOOD Glucose-77 UreaN-5* Creat-0.6 Na-143 K-3.9 Cl-107 HCO3-28 AnGap-12 [2118-6-11] 05:36AM BLOOD ALT-35 AST-63* LD(LDH)-215 AlkPhos-86 TotBili-1.0 [2118-6-12] 05:40AM BLOOD Mg-2.0 [2118-6-10] 01:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: Patient was observed in ICU upon admit for high BZD requirement. In the ICU did not require much BZD. Transferred to floor next morning. Abdominal pain improved and tolerating full liquids. Taken off narcotics and given tramadol with good relief. Discharge on HD #2 with prescription for tramadol and # 3 tablets clonazepam until her appointment on Wednesday with her PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ]. At the time of discharge she had minimal abdominal pain, was taking full liquids and was ready to go home. She was also given a prescription for oral ondansetron as needed for nausea. Dr. [Last Name (STitle) ] will need to follow up the final read of the CT abdomen she had performed in the ER as this was still pending at the time of discharge. Medications on Admission: Citalopram 40 mg Daily Folic acid 1 mg PO Daily Clonidine 0.1 mg PO TID Oxcarbazepine 6000 mg PO Daily Quetiapine 200 mg PO QHS Clonopin 1 mg PO TID Discharge Medications: 1. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Quetiapine 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:15 Tablet(s) Refills:0 8. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:15 Tablet, Rapid Dissolve(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute on chronic pancreatitis Alcohol withdrawal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with abdominal pain and alcohol withdrawal. You improved rapidly. You should not drink any alcohol. Follow up with Dr. [Last Name (STitle) ] on Wednesday, it is imperative that you make this appointment. Slowly advance to a regular diet as you are able to tolerate. You were given 15 tablets of tramadol for pain, which worked well for you. Followup Instructions: Department: [Hospital3 249] When: WEDNESDAY [2118-6-15] at 3:25 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4131], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "296.80", "V58.69", "577.0", "291.0", "303.01" ]	icd9cm	[ [ [] ] ]	[ "94.62", "38.93" ]	icd9pcs	[ [ [] ] ]	7237, 7243	5488, 6271	282, 338	7336, 7336	5036, 5465	7874, 8201	3788, 3958		6471, 7214		7264, 7315		6297, 6448			7487, 7851										3973, 5017																												227, 244											366, 2126												7351, 7463			2148, 3429	3445, 3772
46,335	114,333	35451	Discharge summary	report	Admission Date: [2101-7-17] Discharge Date: [2101-7-26] Date of Birth: [2030-2-22] Sex: M Service: MEDICINE Allergies: Lyrica / Ambien Attending:[First Name3 (LF) 759] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is a 71 yo man with h/o IPF, followed by Dr. [Last Name (STitle) ], who presents with one week history of worsening SOB. Per the patient and his family, his symptoms began last Tuesday when he developed a sore lesion on the right side of his buttock. He was seen by his PCP, [Name10 (NameIs) 1023] started him on Cefalexin for possible bacterial infection. Shortly thereafter, as he was unable to take deep breaths secondary to the pain from this lesion, he began to experience increased shortness of breath and a non-productive cough. Over the past few days, he has had increased dizziness and his O2 sats dropped to the low 70s and high 60s (baseline in the 80s on 2L O2 at home). Yesterday, he had a low-grade fever of 100.2 and an episode of fecal incontinence. Per the patient, he has also been experiencing a "tingling" sensation in his legs for the past three days, and he had an associated mechanical fall last night while walking to the kitchen. Given concerns over these events, the patient's wife and daughter brought him to the [Name (NI) ] this morning. . Of note, the patient was diagnosed with IPF in [2100-12-26]. He had biopsies performed at [Hospital1 2177] and is currently followed by Dr. [Last Name (STitle) ]. Per the patient, he has had a significant clinical decline since this time and was most recently hospitalized at [Hospital3 3583] in [2101-1-23] for PNA. . In the ED, his VS were T 98.2, P 109, BP 118/65, R 20, O2 87% on 3L. He was had 3 word dyspnea and was placed on 4L, and his O2 sat increased to 91-92%. CXR showed new area of opacity in LUL, so he was started on Ceftriaxone and Levofloxacin for CAP. . On the floor, the patient continues to complain of increased SOB and tingling in his legs. He admits to increased lower back and abdominal pain, as well as difficulty swallowing for the past three days. Finally, he states that he has had increased urinary retension over the past week. Past Medical History: Idiopathic Pulmonary Fibrosis (FVC 1.6, FEV1 1.53, FEV1/FVC 96%, DLCO 42% pred) Trigeminal Neuralgia Hyperlipidemia h/o Duodenal Ulcer h/o Rheumatic fever Borderline DM2 Appendectomy Tonsillectomy Lumbar spinal fusion in [10-2] Social History: He was previously a welder and he designed [Holiday ] ornaments with his wife. [Name (NI) ] currently lives with his wife in [Name (NI) 8072], MA. He never smoked, though he was exposed to significant second hand smoke as a child. No drugs, occ EtOH. Family History: The patient's sister and mother died from lung disease (unclear history). No h/o CAD. Physical Exam: Vitals: T: 98.4, BP: 118/70 P: 104 R: 29 O2: 90% on 4L General: Three-word dyspnea, AAOx3, in obvious respiratory distress. HEENT: PERRL, EOMI, oropharynx clear, dry mucous membranes Neck: Supple, JVP not elevated, no LAD, clear use of accessory muscles Lungs: Diffuse crackles over all lung fields CV: Tachycardic, sinus rhythm. Normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, soft, diffusely tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley in place Ext: 3/5 strength in [Name Prefix (Prefixes) ] [Last Name (Prefixes) 6816]. warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: erythematous ulcerated rash in the S2-S3 dermatomal distribution Pertinent Results: ADMISSION LABS: . [2101-7-17] 01:20PM BLOOD WBC-12.4* RBC-4.26* Hgb-13.5* Hct-40.0 MCV-94 MCH-31.6 MCHC-33.6 RDW-14.2 Plt Ct-230 [2101-7-17] 01:20PM BLOOD Neuts-89.2* Lymphs-8.0* Monos-1.9* Eos-0.6 Baso-0.2 [2101-7-17] 01:20PM BLOOD Plt Ct-230 [2101-7-17] 05:03PM BLOOD PT-13.5* PTT-23.2 INR(PT)-1.2* [2101-7-17] 01:20PM BLOOD Glucose-135* UreaN-31* Creat-0.8 Na-137 K-4.0 Cl-98 HCO3-26 AnGap-17 [2101-7-17] 05:03PM BLOOD Calcium-8.7 Phos-2.9 Mg-2.5 [2101-7-17] 06:10PM BLOOD Type-ART pO2-60* pCO2-36 pH-7.51* calTCO2-30 Base XS-5 Intubat-NOT INTUBA Comment-O2 DELIVER [2101-7-17] 01:28PM BLOOD Lactate-1.6 . . PERTINENT LABS/STUDIES: Hct: 40.0 -> 35.4 WBC: 12.4 -> 10.5 -> 14.6 BNP: 163 . Micro: CSF: 93 WBC (4 PMNs, 38 L, 51 Monos), TProtein: 98, Glucose 122 DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final [2101-7-19]): POSITIVE FOR VARICELLA-ZOSTER VIRUS. Viral antigen identified by immunofluorescence. REPORTED BY PHONE TO P.KIZHA ON [2101-7-19] AT 11:15 CC7D. . Pending labs: [Doctor First Name ] ANCA Anti-GBM BAL Cultures CSF Cultures CXR ([7-17]): Worsening interstitial opacities, more confluent in the LUL. Although these changes may be related to worsening nterstitial lung disease, a superimposed pneumonia in the left upper lobe cannot be excluded. CT Chest ([7-17]): 1. No evidence of central, lobar or segmental pulmonary embolism or acute aortic syndrome. 2. Moderately progressive worsening of pulmonary fibrosis without focal consolidations. MRI L-Spine ([7-18]): 1. Enhancement of the cauda equina extending from L3 to L5 consistent with arachnoiditis. 2. No evidence of cauda equina or spinal cord compression. Brief Hospital Course: The patient is a 71 yo man with IPF, who presents with a one-week history of worsening hypoxia and found to have zoster of S2-S3 and lumbar arachnoiditis (likely [12-27] VZV) causing weakness in hip flexion bilaterally. . #. Ideopathic Pulmonary Fibrosis: The patient has a h/o IPF, which was diagnosed 6 months ago. He was seen by pulmonary as an inpatient who felt his shortness of breath to likely be an IPF exaxerbation, but also considered superimposed PNA or viral infection. He has had increasing hypoxia over the past week, with recent ABG of 7.51/36/60/30. He is currently taking Prednisone, Acetylcystine, and Azathioprine and his prednisone was increased to 60 mg [Hospital1 ], but will be tapered down to 40 mg daily over a 3 week course. CXR showed new LUL infiltrate for which he was started on ceftriaxone and levofloxacin, later narrowed to levofloxacin. He has significant desats on even mild exertion to the mid to high 70s. During his time in the hospital, his O2 sats improved. Upon admission, he desatted to the low 70's when he stood up. Now, he can take 10 steps before having to rest, and his sats stay in the low 80s. His new O2 requirement is, however, higher than before. He reports using 2L at rest and 3L with activity, and now it appears he needs 4-5L at rest. He will still be continued on his Mucomyst, Azathioprine, and Prednisone, and Bactrim for PCP [Name Initial (PRE) 1102]. He finished his course of Levo in the hospital, and will require 2 more week of Acyclovir PO after being discharged. His current respiratory status is much improved from admission and likely represents his new baseline. . # Zoster: The patient developed an ulcerated lesion in his coccyx several days before presenting to the hospital. It developed into an expanding rash in the S2,S3 dermatomal distribution early in his hospital stay. He was seen by Derm and ID who swabbed the rash and determined it to be Zoster. He was started on a 10 day course of IV Acyclovir, the last day of which is [7-29]. The rash is only minimally painful now and much improved from the first few days after it developed when the patient described [9-3] pain. . # Arachnoiditis - Likely cause for fecal incontinence and BLE weakness. CSF labs are consistent with viral etiology as there was an elevated WBC with a predominance of lymphocyte with elevated protein and normal glucose; varicella PCR came back positive, HSV PCR pending. Varicella zoster is likely etiology given the patient's current active dermatologic manifestation and presence of immunosuppression. He was initially on ceftriaxone, ampicillin but bacterial cultures were negative. He was started on a 10 day course of IV Acyclovir, the last day of which is [7-29]. He BLE weakness has improved and he feels more steady walking than he did before admission, however, he does not have full strength. He also has more sensation in BLE than before. He still does not have control of his bowels and reports daily episode of fecal incontinence, but reports having a much better sense of when he's about to go than before and feels like this is continually improving. . # Code: DNR/DNI, discussed with palliative care. The patient understands that if a situation were to occur that required intubation, given his underlying lung disease, there is a very small chance that he would ever be extubated. With this knowledge the patient and his family agree that he would be better off as DNR/DNI. This was discussed at length with the medical team and palliative care team present. Medications on Admission: Acetylcysteine 600 mg TID Alendronate 70 mg qweek Azathioprine 25 mg daily Lorazepam 0.5 mg qhs prn Percocet 1-2 tablets q4-6h prn for pain Pantoprazole 40 mg daily Prednisone 40 mg daily Simvastatin 80 mg daily Calcium 600 mg daily Colace 100 mg [Hospital1 ] Multivitamin Omega-3 Fatty Acids 1000 mg daily Bactrim 400 mg-800 mg M/W/F Cephalexin 500 mg qid Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Tablet(s) 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 4. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Six Hundred (600) mg Miscellaneous TID (3 times a day). 5. Azathioprine 50 mg Tablet Sig: 0.5 Tablet PO once a day. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Prednisone Taper Please take prednisone according to this schedule: [7-26] - [7-31]: take 60 mg in the AM, 60 mg in the PM [7-31] - [8-4]: take 60 mg in the AM, 40 mg in the PM [8-5] - [8-9]: take 40 mg in the AM, 40 mg in the PM [8-10] - [8-14]: take 40 mg in the AM, 20 mg in the PM [8-15] and onwards: take 40 mg one time daily 16. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day): Please give prednisone according to attached taper schedule. 17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 18. Morphine 10 mg/5 mL Solution Sig: Five (5) mg PO Q6H (every 6 hours) as needed for pain, SOB. 19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 20. Acyclovir Sodium 500 mg Recon Soln Sig: Seven Hundred (700) mg Intravenous Q8H (every 8 hours) for 4 days: Please continue IV acyclovir q8hrs until [2101-7-29]. 21. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO 5 times/day for 12 days: Please give from [7-30] - [8-10] . Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: Primary Diagnosis: Idiopathic Pulmonary Fibrosis Exacerbation VZV encephalitis . Secondary Diagnosis: Type II Diabetes Trigeminal Neuralgia s/p gamma knife therapy Hyperlipidemia h/o Duodenal Ulcer h/o Rheumatic fever s/p Appendectomy s/p Tonsillectomy s/p Lumbar spinal fusion in [10-1] Discharge Condition: Good, afebrile, saturating well on 5 L of O2 Discharge Instructions: You were seen at the [Hospital1 69] on [2101-7-17] because you were found to have worsening shortness of breath, a painful rash on your bottom, and weakness in your legs. This was worrisome for an infection in your lungs or worsening of your IPF and for reactivation of the virus that causes chicken pox. While you were here, we put in an intravenous line into your arm so that we could give you fluids and medicines. We gave you an antiviral medication called Acyclovir to treat the viral infection and an antibiotic called Levofloxacin for your potential pneumonia. We also did a number of lab tests to give us a better idea of what was going on. We gave you your normal home medications while you were here. We found that you had reactivation of your varicella, or chicken pox, infection (aka shingles) that was causing the rash on your left buttock. This was also affecting your spinal cord, which caused your leg weakness and fecal incontinence. We also found that your O2 sats were low because of either an infection in your lungs or worsening of your IPF or most likely both. The medications we gave you improved your rash and leg weakness and your O2 sats increased as well. While you were here, we increased your dose of Prednisone. We are now in the process of lowering the dose to your normal home dose of 40mg PO Daily. We are also continuing you on the acyclovir that we started in the hospital. Please continue to take it as prescribed. Please take prednisone according to this schedule: [7-26] - [7-31]: take 60 mg in the AM, 60 mg in the PM [7-31] - [8-4]: take 60 mg in the AM, 40 mg in the PM [8-5] - [8-9]: take 40 mg in the AM, 40 mg in the PM [8-10] - [8-14]: take 40 mg in the AM, 20 mg in the PM [8-15] and onwards: take 40 mg one time daily Please continue the acyclovir according to this schedule: Until [7-29] - acyclovir 700 mg IV every 8 hours [7-29] - [8-10] - acyclovir 800 mg PO 5 times a day If you experience the following symptoms: increased shortness of breath, fever/chills, new cough, chest pain, worsening leg weakness, fecal or urinary incontinence, or any other worrisome symptoms, please contact your PCP or go to the Emergency Department. Followup Instructions: Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2101-8-15] 11:30 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2101-8-15] 11:30 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. (Pulmonary) Phone:[Telephone/Fax (1) 612] Date/Time:[2101-8-15] 12:00 Please make an appointment to see your PCP [Last Name (NamePattern4) ] [2-28] weeks.	[ "053.19", "272.4", "515", "V45.79", "350.1", "518.81", "532.90", "787.6", "V58.65", "053.0", "250.00", "V45.4", "486" ]	icd9cm	[ [ [] ] ]	[ "33.24", "03.31" ]	icd9pcs	[ [ [] ] ]	11849, 11931	5465, 9048	283, 290	12267, 12314	3720, 3720	14615, 15163	2857, 2946		9460, 11826		11952, 11952		9074, 9437			12338, 14592										2961, 3701																												236, 245											318, 2301			12054, 12246				3736, 5442	11971, 12033							2323, 2557	2573, 2841
55,163	167,775	37760	Discharge summary	report	Admission Date: [2103-1-25] Discharge Date: [2103-1-31] Date of Birth: [2049-12-27] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 64] Chief Complaint: Left Hip Pain Major Surgical or Invasive Procedure: Revision Left Total Hip Arthroplasty History of Present Illness: Patient is a 53 yo M with a history of left hip pain. In [Month (only) 205] [2101] the patient underwent a primary left total hip replacement for osteoarthritis. Apparently, the patient had problems with perioperative bleeding and low platelet counts. The patient states he did well for the first month postoperatively but noted persistent left hip pain. At this point, he rates his pain at rest as [7-17] and with activity and weightbearing as [9-16]. He has to use supports to ambulate. The patient was finally diagnosed with a mechanically loose femoral component. He has no evidence of infection. He requires a revision of the femoral component for stabilization and pain relief. He presents for revision left THA. Past Medical History: PMH: Anxiety, COPD, HTN, possible CHF PSH: Left primary THA on [2102-6-14]. The patient also had a motorcycle accident back in [Country 6257] in [2071] which required extensive surgery. Social History: Married but presently unemployed. He smokes half a pack or more for the past 40 years. He does not take alcohol. Family History: Noncontributory. Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Left Lower Extremity: * Incision healing well with staples * Moderate serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength TA/GS/[Last Name (un) 938]/FHL * SILT DP/SP/T/S/S * Toes warm, 1+ DP pulse * 1+ pedal edema Pertinent Results: [2103-1-25], AP pelvis. FINDINGS: Comparison is made to prior study from [2103-1-25]. There has been placement of a left revision total hip arthroplasty. There are no signs for hardware-related complications. Lateral surgical skin staples are seen. There are mild to moderate degenerative changes of the right hip with spurs and mild joint space narrowing. [2103-1-27], CTA chest: 1. No evidence of pulmonary embolism noting the limitations or motion artifact and incomplete distal arterial branch filling. 2. Focal patchy right upper and middle lobe opacities suggesting bronchopneumonia in the appropriate clinical setting. 3. Ascites and suspected splenomegaly. An abdominal ultrasound examination is recommended to evaluate further, as well as correlation with clinical factors, given that intrinsic liver disease is a distinct possibility. 4. Small lung nodules (the larger of two measuring 4 mm). According to the [Last Name (un) 8773] society guidelines, if there are no special risk factors for malignancy such as a history of smoking or known prior malignancy, then follow-up is probably unnecessary. Otherwise a chest CT could be considered for surveillance in one year. [2103-1-26] 05:08AM BLOOD CK-MB-6 cTropnT-<0.01 [2103-1-26] 10:59AM BLOOD CK-MB-6 cTropnT-<0.01 [2103-1-27] 04:11AM BLOOD CK-MB-6 cTropnT-<0.01 [2103-1-25] 06:13PM BLOOD WBC-20.3# RBC-3.59 Hgb-10.0* Hct-30.1* MCV-84 MCH-27.9 MCHC-33.3 RDW-15.0 Plt Ct-122* [2103-1-25] 06:13PM BLOOD Glucose-139* UreaN-18 Creat-0.6 Na-137 K-4.7 Cl-109* HCO3-21* AnGap-12 Calcium-8.2* Phos-4.5 Mg-1.5* [2103-1-26] 05:08AM BLOOD WBC-18.1* RBC-3.01* Hgb-8.6* Hct-25.4* MCV-84 MCH-28.7 MCHC-34.0 RDW-15.6* Plt Ct-94* [2103-1-26] 05:08AM BLOOD PT-17.3* PTT-34.4 INR(PT)-1.5* [2103-1-26] 05:08AM BLOOD Glucose-127* UreaN-20 Creat-0.8 Na-136 K-5.2* Cl-108 HCO3-22 AnGap-11 Calcium-8.6 Phos-4.1 Mg-2.2 [2103-1-27] 04:11AM BLOOD WBC-7.9# RBC-2.96* Hgb-8.6* Hct-24.9* MCV-84 MCH-28.9 MCHC-34.4 RDW-15.5 Plt Ct-56* [2103-1-27] 04:11AM BLOOD Glucose-139* UreaN-16 Creat-0.6 Na-136 K-4.3 Cl-105 HCO3-28 AnGap-7* Calcium-8.3* Phos-2.3# Mg-1.9 [2103-1-28] 06:46AM BLOOD WBC-12.3# RBC-3.25* Hgb-9.4* Hct-27.6* MCV-85 MCH-28.9 MCHC-34.0 RDW-15.3 Plt Ct-103# [2103-1-28] 06:46AM BLOOD PT-14.6 PTT-29.3 INR(PT)-1.3* [2103-1-28] 06:46AM BLOOD Glucose-124* UreaN-25* Creat-0.8 Na-137 K-4.6 Cl-103 HCO3-27 AnGap-12 Calcium-8.9 Phos-4.0# Mg-2.0 [2103-1-29] 03:51AM BLOOD WBC-11.2* RBC-3.15* Hgb-9.2* Hct-27.0* MCV-86 MCH-29.3 MCHC-34.2 RDW-16.1* Plt Ct-124* [2103-1-29] 03:51AM BLOOD Glucose-142* UreaN-37* Creat-1.0 Na-139 K-4.6 Cl-104 HCO3-26 AnGap-14 Calcium-8.2* Phos-4.2 Mg-2.0 [2103-1-30] 07:25AM BLOOD WBC-5.2# RBC-2.88* Hgb-8.4* Hct-25.0* MCV-87 MCH-29.1 MCHC-33.5 RDW-16.4* Plt Ct-91* [2103-1-31] 06:40AM BLOOD WBC-4.8 RBC-3.04* Hgb-8.8* Hct-25.9* MCV-85 MCH-28.8 MCHC-33.7 RDW-15.9* Plt Ct-102* [2103-1-31] 09:10AM BLOOD ESR-40* CRP-49.7* Brief Hospital Course: In preparation for the surgery the patient was crossmatched for 4 units PRBC and several units of platelets for his history of post-operative bleeding and thrombocytopenia. He saw a hematologist preoperatively and workup was negative. He is also MRSA positive and the plan was made to give peri-operative vancomycin. The patient was taken to the operating room on [2103-1-25] by Dr. [Last Name (STitle) ] for a revision left total hip arthroplasty. Please see operative report for details; in short, the femoral component was replaced but the acetabular component was stable and left in place. The surgery was uncomplicated and the patient tolerated the procedure well. However the patient was tachycardic in the PACU and was found to have a K of 7. He was admitted to the MICU for tachycardia and hyperkalemia. He received several transfusions of PRBC and medications to decrease his K. Although his K normalized his tachycardia did not so a PE CT was ordered. Cardiac enzymes were cycled and found to be negative. Chest CT was negative for PE, though pulmonary nodules were noted. The patient was transferred out of the MICU after his tachycardia improved. However, the following day he had an episode of unresponsiveness and was transferred back to the MICU. His unresponsiveness was felt to be secondary to apnea in setting of sedating meds and high probability of OSA. He was transiently placed on bipap but improved quickly. Respiratory and mental status at baseline within several hours and transferred out of the MICU the following morning. He continued to do well. Chest Xrays were negative for PNA though they demonstrated mild edema so his home lasix was restarted. Peri-operative antibiotics and Lovenox for DVT prophylaxis were given as per routine. Since the patient has a history of MRSA he was given peri-operative vancomycin. Pain was controlled initially with a PCA and then transitioned to oral pain meds on POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout his hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. He was afebrile with stable vital signs. The patient's hematocrit was stable, and his pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. There was moderate serosanguinous wound drainage but no sign of infection. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] dressing was placed to facilitate TID dressing changes. The patient progressed well with physical therapy. Post-operative Xrays demonstrated hardware in good position. The patient was discharged to rehabilitation in stable condition. The patient's weight-bearing status is 50% weight bearing on the left lower extremity with posterior hip precautions. A message was left with the patient's PCP [Last Name (NamePattern4) ]. [First Name11 (Name Pattern1) 7422] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] [Telephone/Fax (1) 40575] on [2103-1-31] at 1:00pm with respect to several issues that need follow-up: 1. The patient's new diagnosis of OSA and need for an outpatient sleep study. 2. Imaging evidence of pulmonary nodules which require further workup. 3. Addition of metoprolol to his medications for cardioprotection and heart rate control. Medications on Admission: MEDS: Spiriva, Lasix, Xanax, and oxycodone 15 mg TID for pain. ALL: NKDA Discharge Medications: 1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg Syringe Subcutaneous DAILY (Daily) for 3 weeks: Please take lovenox daily for three weeks. After finishing lovenox take aspirin 325mg daily for an additional three weeks. Disp:21 40mg Syringe Refills:0 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day for 3 weeks: Please take lovenox daily for three weeks. After finishing lovenox take aspirin 325mg daily for an additional three weeks. Disp:21 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stools. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. 8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 9. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing, shortness of breath. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing, shortness of breath. 15. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 16. Hydromorphone 2 mg Tablet Sig: 1 to 3 Tablet PO Q3H (every 3 hours) as needed for Pain: Do not drive, operate machinery, or drink alcohol while taking this medication. As your pain decreases, take fewer tablets and increase the time between doses. Take a stool softener to prevent constipation. Disp:100 Tablet(s) Refills:0 17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<100, HR<60. 18. Alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for anxiety. 19. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital1 3894] Nursing & Rehabilitation Center - [Location (un) 5503] Discharge Diagnosis: Failed Left Total Hip Arthroplasty 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician, [First Name11 (Name Pattern1) 7422] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] at [Telephone/Fax (1) 40575], regarding this admission and any new medications and refills. We have started a cardiac medication called metoprolol. Please follow up with your PCP for blood pressure checks and dosing of this medication. In addition, pulmonary nodules were seen on your chest Xrays and chest CT. Please ask Dr. [Last Name (STitle) ] to help determine the cause of the nodules and any treatment that may be necessary. You have also been newly diagnosed with sleep apnea and you require breathing support while sleeping. You will need an outpatient sleep study and a home CPAP unit. Aquisition of these should be facilitated by Dr. [Last Name (STitle) ]. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may shower starting five days after your incision has stopped draining, but no tub baths or swimming for at least four weeks. No dressing is needed if wound is not draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for three weeks to help prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. Use the [Last Name (un) 84560] dressing and replace the dry sterile dressing three times a day until the wound is no longer draining. It is okay to shower five days after the wound stops draining, but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound three times a day if there is drainage, otherwise remove the [Location (un) ] dressing and leave the incision open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: 50% partial weight bearing on the left lower extremity. Posterior hip precautions. No strenuous activity until follow up appointment. Physical Therapy: ACTIVITY: 50% partial weight bearing on the left lower extremity. Posterior hip precautions. No strenuous activity until follow up appointment. Treatments Frequency: WOUND CARE: Please keep your incision clean and dry. Use the [Last Name (un) 84560] dressing and replace the dry sterile dressing three times a day until the wound is no longer draining. It is okay to shower five days after the wound stops draining, but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound three times a day if there is drainage, otherwise remove the [Location (un) ] dressing and leave the incision open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. Followup Instructions: Provider: [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3260], [MD Number(3) 3261]:[Telephone/Fax (1) 1228] Date/Time:[2103-2-23] 11:20 Completed by:[2103-1-31]	[ "V43.64", "785.0", "496", "287.5", "428.0", "788.20", "V02.54", "E878.1", "327.23", "996.41", "571.5", "401.9", "518.89", "518.0", "285.1", "276.51", "286.9", "276.7", "305.1", "997.1", "276.2" ]	icd9cm	[ [ [] ] ]	[ "00.72", "93.90" ]	icd9pcs	[ [ [] ] ]	11436, 11542	5135, 8772	332, 371	11621, 11621	2115, 5112	16204, 16436	1509, 1527		8897, 11413		11563, 11600		8798, 8874			11798, 14345										1542, 2096	15327, 15471	15493, 15493																										279, 294								15505, 16181			399, 1136												11635, 11774			1158, 1361	1377, 1493
58,128	100,018	16580	Discharge summary	report	Admission Date: [2176-8-29] Discharge Date: [2176-9-6] Date of Birth: [2121-2-13] Sex: M Service: MEDICINE Allergies: Penicillins / Keflex Attending:[First Name3 (LF) 1928] Chief Complaint: Upper extremity weakness Major Surgical or Invasive Procedure: C5-C6 anterior cervical decompression and fusion, C1 tumor removal History of Present Illness: 55-year-old man with diabetes mellitus type 2, hypertension, severe peripheral [First Name3 (LF) 1106] disease s/p R SFA stent angioplasty and L SFA stent placement, congenital pulmonic valve stenosis, CAD s/p BMS stents, diastolic CHF, atrial fibrillation s/p ablation on warfarin, stage 3 diabetic nephropathy, intradural tumor compressing his spinal cord at C1/C2, who was admitted on [2176-8-29] to neurosurgery for anterior cervical decompression at C5/6 fusion ([8-29]) and extradural tumor removal of C1 intradural tumor ([8-30]). The patient was post-operatively managed in the ICU with a dexamethasone taper. He developed a small subdural hematoma ([8-30]) with no new neurologic symptom. Aspirin and heparin SC were restarted. Clopidogrel, for L SFA stent, is scheduled to be restarted on POD#5, [2176-9-4], and warfarin, for atrial fibrillation, to be restarted on [2176-9-9]. Patient was extubated on [9-1], and is coming off a furosemide drip for dCHF. [Month/Day (4) ] is following the patient for a mottled right foot and his recent [Month/Day (4) 1106] procedures. Patient's other medical issues diabetes, HTN, CKD (Cr 1.1), atrial fibrillation (HRs 70s-80s), CAD s/p stent and "chronic hyponatremia" (Na 138) have been stable. Transfer is requested for ongoing management of diastolic CHF. On evaluation in the SICU before transfer, patient was sleeping but arousable, complaining of old back pain and of constipation. Vital signs were stable with O2 saturation 98% on 3L. Past Medical History: (1) Type 2 diabetes mellitus, requiring insulin, and the complications from years of poor glycemic control: -hypertension -severe peripheral [Month/Day (4) 1106] disease -peripheral neuropathy -pressure, venous stasis, and neuropathic ulcers on his right and left lower extremities -stage 3 diabetic nephropathy -renal insufficiency (baseline creatinine 1.5 to 1.7) (2) Atrial fibrillation status post ablation [2169] and [2174], on coumadin (3) Congenital pulmonic valve stenosis status post two childhood surgeries -history of RV failure -history of peripheral edema and anasarca (4) Chronic hyponatremia (5) Chronic low back pain status post car accident (6) Spinal cord meningioma compressing his spinal cord at C1/C2 (7) COPD (8) Coronary artery disease status post stenting [2169] (bare metal stent by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] ([Telephone/Fax (1) 8725])) and repeat stenting at [Hospital1 18] in [2174] (bare metal stent - see d/c summary [2175-2-7]) (9) MI in [2161] Social History: The patient is married and has two adult sons who do not live at home. He lives in [Hospital1 1474], MA. His wife works 60 hours a week, and he is left at home for most of the day. He has been bedbound for several years. A visiting nurse can only come once a week to change the dressings on his lower extremity ulcers. His sons struggle with alcoholism and heroin abuse. His younger son has recently threatened suicide and homicide (against the patient's wife), a source of much stress at home. He used to work as a "bouncer" and in construction, and enjoyed riding his motorcycle. The patient says he tries to keep a positive attitude about his condition. He says he feels depressed, but says he is not interested in therapy or medication for depression. He has not seen his primary care physician [Last Name (NamePattern4) ] 2 years because he will only travel in an ambulance but his PCP's office is in touch with the patient and wife weekly. -[Name2 (NI) ] has a 2 pack per year smoking history for "several years" -He drinks alcohol occasionally, and has never had a problem with alcoholism -He denies recreational or IV drug use Family History: Heart disease in unspecificed family members. Physical Exam: Physical exam on admission: Gen: obese, deconditioned, pain with movement of extremities. Extrem: B LE edema Neuro: Mental status: Awake and alert, cooperative with exam. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Motor: Patient with severe bilateral wasting of muscles of hand. UE's: FI's:[2-1] WE 4+/5 Grip 4+/5 Bi4+/5 Tri 4+/5. RLE: [1-4] PF/DF 0/5 LLE: IP3/5 PF/DF 0/5 Pertinent Results: [2176-8-29] 12:10PM GLUCOSE-94 UREA N-42* CREAT-1.2 SODIUM-133 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-28 ANION GAP-14 [2176-8-29] 12:10PM estGFR-Using this [2176-8-29] 12:10PM WBC-7.6 RBC-3.91* HGB-9.7* HCT-30.5* MCV-78* MCH-24.9* MCHC-31.9 RDW-13.6 [2176-8-29] 12:10PM PLT COUNT-206 IMAGING STUDIES: # C-spine Xray [8-29]: Single lateral view of the cervical spine obtained portably in the OR, labeled #1. C1 through the C4/5 disc space is visualized. The C5 vertebral body is faintly seen -- bony structures lower than this are obscured by overlying soft tissues. However, surgical markers are seen overlying the anterior aspects of the C4-5 and C5-6 disc spaces, from an anterior approach. Support tubing and temperature probles noted. # C-spine CT [2176-8-29]: 1. New interval C5-C6 anterior fusion with intervertebral disc spacer, no immediate hardware complication. Post-surgical changes in the soft tissue with subcutaneous emphysema mostly in the right submandibular region. 2. Mass at C1 level with associated cord compression consistent with known meningioma better described on recent MRI. 3. Soft tissue thickening at the right lung apex, not fully characterized on the current CT. In comparison with CT neck from [2176-8-9], it has increased in size. CT chest is recommended to evaluate this further, if clinically warranted. # Head CT [2176-8-30]: 1. New interval left frontal subdural hyperdense extra-axial fluid collection with new interval subdural subfalcine extra-axial hyperdense fluid collection, indicating subdural hemorrhage, likely post-surgical but clinical correlation recommended. 2. Pneumocephalus with distribution at the basilar cisterns, mostly at the left sylvian fissure, and bifrontally at the falx, likely post-surgical, and additionally in the posterior fossa near the site of the occipital craniotomy. 3. Post-surgical changes with left craniotomy at the occipital bone and laminectomy at C1 with subcutaneous emphysema and hyperdense products, likely post-surgical. 4. Soft tissue hyperdensity at the posterior parietal, occipital soft tissue region, could be small post-surgical hematoma. . # C-spine MRI [2176-8-31]: Status post resection of C1 extradural tumor, likely meningioma with expectorated postoperative changes. No large intraspinal hematoma seen. There remains some persistent narrowing of the spinal canal at C1 level with indentation on the posterior aspect of the spinal cord. Continued followup recommended. Mild spinal cord atrophy could be secondary to chronic myelomalacia. . # LE arterial Duplex [2176-9-3]: The peak systolic velocity involving the native right common femoral artery is 104 cm/sec. Velocities within the superficial femoral artery range from 85 to 234 cm/sec and that within the popliteal artery on the right, is 25 cm/sec. On the left, peak systolic velocity within the common femoral artery is 132 cm/sec, SFA, velocities range from 146-75 cm/sec and that within the popliteal artery is 85 cm/sec. IMPRESSION: Findings as stated above which indicate widely patent common femoral, superficial femoral and popliteal arteries bilaterally. . PATHOLOGY: # C1 tumor [2176-8-30]: Cervical medullary junction tumor: Meningioma, psammomatous subtype (WHO Grade I). The tumor is composed of meningothelial cells with numerous psammoma bodies and collagen deposition with no typical features or mitotic activity. Brief Hospital Course: 55-year-old man with diabetes mellitus type 2, severe peripheral [Month/Day/Year 1106] disease, CAD, diastolic CHF, atrial fibrillation, presented for planned anterior cervical decompression at C5-6 and removal of C1 meningioma. # Cervical myelopathy and meningioma: Patient underwent anterior cervical decompression and C5/6 fusion on [2176-8-29] and removal of C1 meningioma on [2176-8-30]. The patient was post-operatively managed in the ICU with a dexamethasone taper. He developed a small subdural hematoma on [2176-8-30] with no new neurologic symptom. Per neurosurgery recommendations, aspirin and heparin SC were restarted. Clopidogrel, for recent left SFA stent, was restarted on POD#5, [2176-9-4], and warfarin, for atrial fibrillation, is to be restarted on [2176-9-9]. Of note, there was some concern that he had developed LE weakness after his procedure, but after re-evaluation with the neurosurgery team they felt that his strength in his legs were his baseline and this was not a change. He continued to work with PT during his hospitalization. # Diastolic heart failure: The patient experienced an acute exacerbation of his diastolic heart failure likely secondary to significant fluid administration during surgery. He was placed on a furosemide gtt in the SICU, which was transitioned to his home dose of lasix on the floor. At discharge he was slightly under his admission weight of 115kg with O2 sats in the mid 90's on room air. # Peripheral [Date Range ] disease. The patient recently underwent bilateral SFA angioplasties and Left SFA stenting. In preparation for his neurosurgery, the plavix was held pre-procedure and was subsequently re-started on [2176-9-4]. He underwent bilateral arterial ultrasound on [2176-9-3] which demonstrated patent SFA and femoral arteries. # Atrial fibrillation: The patient was not in atrial fibrillation during his hospitalization. Given his need for neurosurgery his coumadin was held. It is scheduled to be restarted 10 days post-procedure ([2176-9-9]). He was well rate controlled at the time of discharge. # DM II. The patient's insulin regimin was adjusted to 50 units of insulin glargine nightly with humalog insulin sliding scale and achieved good control of his blood sugars (FSBS 100-180). # Pressure ulcers. The patient has a 2x2cm right heel full thickness ulcer that was without odor or drainage. A right dorsum small 1x1cm partial thickness ulcer. Wound care nursing consult was obtained. Pressure ulcer care was performed by repositioning, skin cleansing and conditioner application, and cover with ABD and kerlex. # Coping. The pt expressed to some staff members that his mood was poor and he was not coping well after his surgery. He never expressed suicidal ideations. He further expressed that he was extremely frustrated with his hospitalization and his inability to walk and function independently. Discussed the possibility of talking to psychiatrists in the hospital, but he declined. He felt that if these feeling persisted he would pursue further psychiatric care. A number for psychiatric services was provided to him on discharge. # Chronic pain syndrome: The patient was continued on his home regimen of dilaudid 4mg PO Q3H:prn # Chronic hyponatremia. The patient had a history of chronic hyponatremia although his sodium remained between 130-140 during this admission. Medications on Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID: PRN as needed for constipation. 2. Furosemide 10 mg/mL Solution Sig: Sixty (60) mg Injection [Hospital1 ] (2 times a day): Hold for SBP<100. 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<100 or HR<60. 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 8. Petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily): Please apply to leg wounds per wound care orders. thank you! . 9. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation q6H: PRN as needed for shortness of breath or wheezing. 11. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain: Hold for RR<12 or sedation. 12. Simvastatin 10 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. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO q6H: PRN as needed for itching. 15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) g PO BID: PRN as needed for constipation. 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation: hold for diarrhea. 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 18. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for dry mouth, sore throat. 19. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): Please apply to upper forehead and scalp for seborrheic dermatitis (day 1 = [2176-8-11]). Also, please apply to wound on left shin for overlying fungal infection(day 1 = [2176-8-15]). Thank you! . 20. Glycerin (Adult) Suppository Sig: One (1) Suppository Rectal PRN (as needed) as needed for constipation. 21. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for headache: Hold for somnolence. 22. Heparin drip Heparin IV Sliding Scale (please see included scale): Diagnosis: DVT/A-fib, Patient Weight: 114.76 kg, Initial Bolus: 0 units IVP, Initial Infusion Rate: 1450 units/hr, Target PTT: 60 - 100 seconds, . PTT <40: 4600 units Bolus then Increase infusion rate by 450 units/hr, PTT 40 - 59: 2300 units Bolus then Increase infusion rate by 250 units/hr, PTT 60 - 100:, PTT 101 - 120: Reduce infusion rate by 250 units/hr, PTT >120: Hold 60 mins then Reduce infusion rate by 450 units/hr, 23. Insulin sliding scale Glargine 46 units at bedtime; Humalog sliding scale per included sliding scale. Discharge Medications: 1. Hydroxyzine HCl 25 mg/mL Solution Sig: One (1) Intramuscular Q6H (every 6 hours) as needed for pruritis. 2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO Q4H (every 4 hours). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [12-1] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO Q3hr:prn. 13. simvistatin 10mg Qday 14. Petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily). 15. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 16. Outpatient Lab Work Chem 10 to monitor electrolytes and creatinine while taking lasix 17. Turn and reposition off back prn and limit sit time to 1hour at a time using pressure redistribution cushion. Cleanse skin with wound cleanser or NS then pat dry nad apply aquafor to gluteals and legs and feet daily 18. For heel and lateral foot ulcer apply thin layer of duoderm wound gel, cover dorsum and lateral wound with adaptic and heel with gauze followed by ABD pad, wrap iwth kerlix and change daily 19. headrest to occiput with frequent repositioning 20. please remove sutures from posterior neck on tuesday [9-10] [2175] 21. Please start warfarin on [2176-9-9] (post op day 10) and monitor INR prn 22. check weight Qday Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: Cervical myelopathy C1 tumor with cervical myelopathy Acute on chronic diastolic heart failure Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to [Hospital1 18] on [2176-8-29] for worsening upper extremity weakness due to your spinal tumor. You underwent an operation to remove the tumor. You also underwent an operation to decrease the pressure on the spinal cord in your neck. You will need to have the staples out from your surgical site on [2176-9-10], which they will do at your rehab facility. An appointment was made for you to follow up with Dr. [Last Name (STitle) ] in 6 weeks. Please return to the Emergency department for fever, chills, difficulty breathing, worsening upper extremity weakness, or worsening symptoms. Followup Instructions: 1. [Last Name (STitle) ] LAB [Hospital1 18] [Hospital Unit Name ], [Location (un) ] [Location (un) ] surgery Phone:[Telephone/Fax (1) 1237] Date/Time:[2176-9-26] 3:15 2 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD LM [Hospital Unit Name ], [Location (un) ] [Location (un) ] surgery Phone:[Telephone/Fax (1) 2625] Date/Time:[2176-9-26] 4:15 3. Dr. [Last Name (STitle) 47032] [Name (STitle) ] address: [Doctor First Name ] [Hospital Unit Name ] [Location (un) 470] [Hospital Unit Name ] phone: [Telephone/Fax (1) ] appointment: [2176-10-8] 1:15PM 4. Psychiatry Clinic [Hospital1 18] Psychiatry Clinic Please call the bottom number to schedule an appointment if your mood is sad or you are not taking pleasure in life: [Telephone/Fax (1) *]	[ "427.31", "V62.84", "276.1", "250.70", "278.00", "412", "722.71", "403.10", "428.0", "250.40", "336.3", "511.9", "225.4", "746.02", "707.23", "443.81", "682.7", "496", "414.01", "V58.61", "707.07", "250.60", "585.3", "V45.82", "432.1", "428.33", "997.02", "357.2", "536.3" ]	icd9cm	[ [ [] ] ]	[ "03.4", "80.51", "03.09", "38.93", "81.62", "81.02", "84.51" ]	icd9pcs	[ [ [] ] ]	16627, 16709	8204, 11621	305, 373	16848, 16867	4740, 5047	17537, 18401	4204, 4251		14692, 16604		16730, 16827		11647, 14669			16891, 17514										4266, 4280																												241, 267											401, 1937										4294, 4382		4397, 4721			1959, 3019	3035, 4188					5064, 8181
17,802	136,091	29382	Discharge summary	report	Admission Date: [2173-12-14] Discharge Date: [2173-12-26] Date of Birth: [2102-8-12] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 6169] Chief Complaint: Alveolar hemorrhage Major Surgical or Invasive Procedure: Bronchoscopy Intubation Arterial line placement Central line placement Quentin catheter placement History of Present Illness: 71M with MDS, diagnosed in [10-25] treated with prednisone, hydroxyurea, and danzol. He was recently admitted to [Hospital1 18] on [2173-11-30] for community aquired pneumonia requiring brief MICU stay for hypoxia but ultimately discharged on a 7 day course of Levaquin and Cefpodoxime. Induced sputum GS showed gram negative rods and gram positive cocci in pairs, culture was oropharyngeal flora. He had a negative Legionella and PCP smear, and negative rapid flu antigen. During a routine check-up in onc clinic on [2173-12-14], he was noted to be slightly SOB, oxygenating 90% RA. He was then admitted from clinic for possible IV Abx and further work-up. He reports that after his recent dicharge, he had been feeling close to his baseline with minimal shortness of breath. Then on [Holiday ], he began to notice that he was feeling more fatigued. Then on the morning of admission, he notes increased SOB and dyspnea. He is still able to climb the 8 steps to his home without difficulty, but his endurance has decreased. ROS pos for cough productive of bloody sputum (occasionally tinged but sometimes large amts). No fever, chills, rigors. No nausea/vomiting/diarrhea. +rhinorrhea/sore throat. He has been near his grandchildren all of whom have had colds recently. He notes some chest pressure (mostly in right side) associated with shortness of breath, but no chest pain. No PND, sleeps on 1 pillow. He has had no recent travel, no changes in meds. He has eaten several salty meals of fish in last few days. A chest CT was obtained that showed extensive central interstitial pulmonary abnormalities concerning for hemorrhage versus atypical infections. He was diuresed 1.5 L over past 24 hours with slight improvement in his SOB. A bronch was performed on [2173-12-15] and showed alveolar hemorrhage. A few hours after the bronch, his sats dropped to low 90's on NRB (60's on RA) and was felt he should be observed in ICU overnight. Past Medical History: MDS - Chronic MyeloMonocytic Leukemia transformed to AML HTN Gout CAD - s/p CABG in [2161] s/p appendectomy [2162] Social History: He has a 40-pack-year history of cigarette smoking, stopped approximately 15 years ago. He drinks approximately two drinks at night. He worked as a sheet metal cutter. Family History: There is no family history of any underlying hematological disorders. Physical Exam: VITALS: AF 142/67, 70's, 24, 98% on 15L NRB Gen: NAD, breathing comfortably HEENT: Clear OP, MMM, Sclerae is anicteric, no oral lesions. NECK: Supple, JVP not elevated, no cervical adenopathy. CV: RRR; NL S1, S2. + systolic murmur best heard at LSB LUNGS: crackles bibasilar L>R ABD: Soft, NT, ND. NL BS. spleen is palpable, 6-8 cm below the left costal margin, liver edge 2 cm below the right costal margin. EXT: trace edema in lower legs; 2+ DP pulses BL SKIN: No lesions Pertinent Results: [2173-12-14] 09:50AM BLOOD WBC-10.1# RBC-3.05* Hgb-9.2* Hct-27.3* MCV-90 MCH-30.0 MCHC-33.5 RDW-18.1* Plt Ct-54* [2173-12-15] 07:45AM BLOOD WBC-8.3 RBC-3.05* Hgb-9.1* Hct-26.9* MCV-88 MCH-30.0 MCHC-33.9 RDW-18.3* Plt Ct-53* [2173-12-16] 03:47AM BLOOD WBC-5.8 RBC-2.68* Hgb-8.1* Hct-23.9* MCV-89 MCH-30.1 MCHC-33.9 RDW-17.9* Plt Ct-64* [2173-12-16] 03:01PM BLOOD Hct-24.0* [2173-12-17] 04:57AM BLOOD WBC-13.4# RBC-2.46 Hgb-7.2* Hct-21.7* MCV-89 MCH-29.4 MCHC-33.2 RDW-18.2* Plt Ct-72* [2173-12-17] 04:58PM BLOOD WBC-14.8* RBC-2.85* Hgb-8.6* Hct-25.0* MCV-88 MCH-30.1 MCHC-34.4 RDW-17.7* Plt Ct-79* [2173-12-18] 06:20AM BLOOD WBC-17.5* RBC-2.71* Hgb-8.1* Hct-24.1* MCV-89 MCH-29.7 MCHC-33.5 RDW-17.4* Plt Ct-83* [2173-12-18] 05:30PM BLOOD WBC-16.7* RBC-2.75* Hgb-8.1* Hct-24.2* MCV-88 MCH-29.6 MCHC-33.5 RDW-17.4* Plt Ct-83* [2173-12-19] 06:32AM BLOOD WBC-16.8* RBC-2.61* Hgb-7.8* Hct-22.9* MCV-88 MCH-30.0 MCHC-34.2 RDW-17.3* Plt Ct-76* [2173-12-19] 12:15PM BLOOD WBC-14.1* RBC-2.62* Hgb-7.7* Hct-23.2* MCV-89 MCH-29.4 MCHC-33.2 RDW-17.2* Plt Ct-77* [2173-12-19] 04:56PM BLOOD WBC-27.7# RBC-2.38 Hgb-7.1* Hct-23.9* MCV-100# MCH-29.8 MCHC-29.8# RDW-17.1* Plt Ct-181# [2173-12-19] 11:37PM BLOOD WBC-40.0* RBC-2.71* Hgb-8.1* Hct-23.9* MCV-88# MCH-29.8 MCHC-33.7# RDW-16.4* Plt Ct-259 [2173-12-20] 05:00AM BLOOD WBC-10.3# RBC-2.87* Hgb-8.8* Hct-24.2* MCV-84 MCH-30.7 MCHC-36.4* RDW-15.9* Plt Ct-102# [2173-12-20] 09:10AM BLOOD WBC-21.0# RBC-3.47* Hgb-10.6* Hct-28.7* MCV-83 MCH-30.6 MCHC-37.0* RDW-15.5 Plt Ct-135* [2173-12-20] 04:35PM BLOOD WBC-13.9* RBC-3.15* Hgb-9.4* Hct-26.1* MCV-83 MCH-29.9 MCHC-36.1* RDW-16.1* Plt Ct-115* [2173-12-21] 04:30AM BLOOD WBC-13.4* RBC-3.17* Hgb-9.7* Hct-27.3* MCV-86 MCH-30.6 MCHC-35.6* RDW-16.0* Plt Ct-134* [2173-12-21] 02:43PM BLOOD WBC-13.7* RBC-3.13* Hgb-9.6* Hct-27.4* MCV-88 MCH-30.6 MCHC-34.9 RDW-16.4* Plt Ct-117* [2173-12-22] 03:53AM BLOOD WBC-9.4 RBC-2.89* Hgb-8.8* Hct-25.0* MCV-87 MCH-30.5 MCHC-35.2* RDW-16.0* Plt Ct-85* [2173-12-22] 03:45PM BLOOD WBC-9.3 RBC-2.89* Hgb-8.8* Hct-24.9* MCV-86 MCH-30.4 MCHC-35.3* RDW-16.4* Plt Ct-90* [2173-12-22] 09:46PM BLOOD Hct-27.3* Plt Ct-93* [2173-12-23] 04:05AM BLOOD WBC-12.5* RBC-3.60* Hgb-10.6* Hct-31.0* MCV-86 MCH-29.5 MCHC-34.3 RDW-15.9* Plt Ct-122* [2173-12-23] 11:37AM BLOOD Hct-28.0* [2173-12-24] 03:54AM BLOOD WBC-9.3 RBC-3.30* Hgb-9.8* Hct-28.4* MCV-86 MCH-29.8 MCHC-34.6 RDW-15.8* Plt Ct-86* [2173-12-25] 02:14AM BLOOD WBC-5.5 RBC-2.97* Hgb-8.9* Hct-25.3* MCV-86 MCH-30.0 MCHC-35.2* RDW-15.6* Plt Ct-73* [2173-12-25] 12:31PM BLOOD WBC-5.3 RBC-2.90* Hgb-8.9* Hct-24.9* MCV-86 MCH-30.6 MCHC-35.7* RDW-16.0* Plt Ct-61* [2173-12-26] 02:35AM BLOOD WBC-4.4 RBC-3.01* Hgb-9.2* Hct-25.8* MCV-86 MCH-30.6 MCHC-35.7* RDW-15.4 Plt Ct-93* [2173-12-26] 09:39AM BLOOD WBC-3.6* RBC-2.90* Hgb-8.8* Hct-24.9* MCV-86 MCH-30.3 MCHC-35.2* RDW-15.3 Plt Ct-87* [2173-12-14] 09:50AM BLOOD Neuts-41.8* Bands-0.9 Lymphs-12.7* Monos-24.5* Eos-0.9 Baso-0.9 Atyps-18.2* [2173-12-15] 07:45AM BLOOD Neuts-47.5* Lymphs-14.1* Monos-38.4* Eos-0 Baso-0 [2173-12-16] 03:47AM BLOOD Neuts-65 Bands-2 Lymphs-13* Monos-19* Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [2173-12-17] 04:57AM BLOOD Neuts-75* Bands-4 Lymphs-6* Monos-10 Eos-0 Baso-0 Atyps-5* Metas-0 Myelos-0 [2173-12-18] 06:20AM BLOOD Neuts-81* Bands-0 Lymphs-7* Monos-12* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2173-12-20] 05:00AM BLOOD Neuts-51 Bands-1 Lymphs-8* Monos-34* Eos-0 Baso-0 Atyps-5* Metas-1* Myelos-0 [2173-12-21] 04:30AM BLOOD Neuts-80.2* Lymphs-7.7* Monos-11.6* Eos-0.3 Baso-0 [2173-12-23] 04:05AM BLOOD Neuts-86.1* Lymphs-4.5* Monos-9.3 Eos-0.2 Baso-0 [2173-12-24] 03:54AM BLOOD Neuts-92.0* Lymphs-0* Monos-8.0 Eos-0 Baso-0 [2173-12-25] 02:14AM BLOOD Neuts-79* Bands-0 Lymphs-11* Monos-10 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2173-12-14] 09:50AM BLOOD Glucose-168* UreaN-25* Creat-1.5* Na-145 K-3.8 Cl-106 HCO3-28 AnGap-15 [2173-12-15] 07:45AM BLOOD Glucose-85 UreaN-26* Creat-1.4* Na-140 K-3.7 Cl-104 HCO3-27 AnGap-13 [2173-12-16] 03:47AM BLOOD Glucose-127* UreaN-29* Creat-1.5* Na-140 K-4.6 Cl-103 HCO3-24 AnGap-18 [2173-12-17] 04:57AM BLOOD Glucose-133* UreaN-39* Creat-2.4* Na-138 K-4.0 Cl-101 HCO3-24 AnGap-17 [2173-12-17] 04:58PM BLOOD Glucose-138* UreaN-53* Creat-3.4* Na-135 K-4.2 Cl-100 HCO3-21* AnGap-18 [2173-12-18] 06:20AM BLOOD Glucose-116* UreaN-68* Creat-4.0* Na-137 K-4.6 Cl-102 HCO3-21* AnGap-19 [2173-12-18] 05:30PM BLOOD Glucose-137* UreaN-77* Creat-4.9* Na-135 K-4.5 Cl-101 HCO3-19* AnGap-20 [2173-12-19] 06:32AM BLOOD Glucose-119* UreaN-91* Creat-5.4* Na-134 K-4.7 Cl-100 HCO3-17* AnGap-22* [2173-12-19] 12:15PM BLOOD Glucose-164* UreaN-93* Creat-5.5* Na-135 K-4.9 Cl-99 HCO3-16* AnGap-25* [2173-12-19] 04:56PM BLOOD Glucose-359* UreaN-96* Creat-6.1* Na-137 K-5.4* Cl-100 HCO3-7* AnGap-35* [2173-12-19] 07:00PM BLOOD Glucose-362* UreaN-98* Creat-6.5* Na-136 K-5.8* Cl-97 HCO3-13* AnGap-32* [2173-12-19] 11:37PM BLOOD Glucose-731* UreaN-99* Creat-5.8* Na-131* K-4.3 Cl-85* HCO3-25 AnGap-25 [2173-12-20] 05:00AM BLOOD Glucose-694* UreaN-88* Creat-5.3* Na-133 K-3.5 Cl-77* HCO3-41* AnGap-19 [2173-12-20] 09:10AM BLOOD Glucose-85 UreaN-76* Creat-4.9* Na-142 K-3.7 Cl-88* HCO3-39* AnGap-19 [2173-12-20] 11:12AM BLOOD Glucose-72 UreaN-75* Creat-4.8* Na-141 K-3.7 Cl-88* HCO3-39* AnGap-18 [2173-12-20] 04:35PM BLOOD Glucose-104 UreaN-69* Creat-4.6* Na-136 K-4.7 Cl-91* HCO3-33* AnGap-17 [2173-12-20] 10:30PM BLOOD Glucose-138* UreaN-72* Creat-4.7* Na-137 K-5.2* Cl-99 HCO3-24 AnGap-19 [2173-12-21] 04:30AM BLOOD Glucose-150* UreaN-74* Creat-4.7* Na-139 K-5.3* Cl-104 HCO3-19* AnGap-21* [2173-12-21] 09:14AM BLOOD Glucose-158* Na-137 K-5.5* Cl-104 HCO3-15* AnGap-24* [2173-12-21] 02:43PM BLOOD Glucose-125* UreaN-73* Creat-4.4* Na-138 K-5.3* Cl-102 HCO3-16* AnGap-25 [2173-12-21] 08:45PM BLOOD Glucose-141* UreaN-77* Creat-4.5* Na-138 K-5.2* Cl-102 HCO3-19* AnGap-22* [2173-12-22] 03:53AM BLOOD Glucose-104 UreaN-76* Creat-4.3* Na-138 K-5.1 Cl-100 HCO3-20* AnGap-23 [2173-12-22] 09:46PM BLOOD Glucose-106* UreaN-76* Creat-4.1* Na-136 K-4.9 Cl-100 HCO3-21* AnGap-20 [2173-12-23] 04:05AM BLOOD Glucose-105 UreaN-73* Creat-4.0* Na-135 K-4.8 Cl-97 HCO3-20* AnGap-23* [2173-12-23] 11:37AM BLOOD Glucose-136* UreaN-78* Creat-4.2* Na-137 K-4.9 Cl-99 HCO3-22 AnGap-21* [2173-12-24] 03:54AM BLOOD Glucose-111* UreaN-106* Creat-5.8# Na-135 K-4.8 Cl-98 HCO3-21 AnGap-21* [2173-12-25] 02:14AM BLOOD Glucose-123* UreaN-90* Creat-5.6* Na-138 K-4.9 Cl-100 HCO3-24 AnGap-19 [2173-12-26] 02:35AM BLOOD Glucose-155* UreaN-112* Creat-6.7# Na-140 K-5.3 Cl-100 HCO3-21* AnGap-24 [2173-12-14] 09:50AM BLOOD ALT-28 AST-24 LD(LDH)-380* CK(CPK)-42 AlkPhos-25* TotBili-0.4 [2173-12-15] 07:45AM BLOOD ALT-23 AST-23 LD(LDH)-414* AlkPhos-23* TotBili-0.7 [2173-12-19] 04:56PM BLOOD LD(LDH)-705* [2173-12-20] 05:00AM BLOOD ALT-85* AST-131* LD(LDH)-891* CK(CPK)-732* AlkPhos-45 Amylase-182* TotBili-0.6 [2173-12-20] 09:10AM BLOOD LD(LDH)-1297* CK(CPK)-921* [2173-12-20] 04:35PM BLOOD LD(LDH)-1280* [2173-12-21] 04:30AM BLOOD ALT-108* AST-169* LD(LDH)-1475* AlkPhos-49 Amylase-169* TotBili-0.5 [2173-12-21] 02:43PM BLOOD LD(LDH)-1509* [2173-12-22] 03:53AM BLOOD ALT-90* AST-103* LD(LDH)-1364* AlkPhos-42 TotBili-0.6 [2173-12-23] 04:05AM BLOOD ALT-85* AST-77* LD(LDH)-1395* AlkPhos-52 Amylase-108* TotBili-0.8 [2173-12-24] 03:54AM BLOOD LD(LDH)-1317* [2173-12-25] 02:14AM BLOOD LD(LDH)-1151* [2173-12-26] 02:35AM BLOOD LD(LDH)-1022* [2173-12-15] 06:19PM BLOOD [Doctor First Name ]-POSITIVE Titer-1:40 [2173-12-15] 06:19PM BLOOD ANCA-POSITIVE [2173-12-19] 08:53PM BLOOD Lactate-9.9* CXR ([12-14]): Sternotomy and presence of multiple surgical clips mostly in the anterior left-sided mediastinum are typical for previous bypass surgery. The heart appears moderately enlarged, although the cardiac contours are partially obscured by the existing pulmonary parenchymal densities. The latter have mostly central location, a finding which was already observed on previous chest examinations of [11-25], 8 and 11 and which led to the recommendation that the densities indicated cardiogenic pulmonary edema. When comparison is made, it can be stated that the parenchymal densities both in intensity and extension were more extensive on [11-25] and 8 and had regressed on examination [11-29]. They appear unchanged now or may have progressed slightly. Other important observations, however, is the absence of peri-bronchial cuffing and complete absence of any pleural effusion in either lateral or posterior pleural sinuses which sheds some doubt that the densities represent cardiogenic pulmonary edema. Thus an infectious process in this patient with history of MDS appears more likely. CT chest ([12-14]): 1. Extensive perihilar interstitial pulmonary abnormality at least three weeks old, not cardiogenic pulmonary edema, could be diffuse pulmonary hemorrhage, drug toxicity, atypical infections including viral etiologies and pneumocystis, less likely acute interstitial pneumonia because of protracted course. 2. Asbestos-related pleural plaques. Possible mild asbestosis. 3. Tiny noncalcified right middle and upper lobe nodules, difficult to distinguish from extensive background changes, should be reassessed following resolution of more acute process. Echo ([12-15]): The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function appears normal (LVEF 60-70%). 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. There is no ventricular septal defect. 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. Renal U/S ([12-18]): No hydronephrosis bilaterally Torso CT ([12-22]): 1. Interval increase in diffuse ground glass opacities within both lungs with increased consolidation within both lung bases, which may represent worsening pulmonary hemorrhage, inflammatory, or infectious process. 2. Small new right pleural effusion. 3. New ascites. 4. Sigmoid diverticulosis without evidence of diverticulitis. 5. No evidence of retroperitoneal hemorrhage. Head CT ([12-22]): Limited study due to patient's motion. Small hypodensities in the right thalamus and superior aspect of the right frontal lobe, of unknown chronicity. Cerebral and cerebellar atrophy. No evidence of intracranial hemorrhage, mass, or edema. CXR ([12-23]): Lower lung volumes today may account for apparent worsening of diffuse infiltrative abnormality in the left lung. There appears to have been some improvement since [12-20], which may represent a decrease in a component of pulmonary edema rather than the underlying pulmonary abnormality. Mild cardiomegaly is present. ET tube, right jugular and left subclavian lines are in standard placements, and a nasogastric tube ends in the upper stomach and would need to be advanced at least 4 cm to move all the side ports well beyond the gastroesophageal junction. No pneumothorax. Brief Hospital Course: ICU COURSE: 71 y/o M hx MDS recently s/p course Abx for pneumonia who was admitted with SOB, hypoxia and found to have diffuse alveolar hemorrhage on bronchoscopy, developed worsening hypoxia following bronchoscopy. Developed acute renal failure during ICU stay. Had respiratory arrest followed by brief period of asystole. Eventually extubated and discharged to the floor. On floor pt developed acute worsening of hemoptysis with associated hypoxia, was DNR/DNI at time, suctioning of blood unable to overcome obstruction, pt suffered hypoxic respiratory failure and died. See below for further details of hospital course. ## Respiratory failure: Event occurred in the setting of lying flat during Quentin catheter insertion. Pt was c/o increasing shortness of breath. Likely secondary to small amount of volume overload vs. continued alveolar hemorrhage vs. aspiration. Intubated and required high FiO2 early after intubation, but slowly responded to conservative therapy and was eventually weaned off of the ventilator to BIPAP. Considered due to Wegners, v. pulmonary edema from ARF, v. paraneoplastic syndrome. . ## Hemoptysis/renal failure: Initially thought to be paraneoplastic syndrome from his MDS/CMML/AML, less likely either Wegener's granulomatosis (given ANCA positivity) vs. Goodpasture's syndrome (10-40% of pts with Goodpasture's are ANCA positive). Anti-GBM eventually came back negative, essentially ruling out Goodpasture's. ANCA markedly positive. Was on CVVH for short time after intubation, then changed to HD by the time he was discharged to the floor. He was covered broadly for infectious sources with cefepime, azithromycin, vancomycin and voriconazole. In addition, he was continued on methylprednisolone 125 mg IV big after a short time of 250 mg [Hospital1 ]. After many consultations involving both nephrology and oncology, it was decided to treat his CMML/AML aggressively in hopes of keeping his likely paraneoplastic syndrome in check. He was therefore treated with hydroxyurea 1000 mg tid and ARA-C [Hospital1 ]. Plasmapheresis and cyclophosphamide were considered, however, oncology did not feel this was warranted and would likely result in tumor lysis syndrome. ## Anemia/thrombocytopenia: Hct was persistently low despite numerous transfusions. Unlikely GI losses, as he has had no melena or hematochezia. Unlikely [1-21] hemoptysis as there was never [Known firstname ] hemoptysis during his ICU course. Likely [1-21] marrow suprpession. Same for thrombocytopenia. Transfused plateletes and RBCs to maintain >100,000 and 25, respectively. ## MDS: as we thought that his initial presentation was [1-21] to a paraneoplastic syndrome, we treated his malignancy aggressively. He never developed signs of tumor lysis syndrome. Medications on Admission: HOME MEDICATIONS: Amlodipine 5 mg PO DAILY Prednisone 20 mg Daily Atorvastatin 20 mg DAILY Citalopram 20 mg DAILY Atenolol 25 mg QD Hydroxyurea 500 mg QD Danazol 200 mg [Hospital1 ] Omeprazole 20 mg QD Allopurinol 100 mg [Hospital1 ] Meds on Transfer: Allopurinol 100 mg PO BID Amlodipine 5 mg PO DAILY PredniSONE 20 mg PO DAILY Solumedrol 500 mg IV x1 Levofloxacin 500 mg QD day2 Bactrim DS day 1 Voriconazole 200 mg Q12 day 1 Atenolol 25 mg PO DAILY Atorvastatin 20 mg PO DAILY Pantoprazole 40 mg QD Citalopram 10 mg PO DAILY Docusate Sodium 100 mg PO BID Zolpidem Tartrate 5 mg PO HS:PRN Discharge Medications: Deceased Discharge Disposition: Extended Care Facility: [Last Name (un) 14991] - [Location (un) 1411] Discharge Diagnosis: AML Diffuse alveolar hemorrhage. Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased Completed by:[2174-3-29]	[ "518.84", "995.94", "790.29", "401.9", "584.9", "427.5", "486", "205.00", "707.03", "581.9", "274.9", "286.9", "786.3", "V58.65", "428.0", "446.4", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "33.24", "96.04", "99.05", "99.25", "96.72", "93.90", "99.60", "99.04", "39.95", "38.95", "00.17" ]	icd9pcs	[ [ [] ] ]	18587, 18667	15108, 17903	294, 393	18743, 18753	3320, 15085	18810, 18849	2739, 2810		18554, 18564		18688, 18722		17929, 17929			18777, 18787										2825, 3301					17947, 18172																							235, 256											421, 2389															2411, 2535	2551, 2723			18190, 18531
17,518	102,010	54587	Discharge summary	report	Admission Date: [2125-6-11] Discharge Date: [2125-6-19] Date of Birth: [2050-6-24] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: s/p mvc Major Surgical or Invasive Procedure: intubation bilateral chest tubes History of Present Illness: 74 year old male s/p MVC vs tree with a 20 minute extrication, presented to [Hospital ] Hospital with GCS 15 & complaints of SOB/CP. A chest Xray showed bilateral pneumothoraces and bilateral chest tubes were placed. His SBP dropped to 90s and he was intubated and transferred to [Hospital1 18]. Past Medical History: HTN MI Physical Exam: on arrival in the trauma bay: vitals: 99.0, 87, 127/85, 100% intubated, sedated PERRL bilaterally 2->1mm TMs with wax no facial trauma CTAB with bilateral crepitus RRR, s1 s2, abrasions L costal margin Abd soft ND rectal guaiac neg, poor tone abrasions L forearm and L patella on discharge: Gen: elderly gentleman, pleasant, alert and oriented x 4 HEENT: cervical collar in place, PERRL, EOMI, OP clear PULM: poor air movement at bilateral bases, no wheeze, equal BS bilaterally CV: regular with normal S1,S2 ABD: soft, Nontender, nondistended, tolerating PO EXT: moving all four extremities, full weight bearing, able to ambulate and perform ADL NEURO: CN II-XII intact, no focal motor or sensory deficits Pertinent Results: [2125-6-11] CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Reason: TRAUMA Field of view: 40 Contrast: OPTIRAY INDICATION: 74-year-old man with trauma. TECHNIQUE: After administration of IV contrast, a multidetector scanner was used to obtain contiguous axial images from the thoracic inlet to the pubic symphysis. These were then reconfigured and reformatted into coronal and sagittal planes. CT OF THE CHEST WITH IV CONTRAST: The patient is intubated. There is a moderate right pneumothorax and a small left apical pneumothorax. Additionally, some mediastinal air is identified. Bilateral chest tubes are seen; the one on the right traverses through the lung parenchyma and enters the posterior pleural space. The left chest tube also traverses through the lung, and ending adjacent to the pericardium; as previously stated, there is only a small left posterior apical pneumothorax. Small bilateral pleural effusions and bibasilar atelectasis are seen. A minor amount of air extends below the crus of the diaphragm, in association with the mediastinal air. Extensive subcutaneous emphysema is seen on the right; only a small amount is seen on the left. The heart and great vessels are unremarkable; no dissection or pulmonary embolism is identified. There is no pericardial effusion. CT OF THE ABDOMEN WITH IV CONTRAST: A small low density lesion is seen at the dome of the liver, which is too small to characterize, but probably represents a cyst. Two small low density lesions are seen on the right kidney, also too small to characterize, but probably representing cysts. Both kidneys have extrarenal pelves. The spleen, adrenals, and pancreas are unremarkable. An NG tube is seen coiling in the stomach, ending in the pylorus. The imaged bowel is unremarkable, and there is no evidence of vascular compromise. Of note, the infrarenal abdominal aorta is dilated to a maximum diameter of 5.0 x 5.4 cm; there is no evidence of dissection, and the abdominal aorta returns to normal caliber at the bifurcation; however, both iliac arteries are ectatic and mildly dilated. Vascular calcification is seen. Also of note is a moderately stenotic but patent superior mesenteric artery. There is a small amount of fatty infiltration around the gallbladder. CT OF THE PELVIS WITH IV CONTRAST: No fluid is seen within the pelvis. Diverticulosis is present, without evidence of diverticulitis. The collapsed bladder has a thickened wall. A Foley is present. There is an enlarged prostate and fat-containing small inguinal hernias. Several rib fractures are identified on the right, including the anterolateral aspects of #2, #3, #4, #5, #6, #7, #8, #9, and the anterior aspect of the left second rib, in two places. With the left rib fractures, there is a small amount of associated hematoma in the chest wall, and subcutaneous emphysema. There is a small amount of stranding in the right inguinal region, consistent with the patient's recent arterial phlebotomy in that region. Coronal and sagittal reconfigurations were essential in establishing the diagnoses above (MPR value 4). IMPRESSION: 1. No findings to explain patient's hypotension. 2. Bilateral pneumothoraces and mediastinal air, with multiple bilateral rib fractures and subcutaneous air, right greater than left. Chest tubes are also malpositioned. Small bilateral pleural effusions and dependent atelectasis. 3. Infrarenal abdominal aortic aneurysm dilated to a maximum diameter of 5.4 cm, without evidence of dissection. Vascular calcification in the aorta and iliac arteries. [2125-6-11] CT C-SPINE: No fracture is seen. There is separation of the left C3-4 facet joint, possibly representing ligamentous disruption. Degenerative changes are seen at multiple levels. There is no prevertebral soft tissue swelling. The patient is intubated, and a small amount of fluid is noted around the ET tube. Bilateral apical pneumothoraces are noted in the visualized portion of the lung apices. MRI [2125-6-13] of Cervical and thoracic spine. FINDINGS: The widened left C3-4 facet joint space is again demonstrated, with irregularity of the joint space surfaces that correlate with the recent CT scan. The STIR images do not appear to show contiguous edema of the surrounding soft tissues. There is mild infolding of the ligamentum flavum at the C5-6 and C6-7 interspace levels. The bony central spinal canal is quite capacious. Uncovertebral spurring produces moderate right-sided neural foraminal narrowing at C5-6. There is a longitudinally extensive but relatively thin (2 mm to 3 mm) prevertebral soft tissue swelling anterior to the odontoid process and extending down to the C3-4 level. This finding is suspicious for ligamentous injury involving the anterior longitudinal ligament. Adjacent to this region is a 2 cm mass with low T1 and high T2 signal within the midline posterior nasopharyngeal soft tissues. The finding is suspicious for a large Tornwaldt cyst. CONCLUSION: Continued demonstration of distraction of the left C3-4 facet joint complex. The finding could represent a local injury, although the irregularity of the bone surfaces seems more in keeping with a degenerative arthritic process. However, there is prevertebral soft tissue swelling in the upper cervical spine, suspicious for ligamentous injury. The findings, as well as the additional observations noted above were discussed in detail with the trauma resident. MR scan of the thoracic spine was performed using sagittal T1 and T2-weighted images. FINDINGS: There are somewhat linear regions of elevated T2 signal within the upper three thoracic vertebral bodies. However, there is no definite sign of deformation of these bodies to indicate an overt compression fracture. Clearly, when the patient becomes conscious, a detailed physical examination of this area as well as the cervical spine will help to determine whether these findings of abnormal signal could indicate rather subtle trauma. The thoracic spinal canal is capacious. There is no definite sign of spinal cord abnormality appreciated. Within the limits of sagittal imaging, no gross paraspinal pathology is apparent. labs: Brief Hospital Course: Admission to [2125-6-18]: After arrival to [Hospital1 18], the patient was stabilized and transferred to the trauma SICU for further care. The results of his imaging revealed his chest tubes were in good position with no pneumothoracices. His head CT revealed an old infarct but no acute hemorrhage. The CT of his C-spine revealed a C3-C4 facet distraction which was further investigated with an MRI study. Neurosurgery was consulted and this injury was non-operatively managed with a hard cervical collar that should be worn at all times for a total of 6 weeks. After this the patient will have repeat x-rays and follow up with Dr. [Last Name (STitle) 1327] to determine further care. The patient's CT of his torso revealed right and left rib fractures as well as an infrarenal AAA. The patient was referred to Dr. [Last Name (STitle) 3407] of vascular surgery and will follow up as an outpatient for further monitoring of his AAA. During this admission the patient initially was noted to have elevated CK but never had an elevated troponin. An epidural was placed for pain control of the patient's rib fractures. Extubation was attempted on [6-14], but the patient was reintubated secondary to respiratory distress. The patient developed a fever and his chest x-ray indicated he may have developed a ventilator associated pneumonia; therefore he was started on antibiotic coverage with levaquin and vancomycin for a five day course. Blood, urine, and sputum cultures remained negative. The chest tubes remained in place until [2125-6-16]. The patient was successfully extubated on [6-16] and his respiratory function continued to improve. The patient remained afebrile and did well with physical therapy and was able to be transferred to the hospital floor. [6-18] to [2125-6-19]: The patient was tolerating PO, urinating without difficulty, ambulating without assistance. He was discharge to home with outpatient physical therapy services. Medications on Admission: ASA Beta blocker Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:20 Tablet(s) Refills:0 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. Lipitor 10 mg Tablet Sig: [2-4] Tablet PO once a day. Tablet(s) 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: While taking percocet. Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Multiple rib fractures C3-4 facet distraction Bilateral pneumothoraces Hypertension Discharge Condition: Good Discharge Instructions: You need to wear your hard cervical neck collar AT ALL TIMES until you follow up with Dr. [Last Name (STitle) 1327] from neurosurgery. You may take all of your regular medications prescribed by your regular primary care doctor. [Name8 (MD) ] MD for temp >101, persistent pain, nausea or vomiting, headache, numbness, tingling, or weakness in your arms or legs, or any other questions. Followup Instructions: Follow up with Dr. [Last Name (STitle) 1327] in neurosurgery in 6 weeks. Call tomorrow morning to schedule an appointment. The phone number is [Telephone/Fax (1) 1669]. You should also follow up with Dr. [Last Name (STitle) ], vascular surgeon, for your aortic anuerysm. Please call [Telephone/Fax (1) 1241] for an appointment. Follow up with your regular primary care physician by the end of this week. Call today to schedule an appointment.	[ "846.0", "E849.5", "V12.59", "414.01", "E816.0", "807.07", "860.0", "958.7", "412", "486", "401.9", "441.4" ]	icd9cm	[ [ [] ] ]	[ "96.72", "99.04", "04.81", "38.93", "96.71", "34.04", "96.6", "03.90", "96.04" ]	icd9pcs	[ [ [] ] ]	10158, 10241	7641, 9623	322, 356	10369, 10375	1464, 7618	10817, 11282			9690, 10135		10262, 10348		9649, 9667			10399, 10794										736, 1014																	1028, 1445											275, 284											384, 691															713, 721
14,084	167,022	49606	Discharge summary	report	Admission Date: [2160-12-24] Discharge Date: [2160-12-26] Date of Birth: [2089-10-11] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 71 yof with h/o bladder cancer and newly found gastric mass and liver lesions, admitted with FTT x 3 weeks and hypotensive episode after EGD today. Patient states that she has had a caugh for the past 1 day, unsure about fevers at home. She was seen by Dr. [Last Name (STitle) 1266], PCP, [Name10 (NameIs) 1262] and at the time had a low blood pressure and was recommended to [Last Name (un) 5511] the ER but pt declined. Earlier this AM ([12-24]) patient underwent EGD with Dr. [First Name (STitle) 679], received midazolam 0.5mg IV and fentanyl 25mcg IV, subsequently with no measurable blood pressure. She was reportedly 60/30s after 500cc bolus. She came up to 94/47 after 2L NS. She was reportedly pale but alert during the episode. She was transferred to the ED from EGD. . In the ED, her VS were T 96.9, HR 101, BP 94/60, RR 26, O2sat 98% 2L. She was given 2L NS, ceftriaxone 1g IV and azithromycin 500mg po. She had a CXR that showed early LLL infiltrate. CT abdomen with stable R hydroureteronephrosis and fluid overload. . On ROS, she states she has had decreased appetite secondary to nausea and [4-17] lb weight loss in the last 3 weeks. She has had fatigue and malaise x 1 week. She has had no associated N/V, abdominal pain, dysphagia, odynophagia, sick contacts, rash. She denies dysuria or change in urinary frequency but reports dark brown urine x 2 weeks. . Patient was admitted to the Medical floor and was noted to have BP in 80s again, she was also noted to be tachypneic and transferred to the MICU. Past Medical History: 1. Bladder cancer- followed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9125] of Urology, status post intravesical BCG, atrophic right kidney, chronic R ureteral lesion with R hydronephrosis, stenting unsuccessful per pt 2. s/p bilateral cataracts surgery [2150] 3. Osteoporosis. Social History: Lives alone, reports independence with ADLs but assistance with IADLs; + tobacco- ~50pk-yr, quit >20y ago; denies EtOH and drugs . Family History: father died of unknown cancer Physical Exam: Vitals- t 98.4 BP 86/46 HR 116 RR 20 O2sat 93%2L. Pulsus -2 mmHg . General- elderly cachectic appearing woman lying in bed. HEENT- dry mucous membranes, sclare anicteric, op clear. Neck- no JVD Chest - CTAb. CVR - Tachycardic, regular, 3/6 SEM heard throught ?RUB Abdomen - soft, mildly distended, no rebound or guarding Ext - trace edema bilaterally Neuro - A&O X3, able to relay history without difficulty Pertinent Results: Admission labs: WBC 5.7, Hct 13.1, plt 84 Na 136, K 4, cl 105, bicarb 20, BUN 41, Cr 2.4 . Dispo labs include: bicarb 8, Cr 1.6 Plt 62, Fi 79, FDP 80-160, AST 1032, ALT 2121, LD 1600, bili 1.0, AP 282 . EKG: NSR at 114, nl axis, nl intervals. small qwaves inferiorly. low limb lead voltage. . STUDIES: CXR ([12-24])- Question early developing airspace process in the lingular segment. There may be superimposed mild edema or more chronic interstitial lung disease evident. . CT abd/pelv ([12-24], wet read)- 1. New bilateral pleural effusions, small amount of ascites, and free fluid in the pelvis are consistent with volume overload. 2. stable severe right hydronephrosis. 3. diverticulosis without evidence of diverticulitis. 4. hiatal hernia. 5. liver lesions better seen on prior ct with contrast. . CT abd/pelv ([12-17])- 1. Interval worsening of the right-sided hydroureteronephrosis with interval increase in size of a distal ureteral enhancing lesion suspicious for tumor versus progression of scar tissue. 2. Interval development of the gastric antral mass and peri-celiac and intra aorta caval lymphadenopathy is suspicious for gastric adenocarcinoma, less likely lymphoma. In addition, there has been interval development of multiple lesions within the liver, which are suspicious for metastatic disease. 3. Four 1-2 mm nodules in the right lower lobe, which are most likely inflammatory. 4. Colonic diverticulosis without evidence of diverticulitis. . eccho: The left atrium is normal in size. A large probably sessile mass is seen in the body of the left atrium, occupying the majority of the chamber, but does not appear to be occluding the mitral valve. The attachment point is not well-defined, but may be the interatrial septum. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). 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 moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Brief Hospital Course: This is a 71 yof with h/o bladder cancer and recently found gastric mass with liver involvement admitted with hypotension. Ms [Known lastname ] was considered likely to be significantly hypovolemic considering her h/o decreased po intake, her urine electrolyes which were prerenal, and her physical exam including flat neck veins, tachycardia, hypotension. She was felt less likely to be septic given her lack of fever or leukocytosis but was nevertheless treated for CAP. Cortisol stim test revealed appropriate stim. She was aggressively fluid recussitated with near 10L IVF over 36 hrs without improvement in oliguria, tachycardia, or hypotension. She was unfortunately found on ecchocardiogram to have a large sessile mass nearly occluding her right atrium. It became clear that this was likely impairing left heart filling; her LV was noted to be remarkably small and hyperdynamic on eccho which would fit this picture. Ms. [Known lastname ] eventually became quite tachypneic with labored breathing and evidence of pulmonary edema on CXR (although it is likely that her tachypnea was also fueled by her serious metabolic acidosis with a bicarb of 8). She was also noted to have thrombocytopenia and labs consistent with DIC. Because of Ms. [Known lastname 17064] underlying poor prognosis with an atrial mass and likely malignancy, discussions were had with the patient and her nephew [Name (NI) 382] and they decided to not pursue further invasive care such as central line placement and vasopressors. She was made comfort measures only and received only one dose of 2mg morphine for respiratory discomfort and she passed away within 30 minutes with her family at her side. She had met with [First Name8 (NamePattern2) 2270] [Last Name (NamePattern1) 1764] with palliative care the day prior as well as Father [Name (NI) ] from pastoral care. It was an honor to care for Ms. [Known lastname ] in her last days and I wish her family the best. Medications on Admission: Lisinopril 10mg qd (stopped 1 day PTA by Dr. [Last Name (STitle) 1266] Timolol eye gtt Actonel (stopped 1 day PTA by Dr. [Last Name (STitle) 1266] Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Left atrial mass gastric mass metabolic acidosis DIC Discharge Condition: deceased	[ "197.7", "286.6", "276.51", "151.2", "V10.51", "584.9", "733.00", "486", "591" ]	icd9cm	[ [ [] ] ]	[ "45.13" ]	icd9pcs	[ [ [] ] ]	7552, 7561	5323, 7318	330, 336	7657, 7668	2891, 2891		2417, 2448		7523, 7529		7582, 7636		7344, 7500													2463, 2872																												279, 292											364, 1919							2907, 5300								1941, 2253	2269, 2401
63,544	124,914	682	Discharge summary	report	Admission Date: [2140-7-15] Discharge Date: [2140-7-17] Date of Birth: [2077-7-22] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1515] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization with 3 BMS placed in RCA History of Present Illness: Mr [Known lastname 5108] is a 62 year-old man with past medical history of HIV/AIDS, hyperlipidemia, former heavy tobacco use, and prostate cancer s/p brachytherapy, who was transferred from [Hospital1 5109] for STEMI. He reports three hours of substernal chest pain that awoke him from sleep, with associated diaphoresis. At [Hospital1 2436], EKG showed inferior ST-elevations, new from prior in that system from [2133]. He was subsequently transferred to [Hospital1 18] for management of his STEMI. . In the cath lab he underwent a Right radial approach. Found proximal RCA occlusion. Passed wire and baloon inflation with vagal response requireing 1 dose of atrompine and transient hear block. Venous sheath placed but no transveous pacer placed. BP's hung around 100's and response to IVF. Placed 3 BMS in RCA from proximal to distal. Large vessel. Did not have complete resolution of STE with some residual [3-26] CP that is steadily improviong. Has ASA, and PLavix on board and integrillin x18 hours. Will leave venous sheath in for access. Otherwise stable. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, + Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: -CABG: - -PERCUTANEOUS CORONARY INTERVENTIONS: - -PACING/ICD: - 3. OTHER PAST MEDICAL HISTORY HIV: Diagnosed approximately six years ago when the patient presented with pneumocystis pneumonia. He is on HAART. The patient's most recent CD4 count (per patient report) was approximately 300 and his most recent viral load was undetectable. Skin cancer. Prostate cancer s/p brachytherapy in [2139]. Social History: The patient is single and lives in [Location 2199]. He quit smoking in [2139-1-17], after 15 to 20 years of intermittent smoking. The patient does not drink alcohol. He denies current recreational drug use. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On Admission GENERAL: Patient was comfortable and in NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. 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: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: obese abdomen, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Right groin line in place 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+ On Discharge VS: BP90's-100's/60's, P-61, RR-16, 96% on RA GENERAL: Patient was comfortable and in NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No 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. R radial site clean. 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: [2140-7-15] 04:49PM SODIUM-135 POTASSIUM-4.0 CHLORIDE-103 [2140-7-15] 04:49PM SODIUM-135 POTASSIUM-4.0 CHLORIDE-103 [2140-7-15] 04:49PM PLT COUNT-179 [2140-7-15] 09:45AM GLUCOSE-128* UREA N-20 CREAT-1.0 SODIUM-134 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-28 ANION GAP-9 [2140-7-15] 09:45AM WBC-6.5 RBC-4.09* HGB-13.1* HCT-38.2* MCV-93 MCH-31.9 MCHC-34.2 RDW-12.7 [2140-7-17] 06:56AM BLOOD WBC-5.5 RBC-3.79* Hgb-12.6* Hct-36.1* MCV-95 MCH-33.2* MCHC-34.8 RDW-13.1 Plt Ct-178 [2140-7-17] 06:56AM BLOOD Glucose-96 UreaN-14 Creat-1.0 Na-140 K-4.0 Cl-106 HCO3-27 AnGap-11 [2140-7-17] 06:56AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9 [2140-7-16] 05:04AM BLOOD %HbA1c-5.6 eAG-114 [2140-7-16] 05:04AM BLOOD Triglyc-123 HDL-45 CHOL/HD-4.0 LDLcalc-109 Brief Hospital Course: In the cath lab he underwent a Right radial approach. Found proximal RCA occlusion. Passed wire and baloon inflation with vagal response requireing 1 dose of atrompine and transient hear block. Venous sheath placed but no transveous pacer placed. BP's hung around 100's and response to IVF. Placed 3 BMS in RCA from proximal to distal. Large vessel. Did not have complete resolution of STE with some residual [3-26] CP that is steadily improviong. Has ASA, and PLavix on board and integrillin x18 hours. Will leave venous sheath in for access. Otherwise stable. After patient received 3 BMS to RCA, he had an uneventful hospital course. He remained hemodynamically stable. ST elevations on his ECG began to resolve. He was successfullty started on ASA 325mg, atorvastatin 80mg, Plavix 75mg, Metoprolol 12.5 Daily and Lisinopril 2.5. Integrellin was d/c'ed Patient had echo done after cardiac catheterization, which revealed: "The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) secondary to inferior and posterior wall akinesis with focal posterior wall dyskinesis. The right ventricular free wall thickness is normal. Right ventricular chamber size is normal. with severe global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion." Patient complained of no CP on discharge. PT evaluated the patient. He was able to walk briskly with no CP or SOB. While hospitalized, the patient's doxazosin and methyphenidate were held. He was instructed to hold these medications upon discharge. Patient was contact[Name (NI) ] after discharge and a message was left on his cell phone. He was informed that Outpatient Cardiology ([Telephone/Fax (1) 3942] will be contacting him with an appointment in the next 1-2 weeks. During hospitalization, the patient's HIV medications were given at his normal home doses. As a follow-up, the patient will need a repeat echocardiogram to assess interval improvement of LV and RV function. His heart failure meds can be titrated up as tolerated and consider adding spironolactone to his regimen. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from Patient. 1. Atazanavir 300 mg PO DAILY 2. Acyclovir 400 mg PO Q8H 3. LaMIVudine 300 mg PO DAILY 4. RiTONAvir 100 mg PO DAILY 5. Ranitidine 150 mg PO BID 6. Doxazosin 2 mg PO HS 7. Sildenafil Dose is Unknown PO PRN sexual intecourse 8. MethylPHENIDATE (Ritalin) 5 mg PO Frequency is Unknown 9. Fish Oil (Omega 3) 1000 mg PO BID 10. Abacavir Sulfate 600 mg PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Atazanavir 300 mg PO DAILY 3. LaMIVudine 300 mg PO DAILY 4. Ranitidine 150 mg PO BID 5. RiTONAvir 100 mg PO DAILY 6. Abacavir Sulfate 600 mg PO DAILY 7. Aspirin EC 325 mg PO DAILY RX aspirin 325 mg 1 Tablet(s) by mouth daily Disp #30 Tablet Refills:3 8. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 Tablet(s) by mouth once a day before bedtime Disp #30 Tablet Refills:3 9. Clopidogrel 75 mg PO DAILY Duration: 1 Months Your outpatient cardiologist will determine when to stop this medication. RX Plavix 75 mg 1 Tablet(s) by mouth daily Disp #30 Tablet Refills:3 10. Lisinopril 2.5 mg PO DAILY hold: BP<100 RX lisinopril 2.5 mg 1 Tablet(s) by mouth daily Disp #30 Tablet Refills:3 11. Metoprolol Succinate XL 12.5 mg PO DAILY Hold if SBP<90, HR<50 RX metoprolol succinate 25 mg 0.5 (One half) Tablet(s) by mouth daily Disp #20 Tablet Refills:3 12. Fish Oil (Omega 3) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: ST Elevation Myocardial Infarction Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: You came to the hospital with chest pain and were found to have a severe heart attack. This was successfully treated by placing 3 stents in your right coronary artery. Ultrasound of your heart revealed abnormal function. You have been started on several new medications to treat your heart disease. These include: Aspirin 325mg Daily Atorvastatin 80mg Daily Clopidogrel 75mg Daily- you MUST take this medication every day Metoprolol Succinate XL 12.5 mg Daily Lisinopril 2.5 mg Daily Followup Instructions: You need to follow-up with an outpatient Cardiologist. We suggest you contact Dr. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 2037] or Phone: [Telephone/Fax (1) 4105*]. You should make an appointment to see him within the next 1-2 weeks. We will try to arrange this appointment for you. However, if you do not hear from us by tomorrow, please call the office to schedule it yourself.	[ "V15.82", "997.2", "426.12", "V58.83", "042", "414.01", "272.4", "412", "V10.46", "780.2", "410.31" ]	icd9cm	[ [ [] ] ]	[ "99.20", "00.66", "00.47", "00.40", "88.56", "36.06", "37.22" ]	icd9pcs	[ [ [] ] ]	8941, 8947	4899, 7454	315, 366	9026, 9116	4091, 4876	9689, 10128	2251, 2366		7983, 8918		8968, 9005		7480, 7960			9177, 9666										2381, 4072				1595, 2000																								265, 277											394, 1487												9131, 9153			1509, 1575	2016, 2235
42,795	186,904	34582	Discharge summary	report	Admission Date: [2174-9-27] Discharge Date: [2174-10-8] Date of Birth: [2116-10-23] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3190] Chief Complaint: Back pain Major Surgical or Invasive Procedure: ANTERIOR corpectomy T12 with T10-L2 posterior fusion with instrumentation History of Present Illness: 57yo M with non-small-cell lung cancer with metastases to brain and T12, who presents with progressive back and R leg pain. Pt reports that he has been having significant pain over his lower back and behind his right leg for one month. The pain is [5-10] when the patient is seated, but becomes a [11-9] when he stands up. When he stands up, the pain sometimes radiates down to his right foot. Patient cannot replicate this pain by extending his leg while seated. He experiences similar radiating pain when he coughs. Pt describes having pain in the left leg as well, but significantly less than in the right. He experiences partial relief from pain with home oxycodone q6h. Pt denies any sensory deficits over his legs, leg weakness, urinary or fecal incontinence, and difficulty urinating. Pt has also experienced nausea regularly, sometimes with emesis as well. Past Medical History: 1. Inoperable stage IIIB (stage IV by the 7th TNM classification) nonsmall cell lung cancer (adenocarcinoma) diagnosed on [Month (only) ] [2168]. 2. Nonsmall cell lung cancer with metastatic disease (stage IV: multiple lung and pleural metastasis) diagnosed on [2170-10-31]. Tumor was EGFR mutated (exon 19 deletion delE746-A750) and KRAS wild-type. 3. Brain metastases diagnosed on [2173-12-30]. 1. Status post platinum-based chemotherapy (agents and doses unknown but we suspect cisplatin/etoposide) and thoracic radiation (fields and does unknown) in [2168-9-30] attaining a partial response (treatment performed in [Country 651]). 2. Status post erlotinib monotherapy started on [2171-3-1] (at [Hospital1 79384] [[Hospital1 18]]). Doses of erlotinib 25 mg/day from [2-28] to [2171-8-19]; 50 mg/day from [8-20] to [2171-11-4] and 150 mg/day from [11-5] to [2172-1-21]. Initial partial response prior to radiographic progression at the 6-month plus mark of erlotinib therapy. 3. Status post erlotinib 150 mg/day + R1507 (IGF-1R antibody) on [2171-12-31]. 4. Status post 26 cycles of carboplatin and pemetrexed. Status post 6 cycles of carboplatin 5 AUC and pemetrexed 500 mg/m2 from [2172-2-3] to [2172-5-19]. Status post 4 cycles (cycle 7, 8, 9, 10) of single [Doctor Last Name 360] maintenance pemetrexed 500 mg/m2 from [2172-6-9] to [2172-8-25]. Status post 16 cycles (cycle 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26) of carboplatin 2.5->4 AUC and pemetrexed 500 mg/m2 on [2172-9-15], [2172-10-6], [2172-10-27], [2172-11-17], [2172-12-8], [2172-12-29], [2173-1-19], [2173-2-16], [2173-3-9], [2173-3-30], [2173-4-20], [2173-5-11], [2173-6-1], [2173-6-22], [2173-7-13], [2173-8-10], [2173-10-5]. Continued on erlotinib at 25 mg/day. 5. Status post 3000 cGy of radiotherapy to chest wall completed on [2173-12-8]. 6. Status post 3000 cGy of whole brain radiotherapy completed on [2174-3-15]. 7. Erlotinib 25 mg/day from [2171-3-1] to [2174-4-25] (see above for dose changes during the last 3 years). 8. Started erlotinib 100 mg/day and MM-121 20 mg/kg D1, D15 of a 28-day cycle on [2174-4-26]. Status post 2 cycles (last infusion of MM-121 20 mg/kg on [2174-6-7] and last dose of erlotinib 100 mg/day on [2174-6-20]). 9. Re-started erlotinib 25 mg/day on [2174-6-22] to date. Social History: The patient started smoking cigarettes at age 16 and quit at age 50. He smoked one and a half packs per day. This places him at that 68-pack-year history of smoking. No significant alcohol use. Lives with family in MA. From [Country 651]. Family History: Non-contributory Physical Exam: ADMISSION: VS 98.4 120/8- 92 16 100% RA GEN: Alert, oriented, no acute distress, cachectic HEENT: NCAT MMM EOMI sclera anicteric, OP clear and without exudate NECK: supple, no JVD, no LAD PULM: Moderate aeration, CTAB, no wheezes or rhonchi CV: RRR normal S1/S2, no mrg ABD: soft, flat, NT, ND, normoactive bowel sounds, no rebound or guarding BACK: Diagonal scar medial to left scapula, no tenderness to palpation along length of spine EXT: WWP, 2+ radial and pedal pulses palpable bilaterally, clubbing of digits NEURO: CNs [4-11] intact, 5/5 strength in all extremities, no weakness in right leg, 2+ patellar reflexes SKIN: no ulcers or lesions Pertinent Results: ON ADMISSION: [2174-9-27] 06:10PM BLOOD WBC-5.5 RBC-4.40* Hgb-12.5* Hct-38.6* MCV-88 MCH-28.4 MCHC-32.4 RDW-14.5 Plt Ct-396 [2174-9-27] 06:10PM BLOOD Neuts-79.9* Lymphs-14.4* Monos-4.0 Eos-0.9 Baso-0.7 [2174-9-27] 06:10PM BLOOD Plt Ct-396 [2174-9-27] 06:10PM BLOOD Glucose-102* UreaN-11 Creat-0.6 Na-133 K-4.4 Cl-92* HCO3-29 AnGap-16 PRIOR TO TRANSFER TO ORTHO SPINE: [2174-9-30] 04:30AM BLOOD WBC-4.4 RBC-3.60* Hgb-10.4* Hct-31.3* MCV-87 MCH-28.9 MCHC-33.3 RDW-14.4 Plt Ct-378 [2174-9-30] 04:30AM BLOOD PT-11.4 PTT-39.3* INR(PT)-1.1 [2174-9-30] 04:30AM BLOOD Glucose-82 UreaN-10 Creat-0.5 Na-136 K-3.9 Cl-96 HCO3-33* AnGap-11 [2174-9-30] 04:30AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.9 [2174-10-1] 04:55AM BLOOD WBC-3.8* RBC-3.64* Hgb-10.5* Hct-32.1* MCV-88 MCH-28.8 MCHC-32.8 RDW-14.4 Plt Ct-367 [2174-10-1] 10:50PM BLOOD WBC-7.4 RBC-3.85* Hgb-11.7* Hct-33.9* MCV-88 MCH-30.3 MCHC-34.4 RDW-14.3 Plt Ct-225 [2174-10-3] 02:15AM BLOOD WBC-5.1 RBC-2.98* Hgb-9.2* Hct-25.8* MCV-87 MCH-30.8 MCHC-35.4* RDW-14.6 Plt Ct-214 [2174-10-3] 12:43PM BLOOD WBC-5.5 RBC-3.62* Hgb-11.3* Hct-30.8* MCV-85 MCH-31.2 MCHC-36.7* RDW-14.2 Plt Ct-193 [2174-10-4] 02:09AM BLOOD WBC-6.3 RBC-3.00* Hgb-9.0* Hct-25.8* MCV-86 MCH-30.1 MCHC-34.9 RDW-14.6 Plt Ct-182 [2174-10-4] 07:30PM BLOOD WBC-5.5 RBC-2.79* Hgb-8.6* Hct-24.0* MCV-86 MCH-30.6 MCHC-35.7* RDW-15.1 Plt Ct-183 [2174-10-7] 05:02AM BLOOD WBC-5.1 RBC-2.90* Hgb-8.6* Hct-25.7* MCV-89 MCH-29.8 MCHC-33.6 RDW-14.4 Plt Ct-295 [2174-10-8] 10:42AM BLOOD WBC-6.0 RBC-3.50* Hgb-10.2* Hct-30.4* MCV-87 MCH-29.2 MCHC-33.7 RDW-15.6* Plt Ct-362 IMAGING: [2174-9-27] CT Chest IMPRESSION: 1. Progression of multifocal metastasis, including size and number of right lung nodules, lower thoracic spine vertebral metastasis now involving vertebral canal, progression of extensive left pleural and extrapleural tumor and mediastinal invasion. I discussed the findings by telephone with Dr [Last Name (STitle) ] at the time of dictation. Brief Hospital Course: 57yo M with non-small-cell lung cancer with metastases to brain, who presents with worsening back and R leg pain. Imaging on admission demonstrated metastatic disease of T12 with spinal canal involvement, explaining the patient's pain. Although the patient had no focal neurologic symptoms, there was concern for possible cord compression. Patient underwent evaluation by Rad Onc and Ortho Spine Surgery. ACTIVE ISSUES: # Metastatic lung cancer: Patient referred by PCP for evaluation by Radiation Oncology and Ortho Spine Surgery to determine the role of radiation therapy and/or spinal fusion to prevent cord compression. Patient continued erlotinib therapy in the hospital. Due to extensive disease, Radiation Oncology team decided that surgical treatment would be the initial best approach. Patient underwent spine MRI which showed cord compression from tumor at T12. Also showed metastases within the L4 verterbral body. Patient underwent spine surgery on [10-1] and [10-2]. # Back pain: Secondary to metastatic vertebral involvement and cord compression. Pain was well controlled with oxycontin 20 mg [Hospital1 ], acetaminophen 650 mg q6h, and ibuprofen 600 mg tid, with oxycodone for breakthrough. Ibuprofen was discontinued in preparation for surgery. Pain continued to be well controlled. # Nutrition: Patient is cachectic on exam secondary to metastatic disease as well as poor PO intake from nausea. Patient was followed by Nutrition team while in hospital. Nausea was controlled with zofran 8mg PRN. Mr. [Known lastname ] was transferred to the [Hospital1 18] Spine Surgery Service on [2173-9-29] and taken to the Operating Room for a T12 vertebrectomy through an anterior approach. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. He returned to the operating room for a scheduled T10-L2 decompression with PSIF as part of a staged 2-part procedure. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the SICU in a stable condition. Postoperative HCT was low and he was transfered PRBC with good effect. A bupivicaine epidural pain catheter placed at the time of the posterior surgery remained in place until postop day one. He was kept NPO until bowel function returned then diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2 from the second procedure. He was fitted with a TLSO brace for ambulation. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. He will follow up with Heme/Onc for radiation planning and with Dr. [Last Name (STitle) 363] for xrays and a wound check. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain 2. Erlotinib 25 mg PO DAILY Start: In am 3. Senna 1 TAB PO BID:PRN constipation Start: In am Discharge Medications: 1. OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain RX oxycodone 5 mg [1-31] tablet(s) by mouth every four (4) hours Disp #100 Tablet Refills:0 2. Senna 1 TAB PO BID:PRN constipation RX sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #60 Tablet Refills:0 3. Midodrine 5 mg PO TID RX midodrine 5 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 4. Neutra-Phos 1 PKT PO TID RX potassium & sodium phosphates [Phos-NaK] 280 mg-160 mg-250 mg 1 Powder(s) by mouth once a day Disp #30 Tablet Refills:0 5. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation RX polyethylene glycol 3350 17 gram 1 packet by mouth once a day Disp #30 Tablet Refills:0 7. traZODONE 25 mg PO HS:PRN insomnia RX trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime Disp #60 Tablet Refills:0 8. Erlotinib 25 mg PO DAILY Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: T12 metastatic leision Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR corpectomy T12 with T10-L2 posterior fusion with instrumentation Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Ambulate as tolerated in TLSO brace Treatments Frequency: Keep incisions clean and dry/ ambulate as tolerated in TLSO Followup Instructions: Wtih Dr. [Last Name (STitle) 363] in 10 days. Call [Telephone/Fax (1) ] for an appointment. Provider: [Name10 (NameIs) ] [Name8 (MD) 831], MD Phone:[0-0-] Date/Time:[2174-10-25] 11:30 Provider: [First Name4 (NamePattern1) 2353] [Last Name (NamePattern1) ], MD Phone:[0-0-] Date/Time:[2174-10-25] 2:30 Completed by:[2174-11-9*]	[ "V15.82", "162.5", "263.1", "336.3", "198.5", "198.3", "197.2", "338.3" ]	icd9cm	[ [ [] ] ]	[ "81.05", "84.51", "03.90", "80.99", "81.04", "77.71", "77.79", "81.62" ]	icd9pcs	[ [ [] ] ]	11330, 11378	6848, 7254	320, 396	11445, 11452	4801, 4801	13588, 13961	4096, 4114		10339, 11307		11399, 11424		10066, 10316			11476, 11596										4129, 4782	13446, 13482	13504, 13565																11632, 11825										270, 282		7270, 10040					11861, 12316	12328, 13428			424, 1299										4815, 6825					1321, 3819	3835, 4080
40,881	140,137	49298+49299	Discharge summary	report+report	Admission Date: [2177-2-1] Discharge Date: [2177-2-11] Date of Birth: [2120-6-14] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: unstable angina Major Surgical or Invasive Procedure: [2177-2-4] Cardiac catheterization [2177-2-7] 1. Coronary artery bypass grafting x3: Left internal10 mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch of the posterior descending artery. 2. Modified left-sided maze procedure (pulmonary vein isolation) with radiofrequency ablation and the left atrial appendectomy. History of Present Illness: 56 year old male who was admitted [Date range (1) 49803]/10 with atypical chest pain, now readmitted with similar chest pain. On last admission he ruled out for a MI and underwent a MIBI stress test that was negative and remarkable only for enlarged ventricles. He was in intermittent AFib during hospitalization which did not correlate with angina episodes. He was discharged with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts monitor for further evaluation of arrythmias and was to follow up as an outpatient with Dr. [Last Name (STitle) ] for an ablation on [2177-2-25]. He represented to ED on [2177-2-1] with chest pain. He was given SL NTG, ASA, morphine and zofran with resolution of chest pain. EKG showed no new acute changes. Initial cardiac enzymes were negative. He has had 1 episode of rest angina during this admission which resolved with Morphine. Cardiac catherization today revealed 3 VD. We have been ask to consult for surgical revascularization. Past Medical History: Paroxysmal atrial fibrillation Hypertension Diabetes mellitus type 2 Social History: Lives with: wife [Name (NI) 2270] [Name (NI) 1395](she is employed as an OT at [Hospital1 18]) Occupation: teaches physical therapy at [University/College ]. Active functional status, but activity tolerance has decreased from running [11-23] marathons to being able to run <15min over last 3 years Tobacco:denies ETOH:occasional Family History: sister afib, uncle died of sudden cardiac death in 50's. Mom alive with DM, renal failure, CHF. Paternal grandfather with MI in 50's. Physical Exam: Pulse:64 Resp:18 O2 sat: 100% RA B/P Right:144/99 Left: 148/70 Height: 70" Weight:98.8 kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] 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: Dressing in place Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: 0 Left: 0 Pertinent Results: [2177-2-11] 05:55AM BLOOD WBC-10.4 RBC-3.22* Hgb-9.8* Hct-29.3* MCV-91 MCH-30.5 MCHC-33.5 RDW-13.9 Plt Ct-187 [2177-2-1] 05:40AM BLOOD WBC-11.4* RBC-4.50* Hgb-14.1 Hct-41.5 MCV-92 MCH-31.4 MCHC-34.0 RDW-13.1 Plt Ct-241 [2177-2-11] 05:55AM BLOOD Plt Ct-187 [2177-2-11] 05:55AM BLOOD PT-15.3* PTT-25.8 INR(PT)-1.3* [2177-2-1] 05:40AM BLOOD Plt Ct-241 [2177-2-1] 05:40AM BLOOD PT-24.4* PTT-26.7 INR(PT)-2.3* [2177-2-11] 05:55AM BLOOD Glucose-99 UreaN-13 Creat-0.9 Na-138 K-4.7 Cl-100 HCO3-32 AnGap-11 [2177-2-1] 05:40AM BLOOD Glucose-177* UreaN-16 Creat-1.0 Na-138 K-5.1 Cl-101 HCO3-25 AnGap-17 [2177-2-4] 12:40PM BLOOD ALT-43* AST-35 AlkPhos-53 TotBili-0.4 [2177-2-3] 09:20AM BLOOD CK-MB-NotDone [2177-2-11] 05:55AM BLOOD Mg-2.2 [2177-2-1] 05:40AM BLOOD Calcium-9.5 Phos-2.6* Mg-2.0 [2177-2-4] 12:40PM BLOOD %HbA1c-7.4* eAG-166* Findings LEFT ATRIUM: Moderate LA enlargement. Mild spontaneous echo contrast in the body of the LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness and cavity size. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Mildly dilated ascending aorta. Complex (>4mm) atheroma in the aortic arch. Mildly dilated descending aorta. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) 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 rhythm appears to be atrial fibrillation. Results were personally reviewed with the MD caring for the patient. Conclusions PRE BYPASS The left atrium is moderately dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). The right ventricle dispalys normal free wall contractility. The ascending aorta is mildly dilated. There are complex (>4mm) 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 (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). 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 a-paced. There is normal biventricular systolic function. The thoracic aorta appears intact. Valvualr funstion is unchanged from the 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) ] [2177-2-7] 17:23 Brief Hospital Course: Presented to the emergency department for chest discomfort and was ruled out for myocardial infarction. He underwent worup that included cardiac catheterization that revealed coronary artery disease, surgery was consulted for surgical intervention. He underwent preoperative evaluation and on [2177-2-7] was taken to the operating room for coronary artery bypass graft and MAZE surgery. See operative report for further details. He received vancomycin for perioperative antibiotics because he was in the hospital preoperatively. Post operatively he was transferred to the intensive care unit for management. In the first twenty four hours he was weaned from sedation, awoke neurologically intact, and was extubated without complications. He continued to progress and was transferred to the floor on post operative day one. Physcial therapy worked with him on strength and mobility. He was started on coumadin for anticoagulation for MAZE. He continued to progress and was ready for discharge home with services on post operative day four. Medications on Admission: Metformin 750mg twice a day Actos 45 mg daily Byetta 10mcg/0.04 ml pen injector twice a day Warfarin 5mg every M/W/F Warfarin 7.5 mg every T/TH/Sat/Sun Fish oil 1 cap twice a day Glucosamine Sulf-Chondroitin 500-400mg once a day Diltiazem HCL Sustained release 240mg once a day Cialis prn 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 once a day. Disp:30 Tablet(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Outpatient Lab Work Labs: PT/INR for coumadin dosing for s/p MAZE with goal INR 2.0-2.5 - results to Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 5768] with first draw [2-13] 7. Warfarin 5 mg Tablet Sig: goal INR 2.0-2.5 Tablets PO once a day: dose to vary based on INR - please take 7.5 mg on [2-12] and lab to be drawn [2-13] with further dosing by Dr [Last Name (STitle) ] . Disp:120 Tablet(s) Refills:0 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp:10 Tablet(s) Refills:0 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 10 days. Disp:10 Capsule, Sustained Release(s) Refills:0 11. Metformin 750 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO twice a day. Disp:60 Tablet Sustained Release 24 hr(s) Refills:0 12. Byetta 10 mcg/0.04 mL Pen Injector Sig: Ten (10) mcg Subcutaneous twice a day. Disp:600 mcg Refills:0 13. Propoxyphene N-Acetaminophen 100-500 mg Tablet Sig: [11-23] Tablets PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA of [Location (un) 86] Discharge Diagnosis: Coronary artery disease s/p CABG Paroxysmal atrial fibrillation s/p MAZE Hypertension Diabetes mellitus type 2 Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with darvocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please monitor blood glucose - important to maintain normal blood glucose for wound healing Followup Instructions: [Name6 (MD) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2177-3-13] 1:00 Please call to schedule appointments Primary Care Dr [Last Name (STitle) ] in [11-23] weeks [Telephone/Fax (1) 24396] Cardiologist Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [11-23] weeks Labs: PT/INR for coumadin dosing for s/p MAZE with goal INR 2.0-2.5 - results to Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 5768] with first draw [2-13] Completed by:[2177-2-11] Admission Date: [2177-2-17] Discharge Date: [2177-2-20] Date of Birth: [2120-6-14] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Mr.[Known lastname 103312] is a 56 year old male well known to the csurg service as he recently underwent coronary bypass surgery x 3 grafts/MAZE procedure with Dr.[Last Name (STitle) ] on [2177-2-7]. He presents to the ED today with shortness of breath. TTE in the ED was reported as negative for a pericardial effusion. CTA to eval for pulmonary embolism is currently pending. Mr.[Known lastname 103312] presents with a supratherapeutic INR =3.7 for atrial fibrillation. He reports shortness of breath starting this afternoon after a coughing jag. Denies chest pain, fever/chills/sputum. Past Medical History: Coronary artery disease s/p CABG Paroxysmal atrial fibrillation s/p MAZE Hypertension Diabetes mellitus type 2 Social History: Lives with: wife [Name (NI) 2270] [Name (NI) 1395](she is employed as an OT at [Hospital1 18]) Occupation: teaches physical therapy at [University/College ]. Active functional status, but activity tolerance has decreased from running [11-23] marathons to being able to run <15min over last 3 years Tobacco:denies ETOH:occasional Family History: sister afib, uncle died of sudden cardiac death in 50's. Mom alive with DM, renal failure, CHF. Paternal grandfather with MI in 50's. Physical Exam: Pulse:93 SR w/ PACs/PVCs Resp:18 O2 sat: 2Lpm=99% B/P Right: 108/64 Left: Height: 70" Weight:206.8 LBs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [] Full ROM [] Chest: Lungs decreased bilateral bases, (l)>(r) Heart: RRR [] Irregular [x] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None []trace LE edema Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right:2+ Left:2+ PT [Name (NI) 167]: Left: Radial Right: Left: Incisions: Sternum stable. No [Doctor Last Name ]/click. C/D/I EVH=C/D/I Pertinent Results: [2177-2-17] 04:40PM BLOOD WBC-12.3* RBC-3.98* Hgb-12.6# Hct-36.8# MCV-93 MCH-31.7 MCHC-34.2 RDW-14.3 Plt Ct-441# [2177-2-17] 04:40PM BLOOD PT-36.4 PTT-29.5 INR(PT)-3.7* [2177-2-18] 01:00PM BLOOD PT-27.6* INR(PT)-2.7* [2177-2-19] 02:03AM BLOOD PT-23.9* INR(PT)-2.3* [2177-2-18] 01:00PM BLOOD Glucose-234* UreaN-17 Creat-1.1 Na-135 K-4.8 Cl-96 HCO3-29 AnGap-15 [2177-2-19] 02:03AM BLOOD UreaN-24* Creat-1.4* Na-136 K-4.1 Echo [2177-2-18] Conclusions The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with focal hypokinesis of the mid to distal anterior septum, anterior wall, and apex The remaining segments contract normally (LVEF = 35-40 %). The estimated cardiac index is normal (>=2.5L/min/m2). 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 arch is mildly dilated. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Regional left ventricular systolid dysfunction c/w CAD. Mild thoracic aortic dilation. Brief Hospital Course: The patient was admitted for further workup and management of dyspnea. Pulmonary embolism was ruled out by CT, however, left sided pleural effusion was found to be small-moderate. The patient was diuresed. Lopressor was changed to Coreg given the patient's low ejection fraction. Additionally, ACE inhibitor was initiated, however the patient was unable to tolerate this, as he became hypotensive. His blood pressure had stabilized but was not adequate to resume ace inhibitor. Amiodarone was started for atrial fibrillation, and coumadin was held in the setting of supratherapeutic INR. Coumadin was resumed at 2.5mg and his INR on [2177-2-20] was 1.8. He was claered for discharge to home by Dr. [Last Name (STitle) ] on HD#4. Medications on Admission: 1.Docusate Sodium 100 mg (2)2. Ranitidine HCl 150 (1)3. Aspirin 81 (1)4. Atorvastatin 80 (1)5.Pioglitazone 45 (1)7. Warfarin 5 mg/alt with 7.5 mg Tablet: goal INR 2.0-2.5 8. Metoprolol Tartrate 50 (2)9. Furosemide 40 (1)x10 days on discharge 10. Potassium Chloride 10 mEQ (1)x 10days on discharge 11. Metformin 750(2)12. Byetta 10 mcg/0.04 mL Pen Injector Sig: Ten (10) mcg (2)13. Propoxyphene N-Acetaminophen 100-500 mg Tablet Sig: 1-2 Tablets q6h prn pain Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Warfarin 1 mg Tablet Sig: as directed below Tablet PO Once Daily at 4 PM: dose will change daily for goal INR 2-2.5, Dr. [Last Name (STitle) ] to manage INR/coumadin dosing. 7. Outpatient Lab Work serial PT/INR goal 2-2.5 dx: atrial fibrillation, s/p Maze procedure Results to Dr. [Last Name (STitle) ] [Telephone/Fax (1) 5768] 8. Exenatide 10 mcg/0.04 mL Pen Injector Sig: 10mcg subcutaneous Subcutaneous twice a day. 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [Hospital1 ] x 4 days, then 400mg daily x 7 days, then 200mg daily. Disp:120 Tablet(s) Refills:2 10. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. Metformin 500 mg Tablet Sig: 1 [11-23] Tablet PO twice a day. 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 13. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:5 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: left sided pleural effusion and shortness of breath PMH: Coronary artery disease s/p CABG Paroxysmal atrial fibrillation s/p MAZE Hypertension Diabetes mellitus type 2 Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with tylenol prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please monitor blood glucose - important to maintain normal blood glucose for wound healing Followup Instructions: [Name6 (MD) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2177-3-13] 1:00 Please call to schedule appointments Primary Care Dr [Last Name (STitle) ] in [11-23] weeks [Telephone/Fax (1) 24396] Cardiologist Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in 1 week Labs: PT/INR for coumadin dosing for s/p MAZE with goal INR 2.0-2.5 - results to Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 5768] with first draw [2177-2-21] Completed by:[2177-2-20]	[ "427.31", "E935.8", "300.00", "250.00", "511.9", "V58.61", "411.1", "292.12", "401.9", "786.05", "414.01" ]	icd9cm	[ [ [] ] ]	[ "36.15", "36.12", "39.63", "37.33", "88.56", "88.72", "37.22", "39.61", "88.53" ]	icd9pcs	[ [ [] ] ]	18024, 18081	15289, 16031	11967, 11974	18293, 18388	13980, 15266	19021, 19596	13129, 13266		16540, 18001		18102, 18272		16057, 16517			18412, 18998										13281, 13961																												11908, 11929											12002, 12610															12632, 12745	12761, 13113
41,118	167,641	38891+58244	Discharge summary	report+addendum	Admission Date: [2148-3-30] Discharge Date: [2148-3-31] Date of Birth: [2101-4-21] Sex: M Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 3326] Chief Complaint: hypoxia s/p ERCP Major Surgical or Invasive Procedure: ERCP [3-30] History of Present Illness: 46 y/o with h/o HL s/p lap CCY [3-28]. CCY was elective after an episode of pancreastitis last summer. He was without symptoms prior to surgery. He presented back to [First Name5 (NamePattern1) 46] [Last Name (NamePattern1) 4046] [3-29] with worsening diffsue abdominal pain and distension. He also had chills and night sweats. No N/V/D. On arrival to [Hospital1 46] KUB showed enlarged small bowel loops. CT at [Hospital1 46] showed a small biloma in the gallblader fossa. HIDA confirmed a bile leak. Therefore he was transfered to [Hospital1 18] for ERCP. On arrival pt had temp of 100. During ERCP a sphincterotomy was perfomred and extravasation into the GB fossa was confirmed. A 7cm stent was placed successfully. He was normotonsive during the procedure and received 2L LR. After the procedure pt was hypoxic and was difficult to wean from the vent. However, prior to transfer he was extubated. VS at time of transfer to floor 99.5, 130/67, 98, 29, 93 on 6L FM. . On the floor, he has [5-9] abd pain, improved from [9-8] prior to the procedure. He complained of SOB improved with nebs, sitting upright, and dilaudid. Past Medical History: Hyperlipidemia anxiety Kidney stones osteomylitis borderline DM [3-28] lap CCY with intraoperative fluoro cholangiogram and Repair of incarcerated umbilical hernia Social History: No tobacco, social etoh. No illicits. married with two kids. Currently unemployed but works as an accountant. Lives in [Location 3320]. Family History: Father with cholecystitis. GF with colorectal cancer. GM with MI at 98. Physical Exam: Vitals: T:100.3 BP: 141/66 P: 109 R: 32 improved to 24 O2: 86% 6L improved to 95% on 3L NC. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: BL crackles at bases., CV: regularly irregular., normal S1 + S2, no murmurs, rubs, gallops Abdomen: tense, distended, tender R> L abd. bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2148-3-30] 10:47PM PT-12.8 PTT-23.7 INR(PT)-1.1 [2148-3-30] 08:31PM GLUCOSE-129* UREA N-10 CREAT-0.9 SODIUM-141 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-24 ANION GAP-16 [2148-3-30] 08:31PM ALT(SGPT)-45* AST(SGOT)-38 LD(LDH)-227 ALK PHOS-48 TOT BILI-1.1 [2148-3-30] 08:31PM LIPASE-886* [2148-3-30] 08:31PM CALCIUM-8.4 PHOSPHATE-2.0* MAGNESIUM-2.3 [2148-3-30] 08:31PM WBC-11.2* RBC-4.00* HGB-13.2* HCT-38.1* MCV-95 MCH-32.9* MCHC-34.6 RDW-12.9 [2148-3-30] 08:31PM NEUTS-81.4* LYMPHS-10.9* MONOS-7.2 EOS-0.4 BASOS-0.1 [2148-3-30] 08:31PM PLT COUNT-243 . [3-30] CXR: IMPRESSION: Limited study demonstrating bibasilar subsegmental atelectasis. . [3-30] ERCP: Impression: Cannulation of the biliary duct was successful and deep with a 5-4-3 tapered catheter using a free-hand technique. Contrast medium was injected resulting in complete opacification. A partial sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Late, small extravasation was noted at the biliary tree after fully visualizing the hepatic branches, in the RuQ, approximately in the area of the gallbladder fossa. A 7cm by 10FR biliary stent was placed successfully, resulting in adequate biliary drainage. Otherwise normal ercp to second part of the duodenum Brief Hospital Course: This is a 46 year old male with PMH of pancreatitis and kidney stones, s/p ERCP with stenting for bile leak after a CCY on [3-28]. # Bile leak s/p CCY: The patient successfully underwent an ERCP with stenting for a HIDA showing a bile leak s/p CCY at [Hospital1 46] on [3-28]. His abdominal pain improved after the procedure but he continued to have abdominal distention and ileus. He was started on empiric cipro/flagyl for biliary tree coverage. Blood cultures from [3-30] were negative to date. He initially remained NPO but was advanced to clears on [3-31] prior to transfer. His LFTs and CBC should be trended. He was given a Dulcolax suppository to help induce a bowel movement. He will need a repeat ERCP in 8 weeks for stent removal and should remain off ASA, Plavix, Coumadin for 7 days s/p procedure. Diet be advanced as tolerated if stable and pain-free. #. Hypoxia: The patient was noted to be hypoxic after his ERCP. A CXR and CT showed poor inspiratory effect and atelectasis likely secondary to abdominal pain/distention and splinting. There may be underlying OSA given his body habitus and hypoxia following sedation. There was also an element of volume overload noted and the patient was diuresed with furosemide 20mg IV once. He responded well to pain control with IV Dilaudid, nebulizer treatments, and furosemide to the point where he was satting in the mid 90s on 3 liters nasal cannula prior to transfer. Plan is aggressive incentive spirometry, additional lasix if volume status felt to still be increased, and weaning of nasal cannula oxygen. #. Ventricular ectopy: The patient went into asymptomatic bigeminy after arrival to the ICU. No acute ischemic changes were noted on EKG, although questionable Q waves were present in the inferior leads which may indicate underlying CAD. His electrolytes were repleted, but he continued to go in and out of bigeminy and normal sinus rhythm. This may have been driven by hypoxia. He was monitored on telemetry. It is recommended that he have an outpatient evaluation for possible underlying CAD. #. Hyperlipidemia: Home Simvastatin was held given biliary procedure, plans to restart after stent removal. #. Anxiety: Continue home regimen of citalopram. #. Borderline DM: On HISS while inpatient. #. Code: Confirmed full code. #. Communication: With patient and his wife, [Name (NI) 86303] who can be reached at [Telephone/Fax (1) 86304] Medications on Admission: Home Medications: Simvastatin 20mg qhs celexa 40mg daily . Meds on Transfer: Dilaudid 1-2mg prn pain cefoxitin 1gm diphenhydramine 50mg IV acetaminophen supp 650mg PR zofran 4mg IV Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) ampule Inhalation Q2H (every 2 hours) as needed for SOB. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) ampule Inhalation Q6H (every 6 hours). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 4. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Hydromorphone 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4 hours) as needed for abd pain. 8. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours). 9. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Four Hundred (400) mg Intravenous Q12H (every 12 hours). 10. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 11. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection once a day as needed for fluid overload. Discharge Disposition: Extended Care Discharge Diagnosis: Biliary leak s/p ERCP with biliary stenting, hypoxemia, ventricular bigeminy . Secondary diagnoses: -Hyperlipidemia -Anxiety -Kidney stones -Osteomyelitis -borderline DM -s/p [3-28] laparoscopic CCY with intraoperative fluoro cholangiogram and repair of incarcerated umbilical hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Respiratory Status: 95% on 3 LNC O2 Discharge Instructions: You were transferred to [Hospital1 69] from [Hospital3 3583] for a procedure called an ERCP that was necessary to fix a biliary leak after a cholecystectomy. During the ERCP a sphincterotomy was performed and a biliary stent was placed. You should remain off of all blood thinners for 7 days after the procedure. You will also need a repeat ERCP in 8 weeks to remove the stent. You tolerated the procedure well except for some shortness of breath which required you to be admitted to the ICU for monitoring of your respiratory status. Your respiratory status improved with pain control, nebulizer treatments, and diuresis. You are being transferred back to [Hospital3 3583] under the care Dr. [Last Name (STitle) ] [Name (STitle) 33629] to complete your recovery. Followup Instructions: Please follow-up with the doctors [First Name (Titles) ] [Hospital3 3583]. You should follow-up with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 73382], MD [First Name (Titles) ] [Last Name (Titles) ] [Name8 (MD) 6220], MD in 8 weeks for repeat ERCP with stent removal. Please call ([Telephone/Fax (1) 2233] to schedule this procedure. Name: [Known lastname ],[Known firstname ] T. Unit No: [Numeric Identifier 13663] Admission Date: [2148-3-30] Discharge Date: [2148-3-31] Date of Birth: [2101-4-21] Sex: M Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 2097] Addendum: Today's lab values addended. Pertinent Results: [2148-3-31] 01:44AM BLOOD WBC-8.5 RBC-3.77* Hgb-12.4* Hct-36.0* MCV-96 MCH-33.0* MCHC-34.5 RDW-12.9 Plt Ct-246 [2148-3-31] 01:44AM BLOOD Neuts-81.4* Lymphs-13.3* Monos-4.3 Eos-0.9 Baso-0.2 [2148-3-31] 01:44AM BLOOD Glucose-127* UreaN-11 Creat-0.8 Na-138 K-3.9 Cl-103 HCO3-28 AnGap-11 [2148-3-31] 01:44AM BLOOD ALT-36 AST-28 LD(LDH)-196 AlkPhos-47 TotBili-1.0 [2148-3-31] 01:44AM BLOOD Albumin-3.6 Calcium-8.5 Phos-2.2* Mg-2.3 Discharge Disposition: Extended Care [First Name11 (Name Pattern1) 126] [Last Name (NamePattern4) 2098] MD [MD Number(1) 2099] Completed by:[2148-3-31]	[ "300.00", "518.0", "997.39", "E879.8", "997.4", "560.1", "799.02", "427.69", "E878.6", "272.4", "276.6", "E849.7", "576.8" ]	icd9cm	[ [ [] ] ]	[ "51.85", "51.87" ]	icd9pcs	[ [ [] ] ]	10295, 10470	3842, 6293	286, 303	8031, 8031	9825, 10272	9056, 9806	1858, 1931		6525, 7661		7720, 7799		6319, 6319			8243, 9033										1946, 2469			7820, 8010		6337, 6378																							230, 248											331, 1494												8046, 8219			1516, 1685	1701, 1842			6396, 6502
22,930	121,115	54240	Discharge summary	report	Admission Date: [2187-11-15] Discharge Date: [2187-11-19] Date of Birth: [2138-10-14] Sex: M Service: MEDICAL INTENSIVE CARE UNIT, [Hospital Ward Name ] CHIEF COMPLAINT: Alcohol intoxication, nausea and vomiting. HISTORY OF PRESENT ILLNESS: This is a 49-year-old man with multiple prior admissions with alcohol intoxication and withdraw, complicated by ketoacidosis and delirium tremens, who had been sober for approximately 21 months until [2187-10-17]; he was subsequently admitted to the [Hospital6 1760] in late [2187-10-7] for alcohol intoxication and withdraw prophylaxis. Following his discharge on [2187-11-1], the patient went to outpatient alcohol rehabilitation and remained sober until five days prior to admission when he began drinking again. That evening, he went to an outside hospital complaining of alcohol intoxication; he was administered intravenous fluids in the Emergency Department and was discharged to home. Three days prior to admission he resumed drinking, and over the three days prior to admission he reported that he drank one six pack of beer, one bottle of wine, and one liter of vodka. He stated that he has had "essentially constant" nausea and vomiting over these three days. Prior to admission, he noted that he had one small episode of coffee-ground emesis (approximately the diameter of a quarter) during this time, but otherwise he denied hematemesis or coffee-ground emesis. He stated that he has had coffee-ground emesis in the past; he added that he had an EGD approximately five years ago that was negative per patient report. He denied abdominal pain. He stated that he has eaten very little over the past three days due to a combination of anorexia and the inability to keep anything down. PAST MEDICAL HISTORY: 1. Alcohol abuse necessitating multiple prior hospital admissions; history of withdraw seizures, DTs, and alcoholic and starvation ketoacidosis. 2. Chronic pancreatitis. 3. History of polysubstance abuse (cocaine, heroin, amphetamines, benzodiazepines). Last use approximately six years ago. 4. History of pancytopenia secondary to chronic alcohol abuse. 5. Left gynecomastia with negative mammogram in the past. 6. Genital herpes. 7. Depression. 8. Right clavicular fracture in [2185-4-6]. 9. Peptic ulcer disease with history of upper gastrointestinal bleeding. 10. Left ulnar neuropathy entrapment syndrome with pain and weakness secondary to a remote burn injury. 11. History of slipped disk. 12. Tinea pedis. 13. History of eczema. 14. Allergic rhinitis. 15. Childhood asthma. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: Citalopram 40 mg p.o. q.d., Pantoprazole 20 mg p.o. q.d., Gabapentin 800 mg p.o. q.i.d., Trazodone 100 mg p.o. q.h.s., Atenolol 25 mg p.o. q.d. SOCIAL HISTORY: The patient has been divorced since [2176]. He has one daughter and two step-daughters. [Name (NI) ] sells art and antiques and has his own business. He is eager to participate in rehabilitation programs. He stated that his current financial turmoil caused him to start drinking again. FAMILY HISTORY: Alcoholism in his parents and brother; father died secondary to cerebrovascular accident. Mother has [Name (NI) 2481] disease. PHYSICAL EXAMINATION: Vital signs: Temperature 97??????, blood pressure 166/107, heart rate 121, respirations 20, oxygen saturation 96% on room air. General: He was a pleasant, anxious, tremulous man, talkative and appropriate, and in mild distress secondary to tremors. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Conjunctivae clear. Dry mucous membranes. Oropharynx clear. Neck: Soft and supple. Tender over the midline. No lymphadenopathy. Heart: Tachycardiac. Regular rhythm. Normal S1 and S2 heart sounds. There were no murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally posteriorly. Abdomen: Soft, extremely tender, nondistended. There were active bowel sounds. There was no rebound, although there was voluntary guarding. He had no paraspinal or CVA tenderness. Extremities: Warm. There were 2+ dorsalis pedis pulses bilaterally. There was no calf tenderness. There was no edema. Neurological: Cranial nerves II-XII intact. He had 5 out of 5 muscular strength diffusely. Sensation to touch was intact diffusely. LABORATORY DATA: On initial laboratory evaluation, the patient's WBC was 14.8, hematocrit 49.9, platelet count 305, differential demonstrated 88 polys, no bands, 5 lymphs, 7 monos; PT 13.4, PTT 26.1, INR 1.2; initial serum chemistries demonstrated a sodium of 141, potassium 3.8, chloride 90, bicarbonate 19, BUN 14, creatinine 1.4 , glucose 240; calcium 9.2, magnesium 1.7, phosphate 2.8; ALT 50, AST 60, amylase 257, lipase 110, LDH 327, total bilirubin 0.5; alcohol level 177; initial ABG demonstrated a pH of 7.63, pCO2 16, pAO2 117, there was a lactate level of 9.6; initial urinalysis was negative. Chest x-ray demonstrated no acute cardiopulmonary disease, no free air under the diaphragm, stable wedge deformities of several upper thoracic vertebral bodies. CT of the abdomen and pelvis demonstrated an atrophic pancreas with dense calcifications consistent with chronic pancreatitis without inflammation or pseudocyst that would have suggested acute pancreatitis, a large stable hiatal hernia without change from a [2185-10-7] study, a diffusely hypodense liver consistent with fatty infiltration, and an overall stable appearance of the abdomen and pelvis on CT. Initial electrocardiogram demonstrated tachycardia at 132 beats per minute, sinus rhythm, normal axis, normal intervals, less than 1 mm ST segment depressions in leads V4-V6, and no significant acute ST segment or T-wave changes. HOSPITAL COURSE: This is a 49-year-old alcoholic man with multiple prior admissions for alcohol intoxication and withdraw who presented to the Emergency Department with a mixed acid base disorder secondary to recurrent emesis, lactic acidosis, and a presumed alcoholic/starvation ketoacidosis. 1. Acid/base imbalance: The patient presented with a complicated acid-base picture. Homicidal ideation ABG indicated that he was alkalemic, and his primary acid-base disturbance appeared to be metabolic alkalosis secondary to protracted episodes of vomiting. His delta-delta of 20/5 is consistent with this picture. He also had a metabolic alkalosis that was probably two-fold in etiology. First, given the presence of ketones in his urine, he appeared to be in alcoholic, with or without starvation, ketoacidosis. His recent alcohol binge in concert with his elevated anion gap supported this diagnosis. In addition, he stated that he had eaten very little over the three days prior to admission, indicating that there may be a starvation component to his ketoacidosis as well. His serum lactate of 9.6 supported the diagnosis of a lactic acidosis, the most likely etiology of which was tissue hyperperfusion in the setting of alcoholic ketoacidosis. He denied any additional toxic ingestions that could have been contributing to his metabolic acidosis, and he was not uremic. Finally, his arterial pCO2 of 16 indicated that he was falling off excess CO2. This finding supported the diagnosis of a compensatory respiratory alkalosis superimposed on his metabolic acidosis. For these complex metabolic abnormalities, the patient was hydrated with intravenous fluids. He was given D5 normal saline at 150 cc/hr, with the hope that the D5 would increase Insulin and decrease glucagon secretion, and the saline would replace his fluid losses. He was also started on Droperidol as needed for nausea to prevent further emesis that would further deplete his fluids and electrolytes. His metabolic abnormalities rapidly improved with these interventions, and by hospital day #2, his acid base balance had essentially returned to [Location 213]. He was continued on intravenous fluids until he was able to take p.o. fluids without difficulty. 2. Alcohol intoxication: The patient presented to the Emergency Department with an alcohol level of 177, and he admitted to a recent alcohol binge. He also reportedly had a history of seizures secondary to alcohol withdraw, as well as delirium tremens. He initially required Diazepam 10 mg IV every 30-60 min to prevent tremulousness, diaphoresis, and anxiety. Throughout the course of his hospitalization, his frequency of dosing with Diazepam 10 mg IV decreased to approximately every 2-4 hours by the time of discharge. The patient expressed a strong desire to be entered into an alcohol rehabilitation treatment program once stable for discharge from the hospital. Arrangements were therefore made for the patient to have inpatient rehabilitation treatment following his discharge from the hospital. 3. Pancreatitis: The patient has a history of chronic pancreatitis. In addition, he had mild laboratory abnormalities in conjunction with protracted nausea and vomiting on admission, indicating that he may have had a mild acute pancreatitis on presentation. The absence of significant inflammation on the CT exam, as well as his only mild elevation in his serum lipase argued against a more significant acute pancreatitis. He was initially kept NPO except for his medications and ice chips, and he gradually advanced his diet throughout the course of his hospitalization. At the time of discharge, the patient was tolerating a full-liquid diet. 4. Coffee-ground emesis: The patient reported one small episode of coffee-ground emesis on the day prior to admission. He stated that he has had a history of coffee-ground emesis, but he had a negative EGD approximately five years ago. His emesis was heme negative in the Emergency Department. He was also guaiac negative on digital rectal examination in the Emergency Department. A GI consult was deferred given his lack of coffee-ground emesis during this admission. He was started on Pantoprazole 40 mg IV b.i.d. for his history of gastritis and his report of recent coffee-ground emesis; he was changed to oral dosing once tolerating adequate p.o. intake. His stool and emesis remained heme negative throughout this admission. The patient was instructed to contact his primary care physician to make arrangements to have an EGD on an outpatient basis for further evaluation of his gastritis and reported recent history of coffee-ground emesis. 5. Hyperglycemia: The patient was hyperglycemic on admission. His hemoglobin A1C came back at 5.1% indicating that he likely does not have diabetes. While the mechanism of his admission hyperglycemia is poorly understood, it was likely secondary to his alcoholic ketoacidosis and may be a stress response. 6. Malnutrition: The patient reportedly had been eating poorly over the three days prior to admission. He was started and continued on Thiamin, Folate, and a Multivitamin throughout his admission. At the time of discharge, he was tolerating a full-liquid diet. 7. Neuropathic pain: The patient was continued on his baseline dose of Gabapentin. 8. Depression: The patient was continued on his baseline Citalopram and Trazodone. 9. Tachycardia: An electrocardiogram was repeated on the patient's arrival to the MICU. This electrocardiogram demonstrated no acute changes, and his tachycardia resolved with the resolution of his metabolic abnormalities. CONDITION ON DISCHARGE: Stable. DISCHARGE PLACEMENT: To alcohol rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Diabetic ketoacidosis. 2. Chronic alcoholism. 3. Chronic pancreatitis. 4. History of polysubstance abuse. 5. History of pancytopenia secondary to chronic alcohol abuse. 6. Left gynecomastia with a negative mammogram in the past. 7. Genital herpes. 8. Depression. 9. History of right clavicular fracture. 10. Peptic ulcer disease with a history of upper gastrointestinal bleeding. 11. Left ulnar neuropathy entrapment syndrome. 12. History of slipped disk. 13. Tinea pedis. 14. History of eczema. 15. Allergic rhinitis. DISCHARGE MEDICATIONS: Citalopram 40 mg p.o. q.d., Pantoprazole 40 mg p.o. q.d., Gabapentin 800 mg p.o. q.i.d., Trazodone 100 mg p.o. q.h.s., Diazepam 5-10 mg p.o. q.2-4 hours p.r.n. per CIWA scale, Thiamin 100 mg p.o. q.d., Folate 1 mg p.o. q.d., Multivitamin 1 cap p.o. q.d. DISCHARGE INSTRUCTIONS: The patient was instructed to contact his primary care physician following his discharge from his alcohol rehabilitation treatment program to arrange for an outpatient EGD for evaluation of his gastritis and recent coffee-ground emesis. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Name8 (MD) 2507] MEDQUIST36 D: [2187-11-19] 11:04 T: [2187-11-19] 11:19 JOB#: [Job Number 111134]	[ "311", "571.0", "577.1", "276.5", "303.00", "535.10", "276.4", "291.0", "790.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]							3163, 3296		12155, 12410		11599, 12131			5852, 11485		12435, 12906																									3319, 5834													208, 252											281, 1799															1822, 2831	2848, 3146	11510, 11578
1,569	100,045	13458	Discharge summary	report	Admission Date: [2176-2-5] Discharge Date: [2176-2-15] Date of Birth: [2106-8-2] Sex: F Service: MEDICINE Allergies: Aspirin / Heparin Agents Attending:[First Name3 (LF) 2181] Chief Complaint: Mental status changes Major Surgical or Invasive Procedure: Intubation History of Present Illness: 69 yo F with history of ESRD on HD, DM, recently admitted to [Hospital1 18] for ORIF for left distal femur fracture (uncomplicated hospital course) referred to ED today after she developed acute change in mental status associated with decreased responsiveness during a dialysis treatment today. History per daughter stated that she last spoke to her mother night PTA and she was "fine" (asking her daughter about her finances, etc.). She denies that her mother has ever had a seizure, stroke in the past. Denies any baseline weakness or numbness. States the patient was living on her own prior to her recent hip fracture. . Per sparse history on dialysis notes, patient was given percocet at approximately 9:55AM and at approximately 10:30AM developed acute mental status changes, including confusion. Patient continued through dialysis with stable vital signs (BP 130's-140's/60's, HR 40's-50's). After completion of dialysis, EMS was called for transfer to the hospital. . EMS notes were significant for noting "rapid deterioration in mental status", right gaze, dry blood on lips, no response to pain, aphasia. EMS noted decreased HR to 30's x 2 on transfer, FSBS = 185. . On presentation to ED at [Hospital1 18], exam was notable for minimal responsiveness, GCS 13, withdrawl of all extremities to pain, following occasional commands, non-verbal (groans). VSS with T 98.8, HR 58, BP 132/102, O2 sat 98%. Labs were notable for WBC 9.5 with 86 N and 2 B, Cr 5.1 (hx ESRD on HD), AST 59, LDH 450, AP 218, T bili 3.9, lactate 2.8. Blood cxs x 2 were sent in ED. Head CT demonstrated no evidence of intracranial bleed or edema. CXR was wnl. MRI/A scan was performed (read pending). Evaluation by neuro yielded diagnosis of possible seizure activity. Pt was given narcan 0.4mg IV x 1, Ativan total of 2mg IV, dilantin load (total of 2gm IV). She was intubated for airway protection (given FFP prior to intubation as INR 1.9, on coumadin as outpt as s/p hip surgery) and transferred to the ICU for further managment. Past Medical History: 1. Diabetes type 2 2. ESRD on HD Q M,W,F 3. s/p infection in left knee 4. h/o MRSA/C.diff 5. NASH [3-7] to tylenol 6. s/p ORIF for left distal femur fracture on [2176-1-23] Social History: SOH: lives at home with daughters. [Name (NI) ] ETOH/TOB/illicts. Family History: FH: non-contributory Physical Exam: Gen- intubated and sedated HEENT- Pinpoint pupils, reactive b/l. 2 cm healed scar of R upper forehead. c/d/i Neck- Supple, unable to assess JVP Chest- CLA anteriorly, b/l CV- Regular, bradycardic. no m/r/g Abd- +bs. soft. nd. no hepatosplenomegaly. no masses [Name (NI) ]- 1+ le edema. 2+ dp pulses. . On transfer to the floor: Physical Exam: VS: BP 131-143/41-57, HR 74-85 RR 20 O2 92-96% RA Gen - lying in bed, slurred speech, intermittently opens eyes, intermittently answers questions HEENT - PERRLA. 2 cm healed scar of R upper forehead. anicteric sclerae Neck - Supple, unable to assess JVP, patient with left subclavian line Chest - decreased breath sounds in left base CV - RRR, S1S2 normal, systolic murmur [4-8] radiating into the axillae Abd - +bs. soft. nd. no hepatosplenomegaly. no masses, mild tenderness in RUQ on deep palpation. Ext - trace LE edema. 2+ dp pulses. Pertinent Results: [2176-2-5] 02:10PM PT-16.8* PTT-36.5* INR(PT)-1.9 [2176-2-5] 02:10PM PLT SMR-LOW PLT COUNT-149# [2176-2-5] 02:10PM NEUTS-86 BANDS-2 LYMPHS-5* MONOS-6 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2176-2-5] 02:10PM WBC-9.5# RBC-3.92* HGB-13.2# HCT-37.7# MCV-96 MCH-33.6* MCHC-35.0 RDW-20.1* [2176-2-5] 02:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2176-2-5] 02:10PM T4-19.8* [2176-2-5] 02:10PM TSH-3.6 [2176-2-5] 02:10PM CALCIUM-9.4 PHOSPHATE-4.0# MAGNESIUM-1.8 [2176-2-5] 02:10PM LIPASE-524* [2176-2-5] 02:10PM ALT(SGPT)-15 AST(SGOT)-59* LD(LDH)-450* ALK PHOS-218* TOT BILI-3.9* [2176-2-5] 02:10PM GLUCOSE-186* UREA N-29* CREAT-5.1* SODIUM-131* POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-22 ANION GAP-20 . Imaging: [2176-2-5] CT head w/out contrast: No evidence of intracranial hemorrhage or edema. [2176-2-5] CXR: Unremarkable chest radiograph. [2176-2-5] MRI brain w/out contrast [2176-2-5]: No evidence of acute brain ischemia. Small arachnoid cyst in the right cerebellopontine angle cistern. Limited MR angiography study- the distal vasculature is poorly visualized, which could be secondary to low cardiac output. [2176-2-6] Liver U/S - Limited examination. Patent hepatic arteries and veins and portal veins with flow in the appropriate direction. [2176-2-7] EEG - Markedly abnormal portable EEG due to the slow and disorganized background and very frequent generalized sharp wave discharges. These findings indicate a widespread encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. The sharp waves were prominent and frequent and suggest an increased risk of seizures. Nevertheless, they were not particularly rhythmic or of higher frequency during this recording so as to suggest ongoing seizures at the time of the recording. There were no prominent focal findings although encephalopathies can obscure such findings. If concern for seizures persist clinically, a repeat tracing could be of assistance. [2176-2-8] MR [Name13 (STitle) 430] - Severely limited study. No large gross changes identified compared to [2176-2-5], but more subtle acute changes will not be discernable on today's study. If indeed there is high clinical suspicion of an acute change from [2-5], repeat imaging may be necessary. [2175-2-9] Abdominal U/S - There is no ascites. Marked splenomegaly Brief Hospital Course: # Mental status change: Initial exam was notable for minimal responsiveness, withdrawal of all extremities to pain, following occasional commands, non-verbal (groans). VSS with T 98.8, HR 58, BP 132/102, O2 sat 98%. Head CT demonstrated no evidence of intracranial bleed or edema. CXR was wnl. MRI/A scan was performed and did not show any evidence of ischemia. Evaluation by neuro yielded diagnosis of possible seizure activity. Pt was given narcan 0.4mg IV x 1, Ativan total of 2mg IV, dilantin load (total of 2gm IV). She was intubated for airway protection and transferred to the ICU for further managment. She was also covered for possible encephalitis/ meningitis with Acyclovir, CTX, Vanco and Ampicillin. A LP was done but did not show any signs of meningitis or encephalitis. The pt continued to have waxing and [Doctor Last Name 688] mental status. She was found to have elevated LFTs and was thought to have a component of hepatic encephalopathy. First EEG supporting seizure activity. Repeat EEG showed slowed activity c/w encephalopathy. Possible hepatic encephalopathy: Ammonia elevated at 65, therefore pt has been started on lactulose to attempt to improve MS. Repeat was in 30's. Abx were discontinued. On the [2-8] the pt self extubated and was reintubated to be extubated on the [2-9]. A NG tube was placed for nutrition. Over the following two days the pt was more lucid and stable. She was called out to the floor for further management. The pt continued to improve and became more lucid and oriented x3. Dilantin was continued orally at 300mg QD. Free Dilantin levels were checked and below therapeutic levels and therefore Dilantin was increased to 150 TID. Free Dilantin level should be repeated in three days. Lactulose and Rifaximin were continued. Lactulose should be titrated to three bowel movements. . # Liver disease: Per pt's daughter the pt had tylenol induced liver damage in past. Per daughter no ETOH/drug abuse in the past. Hep A neg, B surface pos, core neg, Hep C neg. Serum IgG, IgA, IgM were elevated without any specific pattern suggestive of a disease process. [Doctor First Name ] was negative, but Anti-SM and AMA were mildly positive (Titer 1:20). HSV PCR was negative. Possible primary biliary cirrhosis also consistent with obstructive enzyme pattern. Also possible steatosis hepatis from obesity. RUQ U/S showed splenomegaly, no ascites, no focal lesions in liver, no sign of biliary dilatiation. Flow in appropriate direction in portal vein. LFTs were followed up and were trending down. Follow up of LFT, CBC and Chem 7 should be obtained once in the following week. The pt has follow up arranged for her with Dr. [Last Name (STitle) 497] on the [2-13] at 9.40am. A liver biopsy might be considered to investigate the etiology of the problem further. The pt should be given hepatitis A vaccine once she is more stable. She was adviced to avoid hepatotoxic medications. . # Transient Leukocytosis and intermittent fever spike: Urine with WBC, and one time positive urine culture for klebsiella. Pt was initially treated for suspected meningitis with Ampicillin, Vancomycin and Ceftraixone. Antiobiotics were discontinued five days into her hospital course. The pt was afebrile after discontinuation of the antibiotics and remained with a normal WBC. The pt was found to have a new systolic murmur on exam, radiating into her axilla, most consistent with a mild mitral regurgitation. Follow up ECHO should be obtained. Given the fact that all blood cultures were negative and the pt remained afebrile and no other physical signs on examinations were found consistent with endocarditis the suspicion for endocarditis was considered low and no further workup was obtained. . # ESRD: Pt continued her outpatient dialysis schedule in house. She tolerated dialysis well. . # Hypernatremia: transient. Due to lack of free water because of to prolonged initial period without feeding as complicate NGT placement. Free water deficit was calculated as about 4L. Pt was repleted with free water boluses via NGT 250cc TID. Hypernatremia resolved. . # Anemia - pt has baseline anemia - about three points decreased from her baseline at around 29. Likely sequestration in spleen and possible low grade hemolysis due to liver disease in addition to renal anemia in ESRD. Hemolysis labs difficult to interpret in the setting of liver disease. Iron studies consistent with anemia of chronic disease, no iron deficiency. Erythropoetin was administered during dialysis. . # Thrombocytopenia & elevated INR: HIT AB POSITIVE. Also with splenomegaly and chronic liver disease, likely sequestering. All heparin containing products were avoided. Thrombocytes were consistently above 50,000. . # DM2: Endocrinology was consulted and sliding scale was adjusted per recommendations. Lantus 20 and RISS to be continued as outpatient. Pt had a one time episode of hypoglycemia to 49. ISSC was decreased by unit two days prior to discharge. Further fine adjustment should be achieved in the rehabilitation center. . # ORIF: pt was seen by orthopedics in house. Knee XR was obtained. No dislocation of the hardware was seen. The pt should remain not weight bearing on her L leg for 5 more weeks. F/u appointment with ortho was obtained in 5 weeks. Medications on Admission: 1. Colace 100 mg [Hospital1 ] 2. Pantoprazole 40 mg QD 3. Acetaminophen 500 mg q6 4. Metoprolol Tartrate 25 mg [Hospital1 ] 5. Warfarin 1 mg QD 6. Calcium Carbonate 500 mg TID 7. Hydromorphone 2 mg q6 8. Senna 8.6 mg [Hospital1 ] 9. Bisacodyl 10 mg Tablet, QD 10. Sevelamer 800 mg TID Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 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. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:qs Refills:2 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). Disp:1350 ML(s) Refills:2 6. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) Subcutaneous As directed. Disp:qs Refills:2 7. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO TID (3 times a day). Disp:270 Tablet, Chewable(s) Refills:2 8. Insulin Glargine 100 unit/mL Solution Sig: as directed Subcutaneous at bedtime. Disp:qs Refills:2 Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Mental status changes EEG with seizure like activity Liver failure Hepatic encephalopathy ................... Diabetes type 2 ESRD on HD Q M,W,F s/p ORIF for left distal femur fracture on [2176-1-23] Discharge Condition: Good, Pt [Name (NI) 9830]3, mental status changes resolved Discharge Instructions: Please come back to the hospital or see your primary care doctor if you experience any worsening mental status, confusion, headaches, jaundice or any other concerns. . Please take all medications as instructed. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 497] on the [2-13] at 9.40am for your liver disease. . Please follow up with Neurology, Dr. [Last Name (STitle) ] on the [3-22] at 11.00am, [Location (un) ] of [Hospital Ward Name 23] building. . Please also follow up with your primary care doctor. . And follow up with orthopedics for your fracture: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2176-3-19] 9:00	[ "780.39", "287.5", "276.1", "250.80", "572.2", "571.5", "599.0", "285.21", "571.8", "V54.13", "276.0", "585.6" ]	icd9cm	[ [ [] ] ]	[ "96.04", "39.95", "38.93", "96.71", "96.6", "99.07", "03.31" ]	icd9pcs	[ [ [] ] ]	12799, 12869	6172, 11466	305, 317	13117, 13181	3627, 6149	13441, 13967	2678, 2701		11813, 12776		12890, 13096		11492, 11790			13205, 13418										3063, 3608																												244, 267											345, 2369															2391, 2574	2590, 2662
63,354	156,893	1796+55316	Discharge summary	report+addendum	Admission Date: [2139-3-3] Discharge Date: [2139-3-9] Date of Birth: [2079-4-8] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: [2139-3-3] Re-do aortic valve replacement with 21-mm Regent St. [Hospital 923] Medical mechanical valve History of Present Illness: 59 year old male with history of endocarditis s/p AVR (tissue) in [2126] with Dr. [First Name (STitle) 10102]. He had done well since until he recently developed fatigue and dyspnea on exertion. He had a recent admission for CHF/pneumonia. Echo reveals declining heart function, and increasing aortic valve gradients. He presents for surgical evaluation. Past Medical History: Hypertension Hyperlipidemia HIV, CD4 815, undetectable viral load x 12 yrs (per patient) Chronic Systolic Heart Failure Endocarditis [2126] -due to cat litter (not IVDU) c/b right femoral artery embolus Past Surgical History: [2126] AVR (tissue), repair LV aneurysm, Dr. [First Name (STitle) 10102] [2126] SFA->posterior tibial bypass Dr. [Last Name (STitle) ] tonsillectomy Social History: Race: Caucasian Last Dental Exam: [2138-12-6], calling office to fax clearance Lives with: alone Occupation: works part-time as HIV educator in schools and prisons Tobacco: quit 9 yrs. ago ETOH: quit 24yrs. ago IVDU: quit 24yrs. ago Family History: mother with CAD in her 70s, died at 84yo father's mom died of MI at 45yo Physical Exam: Pulse: 88 Resp: 18 O2 sat: 98%RA B/P Right: 101/65 Left: 97/60 Height:5'4" Weight:140 lbs General: NAD, WGWN, appears stated age 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 [2-8] harsh systolic ejection murmur best heard at 3rd ICS/parasternal space on the left. Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] well healed incision of the RLE- median aspect ankle to groin Neuro: Grossly intact x Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ PT [Name (NI) 167]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit: radiation of cardiac murmur +thrill bilaterally Pertinent Results: [3-3] Echo: PRE-CPB: The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is moderately depressed (LVEF= 30-40 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. A bioprosthetic aortic valve prosthesis is present. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen. Trivial mitral regurgitation is seen. POST-CPB: A mechanical bileaflet valve is seen in the aortic position. The valve is well seated with normal leaflet motion. The normal washing jets are seen. There is no paravalvular leak. The peak gradient across the aortic valve is 27mmHg, the mean gradient is 14mmHg with a cardiac output of 6. The LV systolic function remains moderately impaired, the estimated EF is 35-40%. Hypokinesis is most notable in the anteroseptal wall. There is no evidence of aortic dissection. Brief Hospital Course: Mr. [Known lastname 5890] was a same day admit after undergoing pre-operative work-up prior to admission. On [3-3] he was brought to the operating room where he underwent a Re-do aortic valve replacement with 21- mm Regent St. [Hospital 923] Medical mechanical valve . Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. All pressors weaned off. Beta-blocker/Statin/Aspirin and diuresis were initiated. All lines and drains were discontinued per protocol. He was transferred to the step down unit for further monitoring. Physical Therapy was consulted to evaluate strength and mobility. The remainder of his hospital course was essentially uneventful. Anticoagulation was intitiated with Coumadin and a Heparin bridge. On POD# 6 his INR was therapeutic and Mr.[Known lastname 5890] was cleared for discharge to home with VNA. All Follow up appointments were advised. Medications on Admission: ACYCLOVIR - 400 mg Tablet - ONE Tablet(s) by mouth twice a day BUPROPION HCL [WELLBUTRIN XL] - 150 mg Tablet Extended Release 24 hr - One Tablet(s) by mouth once daily. CARVEDILOL - 3.125 mg Tablet - 2 Tablet(s) by mouth twice per day. CLARITHROMYCIN [BIAXIN] - 500 mg Tablet - ONE Tablet(s) by mouth once daily. CLINDAMYCIN HCL - 150MG Capsule - 4 TABLETS ONE HOUR PRE-DENTAL WORK DIGOXIN - 125 mcg Tablet - One Tablet(s) by mouth once daily. EFAVIRENZ [SUSTIVA] - 600 mg Tablet - one Tablet(s) by mouth once a day at bedtime ENALAPRIL MALEATE [VASOTEC] - 10 mg Tablet - ONE Tablet(s) by mouth once a day FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - 48 mg Tablet - One Tablet(s) by mouth once daily for control of elevated triglycerides. FOLIC ACID - 1 mg Tablet - ONE Tablet(s) by mouth once a day FUROSEMIDE - 20 mg Tablet - One Tablet(s) by mouth once daily. HYDROCORTISONE - 2.5 % Ointment - apply to rash once a day LAMIVUDINE-ZIDOVUDINE [COMBIVIR] - 150 mg-300 mg Tablet - ONE Tablet(s) by mouth twice a day LORAZEPAM - 0.5 mg Tablet - One Tablet(s) by mouth hs as needed for sleep. SIMVASTATIN - 40 mg Tablet - One Tablet(s) by mouth once daily for control of cholesterol. SODIUM FLUORIDE [DENTAGEL] - 1.1 % Gel - Use to brush teeth 3-4 times per day Medications - OTC CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (OTC) - 500 mg-200 unit Tablet - One Tablet(s) by mouth once daily. LACTOBACILLUS ACIDOPHILUS [ACIDOPHILUS] - (OTC) - 500 million cell Tablet - One Tablet(s) by mouth once daily. LORATADINE - 10 mg Tablet - one Tablet(s) by mouth once a day MULTIVITAMIN - (OTC) - Tablet - One Tablet(s) by mouth once daily Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 2. enalapril maleate 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 8. acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day. 9. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day. 10. efavirenz 600 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 11. fenofibrate micronized 48 mg Tablet Sig: One (1) Tablet PO daily (). 12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 weeks. 14. lamivudine-zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 16. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. DentaGel 1.1 % Gel Sig: One (1) to tooth brush Dental four times a day: use to brush teeth 3-4 times a day . 18. lactobacillus acidophilus 500 million cell Tablet Sig: One (1) Tablet PO once a day. 19. loratadine 10 mg Tablet Sig: One (1) Tablet PO daily (). 20. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 21. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 22. warfarin 2 mg Tablet Sig: goal INR 2.5-3 Tablets PO to be dosed based on INR : you are receiving two different doses of coumadin so that your dose can be adjusted based on lab results . Disp:60 Tablet(s) Refills:2 23. warfarin 5 mg Tablet Sig: goal INR 2.5-3 Tablets PO to be dosed based on INR : you are receiving two different doses of coumadin so that your dose can be adjusted based on lab results . Disp:60 Tablet(s) Refills:2 24. coumadin please take 5 mg coumadin on [3-10] and then VNA to check INR level on [3-11] further dosing will be based on INR results Cardiac surgery office [Telephone/Fax (1) 170] will dose coumadin until set up with Dr [Last Name (STitle) ] Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Prosthetic aortic valve stenosis s/p Redo-sternotomy, Aortive valve replacement Past medical history: Hypertension Hyperlipidemia HIV, CD4 815, undetectable viral load x 12 yrs (per patient) Chronic Systolic Heart Failure Endocarditis [2126] -due to cat litter (not IVDU) c/b right femoral artery embolus Past Surgical History: [2126] AVR (tissue), repair LV aneurysm, Dr. [First Name (STitle) 10102] [2126] SFA->posterior tibial bypass Dr. [Last Name (STitle) ] tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with dilaudid Incisions: Sternal - healing well, no erythema or drainage Edema none 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 [3-26] at 1:15PM Cardiologist: Dr. [Last Name (STitle) ] on [4-13] at 10 am for echo and then appt with Dr [Last Name (STitle) ] at 11 am Wound Check in [Hospital Unit Name ], [Hospital Unit Name ] on [3-17] at 10am Primary Care Dr. [Last Name (STitle) 10103] on [3-24] at 10:00AM Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication: Mechanical valve Goal INR 2.5-3.0 First draw [3-11] wednesday Results to Cardiac surgery office phone [Telephone/Fax (1) 170] until set up with Dr [Last Name (STitle) ] office Completed by:[2139-3-9] Name: [Known lastname 1393],[Known firstname 389] Unit No: [Numeric Identifier 1394] Admission Date: [2139-3-3] Discharge Date: [2139-3-9] Date of Birth: [2079-4-8] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 741] Addendum: correction to lasix - for 10 days Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. [Name6 (MD) ] [Name8 (MD) 747] MD [MD Number(2) 748] Completed by:[2139-3-9]	[ "424.1", "E878.1", "V08", "401.9", "428.22", "428.0", "996.71", "272.4" ]	icd9cm	[ [ [] ] ]	[ "35.22", "39.61" ]	icd9pcs	[ [ [] ] ]	11864, 12042	3586, 4652	283, 396	9533, 9702	2421, 3563	10625, 11841	1480, 1554		6336, 8914		9014, 9094		4678, 6313			9726, 10602								9346, 9512		1569, 2402																												236, 245											424, 792															9116, 9323	1226, 1464
27,157	192,424	7520	Discharge summary	report	Admission Date: [2101-3-3] Discharge Date: [2101-4-1] Date of Birth: [2054-10-22] Sex: M Service: NEUROSURGERY Allergies: Hydralazine Attending:[First Name3 (LF) 78] Chief Complaint: HEADACHE Major Surgical or Invasive Procedure: CEREBRAL ANGIOGRAMS RIGHT/LEFT ICA COILING OF ANEURYSMS TRACHEOSTOMY PEG PLACEMENT History of Present Illness: HPI: 46M with mild HA x 2 days. Headache became severe with near fainting at 3 hours prior to presentation. Initially went to [Hospital6 3105] and CT showed large SAH. At OSH pt had near syncopal episode with vomiting. Pt also reported neck/back pain that was worse with movement. No history of trauma. Denies fevers, chills, change in vision, diarrhea, chest pain, or SOB. Pt transferred to [Hospital1 18] for further management. Past Medical History: Hep C splenectomy Spine surgery - 6 screws Social History: Social Hx: Lives in [Hospital1 487], h/o IVDU quit 20+ years ago, 1/4pack cigs/day, social ETOH Spanish is primary language Family involved in care/decision making. Family History: NC Physical Exam: PHYSICAL EXAM: O: T: 99.2 BP: 134/77 HR: 94 R: 16 97% 3LNC O2Sats Gen: mild grimace, NAD. HEENT: Pupils: B 2mm with minimal reactivity EOMI Neck: Pain with passive or active ROM Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round but minimally reactive to light, Measure 2mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-30] throughout. No pronator drift Sensation: Intact to light touch all 4 extremities Reflexes: B Pa Right 2+ 1+ Left 2+ 1+ Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Neurological Exam: Opens eyes to voice, follows basic commands to squeeze/let go with Right hand, shows thumb/2fingers. Right gaze preference Nonverbal, does not attempt to mouth words, tracheostomy in place Face symmetric, Pupils with R>L 3.5-3/3-2.5 RUE spontaneous and purposeful, generalized weakness 4/5. RLE slight withdrawal to noxious stimuli. LUE flaccid 0/5 LLE minimal withdrawal to pain. Grimaces to pain Toes downgoing bilaterally Pertinent Results: BELOW ARE THE MOST RECENT REPORTS OF THE NOTED STUDIES/. ABDOMEN (SUPINE & ERECT) [2101-3-28] 5:33 PM INDICATION: No bowel movement for multiple days with PEG feeding tube. PORTABLE ABDOMEN: Supine and left lateral decubitus views are provided. TheBowel gas pattern is unremarkable and no abnormally dilated loops of bowel are seen. Stool is noted throughout much of the colon with air seen in the rectum. There is no evidence of free air. A gastrostomy tube is noted in the left upper quadrant. Scattered left abdominal clips are seen with left upper quadrant clips consistent with history of splenectomy. Lumbosacral fusion hardware is again noted. IMPRESSION: No evidence of obstruction. RADIOLOGY Final Report CT HEAD W/O CONTRAST [2101-3-26] 10:03 AM Reason: r/o evolving stroke and make sure there is no new hemorrhage [Hospital 93] MEDICAL CONDITION: 46 year old man with h/o SAH's, stroke REASON FOR THIS EXAMINATION: r/o evolving stroke and make sure there is no new hemorrhage CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 46-year-old man with history of subarachnoid hemorrhage and stroke. Please evaluate for evolving stroke and hemorrhage. COMPARISON: CTA of the head [2101-3-24]. NON-CONTRAST HEAD CT: There has been further evolution of large right MCA stroke with a well-defined hypoattenuating area indicating edema and progressive encephalomalacia. There is mild ex vacuo dilatation of the right lateral ventricle. No acute intracranial hemorrhage identified. No midline shift or evidence of subfalcine or uncal herniation. There is trace residual high attenuation along the skull vertex consistent with mild residual subarachnoid hemorrhage. Aneurysmal clips in the bilateral supraclinoid ICA are noted limiting adequate evaluation of this area. Air-fluid level and aerosolized secretions within the left maxillary sinus and left frontal sinus as well as opacification of the mastoid air cells were seen on the prior exam and likely relate to the patient's previous intubated status. IMPRESSION: 1. Continued evolution of right MCA infarct. No evidence of hemorrhagic transformation. 2. Persistent pansinusitis. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 3296], [Known firstname ] [Hospital1 18] [Numeric Identifier 27489]Portable TTE (Complete) Done [2101-3-24] at 10:20:09 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] J. [Hospital1 18] - Division of Neurosurger [Hospital Unit Name 18400] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2054-10-22] Age (years): 46 M Hgt (in): 71 BP (mm Hg): 135/80 Wgt (lb): 189 HR (bpm): 100 BSA (m2): 2.06 m2 Indication: Source of embolism. ICD-9 Codes: 424.0, 424.2 Test Information Date/Time: [2101-3-24] at 10:20 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171], MD Test Type: Portable TTE (Complete) Son[Name (NI) 930]: [Name2 (NI) 27490] [Last Name (un) 27491] Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2008W002-0:22 Machine: Vivid [8-2] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.2 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.6 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.4 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.7 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.8 cm Left Ventricle - Fractional Shortening: 0.43 >= 0.29 Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 1.1 m/sec Mitral Valve - E/A ratio: 0.91 Mitral Valve - E Wave deceleration time: 182 ms 140-250 ms Findings LEFT ATRIUM: Elongated LA. No LA mass/thrombus (best excluded by TEE). RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO by 2D, color Doppler or saline contrast with maneuvers. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No LV mass/thrombus. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of agitated normal saline at rest. Conclusions The left atrium is elongated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: No PFO, ASD, or cardiac source of embolism seen. Normal global and regional biventricular systolic function. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171], MD, Interpreting physician [Last Name (NamePattern4) ] [2101-3-24] 11:02 RADIOLOGY Final Report BILAT LOWER EXT VEINS PORT [2101-3-23] 4:35 PM BILAT LOWER EXT VEINS PORT Reason: r/o DVT for source of embolic stroke [Hospital 93] MEDICAL CONDITION: 46 year old man with R MCA stroke REASON FOR THIS EXAMINATION: r/o DVT for source of embolic stroke INDICATION: 46-year-old man with stroke, evaluate for embolic source. COMPARISON: None. FINDINGS: [Doctor Last Name ]-scale and Doppler son[Name (NI) 1417] of the right and left common femoral, superficial femoral, and popliteal veins were performed. These demonstrate normal compressibility, augmentation, waveforms and flow. No intraluminal thrombus is identified. Rounded hypoechoic area adjacent to the proximal right common femoral vein demonstrates doppler color flow, with to and fro flow, with "[Doctor First Name ]-[Doctor Last Name ]" pattern suggesting pseudoaneurysm. IMPRESSION: 1. No evidence of lower extremity DVT. 2. Findings suggesting right groin pseudoaneurysm. Discussed with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 27492] at 7:50 p.m., [2101-3-23]. RADIOLOGY Final Report BILAT UP EXT VEINS US [2101-3-23] 4:36 PM BILAT UP EXT VEINS US; -59 DISTINCT PROCEDURAL SERVIC Reason: r/o DVT for source of embolic stroke [Hospital 93] MEDICAL CONDITION: 46 year old man with R MCA stroke REASON FOR THIS EXAMINATION: r/o DVT for source of embolic stroke INDICATION: 46-year-old man status post stroke, evaluate for embolic source. COMPARISON: None. FINDINGS: Grayscale and Doppler son[Name (NI) 1417] of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. These demonstrate normal compressibility, augmentation, waveforms and flow. No intraluminal thrombus identified. Right brachial PICC noted. IMPRESSION: No evidence of upper extremity DVT. RADIOLOGY Final Report CTA HEAD W&W/O C & RECONS [2101-3-22] 11:34 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Reason: RECENT SAH, NOW WITH RT MCA STROKE. Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 46 year old man with recent SAH now w/ R MCA stroke REASON FOR THIS EXAMINATION: Please perform CT PERFUSION study in addition to CTA. Center perfusion study on frontal horns of lateral ventricles (4 above, 4 below). Page [Numeric Identifier 27493] if need further instruction. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 46-year-old male patient, with recent subarachnoid hemorrhage, now with right MCA stroke, to perform CT perfusion. PRELIMINARY REPORT: CTA is markedly limited in the Circle of [Location (un) 431] secondary to metallic artifact. The visualized secondary branches of the right MCA are patent. Redemonstrated is large right MCA infarct. MRA will also be limited. AHB. TECHNIQUE: Noncontrast CT head, followed by CT angiogram of the head and neck and CT cerebral perfusion study was performed with IV contrast. COMPARISON: CT of the head done on [2101-3-22], CT of the head done on [2101-3-13]. FINDINGS: NON-CONTRAST CT HEAD: As seen on the most recent noncontrast CT, there is a large hypodense area in the right cerebral hemisphere in the MCA territory, representing acute infarction. There is no significant change, compared to the scan done a few hours earlier. However, this appearance is new, compared to the CT head done on [2101-3-17]. There is unchanged appearance of the small hypodense foci, representing continued evolution of the multiple bilateral previously noted watershed infarcts, particularly prominent in the bilateral frontal lobes, right greater than left. Small areas of subarachnoid hemorrhage noted in the vertex, as before, unchanged. Aneurysm clips in the bilateral supraclinoid ICA are noted, limiting adequate evaluation in this area. CT PERFUSION: There is increased mean transit time, corresponding to the area of hypodensity in the right cerebral hemisphere with decreased blood flow and slightly decreased blood volume, compared to the left cerebral hemisphere, with no mismatch between the areas of decreased blood flow and blood volume, and hence, representing acute infarction. CT ANGIOGRAM OF THE HEAD AND NECK: The origins of the arch vessels are patent. The common carotid, cervical internal carotid and intracranial internal carotid arteries are patent, except for the supraclinoid segments, which are not adequately evaluated due to artifacts from the aneurysm clips. Limited evaluation of the anterior and the middle cerebral arteries till the M2 segments. The branches of the middle cerebral arteries appear to be grossly patent. The vertebral arteries are patent from their origins throughout their course, till their [Hospital1 ] to form the basilar artery. The basilar artery and the posterior cerebral arteries are patent. However, the basilar artery is diminutive in caliber with no significant change, compared to the prior CT done on [2101-3-13]. The posterior cerebral artery on the right side is small in caliber, likely due to hypoplasia, with visualized posterior communicating artery and is unchanged in appearance. Multiple lymph nodes are noted in both sides of the neck, the largest in the right level 1B, measuring 1.0 cm, and not enlarged by CT size criteria. Symmetry of the pharyngeal soft tissues is difficult to assess, as the patient is rotated to the right side. Moderate opacification is noted in the left maxillary sinus, left side of the sphenoid and frontal sinuses, and mild in the mastoid air cells on both sides, representing fluid or mucosal thickening. Degenerative changes are noted in the cervical spine, not adequately evaluated on the present study. There is also rotation of the tip of the odontoid, with reference to the atlas with discrepancies in the lateral atlantoaxial distances; however, this is not completely evaluated, as the patient is rotated. Pleuro parenchymal scarring is noted in the lung apices, not adequately evaluated on the present study. The patient is intubated with the endotracheal tube ending 3.7 cm above the tracheal bifurcation. IMPRESSION: 1. Interval development of large right MCA territory acute infarction, as seen on non-contrast and CT Perfusion studies, compared to the study done on [2101-3-17]. 2. The visualized segments of the major arteries are patent. Limited evaluation of the supraclinoid segments, anterior and middle cerebral arteries due to artifacts from the aneurysm clips/coils. RADIOLOGY Final Report CT BRAIN PERFUSION [2101-3-22] 11:34 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Reason: RECENT SAH, NOW WITH RT MCA STROKE. Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 46 year old man with recent SAH now w/ R MCA stroke REASON FOR THIS EXAMINATION: Please perform CT PERFUSION study in addition to CTA. Center perfusion study on frontal horns of lateral ventricles (4 above, 4 below). Page [Numeric Identifier 27493] if need further instruction. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 46-year-old male patient, with recent subarachnoid hemorrhage, now with right MCA stroke, to perform CT perfusion. PRELIMINARY REPORT: CTA is markedly limited in the Circle of [Location (un) 431] secondary to metallic artifact. The visualized secondary branches of the right MCA are patent. Redemonstrated is large right MCA infarct. MRA will also be limited. AHB. TECHNIQUE: Noncontrast CT head, followed by CT angiogram of the head and neck and CT cerebral perfusion study was performed with IV contrast. COMPARISON: CT of the head done on [2101-3-22], CT of the head done on [2101-3-13]. FINDINGS: NON-CONTRAST CT HEAD: As seen on the most recent noncontrast CT, there is a large hypodense area in the right cerebral hemisphere in the MCA territory, representing acute infarction. There is no significant change, compared to the scan done a few hours earlier. However, this appearance is new, compared to the CT head done on [2101-3-17]. There is unchanged appearance of the small hypodense foci, representing continued evolution of the multiple bilateral previously noted watershed infarcts, particularly prominent in the bilateral frontal lobes, right greater than left. Small areas of subarachnoid hemorrhage noted in the vertex, as before, unchanged. Aneurysm clips in the bilateral supraclinoid ICA are noted, limiting adequate evaluation in this area. CT PERFUSION: There is increased mean transit time, corresponding to the area of hypodensity in the right cerebral hemisphere with decreased blood flow and slightly decreased blood volume, compared to the left cerebral hemisphere, with no mismatch between the areas of decreased blood flow and blood volume, and hence, representing acute infarction. CT ANGIOGRAM OF THE HEAD AND NECK: The origins of the arch vessels are patent. The common carotid, cervical internal carotid and intracranial internal carotid arteries are patent, except for the supraclinoid segments, which are not adequately evaluated due to artifacts from the aneurysm clips. Limited evaluation of the anterior and the middle cerebral arteries till the M2 segments. The branches of the middle cerebral arteries appear to be grossly patent. The vertebral arteries are patent from their origins throughout their course, till their [Hospital1 ] to form the basilar artery. The basilar artery and the posterior cerebral arteries are patent. However, the basilar artery is diminutive in caliber with no significant change, compared to the prior CT done on [2101-3-13]. The posterior cerebral artery on the right side is small in caliber, likely due to hypoplasia, with visualized posterior communicating artery and is unchanged in appearance. Multiple lymph nodes are noted in both sides of the neck, the largest in the right level 1B, measuring 1.0 cm, and not enlarged by CT size criteria. Symmetry of the pharyngeal soft tissues is difficult to assess, as the patient is rotated to the right side. Moderate opacification is noted in the left maxillary sinus, left side of the sphenoid and frontal sinuses, and mild in the mastoid air cells on both sides, representing fluid or mucosal thickening. Degenerative changes are noted in the cervical spine, not adequately evaluated on the present study. There is also rotation of the tip of the odontoid, with reference to the atlas with discrepancies in the lateral atlantoaxial distances; however, this is not completely evaluated, as the patient is rotated. Pleuro parenchymal scarring is noted in the lung apices, not adequately evaluated on the present study. The patient is intubated with the endotracheal tube ending 3.7 cm above the tracheal bifurcation. IMPRESSION: 1. Interval development of large right MCA territory acute infarction, as seen on non-contrast and CT Perfusion studies, compared to the study done on [2101-3-17]. 2. The visualized segments of the major arteries are patent. Limited evaluation of the supraclinoid segments, anterior and middle cerebral arteries due to artifacts from the aneurysm clips/coils. Neurophysiology Report EEG Study Date of [2101-3-15] OBJECT: HISTORY OF SUBARACHNOID HEMORRHAGE, ANEURYSM COILING, RULE OUT SEIZURES. REFERRING DOCTOR: DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] FINDINGS: ABNORMALITY #1: Throughout the recording, the background was disorganized and consisted of low voltage fast activity admixed with excessive theta and delta frequencies. The background was interrupted by brief bursts of moderate amplitude generalized mixed theta and delta frequency slowing. There were no areas of prominent focal slowing. There were no epileptiform features. BACKGROUND: As above. HYPERVENTILATION: Could not be performed as this was a portable study. INTERMITTENT PHOTIC STIMULATION: Could not be performed as this was a portable study. SLEEP: No normal waking or sleeping morphologies were noted. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 78 beats per minute but with frequent ectopic beats. IMPRESSION: This is an abnormal portable EEG due to the disorganized and low voltage fast background activity admixed with excessive theta and delta frequencies and interrupted by brief bursts of moderate amplitude generalized mixed theta and delta frequency slowing. These findings are consisent with a moderate global encephalopathy and suggest dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbances, and infection are among the common causes of encephalopathy but there are others. There were no areas of prominent focal slowing, although encephalopathic patterns can sometimes obscure focal findings. There were no epileptiform features. No electrographic seizure activity was noted. INTERPRETED BY: [Last Name (LF) 96],[First Name3 (LF) 125] H. (08-0504C) RADIOLOGY Final Report LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [2101-3-13] 9:58 AM LIVER OR GALLBLADDER US (SINGL Reason: EVAL OF GB, ABD PAIN [Hospital 93] MEDICAL CONDITION: 46 year old man with large SAH now with pancreatitis REASON FOR THIS EXAMINATION: evaluation of gallbladder CLINICAL HISTORY: 46-year-old male with large subarachnoid hemorrhage, now with pancreatitis. Evaluate gallbladder. COMPARISON: [2101-3-10]. FINDINGS: Right upper quadrant ultrasound was performed. Liver is diffusely echogenic, consistent with fatty infiltration. No focal hepatic lesion is identified. Limited views of the gallbladder are unremarkable without stones. No intra- or extra- hepatic biliary dilatation is appreciated. The common duct measures 6 mm. The portal vein is patent with hepatopetal flow. IMPRESSION: 1. Echogenic liver consistent with fatty infiltration. More advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this exam. No focal hepatic lesion is identified. 2. Limited views of the gallbladder are unremarkable. The study and the report were reviewed by the staff radiologist. RADIOLOGY Final Report US ABD LIMIT, SINGLE ORGAN PORT [2101-3-10] 4:38 PM US ABD LIMIT, SINGLE ORGAN POR Reason: eval for perotneal fluid [Hospital 93] MEDICAL CONDITION: 46 year old man with cva, on triple h therapy now with bladder pressure of 35 REASON FOR THIS EXAMINATION: eval for perotneal fluid INDICATION: 46-year-old man with CVA, bladder pressure of 35, evaluate for peritoneal fluid. COMPARISON: None. FINDINGS: Limited ultrasound of the abdomen demonstrates small-to-moderate amount of free fluid, predominately in the left lower quadrant. Small amount of fluid also seen around the liver. Incidentally noted is diffuse coarse echogenicity of the liver, incompletely evaluated on current study, raising the possibility of generalized fatty infiltration or other diffuse process LAB RESULTS: [2101-3-3] 10:25PM GLUCOSE-140 UREA N-12 CREAT-0.8 SODIUM-136 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-27 ANION GAP-13 [2101-3-3] 10:25PM estGFR-Using this [2101-3-3] 10:25PM WBC-18.0# RBC-4.56 HGB-15.1 HCT-44.3 MCV-97 MCH-33.1# MCHC-34.0 RDW-13.2 [2101-3-3] 10:25PM NEUTS-60.1 LYMPHS-34.2 MONOS-4.6 EOS-0.8 BASOS-0.2 [2101-3-3] 10:25PM PLT COUNT-170 [2101-3-3] 10:15PM PT-13.2 PTT-28.8 INR(PT)-1.1 Brief Hospital Course: [2101-3-3] Patient was admitted to the ICU for q1 hour neuro checks, BP control, dilantin, and HOB elevation. On [3-4] pt went to OR to have a R. ICA aneurysm coiled Dr. [First Name (STitle) ]. Patient returned to the ICU. Post operative CT was stable with no hydrocephalus/no hemorrhage. Over next 48hrs pt's mental status declined with decreased UE movement, decreased responsiveness. On [3-7] pt went to OR to have L.ICA aneurysm coiled by Dr. [First Name (STitle) ] and tolerated the procedure well. Patietn returned to the ICU. On [3-8] pt spiked a temperature to 102.5 and was pan cultured. Had a CT Perfusion (CTP) study which showed no vasospasm. Pt also had an echo which showed no valve vegetations and mild mitral regurgitation. On [3-9] pt had angio that showed vasospasm and continued to be febrile. Triple H therapy maintained. Repeat angio on [3-10] showed mild vasospasm -BP maintained at 180-200. CTP on [3-11] showed no vasospasm and nimodipine was discontinued due to hypotension. Secondary to patient developing edema Lasix drip was started and pressors were d/c'ed. [3-13] pt had a repeat CTA/CTP which showed distal spasm of m2 vessels. An U/S of gallbladder obtained due to elevated pancreatic enzymes. U/S showed no stones or ductal dilatation. Pt's mental status remained poor. [3-14] pt had and MRI which showed small areas of watershed infarct. Pt continued with elevated temperature spikes. Fever workup obtained. [3-15] dilantin was switched to keppra for possible drug fever. C.diff was negative x 2, flagyl was stopped. EEG showed moderate global encephalopathy. [3-6] blood cultures from a-line grew back coag negative staph. A-line d/c'ed and continued on abx. [3-17] pt was started on NaCl drip due to hyponatremia. TPN was initiated for bowel rest due to pancreatitis. CT head showed mild expansion of stroke. Trach and PEG placed. [3-18] WBC trending down. Wound cx negative. [3-20] Following commands with RUE. [3-21] pt neurologically improved with purposeful movement, following commands and eye tracking. Pt withdrawing all 4 ext to pain and moving RUE to command. Lasix was decreased and NaCl was weaned. Ceftriaxone course was completed. On [3-22], the patient was noted to have rightward eye deviation, and a repeat CT head showed findings consistent with right MCA infarct. He was started on normal saline for hydration to perfuse infarct area. A Passymuir valve was fitted that am. [3-31] Pt continues to be nonverbal,opening eyes, following commands with RUE. Able to show 4 fingers when asked to add 2+2, minimal w/d to noxious stimuli with BLE's. Pt neurologically waxing/[Doctor Last Name 688] with periods of decreased responsiveness. Modafinil started. Diet advanced to goal tube feeds through PEG site. Activity increased with Physical/Occupational therapy, tolerating OOB to chair by [Doctor Last Name ] lift. Medications on Admission: Medications prior to admission: Methadone 115mg/daily Discharge Medications: 1. Nicotine Transdermal 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [1-26] Puffs Inhalation Q6H (every 6 hours) as needed. 4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Methadone 10 mg/mL Concentrate Sig: One (1) PO DAILY (Daily). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aspirin 325 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). 10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 11. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Bisacodyl 10 mg Suppository Sig: [1-26] Suppositorys Rectal DAILY (Daily). 13. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 7 days. 14. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) ] Discharge Diagnosis: Bilateral ICA ANEURYSMS RIGHT FEMORAL ARTERY PSEUDOANEURYSM HYPONATREMIA/RESOLVED RIGHT MIDDLE CEREBRAL ARTERY STROKE PANCREATITIS Discharge Condition: Neurologically stable Continues to improve neurologically. Left arm remains flaccid. Discharge Instructions: DISCHARGE INSTRUCTIONS FOR HEAD INJURY . Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may shower ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] IF YOU NEED TO CANCEL YOUR SCHEDULED APPOINTMENT WITH DR. [First Name (STitle) ]. YOUR APPOINTMENT IS SCHEDULED FOR [5-5] AT 1:30. PRIOR TO THE APPOINTMENT YOU WILL HAVE A CAT SCAN SCHEDULED AT 11:30AM. Completed by:[2101-4-1*]	[ "276.1", "430", "442.3", "434.91", "518.5", "070.54", "997.02", "577.0" ]	icd9cm	[ [ [] ] ]	[ "96.6", "96.72", "88.48", "88.41", "33.23", "31.1", "38.93", "96.04", "39.72", "43.11", "99.15" ]	icd9pcs	[ [ [] ] ]	28776, 28846	24523, 27503	282, 367	29021, 29108	2912, 3838	30261, 30540	1114, 1118		27608, 28753	23428, 23506	28867, 29000		27529, 27529			29132, 30238										1148, 1427												27561, 27585															2465, 2893	234, 244	23535, 24500										395, 842	1679, 2446	16836, 22240		4247, 9273								1442, 1663			864, 909	925, 1098
32,285	127,412	33201	Discharge summary	report	Admission Date: [2174-1-11] Discharge Date: [2174-1-20] Date of Birth: [2128-2-10] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Morphine Attending:[First Name3 (LF) 338] Chief Complaint: Bloody diarrhea Major Surgical or Invasive Procedure: Flexible sigmoidoscopy History of Present Illness: The patient is a 45 yo M, with new diagnosis of HIV ([2173-12-28] with CD4 200, VL 5.8mil) who is 5 days s/p discharge from [Hospital 58921] in NH on bactrim/prednisone for PCP PNA presented with 1 day history of blood in stool. He notes starting the AM PTA he had soft brown stool with bright red blood drops in toilet bowl with progressive increase in blood to 3 teaspoons and [6-28] bowel movements over the course of the day. He also notes mucous in stool and bloody streaks on his toilet paper. Prior to this, his stool has been normal and he denies eating any exotic or uncooked foods, denies sick contacts, travel, or drinking of unpurified water. He has had no h/o GIB or GI studies such as colonoscopy, but had known hemorrhoids which have never led to blood in stool. . In terms of his HIV/PCP and last hospital stay, he had a new diagnosis of HIV on [2173-12-28] at OSH when he was evaluated to have fever to 105 and bilateral PNA. He was started on course of prednisone taper, bactrim, and fluconazole for oral thrush. On retrospect, the patient has had 25 lb weight loss in past 4 months. Since discharge, he noted decreased cough, and was breathing comfortably on 3l NC O2. He has been staying with his sister in [Name (NI) 6151]. Was scheduled to see [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital1 778] for the newly diagnosed PCP. [Name10 (NameIs) 17613] good PO intake until this morning. . In the ED, inital vitals were 97.2 115/82 98 18 100%3L. 2 peripheral IV's were placed. Vital signs remained stable. Initial potassium 5.7. Repeat 5.4. No peaked T's on EKG. Received 1 dose of kayexalate. Received 2L NS in ED. Inital Hct was 35 (hct on [2173-12-29] was 34.8). Also, sodium was 120 on admission ([2173-12-29] Na=131). EKG showed NSR/NA/NI with evidence of early repolarization so enzymes were sent in the ED. Past Medical History: -- HIV - diagnosed at the beginning of [Month (only) 404] after presenting with PCP [Name Initial (PRE) 11091]; CD4 200, VL 5.8 million -- Splenectomy [2147] [1-22] MVA Social History: Manages Ski Resort Store in NH. Homosexual. Denies ETOH, tobacco, drugs. Currently lives with sister in [Name (NI) 6151]. Family History: DM throughout both sides Physical Exam: Vitals - Tc 98.4, 113/75, HR 110 (98-112), RR 24, 93% on 4L Stool: watery, incontinent, loose and guiac positive General - thin cachetic male, + temporal wasting, NAD, AAO x 3 HEENT - PERRL, EOMI, no oral thrush, no exudate Neck - supple CV - tachycardic, no murmur, rubs, gallops Lungs - CTA bilaterally, no wheezes, crackles, good air movement Abdomen - soft, NT/ND, no guarding or rigidity Ext - no edema, 2+ pulses b/l Pertinent Results: [2174-1-11] 05:45PM PT-14.8* PTT-27.0 INR(PT)-1.3* [2174-1-11] 05:45PM PLT SMR-NORMAL PLT COUNT-411 [2174-1-11] 05:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2174-1-11] 05:45PM NEUTS-87.6* BANDS-0 LYMPHS-7.6* MONOS-4.4 EOS-0.4 BASOS-0.1 [2174-1-11] 05:45PM WBC-7.5 RBC-4.18* HGB-12.7* HCT-35.4* MCV-85 MCH-30.5 MCHC-36.0* RDW-14.6 [2174-1-11] 05:45PM CK-MB-NotDone cTropnT-<0.01 [2174-1-11] 05:45PM CK(CPK)-40 [2174-1-11] 05:45PM estGFR-Using this [2174-1-11] 05:45PM GLUCOSE-108* UREA N-19 CREAT-1.2 SODIUM-121* POTASSIUM-5.7* CHLORIDE-93* TOTAL CO2-18* ANION GAP-16 [2174-1-11] 07:38PM K+-5.4* Brief Hospital Course: 45 yo M, with new diagnosis of HIV ([2173-12-28] with CD4 200, VL 5.8mil) who is 5 days s/p discharge from OSH on bactrim/prednisone for PCP PNA presents with bloody diarrhea, transferred to the ICU for respiratory distress. . #. Respiratory distress. On [1-13] his oxygen requirement increased from 3L to 5L. A repeat chest X-ray showed no significant changes. Induced sputum was attempted but sample was inadequate. He was stable through [1-14] with shortness of breath with minimal exertion. At 5am on the morning of transfer, he was noted to be tachypneic in the 30's with a sat of 78% on 4L. He was transitioned to a NRB mask, and his oxygen saturation improved to 89%. ABG at that time was 7.54/23/52/20, and he was transferred to the MICU for worsening hypoxia. He was intubated on arrival to the MICU. Thought to be worsening PCP [Last Name (NamePattern4) ]. CMV pneumonia vs. superinfection, although bronchoscopy revealed only PCP. [Name10 (NameIs) ] the next several days, his ventilatory requirements increased and he was proned for increased V/Q matching. After a meeting with the family, care was withdrawn, and the patient expired soon thereafter. . #. Bloody diarrhea - Found to have CMV colitis on sigmoidoscopy with biopsies. Started on ganciclovir, which was continued on transfer to the MICU given concern for systemic CMV infection/CMV pneumonitis. Medications on Admission: -- Prednisone 40mg (x5days, last day of this dose [2174-1-12]); then startnig prednisone 20mg x 11 days. -- Bactrim DS 2 tabs TID until [2174-1-16] -- Lorazepam 0.5mg q4PRN -- Avelox 1 tab daily (last day [2174-1-13] - 7 day course) -- Fluconazole 200mg daily (last day [2174-1-14] - 7 day course) Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "995.92", "042", "276.7", "112.0", "136.3", "078.5", "008.69", "455.6", "V46.2", "518.81", "V85.1", "707.05", "V18.0", "038.9", "276.1", "785.52", "584.9", "484.1", "300.00" ]	icd9cm	[ [ [] ] ]	[ "96.72", "33.24", "96.04", "48.24", "38.93" ]	icd9pcs	[ [ [] ] ]	5657, 5666	3870, 5261	307, 331	5717, 5726	3128, 3847	5782, 5792	2643, 2669		5625, 5634		5687, 5696		5287, 5602			5750, 5759										2684, 3109																												252, 269											359, 2273															2295, 2481	2497, 2627
6,942	189,542	53217+59512	Discharge summary	report+addendum	Admission Date: [2201-1-4] Discharge Date: [2201-1-10] Service: VASCULAR CHIEF COMPLAINT: Peripheral vascular disease. HISTORY OF PRESENT ILLNESS: This is an 89 year-old female with a complicated past medical history with peripheral vascular disease now presents for lower extremity bypass. She was initially admitted to our institution on [10-24] with mental status changes and hypotension. At the same time she was worked up for right lower extremity cellulitis with arterial noninvasives showing arterial insufficiency and MRI was done, which was negative for osteomyelitis and arteriogram showed superficial femoral artery disease. The patient was discharged home in stable condition. The patient now returns for elective revascularization. ALLERGIES: Sulfa, intravenous contrast, manifestations not documented. MEDICATIONS: 1. Aspirin 81 mg q.d. 2. Atenolol 100 q.d. 3. Lipitor 80 q.d. 4. Diovan 80 q.d. 5. Insulin b.i.d. 6. Nitroglycerin sublingual prn. 7. Protonix 40 q day. 8. Plavix 75 mg q.d. last dose was [11-23]. 9. Ciprofloxacin 500 mg q.d. 10. Flagyl 250 mg q.d. 11. Nifedipine XL 30 mg. 12. Lasix 20 mg. 13. Imdur 30 mg t.i.d. 14. Potassium 10 milliequivalents q.d. These have all been held in preparation for surgery. PAST MEDICAL HISTORY: 1. Coronary artery disease with angioplasty to the right coronary artery in [2191]. 2. History of rheumatic fever. 3. History of type 2 diabetes insulin dependent. 4. History of dyslipidemia. 5. History of deep venous thrombosis. 6. History of breast carcinoma. 7. History of renal stones. 8. History of anemia of chronic disease. 9. History of osteoporosis. 10. History of diverticulosis. 11. Cerebrovascular accident with a history transient ischemic attacks hospitalized in [2200-10-20]. 12. Carotid stenosis 60 to 69% on the right internal carotid and less then 40% in the left internal carotid artery. PAST SURGICAL HISTORY: 1. Mastectomy in [2176]. 2. Multiple vitreous hemorrhages repair. 3. Partial hysterectomy in the [2156]. PHYSICAL EXAMINATION: Vital signs 97.2, 72, 98/60, 18, 02 sat 99% on room air. Chest examination lungs are clear to auscultation bilaterally. Heart regular rate and rhythm. Abdominal examination is with bowel sounds, otherwise unremarkable. Extremities are without edema. Pulse examination shows 2+ radial pulses, 2+ femoral pulses, popliteals are absent. Right dorsalis pedis pulse is dopplerable monophasic. Posterior tibial pulse is absent. The left dorsalis pedis pulse and posterior tibial pulse are dopplerable monophasic signals. ADMISSION LABORATORIES: White blood cell count 7.5, hematocrit 30.2, BUN 23, creatinine 1.2. Electrocardiogram normal sinus rhythm, normal axis, no acute changes. Chest x-ray unremarkable. HOSPITAL COURSE: The patient was admitted to the Vascular Service and started on intravenous antibiotics. She underwent on [2201-1-5] a right common femoral to BK popliteal with in situ saphenous vein angioscopy valve lysis. She required 1 unit of packed red blood cells intraoperatively. She was transferred to the PACU in stable condition. Postoperative hematocrit was 27.7. The patient continued to do well and was transferred to the VICU for continued monitoring and care. Postoperative day one the patient was given Ativan and 5 of Morphine resulting in increasing sedation, analgesics and antilytics were held. The patient was transfused a second unit of packed red blood cells. Physical examination was unremarkable. A doppler examination showed a dopplerable peroneal, dopplerable dorsalis pedis pulse and posterior tibial pulse. Mental status showed improvement with holding analgesics and Ativan. The patient remained in the VICU for hemodynamic monitoring. The patient was agitated requiring restraint so she would not discontinue her Swan or arterial line. Cardiac enzymes were flat. Electrocardiogram without changes. Urinalysis obtained, which showed 6 to 10 white blood cells with occasional bacteria, nitrite negative. Culture was sent, which was finalized on [2200-12-19] as no growth. The patient was delined on postoperative day number three and transferred to the regular nursing floor. Physical therapy was requested to see the patient in participation for evaluation for discharge planning. The family will manage the patient at discharge even if rehab needs are required. The remaining hospital course was unremarkable. Foley was discontinued on postoperative day three. The patient was discharged in stable condition. Wounds were clean, dry and intact. She had a biphasic dorsalis pedis pulse. Artery pulse peroneal was a triphasic signal. The patient is to follow up with Dr. [Last Name (STitle) ] in two weeks time. DISCHARGE MEDICATIONS: 1. Atorvastatin 80 mg q.d. 2. Plavix 75 mg q.d. 3. Aspirin 81 mg q.d. 4. Atenolol 100 mg q.d. hold for systolic blood pressure less then 100, heart rate less then 60. 5. Nifedipine CR 30 mg q.d. hold for systolic blood pressure less then 120. 6. Valsartan 80 mg q.d. hold for systolic blood pressure less then 110. 7. Protonix 40 mg q.d. 8. Calcium carbonate 500 mg discontinued. 9. Acetaminophen 325 to 650 mg q 4 to 6 hours prn for pain. DISCHARGE DIAGNOSES: 1. Peripheral vascular disease, fem tibial disease, status post right common femoral artery to BK popliteal bypass graft and nonreverse saphenous vein and vein angioplasty to the common femoral artery. 2. Type 2 diabetes insulin dependent, controlled. 3. Blood loss anemia, corrected. 4. Postoperative confusion secondary to sedation, resolved. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) ], M.D. [MD Number(1) 19472] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2201-1-8] 08:54 T: [2201-1-8] 08:56 JOB#: [Job Number 109565] Name: [Known lastname 17974], [Known firstname 1049] Unit No: [Numeric Identifier 17975] Admission Date: [2201-1-4] Discharge Date: [2201-1-12] Date of Birth: [2111-7-17] Sex: F Service: ADDENDUM: The [Hospital 1325] hospital discharge was delayed secondary to requiring continued physical therapy and continued antibiotic therapy with levofloxacin and Flagyl for right foot metatarsal joint two tenderness which improved after antibiotics. CONDITION AT DISCHARGE: The patient was discharged in stable condition. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to continue on antibiotics until seen in followup with Dr. [First Name4 (NamePattern1) 255] [Last Name (NamePattern1) 4107]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4108], M.D. [MD Number(1) 4109] Dictated By:[Last Name (NamePattern1) 145] MEDQUIST36 D: [2201-1-12] 08:58 T: [2201-1-12] 09:37 JOB#: [Job Number 17976]	[ "733.00", "V10.3", "285.1", "440.23", "424.0", "E878.2", "250.00", "292.81", "707.15" ]	icd9cm	[ [ [] ] ]	[ "38.22", "39.29", "99.04" ]	icd9pcs	[ [ [] ] ]								5288, 6437	4817, 5267					2834, 4794				6535, 6964						1961, 2078																	2101, 2816	6452, 6501												111, 141											170, 1288															1310, 1938
10,220	123,351	54177	Discharge summary	report	Admission Date: [2120-1-11] Discharge Date: [2120-1-18] Date of Birth: [2051-6-14] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 943] Chief Complaint: Fever and respiratory distress. Major Surgical or Invasive Procedure: Endotracheal intubation Post-pyloric tube placement PICC line placement History of Present Illness: Mr. [Known lastname 111034] is a 68 year-old man with a history of hepatitis C/ cirrhosis hepatocellular carcinoma s/p cadaveric liver transplant in [1-/2118], also with a history of CAD s/p RCA and LAD stenting in [1-/2118], HTN, GERD, DM type 2, dementia, recently admitted to [Hospital1 18] [Hospital1 18] [Date range (3) 111043] for fever and hypoxia felt [1-31] RLL pneumonia and treated with Flagyl, Vancomycin and Levofloxacin empirically, now presenting with recurrent fever, hypoxia and mental status changes for 1 day. Per rehab reports, on [2120-1-10], patient developed a fever (to 102), hypoxia (91% on 2L) and lethargy ("stopped speaking"). In the [Hospital1 ] ED, T 102, HR 112, BP 144/63, R 27, O2 sat 92% 5L. An ABG initially revealed 7.43/37/76. A CXR revealed persistent bilateral pleural effusions and RLL atelectasis versus infiltrate. He was started on vancomycin, ceftazidime and metronidazole. However, while in the ED, Mr. [Known lastname 111034] developed increasing respiratory distress and was intubated for increased work of breathing. He was transferred to the [Hospital1 18] [Hospital Unit Name 153] for further care. Past Medical History: 1. Hepatitis C/cirrhosis /HCC, status post cadaveric liver transplant in [2118-4-28] 2. Coronary artery disease, status post RCA and LAD stenting 3. Hypertension 4. Gastroesophageal reflux disease 5. Diabetes mellitus type 2 6. Dementia Social History: Ms. [Name14 (STitle) 111044] recently moved to a NH ([2119-1-29]) secondary to his progressive dementia. He was born in Sicily. Ex-smoker, with 10 pack-year smoking history. No h/o IVDU or blood transfusion prior to [2104]. Past history of EtOH consumption. Of note, received flu shot in 12/[2118]. Family History: Liver disease per OMR notes. Physical Exam: Per initial ICU evaluation: VITALS: T 102, BP 140/80, HR 70s regular, RR 25, Sat 95% on 3L via NC. GENERAL: Ill-appearing elderly male, lethargic, not responding verbally but opens eyes to name and follows commands. HEENT: PERRL, EOMI, anicteric. RESP: Bibasilar rales. CVS: Normal S1, S2. No S3, S4. No murmur or rub. GI: BS hypoactive. Abdomen soft and non-tender. EXT: 3+ pitting edema bilaterally to hips. In ED, patient subsequently developed increased work of breathing and was intubated, although a repeat blood gas was essentially unchanged. Pertinent Results: Relevant laboratory data on admission: CBC: WBC-13.0# RBC-4.51 HGB-12.4* HCT-37.5* MCV-83 MCH-27.4 MCHC-32.9 RDW-17.3* (NEUTS-87.5* LYMPHS-7.7* MONOS-4.5 EOS-0.2 BASOS-0.1) PLT COUNT-280 Coagulation profile: PT-13.9* PTT-23.9 INR(PT)-1.2 Chemistry: GLUCOSE-235* UREA N-30* CREAT-1.1 SODIUM-138 POTASSIUM-5.6* CHLORIDE-107 TOTAL CO2-21* ANION GAP-16 ALT(SGPT)-17 AST(SGOT)-42* ALK PHOS-65 AMYLASE-44 TOT BILI-0.4 LIPASE-19 TOT PROT-6.1* ALBUMIN-2.8* GLOBULIN-3.3 CALCIUM-8.5 LACTATE-2.3* ABG in ED: TYPE-ART RATES-/27 O2 FLOW-10 PO2-170* PCO2-34* PH-7.42 TOTAL CO2-23 Urinalysis: COLOR-Straw APPEAR-Hazy SP [Last Name (un) 155]-1.020 BLOOD-TR NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD RBC-0-2 WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0-2 EKG on admission: Sinus rhythm, rate 100. Normal tracing. Compared to the previous tracing of [2119-12-27], upright T waves in leads V3-V4. CXR [2120-1-10]: The heart size and mediastinal contours are unchanged. In comparison with the previous examination, the lung volumes have increased. There are stable emphysematous changes bilaterally, and stable prominence of the interstitial markings and upper zone pulmonary vascular redistribution. Moderate right pleural effusion appears slightly increased. No pneumothorax. Persistent opacity at the right base is suggestive of compressive atelectasis versus consolidation within the right lower lobe. The osseous structures appear unremarkable. IMPRESSION: Increased right pleural effusion. Persistent bibasilar atelectasis versus consolidation at the right lower lobe. Stable pulmonary congestion and emphysematous change. Relevant data in hospital: [2120-1-11] U/S ABDOMEN: A 4-quadrant son[Name (NI) 493] examination of the abdomen was performed to evaluate for ascites. No ascites was demonstrated. No attempted paracentesis or marking of spot was made. [2120-1-11] CXR An endotracheal tube terminates at the thoracic inlet. An NG tube curls within the stomach with its distal tip at the fundus. The heart is not enlarged. There is mild pulmonary edema. Bilateral effusions are present along with atelectasis at both lung bases that appear unchanged when compared to the prior examination. No osseous abnormalities are seen. No pneumothorax is identified. [2120-1-17] CXR: AP single view obtained with the patient in semierect position, is analyzed in direct comparison with a previous chest examination dated [2120-1-11]. The patient is now extubated. An NG tube remains and reaches below the diaphragm, apparently curled up in the stomach. There is no evidence of pneumothorax. Both lungs are well expanded. The bases are somewhat diffusely obscured, more marked on the right than on the left. A right diaphragmatic contour is obliterated and a density along the lateral wall is suggestive of pleural effusion layering mostly posteriorly. There is no conclusive evidence for any parenchymal infiltrate. In answer to specific question of free abdominal air, there is no conclusive evidence of such finding, but this cannot be completely eliminated as the patient is in semierect position only. Brief Hospital Course: 68 year-old man with a history of hepatitis C/cirrhosis/hepatocellular carcinoma s/p cadaveric liver transplant in [1-/2118], also with a h/o CAD s/p RCA and LAD stenting, dementia and recent admission for pneumonia, now presenting with a 1-day history of fever, hypoxia and mental status changes. His hospital course will be reviewed by problems. 1) Fever: A CXR on admission was suspicious for a RLL infiltrate (atelectasis versus pneumonia), and Mr. [Known lastname 111034] was initially started on broad spectrum antibiotics with Vancomycin, Flagyl and Ceftazidime pending culture data. His urine eventually grew Klebsiella, and sputum cultures revealed GNR. In light of these results, Vancomycin was D/C'd on [2120-1-11], and Cipro was added for double gram negative coverage pending final organism identification and sensitivites. Sensitivities revealed Klebsiella resistant to Cephalosporins, and sensitive to Imipenem. Hence, Ceftazidime and Flagyl were D/C'd on [2120-1-12], and Imipenem was started. The sputum culture eventually grew Klebsiella with the same sensitivities as in the urine, and Cipro was D/C'd on [2120-1-15]. The patient defervesced on the above antibiotherapy, and plan is to complete a 14-day course of Imipenem monotherapy (last doses on [2120-1-25]). While in hospital, he developed diarrhea, negative for C.difficile. Also of note, Mr. [Known lastname 111034] has sacral and heel pressure ulcers, which will need to be followed up. The patient was seen by the wound care nurse while in hospital. 2) Respiratory failure: His initial respiratory failure was felt most likely secondary to pneumonia +/- chemical pneumonitis in the setting of a depressed mental status. As noted above, Mr. [Name13 (STitle) 111045] was intubated shortly after admission, and transferred to the [Hospital Unit Name 153] for further care. He was quickly extubated on [2120-1-11] at night, and remained stable from a respiratory standpoint following extubation. He was transferred back to the floor on [2120-1-12] on supplemental oxygen 4L via NC. A CXR on [2120-1-11] was consistent with mild CHF, and Mr. [Known lastname 111034] was gently diuresed while on the floor with Lasix 20 mg IV prn with goal negative 500cc/day, with good response. He was weaned from 4 to 1L/min via NC at the time of discharge, and was able to tolerate extended periods on room air (94%). He will need continued chest physiotherapy as an out-patient. 3) Hypertension: Patient hypertenssive in the ICU and on the floor. Both Metoprolol and Captopril were titrated up, with improved blood pressure control, although systolic blood pressure remains elevated at discharge (130-160). Regimen at discharge includes Metoprolol 100 mg PO TID and Captopril 50 mg PO TID. 4) CAD: Patient with known CAD s/p RCA and LAD stenting in 2/[2117]. While in hospital, Mr. [Known lastname 111034] was continued on BB, ACEI. Aspirin therapy was resumed (stopped for an unclear reason during a prior admission) after confirming with Dr. [Last Name (STitle) 497]. No acute issues while in hospital. 5) Status post liver transplant: Patient on Tacrolimus therapy 1.5 mg PO BID with goal trough [5-5]. Mr. [Known lastname 111034] was followed by the hepatology service throughout his hospital stay. Tacrolimus levels therapeutic (5.6 on [2120-1-17]) and LFT WNL during hospital course. 6) DM type 2: While in hospital, Avandia was held and patient was kept on a regular insulin sliding scale, with fair glycemic control. Avandia 8 mg PO QAM resumed on [2120-1-18]. 7) Dementia: Patient admitted with acute on chronic mental status change, likely in the setting of his acute infection. At baseline, he is minimally verbally responsive, but certainly interactive. His mental status gradually improved while in hospital, and back at baseline at the time of discharge (per wife). Of note, prior to admission, patient started on Sinemet and ? Ritalin [Hospital1 ], and unclear if Prozac D/C'd. While in hospital, he was continued on Fluoxetine. Will discharge on Fluoxetine and Sinemet, and leave it to his PCP to decide re: Ritalin. 8) FEN: While in the ICU, a bedside swallowing evaluation and video swallowing revealed aspiration with thin liquids but adequate swallowing with pureed foods/nectar-thick liquids consistency. A caloric count was performed while in hospital, which revealed sub-optimal caloric intake. After discussion with the patient and his wife, a post-pyloric feeding tube was placed and tube feeds initiated on [2120-1-16]. Unfortunately, patient removed tube on [2120-1-17]. By the wife account, patient able to consume enough calories if he is fed slowly. She expressed a desire to feed him and ensure adquate caloric intake. When fed adequately, patient does have adequate intake. Hence, the feeding tube was not replaced and MR. [Known lastname 111034] was discharged on PO feeds. Medications on Admission: 1. Fluoxetine HCl 20 mg po qd 2. Multivitamin 1 tablet po qd. 3. Metoprolol 50 mg po bid. 4. Docusate Sodium 100 mg po bid. 5. Galantamine 12 mg po bid. 6. Tamsulosin 0.4 mg po qhs. 7. Trimethoprim-Sulfamethoxazole 80-400 mg po qd. 8. Tacrolimus 1.5 mg po bid. 9. Captopril 25 mg po tid. 10. Albuterol 0.083 % 1 neb inhaled q6h. 11. Ipratropium 0.02 % 1 neb inhaled q6h. 12. Ferrous Sulfate 325 (65) mg po tid. 13. RISS. 14. Heparin 5,000 U sc tid. Discharge Medications: 1. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Galantamine Hydrobromide 4 mg Tablet Sig: Three (3) Tablet PO bid (). 6. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Tacrolimus 5 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 12. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q1-2H () as needed for wheezing. 13. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 14. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Imipenem-Cilastatin 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous every six (6) hours for 8 days: Please give last doses on [2120-1-25]. 18. Sinemet 25-100 mg Tablet Sig: One (1) Tablet PO three times a day. 19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) mL PO TID:PRN as needed for constipation: Titrate to 1 BM per day. 20. Regular insulin sliding scale 21. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 22. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for fever or pain. 23. Rosiglitazone Maleate 8 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Location (un) 29393] - [Location (un) 2251] Discharge Diagnosis: Urosepsis Right lower lobe pneumonia Hypertension Coronary artery disease status post RCA and LAD stenting Status post cadaveric liver transplant in [2118-1-29] Diabetes mellitus type 2 Dementia Discharge Condition: Patient discharged to nursing home in fair condition. Discharge Instructions: Ms. [Known lastname 111034] has a scheduled appointment with Dr. [Last Name (STitle) 497] on [2120-1-31], at 08:40. He also has a scheduled appointment with neurology on [1-29], [2119] at 14:30. Please see below for location. Please call patient's PCP and schedule an appointment to see him within 2 weeks of discharge. Patient should return to the ED if recurrent fever, N/V, increasing oxygen requirements or mental status change. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 497] and Dr. [Last Name (STitle) ] as scheduled below. 1. Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Where: LM [Hospital Unit Name 3126] Phone:[Telephone/Fax (1) 673] Date/Time:[2120-1-31] 8:40 2. Provider: [First Name8 (NamePattern2) 539] [Last Name (NamePattern1) 540] MD Where: [Hospital6 29] NEUROLOGY Phone:[Telephone/Fax (1) 541] Date/Time:[2120-1-29] 2:30 Please also call Mr. [Known lastname 111046] PCP and schedule an appointment to see him within 2 weeks of discharge. Completed by:[2120-1-18]	[ "599.0", "482.0", "294.8", "250.00", "518.81", "V45.82", "263.9", "530.81", "707.07", "507.0", "414.01", "401.9", "707.03", "V42.7", "428.0", "V10.07", "276.7", "492.8" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.71", "96.04", "96.6" ]	icd9pcs	[ [ [] ] ]	13522, 13601	6041, 11014	312, 386	13843, 13898	2842, 2867	14402, 15017	2226, 2256		11513, 13499		13622, 13822		11040, 11490			13922, 14379										2271, 2823																												241, 274											414, 1613										3654, 6018					1635, 1877	1893, 2210
42,054	159,025	42457+58530	Discharge summary	report+addendum	Admission Date: [2103-12-6] Discharge Date: [2103-12-21] Date of Birth: [2059-4-15] Sex: F Service: MEDICINE Allergies: Zosyn / meropenem / azithromycin / vancomycin Attending:[First Name3 (LF) 4095] Chief Complaint: Rash Major Surgical or Invasive Procedure: -Endotracheal intubation -Mechanical Ventilation -Bronchoscopy -Dermal Biopsy -VATS procedure -Lung biopsy History of Present Illness: HISTORY OF PRESENT ILLNESS: 44F w maculopapular rash total body since 5 days ago, starting on chest. This rash has worsened and she presented to OSH today. She was recently hospitalized for ETOH hepatitis. Denies any drinking since before [Holiday 1451]. . Also noted increased shortness of breath over past several days, fever to 102 at PCP [Name Initial (PRE) 3011]. Presented to OSH and found to have PNA --> treated w/ vanc/zosyn; also given benadryl or pruritis. Transferered to our ED for further care, vitals upon arrival 98.4 92 112/78 18 97%. Also given acyclovir for concern of herpetic rash and azithromycin. . Vitals upon transfer 97.5, 93, 20, 140/73, 98%RA. . REVIEW OF SYSTEMS: Denies chills, night sweats, headache, vision changes, rhinorrhea,burning in vagina, nose, eyes, or anal mucosa. Past Medical History: Alcohol abuse Social History: Lives with his eldest of 2 sons. [Name (NI) ] lots of family support (mother, sisters, [Name2 (NI) 12232]) - requires 24 hour care at home. Not currently employed, on SSI. - Smoking: quit > 16 yrs ago, 25 pack year history - EtOH: history of abuse, denies any alcohol use since last admission - Drugs: history of polysubstance abuse including cocaine, crack, barbiturates, amphetamines, and marijuana. None for 20 years. Family History: No pertinent family history, including PSC, liver disease, or other gastrointestinal disease. (Has identical twin brother without above conditions). Grandfather with diabetes. Physical Exam: ON ADMISSION: VS - Temp 97.5 F, BP 112/68, HR 94, R 18, O2-sat % 100 RA GENERAL - Slightly uncomfortable in NAD HEENT - NC/AT, PERRLA, EOMI, sclerae slightly icteric. MMM with torus on roof of mouth. Lips with resolving cold sore. NECK - supple, LUNGS - Crackles at left base. No r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - Patient with diffuse erythematous macules coalesing into patches and plaques most notably on face, chest, back, and thighs bilaterally. No evidence of nose, mouth, conjunctival, or anal mucossa involvement. Some secondary excoriations; some of the lesions may have tiny pustular component. NEURO - awake, A&Ox3, CNs II-XII grossly intact . DISCHARGE EXAM: VS 98.3, 129/72, 69, 18, 97 RA GENERAL - well-appearing, NAD, comfortable HEENT - PERRL, sclerae anicteric, MMM, OP clear NECK - supple, no JVD LUNGS - good air movement, no other focal findings, no accessory musc use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - Obese, nontender, no rebound/guarding EXTREMITIES - significant pitting edema in the lower extremities bilaterally SKIN - diffuse errythema without macules or pustules and dry scaling across all of her skin. NEURO - awake, A&Ox3, moving all extremities, CNs II-XII grossly intact Pertinent Results: ADMISSION LABS: [2103-12-6] 07:20PM BLOOD WBC-31.2* RBC-2.85* Hgb-8.7* Hct-30.1* MCV-106* MCH-30.5 MCHC-28.9* RDW-17.7* Plt Ct-537* [2103-12-6] 07:20PM BLOOD Neuts-92.4* Bands-0 Lymphs-4.4* Monos-0.7* Eos-1.9 Baso-0.6 [2103-12-6] 08:45PM BLOOD PT-25.1* PTT-43.8* INR(PT)-2.4* [2103-12-6] 07:20PM BLOOD Glucose-136* UreaN-56* Creat-1.9* Na-136 K-4.7 Cl-106 HCO3-17* AnGap-18 [2103-12-6] 07:20PM BLOOD ALT-47* AST-154* LD(LDH)-388* AlkPhos-314* TotBili-3.1* [2103-12-6] 07:20PM BLOOD Albumin-2.5* Calcium-8.2* Phos-5.4* Mg-1.9 [2103-12-6] 08:59PM BLOOD Lactate-1.5 [2103-12-6] 09:30PM URINE RBC-2 WBC-28* Bacteri-NONE Yeast-NONE Epi-5 [2103-12-6] 09:30PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM . DISCHARGE LABS: [2103-12-21] 05:12AM BLOOD WBC-31.0* RBC-2.37* Hgb-7.0* Hct-23.2* MCV-98 MCH-29.5 MCHC-30.2* RDW-19.6* Plt Ct-261 [2103-12-18] 04:18AM BLOOD Neuts-94.2* Lymphs-3.1* Monos-2.2 Eos-0.3 Baso-0.3 [2103-12-19] 05:03AM BLOOD PT-17.5* PTT-30.6 INR(PT)-1.6* [2103-12-21] 05:12AM BLOOD Glucose-103* UreaN-39* Creat-0.7 Na-140 K-3.5 Cl-106 HCO3-25 AnGap-13 [2103-12-20] 05:53AM BLOOD ALT-141* AST-165* AlkPhos-234* TotBili-2.0* [2103-12-19] 05:03AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1 . MICROBIOLOGY: --------------- #From Lung Biopsy: GRAM STAIN (Final [2103-12-17]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2103-12-20]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [2103-12-18]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [2103-12-18]): NO FUNGAL ELEMENTS SEEN. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2103-12-18]): NEGATIVE for Pneumocystis jirovecii (carinii).. #PLEURAL FLUID RIGHT PLEURAL FLUID. GRAM STAIN (Final [2103-12-17]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2103-12-20]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [2103-12-18]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [2103-12-18]): NO FUNGAL ELEMENTS SEEN. # VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. Respiratory Viral Culture (Final [2103-12-15]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus # VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. # CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final [2103-12-16]): Negative for Cytomegalovirus early antigen by immunofluorescence. Refer to culture results for further information. # BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [2103-12-12]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2103-12-14]): ~[2091]/ML Commensal Respiratory Flora. YEAST. ~[2091]/ML. LEGIONELLA CULTURE (Final [2103-12-19]): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [2103-12-12]): Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2103-12-13]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [2103-12-13]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. # Legionella Urinary Antigen (Final [2103-12-11]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. # VARICELLA-ZOSTER IgG SEROLOGY (Final [2103-12-11]): POSITIVE BY EIA. A positive IgG result generally indicates past exposure and/or immunity. # CMV IgG ANTIBODY (Final [2103-12-14]): POSITIVE FOR CMV IgG ANTIBODY BY EIA. 108 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. # CMV IgM ANTIBODY (Final [2103-12-14]): POSITIVE FOR CMV IgM ANTIBODY BY EIA. Interpret IgM result with caution; liver disease, autoimmune and lymphoproliferative diseases may cause false positive results. A positive IgG result generally indicates past exposure. Infection with CMV once contracted remains latent and may reactivate when immunity is compromised. IgM antibody may persist for 6 months or longer after primary infection and may reappear during reactivation. Greatly elevated serum protein with IgG levels >[2091] mg/dl may cause interference with CMV IgM results. Submit follow-up serum in [1-11] weeks. # Blood Culture, Routine (Final [2103-12-12]): NO GROWTH. # URINE CULTURE (Final [2103-12-10]): <10,000 organisms/ml. # RAPID PLASMA REAGIN TEST (Final [2103-12-11]): NONREACTIVE. # HEPATITIS HBsAg NEGATIVE # HIV SEROLOGY HIV Ab: NEGATIVE # B-GLUCAN (negative) # HISTOPLASMA ANTIBODY 1:1 (negative) # COCCIDIOIDES ANTIBODY 1:16 (negative) # VZV AB IGM, EIA 3.76 H (positive) # HSV 1 IGG TYPE SPECIFIC AB >5.00 (positive) # HSV 2 IGG TYPE SPECIFIC AB 3.99 (positive) # HSV 1 IgM, IFA <1:20 (negative) # HSV 2 IgM, IFA <1:20 (negative) # ASPERGILLUS ANTIGEN 0.1 (negative) IMMUNOLOGY: ------------- # AUTOANTIBODIES Smooth ANCA NEGATIVE B1 # IMMUNOLOGY [Doctor First Name ]: NEGATIVE # GASTROINTESTINAL tTG-IgA 101 # GLOMERULAR BASEMENT MEMBRANE <1.0 (negative) # SOLUBLE LIVER ANTIGEN (SLA) <20.1 (negative) IMAGING: ---------- # CXR [2103-12-7]: Bilateral multifocal pneumonias are in a similar distribution and extent as compared to prior radiograph from [2103-12-6]. However, some of these cavitations are showing central lucencies which is concerning for cavitation. Bilateral small pleural effusions are present, which are unchanged. Top normal heart size, mediastinal and hilar contours are stable. # Abdominal US [2103-12-7]: 1. Patent hepatic vasculature. 2. Cholelithiasis without cholecystitis or intra-/extra-hepatic biliary dilatation. 3. Echogenic liver, compatible with fatty infiltration, although other forms of cirrhosis/fibrosis cannot be excluded. 4. Trace ascites and splenomegaly. # Chest CT [2103-12-8]: 1. Diffuse ground-glass opacities in both lungs some of which are nodular, but not cavitated, most likely representing multifocal pneumonia. 2. The moderate right pleural effusion and scattered mediastinal, hilar, axillary lymph nodes are likely reactive. # Chest CT [2103-12-11]: 1. Extensive largely interstitial infiltration and nonconsolidated alveolitis worsened throughout both lungs. Pulmonary hemorrhage and viral pneumonia would be leading possibilities. Smaller regions of consolidation are less prominent today than five days ago, suggesting some improvement in what might have been smaller foci of severe hemorrhage or pneumonia due to another pathogen. Since there has been an increase in a moderate nonhemorrhagic pleural effusion, pulmonary edema is an alternative third explanation for the widespread pulmonary abnormality. # ECHO [2103-12-13]: The left atrium is mildly dilated. The left atrium is elongated. The estimated right atrial pressure is 5-10 mmHg. 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 diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild-moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: No endocarditis or abscess seen. Normal regional and global biventricular systolic function. Mild-moderate pulmonary artery systolic hypertension. # CXR [2103-12-19]: In comparison with the study of [12-18], the endotracheal tube and nasogastric tubes have been removed. Following chest tube removal, there is no definite evidence of pneumothorax. Diffuse bilateral pulmonary opacifications persist, though they may be somewhat decreased since the previous study. The appearance probably reflects a combination of pulmonary edema and multifocal pneumonia. # CXR [2103-12-21]: PATHOLOGY: ---------- # RUE Biopsy: Skin, right upper arm, punch biopsy (A): Focal intraepidermal pustule, mild spongiosis, dyskeratosis, and superficial perivascular infiltrate with focal neutrophils and rare eosinophils. Note: The pustule appears in deeper sections. The combined findings of an intraepidermal pustule, dyskeratosis, and dermal eosinophils favors a pustular drug eruption or acute generalized exanthematous pustulosis (AGEP). AGEP is usually due to a drug, however, rarely cases may be associated with a bacterial or viral infection. Gram stain is negative for bacteria. Preliminary findings discussed with Dr. [Last Name (STitle) ], Dermatology on [2103-12-15]. # LUNG BIOPSY: I. Lung, lower lobe superior segment, wedge biopsy (A-E): Acute and organizing pneumonia with hemorrhage, see note. II. Lung, right upper lobe, wedge biopsy (F-K): Acute and organizing pneumonia with hemorrhage, see note. III. Lung, right middle lobe, wedge biopsy (L-M): Acute and organizing pneumonia with hemorrhage, see note. Note: Likely causes include viral and bacterial etiologies. Special stains for bacterial organisms, fungi, and PCP will be issued in an addendum. PULMONARY FUNCTION TESTS: SPIROMETRY 10:05 AM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 1.54 3.68 42 FEV1 1.32 2.84 47 MMF 1.72 3.19 54 FEV1/FVC 86 77 112 LUNG VOLUMES 10:05 AM Pre drug Post drug Actual Pred %Pred Actual %Pred TLC 2.51 5.54 45 FRC 1.30 3.01 43 RV 0.98 1.86 53 VC 1.56 3.68 42 IC 1.21 2.53 48 ERV 0.31 1.15 27 RV/TLC 39 34 117 He Mix Time 2.25 DLCO 10:05 AM Actual Pred %Pred DSB 9.21 21.31 43 VA(sb) 2.03 5.54 37 HB 7.50 DSB(HB) 12.20 21.31 57 DL/VA 6.01 3.84 156 Brief Hospital Course: ASSESSMENT AND PLAN: 44F with recent alcoholic hepatitis who presented with shortness of breath, leukocytosis, fever, rash. She was treated with vanc and zosyn at an outside hosptial for possible hospital acquired pneumonia based on CXR. Her rash was felt to be related to a drug reaction and despite removing the most likely offending [Doctor Last Name 360] (zosyn) her respiratory status worsened and she was treated with IV steroids. Her rash evolved in this setting and initial concern for dismemiated zoster was raised, this ultimately was not felt to be the cause of her skin or lung pathology. As patient had worsening hypoxia and increase in interstitial process seen on interval Chest CTs despite antibacterial and antiviral therapy a bronchoscopy was preformed which did not show evidence of bacterial infection. The patient was started again on IV steroids and a lung biopsy by VATS preformed for evaluation of her lung process. Pathology demonstrated both a chronic cryptogenic organizing pneumonia as well as a more acute process with evidence of alveolar hemorrhage. The patient improved with steroids after a total of three trips to the ICU for respiratory distress. She was transitioned to PO steroids and had marked improvement in her oxygenation and rash. She was discharged to follow up with her PCP, [Name10 (NameIs) ] hepatologist and pulmonologist with a plan for drug allergy testing at a later date. . # AGEP: The patient presented from an outside hospital after developing a diffuse errythematous, puritic and pustulitic drug rash over her limbs, trunk and face. This occured approx 10 days after completing a course of vanc/zosyn for a hospital acquirred pneumonia during a previous admission. Drematology saw the patient on presentation and felt it was likely a simple drug rash that would improve with cesation of the causitive [Doctor Last Name 360], most likely felt to be zosyn. Patient did recieve this medication prior to transfer from the OSH complicating the evolution of her drug rash. The rash worsened over the next several days despite conservative managment developing diffuse pustules initially concerning for diseminated zoster. IgG was positive and IgM for viracella was positive as well, patient recieved a 7 day course of acyclovir while her pulmonary process was evaluated out of convern for a zoster pneumonitis. A skin biopsy was preformed which showed acute generalized errythematous pustulosis, a rare neutrophil mediated drug reaction. The patient ultimately recieved 5 days of IV solumedrol prior to being converted to 60 mg prednisone with marked improvement in her rash. . # Acute on Chronic Cryptogenic Organizing Pneumonia: prior to discharge from [Hospital1 18] in mid [2103-11-8] the patient developed respiratory distress and found to have a presumed multifocal pneumonia and was treated with vanc/zosyn for likely healthcare associated pneumonia. 10 days after her exposure to these drugs she developed the drug rash outlined above. She also reports an indolent history of SOB and DOE prior to her [Month (only) 1096] admission. Upon presentation to the OSH as CXR showed multifocal pneumonia for which she recieved vanc/zosyn, on arrival to [Hospital1 18] this was changed to Vanc/meropenem out of concern for drug rash. As her skin improved her respiratory status worsened despite antibiotics, Chest CT was preformed which showed diffuse ground glass opacities concerning for pneumoina. Her respiratory status continued to deteriorate and a pulmonary consult preformed a bronchoscopy which was not reveiling. Prior to this procedure, which was preformed in the ICU, the patient developed stridor and was started on solumedrol. ENT evaluated the patient and did not find evidence of layrngeal inflammation. As her interval chest imgaging continued to show worsening of her inflammatory process with steroids a VATS procedure for biopsy was preformed. Pathology demonstrated both a chronic cryptogenic organizing pneumonia as well as a more acute process with evidence of alveolar hemorrhage. The decision was made to continue steroids as infectious processes for her lung pathology were excluded by multiple cultures and serologies. She improved dramatically with this treatment and was no longer hypoxic. She had PFTs which showed a restrictive pattern and the patient was discharged on 60 mg prednisone daily, bactrim ppx, vitamin D and Calcium for a steroid course to be determined by outpatient pulmonology. . # Elevated LFTs: The patient was noted to have elevated AST and ALT as well as T bili from the time of discharge 2 weeks prior. This was initially felt to be possibly related to a DRESS phenomenon, though ultimately acute illness was the likely cause. Abdominal Ultrasound did not show acute liver process. Her LFTs continued to fluctate over the course of her stay, but she did not have signs of hepatic compromise. She will follow up with her primary hepatologist after discharge. . # Acute on chronic renal failure: patient had rise in her creatinine to 1.8 over the course of her stay, renal ultrasound was normal and patient responded to albumin challenge. She had urine eosinophils suggesting that the actue drug reaction may have caused a transient nephritis at the time of discharge her creatinine was 0.8. . # Leukocytosis: Patient was noted to have a leukocytosis of 30-40 over the course of her hospitalization. This was felt to be secondary to her alcoholic hepatitis and not an infectious process. She was discharged with a leukocytosis in the 30s that was normal for her. . # Hypercarbic failure: Post VATS procedure and extubation the patient was noted to be hypercarbic with a pH of 7.19. This was felt to be secondary to poor clearance of her anastehtic agents due to hepatic insufficency and the patient was reintubated and sent to the ICU. She was extubated 24 hours later without incident. . # Oral Candidiasis: Patient was noted to have non-painful candidial placques on her mouth and tounge in the setting of high dose steroids. She was given nystatin oral rinse without response adn was therefore treated with a 7 day course of oral fluconazole to be completed as an outpatient. . # Leg Swelling: felt to be secondary to hepatic chirrosis and vascular congestion, but patient was having improvement with diuresis with lasix. Was discharged on 80 mg lasix and 25 mg spirinolactone daily. . TRANSITIONAL ISSUES: -Patient is a full code confirmed on this admission -Patient will need to undergo allergy testing 1-2 months after resolution of her acute illness as the specific [Doctor Last Name 360] has yet to be identified and carrying unconfirmed allergies to such broad spectrum antibiotics would severely limit future antibiotic regimens. Medications on Admission: 1. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as needed) as needed for rectal irritation. Disp:1 tube Refills:0 6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a day. Disp:1800 ML(s) Refills:1 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every twelve (12) hours as needed for nausea. Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing/SOB. Disp:1 inhaler Refills:2 2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. Disp:1 tube Refills:10 4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 5. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 9. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:6 Tablet(s) Refills:0 10. calcium carbonate-vitamin D3 500mg (1,250mg) -600 unit Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: VNA of [Hospital3 ] Discharge Diagnosis: PRIMARY: -Cryptogenic organizing pneumomina -acute pulmonary inflammation -acute generalized errythematous pustulosis (drug reaction) -alcholic hepatitis -acute renal failure -hypercarbic respiratory failure 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: It was a pleasure taking care of you while you were in the hospital. You were admitted for evaluation and treatment of your rash, which was felt to be an allergic reaction to antibiotics. We are not sure which antibiotic caused this as you were exposed to several including: Vancomycin, zosyn, meropenem and azithromycin. The most likely cause was zosyn however. You will need to have allergy testing in the next few months to determine which antibiotics are safe for you to take. Your skin was biopsied and confirmed a drug reaction called acute generalized errythematous pustulosis or AGEP. This rash improved with topical creams and systemic steroids. . You were also transfered to the [Hospital1 18] with concern for a pneumonia. You recieved antibiotics at the outside hospital that may have contributed to the worsening of your rash and upon arrival to [Hospital1 18] these were changed and you continued to be treated for a bacterial pneumonia. Despite antibiotics your breathing and oxygenation actually got worse and you were seen by our pulmonologists who felt that your rash and breathing could have been caused by a severe case of chicken pox, you were treated for this but ultimately this was not felt to be the cause of your sypmtoms. A CT scan of your chest showed a large amount of inflammation in your lungs that despite steroids and antibiotics got worse on a repeat scan two days later. You were brought to the ICU for a procedure called a bronchoscopy and cultures were sent from this material which were negative. As it was not clear to any of the doctors [Name5 (PTitle) 40087] for [Name5 (PTitle) ] whether you had an infection or an allergic reaction in your lungs a lung biopsy was preformed. You tolerated the procedure well, but were slow to wake up so you were sent to the ICU for monitoring overnight. The biopsy results were unexpected. It appears that part of your lung was affected by a chronic condition called cryptogenic organizing pneumonia while other parts of your lung were affected by more acute inflammation. You likely developed the chronic condition prior to your hospitalization in early [Month (only) 1096] and during this most reccent hospitalization had acute inflammation from a viral infection. Both of these processes are treated with steroids and you improved greatly with steroids while in the hospital. You were discharged on steroids and will follow up with our pulmonologists in a few weeks to determine the course of treatment. You should continue to quit smoking and avoid any contact with smokers while your lungs heal. Your liver enzymes were also noticed to be elevated which was felt to be from an acute stress on your liver from your acute illness. You do still have signs of the alcoholic hepatitis that you were admitted for in [Month (only) ]. You will need to follow up with your liver doctor Dr. [First Name (STitle) 679] in a few weeks. We recommend that you continue to abstain from drinking and attend AA meetings as you have expressed interest in. Continuing to drink will have severe consequences to your health and may very well kill you. You will be discharged home on prednisone which is a steroid. As you will be on this medication for several weeks you will need to take a medication called bactrim daily to prevent infections, vitamin D and calcium to prevent osteoperosis. You have a fungal infeciton in your mouth from these steroids that you will treat with a medication called fluconazole for the next 7 days. The following changes were made to your medications: -START Fluconazole 200 mg daily for 6 more days -START Prednisone 60 mg daily -START Vitamin D/Calcium supplement daily -START Bactrim SS 1 tablet daily -START Lasix 80 mg daily -START Spironolactone 25 mg daily -START Albuterol 2 puffs every 6 hours as needed for wheezing -START Moisturizing lotion daily -CONTINUE Lactulose 30 ml twice daily -CONTINUE Rifaximin 550 mg twice daily -CONTINUE Pantoprazole 50 mg daily -CONTINUE Followup Instructions: Name: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Address: 99 [Location (un) ] STRAITS, [Hospital1 ],[Numeric Identifier 19665] Phone: [Telephone/Fax (1) 72602] It is recommended that you see your primary care doctor within one week. Please call Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 91911] office to schedule an appointment. Name: [Last Name (LF) ],[First Name3 (LF) ]/GASTROENTEROLOGY Address: [Doctor First Name ],STE 8A, [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 682] When: [Last Name (LF) 766], [12-31], 2:15 PM Department: PULMONARY FUNCTION LAB When: [First Name3 (LF) ] [2104-1-21] at 10:40 AM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES/PULMONARY When: [Hospital Ward Name ] [2104-1-21] at 11:00 AM With: [Name6 (MD) 610] [Name8 (MD) ] RN/DR. [Last Name (STitle) 611] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: DIV OF ALLERGY When: THURSDAY [2104-2-7] at 1 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 9316] Building: One [Location (un) ] Place ([Location (un) ], MA) [Location (un) 895] Campus: OFF CAMPUS Best Parking: Parking on Site Name: [Known lastname 14466],[Known firstname 7401] M Unit No: [Numeric Identifier 14467] Admission Date: [2103-12-6] Discharge Date: [2103-12-21] Date of Birth: [2059-4-15] Sex: F Service: MEDICINE Allergies: Zosyn / meropenem / azithromycin / vancomycin Attending:[First Name3 (LF) 4091] Addendum: Correction to Social History: - She has 1 son who is not living with her. - She was employed until her hospitalization in [Month (only) 531] and is out on FMLA. - Had her last drink in early [2103-10-9]. - She and her sister report no history of polysubstance abuse. Social History: Correction to Social History: - She has 1 son who is not living with her. - She was employed until her hospitalization in [Month (only) 531] and is out on FMLA. - Had her last drink in early [2103-10-9]. - She and her sister report no history of polysubstance abuse. Discharge Disposition: Home With Service Facility: VNA of [Hospital3 709] [First Name8 (NamePattern2) 1558] [Last Name (NamePattern1) ] MD [MD Number(1) 2301] Completed by:[2104-3-8*]	[ "584.9", "303.93", "693.0", "285.21", "571.2", "571.1", "518.81", "585.9", "516.36", "112.0", "572.2", "305.93", "V15.82", "E930.0", "276.2" ]	icd9cm	[ [ [] ] ]	[ "32.20", "96.04", "33.24", "38.97", "86.11", "96.71" ]	icd9pcs	[ [ [] ] ]	30659, 30870	14481, 20940	312, 421	23767, 23767	3408, 3408	28002, 30080	1765, 1942		22325, 23438		23536, 23746		21323, 22302			23950, 27979			4217, 4956							1957, 1957						7631, 14458		2849, 3389	7483, 7595										20961, 21297			1150, 1265						268, 274											477, 1131							3424, 4201			1971, 2833	5687, 5797	23782, 23926			1287, 1302	30389, 30636
29,354	136,868	20401	Discharge summary	report	Admission Date: [2101-6-11] Discharge Date: [2101-6-15] Service: NEUROLOGY Allergies: Demerol / Nembutal Sodium / Vancomycin / Bacitracin Attending:[First Name3 (LF) 5018] Chief Complaint: emesis, lethargy, and dysarthria, r/o acute stroke Major Surgical or Invasive Procedure: None History of Present Illness: 85 y/o RHF female with afib on Coumadin, HTN, PMHx TIA (consisting of loss of vision in both eyes in a curtain being pulled down pattern in [2097-5-21]; treated at [Hospital ] Hospital in [State 21380]; her daughter who is present today was not told there was any other cause identified than the afib; she was on Coumadin at that time), severe RA since '[54] complicated by LLE vasculitis s/p above-knee amputation in [1-28] due to failure of ulcer healing. She was discharged 10 days ago from [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] rehab, where she had been treated following her amputation, to [Hospital3 537] assisted-living facility. She has been bed-bound since [2099-1-21]. Her daughter stated that today she noticed the patient demonstrated slurred speech, emesis x 3 and lethargy, starting about noon today. Generalized weakness, no focal assymetries or facial droop noted. Does endorse pain around her R eye but otherwise no h/a. No numbness/paresthesias, no swallowing difficulty. No fever or recent illness except resolving L upper arm shingles. She was transferred to [Hospital1 18] with concern for acute stroke. Stroke fellow was called at 7pm and saw pt. Glucose here 165. A NCHCT was done (due to inability to obtain iv access no CTA was obtained) and showed large R cerebellar hypodensity concerning for subacute infarct. Recent UTI treated with Cipro [6-4]. 2 days ago complained of R eye blurriness. ROS: poor appetite and weight loss, thought to be due to depression. Past Medical History: -rheumatoid arthritis and LLE vasculitis s/p above-knee amputation; multiple surgeries including left hip replacement, bilateral total knee replacements(including 3 sx on the right knee), bilateral ankle fusion, bilateral knuckle repair. -hypertension -LBBB -TIAs -afib -bilat cataracts s/p recent extraction -osteopenia and and possible hyperparathyroidism -glaucoma and macular degeneration Social History: No tobacco; social EtOH; her husband lives in the same assisted-living facility; her daughter is her HCP [Name (NI) 9036] [Name (NI) 54692] home [Telephone/Fax (1) 54693], work [Telephone/Fax (1) 54694], cell [Telephone/Fax (1) 54695]). Family History: extensive for RA; father died of "Bright's disease" which is some form of nephritis; mother died of "old age." Physical Exam: T 98.1 HR 72, BP 119-140/48-64, RR 18, O2 sat 100% RA Gen: WD/WN, comfortable, NAD. HEENT: mmm Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR, S1/S2, [2-24] pansystolic murmur left sternal border. Abd: Soft, NT, BS+ Extrem: above-knee amputation, L upper arm resolved shingles. NEURO MSE: Awake but drowsy, keeps her eyes closed most of the time, follows cpmplex commands, mild dysarthria. Memory [1-23] delayed recall. Fully oriented. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Nml calculation, praxis and no L-R confusion. CN: I: Not tested II: Surgical pupils minimally reactive to light 2-1.5 bilaterally, VFFC. 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: Contractures throughout UEs bilat. Normal bulk and tone bilaterally. No abnormal movements, tremors. Difficult to perform formal strength testing due to severe joint contractures/swelling and pain but prox UEs only [2-23] and distally [3-26] and symmetric, no RLE drift, nml IP strength in LLE but above-knee amputation. Sensation: Intact to light touch, cold temperature, propioception, and vibration bilaterally. Reflexes: DTRs absent, R plantars equivocal. Coordination: no dysmetria on finger-nose-finger but difficulty performing task due to limited ROM, rapid alternating movements intact. Gait: she does not ambulate at baseline. Pertinent Results: [2101-6-11] 09:30PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.011 [2101-6-11] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2101-6-11] 07:50PM GLUCOSE-151* UREA N-17 CREAT-0.6 SODIUM-135 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-23 ANION GAP-12 [2101-6-11] 07:50PM CK(CPK)-26 [2101-6-11] 07:50PM CK-MB-NotDone cTropnT-<0.01 [2101-6-11] 07:50PM CALCIUM-10.7* PHOSPHATE-2.9 MAGNESIUM-2.3 [2101-6-11] 07:50PM WBC-10.4 RBC-3.91* HGB-11.1* HCT-36.1 MCV-92 MCH-28.3 MCHC-30.7* RDW-15.4 [2101-6-11] 07:50PM NEUTS-87.9* LYMPHS-8.9* MONOS-2.6 EOS-0.4 BASOS-0.1 [2101-6-11] 07:50PM PLT COUNT-458* [2101-6-11] 07:50PM PT-16.5* PTT-28.0 INR(PT)-1.5* [2101-6-15] 07:40AM BLOOD PT-24.6* PTT-30.3 INR(PT)-2.4* [2101-6-12] 02:12AM BLOOD %HbA1c-5.3 [2101-6-12] 02:12AM BLOOD Triglyc-113 HDL-47 CHOL/HD-2.9 LDLcalc-65 Non-contrast CT head [2101-6-11]: There is a subtle area of hypoattenuation within the right cerebral hemisphere, which may represent an area of acute infarction. MRI with diffusion-weighted imaging is recommended for further evaluation. MRI/MRA head [2101-6-12]: IMPRESSION: 1. Large area of acute infarction in the right cerebellar hemisphere, predominantly anteriorly and superiorly. Additional small foci of restricted infarction in the left occipital, left temporal, and the pontomedullary junction on the left side, which may represent additional acute infarctions, assessment of which is limited on the ADC sequence due to their small size. Given the multiple territories of the abnormalities, embolic etiology is most likely, which correlates with the given history of atrial fibrillation. 2. Mild mass effect noted on the right side of the pons and the superior aspect of the fourth ventricle, new since the Ct done the day before and effacement of the right CP angle cistern from the edema related to the right cerebellar acute infarct. Continued close followup is recommended. 3. No abnormal enhancement. Small foci of calcification versus microhemorrhages in the supratentorial compartment as described above. 4. Degenerative changes in the upper cervical spine as described above, not completely assessed. Non-contrast CT head [2101-6-14]: IMPRESSION: Subacute right cerebellar infarct, with no change in degree of mass effect upon the collicular and ambiens cisterns. CXR [2101-6-12]: Cardiac silhouette remains enlarged. Aorta is tortuous. No focal areas of consolidation are identified. Linear opacities at left base are unchanged and attributed to focal scarring. Asymmetrical apical thickening, left greater than right, is also without change. Brief Hospital Course: The patient was admitted to the neurologic ICU for further evaluation and management, given a relatively large right cerebellar infarct on imaging. The mechanism was presumed to be cardioembolic, in the setting of a subtherapeutic INR while on coumadin for atrial fibrillation. Repeat imaging by MRI showed some progression of the infarct with mild compression on the fourth ventricle. Mannitol was started. However, the patient remained stable clinically, and was transferred to the stepdown unit. She was awake, alert, oriented x 3 and her examination back to baseline. The mannitol was stopped and a second CT head revealed a stable infarct and ventricular size. The patient was risk stratified; her A1C was normal and fasting lipid profile excellent (ldl 65, hdl 47). The patient was stable for discharge on [2101-6-15]. Medications on Admission: -Coumadin 4mg qday -Celebrex 200 mg [Hospital1 ] Lyrica 50 po bid Ultram 50 po qid Evista 60 mg Fentanyl 25 mcg/hr topical patch Q72 hrs Tylenol with Codeine #3 330mg-30mg QID -Folate 1 mg Qday -xalatan 0.005%to each eye 1 gtt QHs Cosopt 2%-0.5% to each eye 1 gtt [Hospital1 ] Brimonidine ophthalmic 0.2% OS [Hospital1 ] Ocuvite MVI Qday Restasis 0.05% Q12hrs -imdur 60 qAm amlodipine 10 mg qd trental 400 mg tid -Colace 100 [Hospital1 ], Senekot S 50 mg-8.6 mg 2 tabs Qhs -Ferrous sulfate 325 Qday, Prilosec 20 Qday, MVI w minerals Qday Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 2. Brimonidine 0.2 % Drops Sig: One (1) drop to left eye Ophthalmic twice a day. 3. Ocuvite Tablet Sig: One (1) Tablet PO once a day. 4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO q am. 5. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Senna 8.6 mg Capsule Sig: Two (2) Capsule PO at bedtime. 7. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO four times a day. 8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 10. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for severe RA. 11. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO Qday () as needed for osteoporosis. 12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime) as needed for glaucoma. 13. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day) as needed for glaucoma. 14. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic Q12 hrs (). 16. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 17. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day). 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 21. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 22. Outpatient Lab Work Please have your INR checked on Friday, [2101-6-17] have your warfarin dosed accordingly. 23. Wound care Please use the following wound care regimen recommended as an inpatient: 1. Apply aloe vesta to right leg and foot for moisturizing dry skin apply no sting barrier wipe to left stump skin 2. Apply small amount of wound gel to both left stump ulcers and right leg ulcer beds 3. Cover right leg with adaptic, left stump with dry gauze, wrap with kerlix or use tubular stockinette, change daily Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Right cerebellar infarction Discharge Condition: Stable. Discharge Instructions: Please take your medications as prescribed and follow-up with appointments as scheduled. If you experience any new, worsening, or concerning symptoms, please call your primary care physician, [Name10 (NameIs) ] neurologist (Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] at [Hospital1 18], [Telephone/Fax (1) 657]), or head immediately to the nearest emergency room. Please take your warfarin as directed. Your INR should be maintained in a range of [1-23]. Please have your INR checked on Friday, [2101-6-17] have your warfarin dosed accordingly. Followup Instructions: Please call your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ], this week to have a follow-up appointment within 1-2 weeks after discharge. Neurology Follow-Up: Provider: [Name10 (NameIs) 4267] [Last Name (NamePattern4) 4268], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 657] Date/Time:[2101-8-16] 2:00 [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023]	[ "V43.65", "V49.76", "434.91", "V58.61", "714.0", "427.31", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11022, 11079	7222, 8060	312, 319	11151, 11161	4454, 7199	11794, 12274	2618, 2730		8676, 10999		11100, 11130		8086, 8653			11185, 11771										2745, 4435																												221, 274											347, 1910															1932, 2327	2343, 2602
49,138	141,813	54651	Discharge summary	report	Admission Date: [2111-6-23] Discharge Date: [2111-7-1] Date of Birth: [2084-12-26] Sex: M Service: MEDICINE Allergies: Cipro Attending:[Last Name (un) 2888] Chief Complaint: Hypoxic respiratory failure after VT arrest Major Surgical or Invasive Procedure: Endotracheal intubation Central Line placement [2111-6-23] Arterial Line placement [2111-6-23] History of Present Illness: This is a 26 year old male with a past medical history of pericarditis and myocarditis when he was 18 years old. He had recently been on vacation oin Cancun. While there he believe that he ate some contaiminated food or water and began to have diarrhea, fever, chills, and weakness. On the plane flight home he developed chest pain, which felt similar to his prior episode of myocarditis. The pain was described as a middle to left chest pain, nonradiating. It was associated with weakness and SOB. This chest pain along with fevers/ chills / vomiting/ dirrhea since returning from [Country 149] prompted his admission to [Hospital3 12748]. During his hospital stay he was ruled out for MI. Last night per records, pt c/o increasing chest pain at 2245. He was given toradol 30mg IV per order. At 2305 (day before transfer) telemetry monitor alarmed demonstrated vfib. Pt appeared to be seizing, eyes rolling back, skin with purplish tint. Pt had a pulse but unresponsive. Then per verbal signout he developed ? poor pulse arrest V-fib/V-tach arrest s/p CPR x2 and shocked x 1 with return to spontaneous circulation. He was not intubated at that time. Approximately 4 hours later he was having hypoxic respiratory failure and sating in the 50's just prior to a successful intubation. Moreover, the patient was a difficult intubation requiring 5 attempts and complicated by copious amounts of vomiting. He was transfer to [Hospital1 18] for further management. At the time of transfer he was on amiodorone gtt, heparin gtt (for presumed PE), norepi gtt and paralyzed 1 hour just prior to transfer. Past Medical History: myocarditis Social History: he denies tobacco use. he does use alcohol socially and recently on vacaction. he denies any illegal drug use, hx of IV steroid use Family History: Mother reports having PVCs and palpitations Physical Exam: ADMISSION: General: Intubated and sedated HEENT: pupils are constricted, anicteric, reactive to light, neck supple Cardiac: RRR, no MRG appreciated Lungs: Rhonchorous throughout anteriorly Abd: Soft, nondistended Extremities: Skin- no rashes, multiple tattoos Pulses: decreased DP pulses bilaterally, dopplerable DISCHARGE: 98.2 92/55-102/60 60-76 18 98% RA GENERAL- NAD HEENT- NCAT. Sclera anicteric. PERRL, EOMI. MMM NECK- Supple with JVP of at clavicle when sitting at 90 degrees 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. decreased breath sounds and poorer aeration than would be expected in a younger individual, 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 or ulcers PULSES- Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION: [2111-6-23] 07:59AM BLOOD WBC-4.3 RBC-6.06 Hgb-17.9 Hct-54.1* MCV-89 MCH-29.5 MCHC-33.1 RDW-12.9 Plt Ct-182 [2111-6-23] 07:59AM BLOOD Neuts-62 Bands-4 Lymphs-24 Monos-8 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-1* [2111-6-23] 07:59AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Burr-OCCASIONAL [2111-6-23] 07:59AM BLOOD PT-14.4* PTT-64.3* INR(PT)-1.3* [2111-6-23] 07:59AM BLOOD Glucose-130* UreaN-23* Creat-1.8* Na-140 K-4.0 Cl-107 HCO3-22 AnGap-15 [2111-6-23] 07:59AM BLOOD ALT-120* AST-125* LD(LDH)-469* CK(CPK)-596* AlkPhos-78 TotBili-1.0 [2111-6-23] 07:59AM BLOOD CK-MB-21* MB Indx-3.5 cTropnT-2.45* [2111-6-23] 07:59AM BLOOD Albumin-3.1* Calcium-7.9* Phos-5.1* Mg-1.5* [2111-6-24] 05:27PM BLOOD HIV Ab-NEGATIVE [2111-6-23] 08:04AM BLOOD pO2-58* pCO2-64* pH-7.20* calTCO2-26 Base XS--3 [2111-6-23] 08:04AM BLOOD Lactate-1.5 [2111-6-24] 04:30AM BLOOD CK-MB-8 cTropnT-1.09* [2111-6-25] 03:05AM BLOOD CK-MB-4 cTropnT-0.68* DISCHARGE: [2111-7-1] 08:20AM BLOOD WBC-6.2 RBC-6.04 Hgb-17.7 Hct-52.6* MCV-87 MCH-29.2 MCHC-33.6 RDW-13.6 Plt Ct-365 [2111-7-1] 08:20AM BLOOD Glucose-90 UreaN-21* Creat-1.0 Na-140 K-4.7 Cl-103 HCO3-26 AnGap-16 [2111-7-1] 08:20AM BLOOD CK-MB-2 cTropnT-0.02* [2111-7-1] 08:20AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1 Cholest-146 [2111-7-1] 08:20AM BLOOD Triglyc-153* HDL-21 CHOL/HD-7.0 LDLcalc-94 [2111-6-28] 05:40PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [2111-6-30] 07:25AM BLOOD [Doctor First Name ]-NEGATIVE [2111-6-29] 06:52AM BLOOD dsDNA-NEGATIVE [2111-6-24] 05:27PM BLOOD HIV Ab-NEGATIVE Imaging: EKG [2111-6-23]: sinus rhythm. ST segment elevation in leads I, II, and V3-V6 with biphasic and inverted T waves suggesting a non-ST segment elevation myocardial infarction which could be recent/acute. T wave inversions are also present in leads III and aVF. No previous tracing available for comparison. QTc 421 TTE [2111-6-23]: The left atrium is mildly dilated. A patent foramen ovale is present. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (LVEF = 20%), with apical segments contracting slightly better (suggestive of non-ischemic etiology). Right ventricular chamber size is normal with borderline normal free wall function. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: Patent foramen ovale with small amount of right-to-left shunting at rest. Non-dilated left ventricle with severe global systolic dysfunction. Mild right ventricular systolic dysfunction. CXR [2111-6-23]: Cardiac size is top normal. ET tube is in standard position. NG tube tip is out of view below the diaphragm. Right IJ catheter tip is in the mid SVC. There are extensive bilateral consolidations, larger on the left side. They are partially obscured by large radiopaque monitoring devices placed on the chest wall. TTE [2111-6-24]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses are normal. Left venticular cavity size is borderline increased. There is moderate global left ventricular hypokinesis (LVEF = 35 %). Systolic function of apical segments is relatively preserved. The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size is normal. with borderline normal free wall function. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Borderline left ventricular cavity enlargement with global hypokinesis most suggestive of a non-ischemic cardiomyopathy. Compared with the prior study (images reviewed) of [2111-6-23], global biventricular systolic function is improved. CXR [2111-6-28]: The endotracheal tube, NG tube, left subclavian line have been removed. There is a small right pleural effusion. Compared to the prior study, the alveolar infiltrates and vascular redistribution are much improved. CARDIAC MRI [2111-6-29]: The left and right atrial sizes were normal. Normal left ventricular cavity size and wall thickness. Mild global hypokinesis with mild systolic dysfunction. No signs of myocardial edema/inflammation on T2 sequences, and no signs of fibrosis/scar on late enhancement sequences. Normal right ventricular cavity size and function. The ascending aorta, descending aorta and main pulmonary artery were normal. Normal origin and location of coronary arteries with no significant obstrution in proximal branches. Trace mitral regurgitation . Mild aortic and tricuspid regurgitation. Normal pericardium, with trace pericardial effusion and no signs of constriction. Brief Hospital Course: Mr. [Known lastname ] is a 26 yo M w/ PMH of pericarditis who recetnly had a diarrheal illness and was at an OSH when he went into a VT arrest and had a complicated intubation who was transferred to the ICU from OSH ICU for workup of his respiratory failure likely due to aspiration pneumonitis leading to ARDS which resolved and was extubated without problem. . ACUTE #Hypoxic respiratory failure/ ARDS/ Aspiration Pneumonitis - Patient had hypoxic respiratory failure on arrival with diffuse fluffy infiltrates on Xray and was difficult to oxygenate despite 100% FiO2 and acidotic. A swan ganz catheter was placed through his right IJ which showed normal CO, making pulmonary edema less likely as the source, in addition he responded to IV fluids. He was quickly weaned down on his FiO2 and his respiratory status improved gradually over a few days and he was extubated on [6-27] without problems after administration of IV lasix. His CXR continued to showed a diffuse infiltrate pattern consistent with ARDS, likely due to aspiration pneumonitis vs ARDS from his prolonged attempt at intubation at the OSH. His CXR was greatly improved on the day after extubation with no evidence of bilateral infiltrates. While he spiked fevers and developed a white count with bandemia it was consistent with a systemic inflammatory response to the aspiration and antibiotic were stopped on transfer from the OSH. On transfer to the floor, he was without an oxygen requirement. He was minimally deconditioned but was cleared by PT. On discharge, he was experiencing no shortness of breath with exertion. . #VTach arrest- Patient had a VT arrest, which based on telemetry appeard to be secondary to an R on T phenomenon. He did not have a prolonged QT on the telemetry strip prior to this arrest. It was felt that his episode represented a constellation of events including cipro administration for traveler's diarrhea, myocarditis, and electrolyte abnormalities in the setting of diarrhea. In the ICU he was optimized on his electrolyte management and was started on metoprolol tartrate 12.5mg [Hospital1 ], which was ultimately uptitrated to metooprolol succinate 50 daily to prevent PVCx and runs of NSVT. His ectopy was adequately suppressed on this regimen. An ICD was discussed with the patient. However, he decided to forgo this option despite our strong recommendations as it would severely limit his lifestyle. This will be an ongoing discussion in the future with f/u in heart failure and EP clinics. . #Distributive shock- On admission he was pressor dependent which was weaned off over the first couple of days. He received IV fluids and was weaned off of these as his sedation was weaned. He was febrile and diaphoretic on admission, but this resolved despite discontinuation of antibiotics. . #Systolic Heart Failure- On presentation to our MICU, his EF was 20% in the setting of suspected recurrent myocarditis with chest pain at OSH and CKMB of 30. EF improved to 35% and was then noted to be 48% by Cardiac MRI with mild MR and no structural abnormalities to explain VT. There was no evidence of volume overload on transfer to the floor No evidence of volume overload. Troponins essentially normalized to 0.02. dsDNA and [Doctor First Name ] were negative. He was started on lisinopril 2.5 on discharge. . #GI upset- Patient reported GI upset prior to presenting to [Hospital3 ] likely from traveler diarrhea for which he was treated with cipro. Now resolved. There was no indication for further management. . Transitional issues # continue conversation for ICD placement # f/u with EP # f/u with heart failure # obtain PCP Medications on Admission: None Discharge Medications: 1. Metoprolol Succinate XL 50 mg PO DAILY hold for sbp<90, hr<55 RX metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Lisinopril 2.5 mg PO DAILY hold for sbp < 100. RX lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Acetaminophen-Caff-Butalbital 1 TAB PO ONCE:PRN headache RX butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 capsule(s) by mouth once Disp #4 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Cardiac Arrest, Myo/pericarditis, Respiratory Failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [Known lastname ], It was a pleasure caring for your during your recent admission to [Hospital1 18]. You were transferred here after a cardiac arrest at [Hospital3 ] which was complicated by aspiration resulting in respiratory failure. We believe that this arrest was caused by a rhythm because of electrolyte abnormalities, myocarditis, and ciprofloxacin. In our ICU, you remained intubated. You were initially treated with antibiotics but it was felt that your respiratory failure was due to inflammation, not infection. Antibiotics were discontinued and you were given medication to make you urinate to get rid of fluid in your lungs. You were then extubated. You heart function has improved dramatically since your admission. Your shortness of breath, diarrhea, and chest pain has resolved. We advised you to have a defibrillator placed, but you chose not to at the moment. This can be an ongoing discussion between you and your cardiologists. You should be certain to make any future medical providers aware of this event. You were started on two new medications to treat your weakened heart and decrease the chance of you having an abnormal rhythm. START metoprolol succinate 50 mg by mouth daily lisinopril 2.5 mg by mouth daily fioricet 50 mg q6hrs by mouth daily as needed for headache Followup Instructions: It is recommended you be seen by a Primary Care Doctor within 1 week of discharge. I have listed a few locations in your area to call and book an appointment. [Hospital ] Medical Associates in [Location (un) ] (1 Park Way) , [Telephone/Fax (1) 45283]. There is also a location in [Hospital1 487] ([Location (un) 111782]at the Riverwalk), [Telephone/Fax (1) 34574]. Department: CARDIAC SERVICES When: MONDAY [2111-7-6] at 9:00 AM 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 Department: CARDIAC SERVICES When: THURSDAY [2111-7-30] at 8:40 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "038.9", "420.90", "584.9", "507.0", "428.21", "785.59", "780.8", "995.92", "009.2", "518.81", "745.5", "570", "428.0", "427.1" ]	icd9cm	[ [ [] ] ]	[ "38.97", "96.71", "89.64", "96.6", "38.91" ]	icd9pcs	[ [ [] ] ]	12937, 12943	8742, 12411	309, 413	13050, 13050	3466, 8719	14552, 15567	2250, 2295		12466, 12914		12964, 13029		12437, 12443			13201, 14529										2310, 3447																												225, 271											441, 2050												13065, 13177			2072, 2085	2101, 2234
54,935	149,825	41152	Discharge summary	report	Admission Date: [2191-4-24] Discharge Date: [2191-4-26] Date of Birth: [2150-7-7] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2186] Chief Complaint: pounding, racing heart Major Surgical or Invasive Procedure: 40 y/o male with numerous prior admissions for EtOH and atrial fibrillation, BIBA with afib w/ RVR. EMS gave diltiazem 10 mg IV. Patient had three admissions in the the last month for the same complaint. Pt was recently discharged after admission for same. Pt has been drinking heavily since discharge and not taking his medications. Patient states that he was told that he was "not looking good" at dinner. He describes his heart as pounding and racing. He states that he was unable to pick up the medications he was prescribed and that he "misses" and "forgets" to take his medications. He denies fever, chills, cough. Denies melena, BRBPR, hematemesis. Last drink yesterday at 3 pm. In the ED, initial VS - 97.8, 120, 108/70, 16, 100% 4L NC. Exam notable for withdrawal sx. Labs notable for wbc 5.4, hct 41.4, plt 369, INR 1.2, serum EtOH 280, positive serum benzos, negative Stox, Na 148, troponin x 1 negative. CXR showing no acute process. EKG showing afib with RVR without ischemic changes. Patient was given 60 mg po diltiazem, 10 IV diltiazem, 30 mg IV valium, aspirin 325 mg prior to transfer. Vitals on transfer - afebrile, 112, 133/79, 22, 100 RA Access - 2 PIV Past Medical History: Hypertension Atrial fibrillation Alcohol abuse Social History: Originally from [First Name9 (NamePattern2) 8880] [Country ]. Currently homeless. Has a sister in [Name (NI) ] but does not know her phone number. Does not smoke or use recreational drugs but drinks alcohol, generally a pint of vodka every 2-3 days. He denies any history of seizure or DTs, though does say he has "dizziness" when he does not drink (though this can also happen when he is drinking). Family History: Mother and grandmother both have history of hypertension and MI. Physical Exam: On admission: VS: T afebrile, 111, 148/85, 16, 98% GA: AOx3, NAD, intoxicated HEENT: PERRLA, MM slightly dry, no LAD, no JVD, neck supple Chest wall: tenderness to palpation over chest wall, no lesions c/w zoster CV: PMI palpable at 5/6th IC space. Tachycardic with irregular rhythm. No m/r/g. Pulm: CTAB with no crackles or wheezes. Abd: soft, NT, mildly tender in periumbilical and right upper quadrant area, + BS normoactive. Some voluntary guarding present. Extremities: WWP, no edema, DPs/PTs 2+ Skin: no rashes noted on trunk or extremities Neuro/Psych: AOx3, intoxicated. Pertinent Results: [2191-4-24] 03:59PM BLOOD WBC-5.4 RBC-4.19* Hgb-13.9* Hct-41.4 MCV-99* MCH-33.1* MCHC-33.5 RDW-13.2 Plt Ct-369# [2191-4-24] 03:59PM BLOOD Neuts-41.9* Lymphs-52.7* Monos-3.6 Eos-1.0 Baso-0.8 [2191-4-24] 03:59PM BLOOD PT-13.6* PTT-25.0 INR(PT)-1.2* [2191-4-24] 03:59PM BLOOD Glucose-130* UreaN-16 Creat-0.8 Na-148* K-4.0 Cl-109* HCO3-23 AnGap-20 [2191-4-24] 11:19PM BLOOD ALT-25 AST-62* LD(LDH)-286* CK(CPK)-58 AlkPhos-115 TotBili-0.4 [2191-4-24] 03:59PM BLOOD cTropnT-<0.01 [2191-4-24] 11:19PM BLOOD CK-MB-2 cTropnT-<0.01 [2191-4-25] 05:08AM BLOOD CK-MB-2 cTropnT-<0.01 [2191-4-24] 11:19PM BLOOD Lipase-39 [2191-4-24] 11:19PM BLOOD Albumin-3.4* Calcium-8.1* Phos-3.5 Mg-1.4* [2191-4-24] 03:59PM BLOOD ASA-NEG Ethanol-280* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG CXR: ONE VIEW OF THE CHEST: The lungs are low in volume, but clear. The cardiac silhouette is enlarged, unchanged. The mediastinal silhouette and hilar contours are normal. No pleural effusion or pneumothorax is present. IMPRESSION: No acute intrathoracic process. Brief Hospital Course: 40M with hx of heavy ETOH abuse and AF with RVR admitted following a ETOH binge (1 gallon of Vodka) and was subsequently treated for AF with RVR ACTIVE ISSUES: # Atrial fibrillation with RVR: Patient with multiple admissions for afib with RVR because when he leaves the hospital he starts drinking again and does not take medications. On arrival his rate was 130s, irregular and his blood pressure was >110s. CHADS2 score 1 so full dose aspirin. Patient has been difficult to rate control on recent admissions, and responds best to diltiazem.He received 20 IV dilt x2 and then was started on PO diltiazem and metoprolol and his heart rate remained <100. He had a negative infectious work up and no evidence for strain pattern on EKG to suggest PE, and he had a normal TSH. Pt was discharged on his home regimen of rate control agents. He was explicitly told to cut down on his ETOH content as this is the cause of his episodes and may result in death if he does not seek treatment for his heavy ETOH abuse. . # Chest pain: tenderness to palpation, lack of ischemic changes, and negative enzymes point against ACS. PAtient given omeprazole and GI cocktail with some improvement. Lipase was normal. . # Alcohol intoxication: Presented with ETOH level >400. PAtient put on CIWA with diazepam and received 2 doses in the ICU. He was given IV and then PO thiamine, folate, MVI. Sent out on his oral regimen. No signs of withdrawl prior to d/c. . # Abdominal pain: pt with mild RUQ abd pain with some mild tenderness to palpation, LFTs including lipase were normal, this was thought to be [1-26] EtOH gastritis. Improved over time with supportive measures. . INACTIVE ISSUES # HTN : Patient continued on home medications and SBP well controlled. . TRANSITION ISSUES: The pt stated he would be going to the beach in [Location 8391] and would seek further treatment for his ETOH abuse at [Street Address(1) 89648] Inn and the [Location (un) 33316] House in downtown crossing. His PCP was attempted to be [Name (NI) 653], however was not available. The pt states he will likely return to [Male First Name (un) 1056] in the next month where a family member serves as his physician. [Name10 (NameIs) ] story could not be re-confirmed. . The pt is full code. Medications on Admission: - aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 - thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 - folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 - multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 - omeprazole 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:0 - Toprol XL 25 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day. Disp:90 Tablet Extended Release 24 hr(s) Refills:0 - diltiazem HCl 240 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO once a day. Disp:60 Capsule, Ext Release 24 hr(s) Refills:0 Discharge Medications: 1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. diltiazem HCl 240 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 4. aspirin 325 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. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO three times a day. 8. Campral 333 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis - Atrial Fibrillation with Rapid Ventricular Response - ETOH Abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital following an episode of heavy alcohol drinking. You were admitted with a fast irregular heart rhythm known as atrial fibrillation. . We have made no changes to your medications, however, the most important thing is for you to cut down on your intake of you alcohol. Followup Instructions: Please follow-up with your PCP [Name Initial (PRE) 176] 1 week. . Please seek ETOH Counseling at [Street Address(1) 5904] Inn and the [Location (un) 70873] House.	[ "V15.81", "291.81", "786.59", "V60.0", "401.9", "427.31", "305.00" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7751, 7757	3805, 3951	326, 1504	7886, 7886	2701, 3782	8361, 8539	2020, 2086		7006, 7728		7778, 7865		6115, 6983			8037, 8338										2101, 2101																												264, 288		3966, 6089																			2115, 2682		7901, 8013			1526, 1575	1591, 2004
16,412	171,732	53122	Discharge summary	report	Admission Date: [2195-8-26] Discharge Date: [2195-9-7] Service: VASCULAR CHIEF COMPLAINT: Abdominal aortic aneurysm. HISTORY OF PRESENT ILLNESS: Patient was referred to Dr. [Last Name (STitle) 1476] by Dr. [Last Name (STitle) 109430] at [Location 1268] VA for an abdominal aortic aneurysm of 5.5 x 4.5 cm. Patient is well known to Dr. [Last Name (STitle) 1476], who did previous arterial reconstruction on the lower extremities bilaterally. Patient admits to half a block claudication on both calves, but some of this he relates to his back and spine disease. He feels at this time given consideration, we are not sure as the growth rate of the aneurysm, and he should undergo elective repair. The patient now is admitted for elective abdominal aortic repair. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. History of arrhythmias, which she takes quinidine tablets two q day as well as Lanoxin. 3. He uses Serevent and Azmacort for his chronic obstructive pulmonary disease. 4. Hypertension, which he is on Lasix for. ALLERGIES: He denies any allergies. MEDICATIONS: 1. Aspirin 325 mg daily. 2. Lanoxin 0.1 mg daily. 3. Quinidine 324 mg tablets two [Hospital1 ]. 4. Lipitor 40 mg qid. 5. Lasix 20 mg q day. 6. Lisinopril 5 mg q day. 7. Albuterol, Azmacort, Serevent, and Atrovent inhalers. PAST SURGICAL HISTORY: 1. Bilateral fem-tibial bypass in [2185] and in [2184]. 2. Status post bronchoscopy. PHYSICAL EXAMINATION: This is an elderly male in no acute distress. The patient has difficulty with word finding. Does have a resting tremor, is hard of hearing. Chest: Diminished breath sounds throughout without adventitious sounds. Carotids are without bruits. Cardiac examination: Regular rhythm, no murmur. Abdominal examination is benign except for a pulsatile mass at the mid abdomen with no abdominal bruits. Extremities show bilateral pitting edema with diminished hair on the lower extremities, and extremities slightly cooler. Pulse examination demonstrates 4+ femorals bilaterally. On the left side, he has no pulses below the femoral level. On the right side, he has a patent graft to the posterior tibial artery with a [4-7]+ posterior tibial pulse. PREOPERATIVE LABORATORY WORK: Electrolytes: BUN 20, creatinine 1.4, potassium 4.1. LFTs: ALT, AST, 18 and 16 respectively, alkaline phosphatase 89, total bilirubin 0.4, albumin 3.8, globulin 2.4. Complete blood count: White count 8.2, hematocrit 34.5, platelets 176 k. PT and PTT were normal. ELECTROCARDIOGRAM: Showed a sinus rhythm, normal axis with interventricular conduction defect, nondiagnostic Q waves in II, III, aVL, aVF, V5 and 6. CHEST X-RAY: Consistent with chronic obstructive pulmonary disease. The patient underwent a cardiac catheterization on [2195-8-14] which demonstrated single vessel disease involving the right coronary artery with bridging collaterals. The right coronary artery is dominant system. Left main trunk was without disease. The left anterior descending artery had mild luminal irregularities about 20%. Left circumflex was without critical disease and supplied collaterals to the right coronary artery. The right coronary artery was totally occluded proximally. Patient was admitted to the preoperative holding area, and underwent on [2195-8-26] abdominal aortic aneurysm repair with a 16 x 8 graft and a right renal artery bypass. Patient was transferred to the PACU in stable condition. Patient had an episode of hypertension requiring fluid bolus and 1 mg of Neo-Synephrine. He did receive 1 unit of packed red blood cells intraoperatively. His postoperative hematocrit was 37. He otherwise was doing well. Patient was extubated. Gasses were 7.33, 45, 130, 25, and -2. His systolic blood pressure remained 90-110 with adequate urinary output. Patient was transferred to the VICU for continued monitoring and care postoperative day one. There were no further overnight events. He was afebrile. His systolic blood pressure was 104, diastolic 47. CVP 13, PA 36/18. Index was 3.44. Examination was unremarkable. Wounds were clean, dry, and intact. Abdomen was soft, nondistended, palpable femorals, and dopplerable PTs bilaterally with absent DP on the left and dopplerable DP on the right. Patient remained with epidural in place, and was followed by the Acute Pain Service. On postoperative day three, he was off his perioperative Kefzol. His systolic blood pressure improved to 134/diastolic 53, CVP 15, PA 41/18. BUN and creatinine remains stable. Hematocrit was 30.5. His examination remained essentially unchanged. He had no bowel sounds and did not pass flatus. IV fluids rate was decreased. He remained on bed rest and in the VICU. Postoperative day three, onset of burping, but no flatus was passed. Hematocrit drifted to 26.5. BUN was 26, creatinine 1.0, and IV fluids were D5 and half at 125 cc/hour. Electrocardiogram was obtained, was a normal sinus rhythm at 70 with no acute changes. He remained NPO. He was transfused 2 units of packed red blood cells with a hematocrit of 26.5 with Lasix between. He did show some thrombocytopenia. His Heparin was discontinued, and HIT was sent. Postoperative day four his post-transfusion hematocrit was 28.3. He still had no bowel movements. Continued on the epidural. He remained in the VICU. He did require on postoperative day five, additional Lasix dosing for elevated central venous pressure secondary to volume overload. With adequate diuresis, his hematocrit remained stable at 29. Abdomen remained mildly distended, but soft. Wounds were clean, dry, and intact, and bowel sounds were heard. Electrolytes repleted as necessary. PA catheter was changed to triple lumen catheter. Ambulation to chair was begun. He was continued NPO. Epidural catheter was discontinued, and he was converted to IV IM medications. Postoperative day six flatus with bowel movement, significant diuresis. His HIT antibody was negative. Heparin was restarted for DVT prophylaxis. Hematocrit was 31 and stable. BUN 27, creatinine 1.0. Examination was unremarkable. Ambulation was continued. He continued to be monitored in the VICU. Physical Therapy was requested to see the patient and they felt that he was limited by a decrease endurance, and the need for supplemental O2, they would continue to see the patient and recommend that he be discharged to rehabilitation when medically stable. Patient with a low grade temperature on postoperative day seven and a white count of 20.0. Urine was obtained which was negative. Wounds were clean, dry, and intact. A chest x-ray was obtained which showed a right and left lower lobe pneumonia. Sputum showed 3+ oropharyngeal with greater than 25 polys and less than 10 epithelials. He was begun on levofloxacin. On postoperative day seven, the patient was requested a DNR/DNI because of some depression related to his slow postoperative progress. This was signed by Dr. [Last Name (STitle) 1476]. Postoperative day eight, he had positive blood cultures for gram-positive cocci [5-8] and positive sputum for Staph-coag positive, gram-negative rods. Vancomycin was added to his antibiotic regimen. Lungs were noted to be clear with poor air movement. Abdomen was soft with bowel sounds. Pedal pulse examination remained unchanged, although there remained some mild edema. The Foley was discontinued. He was continued to be seen by Physical Therapy. On postoperative day #9, the patient was transferred to the regular nursing floor. He remained with a low grade temperature of 99 to 98.5. His white count came down to 7.8. BUN and creatinine remained stable at 21 and 0.9. Vancomycin was discontinued secondary to sensitivity of organisms on culture. Patient's blood cultures were finalized as Staph coag positive sensitive to clindamycin, erythromycin, gentamicin, levofloxacin, oxacillin, resistant to penicillin. Anaerobes were also positive. Urine culture grew Enterococcus which was sensitive to ampicillin, levofloxacin, nitrofurantoin, and Vancomycin. Patient was continued on levofloxacin until discharge. His clinical status continued to show improvement. At the time of discharge, his staples were discontinued. Wounds were clean, dry, and intact. Was tolerating po, ambulating, but would require rehab, continue endurance. DISCHARGE MEDICATIONS: 1. Albuterol nebulizers one q6h. 2. Fluticasone propionate 110 mcg puffs two inhalers [Hospital1 ]. 3. Ipratropium bromide nebulizers one q6. 4. Aspirin 325 mg q day. 5. Pepcid 20 mg [Hospital1 ]. 6. Prochlorperazine 10 mg q6h prn. 7. Digoxin 0.125 mg q day. 8. Enalapril 5 mg q day hold for systolic blood pressure less than 110. 9. Chlorpromazine hydrochloride 25 mg q8h prn for hiccups. 10. ........... 40 mg q day. 11. Quinine gluconate 648 mg q12h. 12. Oxycodone acetaminophen tablets [2-5] q4-6h prn for pain. 13. Benadryl 25 mg q6h prn. 14. Zolpidem 5 mg at hs. 15. Dulcolax suppositories q day prn. DISCHARGE DIAGNOSES: 1. Abdominal aortic aneurysm status post repair. 2. Blood loss anemia corrected. 3. Thrombocytopenia with negative HIT antibody, improved. 4. Staphylococcus coag positive blood cultures treated. 5. Enterococcus urinary tract infection treated. 6. Chronic obstructive pulmonary disease stable. FOLLOW-UP INSTRUCTIONS: The patient should follow up with Dr. [Last Name (STitle) 1476] as directed. Levofloxacin should be continued for a total of seven days postdischarge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1477], M.D. [MD Number(1) 1478] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2195-9-7] 09:01 T: [2195-9-7] 09:05 JOB#: [Job Number 109431]	[ "441.4", "038.11", "599.0", "285.1", "496", "486", "276.5", "414.01", "287.5" ]	icd9cm	[ [ [] ] ]	[ "38.93", "39.24", "38.44", "39.25" ]	icd9pcs	[ [ [] ] ]								9073, 9367	8432, 9052															1385, 1479																	1502, 8409													111, 139											168, 804													9392, 9827		826, 1362
27,434	175,412	1016	Discharge summary	report	Admission Date: [2122-4-1] Discharge Date: [2122-4-5] Date of Birth: [2063-3-30] Sex: M Service: CARDIOTHORACIC Allergies: Rocephin Attending:[First Name3 (LF) 1505] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Coronary artery bypass graft x3 (left internal mammary artery > left anterior descending, Saphenous vein graft > obtuse marginal, saphenous vein graft > posterior descending artery) [2122-4-1] History of Present Illness: 58 year old male with positive stress test, underwent cardiac catherization that revealed coronary artery disease and was referred for cardiac surgery Past Medical History: Diabetes mellitus Hypertension Elevated cholesterol CVA Pericarditis s/p pericardiocentesis Hypothyroid Hiatal hernia Social History: Natural gas leak consultant Lives alone Denies tobacco Rare alcohol Family History: Noncontributory Physical Exam: General NAD Skin Rubor HEENT unremarkable Neck supple full ROM Chest anterior/lateral CTA Heart RRR Abdomen soft, NT, ND +BS Extremeties warm well perfused no edema Varicosities none Neuro grossly intact Pertinent Results: [2122-4-5] 06:55AM BLOOD WBC-10.2 RBC-3.26* Hgb-9.6* Hct-27.8* MCV-85 MCH-29.4 MCHC-34.5 RDW-13.5 Plt Ct-301 [2122-4-1] 02:40PM BLOOD PT-14.7* PTT-34.3 INR(PT)-1.3* [2122-4-4] 07:30AM BLOOD Glucose-159* UreaN-23* Creat-1.2 Na-138 K-4.7 Cl-103 HCO3-20* AnGap-20 [2122-4-4] 01:44PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.017 URINE Blood-SM Nitrite-NEG Protein-30 Glucose-300 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR URINE RBC-4* WBC-7* Bacteri-FEW Yeast-NONE Epi-<1 CHEST (PA & LAT) [2122-4-4] 5:05 PM [Hospital 93] MEDICAL CONDITION: 59 year old man with REASON FOR THIS EXAMINATION: r/o inf, eff CMG unchanged, increased retrocardiac opacity concerning for worsening atelectasis, early infiltrate. Also small left pleural effusion. Brief Hospital Course: On [4-1] was brought to the operating room and underwent coronary artery bypass graft surgery. See operative report for further details. He was transferred to the intensive care unit for further hemodynamic monitoring. In the first 24 hours he was weaned from sedation, awoke neurologically intact, and was extubated without difficulty. He was started on beta blockers and was gently diuresed. On POD 1 he was transferred to the floor. Physical therapy worked with him for strength and mobility. He continued to progress, his chest tubes, foley. amd pacing wires were DC'd without incidence. Pt did have lowgrade temp 99. On Dc WBC is decreased, ua negative, cxr atelectasis Pt [Name (NI) 1788] home in stable condition Medications on Admission: Lipitor 40 daily lotrel 5-40 daily Zetia 10 daily HCTZ 25 daily Plavix 75 daily Synthroid 112 daily Toprol XL 50 daily Protonix 40 daily ASA 81 [1-25] x/week Lantus 50 units in am, 30-40units in pm Humalog sliding scale Discharge Medications: 1. 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 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 12. Lantus 50 units in am, 30-40units in pm Humalog sliding scale Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Coronary artery disease s/p CABG post op atrial fibrillation Diabetes Mellitus Hypertension Hiatal Hernia Hypothyroid Pericarditis s/p pericardiocentesis Elevated cholesterol Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) 6700] in 1 week ([Telephone/Fax (1) 6699]) please call for appointment Dr [Last Name (STitle) ] in [1-25] weeks Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3633]) Completed by:[2122-4-5]	[ "E878.2", "401.9", "443.9", "518.0", "250.00", "414.01", "272.0", "278.01", "997.1", "244.9", "427.31" ]	icd9cm	[ [ [] ] ]	[ "88.72", "39.61", "36.12", "36.15" ]	icd9pcs	[ [ [] ] ]	4421, 4476	1990, 2728	293, 492	4695, 4702	1171, 1729	5214, 5603	915, 932		3002, 4398	1766, 1787	4497, 4674		2754, 2979			4726, 5191										947, 1152																												234, 255	1816, 1967										520, 672															694, 813	829, 899
384	168,049	13319	Discharge summary	report	Admission Date: [2161-6-29] Discharge Date: [2161-7-7] Date of Birth: [2093-1-6] Sex: F Service: NEUROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 5378] Chief Complaint: ALtered mental status Major Surgical or Invasive Procedure: MRI, MRA, CT, hemodialysis History of Present Illness: 68 year old woman with hx ESRD and hx noncompliance with HD at times, recently admitted between [Month (only) 958] and [2161-6-1] following an initial episode of unresponsiveness at dialysis, who returns apparently after missing several sessions of hemodialysis. Her VNA had reported her to be "confused" at home. She was brought to the ED and was noted to be "leaning to the left" when she walked. The patient was seen after receiving some ativan, and is fairly inattentive, thus unable to provide a more detailed account. She is unaccompanied in the ED. She was seen by neurology on [2161-4-7] for unresponsiveness following emergent hemodialysis after missing hemodialysis for two weeks - her outpatient nephrologist Dr. [First Name (STitle) 805] had signed a section 12 order to have her brought into the hospital for hemodialysis, and she had arrived on [2161-4-6]. She had been found on imaging to have an area of hypodensity on head CT in right midbrain thought to be c/w infarction or edema. MRI revealed a more extensive area of hyperintensity bilaterally throughout the brainstem, cerebellar and middle cerebral peduncles, the differential of which included central pontine myelinolysis, infarction, encephalitis, demyelination. Overnight she had woken up with a nearly normal neuro exam the following day. She subsequently had a lengthy hospital course that involved initial hypertension, then hypotension and unresponsiveness following further hemodialysis, refusal of dialysis sessions and subsequent imbalance of electrolytes, anemia, hematochezia thought to be related to abrasion with enemas though no colonoscopy during the admission, followed by psychiatry for her bipolar disorder and for advice on pursuing guardianship, UTI treated with levaquin, coagulopathy of unknown origin. Please see excellent discharge summary from the department of medicine for further details. She was eventually discharged home with VNA. She had imaging that included a CTA of the head and neck with no evidence of thrombus in the vertebrobasilar system; MRI as detailed above (discharge summary reads: "consistent with extensive infarction of the brainstem and right midbrain" - however, her clinical appearance was not consistent with this diagnosis. See above differential.) Past Medical History: 1. ? bipolar disorder (Psych history is unclear) 2. Diabetes insipitus ([3-5] lithium use) 3. ESRD on HD - secondary to Lithium 4. HTN Social History: Pt is a homemaker. She used to work at [Location (un) 40552] as a technician. No history of smoking or EtOH. No drugs. Graduated college. She is widowed and has two children. Family History: No psychiatric disorders in the family. Physical Exam: Examination: afeb, BP 230s/90s (pt moving arm), HR 84 RR 18 General appearance: well appearing, keeps eyes closed, slightly disheveled Head/Neck: MMM, neck supple, anicteric sclera Heart: regular rate and rhythm Lungs: clear to auscultation bilaterally Abdomen: soft, nontender +bs Extremities: warm, well-perfused Mental Status: The patient is awake but inattentive. She is oriented to [Hospital1 18], "end of [Month (only) 116]," "[Hospital1 107] Day," says "I never had much use for date" when asked about year. She knows that VNA recommended she come to ED but will not provide information about why. Denies difficulty walking. Of note, recently received ativan per nsg, and is in restraints. Cannot perform DOW bkwds (repeats "Sunday" several times). Language fluent, names fingers but not knuckles, little interest in naming other items. Repetition intact, cannot recall at 30 seconds. No agnosia. Keeps eyes closed. Cranial Nerves: The visual fields are full to confrontation. The optic discs are normal in appearance. Eye movements are slightly restricted with upgaze, but normal horizontally with no nystagmus. Pupils react equally to light 3 to 2 mm, both directly and consensually. Sensation on the face is intact to light touch, pin prick. Facial movements are normal and symmetrical. Hearing is intact to finger rub. The palate elevates in the midline. The tongue protrudes in the midline and is of normal appearance. Motor System: Appearance and tone is normal in all 4 limbs; there is motor impersistence and poor effort in the deltoids, bilateral finger extensors, triceps and biceps of the left arm, ileopsoas of the right leg, bilateral hamstrings, and foot plantar and dorsiflexors. Strength appears normal in the biceps and triceps of the right arm, bilateral wrist extensors, finger flexors, bilateral quads, ileopsoas on the left. She is in restraints bilaterally and exam is further limited. There is a postural tremor in the left hand; there is no myoclonus, nor fasciculations. Reflexes: DTRs are very brisk throughout, with 3-4 beats of clonus in each ankle, and crossed adductors at the knees. The plantar reflexes are extensor bilaterally, [Doctor Last Name 937] is present on the right. Sensory: Sensation is intact to pin prick, light touch, vibration sense, and position sense in all extremities. Coordination: There is some slow finger tapping bilaterally and difficulty following further directions for coordination testing. Gait: Gait could not be assessed, as pt must stay in restraints. Physical Exam on Discharge Patient is alert and awake. Her speech is fluent and her comprehension is full. Thought content is disorganized and tangential. There is no focal motor weakness. She is able to walk with some minor assistance most likely secondary to deconditioning. Lungs are clear Heart II/VI SEM Abdomen: soft NT ND Ext: no edema Pertinent Results: [2161-7-6] 07:30AM BLOOD WBC-6.4 RBC-3.51* Hgb-10.8* Hct-34.6* MCV-99* MCH-30.8 MCHC-31.3 RDW-16.9* Plt Ct-226 [2161-7-5] 05:00AM BLOOD WBC-7.5 RBC-3.77* Hgb-11.9* Hct-37.0 MCV-98 MCH-31.5 MCHC-32.0 RDW-17.8* Plt Ct-204 [2161-7-4] 11:25AM BLOOD WBC-7.2 RBC-3.99* Hgb-12.6 Hct-39.0 MCV-98 MCH-31.5 MCHC-32.2 RDW-17.2* Plt Ct-260 [2161-7-2] 09:30AM BLOOD WBC-8.8 RBC-4.10* Hgb-12.7 Hct-40.6 MCV-99* MCH-31.0 MCHC-31.3 RDW-17.5* Plt Ct-258 [2161-7-1] 03:00AM BLOOD WBC-12.2* RBC-4.55 Hgb-14.4 Hct-45.0 MCV-99* MCH-31.6 MCHC-32.0 RDW-18.4* Plt Ct-291 [2161-6-29] 07:20PM BLOOD WBC-9.6 RBC-4.41 Hgb-13.8 Hct-43.2 MCV-98 MCH-31.2 MCHC-31.9 RDW-18.4* Plt Ct-294 [2161-7-6] 07:30AM BLOOD Plt Ct-226 [2161-7-5] 05:00AM BLOOD Plt Ct-204 [2161-6-30] 06:29AM BLOOD ESR-7 [2161-7-6] 07:30AM BLOOD Glucose-98 UreaN-53* Creat-7.1# Na-141 K-4.1 Cl-103 HCO3-22 AnGap-20 [2161-7-5] 05:00AM BLOOD Glucose-101 UreaN-31 Creat-5.3# Na-141 K-3.9 Cl-103 HCO3-27 AnGap-15 [2161-7-4] 11:25AM BLOOD Glucose-137 UreaN-37* Creat-6.4* Na-142 K-4.6 Cl-102 HCO3-25 AnGap-20 [2161-7-3] 05:25AM BLOOD Glucose-82 UreaN-40* Creat-7.0# Na-140 K-5.2 Cl-101 HCO3-22 AnGap-22* [2161-7-2] 07:59AM BLOOD Glucose-122* UreaN-27* Creat-5.3# Na-141 K-5.2 Cl-101 HCO3-26 AnGap-19 [2161-7-3] 05:25AM BLOOD Amylase-72 [2161-6-30] 02:29PM BLOOD CK(CPK)-174* [2161-6-30] 06:29AM BLOOD ALT-22 AST-23 AlkPhos-141* Amylase-45 TotBili-0.4 [2161-6-30] 05:30AM BLOOD CK(CPK)-94 [2161-6-29] 08:30PM BLOOD CK(CPK)-40 [2161-7-3] 05:25AM BLOOD Lipase-11 [2161-6-30] 06:29AM BLOOD Lipase-15 [2161-6-30] 02:29PM BLOOD CK-MB-10 MB Indx-5.7 cTropnT-0.06* [2161-6-30] 05:30AM BLOOD CK-MB-NotDone cTropnT-0.04* [2161-6-29] 08:30PM BLOOD cTropnT-0.04* [2161-7-6] 07:30AM BLOOD Albumin-3.4 Calcium-9.6 Mg-2.2 Iron-PND [2161-7-5] 05:00AM BLOOD Calcium-9.8 Phos-4.1# Mg-2.0 [2161-7-4] 11:25AM BLOOD Calcium-9.9 Phos-6.3* Mg-2.1 [2161-7-3] 05:25AM BLOOD Calcium-10.2 Phos-6.5* Mg-2.2 [2161-7-2] 11:00AM BLOOD PTH-68* [2161-6-30] 06:29AM BLOOD CRP-1.1 [2161-7-2] 11:00AM BLOOD Phenyto-10.7 Phenyfr-1.8 %Phenyf-17* [2161-6-29] 08:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2161-6-30] 10:07AM BLOOD Lactate-1.2 EEG [7-1] FINDINGS: ABNORMALITY #1: Throughout the recording the background rhythm was slow and disorganized, typically remaining at 5 Hz or slower much of the time. The background was of much higher voltage and more chaotic early in the recording. There were a few sharp features in the right hemisphere but no spike and slow wave discharges. ABNORMALITY #2: There were additional bursts of generalized slowing and some suppressive bursts with a relative attenuation of the background in all areas for one second or so. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: The patient appeared to have some pattern suggestive of sleep toward the end of the recording though no normal waking or sleeping morphologies were present overall. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Abnormal portable EEG due to the slow and disorganized background and bursts of generalized slowing or suppression. These findings indicate a widespread encephalopathic condition affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. The recording could also represent a post-ictal state, especially as the beginning was more chaotic and slower in background than the end. There were a few sharp features on the right side but no overtly epileptiform abnormalities. There were no electrographic seizures during the recording. MR HEAD W & W/O CONTRAST [2161-6-30] 5:31 PM MRI: There are no new abnormal areas of restricted diffusion to suggest acute infarction. There is no evidence of acute hemorrhage. Again seen are multiple areas of abnormal increased T2 signal. Again seen are areas of increased signal in the periventricular white matter of both cerebral hemispheres, consistent with chronic microvascular infarction. There is also evidence of increased T2 signal in the area of the posterior limb/internal capsule bilaterally, suggesting old microvascular infarction versus extrapontine myelinolysis. Again seen is uniform and confluent increased T2- signal throughout the pons and middle cerebellar peduncles, slightly more clearly defined on today's study compared to prior, likely representing central pontine myelinolysis. Compared to prior study, there are new areas of increased T2-signal in the parietal/occipital regions bilaterally without associated restricted diffusion, suggesting posterior reversible leukoencephalopathy (HTE), perhaps related to missed dialysis and hypertension. Also seen on today's study are tiny foci of susceptibility within the pons, likely representing small petechial hemorrhage. No new areas of pathologic enhancement are seen within the brain. There is no shift of normally midline structures or evidence of mass lesion. MRA: There appears to be hypoplastic A1 segment of the left ACA, with a prominent ACOM. Otherwise, the major vessels of the circle of [Location (un) 431] appear patent without evidence of significant stenosis or aneurysmal dilatation identified. IMPRESSION: No evidence of acute infarct or hemorrhage. Multiple areas of increased abnormal T2 signal, likely representing a combination of chronic microvascular infarction as well as established central pontine and possible extrapontine myelinolysis. New and relatively symmetric increased [Name (NI) ] signal in the parietal/occipital regions, bilaterally, without associated restricted diffusion, in this context, suggestive of hypertensive encephalopathy. Also seen is evidence of small petechial hemorrhage within the pons, likely hypertensive and of indeterminate age. MR [First Name (Titles) 4058] [Last Name (Titles) 4059] hypoplastic left A1 vessel with prominent ACOM, but otherwise patent vessels of the circle of [Location (un) 431]. CT HEAD W/O CONTRAST [2161-6-29] 7:19 PM FINDINGS: There is no evidence of acute intracranial hemorrhage. No mass effect. No shift of normally midline structures. Again note is made of hypodensity in the pons and brainstem, as noted on the prior exam, corresponding to the finding on prior MRI. Note is made of somewhat prominent ventricles, as well as slight increase of the size of 3rd ventricle measuring up to 13 mm in width. The osseous and soft tissue structures are unremarkable. IMPRESSION: No acute intracranial hemorrhage. Hypodensity in pons and brainstem, probably corresponding to the finding on MRI. Somewhat prominent 3rd ventricle. MRI is recommended for further evaluation. The information was flagged to ED dashboard. PICC line placement RADIOLOGY Preliminary Report [Numeric Identifier ] PICC W/O PORT [2161-7-1] 7:30 AM The procedure was performed entirely by Dr. [Last Name (STitle) 12166], attending radiologist. Following standard preparation and local anesthesia, under ultrasound guidance, a 21-gauge needle was used to puncture the brachial vein in the mid right upper forearm. Hard copy ultrasound images were obtained before and after venous access documenting vessel patency. A guidewire was advanced centrally. A 31 cm 4- French PICC line was then placed with the tip in the distal SVC under flouroscopic guidance, above SVC/right atrial junction. No complications encountered. The line appear to aspirate and inject easily. IMPRESSION: Ultrasound-guided puncture of the right brachial vein in the upper Brief Hospital Course: Ms. [Known lastname 1726] was admitted to the Medical ICU for control of malignant hypertension and altered mental status. She was noted to have a single seizure episode lasting 2-3 minutes with right face and arm shaking with residual [Doctor Last Name 555] paralysis that then resolved. She was loaded with dilantin and maintained on a daily maintenance dose. Brain MRI showed new T2 hyperintensity in the bilateral parietal occipital areas consitent with reversible hypertensive leukoencephalopathy. Her mental status gradually improved and she was trasnferred to the Neurology Service for continued care. Her mental status continued to improved until she was near her baseline, according to her caretaker/guardian. 1. Hypertension - secondary to renal failure and non-compliance with hemodialysis. Also the likely cause of her seizure. She continues to be fairly well-controlled on amlodipine and lisinopril. She has required, and responded well to, occasional doses of hydralazine PRN 2. Altered mental status - mostly if not totally resolved. ALso, likely secondary to profound electrolyte imbalances, uremia, and malignant hypertension 3. Seizure - HTE. Currently on Dilantin 300 daily. Levels have been therapuetic range. If seizure-free for 6 months, dilantin should likely be weaned under the supervision of a Neurologist. 4. ESRD - requires HD [2161-7-8] and at least three times weekly. She should have her electrolytes checked regularly. She is currently on Sevelamer (Renagel), Nepho-caps, Cinacalcet. 5. Bipolar - patient with continued odd thought content with frequent paranoid feature. Continue Zyprexa and lanthanum. Guardianship has been court-appointed. 6. Code status - FULL 7. Abnormal pontine lesion - this is of unclear etiology. Unlikely to be central pontine myelinolysis as there is no clear history of rapid correction of hyponatremia nor does the lesion have typical appearance for CPM. 8. Patient self-removed her PICC line. Medications on Admission: B Complex-Vitamin C-Folic Acid 1 mg Atorvastatin 10 mg Cinacalcet 30 mg Aspirin 81 mg Sevelamer 800 mg tabs, Two PO TID W/MEALS Donepezil 5 mg Tablet HS Amlodipine 10 mg Lisinopril 20 mg Calcium Carbonate 1000 mg Lanthanum 500 mg TID W/MEALS Olanzapine 7.5 mg HS Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Disp:1 month supply 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 6. Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Lanthanum 250 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO TID (3 times a day). Disp:360 Tablet, Chewable(s) Refills:2 9. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 10. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:2 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 13. Dilantin 100 mg Capsule Sig: Three (3) Capsule PO HS. Disp:90 Capsule(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Hypertensive Encephalopathy Pontine T2 signal abnormality ESRD Bipolar disorder Hypertension Discharge Condition: Improved Discharge Instructions: Please take your medication Please follow-up with your dialysis schedule Please follow-up Followup Instructions: Neurology Follow-up at [Hospital1 18] within 2-4 weeks - [Telephone/Fax (1) 40554] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5379] MD, [MD Number(3) 5380]	[ "253.5", "V15.81", "403.01", "276.9", "794.00", "344.89", "585.6", "296.80", "584.9", "323.8" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.93" ]	icd9pcs	[ [ [] ] ]	17460, 17530	13741, 15719	293, 322	17667, 17678	6019, 13718	17816, 18039	3037, 3078		16033, 17437		17551, 17646		15745, 16010			17702, 17793										3093, 3410																												232, 255											350, 2662	4054, 6000											3425, 4038			2684, 2824	2840, 3021
27,547	103,061	8906	Discharge summary	report	Admission Date: [2201-2-27] Discharge Date: [2201-3-10] Date of Birth: [2122-4-8] Sex: F Service: MEDICINE Allergies: Morphine / Oxycodone / Dilaudid Attending:[First Name3 (LF) 1674] Chief Complaint: Delerium Major Surgical or Invasive Procedure: None History of Present Illness: 78 y/o F with PMHx of CAD s/p MI/PTCA & recent BMS [1-17], systolic HF (LVEF 45-50%, MGUS, recent c.diff infxn, seen by her PCP on day of admission and found to be delerious with labs, showing new hyponatremia (127), hypercalcemia (12.2), and acute on chronic renal failure (Cr 2.4 up from baseline Cr 1.8-2.0). She was sent to ER where family also reported worsening back pain, also some cough with white "spit". The family reported to the PCP that the patients mental status had been clouded for several months and that the presentation was typical of this new baselin. Denied any fever, chills, or SOB prior to admission. At the time of admission she reported no dysuria, N/V, abd pain, hematuria, or diarrhea. Recently her oncologist had been concerned about development of multiple myeloma. In the ED she was afebrile, and VSS were stable. CXR showed a ? LLL infiltrate vs atelectasis, wbc count normal. She was given Levaquin 750mg IV and admitted to the floor. Past Medical History: 1) HTN 2) CAD s/p MI with PCTA in [2190] @ [Hospital1 2025], s/p PCI [2198] with stent to LAD, RCA totally occluded and filled by collaterals 3) Breast cancer B Masectomy in [2175] 4) B/L ORIF 5) R Olecranon fracture 6) Ulnar nerve surgery x 3 7) Pulmonary stenosis s/p valvuloplasty in [2183] 8) s/p appendectomy 9) MGUS BM in [3-15] nml flow with 5% plasma cells; receives transfusion on regular basis 10) H/o anxiety 11) Hypercholesterolemia 12) GERD 13) Recent c.dif infection treated with Flagyl/PO Vanco ([1-/2201]) 14) CRI - baseline Cr 1.8-2.0 Social History: Significant for the absence of current tobacco use. There is no history of alcohol abuse. 1 daughter in CT and 1 daughter in [Name2 (NI) ]. Family History: Father died of heart disease in this 40s. Sister-congenital pulmonary stenosis Physical Exam: ON ADMIT T:98.0 BP:134/79 P:111 RR:20 O2 sats:100% on RA Gen: Elderly, frail female in Resp distress, on NRB, confused, +rigors HEENT: NCAT, PERRL, EOMI, Anicteric, MM dry Neck: JVP difficult to assess [3-14] rigors CV: Reg, nml s1,s2. Resp: Crackles throughout (anteriorly) Abd: Soft, NTND, NABS Ext: No c/c/e Neuro: Oriented to person, but not place/time Pertinent Results: Stool: positive for c diff CXR: possible consolidation atelectasis SPEP consistent with multiple myeloma Serum viscosity within normal Skeletal survey with many lytic lesions MRI of l and t spine and CT of L spine and pelvis without fracture. Diffuse myelomatous invasion of bones (entire spinal cord, pelvis) Serum lambda and kappa pending Brief Hospital Course: #C diff colitis: No response to Flagyl and so started on po vancomycin with good response. Plan to continue vancomycin with taper. #Pneumonia: On hospital day # 3 became sob and febrile. At same time pt was in acute chf, as well as septic, though possibly from c diff colitis. Given CXR with consolidation v atelectasis and severity of illness, started on zosyn for possible HAP. Planned 10 day course of Zosym with final day on [3-11]. Midline placed for access. #Acute on chronic systolic CHF: On hospital day #3 pt became hypoxic after blood transfusion (receives chronic transfusions for anemia assoc w/ MGUS), transferred to ICU for monitoring, did not require intubation; managed well with IV lasix daily. # Delerium: Multifactorial, hypercalcemia, sepsis, and finally from dexamethosone treatment for multiple myeloma; resolved with treatment. # Multiple myeloma: Spep/upep c/w new dx of multiple myeloma. Heme/onc team consulted and recommended to start treatment with dexamethasone 40 mg q wk. Pt received first treatment of dexamethasone [2201-3-4]. Follow up to be arranged via. pt.s oncologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2539] - this discussed with oncology team and with pt.s daughter and health care proxy. Instructions below. # Pain - pain team consulted. No focal area on imaging indicating indication or utility of focal, palliative, irradiation, or injection. Recommended fentanyl patch. # High TSH low T4, during acute illness. Will need repeat check once acute infectious process treated and resolved; as TFTs not reliably interpretable in acute illness. Medications on Admission: asa 325mg daily colace furosemide 20mg daily saline nasal spray prn senna Lidoderm Lipitor 80mg daily MVI tylenol prn metoprolol SR 150mg daily pantoprazole 40mg daily propoxyphene 65mg q6hrs -hold if lethargic Discharge Medications: 1. Dexamethasone 4 mg Tablet Sig: Forty (40) mg PO Q Wednesday for 3 doses. Disp:30 tablets Refills:0 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) u Injection at bedtime. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for low back pain: apply to area of pain over the right SI joint. Adhesive Patch, Medicated(s) 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 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. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pain. 9. pipercillin-tazobactam 2.25g IV q 8 hours with last day of treatment [2201-3-11] 10. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [6-20] MLs PO Q6H (every 6 hours). 14. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 16. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO twice a day for 35 days: as follows: 1 capsule [Hospital1 ] for 7 days; 1 capsule QD for 7 days; 1 capsule QOD for 7 days; 1 capsule Q 3 days for 14 days. 17. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 20. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 21. Furosemide 10 mg/mL Solution Sig: Two (2) mL Injection DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: multiple myeloma widely metastatic to bones diffusely heart failure (acute on chronic systolic) acute renal failure c diff colitis Discharge Condition: stable Discharge Instructions: Please call your PCP with increasing shortness of breath, fever, dizziness, or other concerning symptoms. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1239], [Name Initial (NameIs) ].O. Phone:[Telephone/Fax (1) 719] Date/Time:[2201-3-13] 9:30 Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of oncology will contact pt's daughter [Name (NI) 5627] directly during the week of [3-8] - [3-13] to notify her of appointment time/day, and name of her assigned physician in [Name9 (PRE) 20722]; if you have not heard from him, call Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2539] to find out when and who will be following up with you, at: ([Telephone/Fax (1) 16387]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 1677]	[ "272.0", "584.9", "585.9", "530.81", "428.0", "428.23", "293.0", "276.1", "008.45", "414.01", "203.00", "707.02", "112.3", "458.0", "275.42", "403.90", "486" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	6971, 7045	2937, 4578	300, 306	7220, 7229	2571, 2914	7383, 8173	2095, 2175		4840, 6948		7066, 7199		4604, 4817			7253, 7360										2190, 2552																												252, 262											334, 1312															1334, 1916	1932, 2079
79,142	157,295	13419+56453	Discharge summary	report+addendum	Admission Date: [2140-1-21] Discharge Date: [2140-1-26] Date of Birth: [2059-9-30] Sex: F Service: ORTHOPAEDICS Allergies: morphine / Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 11415] Chief Complaint: hip pain after fall Major Surgical or Invasive Procedure: [2140-1-25] - DC cardioversion with restoration of sinur rhythm [2140-1-21] - open reduction and intramedullary fixation with cehalomedullary device History of Present Illness: 80f s/p trip and fall when she lost her balance. did not hit head. no loc. has a hx of balance problems. xray in ER shows proximal femur fx. Past Medical History: DM, HLD, CHF in [2134] no problems since then Social History: lives home with husband, uses a cane Family History: nc Physical Exam: on admission: v/s: 97.7 100 140/76 16 100% A&O x 3 Calm and comfortable lungs: cta b/l abd: soft, non-tender MSK: R leg rotated laterally, +DP and PT pulse, normal sensation, swelling at prox quadriceps muscle, no bruising or skin tenting on discharge: AVSS, NAD, A&Ox3 RLE: dressing c/d/i in place Extremity without obvious deformity [Last Name (un) 938] FHL GS TA PP Fire SILT LFCN, PFCN, Obturator, Saphenous, Sural, DP, SP, Plantar 1+ DP, PT pulses; foot warm, well-perfused Compartments soft (thigh, leg, foot) Pertinent Results: [2140-1-26] 06:50AM BLOOD WBC-6.4 RBC-3.29# Hgb-9.9# Hct-30.2# MCV-92 MCH-30.2 MCHC-33.0 RDW-15.3 Plt Ct-184 [2140-1-26] 06:50AM BLOOD Glucose-100 UreaN-20 Creat-0.7 Na-145 K-3.8 Cl-110 HCO3-27 AnGap-12 [2140-1-26] 06:50AM BLOOD Calcium-8.4 Mg-1.6 [2140-1-26] 06:50AM BLOOD PT-13.4* PTT-29.2 INR(PT)-1.2* Brief Hospital Course: Ms. [Known lastname ] ?????? was admitted to the Orthopedic service on [2140-1-21] for right hip fracture after being evaluated and treated with closed reduction in the emergency room. She underwent open reduction internal fixation of the fracture without complication on [2140-1-21]. Please see operative report for full details. She was extubated without difficulty and transferred to the recovery room in stable condition. In the early post-operative course she did well and was transferred to the floor in stable condition. On HD3 she developed atrial fibrillation with rapid ventricular response. #Atrial fibrillation with rapid ventricular rate - In the post-op period, the patient developed Afib with RVR and was transferred to the CCU. Chemical cardioversion was first attempted with ibutilide which did not permanently restore sinus rhythm. She was subsequently electrically cardioverted the next day with 200J and maintained sinur rhythm until discharge. She will require anticoagulation with warfarin for 4-6 weeks after the cardioversion. She was also started on Metoprolol Succinate. #Transitional issues: -Will need anticoagulation with warfarin at goal INR [3-12] for [5-13] weeks after discharge On hospital day 4 she was transfused 2 U PRBC for post-operative anemia. On HD5 she started complaining of blisters and pain in her mouth. She was started on Nystatin mouthwash and Acyclovir ointment. She was aslo evaluated by speach and swallow consult who recommended: 1- PO diet: thin liquids/soft solids (advance to regular when mouth sores heal at RN's discretion) 2- Repeat bedside eval is not necessary for an upgraded diet 3- PO meds: whole with thin liquid 4- TID oral care She had adequate pain management and worked with physical therapy while in the hospital. The remainder of her hospital course was uneventful and she is being discharged to rehab in stable condition. Medications on Admission: Levothyroxin 175mcg qd Lasix 20 [Hospital1 ] nexium 40mg po daily ? omeprazole 20mg daily spironolactone 25 mg PO daily Metformin 500mg [Hospital1 ] simvastatin 20mg daily centrum senna colace fish oil glucosamine chondroitin Discharge Medications: 1. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous HS (at bedtime): Until INR therapeutic. Disp:20 doses Refills:0 2. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM for 4-6 weeks. Disp:150 Tablet(s) Refills:0 3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. Disp:45 Tablet Extended Release 24 hr(s) Refills:0 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for Pain: taper dose and frequency as your pain improves. do not drink alcohol or drive/operate machinery while on this medication. Disp:90 Tablet(s) Refills:0 12. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day). 14. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 15. alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every Wednesday): Take first thing in the morning on an empty stomach. Take with at least 8 ox of water. Remain upright for at least 30 minutes. Do not eat, drink or take other medications for at least 30 minutes. Disp:20 Tablet(s) Refills:2 16. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO daily (). 17. acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR (AS DIRECTED). 18. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for oral ulcers for 5 days. 19. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Last Name (un) 1687] House Discharge Diagnosis: Right subtrochanteric femoral shaft fracture. Atrial fibrilation 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: Wound Care: - Keep Incision clean and dry. - You can get the wound wet or take a shower starting from 7 days after surgery, but no baths or swimming for at least 4 weeks. - Dry sterile dresssing may be changed daily. No dressing is needed if wound continues to be non-draining. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. Activity: - Continue to be weight bearing AS TOLERATED on your right leg - You should not lift anything greater than 5 pounds. - Elevate right leg to reduce swelling and pain. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Coumadin to prevent blood clots for at least 4-6 weeks. You will receive further instructions on your cardiology follow-up appointment. - You are being started on a Bisphosphonates to help prevent fragility fractures. Take Alendronate weekly as prescribed. Take first thing in the morning on an empty stomach. Take with at least 8 ox of water. Remain upright for at least 30 minutes. Do not eat, drink or take other medications for at least 30 minutes. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. - If you have questions, concerns or experience any of the below danger signs then please call your doctor at [Telephone/Fax (1) 1228] or go to your local emergency room. The following changes were made to your medications: START warfarin 3mg by mouth daily for 4-6 weeks after discharge START metoprolol succinate 75mg by mouth daily Physical Therapy: RLE: WBAT, ROMAT Treatments Frequency: Wound Care: - Keep Incision clean and dry. - You can get the wound wet or take a shower starting from 7 days after surgery, but no baths or swimming for at least 4 weeks. - Dry sterile dresssing may be changed daily. No dressing is needed if wound continues to be non-draining. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. On discharge, we have started calcium carbonate and vitamin d 800 IU daily. In addition, we are recommending that alendronate sodium 70mg qweek is started two weeks after discharge. Clinical trial data supports that two weeks following fracture is a safe time to initiate bisphosphonates and it should not interfere with bone healing. Patients who have been treated with bisphosphonates starting at two weeks following fracture have been shown to have decreased incidence of recurrent fracture and decreased overall mortality. While bisphosphonates are indicated and safe for most patients with osteoporosis related fractures, there are exceptions. Contraindications to bisphosphonates include renal failure with creatinine clearance less than 35 ml/minute, esophageal dysmotility including strictures or achalasia, active esophagitis or gastritis, esophageal or gastric ulcers, hypocalcemia, or inability to comply with dosing instructions. Please note that controlled GERD is NOT a contraindication to bisphosphonates. While we have ordered this medication on discharge, it is up to your discretion to discontinue it if you feel that it is contraindicated for your patient. For the majority of patients at average risk of suffering an osteoporosis related fracture, the current data supports treatment with bisphosphonates for a total of five years. Followup Instructions: Please call the office of Dr. [Last Name (STitle) 1005] to schedule a follow-up appointment with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 2 weeks at [Telephone/Fax (1) 1228]. You will be contact[Name (NI) ] by [Hospital1 18] cardiology regarding your follow up appointment. You can call [Telephone/Fax (1) 10464] with questions regarding your cardiology follow up. Please follow-up with your primary care physician regarding this admission. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417] Completed by:[2140-1-26] Name: [Known lastname 7330],[Known firstname ] Unit No: [Numeric Identifier 7331] Admission Date: [2140-1-21] Discharge Date: [2140-1-26] Date of Birth: [2059-9-30] Sex: F Service: ORTHOPAEDICS Allergies: morphine / Penicillins / Sulfa (Sulfonamide Antibiotics) / adenosine Attending:[First Name3 (LF) 7332] Addendum: Clarification of discharge documentation per Health Information Management request: Patient developed anemia postoperatively secondary to blood loss from surgery that was treated with 2 units of PRBC. As mentioned in records, on post-op day #2, she developed atrial fibrillation with rapid ventricular response, complicated by hypotension to sBP in the low 80s and altered mental status. She was transferred to the CCU, where she was first administered ibutilide. This medication resulted in temporary resumption of normal sinus rhythm, but after a few minutes she reverted back to atrial fibrillation. Therefore, next day, she was electrically cardioverted and maintained sinus rhythm until discharge. Please see cardiology notes for details regarding her afib management. Discharge Disposition: Extended Care Facility: [Last Name (un) 7333] House [First Name11 (Name Pattern1) 651] [Last Name (NamePattern1) 7334] MD, [MD Number(3) 7335] Completed by:[2140-3-14]	[ "250.00", "285.1", "272.4", "E885.9", "528.00", "458.29", "244.9", "496", "427.31", "724.5", "820.22", "401.9", "V10.05" ]	icd9cm	[ [ [] ] ]	[ "79.15", "99.62" ]	icd9pcs	[ [ [] ] ]	12385, 12604	1731, 2850	342, 502	6250, 6250	1382, 1708	10525, 12362	818, 822		3944, 6060		6162, 6229		3686, 3921			6433, 6433										837, 837	8724, 8741	8763, 8763															1094, 1363		2871, 3660									283, 304								8775, 10502			530, 673										852, 1079		6265, 6409			695, 747	763, 802
27,049	145,121	25529	Discharge summary	report	Admission Date: [2199-3-18] Discharge Date: [2199-4-2] Date of Birth: [2144-10-24] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 492] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: tracheostomy G-tube intubation with mechanical ventilation Right IJ and central line placed and pulled History of Present Illness: 54 year old female with h/o COPD, CHF (EF 50%), PVD s/p grafting and R AKA, ILD, DM, and recent Staph pneumonia requiring transient intubation who presents from rehab to OSH, then sent here with respiratory distress. . Of note, patient was recently hospitalized [Date range (1) 63766] with Staph aureus pneumonia with associated MSSA bacteremia. Discharged [1-25] to complete a 4 week course of ceftriaxone to continue through [2-12]. Returned [1-31] and was started on vancomycin, ceftriaxone and clindamycin on [1-31]. Changed to Vancomycin/Clinda/Cefepime as well as oseltamivir for flu B on [2-2] when decompensated. She was intubated from [2-6] to [2-11] for respiratory distress. Cefepime and clinda were continued for 8 days and transitioned to cefazolin [2-10]. Pt had extensive workup for other sources which was unrevealing. She had a negative TEE, CTA of the right stump and no evidence of increased uptake on WBC scan. She was discharged to rehab with PICC and completed Cefazolin course through 3/31 per last ID note. . On [3-13], she developed tremor, myoclonus and lethargy at rehab. Amitryptilin was held. CXR with consolidation. Pt was started on IV Vanc, Cefepime and Flagyl. . On [3-17], she developed increased respiratory distress and her O2 sats were dropping to 80s. She received 40 IV Lasix, 2mg IV morphine and was sent to OSH ED on NRB. At [Hospital 8] Hospital [Last Name (LF) ], [First Name3 (LF) ] ABG was 7.39/53/49 (?on NRB). A CXR showed supposedly signs of CHF. BNP was elevated >5000 and was sent to [Hospital1 18] ED. . In the ED, her VS were T32 (rectally), 84, 160/90, RR in 40s, O2 sats in low 90s on NRB. Exam notable for crackles 3/4th way up b/l. Her temp came up to 35.1 on warming blanket. Given her respiratory distress, she was intubated with Etom and Succ. Her VS post-intubation were stable. It was felt that she also has a COPD flare and received 125 IV solumedrol and combivent nebs. In addition she was empirically covered with Vanc 1gm IV, Cefepime 1gm IV and Flagyl 500 IV(unclear if Cefepime and Flagyl given) b/o hypothermia and slight WBC elevation. A R IJ was placed. CXR showed CVL and ETT in good position. Pt was admitted to ICU for further care. . On arrival to the ICU, pt was intubated, sedated on AC. Past Medical History: 1. s/p AKA [11-10] (right) 2. s/p VATS and hypoxemia, biopsy c/w Respiratory Bronchiolitis-interstitial lung disease (RB-ILD) -- now on intermittent supplemental oxygen 3. PVD - s/p rt. ileo-fem bpg [12-10] complicated by lymphocele s/p drainage [2198-1-11],rt. ililac/femoral thrombectomy [4-10],rt. ileo-fem graft thrombectomy with bovine patchangioplasty [2196],rt. ileofem bpg with PTFE [2195], 4. chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [2189] 5. ETOH cirrhosis/chronic pancreatitis 6. L breast cyst s/p excision 7. GERD, pud 8. esophagitis with stricture 9. small bowel obstruction 10. PV,SMV thrombosis; h/o DVT/PE 11. asthma/copd on inhalers 12. cervical ca s/p multiple d/c's 13. DM2 insulin dependent 14. entero-colonic fistula 15. cholecystectomy [06]. cdiff colitis 17. acute renal failure Social History: per last DC summary - Currently at rehab. Married and lives at home generally with her husband, no children. Previously worked as a counselor in drug and alcohol programs. She quit smoking approximately [12/2198] with an over 80-pack year history of smoking. She quit drinking alcohol 23 years ago. She has no known exposure to tuberculosis. She was cleaning her husband's clothes during the time that he was working with asbestos for a three-month period. Family History: Noncontributory Physical Exam: T 95.8 BP 152/74 HR 84 RR 17 100% on AC 480x16, FiO2 0.4, PEEP 5 Gen - intubated, sedated. HEENT - PERRL, ETT in place NECK - supple, R IJ in place CV - RR, nl S1, S2, no murmurs appreciated. LUNGS - Dry crackles b/l anteriorly, no wheezes, diffuse rhonchi. ABD - NABS, soft, non-tender, non-distended. Significant scarring on abdomen from pancreatic surgeries and feeding tubes. EXT - no lower extremity edema. 1+ palpable pulse on L. R above knee amputation scar intact without ecchymoses or skin breakdown. SKIN: No rashes/lesions, ecchymoses. NEURO - sedated, only opening eyes to command Pertinent Results: 151 112 42 ============ 319 5.1 28 1.1 . CK: 105 MB: 7 Trop: 0.03 Lactate 0.9 Ca: 8.8 Mg: 2.1 P: 4.2 proBNP: >[Numeric Identifier ] . WBC 11.3 Hb 10.6 Hct 33.2 Plt 380 N:90.3 Band:0 L:6.0 M:2.5 E:0.9 Bas:0.2 . PT: 20.4 PTT: 34.1 INR: 1.9 . . STUDIES: EKG: SR at 67, normal axis, nonspecific ST changes . CXR in ED (prelim): AP view of the chest in semi-upright position. There is an NG tube with the tip within the stomach. Right-sided PICC with tip at the level of the mid SVC. Since prior exam, there has been worsening the right-sided pleural effusion and pulmonary edema. Persistent wedge-shaped opacity in the left mid lung zone. IMPRESSION: Worsening right-sided pleural effusion and pulmonary edema. . Previous studies: CT chest w/o contrast [2199-3-6]: 1. Left upper lobe consolidation is minimally decreased compared to [2199-2-2] and smaller than [2199-1-16]. While the cavitation favors a necrotizing infectious etiology, the slow change in appearance raises the possibility of organizing pneumonia. 2. Improvement in pulmonary edema and anasarca. 3. Increase in size of moderate right pleural effusion and decrease in small left pleural effusion. 4. Slight increase in mediastinal adenopathy. . CHEST AP [2-12]: Cardiac, mediastinal and hilar contours are unchanged. Endotracheal and nasogastric tubes have been removed. Right-sided PICC tip is in the SVC. The left pulmonary opacities are not significantly changed from prior exam. There continues to be right lower lobe atelectasis. There are moderate bilateral pleural effusions which accounting for differences in technique are not significantly changed. Re-distribution of effusion along the left lateral chest is likely positional in nature. IMPRESSION: Accounting for differences in technique, the bilateral pulmonary opacities and moderate pleural effusions are not significantly changed. . TEE [2199-2-6]: No 2D echocardiographic evidence of endocarditis or abscess. Mild to moderate mitral regurgitation. Depressed LV function. . TTE [2199-2-4]: Compared with the prior study (images reviewed) of [2198-12-13], trace aortic regurgitation and low normal left venticular systolic function are seen on the current study (c/w diffuse process - toxin, metabolic, etc.). A PDA is not seen on review of the prior study nor on the current study. Brief Hospital Course: Summary: Ms. [Known lastname 7168] is a 54 year old female with h/o interstitial lung disease (COP), COPD, diastolic CHF (EF 50%), PVD s/p grafting and R AKA, DM, and recent Staph pneumonia requiring transient intubation who presented from rehab to an OSH, then sent here with respiratory distress. She was initially intubated, started on empiric antibiotics for possible PNA, although cultures returned negative and these were stopped. She was also felt to have an acute on chronic diastolic CHF exacerbation, responding well to having her transudative pleural effusion tapped and gentle diuresis as needed. She was found to have C diff colitis and is being treated with flagyl. She was given tracheostomy and G-tube on [3-28]. . # Respiratory failure: Most likely multifactorial with known COPD, RB-ILD, CHF exacerbation, recent necrotizing staph aureus pneumonia with MSSA bacteremia. Given all cultures have remained negative, this is unlikely to be infection and antibiotics were stopped and BAL on [3-23] with no WBC. Given rapid response to thoracentesis, unlikely to be purely her underlying lung disease and steroids were discontiued after a few days. She responded well to high volume thoracentesis (1.2L), with ability to wean on vent settings after this. Thoracentesis consistent with transudate - likely due to CHF. Her rate was well controlled iwht metoprolol. Goal ins/outs were to remain even and the patient received lasix 40mg IV on a prn basis, although she began autodiuresing well with net negative 500cc for the last three days of her stay with out medications. Notably, her BNP on admission was greater than 70,000. She was extubated on [3-22] and re-intubated for persistent respiratory distress. Pt self extubated [3-23], but reintubated early morning [3-24] due to respiratory distress. The patient did well on pressure support of [4-8]. On [3-28] she had tracheostomy and G-tube. Since then she has been maintained on 50% trach collar with PSV 5/5 available on a prn basis only. . # C dificile colitis: The patient was found to have C dificile colitis and was started on Flagyl PO 500mg po tid for planned 14 day course. Day 1 was [3-22] and the patient should continue this medication until [2199-4-4]. . # H/o arterial and venous thrombi s/p thrombectomy: The patient was maintained on a heparin drip with goal of PTT 60-70 (this was tightened after she had some bloody OGT contents at higher PTT levels). Her coumadin dose on admission was 3mg po qday, and she was restarted on coumadin 5mg on [3-29] after trach/PEG. Her INR jumped in one day from 1.4 to 2.0, so this was decreased to 3mg po qday on [3-30]. She was continued on heparin drip until her INR was therapeutic at goal of [1-6]. Her INR should be monitored frequently to alter her coumadin dose as needed for INR [1-6] (current dose 4mg po qday). Interactions with flagyl discontinuation should be considered. . # Altered Mental Status: The patient was initially altered at her rehab, likely due to hypoxia and hypercarbia with rapid shallow breathing (she demonstrated this repeatedly early on in her stay whenever her ventilator settings were changed to PSV. This breathing pattern resolved after large volume thoracentesis.) Off sedation the patient has been alert and interactive. She does become quite anxious/agitated, especially at night, and especially while lying in bed as she prefers to sit in a chair. She is also quite disoriented in the early morning and immediately after waking. When she initially wakes up, she complains of total body pain and seems quite distressed. Once she is awake, by mid-morning, she is again alert and able to give a true report of her status. She was treated with olanzapine 10mg qhs and 5mg qam. She also recieved ativan 0.5mg q6h prn anxiety. Generally speaking she is more agitated at night, and by day sits up in chair without problem. . # Acute on chronic diastolic CHF: EF of 50% on last echo. As above, the patient had likely diastolic CHF exacerbation on admission with crackles, veyr elevated BNP and CXR with edema. She improved with prn IV lasix (last needed several days prior to discharge), and had a transudative effusion that was tapped for 1200cc. We continued her metoprolol and captopril for diastolic CHF and continued home ASA 325. Home Lasix was restarted eventually and uptitrated to 80 mg PO daily, to be titrated as needed. . # h/o COPD: The patient's COPD was stable during her stay. We continued the patient's nebulizers and inhaled steroids while in-house. These should be continued as an outpatient as well. . # Anemia: Hct was stable between 23-26. She had bloody gastric content from OGT on [3-19] and guaiac + stool, but no frank blood. In preparation of her trach/Gtube placement she was given 1uPRBC [3-26]. . # Diabetes Mellitus Type II: The patient was admitted on ISS and NPH 4 [Hospital1 ]. Due to her initial pulse steroids, hte patient had very elevated FS to the 300s and was maintained on an insulin drip for better glucose control. She was eventually restarted on NPH at 6 units qam and 6 units qpm and insulin slide scale and should continue this dosing on discharge; to be adjusted as needed per FS. . # Peripheral Vascular Disease: Ms. [Known lastname 7168] is s/p Right AKA [11-10] for non-healing leg ulcer. Her skin remained intact throughout her stay. . # EtOH cirrhosis: Ammonia and LFTs were normal. Although it is unclear when the patient last had alcohol, she has been between hospitals and rehab for the past four months. She was treated with MVI, folate, thiamine. . # h/o pancreatic insufficiency: s/p chronic pancreatitis. While the patient is on tube feeds or eating she should be maintained on viokase TID. . # h/o GERD: we continued her on a PPI throughout her stay. . # FEN: The patient was not deemed ready for a swallow study at the time of discharge. She remains NPO with meds crushed through G-tube. tube feeds were intitiaed through her Gtube on [3-29] in the afternoon, 24 hours after it was placed. She was initially admitted with hypernatreia requiring free water boluses, but this resolved and they were stopped. . # Prophylaxis: Ms. [Known lastname 7168] was maintained on PPI and heparin drip throughout her stay. . # Access: Ms. [Known lastname 7168] had a Right IJ central venous catheter placed in ED on [3-18], and removed on [3-27] in preparation for tracheostomy. She has a Right PICC which was placed in early [2-9] at [Hospital1 18]. This is still present and used as access. This does not appear to be infected. however given the high infection risk, this should be pulled as soon as her heparin drip is discontinued. . # CODE - full code per her husband and health care Proxy, [First Name8 (NamePattern2) ] [Name (NI) 7168]. Phone number [Telephone/Fax (1) 63765] . # Disposition: The patient is stable for discharge to an acute rehab facility where her trach can be managed (PSV prn, in future evaluate for Passy-Muir valve), her heparin drip can be continued as a bridge to coumadin anticoagulation with goal INR [1-6], and she can continue Flagyl for her c difficile colitis. Her leg should be monitored for possible cellulitis, but as of discharge patient has no white count, no fevers, no tenderness. Antibiotics should be started in conjuction with Flagyl as patient is high risk for antibiotic-associated C diff infection. Medications on Admission: Cefepime 1 gm IV daily Vanco 0.75 gm daily Flagyl 250 IV q8h Viokase 1 tab tid Lipitor 20 daily Dulcolax 10mg supp daily Atrovent nebs q2h prn Nicotine lozenge prn Medium chain TG oil tid Thiamine 100 dialy Coumadin ?1 dose daily Colace 100 [Hospital1 ] HISS NPH 4U [Hospital1 ] Atrovent nebs q6h Lactulose 20 gm tid Lansoprazole 30 daily Lidocaine patch daily Lopressor 75 tid MVI . Per last DC summary, pt was also in recent past on: Lisinopril 20 mg qd Tiotropium Bromide 18 mcg qd Fexofenadine 60 mg [Hospital1 ] Gabapentin 400 mg tid Aspirin 325 mg qd Amitriptyline 50 mg qhs Oxycodone 5 mg q4 prn Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Hospital1 ]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 2. Hexavitamin Tablet [Hospital1 ]: One (1) Cap PO DAILY (Daily). 3. Folic Acid 1 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 4. Captopril 12.5 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day). 5. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day): TID while having tube feeds or eating. 6. Metoprolol Tartrate 50 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day). 7. Aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 8. Olanzapine 5 mg Tablet, Rapid Dissolve [Hospital1 ]: Two (2) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 9. Olanzapine 5 mg Tablet, Rapid Dissolve [Hospital1 ]: One (1) Tablet, Rapid Dissolve PO QAM (once a day (in the morning)). 10. Lorazepam 1 mg Tablet [Hospital1 ]: One (1) Tablet PO BID prn as needed for anxiety. 11. Thiamine HCl 100 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 12. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [Hospital1 ]: One (1) Puff Inhalation [Hospital1 ] (2 times a day). 13. Fentanyl 50 mcg/hr Patch 72 hr [Hospital1 ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 15. Metronidazole 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day) for 6 days: Last day is [2199-4-4]. 16. Warfarin 3 mg Tablet [Month/Day/Year ]: One (1) Tablet PO DAILY16 (Once Daily at 16): please titrate does to goal INR [1-6]. 17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [Month/Day (3) ]: One Hundred (100) units Intravenous DAILY (Daily) as needed: flush each lumen of PICC with 10mL NS followed by 100 units heparin (1mL) qday and prn. 18. Morphine 15 mg Tablet [Month/Day (3) ]: 1-2 Tablets PO q4hrs prn as needed for pain. 19. Sodium Chloride 0.65 % Aerosol, Spray [Month/Day (3) ]: [12-5] Sprays Nasal QID (4 times a day) as needed for dry nose. 20. heparin IV drip Please titrate as needed for goal PTT 60-70. Please stop heparin IV drip when pt's INR is greater than 2. (bridge to anticoagulation with coumadin only) 21. insulin Please give insulin NPH 5units qam and 5 units qPM. Please check FS q6 hours and treat with regular insulin by slide scale (starting dose 2 units if FS 151-200, increase by 2 units for every increase of FS by 50) 22. Albuterol Sulfate 1.25 mg/3 mL Solution for Nebulization [Month/Day (2) ]: One (1) nebulization Inhalation every six (6) hours as needed for shortness of breath or wheezing. 23. Ipratropium Bromide 0.02 % Solution [Month/Day (2) ]: One (1) nebulization Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Interstitial lung disease congestive heart failure c dificile colitis anxiety EtOH cirrhosis Peripheral vascular disease s/p AKA anemia COPD pancreatic insufficiency GERD Discharge Condition: blood pressure stable, O2 sat high 90s on 50% trach collar, sitting up in chair, interactive Discharge Instructions: Patient had Trach/G-tube placed on [3-28]. G-tube ok to use as of 2pm on [3-29]. Patient was able to tolerate an oral diet of nectar thick liquids and ground solids. Will likely need nutrition consult for calorie counts and for supplemental tube feedings. Patient has known arterial/venous thrombi. We restarted her coumadin on [3-29] at 5mg po qday and adjusted as needed. Her prior dose was 3mg po qday. Coumadin dose should be adjusted for goal INR [1-6] after discharge. The patient is currently on 50% trach cuff. We anticipate that she will need to return to PSV 5/5 as needed, potentially overnight or intermittently throughout the day. Patient is tolerating Passy-Muir valve. The patient has C difficile colitis and is taking flagyl per Gtube. She should continue this until [4-4] for a total of 14 days. The patient has a R sided PICC that was placed in [2-9] on her last admission at [Hospital1 18]. Please pull this PICC as soon as not needed anymore in order to prevent infection. Patient needs to have her L leg monitored for possible cellulitis - it is slightly erythematous on day of discharge. No white count, no fevers, no tenderness. Given her tendency to have anti-biotic associated C diff infections, please be sure she has cellulitis before starting antibiotics and consider concurrent flagyl. Patient has waxing and [Doctor Last Name 688] mental status. In the mornings immediately upon wakening she is often disoriented and complains of total body pain. By mid-morning her mental status has cleared and she is able to give a true self-assessment. Followup Instructions: Please evaluate oxygen needs by trach. Currently on 50% trach collar, anticipate may need PSV 5/5 prn. Please call Dr. [Last Name (STitle) 7443] for a follow up appointment in infectious disease in 2 weeks. [Telephone/Fax (1) 457] Please call your primary care physician for [Name Initial (PRE) ] follow up appointment in the next 2 weeks. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [Doctor First Name 494]	[ "303.91", "707.19", "571.2", "V49.76", "428.33", "584.9", "112.89", "V58.61", "799.02", "577.8", "486", "250.00", "276.0", "530.10", "530.81", "790.92", "515", "530.3", "285.9", "440.23", "300.00", "428.0", "577.1", "008.45", "V10.41", "493.20", "511.9", "518.81" ]	icd9cm	[ [ [] ] ]	[ "96.72", "96.07", "96.04", "34.91", "31.1", "33.24", "38.93", "43.11", "99.04" ]	icd9pcs	[ [ [] ] ]	18280, 18359	7142, 10123	285, 390	18574, 18669	4762, 7119	20330, 20799	4114, 4131		15297, 18257		18380, 18553		14657, 15274			18693, 20307										4146, 4743																												238, 247											418, 2744												10138, 14631			2766, 3619	3635, 4098
59,505	139,500	51188	Discharge summary	report	Admission Date: [2120-3-14] Discharge Date: [2120-3-16] Date of Birth: [2035-9-16] Sex: M Service: MEDICINE Allergies: Rituxan Attending:[First Name3 (LF) 338] Chief Complaint: rituxan desensitization Major Surgical or Invasive Procedure: None History of Present Illness: 84M history of lymphoplasmacytic lymphoma/splenic lymphoma s/p 4 weekly doses of Rituxan in [7-/2119], and recent Bendamustine (C2D1 on [2120-2-29]), who had recent admission for rituximab cycle 2 on [12-5] complicated with rituximab reaction manifesting as dyspnea. Pt now being admitted to ICU for close monitoring during rituximab desensitization prior to receiving cycle #3 rituximab. . On arrival to the ICU, pt is comfortable. He reports 1 episode of diarrhea today, no further episodes. Feels well otherwise. No shortness of breath, no cough, does note mildly increased pedal edema. Past Medical History: PAST ONCOLOGIC HISTORY: Patient and his nephew report several years of low grade pancytopenia and progressive fatigue. In the last year fatigue has reached the point that the patient has difficulty with some activities of daily living such as shoveling snow and ambulating outside of his house. Patient also reports a recent weight loss but denies fevers, chills, or night sweats. Given the progression of symptoms and counts a bone marrow biopsy was performed which demonstrated a monoclonal B cell population consistent with a lymphoplasmacytic lymphoma. Patient underwent 4 weekly doses of Rituximab in [7-/2119], with improvement in splenomegaly, counts, and energy, but he had relative rapid recurrence of disease. He was started on R-Bendamustine 80mg/m2 x 2days on [2120-2-9]. OTHER PAST MEDICAL HISTORY: - Hypertension - Hyperlipidemia - Dementia, patient reports trouble with memory - BPH - anemia - GERD - Back pain - Peripheral neuropathy - Inguinal hernia - Ventral hernia - Venous stasis PAST SURGICAL HISTORY: - Cholecystectomy - Excision of scalp skin cancer Social History: Single, never married, no children. Lives alone in [Location (un) 3146]. Previously worked in communication. Nephew [Known firstname 1692] is HCP; this nephew has severe psychiatric illness and patient reports he cares for him. Denies tobacco, EtOH, illicits. Family History: Mother d. age [Age over 90 ], Father d. age 54 of presumed PE. Twin brother with [Name2 (NI) 499] cancer. No other cancers in the family. Physical Exam: Vitals: T 96.1, HR 68, RR 20, 98%RA, 119/55 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: crackles bilaterally R>L CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2120-3-16] 04:30AM BLOOD WBC-1.4* RBC-3.40* Hgb-9.5* Hct-29.2* MCV-86 MCH-28.1 MCHC-32.7 RDW-16.4* Plt Ct-13# [2120-3-16] 04:30AM BLOOD Neuts-84.7 Lymphs-10.8* Monos-3.8 Eos-0.5 Baso-0.2 [2120-3-16] 04:30AM BLOOD Glucose-134* UreaN-26* Creat-1.2 Na-141 K-3.6 Cl-101 HCO3-27 AnGap-17 [2120-3-16] 04:30AM BLOOD ALT-12 AST-26 LD(LDH)-594* AlkPhos-117 TotBili-0.8 [2120-3-16] 04:30AM BLOOD Albumin-3.5 Calcium-8.4 Phos-4.1 Mg-1.9 [2120-3-15] ECHO Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). The right ventricular cavity is dilated with focal hypokinesis of the apical free wall. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the findings of the prior study (images reviewed) of [2120-2-8], the pericardial effusion is slightly larger; still no evidence of frank tamponade, but careful serial clinical and echocardiographic followup is recommended. Brief Hospital Course: 84 year old M with history of lymphoplasmacytic lymphoma/splenic lymphoma s/p 4 weekly doses of Rituxan in [7-/2119], and recent [Last Name (un) 106229]-R x2 (C2D1 on [2-29]) who is admitted for Rituximab desensitization. ACUTE # Rituxan desensitization: On recent admission [Date range (1) 23751], pt developed hypotension/dyspnea/hypoxemia/fever during infusion of rituximab. He was treated with tylenol, bendaryl, decadron, hydrocortisone. Started infusion on the evening of [3-14], initially with low concentration then higher concentration. While infusing the 3rd bag, he became tachypneic, tachycardic, hypertensive (150/105)(had gotten benadryl 25mg at 10:30), mildly stridorous and with rigors, gave an additional 25mg benadryl and an albuterol neb. Infusion was held overnight. On the following day it was restarted at a slower rate and was well-tolerated. Discharged home with family. . #Dyspnea: CXR showed a large right sided pleural effusion of unknown etiology. After his initial reaction to the rituxan, he was given lasix for diuresis which improved his saturation and his dyspnea. CHRONIC # Lymphoplasmacytic lymphoma: s/p four doses of Rituxan [7-/2119], s/p C2 R-Bendamustine [1-/2120] c/b infusion reaction to Rituxan. Received a unit of PRBCs for anemia. . #Seizure prophylaxis -continue home keppra for seizure prophylaxis. # Hypertension/CHF: Has mild sHF, recent echo EF 40-45%. In setting of rituximab desensitization, held home lisinopril, metoprolol and resumed on discharge. # BPH: -continue home oxybutynin # Anemia: Continued home iron supplementation. Received one unit PRBCs. TRANSITIONAL ISSUES # Chest xray shows large right pleural effusion of unknown etiology. # Echocardiogram shows an increasing pericardial effusion that should be followed regularly. Medications on Admission: fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO twice a day. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. furosemide 40 mg Tablet (recently increased from 20-> 40mg daily) STOPPED: allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day. Disp:60 Tablet Extended Release(s) Refills:2 Discharge Medications: 1. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO twice a day. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 10. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day. Discharge Disposition: Home With Service Facility: Visiting nurses Discharge Diagnosis: Lymphoplasmacytic lymphoma Rituxan sensitivity Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Confused - sometimes. Discharge Instructions: Mr. [Known lastname 106228], It was a pleasure caring for you at [Hospital1 18]. You were admitted to the hospital for monitoring while receiving Rituxan. You initially had a reaction, but then your infusion was slowed and you successfully received the dose of Rituxan. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. No medication changes Followup Instructions: Please have your blood counts checked at Dr.[Name (NI) 666] clinic on Monday. Please contact his office for followup [Name (NI) 4314].	[ "402.91", "272.4", "428.22", "V14.8", "786.1", "285.9", "786.06", "736.79", "428.0", "V58.11", "459.81", "780.64", "E933.1", "276.8", "785.0", "356.9", "V07.1", "V58.69", "287.49", "200.80", "284.19", "294.10", "600.00" ]	icd9cm	[ [ [] ] ]	[ "99.12", "99.25" ]	icd9pcs	[ [ [] ] ]	8086, 8132	4393, 6219	291, 297	8222, 8312	2996, 4370	8790, 8935	2340, 2488		7220, 8063		8153, 8201		6245, 7197			8374, 8767								1986, 2038		2503, 2977																												228, 253											325, 930												8327, 8350			1773, 1963	2054, 2324
51,485	139,193	35607	Discharge summary	report	Admission Date: [2135-9-30] Discharge Date: [2135-10-16] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2782] Chief Complaint: Nausea, vomiting, abdominal tenderness Major Surgical or Invasive Procedure: ERCP ([9-30]) Central venous line placement ([10-1]) Arterial line placement ([10-1]); removal ([10-2]) ERCP for stent replacement ([10-10]) ERCP for stent replacement ([10-12]) History of Present Illness: The patient rpeorts that he symtpoms began yesterday when she began to experience nausea and had several episodes of vomiting. She has also been noticing that he belly has been distended recently. She complains of on-and-off-diarrhea every five weeks or so, but has not experienced any diarrhea this week. The patient says that her abdomen hurts only when people push on it; alone and undisturbed, her abdomen is non-tender. The patient has no history of gallbladder or liver disease that she knows of. She further denies any RUQ pain. She has not experienced and hematuria or dysuria. (Per reports from [Location (un) 620], the patient may not have been accurate in my interview. There she was brought in with complaints of LLQ pain and jaundice.) At [Location (un) 620], the patient received metoprolol IV 5 mg, Zofran, and 3 liters of fluid. . In the Emergency Department, a CT scan showed "Severe intra/extrahepatic biliary dilatation; severe pancreatic duct dilatation with pancreatic atrophy; nodular enhancement at ampulla suggests possible malignancy. 2. Distended gallbladder with wall edema and perihepatic ascites, likely [2-23] severe biliary dilatation. 3. Stool distending the entire colon; distended small bowel likely [2-23] to the stool. L spigelian hernia contains a colon loop and free fluid, but no obstruction is seen at the level of the hernia, and no bowel wall thickening. 4. AVN of L femoral head again seen." The Emergency Department had discussed with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and arranged direct admit to surgical floor and possible ERCP evaluation, but then they noted that she was in AFib RVR 120's. Also has [Apartment Address(1) ] mm in lead III, and ST depressions in V [2-27], worse since prior EKG. Has had a silent NSTEMI in past. Cardiology saw the patient and felt that negative stress from 8 months ago made Mi very unlikely. The patient was given metoprolol both PO and IV and a dose of Zosyn. . On the floor, the patient was tired but denied any specific abdominal pain. She denies being nauseated. She also denied feeling any palpitations. Past Medical History: hypertension, cataracts with a recent iridectomy in [10/2133], hyperreflexic bladder, degenerative arthritis of her neck and back, and osteoporosis. Social History: Lives with her daughter, ambulates at home with a cane. No smoking or alcohol. Family History: Her family history is positive for a stroke in her brother. Otherwise, it is noncontributory. Physical Exam: ADMISSION PHYSICAL EXAM: VS:T 97.9 BP 131/88 HR 103 RR 20 93% on 3L GENERAL: Frail, elderly woman in no acute distress HEENT: NC/AT, PERRL, EOMI, sclerae mildly icteric, oropharynx clear. NECK: Supple, no JVD. HEART: S1, S2, no murmurs auscultated. LUNGS: CTA bilaterally to anterior auscultation. ABDOMEN: Soft, distended, diffusely tender to palpation, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no edema, 2+ peripheral pulses. SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs III-XII grossly intact, muscle strength [5-26] throughout, patellar reflexes 2+. LABS: See below. . DISCHARGE PHYSICAL EXAM: VS: 97.0 130/60 58 18 96% RA Gen: No acute distress HEENT: PERRL, EOMI, sclerae anicteric, OP clear CV: RRR, nl S1 S2, no MRG Resp: CTA bilaterally Abd: soft, mildly distended, non-tender. No rebound or guarding. No HSM. Ext: WWP, 1+ pitting edema to knee. No decrease in ROM (passive or active) in right hip. No pain on movement of any of the extremities. Psych: calm, appropriate, A&O x3 Neuro: CN II-XII grossly intact, strength 4+/5 throughout Pertinent Results: Admission Labs: [2135-9-29] 06:55PM WBC-8.2 RBC-3.17* HGB-10.3* HCT-30.5* MCV-96 MCH-32.5* MCHC-33.7 RDW-13.8 [2135-9-29] 06:55PM NEUTS-91.9* LYMPHS-4.2* MONOS-3.3 EOS-0.4 BASOS-0.2 [2135-9-29] 06:55PM PT-12.2 PTT-25.0 INR(PT)-1.0 [2135-9-29] 06:55PM GLUCOSE-113* UREA N-19 CREAT-0.6 SODIUM-128* POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-21* ANION GAP-16 [2135-9-29] 06:55PM ALT(SGPT)-265* AST(SGOT)-239* CK(CPK)-63 ALK PHOS-956* TOT BILI-4.3* [2135-9-29] 06:55PM cTropnT-0.08* [2135-9-29] 06:55PM CK-MB-9 cTropnT-0.07* [2135-9-29] 06:55PM MAGNESIUM-1.7 [2135-9-29] 09:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-2* PH-5.5 LEUK-NEG [2135-9-29] 09:40PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-<1 . [Hospital3 ]: [2135-10-1] 07:30AM BLOOD WBC-10.7 RBC-2.76* Hgb-9.1* Hct-26.0* MCV-94 MCH-32.8* MCHC-34.9 RDW-14.4 Plt Ct-300 [2135-10-1] 11:24AM BLOOD Hct-19.9* [2135-10-1] 12:55PM BLOOD Hct-25.3# [2135-10-1] 07:18PM BLOOD Hgb-9.9 Hct-28.2* [2135-10-4] 01:42PM BLOOD Hct-30.2* [2135-10-11] 04:40PM BLOOD Hct-27.8* . [2135-10-1] 07:30AM BLOOD Glucose-59* UreaN-31* Creat-0.9 Na-135 K-2.8* Cl-104 HCO3-18* AnGap-16 [2135-10-1] 11:24AM BLOOD UreaN-32* Creat-0.9 Na-134 K-2.2* Cl-104 HCO3-19* AnGap-13 [2135-10-1] 07:18PM BLOOD Glucose-74 UreaN-31* Creat-0.9 Na-138 K-3.1* Cl-108 HCO3-18* AnGap-15 . [2135-9-30] 06:15AM BLOOD ALT-287* AST-342* LD(LDH)-341* CK(CPK)-112 AlkPhos-1062* TotBili-5.0* [2135-10-1] 07:30AM BLOOD ALT-196* AST-155* AlkPhos-857* TotBili-1.9* [2135-10-1] 12:55PM BLOOD CK(CPK)-157 Amylase-13 [2135-10-1] 12:55PM BLOOD Albumin-1.6* Calcium-6.2* Phos-3.2 Mg-1.6 [2135-10-2] 03:12AM BLOOD ALT-139* AST-80* LD(LDH)-304* CK(CPK)-124 AlkPhos-645* TotBili-1.2 [2135-10-8] 08:40AM BLOOD ALT-97* AST-212* AlkPhos-1144* TotBili-2.5* [2135-10-9] 06:35AM BLOOD ALT-139* AST-300* AlkPhos-1328* TotBili-2.1* [2135-10-10] 06:33AM BLOOD ALT-113* AST-136* AlkPhos-1163* TotBili-1.7* [2135-10-11] 06:40AM BLOOD ALT-117* AST-255* AlkPhos-1195* TotBili-3.8* [2135-10-11] 04:40PM BLOOD ALT-124* AST-234* AlkPhos-1419* TotBili-4.2* [2135-10-12] 08:28AM BLOOD ALT-129* AST-267* AlkPhos-1379* TotBili-5.2* [2135-10-13] 06:15AM BLOOD ALT-96* AST-108* AlkPhos-1019* TotBili-1.5 [2135-10-14] 07:05AM BLOOD ALT-78* AST-49* AlkPhos-962* TotBili-1.3 [2135-10-15] 06:40AM BLOOD ALT-63* AST-34 AlkPhos-761* TotBili-1.0 . [2135-9-30] 06:15AM BLOOD CK-MB-20* MB Indx-17.9* cTropnT-0.34* [2135-9-30] 12:50PM BLOOD CK-MB-15* MB Indx-17.9* cTropnT-0.42* [2135-10-1] 12:55PM BLOOD CK-MB-18* MB Indx-11.5* cTropnT-0.50* . [2135-10-1] 11:35AM BLOOD Type-ART pO2-64* pCO2-31* pH-7.41 calTCO2-20* Base XS--3 . Discharge Labs: [2135-10-16] 07:00AM BLOOD WBC-5.7 RBC-2.82* Hgb-9.2* Hct-28.0* MCV-99* MCH-32.4* MCHC-32.7 RDW-16.8* Plt Ct-556* [2135-10-16] 07:00AM BLOOD Glucose-103* UreaN-17 Creat-0.5 Na-137 K-3.3 Cl-103 HCO3-26 AnGap-11 [2135-10-16] 07:00AM BLOOD ALT-62* AST-40 AlkPhos-678* TotBili-1.0 [2135-10-16] 07:00AM BLOOD Calcium-7.1* Phos-2.9 Mg-1.7 . Microbiology: [2135-10-1] URINE CULTURE-negative [2135-9-30] BLOOD CULTURE-negative [2135-9-30] BLOOD CULTURE-negative . Imaging: RIGHT UPPER QUADRANT ULTRASOUND: There is marked intra- and extra-hepatic biliary ductal dilation, as seen on recent CT. The common bile duct measures up to 1.2 cm. Gallbladder is distended, likely reflecting biliary obstruction. There are no stones within the gallbladder, nor is there sludge identified. There is no gallbladder wall thickening or pericholecystic fluid. There is trace fluid in Morison's pouch, without generalized ascites. The pancreas could not be well visualized due to significant bowel gas in the midline. . IMPRESSION: 1. Intra- and extra-hepatic biliary ductal dilation, as seen on recent CT. Further evaluation with ERCP or MRCP is recommended. 2. Distended gallbladder, likely reflecting biliary obstruction, without cholelithiasis or son[Name (NI) 493] evidence of acute cholecystitis. . ERCP Impression ([9-30]): - The major papilla appeared like ''fish-mouth''. There was copious thick mucin extruding out. - The minor papilla was bulging. There was some thick mucin extruding out. - Immediately below the minor papilla there was a small opening suspicious for fistula. - A diffuse dilation was seen at the CBD and intrahepatic ducts with the CBD measuring 15-16 mm. - Copious amount of mucin was extracted successfully using a 15 mm RX balloon. - Spyglass cholangioscope showed large amount of mucin in CBD and no discrete lesion was found. - PD was cannulated from the major papilla and small amount of contrast was injected. There was one filling defect in the proximal main PD suspicious for intraductal neoplasm. The guidewire was not able to traverse. - The Santorini duct was cannulated from the minor papilla and small amount of contrast was injected. There was one filling defect in the proximal main PD suspicious for intraductal neoplasm. - Cytology samples were obtained for histology using a brush in the CBD. - Because of the severely dilated CBD and large amount of mucin, a 5cm by 10FR double pig tail biliary stent was placed successfully in the CBD. Then a 7cm by 10FR Cotton [Doctor Last Name ] biliary stent was placed side-by-side successfully in the CBD. - Otherwise normal ercp to third part of the duodenum. . KUB ([10-3]): IMPRESSION: No evidence of obstruction with a large amount of gas in the bowel which may be indicative of ileus. . CXR ([10-4]): FINDINGS: There is progressive increase in diffuse bilateral parenchymal opacities, consistent with rapid accumulation of moderate-to-severe pulmonary edema. More focal areas of opacity including within the right apex may represent asymmetric edema versus superimposed aspiration/consolidation. Elevation of the right minor fissue is suggestive of volume loss/atelectasis in the right upper lobe. Bilateral pleural effusions are present and appear progressed with associated bibasilar atelectasis. No pneumothorax is seen. The heart size is top normal. There are calcifications of the aortic arch. A left-sided central line is unchanged with tip in the low SVC. . Echo ([10-3]): The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The estimated right atrial pressure is 0-5 mmHg. 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 diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral leaflets are mildly thickened. No mitral valve prolapse is seen. An eccentric, anteriorly directed jet of severe (3+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Moderate to severe mitral regurgitation. Pulmonary artrery hypertension. . ERCP ([10-10]): The major papilla appeared like ''fish-mouth''. There was some thick mucin extruding out. The minor papilla was bulging. There was some thick mucin extruding out. Two previously placed biliary stents were seen at the major papilla. One stent partially migrated distally. Both stents were removed with a snare. Cannulation of the biliary duct was successful and deep with a sphincterotome. A straight tip 0.035 in dreamwire was placed. A diffuse dilation was seen at the CBD and intrahepatic ducts with the CBD measuring 15-16 mm. Because patient developed obstruction with plastic stents and patient and family agreed with the metal stent placement, a 8cm by 10mm Wallflex fully covered biliary stent (Ref: 7054; Lot: [Numeric Identifier 81030]) was placed successfully in the CBD. The bile flow was good. Otherwise normal ercp to third part of the duodenum. . ERCP ([10-12]): Copious amount of mucin was seen at the major and minor papilla. The major papilla appeared like ''fishmouth''. The previously placed FCSE metal stent was seen at the major papilla. It largely migrated distally. It was removed with a snare. Cannulation of the biliary duct was successful and deep with a balloon catheter. A straight tip .035in guidewire was placed. Because of the copious amount of mucin causing obstruction, small amount of contrast was injected. There was filling defect (mucin) at the CBD. CBD measured 15-16 mm. Large amount of mucin was extracted successfully with a balloon. Because patient has failed plastic stents and FCSE metal stent, a 8cm by 10mm Uncovered Wallflex biliary stent (Ref: 7065; Lot: [Numeric Identifier 81031]) was placed successfully in the CBD. The bile flow was good. Otherwise normal ercp to third part of the duodenum. Brief Hospital Course: 89 y/o F with Hx dCHF, recent NSTEMI ([6-1]) presents with cholangitis and new-onset A fib with RVR, found to have signs of IPMN and adenocarcinoma. . 1. Biliary obstruction/cholangitis: The patient's CT and RUQ ultrasound both suggestive of biliary obstruction. She was evaluated via ERCP on [9-30], which revealed substantial obstruction of the bile ducts secondary to copious mucin. Two plastic stents were placed. The patient was given prophylactic antibiotics with Zosyn prior to and immediately following the procedure. Her abdominal distension slowly resolved and her LFTs normalized. One week following the procedure, she was found to have rising LFTs and increased abdominal distension. On [10-10] she underwent repeat ERCP to replace the plastic stents with a metal stent, as the previous stent had slipped. This did not successfully stay in place, and required replacement on [10-12]. Despite this replacement, it is possible that the blockage will recur, in which case repeat ERCP would be indicated to replace the stents. On discharge, her LFTs were stable for 48 hours and abdominal exam remained benign. . 2. Adenocarcinoma: The findings on the ERCP, combined with the papillary mass found on CT, were highly suggestive of IPMN. Cytology brushings revealed adenocarcinoma cells, likely malignant. The patient indicated prior to the ERCP that she would not wish to undertake therapy for any cancer found as a result of the procedure. She is not a surgical candidate. There may be chemotherapeutic options. The patient may also prefer a comfort care/hospice approach. An appointment with a medical oncologist was set for her following discharge. . 3. New onset atrial fibrillation: On admission, the patient was found to be in Afib with RVR. She was successfully rate controlled with IV and PO metoprolol. Cardiology was consulted and attributed her symptoms to demand ischemia. She was monitored and continued on beta blocker throughout her stay. As her CHADS score is 3, she is a candidate for long-term anti-coagulation. However, her primary care physician felt that this was not appropriate therapy given her risk of bleeding. She will continue metoprolol for rate control. . 4. Hypotension: resolved. The patient was found to be somnolent and hypotensive on [10-1] following an episode of coffee ground emesis. She was transferred to the MICU for pressor support. This was thought secondary to Afib with bradycardia. She was in the ICU overnight and on pressors for roughly 8 hours. She did not require ventilation report. Following immediate management, she was maintained in NSR with metoprolol and had no recurrence of the hypotension. Her hematocrit was stable and there was no further sign of bleeding. . 5. Diastolic heart failure: The patient has a history of diastolic HF, but at home required no oxygen support. On admission she was found to have some demand ischemia with troponin 0.4-0.5. Her hypoxia responded to diuresis, indicating heart failure as the etiology. She was resumed on home lasix 20 mg daily, and was felt to be euvolemic on discharge. . 6. Delirium with hallucination: resolved. The patient experienced waxing and [Doctor Last Name 688] orientation following her return from ICU. She also experienced visual hallucinations. This was attributed to hospital-associated delirium. Any exacerbating medications were discontinued, and the patient was managed according to the [Doctor First Name ] protocol. . Inactive issues: 7. CAD: Continued aspirin 8. Back pain: Held home tizanidine. 9. Hypertension: Continue home lisinopril. 10. Urinary incontinence: Held home oxybutynin. 11. Glaucoma: Continue home timolol. . Code: DNR/DNI . Transitional Issues: - Please monitor liver function tests (AST, ALT, Alkaline phosphatase, Total bilirubin) daily until normalized. If there is an increase, or if her abdominal exam worsens, call the ERCP team for follow-up as stents may have slipped. - Once liver function tests have normalized, you may wish to restart Zocor, tizanidine, and oxybutynin. - Please monitor electrolytes and consider restarting KCl if necessary. - If respiratory function improves, nebulizers can be d/c. The patient does not have obstructive disease at baseline. - Oncology appointment to review cytology and determine possible treatment options, discuss prognosis, and select a path forward. This may lead to treatment or to a comfort care/hospice option. Medications on Admission: ASA 325mg daily Calcium 600 + D 1 tab daily oxybutynin 0.5 QHS Lasix 20mg QAM lisinopril 5mg daily MVI KCl SR 10mEq daily timolol 0.5% drops 1 drop to right eye [Hospital1 ] tizanidine 4mg [Hospital1 ] vit D 1000unit 1 tab daily Zocor 10mg QHS omeprazole 20mg daily Immodium, MoM, [Name (NI) ] PRN Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulized Inhalation every six (6) hours as needed for SOB, wheezing. 2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/Wheezing. 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 8. Multi-Day Tablet Sig: One (1) Tablet PO once a day. 9. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. ampicillin-sulbactam 1.5 gram Recon Soln Sig: One (1) Recon Soln Injection Q6H (every 6 hours): 1.5 g Q6H end on [10-17]. 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: max 3 g/day. 13. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pruritis: HOLD for mental status changes. 14. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 15. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Outpatient Lab Work Please obtain daily chemistry 7 panel along with daily AST, ALT, alkaline phosphatase, and total bilirubin. Please call results to Dr. [Last Name (STitle) ],[First Name3 (LF) 1730] P. [Telephone/Fax (1) 19980] Discharge Disposition: Extended Care Facility: [Hospital 11851] Healthcare & Rehabilitation Center - [Location (un) 620] Discharge Diagnosis: Primary: obstructive cholangitis Secondary: adenocarcinoma (likely pancreatic), atrial fibrillation, diastolic heart failure Discharge Condition: Mental Status: Confused - sometimes. Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mrs [Known lastname 6483], . You came to our [Hospital3 ] with nausea, vomiting, abdominal pain, and jaundice. A CT scan showed dilated bile ducts, most likely due to an obstruction. You were transferred to our [Hospital 86] hospital for ERCP (endoscopic retrograde cholangiopancreatography) to investigate the cause of this blockage and to relieve it. Stents were placed to hold open the bile ducts. Samples of the wall of the bile duct were taken; these were shown to be cancerous. . During your recovery from the ERCP, you experienced a rapid, irregular heart rate. On [10-1] your blood pressure dropped to a dangerously low level, and you were transferred to our ICU. You returned to the medical floor on [10-2]. For several days you needed additional oxygen support due to fluid in your lungs. You were given medications to control your heart rate, keep your blood pressure in the normal range, and reduce any extra fluid in your body. As these medications took effect, you were able to reduce your need for extra oxygen. During your stay on the medical floor, you were found to be confused at times and to have some visual hallucinations. This is a [Last Name ] problem when people are in the hospital, and you were able to recover from this confusion as your health improved. . A week after your ERCP, we determined that one of the stents had slipped out of place, allowing the duct to close. You underwent a repeat ERCP on [10-10] to replace this stent. You required an additional ERCP on [10-12] to replace the stents once again. Following this 3rd procedure the stent appeared to remain in place. You will have daily bloodwork at rehab for liver function tests to ensure that everything is stable. . Our physical therapy team worked with you and determined you were weakened from the long hospital stay. You were transferred to a rehab facility to build your strength. . We made the following changes to your medications: STOP oxybutynin STOP Potassium Chloride (may restart depending on electrolyte monitoring) STOP tizanidine (may restart once liver function normalizes) STOP Zocor (may restart once liver function normalizes) . INCREASE lisinopril from 5mg to 10mg daily for better blood pressure control . START albuterol nebulizer treatments PRN to ease breathing START iprotropium nebulizer treatments PRN to ease breathing START metoprolol XR 100mg daily for A fib rate control and blood pressure management START hydoxyzine 25mg Q6H PRN itching for rash . Please follow-up with your primary care physician when you are discharged from rehab to determine any further medication changes. . Please also follow-up with an Oncologist to discuss your new diagnosis, your treatment choices, and how you wish to proceed. We have made an appointment for you in [Location (un) 620] on Monday. Followup Instructions: Please follow-up with your primary care physician following your discharge from rehab. . Name: [First Name8 (NamePattern2) ] [Name8 (MD) 3274], MD Specialty: Hematology/Oncology Location: [Hospital ] Hospital - [Hospital 620] Campus [Street Address(2) 3001], [Location (un) 1773], [Location (un) 620], Ma Phone: [Telephone/Fax (1) 38619] When: MONDAY [2135-10-17] at 3:00 PM	[ "578.0", "157.8", "365.9", "721.0", "412", "625.6", "414.01", "721.3", "553.29", "458.29", "576.2", "428.33", "427.89", "401.9", "790.4", "576.1", "780.09", "427.31", "596.54", "V49.86", "724.2", "428.0", "576.8", "733.00" ]	icd9cm	[ [ [] ] ]	[ "51.85", "38.93", "51.87", "51.14", "38.91", "51.10", "97.05" ]	icd9pcs	[ [ [] ] ]	19910, 20018	13313, 16818	291, 495	20190, 20190	4208, 4208	23248, 23662	2963, 3058		18150, 19887		20039, 20169		17816, 18127			20368, 22322			7029, 13290							3098, 3698																			17066, 17790		22351, 23225							213, 253											523, 2675						16835, 17045	4224, 7013					20205, 20344			2697, 2851	2867, 2947				3723, 4189
22,623	185,466	1701	Discharge summary	report	Admission Date: [2193-7-3] Discharge Date: [2193-7-13] Date of Birth: [2125-4-7] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This is a 68-year-old male patient with known heart murmur with bicuspid valve since childhood followed by serial echocardiograms. Cardiac echocardiogram on [2193-4-3] showed bicuspid valves, severe aortic stenosis, aortic valve area of 0.5 cm, peak gradient 135, mean gradient 70, moderate left ventricular hypertrophy with an EF of 55 percent. Cardiac catheterization on [5-14] showed normal coronaries with severe AS, PA pressure of 25/10. The patient was referred for cardiac surgery with plans to undergo aortic valve replacement on [2193-7-3]. PHYSICAL EXAMINATION ON PRESENTATION: Heart rate 56, blood pressure 120/60, respiratory rate 20, height 5'8" tall, and weight 170 pounds. General: In no acute distress. Skin: No lesions. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact, anicteric. Neck is supple. Carotids with radiated murmur. Chest was clear to auscultation bilaterally. Heart: Regular, rate, and rhythm, S1, S2, 4/6 systolic ejection murmur. Abdomen is soft, nontender, nondistended, with minimal active bowel sounds. Extremities are warm and well perfused, no edema, no varicosities. Neurologic: alert and oriented times three. Moves all extremities. Strength: Equal in upper and lower extremities. Sensation is intact. Pulses: Femoral 2 plus right and left. Dorsalis pedis 2 plus right and left. PT 2 plus right and left. Radial 2 plus right and left. LABS FROM [2193-5-2]: White count 11.3, hematocrit 44.3, platelets 208. INR 1.1, PT 12.7. Sodium 141, potassium 3.9, chloride 104, bicarb 28, BUN 12, creatinine 0.9, glucose 101. EKG: Sinus bradycardia at 56. Inverted T waves in I, II, aVL, and V5 through V6, 2.94 V. CAROTID ULTRASOUND: Carotid ultrasound with no significant disease. Minimal plaque at the origin of ICAs bilaterally. SUMMARY OF PFTS: FVC was 88 percent of predicted, FEV1 105 percent of predicted, FEV1:FVC ratio 120 percent of predicted. SUMMARY OF HOSPITAL COURSE: The patient was admitted on his surgical date, [2193-7-3]. Went to the operating room and underwent an aortic valve replacement with a 23 mm Perimount Tissue Valve under general anesthesia with an indication of severe aortic stenosis with an aortic valve area of 0.5 cm, peak gradient of 134, and mean gradient of 70 by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70]. His cardiopulmonary bypass time was 153 minutes with a cross-clamp time of 126 minutes. He was transferred out of the operating room to the Cardiac Surgery Recovery Unit with a mean arterial pressure of 78, CVP/RA of 15, PAD 17, [Doctor First Name 1052] 23, A paced at a rate of 80 per minute. He was on a Neo-Synephrine drip at 0.5 mg/minute and a propofol drip of 15 mcg/kg/minute. He was rapidly weaned and extubated on the evening of his postoperative day. He was atrial paced at a rate of 80 throughout the evening of postoperative day. On postoperative day one, he converted to atrial fibrillation with a max heart rate of 136 treated with intravenous Lopressor for rate control. He was also started on amiodarone. He was continued on small Neo-Synephrine drip for blood pressure support. On postoperative day one, his chest tubes were discontinued. On postoperative day three, his Neo-Synephrine was weaned to off. His insulin drip was off and amiodarone was changed to p.o. and he was in a sinus rhythm with a rate of 70. He was transferred 2 units of packed red blood cells for a hematocrit of 23.9, and he was transferred to the inpatient floor. On the morning of [7-7], heart rate converted again to atrial fibrillation at a rate of about 140 alternating with sinus bradycardia and premature atrial contractions. When in sinus rhythm and sinus bradycardia, he had a first degree A-V block with elongated Q-T interval. On postoperative day number five, [2193-7-8], the amiodarone was decreased secondary to sinus bradycardia with EKGs follow QTc, atrial and ventricular pacing wires were discontinued also. He continued to have some short bursts of atrial fibrillation on the morning of [7-10], postoperative day six. He experienced continued rapid atrial fibrillation with a rate of 140, blood pressure of 120-160 systolic. He received an IV amiodarone bolus, which converted him to a normal sinus rhythm with stable blood pressure. At this time, it was decided that the patient should be anticoagulated and he was started on a Heparin drip with p.o. Coumadin. He began receiving Coumadin on the 9th, receiving 2 mg of Coumadin on [7-8] mg on [7-9].5 mg on [7-10] with no Coumadin on the 12th and 2 mg on the 13th. His INRs respectively were 1.1 on the 9th, 1.1 on the 10th, 2.5 on the 12th, and 3.2 on the 13th. Plan is to discharge the patient home when his INR is therapeutic. The patient has also experienced an increased white count throughout his hospital stay with a high of 22.9 on postoperative day 1, low of 11.7 on postoperative day three. On the 13th, his white count is 8.2, still with no conclusive reason for this increased white count. No signs or symptoms of infection with cultures pending and differential pending. On the afternoon of [7-12], postoperative day eight, he has had no episodes of rapid atrial fibrillation for greater than 24 hours. The patient has been followed by Physical Therapy throughout his hospital stay and was found to be safe for home from the physical therapist's standpoint. The patient will be discharged home on the morning of [2193-7-13] with visiting nurses to follow his INR and white blood cell count. DISCHARGE STATUS: Good. PHYSICAL EXAMINATION: Temperature 98.4, pulse 59 in sinus rhythm/sinus bradycardia, blood pressure 149/64, respiratory rate 16, room air oxygen saturation 99 percent. Neurologic: Awake, alert, and oriented times three, nonfocal. Cardiovascular: Regular, rate, and rhythm with a 2/6 systolic ejection murmur. Respiratory: Lung sounds are coarse bilaterally with scattered wheezes. Gastrointestinal: Positive bowel sounds. Abdomen is soft, nontender, nondistended, tolerating regular diet, and positive bowel movement. Extremities: Trace edema. Sternal incision: Clean, dry, and intact. Sternum stable. LABORATORIES: White count 18.2, hematocrit 36.5, platelets 335. Sodium 142, potassium 4.4, chloride 107, bicarb 24, BUN 17, creatinine 1.0, glucose 105. PT 22.6, INR 3.2. Chest x-ray on [2193-7-11] shows bilateral pleural effusions with the left pleural effusion smaller in size from the previous studies. Also shows bilateral apical pleural thickening. Pulmonary vascular is within normal limits. The right-sided effusion is smaller than the left. DISCHARGE DIAGNOSES: Status post aortic valve replacement on [2193-7-3] with Perimount Tissue Valve. Chronic obstructive pulmonary disease. Rapid atrial fibrillation. DISCHARGE MEDICATIONS: 1. Coumadin 2 mg p.o. q.d. 2. Lopressor 25 mg p.o. b.i.d. 3. Captopril 12.5 mg p.o. t.i.d. 4. Albuterol 1-2 puffs inhaled q.6h. prn. 5. Amiodarone 200 mg p.o. b.i.d. 6. Aspirin 81 mg p.o. q.d. 7. Percocet 5/325 mg 1-2 tablets p.o. q.4-6h. prn. 8. Zantac 150 mg p.o. b.i.d. 9. Colace 100 mg p.o. b.i.d. FOLLOW-UP PLANS: Visiting nurses to see patient at home, Dr. [Last Name (STitle) 70] in four weeks, Dr. [First Name (STitle) ] in [11-30] weeks, and Dr. [Last Name (STitle) 120] in [1-2] weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5662], [MD Number(1) 5663] Dictated By:[Last Name (NamePattern1) 9777] MEDQUIST36 D: [2193-7-12] 16:46:50 T: [2193-7-13] 06:19:52 Job#: [Job Number 9778]	[ "E878.8", "424.1", "427.31", "496", "426.10", "427.61", "V10.46", "285.9", "997.1" ]	icd9cm	[ [ [] ] ]	[ "35.21", "99.04", "39.61" ]	icd9pcs	[ [ [] ] ]								6934, 7087	7110, 7414																												2185, 5838				5861, 6912					7432, 7901																			163, 2156
64,421	127,150	42126	Discharge summary	report	Admission Date: [2149-12-13] Discharge Date: [2149-12-17] Date of Birth: [2097-5-8] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2777] Chief Complaint: chest and back pain Major Surgical or Invasive Procedure: [2149-12-16]: Cardiac Catheterization History of Present Illness: 52M with a history of thoracic aortic aneurysm presents to the [Hospital1 18] ER with a 3 hour history of a tearing chest pain that radiated to his back. He states the pain began during the day, however was a lower grade pain and around 11PM the pain became sharp, severe and constant. The pain intensity did not subside therefore he decided to be evaluated in the ER. He also reports he had a similar episode 2 weeks ago where he was evaluated at [Hospital1 2025] and was told he had a thoracic aneurysm. He was evaluated by a surgeon who suggestive operative repair, however the patient was unable to go to his follow up appointments. Past Medical History: Hep C, type A aortic dissection (caused by htn/drug use per pt) PSH: Bentall with mechanical AVR, L THR x 3, removal of hardware Social History: Lives with son, recently moved to [State 350], on disability, drink 3 40oz beers a day along with 2-3 shots of liquor, smokes [1-19] cigarettes/day, smokes occasional marijuana Does not work Family History: denies hx of aortic aneurysms, dissections or valvular disease Physical Exam: bp 106/62 HR 56 reg RR 12 Gen: 52yom lying in bed in NAD. Alert and oriented CV: RRR, audible click from mechanical aortic valve Lungs: CTA bilat Abd: Soft no m/t/o Extremities: Warm, well perfused, palpable lower extremity pulses bilat Wound: groin puncture c/d/i Pertinent Results: Admission labs: [2149-12-13] 03:19AM BLOOD WBC-4.0 RBC-3.84* Hgb-12.2* Hct-35.9* MCV-93 MCH-31.7 MCHC-33.9 RDW-13.6 Plt Ct-268 [2149-12-13] 03:19AM BLOOD PT-15.0* PTT-27.2 INR(PT)-1.3* [2149-12-13] 07:23AM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-139 K-4.0 Cl-108 HCO3-23 AnGap-12 [2149-12-13] 07:23AM BLOOD ALT-22 AST-29 CK(CPK)-55 AlkPhos-73 TotBili-0.8 [2149-12-13] 03:19AM BLOOD Lipase-17 [2149-12-13] 07:23AM BLOOD CK-MB-1 cTropnT-<0.01 [2149-12-13] 07:23AM BLOOD Albumin-3.7 Calcium-8.4 Phos-3.4 Mg-1.6 Discharge: [2149-12-17] 10:00AM BLOOD WBC-2.7* RBC-3.86* Hgb-12.3* Hct-36.7* MCV-95 MCH-32.0 MCHC-33.6 RDW-13.6 Plt Ct-194 [2149-12-17] 10:00AM BLOOD Glucose-126* UreaN-7 Creat-0.9 Na-136 K-4.1 Cl-100 HCO3-24 AnGap-16 [2149-12-17] 10:00AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.8 Cardiac Enzymes: [2149-12-13] 07:23AM BLOOD CK-MB-1 cTropnT-<0.01 [2149-12-13] 01:32PM BLOOD CK-MB-1 cTropnT-<0.01 [2149-12-15] 01:30PM BLOOD cTropnT-<0.01 Brief Hospital Course: Pt admitted from ED with Type B aortic dissection, uncontrolled hypertension and pain. He was admitted to the CVICU and placed on nipride/esmolol drips for blood pressure control. His INR was sub-therapeutic and he was started on a heparin gtt for his mechanical avr. Given his heavy ETOH history, the pt was placed on withdrawl precautions and a ciwa scale. He was evaluated by the cardiology service who made recommendations for oral blood pressure meds. His drips were weaned off and his BP was controlled with oral agents. Once off the drips he was transfered to the VICU where he continued to be monitored closely. His pain and blood pressure were well controlled. He was seen by addiction medicine and social work and followed throughout his stay. CT scan showed:"thoracic aorta dissection most consistent with [Initials (NamePattern4) ] [Last Name (NamePattern4) 11916] type B dissection. The dissection starts just distal to the left subclavian artery and ends just proximal to the bilateral renal arteries. The dissection extends into the proximal SMA. The visualized vessels are patent." Cardiac surgery was consulted and evaluated the patient. They determined that he would need an open repair and asked for a cardiac catheterization prior to surgery. On [12-16] the patient went for a cardiac cath, which showed no coronary artery disease. He remained in the VICU through [12-17] at which time it was determined he was stable for discharge home. His pain and blood pressure were well controlled. He will return in a few weeks for open surgical repair of his dissection with Dr. [Last Name (STitle) 914] and Dr. [Last Name (STitle) ]. We reviewed the seriousness of his condition, including the importance of medication compliance, blood pressure control and refraining from any drugs. Medications on Admission: [Last Name (STitle) 197] 5', Folic Acid 1', ISMN ER 30', Nifedical XL 30', Carvediolol 12.5'' Discharge Medications: 1. enoxaparin 80 mg/0.8 mL Syringe Sig: 70 mg Subcutaneous [Hospital1 ] (2 times a day): 70mg or 0.7mL . Disp:20 Refills:0 2. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Disp:90 Tablet(s) Refills:0 3. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for hr <55, sbp<100. 4. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). Disp:60 Tablet Extended Release(s) Refills:1 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Type B Aortic Dissection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You have an aortic dissection and will need surgery to repair it. You must keep your blood pressure under good control until your follow up and surgery with the cardiac surgery division. You should not lift anything >10 lbs. Do not drive while taking narcotic pain medication. You have a mechanical aortic valve replacement and must be anticoagulated for this. You have been started on Lovenox (short term blood thinner) and restarted on [Hospital1 197] (long term blood thinner). Contine both and have your blood level (INR) checked at least 2x week. When your INR is >2, you will stop the Lovenox injections but continue on [Hospital1 197]. Do not change your dose or discontiue either medication without your PCP's instruction. Discharge Instructions: Taking [Hospital1 197] (Warfarin) Your doctor [First Name (Titles) 2875] [Last Name (Titles) 197] (warfarin) for you. Be sure to take it as directed. Because [Last Name (Titles) 197] helps keep your blood from clotting, you also need to protect yourself from injury, which could lead to excessive bleeding. Guidelines for Medication Use Follow the fact sheet that came with your medication. It tells you when and how to take your medication. Ask for a sheet if you didn??????t get one. Do not take [Last Name (Titles) 197] during pregnancy because it can cause birth defects. Talk to your doctor about the risks of taking [Last Name (Titles) 197] while pregnant. Take [Last Name (Titles) 197] at the same time each day. If you miss a dose, take it as soon as you remember??????unless it??????s almost time for your next dose. In that case, skip the dose you missed. [Male First Name (un) ]??????t take a double dose. Keep appointments for blood (protime/INR) tests as often as directed. [Male First Name (un) ]??????t take any other medications without checking with your doctor first. This includes over-the-counter medications and any herbal remedies. Other Precautions Tell all your healthcare providers that you take [Male First Name (un) 197]. It??????s also a good idea to carry a medical identification card or wear a medical ID bracelet. Use a soft toothbrush and an electric razor. [Male First Name (un) ]??????t go barefoot. [Male First Name (un) ]??????t trim corns or calluses yourself. Keep Your Diet Steady Keep your diet pretty much the same each day. That??????s because many foods contain vitamin K. Vitamin K helps your blood clot. So eating foods that contain vitamin K can affect the way [Male First Name (un) 197] works. You [Male First Name (un) ]??????t need to avoid foods that have vitamin K. But you do need to keep the amount of them you eat steady (about the same day to day). If you change your diet for any reason, such as due to illness or to lose weight, be sure to tell your doctor. Examples of foods high in vitamin K are asparagus, avocado, broccoli, and cabbage. Oils, such as soybean, canola, and olive oils are also high in vitamin K. Alcohol affects how your body uses [Male First Name (un) 197]. Talk to your doctor about whether you should avoid alcohol while you??????re using [Male First Name (un) 197]. Herbal teas that contain sweet clover, sweet [Location (un) ], or tonka beans can interact with [Location (un) 197]. Keep the amount of herbal tea you use steady. Possible Side Effects Tell your doctor if you have any of these side effects, but [Male First Name (un) ]??????t stop taking the medication until your doctor tells you to. Mild side effects include the following: More gas (flatulence) than usual Bloating Diarrhea Nausea Vomiting Hair loss Decreased appetite Weight loss When to Call Your Doctor Call your doctor immediately if you have any of the following: Trouble breathing Swollen lips, tongue, throat, or face Hives or painful rash Black, bloody, or tarry stools Blood in your urine Vomiting or coughing up blood Bleeding gums or sores in your mouth Urinating less than usual Yellowing of the skin or eyes (jaundice) Dizziness Severe headache Easy bleeding or bruising Purple discoloration of your toes or fingers Sudden leg or foot pain Any chest pain Lovenox/Enoxaparin injection What is enoxaparin injection? ENOXAPARIN (Lovenox??????) is commonly used after knee, hip, or abdominal surgeries to prevent blood clotting. Enoxaparin is also used to treat existing blood clots in the lungs or in the veins. Enoxaparin is similar to heparin. Enoxaparin is known as an anticoagulant, and is sometimes called a blood thinner. However, enoxaparin does not actually thin the blood, but decreases the ability of blood to form clots. Generic enoxaparin injections are not yet available. What should my health care professional know before I receive enoxaparin? They need to know if you have any of these conditions: bleeding disorders, hemorrhage, or hemophilia brain tumor or aneurysm decreased kidney function diabetes high blood pressure infection of the heart or heart valves receiving injections of medications or vitamins liver disease previous stroke prosthetic heart valve recent surgery or delivery of a baby ulcer in the stomach or intestine, diverticulitis, or other bowel disease undergoing treatments for cancer an unusual or allergic reaction to enoxaparin, heparin, pork or pork products, other medicines, foods, dyes, or preservatives pregnant or trying to get pregnant breast-feeding How should I use this medicine? Enoxaparin is for injection under the skin. It is usually given by a health-care professional, or you or a family member may be trained on how to give the injections. If you are to give yourself injections, make sure you understand how to use the syringe, measure the dose if necessary, and give the injection, and how to dispose of used syringes and needles. Use the syringes only once, and throw away syringes and needles in a closed container to prevent accidental needle sticks. Use exactly as directed. Do not exceed the [Male First Name (un) 2875] dose, and try not to miss doses. To avoid bruising, do not rub the site where enoxaparin has been injected. What if I miss a dose? It is important to administer enoxaparin at regular intervals as [Male First Name (un) 2875] by your health care professional. Depending on your condition, enoxaparin is usually given either once daily (every 24 hours) or twice daily (every 12 hours). If you have been instructed to use enoxaparin on a regular schedule, use missed doses as soon as you remember, unless it is almost time for the next dose. Do not use double doses. What drug(s) may interact with enoxaparin? antiinflammatory drugs such as ibuprofen (Motrin??????), naproxen (Aleve??????), or ketoprofen (Orudis-KT??????) clopidogrel dipyridamole fish oil (omega-3 fatty acids) supplements herbal products containing feverfew, garlic, ginger, gingko, or horse chestnut ticlopidine Tell your prescriber or health care professional about all other medicines you are taking, including non-prescription medicines, nutritional supplements, or herbal products. Also tell your prescriber or health care professional if you are a frequent user of drinks with caffeine or alcohol, if you smoke, or if you use illegal drugs. These may affect the way your medicine works. Check with your health care professional before stopping or starting any of your medicines. What should I watch for while taking enoxaparin? In case of an accident or emergency, it is recommended that you place a notification in your wallet that you are receiving enoxaparin. Your condition will be monitored carefully while you are receiving enoxaparin. Notify your prescriber or health care professional and seek emergency treatment if you develop increased difficulty in breathing, chest pain, dizziness, shortness of breath, swelling in the legs or arms, abdominal pain, decreased vision, pain when walking, or pain and warmth of the arms or legs. These can be signs that your condition has worsened. Monitor your skin closely for easy bruising or red spots, which can indicate bleeding. If you notice easy bruising or minor bleeding from the nose, gums/teeth, in your urine, or stool, contact your prescriber or health care professional immediately, these are indications that your medication needs adjustment or evaluation. Keep scheduled appointments with your prescriber or health care professional to check on your condition. If you are going to have surgery, tell your prescriber or health care professional that you have received enoxaparin. Be careful to avoid injury while you are using enoxaparin. Take special care brushing or flossing your teeth, shaving, cutting your fingernails or toenails, or when using sharp objects. Report any injuries to your prescriber or health care professional. What side effects might I notice from receiving enoxaparin? Side effects that you should report to your prescriber or health care professional as soon as possible: Rare or uncommon: signs and symptoms of bleeding such as back or stomach pain, black, tarry stools, blood in the urine, or coughing up blood difficulty breathing dizziness or fainting spells More frequent: bleeding from the injection site fever unusual bruising or bleeding: bleeding gums, red spots on the skin, nosebleeds Side effects that usually do not require medical attention (report to your prescriber or health care professional if they continue or are bothersome): pain or irritation at the injection site skin rash, itching Where can I keep my medicine? Keep out of the reach of children. Store at room temperature below 25 degrees C (77 degrees F); do not freeze. If your injections have been specially prepared, you may need to store them in the refrigerator - ask your pharmacist. Throw away any unused medicine after the expiration date. Make sure you receive a puncture-resistant container to dispose of the needles and syringes once you have finished with them. Do not reuse these items. Return the container to your prescriber or health care professional for proper disposal Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 85918], MD Phone:[Telephone/Fax (1) 3070] Date/Time:[2149-12-19] 11:20. This is for INR follow-up. [Street Address(2) 91381], [Location (un) ] MASS. [Telephone/Fax (1) 3070] * do not miss [First Name (Titles) ] [Last Name (Titles) ]t* [Doctor Last Name ] [Doctor Last Name ] DAMN, WEND [1668-12-30] HRS. [Street Address(2) ], [Location (un) ] MASS. [Telephone/Fax (1) 3070]. NEW PCP Your surgery will be scheduled sometime in the next several weeks. Dr.[Name (NI) 9379] (cardiac surgeon) office will call you with your surgery date. His number is ([Telephone/Fax (1) 1504] Completed by:[2149-12-17]	[ "401.9", "441.4", "412", "305.1", "425.4", "440.20", "414.00", "428.0", "296.80", "441.03", "303.91", "V45.81", "V58.61", "V15.81", "V43.3", "304.23", "786.51", "070.70", "428.22", "304.43" ]	icd9cm	[ [ [] ] ]	[ "88.56", "88.42", "37.22" ]	icd9pcs	[ [ [] ] ]	5668, 5674	2814, 4641	324, 368	5743, 5743	1797, 1797	15985, 16732	1432, 1496		4790, 5645		5695, 5722		4667, 4767			6661, 15962										1511, 1778																							2639, 2791					265, 286											397, 1044							1813, 2621					5758, 5870			1066, 1198	1214, 1416
2,166	161,124	16636	Discharge summary	report	Admission Date: [2185-12-8] Discharge Date: [2185-12-11] Date of Birth: [2147-6-26] Sex: M Service: CCU-MED CHIEF COMPLAINT: The patient is status post myocardial infarction. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 47126] is a 37-year-old gentleman with no known past medical history (as he has not seen a physician in many years). He has no known cardiac risk factors and no family history of coronary artery disease. The patient presented to an outside hospital at 7 a.m. on [2185-12-8] complaining of severe back pain that was mostly left-sided and scapular in nature. The patient states that the pain began on [2185-12-7] when the patient was outside in his yard at [Hospital3 ] in the cold air putting together a basketball net for one of his children. The patient states that the pain came on suddenly, went across the middle of his back (infrascapular), left greater than right, with no associated shortness of breath. No nausea or vomiting, and no radiation of the pain. The patient states that a few days prior to the initiation of the back pain, he had flu-like symptoms; describing fatigue and muscle aches with subjective fevers and chills. He denies any upper respiratory symptoms. No cough. No congestion. He denies gastrointestinal symptoms. He states that his main symptoms were fevers, chills, weakness, and bach ache. Over the evening of [2185-12-7], he states that the back pain was coming in waves, and he began to have associated diaphoresis. The pain was so bad by the morning of [12-8] that he "couldn't lay flat," so he went to the Emergency Department at a local hospital. In the Emergency Department, he described the pain as [6-15]. With morphine, the pain was decreased to [12-16]. The patient was noted to have the following electrocardiogram changes at the outside hospital; he had Q waves in II, III, aVF, V4 through V6. He had an R wave in V1 (suggestive of a posterior myocardial infarction), and he had 1-mm ST elevations in V4 through V6. At the outside hospital, the patient was given aspirin, three sublingual nitroglycerin tablets, nitroglycerin paste, morphine sulfate (2 mg intravenously times four), Lopressor (5 mg intravenously times one), and was started on a heparin drip. He was then transferred to [Hospital1 190] for cardiac catheterization. PAST MEDICAL HISTORY: The patient denies any significant past medical history; although, he has not seen a physician in many years. PAST SURGICAL HISTORY: No past surgical history. CARDIAC RISK FACTORS: Coronary artery disease risk factors include no known elevation of cholesterol. He is a nonsmoker. No family history. The patient is obese and states that he has been for years. He weighs approximately 250 pounds and is 5 feet 11 inches tall. MEDICATIONS ON ADMISSION: The patient was taking a multivitamin and Motrin as needed for back pain. ALLERGIES: He has no known drug allergies. FAMILY HISTORY: No history of cardiac disease. No diabetes. His father died secondary to lung cancer from a long smoking history. He has no communication with his mother. [Name (NI) ] has one sister who is healthy. SOCIAL HISTORY: The patient owns a cleaning and maintenance service on [Hospital3 ]. He has two people who work for him, but does a lot of the maintenance on his own; which includes heavy lifting. He does not smoke and has never smoked in the past. He drinks alcohol occasionally; drinking a few beers per week. He denies intravenous drug abuse and denies cocaine use. REVIEW OF SYSTEMS: On review of systems, the patient complained of subjective fevers with chills times three to four days. The back pain (as stated in the History of Present Illness) began on [12-7] and continued until [12-8] and was associated with diaphoresis as of the morning of [12-8]. He denied nausea, vomiting, and diarrhea. No upper respiratory symptoms. No urinary tract infection symptoms. At baseline, the patient states he can walk one to two miles with no difficulty. He plays football and basketball with his sons. [Name (NI) ] has never had chest pain, and he has never had to stop exercise for shortness of breath or chest pain. However, the patient states for the last few years he does not regularly exercise. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed heart rate was 89, blood pressure was 135 to 155/85 to 87, respiratory rate was 18, oxygen saturation was 96% on 3 liters, and afebrile. In general, the patient was in no apparent distress. He was lying flat in bed and denied pain. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light and accommodation. Extraocular muscles were intact. Jugular venous pressure at the angle of the jaw. Heart examination revealed a regular rate and rhythm. Normal first heart sound and second heart sound. No murmurs, rubs, or gallops. The lungs revealed bibasilar crackles. Abdominal examination revealed obese, soft, nontender, and nondistended. Positive bowel sounds. The extremities were warm with no edema and good distal pulses. Neurologically, alert and oriented times three. Cranial nerves II through XII were grossly intact. PERTINENT LABORATORY VALUES ON PRESENTATION: Other data from the outside hospital revealed his hematocrit was 50.9. His white blood cell count was 17.9, and his platelets were 209. He chemistries revealed sodium was 141, potassium was 4, chloride was 100, bicarbonate was 28, blood urea nitrogen was 10, creatinine was 1, and blood glucose was 119. Albumin was 4.3. At the outside hospital, his initial creatine kinase was 1892, with a MB of 151, and a troponin of 4.14. Status post catheterization at 4 p.m. at [Hospital1 346], his creatine kinases peaked at 9753, with a MB of 862, and a troponin of greater than 50. At 7 p.m. (status post catheterization), his creatine kinases were 7259, with a MB of 570. Also, after the catheterization, his electrocardiogram changes had not resolved significantly. His electrocardiogram showed a normal sinus rhythm, with a rate of 90 to 100, a leftward axis, normal intervals, Q waves in II, III, aVF, V4 through V6, and R wave in V1, ST elevations of around 1 mm in V4 through V6. RADIOLOGY/IMAGING: Significant laboratory data revealed cardiac catheterization which showed the following hemodynamics; right atrial pressure of 12, right ventricular pressure of 45/10, pulmonary artery pressure elevated at 42/27, pulmonary artery pressure mean was 32, pulmonary capillary wedge pressure was 27. Cardiac output was 5.14. Cardiac index was 2.2. Angiography at catheterization showed left anterior descending artery with no tight stenoses, left circumflex was 100% occluded in the medial portion, and the right coronary artery showed no tight stenoses. For intervention, the patient had an Angio-Jet thrombectomy and stent to his medial circumflex. ASSESSMENT: This is a 37-year-old gentleman with no known past medical history presenting with a large inferolateral posterior myocardial infarction with a large infarct territory by electrocardiogram findings and significant creatine kinase leak. The patient has unknown risk factors since no medical followup. He was status post a stent to the circumflex. HOSPITAL COURSE BY SYSTEM: 1. CARDIOVASCULAR SYSTEM: (a) CORONARY ARTERY DISEASE: For his coronary artery disease, the patient had a stent to his left circumflex. He was placed on Plavix 75 mg p.o. q.d. and aspirin 325 mg p.o. q.d. He was continued on an Integrilin drip for 18 hours. His creatine kinases were cycled. His peak, as stated above, was 9753, and his creatine kinases continued to trend down. His creatine kinase on [12-9] was 3774, with a MB on that creatine kinase of 174. His creatine kinase on [2185-12-11] had gone down to 902, with a MB of 21. For his coronary artery disease, the patient was placed on a beta blocker which was titrated up as tolerated. He was persistently in sinus tachycardia with heart rates ranging anywhere from 80 to 120. Therefore, by the day of discharge (on [12-11]), he was on metoprolol 75 mg p.o. b.i.d. He was discharged on atenolol 75 mg p.o. q.d. The patient was also placed on an ACE inhibitor to help prevent remodeling after this large infarct. He was tolerating captopril 12.5 mg p.o. t.i.d. by the day of discharge, and this was changed to lisinopril 2.5 mg p.o. q.d. The patient's cholesterol panel was checked, and his cholesterol values were the following: His total cholesterol was 234, with an high-density lipoprotein of 38, an low-density lipoprotein of 168, and triglycerides of 138. The patient was empirically started on atorvastatin 20 mg p.o. q.h.s. prior to these levels coming back, and he was continued on this throughout his hospital course. A homocystine level was also checked as the patient had no known risk factors; it was felt that he could possibly have hypercoagulable state. However, his homocystine level was normal at 6.4. As far as other risk factors, the patient had a random sugar of 140 on admission. Therefore, a hemoglobin A1c was sent; however, this value did not return by the day of discharge. It was felt that the patient could have glucose intolerance; however, further fasting sugars came back 100 or less, so this was less likely but should be followed up as an outpatient. (b) PUMP: The patient had an echocardiogram on [2185-12-9]. The echocardiogram showed the following: The patient had an ejection fraction of 35%. His left atrium a normal in size. There was a moderate regionally left ventricular systolic dysfunction with akinesis of the inferoposterior wall and hypokinesis of the lateral wall. The right ventricular chamber size and free wall motion were stated to be normal. The aortic root was moderately dilated. The aortic valve leaflets appeared structurally normal with good leaflet excursion, and no aortic regurgitation. The mitral valve leaflets were structurally normal with mild-to-moderate 1 to 2+ mitral regurgitation, trivial pericardial effusion. As stated above, the patient was started on an ACE inhibitor to help prevent remodeling and was titrated up to 12.5 mg p.o. t.i.d. which he tolerated without orthostasis or hypotension. As the patient had an evaluated pulmonary capillary wedge pressure of 26 in the catheterization laboratory, and he had signs of congestive heart failure on physical examination and chest x-ray, he was given three doses of 20 mg Lasix intravenously. He diuresed well to this and was euvolemic by the day of discharge. (c) RHYTHM: The patient continued to have sinus tachycardia, status post his myocardial infarction. His beta blocker was titrated up (as stated above), so that he was at 75 mg p.o. b.i.d. of Lopressor by the day of discharge. He had no telemetry events other than sinus tachycardia. Given that the patient had a significantly large myocardial infarction and had some left ventricular hypokinesis, and electrophysiology study was considered; however, it was decided that as his ejection fraction was greater than 30%, his risk of ST depressions was relatively low. Therefore, he did not require an electrophysiology followup at this point. 2. RENAL SYSTEM: With such high elevations in creatine kinases, there was some concern that the patient may be at risk for rhabdomyolysis. Therefore, a urinalysis was checked on [2185-12-9] and [2185-12-8]. On neither urinalysis was there evidence of rhabdomyolysis and no evidence of infection. The patient's creatinine remained stable at 1 to 1.1. DISCHARGE DISPOSITION: The patient was seen by Physical Therapy during his admission. He was able to ambulate without chest pain or back pain, and his heart rate and blood pressure rose appropriately. He did not desaturate. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with a cardiac rehabilitation facility on [Hospital3 ]; which he was interested in doing. 2. It was also emphasized to the patient the importance of no heavy lifting or labor for at least two to three weeks status post his large myocardial infarction. As he is the owner of a maintenance company, he said this may be difficult, and it was stressed to the patient multiple times that he needs to stay away from the activities for at least two to three weeks. 3. The patient was to follow up (as stated above) with cardiac rehabilitation and to establish a cardiologist on [Hospital3 ]. DISCHARGE STATUS: The patient was discharged to home. MEDICATIONS ON DISCHARGE: (The patient was discharged on the following medication) 1. Atenolol 75 mg p.o. q.d. 2. Lisinopril 2.5 mg p.o. q.d. 3. Atorvastatin 20 mg p.o. q.h.s. 4. Plavix 75 mg p.o. q.d. (to be continued for nine months status post catheterization with intervention). 5. Aspirin 325 mg p.o. q.d. 6. Ranitidine 150 mg p.o. b.i.d. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7169] Dictated By:[Last Name (NamePattern1) 47127] MEDQUIST36 D: [2185-12-11] 11:44 T: [2185-12-13] 07:21 JOB#: [Job Number 47128]	[ "410.31", "429.9", "416.8", "278.00", "424.0", "272.9", "414.01" ]	icd9cm	[ [ [] ] ]	[ "36.01", "99.20", "88.56", "37.23", "36.06" ]	icd9pcs	[ [ [] ] ]	11716, 11920						3006, 3214					12677, 13299	2868, 2988					11953, 12650			7387, 11692			2543, 2841																								3613, 7359						155, 206											235, 2385															2408, 2519	3231, 3593
7,110	117,185	7114	Discharge summary	report	Admission Date: [2190-4-5] Discharge Date: [2190-4-21] Service: MEDICINE Allergies: Aspirin / Unasyn Attending:[First Name3 (LF) 678] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 87 yo woman with poorly controlled HTN and CKD (baseline Cr 1.4-1.6) who initially presented from Benchmark [Hospital ] Facility after falling out her bed resulting in a left shoulder dislocation. This was reduced in the ED. However, she was also found to have an NSTEMI secondary to demand ischemia on admission. She was seen by cardiology and felt not to be a good candidate for cardiac cath and recommended medical management. She was started on ASA and continued on BB and statin. . She also continued to complain of RUQ pain and had an elevated AST/ALT/WBC for which she underwent RUQ ultrasound which showed GB edema and possible cholecystitis. She was started on Unasyn and surgery was consulted and recommended HIDA scan which was attempted but adequate study could not be performed. Given that her WBC trended down and pain improved and was toleraing PO's surgery felt there was a low suspicion for acute cholecystitis. Also noted to have worsening ARF during her stay and had a trigger on [4-7] for low urine output. Urine sent yesterday was positive for eosinophils. . This evening a code blue was called after patient was found on the floor in her room and non-responsive. Per the nursing the patient had looked well throughout the day with no specific changes. They heard the bed alarm go off and found her on the ground non-responsive. CPR was initiated, although according to the first responder resident she never lost a pulse and code blue called as she was reportedly apneic. When the MICU team arrived she was noted to have a sinus rhythm on tele at 50-70 with PAC's, blood pressure was 70/dop, O2sat could not be obtained and was being bagged by respiratory. At times she was breathing spontaneously, however was otherwise not responsive. A central line was placed in the right femoral vein. She was subseuquently intubated without sedation for airway protection. BP responded without intervention to the 140's/dop. ABG showed 7.08/41/256. She was given propofol for agitation after the intubation. She was given IVF's and BP remained stable and was then transferred to the MICU for further care. after arrival in the MICU an arterial line was placed with SBP 70s and she was given 1L NS bolus, after which her pressure rose to 120s. Past Medical History: - stage III - IV chronic kidney disease secondary to hypertension and renovascular disease (baseline Cr of 1.4-1.6) - HTN (poorly controlled) - Chronic back pain - Colitis-collagenous - Cervical stenosis - Remote BR CA [2157] tx with mastectomy - TAH secondary to fibroids; BSO - Echo [2189] with mild LVH EF 30-35%; mild MR - Migraines - Neuropathy - GERD - anemia - s/p left eye lens implant - secondary hyperparathyroidism Social History: Lives in [Hospital3 ]. Uses walker. Non-smoker. Daughter close by. Son in [Name2 (NI) ]. Family History: NC Physical Exam: Tc 97.0 BP 99/53 HR 73 RR 23 100% on AC 500x12 peep 5, fiO2 100 Gen: cachetic elderly female appears uncomfortable rolling around in bed, uncooperative with exam HENNT: dry MM, anicteric Neck: no LAD, no JVD, no bruits CV: RRR, nl S1S2, II/VI systolic murmur heard best at the apex Lungs: anteriorly CTAB Abd: soft, LLQ tenderness, +distention, tympanitic, +somewhat high pitched BS Rectal: guaiac neg, normal rectal tone per ED report Ext: 2+ edema BLE, palpable DP/PT pulses bilaterally Neuro: A&Ox0, moving all extremities Skin: no rash Pertinent Results: SHOULDER (AP, NEUTRAL & AXILLARY) LEFT [2190-4-4] LEFT SHOULDER, THREE VIEWS: The axillary view is limited by patient positioning. The left humerus now appears to articulate with the glenoid post reduction, but is minimally anteriorly subluxed. The large [Doctor Last Name ]-[Doctor Last Name 3450] deformity is again appreciated. On the current exam, there is the question of a Bankhart lesion. There is extensive calcification of the acromioclavicular articulation. IMPRESSION: Limited examination suggests successful reduction of left shoulder dislocation, though there is evidence of laxity. Question of bony Bankhart lesion as well. . CHEST (PA & LAT) 7:48 PM FINDINGS: Two views of the chest demonstrate stable cardiomegaly with left ventricular configuration. The aorta is tortuous as before with calcifications of the arch. There is enlargement of the pulmonary arteries which is chronic. There is no focal lung parenchymal consolidation, pleural effusion, or pneumothorax. There is chronic inferomedial positioning of the left humeral head with a large preexisting [Doctor Last Name ]-[Doctor Last Name 3450] deformity noted. On this frontal view, the left humeral head appears to be located within the glenoid fossa. Also demonstrated are chronic severe degenerative changes of the right glenohumeral articulation with pseudoarthrosis with the coracoid process. IMPRESSION: 1. No acute cardiopulmonary process. 2. Chronic inferomedial positioning of the left humeral head with large pre- existing [Doctor Last Name ]-[Doctor Last Name 3450] deformity. 3. Extensive degenerative change of the right glenohumeral articulation. . HUMERUS (AP & LAT) LEFT [2190-4-4] FINDINGS: Three views of the left shoulder and three views of the left humerus were obtained. The left humeral head is anteriorly dislocated relative to the glenoid. No definite acute fracture is identified. There is a large pre-existing [Doctor Last Name ]-[Doctor Last Name 3450] deformity of the left humeral head. There are extensive degenerative changes of the acromioclavicular and glenohumeral articulations. No soft tissue abnormality is identified. IMPRESSION: Anterior dislocation of the left humeral head with large pre- existing [Doctor Last Name ]-[Doctor Last Name 3450] deformity. . EKG [2190-4-4]: 87bpm, NSR, 1st degree AV delay, LVH . HIDA scan [2190-4-5] The study is limited by patient cooperation. Serial flow images over the abdomen show poor uptake of tracer into the liver, but excretion into a tubular structure which may represent a dilated common bile duct. Tracer activity is then seen in the duodenum. 90 minute static images demonstrate activity in the bowel, but no clear visualization of the gallbladder. Repeat images were attempted, but the patient did not wish to continue with the examination. IMPRESSION: Non-diagnostic examination due to technical reasons and patient cooperation without visualization of the gallbladder. There may be a dilated common bile duct. A repeat study the following day after the administration of CCK was recommended. . ABDOMEN (SUPINE ONLY) [2190-4-5] FINDINGS: One view of the abdomen in supine position. The lower pelvis and inguinal region are excluded, which limits the study. No evidence of obstruction. No evidence of dilatation. No intraperitoneal free air is seen. Severe scoliosis is again noted. IMPRESSION: Limited study due to exclusion of the lower pelvis and inguinal region. No evidence of obstruction. . ABDOMEN U.S. (COMPLETE STUDY) [2190-4-5] RIGHT UPPER QUADRANT ULTRASOUND: Compared to MR abdomen of [2186-9-19]. No focal mass lesions are seen in the liver, however, there is a diffusely prominent pattern of echogenic portal triads, a nonspecific finding, but occasionally seen with hepatitis. There is a trace amount of ascites. The gallbladder wall demonstrates massive edema, with layering sludge, and a small amount of pericholecystic fluid. The patient is diffusely tender over the liver, however, more focally tender over the gallbladder. Multiple large simple- appearing or singly-septated exophytic renal cysts are only partially imaged on this study. The aorta demonstrates diffuse atherosclerotic calcification. Pancreas is not well visualized. Main portal vein is patent with appropriate hepatopetal flow. There is no extrahepatic biliary ductal dilatation. There is equivocal mild intrahepatic biliary ductal dilatation. IMPRESSION: 1) Sludge filled gallbladder with severe wall edema, and a small amount of pericholecystic fluid. Positive [Doctor Last Name ] sign, however, the patient is also diffusely tender over the liver to a lesser degree. These findings may represent acute cholecystitis, however, alternatively could represent wall edema secondary to underlying liver disease or other causes for third spacing of fluids. 2) Echogenic portal triads, a nonspecific finding, but occasionally seen with hepatitis, correlate with clinical picture. 3) Trace ascites. 4) Large exophytic right renal cysts only partially imaged. 5) Diffuse aortic atherosclerotic plaque. . TTE: LVEF 50% [Name Prefix (Prefixes) ] [Last Name (Prefixes) 3841] dilated mild symmetric LV hypertrophy, nl size Mild regional LV systolic dysfunction with mild focal hypokinesis of mid inferolateral wall. (Aortic root is mildly dilated (at sinus level)) (ascending aorta moderately dilated) no AS, 1+ AR 2+ MR 2+TR mild pulmonary artery HTN trivial/physiologic pericardial effusion. \ Compared with the prior study (images reviewed) of [2189-7-31], regional left ventricular systolic dysfunction is new. The severity of tricuspid regurgitation and the estimated pulmonary artery pressure is also increased. . HIDA: did not tolerate x2 . PELVIS (AP & FROG HIPS) [2190-4-7] IMPRESSION: 1. Osteopenia. No definite right hip fracture, but if clinical suspicion remains high, further evaluation by MRI is recommended as much of the proximal femur is obscured by overlying calcifications. 2. Very unusual periarticular soft tissue calcifications and calcification of the pubic symphysis, which has progressed compared with [2183-4-24]. This may represent very dense atypically distributed chondrocalcinosis -- this can be seen with cppd, hemochomratosis, and hyperparathyroidism, among other processes. The differential diagnosis includes calcification in gouty tophi, but no erosions are detected. The distribution raises the question of a very unusual form of calcification within synovium. 3. Marked djd and scoliosis in the spine, with evidence of vertebral body compression. . GLENO-HUMERAL SHOULDER (W/ Y VIEW) LEFT [2190-4-7] IMPRESSION: 1. Anatomic alignment of the left shoulder. No evidence of dislocation. 2. Unchanged appearance of large [Doctor Last Name ]-[Doctor Last Name 3450] deformity. 3. Unchanged appearance of extensive acromioclavicular and glenohumeral degenerative change. . RIB UNILAT, W/ AP CHEST RIGHT [2190-4-7] The lungs are hyperinflated and the diaphragms are flattened, consistent with COPD. There is moderately severe cardiomegaly. The aorta is calcified and tortuous. Additional calcification is seen in the superior mediastinum, ? vascular vs pleural-based. Prominence of the right paratracheal soft tissues likely represents vascular structures in an individual of this age. There is prominence of hila suggesting element of pulmonary hypertension. There is upper zone redistribution and mild diffuse vascular blurring, consistent with very mild CHF. No overt failure is identified. No focal consolidation or effusion is seen. No pneumothorax is present. A prominent [Doctor Last Name ]-[Doctor Last Name 3450] deformity is seen in left shoulder, better evaluated on a dedicated shoulder film. There is also severe degenerative change of the right shoulder. Marker indicates a site over the base of the right ribs. There is a fracture of the right fifth rib laterally and probably also fractures of the right sixth and seventh ribs. IMPRESSION: Multiple right-sided rib fractures. No effusion, pneumothorax or pulmonary contusion identified. . Repeat RUQ US [4-7] CONCLUSION: The appearance remains concerning for acute cholecystitis, but the degree of wall edema has diminished and the amount of distention of the gallbladder lumen has also diminished in comparison to the scan two days ago. The initial HIDA scan was technically unsatisfactory and a repeat HIDA scan with CCK is recommended for further evaluation, as this process may be partially resolving. Brief Hospital Course: 87 yo woman with poorly controlled HTN and CKD who presents s/p fall resulting in a left shoulder dislocation and found to have NSTEMI and gallbladder edema. Was transferred to MICU peri-code s/p found down minimally responsive with intubation for airway protection. Transient hypotension responded to fluids. . 1. FALL: The patient experienced an unwitnessed fall at her NH. When she arrived at the ER, she had an anteriorly dislocated left shoulder which was reduced and rib fractures. . 2. NSTEMI: The patient was seen by Cardiology and the NSTEMI was thought to be secondary to demand ischemia in the setting of recent fall. She was not a good candidate for revascularization and was, thus medically management. She was started on aspirin 325. She was not on aspirin on admission because she had a history of GI bleed in the setting of NSAID use. She was also given a beta blocker. ACE inhibitor was held in the setting of ARF. Statin was also held given elevated transaminases. . 3. AFIB with RVR: The patient had several episodes of atrial fibrillation with RVR which converted to normal sinus rhythm with IV metoprolol. She was well rate-controlled with metoprolol. She was continued on aspirin, but other anticoagulation was not initiated as the patient has a history of GI bleeding and falls; this was discussed with her PCP, [Name10 (NameIs) ] [First Name (STitle) 216]. . 4. HYPOXIA/HYPOTENSION: During this admission, the patient was found on the floor after her bed alarmed. She was apneic and hypotensive. CPR was intiated. ABG was 7.08/41/256. The etiology of her fall was unclear, but possible etiologies include mechanical vs MI vs orthostatic hypotension vs sepsis. She was transferred to the ICU and intubated for airway protection. She was volume resuscitated and treated empirically for sepsis with broad coverage antibiotics. WBC trended down, she was extubated without complications and she remained hemodynamically stable for the remainder of her course. She received a 10 day course of antibiotics and remained afebrile. She did have a cortisol stimulation which was normal. Per her son's report, the patient has labile blood pressures at baseline. . 5. METABOLIC ACIDOSIS: The patient had a mixed anion gap (lactic acidosis and uremia) and non-anion gap (renal failure with low bicarb as renal failure worsened) acidosis on transfer to the MICU. She was transiently required bicarbonate supplementation and received 1 unit of PRBC (citrate in blood will be converted to bicarb). As her renal failure improved, her bicarbonate normalized and she no longer required supplementation. . 6. Acute on chronic renal failure (stage III-IV CKD): Acute renal failure was likely secondary to acute interstitial nephritis from unasyn which was started for concern of cholecystitis. She may have also had some component of ATN secondary to hypotension. She was seen by the Renal team. There was no indication for dialysis. She was agressively diuresed and her creatinine continued to improve. . 7. GB Edema: On admission, there was concern for cholecystitis given RUQ pain, elevated transaminases and GB edema on U/S. She was started on broad coverage antibiotics. Repeat RUQ US demonstrated decreased edema and distention of GB. HIDA scan [4-15] did not demonstrate acute cholecystitis and RUQ pain had resolved, so antibiotics were stopped. Blood cultures were negative on discharge. Acute hepatitis panel negative. . 8. Elevated Transaminases and chemical pancreatitis: There was possibly shock liver following hypotensive episode vs intermittent choledocholithiasis vs possible cholecystitis. Viral serologies negative. Ultrasound did not demonstrate cholelithiasis; MRCP was recommended by GI consultant but [Hospital 228] healthcare proxy requested that MRI, which would cause anxiety for patient, be avoided unless her clinical condition was wornsening. Transaminases were close to normal at discharge. . 9. Left Shoulder dislocation: The patient has a histroy of L shoulder dislocation 2 years ago. Her shoulder was dislocated on admission. Although it was reduced, it was later noted to be dislocated on CXR. She underwent CT of the left shoulder which demonstrated anterior dislocation and significant joint destruction. The patient may benefit from arthroplasty. However, she can be evaluated for this as an outpatient. She can call the Orthopaedics Department at [Hospital1 18] to make an appointment in 4 weeks. She should continue to wear a sling until she has follow up. . 10. Allopurinol was continued for gout. . CODE STATUS: DNR/DNI . ## Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 216] ([Telephone/Fax (1) 2756]) should be contact[Name (NI) ] if there are any questions regarding this patient's medications. . Communication: Daughter, [Known firstname 26505], [Telephone/Fax (1) 26506] is HCP. [Name (NI) ], [Name (NI) 122] [Telephone/Fax (1) 26507], lives in VA, was HCP while daughter [Name (NI) 26505] was traveling out of the country. Home Health Care Nurse [Last Name (Titles) ], from [Hospital1 ] Child and Family services ([Telephone/Fax (1) 26508]). Medications on Admission: - Toprol 100 mg [Hospital1 ] - .Lisinopril 20 mg [Hospital1 ] - .Lasix 20 mg [Hospital1 ] - Aldactone 25 mg QD - ranitidine 150 mg at qhs - .Actonel 35 mg q week - Calcitriol 0.25 mcg QD - .Neurontin 300 mg 1 tab QAM, 2 tabs QPM - .Allopurinol 100 mg QD - Trazadone 50 mg QHS - Ativan PRN - PeptoBismol PRN for diarrhea - nexium 40 daily - percocet prn Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 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. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: 1. L shoulder anterior dislocation 2. NSTEMI 3. Acute interstitial nephritis/ARF 4. Elevated transaminases 5. Respiratory failure 6. Hypotension . Secondary: - Stage III - IV CKD [2-12] HTN (baseline Cr of 1.4-1.6) - HTN (poorly controlled) - Chronic back pain - Collagenous colitis - Cervical stenosis - Remote BR CA [2157] tx s/p mastectomy - TAH secondary to fibroids; BSO - Echo [2189] with mild LVH EF 30-35%; mild MR - Migraines - Neuropathy - GERD - anemia - s/p left eye lens implant - secondary hyperparathyroidism Discharge Condition: Stable. Toleration PO. Afebrile. Discharge Instructions: You were admitted after experiencing a fall. Your left shoulder was dislocated and this was repaired. There was also evidence that you may have had a heart attack. You should return to the emergency room or call your doctor if you experience any of the following symptoms: fever > 101.4, chest pain, shortness of breath, intractable nausea/vomiting/abdominal pain or any other concerning symptoms. . Please take all medications as prescribed. . Please follow up with all appointments as prescribed. Followup Instructions: The following appointments have been scheduled for you: 1. Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2334], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2190-4-28] 1:45 2. Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2190-5-3] 11:50 3. Provider: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. Phone:[Telephone/Fax (1) 435] Date/Time:[2190-5-26] 10:30 . Please call [Telephone/Fax (1) 1228] to schedule an appointment with Dr. [Last Name (STitle) 1005] (Orthopaedics) in 4 weeks. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(1) 684]	[ "733.00", "458.9", "723.0", "427.31", "E884.4", "585.9", "276.2", "583.89", "274.9", "403.90", "530.81", "428.0", "V10.3", "355.9", "790.5", "584.9", "831.00", "346.90", "285.21", "410.71", "518.81" ]	icd9cm	[ [ [] ] ]	[ "38.91", "38.93", "79.71", "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	19295, 19361	12323, 17504	231, 237	19950, 19985	3726, 12300	20532, 21260	3140, 3144		17920, 19272		19382, 19929		17530, 17897			20009, 20509										3159, 3707																												183, 193											265, 2551															2573, 3009	3025, 3124
27,614	113,252	26797	Discharge summary	report	Admission Date: [2171-9-11] Discharge Date: [2171-9-17] Date of Birth: [2120-2-12] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1171] Chief Complaint: mitral [Last Name (NamePattern1) ] Major Surgical or Invasive Procedure: mitral [Last Name (NamePattern1) ] [2171-9-13] History of Present Illness: Patient is a 51 year old Cantonese speaking man with history of rheumatic mitral stenosis, prior pulmonary embolism, and left atrial clot. He presents today for admission for heparin drip in preparation of TEE and mitral [Month/Day/Year ]. Of note, patient was admitted in [2171-4-23] for chest pain, and was found to be in atrial fibrillation. During that admission, a transthoracic echocardiogram demonstrated rheumatic mitral stenosis with an ejection fraction of 40-50%. A transesophageal echocardiogram demonstrated a left atrial appendage, and he was started on Coumadin. A [Year (4 digits) ] and cardioversion were deferred at that time given the finding of the clot. History done through an interpreter. Since [Month (only) 547] admission patient's symptoms have been stable (not worse or better). Describes shortness of breath with exertion. Tends to feel dizzy when he bends over. Denies chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, or syncope. Patient describes mild nausea, denies abdominal pain or vomiting. Wife states he had an EGD which demonstrated ulcers and was started on "medication" for 2 months. Denies black or bloody stool. Patient aware he is in a hospital for a valve procedure. He has not taken his warfarin since last saturday night. Past Medical History: - Rheumatic mitral stenosis - History of pulmonary embolism [2169] - Atrial fibrillation Social History: Worked in a restaurant kitchen. Lives with wife. Smoked [11-11] cigarettes daily for 10 years, not currently smoking. No EtOH or drug use. Family History: Father with "enlarged heart" died at age 84. Mother has [Last Name ] problem, but patient does not know what it is. Physical Exam: On Discharge: VS: T97.8, BP105/84, HR 85, RR12, 100% 2lNC Gen: NAD, no resp dist. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3, 3/6SEM heart over precordium Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: soft, nt/nd, positive bowel sounds, no HSM or tenderness. Ext: No c/c/e. No femoral bruits, L and R femoral sites without signs of bleed or hematoma. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [2171-9-11] ALT(SGPT)-32 AST(SGOT)-24 LD(LDH)-199 ALK PHOS-93 AMYLASE-90 TOT BILI-0.4 [2171-9-11] WBC-6.3 RBC-4.31* HGB-13.4* HCT-40.2 MCV-93 MCH-31.1 MCHC-33.3 RDW-14.9 [2171-9-11] PT-15.1* PTT-32.9 INR(PT)-1.3* H. pylori: POSITIVE MITRAL [Month/Day/Year ]/CARDIAC CATH [2171-9-13]: 1. Severe mitral stenosis with mean gradient of 15mmHg and area of 0.68cm2. 2. Successful transeptal puncture with intracardiac echo guidance. 3. Successful mitral [Month/Day/Year ] using Inoue balloon inflated to a maximum diameter of 30mm. POST-PROCEDURE ECHOS: TTE [2171-9-13] at 12:45:00 PM: Study immediately post balloon mitral [Year (4 digits) ]. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets are moderately thickened. The mitral valve shows characteristic rheumatic deformity. There is moderate valvular mitral stenosis (area 1.0-1.5cm2). Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. Compared with the prior study (images reviewed) of [2171-4-29], the MVA area is greater and the mean mitral gradient has decreased. There is now moderate mitral regurgitation. TEE [2171-9-13] at 2:40:05 PM: The left atrium is dilated. Moderate to severe spontaneous echo contrast and a layering thrombus is present in the left atrial appendage. There is organizinf thrombus in the LAA situated deep within the structure and away from the mouth of the structure, measuring 2.2x 2.1cm in maximal diameter. The left atrial appendage emptying velocity is depressed (<0.2m/s). The right atrium is dilated. The right atrial appendage ejection velocity is depressed (<0.2m/s). There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets that are moderately thickened. The left and right leaflet appears fused but frank aortic stenosis ids not present. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened and shows characteristic rheumatic deformity. There is at least moderate valvular mitral stenosis (area 1.0-1.5cm2). There is no chordal deformation/thickening. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. Compared with the prior study (images reviewed) of [2171-5-3], the left atrial appendage thrombus is consdierably smaller, not as mobile, and situated away from the mouth of the atrial appendage. CT Abdomen/Pelvis [2171-9-13]: 1. Resting hemodynamics revealed a mean mitral valve gradient of 15mmHg and estimated valve area of 0.68cm2. 2. Successful transeptal puncture and mitral [Month/Day/Year ] using a an Inoue balloon inflated to 26mm, 28mm and 30mm diameter. 3. Improvement of mean gradient to 6mmHG and valve area to 1.98cm2. Patient left cathlab in stable condition. CXR [2171-9-14]: Moderate-to-marked cardiomegaly is stable. Small bilateral pleural effusions are unchanged. There is no overt CHF. There are bibasilar atelectases. ULTRASOUND [2171-9-15]: No evidence of bilateral groin hematoma, fluid collections or vascular abnormalities in the common femoral vessels. Brief Hospital Course: Mitral Stenosis secondary to Rheumatic disease: Mitral [Month/Day/Year ] [2171-10-14]. Intra-procedure SBPs 70s-110 and required doputamine support. Post-procedure SBP 70s and was transferred to CCU for observation. Hypotension differential included tamponode vs. bleed (RP or groin). ECHO X 2 negative for tamponode or effusion. Groin sites intact and CT ab/pelvis negative for bleed. Most likely related to procedure medications and new onset MR. [Name13 (STitle) ] was stable in unit and transferred back to the floor on [2171-10-15]. On [2171-10-16] patient developed hematoma at R cath site, heparin was continued but coumadin was held. Blood pressure and HCT were stable, ultrasound imaging on [2171-10-16] was negative for hematoma b/l. Patient developed mild-moderate MR [First Name (Titles) 767] [Last Name (Titles) ]. Patient's SBP averaged 100s and felt too low to start afterload reducer inpatient. Consider outpatient afterload reducer if BP tolerates. Follow-up ECHO in [2-24] weeks. Rhythm: Atrial fibrillation. No RVR during entire admission, heart rate < 100. TEE demonstrated persistant left atrial thrombus, though smaller and less mobile since [2171-5-3] TEE. Unable to convert due to thrombus. Continued Metoprolol Tartrate 50 mg PO BID for rate control during admission, discharged on Toprol XL 100 mg. Anti-coagulation: Required for 1) L atrial thrombus 2) History of PE 3) A Fib. On weight-based heparin drip throughout admission. Restarted Coumadin 4 mg qhs during admission, discharged on Lovonex until therapeutic. Mild Nausea: Patient reported mild nausea on admission. No abnormalities on CT abdomen or pelvis. All stools guaiac negative. Started and discharged on Omeprazole 20 mg qd. H. pylori POSITIVE, pending at discharge. Will contact primary care provider regarding results. Patient was discharged on Omeprazole, but will require course of antibiotics. Medications on Admission: - Coumadin 4 mg qhs - Metoprolol XR 100mg qd Discharge Medications: 1. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous once a day for 10 days: 10 day supply . Disp:10 syringe Refills:0 2. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: Take as instructed. 3. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 4. 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 Discharge Disposition: Home Discharge Diagnosis: Primary: Mitral stenosis status post valvuplasty Secondary: Atrial fibrillation with left atrial thrombus History of Pulmonary embolism Discharge Condition: Ambulating with stable vitals. Pain free. Discharge Instructions: You were admitted for a mitral valvuplasty for your mitral stenosis. It was necessary to give you heparin and stop your coumadin due to your history of clot in your heart and lung. You underwent the mitral [Month/Day/Year ] and were monitored in the cardiac intensive care unit afterwards. You were started on Lovenox, a medication to thin your blood, until your coumadin level (called INR) was therapeutic. . Please call your primary care physician or cardiologist if you experience any bleeding, shortness of breath, chest pain, or other concerning symptoms. You will need a follow up echocardiogram to assess your heart function and valve function. . You will need to take the Lovenox injections once daily until your Coumadin level (INR) is at goal. You will see Dr. [First Name (STitle) ] [Name (STitle) ] on [Name (STitle) 2974] to have your Coumadin level (INR) checked. . You were started on Lovenox and should take this until instructed otherwise. You were started on a medication called omeprazole for symptoms of reflux. Please take this for one month and discuss further with your primary care provider. No other medications were changed. Followup Instructions: Please attend the following appointments: 1) Cardiology: Please follow up with Dr. [First Name (STitle) ] in the department of cardiology at an appointment made for you on [10-5] at 4:15 PM. The number for Dr.[Name (NI) 65972] office is ([Telephone/Fax (1) 65973]. Please have them schedule a follow-up ECHO in [2-24] weeks for mitral regurgitation. 2) Primary care provider: [Name10 (NameIs) 357] follow up with Dr. [Last Name (STitle) ] at an appointment made for you on [Last Name (LF) 2974], [9-20] at 10:00 AM. You will need your Coumadin level (INR) checked at that time to determine whether you should continue the Lovenox injections. Completed by:[2171-9-23]	[ "427.31", "787.02", "412", "398.91", "998.12", "V58.61", "V12.51", "416.8", "394.0", "458.29" ]	icd9cm	[ [ [] ] ]	[ "35.96", "88.72" ]	icd9pcs	[ [ [] ] ]	8946, 8952	6400, 8334	362, 418	9133, 9177	3016, 6377	10394, 11103	2056, 2177		8429, 8923		8973, 9112		8360, 8406			9201, 10371										2192, 2192																	2207, 2997											284, 324											446, 1763															1785, 1880	1896, 2040
468	109,718	1214	Discharge summary	report	Admission Date: [2136-2-24] Discharge Date: [2136-3-12] Date of Birth: [2085-7-19] Sex: M Service: MEDICINE Allergies: Mezlocillin / Oxacillin Attending:[First Name3 (LF) 2181] Chief Complaint: Change in mental status Major Surgical or Invasive Procedure: NGT tube Temporary dialysis catheter LIJ Tunnelled dialysis catheter LIJ History of Present Illness: This is a 50 year old male with history of hypertension, osteomyelitis, chronic pain and depression who was brought in from home after an attempted suicide by narcotic overdose. Per patient's wife, she heard a thud in the other room and found the patient "jerking" on the ground. EMS was called and found the patient to be in cardiac arrest, administered epinephrine with return of sinus rhythm (no shock given) and subsequently intubated the patient for airway protection. Patient was found with an empty bottle of dilaudid. Patient takes methadone and dilaudid for chronic ankle pain. [Name (NI) ] wife noted that he had been very depressed and crying at times over the past few months. . In the ED, vitals 101.8, 110, 75/20, 19, 99%. Toxicology screen was positive for methadone/opiates and ETOH (level 88), otherwise negative for aspirin and tylenol. Stat head CT was negative for bleed or emboli. Chest x-ray showed no acute infiltrate. EKG showed sinus tach with 1/2mm ST depressions in V3-V4. Patient's initial lactate 27 and he was given 3 amps of HCO3 with repeat lactate 10. Patient's initial ABG 6.65/91/348-bicarb 12. Repeat ABG 7.11/44/142/15. . Toxicology was consulted. Patient admitted to taking double his usual methadone dose, but denied ASA, tylenol or other agents. Toxicology did not fell that patient's presentation was consistent with narcotic overdose as patient improved without narcan. . Patient was started on Vancomycin, Levofloxacin and Flagyl. He was bolused 4 liters normal saline. Three PIVs were placed and Levophed was started peripherally. Patient's SBP increased to SBO 100s and levaphed was weaned. Patient's levophed stopped prior to transfer to the MICU. Past Medical History: 1. chronic pain 2. depression 3. osteomyelitis 4. TR/small ASD 5. HTN 6. microcytic anemia 7. ? OSA 8. pulm nodules-Has abnormal nodules on CXR and CT. ? granulomas vs. metastatic dz. Had bronch and bx which showed inflammatory lesions like granulomas around airways. No definite cause. PFTs normal and patient generally asymptomatic. 9. melanoma s/p resection Social History: Patient is married with no children. He works as a speech pathologist for special children. He drinks 2 beers per night 7 days a week for years, but he and his wife quit 1 month ago. Patient does not currently use tobacco and quit in college. Family History: Parents are alcoholics. Physical Exam: VITAL SIGNS: T 101.8 BP 136/81 RR 26 HR 93 O2 sat 97% VENT: AC 0.6/ 700/ 5/ 26 GENERAL: alert, responding to commands, intubated HEENT: ncat, epmi, pupils mid size, equal and responsive, neck supple CV: RRR 2/6 SM at RUSB LUNGS: + rhonchi bilat ABD: +BS, soft, NT, ND EXT: no c/c/e, + healing scars on RLE NEURO: MAEW, nonfocal SKIN: c/d/i- no rash Pertinent Results: Labs on admission: Glucose-162* UreaN-20 Creat-1.3* Na-138 K-2.8* Cl-103 HCO3-19* AnGap-19 Calcium-5.9* Phos-6.5# Mg-3.0 . WBC-8.1 RBC-5.35 Hgb-17.0 Hct-52.2* MCV-98 MCH-31.8 MCHC-32.6 RDW-12.8 Plt Ct-262 . Neuts-89.6* Bands-0 Lymphs-7.5* Monos-2.1 Eos-0.7 Baso-0.1 Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Tear Dr[Last Name (STitle) 833] Ret Aut-1.1* . D-Dimer-6501* FDP-40-80 . ALT-318* AST-1765* LD(LDH)-2396* CK(CPK)-[Numeric Identifier 7668]* AlkPhos-51 TotBili-0.4 Lipase-74* GGT-92* Albumin-2.9* UricAcd-15.7* HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE Smooth-NEGATIVE [Doctor First Name ]-NEGATIVE IgG-560* HCV Ab-NEGATIVE HEPARIN DEPENDENT ANTIBODIES-NEG HERPES SIMPLEX (HSV) 2, IGG-TEST NEG HERPES SIMPLEX (HSV) 1, IGG-Test NEG CERULOPLASMIN-Test WNL . PT-16.4* PTT-52.8* INR(PT)-1.5* Fibrino-282 Lactate-27.1* . [2136-2-24] 01:37PM BLOOD CK-MB-4 cTropnT-<0.01 [2136-2-24] 05:15PM BLOOD CK-MB-17* MB Indx-0.1 cTropnT-0.02* [2136-2-24] 09:42PM BLOOD CK-MB-20* MB Indx-0.1 cTropnT-0.02* [2136-2-25] 02:00AM BLOOD CK-MB-23* MB Indx-0.0 cTropnT-0.03* . Iron-18* calTIBC-215* Hapto-143 TRF-165* Ferritn-595* VitB12-339 Folate-15.9 . Osmolal-289 TSH-4.2 Cortsol-28.5* . BLOOD ASA-NEG Ethanol-88* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . ART pO2-348* pCO2-91* pH-6.65* calHCO3-12* Base XS--31 ART pO2-322* pCO2-70* pH-6.86* calHCO3-14* Base XS--23 -ASSIST/CON Intubat-INTUBATED Comment-VENT 700/2 COHgb-0 MetHgb-1 . URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.016 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG RBC-0-2 WBC-[6-23]* Bacteri-MANY Yeast-NONE Epi-0-2 Sperm-FEW . URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-POS . [2136-2-25] 04:12AM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.010 Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR RBC-0-2 WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0-2 AmorphX-MANY Myoglob-PRESUMPTIV . CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0 Lymphs-44 Monos-56 TotProt-51* Glucose-105 . [2136-3-8] CATHETER TIP-IV WOUND CULTURE-NO GROWTH [2136-3-1] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-NONREACTIVE [2136-2-27] MRSA SCREEN MRSA SCREEN-NEGATIVE [2136-2-27] EBV IgG/IgM/EBNA Antibody Panel [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgG AB-FINAL; [Doctor Last Name ]-[Doctor Last Name ] VIRUS EBNA IgG AB-POSTIIVE; [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgM AB-NEGATIVE [2136-2-27] CMV Antibodies CMV IgG ANTIBODY-NEGATIVE; CMV IgM ANTIBODY-NEGATIVE [2136-2-27] SEROLOGY/BLOOD VARICELLA-ZOSTER IgG SEROLOGY-NEGATIVE [2136-2-27] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-NEGATIVE [2136-2-27] MRSA SCREEN MRSA SCREEN-NEGATIVE [2136-2-25] SPUTUM GRAM STAIN-OROPHARYNGEAL FLORA; RESPIRATORY CULTURE-FINAL OROPHARYNGEAL FLORA [2136-2-25] BLOOD CULTURE AEROBIC BOTTLE-no growth; ANAEROBIC BOTTLE-no growth [2136-2-25] BLOOD CULTURE AEROBIC BOTTLE-no growth; ANAEROBIC BOTTLE-no growth [2136-2-25] URINE URINE CULTURE-no growth [2136-2-24] CSF;SPINAL FLUID GRAM STAIN-negative; FLUID CULTURE-no growth [2136-2-24] URINE URINE CULTURE-no growth [2136-2-24] BLOOD CULTURE AEROBIC BOTTLE-no growth; ANAEROBIC BOTTLE-no growth [2136-2-24] BLOOD CULTURE AEROBIC BOTTLE-no growth; ANAEROBIC BOTTLE-no growth . . STUDIES: Head CT: [2136-2-24]: no acute intracran process extensive fluid in nasal cavity, post nasopharynx and R sph sinus, likely rel to supine position and intubation pre-exist mild sinus inflamm chgs . C-spine CT:[2136-2-24] no acute fx/alignmt abnlty, poss old compr'n, sup endplate C6, [Last Name (un) ] chgs C5/6, w/mod L nf narrowing, ET/NGTs . CXR: [2136-2-24] no acute CP procedd, NGT and ETT in appropriate position . EKG [2136-2-24] Sinus tachycardia Possible left atrial abnormality Incomplete right bundle branch block Poor R wave progression - probably a normal variant but consider old anteroseptal infarct No change from previous Intervals Axes Rate PR QRS QT/QTc P QRS T 117 168 114 300/[Telephone/Fax (2) 7669] 6 . MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST FINDINGS: BRAIN MRI: IMPRESSION: Signal abnormalities at both posterior frontal and parietal convexity region on FLAIR and T2-weighted images without corresponding enhancement or diffusion abnormalities. These findings could be secondary to previous infarcts. No enhancing lesions are seen. If the patient has prior MRI examinations, comparison would be helpful. The appearances are not typical for reversible encephalopathy. Small areas of microhemorrhages are seen in both cerebral hemispheres near the convexity indicating old hemorrhages. No enhancing lesions are seen. MRA OF THE HEAD: Normal MRA OF THE HEAD: MRV OF THE HEAD: Normal MRV of the head. . DUPLEX LIVER OR GALLBLADDER US [2-25]: 1. Normal Doppler study. 2. Extrahepatic biliary ductal dilatation with mild intrahepatic biliary ductal dilatation. An MRCP would be helpful in order to assess for any obstructive process. 3. Marked wall thickening of the gallbladder with intramural edema. This can be seen in several clinical scenarios, including cholecystitis but other features of cholecystitis are not present such as stones and distention. If however this diagnosis is strongly suspected clinically a HIDA scan could be performed. The appearance can be seen in acute hepatic disease and hypoalbuminemia as well. 4. Possible edema around the head of the pancreas. Correlation with pancreatitic enzymes to exclude coincident pancreatitis is recommended. . EEG [2-25]: BACKGROUND: Consisted of a 10 Hz posterior predominant rhythm bilaterally. At times, faster beta rhythms were observed. This may be due to medications. HYPERVENTILATION: Could not be performed as the patient could not comply. INTERMITTENT PHOTIC STIMULATION: Could not be done as this was a portable EEG. SLEEP: The patient progressed from wakefulness into drowsiness but no stage II sleep was seen. CARDIAC MONITOR: Showed a generally regular rate and rhythm with a rate of approximately 70 bpm. IMPRESSION: This is a normal EEG in the awake and drowsy states. No focal or epileptiform features were observed. . ECHO [2-25]: The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The ascending aorta is moderately dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2135-5-4], there is less tricuspid regurgitation, pulmonary pressures are lower . MRI ABDOMEN W/O CONTRAST [2136-2-26]: 1. Underdistended gallbladder with no apparent stones. Gallbladder wall edema/pericholecystic fluid is not a specific finding. If clinical concern exists for chronic cholecystitis, a HIDA scan would be the study of choice. 2. Prominent extrahepatic bile duct tapers normally and demonstrates no evidence of choledocholithiasis. 3. Extensive subcutaneous edema. 4. Bilateral small-to-moderate pleural effusions. Of note, technical issues prevented complete normal study and no gadolinium was administered. . CHEST (PA & LAT) [2136-2-28]: PA and lateral radiographs of the chest are reviewed, and compared with the previous study of [2136-2-25]. The patient has been extubated. The previously identified congestive heart failure has been improving. There is continued cardiomegaly and small right pleural effusion associated with bilateral lower lobe patchy atelectasis. Note is made of a question of nodular opacity in the right apex, which can be composite shadow. When patient is better, evaluate with repeated PA, bilateral shallow oblique radiographs of the chest. IMPRESSION: 1. Improving congestive heart failure with remaining cardiomegaly and small right pleural effusion. 2. Question of nodular opacity in the right apex. . UNILAT UP EXT VEINS US RIGHT [2136-2-29]: DVT within one of the distal right brachial veins as well as cephalic vein. Basilic vein was not visualized. No evidence of hematoma within the right upper neck. . C1894 INT.SHTH NOT/GUID,EP,NONLASER [2136-3-1]: Successful placement of a 14-French 20-cm double-lumen hemodialysis catheter by way of the left internal jugular vein with tip in the superior vena cava. The catheter can be used immediately. . UNILAT LOWER EXT VEINS RIGHT [2136-3-2]: No evidence of DVT in the right lower extremity. . [Numeric Identifier 7670] FLUORO 1 HR W/RADIOLOGIST [2136-3-8]: Successful conversion from a temporary left internal jugular to a tunneled hemodialysis catheter (27 cm from cuff to tip). The catheter is ready for immediate use. Brief Hospital Course: Briefly, this is a 50 year old man with history of hypertension, depression, chronic pain and osteomyelitis who presented with likely cardiac arrest secondary to opioid overdose and possible associated seizure. On admission to the emergency department, patient was only briefly hypotensive with systolic in 70's which responded to IV fluid resuscitation and required transient peripheral levophed. Patient was also empirically started on broad spectrum antibiotics and given PO charcoal. A LP was performed to rule out meningitis in setting of witnessed seizure. Also, of note, patient was in severe lactic acidosis with pH <7.0 which responded to stat administration of 3 amps of sodium bicarbonate. Patient's mental status improved after ED resuscitation and he was transferred to the MICU for further care. . In the MICU, patient subsequently developed elevated LFTs, rhabdomyolysis and acute renal failure. Patient remained intubated for airway protection. Initially, patient had a severe anion gap and non-anion gap metabolic acidosis and respiratory acidosis. Metabolic acidosis was likely secondary to lactic acidosis in setting of cardiac arrest decreased organ perfusion and possible seizure. Etiology of non-gap acidosis was unclear. Patient's mental status and respiratory acidosis improved and he was extubated on [2-26] after a RSBI ~10. Patient sating 94% on 5L nasal cannula after extubation. Repeat CXR was improved but continued to show pulmonary edema. Patient remained stable and was subsequently transferred to the floor. . #. ?Seizure: Patient was initially worked up for seizure with a differential diagnosis of opiate overdose, vasovagal induced, infection induced or EtOH withdrawal induced. MRI/MRA/MRV were negative for emboli or other abnormalities. Repeat ECHO this admission largely unchanged from prior if not improved. LP was performed and not consistent with meningitis. Patient with positive tox screen for alcohol and opiates. Patient admitted to drinking cough syrup at home. He and his wife had quit drinking alcohol approximately 1 month ago. Patient was placed on CIWA scale while on the floor. Unclear whether patient actually seized or had post cardiac arrest movements however if patient did seize the likely etiology was either alcohol withdrawal or opiate overdose induced metabolic derangement. Patient's mental status returned to baseline and no recurrence of seizures occurred while in hospital. EEG was negative for seizure. Nonspecific vascular findings on MRI, per neurology were old and would not have contributed to current presentation. Plan is to have patient follow-up with a repeat MRI and see neurology as an outpatient in [6-21] weeks time. . #. Rhabdomyolysis: Etiology likely secondary to immobilization and ischemic compression of muscle induced by opioid overdose versus drug induced seizures or hyperthermia associated with excess muscle energy demands. Also, metabolic derangement including hypokalemia (2.8 on admission) and hypocalcemia (5.9) may have contributed or caused the rhabdo but unclear etiology of electrolyte abnormalities ?opioid overdose. CPK peaked at 150,000 on [2-25] and then continued to downtrend. Calcium was repleted aggressively while alkalinizing his urine to prevent further renal damage. . #. ARF: On admission, Cr 1.0 increaed to 4.8 on [2-26] and continued to increase to peak of 10.3 on [3-1]. Etiology of acute renal failure likely secondary to hypovolemia during cardiac arrest and rhabdomyolysis. Patient was intially aggressively hydrated and his urine was alkalinized with HCO3 to avoid further renal damage from myoglobin. He was also given mannitol to osmotically diurese which was eventually held on [2-26]. There was an unsuccessful RIJ line placement on [2-29], no hematoma was seen on neck US. IR placed temporary dialysis catheter in LIJ on [3-1] and then switched over a tunnelled cath into LIJ on [3-8]. Patient initally required daily dialysis and then three times a week. At time of discharge, patient had gone for 5 days without dialysis and was making large volumes of urine. Electrolytes were followed carefully and phosphate binders were used as needed. He will need to have his electrolytes (Chem 7, calcium, magnesium, phosphate) checked in 48 hours, 1 week, and two weeks to ensure recovery of kidney function. He will need removal of his tunneled hemodialysis catheter in two days, on [2136-3-14], to be done by interventional radiology. A renal consult should be obtained for follow up of chemistries. The renal consult service will decide when patient will be able to have his tunneled catheter removed by interventional radiology. . #. Chronic pain/R LE pain: Patient with history of right ankle injury requiring multiple surgeries between [2126]-[2130]. It was recommended in [2130] that he have his R ankle amputated however patient decided not to have the amputation and to medically treat his chronic pain. Had been on methadone and dilaudid PO as an outpatient. Pain medications were held until patient's mental status was at baseline and then he was started and gradually titrated up on a fentanyl patch with oxycodone PRN for breakthrough. IV diladudid was used as breakthrough which was subsequently switched to PO dilaudid and then discontinued due to adequate pain control. Please obtain pain management consult for pain control if pain is unable to be controlled with fentanyl patch with oxycodone. . #. Depression: Patient now at baseline mental status however severely depressed. Psychiatry was consulted regarding the opiate overdose and felt that patient required inpatient admission for suicide attempt. Continued to hold Zoloft. Continued 1:1 sitter. As patient was medically stable, he was transferred to an inpatient psychiatry floor for further care. . #. Anemia: Unclear etiology. Hct baseline 29.0. Paitnet received 2 units in hemodialysis on [3-5]. Hct remained stable thereafter. Guaiaced all stools which have been negative. . #. R UE brachial DVT: Patient received anti-coagulation for 1 week with IV heparin and then for a short period of time on coumadin. Review of US with radiology showed distal location of possible clot and low risk for embolization and so no further anti-coagulation was planned. Decision not to anticoagulate was approved by Dr. [Last Name (STitle) ]. Patient will not need to have heparin SC injections for DVT prophylaxis if he continues to ambulate. . #. Increased LFTs: most likely secondary to acidemia, possibly shock liver. Initially, RUQ US suggestive for cholecystitis however subsequent abdominal MRI showed prominent extrahepatic bile duct tapers normally and demonstrates no evidence of choledocholithiasis. Liver was consulted and recommended the following tests: VZV IgG negative, CMV negative, ceruloplasmin wnl, Hep A, B, C negative, [Doctor First Name ] and anti-smooth Ab negative, IgG low, HSV1 IgG-, HSV2 IgG-, EBV IgG+ IgM-. Alkaline phosphatase and total bilirubin began to downtrend without intervention and so no HIDA/MRCP was pursued. Near resolution of elevated LFTs at time of discharge. . #. ID: Patient with very high temp in ED. Differential diagnosis included seizure versus infectious etiology. Patient was pan-cultured in ED with no growth. Patient was only briefly hypotensive and on transient levophed. Patient initially empirically covered with vanco, levo and flagyl. LP negative for organisms and not consistent with meningitis. On [2-26], antibiotics were discontinued given low suspicion for infection. . #. HTN: Continued to hold BP agents and follow SBP closely. . #. Obstructive sleep apnea: Unclear whether patient suffers from this but he can schedule a sleep study as outpatient. . #. Abnormal chest x-ray findings: Patient will need to follow-up with chest x-ray with PA/LAT/bilateral shallow oblique views to re-evaluated possible nodular opacity in right apex of lung seen on chest x-ray [2136-2-28]. However this admission, no definite opacity in right apex of lung was seen in subsequent chest x-rays. Patient has a remote history of pulmonary nodules of unclear etiology. He would likely benefit from repeat imaging. . #. FEN: Patient is no longer requiring dialysis, watch for electrolyte abnormalities . #. PPX: SC heparin, encouarge ambulation, pneumoboots . #. Access: Tunneled hemodialysis catheter. Peripheral IVs . #. Communication: Wife: [Telephone/Fax (1) 7671] (c) and [Telephone/Fax (1) 7672] (h) [Doctor First Name ] . #. Code: Full . #. Patient is medically stable to be discharged from the medical floor for transfer to psychiatry. Medications on Admission: 1. Aspirin 235mg PO QD 2. Methadone 40mg PO TID 3. HCTZ 25mg QD 4. Lisinopril 10mg QD 5. Zoloft 100mg QD 6. Dilaudid 4mg Q4H:PRN Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO at bedtime as needed for insomnia. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) patch Transdermal every seventy-two (72) hours. 8. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units Injection QMOWEFR (Monday -Wednesday-Friday). 10. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. 11. Outpatient Lab Work Chem 7, calcium, magnesium, phosphate to be checked on: [2136-3-14]. [2136-3-19]. [2136-3-26]. This should be followed by the renal consult service. Discharge Disposition: Extended Care Facility: [Hospital1 69] - [Location (un) 86] Discharge Diagnosis: Primary diagnosis: opiate overdose alchohol abuse/dependence cardiac arrest rhabdomyolysis acute renal failure depression NOS . Secondary diagnosis: chronic right ankle pain history of osteomyelitis hypertension Discharge Condition: Good Discharge Instructions: Please take medications as prescribed. Consider restarting blood pressure medications once renal function improves. . Please get repeat chest x-ray (PA/LAT/bilateral shallow oblique views) to re-evaluated possible nodular opacity in right apex of lung seen on chest x-ray [2136-2-28]. . Please remember to get a repeat brain MRI as scheduled by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7673]. . If you have any change in mental status, shortness of breath, chest pain, nausea/vomitting, decreased urine output, return to the emergency department. . If pain is not well controlled on the fentanyl patch with oxycodone, obtain pain management consult. . Patient does not need heparin SC for DVT prophylaxis if he is able to ambulate. . Obtain renal consult for follow up of acute renal failure. Please have your blood work checked for recovery of your renal function. You will need the following labs checked on [2136-3-14], [3-19], [2136], and [2136-3-26]. Chem 7, calcium, magnesium, phosphate. This will be followed by the renal consult service. . You will need to have your hemodialysis catheter removed by interventional radiology. This should happen in [2-17] days. The renal consult service will determine when this happens. Followup Instructions: PROVIDER: [First Name8 (NamePattern2) 1409] [Last Name (NamePattern1) ] NP/[Name6 (MD) ] [Name8 (MD) ] MD DATE/TIME: [2136-3-26] 1:20pm LOCATIONS: [Hospital Ward Name 23] Clinical Center [Location (un) 895] PHONE: [Telephone/Fax (1) 250] . PROVIDER: [First Name8 (NamePattern2) 674] [Last Name (NamePattern1) ], MD (NEUROLOGY) DATE/TIME: [2136-4-17] 8:00am LOCATION: [Hospital Ward Name 23] Clinical Center [Location (un) 861] PHONE: [Telephone/Fax (1) 541] . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], M.D. (CARDIOLOGY) Phone:[Telephone/Fax (1) 127] Date/Time:[2136-4-10] 3:15 . Please follow-up in [Hospital 2793] clinic by calling [Telephone/Fax (1) 60] and scheduling an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7674]. .	[ "570", "E950.0", "453.8", "518.81", "584.9", "719.47", "401.9", "285.9", "780.39", "303.91", "311", "728.88", "276.2", "965.00", "276.52" ]	icd9cm	[ [ [] ] ]	[ "96.71", "38.95", "03.31" ]	icd9pcs	[ [ [] ] ]	22445, 22515	12528, 21184	308, 382	22771, 22778	3193, 3198	24107, 24991	2771, 2796		21364, 22422		22536, 22536		21210, 21341			22802, 24084										2811, 3174																												245, 270											410, 2109			22685, 22750	6751, 8116	8157, 12505			22555, 22664		3212, 6742					2131, 2494	2510, 2755
72,545	192,969	8392	Discharge summary	report	Admission Date: [2183-8-25] [Month/Day/Year ] Date: [2183-8-30] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1171] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation with sedation History of Present Illness: 89 year old Russian speaking male with CAD s/p CABG in [2169], medically managed NSTEMI [9-/2182], Afib (not on coumadin), tachy/brady syndrome s/p dual chamber PPM [2175], DM, CHF (EF 45-50%), and PVD who presented to the [Hospital1 18] ED with progressive SOB over the last 3 days. He was recenrlt discharged from rehab, and had not been taking any coreg or diuretic. His appetite in rehab was poor, and once he returned home he started eating more food with high salt content. He had gained some weight recently (unclear how much), buit the family thinks this was in the setting of his increased appetite. He did not have any significant edema, and it was unclear if he had any orthopnea or PND. On arrival to the ED his VS were T:98.6, HR:74, BP:195/86, O2:88% on RA -> 98% on 100% NRB. CXR revealed bilateral fluffy infiltrates c/w pulmonary edema or a diffuse infectious process/ARDS. Due to increased respiratory distress the patient was intubated. He was given CTX/azithromycin for possible CAP, and about 1.3L of IVF total. Initial labs were notable for mildly increased BUN/Cr (Cr 1.1 up minimally from baseline if 0.9-1.0), a normal CKMB of 3, a Tn of 0.01, WBC of 10.1, stable HCT/plts, and a lactate of 1.3. ECG revealed V-pacing without significant ischemic changes. The patient was transfered to the MICU for further monitoring. He was given broad spectrum abx for possible HCAP, and given lasix and nitroglycerine for possible CHF. Cardiology was consulted for assistance in managing the patient's possible heart failure. The patient is unable to provide information on his review of systems Past Medical History: -Atrial fibrillation with tachy brady syndrome, s/p PPM in [2175], off coumadin -Diabetes mellitus, type II with complications, including neuropathy and [Year (4 digits) 1106] disease -CAD s/p CABG in [2169], with recent NSTEMI [10-9] -Peripheral [Month/Year (2) 1106] disease, Left first toe ampuation -Chronic systolic CHF, EF 45-50% [10-9] -Orthostatic hypotension -Eye blindness, left eye -Cataracts -Glaucoma -Likely dementia Social History: Currently at [Hospital3 2558]. Previously with wife at home. Wheelchair bound. No alcohol, smoking per omr Family History: Unavailable at present from patient. Physical Exam: [Hospital3 ] Physical Exam: Vitals: 98.0 150/70 60 20 95 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: bilateral basilar crackles 1/3 up Abdomen: soft, non-tender, non-distended Ext: trace peripheral edema Pertinent Results: ADMISSION LABS [2183-8-25] 10:20AM WBC-10.1# RBC-3.96* HGB-12.3* HCT-38.3* MCV-97 MCH-31.1 MCHC-32.2 RDW-15.1 [2183-8-25] 10:20AM NEUTS-75.3* LYMPHS-13.4* MONOS-10.2 EOS-0.9 BASOS-0.3 [2183-8-25] 10:20AM cTropnT-0.01 [2183-8-25] 10:20AM CK-MB-3 proBNP-5457* [2183-8-25] 10:20AM GLUCOSE-142* UREA N-33* CREAT-1.1 SODIUM-143 POTASSIUM-4.6 CHLORIDE-110* TOTAL CO2-24 ANION GAP-14 [2183-8-25] 11:20AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2183-8-25] 11:57AM TYPE-ART PO2-147* PCO2-35 PH-7.44 TOTAL CO2-25 BASE XS-0 [Month/Day/Year 894] LABS [2183-8-30] 10:00AM BLOOD WBC-8.1 RBC-3.75* Hgb-11.6* Hct-36.2* MCV-96 MCH-30.9 MCHC-32.0 RDW-14.9 Plt Ct-159 [2183-8-30] 10:00AM BLOOD Glucose-212* UreaN-33* Creat-1.4* Na-141 K-4.0 Cl-100 HCO3-35* AnGap-10 [2183-8-30] 10:00AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.0 MICROBIOLOGY - all negative [2183-8-25] URINE Legionella Urinary Antigen -FINAL INPATIENT [2183-8-25] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2183-8-25] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL EMERGENCY [Hospital1 ] [2183-8-25] URINE URINE CULTURE-FINAL EMERGENCY [Hospital1 ] [2183-8-25] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2183-8-25] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] IMAGING [2183-8-25] CHEST X-RAY IMPRESSION: Severe pulmonary edema with bilateral pleural effusions. [2183-8-26] CHEST X-RAY FINDINGS: As compared to the previous radiograph, there is an increase in extent of the pre-existing bilateral pleural effusions. The signs of moderate pulmonary edema are unchanged. Increasing extent of the pre-existing basilar areas of atelectasis. Unchanged size of the cardiac silhouette. Unchanged monitoring and support devices. [2183-8-27] CHEST X-RAY IMPRESSION: AP chest compared to [8-26], 2:52 a.m. Following extubation, lung volumes are slightly lower, exaggerating volume of the already moderate-to-large left pleural effusion. Slightly smaller right pleural effusion has decreased. Previous mild pulmonary edema in the upper lungs has improved, but atelectasis at the left lung base has worsened. Mild-to-moderate cardiomegaly is unchanged. No pneumothorax. Transvenous right atrial and right ventricular pacer leads are continuous from the left axillary pacer. [2183-8-28] CHEST X-RAY IMPRESSION: Extensive pulmonary edema. Bilateral pleural effusions, left greater than right. Partial left lower lobe collapse secondary to effusion. [2183-8-29] CHEST X-RAY In comparison with the study of [8-28], there is continued substantial pulmonary edema with bilateral effusions and compressive atelectasis in a patient with previous CABG and dual-channel pacemaker device in place. [2183-8-28] UPPER EXTREMITY ULTRASOUND No evidence of DVT within the left upper extremity. [2183-8-26] TRANSTHORACIC ECHO The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with inferior/inferolateral hypokinesis and apical hypokinesis/akinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. 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. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. Compared with the prior study (images reviewed) of [2182-10-18], apical hypokinesis/akinesis appears to be new. Comparison with prior study is limited by suboptimal views. Brief Hospital Course: 88M history of AF with tachy/brady syndrome s/p PPM in [2175] not on AC, DMII, CAD s/p CABG and recent NSTEMI, sCHF with EF45-50% and orthostatic hypotension who presents with increased work of breathing per the wife. # Respiratory Failure: DDx originally included infectious versus cardiovascular. Sepsis is felt to be unlikely given normal lactate, no bandemia, and negative U/A. Infectious source could possibly be lungs, with history of SOB, although collateral history is somewhat vague, per ED the patient did not have any fevers at home. Was felt to most likely be secondary to a cardiogenic source, given patent was hypertensive on arrival, with SBP in the 200s, as well as a history of HF with an EF <45% with CXR consistnent with pulmonary edema. In addition, BNP is elevated from prior admission. ECHO showed a new decrease in EF to 30% with FWM abnormalities. The patient was treated with a nitro gtt as well as daily diuresis with IV Furosemide (had not been on diuretics prior) which quickly weaned him from the need for BiPap. He was called out to the floor off of a nitrogen gtt, with a plan to increase his blood pressure regimen to prevent further episodes of flash pulmonary edema. The patient was also briefly on HCAP antibiotics, but upon [Year (4 digits) ] from the ICU was felt to no longer need these medications given a presumed cardiogenic etiology. Antihypertensive medications were uptitrated and upon [Year (4 digits) ], he was normotensive with SBP 120-130, appeared euvolemic, with no oxygen requirement. Sent home with PO torsemide 40mg daily. # acute on chronic systolic CHF, EF 45-50% [10-9]: Please see above discussion regarding respiratory failure. Multiple medications including Carvedilol and Lisinopril initially helped in the ICU, subsequently patient transitioned back onto home Carvedilol and TID captropril (plan to transition back to lisinopril) as well as amlodipine, for BP control. - Lisinopril 10mg - Increased carvedilol to 6.25 [Hospital1 ] - Diuresed over 8L with IV lasix, transitioned to PO torsemide 40 mg daily. # Hypertension: SBP 200s on admission likely contributed to flash pulmonary edema. [Name (NI) 1094] wife reports that carvedilol was stopped for unclear reasons at rehab, which may have contributed to uncontrolled blood pressure. Adjusted medications as above and normotensive on [Name (NI) ]. # Altered Mental Status - pt self dc'ed lines overnight [8-28]. Has baseline dementia and h/o hospital delirium. - Negative infectious workup to date, afebrile, no leukocytosis, negative legionella, sputum, urine cx, CXR shows stable pleural effusion, LLL lung collapse # Acute kidney injury - developed [Last Name (un) ] with Cr 1.4 (from baseline 1.0-1.1) in the setting of aggressive diuresis, remained stable and was 1.4 on [Last Name (un) ]. # Atrial fibrillation with tachy brady syndrome, s/p PPM in [2175]: - Increased carvedilol 6.25 mg [Hospital1 ], continued Amiodarone 200 mg PO Daily # CAD s/p CABG in [2169], with recent NSTEMI [10-9] - Cont ASA 81 mg Daily, Atrovastatin 80 mg Daily - Increase lisinopril to 10 mg Daily # Peripheral [Month/Year (2) 1106] disease, Left first toe ampuation and chronic necrotic eschar on left 2nd toe without evidence of infection - Cont ASA 81 mg Daily, Atrovastatin 10 mg Daily - Follow-up with [Month/Year (2) 1106] surgery regarding possible amputation # Diabetes mellitus, type II with complications, including neuropathy and [Month/Year (2) 1106] disease: Cont home sliding scale insulin # GERD: Cont ranitidine # Presumed BPH: Cont tamsulosin HS # Glaucoma: cont lantanoprost 0.005% qHS & dorzolamide-timolol eye drops [Hospital1 ] # PSYCH: cont sertraline and mirtazapine # General Care - Continue multivitamin - cholecalciferol 800 mg Daily TRANSITION OF CARE ISSUES - Continue aggressive chest physical therapy - Collapse of left lower lobe of the lung is most likely caused by pleural effusion from exacerbation of congestive heart failure. A chest x-ray should be checked in approximately 4 weeks (around [9-28]) to confirm resolution of collapse. If it persists, may consider bronchoscopy to rule out obstructing mass or lesion. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from AtriuswebOMR. 1. DuoNeb NF (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation Q6H:PRN bronchospasm 2. Docusate Sodium 100 mg PO BID 3. Multivitamins 1 TAB PO DAILY 4. Carvedilol 3.125 mg PO BID 5. Lactulose 15 mL PO DAILY 6. Bisacodyl 10 mg PR HS:PRN constipation 7. Tamsulosin 0.4 mg PO HS 8. Senna 1 TAB PO BID 9. Ranitidine 150 mg PO DAILY 10. Vitamin D 800 UNIT PO DAILY 11. Sertraline 25 mg PO DAILY 12. Amiodarone 200 mg PO DAILY 13. Atorvastatin 10 mg PO DAILY 14. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [Hospital1 ] 15. Lisinopril 10 mg PO DAILY 16. Fluticasone Propionate NASAL 1 SPRY NU DAILY 17. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 18. Aspirin 81 mg PO DAILY 19. Amlodipine 5 mg PO DAILY Hold for SBP <100, HR <60 20. bimatoprost NF 0.03 % OU QHS 21. NovoLOG Mix 70-30 NF (insulin asp prt-insulin aspart) 100 unit/mL (70-30) Subcutaneous [Hospital1 ] directed 15 u am, 4 u before dinner 22. Albuterol-Ipratropium [12-30] PUFF IH Q6H:PRN SOB 23. Lidocaine 5% Patch 1 PTCH TD DAILY apply to site of pain 12 hours on and 12 hours off 24. Mirtazapine 7.5 mg PO HS 25. Acetaminophen 325 mg PO Q4H:PRN pain/fever 26. Milk of Magnesia 30 mL PO DAILY:PRN constipation 27. Ferrex 150 NF (polysaccharide iron complex) 150 mg Oral Daily 28. Fleet Enema 1 Enema PR DAILY:PRN constipation [Month/Day (2) ] Medications: 1. Amiodarone 200 mg PO DAILY 2. Amlodipine 5 mg PO DAILY Hold for SBP <100, HR <60 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO DAILY 5. Bisacodyl 10 mg PR HS:PRN constipation 6. Carvedilol 6.25 mg PO BID hold for SBP < 100 or HR < 60 7. Docusate Sodium (Liquid) 100 mg PO BID 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 9. Lisinopril 10 mg PO DAILY Hold for SBP < 100 or K > 5.0 10. Multivitamins 1 TAB PO DAILY 11. Senna 1 TAB PO BID 12. Sertraline 25 mg PO DAILY 13. Tamsulosin 0.4 mg PO HS 14. Vitamin D 800 UNIT PO DAILY 15. Clotrimazole Cream 1 Appl TP [Hospital1 ] between toes 16. Acetaminophen 325 mg PO Q4H:PRN pain/fever 17. Albuterol-Ipratropium [12-30] PUFF IH Q6H:PRN SOB 18. bimatoprost NF 0.03 % OU QHS 19. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [Hospital1 ] 20. DuoNeb NF (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation Q6H:PRN bronchospasm 21. Ferrex 150 NF (polysaccharide iron complex) 150 mg Oral Daily 22. Fleet Enema 1 Enema PR DAILY:PRN constipation 23. Fluticasone Propionate NASAL 1 SPRY NU DAILY 24. Lactulose 15 mL PO DAILY 25. Lidocaine 5% Patch 1 PTCH TD DAILY apply to site of pain 12 hours on and 12 hours off 26. Milk of Magnesia 30 mL PO DAILY:PRN constipation 27. Mirtazapine 7.5 mg PO HS 28. Ranitidine 150 mg PO DAILY 29. NovoLOG Mix 70-30 NF (insulin asp prt-insulin aspart) 100 unit/mL (70-30) SUBCUTANEOUS [Hospital1 ] directed 15 u am, 4 u before dinner 30. Humalog 75/25 15 Units Breakfast Humalog 75/25 4 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 31. Torsemide 40 mg PO DAILY hold for SBP<100 [Hospital1 ] Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Location (un) ] [Location (un) ] Diagnosis: PRIMARY: Acute on chronic systolic congestive heart failure exacerbation, Pulmonary Edema SECONDARY: Coronary artery disease, Hypertension, Diabetes Mellitus, Peripheral [Location (un) 1106] disease, Atrial fibrillation [Location (un) ] Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. [Location (un) ] Instructions: Dear Mr. [Known lastname 656], It was a pleasure taking care of you during your recent hospitalization for difficulty breathing. You were found to have fluid in your lungs which is likely because your blood pressure was elevated and your heart could not move fluid effectively. We gave you medications to help you clear the fluid, and your breathing improved. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Please attend the following appointments we have made for you. TRANSITION OF CARE ISSUES: - Continue aggressive chest physical therapy - Collapse of left lower lobe of the lung is most likely caused by pleural effusion from exacerbation of congestive heart failure. A chest x-ray should be checked in approximately 4 weeks (around [9-28]) to confirm resolution of collapse. If it persists, may consider bronchoscopy to rule out obstructing mass or lesion. Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [2183-9-5] at 9:30 AM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: FRIDAY [2183-9-5] at 10:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: MONDAY [2183-9-8] at 2:10 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2183-8-31]	[ "584.9", "365.9", "412", "366.9", "428.23", "250.60", "414.00", "518.0", "V45.01", "427.31", "294.20", "428.0", "V45.81", "518.81", "369.60", "250.80", "357.2", "459.9", "458.0" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]		7246, 11496	291, 317		3064, 7223	16166, 17065	2595, 2633						11522, 14625													2680, 3045																									14770, 14998			232, 253			15030, 15030	14655, 14738	15221, 16143						345, 1971												15045, 15186			1993, 2449	2465, 2579
67,164	140,646	34527	Discharge summary	report	Admission Date: [2168-2-16] Discharge Date: [2168-2-23] Date of Birth: [2105-2-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1257] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: nasogastric tube lumbar puncture History of Present Illness: This is a 62M with inclusion body myositis on steroids who was recently hospitalized for a SAH and is brought in by his family for altered mental status. Patient had a fall approximately one month ago as a result of which he suffered bilateral frontal SAH. Patient seemed slightly confused to his family this AM, but able to give short answers to questions. Following a nap, he was more lethargic but able to give yes/no responses. Speech then became repetitive (asking "why" over and over) and he developed a stare. He had mild twitching of his left upper extremity, and the family then called EMS. . Of note, patient had been experiencing polyuria, blurred vision, and urinary incontinence at home over the last few days. He had no known history of diabetes, but had been on prednisone for his myositis. No history of seizures previously. He was discharged on keppra prophalactically following his SAH and apparently was not taking it as directed (pill bottle not emptied as expected per family). No fevers, chills, sweats. He did have a fall approximately 3 days prior to admission but no head trauma or loss of consciousness at that time. No sick contacts other than wife with ?sinus infection recently, no travel. . In the ED, vitals were 99.8 92 142/98 24 99% NRB. He was seen by neuro who thought he was in non-convulsive status. Neuro exam was notable for R gaze deviation and R beating nystagmus, unresponsive to noxious stimulus though did have preserved gag and corneal reflexes. Got 1g dilantin, 4mg ativan. No longer seizing clinically or by EEG. Given vancomycin, ceftriaxone; acyclovir ordered but not hung. Given 3L of NS. 99.4 88 124/63 18 99 4L. Past Medical History: - Inclusion Body Myositis ; walks with a cane at baseline - Hypertension - Hyperlipidemia - Fatty Liver Disease / chronic transaminitis; preserved synthetic function; (elevated IgG, iron studies normal, [Last Name (un) ] Ab neg, AMA, anti-sm AB neg) - Osteoarthritis - h/o Gastritis - Obesity - Venous insufficiency Social History: Lives with with wife, son, and nephew. Ambulates with walker. Needs help with basic ADLs. Per nephew no EtOH, smoking, or ilicits. Per OMR, former heavy EtoH. Family History: Father has DM2, passed away from complications of diabetes, patient uncertain of specific details. No known autoimmune diseases in family per patient. Physical Exam: Vitals 99.8 89 131/73 20 100% on 3L NC General obese man lying in bed snoring HEENT PEARL, conjunctiva slightly injected bilateraly, does not open mouth for inspection Neck unable to assess for nuchal rigidity Pulm lungs clear bilaterally CV tachycardic regular soft systolic murmur throughout precordium Abd obese nontender +bowel sounds nontender Extrem warm trace peripheral edema Neuro opens eyes to voice and sternal rub but does not follow commands, no gross focal deficits Derm no rash Pertinent Results: [2168-2-16] 11:26PM CEREBROSPINAL FLUID (CSF) PROTEIN-25 GLUCOSE-385 [2168-2-16] 11:26PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-17* POLYS-69 LYMPHS-30 MONOS-1 [2168-2-16] 11:26PM CEREBROSPINAL FLUID (CSF) WBC-15 RBC-1330* POLYS-51 LYMPHS-22 MONOS-14 ATYPS-13 [2168-2-16] 10:47PM GLUCOSE-519* UREA N-25* CREAT-0.7 SODIUM-150* POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-31 ANION GAP-13 [2168-2-16] 10:47PM CK(CPK)-82 [2168-2-16] 10:47PM GGT-23 [2168-2-16] 10:47PM CK-MB-NotDone cTropnT-0.15* [2168-2-16] 10:47PM ALBUMIN-3.2* MAGNESIUM-2.4 [2168-2-16] 10:47PM WBC-11.2* RBC-5.84 HGB-13.2* HCT-40.1# MCV-69* MCH-22.7* MCHC-33.0 RDW-14.8 [2168-2-16] 10:47PM NEUTS-82.4* LYMPHS-12.4* MONOS-4.4 EOS-0.7 BASOS-0.1 [2168-2-16] 10:47PM PLT COUNT-197 [2168-2-16] 10:34PM TYPE-[Last Name (un) ] TEMP-37.6 RATES-/18 PO2-31* PCO2-75* PH-7.28* TOTAL CO2-37* BASE XS-4 INTUBATED-NOT INTUBA COMMENTS-NASAL [Last Name (un) 154] [2168-2-16] 10:34PM GLUCOSE-471* LACTATE-3.7* NA+-150* K+-3.8 CL--100 [2168-2-16] 10:34PM freeCa-1.26 [2168-2-16] 07:10PM COMMENTS-GREENTOP [2168-2-16] 07:10PM LACTATE-3.3* K+-4.4 [2168-2-16] 03:40PM GLUCOSE-921* UREA N-31* CREAT-1.1 SODIUM-143 POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-33* ANION GAP-20 [2168-2-16] 03:40PM estGFR-Using this [2168-2-16] 03:40PM ALT(SGPT)-62* AST(SGOT)-12 LD(LDH)-463* CK(CPK)-137 ALK PHOS-90 AMYLASE-322* TOT BILI-0.3 [2168-2-16] 03:40PM LIPASE-413* [2168-2-16] 03:40PM CK-MB-21* MB INDX-15.3* cTropnT-0.10* [2168-2-16] 03:40PM CALCIUM-9.9 PHOSPHATE-6.9* MAGNESIUM-2.9* [2168-2-16] 03:40PM AMMONIA-13 [2168-2-16] 03:40PM TSH-1.2 [2168-2-16] 03:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2168-2-16] 03:40PM URINE HOURS-RANDOM [2168-2-16] 03:40PM URINE HOURS-RANDOM [2168-2-16] 03:40PM URINE GR HOLD-HOLD [2168-2-16] 03:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2168-2-16] 03:40PM WBC-8.8 RBC-6.8* HGB-15.8 HCT-52 MCV-72* MCH-22.3* MCHC-31.1 RDW-14.7 [2168-2-16] 03:40PM NEUTS-85.9* LYMPHS-7.1* MONOS-6.3 EOS-0.6 BASOS-0.1 [2168-2-16] 03:40PM PT-12.2 PTT-19.7* INR(PT)-1.0 [2168-2-16] 03:40PM PLT COUNT-255 [2168-2-16] 03:40PM FIBRINOGE-295 [2168-2-16] 03:40PM URINE RBC-[7-6]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [2168-2-16] 03:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2168-2-16] 03:40PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.031 EKG SR @96, nl axis, nl intervals, STD with TWF/TWI in V5-V6, II,III,vF. +LVH by aVL. No old EKG available for comparison. . CTA head No evidence of acute intracranial abnormalities. Mild atherosclerosis. No evidence of an aneurysm. Final interpretation is pending upon reformatted images. . CXR hila prominent with few patchy opacities bilateral bases . CT abdomen prelim per d/w radiology resident: pancreas without apparent stranding or necrosis, no free air in abdomen Brief Hospital Course: This is a 62M with inclusion body myositis on prednisone who presents with altered mental status and was found to have nonconvulsive status epilepticus in the setting of a hyperosmolar state and new diagnosis of type 2 diabetes mellitus. . 1. Altered mental status, s/p seizure Most likely multifactorial but maily related to hyperosmolar encephalopathy. Meningitis seems much less likely - no significant fevers, but may be masked with steroids. He had LP with reassuringly (tube4) wbc of <5 (note: tap was traumatic). In addition, antibiotics given in ED may lead to falsely negative CSF cultures. There was no evidence of new CVA on CT head. Multiple additional possible precipitants for this patient's seizure, including acidosis, hyperglycemia, electrolyte imbalance. Patient was started on Ceftriaxone, Vancomycin and acyclovir, which was continued for 48 hours. His Keppra was increased 24 hours after a dilatin load, which was eventually stopped. Neurology was consulted and a continuous EEG did not show any further seizure activity. The patient's mental status continued to improve to where he was able to converse without difficulty and he was A/O x3. The patient did have elevated cardiac enzymes, but they peaked at .26. Patient was then transferred to the floor. He was stable on Keppra without any further seizure activity. Mental status remained clear and he was at his baseline. This was all likely due to hyperosmolar state and his dose of Keppra should be decreased or stopped altogether by his outpatient neurologist whom patient will follow up with upon discharge. . # New onset type 2 diabetes mellitus Patient not known to be a diabetic - though given his habitus may well have been glucose intolerant and tipped over by recent prednisone. Patinets sugars normalized on a insulin drip. [Last Name (un) ] consult was obtained for recommendations regarding insulin. He was started on 36 units of glargine in the ICU with a regular insulin sliding scale at mealtime and humalog at night. He was stable on a subcutaneous insulin regimen and received diabetes education. Upon discharge he was on 42 units of glargine and an aggressive Lispro sliding scale [First Name8 (NamePattern2) ] [Last Name (un) ]. He has an appointment on the day after discharge ([2-24] 0930) at the [Last Name (un) ] for follow up. . # Acute renal failure Very likely secondary to pre-renal state from dehydration; his marked hyperglycemia would lead to osmotic diuresis. No history of hypotension to suggest ATN. Creatinine normalized with rehydration. . # Hypertension: home HCTZ was restarted on [2-20] and dose upon discharge was 25mg. Norvasc was discontinued in favor of lisinopril 5mg given he is diabetic, although screen for microalbuminuria was not done. . # Inclusion body myositis: he will follow up with his outpatient neurologist to discuss the tapering of his prednisone. He was continued on 20mg PO BID at discharge. . # Hypernatremia Sodium at admission falsely in normal range 2/2 marked hyperglycemia. Free water deficit ~8L at admission. Resolved with fluid repletion. . Medications on Admission: hctz 50 fe 300 prednisone 20 [Hospital1 ] keppra 500 [Hospital1 ] amlodipine 5 daily asa 81 daily vitamins Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a day. 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 9. Insulin Glargine 100 unit/mL Solution Sig: Forty Two (42) units Subcutaneous once a day. Disp:1 month supply Refills:2 10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:90 Tablet(s) Refills:0 11. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:45 Tablet(s) Refills:0 12. Syringe 1ml 29G Insulin syringe 1 month suppl with 3 refills 13. Glucometer Patient needs standard blood glucometer for new onset diabetes mellitus 14. Lancet strips Patient needs order for Lancet glucose testing strips. Needs 1 month supply with 3 refills 15. Insulin Lispro 100 unit/mL Cartridge Sig: sliding scale as directed Subcutaneous four times a day: as directed by sliding scale. Disp:1 month supply Refills:2 16. alcohol swabs month supply alcohol swabs Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: primary: seizure hyperglycemic nonketotic ketoacidosis diabetes mellitus type 2 secondary: inclusion body myositis hypertension subarachnoid hemorrhage Discharge Condition: stable Discharge Instructions: You were admitted for a seizure as well as for high blood sugars. You were diagnosed with diabetes mellitus. You were started on insulin to manage your diabetes. You were continued on Keppra(levetiracetam) to manage your seizure disorder. It is very important that you follow up with your outpatient appointments for both of these disorders. It is also very important that you take all of your medications as directed. If you should have confusion, headache/dizzyness, chest pain/shortness of breath, you should call your primary care physician or present to the emergency department. New medications: Glargine 42 units under the skin every morning with breakfast You will check your blood sugar 4 times a day and based on the number you will give yourself an extra amount of insulin based on a scale which will be given for you. Lisinopril 5mg by mouth once daily Medications that were stopped: Do not take the Norvasc anymore, also called amlodipine The dose of your hydrochlorothiazide was decreased to 25mg once a day Followup Instructions: Please call Dr. [Last Name (STitle) 13983] for a follow up appointment so that he can check your blood work in the upcoming week call at [Telephone/Fax (1) 13987]. Please follow up with with your neurologist Dr. [Last Name (STitle) ] so that he can decide to taper the prednisone which you are on. You have an appointment this Wednesday [2-24] at 930AM with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11712] at the [Last Name (un) ] Center, it is extremely important for you to make this appointment.	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48,999	181,533	6009	Discharge summary	report	Admission Date: [2133-8-5] Discharge Date: [2133-8-8] Date of Birth: [2062-8-11] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 598] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr [Known lastname 23648] presents to the ED with multiple complaints, most are relevant to poor PO tolerance. He has crampy abdominal pain, diarrhea, constipation, nausea, reflux, fatigue, fever and food tastes terrible. His symptoms began one month ago when he was transferred to [Hospital1 18] from [Location (un) 620] with RUQ abdominal pain. He was found to have a stone obstructing the cystic duct and a percutaneous cholecystostomy tube was placed. He was sent home with drain care. The tube broke once and was replaced by IR. On follow-up with Dr [Last Name (STitle) 853] last week, he complained of pain at the drain site, poor appetite and weight loss. He reports no improvement in syptoms since the perc chole tube was placed. Tube drainage has been 300-500cc/day. He called Dr [Last Name (STitle) ] last night who recommended he come to the ED today for evaluation. Of note, he was scheduled to see Dr [Last Name (STitle) ] in clinic in 5 days time for these same issues. He became briefly hypotensive (SBP 75, remained asymptomatic) in the ED, was given 3L boluses and started on levo gtt, vanc/zosyn. Past Medical History: Coronary artery disease -- s/p multiple PCI, last in [Hospital1 18] records from [2124] -- s/p MI in [2130] with stent placement Dilated Cardiomyopathy -- LVEF of 20-25% -- s/p PPM/ICD placement Hypertension Hyperlipidemia Hypothyroidism Depression ICH -- while on Coumadin Benign Prostatic Hypertrophy Bilateral Hydroceles Colonic polyps Hand osteomyelitis history Babesiosis history SCC -- left 4th finger and penis Appendectomy Gout Social History: He lives with his wife and has 3 sons. Smoked 1 PPD for several years in his 20s but none since. Drinks [2-1] glasses of wine on social occasions or when eating at restaurants, none at home. Drugs: None Family History: -Father -- died from throat cancer at age 63, heavy smoker and alcohol consumption - Mother -- congenital [Last Name ] problem (unsure what), but lived into her 90s - Brother -- renal cancer, treated Physical Exam: T 97.7 P 77 BP 99/55 RR 18 O2 98% RA A&O x 3, NAD, PERRL, EOMI, anicteric sclera RRR; pulses palp and symmetric CTAB Abdomen: S/NT/ND; perc chole tube site C/D/I LE warm, no edema Pertinent Results: [2133-8-6] 12:19AM BLOOD WBC-8.7 RBC-3.99* Hgb-11.1* Hct-32.3* MCV-81* MCH-27.8 MCHC-34.3 RDW-14.4 Plt Ct-200 [2133-8-6] 06:11PM BLOOD Glucose-120* UreaN-15 Creat-0.8 Na-140 K-3.8 Cl-111* HCO3-21* AnGap-12 [2133-8-6] 12:19AM BLOOD Glucose-108* UreaN-33* Creat-1.0 Na-140 K-4.0 Cl-114* HCO3-19* AnGap-11 [2133-8-6] 12:19AM BLOOD ALT-20 AST-29 AlkPhos-39* TotBili-0.4 [2133-8-5] 10:50AM BLOOD ALT-21 AST-38 AlkPhos-58 TotBili-0.4 [2133-8-6] 06:11PM BLOOD Calcium-8.7 Phos-2.1* Mg-1.9 [2133-8-6] 12:19AM BLOOD Calcium-8.0* Phos-2.7# Mg-1.9 [2133-8-6] 09:56AM BLOOD TSH-4.3* [2133-8-6] 09:56AM BLOOD T4-5.6 T3-64* [8-5] RUQ U/S: IMPRESSION: Cholecystostomy tube within a decompressed gallbladder. No intra- or extra-hepatic biliary dilatation. No free fluid or fluid collection. [8-6] CT Abd/Pelvis: IMPRESSION: 1. No evidence of abscess or acute abdominal process. 2. Stable appearance of cholecystostomy tube within the gallbladder. [8-6] TTE: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) with regional variation. The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with borderline normal free wall function. The aortic root is mildly 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. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion Brief Hospital Course: Mr. [Known lastname 23648] was admitted to the hospital on [8-5] for worsening abdominal pain in the setting of chronic abdominal pain. He was hypotensive (SBP 75-80) in the ED and was given 3L of fluid boluses, started on levo gtt and given a dose of vanc/zosyn. Following fluid resuscitation, his blood pressure improved and he was off pressors within 24 hours. He underwent CT abdomen which showed no evidence of abscess or acute abdominal process, stable appearance of cholecystostomy tube within the gallbladder. His pacer was interrogated HD2 and found to be in working order. No further antibiotics were given. On HD3 he was transferred to the floor, given a regular diet and oral medications. This he tolerated well. The team debated performing cholecystectomy acutely or in a few weeks time, and we felt it was in his best interest to wait 3 weeks. He was discharged home with cholecystostomy tube in place with instructions to return [2133-8-24] for pre-operative testing. Medications on Admission: carvedilol 12.5", digoxin 125mcg', acetaminophen 650 prn, lidocaine patch, aspirin 81', famotidine 20", allopurinol 300', spironolactone 25', tamsulosin 0.4 qhs, finasteride 5', levothyroxine 125', docusate sodium 100", venlafaxine 225', lorazepam 0.5", seroquel 25 qhs, Plavix 75' (held for past month) Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fevers > 101F. 2. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3) Capsule, Ext Release 24 hr PO DAILY (Daily). 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for gerd. 4. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 7. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. metoclopramide 5 mg/mL Solution Sig: One (1) ml Injection Q6H (every 6 hours) as needed for nausea/bloating. 9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for anxiety. 10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Please follow-up with your primary care physician. Followup Instructions: Please call [Hospital 2536] clinic if any issues arise: [Telephone/Fax (1) 600] [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601]	[ "789.09", "244.9", "V45.82", "V10.83", "V45.02", "425.4", "272.4", "V12.54", "401.9", "412", "311" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7021, 7027	4589, 5585	315, 322	7086, 7086	2630, 4566	7527, 7725	2205, 2411		5940, 6998		7048, 7065		5611, 5917			7237, 7504										2426, 2611																												261, 277											350, 1491												7101, 7213			1514, 1964	1980, 2189
70,319	116,426	45479+58820	Discharge summary	report+addendum	Admission Date: [2153-7-15] Discharge Date: [2153-8-10] Date of Birth: [2070-7-21] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 17197] Chief Complaint: Left Lower Quadrant pain s/p fall Major Surgical or Invasive Procedure: [2153-7-18]:Endovascular repair of abdominal aortic aneurysm History of Present Illness: 82F w/ h/o chronic LE venous stasis disease w/ LLE swelling and multiple falls s/p mechanical fall two days ago that caused LUE injuries including possible regional hand/wrist fracture, elbow lac and hand/arm ecchymosis/pain. She was attempting to get up from chair but felt weak and couldn't support herself. She denies head trauma/LOC. Presented to [Hospital1 18] [Location (un) 620] ED and was discharged after negative work-up. The patient also c/o LLQ/flank pain that had started shortly after fall but this has been persistently intermittent and worse with movement. She is unable to definitively state if she had hit her LLQ/flank w/ fall. She returned to the [Hospital1 18] [Location (un) 620] ED earlier today. She denies F/C/N/V/SOB/CP/changes in bowel/bladder function. On w/u a CT torso w/ contrast was performed that demonstrated incidental finding of 6x5.6cm infrarenal AAA w/o any evidence of extravasation. We are consulted for AAA. Past Medical History: Hypertension Hypothyroidism LLE DVT Dementia Chronic LLE edema/rash Multiple falls Frontal hematoma cholecystectomy Social History: lives in senior housing, lives alone and ambulates w/ walker, has remote smoking history, denies ETOH/IVDU Family History: NC Physical Exam: PHYSICAL EXAM Vital Signs: Temp: 96.8 RR: 16 Pulse: 70 BP: 190/91 O2 Sat: 96%3L Neuro/Psych: Oriented x3, Affect Normal, NAD. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, Obese, +LLQ/flank TTP mostly localized to ASIS/lat abdomen, no ecchymosis, no TTP otherwise, no guarding/rebound. Rectal: Not Examined. Extremities: Abnormal: LLE edema/erythema/scaling w/ venous stasis changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RLE Femoral: P. Popiteal: D. DP: D. PT: N. LLE Femoral: P. Popiteal: D. DP: D. PT: N. Pertinent Results: [2153-7-15] 06:38AM BLOOD WBC-7.8 RBC-3.95* Hgb-12.1 Hct-35.9* MCV-91 MCH-30.6 MCHC-33.6 RDW-14.5 Plt Ct-153 [2153-8-4] 03:28AM BLOOD WBC-8.1 RBC-3.16* Hgb-9.4* Hct-29.3* MCV-93 MCH-29.8 MCHC-32.2 RDW-16.6* Plt Ct-204 [2153-8-5] 12:26AM BLOOD WBC-7.1 RBC-2.78* Hgb-8.5* Hct-25.7* MCV-93 MCH-30.5 MCHC-33.0 RDW-16.8* Plt Ct-189 [2153-8-6] 03:41AM BLOOD WBC-6.3 RBC-2.76* Hgb-8.6* Hct-26.0* MCV-94 MCH-31.2 MCHC-33.1 RDW-16.9* Plt Ct-156 [2153-8-7] 02:21AM BLOOD WBC-5.9 RBC-2.74* Hgb-8.4* Hct-26.0* MCV-95 MCH-30.8 MCHC-32.5 RDW-17.1* Plt Ct-163 [2153-8-8] 04:00AM BLOOD WBC-5.7 RBC-2.75* Hgb-8.2* Hct-25.5* MCV-93 MCH-29.9 MCHC-32.2 RDW-17.2* Plt Ct-136* [2153-8-9] 04:35AM BLOOD WBC-5.9 RBC-2.58* Hgb-8.0* Hct-24.3* MCV-94 MCH-31.1 MCHC-33.0 RDW-17.3* Plt Ct-139* [2153-8-10] 06:42AM BLOOD WBC-4.9 RBC-2.84* Hgb-8.9* Hct-26.5* MCV-93 MCH-31.3 MCHC-33.6 RDW-17.4* Plt Ct-129* [2153-8-9] 04:35AM BLOOD PT-13.0 PTT-63.6* INR(PT)-1.1 [2153-8-10] 06:42AM BLOOD Plt Ct-129* [2153-7-15] 06:38AM BLOOD Glucose-111* UreaN-26* Creat-1.1 Na-142 K-3.9 Cl-104 HCO3-28 AnGap-14 [2153-8-4] 03:28AM BLOOD Glucose-117* UreaN-41* Creat-1.4* Na-146* K-3.9 Cl-104 HCO3-35* AnGap-11 [2153-8-5] 12:26AM BLOOD Glucose-112* UreaN-40* Creat-1.3* Na-144 K-3.7 Cl-103 HCO3-34* AnGap-11 [2153-8-6] 03:41AM BLOOD Glucose-110* UreaN-36* Creat-1.4* Na-139 K-3.9 Cl-100 HCO3-33* AnGap-10 [2153-8-7] 02:21AM BLOOD Glucose-122* UreaN-38* Creat-1.3* Na-138 K-4.1 Cl-99 HCO3-34* AnGap-9 [2153-8-8] 04:00AM BLOOD Glucose-122* UreaN-43* Creat-1.3* Na-139 K-4.5 Cl-100 HCO3-34* AnGap-10 [2153-8-9] 04:35AM BLOOD Glucose-243* UreaN-59* Creat-1.4* Na-140 K-4.0 Cl-101 HCO3-31 AnGap-12 [2153-7-18] 06:41PM BLOOD CK(CPK)-78 [2153-7-19] 03:59AM BLOOD CK(CPK)-146 [2153-7-19] 12:27PM BLOOD CK(CPK)-651* [2153-7-20] 03:07AM BLOOD CK(CPK)-1134* [2153-7-20] 10:32AM BLOOD CK(CPK)-952* [2153-7-21] 03:06AM BLOOD CK(CPK)-1518* [2153-7-30] 02:59AM BLOOD ALT-18 AST-20 AlkPhos-92 TotBili-0.3 [2153-8-5] 12:26AM BLOOD ALT-23 AST-23 LD(LDH)-193 AlkPhos-92 TotBili-0.4 [2153-7-18] 06:41PM BLOOD CK-MB-4 cTropnT-<0.01 [2153-7-19] 03:59AM BLOOD CK-MB-4 cTropnT-<0.01 [2153-7-19] 12:27PM BLOOD CK-MB-7 cTropnT-<0.01 [2153-7-20] 03:07AM BLOOD CK-MB-6 [2153-7-21] 03:06AM BLOOD CK-MB-14* MB Indx-0.9 [2153-7-27] 02:09AM BLOOD calTIBC-190* Ferritn-285* TRF-146* [2153-7-28] 02:09AM BLOOD calTIBC-196* Ferritn-270* TRF-151* [2153-8-4] 06:41PM BLOOD %HbA1c-5.5 eAG-111 [2153-7-17] 04:15PM BLOOD T4-8.2 [2153-8-9] 09:15PM BLOOD T4-5.4 T3-46* [2153-8-3] 05:50AM BLOOD Vanco-26.5* [Known lastname ],[Known firstname 95] [Medical Record Number 97044] F 83 [2070-7-21] Radiology Report MR HEAD W/O CONTRAST Study Date of [2153-8-4] 9:19 AM [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 6889] CSRU [2153-8-4] 9:19 AM MR HEAD W/O CONTRAST Clip # [Clip Number (Radiology) 97045] Reason: eval for stroke [Hospital 93] MEDICAL CONDITION: 83 year old woman with left sided weakness REASON FOR THIS EXAMINATION: eval for stroke CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: AFSN SAT [2153-8-4] 12:56 PM Somewhat limited study by motion. Acute right periventricular subcortical infarct is seen. Other hyperintensities on diffusion images could be due to shine through or subacute infarcts. Severe changes of small vessel disease are seen. Also noted is a 2-cm mass partially visualized on diffusion images within the right parotid. This can be further evaluated with CT of the neck or MRI of the neck as clinically appropriate. Final Report EXAM: MRI of the brain. CLINICAL INFORMATION: Patient with left-sided weakness. TECHNIQUE: T1 sagittal and FLAIR T2 susceptibility and diffusion axial images of the brain were acquired. Correlation was made with CT of [2153-7-24]. FINDINGS: Diffusion images demonstrate an area of acute subcortical periventricular infarct in the right periventricular region adjacent to the posterior portion of the body of the right lateral ventricle. Subtle hyperintensities in the left periventricular region and right occipital region on diffusion images appear to be T2 shine through or could be due to subacute infarcts. Diffuse small vessel disease is identified in the white matter. Several subcortical lacunes are seen in both basal ganglia region. Thalami also demonstrate chronic infarcts. There is mild to moderate brain atrophy seen. Vascular flow voids are maintained. IMPRESSION: Somewhat limited study by motion. Acute right periventricular subcortical infarct is seen. Other hyperintensities on diffusion images could be due to shine through or subacute infarcts. Severe changes of small vessel disease are seen. Also noted is a 2-cm mass partially visualized on diffusion images within the right parotid. This can be further evaluated with CT of the neck or MRI of the neck as clinically appropriate. [Known lastname ],[Known firstname 95] [Medical Record Number 97044] F 83 [2070-7-21] Radiology Report CHEST (PORTABLE AP) Study Date of [2153-8-5] 1:22 PM [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 6889] CSRU [2153-8-5] 1:22 PM CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 97046] Reason: please eval interval change [Hospital 93] MEDICAL CONDITION: 83 year old woman with s/p EVAR, post-op course c/b respiratory failure REASON FOR THIS EXAMINATION: please eval interval change Final Report HISTORY: Status post EVAR, respiratory failure. CHEST, SINGLE AP PORTABLE VIEW. A stent overlies the midline in the upper abdomen, presumably an aortic stent. An oral-type tube is present, extending beneath diaphragm, overlying stomach. Right IJ central line is present, tip over distal SVC. There is mild cardiomegaly. The left hemidiaphragm is slightly elevated, with patchy opacity at the left base with possible minimal pleural effusion. Upper zone redistribution, without overt CHF. Minimal atelectasis right base. No focal consolidation or pleural effusion on the right. ? background COPD. [Known lastname ],[Known firstname 95] [Medical Record Number 97044] F 83 [2070-7-21] Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of [2153-8-9] 1:10 PM [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 6889] FA5 [2153-8-9] 1:10 PM VIDEO OROPHARYNGEAL SWALLOW Clip # [Clip Number (Radiology) 97047] Reason: video swallow eval [Hospital 93] MEDICAL CONDITION: 83 year old woman with swallowing difficulty REASON FOR THIS EXAMINATION: video swallow eval Wet Read: [First Name9 (NamePattern2) ] [Doctor First Name ] [2153-8-9] 1:40 PM 1. Mild penetration with thin barium. 2. Difficulty and delay in bolus formation in the oral cavity at the initiation of the oropharyngeal phase of swallowing. Wet Read Audit # 1 Final Report HISTORY: 83-year-old woman, with swallowing difficulty. COMPARISON: None. TECHNIQUE: Swallowing oropharyngeal fluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. FINDINGS: The patient continues to demonstrate difficulty in initiation of bolus formation. There is also reduced hyolaryngeal excursion. Minimal penetration is noted with thin barium, but there is no frank aspiration. There is no induced gag reflex or cough. IMPRESSION: 1. Mild penetration with thin barium. 2. Difficulty and delay in bolus formation, and reduced hyolaryngeal excursion. Please refer to the speech therapist's report for detailed evaluation and recommendation. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 95] [Hospital1 18] [Numeric Identifier 97048]TTE (Complete) Done [2153-7-23] at 11:48:27 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 18], Division of Vascular [Last Name (un) ] [Hospital Unit Name 22682] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2070-7-21] Age (years): 83 F Hgt (in): 67 BP (mm Hg): 149/53 Wgt (lb): 173 HR (bpm): 77 BSA (m2): 1.90 m2 Indication: New atrial fibrillation. ?thrombus. ICD-9 Codes: 427.31, 424.0, 424.2 Test Information Date/Time: [2153-7-23] at 11:48 Interpret MD: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4083], MD Test Type: TTE (Complete) Son[Name (NI) 930]: [First Name8 (NamePattern2) 2270] [Last Name (NamePattern1) ] Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Suboptimal Tape #: 2011W000-0:00 Machine: Vivid q-1 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 2.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.8 cm <= 5.2 cm Right Atrium - Four Chamber Length: 5.3 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.4 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.1 cm Left Ventricle - Fractional Shortening: 0.38 >= 0.29 Left Ventricle - Ejection Fraction: >= 60% >= 55% Left Ventricle - Stroke Volume: 71 ml/beat Left Ventricle - Cardiac Output: 5.46 L/min Left Ventricle - Cardiac Index: 2.87 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.14 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.06 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 10 < 15 Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Arch: 2.7 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 25 Aortic Valve - LVOT diam: 1.9 cm Aortic Valve - Pressure Half Time: 553 ms Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - E Wave deceleration time: 219 ms 140-250 ms TR Gradient (+ RA = PASP): 36 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Elongated LA. No LA mass/thrombus (best excluded by TEE). RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). Estimated cardiac index is normal (>=2.5L/min/m2). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. The patient appears to be in sinus rhythm. Frequent atrial premature beats. Conclusions The left atrium is elongated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild [1+] mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Pulmonary artery systolic hypertension. Mild mitral regurgitation. No intra-atrial thrombus seen (best excluded by TEE). Brief Hospital Course: [7-17]- Cleared by Medicine team for OR. Underwent emergent EVAR that evening for worsening abdominal pain. [7-18]- Intubated for resp distress and pressors started. Transferred to CVICU. Underwent emergent Bronch for RLL collapse [7-19]- Intubated, sedated. CTA done, negative for PE. LENIs neg for clot. [7-20]- Started Vanc and Zosyn for VAP. Continue diuresis [7-21]- Tube feeds started via dobhoff. Continue diuresis. [7-22]- Extubated. Tube feeds at goal. Antibiotics discontinued. [7-23]-Amiodarone gtt started for intermittent rapid atrial fibrillation. Continue diuresis.Echo done- EF >60%. [7-24]-Continue aggressive pulm toilet. Continue Tube feeds.Geriatrics consulted for lethargy/ICU delirium.CT head negative. [7-25]- Converted to Sinus rhythm. Reintubated overnight for somnolence, inability to clear secretions. [7-26]-Intubated. Started on Vanc/Zosyn for hospital aquired pneumonia, GNR in sputum. Bronchoscopy showed left pleural effusion, BAL with GN diplococci and Staph auresu coag +.. [7-27]-Continue lasix with diamox. [7-28]-mental status improving. Extubated. [7-29]-SVT. Vancomycin discontinued. Requiring bipap PRN and NT suctioning. Family meeting [7-30]- [7-31]-Bursts of Afib.Episode of emesis with turning, concerning for possible aspiration. Tube feeds held. Bedside swallow eval done-pt made NPO. CXR done. Still lethargic with minimal left arm movement. Neurology consulted and recommended MRI brain and to continue aspirin. [8-1]- Pt more awake. Back in atrial fibrillation- titrated lopressor and continue amiodarone. [8-2]-Improving mental status. Bedside swallow re-eval: continue NPO. [8-3]- Amiodarone changed to 400mg po BID. No Coumadin secondary to fall risk. PT eval. [8-4]-MRI:acute right periventricular subcortical infart. Likely embolic per Neuro. with left sided weakness. Heparin gtt started per Neurology recomendations as not a coumadin candidate given history of falls. Aspirin d/c'd. [8-5]- Tube feeds restarted. [8-6]- Antibiotics discontinued. Statin started. Carotid ultrasound done- <30% [Doctor First Name 3098], [Country ] cannot be seen due to presence of dressing. PT re-eval. Speech and swalllow: ground solids/thin liqs. Nutrition consult. [8-7]-Neurology signed off. Dobhoff removed. Diet advanced. Heparin gtt continues.Continue diuresis. OT eval. [8-8]-Continues on Heparin gtt. Calorie counts for poor po intake. Speech and Swallow recommended ground solids and thin liquids, meds crushed in applesauce. [8-9]-Transferred to floor. ? aspirated while eating breakfast. Speech and Swallow re-eval with video swallow: rec nectar thick liqs and moist soft diet with 1:1 supervision. Transfused 1unit of PRBCs for hct 24.3. [8-10]-Heparin gtt discontinued. Started on 325mg of Aspirin for embolic stroke.Hct stable at 26 Medications on Admission: amlodipine 10', levothyroxine 112mcg', valsartan [Diovan] 320', vit B1' Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Month/Year (2) ]: One (1) neb Inhalation Q4H (every 4 hours) as needed for wheeze. 2. ipratropium bromide 0.02 % Solution [Month/Year (2) ]: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheeze. 3. docusate sodium 50 mg/5 mL Liquid [Month/Year (2) ]: Fifty (50) mg PO BID (2 times a day): Hold for loose stools. 4. levothyroxine 112 mcg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet [Month/Year (2) ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 7. valsartan 160 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 8. amiodarone 200 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO BID (2 times a day) for 1 weeks. 9. amiodarone 200 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day for 1 weeks: Start after 400 [Hospital1 ] taper finished. 10. amiodarone 200 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day: Continue after 200mg [Hospital1 ] taper until follow up with PCP. 11. simvastatin 10 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 12. metoprolol tartrate 25 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day). 13. hydralazine 10 mg Tablet [Hospital1 ]: One (1) Tablet PO q6H PRN as needed for SBP>140. 14. miconazole nitrate 2 % Powder [Hospital1 ]: One (1) Appl Topical TID (3 times a day) as needed for yeast. 15. dextrose 50% in water (D50W) Syringe [Hospital1 ]: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 16. glucagon (human recombinant) 1 mg Recon Soln [Hospital1 ]: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 17. Regular Insulin Sliding Scale Breakfast Lunch Dinner Bedtime Regular 0-70 Proceed with hypoglycemia protocol 71-150 0Units 0Units 0Units 0Units 151-200 3Units 3Units 3Units 3Units 201-250 6Units 6Units 6Units 6Units 251-300 9Units 9Units 9Units 9Units 301-350 12Units 12Units 12Units 12Units > 350 Notify M.D. Notify 18. aspirin 325 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO once a day: for stroke prophylaxis as coumadin contraindicated. 19. heparin [Hospital1 ]: 5000 (5000) units Subcutaneous three times a day: For DVT prophylaxis. [Month (only) 116] discontinue when ambulating TID. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Abdominal Aortic Aneurysm Respiratory Failure Embolic CVA Atrial Fibrillation Anemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? 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 [3-22] 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 pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [5-23] 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: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 20205], MD Phone:[Telephone/Fax (1) 20206] Date/Time:[2153-9-14] 12:30 Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2153-9-14] 11:30 Completed by:[2153-8-10] Name: [Known lastname ],[Known firstname 300] Unit No: [Numeric Identifier 15445] Admission Date: [2153-7-15] Discharge Date: [2153-8-10] Date of Birth: [2070-7-21] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 15446] Addendum: Lasix 40mg IV BID inadvertently omitted from transfer orders to rehab. Called [Hospital1 ] in [Location (un) ] to resume lasix 40mg IV BID. Discharge Disposition: Extended Care Facility: [Hospital3 1174] [Hospital ] Hospital - [Location (un) ] [First Name11 (Name Pattern1) 4095] [Last Name (NamePattern4) 15447] MD [MD Number(2) 15448] Completed by:[2153-8-11]	[ "518.0", "459.81", "041.11", "293.0", "492.8", "518.5", "412", "349.82", "V15.88", "427.31", "294.10", "997.02", "441.4", "434.11", "244.9", "507.0", "454.9", "276.4" ]	icd9cm	[ [ [] ] ]	[ "39.71", "88.47", "96.72", "33.24", "96.6", "96.05" ]	icd9pcs	[ [ [] ] ]	24199, 24457	14669, 17563	338, 405	20596, 20596	2309, 5390	23359, 24176	1690, 1694		17686, 20347	9076, 9121	20488, 20575		17589, 17663			20776, 22779	22805, 23336									1709, 2290																												265, 300	9153, 14646										433, 1407												20611, 20752			1429, 1548	1564, 1674
11,311	181,688	27102	Discharge summary	report	Admission Date: [2201-1-6] Discharge Date: [2201-1-19] Date of Birth: [2136-9-26] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: DOE Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to OM, PDA) [2201-1-9] Cardiac Catheterization [2201-1-6] History of Present Illness: Mr. [Known lastname 10653] is a 64 y/o male who recently presented to his PCP last week [Name Initial (PRE) ]/o progressive DOE. He was subsequently scheduled for an ETT. The patient exercised for 4 minutes stopping d/t fatigue and chest tightness. EKG exhibited ST elevation inferiorly and Nuclear MIBI showed lateral wall defect. Patient was then tranferred to [Hospital1 18] for cardiac cath and further management. Cath revealed significant three vessel disease and patient was referred for surgical management. Past Medical History: Hypertension Hypercholesterolemia Diabetes Mellitus Benign Prostatic Hypertrophy Gout Social History: Married, retired, lives with wife. Denies [Name2 (NI) 1139] and ETOH. Family History: No FH of CAD Physical Exam: General: WDWN white male in NAD HEENT: NC/AT, PERRL, EOMI, OP Benign Neck: Supple, FROM, -Lymphadenopathy, Carotids 2+ without bruits Lungs: CTAB -w/r/r Cor: RRR +S1S2, -c/r/m/g Abd: Soft, NTND, +BS Ext: Warm, -c/c/e, 2+ pulses throughout Neuro: Non-focal, MAE, A&O x 3 Pertinent Results: CT [1-7]: 1. No evidence of aortic dilatation. 2. 3-mm noncalcified pulmonary nodule in the left lower lobe. Please follow in one year if this patient has no history of malignancy. 3. Right renal cyst. 4. Focal calcification in the segment VIII of the liver. 5. Coronary artery calcification. [1-13]: Although lung volumes have improved since [1-10], left lower lobe collapse has not cleared. Small bilateral pleural effusions remain. Postoperative widening of the cardiomediastinal silhouette improved between [1-10] and 13 and is subsequently unchanged. There is no pneumothorax or pulmonary edema. Cath [1-6]: Selective coronary angiography of this right dominant system revealed three vessel coronary artery disease. The LMCA had distal 20% stenosis with moderate calcification. The LAD had calcified 80% mid segments stenosis and mid-distal 60% stenosis. The LCX had diffuse disease with 40% stenosis in the AV groove. The OM1 had 90% proximal stenosis. The ramus intermedius was patent. The RCA had proximal 95% stenosis with TIMI 2 flow. Left ventriculography revealed trace mitral regurgitation. There was evidence of mild inferior and posterobasal hypokinesis. Calculated ejection fraction was 70%. Echo [1-12]: The left ventricular cavity size is normal. The aortic valve leaflets are mildly thickened. There is a small circumferential partially echofilled pericardial effusion. No definite right atrial collapse is identified. [2201-1-15] 06:10AM BLOOD WBC-14.3* RBC-3.35* Hgb-9.1* Hct-27.5* MCV-82 MCH-27.1 MCHC-33.0 RDW-15.4 Plt Ct-286 [2201-1-16] 06:25AM BLOOD PT-23.8* INR(PT)-2.4* [2201-1-16] 06:25AM BLOOD Glucose-85 UreaN-32* Creat-1.8* Na-139 K-5.1 Cl-104 HCO3-23 AnGap-17 [2201-1-17] 05:10AM BLOOD WBC-12.9* RBC-3.49* Hgb-9.9* Hct-29.2* MCV-84 MCH-28.5 MCHC-34.0 RDW-15.6* Plt Ct-378 [2201-1-19] 06:30AM BLOOD PT-29.1* INR(PT)-3.0* Brief Hospital Course: As mentioned in the HPI, patient underwent cardiac cath which revealed 3 vessel disease. Cardiac surgery was consulted. Patient underwent usual pre-operative work-up. Along with a Chest CT to r/o Aorta dilatation (please see pertinent results). UA appeared to be positive for UTI and he was started on Levaquin. He was eventually cleared and consented for surgery and on [2201-1-9] was brought to the operating room where he underwent a coronary artery bypass graft x 3. Please see op not for surgical details. Following surgery patient was transferred to the CSRU in stable condition. Later on op day sedation was weaned and patient awoke neurologically intact. He was then extubated. B-Blockers, Aspirin, and Diuretics were initiated per protocol. He was gently diuresed during hospital course towards pre-operative weight. On post-op day one his chest tubes were removed and he was transferred to the cardiac surgery step-down unit. Post-op day two his epicardial pacing wires were removed. Physical therapy began working with patient post-operatively for strength and mobility. On post-op day three patient heart rhythm converted to rapid Atrial fibrillation/flutter. Lopressor and Amiodarone were given. Patient became hypotensive along with decrease in oxygen saturation. He was then transferred back to the CSRU for closer management. He eventually converted back to SR and appeared stable. He was started on coumadin and then transferred back to the step-down unit. He stayed on the floor for observation/management of INR. He will go home with foley in place and is to follow up with his urologist on Monday [1-19]. His WBC count increased to 16.2 and he was held for additional labs and an increased INR of 3.2. Foley was ultimately removed and INR moved to therapeutic range and WBC normalized. Discharged to home with VNA on POD #10. Dr. [Last Name (STitle) 1637] follow coumadin/INR. Blood draw scheduled for Tues. [1-20]. Medications on Admission: 1. Glucophage 1000mg [Hospital1 ] 2. Glyburide 5mg qd 3. Allopurinol 100mg qd 4. Lopressor 50mg qd 5. Cardura 4mg qd Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 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:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 8. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: 1mg [1-19], check INR with Dr. [Last Name (STitle) 56051] [1-20]. Disp:30 Tablet(s) Refills:0 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:0 11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks. Disp:7 Tablet(s) Refills:0 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily) for 1 weeks. Disp:14 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Hypertension Hypercholesterolemia Diabetes Mellitus Benign Prostatic Hypertrophy Gout Afib Discharge Condition: good Discharge Instructions: Can take shower. Wash incisions with water and gentle soap. Gently pat dry. Do not apply lotions, creams, ointments or powders to incisions. Do not take bath. Do not drive for 1 month. Do not lift more than 10 pounds for 2 months. Please contact office immediately if you notice sternal/chest drainage or develop fever more than 101.5 Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks Cardiologist in [1-2] weeks Dr. [Last Name (STitle) 1637] in [12-1] weeks See urologist on Monday [1-19] Completed by:[2201-3-27]	[ "272.4", "403.91", "414.01", "600.01", "250.00", "413.9", "794.39", "428.30", "997.1", "427.31", "790.92", "428.0", "274.9", "458.8", "V58.83", "599.0" ]	icd9cm	[ [ [] ] ]	[ "36.15", "88.53", "36.12", "37.22", "99.20", "88.56", "99.04", "39.61" ]	icd9pcs	[ [ [] ] ]	7243, 7298	3454, 5409	324, 442	7493, 7499	1534, 3431	7882, 8074	1215, 1229		5580, 7220		7319, 7472		5435, 5557			7523, 7859										1244, 1515																												281, 286											470, 999															1021, 1108	1124, 1199
532	193,338	2125	Discharge summary	report	Admission Date: [2138-11-27] Discharge Date: [2138-11-27] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: SOB Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 87 y/o woman w/ h/oMI and CAD, presented on transfer from OSH after presenting there [11-20] with SOB, CHF, pulmonary edema. Diuresed well w/lasix, ruled out for MI. Had diagnostic cath at OSH revealing 3VD, 90%RCA, occluded LAD and PDA. Presented for repeat cath and likely intervention. Past Medical History: CAD DM carotid stent [9-1] HTN anemia Social History: no tobacco or ETOH currently Family History: HTN Physical Exam: Deferred. Pertinent Results: [2138-11-27] 07:02PM TYPE-ART PO2-128* PCO2-57* PH-7.19* TOTAL CO2-23 BASE XS--6 [2138-11-27] 08:24PM CALCIUM-6.2* PHOSPHATE-4.4 MAGNESIUM-1.3* [2138-11-27] 08:24PM CK(CPK)-20* [2138-11-27] 08:24PM GLUCOSE-220* UREA N-30* CREAT-0.7 SODIUM-139 POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-15* ANION GAP-17 [2138-11-27] 08:38PM LACTATE-5.7* [2138-11-27] 08:38PM TYPE-ART PO2-135* PCO2-30* PH-7.29* TOTAL CO2-15* BASE XS--10 [2138-11-27] 09:04PM TYPE-ART PO2-249* PCO2-22* PH-7.12* TOTAL CO2-8* BASE XS--20 Brief Hospital Course: The patient was admitted directly to cath lab. Cardiac catheterization complicated by LAD dissection s/p stenting, severe systolic ventricular dysfunction, cardiogenic shock, moderate pericardial effusion without echocardiogeaphic evidence of tamponade. Pt was dependent upon pressors post-cath upon arrival to ICU and acutely decompensated within 30 minutes of arrival there. Despite aggressive resucitative efforts, intubation, and emergent pericardial drainage of <100cc sanguinous material, the pt had refractory PEA/V fib arrest. Time of death 20:57 [2138-11-27]. Interventional attending, daughter and grand-daughter present at bedside. Medications on Admission: colace protonix lopressor imdur glyburide meclizine aspirin vitamin B12 levoxyl vitmain c iron NPH insulin digoxin lasix amiodarone Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cardiac arrest Discharge Condition: Expired	[ "427.41", "414.01", "785.51", "428.0", "E879.0", "250.00", "423.9", "997.1", "414.11", "401.9" ]	icd9cm	[ [ [] ] ]	[ "99.20", "99.60", "88.56", "37.23", "36.01", "96.04", "36.06", "88.52", "96.71", "37.0" ]	icd9pcs	[ [ [] ] ]	2216, 2225	1355, 2005	267, 292	2283, 2293	792, 1332		742, 747		2187, 2193		2246, 2262		2031, 2164													762, 773																												224, 229											320, 614															636, 680	696, 726
44,128	141,304	40832+40833	Discharge summary	report+report	Admission Date: [2149-6-8] Discharge Date: [2149-6-17] Date of Birth: [2098-7-25] Sex: M Service: SURGERY Allergies: iodide / Iodine Attending:[First Name3 (LF) 4691] Chief Complaint: Polytrauma secondary to motocycle collision Major Surgical or Invasive Procedure: [2149-6-13] ORIF L ulnar/radius [2149-6-8] Ex fix and VAC placement LUE History of Present Illness: The patient is a 50-year-old male who was riding his motorcycle and collided with a car. He was thrown [10-25] feet. He was helmeted and denies any loss of conciousness. His injuries include: - Open L forearm fx (radius and ulnar) - LUL small PTX only seen on CT chest - Posterior L rib fxs [2148-8-19] - 8&9 unstable - R lateral 6th rib fracture - C7 [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] (superior facet joint - incomplete, non-displaced) - L comminuted medial clavicular fx - Lg R lateral knee hematoma - Unstable T10 fx inolving vert body (25% compression), bilat inf facets, and spinous process - T7, T8, T9 and T10 spinous process fractures - T9 bilat inferior facet fractures - T8, T9 and T10 R transverse process fracture - T11 compression fracture of vertebral body - Aspiration R mainstem bronchus Past Medical History: skin cancer with operative removal Social History: (+)Tobacco /(-)EtOH,(+)Employeed-Works at a machine shop Family History: Non-contributory Physical Exam: physical examination upon admission: [2149-6-8]: PHYSICAL EXAMINATION HR:115 Constitutional: Comfortable HEENT: Multiple facial abrasions, Pupils equal, round and reactive to light, Extraocular muscles intact Cervical collar in place Chest: Clear to auscultation, no chest wall ecchymosis Cardiovascular: Tachycardic Abdominal: Soft, Nontender; FAST exam negative Extr/Back: Left arm is in a splint, distally his radial nerve palsy; lower extremities appear atraumatic. Distal pulses normal Skin: Abrasions of her face, bilateral legs Neuro: Cranial nerves intact, motor and sensation normal Psych: Normal mood, Normal mentation Physical examination upon discharge: [2149-6-17] Vital signs: t=98.7, hr=98, bp=140/86, resp rate=18, oxygen saturation 97% room air General: Pleasant, A+O x 3, speech clear, splint left arm, cervical collar CV: Ns2, s2, -s3, -s4 LUNGS: Clear ABDOMEN: soft, non-tender EXTREMITIES: splint left arm, +CSM left fingers, + dp bil. no pedal edema bil., left inner thigh eccyhmosis, ecchymosis toes left, strength lower ext. +4/+5 bil. Pertinent Results: CT head ([2149-6-8]) - Subtle hyperdensity overlying the right frontal lobe is likely artifactual although a tiny subdural hematoma cannot be excluded. Otherwise, no acute intracranial process. CT cspine ([2149-6-8]) - Non-displaced incomplete fracture of the left C7 superior facet, extending into the subjacent articular pillar. CT chest ([2149-6-8]) - The visible osseous structures show compression fractures of the T10 and T11 vertebral bodies. There is minimal loss of vertebral body height, however, the T10 fracture extends through both pedicles bilaterally into the spinous processes. Also noted are spinous process fractures of T7, T8, T9 vertebral bodies. There are also noted mildly displaced fractures of the inferior facet on the right of the ninth and tenth vertebral body and the eighth, ninth and tenth right transverse process. The left clavicular head has a comminuted fracture. No pneumothorax is noted. CT A/P ([2149-6-8]) - No acute intra-abdomial or pelvic process. Multiple fractures in the lower thoracic spine, better described on concurrent chest CT. MR [Name13 (STitle) 2854] ([2149-6-8]) - Acute compression fractures involving the T9 through T11 vertebrae with involvement of the posterior elements, particularly evident at the T10 level, better demonstrated as Chance-type fractures on the prompting CT. There is central compression of the T10 and T11 vertebrae with little loss of height, as on the CT. Small acute epidural hematoma, occupying the dorsal portion of the spinal canal, centered at the T10 level, with only minor mass effect upon the dorsal aspect of the thecal sac. Normal spinal cord caliber and intrinsic signal intensity. [2149-6-11]: Chest x-ray: IMPRESSION: Unchanged appearance of diffuse bilateral lung opacities and mediastinal widening. These findings are not well characterized and again may represent a combination of pulmonary edema and volume overload, but concomitant widespread pneumonia, fat embolism or pulmonary hemorrhage cannot be completely excluded in this study. [2149-6-11]: LENI;s: IMPRESSION: No DVT in the left or right lower extremity [2149-6-12]: chest x-ray: FINDINGS: As compared to previous radiograph, there is minimally improved ventilation of the lung apices. Otherwise, there is no relevant change. Unchanged bilateral parenchymal opacities, unchanged size of the cardiac silhouette, unchanged suspicion of a small left pleural effusion. [2149-6-13]: chest x-ray: FINDINGS: In comparison with the study of [6-12], the patient has taken a better inspiration. There is still increase in pulmonary vessels consistent with some elevated pulmonary venous pressure. The right hemidiaphragm is sharply seen at this time. The left hemidiaphragm continues to beobscured, consistent with effusion and atelectasis at the left base. In the appropriate clinical setting, the possibility of supervening consolidation would have to be considered. [2149-6-13]: Upper ext. fluro: FINDINGS: Multiple views from the operating suite show metallic fixation devices about fractures of the proximal portions of the radius and ulna. Further information can be gathered from the operative report. [2149-6-13]: x-ray of left forearm: FINDINGS: Multiple views from the operating suite show metallic fixation devices about fractures of the proximal portions of the radius and ulna. Further information can be gathered from the operative report. [2149-6-16]: x-ray of T-spine: FINDINGS: There is substantial loss of height of the T10 and T11 vertebral bodies with no evidence of displacement. Mild kyphosis is seen at this level. [2149-6-15] 05:45AM BLOOD Hct-27.3* [2149-6-14] 06:00AM BLOOD WBC-11.4* RBC-2.98* Hgb-9.5* Hct-28.2* MCV-95 MCH-31.9 MCHC-33.7 RDW-13.6 Plt Ct-345 [2149-6-13] 02:17AM BLOOD WBC-16.7* RBC-3.05* Hgb-9.9* Hct-28.6* MCV-94 MCH-32.5* MCHC-34.7 RDW-13.8 Plt Ct-321 [2149-6-8] 07:12PM BLOOD WBC-14.5* RBC-3.52* Hgb-11.5* Hct-33.5* MCV-95 MCH-32.7* MCHC-34.3 RDW-13.9 Plt Ct-220 [2149-6-8] 12:10PM BLOOD WBC-21.1* RBC-4.08* Hgb-13.4* Hct-39.1* MCV-96 MCH-32.9* MCHC-34.3 RDW-13.9 Plt Ct-278 [2149-6-14] 06:00AM BLOOD Plt Ct-345 [2149-6-14] 06:00AM BLOOD PT-12.8 PTT-26.4 INR(PT)-1.1 [2149-6-13] 02:17AM BLOOD Plt Ct-321 [2149-6-8] 12:10PM BLOOD Fibrino-376 [2149-6-14] 06:00AM BLOOD Glucose-111* UreaN-22* Creat-0.7 Na-139 K-3.8 Cl-99 HCO3-31 AnGap-13 [2149-6-12] 02:17AM BLOOD Glucose-118* UreaN-18 Creat-0.7 Na-139 K-4.3 Cl-96 HCO3-32 AnGap-15 [2149-6-12] 02:17AM BLOOD CK(CPK)-815* [2149-6-11] 04:53PM BLOOD CK(CPK)-1138* [2149-6-8] 12:10PM BLOOD Lipase-17 [2149-6-12] 02:17AM BLOOD CK-MB-4 [2149-6-11] 04:53PM BLOOD CK-MB-5 [2149-6-10] 03:45PM BLOOD CK-MB-10 cTropnT-<0.01 [2149-6-14] 06:00AM BLOOD Calcium-8.0* Phos-1.9* Mg-2.1 [2149-6-11] 03:06AM BLOOD freeCa-1.15 Brief Hospital Course: The patient was initially admitted to the floor. He underwent external-fixation of his LUE open fracture with Orthopedics on [2149-6-8]. He went back to the floor post-operatively but developed respiratory distress and was transferred to the intensive care unit. Imaging demonstrated a large gastric bubble and [First Name8 (NamePattern2) ] [Last Name (un) ]-gastric tube was placed for decompression. He initially required a non-rebreather which was able to be weaned down to a face mask. He was originally supposed to go back to the operating room on [6-11] for further repair of his arm but this was postponed. Over the next two days he was diuresed and continued to improve from a respiratory standpoint. His T-spine MRI was repeated on [6-12] per the spine service to monitor his epidural hematoma, which was unchanged. He was stable for the operating room with Orthopedics on [6-13] where he underwent an ORIF left radius and ulnar fracture. His operative course was stable with minimal blood loss. He was extubated in the operating room and monitored in the recovery room. He was transferred to the surgical floor for further monitoring. His post-operative course was stable. He cervical spine was supported with the [Location (un) 2848] J collar. He was restricted to bedrest with log-roll precautions until he was fitted for his TLSO brace. His T-spine x-ray with the TLSO brace showed no displacment. His vital signs are stable and he is afebrile. He is tolerating a regular diet. His pain from his fractures is controlled with oral analgesia. He has been evaluated by physical and occupational therapy and recommendations have been outlined for his discharge. He is preparing for discharge with instructions to follow up withe the acute care service,ortho-spine and hand-plastics. Medications on Admission: cialis Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 3. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gms PO DAILY (Daily). 8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain: may cause drowsiness. 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). 10. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 ] [Hospital1 189] Discharge Diagnosis: Trauma: Open L forearm fx LUL sm PTX Posterior L rib fxs [2148-8-19] unstable C7 [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] L comminuted medial clavicular fx Lg R lateral knee hematoma New onset AFib T7-10 spinous process fractures R lateral 6th rib fracture T9 bilat inferior facet fractures T8-10 R transverse process fracture T11 compression fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair ( TLSO brace) Discharge Instructions: You were admitted to the hospital after you were hit by a car while riding your motor-cycle. You sustained fractures to your ribs, left forearm, back, and neck. You went to the operating room where you had your left forearm repaired. You are now preparing for discharge with the following instructions: You sustained rib fractures: Your injury caused left posterior [8-20] rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). You also sustained a fracture to your arm, please follow these instructions: report any decreased sensation/numbness fingers sling left arm when out of bed elevate arm on pillows when lying down please report increased pain left arm Please wear cervical collar for 6 weeks Followup Instructions: Please follow up with the acute care service in 2 weeks. You can schedule this appointment by calling # [Telephone/Fax (1) 600]. Please follow up with Ortho-spine, Dr. [Last Name (STitle) 1007], in 2 weeks. You can schedule your appointment by calling #[Telephone/Fax (1) 3736] You will also need to follow up with Hand-plastics in 2 weeks. You can schedule this appointment by calling #[Telephone/Fax (1) 5343] Completed by:[2149-6-24] Admission Date: [2149-6-20] Discharge Date: [2149-6-23] Date of Birth: [2098-7-25] Sex: M Service: MEDICINE Allergies: iodide / Iodine Attending:[First Name3 (LF) 5134] Chief Complaint: Tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 50 year old man in good health until a motorcycle accident on [2149-6-8] who presented from rehab with tachycardia and concern for a pulmonary embolism. Mr. [Known lastname ] crashed a motorcycle on [2149-6-8] at which point he sustained multiple orthopedic injuries including T10/11 compression fracture with small epidural hematoma, C7 non-displaced pedicle fracture, multiple spinous process and transverse process fractures, and left radial/ulnar open fractures. He underwent multiple orthopedic procedures at [Hospital1 18] and was discharged to rehab on [2149-6-17]. Since then he had been doing well and progressing with physical therapy. Two days prior to presentation, however, he was noted to be tachycardic and his O2 sat dropped to the 80's once during PT. Due to these issues he was sent to an outside hospital where he had a CT that raise concern for PE though he continued to deny any chest pain or dyspnea. He had a chest radiograph that was concerning for pneumonia and went on to receive a dose of levofloxacin at the outside hospital. He denied cough, fevers, chills, or hypoxia. After the concern for PE was raised the patient was transferred from the outside hospital to [Hospital1 18] in order to manage anticoagulation in the context of multiple recent traumas and epidural hematoma. In the ED, initial vs were: T 98, P 110, BP 145/90, RR 20, O2 Sat 98% on RA. Labs were notable for a WBC 14.7, Hct 33, and platelet count of 552 K. He received levofloxacin, vancomycin, morphine, and heparin gtt and was admitted to the ICU. VS on transfer 102, 112/66, 16, 97% on RA. He reported pain from his recent injuries but no other acute issues. Past Medical History: -Status post motorcycle accident [2149-6-8] complicated by... ----T10/11 compression fracture with small epidural hematoma ----C7 non-displaced pedicle fracture ----multiple spinous process and transverse process fractures ----left radial/ulnar open fractures -Pilonidal cyst Social History: He owns a machine shop. Smokes approximately [1-12] pack per day of cigarettes. Alcohol use is approximately one drink per week. Family History: Father died of cerebrovascular disease. Physical Exam: ADMISSION EXAM: VS: T 98.8, HR 104, BP 124/89, RR 20, SpO2 98% on RA General Appearance: Well nourished HEENT: PERRL, Normocephalic, anicteric sclerae, MMM Head, Ears, Nose, Throat: Normocephalic Cardiovascular: Normal S1 and S2, regular rate and rhythm without murmurs, rubs, or gallops Respiratory: Expansion symmetric bilaterally with clear breath sounds, no wheezes, rhonchi, or rales. Abdominal: Soft, Non-tender, Non-distended, Bowel sounds present Neurologic: Alert and oriented 3, responding to all questions appropriately, moving all extremities equally Extremities: Warm and Well perfused, no clubbing, cyanosis, or edema; 1+ pulses in radials and DPs bilaterally DISCHARGE EXAM: VS: 97.5, 134/83, 91, 20, 96% RA GENERAL: resting in bed, comfortable appearing, cervical collar in place, NAD HEENT: sclera anicteric, MMM NECK: in [Location (un) 2848]-J collar CARDIAC: RRR, normal S1, S2, no r/m/g LUNGS: diminished breath sounds at bases bilaterally, no wheezing, crackles, or rhonchi ABDOMEN: bowel sounds present, soft, non-tender, non-distended EXTREMITIES: warm, well-perfused, DP/PTs 2+ bilaterally, no lower extremity edema, L arm in cast NEURO: AAOx3, moving all four extremities, strength 5/5 in bilateral lower extremities, patellar reflexes 2+ bilaterally, toes down-going SKIN: diffuse blanching erythematous macular-papular rash on back, erythematous papules and excoriations mainly on left side of abdomen Pertinent Results: ADMISSION LABS: [2149-6-20] 07:45PM BLOOD WBC-14.7 RBC-3.46* Hgb-11.0* Hct-33.0* MCV-95 MCH-31.9 MCHC-33.4 RDW-15.0 Plt Ct-552# [2149-6-20] 07:45PM BLOOD Neuts-72 Bands-0 Lymphs-20 Monos-6 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [2149-6-20] 07:45PM BLOOD PT-12.4 PTT-26.9 INR(PT)-1.0 [2149-6-20] 07:45PM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-131* K-5.4* Cl-93* HCO3-25 AnGap-18 DISCHARGE LABS: [2149-6-23] 07:45AM BLOOD WBC-10.1 RBC-3.23* Hgb-10.6* Hct-30.6* MCV-95 MCH-33.0* MCHC-34.9 RDW-14.5 Plt Ct-565* [2149-6-23] 07:45AM BLOOD PT-12.7 PTT-29.9 INR(PT)-1.1 [2149-6-23] 07:45AM BLOOD Glucose-91 UreaN-14 Creat-0.8 Na-133 K-4.5 Cl-95* HCO3-30 AnGap-13 MICROBIOLOGY: Blood cultures [2149-6-20]: pending IMAGING: [Hospital3 20284] Center CT Chest with IV Contrast, [2149-6-20]: Impression: c/w elevated wbc, there appears to be pneumonia with air bronchograms at the left base. The opacities at the right base could reflect pneumonia but may be limited to atelectasis. There is a left pleural effusion consistent with pneumonia. There is a very subtle filling defect in the lateral segment of the right upper lobe consistent with pulmonary embolus. Compression fxs of t10/11 vertebral bodies and horizontal fxs of posterior elements from t8 caudally through t10. This is a multicolumn fx complex and not stable. Suspicion of gallstones, u/s recommended. . EKG OSH: sinus tachycardia 109, NA, NI, No st/t changes. CXR [2149-6-21]: Comparison is made to the previous study from [6-13], [2149]. There is again seen a left retrocardiac opacity. There is atelectasis at the right lung base. There are no signs for pulmonary consolidation or pulmonary edema. The cardiac silhouette and mediastinum are within normal limits. Bilateral Lower Extremity Vein Ultrasound [2149-6-21]: [Doctor Last Name ]-scale and Doppler son[Name (NI) 867] of the bilateral common femoral, superficial femoral, popliteal, peroneal, and posterior tibial veins demonstrates normal flow, compressibility and augmentation, without evidence of deep venous thrombosis. IMPRESSION: No evidence of lower extremity deep venous thrombosis Brief Hospital Course: 50yo male who sustained multiple orthopedic injuries with small epidural hematoma in a motorcycle accident on [2149-6-8], recently discharged to rehab [2149-6-17], who was re-admitted with tachycardia and concern for PE and PNA, though with review of OSH imaging less concerning for PE and infection. . # Sinus tachycardia: Was initial concern for segmental PE in RUL based on OSH CT chest, and patient was started on anticoagulation with heparin gtt after case was discussed with Ortho Spine surgery. Patient was initially admitted to ICU in order to manage anticoagulation in the context of recent trauma and epidural hematoma. However, after reviewing images with Radiology at [Hospital1 18], was felt imaging did not show clear evidence of PE and heparin gtt was stopped. LENIs were negative for DVT. EKG and telemetry monitoring demonstrated sinus tachycardia, which may be secondary to increased pain in setting of multiple recent fractures, as well as anxiety. [Month (only) 116] also have been component of mild dehydration, as patient reported decreased PO intake at rehab, and tachycardia improved with IVF administration. Anemia may also be contributing to tachycardia. HR improved to 90s with administration of 1L IVF and improved pain control, and patient remained asymptomatic and hemodynamically stable. . # Atalectasis: Was report of desat at rehab facility, and initial concern for PNA based on chest imaging at OSH. CXR here showed left retrocardiac opacity, though of note patient had changes on CXR suggestive of possible consolidation on left during prior admission, and review of OSH CT scan with Radiology at [Hospital1 18] suggested PNA less likely. While patient had leukocytosis on admission, he remained afebrile and denied any chest pain, cough, or dyspnea. Review of labs from recent admission also showed that overall leukocytosis had trended down since initial injury, and leukocytosis resolved quickly this admission. Patient was initially started on antibiotics with vanc/levofloxacin, though given lower suspicion for PNA, antibiotics were discontinued. He was encouraged to use incentive spirometer, and will continue to use incentive spirometer at home on discharge. He did not require supplemental O2 this admission, and maintained sats in the mid-high 90s on room air. . # Leukocytosis: WBC elevated to 14.7 on admission, with 72% neutrophils but no bands. WBC trended down to within normal limits by HD #2. Patient remained afebrile, without respiratory symptoms, and was satting well on room air. No dysuria to suggest UTI. Blood cultures remained negative to date at time of discharge. . # s/p Motorcycle Accident: Patient with multiple orthopedic injuries including T10/11 compression fracture with small epidural hematoma, C7 non-displaced pedicle fracture, multiple spinous process and transverse process fractures, and left radial/ulnar open fractures. Suspected pain may be contributing to tachycardia, and pain regimen was increased to Oxycontin 30mg PO Q12H, with oxycodone 10mg Q4H prn pain. Ortho-Spine surgery followed along during this admission. Patient will continue to wear [Location (un) 2848]-J collar for 6 weeks from time of accident, and will also continue to wear TLSO brace when ambulating and when working w/PT. He was evaluated by PT and OT, and will receive PT and OT services at home upon discharge. Has follow-up scheduled in Hand Clinic, and with general and orthopedic surgery. Pain regimen will need to be adjusted as needed in outpatient follow-up. . # Anemia: Hct was monitored closely in setting of epidural hematoma and anticoagulation early in hospital course. Hct remained stable, similar to baseline from previous admission, and patient remained hemodynamically stable. . # Contact dermatitis: Blanching macular/papular rash, mainly on back. Ordered sarna lotion QID prn itching. . # Constipation: In setting of narcotic pain med administration. Continued bowel regimen with colace, senna, lactulose. LABS/STUDIES PENDING AT TIME OF DISCHARGE: Blood cultures [2149-6-20]: pending, no growth to date ISSUES REQUIRING FOLLOW-UP: -Patient will need follow-up with PCP [Name10 (NameIs) ] will have PT, OT, and VNA services at home -Patient will continue to wear TLSO brace when OOB, and [Location (un) 2848] J collar for 6 weeks from time of injury ([2149-6-8]) Medications on Admission: Albuterol/ipratropium inhaler q6hrs Docusate 100mg [Hospital1 ] Famotidine 20mg po q12hrs Heparin 5000u tid Levofloxacin 500mg daily Oxycontin 10mg [Hospital1 ] Miralax daily Senna [Hospital1 ] Tamsulosin .4mg qhs Tylenol prn Diazepam 5mg q6hrs prn Lactulose prn Bisacodyl prn Oxycodone 10mg q3hrs prn pain Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:1 3. Miralax 17 gram/dose Powder Sig: One (1) Packet PO once a day as needed for constipation. Disp:500 grams Refills:0 4. oxycodone 30 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours) for 10 days: please do not drive or operate heavy machinery while taking this medication. Disp:20 Tablet Extended Release 12 hr(s) Refills:0 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: please do not drive or operate heavy machinery while taking this medication. Disp:100 Tablet(s) Refills:0 6. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for muscle spasm or anxiety: please do not drive or operate heavy machinery while taking this medication. Disp:20 Tablet(s) Refills:0 7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. Disp:30 Capsule, Ext Release 24 hr(s) Refills:1 8. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Home With Service Facility: [Hospital3 ] home care Discharge Diagnosis: Primary: Tachycardia, atalectasis Secondary: Anemia, constipation, contact dermatitis, multiple fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], You are admitted to the hospital with a fast heart rate. There was concern that you may have a pneumonia, and also some concern that you may have a blood clot in the lungs. You were started on blood thinners and antibiotics. However, we reviewed your CT scan with the radiologists, who felt you did not have a blood clot, and that it is also unlikely you have a pneumonia. You did not have any fevers, chest pain, cough, or difficulty breathing while you were here. You also did not require any oxygen. Therefore, we stopped the blood thinners and antibiotics. You were seen by the physical therapists while you were here, who felt you were ready to be discharged home. You will continue to work with physical therapy at home. We made the following changes to your medications that you were on while at rehab: 1. STOPPED albuterol/ipratropium nebulizers 2. CONTINUED docusate sodium 100mg twice daily (stool softener) 3. STOPPED famotidine 4. STOPPED heparin injections 5. STOPPED levofloxacin 6. INCREASED oxycontin to 30mg every 12 hours 7. CONTINUED polyethylene glycol (to prevent constipation) 8. CONTINUED senna (stool softener) 9. CONTINUED tamsulosin 10. CONTINUED acetaminophen as needed for pain 11. STOPPED bisacodyl 12. CONTINUED diazepam as needed for muscle spasm or anxiety 13. STOPPED lactulose 14. CONTINUED oxycodone 5-10mg every 4 hours as needed for breakthrough pain Please discuss your pain medications with the surgeons at your follow-up appointments. They will assess your pain and help determine what medications you should be on. Please keep all follow-up appointments as scheduled. Please also call your PCP's office to schedule a follow-up appointment as soon as possible. You will need to wear your cervical collar for 6 weeks from the time of your injury. You sustained rib fractures during your recent accident: -Your injury caused left posterior [8-20] rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. -You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. [Name10 (NameIs) 89208] is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. -You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. -Symptomatic relief with ice packs or heating pads for short periods may ease the pain. -Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. -Do NOT smoke -If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. -Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs You also sustained a fracture to your arm, please follow these instructions: -report any decreased sensation/numbness in fingers -elevate arm on pillows when lying down -please report increased pain left arm You should wear your brace when you are out of bed Followup Instructions: Department: ORTHOPEDICS When: TUESDAY [2149-7-1] at 8:30 AM With: HAND CLINIC [Telephone/Fax (1) 3009] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: THURSDAY [2149-7-3] at 1:30 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 2359] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: ORTHOPEDICS When: WEDNESDAY [2149-7-16] at 9:40 AM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [Last Name (LF) ],[First Name3 (LF) ] P Location: [Location (un) 4499] INTERNAL MEDICINE Address: [Location (un) 89209], [Location (un) 4499],[Numeric Identifier 4501] Phone: [0-0-] Please schedule an appointment to see Dr. [Last Name (STitle) *] within 1 week post discharge.	[ "V10.83", "560.1", "564.00", "285.9", "810.03", "E812.2", "881.20", "785.0", "807.04", "427.31", "860.0", "813.18", "788.29", "276.51", "805.07", "955.2", "305.1", "861.21", "692.9", "276.69", "805.2" ]	icd9cm	[ [ [] ] ]	[ "86.59", "79.32", "82.43", "78.13", "78.63", "79.62", "83.62" ]	icd9pcs	[ [ [] ] ]	25999, 26056	19918, 24324	13967, 13973	26207, 26207	17716, 17716	29957, 31113	16199, 16240		24693, 25976		26077, 26186		24350, 24670			26358, 29934			18131, 19895							16255, 16931								16947, 17697																				13916, 13929										2135, 2543	14001, 15727							17732, 18115			1498, 2119		26222, 26334			15749, 16030	16046, 16183
19,213	170,803	52404	Discharge summary	report	Admission Date: [2202-8-11] Discharge Date: [2202-8-13] Date of Birth: [2168-10-6] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old female with type 1 diabetes with complications of gastroparesis who presented to the Emergency Department on [8-11] with 10/10 chest pain. In the Emergency Department, she had no electrocardiogram changes compared to previous electrocardiograms, and cardiac enzymes drawn were negative times two. She also complained of nausea and vomiting for which she received Zofran with some relief. Her initial fingersticks in the Emergency Department were 280. She was treated with subcutaneous Humalog insulin. Her initial anion gap was 19. Her fingerstick blood sugar decreased to 131. She was started on normal saline at 150 cc per hour. She was admitted to the floor with an anion gap of 15 and a fingerstick that had risen to 389 at 7 p.m. on [8-11]. Humalog 10 units subcutaneously were given on the floor, and she was started on D-5 half normal saline with 20 mEq of potassium at 150 cc per hour. She was also started on a regular insulin drip on the floor. Her urinalysis showed positive ketones and glucose, and she had moderate acetones in her serum. Her arterial blood gas on the floor revealed a pH of 7.38, PCO2 of 37, and a PO2 of 170 on 2 liters to 3 liters of nasal cannula oxygen. Over the next few hours, intravenous access was lost, so the insulin drip was off. Her fingerstick blood sugar increased to the 400s at 9:30 p.m. and the gap increased to 20. She was admitted to the Medical Intensive Care Unit for every one hour fingersticks. In addition to her diabetic ketoacidosis, and chest pain, and nausea, and vomiting, the patient also had a complaint of a persistent vaginal cyst which had previously been drained on a prior admission one week before. PAST MEDICAL HISTORY: 1. Type 1 diabetes for 20 years. 2. Gastroparesis. 3. Hypertension. 4. Asthma. 5. Chronic renal insufficiency (with a baseline creatinine of 1.5 to 2). 6. Status post [Doctor First Name ]-[Doctor Last Name ] tear. 7. Hyperlipidemia. 8. Diabetic neuropathy. 9. Severe left ventricular hypertrophy. MEDICATIONS ON ADMISSION: 1. Lantus insulin 9 units subcutaneously q.h.s. 2. Humalog sliding-scale. 3. Protonix 40 mg by mouth once per day. 4. Zestril 30 mg by mouth once per day. 5. Atenolol 50 mg by mouth once per day. 6. Multivitamin one tablet by mouth once per day. 7. Nitroglycerin as needed. ALLERGIES: 1. ASPIRIN (causes tongue swelling). 2. BARIUM DYE. 3. BEEF INSULIN. 4. COMPAZINE. 5. CODEINE. SOCIAL HISTORY: She has a 10-pack-year smoking history. She denies alcohol. She denies intravenous drug use. She lives with her fiance and has four daughters. FAMILY HISTORY: She has diabetes on the paternal side of her family as well as cancer; although, she is not sure exactly what type of cancer. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed she had a temperature of 98 degrees Fahrenheit, her blood pressure was 110/50, her heart rate was 88, her respiratory rate was 18, and her oxygen saturation was 99% on 3 liters nasal cannula. In general, the patient was a young African-American female who appeared mildly ill. She was anicteric. She had moist mucous membranes without any lesions. Cardiovascular examination revealed she was tachycardic with normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. Her lungs were clear to auscultation bilaterally. Her abdomen was soft, nontender, and nondistended. Positive bowel sounds. She had a firm 3-cm to 4-cm nodule located at about 11 o'clock on the right mons pubis. He extremities were without cyanosis, clubbing, or edema. She had a 3-cm X 1-cm ulceration on the dorsum of her right base with a clean base. No erythema. Her dorsalis pedis pulses were 1+ bilaterally. Neurologic examination revealed she was alert and oriented times three. Her neurologic examination a grossly nonfocal. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed her white blood cell count was 8.8, her hematocrit was 28.9, and her platelet count was 735. Her Chemistry-7 revealed her sodium was 138, potassium was 4.8, chloride was 98, bicarbonate was 21, blood urea nitrogen was 48, creatinine was 2.2, and blood glucose was 378. She had a urine culture drawn which eventually grew Klebsiella. PERTINENT RADIOLOGY/IMAGING: She had a chest x-ray which was normal; without any evidence of acute processes. Her electrocardiogram in the Emergency Department had a rate of 104, normal axis and normal intervals. Poor baseline but without any ST-T wave changes or T wave inversions. She had borderline left ventricular hypertrophy compared with a previous electrocardiogram on [2202-8-4]. On the series of electrocardiograms she had in the Emergency Department, she had no changes. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient is a 33-year-old woman who was admitted for chest pain, diabetic ketoacidosis, nausea, vomiting, and groin pain due to a cyst that she has there. 1. DIABETIC KETOACIDOSIS ISSUES: The patient was initially admitted to the floor; however, because of loosing her intravenous access, her drip was stopped. Her fingersticks and anion gap become uncontrolled, and she was admitted to the Medical Intensive Care Unit for every one hour fingersticks and an insulin drip administration. Over the course of the next 24 hours, her fingersticks decreased while on the insulin drip. The insulin drip was titrated down, and subcutaneous insulin was started. After her anion gap closed, the insulin drip was stopped. She was continued on subcutaneous Humalog insulin, and it was adjusted according to her fingersticks in house. At the time of discharge, her fingerstick blood sugars were in the high 100s. Her Humalog was adjusted to control her fingerstick blood sugars. We increased her Lantus to 20 units subcutaneously q.h.s. to cover for the amount of Humalog insulin she was requiring during the day. She will need to be seen by her primary care physician within the next week to review her insulin requirements and make appropriate changes. 2. URINARY TRACT INFECTION ISSUES: The patient was treated for her urinary tract infection with levofloxacin with an initial dose of 500 mg and subsequent doses of 250 mg, and she had completed her course while hospitalized. 3. CARDIOVASCULAR ISSUES: Ruled out for a myocardial infarction. The patient had chest pain on admission without significant electrocardiogram changes in the Emergency Department, and no changes in her cardiac enzymes. While in the Medical Intensive Care Unit, she also had one additional episode of chest pain that was relieved with two sublingual nitroglycerin tablets; also without electrocardiogram changes or elevated cardiac enzymes. The patient had a recent stress test in [2198] which did not show any ischemia; however, the patient only lasted six minutes on the treadmill. She had a recent echocardiogram in [Month (only) 547] of this year which showed left ventricular hypertrophy. We tried have the patient complete a Persantine stress test while in house; however, she refused the examination. 4. CHRONIC RENAL FAILURE ISSUES: Initially, her creatinine had bumped to 2.2, and 2.4, and 2.6. With hydration, her creatinine returned to baseline at 2. Initially, her ACE inhibitors were held; however, when her creatinine was at baseline she was restarted on captopril with increasing doses. At the time of discharge, she was changed back to her home medication of lisinopril. 4. PAIN ISSUES: Initially, when the patient was admitted, she had severe pain secondary to the cyst in her groin. She was given as needed morphine and Tylenol for the pain. 5. GROIN CYST ISSUES: The patient was seen by Gynecology for incision and drainage of the cyst. Wound cultures at the time of discharge were pending. She was noted to have vaginal candidiasis and received one dose of fluconazole 150 mg intravenously. The patient was to follow up with Gynecology in one week after the time of discharge. 6. GUAIAC-POSITIVE EMESIS ISSUES: While in the Emergency Department, the patient vomited and was guaiac-positive. She did not require a transfusion. We continued her Protonix while on the floor, and she had no further episodes of emesis. 7. ASTHMA ISSUES: The patient has no issues with asthma while on the floor. We continued her albuterol medication as needed. 8. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was initially nothing by mouth; however, as diabetic ketoacidosis resolved her diet was advanced to a full diet. 9. CODE STATUS: Her code status is full. CONDITION AT DISCHARGE: Condition on discharge was fair. DISCHARGE STATUS: Discharge status was to home with followup. DISCHARGE DIAGNOSES: 1. Diabetic ketoacidosis. 2. Abscess in the right groin. 3. Urinary tract infection. MEDICATIONS ON DISCHARGE: 1. Lantus insulin 20 units subcutaneously q.h.s. 2. Humalog sliding-scale. 3. Protonix 40 mg by mouth once per day. 4. Zestril 30 mg by mouth once per day. 5. Atenolol 50 mg by mouth once per day. 6. Multivitamin one tablet by mouth once per day. 7. Nitroglycerin as needed. 8. Nicotine patch. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up in one week with her primary care physician (Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]). 2. The patient was instructed to follow up in one week with Gynecology provider for follow up of her cyst. 3. It was recommended that the patient follow up with her nephrologist within the next two weeks as well. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] Dictated By:[Last Name (NamePattern1) 2706] MEDQUIST36 D: [2202-8-13] 11:25 T: [2202-8-13] 11:44 JOB#: [Job Number 108294]	[ "357.2", "623.8", "493.90", "250.61", "599.0", "593.9", "401.9", "250.11", "536.3" ]	icd9cm	[ [ [] ] ]	[ "71.22" ]	icd9pcs	[ [ [] ] ]							2821, 4973	8950, 9039				9065, 9368	2246, 2640					9401, 10053																					5007, 8816			8831, 8929																							166, 1883															1905, 2220	2657, 2804
77,220	194,404	35766	Discharge summary	report	Admission Date: [2190-3-31] Discharge Date: [2190-4-2] Date of Birth: [2133-6-4] Sex: M Service: SURGERY Allergies: Bactrim Attending:[First Name3 (LF) 148] Chief Complaint: Diarrhea Dehydration Major Surgical or Invasive Procedure: None History of Present Illness: 56 yo M with h/o necrotizing pancreatitis & pancreatic pseudocyst s/p ex-lap, open cholecystectomy, pancreatic pseudocyst jejeunostomy, modified roux-en-y and pancreatic necrosectomy by Dr. [Last Name (STitle) ] on [2189-7-30]. His post operative course has been c/b bilateral chylothorax requiring pleurodesis and chylous ascites requiring therapeutic paracentesis. Mr. [Known lastname 81329] now presents with multiple episodes of diarrhea since yesterday (>12 episodes). The diarrhea is clear and he feels he is losing a large amount of water. He presents in SVT to 170 and hypotensive to sBP 80s which he reports he has a history of and has had multiple similar presentations to the ED in the past. Patient reports he is extremely lightheaded, nausea, but denies vomiting, fever, chills, hematochezia and abdominal pain currently. He reports that he woke up this morning and was short of breath. The patient was discharged home on [2190-3-28] and reports that at that time he was having a few loose stools per day. He was not given any antibiotics on his last hospital visit. He denies sick contacts. The stools then increased in frequency and became more loose. He had a low fat diet of cereal and pasta yesterday. He currently supplements his nutrition with home TPN, which he does at night. Past Medical History: PMH: Necrotizing pancreatitis, DMII, dx [10-28], L5 herniated disc, B/L pleural effusions, SMV thrombosis, Hx melanoma, w subsequent follow-up with no recurrence, Hx SVT PSH: [2189-7-30]: Exploratory laparotomy, open cholecystectomy, pancreatic pseudocyst jejunostomy, roux-en-Y formation via an omega loopa, and pancreatic necrosectomy. [2189-10-29]: bilateral talc pleurodesis for chylothorax Social History: He works with a software business company. He lives at home with his children. He does not smoke, and drinks occasionally five to six glasses of alcohol a week (prior dx. of pancreatitis). He denies any history of IV drug abuse. Family History: No biliary or pancreatic disease Physical Exam: On Discharge: Vitals: 99.1, 83, 108/54, 20, 96% RAS GEN: A&O, NAD HEENT: No scleral icterus, dry mucus membranes CV: RRR, No M/G/R PULM: mildly decreased breath sounds at lung bases, mild crackles bilaterally ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No LE edema, LE warm and well perfused Pertinent Results: [2190-3-31] 11:30AM BLOOD WBC-12.2# RBC-4.61 Hgb-12.0 Hct-36.2* MCV-79* MCH-26.0* MCHC-33.1 RDW-16.7* Plt Ct-491# [2190-3-31] 11:30AM BLOOD Glucose-227 UreaN-24* Creat-0.7 Na-137 K-4.7 Cl-105 HCO3-19* AnGap-18 [2190-3-31] 11:30AM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.6* Mg-2.0 [2190-4-2] 02:11AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.0 [2190-3-31] 04:40PM BLOOD CK-MB-3 cTropnT-0.01 [2190-4-1] 12:02AM BLOOD CK-MB-3 cTropnT-0.03* [2190-4-1] 05:07PM BLOOD CK-MB-3 cTropnT-<0.01 [2190-3-31] 04:40PM BLOOD CK(CPK)-27* [2190-4-1] 12:02AM BLOOD CK(CPK)-31* [2190-4-1] 05:07PM BLOOD CK(CPK)-31* [2190-4-2] 02:11AM BLOOD WBC-6.2 RBC-3.96* Hgb-10.5* Hct-30.5* MCV-77* MCH-26.5* MCHC-34.5 RDW-16.7* Plt Ct-310 [2190-3-31] 3:40 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2190-4-2] MRSA SCREEN (Final [2190-4-2]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. [2190-4-1] 2:30 am BLOOD CULTURE FROM RT PICC # 2. Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS. [2190-3-31] EKG: Narrow complex supraventricular tachycardia at a rate of 182 with diffuse ST-T wave abnormalities. Compared to the previous tracing of [2189-12-16] the abnormalities and the tachycardia are new but they were present on the earlier tracing of [2189-12-16]. [2190-4-1] EKG: Sinus rhythm. Minor inferior T wave flattening. Compared to tracing #1 supraventricular tachycardia has resolved. [2190-3-31] CHEST PA: IMPRESSION: 1. Slightly retracted right PICC, now at cavoatrial junction. 2. Stable bilateral small effusions and bibasilar atelectasis. Brief Hospital Course: The patient well known for pancreaticobiliary service was admitted on [2190-3-31] with c/c of diarrhea, dehydration and palpitations. In ED, the patient was found to have SVT, which was converted to regular rhythm with adenosine. The patient was given IV fluid resuscitation and transferred into ICU for observation. On HD #2, repeat EKG revealed RRR, cardiac enzymes were negative, the patient was transferred on the floor. Diet was advanced to regular no fat, TPN was restarted. The patient was hemodynamically stable. One set of blood cultures drawn in the ED grew coag negative staph. Follow up blood/urine cultures were no growth to date. Given that only one set was positive this was likely a contaminated set. The patient was discharged home on HD # 3 in stable condition. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Ranitidine 150'', diltiazem 120 ER', metformin 1,000'', glimepiride 1', hydromorphone 2 ([11-22] Q6H PRN)Colace 100'', senna 8.6 '' Discharge Medications: 1. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 3. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 4. glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day. 5. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:40 Tablet(s) Refills:0 6. insulin regular human 100 unit/mL Solution Sig: 2-14 units Injection ASDIR (AS DIRECTED): Please follow the sliding scale. 7. vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO once a day for 2 weeks. 8. vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 9. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a day for 2 months. Discharge Disposition: Home With Service Facility: [Location (un) 511] Home Therapy Discharge Diagnosis: 1. Necrotizing pancreatitis 2. Pancreatic pseudocyst 3. Supraventricular tachycardia 4. Diarrhea and dehydration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [3-30] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Please call your doctor or nurse practitioner if you experience the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. PICC Line: Please monitor the site regularly, and [Name6 (MD) 138] your MD, nurse practitioner, or [Name6 (MD) 269] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * [Name6 (MD) ] your MD [First Name (Titles) ] [Last Name (Titles) 10836] to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry. Contact your [Name2 (NI) 269] Nurse if the dressing comes undone or is significantly soiled for further instructions. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2832], MD Phone:[Telephone/Fax (1) 1231] Date/Time:[2190-5-7] 10:30 [Hospital Ward Name 23] 3, [Hospital Ward Name ] . Provider: [Name Initial (NameIs) ] 2 (ST-4) GI ROOMS Date/Time:[2190-7-1] 11:00 Provider: [Name10 (NameIs) 1948] [Last Name (NamePattern4) 1949], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2190-7-1] 11:00 . Please follow up with [Name6 (MD) 251] [Last Name (NamePattern4) 677], MD (ELECTROPHYSIOLOGY) in [1-22] weeks to discuss treatment options for your SVT. Call [Telephone/Fax (1) 7332] to schedule an appointment. Completed by:[2190-4-2]	[ "V10.82", "787.91", "577.0", "785.1", "250.00", "V12.51", "276.51", "427.0", "577.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	6640, 6707	4476, 5602	285, 292	6864, 6864	2772, 3775	9265, 9965	2343, 2378		5789, 6617		6728, 6843		5628, 5766			7015, 9242										2393, 2393							3813, 4453										2407, 2753											225, 247											320, 1644												6879, 6991			1666, 2077	2093, 2327
43,561	111,010	42729	Discharge summary	report	Admission Date: [2160-7-10] Discharge Date: [2160-7-15] Date of Birth: [2079-4-20] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2160-7-10]: Aortic valve replacement with 19 mm tissue and Coronary Artery bypass graft x 1 (RSVG->RCA) History of Present Illness: 80 year old female with known aortic valve disease which has been followed by serial echocardiograms. Her most recent echocardiogram showed severe aortic stenosis, moderate aortic insufficiency and mild mitral regurgitation. She is quite symptomatic with severe dyspnea on exertion. She has also had an two admissions for heart failure in the past few months and for the past two months she has been at rehab. Given the severity of her disease, she has been referred for tissue AVR/CABG. Past Medical History: Coronary artery disease Aortic stenosis Diastolic heart failure Myocardial infarction Mitral regurgitation CVA [60] yrs ago Anxiety/Depression Hyperlipidemia Hypertension Gout History of blood clot in left leg/? iliac chronic neck/back pain osteoarthritis chronic sacral ulcer colitis tobacco abuse recently stopped anemia recent fall left thigh hematoma decubitus of coccyx Social History: Race:Caucasian Last Dental Exam: 1-2 weeks ago Lives with: Currently at rehab but was living with son in his home. Has in-law-apartment in son's home, [Location (un) ] VNA nurse 3 x per wk dressing changes Contact:[Name (NI) ] (son) Phone #[Telephone/Fax (1) 92341] Occupation:retired Cigarettes: Smoked no [] yes [x] quit few weeks ago Hx:30-50 PY Hx Other Tobacco use:denies ETOH: [x] [2-26] drinks/week Illicit drug use:denies Family History: Family History:Premature coronary artery disease- father with MI age 62 Physical Exam: Physical Exam: [2160-7-3] Pulse:72 Resp:18 O2 sat:95/RA B/P Right:119/74 Left:120/74 Height:5'3" Weight:130 lbs General: NAD, AAOx3 Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] SEM grade III/VI Abdomen: Soft [x] non-distended [x] non-tender [x] Extremities: Warm [x], well-perfused [x] Edema [] Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: palp Left: palp DP Right: palp Left: palp PT [Name (NI) 167]: palp Left: dop Radial Right: palp Left: palp Carotid Bruit Right: none Left: none Pertinent Results: Echocardiogram [2160-7-10] Conclusions PRE BYPASS The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricle displays normal free wall contractility. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area 0.6cm2). Mild to moderate ([1-21]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The posterior leaflet is calcified and immobilized. Mild to moderate ([1-21]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is AV paced. There is normal biventricular systolic function. There is a bioprosthesis in the aortic position. It appears well seated. The ;leaflets can not be definitively seen. There is trace valvualr and trace paravalvular aortic regurgitation seen. At a cardiac output of 4.5 liters/minute, the maximum gradient through the valve was 35 mmHg with a mean of 17 mmHg at an effective area of 1.4 cm2. The mitral regurgitation is improved and is now mild. The tricuspid regurgitation is also improved, now mild. The thoracic aorta is intact after decannulation. . [2160-7-15] 04:51AM BLOOD WBC-10.9 RBC-3.11* Hgb-9.2# Hct-28.3 MCV-91 MCH-29.6 MCHC-32.5 RDW-16.5* Plt Ct-172 [2160-7-14] 04:28AM BLOOD WBC-9.8 RBC-2.51* Hgb-7.3* Hct-23.3* MCV-93 MCH-29.0 MCHC-31.2 RDW-17.4* Plt Ct-127* [2160-7-15] 04:51AM BLOOD Glucose-85 UreaN-54* Creat-1.7* Na-141 K-3.9 Cl-97 HCO3-34* AnGap-14 [2160-7-14] 04:28AM BLOOD Glucose-80 UreaN-46* Creat-1.7* Na-138 K-3.7 Cl-100 HCO3-32 AnGap-10 Brief Hospital Course: The patient was brought to the operating room on [2160-7-10] where the patient underwent Aortic valve replacement ([First Name8 (NamePattern2) 17167] [Male First Name (un) 923]) and coronary artery bypass graft (SVG-distal RCA). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. She extubated POD1. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. Respiratory: Aggressive pulmonary toilet, nebs and ambulation her oxygenation improved. Inhalers were continued. Cardiac: hemodynamically stable in sinus rhythm. SBP 130-140's low-dose Lisinopril was started. Statin restarted. GI: history of constipation. Her previous laxatives were resumed. Renal; gently diuresed toward her preop weight- contiues to require diuresis. Baseline CRE 1.7-2.0. Electrolytes were repleted as needed. Endocrine: Insulin sliding scale to maintain BS < 150. Colchicine was restarted for her history of gout. Skin: She was followed by the wound care service for a longstanding stage 4 pressure ulcer following pilonidal cyst measuring 2 x1 cm with minimal depth. Some undermining. Peri wound tissue is macerated with copious serous drainage. They recommended pressure ulcer guidelines and dressing changes. Neuro: Antidepressant was restarted. Valium held secondary to lethargy. once mental status returned to baseline her Oxycodone for standing back pain was resumed and toelrated well. Nicotine patch applied. Disposition: She was followed by physical therapy. She was returned to [Hospital 392] Rehabilitation & Nursing Center [Telephone/Fax (1) 92342] on POD# 5. Medications on Admission: CITALOPRAM 10 mg Daily COLCHICINE 0.6 mg Daily DIAZEPAM 10 mg HS ADVAIR DISKUS 500 mcg-50 mcg/Dose Disk with Device - one puff inhaled [Hospital1 ] FUROSEMIDE 20 mg daily. HYDROCORTISONE ACETATE 25 mg Suppository - PRN METOPROLOL TARTRATE 12.5 mg [Hospital1 ] OXYCODONE 15 mg - 1-2 Tablets every six hours POLYETHYLENE GLYCOL 3350 17 gram/dose Powder - one capful Daily SIMVASTATIN 10 mg Daily ASPIRIN 81 mg Daily DULCOLAX as directed PRN DOCUSATE SODIUM 100 mg Daily MULTIVITAMIN Dosage 1 tablet daily SENOKOT 8.6 mg Daily Nicotine patch Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN fever, pain 2. Aspirin EC 81 mg PO DAILY 3. Bisacodyl 10 mg PR DAILY:PRN constipation 4. Citalopram 10 mg PO DAILY 5. Colchicine 0.6 mg PO EVERY OTHER DAY 6. Docusate Sodium 100 mg PO BID 7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [Hospital1 ] 8. Metoprolol Tartrate 50 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. 9. Milk of Magnesia 30 ml PO HS:PRN constipation 10. Nicotine Patch 7 mg TD DAILY 11. Polyethylene Glycol 17 g PO DAILY 12. Potassium Chloride 20 mEq PO Q12H Hold for K+ > 4.5 13. Ranitidine 150 mg PO DAILY 14. Simvastatin 10 mg PO DAILY 15. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX oxycodone 5 mg [1-22] Tablet(s) by mouth every four (4) hours Disp #90 Tablet Refills:0 16. Amlodipine 5 mg PO DAILY 17. Furosemide 40 mg PO BID 18. Senna 1 TAB PO BID 19. Multivitamins 1 TAB PO DAILY Discharge Disposition: Extended Care Facility: [Hospital1 ] Transitional Care and Rehab - [Hospital1 392] Discharge Diagnosis: Coronary artery disease Aortic stenosis Diastolic heart failure Myocardial infarction Mitral regurgitation CVA [60] yrs ago Anxiety/Depression Hyperlipidemia Hypertension Gout History of blood clot in left leg/? iliac chronic neck/back pain osteoarthritis chronic sacral ulcer colitis tobacco abuse recently stopped anemia recent fall left thigh hematoma decubitus of coccyx Discharge Condition: Alert and oriented x3 nonfocal Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema 1+, ecchymotic RLE from thigh to knee (ace wrap right thigh daily) Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours* Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] [8-6] at 2pm in the [Hospital ] medical office building, [Doctor First Name ], [Hospital Unit Name ] Please call to schedule the following: Primary Care Dr. [Last Name (STitle) ] [Telephone/Fax (1) 39662] in [4-24] weeks Cardiologist Dr. [Last Name (STitle) ] upon discharge from rehab Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2160-7-21]	[ "V12.51", "E935.2", "401.9", "V15.82", "428.32", "424.1", "707.24", "428.0", "496", "414.01", "424.0", "272.4", "707.8", "274.9", "V12.54", "715.90", "285.9", "707.03", "564.00", "300.4", "412", "338.29", "298.9", "924.00", "723.1", "724.5", "E888.9" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.11", "38.93", "35.21" ]	icd9pcs	[ [ [] ] ]	8470, 8563	5055, 6952	330, 441	8985, 9190	2647, 5032	10062, 10690	1858, 1917		7553, 8447		8584, 8964		6978, 7530			9214, 10039										1947, 2628																												271, 292											469, 959															981, 1362	1378, 1827
23,988	180,625	20240	Discharge summary	report	Admission Date: [2181-10-10] Discharge Date: [2181-10-11] Service: MICU [Location (un) ] HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old male with history of hypertension and cirrhosis who presents with elevated white blood cell count. The patient has been in usual state of health until two days prior to admission when he began experiencing fatigue, weakness and pain in his legs along with some shortness of breath. The patient presented to an outside Emergency Room and was found to have an elevated white count to 374,000, 96% blasts. Platelet count was 18,000. He was transferred to the [Hospital1 346] for further care. At [Hospital1 346] he was found to have a white count of 337, platelets of 22. In the Emergency Room he had a right IJ pheresis catheter placed. He had leukopheresis which went well until just prior to the end of the procedure when he had a temperature to 104. The pheresis was held and he received Vancomycin and Cefepime. Blood cultures were drawn. Just prior to pheresis, the patient had also received one unit of packed RBCs. He also received platelets and two units of FFP. The patient was originally put on a non rebreather and then bi-PAP for worsening respiratory status, however, he improved and was able to tolerate face mask. PAST MEDICAL HISTORY: Hypertension, cirrhosis, alcohol use. MEDICATIONS: Propranolol, Hydrochlorothiazide and Felodipine. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives alone, is a retired night club owner. Habits: No etoh, quit 20 years ago, no drugs, no tobacco, quit 60 years ago. The [Hospital 228] health care proxy was his friend, [Name (NI) ] [Name (NI) 54354]. PHYSICAL EXAMINATION: This is a tired appearing elderly male in no acute distress. Cardiovascular exam revealed tachycardia, normal S1 and S2. Pulmonary exam clear to auscultation bilaterally. Abdomen soft, nontender, non distended with good bowel sounds. Extremities showed diffuse ecchymosis, also ecchymosis over his lumbar spine and lower extremities bilaterally. Dorsalis pedis were 2+ bilaterally. The patient was alert and oriented times two, cranial nerves II through XII intact. Sensation intact grossly. He did have 3/5 strength in his left upper and left lower extremities which the patient reported as old. LABORATORY DATA: On admission revealed a white count of 337, this was decreased to 227 after leukopheresis. In addition to this, the patient had an INR of 2, d-dimer 7,540, fibrin 91. Chest x-ray showed no congestive heart failure or focal consolidation. HOSPITAL COURSE: The patient received leukopheresis in the Emergency Room and then was transferred to the MICU for further care where he again received leukopheresis. He did experience an episode of hypotension during the leukopheresis, however, otherwise tolerated the procedure well. The patient was monitored for signs of tumorlysis syndrome as he was receiving Hydrea for his blast crisis. The patient did not experience further issues with shortness of breath. The patient's hematologic status was monitored closely and he received platelets as well as FFP. On the morning of [10-11], the patient had an acute change in mental status. Blood gases were within normal limits. EKG was within normal limits. Chest x-ray was largely unremarkable. A head CT was performed which showed a large right frontal stroke as well as multiple other areas of smaller hemorrhage. The patient's designee of next of [Doctor First Name ] was notified that he visit the patient and on the same day the patient passed away. Approximately 9 hours after the acute change in mental status, the patient was pronounced, likely secondary to the acute bleed which resulted in his respiratory and cardiac arrest. [First Name8 (NamePattern2) ] [Doctor Last Name ], M. D. [MD Number(1) 7585] Dictated By:[Doctor Last Name 32868] MEDQUIST36 D: [2181-10-11] 17:05 T: [2181-10-12] 20:42 JOB#: [Job Number 54355]	[ "286.6", "401.9", "205.00", "571.2", "571.5", "431", "V11.3", "E947.8", "584.8" ]	icd9cm	[ [ [] ] ]	[ "99.72", "38.93", "93.90" ]	icd9pcs	[ [ [] ] ]														2638, 4088																											1756, 2620																								140, 1318															1341, 1482	1499, 1733
18,434	171,452	4421+4451+55580	Discharge summary	report+report+addendum	Admission Date: [2174-3-16] Discharge Date: [2174-3-26] Service: MEDICINE HISTORY OF PRESENT ILLNESS: [First Name8 (NamePattern2) ] [Known lastname 19013] is an 80 year old female with a history of diabetes mellitus, hypertension, hypercholesterolemia, chronic obstructive pulmonary disease, cerebrovascular accident, hypothyroidism, and metastatic breast cancer who presented to [Hospital3 417] Hospital on [3-11], with complaint of transient ischemic attack type symptoms, slurred speech, facial droop, lower extremity tingling and numbness times one to two weeks. She was admitted for work-up of her neurological symptoms. During her hospitalization there, she was noted to be in rhabdomyolysis with a CK in the six thousands. Her initial examination there was only significant for right calf tenderness. Bilateral lower extremity Dopplers were obtained but were poor studies. She was transferred to [Hospital1 346] per her request for further management. On admission here, she was found to have bilateral compartment syndrome and subsequently underwent bilateral fasciotomy on [3-17]. The etiology of her rhabdomyolysis was presumed secondary to either her Mevacor or her hypothyroidism, which was under-treated secondary to non-compliance with her thyroid replacement. Her postoperative course was complicated by intubation for respiratory distress from fluid overload. She subsequently had an episode of upper gastrointestinal bleeding in the setting of a super-therapeutic PTT while on heparin for presumed deep vein thrombosis. This resulted in hypotension requiring temporary pressors as well as acute renal failure secondary to ATN. She was started on hemodialysis on [3-23]. She was called out to the Floor on [3-24]. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes mellitus type 2. 3. Hypercholesterolemia. 4. Transient ischemic attack versus cerebrovascular accident. 5. Chronic obstructive pulmonary disease. 6. Hypothyroidism status post thyroidectomy for goiter in remote past. 7. Status post appendectomy. 8. Chronic renal insufficiency. 9. Breast cancer diagnosed in [2171-4-16], metastatic to bone, including rib, spine and pelvis. Biopsy in [2171-4-16], revealed poorly differentiated carcinoma ER and PR positive, HER-2 negative. Status post Tamoxifen, XRT and chemotherapy in the past; last treatment in [2172-9-16]. The patient also underwent left lumpectomy in [2171-6-16]. MEDICATIONS AT HOME: 1. Accupril 40 mg p.o. once a day. 2. Lasix 40 mg p.o. once a day. 3. Imdur 60 mg p.o. once a day. 4. Tiazac 250 mg p.o. once a day. 5. Mevacor 40 mg p.o. once a day. 6. MS-Contin. 7. Amitriptyline 25 mg p.o. once a day. 8. NPH 52 units q. a.m. and 22 units q. p.m. ALLERGIES: Sulfa causes a rash. SOCIAL HISTORY: Lives with son and daughter-in-law, but was planning to move out in order to live on her own. No smoking, occasional alcohol. She has five children. MEDICATIONS: At time of transfer to the Floor: 1. Regular insulin sliding scale. 2. Colace. 3. Epogen 40,000 Units subcutaneously q. week. 4. Protonix 40 mg intravenous q. 12. 5. Diltiazem 60 mg p.o. four times a day. 6. Levothyroxine 0.15 mg p.o. once a day. 7. Atrovent and Albuterol. 8. Heparin 5,000 units subcutaneously twice a day. 9. Isordil 20 mg p.o. three times a day. 10. Lopressor 50 mg p.o. twice a day. 11. Cefazolin 2 grams intravenously post-dialysis. 12. Morphine p.r.n. 13. Ativan p.r.n. 14. Senna p.r.n. PHYSICAL EXAMINATION: Upon transfer to the Floor, vital signs with temperature of 97.4 F.; heart rate 70; blood pressure 160/70; respirations 18; 100% on two liters nasal cannula. In general, in no apparent distress, no respiratory distress. An obese elderly female. HEENT: Pupils slightly asymmetric but reactive. Sclerae anicteric. Oropharynx clear. Moist mucous membranes. Neck: Right internal jugular Quinton in place; difficult to assess JVP. No lymphadenopathy. Lungs: Bilateral crackles two-thirds of the way up, diffusely decreased breath sounds. Cardiac: Distant heart sounds due to body habitus. No murmurs, rubs or gallops appreciated. Abdomen: Difficult examination secondary to obesity. Soft, nontender, no organomegaly or masses appreciated. Normal active bowel sounds. Extremities: Bilateral lower extremities with medial and lateral fasciotomies, tense edema, erythema and warmth. Unable to detect pulses by palpation. LABORATORY: White blood cell count 13.7, hematocrit 32, platelets 246. INR 1.1; PTT 32.6. Sodium 135, potassium 4.4, chloride 97, bicarbonate 25, BUN 48, creatinine 6.4, glucose 143. Calcium 7.5, phosphorus 7.0, magnesium 2.1. CK was 3400. SUMMARY OF HOSPITAL COURSE: An 80 year old female who presented with rhabdomyolysis to an outside hospital and transferred here with bilateral compartment syndrome, status post bilateral fasciotomies. Hospital course was complicated by fluid overload, upper gastrointestinal bleed and acute renal failure. 1. Musculoskeletal: The patient's rhabdomyolysis was blamed on either her medication Mevacor, or on her hypothyroidism which was under-treated due to non-compliance with medication. She presented in bilateral compartment syndrome. The presence of deep vein thrombosis was unable to be ruled out given lower extremity Dopplers which were difficult to interpret due to her body habitus and edema. Her CK peaked in the 20,000 but then trended down. She underwent fasciotomies on [3-17], with medial and lateral fasciotomies bilaterally. At the time of dictation, her medial fasciotomies appeared to be healing well; however, her lateral fasciotomies may need future debridement. 2. Pulmonary: The patient's postoperative course was complicated by fluid overload and respiratory distress, necessitating intubation. She was extubated without difficulty and transferred to the Floor on nasal cannula. At the time of dictation, she is stable on two liters of O2. 3. Gastrointestinal: The patient had an episode of upper gastrointestinal bleeding in the setting of super-therapeutic PTT while on heparin. She was started on heparin because deep vein thromboses could not be ruled out and were on the differential for etiologies for her compartment syndrome. She does not have known gastrointestinal pathology. Her gastrointestinal bleed resulted in hypotension requiring pressors temporarily. She was not scoped during this hospitalization, but will likely need gastrointestinal outpatient work-up for this. 4. Renal: The patient developed acute renal failure secondary to ATN blamed on her hypotensive episodes status post her upper gastrointestinal bleed. She began hemodialysis on [3-23]. At the time of dictation, she has undergone three hemodialysis sessions with removal of four kilograms of fluid each time. She will continue to undergo hemodialysis and the Renal Consultation Team feels that she will likely recover her renal function. She has chronic renal insufficiency at baseline. 5. Cardiovascular: The patient with history of hypertension. After her episode of hypotension requiring pressors had resolved, she was restarted on her anti-hypertensive regimen, which included Lopressor, Isordil and Diltiazem. 6. Infectious Disease: Per Surgery recommendations, the patient was started on Cefazolin intravenously after her surgery. 7. Endocrine: Known diabetic; continued on Regular insulin sliding scale. She will likely need her NPH regimen to be added back as her p.o. increases. She was restarted on her Synthroid, which she had stopped taking at home. 8. Access: Right internal jugular Quinton for hemodialysis access. 9. Code Status: The patient is currently Full Code. DISPOSITION: Anticipate discharge to rehabilitation when surgical issues are stable. CONDITION AT DISCHARGE: Discharged to rehabilitation in stable condition. DISCHARGE DIAGNOSES: 1. Rhabdomyolysis. 2. Bilateral compartment syndrome, status post bilateral fasciotomies. 3. Upper gastrointestinal bleed in the setting of super-therapeutic PTT on heparin. 4. Acute renal failure secondary to ATN secondary to hypotension secondary to gastrointestinal bleed. 5. Status post intubation for fluid overload postoperatively. 6. Hypothyroidism. DISCHARGE MEDICATIONS: 1. Regular insulin sliding scale. 2. Epogen 40,000 units subcutaneously once a week. 3. Protonix 40 mg p.o. twice a day. 4. Diltiazem 60 mg p.o. four times a day. 5. Levothyroxine 150 micrograms p.o. once a day. 6. Albuterol inhaler p.r.n. 7. Atrovent inhaler p.r.n. 8. Senna, one tablet p.o. twice a day p.r.n. 9. Ativan 2 to 4 mg p.o. or intravenously q. two hours p.r.n. 10. Morphine 2 mg intravenously q. two hours p.r.n. 11. Isordil 20 mg p.o. three times a day. 12. Heparin 5000 units subcutaneously twice a day. 13. Dulcolax p.r.n. 14. Metoprolol 50 mg p.o. twice a day. 15. Cefazolin 2 grams intravenously post-dialysis. 16. Colace 100 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. Wound care: Bilateral fasciotomy wounds: Medial fasciotomy wounds should have normal saline wet-to-dry dressing twice a day. Lateral fasciotomy wounds should have Adaptic with dry sterile dressing twice a day. Lower extremities should then be wrapped with Kerlix and ACE bandage. 2. Physical Therapy when patient is off bed rest. 3. Doppler pulses bilaterally once a day. [Name6 (MD) 7853] [Last Name (NamePattern4) 7854], M.D. [MD Number(1) 7855] Dictated By:[Name8 (MD) 4925] MEDQUIST36 D: [2174-3-25] 20:29 T: [2174-3-25] 20:51 JOB#: [Job Number 19014] Admission Date: [2174-3-16] Discharge Date: [2174-4-19] Service: ADDENDUM TO PREVIOUSLY DICTATED DISCHARGE SUMMARY: Ms. [Known lastname 19013] felt dizzy while sitting up the day before discharge. Her hematocrit on the day before discharge. Her hematocrit was checked, which was found to be 27.6. For this hematocrit and symptoms she was transfused one unit of packed red blood cells. Her hematocrit rose approximately to 29.2 and her symptoms resolved. Also on this day her staples were removed from her arm. Ms. [Known lastname 19013] has remained stable and is ready to go to rehab as previously planned. All previously dictated medications and instructions remain unchanged. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], M.D. [MD Number(1) 6223] Dictated By:[Last Name (NamePattern1) 6355] MEDQUIST36 D: [2174-4-19] 12:14 T: [2174-4-19] 12:25 JOB#: [Job Number 19094] Name: [Known lastname 3117], [Known firstname 2803] Unit No: [Numeric Identifier 3118] Admission Date: [2174-3-17] Discharge Date: [2174-4-26] Date of Birth: [2093-9-18] Sex: F Service: VASCULAR ADDENDUM TO PREVIOUSLY DICTATED DISCHARGE SUMMARY: CONTINUATION OF HOSPITAL COURSE BY ORGAN SYSTEM: #1. MUSCULOSKELETAL: The patient's bilateral fasciotomy sites required debridement. On [2174-3-31], the Plastic Surgery Service, which had been consulted previously, brought Mrs. [Known lastname ] to the operating room, whereupon they performed debridement of the lower extremity fasciotomy sites bilaterally. The wounds were continuing to be observed and tissue cultures were sent. Prior to this point, she had been on Ancef for antibiotic coverage. However, the coverage was changed when she was found to have grown Methicillin-resistant Staphylococcus aureus. Please see the Infectious Disease Section of this discharge summary for more details. Mrs. [Known lastname ] wound's on the right lower extremity continued to look less and less promising. Over the next week or so, they looked increasingly dusky. The prospect of salvaging the limbs seemed dim. On [2174-4-12], Mrs. [Known lastname ] was brought to the operating room by the Vascular Surgery Team, whereupon, she had right above-knee amputation. Mrs.[Last Name (un) 3119] left lower extremity wounds continued to be dressed with normal saline wet-to-dry pack. The wounds continued to be observed and by [2174-4-20], the Plastic Surgery Service evaluated the wound again and brought the patient back to the operating room for further debridement and this time placement of VAC dressing to the wound. This dressing remained in place for three days and then it was changed on the third day. On the third day, when the VAC was removed, wound appeared viable; continue treatment with this type of dressing. Mrs. [Known lastname ] will be discharged to rehabilitation with VAC dressing. #2. PULMONARY: Mrs. [Known lastname ] was weaned from her nasal cannula and eventually able to saturate in the high 90s on room air. Pulmonary status remained stable throughout the remainder of the hospitalization. #3. GASTROINTESTINAL: Mrs. [Known lastname ] remained on Protonix for the duration of the hospitalization and was eventually able to tolerate full regular diet. She had no further gastrointestinal complaints during this hospitalization. #4. RENAL: Mrs. [Known lastname ] remained on hemodialysis, but eventually the kidney function began to return. She was weaned off hemodialysis on the first of [Month (only) ] and on discharge the most recent creatinine was 1.6. The renal function is stable. #5. CARDIOVASCULAR: Mrs. [Known lastname ] remained stable and had a regimen, which included Amlodipine 5 mg p.o.q.d.; Lopressor 12.5 mg p.o.q.d.; and ....................12.5 mg p.o.q.d. #6. INFECTIOUS DISEASE: Mrs.[Known lastname 3120] cultures from the operating room on [3-31] revealed Methicillin-resistant Staphylococcus aureus. Tissue samples from both the left and the right lower extremities grew out this organism. Because of this, she was started on Vancomycin, Ciprofloxacin, and Flagyl. All these drugs were renally dosed. Vancomycin was delivered with hemodialysis initially and dosed at a therapeutic level. These antibiotics were discontinued after a two-week course. For several days after the discontinuation of the antibiotics, Mrs. [Known lastname ] remained without clinical evidence of infection. However, her right above-knee amputation stump became erythematous. She was treated with two days of Ancef with no resolution of the erythema. She was then promptly switched to Vancomycin. While on Vancomycin, the erythema resolved quite rapidly to the point where it was almost negligible on discharge. Of note: OR cultures from the final debridement on [4-20], grew out Vancomycin-resistant enterococcus. This was not treated as it was felt that the wound culture was without clinical evidence of infection. She remained stable without coverage for the VRE. #7. ENDOCRINE Mrs. [Known lastname ] blood sugar and thyroid function was monitored closely by the [Hospital 616] Clinic. On discharge, she was stable at 200 mcg of Levothyroxine q.d. She was stable on the morning and evening NPH with Humalog sliding scale. #8. RHEUMATOLOGY: During this hospitalization, MRV was obtained, which ruled out lower extremity DVT. Mrs. [Known lastname ] will be discharged to rehabilitation CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: Discharge diagnoses are as previously dictated. DISCHARGE MEDICATIONS: 1. Amlodipine 5 mg p.o.q.d. 2. Calcium carbonate 500 mg p.o.t.i.d. with meals. 3. Colace 100 mg p.o.b.i.d. 4. Ipratropium MDI two puffs q.i.d.p.r.n. 5. Albuterol MDI one puffs q.6h.p.r.n. 6. Levothyroxine 200 mcg p.o.q.d. 7. Lopressor 12.5 mg p.o.q.d. 8. Protonix 40 mg p.o.q.d. 9. Dulcolax suppositories one suppository per rectum p.r.n.q.d. 10. Percocet one to two tablets p.o.q.4h. to 6h.p.r.n. 11. Vancomycin one gram IV q. 24h. 12. NPH 58 units q.AM 4 units q.PM.; Humalog sliding scale. Please see page #1 for the sliding scale. DISCHARGE INSTRUCTIONS: 1. Wound care: VAC dressing to the left lower extremity. Please change VAC dressing every third day. The VAC dressing was last changed on [2174-4-26]. 2. Left lower extremity should be in a MultiPodus boot, resting splints to prevent flexure contraction while in bed. 3. Nonweightbearing status: The patient may bear weight on the left lower extremity as tolerated. Please see the Department of Physical Therapy's recommendations for more specific goals. FOLLOW-UP CARE: The patient will followup with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. The patient should call Dr.[Name (NI) 3121] clinic to arrange for an appointment. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 273] Dictated By:[Last Name (NamePattern1) 2383] MEDQUIST36 D: [2174-4-26] 11:20 T: [2174-4-26] 12:28 JOB#: [Job Number ]	[ "276.6", "244.9", "401.9", "785.4", "729.9", "496", "250.00", "584.5", "728.89" ]	icd9cm	[ [ [] ] ]	[ "83.14", "96.04", "96.71", "83.21", "86.22", "84.17", "83.45", "38.95" ]	icd9pcs	[ [ [] ] ]								15389, 15438	15461, 16006							16030, 16034						2516, 2826															4761, 7872				3552, 4731	7888, 7939																				16047, 17005			123, 1795															1817, 2495	2843, 3529	15358, 15367
27,735	103,799	31945	Discharge summary	report	Admission Date: [2170-12-10] Discharge Date: [2170-12-14] Date of Birth: [2099-10-21] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: AVR (25mm mosaic porcine) [12-10] History of Present Illness: 71 yo F who was noted to have a mheart murmur on physical exam. An echo on [2170-9-27] showed AS. Past Medical History: AS, Hysterectomy, Appendectomy [2151], RT tib/fib fx from MVC, Anxiety Social History: retired lives with husband rare etoh 1 ppd tob x 50 years Family History: mother deceased from MI in 60s Physical Exam: WDWN elderly F in NAD HR70 RR 16 Pertinent Results: [2170-12-14] 07:17AM BLOOD WBC-8.0 RBC-2.98* Hgb-9.7* Hct-28.1* MCV-94 MCH-32.5* MCHC-34.4 RDW-13.9 Plt Ct-175 [2170-12-14] 07:17AM BLOOD Plt Ct-175 [2170-12-13] 08:10AM BLOOD Glucose-96 UreaN-10 Creat-0.5 Na-138 K-3.7 Cl-100 HCO3-29 AnGap-13 Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 60% >= 55% Aorta - Annulus: 2.5 cm <= 3.0 cm Aorta - Sinus Level: 3.6 cm <= 3.6 cm Aorta - Ascending: 3.7 cm <= 3.4 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: 70 mm Hg < 20 mm Hg Aortic Valve - LVOT diam: 2.2 cm Aortic Valve - Valve Area: 0.8 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Focal calcifications in aortic root. Mildly dilated ascending aorta. Focal calcifications in ascending aorta. Simple atheroma in aortic arch. Focal calcifications in aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: ?# aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Calcified tips of papillary muscles. Mild (1+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. 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. Suboptimal image quality. Frequent ventricular premature beats. Results were Conclusions PRE-BYPASS: 1. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 4. Right ventricular chamber size and free wall motion are normal. 5. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. There are focal calcifications in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 6. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area = 0.8cm2). Trace aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POST-BYPASS: Patient removed from cardiopulmonary bypass on phenylephrine infusion and atrially paced. 1. There is a bioprosthesis in the aortic position. The valve is well seated. The leaflets are only poorly seen but do appear to be working. There appaers to be a trace perivalvular leak seen in the deep transgastric views. No valvular aortic regurgitation is seen. The peak gradient across the valve is 17.8mmHg. 2. Biventricular function is maintained; LVEF>55%. 3. The degree of mitral regurgitation has decreased to trace. 4. Aortic contours are intact post-decannulation. Brief Hospital Course: Admitted on [2170-12-10], taken to the OR and underwent AVR (25mm mosaic porcine). Post-operatively, she was taken to the CVICU in stable condition. She was weaned from mechanical ventilation and extubated. She was started on Lasix & beta blocker, chest tubes were removed, and was transferred to the telemetry floor on POD # 1. Early am on POD # 3, she had rapid AFib, and was treated with increased lopressor, and amiodarone. She subsequently went in to junctional rhythm, with stable hemodynamics, and her lopressor & amiodarone were decreased. Her rhythm has returned to NSR today, and she is ready for discharge home. Medications on Admission: Lorazepam 0.5" Toprol XL 12.5' 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 DAILY (Daily). 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: One (1) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s)* Refills:2 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: AS now s/p AVR Hysterectomy, Appendectomy [2151], RT tib/fib fx from MVC, Anxiety Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incision. No lifting more than 2 pounds or driving until follow up with surgeon. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (STitle) ] 2 weeks Dr. [Last Name (STitle) 7047] 2 weeks Dr. [Last Name (Prefixes) ] 4 weeks Completed by:[2170-12-14]	[ "V45.77", "305.1", "424.1", "300.00", "V17.3" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.22" ]	icd9pcs	[ [ [] ] ]	6412, 6467	4688, 5320	337, 377	6598, 6606	797, 4665		697, 729		5401, 6389		6488, 6577		5346, 5378			6630, 6880				6931, 7083						744, 778																												285, 299											405, 508															530, 606	622, 681
78,365	102,141	16055	Discharge summary	report	Admission Date: [2137-2-5] Discharge Date: [2137-2-21] Date of Birth: [2071-9-17] Sex: F Service: CARDIOTHORACIC Allergies: Amiodarone Attending:[First Name3 (LF) 922] Chief Complaint: DOE/worsening fatigue Major Surgical or Invasive Procedure: [2137-2-7] Aortic Valve Replacement (23 mm CE pericardial)/ Mitral Valve Replacment ([Street Address(2) 44058]. [Male First Name (un) 923] porcine)/ Tricuspid Valve repair (28 mm [Doctor Last Name ] MC3 annuloplasty ring)/ Maze with left atrial appendage ligation History of Present Illness: 65 yo female with RHD and recurrent AFib. Episode of CHF in [1-4]. Known AI, MS, MR [First Name (Titles) ] [Last Name (Titles) ] by echo and cath. Referred for surgery. Past Medical History: rheumatic heart disease Atrial fibrillation (s/p ablation/PVI [2134] and mult. DCCVs) chronic diastolic heart failure depression hypothyroidism GI bleed secondary to ASA in past history of amiodarone toxicity ( hypothyroid/neuropathy) hiatal hernia TIA [2135] DVT left foot [2127] varicose veins Social History: lives alone retired social ETOH only remote tobacco Family History: non contributory Physical Exam: (from thoracic surgery and cardiac pre-op) 68" 79.3 kg 97% RA sat RR 22 HR 70-100 afib 130-180/70 bowel sounds present in chest HEENT unremarkable 1+ edema left leg 2/6 systolic murmur at RUSB, 1/6 systolic murmur at left mid-ax. line, [Last Name (un) ] neuro unremarkable no lymphadenopathy skin unremarkable 2+ bil. fems/radials 1+ bil. DP/PTs no carotid bruits appreciated Pertinent Results: [2137-2-21] 05:52AM BLOOD WBC-12.8* RBC-2.84* Hgb-8.8* Hct-26.3* MCV-93 MCH-31.0 MCHC-33.4 RDW-15.3 Plt Ct-426 [2137-2-21] 05:52AM BLOOD Glucose-92 UreaN-22* Creat-1.4* Na-135 K-4.5 Cl-103 HCO3-23 AnGap-14 [2137-2-21] 05:52AM BLOOD Mg-1.6 [2-7] Echo: PRE-CPB:1. The left atrium is markedly dilated. Moderate to severe 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. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the ascending aorta. 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. Moderate (2+) aortic regurgitation is seen. The aortic annulus is 22 cm. 6. The mitral valve leaflets are severely thickened/deformed. The mitral valve shows characteristic rheumatic deformity. There is moderate valvular mitral stenosis (area 1.0-1.5cm2). Mild (1+) mitral regurgitation is seen. 7. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The tricuspid annulus is 3.2 cm. Dr. [Last Name (STitle) 914] was notified in person of the results. POST-CPB: On infusion of milrinone, phenylephrine. Apacing for slow sinus rhythm. Preserved biventricular systolic function. LVEF now 50 % on inotropic support. 1. Well-seated bioprosthetic valve in the mitral position. No MR, no paravalvular leak. Transmitral gradient is 11 mmHg with a mean of 6 at the time the cardiac output is 7.6 L/min. 2. Well-seated bioprosthetic valve in the aortic position with no AI, no paravalvular leak. Good flow is seen in the left main coronary artery. Unable to obtain transgastric views due to a hiatal hernia, so unable to calculate gradients across the aortic valve. 3. Well-seated ring in the tricuspid position with trace TR. 4. Descending aortic contour appears normal post decannulation. [2-6] CT: 1. Enlarged left atrium. 2. Large hiatal hernia involving almost all the stomach and part of the colonic splenic flexure, with the left inferior pulmonary vein sitting just above it. 3. Grade I anterolisthesis of L4 on L5 and scoliosis. 4. 1-mm left upper lobe nodule, does not warrant further followup if the patient has no risk factor for malignancy. 5. Bibasilar ground-glass opacity, could be atelectasis or chronic aspiration given the history of large hiatus hernia. [2137-2-15] 05:47AM BLOOD WBC-10.5 RBC-3.05* Hgb-9.5* Hct-28.4* MCV-93 MCH-31.1 MCHC-33.4 RDW-15.2 Plt Ct-331 [2137-2-5] 10:20PM BLOOD WBC-6.2 RBC-3.64* Hgb-12.0 Hct-33.7* MCV-93 MCH-33.0* MCHC-35.7* RDW-14.9 Plt Ct-215 [2137-2-15] 05:47AM BLOOD PT-14.7* INR(PT)-1.3* [2137-2-5] 10:20PM BLOOD PT-16.7* PTT-133.9* INR(PT)-1.5* [2137-2-15] 05:47AM BLOOD Glucose-93 UreaN-22* Creat-1.0 Na-143 K-3.0* Cl-99 HCO3-35* AnGap-12 [2137-2-5] 10:20PM BLOOD Glucose-106* UreaN-22* Creat-0.8 Na-142 K-4.1 Cl-108 HCO3-25 AnGap-13 [Known lastname ],[Known firstname ] F. [Medical Record Number 45942] F 65 [2071-9-17] Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [2137-2-14] 12:57 PM [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] CSRU [2137-2-14] 12:57 PM CHEST PORT. LINE PLACEMENT Clip # [Clip Number (Radiology) 45943] Reason: please check PICC tip 43 cm left basilic please page with w [Hospital 93] MEDICAL CONDITION: 65 year old woman with REASON FOR THIS EXAMINATION: please check PICC tip 43 cm left basilic please page with wet read thanks [Doctor First Name ] [8-/2571] Final Report INDICATION: PICC placement. FINDINGS: A new left-sided PICC terminates in the SVC. As compared to [2137-2-12], there has been marked improvement of now only mild pulmonary edema. Large left lower lobe atelectasis and small pleural effusion are unchanged. The patient is status post aortic valve, mitral valve, and tricuspid valvular repair. IMPRESSION: PICC in SVC. The study and the report were reviewed by the staff radiologist. DR. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 16277] DR. [First Name (STitle) ] [Initials (NamePattern5) 3250] [Last Name (NamePattern5) 3251] Approved: [Doctor First Name ] [2137-2-14] 4:19 PM Imaging Lab Brief Hospital Course: Admitted [2-5] for IV heparin for Afib and to complete pre-op workup. CT chest/abd done with thoracic surgery consult to evaluate large hiatal hernia. On [2-7] she underwent Aortic valve replacement (#23 mm [Doctor Last Name ] pericardial )/Mitral Valve Replacement (#29mm St.[Male First Name (un) 923] tissue valve)/Tricuspid Valve repair (#28,,[Doctor Last Name ] MC3 annuloplasty)/MAZE. Cross clamp time: 137 minutes,Cardiopulmonary bypass time: 179 minutes.Please see Dr[Last Name (STitle) 5305] operative report for further surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable but critical condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and was extubated. She was initially requiring inotropic/pressor support to optimise her cardiac output. She remained hemodynamically stable and was successfully weaned off Milrinone and Neo drips. All lines and drains were discontinued in a timely fashion. She was transfused with red blood cells for postoperative anemia. Ms.[Known lastname 19849] did complain of severe pain which was treated with a dilaudid infusion. Aggressive diuresis was initiated. She had moments of extreme aggitation which was treated with haldol and ativan. As her daughter had reported she consumed daily alcohol, thiamine and folic acid were started. Multiple inhalers were used for worsening atelectasis and a high oxygen requirement. Postoperatively, Beta-blocker and aspirin were initiated. [2-10] anticoagulation was initiated with Coumadin for her MAZE procedure. Her INR levels subsequently increased to 7.5. Ms.[Known lastname 19849] was given vitamin K and fresh frozen plasma to correct this level and Coumadin was held. On [2-13] her rhythm went into atrial fibrillation. Given her continued her confusion, a swallow evaluation was performed which she failed due to her altered mental status. Tube feeds were started for nutritional support. Due to Ms.[Known lastname 45944] extreme state of confusion and agitation, it was not until POD#7 that she was transferred to the step down unit for further monitoring and progression. Her mental status improved to full orientation on [2-15] with continued low dose Haldol. Per Dr.[Last Name (STitle) ], Ms.[Known lastname 19849] was started on heparin drip to bridge her subtherapeutic INR and low dose Coumadin restarted. She continued to progress, diet was advanced with improving mental status, and she was ready for discharge to home on POD 14. She was advised of all follow up appointments. Medications on Admission: Coumadin 4 mg daily (LD [2-2]) digoxin 0.25 mg daily verapamil 240 mg [Hospital1 ] synthroid 25 mcg daily neurontin 300 mg TID nortriptyline 10-40 mg daily lasix 20 mg daily protonix 20 mg daily fluoxetine 40 mg daily ambien 10 mg QHS fluticasone spray 50 mcg Discharge Medications: 1. Acetaminophen 325 mg Tablet [Hospital1 ]: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Magnesium Hydroxide 400 mg/5 mL Suspension [Hospital1 ]: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 3. Sodium Chloride 0.65 % Aerosol, Spray [Hospital1 ]: Two (2) Spray Nasal QID (4 times a day) as needed. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Hospital1 ]: One (1) Inhalation Q4H (every 4 hours) as needed. 5. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [Hospital1 ]: Two (2) Puff Inhalation Q4H (every 4 hours). 6. Fluticasone 110 mcg/Actuation Aerosol [Hospital1 ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 7. Bisacodyl 10 mg Suppository [Hospital1 ]: One (1) Suppository Rectal DAILY (Daily). 8. Folic Acid 1 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 9. Ibuprofen 100 mg/5 mL Suspension [Hospital1 ]: Three (3) PO Q8H (every 8 hours) as needed for pain. 10. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 11. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 13. Thiamine HCl 100 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 14. Multivitamin Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 15. Levothyroxine 25 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 16. Warfarin 2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day for 1 doses: titrate as directed by the office of Dr. [Last Name (STitle) 45945]. . Disp:30 Tablet(s) Refills:2 17. Outpatient Lab Work INR to be drawn on [2137-2-22] with results faxed to the office of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 45945] at ([Telephone/Fax (1) 45946]. Phone ([Telephone/Fax (1) 45947]. 18. Lasix 20 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 19. Fluoxetine 20 mg Capsule [Telephone/Fax (1) ]: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 20. Nortriptyline 10 mg Capsule [Telephone/Fax (1) ]: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:0 21. Gabapentin 300 mg Capsule [Telephone/Fax (1) ]: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 22. Metoprolol Tartrate 50 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 23. Ciprofloxacin 500 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO Q12H (every 12 hours) for 7 days: through Thursday, [2-28]. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Rheumatic heart disease s/p Aortic Valve Replacement, Mitral Valve Replacment, Tricuspid Valve repair Atrial fibrillation (s/p ablation/PVI [2134] and mult. DCCVs) s/p MAZE procedure with left atrial appendage ligation Chronic diastolic heart failure Secondary: Depression, Hypothyroidism, GI bleed secondary to ASA in past, history of amiodarone toxicity ( hypothyroid/neuropathy) Discharge Condition: deconditioned Discharge Instructions: no lotions, creams or powders on any incision shower daily and pat incisions dry no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness, drainage or weight gain of 2 pounds in 2 days Followup Instructions: see Dr. [Last Name (STitle) ] in [12-28] weeks see Dr. [Last Name (STitle) 23651] in [1-29] weeks see Dr. [Last Name (STitle) 914] in 4 weeks [Telephone/Fax (1) 170] please call for all appts. Completed by:[2137-2-21]	[ "293.0", "427.32", "E878.1", "357.6", "428.32", "V12.51", "428.0", "427.31", "518.81", "518.0", "396.8", "E942.0", "244.3", "338.12", "311", "285.9", "397.0", "746.9", "553.3" ]	icd9cm	[ [ [] ] ]	[ "35.14", "39.61", "35.21", "35.23", "96.6", "37.36" ]	icd9pcs	[ [ [] ] ]	12153, 12204	6337, 8957	297, 578	12633, 12649	1640, 5393	12940, 13188	1204, 1222		9276, 12130	5433, 5456	12225, 12612		8983, 9253			12673, 12917										1237, 1621																												236, 259	5488, 6314										606, 788															810, 1119	1135, 1188
78,779	144,966	40332	Discharge summary	report	Admission Date: [2114-11-20] Discharge Date: [2114-11-27] Date of Birth: [2046-8-25] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1390] Chief Complaint: Right sided chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 68 yo M involved in rollover MVA. Pt was driving at approx 40mph and swerved to avoid a coyote causing his car to rollover. He was wearing his seat belt and recalls the entirety of the event/denies LOC. On EMS arrival he was GCS 15 and easily extricated. He was taken to OSH where he was found to have multiple R sided rib fx. He was transferred to [Hospital1 18] for CT scan and TSICU admission. On arrival to the [Hospital1 18] ED he was AOx3 complaining of significant R sided chest pain with breathing and L wrist pain. Pt underwent CT scan demonstrating R sided rib fx 3-8th, sternal fx, minimally displaced L distal radius fx and P1 fx of R foot. Orthopaedics was consulted for further evaluation. Past Medical History: NIDDM, chronic back pain (morphine pump), HTN, depression PSH: multiple spinal fusions (x6, most recent 9/10 L-spine), Lap hernia repair, morphine pump placement and replacement. Social History: denies tob, former EtOH (>20 years sober), lives alone. Family History: non contributory Physical Exam: Temp 98 HR 95 BP 140/70 RR 18 Sensorium: Awake (x) Awake impaired () Unconscious () Airway: Intubated () Not intubated (x) Breathing: Stable (x) Unstable () shallow breathing secondary to significant R sided and sternal chest pain Circulation: Stable (x) Unstable () Chest clear COR RRR Abd large soft non tender ecchymosis over right hip and flank Musculoskeletal Exam Neck Normal (x) Abnormal () Comments: c-collar in place, no midline/point tenderness. Spine Normal (x) Abnormal () Comments: Clavicle R Normal () Abnormal (x) Comments: no stepoffs but tender to palpation, brusing over L clavicle L Normal (x) Abnormal () Comments: no stepoffs Shoulder R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Arm R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Elbow R Normal (x) Abnormal () Comments: L Normal () Abnormal () Comments: abrasions over olecranon/lateral epicondyle. no point tenderness, full ROM (passive/active) Forearm R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: superficial abrasions over the L lateral forearm without pain or stepoffs. Wrist R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: mild radial deviation of wrist with ?radial shift/subluxation. tenderness throughout distal radius and radial styloid. ROM (passive/active) limited by pain but no notable crepitus/bone on bone articulation appreciated. Hand R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: wrist as above Pelvis R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Hip R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Thigh R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: excoriations (superficial) over the anterior surface of the distal thigh and lower leg. Knee R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: tender over the inferior border of the L patella. Leg raise intact. Minimal effusion. Negative Lockmans/ant drawer. Leg R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: abrasions over ant surface (superficial) Ankle R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: point tenderness over the lateral malleolus. no ankle subluxation/joint instability. No brusing. Foot R Normal () Abnormal (x) Comments: significant brusing over the 1st phalangeal surface of great toe. Tender with deep palpation. Full ROM(passive/active) at MTP and IP. L Normal (x) Abnormal () Comments: Vascular: Radial R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () Poplitea R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () DP R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () PT R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () Neuro: Deltoid R (x) L (x) Biceps R (x) L (x) Triceps R (x) L (x) Wrist Flx R (x) L (x) pain w/ L wrist movement Wrist Ext R (x) L (x) pain w/ L wrist movement Finger Flx R (x) L (x) Finger Ext R (x) L (x) Thumb Ext R (x) L (x) 1st DIP R (x) L (x) Index Abd R (x) L (x) Thumd Add R (x) L (x) Quad R (x) L (x) Ant Tib R (x) L (x) [Last Name (un) 938] R (x) L (x) Peroneal R (x) L (x) GS R (x) L (x) Pertinent Results: [2114-11-20] 05:49AM WBC-12.4* RBC-3.72* HGB-11.2* HCT-32.2* MCV-86 MCH-30.1 MCHC-34.9 RDW-14.9 [2114-11-20] 05:49AM PLT COUNT-216 [2114-11-20] 05:49AM PT-12.4 PTT-25.2 INR(PT)-1.0 [2114-11-20] 05:49AM GLUCOSE-146* LACTATE-1.5 NA+-138 K+-4.5 CL--98* TCO2-30 [2114-11-20] 05:49AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2114-11-20] 05:49AM UREA N-22* CREAT-0.9 [2114-11-20] 12:44PM WBC-8.4 RBC-3.42* HGB-10.1* HCT-30.3* MCV-89 MCH-29.7 MCHC-33.5 RDW-14.8 [2114-11-20] CT Torso : 1. Right 3rd-8th rib fractures and small nondisplaced superior sternal fracture. 2. Extensive atherosclerotic disease including coronary arterial calcification. 3. Diverticulosis. [2114-11-20] Right foot: Three views of the right foot are interpreted without comparison. There is an oblique fracture through the proximal phalanx of the great toe with no evidence of displacement or intra-articular extension. Joint spaces are normal. Note is made of a small os peroneum. There is no radiopaque foreign body. [2114-11-20] Left ankle : Nondisplaced fracture of the left lateral malleolus without angulation. Preservation of ankle mortise. [2114-11-20] Left arm : Three views of the left elbow without comparison show no fracture or dislocation. Joint spaces are normal. There are no radiopaque foreign bodies or soft tissue calcifications. Punctate densities overlying the dermis along the dorsum of the proximal forearm should be correlated to physical exam for possible abrasion in that location. Four views of the left wrist demonstrate a comminuted distal radial fracture with extension to the radiocarpal joint. Alignment is near anatomic. There is no other fracture or dislocation. Joint spaces are preserved. [2114-11-22] CTA Chest : 1. No evidence of pulmonary embolism as questioned. 2. Small right pleural effusion with right basilar compressive atelectasis. 3. Multiple right-sided rib fractures along with sternal fractures. 4. Hepatic steatosis. [2114-11-22] Duplex scan B/L lower extremities : No evidence of deep venous thrombosis in bilateral lower extremities. Brief Hospital Course: Mr. [Known lastname 10643] was evaluated by the trauma team in the Emergency Room and admitted to the Trauma ICU for pain control and evaluation by the Orthopedic service for multiple fractures. He has chronic back pain and has a morphine pump in place which prompted consultation by the pain service for supplemental medication for pain control. Due to his rib fractures his pain was substantial and additional IV Morphine was effective. He was able to use his incentive spirometer`but required bronchodilators due to intermittent episodes of wheezing. Following transfer to the Trauma floor he continued aggressive pulmonary toilet but eventually desaturated`and became delirious prompting transfer back to the ICU. He underwent a chest CTA, a duplex scan of both legs and a Head CT all which were negative.``He was a bit hypercarbic with a pCO2 of 58 and after evaluation by the pain service his IV Morphine was stopped and his additional pain was controlled with oral oxycodone. His mental status gradually returned to [Location 213], his pain was controlled and he was transferred back to the Trauma floor. The Orthopedic service followed him daily. His left arm was placed in a dorsal splint and is non weight bearing. His left ankle is in an Aircast boot for a fracture of the lateral malleolus and his right foot is in a surgical boot for his fractures 1st digit. Both lower extremities are weight bearing as tolerated.`````` The Physical Therapy service evaluated him and felt that due to his multiple injuries and limitations he would benefit from a short term rehab prior to his return home for balance, gait training and increasing endurance. At the time of discharge he was eating well, working with Physical Therapy and having adequate pain control. He will follow up with the Acute Care Clinic and the [Hospital ] Clinic in [1-31] w e e k s . ` ` ` ```````````````````````````````````````````````````````````````` Medications on Admission: Effexor 300mg QD, Metformin 250 [Hospital1 ], Ambien, metoprolol, ASA 81, morphine pump, oxycodone Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 3. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. venlafaxine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 13. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 14. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily): Hold for SBP < 110 HR < 60. 15. oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 16. oxycodone 20 mg Tablet Sig: 2 [12-30] Tablets PO Q4H (every 4 hours) as needed for pain. 17. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 18. Morphine pump Morphine 25mg/ml Bupivicaine 20 mg/ml Clonidine 400 mcg/ml Mode : MS 6.602 mg/day Bupivicaine 5.28 mg/day Cloniidine 105.63 mcg/day Reservoir volume 15.2 ml 19. insulin regular human 100 unit/mL Solution Sig: 2-10 units Injection four times a day as needed for per sliding scale. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: S/P Rollover 1. Right rib fractures [3-5] 2. Sternal fracture 3. Left distal radial comminuted fracture 4. Right foot 1st digit fracture 5. Left lateral malleolar fracture 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: * Your car accident caused multiple injuries including fractured ribs and broken bones. * Your injury caused right rib fractures [3-5] which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * You need to wear an aircast boot on your left foot and you may weight bear as tolerated. * The splint on your left arm will stay in place until further evaluated by the Orthopedic service. Do not bear weight on that arm. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). Followup Instructions: Call the Acute Care Clinic at [Telephone/Fax (1) 600] for a follow up appointment in [1-31] weeks. Call the [Hospital ] Clinic at [Telephone/Fax (1) 1228] for a follow up appointment in 2 weeks. Completed by:[2114-11-27]	[ "V45.89", "807.06", "E816.0", "V11.3", "338.11", "250.00", "824.2", "813.42", "807.2", "V58.67", "338.29", "721.3", "401.9", "293.0", "311", "826.0", "V45.4" ]	icd9cm	[ [ [] ] ]	[ "79.02" ]	icd9pcs	[ [ [] ] ]	11497, 11594	7295, 9252	339, 346	11814, 11814	5106, 7272	13532, 13776	1381, 1399		9408, 11474		11615, 11793		9278, 9383			11997, 13509										1414, 5087																												277, 301											374, 1088												11829, 11973			1110, 1291	1307, 1365
31,514	114,047	34531	Discharge summary	report	Admission Date: [2175-7-31] Discharge Date: [2175-9-1] Date of Birth: [2124-8-14] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1257] Chief Complaint: Found down/altered mental status Major Surgical or Invasive Procedure: RIJ Endotracheal intubation Right femoral temporary dialysis catheter placement and removal LUE fasciotomy status post skin graft placement R subclavian tunneled dialysis catheter placement and removal History of Present Illness: Mr. [Known lastname 1726] is a 50M with a PMH of polysubstance abuse, Hepatitis C, and depression who was found down by his family with altered mental status on the evening of [7-29]. Per the patient's family, he had been on a week-long binge with multile substances, those of which are known to the family include: ETOH, benzodiazapines, heroin, trazodone, and crack. He was discovered asleep in his car outside of his family's house on the evening of [7-29]. The next morning, he was not fully arousable. He was taken to [Location (un) 21541] Hospital on the morning of [7-30] for altered mental status. The work-up at [Hospital3 ] included: 1. Liver failure 2. Acute renal failure 3. Elevated cardiac enzymes 4. Left arm skin breakdown with compartment syndrome. 5. MRI of the head showing multiple embolic CVA's 6. Rhabdomyolysis He was transferrd to the [Hospital1 18] for further management. In our ED, he presented with the following vital signs: 190/95, 104, 97%RA. Clinically he was somnolent, following simple commands, hypertensive, and tachycardic. He was given valium for presumed alcohol withdrawl, and was then intubated for airway protection. Serum/urine tox confirmed the presence of benzodiazapines and cocaine. He was found to be in fulminant liver failure with a transaminitis and coagulopathy. It was unclear if this was due to tylenol toxicity vs. shock picture, so the ED administered N-acetyl cysteine with the toxicology service consulting, despite negative tylenol on his tox screen. He received a 150mg/kg bolus over 60 minutes Neurology was consulted for the acute mental status changes with embolic strokes- they had no further recommendations, as anticoagulating him would not be possible given his coagulopathy. Orthopedics was consulted for his left arm compartment syndrome, and plan for a faciotomy. His rhabdomyolysis was managed with saline diuresis, with approximately 6-7L of NS. He was also found to be in acute renal failure, with a Cr of 3.7. His CK-MB and troponin were elevated, cardiology was notified of the admision, but had no current recommendations. Labs were otherwise notable for a positive UA, a normal lactate level, hyponatremia, hypocalcemia, hypomagnesemia. Our ED ordered a CT torso and cervical spine. Past Medical History: Depression Hepatitis C Polysubstance abuse Social History: Works as a truck driver, just left a substance abuse rehabilitation facility on Sunday. No tobacco, polysubstance abuse as detailed above. Supportive family including 3 daughters. Legally divorced from wife; primary decision maker is oldest [Last Name (LF) ], [First Name3 (LF) 8771]. Family History: NC Physical Exam: Admission Day exam- T=afebrile... BP=187/117... HR=94... RR=... O2=100% AC 600x20, FiO2 40%, PEEP5 GENERAL: Intubated, sedated HEENT: Pupils sluggish bilaterally. Intubated. RIJ in place with minimal bleeding at the sige. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. LUNGS: Course bilateral breath sounds ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: RUE s/p fasciotomy, wound vac in place. Cool extremities with 1-2+ pulses SKIN: Multiple areas of skin break down and ecchymosis NEURO: Sedated, babinskis down-going bilaterally At discharge his exam was: GEN: NAD, confused HEENT: OP clear, no SI, MMM NECK: no JVD, supple, no LAD, no masses CV: RRR, no Murmur, S1 S2, pulses 2+ bilaterally CHEST: CTA B ABD: NABS, soft, NT, ND, no HSM EXT: graft site on Lt forearm with 4cm necrotic area, dry, stable; rest of graft is eythematous and without change; left hand contracted; left trochanter ulcer, skin wounds on both LE, knee, dressings c/d/i, limbs with no edema, warm and well perfused. NEURO: A and O x 2, MS waxing and [Doctor Last Name 688], decreased strength on left arm, CNII-XII grossly intact Pertinent Results: ================== ADMISSION LABS ================== [2175-7-30] 10:48PM BLOOD WBC-8.7 RBC-3.27* Hgb-10.9* Hct-31.0* MCV-95 MCH-33.3* MCHC-35.1* RDW-13.7 Plt Ct-96* [2175-7-30] 10:48PM BLOOD Neuts-94.5* Bands-0 Lymphs-2.9* Monos-2.4 Eos-0.1 Baso-0 [2175-7-30] 10:48PM BLOOD PT-25.5* PTT-66.3* INR(PT)-2.5* [2175-7-30] 10:48PM BLOOD Glucose-144* UreaN-45* Creat-3.7* Na-150* K-2.8* Cl-126* HCO3-15* AnGap-12 [2175-7-30] 10:48PM BLOOD ALT-2543* AST-6223* CK(CPK)-[Numeric Identifier 79316]* AlkPhos-51 TotBili-0.4 [2175-7-30] 10:48PM BLOOD Lipase-22 [2175-7-30] 10:48PM BLOOD CK-MB-245* MB Indx-0.6 [2175-7-30] 10:48PM BLOOD cTropnT-0.95* [2175-7-30] 10:48PM BLOOD Calcium-3.5* Phos-3.2 Mg-1.5* [2175-7-31] 02:28AM BLOOD Type-ART Rates-0/5 Tidal V-670 O2 Flow-100 pO2-364* pCO2-52* pH-7.20* calTCO2-21 Base XS--7 Vent-CONTROLLED DISCHARGE LABS ============== [2175-8-31] 07:25AM BLOOD WBC-7.7 RBC-2.85* Hgb-9.3* Hct-26.1* MCV-92 MCH-32.8* MCHC-35.8* RDW-13.0 Plt Ct-391 [2175-8-17] 07:10AM BLOOD PT-13.7* PTT-32.5 INR(PT)-1.2* [2175-8-29] 08:20AM BLOOD Glucose-117* UreaN-17 Creat-1.3* Na-135 K-4.2 Cl-99 HCO3-27 AnGap-13 [2175-8-31] 07:25AM BLOOD UreaN-13 Creat-1.1 Na-136 K-3.9 [2175-8-11] 07:25AM BLOOD Glucose-90 UreaN-60* Creat-7.0# Na-132 K-4.0 Cl-95* HCO3-24 AnGap-17 [2175-8-29] 08:20AM BLOOD estGFR-Using this [2175-7-31] 03:58AM BLOOD ALT-3739* AST-9036* LD(LDH)-6453* CK(CPK)-[Numeric Identifier 79317]* AlkPhos-80 TotBili-1.4 [2175-8-5] 04:37AM BLOOD ALT-395* AST-117* LD(LDH)-637* CK(CPK)-3586* [2175-8-21] 04:13PM BLOOD ALT-29 AST-29 [2175-7-31] 02:26PM BLOOD CK-MB-156* MB Indx-0.4 cTropnT-1.34* [2175-8-1] 05:41AM BLOOD CK-MB-81* MB Indx-0.4 cTropnT-1.02* [2175-8-2] 03:16AM BLOOD CK-MB-40* MB Indx-0.4 cTropnT-1.10* [2175-8-31] 07:25AM BLOOD Mg-1.9 [2175-8-14] 07:15AM BLOOD calTIBC-254* VitB12-1351* Folate-9.6 TRF-195* [2175-8-23] 09:30AM BLOOD calTIBC-270 TRF-208 [2175-7-31] 03:58AM BLOOD HBsAg-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2175-7-30] 10:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2175-8-9] 07:58AM BLOOD freeCa-1.03* [2175-7-31] 4:55 am BLOOD CULTURE Source: Line-ALine. FINAL REPORT [2175-8-7] Blood Culture, Routine (Final [2175-8-6]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. PENICILLIN SENSITIVITY AVAILABLE ON REQUEST. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S Anaerobic Bottle Gram Stain (Final [2175-8-1]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Doctor Last Name ] @ 0645 ON [2175-8-1]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS [2175-7-31] 5:09 am URINE Source: Catheter. FINAL REPORT [2175-8-2] URINE CULTURE (Final [2175-8-2]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. PENICILLIN SENSITIVITY AVAILABLE ON REQUEST. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R NITROFURANTOIN-------- <=16 S OXACILLIN-------------<=0.25 S PENICILLIN G---------- 0.12 R [2175-7-31] 3:54 am SPUTUM Source: Endotracheal. FINAL REPORT [2175-8-4] GRAM STAIN (Final [2175-7-31]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [2175-8-4]): OROPHARYNGEAL FLORA ABSENT. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. STAPH AUREUS COAG +. HEAVY GROWTH. Please contact the Microbiology Laboratory ([6-/2473]) immediately if sensitivity to clindamycin is required on this patient's isolate. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STREPTOCOCCUS PNEUMONIAE. HEAVY GROWTH. Note: For treatment of menigitis, penicillin G MIC breakpoints are <=0.06 ug/ml (S) and >=0.12 ug/ml (R) Note: For treatment of meningitis, ceftriaxone MIC breakpoints are <=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R) For treatment with oral penicillin, the MIC break points are <=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R). GRAM NEGATIVE ROD(S). SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| STREPTOCOCCUS PNEUMONIAE \| \| CEFTRIAXONE----------- =>4 R ERYTHROMYCIN---------- =>8 R =>1 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S 1 S OXACILLIN-------------<=0.25 S PENICILLIN G----------<=0.03 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S =>16 R VANCOMYCIN------------ <=1 S HCV VIRAL LOAD (Final [2175-8-1]): 6,340,000 IU/mL. [2175-8-4] 5:37 pm SPUTUM Source: Endotracheal. FINAL REPORT [2175-8-8] GRAM STAIN (Final [2175-8-4]): [10-21] PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2175-8-8]): OROPHARYNGEAL FLORA ABSENT. SERRATIA MARCESCENS. MODERATE GROWTH AMIKACIN SUSCEPTIBILITY REQUESTED BY DR. [Last Name (STitle) 79318] (#[Numeric Identifier 65017]) [2175-8-7]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ SERRATIA MARCESCENS \| AMIKACIN-------------- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2175-8-5] 4:36 am URINE Source: Catheter. FINAL REPORT [2175-8-8] URINE CULTURE (Final [2175-8-8]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| AMIKACIN-------------- 4 S CEFEPIME-------------- 16 I CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- =>16 R PIPERACILLIN---------- R PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ 8 I [2175-8-15] 3:49 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [2175-8-16] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2175-8-16]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [2175-7-30] CT without contrast of chest, abd, pelvis IMPRESSION: 1. Diffusely decreased hepatic attenuation, which is commonly seen in liver steatosis, less common etiologies include hepatitis, toxic hepatic injury, or metabolic disorders. 2. Nonspecific perinephric stranding. [2175-7-31] ECHO The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate global left ventricular hypokinesis (LVEF = 40-45 %). Systolic function of apical segments is relatively preserved. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size is normal with mild free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: No valvular pathology or pathologic flow identified. Mild symmetric left ventricular hypertrophy with mild biventricular global hypokinesis c/w diffuse process (toxin, metabolic, tachycardiac, etc.). Abd u/s [2175-7-31] IMPRESSION: 1. Patent hepatic vasculature with appropriate waveforms. 2. No liver masses and no biliary dilatation. 3. Trace of ascites. Carotid U/S [2175-7-31] IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis. HEAD MRI without contrast IMPRESSION: Acute bilateral globus pallidus infarcts and acute to subacute infarcts in both cerebellar hemispheres. No prior examinations for comparison. -------------------- Brief Hospital Course: [Known firstname ] [Known lastname 1726] is a 50 year-old male with a history of polysubstance abuse who presented [2175-7-31] with altered mental status after being found down by family members. Extended hospital course was as follows, by problem: #. Rhabdomyolysis and acute renal failure: Patient presented with CK ~40,000 in the setting of ARF, compartment syndrome, and hypocalcemia. This was likely secondary to immobilization after polysubstance intoxication. Patient was hydrated and received approximately 24 liters. The decision was made to start HD and his CK slowly began trending down; initially, temporary HD catheter was placed in femoral artery. Later IR placed a tunneled catheter in the right subclavian artery which had to be replaced after patient pulled it out. Over his hospitalization his Cr and urine output improved. Patient received last hemodialysis treatment on [Last Name (LF) 2974], [8-18]. On [8-22], hemodialysis catheter was removed by interventional radiology. Cr at discharge was 1.1. #. Altered mental status: Patient was obtunded and comatose at presentation - intubated for airway protection. MRI showed multiple embolic strokes, and toxicology showed alcohol, heroin, and crack/cocaine. Differential included multiple CVAs, substance abuse, hepatic encephalopathy (stage II-III), infection, and delirium. On the medicine floor, patient was oriented only to himself initially and required a sitter. Haldol used PRN for agitation and confusion. Poor mental status had a component secondary to the strokes with superimposed delirium. On discharge, mental status was improved, but patient still having confusion and memory problems. [Name (NI) ] clear source was found for the strokes. Patient had a repeat echocardiogram which was negative for a PFO. Possibly due to arrythmia and/or transient wall motion abnormality during drug intoxication that produced thrombi in the heart, which then embolized to brain. At [Hospital1 18], neurology involved and decision was made not to anticoagulate given severe coagulopathy on admission. Carotid ultrasound was done and 40% stenosis bilaterally. Blood cultures grew staph aureus in [12-30] bottles from arterial line and he was placed on vancomycin dosed by HD with a plan for 14 day course. Subsequent blood cultures were negative, and vancomycin was discontinued. Echocardiogram was without vegetation. Following closure of left upper extremity fasciotomy and resolution of acute liver failure, patient was placed on aspirin and Statin. On floor begin rehab with PT, OT. Will need these services at rehab. #. Fulminant liver failure: Unclear etiology. At level of transaminitis at presentation, the differential was narrowed to toxin-induced, shock state, and viral hepatitis. [Month (only) 116] have been transaminitis secondary to rhabdomyolysis. The patient has known hepatitis C, viral load 6.3 million. Serum was negative for acetaminophen, although he was started on NAC in the ED. Doppler study of the portal and hepatic veins was done and showed patent vessels. Albumin on presentation was 2.8. AST and ALT peaked at 3739 and 9036. Trended to normal over his admission. Consider Ribavirin and interferon after resolution of acute illness and depression. #. Left upper extremity compartment syndrome: Unclear if the patient suffered a crush injury versus bleed into the arm from coagulopathy. On presentation, patient was taken for emergent fasciotomy in the operating room. A wound vac was placed, and plastics involved for grafting area. Wound vac was removed on [8-22]. Patient had limited movement of left digits. Physical therapy and occupational therapy were also involved. Per plastics recommendations, patient is to follow up with plastics clinic during the week of discharge. Post op a 4cm area of necrosis in the center of his graft developed, was stable, did not appear infected. Plastics thought it was a region of failed graft tissue recommended close observation. OT recommended placing splint (over padding) on left hand to prevent contracture. #. Alcohol withdrawal - Placed on CIWA protocol with lorazepam prn >10 given hepatic failure. Did not have withdraw sx. After several days, patient was discharged off of CIWA protocol. Social work became involved for substance abuse counseling. #. NSTEMI: On admission, cardiac biomarkers were elevated. Likely demand during multi-organ system failure. EKG did not show ischemic changes. Cardiology was involved; given coagulopathy, fasciotomy, and liver failure, aspirin and Statin were not started initially. Beta-blocker was added. Later, patient was started on low-dose aspirin and Statin. #. Diarrhea: In ICU and on medicine floor, patient continued to have loose stools. C. diff toxin was sent and was found to be negative. Stool cultures were also sent and showed no organisms. Diarrhea resolved. #. Fever - On [2175-8-2], the patient had a witnessed aspiration event. CXR showed possible aspiration pneumonia; this cleared on subsequent x-rays. On [2175-8-3], had fevers to 101.7 and developed a leukocytosis to 14.7 with left shift. Right femoral line d/c'ed. Due to possible aspiration PNA, started on Unasyn and kept on Vancomycin. As he continued spiking fevers, the concern for HAP/VAP was raised. Unasyn changed to Zosyn and levofloxacin, continued on Vancomycin on [8-5]. Sputum cultures were obtained showing pan-sensitive serratia. Urine Culture on [8-5] grew pseudomonas only sensitive to amikacin. Vanc and Zosyn were discontinued on [8-7] as there was no MRSA and as serratia was pansensitive. On [8-7], amikacin was started. ID consultant thought that Pseudomonas in urine was not clinically significant (as urine had cleared) and that Serratia in sputum was not likely pathologic in this patient's case; antibiotics were discontinued [8-8]. #. Right leg bone infarct - Patient was found to have pain in right knee. Plain film was done and showed right bone infarct. Orthopedics was consulted and felt that no further imaging/intervention was necessary. Patient may required knee replacement in future. Source for infarct was believed to be from embolic strokes. #. Depression - Reports a history of depression, formerly on Paxil and trazodone. During long hospitalization expressed worsening of depression symptoms. On [8-31] Paxil and trazodone were restarted. These doses may need to be adjusted. Social work consult to discuss current situation. #. Anemia - Likely multifactorial, including bone marrow suppression from substance abuse, bleeding from LUE. B12, folate studies normal. Iron studies not consistent with iron-deficiency anemia or anemia of chronic disease. Threshold for transfusion hematocrit <= 21. Did not require transfusion. Will need to be monitored. #. FEN - Diet changed [2175-8-18] to thin liquids and soft foods. Ensure twice daily. #. Skin wounds- several skin wounds, graft site on left forearm. Also, pressure ulcers on lower extremities. Will need daily dressing changes and monitoring for infection. Patient will be discharged to rehab to improve strength and mobility and will need follow up care with plastic surgery and his PCP. Medications on Admission: Famotidine 20 mg IV Q24H Heparin 5000 UNIT SC TID Labetalol 100 mg PO TID Alteplase (Catheter Clearance) 2 mg IV 2X Lorazepam 2 mg IV Q6H:PRN Albuterol MDI [6-6] PUFF IH Q4H:PRN Artificial Tear Ointment 1 Appl BOTH EYES PRN Discharge Medications: 1. Artificial Tear with Lanolin Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eye. 2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime): pt may refuse. 3. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for SBP<110. 8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Rhabdomyolysis Acute compartment syndrome s/p fascitomies on left arm Multifocal embolic strokes Fulminant liver failure Acute renal insufficeny requiring hemodialysis Non-ST elevation myocardial infarction Polysubstance abuse Hepatitis C Urinary tract infection Bacteremia Pneumonia Depression Right leg bone infarct Pressure ulcers Discharge Condition: Hemodynamically stable, afebrile, poor orientation, weakness on left side. Discharge Instructions: You were transfered to [Hospital1 18] for further treatment of your multiple medical problems after being found unreponsive in your car. Initally you had liver failure, kidney problems, a heart attack, and multiple strokes. You required temporary dialysis for your kidney. You also had a fasciotomies of your left forearm that required a skin grafts. You had a stroke resulting in weakness on the left side of your body. You spent part of your admission in the ICU for these problems. [Name (NI) ] will require physical therapy at the rehab center. Please keep your follow up appointments. Please do not use IV or street drugs or drink alcohol, they are harmful for your health. Take your medications as instructed. Changes were made to your home medications. If you have chest pain, shortness of breath, fever, drainage from your wounds, or any other concerning symptom please seek medical attention or go to the ER. Followup Instructions: Plastic Surgery clinic, Please Call ([Telephone/Fax (1) 65943] to schedule a follow up appointment. Please make an appointment to see your PCP as soon as you leave the hospital. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Telephone/Fax (1) 14916]. Completed by:[2175-9-1**]	[ "305.61", "041.11", "733.49", "790.7", "305.51", "518.82", "280.0", "291.81", "E879.8", "996.62", "728.88", "584.9", "410.71", "311", "486", "293.0", "729.71", "434.11", "570", "286.9", "707.09", "599.0", "305.41", "070.70" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.91", "93.57", "83.32", "38.95", "96.04", "83.09", "96.72", "97.49", "86.69", "39.95" ]	icd9pcs	[ [ [] ] ]	23349, 23422	14984, 16041	348, 551	23800, 23877	4488, 14961	24855, 25170	3278, 3282		22496, 23326		23443, 23779		22243, 22473			23901, 24832										3297, 4469																												275, 310											579, 2884												16056, 22217			2906, 2951	2967, 3262
32,237	102,644	31247+57736	Discharge summary	report+addendum	Admission Date: [2193-10-14] Discharge Date: [2193-10-20] Date of Birth: [2143-2-1] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: chest pain Major Surgical or Invasive Procedure: CABG x3 (LIMA>LAD, SVG>OM, SVG>PDA) AVR (23 ONX) [10-14] History of Present Illness: 50 yo M who presented to [Hospital 1474] Hospital with chest pain, ruled in for NSTEMI, was transferred to [Hospital1 18] for cath which showed 3VD. Echo showed severe AS. Referred for CABG/AVR. Past Medical History: - CAD: s/p cath in [6-25] with occluded RCA, 50% prox LAD - Moderate AS with peak gradient 20-25mmHg per cath - HTN - DM2 - last A1c 7.1% - Hyperlipidemia: Chol 157, HDL 53, LDL 82, in [6-25] - has had it checked since then, results unknown - Chronic back pain - Neuropathic leg pain Social History: He lives with his wife who is a nurse, and his 16yo son. [Name (NI) 1139]: never smoked EtOH: 1-2 beers/weekend Illicits: denies, including no cocaine Family History: Father passed away at 54 of CVA, brother with stents placed at 43, another brother with AS Physical Exam: NAD 67 16 127/86 CV RRR SEM heard t/o -> carotids Lungs CTAB ant/lat Abdomen benign Extrem warm, no edema No varicose veins 5'[95]" 205# Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 73736], [Known firstname 251] [Hospital1 18] [Numeric Identifier 73737] (Complete) Done [2193-10-14] at 11:51:21 AM FINAL Referring Physician [Name9 (PRE) ] Information [Last Name (Prefixes) 413], [First Name3 (LF) 412] 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: [2143-2-1] Age (years): 50 M Hgt (in): 70 BP (mm Hg): / Wgt (lb): 205 HR (bpm): BSA (m2): 2.11 m2 Indication: Intraoperative TEE CABG/AVR ICD-9 Codes: 746.9, 410.91, 440.0, 424.1 Test Information Date/Time: [2193-10-14] at 11:51 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5740], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW2-: Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.5 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Left Ventricle - Stroke Volume: 59 ml/beat Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Descending Thoracic: 2.7 cm <= 2.5 cm Aortic Valve - Peak Velocity: 0.5 m/sec <= 2.0 m/sec Aortic Valve - LVOT pk vel: 0.61 m/sec Aortic Valve - LVOT VTI: 17 Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: 0.6 cm2 >= 3.0 cm2 Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic 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: 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. Overall left ventricular systolic function is normal (LVEF>55%). 3. The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. 4. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets that are fused along the right and non-coronary cusps and is a functionally bicuspid valve.. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation is seen. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. POST-BYPASS: The patient was removed from cardiopulmonary bypass on phenylephrine infusion and AV pacing. 1. There is a mechanical prosthetic valve in the aortic position. The valve is well seated and there is no evidence of paravalvular leaks or aortic regurgitation. There is noted washing jets from the valve. The peak gradient across the valve is 25mmHg and the mean gradient is 14mmHg. 2. Biventricular function is preserved; LVEF> 55%. 3. Aortic contours are intact post-decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5209], MD, Interpreting physician [Last Name (NamePattern4) ] [2193-10-15] 06:44 RADIOLOGY Final Report CHEST (PORTABLE AP) [2193-10-16] 5:07 PM CHEST (PORTABLE AP) Reason: eval for hemothorax in pt with dropping Hct [Hospital 93] MEDICAL CONDITION: 50 year old man s/p CABGx3 REASON FOR THIS EXAMINATION: eval for hemothorax in pt with dropping Hct REASON FOR EXAMINATION: Dropping hematocrit in a patient after CABG. Portable AP chest radiograph compared to [2193-10-15]. No change in the global or mediastinal contour is demonstrated since the previous study although there is overall increased fullness at the level of the ascending aorta and azygos vein. There is gradual worsening of left retrocardiac atelectasis with slight increase in left pleural effusion although still small to moderate. There is no pneumothorax. There is no evidence of pulmonary edema. The study and the report were reviewed by the staff radiologist. DR. [First Name4 (NamePattern1) 2618] [Last Name (NamePattern1) 2619] DR. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1508]Approved: [Doctor First Name ] [2193-10-17] 12:29 PM Brief Hospital Course: He was taken to the operating room on [10-14] where he underwent a CABG x 3 and AVR (On-X mechanical valve). He was transferred to the ICU in critical but stable condition. He was extubated later that same day. He was weaned from his neosynephrine and transferred to the floor on POD #1 to begin increasing his activity level. Chest tubes and pacing wires removed without incident. Coumadin started for mechanical valve. INR therapeutic on POD #6 and cleared for discharge to home. Target INR is 2.0-3.0. Medications on Admission: ASA 325 mg daily glyburide 10 mg [Hospital1 ] pioglitazone 15 mg daily vytorin daily lisinopril 10 mg daily oxycodone 15 mg [Hospital1 ] 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s) Refills:0 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. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours) as needed. Disp:50 Tablet(s) Refills:0 10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day as needed for AVR (onx). Disp:40 Tablet(s) Refills:0 11. Keflex 500 mg Capsule Sig: Two (2) Capsule PO three times a day for 7 days. Disp:42 Capsule(s) Refills:0 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 13. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: CAD, AS now s/p CABG & AVR NSTEMI, HTN, DM, ^ chol, Chronic back pain, Neuropathic leg pain Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. COUMADIN dosing/INR follow up with......... First blood draw............ Target INR 2.0-3.0 [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (STitle) 17887] 2 weeks Dr. [Last Name (STitle) ] 2 weeks Dr. [Last Name (Prefixes) ] 4 weeks [Telephone/Fax (1) 170] Completed by:[2193-10-21] Name: [Known lastname 12218],[Known firstname 116] Unit No: [Numeric Identifier 12219] Admission Date: [2193-10-14] Discharge Date: [2193-10-20] Date of Birth: [2143-2-1] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 674] Addendum: Coumadin dosing and INR follow up with Dr. [Last Name (STitle) 12220]. [2193-10-21] Spoke with Mr. [Known lastname 12221] wife after discharge, she spoke with Dr. [Last Name (STitle) 12222] office and he will follow coumadin, blood was already drawn today. Also called in prescription for lopressor to Duvalls Pharmacy in [Location (un) 12223], prescription was left out of discharge paperwork. Discharge Disposition: Home With Service Facility: [Hospital3 413] VNA [Doctor Last Name ] [Last Name (Prefixes) ] MD [MD Number(1) 681] Completed by:[2193-10-21]	[ "355.8", "424.1", "746.4", "272.4", "401.9", "250.00", "V58.61", "414.01" ]	icd9cm	[ [ [] ] ]	[ "99.04", "35.22", "36.12", "36.15", "39.61" ]	icd9pcs	[ [ [] ] ]	11010, 11201	7169, 7680	333, 396	9564, 9572	1405, 6199		1132, 1224		7875, 9353	6236, 6263	9448, 9543		7706, 7852			9596, 9942				9993, 10987						1239, 1386																												283, 295	6292, 7146										424, 628															650, 943	959, 1116
78,419	175,528	6767	Discharge summary	report	Admission Date: [2179-7-31] Discharge Date: [2179-8-6] Date of Birth: [2120-3-16] Sex: F Service: SURGERY Allergies: Penicillins / Iodine / Talwin Attending:[First Name3 (LF) 4748] Chief Complaint: Dysarthria Major Surgical or Invasive Procedure: [2179-8-3]: Left carotid endarterectomy with Dr. [Last Name (STitle) 1391] History of Present Illness: Ms. [Known lastname ] is a 59 year old female s/p liver [Known lastname ] in [Month (only) 205] [2178], DM, HTN, who presented with inability to speak. Her husband reported that the patient woke at 430 am the day of presentation and couldn't speak. The husband notes that it appeared that she understood him, but could only respond with sounds. He did not note any other abnormalities. The patient did not appear weak. She was able to get out of bed by herself. Ms. [Known lastname ] notes that she could have walked out of the house to the hospital if need be. She was last seen well at 1 am. The patient was noted to have diarrea a few days prior. No commpaints of headache. There was no vomiting. Past Medical History: PMH: GBS cellulitis L leg 10, alcoholic hepatitis, hep C cirrhosis, portal HTN, hepatic encephalopathy, COPD PSH: liver tx [2179-6-6], hysterectomy 01, lap bx uterine fibroid Social History: Married, smokes. Previous heavy alcohol use,. Stopped 1 1/2 years back. Previous cocaine use. Family History: non contributory Physical Exam: PE on admission: General: Awake, aphasic. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, Awake. Appears to understand and will follow commands but is aphasic. Language is aphasic. Unable to assess repetition.Unable to assess prosody. Able to follow both midline and appendicular commands. No evidence of neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. VII: Right lower facial droop. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift . Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 5 5 5 5 5 5 5 5 5 5 5 R 4+ 4+ 4 4 4 5 5 5 5 5- 5 -Sensory: No deficits to light touch, No extinction to DSS. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2+ 2+ 2+ 2+ 1 R 2+ 2+ 2+ 2+ 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria or ataxia noted through observation. PE on discharge: Gen: AAOx4, interactive, follows commands, indicates needs by pointing, miming. No acute distress. Severe expressive aphasia. CVS: Regular, no M/R/G Pulm: Clear bilaterally Abd: Soft, nontender, nondistended. Well healed scar. Ext: Right side weakness relative to left, but improved since admission. No clubbing, cyanosis, or edema. Pulses: Fem: palpable b/l, R: DP/PT [Name (NI) ], L: DP [Name (NI) 17394], no PT. Neuro: Right facial droop. Right side weakness relative to left. Extraocular movements intact. Dysarthric with severe expressive aphasia. Able to say "None" and "and". Brief Hospital Course: Ms. [Known lastname ] was admitted on [2179-7-31] after presenting with new onset dysarthria. A code stroke was called and she was immediately evaluated by the stroke team. She was admitted to the SICU after undergoing MRA/MRI which revealed a stroke in the distribution of the left MCA. There appeared to be shower of emboli with no major occlusion. She was outside the window to receive tPA and there was no neurosurgical intervention possible per the neurology team. A carotid duplex study was performed in workup of possible etiology, and revealed Left ICA 70-79% stenosis. A vascular surgery consult was requested on [8-3] for evaluation and possible surgical intervention. On [8-3], she was seen and examined by the vascular team, who recommended left carotid endarterectomy during the current admission. After discussion of the risks and benefits of surgical intervention, Ms. [Known lastname ] and her husband agreed. She underwent left carotid endarterectomy with internal carotid artery shunting and cerebral oximetry on [8-3], and after initial recovery in the PACU, she was transferred to the vascular surgery service for further recovery and monitoring. On [8-4], Ms. [Known lastname ] continued to be hypertensive, requiring IV nitroglycerin to titrate systolic blood pressure to 100-150. She was transfused 2 units of pRBCs for post-operative anemia, which resolved. She remained otherwise stable, and she was seen and evaluated by the speech and swallow team, physical therapy, occupational therapy, neurology, and the [Known lastname ] surgery team. She had daily labs, including tacrolimus levels, and her medications were adjusted daily according to the liver [Known lastname ] protocols. Her home medications were resumed, including oral lopressor. On [8-5], Ms. [Known lastname ] was still requiring a nitroglycerin drip to maintain target blood pressure, but was otherwise recovering well from her carotid surgery. Her neurologic exam continued to improve, and she was able to use 2 new words. Her arterial line was removed, and she was able to be out of bed to a chair. She was started on oral hydralazine in addition to lopressor in order to wean the nitroglycerin drip while maintaining target SBP. She was started on aspirin and a statin per the neurology and [Known lastname ] teams. On [8-6], Ms. [Known lastname ] was successfully weaned from nitro at 8am, and her blood pressure remained stable at goal throughout the day on her home medications and oral hydralazine. Her creatinine continued to trend down slowly at 1.6. Her Tacro level was 13.1, and her dose was adjusted accordingly by the [Known lastname ] team. She was tolerating a ground/thin liquid diet, out of bed with physical therapy, and reported good pain control on oral pain medications. Her left neck incision staples were removed and steri strips applied. Her foley catheter was removed, and she voided without difficulty. She was instructed to follow up with the [Known lastname ] service as scheduled, the neurology stroke clinic on [10-6], and the vascular surgery clinic in 2 weeks. A packet of lab slips and requests was prepared by the [Month (only) ] team and provided to the rehabilitation facility with instructions. She will require daily physical and occupational therapy, speech therapy, and frequent bloodwork, and has worked with case management to choose an appropriate acute care rehabilitation facility near her home. Ms. [Known lastname ] and her husband understood and agreed with the plan, and she was discharged to rehab on [2179-8-6] in good condition. Medications on Admission: Fluconazole 400', Gabapentin 100''', Dilaudid 4 prn, Humalog SS, Lidoderm patch, Metoprolol 50''', Myfortic 360'', Zofran prn, Pantoprazole 40'', Prednisone 17.5', Kayexalate prn, Bactrim SS, Tacrolimus 4.5'', Valcyte 450 QOD Discharge Medications: 1. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. mycophenolate sodium 180 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 4. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 8. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 12. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for SBP > 140: Hold for systolic blood pressure less than 110. 13. insulin regular human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED): See sliding scale. 14. Insulin sliding scale Insulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-100 mg/dL 0 Units 101-150 mg/dL 2 Units 151-200 mg/dL 4 Units 201-250 mg/dL 6 Units 251-300 mg/dL 8 Units > 300 mg/dL 10 Units Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Left middle cerebral artery cerebrovascular accident Left internal carotid artery stenosis Discharge Condition: Mental Status: Clear and coherent, severe expressive aphasia. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You may resume your usual activity level as tolerated. You should continue physical therapy, speech therapy, and occupational therapy daily. Please leave your steri strips in place until they fall off on their own. Please keep your follow up appointments! Avoid heavy lifting and strenuous activity until you are seen in vascular surgery clinic. You may shower and clean your wound with soap and water. Avoid soaking in the tub or swimming until you are cleared by your surgeon. Followup Instructions: Please call to schedule a follow up appointment with Dr. [Last Name (STitle) 1391] in vascular surgery clinic in 2 weeks. Please follow up in stroke clinic on [10-6] as scheduled. Please follow up with [Month (only) ] clinic as scheduled Please have [Month (only) ] labs drawn using the lab slips provided, qMondays and Thursdays as directed.	[ "784.3", "784.51", "285.9", "433.10", "V42.7", "585.9", "584.9", "434.11", "342.91", "250.00", "305.1", "496", "403.90" ]	icd9cm	[ [ [] ] ]	[ "38.12", "00.40" ]	icd9pcs	[ [ [] ] ]	9246, 9318	3700, 7384	299, 384	9453, 9453		10167, 10531	1472, 1491		7661, 9223		9339, 9432		7410, 7638			9663, 10144							2237, 3063			1506, 1509																	3077, 3677											249, 261											412, 1140										1523, 1972		9468, 9639			1162, 1344	1360, 1456
47,940	111,433	1431+55284	Discharge summary	report+addendum	Admission Date: [2163-2-18] Discharge Date: [2163-2-24] Date of Birth: [2080-6-6] 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: [2163-2-18] Coronary artery bypass grafting x3; left internal mammary artery grafted to left anterior descending, reverse saphenous vein graft to the ramus intermedius and marginal branch. History of Present Illness: 2 year old russian speaking female with complaints of substernal chest pain with minimal exertion. She has refused cardiac catheterization for the past 3 years, but has recently agreed. Catheterization showed severe 3VD and she was referred for surgical revascularization. Today she presents for pre-operative testing prior to surgery [2-18]. Past Medical History: Hypertension Chronic Kidney Disease Diabetes Mellitus Gout s/p Cholecystectomy Social History: Race: Caucasian Last Dental Exam: many years ago Lives with: alone Occupation: previously worked in food store Tobacco: denies ETOH: denies Family History: non-contributory Physical Exam: Height:5'6" Weight:150 LBS General: No acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema trace bilat Varicosities: multiple superficial bilateral lower extremities Neuro: Grossly intact oriented per interpretter Pulses: Femoral Right: +2 Left: +2 DP Right: +1 Left: +1 PT [Name (NI) 167]: +1 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: no bruit Left: no bruit Pertinent Results: [2163-2-18] Echo: PRE BYPASS The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Left ventricular wall thicknesses and cavity size are normal. At the start of the study, in the presence of downsloping inferolateral ST segments on EKG, the left ventricle displayed severe global hypokinesis with an ejection fraction near 20%. At that time, the mitral regurgitation was moderate. The patient was treated with IV nitroglycerin and esmolol and this improved global function such that the patient was left with moderate to severe septal and apical hypokinesis. The inferior and lateral walls had just mild hypokinesis. The mitral regurgitation improved to mild to moderate. The right ventricle displayed focal hypokinesis of the apical free wall. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 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 moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST BYPASS: The patient is not receiving inotropic support post-CPB. Biventricular systolic function is similar to pre-bypass function. All other finding are consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings communicated to the surgeon. [2163-2-18] 02:09PM BLOOD WBC-18.3# RBC-3.44# Hgb-9.4# Hct-28.3# MCV-82 MCH-27.2 MCHC-33.1 RDW-14.3 Plt Ct-168 [2163-2-23] 05:22AM BLOOD WBC-10.7 RBC-3.29* Hgb-9.1* Hct-27.8* MCV-85 MCH-27.8 MCHC-32.8 RDW-14.5 Plt Ct-235 [2163-2-18] 02:09PM BLOOD PT-16.2* PTT-52.5* INR(PT)-1.4* [2163-2-18] 03:19PM BLOOD UreaN-48* Creat-1.4* Cl-118* HCO3-18* [2163-2-23] 05:22AM BLOOD Glucose-99 UreaN-51* Creat-1.6* Na-143 K-4.1 Cl-106 HCO3-30 AnGap-11 [2163-2-21] 02:30AM BLOOD Calcium-8.7 Phos-5.1* Mg-2.2 Brief Hospital Course: Ms. [Known lastname 8554] was a same day admit after undergoing pre-operative work-up as an outpatient. On [2-18] she was brought directly to the operating room where she underwent a coronary artery bypass grafting x 3. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. On post-op day one she was weaned from sedation, awoke neurologically intact and extubated. Patient remained in CVICU for several more days because of altered mental status. This improved with discontinuation of narcotic pain medications. Chest tubes and epicardial pacing wires were removed per protocol. On post-op day four she was transferred to the telemetry floor. She worked with physical therapy for strength and mobility during her recovery. She did receive an albumin for orthostatic hypotenstion and lightheadedness with walking. She continued to make steady progress and was discharged to rehabilitation on [2163-2-24]. She will follow-up with Dr. [Last Name (STitle) ], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Hyzaar 50 mg-12.5mg qd, Metoprolol Succinate 50 mg qd, Crestor 10mg qd, Aspirin 81mg qd Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Location (un) 583] House Discharge Diagnosis: Coronary artery disesae s/p coronary artery bypass graft x 3 Past Medical History: Hypertension Chronic Kidney Disease Diabetes Mellitus Gout Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with Acetaminophen prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Date/Time:[2163-3-24] 1:30PM Primary Care Dr. [Last Name (STitle) ] in [1-8] weeks Cardiologist Dr. [Last Name (STitle) 171] in [1-8] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Completed by:[2163-2-24] Name: [Known lastname 1133],[Known firstname 1134] Unit No: [Numeric Identifier 1135] Admission Date: [2163-2-18] Discharge Date: [2163-2-24] Date of Birth: [2080-6-6] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 741] Addendum: Discharged on 20mg lasix for 2+ LE edema and supplemental potassium for 10 days or until LE dema resolves and at pre-op weight. Discharge Disposition: Extended Care Facility: [Location (un) 177] House [Name6 (MD) ] [Name8 (MD) 747] MD [MD Number(2) 748] Completed by:[2163-2-24]	[ "518.0", "511.9", "250.00", "413.9", "274.9", "585.9", "458.0", "403.90", "780.02", "414.01", "E885.9", "E935.8", "285.9" ]	icd9cm	[ [ [] ] ]	[ "36.15", "39.61", "36.12" ]	icd9pcs	[ [ [] ] ]	8032, 8211	4227, 5359	331, 525	6345, 6445	1898, 4204	7068, 8009	1176, 1194		5497, 6081		6181, 6242		5385, 5474			6469, 7045										1209, 1879																												281, 293											553, 901															6264, 6324	1019, 1160
20,414	193,353	50355	Discharge summary	report	Admission Date: [2141-11-13] Discharge Date: [2141-11-25] Date of Birth: [2085-8-7] Sex: M Service: CARDIOTHORACIC Allergies: Penicillin G Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2141-11-13] Redo-sternotomy. Aortic Valve Replacement utilizing 23mm CE Pericardial Valve. Replacement of Ascending Aorta utilizing a 28mm Gelweave Graft. History of Present Illness: Mr. [Known lastname 98217] is a 56 year male with congenital bicuspid aortic valve who is s/p aortic valve replacement in [2130]. Serial echocardiograms since that time have shown evidence of ascending aortic aneurysm. Most recent ECHO from [2141-9-17] showed ascending aorta measuring 5.6 centimeters. His aortic valve was well seated with no aortic insufficiency. His LVEF was estimated at 60%. Subsequent CT scan measured his ascending aortic aneurysm at 5.1 x 5.7 centimeters. Cardiac catheterization in [Month (only) ] showed normal coronary arteries. Following dental clearance, he was admitted for cardiac surgical intervention. Past Medical History: Ascending Aortic Aneurysm, Bicuspid Aortic Valve - s/p Aortic Valve Replacement(Tissue) in [2130], Pacemaker Implantation in [2130], Hypertension, Obesity, Hypercholesterolemia, Bipolar Disorder, Diverticulosis, Cholelithiasis, Keratitis, Acne Social History: Denies tobacco history. Admits to only occasional ETOH. Works as a CPA. He is married. Family History: Father suffered MI at age 48, CABG at age 60. Uncle died of MI at age 55. Paternal grandfather died of MI at age 55. Physical Exam: Vitals: BP 130-140/70-80, HR 80, RR 12 General: pleasant, obese male in no acute distress HEENT: oropharynx benign, PERRL, EOMI Neck: supple, no JVD, no carotid bruits Heart: regular rate, normal s1s2, soft systolic murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, ntrace edema, no varicosities Pulses: 2+ distally, no femoral bruits Neuro: nonfocal Pertinent Results: [2141-11-23] 06:30AM BLOOD WBC-14.5* [2141-11-22] 09:25AM BLOOD WBC-12.8* RBC-3.22* Hgb-10.3* Hct-29.1* MCV-90 MCH-31.8 MCHC-35.3* RDW-15.0 Plt Ct-342 [2141-11-21] 05:30AM BLOOD WBC-10.7 RBC-3.12* Hgb-10.0* Hct-28.3* MCV-91 MCH-32.0 MCHC-35.4* RDW-15.0 Plt Ct-264 [2141-11-22] 09:25AM BLOOD Plt Ct-342 [2141-11-21] 05:30AM BLOOD Plt Ct-264 [2141-11-20] 02:14AM BLOOD Plt Ct-207 [2141-11-23] 06:30AM BLOOD Glucose-150* UreaN-32* Creat-1.8* Na-141 K-4.7 Cl-109* HCO3-18* AnGap-19 [2141-11-22] 09:25AM BLOOD UreaN-32* Creat-1.9* Na-141 K-4.6 [2141-11-21] 05:30AM BLOOD Glucose-219* UreaN-36* Creat-2.3* Na-140 K-4.0 Cl-106 HCO3-22 AnGap-16 [2141-11-23] 06:30AM BLOOD Amylase-173* [2141-11-22] 04:49PM BLOOD ALT-177* AST-49* LD(LDH)-558* AlkPhos-77 Amylase-181* TotBili-0.3 [2141-11-21] 05:15PM BLOOD ALT-236* AST-46* LD(LDH)-465* AlkPhos-73 Amylase-148* TotBili-0.4 [2141-11-20] 02:14AM BLOOD ALT-393* AST-72* AlkPhos-72 TotBili-0.5 [2141-11-18] 02:34AM BLOOD ALT-872* AST-288* LD(LDH)-439* AlkPhos-59 Amylase-130* TotBili-0.5 [2141-11-17] 04:00AM BLOOD ALT-1154* AST-649* LD(LDH)-618* AlkPhos-50 Amylase-129* TotBili-0.5 DirBili-0.2 IndBili-0.3 [2141-11-16] 02:17AM BLOOD ALT-1566* AST-1233* CK(CPK)-2185* AlkPhos-49 Amylase-56 TotBili-0.6 [2141-11-23] 06:30AM BLOOD Lipase-417* [2141-11-22] 04:49PM BLOOD Lipase-430* [2141-11-21] 05:15PM BLOOD Lipase-270* [2141-11-15] 01:50AM BLOOD HBcAb-POSITIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2141-11-15] 07:03PM BLOOD [Doctor First Name ]-POSITIVE Titer-1:40 [2141-11-15] 01:50AM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: Mr. [Known lastname 98217] was admitted and taken directly to the operating room where Dr. [Last Name (STitle) 1290] performed redo sternotomy, aortic valve replacement and replacement of his ascending aorta. For further surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. His early postoperative course was complicated by fevers, agitation, diabetes insipidus, hepatitis and acute renal insufficiency. The renal service was consulted and attributed his diabetes insipidus to Lithium. He was treated with free water and Ddavp while Sodium levels were monitored closely. The Hepatology service was also consulted and attributed his hepatitis to peri-operative shock liver. A renal/abdominal ultrasound on postoperative day one was unremarkable. He was intermittently transfused to optimize hemodynamics, while all nephrotoxins and hepatotoxins were avoided. Given agitation and clinical status, he was kept sedated and intubated for several days. He was pan-cultured for fevers with all cultures remaining negative. His creatinine peaked to 2.9. His LFTs peaked with an ALT of [2066] and AST of 3202. Bilirubins remained within normal limits. Amylase and lipase levels peaked later in his postoperative course - 181 and 430 respectively. The Psychiatric service was also consulted and recommended to continue to hold Lithium with reevaluation for another mood stablizer once medical issues stablize. Lithium levels were monitored closely as well. Mr. [Known lastname 98217] was eventually extubated on postoperative day four. By that time, he made significant clinical improvements as did his renal and liver function. He was out of bed, alert and oriented without agitation, and tolerating a diet. He continued to make progress and eventually transferred to the SDU on postoperative seven. He continued to progress and work with physical therapy. Psychiatry continued to follow him and on post operative day 10 he was started on lamictal and zyprexa. He continued to increase activity and was ready for discharge home with VNA on postoperaive day 12. Medications on Admission: Lithium 900 qam and 600 qpm, Doxycycline 100 qd, Atenolol 25 qd, Tricor 165 [Last Name (LF) ], [First Name3 (LF) ] 60 qd, Aspirin 81 qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:QS Refills:0 5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 12 days. Disp:12 Tablet(s) Refills:0 6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:40 Tablet(s) Refills:0 7. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day) for 2 weeks: then dose to be adjusted by Dr [Last Name (STitle) 3314]/[Doctor Last Name 17446]. Disp:14 Tablet(s) Refills:0 8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation/insomnia. Disp:30 Tablet(s) Refills:0 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 701] VNA Discharge Diagnosis: Ascending Aortic Aneurysm - s/p repair, Postop Acute Renal Insufficiency, Postop Hepatitis, Postop Diabetes Insipidus, Postop Pancreatitis, Postop Fevers, History of Aortic Valve Replacement(Tissue) in [2130], Pacemaker Implantation in [2130], Hypertension, Obesity, Hypercholesterolemia, Bipolar Disorder, Diverticulosis, Cholelithiasis Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Dr. [Last Name (STitle) 1290] in [3-22] weeks, call for appt Dr. [Last Name (STitle) 12646] in [1-20] weeks, call for appt Dr. [Last Name (STitle) ] in [1-20] weeks, call for appt Dr [Last Name (STitle) 3314] follow up outpatient counseling appointment please call for appt Dr [Last Name (STitle) 17446] follow up consultation appointment please call for appt Completed by:[2141-11-25]	[ "272.0", "787.91", "401.9", "E939.8", "588.1", "585.9", "441.2", "296.80", "570", "780.6", "423.1", "577.0", "V43.3", "746.4", "584.5", "V53.31", "V17.3", "278.00", "276.0" ]	icd9cm	[ [ [] ] ]	[ "96.6", "39.61", "38.93", "99.04", "37.12", "88.72", "35.21", "38.45" ]	icd9pcs	[ [ [] ] ]	7373, 7431	3761, 5920	300, 462	7821, 7828	2087, 3738	8146, 8570	1538, 1656		6114, 7350		7452, 7800		5946, 6091			7852, 8123										1671, 2068																												241, 262											490, 1143															1165, 1418	1434, 1522
27,856	118,769	33190	Discharge summary	report	Admission Date: [2103-2-27] Discharge Date: [2103-3-6] Date of Birth: [2023-12-17] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: recent GI bleed/bacteremia/new murmur Major Surgical or Invasive Procedure: [2103-2-27] AVR ( 27mm St. [Male First Name (un) 923] Epic porcine valve)/MVR 31mm St. [Male First Name (un) 923] Epic porcine valve)/ replace. asc./hemiarch aorta (34mm Gelweave graft) History of Present Illness: 79 yo male with lower GI bleed/strep B bacteremia recently and diagnosed with new murmur at that time. Echo showed 2+ AI, severe MR [First Name (Titles) 151] [Last Name (Titles) 12223],2+ TR, and ascending aorta 5.8 cm. Referred for surgery. Past Medical History: colon polyp GI bleed bacteremia HTN asbestos exposure PSH: open chole [2102] Social History: never used tobacco lives alone retired plumber no ETOH use Family History: both parents died of MIs 3 brothers and one sister died of MIs Physical Exam: 64" 160# HR 88 RR 14 right 123/84 NAD skin/HEENT unremarkable neck supple, full ROM, no carotid bruits appreciated CTAB holosystolic murmur soft, NT, ND, warm, well-perfused, no peripheral edema no obvious varicosities neuro grossly intact 3+ bil. fems/radials 1+ bil. DP/PTs Pertinent Results: [2103-3-6] 06:50AM BLOOD WBC-6.0 RBC-3.34* Hgb-10.1* Hct-29.3* MCV-88 MCH-30.3 MCHC-34.5 RDW-14.6 Plt Ct-136* [2103-3-6] 06:50AM BLOOD PT-16.9* PTT-62.9* INR(PT)-1.5* [2103-3-6] 06:50AM BLOOD Plt Ct-136* [2103-3-5] 05:00AM BLOOD Glucose-99 UreaN-17 Creat-0.9 Na-138 K-4.1 Cl-105 HCO3-24 AnGap-13 [2103-3-5] 05:00AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.0 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 77128] (Complete) Done [2103-2-27] at 1:05:25 PM PRELIMINARY Referring Physician [Name9 (PRE) ] Information [Last Name (Prefixes) 413], [First Name3 (LF) 412] 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: [2023-12-17] Age (years): 79 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Left ventricular function. Mitral valve disease. Mitral valve [Year (4 digits) 12223]. Prosthetic valve function. Valvular heart disease. ICD-9 Codes: 440.0, V43.3, 396.9 Test Information Date/Time: [2103-2-27] at 13:05 Interpret MD: [First Name8 (NamePattern2) 6506] [Name8 (MD) 6507], MD Test Type: TEE (Complete) 3D imaging. Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 6507], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.7 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 6.4 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% to 55% >= 55% Aorta - Sinus Level: 4.1 cm <= 3.6 cm Aorta - Ascending: 5.9 cm <= 3.4 cm Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast in the body of the LA. No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. No LA mass/thrombus (best excluded by TEE). All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA. Normal interatrial septum. No ASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with >55% decrease during respiration (estimated RAP (0-5mmHg). LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Moderately dilated LV cavity. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Moderately dilated aortic sinus. Dilated sinuses of Valsalva. Markedly dilated ascending aorta. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. Abnormal aortic valve. Moderate to severe (3+) AR. MITRAL VALVE: Myxomatous mitral valve leaflets. Moderate/severe MVP. Partial mitral leaflet flail. Mild mitral annular calcification. Moderate thickening of mitral valve chordae. Moderate to severe (3+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [[1-17]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic 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 TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The sinuses of Valsalva are dilated. The ascending aorta is markedly dilated The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. The aortic valve is abnormal. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are myxomatous. There is moderate/severe mitral valve [Month/Day (2) 12223]. There is partial mitral leaflet flail. There is moderate thickening of the mitral valve chordae. Moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Prosthetic Valve in the aortic and mitral position. Well seated and stable, good leaflet excursion and trace MR [First Name (Titles) ] [Last Name (Titles) ]. No appreciable gradient. 2. Unchanged LV and RV systolic function. 3. Tube graft in ascending aortic position. Interpretation assigned to [First Name8 (NamePattern2) 6506] [Name8 (MD) 6507], MD, Interpreting physician RADIOLOGY Final Report CHEST (PORTABLE AP) [2103-3-2] 1:08 PM CHEST (PORTABLE AP) Reason: r/o ptx [Hospital 93] MEDICAL CONDITION: 79 year old man s/p avr and ct removal REASON FOR THIS EXAMINATION: r/o ptx PROCEDURE: Chest portable AP on [2103-3-2]. COMPARISON: [2103-2-27], chest radiograph. HISTORY: 79-year-old man status post AVR and chest catheter removal, rule out pneumothorax. FINDINGS: There is no pneumothorax. The chest drainage catheter has been removed. In addition, the endotracheal tube has been removed. A sheath for a Swan-Ganz catheter persists after the removal of the Swan-Ganz. Note, however, that there is increase in the size of the cardiac shadow with a prominent left atrium visualized. Small bibasilar atelectasis is noted. IMPRESSION: 1. Status post removal of a chest drainage catheter with no complication like pneumothorax. 2. The endotracheal tube and Swan-Ganz catheter have been removed. A sheath for a Swan-Ganz catheter persists terminating in the right brachiocephalic vein. 3. Cardiac decompensation or pericardial effusion may explain the increase in the size of the cardiac shadow. Prominent left atrium. ab The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 11004] [Name (STitle) 11005] DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Approved: MON [2103-3-5] 6:32 AM RADIOLOGY Final Report CT HEAD W/O CONTRAST [2103-3-3] 9:11 AM CT HEAD W/O CONTRAST Reason: assess for infarct [Hospital 93] MEDICAL CONDITION: 79 year old man s/p avr, post-op weakness L upper ext REASON FOR THIS EXAMINATION: assess for infarct CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Postop weakness in the left upper extremity. Evaluate for infarct. COMPARISON: None. TECHNIQUE: Non-contrast axial images of the head are obtained with 5-mm section thickness. CT HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage or shift of normally midline structures. Right frontal subcortical rounded hyperdensity measuring approximately 15 x 10 mm and extending inferiorly into the centrum semiovale that may represent a subacute infarct though this is unclear. A posterior right parietal hypodense focus also could be due to acute/subacute infarct. More inferiorly a less hypodense focus (2:16) may represent a more recent, subacute, infarct. Surrounding osseous structures are unremarkable. Sphenoid sinus opacification is noted. Cerumen is noted within the external auditory canals bilaterally. IMPRESSION: Hypodense areas in right cerebral hemisphere indicate infarcts of undetermined age but could be subacute. MRI can help for further assessment. No hemorrhage. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3904] DR. [First Name (STitle) 3905] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3906] Approved: SAT [2103-3-3] 1:01 PM Brief Hospital Course: Admitted [2-27] and underwent AVR/MVR/repl. ascending and hemiarch aorta with Dr. [Last Name (STitle) 1290]. Transferred to CVICU in stable condition on phenylephrine and propofol drips. Extubated the morning of POD #1. Pt. had left-sided weakness, but moved all extremities to command. This was monitored over the next few days. Chest tubes and pacing wires removed without incident. His left sided strength improved. Went into A fib on POD #2. He was transfused. He was transferred to the floor on POD #4. He was started on heparin and coumadin for a fib. Head CT showed "Hypodense areas in right cerebral hemisphere indicate infarcts of undetermined age but could be subacute". He was ready for discharge to rehab on POD #7. Medications on Admission: lisinopril 10' Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 days: dose for today only [3-6]; then all further daily dosing per rehab provider. Discharge Disposition: Extended Care Facility: The Rehab Hospital of [Location (un) ] and Islands Discharge Diagnosis: MR/AI/ascending aortic aneurysm s/p AVR/MVR/replacement asc./hemiarch aorta asbestos exposure HTN prior GI bleed /colon polyp postop CVA postop A fib Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision SHOWER daily and pat incisions dry no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness or drainage Followup Instructions: see Dr. [Last Name (STitle) 31] in [1-17] weeks see Dr. [Last Name (STitle) ] [Last Name (STitle) ] [2-18] weeks see Dr. [Last Name (STitle) 1290] in 4 weeks [Telephone/Fax (1) 170] Completed by:[2103-3-6*]	[ "997.02", "434.91", "396.3", "427.31", "E878.1", "401.9", "397.0", "997.1", "285.9", "441.2" ]	icd9cm	[ [ [] ] ]	[ "38.45", "35.23", "35.21", "39.61", "99.04" ]	icd9pcs	[ [ [] ] ]	11775, 11856	10292, 11029	359, 560	12050, 12057	1413, 5278	12312, 12553	1035, 1099		11094, 11752	8847, 8901	11877, 12029		11055, 11071			12081, 12289									5327, 6757	1114, 1394																												282, 321	8930, 10269										588, 839															861, 943	959, 1019						6767, 7274
19,547	106,062	43699	Discharge summary	report	Admission Date: [2151-5-10] Discharge Date: [2151-6-4] Service: SURGERY Allergies: Cipro / Nitrofurantoin / Acyclovir / Bactrim Attending:[First Name3 (LF) 2777] Chief Complaint: Surgical wound erythema and drainage Major Surgical or Invasive Procedure: Wound debridement bedside OR wound debridement PICC line placement VAC placejment History of Present Illness: The patient is an 83-year-old female with a history of diabetes who underwent a left fem below-the-knee [Doctor Last Name ] bypass in [Month (only) 956] [2151] for a nonhealing foot ulcer and presented to [Hospital1 18] on [5-10], [2151] with wound erythema and drainage. This had been treated with a vac dressing and was found to need further operative debridement. Past Medical History: DM x 20 + years, on oral hypoglycemics HTN s/p b/l hip replacement with chronic hip pain constipation chronic UTI's on prophylactic Keflex hypercholesterolemia s/p CVA- (right-sided) osteoporosis lumbo-sacral arthritis disc disease with spinal stenosis at L3-4 level DJD b/l hips Social History: Lives at home, has home aide 4 hours per day/ VNA. Ambulates with walker, uses motorized chair for longer distances. No tobacco, ETOH, or alcohol. Daughter involved with care. Family History: NC Physical Exam: elderly female a/ox3 nad rrr cta abd - benign palp L [Doctor Last Name ], dopp L DP/PT Open wound / clean and dry Pertinent Results: [2151-5-27] 05:04AM BLOOD WBC-6.1 RBC-2.94* Hgb-8.6* Hct-26.8* MCV-91 MCH-29.2 MCHC-32.1 RDW-16.1* Plt Ct-231 [2151-6-4] 05:30AM BLOOD PT-16.8* INR(PT)-1.5* [2151-5-27] 05:04AM BLOOD Glucose-108* UreaN-16 Creat-1.2* Na-141 K-3.6 Cl-101 HCO3-35* AnGap-9 [2151-5-12] 04:58AM BLOOD ALT-9 AST-13 LD(LDH)-176 AlkPhos-60 Amylase-40 TotBili-0.2 [2151-5-27] 05:04AM BLOOD Albumin-3.0* Calcium-8.9 Phos-4.0 Mg-2.0 Iron-23* [2151-5-25] 09:01AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.009 URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 [2151-5-10] 8:55 pm SWAB L. LE. GRAM STAIN (Final [2151-5-11]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [2151-5-13]): STAPH AUREUS COAG +. HEAVY GROWTH. STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- S VANCOMYCIN------------ <=1 S [2151-5-12] 10:15 AM CHEST PORT. LINE PLACEMENT Reason: Left arm PICC HISTORY: 83-year-old female with fever, lethargy and new left PICC line. Evaluate thorax. FINDINGS: Portable radiograph, comparison [2151-5-10], demonstrates interval placement of a left PICC line which terminates approximately 2.5 cm below the cavoatrial junction. The right pleural effusion has decreased since prior study. There has also been interval clearing at the right base. There is increased opacity at left base, likely atelectatic. The heart and mediastinum are normal in appearance. IMPRESSION: 1. Interval placement, left PICC line terminating in the upper right atrium. 2. Likely atelectasis at left base. Brief Hospital Course: pt admitted cx's taken coumadin stopped / heparin started broad spectrum AB started OR for wound debridment - no complications or sequela coumadin started / heparin bridge - for DVT PICC line placed / xray confirms placement VAC changed q 3 days. AB tailored to sensitiviteis Wound looks good for DC Stable to rehab Medications on Admission: Fentanyl 75 mcg/hr Patch 72HR, Atorvastatin 40', Aspirin 325', Gabapentin 300", Panntoprazole 40', Furosemide 40 mg', Metoprolol 25", Docusate 100", Rosiglitazone 8', Mirtazapine 15 QHS, Glipizide 5', Lisinopril 20', Coumadin 1 or 2' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): goal INR [2-13]. 5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 11. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. 12. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 14. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 16. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 18. Bisacodyl 10 mg Suppository Sig: [1-12] Suppositorys Rectal HS (at bedtime) as needed. 19. PICC LINE CARE Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 20. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q48H (every 48 hours): PLEASE DRAW TROUGHS EVERY 3 RD DOSE / DOSE VANCOMYCIN FOR TROUGH BETWEEN 15-29. Discharge Disposition: Extended Care Facility: [Hospital1 ] Discharge Diagnosis: non healing foot ulcer dvt - COUMADIN GOAL [2-13] wound dehiscance with wound infection cellulitis htn uti pvd Discharge Condition: stable Discharge Instructions: Open Wound: VAC DRESSING Patient's Discharge Instructions Introduction: This will provide helpful information in caring for your wound. If you have any questions or concerns please talk with your doctor or nurse. You have an open wound, as opposed to a closed (sutured or stapled) wound. The skin over the wound is left open so the deep tissues may heal before the skin is allowed to heal. Premature closure or healing of the skin can result in infection. Your wound was left open to allow new tissue growth within the wound itself. The wound is covered with a VAC dressing. This will be changed around every three days. The VAC: _ helps keep the wound tissue clean _ absorbs drainage _ prevents premature healing of skin - promotes healing When to Call the Doctor: Watch for the following signs and symptoms and notify your doctor if these occur: Temperature over 101.5 F or chills Foul-smelling drainage or fluid from the wound Increased redness or swelling of the wound or skin around it Site: THIGH LE Type: Surgical Dressing: VAC, Continuous, Black Foam, Target Presure 125 mm Hg Change dressing: Other Comment: Q 3RD DAY DRESSING CHANGE PICC care. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Moniter vanco trough / goal is 15-20. please check trough every third dose and adjust accordingly INR moniter, goal is [2-13], Pt with hx of DVT. Pt PCP may DC at his discresion. Pt with foley. DC at rehab when pt is mobile enough to go to bathroom Increasing tenderness or pain in or around the wound Followup Instructions: Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 252], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2151-7-26] 11:00 Call Dr [Last Name (STitle) ] office at [Telephone/Fax (1) 2625]. You have an appointment scheduled on the [7-1] at 1430 hrs Completed by:[2151-6-4]	[ "998.32", "998.59", "724.02", "272.0", "041.11", "564.00", "250.00", "E878.2", "V43.64", "V58.61", "401.9", "733.00", "682.6", "707.15", "703.8" ]	icd9cm	[ [ [] ] ]	[ "86.04", "38.93", "86.27", "86.22" ]	icd9pcs	[ [ [] ] ]	6125, 6168	3575, 3902	288, 372	6327, 6336	1465, 3552	8037, 8348	1307, 1312		4186, 6102		6189, 6306		3928, 4163			6360, 8014										1327, 1446																												211, 250											400, 793															815, 1097	1113, 1291
9,665	111,945	28873+57612	Discharge summary	report+addendum	Admission Date: [2178-7-25] Discharge Date: [2178-7-31] Service: NEUROLOGY Allergies: Dilantin Attending:[First Name3 (LF) 2569] Chief Complaint: status epilepticus Major Surgical or Invasive Procedure: Intubation CT MRI Lumbar Puncture History of Present Illness: This is a 84 y/o woman with h/o seizures starting in [2178-9-20], HTN, spinal stenosis who was in her usual state of health this morning, when she reported to her daughter a sudden onset of headache followed by a "feeling of something bad". Her daughter took her to a pharmacy to get BP checked. It was 222/104. Upon returning home, the pt. started with an automatism, but was verbalizing appropriately. Daughter called EMS and patient was seizing by the time EMS arrived. Her daughter described the seizure as face contortion. The [Hospital1 ] ED attending reported a generalized seizure with R > L movements and R-sided gaze. She was initially given 4 mg ativan in the ED which temporarily stopped seizure activity, but she resumed seizing shortly thereafter. An additional 4mg ativan was given, which again worked temporarily. A final dose of 4 mg ativan was given, for a total of 12 mg, and propofol was started, given her allergy to dilantin. She was intubated for airway protection. Past Medical History: -seizures: Her first seizure of record was in [2178-9-20] but was not worked up fully. In [2178-3-21], she had an episode similar to today's episode starting with a HA and progressing to a seizure (confused with repetitive movements and right arm shaking, BP 233/110) and was brought to [Hospital1 2025] where she was intubated for airway protection. She had a full seizure workup at [Hospital1 2025] with LP which was negative for infection, EEG which was abnormal due to diffuse background slowing but showed no epileptiform discharges, MRI which showed evidence for PRES, CTA showed moderate narrowing of Right P2 segment and small areas of hypodensity in occipital and parietal lobes. . -HTN -hypercholesterolemia -gout -anxiety -spinal stenosis Social History: lives with daughter at home. Questionable medication compliance. Family History: n/a Physical Exam: Vitals: T 102.8; BP 170/75; P 70; O2- 100% ventilated (CMV, TV- 500, PEEP 5, Rate 12) . General: lying in bed intubated HEENT: NCAT, moist mucous membranes Neck: supple Pulmonary: CTA b/l Cardiac: regular rate and rhythm, with no m/r/g Carotids: no blood flow murmur Abdomen: soft, nontender, non distended, normal bowel sounds Extremities: no c/c/e. . Neurological Exam: Mental status: unersponsive on arrival to ED, no spontaneous movements, no purposeful withdrawal from pain, no doll-eye movement with eyes fixed forward gaze, pupils 2mm unreactive bilaterally, . Motor: Normal bulk. Normal tone. No adventitious movements. unable to assess strength . Reflexes: Bic T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes mute bilaterally. Pertinent Results: [2178-7-25] 08:58PM CK-MB-5 cTropnT-0.04* [2178-7-25] 12:12PM CK(CPK)-304* [2178-7-25] 04:58AM TYPE-ART PO2-207* PCO2-33* PH-7.48* TOTAL CO2-25 BASE XS-2 [2178-7-25] 03:30AM GLUCOSE-111* UREA N-10 CREAT-0.9 SODIUM-141 POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15 [2178-7-25] 03:30AM ALT(SGPT)-10 AST(SGOT)-18 LD(LDH)-252* CK(CPK)-217* ALK PHOS-72 TOT BILI-0.4 [2178-7-25] 03:30AM VIT B12-294 [2178-7-25] 03:30AM %HbA1c-5.8 [Hgb]-DONE [A1c]-DONE [2178-7-25] 03:30AM TSH-2.4 [2178-7-25] 03:30AM WBC-13.1* RBC-3.74* HGB-9.7* HCT-27.8* MCV-74* MCH-25.8* MCHC-34.8 RDW-17.5* [2178-7-24] 09:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-71* GLUCOSE-76 [2178-7-24] 09:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-57* POLYS-17 LYMPHS-60 MONOS-22 ATYPS-1 [2178-7-24] 09:00PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1370* POLYS-57 LYMPHS-31 MONOS-10 ATYPS-2 . Head CT: No intracranial hemorrhage or mass effect is identified. . MRI with/without Gad: Bilateral posterior foci and supratentorial signal changes predominantly in the subcortical region with a distribution suggestive of posterior reversible encephalopathy/hypertensive encephalopathy. No evidence of slow diffusion or abnormal enhancement seen in these regions. No mass effect or hydrocephalus . EEG [7-25]: This is a moderately abnormal EEG due to the presence of a slow background with occasional bifrontal slow waves seen. This pattern is consistent with an encephalopathy of toxic, metabolic, or anoxic etiology, or can be seen with disorders affecting midline or bilateral white matter areas, particularly in the frontal lobes. Occasionally, patients with raised intracranial pressure can have bifrontal slow waves. Clinical correlation is recommended. No evidence of ongoing or potential epileptogenesis is seen at this time . EEG [7-29]: BACKGROUND: Included a well-formed 9 Hz alpha frequency in posterior areas bilaterally during wakefulness. There was a faster superimposed beta rhythm as well. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: The patient appeared to remain awake or minimally drowsy throughout the recording. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Mildly abnormal EEG in the waking state due to the frequent but brief theta slowing in the left temporal region. There were no areas of more persistent focal slowing, and there were no epileptiform features. Brief Hospital Course: ICU Course Neuro: Intubated in the ED for airway protection. After an initial examination, she was sent for a STAT head CT which showed no new hemorrhage or major territorial infarction (see results above). Following this, an LP was performed as there was concern for CNS infection as seizure source based on her fever. LP findings negative except as traumatic tap (see results above). MRI performed later the following morning showed findings consistent with hypertensive leukoencephalopathy. This was felt to be the etiology of her seizure, as pt. had no evidence of other pathology, such as stroke or mass, on her MRI. Patient was extubated on [7-26] without complications. Passed a speech and swallow for solids and thickened liquids on [7-27] and was transferred to the floor. . Seizure prophylaxis was maintained with propofol and Keprra 1000mg NG [Hospital1 ]. After extubation, only Keppra was continued. . CVS: Blood pressure in the ICU was managed with patient's home medication regimen: Metoprolol 100mg PO TID, Valsartan 180mg Daily, Lasix 10mg IV (takes 20 PO at home) as well as addition of prn Hydralazine IV for SBP greater than 160. . ID: Febrile on admission, but defervesced quickly. Blood cultures sent on admission and within 20 minutes of IV Vancomycin and Ceftriaxone starting. CSF sent for cultures, GS and HSV PCR, all of which returned negative. Initially covered broadly with empiric doses of ABX for suspected CNS infection with IV Ampicillin, Vancomycin, Ceftriaxone. Also treated with Acyclovir at CNS infection doses (10mg /kg Q8 hrs). These were d/ced as cultures came back negative. . Renal: Some renal insufficiency on admission which resolved with IV fluids. Received extra fluid boluses with each dose of Acyclovir. . Floor Course: Neuro: Pt. was initially continued on Keppra 1000 [Hospital1 ], and had no further seizures. Pt. became more confused on her second day on the floor. Infection was considered, however pt. was afebrile and CXR, UA, Urine Cx and blood cx were negative. NCSE was considered, however repeat EEG was negative. Med effect was considered, and symptoms resolved with decreasing Keppra dose to 750 [Hospital1 ] and d/cing Acyclovir when CSF HSV came back negative. Of note, BP control improved as MS improved it was felt that this may also have contributed. Pt. was seen by PT and OT, who recommended acute rehab given weakness below baseline. . CV: BP control was continued as above (see ICU course) Pt. was noted to have several episodes of narrow complex tachycardia with rates of 140s-160s on telemetry. These were asymptomatic and not associated with hypotension, although pt. was noted to have ST depressions in inferior and lateral leads during the episodes that resolved when her rhythm returned to baseline. Acute episodes responded to 10 mg IV Diltiazem and did not recur after Diltiazem 30 mg PO QID was started and Metoprolol titrated up to 125 TID per recommendation of the cardiology service. Diltiazem was increased to 60 QID on [7-31] given inadequate BP control on lower doses, and should continue to be titrated as necessary at Rehab. Once dosing is stable pt. could be converted to once a day long-acting CCB. Cardiology recommended a TTE, which was performed on the day of discharge. Results of this were pending at time of discharge and should be followed up by pt's physician at [Name9 (PRE) ]. The Echo lab here can be reached at [Telephone/Fax (1) 3312]. Medications on Admission: keppra 500 mg [Hospital1 ] lasix 20 qd lipitor 40mg qd diovan 160 qd metoprolol 100 tid klonopin 1mg TID PRN FA Discharge Medications: 1. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 4. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Hypertensive Encephalopathy Generalized Tonic Clonic Seizure [1-22] hypertensive encephalopathy Hypertension, poorly controlled Discharge Condition: Improved- no further seizures, tolerating medications, BP controlled 130s-150s. Discharge Instructions: Please call your doctor or go to the ER if you have any further seizures, headache, nausea, vomiting, fevers, chills, numbness, weakness, or any other symptoms that concern you. . Please take all medications as prescribed Followup Instructions: Primary Care: Please call Dr. [Last Name (STitle) 69676] at [Telephone/Fax (1) 31553] to set up a follow up appointment for 1-2 weeks after you are discharged from [Hospital1 ]. Cardiology: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4450], M.D. Phone:[Telephone/Fax (1) 4451] Date/Time:[2178-9-23] 9:40 [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2178-7-31] Name: [Known lastname 5339],[Known firstname 11852] Unit No: [Numeric Identifier 11853] Admission Date: [2178-7-25] Discharge Date: [2178-7-31] Date of Birth: [2093-7-29] Sex: F Service: NEUROLOGY Allergies: Dilantin Attending:[First Name3 (LF) 3326] Addendum: TTE read: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 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. Mild to moderate ([12-22]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Discharge Disposition: Extended Care Facility: [Hospital3 14] & Rehab Center - [Hospital1 15] [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 3327] Completed by:[2178-7-31]	[ "294.8", "427.89", "272.0", "275.3", "437.2", "275.42", "593.9", "401.0", "E938.3", "345.3", "276.2", "298.9", "300.00", "724.00", "280.9", "272.4" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "96.6" ]	icd9pcs	[ [ [] ] ]	11993, 12211	5511, 9007	237, 273	10134, 10216	2997, 3909	10486, 11970	2201, 2207		9174, 9856		9979, 10113		9033, 9151			10240, 10463										2222, 2575																											2594, 2594	178, 199											301, 1309				3918, 5488								2609, 2978			1331, 2102	2118, 2185
8,459	157,054	30518	Discharge summary	report	Admission Date: [2115-2-22] Discharge Date: [2115-3-8] Date of Birth: [2036-2-24] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 9240] Chief Complaint: s/p fall and unable to get up x 2hrs Major Surgical or Invasive Procedure: TEE History of Present Illness: 78 yo M h/o HTN, hyperchol, who presents brought in by EMS found down at home by niece. Patient is poor historian. Per report, patient fell out of bed this AM and was able to get up and walk around. Later fell again, and was down for 2+ hours, unable to get up. Patient only remebers the first fall when he was able to get back up. Reports dizziness/lightheadedness prior to the fall, denies LOC. He reports pain in his R knee and R side, which he says has been present >4yrs since a motor vehicle accident. Patient reports recent N/V x 2 days. Reports in ED records that niece noticed several days of N/V/Diarrhea. Denies CP, SOB, palp, fever, or chills. . In the ED, patient was tachycardic 100-120's, febrile to 102.8. c/o pain in neck, shoulder, back, knees. Elevated WBC w/ bandemia. Labs also c/w with rhabdo (CK 7926). UA negative. Blood and urine cxs sent. CT head neg for ICH, CT neck neg for fracture. Persistently febrile & tachycardic despite 4LNS in ED. Also given vanco and ceftriaxone, then admitted to MICU for further management. Past Medical History: HTN Hypercholesterolemia Borderline Mentally Challenged (limited education) Social History: Lives alone, niece living downstairs. Denies tob/EtOH/drug use. Family History: DM - Brother Physical Exam: VS: T: 98.8 (Tm 102.8); HR: 99; BP: 104/66; RR 19; O2 97% 2LNC GEN: elderly man, lying in bed, NAD HEENT: PERRL bilat, EOMI bilat, anicteric, MMM, OP clear NECK: JVP not elevated CV: RRR, grade III/VI SEM at apex CHEST: CTA bilat. no crackles/wheezes. ABD: NABS, soft, ND, NT, no hepatosplenomegaly EXT: R knee with effusion, warm to touch, no decreased ROM NEURO: A&Ox3, CN 2-12 intact bilat, FTN testing intact bilatsensory/motor exam intact bilat Pertinent Results: [2115-2-27] 08:25AM BLOOD HCV Ab-NEGATIVE [2115-2-27] 08:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2115-2-23] 04:28AM BLOOD TSH-2.0 [2115-2-22] 07:50PM BLOOD cTropnT-<0.01 [2115-2-23] 02:30AM BLOOD CK-MB-12* MB Indx-0.2 cTropnT-<0.01 [2115-2-23] 04:28AM BLOOD CK-MB-12* MB Indx-0.2 cTropnT-<0.01 [2115-2-22] 07:50PM BLOOD CK(CPK)-7926* [2115-2-27] 08:25AM BLOOD ALT-63* AST-49* CK(CPK)-151 AlkPhos-121* TotBili-1.4 [2115-2-28] 06:30AM BLOOD ALT-51* AST-34 AlkPhos-120* TotBili-1.0 [2115-2-22] 07:50PM BLOOD Glucose-133* UreaN-31* Creat-1.2 Na-136 K-4.2 Cl-99 HCO3-23 AnGap-18 [2115-3-2] 06:45AM BLOOD Glucose-104 UreaN-12 Creat-1.1 Na-142 K-4.3 Cl-106 HCO3-27 AnGap-13 [2115-2-22] 07:50PM BLOOD WBC-17.5* RBC-4.69 Hgb-15.4 Hct-44.6 MCV-95 MCH-32.8* MCHC-34.4 RDW-12.7 Plt Ct-115* [2115-3-2] 06:45AM BLOOD WBC-13.1* RBC-4.04* Hgb-12.7* Hct-39.2* MCV-97 MCH-31.3 MCHC-32.3 RDW-13.2 Plt Ct-359 [2115-2-22] 08:20PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.025 [2115-2-22] 08:20PM URINE Blood-LG Nitrite-POS Protein-30 Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2115-2-22] 08:20PM URINE RBC-[3-4]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [2115-2-26] 10:41AM JOINT FLUID WBC-[Numeric Identifier ]* RBC-1250* Polys-93* Lymphs-1 Monos-4 Atyps-1* Other-1* [2115-2-26] 10:41AM JOINT FLUID Crystal-NONE . [2-22] Blood Culture: SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R . CXR#1: Increased airspace opacity involving the bilateral lung bases. Diagnostic considerations include pneumonia. Equivocal, small, left-sided pleural effusion. . CXR #2: Interval mild-to-moderate worsening of the bibasilar airspace opacities, now associated with retrocardiac consolidation. Also, worsening in bibasilar pleural effusions as compared to three days ago. . CXR#3: Small bilateral pleural effusions greater in the right side have decreased in amount. Mild pulmonary edema is resolved. Cardiac size is normal. The aorta is unfolded. There is no pneumothorax. . TEE No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are severely thickened/deformed. There is moderate/severe bileaflet mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Impression: Bileaflet mitral valve prolapse with moderate mitral regurgitation. No echo evidence of endocarditis. . RUQ U/S: Findings equivocal for acute cholecystitis. If this remains a clinical concern HIDA scan could be performed. . CT chest/abd/pelvis: 1. Distended gallbladder with intraluminal stones and debris. Cholecystitis cannot be excluded from this study and if clinical concern, recommend ultrasound for further evaluation. 2. Bibasilar consolidation consistent with pneumonia and a small right-sided effusion. 3. Ventral and left inguinal hernias. No evidence of bowel obstruction. 4. Air within the bladder and anterior bladder diverticulum, please clinically correlate (? recent Foley placement). . TTE: Conclusions: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 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 arch 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. There is moderate/severe mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. No vegetation seen (cannot definitively exclude). . Brief Hospital Course: #s/p Fall: though patient unable to give much history, no focal neuro findings; serial CE negative. Head CT without ICH or CVA. . #MSSA Bacteremia/PNA: bacteremia likely from underlying PNA. Given lower lobe PNA, ? if patient aspirated after he fell. Regardless, initially treated with Levaquin, but then switched to IV Nafcillin per ID recommendations. Will complete a total of a 3 week course from last negative culture. TEE negative for endocarditis. Repeat TTE also negative for endocarditis. . #ileus:On [3-1] pt. developed n/v and abd distention worrisome for a bowel obx. An NGT was placed which drained ~1L fluid after placement c/w obstruction. However, CT abdomen did not show bowel obx. It revealed a dilated GB with some stones. A follow up RUQ U/S showed a dilated GB with stones, no wall thickening and negative son[Name (NI) 493] [Name (NI) ] sign. Given no clinical signs of cholecystitis a HIDA scan was not persued. ID was consulted however given that his WBC rose from 19 to 43, with no clear source other than his PNA. He did begin to have some diarrhea, which was negative for C. Diff but ID recommended treating empirically with flagyl for one week longer than his nafcillin course. They recommended changing his nafcillin to q4h from q6h. Surveillance BCx remained negative and his ileus and leukocytosis resolved. He was tolerating a regular diet at discharge. #R knee effusion: ?Sympathetic from fall and knee contusion. Was tapped (as patient was bacteremic); no evidence of septic arthritis or crystal arthropathy. . #Atrial Flutter: during the first few days in house, the patient was intermittently in A fib/Flutter, which responsed to treatment with nodal agents. Eventually transitioned to PO Diltiazem and pt remained in sinus rhythm. Given flutter was likely related to acute illness, decision was made to hold on Anticoagulation. This was discussed with the patient's PCP. . #Mitral Valve Prolapse/MVR: as noted on TEE. Should receive abx prior to dental procedures, etc. . #Left eye posterior vitreous detachment/Floater: the patient complained of some blurriness in his left eye associated with decreased visual acuity. Seen by ophthalmology and seen to have a small posterior vitreous detachment, instructed to f/u with ophtho in one month. . #E Coli UTI: treated with Levaquin and eventually Nafcillin (was Pan-S). . #Rhabdomyolysis: resolved after IVF. No impairment of renal fx. . #Mildly elevated LFTs: resolved spontaneously, likely mildly elevated AST from rhabdo. Hep B/C negative. Statin held. Medications on Admission: HCTZ Lipitor (unsure of doses) Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 units Injection TID (3 times a day). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 weeks. 8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. 9. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) g Intravenous Q4H (every 4 hours) for 2 weeks. 10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 11. Outpatient Lab Work Please check CBC with diff, Cr, LFTs every Monday Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: 1. s/p Fall 2. MSSA Bacteremia/PNA 3. R knee effusion, ?sympathetic 4. Atrial Flutter 5. Mitral Valve Prolapse, no signs of endocarditis 6. Left eye posterior vitreous detachment/Floater 7. E Coli UTI 8. Rhabdomyolysis, resolved Discharge Condition: stable Discharge Instructions: Please come back to the ED should you develop any fevers, chills, sweats, nausea, vomiting, cough, shortness of breath, or worsening visual changes. Followup Instructions: Please f/u with Dr. [First Name (STitle) 4223] within 2 weeks. [Apartment Address(1) 72470] [Hospital1 8], [Numeric Identifier 72471] Phone: ([Telephone/Fax (1) 72472] Please f/u with Opthamology within 1 month. [Telephone/Fax (1) 253].	[ "424.0", "560.1", "719.06", "401.9", "427.32", "511.9", "599.0", "272.0", "041.4", "482.41", "427.31", "379.21", "728.88", "276.51", "E885.9", "038.11", "995.91" ]	icd9cm	[ [ [] ] ]	[ "38.93", "81.91", "88.72" ]	icd9pcs	[ [ [] ] ]	10995, 11074	7204, 9774	351, 356	11347, 11356	2143, 7181	11553, 11819	1643, 1657		9855, 10972		11095, 11326		9800, 9832			11380, 11530										1672, 2124																												275, 313											384, 1446															1468, 1545	1561, 1627
71,513	183,120	53664	Discharge summary	report	Admission Date: [2107-5-16] Discharge Date: [2107-5-24] Date of Birth: [2020-8-7] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Aortic valve replacement (#23 Tissue)/CABG x3 (LIMA-LAD; SVG to OM; SVG to PDA) [2107-5-17] History of Present Illness: This is a 86 year old male with known aortic stenosis and coronary artery disease. Serial echocardiograms have shown progression of his aortic stenosis. Current symptoms include occasional, non-exertional dizzy spells and mild dyspnea on exertion. He denies exertional chest pain. He has no history of syncope, orthopnea, PND, or pedal edema. He was referred to Dr. [Last Name (STitle) ] to discuss aortic valve replacement surgery. He presents for pre-op cath today and is admitted for surgery tomorrow. Past Medical History: - Aortic Stenosis/Coronary Artery Disease - Hypertension - Dyslipidemia - Factor V Leiden deficiency, no history of clotting problems - Neurogenic Bladder, patient self caths 3-4 times daily - Bladder Calculus - ? TIA post cath [2105-1-9], no residual symptoms - Hypothyroidism - Diverticulosis - Calcified Pulmonary Granulomas on CT scan - Umbilical Hernia - Varicose Veins(mostly right leg) - Bilateral Hearing Loss Past Surgical History: - Endovascular AAA repair [2105-11-9] - Tonsillectomy - Melanoma Excision on back Past Cardiac Procedures: - s/p PPM Implantation [Company 1543] Sensia DR SEDR01, [2103-9-10] - Rotablation of prox LAD with PCI/[Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2(Xience), Social History: Lives: Alone in [Location (un) 5622], daughter and son-in-law live in JP (son-in-law is a [Hospital1 ] PCP) Cigarettes: 20-30 PYH, quit 30 years ago ETOH: 2 glasses of wine per day Illicit drug use: Denies Family History: Denies premature coronary artery disease Physical Exam: Pulse: 55 Resp: 16 O2 sat: 100% B/P Right: 108/61 Left: General: Pleasant Elderly male in no acute distress Skin: Dry [x] intact [x] - well healed incision on back HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade 3/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: Trace Varicosities: R GSV diffusely varicosed. L GSV with varicosity noted calf region otherwise appeared OK Neuro: Grossly intact [x] Pulses: Femoral Right: 2 Left: 2 - bilateral femoral scars noted DP Right: 1 Left: 1 PT [Name (NI) 167]: 1 Left: 1 Radial Right: TR band Left: 2 Carotid Bruit: transmitted murmurs bilaterally Pertinent Results: [2107-5-17] Intra-op TEE Conclusions Prebypass No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are complex atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results on [2107-5-17] at 900 am. Post bypass Patient ia AV paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Bioprosthetic valve seen in the aortic position. It appears well seated and the leaflets move well. There is mild mitral regurgitation. The aorta is intact post decannulation. Rest of the examination is unchanged post bypass. . [2107-5-24] 04:45AM BLOOD WBC-6.6 RBC-2.92* Hgb-9.6* Hct-30.4* MCV-104* MCH-32.9* MCHC-31.7 RDW-13.3 Plt Ct-247 [2107-5-22] 06:35AM BLOOD WBC-5.5 RBC-2.96* Hgb-10.1* Hct-30.5* MCV-103* MCH-34.0* MCHC-33.0 RDW-13.3 Plt Ct-194 [2107-5-24] 04:45AM BLOOD PT-15.0* INR(PT)-1.4* [2107-5-23] 10:55AM BLOOD PT-13.1* INR(PT)-1.2* [2107-5-22] 06:35AM BLOOD PT-12.5 INR(PT)-1.2* [2107-5-18] 02:03AM BLOOD PT-12.6* PTT-29.7 INR(PT)-1.2* [2107-5-17] 01:23PM BLOOD PT-12.9* PTT-32.0 INR(PT)-1.2* [2107-5-17] 12:09PM BLOOD PT-15.8* PTT-26.4 INR(PT)-1.5* [2107-5-24] 04:45AM BLOOD UreaN-26* Creat-0.8 Na-138 K-4.4 Cl-106 [2107-5-21] 06:35AM BLOOD Glucose-103* UreaN-27* Creat-1.0 Na-137 K-3.4 Cl-101 HCO3-25 AnGap-14 Brief Hospital Course: The patient was brought to the Operating Room on [2107-5-17] where the patient underwent AVR, CABG with Dr. [Last Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Mr. [Known lastname 732] developed [Last Name (un) ]-operative delirium once extubated and required haldol therapy with good results. As his mental status returned to baseline, the haldol was weaned off. The patient was transferred to the telemetry floor for further recovery. Permanent pacer was interrogated. Mr. [Known lastname 732] developed post-operative atrial fibrillation and was treated with betablockaide and amiodarone. Plavix was discontinued and Coumadin started. By the time of discharge, he was in sinus rhythm. 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 7 the patient was ambulating,yet deconditioned, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to Newbridge on the [Doctor Last Name ] in good condition with appropriate follow-up instructions. Medications on Admission: Aspirin 81mg every other day Plavix 75mg daily, last dose [2107-5-10] Atenolol 50mg daily Levothyroxine 112mcg daily Levofloxacin 250mg prn UTI sxs Losartan 50mg daily Simvastatin 40mg daily Citrucel prn Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR Coumadin for post-op AFib Goal INR 2-2.5 First draw [2107-5-25] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by [Provider Number 110203]. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 13. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [Hospital1 ] x 1 week, then 400mg daily x 1 week, then 200mg daily. 14. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: MD to dose daily for goal INR 2-2.5. 16. furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days. 17. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 7 days. Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] - [Location (un) 1411] Discharge Diagnosis: - Aortic Stenosis/Coronary Artery Disease - Hypertension - Dyslipidemia - Factor V Leiden deficiency, no history of clotting problems - Neurogenic Bladder, patient self caths 3-4 times daily - Bladder Calculus - ? TIA post cath [2105-1-9], no residual symptoms - Hypothyroidism - Diverticulosis - Calcified Pulmonary Granulomas on CT scan - Umbilical Hernia - Varicose Veins(mostly right leg) - Bilateral Hearing Loss Past Surgical History: - Endovascular AAA repair [2105-11-9] - Tonsillectomy - Melanoma Excision on back Past Cardiac Procedures: - s/p PPM Implantation [Company 1543] Sensia DR SEDR01, [2103-9-10] - Rotablation of prox LAD with PCI/[Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2(Xience), Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: trace - 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] Date/Time:[2107-6-22] 1:30 in the [Hospital ] medical office building, [Doctor First Name ], [Hospital Unit Name ] Cardiologist: [First Name8 (NamePattern2) ] [Doctor Last Name ] - office to call patient with appointment Please call to schedule the following: Primary Care Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 110204] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR Coumadin for post-op AFib Goal INR 2-2.5 First draw [2107-5-25] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by provider Completed by:[2107-5-24]	[ "396.2", "780.09", "V45.01", "289.81", "427.31", "997.1", "V70.7", "244.9", "596.54", "397.0", "V10.82", "414.01", "V53.31", "401.9", "272.4", "V12.54" ]	icd9cm	[ [ [] ] ]	[ "36.15", "35.21", "36.12", "88.56", "37.23", "39.61" ]	icd9pcs	[ [ [] ] ]	8536, 8630	4983, 6540	330, 428	9410, 9586	2860, 4960	10374, 11247	1976, 2019		6799, 8513		8651, 9073		6566, 6776			9610, 10351								9096, 9389		2034, 2841																												270, 292											456, 968															990, 1412	1744, 1960
26,612	182,331	47288	Discharge summary	report	Admission Date: [2142-12-8] Discharge Date: [2142-12-19] Date of Birth: [2108-7-17] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 43784] Chief Complaint: Fever, abdominal pain, sreosanguinous wound discharge Major Surgical or Invasive Procedure: Reexploration and irrigation of abdominal incision History of Present Illness: This patient is a 34-year-old female who underwent a supracervical hysterectomy and left salpingectomy on [2142-12-3]. She was discharged home on [2142-12-5]. She presented to the office on [2142-12-6] complaining of watery drainage from her incision. Her wound was opened and a moderate amount of serous fluid was drained. Her wound was packed and she was arranged to have visiting nurse visits for wound dressings at home. On [2142-12-7], the patient felt well, however, on [2142-12-8] she presented to the emergency room at [Hospital3 1443] Hospital with abdominal pain and some vomitting. Abdominal CT scan showed some dilated loops of small bowel suggesting a small bowel obstruction and she was noted to have copious watery drainage from her incision. There was concern for possible wound dehiscence and so she was transferred to the emergency room on the [Hospital Ward Name 517] of [Hospital1 ] Hospital. While at [Hospital3 1443] Hospital, pt received up to 22mg Morphine sulfate for pain management. On her initial assessment at emergency room at [Hospital1 ], it was difficult to examine her, and because of the watery discharge, surgical consult was obtained. Recommendation was made for exam under anaesthesia. It was felt appropriate to take this patient back to the operating room for wound exploration under anesthesia to get adequate assessment and ensure fascia is intact and to rule out dehiscence. The appropriate consent was obtained and she was taken to the operating room. Past Medical History: PMH: chronic pelvic pain, asthma, narcotic dependency, anemia, morbid obesity, anxiety, depression PSH: abdominal myomectomy, supracervical hysterectomy OB: G0 Gyn: menorrhagia, fibroids, pelvic pain Social History: Currently does not work, social drinker, denies any illicit drug usage, 15 pack year cigarrette hx claims she quit 5 mos ago Family History: Mother with Asthma, DM II, Sleep Apnea Sister: DM [Name (NI) ] Physical Exam: On admission T: 99.4 HR 99 BP 139/59 RR 23 O2 98%RA obese AA Female, in mod distress s1,s2 RRR Poor insp effort, CTAB obese, mod distention, +bowel sounds wound open, drainage of serosang fluid, Ext obese, nontender Pertinent Results: [2142-12-8] 09:35AM WBC-6.1 RBC-3.13* HGB-9.9* HCT-29.1* MCV-93 MCH-31.4 MCHC-33.9 RDW-13.1 [2142-12-8] 09:35AM NEUTS-73.1* LYMPHS-16.7* MONOS-7.3 EOS-2.8 BASOS-0.1 [2142-12-8] 09:35AM PLT COUNT-310 [2142-12-8] 09:35AM GLUCOSE-101 UREA N-6 CREAT-0.7 SODIUM-138 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16 [2142-12-8] 11:10AM PT-13.4* PTT-24.3 INR(PT)-1.2 [12-10] Hct 21.3% 11/2 Hct 24.7% 11/6 Hct 31.8%, glucose 142 CT Abd/Pelv [12-8] IMPRESSION: 1. Findings consistent with a small-bowel obstruction with transition point in the right lower quadrant. 2. Bibasilar dependent atelectasis. 3. Stranding and superficial gas within the patient's known [Last Name (un) 22790] incision. Small amount of phlegmonous change/fluid is demonstrated along the left aspect of the wound. Underlying infection cannot be excluded. No drainable collections or protrusion of bowel is identified. CXR [12-8] The ET tube tip is in satisfactory position, approximately 2.6 cm above the carina. An NG tube is present, tip over fundus. There are dense diffuse bilateral alveolar infiltrates with air bronchograms. Brief Hospital Course: The patient was taken to the operating room on [12-8] for exploration of surgical incision and placement of wound vacuum. See operative report for details. The procedure was complicated by hypoxia following extubation requiring reintubation and ICU admission. The remainder of her post operative course is as follows. Respiratory failure - her respiratory complications were thought to be multifactorial in etiology with underlying asthma, obesity, tobacco use, and possible obstructive apnea, in the setting of two intubations within a week. She had no evidence of cardiac etiology with normal echocardiogram. These findings were also not consistent with pulmonary embolism. She was initially treated for presumed pneumonia with levofloxaxin. She remained afebrile after antibiotics were discontinued. Serial chest x-rays showed persistant consolidation in the lower lung fields R>L, however, these were attributed to atelectasis. She remained without cough, fever, or leukocytosis. She remained intubated for 4 days post operatively. She was seen by the pulmonary service who recommended outpatient evaluation with repeat CXR and sleep studies. Wound care - she was followed by the general surgery service for management of her wound vacuum. Her inicision continued to heal well and she will continue with outpatient wound care with wet to dry dressings and wound vac. She had no evidence of wound infection. Partial small bowel obstruction - A nasogastric tube was placed and remained for 5 days post operatively. She had signs of clinical improvement. Her diet was advanced and she had normal bowel movements and flatus and no further nausea or distention. Post operative pain - the patient was followed by the pain medicine service for management of post operative pain in the setting of prior narcotic tolerance. She was well managed on morphine PCA and then oral dilaudid. She will have pain medications prescribed by her PCP as an outpatient. Medications on Admission: mirtazipine, gabapentin, lorazepam, zoloft, flovent, albuterol Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: [2-12] (one to three) Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: wound seroma post operative respiratory failure post operative hypovolemia post operative pneumonia/atelectasis post operative partial small bowel obstruction with ileus post operative blood loss anemia Secondary: asthma, obesity, chronic pelvic pain Hypoxia possibly due to sleep apnea Discharge Condition: good. stable Discharge Instructions: call with pain, bleeding, fever, concerns Instructions per nursing discharge sheet Office visit with Dr [Name6 (MD) 14002] and RN on [2143-1-4] at 12:30pm for wound check and dressing change Call Dr [Last Name (STitle) 13275] if you have not heard from her office by [12-21] to make appointment for follow up Need follow up with Dr [Last Name (STitle) 13275] to discuss test for sleep apnea, repeat cxr, head MRI and pain med management if needed Arrangemens have been made for VNA to do vac dressing changes and possible removal [2142-12-24] Followup Instructions: Office visit with Dr [Name6 (MD) 14002] and RN on [2143-1-4] at 12:30pm for wound check and dressing change Call Dr [Last Name (STitle) 13275] if you have not heard from her office by [12-21] to make appointment for follow up Need follow up with Dr [Last Name (STitle) 13275] to discuss test for sleep apnea, repeat cxr, head MRI and pain med management if needed Arrangemens have been made for VNA to do vac dressing changes and possible removal [2142-12-24] Need to make appt with Behavioral Health provider, [Name10 (NameIs) ] [First Name (STitle) ], to manage anxiety and depresion meds [Hospital 2274] [Numeric Identifier 100107]	[ "278.00", "560.9", "560.1", "292.81", "518.0", "997.3", "276.52", "518.81", "998.13", "E878.8", "486", "493.90", "780.57", "997.4" ]	icd9cm	[ [ [] ] ]	[ "86.04", "96.04", "96.72" ]	icd9pcs	[ [ [] ] ]	6151, 6222	3889, 5863	384, 436	6553, 6568	2714, 3866	7183, 7862	2390, 2459		5976, 6128		6243, 6532		5889, 5953			6592, 7160										2474, 2695																												291, 346											464, 2005															2027, 2231	2247, 2374
67,468	115,119	35977	Discharge summary	report	Admission Date: [2199-11-17] Discharge Date: [2199-11-26] Date of Birth: [2120-3-31] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Called by Emergency Department to evaluate ICH Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 79-year-old right-handed man with a history of Left CEA on [2199-11-12] who presents with acute onset language impairment, found to have a left occipital hemorrhage. The history begins on the weekend before [Holiday 1451], about 3 weeks prior to this. He was at that time driving alone on the [Location (un) 81675] and went off the road. Apparently, it's thought that he lost consciousness, causing him to lose control. When EMS found him, he was awake, but reportedly "confused" and has no memory of the events for several hours after the event. Based on this, he was apparently diagnosed with a TIA. In the work-up for the TIA, he was found to have 98% stenosis of his right carotid and at least 90% of the left. He underwent RIGHT CEA shortly thereafter, and had a LEFT CEA performed on [2199-11-12], both at [Hospital1 ]. After this second CEA he was doing well except for some constipation. This afternoon, he told his wife he was not feeling well (not further elaborated on) and went quickly to the bathroom. He apparently had a bowel movement, but was in the bathroom for a while. His wife called for him, but initially got no answer. He then flushed the toilet and came out of the bathroom on his own, but said nothing to his wife, only [Name2 (NI) 27723] at her. His wife believes he did not understand what she was saying to him, as he was not doing as she asked. She led him to bed. She noted that he was "wobbling" back and forth, but did not run in to anything. She called her daughter, his doctor, and then EMS. EMS found his initial BP in the field to be 240/110. He was taken by EMS to [Hospital1 ], where a head CT showed a hyperdensity in the left occipital lobe about 1 cm x 0.5 cm, surrounded by hypodensity. HIs maximum BP was 270/150, and he received 10 mg labetalol. He was seen by a neurologist, who noted right eye deviation and thought he was having a seizure, so the pt received Dilantin 1.6 g IV. He developed "son[Name (NI) 7884] respirations" and was intubated, receiving Ativan 0.5 mg, Etomidate 20 mg/Succ 80 mg/Lidocaine 100 mg/Vecuronium 12 mg at [2100], 2 mg Versed, and 2 mg Morphine. After administration of all this medication, his BP dropped into the 80s systolic, coming up when propofol was held for a few minutes. In our ED, he received propofol gtt and Tylenol 650 mg PR for fever to 101.4. Formal ROS is not possible; per his wife, he was not complaining of anything other than constipation Past Medical History: Motor vehicle accident ~[2199-10-26] due to LOC Diagnosed with "TIA" after losing consciousness while driving (no known focal features, so unclear what this diagnosis was based on) s/p RIGHT CEA late [2199-10-5] s/p LEFT CEA [2199-11-12] HTN DM2 Gout Report by family that he has a renal cyst(?) seen on torso CT at time of MVA trauma work-up. Social History: Former smoker but quit many years ago. No EtOH use. Former jewelry salesman. Family History: NC Physical Exam: Vitals: T: 99.3 (101.4 max) P: 91 R: 16 BP: 157/80 (83/50-175/93) SaO2: 100% AC General: Intubated, off propofol for 10 minutes. HEENT: Anicteric. Surgical wound on left neck with surrounding edema and erythema, tense to palpation. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Neurologic: -Mental Status: Opens eyes to voice, follows one-step commands, but grossly inattentive, requiring frequent stimulation. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1.5mm. Appears not to blink to threat. III, IV, VI: EOMI without nystagmus. V: Not tested. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to voice. IX, X: Intubated, gag intact. [Doctor First Name 81]: Not tested. XII: Not tested. -Motor: Normal bulk throughout. Slightly spastic tone in B LEs. Does not cooperate with FST but moves all extremities antigravity with apparently equal vigor. -Sensory: Withdraws from light touch in all 4 ext. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 1 1 1 0 R 2 1 1 1 0 Plantar response was flexor bilaterally. -Coordination & Gait: Could not be tested due to patient's somnolence. Pertinent Results: [2199-11-17] 07:39AM GLUCOSE-211* UREA N-23* CREAT-1.2 SODIUM-142 POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-33* ANION GAP-14 [2199-11-17] 07:39AM CK(CPK)-64 [2199-11-17] 07:39AM CK-MB-NotDone cTropnT-0.11* [2199-11-17] 07:39AM CALCIUM-9.1 PHOSPHATE-4.3 MAGNESIUM-1.9 CHOLEST-162 [2199-11-17] 07:39AM %HbA1c-6.3* [2199-11-17] 07:39AM TRIGLYCER-160* HDL CHOL-42 CHOL/HDL-3.9 LDL(CALC)-88 [2199-11-17] 07:39AM OSMOLAL-300 [2199-11-17] 07:39AM PHENYTOIN-4.8* [2199-11-17] 07:39AM WBC-10.5 RBC-3.35* HGB-11.4* HCT-30.8* MCV-92 MCH-34.1* MCHC-37.0* RDW-13.5 [2199-11-17] 07:39AM PLT COUNT-256 [2199-11-16] 10:46PM GLUCOSE-187* UREA N-21* CREAT-1.4* SODIUM-137 POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-31 ANION GAP-14 [2199-11-16] 10:46PM estGFR-Using this [2199-11-16] 10:46PM CK(CPK)-72 [2199-11-16] 10:46PM CK-MB-NotDone cTropnT-0.17* [2199-11-16] 10:46PM CALCIUM-9.3 PHOSPHATE-4.6* MAGNESIUM-2.0 [2199-11-16] 10:17PM TYPE-ART RATES-/16 TIDAL VOL-500 PEEP-5 O2-100 PO2-445* PCO2-47* PH-7.41 TOTAL CO2-31* BASE XS-4 AADO2-244 REQ O2-47 -ASSIST/CON INTUBATED-INTUBATED [2199-11-16] 09:05PM URINE HOURS-RANDOM [2199-11-16] 09:05PM URINE GR HOLD-HOLD [2199-11-16] 09:05PM WBC-13.0* RBC-3.72* HGB-12.7* HCT-34.8* MCV-94 MCH-34.3* MCHC-36.6* RDW-13.6 [2199-11-16] 09:05PM NEUTS-89.6* LYMPHS-6.3* MONOS-3.3 EOS-0.7 BASOS-0.2 [2199-11-16] 09:05PM PLT COUNT-250 [2199-11-16] 09:05PM PT-12.8 PTT-21.4* INR(PT)-1.1 [2199-11-16] 09:05PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.010 [2199-11-16] 09:05PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0 LEUK-NEG [2199-11-16] 09:05PM URINE RBC-[5-14]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 MRI brain with and without contrast: Markedly motion degraded study. Subacute hematoma in the left occipital lobe with mild leptomeningeal enhancement which may reflect hyperemia secondary to subacute hematoma. No convincing underlying mass lesion is noted; however, recommend followup imaging after resolution of acute blood products for better assessment. CTA head with and without contrast: No convincing evidence for an AVM. There is very slight hyperemia in the region of the prior hemorrhage. Recommend attention on followup imaging. Irregularity and diminutive appearance of the basilar artery may reflect a combination of atherosclerotic disease and fetal type PCA distribution on the left. ECHO: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace 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 a very small inferolateral pericardial effusion without evidence for hemodynamic compromise. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. EEG: This is an abnormal routine EEG due to the presence of diffusely slow background and periodic left temporal sharp activity. There was also an electrographic seizure seen broadly over the left hemisphere with no associated clinical correlate. NCHCT: There is a small focus of intraparenchymal hemorrhage in the left occipital lobe adjacent to an area of edema involving the posterior watershed of the left cerebrum. Compared to the earlier study, the involved area of predominantly vasogenic edema is less well defined and less extensive. The findings do suggest a hypoperfusion pattern considering the distribution and given history of recent carotid endarterectomy. Therefore the small focus of hemorrhage must be presumably hemorrhagic conversion. MRI with diffusion-weighted sequence is recommended to assess for elements of acute ischemia. EKG: Sinus rhythm. Non-specific ST-T wave changes. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 93 172 94 360/417 66 -29 44 Brief Hospital Course: Mr. [Known lastname ] is a 79-year-old right-handed man with a history of Left CEA on [2199-11-12] who presented with acute onset language impairment, found to have a left occipital hemorrhage. His exam neurological exam was non focal. The hemorrhage was most likely due to a hyperperfusion syndrome conversion although an an underlying mass can not be ruled out. Given the recent CEA, a hyperperfusion syndrome is indeed most likely (patient was also found to have a fetal PCA on head CTA). Patient was intubated in ICU for a few days. Because of his fever on admission and change in behavior, he was treated empirically with acyclovir. Because there was a history suggestive of a seizure at the OSH and here EEG showed diffusely slow background and periodic left temporal sharp activity, patient was loaded with dilantin and had levels checked regularly. He will need to have his dilantin level followed-up as outpatient. When extubated and transferred to the wards, patient was agitated, requiring olanzapine. His mental status improved over time, being alert and oriented to time and place upon discharge. He is also being treated for hospital acquired pneumonia with vancomycin and ceftriaxone (he will need another week of antibiotics to complete 14 day-course). Medications on Admission: ASA 81 mg po daily Lisinopril 40 mg po daily Metformin 1000 mg po daily Allopurinol 100 mg po daily Amlodipine 2.5 mg po daily Janumet 50-500 mg po qpm Discharge Medications: 1. Dilantin Extended 100 mg Capsule Sig: Two (2) Capsule PO three times a day: You should have your levels checked with PCP [Name Initial (PRE) ] [9-23]. Disp:180 Capsule(s) Refills:2 2. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 3. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 4. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every twelve (12) hours for 7 days. 6. Ceftriaxone 1 gram Piggyback Sig: One (1) Intravenous once a day for 7 days. 7. Janumet 50-500 mg Tablet Sig: One (1) Tablet PO qpm. 8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. Haldol 5 mg/mL Solution Sig: 0.5 mg Injection qpm MRx1 as needed for sundowning, agitation. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: - small left occipital intracranial hemorrhage; probably due to hyperperfusion - left lower lobe pneumonia - abnormal electroencephalogram Discharge Condition: Stable Discharge Instructions: You were transferred to this hospital with confusion, difficulty speaking. You had recently undergone a left carotid endarterectomy Your head CT showed a small left occipital intracranial hemorrhage thought to be due to hyperfusion syndrome. You are being treated with a 2 week course of IV vancomycin and ceftriaxone for a retrocardiac opacity and presumed hospital acquired pneumonia. You are also on dilantin due to left temporal spikes and an electrographic seizure seen on long term monitoring by electroencephlogram. You should continued on dilantin until your follow-up in [Hospital 4038] clinic. You should follow-up in [Hospital 878] clinic. Further brain imaging may be necessary. You should have your dilantin level checked with your PCP (level goal [9-23]). Please take medications as prescribed. Please keep your follow-up appointments. If you have any worsening or worrying symptoms, please contact your PCP or return to the emergency room. Followup Instructions: PCP: [Name6 (MD) ] [Name8 (MD) ], M.D. Phone: [Telephone/Fax (1) 60170] Please follow-up with your PCP [Name Initial (PRE) 176] 1-2 weeks of discharge. Neurology: [Name6 (MD) ] [Name8 (MD) ], M.D. ([Hospital 4038] clinic) Phone:[Telephone/Fax (1) 2574] Date/Time:[2199-12-31] 1:30 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2199-11-26]	[ "997.01", "V12.54", "274.9", "794.02", "432.9", "E879.8", "599.70", "250.00", "401.9", "784.3", "486", "V45.89" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.71" ]	icd9pcs	[ [ [] ] ]	11872, 11946	9219, 10499	365, 372	12128, 12137	4797, 9196	13159, 13601	3398, 3403		10702, 11849		11967, 12107		10525, 10679			12161, 13136							4038, 4778			3418, 3900																												278, 327											400, 2907												3915, 4021			2929, 3287	3303, 3382
80,045	146,794	3200	Discharge summary	report	Admission Date: [2149-6-12] Discharge Date: [2149-6-16] Service: MEDICINE Allergies: Ibuprofen Attending:[First Name3 (LF) 10488] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: induced sputum x3 History of Present Illness: The patient is a [Age over 90 ] y/o F with PMHx significant for pulmonary tuberculosis treated 50 years ago, PAF, MGUS, osteoporosis, who presents with hemoptysis. Per report, the patient has been experiencing cough and URI s/s for several days. CXR was reportedly negative, and she was diagnosed with "bronchitis." However, she also had a fever to 100 and was started on levofloxacin on the evening prior to admission. During this time, she has also developed hemoptysis, her children noting blood in her tissues after she coughs as well as blood on her sheets. She has also had weight loss and decreased appetite over the past several weeks. She also had increased O2 requirement at her [Hospital1 1501] and was referred to the ED for evaluation. Of note, the patient did have a recent OSH admission in [2149-5-11] for hematemesis. Per report, she had a negative EGD during that admission and hematemesis was attributed to supratherapeutic INR. She denies any current hematemesis, black stools, or bloody stools. . In the ED, the patient tachycardic to low 100's, afebrile, satting 100% on 3L. Exam was notable for scattered rhonchi at the bases as well as increased swelling in the LLE which was reported to be chronic. She underwent CTA, which ruled out PE but did show left pleural effusion and bibasilar consolidations. She was given vanc/CTX. Labs in the ED were significant for Hct 34.2 (from 38) as well as an INR of 3.7. She did not have any episodes of hemoptysis in the ED. IP was contact[Name (NI) ] in the [Name (NI) ] and planned to possibly bronch the following day. . On arrival to the ICU, the patient's VS were BP 117/55 HR 99 RR 29 Satting 99%RA. On examination, she denies any complaints. She says that she hhas had a productive cough recently. She says that she has been told that she has been coughing up blood; however, she has not noticed this. She also has been told that she has lost weight; however, she has not noticed this either. She denied any night sweats. He family reports that she has significantly improved after being started on levofloxacin yesterday. . Review of sytems: (+) Per HPI (-) Denies chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied 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: - Paroxysmal atrial fibrillation - History of pulmonary tuberculosis --->treated with pneumothoraces and subsequently with PAS/INH 50 years ago --->PFTs [2144]: FEV1 0.86, FEV1/FVC 128% predicted. DLSO not performed --->prior CT revealing for calcified granulomas in the right lower lobe and left lower lobe, calcified pleural scar on the right, and fibrotic changes in the right lower lobe leading to a mediastinal shift to the right - MGUS - Osteoporosis - Cervical Osteoarthritis - s/p cataract extraction Social History: The patient is currently a resident at [Location (un) 5481] independent living. She has two children, who do not live in the area. She was previously employed as a dental hygienist. She is independent in her ADL's. She denies tobacco or EtOH use. Family History: Mother: Died age 80 [2-12] MI Father: Died in 80s [2-12] MI No family history of lung cancer or other lung disease. Physical Exam: BP 117/55 HR 99 RR 29 O2Sat 99%RA General: Alert, orientedx3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple Lungs: Wheezes heard throughout, no crackles or rhonchi appreciated CV: Irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, some LE edema (L>R) that is chronic, no calf tenderness Pertinent Results: [2149-6-12] 02:27PM BLOOD WBC-5.1 RBC-3.63* Hgb-11.2# Hct-34.2 MCV-94 MCH-30.9 MCHC-32.8 RDW-15.1 Plt Ct-285 [2149-6-12] 02:27PM BLOOD Neuts-66.3 Lymphs-25.3 Monos-7.0 Eos-0.7 Baso-0.7 [2149-6-12] 02:27PM BLOOD PT-36.4* PTT-28.1 INR(PT)-3.7* [2149-6-12] 02:27PM BLOOD Glucose-115* UreaN-10 Creat-0.7 Na-139 K-3.5 Cl-97 HCO3-33* AnGap-13 [2149-6-13] 05:18AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8 [2149-6-12] 02:26PM BLOOD Lactate-1.1 [2149-6-14] 06:50AM BLOOD WBC-7.0 RBC-3.60* Hgb-11.2* Hct-34.3* MCV-95 MCH-31.2 MCHC-32.8 RDW-14.3 Plt Ct-299 [2149-6-13] 05:18AM BLOOD WBC-6.7 RBC-3.55* Hgb-11.0* Hct-33.3* MCV-94 MCH-30.9 MCHC-32.9 RDW-14.3 Plt Ct-320 [2149-6-12] 02:27PM BLOOD WBC-5.1 RBC-3.63* Hgb-11.2# Hct-34.2 MCV-94 MCH-30.9 MCHC-32.8 RDW-15.1 Plt Ct-285 [2149-6-12] 02:27PM BLOOD Neuts-66.3 Lymphs-25.3 Monos-7.0 Eos-0.7 Baso-0.7 [2149-6-14] 06:50AM BLOOD Plt Ct-299 [2149-6-14] 06:50AM BLOOD PT-26.7* INR(PT)-2.6* [2149-6-13] 12:42PM BLOOD PT-31.7* PTT-29.9 INR(PT)-3.1* [2149-6-13] 05:18AM BLOOD Plt Ct-320 [2149-6-12] 02:27PM BLOOD Plt Ct-285 [2149-6-12] 02:27PM BLOOD PT-36.4* PTT-28.1 INR(PT)-3.7* [2149-6-14] 06:50AM BLOOD Glucose-95 UreaN-11 Creat-0.6 Na-141 K-4.1 Cl-98 HCO3-34* AnGap-13 [2149-6-13] 05:18AM BLOOD Glucose-97 UreaN-8 Creat-0.6 Na-139 K-3.6 Cl-98 HCO3-32 AnGap-13 [2149-6-12] 02:27PM BLOOD Glucose-115* UreaN-10 Creat-0.7 Na-139 K-3.5 Cl-97 HCO3-33* AnGap-13 [2149-6-14] 06:50AM BLOOD Mg-2.0 [2149-6-13] 05:18AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8 [2149-6-12] 02:26PM BLOOD Lactate-1.1 . [6-13] CT of the chest-IMPRESSION: 1. No pulmonary embolism. 2. Bilateral lower lobe and right middle lobe consolidations worrisome for pneumonia. Small left pleural effusion. 3. Calcified right fibrothorax with associated volume loss. 4. Extensive mucous plugging of the right sided airways. 5. Moderate-to-large sized hiatal hernia, unchanged . CXR [6-13]-Moderate right pleural effusion has developed in the setting of probable right pleural scarring. Mild cardiomegaly is new. Large hiatus hernia is bigger. Pulmonary vascular congestion persists. There may be mild right perihilar edema. No pneumothorax. Small left pleural effusion is new as well. . [2149-6-13] SPUTUM ACID FAST SMEAR-PRELIMINARY; ACID FAST CULTURE-PENDING INPATIENT [2149-6-13] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-PENDING; Respiratory Viral Antigen Screen-FINAL INPATIENT [2149-6-13] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [2149-6-13] URINE Legionella Urinary Antigen -FINAL INPATIENT [2149-6-12] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY INPATIENT [2149-6-12] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2149-6-12] BLOOD CULTURE Blood Culture, Routine-PENDING Brief Hospital Course: [Age over 90 ] y/o F with PMHx significant for pulmonary tuberculosis treated 50 years ago, PAF, MGUS, osteoporosis, who presents with hemoptysis. # Hemoptysis (PNA and bronchiectasis)- History points to a very small amount of hemoptysis at home. Multiple possible etiologies are possible. Reviewing CTA showed upper lobe bronchiectasis. Symptoms consistent with viral URI in the setting of bronchiectasis, leading to hemoptysis. Given patient's history of prior TB infection, reactivation TB needs to be considered, although time course is more acute in her case. PE less likely given negative CTA. However, CTA did show bibasilar consolidations, concerning for possible PNA. It is also notable that the patient was started on levofloxacin prior to admission with significant improvement in her symptoms since then. Additionally, the patient has recently been diagnosed with bronchitis, which could cause hemoptysis. Malignancy should also be on the differential, given hemoptysis and weight loss, although CTA does not suggest so. IP was contact[Name (NI) ] in the [Name (NI) ]. Pt was placed on ceftriaxone and azithromycin and she clinically improved. Of note, pt reports her baseline RA sat is 90-91%. Sputum was sent for AFBx3 and returned negative. Coumadin was held in the setting of hemoptysis and supratherapeutic INR, and restarted on [2149-6-15] (INR 2.0 on restart). Continued outpt advair. She will be discharged on azithromycin and cefpodoxime to complete total of 7 day course of antibiotics (ending on [2149-6-18]). . # Atrial Fibrillation: Rate controlled. Metoprolol was uptitrated to 25mg [Hospital1 ]. Coumadin was initially held and restarted on [2149-6-15] (INR 2.0 on restart). . # MGUS: No acute issues. - outpt f/u . # Osteoporosis: - continue Ca/Vit D - outpt f/u . # HLD: - continue lipitor . # Dementia: Likely early dementia as no clear signs on exam. - continue aricept and remeron . FEN: IVF's PRN, replete electrolytes as needed, regular diet Prophylaxis: pneumoboots Access: peripherals Code: DNR/DNI, confirmed with patient and children Communication: Patient and her son and daughter Medications on Admission: (per ED medication reconciliation form, needs confirmation): - calcium 500 mg TID - omeprazole 20 mg daily - premarin 0.3 mg daily - multivitamin daily - aricept 5 mg daily - metoprolol 12.5 mg qAM and 25 mg qPM - remeron 15 mg daily - advair 250/50 once daily - vitamin b complex daily - vitamin d [2138] units daily - lipitor 5 mg daily - coumadin 3 mg tablets - 1 tablet daily 5x per week and [1-12] tablet daily 2x per week Discharge Medications: 1. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. conjugated estrogens 0.3 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation DAILY (Daily). 8. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. azithromycin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. Disp:3 Tablet(s) Refills:0 12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 13. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 14. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:6 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: Commons Residence At Orchard - [Location (un) 2624] (a.k.a. [Location (un) 5481]) Discharge Diagnosis: hemoptysis community acquired pneumonia atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for evaluation of coughing up blood. You were found to have a pneumonia and were started on antibiotic therapy. The episodes of coughing up blood resolved during admission. In addition, given your prior history of TB, you had your sputum tested for TB and this returned negative. Some of your coumadin doses were held during admission. . Medication changes: 1.your metoprolol was increased to 25mg twice a day 2.please start cefpodoxime and azithromycin for total of 7 days (until [2149-6-18]) . Please take all of your medications as prescribed and follow up with the appointments below. Followup Instructions: Please call your PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) 5482] at [Telephone/Fax (1) 5483] to schedule a follow up appointment after discharge. . Department: CARDIAC SERVICES When: FRIDAY [2149-10-3] at 1:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES When: TUESDAY [2150-7-14] at 12:00 PM With: BONE DENSITY TESTING [Telephone/Fax (1) 4586] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES When: TUESDAY [2150-7-14] at 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10545], M.D. [Telephone/Fax (1) 4586] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "427.31", "482.9", "733.00", "V12.01", "790.92", "494.0", "V49.86", "V58.61", "276.3", "273.1", "294.8" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11052, 11168	7139, 9297	229, 249	11272, 11272	4208, 7116	12058, 13171	3566, 3691		9783, 11029		11189, 11251		9323, 9760			11423, 11779										3706, 4189																								11799, 12035				179, 191						2408, 2746					277, 2390												11287, 11399			2768, 3282	3298, 3550
62,248	149,164	52814	Discharge summary	report	Admission Date: [2101-5-7] Discharge Date: [2101-5-17] Service: SURGERY Allergies: Ultram / Codeine / Morphine Sulfate / Darvon Attending:[First Name3 (LF) 1390] Chief Complaint: vomitting, diarrhea Major Surgical or Invasive Procedure: I and D of the L gluteal abscess [5-8] History of Present Illness: 86 yoF s/p complicated diverticulitis controlled by IR drainage of abscess, discharged yesterday, now returns with copious diarrhea, general malaise and Left buttock pain. Patient states that within a few hours of discharge she began to have worsening malaise, and diarrhea. She returned to the ED tonight for work up. Past Medical History: 1. Hyperlipidemia. 2. Hypertension. 3. Carotid artery stenosis with a right carotid bruit. She had a carotid series in [2095], which showed less than 40% occlusion of the right side. 4. Macular degeneration which is dry. 5. Osteoarthritis. 6. Coronary artery disease s/p CABG in [2078] 7. Status post myocardial infarction in [2077]. 8. Hypothyroidism. 9. Diabetes type 2 for which she is followed at the [Hospital ] Clinic 10. Osteopenia. 11. Tobacco abuse. She smokes five cigarettes a day. 12. R hip replacement x3 Social History: : She was born and raised in [Location (un) 86]. She works with her husband for many years in a sanitary maintenance business. She was a ballet instructor. She was married, divorced and widowed. She has three children. The patient lives at [Last Name (NamePattern1) 108901] independently. Family History: Her father died of a myocardial infarction. He had diabetes. Her mother died at age 67. She has several half sisters and brothers. Physical Exam: PHYSICAL EXAMINATION: upon admission [2101-5-7] Temp:100.2 HR:80 BP:152/63 Resp:18 O(2)Sat:93 Normal Constitutional: Awake alert, nontoxic in appearance HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Normal first and second heart sounds Abdominal: Abdomen is soft and nontender GU/Flank: No costovertebral angle tenderness Extr/Back: Patient has induration at the site of the sacral strain Physical examination upon discharge: [2101-5-17] Vital signs: t=98.9, hr=76, bp=130/58, resp. rate 20, oxygen saturation 97% room air General: frail, female, conversant, alert and oriented x 3, speech clear CV: Ns1, s2, -s3, -s4 LUNGS: Clear ABDOMEN: soft, non-tender EXT: +1 edema feet bil., + dp bil Buttock: DSD with packing to drain site left buttock, ostomy coccyx appliance with loose light brown stool. Pertinent Results: [2101-5-7]: cat scan of abdomen and pelvis: IMPRESSION: 1. Extensive inflammation of the sigmoid colon consistent with ongoing diverticulitis, with new extension of the adjacent presacral abscess into the overlying gluteus maximus muscle and rapid formation of a new large intramuscular abscess, as detailed above. The pigtail drainage catheter is well-situated within the original pre-sacral collection. 2. New small right pleural effusion. 3. Hiatus hernia. 4. Extensive coronary and aortic atherosclerotic disease. [2101-5-8]: EKG: Atrial fibrillation with a controlled ventricular response. ST-T wave changes. Delayed R wave transition. Cannot exclude prior anterior wall myocardial infarction. Compared to the previous tracing of [2095-6-1] atrial fibrillation is new [2101-5-8]: Echo: Conclusions The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Mild concentric LVH, mild MR, normal biventricular systolic function, diastolic dysfunction. [2101-5-8]: chest x-ray: Allowing for the inherent differences in AP versus PA technique, moderate cardiomegaly may have increased, there is an indeed greater distention of mediastinal veins and upper lobe pulmonary vasculature, and there is new small right pleural effusion, but most of the difference in the appearance of the right lung is due to new atelectasis in region of right juxtahilar scarring and a small region of consolidation in the right upper lung or fluid trapped in the adjacent interlobar fissure. As such pneumonia cannot be excluded. A conventional chest radiographs strongly recommended. [2101-5-10]: chest x-ray: IMPRESSION: Worsening right middle lobe atelectasis [2101-5-15]: cat scan of the abdomen: IMPRESSION: 1. Leak from the distal sigmoid colon with feculent material in the presacral space, and along a tract that passes transgluteally and opens onto the skin of the left buttock consistent with colocutaneous fistula. 2. Thickening at the left gluteal muscles with at least two small loculations of fluid and gas and evidence of a fistula tract onto the lateral gluteal wall. While the collection in the left gluteal muscle has decreased in size since [2101-5-7], persistent enlargement and hyperenhancement of the left gluteal muscles along with some air and fluid remain. [2101-5-7] 05:53PM LACTATE-1.3 [2101-5-7] 05:45PM GLUCOSE-169* UREA N-13 CREAT-0.7 SODIUM-131* POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-23 ANION GAP-11 [2101-5-7] 05:45PM estGFR-Using this [2101-5-7] 05:45PM ALT(SGPT)-16 AST(SGOT)-19 ALK PHOS-77 TOT BILI-0.4 [2101-5-7] 05:45PM LIPASE-15 [2101-5-7] 05:45PM WBC-15.0# RBC-3.76 HGB-11.3* HCT-32.6* MCV-87 MCH-30.1 MCHC-34.6 RDW-13.7 [2101-5-7] 05:45PM NEUTS-90.7* LYMPHS-6.7* MONOS-2.4 EOS-0.1 BASOS-0.1 [2101-5-7] 05:45PM PLT COUNT-455* COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2101-5-17] 05:45 12.4* 2.95* 9.2* 26.5* 90 31.2 34.7 14.3 466* DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [2101-5-8] 03:55 90.0* 6.0* 3.7 0 0.3 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2101-5-17] 05:45 466* LAB USE ONLY [2101-5-17] 05:45 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2101-5-17] 05:45 1081 13 0.7 132 4.5 97 29 11 IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES ESTIMATED GFR (MDRD CALCULATION) estGFR [2101-5-16] 04:40 Using this1 Using this patient's age, gender, and serum creatinine value of 0.6, Estimated GFR = >75 if non African-American (mL/min/1.73 m2) Estimated GFR = >75 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2101-5-8] 17:49 1111 Source: Line-A-line [2101-5-8] 03:55 17 27 238 73 21 0.3 NEW REFERENCE INTERVAL AS OF [2100-1-11];UPPER LIMIT (97.5TH %ILE) VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201 BLACKS 801/414 ASIANS 641/313 OTHER ENZYMES & BILIRUBINS Lipase [2101-5-8] 03:55 15 CPK ISOENZYMES CK-MB cTropnT [2101-5-8] 17:49 4 <0.011 <0.01 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2101-5-17] 05:45 7.8* 3.6 2.5 HEMATOLOGIC calTIBC Ferritn TRF [2101-5-8] 03:55 150* 408* 115* LIPID/CHOLESTEROL Cholest Triglyc [2101-5-8] 03:55 1041 LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE IMMUNOLOGY CEA [2101-5-16] 04:40 101 MEASURED BY [Doctor Last Name 8721] ELECSYS (ECLIA) CARDIAC/PULMONARY Digoxin [2101-5-11] 05:45 1.6 Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS [2101-5-8] 18:38 ART 109 36 7.43 25 0 [2101-5-8] 17:51 ART 78* 44 7.39 28 0 [2101-5-8] 14:03 ART 98 47* 7.33* 26 -1 WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate [2101-5-8] 18:38 0.9 [2101-5-8] 17:51 0.7 [2101-5-8] 14:03 1.9 Brief Hospital Course: Ms [Known lastname 92003] was admitted to the ACS service for managment of a left gluteal abscess. She was taken to the operating room on [5-8] where she underwent incision and drainage of left gluteal abscess. Post operatively she was brought to SICU for new onset rapid Afib. Blood cultures were drawn and she was started on a dilt gtt. She converted to NSR. Atenolol dose was increased to 75. Subsequently her blood pressure dropped to the 70's. She was bolused a liter of IVF with good response. Atenolol was discontinued and she was started on lopressor [Hospital1 ]. On POD 1 she was confused. Narcotics were minimized and she was started on scheduled tylenol. In the evening of POD 1 she was having episodes of desaturations so IVF were discontinued and she was started on lasix. On POD 2, she was restarted on atenolol and given lasix and albumin. Chest x ray showed evidence of volume overload. On POD 3 she was started on digoxin for atrial fibrillation, continued the lasix and atenolol was changed to [Hospital1 ] dosing. She remained hemodynamically stable and was transfered to the floor. Transferred to the surgical floor on POD #2. As part of her work-up for atrial fibrillation, she underwent an echocardiogram which showed moderate LV diastolic dysfunction, with an EF >55%. She did have an isolated episode of rapid heart rate and continued on her anti-arrhytmics. Her nutritional status was addressed by the nutritionist and her caloric intake was monitored. Because her appetite was diminished, she was started on an appetite stimulant. The penrose drain was removed on POD # 3 and the flexiseal of POD #4. Her c.diff cultures were negative. She continued on her ciprofloxacin and flagyl. Her foley catheter was discontinued on POD #4, but she was unable to void and the foley catheter was re-inserted. On POD # 5, she was evaluated by the Geriatric service regarding her occasional episodes of confusion at night. They identified potential factors which may be contributing to her confusion and made recommendations. On POD #7, she was noted to have leaking stool from her left hip and buttock wound. She underwent a cat scan and was found to have a leak from the distal sigmoid colon with feculent material in the presacral space, and along a tract that passes transgluteally and opens onto the skin of the left buttock consistent with colocutaneous fistula. Patient was informed of findings, along with surgical options and the patient did not want to pursue any further treatment. She was evaluated by social services, and the geriatric service to re-address her concerns. Psychiatry was consulted to evaluate her capacity to refuse medical and surgical interventions and deemed that she does have the capacity to refuse life-saving interventions. She was evaluated by physical therapy and recommendations were made for an extended care facility to help her regain her strength and mobility. Her vital signs are stable and she is afebrile. She is eating a regular diet but with She has been out of bed but does require assistance. She is voiding without difficulty. The colcutaneous fistula has an ostomy appliance over it. She is preparing for discharge to an extended care facility with instructions to follow-up in the acute care clinic in 2 weeks. Please schedule visit with Palliative care service at your facility to address patients wishes for medical/surgical intervention if there is a decline in her health status. Medications on Admission: ATENOLOL - 25 mg Tablet daily CLOPIDOGREL [PLAVIX] - 75 mg daily FLUTICASONE - 50 mcg Spray, Suspension - 1 spray each nostril daily ISOSORBIDE MONONITRATE - 30 mg ER [Hospital1 ] LACTULOSE - 10 gram/15 mL Solution - 1 Tsp daily prn constipation LISINOPRIL - Dosage uncertain LORAZEPAM - 0.25 mg Tablet qhs prn severe anxiety PRAVASTATIN - 10 mg Tablet daily ASPIRIN - 325 mg Tablet daily BISACODYL [FLEET BISACODYL] - 10 mg/30 mL Enema prn constipation . Discharge Medications: 1 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 6. isosorbide mononitrate 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 8. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 9. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for hr <80, systolic blood pressure <100. 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 14. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation. 15. 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. 16. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day: with meals as needed. 17. morphine sulfate IR Sig: 7.5 mg every six (6) hours: as needed for pain. 18. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days: started on [5-9]...2 week course. 19. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 14 days: started on [5-9]....2 week course. Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] - [Location (un) 1411] Discharge Diagnosis: left gluteal abscess 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 re-admitted to the hospial with nausea and vomitting and left buttock pain. You had been recently discharged from the hospital with diverticulitis and drainage of a pelvic abscess. At this admission, you were found to have a gluteal abscess which you went to the operating room for drainage. You were placed on antibiotics. Your diarrhea has decreased and you are now preparing for discharge to an extended care facility with the following instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you Followup Instructions: Please follow up with the acute care service in 2 weeks. You can schedule this appointment by calling # [Telephone/Fax (1) 600] Completed by:[2101-5-17]	[ "V45.81", "244.9", "569.81", "250.00", "272.4", "427.31", "V43.64", "401.9", "733.90", "414.00", "567.22", "788.29", "412", "V45.82", "728.89", "305.1", "562.11" ]	icd9cm	[ [ [] ] ]	[ "38.91", "83.02" ]	icd9pcs	[ [ [] ] ]	14252, 14346	8525, 12028	270, 314	14411, 14411	2645, 8500	15914, 16078	1552, 1685		12540, 14229		14367, 14390		12054, 12517			14594, 15891										1700, 1700															1723, 2225													211, 232										2242, 2626	342, 663												14426, 14570			685, 1220	1237, 1535
15,987	166,587	4319	Discharge summary	report	Admission Date: [2165-6-23] Discharge Date: [2165-7-8] Date of Birth: [2116-11-2] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 48 year old African American male with a past medical history significant for hypertension who presented to [Hospital ] Hospital with a chief complaint of blood rushing to his head and headache at 3 a.m., and presented to the outside hospital Emergency Department by 06:00 a.m. by ambulance called by the patient's fiance. The patient took two aspirin following the onset of symptoms and described generalized weakness, particularly in the lower extremities. He recalls drinking two glasses of wine on the night prior to admission. He denies loss of consciousness, and no neurological deficits besides weakness. He has no shortness of breath, no chest pain, no nausea, vomiting or constipation. The patient was ambulatory, awake, alert, oriented times three upon presentation to the outside hospital Emergency Department and [Hospital1 69] Emergency Department. The patient is repetitive and has short term memory loss; otherwise in no apparent distress. Complains of mild meningismus and pain throughout his spine. PAST MEDICAL HISTORY: 1. Hypertension. MEDICATIONS ON ADMISSION: 1. Diltiazem. 2. Hydrochlorothiazide. ALLERGIES: No known drug allergies. PAST SURGICAL HISTORY: None. FAMILY HISTORY: Hypertension; no renal disease; no aneurysms. SOCIAL HISTORY: Remote tobacco, social alcohol use. PHYSICAL EXAMINATION: Vital signs on admission: The patient is afebrile; blood pressure is 155/107; heart rate is 100, breathing at 20; O2 saturation 100%. On physical examination, he is awake, alert, oriented times three. Converses appropriately. Cranial nerves II through XII are intact. Strength in upper and lower extremities is five out of five bilaterally. Reflexes are two plus in the upper extremities and lower extremities bilaterally. He is grossly nonfocal. The patient has diminished short-term memory. Thoughts are repetitive. LABORATORY: MRI and CT scan of the head shows blood in the third and fourth ventricles, possible basilar tip aneurysm. HOSPITAL COURSE: The patient was admitted to the Neurosurgery Service initially to the Intensive Care Unit on [2165-6-23]. He received morphine for pain and Decadron which was started at 6 mg, intravenous Zantac, sliding scale insulin, Dilantin, and Amlodipine. His initial blood pressures were titrated for less than 130 with intravenous Labetalol and Nipride. The patient continued to complain of headache on [2165-6-24]. The patient had his aneurysm clipped after craniotomy was performed on [2165-6-25]. He tolerated this procedure well and went to the Neurosurgical Intensive Care Unit after the procedure. The patient's postoperative course was significant for fevers which were worked up including several samples of cerebrospinal fluid cultures; these were negative. The patient will be discharged to rehabilitation on [2165-7-8]. DISCHARGE MEDICATIONS: 1. Percocet one to two tablets p.o. q. four to six hours p.r.n. 2. Colace 100 mg p.o. twice a day. 3. Zantac 150 mg p.o. twice a day. 4. Heparin 5000 units subcutaneously q. 12 hours. 5. Dilantin 200 mg p.o. twice a day. 6. Amlodipine 60 mg p.o. q. four hours until [7-16]. DISCHARGE DIAGNOSES: 1. Interventricular hemorrhage secondary to pseudo-aneurysm of the posterior and inferior cerebellar artery on the right. DISPOSITION: The patient is being discharged to rehabilitation. CONDITION AT DISCHARGE: Stable. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Last Name (NamePattern1) 5476] MEDQUIST36 D: [2165-7-8] 09:05 T: [2165-7-8] 09:18 JOB#: [Job Number 18689]	[ "998.89", "401.9", "780.6", "430" ]	icd9cm	[ [ [] ] ]	[ "02.2", "39.51", "38.91" ]	icd9pcs	[ [ [] ] ]							1403, 1450	3366, 3567	3060, 3345				1275, 1355	2192, 3037										1379, 1386																	1527, 1539	3583, 3845																							159, 1208										1554, 2174					1230, 1249	1467, 1504
24,950	124,783	101	Discharge summary	report	Admission Date: [2108-2-17] Discharge Date: [2108-2-22] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1145] Chief Complaint: SOB Major Surgical or Invasive Procedure: cardioversion History of Present Illness: 83 y/o F with h/o MI s/p 4 vessel CABG, CHF, mitral regurgitation with worsening SOB and DOE over the last few months. Pt reports that she is now able to walk much less than a block without feeling short of breath, and that this has gotten worse in the last few months. However, she denies an acute worsening of shortness of breath/DOE prior to her admission. Shortness of breath has not been associated with wheezing. No associated chest pain. Pt notes paroxysmal nocturnal dyspnea, about 2-3 episodes per night, every night. Denies orthopnea and notes no changes in the number of pillows used. Denies fevers, cough, rhinorrhea, chest pain, diarrhea, or dysuria. Denies lower extremity edema. Denies palpitations. Reports that she has been taking her medications without missing doses or running out of medicine. Denies any change in her diet; denies eating canned soups or other canned food. Patient did not get fluvax or pneumovax this year. On the day of admission, she was seen by her PCP, [Name10 (NameIs) 1023] sent her to the ED due to hypoxia. In the ED she was found to be have 02 sat of 84% on RA was given 4L in NC 02 sat increased to 96%. Past Medical History: 1. coronary artery disease, s/p MI and 4 vessel CABG in [2095] 2. chronic obstructive pulmonary disease - emphysema, does not use O2 at home 3. hypercholesterolemia 4. history of cataracts Social History: Pt has 15 pack year history of tobacco; quit 20 years ago. Denies EtOH or IVDU. Lives alone, but with her son living in the same building on the [Location (un) 448]. Pt reports she is able to perform all of her ADLs, including shopping and cooking. Is able to ambulate, but is limited by SOB. Family History: no FH of CAD, MI, DM Physical Exam: T 97.6 BP 122/55 P 92 RR 28 O2sat 88% on RA 93%on 4L Gen: frail, appears older than her stated age. HEENT: PERRL. EOMI. OP clear, MM somewhat dry. Neck: JVD to about 12cm, with movement of her earlobes; no LAD CV: RRR, 3/6 systolic murmur loudest at apex radiating into axilla; PMI mildly displaced laterally Pulm: decreased breath sounds at both apices, crackles at L base, no dullness to percussion Abd: soft, NT/ND, + BS, no masses Ext: 2+ pitting edema bilaterally, symetrical. Neuro: CN 2-10 intact, 5/5 strength in UE and LE. Not oriented to time or place, but oriented to person (says [2102-10-6], cannot name hospital but knows she is in one) Pertinent Results: portable CXR - Large heart. flattened diaphrams. Lft costal phrenic border is not visualized on left. vasculature visualized out to border. offically read as not c/w acute cardiopulm process. CTA: 1. No evidence of pulmonary embolism. 2. Severe emphysema. 3. Small bilateral pleural effusions. 4. Left lower lobe atelectasis EKG: NSR 85 bpm, small Q waves in II, III, aVF, early R wave progression, evidence of LVH, nl intervals, RBBB, no evidence of acute ischemia Admission labs: CBC: WBC-6.6 RBC-3.79* HGB-11.6* HCT-35.5* MCV-94 MCH-30.7 MCHC-32.8 RDW-13.7 NEUTS-77.6* LYMPHS-16.1* MONOS-5.5 EOS-0.2 BASOS-0.7 PLT COUNT-362 electrolytes: GLUCOSE-121* UREA N-37* CREAT-1.2* SODIUM-138 POTASSIUM-5.9* CHLORIDE-99 TOTAL CO2-35* ANION GAP-10 above somewhat hemolyzed; repeat K shows K+-5.1 cardiac enzymes: CK(CPK)-88 CK-MB-NotDone cTropnT-0.03* Brief Hospital Course: Ms. [Known lastname 1146] was initially treated for a COPD exacerbation, which was felt to be the primary contributor to her SOB especially given that she wasn't on any inhalers at home despite an FEV1 of 25% predicted in [2095]. She was also ruled out for MI. Her creatinine initially trended down with gentle hydration. On the evening of [2108-2-18], she was found to be in Afib w/RVR to the 150s. She was given metoprolol 5 mg IV x3 and diltiazem x 1 dose without successful slowing. She became more tachypneic and short of breath, and hypotensive to the 70s. She was intubated, cardioverted to NSR w/100 Jx1, and started on dopamine. She was transferred to the CCU. Overnight, she went back into afib w/RVR and required cardioversion twice (second time successful at 200J). She was only in NSR for a short time, and again went back into afib. She was bolused w/amiodarone 150 mg and begun on an amio infusion at 1 mg/min. Cardioversion was again briefly successful but she ultimately went back into afib. Her dopamine was weaned off on [2-19]. Her rhythm was in and out of afib but eventually converted to sinus with the amio infusion. She had a TTE which revealed an EF 30-35%, repeat CXR c/w worsening failure, and diuresis was attempted with a lasix gtt. Her vent was changed from AC to PS but she became progressively acidemic (ABG from 7.42/42/92 to 7.21/56/66). Her creatinine began to increase with the attempt at diuresis, from 1.0 to 1.5. At this point she also developed a cold/purple R foot, and a heparin gtt was started. This resolved the problem. Vascular surgery evaluated the pt and agreed with this treatment. Because of her severe COPD, it was felt that it would be very difficult to wean her from the vent. At that point, there was a discussion between the PCP (Dr. [Last Name (STitle) 1147] and the family, who felt it was best to extubate her and keep her comfortable. She was then extubated at that time and given morphine for comfort. She died at 3:15 pm on [2108-2-22] with her family by her side. Medications on Admission: 1. Ascriptin 325 milligrams every day. 2. caltrate 600mg once daily 3. Metoprolol 50 milligrams two times a day. 4. Fosomax 70 mg q week 5. zocor 4 mg once daily. 6. MVT 1T daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: atrial fibrillation chronic obstructive pulmonary disease congestive heart failure Discharge Condition: expired Discharge Instructions: none Followup Instructions: none	[ "491.21", "V45.81", "276.2", "428.0", "276.3", "401.9", "428.33", "424.0", "412", "272.0", "584.9", "427.31", "518.81" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "00.17", "99.04", "38.91", "38.93", "00.13", "99.62" ]	icd9pcs	[ [ [] ] ]	5960, 5969	3631, 5702	266, 281	6095, 6104	2755, 3225	6157, 6164	2033, 2055		5931, 5937		5990, 6074		5728, 5908			6128, 6134										2070, 2736																							3568, 3608					223, 228											309, 1478							3242, 3551								1500, 1699	1715, 2017
74,942	161,910	42020	Discharge summary	report	Admission Date: [2101-9-2] Discharge Date: [2101-9-6] Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 10593] Chief Complaint: Acute cholangitis Major Surgical or Invasive Procedure: ERCP History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE Date: [2101-9-4] Time: 22:17 The patient is a [Hospital 91225] nursing home resident with dementia, hypothyroidism, and diabetes presenting with fevers x 1 week, abdominal pain, and AMS. Per family report, pt has been having fevers at nursing home for about a week which was initially attributed to her having received the flu shot recently. She has chronic abdominal pain at baseline, not complaining about it more than usual. She has been having abdominal pain and poor appetite for over one year. She had an episode of vomiting on Wednesday and was put on nasal cannula for reasons that are unclear to the family. She has also been having worsening mental status during this time, more confused than usual. She has constipation at baseline and her family was not told of any changes in bowel habits recently. She presented to [Hospital3 ] Hospital [2101-9-2] where labs were significant for WBC 38, total bili 4.6, AST/ALT 85. CT A/P showed no stones but common bile duct dilation to 2cm. She was given IV ceftriaxone 1g prior to transfer to [Hospital1 18] ED. At [Hospital1 18] ED, inital vitals were T99, BP 173/79, HR100, RR14, O2 sat 93%RA. She received IV cipro 400mg and IV flagyl 500mg. She was also given 1.5L IV fluids and IV zofran 4mg. Surgery was consulted who felt that since pt was s/p cholecystectomy, there was no role for surgical intervention. ERCP was also contact[Name (NI) ] and planned to perform ERCP in the morning. On the floor, pt appears comfortable. States that she has been having abdominal pain "off and on" for a long time. She reports feeling a "hard bone-like" protrusion in her left top gum area. Denies any pain currently. Review of Systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea on exertion. Denies shortness of breath, cough or wheezes. Denies nausea, vomiting, heartburn, diarrhea, constipation, BRBPR, melena. No dysuria, urinary frequency. Denies arthralgias or myalgias. Denies rashes. No increasing lower extremity swelling. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: Dementia Diabetes Hypothyroidism Depression Chronic constipation Lumbar fracture Hypertension Social History: Has been living at a nursing home since [2093]. Hx of smoking in the [2059]. No alcohol or illicit drug use. Family History: Twin sister: gastric cancer Physical Exam: VS: 96.0 96/50 74 16 94%RA, glucose 178; pain 0/10 GEN: No apparent distress, pleasant HEENT: pupils round and reactive to light and accommodation, no LAD, oropharynx: 5 x 2 mm abrasion vs growth in left maxillary gingival region, no exudates, edentulous CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII intact, [3-24] motor function globally DERM: no lesions appreciated Pertinent Results: [2101-9-2] 10:57PM LACTATE-1.9 [2101-9-2] 10:45PM GLUCOSE-125* UREA N-47* CREAT-1.0 SODIUM-143 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-25 ANION GAP-17 [2101-9-2] 10:45PM ALT(SGPT)-75* AST(SGOT)-106* AMYLASE-22 TOT BILI-5.0* [2101-9-2] 10:45PM LIPASE-17 [2101-9-2] 10:45PM PHOSPHATE-2.6* MAGNESIUM-1.7 [2101-9-2] 10:45PM WBC-37.4* RBC-3.81* HGB-12.1 HCT-35.6* MCV-94 MCH-31.7 MCHC-33.9 RDW-14.3 [2101-9-2] 10:45PM NEUTS-89* BANDS-3 LYMPHS-3* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2101-9-2] 10:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2101-9-2] 10:45PM PLT SMR-LOW PLT COUNT-112* [2101-9-2] 10:45PM PT-15.1* PTT-32.0 INR(PT)-1.3* CHEST (PORTABLE AP): REASON FOR EXAMINATION: New oxygen requirement. Portable AP radiograph of the chest was reviewed in comparison to CT abdomen obtained on [2101-9-2]. Right lower lobe consolidation is noted as well as linear atelectasis of the left lung base. Upper lungs are clear. Calcified and tortuous aorta is noted. No appreciable cardiomegaly is seen. No pneumothorax is seen. LATEST LABS [2101-9-6] 07:50AM BLOOD WBC-7.2 RBC-3.43* Hgb-10.6* Hct-32.2* MCV-94 MCH-30.9 MCHC-32.9 RDW-14.0 Plt Ct-121* [2101-9-6] 07:50AM BLOOD Glucose-109* UreaN-29* Creat-0.7 Na-139 K-3.5 Cl-106 HCO3-23 AnGap-14 [2101-9-5] 08:25AM BLOOD ALT-31 AST-29 AlkPhos-200* TotBili-1.4 Brief Hospital Course: [Hospital 91225] nursing home resident with dementia, hypothyroidism, and diabetes presenting with fever in setting of leukocytosis and elevated bilirubin with CT abdomen/pelvis showing CBD dilation. Pt was transferred on [2101-9-2] with fever, leukocytosis and hyperbilirubinemia. . #Acute cholangitis/bacteremia/septicemia: transferred from [Location (un) 21541] Hospital to [Hospital1 18] for ERCP. WBC on [9-2] was 34.7. Initially treated with ceftrixone at [Hospital3 ] Hospital, then iv Unasyn, then iv Zosyn here. ERCP on [9-3] revealed many periampullary diverticula, and distorted biliary tree; biliary stent was placed, with immediate rush of pus and bile. Her blood pressure was as low as 90s systolic. Her abd pain improved, and WBC trended downward. LFTs trended downward. Blood cultures from [Hospital3 ] Hospital grew E. coli and Klebsiella pneumoniae (both pan-sensitive); switched to oral ciprofloxacin and metronidazole on [9-5] (the latter for anaerobe coverage and for reducing the risk of Cdiff colitis). She will continue oral ciprofloxacin and metronidazole through [2101-9-12] to complete a 10 day course. She should have a repeat ERCP procedure in 4 weeks to remove the stent. . # Dementia: Initial concern for delirium on top of baseline dementia, possibly due to infection. She has a tendency for increasing confusion during illness. Of note, pt was found to have exelon patch on neck dated [2101-8-30] which was removed. Mental status improved to baseline, per conversation with her daughter. . # Diabetes mellitus, type 2, controlled, without complications: held metformin here, placed on insulin sliding scale. Sugars were in good range. Metformin can be restarted. . #. Left maxillary lesion: Likely abrasion vs [Last Name (un) 2043] protrusion. No pus. Will likely need to be further evaluated in an outpatient #. Hypertension, benign: Stable. Held home furosemide given lower BPs and limited po intake. Treated with diltiazem 30 mg QID. . #. Hypothyroidism: - Continued home levothyroxine 100 mcg daily . #. Depression: Continued home sertraline 25 mg daily . #. Chronic back pain: Stable. - Scheduled tylenol . #. Chronic constipation: - Continued home senna, with additional psyllium . # Oral lesion: had what appeared to be a small canker sore. Can treat with topical Orabase. . # Thrombocytopenia: baseline unclear. Plt count low here but stable. Plts 121 on discharge. Can follow-up after discharge. . # Code status: DNR, OK to intubate Medications on Admission: (Unable to verify b/c pt doesn't remember and not in OMR) (Per ED dashboard): Lasix -- Unknown Strength TUMS Extra Strength Smoothies -- Unknown Strength calcium -- Unknown Strength levothyroxine -- Unknown Strength senna -- Unknown Strength Exelon -- Unknown Strength Metformin Hydrochloride morphine -- Unknown Strength sertraline -- Unknown Strength diltiazem HCl -- Unknown Strength amoxicillin -- Unknown Strength Discharge Medications: 1. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 13 doses: through [2101-9-12]. Disp:13 Tablet(s)* Refills:0 9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 19 doses: through [2101-9-12]. Disp:19 Tablet(s) Refills:0 10. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) GRAMS PO DAILY (Daily) as needed for constipation. 11. metformin Oral 12. psyllium Packet Sig: One (1) Packet PO BID (2 times a day) as needed for constipation. 13. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 15. benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID (4 times a day) as needed for oral pain. Disp:1 TUBE Refills:0 Discharge Disposition: Extended Care Facility: [Location (un) 38380] Discharge Diagnosis: Acute cholangitis Bacteremia Septicemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [Known lastname ], you were transferred to [Hospital1 18] for management of cholangitis (infection of the biliary ducts that spread into your blood). You underwent an ERCP procedure and had a stent placed in your bile duct. You were treated with antibiotics and improved. You should continue to take the antibiotics ciprofloxacin and metronidazole (Flagyl) through [2101-9-12]. You should have another ERCP procedure in 4 weeks to remove the stent. Followup Instructions: Repeat ERCP in 4 weeks for stent removal	[ "244.9", "528.2", "401.1", "576.1", "V49.86", "287.5", "038.42", "995.91", "427.89", "285.9", "276.0", "294.8", "293.0", "564.09", "250.00", "311", "518.0" ]	icd9cm	[ [ [] ] ]	[ "51.87" ]	icd9pcs	[ [ [] ] ]	9570, 9622	5104, 7631	232, 238	9706, 9706	3639, 5081	10384, 10428	2927, 2957		8101, 9547		9643, 9685		7657, 8078			9891, 10361										2972, 3620																						2028, 2658						175, 194											266, 2009												9721, 9867			2680, 2775	2791, 2911
76,880	109,739	42009	Discharge summary	report	Admission Date: [2192-3-17] Discharge Date: [2192-5-28] Date of Birth: [2127-11-3] Sex: F Service: MEDICINE Allergies: penicillin G Attending:[First Name3 (LF) 13256] Chief Complaint: Fall Major Surgical or Invasive Procedure: [2192-3-18] Open reduction and intramedullary nail fixation right femur fracture [2192-3-26] Cyberknife [2192-3-28] Cyberknife [2192-3-29] Cyberknife [2192-4-8] IR-guided therapeutic paracentesis [2192-4-17] IR-guided therapeutic paracentesis [2192-4-18] Cyberknife [2192-4-19] Cyberknife [2192-4-20] Cyberknife [2192-4-23] IR-guided therapeutic paracentesis [2192-5-5] Therapeutic paracentesis History of Present Illness: 64yo woman, Hindi/Urdu-speaking only, with h/o Hepatitis C cirrhosis (in past, has been decompensated with ascites, encephalopathy; has known varices), probable HCC w/ plans for Cyberknife, DMII, recently discovered L2-4 lumbar fx (just discharged yesterday for this) who presents with L hip fracture. She was discharged yesterday from [Hospital1 18] after being admitted from [3-13]->[3-16] - was admitted for back pain and found to have L2-L4 compression fractures on MRI. She was doing well at home, her appetite was returning and her back pain was better controlled overnight. This morning ~ 9 AM she got up to get out of bed and reached for her walker, but tripped and fell and landed on her R hip. Her son was in the next room and heard her cry out - she did not lose consciousness, did not hit her head, was not confused. She complained of pain - EMS was called and she was taken to [Hospital3 ]. There, Xray showed 'left intertrochanteric and subtrochanteric proximal left femur fracture with mild varus angulation. femoral shaft is displaced 1cm med, 1cm anterior, no dislocation.' She was given 4 mg IV morphine x 4, zofran, and 1L NS and transferred to [Hospital1 18] at the request of her family since here care is here. . In the ED, initial VS 98.0 98 118/68 18 97% on RA. She was in extreme pain w/ L hip flexed and externally rotated. Labs were mostly at baseline though K was 5.6. CXR showed no acute process. Ortho was consulted and recommended admission to medicine for optimization prior to surgery. They plan to take her to the OR either tmrw PM or on Monday. . Currently, the patient is in pain. Her R leg is flexed up and her L leg is flexed and externally rotated. She intermittently moans in pain. Her son helps to translate. Other than the back pain, she has not otherwise been recently ill. She ambulates with a walker at home and has been doing well with this. She is oriented x 3 and has no complaints other than L hip pain. The morphine helped a little with the pain at OSH. Oxycodone makes her very nauseated. . ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -Complications of her hepatitis C: ascites, esophageal varices, has had banding performed on three occasions in [Country 9819], the most recent of which was 1.5 years ago. She is known to have esophageal varices documented by an endoscopy in [Hospital ] Hospital and is currently on nadolol. She has had four to five paracenteses, the last of which was performed in [Month (only) ] and is maintained now on diuretics without any recurrence of ascites. -She has had intermittent periods of confusion and difficulty sleeping and is maintained on lactulose for treatment of hepatic encephalopathy. -Diabetes for 30 years. -She has been tested negative for TB -thyroid surgery performed in the past, but again there was no evidence of any cancer. - L2,3,4 compression fractures from [2-/2109] MRI; there is some question of pathologic fractures -Appendiceal mucocele diagnosed on abdominal CT [2-16] - Sub-5-mm cystic lesions noted within the inferior aspect of the head of the pancreas which may represent either side branch IPMN vs. other cystic lesions of the pancreas from [11-25] CT w/ elevated CA [99]-9 to 238 - Right adrenal lesion with MR [First Name (Titles) ] [Last Name (Titles) ] concerning for phaeochromocytoma; catecholamines normal Social History: SOCIAL HISTORY: She recently moved from [Country 9819] to the United States one year ago. She has two sisters and two brothers who live nearby and have been helping her with care. She is married and she lives with her son and daughter-in-law. She is a former teacher who retired 15 years ago in [Country 9819]. She speaks Urdu and Hindi. She does not drink any alcohol and she smokes one cigarette per day for the last two years.She has received two blood transfusions, one about one and a half years ago and the second one about 30 years ago. She has no history of intravenous drug use or tattoos. Family History: FAMILY HISTORY: Her mother also was diagnosed with cirrhosis. She reports that one of her brothers had lung nodules but this disappeared without any treatment. She otherwise denies any history of cancer in the family. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98.0 96 106/58 18 97% on RA GENERAL: Looks uncomfortable, intermittently moans in pain, wearing back brace HEENT: Sclera icteric. MMM CARDIAC: RRR with no excess sounds appreciated LUNGS: As she is wearing back brace only eval'd anterior lung fields - clear ABDOMEN: soft, ND, NT EXTREMITIES: no edema, WWP; R leg is flexed up, L leg is flexed and externally rotated; 2+ dp pulses bilaterally, sensation in L leg intact Neuro: A&Ox3, EOMI, full strenth in bil UE, wiggles toes in bil. LE . DISCHARGE PHYSICAL EXAM: Physical Exam: Vitals: 97.9 123/55 99 20 100%RA General- alert, diffusely jaundice HEENT- Sclera icteric Lungs- coarse breath sounds throughout CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- non-tender, soft, mildly distended, bowel sounds present, no rebound tenderness or guarding Ext- warm, well perfused, 2+ edema to the knees, pneumoboots in place Neuro- A&O x3 Pertinent Results: [2192-3-16] 05:05AM BLOOD WBC-3.2* RBC-3.80* Hgb-9.1* Hct-29.8* MCV-78* MCH-24.0* MCHC-30.6* RDW-17.9* Plt Ct-48* [2192-3-17] 07:40PM BLOOD WBC-6.4# RBC-4.04* Hgb-9.8* Hct-30.3* MCV-75* MCH-24.4* MCHC-32.5 RDW-18.0* Plt Ct-71* [2192-3-18] 07:05AM BLOOD WBC-5.7 RBC-3.54* Hgb-8.8* Hct-26.6* MCV-75* MCH-25.0* MCHC-33.2 RDW-18.2* Plt Ct-63* [2192-3-18] 10:57AM BLOOD WBC-8.5 RBC-3.77* Hgb-9.7* Hct-29.0* MCV-77* MCH-25.8* MCHC-33.6 RDW-17.8* Plt Ct-118# [2192-3-19] 06:25AM BLOOD WBC-7.6 RBC-2.99 Hgb-7.6* Hct-23.4* MCV-78* MCH-25.4* MCHC-32.6 RDW-17.9* Plt Ct-91* [2192-3-19] 05:00PM BLOOD WBC-7.9 RBC-3.65* Hgb-10.1# Hct-28.4 MCV-78* MCH-27.8 MCHC-35.7* RDW-17.3* Plt Ct-70* [2192-3-20] 06:20AM BLOOD WBC-7.6 RBC-3.72* Hgb-10.1* Hct-29.5* MCV-79* MCH-27.2 MCHC-34.3 RDW-17.8* Plt Ct-62* [2192-3-21] 05:15AM BLOOD WBC-6.3 RBC-3.44* Hgb-9.4* Hct-28.2* MCV-82 MCH-27.4 MCHC-33.4 RDW-18.2* Plt Ct-70* [2192-3-22] 06:35AM BLOOD WBC-5.5 RBC-3.53* Hgb-9.8* Hct-28.9* MCV-82 MCH-27.7 MCHC-33.8 RDW-18.5* Plt Ct-80* [2192-3-23] 06:30AM BLOOD WBC-4.5 RBC-3.22* Hgb-9.0* Hct-26.9* MCV-83 MCH-27.9 MCHC-33.5 RDW-19.3* Plt Ct-55* [2192-3-24] 06:50AM BLOOD WBC-5.3 RBC-3.18* Hgb-9.0* Hct-26.3* MCV-83 MCH-28.3 MCHC-34.3 RDW-19.7* Plt Ct-70* [2192-3-25] 06:40AM BLOOD WBC-5.9 RBC-2.98* Hgb-8.4* Hct-25.1* MCV-84 MCH-28.2 MCHC-33.4 RDW-20.7* Plt Ct-53* [2192-3-26] 06:30AM BLOOD WBC-5.0 RBC-2.85* Hgb-8.1* Hct-24.6* MCV-86 MCH-28.4 MCHC-32.9 RDW-22.0* Plt Ct-60* [2192-3-27] 06:50AM BLOOD WBC-4.3 RBC-2.77* Hgb-8.1* Hct-23.8* MCV-86 MCH-29.1 MCHC-33.9 RDW-22.2* Plt Ct-83* [2192-3-28] 06:05AM BLOOD WBC-5.5 RBC-2.78* Hgb-8.3* Hct-24.8* MCV-89 MCH-29.8 MCHC-33.4 RDW-23.2* Plt Ct-103* [2192-3-29] 06:00AM BLOOD WBC-6.5 RBC-2.89* Hgb-8.5* Hct-26.5* MCV-92 MCH-29.3 MCHC-32.1 RDW-23.7* Plt Ct-127* [2192-3-30] 05:58AM BLOOD WBC-6.1 RBC-2.64* Hgb-7.8* Hct-24.5* MCV-93 MCH-29.5 MCHC-31.7 RDW-24.5* Plt Ct-126* [2192-3-31] 06:00AM BLOOD WBC-5.9 RBC-2.68* Hgb-8.0* Hct-26.3* MCV-98 MCH-29.6 MCHC-30.3* RDW-24.7* Plt Ct-128* [2192-4-1] 05:15AM BLOOD WBC-6.3 RBC-2.80* Hgb-8.5* Hct-27.8* MCV-99* MCH-30.4 MCHC-30.6* RDW-24.8* Plt Ct-118* [2192-4-2] 05:35AM BLOOD WBC-6.5 RBC-2.81* Hgb-8.3* Hct-27.7* MCV-99* MCH-29.6 MCHC-30.0* RDW-24.8* Plt Ct-106* [2192-4-3] 05:30AM BLOOD WBC-4.2 RBC-2.71* Hgb-8.2* Hct-27.1* MCV-100* MCH-30.2 MCHC-30.3* RDW-24.5* Plt Ct-91* [2192-4-4] 05:20AM BLOOD WBC-3.8* RBC-2.71* Hgb-8.2* Hct-26.8* MCV-99* MCH-30.1 MCHC-30.4* RDW-24.3* Plt Ct-81* [2192-4-27] 05:15AM BLOOD WBC-5.4 RBC-2.66* Hgb-8.4* Hct-27.4* MCV-103* MCH-31.6 MCHC-30.7* RDW-20.4* Plt Ct-80* [2192-4-28] 06:27AM BLOOD WBC-4.8 RBC-2.51* Hgb-8.1* Hct-26.6* MCV-106* MCH-32.2* MCHC-30.4* RDW-20.2* Plt Ct-62* [2192-5-3] 06:30AM BLOOD WBC-6.0 RBC-2.12* Hgb-6.6* Hct-21.6* MCV-102* MCH-30.9 MCHC-30.3* RDW-19.8* Plt Ct-63* [2192-5-4] 04:49PM BLOOD WBC-6.1 RBC-2.50* Hgb-8.1* Hct-25.4* MCV-101* MCH-32.2* MCHC-31.8 RDW-21.1* Plt Ct-63* [2192-5-7] 05:55AM BLOOD WBC-5.0 RBC-1.97* Hgb-6.3* Hct-20.0* MCV-102* MCH-32.0 MCHC-31.5 RDW-20.8* Plt Ct-49* [2192-5-8] 02:59AM BLOOD WBC-5.1 RBC-2.77* Hgb-8.8* Hct-28.0* MCV-101* MCH-31.8 MCHC-31.4# RDW-21.0* Plt Ct-44* [2192-5-13] 06:00AM BLOOD WBC-7.3 RBC-2.78* Hgb-9.0* Hct-28.1* MCV-101* MCH-32.4* MCHC-32.0 RDW-21.0* Plt Ct-27* [2192-5-16] 05:20AM BLOOD WBC-3.9* RBC-2.32* Hgb-7.6* Hct-23.6* MCV-102* MCH-32.8* MCHC-32.3 RDW-21.5* Plt Ct-33* [2192-5-20] 06:00AM BLOOD WBC-4.7 Hct-25.5* Plt Ct-39* [2192-5-21] 05:09AM BLOOD WBC-4.5 RBC-2.48* Hgb-8.4* Hct-26.2* MCV-106* MCH-33.8* MCHC-32.1 RDW-22.3* Plt Ct-36* [2192-5-22] 05:25AM BLOOD WBC-4.2 RBC-2.31* Hgb-7.9* Hct-23.9* MCV-103* MCH-34.0* MCHC-32.9 RDW-22.2* Plt Ct-36* [2192-5-24] 05:21AM BLOOD WBC-3.8* RBC-2.28* Hgb-7.9* Hct-23.7* MCV-104* MCH-34.6* MCHC-33.3 RDW-22.6* Plt Ct-37* [2192-5-25] 04:38AM BLOOD WBC-4.6 RBC-2.33* Hgb-7.7* Hct-24.4* MCV-105* MCH-33.0* MCHC-31.7 RDW-22.5* Plt Ct-38* [2192-5-26] 06:33AM BLOOD WBC-4.4 RBC-2.28* Hgb-8.0* Hct-23.7* MCV-104* MCH-35.0* MCHC-33.7 RDW-22.5* Plt Ct-40* [2192-5-27] 05:09AM BLOOD WBC-3.5* RBC-2.23* Hgb-7.7* Hct-23.5* MCV-106* MCH-34.6* MCHC-32.7 RDW-22.4* Plt Ct-44* [2192-5-28] 06:49AM BLOOD WBC-2.8* RBC-2.21* Hgb-7.8* Hct-23.0* MCV-104* MCH-35.3* MCHC-33.9 RDW-22.6* Plt Ct-45* [2192-3-16] 05:05AM BLOOD PT-14.6* PTT-32.4 INR(PT)-1.4* [2192-3-17] 07:40PM BLOOD PT-14.3* PTT-34.2 INR(PT)-1.3* [2192-3-20] 06:20AM BLOOD PT-16.6* PTT-36.2 INR(PT)-1.6* [2192-3-29] 06:00AM BLOOD PT-17.4* PTT-41.8* INR(PT)-1.6* [2192-3-30] 05:58AM BLOOD PT-20.7* PTT-43.8* INR(PT)-2.0* [2192-4-1] 05:15AM BLOOD PT-23.4* PTT-66.6* INR(PT)-2.2* [2192-4-6] 05:30AM BLOOD PT-21.2* PTT-45.4* INR(PT)-2.0* [2192-4-8] 05:40AM BLOOD PT-19.7* PTT-44.2* INR(PT)-1.9* [2192-4-20] 05:40AM BLOOD PT-18.8* PTT-36.5 INR(PT)-1.8* [2192-4-22] 05:50AM BLOOD PT-17.9* PTT-34.1 INR(PT)-1.7* [2192-4-30] 05:45AM BLOOD PT-22.1* PTT-51.4* INR(PT)-2.1* [2192-5-3] 06:30AM BLOOD PT-25.9* PTT-45.0* INR(PT)-2.5* [2192-5-4] 06:21AM BLOOD PT-27.3* PTT-53.5* INR(PT)-2.6* [2192-5-8] 02:59AM BLOOD PT-31.8* INR(PT)-3.1* [2192-5-9] 02:25PM BLOOD PT-35.5* PTT-59.9* INR(PT)-3.5* [2192-5-9] 05:44PM BLOOD PT-36.6* PTT-59.9* INR(PT)-3.6* [2192-5-10] 03:57AM BLOOD PT-35.2* PTT-54.6* INR(PT)-3.4* [2192-5-21] 05:09AM BLOOD Plt Ct-36* [2192-5-22] 05:25AM BLOOD PT-28.8* PTT-51.8* INR(PT)-2.8* [2192-5-25] 04:38AM BLOOD PT-27.1* PTT-45.2* INR(PT)-2.6* [2192-5-27] 05:09AM BLOOD PT-26.0* PTT-45.0* INR(PT)-2.5* [2192-5-28] 06:49AM BLOOD PT-25.4* PTT-44.7* INR(PT)-2.4* [2192-3-16] 05:05AM BLOOD Glucose-135* UreaN-19 Creat-1.1 Na-132* K-4.6 Cl-99 HCO3-27 AnGap-11 [2192-3-17] 07:40PM BLOOD Glucose-100 UreaN-21* Creat-1.1 Na-128* K-5.6* Cl-95* HCO3-24 AnGap-15 [2192-3-18] 07:05AM BLOOD Glucose-78 UreaN-24* Creat-1.2* Na-131* K-5.1 Cl-98 HCO3-24 AnGap-14 [2192-3-18] 10:57AM BLOOD Glucose-87 UreaN-22* Creat-1.2* Na-135 K-5.2* Cl-100 HCO3-26 AnGap-14 [2192-3-19] 06:25AM BLOOD Glucose-269* UreaN-22* Creat-1.1 Na-131* K-4.7 Cl-102 HCO3-19* AnGap-15 [2192-3-19] 05:00PM BLOOD Glucose-247* UreaN-20 Creat-1.0 Na-134 K-3.9 Cl-105 HCO3-20* AnGap-13 [2192-3-20] 06:20AM BLOOD Glucose-158* UreaN-20 Creat-0.9 Na-135 K-3.5 Cl-102 HCO3-26 AnGap-11 [2192-3-21] 05:15AM BLOOD Glucose-179* UreaN-20 Creat-0.8 Na-134 K-3.9 Cl-103 HCO3-24 AnGap-11 [2192-3-24] 06:50AM BLOOD Glucose-162* UreaN-19 Creat-0.6 Na-129* K-4.4 Cl-100 HCO3-25 AnGap-8 [2192-3-26] 06:30AM BLOOD Glucose-156* UreaN-16 Creat-0.8 Na-131* K-4.9 Cl-99 HCO3-26 AnGap-11 [2192-3-28] 06:05AM BLOOD Glucose-245* UreaN-25* Creat-1.5* Na-130* K-5.2* Cl-98 HCO3-24 AnGap-13 [2192-3-29] 06:00AM BLOOD Glucose-176* UreaN-29* Creat-1.8* Na-130* K-5.4* Cl-96 HCO3-27 AnGap-12 [2192-3-29] 03:30PM BLOOD UreaN-29* Creat-1.9* Na-133 K-5.4* Cl-99 HCO3-26 AnGap-13 [2192-4-4] 05:20AM BLOOD Glucose-112* UreaN-12 Creat-0.7 Na-131* K-4.1 Cl-101 HCO3-24 AnGap-10 [2192-4-6] 05:30AM BLOOD Glucose-133* UreaN-12 Creat-0.7 Na-131* K-4.4 Cl-100 HCO3-25 AnGap-10 [2192-4-9] 05:40AM BLOOD Glucose-67* UreaN-12 Creat-0.8 Na-132* K-4.2 Cl-99 HCO3-26 AnGap-11 [2192-4-10] 05:45AM BLOOD Glucose-240* UreaN-10 Creat-0.7 Na-127* K-4.9 Cl-96 HCO3-26 AnGap-10 [2192-4-13] 05:40AM BLOOD Glucose-234* UreaN-14 Creat-0.7 Na-127* K-5.3* Cl-95* HCO3-25 AnGap-12 [2192-4-14] 05:45AM BLOOD Glucose-218* UreaN-16 Creat-0.8 Na-127* K-5.3* Cl-95* HCO3-26 AnGap-11 [2192-4-27] 05:15AM BLOOD Glucose-274* UreaN-39* Creat-0.9 Na-129* K-4.2 Cl-93* HCO3-30 AnGap-10 [2192-4-28] 06:27AM BLOOD Glucose-181* UreaN-40* Creat-0.8 Na-130* K-4.3 Cl-94* HCO3-30 AnGap-10 [2192-4-30] 05:45AM BLOOD Glucose-152* UreaN-47* Creat-1.0 Na-127* K-5.3* Cl-93* HCO3-28 AnGap-11 [2192-5-3] 06:30AM BLOOD Glucose-217* UreaN-70* Creat-1.5* Na-125* K-5.1 Cl-88* HCO3-27 AnGap-15 [2192-5-5] 05:15AM BLOOD Glucose-164* UreaN-90* Creat-1.9* Na-126* K-4.6 Cl-88* HCO3-28 AnGap-15 [2192-5-5] 05:15PM BLOOD Glucose-98 UreaN-95* Creat-2.0* Na-128* K-4.6 Cl-88* HCO3-25 AnGap-20 [2192-5-6] 04:55AM BLOOD Glucose-209* UreaN-100* Creat-2.1* Na-123* K-5.3* Cl-86* HCO3-23 AnGap-19 [2192-5-7] 05:55AM BLOOD Glucose-193* UreaN-113* Creat-2.5* Na-123* K-5.7* Cl-84* HCO3-20* AnGap-25* [2192-5-7] 05:48PM BLOOD Glucose-669* UreaN-102* Creat-2.4* Na-110* K-4.1 Cl-73* HCO3-17* AnGap-24* [2192-5-7] 07:15PM BLOOD Glucose-171* UreaN-117* Creat-2.5* Na-127* K-4.8 Cl-86* HCO3-19* AnGap-27* [2192-5-8] 02:59AM BLOOD Glucose-150* UreaN-118* Creat-2.7* Na-125* K-5.2* Cl-87* HCO3-18* AnGap-25* [2192-5-8] 04:01PM BLOOD Glucose-125* UreaN-117* Creat-2.6* Na-124* K-5.9* Cl-89* HCO3-22 AnGap-19 [2192-5-9] 02:07AM BLOOD Glucose-90 UreaN-117* Creat-2.4* Na-128* K-5.5* Cl-89* HCO3-21* AnGap-24* [2192-5-9] 02:25PM BLOOD Glucose-147* UreaN-110* Creat-2.0* Na-130* K-5.2* Cl-90* HCO3-22 AnGap-23* [2192-5-9] 05:44PM BLOOD Glucose-170* UreaN-109* Creat-1.8* Na-131* K-5.3* Cl-90* HCO3-23 AnGap-23* [2192-5-10] 03:57AM BLOOD Glucose-228* UreaN-103* Creat-1.4* Na-137 K-4.4 Cl-96 HCO3-25 AnGap-20 [2192-5-10] 02:04PM BLOOD Glucose-214* UreaN-77* Creat-0.8 Na-138 K-3.3 Cl-101 HCO3-23 AnGap-17 [2192-5-21] 05:09AM BLOOD Glucose-88 UreaN-42* Creat-0.3* Na-133 K-5.5* Cl-96 HCO3-29 AnGap-14 [2192-5-21] 02:15PM BLOOD Glucose-79 UreaN-41* Creat-0.4 Na-133 K-5.0 Cl-95* HCO3-29 AnGap-14 [2192-5-25] 04:38AM BLOOD Glucose-114* UreaN-37* Creat-0.7 Na-129* K-5.1 Cl-91* HCO3-26 AnGap-17 [2192-5-26] 06:33AM BLOOD Glucose-92 UreaN-38* Creat-0.7 Na-126* K-5.0 Cl-90* HCO3-25 AnGap-16 [2192-5-27] 05:09AM BLOOD Glucose-117* UreaN-40* Creat-0.9 Na-129* K-5.1 Cl-92* HCO3-25 AnGap-17 [2192-5-28] 06:49AM BLOOD Glucose-84 UreaN-40* Creat-0.8 Na-125* K-5.0 Cl-89* HCO3-27 AnGap-14 [2192-3-16] 05:05AM BLOOD ALT-34 AST-69* LD(LDH)-141 AlkPhos-168* TotBili-1.6* [2192-3-17] 07:40PM BLOOD ALT-40 AST-97* CK(CPK)-31 AlkPhos-191* TotBili-2.1* [2192-3-18] 07:05AM BLOOD ALT-40 AST-88* AlkPhos-180* TotBili-2.1* [2192-3-19] 06:25AM BLOOD ALT-26 AST-63* LD(LDH)-210 AlkPhos-139* TotBili-2.3* [2192-3-20] 06:20AM BLOOD ALT-18 AST-39 LD(LDH)-165 AlkPhos-115* TotBili-5.8* [2192-3-21] 05:15AM BLOOD ALT-20 AST-41* LD(LDH)-153 AlkPhos-117* TotBili-2.9* [2192-3-22] 06:35AM BLOOD ALT-17 AST-38 LD(LDH)-144 AlkPhos-135* TotBili-2.8* [2192-3-23] 06:30AM BLOOD ALT-15 AST-31 LD(LDH)-129 AlkPhos-114* TotBili-5.0* [2192-3-24] 06:50AM BLOOD ALT-16 AST-38 LD(LDH)-139 AlkPhos-131* TotBili-4.9* [2192-3-25] 06:40AM BLOOD ALT-14 AST-34 LD(LDH)-143 AlkPhos-109* TotBili-6.2* DirBili-2.5* IndBili-3.7 [2192-3-26] 06:30AM BLOOD ALT-13 AST-34 LD(LDH)-125 AlkPhos-110* TotBili-6.6* [2192-3-27] 06:50AM BLOOD ALT-11 AST-32 LD(LDH)-142 AlkPhos-110* TotBili-7.3* [2192-3-28] 06:05AM BLOOD ALT-14 AST-36 LD(LDH)-178 AlkPhos-129* TotBili-7.2* [2192-3-30] 05:58AM BLOOD ALT-9 AST-34 LD(LDH)-174 AlkPhos-90 TotBili-8.6* [2192-3-31] 06:00AM BLOOD ALT-15 AST-55* LD(LDH)-221 AlkPhos-108* TotBili-8.9* [2192-4-1] 05:15AM BLOOD ALT-17 AST-66* AlkPhos-111* TotBili-9.1* [2192-4-2] 05:35AM BLOOD ALT-16 AST-54* LD(LDH)-187 AlkPhos-115* TotBili-8.2* [2192-4-3] 05:30AM BLOOD ALT-15 AST-48* LD(LDH)-199 AlkPhos-118* TotBili-7.5* [2192-4-4] 05:20AM BLOOD ALT-13 AST-44* LD(LDH)-201 AlkPhos-129* TotBili-7.0* [2192-4-5] 05:15AM BLOOD ALT-15 AST-44* LD(LDH)-217 AlkPhos-143* TotBili-6.5* [2192-4-6] 05:30AM BLOOD ALT-15 AST-41* LD(LDH)-210 AlkPhos-141* TotBili-5.8* [2192-4-7] 06:13AM BLOOD ALT-12 AST-45* LD(LDH)-202 AlkPhos-156* TotBili-5.7* [2192-4-8] 05:40AM BLOOD ALT-17 AST-44* AlkPhos-162* TotBili-5.4* [2192-4-9] 05:40AM BLOOD ALT-15 AST-38 LD(LDH)-214 AlkPhos-162* TotBili-4.7* [2192-4-10] 05:45AM BLOOD ALT-15 AST-39 LD(LDH)-242 AlkPhos-193* TotBili-4.7* [2192-4-11] 05:33AM BLOOD ALT-15 AST-41* LD(LDH)-204 AlkPhos-168* TotBili-4.7* [2192-4-15] 04:45AM BLOOD ALT-18 AST-48* AlkPhos-195* TotBili-4.4* [2192-4-17] 05:48AM BLOOD ALT-22 AST-58* AlkPhos-198* TotBili-4.5* [2192-4-18] 05:44AM BLOOD ALT-21 AST-66* AlkPhos-179* TotBili-4.4* [2192-4-19] 06:06AM BLOOD ALT-23 AST-81* AlkPhos-212* TotBili-4.1* [2192-4-20] 05:40AM BLOOD ALT-21 AST-70* AlkPhos-209* TotBili-3.8* [2192-4-21] 05:50AM BLOOD ALT-26 AST-79* AlkPhos-247* TotBili-4.1* [2192-4-30] 05:45AM BLOOD ALT-44* AST-134* AlkPhos-247* TotBili-3.8* [2192-5-3] 06:30AM BLOOD ALT-83* AST-235* AlkPhos-198* TotBili-4.7* [2192-5-9] 02:07AM BLOOD ALT-34 AST-101* AlkPhos-100 TotBili-14.0* [2192-5-9] 02:25PM BLOOD ALT-30 AST-96* LD(LDH)-281* AlkPhos-88 TotBili-13.4* [2192-5-9] 05:44PM BLOOD ALT-32 AST-100* LD(LDH)-298* AlkPhos-90 TotBili-13.8* [2192-5-10] 03:57AM BLOOD ALT-32 AST-99* AlkPhos-99 TotBili-15.4* [2192-5-11] 02:22AM BLOOD ALT-28 AST-85* AlkPhos-86 TotBili-15.6* [2192-5-12] 05:00AM BLOOD ALT-27 AST-76* LD(LDH)-186 AlkPhos-90 TotBili-16.8* [2192-5-13] 06:00AM BLOOD ALT-32 AST-86* LD(LDH)-264* AlkPhos-102 TotBili-23.7* [2192-5-14] 03:40AM BLOOD ALT-34 AST-102* LD(LDH)-232 CK(CPK)-22* AlkPhos-106* TotBili-25.9* DirBili-15.8* IndBili-10.1 [2192-5-15] 04:08AM BLOOD ALT-35 AST-116* LD(LDH)-264* AlkPhos-97 TotBili-27.0* [2192-5-16] 05:20AM BLOOD ALT-28 AST-89* AlkPhos-78 TotBili-26.2* [2192-5-17] 06:00AM BLOOD ALT-25 AST-79* AlkPhos-103 TotBili-25.4* [2192-5-18] 05:19AM BLOOD ALT-27 AST-82* AlkPhos-111* TotBili-27.6* [2192-5-19] 05:00AM BLOOD ALT-28 AST-89* LD(LDH)-250 AlkPhos-117* TotBili-27.7* [2192-5-20] 06:00AM BLOOD ALT-30 AST-100* AlkPhos-131* TotBili-29.7* [2192-5-21] 05:09AM BLOOD ALT-33 AST-118* AlkPhos-137* TotBili-30.4* [2192-5-22] 05:25AM BLOOD ALT-27 AST-92* LD(LDH)-251* AlkPhos-121* TotBili-28.5* [2192-5-23] 05:11AM BLOOD ALT-28 AST-97* AlkPhos-140* TotBili-29.6* [2192-5-24] 05:21AM BLOOD ALT-33 AST-102* AlkPhos-156* TotBili-31.3* [2192-5-25] 04:38AM BLOOD ALT-35 AST-107* LD(LDH)-276* AlkPhos-168* TotBili-33.4* [2192-5-26] 06:33AM BLOOD ALT-40 AST-107* AlkPhos-191* TotBili-33.8* [2192-5-27] 05:09AM BLOOD ALT-37 AST-106* AlkPhos-184* TotBili-36.3* [2192-5-28] 06:49AM BLOOD ALT-40 AST-102* AlkPhos-194* TotBili-34.2* [2192-5-9] 02:20PM BLOOD calTIBC-113* Ferritn-244* TRF-87* [2192-3-25] 06:40AM BLOOD Hapto-33 [2192-5-9] 02:20PM BLOOD Triglyc-53 HDL-4 CHOL/HD-6.8 LDLcalc-12 LDLmeas-<50 [2192-5-9] 02:20PM BLOOD 25VitD-11* [2192-3-29] 06:00AM BLOOD Cortsol-8.9 [2192-5-9] 02:20PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE [2192-5-9] 02:20PM BLOOD AMA-NEGATIVE [2192-5-9] 02:20PM BLOOD [Doctor First Name ]-NEGATIVE [2192-5-9] 02:20PM BLOOD CEA-5.6* AFP-3.2 [2192-5-9] 02:20PM BLOOD IgG-1443 IgA-368 [2192-4-1] 03:20PM BLOOD C3-51* C4-12 [2192-5-18] 05:19AM BLOOD Vanco-22.6* [2192-5-11] 08:50AM BLOOD Vanco-12.2 [2192-3-20] 06:20AM BLOOD Phenyto-<0.6* [2192-5-9] 02:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2192-5-9] 02:20PM BLOOD HCV Ab-POSITIVE* [2192-3-30] 12:42AM BLOOD Lactate-2.7* Na-131* K-4.8 Cl-97 [2192-3-31] 07:04AM BLOOD Lactate-2.9* [2192-5-7] 10:04AM BLOOD Lactate-4.6* Na-121* K-4.8 [2192-5-8] 04:49PM BLOOD Lactate-2.1* [2192-5-15] 01:30PM BLOOD Lactate-1.8 [2192-5-9] 02:20PM BLOOD CA [99]-9 -Test [2192-5-9] 02:20PM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Name [2192-5-9] 02:20PM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test Microbiology: [2192-3-18] 10:58 am URINE Source: Catheter. FINAL REPORT [2192-3-20] URINE CULTURE (Final [2192-3-20]): 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 [2192-3-24] 12:50 pm URINE Source: Catheter. FINAL REPORT [2192-3-26] URINE CULTURE (Final [2192-3-26]): KLEBSIELLA PNEUMONIAE. 10,000-100,000 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 _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- 8 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-------- 128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2192-5-9] 2:26 pm URINE Source: Catheter. FINAL REPORT [2192-5-13] URINE CULTURE (Final [2192-5-13]): [Female First Name (un) ] (TORULOPSIS) GLABRATA. 10,000-100,000 ORGANISMS/ML.. SPECIATION REQUESTED BY [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] #[Numeric Identifier 91204]. CT Abd [4-8] IMPRESSION: 1. Rapidly enlarging abdominal ascites accounts for abdominal distention. No bowel obstruction. 2. Cirrhosis with two known lesions in the dome and segment III, both status post CyberKnife treatment. No definite new lesion on this single phase study but assessment is limited. 3. Cirrhosis, splenomegaly, and large effusion with likely varices, consistent with portal hypertension. 4. Splenic cyst and bilateral renal cysts. 5. Known pancreatic cystic lesions seen on prior MR [First Name (Titles) ] [Last Name (Titles) 91205] on current exam. 6. Enhancing right renal nodule, characterized on prior MR as concerning for pheochromocytoma.resolution to exclude neoplasm. 7. Tree-in-[Male First Name (un) 239] appearing nodular opacity in the right lung base, suggestive of infection or inflammation but should be followed to 8. Multilevel thoracolumbar wedge compression fractures involving T12-4, new lesions at T12, L1, and L3. Wedge compressions in L2 and 4 are stable as compared to [Month (only) 956] [2192]. 4 mm retropulsion at T12. TTE [2192-5-12] The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. IMPRESSION: Right ventricular cavity dilation with preserved systolic function. Normal left ventricular cavity size with preserved global systolic function. Moderate to severe tricuspid regurgitation. At least borderline pulmonary artery systolic hypertension. Abdominal U/S [5-14] IMPRESSION: 1. Very slow flow in the portal veins without definite evidence of thrombus. If clinical concern for thrombus persists, a multiphase CT may be performed. 2. Sludge-filled gallbladder. MRI Abd [2192-5-15] IMPRESSION: 1. Cirrhosis with large volume intra-abdominal ascites, and splenomegaly. The portal vein is patent. 2. Previously described lesions consistent with HCC which have undergone previous CyberKnife are not delineated on this examination due to non-breathhold technique and sub-optimal contrast bolus. If these need to be further evaluated immediately then a multiphasic CT of the liver should be performed. Brief Hospital Course: Primary Reason for Hospitalization: 64yo lady, Hindi/Urdu-speaking only, with h/o Hep C cirrhosis c/b ascites, encephalopathy, varices, HCC undergoing Cyberknife, recently hospitalized for L2-L4 vertebral fractures readmitted for L hip fracture Active Issues: # L hip fracture: Pt underwent open reduction and intramedullary nail fixation for her left femur fracture on [2192-3-18]. She tolerated the procedure well, although pain control was a significant issue post-operatively. Initially pain was controlled with PO oxycodone, however she had nausea/vomiting and AMS. Also developed poor GI motility (see below). Narcotics were discontinued and her pain was managed with tylenol and tramadol. She was started on calcium and vitamin D, and calcitonin. There was some concern whether her recent fractures (vertebral body fractures and now femur fracture) could be pathologic fractures [2-16] progression of her HCC, however she had a bone scan which showed no uptake at areas other than her fractures so this was felt unlikely. She received daily physical therapy and her mobility improved, especially with a rolling walker. She should f/u with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4223] four weeks after discharge. # N/V, Abdominal Distension: Patient had intermittent nausea/vomiting and abdominal distension during her hospitalization. She continued to have regular BMs on lactulose so ileus and SBO were felt unlikely. Thought most likely due to a combination of ascites and slow GI motility [2-16] narcotic pain medications. Narcotic pain medications were discontinued, and an NG tube was placed to suction to decompress the stomach. She had a CT scan of her abdomen which showed large volume ascites. She had IR-guided therapeutic paracenteses on [4-8] and and [4-17] and her abdominal distension improved. Diuretics were uptitrated on [5-18] which produced adequate diuresis to prevent frequent [Doctor First Name 4397]. She also had bedside paracentesis on [5-22] with 6L tap with improvement in distention and pain. She had a dobhoff tube placed and remained on tube feeds for the majority of her hospitalization, removed upon discharge due to her ability to tolerate a normal diet without abdominal discomfort or nausea/vomiting. # HCC: Pt had two focal HCC lesions. Not a good candidate for RFA or TACE given her impaired liver function, had been evaluated by rad/onc prior to admission for CyberKnife therapy. Given her frequent hospitalizations, it was decided to proceed with CyberKnife in the inpatient setting. She completed 6 treatments. # ARF with oliguria: Early in hospital course, creatinine increased from 0.6 to 1.9 while urine output decreased to 10-15cc/hr. Thought most likely due to poor renal perfusion [2-16] cirrhosis and hypervolemia. She was fluid repleted with IV 5% albumin and her renal failure resolved. However, at HD44, creatinine began to rise again. There was concern for HRS, and patient was treated with albumin for intravascular repletion. Renal ultrasound was unmarkable. She developed increasing somnolence, hypotension and anuria requiring transfer to ICU for monitoring. The cause of her [Last Name (un) ] during this ICU stay was thought to be pre-renal and from her sepsis physiology. She improved with IV fluids and her creatine returned to baseline. She was transferred back to the floor and her creatinine remained stable. HRS was not thought to be the cause of her elevated creatinine as she improved rapidly with IV fluids and albumin. #Altered mental status: On [5-7], she was found to be obtunded and minimally responsive on the floor. She was transferred to the ICU where she was started on broad spectrum antibiotics and given aggressive doses of lactulose. Her MS subsequently improved. She was continued on fluconazole/vanc/meropenem for a 7 day course, the source of her presumed infection was not clearly identified. After her antibitoics were discontinued, her MS again slowly deteriorated and she was again transferred to the ICU on [5-14] when she was found to be obtunded and there was concern that she would be unable to protect her airway. On [5-16] she returned to the floor and remained there in stable condition with standing lactulose/rifaximin. # UTIS: Developed Klebsiella UTI during hospitalization, treated as complicated UTI due to indwelling foley catheter and treated with 10 day course of ciprofloxacin. Later in hospital course urine cultures grew E coli, and she was treated with 10 day course of levofloxacin (levofloxacin used to cover for concurrent pneumonia). This was followed by urine culture positive for yeast, which was treated with fluconazole for 14 days. She then developed a UTI with presumed streptococcus, which was treated with 7 days of levofloxacin. # Vertebral compression fractures: Pt had L2-L4 lumbar fractures (seen on imaging during previous hospitalization). Initially concerning for pathologic fractures given known HCC, however bone scan showed uptake at areas of fractures but no other areas of uptake, which lowered suspicion for metastatic disease. She continued to wear TLSO brace when OOB, and was continued on calcium/Vitamin D and calcitonin. Pain was managed with tylenol, lidoderm patch, and tramadol. Upon discharge, she was ambulatory with assist and walker, working with PT daily. # Orthostatic hypotension: Pt had significant orthostatic hypotension post-operatively, also endorsed postural dizziness. Felt most likely [2-16] hypovolemia given poor PO intake and concurrent renal failure and decreased UO. She was fluid repleted with IV 5% albumin. Her nadolol was discontinued and she was started on midodrine, and her orthostasis improved. # Liver Cirrhosis: Pt has cirrhosis due to h/o chronic HCV genotype C, c/b ascites, encephalopathy and varices. Her bilirubin continued to rise and upon discharge was ~30. Her MELD scores were consistently near 30. Not eligible for transplant (see below). Continued on lactulose/rifaximin upon discharge, as well as lasix 40 [Hospital1 ] and aldactone 100 [Hospital1 ]. # Social: Since she is in this country illegally she is only eligible for limited insurance, which would not provide for a liver transplant. Family was looking into attempts to return the patient to [Country 9819]/[Country 11150] for possible transplant evaluation there. Social work and case management worked closely with the family of the patient, particularly her son, who upon discharge was her primary caretaker as she is not elligible for rehab/[Hospital1 ] placement due to her insurance/immigration status. She unfortunately is also not eligible for services at home. Her family ensured the staff that they would pay out of pocket for 24/7 home services, however as her son has vacation for 3 weeks after discharge, he was not willing to initiate services until he needs to return to work. #DM: Blood sugars were often labile during hospitalization, possibly [2-16] enteral feeding. [Last Name (un) ] consult provided assistance with adjustment of standing glargine and sliding scale. At the time of discharge, FSBS were stable. Medications on Admission: Calcium + D qday Vitamin D [Numeric Identifier 1871] 1/week x 8 weeks Lasix 60 mg qday Lantus 50U at bedtime HISS Lactulose 30 ml TID; titrate to [3-18] bm per day Spironolactone 50 mg qday Levothyroxine 125 mcg qday Nadolol 40 mg qday Omeprazole 20 mg qday Rifaximin 550 mg [Hospital1 ] Tylenol prn Clobetasol cream [Hospital1 ] Lidocaine patch 12 hrs on/12 hrs off Calcitonin - 200U qday Ultram 50 mg q4h prn pain Discharge Medications: 1. equipment One Ortho Nova Rolling "Rollator" Walker. Disp #1 No refills. 2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:2700 ML(s) Refills:2 6. spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. insulin glargine 100 unit/mL Solution Sig: 34 AM, 36 PM units Subcutaneous twice a day: 34units qAM 36units qPM. Disp:2100 units Refills:2 9. insulin regular human 100 unit/mL Solution Sig: see attached sliding scale units Injection see attached sliding scale. Disp:1000 units Refills:2 Discharge Disposition: Home Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: End stage liver cirrhosis Left hip fracture s/p ORIF on [2192-3-18] Hepatocellular carcinoma status post cyberknife treatment Acute renal failure Toxic Metabolic encephalopathy Hepatic encephalopathy Sepsis from undetermined source Urinary tract infection Vertebral compression fractures Chronic: Diabetes Mellitus Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a left hip fracture and then suffered from a prolonged hospital course of over 70 days due to many complications from advanced end-stage liver disease. You unfortunately are not a transplant candidate due to insurance/citizenship reasons. You are being discharged home in the care of your family. Because you are are not elligble for full insurance due to your immigration status, you are not eligible for free services at this time. You should have your family call your liver doctor with any concerning signs or symptoms prior to initiating a transfer back to the hospital. You are quite sick and we would like to maximize the amount of time that you have at home with your family. You have been in the hospital for quite some time. We will discharge you with prescriptions for all of your medications. The prescriptions you leave with are your new medications from this point forward; stop taking all old medications that you have at home. Followup Instructions: Department: LIVER CENTER When: FRIDAY [2192-6-1] at 2:20 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital3 249] When: THURSDAY [2192-6-7] at 2:10 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 16163], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "787.01", "996.64", "787.3", "820.22", "E879.6", "E935.8", "250.80", "287.49", "458.0", "995.91", "805.4", "789.59", "E887", "456.21", "286.9", "070.44", "V49.86", "038.9", "785.0", "244.0", "276.1", "155.0", "788.5", "112.1", "349.82", "E885.9", "584.9", "571.5", "599.0" ]	icd9cm	[ [ [] ] ]	[ "92.29", "54.91", "79.15", "96.6", "38.93" ]	icd9pcs	[ [ [] ] ]	35699, 35763	26906, 27152	279, 719	36141, 36141	6226, 26883	37285, 37917	5041, 5246		34612, 35676		35784, 36120		34156, 34589			36291, 37262										5820, 6207																												235, 241		27167, 30490									747, 3070												36156, 36267			3092, 4376	4409, 5008				5805, 5805
26,519	182,864	43108+43109	Discharge summary	report+report	Admission Date: [2188-8-22] Discharge Date: [2188-9-6] Date of Birth: [2127-3-20] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: Patient is a 61-year-old woman with a complicated medical history referred to Intensive Care Unit for worsening dyspnea. She has insulin dependent diabetes status post living related renal transplant in [Month (only) 547] of '[85]. She is status post a CABG with LIMA, LAD, SVG, PDA, SVG OM on [6-15] through [8-1] of this year at this hospital. The LMCA and the RCA graft failed. The patient underwent stenting and a prolonged intubation for respiratory distress. Acute renal failure, polymorphic V-tach, and a recath and the polymorphic V-tach and V-fib, is status post ablation and AICD placement on [2188-7-18]. The patient then underwent a trache and PEG placement, and was discharged to [Hospital3 ]. She was readmitted three days later with dyspnea, hypotension 80/40. She is treated for CHF, acute on chronic renal failure. Creatinine went from 1.0 to 2.1, and urinary tract infection. Chest x-ray shows bilateral pleural effusions. She was ruled out for a MI. She had a P-MIBI which showed an EF of 66%. She had increased dyspnea, worsening, an ABG of 7.43, 49, 30, and increased secretions. PHYSICAL EXAM UPON ADMISSION TO THE INTENSIVE CARE UNIT: Laboratory values: White count was 6.8, hematocrit 30.2, platelets 292. Electrolytes: 131, 8.0, 91, 32, 43, 2.2, 377. Her chest x-ray showed worsening pulmonary edema, persistent left lower lobe pneumonia versus consolidation, atelectasis, bilateral pleural effusions. Her EKG as in sinus, showed diffuse ST changes from previous cardiac events. She was admitted to the Intensive Care Unit for further care. INTENSIVE CARE UNIT COURSE BY PROBLEM: [Name (NI) ] was treated for respiratory failure thought to be a mixed picture between a pneumonia and CHF. Patient was unable to diurese secondary to her hypotension initially upon presentation, not thought to be a PE as patient had clear LENI three days prior to this admission and bilateral effusions on chest x-ray which were too small to tap when we evaluated. Patient was placed on AC over the course of her hospital stay. Was weaned to pressure support of [8-24], with trials of weaning using a sprint/rest method. Patient's respiratory failure progressed. Found to be pneumonia. Patient was septic. She had MRSA in her sputum x3 consecutive sputum samples. She also progressed to meet ARDS qualifications. Patient's trache was changed on [2188-8-28] in the OR to a larger size to assist with suctioning and respiratory distress. Patient's pneumonia: Patient was found to have MRSA in her sputum. She was treated with a course of 14 days of Vancomycin and Zosyn. Her white count which initially rose to 19.9 has trended down overtime. The patient was initially septic on admission with an increased cardiac output and a decreased SVR as noted with her swan and central venous access. She was initially maintained on dopa. Brought to the floor. Changed to Levophed for pressure support. Vasopressin was added and the Levophed was weaned. Over time the decision was made to switch the patient back to dopamine to support her blood pressure and supply adequate mean arterial pressure, to supply blood flow with the kidneys, that she can respond to a Lasix drip for further diuresis of her CHF. Renal failure: The patient was maintained on her antirejection medications. FK-506 levels were checked frequently and followed by the Renal service. Patient was followed by the Renal service, who suggested diuresis once the patient's blood pressure was stable and her sepsis had resolved. Patient's dry weight is 65 kg. At the peak of her hospital admission, her weight was 90 kg. Patient began diuresis with dopamine and a Lasix drip and responded well. Patient did not respond well to Lasix boluses. Patient is observed to have an adequate urine output with mean arterial blood pressure ranged 80-90. Urine output would fall off when blood pressure was below this goal. Initially the patient was bolused to increase urine output with no effect and only response to the Lasix drip. Patient's creatinine upon admission rose to 2.1 and trended down over the course of her hospital stay to approach her baseline at 1.3. Patient was found to be CMV positive IgG and IgM, although IgM was weakly positive, likely to be related to her renal transplant. She was not treated for this infection. Volume status: Patient had a Swan-Ganz catheter placed twice as her volume status was hard to assess. Her PA pressures initially were 40/21, wedge pressure of 14-19, cardiac output 5.2, index 2.6. On her second Swan, patient's PA pressures were 34/17, wedge of 14, 6, 4.85, SVR of 1300 on the pressors. Swan was D/C'd and patient was maintained on central venous access and A-line only throughout the course of her hospital stay. Patient's diabetes was controlled with careful insulin monitoring q.4. blood sticks and appropriate glucose control. FEN/GI: Patient had a PEG tube and received tube feeds, and was followed by Nutrition throughout the course of her hospital stay. Wound care: Patient was noted to have a defervescence of her CABG saphenous vein harvesting on the lower right extremity. CT Surgery was contact[Name (NI) ] and reviewed this complication. This is likely secondary to increased body edema, peripheral edema, and anasarca at the time. They debrided the wound and it was followed with dressing changes and wound care. Chest pain: Patient initially had some chest pain and was ruled out for MI. Was transfused to keep her hematocrit above 30. This did not progress throughout the course of admission, and this is also thought to be likely related to anxiety. Heme: The patient was maintained on her Epogen which was increased in dosage. Iron studies showed an iron deficiency anemia coupled with an anemia of chronic disease. Patient was started on iron supplementation. Patient did receive 2 units of packed red blood cells within the first two days of her admission to maintain her hematocrit above 30. No obvious source of bleeding. Patient's platelet count was noted to fall from 362 to 188 over the course of her hospital stay. She was noted to have prolonged bleeding after subcutaneous injections and line changes. Patient was found to have HIT positive antibodies. Was assessed by Hematology/Oncology, who suggested that it was only weakly positive, and a Hematology/Oncology followup as an outpatient for further evaluation of her Heparin sensitivity would be appropriate. This patient may need to go for further catheterization in the future. It would be difficult to maintain the patient without the use of Heparin. The patient is currently labeled as HIT positive and Heparin is listed as an allergy. Psychiatry: The patient was noted to have increased anxiety beginning [9-3]. Psychiatry was consulted for patient's emotional lability. The patient remained buoyant and then extremely depressed, and had increasing anxiety over her sprinting and weaning trials off her vent although she was physically able to complete these trials and support her own breathing. They were stopped secondary to her tachypnea and anxiety. Psychiatry believed patient had anxiety disorder only and no acute depressive issue. Over the course of the next three days, the patient's anxiety worsened. Patient on the evening of [9-5], developed a fixed delusion that her room is not her own and she had been moved. Patient was oriented to self, time, and hospital, but maintained a fixed delusion, and was reassessed by Psychiatry, who believed patient was having a delirium and suggested that she be treated with Haldol prn. Herpes simplex virus II: Patient was noted to have developing vesicular lesions in the perirectal area extending towards the vagina. These lesions became more numerous. They were white and erythematous base. Dermatology was consulted. Patient was found to be positive for HSV II. Was started on acyclovir and lidocaine for pain control. Communication was with the patient's husband, who expressed concern over her treatment at [Hospital3 ]. Felt patient was neglected. Family was referred to Social Work to further address these concerns and find a suitable and appropriate rehab hospital for patient upon discharge. Disposition: Patient will be diuresed on Lasix and dopamine drip. Dopamine to support her blood pressure while her Lasix drip is working with a projecting fluid balance of -1.5 liters/day. Goal is to get patient down closer to her dry weight of 65, although a dry weight in the 70s would likely be appropriate. We do not choose to use hemodialysis at this time as her diuresis with the Lasix drip with dopamine support is working. Once the patient is diuresed and is stable, maintained off her dopamine drip, she will be able to be discharged to a rehab facility for [Hospital 4820] rehabilitation, and follow up with Hematology/Oncology, Cardiology, Endocrine, and Pulmonary. Patient will not need to be weaned completely from the vent in order to go to a rehab facility. MEDICATIONS IN THE MICU: 1. Haldol. 2. Lidocaine ointment. 3. Acyclovir. 4. Senna. 5. Docusate. 6. Furosemide drip. 7. Dopamine drip. 8. Lorazepam. 9. Ferrous sulfate. 10. Midodrine. 11. Potassium chloride. 12. Insulin-sliding scale and fixed dose of glargine. 13. Epoetin. 14. Tacrolimus. 15. Hydromorphone prn pain. 16. Ondansetron. 17. Nitroglycerin. 18. Ipratropium bromide. 19. Levothyroxine sodium for hypothyroid. 20. Bisacodyl. 21. Lansoprazole oral suspension. 22. Miconazole. 23. Amiodarone. 24. Aspirin. 25. Nebulizers. 26. Mycophenolate. 27. Clopidogrel. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3090], M.D. [MD Number(1) 3091] Dictated By:[Last Name (NamePattern1) 5713] MEDQUIST36 D: [2188-9-6] 13:12 T: [2188-9-9] 06:49 JOB#: [Job Number 92946] Admission Date: [2188-9-6] Discharge Date: [2188-9-18] Date of Birth: [2127-3-20] Sex: F Service: MICU ADDENDUM TO MEDICAL INTENSIVE CARE UNIT HOSPITAL COURSE BY PROBLEM: 1. Respiratory failure: As mentioned in the previous discharge summary, Ms. [Known lastname ] had a tracheostomy and was maintained on a ventilator with pressure support. This was slowly weaned, and by the time of discharge, she was tolerating a tracheostomy mask throughout the day and was rested on the ventilator with pressure support of 5 and PEEP of 5 overnight. Most of the inability to wean her from her ventilator was felt to be secondary to anxiety as she did well all throughout the day when off the ventilator. Her dependency on the ventilator will be further weaned at rehabilitation. It was felt that her respiratory failure was most likely a combination of volume overload, which improved with diuresis, and her muscular weakness, and possibly respiratory suppression due to her metabolic alkalosis. 2. Renal failure: She continued to be followed by the Renal Consult Team and was maintained on her tacrolimus and mycophenolate mofetil with frequent monitoring of FK506 levels. She was also maintained on Epogen two times per week and ferrous sulfate. At the time of discharge, her creatinine was ranging from 1.8 to 2, and it was felt that this was secondary to her extreme diuresis over the preceding days with a resultant volume contraction. It is recommended that this be followed up as an outpatient and strictly monitored by her transplant doctor. 3. Volume status: As mentioned in the previous discharge summary, Ms. [Known lastname ] was extremely volume overloaded on transfer to the Medical Intensive Care Unit and her weight was up to 90 kg from 65 kg on dry weight. She was successfully diuresed throughout her admission. She was diuresis with a dopamine drip, Lasix drip, and albumin. She was frequency monitored by the Renal Team. There was difficulty with her dopamine secondary to hypotension when the dopamine was turned off, however, on [9-16], her dopamine and Lasix dose were successfully weaned and she was diuresing on her own. At this point, her albumin was also stopped. At one point, she had been placed on metolazone at 2.5 mg b.i.d., however, this was only maintained for several days, and was discontinued secondary to metabolic alkalosis from volume contraction. She was started on acetazolamide 250 mg b.i.d. on [9-15] to further facilitate diuresis, but mostly to help with her contraction alkalosis. She was also started on Sinemet in an effort to facilitate weaning from the dopamine drip and it was felt that Sinemet could possibly replete her body source of presynaptic dopamine and facilitate weaning from the dopamine drip. She will not be sent to rehabilitation on Sinemet on her own and had begun to have a decrease in urine output which was felt to be secondary to over diuresis and resultant dehydration. She was bolused between 50 cc of normal saline several times to facilitate bicarbonate excretions, and for slight volume replacement. At discharge, she was felt to be euvolemic to partially dry. She will follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in the Department of Cardiology for further maintenance of her heart failure. 3. Diabetes: As mentioned above in the previous discharge summary, she was maintained on a sliding scale insulin with six doses of glargine for maintenance of her diabetes. She also was monitored frequency with q.i.d. fingersticks. 4. Fluid, electrolytes and nutrition/GI: Ms. [Known lastname ] was maintained on tube feeds through her percutaneous endoscopic gastrostomy that was placed while admitted, at goal. She occasionally suffered from nausea, which was felt to be secondary to her gastroparesis, which was relieved with the Zofran. Her husband brought in medicine by the name of Motilium that she had been on at home for her gastroparesis, however, due to recommendations by the Heart Failure Team, and Renal Team, this medicine was not continued due to risk of cardiac arrhythmia. She was continually passing stools, and with minimal nausea, therefore, she was just maintained with antiemetics. 5. Psychiatry: As mentioned above in previous discharge summary, Ms. [Known lastname ] suffered from anxiety and limited mobility throughout her admission. She was followed by the Psychiatry Consult Service who initially recommended using Ativan for anxiety control. This worked with good effect, however, it was felt that she still had a depressed mood, and >........<. The day prior to discharge, she was started on Zyprexa 1.25 mg b.i.d. in hopes that this was alleviate her anxiety condition in addition to serving as a mood stabilizer. The use of antidepressants have been discussed multiple times with the patient and her husband, both of whom refused, and felt uncomfortable using antidepressants. She agreed to use the Zyprexa, as did her husband, and she will be discharged with Zyprexa 1.25 mg b.i.d. 6. HSV 2/Anal lesions: Ms. [Known lastname ] received a ten day course of acyclovir for her perianal HSV2 lesions, which were improving at the time of discharge. She had been seen by Dermatology while admitted with recommendations of acyclovir. 7. Communication: Throughout her hospital stay, the plan and her status was communicated with the patient frequently and with her husband. They were both aware of the plan of care, and her husband is extremely active in her care. As expressed multiple times by the patient and her husband that they did not feel comfortable with her going back to [Hospital3 ] after discharge due to alleged neglect on the previous admission. They prefer that the patient go to [Hospital1 ], or some other rehabilitation facility. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Coronary artery disease, status post coronary artery bypass grafting. 3. History of renal transplant secondary to end stage renal disease from diabetes mellitus. 4. Diabetes. 5. Tracheostomy, status post respiratory failure. 6. PEG placement. 7. Status post Methicillin resistant Staphylococcus aureus pneumonia. 8. Renal failure, secondary to diabetes mellitus. 9. Hypothyroidism. DISCHARGE MEDICATIONS: 1. Plavix 75 mg q.d. 2. Mycophenolate mofetil 500 mg b.i.d. 3. Albuterol MDI. 4. Ipratropium MDI. 5. Aspirin 325 mg q.d. 6. Amiodarone 400 mg q.d. 7. Lansoprazole 30 mg q.d. 8. Levothyroxine 88 mcg q.d. 9. Tacrolimus 10 mg b.i.d. 10. Epoetin alpha [Numeric Identifier 961] units two times a week. 11. Nitroglycerin 0.3 mg sublingual tablets prn. 12. Ferrous sulfate 300 mg t.i.d. 13. Zyprexa 1.25 mg b.i.d. 14. Senna. 15. Colace. 16. Sliding scale insulin. 17. Glargine insulin 22 units at bedtime. FOLLOW-UP: It is recommended that Ms. [Known lastname ] follow-up with her primary care physician in one to two weeks after discharge. She will also be scheduled for an appointment for follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in the Department of Cardiology. DISCHARGE STATUS: At the time of discharge, Ms. [Known lastname ] was off of her dopamine and Lasix drip. She was tolerating a tracheostomy mask, 10-15 hours a day and was resting on a ventilator with pressure support in the evenings. She was afebrile and denied any shortness of breath or chest pain. She denied any abdominal pain and was passing stools. She had stable vital signs. DR.[Last Name (LF) ],[First Name3 (LF) ] 12-838 Dictated By:[Dictator Info ] MEDQUIST36 D: [2188-9-18] 01:35 T: [2188-9-17] 02:18 JOB#: [Job Number 92947]	[ "038.9", "998.32", "428.0", "996.81", "054.79", "518.82", "250.01", "599.0", "482.41" ]	icd9cm	[ [ [] ] ]	[ "96.6", "33.21", "00.13", "38.93", "34.91", "86.22", "31.74" ]	icd9pcs	[ [ [] ] ]								15999, 16423	16446, 17877																																																					5236, 15978			161, 5223
18,712	160,046	27575	Discharge summary	report	Admission Date: [2133-6-14] Discharge Date: [2133-7-2] Date of Birth: [2074-10-21] Sex: M Service: SURGERY Allergies: Penicillins / Codeine Attending:[First Name3 (LF) 668] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [2133-6-15] ex lap with vac placement 6/3/07Exploratory laparotomy, repair of wound dehiscence/closure of midline incision. History of Present Illness: 58 yo m hep C, EtOH cirrhosis, p/w diffuse abdominal pain x 2 days. He noted that the pain was at times sharp, and more on right side than left. He had no N/V, but was unable to tolerate PO's. He denied any fever, chill. He had daily BMs which were very watery and at times BRBPR. In ED, Temp 100.6. lactate 1.0, guaiac + brown stool. Abd CT revealed SMV thrombosis and bowel ischemia. Patient was evaluated by transplant surgical fellow who asked patient to be admitted to medicine. Patient was started on levo/flagyl and HD stable. On floor, patient was complaining of excruciating abd pain. Last BM was in AM. no N/V, chest pain, SOB. Past Medical History: hep C: genotype 2B; treated w/ ribaviron and interferon for 6 mo ended [4-23] EtOH cirrhosis: followed at [Hospital1 2025] by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. - Liver bx [1-20]: complete cirrhosis, hepatic activity indec [9-5], fibrosis stage 6/6 - Liver MRI [11-24]: no evidence of mass lesion gastric varices portal hypertensive gastropathy EtOH abuse IVDU OSA on CPAP anxiety DJD osteoporosis scoliosis macular degeneration Social History: Smoking: started age 14, now 1.5 ppd EtOH: long history of abuse, last drink in [3-25] Divorced, lives alone, no children. Does not work and on disability. Family History: Father: CAD [Name (NI) ] fam hx colon, liver, GI disease Physical Exam: PE: 96.3 118/73 71 20 97%4L O2 Sats Gen: clearly in severe pain; holding quite still on bed HEENT: Clear OP, MMM CV: RR, NL rate. No murmurs, rubs or [Last Name (un) 549] LUNGS: CTA ant and lat ABD: Soft, diffusely tender throughout R>L; voluntary guarding, no rebound; pain out of proportion to exam EXT: No edema. 2+ DP pulses BL SKIN: No lesions Pertinent Results: ABD CT: IMPRESSION: 1. Marked bowel wall thickening throughout the ileum, with extensive inflammatory stranding within the mesentery. This appearance is consistent with mesenteric ischemia secondary to superior mesenteric vein thrombosis. Of note, the jejunum and colon appear to be spared from this process. 2. Findings consistent with longstanding cirrhosis and portal hypertension. Moderate ascites around the liver. ALT(SGPT)-15 AST(SGOT)-23 LD(LDH)-207 ALK PHOS-73 AMYLASE-23 TOT BILI-1.3 GLUCOSE-159* UREA N-20 CREAT-0.6 SODIUM-138 POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-21* WBC-17.4* RBC-4.88 HGB-15.4 HCT-44.5 MCV-91 MCH-31.6 MCHC-34.7 RDW-15.1 Brief Hospital Course: He was diagnosed with mesenteric ischemia given acute SMV thrombosis and mesenteric ischemia. IV Heparin was started. He was made NPO and started on a PPI. Levo/Flagyl were started. Pain was controlled with dilaudid. On [6-15] he became hypoxic in setting of OSA when not on CPAP and oversedatd from dilaudid. He was given narcan. A CXR showed mild edema -> lasix 20 was given X1 with improvement. His CPAP machine was obtained. He started on spiriva, albuterol IH PRN, fluticasone for COPD. . On [6-15], he underwent ex-lap and small bowel resection of approximately 45 cm, ileoileostomy (hand sewn). Surgeon was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. [Initials (NamePattern4) ] [Last Name (NamePattern4) 406] drain was placed. Please see operative note for further details. Postop, he was transferred to the SICU intubated. IV Heparin continued. He went into afib then self converted on lopressor. Lytes were repleted. Hct was stable. The midline incision was intact. He was extubated on pod 1. On pod 2, he had intermittent bursts of afib which was more responsive to IV diltiazem drip. An echo demonstrated an EF of 55%, trivial thickening of the aortic and mitral leaflets and a small pericardial effusion. Coumadin was not recommended for afib. . On POD 5, the wound appeared slightly erythematous. On [6-20] a small area of the incision was opened and packed. He continued to have paroxysmal afib/flutter treated with diltiazem/O2 and IV fluid boluses for sbp in 80s/HR 150s. He had a temp of 101. His [Doctor Last Name 406] drain fell out. The abdominal incision was opened. He was transferred to the SICU. WBC was 18.3. Vanco and Meropenum were started. On [6-21], he was taken to the OR for Exploratory laparotomy, repair of wound dehiscence/closure of midline incision. Surgeon was Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. The abdomen was irrigated copiously with antibiotic-containing saline solution. There was a small amount of clear ascites in the abdomen. The bowel appeared viable. The culture of the wound swab from [6-21] was + for MRSA. The cline tip returned + for MRSA. Vanco was continued. His creatinine increased to 1.6 in the setting of sepsis. WBC trended down. A wound vac was placed with high outputs. Albumin was given for each liter of vac drainage (ascites). Sodium decreased. Diuretics were held for creatinine of 1.7 then lasix was resumed. Creatinine continued to increase as high as 2.0 on [7-1] from 0.7 on [6-22]. Urine was + for eosinophils. Pharm/ID felt that this could be due to protonix causing interstitial nephritis. Protonix was discontinued. A chem 7 should be drawn every Monday and Thursday. Spironolactone was stopped and lasix was given as 60mg po qd. . A picc line was placed on [6-26] for TPN and antibiotics. A 39.0 cm left basilic single-lumen PICC was noted to terminate in the distal SVC. Coumadin was started and iv heparin was weaned off when inr was 2.2 on [6-28]. INR increased to 3.7 on [7-2]. Coumadin was held. . TPN was started as recommended by Nutrition. His diet was slowly advanced with sufficient kcal intake. TPN was discontinued on [6-26]. He developed an elevated wbc. ID redcommended sending stool for c.diff despite absence of diarrhea. On [6-26], stool was + for C.diff. Flagyl was started for a course duration of 2 weeks after vancoymcin completed. ID had recommended TEE to r/o cardiac vegetation due to MRSA. This was deferred due to h/o of esophageal varices note on [1-24] at [Hospital1 2025]. On [7-1], he was scoped by GI to re-evaluate varices given inr of 3.6 on coumadin. EGD showed grade 1 varices at the gastroesophageal junction and lower third of the esophagus, diffuse portal hypertensive gastropathy, and an otherwise normal EGD to second part of the duodenum. . He will continue IV vanco for a total of 6 weeks (from start of last + bl. cx [6-30])given + blood culture for MRSA on [2133-6-22]. ID recommended extending po flagyl for 2 weeks after IV vanco stops to cover for c.diff. Blood cultures were redrawn on [6-29] and [6-30] in addition to a picc line tip culture that was replaced in the Left arm on [6-30]. The plan is for him to go to [Hospital1 ]. While there, please hold Vanco on [7-3] and resume on [7-4]. Level was 24.6 on [7-2]. He received a dose on [7-2] prior to level being reported. Labs should be drawn on [7-4] for vanco trough level. Vanco trough goal level should be 15-20. INR should be done on [7-3] as inr was high (3.7)on alternating doses of 2 and 3mg. Vac dressing is due to be changed on [7-3] as well. Last done on [6-30]. Medications on Admission: (Based on [Hospital1 2025] note on [2133-5-14]) Propranolol ER 60 daily lactulose [Hospital1 ] ASA 81 Lasix 20 TID Celexa 40 QD albuterol IH Fluticasone 44 mcg Spiriva IH prilosec 4O Daily Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 4. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day): hold if sbp <110 or HR <60. 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): continue for 2 weeks after IV vanco stops. Disp:24 Tablet(s) Refills:0 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 7. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): for SBP prophylaxis. 8. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection four times a day. 9. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 10. Lasix 40 mg Tablet Sig: 1.5 Tablets PO once a day. 11. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous Q 24H (Every 24 Hours) for 6 weeks: 750mg qd. Hold [7-3] then resume on [7-4] after trough level obtained. goal trough 15-20. 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 14. Coumadin 1 mg Tablet Sig: One (1) Tablet PO q 48: check inr [7-3]. goal [2-21].start [7-3]. 15. Coumadin 2 mg Tablet Sig: One (1) Tablet PO q 48: check inr [7-3]. goal [2-21]. alternate 1mg with 2mg. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: ischemic bowel [2-20] SMV thrombosis wound dehiscence HCV cirrhosis MRSA line sepsis C. diff Discharge Condition: good Discharge Instructions: Please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] office [Telephone/Fax (1) 673] if fevers, chills, nausea, vomiting, wound redness/bleedin/increased drainage or any concerns. Vac change every 72 hours with 125mmHg suction. PT/INR q Monday and Thursday. Fax results to [Telephone/Fax (1) 673] attn: [First Name8 (NamePattern2) 5969] [Last Name (NamePattern1) 5970], NP coordinator Followup Instructions: Provider: [Name10 (NameIs) 1344] [Last Name (NamePattern4) 3125], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2133-7-2] 10:50 Completed by:[2133-7-2]	[ "456.1", "785.0", "584.9", "327.23", "286.9", "305.00", "E879.8", "427.32", "557.0", "789.5", "070.70", "567.9", "571.2", "038.11", "998.32", "496", "799.02", "008.45", "996.62", "572.3", "V09.0", "995.91", "427.31", "537.9", "278.00", "E878.2", "998.59" ]	icd9cm	[ [ [] ] ]	[ "54.61", "38.93", "99.15", "45.62", "99.07", "38.91", "45.91", "45.13" ]	icd9pcs	[ [ [] ] ]	9623, 9702	2937, 7687	295, 426	9843, 9850	2258, 2914	10327, 10499	1798, 1860		7938, 9600		9723, 9822		7713, 7915			9874, 10304										1875, 2239																												241, 257											454, 1095															1117, 1604	1620, 1782
66,965	177,338	42499	Discharge summary	report	Admission Date: [2198-1-22] Discharge Date: [2198-2-14] Date of Birth: [2116-6-7] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Attending Info 8238] Chief Complaint: R knee pain Major Surgical or Invasive Procedure: Right knee debridement x2 and washout Trans-esophageal echo and cardioversion Electrophysiology ablation History of Present Illness: 81 M history of AAA repair, COPD, CAD (pt denies any stents of MIs), chronic pedal edema, right knee replacement 10 yrs ago complicated with infection with removal of hardwear and replacement, who is an OSH transfer for septic right knee. Pt states that he had R knee replacement 10 yrs ago. 6 mo later he had infected right knee. Hardware was removed,had spaced x 10 weeks. He was given IV antibiotics and had new implant later that year and has no complicated since then. Pt reports he was in his usual state of health until about a week ago when started having chills. Few days later, noted right knee pain when he stood up and "twisted" his knee. Then noted some swelling. He came to the OSH ED where he was febrile and found to have right septic knee. He met sepsis criteria with fever, tachycardia, leukocytosis and was started on ceftriaxone (day 1/1/8 in evening) and vanco (day 1=[1-20]). Flu swab negative, blood cx neg thus far, UA neg. Pt had arthrocentesis on [1-22] which showed frank pus. He was transfered to [Hospital1 18] for further care. Of note, throughout his hospitalization, he has been tachycardic in the high 130s, febrile up to 103, RR 18, satting 95% on 2L. . On arrival to floor, pt triggered for tachycardia, Hr in the high 140s. Sinus tach on EKG. no ST or TWI changes. Pt also reported indigestion pain. Ambulance had given him SL nitro which improved his heartburn pain. Pt currently feels okay, says he has indigestion pain. No chest pain. he reports mild SOB, currently breathing in mid 90s on 2L NC. he says his abd feels distended, had very small bm this AM but otherwise is not having regular bms. . On arrival to the MICU, patient was in moderate distress with venturi mask in place. Satting 94% on venturi mask with RR of 35. He is c/o dyspnea and mild Gerd-like symptoms. Past Medical History: COPD AAA [11/2196] repair CAD chronic pedal edema bilateral knee replacement melanoma of nose colon polyps Social History: Active smoker most of his life 70+ years. No EOTH, no drugs. Quit ETOH at age 50. used to be a big drinker. last drink 1 yr ago. Family History: father - died 86 mother - died 89 GM - Dm2 Physical Exam: ADMISSION EXAM VS - T 99.5, HR 140, BP 122/80, RR 24,94%2L GENERAL - ill appearing M in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - poor breath sounds bilaterally, crackles in the bases bilaterally HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - distended, soft, non tender EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, right knee: effusion, warm DISCHARGE EXAM: VS: 98.1 119/64 78 20 93% RA 1560/2250 Gen: NAD, AAOx3, breathing comfortably HEENT: MMM, OP clear, neck supple, no JVP Chest: CTA b/l CV: RRR, s1/s2 -m/r/g ABD: soft, slightly distended EXT: R knee in brace, non-erythematous, 1+ LE edema to knees bilaterally, 2+ peripheral pulses Pertinent Results: ADMISSION LABS [2198-1-22] 11:34PM BLOOD WBC-14.2* RBC-3.84* Hgb-12.0* Hct-34.3* MCV-89 MCH-31.4 MCHC-35.1* RDW-12.8 Plt Ct-175 [2198-1-22] 11:34PM BLOOD Neuts-90.1* Lymphs-5.8* Monos-3.9 Eos-0.1 Baso-0.1 [2198-1-22] 11:34PM BLOOD Glucose-151* UreaN-14 Creat-0.8 Na-133 K-4.0 Cl-100 HCO3-23 AnGap-14 [2198-1-23] 09:58AM BLOOD Type-ART O2 Flow-2 pO2-72* pCO2-37 pH-7.45 calTCO2-27 Base XS-1 Intubat-NOT INTUBA CTA CHEST [2198-1-23] 1. No evidence of central pulmonary embolism. However, due to suboptimal bolus timing, evaluation of subsegmental arteries is limited. 2. Ground-glass opacities at the right lung base, likely a combination of atelectasis and aspiration. Secretions in the trachea. 3. Small bilateral pleural effusions, right greater than left. Bibasilar atelectasis, right greater than left. 4. Left lower lobe pulmonary nodule measuring 5 mm. Followup chest CT in 6 to 12 months is recommended. 5. Coronary artery and aortic valve calcifications. 6. Prominent right and left pulmonary arteries, suggestive of pulmonary hypertension. 7. Left adrenal adenoma. 8. Diffuse thickening of the esophagus, likely due to diffuse esophagitis, with a small hiatal hernia. TTE [2198-1-24] The left atrium is normal in size. 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 are mildly thickened.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Tricuspid regurgitation is present but cannot be quantified. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Preserved left ventricular systolic function. The TR jet velocity suggests mild pulmonary hypertension, though the right ventricle is not well seen to evaluate for RV pressure/volume overload. TEE [2198-1-25] No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. Right atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta to 40 centimeters from the incisors. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. Tricuspid regurgitation is present but cannot be quantified. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No evidence of intracardiac mass/thrombus. Mildly dilated aortic root and ascending aorta. Simple atheroma aortic arch. Complex atheroma in the descending thoracic aorta. Mild mitral regurgitation. Significant tricuspid regurgitation. CTA [2-5]: IMPRESSION: 1. Retroperitoneal bleed into the left posterior pararenal space and into the left psoas region. 2. A rounded cystic lesion measuring 18 x 19 mm is seen,located in proximity to the left adrenal and the gastroesophageal junction. This might represent an adrenal adenoma or an enteric diverticulum. CTA [2-6]: IMPRESSION: 1. No acute pulmonary embolism or thoracic aortic pathology. 2. Large left retroperitoneal hematoma extending into the pelvis, stable in extent and size since the prior study. 3. Stable left adrenal adenoma. [2198-1-22] 11:34PM BLOOD WBC-14.2* RBC-3.84* Hgb-12.0* Hct-34.3* MCV-89 MCH-31.4 MCHC-35.1* RDW-12.8 Plt Ct-175 [2198-1-23] 12:05AM BLOOD WBC-14.4* RBC-3.87* Hgb-12.5* Hct-34.6* MCV-89 MCH-32.3* MCHC-36.2* RDW-12.8 Plt Ct-163 [2198-1-23] 05:45AM BLOOD WBC-15.2* RBC-3.64* Hgb-11.5* Hct-33.0* MCV-91 MCH-31.8 MCHC-35.0 RDW-13.0 Plt Ct-194 [2198-1-23] 01:30PM BLOOD WBC-14.7* RBC-3.58* Hgb-11.3* Hct-32.5* MCV-91 MCH-31.4 MCHC-34.6 RDW-12.9 Plt Ct-250 [2198-1-24] 01:41AM BLOOD WBC-10.4 RBC-3.23* Hgb-10.1* Hct-29.1* MCV-90 MCH-31.5 MCHC-34.9 RDW-12.9 Plt Ct-192 [2198-1-25] 02:24AM BLOOD WBC-9.0 RBC-3.14* Hgb-9.7* Hct-28.4* MCV-91 MCH-31.0 MCHC-34.3 RDW-13.1 Plt Ct-221 [2198-1-26] 04:44AM BLOOD WBC-10.4 RBC-3.21* Hgb-9.8* Hct-29.3* MCV-91 MCH-30.4 MCHC-33.3 RDW-12.8 Plt Ct-343# [2198-1-27] 12:40AM BLOOD WBC-7.8 RBC-3.00* Hgb-9.5* Hct-27.3* MCV-91 MCH-31.6 MCHC-34.7 RDW-12.6 Plt Ct-323 [2198-1-28] 12:01AM BLOOD WBC-7.0 RBC-3.20* Hgb-9.8* Hct-28.8* MCV-90 MCH-30.6 MCHC-34.0 RDW-12.8 Plt Ct-403 [2198-1-29] 06:00AM BLOOD WBC-8.5 RBC-3.36* Hgb-10.5* Hct-30.6* MCV-91 MCH-31.1 MCHC-34.2 RDW-12.6 Plt Ct-484* [2198-1-29] 03:55PM BLOOD WBC-7.8 RBC-3.10* Hgb-9.4* Hct-28.4* MCV-91 MCH-30.2 MCHC-33.0 RDW-12.8 Plt Ct-476* [2198-1-30] 05:58AM BLOOD WBC-7.2 RBC-3.14* Hgb-9.7* Hct-28.4* MCV-91 MCH-30.8 MCHC-34.0 RDW-13.1 Plt Ct-510* [2198-1-31] 05:59AM BLOOD WBC-6.9 RBC-2.88* Hgb-8.6* Hct-26.4* MCV-92 MCH-29.9 MCHC-32.6 RDW-12.9 Plt Ct-481* [2198-2-1] 05:45AM BLOOD WBC-6.5 RBC-3.07* Hgb-9.2* Hct-27.8* MCV-91 MCH-29.9 MCHC-32.9 RDW-12.9 Plt Ct-493* [2198-2-2] 05:35AM BLOOD WBC-9.2 RBC-2.99* Hgb-9.3* Hct-27.5* MCV-92 MCH-31.1 MCHC-33.8 RDW-13.0 Plt Ct-527* [2198-2-3] 06:35AM BLOOD WBC-9.2 RBC-2.72* Hgb-8.3* Hct-24.7* MCV-91 MCH-30.4 MCHC-33.4 RDW-13.5 Plt Ct-520* [2198-2-4] 11:55AM BLOOD Hct-21.6* [2198-2-4] 07:51PM BLOOD Hct-24.2* [2198-2-4] 11:58PM BLOOD Hct-22.8* [2198-2-5] 02:01AM BLOOD Hct-23.4* [2198-2-5] 06:42AM BLOOD WBC-9.9 RBC-2.58* Hgb-7.7* Hct-22.6* MCV-88 MCH-29.9 MCHC-34.0 RDW-15.1 Plt Ct-578* [2198-2-5] 10:11AM BLOOD Hct-37.1# [2198-2-5] 12:31PM BLOOD WBC-11.3 RBC-2.84* Hgb-8.4* Hct-24.8# MCV-87 MCH-29.6 MCHC-33.8 RDW-14.4 Plt Ct-563 [2198-2-5] 11:57PM BLOOD Hct-26.2* [2198-2-6] 05:18AM BLOOD WBC-11.6* RBC-2.89* Hgb-8.6* Hct-25.0* MCV-87 MCH-29.9 MCHC-34.5 RDW-14.9 Plt Ct-472* [2198-2-6] 05:03PM BLOOD Hct-22.2* [2198-2-6] 09:55PM BLOOD Hct-22.5* [2198-2-7] 03:44AM BLOOD WBC-11.4* RBC-2.51* Hgb-7.4* Hct-21.8* MCV-87 MCH-29.5 MCHC-33.9 RDW-15.4 Plt Ct-437 [2198-2-7] 04:00PM BLOOD Hct-24.3* [2198-2-8] 02:43AM BLOOD WBC-6.5 RBC-2.72* Hgb-8.2* Hct-24.3* MCV-89 MCH-30.1 MCHC-33.7 RDW-14.7 Plt Ct-417 [2198-2-8] 09:07AM BLOOD Hct-23.9* [2198-2-8] 02:42PM BLOOD Hct-24.6* [2198-2-9] 06:33AM BLOOD WBC-5.7 RBC-3.07* Hgb-9.1* Hct-26.9* MCV-88 MCH-29.8 MCHC-33.9 RDW-14.9 Plt Ct-395 [2198-2-10] 04:40AM BLOOD WBC-6.1 RBC-2.95* Hgb-8.9* Hct-26.2* MCV-89 MCH-30.1 MCHC-34.0 RDW-15.1 Plt Ct-406 [2198-2-10] 04:40PM BLOOD Hct-28.8* [2198-2-11] 05:32AM BLOOD WBC-7.2 RBC-3.06* Hgb-9.3* Hct-27.3* MCV-89 MCH-30.3 MCHC-33.9 RDW-14.7 Plt Ct-394 [2198-2-12] 04:45AM BLOOD WBC-9.0 RBC-3.19* Hgb-9.6* Hct-28.4* MCV-89 MCH-30.0 MCHC-33.7 RDW-14.9 Plt Ct-409 [2198-2-14] 06:20AM BLOOD WBC-8.4 RBC-3.11* Hgb-9.4* Hct-27.6* MCV-89 MCH-30.2 MCHC-34.0 RDW-14.9 Plt Ct-430 [2198-2-9] 06:33AM BLOOD PT-13.5* PTT-28.1 INR(PT)-1.3* [2198-2-10] 04:40AM BLOOD PT-13.8* PTT-30.3 INR(PT)-1.3* [2198-1-23] 05:45AM BLOOD ESR-112* [2198-2-9] 06:33AM BLOOD Glucose-108* UreaN-20 Creat-1.3* Na-138 K-3.6 Cl-102 HCO3-31 AnGap-9 [2198-2-9] 03:39PM BLOOD Glucose-117* UreaN-19 Creat-1.3* Na-136 K-3.2* Cl-99 HCO3-32 AnGap-8 [2198-2-10] 04:40AM BLOOD Glucose-105* UreaN-18 Creat-1.2 Na-136 K-3.3 Cl-100 HCO3-31 AnGap-8 [2198-2-10] 04:40PM BLOOD Glucose-173* UreaN-17 Creat-1.1 Na-136 K-3.5 Cl-99 HCO3-30 AnGap-11 [2198-2-11] 05:32AM BLOOD Glucose-121* UreaN-16 Creat-1.1 Na-137 K-4.7 Cl-99 HCO3-31 AnGap-12 [2198-2-12] 04:45AM BLOOD Glucose-99 UreaN-15 Creat-1.1 Na-137 K-3.2* Cl-97 HCO3-33* AnGap-10 [2198-2-12] 03:26PM BLOOD UreaN-17 Creat-1.1 Na-135 K-3.9 Cl-97 HCO3-32 AnGap-10 [2198-2-13] 06:15AM BLOOD Glucose-97 UreaN-16 Creat-1.1 Na-136 K-3.3 Cl-97 HCO3-36* AnGap-6* [2198-2-13] 04:52PM BLOOD Na-137 K-3.7 Cl-97 [2198-2-14] 06:20AM BLOOD Glucose-99 UreaN-18 Creat-1.0 Na-136 K-3.6 Cl-99 HCO3-32 AnGap-9 [2198-2-12] 09:00PM BLOOD CK(CPK)-55 [2198-2-5] 11:57PM BLOOD CK-MB-2 cTropnT-0.08* [2198-2-12] 09:24AM BLOOD CK-MB-3 cTropnT-0.04* [2198-2-12] 09:00PM BLOOD CK-MB-2 cTropnT-0.03* [2198-2-14] 06:20AM BLOOD Calcium-8.7 Phos-2.1* Mg-2.0 [2198-2-13] 04:52PM BLOOD Mg-2.0 [2198-2-6] 05:03PM BLOOD Hapto-173 [2198-1-29] 06:00AM BLOOD TSH-0.20* [2198-1-29] 03:55PM BLOOD T4-5.0 T3-49* Free T4-1.2 [2198-1-23] 05:45AM BLOOD CRP-263.1* [2198-2-9] CXR: Mild pulmonary edema and moderate bilateral pleural effusions have both improved since [2-8]. The heart remains moderately enlarged, and mediastinal and pulmonary vasculature are engorged. Substantial bibasilar consolidation also persists. Whether this is pneumonia or more likely a combination of atelectasis and residual dependent edema is really indeterminate. Right PIC line ends in the mid SVC. No pneumothorax. [2198-2-6] CT Abdomen: IMPRESSION: 1. No acute pulmonary embolism or thoracic aortic pathology. 2. Large left retroperitoneal hematoma extending into the pelvis, stable in extent and size since the prior study. 3. Stable left adrenal adenoma. [2198-1-25] TTE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. Right atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta to 40 centimeters from the incisors. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. Tricuspid regurgitation is present but cannot be quantified. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No evidence of intracardiac mass/thrombus. Mildly dilated aortic root and ascending aorta. Simple atheroma aortic arch. Complex atheroma in the descending thoracic aorta. Mild mitral regurgitation. Significant tricuspid regurgitation. Brief Hospital Course: 81 yo M with COPD, CAD and b/l knee replacements, transferred from OSH on [2198-1-22] with a septic right knee, underwent debridement with hardware repair by ortho surgery. Hospital course complicated by aflutter with RVR and hypotension, fluid overload with pulmonary edema, knee hematoma s/p repeat washout, postop ileus, retroperitoneal bleed, UGIB from esophagitis, delerium and [Last Name (un) ]. # Septic R knee - Initially admitted to the medicine service for a septic R knee, then sent to ortho for debridement. Outside hospital cultures showed MSSA and he was started on nafcillin. Post-debridement he required transfer to the SICU for pressors and continued intubation. He was then transferred to medicine where nafcillin was continued. He required a second debridement of hematoma a few days later, and was then treated with a wound vac until wound could be closed. ID was consulted and recommended treatment with IV nafcillin for 6 weeks, then 6 months of oral suppressive thearpy afterwards with oral rifampin indefinitely. He will need weekly labwork and follow-up as instructed below. . # Atrial flutter - Found to be in aflutter on admission. This was a new rhythm for him. Thought to be related to his septic knee. He required SICU admission post-op for pressors and rate control. He underwent TEE/cardioversion successfully, but then returned to aflutter. He went on an amiodarone drip which converted to sinus. On transfer back to medicine he returned to aflutter with RVR. EP was called and he had an EP study with ablation. Post-ablation he had atrial fib/aberrancy requiring diltiazem for rate control eventually requiring maximum dose diltiazem as well as increasing doses of metoprolol. He was initially started on heparin, then transtioned to lovenox, with plan to bridge to coumadin for 3 months of anticoagulation post-ablation. However, anticoagulation was held due to multiple bleeding risks, including active UGIB, a large RP bleed and hematoma s/p washout of the right knee. He has a CHADS2 score of 2 and so would indicate anticoagulation with coumadin if safe after his repeat EGD in mid-[Month (only) 958]. . # Retroperitoneal bleed - On [2-4], his Hct began to trend down to around 22. He received 2 units without a significant bump in Hct. He then complained of L back pain and was found to have an RP bleed. His Hct remained somewhat stable and he received another 2 units on [2-5]. His lovenox and aspirin were held. His Hct continued to trend down, yet repeat imaging showed a stable RP bleed. At the time of discharge, his hematocrit stabilized. # Suspicion for coronary disease- on [2-12] he had some episodes of tachycardia, during which time an EKG showed anterior ST depressions. These resolved with decreased heart rate. This implies he may have some coronary plaque burden. # Melena: The patient's Hct continued to trend down in the setting of a stable RP bleed. During his MICU stay, the patient had 2-3 episodes of black tarry stool. The patient was started on a PPI IV and transfused 2 units PRBCs. The patient underwent an EGD that showed esophagitis, gastritis, and duodenitis, but no active bleeding and no intervention was undertaken. The patient's Hct was trended and stabilized. He will require a repeat EGD in 8 weeks (mid-[Month (only) 958]) and GI follow-up. . # Hypoxia/hypercapnia/delirium - His ventilation and oxygenation status varied throughout his hospitalization. He was very tachypneic due to infection on admission, and then intubated in the SICU. After extubation his delirium slowly resolved. His hypoxia improved with some diuresis. On [2-5], he required MICU transfer for hypoxic respiratory failure. A CTA ruled out PE. Chest imaging showed slight pulmonary edema, but no consolidations. The patient was further diuresed and weaned down on his O2. His hypoxia resolved by the time of discharge with daily lasix doses. He will be continued on lasix 40mg PO and will require twice weekly Chem 7 testing to assess for renal function, to hold lasix if his renal function increases by more than 50%. . # Acute kidney injury - His basline creatinine was around 0.8. He had intermittent kidney injury with cr up to 1.4 during the hospitalization. Likely ATN in the setting of hypotension vs. contrast. Resolved with time. CHRONIC # COPD - does not use O2 at home. Required O2 while in hospital likely due to pulmonary edema. Continued advair, continued nebs. At discharge, was stably saturating 90-93% on room air (acceptable due to his history of COPD). TRANSITIONAL -- needs 6 weeks of IV nafcillin (start date [2-8], last day [3-22]) as well as indefinite PO rifampin (300mg TID). After his nafcillin course is complete, he will require PO antibiotics for 6 months which will be determined by infectious disease. -- Recommend repeat EGD in 8 weeks to evaluate the GE junction for Barrett's. the area could not be evaluated at this time because of esophagitis. -- consider resuming coumadin after his repeat EGD in mid-[Month (only) 958] -- PFTs should be repeated, with possible sleep study to evaluate for OSA -- Lung nodule seen on imaging that needs to be followed up with repeat CT scan in [6-26] months. . Laboratory monitoring required: CBC c diff, chem-7, LFTs Frequency: Weekly Opat attending visit: [2198-2-16] 2PM Fellow visit: [2198-3-12] 10AM All laboratory results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 1353] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([Telephone/Fax (1) 1354] or to on [Name8 (MD) 138] MD in when clinic is closed Medications on Admission: Advair Atrovent MVI Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO once a day. 2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime): hold for loose stools. 5. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily): hold for loose stools. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas/bloating. 10. ipratropium bromide 0.02 % Solution Sig: One (1) solution Inhalation Q6H (every 6 hours). 11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 12. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heartburn. 13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 16. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath. 17. diltiazem HCl 360 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: In AM. 18. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: In PM. 19. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sbp<100. 20. potassium chloride 20 mEq Packet Sig: One (1) packet PO once a day: discontinue if lasix is discontinued. 21. rifampin 300 mg Capsule Sig: One (1) Capsule PO every eight (8) hours. 22. Nafcillin 2 g IV Q4H 23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. Discharge Disposition: Extended Care Facility: Life Care Center of [Location (un) ] Discharge Diagnosis: PRIMARY Right knee MSSA infection Atrial flutter SECONDARY COPD Gastritis Retroperitoneal hematoma Hemarthrosis Congestive heart failure, diastolic Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 91975], It was a pleasure caring for you at [Hospital1 18]. You were initially admitted to the hospital for an infection in your knee. You required surgery twice and will need IV antibiotics for 6 weeks and oral antibiotics for 6 months afterwards. You also had an arrythmia in your heart that required an ablation procedure and other medictions. Given your long hospital stay, you will be discharged to a rehab facility. Medication changes: START nafcillin 2g every 4 hours for 6 weeks for infection START rifampin 300mg by mouth three times per day START aspirin 325mg daily START docusate sodium 100mg twice daily for stool softener START senna 8.6mg daily as needed for constipation START diltiazem 360mg ER once daily for heart rate control START metoprolol XL 100mg by mouth at night for heart rate control START lasix 40mg by mouth once per day for fluid retention START potassium 20meq by mouth daily while on lasix START colace 100mg by mouth twice per day START senna 1 tab by mouth twice per day START bisacodyl 5 mg by mouth once per day (hold for loose stools) Followup Instructions: Department: INFECTIOUS DISEASE When: FRIDAY [2198-2-16] at 2:00 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Name: [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: HEART ASSOCIATIONS OF [Location (un) ] AT [Hospital3 ] Address: 131 [Last Name (LF) ], [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Building, [Location (un) 1514], MA Phone: [Telephone/Fax (1) 71179] When: Thursday, [3-1], 4:30 PM Department: INFECTIOUS DISEASE When: MONDAY [2198-3-12] at 10:00 AM With: [Name6 (MD) 14621] [Last Name (NamePattern4) 14622], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Orthopaedics: Follow up in 1 week with Dr. [First Name (STitle) ]. Please call [Telephone/Fax (1) 1228] to make an appointment. Name: [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: HEART ASSOCIATIONS OF [Location (un) ] AT [Hospital3 ] Address: 131 [Last Name (LF) ], [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Building, [Location (un) 1514], MA Phone: [Telephone/Fax (1) 71179] When: Thursday, [3-1], 4:30 PM Department: ORTHOPEDICS When: WEDNESDAY [2198-2-21] at 11:05 AM With: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 5500], M.D. [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage *It is recommended you obtain a repeat EGD in 8 weeks. Please call the GI office at [Telephone/Fax (1) 463] to arrange one.*	[ "V43.65", "428.0", "496", "719.18", "250.00", "584.9", "530.19", "V10.82", "V12.72", "568.81", "E940.1", "293.0", "E878.8", "514", "998.12", "560.1", "276.3", "E878.1", "348.31", "285.1", "518.81", "711.06", "038.11", "578.9", "414.01", "996.67", "276.69", "564.09", "V45.82", "428.31", "995.91", "427.32", "997.49" ]	icd9cm	[ [ [] ] ]	[ "00.84", "37.27", "99.62", "80.86", "45.13", "80.76", "38.93", "80.16", "37.34", "96.71", "81.91" ]	icd9pcs	[ [ [] ] ]	22826, 22893	14683, 20366	313, 420	23087, 23087	3538, 14660	24366, 26438	2570, 2615		20437, 22803		22914, 23066		20392, 20414			23238, 23690										2630, 3219								3235, 3519																23710, 24343				262, 275											448, 2274												23102, 23214			2296, 2408	2424, 2554
29,896	195,857	31674	Discharge summary	report	Admission Date: [2126-10-29] Discharge Date: [2126-11-5] Date of Birth: [2062-10-23] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: arm and leg pain Major Surgical or Invasive Procedure: [2126-10-29] Mitral Valve Repair (32mm Annuloplasty Band) with Ligation of Left Atrial Appendage History of Present Illness: 63 y/o male who was recently admitted for leg and arm pain/weakness and ruled out for stroke. Incidently found to have a heart murmur on exam. Echo performed revealed 3+ mitral regurgitation. Past Medical History: Hypertension, Migraines Social History: Lives in [Location ] with spouse. Used to work as mechanic, no longer works because of arm/leg pain and weakness. No tobacco or drugs, rare alcohol. Family History: no family history of stroke or other neurologic disease Physical Exam: VS: 77 18 128/77 5'7" 179# Gen: NAD, A&O x 3 HEENT: EOMI, PERRL NCAT Neck: Supple, FROM -JVD, -bruits Lungs: CTAB -w/r/r Heart: RRR 5/6 holosystolic murmur Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, -varicosities Neuro: MAE, r-sided weakness noted Pertinent Results: [10-29] Echo: PRE-BYPASS: 1. The left atrium is markedly dilated. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. There is moderate/severe mitral valve prolapse of the P1 leaflet, best seen on 3D reconstruction. Severe (4+) mitral regurgitation is seen. There is systolic reversal as noted on the pulse wave doppler of the pulmonary veins. POST-BYPASS: 1. Pt s/p mitral valve annuloplasty ring , there is no mitral regurgitation. Mean gradient across the mitral valve is 1.4mmHg; MV pressure half time is 67msecs with MVA of 3.3 cm2. 2. Biventricular function is preserved 3. Aortic contours are intact post-decannulation. [11-4] Echo: There has been previous median sternotomy and coronary bypass surgery. There is stable postoperative enlargement of the cardiac silhouette. Improving atelectasis is present in both lower lobes, and there are persistent small bilateral pleural effusions. No pneumothorax is identified. Biapical pleural and parenchymal scars without change from the preoperative study. [2126-10-29] 11:17AM BLOOD WBC-23.0# RBC-3.51 Hgb-11.2# Hct-32.6 MCV-93 MCH-32.0 MCHC-34.5 RDW-14.0 Plt Ct-141* [2126-11-4] 06:20AM BLOOD WBC-12.4* RBC-3.63* Hgb-11.4* Hct-34.0* MCV-94 MCH-31.3 MCHC-33.4 RDW-13.3 Plt Ct-360 [2126-10-29] 11:17AM BLOOD PT-14.0* PTT-34.2 INR(PT)-1.2* [2126-11-5] 06:05AM BLOOD PT-17.6* INR(PT)-1.6* [2126-10-29] 12:16PM BLOOD UreaN-12 Creat-0.7 Cl-112* HCO3-27 [2126-11-4] 06:20AM BLOOD Glucose-114* UreaN-13 Creat-1.0 Na-136 K-4.9 Cl-98 HCO3-32 AnGap-11 [2126-11-4] 06:20AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.2 Brief Hospital Course: Mr. [Known lastname 74437] was a same day admit after undergoing all pre-operative work-up as an outpatient or during prior admission. On day of admission he was brought to the operating room where he underwent a mitral valve repair with ligation of left atrial appendage. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one his chest tubes were removed and he was started on beta blockers and diuretics. He was gently diuresed towards his pre-op weight. Later on this day he was transferred to the SDU for further management. Epicardial pacing wires were removed on post-op day three. On this day he had an episode of atrial fibrillation which was treated appropriately. Amiodarone was started but patient continued to have episodes of A FIB or atrial flutter. He was eventually started on Coumadin with a goal INR of 2.5. Over next couple of days he worked with physical therapy for strength and mobility. His heart rhythm converted to sinus rhythm by time of discharge but will continue Amiodarone and Coumadin until stopped by cardiologist. He appeared to be doing well on post-op day seven and was discharged home with VNA services with the appropriate follow-up appointments. Medications on Admission: Tylenol, Fiorocet prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. 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 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take 400mg [Hospital1 ] for 5 days. Then 200mg [Hospital1 ] for 7 days. Then 200mg qd until stopped by cardiologist. Disp:60 Tablet(s) Refills:1 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). Disp:180 Tablet(s) Refills:1 8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed by Dr. [Last Name (STitle) 4888]. Goal INR is 2.5. Disp:30 Tablet(s) Refills:1 9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day as needed: Please take only if asked by Dr. [Last Name (STitle) 4888] to supplement your Coumadin 2.5mg qd tablets to reach goal INR of 2.5. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Mitral Regurgitation s/p Mitral Valve Repair Post-operative Atrial Fibrillation PMH: Hypertension, Migraines 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. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Dr. [Last Name (STitle) 4888] will follow your INR and adjust your Coumadin. VNA will draw blood Monday, Wednesday, Friday and as requested by Dr. [Last Name (STitle) 4888]. Goal INR is 2.5. 8) Call with any questions or concerns. [Last Name (NamePattern4) 2138]p Instructions: Heart [Last Name (NamePattern4) ]: Dr. [Last Name (Prefixes) ] in 4 weeks Cardiologist: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 74438] in [2-9] weeks PCP: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 2563] [Last Name (NamePattern1) 4888] in [1-8] weeks (She will also be following your INR and adjusting your Coumadin accordingly) Completed by:[2126-11-5]	[ "780.6", "997.1", "427.31", "424.0", "998.89", "427.32", "401.9" ]	icd9cm	[ [ [] ] ]	[ "37.99", "39.61", "89.60", "35.33" ]	icd9pcs	[ [ [] ] ]	6365, 6423	3519, 4906	340, 442	6575, 6581	1250, 3496		897, 954		4978, 6342		6444, 6554		4932, 4955			6605, 7502				7553, 7982						969, 1231																												284, 302											470, 663															685, 710	726, 881
65,732	160,296	35812+58035	Discharge summary	report+addendum	Admission Date: [2180-3-3] Discharge Date: [2180-3-7] Date of Birth: [2099-2-4] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 3853] Chief Complaint: "Lower GI bleed." Major Surgical or Invasive Procedure: Central Line Placement at OSH Colonoscopy and EGD at OSH History of Present Illness: 81 yo M with hx of CMP (EF 15%), Afib, HTN, with active LGIB. Presented 10 days ago to QMC, self-resolved, DC'ed to home on [2-25], then returned again on [2-29] with recurrent BRBPR, Hct 27 (baseline 38), has received 4 units over last 24 hours, Hct remains at 27. Had C-scope showing diverticulosis and lots of blood, unable to localize bleeding. Underwent CTA that does not show any obvious source of active GIB, however, he is still having BRBPR ([Name8 (MD) ] RN, has had >10 BM's today with BRBPR, approx 150ml each time). Surgical consult did bedside rigid sigmoidoscopy without identification of a clear source of bleed. Surgical consult recommended transfer to a tertiary care center in the event that he continued to bleed and required an ex-lap/colectomy. Surgery there did not feel comfortable operating given his cardiac co-morbidities. Given that he was still actively bleeding, Hct had not bumped after 4 units PRBC's, and his pre-transfer BP was 93/51 (hospitalist thought BP in 130's, but [Name8 (MD) ] RN in step-down unit, had been trending down all day). Transferred with 2 PIV (22g, 18g). Pt received 6u pRBC, 6u platelets, and 2u FFP total. Hct on presentation was 39 decreased to 27 today with bump to 27.9 after transfusion. . Also seen by his outpatient cardiologist, Dr. [Last Name (STitle) 66687], while at OSH who recommended he be started on digoxin and that his home lasix dose be increased. . On arrival to the MICU on [2180-3-3], he was feeling well. That day he stooled less (2 BMs) than the day prior (10 BMs). Stools continue to be BRBPR. He c/o mild burning w stooling and burping but denied fever, chills, SOB, chest pain, dizziness, abdominal pain. . Review of systems: (+) Per HPI Past Medical History: -Cardiomyopathy EF 15% (but 30-35% on repeat Echo at [Hospital1 18]) s/p BV/ICD on 8/[2179]. -Mild AS, Mild AI, mild MR [Name13 (STitle) 29966] (Coronary Artery Disease): Has been off coumadin and aspirin for "long time" per pt -Atrial fibrillation -DM type 2 (diabetes mellitus, type 2) -Hyperlipidemia LDL goal < 70 -S/P TKR (total knee replacement) -Umbilical hernia -Diverticulosis -Hydronephrosis with renal and ureteral calculous obstruction -Paget disease of bone -Hypertension -Colonic Cancer- s/p R hemicolectomy 20 years ago -Borderline Glaucoma with Ocular Hypertension -BPH (Benign Prostatic Hyperplasia) -LBBB (Left Bundle Branch Block) -OA (Osteoarthritis) -Nephrolithiasis -Varicose Vein Social History: Lives in [Hospital1 392] with wife [Name (NI) ]. Retired construction worker. - Tobacco: pipe/cigar smoker x 50+ years, quit 10 yrs ago - Alcohol: occasional - Illicits: none Family History: noncontributory Physical Exam: ADMISSION EXAM Vitals: 86/31 103 25 95/3L General: Alert, oriented, elderly male pleasant and in no acute distress HEENT: Sclera anicteric, oral mucosa dry and pale, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi, poor respiratory effort Abdomen: soft, +compressible umbilical hernia, mild tenderness to palpation over epigastrum, non-distended, bowel sounds wnl, no organomegaly GU: +foley, DRE negative for blood, +skin tag Ext: warm, well perfused, 2+ pulses, no clubbing, or cyanosis, 2+ edema b/l LE Neuro: CNII-XII grossly intact DISCHARGE EXAM Vitals: Tmax 98.7 Tc 97.4 BP 98-110/58-66 HR 80-88 RR 18 SPO2 95%RA General: Alert, oriented, well-appearing elderly man in no apparent distress HEENT: Sclera anicteric, mucous membranes moist CV: Regular rate and rhythm, [3-13] holosystolic murmur best heard at apex Lungs: Clear to auscultation bilaterally, no wheezes, crackles, or rhonchi. Resonant to percussion throughout. Abdomen: +BS, Soft, nontender, nondistended. Reducible, nontender midline ventral hernias. Midline abdominal scar. No hepatosplenomegaly. Extremities: Warm, well-perfused, 2+ radial and dorsalis pedis pulses bilaterally. No clubbing, cyanosis, or edema. Neuro: CN 2-12 grossly intact, although hearing is impaired in R ear more than L ear. Sensation intact throughout, moves all extremities. Pertinent Results: ADMISSION LABS [2180-3-4] 12:01AM BLOOD WBC-11.0 RBC-2.99* Hgb-9.3* Hct-26.5* MCV-89 MCH-31.0 MCHC-35.0 RDW-14.4 Plt Ct-152 [2180-3-4] 12:01AM BLOOD Neuts-84.1* Lymphs-8.9* Monos-5.9 Eos-0.7 Baso-0.4 [2180-3-4] 12:01AM BLOOD PT-12.6* PTT-23.1* INR(PT)-1.2* [2180-3-4] 12:01AM BLOOD Glucose-144* UreaN-15 Creat-1.1 Na-143 K-3.6 Cl-105 HCO3-25 AnGap-17 [2180-3-4] 12:01AM BLOOD Calcium-8.7 Phos-5.6* Mg-1.5* [2180-3-4] 08:49AM BLOOD Digoxin-0.5* TTE [3-4]: Poor image quality. The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 5-10 mmHg. There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity is moderately dilated. There is probably moderate global left ventricular hypokinesis (LVEF = 30-35 %) but due to atrial fib and LBBB regionality could not be well defined. 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 probably normal. The ascending aorta is mildly dilated. The aortic valve is not well seen. There is probably mild to moderate aortic valve stenosis (valve area 1.0-1.2 cm2). Mild to moderate ([2-7]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a moderate sized pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is mild compression of the RV free wall in diatole without overt collapse (suggestive of elevated intrapericardial pressure without overt tamponade). CXR: There is severe cardiomegaly. A transvenous pacemaker leads are in standard position. There is no pneumothorax. Left lower lobe opacity is a combination of pleural effusion and atelectasis. There is mild right lower lobe atelectasis. There is mild vascular congestion. CTA From OSH: No obvious cause for bleeding seen. Small 5mm blush 6 cm from anal verge ?AVM v valve of [Location (un) ] v internal hemorrhoid. Also showed moderate pericardial effusion and "signs of right heart failure." Mild pneumatosis of cecum likely incidental wo focal bowel wall thickening or surrounding infalmmatory change in this location. No portal venous air. Positive sigmoid diverticulosis wo inflammation. Remainder of colon unremarkable. Small bowel unremarkable. Moderate pericardial effusion 2.8cm thick w signs of R heart failure w significant reflux into the liver (previously measured 19mm). DISCHARGE LABS [2180-3-7] 07:25AM BLOOD WBC-8.1 RBC-3.57* Hgb-10.9* Hct-33.3* MCV-93 MCH-30.5 MCHC-32.8 RDW-14.1 Plt Ct-150 [2180-3-5] 01:34AM BLOOD PT-12.5 PTT-24.8* INR(PT)-1.2* [2180-3-7] 07:25AM BLOOD Glucose-139* UreaN-23* Creat-0.9 Na-142 K-4.1 Cl-102 HCO3-32 AnGap-12 [2180-3-7] 07:25AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.9 [2180-3-4] 08:49AM BLOOD Digoxin-0.5* Brief Hospital Course: 81y M hx of diverticulosis, colon cancer s/p R sided hemicolectomy 20 years prior, AS, afib, and CAD w ischemic cardiomyopathy (EF 30-35%) transferred from [Hospital3 ] for management of acute lower GIB. . 1. Lower GI Bleed: The patient presented to [Hospital6 10353] on [2-29] after recurrent BRBPR (was d/c home on [2180-2-25] after self-resolving BRBPR). His Hct dropped from 38 to 27 and after 6 units of pRBCs, his HCt remained at 27. He had a colonoscopy showing severe diverticulosis throughout colon, internal hemorrhoids, and lots of blood, but unable to localize bleeding. EGD showed mild gastric erythema (biopsied), otherwise normal. Underwent CTA for continued BRBPR that did not show any obvious source of active GIB but showed small 5mm blush 6 cm from anal verge ?AVM v valve of [Location (un) ] v internal hemorrhoid. Surgical consult did bedside rigid sigmoidoscopy without identification of a clear source of bleed. Surgical consult recommends transfer to a tertiary care center in the event that he continues to bleed and requires an ex-lap/colectomy. Surgery there does not feel comfortable operating given his cardiac co-morbidities. Of note, his SBP dropped to 60s after colonoscopy. His pre-transfer BP was 93/51. He was then transferred to the [Hospital1 18] MICU. At [Hospital1 18], the patient received 2 units PRBCs with stabilization of his Hct to 30. Surgery and GI were consulted for possible intervention. The patient's bleeding stopped spontaneously and the patient was transfered to the floor. On the floor the patient remained hemodynamically stable x 4 days and Hct increased to 33.3. The patient should be seen by GI within 1 week of discharge. . # CHF: EF 15-20% s/p BV/ICD placement in 08/[2179]. The patient had a repeat TTE as pre-surgical workup that showed an EF 30-35%. The patient is NYHA class 2 and was maintained on his spironolactone and lasix. His carvedilol and losartan were initially held, but restarted upon stabilization. At the OSH the patient was started on digoxin and lasix was increased to 40mg daily at the OSH by his outpatient cardiologist, Dr. [Last Name (STitle) 66687]. He was discharged on his home doses of spironolactone, lasix, carvedilol, losartan, and digoxin. The patient should follow up with his PCP [Name Initial (PRE) 176] 1 week of discharge. . # Atrial fibrillation: (CHADS2 score = 4) Not on anticoagulated or aspirin given the current and prior GI bleeds. . # DM: Good blood sugar control was achieved on a humalog insulin sliding scale. Patient will return to diet control upon discharge. . # HL: continue home statin Medications on Admission: - Spironolactone (ALDACTONE) 25 mg Oral Tablet 1 by mouth once daily - Losartan (COZAAR) 25 mg Oral Tablet 1 tablet daily - Furosemide 20 mg Oral Tablet 20 /40 mg qod - Ferrous Sulfate 325 mg (65 mg iron) Oral Tablet 1 tab po bid - Simvastatin 10 mg Oral Tablet 1 tablet every evening for cholesterol - Carvedilol (COREG) 25 mg Oral Tablet 1 by mouth twice daily - Triamcinolone Acetonide 0.1 % Topical Cream Apply to affected area twice daily - Lancets (MICROLET LANCET) Misc.(Non-Drug; Combo Route) Misc test once daily - Blood Sugar Diagnostic (ASCENSIA CONTOUR) Misc.(Non-Drug; Combo Route) Strip [Hospital1 ] - Nystatin-Triamcinolone (MYCOGEN II) 100,000-0.1 unit/g-% Topical Cream apply [Hospital1 ] x 2 weeks Discharge Medications: 1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Lower gastrointestinal bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 17920], You were admitted to the Granite State Medical Center with lower GI bleed. You had a colonscopy which showed diverticulosis. You required several blood transfusions. Your were transferred to [Hospital1 69] for further management. The bleeding resolved spontaneously, and although a definite source of the bleeding was not identified, it was most likely due to your diverticulosis. You remained stable and were transferred to the internal medicine floor for observation. You are now being discharged in good condition, with plans to follow up with your GI doctor in one week. Medication Changes: - Change furosemide to 40 mg by mouth daily Start taking Digoxin 0.125mg by mouth daily Followup Instructions: Follow up with your gastroenterologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 81451] at [Hospital ] Medical within one week of discharge. Please also follow up with your primary care provider [Name Initial (PRE) 176] 1 week of discharge and ask him to repeat a 'CBC blood test' and review your discharge medications. Name: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 81452], Nurse [First Name (Titles) ] [Last Name (Titles) 4094]: Internal Medicine When: Thursday [3-16] at 10:45am Location: [Hospital 20086] MEDICAL GROUP Address: [Street Address(2) 20087], STE 3C, [Hospital1 ],[Numeric Identifier 10727] Phone: [Telephone/Fax (1) 7164] You already have an echocardiogram scheduled for this day at 9:50am so the nurse [Telephone/Fax (1) 3639] for Dr. [First Name (STitle) ] will see you for your hospital follow up visit after your echocardiogram at 10:45am. Name: [Known lastname 2872],[Known firstname 2197] Unit No: [Numeric Identifier 13048] Admission Date: [2180-3-3] Discharge Date: [2180-3-7] Date of Birth: [2099-2-4] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 4665] Addendum: This addendum is per the request of coding/medical records department: 1) Presumed etiology of the patients anemia is acute blood loss anemia 2)etiology of CHF is systolic dysfunction Discharge Disposition: Home With Service Facility: [Hospital3 413] VNA [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4666] MD [MD Number(2) 4667] Completed by:[2180-4-1]	[ "285.1", "401.9", "V45.02", "600.00", "V15.82", "250.00", "428.22", "414.01", "V43.65", "458.9", "427.31", "562.12", "428.0", "276.52", "V10.05", "414.8", "272.0" ]	icd9cm	[ [ [] ] ]	[ "38.97" ]	icd9pcs	[ [ [] ] ]	14210, 14420	7675, 10322	287, 345	11759, 11759	4625, 7652	12692, 14187	3081, 3099		11097, 11613		11708, 11738		10348, 11074			11942, 12560										3114, 4606																						2110, 2124		12580, 12669				230, 249											373, 2091												11774, 11918			2146, 2863	2879, 3065
6,714	148,536	24897+57422	Discharge summary	report+addendum	Admission Date: [2166-10-14] Discharge Date: [2166-10-23] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 134] Chief Complaint: transfer from OSH Major Surgical or Invasive Procedure: Cardiac Catheterization Endoscopic Retrograde Cholangiopancreotography History of Present Illness: 88M with history of CAD s/p MI, DM, HTN, Hypercholesterolemia presents from OSH with ACS and possible CBD mass. <br> The patient was in his USOH until [2166-10-13] when he presented to the OSH with mild, substernal to right-sided chest pressure, without radiation or associated N/V, SOB, LHD, palpitations. His first set of enzymes were negative, but subsequently peaked to CK of 155 (MB 10.5 with index 6.8%) and troponin I of 9.65. He was started on heparin gtt and continued on ASA, Plavix, statin and beta blocker. He complained of RUQ pain and had an ultrasound which showed gallstones and possible CBD mass. He was started on Unasyn and GI was consulted. GI recommended checking a CA [80]-9 and CEA and possible MRCP vs. ERCP. <br> The patient is transferred for Cardiac and GI work-up. He currently denies chest pain and states that he has not had CP since admission to the OSH. He also denies F/C, NS, weight loss, fatigue, loss of appetite, SOB, palpitations, abdominal pain, diarrhea, or other problems. Social History: Social Hx: Pt lives in [Location 1110] with his wife of 61 years. Formerly worked as aircraft radio repairman. Quit smoking after WWII. No alcohol. <br> Family Hx: DM in siblings. No CA or CAD. Family History: Family Hx: DM in siblings. No CA or CAD. Physical Exam: Gen: frail appering elderly male, resting in bed, NAD HEENT: PERRLA, purulent d/c from R eye. EOMI HEART: S1, S2, RRR. 3/6 SEM obscuring S1, no radiation to carotids LUNGS: CTAB ABD: +BS, multiple scars. Soft, NT, ND, no RUQ tenderness or [Doctor Last Name 515] sign Neuro/Psy: A&O x3. mild fogetfullness Pertinent Results: [2166-10-14] 08:10PM GLUCOSE-214* UREA N-36* CREAT-1.7* SODIUM-136 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15 [2166-10-14] 08:10PM CK(CPK)-91 [2166-10-14] 08:10PM CK-MB-NotDone cTropnT-0.63* [2166-10-14] 08:10PM CALCIUM-8.8 PHOSPHATE-3.5 MAGNESIUM-1.8 [2166-10-14] 08:10PM WBC-8.4 RBC-3.72* HGB-11.5* HCT-33.4* MCV-90 MCH-30.9 MCHC-34.4 RDW-12.4 [2166-10-14] 08:10PM NEUTS-80.5* LYMPHS-11.9* MONOS-4.8 EOS-2.4 BASOS-0.4 [2166-10-14] 08:10PM PLT COUNT-115* [2166-10-14] 08:10PM PT-14.2* PTT-104.9* INR(PT)-1.4 _______________________________ Cardiac Catheterizaiton BRIEF HISTORY: Mr [Known lastname 62612] is an 88 year old male with a history of diabetes, hypertension, hyperlipidemia and known CAD with cathin [2163] which showed totally occluded LAD, 80% LCX and 80% PDA who was admitted with chest pain. Pt with [Hospital 7792] transferred to [Hospital1 18] for cardiac catheterization. INDICATIONS FOR CATHETERIZATION: Coronary artery disease, NSTEMIS, preop evaluation. PROCEDURE: Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 6 French left [Last Name (un) 2699] catheter, advanced to the ascending aorta through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 6 French JL4 and a 6 French JR4 catheter, with manual contrast injections. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM RIGHT CORONARY 1) PROXIMAL RCA DIFFUSELY DISEASED 30 2) MID RCA DISCRETE 90 3) DISTAL RCA DISCRETE 90 4) R-PDA DISCRETE 90 ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD NORMAL 6A) SEPTAL-1 NORMAL 7) MID-LAD DISCRETE 95 8) DISTAL LAD DIFFUSELY DISEASED 30 9) DIAGONAL-1 NORMAL 12) PROXIMAL CX NORMAL 13) MID CX DISCRETE 90 13A) DISTAL CX NORMAL TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 35 minutes. Arterial time = 29 minutes. Fluoro time = 9.7 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 60 ml Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin 0 units IV Cardiac Cath Supplies Used: 100CC MALLINCRODT, OPTIRAY 100CC COMMENTS: 1. Selective coronary angiography of this right dominant system revealed 3 vessel coronary artery disease. The LMCA had dual os and had no angiographically apparent flow limiting lesions. The LAD was a small vessel with a 95% stenosis in the mid vessel. The LCX was a large vessel and had a 90% mid vessel stenosis. The RCA was dominant and was a small vessel with diffuse disease. There was a 90% stenosis in the mid RCA. The RCA gave rise to the PDA which had a 90% stenosis. 2. Limited resting hemodynamic revealed elevated systemic pressures. 3. Left ventriculography was deferred dur to renal insufficiency. FINAL DIAGNOSIS: 1. Angiograohic evidence of three vessel coronary artery disease. 2. Elevated systemic pressures. ATTENDING PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. REFERRING PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. YOUNG,[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] CARDIOLOGY FELLOW: [Last Name (LF) 3904],[First Name3 (LF) 2482] P. ATTENDING STAFF: [Last Name (LF) ],[First Name3 (LF) ] D. ____________________________________________ [2166-10-22] ERCP: Medications: Cetacaine topical spray Fentanyl 75 micrograms Phenergan 6.25 mg Glucagon 0.2 mg Midazolam 2.5mg ASA Class: P2 Procedure: The procedure, indications, preparation and potential complications were explained to the patient's parent or guardian, who indicated his understanding and signed the corresponding consent forms. A physical exam was performed. The patient was administered Conscious sedation anesthesia. The patient was placed in the prone position and an endoscope was introduced through the mouth and advanced under direct visualization until the second part of the duodenum was reached. Careful visualization was performed. The procedure was not difficult. The quality of the preparation was good. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Normal major papilla Cannulation: Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. Biliary Tree: Many stones ranging in size from 5mm to 15mm were seen at the common bile duct. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Many various sized stones and sludge were extracted successfully using a 15 mm balloon. Impression: 1. Choledocholithiasis 2. Sphincterotomy and balloon sweep yielding multiple variable sized stones and sludge. Recommendations: NPO overnight , then advance diet as tolerated in AM. Follow-up with referring physician [Name9 (PRE) ] [Name9 (PRE) 4532] for 1 week Additional notes: The procedure was performed by Dr. [Last Name (STitle) ] (attending physician) and ERCP fellow. _________________________________ [Name6 (MD) ] [Name8 (MD) ], MD _________________________________ [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 62613], MD _________________________________ [First Name4 (NamePattern1) 7306] [Last Name (NamePattern1) 7307], M.D. Case documented on [2166-10-22] 9:32:10 AM Brief Hospital Course: A/P: 88M with history of CAD s/p MI, DM, HTN, Hypercholesterolemia presents from OSH with ACS and possible pancreatic mass. . 1. CAD: Pt ruled in for MI at the OSH without EKG changes, with known CAD by cardiac catheterization previously medically managed. Cath from [10-17] revealed:LAD with 95% stenosis, Lcx with 90% stenosis, rca with 90% stenosis at crux of PDA. -Pt cath'd 2d ago revealing 3 vessel dz. Will receive intervention post-ERCP -Will continue ASA beta blocker, statin. Have D/C'd plavix in anticipation for inpt ERCP. Hep d/c'd. -will follow up with outpatient cardiologist to arrange further intervientions -will restart plavix 75 qd as an outpatient 1 week after ERCP. . 2. Rhythm: Pt is s/p PM placement for sick sinus syndrome and neurovascular syncope. Episodically AV-paced. No issues during hospitalization . 3. CBD stones/Choledochilithaisis: At OSH pt complained of RUQ abdominal pain with elevated lipase and amylase (nml LFTs) and US which showed gallstones and 12mm focus in CBD. He was started on Unasyn and was transferred for GI work-up. LFTs normalized upon transfer and RUQ pain was resolved. Abx were dc'ed. RUQ US [Hospital1 18]: stones in CBD obstructing neck. GB wall edema. Hyperechoic lesion in liver likely hemangioma. Patient likely had pancreatitis from a stone transiently obstructiong CBD. ----------------- Had ERCP: The procedure, indications, preparation and potential complications were explained to the patient's parent or guardian, who indicated his understanding and signed the corresponding consent forms. A physical exam was performed. The patient was administered Conscious sedation anesthesia. The patient was placed in the prone position and an endoscope was introduced through the mouth and advanced under direct visualization until the second part of the duodenum was reached. Careful visualization was performed. The procedure was not difficult. The quality of the preparation was good. The patient tolerated the procedure well. There were no complications. Amp/Gent given. . Many stones ranging in size from 5mm to 15mm were seen at the common bile duct. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Many various sized stones and sludge were extracted successfully using a 15 mm balloon. Recs: NPO overnight , then advance diet as tolerated in AM. Follow-up with referring physician [Name9 (PRE) ] [Name9 (PRE) 4532] for 1 week -will need GI f/u as outpt if problems arise. -Repeat LFTs, Amylase, Lipase all trending down . . 4. Hypercholesterolemia: Well-controlled on statin. . 5. Renal insufficiency: Pt's creatinine now down to 1.5. Unclear baseline, but likely has some renal insufficiency in setting of DM. -has completed post-cath hydration and mucomyst . 6. DM: Sugars continue to be elevated in the patient with known DM. Started on outpt dose of 6uNPH qhs, but not enough, wills start NPH 4 u at breakfast as well and a more aggressive sliding scale. Family refused PM NPH, so consequently the patient's sugars ran between 300-400, and requested pt to be started on home regimen of Humalog 75/25 30 u sq q am. Family did not want the patient to be on a sliding scale insulin since they are trying to get him into a facility that does not accept sliding scale insulin. The team continues to suggest more aggressive sliding scale, but the family continues to refuse PM sliding scale insulin. -cont humalog 72/25. q am. -cont ISS . 7. Cognitive Impairment: -on home donepezil/will take his own namenda, no changes during hospitalization. . Medications on Admission: MEDS (on transfer): 1. Heparin gtt 2. ASA 81mg daily 3. Plavix 75mg daily 4. Zocor 40mg daily 5. Atenolol 75mg daily 6. Protonix 40mg daily 7. Nitropaste 1" q6h 8. Acetaminophen prn 9. Aricept 10mg daily 10. Ativan prn 11. Folate 1mg daily 12. Unasyn 3g IV q6h 13. Regular insulin SS 14. NPH 6U apm Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:30 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 6. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Thirty (30) units Subcutaneous qAM. Disp:1 vial Refills:2 7. Nitroglycerin 0.4 mg/SPRAY Spray, Non-Aerosol Sig: [1-12] sprays Translingual PRN as needed for chest pain. Disp:1 unit Refills:2 8. Atenolol 50 mg Tablet Sig: 1 and [1-12] Tablet PO once a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 30191] Discharge Diagnosis: Coronary Artery Disease (Diffuse 3 Vessel) Non ST elevation Myocardial Infarction Choledocholithaisis Discharge Condition: stable, afebrile, ambulatory, chest pain free, abdominal pain free Discharge Instructions: -please take all your medications as directed -please follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1075] ([Hospital1 ] Cardiology) -please follow up with your PCP [Name10 (NameIs) 19288] you should have any more chest pain, please take your medications and phone your primary care provider immediately [Name9 (PRE) ] administer your insulin as directed by a physician [Name10 (NameIs) ] resume taking medication called Plavix on [2166-10-27] - Follow-up also with Dr [Last Name (STitle) 1295] for multivessel PCI Followup Instructions: Cardiology: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], ([Telephone/Fax (1) 20259] in [2-13] weeks Gastroenterology: Dr. [First Name4 (NamePattern1) 60252] [Last Name (NamePattern1) 62614], ([Telephone/Fax (1) 62615],, only if you have problems [Name10 (NameIs) 62616] call PCP regarding making an appointment Completed by:[2166-10-23] Name: [Known lastname 11223],[Known firstname 2636] Unit No: [Numeric Identifier 11224] Admission Date: [2166-10-14] Discharge Date: [2166-10-23] Date of Birth: [2078-5-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6568] Addendum: Patient should be given a prescription for Plavix 75mg qd. The prescription was not written in the original discharge scripts, but the information was relayed to the patient to resume taking plavix 6 days after discharge. Plavix was called in to a [Company 11225] at [Telephone/Fax (1) 11226] on [2166-10-23] at 1800. Medications on Admission: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:30 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 6. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Thirty (30) units Subcutaneous qAM. Disp:1 vial Refills:2 7. Nitroglycerin 0.4 mg/SPRAY Spray, Non-Aerosol Sig: [1-12] sprays Translingual PRN as needed for chest pain. Disp:1 unit Refills:2 8. Atenolol 50 mg Tablet Sig: 1 and [1-12] Tablet PO once a day. Disp:60 Tablet(s) Refills:2 Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:30 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 6. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: Thirty (30) units Subcutaneous qAM. Disp:1 vial Refills:2 7. Nitroglycerin 0.4 mg/SPRAY Spray, Non-Aerosol Sig: [1-12] sprays Translingual PRN as needed for chest pain. Disp:1 unit Refills:2 8. Atenolol 50 mg Tablet Sig: 1 and [1-12] Tablet PO once a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 5276] Discharge Diagnosis: Coronary Artery Disease (Diffuse 3 Vessel) Non ST elevation Myocardial Infarction Choledocholithaisis Discharge Condition: stable, afebrile, ambulatory, chest pain free, abdominal pain free Discharge Instructions: -please take all your medications as directed -please follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]([Hospital1 ] Cardiology)in [2-13] weeks -please follow up with your PCP [Last Name (NamePattern4) ] 1 month -if you should have any more chest pain, please take your medications and phone your primary care provider immediately [Name9 (PRE) 11227] administer your insulin as directed by a physician [Name10 (NameIs) 11227] resume taking medication called Plavix on [2166-10-27] Followup Instructions: Cardiology: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], ([Telephone/Fax (1) 3379] in [2-13] weeks Gastroenterology: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11228], ([Telephone/Fax (1) 11229],, only if you have problems [Name10 (NameIs) 11230] call PCP regarding making an appointment [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3518] MD [MD Number(1) 3519] Completed by:[2166-10-23]	[ "V45.01", "285.9", "414.01", "V58.67", "410.71", "574.91", "428.0", "250.40", "331.0", "585.9", "V15.82", "372.30", "403.91", "294.10", "427.81", "412", "272.0" ]	icd9cm	[ [ [] ] ]	[ "88.56", "51.88", "37.22", "51.85" ]	icd9pcs	[ [ [] ] ]	16919, 16970	7891, 11485	281, 354	17116, 17185	2031, 2998	17773, 18288	1643, 1686		15902, 16896		16991, 17095		14885, 15879		5073, 7868	17209, 17750										1701, 2012														4089, 5056												3031, 4070		224, 243											382, 1411																1427, 1627
43,738	149,453	22437+57300	Discharge summary	report+addendum	Admission Date: [2199-6-7] Discharge Date: [2199-6-27] Date of Birth: [2126-6-28] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 78] Chief Complaint: s/p fall SDH, tSAH Major Surgical or Invasive Procedure: Tracheostomy [2199-6-24] PEG [2199-6-24] History of Present Illness: This is a 72 year old woman on plavix for CAD who tripped and fell on the concrete striking her head. She was taken to OSH where CT head showed L SDH and bilateral SAH. She was transferred to [Hospital1 18] for further evaluation. She is known to service for previous VPS revision in [2196]. Past Medical History: * Hypertension * Alzheimer Dementia * Urinary Urgency * Hydrocephalus s/p VP shunt placement ([2168]) * CAD s/p angioplasty (PTCA) ([2191]) * Type 2 Diabetes * Dyslipidemia PSHx: * Cholecystectomy ([2157]) * Varicose Vein stripping ([2163]/[2165]) * Benign brain tumor excision ([2168]) * Hydrocephalus s/p VP shunt ([2168]) * Hiatal hernia repair ([2180]) * Hysterectomy ([2180]) * Angioplasty ([2191]) * Left knee replacement ([2196-4-10]) Social History: Social Hx: Married, resides at home with husband. Functional baseline is ambulation with walker and taking own medications. Tobacco, Alcohol, Drugs unknown. Family History: Family Hx: Non-contributory Physical Exam: On admission: PHYSICAL EXAM: BP: 164/87 HR: 88 R 16 O2Sats 94 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [4-12] EOMs Full Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person and year. Language: Speech garbled Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,3 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. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [6-15] throughout. No pronator drift Sensation: Intact to light touch At Discharge: EO spont, follows simple commands bil R>L, answers some yes/no questions with head shaking Pertinent Results: [2199-6-7] Head CT: IMPRESSION: 1. Bilateral subarachnoid hemorrhages. 2. Small left subdural hematoma without significant mass effect. 3. Possible intraparenchymal hemorrhage in the right temporal lobe, although it may be contiguous with the subarachnoid hemorrhage. 4. VP shunt in unchanged position without evidence of hydrocephalus. The ventricles are unchanged in size and configuration. 5. Right occipital subgaleal hematoma. 6. Sinus disease, some of which may be acute, as there is an air-fluid level in the left sphenoid sinus. [2199-6-7] CT Cspine: IMPRESSION: 1. No acute fracture or traumatic malalignment of the cervical spine. 2. 1.7 x 1.0 cm right thyroid nodule, correlate with any history of abnormal thyroid dysfunction or ultrasound. 3. Right supraclavicular soft tissue contusion, not fully imaged. [2199-6-7] Left Hand Xray: IMPRESSION: No acute fracture. Moderate osteoarthritis. [2199-6-8] Head CT: Stable head CT [2199-6-8] R clavicle Xray: Two portable views of the right clavicle are submitted. These confirm the presence of a comminuted distal clavicular fracture with approximately 1.5 to 2 cm of foreshortening. The acromioclavicular joint remains intact. [6-9] EEG This is an abnormal continuous ICU monitoring study because of a diffuse encephalopathy alternating with paroxysmal generalized potential epileptic activity. Many at the end of the record were several brief runs of rhythmic activity in the left central temporal region that may represent brief electrographic seizures without a clear clinical accompaniment. [6-9] CT Head 1. Unchanged bihemispheric subarachnoid hemorrhage. 2. Stable left-sided subdural hematoma without significant mass effect. 3. Ventriculostomy in unchanged position without hydrocephalus. [6-9] CXR As compared to the previous radiograph, the monitoring and support devices are unchanged. There is minimally improved ventilation of the previously opacified left lung apices. However, a large, predominantly atelectatic consolidation at the left lung base persists. There is unchanged leftward shift of the mediastinum and the heart [6-9] CXR As compared to the previous radiograph, the monitoring and support devices are unchanged. There is minimally improved ventilation of the previously opacified left lung apices. However, a large, predominantly atelectatic consolidation at the left lung base persists. There is unchanged leftward shift of the mediastinum and the heart. The right lung appears normal and unchanged. No evidence of right-sided pneumonia. [2199-6-10] EEG This is an abnormal continuous ICU monitoring study because of disorganized slow background and frequent generalized sharp discharges indicative of mild to moderate diffuse encephalopathy. At times, sharp discharges appeared to be predominantly over the left hemisphere and there were bursts of rhythmic activity in the left central temporal region indicative of a focal area of epileptogenic potential. There were no sustained electrographic seizures [2199-6-10] CXR Improved left lower lobe aeration, with small residual effusion. [2199-6-11] EEG This is an abnormal continuous ICU monitoring study because of disorganized slow background and frequent generalized sharp discharges indicative of mild to moderate diffuse encephalopathy. At times, sharp discharges appeared to be predominantly over the left hemisphere and there were bursts of rhythmic activity in the left central temporal region indicative of a focal area of epileptogenic potential. There were no sustained electrographic seizures. [2199-6-11] EKG Atrial fibrillation with rapid ventricular response. Occasional ventricular premature beats. Compared to the previous tracing of [2199-6-9] atrial fibrillation is new [2199-6-11] CT head 1. Unchanged extent of bilateral subarachnoid hemorrhage with evidence of redistribution. 2. Stable left-sided subdural hematoma extending along the falx cerebri, tentorium and left hemispheric convexity without significant mass effect. 3. Stable small hemorrhagic contusion of the right temporal lobe. [2199-6-11] CXR As compared to the previous radiograph, there is unchanged evidence of mild fluid overload. An atelectasis at the left lung base has increased in extent, there is now blunting of the left costophrenic sinus, potentially caused by a minimal left pleural effusion. Endotracheal tube, nasogastric tube, and left subclavian central venous catheter are unchanged in course and position [2199-6-12] EEG This is an abnormal continuous ICU monitoring study because of a moderately severe to severe diffuse encephalopathy. Superimposed upon this is asymmetric delta broadly present over the left hemisphere and, at times, similar delta frequency noted over the right hemisphere. The left, however, predominates. There were no seizures and no clear interictal spike or spike wave discharges. [2199-6-13] EEG This is an abnormal continuous ICU monitoring study because of a diffuse encephalopathy of moderate to moderately severe quality. There were no clear electrographic seizures. There were no clear interictal discharges. Compared to the prior day's recording, there were no significant changes. [2199-6-13] CXR Stable, essential change from prior radiograph, although there may be minimal worsening of fluid overload and effusions in the lung bases. Certainly when compared to the radiographs dated [2199-6-12] at 05:35, there is significant improvement in the left lung [2199-6-14] CXR Left lower lobe collapse is persistent. There is increased opacity in the left perihilar region, worrisome for aspiration. Bilateral pleural effusions, larger on the right side, are stable. Mild vascular congestion is stable. The cardiomediastinum is still shifted towards the left side. There is no evident pneumothorax. ET tube is in standard position. NG tube tip is in the stomach. Right IJ catheter tip can be followed to the SVC, but the tip is not clearly visualized. [2199-6-15] EEG This is an abnormal continuous ICU monitoring study because of moderately severe diffuse encephalopathy. There are paroxysmal triphasic waves also seen suggesting that the encephalopathy is slightly more slightly severe than on the previous tracing. There were no electrographic seizures nor were there any clinical events that would suggest ongoing seizure activity. Some of the paroxysmal sharp transients may have an epileptic origin but most appeared encephalopathic. [2199-6-16] EEG This is an abnormal continuous ICU monitoring study because of a moderately severe diffuse encephalopathy. There were paroxysmal triphasic waves that appeared similar to the previous today's recording. There were no clear electrographic seizures nor were there any clear electrographic markers for interictal epileptic activity. Compared to the prior day's recording, there was little to no significant change. [2199-6-16] ECG Sinus rhythm. Non-specific T wave changes in leads III and aVF. Compared to the previous tracing of [2199-6-11] rapid atrial fibrillation has been replaced with sinus rhythm. Premature ventricular contractions are absent. [2199-6-16] CXR As compared to the previous radiograph, there is little change in comparison to the prior study. Bilateral pleural effusions. Adjacent atelectasis. Continued enlargement of the pulmonary vessels, consistent with mild-to-moderate fluid overload. The monitoring and support devices are constant. [2199-6-17] EEG This is an abnormal continuous ICU monitoring study because of a mild to moderate diffuse encephalopathy. There were paroxysmal triphasic waves that appeared similar to the previous today's recording. There were two patient events suspicious for seizure activity as seen on video but there were no clear electrographic seizures. There were no clear electrographic markers for interictal epileptic activity. Compared to the prior day's recording, there was slight improvement in encephalopathy. [2199-6-17] Bil UE US No evidence of DVT in either right or left upper extremity. [2199-6-17] CXR As compared to the previous radiograph, there is a slightly different distribution of the extensive bilateral pleural effusions with accompanying atelectasis. Additional evidence of left-sided volume loss. The nasogastric tube and the chest tube are in unchanged position. After bronchoscopy there is no evidence of pneumothorax. The study and the report were reviewed by the staff radiologist. [2199-6-18] EEG This is an abnormal continuous ICU monitoring study because of a mild to moderate diffuse encephalopathy. There were no clear electrographic markers for interictal epileptic activity and no seizures. Compared to the prior day's recording, there was no significant change [2199-6-18] CXR As compared to the previous radiograph, there is minimally improved ventilation of the left lung. No evidence of pneumothorax is present. Bilateral extensive pleural effusions persist, as do the areas of atelectasis at the lung bases. The monitoring and support devices are constant. [2199-6-19] CXR Cardiomegaly is stable. Bilateral pleural effusions are less conspicuous than before, larger on the left. Bibasilar atelectasis noted on the left side has minimally improved more so on the right. There is mild vascular congestion. Lines and tubes are in unchanged and standard position. There are no new lung abnormalities. [2199-6-20] CXR The ET tube tip is 3.5 cm above the carina. The NG tube tip is in the stomach. Heart size and mediastinum appears to be unchanged including mild cardiomegaly and potentially prominence of the main pulmonary artery, consistent with pulmonary hypertension. Diffuse interstitial opacities in the lungs most likely reflect mild interstitial pulmonary edema. [2199-6-20] CT TORSO 1. Post-surgical changes at the hiatus, compatible with fundoplication. 2. Small bilateral pleural effusions, partially loculated on the left, with adjacent compressive atelectasis. 3. Heterogeneously enhancing left renal lesion, probably an angiomyolipoma, but further evaluation with non-urgent MRI is recommended [2199-6-24] Portable Abdomen X-ray A gastrostomy tube projects over the left upper quadrant; exact placement is indeterminate on this study. The bowel is insufflated with air without evidence for obstruction. [2199-6-24] CXR In comparison with the study of [6-24], there is little interval change. Again there is enlargement of the cardiac silhouette with pulmonary vascular congestion and poor definition of the hemidiaphragms consistent with small effusions and basilar atelectasis. Retrocardiac volume loss is again seen. Tracheostomy tube remains in position. Lung volumes remain relatively low [2199-6-25] CXR: FINDINGS: In comparison with the study of [6-24], there is little interval change. Again there is enlargement of the cardiac silhouette with pulmonary vascular congestion and poor definition of the hemidiaphragms consistent with small effusions and basilar atelectasis. Retrocardiac volume loss is again seen. [2199-6-26] CT Head: 8mm left parietal hygroma, final read pending at time of discharge but imaging reviewed with neurosurgical attending Brief Hospital Course: This ia a 72F admitted to Neurosurgery for monitoring. On [6-7] eve she c/o R shoulder and chest pain, a shoulder xray was negative but suggested a clavicle fracture. A xray confirmed a right clavicle fracture and Ortho was consulted and no surgical intervention was required. A sling was ordered. A repeat head CT was stable. On [6-8] she was oriented x 2, and following simple commands. Her speech was mumbled and she was moving all of her extremities. Overnight into [6-9] she had an episode of tachycardia with PVC's, she is on a betablcoker at home and had not been getting it secodnary to inability to take PO's. She was given Lopressor x 1 with good effect. On the morning of [6-9] she developed runs of ventricular tachycardia. Lopressor IV was again given, cardiology was consulted, labs were checked and potassium and phos were repleted. HSe had an EEG which showed active seizures, Keppra was given as was ativan and she was transferred to teh ICU. She had a NCHCT which was stable, her Keppra was increased, and Dilantin was started in addition per consult from neruology. She had another episode of VTach to teh 190's and recieved Lopressor 5mg IV x 3, ativan x 1, and amiodarone 300mg IVP. She was subsequently intubated, arterial and central lines were placed, and she had blood cultures, a bronchal lavage, and urine cultures sent. On 4.30 she was febrile to 101.3, cardiac enzymes continued to be trended, and her corrected dilantin level was 20.6. On the evening of [6-10] she went into SVT and on [6-11] into Afib and was started on an Amiodrone drip. A repeat head CT was unchanged from pervious. On [6-12], ID recommended changing zoysn to ceftriaxone. Her exam remains unchaged and 24 hr EEG was negative for seizure activity. On [6-13], The EEG which was consistent with an abnormal continuous ICU monitoring study because of a diffuse encephalopathy of moderate to moderately severe quality. There were no clear electrographic seizures. There were no clear interictal discharges. Compared to the prior day's recording, there were no significant changes. As there were no seizures and the test was stable the EEG was discontinued. Valproic acid was discontinued per neurology recommendations and the patient continued on dilantin and keppra. On exam, the patient was able to follow commands on right and localize on left. The patient withdrew to noxious stimulous in the lower extremities. The patient was febrile to 101.5 and sputum, blood, urine cultures were sent for culture. On [6-14], The patient was able to localize with upper extremities Right > Left. The patient continued to be febrile. A chest x ray wa performed which was consistent with increased opacity in the left perihilar region, worrisome for aspiration. Bilateral pleural effusions, larger on the right side, are stable. Mild vascular congestion is stable. On [6-15], The patient was changed to phosphenytoin from dilantin. The patient was noted to be more lethargic on exam and a EEG ordered to rule out seizures. The EEG was consistent with abnormal continuous ICU monitoring study because of moderately severe diffuse encephalopathy. There are paroxysmal triphasic waves also seen suggesting that the encephalopathy is slightly more slightly severe than on the previous tracing. There were no electrographic seizures nor were there any clinical events that would suggest ongoing seizure activity. Some of the paroxysmal sharp transients may have an epileptic origin but most appeared encephalopathic. The dilantin level corrected at 8.5 and phosphenytoin bolus of 500mg. On exam, the patient continued to be intubated. The pupils were equal and reactive. The patient opened eyes to loud voice and withdrew in the lower extremities and the left upper extremity to noxious stimulus. The patient localized with the right upper extremity. The patient did not follow commands. On [6-16], The patient's serum dilantin level was corrected at 10. Given the patients prior seizures that patient was given a phisphenytpin bolus of 500 mg IV x 1 in an attempt to obtain a therapeutic dilantin level of 15. An EEG continued and was consistent with abnormal continuous ICU monitoring study because of a moderately severe diffuse encephalopathy. There were paroxysmal triphasic waves that appeared similar to the previous today's recording. There were no clear electrographic seizures nor were there any clear electrographic markers for interictal epileptic activity. Compared to the prior day's recording, there was little to no significant change. The epilepsy service recommended that the patient continue the EEG for another day. On [6-17], The EEG was consistent with no seizures. Decision was made by the ICU team and neurology to continue the EEG so that the patient may be monitored as attemp is made at decreasing antileptic therapy. On exam, The patient was able to localize with the right upper extremity with delayed localization in the left upper extremity. The corrected dilantin level was 14 and fosphenytoin was discontinued. On [6-18] her exam was slightly improved in that she was intermittently following commands with her RUE and RLE. A Family meeting was held on [2199-6-19] and the husband opted to proceed with tracheostomy and PEG placement. EEG leads were discontinued. She continued to be on Keppra as her only AED [Doctor Last Name 360] and she was without sign of seizure activity. On [6-20], the patient was extubated. On [6-21], the patient was neurologically stable. The patient continues to be extubated and was on a 100% face tent. The Chest X ray was consistent with a , but with partially collapsed lung. There was question of focal sz noted by neurology resident and keppra was increased 1250bid. On [6-22], The patient was reintubated for a left lung collapse. On [6-24], The patient underwent a bedside trach/peg. A consult was placed for PT/OT. The patient was following commands in all four extremities. Her eyes were open spontaneously. She was being screened for rehab. She was diuresed for respiratory purposes with Lasix. On [6-25] tube feeds were started and adanced towards goal, she was OOB to chair and worked with PT. On [6-26] She had a head CT which showed an 8mm left parietal hygroma. She received a bed offer from a vented rehab, was on trach mask, and discharged to rehab with instructions for followup TRANSTIONAL CARE ISSUES: Heterogeneously enhancing left renal lesion, probably an angiomyolipoma noted on our imaging, so patient will need a non-urgent MRI for further evaluation. Medications on Admission: atenolol 50 daily, plavix 75 daily, restasis 1 drop both eyes daily, aricept 10mg daily, neurontin 300 daily, isosorbide 30mg daily, xalatan 1 drop each eye, nitrofurantoin 50mg qhs, protonix 40 daily, pravastatin 10 daily, detrol 4mg daily, derrous sulfate 27mg daily, MVI daily Discharge Medications: 1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 9. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 10. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 13. isosorbide mononitrate 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 14. therapeutic multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 15. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze/rhonchi. 18. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 19. insulin regular human 100 unit/mL Solution Sig: per sliding scale Injection per sliding scale. 20. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous QHS. 21. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [2-11] IH Inhalation Q6H (every 6 hours) as needed for SOB. 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. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 24. Pantoprazole 40 mg IV Q24H 25. 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. 26. Lorazepam 0.5-2 mg IV Q2H:PRN seizures hold rr < 12 27. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 28. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 29. HydrALAzine 10-20 mg IV Q4H:PRN sbp>160 [Month (only) 116] repeat x1 at 15 minutes after first dose if no response 30. 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. 31. LeVETiracetam 1250 mg IV BID Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Left frontal subdural hematoma Bifrontal traumatic subarachnoid hemorrhage Right clavicle fracture Respiratory Failure Seizures UTI Ventricular Tachycardia Pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? You were on Plavix (clopidogrel) prior to your injury, you decision on safely restarting this will be made at your post-operative follow-up visit. ?????? You have been prescribed Keppra (Levetiracetam), you will not require blood work monitoring. Followup Instructions: Please follow-up with Dr [First Name (STitle) ] in 4 weeks with a head CT w/o contrast. Please call [Telephone/Fax (1) 4296] to make this appointment. You will also need to follow up with Orthopedics for your right clavicle fracture: Please call Dr. [Last Name (STitle) 7376] at ([Telephone/Fax (1) 2007] to schedule this appointment. You will need an MRI of the Kidneys due to the finding of a cyst on your inpatient imaging. This can be arranged with your PCP in about 2-3 months. Completed by:[2199-6-26] Name: [Known lastname 10801],[Known firstname ] Unit No: [Numeric Identifier 10802] Admission Date: [2199-6-7] Discharge Date: [2199-6-27] Date of Birth: [2126-6-28] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 40] Addendum: Discharge was delayed secondary to opthalmic evaluation. No acute treatment was determined. Thus, on [6-27] patient was again stable for discharge. Discharge Disposition: Extended Care Facility: [Hospital6 2876] - [Location (un) 3542] [Name6 (MD) ] [Last Name (NamePattern4) 43] MD [MD Number(2) 44] Completed by:[2199-6-27]	[ "810.03", "V45.82", "V12.41", "331.0", "788.63", "427.0", "263.9", "348.30", "427.31", "401.9", "512.1", "250.00", "593.9", "518.51", "427.1", "E879.9", "852.01", "V43.65", "272.4", "285.9", "112.2", "345.3", "294.10", "V45.2", "041.11", "E879.8", "276.3", "041.09", "997.31", "E880.9" ]	icd9cm	[ [ [] ] ]	[ "33.24", "31.1", "43.11", "96.6", "96.72" ]	icd9pcs	[ [ [] ] ]	25975, 26184	13793, 20437	324, 375	23910, 23910	2466, 2481	24888, 25952	1406, 1435		20768, 23603		23721, 23889		20463, 20745			24087, 24865										1480, 1603																2355, 2447												266, 286											403, 705	1757, 2341	13649, 13770		3408, 13640						1464, 1464		23925, 24063			727, 1215	1231, 1390
8,581	150,894	45376	Discharge summary	report	Admission Date: [2139-5-26] Discharge Date: [2139-6-17] Date of Birth: [2062-12-27] Sex: M Service: NEUROSURGE HISTORY OF PRESENT ILLNESS: This is a 75 year old man who presents with a complex medical history including paranoia, olfactory groove meningioma and coronary artery disease. He underwent four-vessel coronary artery bypass grafting on [2138-9-5]. This was complicated by a postoperative deep venous thrombosis and hematuria. The patient was quite confused from his large meningioma. He was felt to be stable from a medical standpoint. He is now admitted for resection of his olfactory groove meningioma. PAST MEDICAL HISTORY: 1. Meningioma. 2. Paranoid schizophrenia. 3. Benign prostatic hypertrophy. 4. Peripheral neuropathy. 5. Coronary artery bypass grafting times four. 6. Nephrolithiasis. 7. Methicillin resistant Staphylococcus aureus urinary tract infection which was treated [2138-8-28]. 8. Hypertension. 9. Hypercholesterolemia. 10. Herpes zoster. 11. Status post subtotal gastrectomy. 12. History of bleeding peptic ulcer. 13. Spinal stenosis. 14. Peripheral neuropathy. ALLERGIES: He reportedly has an allergy to sulfa and is sensitive to Norvasc. SOCIAL HISTORY: The patient has been living at Star of [Doctor Last Name ]. He denies ethanol, tobacco or intravenous drug use. He was born and raised in [Location (un) 86]. His mother is 102. [Name2 (NI) ] is divorced with three children. He has a daughter with Down's Syndrome. He originally came to medical attention in [2138-2-20], when the patient's landlord called the police because of his inability to maintain his apartment. He is a graduate of [University/College ] and the [Doctor Last Name ] Business School. His son [Name (NI) ], has guardianship. PAST PSYCHIATRIC HISTORY: The patient has a long-standing, greater than 30 year history, of unchecked paranoia without treatment. He had one hospitalization in [2105]. MEDICATIONS: 1. Dilantin. 2. Decadron. 3. Ranitidine. 4. Metoprolol. 5. Milk of Magnesia. 6. Heparin. 7. Colace. 8. Lisinopril. PHYSICAL EXAMINATION: On physical examination, the patient is awake, alert and agitated. He is confused. He is oriented times one. He has no sense of taste or smell. His cranial nerves are otherwise intact. He has no drift. He is clumsy with both his arms and legs. His speech is fluent. He is moving all four extremities spontaneously. HOSPITAL COURSE: The patient was taken to the Operating Room on [2139-5-26]. At that time, he underwent bifrontal craniotomy for resection of a large olfactory groove meningioma. This had eroded into the skull base at the Crista galli. Immediately postoperatively, the patient was awake and alert but agitated. He was moving all four extremities. He was complaining of a headache. Over the first 72 hours, the patient's mental status gradually deteriorated. A CT scan of the head was obtained. This showed no hydrocephalus. There were two small areas of hemorrhage in the frontal lobes at the site of the tumor resection. There was extensive swelling throughout both frontal lobes. It was felt that this swelling was the likely cause of his somnolence. For that reason, he was started on Decadron. Cultures of cerebrospinal fluid and blood were also done; these were negative. Over the course of the next 48 hours, the patient's mental status gradually improved. He was noted to have some drainage from his right nostril; this was postural. This likely was through the area where the tumor had eroded through the skull base, therefore, a lumbar drain was placed on [2139-6-5]. This was left in place for one week. Following this, the patient's wound remained completely flat. He had no further drainage from his wound. Cultures of the spinal fluid remained negative. The patient was quite agitated and was requiring sitters in his room. His agitation gradually cleared. He had to be restrained but was quite comfortable in a chair. He was able to void when his Foley catheter was removed. His Decadron was tapered from 4 mg q. six hours to 1 mg twice a day. This remaining Decadron should be tapered over ten weeks' time. His staples were removed. His wound remained clean and dry. FINAL DISCHARGE DIAGNOSES: 1. Olfactory groove meningioma. 2. Paranoid schizophrenia. 3. Benign prostatic hypertrophy. 4. Peripheral neuropathy. 5. Cerebrospinal fluid. 6. Rhinorrhea. 7. Coronary artery disease. 8. Nephrolithiasis. 9. Hypertension. 10. Hypercholesterolemia. 11. Herpes zoster. 12. Peptic ulcer disease. 13. Spinal stenosis. 14. Peripheral neuropathy. DISCHARGE INSTRUCTIONS: 1. The patient is being transferred for inpatient rehabilitation. 2. He continues to need intermittent sedation. 3. His oral intake has improved dramatically over the last three to four days. 4. The patient will be seen in follow-up in two weeks' time. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3653], M.D. [MD Number(1) 3654] Dictated By:[Last Name (NamePattern4) 3655] MEDQUIST36 D: [2139-6-17] 09:36 T: [2139-6-17] 09:51 JOB#: [Job Number 26379]	[ "225.2", "401.9", "272.0", "295.30", "600.0", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "03.09", "01.59" ]	icd9pcs	[ [ [] ] ]														2505, 4304		4706, 5242																									2164, 2487																						4331, 4682		173, 659															681, 1231	1248, 2141
28,820	116,384	10422	Discharge summary	report	Admission Date: [2201-4-14] Discharge Date: [2201-4-20] Date of Birth: [2120-10-14] Sex: M Service: MEDICINE Allergies: Alprazolam / Hydrochlorothiazide / Sulfonamides / Iodine / Clindamycin / Amoxicillin / Doxycycline / Cefaclor / Erythromycin Base / Amiodarone / Levofloxacin Attending:[Doctor First Name 1402] Chief Complaint: Shortness of breath, ICD firing Major Surgical or Invasive Procedure: ICD battery replacement History of Present Illness: This is a 80 year old patient with a history of nonischemic cardiomyopathy and cardiac arrest w/AICD placement [2194], DM2 and [Hospital ] transferred from OSH with AICD firing found to be in VT. OSH course: He presented to the OSH on [4-12] w/SOB which was thought to be due to CHF and possible respiratory infection. He was started on levofloxacin and received furosemide(which he tolerated). His sx improved on HD2, but then had episode of rapid VT and AICD firing where pt was shocked 9 times. This was terminated w/300mg IV amiodarone bolus. He then went into V-paced rhythm w/underlying LBBB pattern. He did not have any hypotension during this episode, but did desat transiently requiring NRB. CEs were cycled and negative x 2, bnp 242. He was seen by the cardiology service who recommended no further diuresis with lasix because of concern for potassium depletion being the inciting cause of prior VT arrest in [2194]. Also, Amio was started initially but held b/c thought to have had increased pt's QTc in the past. . Estimated he had approx 34 shocks of AICD. Device interrogated by Dr. [Last Name (STitle) ] which showed battery needs replacement. He was overdrive paced at 95 w improvement in QTc. He was then transferred to [Hospital1 18]. . He was admitted to cardiology with EP service following. On [2201-4-15] he had temporary transvenous pacing and replacement of AICD generator. He returned to the floor in stable confusion, but did have one episode of confusion. . On AM of [2201-4-16], pt had repeat episode of VT with AICD firing. Rhythm was terminated w/lidocaine 20mg and he was started on a lidocaine gtt. Past Medical History: 1. As child, question big heart according to the father. 2. Hypertension. 3. Noninsulin dependent diabetes mellitus . 3. Hiatal hernia. 4. History of left bundle branch block. 5. Status post cardiac arrest [2194] with ICD placement at that time. 6. Status post right epididymectomy in [2163] and right inguinal hernia surgery in [2163]. 8. [2194-3-31] echocardiogram with mild left atrial dilatation, mild dilated left ventricular cavity, moderate to severe left ventricular systolic dysfunction, delayed relaxation for c/w left ventricular infiltrate, transaortic regurgitation. 9. CAD: On [2194-3-31], catheterization showed no significant coronary artery disease with hypokinesis of the anterior basal, anterolateral, apical, inferior posterior basal walls with ejection fraction of 25% to 30% and elevated LVEDP at 22. 10. VT/torsades in [2194] in setting of prolonged QTc (approx 70 shocks at that time) Social History: Married. Tobb 36yrs ago. 1 dtr. no etoh. R and D engineer, now retired. Can walk 1 block. Family History: no early CAD Physical Exam: VS: T BP 132/76 HR 95 136 kg 100% AC PEEP 5 TV 700 Gen: intubated, sedated, NAD HEENT: MMM unable to assess, lying flat Cards: RRR nl S1S2 no MGR, PMI displaced laterally Resp: Coarse bilat. no wheezes Abd: BS+ NTND soft, no HSM Back: No CVA tenderness Ext: 2+ DP, PT bilat, no edema Neuro: moving all 4 extremities Skin: no rash Pertinent Results: [2201-4-14] 09:15PM BLOOD WBC-9.1 RBC-4.39* Hgb-13.8* Hct-38.9* MCV-89 MCH-31.4 MCHC-35.5* RDW-13.8 Plt Ct-167 [2201-4-17] 04:48AM BLOOD PT-15.6* PTT-27.7 INR(PT)-1.4* [2201-4-14] 09:15PM BLOOD Glucose-180* UreaN-27* Creat-1.1 Na-138 K-4.8 Cl-100 HCO3-30 AnGap-13 [2201-4-14] 09:15PM BLOOD CK(CPK)-538* [2201-4-16] 10:02AM BLOOD CK(CPK)-284* [2201-4-14] 09:15PM BLOOD CK-MB-5 cTropnT-<0.01 [2201-4-16] 10:02AM BLOOD CK-MB-4 cTropnT-<0.01 [2201-4-14] 09:15PM BLOOD Calcium-9.2 Phos-2.7 Mg-2.5 CXR: 1. More pronounced tortuosity and probable dilatation of the aorta. 2. Bibasilar opacities which might be consistent with aspiration/pneumonia, please correlate clinically. 3. Pacemaker defibrillator lead terminates in right ventricle. TTE: There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 30-40 %) with regional variation; there is relative preservation of contractile function at the base of the left ventricle. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified). There is no pericardial effusion. The right ventricle was not well seen. Compared with the findings of the prior report (images unavailable for review) of [2194-3-31], left ventricular function remains at least moderately reduced. Brief Hospital Course: Mr. [Known lastname 6930] was admitted with VT storm and ICD firing an estimated 30 times. He was noted to be in a paced rhythm upon admission with notable QTc prolongation on EKG. It is likely that his initial VT event was due to recent quinolone-induced QTc prolongation. He was recently treated for pneumonia diagnosed by his PCP. [Name10 (NameIs) ] patient's QTc improved though continued at a top normal range of 450. He underwent uncomplicated ICD generator change on hospital day 2. While going for echocardiogram on hospital day 3 the patient's ICD began firing again. He was found to be in VT storm. He received an estimated 15 shocks from his ICD. Code blue was called. The patient was treated with lidocaine bolus (200mg) then drip and magnesium bolus of 2g. He successfully converted back to paced rhythm however due to mental status changes he was intubated and transferred to the ICU. The patient had an uneventful ICU course. He was rapidly extubated approximately 24 hours later and had no further VT. Echocardiogram revealed significant AS (not quantified) and EF 30-40% with regional variation. The images were of poor quality. He was transitioned to PO mexilitine and was titrated up on beta blocker and calcium channel blocker. His home spironolactone dose was also increased. His home ACEi was discontinued. The patient's home glipizide was discontinued as this can cause QT prolongation. The patient's rhythm was not felt to be amenable for induction/ablation. . The patient will follow-up with Dr. [Last Name (STitle) ] from EP on [2201-4-28] for further management of his rhtyhm issue. He will continue on 150mg toprol-xl, mexilitine 200mg Q8H, 120mg verapamil long acting. He should likely under repeat echo at a time more distant from recent defibrillations. He was also transitioned from glipizide to metformin at discharge. Metformin was chosen, because it is a non-QT prolongating [Doctor Last Name 360]. Metformin is still a less than ideal choice, because if patient has an arrest risk of increased acidosis. He will address further management of diabetes with Dr. [Last Name (STitle) 34488] on [4-23]. All medications should be reviewed w/ PCP with the specific focus on choosing non-QT prolonging agents. . Patient was told that legally he is not allowed to drive or operate heavy machinery given his history of VT. . On the day prior to discharge the patient had a routine portable chest x-ray which raised concern for worsening double contour of the aorta. Non-contrast CT revealed this abnormality to be mediastinal fat captured at changing angles due to patient positioning. Radiology recommended no further evaluation including no need for contrast CT to further evaluate the aorta. Medications on Admission: VS: T BP 132/76 HR 95 136 kg 100% AC PEEP 5 TV 700 Gen: intubated, sedated, NAD HEENT: MMM unable to assess, lying flat Cards: RRR nl S1S2 no MGR, PMI displaced laterally Resp: Coarse bilat. no wheezes Abd: BS+ NTND soft, no HSM Back: No CVA tenderness Ext: 2+ DP, PT bilat, no edema Neuro: moving all 4 extremities Skin: no rash Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:45 Tablet Sustained Release 24 hr(s) Refills:2 7. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:90 Capsule(s) Refills:2 8. Verapamil 120 mg Cap,24 hr Sust Release Pellets Sig: One (1) Cap,24 hr Sust Release Pellets PO once a day. Disp:30 Cap,24 hr Sust Release Pellets(s) Refills:2 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 10. Prescription You are not legally allowed to drive given your history of ventricular tachycardia Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis 1.Ventricular tachycardia 2.ICD change 3.Intubation . Secondary Diagnosis 1.Hypertension 2.DM type 2 3.s/p cardiac arrest [2194] w/ ICD placement at that time 4.Hx of Right inguinal hernia repair in [2163]. Discharge Condition: Stable Discharge Instructions: You were admitted with an unsafe heart rhythm and firing of your implanted defibrillator. Your recent antibiotic (levofloxacin) may have caused this though you are still at risk for further recurrence. You were started on 2 new medications - Verapamil and Mexilitine - to try to prevent recurrence. You should have a repeat echocardiogram in the future. Please discuss this further with your outpatient cardiologist. . Please weigh yourself daily and limit your salt intake to less than 2gm per day. Please notify your cardiologist if you gain more than 3lbs per day. . Please eat a bannana daily or other fruits high in potassium. . Discuss management of your blood sugars with metformin (instead of glipizide) with your primary care doctor. Glipizide was discontinued due to the risk that this medication can cause arrhythmia. It is our recommendation that your endocrinologist consider starting you on insulin, as another cardiac arrest while on metformin can lead to worsening acidosis than otherwise expected. . Take all medications as prescribed. New medications include verapamil sustained release 120mg daily, mexilitine 200mg three times a day and metformin 500mg twice daily. Please take toprol XL 150mg daily and discontinue metoprolol 75mg three times daily that you were taking prior to admission. Increase your home spironolactone to 50mg daily. . Discontinue your home glipizide as this can sometimes cause arrhythmias. Instead take metformin for blood sugar control. Also discontinue your home quinapril that you were taking prior to admission. . Keep all of your followup appointments as listed below. . You had a change in your ICD during this hospital stay. . Please do not shower for the next week, you can change the gauze, around the ICD site, but do not change the steri strips. If you notice, redness or swelling around the site please go to the emergency room or call Dr.[Name (NI) 1565] office [Telephone/Fax (1) 285]. . Your diagnosis of Ventricular Tachycardia legally prevents you from driving or operating heavy machinery. . Call 911 or return to the hospital for any firing of your implanted defibrillator, chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: You are sceduled for electophysiology follow up with Dr. [Last Name (STitle) ] on [2205-4-28]:20 on the [Location (un) 436] of the [Hospital Ward Name 23] building [Hospital Ward Name ] of [Hospital1 18]. If you have to change this appointment please call [Telephone/Fax (1) 285] . You should also be seen by your cardiologist or primary care physician [Name Initial (PRE) 176] 1 week. Follow-up in the device clinic as scheduled. Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2201-4-24] 11:30 . Please follow up with your endocrinologist Dr. [Last Name (STitle) 34488] at [Street Address(2) 34489], [Location (un) 24356] Ma. Ph# [Telephone/Fax (1) 3183]. You are scheduled for a follow up appointment on [4-23] at 1145am. . You are scheduled for a follow up with your primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on 3:15 pm on [2201-4-21]. Office location is 15 Rocat way, [Apartment Address(1) ], [Location ], MA. If you have to change this appointment Dr.[Name (NI) 33490] office number is [Telephone/Fax (1) 8725].	[ "427.1", "E879.8", "E849.7", "427.5", "401.9", "E939.4", "E849.8", "518.81", "250.00", "507.0", "996.04", "426.0", "425.4", "458.29" ]	icd9cm	[ [ [] ] ]	[ "96.07", "37.98", "38.93", "99.60", "88.72", "96.04", "96.71", "37.78" ]	icd9pcs	[ [ [] ] ]	9362, 9368	5068, 7818	452, 477	9645, 9654	3634, 5045	11915, 13133	3253, 3268		8199, 9339		9389, 9624		7844, 8176			9678, 11892										3283, 3615																												381, 414											505, 2172															2194, 3129	3145, 3237
79,921	122,193	38720	Discharge summary	report	Admission Date: [2141-2-6] Discharge Date: [2141-2-15] Date of Birth: [2058-10-8] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2141-2-9] Aortic valve replacement with a size 19 [Last Name (un) 3843]-[Doctor Last Name ] Magna tissue valve. [2141-2-14] Generator change on permanent pacemaker History of Present Illness: 82 year old female with known aortic stenosis followed with serial echocardiograms. Seen originally in clinic 2 weeks ago, and she stopped coumadin for preoperative cardiac catheterization on [1-24], with catheterization done [2141-1-31]. Coumadin not restarted and she was admitted from intravenous heparin and preoperative workup, when she was found to be off her coumadin. Past Medical History: aortic stenosis Atrial fibrillation Hypertension hyperlipidemia hypothyroidism gout pacemaker Social History: lives with granddaughter retired quit smoking 50 yrs ago no ETOH Family History: non contributory Physical Exam: HR 90 BP 144/89 R 18 99% RA Weight 78.3 kg Height: 64 inches Gen: AAO x 3 in NAD, pleasant Skin: dry and intact. Well healed mid abdomen scar and B/L knee scars HEENT: PERRLA. Neck is supple. No JVD, Carotids 2+ Chest: lungs are clear bilaterally. CVS: Irregular with III/VI SEM best heard at LLSB. Abdomen: soft, nondistended, and nontender with positive bowel sounds. No masses Extremities are warm and well perfused. 2+ LE edema with chronic venous status changes Neurologically: Intact. No gross deficits Carotids: transmitted murmur B/L Pertinent Results: [2141-2-14] 06:00AM BLOOD WBC-5.7 RBC-3.00* Hgb-9.3* Hct-28.0* MCV-93 MCH-31.1 MCHC-33.4 RDW-14.6 Plt Ct-113* [2141-2-7] 12:50AM BLOOD WBC-5.2 RBC-3.80* Hgb-11.7* Hct-36.2 MCV-95 MCH-30.7 MCHC-32.2 RDW-14.5 Plt Ct-158 [2141-2-14] 06:00AM BLOOD Plt Ct-113* [2141-2-14] 06:00AM BLOOD PT-15.2* PTT-25.4 INR(PT)-1.3* [2141-2-14] 06:00AM BLOOD PT-15.2* PTT-25.4 INR(PT)-1.3* [2141-2-7] 12:50AM BLOOD Plt Ct-158 [2141-2-7] 12:50AM BLOOD PT-14.3* PTT-26.3 INR(PT)-1.2* [2141-2-7] 12:50AM BLOOD PT-14.3* PTT-26.3 INR(PT)-1.2* [2141-2-14] 06:00AM BLOOD Glucose-84 UreaN-22* Creat-0.9 Na-141 K-3.7 Cl-104 HCO3-28 AnGap-13 [2141-2-7] 12:50AM BLOOD Glucose-90 UreaN-20 Creat-1.0 Na-143 K-4.3 Cl-110* HCO3-23 AnGap-14 [2141-2-7] 12:50AM BLOOD ALT-55* AST-53* LD(LDH)-228 AlkPhos-85 Amylase-43 TotBili-0.6 [2141-2-7] 12:50AM BLOOD Lipase-25 [2141-2-14] 06:00AM BLOOD Mg-1.8 [2141-2-7] 12:50AM BLOOD Albumin-3.9 Calcium-9.1 Phos-2.9 Mg-1.9 [2141-2-7] 12:50AM BLOOD %HbA1c-5.6 eAG-114 [2141-2-11] 12:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Final Report INDICATION: 82-year-old female with aortic valve replacement on [2-9]. COMPARISON: [2141-2-11]. CHEST, PA AND LATERAL: Again noted are changes of prosthetic aortic valve replacement, with median sternotomy wires in alignment. A right chest wall pacemaker is seen with single lead overlying the right ventricle. Skin staples are present overlying the left chest. Minimal residual interstitial edema is present. There is slight increase in the small right effusion, and stable small left pleural effusion. There is persistent bibasilar atelectasis, without focal consolidation. The cardiac silhouette is stably enlarged, with resolving pneumopericardium. Again noted is osseous demineralization, with degenerative changes in the thoracic spine. The soft tissues are unremarkable. IMPRESSION: Resolving vascular congestion and pneumopericardium. Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% to 50% >= 55% Left Ventricle - Stroke Volume: 36 ml/beat Left Ventricle - Cardiac Output: 2.42 L/min Left Ventricle - Cardiac Index: 1.34 >= 2.0 L/min/M2 Aorta - Annulus: 2.0 cm <= 3.0 cm Aorta - Sinus Level: 2.3 cm <= 3.6 cm Aorta - Sinotubular Ridge: 1.9 cm <= 3.0 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Arch: 2.1 cm <= 3.0 cm Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm Aortic Valve - Peak Velocity: 3.8 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 60 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 35 mm Hg Aortic Valve - LVOT pk vel: 5.70 m/sec Aortic Valve - LVOT VTI: 14 Aortic Valve - LVOT diam: 1.8 cm Aortic Valve - Valve Area: 0.4 cm2 >= 3.0 cm2 Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Dilated LA. No thrombus/mass in the body of the LA. No spontaneous echo contrast is seen in the LAA. Good (>20 cm/s) LAA ejection velocity. 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. Normal LV cavity size. Mildly depressed LVEF. No LV mass/thrombus. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). Mild (1+) AR. MITRAL VALVE: Mild to moderate ([11-26]+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The rhythm appears to be atrial fibrillation. The patient is in a ventricularly paced the patient. Conclusions Prebypass: 1. The left atrium is dilated. No thrombus/mass is seen in the body of the left atrium. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). No masses or thrombi are seen in the left ventricle. 3. Right ventricular chamber size and free wall motion are normal. Pacing wire is located within the right ventricle. 4. There are simple atheroma in the ascending aorta. There are complex (>4mm) 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 severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. 6. Mild to moderate ([11-26]+) mitral regurgitation is seen. 7. There is a small pericardial effusion. 8. Dr. [Last Name (STitle) ] was notified in person of the results on [2141-2-9] at 1130am. Postbypass: The patient is A-V paced and on an infusion of phenylephrine post-bypass There a well seated bioprosthetic valve in the aortic position. There is no perivalvular or valvular aortic regurgitation. Biventricular function is preserved post-bypass. The aorta is intact post-decannulation. Findings were discussed in person with Dr. [Last Name (STitle) ]. Brief Hospital Course: She was admitted when found to be off her coumadin and placed on intravenoous heparin for anticoagulation. She underwent preoperative workup. On [2141-2-9] she was brought to the operating room and underwent aortic valve replacement. See operative report for further details. She received vancomycin for perioperative antibiotics because she was in the hospital preoperatively. Post operatively she was transferred to the intensive care unit for management. In the first twenty four hours she was weaned from sedation, awoke neurologically intact, and was extubated without complications. EP was consulted for postoperative pacer interrogation and found that the pacer required change, her epicardial wires remained and coumadin held for pacer change. Physical therapy worked with her on strength and mobility. On [2-14] she was taken for pacemaker generator change, see procedure note. Her coumadin was started for atrial fibrillation. She continued to do well and was ready for discharge to rehab on [2141-2-15]. Medications on Admission: Allopurinol 300 mg daily Amiodarone 200 mg daily Lipitor 20 mg daily Diltiazem CR 360 mg daily Synthroid Lisinopril 10 mg twice a day K-Dur 20 mEq twice a day Dyazide daily Coumadin for atrial fibrillation (last dose taken [2141-1-24]) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. Enteric Coated Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 7 days. 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q6H (every 6 hours) as needed for itching . 11. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): further daily dosing for coumadin per rehab provider. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] [Hospital 1108] Rehab Unit at [Hospital6 1109] - [Location (un) 1110] Discharge Diagnosis: Aortic stenosis s/p Aortic Valve Replacement Atrial Fibrillation Hypertension Hyperlipidemia Hyperthyroidism Gout Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Sternal pain managed with percocet prn Discharge Instructions: No showering and getting pacer insertion wet until after interrogation 1 week post device insertion, after that please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Due to pacemaker insertion no lifting .... elbow above shoulder for six weeks Chest staples to be removed 2 weeks from day of surgery- [2141-3-1]. Followup Instructions: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2141-3-20] 1:45 Please call to schedule appointments: PCP/Cardiologist Dr. [Last Name (STitle) 8051] in [11-26] weeks [Telephone/Fax (1) 35835] Device check f/u - 1 week with Dr [Last Name (STitle) 8051] please call to schedule Labs: PT/INR for coumadin dosing with goal INR 2.0-2.5 for atrial fibrillation, first draw Thursday [2-16] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2141-2-15*]	[ "782.1", "V53.31", "440.0", "401.9", "244.9", "V15.82", "413.9", "518.0", "427.31", "V58.61", "424.1", "458.29", "272.4", "274.9" ]	icd9cm	[ [ [] ] ]	[ "35.21", "39.61", "37.86" ]	icd9pcs	[ [ [] ] ]	9983, 10128	7660, 8699	339, 522	10286, 10385	1752, 7637	11273, 11857	1152, 1170		8991, 9960		10149, 10265		8725, 8968			10409, 11250										1185, 1733																												280, 301											550, 936															958, 1054	1070, 1136
19,620	105,517	49799+49800+59201	Discharge summary	report+report+addendum	Admission Date: [2163-4-28] Discharge Date: [2163-5-5] Date of Birth: [2120-9-25] Sex: F Service: [Doctor Last Name 1181] HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 104077] is a 41-year-old woman with diabetes mellitus Type 1, end stage renal disease, and multiple recent admissions for diabetic ketoacidosis as well as sepsis. The patient has a history of living related renal transplantation in [2150], which was complicated by chronic rejection, and is again on hemodialysis with a recent [2163-4-13] creation of a left arteriovenous fistula, brachial artery to basilic vein. The patient also had a right tunneled Perma-Cath placed, and had been doing well on hemodialysis, and had initially been on cyclosporin and Imuran, although the Imuran was recently discontinued. The patient was started on Rapamune, and cyclosporin was discontinued after some overlap. The patient, however, had ceased making urine the weekend prior to admission, and had been placed on a short course of prednisone for question of rejection. On [2163-4-26], the patient was noted to have drainage from the exit site of her right-sided Perma-Cath, however, the patient was afebrile at that time, with no rigors. Blood cultures were obtained, and the patient was given vancomycin as well as gentamicin. When blood cultures subsequently grew gram-positive cocci in clusters, resistant to oxacillin (i.e., methicillin resistant staphylococcus aureus), the patient was sent for admission, and Surgery was consulted. Prior to arriving on the Medical floor, the patient did have her Perma-Cath pulled out by Surgery, given the presence of bacteremia. PAST MEDICAL HISTORY: Diabetes mellitus Type 1 for 33 years, end stage renal disease secondary to diabetes mellitus, status post living related renal transplantation in [2150] complicated by chronic rejection, hypertension, negative ETT Thallium in [6-20], steroid-induced osteoporosis, hydradenitis suppurativa, recurrent urinary tract infections, eating disorder, neuropathy, personality disorder. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Rapamycin 2 mg by mouth once daily, Procrit 4000 per week, aspirin 325 by mouth once daily, Lantus 10 units daily at bedtime, sliding scale insulin, Lopressor 50 mg by mouth twice a day, lasix 80 mg by mouth twice a day, Neurontin 100 mg by mouth twice a day, Urecholine 25 mg by mouth three times a day, Zocor 20 mg by mouth once daily. PHYSICAL EXAMINATION: At the time of admission, temperature was 103.2, blood pressure 154/80, pulse 108, respirations 20. In general, the patient appeared anxious and fatigued, and she was curled up in the fetal position. The eyes were anicteric. The right Perma-Cath site was noted to have some erythema, and an intact dressing. There was no jugular venous distention. The patient was tachycardic, with a regular rhythm. No murmurs were noted. The chest was clear to auscultation anteriorly. The abdomen was soft, nontender, nondistended. The extremities demonstrated no edema. The left arteriovenous fistula site had a bruit with no erythema present. The patient was alert and oriented at the time of initial examination. (Please note that the patient did refuse examination of some examiners, and this examination was a composite therefore.) DATA: CBC at the time of admission revealed a white count of 9.1, hematocrit of 33.9, with 77% neutrophils, 5% bands, 7% lymphocytes, 11% monocytes, no eosinophils. Platelet count was 235. PT was 14.9, with an INR of 1.5, PTT 103.0, which later decreased. Chem 7 at the time of admission revealed a sodium of 135, potassium 5.6, chloride 94, bicarbonate 12, BUN 20, creatinine 3.9, glucose 471, with an anion gap of 35. Calcium was 8.4, phosphate 5.5, magnesium 1.7. There was moderate acetone measured at 1 o'clock A.M. on [2163-4-29]. A rapamycin level from [2163-4-29] was 7.2, with a reference range of 3 to 20 nanograms/ml. Acetone was measured on [4-29] and found to be moderate. On [5-2], it was negative. Please see record for levels of vancomycin, however, the most recent vancomycin level was 24.9 on [5-5]. A blood culture from [2163-5-3] showed one out of four bottles positive for gram-positive rods, speciation is pending at this time. A blood culture from [2163-4-28] demonstrated no growth. A blood culture from [2163-4-26] showed coag-positive staphylococcus aureus, resistant to oxacillin, sensitive to clindamycin, erythromycin and vancomycin. A blood culture from [2163-4-21] had demonstrated no growth. Catheter tip culture from [2163-4-28] demonstrated again staphylococcus aureus coag-positive, with the same sensitivities. A swab taken from the right Perma-Cath site likewise demonstrated staphylococcus aureus. A chest x-ray was performed on [2163-5-3], showing no evidence for pneumonia. An Indium scan is pending at the time of this dictation. HOSPITAL COURSE: The patient was admitted with the above complaint of bacteremia, likely secondary to Perma-Cath line infection, this line having been discontinued the day of admission. The patient was initially placed on gentamicin and vancomycin for coverage of resistant staphylococcus aureus, however, sensitivities ultimately returned resistant to gentamicin, and this drug was discontinued on or about [2163-5-4], at which time Rifampin 300 mg by mouth twice a day was started. The patient was febrile at the time of admission, however, rapidly defervesced and, for much of the rest of this interval dictation, was afebrile, though complaining of chills and profuse diaphoresis, which soaked the bed sheets. The patient again had a fever of 101.5 on [2163-5-3], with blood cultures as noted above, and has not had a fever since [2163-5-3] at this time. The patient was followed by the [Last Name (un) ] Diabetes service, with whom decision was made regarding the patient's Glargine as well as Humalog sliding scale dosing (please see below and page one for current dosing). The patient was dialyzed with a temporary line on [2163-4-30], with a right femoral Quinton, which was then discontinued after dialysis. The patient was refusing to allow phlebotomy on several days during this admission, despite our best efforts at convincing her otherwise. The patient appeared to understand the risks of refusing testing, including laboratory testing, and was also noted on several occasions to refuse examination or to fail to comply with the instructions of house staff, including instruction to keep the right leg stable after placement of a second right groin catheter. On [2163-5-2], the patient was noted to have a critically high finger stick at 2 A.M., and received Humalog, with again an elevated finger stick in the critical range at 3:30 A.M. This apparent diabetic ketoacidosis resolved during the day without the use of an insulin drip, however, recurred on [2163-5-3], and the patient was noted to be febrile to 101.5, with worsening diaphoresis, and blood cultures were sent as described above. On [2163-5-3], as noted above, the patient was changed from gentamicin to Rocephin, and continued on vancomycin for coverage of presumed continued staphylococcal bacteremia, and a right groin line was placed for hemodialysis access. The patient remained tearful through much of the course of this hospital course to date, claiming that "I just can't take it anymore," however, refusing psychiatric consultation or other evaluation or intervention. The patient did deny any intent to hurt herself at this time. On [2163-5-5], the patient was injected with nuclear medicine tracer to assess for uptake in the rejected right lower quadrant kidney, as well as to search for signs of occult infection possibly contributing to the patient's ongoing labile blood sugars as well as sweats. The results of this study are pending at the time of this dictation. This report will be addended at a later date with discharge medications as well as additional discharge diagnoses by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. NEW DIAGNOSES AT THE TIME OF THIS DICTATION: 1. Recurrent diabetic ketoacidosis 2. Staphylococcal bacteremia, probably secondary to line infection [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7576] Dictated By:[Name8 (MD) 2058] MEDQUIST36 D: [2163-5-5] 22:46 T: [2163-5-6] 00:49 JOB#: [Job Number 104078] Admission Date: [2163-4-28] Discharge Date: Date of Birth: [2120-9-25] Sex: F Service: [Doctor Last Name ] This is to summarize the events from [2163-5-6] until [2163-5-18]. CONTINUATION OF COURSE IN HOSPITAL: 1. Endocrine - The patient continued to have very labile sugar control which included both hypoglycemia and hyperglycemia with near diabetic ketoacidosis events. Her blood glucose continued to be difficult to manage. She was followed by the [Last Name (un) ] Diabetes Service who made frequent adjustments to the patient's insulin regimen. Of note it is important that the patient always received her glargine insulin regardless of NPO status as this represents baseline insulin requirements for this diabetes mellitus type I patient. 2. Renal - The patient continued to have hemodialysis. She was to have a tunnel perma cath placed on [2163-5-9] but this was aborted because of hypothermia as described below. Instead a temporary IJ was placed for continued hemodialysis. She had hemodialysis through this catheter successfully. On [2163-5-11] the patient's transplanted kidney was removed. Please see operative note for full details. This was removed as it was thought to be the cause of the patient's chills and sweats as described below. The patient's postoperative course was uncomplicated with the exception of no resolution in her presenting symptoms of chills and sweats. Further evaluation of this is described as below. While in house she continued to have hemodialysis to adjust her electrolytes and fluid balance. 3. Hematologic - The patient was found on dialysis [2163-5-6] to be hypotensive with one to two unit bleed while in the hemodialysis unit. The dialysis nurses felt that line malfunction was effectively ruled out leaving gastrointestinal or vaginal sources of the patient's bleed. Her blood pressure did fall to approximately 60 systolic in the setting of this bleed. She was stabilized and transferred to the Medical Intensive Care Unit for close observation that evening. She was seen in consultation by the Gastroenterology service who were unable to find a source of the patient's bleeding. She did not undergo any work up for this as the patient stopped bleeding and remained stable during that evening. On [2163-5-7] the patient was called out of the Medical Intensive Care Unit. Her crit has since been generally stable as her blood pressure. Of note even with the systolic blood pressure of 60 the patient mentated and maintained a normal mental status. In addition she continues to receive Epogen at hemodialysis. 4. Infectious Disease - Chills the patient received the white blood cell scan as described in the prior report. This revealed the focus of increased .labelled-wbc................... localization overlying the right mid thorax possible a focus of infection on the chest wall. There was minimal asymmetry in the upper extremities left greater than right of uncertain significance. This scan was felt to be mainly negative with the exception of indicating a perma cath infection which had been previously diagnosed as in the prior dictation for which the patient was already undergoing treatment. She continued on her course of Vancomycin and Rifampin for MRSA presumed secondary to the perma cath as described in the previous dictation. However he chills and sweats did not resolve. Her transplanted kidney was felt to be in a state of chronic rejection and was implicated for the cause of the patient's symptoms. As described above on [2163-5-11] the patient's kidney was removed. The patient completed her course of Rifampin. While on the surgical service perioperatively she was maintained on Levaquin for empiric coverage of gram negative. This was discontinued on [2163-5-14] with a question of a drug rash. The patient was seen in consultation by the Infectious Disease service on [2163-5-13] as requested by the surgical service. They recommended that the Vancomycin course be continued to three weeks and that Rifampin and Levaquin be discontinued. Additionally it was their opinion that the lactobacillus growing in blood cultures was a contaminant. Selected microbiologic studies since the prior dictation summary. A [2163-5-3] blood culture was growing lactobacillus species. A [2163-5-8] stool study was C difficile negative times two. A [2163-5-9] blood culture was negative. A [2163-5-9] stool culture for C difficile was negative. A [2163-5-12] blood culture was negative. A [5-15], stool culture for C difficile was negative. A [2163-5-15] stool culture for C difficile was negative again. A [2163-5-18] CMV antigen and antibody is pending at the time of this dictation. The patient's Vancomycin was discontinued on [2163-5-17] because she had a very high Vancomycin level which was felt would complete her course of Vancomycin to a total of three weeks before it was subtherapeutic. 5. Chills and Sweats - The Infectious Disease work up occurred as described above. However it appeared there was no infectious cause of the patient's symptoms and there was no resolution after nephrectomy. To further evaluate for this the patient is currently scheduled for CT scan of the body to look for lymphoproliferative disease or lymphoma. The renal team felt that because the patient has no kidney and is already on dialysis IV contrast would be acceptable. Additionally on [2163-5-9] when the patient was to receive the tunnel perma cath as described above she was found to be hypothermic to 93 F. Sepsis was considered. Blood cultures remain negative. The patient remained normothermic thereafter. An explanation for this event has not yet been determined. 6. Psychiatric - While in the Medical Intensive Care Unit the patient was seen by the inpatient psychiatry service as she was combative and refusing treatment. The inpatient psychiatric service felt that the patient was not competent to leave against medical advice but was competent to refuse minor medical procedures such as blood draws. They did not however feel she was competent to refuse life saving procedures and recommended that if she were to refuse life saving medical procedures she should be restrained in order to protect her life. They also recommended administration of .................... which was started and continued. Additionally it should be noted that the patient is very resistant to IV fluids. 7. Access - The patient had multiple access problems including but not limited to the difficulties with Tunnel perma cath on [5-9]. At that time she received a temporary IJ which was used successfully. Her AV fistula is continuing to mature as of the time of this dictation and she needs temporary access until it is mature for use in dialysis. On [2163-5-18] the patient received a Tunnel perma cath as well as a PIC line placement. 8. Hypotension - The patient was hypotensive on [5-16] and 28th as described she refuses intravenous fluid frequently and this can be difficult to administer to her. On [2163-5-17] the patient had no intravenous access and hence was not capable to be treated with intravenous fluids. She was maintained on a high salt diet. She remained lightheaded, dizzy and likely orthostatic but mentated properly. On [2163-5-18] she was treated with intravenous fluids to correct her blood pressure. 9. Fluids, Electrolytes and Nutrition - The patient's electrolytes are adjusted in hemodialysis. She was hyperkalemic on several occasions and was treated appropriately for this. The remainder of the patient's course, discharge diagnosis and discharge medications and follow up instructions will be dictated at a later time. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7576] Dictated By:[Name8 (MD) 2665] MEDQUIST36 D: [2163-5-18] 14:16 T: [2163-5-18] 14:26 JOB#: [Job Number ] Name: [Known lastname 16865], [Known firstname ] Unit No: [Numeric Identifier 16866] Admission Date: [2163-4-28] Discharge Date: Date of Birth: [2120-9-25] Sex: F Service: [Doctor Last Name 633] DISCHARGE SUMMARY ADDENDUM: This covers her course from [2163-5-18] through [2163-5-21]. The additional information is here discharge medications. 1. Bethanechol 25 mg po tid. 2. Neurotonin 100 mg po bid. 3. Nephrocaps one tablet po q day. 4. Paxil 20 mg po q day. 5. Protonix 40 mg po q day. 6. Renagel 800 mg po tid. 7. Lipitor 10 mg po q day. 8. She is also on Glargine which is Lantus and a Humalog sliding scale that is 10 to 12 units q HS. Humalog sliding scale based on carb counts 1 unit of Humalog per 15 carbs. The patient is being discharged to home. In this time in addition her CT scan of the torso showed tiny red pulmonary nodules status post right transplant nephrectomy with residual debris within the nephrectomy bed most likely representing hematoma or ..................... However the key is that she does not have post transplant lymphoproliferative disorder and she also had her FSH and LH levels checked 1.2 and less than 1.0 respectively which indicates she is not undergoing early menopause. Of note she is to be given her Glargine at night regardless of whether she is NPO. The patient is going to follow up on Tuesday morning, [2163-5-24] at 8 A.M. to have a Perm-A-Cath placed by the surgery unit at [Hospital1 536]. She will then undergo hemodialysis here and she will resume with [Hospital1 2314] hemodialysis after that. She is being discharged to her mother's home. She will be taken by her sister. She will follow up with Dr. [Last Name (STitle) ] of the [Last Name (un) 616] service within two to four weeks. Of note she developed a morbilliform rash that is thought to be consistent with antibiotics most likely Rifampin was the thought. She was taking Benadryl prn for the pruritus associated with that. Of note the Humalog sliding scale begins at 101 to 150 at breakfast, lunch and dinner for two units and then increased by two units for every 50 mg per deciliter of glucose and for example 101 to 150 is two units, 151 to 200 is four units of Humalog. At night the scale changes at bedtime. She is to get one unit at 201 to 250, two units 252 to 300, four units at 301 to 350 and greater than 350 gets five units. Again now she gets the Lantus 13 units at bedtime. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 16867] m.d. [MD Number(1) 2435] Dictated By:[Last Name (NamePattern1) 771] MEDQUIST36 D: [2163-5-21] 11:59 T: [2163-5-23] 09:28 JOB#: [Job Number ]	[ "996.62", "790.7", "E878.0", "E879.8", "250.11", "250.41", "733.09", "403.91", "996.81" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.95", "55.53" ]	icd9pcs	[ [ [] ] ]													2170, 2509	5018, 19365																											2533, 4999																								189, 1692															1716, 2142
3,952	139,869	5121	Discharge summary	report	Admission Date: [2129-2-17] Discharge Date: [2129-2-18] Date of Birth: [2071-6-27] Sex: M Service: MEDICINE Allergies: Tapazole Attending:[First Name3 (LF) 2297] Chief Complaint: hyperglycemia Major Surgical or Invasive Procedure: none History of Present Illness: 57 yo M with a past history of DMI, ESRD on HD, CHF, PVD who presents to the ED with hyperglycemia noted at dialysis. Patient arrived for scheduled HD today feeling in his USOH and was found to have a "critically high" finger stick glucose, so patient was transferred to the ED. Patient denies frank symptoms including fever, chills, abdominal pain, chest pain, nausea, vomiting and cough. Patient does report medicine noncompliance, and tells me that he did not take his insulin today or yesterday because he "did not feel like it", and "because I know when I'm in DKA". Patient has a history of noncompliance, and takes several of his other medications on a periodic basis, including his statin and steroid. Other than not taking his 2 dogs for a walk yesterday, but he states this was not because he was lethargic or confused. . In the ED, patient was noted to have a serum glucose of 639 with an AG of 20, and a VBG with a pH of 7.36. He received an IV bolus of Regular 8U, and was started on an insulin drip of 8 U/hr. No imaging was performed and a UA was not obtained. He received 1L of saline. [Name (NI) ] father, who is legal guardian, was [Name (NI) 653] in the [Name (NI) ]. On transfer, VS were 96.9, 79, 112/42, 99% RA. . In the ICU, patient reports feeling well. He is asking to go home, but is happy to stay in the hospital as long as his doctors [Name5 (PTitle) ] [Name5 (PTitle) 21035]. . Of note, patient was admitted [9-25] - [9-26] with acute hyperglycemia in the setting of prednisone tapering. Finger sticks during admission were in 200s-300s. He was discharged with prednisone 5 mg [Hospital1 ] and his insulin regimen was unchanged. Of note he missed his follow up appointments with [Last Name (un) ] and and his PCP. . 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. Type 1 diabetes with questionable insulin autoantibody receptor syndrome -since age 16 on insulin, followed by Dr. [Last Name (STitle) 10088] [Name (STitle) 21002] hypoglycemic episodes, has required intubation for altered MS in the past -complicated by nephropathy -complicated by retinopathy (s/p right eye laser surgery, repeated [8-2]) -on immunosuppression ?? no records at [Hospital1 18] 2. End-stage renal disease on dialysis Tu/Th/Sa 3. Diastolic heart failure (LVEF>55% in [12/2124]) 4. Hypertension 5. Hyperlipidemia 6. Peripheral vascular disease 7. Hypothyroidism 8. Anemia 9. Burn on his left upper extremity, now s/p skin graft 10. S/p left first toe distal phalangectomy in [2127-9-28] 11. Pancreatic lesions seen on an abdominal CT done in [2127-5-28] Social History: Lives with [Year (4 digits) ]. Previously worked in construction but is now unemployed. No alcohol, drugs, or tobacco. He has never been married and has two adult children. Family History: Mother - Type 2 Diabetes [Year (4 digits) ], Rheumatoid Arthritis Maternal Aunt - Type 2 Diabetes [Name (NI) ] Nephew - Type 1 Diabetes [Name (NI) ] Physical Exam: ADMISSION EXAM: Vitals: T: 96.2 BP: 117/54 P: 68 R: 15 O2: 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Somewhat cushingoid appearance, supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: HD line left chest c/d/i non tender, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [2129-2-17] 08:10AM BLOOD WBC-4.5 RBC-4.36* Hgb-10.7* Hct-34.3* MCV-79* MCH-24.6* MCHC-31.2 RDW-15.3 Plt Ct-216 [2129-2-17] 08:10AM BLOOD Neuts-52.7 Lymphs-37.1 Monos-6.8 Eos-2.4 Baso-1.0 [2129-2-17] 08:10AM BLOOD Glucose-639* UreaN-48* Creat-5.9# Na-131 K-4.6 Cl-92* HCO3-19* AnGap-25* [2129-2-17] 03:19PM BLOOD Calcium-9.3 Phos-3.7 Mg-1.9 [2129-2-17] 09:31AM BLOOD pO2-102 pCO2-36 pH-7.36 calTCO2-21 Base XS--4 Intubat-NOT INTUBA . DISCHARGE LABS: [2129-2-18] 08:03AM BLOOD WBC-5.6 RBC-4.27* Hgb-10.7* Hct-31.9* MCV-75* MCH-25.0* MCHC-33.5 RDW-15.3 Plt Ct-237 [2129-2-18] 08:03AM BLOOD Neuts-50.1 Lymphs-37.6 Monos-6.5 Eos-5.0* Baso-0.7 [2129-2-18] 08:03AM BLOOD Glucose-180* UreaN-64* Creat-7.1* Na-130* K-4.4 Cl-91* HCO3-26 AnGap-17 . MICROBIOLOGY: None . IMAGING: None Brief Hospital Course: 57 yo man with type 1 DM, ESRD on HD, CHF, PVD, who presents with DKA in the setting of insulin noncompliance. . # Hyperglycemia with anion gap: Most likely etiology is dietary noncompliance. No evidence of infection given lack of fevers, and normal WBC. EKG at baseline without evidence of ischemia. No history of intoxication. Patient did have elevated AG, but VBG was without evidence of acidosis. He was continued on an insulin drip until the gap closed at which point we restarted glargine 2 units daily (patient on levemir at home) with humalog SS. Continued prednisone 5mg [Hospital1 ] which patient takes at home for autoimmune induced diabetes. . # ESRD secondary to DM: Patient received HD on HD#2 prior to discharge, and was set up for an extra session at his outpatient facility on the day after discharge. Continued sevelamer and nephrocaps. . # Hypertension: Continued CCB, Minoxidil, and beta blocker. . # Hyperlipidemia: Continued statin Medications on Admission: 1. allopurinol 100 mg po qod 2. calcitriol 0.25 mcg daily 3. diltiazem HCl 120 mg po daily 4. levothyroxine 75 mcg daily 5. doxazosin 4 mg po qhs 6. minoxidil 5 mg [Hospital1 ] 7. B complex-vitamin C-folic acid 1 mg daily 8. dorzolamide 2 % Drops [Hospital1 ] 9. sevelamer carbonate 800 mg TID 10. rosuvastatin 20 mg po qhs 11. ferrous sulfate 300 mg (60 mg Iron) po daily 12. metoprolol succinate 100 mg po qam and 50 mg qpm 13. prednisone 5 mg Tablet po BID 14. Levemir 2U qam Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. minoxidil 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 9. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 14. prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Levemir 100 unit/mL Solution Sig: Two (2) units Subcutaneous QAM. 16. Humalog 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Diabetic Ketoacidosis Secondary: End-stage renal 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 high levels of sugar and acid in your blood, a condition known as Diabetic Ketoacidosis. We think this is because you did not take your insulin the day prior to admission. It is essential that you take your insulin as prescribed every day in order avoid this problem. Followup Instructions: Department: [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 250] When: WEDNESDAY [2129-2-23] at 8:50 AM With: Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage NOTE: This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [Name10 (NameIs) 616] this visit, you will see your regular primary care doctor in follow up. Name: [Last Name (LF) 10088], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Last Name (un) ] DIABETES CENTER Address: ONE [Last Name (un) ] PLACE, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 2378] Appt: [2-23] at 4:30pm Completed by:[2129-2-19]	[ "V58.67", "530.81", "428.0", "V45.11", "403.91", "428.30", "244.9", "585.6", "272.4", "250.13" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	8079, 8085	5249, 6209	283, 289	8196, 8196	4400, 4400	8710, 9661	3601, 3764		6747, 8056		8106, 8175		6235, 6724			8379, 8687			4888, 5226							3779, 4381																						2119, 2566						230, 245											317, 2100							4416, 4872					8211, 8355			2588, 3389	3405, 3585
1,571	197,438	2670	Discharge summary	report	Admission Date: [2116-12-5] Discharge Date: [2116-12-10] Date of Birth: [2049-10-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: fever & hypotension Major Surgical or Invasive Procedure: Hemodialysis via R IJ tunneled catheter History of Present Illness: 67 yo man w/ h/o ESRD [1-23] IgA nephropathy on HD, HTN, COPD, ETOH hepatitis who presented from HD [2116-12-5] with fever to 101. On arrival was febrile to 102.3. No localizing sources known. Has had R IJ tunnelled cath x 2 months, and had fisutlogram done the day before admission. On admission, his SBP was noted to be slightly down from baseline at 70-90's in ED (normal 110s). BP on admission to ED was 77/33. Lactate was also elevated on admission (5.3 on HD w/ ESRD, so utility questionable, repeat [12-6] 1.5). He noted a fever on the day before admission at home. Also c/o chills/rigors after returning home from his fistulogram. Also c/o productive cough (white sputum); however, this is chronic. He denies CP, Palps, SOB, abd pain, N/V, dysuria, or diarrhea. He continues to make urine daily. . While at HD, the patient received a dose of Vanco and Gent. It is unclear if blood cxs were drawn prior to this. In the ED, he received 1L NS. CXR and RUQ U/S were both unrevealing. Blood cultures were drawn peripherally (not from HD line). He was given a dose of Ceftriaxone in ED as well. He was then transferred to MICU for closer monitoring. . MICU Course: patient continued on Vancomycin (s/p 1000mg [12-5]). Has not received further doses of gent. Given IVF and antihypertensives held. T max 101 overnight [12-5] --> [12-6] Past Medical History: -ESRD [1-23] IgA nephropathy s/p Initiation of HD [2116-9-26] -L UE Fistula -R-IJ HD catheter placed [9-/2116] -HTN -COPD -Arthritis/Gout -Alcoholic Hepatitis/Cirrhosis (w/ active ETOH use) -Anemia [1-23] CKD on aranesp -Asteototic Eczema Social History: Lives in [Hospital1 392] w/his wife. [Name (NI) 1139] use (56 pack year hx), now smokes ~8cigs/day. +ETOH 2 beers/day. Denies any other drug use. Family History: non-contributory Physical Exam: VS: T=99.0 (Tm=101); BP=112/70 (89-113/33-72); HR=72 (51-73); RR=20; O2=98% (92-98%) I/O = +1360 GEN: NAD, alert, comfortable HEENT: PERRL, EOMI, OP clear w/o erythema/exudates, dry MM CV: RRR, normal S1/S2, no M/R/G RESP: CTA bilat, no crackles/wheezing ABD: NABS, Soft, mildly distended, NT/ND, no guarding, no rebound EXT: no edema, warm, R-IJ line w/o erythema or tenderness. PULSES: 2+DP pulses b/l; palpable thrill of L arm NEURO: A&0x3, CN II-XII intact, strenght [4-24] bilat Pertinent Results: Admission labs: 12.3 7.7>----<112 38.5 Comments: Id Labels Verified . PT: 13.3 INR: 1.2 . 142 98 16 -----------<146 3.5 30 3.3 estGFR: 19/23 (click for details) Ca: 8.5 Mg: 1.8 P: 1.7 D ALT: 28 AP: 151 Tbili: 2.3 AST: 43 TProt: 6.2 [Doctor First Name ]: 103 Lip: 124 . 11.3 27.5>----< 72 33.5 N:91.7 Band:0 L:4.7 M:3.5 E:0 Bas:0.2 Anisocy: 2+ Poiklo: 1+ Macrocy: 1+ Microcy: OCCASIONAL Polychr: 2+ Ovalocy: 1+ Plt-Est: Low . PT: 14.6 PTT: 35.5 INR: 1.3 . UA: Color Yellow Appear Clear SpecGr 1.019 pH 8.0 Urobil Neg Bili Sm Leuk Neg Bld Mod Nitr Neg Prot Tr Glu Neg Ket Tr RBC 0-2 WBC 0-2 Bact Few Yeast Rare Epi 0-2 . MICRO: BLOOD CX ([2116-12-5]): 1/6 bottles w/ MSSA; cultures from [Hospital1 392], off line, [1-23] staph aureus URINE CX [2116-12-5]: <10,000 organisms/ml catheter tip culture pending [2116-12-8] . CXR ([2116-12-5]): No acute cardiopulmonary process identified. . ABD U/S ([2116-12-5]): 1. No acute son[Name (NI) 493] findings to explain the patient's symptoms. 2. Cholelithiasis without evidence of acute cholecystitis. 3. Cirrhotic liver with mild ascites. No focal lesions appreciated. . FISTULOGRAM ([2116-12-4]): 1. Initial AV fistulogram demonstrates an area of kinking within the cephalic vein, with two prominent venous collaterals proximal to this area. 2. Angioplasty of this area of kinking was performed, which demonstrated mild improvement. . Brief Hospital Course: 67 yo man w/ h/o ESRD [1-23] IgA nephropathy on HD, HTN, COPD, ETOH hepatitis initally admitted to MICU after being sent from HD with fever and hypotension clinically improved but with MSSA [12-27] blood cultures, staph aureus 2/2 blood cultures from HD ([Hospital1 392]). . 1-FEVER: Improved, likely line sepsis given + blood cultures: MSSA [12-27] blood cultures, staph aureus 2/2 blood cultures from HD ([Hospital1 392]). No other localizing sxs. Also had elevated lactate and WBC (improved). RUQ U/S and CXR unremarkable. Fistulogram unrevealing for clot or abscess. Peripheral cultures drawn, however received Vanco/Gent at HD prior to dose, cultures from HD NGTD. Other potential source could be pulmonary, but unlikely. Has chronic cough related to COPD, unchanged. He had his tunneled catheter removed [12-8] at the bedside, attempted HD via fistula [12-9] which did not work, so required replacement of tunnerled HD catheter on [12-10], followed by HD, and was stable for discharge. He was started on levofloxacin on [12-7] out of concern for bronchitis with COPD but given + blood cultures, lack of respiratory symptoms, this was stopped [12-10]. . 2-Contact Dermatitis: [Name2 (NI) ] at line removal site corresponding to tegaderm, ? cotnact dermatitis, tegaderm removed, will try sarna cream and use gauze/tape. Other sites of tegaderm (IV) not errythematous/indurated/pruruitic, improved slightly with sarna lotion, recommend to continue this. . 3-HYPOTENSION: Pt initially w/episode of hypotension in ED. may have been related to HD w/ fluid removal; however, also had fever, leukocytosis, and elevated lactate c/w SIRS/sepsis (line as potential source). BP stablized after first hospital day, no tachycardia, but BP remained 120's systolic so he was not resarted on metoprolol, this should be restarted when BP increases. . 4-ESRD on HD: renal followed in the hospital. Continue HD sessions per outpatient regimen, had attempt via fistula which was not successful so he had a tunneled line placed. Will resume T/T/S schedule, to follow-up with transplant for fistula, continued on nephrocaps. . 5-COPD: Pt seems to be at baseline, has h/o chronic cough, satting well, on levofloxacin as above for possible bronchitis though that was stopped as sputum unchanged. . 6-THROMBOCYTOPENIA: stable to improving, likely [1-23] to cirrhosis, although trending down since [9-25]. ?consumption [1-23] to sepsis. No signs of bleeding, followed platelet count in house and it trended up to 165 by discharge. . 7-ELEVATED [Doctor First Name 674]/LIP: mild elevation, trending down, not associated signs or symptoms of pancreatitis but chronic etoh. ?[1-23] to EtOH. . 8-Hyperglycemia: blood glucose to 200 intermittantly, covered with SSHI/monitor blood glucose qid, no known diabetes, ? stress reaction [1-23] infection, will need to be followed as an outpatient. . 9-ETOH abuse: monitored on CIWA while here with no signs or symptoms of withdrawl, no medication needed. . 10-PPX: pneumoboots, bowel regimen, no GI currently indicated . 11-CODE: Full (confirmed with patient) Medications on Admission: - Moexipril 15 mg Daily - Ferrous Sulfate 325 [Hospital1 ] - Camphor-Menthol 0.5-0.5 % Lotion Topical [Hospital1 ] prn - Nephrocaps 1 mg once a day - Metoprolol Tartrate 25 mg [Hospital1 ] - Albuterol 90 mcg/Actuation Aerosol Sig: [12-23] Inhalation q6hr prn - Atrovent 18 mcg/Actuation Aerosol Sig: 1 Inhalation q6hr prn Discharge Medications: 1. Nephrocaps 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for itching. 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation every six (6) hours as needed. 5. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous q hemodialysis for 10 days: to be dosed at hemodialysis by level. 6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-23] Sprays Nasal QID (4 times a day) as needed. Disp:1 bottle Refills:0 7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [3-26] hours as needed for pain for 10 doses. Disp:10 Tablet(s) Refills:0 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia for 10 doses. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Staph Aureus Line Sepsis. 2. SIRS. Secondary: 1. CKD Stage V - IgA Nephropathy on HD. 2. ETOH Cirrhosis. 3. ETOH Abuse. 4. COPD. 5. Hypertension. 6. Gout. Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please return to the Emergency room or call your primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5781] at ([Telephone/Fax (1) 6301] if you experience fevers, chills, sweats, nausea, vomitting, diarrhea, constipation, worse cough, head ache, shortness of breath, chest pain, pain with passing your urine, dizziness or any symptoms that concern you. Followup Instructions: Please follow-up with your primary care doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5781] on Friday, [2116-12-18], at 10:40am. Please call ([Telephone/Fax (1) 1300] if questions or you need to change this appointment. . Please follow up with Dr. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [2116-12-31] at 3:00pm. Please call ([Telephone/Fax (1) 7144] if questions. . Please continue your scheduled hemodialysis tuesdays, thursdays and saturdays.	[ "287.4", "038.11", "995.91", "496", "571.2", "403.91", "285.21", "996.62", "305.00", "274.9", "585.5" ]	icd9cm	[ [ [] ] ]	[ "86.09", "38.95", "39.95" ]	icd9pcs	[ [ [] ] ]	8731, 8737	4255, 7403	334, 375	8949, 8959	2775, 2775	9515, 10037	2233, 2251		7792, 8708		8758, 8928		7429, 7769			8983, 9492										2266, 2756																												275, 296											403, 1765							2795, 4232								1787, 2044	2061, 2217
22,527	153,386	18263	Discharge summary	report	Admission Date: [2109-10-16] Discharge Date: [2110-1-15] Date of Birth: [2065-3-29] Sex: M Service: PLASTIC SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 44 year-old male with recurrent malignant melanoma of the scalp was admitted for debridement and biopsy of mass. He has had five operations prior to admission to remove and control the cancer. It was first diagnosed in [2108-8-2] and [2108-11-2] he had excision and repair with latissimus free flap by Dr. [Last Name (STitle) ]. The cancer had recurred by [2109-11-2] and [2109-3-2] he had excision and latissimus free flap again. The cancer recurred again in [Month (only) 547] and he had excision in [Month (only) 116] with closure. He has been followed by Dr.[Name (NI) 50391] oncology and Dr. Frank______ surgical oncology. Prior closures and repairs by Dr. [Last Name (STitle) ]. The patient denies pain, positive odor, positive drainage of yellow to red fluid. He has had q.d. dressing changes with wet to dry. He had one round of chemo Temodar times five days in early [2109-9-2]. He has not had any more chemotherapy secondary to possible surgery. He denies headache or vision changes. MEDICATIONS: 1. Starlix. 2. Avandia. 3. Aspirin. 4. Vitamin E. 5. Multivitamin. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. Scalp melanoma. ALLERGIES: No known drug allergies. PAST SURGICAL HISTORY: 1. [2108-8-2] below the knee amputation secondary to blood clot. 2. [2088] crush injury to hips and legs with fixation. FAMILY HISTORY: Mother died of thyroid cancer. No other cancer history. PHYSICAL EXAMINATION: Temperature 98.7. Heart rate 118. Blood pressure 128/76. O2 sat 98% on room air. In general, alert, no acute distress. Head dressing intact with minimal drainage, positive foul odor. Lungs clear to auscultation bilaterally. Cardiovascular tachy, regular rhythm, no murmur. Abdomen soft, nontender. Positive bowel sounds. Extremities left below the knee amputation. Right scar with STSG to inner calf and thigh well healed. Good pulses. Good deep tendon reflexes. Good range of motion in all extremities. HOSPITAL COURSE: The patient was admitted to the Plastic Surgery Service. He was taken to the Operating Room on [2109-10-18] and [2109-10-23] for debridement of his scalp wound. On [2109-10-25] the patient went to the Operating Room for an omental flap given the size of the defect in the scalp. The patient returned to the Operating Room on [2109-10-31] as part of the flaps became necrotic. The areas of necrosis were debrided in the Operating Room. Part of the flap was viable at that time. The wound continued to be treated with V.A.C. placement, which was changed every three to four days. The patient returned to the Operating Room for debridement on [11-8], 8, 12, 15, 19, 22, 24 and 26 with V.A.C. changes. The omental flap was ultimately deemed to nonviable and the patient was in need of further flap to bridge the soft tissue defect. The patient had no feasible blood vessels in the head for the flap. Thus an AV fistula from the left neck with vein graft from the right arm was performed to make a vascular loop on [2109-12-2]. The patient's V.A.C. was changed on [12-23], [12-16]. The AV fistula was allowed to mature for two weeks and on [2109-12-19] a free rectus abdominis muscle flap was performed to fill the skull/scalp defect. Intraoperatively the graft was noted to become ischemic and the patient was started on heparin with improved perfusion of the flap. The graft remained well perfuse and the patient remained on heparin for several weeks following the operation. The patient returned to the Operating Room on [2109-12-23] for a split thickness skin graft to cover the muscle flap. Prior to the free rectus abdominis flap the patient was noted to have Pseudomonas growing from the old flap, which possibly involved the plate that was covering the skull defect. The patient had been placed on Zosyn and Gentamycin per infectious disease consult. The patient continued to improve and on [2110-1-8] after the flap and skin graft had time to mature the plate was removed from his skull and the flap/graft was reclosed. This was done with neurosurgical involvement. The patient was also started on Fluconazole on [2109-12-29] for a yeast fungemia and a blood culture from [2109-12-25]. The patient had a PICC line, which grew out negative cultures after this and remained and the patient's heparin was discontinued on [2109-1-8] after the Operating Room and the patient's dressing was removed on [2109-1-13]. The flap and skin graft are well appearing with 100% take. The cultures from the plate and bone from intraoperative extraction were negative. On [2109-1-7] the patient was noted to develop a rash on his chest and arms. The Vancomycin was stopped and the patient's rash improved. The rash was likely secondary to a Vancomycin allergy. The patient remained stable and was discharged home with services on [2110-1-15]. DISCHARGE DIAGNOSES: 1. Scalp melanoma. 2. Failed omental and latissimus flaps times two. 3. Status post multiple debridements. 4. Infected skull plate. 5. Status post vascular loop. 6. Status post rectus abdominis free flap. 7. Status post split thickness skin graft. 8. Status post skull plate removal. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg po q.d. 2. Unasyn 4.5 grams intravenously q 6 until [2110-1-22]. 3. Ciprofloxacin 750 mg po b.i.d. times four weeks starting [2110-1-22]. 4. Percocet one to two tabs q 4 to 6 hours prn. FOLLOW UP: 1. The patient will follow up with Dr. [Last Name (STitle) 5385] and call his office for an appointment [0-0-]. 2. The patient should follow up with his oncologist. The patient was provided a protective helmet to be worn on top of the dressing and VNA Services will change his dressing q.d. and provide him with his intravenous antibiotics. The patient was discharged in good condition and advised that he could resume his normal activities with the helmet in place and to avoid getting his head or head dressing wet. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 7738] Dictated By:[Name8 (MD) 17848] MEDQUIST36 D: [2110-1-17] 09:34 T: [2110-1-17] 09:44 JOB#: [Job Number 50392]	[ "998.59", "996.67", "117.9", "172.4", "996.52", "998.11", "280.0", "682.8", "196.0" ]	icd9cm	[ [ [] ] ]	[ "86.69", "83.82", "02.07", "86.22", "93.59", "86.4", "39.29", "86.75", "99.04", "40.11", "38.93" ]	icd9pcs	[ [ [] ] ]							1608, 1666	5169, 5462				5488, 5705		2224, 5148										1460, 1591												5716, 6509					1689, 2206																								178, 1326															1348, 1437
54,066	128,987	39665	Discharge summary	report	Admission Date: [2103-7-18] Discharge Date: [2103-7-25] Date of Birth: [2085-6-20] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 598] Chief Complaint: S/P MVC Major Surgical or Invasive Procedure: [2103-7-18] 1. Open reduction of a left thumb metacarpophalangeal joint dislocation. 2. Ulnar collateral ligament repair to the thumb metacarpophalangeal joint. 3. Extensor repair the extensor pollicis longus and extensor pollicis brevis tendons. 4. Repair of thumb adductor muscle. 5. Open reduction and internal fixation left second digit proximal phalanx fracture. 6. Repair of extensor tendon to the second digit. 7. Closed reduction fifth finger proximal phalanx fractures. 8. Irrigation and debridement down to bone in both the index finger and the thumb. 9. Repair of 20-cm laceration as part of the wound. 10.Rearrangement of local flaps. History of Present Illness: 18 yo M who was an unrestrained driver in rollever MVC. Patient was ejected approx 30-40 ft. One passenger dead at the scene. No reported LOC. GCS 15 in the Emergency Department. Multiple lacerations including right thigh, abdomen, occiput and left hand. Past Medical History: none Social History: no ETOH, no tobacco, denies drug use Family History: non contributory Physical Exam: T:98 BP: 121/58 HR:94 R:20 O2Sats: 100% Gen: Slightly sedated, Comfortable HEENT: Pupils: 4->3 b/l EOMs - Full, intact Neck: C-Collar in place Abd: Multiple large, repaired laceration Extrem: Right hand, bilateral LE wwp - L hand in dressing Neuro: Mental status: Awake, cooperative with exam, Orientation: Oriented to person, place (hospital, did not know which city), and date. Motor: D B T WE WF IP Q H AT [Last Name (un) 938] G R 5 5 5 5 5 5 5 5 5 L 5 5 5 5 LUE exam limited by pain due to injured hand. LLE exam limited by large reparied laceration to right thigh. Sensation: Intact to light touch in Right hand, bilateral lower extremeties. Pertinent Results: [2103-7-18] 03:35PM WBC-22.2* RBC-4.96 HGB-12.0* HCT-36.9* MCV-74* MCH-24.3* MCHC-32.7 RDW-14.2 [2103-7-18] 03:35PM PLT COUNT-310 [2103-7-18] 03:35PM PT-14.6* PTT-26.4 INR(PT)-1.3* [2103-7-18] 03:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2103-7-18] 03:35PM UREA N-14 CREAT-1.0 [2103-7-18] 03:52PM LACTATE-3.7* [2103-7-18] CT Torso : 1. Bilateral pulmonary contusions, most severe in the left upper lobe. 2. Spinous process fractures at T5 and T4. Transverse process disruptions at L1 may be fractures or congenitally unfused transverse processes. 3. Superficial lacerations as above. [2103-7-18] Left hand and wrist : ) Fifth proximal phalanx fracture. 2) Second proximal phalanx fracture. 3) Extensive soft tissue injury. 4) Question subluxation versus dislocation at first MCP and/or IP joints, suboptimally visualized. Brief Hospital Course: Mr.[Known lastname 29608] was evaluated in the Emergency Room by the Trauma team as well as Urology and the hand service. Due to his crush injury to his left hand he was taken to the Operating Room for washout, debridement and repair. He tolerated the procedure well and returned to the Trauma ICU in stable condition. He remained intubated overnight and maintained stable hemodynamics. He underwent leech therapy to his left thumb and 2nd digit as well as splinting and elevation. His perfusion remained intact to all digits. For pain control he had a left infraclavicular catheter placed for Bupivacaine infusion which worked well. He was extubated without any difficulty and maintained good oxygen saturations. His pulmonary contusions improved daily as noted by chest xray and he remained free of any other pulmonary complications. After removal of his infraclavicular catheter his pain was controlled with Oxycodone. The Urology service evaluated him daily and wanted to continue wet to dry dressing changes as his penile wound was granulating. He will need some type of delayed closure with a skin graft or possible circumcision but that will be done at a later date and for now he will continue dressing changes, His Foley catheter was removed without difficulty and he was voiding sufficiently. His WBC was elevated on admission and remained elevated at 17-20K. He was placed on broad spectrum antibiotics. Following his operative procedures he had temperatures > 101 and was pan cultured. All cultures were negative and currently he is completing a course of Cipro prophylactically for his hand. The events and after effects of his accident were explored with the Social Worker and after he was told of his friends death in the accident he was very tearful and depressed as expected. He was however able to continue with therapy, stay hydrated and eat and get up and ambulate. After a long hospitalization he was discharged to home on [2103-7-25]. He and his family were taught how to care for his hand and dressing changes to his penis. He will follow up next week with the Orthopedic service. Please see discharge instructions for further appointments. Medications on Admission: none Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for PRN pain >5. Disp:80 Tablet(s) Refills:0 4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): thru [2103-8-2]. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: S/P MVC 1. penile degloving injury 2. Open fracture left thumb & index finger 3. Pulmonary contusions 4. T4, T5 spinous process fractures process fracture 5. L1 transverse process fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Followup Instructions: -You should continue taking the antibiotics as prescribed. -Take 1.5 baby aspirin everyday for the next 30 days. -Elevate your left arm as much as possible and maintain it in your splint. -Please keep your left arm dry - If your left arm/fingers begins to worsen after discharge home with an acute increase in swelling or pain, please call the Hand Clinic at the number given and ask to speak with a doctor. * Saline wet to dry dressing changes to penis twice daily * Follow up in the [Hospital 159] Clinic in 1 week. * Your stitches and staples will be removed by the Plastic surgeons. Medications: * Resume your regular medications unless instructed otherwise. * You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. * Take prescription pain medications for pain not relieved by tylenol. * Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication to prevent constipation. You may use a different over-the-counter stool softerner if you wish. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. Followup Instructions: Hand Clinic: ([Telephone/Fax (1) 32269] [Hospital Ward Name 516], [Hospital Ward Name 23] Building, [Location (un) ] Please follow up in the Hand Clinic on Tuesday, [2103-7-31]. You must call ([Telephone/Fax (1) 32269] to make an appointment so they know you are coming. The clinic is open from 8-12pm most Tuesdays and you may show up at any time between those hours, despite your formal appointment time. The clinic is located on the [Hospital Ward Name 5074], [Hospital Ward Name 23] Building, [Location (un) ]. Please make sure that you obtain a referral from your insurance company prior to your clinic appointment. Call the [Hospital 159] Clinic at [Telephone/Fax (1) 164] for a follow up appointment in 1 week. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2103-7-25]	[ "879.4", "816.01", "874.8", "891.0", "E816.0", "883.2", "903.5", "805.4", "861.21", "780.60", "834.11", "878.0", "805.2", "880.00", "955.6", "873.0", "816.11" ]	icd9cm	[ [ [] ] ]	[ "81.79", "79.64", "54.63", "86.61", "79.34", "83.64", "39.31", "86.59", "79.84", "64.41", "79.04", "39.56" ]	icd9pcs	[ [ [] ] ]	5866, 5872	3164, 5356	321, 998	6105, 6105	2233, 3141	8158, 9063	1382, 1400		5411, 5843		5893, 6084		5382, 5388			6256, 6256										1415, 1678																												274, 283											1026, 1284												6120, 6232			1306, 1312	1328, 1366
58,163	104,737	38392	Discharge summary	report	Admission Date: [2187-9-17] Discharge Date: [2187-9-20] Date of Birth: [2151-1-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 15287] Chief Complaint: DKA Major Surgical or Invasive Procedure: Dialysis History of Present Illness: 36M with DMI and gastroparesis recently admitted for DKA (d/c'd on [2187-8-29]) now with nausea/vomiting that started last night. Emesis is coffee-ground. Pt denies any abd pain, chest pain, dizziness, blood in stool, dark stools, cough, fever or chills. Pt last BM last night. ESRD on HD (M,W,F), missed appt today d/t symptoms. Reports glucose this morning was 211. Feels nauseaous In the ED, initial VS were: T-96.0 P 103 BP 224/122 R18 100% RA Pt was found to have AG of 29 with an initial glucose of 209. Pt was started on insulin drip and 1 L of NS bolus. Pt received 2 doses of zofran and ativan for nausea. LFTs and lipase were negative in the ED and EKG did not show any signs of ischemia. Pt gap started to close on insulin drip. On arrival to the MICU, the patient continues to complain of mild nausea. He otherwise feels well. Pt denies any chest pain, abdominal pain, fever, chills, or cough. Past Medical History: - Type I diabetes: since age 19, complicated by gastroparesis, retinopathy (laser treatment), DKA, chronic kidney disease - ESRD, on HD MWF, started [9-4]; currently on transplant list - s/p left brachiocephalic AV fistula created on [2186-7-18] s/p angioplasty of the arterial anastomosis, mid cephalic and cephalic arch, complicated by an extravasation and mid-fistula hematoma (still usable) - [Doctor Last Name 9376] syndrome - Hypertension - Asthma - HLD - chronic multifactorial anemia, on Epo, h/o pRBC transfusion x2 Social History: Lives with his parents. Denies tobacco use, alcohol use, or illicit drug use Family History: Father with CAD/MI, HLD, type II DM. Mother with thyroid cancer Physical Exam: Admission: Vitals: T:afebrile BP:189/110 P:91 R: 18 O2:98 on RA General: Alert, oriented, no acute distress; appears mildly uncomfortable HEENT: Sclera anicteric, MM slightly dry, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Tachycardic S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, mildly tender to palpation in epigastrium; no rebound or guarding GU: no foley Ext: AV fistula in left upper extremity with thrill; warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Discharge: Vitals: Patient was afebrile, normotensive, non-tachycardic, non-tachypneic, 98% on room air General: Alert, oriented, NAD HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: RRR, transmitted flow murmur from fistula, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, nontender, no rebound or guarding Ext: AV fistula in left upper extremity with palpable thrill and audible bruit, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Pertinent Results: Admission: [2187-9-17] 06:45PM BLOOD WBC-9.5# RBC-4.02* Hgb-11.5* Hct-36.4* MCV-90 MCH-28.6 MCHC-31.6 RDW-15.2 Plt Ct-218 [2187-9-17] 06:45PM BLOOD Glucose-209* UreaN-88* Creat-12.4# Na-138 K-5.0 Cl-95 HCO3-20* AnGap-28* [2187-9-17] 06:45PM BLOOD Lipase-58 [2187-9-17] 11:36PM BLOOD cTropnT-0.07* [2187-9-17] 06:45PM BLOOD ALT-18 AST-25 AlkPhos-116 TotBili-0.7 [2187-9-17] 08:43PM BLOOD Type-[Last Name (un) ] pO2-77* pCO2-48* pH-7.32* calTCO2-26 Base XS--1 Comment-GREEN TOP Pertinent: [2187-9-19] 02:30AM BLOOD Glucose-213* UreaN-36* Creat-7.0* Na-133 K-4.3 Cl-96 HCO3-29 AnGap-12 [2187-9-18] 05:18PM BLOOD Glucose-91 UreaN-27* Creat-6.1# Na-138 K-4.0 Cl-97 HCO3-33 AnGap-12 Discharge: [2187-9-20] 06:00AM BLOOD WBC-6.3 RBC-3.70* Hgb-10.7* Hct-33.5* MCV-91 MCH-28.9 MCHC-31.9 RDW-15.0 Plt Ct-172 [2187-9-20] 06:00AM BLOOD Glucose-160* UreaN-29* Creat-5.6# Na-138 K-4.4 Cl-97 HCO3-30 AnGap-15 [2187-9-20] 06:00AM BLOOD Calcium-8.9 Phos-5.8 Mg-2.1 Brief Hospital Course: Brief Course: 36M with type I DM and gastroparesis recently admitted for DKA (discharged on [2187-8-29]) who presented with nausea and coffee ground emesis and DKA. He was treated with insulin drip and received dialysis in house. Active Issues: #DKA: Likely secondary to witholding his insulin in the setting of not eating due to nausea and vomiting from gastroparesis. Anion gap was 29 on presentation with glucose of 209. Electrolytes were initially checked q 4 hours and repleted when needed until the gap was closed. Patient was started on insulin drip and transitioned to subcutaneous insulin after his gap had closed with 2 hour overlap. Patient is tolerating good PO and is discharged on his home insulin regimen. #Gastroparesis: Complication of type I DM. Likely the cause of his nausea and vomiting. Patient's outpatient GI doctor has seen the patient in the hospital. He was continued on eythromycin and metoclopramide and given zofran and prochlorperazine prn for nausea. #Coffee ground emesis: Had similar episode in [Month (only) 1096], and EGD at that time was largely normal. No more episodes while in hospital and hematocrit was stable. Maintained active type and screen. Possibly due to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tear from vomiting. PUD, gastritis also in differential. Placed on PPI. Tolerating good PO. #ESRD: Chronic secondary to diabetes, on hemodialysis MWF. The patient is currently on the dual pancreatic/kidney transplant list. He missed his Monday dialysis session because it was the day he came into the hospital, so he was dialyzed while in the hospital on Tuesday and Wednesday. He will continue his scheduled dialysis along with nephrocaps and sevelamer. #HTN: Normalized after dialysis. Pt states that BP is usually elevated prior to dialysis. He was continued on his home clonidine patch, labetolol and lisinopril without issues. Transitional Issues: 1. Code status: Full 2. Communication: Patient 3. Medication changes: None 4. Pending studies: None 5. Follow up: PCP, [Name Initial (NameIs) ] Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTUES 2. Metoclopramide 10 mg PO QIDACHS 3. Nephrocaps 1 CAP PO DAILY 4. Omeprazole 20 mg PO DAILY 5. sevelamer CARBONATE 2400 mg PO TID W/MEALS 6. Labetalol 200 mg PO TID 7. Lisinopril 10 mg PO DAILY 8. Erythromycin 250 mg PO TID 9. Insulin SC Sliding Scale Insulin SC Sliding Scale using Novolog Insulin Discharge Medications: 1. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTUES 2. Erythromycin 250 mg PO TID 3. Labetalol 200 mg PO TID 4. Lisinopril 10 mg PO DAILY 5. Nephrocaps 1 CAP PO DAILY 6. sevelamer CARBONATE 2400 mg PO TID W/MEALS 7. Metoclopramide 10 mg PO QIDACHS 8. Omeprazole 20 mg PO DAILY 9. Glargine 5 Units Breakfast Glargine 4 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home Discharge Diagnosis: Primary: DKA ESRD on dialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 14782], You were admitted for DKA. You were treated with IV insulin and transistioned back to your home insulin regimen. Your nausea resolved and you were able to tolerate food. We have made no changes to your medications. Please follow up with your doctors as described below and continue dialysis at your previous schedule. Followup Instructions: Name: [Doctor Last Name ] [Last Name (NamePattern4) 85503], MD Specialty: Endocrinology When: Tuesday [9-25] at 1pm Location: [Last Name (un) ] DIABETES CENTER Address: ONE [Last Name (un) ] PLACE, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 3402] Name: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 6104] Np Specialty: Primary Care When: Tuesday [10-2] at 2pm Location: [Hospital1 641] Address: [Street Address(2) 642], [Location (un) ],[Numeric Identifier 643] Phone: [Telephone/Fax (1) 644] Completed by:[2187-9-20]	[ "362.01", "272.4", "585.6", "250.53", "250.43", "403.91", "250.63", "493.90", "250.13", "V45.11", "277.4", "V58.67", "V49.83", "536.3" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	7339, 7345	4349, 4584	317, 328	7419, 7419	3320, 4326	7951, 8576	1945, 2011		6943, 7316		7366, 7398		6461, 6920			7570, 7928										2026, 3301										6400, 6435									6286, 6336					6356, 6389				274, 279		4599, 6265									356, 1271												7434, 7546			1293, 1833	1849, 1929
23,657	113,800	13531	Discharge summary	report	Admission Date: [2147-6-13] Discharge Date: [2147-6-15] Date of Birth: [2112-11-14] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil / Hydralazine / cefepime Attending:[First Name3 (LF) 1253] Chief Complaint: DKA, Hypertensive Urgency, Hyperkalemia Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 34 y/o M with PMHx of DM1, ESRD on HD TTR, gastroparesis with frequent hospitalizations for N/V, uncontrolled hypertension and diabetes presented to the ED with N/V and hypoxemic respiratory failure. . Began having abdominal pain, nausea, vomiting today, did not take insulin, progressively worsened, came to ED. No fevers. No shortness of breath, no chest pain. States quality of pain identical to previous episodes of gastroparesis, severity is slightly worse, however. . Prior to this admission, he states symptoms worse than his usual gastroparesis. Afebrile. No sick contacts. [Name (NI) ] recent travel or eating out. Last BM this AM, normal, nonbloody. . In the ED, initial vitals were: 98.0 110 223/119 16 100%. Initial labs were significant for an elevated potassium, creatinine of 11. An EKG demonstrated peaked T waves. He was given insulin 10 units of humulog x 3?, 2mg of calcium gluconate with repeat blood sugar in the 200s. Repeat K+ was 4.8. He was subsequently started on an insulin gtt at 7.5 units/hr in D5. He was given zofran 4mg x1, reglan 10mg, morphine 5mg x 2 and dilaudid 1mg IV for management of his abdominal pain and nausea. For management of his hypertension which was labile and ranged from 165-209/109-113 he was given 20mg IV labetolol. Admission the ICU was requested for management of labile hypertension and insulin gtt. 102 28 165/109 99% on room air. He was comfortable on transfer. . On arrival to the MICU he was comfortable in no apparent distress; his blood pressure was 160, his glucose was 246. Past Medical History: - DM type I since age 19, followed at [Last Name (un) ]. Complicated by nephropathy, neuropathy, gastroparesis, retinopathy. Multiple prior hospitalizations with DKA, nausea/vomiting [2-9] gastroparesis - ESRD on HD T/Th/S via right arm fistula @ [Location (un) ] [Location (un) ], dry weight 73kg - Hypoglycemia - Hyperglycemia/DKA: requiring insulin gtt - Hypertension - Nonischemic cardiomyopathy with EF 30-35% - Anemia: [2-9] iron deficiency and advanced CKD - Depression - Pulmonary hypertension - Migraines Social History: Lives with girlfriend. Mother also local. College degree in marketing, worked at [Company 2475] previously. Tobacco: trying to quit; relapsed and smokes ~1 pack per week EtOH: previously drank heavily (30-40 drinks/week) but has not used alcohol since [2144-11-14] Denies other drugs. Family History: Paternal grandfather had DM2. [Name2 (NI) ] FH DM1. Hypertension in a few family members. [Name (NI) 6419] [Name2 (NI) ] and several siblings alive and healthy, without known medical problems. Physical Exam: Admission Physical: . General: Alert and oriented, pleasant in no apparent distress HEENT: Sclera anicteric, slightly dry oral mucosa, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Tachycardic, Regular rhythm, normal S1 + S2, 3/6 SEM LSB, no rubs, no gallops, 18G R EJ, 22, L 4th digit Lungs: clear to auscultation bilaterally with good air movement and excursion, no wheezing or rhonchi Abdomen: soft, nontender, active bowel sounds, no rebound or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: Admission Labs: . [2147-6-12] 10:50PM BLOOD WBC-11.9# RBC-4.65# Hgb-14.1# Hct-43.7# MCV-94 MCH-30.3 MCHC-32.2 RDW-13.4 Plt Ct-158 [2147-6-12] 10:50PM BLOOD Neuts-94.2 Lymphs-3.2* Monos-2.0 Eos-0.3 Baso-0.3 [2147-6-12] 10:50PM BLOOD PT-10.0 PTT-29.9 INR(PT)-0.9 [2147-6-12] 10:50PM BLOOD Plt Ct-158 [2147-6-12] 10:50PM BLOOD Glucose-501* UreaN-52* Creat-11.3# Na-133 K-6.5 Cl-89* HCO3-16* AnGap-35* [2147-6-12] 10:50PM BLOOD ALT-21 AST-33 AlkPhos-181* TotBili-0.4 [2147-6-12] 10:50PM BLOOD Lipase-78* [2147-6-12] 10:50PM BLOOD Albumin-4.9 [2147-6-12] 11:06PM BLOOD Lactate-3.4* . Imaging: [6-12]: CT Abd/Pelvis: IMPRESSION: 1. No acute process in the abdomen and pelvis. 2. Moderate cardiomegaly and mild pulmonary edema. CXR: IMPRESSION: No focal lung consolidation. Moderate cardiomegaly and mild pulmonary edema, slightly improved from [2147-5-14]. . Brief Hospital Course: 34 y/o M with DM1, gastroparesis, HTN, non-ischemic cardiomyopathy (EF30-35%), admitted to the MICU with diabetic ketoacidosis and abdominal pain c/w gastroparesis, hypertensive urgency. # DKA- DM1 since age 19. History of uncontrolled blood glucose, also with gastroparesis and frequent N/V. Bglc on transfer to MICU 246. Anion gap = 29 on arrival to ED. ICU Course: the patient presented initially with hyperglycemia, but no initial gas to confirm acidosis, this was treated in the ED and blood sugars had normalized and the gap had closed appreciably, he was initially on an insulin drip which was discontinued the next morning when he began taking POs; he had labile blood sugars on HD2 likely due to nausea after his glargine dose and then attempting to correct for the resulting hypoglycemia. He had normalized by the morning of HD3 and was tolerating a regular diet and blood sugars were well controlled. He never needed to go back on the drip. [Last Name (un) ] was consulted and was following the patient. Floor course: Pt had labile sugars while on the floor, ranging from 60-300s. His insulin regimen was titrated. Patient left against medical advice on [6-15]. # Hypertensive urgency- History of labile BP, with multiple admissions for hypertensive urgency/emergency. Unclear etiology of labile BP. On home regimen of lisinopril, amlodipine, patch. Currently hypertension is under control, will resume home medication regimen. ICU Course: the patient received 20mg of IV labetalol in the emergency department which improved his pressures, but subsequently became hypertensive again and a nitroglycerine drip was initiated in the MICU- the patient remained on this drip through most of HD2 has he was still nauseous and would not tolerate his PO antihypertensives. The drip was discontinued on HD3 and the patient took his home medications. He never had any neuro changes, and his renal function was baseline and he was dialyzed regardless. Floor Course: BP remained stable on the floor with home labetalol and [Month/Day (4) 40899] regimen. He left AMA shortly after arriving on the floor to go to a Celtics basetball game. #HyperKalemia - in the setting of ESRD, DKA, he was treated in the ED, downtrended to 4.8. Improved with medical management and hemodialysis. # ESRD: On TuThSa HD. He was given HD for hypertensive emergency/pulmonary edema and hyperkalemia. Received HD on hospital Day 2 and 3. # Gastroparesis: patient with history of gastroparesis, receives relief with zofran, dilaudid, morphine ICU Course: treated with antiemetics and pain medications. #Against medical advice: pt left AMA. He was explained the risks and understood them well. He wanted to attend a basketball game. Medications on Admission: 1. amlodipine 10 mg Tablet daily 2. aspirin 81 mg Tablet, daily 3. [Month/Day (4) 40899] 0.3 mg/24 hr Patch Weekly qMONDAY 4. insulin glargine 14 units qAM 5. insulin lispro 100 unit/mL Solution ISS 6. B complex-vitamin C-folic acid 1 mg Capsule daily 7. lisinopril 40 mg Tablet daily 8. sevelamer carbonate 800 mg Tablet Two (2) Tablet PO TID W/MEALS 9. sertraline 50 mg Tablet [Month/Day (4) ]: Two (2) Tablet PO DAILY (Daily). 10. hydromorphone 2 mg Tablet [Month/Day (4) ]: Two (2) Tablet PO twice a day prn 11. ondansetron HCl 4 mg Tabletq8hrs prn nausea 12. labetalol 200 mg Tablet [Month/Day (4) ]: Three (3) Tablet PO BID 13. labetalol 100 mg Tablet [Month/Day (4) ]: Three (3) Tablet PO at bedtime. Discharge Medications: 1. aspirin 81 mg Tablet, Chewable [Month/Day (4) ]: One (1) Tablet, Chewable PO DAILY (Daily). 2. amlodipine 5 mg Tablet [Month/Day (4) ]: Two (2) Tablet PO DAILY (Daily). 3. [Month/Day (4) 40899] 0.3 mg/24 hr Patch Weekly [Month/Day (4) ]: One (1) Patch Weekly Transdermal QFRI (every Friday). 4. labetalol 200 mg Tablet [Month/Day (4) ]: Three (3) Tablet PO BID (2 times a day). 5. labetalol 100 mg Tablet [Month/Day (4) ]: Three (3) Tablet PO QHS (once a day (at bedtime)). 6. sevelamer carbonate 800 mg Tablet [Month/Day (4) ]: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. B complex-vitamin C-folic acid 1 mg Capsule [Month/Day (4) ]: One (1) Cap PO DAILY (Daily). 8. lisinopril 20 mg Tablet [Month/Day (4) ]: Two (2) Tablet PO DAILY (Daily). 9. sertraline 50 mg Tablet [Month/Day (4) ]: Two (2) Tablet PO DAILY (Daily). 10. lidocaine (PF) 10 mg/mL (1 %) Solution [Month/Day (4) ]: One (1) ML Injection DAILY (Daily) as needed for before dialysis. 11. Dilaudid 4 mg Tablet [Month/Day (4) ]: One (1) Tablet PO twice a day as needed for pain. 12. insulin glargine 100 unit/mL Solution [Month/Day (4) ]: Twelve (12) units Subcutaneous once a day: Breakfast. 13. insulin humalog [Month/Day (4) ]: 0-7 per sliding scale: as directed per sliding scale. Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Hypertensive Urgency Acute on chronic renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital for diabetic ketoacidosis and hypertension. You were admitted to the intensive care unit for close monitoring. Your DKA improved but your sugars and blood pressure remained labile. You decided to leave against medical advice. The risks were explained to you and you understood them. These risks include recurrent DKA, severe hypertension, death, stroke, heartattack, arrythmias. We strongly encourage you to return to the hospital if you feel sick. Weigh yourself every morning, [Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please arrange to followup with your primary care doctor and your diabetes doctors within the next few days.	[ "425.4", "V45.11", "311", "403.91", "276.7", "250.63", "585.6", "250.13", "584.9", "536.3", "250.43", "280.9", "362.01", "250.53", "416.8", "346.90", "V58.67", "357.2", "285.21" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	9433, 9439	4559, 7300	364, 378	9557, 9557	3632, 3632	10297, 10409	2841, 3047		8079, 9410		9460, 9536		7326, 8056			9708, 10274										3062, 3613																												285, 326											406, 1956							3648, 4536					9572, 9684			1978, 2514	2530, 2825
2,187	186,282	7997	Discharge summary	report	Admission Date: [2134-6-24] Discharge Date: [2134-7-2] Date of Birth: [2087-11-5] Sex: M Service: MEDICINE Allergies: Cephalosporins / Morphine / Fentanyl Attending:[First Name3 (LF) 2297] Chief Complaint: Respiratory compromise with hypoxia and hypercarbia. Major Surgical or Invasive Procedure: None. History of Present Illness: 46 year old man with a history of morbid obesity, OSA, COPD, chronic trach, who was hospitalized in [2134-4-3] with VAP (cultures + for acinetobacter and pseudomonas), who presents with fever, hypoxia and multifocal pneumonia on CXR. He initially traveled to [Location (un) 620] on [2134-6-24] with oxygen saturations between 78-82% and somnolence. He was started on ceftazidime, vancomycin, flagyl and levofloxacin. A femoral line was placed, cultures drawn, and his trach was changed from a 6.0 Shily w/o cuff to a 6.0 portex cuff trach. He was transferred to [Hospital1 18] on [2134-6-24] with a temp of 101.3, HR 110, and BP 157/83. An ABG showed pH7.24 pCO2 81 pO2 76 on 100% trach collar. He was then ventilated on PS 10/5. Repeat ABG was pH 7.24 pCO2 79 pO2 88. In the MICU, [2-6] blood cultures were positive for GPC, with sputum and urine cultures still pending. Wide spectrum antibiotics were chnaged to ampicillin, although it remains uncertain if the bacteria are, in fact, ampicillin sensitive, despite clinical improvement. Source remains uncertain. He has continued to tolerate the trach mask with high saturations on venous blood gas. He remains on 50% csm with saturations to the high 90's and a respiratory rate in the teens. Suction for the trach has remained q3-4hrs. Transferred to floor on [6-27]. Past Medical History: -DM2 diagnosed [2114] with triopathy(retinopathy, nephropathy, neuropathy): Cr has been as low as 1 in the past few months, however widely fluctuant when hospitalized 1-2.5. -COPD -Multiple episodes of respiratory failure requiring intubation in recent years (trach placed in [12/2132]) -Multiple VAP with resistent organisms: pseudomonas, MRSA, acinetobacter, citrobacter -Acalculous cholecystitis requiring cholecystostomy tube -G-tube -OSA on CPAP -VRE, S/p tracheostomy, as above in [1-7] -HTN -CHF -Anemia of chronic disease (multiple transfusions in past) -s/p BKA for chronic LE ulcer -TIA in [2125] -Difficult intubation; fiberoptic guidance in [2131-10-3]. -Urinary retention -Osteoarthritis -Depression -C. Difficile in [2129] -Hypogonadism -Morbid obesity Past Surgical History Bilateral carpal tunnel release in [2123]. Hydrocele repair in [2126-4-3]. Quadriceps tendon repair in [2127]. Status post partial resection of transverse colon, end transverse colostomy, mucus fistula, jejunostomy tube Percutaneous tracheostomy on [2132-12-16]. Social History: Social History: Lives in rehabilitation facility. Health aide comfortable with suctioning. Family History: Family History: Non contributory. Physical Exam: T 98.5 HR 68 BP 166/P RR 20 O2sat: 100% on 50%cold steam mask GENL: Obese male in NAD. Slightly sleepy but attentive and pleasant. HEENT: +trach in place. Slightly dry mucous membranes. Unable to palpate cervical nodes. CV: RRR. Normal S1 and S2. No murmur, rubs, or gallops. Lungs: On ventral side, CTA bilaterally with no wheezes or crackles. Abd: Active bowel sounds. Soft, obese, colostomy bag, midline ovaloid scar. Ext: Red brawny area on R lower leg, with no edema. 2+ right dorsalis pedis pulse. [Male First Name (un) 28635] lines in all ten fingernails. L BKA. Pertinent Results: [2134-6-27] 03:25AM BLOOD WBC-6.1 RBC-2.97* Hgb-9.2* Hct-26.3* MCV-89 MCH-30.9 MCHC-34.9 RDW-15.5 Plt Ct-167 [2134-6-24] 10:30PM BLOOD WBC-11.0# RBC-3.46* Hgb-10.5* Hct-31.1# MCV-90 MCH-30.4 MCHC-33.8 RDW-15.7 Plt Ct-197 [2134-6-25] 01:27AM BLOOD Neuts-79.2* Bands-0 Lymphs-13.3* Monos-3.7 Eos-3.3 Baso-0.5 [2134-6-27] 03:25AM BLOOD Plt Ct-167 [2134-6-24] 10:30PM BLOOD PT-12.9 PTT-27.7 INR(PT)-1.1 [2134-6-27] 03:25AM BLOOD Glucose-137* UreaN-25* Creat-1.2 Na-142 K-4.5 Cl-107 HCO3-29 AnGap-11 [2134-6-24] 10:30PM BLOOD Glucose-182* UreaN-34* Creat-1.7* Na-140 K-5.5* Cl-103 HCO3-32 AnGap-11 [2134-6-24] 10:30PM BLOOD ALT-14 AST-15 AlkPhos-44 Amylase-35 TotBili-0.4 [2134-6-27] 03:25AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.0 [2134-6-24] 10:30PM BLOOD Albumin-3.8 Calcium-9.1 Phos-4.4 Mg-1.9 [2134-6-26] 03:22PM BLOOD Type-[Last Name (un) ] pO2-33* pCO2-59* pH-7.35 calHCO3-34* Base XS-4 [2134-6-24] 10:32PM BLOOD pO2-76* pCO2-81* pH-7.24* calHCO3-36* Base XS-4 [2134-6-25] 07:07AM BLOOD Type-ART Temp-37.8 Rates-14/ PEEP-5 FiO2-50 pO2-105 pCO2-45 pH-7.44 calHCO3-32* Base XS-5 Intubat-INTUBATED Vent-CONTROLLED [2134-6-26] 12:11PM BLOOD K-4.4 [2134-6-24] 10:32PM BLOOD Glucose-185* Lactate-1.3 Na-139 K-5.6* Cl-102 [2134-6-28] ECHO - The left atrium is mildly dilated. There is symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. No vegetation seen (cannot exclude). Brief Hospital Course: The patient is a 46 yo M with h/o morbid obesity, OSA, COPD, chronic trach, recent hospitalization in [4-/2134] with VAP with cultures + for acinetobacter and pseudomonas who presented to [Location (un) 620] on [6-24] with O2 sats of 78-82% and somnolence. He was given ceftazidime, vancomycin, flagyl and levofloxacin. Cultures were drawn. His trach was changed from a 6.0 Shily w/o cuff to a 6.0 portex cuff trach. He was transferred to [Hospital1 18] where he was febrile to 101 and his ABG was notable for pH 7.24 pCO2 81 pO2 76 on 100% trach collar. He was then ventilated on PS 10/5. Repeat ABG was pH 7.24 pCO2 79 pO2 88. He was started on vanco/gent. While in the MICU, his respiratory status improved and his blood cultures were notable for [2-6] Enterococcus so his abx were changed to ampicillin and he defervesced (he will need to complete a 14 day course of amp - to be completed on [2134-7-9]). He was transferred to the floor on [6-27]. He did well until pm of [6-29] when he became tachypneic. The tachypnea improved with suctioning. On [6-30], he again became tachypneic to RR 40s and O2 sats decreased to 79% on 40% trach mask. Respiratory therapy got little mucus return with suctioning so they bagged him with improvement in O2 sats to 99%. He was changed to 100% trach mask with O2 sats 97-99% but continued tachpnea in 30s so he was transferred to the ICU team for PS o/n. The patient was supported on pressure support ventilation and his setting were weaned down. He did well with a trach mask on [2134-7-2]. His blood pressure continued to be elevated. He was restarted on his home labetalol and clonidine. He was started on captopril which was titrated up during the course of admission. If his BP remains elevated at rehab, his clonidine dose can be increased. Regarding the patients chronic back pain, he was given PO dilaudid PRN which was sufficient for pain control. Increasing his pain medication should be avoided. The patient was hypoglycemic at times during his MICU course. His home insulin regimen was Insulin Glargine 50 units [Hospital1 ] and Humalog SS. His glargine was cut in half to 25 units [Hospital1 ]. If his sugars are elevated while at rehab, his lantus can be increased back to his home regimen. Discharge Medications: 1. Acetaminophen 325 mg Tablet [Hospital1 ]: Two (2) Tablet PO Q6H (every 6 hours) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: 5000 (5000) units Injection TID (3 times a day). 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 40 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Paroxetine HCl 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 6. Trazodone 100 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime) as needed. 7. Olanzapine 5 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day) as needed. 8. Clonidine 0.1 mg Tablet [Hospital1 ]: Two (2) Tablet PO BID (2 times a day). 9. Gabapentin 300 mg Capsule [Hospital1 ]: One (1) Capsule PO TID (3 times a day). 10. Clonazepam 1 mg Tablet [Hospital1 ]: Two (2) Tablet PO TID (3 times a day). 11. Hydrocodone-Acetaminophen 5-500 mg Tablet [Hospital1 ]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Docusate Sodium 100 mg Capsule [Hospital1 ]: Two (2) Capsule PO BID (2 times a day). 13. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed. 14. Ampicillin Sodium 2 g Recon Soln [Hospital1 ]: Two (2) g Injection Q6H (every 6 hours) for 7 days: last day should be [2134-7-9]. 15. Tramadol 50 mg Tablet [Month/Day/Year ]: Two (2) Tablet PO QID (4 times a day). 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Month/Day/Year ]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply to left shoulder. 17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 18. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [Last Name (STitle) ]: [6-10] Puffs Inhalation Q4H (every 4 hours). 19. Fluticasone 110 mcg/Actuation Aerosol [Month/Day (3) ]: Four (4) Puff Inhalation [Hospital1 ] (2 times a day). 20. Lorazepam 0.5 mg Tablet [Hospital1 ]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for anxiety. 21. Labetalol 200 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day). 22. Captopril 25 mg Tablet [Hospital1 ]: Two (2) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Hospital1 ] Discharge Diagnosis: Congestive heart failure Edema Enterococcus Bacteremia Discharge Condition: Good. Blood pressure slightly elevated. Will need to continue to titrate up medications at rehab. Discharge Instructions: If you develop any shortness of breath, difficulty breathing, heart palpitations, worsening leg edema, or any other concerning symptoms, please call your doctor or go to an emergency department. Continue on a low sodium diet (2 gm sodium diet). Followup Instructions: --Please make as appointment to see Dr. [Last Name (STitle) 22882] ([Telephone/Fax (1) 28634]) within the next 1 week for blood work and a follow up appointment.	[ "327.23", "790.7", "250.50", "V49.75", "496", "583.81", "401.9", "715.90", "250.40", "428.0", "490", "285.29", "357.2", "518.81", "257.2", "041.04", "276.7", "250.60", "278.01", "V55.3", "V12.59", "V44.0", "362.01", "311", "486", "799.02" ]	icd9cm	[ [ [] ] ]	[ "96.07", "38.93", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	10267, 10342	5601, 7907	349, 356	10441, 10543	3639, 5578	10837, 11010	2999, 3019		7930, 10244		10363, 10420					10567, 10814										3034, 3620																												257, 311											384, 1739															1761, 2857	2889, 2967
24,747	100,283	45148	Discharge summary	report	Admission Date: [2168-12-5] Discharge Date: [2168-12-21] Date of Birth: [2092-6-6] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 2499] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Placement of left sided chest tube Placement of left sided pleuridex catheter History of Present Illness: 77F with NSCLC (LUL involvement, lymphangitis spread, pleural involvement, recurrent L pleural effusion though not pleurodesis candidate, brain mets) s/p cycle #2 paclitaxal/[Doctor Last Name ] ([11-24]), presenting with dyspnea (RR=35) and hypoxia (81%RA). Pleural effusion last drained about 1.5wks PTA. Admision CXR showeed L white out and mediastinal/tracheal shift. ED unable to localize fluid with US for tap. Pt needed CT scan, but unable to lie flat, so she was intubated. Post intubation pt had immediate blood pressure drop responsive to fluids (2 liters), then continuing to have intermittent hypotension requiring bolusing despite minimum sedation and required norepinephrine x2days intermittently. Pt had equivocal cortasyn stimtest to 18.1 but started on stress dose steroid along with fludricorsone for low Na. Pt also transfused 4U PRBCs for hct of 25 with inapropriate rise to 30 although blood loss was thought to be lost in serosanguinous CT drainage and Hct stable for last 24h. On admission to MICU pt started on Cefepime, Vancomycin and Gentamycin due to fever and ANC of 340 and suspected sepsis, which was weaned to only vancomycin on [12-8] due to positive Bld Cx for coag neg staph [1-31] on [12-5]. Pt given GCSF with good effect and ANC up to 1800 yesterday. Admission CT also showed small subsegmental RLL PE but anticoagulation held due to brain mets. CT also showed enormous Left sided effusion with two fluid levels suggestive of hemothorax, mass effect w/ shift of mediastinum to Right. In face of tenuous BP + possible hemothorax, CT [Doctor First Name ] placed Left Chest Tube for volume drainage (2100cc removed). Due to continued large amount of drainage she was planned for pleuradesis with doxycyline which was performed [2168-12-9] with plan for repeat tomorrow. Past Medical History: Past Medical History 1. Mild hypertension medicine controlled 2. diabetes mellitus type 2 diet controlled 3. mild osteoarthritis 4. elevated cholesterol diet controlled 5. s/p cystic breast lesion removal four years ago 6. s/p treatment of fungal meningitis 40 years ago. Social History: Social History Lives with son, She smoked less than one to two cigarettes per day for over 30 years but quit since [2144]. There is no history of ETOH. There is no history of IV drug use. She lives currently with son in [Name (NI) ]/[State 350]. There is no transportation support. She works in a grocery store. Family History: Family History Mother died of uterine cancer, father died of myocardial infarction at age 80, bothers and sisters did not have cancer, do have history of hypertension. Physical Exam: Temp 97.5 BP 135/96 Pulse 106 irreg RR 14 O2 Sat's 97% 2lNC Gen - Alert, no acute distress HEENT - PERRL, anicteric, mucous membranes moist arcus senilis bilat Neck - RIJ in place, no elevated JVD, no cervical lymphadenopathy, thyroid nonpalp, Chest - severe crackles 1/2 up bilat, good air movement at rt apex, dullness at bases bilat CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds Back - No costovertebral angle tendernes Extr - No clubbing, cyanosis, or edema, 1+edema to ankles bilat Neuro - Alert and oriented x 3, 5/5 strength in flexors and extensors of upper and lower extrem bilat, distal sensation intact, [3-30] recall at 3 and 5 min Pertinent Results: [2168-12-20] 08:00AM BLOOD WBC-5.4 RBC-2.97* Hgb-8.8* Hct-27.6* MCV-93 MCH-29.8 MCHC-32.1 RDW-16.0* Plt Ct-68* [2168-12-11] 05:30AM BLOOD WBC-10.4 RBC-3.50* Hgb-10.5* Hct-31.7* MCV-91 MCH-30.0 MCHC-33.2 RDW-15.7* Plt Ct-98* [2168-12-4] 08:36PM BLOOD WBC-1.4* RBC-3.06* Hgb-9.1* Hct-26.9* MCV-88 MCH-29.9 MCHC-34.0 RDW-13.5 Plt Ct-193 [2168-12-20] 08:00AM BLOOD Plt Ct-68* [2168-12-9] 05:49AM BLOOD Plt Ct-114* [2168-12-4] 08:36PM BLOOD Plt Ct-193 [2168-12-17] 03:00PM BLOOD FDP-80-160* [2168-12-17] 03:00PM BLOOD Fibrino-531# D-Dimer-5943 [2168-12-8] 04:00AM BLOOD Gran Ct-1800* [2168-12-20] 08:00AM BLOOD Glucose-85 UreaN-10 Creat-1.1 Na-142 K-4.8 Cl-103 HCO3-30* AnGap-14 [2168-12-4] 08:36PM BLOOD Glucose-169* UreaN-24* Creat-1.4* Na-130* K-6.2* Cl-96 HCO3-24 AnGap-16 [2168-12-5] 01:09PM BLOOD CK(CPK)-242* [2168-12-5] 01:09PM BLOOD CK-MB-5 cTropnT-0.05* [2168-12-20] 08:00AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.8 [2168-12-5] 05:30AM BLOOD Hapto-189 [12-18] CXR There is an increasing hydropneumothorax in the left hemithorax since [2168-12-14]. The right lung is clear. The right IJ line has been removed. [12-13] Chest CT 1) Interval placement of left-sided chest tube with decrease in large left- sided pleural effusion with shift of the mediastinum back to the left. Small pneumothorax with loculated hydropneumothorax. 2) Partial re-expansion of the left lung with patchy opacities. These likely represent areas of atelectasis. 3) Scattered nodules within the right lobe and spiculated mass within the left upper lobe appears stable in short interval. 4) Right renal mass, left adrenal mass and osseous lesions again identified Brief Hospital Course: Pleural Effusion-Pt with known longstanding left sided malignant effusion. CT placed in the ED as per HPI and pt intubated due to inability to lay flat for CT to evaluate effusion but was quickly weaned. Pt had doxycyline Pleurodesis on [12-9] and 14 and CTube removed [12-13] due to pt discomfort and continued low grade fevers. She continued to have dullness at her left base with complete whiteout of L hemithorax except for area of pneumothorax on follow-up CXR, so IP saw pt and placed pleuridex [12-18] and drained 500cc serous fluid with plan for weekly pleurocentesis in pulmonary clinic. She was breathing comfortably and had O2Sats of 94% on room air upon discharge. Pancytopenia-Due to recent chemotherapy with paclitaxol/carboplatin although counts responded briskly to GCSF except for platelets. She was initially treated as neutropenia and sepsis due to hypotension and fever with Vancomycin, gentamycin, cefepime which were discontinued on transfer to the floor since no culture data was positive. Pt has history of thrombocytopenia, and platelet count was slowly declining. We started procrit and followed CBC daily. HitAb neg but held on heparin for HIT I. DIC panel negative. There were no known offending meds but did change ranitidine for protonix since it was only suspected med. Hypotension-Pt had acute episode of hypotension with intial intubation which responded well to aggressive fluid boluses. Pt had corasyn stim test to rule out adrenal insuffuciency which was equivocal at 18, so she was started on stress dose steroids. She was also placed on fludricorisone due to an elevated potassium and low sodium. Pt remained normotensive upon transfer to the floor on [12-10] and weaned off of steroids since there was no suspected reason for acute adrenal insufficiency. BP and lytes remained stable for the remaineder of her hospitalization except for mild hypernatremia that responded well to encouragement of free water intake. SVT-Pt with new afib per attg. Pt with LAA in previous ECG most likely due to longstanding HTN. Acute hypotension and stressed state may have contributed. No anticoagulation since it was thought to be transient. PE-Pt with known subsegmental PE on admission CT. Pt with appropriate sats on room air. SC heparin stopped for HIT possiblity and didn't anticoagulate initially due to brain mets although attending considering anticoagulation. No role for repeat CTPA since she has known PE. Oral thrush-Due to steroid use. Improving on clotrimazole lozenges now that steriods stopped. NSCLC-Pt receiving chemo prior to admission and effusion is not reason to stop treatment. Will restart chemo if Plat ct >100 per attg likely Iressa. Chest CT shows no interval change in size of pulmonary nodules post chemo. DM-Pt had poorly controlled blood sugars while on steroids, but were controlled to <150 when steroids weaned. She was initially on RISS but this was discontinued with steroid taper. Pain-Patient had pain at CTube site initially which was well controlled with oxycontin 10mg q12hours. Percocet prn was added with increasing pain after placement of tunneled pleuridex but plan is to wean as tolerated. 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. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). Disp:12 syringes Refills:2 4. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release 12HR(s) Refills:2 5. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). Disp:120 Troche(s) Refills:2 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). Disp:qs Refills:2 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. Disp:qs ML(s) Refills:0 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:150 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Malignant left pleural effusion Discharge Condition: Stable oxygen saturation on room airHemodynamically stable Discharge Instructions: If you experience any increasing chest pain, shortness of breath, cough, fever or chills you should call your doctor, but if he/she is not available you should go to the emergency room.	[ "284.8", "198.3", "427.31", "250.00", "518.81", "276.9", "401.9", "197.2", "162.3", "458.29", "V15.3", "415.19", "112.0" ]	icd9cm	[ [ [] ] ]	[ "34.04", "96.04", "96.71", "99.04", "38.93", "34.92", "96.6", "34.09" ]	icd9pcs	[ [ [] ] ]	10119, 10198	5600, 8787	343, 423	10274, 10334	3866, 5577		2937, 3107		8810, 10096		10219, 10253					10358, 10546										3122, 3847																												284, 305											451, 2283															2305, 2579	2595, 2921

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