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9,016	132,637	11093+56167	Discharge summary	report+addendum	Admission Date: [2180-11-20] Discharge Date: [2180-11-28] Date of Birth: [2103-10-20] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[First Name3 (LF) 287] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Intubation for respiratory distress. History of Present Illness: 77 YO F W/ CAD, MVR, CHF, recently dc'd after prolonged hospitalization for L MCA stroke. Pt has residual Broca's and r hemiparesis. During that hosp sta was intubated (chf?) w/ difficulty weaning and mult episodes of resp distress post extubation. These were treated w/ IV Lasix. Discharged w/ PEG on [11-1], was well at [Hospital1 ] until [11-19] when found to be tachypneic to 40s, sats around 90%. Given Lasix 20mg IVP, morphine, nitro w/o diuresis. In ED, tachypneic to 30s, 98 NRB. Again given lasix w/o improvement and was subsequently intubated. Past Medical History: 1. Mitral valve replacement with porcine valve, [2179]. Course complicated by respiratory failure. 2. Left vertebrobasilar artery aneurysm found during follow-up for mitral valve replacement. Failed to follow-up with Dr. [Last Name (STitle) 1132] as an outpatient for evaluation of aneurysm. 3. Stroke, 20 years ago. Unclear what his symptoms were at that time, but no residual deficits. 4. Coronary artery disease s/p CABG 5-6 years ago with LIMA to LAD, SVG to distal circumflex marginal and SVG to PDA. Also with multiple stents. 5. Congestive heart failure 6. Rectal cancer status post resection with resultant colostomy, [2177] . No history of chemotherapy or radiotherapy. 7. Hypercholesterolemia 8. Hypertension 9. Gout 10. Status post burn injury to hands as child, status post grafting 11. MRSA positive 12. Chronic renal insufficiency 13. Peripheral vascular disease 14. 50-79% left ICA stenosis on ultrasound 15. History of bacterial endocarditis 16. Degenerative joint disease 17. Hypothyroidism All: Aspirin results in rash, but he reported taking it nevertheless. Social History: Retired construction worker. Emigrated from [Country 2559] as ayoung adult. Moved to [Location (un) 86] at age 30. Smoked 1.5 packcigarettes daily for 40 years; quit 25 years ago. No alcohol ordrug use. Lives with wife. Daughter and son in area and activelyinvolved in care. Speaks English but Italian in primary language. Family History: Brother deceased from stroke at age 77. Coronary artery disease in brother and father. Mother with stroke in her 80s. Physical Exam: tm 101.9, 120/55, p 85, r14, AC vt 500, PEEP 5.0, 100% o2. Sedated, intubated. PERRL Regular S1,S2. difficutl to auscultate heart sounds LCA anteriorly. +bs. soft. nd. no le edema. missining digits of ea hand. Pertinent Results: CBC: [2180-11-20] 06:25AM WBC-7.6 RBC-4.05* HGB-12.2* HCT-39.1* MCV-97 MCH-30.1 MCHC-31.2 RDW-15.0 [2180-11-20] 06:25AM PLT COUNT-154 [2180-11-20] 06:25AM PT-14.0* PTT-28.6 INR(PT)-1.2 Chemistries: [2180-11-20] 06:25AM GLUCOSE-100 UREA N-46* CREAT-1.2 SODIUM-151* POTASSIUM-4.6 CHLORIDE-113* TOTAL CO2-29 ANION GAP-14 [2180-11-20] 06:25AM CALCIUM-7.7* PHOSPHATE-2.9 [2180-11-20] 06:25AM CK-MB-4 cTropnT-0.09* [2180-11-20] 06:25AM CK(CPK)-247* UA negative CTA: no pe, RLL infiltrate. ECG: Sinus tach @115, RBBB, STd in V2-V4. CT head: progression of MCA infarct Brief Hospital Course: 77yo m w/ cad, chf now w/ acute respiratory failure (hypoxemic), RLL infiltrate, and failure to respond to Lasix. 1) Resp failure -likely [2-14] PNA. Pt had low cvp ([1-16]) on admission and RLL infiltrate c/w PNA. Started on zosyn and vancomycin for coverage of nosocomial infection. Pt was received intubated and was remained on the ventilator until hospital day 6. The patient had some difficulty preparing to wean from the vent, with RSBIs around 100. His respiratory status was limited by copious secreations. On previous admission, h/o developing acute pulmonary edema, so the patient was diuresed prior to extubation. He was maintained on a nitro gtt titrated to bp approx 110 systolic during the extubation period, but was rapidly titrated off once stable on NC. On discharge, slightly elev rr in high 20s, sating 96% on ra. Patient should complete seven more days of zosyn and vancomycin. . 2) CAD- ST depression present on ECG at admission concerning for demand ischemia. Initial troponin elevated, and subsequent troponins also mildly increased (approx 0.3). Low clinical probability for ACS given negative cks and story c/w increased demand. ECG changes resolved on Hospital day 1 following stabilization of his respiratory status. Pt was continued on his metoprolol at the dose of 12.5mg [Hospital1 ], and statin, his ACEI had been held to allow for additional BP room for diuresis with lasix. The patient was re-started on his ACE inhibitor (lisinopril 2.5mg once daily) and aggrenox at time of discharge. In addition, he was also maintained on lasix 20mg PO once daily to maintain euvolemia while admitted. . 3) Hypernatremia- Initial sodium of 153 suggested a 4L free water deficit on admission. Deficit was corrected over >48 hours w/ free water boluses and D5W. Loss likely [2-14] to overdiuresis w/ furosemide given hx and initially low cvp. To prevent further episodes of hypernatremia, suggest maintaining free water intake in the form of free water flushed with tube feeds. . 4) Thyroid- continued outpatient synthroid. Medications on Admission: synthroid 25mcg prevacid 30mg qd lopressor 12.5 mg [Hospital1 ] albuterol/atrovent mdi MVI sodium bicarb flagyl cefotaxime celexa dipyridamole RISS lactulose bisacodyl reglan Discharge Medications: 1. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 6. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Piperacillin-Tazobactam 4-0.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 7 days. 10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Dipyridamole-Aspirin 200-25 mg Capsule, Multiphasic Release Sig: One (1) Capsule, Multiphasic Release PO twice a day. 12. Lactulose 10 g/15 mL Syrup Sig: One (1) PO once a day. 13. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day. 14. Reglan 5 mg Tablet Sig: One (1) Tablet PO once a day. 15. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous once a day for 7 days. 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 17. Impact/Fiber Liquid Sig: Seventy (70) cc/hour PO continuous through PEG tube at 70cc/hour. 18. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: Pneumonia Secondary: CAD, CVA, CHF Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L Please take all of your medication Please follow up with your doctors. If you notice any further episodes of shortness of breath please contact your physician. Followup Instructions: Please follow up with yout primary care provider within two weeks of discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 288] MD, [MD Number(3) 289] Completed by:[2180-11-27] Name: [Known lastname 6203],[Known firstname 6204] Unit No: [Numeric Identifier 6205] Admission Date: [2180-11-20] Discharge Date: [2180-11-28] Date of Birth: [2103-10-20] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[First Name3 (LF) 35] Chief Complaint: . Major Surgical or Invasive Procedure: . History of Present Illness: . Past Medical History: . Social History: . Family History: . Physical Exam: . Pertinent Results: . Brief Hospital Course: Pt appears slightly uncomfortable this afternoon, correlating w/ onset of [Last Name (un) 6160]-[Doctor Last Name ] respiratory pattern. In this patient, the most likely etiology is heart failure (pt would be at risk given that he likely has at least NYHA III dz). He has maintained oxygenation on room air and his blood pressure (although his bp occasionally nadirs down to 90 systolic) and heart rate have remained stable. He has no other localizing symptoms or signs of infection and remains clinically well. The patient is slightly volume up (~500cc) today and may require additional diuresis. We restarted his furosemide at 40mg po qday today which he received this morning. Medications on Admission: . Discharge Medications: . Discharge Disposition: Extended Care Facility: [Hospital3 14] & Rehab Center - [Hospital1 15] Discharge Diagnosis: . Discharge Condition: . Discharge Instructions: . Followup Instructions: . [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 36] MD, [MD Number(3) 37] Completed by:[2180-11-28]	[ "V10.05", "276.0", "486", "V45.81", "401.9", "438.20", "428.0", "244.9", "414.8", "V42.2", "518.81", "438.11" ]	icd9cm	[ [ [] ] ]	[ "96.72", "96.04", "96.6" ]	icd9pcs	[ [ [] ] ]	9321, 9402	8550, 9243	8390, 8393	9447, 9450	8524, 8527	9500, 9658	8484, 8487		9295, 9298		9423, 9426		9269, 9272				9474, 9477									8502, 8505																										8349, 8352							8421, 8424		3360, 3388																8446, 8449	8465, 8468
5,772	151,382	49713	Discharge summary	report	Admission Date: [2170-8-20] Discharge Date: [2170-8-24] Date of Birth: [2106-1-30] Sex: F Service: MEDICINE Allergies: Zestril / Omeprazole Attending:[First Name3 (LF) 5266] Chief Complaint: Somnolence, dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 64 yo F w/ PMH significant for Iron Deficiency anemia, DM, Obesity, OSA, CHF, CKD and h/o PE s/p IVC filter who presents to ED c/o somnolence and SOB. Visiting RN saw pt and reported that she had LLL crackles and had been increasingly somnolent during the day. VNA went to check on her and she was very somnolent. Pt herself says she has been very sleepy for months and noted more sleepiness during the day over the past week. She has a home BiPAP machine for diagnosed Sleep apnea but states she has not used the machine in last few days because of poor mask fit and felt her forehead was irritated from it. Pt reports feeling more SOB with exertion and malaise although feels she is not far from her baseline. Denies chest pain, palpitations. Reports cough but no sputum, denies fevers/chills or night sweats. Denies N/V, does report 1 episode of loose stool yesterday but no diarrhea. Reports decreased PO intake. Denies dysuria but does report + frequency. Denies any sick contacts. [Name (NI) ] recent travel. No change in LE swelling or calf tenderness. Past Medical History: - Pulmonary embolism x2, now s/p IVC filter; Post-op pulmonary emboli ([2160]); Sadddle embolus (1/[2168]). Currently on coumadin. - History of bleeding: Abominal wall, thigh and vitreous bleeding - DM2: Complicated by neuropathy and retinopathy - chronic diastolic congestive heart failure by TTE [3-/2170], EF 55% on ECHO [3-31] - Chronic lower extremity edema - Obstructive sleep apnea on BiPAP at night - Obesity - Osteoarthritis - Fibromyalgia - Depression - History of L4-5 herniated disc, status post steroid injections - History of thoracic osteomyelitis status post 6 week treatment with vancomycin - CKD (baseline creatinine 1.0-1.5) - s/p appendectomy - s/p cholecystectomy - s/p partial hysterectomy - legally blind from diabetic retinopathy Social History: Pt lives at in a home she [Last Name (un) ] in [Location 17065], MA. She lives alone in an unit, while her daughter lives upstairs in the same house. She has a VNA and a home health aide. She quit smoking > 20 years ago - she started at age 13 with 1 pack per day and then increased to 2-3 packs per day until she quit. She denies alcohol or recreational drugs. Family History: Her brother had a stroke at age 65. There is a family history of diabetes, hypertension, and multiple sclerosis. Physical Exam: V/S: 97.5, 116/45, 69, 12, 98% 4L NC GEN: Middle aged female, lying in bed with BIPAP in place comfortably conversing; alert and interactive. HEENT: NC/AT, EOMI, PERRL, O/P clear no lesions Neck: No adenopathy, JVP unable to assess [2-24] body habitus CV: RRR no murmurs/rubs PULM: Rhonchi in RUL otherwise clear, no crackles or wheezing ABD: Obese, soft, NT, ND +BS, no rebound/guarding Ext: 2+ non-pitting edema, no calf tenderness, no clubbing/cyanosis Skin: 3cm open lesion/erythema on lateral thighs; no pus or oozing, dressing in place R. Foot ulcer healed; closed. No erythema Bilateral LE has mild erythema, no warmth, non-tender NEURO: A&Ox3, CN 2-12 grossly intact, sensation intact throughout. Pertinent Results: Admission Labs: WBC-6.4 Hgb-12.0 Hct-39.4 MCV-89 MCH-27.0 MCHC-30.5* Plt Ct-214 Neuts-76.4* Lymphs-17.4* Monos-2.3 Eos-3.5 Baso-0.4 PT-36.4* PTT-31.9 INR(PT)-3.9* Glucose-429* UreaN-78* Creat-2.1* Na-136 K-4.1 Cl-94* HCO3-32 Type-ART pO2-72* pCO2-64* pH-7.36 calTCO2-38* Base XS-7 BLOOD Lactate-2.2* %HbA1c-7.7* URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.009 URINE Blood-SM Nitrite-POS Protein-NEG Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD URINE RBC-4* WBC->50 Bacteri-MOD Yeast-NONE Epi-[3-28] URINE Hours-RANDOM UreaN-663 Creat-85 Na-22 [2170-8-20] 7:49 pm URINE Source: Catheter. FINAL REPORT [2170-8-22] URINE CULTURE (Final [2170-8-22]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. 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------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R . . Discharge Labs: WBC-7.6 Hgb-11.3* Hct-35.3* MCV-85 MCH-27.3 MCHC-32.1 Plt Ct-226 PT-18.5* INR(PT)-1.7* Glucose-197* UreaN-84* Creat-1.5* Na-137 K-3.8 Cl-95* HCO3-32 . Studies: [2170-8-20] ECG: Sinus rhythm with atrial premature depolarizations. Borderline left axis deviation. Possible left anterior fascicular block. Non-diagnostic repolarization abnormalities. Compared to the previous tracing of [2170-7-25] no major change. . [2170-8-20] CXR PA & LAT FINDINGS: AP upright and lateral views of the chest were obtained. The study is limited by underpenetration due to body habitus. Lung volumes are low, but stable in comparison to [2170-7-25]. The lungs are clear, without focal airspace consolidation or effusion. Cardiac size is stable. Pulmonary vasculature is within normal limits. Hilar structures are normal. IMPRESSION: No acute intrathoracic process within the limitations of the study. Brief Hospital Course: 64 year old female with anemia, obstructive sleep apnea and a history of pulmonary embolisms who presented with increasing somnolence and mild dyspnea that improved after holding all narcotics and resuming BiPAP overnight. . 1. Somnolence: Initially the patient was placed in the MICU due to her hypercarbic respiratory failure. Her home narcotic use for chronic pain and her recent non-use of her BiPAP machine at home likely contributed to her somnolence. Initially narcotics were held and the patient was put back on BiPAP and she became more alert. She was transfered to the floor and narcotics were tapered per the recommendations of the patient's PCP, [Name10 (NameIs) ] she remained alert for the remainder of her hospitalization. . 2. Dypsnea: The patient's initial dyspnea was likely related to ongoing chronic obstructive pulmonary disease and obstructive sleep apnea. Despite the patient's history of pulmonary emboli, there was low concern for this because she did not have acute hypoxia, she has an IVC filter, and she had a supratherapeutic INR on admission. Her dypsnea resolved with nebulizers and BiPAP therapy. She maintained good oxygen saturation and had no further shortness of breath for the duration of her hospitalization. . 3. Urinary Tract Infection (UTI), Recurrent: The patient had a positive urine analysis on admission and had a recent admission with a UTI growing pan-sensitive E. coli, although she does have a history of resistant UTIs. She was started on ciprofloxacin empirically for her UTI, and then changed to cefpodoxime 3 days later when sensitivities showed that the E. coli UTI was resistant to ciprofloxacin and sensitive to ceftriaxone. The patient was afebrile without a remarkable white count throughout her admission. She had no symptoms of dysuria. She received 2 days of cefpodoxime while hospitalized and was discharged on 8 additional days of treatment for a total of 10 days of therapy for complicated/recurrent UTIs. . 4. Acute on Chronic Renal failure: The patient has a history of Stage III chronic kidney disease secondary to high dose loop diuretics and metolazone. She is followed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] as an outpatient. Her baseline creatinine is 1.0-1.5. It was elevated to 2.1 on admission. Urine lytes were consistent with a pre-renal picture. After IVF's the pt's creatinine improved to 1.5. Medications were renally dosed. . 5. Diabetes, type 2, uncontrolled: The patient had an elevated glucose on admission. She was initially started on her Lantus regimen and ISS, but continued to be hyperglycemic. Of note, her HbA1c was elevated at 7.7. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] diabetes consult was obtained, and over a couple of days her lantus was increased from 50 to 70 QHS and her sliding scale was increased as well. She has a follow-up appointment at the [Last Name (un) ] for further management of her diabetes. . 6. Obstructive Sleep Apnea: The patient had not been using her home BiPAP machine for several days prior to admission as it had been rubbing her forehead and causing her discomfort. She tried several alternative masks during her hospitalization and eventually did find one that fit better than her home mask. She is followed by the sleep clinic as an outpatient and is scheduled to have someone come to her home to help find a better mask fit. . 7. Cardiac: The patient has a history of diastolic congestive heart failure, however she did not appear to be volume overloaded on exam. Her ECG was without ischemic changes. She was continued on bumex, metolazone, aspirin, metoprolol and simvastatin. . 8. Excoriations/Ulcer/Skin Care: The patient had bilateral lateral thigh excoriations that were oozing on admission, likely due to her elevated INR. The wounds did not appear infected, however a wound care consult was requested for assistance with proper skin care. The patient also had a healing ulcer on her left heel that remained stable. She was continued on nystatin per her home regimen. . 9. Anticoagulation: The patient has a history of both pulmonary emboli as well as bleeding episodes. She had a supratheraputic INR on admission. Her coumadin was initially held given the elevated INR and that she was started on a fluoroquinolone antibiotic which can also elevate the INR. Daily INRs were checked. As her INR drifted downward, she was restarted on a lower dose of warfarin and was eventually restarted on her home dose on the day of discharge. Her coumadin clinic was called and she was felt to be safe for discharge despite having a subtherapeutic INR. She will have her INR checked next week through her usual home services. Medications on Admission: ALLOPURINOL - 100 mg daily BUMETANIDE [BUMEX] - 2 mg [Hospital1 ] CALCITRIOL - 0.25 mcg Capsule - 3x/week CITALOPRAM [CELEXA] - 40 mg qday FLUTICASONE - 50 mcg; [1-24] sprays daily FLUTICASONE [FLOVENT HFA] - 110 mcg 2 puffs [Hospital1 ] GABAPENTIN - 300mg daily LANTUS - 50 units qhs at bedtime ATROVENT 17 mcg 2 puffs QID LISPRO sliding scale METOLAZONE - 2.5 mg daily METOPROLOL TARTRATE - 12.5mg [Hospital1 ] NYSTATIN -apply to groin TID OXYCODONE - 5 mg Tablet - [1-24] Tablet(s) by mouth every 4-6 hours OXYCODONE [OXYCONTIN SR] - 30 mg Tablet Sust [Hospital1 ] PRAMIPEXOLE [MIRAPEX] - 0.5 mg Tablet - 2 Tablet by mouth each morning, and 1 tabs at bedtime [Hospital1 ] SULFADIAZINE [SILVADENE] - 1 % Cream - apply to areas every other day SIMVASTATIN - 10 mg qhs WARFARIN - 2mg daily Maalox prn ASPIRIN - 81 mg daily Colace 100mg [Hospital1 ] PRN MVI SENNA PRN Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 4. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Nystatin 100,000 unit/g Powder Sig: One (1) application Topical three times a day. 7. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3x per week. 9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: [1-24] Sprays Nasal DAILY (Daily). 12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Tablet, Delayed Release (E.C.)(s) 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 16. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 8 days: Last day = [2170-8-31]. Disp:15 Tablet(s) Refills:0 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 18. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. 19. Pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO QAM. 20. Pramipexole 0.5 mg Tablet Sig: Two (2) Tablet PO at bedtime. 21. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 22. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:6 Tablet Sustained Release 12 hr(s) Refills:0 23. Warfarin 2 mg Tablet Sig: 6 mg Monday, Wednesday, and Friday; 8 mg on Tuesday, Thursday, Saturday, Sunday Tablets PO Qday16. 24. Insulin Glargine 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous at bedtime. 25. Insulin Lispro 100 unit/mL Solution Sig: according to sliding scale Subcutaneous QIDACHS. Discharge Disposition: Home With Service Facility: [Hospital6 1952], [Location (un) 86] Discharge Diagnosis: Primary Diagnoses: Somnolence Dyspnea Obstructive Sleep apnea Diabetes, type 2 Urinary Tract Infection Secondary Diagnoses Chronic Pain Discharge Condition: Stable, satting well on room air, alert Discharge Instructions: You were admitted to the hospital because of somnolence and difficulty maintaining your oxygenation. With a decrease in your narcotics dose and use of a BIPAP machine, you became more alert and were able to maintain your oxygen saturation. The following changes were made in your medications: Your insulin was increased to glargine 70 units at night. Your sliding scale insulin was increased to 23 units for a blood sugar of 80-120, then 25 units for 121-160, then 28 units for 161-200, then 31 units for 201-241, and so forth, increasing by 3 units. You bedtime sliding scale was increased to 4 units for a blood sugar of 121-160, then increase by 2 units for every 40 point increase in blood sugar. You were started on the antibiotic cefpodoxime to treat a UTI. You should take 10 days total of this medication (last day = [2170-8-31]). Your gabapentin dose was decreased to 300 mg daily. Your oxycontin dose was decreased to 10 mg every 12 hours. Your oxycodone dose was decreased to 5 mg every 6 hours as needed. You should resume your regular home warfarin dose. The [Hospital1 882] lab will be coming to your home on wednesday, [8-29] to check your INR. You should weigh yourself every morning, call your physician if your weight > 3 lbs. You should also adhere to a 2 gm (low) sodium diet. You should go to the follow-up appointments listed below. If you experience increasing sleepiness, shortness of breath, fevers, or other concerning symptoms, you should call your doctor or return to the hospital. Followup Instructions: You have an appointment with sleep medicine: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2967], [Name12 (NameIs) 280] Phone:[Telephone/Fax (1) 5808] Date/Time:[2170-8-27] 9:30 You have iron transfusions scheduled on: Provider: [Name10 (NameIs) 1248],BED ONE [Name10 (NameIs) 1248] ROOMS Date/Time:[2170-8-28] 3:00 Provider: [Name10 (NameIs) 1248],BED THREE [Name10 (NameIs) 1248] ROOMS Date/Time:[2170-8-30] 9:15 You have a follow-up appointment for your diabetes care with Dr. [Last Name (STitle) 19862] at the [Last Name (un) ] Diabetes Center on [2170-9-7] at 11:00 am.	[ "362.01", "327.23", "357.2", "250.50", "496", "428.0", "584.9", "780.09", "599.0", "E937.9", "403.90", "585.3", "250.60", "272.4", "518.83", "707.11", "729.1", "428.32" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13813, 13888	5852, 10596	301, 308	14069, 14111	3478, 3478	15699, 16355	2620, 2734		11548, 13790		13909, 14048		10622, 11525				14135, 15676			4929, 5829						2749, 3459																										242, 263							336, 1419							3494, 4913											1441, 2214	2230, 2604
5,909	150,084	49711	Discharge summary	report	Admission Date: [2183-4-9] Discharge Date: [2183-4-13] Date of Birth: [2125-9-30] Sex: M Service: MEDICINE Allergies: Codeine / Gentamicin / Tessalon Perle / Heparin Agents Attending:[First Name3 (LF) 3984] Chief Complaint: hypotension, foot pain Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 57 year old with type 1 DM s/p failed kidney/pancreas in [2164] on HD, CAD with stents, hx of A fib, hx of C diff colitis, hypothyroidism, HepC cirrhosis who was recently discharged from [Hospital1 18] for GNR bacteremia and dialysis line infection. Patient was discharged on [3-29] and now returns from rehab with hypotension and ? right leg cellulitis and black toes. Patient states that yesterday at rehab they banged his R leg and has been hurting him since. Patient also states that he had a fever at rehab yesterday. . In ED patient with low blood pressure SBP <80 mmHg and sepsis protocol was initiated. Patient given dose of dexamethasone 4mg for ? adrenal insufficiency and was on prednisone taper at rehab. Central line access was attempted in the ED but unable to feed wire through R femoral vein (L fem not attempted given history of L fem-[Doctor Last Name ]) and patients dialysis line was used for access to give levophed. Patient by ED report got vancomycin, ceftaz, and flagyl. Past Medical History: 1. ESRD: status pancreas-kidney transplant [2164], status post cadaveric [Year (4 digits) ] transplantation in [2172], now requiring dialysis 3x/wk 2. CAD: s/p myocardial infarction in [2164], s/p LCX stenting in [2174], s/p LCX and OM3 stenting in [2175], s/p mid-LCX stenting on '[78], s/p OM3 restenting in '[78] 3. DM type I 4. Hypothyroidism 5. Hypercholesterolemia 6. Cirrhosis from Hep C (dx in '[75]) 7. CVA in [2174] with residual left-sided weakness 8. PVD 9. Diverticulitis, status post colostomy and Hartmann's pouch in [2175], status post reversal in [6-3], last Colonscopy ([12-4]): Erythema, friability and granularity in the very distal portion of the colon, just inside the afferent limb of the stoma, with overlying clot. Brown stool with no bleeding proximal to this. 10. PVD s/p multiple digit amputations 11. GERD 12. Wheelchair bound after gentamicin related vertigo 13. PAF: diagnosed in [2175], continued on CCB and started on Amio at that time, s/p pacer [10-5] 14. Benign prostatic hypertrophy, status post transurethral resection of the prostate. 15. SBP [1-31] s/p ex lap 16. CHF with an EF: >55% 4/06 17. C diff colitis [3-6] completed course of flagyl [4-1] 18. Left shoulder rotator cuff evulsion fracture 19. GNR/bacteremia line infection Social History: Patient lives with his wife in [Name (NI) 5176] and presented Rehab. They have two children who live nearby. He previously worked as a plumber but is now retired. He has a 30pk year smoking hx but quit 10 years ago. He denies IVDU and alcohol use. He uses a wheelchair. He uses a walker for transfers. Family History: [Name (NI) 1094] father died at age 56 of MI, with DM and a "big heart". Mother died age 84 of "old age" s/p CVA, with DM and HTN. Sister has Grave's dz and brother died of 56 with DM. Physical Exam: PE: T 99.8 (ax) HR 101 BP 78/36-144/118 RR 20 O2Sat 100% RA Gen: Patient lying in bed in NAD Heent: L pupil pinpoint minimally reactive, R pupil reactive, EOMI, sclera anicteric. Neck: No LAD, JVD not appreciated Chest/Lungs: Left dialysis line in place, non-tender or erythematous. Lungs CTA B/L, no crackles or wheezes Cardiac: RRR S1/S2 Abdomen: large midline scar, slight diffuse tenderness, no rebound or gaurding Ext: Atrophic LE B/L, multiple finger and L toe amputations. R foot swollen and tender on dorsal aspect. Patient able to move ankle and move toes. @nd and 3rd digit of toe appear to black and possible subcutaneous hematoma. Neuro: AAOx3, FROM of all extremeties, CN II-XII intact Pertinent Results: [2183-4-9] 11:57PM WBC-2.6# RBC-3.01 HGB-9.3* HCT-29.8* MCV-99* MCH-30.8 MCHC-31.0 RDW-17.3* [2183-4-9] 11:57PM PLT COUNT-26* [2183-4-9] 11:57PM PT-19.5* INR(PT)-1.9* [2183-4-9] 05:20PM GLUCOSE-285* UREA N-36* CREAT-5.3* SODIUM-134 POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-18* ANION GAP-20 [2183-4-9] 05:20PM ALT(SGPT)-23 AST(SGOT)-25 LD(LDH)-185 CK(CPK)-28* ALK PHOS-324* AMYLASE-12 TOT BILI-1.1 [2183-4-9] 05:20PM LIPASE-6 [2183-4-9] 05:20PM CK-MB-NotDone cTropnT-0.11* [2183-4-9] 05:20PM ALBUMIN-1.7* CALCIUM-7.2* PHOSPHATE-4.5 MAGNESIUM-2.5 [2183-4-9] 05:20PM TSH-1.7 [2183-4-9] 05:20PM VANCO-<2.0* [2183-4-9] 05:20PM WBC-5.8# RBC-3.53* HGB-11.0* HCT-35.0* MCV-99* MCH-31.3 MCHC-31.5 RDW-17.2* [2183-4-9] 05:20PM NEUTS-69 BANDS-29* LYMPHS-1* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2183-4-9] 05:20PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL [2183-4-9] 05:20PM PLT SMR-VERY LOW PLT COUNT-30* [2183-4-9] 05:20PM PT-98.9* PTT-53.4* INR(PT)-13.7* [2183-4-9] 05:20PM FIBRINOGE-527# D-DIMER-772 [2183-4-9] 02:57PM LACTATE-4.0* [2183-4-9] 12:41PM LACTATE-5.5* [2183-4-9] 11:28AM GLUCOSE-175* UREA N-36* CREAT-5.3* SODIUM-138 POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-18* ANION GAP-22* [2183-4-9] 11:28AM CALCIUM-7.6* PHOSPHATE-4.3 MAGNESIUM-2.6 [2183-4-9] 11:28AM WBC-1.8# RBC-3.85 HGB-11.9* HCT-38.0* MCV-99* MCH-31.0 MCHC-31.4 RDW-17.7* [2183-4-9] 11:28AM NEUTS-85* BANDS-10* LYMPHS-3* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [2183-4-9] 11:26AM LACTATE-5.6* . TTE [2183-4-11]: 1. The left atrium is mildly dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed with basal inferolateral and inferior hypokinesis. 3. Right ventricular chamber size and free wall motion are normal. 4.The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. 6. Moderate [2+] tricuspid regurgitation is seen. 7.There is moderate pulmonary artery systolic hypertension. 8.There is no pericardial effusion. . CT abd [2183-4-10]: IMPRESSION: 1) Dense bilateral lower lobe and right middle lobe consolidations, in a pattern most consistent with aspiration pneumonitis. 2) Splenomegaly with chronic segmental infarction. 3) Diffuse mesenteric stranding, small amount of ascites, and subcutaneous edema, consistent with fluid overload. 4) Coronary artery calcification. 5) Left intrahepatic pneumobilia. 6) Unremarkable appearance of the left lower quadrant transplant kidney. Atrophic native kidneys with multiple probable simple cysts too small to characterize. Brief Hospital Course: A/P: 57 y/o with ESRD, PVD, DM type 1, hypothyroidism, Hep C cirrhosis who presents with hypotension and R foot cellulitis . 1. Sepsis: The patient initially presented with septic shock. He was administered antibiotics in the ED after cultures were obtained and was given IV fluids through his dialyisis line. The source was suspected line infection vs pulmonary vs foot infection/cellulitis. He was covered with broad spectrum antibiotics including vanc/flagyl/meropenum to cover pulmonary organisms as well as ESBL klebsiella given his previous history. CT abdomen and plain films of his foot were obtained to rule out intra-abdominal and osteomyelitis as possible sources of infection. These tests were negative. The patient required levophed in te ED, although this was weaned off over the course of the first evening in the ICU. He continued to receive antibiotic coverage over the next several days and remained hemodynamically stable. . 2. Respiratory Distress: In the morning on [4-13], the patient was noted to be in mild respiratory distress. The assessment was that this was secondary to CHF vs PNA. This progressed over the subsequent hours. The team considered non-invasive ventilation vs intubation and ultimately decided to try the non-invasive strategy with the plan to take some additional volume off with the CVVH to improve his SOB. Later in the morning, the patient's condition continued to deteriorate. He was noted to be unresponsive and the physician team was called to the bedside. He was noted to have a pulse in regular rhythm, although blood pressure was unable to be measured due to his poor vascular status, a measurement was not able to be attempted. Given the patient's clearly expressed desire to be DNR/DNI, there were no chest compressions or chemical coding maneuvers. Several minutes later, the heart rhythm was noted to be asystole. No heart sounds were audible. He was declared deceased. . ## ESRD: The [Month/Year (2) ] team followed along. His dialysis catheter was maintained with the plan to treat through the bacteremia, given that it would be a difficult procedure for the patient to undergo the placement of another dialysis line given his vascular status and multiple bleeding risk factors. He was placed on CVVH for volume management. . ## Thrombocytopenia/coagulopathy: Patient was found to have new thrombocytopenia, HIT antibody was found to be positive. He was started on argatroban therapy. . ## Hep C cirrhosis: There is a history of grade II varices per EGD [2182-7-25], elevated coags. He was unable to take lactulose or rifaximin due to inability to take PO. . ## PVD: There was some initial concern in the ED for acute ischemia, with blue toes. Vascular was consulted. The patient has severe PVD with history of finger amputations. Per vascular there was no evidence of acute limb ischemia. . ## DM Type 1: The plasma sugars were followed closely and treated aggressively with insulin. . ## Hypothyrodism: He was continued on levoxyl while he was taking PO. . ## Chronic Pain: Methadone was held given sedation. ## PPx: On argotroban, bowel regiminen, tylenol, PPI. ## Access: L dialysis line, R PIV ## FEN - [Month/Day/Year ], diabetic diet. He was unable to take PO after HD 1 because of poor mental status. NG tube was not placed because of the esophageal varices. He remained NPO. ## Code: DNR/DNI . Medications on Admission: Meds on Admission: B Complex-Vitamin C-Folic Acid 1 mg PO DAILY Epoetin Alfa 10,000 unit/mL qweek Hydroxyzine HCl 25 mg prn Pantoprazole 40 mg PO Q24H Amiodarone 200 mg PO BID Levothyroxine 200 mcg PO DAILY Methadone 5 mg PO TID Amitriptyline 10 mg PO HS Hydromorphone 2 mg prn Lantus 4U at bedtime and RISS Calcium Acetate 667 mg Capsule PO TID W/MEALS Prednisone 10 mg on taper Sodium Chloride 0.65 % Aerosol, Sprays Nasal TID Levofloxacin 250 mg PO q48h completed course [4-8] Dolasetron Mesylate 12.5 mg IV Q8H:PRN Warfarin 5 mg PO DAILY Toprol XL 12.5mg daily Discharge Medications: not applicable Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Cardiovascular arrest Septic shock Pneumonia Hep C Cirrhosis ESRD HIT Discharge Condition: Deceased Discharge Instructions: Not applicable Followup Instructions: Not applicable [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "V45.01", "272.0", "038.49", "287.4", "995.92", "486", "443.9", "V45.82", "682.7", "996.86", "244.9", "V58.67", "E934.2", "785.52", "996.81", "414.01", "250.41", "070.54", "585.6" ]	icd9cm	[ [ [] ] ]	[ "39.95", "99.05", "99.07", "96.04" ]	icd9pcs	[ [ [] ] ]	11083, 11154	7045, 10424	337, 343	11268, 11278	4037, 7022	11341, 11484	3109, 3299		11044, 11060		11175, 11247		10450, 10455				11302, 11318									3314, 4018																										275, 299							371, 1402									10469, 11021									1424, 2770	2786, 3093
31,686	165,051	34508	Discharge summary	report	Admission Date: [2162-6-25] Discharge Date: [2162-7-6] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5018] Chief Complaint: headache, nausea, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname ] is an 88-year-old woman with a history of HTN, prior strokes and MI who presents with dizziness, vomiting, found to have cerebellar ICH at OSH. She was on a day-trip with her daughter and son-in-law from their home in [State 792]to [Location (un) 28318]. At 12:30, she was normal. Then she suddenly said she needed to go to the bathroom badly, and said she felt "dizzy." They pulled off the highway into a restaurant's parking lot. When they tried to get her out of the car, they noticed she was leaning to the left. They thought she had a right facial droop, as well. They brought her into the bathroom, discovering that she had had fecal incontinence - this she has at baseline to some extent, but this was worse. She also vomited. Because of these concerns, 911 was called. She was brought to [Doctor Last Name 38554] hospital at 1:30 pm, where initial BP was 205/83. A head CT showed an 18-mm cerebellar ICH. She began vomiting again, and received 12.5 mg Phenergan and 4 mg Zofran at 2:30 pm. Although her GCS was consistenly 14, they decided to intubate for airway protection. She was given Etomidate and succinycholine at 3 pm, and Versed at 3 and at 5 pm. She was transported to [Hospital1 18] ED for further eval. ROS is not possible at this time. Per her family, she had not complained of any other symptoms prior to this Past Medical History: Prior strokes - [2147] caused significant language impairment and she had other "small" strokes in late [2143], but she had no residual symptoms. CAD s/p MI and 3-V CABG [2147] DM2, diet controlled HTN Rectal Prolapse Osteoarthritis Social History: Lives in [State 792]with daughter and son-in-law; they were on a day-trip to [Location (un) 28318] at the time of the event. Drinks one glass of wine per day. No tobacco history. Independent in ADLs. Family History: NC Physical Exam: Vitals: T: 99.8 PR P: 81 R: 14 BP: 172/91 SaO2: 100% AC 450x14 FiO2 100 General: Intubated, unresponsive, having received Zofran, Phenergan, Versed, Etomidate, Succinylcholine, and Propofol. HEENT: NC/AT, no scleral icterus noted, MMM 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. Surgical scars over knees. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Limited exam due to heavy sedation she recently received before transport. Eyes closed, non-verbal, spontaneous movement. -Cranial Nerves: I: Olfaction not tested. II: PERRL 1 to 0.5mm. No blink to threat. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: No doll's eyes. V: Corneal intact bilaterally. VII: No facial droop, facial musculature symmetric. VIII: Not tested. IX, X: Gag not tested. [Doctor First Name 81]: Not tested. XII: Not tested. -Motor: Moves all extremities spontaneously, possibly right more than left but difficult to say. Withdraws all extremities briskly from noxious. -Sensory: Pain intact. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 1 1 1 4 3 R 2 1 1 4 3 Plantar response was extensor bilaterally. -Coordination & Gait not testable. Pertinent Results: [2162-7-6] 06:35AM BLOOD WBC-10.4 RBC-2.98* Hgb-8.9* Hct-27.0* MCV-91 MCH-29.8 MCHC-32.9 RDW-13.1 Plt Ct-306 [2162-7-5] 06:05AM BLOOD WBC-9.8 RBC-3.02* Hgb-9.2* Hct-27.6* MCV-91 MCH-30.4 MCHC-33.3 RDW-13.4 Plt Ct-313 [2162-7-3] 03:05PM BLOOD WBC-9.4 RBC-3.35* Hgb-10.1* Hct-30.7* MCV-92 MCH-30.3 MCHC-33.1 RDW-13.4 Plt Ct-284 [2162-7-1] 06:10AM BLOOD WBC-9.4 RBC-3.28* Hgb-9.9* Hct-29.5* MCV-90 MCH-30.2 MCHC-33.7 RDW-13.4 Plt Ct-221 [2162-6-30] 06:15AM BLOOD WBC-8.7 RBC-3.41* Hgb-10.4* Hct-31.3* MCV-92 MCH-30.5 MCHC-33.2 RDW-13.5 Plt Ct-214 [2162-6-29] 06:22AM BLOOD WBC-7.2 RBC-3.39* Hgb-10.4* Hct-31.7* MCV-94 MCH-30.6 MCHC-32.7 RDW-13.2 Plt Ct-229 [2162-6-27] 12:30PM BLOOD WBC-8.8 RBC-3.52* Hgb-10.9* Hct-31.8* MCV-90 MCH-31.0 MCHC-34.3 RDW-13.3 Plt Ct-252 [2162-6-26] 02:21AM BLOOD WBC-11.1* RBC-3.57* Hgb-10.8* Hct-31.8* MCV-89 MCH-30.3 MCHC-34.1 RDW-13.4 Plt Ct-258 [2162-6-25] 07:15PM BLOOD WBC-10.0 RBC-3.86* Hgb-11.8* Hct-35.6* MCV-92 MCH-30.4 MCHC-33.0 RDW-13.4 Plt Ct-233 [2162-6-30] 06:15AM BLOOD Neuts-71.4* Lymphs-20.9 Monos-5.7 Eos-1.6 Baso-0.3 [2162-6-29] 06:22AM BLOOD Neuts-64.4 Lymphs-25.3 Monos-5.9 Eos-4.2* Baso-0.3 [2162-6-25] 07:15PM BLOOD Neuts-82.8* Bands-0 Lymphs-12.8* Monos-3.9 Eos-0.4 Baso-0.1 [2162-6-25] 07:15PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-NORMAL [2162-7-6] 06:35AM BLOOD Plt Ct-306 [2162-7-5] 06:05AM BLOOD Plt Ct-313 [2162-7-3] 03:05PM BLOOD Plt Ct-284 [2162-7-1] 06:10AM BLOOD Plt Ct-221 [2162-6-30] 06:15AM BLOOD Plt Ct-214 [2162-6-29] 06:22AM BLOOD Plt Ct-229 [2162-6-27] 12:30PM BLOOD Plt Ct-252 [2162-6-26] 02:21AM BLOOD Plt Ct-258 [2162-6-26] 02:21AM BLOOD PT-12.4 PTT-24.6 INR(PT)-1.0 [2162-6-25] 07:15PM BLOOD Plt Ct-233 [2162-6-25] 07:00PM BLOOD PT-11.4 PTT-19.0* INR(PT)-0.9 [2162-7-5] 06:05AM BLOOD Glucose-132* UreaN-25* Creat-0.6 Na-139 K-4.1 Cl-101 HCO3-25 AnGap-17 [2162-7-3] 03:05PM BLOOD Glucose-122* UreaN-29* Creat-0.9 Na-139 K-3.9 Cl-101 HCO3-25 AnGap-17 [2162-7-2] 06:50AM BLOOD Glucose-106* UreaN-26* Creat-0.8 Na-143 K-4.0 Cl-106 HCO3-24 AnGap-17 [2162-7-1] 06:10AM BLOOD Glucose-124* UreaN-20 Creat-0.7 Na-143 K-3.0* Cl-102 HCO3-26 AnGap-18 [2162-6-30] 06:15AM BLOOD Glucose-147* UreaN-19 Creat-0.7 Na-141 K-3.9 Cl-107 HCO3-23 AnGap-15 [2162-6-28] 07:45PM BLOOD Glucose-214* UreaN-25* Creat-0.7 Na-144 K-4.1 Cl-108 HCO3-27 AnGap-13 [2162-6-27] 12:30PM BLOOD Glucose-268* UreaN-20 Creat-0.6 Na-139 K-3.7 Cl-102 HCO3-23 AnGap-18 [2162-6-26] 02:21AM BLOOD Glucose-103 UreaN-16 Creat-0.6 Na-140 K-3.3 Cl-104 HCO3-25 AnGap-14 [2162-6-25] 06:15PM BLOOD Glucose-234* UreaN-15 Creat-0.7 Na-139 K-3.8 Cl-103 HCO3-23 AnGap-17 [2162-7-1] 06:10AM BLOOD ALT-10 AST-34 AlkPhos-58 Amylase-68 TotBili-0.4 [2162-6-29] 04:00PM BLOOD CK(CPK)-143* [2162-6-29] 06:22AM BLOOD ALT-10 AST-27 LD(LDH)-250 AlkPhos-54 Amylase-82 TotBili-0.4 [2162-6-28] 07:45PM BLOOD CK(CPK)-214* [2162-6-26] 09:24AM BLOOD CK(CPK)-87 [2162-6-26] 02:21AM BLOOD CK(CPK)-95 [2162-6-25] 07:00PM BLOOD CK(CPK)-107 [2162-7-1] 06:10AM BLOOD Lipase-19 [2162-6-29] 06:22AM BLOOD Lipase-47 [2162-6-30] 06:15AM BLOOD cTropnT-0.20* [2162-6-29] 04:00PM BLOOD CK-MB-5 cTropnT-0.26* [2162-6-29] 06:22AM BLOOD CK-MB-6 cTropnT-0.31* [2162-6-28] 07:45PM BLOOD CK-MB-10 MB Indx-4.7 cTropnT-0.36* [2162-6-26] 09:24AM BLOOD CK-MB-NotDone cTropnT-0.10* [2162-6-26] 02:21AM BLOOD CK-MB-NotDone cTropnT-0.17* [2162-6-25] 07:00PM BLOOD CK-MB-4 cTropnT-0.09* [2162-7-5] 06:05AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.9 [2162-7-2] 06:50AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.3 [2162-7-1] 06:10AM BLOOD TotProt-6.0* Albumin-3.2* Globuln-2.8 Calcium-8.9 Phos-3.3 Mg-1.7 [2162-6-30] 06:15AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.7 [2162-6-29] 06:22AM BLOOD Albumin-3.3* [2162-6-28] 07:45PM BLOOD Calcium-9.4 Phos-2.7 Mg-2.0 [2162-6-27] 12:30PM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0 [2162-6-26] 02:21AM BLOOD Calcium-9.6 Phos-3.3 Mg-1.9 Cholest-194 [2162-6-25] 06:15PM BLOOD Calcium-9.4 Phos-3.2 Mg-2.0 [2162-6-26] 02:21AM BLOOD Triglyc-73 HDL-86 CHOL/HD-2.3 LDLcalc-93 Brief Hospital Course: This 88 yo woman was admitted with sudden nausea/vomiting and headache, and NCHCT demonstrated 1.7 cm hyperdense lesion adjacent in posterior fossa midline, with surrounding edema and mass effect on 4th ventricle. Tiny amout of intraventricular blood layering in bilateral lateral ventricles. No hydrocephalus. Old left cerebellar infarct. Mild atrophy and small vessel disease. Pt was admitted to the neuro ICU intubated and sedated. She was extubated within 24 hours and transferred to the stroke floow with tele within 48 hours. Although her speech is fluent and conversational, she remains to this day largely disoriented to date and place, although she becomes somewhat better in the presence of her family. She had no further headaches or nausea or vomiting. She had repeat NCHCT's on [6-26] and [6-27] which showed stable R bleed. Her neurological deficits, including mainly RUE ataxia and b/l UE weakness and inability to ambulate remain the same. the pt's course was complicated by some low grade fevers, for which a variety of cultures were drawn. She was found to have had a UTI with a poly-sensitive E.Coli, for which she was treated with Ceftriaxone. Despite this, she continued to have low grade fevers, but further culture of her blood, urine, stool, and sputum remained negative and CXR showed a questionble retrocardiac infiltrate, but nothing definite. A renal U/S was done to look for hidden abscess or pyelo, but was negative. Eventually the temperature curve came down and pt was afebrile for 48 hours before discharge. The pt's course was also complicated by her tachycardia and steep cardiac compliance curve. The pt was very sensitive to small fluid changes. A cardio consult was called, and they recommended fairly aggressive diuresis. This was done until it was noticed that pt's UO was decreasing and BUN/Cre increasing. At this point she was given back a small amount of NS. This, along with some mildly increased doses of metoprolol helped control her heart rate. The patient worked with PT and OT while here and will continue to work with them at rehab. She was discharged on [2162-7-6]. Medications on Admission: ASA 325 daily Metoprolol (pt cannot recall full list) Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 4. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [Hospital 792]Rehab Discharge Diagnosis: Right cerebellar hemorrhage. Discharge Condition: stable neurological and cognitive deficits Discharge Instructions: You have had a bleed in your right cerebellum. The bleed has been stable in size and affects your sense of coordination, and to some extent, your cognition. In order to prevent a recurrent bleed, it is important to control your risk factors, predominantly your blood pressure. Please return to the ER if you experience any sudden vomiting, headache, blurry or double vision, any weakness, vetigo, change in sensation, inability to speak, or anything else that concerns you seriously. Followup Instructions: with Dr. [Last Name (STitle) ] for neurology [Telephone/Fax (1) 1694] with PCP: [Name10 (NameIs) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 63169] [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2162-7-6]	[ "V45.81", "428.40", "599.0", "428.0", "401.9", "414.00", "431", "041.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10888, 10938	7990, 10130	289, 296	11011, 11056	3723, 7967	11588, 11941	2213, 2217		10234, 10865		10959, 10990		10156, 10211				11080, 11565						2997, 3704			2232, 2842																										223, 251							324, 1702											2857, 2980							1724, 1971	1987, 2197
82,048	133,456	4045	Discharge summary	report	Admission Date: [2126-7-4] Discharge Date: [2126-7-17] Date of Birth: [2062-10-18] Sex: F Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 301] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Laparscopic converted to open cholecystectomy with adhesion lysis Exploratory laparotomy A-line placement IJ line placement ERCP with stent placment History of Present Illness: Ms. [Known lastname 17819] is a 63yo woman with h/o chronic cholecystitis who initially presented for day surgery for a laparoscopic cholecystectomy on [7-4]. Her procedure was converted to an open cholecystectomy because of difficulty with adhesions. There was some minor bleeding in the "hepatic fossa" per the op note; EBL was 140cc. She was extubated without difficulty after the operation, and she was admitted to the surgical floor post-op for monitoring. . Overnight, she had problems with persistent abdominal pain for which she received IV morphine, dilaudid and was put on a PCA pump. She had nausea and dry heaving but no frank emesis, although there was some concern from the team that she may have aspirated. Her urine output fell off and she complained of dizziness with standing. She was receiving standard post-op fluids at 115cc/hr overnight. . At 8am on the morning of transfer, she triggered for marked nursing concern in the setting of increasing oxygen requirement (dropped from 99 to 90% on 2L) and poor urine output. A Bladder scan showed 154cc of urine and a Foley was placed. She was noted to have crackles and be wheezing. She was started on antibiotics with [Doctor Last Name ]/flagyl/levo for possible pneumonia. In the setting of her worsening clinical status, she was transferred to the medical ICU for further care. . Upon arrival to the ICU, she was sleepy but answering questions appropriately. She had pain with deep inspiration or movement. . Of note, Ms. [Known lastname 17819] reports having a slight non-productive cough prior to her surgery. Otherwise had been feeling well. No fatigue, fevers, or chills. Past Medical History: Hypertension Lichen sclerosis Hypothyroidism OSA on CPAP Attention deficit disorder s/p TAH for uterine abscess (per prior notes) s/p appendectomy Social History: Works as a school teacher. Lives alone. Has three children who live nearby. Smoked in the past but quit around age 30. Has one glass of wine per week. No drugs (per family). . Family History: +DM, asthma, and HTN in brother Physical Exam: 100.3 108/50 103 17 96% on 40% face mask Sleepy but rousable with some effort. Oriented to family, place, and year. Face symmetric, Pupils equal but small b/l. No scleral icterus. OP clear. MMM. Neck supple, no thyroid enlargement or adenopathy. S1, S2, regular tachycardia, +2/6 systolic murmur at apex. No rub. Decreased breath sounds at bases with bronchial breath sounds at right base. + expiratory wheeze. Tender throughout her abdomen, especially at RUQ. +peritoneal signs with rebound and guarding present. Bowel sounds are present. Able to move all her extremities with significant urging. No tremor. Finger grip intact b/l. No LE edema b/l. DP+1 b/l. No rash. Pertinent Results: [2126-7-5] 10:02AM BLOOD WBC-8.9 RBC-3.38* Hgb-10.4* Hct-31.9* MCV-95 MCH-30.8 MCHC-32.5 RDW-13.3 Plt Ct-331 [2126-7-5] 10:02AM BLOOD Neuts-86.0* Lymphs-8.3* Monos-5.0 Eos-0.5 Baso-0.1 [2126-7-5] 10:02AM BLOOD PT-12.0 PTT-25.3 INR(PT)-1.0 [2126-7-5] 10:02AM BLOOD Glucose-119* UreaN-33* Creat-2.5# Na-135 K-4.6 Cl-99 HCO3-24 AnGap-17 [2126-7-5] 10:02AM BLOOD ALT-131 AST-104* LD(LDH)-207 AlkPhos-69 TotBili-0.5 [2126-7-5] 10:44PM BLOOD Lipase-436* [2126-7-6] 03:45AM BLOOD Lipase-1149* [2126-7-5] 10:44PM BLOOD ALT-85* AST-75* AlkPhos-60 Amylase-163* TotBili-1.0 DirBili-0.5* IndBili-0.5 [2126-7-6] 03:45AM BLOOD ALT-87* AST-77* LD(LDH)-216 AlkPhos-70 Amylase-500* TotBili-1.1 [2126-7-5] 10:02AM BLOOD Calcium-9.1 Phos-5.8* Mg-2.0 [2126-7-5] 01:44PM URINE Osmolal-533 [2126-7-5] 01:44PM URINE Hours-RANDOM UreaN-568 Na-72 Uric Ac-51.3 [2126-7-5] 01:44PM URINE CastHy-4* [2126-7-5] 01:44PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-<1 [2126-7-5] 01:44PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2126-7-5] 01:44PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 BAL [2126-7-6] 1:08 am BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [2126-7-6]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. [2126-7-5] 1:00 pm SPUTUM Source: Expectorated. GRAM STAIN (Final [2126-7-5]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH OROPHARYNGEAL FLORA. Influenza DFA negative Brief Hospital Course: 63yo woman admitted after open cholecystectomy and transferred to the ICU in the setting of persistent post-op pain, hypoxia, and decreased urine output. . # Leukocytosis and fever: [Name (NI) 17820] unclear cause. However on investivgation her CXR was suggestive of infection. Given history of recent emesis, may have been from aspiration. On transfer to [Hospital Unit Name 153] she was very tachypnic and later the day of transfer she required intubation due to increased work of breathing. She also had a-line and central line placed. Also we were concerned about other posible abdominal sources of infection given persistent, severe post-op pain. Surgery closely followed the pt while in [Hospital Unit Name 153] and due to her presistant pain, increased abomnial distension, and fevers they were concerned about abdominal process. On [7-6] she had a repeat ERCP without albnormality. They she was taken back to OR for exploratory lap without casue of fevers and pain found. Back in the [Hospital Unit Name 153] she had a brochoscopy with BAL, and the [Last Name (un) 1066] showed increased thick secretions in RML concerning for aspiration PNA. She was Continued on tx with vanc/levo/flagyl. Her WBC started to trend down and she was transferd to the SICU for closer post operative monitoring. She had a negative flu test. Sputum cultuers showed _____. . # Acute renal failure: Was thought to be prerenal. Cr up to >2 on day of admission. Given aggressive IVF and it improved to 1.2. Medications were renally dosed. . # Altered mental status: This as likely from narcotic pain medications, but also partially likely from hypercarbic respiratory failure. Alternatively, altered mental status may have been a sign of developing sepsis. At transfer pt was sedated and intuabted. . # Respiratory acidosis: [Month (only) 116] be due to underlying OSA/chronic hypoventilation vs decreased respiratory drive while on narcotics. She had an a-line placed on day of admission. She will need CPAP again once extubated. . # Pain control: Was [Month (only) ] very difficult to control. Changed from demerol to fentynl. After ERCP and ex-lap pain was thought to be mainly from regular post op recovery. . # Pancreatits: Lipase became elevated as abd enlarged and was more tender. I/O monitored to keep pt hydrated, but not compromise resp funciton. . # Anemia: baseline Hct 36, at admission was Hct 29. Hct was serially monitored. Active type and screen. Negative hemolysis labs. . # HTN: Home meds were held dut to concern for hypotension due to shock. . # Hypothyroidism: continued on levothyroxine . # ADD: held home adderall . # Comm: with surgery ([Name (NI) ] [Name (NI) ] [Numeric Identifier 17821]) and family (daughter [Name (NI) ] is HCP [Telephone/Fax (1) 17822]) Was transfered from [Hospital Unit Name 153] to SICU on [7-6] for closer post operative care by surgery. Patient continued to recover on the floor. Currently she is up ambulating independently, on regular diet and tolerating well. Abdominal incision is oozing small amounts of fluid. Dressing changes done daily. She is still having problems with urinary incontinence. Urine culture and analysis negative with no urinary retention. Will have her follow up with Dr. [Last Name (STitle) ] [Last Name (STitle) ] [7-29]. She will also follow up with Dr. [Last Name (STitle) ]. Medications on Admission: Home Meds (confirmed with family): Ibuprofen 800mg daily Lisinopril/HCTZ 20/25mg daily Synthroid 150mcg daily Adderall 20mg daily prn project/study needs MVI daily Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 2. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:2 Tablet(s) Refills:0 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 8. Bed Semi-electric bed for home DX; Asp. Pneumonia/abd. incision Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary Diagnosis: Cholecystitis Discharge Condition: Stable Discharge Instructions: You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [11-7] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 304], MD Phone:[Telephone/Fax (1) 274] Date/Time:[2126-7-19] 3:00 Please follow up with your primary care provider [Last Name (NamePattern4) ] [4-29] weeks to obtain chext x-ray to ensure pneumonia has resolved. Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ] (urologist) [7-29] Monday at 9:30 [Hospital Ward Name 23] Building [Location (un) 470]. Completed by:[2126-7-17]	[ "995.92", "574.10", "401.9", "584.9", "577.0", "244.9", "507.0", "518.81", "327.23", "568.0", "V64.41", "285.1", "276.2", "314.00", "038.9" ]	icd9cm	[ [ [] ] ]	[ "96.71", "54.59", "38.93", "51.22", "51.87", "38.91", "33.24", "54.12", "96.04" ]	icd9pcs	[ [ [] ] ]	9403, 9454	5040, 6599	285, 435	9531, 9540	3246, 4919	11132, 11636	2507, 2540		8676, 9380		9475, 9475		8487, 8653				9564, 10763									2555, 3227											4957, 5017															231, 247					10775, 11109		463, 2126								9494, 9510			6615, 8461							2148, 2297	2313, 2491
8,489	112,082	28791	Discharge summary	report	Admission Date: [2134-10-14] Discharge Date: [2134-10-21] Date of Birth: [2062-5-25] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: fevers, MS changes, increased upper respiratory congestion Major Surgical or Invasive Procedure: CT scan of the abdomen, head central venous line placement Peripheral intravenous central catheter placement nasogastric tube placement History of Present Illness: 72 y/o male nursing home resident brought in by ambulance for fever to 103.6, mental status change, and increased upper respiratory congestion. Nurses noted change in mental status since 6AM on morning of admission, as well as low grade fevers starting the day prior with max to 103.6 at 6AM th emornig of admission. At baseline he is disoriented to person, place, and time. He is exclusively bedbound. He has had several days of non productive cough, distended abdomen, and large-loose/oozing stools. EMS noted patient lying in bed, extremely diaphoretic, with fever to 103.6, and distended abdomen. . In ED, code sepsis initiated, right IJ sepsis line placed, intubated for airway protection, blood, urine cultured, given Vanco 1g IV, levofloxacin 500 mg IV, clindamycin 600 mg IV, and 1g Ceftriaxone IV. CXR did not show any infiltrate, CT of Abdomen showed enlarged sigmoid colon and bibasilar consolidations, and Head CT showed old infarct and atrophy. He was admitted for treatment of sepsis. Past Medical History: Hypertension h/o right MCA CVA and left PCA CVA with severe encephalomalacia predominantly within the right temporal parietal and left occipital lobes and residual left sided weakness Seizures Dementia h/[Initials (NamePattern4) ] [Last Name (NamePattern4) 3696] Syndrome (colonic pseudo-obstruction) h/o aspiration PNA Gastritis with h/o GI bleed Anemia of CHronic Disease s/p laminectomy for disc herniation with internal fixation s/p left total hip replacement s/p IVC filter for DVT legally blind Social History: Lives in [Location ] St. [Doctor Last Name 11042]/[First Name4 (NamePattern1) 3504] [Last Name (NamePattern1) ] in [Location (un) 16174]. His son is his health care proxy. [Name (NI) 4084] a smoker. No alcohol use in the past ten years. Family History: NC Physical Exam: T 97.8 BP 133/72 HR 78 on Vent AC 500 x 14 with FiO2 0.60 PEEP 5 General: Intubated and sedated, responds with eye opening and mouth opening to sternal rub PERRL NG tube in place with bloody output. ET tube in mouth. Poor dentition. NO LAD, normal carotid pulses No supraclaviular or axilllary LAD Lungs clear anterioroly without wheezing. Mild decreased breath sounds at right base, otherwise claer posteriorly without wheezes. Heart: RRR. No M/G/R. ABD: high pitched bowel sounds, distened, tense, tympanic RECTAL: no masses, normal prostate, guaiac positive, no gross blood or melena BACK: sacral decubitus ulcer EXT: tight, shiny skin, bood upper ext pulses, good femoral and popliteal pulses, weak DP pulses. Left heel with ulcer and tendon exposure. NEURO: Hyperreflexic and tonic/clonic on the left upper and lower ext compared to right. Toes upgoing bilaterally. Myoclonus of left lower extremity with ankle flexion. Pertinent Results: [2134-10-14] 10:40AM BLOOD WBC-12.2# RBC-6.46# Hgb-19.7# Hct-58.0# MCV-90 MCH-30.5 MCHC-34.1 RDW-15.0 Plt Ct-156 [2134-10-14] 11:59PM BLOOD WBC-13.0* RBC-4.02* Hgb-12.3* Hct-35.9* MCV-89 MCH-30.7 MCHC-34.3 RDW-15.1 Plt Ct-64* [2134-10-16] 03:33AM BLOOD WBC-10.6 RBC-3.93* Hgb-12.0* Hct-34.6* MCV-88 MCH-30.5 MCHC-34.7 RDW-15.0 Plt Ct-66* [2134-10-20] 05:35AM BLOOD WBC-7.6 RBC-3.33* Hgb-10.4* Hct-29.4* MCV-88 MCH-31.1 MCHC-35.2* RDW-14.7 Plt Ct-109* [2134-10-21] 05:49AM WBC 6.7 RBC 3.40* HGB 10.6* HCT 30.0* MCV 88 MCH 31.3 MCHC 35.5* RDW 14.7 PLT 127* [2134-10-14] 10:40AM BLOOD Neuts-79.1* Lymphs-16.3* Monos-4.4 Eos-0 Baso-0.2 [2134-10-15] 03:02AM BLOOD Neuts-79.7* Bands-0 Lymphs-16.3* Monos-3.2 Eos-0.1 Baso-0.7 [2134-10-14] 12:05PM BLOOD PT-15.2* PTT-29.3 INR(PT)-1.4* [2134-10-15] 03:02AM BLOOD PT-14.5* PTT-40.0* INR(PT)-1.3* [2134-10-18] 12:07PM BLOOD PT-13.4* PTT-70.2* INR(PT)-1.2* [2134-10-14] 08:33PM BLOOD Fibrino-269 D-Dimer->[Numeric Identifier 961]* [2134-10-14] 08:33PM BLOOD FDP-160-320* [2134-10-15] 03:02AM BLOOD Fibrino-287 [2134-10-14] 12:05PM BLOOD Glucose-165* UreaN-70* Creat-4.4# Na-160 K-2.5* Cl-120* HCO3-23 AnGap-20 [2134-10-14] 11:59PM BLOOD Glucose-162* UreaN-58* Creat-3.0* Na-159* K-4.1 Cl-128* HCO3-20* AnGap-15 [2134-10-15] 11:55AM BLOOD Glucose-150* UreaN-46* Creat-2.6* Na-156* K-3.8 Cl-129* HCO3-18* AnGap-13 [2134-10-17] 08:17PM BLOOD Glucose-135* UreaN-28* Creat-1.7* Na-149* K-3.1* Cl-117* HCO3-22 AnGap-13 [2134-10-20] 05:35AM BLOOD Glucose-127* UreaN-20 Creat-1.5* Na-144 K-3.4 Cl-114* HCO3-22 AnGap-11 [2134-10-21] 05:49AM GLU 116* BUN 15 Cr 1.4* Na 144 K 3.5 Cl 114* HCO3 23 AG 11 [2134-10-14] 12:05PM BLOOD ALT-753* AST-531* CK(CPK)-440* AlkPhos-117 Amylase-202* TotBili-0.6 [2134-10-14] 11:59PM BLOOD ALT-494* AST-249* Amylase-338* [2134-10-16] 03:33AM BLOOD ALT-291* AST-90* LD(LDH)-307* CK(CPK)-421* AlkPhos-66 Amylase-170* TotBili-0.5 [2134-10-20] 05:35AM BLOOD ALT-166* AST-94* LD(LDH)-325* Amylase-143* [2134-10-14] 12:05PM BLOOD Lipase-126* [2134-10-14] 11:59PM BLOOD Lipase-650* [2134-10-18] 12:07PM BLOOD Lipase-180* [2134-10-14] 12:05PM BLOOD CK-MB-2 cTropnT-0.37* [2134-10-14] 08:33PM BLOOD CK-MB-5 cTropnT-0.28* [2134-10-15] 03:02AM BLOOD CK-MB-6 cTropnT-0.20* [2134-10-16] 03:33AM BLOOD CK-MB-3 cTropnT-0.12* [2134-10-14] 08:33PM BLOOD Albumin-2.8* Calcium-6.7* Phos-4.2 Mg-2.1 Iron-36* [2134-10-16] 03:33AM BLOOD Albumin-2.4* Calcium-6.9* Phos-2.0* Mg-2.0 [2134-10-20] 05:35AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.1 [2134-10-14] 08:33PM BLOOD calTIBC-178* Ferritn-1353* TRF-137* [2134-10-17] 08:17PM BLOOD Triglyc-83 HDL-34 CHOL/HD-3.6 LDLcalc-73 [2134-10-14] 08:33PM BLOOD Osmolal-359* [2134-10-16] 03:33AM BLOOD Osmolal-320* [2134-10-14] 12:05PM BLOOD Cortsol-54.9* [2134-10-15] 06:40AM BLOOD Vanco-9.6* [2134-10-14] 12:26PM BLOOD Type-[Last Name (un) ] pO2-46* pCO2-35 pH-7.43 calTCO2-24 Base XS-0 Comment-GREEN TOP [2134-10-14] 08:47PM BLOOD Type-MIX Temp-37.9 Rates-/20 Tidal V-470 PEEP-5 FiO2-60 pO2-54* pCO2-52* pH-7.19* calTCO2-21 Base XS--8 -ASSIST/CON Intubat-INTUBATED [2134-10-15] 06:02AM BLOOD Type-ART Temp-36.7 pO2-177* pCO2-31* pH-7.34* calTCO2-17* Base XS--7 Intubat-INTUBATED [2134-10-15] 07:02PM BLOOD Type-[Last Name (un) ] Temp-38.4 pO2-39* pCO2-38 pH-7.33* calTCO2-21 Base XS--5 [2134-10-14] 12:26PM BLOOD Lactate-3.1* [2134-10-14] 02:36PM BLOOD Glucose-140* Lactate-1.7 Na-160* K-2.3* Cl-131* [2134-10-15] 06:02AM BLOOD Lactate-2.0 [2134-10-14] 02:36PM BLOOD O2 Sat-99 [2134-10-14] 08:47PM BLOOD O2 Sat-77 [2134-10-15] 12:01PM BLOOD O2 Sat-81 [2134-10-14] 02:36PM BLOOD freeCa-1.07* [2134-10-15] 03:36AM BLOOD HEPARIN DEPENDENT ANTIBODIES- NEG NEGATIVE HEPARIN PF4 ANTIBODY BY [Doctor First Name ] [2134-10-14] 12:05 pm URINE Site: NOT SPECIFIED FINAL REPORT [2134-10-17] URINE CULTURE (Final [2134-10-16]): ESCHERICHIA COLI. 10,000-100,000 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------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2134-10-14] 8:39 pm urine/serology FINAL REPORT [2134-10-15] Legionella Urinary Antigen (Final [2134-10-15]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. Performed by Immunochromogenic assay. Reference Range: Negative. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [2134-10-14] 11:30 am BLOOD CULTURE FINAL REPORT [2134-10-20] AEROBIC BOTTLE (Final [2134-10-20]): NO GROWTH. ANAEROBIC BOTTLE (Final [2134-10-20]): NO GROWTH. [2134-10-14] 11:00 am BLOOD CULTURE FINAL REPORT [2134-10-20] AEROBIC BOTTLE (Final [2134-10-20]): NO GROWTH. ANAEROBIC BOTTLE (Final [2134-10-20]): NO GROWTH. [2134-10-15] 1:01 am STOOL CONSISTENCY: WATERY FINAL REPORT [2134-10-15] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2134-10-15]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. [2134-10-15] 6:32 am STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [2134-10-15] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2134-10-15]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. Time Taken Not Noted Log-In Date/Time: [2134-10-15] 7:24 am ASPIRATE Source: Nasopharyngeal aspirate. VIRAL CULTURE (Preliminary): No Virus isolated so far. Rapid Respiratory Viral Antigen Test (Final [2134-10-15]): Respiratory viral antigens not detected. CULTURE CONFIRMATION PENDING. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. This kit is not FDA approved for direct detection of parainfluenza virus in specimens; interpret parainfluenza results with caution. [2134-10-19] 05:14PM CLOSTRIDIUM DIFFICILE TOXIN B ASSAY Results Pending EKG: Sinus Tach at 118, Q waves in II, III, aVF (old), no ST segment depression or elevations, no T wave inversions . Radiology: CXR: Gas distention, mostly in colon results in relatively high-positioned diaphragms obscuring slightly the lung bases. There is, however, no evidence of any acute parenchymal infiltrate in either side of the thorax nor is there evidence of pulmonary congestion. No pneumothorax identified. Heart size difficult to assess, but no gross enlargement suspected. . CT ABDOMEN: 1. Distended loop of sigmoid colon with no transition point is again identified. There is no evidence of obstruction. The diagnosis of [Last Name (un) ] syndrome should again be considered. There is no evidence of perforation. 2. Bilateral lower lobe dense consolidations consistent with pneumonia or aspiration. 3. Hypodensities within the kidneys are not completely characterized with this non-contrast enhanced-study. . CT HEAD: Extensive encephalomalacic changes are again noted in right parietal and temporal lobes and the left occipital lobe. Hypodensity in the periventricular white matter is also seen in both cerebral hemispheres. Findings are unchanged from the prior examination. There is no new acute intracranial hemorrhage, shift of midline structures, or hydrocephalus. There is a moderate amount of atrophy. Moderate mucosal thickening is seen in the ethmoid sinuses. Soft tissues and osseous structures are normal. . [2134-10-18] ECHO: The left atrium is normal in size. 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 ascending aorta and arch are 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 appears structurally normal with trivial mitral regurgitation. There is an anterior space which most likely represents a fat pad. IMPRESSION:Mild symmetric left ventricular hypertrophy with preserved globall and regional biventricular systolic function. Mild aortic regurgitation. . [10-18] Abd xray for NGT placement: FINDINGS: A single supine abdominal radiograph reviewed. NG tube overlies the left upper quadrant likely in the stomach. Multiple gas-filled bowel loops are identified, mostly large bowel. No distended small bowel loops are identified. Note is made of particularly distended gas-filled sigmoid colon, relatively unchanged from [2134-10-14]. IVC filter, lower lumbar fusion device, and total left prostheses again noted. Surgical clips present in the pelvis. IMPRESSION: Distended air-filled sigmoid unchanged from [10-14], [2133]. NG tube in stomach. Brief Hospital Course: A/P: 72 y/o male nursing home resident with h/o HTN, h/o CVA, dementia, Ogilve's Syndrome, and h/o aspiration PNA presented with fevers, altered mental status, and cough with upper respiratory congestion, from his nursing home and was intubated for airway protection, and given broad spectrum antibiotics for sepsis. . ICU Course: 1. Sepsis: The initial differential diagnosis included infectious sources from: Respiratory (Institutional Acquired PNA, asp PNA, Influenza, Legionella), GI (given distended abdomen), and GU (though less likely given negative initial U/A, prostate not boggy on exam), decubitus ulcers (less likely given no evidence of cellulitis). He got vanco, levo, clinda, ceftriaxone in ED. - The infection was treated with Vanco to cover MRSA given nursing home dwelling, Levofolxacin for possible GI source/asp PNA, and Flagyl for C.Diff given abd distention/diarrhea. - IJ CVL was placed to help give IV fluids to keep MAP>65 and venous O2 sat >70%. - Blood cultures, urine cultures were sent and blood cultures were negative x2 and the urine culture came back positive for e. coli that was later determined to be resistant to cipro and levofloxacin. Pt was kept on the broad spectrum antibiotics until the culture returned and pt was left on just levofloxacin on HD#3 but was switched to ceftriaxone on HD#4 when the sensitivities showed that the e. coli was resistant to levo and susceptible to ceftriaxone. - Legionella urinary antigen was negative. - Sputum for gram stain, culture, and viral screen was negative - Influenza was ruled out and droplet precautions were removed. - Pt became afebrile HD#2. . 2. Respiratory Distress: Pt was intubated for airway protection given altered mental status. CT showed a possible lower lobe PNA vs Asp PNA. Oxygenation and ventilation were sufficient on pre intubation blood gases. - Pt was originally put on AC ventilation HD#1 and was weaned the next day. Repeat arterial blood gas showed good oxygenation and ventilation. Pt was extubated on HD#2. . 3. Hypernatremia: Pt was severely hypernatremic to 160 on admission. He appeared dry in the ED and received 9 L NS HD#1. Once he was volume repleted (CVP >10), the hypernatremia was slowly corrected with D5 1/2 NS. . 4. Non Gap Acidosis: Primary mild metabolic acidosis with respiratory compensation. Likely renal losses given hypokalemia. No diarrhea was noted. - HCO3 and chemistries were followed and corrected. . 5. Acute Renal Failure: Likely prerenal due to sepsis and was corrected with volume repletion. . 6. Elevated Cardiac Enzymes: Elevated in the setting of sepsis and RF. Trending down with treatment of sepsis, no EKG changes. Likely due to demand ischemia given tachycardia. Enzymes did trend down. EKG showed q waves evident of old infarct. . 7. Transaminitis and elevated Amylase/Lipasewas likely due to tissue hypoxia, and was not high enough for shock liver and with no recent alcohol use and no evidence of biliary tract obstruction to suggest alternate reason for increase. LFTs and anylase and lipase trended down. . 8. Anemia: History of ACD - Iron studies c/w ACD. . 9. Mild Coagulapathy/thrombocytopenia: HIT Antibody neg. DIC labs neg. Likely decreased from inflammatory/infectious process of sepsis. Plt returned to nl at time of discharge. . 10. FEN: Tube feedings started HD#3 through NGT and free water replacement through NGT also to help correct Na. . 11. PPX: SQ heparin, PPI, HOB elevation at 30% **HD#3 Pt was HD stable and transferred to the floor. . 1. Sepsis: Resolved and hemodynamically stable on HD#3. A urinary source was suspected given E.Coli UTI. Blood cultures were negative, Leigonella negative, CXR w/equivocal lower lobe pneumonia. Initially with broad spectrum abx, now HD stable on monotherapy with levofloxacin day 4 (started [2134-10-14]). HD#4 e coli from urine was noted to be levofloxacin and cipro resistant but susceptible to everything else and ceftriaxone was started. Pt is to continue on total of 14 day course of ceftriaxone (started [2134-10-18]) requiring 10 more days of treatment after discharge. Pt remained afebrile. Pt's BPs remained low in 100-110s but stable. . 2. Altered Mental Status: Baseline disorientation due to dementia. Likely metabolic encephalopathy, hypernatremia. Pt had improving alertness following antibiotics, correction of serum sodium. . 3. Hypernatremia: Pt was severely hypernatremic to 160 on admission and appeared dry in ED. He was s/p 9 L NS on HD#3. The sodium was down-trending to 150 with free water flushes through NGT on HD#3. The pt received a PICC line HD#5 because labs could not be drawn and to help rehydrate the pt more. A right arm PICC was placed in IR. D5W was given at 100cc an hr for 2500cc with 40 of K to help correct his hypernatremia and hypokalemia. HD#6 his labs were wnl. He was maintained on D5 1/2 NS at 125cc/hr with 40mEq of K to keep his labs wnl. Pt was being given free water and K through the NGT also to help correct his electrolyte imbalances, but the NGT came out the evening of HD#5 and was replaced HD#6 and tube feeds and free water replacement were continued. . 4. Acute Renal Failure: Likely prerenal due to sepsis. Improving with fluid hydration. Creatinine down-trending to 1.4 on discharge. . 5. NSTEMI: Elevated in the setting of sepsis and renal failure. Now trending down with treatment of sepsis. no EKG changes. Likely due to demand ischemia given tachycardia. Start b-blocker, aspirin now that HD stable. Check ECHO to eval for systolic [Last Name (LF) 69556], [First Name3 (LF) ]-motion abnormality. Restart low dose metoprolol, ASA, statin. - ECHO done [10-18]: Mild symmetric left ventricular hypertrophy with preserved globall and regional biventricular systolic function. Mild aortic regurgitation. . 6. Transaminitis/Chemical Pancreatitis: Likely due to tissue hypoxia, not high enough for shock liver. No recent alcohol use. No evidence of biliary tract obstruction to suggest gallstone pancreatitis. LFTs were consistently returning to baseline. Should be rechecked one week post-discharge to reassess. . 8. Anemia: Pt has a history of anemia of chronic disease and iron studies obtained on this admission were consistent with that diagnosis. His HCT was stable at 30 at time of discharge and his PLT count had returned to [Location 213]. . 9. h/o CVA with seizures. Not on antiseizure meds. Plavix was continued for secondary prevention. . 10. h/o dementia: Chronic. Likely conmination of CVA's and organic dementia (evidence of atrophy on CT of head). . 11. h/o Gastritis: PPI was continued. Hct was stable at time of discharge. Stool was guaiac positive. Pt had rectal tube inserted while in ICU that was removed once on the floor. . 12. Bowel distension - Had been noted in past hospitalizations and rectal tube inserted to relieve distention and given a diagnosis of Ogilve's Syndrome. - Rectal exam was grossly positive for blood (pt did have a rectal tube two days prior), no stool impaction noted. - C diff B toxin was sent but was still pending at time of discharge. Stool tested negative for c diff A toxin. - GI suggested aggressive bowel regimen and outpt f/u colonoscopy (pt on home regimen of senna, colace, lactulose). . 13. FEN: - TF down NGT. - NGT came out [10-17] and S&S saw and assessed pt prior to new NGT being put in. They recommended pt be NPO as he was not able to handle secretions, and to continue the NGT, TF, suctioning. They recommended reassessing within 1-2wks. - NGT was replaced, xray confirmed placement, TF and free water replacement restarted. . 14. PPX: SQ heparin, PPI . CODE: FULL per son, possibility of pt requiring a PEG tube was discussed as was fact that with each illness and hospitalization, pt's mental status is likely to deteriorate further. . COMMUNICATION: with son, HCP [Name (NI) ] [Name (NI) ] cell [Telephone/Fax (1) 69557], home [Telephone/Fax (1) 69558], work [Telephone/Fax (1) 69559] Medications on Admission: Vit D 400 units Daily MVA 1 tablet Daily Clopidogrel 75 mg Daily Propoxy/APAP 100-650 mg with dressing changes Colace 100 mg [Hospital1 ] Heparin 5,00o units TID Lactulose 30 ml TID Baclofen 5 mg TID Senna 2 Tab QHS Risperdal 0.25 mg QHS Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 3. Therapeutic Multivitamin Liquid [Last Name (STitle) ]: One (1) Cap PO DAILY (Daily). 4. Docusate Sodium 150 mg/15 mL Liquid [Last Name (STitle) ]: One (1) PO BID (2 times a day). 5. Baclofen 10 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO TID (3 times a day). 6. Senna 8.6 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO HS (at bedtime). 7. Risperidone 0.25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO HS (at bedtime). 8. Clopidogrel 75 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO BID (2 times a day). 10. Aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). 11. Atorvastatin 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO HS (at bedtime). 12. Lactulose 10 g/15 mL Syrup [Last Name (STitle) ]: Thirty (30) ML PO TID (3 times a day). 13. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: One (1) Injection TID (3 times a day). 14. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback [Last Name (STitle) *]: One (1) gm Intravenous Q24H (every 24 hours) for 10 days. Disp:10 gm* Refills:0 15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [Last Name (STitle) ]: Two (2) ML Intravenous DAILY (Daily) as needed. 16. Acetaminophen 325 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: urosepsis altered mental status acute renal failure transaminitis/chemical pancreatitis large bowel distention Secondary: dementia amemia Discharge Condition: stable Discharge Instructions: You were admitted for a urinary tract infection that caused you to become septic and hypotensive. You required a stay in the ICU in order to treat your infection and low blood pressure. You needed a lot of fluid resuscitation and antibiotics. You are requiring a nasogastric tube in order to receive nutrition. You will be re-evaluated in approximately a week to see if you are able to safely handle your own secretions. You may be able to have the NGT out at that time. Please notify a doctor if pt experiences: - fever >101.5 - severe abdominal distention - is unable to tolerate tube feedings - severely decreased urine output - severe constipation - breathing difficulties - signs/sx of stroke - changes in mental status - any other questions or concerns Please take all medications as directed. Please follow up with your PCP and GI for your colonoscopy. Followup Instructions: Please follow up with your PCP or the doctor who takes care of you at the rehabilition center within 1-2wks of discharge. You will need to call the gastroenterology department at: [Telephone/Fax (1) 463], in order to schedule a colonoscopy to examine your large bowel. If you wish you may also set up an appointment to see a gastroenterologist by calling [Telephone/Fax (1) 69560]. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "401.9", "535.50", "041.4", "276.2", "599.0", "437.0", "707.03", "410.71", "560.89", "290.40", "038.9", "584.9", "287.5", "995.92", "276.51", "507.0", "285.29", "276.0", "577.0", "707.07" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.93", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	23395, 23461	13350, 15899	375, 513	23644, 23653	3335, 11451	24568, 25084	2369, 2373		21645, 23372		23482, 23623		21378, 21622				23677, 24545									2388, 3316																						15916, 17546				277, 337							541, 1542		11460, 13327									17561, 21352							1564, 2075	2091, 2353
71,013	149,712	54106	Discharge summary	report	Admission Date: [2190-10-4] Discharge Date: [2190-10-13] Date of Birth: [2118-4-21] Sex: F Service: MEDICINE Allergies: Naprosyn / Iodine-Iodine Containing / Barbiturates Attending:[First Name3 (LF) 10593] Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: PICC Placement History of Present Illness: 72 y/o woman with panhypopituitarism [3-10] pituitary apoplexy, LBO s/p L colectomy, prior CVA and multiple hospital admissions (most recent discharge on [2190-9-28] with AMS and UTI) presents from her long-term care facility with N/V x2 today found to have K 7.7, Cr 7.9 (baseline 1.0) and ABG 7.26/28/69. She had EKG changes (peaked T waves) in the ED and was given calcium gluconate, IVF, insulin glucose, HCO3, and Kayexalate with improvement in K to 5.5. Renal was called and recommended admission to the floor and starting HCO3 gtt @ 150meq/hr, q4h lytes and kayexalate. . On the floor, she endorsed increased ostomy output over the past 24 hours that she described as watery. She denied any CP/SOB/F/C. She was transiently hypoglycemic to 43. She was started on 150mEq NaHCO3 in D5W at 150cc/hr and blood and urine cultures were sent. She was doing fine on the floor until she developed a 20sec run of NSVT and became unresponsive for 30 seconds. She spontaneously became responsive again. She refused IV access and requested full code. Given nursing concern, patient was transferred to MICU for close observation. Past Medical History: - Panhypopituitarism s/p pituitary apoplexy in her 40s - Large bowel obstruction - Osteoporosis with recurrent fragility fractures ----> Pelvic fracture ----> Right humerus fracture ----> Right femur fracture - Seizure disorder (last seizure reportedly 9 years ago) - Left basal ganglia CVA (no residual deficit) - [Location (un) 3484] Syndrome - Type 2 DM - Bipolar Disorder - Anxiety NOS - Gait instability - Bowel resection (left colectomy) with colostomy &Hartmann's Pouch for large bowel obstruction in [2189] at OSH - Left colectomy with ostomy placement for unclear reasons - Abdominal wall abscess s/p IR drainage in [8-16] - R hip replacement - S/p right nephrectomy - S/p cholecystectomy - s/p splenectomy - Cataract surgeries - Splenectomy [2175] (s/p MVA) Social History: - Ex-smoker - Denies EtOH/illicits - Currently living in ECF as a result of recent admissions, but was previously in [Hospital3 ] facilities. Family History: NC Physical Exam: Admission Exam: Vitals: T: 97.5 BP:119/53 P:72 R: 18 O2: 100% RA GENERAL - NAD HEENT - NC/AT, PERRL, EOMI, mucous membranes dry NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - Large well healed midline scar. NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [6-10] throughout, sensation grossly intact throughout . Discharge Exam: VS: T 97-98 BP 130-180/60-90 HR 60-70 RR 18 O2 Sat 98% RA GEN: Elderly woman in NAD HEENT: EOMI, NCAT CV: RRR, nl s1/s2, no s3/s4. No m/r/g. Unable to asses JVP 2/2 habitus. PULM: CTAB, no increased WOB. ABD: Well healed midline scar. non tender, no rigidity, rebound or guarding. NABS. No suprapubic tenderness. EXT: WWP, no c/c/e NEURO: A/Ox2, CN II-XII grossly intact. Non focal. Pertinent Results: CXR PA/LAT ([2190-10-7]): As compared to the previous radiograph, there is no relevant change. Moderate cardiomegaly with mild pulmonary edema. The lateral image also shows mild bilateral pleural effusions. Minimal areas of atelectasis at the right lung base. Unchanged course and position of the right-sided PICC line. . CXR PA/LAT ([2190-10-12]): Stable small bilateral pleural effusions, possibly slightly decreased on the left. Right PICC in unchanged position - cavoatrial jxn. Low lung volumes - though no overt pulmonary edema. No focal consolidation. Tortuous aorta. . Admission Labs: [2190-10-4] 04:30PM BLOOD WBC-8.7# RBC-4.45 Hgb-12.1 Hct-37.3 MCV-84 MCH-27.1 MCHC-32.4 RDW-18.9* Plt Ct-531* [2190-10-4] 04:30PM BLOOD Neuts-81.7* Lymphs-11.9* Monos-4.7 Eos-1.2 Baso-0.5 [2190-10-4] 04:30PM BLOOD Glucose-92 UreaN-65* Creat-7.9# Na-127 K-7.7* Cl-92* HCO3-10* AnGap-33* [2190-10-4] 09:10PM BLOOD ALT-12 AST-25 CK(CPK)-38 AlkPhos-125* TotBili-0.2 [2190-10-4] 09:10PM BLOOD CK-MB-4 [2190-10-7] 12:22PM BLOOD CK-MB-2 cTropnT-<0.01 [2190-10-7] 07:20PM BLOOD cTropnT-<0.01 [2190-10-4] 04:30PM BLOOD Calcium-9.2 Phos-6.3# Mg-1.6 [2190-10-4] 11:40PM BLOOD TSH-0.14 [2190-10-4] 11:40PM BLOOD Free T4-1.1 [2190-10-4] 06:30PM BLOOD Type-[Last Name (un) ] pO2-69* pCO2-28* pH-7.26* calTCO2-13* Base XS--12 [2190-10-5] 01:24AM BLOOD Type-[Last Name (un) ] pH-7.15* Comment-GREEN TOP . Discharge Labs: [2190-10-12] 07:39AM BLOOD WBC-6.6 RBC-3.59* Hgb-9.7* Hct-29.6* MCV-83 MCH-27.2 MCHC-32.9 RDW-19.1* Plt Ct-411 [2190-10-12] 07:39AM BLOOD Plt Ct-411 [2190-10-12] 07:39AM BLOOD Glucose-93 UreaN-26* Creat-3.1* Na-141 K-4.0 Cl-100 HCO3-31 AnGap-14 [2190-10-11] 06:28AM BLOOD Calcium-8.5 Phos-4.8* Mg-1.7 [2190-10-10] 06:06AM BLOOD calTIBC-294 VitB12-494 Folate-11.5 Ferritn-99 TRF-226 Brief Hospital Course: Primary Reason for Admission: 72-year-old female with panhypopituitarism [3-10] pituitary apoplexy, LBO s/p L colectomy, prior CVA and multiple hospital admissions (most recently for pan sensitive e coli UTI treated with cipro) presenting with hyperkalemia, ARF and metabolic acidosis. . # Hyperkalemia: Likely secondary to acute metabolic acidosis given acuity of renal failure, prior Cr. was 1.1 less than a week prior to admission. Effective volume depletion and hypoaldo states ([3-10] adrenal insufficiency) may have contributed to her hyperkalemia. She received insulin, glucose, calcium gluconate, kayexalate and NaHCO3 in the ED with improvement in K to 5.5. Subsequent K was 6.2. Renal was called and deferred HD and recommended IFV with NaHCO3, q4h lytes and q4 EKG. Patient was transferred to the ICU for NSVT and transient AMS. She was treated with bicarb and transitioned to normal saline and her potassium normalized. She was initially treated with hydrocortisone 100mg PO Q8H for adrenal insufficiency which we started to taper on [10-6] until she was resumed on her home hydrocortisone on [2190-10-7]. Her K was normal by HD #3 and reamined WNL for the remainder of her hospital course. . # Transient AMS: In the setting of NSVT, hyperkalemia, history of seizure (last seizure was 9 yrs ago), admission hypoglycemia, and potentional TIA event. Exam is non-focal. Patient's lamotrigine was increased back to baseline [Hospital1 ] while in ICU. Unclear what caused her transient AMS, but was likely not seziure given she was not post-ictal. Possibly related to NSVT and non-perfusing rhythm, which resolved spontaneously. She had no further arrhythmias s/p correction of acidemia and electrolyte abnormalties. . # Hypotension/Hypertension: Patient had transient episodes of asymptomatic hypotension to SBPs in mid 80s in ICU on [10-5] and [10-6], at first while sleeping. Her BP was fluid responsive though UOP slowed during the time of these episodes. Thus, they were felt to be due to continued hypovolemia. Maintenance fluid was resumed at time of transfer to the floor with SBPs 100-110s. She received a total of 9L NS in the ICU. On the floor on [2190-10-7] she was found to be hypertensive to 204/108 and acutely SOB. She also endorsed chest tightness. CXR showed small b/l pleural effusions. She was given 80mg IV lasix, nitro s/l x3, 100mg po labetalol and albuterol/atrovent nebs with improvement in her BP to 140/90 and resolution of her SOB and chest tightness. Her HTN was felt to be [3-10] fluid overload. Blood and urine cultures were negative. TRANSITIONAL ISSUES: At the time of discahrge, the pt's BP remained labile and intermittently high to the SBP 180s. Ongoing management of her HTN should be addressed at her upcoming outpatient geriatrics appointment. . # AG metabolic Acidosis: Likely multifactorial given uremia in the setting of ARF and lactic acidosis in the setting of dehydration. C diff was negative and cipro was stopped s/p 7d course for UTI. Diarrhea improved and acidosis resolve with bicarbonate. . # ARF: Pt was dry on initial exam and in the setting of markedly increased ostomy output, this could be pre-renal failure, liekly c/b ATN given delayed response to IVF. Renal US was stable. Urine eos were negative. Her serum Cr was downtrending at the time of discahrge and renal signed off with instructions to f/u in clinic. Most recent Cr was 3.1 and she was making >1cc/kg/hr of urine. TRANSITIONAL ISSUES: Ms [Name13 (STitle) 110906] has Renal follow up; it is important that she see the nephrologist to f/u resolution of her ARF. . # Increased ostomy output: Pt is s/p partial colectomy. This may have been [3-10] antibiotic assocaited diarrhea. After c diff was negative, Flagyl was stopped. At the time of discharge she was hemodynamically stable with normal ostomy output. . # Cognitive impairment: patient carries diagnosis of mild cognitive impairment. During this admission, her mental status and level of orientation was not consistent. On same days, she could tell exactly where she was and the date, and on other days she was not able to remember. She was intermittently tearful and frustrated by her memory difficulties. No infectious-toxic-metabolic source of her cognitive impairment was identified, and it was felt that this was likely a reflection of slowly declined cognitive function, plus possibly pseudodementia/depression. This was explained to her son, [Name (NI) ]. On the morning of discharge, patient was seen by her outpatient psychiatrist, Dr. [Last Name (STitle) 17446], who felt she was at her baseline mental status. . # UTI: Pt completed 7 day course for previously diagnosed UTI, E coli sensitive to cipro. UA prior to discharge grew Staph and Enterococcus (<3000 colonies each), which likely represents contamination given the low colony number and the fact that she was asymptomatic; UA had no pyuria or nitrite. If she develops dysuria or fever, she should see her PCP for presumed UTI. . # Panhypopituitarism : Was given stress dose steroids which were decreased on [10-6] with plan to decrease to home dosing on [10-7]. She was continued on her home meds throughout her admission. . # DM: On admission to the floor, BG was 43, likely [3-10] insulin/glucose in the ED. She received juice and repeat BG was 25-->32-->89. Home metformin was held and she was covered with ISS throughout her admission. Her home metformin was re-started at discharge. . Transitional Issues: Ms [Name13 (STitle) 110906] was discharged to [Hospital 745] Healthcare with Geriatrics (new PCP), Neurology and Nephrology follow up. See above for details of important transitional issues. Notably, she needs PCP follow up for her BP and cognitive impairment and nephrology follow up for ATN. Medications on Admission: clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. -levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY -omeprazole 20 mg Capsule PO DAILY -lidocaine 5 % Adhesive Patch, Topical DAILY (Daily). -trazodone 25 mg PO HS as needed for insomnia. -quetiapine 100 mg PO QHS -hydrocortisone 10 mg PO QAM -hydrocortisone 5 mg PO QHS -lorazepam 0.5 mg PO once a day PRN anxiety -calcium carbonate 200 mg PO BID -cholecalciferol (vitamin D3) 400 unit PO once a day. -clotrimazole 1 % Cream 1 Topical twice a day. -lamotrigine 200 mg Tablet PO BID (2 times a day). -metformin 850 mg Tablet One (1) Tablet PO twice a day. -calcitonin (salmon) 200 unit [Unit Number ] Spray Nasal DAILY -clobetasol 0.05 % Ointment 1 Appl Topical [Hospital1 ] prn rash. -ciprofloxacin 500 mg Tablet PO Q12H for 10 days -acetaminophen 325 mg Tablet 1-2 Tablets PO TID PRN pain. -camphor-menthol 0.5-0.5 % Lotion 1 app DAILY (Daily). -oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO q4h prn pain. Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 5. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. calcitonin (salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) Nasal DAILY (Daily): One spray in one nostril daily. Alternate nostrils daily. . 9. lamotrigine 100 mg Tablet Sig: Two (2) Tablet 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. hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 12. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [Hospital1 ] PRN () as needed for rash on back. 13. clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 14. hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO qam. 15. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 16. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain. 17. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4 hours) as needed for moderate pain. 18. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO at bedtime. 19. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Topical once a day. 20. clobetasol 0.05 % Ointment Sig: One (1) Topical twice a day as needed for rash. 21. Outpatient Physical Therapy Please evaluate and treat for falls and low back pain Discharge Disposition: Extended Care Facility: [Hospital 745] Healthcare Discharge Diagnosis: Acute Tubular Necrosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms [Last Name (Titles) 110906], It was a pleasure caring for you at the [Hospital1 827]. You were admitted because your potassium levels were too high. We also found that there was too much acid in your blood, which is also a potentially dangerous condition. While you were here you had an abnormal heart rhythm that was likely caused by your acid and potassium abnormalties. You were also briefly unarousable during the night, and this prompted your doctors to admit [Name5 (PTitle) ] to you ICU. In the ICU we gave you fluid and your acid level and potassium level returned to [Location 213]. It is likely that you were dehydrated when you came in becuase of your incresed ostomy output, which was probably due to the antibiotics you were discharged on. You kidneys were damaged by your dehydration, but fortunately it appears that your kidneys are recovering well. We have arranged for follow up with a new primary care physician, [Name10 (NameIs) ] psychiatrist Dr [Last Name (STitle) 17446] and the kidney doctors who saw [Name5 (PTitle) ] here in the hospital. Establishing care with your new PCP should be [Name Initial (PRE) ] top priority, as your outpatient doctor should be your first resource for medical concerns or questions. No changes were made to your medications. Thank you for allowing us to participate in your care. Followup Instructions: Department: GERONTOLOGY When: FRIDAY [2190-10-15] at 10:00 AM With: [Name6 (MD) ] [Last Name (NamePattern4) 13171], MD [Telephone/Fax (1) 719] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: NEUROLOGY When: TUESDAY [2190-11-2] at 10:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 12567] [Name8 (MD) ], MD [Telephone/Fax (1) 1844] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: WEST [Hospital 2002] CLINIC When: THURSDAY [2190-12-2] at 10:30 AM With: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 720], M.D. [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "276.2", "733.00", "V44.3", "584.5", "427.1", "250.00", "276.7", "345.90", "V43.64", "780.97", "253.2", "255.0", "300.00", "296.80", "276.1", "V15.82", "V45.73" ]	icd9cm	[ [ [] ] ]	[ "38.97" ]	icd9pcs	[ [ [] ] ]	14286, 14342	5518, 8129	326, 343	14409, 14409	3626, 4211	15996, 17025	2496, 2500		12386, 14263		14363, 14388		11380, 12363				14592, 15973			5092, 5495						2515, 3205								3221, 3607										11051, 11354								274, 288							371, 1507							4227, 5076				14424, 14568							1529, 2315	2331, 2480
12,631	149,700	9626	Discharge summary	report	Admission Date: [2126-2-6] Discharge Date: [2126-2-8] Date of Birth: [2070-1-3] Sex: F Service: SURGERY Allergies: Lipitor Attending:[First Name3 (LF) 17683] Chief Complaint: post-operative bleeding Major Surgical or Invasive Procedure: total thyroidectomy and parathyroid adenoma resection History of Present Illness: Surgeon - Parengi Ms. [Known lastname 32610] is a 56 yo F w/ PMH recently diagnosed papillary thyroid cancer, symptomatic hyperparathyroidism, bleeding after dental procedures who was taken to the OR on the morning of admission for a total thyroidectomy and parathyroid adenoma resection and was found to have bleeding at the surgical site a few hours after the procedure. She was taken back to the OR for dysphagia and hematoma at the incision site. She was given DDAVP in the OR and the hematoma was evacuated. She was transferred to the ICU for observation overnight. . She currently denies neck pain. She reports her voice is stably hoarse since prior to her surgery. She denies worsening dysphagia, sore throat, odynophagia. She denies lightheadedness, leg cramps, perioral tingling. . ROS: She denies fatigue, fevers, chills, sweats. She denies nausea, vomiting, abdominal pain. She denies diarrhea or urinary sx. She denies easy bruising, bleeding, gingival bleeding, epistaxis. Past Medical History: 1. Papillary Thyroid Cancer - Thyroid US on [2125-1-23] was notable for a hypoechoic solid nodule measuring 2.6 x 2.0 x 1.8 cm which demonstrated central vascularity. FNA on [2125-1-24] was notable for papillary carcinoma with micro and macrofollicles showing thyroid chromatin and findings consistent with thyroid cancer. She underwent total thyroidectomy with central and thymic lymph node dissection on the day of admission. 2. Hyperparathyroidism - The patient has had an elevated calcium since [2119] (10.8). PTH at that time was 59. She continued to have an elevated calcium which increased to 11.7 as of [12-30]. At that time, a PTH was repeated and was 92. Her main symptom is depression characterized by poor mood. She has no h/o kidney stones, abdominal complaints. She had a thyroid US on [2126-1-23] which did not show an obvious adenoma. She had a sestamibi scan on [2126-2-1] which did not show an obvious adenoma. She underwent LUL parathyroid adenoma resection on the day of admission with decrease in her PTH from 89 to 7. 3. History of bleeding after dental resection at age 12. Never worked up for VWF. 4. B cell Lymphoma - extranodal marginal zone type involving dermis and superficial panniculus, [2118] - back - CD20, CD43, bc12 (+); CD10, CD5, CD23, bcl-2 (-); s/p resection only 4. HTN 5. Hypothyroidism - several years per pt; was on stable dose of 50 mcg levothyroxine 6. Hypercholesterolemia . PSH: 1. Dental extractions - c/b excessive bleeding 2. Breast reduction surgery - no complications except extensive ecchymoses . PGH: 1. Heavy Menses thought to be [1-25] Fibroids. Social History: She works as a technical writer. She lives alone with her parrot. She does not smoke or drink any alcohol. Family History: Cousin - [Name (NI) ] [Last Name (Prefixes) 4516] Disease. No FH of thyroid/parathyroid disease but her brother had kidney stones. Her mother had breast cancer at age 48. Physical Exam: PE: Temp 97.9 BP 135/71 Pulse 100 Resp 16 O2 sat 95% 2L Gen - Alert, no acute distress HEENT - PERRL, extraocular motions intact, sclera anicteric, mucous membranes moist. No Chvosteks Neck - Incision site - dressing c/d/i, no hematoma LN - No cervical, supraclavicular LAD Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds, No HSM appreciated Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, cranial nerves [2-4] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Skin - No rash Brief Hospital Course: Hospital course: This is a 56 yo F w/ parathyroid adenoma, papillary thyroid carcinoma s/p adenoma resection and total thyroidectomy w/ lymph node dissection c/b post-op hematoma admitted to the ICU for observation. . 1) Post-Op bleeding - There was a concern that this patient has [First Name5 (NamePattern1) ] [Last Name (Prefixes) 4516] disease as she reports excessive bleeding after a dental extraction as a child and her positive family history. She was given DDAVP in the OR and she had no evidence of bleeding at her incision site. No site of oozing was seen during the reexploration and hematoma excavation.The pt. remained stable during her observation period in the ICU. Hematology was consulted and labs were sent to further explore possible diagnosis of VW. DDAVP was stopped per heme. She will follow up with hematology as an outpatient. . 2) Hyperparathyroidism - The patient is s/p adenoma removal. She was without evidence of hypocalcemia. . 3) Papillary Thyroid Carcinoma - s/p total thyroidectomy, she was stable on her current dose of levothyroxine which was to be increased as necessary. She will have radioactive iodine scans and ablation as an outpatient. . 4) Pain control - Vicodin + IV dilaudid for breakthrough . 5)HTN - Cont HCTZ . 6) Hypercholesterolemia - Cont Pravastatin . #CODE - Full Medications on Admission: #Levothyroxine 75 mcg daily (increased pre-op by Dr. [Last Name (STitle) 32611] #HCTZ 25 mg daily #Fluoxetine 20 mg daily #Pravastatin 20 mg daily Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO Q 12H (Every 12 Hours). Disp:180 Tablet, Chewable(s) Refills:2 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Thyroid neoplasm Hyperparathyroidism hematoma Discharge Condition: Stable Discharge Instructions: You may resume your regular activites as tolerated. You may resume your regular diet. Resume your regular home medications. Followup Instructions: You have an appointment with Dr. [Last Name (STitle) ] on [2126-3-19]. [Telephone/Fax (1) 10533] Please call your hematologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for a follow up appointment ([Telephone/Fax (1) 15328]. [Name6 (MD) 843] [Name8 (MD) 844] MD [MD Number(1) 845] Completed by:[2126-5-14]	[ "193", "998.12", "202.80", "E878.6", "252.01", "227.1", "196.0" ]	icd9cm	[ [ [] ] ]	[ "06.02", "40.3", "06.4", "06.89" ]	icd9pcs	[ [ [] ] ]	6000, 6006	4064, 4064	289, 344	6096, 6105		6279, 6677	3163, 3345		5593, 5977		6027, 6075		5418, 5570	4081, 5392			6129, 6256									3360, 4041																										226, 251							372, 1363																		1385, 3021	3037, 3146
76,386	123,768	41484+58451	Discharge summary	report+addendum	Admission Date: [2116-4-9] Discharge Date: [2116-4-15] Date of Birth: [2058-3-10] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2181] Chief Complaint: Hypoxemic respiratory failure, chest pain Major Surgical or Invasive Procedure: Mechanical Intubation Central Venous Line insertion History of Present Illness: 58 yo male with history of recent pneumonia, treated as outpatient, had acute onset of chest pain and worsening of dysnea night prior to admission and called 911. Arrived to [Hospital 1562] Hospital ED satting 94% on NRB. Was intubated there and was given levofloxacin. CTA performed with no pulmonary embolism seen, though did have pulmonary edema +/- infection. Was transferred to [Hospital1 18] ED for further care. . Upon arrival to the [Hospital1 18] ED vitals were: T 98, HR 114, BP 204/166, RR 25, O2Sat 100% on AC 550 x 24 with PEEP 10. Blood pressure precipitously dropped to 45/25 approximately 1 hour into ED course and patient was given 2 L NS wide open and started on dobutamine. CVC triple lumen was placed and patient was given vanc, ceftriaxone, azithromycin. Patient was given albuterol/ipratropium and solumedrol 125 mg IV. CVP measured from central line was 15 at end of ED course. Made 400 mL of urine through ED course. Vitals prior to transfer to the MICU were: HR 92, BP 103/73, RR 24, O2Sat 100%. . Family at the bedisde in MICU unable to provide much additional history. Patient had not complained of feeling ill prior to presentation. He had mentioned that one person at work was recently hospitalized, though unknown reason. No known history of fevers. . REVIEW OF SYSTEMS: unable to obtain Past Medical History: 1) Hypertension - reportedly ran out of meds 2) Hyperlipidemia Social History: Lives with his aunt and works in warehouse for [Name (NI) ] auto parts. Has a daughter, [Name (NI) ]. His daughter, mother, and brother all live together. TOBACCO: 1 PPD smoker for 40+ years EtOH: unknown ILLICITS: unknown Family History: Extended family history of pancreatic cancer in one aunt, diabetes in another aunt Physical Exam: Tc: 98.7 Tm: 98.7 BP: 120-138/68-87 (137/76) HR: 67-86 RR: 18 O2: 92% I: 890 O: 1750 General: pleasant AA male, no acute distress HEENT: EOMI, MMM. no LAD, poor dentition with multiple missing teeth Neck: Supple, no JVD appreciated Cards: RRR, normal S1, S2, no m/r/g Pulm: good air movement in all lung fields. no wheezing, crackles Abd: soft, NT, +BS. no g/rt. neg HSM. neg [Doctor Last Name 515] sign. Extremities: wwp, no peripheral edema. DPs, PTs 2+. Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. grossly normal sensation. Normal gait Pertinent Results: Admission Labs: [2116-4-9] 03:25AM BLOOD WBC-24.0* RBC-5.17 Hgb-15.7 Hct-48.3 MCV-94 MCH-30.4 MCHC-32.6 RDW-13.4 Plt Ct-195 [2116-4-9] 03:30AM BLOOD PT-13.0 PTT-22.5 INR(PT)-1.1 [2116-4-9] 03:25AM BLOOD Glucose-234* UreaN-18 Creat-1.4* Na-141 K-5.2* Cl-105 HCO3-22 AnGap-19 [2116-4-9] 03:25AM BLOOD ALT-109* AST-135* AlkPhos-166* TotBili-0.5 [2116-4-9] 03:30AM BLOOD cTropnT-0.04* [2116-4-9] 09:48AM BLOOD CK-MB-6 cTropnT-0.07* [2116-4-9] 03:25PM BLOOD CK-MB-6 cTropnT-0.03* [2116-4-9] 03:25AM BLOOD Albumin-4.5 Calcium-8.3* Phos-5.4* Mg-2.3 IMAGING: [Hospital 1562] Hospital CTA [2116-4-9] - [Hospital1 18] Radiology Read FINDINGS: There is marked pulmonary edema in the dependent lungs with relatively small bilateral pleural effusions. It has a consolidative appearance in the left lower and right upper lobes. There is underlying emphysema. The central airways appear patent. There is an endotracheal tube appropriately positioned within the trachea. Though incompletely imaged on the images submitted, there is no evidence of acute aortic syndrome of the thorax. The abdominal aorta measures at least 3.7cm in the imaged portion. The heart is normal in size without pericardial effusion. There are no pathologically enlarged hilar, mediastinal, or axillary lymph nodes. The pulmonary arteries are patent to the subsegmental level. Numerous hypodensities within the liver are not fully evaluated. The left adrenal is prominent measuring 12 mm. No concerning osseous lesions are seen. IMPRESSION: 1. No pulmonary embolus. 2. Severe pulmonary edema which with left lower and right upper lobar consolidation. Likely pneumonia resulting in edema. 3. 3.7 cm suprarenal abdominal aortic aneurysm, incompletely imaged. CXR [4-13]: FINDINGS: In comparison with the study of [4-12], there is little overall change. Monitoring and support devices remain in place. Continued pulmonary vascular congestion with layering pleural effusions. Area of increased opacification in the right mid and lower zones persists, concerning for pneumonia. Retrocardiac opacification is consistent with volume loss, though superimposed pneumonia at the left base can certainly not be excluded. CXR [4-12]: Left lung is clear, since resolution of pulmonary edema. Right mid and lower lung zones are more consolidated today than yesterday and there may have been an increase in moderate pleural effusion. Heart size is normal. ET tube and right jugular line are in standard placements and a nasogastric tube passes into the stomach and out of view. Echocardiogram [2116-4-9]: The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is mild to moderate global left ventricular hypokinesis (LVEF = 35-40%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. 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. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mildly dilated left ventricular cavity with mild to moderate global systolic dysfunction. Mild aortic and mitral regurgitation. EKG [2116-4-9]: Sinus tachycardia. Biatrial abnormality. Left ventricular hypertrophy. No previous tracing available for comparison. Discharge Labs: Brief Hospital Course: Assessment and Plan: 58 year old male with PMHx HTN, Hyperlipidemia who presented with hypoxemic respiratory failure thought to be secondary to severe CAP and a question of COPD/pulm edema with EF of 35-40%. Treated with vancomycin, ceftriaxone, azithromycin for CAP, prednisone for ?COPD, and diuresis for pulmonary edema. . # Hypoxemic respiratory failure secondary to Community acquired pneumonia, COPD, and pulmonary edema - Patient was transferred to [Hospital1 18] after intubated at [Hospital 1562] Hospital. CTA at OSH showed no PE, multi-focal pneumonia, and pulmonary edema. Patient was treated with IV antibiotics, initially vancomycin, ceftriaxone, and azithromycin. He finished a course of azithromycin but his vancomycin was stopped on transfer to the floor. He was to finish an 8 day course of ceftriaxone, with the last day being cefpodoxime. He also completed a 5 day burst with prednisone with albuterol/ipratropium nebulizers to treat COPD. He was diuresed while in the ICU. Was extubated and tolerated room air without difficulty, was ambulating without deficit. . # Acute systolic heart failure - TTE in ICU showed an ejection fraction of 35-40%. The patient was initially diuresed as above. On transfer to the floor, he had no evidence of fluid overload and required no lasix. He was started on lisinopril and carvedilol for management of his heart failure. . # Hypertension - The patient was initially on verapamil, however once his EF was known, the patient was switched to lisinopril. Also on carvedilol as above. . Inactive Issues: . # Hyperlipidemia - The patient's lipids are moderately high. A statin should be considered, however his LFTs are elevated as below. . # Hepatitis - The patient's AST and ALT were elevated to 48 and 77 respectively. The patient should undergo hepatitis screening as an outpatient. . # Ethanol ingestion - The patient admits to drinking at least 2 shots of scotch a day. This issue needs to be further investigated. He was discharged on folate, B-12, and thiamine supplementation. . # Abodominal Aortic Aneurysm - The patient had a CT scan that showed a AAA. This should be further evaluated with ultrasound given the patient's age and past smoking history. This was discussed with the patient. . # FULL CODE . Transitional Issues: - PCP f/u - Potassium should be followed up on Friday as lisinopril was started - Pulmonary f/u with formal PFTs - Abdominal U/S to evaluate for AAA - f/u Echo in 3 months to re-evaluate systolic function - Hepatitis evaluation - Consider initiation of statin - Continued smoking cessation - Alcohol counseling Medications on Admission: ?verapamil Discharge Medications: 1. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 3. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:2 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. thiamine HCl 250 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 1 days. Disp:2 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Severe Community Acquired Pneumonia, ?Chronic obstructive pulmonary disease, acute systolic congestive heart failure, Hypertension, Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you during your hospitalization. You were admitted to the hospital because you were having difficulty breathing and had chest pain. You were intubated and then transferred to [Hospital1 18] for further care. A CT scan of your chest showed no evidence of blood clot, but did show severe pneumonia and fluid in your lungs. It also showed evidence of emphysema. You were treated with antibiotics for the pneumonia, steroids, for the ephysema, and diuretics which remove water from the body for the fluid in your lungs. We were able to remove the breathing tube and you were breathing room air without difficulty. We did check an echocardiogram which showed that your heart does not pump as well as it should, a condition called Congestive Heart Failure. We started medications to help treat this condition. . We checked your cholesterol to look for risk factors for heart disease and your numbers are elevated with total cholesterol of 225, LDL of 156, and HDL of 40. Your Hemoglobin A1c, a marker for diabetes is 5.2% which is very good. . Your liver enzymes were elevated when you were admitted. You should talk to your new doctor about being tested for Hepatitis to make sure this is not the cause. . Congratulations on your decision to stop smoking! This is a very difficult thing to do, but it is one of the most important interventions you can do to improve your health. . We made the following changes to your medications: STARTED Lisinopril 20mg by mouth daily Carvedilol 3.125 mg by mouth twice daily Albuterol-ipratropium inhalers every 6 hours as needed for shortness of breath/wheezing . Please follow up with the appointments below Followup Instructions: WHO: Dr. [First Name8 (NamePattern2) ] [Name (STitle) 90240], M.D WHEN: [4-17], 2:30pm WHERE: [Location (un) 9188] Family Medicine [Apartment Address(1) 90241] - [Location (un) 9188] [Telephone/Fax (1) 90242] . Department: PULMONARY FUNCTION LAB When: MONDAY [2116-4-27] at 3:40 PM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: PFT When: MONDAY [2116-4-27] at 4:00 PM Department: MEDICAL SPECIALTIES When: MONDAY [2116-4-27] at 4:00 PM With: [Name6 (MD) ] [Name8 (MD) 611], M.D. [Telephone/Fax (1) 612] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2116-4-15] Name: [Known lastname ],[Known firstname ] Unit No: [Numeric Identifier 14274] Admission Date: [2116-4-9] Discharge Date: [2116-4-15] Date of Birth: [2058-3-10] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 342] Addendum: Also needs screening colonscopy scheduled Discharge Disposition: Home [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 347] MD [MD Number(1) 348] Completed by:[2116-4-15]	[ "482.9", "570", "441.4", "428.0", "995.92", "401.9", "272.4", "518.81", "428.21", "305.01", "293.0", "573.3", "785.52", "305.1", "038.9", "491.21" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.6", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	13340, 13501	6468, 8028	345, 399	10147, 10147	2797, 2797	12046, 13317	2113, 2197		9157, 9918		9968, 10126		9122, 9134				10298, 11777			6445, 6445						2212, 2778																		8783, 9096		11807, 12023	1740, 1761					264, 307							427, 1721						8045, 8762	2814, 6427				10162, 10274							1783, 1848	1864, 2097
3,482	153,264	50032	Discharge summary	report	Admission Date: [2153-1-6] Discharge Date: [2153-1-21] Date of Birth: [2097-4-20] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine / Pork Derived (Porcine) Attending:[First Name3 (LF) 1990] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Intubation Right sided internal jugular central venous line History of Present Illness: This is a 55 year old male with multiple prior admissions for COPD exacerbations, hx of CAD s/p MI and 2-vessel CABG, and long history of medication and O2 noncompliance, who called EMS in respiratory distress after 1-2 days of increased dyspnea and was found altered and confused. On arrival to the ED, he was "minimally responsive" and started on BiPAP breifly, but was requesting intubation. After BiPAP did not seem to resolve his dyspnea, he was intubated. In the ED, he was given Solumedrol 125mg, Vanco/Ceftriaxone/Levaquin, MDI treatments, as well as Versed and Fentanyl while intubated. Blood cx's drawn x2, one before abx and one after some abx given. With high PaCO2 on ABG (7.18 / 73 / 400 / 29), RR increased from 14 to 22. Peep 5, TV 500ml, FiO2 40%. The following ABG showed improvement: 7.24 / 61 / 82 / 27 on TV 500, RR 22, PEEP 5, and ?FiO2. Baseline PaCO2 in high 50s-60s. An EJ was placed, but was subsequently lost, so an add'l PIV was placed. He then developed hypotension, CVL was placed, and was started on norepinephrine. He had received a total of 5L IVF. CXR showed no infiltrate, ET in proper placement. . He was previously admitted on [2152-11-15] with a severe COPD exacerbation with desats to 60s on RA and subsequent intubation and mechanical ventilation. He was covered with vancomycin and levofloxacin for MRSA pneumonia. After three days on mechanical ventilation, he was extubated without issue and discharged on antibiotics and a prednisone taper. He was then re-admitted with a recurrent MRSA pneumonia on [2152-12-4], treated with Linezolid for 14-day course due to presumed recurrence/treatment failure in setting of his previous antibiotic regimen. . Of note, during this hospitalization in early [Month (only) 404], a family meeting was held to help address the patient's recurrent hospitalizations. His medication noncompliance, persistent smoking habit, and refusal to wear his oxygen on a daily basis were all addressed. He apparently recognized that he needs to change his ways before he becomes fatally ill and agreed to have VNA services help him out at home. At this point, his code status was changed from DNR to full code. . ROS: Unable to perform due to patient's sedated state . Past Medical History: 1) CAD s/p MI and CABG PCI [5-/2150]: patent LIMA-->LAD, RIMA-->RCA, BMS--> RCA distal to RIMA touchdown. Cath [12/2150]: widely patent LIMA and RIMA grafts; patent distal RCA stent and known occluded native LAD and RCA. Nuclear Stress [1-/2151] Nuclear Perfusion Stress: no anginal symptoms or ischemic ST segment changes. REVEAL rhythm analyzer placed in [2152-12-2] 2) Tobacco abuse - 1 ppd/3 days since age 21 3) Hypercholesterolemia 4) Hypertension 5) COPD on 2L home O2 6) History of head trauma in [2118] from MVA with post-traumatic grand mal seizure, now off antiepileptics 7) Thoracic aortic anuerysm s/p repair [2148] 8) neurogenic claudication 9) s/p spinal stenosis surgery [1-/2152], on narcotics 10) MRSA PNA with cavitation, tx with linezolid [2152-12-18] x 14 days . Social History: Social History: Widower. Patient lives with his sister-in-law and her children. -Tobacco history: 30 pk/year hx, recently "quit" on previous discharge. Has not smoked a cigarette since [2152-11-1] -ETOH: previous hx of 16-30 beers/day, cut back a year ago, now occasional 1-2 beers. -Drug: denies hx of IVDU . Family History: Family History: Mother died of MI at 59. Father died at 61 of "MI and cancer." Cousin with MI at 41. Paternal uncle died with MI at 41. Sister with borderline diabetes. Brother died of throat cancer. Physical Exam: VS: Temp: 98.6, BP: 111/53, HR: 101 RR: 22 O2sat 98% --vent settings AC Vt 500, RR 22, PEEP 5, FiO2 50% GEN: intubated, sedated HEENT: pupils constricted, reactive. No JVD appreciated RESP: Decreased air movement over left lateral lung fields compared to right. Anterior lung fields clear. Slight expiratory wheezes, no rales/rhonchi CV: tachycardic, S1/S2 wnl, II/VI SEM heard best over LUSB ABD: hypoactive BS, soft, NT/ND, no masses or hepatosplenomegaly EXT: no c/c/e, WWP, 2+ DP and PT pulses SKIN: no rashes/no jaundice NEURO: sedated, plantar reflexes intact . Pertinent Results: [2153-1-6] 07:55PM BLOOD WBC-8.3 RBC-3.28* Hgb-8.4* Hct-27.1* MCV-83 MCH-25.7* MCHC-31.1 RDW-18.3* Plt Ct-219 [2153-1-6] 07:55PM BLOOD Neuts-75.2* Lymphs-20.9 Monos-2.9 Eos-0.6 Baso-0.4 [2153-1-6] 08:15PM BLOOD PT-12.5 PTT-23.2 INR(PT)-1.1 [2153-1-6] 08:15PM BLOOD Glucose-255* UreaN-13 Creat-0.6 Na-132* K-4.7 Cl-95* HCO3-24 AnGap-18 [2153-1-8] 04:06AM BLOOD ALT-7 AST-12 LD(LDH)-150 AlkPhos-44 TotBili-0.2 [2153-1-7] 03:01AM BLOOD Calcium-7.5* Phos-2.4* Mg-1.5* [2153-1-6] 08:12PM BLOOD Lactate-1.3 [2153-1-6] 08:50PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0 [2153-1-6] 08:50PM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . Urine culture: No growth. . Blood culture: No growth to date. . EKG: Sinus tachycardia. Biatrial enlargement. Cannot exclude prior anteroseptal wall myocardial infarction, age indeterminate. Compared to the previous tracing of [2152-12-12] the heart rate is faster. There may be slight loss of R waves in the anteroseptal leads. Clinical correlation is suggested. This may be secondary to lead positioning versus interim anteroseptal wall myocardial infarction. Biatrial enlargement is now apparent. . CXR ([2153-1-6]): 1. Standard positioning of the endotracheal tube and nasogastric tube. 2. Ill-defined opacity within the right mid lung field persists, compatible with an area of resolving pneumonia. CXR ([2153-1-7]): No evidence of pneumothorax. Status post extubation. No focal parenchymal opacity suggesting pneumonia. Normal size of the cardiac silhouette. Brief Hospital Course: 55 yo M with severe COPD on home O2, CAD, poor medication and oxygen compliance with recurrent hypercarbic respiratory failure due to a COPD exacerbation requiring intubation, hospital course complicated by DVT in the left brachial vein. The patient has had multiple hospitalizations for dyspnea within the past year with his most recent intubation in [Month (only) 1096] of [2151] due to MRSA pneumonia. He has a history of medication and home O2 noncompliance. His COPD remains very poorly controlled as a result. On admission this time, he developed severe shortness of breath and wheezing requiring intubation for hypercarbic respiratory failure due to a COPD exacerbation. He was started of pulse dose IV steroids, broad spectrum antibiotics and nebs. The patient clinically improved, was extubated, placed on an oral steroid taper with a 7 day total course of levofloxacin monotherapy and ongoing nebulizer, steroid inhaler and oxygen use. The patient complained of left arm swelling and was found to have a left brachial vein thrombus. He was started on systemic anticoagulation with warfarin without complication. The remainder of the [Hospital 228] medical problems including CAD, HLD, HTN and back pain were stable. This pt. has had repeated hospitalizations for COPD exacerbations. I tried to have him admitted to a pulmonary rehabilitation program, however, medicare declined to cover this given his level of function at the time of evaluation. Medications on Admission: Medications at home: -Albuterol sulfate 2.5 mg /3 mL (0.083 %) neb Q6H prn SOB -Albuterol sulfate 90 mcg HFA INH, 1-2 puffs, q4-6h prn sob -Fluticasone 110 mcg x 2 INH [Hospital1 ] -Salmeterol 50 mcg/dose [Hospital1 ] -Tiotropium bromide 18 mcg Capsule, w/Inhalation INH qday. -oxygen at 2L/min continuous -Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). -Furosemide 40 mg PO DAILY -Lisinopril 20 mg PO DAILY -Metoprolol tartrate 100 mg HS -Simvastatin 40 mg PO QHS -Guaifenesin 100 mg/5 mL PO Q6H prn cough -Iron 325 mg PO once a day. -Aspirin 325 mg PO once a day. -clotrimazole 10 mg Troche 3-4 times daily -oxycodone-acetaminophen 5 mg-325 mg Tablet [12-3] Tablet(s) q6h PRN . Allergies: NKDA Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR): Take this medication three times per week for as long as you are taking 20 mg or more per day of prednisone. Disp:30 Tablet(s) Refills:0 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) inhallation/activation Inhalation [Hospital1 ] (2 times a day). 6. guaifenesin 100 mg/5 mL Liquid Sig: Five (5) mL PO every six (6) hours as needed for cough. 7. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 10. oxycodone-acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: as we discussed - do not drive or drink alcohol or operate machinery while taking this medication. Disp:240 Tablet(s) Refills:0 11. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 12. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TIDAC (3 times a day (before meals)). Disp:180 Tablet, Chewable(s) Refills:0 13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO once a day. Disp:120 Tablet(s) Refills:0 14. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours): as we discussed - do not drive or drink alcohol or operate machinery while taking this medication. Disp:60 Tablet Extended Release(s) Refills:0 15. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily): Take this medication once per day while you are taking prednisone. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:0 17. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 3 months: your levels of this medication will need to be managed and dosed by Dr [Last Name (STitle) ] (your primary care MD). GOAL INR 2.0-3.0; DO NOT TAKE THIS MEDICATION UNTIL INSTRUCTED TO DO SO BY YOUR VISITING NURSE AND YOUR PRIMARY MD ([Doctor Last Name ]). Disp:120 Tablet(s) Refills:0 18. prednisone 10 mg Tablet Sig: as per taper regimen Tablet PO once a day for 22 days: [Date range (1) 86563]: 4 tab/day [Date range (1) 35039]: 2 tab/day [Date range (1) 104475]: 1 tab/day then stop. Disp:45 Tablet(s) Refills:0 19. INR blood test Sig: One (1) lab draw twice per week: Next test to be done ON [2153-1-23]. Result should be communicated to THE [Hospital 191] [Hospital ] CLINIC AT: ([Telephone/Fax (1) 10844] FOR INSTRUCTIONS ON DOSING. Disp:6 lab draws Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: COPD exacerbation Hypercarbic respiratory failure DVT in left brachial vein Hypertension CAD Hyperlipidemia Back pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with an exacerbation of your lung disease. You also developed a blood clot in a vessel in the arm. You must take a blood thinning medication to treat this for three months. We have arranged a nurse to come to your house to check your blood levels of this medication (coumadin) and coordinate your dosages of coumadin with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) ]. Followup Instructions: Department: [Hospital3 249] When: [Hospital3 ] [2153-1-29] at 11:30 AM With: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Location: [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage 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.	[ "V12.04", "V45.81", "428.22", "401.9", "995.92", "453.82", "305.1", "486", "280.9", "428.0", "276.1", "491.21", "V15.81", "518.81", "785.52", "038.9" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "38.93" ]	icd9pcs	[ [ [] ] ]	11622, 11680	6292, 7770	314, 376	11842, 11842	4659, 6269	12424, 13058	3866, 4051		8543, 11599		11701, 11821		7796, 7796				11993, 12401				7817, 8520					4066, 4640																										267, 276							404, 2661											11857, 11969							2683, 3501	3533, 3834
5,060	143,525	24309	Discharge summary	report	Admission Date: [2182-10-7] Discharge Date: [2182-10-8] Date of Birth: [2144-9-28] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 338] Chief Complaint: EtOH Intoxication Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 38 yo male with a PMH significant for Etoh and Poly substance abuse, Hep B, and Hep C. Pt was found down on the street stating that he wanted to be run over by a car. Pt recently was admitted to the MICU with EtOH intoxication yesterday, pt left AMA. In ED patient vitals were BP 93/58 - 156/89, HR 70-80s, T 98, 100% on 2L. Initially given 5mg haldol for agitation/combative behavior, later given 10mg Valium PO. No access attained. Complained of some tail bone pain which was worked up with plain film of coccyx. ED was prepared for DC however pt reported difficulty walking. Patient appears intoxicated and is not willing to answer questions. Pt does not some abdomen, back, and extremity pain globally. Past Medical History: Per Discharge Summary ([2182-6-18]) Poly Substance Abuse: Benzo/Opiates/IVDU 2. Ethanol Abuse: hx of DTs and withdrawal seizures, intubated in the past. 3. Hepatitis C 4. Hepatitis B 5. Compartment Syndrom RLE, [2171] 6. OCD and Anxiety 7. Depression with hx of suicidal ideations 8. Sever Peripheral Neuropathy Social History: From previous DC summary. States he does not speak to any family members, never married, no children. Homeless, states he does not like shelters because he gets "nervous around all the people." Family History: Father with depression, OCD and alcoholism. Mother died of DM complications Physical Exam: T BP 121 HR 76 RR 20 O2sat 100% on RA General - Resting comfortably in bed, no acute distress, Appears intoxicated and is not interested in answering questions. HEENT - Sclera anicteric, Lips dry Neck - Supple, JVP not elevated, no LAD Pulm - CTA bilaterally; no wheezes, rales, or rhonchi CV - RRR, normal S1/S2; no murmurs, rubs, or gallops Abdomen - Soft, Mild tenderness on palpation of abdomen Ext - Warm, well perfused, radial and DP pulses 2+; no clubbing, cyanosis or edema. Pain with palpation of lower extremity. Neuro - Pt is not willing to participate with exam. Still appears somewhat intoxicate, however mental status is improving. Able to move all extremities. PERRL. EOMI. Pertinent Results: Radiograph Coccyx: Normal bony mineralization and alignment. No evidence of fracture. Apparent mild sclerosis overlying the right S1, S2 region is not appreciated on the more tilted views and is likely artifactual. No evidence of fracture. Views of the L5-S1 region do show some evidence of degenerative osteophyte formation of the anterosuperior aspect of L5, probably some posterior osteophytes of the L5-S1 disc interspace. Brief Hospital Course: Pt is a 38 year old male with significant hx of EtOH/Polysubstance abuse, who presented today with EtOH intoxication and developed respiratory distress, felt to be self induced airway obstruction. . # Airway obstruction: Required a Code Blue, and at first there was concern about a allergic response, later thought to be psychogenic. It resolved without intubation. Sats remained normal. . #.EtOH Intoxication/Withdrawal: Received multiple doses of ativan and valium. No objective signs of withdrawal by time of his transfer to the MICU. Was also given MV and thiamine and folate. . #. Scabies: Found to have extensive infection. Was treated with 5% permethrin cream x 1, but will need repeat out pt treatment in one week. . #.Hep B/Hep C: Hep B infection cleared based on most recent serologies. AST>ALT on recent liver function tests, most likely was secondary to EtOH abuse. . #. Code status: DNR/DNI confirmed 2 days prior with psych . Pt leave AMA on the morning of [2182-10-8]. Medications on Admission: Per Discharge Summary ([2182-6-18]), Unknown Compliance 1. Folic Acid 1mg Daily 2. Thiamine 100mg Daily 3. MVT One tab Daily 4. Ferrous Sulfate 325mg One Tab Daily 5. Oxcarbazepine 300mg one tablet [Hospital1 ] 6. Gabapentin 200mg PO Q8H 7. Prozac 40mg Once Daily Discharge Medications: left AMA Discharge Disposition: Home Discharge Diagnosis: Left AMA Discharge Condition: Left AMA Discharge Instructions: Left AMA Followup Instructions: Left AMA Completed by:[2182-10-9]	[ "070.54", "291.81", "V60.0", "300.4", "V62.84", "786.09", "301.4", "133.0", "070.32", "357.5" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	4210, 4216	2864, 3854	289, 295	4269, 4280	2413, 2841	4337, 4377	1611, 1688		4177, 4187		4237, 4248		3880, 4154				4304, 4314									1703, 2394																										232, 251							323, 1040																		1062, 1384	1400, 1595
65,469	117,840	42218+58381	Discharge summary	report+addendum	Admission Date: [2195-6-18] Discharge Date: [2195-6-22] Date of Birth: [2116-5-13] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2782] Chief Complaint: Fever, abdominal pain, jaundice Major Surgical or Invasive Procedure: ERCP History of Present Illness: Mr. [Known lastname 91520] is a 79 year old male with hx of HTN, HL, DM2, and chronic pancytopenia, transferred here from [Hospital3 ] with fever, abdominal pain, and jaundice for further evaluation. He initially presented to [Hospital1 ] on [6-12] with epigastric pain, abdominal distension with mild nausea/vomiting. Labs and CT scan were done and unremarkable and he was sent home. He then re-presented with similar symptoms to an acute care visit in his PCP's office, who noticed he was jaundiced and febrile and sent him to the [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] once again. His pain was [6-7] at its worst and seemed to improve with Gas-X. He was febrile to 102.3 and given a dose of zosyn and vanco. CT abdomen was again unremarkable, but RUQ U/S showed a small echogenic calculus in the GB neck. CXR was unremarkable, per OSH read. Labs were notable for Tbili 5.7, ALT 364, AST 426, AP 155, creat 2.4, wbc 4.7, INR 0.99, and guaiac neg. In the [Hospital1 18] ED, initial vitals were: 96.6, 70, 82/49, 16, 99%. RUQ U/S was repeated, confirming the presence of a 7mm stone in the GB. Foley was placed to monitor UOP and he was given a total of 5L IVF for his hypotension with good response. Surgery was consulted and recommended ERCP, IVF, abx coverage, and admission to the ICU. ERCP was consulted and will see in the AM unless patient worsens overnight. Upon transfer, his vitals were: 75, 101/51, 20, 98% RA. In the ICU, the patient is quite comfortable and explains that he has been pain-free all day. His blood pressure continued to remain stable without pressors. . Review of systems: (+) Per HPI (-) Denies 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 diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes. Past Medical History: Past Medical History: -Waldenstrom's diagnosed by BM biopsy and followed by Dr. [First Name (STitle) 4223] at [Hospital ] Hosp. -HTN -HL -NIDDM -Anemia (on iron supplementation) -Chronic pancytopenia -BPH -Bilateral inguinal hernias, never repaired -CKD Social History: - Tobacco: 1 pk/day for about 15 years - Alcohol: glass of wine per night, denies previous EtOH abuse - Illicits: denies Family History: DM2, HTN, breast CA Physical Exam: ADMISSION PHYSICAL EXAM: General: jaundiced, alert, oriented, no acute distress HEENT: icteric sclera, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema ICU Discharge PE: VS: T 96.7 HR 78 BP 136/80 RR 17 O2Sat 97% on RA General: Patient is laying in bed comfortably, alert and oriented HEENT: Sclera icteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally with no added sounds CVS: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs or gallops GI: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley removed EXT: Warm, well-perfused with no clubbing, cyanosis or edema; 2+ pulses NEURO: Alert and oriented to person, place and situation; gross neurological exam normal DERM: No lesions appreicated Pertinent Results: ADMISSION LABS: [2195-6-18] 09:17PM LACTATE-1.3 [2195-6-18] 09:15PM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.018 [2195-6-18] 09:15PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-2* PH-5.5 LEUK-NEG [2195-6-18] 09:15PM URINE RBC-1 WBC-10* BACTERIA-FEW YEAST-NONE EPI-0 [2195-6-18] 09:15PM URINE GRANULAR-17* HYALINE-6* [2195-6-18] 07:33PM COMMENTS-GREEN TOP [2195-6-18] 07:33PM GLUCOSE-173* LACTATE-1.2 K+-4.7 [2195-6-18] 07:15PM GLUCOSE-182* UREA N-46* CREAT-2.8* SODIUM-136 POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-15* ANION GAP-20 [2195-6-18] 07:15PM estGFR-Using this [2195-6-18] 07:15PM ALT(SGPT)-358* AST(SGOT)-379* ALK PHOS-143* TOT BILI-5.5* [2195-6-18] 07:15PM LIPASE-68* [2195-6-18] 07:15PM VIT B12-1292* FOLATE-GREATER TH [2195-6-18] 07:15PM WBC-3.9* RBC-2.51* HGB-8.9* HCT-25.4* MCV-101* MCH-35.4* MCHC-35.0 RDW-14.1 [2195-6-18] 07:15PM NEUTS-81.5* LYMPHS-11.2* MONOS-6.9 EOS-0.2 BASOS-0.1 [2195-6-18] 07:15PM PLT COUNT-100* [2195-6-18] 07:15PM PT-12.7 PTT-26.9 INR(PT)-1.1 [2195-6-20] 03:41AM BLOOD WBC-1.9* RBC-2.46* Hgb-8.5* Hct-24.5* MCV-100* MCH-34.5* MCHC-34.7 RDW-13.1 Plt Ct-69* [2195-6-20] 03:41AM BLOOD PT-12.7 PTT-27.0 INR(PT)-1.1 [2195-6-20] 03:41AM BLOOD Glucose-91 UreaN-23* Creat-1.6* Na-138 K-4.1 Cl-108 HCO3-15* AnGap-19 [2195-6-20] 03:41AM BLOOD ALT-215* AST-157* AlkPhos-148* TotBili-6.3* DirBili-5.6* IndBili-0.7 [2195-6-20] 03:41AM BLOOD Calcium-8.6 Phos-2.3* Mg-1.6 Micro: Urine culture: Negative Blood cultures: Pending Imaging: RUQ U/S: Non-distended benign-appearing gallbladder with a single 7mm stone. Focal wall thickness in the gallbladder fundus is most likely secondary to adenomyomatosis. Focal GB carcinoma cannot be completely excluded. ERCP [2195-6-19]: Impression: Sphinctrotomy performed. Small CBD stone/sludge removed. No pus seen. Cystic duct stone could not be removed. Otherwise normal ercp to third part of the duodenum Brief Hospital Course: 79 year old man with history of HTN, HTL, DM, Waldenstrom's macroglobulinemia, chronic pancytopenia, and CKD presented to [Hospital3 ] with fever, RUQ pain, jaundice and an obstructive pattern to his LFTs consistent with acute cholangitis. # Acute cholangitis -[2195-6-19] - ERCP with sphincterotomy - small CBD stone/sludge was removed, and a cystic duct stone was seen but could not be removed -Was hypotensive in the ED and admitted initially tot he ICU but responded rapidly to IVF and IV unasyn ([Date range (1) 18857]). Blood and urine cultures from [6-18] remain negative. He was changed to PO cipro/flagyl on [6-21] for a 10d course to end on [6-26]. . # Macrocytic anemia: Hct on admission low at 25.4 with an MCV of 101. His baseline is 32 (in [2195-2-27]). He is only on iron supplementation as an outpatient, but his MCV seems to indicate that his anemia may be caused by B12/folate deficiency or MDS. B12 and folate were tested and found to be high. This makes most likely cause of macrocytosis his obstructive jaundice, as phospholipids can be deposited on cell membrane surface. His Hct with aggressive hydration dropped to 22 on [6-21] but he was completely asymptomatic and refused transfusion. He will be monitored closely and restarted on iron. There was no clinical evidence of bleeding. His [Month/Year (2) 9766] 81mg/day (at home) will be held for at least 7 days after the sphincterotomy, until [6-26]. . # Chronic pancytopenia: In addition to the anemia above, patient is also leukopenic and thrombocytopenic. This can be from a variety of different causes including viral infections like HIV, heme conditions such as MDS, and vitamin deficiencies as above. Daily CBCs were drawn to trend WBC and plts showing downward trends of all cell lines which may be dilutional. He is followed by hematology at [Hospital3 ] as an outpatient (Dr. [First Name (STitle) 4223]. On [6-22] his hematocrit was 25, wbc 2.4, and plts 74 . # Acute kidney injury in the setting of CKD: Creatinine elevated at 2.8 on admission. Likely pre-renal in the setting of infection and the patient was bolused 5L in the ED. Serum Cr decreased to 1.6. He continued his [Last Name (un) ] (diovan) # DM II: On admission, his pioglitazone was held. During the admission, he was started on ISS with FSBGs QACHS while NPO. Once he started eating, his home medications were restarted. He had previously been on glipizide, which was stopped in [2195-4-29] after an episode of hypoglycemia. # Hypertension: His home metoprolol and diovan were held for initially given hypotension in ED, then were subsequently restarted. . # Hyperlipidemia: His home statin was held given abnormal LFTs and his niacin 1500mg per day is being held. His statin was resumed. Med changes: ASA held till [6-26] cipro & flagyl to end [6-26] Niaspan held ITEMS for f/u per PCP []anemia workup and management (Patient has outpatient hematologist as well) []f/u of gallstones with GI []followup of glucose and diabetes Medications on Admission: Actos 45mg daily Niaspan 1500mg daily Metoprolol 100mg [Hospital1 *] Diovan 160mg daily Simvastatin 20mg qhs Prandin 1mg prior to evening meal if BS>140 "Iron" 325mg daily MVI daily ASA 81mg Discharge Medications: 1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:9 Tablet(s)* Refills:0 2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 4 days. Disp:12 Tablet(s) Refills:0 3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. repaglinide 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Outpatient Lab Work please have your PCP's office repeat your CBC and LFTs Discharge Disposition: Home Discharge Diagnosis: Cholangitis Choledocholithiasis with obstruction; resolved Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with blocked bile ducts and a procedure called an ERCP with sphincterotomy was performed to remove the gallstones which were causing the obstruction. There was also infection of your bile ducts which was treated with antibiotics. Your blood counts dropped, and you will need to have labs drawn after discharge by your primary care physician. [Name10 (NameIs) 9766] and niancin have not been restarted. Followup Instructions: Name: NP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 91521] Location: [Hospital3 ] INTERNAL MEDICINE ASSOCIATES Address: [Street Address(2) 4472], [Apartment Address(1) 4473], [Hospital1 ],[Numeric Identifier 9331] Phone: [Telephone/Fax (1) 4475] Appointment: Wednesday [2195-6-24] 11:30am Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4469] [Telephone/Fax (1) 76066] [7-15] 11AM This is a follow up appointment of your hospitalization. You will be reconnected with your primary care physician after this visit. Name: [Known lastname 14092],[Known firstname ] Unit No: [Numeric Identifier 14093] Admission Date: [2195-6-18] Discharge Date: [2195-6-22] Date of Birth: [2116-5-13] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2149] Addendum: patient received pneumovax vaccination on [6-21] Discharge Disposition: Home [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2150] MD [MD Number(2) 2151] Completed by:[2195-6-22**]	[ "250.00", "574.91", "576.1", "584.9", "V64.1", "458.9", "403.90", "273.3", "284.1", "585.3" ]	icd9cm	[ [ [] ] ]	[ "51.88", "51.85" ]	icd9pcs	[ [ [] ] ]	12068, 12231	6168, 9236	337, 343	10421, 10421	4093, 4093	11020, 12045	2858, 2880		9481, 10289		10339, 10400		9262, 9458				10572, 10997									2920, 3406																					2035, 2418			3420, 4074		265, 299							371, 2016							4110, 6145				10436, 10548							2462, 2703	2719, 2842
2,989	123,744	690	Discharge summary	report	Admission Date: [2123-2-2] Discharge Date: [2123-2-4] Date of Birth: [2067-12-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4219] Chief Complaint: Vague diffuse abdominal discomfort Major Surgical or Invasive Procedure: none History of Present Illness: 55 yo M with h/o chronic EtOH abuse, HTN, ?DM2, and asthma, recently admitted to [Hospital1 18] [1-8]->[2123-1-9] with intoxication and right rib fracture, now transferred to [Hospital1 18] ED after presenting to clinic intoxicated. He was initially combative and agitated, but improved. He complained of chest pain and was found to have a troponin of 0.02. On last admission, he was ruled out for MI with negative cardiac enzymes. . In the ED he received 10 IV valium x 2, 40 meq K, banana bag, and Mag. He fell out of bed and a head CT was obtained. He had an episode of vomiting and became hypoxic, requiring a NRB mask, and was sent for CXR. . He now complains of diffuse abdominal pain. He is unable to provide much history, due to recently receiving valium. He denies SOB, chest pain, N/V/D, headache, constipation, blood in BMs, palpitations or anxiety. . ROS: Per patient and OMR records, he was hit by a car in early [Month (only) 1096] with consequent rib fracture. Past Medical History: Hypertension EtOH abuse Asthma ? DM2 rib fracture Social History: He is homeless, and stays in a shelter. Ongoing alcohol abuse, about [1-25] pint of vodka per day. Last drink 24 hours ago. No IVDU. Current smoker, 1ppd X 40 years. Patient declines rehab. Family History: Non-contributory Physical Exam: VITALS: T 96.3, HR 98, BP 171/96, RR 17, O2 96% 2L NC GEN: Somnolent but rousable, smells of EtOH. HEENT: EOMI, PERRL ?Mild icterus, conjunctival injection b/t. OP clear. MMM. RESP: Diffuse expiratory wheezes. Distant BS. No crackles. CVS: RRR. Normal S1, S2. No murmur or rub. GI: + BS. Diffuse abdominal tenderness. Voluntary guarding on deep palpation. No rebound. No mass palpable. EXT: Some superficial skin wounds. No edema. warm. Pertinent Results: CXR: In the frontal view, a sliver of lucency projects above the splenic flexure without a clear corresponding abnormality on the lateral. If symptoms persist, I would recommend radiographic evaluation of the left hemidiaphragm in the right decubitus position to exclude small volume of pneumoperitoneum. The region of the right hemidiaphragm is normal. Mild cardiomegaly is unchanged and mild interstitial pulmonary abnormality is stable since at least [1-7] and probably more chronic. . CT Abd: 1. Acute left posterior rib fracture - eleventh rib associated with small focal muscle hematoma with no associated visible injury to the left kidney or spleen. There is associated atelectasis at the left lung base and this should be followed up with imaging to assure clearance. 2. Atherosclerosis including visceral branches and dense plaque at the origin of left renal artery end coronary atherosclerosis. 3. Fatty liver. 4. Distended urinary bladder. . CT Head: No evidence of acute mass effect or hemorrhage. . EKG: sinus tach @ 101. nl intervals. <0.[Street Address(2) 1755] dep in inferior leads on initial EKG. resolved on subsequent. . CXR [2-3]: no change [2123-2-2] 03:20AM ASA-NEG ETHANOL-213* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2123-2-1] 09:00PM GLUCOSE-173* UREA N-8 CREAT-0.9 SODIUM-149* POTASSIUM-3.1* CHLORIDE-108 TOTAL CO2-25 ANION GAP-19 [2123-2-1] 09:00PM CK(CPK)-416* [2123-2-1] 09:00PM cTropnT-0.02* [2123-2-1] 09:00PM CK-MB-5 [2123-2-1] 09:00PM WBC-5.2 RBC-4.09* HGB-13.2* HCT-38.4* MCV-94 MCH-32.1* MCHC-34.3 RDW-16.6* [2123-2-1] 09:00PM PT-12.0 PTT-27.2 INR(PT)-0.9 [2123-2-1] 09:00PM PLT COUNT-208 [2123-2-2] 09:18AM CK(CPK)-376* [2123-2-2] 09:18AM CK-MB-4 cTropnT-0.02* [2123-2-2] 06:20PM CK-MB-3 cTropnT-0.03* [2123-2-2] 06:20PM CK(CPK)-348* [2123-2-2] 03:20AM ALT(SGPT)-65* AST(SGOT)-151* LD(LDH)-317* CK(CPK)-397* ALK PHOS-129* AMYLASE-219* TOT BILI-0.4 [2123-2-2] 03:20AM LIPASE-157* Brief Hospital Course: This is a 55 yo M with history of EtOH abuse, asthma, and HTN who presented with diffuse abdominal pain and was undergoing EtOH detoxication. The patient was placed on valium per CIWA scale for acute alcohol withdrawal. Since he presented s/p fall, a head CT was done that was negative for bleed. He was quite somnolent, diaphoretic, and agitated on his day of admission and was transferred to the ICU overnight for monitoring. He was transferred back to the floor the next day. He continued to become agitated but required less valium. The patient expressed no interest in stopping EtOH consumption. SW was consulted but was not able to see the patient before he left AMA. He did receive a banana bag in the ED, and thiamine, folate, and MVI daily. He was monitored for aspiration and fall. . The patient's abdominal pain was vague and chronic; it was thought likely to be EtOH pancreatitis vs hepatitis or referred pain from his broken rib. CXR showed no pneumonia. He was tolerated a regular diet on discharge and his LFTs were stable. Ibuprofen was administered for rib pain. . The patient was slightly hypoxic on admission. This was thought to be due to aspiration pneumonitis vs PNA from vomiting in the ED. The patient was given albuterol and atrovent nebs. He remained afebrile and his oxygenation improved on its own. . The patient was also noted to have a pruritic erythematous rash to trunk and neck. This was concerning for allergic reaction or contact dermatitis. It responded to one dose of benadryl. . He was ruled out for MI with serial cardiac enzymes. Initial EKG showed ST depressions in inferior leads that resolved on subsequent EKGs. He was started on aspirin in house. . The patient left the hospital AMA abruptly, before he could be seen or evaluated by the attending medical physician Medications on Admission: None Discharge Medications: patient left AMA Discharge Disposition: Home Discharge Diagnosis: EtOH withdrawal .. DM HTN Discharge Condition: patient left AMA, stating that, "I don't think I'm ready to quit drinking", "I'm not an every day alcoholic." Discharge Instructions: none, left AMA Followup Instructions: none, left AMA [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 4231]	[ "276.3", "E884.4", "401.9", "V60.0", "493.20", "786.50", "789.07", "291.81", "E947.8", "276.8", "303.00", "250.00", "693.0" ]	icd9cm	[ [ [] ] ]	[ "94.62" ]	icd9pcs	[ [ [] ] ]	6180, 6186	4256, 6084	349, 355	6255, 6366	2191, 3157	6429, 6538	1690, 1708		6139, 6157		6207, 6234		6110, 6116				6390, 6406									1723, 2172																										275, 311							383, 1387		3166, 4233																1409, 1460	1476, 1674
10,251	115,601	11309	Discharge summary	report	Admission Date: [2102-3-13] Discharge Date: [2102-4-11] Date of Birth: [2027-4-28] Sex: F Service: NEUROLOGY Allergies: Oxycontin / Morphine Attending:[First Name3 (LF) 618] Chief Complaint: "swollen tongue" Major Surgical or Invasive Procedure: LP x2 History of Present Illness: 74 yo F with chronic low back pain s/p multiple procedures, urinary incontinence, and dementia who presented to the ED with tongue swelling after falling onto her face. Per report she was walking and fell forward. No apparent LOC or preceeding symptoms. She appeared to loose her balance. She sustained a right orbital hematoma and bit her tongue. She did not require sutures. She is being admitted to the [Hospital Unit Name 153] for airway monitoring given her swollen tongue. . She was seen at [Hospital3 ] today for a pre-op assessment prior to a urinary sling procedure. Her husband reports increasing confusion and frequent falls over the last two weeks. She was treated for a UTI with Amoxicillin 1 month ago. He reports she is forgetful at baseline. She has been on several different medications for urinary incontinence over the last 2 yrs including detrol and vesicare. Her recent confusion appears to correlate with starting Vesicare on [2102-2-21]. She also discontinued her fluphenazine on [2102-3-9] after 40 yrs of use. . In the ED a Head CT revealed chronic microvascular angiopathy without acute fracture or hemorrhage. Her UA was negative. . She is alert and oriented to self only. She denies pain, dysuria, or SOB. Husband reports her wt has been stable and she has a good appetite. Past Medical History: - ?dementia - urinary incontinence since [2099] - chronic low back pain/degenerative disk disease s/p failed back surgery, epidural steroid injections, nerve blocks, facet injections, trigger point injections - hyperlipidemia - hypertension - major depression Social History: She lives at home with her husband. She is independent of her ADL's. She quit smoking tob in [2049]; ~10 pack year history. Occasional EtOH. Denies illicit drug use. Husband, [Name (NI) 892] [Name (NI) 3647], is HCP ([Telephone/Fax (1) 36275]). Son [Telephone/Fax (1) 36276]. Family History: Mother died of [Name (NI) 11964]. Two sisters are healthy. Youngest child with mental retardation; lives in group home. Physical Exam: Admission: Tc 98.6 BP 170/100 HR 96 RR 18 Sat 95% RA Gen: appears comfortable, NAD HENNT: swollen tongue, multiple ecchymoses and abrasions over right orbit, lips, and cheeks. MMM, anicteric, PERRL Neck: no LAD, no JVD CV: RRR, nl S1S2, II-III/VI systolic murmer heard best at apex Lungs: CTAB Abd: soft, NT/ND, +BS, No HSM Ext: no peripheral edema, strong DP/PT pulses bilaterally Neuro: A&O to self, moving all extremities Pertinent Results: [2102-3-13] 09:25PM BLOOD WBC-10.5 RBC-4.27 Hgb-14.0 Hct-37.8 MCV-89 MCH-32.7* MCHC-36.9* RDW-13.7 Plt Ct-267 [2102-3-13] 09:25PM BLOOD Neuts-88.9* Bands-0 Lymphs-4.3* Monos-5.0 Eos-1.3 Baso-0.6 [2102-3-13] 09:25PM BLOOD PT-11.6 PTT-19.1* INR(PT)-1.0 [2102-3-13] 09:25PM BLOOD Glucose-116* UreaN-18 Creat-1.1 Na-139 K-3.7 Cl-102 HCO3-25 AnGap-16 [2102-3-13] 09:25PM BLOOD CK(CPK)-201* [2102-3-14] 05:55AM BLOOD ALT-23 AST-26 LD(LDH)-192 CK(CPK)-171* AlkPhos-95 Amylase-50 TotBili-0.4 [2102-3-13] 09:25PM BLOOD CK-MB-6 cTropnT-<0.01 [2102-3-14] 05:55AM BLOOD CK-MB-4 cTropnT-<0.01 [2102-3-14] 05:55AM BLOOD Lipase-22 [2102-3-13] 09:25PM BLOOD Calcium-9.5 Phos-3.5 Mg-1.7 [2102-3-14] 05:55AM BLOOD TSH-0.63 [2102-3-14] 05:55AM BLOOD VitB12-1012* Folate-GREATER TH . [3-13] ECG: Sinus rhythm Prior inferior myocardial infarction No previous tracing available for comparison . [3-13] CT Head: 1. No intracranial hemorrhage or mass effect. 2. Chronic microvascular angiopathy. 3. Right supraorbital facial swelling. 4. No fracture identified. . [3-13]: CT C-spine: No evidence of acute fracture or listhesis. Multilevel degenerative changes as described above. . [3-13] CT Orbits/face: 1. Soft tissue swelling over the right orbit. 2. No evidence of acute fracture. Note added at attending review: There is a fracture of the tip of the coronoid process of the right mandible. . [3-14] MRI Head: Significantly limited MRI of the brain due to motion artifact. Extensive chronic periventricular microvascular ischemic changes. Scattered old lacunar infarcts within the brainstem. No acute territorial infarcts are seen within the brain. . [3-30] Most recent head MRI: This study, slightly degraded by patient motion artifact, is compared with recent contrast-enhanced MR examination dated [2102-3-20]; the overall appearance is unchanged. There is mild-moderate cortical atrophy. There is severe, confluent FLAIR-hyperintensity in bihemispheric periventricular and subcortical white matter, representing extensive chronic microischemic change. However, there is no focus of restricted diffusion to indicate acute infarction. There is no evidence of acute hemorrhage. There are a few punctate foci of blooming susceptibility artifact, unchanged, likely representing hemosiderin from past petechial hemorrhage, related to small vessel infarction. Again noted is a prominent developmental venous anomaly ("venous angioma") in the right paramedian cerebellar vermis, with no associated cavernous angioma or hemorrhage. There is no other pathologic focus of parenchymal, leptomeningeal or dural enhancement. IMPRESSION: 1) No acute process and no significant interval change since the [3-20] examination. 2) Severe chronic micro-ischemic change in bihemispheric white matter. 3) Extensive fluid within bilateral mastoid air cells, significantly worse since the previous examination, and bilateral ethmoid mucosal thickening with small amount of fluid in the sphenoid sinus, some of which may relate to protracted supine positioning (is there clinical suspicion of either sinusitis or mastoiditis?). . CXR [2102-4-11]: The heart size is moderately enlarged, unchanged. There is a prominent mediastinal venous engorgement with no overt pulmonary edema. Bibasilar mild atelectasis are unchanged. The tracheostomy and the right subclavian venous line are in good position, stable. See OMR for further studies. Brief Hospital Course: Mrs [Known lastname 3647] was initially admitted to the medicine ICU for observation given her chronic tongue swelling and fall on her face with trauma. She was monitored overnight on standard ICU monitoring and a 1:1 sitter with no problems or events. Dementia work up was initiated, and she completed an MRI of the head. The dementia workup was negative and the MRI (limited study) was significant for no acute stroke. The pt was noted to have extensive chronic periventricular microvascular ischemic changes and scattered old lacunar infarcts within the brainstem. The pt's electrolytes were checked and repleted. She was disoriented throughout her stay, and agitated and somnolent at times. She was stable the day after admission morning, and transferred to the medical floor as she had a stable respiratory status, and did not require ICU level care any longer. On the morning of transfer to the floor the pt has a CT head that showed an isolated fracture of her mandible. The pt was evaluated by the oro-maxillofacial surgery service from the [Hospital1 756] and no intervention was recommended. The pt became increasingly somnolent on arrival to the floor and had decreased responsiveness. She became mildly rousable on her third day on the floor. The pt was noted to be hyperventilating. Due to concern for altered mental status secondary to meningitis/encephalitis, an LP was attempted by the Anesthesia team and house staff. Due to the pt's multiple back surgeries and spine fusions, an LP was not successful. The pt was empirically started on Vanc/Ceftriaxone/Acyclovir and Ampicillin. A day after initiation of these medications, there was an interval increase in creatinine from 0.9 to 2.2. Due to concern for Vancomycin or Acyclovir induced nephrotoxicity, these medications were held and Cr was rechecked; it normalized within days. . The [Hospital ] hospital course was significant for the following problems: . # Frequent falls/altered mental status: The pt was noted to have a progressive decline in mental status over the last few years with a significantly accelerated decline over the last 2-3 weeks. The pt's fall did not appear to be a syncopal event and her labs and urinalysis were unremarkable. Her head CT revealed chronic microvascular angiopathy likely representing dementia. A metabolic workup was negative. The pt was noted to have a waxing and [Doctor Last Name 688] mental status. During a neurology team evaluation the pt was noted to have ?mild myoclonus of toe. A STAT EEG showed markedly abnormal brain activity indicating severe encephalopathy. The pt was started on seizure prophylaxis with Phenytoin IV. In light of mental status changes, the pt was also empirically started on Ampicillin, Vancomycin, Acyclovir and Ceftriaxone after 4 failed attempts at LP (pt has spine fusions from L3 to S1). The Ampicillin was subsequently discontinued. [3-19] the patient was noted to have tonic extension of her arms thought to be a generalized seizure. Her dilantin level was found to be subtherapeutic at 2.5. She shortly after developed tachycardia, tachypnea, elevated BP, and acidemia. She was intubated and transferred to the ICU. She was then loaded with dilantin and transferred to the neuro ICU on the [Hospital Ward Name ]. Blood and urine cultures were ultimately unrevealing. A lumbar puncture was performed and found to be negative. All antibiotics were discontinued. In the neuro ICU the patient was placed on continuous EEG monitoring. Her EEG showed evidence of a deep encephalopathy. She was started on IV glycerine to treat brain edema related to her fall. She remained minimally responsive. A tracheostomy and g-tube were placed and the patient was transferred to the neurology step down unit. Thyroid function tests were repeated and were once again unremarkable; ammonia was sent and was normal. In the stepdown unit, her exam improved slightly - she began to open her eyes and keep them open to sternal rub, and then spontaneously opened her eyes on [3-31]. Initially, she had absent reflexes and no withdrawal to noxious stimuli; she began to regain reflexes and withdrew her lower limbs to nailbed pressure, raising the possibility of resolving critical illness polyneuropathy. Dilantin dosing was initially increased, then transitioned to Keppra. MRI was repeated and showed stable subcortical white matter changes. As she did not follow commands, further workup was pursued, including sending anti-TPO antibody to check for Hashimoto's encephalitis. Results of this were negative. LP was also repeated to look specifically for signs of limbic encephalitis (anti-[Doctor Last Name ]), intravascular lymphoma (LDH), and Creutzfield-[Doctor Last Name ] Disease (CSF for CJD). Results were pending at time of discharge for CJD. The LDH was normal as was the anti-[Doctor Last Name ]. By the end of her course, she had received 4 MRIs of the head which were all stable and unrevealing of a problem that would explain her encephalopathy. Multiple blood and urine cultures were sent which showed no signs of infection. She also had several days of EEG monitoring with no evidence of seizure, and only showing encephalopathy. She also had several routine EEGs with similar findings. . # Renal - the patient temporarily developed ARF on IV acyclovir. The medication was discontinued and the patient received aggressive IV hydration. Her creatinine eventually normalized. . # Swollen tongue: The pt was noted to have a swollen tongue on admission but this was not noted in admission to the floor; in fact the pt had had a large tongue (per husband) for the last 40 years secondary to chronic Fluphenazine use. The pt did not have any evidence of airway compromise. The pt was monitored in the [Hospital Unit Name 153] overnight. The pt's husband reported that the pt has h/o tongue angioedema scondary to chronic (>40y) fluphenazine use. She was given decadron 10 mg x1; this resolved. . # Thyroid mass Pt noted to have a 4.4-cm mass in the right lobe of the thyroid on ultrasound. Thyroid function was normal during the admission. She could be considered for ultrasound-guided biopsy of the mass in the future. . # Urinary incontinence. Appeared chronic. No evidence of acute infection or retention. Sling procedure was planned by urology prior to hospitalization. . # HTN. BP was elevated upon arrival to medical ICU; this was thought to be likely secondary to agitation. She was started on Metoprolol 50 [Hospital1 ] in ICU (home dose was atenolol 50 daily). Blood pressure stabilized after transfer to neuro ICU and finally to SDU. She had no further BP issues while on the floor and was stable on discharge. She did have a small amount of captopril added while she was here and was sent out on this. . # Psych. The patient had been on Fluphenazine x 40 yrs- initially, this was thought to be related to change in mental status; however, two weeks later when she remained in coma, this was thought less likely. Upon further questioning, her husband described a gait that resembled a Parkinsonian gait - she likely had an element of drug-induced Parkinsonism prior to hospitalization; it is possible that an unsteady gait contributed to her fall. #Pulm: The patient had a tracheostomy performed while here and then required oxygen through a trach mask for the remainder of her stay. She had to have frequent suctioning as she makes a significant amount of secretions. She oxygenated well throughout. She did develop a bilateral PNA which was successfully treated and subsequent CXRs were clear. She also had an element of mild fluid overload on some of the CXRs. Her most recent CXRs did not show this. Of note, the patient is tachypneic at times with no other instability with rates of ~30. This comes and goes over days. Most recent CXR [4-11] was normal. #In summary, the patient had a rapidly progressive encephalopathy while in the hospital. She had a fall, then became unresponsive fairly soon after. She was then likely in intermittent status for an unknown period of time. She also developed ARF likely due to med effect. She then had a tension pneumothorax requiring chest tube. She later developed a pneumonia which was treated. She recovered from all of this, but failed to wake up. A large work-up, including MRIx4, LPx2, and multiple blood tests yielded no reason for her symptoms. The theory as to what is causing her problems is that she has a large amount of small vessel disease at baseline. Then, she had these multiple medical problems, including likely several days of seizure. This has resulted in her current unresponsiveness. It may simply take a long time for her to recover in this setting. Her exam currently is that she opens her eyes to sternal rub and keeps them open, but only looks midline. She does not track at all or look around. Her brainstem reflexes are normal, with normal corneals, gag, cough, OCRs, nasal tickle, and pupils. She also withdraws her extremities to pain much of the time, but not always. She has no spontaneous movement or attempts at speech. Her toes are downgoing. Medications on Admission: Home Meds: - Fosamax 35 daily - niacin 500 daily - Atenolol 50 daily - Fluphenazine 5 [Hospital1 ] - MVI - Ca/VitD - VitE - Advil prn - Alleve prn - tylenol prn - HCTZ 25 daily (d/c'ed [2102-3-9] secondary to hypokalemia) - Vesicare ([2102-2-21] - [2102-3-9]) Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Alendronate 70 mg Tablet Sig: 0.5 Tablet PO QSUN (every Sunday). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Ranitidine HCl 15 mg/mL Syrup Sig: One [Age over 90 1230]y (150) mg PO BID (2 times a day). 7. Insulin Regular Human 100 unit/mL Solution Sig: as directed units Injection ASDIR (AS DIRECTED): Standard insulin sliding scale. 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): hold hr<60, SBP<100. 9. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): Hold for SBP < 100 . 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Persistent encephalopathy thought to be due to recent status epilepticus as well as severe small vessel cerebral disease. -- HTN Thyroid nodule Discharge Condition: Pt is unreponsive, but opens her eyes to sternal rub. She is flaccid otherwise. She has intact brainstem reflexes. Discharge Instructions: Please tell the doctors [First Name8 (NamePattern2) ] [Last Name (Titles) ] if there is any worsening of breathing, or apaprent change in her clinical status Followup Instructions: Please follow-up as the doctors [First Name8 (NamePattern2) ] [Last Name (Titles) ] arrange. -- You should follow-up with Dr [Last Name (STitle) ] in the stroke service at [Hospital1 18] after you are discharged. The staff at [Hospital1 ] can schedule this at discharge. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "486", "401.9", "276.2", "512.1", "290.40", "920", "802.23", "348.39", "788.34", "529.8", "E888.9", "E931.7", "V15.88", "921.2", "584.9", "518.81", "241.0", "437.0", "345.3", "V45.4" ]	icd9cm	[ [ [] ] ]	[ "34.04", "03.31", "31.1", "96.04", "96.72", "96.6", "43.11" ]	icd9pcs	[ [ [] ] ]	17123, 17193	6358, 8323	298, 306	17381, 17499	2855, 3791	17713, 18099	2269, 2394		15861, 17100		17214, 17360		15561, 15838				17523, 17690									2409, 2836																										242, 260							334, 1653		3800, 6335									8338, 15535							1675, 1940	1956, 2253
25,019	171,458	52516	Discharge summary	report	Admission Date: [2136-7-22] Discharge Date: [2136-8-21] Service: MED Allergies: A.C.E Inhibitors / B-12 Attending:[First Name3 (LF) 2181] Chief Complaint: Change in Mental Status, hypotension, hypernatremia, renal failure Major Surgical or Invasive Procedure: none History of Present Illness: 87 y.o. male with multi-infarct dementia who presents with 1 week of failure-to-thrive (decreased po intake, lethargy, more frequent falls, unwillingness to ambulate). Per daughter (his primary care giver and proxy) his baseline mental status is A/O x 1 and able to eat with assistance. ROS: +diarrhea, pressure sore on left hip In ED given 1gram vanco and 500 mg levaquin with concern for sepsis. CT Head (-) for acute bleed. CXR (-) for pneumonia Past Medical History: 1)Multi-infarct Dementia 2)Hypertension 3)Urinary incontinence 4)EtOH Abuse (distant past) 5)Chronic Diarrhea (2-3x/day) x 20 years 6)Coronary Artery Disease: 11" on [Doctor First Name ] in [2131] w/o changes or sx with normal perfusion on MIBI. EF 50%. 7)B12 deficiency. 8)RPR positive, neuro syphilis, treated with three IM penicillin injections 9)Esophagitis. 10)Gastritis. 11)History of bee allergy. 12)Elevated PSA with likely prostate ca. Seen in urology clinic and chose to manage conservatively with serial PSA. 13)Angioedema. 14) Mental status changes during hospitalizations, secondary to etoh w/d and sensitivity to anti-cholinergics. Social History: Lives with daughter (primary care taker and healthcare proxy), walks with a cane, No tobacco use. Recent history of EtOH use. No drug use. FULL CODE (discussed with daughter) Family History: non-contributory Physical Exam: T:98.9, BP:90/54, HR:68, RR:16, 100% RA Gen: Cachectic, chronically ill, alert, demented, NAD HEENT: Mildly reactive pupils OU, dry mm, hazy sclerae Neck: No LAD/JVD Lungs: CTA B/L CV: RRR, No R/M/G ABD: Scaphoid, soft, NT/ND, NABS, no masses Ext: contractures of LE b/l, no edema Skin: Left hip stage IV pressure ulcer Neuro: Moving all extremeties, Downgoing babinski b/l, the balance of the exam could was not reliable due to impaired mental status. Pertinent Results: [2136-7-22] 08:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.015 [2136-7-22] 08:00PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2136-7-22] 08:00PM URINE RBC-15* WBC-196* BACTERIA-NONE YEAST-NONE EPI-2 [2136-7-22] 06:29PM GLUCOSE-103 UREA N-58* CREAT-2.9* SODIUM-154* POTASSIUM-3.4 CHLORIDE-123* TOTAL CO2-20* ANION GAP-14 [2136-7-22] 06:29PM ALT(SGPT)-43* AST(SGOT)-89* ALK PHOS-86 TOT BILI-0.4 [2136-7-22] 06:29PM ALBUMIN-2.5* CALCIUM-7.5* PHOSPHATE-5.4# MAGNESIUM-2.3 [2136-7-22] 06:29PM WBC-8.7 RBC-2.79 HGB-7.4* HCT-24.6* MCV-88 MCH-26.5* MCHC-30.1* RDW-16.7* [2136-7-22] 06:29PM PLT COUNT-205 [2136-7-22] 11:43AM LACTATE-2.0 [2136-7-22] 10:50AM IRON-11* [2136-7-22] 10:50AM calTIBC-165* VIT B12-1835* TRF-127* [2136-7-22] 10:50AM WBC-9.5# RBC-2.98# HGB-8.0# HCT-26.1# MCV-88# MCH-26.8 MCHC-30.6* RDW-16.7* [2136-7-22] 10:50AM NEUTS-79* BANDS-8* LYMPHS-9* MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2136-7-22] 10:50AM PLT COUNT-215 [2136-7-22] 10:10AM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.016 [2136-7-22] 10:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-8.0 LEUK-MOD [2136-7-22] 10:10AM URINE RBC-[3-23]* WBC-[12-8]* BACTERIA-MANY YEAST-NONE EPI-[3-23] [2136-7-22] 10:10AM URINE AMORPH-MANY [2136-7-22] Blood Cx: Anaerobic/Aerobic no growth [2136-7-22] STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. PREVIOUSLY REPORTED AS STAPHYLOCCOCUS,COAGULASE NEGATIVE([2136-7-24]). SENSITIVITIES GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S NITROFURANTOIN-------- <=16 S OXACILLIN-------------<=0.25 S PENICILLIN------------ =>0.5 R [2136-7-24] L hip swab: GRAM STAIN (Final [2136-7-23]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [2136-7-26]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF SWARMING PROTEUS SPP.. PROTEUS SPECIES. MODERATE GROWTH. GRAM NEGATIVE ROD #2. MODERATE GROWTH. BETA STREPTOCOCCUS NOT GROUP A OR B. MODERATE GROWTH. ALPHA STREPTOCOCCI. QUANTITATION NOT AVAILABLE. PROBABLE ENTEROCOCCUS. QUANTITATION NOT AVAILABLE. URINE CULTURE (Final [2136-7-25]): <10,000 organisms/ml [2136-7-27] urine culture: MSSA CENTRAL LINE TIP Cx: No significant growth. 7/10,12,13,17 blood cultures negative Labs on transfer: WBC: 8.1, crit 26.5, plateletes 388 sodium 131, potassium 5.0, chloride 99, bicarb 23, BUN 22, cr. 0.6 mg 1.5, ca 8.0, phos 3.9 Brief Hospital Course: This is an 87 y.o. male with multi-infarct dementia who presented with 1 week of failure-to-thrive (decreased po intake, lethargy, more frequent falls, unwillingness to ambulate). U/A positive for increased WBC, gram positive organisms = Coag pos Staphlococcus. Left hip ulcer positive for multiple organisms. Mental status in setting of end-stage multi-infarct dementia, h/o neurosyphyllis, infection: Patient's mental status has improved slightly during this admission, as he is more alert and sometimes responsive to direct questioning, with treatment of underlying infections, electrolyte disturbances (hypernatremia on admission to 156) and aggressive nutrition and augmentation with TPN. His overall prognosis, however, remains extremely poor given overwhelming infection in the setting of end stage dementia. His ulcer has improved from a Grade4 ulcer to a Grade 3, still with ulcer to muscle. It has not improved over the past week and surgical options are limited given poor nutritional state/overall poor prognosis. His UTI has been treated with levofloxacin and levo has been maintained because of overwhelming infection. It is likely that his infection is static given no real change in fevers, leukocytosis but complete resolution of infection is unlikely. He appears to be at his baseline mental status which is alert and sometimes responsive to direct questioning with simple one-word answers MSSA UTI, osteomyletis: Both infections are being treated currently. He has improved clinically on levoquin and clindamycin. Becasue of patient's end-stage dementia, non-healing ulcer and poor nutritional state, antibiotics have been maintained despite no current evidence of bacteremia for treatment and should be maintained at the discretion of the treating physicians at Mr. [Known lastname 108479] future extended care facility. Given limited surgical options on his ulcer, it is unlikely that he will be able to fully clear his infection. Anemia: W/u shows anemia of chronic disease. Has been transfused to maintain crit, full correction to baseline is difficult given end stage disease. Electroylytes: On this admisison, sodium has been corrected from 156 to normal levels and recently he is hyponatremic. Patient treated with normal saline with good response. Acute renal failure has resolved with hydration/treatment of infection. Hypertension: blood pressure has fluctuated on this admission with increased pain, but he has been normotensive on atenolol. Diabetes Mellitus: blood sugars have fluctuated widely with TPN, varying PO intake and infection. He has therefore been covered with a sliding scale. Diarrhea/Constipation--patient incontinent of stools, delicate balance of docusate, senna have been used as bowel regimen. Nutrition: Patient's PO intake has improved greatly. He has received TPN while here, but family understands he will not receive TPN at extended care facility. Patient evaluated for PEG but risks are prohibitive and PO intake is preferred given patient's functioning GI tract. Prophylaxis: Patient has been maintained on subcu heparinfor DVT prophylaxis and ranitidine for GI prophylaxis. Haldol has been used minimally for rare occasions of agitation. Pain management: Given patient's end-stage dementia and severe pain secondary to Left hip ulcer, appropriate pain control has been maintained with morphine round the clock and additional doses for dressing changes. Discharge Medications: Multivitamins 1 CAP PO QD Folic Acid 1 mg PO QD Thiamine HCl 100 mg PO QD Ranitidine 150 mg PO BID Docusate Sodium 100 mg PO BID:PRN constipation Senna 1 TAB PO BID:PRN constipation Acetaminophen 650 mg PO Q4-6H:PRN Fever > 101 Atenolol 25 mg PO QD Clindamycin 600 mg IV Q8H Haloperidol 0.5 mg IV HS:PRN Agitation Levofloxacin 250 mg IV Q24H Morphine Sulfate 0.5-1.5 mg IV Q4H:PRN Discharge Disposition: Extended Care Facility: [Hospital1 33092] - [Location 1268] Discharge Diagnosis: Sepsis (UTI + left hip ulcer stage 4) FTT Discharge Condition: stable with poor prognosis Followup Instructions: Management as per facility doctors. [First Name (Titles) ] [Last Name (Titles) ] abx.	[ "783.7", "584.9", "707.0", "276.0", "276.5", "038.8", "599.0", "585", "263.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "86.28", "99.04", "99.15", "86.22" ]	icd9pcs	[ [ [] ] ]	9214, 9284	5338, 8784	293, 299	9370, 9398	2182, 5315	9421, 9518	1673, 1691		8807, 9191		9305, 9349															1706, 2161																										187, 255							327, 783																		805, 1463	1479, 1657
67,624	194,115	36250	Discharge summary	report	Admission Date: [2180-4-29] Discharge Date: [2180-5-4] Date of Birth: [2129-9-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3531] Chief Complaint: Nausea / Vomiting Major Surgical or Invasive Procedure: Hemodialysis initated on [2180-4-30] History of Present Illness: Mr. [Known lastname 82188] is a 50 yo M with PMH of HTN, IDDM1 x >20 years, ESRD s/p fistula placement who presented to the ED with vomiting since this morning. According to the Pt, he was in his usual state of health until yesterday evening when he ate a Chinese food meal of shrimp fried rice. He reported that a few hours later he began to feel nauseous and had multiple episodes of vomiting. He describes the vomiting as non-bloody, and non-bilious. He denies associated fevers, chills, diarrhea, or shortness of breath. He checked a FS and noted it to be over 300 which he says is normal for him. He went to bed and in the morning he continued to feel nauseous with vomiting, despite drinking ginger ale and tea. He then decided to proceed to the [Hospital1 18] ED. He denies recent sick contacts, alcohol ingestion, and chest pain. He admits to recent medication non-compliance. He states that typically is FS are in the 300s, and that they are over 500 on average "a few times per week." In the ED, initial ED VS 98.0, 203/94, 95, 18 and 100/RA. Physical exam notable for clear lungs but mild diffuse tenderness. An insulin gtt was started with initial 10U bolus and 7U/hr. He was given Zofran 4 mg IV x 1. VS on transfer 97.4, 93, 185/83, 28, 97/3L. He was noted to have a K of 6.4 and EKG showed peaked T-waves. He was given calcium chloride, and admitted to the MICU. Past Medical History: - Diabetes, insulin dependent x 24 years - Hypertension. - CKD Social History: Currently employed in 2 nursing homes. No hx of EtOH, smoking. Has issues coping w/ insulin regiment yet denies financial hardships as a cause. Instead, likely due to miscommunication; pt is from [Country 2045] & may not necessarily understand the ramifications of poor glycemic control & has poor vision. Family History: Grandmother diagnosed w/DM2. Father is alive at 68 and is "never sick". Mother died suddenly at 37. Siblings w/sickle cell. 1 child w/DM1. Physical Exam: Vitals: T: 97.4 HR 101 BP 191/101 rr 18 100% on 3L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, EOMI Neck: supple, JVP elevated to 11 cm, no LAD Lungs: + crackle at b/l lung bases, no wheezing or ronchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, bowel sounds present, no organomegaly Ext: +2 edema to the shin b/l, warm, well perfused, 2+ pulses, no clubbing, cyanosis. . Neuro: a/ox3, CNs [3-31] intact, strength and sensation intact throughout, 2+ DTRs, [Name (NI) 14451] [Name2 (NI) ] Pertinent Results: LABS ON ADMISSION: [2180-4-29] 05:00PM BLOOD WBC-9.0 RBC-3.30* Hgb-8.7* Hct-27.8* MCV-84 MCH-26.2* MCHC-31.1 RDW-14.6 Plt Ct-226 [2180-4-29] 05:00PM BLOOD Neuts-91.2* Lymphs-6.5* Monos-1.5* Eos-0.7 Baso-0.1 [2180-4-29] 05:00PM BLOOD Plt Ct-226 [2180-4-29] 05:00PM BLOOD PT-12.1 PTT-28.5 INR(PT)-1.0 [2180-4-29] 05:00PM BLOOD UreaN-83* Creat-10.4# Na-133 K-6.4 Cl-96 HCO3-16* AnGap-27* [2180-4-29] 05:00PM BLOOD ALT-44* AST-19 LD(LDH)-267* AlkPhos-125 TotBili-0.4 [2180-4-29] 07:00PM BLOOD CK(CPK)-441* [2180-4-29] 05:00PM BLOOD Lipase-51 [2180-4-29] 05:00PM BLOOD cTropnT-0.08* [2180-4-29] 07:00PM BLOOD CK-MB-6 cTropnT-0.06* [2180-4-30] 08:17AM BLOOD CK-MB-6 cTropnT-0.28* [2180-4-29] 07:00PM BLOOD Albumin-3.7 Calcium-9.2 Phos-4.8* Mg-2.6 [2180-4-30] 12:41AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.6 [2180-4-30] 10:59AM BLOOD PTH-215* [2180-4-29] 05:01PM BLOOD Type-[Last Name (un) ] pO2-53* pCO2-36 pH-7.26* calTCO2-17* Base XS--9 [2180-4-29] 07:20PM BLOOD Type-[Last Name (un) ] pO2-61* pCO2-32* pH-7.27* calTCO2-15* Base XS--10 Comment-GREEN TOP [2180-4-29] 05:01PM BLOOD Glucose-523* Lactate-2.4* Na-135 K-6.7* Cl-100 [2180-4-29] 07:20PM BLOOD Glucose-383* K-4.7 Cl-106 SERIAL CHEMISTRIES/GAP: [2180-4-29] 05:00PM BLOOD UreaN-83* Creat-10.4# Na-133 K-6.4 Cl-96 HCO3-16* AnGap-27* [2180-4-29] 07:00PM BLOOD Glucose-384* Na-140 K-4.5 Cl-105 HCO3-13* AnGap-27* [2180-4-30] 12:41AM BLOOD Glucose-97 UreaN-81* Creat-9.9* Na-142 K-5.4* Cl-111* HCO3-20* AnGap-16 [2180-4-30] 03:57AM BLOOD Glucose-95 UreaN-81* Creat-9.8* Na-142 K-5.3* Cl-111* HCO3-20* AnGap-16 [2180-4-30] 08:17AM BLOOD Glucose-136* UreaN-83* Creat-10.2* Na-142 K-4.6 Cl-107 HCO3-21* AnGap-19 [2180-4-30] 02:50PM BLOOD Glucose-264* UreaN-86* Creat-10.5* Na-140 K-4.8 Cl-107 HCO3-20* AnGap-18 CBC: [2180-5-3] 05:35AM BLOOD WBC-5.6 RBC-3.07* Hgb-8.1* Hct-24.6* MCV-80* MCH-26.3* MCHC-32.8 RDW-14.5 Plt Ct-240 [2180-5-2] 06:45AM BLOOD WBC-5.2 RBC-3.05* Hgb-8.2* Hct-24.6* MCV-81* MCH-27.0 MCHC-33.5 RDW-14.4 Plt Ct-219 [2180-5-1] 05:58AM BLOOD WBC-8.6 RBC-2.79* Hgb-7.9* Hct-23.2* MCV-83 MCH-28.4 MCHC-34.1 RDW-15.2 Plt Ct-232 [2180-4-30] 09:15AM BLOOD WBC-12.7* RBC-3.10* Hgb-8.1* Hct-25.0* MCV-81* MCH-26.2* MCHC-32.4 RDW-14.7 Plt Ct-227 [2180-4-29] 05:00PM BLOOD WBC-9.0 RBC-3.30* Hgb-8.7* Hct-27.8* MCV-84 MCH-26.2* MCHC-31.1 RDW-14.6 Plt Ct-226 Iron Studies [2180-5-1] 01:50PM BLOOD Iron-62 [2180-5-1] 01:50PM BLOOD calTIBC-234* Ferritn-132 TRF-180* Hepatitis Panel [2180-5-2] 06:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HCVAb-NEGATIVE URINE: [2180-4-29] 06:50PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.013 [2180-4-29] 06:50PM URINE Blood-SM Nitrite-NEG Protein-500 Glucose-1000 Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2180-4-29] 06:50PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-<1 CXR [2180-4-29]: Single AP upright portable view of the chest was obtained. Bibasilar airspace opacities are seen, concerning for infectious process. Findings could also relate to interstitial edema and clinical correlation is advised. There is a small left pleural effusion. The cardiac silhouette is enlarged. The aorta is tortuous. CXR [2180-4-30]: PA and Lateral: Compared to the prior study there is a more focal patchy feature at the right lung base and the retrocardiac region appears denser. These findings are most consistent with an evolving pneumonia in the anterior segment of the right lower lobe. There is less distension of the interstitial markings suggesting a slight improvement in fluid status although there are bilateral effusions. Cardiomegaly is unchanged versus prior. IMPRESSION: Evolving airspace disease at the anterior segment of the right lower lobe which could be pneumonia in the appropriate clinical setting. Diminished but persistent features of CHF. Brief Hospital Course: 50 yo male with DM type I, HTN, ESRD presents with n/v, found to be in DKA, s/p ICU admission for insulin drip. Anion gap closed, now at 10. . #. DKA - Patient is poorly controlled type I diabetic. Found to have an anion gap metabolic acidosis and ketonuria on admission. Originally admitted to the MICU for insulin drip. His anion gap closed and he was transitioned to insulin sliding scale. Uncertain what precipitated this episode of DKA, possibly gastroenteritis or pneumonia. Patient was continued on lantus 14 units qhs with humalog sliding scale as per his outpatient regimen. . #. ESRD - patient is followed by Dr. [Last Name (STitle) 4090]. He is s/p L fistula placement but was not amenable to HD on admission. After transfer to the floor, Dr. [Last Name (STitle) 4090] had a discussion with him after which he decided to initiate HD. HD was started on [2180-4-30]. Patient had PPD placed on [2180-5-1] on his RUE which was read as negative on [2180-5-3]. Patient received 3 sessions of HD prior to discharge. He will continue HD as an outpatient on a Tues, Thurs, Saturday schedule. . #. Hypertension - patient was contined on carvedilol and furosemide. Can consider starting an ACE inhibitor as an outpatient now that patient is on HD for further control of hypertension. . #. Hyperkalemia - on presentation his K was 6.4, with peaked T waves in anterolateral leads. This improved with IVF and correction of DKA. Electrolytes continued to improve with initiation of hemodialysis. . #. Pneumonia - question of a right lower lobe pneumonia seen on CXR. Patient started on renally dosed levofloxacin. . #. Anemia - Likely related to ESRD. Patient was asked multiple times for blood consent, but refused. Patient was started on epogen during dialysis sessions. . #. Social issues - Pt had initially refused to sign ICU consent and initially refused HD. Seems to be very frustrated and mistrusting of healthcare system in relation to inability to obtain visa for sister to travel to US to serve as donor for renal transplant. . #. Code Status - patient expressed wishes to be DNR/DNI. Medications on Admission: Carvedilol 25 mg po BID Lantus 10U SC QHS ---> Pt reports taking intermittnetly. Humalog sliding scale Fosrenol 500 mg chewable at breakfast and lunch Sodium bicarbonate 650 mg po TID Aspirin 81 mg po daily---> Pt states recently stopped Calcitriol 0.5 mcg cap; 3 capsules by mouth daily Furosemide 80 mg [Hospital1 ] Docusate 100mg [Hospital1 ] PRN constipation Amlodipine 10 mg po daily Simvastatin 20 mg daily Discharge Medications: 1. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Lantus 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime. 6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 9. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous qAC and qHS. 10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Diabetic Ketoacidosis ESRD on HD Secondary Diagnosis: Diabetes Mellitus Type I Hypertension 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 nausea and vomiting. You were found to be in diabetic ketoacidosis. You were initially admitted to the intensive care unit so that you could be monitored closely. Once you were on the regular medicine floors, you were started on hemodialysis. You will need outpatient hemodialysis from now on. Your medications have changed, please make note of the following changes: - stop taking: calcitriol - stop taking: sodium bicarbonate - changed dosage: furosemide (lasix) 80 mg once a day - start: nephrocaps 1 tablet once a day The rest of your medications have not changed, please continue to take them as originally prescribed. Please keep all your medical appointments If you experience chest pain, shortness of breath, or any other worrisome symptoms, please return to the emergency room Followup Instructions: Appointment #1 MD: Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Specialty: Primary Care Date/ Time: [5-10] at 10:45am Location: [Street Address(2) 82189] , [Location (un) 2268] Phone number: [Telephone/Fax (1) 9470] Appointment #2 MD: Dr [Last Name (STitle) ] [Name (STitle) 27172] Specialty: Nephrology Date/ Time: [5-12] at 9:30am Location: [Last Name (un) ] Phone number: [Telephone/Fax (1) 3637]	[ "486", "V58.67", "250.13", "276.7", "403.91", "285.21", "585.6", "275.3" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	10465, 10471	6982, 9112	331, 374	10626, 10626	3010, 3015	11635, 12099	2221, 2361		9583, 10442		10492, 10492		9138, 9560				10774, 11612									2376, 2991																										274, 293							402, 1790				10565, 10605				10511, 10544	3029, 6959		10641, 10750							1812, 1877	1893, 2205
77,665	144,719	20697	Discharge summary	report	Admission Date: [2145-12-11] Discharge Date: [2145-12-15] Date of Birth: [2075-5-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 1402] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: Ms. [Known lastname 55262] is a 70 year old female with no significant past medical history who presents with increasing LE edema x 4 weeks and chest tightness with exertion x 1 day. The patient sings in a choir and intermittently has LE edema after long periods of standing however this typically resolves within a day without intervention. Approximately four weeks ago after several days of prolonged standing she developed LE edema which did not resolve. She tried TEDS for compression with only minimal improvement. According to her daughter (a physician) she had truncal edema and appeared anasarcic during this time. She has also noted some increase in abdominal girth. She denies [First Name8 (NamePattern2) 691] [Last Name (un) 55263] shortness of breath or chest pain over this time, but on more direct questioning, may have had some increased fatigue with activity. . Yesterday while ambulating she developed some chest tightness/heaviness radiating up her neck. She also had some associated shortness of breath. She also reported dyspnea with walking one flight of stairs. She has no history of angina or known coronary artery disease. These symptoms resolved with rest. At baseline she is a very active woman with no limitations to her activity and reports that she has never had these symptoms previously. At baseline she is able to lie flat but recently has required 2 pillows due to shortness of breath. She describes approximately 10 lb weight gain over the last month. The patient was noted by her daughter to have distended neck veins, and decided to bring the patient into the ED. . She denies any recent fevers, chills, abdominal pain, nausea or vomiting however does regularly take care of young grandchildren who may have been sick. She had an oral herpetic lesion three months ago which has now resolved. She does note some mild lower abdominal fullness and possibly decreased urinary output than previously. She has had no recent foreign travel, cough, or hemoptysis. She is up to date with screening mammogram and pap smear, but has never had a colonoscopy. She has no history of thyoid dysfunction. . In the ED, the patient's vital signs were T 97.3, BP 123/88, HR 118, O2 sat 97% on RA. Exam notable for decreased breath sounds bilaterally, LE edema. EKG borderline low voltage, no evidence of ischemia. Labs are unremarkable. CXR with bilateral effusions. Bedside echo with significant pericardial effusion, no evidence of tamponade (unreliable). The patient is admitted to [Hospital Unit Name 196] for work up and evaluation of pericardial effusion. . The patient remianed stable on the floor. A formal TTE was acquired, which confirmed a pericardial effusion, but also demonstrated evidence of RV collapse. Her pulsus as taken by the [Hospital Unit Name 196] team was [3-20]. The decision was made to transfer the patient to the CCU for continued monitoring. . . 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 chest pain, dyspnea on exertion, orthopnea, ankle edema, palpitations. She denies paroxysmal nocturnal dyspnea, syncope or presyncope. . Past Medical History: 1. Osteopenia 2. Basal cell carcinoma - left chest and nose 3. Cataract surgery, L eye 4. Gravida 6, para 6, NSVD x6. 5. Status post tonsillectomy. 6. Premature menopause in her late 30s or early 40s. . Cardiac Risk Factors: (-)Diabetes, (-)Dyslipidemia, (-)Hypertension . Cardiac History: CABG: None. . Percutaneous coronary intervention: None . Pacemaker/ICD: None. . Other Past History: None. . Social History: Social history is significant for the absence of current tobacco use. She drinks occasional wine with dinner. Family History: There is no family history of premature coronary artery disease or sudden death. Her father died of esophageal cancer, mother died at 92. She had a brother with melanoma and an aunt with liver cancer. . Physical Exam: VS BP 98/75, HR 90, RR 18, O2 sat 99% on RA, pulsus 4. Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP to angle of the jaw, no HJR. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, ? fix split S2. No m/g. No thrills, lifts. + Rub. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Decreased breath sounds at bilateral bases. Abd: Soft, mild distenstion. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. No fluid wave. Ext: 2+ bilateral LE edema. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: EKG demonstrated normal sinus rhythm, normal axis, normal intervals, no ST or TW changes and low volage. . TELEMETRY demonstrated: NSR . 2D-ECHOCARDIOGRAM: . The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 10-20mmHg. 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 regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is a moderate to large sized circumferential pericardial effusion measuring 1.5cm lateral to the LV, 1.8cm at the apex and anterior to the RV, and 2.8cm inferior to the LV. There is right atrial, right ventricular, and left atrial diastolic collapse, consistent with impaired fillling/tamponade physiology. IMPRESSION: Moderate to large circumferential pericardial effusion with echocardiographic evidence for hemodynamic compromise/tamponade physiology. . ETT demonstrated: No prior ETTs . CARDIAC CATH demonstrated: No history of cardiac catheterization. . Other testing: [12-11] CXR: Mild cardiomegaly, bilateral pleural effusions, new since [2143-11-26]. . LABORATORY DATA: See below. CK 168 Troponin <0.01 CK-MB 6 BNP 188 ESR 4 TSH:2.4 . . . [2145-12-11] 09:00AM BLOOD WBC-5.3 RBC-4.19* Hgb-13.3 Hct-39.8 MCV-95 MCH-31.8 MCHC-33.5 RDW-13.7 Plt Ct-233 [2145-12-11] 09:00AM BLOOD Neuts-69.8 Lymphs-22.4 Monos-6.3 Eos-1.1 Baso-0.4 [2145-12-11] 09:00AM BLOOD ESR-4 [2145-12-11] 09:00AM BLOOD Glucose-83 UreaN-20 Creat-0.7 Na-142 K-4.2 Cl-106 HCO3-29 AnGap-11 [2145-12-11] 04:45PM BLOOD ALT-49* AST-45* LD(LDH)-279* CK(CPK)-108 AlkPhos-88 TotBili-0.3 [2145-12-12] 04:30AM BLOOD Lipase-21 [2145-12-11] 09:00AM BLOOD CK-MB-6 proBNP-188 [2145-12-11] 09:00AM BLOOD cTropnT-<0.01 [2145-12-11] 04:45PM BLOOD CK-MB-4 cTropnT-<0.01 [2145-12-12] 04:30AM BLOOD TotProt-5.1* Albumin-3.4 Globuln-1.7* Calcium-8.9 Phos-3.8 Mg-1.7 [2145-12-12] 04:30AM BLOOD Hapto-100 [2145-12-11] 09:00AM BLOOD TSH-2.4 [2145-12-11] 09:00AM BLOOD RheuFac-6 CRP-4.1 [2145-12-11] 04:36PM BLOOD [Doctor First Name ]-NEGATIVE [2145-12-11] 05:03PM BLOOD CA [55]-9 -PND . . PERICARDIAL FLUID: [2145-12-12] 11:39AM OTHER BODY FLUID WBC-2556* Hct,Fl-10.5* Polys-27* Lymphs-46* Monos-0 Eos-2* Mesothe-1* Macro-24* [2145-12-12] 11:39AM OTHER BODY FLUID CD23-D CD45-D HLA-DR[Initials (NamePattern4) ] [Last Name (NamePattern4) 7736]7-D Kappa-D CD2-D CD7-D CD10-D CD19-D CD20-D Lamba-D CD5-D [2145-12-12] 11:39AM OTHER BODY FLUID CD3-D [2145-12-12] 11:39AM OTHER BODY FLUID IPT-D [2145-12-12] 11:39AM OTHER BODY FLUID TotProt-3.9 Glucose-83 LD(LDH)-1185 Amylase-29 Albumin-2.9 . . ECHOCARDIOGRAM ([12-11]): The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 10-20mmHg. 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 regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is a moderate to large sized circumferential pericardial effusion measuring 1.5cm lateral to the LV, 1.8cm at the apex and anterior to the RV, and 2.8cm inferior to the LV. There is right atrial, right ventricular, and left atrial diastolic collapse, consistent with impaired fillling/tamponade physiology. IMPRESSION: Moderate to large circumferential pericardial effusion with echocardiographic evidence for hemodynamic compromise/tamponade physiology. Clinical correlation and serial evaluation are suggested. . PELVIC ULTRASOUND ([12-11]): Transabdominal and transvaginal ultrasound were performed, the latter to better evaluate the ovaries and endometrium. The uterus is anteverted and measures 5.3 x 2.5 x 3.9 cm. The uterine cavity is distended with fluid. The endometrium measures approximately 2mm. The left ovary is normal. The right ovary is not visualized. There is no hydronephrosis. There is a small amount of pelvic free fluid. Targeted ultrasound in the area left of the umbilicus in the region of patient's tenderness shows no abnormality. IMPRESSION: 1. Fluid in the uterine cavity in postmenopausal female. Recommend further evalution to exclude endometrial cancer. 2. The left ovary is normal. The right ovary is not visualized. No pelvic mass seen. 3. Small amount of pelvic free fluid. . . CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST ([12-11]): Bilateral pleural effusions are present, moderate on the right, small on the left. There is adjacent compressive atelectasis, with smaller areas of subsegmental atelectasis in the bilateral upper lobes adjacent to the fissures. No worrisome nodule or mass is identified, although lesions can be obscured in the regions of atelectatic lung, especially without intravenous contrast. The heart size is normal. There is a moderately large pericardial effusion. The thoracic aorta is normal caliber and contour. No mediastinal or axillary lymphadenopathy is appreciated. Limited views of the upper abdomen shows periportal edema, fluid in the pancreatic-duodenal groove and left paracolic [Last Name (un) 55264]. Note is made of either small calcifications or hemorrhagic products in the left renal cortex. IMPRESSION: 1. Bilateral pleural effusion and moderately large pericardial effusion with atelectasis. 2. Body wall anasarca, periportal edema, and fluid in the pancreatic-duodenal groove/paracolic gutters, which may be relate to fluid overload or hypoalbuminemia. Correlation is recommended. . . CARDIAC CATHETERIZATION ([12-12]): 1. Pericardial tamponade. 2. Drainage of 460cc of bloody fluid with improvement in hemodynamics. . . PERICARDIAL FLUID CYTOLOGY ([12-12]): ATYPICAL. Atypical cells, favor reactive mesothelial cells. Abundant blood with macrophages and lymphocytes. . . ECHOCARDIOGRAM ([12-12]): Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. The mitral valve leaflets are structurally normal. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2145-12-11], the pericardial effusion and tamponade physiology have resolved. . . ECHOCARDIOGRAM ([12-13]): The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with normal free wall contractility. There is abnormal septal motion/position. The number of aortic valve leaflets cannot be determined. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Pericardial constriction cannot be excluded. IMPRESSION: Trivial pericardial effusion without evidence of tamponade. There is a septal "bounce" seen on the sub-costal images. This may be due to a conduction abnormality or prior surgery but constriction cannot be excluded. Compared with the prior study (images reviewed) of [2145-12-12], the appearance of the effusion is similar. . . TORSO CT-SCAN ([12-13]): CHEST FINDINGS: Bilateral pleural effusions, moderately sized on the right and small on the left are unchanged from the previous study. Subsequent to this is compressive atelectasis bilaterally. There is no suspicious pulmonary nodule or mass. The heart and great vessels are notable for a newly placed pericardial drain with interval decrease in the size of pericardial effusion, which is now trace in size. No mediastinal or axillary lymphadenopathy is visualized. ABDOMINAL FINDINGS: The spleen, adrenal glands, kidneys, pancreas, gallbladder, stomach, and proximal small bowel are unremarkable. There is no free gas in the abdomen. Tiny low attenuating lesions (2:52) in segment II and [Doctor First Name ] as well as in segment VIII are too small to characterize, possibly hepatic cysts. There is no retroperitoneal or mesenteric lymphadenopathy. PELVIC FINDINGS: A small amount of free fluid is seen in the pelvis. The bladder is distended and otherwise unremarkable. The uterus is unremarkable. The rectum and colon are normal. There is no pelvic or inguinal lymphadenopathy. OSSEOUS FINDINGS: Degenerative changes are noted in the lower lumbar spine and there are no suspicious sclerotic or lytic osseous lesions. IMPRESSION: 1. Unchanged bilateral pleural effusions and decreased pericardial effusion following pericardial drain placement. 2. No evidence of neoplastic disease in the torso. . . CXR ([12-14]): FINDINGS: The pericardial drain is present overlying cardiac contour. There is a moderate-to-large right pleural effusion. A small- to moderately- sized effusion is seen on the left. The left lower lobe opacity is most likely a combination of atelectasis and pleural effusion. The remainder of the lungs appears clear. The heart size is slightly smaller than on [2145-12-11]. IMPRESSION: 1. Moderate-to-large right-sided pleural effusion and small- to moderately-sized left pleural effusion, not significantly changed since CT torso of [2145-12-13]. 2. Pericardial drain in place. . . Brief Hospital Course: Ms. [Known lastname 55262] is a 70 year old female with no significant medical history who presents with LE edema and chest pain found to have bilateral pleural effusions and pericardial effusion with tamponade. . # Pericardial effusion: The patient described worsening symptoms of lower extremity edema over the month leading up to her hospitalization, and was found to have a large pericardial effusion with tamponade physiology. This was felt to most likely be a sub-acute to chronic process. Differential included idiopathic, malignant, uremic, post-MI, infectious (viral), autoimmune, and hypothyroidism, the most concerning diagnosis of which would be a malignant effusion. Her TSH, BUN, and creatinine were normal and there was no history to suggest an MI with normal cardiac enzymes x1. She also had a normal [Doctor First Name ], RF, ESR, but an elevated CRP at 4. She is reportedly up-to-date on her malignancy screening, with the exception of a colonoscopy, and she has a CA [55]-9 pending on discharge. There was no evidence of a pulmonary process on chest X-ray, and there was no history of recent viral URI other than an oral herpes lesion three months prior. She additionally had a pelvic ultrasound to investigate for GYN malignancy and Torso CT to investigate for any malignant processes, which were both negative. She underwent a pericardiocentesis on [2145-12-12], which revealed bloody fluid. This fluid was sent for analysis including cytology (reactive mesothelials), cell count / differential (large WBC), gram stain (PMNs, no microorganisms), cultures (bacterial, fungal, viral, mycobacterial - pending on discharge). A pericardial drain was left in place, which continued to drain fluid for approximately 48hours before it was removed. No clear source of the effusion was identified, and the patient remained hemodynamically stable, with resolution of the pericardial effusion on repeat Echocardiography. . # Pleural effusions: The patient was also noted to have bilateral pleural effusions on imaging, the differential for which again includes heart failure and serositis that would also cause the concurrent pericardial effusion. The patient's BNP was normal and there was no evidence of CHF on her chest imaging. Autoimmune processes were evaluated with the above laboratory tests, which were normal. Meig's syndrome was also considered given her constellation of symtpoms, but pelvic ultrasound ruled-out ovarian malignancy. Finally, a viral etiology could be considered, but there was no history consistent with this. Medications on Admission: None. Discharge Medications: None. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Pericardial effusion with tamponade - Pleural effusions Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: You were admitted to the CCU at [Hospital1 1170] for a pericardial effusion and tamponade. You were also noted to have pleural effusions. You had a pericardiocentesis done and a pericardial drain was left in place for drainage. This was removed after the drainage decreased. Evaluation for the cause of the pericardial and pleural effusions has yet been unrevealing, including autoimmune studies, thyroid studies, CT-scans for malignancy, and cytology. There are a few remaining studies that are still pending on discharge, including CA [55]-9 (a tumor marker) and flow cytometry from the pericardial fluid, which should be followed-up by your primary care physician. [Name10 (NameIs) ] recommendation is that the next step in your evaluation be an upper endoscopy and evaluation by Gastroenterology given your history of difficulty swallowing. You otherwise did very well during the hospitalization, and will need a follow-up echocardiogram in [12-16] weeks and follow-up with Cardiology in the coming month. . If you develop any recurrent symptoms or other concerning symptoms at home, including chest pain, shortness of breath, palpitations, fevers, chills, headache, dizziness, abdominal pain, vomiting or diarrhea, you should call your doctor or return to the Emergency Room for evaluation. Followup Instructions: UPPER ENDOSCOPY: Thursday, [12-29], 9:00am - Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] . ECHOCARDIOGRAM: [Last Name (LF) 2974], [12-23], 8:00am . CARDIOLOGY: Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] - [Last Name (LF) 2974], [12-30], 2:20pm . PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (STitle) 9006] - Tuesday, [2147-12-21]:10am	[ "423.8", "733.90", "423.3", "511.9", "V10.83", "420.90", "V45.61" ]	icd9cm	[ [ [] ] ]	[ "37.0", "37.21" ]	icd9pcs	[ [ [] ] ]	18456, 18462	15804, 18370	329, 350	18583, 18615	5573, 15781	19975, 20421	4403, 4608		18426, 18433		18483, 18483		18396, 18403				18639, 19952									4623, 5554																										279, 291							378, 3837								18502, 18562										3859, 4259	4275, 4387
32,643	101,340	48863	Discharge summary	report	Admission Date: [2107-10-16] Discharge Date: [2107-10-26] Service: NEUROSURGERY Allergies: Penicillins / Naprosyn / Tetanus Antitoxin Attending:[First Name3 (LF) 2724] Chief Complaint: FALL Major Surgical or Invasive Procedure: right subdural hematoma evacuation via burr holes History of Present Illness: HPI: 88yo F lives by herself at home, was found on the floor at home today. Per her family, she was awake and moving all extremities when found, but not as alert as usual. No external bleeding or apparent injury. c/o of pain during hospital transfer. the last time she was spoken to on the phone was Friday (two days ago). She also fell on her front porch 10days ago and was taken to home by a neighbor, no medical evaluation since pt seemed fine after the fall. Past Medical History: PMHx: CAD, kyphosis. denied MI/stroke. Social History: Social Hx: lives alone at home; her nephew checks on her once or twice a week. Nonsmoker/nondrinker Family History: Family Hx: NC Physical Exam: PHYSICAL EXAM: O: T: 98.6 BP: 150/64 HR: 88 R 18 O2Sats 95% Gen: eyes closed. open to voice. HEENT: Pupils: PERRLA Neck: on hard collar Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: sleepy but arousable, follow some commands during exam. Orientation: Oriented to self, place, and year/month. Language: simple answer to questions; some difficulty with comprehension. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2mm to 1.5 mm bilaterally. Tongue in midline. The rest of CNs difficult to exam due unable to follow instruction. Motor: increasing tone of LE bilaterally. No abnormal movements, tremors. Moving both UE spontaneous/purposeful and antigravity. Wiggle bilat toes to commands; withdrawal of both LE to pain, but not antigravity. unable to fully assess strength. Sensation: withdrawal to pain of all the four extremities symmetrically. Reflexes: [12-2] thoughout. Toes upgoing on right and downgoing on left. Coordination: unable to assess on discharge she is aaox3, clear speech, appropriate conversation, no facial asymmetry, motor full, no drift, gait not tested. Pertinent Results: CT/MRI: CT heaD: Large, mixed attenuation extraaxial collection overlying the right cerebral hemisphere causing leftward shift of the midline consistent with acute on chronic subdural hemorrhage. Dilatation of the temporal [Doctor Last Name 534] of the left lateral ventricle concerning for obstructive hydrocephalus. CT c-spine: Extensive, multilevel degenerative changes throughout the cervical spine. Grade I anterolisthesis of C3 on C4 and C4 on C5, likely degenerative. However, ligamentous injury cannot be excluded on CT. If there is clinical concern, an MRI of the cervical spine is recommended. LABS: CK 4079; CK-MB 136; TROPONIN 0.03 EKG: ST-T changes on lateral leads Brief Hospital Course: PT WAS ADMITTED TO THE ICU/ NEUROSURGERY SERVICE for close monitoring. She was brought to the OR where under general anesthesia she underwent right burr hole drainage of SDH. She tolerated this procedure well and was transferred back to ICU. She was hemodynamically stable, her neurologic exam slowly improved and she was ultimately weaned from ventilator. She was transferred out of ICU to floor. Her incisions were clean and dry and sutres were removed. She was able to tolerate PO. Foley was removed and she urinated without difficulty. She was seen by PT and OT and appropriate for rehab. Medications on Admission: Medications prior to admission: Unclear. Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days: dc after 11/2 doses. 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: subdural hematoma Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? 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) ] TO SCHEDULE AN APPOINTMENT WITH DR.[Last Name (STitle) ] TO BE SEEN IN 6 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST Completed by:[2107-10-26]	[ "707.09", "414.01", "348.8", "728.88", "737.10", "E888.9", "244.9", "458.9", "E849.0", "852.21", "692.9", "784.5" ]	icd9cm	[ [ [] ] ]	[ "96.6", "01.31" ]	icd9pcs	[ [ [] ] ]	4228, 4298	2966, 3566	261, 313	4360, 4384	2253, 2261	5770, 5978	1003, 1019		3658, 4205		4319, 4339		3592, 3592				4408, 5747									1049, 1282													3624, 3635													217, 223							341, 806	1498, 2234	2270, 2943									1297, 1482							828, 869	885, 987
75,281	123,732	24709	Discharge summary	report	Admission Date: [2137-7-21] [Month/Day/Year ] Date: [2137-8-19] Date of Birth: [2080-5-26] Sex: F Service: SURGERY Allergies: Tussionex / Mercaptopurine / Heparin Agents Attending:[First Name3 (LF) 3376] Chief Complaint: PCP:[Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 3183] . Transferring physician: [Name Initial (NameIs) 62331] [Telephone/Fax (1) 62332] . CHIEF COMPLAINT: atypical chest pain/ UC flare Major Surgical or Invasive Procedure: EGD/colonoscopy [Month (only) ] total colectomy w/ end ileostomy; takeback [8-7] Ostomy revision, hematomay evac History of Present Illness: 57 year-old woman with past medical history of ulcerative colitis on Humira as an outpatient whopresented to OSH for atypical chest pain on [2137-7-18]. Patient stated that while she was getting ready to leave her house she had an episode of sudden onset chest pain located mostly in the substernal and left side of the chest which was nonradiating and was not associated with any diaphoresis, nausea, vomiting or shortness of breath. Pain was pressure-like sensation an dlasted for approximately 1 [2-15]- 2 hours. Pain subsided in response to sublingual nitrogen in the ER. Described as chest pounding. Denied any fever, chills, or rigors at that time. No sick contacts. At OSH, CTA was negative for PE. EKG at OSH demonstrated normal sinus rhythm with non-specific ST-T wave changes. CXR at OSH demosntrated no acute cardiopulmonary process. Patient was ruled out on telemetry. Cardiology recommended a persantine stress test. Stress test was aparrently cancelled given drop in crit to 25.5. Patient was transfused 2 units of pRBCs. Patient during her admission complained of abdominal pain, diarrhea, and blood per rectum. Patient apparently developed klebsiella UTI, which is being treated with Cipro (sensitive to cipro). Patient was started on cipro 250 mg PO BID with florastor 500 mg PO BID. Stool studies at OSH demosntrated + fecal leukocytes and was negative for c. diff but positive for fecal occult blood. Lactate was WNL. Her ulcerative colitis has been active lately. She is being treated with Humira (adalimumab) and her prednisone has been taperred off. Pt was hemodynamically stable. . Review of systems: (+) Per HPI, endorses + weight loss of over 10 pounds over the past few weeks . Endorses shortness of breath with extended activity. Also endorses some chest pain after walking for several minutes. (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied palpitations. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Ulcerative colitis (diagnosed in [2133] - refractory to steroid, 6-mercaptopurine, and mesalamine) - insomnia - Depression - COPD with PFTs from [2134] which demonstrate mild obstructive defects - Fibromyalgia vs RA - Macrocytic anemia Social History: Patient lives alone in an apartment. Her daughter lives in [State 5887]. Patient has been less able to do activities of daily living given weakness and shortness of breath with activity. Previous smoker, quit smoking > 5 years ago. Previously smoked 1 pack per day for > 40 years. no ETOH or IVDU. Family History: Maternal uncle with ulcerative colitis, maternal unckle and brother with type II diabetes, mother with emphysema. No early family history of MIs. Physical Exam: VS: Temp 97.5, BP 120/72, P 93, R 18, 95% on RA GENERAL: NAD, middle aged female, NAD HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, CARDIAC: RR. Normal S1, S2. No m/r/g. LUNGS: CTA B, good air movement biaterally. ABDOMEN: +BS in all 4 quadrants, + tenderness to palpation over left abdomen, soft, guarding only after exam EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [2-15]+ reflexes, equal BL. Gait assessment deferred Pertinent Results: [2137-7-21] 09:20PM BLOOD WBC-8.1 RBC-3.81# Hgb-11.9 Hct-36.0 MCV-95# MCH-31.1 MCHC-33.0 RDW-16.8* Plt Ct-466* [2137-7-23] 06:30AM BLOOD Neuts-78.1* Lymphs-15.4* Monos-5.9 Eos-0.4 Baso-0.2 [2137-7-21] 09:20PM BLOOD PT-14.4* PTT-31.2 INR(PT)-1.3* [2137-7-21] 09:20PM BLOOD Glucose-91 UreaN-13 Creat-0.8 Na-141 K-4.6 Cl-105 HCO3-24 AnGap-17 [2137-7-21] 09:20PM BLOOD ALT-5 AST-12 LD(LDH)-233 CK(CPK)-35 AlkPhos-132* TotBili-0.3 [2137-7-21] 09:20PM BLOOD CK-MB-2 cTropnT-<0.01 [2137-7-21] 09:20PM BLOOD Albumin-3.5 Calcium-9.0 Phos-3.3 Mg-1.9 [2137-7-21] 09:20PM BLOOD CRP-51.8* [2137-8-16] 04:00PM BLOOD TSH-1.5 [2137-8-16] 04:00PM BLOOD T4-8.1 [2137-8-17] 07:15AM BLOOD WBC-7.9 RBC-3.00* Hgb-9.6* Hct-28.0* MCV-93 MCH-31.9 MCHC-34.3 RDW-15.9* Plt Ct-143# [2137-8-18] 10:00AM BLOOD PT-26.8 PTT-36.5* INR(PT)-2.6* [2137-8-17] 07:15AM BLOOD Glucose-90 UreaN-14 Creat-0.9 Na-141 K-4.2 Cl-106 HCO3-24 AnGap-15 [2137-8-17] 07:15AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.3 Brief Hospital Course: The patient has a history of active ulcerative colitis. She is most recently on Humira and been tapered off outpatient steroids. She had a HCT drop from 29 => 25 at OSH and received 2 units of pRBCs with stable HCT from admission until surgery. At OSH she was negative for c. diff. Negative for c. diff x 2 here, stool culture negative as well. EGD was WNL but flex sigmoidoscopy demonstrated severe active colitis. Gi biopsy demonstrated chronic active colitis with ulceration and fibrinopurulent exudate without granulomas or dysplasias and without evidence of viral cytopathic changes. CT abdomen/pelvis demonstrated interval progression of UC from scan from [12/2136] now involving distal transverse colon along with rectum involvement without free air, fluid or fistula. General surgery was consulted as well as GI. She was taken to surgery by Dr. [Last Name (STitle) 1120] on [2137-7-31] and a total proctocolectomy with end ileostomy was performed. Her postoperative course was complicated by a pulmonary embolism requiring a heparin drip, which resulted in a large pelvic hematoma. She was slow to progress and a CT scan was performed. Imaging studies showed small locules of intra-abdominal free air as well as an extensive amount of subcutaneous air throughout the abdominal wall adjacent to the ileostomy. She had intermittent tachycardia and worsening complaints of right lower quadrant abdominal pain with exquisite tenderness on exam and therefore was taken back to the OR for an exploratory laparotomy on [2137-8-7]. The pelvic hematoma was evacuation, lysis of adhesions was performed, and she had a small bowel resection and ileostomy revision. She remained intubated overnight and was extubated on POD1. Post-operatively she was in the ICU for two days, then transfered to the surgical floor. She had blood loss anemia and was transfused 2U PRBCs on POD2. She was restarted on her heparin drip for her PE on POD2 as well after her HCT was shown to be stable. Her ileostomy was functioning, but she had persistent complaints of pain, discomfort, and nausea that slowly improved over her post-operative course. She was on TPN postoperatively as her nausea and pain prevented advancement of diet initially. This gradually improved and her diet was slowly advanced to regular. She has been followed by the wound care/ostomy nurse throughout her stay. Chronic pain was also consulted and a fentanyl patch was started in addition to oral medications titrated which resulted in a significant improvement. Physical therapy worked with the patient during her postoperative course as well. Upper extremity ultrasound on [8-8] showed a DVT at her right PICC site and this was removed. The heparin drip was being restarted at that time. Lower extremity ultrasounds were negative. A PICC was placed on [2137-8-11] on the other arm for TPN and again, an upper extremity ultrasound showed that she had a DVT in the left subclavian vein on [2137-8-14] around the picc as well, so this was also removed. Her heparin was slightly subtherapeutic at that time given concerns of over-anticoagulation because of her prior pelvic hematoma and a difficulty in titrating her PTT to goal, however heparin dependent antibodies were checked at this time since she had a clot while on heparin and her platelets had been trending down. This came back positive and her heparin drip was discontinued that day and she was placed on fondaparinux. Coumadin was also begun and titrated to INR goal then fondaparinux was discontinued on [2137-8-18]. . Additional issues from admission/hospital course: # Chest pain - Patient with chest pain prior to admission at outside hospital. Patient states that she gets some shortness of breath with extensive walking with occassional stabbing chest pain. Patient with long smoking history history of COPD. Patient was ruled out at OSH with negative troponins. EKG at OSH with non-specific ST-T wave changes (T wave inversion in V1-V3 without ST elevation or depression). Patient was ruled out here for an MI as well. Telemetry noted for elevated HRs in 120-140s. EKG here sinus without ST or T wave changes. LDL low. Myocardial perfusion study was within normal limits. Postoperatively she was borderline tachycardic consistently without complaints of chest pain. . # Cough/SOB - CT chest demonstrates evidence of emphysematous changes as well as RLL nodule and LLL ground glass opacity which needs interval follow-up on [Date Range ]. Patient with cough during admission with allergy to tussonex. Patient experiences significant shortness of breath with exertion and also some chronic cough over the past couple of weeks. CXR without acute process. CTA at OSH without PE. Pulmonary was consulted and recommended sputum culture, to check a repeat interval CXR, to try to obtain CT chest from [Hospital1 ] and to repeat CT in 3 months given new nodule. This should happen as an outpatient. . # Psych issues - seen by psychiatry given coping issues during this admission who recommended d/c of quietapine and starting remeron instead. Post-operatively psychiatry was again consulted for mood/behavior issues and chronic pain and agitation. Final recommendations were mirtazapine 15 mg qhs and lorazepam 0.25 mg q6h which she is currently on. . Medications on Admission: Adalimumab [Humira Pen] 40 mg/0.8 mL Pen Injector Kit 40 mg SC every two weeks (stable dose) [2137-4-12] nr Alprazolam 1 mg Tablet one Tablet(s) by mouth three times a day Famotidine 20 mg Tablet - one Tablet(s) by mouth once a day Folic Acid 1 mg Tablet - one Tablet(s) by mouth once a day Hydrocortisone - 1 % Lotion apply a thin layer the affected area as directed twice a day [2137-6-21] Ipratropium Bromide [Atrovent] Loperamide - 2 mg Capsule - 2 Capsule(s) by mouth four times a day Nabumetone - 750 mg Tablet - one Tablet(s) by mouth twice a day (Prescribed by Other Provider) Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal one Tab(s) by mouth once a day Quetiapine [Seroquel] 25 mg Tablet - 2 Tablet(s) by mouth once a day at bedtime Tramadol- 50 mg Tablet - one Tablet(s) by mouth four times a day as needed for pain Ergocalciferol (Vitamin D2) [Vitamin D] 400 unit Capsule Capsule(s) by mouth (OTC) Multivitamin - 1 Tablet(s) by mouth (OTC) [2135-10-21] [Year (4 digits) ] Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for perirectal rash. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for intching. 5. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q6H (every 6 hours) as needed for itching. 6. Nabumetone 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: not to exceed 4g in 24 hrs . 9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for Pain. 12. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for anxiety. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Please give at 1600. [Hospital1 ] Disposition: Extended Care Facility: [Hospital ] Rehab and Nursing Center [Hospital ] Diagnosis: Primary: 1) Ulcerative Colitis 2) Acute blood loss anemia 3) post op Hematoma 4) Bilat UE DVT 5) Left PE 6) new dx of HIT Secondary: 1) Depression 2) insomnia 3) h/o asthma 4) h/o pneumonia [Hospital ] Condition: Stable. Tolerating regular diet. Pain well controlled with oral medications [Hospital ] Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 1000mL to 1500mL per day. -If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours . You were noted to have a nodule on your chest CT. You need your PCP on [Hospital ] to refer you to pulmonary doctor [First Name (Titles) ] [Last Name (Titles) ] for continued evaluation and have repeat CT scan in 3 months as discussed below. . Followup Instructions: 1. Please follow up with Dr. [Last Name (STitle) 1120] in one week. [Telephone/Fax (1) 160] . On CT Scan of your chest, you had 'A 6 mm nodule within the right lower lobe which was not present on a prior study of [5-27], [2134]. You need to have a repeat CT chest within 3 months for furthur evaluation'* Please talk to Dr. [Last Name (STitle) ] about getting a repeat CT scan at that time. Provider: [First Name11 (Name Pattern1) 20] [Last Name (NamePattern4) 21383], MD Phone:[Telephone/Fax (1) 1983] Date/Time:[2137-7-26] 9:30 NEITHER DICTATED NOR READ BY ME Completed by:[2137-8-19]	[ "998.11", "569.62", "799.02", "041.04", "998.59", "E878.8", "496", "E878.6", "V15.41", "E849.7", "285.1", "482.9", "780.52", "518.0", "415.11", "998.12", "567.22", "E879.8", "556.3", "568.89", "263.9" ]	icd9cm	[ [ [] ] ]	[ "48.24", "99.15", "45.82", "46.21", "38.93", "45.62", "54.12", "45.13", "97.49", "45.25", "54.91", "46.41" ]	icd9pcs	[ [ [] ] ]		5157, 8775	564, 687		4112, 5134	15565, 16200	3352, 3499						10512, 12952	8792, 10486										14561, 15542		3514, 4093																					2347, 2748					494, 526		12982, 14546					715, 2328																		2770, 3017	3033, 3336
29,035	117,343	16126	Discharge summary	report	Admission Date: [2152-8-9] Discharge Date: [2152-8-19] Date of Birth: [2089-12-13] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Indomethacin / Actonel / Reglan Attending:[First Name3 (LF) 949] Chief Complaint: increasing weight gain, abdominal girth, and lower extremity swelling Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 62 F h/o NASH cirrhosis, stage IV, grade 2 inflammation, ?portal vein thrombosis, depression with psychosis, hx of hepatic encephalopathy recently admitted on [2152-6-2]-5/08 for altered mental status and found to have seizure disorder. . She had been in her usual state of health since her discharge from the hospital with no changes in any of her liver meds. She had been stable weight/abd girth for several years on a regimen of PO lasix 120 mg [Hospital1 ] and spironolactone 100 mg [Hospital1 ]. Then, roughly 3-4 weeks ago, she began to notice rapid weight gain and increaseing abd girth and LE swelling. She has gained greater than 20 pounds in 1 month. Last Wednesday, Dr. [Last Name (STitle) 497] increased her diuretics to 100 mg IV lasix QAM, 120 mg PO QPM, spironolactone 100 mg [Hospital1 ]. This has had no effect on her weight, in fact she notes continued increase in weight. . She notes worsening DOE, now getting SOB when walking [2-9] block as opposed to 1 block. She denies any CP, palpitations. She denies PND, but has 2 pillow orthopnea X 1 year. She has had no confusion, dry mouth, no abdominal pain, jaundice, pale stools, dark urine, hematemesis, or melena. She denies any dietary indiscretions, eating cereal/juice,grapefruit for breakfast, grilled chicken [Location (un) 6002] lunch, fish for dinner. . Upon arrival to the floor, 98.7 120/58 64 18 95%RA. She currently feels well, although feels sad b/c today is anniversary of husband's death. Past Medical History: NASH/Cirrhosis: (Liver bx [9-6] = Stage IV cirrhosis, Grade 2 inflammation) EGD [7-13] = 3 cords of grade 1 Thrombocytopenia Previous ascites and encephalopathy GERD DM2 with retinopathy HTN Retinal hemmorhape; diabetic retinopathy Diabetic neprhopathy sleep apnea Leg crams/? RLS DJD of neck ? ASD/murmur on exam Hyperdymanic LVF (75% on echo 1 yr ago Intermittent, atypical CP (stress test had been planned but not done). H/o Dermoid cyst Right adrenal mass . Past Surgical History: s/p cholecystectomy followed by tubal ligation, s/p left oopherectomy, s/p Appy . Past Psychiatric History: Psychiatrist: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]; Psychologist: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Depression first experienced in HS First hospitalization in [2131] (after husband's death). 12 previous psychiatric hospitalizations in all Most recently treated at [Doctor First Name 1191] (and transferred to Bay State) in [2146-3-11]. H/o cutting and burning self. H/o OD on meds in SA. h/o 1 course of ECT in past that was helpful Social History: Widowed, lives in [Hospital3 ] and recently do to meds non-compliance, they are giving her meds at [Hospital3 ] Has 4 children, several in MA Smoking: none EtOH: never Illicits: none Family History: Mom: CAD, stroke Dad: HTN, DM Physical Exam: PE: 98.7 120/58 64 18 98%RA Gen: pleasant, NAD, obese HEENT: PERRL, EOMI, no thyromegaly Neck: JVP difficult to assess given neck circumference CV: 4/6 SEM, RRR Resp: clear bilaterally, no crackles Abd: very distended, but soft, non-tender, choly scar in ruq, +shifting dullness Ext: 1+ pitting edema Skin: no lesion Pertinent Results: Admission Labs: WBC-4.7 Hgb-9.4* Hct-26.9* MCV-92 Plt Ct-78* PT-15.6* PTT-26.8 INR(PT)-1.4* Glucose-84 UreaN-55* Creat-1.6* Na-132* K-4.5 Cl-94* HCO3-29 ALT-15 AST-32 LD(LDH)-224 AlkPhos-134* TotBili-0.9 Albumin-4.3 Calcium-9.1 Phos-4.3# Mg-3.0* Iron-65 calTIBC-436 VitB12-862 Folate-GREATER TH Ferritn-73 TRF-335 . Discharge Labs: . ECHO [2152-7-21]: The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is borderline pulmonary artery systolic hypertension. . IMPRESSION: No evidence of intrapulmonary shunting by bubble study. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Diastolic dysfunction with elevated PCWP. Mild aortic stenosis. Mild mitral regurgitation. Borderline pulmonary hypertension. . Compared with the prior study (images reviewed) of [2151-11-26], the findings are similar. . . EKG [2152-8-9]: Sinus rhythm with frequent atrial ectopy. Q-T interval prolongation. Compared to the previous tracing of [2152-6-2] atrial ectopy has appeared. Otherwise, no diagnostic interim change. . [2152-8-9] Abd/Pelvis U/S & duplex doppler: IMPRESSION: 1. Heterogeneous and coarsened liver without focal lesion. 2. No ascites. 3. Splenomegaly. 4. Left lower quadrant cystic structure. Pelvic ultrasound to further evaluate continues to be recommended. ADDENDUM: The left lower quadrant cystic structure is unchanged in size and character from the prior CT of [2151-10-5]. However, it is new from the CT abdomen and pelvis of [2149-6-10]. 6- to 12-month pelvic ultrasound followup is recommended to ensure stability. . [2152-8-9] Chest x-ray: COMPARISON: [2152-6-8]. As compared to the previous examination, there is moderate improvement. The lung volumes are still small and the hemidiaphragms are elevated, but the extent of the right-sided pleural effusion has markedly decreased. The effusion now reaches the height of 4 cm in the dorsal sinus. The size of the cardiac silhouette is at the upper range of normal, the diameter of the pulmonary vessels still indicates minimal overhydration. There is no focal parenchymal opacity suggestive of pneumonia. No pneumothorax. . [2152-8-15] Chest x-ray: FINDINGS: As compared to the previous examination, there is no major change. The lung volumes are unchanged. Also unchanged is the size of the cardiac silhouette and the appearance of the lung parenchyma. On the frontal radiograph, no pleural effusion is seen. The mediastinum has unchanged appearance. . [2152-8-18] Wrist x-rays: Preliminary report - no fractures. Brief Hospital Course: 62 y/o F with a history of NASH cirrhosis now with weight gain and increasing abdominal girth and lower extremity edema for 1 month. . 1. Weight gain/abd distention: The differential diagnosis broadly is primary hepatic vs cardiac. She had previously patent vessels and no ascites on her last U/S. No ascites was noted on a repeat ultrasound on this admission and vessels were patent. Cardiac causes including MI/CHF were also considered, however, an echo on [7-21] showed a normal EF. She does have marked diastolic dysfunction which may be contributing to volume overload. TSH was normal in 4/[2152]. The patient was diuresed, initially with lasix 100 mg IV BID and aldactone 100 mg PO BID. After a couple of days this regimen was changed to lasix 80 mg [Hospital1 ] and aldactone 300 mg PO QD. She had a good response to these diuretics with her weight decreasing from 112+kg on admission to almost 102 kg. Diuretics were held when she entered the MICU on [8-14] and were restarted the morning of [8-16] at which time her weight was 103.5 kg. Her weight on the morning of discharge was 104.5 kg. . 2. Upper GI bleed: Mrs. [Known lastname ] had about 1L of hematemesis on [8-14] and was transfered to the MICU where she received a 2 units of RBCs and underwent endoscopy. The first EGD showed no intervenable varices but the repeat EGD showed 2 bands of grade II varices and 2 bands of grade I varices and 2 bands were placed. Her post procedure Hct has been stable. After a night in the MICU, she was transferred back to the floor on octreotide and protonix drips and switched to a PO PPI the following day. She received ceftriaxone as prophylaxis x 3 doses and sucrafate 1 g PO BID x 3 days. Ferrous sulfate and SC heparin were discontinued. . 3. Cirrhosis: The patient has stage IV cirrhosis by biopsy. There were no significant changes in her LFTs during her stay. . 4. Chronic kidney disease: The patient's baseline creatinine is 1.3-1.7. Her creatinine remained within this range during most of her admission. It increased to 1.9 after diuretics were resumed post-GI bleed, likely because her volume overload had improved significantly and she was slightly dry. The diuretic dose was decreased to lasix 80 mg PO BID and aldactone remained at 300 mg PO QD. Her medications were renally dosed. Her creatinine on the morning of discharge was 1.8. . 5. Pelvic cyst: The patient has a cyst on the broad ligament, previously visualized by CT scan in [2150], although this finding is new compared to a CT scan in [2149]. The cyst has remained stable in size. Radiology recommends reimagining in [7-20] months to confirm that the mass is stable. The patient has been advised to follow-up with a gynecologist of her choosing. . 6. Seizures: The patient has a history of seizures. Her home regimen of keppra and lamictal were continued. No overt seizures were noted. . 7. Depression/Anxiety: The patient has a history of depression. Her home dose of seroquel was continued. Additionally, she received her home dose of alprazolam for anxiety. . 8. DM: The patient was placed on sliding scale insulin. . 9. CAD: The patient has had a previous CABG and known 3 vessel disease on cardiac cath in [2151]. She is not currently on an ACEI, statin, or aspirin. Given her history of variceal bleeding, it was decided not to start her on an aspirin. The patient is quite anxious about her cardiac status, especially since it is the anniversary of her husband's death. It was decided to defer starting an ACEI or statin and to have her discuss this these therapies with her cardiologist in follow-up. . 10. Thrombocytopenia: The patient's thrombocytopenia has been stable. . 11. Anemia: The patient has a baseline anemia. Iron studies revealed that she is iron deficient, and she was started on ferrous sulfate supplementation. As she continued to feel poorly, even after losing 7 kg of fluid, it was decided to transfuse her with 2 units of RBCs. Her stools were guiac tested. One was negative; one was trace positive. Then on [8-14] she had an episode of 1L of hematemesis and she received another 2 units of RBCs. Her hematocrit has remained stable between 24-27. Ferrous sulfate was discontinued immediately after the GI bleed. . 12. FEN: The patient was given a low salt, cardiac and diabetic diet. She was initially hyponatremic, likely from increased diuretic use. This was carefully monitored and resolved. . 13. Prophylaxis: The patient received heparin sc tid until her upper GI bleed. She was also placed on a bowel regimen. . 14. Code: Full Medications on Admission: Allopurinol 300 mg daily Amlodipine 5 mg daily Calcium 1200 mg QOD Citalopram 40 mg daily folic acid 1 mg daily lasix 120 mg daily keppra 500 mg [Hospital1 ] lamictal 100 mg HS MVI nadolol 40 mg daily provigil 200 mg daily seroquel 100 mg QHS spironolactone 100 mg [Hospital1 ] [Last Name (un) ] 500 mg [Hospital1 ] novolog SS Lantus 65 unit [Hospital1 ] neurontin 600 qam, 300 lunch, 300 dinner rifaximin 400 tid Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Quetiapine 200 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 11. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QAM (once a day (in the morning)). 14. Provigil 200 mg Tablet Sig: One (1) Tablet PO once a day. 15. Neurontin 300 mg Capsule Sig: Three (3) Capsule PO at bedtime. 16. insulin Please resume your home regimen of Lantus 65 units [Hospital1 ] and humalog sliding scale 17. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 18. Spironolactone 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: Forge [Doctor Last Name ] senior living Discharge Diagnosis: Primary Diagnosis: Volume overload Additional Diagnoses: NASH/cirrhosis Thrombocytopenia GERD Type 2 Diabetes Major Depression with psychosis Hypertension Diabetic nephropathy Obstructive sleep apnea Discharge Condition: stable, satting well on room air, pain free. Discharge Instructions: You were admitted to the hospital because of rapid weight gain, increased abdominal size, and increased leg edema concerning for water retention. The abdominal ultrasound study that was performed did not show any ascites. However, with IV lasix and increased doses of oral spironolactone you were able to urinate the excess water and lose weight. The abdominal ultrasound also showed a cystic structure in your pelvis that was noticed 2 years ago on a CT study, but was not seen on a study 3 years ago. The structure has remained approximately the same size. The radiologist recommended another pelvic ultrasound in [7-20] months to confirm that the cyst is not changing in size. We recommend that you follow-up with a gynecologist to further evaluate this finding. In addition, the echocardiogram that was performed on [2152-7-21] was significant for some diastolic dysfunction. This finding may help to partly explain why you are retaining excess water and having increased shortness of breath. Given your history of coronary artery disease, we recommend that you follow-up with a cardiologist to discuss possible options for further medical management. We recommend that you discuss with your cardiologist whether starting a statin medication and/or an ACE inhibitor may be beneficial for your heart. During your admission you were started on ferrous sulfate because you were noted to have an iron deficiency anemia. You also received 1 unit of red blood cells because of a low hematocrit. You have an appointment with Dr. [Last Name (STitle) 497] on Wednesday, the 16th at 3:00 PM. he will adjust your diuretic doses. In addition, he will discuss your repeat EGD. Your diuretic therapy was changed to lasix 80 mg PO twice daily and spironolactone 300 mg daily. If you experience any fevers, chills, increased shortness of breath, rapid weight gain, or other concerning symptoms, you should return to the hospital. Followup Instructions: - [Location (un) 620] Cardiology, Dr. [Last Name (STitle) 1016], [9-26] at 11:30 am - Gynecologist of your choosing You have an appointment with Dr. [Last Name (STitle) 497] on Wednesday, the 16th at 3:00 PM.	[ "403.90", "362.01", "585.3", "571.8", "276.1", "276.6", "584.9", "620.8", "287.5", "250.40", "571.5", "345.90", "456.20", "537.89", "250.50", "285.1", "296.20" ]	icd9cm	[ [ [] ] ]	[ "45.13", "99.04", "42.33" ]	icd9pcs	[ [ [] ] ]	13568, 13638	7067, 11696	381, 387	13883, 13930	3677, 3677	15923, 16152	3281, 3313		12181, 13545		13659, 13659		11722, 12158				13954, 15900			4010, 7044					2438, 3056	3328, 3658																										272, 343							415, 1922							3693, 3993	13678, 13862										1944, 2415	3072, 3265
70,254	115,473	38189	Discharge summary	report	Admission Date: [2143-6-6] Discharge Date: [2143-6-19] Date of Birth: [2080-7-13] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2143-6-11] Urgent coronary artery bypass grafting x5 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from aorta to first diagonal coronary artery; reverse saphenous vein single graft from aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from aorta to the second obtuse marginal coronary artery; as well as reverse saphenous vein single graft from aorta to posterior descending coronary artery History of Present Illness: 62 year old man with Diabetes experiencing new onset chest pressure and right arm numbness since yesterday. Initialy thought it was indigestion but was concerned about the arm tingling and therefore presented to ER this AM where he wwas tx for a STEMI with ASA, integrellin, Plavix and brought to the cardiac catheterization lab where he was found to have 3VD. Transferrred to [Hospital1 18] for CABG. Currently pain free on Heparin and Ntg infusions. Past Medical History: Diabetes Mellitus Social History: Race: caucasian Last Dental Exam: Lives with: self Occupation: machinist Tobacco:pipe ETOH: 2oz brady/day recreational drugs: none Family History: Brother had CABG at 50yo, father had AAA Physical Exam: Pulse: 72 SR Resp: 16 O2 sat: 100%-2LNP B/P Right: 149/66 Left: Height: 176cm Weight: 77kg General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur- no M/R/G Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact, non-focal exam Pulses: Femoral Right: cath site Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit no Pertinent Results: [2143-6-7] Carotid U/S: 1. 60-69% right ICA stenosis. 2. 70-79% left ICA stenosis. 3. Bilateral moderate-to-high grade external carotid artery stenoses. [2143-6-11] Echo: Pre-bypass: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Post-bypass: The patient is receiving no inotropic support post-CPB. Biventricular systolic function is preserved and all findings are consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings communicated to the surgeon intraoperatively. Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname ] presented to outside hospital with chest pain and found to be having a myocardial infarction. Underwent cardiac cath which revealed severe three vessel coronary artery disease. Transferred to [Hospital3 ] to undergo coronary artery bypass surgery. Upon admission he was appropriately medically managed and underwent pre-operative work-up while awaiting Plavix washout. On [6-11] he was brought to the operating room where he underwent coronary artery bypass grafting to five vessels. Please see operative note 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. On post-op day one he was started on beta-blockers and diuretics and diuresis was started towards his pre-operative weight. He was then transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. Physical therapy worked with patient during post-op course for strength and mobility. Ciprofloxacin was started for treatment of a urinary tract infection. An ace inhibitor was started given his preoperative myocardial infarction. He had postoperative anemia which required two transfusions with packed red blood cells. On POD#2 Mr. [Name13 (STitle) 10123] was noted to have scant serosanguinous drainage from the distal aspect of his chest incision. Given his history of diabetes and his long beard, he was started and mainatined on IV cefazolin until his drainage decreased. His incision was cleansed daily and kept covered. His WBC remained normal and he was afebrile. On POD# 8 he was cleared for discharge to home by Dr. [Last Name (STitle) 914] with VNA follow-up and a wound check in one week. Medications on Admission: Glyburide Metformin 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:65 Tablet(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 11. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a day for 10 days. Disp:30 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5 Myocardial Infarction Past Medical History: Diabetes Mellitus Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema but scant serosanguinous drainage from lower aspect of his sternal incision-started on keflex. Leg Right/Left - both legs w/ harvest sites healing well, no erythema or drainage. Edema -trace edema lower extremity 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. Wash your incision with soap and water twice daily, pat dry and cover with a clean dry dressing twice daily. 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 call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) 914] on [7-9]. [2142] at 1:45PM [Telephone/Fax (1) 170] Wound check on [Hospital Ward Name ] [6-25] at 11am. Please call to schedule appointments with your Primary Care Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 14751] in [12-22] weeks Cardiologist Dr. [First Name (STitle) ] [Name (STitle) 33746] in [12-22] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2143-6-19]	[ "414.01", "458.29", "782.3", "410.71", "599.0", "E878.2", "250.00", "285.1" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.14", "36.15" ]	icd9pcs	[ [ [] ] ]	6783, 6838	3528, 5369	330, 835	7004, 7356	2244, 3505	8221, 8906	1525, 1567		5439, 6760		6859, 6942		5395, 5416				7380, 8198									1582, 2225																										280, 292							863, 1320																		6964, 6983	1377, 1509
19,937	190,864	51089+59309	Discharge summary	report+addendum	Admission Date: [2125-5-19] Discharge Date: [2125-6-1] Date of Birth: [2063-1-15] Sex: F Service: MICU CHIEF COMPLAINT: Acute renal failure, unable to obtain vascular access. HISTORY OF PRESENT ILLNESS: This is a 63-year-old female hospitalized at an outside hospital on [5-1] with several sputum production. On presentation, her creatinine was somewhat above baseline. She was intubated at that time for a questionable congestive heart failure or hypercarbia. Over the course of the hospitalization, she was extubated and reintubated times two for fatigue, hypercarbia plus or minus hypoxia. In mid [Month (only) ], she developed hypotension and creatinine started to rise rapidly. At that point, she not be done because she had severe central stenosis of all vessels and no access was attempted at that point due to fear of more thrombosis as patient had a transplanted kidney, which was the only accessible vein. She was transferred to [Hospital6 256] for decisions about access and treatment of her renal failure. MEDICATIONS ON ADMISSION: She was on Imuran, cyclosporin, Solu-Medrol, cephaeline, Lasix, Renagel, iron, Lopressor, heparin and versed. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No alcohol, no tobacco. FAMILY HISTORY: Myocardial infarction, renal failure. Mother had diabetes. BRIEF PHYSICAL EXAMINATION: Patient intubated and sedated. Vital signs: Afebrile. Pulse 66. Blood pressure 144/65. 02 saturation 100%. Vent settings, pressure support of 5, total volume 700, rate 12, PEEP of 5, FIO2 30%. Heart: Regular rate and rhythm, normal S1, S2, no murmurs, rubs or gallops. Lungs clear to auscultation. Abdomen: Obese, positive bowel sounds, soft, nontender. Extremities: Decreased skin turgor plus edema. LABORATORIES ON ADMISSION: Sodium 143, potassium 3.8, chloride 103, bicarbonate 20, BUN 126, creatinine 7.5, glucose 83, calcium 10.6, magnesium 1.9, phosphorus 2.4, PT 14, INR 1.3, PTT 94. White blood cell count 7. Hematocrit 28.6 and platelets 146,000. Troponin is negative. Urinalysis greater than 300 protein, [5-14] white blood cells and specific gravity of 1.015. In addition, outside venogram demonstrated central stenosis of all upper extremity vessels and the left femoral was not accessible. The right femoral was open. She also has demonstrated left axillary deep vein thrombosis by ultrasound. BRIEF HOSPITAL COURSE: On [5-19], Mrs. [Known lastname 17597] was transferred to [Hospital6 256] for access issues. She has continued to have poor intravenous access at hospital. Many stenosed veins, barring placement of catheter. A Quinton catheter into her right femoral to serve as intravenous access, drawing line, and possibly for hemodialysis if needed. After the placement of the Quinton, she started to experience a drop in hematocrit and was currently being heparinized at the time for multiple deep vein thromboses in the past. Abdominal CT at the time showed no retroperitoneal bleed, but there was a large hematoma surrounding the Quinton. The Quinton catheter was determined to be functional at that time, even though she had a hematoma. She was transfused with five units of packed red blood cells to raise her hematocrit and subsequently given two more units of packed red blood cells that went into the hematoma. Patient's hematoma then stabilized on the [5-28] with a tense hematoma at the site of the Quinton catheter, approximately 10 cm in diameter and the total hematoma was 25 x 25 cm. Over the course of her stay, she was extubated, but required BiPAP at night for sleeping due to questionable sleep apnea and/or hypoxic episodes due to her obesity. She is morbidly obese. Over the course of the stay, the decision was made to leave the Quinton in because that was her only access. On [5-29], the Quinton was replaced over a wire with a new Quinton to try and stabilize the bleed. At that point, the hematoma stopped expanding and her hematocrit stabilized. The right femoral Quinton remains her only access line. On [5-31], Mrs. [Known lastname 17597], was discharged to the floor in care of another team with the Quinton line in place. MEDICATIONS ON TRANSFER: 1. Renagel 1600. 2. Insulin sliding scale. 3. Prednisone 10 po. 4. Oxycodone. 5. Lactulose. 6. Cyclosporin. 7. Epogen. 8. Calcitrel. 9. Colace. 10. Dulcolax. 11. Tylenol. 12. Versed. 13. Ativan. 14. Protonix. 15. Iron. 16. Lopressor. 17. Azathioprine. DISCHARGE DIAGNOSES FROM THE FLOOR: End stage renal disease with multiple access problems. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-948 Dictated By:[Name8 (MD) 23023] MEDQUIST36 D: [2125-6-1] 22:56 T: [2125-6-1] 22:56 JOB#: [Job Number ] Name: [Known lastname ], [Known firstname 3441] Unit No: [Numeric Identifier 17272] Admission Date: [2125-5-19] Discharge Date: [2125-6-6] Date of Birth: [2063-1-15] Sex: F Service: MEDICINE ADDENDUM: BRIEF HOSPITAL COURSE SINCE TRANSFER FROM THE MEDICAL INTENSIVE CARE UNIT: The patient was transferred to a Regular Medical Floor on [5-31]. Her condition upon transfer was very stable. Her main issue remained access. The only available access that we had was a tunnelled hemodialysis catheter in her right groin. Since she was medically improving, it was felt that it would be in her best interest if the line was removed as there was a significant risk of infection. There was no need to follow labs on her and therefore lack of intravenous access was not a pressing issue. During her stay, she was on night Bi-PAP for presumed sleep apnea. The patient had never had a formal study of sleep apnea and we would appreciate your cooperation in arranging such a study. Her cardiovascular function remained stable. The only outstanding issue was hypertension with systolic pressure between 140 and 160 and diastolic between 80 and 100, which required an increase in her Lopressor to 25 p.o. twice a day. From a Hematology standpoint, the patient's hematocrit upon transfer was 24. She received two units of packed red blood cells and her hematocrit stabilized at 30. In addition, her Epogen dose was increased to 800 three times a week. It was decided that anti-coagulation would not be in her best interest: All her previous clots had been in the upper extremities and she had a history of gastrointestinal bleed on Coumadin. Her renal function remained stable, although it did not return to her pre-hospital levels. She never required hemodialysis and it is likely that she will require some in the near future. She was continued on her immunosuppression. It is recommended that the patient drinks about 400 cc. of water every four hours when awake. She should be on a renal diet. On the day before discharge, her access line was removed and with no complications associated with this procedure. CONDITION ON DISCHARGE: Stable. DISPOSITION: Discharged to an acute care rehabilitation facility. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg twice a day. 2. Epogen 8000 units three times a week. 3. Senna one tablet p.o. twice a day. 4. Dulcolax 10 mg p.o. q. day. 5. Protonix 40 mg q. day. 6. Remegel 1600 mg p.o. three times a day. 7. Prednisone 10 mg q. day. 8. Cyclosporin 100 mg p.o. q. day. 9. Ferrous sulfate 325 mg p.o. q. day. 10. Imuran 100 mg p.o. q. day. 11. Tylenol 325 to 650 mg p.o. q. four to six hours p.r.n. for pain. 12. Maalox 15 to 30 ml p.o. four times a day p.r.n. DR.[Last Name (STitle) 639],[First Name3 (LF) 77] 12-948 Dictated By:[Name8 (MD) 2940] MEDQUIST36 D: [2125-6-8] 14:00 T: [2125-6-14] 22:25 JOB#: [Job Number ]	[ "707.0", "998.12", "V42.0", "518.81", "401.9", "278.01", "584.9", "E879.8" ]	icd9cm	[ [ [] ] ]	[ "96.71", "38.95", "38.93" ]	icd9pcs	[ [ [] ] ]		2443, 4221					1301, 1367		7132, 7824				1093, 1242																												1390, 1814											148, 204							233, 1067									1829, 2419								4246, 7005		1259, 1284	7031, 7109
74,795	102,641	42606	Discharge summary	report	Admission Date: [2105-1-14] Discharge Date: [2105-1-20] Date of Birth: [2042-8-11] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 922] Chief Complaint: Worsening fatigue (sleeps 12 hrs /day) and exertional angina Major Surgical or Invasive Procedure: [2104-1-15] 1. Aortic valve replacement with a 23 mm [Doctor Last Name ] pericardial valve, model number 3300TFX, serial number [Serial Number 92165]. 2. Coronary artery bypass grafting x2, left internal mammary artery to left anterior descending coronary artery and reverse saphenous vein graft from the aorta to the posterior descending coronary artery. 3. Endoscopic greater saphenous vein harvesting. History of Present Illness: This is a 62 year old male with known aortic stenosis and coronary artery disease. He has been followed with serial echocardiograms which have shown progression of his aortic valve disease. Most recent echocardiogram in [2104-11-11] revealed severe aortic stenosis, with [Location (un) 109] ~ 0.8 cm2 with peak/mean gradients of 80/46 mmHg. Given the above findings, he has been referred for surgical consultation. Past Medical History: - Aortic Stenosis - Coronary Artery Disease, s/p LAD angioplasty in [2086] - History of TIA [2099] - Severe intracranial left internal carotid disease - Obesity - Dyslipidemia - Obstructive Sleep Apnea - Impaired Glucose Tolerance - Asthma - Depression - Erectile Dysfunction - Colonic Polyps Past Surgical History - R thoracotomy/rib resection ( benign mass at age 1) Past Cardiac Procedures: PTCA of LAD in [2086] Social History: Race: Caucasian Last Dental Exam:5 months ago Lives with: Wife Contact: same Phone # Occupation: Electronic Tech Cigarettes: Denies Other Tobacco use:never ETOH: < 1 drink/week [x] [2-17] drinks/week [] >8 drinks/week [] Illicit drug use-none Family History: Non-contributory Physical Exam: Pulse:59 Resp:16 O2 sat: 98% B/P Right: 112/63 Left: 128/68 Height: 67" Weight:205 General:NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera; OP unremarkable Neck: Supple [x] Full ROM [x]no JVD appreciated Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade 4/6 SEM radiates throughout precordium and into B carotids Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds + [x] no HSM, pinpont epigastric tenderness on deep palpation; no CVA tenderness Extremities: Warm [x], well-perfused [x] Edema [] none_____ Varicosities: None [x]; 2.5 cm scar at each medial malleolus (venous cutdowns during pediatric surgery) Neuro: Grossly intact ,nonfocal exam, MAE [5-16] strengths Pulses: Femoral Right: 1+ Left:1+ DP Right: 2+ Left:2+ PT [Name (NI) 167]: 2+ Left:2+ Radial Right: 2_ Left:2+ Carotid Bruit: murmur radiates to B-carotids Pertinent Results: ECHO [2104-1-15] 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 right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to moderate ([1-12]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([1-12]+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results before surgical incision. POST-BYPASS: Preserved biventricular systolic function. LVEF 55%. Intact thoracic aorta. The aortic bioprosthesis is stable, functioning well with peak 18 and meann 9 mm of Hg. Mild MR. [2105-1-18] CXR: Post-sternotomy wires and replaced aortic valve are unremarkable. There is overall improvement in the aeration of both lungs with still present opacities seen in right upper, right lower, and left lower lung. There is small amount of bilateral pleural effusion still present. There is no evidence of pneumothorax. [2105-1-19] 04:45AM BLOOD Glucose-119* UreaN-23* Creat-0.8 Na-134 K-3.6 Cl-94* HCO3-28 AnGap-16 [2105-1-19] 04:45AM BLOOD WBC-12.2* RBC-3.38* Hgb-10.4* Hct-30.3* MCV-90 MCH-30.6 MCHC-34.3 RDW-12.9 Plt Ct-236 Brief Hospital Course: This is a 62 year old male with known aortic stenosis and coronary artery disease who was a same day admission into the operating room for aortic valve replacement and coronary bypass grafting with Dr [Last Name (STitle) 914]. Please see the operative report for details, in summary he had Aortic valve replacement and Coronary artery bypass grafting x 2. His bypass time was 121 minutes, with a cross clamp time of 101 minutes. He tolerated the operation well and post-operatively was transferred to the cardiac surgery ICU in stable condition on Neo-Synephrine to support his blood pressure. In the immediate post-op period he remained hemodynamically stable, anesthesia was reversed-he woke neurologically intact and was extubated. On post-op day one he was started on diuretics and beta-blockers and transferred to the stepdown floor for continued recovery. All tubes, lines, and drips were removed per cardiac surgery protocol. Once on the floor he worked with nursing and physical therapy to advance his activity and endurance. The remainder of his hospital course was uneventful. He was discharged to Lifecare of [Location (un) 2199] with visiting nurses on post-op day six. He is to follow up with Dr. [Last Name (STitle) 914] in 1 month. Medications on Admission: Medications at home: - Aspirin 325mg daily - Atenolol 25mg daily - Crestor 40mg daily - Sertraline 200mg daily - Flovent HFA 110mcg 1 inhale twice daily prn - Ventolin HFA 90mcg 2 puffs every 4-6 hours prn - Fluticasone Nasal spray - Omega 3 Fatty Acids 1000 mg daily - Multivitamin Centrum daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 9. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 14. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO twice a day for 7 days. Discharge Disposition: Extended Care Facility: Lifecare Center of [Location (un) 2199] Discharge Diagnosis: Aortic Stenosis s/p Aortic valve replacement Coronary Artery Disease s/p Coronary artery bypass graft x 2 Past medical history: - s/p LAD angioplasty in [2086] - History of TIA [2099] - Severe intracranial left internal carotid disease - Obesity - Dyslipidemia - Obstructive Sleep Apnea - Impaired Glucose Tolerance - Asthma - Depression - Erectile Dysfunction - Colonic Polyps Past Surgical History - R thoracotomy/rib resection ( benign mass at age 1) Past Cardiac Procedures: PTCA of LAD in [2086] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage Edema: 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for one month or while taking narcotics. Drivng will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [Last Name (STitle) 914] [Telephone/Fax (1) 170] in the [Hospital ] Medical Office on [2-23] at 1:15pm Cardiologist: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2-11] at 11:10am Vascular: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Please call to schedule appointments with your Primary Care: Dr. [First Name (STitle) ], [First Name3 (LF) 1785] K. [Telephone/Fax (1) 31019] in [4-16] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2105-1-20]	[ "311", "413.9", "278.00", "395.0", "327.23", "433.10", "493.90", "780.62", "285.9", "V12.54", "272.4", "414.01" ]	icd9cm	[ [ [] ] ]	[ "36.11", "36.15", "39.61", "35.21" ]	icd9pcs	[ [ [] ] ]	7569, 7639	4705, 5965	358, 776	8195, 8423	2974, 4682	9155, 9886	1980, 1998		6312, 7546		7660, 7766		5991, 5991				8447, 9132				6012, 6289					2013, 2955																										258, 320							804, 1228																		7788, 8174	1695, 1964
3,267	134,370	48384	Discharge summary	report	Admission Date: [2193-8-7] Discharge Date: [2193-8-28] Date of Birth: [2138-3-6] Sex: F Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 3556] Chief Complaint: Right leg pain Major Surgical or Invasive Procedure: R BKA [8-27] PICC triple lumen Left IJ CVL History of Present Illness: Ms. [Known lastname 37559] is a 55 yo W with PMH of ESRD on HD, PVD, DM, renal cell ca, presents with RLE pain x 1 week, n/v and abdominal tenderness. She reports sharp pain in ankle, toes, calf and knee for approx. 1 week. Nothing improves or exacerbates symptoms. She notes some swelling throughout but denies joint swelling or redness. No fevers or chills. She has not had similar symptoms in the past. No trauma to the area. She is non ambulatory at baseline. Pt presented to ED from nursing home for further evaluation. Also reports nausea and vomiting x1 day. Took compazine in AM which improved symptoms. No abdominal pain or diarrhea. Has been eating per baseline. In the ED, VS: 98/51 58 15 98 RA. She had XR lower leg, CT abd/pelvis negative for abnormalities. CXR without infiltrate. BP was in the 100s. EKG was without ischemic changes. BP ranging from sys 60-100s. Received approximately 750cc NS in ED. Received vanco and zosyn for concern for sepsis. Received dilaudid 2mg PO x 1 with some relief. Compazine before arrival. Wears O2 at baseline. ROS: Rash on bilateral flanks and abscess in groin Past Medical History: -Peripheral vascular disease s/p left SFA-DP bypass in [2187] for gangrenous heel, s/p R proximal SF-proximal AT bypass in [4-4], s/p L BKA in [1-6] for non-healing ulcer - Left stump osteomyelitis in [4-5] treated with vanco/[Last Name (un) 2830] from [Date range (1) 101854] - H/o MRSA vertebral osteomyelitis with MRSA bacteremia - ESRD on HD - TTSat schedule per nephrology ED note - HTN - CAD s/p NSTEMI - Diabetes Mellitus - Renal Cell Carcinoma s/p right nephrectomy - Obesity - Depression - s/p CCY - Gastric Ulcer - Obstructive Sleep Apnea. - Gastroparesis - COPD on 3-4L NC baseline - H/o ischemic colitis - Left adrenal adenoma Social History: Admitted from nursing home. Has two sisters, one daughter. [Name (NI) ] is a former smoker with a 30 pack year history, quit 20 years ago. Family History: Mother died of stomach cancer in her 40s. Father had an unknown cancer in his 70s. Stated that diabetes, high cholesterol, and high blood pressure run in her family. Physical Exam: VS: T sys 140 w/ doppler HR 54 100% RA Gen: Pleasant obese african american female in NAD HEENT: PERRL, EOMI, o/p clear CV: RRR, distant heart sounds Pulm: CTABL no w/r/r Abd: obese, soft, NT, ND; old surgical scar well healed in RLQ Ext: L BKA; RLE with 1+ pitting edema; dopplerable DP pulse Neuro: alert and oriented x 3, moving all extremities, CNs [1-10] intact; no focal deficits SKIN: intertriginous erythema GYN: firm purulent abscess over right labia Pertinent Results: LABS: [2193-8-7] 01:35PM BLOOD WBC-9.1# RBC-3.30* Hgb-10.1* Hct-33.1* MCV-100* MCH-30.6 MCHC-30.5* RDW-16.0* Plt Ct-136* [2193-8-7] 01:35PM BLOOD Neuts-83.9* Lymphs-13.3* Monos-2.6 Eos-0.1 Baso-0.2 [2193-8-7] 01:35PM BLOOD Glucose-131* UreaN-28* Creat-4.8* Na-142 K-3.6 Cl-101 HCO3-28 AnGap-17 [2193-8-7] 01:35PM BLOOD CK(CPK)-35 [2193-8-7] 01:35PM BLOOD cTropnT-0.27* [2193-8-7] 10:02PM BLOOD CK-MB-3 cTropnT-0.24* [2193-8-8] 05:01AM BLOOD CK-MB-NotDone cTropnT-0.24* [2193-8-8] 05:01AM BLOOD Calcium-7.9* Phos-5.9* Mg-1.8 [2193-8-7] 01:44PM BLOOD Lactate-2.0 STUDIES: Right Tib/Fib/Knee Xray: IMPRESSION: = 1. Diffuse severe osteopenia, making evaluation for subtle fracture suboptimal. Given this, no evidence of acute fracture. No dislocation or suprapatellar joint effusion. Doppler LE- Right: IMPRESSION: No evidence of DVT. CTA Abdomen: IMPRESSION: 1. No evidence of acute mesenteric ischemia or ischemic colitis. 2. Nonspecific cecal thickening; consider correlation with colonoscopy. 3. Stable extensive vascular calcifications. 4. Stable 1 cm enhancing splenic lesion, may represent hemangioma or hamartoma. Graft Duplex Ultrasound: The patient's prior right-sided lower extremity graft is not visualized, the native superficial femoral artery on the right is visualized with a monophasic waveform indicating distal ischemia. Please note, these findings are similar to a prior exam of [2191-7-4]. CT Head: No hemorrhage, no acute intracranial pathology. . Echo [8-28] There is severe regional left ventricular systolic dysfunction with severe hypokinesis/akinesis of the distal half of the left ventricle. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis (with perservation of the very base of the right ventricle). There is abnormal septal motion/position. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is at least mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2193-8-15] and [2193-2-22], the right ventricular function is similar with increased severity of tricuspid regurgitation. The left ventricular systolic function has worsened. . [2193-8-25] 5:02 am BLOOD CULTURE Source: Line-picc. Blood Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). OF TWO COLONIAL MORPHOLOGIES. GRAM NEGATIVE ROD #2. POSSIBLE SECOND MORPHOLOGY. Aerobic Bottle Gram Stain (Final [2193-8-26]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] @ 0314 ON [8-26] - [Numeric Identifier 100088]. GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [2193-8-26]): GRAM NEGATIVE ROD(S). Brief Hospital Course: Ms. [Known lastname 37559] is a 54 yo female with ESRD on HD, HTN, DM, OSA, COPD, obesity, PVD admitted for right lower extremity pain, hypotension at dialysis and somnolence. #. Hypotension: Patient noted to be hypotensive on arrival to ED though asymptomatic. Accurate blood pressures are difficult to attain given patient's obesity and vascular disease. On initial arrival to the MICU, her blood pressure was manually 140/doppler. However, automatic readings were much lower. It is unclear whether this was a true episode of hypotension or whether measurements were not accurate. She had occasional episodes of hypotension with SBP's in the 80's that seemed to occur after hemodialysis. Her blood pressure returned to [Location 213] range with 500cc boluses of normal saline. She also had episodes of hypertension with SBP's measured in the 200-300 range. However, it was not clear if these readings were accurate and the patient remained asymptomatic throughout these episodes. She was continued on metoprolol throughout the hospitalization, although this was held on days that she was dialyzed. O #. Leg pain: She presented with 1 week of right lower extremity pain without history of trauma and without evidence of DVT on ultrasound. She was initially managed with percocet for pain, which caused her to become sleepy if given more than one tab at a time. As she has a graft in this leg, vascular surgery was consulted for possible arterial occlusion. A graft duplex study showed no flow in her prior graft, and she was started on a heparin drip. She then underwent RLE angiogram which showed some flow through her graft, and vascular surgery felt that arterial occlusion was unlikely to be causing her symptoms. Therefore, her pain was attributed to diabetic neuropathy. Her dose of gabapentin was increased, and she was given lidoderm patches for her foot daily. She was also started on keppra for neuropathic pain. Her pain remained uncontrolled. She then developed skin breakdown on the dorsum of her toes. Her toes began to appear infected with purulent, malodorous drainage and she was treated with IV Vancomycin and Unasyn. Vascular surgery was reconsulted and felt it was most likely a diabetic ulcer. Amputation was considered. #. Episodes of decreased responsiveness: She had multiple episodes of increased somnolence during her hospital stay. She was minimally responsive to sternal rub during these episodes but would wake up to noxious stimuli (such as getting stuck for an arterial blood gas). She had a head CT and MRI which showed no acute process. Neurology was consulted due to concern for possible seizures vs other neurological process. They felt that her episodes were not likely seizures and could represent syncopal episodes or arrhythmias. She was monitored on telemetry and no events were noted. Her blood sugars were in the normal range during these episodes. They were ultimately thought to be a combination of pain, sedating medications, depression, and possibly occult infection. Her seroquel was decreased, narcotics were stopped, and her reglan was discontinued. She continued to be somnolent at times and this was of unclear etiology. #. Hearing difficulty: She had episodes of decreased hearing during hospitalization. During the first episode, there was some concern for an acute bleed in her head as she had recently been started on a heparin drip. A stat head CT was done which showed no acute intracranial process or bleed. It was felt that her hearing difficulty was likely related to earwax obstruction or congestion. Her ears were cleaned out with liquid colace and curettes and her hearing slightly improved but she continued to have bilateral hearing difficulty. It was arranged for her to have an audiology evaluation while an inpatient. #. Bacteremia: She had one positive blood culture that grew Coagulase-negative Staph aureus. She was started on vancomycin for treatment but no immediate clinical improvement was noted. It is unclear whether this positive blood culture was a contaminant. She subsequently grew GNR in her blood. #. CAD: She had an elevated troponin on admission, but her ECG was at baseline. Her troponin increased during her hospital stay and there was concern for a cardiovascular cause of her episodes of decreased responsiveness. Her ECG showed some ST-T changes. Cardiology was consulted who felt that her troponin elevation was due to her renal disease and she did not likely have an acute event while in the hospital. She had a repeat TTE which was a limited study due to lack of patient cooperation. However, it showed new wall motion abnormalities compared to previous. Cardiology felt that the timeline of these abnormalities could not be determined and recommended conservative managemend with statin, aspirin, and beta blocker. She also had been on Plavix on admission for a recent NSTEMI and they recommended continuing this treatment. #. Nausea/Vomiting: She has a history of gastroparesis and had a short episode of nausea and vomiting prior to presentation. CT abdomen showed no acute pathology. She was given reglan to increase motility and her symptoms improved. However, reglan was later discontinued due to concern for contributing to her episodes of decreased responsiveness. She had one subsequent episode of vomiting after her family brought her a large meal from McDonald's. #. Diabetes: She was placed on a diabetic diet and an insulin sliding scale without complication. #. ESRD on HD: She continued on hemodialysis on Tues, Thurs, Sat while in the hospital. She refused one dialysis session and dialysis was delayed without complication. #. COPD: On 3-4L NC at home, continued as needed although she did not typically require oxygen supplementation and her O2 sats were 93-94% RA. #. OSA: Patient refused CPAP multiple times during her hospitalization, but did wear it on some nights. #. Depression: Continued on seroquel and remeron. Her seroquel dose was decreased due to concern that it was sedating her and contributing to her episodes of decreased responsiveness. #. MICU TRANSFER. Ms. [Known lastname 37559] was transfered to the MICU for decreased mentation and difficulty measuring blood pressures in the setting of GNR bacteremia. Arterial catheterization confirmed hypotension, and her shock was treated with vasopressors and fluid resuscitation. The source of infection was believed to be her Right foot with wet gangrene. She was covered broadly with Gent/[Last Name (un) ]/Vanc. Vascular took patient to OR for right BKA. However her lactate continued to climb and she became progressively hypotensive requiring multiple vasopressors for blood pressure support. An echocardiogram showed both RV hypokinesis and LV hypokinesis. Given a known RIJ clot, a lactate that had risen above 7, and prior history of ischemic colitis, differential included pulmonary embolism, ischemic bowel, and myocardial ischemia. She was taken emergently for CT scan to evaluate for PE and ischemic bowel, but arrested during the scan. Family was brought into the arrest with the support of social work. CT was negative for PE and ischemic bowel, and cardiology was consulted for consideration of cath. With full ACLS, she had return of spontaneous circulation and was brought back to the ICU. However, she again arrested and was unable to be resuscitated. Medications on Admission: Lactulose 30 mg prn Seroquel 25 mg q 12 hour Sensipar 60 mg daily Renagel 2400 TIDWF Zemplar 4 mcg MWF IV Nitropaste prn Novolog sliding scale HSQ Senokot 1 [Hospital1 ] Reglan 5 mg TID Nexium 20 mg daily Colace 100 mg daily Zocor 10 mg daily Lopressor 12.5 q 12 hours Lovenox 40 mg daily Aranesp 100 Mo Remeron 15 mg qhs Duralgesic 75 mcq q3day Aspirin 81 daily Nephrocaps 1 daily Ambien 5 mg Ultram 50 [Hospital1 ] Perocet 2 tabs q6hours Neuronitn 300mg prn Insulin Novolog 8, 8, and 10 units before meals and sliding scale. Paricalcitol 6 mg q HD Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560] Completed by:[2193-8-29]	[ "412", "585.6", "403.91", "276.2", "311", "250.62", "327.23", "996.74", "730.07", "038.40", "995.92", "427.89", "536.3", "414.01", "348.30", "440.24", "V45.11", "785.52", "276.7", "453.8", "250.72" ]	icd9cm	[ [ [] ] ]	[ "88.48", "38.93", "39.95", "84.15" ]	icd9pcs	[ [ [] ] ]	14028, 14037	5963, 13387	284, 332	14088, 14097	3010, 4462	14153, 14320	2342, 2510		13996, 14005		14058, 14067		13413, 13973				14121, 14130									2525, 2991							5510, 5940																			230, 246							360, 1479		4471, 5466																1501, 2166	2182, 2326
60,984	128,183	3210	Discharge summary	report	Admission Date: [2114-1-8] Discharge Date: [2114-1-16] Date of Birth: [2048-11-20] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor Last Name 15044] Chief Complaint: Lightheadedness, dizziness, intermittent word-finding difficulties Major Surgical or Invasive Procedure: Left Parietal Craniotomy Lumbar Puncture History of Present Illness: HPI: The patient is a 65 year old right handed man with a history of CAD s/p Cypher stent to OM1 [1-14], hypertension, and bilateral renal cysts (largest 5.4 x 5.3 cm in the right kidney) who presents with 2 months of dizziness initially described as imbalance and lightheadedness upon standing in the setting of tapering off Effexor and later described as vertigo upon looking up or down, who now presents with 2 episodes of difficulty getting his words out who was found to have a left parietal IPH. The patient reports that over the past 2 months he has had dizziness described as imbalance in the setting of tapering off Effexor (per the patient's request to discontinue this medication). He said this was initially a constant sensation, and then ressolved. He also noticed lightheadedness when getting out of his car or going from sitting to standing. He had a similar bout of dizziness 1.5 years prior. He later noticed that when he would look up or down (but not turn his head in a specific direction), he would get vertigo lasting 15-20 seconds. He also noticed a buzzing sound in his head, but this was not unilateral in his ears. He denied weakness, numbness, diplopia, dysarthria, or dysphagia. He was evaluated by his PCP [Last Name (NamePattern4) ] [2113-9-15] and was found to be orthostatic on exam at that time (laying 147/75, standing 113/68). He returned to his PCP [Last Name (NamePattern4) ] [2113-11-15] for tinnitus and vertigo when moving his head "from front to back". He had stopped his Flomax because of these symptoms, and his Effexor continued to be tapered. The patient was referred to ENT. Auditory testing was normal, but ENG showed BPPV with a positive [Last Name (un) ] Hallpike to the right. He reports that he did not do the Epley maneuver at home. Then last Wednesday (5 days prior), he was talking on the phone to his son when driving to work and had the sudden onset of "not getting my thoughts togther" and "couldn't get my words out." He denied any paraphasias, but reported that he felt "in a fog". His son noticed that he wasn't speaking normally. This lasted for 1 hour. When thinking further, he remembers that within the past 2 months he had another similar episode at work when talking to the U.K. He wanted to say something and couldn't get the words out or get his thoughts together. This lasted approximately 1 hour and then ressolved. On ROS, in addition to above, he denies any shaking of his arms or legs, urinary or stool incontinence, or foul tastes/smells. He denies any headaches. He denies any weight loss or night sweats, but has been fatigued recently. He reports a normal colonoscopy in the past 4-5 months. Past Medical History: CAD s/p Cypher stent to OM1 [1-14] Hypertension-per his PCP's records, but the patient denies this diagnosis Hyperlipidemia BPH BPPV Allergic rhinitis Bilateral renal cysts, largest 5.4 x 5.3 cm in the right kidney Anxiety Social History: The patient works as an accountant and lives at home with his wife. [Name (NI) ] denies cigarette use ever, drinks "seldom" EtOH but does not quantify it more than that, and denies illicit drug use including cocaine and heroin. Family History: Father with MI at age 63. There is no family history of stroke or seizure. Physical Exam: VS: temp 97.8, bp 151/48->104/63, HR 55, RR 18, SaO2 100% on RA Genl: Awake, alert, NAD HEENT: Sclerae anicteric, no conjunctival injection, oropharynx clear CV: Regular rate but distant heart sounds, Nl S1, S2, no murmurs, rubs, or gallops Chest: CTA bilaterally anteriorly and laterally, no wheezes, rhonchi, rales Abd: +BS, soft, NTND abdomen Neurologic examination: Mental status: Awake and alert, cooperative with exam, anxious and intermittently tearful during the exam. Initially has some word finding difficulties but think this is due to his anxiety and stress about the possible diagnoses (when asked when his colonoscopy was he says "[3-12]..." and then becomes scared that he cannot remember the time period, but is able to say "what is happening to me, why can't I get my words out?") Oriented to person, place, and date. Inattentive, says [Doctor Last Name 1841] backwards to [Month (only) 216] then perseverates on [Month (only) 216] and says he can't complete the task. Speech is fluent with normal repetition; naming intact to all stroke scale objects except hammock. No dysarthria. [Location (un) ] intact. Registers [2-7], recalls [12-10] in 5 minutes but [1-10] with prompting. No right-left confusion. No evidence of apraxia or neglect. Cranial Nerves: Fundoscopic examination reveals sharp but small disc margins bilaterally. Left pupil 2->1 mm, right pupil 1->0.5 mm. Visual fields are full to confrontation. Extraocular movements intact bilaterally without nystagmus. Sensation intact V1-V3. Slightly decreased left mouth crease when smiling, but no flattening of the NLF. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline, movements intact. Motor: Normal tone in bilateral UE, slightly increased tone in bilateral LE. No observed myoclonus, asterixis, or tremor. No pronator drift. [Doctor First Name ] Tri [Hospital1 ] WE FE FF IP H Q DF PF TE R 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to pinprick and position sense throughout. No extinction to DSS. Reflexes: 2+ in left biceps and brachioradialis, 3+ on the right. 2+ and symmetric in triceps and ankles, 3+ and symmetric in knees. Toes downgoing bilaterally. Coordination: Finger-nose-finger, finger-to-nose, fine finger movements, and [Doctor First Name ] normal. Gait: Narrow based, steady. Romberg negative. Pertinent Results: Blood Tests on Admission: [2114-1-8] 10:15AM BLOOD WBC-6.5 RBC-5.08 Hgb-15.3 Hct-45.6 MCV-90 MCH-30.2 MCHC-33.7 RDW-13.1 Plt Ct-214 [2114-1-8] 10:15AM BLOOD Neuts-63.6 Lymphs-24.2 Monos-7.1 Eos-4.7* Baso-0.4 [2114-1-8] 12:49PM BLOOD PT-11.6 PTT-25.8 INR(PT)-1.0 [2114-1-8] 10:15AM BLOOD Glucose-121* UreaN-16 Creat-1.2 Na-143 K-3.9 Cl-105 HCO3-30 AnGap-12 [2114-1-8] 10:15AM BLOOD CK(CPK)-140 [2114-1-8] 10:15AM BLOOD CK-MB-3 [2114-1-8] 10:15AM BLOOD cTropnT-<0.01 [2114-1-9] 05:15AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2114-1-8] 10:15AM BLOOD Calcium-9.8 Phos-3.4 Mg-2.1 [2114-1-9] 05:15AM BLOOD %HbA1c-6.0* eAG-126* [2114-1-9] 05:15AM BLOOD Triglyc-59 HDL-48 CHOL/HD-2.9 LDLcalc-78 [2114-1-8] 10:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Urine Tests on Admission: [2114-1-8] 11:45AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.017 [2114-1-8] 11:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2114-1-8] 03:04PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG CSF Tests: [2114-1-10] 04:30PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0 Lymphs-48 Monos-52 [2114-1-10] 04:30PM CEREBROSPINAL FLUID (CSF) TotProt-42 Glucose-71 LD(LDH)-19 Misc-PND [2114-1-10] 04:30PM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL GRAM STAIN (Final [2114-1-10]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count. CRYPTOCOCCAL ANTIGEN (Final [2114-1-10]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Performed by latex agglutination. Results should be evaluated in light of culture results and clinical presentation. FLUID CULTURE -NO GROWTH. FUNGAL CULTURE - No growth. POTASSIUM HYDROXIDE PREPARATION -no growth [2114-1-10] CSF Cytology: Pending [2114-1-10] CSF CEA: Pending [2114-1-10] CSF VDRL: Pending [2114-1-10] CSF beta-2-microglobulin: normal [2114-1-8] EEG: This is a normal extended routine EEG in the waking and drowsy states. There were no focal, lateralized, or epileptiform features noted. [2114-1-8] EKG: Sinus bradycardia. Normal tracing. Compared to the previous tracing of [2111-1-28] there is no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 59 182 90 [Telephone/Fax (2) 15045]4 [2114-1-8] CT Head without Contrast: Left parietal lesion, concerning for malignancy, with apparent hemorrhagic components. An MR is recommended if further evaluation is desired. [2114-1-8] MRI Head, MRA Head & Neck: 1. Enhancing mass centered in the left parietal lobe, with surrounding FLAIR hyperintensity and extensive local infiltration. The most likely diagnosis is a high grade glial-based tumor, such as glioblastome multiforme. Other neoplastic processes, such as metastatic disease and lymphoma are considered less likely given the extensive infiltrative behavior. Similarly, tumefactive multiple sclerosis/demyelination or an area of infection are highly unlikely, again due to the infiltrative pattern. 2. Normal MRA of the head and neck without evidence of hemodynamically significant stenosis, dissection or aneurysm. [2114-1-9] CT Chest/Abdomen/Pelvis: 1. No definite findings of malignancy in the chest, abdomen, or pelvis. 2. Tiny lung nodules, some of which were not definitely visualized on prior images, which were degraded by respiratory motion. At least one, however, is not changed from [2110]. 3. Multiple renal hypodensities, many too small to accurately characterize but not substantially changed compared to [2112-10-5] MRI, and the largest representing cysts, without abnormal enhancing focus seen on the current study. 4. Coronary artery calcifications. Aberrant origin of RCA is not evaluated on this non-gated study (reported on prior CTA coronary arteries of [2111-3-2]). 5. Sigmoid diverticula, without inflammatory change. 6. Prostatic enlargement. [2114-1-11] fMRI: Successful functional MRI of the brain, demonstrating the expected activation areas during the different algorithms, few areas of activation are demonstrated adjacent to the left parietal mass lesion. During the movement of the right foot, right hand and also during the movement of the tongue, the areas with high signal within the mass lesion, possibly represent venous contamination, however clinical correlation is needed. Apparently, the dominance for the language is located at the left cerebral hemisphere. [2114-1-12] CT head Preoperative WAND study for left parietal mass, likely high-grade glioma. [2114-1-12] MR [First Name (Titles) ] [Last Name (Titles) ] op Preoperative WAND study for left parietal mass, likely high-grade glioma. [2114-1-12] CT head IMPRESSIONS: 1. Gas as well as curvilinear high density is seen within the right parietal resection bed as well as slightly more anteroinferiorly along the left temporoparietal region. Some of the high density within the resection bed may represent [Month/Day/Year ]-existing blood products in addition to perhaps some new blood products. Overall, surrounding edema and sulcal effacement is not changed. 2. Expected post-operative findings after left parietal mass resection and left parietal craniotomy. [2114-1-13] MR [First Name (Titles) ] [Last Name (Titles) 15046] sequela with limited evaluation of the operative bed due to presence of T1 hyperintense blood products. Stable probable infiltrative neoplasm in the left parietal lobe, thalamus, and splenium of the corpus callosum which does not enhance. Pathology [2114-1-12] Brain tumor frozen section Report not finalized. Assigned Pathologist [Last Name (LF) ],[First Name3 (LF) 488] P. Please contact the pathology department, [Name (NI) ] [Numeric Identifier 1434] PATHOLOGY # [Numeric Identifier 15047] FS left parietal tumor, Brief Hospital Course: Hospital course on Neurology The patient is a 65 year old male who presented with lightheadedness, vertigo, and intermittent word-finding difficulties. Imaging revealed a left parietal bleed and suggested an underlying mass, likely high-grade glioma. CT torso did not reveal other neoplasms. EEG was normal but the patient was started on keppra for seizure prophylaxis given his risk for seizures with the bleed and mass. Neuro-oncology and neurosurgery were consulted, and recommended resection of the lesion. Prior to resection, LP was done by neuro-oncology. Functional MRI was done for [Numeric Identifier ]-operative planning given concern that the lesion could be near the language area, but suggested it was infact more near the region of the right foot and possibly the tongue. On [2114-1-12], the patient was to neurosurgery and undwerwent a left parietal craniotomy for tumor. He was transfered to the ICU post-operatively and then back to neurology floor. He was closely followed by brain tumor team (Dr. [Last Name (STitle) 724], Dr. [First Name (STitle) ] and Dr. [Last Name (STitle) 3929] from radiation oncology) and their recs were followed. the prelim bipsoy results showed malignant glioma but the final result was still pending. Aspirin and Plavix were held on admission due to the intraparenchymal bleeding and in preparation for neurosurgery. Given his cardiac stent, post-operatively these medications were started as per discussion with neurosurgery team. He was on steroids during hospital stay which were continued in dose of dexamethasone 1 mg TID even after discharge. He was started on keppra 750 [Hospital1 ] which was increased to 1000 mg [Hospital1 ] at discharge for prophylaxis for seizures. He was seen and evaluated by PT/OT/Speech therapy and frequently followed upon. It was decided to discharge home with home PT/Speech/ and OT therapy. His physical exam during hopsital course was assesed frequently and it did show gradual but definitive improvement. At DC, the neuro exam was notable for conduction aphasia but no other motor sensory deficits. Medications on Admission: Atenolol 25 mg daily ASA 325 mg daily Plavix 75 mg daily Fluticasone 50 mcg, 2 sprays NU daily Nitroglycerin 0.3 mg prn chest pain Simvastatin 20 mg daily MVI daily Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:30 Capsule(s) Refills:2 6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. 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 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. Disp:30 Tablet(s) Refills:0 12. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for dry eyes. Disp:2 2 Refills:0 13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual Q5min as needed for chest pain: Take prn chest pain, please call 911 or PCP if concerns. 14. Outpatient Speech/Swallowing Therapy 15. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO three times a day: script already printed. 16. Fioricet 50-325-40 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: script already printed. Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Left Parietal Tumor 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 word finding difficulty and found to have a brain tumor in Left parietal area with partial resection on [2114-1-12]. You would be following with Brain tumor clinic on [1-29], at 4 pm, at [Hospital Ward Name 23] 8 , [Hospital Ward Name 516]. Please follow up with outpatient PT/OT/speech therapy recs. General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may shower using shampoo starting [2114-1-19], keep you wound dry until that time. ?????? 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. ?????? Dr. [First Name (STitle) ] has approved for you to start Aspirin and Plavix at one month post-op. 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, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please call Neurosurgery at([Telephone/Fax (1) 88] for any wound issues. - You have a Brain [Hospital 341] Clinic Appointment on [2114-3-29] at 4p Provider: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD Phone:[Telephone/Fax (1) 1844] Date/Time:[2114-1-29] 4:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 15048], MD Phone:[Telephone/Fax (1) 9347] Date/Time:[2114-3-9] 8:00	[ "401.9", "780.39", "386.11", "V45.82", "600.00", "477.9", "593.2", "414.01", "191.3", "518.89", "784.3", "272.4", "431", "300.4" ]	icd9cm	[ [ [] ] ]	[ "03.31", "01.59", "93.59" ]	icd9pcs	[ [ [] ] ]	16514, 16569	12473, 14599	384, 427	16633, 16633	6286, 6298	18391, 18902	3670, 3747		14815, 16491		16590, 16612		14625, 14792				16778, 18368									3762, 4109																										278, 346							455, 3153	5070, 6267								7137, 12450		16647, 16754				4133, 4133			3175, 3404	3420, 3654
11,464	171,574	44578	Discharge summary	report	Admission Date: [2132-10-30] Discharge Date: [2132-11-7] Service: ACOVE Medicine HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old gentleman with a past medical history significant for coronary artery disease (status post coronary artery bypass graft), diverticulosis, and prostate cancer (status post radiation therapy) who presented with [Hospital3 672] Hospital complaining of some bright red blood per rectum. On the evening prior to admission, the patient was noted to have approximately 600 cc of bright red blood in his diaper. He was then transferred to the Emergency Department for further evaluation. The patient denied any abdominal pain, dizziness, chest pain, shortness of breath, or other complaints. He denied any previous occurrence of rectal bleeding. REVIEW OF SYSTEMS: The patient complained of a mild headache which he has had for several weeks. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post coronary artery bypass graft. 2. Hypertension. 3. Gout. 4. Prostate cancer. 5. Status post brachy therapy. 6. Diverticulosis. 7. Diverticulitis. 8. Methicillin-resistant Staphylococcus aureus. 9. Percutaneous endoscopic gastrostomy tube placement. MEDICATIONS ON ADMISSION: 1. Levaquin 250 mg by mouth once per day. 2. Prednisone 60 mg by mouth once per day. 3. Captopril 6.25 mg by mouth three times per day. 4. Protonix 40 mg by mouth once per day. 5. Lopressor 25 mg by mouth twice per day. 6. Aspirin. 7. Colace. 8. Multivitamin one tablet by mouth once per day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a resident at [Hospital6 18042]. He has a legal guardian who is a neighbor. [Name (NI) ] denies any current use of alcohol or tobacco. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed vital signs which included a temperature of 97.1 degrees Fahrenheit, his heart rate was 86, his blood pressure was 140/72, his respiratory rate was 18, and his oxygen saturation was 99% on 2 liters. In general, the patient was a cachectic-appearing gentleman in no acute distress. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Extraocular movements were intact. The sclerae were anicteric. The neck was supple. No jugular venous distention. The lungs were clear to auscultation bilaterally. Cardiovascular examination revealed tachycardia. A regular rhythm. Normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. The abdominal examination revealed positive bowel sounds. The abdomen was soft, nontender, and nondistended. Extremity examination revealed the extremities were warm and dry. No edema. There was a pressure sore on the right heel. Neurologic examination revealed the patient was alert and oriented times three. No focal deficits. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. GASTROINTESTINAL BLEED ISSUES: The patient was admitted with complaints of rectal bleeding with a blood loss of approximately 600 cc. In the Emergency Department, he had another episode of rectal bleeding of approximately 100 cc. The patient received a total of 5 units of packed red blood cells to maintain his hematocrit levels of greater than 30. He was evaluated by Gastroenterology. He had an upper endoscopy which was significant only for mild gastritis. He then had a colonoscopy which showed a fungating rectal mass thought to be the etiology of his bleeding. His hematocrit remained stable, and he did not have any further active bleeding. The Surgical Service also evaluated the patient and felt that the bleeding component of his rectal mass was consistent with radiation prostatitis. They recommended followup with Gastroenterology for Argon laser treatment should the bleeding recur. 2. RECTAL MASS ISSUES: The patient was found to have a fungating rectal mass on colonoscopy. There was concern for recurrence of his prostate cancer (although his prostate-specific antigen was normal) versus a rectal carcinoma primary. Pathology of the mass was sent; however, it was not diagnostic showing cellular atypia consistent with radiation damage. The patient had a transrectal ultrasound which showed evidence of recurrent prostate cancer with invasion into the right anterior wall of the rectum. The patient was referred to Dr. [Last Name (STitle) ] in Oncology for further evaluation and was given an appointment for the week following discharge. 3. CONGESTIVE HEART FAILURE ISSUES: Congestive heart failure with an ejection fraction of 20%. The patient's cardiac medications were initially held upon admission given his gastrointestinal bleeding and concern for hypotension. The patient had an episode of flash pulmonary edema which did respond well to Lasix, nitroglycerin, and hydralazine. The patient was then restarted on his beta blocker and ACE inhibitor in addition to intravenous Lasix. His symptoms improved with this regimen. He was then stabilized on the beta blocker and ACE inhibitor and was taken off the Lasix. The plan was to monitor him as an outpatient, and should he begin to develop symptoms of fluid overload, he should be restarted on his daily dose of Lasix. 4. CHRONIC RENAL INSUFFICIENCY ISSUES: The patient with baseline renal insufficiency with a baseline creatinine ranging from 1.4 to 1.5. His creatinine on admission was 1.4. With diuresis his creatinine did initially trend up and then normalized to his bowel sound value without any further intervention. 5. GASTROINTESTINAL ISSUES: The patient with a history of multiple failed swallowing studies. He had a percutaneous endoscopic gastrostomy tube placed and had been nothing by mouth for approximately four months. The patient was re-evaluated with a Speech and Swallow study and did pass the video swallow study. At this point, he was restarted on a diet of pureed foods and thick liquids. He was also continued on his tube feeds; although the rate was lowered to 30 cc per hour to maintain adequate nutrition. 6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was maintained on tube feeds with by mouth supplementation as above. He was encouraged to consume Boost shakes. His electrolytes were followed and repleted as needed throughout his hospitalization. 7. URINARY TRACT INFECTION ISSUES: The patient's urine grew out Klebsiella of two morphologies which were sensitive to multiple cephalosporins. The patient had initially been on Levaquin and Flagyl and was then transitioned over to a by mouth cephalosporin when the sensitivities came back. His leukocytosis resolved with antibiotic therapy. On antibiotics for a total of seven days of treatment for this complicated urinary tract infection. 8. RIGHT HEEL ULCER ISSUES: The patient with a chronic pressure sore on his right heel. The patient was evaluated by the Plastic Service who recommended bacitracin ointment to keep the wound moist and keeping the wound open. He also was prescribed a pressure boot which was to be kept on his right foot at all times to minimize the risk of pressure to the ulcer. They did not recommend any further intervention at this time. 9. PROPHYLAXIS ISSUES: The patient was maintained on a proton pump inhibitor for gastrointestinal prophylaxis and pneumatic compression boots for deep venous thrombosis prophylaxis throughout his hospitalization. 10. CODE STATUS ISSUES: The patient was full code. His legal guardian did consent him for all procedures. 11. HEADACHE ISSUES: The patient was admitted with a history of headaches. He had been evaluated as an outpatient by Rheumatology for a question of temporal arteritis. His temporal artery biopsy did come back negative. He had been empirically started on prednisone, but given the negative biopsy, he was then tapered off the prednisone. His prednisone taper was to continue following discharge. His headache were well controlled with Tylenol during his hospitalization and were thought to be tension related. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge status was to nursing home. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed. 2. Rectal mass. 3. History of prostate cancer. 4. Prostatitis; status post radiation therapy. 5. Mild gastritis. 6. Congestive heart failure. 7. Impaired swallowing function. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Multivitamin liquid 5 mL by mouth once per day. 2. Lansoprazole extended-release liquid 30 mg by mouth every day. 3. Bacitracin ointment applied to right heel twice per day. 4. Tylenol elixir 650 mg by mouth q.4-6h. as needed. 5. Percocet elixir 5 mL to 10 mL by mouth q.4-6h. (please give prior to physical therapy). 6. Cefpodoxime 200 mg by mouth q.12h. (times seven days). 7. Metoprolol 25 mg by mouth three times per day. 8. Lisinopril 5 mg by mouth once per day. 9. Ativan 0.5 mg by mouth q.4h. as needed (for anxiety). 10. Prednisone taper 20 mg by mouth once per day times four days; then 10 mg by mouth once per day times four days; then 5 mg by mouth once per day times four days; then stop. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up his primary care physician in one to two weeks. 2. The patient was instructed to follow up with Dr. [Last Name (STitle) ] in Oncology; appointment on [11-18] at 10 a.m. The patient was call prior to scheduled appointment to confirm. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1211], M.D. [MD Number(1) 1212] Dictated By:[MD Number(1) 39417] MEDQUIST36 D: [2132-11-7] 10:51 T: [2132-11-7] 10:55 JOB#: [Job Number 95462]	[ "599.0", "593.9", "601.8", "401.9", "535.50", "707.0", "428.0", "185", "578.9" ]	icd9cm	[ [ [] ] ]	[ "45.25", "38.93", "45.13", "96.6" ]	icd9pcs	[ [ [] ] ]								8192, 8402				8429, 9186	1251, 1591						9219, 9776																					2915, 8062		8077, 8171					826, 905												130, 806																		927, 1225	1608, 2880
53,554	191,260	36943	Discharge summary	report	Admission Date: [2124-6-26] Discharge Date: [2124-6-28] Date of Birth: [2055-8-20] Sex: F Service: MEDICINE Allergies: Vancomycin Attending:[First Name3 (LF) 1973] Chief Complaint: Pain and bleeding at site of R AV fistula Major Surgical or Invasive Procedure: Hemodialysis catheter placement Left IJ placement Arterial Line Placement History of Present Illness: 68 yof with ESRD unknown etiology, COPD on chronic steroids, who presents after bleeding from AV fistula followed by hypotension, altered mental status. Friday [6-23] she had uneventful dialysis. Saturday evening [6-24] she was nauseated, vomited x 1. Sunday [6-25] spent mostly in bed with generalized malaise. In afternoon got up, noted her AV fistula to have a "black spot" that "looked infected" so she put an antibiotic-impregnated bandaid on it. It began to ooze blood, and a concerned neighbor called 911. At [Hospital3 26615] Hospital, after a nurse [First Name (Titles) 83353] [Last Name (Titles) 83354] fistula, it opened into an arterial bleed through which she lost 150-400cc of blood. Bleed was controlled with sutures and surgicel. Her BP dropped from 125/79 to 80/60. She received 1 liter NS, and a dose of Vancomycin IV which caused a red rash, treated with Benadryl. Vanc was discontinued and she was given Ancef IV and transferred to [Hospital1 18] ED. On arrival to our emergency department her vitals were T: 99.7 BP: 84/52 HR: 88 RR: 18 O2: 99% on RA. The fistula site demonstrated a palpable thrill, no erythema, the suture site was clean and dry. Her K+ was 6.8 with peaked T waves on EKG, her SBPs drifted into the 70s and her mental status declined. She received 4 L NS, calcium gluconate 2 gram IV x 1, 1 amp D50, 10 units regular insulin SC, 1 amp bicarbonate IV, Zosyn 4.5 grams IV x 1 and was started on Levophed. Nephrology was contact[Name (NI) ] for urgent dialysis evaluation. Left IJ placed for access after failed attempt at right IJ. She was admitted to the MICU. In the MICU she received 5 liters IVF, was weaned off of Levophed 12 hours after arrival. Past Medical History: - End stage renal disease on hemodialysis for two years - Coronary artery disease (recent catheterization with normal coronary arteries) - Diastolic heart failure (EF on recent catheterization 60%) - COPD (on 2L home oxygen at night) Social History: Previous 40 pack year history but quit 4 months ago. No alcohol or illict drug use. Lives by herself. Family History: Strong family history of CAD in father and brother. Physical Exam: Discharge Physical Exam: Vitals: T: 98.5 BP: 110/70 P: 98 R: 19 O2: 91% on RA General: Somnolent, oriented x 3, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Scarce expiratory wheezes bilaterally, otherwise clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 + S2, II/VI SEM heard best at LUSB non-radiating Abdomen: Obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Left upper extremity fistula with dressing in place. 2 sutures in place. No pus or erythema. Palpable thrill present. Pertinent Results: Chemistries: [2124-6-25] 11:54PM GLUCOSE-98 UREA N-74* CREAT-10.5* SODIUM-140 POTASSIUM-6.8* CHLORIDE-100 TOTAL CO2-23 ANION GAP-24* [2124-6-26] 03:00AM GLUCOSE-71 UREA N-73* CREAT-10.3* SODIUM-142 POTASSIUM-5.7* CHLORIDE-102 TOTAL CO2-25 ANION GAP-21* [2124-6-26] 03:08AM LACTATE-0.6 [2124-6-26] 03:00AM CORTISOL-33.5* [2124-6-26] 03:00AM CK-MB-2 cTropnT-0.04* [2124-6-26] 03:00AM CK(CPK)-45 [2124-6-26] 06:27AM TYPE-ART PO2-64* PCO2-54* PH-7.24* TOTAL CO2-24 BASE XS--4 Hematology: [2124-6-25] 11:54PM WBC-9.6 RBC-2.74* HGB-9.5* HCT-28.6* MCV-104* MCH-34.9* MCHC-33.4 RDW-16.8* [2124-6-25] 11:54PM PLT COUNT-157 [2124-6-25] 11:54PM PT-13.2 PTT-24.3 INR(PT)-1.1 Urine Studies: [2124-6-26] 01:15AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 RENAL EPI-0-2 [2124-6-26] 01:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2124-6-26] 01:15AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.010 Right Upper Extremity Ultrasound [2124-6-26]: By report, the patient has a fistula, which is patent on color Doppler examination. Surrounding the fistula, there is hypoechoic material which likely represents a hematoma surrounding the vessel and less likely a pseudoaneurysm with thrombosis. This area measures approximately 1.4 x 1.2 x 1.1 cm. Son[Name (NI) 493] exam over this region did prompt bleeding through the skin at which time the exam was terminated and dressing applied by the patient's nurse. CXR Portable [2124-6-26]: Cardiac silhouette is mildly enlarged. There is no focal consolidation. There are increased interstitial opacities consistent with fluid overload. There is no definite focal consolidation or pneumothorax. The osseous structures are grossly unremarkable. EKG: normal sinus rhythm, normal axis, normal intervals, no st segment elevation or depression, small amount of peaked twaves. Brief Hospital Course: 68 yof with ESRD unknown etiology, COPD on chronic steroids, who presents after bleeding from AV fistula followed by hypotension, altered mental status. On the medicine floor, she was alert and cheerful, with family in the room. # Hemorrhagic Shock Due to Acute Blood Loss Anemia due to Fistula Bleeding: - Differential considerations include septic shock given prodromal illness, possibly from site of AV fistula and possibly [1-24] her chronic steroid dosing; adrenal insufficiency [1-24] chronic steroid use; and hypovolemic shock [1-24] hemorrhage. Blood and urine cxs were sent and remain negative. In the ICU she received stress-dose steroid boluses, a dose of IV Zosyn. She rapidly improved and when she arrived on the medical floors was stable clinically. She was observed with no recurrence of hypotension. # Stage V Chronic Kidney Disease: Given the bleed the AV fistula could not be used. A tunneled hemodialysis catheter was placed in the L subclavian, and she had hemodialysis the morning of her discharge. # Hyperkalemia: Resolved after Calcium, D50, Insulin treatments. Of note she had dialysis while here. # Acute Blood Loss Anemia, Anemia of ESRD: Hct stablized at 25.5. Likely a mix of dilutional anemia (she received 9+ L NS in past 2 days), blood loss from fistula bleed, and chronic anemia of ESRD. - follow Hct as outpatient # COPD: On 2L home oxygen at night. No history of intubations. Uses CPAP overnight for OSA Medications on Admission: Aspirin 81 mg daily Bupropion 100 mg [Hospital1 ] Omeprazole 20 mg [Hospital1 ] Albuterol PRN Metoprolol 12.5 mg [Hospital1 ] Lasix 40 mg daily Simvastatin 40 mg daily Nephrocaps daily Gemfibrozil 600 mg [Hospital1 ] Prednisone 10 mg daily Tums 1 mg Po daily Lisinopril 2.5 mg PO daily Renagel 800 mg PO TID Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID ON NON-DIALYSIS DAYS (TU TH SA [Doctor First Name ]) (). 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY ON NON-DIALYSIS DAYS (TU TH SA [Doctor First Name ]) (). 7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [12-24] Puffs Inhalation Q6H (every 6 hours). 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Bleeding from AV fistula Hyperkalemia Hypovolemic hypotension Secondary diagnoses: - End stage renal disease, unknown etiology, on hemodialysis for two years - Coronary artery disease (recent catheterization with normal coronary arteries) - Diastolic heart failure (EF on recent catheterization 60%) - COPD (on 2L home oxygen at night) - Obstructive sleep apnea (uses CPAP at home at night) Discharge Condition: Afebrile, vital signs stable within normal limits, ambulating, tolerating PO, alert & oriented. Discharge Instructions: You were admitted to [Hospital1 ] from the [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] hospital, after you had a bleed from your AV fistula site, followed by a drop in blood pressure and a change in your mental status. At [Hospital1 18] you were determined to meet criteria for shock from either blood loss, infection or both, and were managed for a day in the Intensive Care Unit (ICU). After the ICU you were released to a medicine floor where you had a new temporary tunneled dialysis catheter placed, had dialysis, and were discharged home. No changes were made to your medications. If you should feel ill, lightheaded, dizzy, have chest pain or trouble breathing or renewed bleeding at your AV fistula, or have any other medically concerning symptoms, please call your doctor or 911 or go to the emergency room. Followup Instructions: Please call your cardiologist, Dr. [Last Name (STitle) 83355] [Name (STitle) 77919], Thursday morning to confirm your appointment with him. Telephone [Telephone/Fax (1) 65733]. You should also call on Thursday, [6-28], to make an appointment to see your primary care provider, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Telephone/Fax (1) 70836], to discuss this hospitalization. Completed by:[2124-6-30]	[ "496", "585.6", "V58.65", "276.7", "285.1", "785.59", "996.73", "428.32", "428.0", "414.01", "E878.2" ]	icd9cm	[ [ [] ] ]	[ "38.93", "39.95", "38.95", "93.90" ]	icd9pcs	[ [ [] ] ]	8546, 8552	5384, 6843	314, 389	9007, 9104	3378, 5361	10001, 10489	2539, 2593		7218, 8523		8573, 8655		6869, 7195				9128, 9978									2608, 2608			8676, 8986																							232, 276							417, 2143																		2165, 2401	2417, 2523				2633, 3359
44,340	162,687	48961	Discharge summary	report	Admission Date: [2188-7-19] Discharge Date: [2188-7-19] Date of Birth: [2108-10-5] Sex: F Service: NEUROSURGERY Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 1271] Chief Complaint: Unwitnessed fall Major Surgical or Invasive Procedure: None History of Present Illness: 79 y.o. female found down in them bathroom per family. Famly heard her fall down in the bathroom. It was unwitnessed fall. Unresponsive and intubated but per EMS was MAEs before arrival to [Hospital6 1597]. Head CT shows extensive SAH, [Doctor Last Name ] grade V, and likely a right MCA rupture with ICH. Neurosurgery consult for further management. Past Medical History: HTN, HLD Social History: unk Family History: NC Physical Exam: O: T: af BP: 166/100 HR:60 R 12 O2Sats 1005 Gen: intubated, chemically paralyzed HEENT: atraumatic, eyes: clear Pupils: blown bilaterally Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: intubated Pupils fixed and dilated at 6mm, No corneals, no gag reflex No movement to noxious stimuli Grade V [Doctor Last Name ], HH 5 On Discharge: Expired Pertinent Results: CT HEad from [Hospital6 2561] massive intracranial SAH bilaterally right greater than left with right SDH, and right temporal ICH likely consistent with right MCA rupture. There is global cerebral edema with right to left shift 1cm. There is compressionon midbrain throughout. brainstem appear hypodense consistent with infarct. There is trapping of right ventricle with impending hydrocephalus Brief Hospital Course: Patient presented to [Hospital1 18] from [Hospital6 ] after found to have severe intracranial hemorrhage. Patient was seen and examined in the ED and due to imaging findings and physical exam withdrawl of care was discussed with the family. The decision was made to make the patient DNR/DNI but to admit to Neuro ICU while awaiting other family members prior to extubation and making patient CMO. Once all family arrived, the patient was extubated and passed away peacefully soon after with her family at her bedside. Medications on Admission: unk Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Subdural hematoma Subarachnoid Hemorrhage Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2188-7-19]	[ "432.1", "V49.86", "348.5", "401.9", "780.01", "430", "272.4", "780.65" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	2282, 2291	1672, 2199	307, 314	2377, 2387	1248, 1649	2443, 2577	775, 779		2253, 2259		2312, 2356		2225, 2230				2411, 2420									794, 1206																	1220, 1229									251, 269							342, 706																		728, 738	754, 759
12,356	197,566	28829	Discharge summary	report	Admission Date: [2182-7-29] Discharge Date: [2182-8-5] Service: MEDICINE Allergies: Amlodipine / Diltiazem / Dilantin Attending:[First Name3 (LF) 30] Chief Complaint: infrarenal AAA Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 82 year old female with history of CHF with preserved EF, HTN (left RAS), hx of CVA and seizure disorder,gout, moderate AS who was initially admitted to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] hospital on [2182-7-25] with chief complaint of DOE and SOB with initial workup revealing for enterococcus and Group B Strep UTI for which she was placed on levofloxacin. Blood cultures subsequently revealed [1-5]+ cultures for MRSA on [2182-7-27] prompting initiation of Vancomycin. However, her WBC increased from 16K to 33K on [2182-7-29] for which Ceftaz was started for broader coverage. . The patient began to complain of back and abdominal pain which prompted an abdominal CT. This revealed an infrarenal aneurysm 4 x 2 cm that was not present on an Abd CT in [2179] or renal U/S performed 3 weeks prior. . The patient was subsequently transferred to [Hospital1 18] for vascular evaluation. Past Medical History: CHF HTN AS CKD (baseline Cr 2.5, known L RAS) h/o CVA seizure d/o Gout s/p TAH/BSO s/p appy Social History: Unattainable from patient Family History: Unattainable from patient Physical Exam: Physical Exam on Transfer to Medicine Floor [2182-8-3]: . Tm/Tc: 100.7 HR: 89 (61-89) BP: 152/36 after hydral 10 mg IV; range is 152-187/36-47 (SBP mainly in 170s); RR: 22 ([8-27]); O2 sat 97% of __ L -exam limited by patient's continual vocalization - Gen: alert and oriented to person, "[2181]", [Hospital 86] Hospital; "my back hurts" "my hip hurts" HEENT: anicteric, proptotic-appearing when coughing CV: regular rhythm, normal rate, III/VI mid-peaking crescendo-decrescendo murmur appreciated throughout the precordium. Chest: limited exam Abd: soft, non-tender, poor ability to assess for organomegaly Ext: 2+ distal pulses, warm, well purfused, multiple eccymotic regions Neuro: alert and oriented to person, [2181], [Hospital 86] Hospital; poor concentration, unable to listen to 2 step questions or provide 2 step responses to questions. Pertinent Results: Pertinent Admission Labs: [2182-7-29] 05:24PM WBC-38.6* RBC-2.94* HGB-9.0* HCT-26.3* MCV-90 MCH-30.5 MCHC-34.1 RDW-15.6* [2182-7-29] 05:24PM GLUCOSE-117* UREA N-70* CREAT-2.4* SODIUM-131* POTASSIUM-4.8 CHLORIDE-92* TOTAL CO2-25 ANION GAP-19 [2182-7-29] 05:24PM ALBUMIN-3.2* CALCIUM-7.9* PHOSPHATE-3.3 MAGNESIUM-3.1* [2182-7-29] 05:24PM ALT(SGPT)-19 AST(SGOT)-17 LD(LDH)-224 ALK PHOS-265* AMYLASE-35 TOT BILI-0.5 [2182-7-29] 05:24PM PT-14.1* PTT-26.9 INR(PT)-1.3* MRA ABDOMEN W&W/O CONTRAST [2182-7-29] 8:04 PM 1. Focal infrarenal aortic aneurysm with non-acute thrombus. Whether this is a true anurysm or the result of remote penetrating atherosclerotic ulcer is uncertain. 2. Right common iliac artery high-grade stenosis, with possible focal dissection. 3. High-grade celiac artery stenosis. 4. High grade left renal artery stenosis. 5. Incompletely-assessed cystic renal lesions. Dedicated renal MR imaging could be performed for optimal assessment. ECHO Study Date of [2182-7-30] The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%), without regional wall motion abnormalitiesl. Right ventricular chamber size and free wall motion are normal. There are three moderately thickened aortic valve leaflets. No masses or vegetations are seen on the aortic valve. There is moderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. CT PELVIS W/O CONTRAST [2182-7-31] 5:26 PM 1. Limited study without IV contrast. There is no bowel wall thickening, dilations or pneumatosis to suggest bowel ischemia at the current time. 2. Atherosclerosis of the abdominal aorta, with a saccular aneurysm at or just below the level of the renal arteries. The presence or absence of dissection cannot be assessed on this study, though the dimensions of the aorta do not appear significantly changed from the prior MRI of [7-29]. There is stranding surrounding the aneurysm of the aorta, raising the possibility of a mycotic aneurysm or vasculitis. 3. Small bilateral pleural effusions, right greater than left, and small free fluid in the pelvis. Mild subcutaneous edema. 4. Coronary artery calcifications. 4. Fullness of the left adrenal. 5. Multiple renal lesions, not fully characterized on this study. There is at least one hyperdense cyst. 6. Sigmoid diverticulosis. IN-111 WHITE BLOOD CELL STUDY [2182-7-31] No definite evidence for myocotic aneurysm in infra-renal abdominal aorta. CHEST (PORTABLE AP) [2182-8-4] 6:29 PM IMPRESSION: Probable lower lobe pneumonia with some failure. Brief Hospital Course: A/P: In summary, this is an 82 yo woman w/ h/o CHF, HTN, moderate AS who was transferred to [Hospital1 18] after initial treatment at an OSH for dyspnea, where she was found to be bactermic and found to have an new infrarenal AAA. Other medical problems that complicated this hosptialization included acute on chronic renal failure and delirium. . She was initially admitted to vascular surgery in the intensive care unit, subsequently transfered to the MICU, and called out to the medicine floor on [2182-8-3]. . AAA: The apparent development of the 4.5 cm AAA over a three week period was very concerning for high likelihood of rupture. Given her bacteremia, there was concern this might be a mycotic aneurysm, however the tagged WBC scan was negative. She was deemed a poor candidate for surgical intervention. Treatment focused on BP control . Bacteremia: Ms. [Known lastname 69602] was continued on vancomycin IV. Official TTE read was negative for endocarditis; though a prolonged course of vancomycin 4-6 weeks was planned given her known bactermia, AAA, and as a TEE was not performed. Given her rapidly changing renal function, daily Vancomycin levels were obtained to determine when to dose the vancomycin. . Acute on Chronic Renal Failure: Ms. [Known lastname 69602] had underlying chronic renal failure with a baseline of Cr of 2.5. Her Cr peaked during the hospital stay at 3.7. She was deemed not to be a hemodialysis candidate. The day prior to her death she was noted to be hypernatremic; her tube feed free water boluses were increased and she was started on D5W to replete her calculated free water deficit. Lasix was held given the concern of her renal function. . Respiratory: On the night of [8-4] to [8-5] Ms. [Known lastname 69602] was noted to have increased work of breathing which did not improve with nebs or respiratory suction. Her CXR earlier in the day demonstrated probable new lower lobe pneumonia with some failure; ABG revealed marked acidosis. She subsequently became hypotensive. As she was DNR/DNI, her health care proxy was [Name (NI) 653]; given her poor prognosis he declared her comfort measures only. Medications on Admission: isosorbide 120 mg daily atenolol 50 mg daily hydral 20 mg AM, 10 mg w dinner, 10 mg qHS tegretol 200 mg [Hospital1 ] lasix 40 mg alternating w/ 80 mg; one dose PO daily ecotrin 81 mg PO daily calcitrol 0.25 mcg daily evista 60 mg PO daily procrit 20,000 units q4-6 weeks cardura 1 mg qHS zyrtec Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased Completed by:[2182-8-6]	[ "486", "V09.0", "285.21", "790.7", "401.9", "440.1", "599.0", "441.4", "584.9", "276.0", "421.0", "780.39", "276.2", "585.9", "428.0", "274.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	7825, 7834	5259, 7443	253, 259	7886, 7896	2351, 2361	7953, 7991	1417, 1444		7792, 7802		7855, 7865		7469, 7769				7920, 7930									1459, 2332																										199, 215							287, 1243							2378, 5236											1265, 1358	1374, 1401
5,013	123,625	43540	Discharge summary	report	Admission Date: [2184-8-3] Discharge Date: [2184-8-11] Service: CARDIOTHORACIC Allergies: Verapamil Attending:[First Name3 (LF) 1505] Chief Complaint: worsening chest pain Major Surgical or Invasive Procedure: CABGx4(LIMA->LAD->, SVG->OM, Diag, PDA) [2184-8-5] History of Present Illness: CAD: cath showed LMCA, 95% lesions - CABG in [Name (NI) ] pt. to have echo, cxr, CT chest today - cont IV heparin, ASA, BB, Imdur, Statin - holding plavix as going for surgery - if CP recurs -> get EKG, page on call cards ([First Name8 (NamePattern2) ] [Doctor Last Name ]) for possible Balloon pump Past Medical History: CAD s/p PTCA of RCA [2171] Hyperlipidemia Hypertension Anemia Carotid Stenosis glaucoma Social History: quit tob 52 years ago no etoh Family History: NC Physical Exam: NAD 97.4 150/82 55 99/2L 83.9 kg HEENT no JVD Heart RRR, No murmurs Lungs CTAB Abd Benign Extrem no edema, dopplerable pulses Neuro grossly intact Pertinent Results: [2184-8-11] 05:36AM BLOOD WBC-10.5 RBC-3.29* Hgb-10.4* Hct-31.2* MCV-95 MCH-31.6 MCHC-33.3 RDW-14.9 Plt Ct-132* [2184-8-11] 05:36AM BLOOD Plt Ct-132* [2184-8-11] 05:36AM BLOOD PT-16.6* INR(PT)-1.5* [2184-8-11] 05:36AM BLOOD Creat-1.0 K-4.2 [2184-8-10] 06:40AM BLOOD Glucose-106* UreaN-30* Creat-1.1 Na-141 K-5.2* Cl-105 HCO3-33* AnGap-8 Brief Hospital Course: He was taken to the operating room on [2184-8-5] where he underwent a CABG x 4. He was transferred to the SICU in critical but stable condition on epinephrine, and propofol. He was extubated and weaned from his vasoactive drips on POD #2. He had some atrial fibrillation for which he was placed on an amiodarone drip and coumadin for goal INR of 1.5-2.0. He was transferred to the floor on POD # 4. He progressed well, he was seen by physical therpay who felt that he would benefit from rehab at discharge, he was ready for discharge on POD # 6. He has received 2 mg of coumadin on [8-8] and 4 mg on [8-9] and [8-10]. Medications on Admission: imdur, lopressor, asa, colace, plavix, zocor, norvasc, flomax, fish oil, MVI, SL NTG, cosopt, xalatan Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Zocor 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): Check INR [8-12]. 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400 mg [Hospital1 ] to [8-16], then 400 mg daily x 1 week, then 200 mg daily ongoing. 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Discharge Disposition: Extended Care Facility: [Hospital 24806] Care Center - [Hospital1 1562] Discharge Diagnosis: CAD PMH: CAD-s/p PTCA of RCA [2171], ^chol., HTN, anemia, carotid stenosis, glaucoma Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incisions, 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 heavy lifting or driving until follow up with surgeon. Followup Instructions: Please call for these appointments: Dr. [Last Name (STitle) ] 2 weeks Dr. [Last Name (STitle) 911] 2 weeks Dr. [Last Name (STitle) ] 4 weeks Already scheduled appointments: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 62] Date/Time:[2184-9-24] 11:00 [First Name11 (Name Pattern1) 198] [Last Name (NamePattern4) 199], M.D. Date/Time:[2184-10-6] 11:40 Completed by:[2184-8-11]	[ "401.9", "427.31", "414.01", "272.4", "412", "285.9", "794.31", "V45.82", "411.1", "997.1" ]	icd9cm	[ [ [] ] ]	[ "88.53", "36.15", "88.72", "88.56", "99.04", "36.13", "39.61", "99.07", "37.22", "38.93" ]	icd9pcs	[ [ [] ] ]	3511, 3593	1387, 2022	243, 300	3726, 3734	1006, 1364	4021, 4480	819, 823		2174, 3488		3614, 3705		2048, 2151				3758, 3998									838, 987																										183, 205							328, 641																		663, 756	772, 803
50,391	189,438	54425	Discharge summary	report	Admission Date: [2187-3-14] Discharge Date: [2187-3-24] Date of Birth: [2104-12-31] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5119] Chief Complaint: hyperglycemia Major Surgical or Invasive Procedure: Attempted nasogastric tube History of Present Illness: 82 F with DM; recent admissions over the last 3-4 months for ascending cholangitis s/p CBD stent placement, CCY tube, ?duodenal drain, and most recent [First Name3 (LF) ] [2-22]; now admit with hyperglycemia, hypernatremia, ARF. Patient lives in nursing home, demented at baseline, and was noted to have glucoses in 400s. Given 10 units regular at 4 pm and again at 6pm. Glucose continued to be > 400 at [Hospital1 1501] and thus sent to ED. . In the ED, initial vitals: could not get temp? - later T98.8, 91/58, 114, R 20, 99% RA. Initial glucose 497. Labs showed she was hemoconcentrated, hypernatremic, and with ARF. 10 units insulin SQ x 1 were given. Total of 3 L NS. HR improved into 80s - 90s, BP in 110s. For infectious workup CXR performed with no obvious pneumonia. Urine not yet sent. ECG pending. Access: 20g x 1. Past Medical History: Osteochondroma of L knee as a child Mitral Valve Prolapse Type II Diabetes Hypertension Alzheimer's disease Right ORIF of hip fracture at age 75 Social History: Not currently smoking, alcohol or illicit drug use. Lives in a nursing home. Full care for all of her activities of daily living. Daughter [Name (NI) 111407], ph: [Telephone/Fax (1) 111408] Family History: Daughter with arthritis, father died of hepatitis C from a blood transfusion. Mother died at age 86 of a myocardial infarction. Son with hypertension. Physical Exam: Physical Examination GEN: NAD HEENT: PERRL, EOMI, oral mucosa slightly dry, oropharynx benign NECK: Supple, no LAD CARD: RR, nl S1, nl S2, no M/R/G PULM: CTAB with no wheezes ABD: BS+, soft, NT, ND, no HSM, EXT: no C/C/E, DP 2+ bilaterally NEURO: Oriented to self and responsive to vocal commands Pertinent Results: [2187-3-15] 02:09AM BLOOD WBC-9.9 RBC-4.07* Hgb-11.5* Hct-36.2 MCV-89 MCH-28.3 MCHC-31.9 RDW-16.4* Plt Ct-153 [2187-3-14] 02:59AM BLOOD WBC-13.7* RBC-4.59 Hgb-12.8 Hct-41.3 MCV-90 MCH-27.8 MCHC-30.9* RDW-16.5* Plt Ct-196 [2187-3-13] 09:57PM BLOOD WBC-14.6# RBC-5.48# Hgb-15.5# Hct-49.5# MCV-90 MCH-28.2 MCHC-31.2 RDW-16.4 Plt Ct-232 [2187-3-13] 09:57PM BLOOD Neuts-85.7* Lymphs-9.3* Monos-3.1 Eos-1.5 Baso-0.3 [2187-3-15] 02:09AM BLOOD Plt Ct-153 PltClmp-1+ [2187-3-14] 02:59AM BLOOD Plt Ct-196 [2187-3-14] 02:59AM BLOOD PT-14.7* PTT-25.7 INR(PT)-1.3* [2187-3-15] 09:49AM BLOOD Glucose-207* UreaN-36* Creat-1.0 Na-156* K-4.1 Cl-129* HCO3-19* AnGap-12 [2187-3-15] 02:09AM BLOOD Glucose-61* UreaN-45* Creat-1.2* Na-158* K-3.6 Cl-130* HCO3-19* AnGap-13 [2187-3-14] 06:40PM BLOOD Glucose-208* UreaN-49* Creat-1.3* Na-158* K-3.5 Cl-128* HCO3-19* AnGap-15 [2187-3-14] 11:25AM BLOOD Glucose-92 UreaN-59* Creat-1.5* Na-167* K-4.1 Cl-138* HCO3-18* AnGap-15 [2187-3-14] 02:59AM BLOOD Glucose-339* UreaN-71* Creat-1.6* Na-163* K-3.4 Cl-132* HCO3-20* AnGap-14 [2187-3-13] 11:00PM BLOOD Glucose-502* UreaN-79* Creat-1.8* Na-162* K-4.2 Cl-129* HCO3-22 AnGap-15 [2187-3-15] 09:49AM BLOOD CK(CPK)-71 [2187-3-15] 02:09AM BLOOD ALT-12 AST-24 LD(LDH)-298* CK(CPK)-86 AlkPhos-90 TotBili-0.3 [2187-3-14] 06:40PM BLOOD CK(CPK)-111 [2187-3-14] 11:25AM BLOOD CK(CPK)-219* [2187-3-14] 02:59AM BLOOD ALT-16 AST-16 LD(LDH)-197 CK(CPK)-275* AlkPhos-110 TotBili-0.3 [2187-3-15] 09:49AM BLOOD CK-MB-NotDone cTropnT-0.39* [2187-3-15] 02:09AM BLOOD CK-MB-NotDone cTropnT-0.47* [2187-3-14] 06:40PM BLOOD CK-MB-7 cTropnT-0.44* [2187-3-14] 11:25AM BLOOD CK-MB-9 cTropnT-0.45* [2187-3-14] 02:59AM BLOOD CK-MB-9 cTropnT-0.49* [2187-3-15] 02:09AM BLOOD Albumin-2.4* Calcium-8.3* Phos-1.8* Mg-2.2 [2187-3-14] 06:40PM BLOOD Calcium-8.3* Phos-2.1* Mg-2.5 [2187-3-14] 11:25AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.8 [2187-3-14] 02:59AM BLOOD Albumin-2.9* Calcium-8.5 Phos-2.6* Mg-1.9 . Cultures: [3-13] Ucx: URINE CULTURE (Final [2187-3-15]): YEAST. >100,000 ORGANISMS/ML. [2187-3-15] C. Difficile toxin POSITIVE . Imaging: [3-13] CXR: No acute cardiopulmonary process . [3-14] Abd U/S: This study is markedly limited due to bowel gas which obscures visualization of multiple abdominal organs. The visualized portion of the right lobe of the liver demonstrates air in the biliary tree. The gallbladder is not visualized. There is an echogenic focus in the region of the gallbladder fossa which may represent air within the gallbladder lumen. Main portal vein is patent with hepatopetal flow. Right kidney measures approximately 9.4 cm. The lower pole of the right kidney is not visualized due to bowel gas. Left kidney measures 9.3 cm. Note is made of an anechoic cyst in the superior pole of the left kidney measuring approximately 3.1 cm. No evidence of hydronephrosis. Spleen is normal in contour and echotexture and measures 10 cm. Pancreas and aorta are not visualized due to bowel gas. Brief Hospital Course: 82F with PMH including DM (reportedly difficult to control/brittle), dementia, recent cholangitis/[Month/Day (4) ] discharged 2 weeks ago; now admit with lethargy and hyperglycemia at [Hospital1 1501] and multiple metabolic derangements. . # Hyperosmolar nonketotic hyperglycemia: Likely that the trigger was C. Diff infection as other infectious etiologies ruled out (blood cultures negative, urine culture with yeast only, CXR negative for PNA). Patient admitted signficantly dehydrated, her initial glucose was 509, she was given 30 units of insulin over 8 hours but her sugar persisted in the 400s. She was started on [12-15] of her glargine dose, and insulin sliding scale with humalog. By the day after admission her serum glucose ranged from 61 to mid-200s. On transfer to the floor she was on glargine 15QHS, humalog sliding scale and remained NPO. Once the patient was seen by speech and swallow she was able to take PO, her insulin was then titrated and she was discharged on a twice daily regimen: -glargine 22 units at dinnertime -AM and dinnertime sliding scale insulin with humalog -goal FSG is 100-300 . # Hypernatremia/Hypovolemia. Likely from dehydration and osmotic diuresis with elevated glucose. Her initial sodium was 163, then up to 167. She was given NS and then LR ( 6 liters in the first 24 hours) until she appeared clinically euvolemic. Then she was transitioned to d5W at 150 cc/hr and her sodium trended down to 156 on transfer to the floor . On the floor she was on d5W for free water replacement and LR while NPO. Patient eventally transitioned to PO and IVF d/c'd. While only on PO patient's sodium ranged from 141-146. -free water and total PO intake should be encouraged and carefully monitored. . # C. Difficile: Patient with increasing diarrhea, C. Diff sent and positive. Started on PO flagyl for 10 day course. Will extend the course of treatment so that the patient will be covered while on cefpodoxime for her ITU -continue PO flagyl through the end of her cefpodoxime course, [2187-3-31]. . # Acute Renal Failure: Admission creatinine 1.6 and this trended to 0.8-0.9 with IVF resuscitation. . # Positive Urinalysis: Positive UA as above. Recent abx exposure to cephalosporins, patient started on ceftriaxone 1 g daily. Urine culture only grew yeast so antibiotics were discontinued. On the day prior to discharge temperature 100.9, U/A with 11WBC. Foley was d/c'd and patient given 7 day course of cefpodoxime (has history of cipro and bactrim resistant E. Coli). . # Wounds: On admission, patient noted to have unstageable (but likely stage 3-4) sacral wound and bilateral heel deep tissue injury). Wound care consulted and recommendations followed. -Goals of wound care:Pressure redistribution. Protection and pressure redistribution of heels Wound care recommendations: - Pressure relief per pressure ulcer guidelines - Support surface: Atmos air mattress - Turn and reposition every 1-2 hours and prn - Heels off bed surface at all times use multipodus Boots - Elevate LE's while sitting. - Moisturize B/L LE's and feet [Hospital1 ]. . (A) Heel wounds: - Cleanse with Commercial wound cleanser - Apply dry dressing ,kerlix wrap 1 x a day - Multipodus boots . (B) Sacrum/Coccyx: - Commercial wound cleanser or normal saline to irrigate/cleanse all open wounds. - Pat the tissue dry with dry gauze. - Apply moisture barrier ointment with anti fungal to the periwound tissue with each dressing change and perineal skin prn - Apply wound gel once daily - Apply 4 x 4 against ulcer then ABD pad - Change dressing 1 x a day - Support nutrition and hydration. . (B) heels: Cleanse with Commercial wound cleanser Apply dry dressing ,kerlix wrap 1 x a day . # Recent Cholangitis: Patient has no abdominal pain, LFTs are stable. Per [Hospital1 ] there is no indication for further imaging. Patient scheduled for outpatient choly next week, unclear if this is still indicated givne her comorbidities. -f/u with [Hospital1 ] on [5-3] for ?removal of plastic stents. . # Nutrition: Patient not taking in PO, in the ICU NG tube placement was attempted but unsuccessful on multiple attempts, likely [1-15] to hiatial hernia. NG tube was removed on the floor and the patient was followed by speech and swallow. She was initially started on thick liquid/pureed diet and then advanced to thin liquids/pureed diet. -encourage PO intake -strict aspiration precautions -thin liquid, puree diabetic diet. . Medications on Admission: Flagyl/cefpodoxime completed ~[3-5]. trazodone 25 [Hospital1 ] Lantus 30 units HS Humalog sliding scale plus 8 units TID with meals Aricept 5 mg HS Senna 1 tab [Hospital1 ] colace 100 mg [Hospital1 ] Discharge Medications: 1. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed. 2. Metronidazole 500 mg Tablet [Hospital1 ]: One (1) Tablet PO Q8H (every 8 hours) for 7 days: last day [2187-3-31]. 3. Docusate Sodium 50 mg/5 mL Liquid [Month/Day/Year ]: One Hundred (100) mg PO BID (2 times a day) as needed. 4. Aspirin 81 mg Tablet, Chewable [Month/Day/Year ]: One (1) Tablet, Chewable PO DAILY (Daily). 5. Trazodone 50 mg Tablet [Month/Day/Year ]: 0.5 Tablet PO HS (at bedtime). 6. Roxanol Concentrate 20 mg/mL Solution [Month/Day/Year ]: Twenty (20) mg PO q1 hour as needed for pain: may give for pain, shortness of breath, restlestness. Disp:30 ml Refills:0 7. Insulin Glargine 100 unit/mL Cartridge [Month/Day/Year ]: Twenty Two (22) units Subcutaneous once a day: Please give glargine at dinner time. Please check AM and dinner time FSG and if finger stick 151-200, please give 6 units humalog, if 201-300 please give 10 units of humalog. 8. Tylenol 325 mg Tablet [Month/Day/Year ]: One (1) gram PO three times a day. 9. Tylenol 325 mg Tablet [Month/Day/Year ]: Two (2) Tablet PO every 6-8 hours as needed for fever or pain: patient should not receive more than 4grams of tylenol in any 24 hour period. 10. Ativan 0.5 mg Tablet [Month/Day/Year ]: 1-2 Tablets PO every four (4) hours as needed for anxiety/agitation. 11. Compazine 10 mg Tablet [Month/Day/Year ]: 2.5 Tablets PO every six (6) hours as needed for nausea: please give PR. 12. Levsin 0.125 mg Tablet [Month/Day/Year ]: One (1) mg PO q2h as needed for increased secretions: may give PO or SL. 13. Wound Gel please dress sacral wound once daily 14. Cefpodoxime 100 mg Tablet [Month/Day/Year ]: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Discharge Disposition: Extended Care Facility: sunrise [Location (un) ] Discharge Diagnosis: Primary diagnoses: - Hyperosmolar nonketotic hyperglycemia - Severe dehydration with acute renal failure - Hypernatremia - Clostridium difficile colitis . Secondary diagnoses: - Dementia - Type 2 diabetes poorly-controlled with complication - Multiple stage III and unstageable decubitus ulcers Discharge Condition: Stable, alert but not oriented, able to track to voice, responding with non-sensical speech. Discharge Instructions: You were admitted to [Hospital1 ] with severe dehydration and acute kidney failure due to severely elevated blood sugar. This may have been triggered by an infectious diarrhea known as C. Difficile. Due to your high blood sugar and dehydration, your sodium level was dangerously high, and you were admitted to the medical ICU. While in the ICU, you were gradually rehydrated and your blood sugar was controlled with insulin. You were given antibiotics for your C. Difficile infection. . Your decubitus ulcers were evaluated by our wound care nurse who made recommendations to assist with their continued healing. . We made the following changes to your medications: ADDED Flagyl 500 po three times daily to continue until [3-25] . If you have any fever, vomiting, diarrhea, abdominal pain, shortness of breath or any symptoms that are concerning to you, please call your hospice nurse. . Please follow up with your doctors as below. Followup Instructions: Provider: [Name Initial (NameIs) ] 2 (ST-4) GI ROOMS Date/Time:[2187-5-3] 9:00 Provider: [Name10 (NameIs) 1948] [Last Name (NamePattern4) 1949], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2187-5-3] 9:00 [First Name7 (NamePattern1) 1569] [Initial (NamePattern1) ] [Name8 (MD) ] MD [MD Number(2) 5122]	[ "008.45", "V58.66", "707.07", "250.20", "584.9", "707.03", "707.25", "276.0", "331.0", "707.23", "V58.67", "294.10", "424.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11791, 11846	5235, 7966	330, 359	12185, 12280	2133, 5212	13273, 13646	1639, 1792		9987, 11768		11867, 12022		9746, 9964			8078, 9720	12304, 12949									1807, 2114			12043, 12164																	12978, 13250						277, 292					7977, 8056		387, 1238																		1260, 1406	1422, 1623
65,786	136,076	41112	Discharge summary	report	Admission Date: [2187-1-2] Discharge Date: [2187-1-6] Date of Birth: [2138-3-23] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2534] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 48 M s/p [2138]0 feet off of a salt truck. The patient states that he lost his balance and fell ~10feet. He did not lose consciousness. He complains of pain at his left chest Past Medical History: Polysubstabce abuse, Chronic neck/back pain after MVC, hypothyroid, GERD. Social History: H/o PSA. Family History: Noncontributory to this problem. Physical Exam: Admission physical HR:81 BP:170/ Resp:22 O(2)Sat:98% RA Normal Constitutional: Patient is boarded and collared, vocalizing loudly that he is in a lot of pain HEENT: Normocephalic, atraumatic, Extraocular muscles intact c-collar in place Chest: + L sided CW TTP Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender Extr/Back: +TTP of midline T spine. eccymoses L ankle Skin: eccymoses L ankle, no abrasions, no lacerations Neuro: Speech fluent, MAEE Pertinent Results: [1-2] - CT CAP - SMall L PTX, First, 4-8th L rib fractures. [1-2] - CT Cspine - No acute cspine injury [1-2] - CT Head - No acute intracranial process Brief Hospital Course: The patient was seen in the trauma bay and was found to have a small pneumothorax as well as Left 1st and 4th-8th rib fractures. A chest tube was placed in the emergency department and placed on wall suction. He was admitted to the TSICU for further management. A pareventricular block was attempted but the patient was unable to tolerate this, and so his pain was controlled with IV dilaudid. This was reattempted the following day and the patient tolerated the procedure and had good pain relief from this. The acute pain service was consulted and he was started on tizanidine, PO dilaudid and toradol for adjunctive pain control. The patient had persistent mental status changes and was seen by psychiatry for this and his history of polysubstance abuse. They recommended he continue on his home psychiatric medications with the addition of seroquel. The patient was transferred to the floor for further management. While on the floor he was kept on telemetry with his chest tube. He was on a regular diet on all his home medications. His pain was controlled with dilaudid. His chest tube was removed on [1-6]. A chest xray taken afterwards and was preliminarily read as no residual pneumothorax. He was discharged home with narcotic pain relief, a sling for comfort for his left clavicle fracture, and an incentive spirometer. He was given instructions for close follow up with the orthopedic surgery clinic and the acute care surgery clinic. Medications on Admission: citalopram 40 mg daily clonazepam 1 mg tid daily levothyroxine 25 mcg daily heparin 5000 [Hospital1 ] ketorlac 15 mg q6Hx3 days dilaudid 2-4 mg po q3 hr pain tizanidine 4 mg TID pain lithium 600 mg daily (dose verified by pcp) potassium chloride SS Mg sulfate SS Calcium gluconate SS Discharge Medications: 1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 3. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: take with colace. Disp:30 Tablet(s) Refills:0 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Pneumothorax Left First, Fourth-Eighth rib fractures Discharge Condition: Good Discharge Instructions: You were admitted to the acute care service after your fall. You had several broken ribs on the left side, a broken clavicle, and a punctured left lung. It is important for you to use your incentive spirometer every hour to keep your lungs inflated. You should wear a sling for comfort with your left clavicle fracture. Please follow up with the orthopedic clinic in one week for care of your clavicle fracture. You have also been discharged with some narcotic pain medication. You should not drive or operate heavy machinery while taking narcotic pain medication. You can also take tylenol to reduce your narcotic pain medicine requirement. Take tylenol as directed. Followup Instructions: Please follow up with the Acute Care service in 2 weeks. Please call [Telephone/Fax (1) 600] for an appointment. You should follow up with the orthopedic clinic in 1 week for care of your clavicle fracture. Please call [Telephone/Fax (1) 1228] to make this appointment.	[ "305.90", "292.81", "805.2", "E935.2", "530.81", "860.0", "244.9", "810.00", "E818.1", "807.06" ]	icd9cm	[ [ [] ] ]	[ "34.04", "99.29", "03.90" ]	icd9pcs	[ [ [] ] ]	3855, 3861	1384, 2840	310, 316	3957, 3963	1197, 1361	4682, 4964	663, 697		3179, 3832		3882, 3936		2866, 3156				3987, 4659									712, 1178																										262, 272							344, 524																		546, 621	637, 647
17,714	105,383	6454	Discharge summary	report	Admission Date: [2178-1-7] Discharge Date: Service: GEN SURGER HISTORY OF PRESENT ILLNESS: The patient is an 85 year old woman who presents for a right hemicolectomy for resection of carcinoma of the cecum. The patient was initially found to be anemic on routine physical examination by her primary care physician and further workup included a colonoscopy which revealed a mass in the cecum as well as diverticulosis. The mass was biopsied and revealed an adenoma with high grade dysplasia. The patient admits to intermittent melena, no bright red blood per rectum. She has mild constipation, no diarrhea, no weight loss, no fevers or chills, no history of chest pain, shortness of breath, dizziness, syncope, nausea or vomiting. PAST MEDICAL HISTORY: 1. Hypertension. 2. Breast cancer in the past which was resected and she had a left mastectomy in [2152], and a right lumpectomy in [2168]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Norvasc 5 mg p.o. q.d. 2. Butoptic one to two drops to each eye b.i.d. for prevention of glaucoma. 3. Trusopt 2% one drop each eye for prevention of glaucoma which runs in her family. SOCIAL HISTORY: Significant for thirty pack year history of tobacco. She quit fifteen years ago. Socially ETOH, less than two drinks per week. She lives alone in [Location (un) 686]. REVIEW OF SYSTEMS: On review of systems, she does get short of breath upon walking one flight of stairs. Otherwise, the review of systems was noncontributory. PHYSICAL EXAMINATION: On physical examination, her temperature was 97.8, heart rate 100, blood pressure 128/78, respiratory rate 16, and she was saturating 96% in room air. She is mildly obese, alert, oriented times three, pleasant in no apparent distress. The pupils are equal, round, and reactive to light and accommodation. Sclera were anicteric. Mucous membranes were moist. No lymphadenopathy. The neck was supple with no carotid bruits. The lungs were clear to auscultation bilaterally. She had a regular rate and rhythm. The abdomen was soft, nontender, protuberant, but nondistended, positive bowel sounds. She had no cyanosis, clubbing or edema. Her pulses were palpable bilaterally. HOSPITAL COURSE: The plan was for a right hemicolectomy. The patient tolerated the procedure well, however, on transfer to the floor from the Post Anesthesia Care Unit, the patient was found to be unresponsive and almost apneic. On workup, she was found to be hypercarbic which was presumed to be most likely due to narcotics from her epidural. The epidural was immediately capped and an electrocardiogram, chest x-ray were done which were essentially within normal limits. Once the epidural was capped, the patient's respiratory rate increased to 30 and she was saturating 91% on 50%. She had bilateral crackles at the bases and was tachycardic. She was brought to the Post Anesthesia Care Unit for more frequent and closer monitoring. Her narcotics and epidural were stopped. The patient was closely monitored and her oxygen saturations came up, however, she continued to have respiratory difficulty and, on repeat blood gases although there was some improvement, she was found to be acidotic and still hypercarbic and breathing with difficulty. Hence, after supportive therapy was maintained for a couple of hours, the decision was made to intubate the patient and transfer to the Intensive Care Unit. She was extubated on the following day, postoperative day two, tolerated extubation well. She had a slight temperature of 101.7 and remained slightly tachycardic but that was her baseline and her oxygen saturations remained within normal limits in the mid to low 90s which was around her baseline. Her temperature came down on its own. The patient was transferred to the floor on postoperative day number two. On postoperative day number three, the patient did well. However, that evening she awoke short of breath, denied any chest pain, tingling in her arms, nausea, vomiting or dizziness. She was saturating 94% on four liters. She did have crackles at the bases bilaterally and some rhonchi. The decision was made to give her some Lasix in which case she quickly responded and shortness of breath dissipated. Another electrocardiogram was done which again was within normal limits. The patient did well the following. Vital signs were all stable. She was saturating well. Her nasogastric tube was taken out and she was started on sips. She continued to do well. On postoperative day five, she started to develop some burping and had still not passed any flatus. Her abdomen became slightly distended. She was kept NPO. However, on postoperative day six, she passed large amounts of stool and decision was made to start her again on clears. She tolerated clears well. On postoperative day seven, she was advanced to a soft regular diet and was discharged to rehabilitation in stable condition. Her vital signs were all stable. She was afebrile. A Clostridium difficile had been sent given she had multiple loose bowel movements, which is still pending. She will follow-up with Dr. [Last Name (STitle) 957]. DISCHARGE DIAGNOSIS: Right hemicolectomy for cecal mass. MEDICATIONS ON DISCHARGE: 1. Trusopt 2% one drop O.U. t.i.d. 2. Butoptic one to two drops O.U. t.i.d. 3. Norvasc 5 mg p.o. q.d. 4. Tylenol #3 one to two tablets p.o. q4-6hours p.r.n. pain. 5. Zinc 220 mg p.o. q.d. 6. Multivitamin. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4007] Dictated By:[Last Name (NamePattern1) 2649] MEDQUIST36 D: [2178-1-15] 10:08 T: [2178-1-15] 10:19 JOB#: [Job Number 24811] and [Numeric Identifier 24812]	[ "562.10", "997.3", "153.4", "E935.2", "401.9", "V15.82", "V10.3", "280.9" ]	icd9cm	[ [ [] ] ]	[ "93.90", "45.93", "96.71", "96.6", "45.73", "96.04" ]	icd9pcs	[ [ [] ] ]											5209, 5246	5272, 5762	988, 1179	2254, 5187																											1556, 2236						1391, 1533												107, 751																		773, 962	1196, 1371
42,400	104,749	42060	Discharge summary	report	Admission Date: [2132-1-10] Discharge Date: [2132-2-1] Date of Birth: [2053-12-20] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2836] Chief Complaint: Chronic pancreatitis Major Surgical or Invasive Procedure: [2132-1-21]: Open distal pancreatectomy and splenectomy, J-tube placement [2132-1-31]: CT-guided placement of 8 French pigtail drain into intra abdominal fluid collection. History of Present Illness: 78F w/ DM & chronic afib on anticoagulation & h/o open cholecystectomy in [2131-6-22] c/b chronic pancreatitis c/b pseudocyst. She has had multiple hospital admissions for these complications, most recently in [2131-11-22] to [Hospital1 18] for ERCP w/ sphincterotomy and sludge extraction on [12-20]. At that time, her ERCP showed CBD dilated to 12mm, a 5 mm stone in bile duct, which was extracted, and small pancreatic duct w/ multiple side branches suggestive of pancreas divisum. She presented to an OSH on [1-6] for worsening abdominal pain, most likely due to her chronic pancreatitis. She was transferred to [Hospital1 18] for an ERCP by Dr. [Last Name (STitle) 77510] and is admitted post-procedure to the surgical service. The ERCP report notes that the minor papilla was unable to be visualized and thus no pancreatic intervention was done. Upon arrival to the floor, the patient appeared to be in significant amount of epigastric abdominal pain and had 200cc of bilious emesis in additional to an episode of emesis immediately post-procedure. Her pain had been present prior to ERCP but acutely worsened post-procedure. She did not want to answer any further questions through the phone interpreter due to her severe pain. The patient was admitted on Dr. [First Name (STitle) ] service for further work up and possible surgical intervention. Past Medical History: -Diabetes -Hyperlipidemia -HTN -AFib -S/p open CCY [2131-7-18] c/b pancreatitis and pancreatic pseudocyst -TPN dependent for 5 months -h/o c. diff Social History: [Location 7979]. Moved here 20 years ago. Currently lives with her daughter, [Name (NI) 1894]. - [Name2 (NI) 1139]: Denies - Alcohol: Denies - Illicits: Denies Family History: No biliary disease Physical Exam: On Admission: Vitals: 96.8 92 200/114 22 100% RA FS 162 GEN: in moderate distress, clutching her abdomen, will not answer further questions due to pain HEENT: No scleral icterus, mucus membranes moist CV: irregularly irregular rhythm, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: soft, nondistended, tender to light palpation in epigastric region Ext: No LE edema, LE warm and well perfused On Discharge: VS:97.1, 80, 124/61, 12, 98% RA GEN: NAD HEENT: No scleral icterus, mucus membranes moist CV: irregularly irregular rhythm, No M/G/R RESP: CTAB ABD: Subcostal abdominal incision open to air with steri strips, LUQ pigtail drain to gravity drainage, JP drain to bulb suction, site c/d/i and covered with drain spounge EXTR: RUE with PICC line in place Pertinent Results: [2132-1-30] 06:13PM ASCITES Amylase-16 [2132-1-31] 11:25AM ASCITES Amylase-[Numeric Identifier 10064] MICRO: [2132-1-26] 9:17 am URINE Source: CVS. FINAL REPORT [2132-1-28] URINE CULTURE (Final [2132-1-28]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S [2132-1-31] 11:25 am PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [2132-1-31]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): Reported to and read back by DR [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 64941] [2132-2-1] @ 1:15 PM. GRAM POSITIVE COCCUS(COCCI). SPARSE GROWTH. ANAEROBIC CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [2132-1-10] ERCP: S/P major papilla sphincterotomy Minor papilla could not be identified despite multiple attempts. Therefore no pancreatic intervention was performed. Otherwise normal ercp to third part of the duodenum. [2132-1-30] CT ABD: IMPRESSION: 1. In this patient status post distal pancreatectomy with fiducial seeds placed in the pancreatic bed and jejunojejunostomy in the left upper quadrant, there is a new large simple fluid collection in the lesser sac measuring 9.2 x 7.4 x 8.7 cm. This collection is amenable to image guided drainage 2. There is a new small left nonhemorrhagic pleural effusion with adjacent atelectasis. 3. The patient is status post splenectomy. 4. Bilateral renal cysts with additional renal hypodensities which are too small to characterize. [2132-1-11] EKG: Atrial fibrillation with a rapid ventricular response. Non-specific ST-T wave changes. Compared to the previous tracing of [2131-12-24] the rate is faster and ST-T wave changes are more prominent. [2132-1-22] EKG: Atrial fibrillation with rapid ventricular response. ST-T wave abnormalities. Since the previous tracing of [2132-1-11] QRS amplitude is somewhat less. Otherwise, unchanged. PATHOLOGY: I. Pancreatic neck, biopsy: Atypical ducts with abundant admixed dense fibrosis consistent with severe chronic pancreatitis; no carcinoma seen. Six levels are examined. II. Pancreas, distal pancreatectomy (B-T): A. Pancreatic intraepithelial neoplasia with micropapillary features and high grade dysplasia (PanIn-3). B. No invasive carcinoma seen. C. Chronic pancreatitis, diffuse, with marked atrophy of acinar tissue, hyperplasia of islet cells, and minimal inflammation. D. Nine peripancreatic lymph nodes, within normal limits. E. Four levels are examined on blocks P and Q. III. Spleen, splenectomy, 215 grams (U-Z): A. Unremarkable splenic parenchyma. B. Ten hilar lymph nodes, within normal limits. IV. Pancreatic duct fluid: NEGATIVE FOR MALIGNANT CELLS. Brief Hospital Course: The patient with history of chronic pancreatitis and chronic PO intolerance was admitted to the General Surgical Service for evaluation and treatment after attempted ERCP. The patient was made NPO with IVF, she was continued on TPN and her pain was controlled with large amount of IV Dilaudid. Dr. [First Name (STitle) ] evaluated the patient and patient was scheduled for elective Puestow procedure. The decision was made to keep patient in hospital prior surgery secondary of pain (required large amount of IV Dilaudid) and atrial fibrillation (can't take home meds PO s/t NPO status). Patient has a history of Afib and her Coumadin was held, Cardiology was consulted and their recommendations were followed. On [2132-1-21], the patient underwent distal pancreatectomy with splenectomy and J-tube placement (Operative Note is unable on discharge). Post operatively patient was transferred in ICU secondary to rapid Afib (HR 150s) and hypertension. The patient was started on Diltiazem gtt and Hydralazine IV. The patient's cardiac status improved, Diltiazem gtt was stopped and she was transferred on the floor in stable condition. The patient arrived on the floor NPO, on IV fluids and TPN, with a foley catheter, IV Dilaudid and Fentanyl patch for pain control. The patient was hemodynamically stable. Neuro: The patient received IV Dilaudid and Fentanyl patch for pain control, she required significant amount of IV Dilaudid for breakthrough pain. When tolerating oral intake, the patient was transitioned to oral pain medications with continued IV for breakthrough pain. Patient's Fentanyl patch was increased and her IV Dilaudid was weaned off. The plan for the patient is continue to wean off her Fentanyl patch and PO Oxycodone as tolerated. CV: The patient has a history of Afib and she is on PO Coumadin, Diltiazem and Digoxin at home. When NPO, patient was given IV Digoxin, IV Metoprolol and Lovenox SC, her Coumadin was held for perioperative period. She continued to have episodes intermittent bradycardia and Cardiology consult was obtained. According to Cardiology recommendations, IV Digoxin was discontinued with anticoagulation therapy, her IV Metoprolol was continued. Post operatively, patient was started on her home regiment with PO Digoxin and Diltiazem. The Diltiazem doze was increased to 45 mg for better rate control. Coumadin was restarted on POD # 7, her INR prior discharge was 1.2, bridging therapy was not indicated. Patient's heart rate was monitored with telemetry during hospitalization. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was TPN dependent since [Month (only) 216], she was continued on TPN prior surgery. TPN was continued 5 days post-operatively, then her diet was advanced to clears. Diet was advanced to regular on POD # 7. The patient was started on TF on POD # 5, and her TF rate was advanced to goal on POD # 7 and started cycling overnight. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. JP amylase was sent on POD # 8, and level was low. On POD # 11, JP fluid was look chylous and fluid was sent fot triglycerides level. Test still pending prior discharge and results will be addressed during her follow up with Dr. [First Name (STitle) ]. Patient's diet was change according to test result. The foley catheter was discontinued at midnight of POD# 2. The patient subsequently voided without problem. ID: The patient's white blood count and fever curves were closely watched for signs of infection. The patient spiked fever on POD # 2, blood and urine cultures were sent. Urine cultures were positive for Enterococcus and patient was started on IV Vancomycin x 5 days. Follow up urine cultures x 2 were negative. On POD # 8, patient's WBC spiked to 30.2 and abdominal CT was obtained. CT demonstrated a new large simple fluid collection in the lesser sac measuring 9.2 x 7.4 x 8.7 cm. On POD # 10, patient underwent percutaneous drainage of this fluid collection. WBC started to trend down, fluid cultures was negative prior discharge with high amylase ([Numeric Identifier 10064]). No antibiotic treatment was indicated prior discharge. Endocrine: The patient's blood sugar was monitored throughout his stay; [Last Name (un) ] was consulted and their recommendations were followed. Patient will continue to follow up with [Last Name (un) ] after discharge. Hematology: The patient's complete blood count was examined routinely, she received 2 units of RBC on POD # 2 for falling HCT. Patient's HCT was stable after transfussion and no further interventions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diabetic diet with cycling tube feed, ambulating with bystander assist, 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: clonidine patch 0.1mg weekly, digoxin 250mcg', diltiazem 30'''', enoxaparin 60'' SQ, fentanyl patch 25mcg q72h, SSI, morphine 4 q4h, zofran 4 q4h, protonix 40', sucralfate 1"", warfarin 6', colace 100'', insulin regular (humulin R) 1 unit before meals & qhs Discharge Medications: 1. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 2. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:120 Tablet(s) Refills:0 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours). 7. lorazepam 0.5 mg Tablet Sig: [12-24] Tablet PO Q8H (every 8 hours) as needed for anxiety. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. diltiazem HCl 90 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). 10. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) for 6 days: please taper Fentanyl patch: 75 mcg for 6 days, than 50 mcg for 15 days, than 25 mcg for 15 days, than stop fentanyl patch. Disp:2 Patch 72 hr(s) Refills:0 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 12. warfarin 3 mg Tablet Sig: Two (2) Tablet PO once a day. 13. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 14. insulin glargine 100 unit/mL Solution Sig: Eight (8) units Subcutaneous before breakfast. 15. insulin glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 16. insulin lispro 100 unit/mL Solution Sig: 2-12 units Subcutaneous before breakfast, lunch, dinner and bedtime: . 17. sliding scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL [Month/Day (2) ] with hypoglycemia protocol [Month/Day (2) ] with hypoglycemia protocol [Month/Day (2) ] with hypoglycemia protocol [Month/Day (2) ] with hypoglycemia protocol 71-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 2 Units 4 Units 4 Units 201-250 mg/dL 4 Units 4 Units 6 Units 6 Units 251-300 mg/dL 6 Units 6 Units 8 Units 8 Units 301-350 mg/dL 8 Units 8 Units 10 Units 10 Units 351-400 mg/dL 10 Units 10 Units 12 Units 12 Units 18. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours for 5 doses. Disp:5 patch Refills:0 19. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours for 5 doses. Disp:5 patch Refills:0 Discharge Disposition: Extended Care Facility: Summit Commons [Hospital ] Nursing and Rehab Center - [Hospital1 789], RI Discharge Diagnosis: 1. Pancreatic intraepithelial neoplasia with micropapillary features and high grade dysplasia. 2. Atrial fibrillation 3. Uncontrolled diabetes 4. Urinary tract infection 5. Large intra abdominal fluid collection in the lesser sac 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 [5-1] 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. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. . General Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or [Month/Year (2) 269] nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . . J-tube: Please flush J-tube with 30 cc of tap water Q4H. Monitor for signs and symptoms of infection and dislocation . Please call [Telephone/Fax (1) 10676] to update you information in [Hospital1 18] . JP Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or [Hospital1 269] nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . 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: Department: SURGICAL SPECIALTIES When: FRIDAY [2132-2-8] at 11:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD [Telephone/Fax (1) 274] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . [Last Name (un) ] CENTER When: [2132-2-6] With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11712], ANP Completed by:[2132-2-1]	[ "427.31", "285.9", "V58.61", "577.0", "V58.67", "427.89", "041.04", "276.2", "401.9", "577.1", "577.2", "599.0", "272.4", "249.01", "577.8", "783.21", "789.59" ]	icd9cm	[ [ [] ] ]	[ "45.13", "41.5", "96.6", "46.39", "99.15", "54.91", "52.52" ]	icd9pcs	[ [ [] ] ]	14764, 14872	6309, 11733	324, 506	15146, 15146	3126, 3964	18927, 19415	2303, 2323		12042, 14741		14893, 15125		11759, 12019				15297, 15873							15888, 18904		2338, 2338									4255, 6286								2755, 3107									264, 286							534, 1922									2352, 2741	4222, 4222	15161, 15273							1944, 2097	2113, 2287		3999, 4185
67,676	152,576	45074	Discharge summary	report	Admission Date: [2155-2-18] Discharge Date: [2155-2-20] Date of Birth: [2089-10-13] Sex: F Service: MEDICINE Allergies: Norpace / Ciprofloxacin Attending:[First Name3 (LF) 1943] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 50891] is a 65 y/o female with a history of syncope (vasovagal), bleed from jejunal varices possibly due to superior mesenteric vein obstruction s/p mesocaval shunt (age 20) and multiple DVTs who presented with an episode of hematemesis. She reports having multiple bouts of nausea, vomiting and diarrhea which started early in the morning. The first bout of emesis contained small amounts of blood however subsequent bouts were clear. She also notes that having some associated abdominal discomfort. She denies any chest pain, shortness of breath, melena or hematochezia. Of notes, she states that the bleeding started when she was 18 years old and she had about 3 procedures done before the mesocaval shunt when she was 20. Since then, she has not had any significant bleeding. She is followed by gastroenterology as an outpatient by Dr. [Last Name (STitle) ]. Her last EGD on [2154-5-1] showed mucosa suggestive of Barrett's esophagus (biopsy, biopsy) otherwise normal EGD to third part of the duodenum. No varices were noted. In the ED, initial vs were: T 97.6 P 70 BP 106/62 R 20 O2 sat 100RA. Patient was started on pantoprazole drip, octreotide drip and zofran. CT scan wetread showed massive varices notably esophageal varices. She refused NG lavage. On the floor, she was comfortable and and in no acute distress. She denied any lightheadedness or nausea. She denies having any recent vomiting bleeding. 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. History of vasovagal syncope with bradycardia, sinus arrest and heart block. 2. History of massive gastrointestinal bleed from jejunal varices possibly due to superior mesenteric vein obstruction. 3. History of bilateral deep vein thromboses. 4. History of mesocaval shunt at age 20. 5. History of five abdominal surgeries. Social History: Drinks 3-4 glasses of wine per week. Denies Tob, recreational drug use. Lives alone. Recent travel history to [Country 7936]. Traveled last year to [Location (un) ]. Family History: Mother and three maternal uncles died from cardiac disease. Her father had [Name (NI) 4278] disease. Physical Exam: ON ADMISSION: Vitals: T: 97.6 BP: 136/56 P: 62 R: 18 O2: 97 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: multiple scars, 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 ON DISCHARGE Tmax 98.7 Tcurrent 97.7 HR 51 BP 126/63 RR 20 O2sat97%RA Gen: NAD, resting in bed Lungs: CTAB Cardiac: RRR nlS1S2, no R/M/G Abd: +BS, NTND, no rebound or guarding, no masses or organomegaly Ext: WWP Pertinent Results: ADMISSION LABS: [2155-2-18] 12:20PM WBC-6.0 RBC-4.40 HGB-14.7 HCT-41.8 MCV-95 MCH-33.5* MCHC-35.3* RDW-12.9 [2155-2-18] 12:20PM NEUTS-89.2* LYMPHS-5.1* MONOS-4.4 EOS-0.7 BASOS-0.6 [2155-2-18] 12:20PM PLT COUNT-184 [2155-2-18] 12:20PM GLUCOSE-144* UREA N-30* CREAT-0.7 SODIUM-140 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14 [2155-2-18] 12:20PM ALT(SGPT)-20 AST(SGOT)-16 ALK PHOS-68 AMYLASE-81 TOT BILI-0.7 [2155-2-18] 12:20PM LIPASE-70* [2155-2-18] 12:20PM PT-13.6* PTT-19.0* INR(PT)-1.2* [2155-2-18] 08:45PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]->1.030 [2155-2-18] 08:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2155-2-18] 08:45PM URINE RBC-[3-22]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 DISCHARGE LABS [2155-2-20] 06:20AM BLOOD WBC-2.9* RBC-4.43 Hgb-14.0 Hct-41.5 MCV-94 MCH-31.7 MCHC-33.8 RDW-12.9 Plt Ct-157 [2155-2-19] 04:17AM BLOOD Neuts-87* Bands-0 Lymphs-8* Monos-3 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [2155-2-20] 06:20AM BLOOD PT-13.5* PTT-24.3 INR(PT)-1.2* [2155-2-20] 06:20AM BLOOD Glucose-103* UreaN-15 Creat-0.6 Na-137 K-4.4 Cl-103 HCO3-24 AnGap-14 [2155-2-20] 06:20AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1 [2155-2-20] 08:50AM BLOOD GASTRIN-PND MICRO: Stool Cx: negative for salmonella, shigella, campylobacter, ova parasites. many PMNs. Charcot [Location (un) 5244] crystals present STUDIES: [2155-2-18] CT ABD/PELVIS: Within the lung bases, no pleural effusion is identified. There is a moderate hiatal hernia. Dilated azygous and hemiazygous veins are seen. Within the abdomen, hyperdensities in segment VII of the liver (2:17) may represent calcified granuloma. The spleen, pancreas, gallbladder, adrenal glands, and kidneys appear grossly unremarkable. Loops of small and large bowel are of normal size and caliber. The IVC below the level of the renal veins appears markedly attenuated and atretic. A mesocaval shunt is noted between the SMV which is small in caliber and the attenuated IVC, however, the shunt appears nonopacified and diminutive (2:37). Multiple collateral vessels are noted throughout the abdomen, anterior abdominal wall and lumbar veins. No free air, free fluid, or pathologically enlarged lymph nodes are seen. Within the pelvis, distal loops of large bowel and rectum are of normal size and caliber. The bladder, distal ureters, and uterus appear grossly unremarkable. No pelvic free air, free fluid, or lymphadenopathy is seen. Again noted are multiple prominent anterior abdominal and lumbar collateral vessels which appear to be draining the femoral and iliac veins. There is compression of the L1 vertebral body with minimal retrolisthesis of L1 on L2. No concerning osseous lesion is seen. IMPRESSION: 1. No specific acute findings to explain abdominal pain. 2. Diminutive mesocaval shunt with multiple collateral vessels suggest chronic nonfunctioning of shunt. [2155-2-19] ABDOMINAL U/S: (prelim) 1. Normal appearance of the liver, without concerning focal lesions. 2. Normal portal venous flow, with patency of the right and left portal system. 3. No splenomegaly or ascites. Brief Hospital Course: Ms. [Known lastname 50891] is a 65 y/o female with a history of syncope (neurogenic), bleed from jejunal varices possibly due to superior mesenteric vein obstruction s/p mesocaval shunt (age 20) and multiple DVTs who presented with an episode of hematemesis. # Hematemesis: She has a significant medical history for upper GI bleeds, however has been stable since her mesocaval shunt was placed years ago. Recent EGD in [2154-4-18] with no signs of varices. Her hematocrit has been stable as well as her vitals. Two large bore PIV were secured and patient was typed and screened. She was started on IV Protonix and octreotide drips. Serial HCTs were checked and remained stable. CT abdomen showed diminutive mesocaval shunt with multiple collateral vessels with no obvious findings to explain her hematemesis and RUQ pain. RUQ ultrasound was within normal limits without thrombus in the portal vein. GI was consulted and Dr. [Last Name (STitle) ] notified- given the patient's stability and lack of esophegeal varices, they recommended discontinuing the Octreotide drip and switching to a PO PPI. GI did not feel she needed to have EGD in house, and felt that her hematemesis was likely [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-[Doctor Last Name ] tear vs secondary to her gastritis/Barrett's. No further episodes of hematemesis in-house. She was set up with GI follow up with Dr. [Last Name (STitle) ], and instructed to continue home Zegerid. # Syncope: She has a history of vasovagal syncope which has been worked up as an outpatient. History was consistent with this given likely dehydration in the setting of vomiting. She was rehydrated with fluids and monitored on telemetry with no significant events. # Diarrhea: This has been going on for a few months now and waxes/wanes in it's frequency and intensity, also occasionally waking her up from sleep. Pt denying melena, hematochezia. Of note, she has had some recent travel to [Country 7936] in the past year so infectious diarrhea was considered. Furthermore in discussing with the GI team, the waxing/[Doctor Last Name 688] of her nausea/diarrhea could be suggestive of a hormonal etiology, including carcinoid. Stool cultures were negative for growth but revealed Charcot-[Location (un) 5244] crystals which could be associated with eosinophilic reaction vs parasitic infection. 24h urine 5-HIAA levels would have ideally been sent off but patient left before this testing could be done. Fasting gastrin level was pending at discharge. She had no episodes of diarrhea after transfer to the floor. # Isuues for follow up: -GI follow up is scheduled for hematemesis and history of Barrett's esophagus -PENDING LAB: Fasting Gastrin level -Follow up significance of charcot-[Location (un) ] crystals Medications on Admission: Atenolol 25 mg Tab 1 Tablet(s) by mouth once a day Multivitamin Cap Aspirin 81 mg Tab Oral 1 Tablet(s) 3 times/week Zegerid 40 mg-1.1 gram Cap 1 Capsule(s) by mouth once a day Discharge Medications: 1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 2. multivitamin Capsule Sig: One (1) Capsule PO once a day. 3. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 4. Zegerid 40-1.1 mg-gram Capsule Sig: One (1) Capsule PO once a day. 5. Calcium 500 + D Oral 6. omega-3 fatty acids-fish oil Oral Discharge Disposition: Home Discharge Diagnosis: Hematemesis GERD Marllory-[Doctor Last Name ] tear Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms [Known lastname 50891], You were admitted to the hospital for nausea, vomiting and diarrhea. There was some blood in your vomit at home, but your vital signs and blood counts were stable in the hospital. You have not had any further episodes of blood in your vomit and we feel you are safe for discharge. You should follow up with Dr. [Last Name (STitle) ] as an outpatient at which point you can discuss doing a repeat endoscopy. You should also follow up with your PCP. We have not made any changes to your medications. You should continue all other medications you were previously taking. Followup Instructions: Department: RADIOLOGY When: MONDAY [2155-2-24] at 8:00 AM With: RADIOLOGY [Telephone/Fax (1) 1125] Building: [Street Address(2) 1126] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking Department: GASTROENTEROLOGY When: MONDAY [2155-3-17] at 8:30 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1982], M.D. [Telephone/Fax (1) 463] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: DERMATOLOGY AND LASER When: TUESDAY [2156-1-20] at 3:30 PM With: [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern1) 13280], MD [Telephone/Fax (1) 3965] Building: [Location (un) 3966] ([Location (un) 55], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site Name: [Last Name (LF) ],[First Name3 (LF) ] S. Address: [Street Address(2) ], 2 WEST, [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 14148] Please call Dr. [Last Name (STitle) *] office to book an appointment within 2 weeks.	[ "572.3", "530.7", "780.2", "V12.51" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	10358, 10364	6961, 9600	297, 303	10462, 10462	3707, 3707	11245, 12413	2806, 2913		10017, 10335		10385, 10441		9817, 9994				10612, 11222									2928, 2928										9611, 9791											1799, 2246					246, 259							331, 1780							3723, 6938		2943, 3688		10477, 10588							2268, 2596	2612, 2790
9,226	188,116	28160	Discharge summary	report	Admission Date: [2116-1-7] Discharge Date: [2116-1-13] Date of Birth: [2064-9-22] Sex: M Service: MEDICINE Allergies: Nsaids Attending:[First Name3 (LF) 3266] Chief Complaint: encephalopathy Major Surgical or Invasive Procedure: EGD with variceal banding History of Present Illness: 51yo man with h/o advanced cirrhosis secondary to chronic hepatitis C and ETOH abuse previously complicated by ascites, hydrothorax, and variceal bleeding(most recently [9-5] at OSH); presents with encephalopathy. Per primary hepatologist, he was at baseline MS last night, then AM of admission, he presented to Day Care center with plans for EGD as part of pre-transplant evaluation, however he was noted to be frankly encephalopathic. He was brought to the ED. . In ED, was agitated and encephalopathic. He was unable to tolerate any studies or procedures. As there was concern for his ability to protect his airway as well as tolerate diagnostic studies, he was intubated electively in the ED. He was found to be guiac (+) on rectal and found to have bloody return from an OG tube. On lavage with 500cc NS, he had persistent return of coffee-grounds which did not clear. He was started on IV protonix and octreotide. GI was consulted in ED. He remained hemodynamically stable with sbp in low 100's. He had two peripheral IVs placed. Past Medical History: 1. cirrhosis 2. h/o hydrothorax 3. h/o variceal bleeding s/p sclerotherapy, banding 4. h/o ascites 5. chronic hepatitis C 6. ETOH abuse 7. chronic kidney disease 8. ESLD- on transplant list MELD score 15([2115-11-15]) Social History: EtOH 10-15 beers / day for >10 years He smokes one pack of cigarettes per day. He denies any IV drug use. He is a retired bus mechanic. Family History: unknown Physical Exam: gen- intubated, sedated on admission heent- anicteric cv - rrr, no m/r/g resp - CTA bilaterally abd - soft, nabs, nt extr - trace, symmetric edema neuro - non-focal much improved exam by discharge Pertinent Results: NG lavage: per ED, lavaged with 500cc NS; had dark brown/black blood (coffee grounds) return. Did not clear with lavage. imaging/data: Abdominal U/S [2116-1-8]:IMPRESSION: 1. Limited ultrasound of liver and Doppler as well as renal ultrasound reveals cirrhotic liver with no focal liver lesions identified. 2. No evidence of hydronephrosis. 3. Distended GB but otherwise normal. . EGD [2116-1-7]: stage III varices one w/ulcer at GE junction, banding x 4. . CT head [2116-1-8](wet read):no acute intracranial process . [12-8] EGD: .Varices (4 cords of grade III varices)at the lower third of the esophagus and middle third of the esophagus (ligation) .Congestion, nodularity and mosaic appearance in the antrum, stomach body and fundus compatible with portal hypertensive gastropathy .Polyps in the antrum .Normal mucosa in the duodenum .Otherwise normal EGD to second part of the duodenum [2116-1-6] 12:40PM PT-13.7* PTT-37.4* INR(PT)-1.2* [2116-1-6] 12:40PM PLT COUNT-145* [2116-1-6] 12:40PM NEUTS-58.4 LYMPHS-25.2 MONOS-8.9 EOS-7.1* BASOS-0.4 [2116-1-6] 12:40PM WBC-7.1 RBC-4.14* HGB-13.3* HCT-37.6* MCV-91 MCH-32.0 MCHC-35.2* RDW-15.4 [2116-1-6] 12:40PM HCV Ab-POSITIVE [2116-1-6] 12:40PM ETHANOL-NEG [2116-1-6] 12:40PM HIV Ab-NEGATIVE [2116-1-6] 12:40PM CEA-1.6 PSA-0.3 AFP-7.5 [2116-1-6] 12:40PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE [2116-1-6] 12:40PM FREE TEST-4.7* [2116-1-6] 12:40PM FREE T4-1.1 [2116-1-6] 12:40PM TSH-4.5* [2116-1-6] 12:40PM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-2.7 MAGNESIUM-2.4 [2116-1-6] 12:40PM ALT(SGPT)-56* AST(SGOT)-75* ALK PHOS-83 TOT BILI-0.7 [2116-1-6] 12:40PM estGFR-Using this [2116-1-6] 12:40PM UREA N-29* CREAT-1.5* SODIUM-141 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 [2116-1-6] 12:40PM GLUCOSE-116* [2116-1-7] 11:50AM PT-14.1* PTT-32.1 INR(PT)-1.3* [2116-1-7] 11:50AM PLT COUNT-136* [2116-1-7] 11:50AM AMMONIA-44 [2116-1-7] 11:50AM TOT PROT-7.4 [2116-1-7] 11:50AM ALT(SGPT)-57* AST(SGOT)-74* LD(LDH)-140 ALK PHOS-72 AMYLASE-65 TOT BILI-0.8 Brief Hospital Course: 1. GI bleeding- Pt presented to the ED with confusion. the NGL was coffee ground and he was guaiac +ve. he was transferred to the micu. he underwent egd there which showed stigmata of bledding on the gr 3 varices. he was banded x 4. was put on PPI and sucralfate. his hct remained stable over the micu course and then was transferred to floor. HCT was stable on discharge. he has a follow up appointment for egd. he was [Last Name (un) 25177] tretaed with prophylactic abx for SBP 2. encephalopathy- pt most probably had hepatic encephalopathy from large GI bleed. he was intubated for airway protection and was transferred to ICU. was started on lactulose. his MS improved over the hospital stay and he was back to baseline. he was given Cipro for SBP prophylaxis 3. CKD- . not sure what the etiology is. was not thought to be HRS. we continued to monitor the Cr and it was stable. no hydronephrosis on U/S. 4. Cirrhosis- continued aldactone/lasix. was started on lactulose 5. fen- regular diet. Medications on Admission: propranolol 10 mg b.i.d. spironolactone 200 mg per day Lasix 80 mg per day lactulose 30 ccs twice a day Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Sixty (60) ML PO TID (3 times a day). Disp:5400 ML(s) Refills:2 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Sucralfate 100 mg/mL Suspension Sig: Thirty (30) mg (30 ml) PO four times a day. Disp:1 month supply Refills:2 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: GI bleed . Secondary: Hep C Alcoholic cirrhosis s/p liver tranplant Discharge Condition: Stable Discharge Instructions: Please take all medications as prescribed. . If you have chest pain, shortness of breath, nausea, vomotting, diarrhea, pain [Female First Name (un) ] abdomen please call your primary doctor or go to the emergency room Followup Instructions: please make a follow up appointment with your primary doctor [First Name (Titles) ] [First Name (STitle) ] ([Telephone/Fax (1) 68442]) within 2 weeks of discharge . Please call your Hepatologist DR [Last Name (STitle) 497] ([Telephone/Fax (1) 24157]). There has been an appointment made for you for repeat banding of your esophageal varices in one week. Completed by:[2116-1-15]	[ "070.54", "572.2", "571.5", "V49.83", "456.20", "585.9", "305.01" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "99.04", "42.33" ]	icd9pcs	[ [ [] ] ]	6104, 6110	4231, 5238	281, 308	6222, 6231	2038, 4208	6501, 6906	1795, 1804		5392, 6081		6131, 6201		5264, 5369				6255, 6478									1819, 2019																										227, 243							336, 1380																		1402, 1625	1641, 1779
55,573	171,479	41226	Discharge summary	report	Admission Date: [2188-3-28] Discharge Date: [2188-4-5] Date of Birth: [2129-5-27] Sex: M Service: MEDICINE Allergies: lisinopril Attending:[First Name3 (LF) 7651] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: -Cardiac catheterization with Drug eluting stents x2 to Left circumflex artery -Hemodialysis History of Present Illness: Mr. [Known lastname 11835] is a 58 year-old man with DM, HTN, COPD, ESRD, history of constrictive pericarditis s/p pericardiectomy who presented to [Hospital6 ] on [2188-3-27] with complaint of sharp non-radiating chest pain that improved slightly with nitroglycerin at home. In the outside ED he reveived 324 mg of ASA and 1 inch of nitropaste. His EKG was notable for IVCD and STDs in V4 and V6 with STE in V2. He also had a low probability V/Q scan. He underwent an echocardiogram that revealed inferior wall hypokinesis with preserved LVEF. He presented with a Troponin T 0.02 which peaked at Troponin 1.14 with a CKMB 25.4 and a CK 266 effectively confirming an NSTEMI. On [2188-3-28], he underwent cardiac catheterization that revealed severe two-vessel disease. He is now transfered to [Hospital1 18] for further management of his CAD and cardiac surgery evaluation. . On initial evaluation at [Hospital1 18], he appears comfortable and is without chest pain. His affect is notable for an avoidant disposition with delayed but frank responses to questions. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes Mellitus Type I, Dyslipidemia, Hypertension, ESRD 2. CARDIAC HISTORY: Constrictive pericarditis s/p pericardiectomy at age 39 3. OTHER PAST MEDICAL HISTORY: - COPD - Psychiatric disorder Social History: - Tobacco history: Quit smoking 10 years ago - ETOH: Patient denies - Illicit drugs: Denies ilicit drugs - Patient is single Family History: Mother and sister have diabetes Physical Exam: Admission: VS: T:97.9 BP: HR:66 RR:16 O2:99% on 4L GENERAL: NAD. Oriented x3. Mood is depressed Affect is blunted. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 12 cm of H2O. CARDIAC: RR, II/VI systolic murmur loudest at the LUSB. Midline well healed scar visible. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. ABDOMEN: Obese, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ LE edema to knees bilaterally. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge: T: 98.9, BP: 158/69 (before dialysis), P: 78, RR: 18, 96% on RA Gen: alert, awake oriented x 3 HEENT: supple, no JVD CV: RR, II/VI systolic murmur loudest at the LUSB. Midline well healed scar visible. RESP: CTAB. Resp were unlabored, no accessory muscle use. ABD: soft, NT, pos BS EXTR: no peripheral edema NEURO: a/o, no focal defects Extremeties: RUE AVF with thrill. Pulses: Right: DP 2+ PT 1+ Left: DP 2+ PT 1+ Skin: intact, no rashes Pertinent Results: Hematology: [2188-4-5] 06:26AM BLOOD WBC-9.8 RBC-3.52* Hgb-10.4* Hct-32.4* MCV-92 MCH-29.5 MCHC-32.0 RDW-15.2 Plt Ct-243 [2188-4-1] 10:08PM BLOOD WBC-8.2 RBC-3.47* Hgb-10.8* Hct-32.2* MCV-93 MCH-31.1 MCHC-33.5 RDW-15.3 Plt Ct-180 [2188-3-31] 03:03AM BLOOD WBC-7.6 RBC-3.15* Hgb-9.8* Hct-29.7* MCV-94 MCH-31.1 MCHC-33.0 RDW-15.3 Plt Ct-169 [2188-3-29] 04:11AM BLOOD WBC-10.6 RBC-3.53* Hgb-10.5* Hct-35.3* MCV-100* MCH-29.9 MCHC-29.9* RDW-15.5 Plt Ct-178 [2188-3-28] 10:09PM BLOOD WBC-10.2 RBC-4.04* Hgb-12.2* Hct-38.5* MCV-95 MCH-30.1 MCHC-31.6 RDW-15.5 Plt Ct-208 [2188-4-2] 07:56AM BLOOD PT-14.6* PTT-33.0 INR(PT)-1.3* [2188-3-28] 10:09PM BLOOD PT-12.9 PTT-44.0* INR(PT)-1.1 Chemistries: [2188-4-5] 06:26AM BLOOD Glucose-228* UreaN-85* Creat-10.6# Na-139 K-4.4 Cl-99 HCO3-20 AnGap-24* [2188-4-4] 07:15AM BLOOD Glucose-334* UreaN-126* Creat-12.5# Na-137 K-5.1 Cl-97 HCO3-15 AnGap-30* [2188-3-29] 04:11AM BLOOD Glucose-458* UreaN-112* Creat-8.2* Na-139 K-5.6* Cl-104 HCO3-19* AnGap-22* [2188-3-28] 10:09PM BLOOD Glucose-229* UreaN-112* Creat-8.0* Na-141 K-5.1 Cl-107 HCO3-20* AnGap-19 [2188-4-5] 06:26AM BLOOD Calcium-9.9 Phos-7.3# Mg-3.0 [2188-3-28] 10:09PM BLOOD Calcium-9.5 Phos-6.7* Mg-3.9* Cardiac Biomarkers: [2188-3-30] 11:35AM BLOOD CK-MB-11* MB Indx-8.4* cTropnT-2.07* [2188-3-29] 10:17AM BLOOD CK-MB-14* MB Indx-50.0* cTropnT-1.76* [2188-3-28] 10:09PM BLOOD CK-MB-22* MB Indx-9.2* cTropnT-1.71* Serologies: [2188-4-2] 07:56AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2188-4-2] 07:56AM BLOOD HCV Ab-NEGATIVE PPD- negative Other: [2188-3-29] 04:11AM BLOOD ALT-10 AST-21 CK(CPK)-167 AlkPhos-101 TotBili-0.1 [2188-4-1] 06:50AM BLOOD calTIBC-204* Ferritn-226 TRF-157* [2188-3-30] 05:44AM BLOOD %HbA1c-7.6* eAG-171* ECHO: [2188-3-31] The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is mild global left ventricular hypokinesis (LVEF = 45 %). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild left ventricular cavity dilation with mild global hypokinesis c/w diffuse process (toxin, metabolic, etc., cannot fully exclude multivessel CAD but appears less likely). Mild mitral regurgitation. CXR [2188-3-29] IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Heart is top normal size, with pulmonary vasculature is engorged in the upper lungs. Even though there is no definite pulmonary edema and minimal if any pleural effusion. This may be an indication of acute cardiac decompensation, depending upon the appearance of prior chest radiographs not currently available. No pneumothorax. No focal pulmonary abnormality. ECG: [2188-4-2]: Sinus rhythm. Ventricular ectopy. Right axis deviation. Left bundle-branch block. Compared to the previous tracing of [2188-4-1] ventricular ectopy is more frequent. ECG: [2188-3-29]: Sinus bradycardia with borderline prolongation of P-R interval. Poor R wave progression - cannot exclude prior anteroseptal myocardial infarction. Inferior and lateral ST-T wave changes may be due to left ventricular hypertrophy or myocardial ischemia. Brief Hospital Course: Patient is a 58 year-old man with DM, HTN, COPD, ESRD, history of constrictive pericarditis s/p pericardiectomy transfered from OSH with NSTEMI and evidence of severe two-vessel disease for further management. # CAD: Patient has evidence of severe two-vessel coronary artery disease in the setting of long standing diabetes. He was initially treated with aspirin 325 mg PO daily, Metoprolol 100mg [Hospital1 ], Nifedipine 90mg Daily, heparin drip. Patient was evaluated by CT surgery and was not felt to be a good candidate for CABG. A PCI was performed on [2188-4-1] and 2 drug eluting stents were placed in the left circumflex artery. Stenosis in the LAD will be evaluated as an outpatient under the care of Dr. [Last Name (STitle) 1295]. # CHF: Patient appears to be mildly volume overloaded on exam and would benefit for gentle diuresis. His worsening renal failure also contributed to his volume overload. He was diuresed with iv lasix and metolazone. # Renal failure/end stage renal disease - the patient was begun on dialysis shortly after circumflex stenting. He tolerated three sessions of dialysis well before discharge. He was started on CVVHD on [2188-4-1] after his cardiac catheterization. All diuretics were discontinued on discharge as patient will have volume removal in dialysis. # Psychosocial issues - He appeared depressed about the prospects of dialysis and treatment of coronary artery disease. He was counselled in depth about the prospects of chronic dialysis. # RHYTHM: Patient remained sinus rhythm with no evidence of arrhythmia while monitored on telemtry. # Type I DM: Patient has insulin dependent diabetes mellitus. He was continued on sliding scale insulin and home glargine. His glargine dose had to be decreased from 20 units to 12 units for poor po intake. He was discharged on glargine 17 units at night. # COPD: continued on Duonebs Q6H:PRN # BPH: Continued doxazosin #Code: Full Code (confirmed) Medications on Admission: - Renvela 800mg QID - Ferrex 150mg [Hospital1 ] - Doxazosin 8mg [Hospital1 ] - ASA 325 Daily - MVI - Furosdemide 40mg [Hospital1 ] - Folic Acid 1mg [Hospital1 ] - Metoprolol 100mg [Hospital1 ] - Losartan 100mg Daily - Nifedipine 90mg Daily - Metolazone 5mg Daily - Combivent PRN - Lantus 20 units QAM - NovaLog SSI - NTG PRN Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. polysaccharide iron complex 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: take up to 3 tablets 5 minutes apart. Call 911 if you have chest pain after 3 tablets. . Disp:25 Tablet, Sublingual(s) Refills:0 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take every day, do not miss [First Name (Titles) 691] [Last Name (Titles) 4319]. Disp:30 Tablet(s) Refills:11 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Ext Release 24 hr(s) Refills:2 8. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:270 Tablet(s) Refills:2 9. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:30 Tablet Extended Release 24 hr(s) Refills:2 10. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 11. insulin glargine 100 unit/mL Solution Sig: Seventeen (17) units Subcutaneous QPM. Disp:900 units Refills:2 12. insulin aspart 100 unit/mL Solution Sig: One (1) syringe Subcutaneous four times a day: Take your blood sugar before each meal and before bed. Administer humalog coverage according to the attached sliding scale:. Disp:900 units Refills:2 13. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: End Stage Renal Disease Acute Systolic congestive Heart Failure: no ACE inhibitor because of renal function Type 1 Diabetes Mellitus Hypertension Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 11835], you had a heart attack and received 2 drug eleuting stents in your left circumflex artery. It is extremely important that you continue to take Plavix and aspirin every day to prevent the stent from clotting off and causing another heart attack and possibly death. Please do not miss [First Name (Titles) 691] [Last Name (Titles) 4319] or stop taking Plavix unless Dr. [Last Name (STitle) 656] tells you it is OK. You had some fluid overload and the dialysis was able to take off some fluid. You will not need to take diuretics anymore. Please weigh yourself every morning, call Dr. [Last Name (STitle) 656] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Please look at the frozen foods that you eat to see if they are high in sodium (salt) You should eat no more that 2000mg total of sodium per day. You were started on dialysis here and have been tolerating this well. Your schedule will be Tuesday, Thursday, Saturday and Dr. [Last Name (STitle) ] will follow you regularly after you are discharged. . We made the following changes to your medicines: 1. Increase Sevelamer to 2400mg before meals to lower your phosphate levels. 2. Discontinue Doxazosin, start Tamulosin 0.4mg at night instead to shrink your prostate 3. Change multivitamins to nephrocaps due to your kidney issues 4. Discontinue Furosemide and Metolozone 5. Discontinue Losartan until your creatinine improves 6. Changed Metoprolol Tartrate to Metoprolol Succinate 7. Start Atorvastatin 80mg daily to lower you cholesterol after the heart attack. 8. Start Plavix 75mg daily every day to prevent the stent from clotting off. YOu will be taking this for at least one year 7. Decresae Glargine to 17 units in the pm until your appetite improves and your blood sugars are running higher. 8. Continue to take nitroglycerin under your tongue for chest pain 5 minutes apart, up to 3 tablets. Call 911 if you still have chest pain after 3 tablets and call Dr. [Last Name (STitle) 656] if you have any chest pain whatsoever. Followup Instructions: FMC - [Location (un) 2725] Dialysis Center [Hospital3 89804] [Hospital1 10478], [Numeric Identifier 89805] Phone: 1-[Telephone/Fax (1) 89806] Outpatient dialysis scheduled will be every Tues, Thurs, and Sat at 4:00pm You will see a Nephrologist during your visits Name: [Last Name (LF) ],[First Name3 (LF) ] Specialty: Internal Medicine Address: [Hospital1 ], [Apartment Address(1) 32874], [Location (un) ],[Numeric Identifier 45328] Phone: [Telephone/Fax (1) 23002] Appointment: Friday [4-11] at 9:30AM Name: [Hospital1 656], [Last Name (NamePattern4) 89807] MD Location: HEART CENTER OF [Hospital1 ] Address: [Hospital1 ],[Apartment Address(1) ], [Location (un) ],[Numeric Identifier 8057] Phone: [Telephone/Fax (1) 42422] Appointment: Monday [4-21] at 1:15PM Please bring your discharge info from the hospital to this visit	[ "410.71", "584.9", "600.00", "428.21", "585.6", "285.21", "250.13", "428.0", "496", "403.91" ]	icd9cm	[ [ [] ] ]	[ "00.66", "36.07", "00.40", "00.45", "37.22", "39.95", "88.56" ]	icd9pcs	[ [ [] ] ]	11478, 11484	7189, 9152	281, 376	11697, 11697	3558, 7166	13932, 14861	2349, 2382		9547, 11455		11505, 11676		9178, 9524				11847, 13909									2397, 3539				2073, 2129																						231, 243							404, 1947											11712, 11823			2160, 2191				1969, 2053	2207, 2333
78,904	196,479	3098	Discharge summary	report	Admission Date: [2182-5-5] Discharge Date: [2182-5-13] Date of Birth: [2124-3-15] Sex: M Service: NEUROSURGERY Allergies: Dilantin Attending:[First Name3 (LF) 1835] Chief Complaint: Weakness Major Surgical or Invasive Procedure: [2182-5-8] LEFT OCCIPITAL CRANI FOR MASS History of Present Illness: Mr. [Known lastname 14696] is a 58 year old male with a PMH significant for HTN, HLD, DM 2, and 40+ pack year smoking history admitted for weakness found to have lung and brain masses. The patient reports that he was in his usual state of health until 1 day prior to admission, at which point he had acute onset of weakness while walking with his wife. [Name (NI) ] describes this an an inability to stay standing last for several minutes, after which he felt unsteady but was able to walk home independently. Per the patient's wife, he did not exhibit any difficulty with walking or gait imbalance. He denies any vertigo, headache, lightheadedness, dysarthria, vision changes, tinnitus, CP/SOB, or nausea. This morning, the patient reports that while walking his dogs he experienced a similar episode requiring him to sit down. After approximately 5-10 minutes, he was able to walk back home. Over the course of the day, the patient felt fatigued and stayed in bed, and this evening the patient was brought to [Hospital1 18] by his family for further evaluation. . In the [Hospital1 18] ED, intial VS 95.8 62 138/84 16 100%RA. The patient was had a CXR that demonsrated a right perihilar spiculated mass, and a CTH that demonstrated extensive left parietal lobe vasogenic edema. The patient was seen by Neurology and Neurosurgery, with the recommendation for MRI, and he was admitted to Medicine for further management. . Currently, the patient is resting comfortably. States that he has a [1-6] right sided headache described as right temple pressure. Denies weight loss, night sweats, hematochezia/melena, cough, hemoptysis, dysuria, hematuria, N/V/D, abd pain. ROS is notable for several months of fatigue, unchanged dyspnea on exertion, and a stutter that is worse than baseline over the past several months. Past Medical History: - Normal MIBI in [2178], though echo shows small area of akinesis - HTN - HLD - DM 2 - COPD (emphysema) - GERD/Barrett's esophagus - Elevated PSA s/p normal biopsy in [2175] - Childhood seizure disorder - last event at 11 or 12 years of age - Anxiety/trouble with anger management, on Risperdal - Learning disability - Multiple hernias - Glaucoma bilaterally - Strabismus - Tonsillectomy - Umbilical hernia repair - Right inguinal hernia repair - "Eye operation" at 6-8 years of age because "I was seeing double" Social History: Married. Works in bottle redemption center. Tobacco - Quit [2182-1-24], 1ppdx40+years. EtOH - Denies. Denies IV, illicit, or herbal drug use. Family History: Very strong family history of lung cancer in mother, grandparents, and multiple aunts&uncles. Physical Exam: VS: 97.4 119/81 60 18 96%RA Gen: Age appropriate male in NAD. HEENT: PERRL, eomi, sclerae anicteric. MMM, OP clear without lesions, exudate, or erythema. CV: Nl S1+S2 Pulm: CTAB, no wheezes Abd: S/NT/ND +bs Rectal: OB brown negative (per ED) Ext: No c/c/e. LAD: No cervical, submental, posterior auricular, supraclavicular or axillary lymphadenopathy. Neuro: Oriented to person, place, and time. Speech notable for stutter, no slurring. CN II-XII intact, visual fields intact. ?Pronator drift on right. 5/5 Strength bilaterally upper and lower extremities. -Babinski, 1+ patellar bilaterally, sensation intact to light touch in all extremities. FTN/HTS intact. +Romberg, gait not assessed. ON DISCHARGE: Awake, Alert and Oriented x3 denies h/a, N/V PERRL 3mm, Left lateral gaze MAE's with good strengths following all commmands + dysmetria R>L Pertinent Results: Admission lab results: [2182-5-5] 02:45PM WBC-3.7* RBC-4.59* HGB-13.5* HCT-40.0 MCV-87 MCH-29.3 MCHC-33.6 RDW-14.2 [2182-5-5] 02:45PM NEUTS-50.4 LYMPHS-39.4 MONOS-8.0 EOS-1.9 BASOS-0.3 [2182-5-5] 02:45PM PLT COUNT-137* [2182-5-5] 02:45PM ALT(SGPT)-22 AST(SGOT)-19 LD(LDH)-146 ALK PHOS-48 TOT BILI-0.5 [2182-5-5] 02:45PM ALBUMIN-4.6 CALCIUM-9.3 PHOSPHATE-4.2 MAGNESIUM-1.9 [2182-5-5] 02:45PM GLUCOSE-72 UREA N-15 CREAT-1.0 SODIUM-141 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13 [2182-5-5] 05:15PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.021 [2182-5-5] 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2182-5-5] 05:15PM URINE RBC-0-2 WBC-[3-1] BACTERIA-FEW YEAST-NONE EPI-0-2 MRI Head PRE OP: IMPRESSION: 1. Heterogeneous enhancing lesions in the left parasagittal parieto-occipital lobe and the left cerebellum, with susceptibility artifacts and extensive left parietal parenchymal edema. The constellation of findings is compatible with hemorrhagic brain metastasis with vasogenic edema. In the clinical context of a spiculated pulmonary mass, this is highly suggestive of squamous cell carcinoma metastasis with hemorrhagic components. 2. No hydrocephalus or significant midline shift. CT torso: IMPRESSION: 1. Right lower lobe mass consistent with primary bronchogenic neoplasm. Lymphadenopathy is identified in the ipsilateral hilum and the subcarina. Equivocal lymph nodes are identified in the contralateral mediastinum. 2. No evidence of hepatic metastases. A tiny right adrenal nodule is too small to characterize. CT Head [5-9](Post-op); expected post-operative changes. MRI Head [5-9](Post-op):1. Post-surgical changes, with hemorrhage in the resection cavity, but no definite evidence of residual or recurrent neoplasm. 2. Small punctate focus of decreased diffusion in the posterior left parietal lobe, and deep to the resection cavity, may represent a tiny infarct versus cytotoxic edema. 3. Stable enhancement and intrinsic T1 hyperintense foci in the left cerebellar hemisphere, also likely representing metastatic disease, and unchanged since the prior study. Brief Hospital Course: Mr. [Known lastname 14696] is a 58 year old male with a PMH significant for HTN, HLD, DM 2, and 40+ pack year smoking history admitted for weakness found to have lung and brain masses. . # Weakness: Almost definitely due to malignancy and brain masses. Given the patient's significant tobacco/smoking history, right perihilar mass concerning for primary lung neoplasm, specifically squamous cell lung cancer, with brain metastasis, although cannot rule out another primary at this time. Chief complaint of weakness in the setting of subtle neurologic findings as detailed by Neurology also concerning in setting of left parietal vasogenic edema. He was started on dexamethasone 4mg IV Q6H and got Q4H neuro checks. Given his history of a Dilantin as a child, he was started on Keppra for seizure prophylaxis. His neurologic exam remained stable, but given the size of the brain mass, he was taken by neurosurgery for surgical resection [2182-5-8]. . # DM 2: His Glipizide and Actos/Metformin forumulation were held. He was covered with a Humalog sliding scale QACHS. . # COPD: Respiratory status stable without hypoxemia. He was initially on an ipratropium inhaler QID, but was then changed back to his home tiotropium daily. Did not require an albuterol rescue. . # Learning disability/anger management: He was continued on his Risperdal. After speaking with the patient and his outpatient case manager, it was felt that he was competent to make his own medical decisions. He was able to articulate understanding of the need for surgery and the potential risks involved. He signed papers to have his uncle, [Name (NI) ] [Name (NI) 14696], as his health care proxy. On [5-8], Mr. [Known lastname 14696] was transferred from the medicine team, to neurosurgery team following open craniotomy for resection of brain mass. He was taken to the ICU for frequent neurological examinations and systolic blood pressure control. He was kept in the ICU until the morning of [5-10], when he was transferred to the floor. His pain was well controlled and his neurological exam remained unchanged. His dexamethasone taper began on [5-10]. On [5-11] he was seen by physical therapy and occupational therapy. His neurological exam remained unchanged. He continued to work with PT on [5-12] and was cleared for discharge home with PT and VNA. He remained inhouse until discharge plans could be coordinated with the hospital social worker and his personal social worker. He was discharged to home on [5-13] with physical therapy and VNA. Medications on Admission: Risperidone 0.5mg [Hospital1 ] Crestor 40mg daily Glipizide ER 5mg daily Actos/metformin 15/850 [Hospital1 ] Tiotropium 1 puff daily Alendronate 75mg weekly Omeprazole 20mg [Hospital1 ] Ca+Vit D [Hospital1 ] ASA 81 daily Timolol 1 drop OU QHS Alendronate weekly Finasteride 5mg daily Discharge Medications: 1. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, headache. 4. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for Wheezing, SOB. 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 12. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic QHS (once a day (at bedtime)). Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Left Occipital mass, left cerebellar masses x2 Discharge Condition: Neurologically Stable Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE: ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You may wash your hair with a mild shampoo 24 hours after your sutures are removed. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. Be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation. MEDICATIONS: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: -Narcotic pain medication such as Dilaudid (hydromorphone). -An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? You were on Aspirin, prior to your surgery, you may safely resume taking this at one month after surgery. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ACTIVITY: The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: FOLLOW UP APPOINTMENT INSTRUCTIONS ??????Please return to the office in [10-10] days (from your date of surgery) for removal of your sutures and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You will be set up for Whole Brain radiation in [Location (un) 47]. One month following the radiation, you will be seen in the Brain [Hospital 341] Clinic. If you are not contact[Name (NI) ] with an appointment time, please call [Telephone/Fax (1) 1844] to set up this appointment. ??????You will not need an MRI of the brain as this was done during your hospitalization. Completed by:[2182-5-14]	[ "250.00", "530.81", "162.8", "287.5", "496", "345.90", "272.4", "348.5", "198.3", "300.00", "401.9", "285.9" ]	icd9cm	[ [ [] ] ]	[ "02.12", "00.39", "01.59" ]	icd9pcs	[ [ [] ] ]	10539, 10598	6153, 8728	281, 328	10689, 10713	3889, 6130	15911, 16731	2914, 3009		9078, 10516		10619, 10668		8754, 9055				10737, 10758									3024, 3715																	3729, 3870								14080, 15888	233, 243					10770, 14053		356, 2191																		2213, 2735	2751, 2898
13,966	166,620	6268	Discharge summary	report	Admission Date: [2187-10-7] Discharge Date: [2187-10-10] Date of Birth: [2113-6-1] Sex: M Service: TRAUMA. HISTORY OF THE PRESENT ILLNESS: This is a 74-year-old man with underlying dementia secondary to Alzheimer disease who fell down the stairs on the day of admission resulting in loss of consciousness. Initially, he had mildly slurred speech with mild word-finding difficulties. He was brought to the [Hospital1 69] by EMS, boarded and collared. At the time he had a GCS of 15. He was hemodynamically stable. He was following commands without any complaints. He did have positive emesis. PAST MEDICAL HISTORY: History is significant for Alzheimer. PAST SURGICAL HISTORY: History is significant for status post CABG times four in [2179]. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: Prozac 40 mg p.o.q.d. SOCIAL HISTORY: The patient denied any alcohol or tobacco use. PHYSICAL EXAMINATION: Physical examination in the emergency department revealed that he was afebrile with a pulse in the 100 range and blood pressure of 160/palpable, saturation 98%. He was alert and oriented with pupils equal, round, and reactive to light going from 3 mm to 2 mm. Tympanic membranes were clear bilaterally. Trachea was midline. Lungs were clear to auscultation. He had no tenderness or stepoff on his chest. His cardiac examination was regular. Abdomen was soft, nontender, and nondistended. Extremities were warm and well perfused. He was moving all four extremities with gross sensory intact. His pulse was stable. Rectal was normal tone. Back showed low lumbar tenderness, no stepoffs. HOSPITAL COURSE: The patient was evaluated in the emergency room and taken to the Department of Radiology, where he underwent an emergency head CT, which showed a small interparenchymal paraventricular hemorrhage on the right without other significant lesions. The patient also underwent a T and L spine, which was negative, as well as a C-spine, CT, which showed degenerative cervical spinal changes. His chest x-ray was without any pneumothorax or hemothorax and his pelvis showed no fractures. At this time, he was admitted to the Surgical Intensive Care Unit for every one hour neurochecks and control of blood pressure and further monitoring given his intracranial hemorrhage. The patient spent two days in the Surgical Intensive Care Unit, where he required a Nipride drip to control the blood pressure, which was in the 60s to 200s systolic prior to the initiation of the drip down to the 120s to 130s on Nipride. He appeared to be doing well. He underwent two subsequent CT scans of his head on consecutive days, which demonstrated stability of the paraventricular hemorrhage. He was transitioned from Nipride over to Lopressor for blood pressure control. He had a stable hematocrit, persistently above 30, and he was transferred to the floor on [10-9]. He was a little confused requiring Haldol. This was believed to be secondary to recent head trauma, as well as his ICU stay. This condition resolved over the next couple of days. He had an MR of his spine, which demonstrated no acute ligamentous injuries, although, it was of poor quality secondary to motion artifact. His cervical spine was cleared both radiographically and clinically without any tenderness in the posterior midline. At this time, it was felt that the patient was stable for discharge. At the time of discharge he was following commands. He was back to his baseline mental status per the family. He was tolerating a regular diet. His Foley was removed and he was able to void. DISCHARGE MEDICATIONS: The patient was discharged on the following medications: 1. Prozac 40 mg p.o.q.d. 2. Lopressor 25 mg p.o.b.i.d. 3. Tylenol p.r.n. FOLLOW-UP CARE: He was instructed to followup with the [Hospital 16364] Clinic for a repeat MRI in one to two months. The phone # for the [Hospital 16364] Clinic was listed as [Telephone/Fax (1) 1669]. He was also evaluated by his primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) ] with whom he would also followup at [Telephone/Fax (1) 608]. He was, otherwise, stable. He was also discharged with a home-safety evaluation visiting nursing association. DISCHARGE DIAGNOSIS: 1. Alzheimer dementia. 2. Status post closed-head injury. 3. Coronary artery disease status post coronary artery bypass grafting times four. 4. Hypertension. DR.[Last Name (STitle) 3598],[First Name3 (LF) ] 02-352 Dictated By:[Dictator Info ] MEDQUIST36 D: [2187-10-10] 14:18 T: [2187-10-10] 14:35 JOB#: [Job Number 24359]	[ "293.0", "E849.0", "V45.81", "E880.9", "853.02", "294.10", "331.0", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]									3670, 4322		4343, 4730			1685, 3646											723, 885																973, 1667																																				660, 699	902, 950
49,853	179,842	41633	Discharge summary	report	Admission Date: [2138-9-26] Discharge Date: [2138-9-30] Date of Birth: [2089-1-6] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3063] Chief Complaint: diarrhea, tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: 49M w/PMHx HIV (CD4 114 in [5-/2138], kaposi's sarcoma) referred in from primary care office due to tachycardia in the setting of diarrhea, nausea, and vomiting x 5 days although nothing since the AM (non bloody, no bilious). Pt reports diarrhea/loose stools once a day x 5 days, non bloody, decreased apetite, fatigue and malaise. He was feeling better today but decided to see PCP. [Name10 (NameIs) ] PCP office, patient noted to behypoxemic to low 90s and tachycardic so he was sent to the ED. Pt reported to the [Name (NI) ], pt was hypoxemic 92% on RA and tachy in the 130s. CT torso was performed and showed bilateral PEs for which he was started on heparin gtt wtih bolus. CT also revealed mesenteric mass suggestive of possible carcinoid tumor vs chronic sclerosing mesenteritis, amyloidosis, calcified metastatic implants, peritoneal echinococcus. Lactate was elevated at 7.8 and he was given 2L IVF and cefepime and vancomycin. In the ED, initial VS were: 99.5 135 162/110 92 Labs: lactate 7.8, Lytes Na 136, K 3.6, Cl 96, bicarb 23, BUN 15, Cr 0.6, Gluc 188 UA sg 1025, pH 6.5, Urobil 2, sm blood, tr protein WBC: 4.1, HCT 41, PLT 93, MCV 134, Neut 78, L 16, D Dimer 8882 Imaging notable for bilateral PEs and mesenteric mass 8x2x2cm, Given 2g cefepime, 1g vano, heparin gtt. Given total of 2L of IVF. Access: 18 g x2 Vitals prior to transfer: HR 101, 157/90, 95%on 2L, comfortable appearing, eating food in the ED. On arrival to the MICU, pt is comfortable, well-appearing, no acute distress, conversant. Vitals T 99.4, HR 103, 130/63, RR 20, 97% on 2L. He denies any flushing, no bronchospasm, no telangiectasias. Past Medical History: --HIV: diagnosed [11/2124] in setting of Cryptosporidium diarrhea, CD4 19, viral load 133,000. Treatment [2124]-[2134]: D4t, 3TC, efavirenz (had resistant mutations K103N, M184V) [2134]-present: 3TC/TDF, atazanavir/rtv -- kaposis sarcoma of feet and LE, stage I-II per bx and CXR --sialadenitis, resolved --ASCUS on anal papsmear-->high res biopsies then neg --HepB infection-cleared -- mod-severe MR [Name13 (STitle) ]/o positive PPD with CXR negative in [2114], repeat PPD negative [2125] Social History: originally from [Last Name (LF) 90491], [First Name3 (LF) ]. Has a brother--also gay--and a sister. Educational background: has a J.D. and an interest in history. He works in research administration at the [Hospital ] Hospital. Has had a tumultuous living situation over the past few months due to a breakup with his recent partner of several years. He now lives alone in an apartment [Location (un) 90492]. He has never smoked, denies ever having used drugs, including IVD, and drinks about 2 EtOH drinks a day (beer). He is not currently sexually active and says his last sexual activity was over a year ago. When sexually active, he engages in receptive anal sex and oral sex. No IV drugs, no cocaine or heroine. Family History: uncle was an alcoholic. Family member with heart valve problem. Physical Exam: ADMISSION Vitals: HR 101, 157/90, 95%on 2L General: Alert, oriented, no acute distress, conversant HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, sinus tachy, 3/6 systolic murmur left sternal border, no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding, normal active bowel sounds GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis,possible vry trace edema bilaterally Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation. No LAD of groin, axilla, neck Pertinent Results: Admissions Labs: [2138-9-26] 01:10PM BLOOD WBC-4.1 RBC-3.10* Hgb-13.4* Hct-41.3 MCV-134* MCH-43.4* MCHC-32.5 RDW-12.9 Plt Ct-93# [2138-9-26] 01:10PM BLOOD Neuts-78.7 Lymphs-16.9* Monos-3.2 Eos-0.4 Baso-0.8 [2138-9-26] 10:50PM BLOOD PT-10.4 PTT-78.1* INR(PT)-1.0 [2138-9-26] 01:10PM BLOOD Glucose-188* UreaN-15 Creat-0.6 Na-136 K-3.6 Cl-96 HCO3-23 AnGap-21* [2138-9-26] 01:10PM BLOOD ALT-45* AST-96* AlkPhos-67 TotBili-3.2* [2138-9-26] 01:10PM BLOOD Albumin-4.3 [2138-9-26] 01:10PM BLOOD D-Dimer-8882* Discharge Labs: [2138-9-30] 07:20AM BLOOD WBC-3.1* RBC-2.83* Hgb-12.4* Hct-37.1* MCV-131* MCH-43.7* MCHC-33.4 RDW-13.6 Plt Ct-106* [2138-9-30] 07:20AM BLOOD PT-9.5 PTT-55.8* INR(PT)-0.9 [2138-9-30] 07:20AM BLOOD Glucose-91 UreaN-10 Creat-0.9 Na-138 K-4.0 Cl-102 HCO3-29 AnGap-11 [2138-9-29] 06:16AM BLOOD ALT-40 AST-67* LD(LDH)-171 AlkPhos-46 TotBili-2.7* [2138-9-30] 07:20AM BLOOD TotProt-6.2* Calcium-8.9 Phos-4.4 Mg-2.2 Other Labs: [2138-9-27] 05:10AM BLOOD WBC-3.4* Lymph-29 Abs [Last Name (un) ]-986 CD3%-92 Abs CD3-906 CD4%-12 Abs CD4-114* CD8%-80 Abs CD8-786* CD4/CD8-0.1* [2138-9-29] 06:16AM BLOOD Ret Aut-3.2 [2138-9-28] 05:55AM BLOOD VitB12-397 Folate-3.6 [2138-9-30] 07:20AM BLOOD TSH-4.1 [2138-9-27] 05:10AM BLOOD IgM HAV-NEGATIVE [2138-9-30] 07:20AM BLOOD PEP-NO SPECIFI [2138-9-27] 05:10AM BLOOD HCV Ab-NEGATIVE [2138-9-26] 01:18PM BLOOD Lactate-7.8* [2138-9-26] 02:33PM BLOOD Lactate-6.1* [2138-9-27] 12:02AM BLOOD Lactate-1.8 [2138-9-27] 05:10AM BLOOD Hapto-5* [2138-9-27] 04:45PM BLOOD Hapto-25* [2138-9-29] 06:16AM BLOOD Hapto-36 [2138-9-27] 01:51AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.018 [2138-9-27] 01:51AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-7.0 Leuks-NEG [2138-9-27] 01:51AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 Pending Labs: [2138-9-30] 07:20AM BLOOD METHYLMALONIC ACID-PND [2138-9-29] 06:16AM BLOOD HERPESVIRUS 8 (HHV-8) DNA, QUALITATIVE PCR W/REFLEX TO [Doctor Last Name ]-PND [2138-9-28] URINE HISTOPLASMA ANTIGEN-PND [2138-9-30] STOOL [Location (un) ]-LIKE VIRUS (NLV) ANTIGEN, EIA-PND [2138-9-30] STOOL VIRAL CULTURE-PENDING [2138-9-26] BLOOD CULTURES PENDING x 2 Micro Studies: C. difficile DNA amplification assay (Final [2138-9-27]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. FECAL CULTURE (Final [2138-9-28]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2138-9-29]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [2138-9-29]): NO OVA AND PARASITES SEEN. FECAL CULTURE - R/O VIBRIO (Final [2138-9-29]): NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [2138-9-29]): NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [2138-9-28]): NO E.COLI 0157:H7 FOUND. Cryptosporidium/Giardia (DFA) (Final [2138-9-29]): NO CRYPTOSPORIDIUM OR GIARDIA SEEN. HIV-1 Viral Load/Ultrasensitive (Final [2138-9-30]):153 copies/ml. HBV Viral Load (Final [2138-9-30]): HBV DNA not detected. CMV Viral Load (Final [2138-9-30]): CMV DNA not detected. [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgG AB (Final [2138-9-29]): POSITIVE BY EIA. [Doctor Last Name ]-[Doctor Last Name ] VIRUS EBNA IgG AB (Final [2138-9-29]): POSITIVE BY EIA. [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgM AB (Final [2138-9-29]): NEGATIVE <1:10 BY IFA. -INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. Radiology: CXR - FINDINGS: The heart size is at the upper limits of normal. The mediastinal and hilar contours are normal. The lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process; please refer to the report from chest CTA performed on the same day. CTA Chest, CT A/P: FINDINGS: CHEST CTA: Enhanced pulmonary vasculature demonstrates multiple bilateral filling defects consistent with acute pulmonary emboli involving most lobar, segmental and subsegmental pulmonary arteries with relative sparing of the left upper lobe branches. The aorta and major branches are normal. There is no axillary, hilar, or mediastinal lymphadenopathy. The airways are patent to the subsegmental levels. There is mild bibasilar atelectasis, but the lungs are without focal consolidation, effusion, or pneumothorax. A tiny granuloma is noted in the right apex (2:8). CT OF THE ABDOMEN WITH IV CONTRAST: The liver is diffusely hypodense suggestive of fatty replacement. Otherwise, the liver, gallbladder, spleen, pancreas, bilateral kidneys, bilateral adrenal glands, stomach, visualized loops of small and large bowel are within normal limits. The celiac, SMA, and [Female First Name (un) 899] are widely patent. The portal and splenic veins are patent. There is no free fluid or free air in the abdomen. There is no mesenteric or retroperitoneal lymphadenopathy by CT size criteria. A calcified soft tissue mass is noted in the root of mesentery with irregular margins and finger-like projections. There is adjacent tethering of bowel without bowel obstruction. The major venous structures appear patent though given the presence of mild mesenteric edema, venous compromise is likely present to some degree. Approximate measurements of this mass are 0.9 cm (transverse) x 2.3 cm (craniocaudal) x 1.9 cm (anterior-posterior). CT OF THE PELVIS WITH IV CONTRAST: The bladder, rectum, prostate, and sigmoid colon are within normal limits. There is no free fluid or free air in the abdomen. There is no pelvic or inguinal lymphadenopathy by CT size criteria. OSSEOUS STRUCTURES: A sclerotic focus is noted in the right femoral head likely represent a bone island (3B:158). There are no lytic or sclerotic foci suspicious for malignancy. Mild degenerative changes are visualized throughout the thoracolumbar spine with disc vacuum phenomenon at L5-S1. IMPRESSION: 1. Bilateral pulmonary emboli. 2. Calcified mass in the root of small bowel mesentery measuring approximately 7.9 x 2.3 x 1.9 cm with tethering of adjacent small bowel. Ddx includes carcinoid tumor vs chronic sclerosing mesenteritis, vs less likely amyloidosis. ECHO: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Diastolic function could not be assessed. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate/severe posterior leaflet mitral valve prolapse. A late systolic jet of moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Moderate to severe prolapse of the posterior leaflet of the mitral valve with moderate to severe mid-systolic mitral regurgitation. Mild elevation of pulmonary artery systolic pressure. Brief Hospital Course: 49M w/PMHx HIV (CD4 114 in [5-/2138], kaposi's sarcoma) referred in from primary care office due to tachycardia, diarrhea, fatigue x5 days with CT Torso revealing bilateral PEs as well as mesenteric mass. # Diarrhea/Vomiting: Given patient's immunosuppression, the differential diagnosis was broad. Stool studies were sent and were negative for c.diff, salmonella, shigella, campylobacter, O&P, vibrio, yersinia, e.coli, crypto, giardia. Stool viral culture and vibrio were pending at the time of discharge. Pt has mesenteric mass that may represent carcinoid tumor which can also manifest as diarrhea/tachycardia/mitral regurge murmur. However, diarrhea self-resolved several days after admission and did not recur. # Tachycardia: Etiology is likely multifactorial and includes ?carcinoid syndrome, tachycardia secondary to hypovolemic state in setting of diarrhea, PE induced sinus tachycardia. Tachycardia improved with treatment of PE and was resolved by the time of discharge. # Bilateral PEs: pt at risk given possible underlying malignancy. Started on heparin drip and then transitioned to lovenox. Pt will remain on lovenox until after his mesenteric mass is excised. # Mesenteric Mass: Surgery was consulted for excisional biopsy; however, it was decided to wait a few weeks to allow for PE clot burden to decrease. Pt will follow in surgery clinic for surgery planning. Pt was seen by [Location (un) 2274] onc who will follow up with him after biopsy is performed. # Transaminitis: Admission transaminases were ALT 40, AST 90, [Female First Name (un) ] 3.2. EBV studies showed prior infection. CMV, HBV, and HCV were negative. It was felt that bilirubinemia (which was predominately indirect) could be related to atazanavir. However, transaminases remained mildly elevated. This will need to be followed in the outpatient setting. # Thrombocytopenia: PLT baseline 130-200s, was 90s on admission. Differential includes destruction (Ex: ITP, TTP, DIC), poor production (marrow involvement), splenic sequestration. TTP unlikely since preserved HCT, no shisto on peripheral lab count. HIV is often associated with thrombocytopenia independently. Platelet count remained stable. Other viral studies were negative as above. Plt count will need to be followed in outpatient setting. # Anemia: Initially with some suggestion of hemolysis (low hapto), however, hap to returned to [Location 213]. MCV quite elevated. B12 and folate borderline low, so supplementation was started. Will need further evaluation as an outpatient. # Mitral Regurgitation: Pt with history of severe MR, confirmed on echo during this admission. # HIV/AIDS: Has biopsy proven stage I-II kaposis sarcoma. Continued home meds: Atazanavir 300mg daily, truvada 200-300 daily, norvir 100mg daily. CD4 count 114. Viral load153. Pt was seen by ID during admission and will follow in [Hospital 18] [Hospital ] clinic after discharge. Transitional Issues: - PENDING labs - MMA, HHV8 viral load, urine histoplasma Ag, stool norovirus Ag, stool viral cutlure, blood cultures - will need outpt surgery eval for mass excision - will remain on lovenox until after excision, then should be transitioned to coumadin - all need [Location (un) 2274] onc f/u after mass is excised - will need further outpatient evaluation of thrombocytopenia, anemia, and transaminitis Medications on Admission: Atazanavir 300mg emtricitabine-tenofovir (truvada) 200-300mg, daily Ritonavir (Norvir) 100mg daily Discharge Medications: 1. Atazanavir 300 mg PO DAILY 2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 3. RiTONAvir 100 mg PO DAILY 4. Atovaquone Suspension 1500 mg PO DAILY RX atovaquone [Mepron] 750 mg/5 mL 10 mL(s) by mouth daily Disp #900 Milliliter Refills:0 RX atovaquone [Mepron] 750 mg/5 mL 10 mL by mouth daily Disp #40 Milliliter Refills:0 5. Cyanocobalamin 250 mcg PO DAILY RX cyanocobalamin (vitamin B-12) 250 mcg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Enoxaparin Sodium 80 mg SC Q12H RX enoxaparin 80 mg/0.8 mL inject 0.8 mL every 12 hours Disp #60 Syringe Refills:0 RX enoxaparin 80 mg/0.8 mL inject one syringe (80 mg) every 12 hours Disp #8 Syringe Refills:0 7. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diarrha, NOS Pulmonary Embolus Mesenteric Mass Secondary HIV/AIDS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with diarrhea and a fast heart rate. You had a CAT scan which showed blood clots in the lungs and a mass in your abdomen. For your diarrhea, you were seen by the infectious disease doctors. Stool studies were sent. At the time of discharge, all of your stool studies were either negative or still pending. These will be followed up by your PCP. [Name10 (NameIs) 2172] diarrhea had resolved at the time of discharge. For your blood clots, you were started on blood thinners (heparin, then switched to lovenox). You will ultimately need to be started on coumadin. However, this will not happen until after your mass is removed. For your abdominal mass, you were seen by the surgeons and the oncologists. It was decided to wait a few weeks before removing the mass to allow you to recover from the blood clots. You will follow-up with the surgeons to plan this procedure. After your mass is removed, you should also follow-up with the [Location (un) 2274] oncologists. MEDICATION CHANGES - start lovenox for your blood clots - start vitamin B12 and folic acid - start atovaquone (to prevent pneumonia) - continue your HIV medications as you were taking them * You were given a short supply of the Lovenox and atovaquone until your mail order medications arrive. * It was a pleasure taking part in your medical care. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) 2890] M. Location: [Hospital1 641] Address: [University/College 2899], [Location (un) ],[Numeric Identifier 2900] Phone: [Telephone/Fax (1) 2115] APPOINTMENT Monday [2137-10-5]:30am With: [Last Name (LF) 853],[First Name3 (LF) ] R. Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: MONDAY [2138-10-6] at 2:30 PM ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 23870], MD [Telephone/Fax (1) 457] Department: INFECTIOUS DISEASE When: WEDNESDAY [2138-11-12] at 11:00 AM Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "284.19", "787.91", "176.1", "415.19", "427.89", "285.9", "070.30", "787.01", "795.51", "790.4", "266.2", "042", "276.2", "235.4", "424.0", "796.71" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	15849, 15855	11518, 14455	325, 332	15974, 15974	4146, 4678	17523, 18500	3317, 3383		15035, 15826		15876, 15953		14911, 15012				16125, 17500			4694, 5122						3398, 4127																		14476, 14885								264, 287							360, 2007											15989, 16101							2029, 2550	2566, 3301			5134, 11495
32,522	148,268	32126+57786	Discharge summary	report+addendum	Admission Date: [2143-12-3] Discharge Date: [2143-12-24] Date of Birth: [2067-4-21] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4748] Chief Complaint: AAA Major Surgical or Invasive Procedure: Open AAA repair [2143-12-3] attempted ERCP [2143-12-18] Right IJ tunneled cath & L subclavian CVL placement [2143-12-19] History of Present Illness: 75 y/o female with known asymptomatic AAA x six years now increasing in size to 5.5cm. She now presents to [Hospital1 18] for repair of her AAA. Past Medical History: AAA history of aortic valve disease, stenosis history of pulmonary hypertension with diastolic LVF dysfunction EF 76% history of hypertension history of dyslipidemia history of former tobacco use x 58 pk yrs (quit [2142]) history of arthritis history of carotid plaques bilaterally without stenosis by U/S history of gastritis, gastric ulcer s/p subtotal gastrectomy [2113] history of nephrolithiasis and renal cyst by CT scan postoperative ischemic colitis, s/p colonoscopy postoperative acute renal failure started on hemodialysis postoperative thrombocytopenia, HIT negative postoperative cholecystitis with pancreatitis, resolving s/p attempetd ERCP postoperative blood loss anemia, transfused postoperative volume overload secondary to renal failure postoperative failure to thrive, s/p TPN Social History: former smoker denies EtOH use Family History: unknown Physical Exam: 98.4, HR 73, BP 142/54, RR 16, 97% on 2L NC GEN: NAD HEENT: soft bilateral carotid bruits L>R Lungs: clear to auscultation HEART: RRR 2/6 harsh ejection mumur at base transmitted to carotid and apex ABD: soft nontender nondistended, well-healed midline abdominal incision PV: palpable femoral pulses bilaterally, pedal pulses dopperable bilaterally Neuro: nonfocal Pertinent Results: [2143-12-3] 10:58AM BLOOD WBC-16.2# RBC-4.09 Hgb-13.6 Hct-40.5 MCV-99* MCH-33.3* MCHC-33.6 RDW-16.1* Plt Ct-190 [2143-12-3] 10:58AM BLOOD PT-14.1* PTT-52.5* INR(PT)-1.3* [2143-12-3] 10:58AM BLOOD Glucose-162* UreaN-24* Creat-1.5* Na-140 K-4.3 Cl-109* HCO3-18* AnGap-17 [2143-12-4] 12:17AM BLOOD ALT-434* AST-567* AlkPhos-53 Amylase-146* TotBili-0.3 [2143-12-5] 03:07AM BLOOD Lipase-59 [2143-12-3] 10:58AM BLOOD CK-MB-5 cTropnT-<0.01 [2143-12-3] 10:58AM BLOOD Calcium-12.1* Phos-7.1* Mg-2.2 [2143-12-23] 09:06PM BLOOD WBC-7.8 RBC-3.12* Hgb-9.9* Hct-29.5* MCV-95 MCH-31.8 MCHC-33.6 RDW-16.6* Plt Ct-364 [2143-12-23] 09:06PM BLOOD Plt Ct-364 [2143-12-24] 03:52AM BLOOD Glucose-98 UreaN-43* Creat-3.7* Na-139 K-3.5 Cl-101 HCO3-25 AnGap-17 [2143-12-22] 04:46AM BLOOD Amylase-108* [2143-12-22] 04:46AM BLOOD Lipase-149* [2143-12-24] 03:52AM BLOOD Calcium-7.9* Phos-4.4 Mg-2.5 [2143-12-8] 04:16AM BLOOD Triglyc-71 [2143-12-16] 08:21PM BLOOD Lactate-1.3 [2143-12-16] 08:21PM BLOOD freeCa-1.06* [2143-12-4] sigmoidoscopy report Erythema, ulceration and friability in the distal sigmoid colon extending through out the proximal descending colon compatible with ischemic colitis The rectal mucosa was normal, there was no evidence of ulcerations or bleeding. RENAL U.S. PORT [2143-12-5] 10:46 AM 1. Markedly abnormal blood flow to the right kidney. This raises concern for renal artery thrombosis. 2) Normal flow to the left kidney. CT ABDOMEN W/O CONTRAST [2143-12-14] 8:39 PM 1. Interval development of mild-to-moderate pleural effusions and small ascites. The free fluid within the pelvis is slightly dense which may represent a component of blood likely related to recent procedure. Cannot rule out acute extravasation due to lack of IV contrast. 2. Bilateral tiny nonobstructive renal stones. 3. Dilated CBD with a 9-mm hyperdense focus within the lumen that could represent a stone. Ultrasound is recommended for further characterization. CT ABDOMEN W/O CONTRAST [2143-12-15] 9:30 AM 1. Exam is still limited by small amount of oral contrast and lack of progression distally. There is still suggestion of wall edema involving the sigmoid colon with remaining intrapelvic bowel appearing unremarkable. No evidence of free air or pneumatosis. 2. Unchanged choledocholithiasis better appreciated on recent ultrasound. Unchanged renal calculi. 3. Stable bilateral simple pleural effusions and adjacent compression atelectasis. Unchanged mild-to-moderate amount of slightly hyperdense free fluid within the abdominal and pelvic cavity. No evidence of retroperitoneal hemorrhage. 4. Unchanged caliber of sub 4-cm abdominal aortic aneurysm status post repair. US ABD LIMIT, SINGLE ORGAN [2143-12-15] 9:39 AM Choledocholithiasis with probable cholelithiasis and findings suggestive of acute vs chronic cholecystitis. Please note in retrospect CBD stone/dilatation appears to have been present on [Month (only) 359] CT [2143-12-18] ERCP Evidence of a previous gastrojujenostomy was seen. The scope was passed through both anastomotic limbs but could not reach the papilla due to either long limb B II or Roux-en-Y anatomy. Brief Hospital Course: [2143-12-3] AAA resection, transfered to PACU intubated and sedated. [2143-12-4] POD#1 remained sedated and intubated. episode of hypotension requiring fluid resustation and dobutamine. HCT 33.5 episode of bright red rectal bleeding. Followed by acute pain service for epidural. patient oliguric and acidotic. GI consulted for bloody stools. Sigmoidoscopy performed: Ischemic colitis of sigmid colon extending to proximal descending colon. General surgery consulted and recommended conserative managment and serial exams. [2143-12-5] POD#2 oligutia continued with climbing creatinine. Renal consulted for CVVH. Thrombocytopenia- HIT sent.(negative) [2143-12-6] POD#3 remained intubated. continued IV zosyn. continued epidural. New radial line placed. Lasix began. CVL changed. [2143-12-7] POD#4 minimal response to lasix. CVVH and TPN started, epidural cath discontinued. [2143-12-8] POD#5 remained in ICU care. [2143-12-9] POD#6 status slowly improved, now on pressure support. [2143-12-10] POD#7 continued CVVH, swan [Last Name (un) ] catheter converted to CVL. Zosyn discontinued. [2143-12-11] POD#8 insulin gtt for hyperglycemia. CVVH discontinued. Hemodialysis instituted. [2143-12-12] POD#9 hemodialyis short run secondary to hypotension. transfuse for HCT of 24 post transfusion Hct.28 CVVH restarted. [2143-12-14] POD#11 extubated. transfused for Hct 26. hemodialyis trial [2143-12-15] POD#12 Zosyn restartred for persistant elevated WBC and CT findings of " fluid in the pelvis" [2143-12-16] POD#13 a-line discontinued. TPN continued. clear sips started for ERCP [2143-12-17].POD#14 Transfered to VICU. U/S performed that demonstrated RUQ common bile duct diltation. [2143-12-18] POD#15 attempted ERCP, unable to reach ampulla due to previous subtotal gastrectomy [2143-12-19] POD#16 tunneled right IJ line placed by transplant for HD. TPN d/c'd, diet advanced. LFT's improving. [2143-12-21] POD#18 HD performed [2143-12-22] POD#19 abdominal incision staples d/c'ed [2143-12-24] POD#21 Pt's creatinine plateau'ed. Pt again dialyzed. Per nephrology, it appears that the patient will not need hemodialysis for an extended period of time. Zosyn d/c'ed, left triple lumen catheter d/c'ed. Pt d/c'ed from [Hospital1 18] to [Hospital 29158] rehab. Medications on Admission: Zestril 20', HCTZ 12.5', Simvastatin 40', Asa 81' Discharge Medications: 1. Erythromycin 5 mg/g Ointment Sig: 0.5 inch OU Ophthalmic QID (4 times a day). 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed. 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual 2X (TIMES 2). 11. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed. 12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [Hospital 5503] Rehab Hospital Discharge Diagnosis: AAA history of aortic valve disease, stenosis history of pulmonary hypertension with diastolic LVF dysfunction EF 76% history of hypertension history of dyslipidemia history of former tobacco use x 58 pk yrs (quit [2142]) history of arthritis history of carotid plaques bilaterally without stenosis by U/S history of gastritis, gastric ulcer s/p subtotal gastrectomy [2113] history of nephrolithiasis and renal cyst by CT scan postoperative ischemic colitis, s/p colonoscopy postoperative acute renal failure started on hemodialysis postoperative thrombocytopenia, HIT negative postoperative cholecystitis with pancreatitis, resolving s/p attempetd ERCP postoperative blood loss anemia, transfused postoperative volume overload secondary to renal failure postoperative failure to thrive, s/p TPN Discharge Condition: stable Discharge Instructions: What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [7-12] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [3-9] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Follow up in 2 weeks with Dr. [Last Name (STitle) 1391]. Please call ([Telephone/Fax (1) 14585] for an appointment. Follow up 2-4 weeks after discharge from rehab with nephrologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4883]. Please call ([Telephone/Fax (1) 24866] for an appointment. Name: [Known lastname 7884],[Known firstname ] Unit No: [Numeric Identifier 12364] Admission Date: [2143-12-3] Discharge Date: [2143-12-24] Date of Birth: [2067-4-21] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 231] Addendum: The patient was discharged to rehab on oxygen by nasal cannula. Instructions were given to titrate the oxygen to maintain SpO2 greater than 93%. Discharge Disposition: Extended Care Facility: [Hospital 2653] Rehab Hospital [First Name11 (Name Pattern1) 77] [Last Name (NamePattern1) 237] MD [MD Number(1) 238] Completed by:[2143-12-24]	[ "585.6", "997.5", "577.0", "428.30", "575.10", "428.0", "285.1", "403.91", "441.4", "557.9", "584.5", "998.11" ]	icd9cm	[ [ [] ] ]	[ "38.91", "38.95", "38.93", "48.23", "96.6", "38.44", "39.95", "51.10" ]	icd9pcs	[ [ [] ] ]	13119, 13338	5169, 7509	319, 454	9686, 9695	1931, 5146	12235, 13096	1522, 1531		7609, 8754		8859, 9665		7535, 7586				9719, 11783	11809, 12212								1546, 1912																										276, 281							482, 632																		654, 1459	1475, 1506
22,761	141,033	6880+6881	Discharge summary	report+report	Admission Date: [2192-3-12] Discharge Date: Date of Birth: [2144-5-11] Sex: M Service: Internal Medicine history of criminal behavior, antisocial personality disorder, spina bifida, recurrent urinary tract infections, well-documented pain medication seeking behavior, who presents with a undergone an incision and drainage at [Hospital3 2576] [Hospital ] medical advice from that hospital complaining of poor treatment from the nursing staff. The patient now complains of left groin pain extending over his perineum and scrotum. He says he was diagnosed with HIV and hepatitis C at [Hospital1 2025]. At the time of admission, the patient was refusing IVs and recommended Haldol, schedule clonazepam, and p.r.n. lorazepam. The patient was seen by surgery who felt that surgery. Fournier's gangrene was ruled out. The patient was started on vancomycin, Zosyn, and clindamycin in the Emergency Department. He had one set of blood cultures drawn before this. The patient was seen by psychiatry who felt that he was not competent to refuse care. PAST MEDICAL HISTORY: 1. Spina bifida. 2. Chronic urinary tract infections. 3. Urostomy. 4. Status post intestinal resection. 5. History of right decubitus ulcer status post flap revision. 6. Bell's palsy. 7. Status post incarceration in [2191-4-27]. 8. Multiple psychiatric hospitalizations for homicidal and suicidal ideation and antisocial personality disorder. 9. History of drug and alcohol abuse. SOCIAL HISTORY: Positive tobacco, positive alcohol, positive illicit drugs, cocaine, marijuana and intravenous drug use as per admission note, history of severe abuse by mother. [Name (NI) ] collects disability. He used to work in masonry up to [2183]. FAMILY HISTORY: Noncontributory. MEDICATIONS ON ADMISSION: 1. Paxil 40 mg p.o. q.d. 2. Klonopin 2 mg p.o. t.i.d. 3. Risperidone 3 mg p.o. q.d. 4. Lithium 900 mg p.o. q.d. ALLERGIES: Latex, morphine and codeine. PHYSICAL EXAMINATION: Vital signs were temperature 102.9, heart rate 118, blood pressure 121/46, respiratory rate 16, saturating 96% on room air. In general he was awake, alert and agitated. HEENT: Pupils equal, round and reactive to light and accommodation, anicteric, extraocular movements intact, no resting nystagmus. Neck: Full range of motion and supple. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, no murmurs, gallops, or rubs. Abdomen: Soft, nontender, nondistended, normal bowel sounds. Urostomy with surrounding erythema. Extremities: Left perianal area covered in feces; left subgluteal region with full-thickness 8 cm wound which cannot be probed, has purulence and surrounding erythema extending proximally over the perineum. No crepitus, very tender to palpation, 2+ peripheral pulses. LABORATORY DATA: No laboratory studies were obtained at the time of admission. ASSESSMENT AND PLAN: This is a 47-year-old man with antisocial personality disorder, spina bifida and polysubstance abuse who presents with a left subgluteal wound infection. The patient was admitted for psychiatric stabilization in the hopes that he could be treated and further worked up. HOSPITAL COURSE: The following is a summary of the [Hospital 228] hospital course. 1. Consult services who participated in the care of this patient were general surgery, psychiatry and infectious disease. The medical intensive care unit team was also called to assist in overseeing the patient after massive amounts of antipsychotics and sedation had been given to him and it was feared that the patient's respiratory status would be compromised. 2. Psychiatry: The psychiatry consult and liaison team was intermittently involved in the patient's care from the moment he was in the Emergency Department. Their initial recommendations were that the patient was not felt to be currently suicidal, that a 1:1 security sitter be placed at the door to decrease patient agitation, that a urine toxicology screen be checked (this was negative), that a lithium level be checked to assess the patient's compliance with his medications (his lithium level was found to be low), that the patient receive Risperdal 2 mg b.i.d., that he not be allowed to leave against medical advice, that the patient be continued on Haldol 2 to 5 mg IV, IM, p.o. and this could be repeated in one hour if no response x 1, that an EKG be checked, that the patient receive Klonopin 2 mg t.i.d., that the patient receive Ativan 1-2 mg q. 4 hours p.r.n. agitation. Unfortunately, these initial recommendations were not enough to put the patient in a position where he could be treated. When the patient was transferred to the [Hospital1 ] he became severely agitated and threatening to the care staff to the point that a code purple had to be called. The patient was placed in five-point restraints, but he continued to refuse care. The patient continued to receive multiple doses of Haldol and Ativan and when these doses reached very high levels, the decision was made to hospitalize the patient in the medical intensive care unit in order to monitor his respiratory status. The patient was thought to be withdrawing from narcotics. He was continued on his Klonopin and Risperdal as well as Haldol. He was given Ativan in conjunction with these. His narcotic withdrawal was treated with oxycodone 30 mg p.o. q. 12 hours and hydromorphone patient-controlled analgesia. On this regimen, the patient's agitation subsided greatly. He no longer required restraints when he was on a regimen consisting of risperidone 3 mg p.o. b.i.d., standing Klonopin, aggressive pain management and Haldol p.r.n. At the time of this dictation the patient is back on the [Hospital1 ], is not requiring restraints, still has a 1:1 security sitter and is not expressing homicidal or suicidal ideation. At the time of this dictation, the current plan is to place the patient in a medical/psychiatric facility for further treatment. 3. Infectious disease: The patient was diagnosed with a left perirectal and gluteal abscess status post incision and drainage with continued infection. Medical records could not be obtained from [Hospital3 2576] [Hospital3 ] initially, so the patient was started on very broad-spectrum antibiotics consisting of vancomycin, Zosyn, and clindamycin. Eventually the patient was changed to just clindamycin and levofloxacin on the recommendation of the infectious disease consult. Medical records were obtained from [Hospital3 2576] [Hospital3 ] on [2192-3-17] and these revealed the following information: A. Blood culture on [2192-3-10], anaerobic bottle, anaerobic Gram-negative coccobacilli which failed to grow on subculture for identification. B. Blood culture on [2192-3-10]. Anaerobic bottle which grew small Gram-positive rods. C. Urine culture grew abundant Acinetobacter calcoaceticus-baumanii complex, also moderate Morganella morganii and a few mixed bacteria susceptible to colistin. The Acinetobacter was susceptible to amikacin, amoxicillin, clavulanate, cefepime, gentamicin, levofloxacin, trimethoprim, sulfamethoxazole, was intermediate to aztreonam, ceftriaxone and tetracycline, and was resistant to ampicillin, cefazolin, cefpodoxime, nitrofurantoin and piperacillin. The Morganella was susceptible to amikacin and cefepime, intermediate to ceftriaxone and gentamicin, and resistant to amoxicillin, clavulanate, ampicillin, aztreonam, cefazolin, cefpodoxime, levofloxacin, nitrofurantoin, piperacillin, tetracycline, trimethoprim and sulfamethoxazole. D. Wound culture from the left hip decubitus grew Acinetobacter calcoaceticus-baumanii complex, abundant beta hemolytic streptococcus group G, abundant Staphylococcus aureus and abundant mixed organisms resembling cutaneous flora. The abundant beta hemolytic streptococcus group G was susceptible to penicillin G, vancomycin, chloramphenicol, clindamycin and ceftriaxone, and resistant to erythromycin. The Staphylococcus aureus was susceptible to oxacillin, vancomycin, erythromycin, clindamycin, tetracycline, trimethoprim, sulfamethoxazole, and resistant to penicillin G. E. Anaerobic culture from perirectal abscess, anus swab revealed mixed anaerobic bacteria. F. Wound culture smear from perirectal abscess, anus swab revealed Gram stain abundant polys, few mononuclear cells, abundant Gram-positive cocci in pairs and short chains, abundant Gram-negative rods of mixed morphologies. The culture revealed abundant beta hemolytic streptococcus group G. A broth tube revealed Staphylococcus aureus. The beta hemolytic streptococcus group G was susceptible to penicillin G, vancomycin, chloramphenicol, clindamycin and ceftriaxone, and resistant to erythromycin. The Staphylococcus aureus was susceptible to vancomycin, tetracycline, trimethoprim, sulfamethoxazole, and resistant to penicillin G, oxacillin, erythromycin, clindamycin and levofloxacin. Based on this information the patient's antibiotic regimen was switched to vancomycin, levofloxacin and Flagyl. The patient had no intravenous access and he was declining placement of an intravenous line or a central line and so at the time of this dictation the patient is to go for a PICC line placement today. Moreover, the patient was consented for an HIV test the results of which have not yet been revealed. The patient does have a history of a positive HIV test at [Hospital3 2576] [Hospital3 ] and this was confirmed with the medical staff at that hospital. The patient has a questionable history of hepatitis C virus also diagnosed at [Hospital3 2576] [Hospital3 ]. This could not be confirmed. The patient has a negative hepatitis C virus antibody test at this hospital during this hospitalization. A HCV PCR is required to establish this diagnosis. The patient has remained afebrile the last few days of his hospitalization. His wound appeared to be healing slowly. His pain seems to be well controlled. He is receiving wound dressing changes and hydrogen peroxide cleanings. He is also undergoing [Last Name (un) ] baths. The remainder of the hospital course will be dictated by the intern rotating through this service. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 13467] Dictated By:[Last Name (NamePattern1) 1595] MEDQUIST36 D: [2192-3-19] 11:12 T: [2192-3-19] 11:42 JOB#: [Job Number 25953] Admission Date: [2192-3-12] Discharge Date: [2192-4-22] Date of Birth: [2144-5-11] Sex: M Service: [Doctor Last Name 1181] MEDICINE CHIEF COMPLAINT: Buttock pain. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old man recently admitted to [Hospital6 1129] with a perirectal abscess. He left the hospital against medical advice and presented to the [Hospital1 188] on the date of admission for re-evaluation. While the patient initially wanted re-evaluation, he became increasingly agitated in the Emergency Department. Received a total of 20 mg of Haloperidol intravenously for sedation, 6 mg of Ativan, 1 mg of cogentin, and was then briefly admitted to the Medical Intensive Care Unit for monitoring. He was then transferred to the Medical Service for further evaluation. Of note prior to admission, the patient received two doses of Vancomycin on [3-12], one dose of Zosyn as well as one dose of levofloxacin. On the morning of admission, the patient received one dose of clindamycin. PAST MEDICAL HISTORY: 1. Recurrent urinary tract infections and a urostomy. 2. Had previously a right sacral decubital ulcer and underwent primary closure at the [Hospital 4415]. 3. The patient had a dubious history of HIV and he had a test done recently, but did not have the results reported to him on this admission. Western blotting confirmed that the patient had the HIV infection with a CD4 count is 20 and viral load is 203. 4. Questionable history of hepatitis C. 5. Spina bifida. 6. Patient has a complicated psychiatric history, no definitive diagnosis has been made, however, he has had suicidal ideas in the past, and has had problems that have resolved largely on this admission. ALLERGIES: 1. Latex. 2. Morphine. 3. Codeine. MEDICATIONS ON PRESENTATION: 1. Paxil 40 mg daily. 2. Clonazepam 2 mg every 8 hours. 3. Risperidone 3 mg once daily. 4. Lithium 900 mg once daily. SOCIAL HISTORY: Significant for injection drug use, cocaine, marijuana, tobacco, and ethanol. Patient is homeless. PHYSICAL EXAMINATION ON PRESENTATION: Temperature 100.8, heart rate 76, respiratory rate 18, blood pressure 100/60 (note that patient's blood pressure is typically 100 systolic and this does not represent an abnormal finding), oxygen saturation of 95% on room air. On presentation, physical examination was not performed. Because of the patient's marked agitation, however, interval examination revealed a rather deep left buttock ulcer approximately 4 cm wide and 7 cm deep. It was not draining pus, however, there was minimal granulation tissue, therefore his physical examination is not normal. LABORATORY EVALUATION ON PRESENTATION: White blood cell count 6.5, hematocrit 29.3, platelets 100, INR of 1.3. Urinalysis was normal. Chemistry panel was unremarkable as stated above. HIV testing confirmed infection, however, the patient was HCV negative, but he was infected with HBV previously. Toxicology screen was negative. HOSPITAL COURSE: 1. Psychiatry: After his brief admission to the Medical Intensive Care Unit, the patient was transferred to the Medical Service, and over the course of several days became less agitated, behavior was well controlled. His psychiatric medications were titrated to Risperidone 3 mg twice daily, clonazepam 2 mg every eight hours. He did not require further Haloperidol for the duration of his hospital course. 2. Buttock ulcer: In consultation with the General Surgery Service, the patient underwent a long course of wet-to-dry dressing changes for his wound with minimal improvement. Likewise, he was on approximately a two week course of Vancomycin and metronidazole upon presentation, though his antibiotics were discontinued because the patient remained afebrile for the duration of his hospital stay. On [2192-4-13], Plastic Surgery consultation was requested for his nonhealing wound. The patient was then taken to the operating room several days later for debridement and primary closure. The patient received approximately four more days of Vancomycin and metronidazole postoperatively. At the time of this dictation, the patient still had [Initials (NamePattern4) ] [Last Name (NamePattern4) 1661]-[Location (un) 1662] drain in place with serosanguinous material draining. The patient's postoperative course was marked by the absence of fevers, however, there was some increased pain requiring titration of his pain medicines, while he is on a stable regimen of long-acting oxycodone. He required additional medicines for pain control. Another complication of his postoperative stay was increasing nausea attributed to his increased demand for pain control, optimum relief of his nausea was achieved with Benadryl by mouth and intravenously. 3. HIV: On this admission, the patient's infection was confirmed in consultation with the Infectious Disease Service. The patient was started on Bactrim prophylactically against pneumocystis carinii pneumonia. The decision to start high reactive antiretroviral therapy was deferred until the patient was discharged and can be assured a stable followup. DISCHARGE DIAGNOSES: 1. Acquired immunodeficiency syndrome. 2. Nonhealing buttock ulcer status post primary closure. 3. Hepatitis B infection. 4. Spina bifida. The remainder of hospital course shall be dictated separately at the time of discharge. Discharge med: bactrim DS 1 qd for PCP [Name Initial (PRE) 1102]. [Doctor First Name 1412] [Name Initial (MD) ] [Name8 (MD) 1413], M.D. Dictated By:[Name8 (MD) 7102] MEDQUIST36 D: [2192-4-19] 08:31 T: [2192-4-19] 08:34 JOB#: [Job Number 25954]	[ "292.0", "263.9", "707.0", "042", "566", "305.90", "599.0", "682.6", "741.90" ]	icd9cm	[ [ [] ] ]	[ "38.93", "86.3" ]	icd9pcs	[ [ [] ] ]							1787, 1805	15680, 16228					1832, 1990	13525, 15659																											2013, 3219											10693, 10708							10737, 11559																		11581, 12453	12470, 13508
4,657	126,358	19983	Discharge summary	report	Admission Date: [2101-12-18] Discharge Date: [2101-12-27] Date of Birth: [2024-8-29] Sex: Service: DATE OF DEATH: [2101-12-26] HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old woman with a history of diabetes, end-stage renal disease, hypertension, and congestive heart failure transferred from an outside hospital for management of sepsis. The patient was recently discharged from an outside hospital to a rehab on [11-14] after a 1-week admission for progressive weakness. At that time she was found to have E-coli resistant to ampicillin, cefazolin, and piperacillin, and had a head CT as part of her workup which showed small vessel disease and atrophy. At the rehab upon discharge, she was noted to be progressively short of breath. Her chest x-ray showed a left lower lobe pneumonia. She received ceftriaxone on the morning of admission and was sent to the Emergency Department for further evaluation. Note that the patient was only at the rehab facility for a short amount of time. At the Emergency Department, the patient's oxygenation was noted to be 89 percent on room air and she had respirations in the 30s. She was subsequently intubated for respiratory failure. Prior to transfer to our hospital, she became hypotensive and was started on a dopamine drip. Her heart rate on the drip was noted to be high in the 150s, and she was treated with IV diltiazem and Lopressor to help slow that down. She also received a 250 cc bolus of normal saline. Upon arrival here at [Hospital1 18], her blood pressure was 60/40 with a heart rate in the 130s. She was immediately bolused with normal saline and the dopamine was changed to Levophed. An A line was placed and she was transferred to our medical ICU for further management. PAST MEDICAL HISTORY: Chronic anemia status post cholecystectomy. ALLERGIES: She has no known drug allergies. MEDICATIONS: Medications on transfer were: 1. Renagel. 2. Aspirin. 3. Nephrocaps. 4. Megace. 5. Reglan. 6. Zoloft. 7. Ritalin. 8. Protonix. 9. Rocephin. 10. Compazine. 11. Epogen. PHYSICAL EXAMINATION: On admission, her temperature was 101 degrees, her blood pressure was 101/41, her ventilator settings were assist-control with a tidal volume of 550, rate of 14, PEEP of 5, and FIO2 of 50 percent. Her ABG on that was 7.34, 38, 97. General, the patient was sedated, on the vent. Her neck was supple. She had no JVD. Cardiac exam demonstrated that there was normal S1 and S2. Respiratory wise, she had decreased breath sounds at the bases, as well as on the right side. Her abdomen was soft and nontender. Bowel sounds were present. Extremities were cool. She had faint dorsalis pedis pulses. Neurologic exam: Again, she was sedated. LABORATORY DATA: On admission, her white count was 23.2, her hematocrit was 34, her platelets were 360, her coags were normal. Her Chem-7 showed sodium of 138, potassium of 4.0, chloride of 98, bicarbonate of 23, BUN of 23, creatinine of 3.1, and glucose of 435. Her LFTs were normal except for an elevated alkaline phosphatase of 280. Her lactate was noted to be 1.7. RADIOGRAPHIC STUDIES: Chest x-ray showed right middle lobe infiltrate and a left retrocardiac infiltrate. Her EKG showed sinus rhythm at 90 beats per minute, a low voltage with normal axis and intervals. HOSPITAL COURSE: The patient is a 77-year-old woman with a history of diabetes, end-stage renal disease, hypertension, basically now admitted for septicemia and hypovolemic shock in addition to respiratory failure. In terms of the patient's septic shock, she was continued on the Levophed and vasopressin to keep her mean arterial pressures above 65. She was started on broad spectrum antibiotics initially with Zosyn. Subsequent blood cultures came back MRSA positive and a sputum culture came back MRSA positive, so she was switched to solo treatment with vancomycin. In terms of her respiratory failure, the patient remained ventilated throughout the course of her admission. ABGs were checked periodically and showed very little improvement in her respiratory status. Throughout the course of the patient's hospitalization, she had frequent episodes of dropping her blood pressure into the 50 systolic. Typically, it would respond to increased doses of the pressors; however, by hospital day number 10, the patient had a little improvement in her overall hemodynamic status. Neurologically, she was not alert or responsive by hospital day number 10 and that was off sedation. At that point, the family decided to make the patient comfort measures only. All antibiotics and pressors were discontinued at that time. The patient died on hospital day number 10. CONDITION ON DISCHARGE: Expired. DISCHARGE STATUS: Not applicable. DISCHARGE DIAGNOSES: Septicemia. Respiratory failure. DISCHARGE MEDICATIONS: Not applicable. FOLLOW-UP PLANS: Not applicable. [Last Name (LF) 2466],[First Name3 (LF) 2467] 12-746 Dictated By:[Last Name (NamePattern1) 267] MEDQUIST36 D: [2102-6-5] 15:51:56 T: [2102-6-6] 08:00:20 Job#: [Job Number 53864]	[ "482.41", "038.11", "518.5", "707.0", "785.52", "995.92", "428.0", "250.40", "403.91" ]	icd9cm	[ [ [] ] ]	[ "96.72", "38.93", "39.95", "38.95", "38.91", "99.10", "96.6", "99.04" ]	icd9pcs	[ [ [] ] ]								4818, 4852	4876, 4893					3369, 4725																											2126, 2727				4911, 5160														192, 1798																2745, 3351		1821, 2103		4750, 4796
1,492	129,648	18848	Discharge summary	report	Admission Date: [2105-11-16] Discharge Date: [2105-11-20] Date of Birth: [2049-10-14] Sex: F Service: MEDICINE/[Hospital1 ] FIRM CHIEF COMPLAINT: Shortness of breath/diabetic ketoacidosis. HISTORY OF PRESENT ILLNESS: This is a 56-year-old female with a history of poorly controlled diabetes mellitus Type 2, insulin dependent and history of hypertension, asthma and a history of thrombocytosis of unclear etiology, who initially presented to the Emergency Department with complaints of increasing dyspnea times one week. Initial presentation to the Emergency Department was eight days prior to admission. The patient was diagnosed with bronchitis with an asthma exacerbation and treated with Azithromycin times five days and a five day course of Prednisone tapered and then discharged home from the Emergency Department. Over the past week the patient has had increasing shortness of breath, productive cough with whitish sputum and polyuria and occasional nausea. The patient denied fevers, chills, sore throat, abdominal pain, melena, dysuria, rashes, joint pain or chest pain. The patient reports good medical compliance with Glargine an insulin sliding scale. The patient notes continued use of her nebulizer without relief of shortness of breath and notes increasing weight loss over the past six months, unintentional. In the Emergency Department the patient was found to have a blood sugar of 570, was found to be tachycardic, afebrile, with an anion gap of 40, small ketones in her urine and total c02 of 7. The patient was admitted overnight to the MICU service on an insulin drip with the anion gap closed on the morning of transfer to the medicine service. A chest x-ray was obtained which was clear without evidence of infiltrate but a dedimer returned with greater than 1,900 and an emergent CTA was done showing a filling defect in the right posterior apical segmental branch with multiple areas of air space opacities within the left upper and left lower lobe concerning for pneumonia. The patient was started on heparin drip overnight. Antibiotics were held off given that she was afebrile and unclear if there was a focal source of the pneumonia. The patient was transferred to the medicine service as she was tolerating a p.o. diet and was given 60 units of Glargine off the insulin drip. The patient reports decreased ambulation over the past week due to fatigue, also denies leg swelling or upper extremity swelling. PAST MEDICAL HISTORY: 1. Asthma since age 8. 2. History of episodic abdominal pain as a teenager. She is G-3, P-2, status post spontaneous abortion and vaginal delivery and cesarean section. 3. Question of pancreatitis status post pancreatotomy with incidental splenectomy at age 28. 4. Migraine headaches. 5. Hypertension. 6. Depression. 7. Anxiety. 8. Diabetes mellitus Type 2, insulin dependent, on Glargine since age 51. 9. Thrombocytosis of unclear etiology, initially diagnosed [7-12]. MEDICATIONS ON ADMISSION: 1. Advair Discus 1 puff twice a day. 2. Albuterol meter dose inhaler. 3. Amlodipine 10 mg p.o. once daily. 4. Amoxicillin 250 mg p.o. three times a day. 5. Clonazepam 0.5 mg p.o. three times a day. 6. Fioricet 325/40/50 one tablet p.o. q6 hours as needed. 7. Fluconazole 150 mg tabs, 2 tabs for yeast infection. 8. Lantus 100 units q p.m. 9. Megace 40 mg p.o. once daily. 10. Reglan 10 mg p.o. q a.c., h.s. 11. Paxil 40 mg p.o. once daily. 12. Ranitidine 150 mg p.o. twice a day. PHYSICAL EXAMINATION: Temperature 99.8/98.9??????, blood pressure 114/68, range 108 systolic to 124/62 to 74. Heart rate 96, range 88 to 102, respiratory rate of 15, satting 99% on room air. GENERAL: In general, slightly tired appearing thin female in no apparent distress with slowed speech, blunted affect. Answers questions appropriately. HEAD, EYES, EARS, NOSE AND THROAT: Normocephalic/atraumatic. Pupils are equal, round, and reactive to light 5 to 3 cm bilaterally. Oropharynx clear. Mucous membranes dry. No scleral icterus. NECK: Supple, no jugular venous distention, no masses. Shoddy cervical lymphadenopathy. No axillary lymphadenopathy. CHEST: Clear to auscultation bilaterally. No wheezing. CORONARY: Regular rate and rhythm,no murmurs, rubs or gallops. Normal S1- S2. Nondisplaced point of maximal impulse. ABDOMEN: Soft, nontender, nondistended, increased bowel sounds, midline scar well healed. No hepatosplenomegaly. EXTREMITIES: Warm and well perfused, 2+ distal pulses bilaterally, no palpable cords. [Last Name (un) 5813] sign negative. NEUROLOGICAL: Alert and oriented times three. Cranial nerves II through XII intact. 5:5 bilateral upper extremity and lower extremity strength. 2+ deep tendon reflexes bilateral knees. LABORATORY DATA: White blood cell count 16.8 with 82$ polys, 5 bands, 6 lymphs, 7 monos, hematocrit 33.6, platelets 440. INR 1.3, dedimer 1,971. Urinalysis - trace protein, greater than 80 ketones, negative leukocytes and nitrites. Admission Electrolytes - sodium 132, potassium 5.7, chloride 94, bicarbonate 7, BUN 24, creatinine 1.1, glucose 571. On transfer - sodium 136, potassium 3.6, chloride 112, bicarbonate 16, BUN 8, creatinine 0.7, glucose 206. Acetone trace, small. CK 53, troponin-T less than 0.01. Electrocardiogram - sinus tachycardia at 114, right atrial enlargement, no ST or T-wave changes. Chest x-ray - lungs are clear, no congestive heart failure, mild pectus. CT angiogram of the chest - positive pulmonary edema in the right posterior apical segmental branch and peripheral pulmonary opacities in the left upper and lower lobes concerning for pneumonia. HOSPITAL COURSE: 1. Shortness of breath. The patient had progressive dyspnea over the past week, initially treated with bronchitis + asthma flare, now found to have a pulmonary edema on the CTA, unclear if initial presentation Emergency Department eight days prior to admission was related to pulmonary edema at the time, however, patient risk factors are, over the past week, with decreased ambulation and mobility secondary to fatigue makes it less likely until recently. 2. Pulmonary edema. The patient had no obvious source on exam. No palpable cords or deep vein thrombosis obvious on exam. Patient has a history of thrombocytosis of unclear etiology, unclear whether or not the patient has a hypercoagulable state. This will likely need to be clarified given the thrombocytosis. However, the patient was initially started on weight-based heparin with a goal PTT of 60-80 and was subsequently transitioned on the day prior to discharge on Lovenox 60 mg subcutaneous twice a day as well as Coumadin loaded while she was in house. The patient had a discharge INR of 1.4 based on two loads of 5 mg and a 7.5 mg load. The patient will be discharged with 5 mg of Coumadin to have her INR followed up with her primary care physician on [2105-11-23]. Patient will also have the [Hospital6 1587] to follow her INR. Until her INR is greater than 2.0 the patient will likely need to have Lovenox shots. Monitor her 02 sats which were greater than 92% on room air. 3. Asthma flare. The patient had peak fluids that were under 400. She had no obvious wheezing on exam. The patient was maintained on nebs around the clock and then transitioned to meter dose inhalers with her Albuterol and subsequently started on her steroid of Salmeterol and Flovent on the day prior to discharge with improvement of her shortness of breath. 4. Hyperglycemia, anion gap closed while in the MICU off the insulin drip. We optimized her blood sugar control with changing her Glargine over to NPH given the fact that her Glargine was also not available on formulary for Medicaid. The patient was maintained on 60 units q a.m. and 20 units q p.m. based on her insulin requirements with stable blood sugar control on the day of discharge. This will likely need to be followed up as a future outpatient in order to adjust her insulin requirements. Diabetic teaching was maintained and the patient was maintained on a diabetic diet. 5. ID. The patient remained afebrile with a white blood cell count that was stable and within normal limits, although there was a question of pneumonia on the chest x-ray. We held off antibiotics for the pneumonia given the fact that clinically she did not appear as if she had any pneumonia, given her being afebrile and no cough. 6. Weight loss/fatigue. Positive constitutional symptoms of unclear etiology including a thrombocytosis. I would follow up with outpatient cancer screening protocol. Albumin was obtained which was low and we had a nutrition consult in house which established patient to have supplements in her nutrition status. 7. Thrombocytosis, unclear etiology, question source, likely will need to be followed up. The patient had a stable platelet count was in house with no acute evidence of infection. 8. FEN. The patient was maintained on [First Name8 (NamePattern2) ] [Doctor First Name ] diet. 9. The patient was maintained on full code status. DISCHARGE CONDITION: Stable. Heart rate, blood pressure, oxygen saturations on room air, afebrile, stable fingerstick blood sugar controlled, no cough or wheezing. DISCHARGE FOLLOW UP: 1. Primary care, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2148], [Last Name (un) 2577] Building, Infectious Diseases, phone no. [Telephone/Fax (1) 457], on [2105-11-23] at 11:30 a.m., phone number is [Telephone/Fax (1) 1419]. FINAL DIAGNOSES: 1. Diabetic ketoacidosis/Type II. 2. Asthma. 3. Pulmonary embolism. 4. Infarct. 5. Hypertension. MAJOR SURGICAL INVASIVE PROCEDURES: CT scan showing pulmonary embolus within the right posterior apical segmental branch. DISCHARGE MEDICATIONS: 1. Amlodipine 10 mg p.o. once daily. 2. Paroxetine 40 mg p.o. once daily. 3. Clonazepam 0.5 mg p.o. three times a day. 4. Warfarin 5 mg p.o. q.h.s. Follow up with your primary care physician [Last Name (NamePattern4) ] [2105-11-23] to check your INR blood level. 5. Albuterol inhaler, 1-2 puffs inhaled q6 hours as needed for wheezing. 6. Salmeterol discus - one inhalation q12 hours. 7. Fluticasone - 2 puffs inhalation to twice a day. 8. NPH insulin 60 units q a.m. 9. NPH insulin - 20 units q p.m. 10. Enoxaparin - 60 mg subcutaneous q12 hours. 11. Ranitidine 150 mg p.o. once daily. 12. Reglan 10 mg p.o. q a.c. h.s. 13. Megace 40 mg p.o. once daily. 14. Fioricet oral, signature unknown. 15. Insulin syringe. 16. Insulin needles. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 9561], M.D. [MD Number(1) 9562] Dictated By:[Last Name (NamePattern1) 5227] MEDQUIST36 D: [2105-11-20] 14:17 T: [2105-11-24] 01:06 JOB#: [Job Number 51582]	[ "401.9", "289.9", "250.12", "493.92", "415.19", "276.2", "305.1", "300.01", "300.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]				9150, 9305					9854, 10896				3048, 3538	5715, 9128																		9604, 9831				9316, 9587					3561, 5698											179, 223							252, 2486																		2508, 3022
45,509	108,390	37817	Discharge summary	report	Admission Date: [2135-2-22] Discharge Date: [2135-2-23] Date of Birth: [2077-12-8] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: Jaundice. Major Surgical or Invasive Procedure: 1. Endoscopic Retrograde Cholangiopancreatography (ERCP) with stent placement History of Present Illness: 57 y/o M with metastatic esophageal adenocarcinoma to liver and lung p/w obstructive jaundice . He is s/p previous esophageal stenting of the distal esophagus. Tbili today was 31. He was referred in to [Hospital1 18] for ERCP for evaluation of obstructive jaundice. ERCP was uncomplicated, a large biliary stricture was noted and a metal stent was placed. . Currently he feels lethargic as he has intermittently for the past few days, no nausea or vomiting, no pain anywhere, no constipation or diarrhea, good PO intake normally but decreased PO intake yesterday. No fevers, chills, rigors or sweats. Weight loss. No chest pain or SOB, rest of review of systems is negative. Past Medical History: h/o ETOH abuse and polysubstance abuse history of PE (noted incidentally on a CT, anticoagulated on coumadin) Metastatic poorly differentiated adenocarcinoma of the esophagus, diagnosed [10-7], metastatic to liver and lung Social History: h/o ETOH abuse and polysubstance abuse (opiates / heroin) denies IVDU, 60pk yr history of smoking Family History: - Brother with GERD - Denies any FH of cancer or heart disease - Extensive family history of EtOH abuse Physical Exam: Upon admission: VS: T 98.0 HR 87 BP 75/46 RR 12 O2 sat 97% on RA GEN: NAD, AOX3 HEENT: MM Dry, JVP flat at 30 degrees, sclera icteric CARD: RRR, no m/r/g PULM: CTAB ABD: soft, enlarged firm nodular liver, non tender, non distended EXT: WWP, no c/c/e NEURO: AOx3, able to move all 4 extremities, very soft spoken and at times very mildly confused. Able to recall his medications. SKIN: Jaundice . At discharge: GEN: jaundice, cachetic without acute distress HEENT: EOMI, icteric, MMM, no jvd, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout, decreased BS throughout CV: RRR, S1 and S2 wnl, no m/r/g ABD: distended, typanic, +b/s, nontender EXT: 3+ edema to above knees SKIN: diffuse jaundice. no rashes no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. 2+DTR's-patellar and biceps. +Asterixis Pertinent Results: Labs: [2135-2-22] 08:55AM BLOOD WBC-16.7# RBC-3.06# Hgb-8.5# Hct-26.0# MCV-85 MCH-27.7 MCHC-32.6 RDW-18.7* Plt Ct-245 [2135-2-22] 02:15PM BLOOD WBC-11.4* RBC-2.46* Hgb-6.8* Hct-21.4* MCV-87 MCH-27.5 MCHC-31.6 RDW-18.8* Plt Ct-200 [2135-2-23] 03:36AM BLOOD WBC-18.5# RBC-2.85 Hgb-8.1* Hct-24.5* MCV-86 MCH-28.6 MCHC-33.3 RDW-18.5* Plt Ct-252 [2135-2-22] 02:15PM BLOOD Neuts-97* Bands-0 Lymphs-0 Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2135-2-22] 08:55AM BLOOD PT-27.4* PTT-36.0* INR(PT)-2.7* [2135-2-23] 03:36AM BLOOD PT-21.6* PTT-33.2 INR(PT)-2.0* [2135-2-22] 08:55AM BLOOD Glucose-93 UreaN-18 Creat-0.9 Na-133 K-3.7 Cl-98 HCO3-25 AnGap-14 [2135-2-22] 02:15PM BLOOD Glucose-88 UreaN-18 Creat-0.8 Na-136 K-3.5 Cl-103 HCO3-23 AnGap-14 [2135-2-23] 03:36AM BLOOD Glucose-85 UreaN-20 Creat-0.9 Na-136 K-3.6 Cl-104 HCO3-24 AnGap-12 [2135-2-22] 08:55AM BLOOD ALT-43* AST-100* LD(LDH)-311* AlkPhos-1088* Amylase-15 TotBili-30.6* DirBili-24.9* IndBili-5.7 [2135-2-22] 02:15PM BLOOD ALT-31 AST-78* LD(LDH)-262* AlkPhos-834* TotBili-23.4* [2135-2-23] 03:36AM BLOOD ALT-37 AST-85* AlkPhos-821* TotBili-25.4* [2135-2-22] 08:55AM BLOOD Albumin-2.4* Calcium-7.8* Phos-2.9 Mg-2.9* [2135-2-22] 02:15PM BLOOD Albumin-1.9* Calcium-6.7* Phos-3.5 Mg-2.5 [2135-2-23] 03:36AM BLOOD Calcium-6.9* Phos-4.2 Mg-2.6 [2135-2-22] 03:14PM BLOOD Lactate-1.7 [2135-2-22] 04:46PM BLOOD Lactate-1.5 . Pathology: [2-23] sputum cytology pending . Microbiology: [2-23] sputum AFB pending [2-22] urine culture pending [2-22] blood culture pending . Imaging: [2-22] ERCP: Successful biliary cannulation. A severe diffuse dilation was seen at the middle third of the common bile duct and upper third of the common bile duct with the CBD measuring 18 mm in maximal diameter. There was also moderate dilation of the intrahepatic ducts as well. A single stricture that was 20 mm long was seen at the middle third of the common bile duct. Successful placement of a 6cm by 10FR fully covered metal Wallflex biliary stent (REF 7[Numeric Identifier 84630]) was placed successfully in the main duct. Otherwise normal ercp to third part of the duodenum. [2-22] CXR: In comparison with study of [2133-10-30], there is large area of opacification with apparent cavitation in the left mid zone. This is consistent with cavitary process for which TB must be also considered. An area of patchy opacification at the right and left bases also are seen, raising the possibility of multifocal infection. Central catheter extends to mid portion of the SVC. Esophageal stent is in place. [2-23]: In comparison with study of [2-22], the cavitary lesion in the left upper zone is again seen. The multiple nodules seen on CT are difficult to appreciate. There are some patchy areas in the right lung that could also represent foci of infection. [2-24] Chest CT: There are multiple pulmonary arterial filling defects, which appear acute. These include filling defects to the right middle lobe (2:28), right lower lobe (2:39), right upper lobe (2:27), lingula (2:33), left lower lobe (2:35) and possibly the left upper lobe (2:17). However, no definite pulmonary infarcts are identified and no evidence for right heart strain is present. Small bilateral pleural effusions are present. In the left upper lobe is a thin-walled space, 4.1 x 3.8 cm, containing no fluid or debris, surrounded by a 9 x 6.5 cm region of consolidation. Additional areas of consolidation or developing abscesses are present in the right middle lobe (2:32) and right lower lobe (2:41, 42). In the right upper lobe is a probable bronchocele (2:24) adjacent to an area of consolidation (2:30). Mild apical emphysema is present. Millimeter sized pulmonary nodules described on the prior examination are less evident on this study, probably subsumed in consolidations. Debris in the right main stem bronchus (2:25), documents aspiration. A long mid esophageal stent which contains fluid and debris, new since the prior study. A stent previously spanning the gastroesophageal junction is now in the stomach. The GE junction mucosa is markedly thickened, similar to prior study. The aorta and SVC are of normal caliber. Left paratracheal lymph nodes measuring up to 11 mm. Soft tissue, difficult to evaluate is present along the inferior anterior mediastinum adjacent to the pericardium (2:51), could be infiltrating tumor. The heart appears normal. Although, this study is not tailored for evaluation of the subdiaphragmatic region. There is heterogeneous attenuation of the liver, suggestive of diffuse metastatic disease. A metallic stent is seen within the region of the CBD, better evaluated and visualized on the recent ERCP. The mid stent appears narrowed and possibly kinked, but this appearance is similar to that seen on the ERCP. A Wallstent is seen within the stomach. Ascites is present. There is probable soft tissue surrounding the celiac axis (2:60), but evaluation is limited on this early arterial study. BONE WINDOWS: No suspicious sclerotic or lytic lesions are present. IMPRESSION: 1. Bilateral pulmonary emboli. The patient has reported history of pulmonary emboli, but no prior imaging available at [Hospital1 18] to permit assessment of the progression. No evidence for heart strain, or pulmonary infarct. 2. Multifocal consolidation and developing abscesses including a probable pneumatocele in the left upper lobe, are probably due to aspiration. These findings suggest a multifocal infection, which could bacterial or tuberculous, although no signs of prior tuberculosis are present. The new lung lesions are probably not metastases, but re-evaluation after antibiotic treatment is suggested. 3. Small bilateral pleural effusions. 4. Ascites, multifocal liver metastases, possibly extending to prevascular mediastinum. Probable soft tissue encasing the celiac axis. 5. Biliary stent which does appear kinked in its mid section but unchanged from the earlier study. 6. Marked esophageal thickening at the GE junction with gastroesophageal stent now in the stomach. Brief Hospital Course: 57 y/o with metastatic esophogeal adenocarcinoma on pallative chemotherapy presented for jaundice and biliary obstructon for ERCP. Post operative course complicated by transient hypotension and mental status changes. #Biliary obstruction: Concern for possible cholangitis. He went for ERCP with stent placement. Blood cultures were drawn and are pending at the time of discharge. He was given Zosyn for two doses then a total 8 day course of levofloxacin/flagyl. #Hypotension: Resistant hypotension with transient AMS after ERCP was concerning for severe sepsis / septic shock. The correlation to the ERCP made bactermia from cholangitis the most worisome infectious etiology. However, his hypotension quickly resolved and his mental status improved. Blood cultures are still pending at the time of discharge. He was continued on an 8 day course of oral levo/flagyl. #Cavity pulmonary lesion: Pt complains of cough with brown sputum and small hemoptysis for two weeks. This finding was first seen on chest xray and then next on chest CT and had not been previously visualized per report from his outpatient oncologist. In setting of his lung metastases the differential includes post obstructive abcess vs multilobar pneumonia vs malignancy. Radiology does not feel that this is TB given its appearance on chest CT. He was covered for infectious etiologies with an 8 day course of levo/flagyl. His sputum was sent for gram stain, culture, AFB stain, and cytology which were all pending at the time of discharge. #Jaundice: ERCP suggests extrahepatic jaundice likely [3-2] known malignancy. LFT's were trending down after ERCP. #Coagulopathy: INR elevated to 2.7 likely secondary to nutritional deficiency. Received vitamin K once. #PE: Known PE's on Lovenox daily as an outpatient. Lovenox held for 5 days prior to ERCP and then for 48 hours after ERCP. His dose was increased to twice daily to be restarted the day after discharge, when his INR would be less than 2. #Metastatic esophogeal cancer: On pallative chemotherapy, followed in [Location (un) 1514] by Dr. [Last Name (STitle) ]. He was contact[Name (NI) ] during the patient's stay. Palliative care was consulted and will send a note with recommendations to Dr. [Last Name (STitle) ]. #GERD: A PPI was continued. #Code Status: FULL CODE during this admission. Medications on Admission: FENTANYL - 150 mcg patch q72 hours LORAZEPAM - 0.5 mg 1-2 tabs qhs prn OMEPRAZOLE - 40mg po bid ONDANSETRON HCL - 8 mg q8hrs prn compazine 10mg po q6hrs prn nausea OXYCODONE - 5 mg Tablet - [3-3] Tablet(s) by mouth every 6-8 hours Tylenol prn colace 100mg po bid multivitamin daily Discharge Medications: 1. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for anxiety or nausea: do not take if driving or drinking alcohol. 3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 4. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 6. oxycodone 5 mg Tablet Sig: 2-3 Tablets PO every 6-8 hours as needed for pain. 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. multivitamin Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 10. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days: last day [2135-2-28], for pneumonia. Disp:7 Tablet(s) Refills:0 11. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days. Disp:21 Tablet(s) Refills:0 12. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous once a day: continue taking your dose at before the hospitalization. Discharge Disposition: Home Discharge Diagnosis: Esophageal Cancer Pulmonary Embolism Cavitary lung lesion secondary to pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for an ERCP and stent placement. After the procedure you had low blood pressures that required observation in the ICU. You were noted to have an abnormality on your CXR thought to be an infection, you will need to complete your course of anitbiotics. You are now improving and will be going home. The following changes were made to your medications: - START levofloxacin and metronidazole (antibiotics), take until [2135-2-28] - RESTART lovenox tomorrow, [2135-2-23] Followup Instructions: Please make an appointment to see your PCP and oncologist once you leave the hospital. You will need follow up for your pneumonia. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "305.50", "E879.8", "197.0", "530.81", "576.2", "V58.61", "416.2", "E849.7", "150.8", "458.29", "790.92", "197.7", "486" ]	icd9cm	[ [ [] ] ]	[ "51.87", "51.84" ]	icd9pcs	[ [ [] ] ]	12697, 12703	8690, 11057	321, 400	12828, 12828	2535, 8667	13513, 13783	1495, 1600		11394, 12674		12724, 12807		11083, 11371				12979, 13490									1615, 1617																2030, 2516										272, 283							428, 1114									1631, 2016		12843, 12955							1136, 1364	1380, 1479
32,511	102,385	43285	Discharge summary	report	Admission Date: [2147-9-22] Discharge Date: [2147-10-2] Service: MEDICINE Allergies: Morphine / Mirtazapine / Ambien Attending:[First Name3 (LF) 7333] Chief Complaint: chest pain s/p ICD firing for sustained VT Major Surgical or Invasive Procedure: elective intubation - [2147-9-25] repeat ablation for recurrent ventricular tachycardia - [2147-9-25] ICD generator change - [2147-10-2] History of Present Illness: Mr. [Known firstname ] [Known lastname ] is a 86 yo man with h/o CAD s/p MI and CABG in [2136], chronic AFib with V-pacing, chronic systolic CHF with EF 20%, multiple recent admission to the CCU for ICD firing, readmitted from [Hospital ] rehab for left sided chest pain. He reports that he had severe left sided chest pain, worse with inspiration and palpation. He denies any dyspnea, nausea, vomiting, abdominal pain, diaphoresis, left arm or jaw pain or any other complaints. He does not know if his ICD fired. Of note he has been admitted numerous times recently for VT and ICD firing due to sustained VT. During his recent admission from [9-19] -[9-21] he was bolused with IV amiodarone twice for episodes of VT during the admission. During that admission he continued to refuse VT ablation and turning off ICD. . In the ER his VS were stable and he his mental status was at his baseline. He was in VT 120-130s without any changes from before on ECG. However, the ER docs were impressed by the abnormalities and wanted to rule him out for MI with CK: 70 MB: Notdone Trop-T: 0.25. He was admitted to the CCU for unclear reasons given he is DNR/DNI and has not wanted to pursue aggresive treatment in the past. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: MI X2 (inferior and anteroseptal) - CABG: LIMA to LAD, SVG to OM/PDA ([Hospital1 112] [2136]) - Afib w/o anticoag (fall risk) - Sustained VTach in [2146] s/p admission - PACING/ICD: BiV ICD ([2122]?). ICD generator changed to [Company 1543] Concerto in [2145]. . 3. OTHER PAST MEDICAL HISTORY: - legally blind secondary to glaucoma - Hiatal hernia - Hepatic cysts/hemangioma and lipoma in hepatic flexure - s/p Lt BKA (WWII trauma [2078]) - BPH s/p suprapubic prostatectomy ([2131]) - s/p cholecystectomy ([2110]) - Chronic low back pain - Osteoarthritis - Positive PPD in past - Depression and anxiety Social History: The patient immigrated from [Country 532] 20 years ago; lives at [Hospital1 100] Senior Center w/ wife. Former oncology surgeon w/ one daughter and grandaughter in [Name (NI) 86]. -Tobacco history: None currently -ETOH: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=99.3 BP=115/76 HR=120 (VT) RR=15 O2 sat=97% GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 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: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: IMAGING: CT abdomen/pelvis [2147-9-28]: 1. Focal colitis in the proximal sigmoid colon. Differential considerations include various infectious causes, such as C. difficile colitis, less likely inflammatory or ischemic etiology. 2. 2.3 x 2.1 cm lobulated, coarsely calcified pulmonary nodule at the left lung base, most probably represents a pulmonary hamartoma. 3. Multiple liver and renal cysts. . CXR portable [2147-9-28]: 1. Persistent left retrocardiac density, which might represent pneumonia/atelectasis. . Portable abdomen [2147-9-28]: Dilated bowels with ileus. . MICRO: C diff [2147-9-27]: negative Urine cx klebsiella 10-100k: sensitive to cipro/ceftriaxone Blood cx [2147-9-28]: negative . Labs on admission: WBC 11.6, Hb 14.3, Hct 42, plt 216 Na 133, K 4.2, Cl 98, bicarb 18, BUN 19, Cr 1.3, glu 150 . Labs on discharge: Brief Hospital Course: Mr. [Known firstname ] [Known lastname ] is a 86 y/o Russian speaking man with h/o CAD s/p MI and CABG in [2136], chronic AFib/recurrent VT with V-pacing, chronic systolic CHF with EF 20%, recently discharged from CCU with ICD firing, now returns with recurrent VT and ICD firing. . #. Rhythm - Pt with known VTach and presents s/p ICD firing. During prior CCU admission, patient was confirmed to be DNR/DNI/no external shocks/do not hospitalize. Patient presented to [Hospital1 18] from [Hospital 100] Rehab due to chest pain associated with ICD firing. Patient has stable vital signs with his slow VT and was in VT at 120-130s. He was bolused with 450 mg of IV amiodarone in the ER and was started on amiodarone gtt. This was transitioned to PO amiodarone, as levels were likely supersaturated. IV lidocaine was initiated at 1 mg/min. Lengthy discussion with patient and family took place regarding whether to keep the ICD on or turn it off (as patient has now presented twice with complaints of ICD firing). After discussion, pt and family would like to keep ICD on, and realize that it will provide painful shocks if his rhythm becomes irregular and dangerous. Patient was informed that repeat ablation is the only way to cure his VT, and he underwent this procedure on [2147-9-25]. On [2147-9-26], pt had five episodes of ICD firing for recurrent VT, which finally brought him out of his VT. Since that time, his ICD has not fired. Upon device interrogation, it was noted that the generator would need to be changed at a point in the near future, as battery was running low. This procedure was performed on [2147-10-2]. Upon discharge, patient was in sinus rhythm and stable. . # Delerium/AMS - pt developed delerium while in the hospital, and on one occasion, pulled out his lines/tubes/clothes. He was initially treated with ativan and zydis. Geriatrics was consulted. His narcotics and ativan were discontinued. His mental status and delerium improved without use of further medications such as haldol. . # Focal colitis - pt developed diffuse abdominal pain with guarding during hospital stay. CT abdomen and pelvis showed focal colitis in the proximal sigmoid colon. Differential considerations included various infectious causes, such as C. difficile colitis, less likely inflammatory or ischemic etiology. Lactate was wnl. Given rapid elevation in WBC to 25, low grade temperature, and diarrhea stool, clinical concern for C. diff despite negative toxin assay. Pt initially placed on PO vancomycin and IV flagyl with resolution of WBC. PO vancomycin was discontinued. IV flagyl therapy was completed for 5 days. . # Klebsiella UTI - urine cloudy, U/A with 9 wbc, and urine cx showed 10-100k klebsiella. Pt was initially started on ciprofloxacin, then switched to ceftriaxone. Sent home with 7 day course of cefpodoxime 200mg PO BID. . #. Pump - No signs of CHF at this time. Pt with known chronic systolic heart failure with EF of 20%. Pt was continued on his home medications: statin, ASA, and metoprolol. ACEi and Lasix were held given hypotension. . #. CAD - Pt with known CAD s/p CABG. Chest pain free, other than his VT and shocks. ASA, statin, BB were continued as above. ACEI held as above, due to hypotension. Enzymes suggest mild cardiac injury after shock, but most likely he is not having ACS. . #. OA - pain was well controlled on Tylenol and oxycodone prn. . #. Code - patient is DNR/DNI/not to be externally shocked. . #. Contact - Next of [Doctor First Name ]: [Last Name (LF) ],[First Name3 (LF) ], Relationship: DAUGHTER, Phone: [Telephone/Fax (1) 93241] (home) and [Telephone/Fax (1) 93242] (cell). She is HCP. Medications on Admission: -Aspirin 81 mg PO Daily -Digoxin 125 mcg QOD -Dorzolamide 2% Both eyes [Hospital1 ] -Escitalopram 10 mg PO Daily -Lasix 120 mg PO BID -Brimonidine 0.15% Both eyes [Hospital1 ] -Latanoprost 0.005% QHS -Lorazepam 1.5 mg PO QHS -Polyethylene Glycol 3350 100% Powed Daily -Simvastatin 20 mg Daily -Amiodarone 200 mg PO Daily -Metoprolol Tartrate 12.5 Tablet PO BID -Nitroglycerin 0.3 mg SL PO PRN chest pain -Captopril 12.5 mg PO TId -Isosorbide Mononitrate SR 30 mg Daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 8. Miralax 17 gram (100 %) Powder in Packet Sig: Seventeen (17) grams PO once a day. 9. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 10. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 7 days. 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Hold SBP< 100, HR<55. 12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day: HOLD SBP<100. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain. 15. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 16. Senna 8.6 mg Capsule Sig: [2-17] Capsules PO twice a day as needed for constipation. 17. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) packet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Ventricular tachycardia Urinary tract infection Secondary diagnoses: MI X2 (inferior and anteroseptal) - CABG: LIMA to LAD, SVG to OM/PDA ([Hospital1 112] [2136]) - Afib w/o anticoag (fall risk) - Sustained VTach in [2146] s/p admission - PACING/ICD: BiV ICD ([2122]?). ICD generator changed to [Company 1543] Concerto in [2145]. - Chronic Systolic Congestive Heart Failure. EF 35% - legally blind secondary to glaucoma - Hiatal hernia - Hepatic cysts/hemangioma and lipoma in hepatic flexure - s/p Lt BKA (WWII trauma [2078]) - BPH s/p suprapubic prostatectomy ([2131]) - s/p cholecystectomy ([2110]) - Chronic low back pain - Osteoarthritis - Positive PPD in past - Depression and anxiety Discharge Condition: stable, afebrile Discharge Instructions: You were admitted to [Hospital1 ] Hospital for chest pain after repeated ICD firings. Your heart was found to be in a rhythm known as ventricular tachycardia which was stimulating your ICD to fire. Your code status was DNR/DNI and your options to fix this condition involved either shutting off the ICD or reversing your code status temporarily and performing an ablation procedure to fix the part of your heart that was triggering this rhythm. You chose to have the ablation procedure. The first procedure was unsuccessful, but it seems like the second ablation procedure has worked well to stop your ventricular tachycardia and your ICD has not fired since [2147-9-26]. Since your ICD was firing so often, it was also noted that the battery life on your device was low and needed replacement. You underwent battery replacement prior to discharge on [2147-10-2]. You were also found to have a urinary tract infection and were treated with antibiotics accordingly. . day or 6 pounds in 3 days. Adhere to a 2 gm sodium diet. The following changes have been made to your home medication regimen: -You will continue your antibiotics regimen with cefpodoxime -Your ACE inhibitor, Captopril was -You Furosemide was held during your hospital stay and you had no symproms of fluid overload. It will be held until your oral intake improves. Please follow-up with all of your outpatient medical appointments listed below. Please seek medical care if you experience any concerning symptoms such as chest pain, increased shortness of breath, painful urination, increased abdominal pain, or bright red blood per rectum. Followup Instructions: Cardiology: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 73] Phone: [Telephone/Fax (1) 62]. Date/Time: [11-9] at 3:00pm. [Location (un) 8661] clinical Center, [Location (un) 436]. [Location (un) ], [Location (un) 86]. . DEVICE CLINIC Phone:[Telephone/Fax (1) 62] Date/Time:[2147-10-11] 1:00. [Hospital Ward Name 23] clinical center, [Location (un) 436]. Completed by:[2147-10-3]	[ "369.4", "V45.81", "599.0", "424.0", "E849.8", "E879.8", "427.31", "041.3", "412", "996.04", "558.9", "427.1", "414.00", "414.8" ]	icd9cm	[ [ [] ] ]	[ "37.96", "37.27", "37.34", "96.04" ]	icd9pcs	[ [ [] ] ]	10804, 10869	5049, 8073	282, 432	11641, 11660	4172, 4898	13339, 13793	3168, 3283		9292, 10781		10890, 10939		8791, 9269				11684, 13316									3298, 4153			10960, 11620		8091, 8765																					200, 244				5026, 5026			460, 2234									4912, 5006					2575, 2897				2256, 2544	2913, 3152
14,472	186,660	2626	Discharge summary	report	Admission Date: [2176-12-27] Discharge Date: [2177-1-8] Service: HISTORY OF PRESENT ILLNESS: This is a 78-year-old Caucasian male, status post coronary artery bypass graft times three and aortic valve replacement on [2176-11-18]. His postoperative course was complicated by atrial fibrillation and seizure. Head CT at that time showed only old cerebrovascular accident. Failure to wean off pressors for several days and failure to wean off ventilator. The patient had been trached during admission. Additionally, the patient had several infections in pleural fluid with yeast, methicillin-resistant Staphylococcus aureus, and Pseudomonas. He had been discharged to rehabilitation at [Hospital1 13199] on [2176-12-21]. In the interim he had been off of ventilation for approximately 72 hours. However, he began to have increasing oxygen requirement and was placed back on ventilation. Additionally, he began to have bloody drainage from the right pigtail catheter and his hematocrit at that time was found to be 18. HOSPITAL COURSE: At this time he was transferred to [Hospital1 1444] for further management. He was treated initially with multiple blood transfusions with continued drainage out of the chest tube. He underwent video-assisted thorascopy on Monday, [2176-12-29]. At that time, decortication was done and two additional chest tubes were placed on the right side. Bilateral pigtail catheter was removed at that time. Mr. [Known lastname ] continued to place minimal drainage from the chest tubes. He was mostly unresponsive but would move all four extremities occasionally as well as occasionally opening his eyes. A repeat echocardiogram on [2176-12-31], showed a decrease in his ejection fraction from greater than 35% postoperatively to less than 15% with minimal left ventricular movement. Echocardiogram was repeated six days later which showed no change. Mr. [Known lastname ] was made do not resuscitate two days prior to his death. On [2177-1-8], his family finally decided to make Mr. [Known lastname ] [Last Name (Titles) ] measures only, and he was taken off of ventilation. At that time, he was placed on trach mask but expired approximately five minutes later from respiratory failure. DATE OF DEATH: [2177-1-8]. TIME OF DEATH: Time of death was approximately 5:30 p.m. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Name8 (MD) 8073] MEDQUIST36 D: [2177-1-10] 11:19 T: [2177-1-11] 04:50 JOB#: [Job Number 13200]	[ "511.8", "V45.81", "276.1", "998.11", "998.59", "510.9", "285.1", "518.81", "V43.3" ]	icd9cm	[ [ [] ] ]	[ "34.51", "34.04", "96.72", "38.91", "96.6" ]	icd9pcs	[ [ [] ] ]														1072, 2614																																													111, 1054
77,149	142,617	50372	Discharge summary	report	Admission Date: [2141-4-25] Discharge Date: [2141-5-1] Service: MEDICINE Allergies: Quinidine / Propranolol / Heparin Agents / Warfarin / Zolpidem Attending:[First Name3 (LF) 2610] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known firstname ] [First Name4 (NamePattern1) 122] [Known lastname ] is a very nice 87 YO M with end-stage diastolic heart faillure (EF 65%), moderate AS, mild AI, mild MR, moderate TR, HTN, HL, Stage IV CKD, positive HIT antibody (negative seronotin assay), recent episode of c diff who comes with somnolence. Patient was discharged from [Hospital1 18] after a hip fracture 11 days ago to [Hospital ] Rehab, where he was noted by his wife to be somnolent, bed-bound, with poor apetite. Lab work on [4-17] showed Tbili: 26, Dbili: 14, AST 101, ALT 31, Alk phos: 644, which was thought to be secondary to either medication (PO Vanc) versus other pathology. Patient has extensive work up including ceruloplasmin, alpha1 anti-tripsin, AMA, anti-smooth muscle, [Doctor First Name ], hepatitis cerologies Ca [49]-9 and everything was negative except [Doctor First Name ], which were mildy positive at 1:40. Initially it was decided to undergo liver biopsy for diagnosis, but after discussion with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 696] it was decided it was too high risk. . Today he was evaluated by ortho in a normal scheduled post-op visit. Dr [Last Name (STitle) 1005] was pleased with the results and he removed the staples (per wife). He was on his way back home, when he was found somnolent and BP was very difficult to take as well as pulse. So he was brought to the ER. . In the ER his initial VS were: T 98.4, HR 54 X', BP 134/93 mmHg, SpO2 100% on RA. His BP dropped to 81/57 and did not respond to 2 L NS, so he was started on peripheral norepinephrine. He wa safebrile and with HR in 50s to 60s. Physical exam reported CTA lung fields, normal JVP. ECG was unchanged from prior. CT scan of the head did not show any acute bleed or pathology, CT abdomen showed anasarca, but no signs of infection, CT chest no PNA and worsening effusions. His WBC was 6, LFTs were unchanged from [4-17] at OSH and slightly worsened compared to prior at [Hospital1 18]. Pt received levofloxacin for possible UTI? and was admitted to the ICU given his multiple medical comorbidities. Past Medical History: -Congestive heart failure with preserved LVEF (65% 1/10) --> per DCS from [2-8], thought to have left HF leading to right HF without primary pulm HTN -Chronic Atrial fibrillation, not on warfarin given recent UGIB ([2-8]) -Pulmonary artery hypertension (30mmHg + RA [11-6]) -Mild MR, moderate TR, mild AI, mild AS (peak 25 mmHg [11-6]) -Mild ascending aortic dilatation (3.7 cm) -Left ventricular hypertrophy -Prostate enlargement (followed by Dr. [Last Name (STitle) ] [Last Name (STitle) 79]) -Hypertension -Hypercholesterolemia -Severe essential tremor, since [2076] (WWII) -Venous stasis, followed by Dr. [Last Name (STitle) ] [Name (STitle) 104985] hernia repair -Anemia, multifactorial (chronic illness, CKD, recent GIB) -Hemorrhoid repair -History of MRSA cellulitis ([2-7]) -Chronic Renal Failure [1-31] poor forward flow from CHF: Stage IV with eGFR of 24 ml/min (MDRD). Near dialysis. Recommend to check PTH every 3 months with target of 70-110. -Left foot abscess s/p I&D -Multiple episodes of C. Diff colitis (third episode this year during [3-17] hospitalization) -GIB ([2141-3-17]) with guaiac positive stools, but no endoscopy performed . Recent hospitalizations: [2140-12-29] to [2141-1-4] -- for CHF exacerbation, given lasix ggt -- left foot cellulitis/fluid collection managed medically with Vanc/Cipro/Flagyl -- AFib subtherapeutic on Coumadin so bridged with Heparin with subsequent rectal bleeding, traumatic hematoma, oozing from newly placed PICC line -- incidentaloma seen in pancreas on RUQ u/s without further w/u . [2141-1-31] to [2141-2-15] -- also for CHF exacerbation, given lasix ggt and metolazone -- supratherapeutic INR on admission, complicated by epistaxis and melena (GI followed but endoscopy was deferred) -- C diff colitis treated with ? both Po flagyl and vancomycin, course should have been completed [2141-2-19] . [2141-3-7] to [2141-3-10] -- Unresponsive while sleeping after trazadone; negative infectious work up -- 16 beat run of VT -- Decreased metoprolol from 12.5mg->6.25mg [Hospital1 ] -- Renal failure attributed to torsemide and pre-renal . [2141-3-17] to [2141-3-31] -- Sent in by rehab for sleepiness, low Hct, weight gain, cough. -- C. Diff colitis -- GIB (Guaiac positive, had been on coumadin until [Month (only) 956] when had presumed UGIB requiring 1U pRBC); transfused for Hct 23.5 (but near baseline of 24) -- Hypotension to the 70s systolic (baseline 90-100s) -- CHF -- UTI -- Acute on chronic kidney disease -- Pancytopenia: found to be HIT antibody positive but serotonin assay negative so not likely HIT; nonetheless heparin products were avoided. Pancytopenia improved over hospital course; thought to be infection related. -- Increased AP and GGT with elevated lipase and an abnormality on ultrasound suggestive of a pancreatic mass. GI was consulted and recommended an outpatient MRCP. . [2141-4-6] to [2141-4-14] -- Hypotension: Most likely due to combination of dehydration +/- acute bleed in setting of poor cardiac function. Responded to fluids. -- Hip fracture: s/p ORIF with TFN -- Acute on chronic renal failure -- LFTs: direct>indirect with elevated alk phos, however no evidence of obstruction on US. Seen by liver. Work up was pending on discharge. -- CHF -- RETROPERITONEAL MASS: Adrenal mass seen on CT this admission (8x6.2 cm). Plan was work up as outpatient. -- Thrombocytopenia: initial concern for HIT, but r/o with negative serotonin assay. Avoiding heparin anyway. Social History: Usually lives with wife, married for >50yrs, currently at [Hospital 100] Rehab. 3 children. No tobacco, EtOH, IVDU. Retired, formerly worked manufacturing and distributing batteries. He smoked cigars for 2-3 years and quit >45 years ago. He has not smoked cigarettes. He does not drink alcohol on a regular basis. Denies IV, illicit, or herbal drug use. Family History: Parents are both deceased. Father (73 years; "heart" disease); Mother (48 years; stomach cancer). He has 2 siblings (80- breast cancer, brother with ? abdominal cancer). He has 3 children (55, 53, 49 years; all well). A son [Doctor Last Name ] has atrial fibrillation. Physical Exam: VITAL SIGNS - BP 115/64 mmHg, HR 59 BPM, RR 11 X', O2-sat 100% 2L NC GENERAL - well-appearing man in NAD, comfortable, appropriate, jaundiced (skin, mouth, conjuntiva) HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI diosplaced to the left, RRR, SEM [2-4] RUSB no radiation, SEM [2-4] apex radiating towards axila, SEM [2-4] in tricuspid region, nl S1-S2, no S3 or S4 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), severe edema SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [5-3] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait. Pt has baseline tremor, no asterexis. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: IMAGING: CT Head ON [2141-4-25]: There is no intracranial hemorrhage, mass effect, or [Doctor Last Name 352]-white matter differentiation abnormality. Prominence of the sulci and ventricles is consistent with age related global atrophy. Periventricular and subcortical white matter hypodensities are compatible with chronic small vessel ischemic disease. Possible right anterior temporal arachnoid cyst is unchanged since [38]/[2134]. Imaged paranasal sinuses and mastoid air cells demonstrate mucosal thickening in the left maxillary sinus. There is also mild mucosal thickening in the right maxillary sinus. . CT OF ABD/PELVIS ON [2141-4-25]: 1. Increased bilateral pleural effusions with adjacent associated atelectasis. Increased intra-abdominal ascites and subcutaneous fluid compatible with anasarca. No evidence to suggest retroperitoneal hematoma. 2. Distended gallbladder containing gallstone. If clinical concern for acute cholecystitis, recommend ultrasound. 3. Known 8cm left adrenal mass containing linear calcification. Again, adrenal MRI is recommended for further evaluation. 4. Subtle nodular contour to the liver could suggest cirrhosis. 5. Enlarged prostate. Please correlate with PSA levels. 6. Questionable nondisplaced left 7th rib fracture. . CXR [2141-4-25]: AP upright frontal and lateral views of the chest are obtained. There are moderate-to-large bilateral pleural effusions, which may be increased since the prior study, although this appearance may in part be due to slight differences in patient positioning. Bibasilar atelectasis and bibasilar opacities may reflect atelectasis and layering effusions although underlying consolidation/infectious process cannot be excluded. There is stable enlargement of the cardiac silhouette. The aorta is calcified and tortuous. IMPRESSION: 1. Moderate-to-large bilateral pleural effusions, likely increased since the prior study. 2. Bibasilar opacities may reflect atelectasis and layering effusion, although superimposed consolidations/infectious process are not excluded. 3. Stable enlargement of the cardiac silhouette. . XRAY OF HIP ON [2141-4-25]: Compared with [2141-4-6], the comminuted fracture of the left proximal femur has been transfixed by gamma nail and short intramedullary rod. Cortical width anterior displacement of the major distal femoral fragment is demonstrated on the lateral view. Overall alignment is otherwise anatomic. No hardware loosening or failure is identified. The fracture lines remain visible. No gross callus formation is identified. Skin staples noted. Background osteopenia, bilateral hip degenerative changes, degenerative changes in the lower lumbar spine are noted. There is diffuse vascular calcification. Rounded density over the right lower abdomen is noted -- ? large gallstone. Probable calcified lymph node over the right inguinal region. A small amount of heterotopic ossification is noted adjacent to the right hip medially. IMPRESSION: Status post ORIF right proximal femur fracture, in overall anatomic alignment. . # ECG Afib with ventricular rate at 60 BPM, with QRS of 150 ms unchanged ro prior with axis at 70 degrees, ST depression in V2-V4 unchanged from prior, TWI inversions in V2-V5 unchanged from prior from [2141-4-7]. . # ECHO ON [2141-4-26]: The left atrium is markedly dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. The right ventricular cavity is markedly dilated with depressed free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2141-1-2], the gradients across the aortic valve have increased. The estimated pulmonary artery systolic pressures are higher on the current study. # ECHO ON [2141-4-27]: No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast . # ABD US ON [2141-4-26]: INDICATION: 87-year-old man with end-stage congestive heart failure, end- stage chronic kidney disease with hypotension requiring pressors and worsening LFTs with cholangitic pattern. Please assess for cholangitis. . FINDINGS: The liver is slightly heterogeneous in echotexture with a markedly dilated IVC. These findings may represent liver congestion from congestive heart failure. The main portal vein is patent with appropriate direction of flow. There is no intrahepatic biliary dilatation. The gallbladder is again distended and demonstrates a large gallstone measuring up to 2.1 cm which is mobile. A small amount of sludge is noted within the gallbladder, although this has decreased in amount since the previous study. There is a small amount of ascites. The visualized head and body of the pancreas appears within normal limits. Small calcification adjacent to the pancreas may be within the splenic artery. The common bile duct is within normal limits given the patient's age. IMPRESSION: No evidence of intrahepatic biliary dilatation. Distended gallbladder with cholelithiasis as seen on the prior study. As there is ascites, minimal gallbladder wall thickening may just be secondary to this. However, if there is continued clinical concern for cholecystitis, HIDA scan could be performed for further evaluation. LABS: [2141-4-25] 06:20PM BLOOD WBC-6.0 RBC-2.87* Hgb-8.6* Hct-27.6* MCV-96 MCH-30.1 MCHC-31.3 RDW-21.3* Plt Ct-140* [2141-4-25] 06:20PM BLOOD Neuts-78.3* Lymphs-14.6* Monos-3.9 Eos-2.5 Baso-0.8 [2141-4-25] 06:20PM BLOOD PT-14.7* PTT-51.2* INR(PT)-1.3* [2141-4-26] 03:47AM BLOOD Fibrino-487* [2141-4-25] 06:20PM BLOOD Ret Man-2.0* [2141-4-25] 06:20PM BLOOD Glucose-81 UreaN-102* Creat-2.7* Na-143 K-5.2* Cl-106 HCO3-24 AnGap-18 [2141-4-25] 06:20PM BLOOD ALT-40 AST-91* AlkPhos-853* TotBili-20.3* [2141-4-25] 06:20PM BLOOD Lipase-117* [2141-4-25] 06:20PM BLOOD proBNP-7419* [2141-4-25] 06:20PM BLOOD cTropnT-0.07* [2141-4-26] 03:47AM BLOOD CK-MB-NotDone cTropnT-0.08* [2141-4-25] 06:20PM BLOOD Albumin-3.2* Phos-5.2* Mg-3.1* Iron-134 [2141-4-25] 06:20PM BLOOD calTIBC-281 Ferritn-1554* TRF-216 [2141-4-26] 08:08AM BLOOD D-Dimer-3130* [2141-4-28] 05:00AM BLOOD WBC-9.2 RBC-2.39* Hgb-7.3* Hct-23.1* MCV-97 MCH-30.7 MCHC-31.8 RDW-21.5* Plt Ct-171 [2141-4-28] 05:00AM BLOOD PT-17.3* PTT-45.1* INR(PT)-1.5* [2141-4-28] 05:00AM BLOOD Glucose-73 UreaN-96* Creat-3.2* Na-148* K-4.8 Cl-113* HCO3-19* AnGap-21* [2141-4-28] 05:00AM BLOOD ALT-34 AST-83* LD(LDH)-359* AlkPhos-556* TotBili-16.6* [2141-4-28] 05:00AM BLOOD Albumin-2.7* Calcium-9.1 Phos-5.0* Mg-2.8* MICROBIOLOGY: # [2141-4-25] 9:20 pm URINE Site: CATHETER FINAL REPORT [2141-4-26] URINE CULTURE (Final [2141-4-26]): <10,000 organisms/ml. # BLOOD CULTURE FROM [2141-4-25] X 2 AND ON [2141-4-26]: NO GROWTH. Brief Hospital Course: Mr. [Known firstname ] [First Name4 (NamePattern1) 122] [Known lastname ] is a very nice 87 YO M with end-stage diastolic heart faillure (EF 65%), moderate AS, mild AI, mild MR, moderate TR, HTN, HL, Stage IV CKD, positive HIT antibody (negative seronotin assay), recent episode of c diff and and hip fracture, s/p ORIF who come to the hospital with somnolence, hypotension, acute on chronic renal failure, and significant elevation of LFTs. Patient had multiple hospitalizations in the last few months for dCHF exacerbation and most recently for hip fracture. He was initially admitted to the ICU and was placed on Norepinephrine drip to maintain his MAP >65. His UO was low and he had worsening of renal function. A repeat TTE which showed markedly dilated left and right atrium, mild symmetric left ventricular hypertrophy, and markedly dilated right ventricular cavity with depressed free wall contractability. Compared with the prior TTE of [2141-1-2], the gradients across the aortic valve have increased. The estimated pulmonary artery systolic pressures were higher on the current study. Head CT showed no acute IC process. ABD/Pelvic CT was notable for increased bilateral pleural effusions, increased intra-abdominal ascites and subcutaneous fluid compatible with anasarca, distended gallbladder containing gallstone, a known 8cm left adrenal mass containing linear calcification and subtle nodular contour to the liver could suggest cirrhosis. His LFTs remained elevated with cholestatic pattern and elevated lipase. He was evaluated by the hepatology team who found that a liver biopsy was too risky given patient's underline problems. [Name (NI) 227] the patients worsening cardiac function, multiple organ failure and his multiple medical problems, the family met with palliative care team. After numerous meetings with the family and the primary care team to discuss goals of care, the family decided that his care should be focus on comfort. He was then made CMO and had the Norepinephrine drip stopped on [2141-04-28] and he was transferred to the general medicine floor. On the transferred to the floor Mr. [Known lastname ] was accompanied by his wife and 3 children. He was lethargic, occ. arousable to tactile stimuli and overall appeared comfortable. Palliative care continued to follow patient and made recommendations for comfort measures. Dilaudid was initially given PRN which was then switched to standing 0.25mg-0.5mg Q 3hrs with 0.25-0.5mg Q 3hrs PRN. He also given Lorazepam 0.5-1 mg IV Q4H as needed. Patient became less responsive and he expired on [2141-5-1]. His wife, 2 daughters and a son were present at the time. The family was offered pastoral and other supportive services. Medications on Admission: Vancomycin 125 mg PO QOD (Until [4-28]) then every third day until [5-12] Pantoprazole 40 mg PO Daily Ativan 0.25 mg PO TID PRN anxiety Amonium lactate 12% cream Ipratropium bromide 0.02% IH Q6hrs PRN SOB/Wheeze Metoprolol 12.5 mg PO BID Ergocalciferol 50,000 PO Q/mo Bisacodyl 10 mg PO Daily Senna 8.6 mg PO BID Aspirin 81 mg PO Daily Acetaminophen 650 mg PO q6 hrs PRN pain/fever Calcium carbonate 500 mg PO BID Cadexomer iodine topical Dextromethorphan-Guaifenesin 10-100 mg/5 mL 5 ML PO Q12HPRN cough Calcium acetate 667 mg PO TID Polyethylen glycol 17 gram PO Daily PRN constipation Oxycodone 5 mg PO Q4 hrs PRN pain Sodium chlroide 0.65% nasal spray PRN nasal congestion Fluticasone 50 mcg Nasaly daily Enoxaparin 30 mg SQ Daily until [5-9] Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: Discharge Instructions: Followup Instructions:	[ "289.84", "276.7", "518.0", "599.0", "574.10", "600.00", "428.33", "585.4", "403.90", "428.0", "427.31", "584.9", "789.59", "459.81", "570", "272.0" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	19199, 19208	15611, 18361	286, 292	19269, 19269	7873, 15588	19321, 19321	6452, 6727		19170, 19176		19229, 19246		18387, 19147				19295, 19295									6742, 7854																										230, 248							320, 2478																		2500, 6060	6076, 6436
23,568	173,185	54209	Discharge summary	report	Admission Date: [2113-8-8] Discharge Date: [2113-8-16] Date of Birth: [2047-6-23] Sex: F Service: PLASTIC Allergies: Influenza Virus Vaccine / Shellfish Derived / Egg / Adhesive Bandage Attending:[First Name3 (LF) 1430] Chief Complaint: Wound drainage Major Surgical or Invasive Procedure: Debridement and placement of a VAC History of Present Illness: 65 year old female with ongoing issues with nonhealing and infection issues with sternal wound. Presented at Dr [First Name (STitle) ] office for wound evaluation and was found to have increased drainage. Was referred for admission and plan for sternal debridement. Past Medical History: -[4-5] Coronary Artery Bypass Graft x 2 (Left internal mammary artery to left anterior descending artery, Saphenous vein graft to posterior descending artery), Mitral valve repair -Severe Mitral regurgitation -Coronary artery disease s/p prior RCA stenting c/b ISR x 2, most recently with Cypher stenting in [2107-4-24] for NSTEMI -Hypertension -Dyslipidemia -'[05]: post cath large retroperitoneal hematoma extending from the right groin superiorly to the level of the lower pole of the right kidney-->required 7 units PRBCs -Non sustained polymorphic VT s/p ICD [2-24] -Depression -History of panic attacks/anxiety, prior psychiatric admission within the past several years -Gastroesophageal reflux disease -Osteopenia -History of pulmonary nodules, followed by serial imaging -Glucose intolerance -History of H. pylori Social History: Retired, worked as hairdresser. Husband died in [12-2] from MI. Lives alone smoked cigarettes x many years, Denies ETOH abuse. Family History: Father died at age 50 of an MI and "enlarged heart." Brother with drug abuse. Mother had depression and panic attacks Physical Exam: Pulse:84 Resp: 18 O2 sat: 96 B/P Right: 155/74 Left: Height: Weight: General: HEENT:mouth w/crusted/scabbed lesions thruout Skin: Dry [x] intact [] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities:cool distally, toes w/some motteling Edema 2+pitting, L ant lower leg w/long area of ecchyosis Neuro: awake, moves all extremities, follows commands Pulses: DP Right:[11-25]+ Left:Tr-1+ PT [Name (NI) 167]:1+ Left:Tr-1+ Radial Right:2+ Left:2+ Sternal incision: 2 open areas on distal incision about 2-3 cm round, very superficial w/surrounding erythema, draining yellow green purulent material. Pertinent Results: [2113-8-15] 09:02AM [Month/Day/Year 3143] WBC-16.5* RBC-3.85# Hgb-11.3# Hct-34.5* MCV-89 MCH-29.4 MCHC-32.8 RDW-18.1* Plt Ct-198 [2113-8-8] 10:10AM [Month/Day/Year 3143] WBC-19.1# RBC-4.02 Hgb-11.6* Hct-38.1 MCV-95 MCH-28.9 MCHC-30.5* RDW-17.9* Plt Ct-336 [2113-8-10] 02:09AM [Month/Day/Year 3143] Neuts-92.7* Lymphs-5.3* Monos-1.8* Eos-0.1 Baso-0.1 [2113-8-15] 09:02AM [Month/Day/Year 3143] Plt Ct-198 [2113-8-15] 09:02AM [Month/Day/Year 3143] PT-12.0 PTT-21.7* INR(PT)-1.0 [2113-8-8] 10:10AM [Month/Day/Year 3143] Plt Ct-336 [2113-8-8] 09:50PM [Month/Day/Year 3143] PT-30.2* PTT-30.8 INR(PT)-3.0* [2113-8-14] 10:24PM [Month/Day/Year 3143] ESR-3 [2113-8-15] 09:02AM [Month/Day/Year 3143] Glucose-140* UreaN-26* Creat-0.5 Na-137 K-3.9 Cl-102 HCO3-28 AnGap-11 [2113-8-8] 10:10AM [Month/Day/Year 3143] UreaN-21* Creat-0.6 Na-148* K-4.1 Cl-111* HCO3-25 AnGap-16 [2113-8-9] 07:00AM [Month/Day/Year 3143] ALT-34 AST-81* LD(LDH)-442* AlkPhos-299* Amylase-31 TotBili-0.6 [2113-8-15] 09:02AM [Month/Day/Year 3143] Calcium-8.3* Phos-2.9 Mg-1.9 [2113-8-8] 10:10AM [Month/Day/Year 3143] TotProt-5.5* Albumin-3.3* Globuln-2.2 [2113-8-14] 10:24PM [Month/Day/Year 3143] CRP-2.3 [2113-8-14] 11:21 am STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [2113-8-14] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2113-8-14]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] @ 11:37P [2113-8-14]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). [2113-8-9] 5:39 pm TISSUE DEEP WOUND. FINAL REPORT [2113-8-14] GRAM STAIN (Final [2113-8-10]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). REPORTED BY PHONE TO [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] AT 0015 ON [2113-8-10]. TISSUE (Final [2113-8-14]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. WORK UP PER DR [Last Name (STitle) 3143] [2113-8-11]. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. ESCHERICHIA COLI. RARE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). QUANTITATION NOT AVAILABLE. ENTEROCOCCUS SP.. QUANTITATION NOT AVAILABLE. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| ESCHERICHIA COLI \| \| ENTEROCOCCUS SP. \| \| \| AMIKACIN-------------- 16 S AMPICILLIN------------ <=2 S <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- 16 I <=1 S CEFTAZIDIME----------- 16 I <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R 0.5 S GENTAMICIN------------ =>16 R <=1 S LINEZOLID------------- 1 S MEROPENEM------------- 4 S <=0.25 S PENICILLIN G---------- 4 S PIPERACILLIN---------- R <=4 S PIPERACILLIN/TAZO----- =>128 R <=4 S TOBRAMYCIN------------ =>16 R <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final [2113-8-13]): NO ANAEROBES ISOLATED. Brief Hospital Course: Admitted and underwent preoperative workup, and was brought to the operating [2113-8-9] for debridement and VAC placement with Dr [First Name (STitle) ], see operative report. She was started on vancomycin and meropenum for antibiotic coverage and infectious disease was consulted. She was resumed on heparin and coumadin for treatment of pulmonary embolism but then per plastics changed to Lovenox due to potential future debridements. However she had increased bleeding from VAC and decrease in hematocrit requiring transfusion. Lovenox was stopped, hematology was consulted for appropriate management and since past the first six weeks and no current evidence of DVT or PE she was placed on lovenox for DVT prevention. Planned for continued antibiotics - meropenum for enterococcus, E coli, pseudomonas and vancomycin for corynebacterium and flagyl for Cdiff, all to continue until further instructions from infections disease. Plan for follow up with plastic surgery and infectious disease as outpatient. Medications on Admission: Medications at rehab: Aspirin 81 mg' Metoprolol Tartrate 50 mg [Hospital1 ] Oxycodone-Acetaminophen 5-325 mg 1 Tablet PO Q4H PRN Lamotrigine 25 mg PO twice daily Citalopram 30 mg PO DAILY Famotidine 20 mg PO Q12H Lorazepam 1 mg PO Q8H PRN Ipratropium Bromide 1 Inh q 6 hrs Albuterol MDI 1 Inh q 6 hrs PRN Lisinopril 5 mg PO DAILY Warfarin 2 mg PO Once Daily Dexamethasone 1mg PO twice daily acyclovir 800mg PO three times daily LD [8-9] Lidoderm 5% patch to thoracic spine 6am-6pm daily floranex tabs PO twice daily flovent 110 mcg 2 puffs daily Iron sulfate 325 mg PO daily vitamin D2 50,000units 2times/week abilify 5mg PO every morning Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 1121] - [Location (un) 1456] Discharge Diagnosis: superficial sternal wound infection Clostridium Difficle Coronary Artery Disease s/p CABG Mitral regurgitation s/p MV repair Hypertension Pulmonary Embolism Dyslipidemia Non sustained polymorphic VT s/p ICD [2-24] Depression History of panic attacks/anxiety Gastroesophageal reflux disease Osteopenia History of pulmonary nodules, followed by serial imaging Diabetes Mellitus H. pylori Discharge Condition: Fair Discharge Instructions: Report any fever or purulent drainage from sternal wound VAC changes qmonday per plastic surgery Any bleeding issues from VAC or with dressing changes please contact plastic surgery, if significant bleeding please transport to emergency department at [Hospital1 18] for plastic surgery evaluation Lovenox for DVT prophalaxis - hold day of VAC change until VAC dressing change complete, no further coumadin Followup Instructions: Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [2113-8-29] at 9:30 am ([Telephone/Fax (1) 1416]) Provider CAT SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2113-8-22] 8:45 Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13896], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2113-8-22] 9:30 Completed by:[2113-8-16]	[ "041.7", "401.9", "414.00", "293.0", "V45.02", "285.1", "424.0", "225.2", "733.90", "530.81", "682.2", "250.00", "E878.2", "V58.61", "300.4", "V45.81", "V12.51", "998.11", "V58.65", "E934.2", "998.59", "998.31", "212.3", "787.91" ]	icd9cm	[ [ [] ] ]	[ "86.22", "38.93" ]	icd9pcs	[ [ [] ] ]	8313, 8413	6592, 7615	342, 379	8847, 8854	2640, 6569	9312, 9705	1708, 1827				8434, 8826		7641, 8290				8878, 9289									1842, 2621																										288, 304							407, 680																		702, 1543	1559, 1692
12,183	180,744	9885	Discharge summary	report	Admission Date: [2197-5-27] Discharge Date: [2197-6-8] Service: CARDIOTHORACIC Allergies: Beta-Adrenergic Blocking Agents Attending:[First Name3 (LF) 492] Chief Complaint: dysnpnea Major Surgical or Invasive Procedure: endotracheal intubation, thrombectomy, IVC filter placement, central venous catheter placement History of Present Illness: Mr. [Known lastname ] is an 84yo man with h/o CAD, diastolic CHF c EF 55%, COPD on home O2 at 2LNC, and recent strep pneumo pna requiring intubation (5d) one month ago, discharged to home from [Hospital ] rehab 1 week ago with new diagnosis of Cdiff now s/p 14d po vanco/flagyl. Yesterday he noted increased dyspnea and his visiting nurse [First Name (Titles) 33166] [Last Name (Titles) ] crackles. He seemed weak per his daughter, and continued to have diarrhea. Last night his edema (usually trace only) and breathing began worsening and he had increased lethargy and decreased mentation today, for which he was brought by EMS to an OSH. . At [Hospital3 1443], ABG was 7.18/65/163 for which he was put on bipap - repeat ABG was 7.26/60/444. He was treated for COPD exacerbation with 125mg IV solumedrol, nebs, and was given 80mg IV lasix x 1 after his BNP returned as 35,000 to which he put out only 100cc, and was transferred to the [Hospital1 18]. On arrival here his SBP was in the 70s-80 (per daughter his baseline is high 80s-90s since last year). He continued on bipap with O2 sats in the 90s. Femoral line was placed and he was initially started on dopamine drip however this caused tachycardia and drip was stopped before transfer to ICU with SBP remaining in the 80s. He was given a dose of levoflox, despite CXR negative for infiltrate (also no sign of pulmonary edema, but did show underlying COPD and bronchiectasis). EKG was reportedly unremarkable. Repeat BNP here was pending at the time of admission. . He denies having had CP, N/V/diaphoresis, dizziness, dysuria, or any other symptoms besides shortness of breath and weakness as above. No cough, no fever or chills. . ROS: currently states breathing feels better than earlier today, no cp, abd pain, n/v. Past Medical History: - HTN, however per daughter no longer, and now hypotensive - diastolic CHF with EF 55% - hypercholesterolemia; - CAD s/p IMI in [2182] - TIA/aphasia [10-2]; s/p L CEA [2-1] - COPD (FEV1 1.57 per [7-2] PFTs, ratio 82% due to poor effort,but tracing appeared obstructive per report); on home 2LNC O2 - BPH s/p TURP [6-1]; - balanitis s/p circumcision [6-1]; - remote nephrolithiasis; - former tobacco use (80 pack/year Hx), - S. pneumoniae pneumonia [4-8], intubated for hypercarbia - C diff diagnosed [5-9] Social History: Before admission in [Month (only) 958] had lived alone with wife. For last week since d/c from [Hospital ] rehab he and wife have been living iwth daughter, who is a nurse here at [Hospital1 18]. 80 pack years of smoking, quit 5 years ago. Family History: noncontributory Physical Exam: VS 96.4, 100, 86/47, 31, 95% on noninvasive bipap 15/8 at FiO2 0.35 Gen: responds with hand gestures and nods to questions, wearing bipap mask, uses abdominal muscles for exhalation HEENT: Pupils small but minimally reactive Neck: JVP mildly distended at 10cm Cor: very decreased heart sounds, s1s2, no murmur Pulm: R base with rales, Left lung clear Abd: soft, NT, ND, +bs Ext: [3-5]+ pitting edema bilateral LE to just below knees Neuro: moves all four, responds to commands Skin: obvious bruises and thin, fragile skin throughout GU: concentrated brown/[Location (un) 2452] urine in foley Pertinent Results: WBC-21.1* RBC-4.58* HGB-13.7* HCT-42.4 MCV-93 MCH-30.0 MCHC-32.4 RDW-15.4 PLT COUNT-285 - NEUTS-96.7* BANDS-0 LYMPHS-1.5* MONOS-1.5* EOS-0.1 BASOS-0.1 GLUCOSE-177* UREA N-38* CREAT-1.3* SODIUM-141 POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-27 CALCIUM-8.8 PHOSPHATE-6.0# MAGNESIUM-1.9 CK(CPK)-19 ->17, cTropnT-0.03* ->0.03 proBNP-[Numeric Identifier 33167]* PT-15.0* PTT-46.0* INR(PT)-1.3* CXR: linear and tubular opacities and ring shadows R>L base consistent with chronic bronchiectasis and scarring from COPD. No new opacity, no significant pleural effusion or edema, but prominent pulmonary arteries suggesting possible pulm artery hypertension. . EKG: unclear baseline in ER. repeat on floor: afib at 83, poor R wave progression, old Q in II, III, F, new TWI v1-4. Low voltage. No STE. . echo [2-6]: The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated. There is mild global right ventricular free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. Brief Hospital Course: A/P: 84yo man with h/o CAD, diastolic CHF, COPD, recent strep pna pneumonia s/p intubation and C diff colitis presented acutely with respiratory failure, right heart failure from massive PE, extensive LE DVT, new afib who developed MRSA pneumonia and aspergilus. Given his lack of improvement in respiration without mechanical ventilation or ability to maintain blood pressure without pressors his family made the decision to change goals of care to comfort. He passed away comfortably with his family at the bedside shortly after. 1. Respiratory failure: This was due to massive PE with high dead space fraction of 92. Fatigued so required intubation to support ventilation. Initially requiring high minute-ventilation (AC 700x32) because of high dead space fraction, tolerating high rates despite COPD. Echocardiogram with RV strain on [5-28]. No clear source of hypercoagulability such as known malignancy or prolonged immobility. Unable to perform CTA due to hemodynamic instability and anuric renal failure. He underwent lysis with tPA on [5-28], without any bleeding complications and had improvement in hemodynamics transiently. He then went for catheter directed thrombectomy on [5-29], and was found to have right-upper and left-lower main [MD Number(3) 33168] that were extracted with Angiojet. These clots were thought to have been embolizstion from lysis of larger main PA clot. LENI's were + so had retractable ivc filter placed by IR [5-30]. He made only minimal improvement in his respiratory failure, and developed subsequent MRSA pneumonia, treated initially with vancomycin then linezolid. He also had aspergilus in his BAL so was started on voriconazole. Despite these measures he was not able to tolerate even a pressure support mode of ventilation due to his persistent high minute ventilation requirement. 2 Fever/Infection: Developed [5-31] despite tylenol, associated with increased pressor requirement, difficulty with ventialation (had to increase MV), CO2 increased and pH decreased. Suspected nosocomial infection (MRSA VAP), UA + but culture just yeast, repeat cx after foley change neg. His CVC was changed [6-4] despite all negative blood cultures. His RUQ US showed gall stone with gallbladder distension, but subsequent ultrasounds showed improvement in this and the wall edema was attributed to anasarca. His lungs were ultrasounded twice to look for pleural effusions for thoracentesis but there was not enough fluid present to sample. CT scan of head, torso showed only source of infection likely was a RUL cavitation which was treated with linezolid for mrsa and voriconazole for aspergilus. He was also treated with zosyn empirically and po vanco given recent history of c.diff colitis, despite negative c.diff toxin x3. ID was consulted to exhaust all potential sources of infection. Amylase and lipase were sampled periodically to assess for pancreatitis but were normal. 3 Hypotension: Pt became markedly hypotensive peri-intubation required maximizing levophed and addition of Neosynephrine. Bedside echocardiogram with markedly dilated RV with hypokinesis and +[Last Name (un) 13367] sign. Blood pressure and pressor requirement transiently improved with systemic lysis but had another deterioration on [5-29] in AM. Cardiology completed thrombectomy on [5-29] with some improvement in hemodynamics. Neosynephrine weaned [Date range (1) 33169]. However, worsening pressor requirement [5-31] thought related to infection/sepsis. He remained on levophed and vasopressin for hemodynamic support throughout his course. IVF resuscitation and empiric steroids did not allow his pressors to be weaned. Furthermore any manipulation such as turning or cleaning caused him to drop his blood pressure despite pressor support. 4 Pulmonary embolism: Echocardiogram with RV strain on [5-28]. No clear source of hypercoagulability such as known malignancy or prolonged immobility. Unable to perform CTA due to hemodynamic instability and anuric renal failure. Underwent lysis with tPA on [5-28]. Then went for catheter directed thrombectomy on [5-29], found to have right-upper and left-lower main [MD Number(3) 33168]. He was treated with heparin drip with goal ptt 60-80 with ivc filter placement. . 5 Leukocytosis: He was admitted with WBC of 30 from recent baseline of 20. This was initially thought related to underlying c.diff with stress reaction. His WBC rose with the development of his MRSA VAP, but continued to climb despite antiobiotics and improvement in fever. Given the severity of the leukocytosis and the number of bands and nucleated red blood cells the smear was reviewed by hem-on, with no unusal forms. This was thought to reflect the response to severe stress. 6 ARF/ATN: He was initially in anuric renal failure but this improved with early treatment of his obsturctive shock. His GFR then remained stable. 7 New afib: Thought related to PE/right heart strain. He returned to sinus rhythm with occaisional runs of NSVT. 8 CAD: His aspirin dose was decreased to 81mg daily, he was continued on his statin. 9 COPD: home O2 2LNC. Will need to administer aggressive MDI to decrease airway resistance. He was restarted on hydrocort [5-6] given elevated airway resistance, which subsequently improved. 10 PPX: on heparin drip, PPI, bowel regimen, insulin sliding scale. Medications on Admission: Aspirin 81 mg po qday Atorvastatin 10 mg po DAILY Fluticasone-Salmeterol 500-50 mcg inhale twice a day. Furosemide 40 mg po DAILY Lorazepam 0.5 mg twice a day pepcid 20mg po qday Prednisone 10 mg PO DAILY Tiotropium 18 mcg Capsule, Inhalation DAILY Florasta 250mg po bid questran packet [Hospital1 ] finished 2w course of po vanco and flagyl yesterday Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Pulmonary embouls with severe obstructive shock, septic shock, MRSA pneumonia, aspergilus pneumonia. Discharge Condition: Deceased. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [Doctor First Name 494]	[ "518.81", "427.31", "276.7", "785.51", "496", "V46.2", "785.52", "401.9", "584.9", "482.41", "428.33", "995.92", "453.40", "285.9", "V09.0", "416.8", "117.3", "415.19", "038.8", "288.60", "008.45", "272.0", "414.00", "458.9", "428.0" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "99.10", "00.40", "39.50", "38.7", "88.43", "96.72", "38.91" ]	icd9pcs	[ [ [] ] ]	10940, 10949	5107, 10504	252, 348	11093, 11217	3685, 5084		3028, 3045		10910, 10917		10970, 11072		10530, 10887													3060, 3666																										204, 214							376, 2181																		2203, 2743	2759, 3012
55,719	143,927	34901	Discharge summary	report	Admission Date: [2178-10-14] Discharge Date: [2178-10-20] Date of Birth: [2116-4-14] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: None (incidental finding of atrial myxoma) Major Surgical or Invasive Procedure: s/p CABG s/p cardiac catheterization s/p Permanent pacemaker implant History of Present Illness: 62 year old woman with medical history noted below who had multiple episodes of pneumonia over the past year. During the most recent evaluation of a pneumonia, she had a chest CT that revealed a left atrial myxoma. She underwent diagnostic cardiac catherization as part of her pre-op workup that revealed a 50% mid LAD lesion. Past Medical History: s/p Multiple pneunmonia anxiety Mild hypertension (no meds) kidney stones s/p right kidney surgery s/p cataract surgery Social History: She works in the [Hospital1 ] school system. She is widowed and lives with her mother. She has never smoked tobacco and has an occasional glass of wine. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Admission: Vitals: HR 83 RR 16 BP 152/100 5'6" 140lbs General: well developed woman in no acute distress HEENT: unremarkable neck: supple, full ROM Chest: lungs clear to auscultation bilaterally Heart: regular rate and rhythm. Abdomen: soft, non-distended, non-tender with normoactive bowel sounds Extremities: warm, well perfused Neuro: grossly intact Pertinent Results: ECHO: PRE-BYPASS: PRE-BYPASS: The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. 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. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild to moderate TR. The prosthetic tricuspid leaflets appear normal. There is no pericardial effusion. A uniform, echodense, peduculated mass is seen in the left atrium. It is attached to the IAS via a thin stalk. It is not adherent to the IAS. It is freely moving, but does not prolapse into the LV. POST-BYPASS: The patient is AV paced and on an infusion of phenyleprhine. The aorta is intact. LV and RV systolic function is preserved. The LA mass is absent. No ASD by 2D or color doppler. TR is now physiologic. The remainder of the study is unchanged. Dr. [Last Name (STitle) 914] was notified of the results intraoperatively. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 15425] [Name8 (MD) 15426], MD, Interpreting physician [Last Name (NamePattern4) ] [2178-10-19] 06:47AM BLOOD WBC-6.3 RBC-3.07# Hgb-9.7 Hct-27.2* MCV-89 MCH-31.7 MCHC-35.7* RDW-14.3 Plt Ct-168# [2178-10-14] 07:10PM BLOOD WBC-4.1 RBC-4.05* Hgb-13.2 Hct-37.6 MCV-93 MCH-32.6* MCHC-35.0 RDW-13.4 Plt Ct-202 [2178-10-20] 05:20AM BLOOD PT-13.6* INR(PT)-1.2* [2178-10-14] 07:10PM BLOOD PT-12.9 PTT-32.4 INR(PT)-1.1 [2178-10-20] 05:20AM BLOOD K-4.1 [2178-10-19] 06:47AM BLOOD UreaN-19 Creat-0.7 Na-137 K-3.8 [2178-10-14] 07:10PM BLOOD Glucose-64* UreaN-17 Creat-1.0 Na-137 K-3.8 Cl-99 HCO3-32 AnGap-10 [2178-10-20] 05:20AM BLOOD Mg-1.7 [2178-10-16] 03:33AM BLOOD Mg-1.7 Brief Hospital Course: 62 year old woman who was discovered to have an asymptomatic left atrial myxoma and single vessel CAD. On [2178-10-15] she was brought to the OR with Dr [Last Name (STitle) 914] and underwent a single vessel CABG (LIMA-LAD) and a left atrial myxoma resection with patch repair of atrial septal defect. Please see operative report for full details. Post-operatively she was brought to the cardiovascular surgical ICU for invasive hemodynamic monitoring. She was weaned and extubated on POD 0. She did require IV nitroglycerine for blood pressure control for a short period of time. She had peristent complete heart block and as a result a permamnent pacemaker was placed by electrophysiology on POD 1. The device was interrogated on POD 2 and her epicardial wires were pulled. She continued to improve and was transferred to the step down unit on post-op day 2. She continued to diurese well. Her hematocrit remained low but stable around 22. She was placed on iron and folate on POD 3. Due to fatigue she was transfused 2 units packed red blood cells. Her hematocrit to improved to above 27 and she improved symptomatically. She went into atrial fibrillation/flutter at 120-130. Her metoprolol was increased and she was placed on Disopyramide for rate control. By POD 5 she was still in atrial flutter but her rate was in the 60's. She was started on coumadin and discharged to home. Medications on Admission: Effexor 112.5 mg po daily Trazodone 100 mg po BID Lorazepam 1 mg po BID Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:50 Tablet(s) Refills:0 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Disp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:0 6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: Three (3) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:90 Capsule, Sust. Release 24 hr(s) Refills:0 9. Disopyramide 100 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Disp:120 Capsule(s) Refills:0 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:10 Tablet(s) Refills:0 12. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: Please take as instructed by Dr[Name (NI) 41631] office. Disp:150 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: CAD s/p CABG x1 (LIMA-LAD) s/p atrial myxoma resection with patch repair of ASD Complete heart block Atrial Fibrillation/Atrial Flutter 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: 1) Dr. [Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment 2) Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 20642] in 1 week ([Telephone/Fax (1) 14328]) please call for appointment 3) Dr. [Last Name (STitle) 10543] in [1-4] weeks ([Telephone/Fax (1) 4475]) please call for appointment 4) Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3071]) 5) You have a post-pacemaker appointment on [10-27] at 9am on the [Location (un) 436] of the [Hospital Ward Name 23] building ([Hospital Ward Name ]) Completed by:[2178-10-20]	[ "414.01", "426.0", "V13.01", "427.32", "427.31", "212.7", "997.1", "E878.2", "780.79" ]	icd9cm	[ [ [] ] ]	[ "89.45", "36.15", "39.64", "39.61", "88.72", "88.56", "37.83", "37.33", "37.72", "88.53", "37.22", "99.04" ]	icd9pcs	[ [ [] ] ]	6850, 6907	3784, 5183	365, 436	7087, 7094	1600, 3761	7606, 8288	1126, 1208		5305, 6827		6928, 7066		5209, 5282				7118, 7583									1223, 1581																										283, 327							464, 793																		815, 936	952, 1110
24,988	146,571	13671	Discharge summary	report	Admission Date: [2135-2-12] Discharge Date: [2135-2-17] Service: MEDICINE Allergies: Enalapril / Verapamil Attending:[First Name3 (LF) 9554] Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: THis is a 87 yo F who was transferred on OSH on balloon pump for cardiogenic shock. Pertinent Results: [2135-2-12] 06:09PM GLUCOSE-172* [2135-2-12] 06:09PM O2 SAT-72 [2135-2-12] 05:29PM GLUCOSE-221* UREA N-37* CREAT-1.5* SODIUM-144 POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-27 ANION GAP-14 [2135-2-12] 05:29PM CALCIUM-7.7* PHOSPHATE-4.9* MAGNESIUM-2.6 [2135-2-12] 05:29PM HCT-29.7* [2135-2-12] 12:35PM GLUCOSE-130* [2135-2-12] 12:35PM HGB-10.3* calcHCT-31 O2 SAT-71 [2135-2-12] 11:58AM URINE HOURS-RANDOM CREAT-74 TOT PROT-60 PROT/CREA-0.8* [2135-2-12] 11:58AM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO [2135-2-12] 11:57AM GLUCOSE-142* UREA N-37* CREAT-1.3* SODIUM-148* POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-29 ANION GAP-14 [2135-2-12] 11:57AM ALT(SGPT)-28 AST(SGOT)-63* LD(LDH)-280* CK(CPK)-436* ALK PHOS-62 AMYLASE-111* TOT BILI-0.2 [2135-2-12] 11:57AM LIPASE-28 [2135-2-12] 11:57AM CK-MB-41* MB INDX-9.4* cTropnT-1.53* [2135-2-12] 11:57AM TOT PROT-5.1* ALBUMIN-3.3* GLOBULIN-1.8* CALCIUM-7.7* PHOSPHATE-5.1* MAGNESIUM-1.7 IRON-28* CHOLEST-181 [2135-2-12] 11:57AM calTIBC-211* TRF-162* [2135-2-12] 11:57AM TRIGLYCER-88 HDL CHOL-71 CHOL/HDL-2.5 LDL(CALC)-92 [2135-2-12] 11:57AM TSH-0.94 [2135-2-12] 11:57AM CORTISOL-26.0* [2135-2-12] 11:57AM WBC-13.5* RBC-3.40* HGB-10.3* HCT-30.4* MCV-89 MCH-30.2 MCHC-33.8 RDW-15.2 [2135-2-12] 11:57AM WBC-13.5* RBC-3.40* HGB-10.3* HCT-30.4* MCV-89 MCH-30.2 MCHC-33.8 RDW-15.2 [2135-2-12] 11:57AM PLT COUNT-191 [2135-2-12] 11:57AM PT-13.2 PTT-32.9 INR(PT)-1.1 [2135-2-12] 06:37AM TYPE-ART TEMP-36.1 RATES-14/ TIDAL VOL-500 O2-100 PO2-239* PCO2-40 PH-7.40 TOTAL CO2-26 BASE XS-0 AADO2-436 REQ O2-75 INTUBATED-INTUBATED [2135-2-12] 06:37AM O2 SAT-98 [2135-2-12] 04:17AM GLUCOSE-214* UREA N-33* CREAT-1.2* SODIUM-144 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-28 ANION GAP-14 [2135-2-12] 04:17AM CK(CPK)-284* [2135-2-12] 04:17AM CK-MB-32* MB INDX-11.3* cTropnT-1.83* [2135-2-12] 04:17AM CALCIUM-7.9* PHOSPHATE-6.4* MAGNESIUM-1.7 [2135-2-12] 04:17AM WBC-13.6# RBC-3.67 HGB-10.9* HCT-33.4* MCV-91 MCH-29.6 MCHC-32.6 RDW-15.2 [2135-2-12] 04:17AM PLT COUNT-198 [2135-2-12] 04:17AM PLT COUNT-198 [2135-2-12] 04:17AM PT-13.3 PTT-39.8* INR(PT)-1.1 Brief Hospital Course: This is a 87 female with history of peripheral vascular disease, hypertension, atrial fibrillation who presented with cardiogenic shock. She was found to have 3VD at cardiac catheterizsation performed at [Hospital1 ]. Her initial EF was 20% which recovered slightly on a repeat echocardiogram with EF of 35-40% with apical akinesis. She was continued on aspirin, metoprolol, plavix and lipitor. Cardiac surgery was consulted for possible revascularization but patient and family declined. SHe was gradually weaned off ballon pump, milrinone and levophed. She was started on hydralazine and nitroglycerin drip for pulmonary hypertension. Pulmoanry embolism was considered but since patient was already on heparin drip for atrial fibrillation, CTA was deferred since patient was not stable enough for the scan. She was also on amiodarone for paroxysmal atrial fibrillation. She was extubated and was stable until [2135-2-17]. She was acutely hypotensive with ischemic looking EKG. She most probably had acute MI from her 3VD. Her family was with her and decided that she would be made CMO. All pressors were withdrawn and she passed away peacefully. Discharge Disposition: Expired Discharge Diagnosis: cardiogenic shock from acute MI Discharge Condition: expired [First Name8 (NamePattern2) 2064] [Last Name (NamePattern1) ] MD [MD Number(2) 2139] Completed by:[2135-2-22]	[ "518.81", "785.51", "486", "427.31", "428.0", "414.01", "416.8", "285.9", "491.21", "276.5", "V10.3", "276.2", "584.9", "V10.42", "410.81", "578.9", "443.9", "401.9", "272.4" ]	icd9cm	[ [ [] ] ]	[ "96.71", "99.04", "38.91", "97.44", "99.20", "89.64" ]	icd9pcs	[ [ [] ] ]	3833, 3842	2652, 3810	240, 246	3917, 4082	378, 2629						3863, 3896																																									190, 202							274, 359
49,024	182,358	40514	Discharge summary	report	Admission Date: [2136-6-26] Discharge Date: [2136-6-30] Date of Birth: [2055-2-17] Sex: M Service: NEUROLOGY Allergies: IV Dye, Iodine Containing Contrast Media Attending:[Last Name (NamePattern1) 1838] Chief Complaint: speech difficulty Major Surgical or Invasive Procedure: IV tPA. History of Present Illness: [Known firstname 4580] [Last Name (NamePattern1) 88722] is an 81 year-old right handed man who presented to [Hospital ] Hospital after he was found by his daughter to be fumbling with a lamp and having difficulty with language. According to his daughter, with whom he lives, he was feeling tired but was speaking with well at around 7:30 pm when he decided to take a nap. Around 10 pm his daughter heard him getting up and he was fumbling with a bedside lamp. When she went into the room she found him and he was having trouble expressing himself. She said he was having some difficulty expressing language and was using the wrong words. She did not think that there was any difficulty with his movement. She called 911 and he was brought to [Hospital ] Hospital. At the OSH he was noted to have an NIHSS of 6 for LOC, facial palsy, language, dysarthria and decision was made to not give tPA and to send to [Hospital1 18] for additional care. On arrival his exam was noted to be consistent with [Hospital1 ] exam, however he quickly worsened and his speech deficits became more profound. He was no longer following simple commands, but within a few minutes he had minimal verbal output and was not following simple commands. In addition his eyes were no longer moving past midline. A discussion was had with his daughter, who was present and the risks were discussed including intracranial bleeding, and given some uncertainty about the time window she asked that he receive the tPA. She also noted that prior to losing all language, she had asked him whether he would want tPA to which he answered yes. The contraindications were reviewed and there were no absolute contraindications. He had a bolus of 6 mg of tPA administered at 1:30 am. At baseline he was an active man who dressed and fed himself and lived with his daughter. [Name (NI) ] received some support from his daughter, but she describes him as cognitively intact. On review he has had no recent fevers, no recent falls, no changes in weight, no diarrhea, no vomiting, no headaches, no chest pains, no dyspnea. Past Medical History: Atrial Fibrillation (diagnosed years ago) - not on coumadin against the advise of his physicians MI (w/ multiple cardiac stents) - stopped Plavix for bleeding ulcer Bladder Cancer - s/p bladder surgery w/ chronic indwelling foley and stoma; frequent UTIs Colon cancer - diagnosed years ago on colonoscopy, has not wanted chemo Cholecystectomy Social History: retired electrician lives with his daughter in [Name (NI) 12415] quit smoking 40+ years ago Family History: Mother: obese with heart failure Father: deceased in 70s from possible stroke brother w/ 8 cardiac stents daughter - cholecystectomy and breast cancer Physical Exam: VS: T 97.1 P 60 BP 161/58 R 16 SpO2 100% GEN: elderly man, NAD, lying in bed HEENT: non-icteric, no erythema CV: irregular rhythm, slow rate, II/VI SEM Pulm: CTABL, no wheezing, rales Abd: soft, NT, ND Ext: no edema, pulses present Neuro: MS: alert; attentive; unable to name hospital, date or name; not following simple commands; unable to read, could not repeat phrase; paying attentive to all visual fields CN: I: Olfaction not tested. II: pupils symmetric and reactive to light b/l; not blinking to threat from the right III, IV, VI: not moving eyes past the midline to the right V: reacting to stimuli b/l on the face VII: R facial droop in UMN pattern VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, slightly increased tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. 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+ 5 5- 5- 5 5- 4+ 5 4+ 5- 5 -Sensory: diminished sensation to pain on the right side. -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 dysmetria on FNF of HTF -Gait: deferred Pertinent Results: [2136-6-26] 12:30AM WBC-5.4 RBC-3.73* HGB-11.1* HCT-32.5* MCV-87 MCH-29.7 MCHC-34.1 RDW-14.3 [2136-6-26] 12:30AM PLT COUNT-206 [2136-6-26] 12:30AM PT-11.9 PTT-24.7 INR(PT)-1.0 [2136-6-26] 12:30AM GLUCOSE-96 UREA N-47* CREAT-2.4* SODIUM-139 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-23 ANION GAP-17 [2136-6-26] 04:59AM TRIGLYCER-79 HDL CHOL-67 CHOL/HDL-2.2 LDL(CALC)-63 [2136-6-26] 04:59AM %HbA1c-5.8 eAG-120 [2136-6-26] 01:12AM URINE RBC-3* WBC-131* BACTERIA-FEW YEAST-NONE EPI-0 Diagnostic Studies: EKG ([2136-6-26]): Atrial fibrillation with slow ventricular response and probable atrial premature beat with aberrancy. ECHO ([2136-6-26]): Overall left ventricular systolic function is normal (LVEF>55%). No cardiac source of embolus (other than atrial fibrillation) identified. CT head ([2136-6-26]): No acute hemorrhage or CT evidence of an acute major vascular territorial infarction. Moderate chronic small vessel disease in the supratentorial white matter. CT head ([2136-6-26]): No acute intracranial hemorrhage. No interval change. CXR (Portable AP) ([2136-6-26]): The image quality is reduced, with missing parts of the left lung. In the visualized lung parenchyma, no evidence of pneumonia is seen. Borderline size of the cardiac silhouette without evidence of pulmonary edema. CT head ([2136-6-27]): No acute hemorrhage. No evidence of a developing major vascular territorial infarction. CT head: ([2136-6-28]): No significant change. No hemorrhage or edema. Brief Hospital Course: NEURO: L MCA stroke [Known firstname 4580] [Known lastname ] is an 81 year-old right handed man with atrial fibrillation (not on Coumadin) who was noted by his daughter to have significant word-finding deficits around 10:30 pm. He was initially taken to [Hospital ] hospital and tPA was not given as they felt that he was outside window given a slightly different story. His NIHSS on presentation at [Hospital1 18] was 14. His exam was notable for a now global aphasia, with a right facial droop and minor amount of weakness in the right arm and leg. A decision was made with his daughter present to give tPA despite potentially being over the window. The exact time of onset was unknown, an it seemed his exam was getting worse between [Hospital1 ] and getting to the [Hospital1 ] ED. 58 mg of IVtPA were given and the patient admitted to the neuro-ICU for post-tPA monitoring. The patient developed epistaxis post-tPA that required packing by ENT, but this did not recur and HCT was stable. His neurologic examination improved over the following 24 hours after tPA, with some improvement in comprehension (able to follow simple commands), but he remained unable to produce any appropriate speech. His right upper and lower extremities were at least 3/5 strength, though particularly RUE was weaker than left. Review of head CT at 24 hours revealed left MCA corona radiata infarct, consistent with a cardioembolic source. Transthoracic echocardiogram revealed normal left atrium size, normal global systolic function, and no thrombus. Telemetry revealed atrial fibrillation with normal rate. After 1 day in the neuro ICU and no evidence of intracerebral hemorrhage, he was transferred to the neurology floor. There, his physical exam was notable for continued nonfluent dysarthric speech and right-sided weakness; in particular, there was a right facial droop and mild right upper and lower extremity weakness (motor strength 4-5 out of 5). The next day, he noted a sudden further decline in right-sided weakness. A repeat physical exam revealed that he had increased dysarthria, increased right facial droop, and noticeably worsened right-sided strength (motor strength 0-1 out of 5). A repeat head CT did not show any significant change from before. A repeat physical exam after his head CT discovered that his strength had returned ([4-24] out of 5 in his right upper and lower extremities). A head MRI showed multiple tiny foci of acute ischemia within the left MCA territory, consistent with the patient's presumed cardioembolic stroke, but no new areas of infarction. An EEG showed general left-sided slowing without evidence of ongoing seizures. Given the transient nature of his sudden decline in strength, the absence of other associated symptoms, and no evidence of new infarct or hemorrhage on imaging, his sudden right-sided weakness and dysarthria were attributed to a seizure. As the patient refused anticoagulation with Coumadin for his atrial fibrillation and had evidence of renal insufficiency, he was started on low dose (75 mg) Dabigatran. Patient's kidney function needs to be checked regularly to ensure proper dosing of Dabigatran. Please call [Telephone/Fax (1) 1694] and ask for Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] if his kidney function improves significantly (GFR >35). At discharge, the patient's physical exam was notable for mild dysarthria, right facial droop, mild right upper and lower extremity weakness (motor strength 4-5 out of 5). ATRIAL FIBRILLATION: Patient was continued on metoprolol. HR was well controlled. He was started on Dabigatran 75mg [Hospital1 ] (which is low dose), as he refused Coumadin and had evidence of renal insufficiency. UTI: Patient had a positive UA at admission, but the urine culture was contaminated. He was started on ciprofloxacin but was switched to Bactrim, as there was a concern for post-stroke seizure and because ciprofloxacin may lower the seizure threshold. Medications on Admission: Atrial Fibrillation (diagnosed years ago) - not on coumadin against the advise of his physicians MI (w/ multiple cardiac stents) - stopped Plavix for bleeding ulcer Bladder Cancer - s/p bladder surgery w/ chronic indwelling foley and stoma; frequent UTIs Colon cancer - diagnosed years ago on colonoscopy, has not wanted chemo Cholecystectomy Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. dabigatran etexilate 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 days. 5. metoprolol tartrate 25 mg Tablet Sig: [1-24] Tablet PO twice a day: 6.25 mg twice daily hold if SBP < 100 or HR < 55. 6. Outpatient Lab Work Creatinine every week - if patient GFR > 35, will need to increase dabigatran dosage. Please call [Telephone/Fax (1) 1694] and ask for Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] if patient's GFR > 35 to ask about uptitrating dabigatran dose. Discharge Disposition: Extended Care Facility: [Hospital6 ] Discharge Diagnosis: left middle cerebral artery stroke Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro Exam: awake, alert, can say his name and 'medicine' when asked where he is. Nonfluent aphasia- able to name high frequency objects and follow simple 1 step commands, will occasionally speak gibberish. Has right sided facial droop; otherwise cranial nerves intact. Has mild right hemiparesis ([4-24] in UE and IP and 5-/5 hamstring) Discharge Instructions: You presented to the hospital after being found by your daughter fumbling with a lamp and having difficulty with language. You initially went to [Hospital ] Hospital and were transferred to [Hospital1 18] for further care. Upon arrival to [Hospital1 18], your speech defecits worsened and after a conversation with your daughter, you received IV tPA for a suspected left middle cerebral artery stroke. You were initially admitted to the ICU for 24 hours after receiving this medication, but were then transferred to the floor once you were stable. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 2574] Date/Time:[2136-8-27] 2:00 Please follow-up with your PCP 1-2 weeks after discharge from rehab Completed by:[2136-6-30]	[ "781.94", "412", "784.7", "729.89", "599.0", "784.3", "V49.86", "427.31", "V44.6", "V10.05", "784.51", "780.39", "434.11", "585.9", "V10.51" ]	icd9cm	[ [ [] ] ]	[ "99.10" ]	icd9pcs	[ [ [] ] ]	11406, 11449	6149, 10166	328, 337	11528, 11528	4583, 6049	12632, 12917	2967, 3120		10559, 11383		11470, 11507		10192, 10536				12048, 12609									3135, 4564																										271, 290							365, 2472		6058, 6126									11543, 12024							2494, 2838	2854, 2951
10,401	112,466	19313	Discharge summary	report	Admission Date: [2111-3-9] Discharge Date: [2111-3-16] Date of Birth: [2034-3-11] Sex: M Service: CARDIAC SURGERY CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old male with a history of insulin dependent diabetes who was admitted to outside hospital on [2111-3-6] following a cardiac catheterization showing a ______ and three vessel coronary artery disease. The patient has been hemodynamically stable and chest pain free since the catheterization. Chest x-ray on admission showed a left lower lobe mass versus atelectasis. CT scan on [3-7] showed superficial opacity at the left lung base measuring 2.5 cm at maximum diameter. The patient was seen by pulmonary and infectious disease who felt that the patient's coronary artery disease should be addressed primarily and follow up CT scan in one month. The patient is now transferred to [Hospital1 69] for evaluation of coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Noninsulin dependent diabetes mellitus. 2. Status post colectomy for colon cancer in the year [2107]. 3. Irritable bowel syndrome. 4. Hiatal hernia status post right inguinal hernia repair. 5. Status post right hydrocele removal. SOCIAL HISTORY: Lives with wife. Retired electrician. The patient smokes one to two cigars per week for the past four or five years. Quit 24 years ago. The patient denies use of alcohol. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Asacol 800 mg po t.i.d. 2. Lopressor 12.5 mg po b.i.d. 3. Enteric coated aspirin 325 mg po q day. 4. Glucotrol 20 mg po q.d. 5. Regular insulin sliding scale. 6. Metformin at home. REVIEW OF SYSTEMS: The patient denies chest pain, fevers or chills, nausea, vomiting, abdominal pain, melena, denies hematochezia, denies dysuria. PHYSICAL EXAMINATION: Temperature 97. Blood pressure 120/70. Heart rate 80. Respiratory rate 18. Satting 96% on room air. The patient is alert and oriented and in no acute distress. Extraocular movements intact. Pupils are equal, round and reactive to light. The patient had no lesions in the mouth. The patient's head was normocephalic, atraumatic. Examination of the neck revealed no lymphadenopathy. No JVD. No bruits. Chest was clear to auscultation bilaterally. Heart revealed a regular rate and rhythm without any murmurs, rubs or gallops. Examination of the abdomen revealed soft, nontender, nondistended abdomen. No hepatosplenomegaly. No splenomegaly. The patient had a surgical scar in the right lower quadrant. The patient's extremities had no clubbing, cyanosis or edema. The patient had 2+ pulses bilaterally, femoral, popliteal, dorsalis pedis and posterior tibial. Cranial nerves II through [Doctor First Name 81] were grossly intact. Extremities sensory and motor were intact. LABORATORY: White blood cell count on admission was 10.9, hematocrit 37.3, platelets 521, INR 1.1, sodium 139, potassium 4.3, chloride 101, bicarb 29, BUN 26, creatinine 1, glucose 192. HOSPITAL COURSE: The patient was admitted to the Cardiac Surgery Service and underwent coronary artery bypass graft times three. The patient had a left internal mammary coronary artery to the left anterior descending coronary artery, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending coronary artery. On postoperative day number one the patient was extubated and remained afebrile with stable vital signs. On postoperative Vancomycin and on insulin drip to control the glucose. Otherwise the patient was doing well. On postoperative day number two the patient continued to do well. The patient was completely weaned off all drips. The patient was put back on home regimen for glucose control. He remained afebrile with stable vital signs. The patient continued to do well and was transferred to the floor. Overnight the patient had a bout of delirium. The patient had a sitter and was put on low dose Haldol. On postoperative day number three the patient continued to do well. The patient was on Lopressor 50 mg b.i.d. and remained afebrile with stable vital signs. The patient had good urine output. The patient's wire was removed and the patient was continued with a sitter for confusion. On postoperative day number four the patient continued to have bouts of confusion, although improved. Urinalysis was negative. The patient remained afebrile with stable vital signs. Physical therapy worked with the patient. A standing dose of Haldol was stopped and put on Captopril and obtained a PA and lateral chest x-ray, which revealed small pleural effusion. No pneumo. On postoperative day number five the patient continued to do well. The patient had eight beats of ventricular tachycardia overnight, which was asymptomatic. EP was consulted who recommended to replete the electrolytes and to do regular follow up with patient's cardiolgoist since the patient has no history of myocardial infarction or signs of ischemia on electrocardiogram. The patient continued to do well. On postoperative day number six the patient had no complaints. Remained afebrile with a blood pressure of 149/76 and a pulse of 80. The patient's Metoprolol was increased to 75 b.i.d. The patient was taking good po and making good urine. The patient was discharged to home. CONDITION ON DISCHARGE: Good. DISPOSITION: Discharged to home. FINAL DIAGNOSES: 1. Status post coronary artery bypass graft. 2. Coronary artery disease. 3. Status post colectomy for colon cancer in [2107]. 4. Noninsulin dependent diabetes mellitus. 5. Irritable bowel syndrome. 6. Hiatal hernia status post right inguinal hernia repair. 7. Status post right hydrocele removal. 8. Lung nodule on x-ray. FO[Last Name (STitle) 996]P PLANS: Please follow up with Dr. [Last Name (Prefixes) ] in four weeks. Please follow up with primary care physician and Dr. [Last Name (STitle) 1655] in one to two weeks. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q.d. 2. Colace 100 mg po b.i.d. 3. Asacol 800 mg po t.i.d. 4. Glipizide 20 mg po q day. 5. Metformin 1000 mg po q.a.m., 500 mg po q.p.m. 6. Captopril 6.725 mg po t.i.d. 7. Percocet one to two tabs po q 4 to 6 hours. 8. Lopressor 75 mg po b.i.d. 9. Sliding scale insulin. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 3118] MEDQUIST36 D: [2111-3-16] 09:06 T: [2111-3-16] 09:22 JOB#: [Job Number 52591]	[ "427.1", "793.1", "305.1", "293.0", "V10.05", "997.1", "414.01", "250.00" ]	icd9cm	[ [ [] ] ]	[ "36.15", "39.61", "36.12" ]	icd9pcs	[ [ [] ] ]									6027, 6595					3072, 5370																		5454, 6004									1873, 3054						1721, 1850					165, 187							216, 1001																		1023, 1266	1283, 1701	5395, 5437
307	132,807	28057	Discharge summary	report	Admission Date: [2162-11-24] Discharge Date: [2162-12-13] Date of Birth: [2088-3-6] Sex: F Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1234] Chief Complaint: ARF Major Surgical or Invasive Procedure: Renal artery stent Chest tube History of Present Illness: The patient is an elderly female who had undergone a left nephrectomy at an outside institution. She had diminished urine output over approximately 48 hours and was diagnosed on MRA with a high-grade right renal artery stenosis. She was urgently transferred to our institution. She was received directly in the cardiac catheterization holding area and brought urgently into the procedure room. She was prepped with ChloraPrep and draped in the usual fashion. Past Medical History: PMH: HTN, TCC, RAS, L. maxillary sinus tumor, TAH/BSO Social History: pos smoker pos drinker Family History: non contributary Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [Doctor Last Name ], pt, dp lle - palp fem, [Doctor Last Name ], pt, dp Pertinent Results: [2162-12-12] 04:50AM BLOOD WBC-12.6* RBC-3.16* Hgb-9.6* Hct-28.4* MCV-90 MCH-30.4 MCHC-33.8 RDW-18.9* Plt Ct-178 [2162-12-7] 03:44AM BLOOD PT-12.7 PTT-26.0 INR(PT)-1.1 [2162-12-12] 04:50AM BLOOD Plt Ct-178 [2162-12-13] 10:13AM BLOOD Glucose-109* UreaN-56* Creat-5.3* Na-137 K-3.7 Cl-101 HCO3-26 AnGap-14 [2162-12-8] 03:48AM BLOOD LD(LDH)-465* TotBili-0.7 DirBili-0.3 IndBili-0.4 [2162-12-13] 10:13AM BLOOD Calcium-8.1* Phos-5.7* Mg-2.0 URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.010 URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD URINE RBC-0-2 WBC->50 Bacteri-MANY Yeast-NONE Epi-0 RenalEp-<1 [2162-11-29] 10:05 pm SPUTUM Site: EXPECTORATED GRAM STAIN (Final [2162-11-30]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [2162-12-1]): MODERATE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). RARE GROWTH. [2162-12-11] 4:16 PM CHEST (PA & LAT) Reason: please reassess pneumonia Comparison is made with the prior chest x-ray of [12-8]. Patchy infiltrates are still present in the right upper lobe, mildly improved since the prior chest x-ray. Bilateral effusions are again seen, probably indicating the presence of some underlying failure as well. The position of the two lines remains unaltered. IMPRESSION: Marginal improvement in right upper lobe pneumonia, some failure persists. Cardiology Report ECHO Study Date of [2162-11-30] INTERPRETATION: Findings: LEFT ATRIUM: Dilated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. Dilated IVC (>2.5 cm), with minimal respiratory variation c/w elevated RA pressure of >20 mmHg. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Mild (1+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Severe PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is dilated. The right atrium is dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60-70%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. 11:16:48 PM EKG Sinus rhythm and occasional ventricular ectopy. Otherwise, compared to the previous tracing of [2162-12-7] no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 72 158 96 428/451.85 9 -24 45 [2162-12-2] 2:29 PM CT CHEST W/O CONTRAST Reason: elevated WBC with persistent right infiltrate, ? pulmonary a Diffuse bilateral pulmonary abnormalities are present, including smoothly thickened septal lines, areas of reticulation, and multifocal ground-glass opacities. These findings involve multiple lobes of both lungs but are asymmetrically distributed. In the left lung, they are most severe in the lingula and in the right lung, most severe in the right upper lobe. Additionally, there are multiple areas of patchy consolidation, most pronounced in the right upper lobe. Within the left lower lobe, there is a focal area of confluent opacity with associated volume loss, favoring atelectasis over consolidation. Similarly, a confluent area of opacity in the right lower lobe, immediately adjacent to pleural fluid is probably due to focal atelectasis. Asymmetric soft tissue density in right supraclavicular region could be due to asymmetrical musculature but is difficult to distinguish from lymphadenopathy in the absence of intravenous contrast. Numerous mediastinal lymph nodes are present, measuring up to 2 cm in diameter in greatest short axis dimension in the precarinal region. Subcarinal nodes measure up to 1.3 cm in short axis dimension. Pulmonary hila are difficult to assess in the setting of enlarged pulmonary arteries and absence of intravenous contrast, but there is likely at least mild hilar lymphadenopathy present. The main pulmonary artery is enlarged at 3.7 cm. The heart is upper limits of normal in size. Coronary artery calcifications are present. Small bilateral dependent pleural effusions are present, right slightly greater than left. Within the imaged portion of the upper abdomen, there is diffuse nonspecific soft tissue stranding within the mesentery. Right renal artery stent is present. No suspicious abnormalities are identified within the liver on this unenhanced study. There is a rounded low attenuation lesion within the spleen measuring about 1.8 cm in diameter, and a second smaller central lesion measuring about 8 mm in diameter. These are also difficult to assess in the absence of contrast. Superficial surgical clips are present in the left posterior upper abdominal wall, and there is nonspecific soft tissue stranding near the clips. Comparison CT abdomen [2162-11-30] demonstrates a similar appearance in this region. The pleural effusions have slightly increased in size bilaterally since the prior abdominal CT, and the left basilar opacity has worsened. Right lower lobe is slightly better aerated posteriorly compared to the prior abdominal CT. With regard to the splenic lesions, the two lesions appear unchanged from the recent abdominal CT. IMPRESSION: 1. Multifocal ground glass opacities and septal thickening, most likely due to hydrostatic pulmonary edema. 2. Asymmetrical consolidation predominantly involving the right upper lobe is concerning for infectious pneumonia given the history of elevated white blood cell count. Asymmetrical edema is within the differential diagnosis. 3. Small bilateral pleural effusions, right greater than left, slightly increased from recent abdominal CT. 4. Bulky mediastinal lymphadenopathy and questionable right supraclavicular nodes. If nephrectomy was performed for renal cell carcinoma, followup CT with intravenous contrast would be recommended to exclude the possibility of metastatic lymphadenopathy. Differential diagnosis includes reactive/hyperplastic lymph nodes. 5. Status post left nephrectomy and right renal artery stenting. 6. Splenic lesions without change from recent abdominal CT [2162-12-1] 3:00 PM CT HEAD W/O CONTRAST FINDINGS: There is no intracranial mass effect, hydrocephalus, shift of normally midline structures, or major vascular territorial infarction. The [Doctor Last Name 352]-white differentiation is preserved. A small rounded area of low attenuation is seen in the head of the caudate nucleus on the right side, representing an old lacunar infarct. A similar area of low attenuation is visualized in the right medial temporal lobe, also representing lacunar infarct, chronic in age. The surrounding soft tissue and osseous structures are unremarkable. There is evidence of a probable left maxillary medial wall antrostomy- please confirm and correlate with prior history. IMPRESSION: No mass effect or hemorrhage RADIOLOGY Final Report [2162-11-28] 11:18 AM MR HEAD W/O CONTRAST TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed. However, this study could not be completed as the patient's sats dropped and patient did not want to continue the study. FINDINGS: The few sequences (sagittal and axial T1, axial T2, and axial FLAIR) are limited due to motion artifacts. The cerebral sulci appear hyperintense on the pre-contrast T1-weighted images. This appearance could be due to the retained CT contrast given intravenously, due to the associated renal failure. The ventricles are unremarkable. No mass effect, shift of normally midline structures noted. The osseous and the soft tissues structures are unremarkable, including the paranasal sinuses and the orbits. IMPRESSION: 1. Incomplete study as the patient's sats dropped and did not want to continue the study. 2. Limited images reveal hyperintense cerebral sulci, which could be due to be retained CT contrast given intravenously, considering the patient's renal failure Brief Hospital Course: The patient is an elderly female who had undergone a left nephrectomy at an outside institution. She had diminished urine output over approximately 48 hours and was diagnosed on MRA with a high-grade right renal artery stenosis. She was urgently transferred to our institution. She was received directly in the cardiac catheterization holding area and brought urgently into the procedure room. Renal stent placed / plavix started / Sheath removed without complications. Nephrology consulted. K normal, anuric x 24 hours. Swam placed / Pt with PNX / chest tube placed without incident [11-25] Pt needs dialysis, persistently anuric evaluated for replacement of right IJ with HD catheter team to decide currently also with left swan ganz. No HD needed, not volume overloaded. TTE w/LVEF, no thrombus [11-26] Acute R hemiplegia and dysarthria. Suspect d/t HTN, vs ? HIT. Still oliguric, K 5.8, 7.33/45/97. kayexelate. HD after head CT. Goal SBP 150-160, UF 1.5 kg, Qb 150-200, x 2 h. Overall volume up, tachypneic but better with suctioning so a lot is upper respiratory. [11-27] BCx x2 neg SpCx w/4+GNR, heavy pseudomonas, klebsiella pan sensitive likely TIA, neuro consulted, CT head neg, EEG neg, CVL changed, moved to SICU [11-28] UCx w/pseudomonas>100k [11-29] SpCx w/2+GPC, 2+GPR, Cx w/oropharyngeal flora Duplex carotids w/bilat<40% stenosis [11-30] CT abd w/o bleed, has bilat effusions TTE w/elevated PA pressures [12-3] Right IJ Perma-Cath placement. No complications. Pt seen by hematology for decreased plts / DIC vs TTP [12-4] stable tolerated HD today with 2 U pRBC some problems with hypotension throughout, chilled dialysate, modeled na seemed to help blood helped most [12-5] doing much better evaluate for HD in am if creatinine continues to increase dialyze but no more than 1kg off, to allow good pressures not expand ATN if cr stable of decreased would hold HD. [12-6] she is fine. the BP running slightly high but no evidence of uremic S/S and volume overload is noted. will get HD on [12-7]. [12-7] got HD. dropped her BP. had SOB. got nebs and 1 unit of PRBC. [12-8] she is feeling fine. no HD. she feels fine. U/O is going up. no need for HD today. LUE PICC placed, CXR w/persistent LLL consolid, bilat infiltrates [12-10] she feels fine. U/O OK. will possibly get HD on [12-11]. [12-11] she is getting better. no volume overload or uremic symptoms. the creatinine is going up but slower every day. no HD done over the weekend. evaluate daily. Nephrology clears for home [12-12] PT / OOb / pt did well / cleared for home [12-13] Final recommendations for home with PT, given by nephrology. Pt to follow-up in [Location (un) 620]. Appointments made for one week. Pt to get lab draws at home. Medications on Admission: lisinopril, HCTZ Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for 10 days: prn. Disp:2 Ipratropium Bromide (Inhalation) 0.02 % Solution Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:2 Albuterol Sulfate (Inhalation) 0.083 % Solution 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. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 9 days. Disp:9 Tablet(s) Refills:0 7. Labs Please draw a chem 10 / Fax the results to [Telephone/Fax (1) 68282] / This should be done [12-16] Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: ARF s/p left nephrectomy PTX requiring chest tube PNA UTI CHF HD M/W/F Discharge Condition: Stable Discharge Instructions: What Is It? There are two general categories of kidney failure: acute and chronic. In acute kidney failure, the kidneys suddenly lose much of their ability to filter blood, often because of an injury, serious damage to the kidneys or other organs, or exposure to a toxin (poison). Some of the illnesses that can lead to acute kidney failure include a severe blood loss, severe dehydration, severe drops in blood pressure, heatstroke, severe muscle damage and heart or liver failure. In addition, anything that blocks the organs' blood supply or the outflow of urine -- including tumors or an enlarged prostate -- can lead to kidney shutdown. The toxins that can trigger acute kidney failure include such medications such as antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and certain anesthetics. Occasionally, procedures done in a hospital can also lead to acute kidney failure. Whatever the cause, acute kidney failure can be deadly. Without the normal waste removal system, the blood often becomes loaded with potassium -- an imbalance called hyperkalemia, which can lead to heart rhythm disturbances. The blood also becomes highly acidic and dangerously low in sodium. If a patient isn't producing enough urine, fluids build up rapidly and swamp other tissues. The death rate from acute renal failure can be high, depending on the cause of the kidney failure and other complications that the patient may have. On the bright side, the kidneys have an amazing capacity to heal themselves. This means most patients who survive acute kidney failure can enjoy a complete recovery within one to two months. Some patients, however, need a year or so before their kidneys are fully functional again. Others, whose kidneys have been severely damaged, may go on to chronic kidney failure. While acute kidney failure can happen in days, chronic kidney failure is a slow decline that often spans several years and often leads to irreversible damage. Diabetes and high blood pressure can slowly damage the kidneys and trigger a long-term decline in function. Other conditions associated with chronic kidney failure include polycystic kidney disease and use of the drug lithium. Kidneys in chronic failure will never recover their normal function. When kidneys go into chronic failure, much of the body suffers. The buildup of fluids and waste products can set off a cascade of complications, including weakened bones, hypertension, stomach ulcers, anemia, miscarriages, changes in skin color, congestive heart failure, and lapses in concentration and memory. (Not all kidney failure patients -- acute or chronic -- have a decrease in urine. In some patients, the kidneys continue to excrete urine that's mainly water without removing most of the body's waste products. While these people don't suffer from fluid buildup, imbalances from excess waste products remain a problem.) When the symptoms of advanced renal failure are present, a person is said to have end-stage renal disease, often called ESRD. At this point, the patient will need treatment -- either dialysis or a kidney transplant -- to stay alive. Followup Instructions: Call Dr [Last Name (STitle) 8888] office, he can be reched at [Telephone/Fax (1) 1241]. Your daughter has scheduled an appoinment with nephrology in [Location (un) 620] for you to continue dialysis. It is very important that you keep this appointment. The point of contact is [Name (NI) ] [Name (NI) 68283], phone number [Telephone/Fax (1) 15173]. Completed by:[2162-12-13]	[ "403.91", "V13.01", "440.1", "599.0", "287.5", "305.1", "E930.8", "693.0", "276.7", "585.6", "428.0", "998.12", "275.3", "512.1", "V10.52", "482.1", "435.9", "584.5" ]	icd9cm	[ [ [] ] ]	[ "89.64", "38.93", "39.90", "99.04", "00.40", "39.95", "38.95", "00.46", "39.50", "88.45", "34.04" ]	icd9pcs	[ [ [] ] ]	14267, 14325	10453, 13286	276, 308	14440, 14449	1443, 10430	17620, 18025	929, 947		13353, 14244		14346, 14419		13312, 13330				14473, 17597									962, 1424																										233, 238							336, 796																		818, 873	889, 913
32,689	170,041	849	Discharge summary	report	Admission Date: [2129-8-8] Discharge Date: [2129-8-9] Date of Birth: [2075-2-14] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[Doctor First Name 1402] Chief Complaint: Atrial fibrillation Major Surgical or Invasive Procedure: Pulmonary vein isolation Pericardiocentesis S/p pericardial drain placement. History of Present Illness: Mr. [Known lastname ] is a pleasant 54 yo gentleman with h/o longstanding atrial fibrillation and single kidney who presents to the CCU after becoming hypotensive during pulmonary vein isolation procedure. . Mr. [Known lastname 5894] atrial fibrillation had been well-controlled on flecainide until recently, when he began experiencing episodes of symptomatic tachycardia despite taking his medication faithfully. During his pulmonary vein isolation procedure today, his blood pressure dropped to 68/55. He was given IV fluids with increase in BP to 94/71, and his heparin gtt was reversed with protamine 25mg. Stat echocardiogram revealed pericardial effusion, and patient underwent urgent pericardiocentesis with removal of 400cc of serous fluid from the pericardial space. BP at end of procedure was 111/64, and he was transferred to the ICU intubated and with his pericardial drain in place. He continued to have good urine output throughout the event. . Shortly after his transfer to the ICU, he was successfully extubated. He reports some discomfort in his chest where the drain is in place, worse with taking a deep breath. He is otherwise comfortable. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Past Medical History: Atrial fibrillation not on coumadin Borderline HTN Solitary left kidney due to surgical complication as a child Atonic bladder--performs self-cath QID; on cefuroxime for PPx h/o bladder surgery in [2090] s/p TURP [2125] s/p inguinal hernia repair Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse; he drinks 2-3 glasses of wine weekly. He lives with his wife and 2 children and works as a writer. Family History: There is no family history of premature coronary artery disease or sudden death. Mother had [Name2 (NI) ] sinus syndrome; father had [Name (NI) 5895]. Physical Exam: VS: T 97.8, BP 99/57, HR 64, RR 13, O2 99% on 2L (s/p extubation) Gen: Middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant but somewhat anxious. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 5 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: Pericardial drain in place; no discharge or erythema. Draining small amount of serosanguinous fluid. No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [2129-8-8] 11:15AM WBC-6.8 RBC-4.13* HGB-12.6# HCT-36.2# MCV-88 MCH-30.5 MCHC-34.7 RDW-12.8 GLUCOSE-109* UREA N-21* CREAT-1.5* SODIUM-143 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-26 ANION GAP-11 [2129-8-8] 11:30AM PERICARDIAL FLUID WBC-667* RBC-[Numeric Identifier 5896]* POLYS-50* LYMPHS-17* MONOS-0 MACROPHAG-33* TOT PROT-0.3 GLUCOSE-160 LD(LDH)-85 AMYLASE-LESS THAN Albumin-LESS THAN Pericardial fluid cytology: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, histiocytes and inflammatory cells. [2129-8-9] Cardiology ECHO Overall left ventricular systolic function is normal (LVEF>55%). with normal free wall contractility. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2129-8-8], there is no significant change. Brief Hospital Course: This is a 54 year old gentleman with atrial fibrillation who presented for a pulmonary vein isolation procedure, became hypotensive during the procedure and was noted to have a pericardial effusion, prompting pericardial tap & placement of a pigtail catheter for drainage of the effusion. Pt was transferred to the CCU for further monitoring and was normotensive on arrival. . Pericardial Effusion: Etiology of the effussion is unclear, possibly related to a recent viral illness/pericarditis. The initial drainage was sent for cytology, which demonstrated no malignant cells. Effusion was serous and found to have a low HCT of 1.3, suggesting this was not due to perforation. Overnight, in the ICU, patient produced approximately 250cc serosanguinous drainage. TTE the morning after admission showed no pericardial effusion. Once resolution of pericardial effusion was verified, pigtail catheter was removed for discharge. Pt was hemodynamically stable and was felt to be stable for discharge. Pt was scheduled for follow up ECHO 2 days following discharge and cardiology follow up with Dr. [Last Name (STitle) ]. . Atrial fibrillation: Pt remained in sinus rhythm after the pulmonary vein isolation procedure and there were no episodes of Afib noted on telemetry. Flecainide dosage was increased to 100mg [Hospital1 ] and pt was continued on Aspirin 325mg and Verapamil 80mg [Hospital1 ] per outpt regimen. . Hypotension: Hypotension was likely multifactorial, including anesthesia, vagal nerve stimulation & pericardial effusion. Pt was not tachycardic & did not require pressors. Blood pressure normalized after pericardial tap & pt remained normo to hypertensive through the rest of his hospital course. Verapamil was initially held because of hypotension during the pulmonary vein isolation, but as his blood pressure remained stable on the floor, verapamil 80mg [Hospital1 ] was restarted on discharge. Medications on Admission: 1. Aspirin 325mg QD 2. Pantoprazole 40mg QD 3. Cefuroxime 250mg QD 4. Flecainide 75mg [Hospital1 ] 5. Verapamil 80mg [Hospital1 ] 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. Cefuroxime Axetil 250 mg Tablet Sig: One (1) tab PO at bedtime. 4. Flecainide 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 5. Verapamil 80 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Pericardial effusion 2. Atrial fibrillation Secondary 1. Borderline hypertension 2. Solitary kidney secondary to childhood surgical complication 3. Atonic bladder 4. S/p bladder surgery ([2090]) 5. S/p TURP [2125] 6. S/p inguinal hernia repair 7. Trigger finger Discharge Condition: Hemodynamically stable for discharge with appropriate follow-up. Discharge Instructions: You presented to [Hospital1 18] for elective pulmonary vein isolation to treat your atrial fibrillation. The procedure was complicated by a drop in your blood pressure, for which you were treated. An echocardiogram done at the time showed fluid around your heart, which was drained. You were admitted to the CCU for observation and further draining. The fluid has been sent off for further evaluation, and you are stable for discharge with appropriate follow-up. The following medication was changed: Flecainide was increased to 100 mg 2x/day for atrial fibrillation. Please take all other home medications as prescribed. If you experience any chest pain, chest pressure with jaw or arm pain, shortness of breath, dizziness, weakness, or any other concerning symptoms, please call 911 or come to the ED. Followup Instructions: Please schedule a follow-up appointment with your primary care physician in the next 1-2 weeks. The following appointments have already been scheduled: - Echocardiogram: on [2129-8-11] at 9am. [Hospital Ward Name ] 3 ([Hospital Ward Name 517]). Please call [Telephone/Fax (1) 3312] with questions. - Cardiology: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2129-8-16] at 1pm. Please call [Telephone/Fax (1) 62] with questions. Please follow up on the lab results from your pericardial effusion.	[ "403.90", "585.9", "427.31", "V45.89", "V45.73", "458.29", "596.4", "423.9" ]	icd9cm	[ [ [] ] ]	[ "37.26", "37.0", "37.27", "37.34" ]	icd9pcs	[ [ [] ] ]	7129, 7135	4568, 6505	305, 384	7462, 7530	3762, 4545	8391, 8945	2613, 2774		6693, 7106		7156, 7441		6531, 6670				7554, 8368									2789, 3743																										246, 267							412, 2092																		2114, 2371	2387, 2597
53,371	190,352	37948	Discharge summary	report	Admission Date: [2148-8-12] Discharge Date: [2148-8-21] Date of Birth: [2110-10-3] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1854] Chief Complaint: Lethargy and nausea Major Surgical or Invasive Procedure: [2148-8-12] External ventricular drain [2148-8-15] Redo stereotactic third ventriculostomy History of Present Illness: The patient woke the morning of admission and had one episode of vomiting with breakfast and then went back to sleep. His uncle got him up for lunch where he again vomited and again wanted to return to sleep. As the patient was recently discharge from [University/College ] Hitchcock s/p abscess removal and hydrocephalus, the patient's uncle and aunt were concerned and brought him into a local ED at [Hospital1 1562]. At [Hospital1 ] he got a head CT w/wo contrast that showed a possible rind enhancing lesion although as they didn't have his prior imaging they could not tell if this was surgical change vs residual/recurrent abscess, and he was sent to [Hospital1 18] for further evaluation. Per the patient and the family he has only had some increased sleepiness, and has not had the headaches, hallucinations and unresponsiveness he had when he was initially diagnosed with his brain lesions. Of note the patient had a motor vehicle accident around mid [Month (only) 205]. He had likely passed out behind the wheel. He was taken to [University/College ] for evaluation when fluid filled cysts were noted on his imaging. Given his immuncompromised history these cysts were removed from the ventricular wall and foramen of [Last Name (un) 2044], and an EVD was placed. The cultures returned C.albicans, and he was placed on a month of amphotericin and 5-flucytosine. The patient EVD was removed and an endoscopic 3rd ventriculostomy was performed. The patient was d/c last week on fluconazole. Past Medical History: chronic mucocutaneous candidiasis (complications include mutiple skin infectious, tooth infections (pt has none of his own teeth) and eye infectiou leading to R eye blindness Social History: Patient usually resides in [State 3914], but currently lives with aunt and uncle after d/c from the hospital. [Name (NI) ] mother is in [Name (NI) 622]. The patient does not smoke, use alcohol or drugs. Family History: NonContributory Physical Exam: On admission: PHYSICAL EXAM: T:99.1 BP: 111/72 HR:88 R:12 100% O2Sats Gen: WD/WN, comfortable, NAD, very sleep but arousable with voice Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert. Patient requires arousal and sustained activity or will fall back asleep, but is able to perform complex tasks. He is cooperative with exam, normal affect.Orientation: Oriented to person, place, knew season but did not know date. Recall: [2-13] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation in L eye, no vision in R eye. 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, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Gait: narrow based and normal On discharge: Alert, oriented to person, place and date. PERRL. Face is symmetric, tongue is midline. Full strength and power throughout upper and lower extremtites. Pertinent Results: Labs on Admission: [2148-8-11] 09:50PM BLOOD WBC-9.0 RBC-3.75* Hgb-11.0* Hct-34.1* MCV-91 MCH-29.2 MCHC-32.1 RDW-13.8 Plt Ct-338 [2148-8-11] 09:50PM BLOOD Neuts-65.4 Lymphs-29.7 Monos-3.6 Eos-0.8 Baso-0.4 [2148-8-12] 01:52AM BLOOD PT-12.3 PTT-23.3 INR(PT)-1.0 [2148-8-11] 09:50PM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-139 K-4.2 Cl-101 HCO3-30 AnGap-12 [2148-8-12] 01:52AM BLOOD ALT-22 AST-19 [2148-8-14] 08:06PM BLOOD CK(CPK)-34* [2148-8-15] 06:30AM BLOOD CK(CPK)-25* [2148-8-14] 08:06PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2148-8-15] 06:30AM BLOOD CK-MB-2 cTropnT-<0.01 [2148-8-12] 01:52AM BLOOD Calcium-9.5 Phos-4.7* Mg-2.1 [2148-8-13] 03:50AM BLOOD Phenyto-19.8 ---------------- IMAGING: --------------- MRI Head [8-12]; There is nodular ependymal enhancement within the right lateral ventricular trigone, extending into the occipital and temporal horns. Similar ependymal enhancement is noted along the right frontal [Doctor Last Name 534]. Additionally, there is a 5- mm subependymal nodule along the left lateral wall of the third ventricle, with nodular enhancement along the ependyma of the left lateral ventricular trigone, abutting the choroid. The regions of enhancement are associated with restricted diffusion as well as extensive parenchymal signal abnormality within the right peritrigonal region. Additionally, there is associated marked ventriculomegaly, with sparing of the fourth ventricle. There is an additional thin linear region of enhancement within the cerebral aqueduct. There is a somewhat angulated configuration to the cervicomedullary junction without focal signal abnormality or syrinx. This is of unclear etiology. The Wackenheim clivus angle is abnormally low at 144 degrees. The cerebellar tonsils reside just about5 mm below the forament magnum, though are somewhat pointed, and the craniocervical junction is moderately crowded. There is marked abnormality of the right globe, which is deformed and demonstrates significant enhancement within the region of the anterior chamber. Additionally, there is enlargement and irregular enhancement of the right lacrimal gland. Of note, this does not appear to be associated with restricted diffusion. Additional nodular enhancement is present throughout the quadrigeminal palte and superior vermian cisterns. There is a questionable enhancing leptomeningeal nodule within the posterior surface of the thoracic spinal cord at the T2. It is unclear whether or not this is venous enhancement. IMPRESSION: 1. There is extensive multifocal nodular ependymal and intraventricular enhancement, extending up to and through the right frontal prior ventriculostomy catheter tract. There is associated restricted diffusion and the findings likely relate to infectious ventriculitis, ependymitis and associated cerebritis with no discrete focus of liquefactive necrosis to suggest abscess. 2. Moderately severe hydrocephalus involving the lateral and third ventricles, with sparing of the fourth ventricle. While this could be secondary to infectious material within the aqueduct, it is possible there are underlying adhesions/webs with chronic hydrocephalus, which would account for the lack of transpendymal migration of CSF; correlation with prior imaging is needed. 3. Marked abnormality and enhancement of the right globe, as well as enlargement and heterogeneous enhancement of the lacrimal gland. Underlying tumor or infection cannot be excluded and should be correlated with patient's history and direct examination. 4. Additional enhancement within the quadigeminal cistern and possibly involving the dorsal surface of the cervical spinal cord, at the C2 level. Dedicated cervical spine imaging would help further evaluate this finding. 5. Craniocervical alignment abnormality with crowding at the craniocervical junction and "kinking" of the cervicomedullary junction, likely on a congenital basis, as discussed above which should be correlated with the patient's prior imaging and clinical history. MRI Flow Study [8-13]: FINDINGS: There has been interval removal of the right frontal catheter and interval placement of a left frontal catheter which terminates at the level of the foramen magnum. There has been slight interval decrease in size of the lateral ventricles when compared to the prior exam. There is a stable ventricular shunt catheter tract extending via the right frontal lobe into the lateral ventricle. There are stable subependymal nodules of enhancement within the right lateral ventricle, the right frontal [Doctor Last Name 534], and the lateral wall of the third ventricle. These regions are also associated with restricted diffusion as well as extensive perilesional FLAIR signal abnormality. There is T2/FLAIR hypointensity involving the wall of the lateral ventricles which although without evidence for enhancement, suggest ventriculitis as well. There is hydrocephalus, slightly decreased when compared to the prior exam. There is a focus of enhancement within the inferior portion of the cerebral aqueduct. This likely is causing the obstruction of flow at this level. There is also a nodule of enhancement in the right temporal lobe. CSF dynamic flow study does not demonstrate any flow through the cerebral aqueduct. IMPRESSION: 1. Stable subependymal nodules of enhancement as detailed above, most consistent with previously described abscesses. 2. Stable focus of enhancement within the inferior aspect of the cerebral aqueduct causing obstruction of outflow and therefore non-communicating hydrocephalus. This is further confirmed with lack of CSF flow through the aqueduct on the dynamic flow study. 3. Minimal interval decrease in size of ventriculomegaly Head CT [8-15]: IMPRESSION: 1. Post-surgical changes with small left frontal pneumocephalus without mass effect or shift of normally midline structures. 2. Unchanged hydrocephalus and right posterior occipital [Doctor Last Name 534] ventriculitis. CT HEAD W/O CONTRAST [2148-8-16] Again seen is bilateral frontal burr hole post- surgical change, with left lateral ventriculostomy with the catheter tip in unchanged position in the frontal [Doctor Last Name 534] of the left lateral ventricle. There has been no interval development of hemorrhage, edema, mass effect, or shift of midline structures. The size of the ventricles is enlarged, but stable measuring 4.0 cm in transverse dimension in the frontal horns of lateral ventricles (2:19). Debris within the posterior [Doctor Last Name 534] of the right lateral ventricle is better characterized on previous MR studies, and there is continued hypodensity posterior to the lateral ventricle which is not changed. There is again enlargement of the lateral and third ventricles out of proportion to the fourth ventricles, which is unchanged. Osseous structures and soft tissues appear otherwise unremarkable, with right globe changes including scleral band and increased density of the vitreous unchanged and better evaluated on previous MRI exam. IMPRESSION: 1. No interval development of hemorrhage, new site of edema, or shift of midline structures. 2. Continued ventriculomegaly of the lateral and third ventricles out of proportion of the fourth ventricle. 3. Additional stable abnormalities include debris in the posterior [Doctor Last Name 534] of the right lateral ventricle, and scleral band and increased vitreous density of the right globe previously better evaluated on MRI. MR HEAD W/O CONTRAST [2148-8-17] (ltd study) T2W sequences appear to demonst artifact relat to turbulent flow at expected site of the III ventriculostomy, in interpeduncular cistern, just ant to the mamillary bodies. this wd seem to suggest patency. final rdg pending interpretation of the sag (cine) phase-contrast sequences. CT HEAD W/O CONTRAST [2148-8-19] FINDINGS: There has been interval removal of a left frontal-approach ventriculostomy catheter. A track is seen into the left lateral ventricle. No hemorrhage is appreciated. Ventricles appear dilated but are unchanged from prior, measuring 39 mm versus 40 mm (bifrontal diameter). The configuration of ventricular dilatation, out of proportion, is unchanged from prior with lateral and third ventricles dilated. There is effacement of the cerebral sulci and basal cisterns, which is unchanged. Altered attenuation material in the right lateral ventricle is unchanged. A right frontal burr hole is also demonstrated. Low lying cerebellar tonsils with small posterior fossa are better evaluated on prior MR studies. The mastoid air cells are clear. There is mild ethmoidal sinus thickening. Scleral bands are seen in the right globe. IMPRESSION: Status post removal of left frontal-approach ventriculostomy catheter with no evidence for new hemorrhage. Unchanged moderate dilatation of the third and lateral ventricles with effacement of the basal cisterns and cerebral sulci. F/u as clinically indicated. Other details as above. Brief Hospital Course: Patient is admitted to the neurosurgical service for further evaluation of hydrocephalus in the setting of mental status change. On [8-12] he was taken to the OR emergently for an external ventricular drain placement. MRI flow study done on [8-14] revealed that the prior 3rd ventriculostomy was not patent and would require re-do surgery. He was taken to the OR by Dr. [Last Name (STitle) ] on [8-15] for this procedure which was tolerated well. The distal EVD catheter was left in place. He was extubated and transfered to the PACU and then the Step Down unit on [8-16]. Hisd arousal state continued to improve. CSF cultures were finalized as negative for bacteria/fungus.. On [2148-8-19] the distal EVD catheter was removed as he exhibited no sign of hydrocephalus. MRI cine flow studies were reviewed by Dr. [Last Name (STitle) ] and he was satisfied with the CSF flow. ID recommended loading of Voriconazole on [2148-8-20]. The IV medications for mucocutaneous candidiasis will be discontinued on [8-21]. At this time his PICC line may be removed and he may be able to be discharge to home. He was given a prescription for 4 weeks of Voriconazole and instructions to be seen by the infectious disease physician [Last Name (NamePattern4) ] [2-14] weeks. Medications on Admission: Voriconazole 200mg Q12 Pred forte 1% eye gtt to right eye q4h when awake Erythromycin gel to R eye QHS Discharge Medications: 1. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QHS (once a day (at bedtime)). Disp:1 tube Refills:0 2. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic Q4 (). Disp:1 bottle Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:30 Capsule(s) Refills:0 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 5. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Hydrocephalus Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [6-21] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. You will need a repeat fundoscopic exam in 2 weeks at home or Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17233] at [Last Name (un) ] Bld. [Telephone/Fax (1) 25524] Please call the Infectious disease clinic at [Telephone/Fax (1) 457] to schedule and appointment with Dr. [Last Name (STitle) 82115] to be seen in [2-14] weeks. You will be taking your Voriconazole until this time. You should also make an appointment to be seen by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2603] in the allergy and immunology clinic in [2-14] weeks. Completed by:[2148-8-21*]	[ "369.00", "112.89", "331.4", "324.0" ]	icd9cm	[ [ [] ] ]	[ "38.93", "02.2" ]	icd9pcs	[ [ [] ] ]	15692, 15698	13640, 14944	340, 441	15756, 15780	4617, 4622	17258, 18496	2455, 2473		15098, 15669		15719, 15735		14970, 15075				15804, 17235									2517, 2755																	4445, 4598									280, 302							469, 2005	3191, 4431								4636, 13617		2770, 3175							2027, 2204	2220, 2439
7,452	109,060	929	Discharge summary	report	Admission Date: [2161-9-25] Discharge Date: [2161-10-5] Date of Birth: [2106-1-16] Sex: M Service: COLORECTAL ADMITTING DIAGNOSIS: 1. End-stage renal disease. 2. Adult respiratory distress syndrome. 3. Severe colitis. 4. Fatal arrhythmia. HISTORY OF PRESENT ILLNESS: The patient is a 54 year old male with end-stage renal disease secondary to post-Streptococcal glomerular nephritis and CPDD, and adrenal insufficiency, who presented with two to three weeks of lower abdominal pain and was found to be Clostridium difficile positive. Upon work-up the patient showed worsening abdominal CT scan consistent with pan-colitis. The patient was initially treated with Vancomycin intravenously with p.o. Ciprofloxacin and Flagyl. On [2161-9-28], the patient was found to be gasping for air while on 100% non-rebreather mask with an arterial blood gases of 7.04, 80, 43. The patient was immediately intubated and admitted to the Surgical Intensive Care Unit at which time the patient was found to have atrial fibrillation with heart rate between 100 to 140. Rate was very difficult to control and Diltiazem drip was initiated. On [2161-9-27], the patient's heart rate remained between 90 to 110 with Diltiazem drip at 10 mg per hour and blood pressure was also difficult to maintain. The patient responded well initially to boluses with decrease in tachycardia, however, due to the worsening pan-colitis, the patient was taken back to the Operating Room for a subtotal colectomy. PHYSICAL EXAMINATION: N/A. SUMMARY OF HOSPITAL COURSE: The patient is a 55 year old male status post subtotal colectomy and end-ileostomy for infarcted small intestine and colitis with pseudomembranes. The patient was initiated on broad-spectrum antibiotics with cultures sent. The patient's CT scan of the abdomen indicated a diffuse thickening of terminal ileum and large intestine to the transverse colon without stranding. A repeat CT scan immediately prior to the subtotal colectomy indicated pan-colitis which progressed from prior scan but no evidence of perforation. Immediately postoperatively, the patient continued to have respiratory distress requiring increased pressor support and required continued transfusion with seven units both of P, two units of packed red blood cells and four liters of Crystalloid. Despite the continued resuscitation, the patient remained hypotensive with continued lactic acidosis requiring bicarbonate replacement. The aggressive resuscitation continued until [2161-10-5], when after a long discussion with the family members, the patient was made comfort measures only. The patient developed a ventricular fibrillation shortly thereafter and expired later on that evening. DISCHARGE DIAGNOSES: Status post subtotal colectomy and ileostomy. DISPOSITION: Death. [Last Name (NamePattern4) 1889], M.D. [MD Number(1) 1890] Dictated By:[Name8 (MD) 6247] MEDQUIST36 D: [2162-2-28] 12:11 T: [2162-2-28] 16:26 JOB#: [Job Number 6248]	[ "557.0", "403.91", "276.2", "518.5", "286.6", "008.45", "785.59", "427.31" ]	icd9cm	[ [ [] ] ]	[ "38.95", "46.20", "45.8", "45.62", "46.13" ]	icd9pcs	[ [ [] ] ]								2781, 3077																														1586, 2759			1551, 1557																		307, 1528												164, 277
63,692	129,788	34339	Discharge summary	report	Admission Date: [2172-4-17] Discharge Date: [2172-4-22] Date of Birth: [2098-5-11] Sex: M Service: MEDICINE Allergies: Epinephrine / Keflex Attending:[First Name3 (LF) 4616] Chief Complaint: Fever, chills, increased abdominal girth. Major Surgical or Invasive Procedure: Diagnostic paracentesis. Therapeutic paracentesis with removal of 4L. Central venous line placement and removal. History of Present Illness: 73 YO M with fatigue, increased abdominal girth, decreased PO intake and chills with low grade temps to 100. Re-initiated oral chemotherapy on [4-13] and is status post 5L paracentesis 4 days prior to admission. Dr [Last Name (STitle) ] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10919] are onc team. Complained of intermittent diffuse abd cramps. Initial VS in ED: 98.1 102 93/66 16 100% Lactate 2.7. Mild tachycardia. BP in 90s. Family reports pt runs in 110s. Mild diffusely tender abd. Guaiac + brown stool. 2PIVs placed initially. CXR unremarkable. Paracentesis done, transudative, did not look like SBP, cultures sent. UA with no infection. CT scan abdomen with ?gasrtric obstruction. Has history of duodenal stent in the past. Surgery evaluated and did not feel that this was clinical gastric outlet syndrome, though with more metastatic disease in abd, most likely leading to more ascites. Over the night in the ED his BP decreased to 80s. Initially he received 500 cc bolus with increase to 88. LIJ was placed...post-CXR fine. CVP 3. Got add'l 500cc NS with increase to SBP 100, HR 105, satting fine on 2L NC. Basically admitted for hypotension, potential infection with unclear source. Got zosyn and vanco, question of allergy to keflex, though has tolerated in the past. VS at time of transfer 105 83/49 99% 2L 16-18. Received add'l fluid bolus prior to transfer, received total of 3L NS in ED. On arrival to [Name (NI) 153] pt's BP in high 80s, low 90s, borderline tachycardia. Complaining of fatigue, increased abdominal girth, decreased appetite. Currently denies abdominal pain. Reports decreased PO intake since chemo on Monday with increasing abdominal girth, lower extremity edema. No diarrhea, no nausea or vomiting, no change in stool. No dizziness/orthostasis. Shaking chills at home. Currently no abdominal pain, responded to low dose morphine. Past Medical History: -Cholangiocarcinoma -Diabetes mellitus II (oral meds) -Atrial fibrillation (on amiodorone) -Chronic left ventricular systolic heart failure (last EF 40-45%) -CAD, known 3VD with s/p BMS to LAD in [8-18] -H/o pneumonia and effusion which was tapped in [State 108] -Mass encircling the biliary stent which was biopsied and found to be cholangiocarcinoma, s/p biliary stent c/b infection s/p stent removal [2171-9-11] -[2171-11-4] ERCP with 10mm x 60mm biliary covered Wallstent in the common bile duct within the previously placed uncovered metal stent 8mm x 60mm. -Chronic renal failure -Depression -Hyperlipidemia -Prior MI by EKG -Hypertension -Anemia Social History: Italian but speaks some English. He is a retired truck driver. He denies smoking or illicit drug use. He lives with his wife; daughter is nearby. Drank about one glass of wine per night with dinner for many years but has not had any alcohol in the last several months. Daughter [Name (NI) ] is HCP ([Telephone/Fax (1) 79023]) Family History: His father had [Name2 (NI) 499] cancer in his 50s. There are no other family members with any GI cancers, liver problems. His mother died at age [Age over 90 ]. He has six children, who are healthy. Physical Exam: Vitals: T:98.6 BP:85/52 P:114 R: 17 SaO2:100% General: Thin elderly man, fatigued, pleasant, NAD HEENT: NCAT, MM dry, no scleral icterus Neck: supple, LIJ in place. JVP visible at 7cm. Pulmonary: Decreased BS at bases bilaterally. No crackles, wheezes. Cardiac: Regular, tachycardic. Abdomen: + ascites, soft, distended. Well healed scar in RUQ. + palpable mass vs liver edge. Non-tender. No rebound or guarding. Extremities: No edema, 2+ radial, DP pulses b/l Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. No abnormal movements noted. No deficits to light touch throughout. No nystagmus, dysarthria, intention or action tremor. 2+ biceps, triceps, brachioradialis, patellar reflexes and 2+ ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: Labs at Admission: [2172-4-17] 12:00AM BLOOD WBC-10.4 RBC-3.49* Hgb-11.8* Hct-34.5* MCV-99* MCH-33.9* MCHC-34.3 RDW-16.1* Plt Ct-267 [2172-4-17] 12:00AM BLOOD Neuts-92.3* Lymphs-6.0* Monos-1.5* Eos-0.1 Baso-0.1 [2172-4-17] 08:24AM BLOOD PT-14.7* PTT-31.8 INR(PT)-1.3* [2172-4-17] 12:00AM BLOOD Glucose-141* UreaN-21* Creat-1.1 Na-131* K-4.8 Cl-98 HCO3-23 AnGap-15 [2172-4-17] 12:00AM BLOOD ALT-24 AST-26 AlkPhos-454* TotBili-1.8* [2172-4-17] 12:00AM BLOOD Lipase-127* [2172-4-17] 12:00AM BLOOD TotProt-6.1* Albumin-2.8* Globuln-3.3 [2172-4-17] 10:30AM BLOOD Albumin-2.2* Calcium-7.3* Phos-3.2 Mg-1.7 [2172-4-17] 12:12AM BLOOD Lactate-2.7* [2172-4-17] 04:32AM BLOOD Lactate-2.1* [2172-4-17] 09:18AM BLOOD Lactate-1.3 BASIC COAGULATION Plt [2172-4-22] 06:50AM 193 [2172-4-21] 05:45AM 153 [2172-4-20] 12:00AM 163 [2172-4-19] 05:35AM 121* [2172-4-18] 07:34PM 109* [2172-4-18] 11:03AM 107* [2172-4-18] 03:29AM LOW 931 [2172-4-17] 03:47PM 139 [2172-4-17] 08:24AM 171 [2172-4-17] 12:00AM 267 HIT Ab - pending Microbiology: Blood culture ([4-17]): Klebsiella pneumoniae, pansensitive Peritoneal fluid culture ([4-17] and [4-21]): no growth to date (NGTD) Peritoneal cytology ([4-17]): NEGATIVE FOR MALIGNANT CELLS. Urine culture ([4-17]): no growth Surveillance blood cultures: BCx x 2 [4-17] - NGTD BCx [4-18] - NGTD Cath tip [4-20] - NGTD Imaging Studies: CT abdomen/pelvis ([4-17]): CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: In the visualized thorax, there is a new small right pleural effusion with associated relaxation atelectasis. The heart is top normal in size. There are coronary artery calcifications. There is no pericardial effusion. In the abdomen, there is increased, now massive ascites. Again seen is a common biliary ductal stent terminating in the third portion of the duodenum. There has been interval placement of a duodenal stent; however, the stomach is distended but the antrum collaped. A new duodenal stent is seen. Multiple enlarged hypodensities within the liver are concerning for metastatic disease, progressed from prior. The spleen, adrenals and pancreas appear normal. The kidneys symmetrically take up and excrete contrast. Multiple retroperitoneal and mesenteric nodes are again seen, but none reach size criteria for pathologic enlargement. No peritoneal implants are specifically identifiable. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: There is a right fluid-containing inguinal hernia (series 2, image 95). The urinary bladder, distal ureters, rectum, sigmoid [Month/Day (4) 499] and prostate are unremarkable. MUSCULOSKELETAL: Again noted is sclerosis of L3. Degenerative changes are seen at multiple levels of the spine and severe degenerative changes are seen in the hip. IMPRESSION: 1. Interval placement of duodenal stent. 2. Progressed metastatic disease in the liver with associated massive ascites. 3. Fluid-filled right inguinal hernia. 4. Unchanged sclerotic L3 vertebral body lesion concerning for metastasis. CXR PA and LAT ([4-17]): CHEST, TWO VIEWS: Heart size, hilar and mediastinal contours are normal. Low lung volumes limit assessment. There is mild bibasilar atelectasis. There is no consolidation, effusion or pneumothorax. Pulmonary vasculature is normal. There is a distended gastric bubble. Two stents are seen in the right upper abdomen. IMPRESSION: No pneumonia. Duplex doppler ultrasound liver ([4-17]): RIGHT UPPER QUADRANT ULTRASOUND: The liver again demonstrates a coarsened echotexture, although without focal masses definitively identified. Mild- moderate intra-hepatic biliary ductal dilatation is unchanged. Stents are noted in the common bile duct and duodenum. There is a moderate amount of ascites. DOPPLER ULTRASOUND: Color and Doppler ultrasound was used to evaluate the hepatic vasculature. The main portal vein demonstrates normal hepatopetal flow, with normal velocity of approximately 20 cm/sec. The left, right posterior, and right anterior portal veins demonstrate normal wall-to-wall flow with appropriate directionality. The right, middle, and left hepatic veins are patent with wall-to-wall flow and normal waveforms. The main hepatic artery demonstrates a brisk upstroke and antegrade diastolic flow. IMPRESSION: 1. Stable appearance of heterogeneous liver with mild-moderate intrahepatic biliary ductal dilatation consistent with cholangiocarcinoma. 2. Moderate ascites. 3. Patent hepatic vasculature. Brief Hospital Course: A 73 yo man with metastatic inoperable cholangiocarcinoma with history of gastric outlet obstruction s/p stenting presented with hypotension, fever/chills, increased ascites and poor po intake. # Hypotension/Klebsiella Bacteremia/Fever: In the ED he received 3-3.5L IVF with persistent hypotension and lactic acidosis so he was admitted to the MICU due to concern for sepsis. Reassuringly the lactate improved from 2.7-->2.1-->1.3 with IVF. He was continued on empiric antibiotics which had been started in the ED with Zosyn for possible GI source for sepsis. Blood cultures from ED grew out GNR which speciated as klebsiella that were pan sensitive. Meanwhile, he was bolused with fluids prn to maintain MAP >60 in addition to which he received albumin to increase oncotic pressure. A diagnostic paracentesis showed transudative fluid without evidence of SBP, his CXR showed no evidence of infection, and his UA was negative so no source was identified. He was converted to oral cipro to complete a fourteen day course which he will finish as an outpatient. Throughout the rest of his hospitalization he remained afebrile. # Poor PO intake: His slowly advance his diet as tolerated. Nutrition service made specific recommendations for dietary supplements. Surgery was consulted for a possible G or J tube placement but his CT scan was without obstruction, however he stated that he felt his ascites was hindering his po intake and given his recent infection surgical options were not further pursued. He was started on marinol 2.5 mg qam daily to help improve his appetite and underwent a therapeutic paracentesis on [4-21] during which 4 L were removed. He was asked to discuss his nutritional status further with his oncologist as an outpatient. # Cholangiocarcinoma: The patient has a history of inoperable cholangiocarcinoma s/p biliary stent and duodenal stent. His primary oncologist here is Dr. [Last Name (STitle) ], however he has been seeing an oncologist at [Hospital3 417] Hospital, Dr. [First Name (STitle) ], more recently for local care. He has been undergoing treatent with xeloda and last received this on [4-13]. We continued his home ursodiol. At discharge the family wanted to follow up with Dr. [First Name (STitle) ] during the next week and the daughter stated she would make the appoitnment. # Ascites: This was felt to be secondary to portal hypertension from diffuse metastases in liver parenchyma. Doppler ultrasound of the liver during this admission did not show evidence of portal venous thrombosis; there was moderate ascites noted. Diagnostic paracentesis, as above, was consistent with transudate. Culture from the peritoneal fluid was negative. As above a therapeutic paracentesis was preformed on [4-21] during which 4 L were removed. His lasix and aldactone were held during his inpatient stay and restarted at his home doses at discharge. # Thrombocytopenia: The patient initially had large drop in his platlet cound (> 50%) so there was concern for HIT, however he did not develop evidence of clotting. Heparin was stopped, however his platlets began to improve even during his last day on heparin. HIT Ab was sent and is pending, but he has a low likelihood of HIT. He had other reasons for thrombocytopenia including bacteremia and zosyn. # Hyponatremia: The patient was slightly hyponatremic during his hospitalization. This was thought toe be secondary to hypervolemic hyponatremia due to his liver disease. # Coronary artery disease: He remained asymptomatic during his hospitalization and he was continued on his home ASA and Plavix. # Atrial fibrillation: He is not anticoagulated as an oupatient; he is on a BB, digoxin and amiodarone at home. His ventricular rate was well-controlled with fluid resuscitation. We continued his home digoxin and amiodorone, and held his metoprolol in the setting of hypotension, however this was restarted when he was moved out from the MICU. # Guaiac positive stool: Hematocrit was initially slightly above baseline, appeared hemo-concentrated, and dropped from 34 to 28 after hydration. Serial hematocrits showed stability in the high 20-low 30s, which is his baseline. He did not require transfusion. # Diabetes mellitus. We held his glipizide and started humalog sliding scale insulin during his hospitalization. His glipizide was restarted at discharge. # Code status: Full Medications on Admission: 1. Amiodarone 100mg daily 2. Ursodiol 300 mg Capsule [Hospital1 ] 3. Clopidogrel 75 mg Tablet daily 4. Bicarbonate 1300 [Hospital1 ] every other day 5. Aspirin 325 mg Tablet daily 6. Digoxin 0.0625mg daily 7. Docusate Sodium 100 mg Capsule [Hospital1 ] 8. Metoprolol Tartrate 25 mg Tablet [Hospital1 ] 9. Omeprazole 20 mg Capsule daily 10. Spironolactone 50 mg Tablet daily. 11. Lasix 40 mg Tablet daily 12. Glipizide 2.5 mg Tab daily 13. Nephrocaps daily Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Ascorbic Acid 250 mg Tablet Sig: One (1) Tablet PO once a day. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Glipizide 2.5 mg Tablet Extended Rel 24 hr (2) Sig: 0.5 Tablet Extended Rel 24 hr (2) PO once a day. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO every other day. 13. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). Disp:30 Capsule(s) Refills:2 14. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days. Disp:16 Tablet(s) Refills:0 15. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. 16. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Primary - Klebsiella pneumoniae bacteremia Ascites Poor nutritional status Thrombocytopenia Hyponatremia Secondary - Cholangiocarcinoma History of coronary artery disease Atrial fibrillation Diabetes type II Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to the hospital due to fevers and were found to have bacteria in your blood. You were treated with antibiotics with improvement. You underwent both a diagnostic, then later a therapeutic paracentesis. There was no evidence of infection in your abdomen. You will need to finish a course of oral antibiotics. Due to your poor oral intake you were started on a medication to improve your appetite. It is very important that you receive adequate nutrition. Please discuss this with your primary oncologist. Medication changes: 1. You will need to complete 8 more days of antibiotic treatment with ciprofloxacin 750 mg twice daily. 2. You were started on Dronabinol 2.5 mg daily in the morning to help increase your appetitie. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Call your primary doctor, or go to the emergency room if you experience fevers, chills, dizziness, shortness of breath, abdominal pain, blood in your stool, or dark black stool. Followup Instructions: As we discussed, please follow up with your oncologist, Dr. [First Name (STitle) ] at [Hospital3 417] Hospital within the next week. Please keep your previously scheduled appointment: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2172-7-17] 1:00 Completed by:[2172-4-22]	[ "414.01", "403.90", "276.50", "537.0", "789.59", "197.7", "272.4", "276.1", "V45.82", "585.9", "428.0", "287.5", "276.2", "428.22", "427.31", "038.49", "250.00", "156.1", "571.5" ]	icd9cm	[ [ [] ] ]	[ "54.91", "38.93" ]	icd9pcs	[ [ [] ] ]	15578, 15633	9327, 13744	323, 437	15886, 15905	4663, 6218	16983, 17359	3434, 3643		14266, 15555		15654, 15865		13770, 14243				15929, 16458									3658, 4644																							16478, 16960			242, 285							465, 2374																		2396, 3066	3082, 3418					6236, 9304
23,013	199,647	17370	Discharge summary	report	Admission Date: [2168-6-15] Discharge Date: [2168-6-19] Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is an 85 year old man with a history of bilateral carotid artery stenosis who has had several recent episodes of left arm numbness and was referred to Dr. [Last Name (STitle) 1132] for angiogram with possible procedure for this carotid artery stenosis. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [2150], status post coronary angioplasty in [2150]. 2. Hypertension. 3. Glaucoma. 4. Wheezing. 5. Status post bilateral hip surgery. 6. Occasional heartburn. 7. Hypercholesterolemia. 8. Status post cataract surgery bilaterally in [2160]. ALLERGIES: Erythromycin. MEDICATIONS ON ADMISSION: 1. Naprosyn 500 mg p.o. twice a day, that was stopped on [2168-6-10]. 2. Hydrochlorothiazide 25 mg p.o. once daily. 3. Detrol 2 mg p.o. once daily. 4. Lipitor 10 mg p.o. once daily. 5. Trental 400 mg p.o. three times a day. 6. Levoxyl 112 mcg p.o. once daily. 7. Cardizem 240 mg p.o. once daily. 8. Diovan 40 mg p.o. once daily. 9. Aspirin 325 mg p.o. once daily. 10. Plavix 75 mg p.o. once daily. PHYSICAL EXAMINATION: On examination, the patient is alert and oriented times three. Cranial nerves II through XII are intact. Upper extremity and lower extremity strength is [5-23] bilaterally. HOSPITAL COURSE: The patient was again admitted with a preoperative diagnosis of bilateral internal carotid artery stenosis with postoperative diagnosis same. The patient underwent angioplasty of the right internal carotid artery without stent placement on [2168-6-15]. The patient tolerated the procedure well. He was sent to the Intensive Care Unit on Aspirin, Plavix and Heparin intravenously. The patient was neurologically intact after this procedure. On [2168-6-17], the patient had a carotid ultrasound that showed luminal narrowing between 60 and 69% in the right internal carotid artery compared to greater than 85% by angiography prior to treatment. This was obtained as baseline for the patient status post angioplasty. The patient was doing very well. He did complain of some left groin pain on [2168-6-17]. He underwent lower extremity ultrasound to rule out a deep vein thrombosis. The patient did not have any deep vein thrombosis based on this study. The patient also had left hip films that showed that his hardware was in good condition and did not show any fractures. The hip pain resolved and the patient was to be discharged to home with home physical therapy on [2168-6-19]. The patient will be discharged on his preoperative medications and will also be discharged on Plavix 75 mg p.o. Once daily and Aspirin 325 mg p.o. once daily. It has been explained to the patient that it is very important that he continue to take these medications. The patient will follow-up with Dr. [Last Name (STitle) 1132] in four weeks. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Dictator Info ] MEDQUIST36 D: [2168-6-18] 19:16 T: [2168-6-18] 20:05 JOB#: [Job Number 48599]	[ "412", "272.0", "414.01", "433.10", "V45.82", "401.9" ]	icd9cm	[ [ [] ] ]	[ "39.50" ]	icd9pcs	[ [ [] ] ]													795, 1207	1428, 3224																											1230, 1410																		126, 396																		418, 769
9,969	140,378	27694	Discharge summary	report	Admission Date: [2169-5-16] Discharge Date: [2169-5-22] Date of Birth: [2103-10-14] Sex: M Service: NEUROLOGY Allergies: Gentamicin / Vancomycin Attending:[First Name3 (LF) 8850] Chief Complaint: Seizure versus syncope. Major Surgical or Invasive Procedure: Brain cyst aspiration on [2169-5-18] and Rickham reservoir placement. History of Present Illness: [Known firstname 449] [Known lastname 67625] is a 65-year-old right-handed man with a history of anaplastic astrocytoma originally transferred to [Hospital1 18] from [Hospital3 1196] on [2169-5-16] for possible seizure activity. Per OMED admit note, he was straining to have a bowel movement and then got up, felt dizzy, and lost consciousness. He then had deep breathing, drooling, and urinary incontinence. He was out for 10 minutes. Head CT at [Hospital3 1196] showed a 3.7 cm x 3.8 cm lesion in the left frontotemporal lobe with adjacent edema and mass, with partial effacement of the left temporal lobe but no herniation or hemorrhage. He was then transferred here for further management. On admission, he noted a history of seizures that were manifested by speech arrest, once this past [2169-3-9] and once in [2169-4-9]. He is on Keppra (recently decreased prior to admission), Trileptal, and dexamethasone. His ROS was also positive for constipation, a recent UTI, s/p levofloxacin which finished on [2169-5-12], word finding difficulties for 4 to 5 months, worsening vision, and left knee pain. He denied all other symptoms. Past Medical History: Past Medical History: -grade 3 astrocytoma: left temporal, diagnosed by biopsy in [12/2166] and s/p partial resection. s/p XRT and Temodar x3. complicated by seizures -hypertension -hyperlipidemia -hypertrophic cardiomyopathy -bilateral knee surgeries now with arthritis -pulmonary embolus (ICH with anti-coag) -h/o bradycardia Past Oncologicl History: Grade III anaplastic Astrocytoma 1. Partial Resection on [2166-12-25] in [State 108] 2. Radiation + Temodar in [State 108] 3. Pulmonary Embolus [2-/2167] 4. Temodar monthly for 15 cycles ending [2168-5-9] in [State 108] 5. Intracerebral hemorrhage [2168-7-12] at [Hospital1 18] 6. Temodar restarted [8-/2168] and completed 18 cycles [10/2168] Social History: He is married less than 2 years ago though they have been together for many years. He is a retired physical education teacher who taught throughout [Location (un) 511]. He spends most of the time in [State 108]. He used to smoke cigars or 0-2 cigarettes daily and drink 1-2 drinks daily but stopped both in [12-14]. He denies illicit drug use. Family History: His mother had CAD. His father had a question of lung cancer. His sister had COPD (she was a smoker). Physical Exam: Vital Signs: Temperature is 97.2 F, heart rate 60, blood pressure 155/77, respiratory rate 20, and oxygen saturation 99% in room air. GENERAL: He is alert, interactive pleasant male in no acute distress. He has word-finding difficulties throughout conversation. HEENT: He has dressing over left side of head c/d/i, pupils 2 mm and equal, sluggishly reactive, and EOMI. NECK: Supple. LUNGS: Bibasilar inspiratory crackles, no wheezes or rhonchi HEART: Regular rate and rhythm, no M/R/G ABDOMEN: Soft, nontender, nondistended, +bs EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: He has diffuse erythematous [Doctor Last Name ] eruption over back, chest, legs NEUROLOGICAL EXAMINATION: He is awake, alert, and able to follow commands. There is no right/left confusion or finger agnosia. His calculation is intact. His language is non-fluent with frequent word-finding difficulty; his comprehension is good. He has difficulty with repetition. Cranial Nerve Examination: His pupils are equal and reactive to light, 3 mm to 2 mm bilaterally. Extraocular movements are full. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. His face is symmetric. Facial sensation is intact bilaterally. His hearing is intact bilaterally. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: He does not have a drift. His muscle strengths are [5-13] at all muscle groups. His muscle tone is normal. His reflexes are 2- at biceps, triceps, brachioradialis, and knees bilaterally. His ankle jerks are absent. His toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. His gait is steady. He does not have a Romberg. Pertinent Results: Admission labs: 137 102 18 ------------<89 3.9 29 1.0 estGFR: 75 / >75 (click for details) Ca: 10.3 Mg: 2.3 P: 2.6 ALT: 18 AP: 78 Tbili: 0.4 AST: 16 11.3 8.0>---<241 32.4 N:82.7 L:12.0 M:3.8 E:1.2 Bas:0.4 Comments: MCV: Verified Macrocy: 1+ PT: 12.0 PTT: 27.8 INR: 1.0 [Month/Day (1) 4338] [2169-5-19]: Slight increase in the size of the cystic region within the left temporal lobe with thickened enhancement along its posterior margin. This is only slightly apparent when compared to [2169-4-13]. However, compared to the prior from [2169-2-6], the thickened enhancement is more pronounced. The nodule from the superior margin of the cyst appears to have less enhancement on today's examination. The degree of adjacent T2 signal abnormality is unchanged. The slightly thickened enhancement is concerning for tumor recurrence. Left temporal cyst aspirate: NEGATIVE FOR MALIGNANT CELLS. Brief Hospital Course: A/P: This is a 65-year-old right-handed man with grade 3 astrocytoma who presents from OSH with questionable syncope versus seizure, who developed with hypotension after antibiotics (vancomycin and gentamicin). (1) Syncope: Initial event that brought him in was thought to be vasovagal in nature due to Valsalve in setting of hypertrophic cardiomyopathy. With treatment of his constipation and drainage of his tumor cyst, this did not recur. (2) Hypotension: This was noted after a dose of gentamicin caused a rash. The medication was stopped and he was given Bendryl and started on ranitidine. He was then given a dose of vancomycin. Overnight his rash progressed from hives to diffuse erythema with pruritis and he became more hypotensive. He had an elevation in his creatinine and 5 point increase in his hematocrit without transfusion. He was given IV fluids and steroids for potential adrenal insufficiency and was sent to the ICU for closer monitoring. He improved and was able to be placed on a steroid taper. elevated Likely etiology is anaphylaxis versus anaphylactoid reaction (although hypotension less likely with anaphylactoid reactions). He is now presumed to have allergy to both gentamicin and vancomycin. (3) Astrocytoma: [Year (4 digits) 4338] from [2169-5-15] revealed increasing cystic mass. For this, he was taken to the OR by neurosurgery on [2169-5-18] where he had a cyst aspiration which was negative for malignant cells. He had a Rickham reservoir placed as well. He will follow-up with Dr. [Last Name (STitle) 4253] as an outpatient for further evaluation and management. (4) Seizure: His antiepileptic regimen was changed to Keppra 1,000 mg 3 times daily (due to peak-dose drowsiness from 1,500 mg twice daily). His Trileptal was changed to 150mg qam/qhs, with 300mg q noon. No seizure activity was noted on this admission. (5) Obstructive Sleep Apnea: His history and body habitus are concerning for OSA, which could exacerbate his seizure disorder. Given that he was ordered for an ouptaient sleep study. (6) Constipation: Treated with an aggressive bowel regimen including enemas with good effect. (7) Anemia: His hematocrit dropped today from 36 to 31; it was around 32 on admission. It was likely from hemodilution given IVF received in setting of anaphylaxis which subsequently remained stable. (8) Urinary Retention: On admission he was noted to have 400 cc PVR so Foley catheter was placed with good effect. 2 days prior to discharge this was removed and he was able to urinate without difficulty. Medications on Admission: Decadron 4 mg po bid Colace SQ heparin Keppra 1000 mg po tid Oxcarbazepine 150/300/150 Oxycodone prn Ranitidine 150 mg po bid Senna Simvastatin 40 mg po daily Discharge Medications: 1. Diovan HCT 160-25 mg Tablet Sig: One (1) Tablet PO once a day. 2. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 weeks: please take until you see your primary care doctor or your oncologist in 2 weeks to make a decision about decreasing the dose. Disp:42 Tablet(s) Refills:0 3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:540 Tablet(s) Refills:1 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please take at noon. Disp:90 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:0 7. Oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO twice a day: please take in the early morning and at night. Disp:180 Tablet(s) Refills:1 8. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO twice a day. Disp:120 Capsule(s) Refills:2 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 10. Lactulose 10 g Packet Sig: One (1) PO twice a day as needed for constipation. Disp:30 Refills:2 11. Milk of Magnesia 7.75 % Suspension Sig: One (1) PO twice a day as needed for constipation. Disp:60 doses Refills:2 12. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [1-10] Tablet, Delayed Release (E.C.)s PO twice a day as needed for constipation. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary Diagnosis: Seizure Hypotension Anaphylaxis Rash Astrocytoma . Secondary Diagnosis: Hypertension Hyperlipidemia Discharge Condition: stable. Discharge Instructions: Please take all of your medications as prescribed. Please keep all follow-up appointments. Please do not take Gentamicin or Vancomycin in the future as these caused a rash and low blood pressure. Please notify your primary care physician if you experience fevers, chills, worsening rash, dizziness, chest pain, shortness of breath, seizures or other concerning symptoms. Followup Instructions: Please follow-up with your primary care doctor, Dr. [Last Name (STitle) 67626], in [1-10] weeks. His phone number is [Telephone/Fax (1) 67627]. Please have your sutures removed [5-28]-24th in follow-up. Please follow-up with Dr. [First Name (STitle) 5005] [Last Name (NamePattern4) 5342], MD [First Name (Titles) ] [2169-5-29] at 1:00pm. Please call [Telephone/Fax (1) 44].	[ "191.2", "327.23", "E849.7", "693.0", "995.0", "285.9", "V12.51", "E930.8", "564.09", "458.29", "425.4", "788.20", "345.90" ]	icd9cm	[ [ [] ] ]	[ "02.2", "01.13" ]	icd9pcs	[ [ [] ] ]	9934, 9983	5656, 8218	310, 385	10146, 10156	4712, 4712	10575, 10988	2740, 2843		8427, 9911		10004, 10004		8244, 8404				10180, 10552									2858, 4693																										247, 272							413, 1587				10095, 10125			4728, 5633	10023, 10074										1631, 2351	2367, 2724
64,420	194,154	981	Discharge summary	report	Admission Date: [2157-3-4] Discharge Date: [2157-3-15] Date of Birth: [2095-10-24] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2157-3-8] Off-pump coronary artery bypass graft x3: Left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal and posterior descending arteries History of Present Illness: 61 year old male with history of Hypertension, Hyperlipidemia, and known 3 vessel CAD who presents with chest pain. Patient states that on [1-13] he was in [Country 6505] visiting his brother when he developed SSCP associated with diaphoresis. Went to the hospital and was found to have an NSTEMI. Cardiac catheterization revealed three vessel CAD with mild LV systolic dysfunction (LAD 70% ostial stenosis, RCA Mid 90% stenosis, OM 70% proximal lesion). Given that the patient had thrombocytopenia secondary to MDS versus CLL he was not taken for CABG. Instead he was medically opitmized and returned to [Location 86] for follow up with his cardiologist. . After his return the patient saw his cardiologist who performed and nuclear stress test which showed inducible ischemia with minmal activity in LAD/RCA distribution. Throughout this time the patient notes intermittent chest pain. He notes that it is very difficult to differentiate between chest pain secondary to GERD versus a cardiac origin. He typically notes worsened chest pain after eating. Further should he eat and attempt to walk he will get worsened chest pain and shortness of breath which will reguire him to stop and rest. Since returning from [Country 6505] patient has used a nitro patch daily with 2-3 SL nitros daily. In the last two days patient has used more SL nitroglycerin and has been using nitropatch at night. Past Medical History: Coronary artery disease s/p coronary angioplasty [2157] myocardial infarction Hypertension Chronic lymphocytic leukemia with autoimmune thrombocytopenia (per BM bx) Myleodysplastic Syndrome with 5q Deletion Gout Gastroesophageal reflux disease Impaired glucose tolerance Chronic obstructive pulmonary disease osteoarthritis Ruptured appendix 30 years ago fractured ribs '[16] Right radial fx Social History: Lives in [Location 86]. Electrical Contractor Not Married Quit smoking 7 months ago (prior smoke [11-20] cigs daily) EtOH occasionally Family History: Grandmother: Gastric Cancer Mother: DM, Ovarian Cancer Father: 57, Unknown [Last Name 3495] Problem Brother: CABG x 3, Age 55 DM runs in the family. Physical Exam: Temp:96.3 HR:66 BP:128/77 - 119/70 Resp:16 O(2)Sat:100 normal Height: Weight: General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Glasses Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [] non-tender [x] bowel sounds + [x] Softly distended. No HSM, no masses Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact x Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ PT [Name (NI) 167]: 2+ Left:2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: none Left: none Pertinent Results: Discharge labs: [2157-3-15] 05:35AM BLOOD WBC-2.8* RBC-3.89* Hgb-9.6* Hct-29.1* MCV-75* MCH- 24.6* MCHC-32.9 RDW-18.0* Plt Ct-60* [2157-3-15] 05:35AM BLOOD UreaN-13 Creat-0.9 K-4.6 [2157-3-14] 05:15AM BLOOD Glucose-113* UreaN-13 Creat-1.0 Na-138 K-4.6 Cl-101 HCO3-29 AnGap-13 [2157-3-14] 05:15AM BLOOD Glucose-113* UreaN-13 Creat-1.0 Na-138 K-4.6 Cl-101 HCO3-29 AnGap-13 Preop Labs: [2157-3-4] 12:30PM BLOOD WBC-8.2 RBC-5.27 Hgb-13.2* Hct-39.6* MCV-75* MCH-25.0# MCHC-33.2 RDW-17.3 Plt Ct-63# [2157-3-8] 02:39AM BLOOD Neuts-64.1 Lymphs-23.9 Monos-8.4 Eos-2.6 Baso-0.9 [2157-3-4] 12:30PM BLOOD Neuts-71.3 Lymphs-23.0 Monos-5.1 Eos-0.4 Baso-0.3 [2157-3-8] 01:21PM BLOOD PT-14.8* PTT-29.2 INR(PT)-1.3* [2157-3-4] 12:30PM BLOOD PT-13.5* PTT-23.8 INR(PT)-1.2* [2157-3-4] 12:30PM BLOOD Glucose-118* UreaN-19 Creat-0.9 Na-136 K-6.1* Cl-100 HCO3-26 AnGap-16 [2157-3-4] 07:15PM BLOOD K-4.2 [2157-3-5] 07:30AM BLOOD ALT-19 AST-15 LD(LDH)-180 CK(CPK)-44* AlkPhos-45 Amylase-60 TotBili-0.5 [2157-3-4] 07:15PM BLOOD CK(CPK)-61 [2157-3-5] 07:30AM BLOOD Lipase-34 [2157-3-5] 07:30AM BLOOD CK-MB-NotDone cTropnT-0.02* [2157-3-8] 02:39AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2 [2157-3-5] 07:30AM BLOOD %HbA1c-6.6* eAG-143* [2157-3-5] 07:30AM BLOOD Triglyc-204* HDL-33 CHOL/HD-3.5 LDLcalc-41 CHEST (PA & LAT) Study Date of [2157-3-13] 1:31 PM COMPARISON: [2157-3-11]. FINDINGS: As compared to the previous radiograph, there is no relevant change. Minimal decrease in size of the pre-existing left retrocardiac atelectasis. Unchanged appearance of the heart, unchanged radiographic aspect of the post-sternal region. No newly appeared focal parenchymal opacities suggesting pneumonia. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] Cardiology Report ECG Study Date of [2157-3-8] 3:15:36 PM Sinus rhythm. Left atrial abnormality. Consider prior inferior myocardial infarction and modest inferolateral lead T wave changes. Baseline artifact makes assessment difficult. Since the previous tracing of [2157-3-5] sinus bradycardia is absent. Otherwise, probably no significant change. Read by: [Last Name (LF) ],[First Name3 (LF) 177] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 83 154 90 352/392 36 7 -7 IntraOp Echocardiogram Findings LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mildly depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+) AR. Eccentric AR jet directed toward the anterior mitral leaflet. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-procedure: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). with mild global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-procedure: The patient never received inotropic support at any point during the off-CPB CABG. No new wall motion abnormalities were seen at any point in the procedure. Biventricular systolic function was preserved and similar to pre-procedure. There is trace mitral regurgitation post-procedure. All other findings are consistent with pre-procedure findings. The aorta is intact post partial clamping for proximal vein graft anastamosis. All findings were communicated to the surgeon intraoperatively. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) 6506] [Name8 (MD) 6507], MD, [Hospital1 18] ECHOCARDIOGRAPHY REPORT-[1-15] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm Right Atrium - Four Chamber Length: 5.2 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 45% >= 55% Left Ventricle - Stroke Volume: 90 ml/beat Left Ventricle - Cardiac Output: 7.40 L/min Left Ventricle - Cardiac Index: 3.51 >= 2.0 L/min/M2 Left Ventricle - Peak Resting LVOT gradient: 2 mm Hg <= 10 mm Hg Left Ventricle - Lateral Peak E': 0.10 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: 3.9 cm <= 3.6 cm Aorta - Ascending: 4.0 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 17 Aortic Valve - LVOT diam: 2.6 cm Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.33 Mitral Valve - E Wave deceleration time: 234 ms 140-250 ms Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mildly depressed LVEF. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root. Moderately dilated ascending aorta. Focal calcifications in ascending aorta. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Normal mitral valve supporting structures. No MS. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal tricuspid valve supporting structures. No TS. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - bandages, defibrillator pads or electrodes. Suboptimal image quality as the patient was difficult to position. Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %) primarily secondary to postoperative septal dyssynchrony. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2157-3-5], the left ventricular ejection fraction is reduced. Electronically signed by [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD, Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname 6508] was admitted from the ED with unstable angina and medically managed. He had known 3vessel coronary artery disease and had a cardiac catheterization on [2157-1-17] at an outside facility. Cardiac surgery was consulted and he underwent usual pre-operative work-up. Hematology was consulted to comment on his CLL/thrombocytopenia. On [3-8] was brought to the operating room where he underwent a off-pump coronary artery bypass grafting. Please see operative report for surgical details. In summmary he had: 1. Off-pump coronary artery bypass graft x3, with Left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal and posterior descending arteries. 2. Endoscopic harvesting of the long saphenous vein. He tolerated the operation well, 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. On post-op day one he was transferred to the telemetry floor for further care. All tubes, lines and drains were removed per cardiac surgery protocol. During post-op course he worked with physical therapy for assistance with strength and mobility. He did develop minimal serosanguinous sternal drainage and was started on keflex. He remained afebrile with a low normal white blood cell count (history of CLL). The remainder of his hospital course was uneventful. He was cleared for discharge to home on POD 7 per Dr. [First Name (STitle) ] with VNA services and follow up wound check on [Hospital Ward Name 121] 6 on Friday [2157-3-18]. Medications on Admission: Zestril 5 mg Daily Omeprazole 20 mg Daily ASA 81 mg Daily SL NTG Lopressor 50 [Hospital1 ] Allopurinol 100 Daily Norvasc 5 Daily NTD patch 10 mg Daily Crestor 10 mg Daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s)* Refills:0 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:60 Tablet(s) Refills:0 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for sternal drainage for 7 days. Disp:28 Capsule(s) Refills:0 6. Sternal wound Sternal incision draining serosanguinous drainage at lower pole of incision- steri strios removed from lower aspect of incision - daily dressing change to distal wound after shower with dry dressing 7. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 8. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:0 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for h pylori for 14 days. Disp:56 Tablet(s) Refills:0 11. Tetracycline 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for h pylori for 14 days. Disp:56 Capsule(s) Refills:0 12. Bismuth 262 mg Tablet, Chewable Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for h pylori for 14 days. Disp:112 Tablet(s) Refills:0 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) as needed for h pylori for 14 days: then resume prilosec as prior to surgery . Disp:28 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary artery disease s/p off-pump Coronary Artery bypass Graft x 3 Past medical history: s/p coronary angioplasty [2157] myocardial infarction Hypertension Chronic lymphocytic leukemia with autoimmune thrombocytopenia (per BM bx) Myleodysplastic Syndrome with 5q Deletion Gout Gastroesophageal reflux disease Impaired glucose tolerance Chronic obstructive pulmonary disease osteoarthritis Ruptured appendix 30 years ago fractured ribs '[16] Right radial fx H.Pylori Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics left leg harvest incision clean and dry. Sternal incision draining serosanguinous drainage at lower pole of incision- steri strios removed from lower aspect of incision - daily dressing change to distal wound after shower with dry dressing 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, 24 hours a day [Telephone/Fax (1) 170] Followup Instructions: Surgeon Dr. [First Name (STitle) ] [Telephone/Fax (1) 170], [2157-4-11], 1pm You have a wound check appointment on Friday [2157-3-18] on [Hospital Ward Name 121] 6 at 10am Please call to schedule appointments: Primary Care Dr. [Last Name (STitle) 6509],[First Name3 (LF) 6510] J. [Telephone/Fax (1) 6511] in [11-20] weeks Cardiologist Dr. [Last Name (STitle) 6512] in [11-20] weeks Please call cardiac surgery office if need arises for evaluation or readmission to hospital [Telephone/Fax (1) 170] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2157-3-15]	[ "790.22", "414.01", "272.4", "E933.1", "458.29", "238.74", "715.90", "411.1", "414.2", "530.81", "424.0", "401.9", "496", "274.9", "412", "204.10" ]	icd9cm	[ [ [] ] ]	[ "36.12", "36.15" ]	icd9pcs	[ [ [] ] ]	15554, 15612	11725, 13400	331, 526	16133, 16472	3410, 3410	17029, 17701	2566, 2720		13625, 15531		15633, 15703		13426, 13602				16496, 17006			3426, 11702						2735, 3391																										281, 293							554, 1965																		15725, 16112	2405, 2550
25,970	115,494	12447	Discharge summary	report	Admission Date: [2186-12-27] Discharge Date: [2187-1-9] Date of Birth: [2123-9-9] Sex: M Service: HISTORY OF PRESENT ILLNESS: Dr. [Known lastname 38669] is a 63 year-old right handed internist who was previously healthy and returned from a trip to Europe when he developed symtpoms of slurred speech and unsteady gait. These symtpoms occurred while he was in the airport and he had previously noted while in flight the development of a right sided headache. His symptoms improved, but as he was removing luggage from a cab at approximately 3:00 p.m. he fell to the ground and was found to be hemiplegic along his left side. The patient was taken to [Hospital6 2561] where he was intubated for airway protection and transferred to [Hospital1 18] for further management. An MRI was obtained, which demonstrated large diffusion abnormality in the right MCA lesion. Susceptibility scan was negative and his MRA demonstrated right ICA and right MCA occlusion. The patient underwent tissue plasminogen activator administration just under six hours after the onset of symptoms with transient improvement in his left sided paresis. The patient was noted to be unable to follow commands, he could localize pain with his right arm and withdraw his left arm from painful stimulus in a nonspecific manner and he could also move his right leg more then left. Tone was decreased in his left lower face. There were no examination findings suggestive of deep venous thrombosis on initial presentation. The patient was admitted to the Neurological Intensive Care Unit for further management. HOSPITAL COURSE: The patient remained intubated and during his initial days in the hospital began having episodes of bradycardia and asystole. This was thought to be possibly be related to infarction or edema involving the insular region. The patient had a lower extremity duplex scan that was normal. Follow up head CT had demonstrated a hemorrhagic conversion of approximately 3 cm of his right MCA infarction. A transthoracic echocardiogram with bubble study demonstrated no PFO and a normal EF, however, the patient was unable to perform specific maneuvers to aid in the recognition of a PFO and the study was felt to be limited. The patient underwent extubation on [12-28], but was reintubated on the 25th after the decision was made to perform a right hemicraniotomy for decompression of his large MCA infarction. He was subsequently extubated on [12-30] and transferred to the floor on [1-3]. During his Intensive Care Unit stay he was noted to have intermittent fevers and had one blood culture that was positive for staph non-aureus for which he was started on Vancomycin. Subsequent blood cultures showed no growth and it is likely that the initial blood culture was contaminated. On transfer to the General Neurologic Service the patient's examination demonstrated that he was awake, alert and had mild difficulty providing details of recent events. He was aware that he had suffered a stroke and could recite the days events and could also recall remote events without difficulty. His speech was slow and slurred and consisted of short sentence structure. He had decrease in flexion. He was noted to have a right gaze preference and left lower facial droop. He was flaccid and hemiplegic on his left side. There was a homonymous hemianopsia in his left visual field. He had no sensory modalities intact on the left side and a dense hemi-neglect was present for his left. The patient was restarted on aspirin and continued to do well during the remainder of his hospital stay. He had evidence of a mild pneumonia along the left lingular area and his Vancomycin was discontinued with the addition of Levofloxacin. A repeat transthoracic echocardiogram has been ordered and is to be performed on the day prior to discharge. The patient also had a hypercoagulability workup performed and the results of these studies are pending at the time of this dictation. DISCHARGE DIAGNOSES: 1. Right internal carotid artery occlusion with right middle cerebral artery ischemic infarction and subsequent left hemiplegia with left sided neglect. 2. Pneumonia. DISCHARGE MEDICATIONS: 1. Aspirin 325 q.d. 2. Tylenol #3 one to two tabs q 4 to 6 hours as needed for neck pain. 4. Skelaxin 800 mg po t.i.d. 5. Flexeril 10 mg po q day. 6. Lipitor 10 mg po q.d. DISCHARGE DIET: Low cholesterol diet. The patient's diet should include aspiration precautions. DISCHARGE ACTIVITIES: As defined by physical therapy. DISCHARGE CONDITION: Good. SPECIAL CONSIDERATIONS: The patient has undergone a right hemicraniotomy and the right cranial region is vulnerable to compressive injury. The patient should not sleep or have pressure applied to the right side of his head. The patient should also continue to have deep venous thrombosis prophylaxis with heparin 5000 units subQ b.i.d. and Venodyne boots while in bed. The patient will also likely require a bowel regimen with Colace 100 mg po b.i.d. and Dulcolax suppositories as needed. DISPOSITION: The patient is to be discharged to a rehab facility. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1941], M.D. [MD Number(1) 37533] Dictated By:[Doctor First Name 38670] MEDQUIST36 D: [2187-1-9] 07:35 T: [2187-1-9] 08:01 JOB#: [Job Number 38671]	[ "434.91", "486", "433.10", "997.3" ]	icd9cm	[ [ [] ] ]	[ "96.6", "01.25", "99.10", "96.71" ]	icd9pcs	[ [ [] ] ]				4601, 5442				4050, 4220	4244, 4579					1647, 4029																																													159, 1629
353	108,923	9273	Discharge summary	report	Admission Date: [2151-3-28] Discharge Date: [2151-4-13] Date of Birth: [2089-7-23] Sex: M Service: MEDICINE Allergies: Ativan / Tetracycline Attending:[First Name3 (LF) 5368] Chief Complaint: Infected Catheter Major Surgical or Invasive Procedure: Tunneled dialysis catheter placement on [2151-4-7] History of Present Illness: 61 yo man with ESRD on HD, DM1, CAD p/w fevers, chills, night sweats x 1 day. Of note, had R subclavian tunnel cath placed [1-29] weeks ago and patient c/o some discomfort at line site. He denies SOB, chest pain, abdominal pain, dysuria. Does have diarrhea but is being treated for C. diff colitis (flagyl Day [1-7]). In ED, pus noted to be coming out of tunnel cath site, fever 100.5, lactate 4.3, leukocytosis. Code Sepsis called when patient became tachycardic. Tunnel cath pulled and L IJ sepsis line placed. In [Name (NI) ] pt. received Vanco and Gent and 100 ml IVF. Past Medical History: - ESRD on HD MWF - DM 1 or 2 c/b PVD, CAD, ESRD - bilateral BKAs - CAD s/p CABG - clot in L arm AV graft - no longer functioning - R SC tunnel cath placed - s/p MSSA bacteremia [12-2] - HTN - h/o VRE, MRSA Social History: Lives in [Location 5110] with his mother. A retired pharmacist. Never smoked, rare etoh use. Family History: Mother and father with DM, father with PVD. No h/o CAD. Physical Exam: Tm 100.5, HR 90, BP 95/57, 95% on 2L NC at rate 20 GEN - NAD, A&Ox3 HEENT - PERRL NECK - no JVD, no LAD HEART - distant, RRR, nl S1s2, no m/r/g LUNGS - CTAB ABD - obese, soft, NT, NABS EXT - b/l BKA, no ulcers, no edema, digital ulcer R finger Pertinent Results: [2151-3-28] 01:30PM WBC-13.1# RBC-3.22 HGB-11.2* HCT-33.3* MCV-103* MCH-34.8* MCHC-33.6 RDW-16.1* [2151-3-28] 01:30PM NEUTS-95.6* BANDS-0 LYMPHS-2.4* MONOS-1.5* EOS-0.3 BASOS-0.1 [2151-3-28] 01:30PM PT-14.2* PTT-24.9 INR(PT)-1.3 [2151-3-28] 01:30PM PLT SMR-NORMAL PLT COUNT-165 [2151-3-28] 01:30PM GLUCOSE-128* UREA N-66* CREAT-7.6# SODIUM-138 POTASSIUM-5.1 CHLORIDE-91 TOTAL CO2-30* ANION GAP-22* [2151-3-28] 01:30PM CALCIUM-10.0 PHOSPHATE-3.0# MAGNESIUM-2.0 [2151-3-28] 01:48PM GLUCOSE-142* LACTATE-4.3* [2151-3-28] 04:33PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2151-3-28] 04:33PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.014 [2151-3-28] 04:33PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [2151-3-28] 06:17PM LD(LDH)-212 [2151-3-28] 06:21PM LACTATE-1.8. . CXR No acute cardiopulmonary abnormality. Cardiomegaly. . [4-1] TTE 1. The left atrium is moderately dilated. The left atrium is elongated. 2.The right atrium is moderately dilated. 3.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is probably normal (LVEF>55%) but given the limited views, difficult to be sure. 4.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 5.The aortic root is moderately dilated. 6.The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. 7.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. No masses or vegetations are seen on the aortic valve. 8.There is mild pulmonary artery systolic hypertension. 9.There is no pericardial effusion. . [4-2] TEE 1. The left atrium is moderately dilated. 2. There is mild global left ventricular hypokinesis. 3. Right ventricular function is depressed. 4. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. 6. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. 7. There is no pericardial effusion. . [4-6] MRI of upper ext and veins FINDINGS: Thoracic aorta is normal in appearance, without evidence of aneurysm or dissection. At the level of the pulmonary artery bifurcation, in the axial plane, the ascending thoracic aorta measures 2.7 cm in diameter, and the descending thoracic aorta measures 2.4 cm. Incidental note is made of bovine arch anatomy. No evidence of stenosis or occlusion of the arch vessels. Both common carotid arteries are likewise widely patent. There is thrombus within the right internal jugular vein, extending into the superior vena cava. An approximately 7 cm length of right internal jugular vein and superior vena cava is involved. Right subclavian vein is patent, as well as the right external jugular vein. Tubular filling defects are seen within the left subclavian vein and left internal jugular vein, corresponding to central lines, as previously shown on chest x-ray dated [2151-4-1]. Minimal areas of irregularity within the left brachiocephalic vein may represent clot surrounding one of the central lines. Additionally, there is suggestion of expansion of an approximately 1 cm long segment of the distal left internal jugular vein surrounding the catheter, which may represent a small focus of thrombus surrounding a central line. Left subclavian vein is patent, though appears somewhat attenuated within the level of the expected area of the basilic vein. No mediastinal adenopathy. No gross pleural effusion. Multiplanar reconstructions confirm the above findings, and were essential for diagnosis. IMPRESSION: 1.Non occlusive thrombus within the right internal jugular vein, extending into the superior vena cava. 2. Left subclavian and left internal jugular venous central lines in place, with likely areas of clot within the left internal jugular vein as described, and possibly a small focus of thrombus surrounding one of the central lines, within the left brachiocephalic vein. Brief Hospital Course: 61 yo man with ESRD on HD, DM 2, CAD presents with line sepsis. . 1) Line sepsis - Patient presenting with signs of symptoms of line infection. Blood cultures and cath tip returned with MRSA. A temp groin cath was placed at IR for HD. Patient was started on Vanc and was still febrile for 3 days. His cultures cleared on [3-31] and remained negfative for the rest of the admission. Patient was ruled out for endocarditis with a negative TTE [4-1] and negative TEE [4-2]. He required central access for meds. On [4-7] he had a tunneled cath placed for HD access. . 2) Bilateral IJ clot - in the work up to receive his tunneled cath patient was found on MRA to have clot inn both of his IJ's. He was started on heparin gtt and coumadin. The patient was sent out on coumadin and heparin was stopped once therapeutic. . 3) DM 2 - continued on glipizide and ISS . 4) CAD s/p CABG - no symptoms of ischemia. Continued on ASA, Zocor, and lopressor. . Full Code Medications on Admission: - flagyl completed 10 days [2151-3-27] - ASA 325 mg po qd - Lopressor 25 mg po bid - Zocor 40 - Zestril 5 - Insulin - Glipizide 7.5 mg qam and 5 mg po qpm - Nephrocaps 1 po qd - PhosLo 667 mg po tid Discharge Medications: 1. Warfarin Sodium 1 mg Tablet Sig: Six (6) Tablet PO at bedtime: ask doctor to adjust dose based on your blood tests (INR). Disp:180 Tablet(s) Refills:2 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED): continue home regimen. 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 7. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO Q AM (). Disp:45 Tablet(s) Refills:2 8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO Q PM (). Disp:30 Tablet(s) Refills:2 9. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:180 Tablet(s) Refills:2 10. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: -bacteremia from dialysis catheter line infection with methicillin resistant staph aureus -diabetes mellitus type 1 -end-stage renal disease on hemodialysis -hypertension -coronary artery disease Discharge Condition: stable Discharge Instructions: Please take all medciations and make all appointments as listed in the discharge paperwork. If you have any fevers, chills, or pain/redness around your line site, please call Dr. [Last Name (STitle) 1538] or come to the hospital. Followup Instructions: -follow-up with primary care physician [Name Initial (PRE) 176] 1-2 weeks -have blood work sent to check your blood thinner level (INR) -Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Where: LM [Hospital Unit Name 3126] CENTER Phone:[Telephone/Fax (1) 673] Date/Time:[2151-5-4] 1:00 -Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Where: LM [Hospital Unit Name 3126] CENTER Phone:[Telephone/Fax (1) 673] Date/Time:[2151-5-11] 10:30 -Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 127] Date/Time:[2151-5-25] 10:30	[ "275.42", "V45.81", "583.81", "038.11", "440.29", "414.01", "250.41", "250.71", "E879.1", "996.62", "V09.0", "403.91", "995.91" ]	icd9cm	[ [ [] ] ]	[ "38.95", "39.95", "88.72", "97.49" ]	icd9pcs	[ [ [] ] ]	8548, 8554	6217, 7197	300, 357	8794, 8802	1674, 6194	9085, 9810	1337, 1394		7451, 8525		8575, 8773		7223, 7428				8826, 9062									1409, 1655																										243, 262							385, 972																		994, 1206	1222, 1321
23,219	172,533	27592	Discharge summary	report	Admission Date: [2175-7-21] Discharge Date: [2175-7-27] Date of Birth: [2110-5-31] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: 65M s/p CABG [6-6] who returned with a pericardial tamponade and underwent R VATS with pericardial window on [7-15]. He was dishcarged on [7-19] and was doing well until the morning of admission when he had drainage from the R chest tube drain site. Major Surgical or Invasive Procedure: Subxyphoid pericardial window [2175-7-24] History of Present Illness: This 65M had a CABG [6-6] and did well but had a pericardial effusion with tamponade on [7-11] and underwent pericardiocentesis followed by R VATS and pericardial window. He did well and was discharged on [7-19]. On [7-21] he had a large amount of serrous drainage from his R chest tube site and presented to the ED. Past Medical History: s/p CABGx3(LIMA->LAD< SVG->Ramus, Diag) [2175-6-6] [Month/Day/Year ] ^chol. [Month/Day/Year 5550] Depression s/p spinal fusion Social History: Lives with wife, works as a carpenter. Cigs: quit in [2138] ETOH: 1-2 drinks/day Family History: Unremarkable. Physical Exam: WDWNWM in NAD AVSS HEENT: NC/AT, PERLA, EOMI, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+= bilat. without bruits. Lungs: R chest has decreased BS at base. CV: RRR without R/G/M, nl. S1, S2 Abd: +BS, soft, nontender without masses or hepatosplenomegaly Ext: without C/C/E Neuro: nonfocal Pertinent Results: [2175-7-27] 06:00AM BLOOD WBC-8.0 RBC-4.06* Hgb-11.3* Hct-34.0* MCV-84 MCH-27.8 MCHC-33.2 RDW-14.7 Plt Ct-437 [2175-7-27] 06:00AM BLOOD Glucose-102 UreaN-15 Creat-0.9 Na-141 K-4.2 Cl-102 HCO3-30 AnGap-13 Cardiology Report ECHO Study Date of [2175-7-27] PATIENT/TEST INFORMATION: Indication: Pericardial effusion. Height: (in) 68 Weight (lb): 200 BSA (m2): 2.05 m2 BP (mm Hg): 130/70 HR (bpm): 76 Status: Inpatient Date/Time: [2175-7-27] at 10:57 Test: TTE (Focused views) Doppler: Limited Doppler and color Doppler Contrast: None Tape Number: 2006W034-1:56 Test Location: West Echo Lab Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name11 (Name Pattern1) 1112] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] MEASUREMENTS: Left Ventricle - Ejection Fraction: 70% (nl >=55%) INTERPRETATION: Findings: LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). PERICARDIUM: Trivial/physiologic pericardial effusion. Conclusions: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 70%). There is a trivial/physiologic pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2175-7-25], no major change is evident. Electronically signed by [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD on [2175-7-27] 11:17. [Location (un) ] PHYSICIAN: [Name10 (NameIs) ],[First Name4 (NamePattern1) ] [Last Name (NamePattern1) 975] RADIOLOGY Final Report CHEST (PA & LAT) [2175-7-26] 4:08 PM CHEST (PA & LAT) Reason: s/p chest tube removal [Hospital 93] MEDICAL CONDITION: 65 year old M s/p R. VATS, pericardial window, drainage of loculated pericardial effusion, s/p CABGx3 REASON FOR THIS EXAMINATION: s/p chest tube removal HISTORY: Chest tube removal post-VATS and pericardial window. PA AND LATERAL CHEST. The cardiac silhouette is enlarged with previous CABG. There is eventration of the anterior right hemidiaphragm and bilateral pleural changes consistent with small effusions and/or pleural thickening particularly on the right. No vascular congestion or consolidations. Since exam two days previous ([2175-7-24]), the slight vascular plethora has improved or resolved and no tubes or catheters identified on current or previous exam. No PTX. IMPRESSION: Little short interval change. DR. [First Name (STitle) ] M. [Doctor Last Name ] Approved: WED [2175-7-26] 6:33 PM Brief Hospital Course: The patient was admitted on [7-21] and Thoracic surgery was consulted. The chest tube site was sutured. He had an echo on [7-22] which revealed a large pleural effusion and tamponade physiology. He was transferred to the CSRU and on [7-23] he underwent a subxyphoid pericardial window. He tolerated the procedure well and was transferred to the CSRU in stable condition. He was extubated on the post op day and transferred to the floor on POD#1 after an echo which showed minimal pericardial effusion. His chest tubes were d/c'd on POD#2 and he had another echo which was unchanged. He was discharged to home in stable condition on POD#3. Medications on Admission: Lopressor 25 mg PO BID Colace 100 mg PO BID Lisinopril 40 mg PO daily ASA 81 mg PO daily Norvasc 10 mg PO daily Lipitor 80 mg PO daily Prilosec 20 mg PO daily Fluoxetine 40 mg PO daily Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:60 Capsule(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 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:2 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Pericardial effusion Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive while taking pain medications. Do not lift more than 10 lbs. for 1 month. Shower daily, let water flow over wounds, pat dry with a towel. Call our office for sternal drainage, increased shortness of breath, temp>101.5 Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 1290] for 4 weeks. Make an appointment with Dr. [First Name (STitle) ] for 1-2 weeks. Completed by:[2175-7-28]	[ "518.0", "424.0", "401.9", "272.0", "V45.81", "511.9", "413.9", "997.1", "530.81", "423.9" ]	icd9cm	[ [ [] ] ]	[ "37.12" ]	icd9pcs	[ [ [] ] ]	6282, 6341	4199, 4858	584, 632	6406, 6414	1655, 1923	6739, 6913	1277, 1292		5093, 6259	3339, 3441	6362, 6385		4884, 5070				6438, 6716					1949, 3057				1307, 1636																										282, 546	3470, 4176						660, 996			3089, 3302															1018, 1158	1174, 1261
43,961	130,062	8202	Discharge summary	report	Admission Date: [2119-12-13] Discharge Date: [2120-1-25] Date of Birth: [2081-2-11] Sex: F Service: MEDICINE Allergies: Dilaudid / Shellfish Derived Attending:[First Name3 (LF) 8388] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 38F with cirrhosis [1-10] autoimmune hepatitis complicated by hepatopulmonary syndrome on 6-8L continuous home O2, portal hypertension, splenomegaly, and encephalopathy admitted with shortness of breath. She was at baseline until this weekend when her shortness of breath worsened. She was admitted at [Hospital1 1474] for 2 days, discharged yesterday, saw Dr. [Last Name (STitle) 497] in clinic and resting O2 sat was in the 60%, improved with non-rebreather. Denies cough, sputum production, fever, chills, nasal congestion, headache, sinus tenderness or sick contacts/recent travel. Has generalized chest discomfort started several days ago, located across chest, not pleuritic in nature, no radiation, no known alleviating or aggravating factors. Has chronic abdominal pain on flanks, she says due to enlarged spleen. Mild nausea, one episode of bilious vomit 2 days ago. Has had some diarrhea, no melena or hematochezia. She has chronic myalgias and arthralgias. No dysuria. . Per hepatology clinic she had a PAo2 of 34 and and O2 sat on 6l of %72. Looked cyanotic on arrival, came up to 100% on NRB, now back on 6L at 92-96%. No known precipitating event to set trigger her worsening shortness of breath. No new medications. . In ED, vitals were 98.2 90 124/68 32 86% on 50%FM. Labs notable for WBC# 3.4 (69% PMN no bands) lactate 3.2. ABG showed 7.51/24/34. CXR unchanged from prior. CTA showed no PE. V/S prior to transfer 75 94/43 19 92%4L . Review of systems: (+) Per HPI Past Medical History: - autoimmune hepatitis dx [2095], [Doctor First Name ] -, SMA +, liver biopsy [1-17]: mild to moderate periportal inflammation including plasma cells, portal fibrosis and possible stage 3 fibrosis - DM 2 - portal hypertension - splenomegaly - hepatopulmonary syndrome (dx [1-/2119] based on platypnea, orthodeoxya and Aa gradient; she had a ? PFO vs. AVM on TEE w/ some echos showing incr. PAP vs. not) - hx of hepatic encephalopathy - migraine headaches - depression - Cholecystectomy in [2112] - Endometrial ablation [2114] (but pt unsure) - Cesarian sections Social History: She lives at home with three of her four children. She does not smoke, use alcohol, or illicit drugs. She is currently unemployed but worked as a bus driver previously. Family History: No h/o autoimmune illnesses or liver disease. Father with CAD, mother had a CVA. Her children are healthy although two of them have asthma. Maternal uncle with esophageal cancer. Physical Exam: UPON ADMISSION: VS - 97.6 106/51 68 22 96-97% 6L O2 GENERAL - well-appearing woman in NAD, respirations slightly labored HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - breath sounds distant, no r/rh/wh, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, + splenomegaly, could not palpate liver edge, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [4-11] throughout . UPON DISCHARGE: pertinent changes only Pertinent Results: Labs upon admission: . [2119-12-13] 09:45AM BLOOD WBC-3.4* RBC-4.34 Hgb-13.4 Hct-37.6 MCV-87 MCH-30.9 MCHC-35.7* RDW-14.6 Plt Ct-139* [2119-12-13] 09:45AM BLOOD Neuts-69.7 Lymphs-23.5 Monos-3.9 Eos-2.4 Baso-0.4 [2119-12-18] 05:50AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+ [2119-12-13] 09:45AM BLOOD PT-14.5* PTT-26.7 INR(PT)-1.3* [2119-12-13] 09:45AM BLOOD Glucose-211* UreaN-10 Creat-0.8 Na-138 K-3.4 Cl-108 HCO3-21* AnGap-12 [2119-12-14] 05:15AM BLOOD ALT-22 AST-30 LD(LDH)-157 AlkPhos-73 TotBili-0.8 [2119-12-15] 05:20AM BLOOD Albumin-3.2* Calcium-8.5 Phos-4.3 Mg-1.7 [2119-12-13] 09:45AM BLOOD HCG-<5 . Arterial Blood Gases: [2119-12-13] 08:57AM BLOOD Type-ART pO2-34* pCO2-24* pH-7.51* calTCO2-20* [2119-12-14] 02:31PM BLOOD Type-ART pO2-175* pCO2-30* pH-7.47* calTCO2-22 [2119-12-15] 01:23PM BLOOD Type-ART pO2-214* pCO2-34* pH-7.44 calTCO2-24 [2119-12-15] 03:00PM BLOOD Type-ART O2 Flow-15 pO2-257* pCO2-38 pH-7.42 calTCO2-25 Base XS-0 Intubat-NOT INTUBA [2119-12-15] 06:42PM BLOOD Type-ART Temp-37.8 FiO2-70 pO2-136* pCO2-39 pH-7.42 calTCO2-26 Base XS-1 Intubat-NOT INTUBA [2119-12-16] 03:34AM BLOOD Type-ART pO2-173* pCO2-40 pH-7.41 calTCO2-26 [2119-12-16] 02:37PM BLOOD Type-ART pO2-107* pCO2-29* pH-7.45 calTCO2-21 [2119-12-16] 05:09PM BLOOD Type-ART pO2-84* pCO2-33* pH-7.44 calTCO2-23 [2119-12-27] 09:59AM BLOOD Type-ART pO2-91 pCO2-32* pH-7.48* calTCO2-25 [2120-1-2] 04:09PM BLOOD Type-ART pO2-57* pCO2-32* pH-7.49* calTCO2-25 [2119-12-13] 08:57AM BLOOD O2 Sat-69 [2119-12-14] 02:31PM BLOOD O2 Sat-98 [2119-12-15] 01:23PM BLOOD O2 Sat-99 [2119-12-27] 09:59AM BLOOD O2 Sat-96 [2120-1-2] 04:09PM BLOOD O2 Sat-90 [2119-12-15] 01:23PM BLOOD freeCa-1.13 [2119-12-13] 10:05AM BLOOD Lactate-3.2* . Labs upon discharge: [2120-1-24] 04:58AM BLOOD WBC-1.9* RBC-3.82* Hgb-12.7 Hct-35.8* MCV-94 MCH-33.3* MCHC-35.6* RDW-14.7 Plt Ct-145* [2120-1-24] 04:58AM BLOOD PT-13.8* PTT-26.3 INR(PT)-1.2* [2120-1-24] 04:58AM BLOOD Glucose-89 UreaN-14 Creat-0.9 Na-136 K-3.9 Cl-100 HCO3-27 AnGap-13 [2120-1-24] 04:58AM BLOOD ALT-44* AST-46* AlkPhos-85 TotBili-0.5 [2120-1-24] 04:58AM BLOOD Albumin-3.6 Calcium-9.0 Phos-4.1 Mg-2.0 . Microbiology: . [2119-12-13]: Blood culture: negative [2119-12-18]: Respiratory viral screen: negative [2119-12-28]: Stool culture and C.diff: negative . Imaging: . CXR [2119-12-13]: IMPRESSION: No evidence for acute intrathoracic process. . CT-A chest [2119-12-13]: IMPRESSION: No evidence for pulmonary embolism or other acute intrathoracic pathology. Cirrhosis and secondary findings or portal hypertension including splenomegaly and varices. . Abdominal ultrasound [2119-12-16]: IMPRESSION: Coarsened liver with nodular contour, compatible with known cirrhosis. Splenomegaly, similar to prior examinations. Overall, no significant change from prior ultrasound of [2119-6-28]. . CXR [2119-12-17]: IMPRESSION: AP chest compared to [12-13]: There is no definite pulmonary abnormality, as far as one can see on bedside chest radiographs. Detection of subtle findings would require at least conventional studies if not CT scans. None was seen on the chest CTA on [12-13]. Heart size is top normal. There is no pleural effusion. . ECHO [2119-12-20]: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. There is a minimal increased gradient consistent with trivial tricuspid stenosis. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Preserved biventricular cavity size and systolic function. Passage of agitated saline at rest via intracardiac communication or pulmonary AVMs. Estimated pulmonary artery pressures are indeterminate. . Abdominal Ultrasound [2119-12-22]; IMPRESSION: 1. Splenomegaly with numerous splenic varices and likely splenorenal shunt, all of which appear to be patent. The splenic vein in the midline can only be partially visualized but it appears patent and demonstrates appropriate directional flow. 2. No ascites is identified. 3. Nodular coarsened hepatic architecture with no focal liver lesion. No biliary dilatation. . CT abdomen w/contrast [2119-12-28]: IMPRESSION: 1. No evidence of splenic vein thrombosis as questioned. 2. Nodular and shrunken liver, compatible with cirrhosis. 3. Stigmata of portal hypertension including marked splenomegaly and varices as described above. . ECHO [2120-1-3]: The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild mitral regurgitation with normal valve morphology. Normal estimated pulmonary artery systolic pressure. . RUQ U/S with Dopplers [2120-1-7]: The liver is shrunken and nodular with coarsened heterogeneous echotexture, compatible with known cirrhosis. A small fluid colleciton is seen within the gallbladder fossa, measuring 2.2 x 1.4 cm, stable compared with prior. The common bile duct is normal in caliber measuring 5 mm. The spleen is enlarged. There is no ascites. Doppler: Normal hepatopetal flow is seen within the right, left and main portal vein. The hepatic veins are patent with normal direction of flow. There is recanalization of the umbilical vein. Innumerable varices are seen, as on recent abdominal CT scan. The splenic vein is patent. IMPRESSION: 1. Hepatic cirrhosis and US findings of portal HTN. 2. Patent portal veins with hepatopedal flow. . HIP UNILAT MIN 2 VIEWS LEFT Study Date of [2120-1-14] 3:33 PM Two views of the left hip and a frontal view of the pelvis show no fracture of the hip and no separation of the pelvic ring. There are no findings in the femur to suggest aseptic necrosis and no narrowing of the joint space to indicate degeneration. Brief Hospital Course: [Known firstname ] [Known lastname ] is a 38 year old female with cirrhosis secondary to autoimmune hepatitis complicated by hepatopulmonary syndrome on 6-8L continuous home O2 prior to admission, portal hypertension, splenomegaly, and history of encephalopathy who was admitted with progressively worsening shortness of breath. . #. Hepatopulmonary Syndrome: She required 10-12L of oxygen by face mask at 70-100% and frequently desaturated to 60-70s on 10-12L when pivoting to commode or eating. She was temporarily transferred to the SICU [Date range (1) 29162] for persistent desaturations despite supplemental oxygen. Intubation was not required. Her progressive shortness of breath was evaluated with CXR x2 that were unrevealing for consolidation or pulmonary edema, respiratory viral screen was negative, and CT-A chest was negative for pulmonary embolism. Etiology of her dyspnea was therefore deemed due to progressive hepatopulmonary syndrome. She was seen by our pulmonary team who recommended evaluation for superimposed porto-pulmonary hypertension. Echocardiogram was favored over right heart catheterization due to high risk for need for intubation during the procedure. Echocardiogram on [2119-12-28] confirmed prediction of normal pulmonary artery pressures and helped confirm etiology of her dyspnea as due to hepatopulmonary syndrome. She was noted to have significant desaturations while sleeping at night. Sleep medicine was consulted. She was started empirically on CPAP after which she did not desaturate at night. She was able to maintain oxygen saturations while asleep in the high 90s on 35% oxygen at 10-12L while on CPAP. At the time of discharge she was fairly stable at rest on 10-12L by facemask at 75% with oxygen saturations in the mid 90s. She continues to desaturate to the 60s with very minimal exertion. Intermittently she was mildly wheezy which improved with albuterol nebs which she will continue as an outpatient as needed. She remained on supplemental oxygen support and was transferred to rehab while awaiting a liver transplant . #. Autoimmune hepatitis/cirrhosis: The patient did not present with any evidence of acute liver decompensation or flare of autoimmune hepatitis. Her LFTs remained stable. Her calculated MELD was consistently 8 but she was awarded exception points for a MELD of 30. Her azathioprine dose was decreased to 50 mg daily in preparation for surgery as her white blood cell count was persistently low and it was thought that she would benefit from improved blood counts prior to transplant. Her prednisone dose was decreased to 10 mg daily. For prophylaxis she is on single strength bactrim three times per week. Would strongly recommend that she be changed to either single strength bactrim daily or double strength bactrim three times per week for prophylaxis. She was continued on alendronate and vitamin D weekly. Though she showed no evidence of hepatic encephalopathy, she has done so in the past and was continued on lactulose and rifaximin during this admission, as well as lasix 40 mg daily and spironolactone 100 mg daily. . #. Left Upper Quadrant Pain: She had persistent LUQ abdominal pain with radiation to left flank and L hip due to splenomegaly and massive splenic varices. An x-ray of her hip was normal. She received three abdominal ultrasounds including one with Dopplers and a CT-A to evaluate her pain, all which confirmed lack of splenic venous thrombus or splenic infarct. Her pain was treated with hot packs, lidocaine patches, oxycontin, and oxycodone. . #. Left Hip Pain: The patient also complained of L hip pain. X-ray was negative. This pain is likely secondary to her bedbound state. Her pain was treated with hot packs, oxycontin, and oxycodone. . #. Type II Diabetes Mellitus: The patient's blood sugar was consistently elevated on admission. Her insulin regimen was changed with an increased morning NPH dose to 14 units and a tightened sliding scale (see discharge medications for scale). . #. Depression: The patient was quite depressed at times during her admission. She was supported by social work and continued on her home dose of fluoxetine. . She was FULL CODE for this admission. . Ms. [Known lastname ] asks that when she returns for her transplant, her children be called only just prior to her going to the OR at [Telephone/Fax (1) 29163] (Shantal) and [Telephone/Fax (1) 29164] ([Doctor First Name 8771]). Medications on Admission: - omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). - alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: please resume prior schedule. Take 30 minutes before other meds or food. Take with 8 oz water and remain upright for 30 mins after dose. - azathioprine 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week: please resume prior regimen. - clotrimazole 10 mg Troche Sig: One (1) Mucous membrane five times a day as needed for white coat on tongue. - fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). - furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): take at the same time as spironolactone. - lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). - oxycodone 5 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain. - prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): please continue as instructed by your Hepatologist. - rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). - spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take at same time as lasix. - sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). - folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 - NPH 10 units qAM and Humalog ISS - Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. - trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every Friday). 3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (FR). 4. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane 5X/DAY (5 Times a Day). 5. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 10. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer treatment Inhalation Q4H (every 4 hours) as needed for SOB/wheezing. 13. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 14. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply to back/side. 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 17. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 18. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). 20. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for breakthrough pain. 21. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 22. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply to right side. 23. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily). 24. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H PRN () as needed for pain: please do not exceed 2 grams per day. 25. NPH insulin human recomb 100 unit/mL Suspension Sig: Fourteen (14) units Subcutaneous qam. 26. insulin lispro 100 unit/mL Solution Sig: 0-18 units Subcutaneous QACHS: per attached sliding scale. 27. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. 28. Laboratory values Please check CBC, LFTs, INR, creatinine every week and fax results to Dr.[Name (NI) 948] office: ([Telephone/Fax (1) 12173] so we can follow her MELD score given she is in transplant list. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary Diagnoses: Hepatopulmonary Syndrome, Autoimmune Hepatitis/Cirrhosis Secondary Diagnoses: Type II Diabetes Mellitus, Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound due to O2 requirements. Discharge Instructions: You were admitted to the hospital for shortness of breath caused by severe hepatopulmonary syndrome secondary to your autoimmune hepatitis. You were treated with high flow oxygen by facemask. You are awaiting a liver transplant which will improve your breathing. . The following changes were made to your medications: Your azathioprine was decreased to 50 mg. Your prednisone was increased to 10 mg. See attached sheet for other changes. . We expect your shortness of breath to be stable. Your oxygen level will go down if you move, eat or try to ambulate. You tried walking with a NRB 100% SpO2 and you could only do a few feet. If yous breathing worsens (after sitting 90 degrees, at rest, with same O2) please come back to the [Hospital1 18] for re-evaluation. Followup Instructions: Please follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 497] on [1-31] at 2:40 PM. His office info is: [Hospital1 18] Office Location:[Last Name (NamePattern1) 13209], [Location (un) 86], [Numeric Identifier 718] Patient Phone:([Telephone/Fax (1) 1582] Patient Fax:([Telephone/Fax (1) 12173]	[ "572.3", "789.2", "V85.38", "278.00", "572.8", "V49.84", "250.00", "456.8", "745.5", "338.29", "789.09", "311", "571.5", "571.42", "518.89", "782.1", "518.81" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	19345, 19417	10436, 14916	298, 304	19596, 19596	3526, 3533	20547, 20904	2639, 2819		16548, 19322		19438, 19514		14942, 16525				19754, 20524									2834, 2836			19535, 19575																		1814, 1827					251, 260						5422, 10413	332, 1795									3547, 5406		19611, 19730							1849, 2437	2453, 2623
48,872	139,324	44316	Discharge summary	report	Admission Date: [2182-11-12] Discharge Date: [2182-12-12] Date of Birth: [2131-7-16] Sex: M Service: SURGERY Allergies: Codeine / Percocet / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 5569] Chief Complaint: DM, HTN, ESRD now s/p Living unrelated kidney transplant Major Surgical or Invasive Procedure: [2182-11-12]: Living unrelated kidney transplant [2182-11-22]: Tunneled hemodialysis catheter [2182-12-5]: Open kidney biopsy [2182-12-6]: Line changed over wire History of Present Illness: The patient is a 51-year-old man with chronic kidney disease due to failing prior transplant. His original kidney disease was due to type 1 diabetes and he underwent a living donor renal transplant followed by deceased donor pancreas transplant. The pancreas transplant has since failed and he has stage V CKD of his transplanted kidney. He has not yet restarted dialysis, and still makes urine Past Medical History: # Diabetes mellitus type I, now Diabetes mellitus type II post pancreas transplant # Status post renal ([2162]), pancreas transplants ([2167]). #. Baseline Cr 2.4-2.8 # Hypertension. # Peptic ulcer disease. # [Female First Name (un) 564] esophagitis # Right lower extremity cellulitis # Left fifth toe amputation for Gangrene # Charcot Arthropathy- Septic left subtalar joint. # Urinary tract infections # Retinopathy, status post vitrectomy # Esophageal achalasia # Hypercholesterolemia # Post-strep GN Social History: Lives with wife who is very involved in his care Tobacco: None ETOH: None Illicits: None Family History: Noncontributory Physical Exam: POst Op VS: 97.4, 80, 120/60, 10, 100% General: Intubated/Sedated Card: RRR Lungs: CTA bilaterally Abd: Obese, distended, Incision dressing C/D/I, JP with sero-sanguinous drainage Extr: Warm, + pulses, 2+ edema Pertinent Results: Post Op: [2182-11-12] 08:20PM BLOOD WBC-17.9# RBC-3.57 Hgb-9.9* Hct-31.2* MCV-87 MCH-27.8 MCHC-31.8 RDW-16.8* Plt Ct-352 [2182-11-12] 08:20PM BLOOD Glucose-233* UreaN-105* Creat-4.4* Na-142 K-4.9 Cl-113* HCO3-15* AnGap-19 [2182-11-12] 08:20PM BLOOD Calcium-7.7* Phos-8.7# Mg-2.0 [2182-11-16] 03:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2182-11-16] 03:15PM BLOOD HCV Ab-NEGATIVE [2182-12-10] 04:45AM BLOOD TSH-0.75 [2182-12-10] 04:45AM BLOOD T4-6.6 T3-64 [2182-12-5]: Kidney Biopsy 1. There is no evidence of acute humoral rejection in this sample. 2. Some foci suggestive of endothelialitis are seen, but no unequivocal changes are noted. Banff 97 Working Classification: Acute rejection g1, o2, t3, c0 KDAR1B: Banff type 1B (i2-3, t3, v0) Number of glomeruli: 36 Number of globally sclerotic: 0 Segmental sclerosis: No Other findings: Peri-tubular capillaries are negative for C4d Brief Hospital Course: 51 y/o male now s/p living unrelated renal transplant. The patient received routine induction immunosuppression to include Solumedrol 500 intra-op with post op taper, cellcept and 4 doses of ATG 125 mg, with the first dose given intra-op. Prograf was started on POD 2. Please see the operative note for surgical detail. In summary, his prior left paramedian incision was reopened, the rectus muscles were significantly stuck to both the anterior and posterior rectus sheath and had to be mobilized extensively. When the peritoneum was entered there were significant adhesions of the omentum to the lateral abdominal wall, the transverse incision and the bowel. Identifying the right common and external iliac arterial system in the right pelvis was made more difficult by the patient's deep body habitus and significant retroperitoneal fat. There were extensive calcifications. and the external iliac vein was chosen as a site for a venous anastomosis. Once the kidney was placed, the kidney was reperfused and had slow reperfusion and then was found to be positional in its perfusion. Intraoperative ultrasound was performed which suggested there may be a flap at the level of the artery and it was determined to redo the arterial anastomosis. Cold perfusion solution was infused and topical ice was placed. Once the repair was completed, this resulted in the kidney pinking up much more nicely, although it did have somewhat of a decreased tone. The patient received additional intra-op antibiotics for the extended case and was transferred to the PACU hemodynamically normal but intubated due to significant upper body edema. He was noted to have a metabolic acidosis immediately post op treated aggressively with bicarbonate. He was maintained on an insulin drip and labetolol was restarted to manage hypertension to the 170's. He was extubated in the PACU, but remained there until POD 2. Transplant ultrasound done on POD 1 showed the new renal transplant seen in limited fashion and shows no hydronephrosis or fluid collections and within technical limitations, reasonably normal flow in the main renal artery and renal vein at the hilum. The area of anastomosis cannot be assessed. Urine output was approximately 300-500 cc daily for the first 3 days post op. Creatinine trended up daily and on POD 4 he underwent hemodialysis after placement of a temporary line for volume management (total body fluid overload) and waste reduction. He received 4 total doses of ATG and prograf dosing was based on daily levels. He was then undergoing hemodialysis since that time generally three times per week. The urine output increased with varying daily outputs from [Telephone/Fax (1) 763] cc daily. However the BUN/creatinine always increased and was managed only through dialysis. Intermittent lasix was attempted, however there was never a significant response. On POD 7 the patient had new onset of Afib on hemodialysis. This converted with Lopressor, he was kept on the labetolol at an increased dose. CK and troponins were sent and were not consistent with MI. He was transferred to the SICU for two days, and remained in sinus rhythm so was able to be transferred back to the surgical floor. The JP drain was removed on POD 11. the incision has remained intact with a small amount of sanguinous drainage, no erythema. A tunneled dialysis line was placed and the temporary HD line d/c'd on [2182-11-25]. The right internal jugular line tip was inserted with its tip at the level of superior SVC under fluoro. There was concern on xray taken at the time for worsening pleural edema and attempts intensified with HD to remove more fluid and try lasix again. Antihypertensive med amlodipine is now held pre dialysis to assist in fluid removal. [Last Name (un) ] has been following patient throughout hospitalization. Once off the IV steroids the patient was able to come off the insulin drip, however he will be remaining of a small dose of prednisone. A derm consult was obtained due to a lesion on the back of the patients head. He is to continue topical antifungals and antibacterial and wash his hair with tar based soap. The lesion has improved significantly on these therapies. The patient was seen by PT on a regular basis. The patient was debilitated from fluid overload, minimal movement out of the bed and generalized weakness post op. The patient suffered a fall during one of his PT sessions. Patient complained of pain in the left shoulder. X-rays showed no evidence of fracture or dislocation, physical exam did not reveal any limitations of movement. Because there was no true return of kidney function, an attempt was made to do a kidney biopsy under ultrasound guidance. However, after two different tries, it was determined there was bowel in place and he was instead taken to the OR on [2182-12-5] with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816] for Laparoscopic converted to open kidney biopsy. He tolerated the procedure without complication. The results of the biopsy showed Banff 1B acute cellular rejection, at which time he was started on solumedrol 500 mg IV x 3 days and ATG 150 x 5 days. The creatinine has only dropped to the mid 4's and he is still undergoing hemodialysis three times weekly. A CD3 count has been sent, and Flow crossmatch had been repeated on a post transplant specimen from around the time of the biopsy which are pending at time of discharge. The blood sugars were again difficult to manage with this round of steroids, [Last Name (un) ] has again made adjustments, and FSBS and insulin management is to be maintained at the rehab facility where he will be discharged for further physical therapy/ rehabilitation and continuation of outpatient dialysis. Of note, hepatitis panel was obtained in anticipation of outpatient HD as well as a negative PPD. Medications on Admission: calcitriol 0.25', Sensipar 30', diltiazem 240', Lasix 80", glipizide 10', Lantus 16-18U', Humalog, Ativan 0.5'PRN, metoprolol, omeprazole, prednisone, Renagel, sirolimus, Cialis, aspirin, and sodium bicarbonate Discharge Disposition: Extended Care Facility: [Hospital6 1293] Discharge Diagnosis: ESRD now s/p living unrelated renal transplant Delayed graft function Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Please send a trough Prograf level Saturday [12-14]. If this is not feasible, please send trough Prograf Sunday [12-15]. Recent medication adjustemnts need to be followed before the usual Monday lab draw. Please call the transplant clinic at [Telephone/Fax (1) 673] if the patient develops fever, chills, nausea, vomiting, diarrhea, constipation, increased pain over the kidney graft, redness, drainage or bleeding from the incision, decreased urine output, inability to take or keep down food, fluids or medications. The patient has delayed graft function and will require short term hemodialysis until the return of kidney function as determined by the transplant clinic. Labs every Monday and Thursday, CBC, Chem 7, Ca, Phos, AST, T bili, Trough Prograf level, UA with results faxed to the transplant clinic at [Telephone/Fax (1) 697] No medications to be changed without discussion with the transplant clinic. Patient may shower, no tub baths or swimming No heavy lifting Followup Instructions: BONE DENSITY TESTING Phone:[Telephone/Fax (1) 4586] Date/Time:[2182-12-19] 12:20 [First Name11 (Name Pattern1) 674] [Last Name (NamePattern4) 675], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2182-12-19] 1:40 [Last Name (LF) ],[First Name3 (LF) ] TRANSPLANT SOCIAL WORK Date/Time:[2182-12-19] 3:30 Completed by:[2182-12-12]	[ "285.9", "403.91", "E888.9", "250.52", "250.42", "996.81", "585.5", "250.62", "V49.72", "275.3", "276.4", "584.5", "996.86", "564.00", "272.0", "V10.05", "E878.0", "357.2", "V64.41", "E932.0", "696.5", "276.69", "362.01", "799.3", "V12.71", "427.31", "719.41" ]	icd9cm	[ [ [] ] ]	[ "55.69", "38.95", "55.24", "39.95", "00.92" ]	icd9pcs	[ [ [] ] ]	8989, 9036	2872, 8727	371, 550	9150, 9150	1903, 2849	10342, 10708	1640, 1657				9057, 9129		8753, 8966				9326, 10319									1672, 1884																										275, 333							578, 977											9165, 9302							999, 1517	1533, 1624
6,944	184,159	20310+20311	Discharge summary	report+report	Admission Date: [2147-10-27] Discharge Date: [2147-11-19] Date of Birth: [2078-5-13] Sex: M Service: MICU DATE OF DISCHARGE IS NOT YET DETERMINED; THIS IS A PRELIMINARY DISCHARGE DICTATION WHICH WILL BE FOLLOWED UP WITH AN ADDENDUM CLOSER TO THE PATIENT'S DISCHARGE. HISTORY OF PRESENT ILLNESS: This patient is a 69 year old male with a recent outside hospital admission for urosepsis, the details of which were unknown at the time of admission. He was at his nursing home on the night before presentation to [Hospital1 69] when he was noted to have an acute onset of respiratory distress and diaphoresis at approximately 08:00 p.m. Emergency Medical Services found the patient awake with a respiratory rate of 40 to 50, diaphoretic with an O2 saturation in the 80s and blood pressure about 150/80; heart rate 120 to 165, and complaining of palpitations. At that point, he was nasotracheally intubated by Emergency Medical [Hospital 54506] transferred to [Hospital 48951]Hospital where he was orotracheally intubated. At that time, an EKG there showed rapid atrial fibrillation and labs there were notable for a CK of 279, MB of 27.6, and troponin of 1.2, as well as a D-Dimer of greater than 1000. Blood gas there on an FIO2 of 1.0, 7.3, 35 and 65. At that time, they attempted diuresis with Lasix 80 mg intravenously times three, Zaroxolyn 10 mg intravenous times one; Bumex 4 mg intravenous and they then gave him Diltiazem 35 mg times one, then 50 mg times one and was started on a Diltiazem drip up to approximately 15. The patient also received Plavix 300 mg times one and Lovenox 160 mg subcutaneously times one. Repeat blood gas at that time showed 7.32, 44, 54. He was then transferred to [Hospital1 69] where he remained in rapid atrial fibrillation upon presentation. In the Emergency Department, they attempted to obtain a chest CT angiogram but were unable to do so secondary to body habitus. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Depression. 4. Degenerative joint disease. 5. Morbid obesity. 6. A left parietal cerebrovascular accident with right hemiparesis. 7. History of transient ischemic attacks. 8. Benign prostatic hypertrophy. MEDICATIONS AS OUTPATIENT: 1. Lipitor. 2. Hydrochlorothiazide. 3. Potassium chloride. 4. Aspirin. 5. Atenolol. 6. Glyburide. 7. Avandia. 8. Lisinopril. 9. Metformin. 10. Paxil. 11. Wellbutrin. 12. Levaquin which he was taking for a urinary tract infection. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a resident of a nursing home. Reported no tobacco use; unclear any alcohol use. His closest relative was his sister. PHYSICAL EXAMINATION: Vital signs on presentation were blood pressure of 168/99; heart rate in the 140s in atrial fibrillation; the patient was intubated with O2 saturation of approximately 98%; temperature taken a few hours later was noted to be 99.4 F. On examination, the patient was intubated, sedated, does not respond to stimuli. Pupils are equal, round and reactive to light. Sclerae were anicteric. He had a very large thick neck so was unable to assess for jugular venous distention. His heart was tachycardic and irregularly irregular; distant heart sounds. His lungs due to body habitus, we were unable to get a good fixateur examination. Anterior and laterally they were clear to auscultation with distant breath sounds. His abdomen was obese, soft, nondistended. Extremities showed chronic venous stasis changes bilateral lower extremities. No edema was noted. He had two plus pulses, the most vibrant of which were the dorsalis pedis pulses which were palpated easily. LABORATORY: Initially, the patient had a white blood cell count of 13.8, hemoglobin and hematocrit of 14.3 and 44.4, platelet count of 400. Differential showed 81 neutrophils, no bands, 15 lymphocytes. Chem 7 was a sodium of 140, potassium 3.6, chloride 101, bicarbonate 24, BUN 24, creatinine 1.2, glucose 247, calcium 8.9, magnesium 1.6, phosphorus 4.0, coagulation studies were PT 14.2, INR 1.3, PTT 28.2. CK of 1607 and troponin of 4.12. EKG showed atrial fibrillation at 140 beats per minute, left axis deviation and intraventricular conduction delay, left ventricular hypertrophy, no ST changes were noted. HOSPITAL COURSE: Overall, the patient was a 69 year old male with multiple cardiac risk factors with recent hospital admission for urosepsis, who presented with the acute onset of respiratory distress. 1. INITIAL HYPOXIC RESPIRATORY FAILURE: It was unclear as to exactly what happened at the nursing home. The possibilities initially included pulmonary embolism, aspiration incident, development of a pneumonia, particularly given his brief hospital stay, and acute myocardial infarction with pulmonary edema, or pulmonary edema due to rapid atrial fibrillation. Initially, it was attempted to get a CT scan to look for pulmonary embolism, however, we were unable to obtain one because of the patient's body habitus and it was considered to be less likely just given the findings of an acute myocardial infarction and the fact that the patient was in rapid atrial fibrillation on presentation. Also, on his initial chest x-ray there was a question of an increasing right lower lobe infiltrate which led to the possibility that the patient had acquired a Nosocomial pneumonia during his hospital stay. Therefore, we decided to cover the patient with Vancomycin and Levaquin and he provided sputum cultures. Early on in his hospital stay, the patient had a bronchoscopy and the bronchial alveolar lavage in the secretions he was able to obtain had a Gram stain of Gram positive cocci, however, the cultures were negative from this, possibly due to colonization already covering with antibiotics. The left lower lobe infiltrate did improve over the hospital stay although difficult to visualized on chest x-ray, and the pneumonia appeared to improve clinically on the Vancomycin and Levaquin. The Vancomycin was then continued for ten days and Levaquin for 14 days. Throughout this time, the patient had decreasing necessity for ventilation, although he did require a constant PEEP of around 10, probably due to the fact that he is morbidly obese with a low chest wall compliance, and therefore had difficulty in recruiting alveoli. Nevertheless, the patient was stable enough to be extubated during his hospital stay and was doing fairly well on a CPAP mask with a PEEP of approximately 10 until he experienced acute onset of respiratory failure again and clinically appeared to be in flash pulmonary edema. Therefore, we managed the flash pulmonary edema which will be discussed under the section of his coronary artery disease, even given management of pulmonary edema and optimization of his cardiac parameters, the patient was not able to be successfully extubated during hospital stay and required a tracheostomy. At the time of this discharge summary, the patient was being maintained on tracheostomy still requiring significant PEEP as well as pressure support, and showing signs of significant respiratory muscle weakness, however, he also did develop a second pneumonia which was likely to be Methicillin resistant Staphylococcus aureus, although this may also represent colonization, therefore, the patient ended up being retreated with Vancomycin for a possible Methicillin resistant Staphylococcus aureus pneumonia. 2. SHOCK: Cardiology initially was consulting on throughout the hospital stay. It was believed at the beginning of the hospital stay that this was due to cardiogenic shock, possibly with a distributive component. The patient did have a pulmonary artery catheter placed to help determine the etiology of his shock and importantly, it showed a pulmonary capillary wedge pressure of 25, central venous pressure of approximately 16, although his cardiac output was 7.85 and his SVR was 673. This led us to believe that there was probably some element of cardiogenic shock given elevated wedge pressure, however, there was a significant component of septic shock validity to increased cardiac output and the SVR on the lower side. For his shock, the patient was initially on Dopamine which was weaned and then transferred to Levophed. Over the course of a few days, the Levophed was successfully weaned as the sepsis was treated. Another element of the treatment of the shock was that the patient, in being a cosyntropin nonresponder, received fludrocortisone hydrocortisone until his shock resolved. 3. RAPID ATRIAL FIBRILLATION: This was controlled via Diltiazem and Lopressor. The patient did end up becoming bradycardic on the first night which was thought to be due to more an overdose of the Diltiazem which was maintained at 15 throughout the first night of his hospital stay. With discontinuation of the Diltiazem and temporary discontinuation of Metoprolol, the patient responded and remained converted in sinus rhythm. The patient did have multiple episodes were he reverted to atrial fibrillation, at times rapid atrial fibrillation during the hospital stay, which was controlled mostly with a combination of Diltiazem and Lopressor. The patient was also started on heparin for his paroxysmal atrial fibrillation which eventually was discontinued due to, first the patient being taken for cardiac catheterization, and then secondary to a falling hematocrit. It was felt that the falling hematocrit represented more danger to the patient than the stroke risks or paroxysmal atrial fibrillation, so the heparin was not restarted temporarily. Consideration was given at the time of this discharge dictation to restarting the patient on heparin once his hematocrit stabilized, versus starting him on an oral regimen of anti-coagulation. The patient had gone several days without reverting to atrial fibrillation at the time of this discharge dictation, possibly because an amiodarone drip was started and then changed to amiodarone p.o., which was continued at the time of this dictation. 4. CORONARY ARTERY DISEASE: For his coronary artery disease, the patient was initially not thought to have had a primary myocardial infarction as his event, and that the rising CK and troponins may have been due to demand ischemia from underlying coronary artery disease and the stress put on his heart from atrial fibrillation and septic shock. When the patient was septic and being treated for such, he was not taken to cardiac catheterization, however, after he experienced his episode of flash pulmonary edema after extubation, it was thought that one of the principal obstacles to permanent extubation was optimization of his cardiac function. Therefore, the patient was taken to Cardiac Catheterization. In Cardiac Catheterization, disease was found primarily in the left anterior descending and obtuse marginal 1, both of which were stented successfully, without any evidence of rethrombosis during his hospital course up until the time of this dictation. Unfortunately, the patient was still not able to be extubated even given the cardiac optimization. For his coronary artery disease, the patient was maintained on aspirin, Plavix, Metoprolol, originally Isordil and hydralazine and the hydralazine was then changed to Captopril once his creatinine reached its baseline level, and Lipitor was added later in the hospital course. 5. NEUROLOGY: It was noted later on in the hospital course that the patient had a question of decreasing movement of the right side of his body; it was unknown at the time that the patient had a right hemiparesis from a left parietal cerebrovascular accident and it was said at this time that the patient's mental status began to improve a bit after weaning of sedation. Therefore, a head CT scan was obtained which showed the old left parietal infarction as well as some hyperdensity in the right temporal lobe. It was unclear at this time whether this represented a subarachnoid hemorrhage or question of meningioma, therefore a repeat CT scan was done the next day which showed unchanging of this lesion. It was felt by Neurology, who was consulted on the case, that this was unlikely to represent hemorrhage and it also did not correlate clinically with the patient's right hemiparesis; therefore, initially the heparin was held because of this and no further work-up was done. Any further work-up will be delayed until the patient is more stable and probably as an outpatient. We likely would have followed this up with an MRI, however, the patient due to his body habitus, was unable to obtain an MRI. Towards the third week of his hospitalization, around [11-19], the patient's mental status improved greatly. He was still showing significant weakness bilaterally likely due to his prolonged Intensive Care Unit course. A CK was done at the time which was normal and his mental status was just watched over time to see that it would improve and how his strength would improved. We also decided at that point to get a Physical Therapy consultation. 6. ENDOCRINE: From an endocrine standpoint, the patient had significant problems with glycemic control which was controlled with an insulin drip. Probably due to his body habitus, he did not respond very well to subcutaneous insulin but was maintained on an insulin drip which will be converted to his oral hypoglycemic medication once he is stable and out of the Intensive Care Unit. 7. GASTROINTESTINAL: From a gastrointestinal standpoint, the patient continued to be guaiac positive throughout much of his hospital stay which we felt did not contribute to a decreasing hematocrit he had a couple of times during hospital course. Towards his third week of hospitalization, the patient did have a significant drop in his hematocrit of about six points which was felt to be due to an expanding hematoma towards the area of cardiac catheterization which was done approximately a week earlier, therefore, an ultrasound was obtained which is pending at the time of this dictation. Regarding his guaiac positive stools, it was felt that there was no necessity for an acute colonoscopy and this should be followed up likely as an outpatient. 8. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was kept on tube feeds for most of his hospital course which were discontinued for approximately a few days due to significant ileus which did resolve. The patient was fed with these tube feeds through an OG tube and when he is more stable will be obtaining a Swallow evaluation to try to re-institute p.o. feeding versus necessity for a long term open G-tube. The patient will likely necessitate a direct gastric feeding tube which will be difficult to obtain without an open surgery due to his body habitus. It is being delayed at the current time of this dictation, due to the patient's sepsis. Otherwise, the patient did require occasional Lasix for diuresis, principally due to inadequate renal function. The patient's renal function did improve throughout his hospital course. He was diuresing well even without the necessity for Lasix and the Lasix was temporarily held in light of his recurrent sepsis. Consideration will be given to restoring the Lasix once the sepsis resolves. As far as access issues goes, we were never able to obtain any central venous access in the patient's right side. No imaging was done to determine whether there was any thrombus from prior hospitalizations or altered anatomy. There was imaging done on the left side due to inability to thread the wire after repeated central venous lines were placed in the left internal jugular and subclavian. No clots were noted in that area and eventually all central venous access was discontinued with his fevers and a right PICC line was able to be obtained. CODE STATUS: The patient per his sister is to be at full code status. The sister is primarily the one who is involved in his care, although it was difficult to arrange any meetings with the sister due to the fact that she lives approximately an hour away from the hospital. As far as his overall disposition at the time of this discharge dictation, the patient was doing well with stable hemodynamics, still requiring ventilatory support, although attempts were being made to decrease his PEEP and pressor support. He was experiencing continued fevers and infection, possibly from pneumonia, possibly from line sepsis, but not having any abdominal pain to give consideration for a work-up of acalculous cholecystitis. He is being continued on Vancomycin at the current time. Overall, the issues remaining for his Intensive Care Unit stay are principally just his sepsis and being weaned from ventilatory support, although if he remains stable, this may be continued at an extended care facility. There should be consideration given to acquiring an open G-tube operation prior to the patient's discharge from the hospital. We are also obtaining a Speech consultation for questioning of the use of a Passey-Muir valve at the current time. An addendum will be made, including follow-up plans and overall discharge medications. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7585] Dictated By:[Name8 (MD) 54507] MEDQUIST36 D: [2147-11-19] 17:25 T: [2147-11-19] 18:29 JOB#: [Job Number 54508] Admission Date: [2147-10-27] Discharge Date: [2147-11-23] Date of Birth: [2078-5-13] Sex: M Service: This dictation summary is an addendum to dictation summary, which was dictated on the [11-19]. Since the last dictation on the 7th the hospital course of the patient has been largely stable. 1. Initial hypoxic respiratory failure: The patient steadily improved on ventilation. The patient began a CPAP trial on [11-21] and did well. The patient was then put on CPAP of a PEEP of 5 and pressure support of 5 on [11-22] and remained to saturate well in the high 90s and showed no signs of respiratory distress. The patient therefore remained on CPAP for the remainder of hospital stay. The patient will be evaluated for a talking trach on the day of discharge and a wait placement into along term facility for bed rehab. service. The patient was hemodynamically stable for the remainder of hospital stay. 3. Rapid atrial fibrillation: The patient remained in sinus rhythm for the remainder of his hospital stay. 4. Coronary artery disease: The patient again displayed pink sputum on the night of [11-19]. Differential for this included pulmonary edema from congestive heart failure. The patient was diuresed prn with Lasix and showed good resolve. The patient had no further episodes of pink frothy sputum throughout the remainder of his hospital stay. An electrocardiogram was obtained at this time and no change was detected from his previous electrocardiogram indicating no acute events. 5. Neurology: Since last dictation the patient continued to steadily improve strength of his left side. The patient had baseline weakness on his right side from a previous cerebral event. The patient was evaluated and received physical therapy for the remainder of his hospital stay. 6. Endocrine: The patient was discontinued on an insulin drip on [11-21] and put on long acting insulin as well as sliding scale. Level of long term insulin was titrated accordingly. 7. Gastrointestinal: The patient continued to have guaiac positive, but no melanotic stool for the remainder of the hospital stay. The patient should be arranged for an outpatient colonoscopy once all other issues have been resolved. The patient's hematocrit remained stable after this MD came on service. 8. Hematocrit: As stated above hematocrit remained stable largely throughout the remainder of his hospital stay. At that time his drop in hematocrit was attributed to his hematoma, which was noted on the right glutea status post catheterization. No further indication of active bleeding was noted as hematocrit remained stable and the patient's vital signs also remained stable. It was likely that the hematoma had stabilized and resorption had begun. 9. Fluids, electrolytes and nutrition: The patient was continued on OG tube feeds. It was noted that the rehab facility will not accept the patient with an OG tube placement. The patient will be sent down for IR assisted placement of a post pyloric nasogastric tube. The patient did not wish for an nasogastric tube to be placed without sedation. 10. Code status: The patient remained in full code status throughout the duration of his stay. DISPOSITION: The patient will be placed in a long term vent facility for rehabilitation and physical therapy. DISCHARGE CONDITION: Stable. MEDICATIONS ON DISCHARGE: 1. Metoprolol 75 mg b.i.d. 2. Captopril 50 mg po t.i.d. 3. Vancomycin 1 gram q.d. to complete a ten day course. The patient is now on day six. 4. Atorvastatin 10 mg po q.d. 5. Epoetin 40,000 units subcutaneous q week. 6. Isosorbide mononitrate 20 mg po b.i.d. 7. Amiodarone 200 mg po q.d. 8. Potassium chloride 40 milliequivalents prn potassium less then 3.5. 9. Aspirin 325 mg po q.d. 10. Clopidogrel 75 mg po q.d. 11. Colace 100 mg po q.i.d. 12. Famotidine 20 mg intravenous q 12. DR [First Name8 (NamePattern2) ] [Name (STitle) ] 12.838 Dictated By:[Last Name (NamePattern1) 21646] MEDQUIST36 D: [2147-11-22] 12:25 T: [2147-11-22] 13:09 JOB#: [Job Number 54509]	[ "250.92", "578.9", "785.52", "486", "518.81", "038.9", "482.41", "410.71", "996.72" ]	icd9cm	[ [ [] ] ]	[ "89.64", "36.07", "36.05", "96.04", "38.93", "31.1", "99.20", "88.56", "37.23", "38.91", "99.15", "33.24", "96.72" ]	icd9pcs	[ [ [] ] ]				20804, 20813								20839, 21574		4330, 20782																											2720, 4311																		330, 1966																		1988, 2553	2571, 2696
13,990	175,912	28037	Discharge summary	report	Admission Date: [2137-10-9] Discharge Date: [2137-10-23] Date of Birth: [2062-1-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: Transfer from [Hospital3 ]- unresponsive, hypotensive Major Surgical or Invasive Procedure: 1. Central Line Placement and Removal 2. Tracheostomy 3. PEG placement 4. EGD 5. Colonoscopy History of Present Illness: 75 y/o female with h/o Breast Ca s/p mastectomy, multiple episodes of PNA with "lung scaring", with several weeks of cough and sputum production, saw PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 23] on Monday, for cough, SOB, given azithromycin taken for one day before presentation. At 11 AM on the day before admission patient found to be in mild resp distress at home by grandson. [Name (NI) ] that day found to be in severe resp distress, with confusion and disorientation. Brought to [Hospital3 ] for altered mental status. There found to have resp distress, elevated BNP to 1367, elevated trop I to 5.62, transient lateral ST depressions, WBC 14.4 with 61% bands, Cr 3.8. Treated with Vanco, Levo, Gent. Intubated. CT head negative for bleed. Abd CT showed trace amount of fluid in upper abd, stranding around colon at hepatic flexure, diverticular disease. Transfered from [Hospital3 3583] on Dopamine by peripheral IV. . Here unresponsive, on vent. Blood Gas 7.22/55/414. Right IJ placed. BP 68/42 off dopamine. Levophed started. Pupils 2mm and nonreactive. T 99.2. Lactate 3.8. Given Ceftriaxone. WBC 8.3. Cr 3.1. AST/ALT markedly elevated. Ck 260, CK-MB 14, index 5.4, Trop 0.70. EKG with nonspecific ST/T wave changes in V1, V2. ST depression in II. Received 3L NS. Past Medical History: h/o Breast Ca S/P mastectomy, no chemo or radiation PNA-last epiosode 6-7 years ago Interstitial Lung Disease s/p CCY Social History: SOCIAL: Non smoker Family History: Unknown Physical Exam: Vitals T 95.4 BP 131/83(on levophed) in ED 68/42 off pressors HR 77 RR 20 Sat 100% on CMV 500/20 PEEP 5 FiO2 .50 Tanned appearance. Unarousable, not reactive to sternal rub, withdraws to noxious stimuli (nailbed pressure) Pupils 1mm b/l and minimally reactive No LAD, good carotid pulses Lungs with crackles b/l over axilla and diffuse rhonchi Abd, soft, non distended, no masses, minimal bowel sounds No peripheral edema, 1+ DP pulses, toes upgoing B/L. Absent reflexes throughout Pertinent Results: ADMISSION LABS: [2137-10-9] 03:45AM BLOOD WBC-8.3 RBC-3.47* Hgb-10.4* Hct-31.4* MCV-90 MCH-30.0 MCHC-33.2 RDW-14.5 Plt Ct-149* [2137-10-9] 03:45AM BLOOD Neuts-83* Bands-8* Lymphs-2* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2137-10-9] 03:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL [2137-10-9] 01:00PM BLOOD Fibrino-487* D-Dimer-6886* [2137-10-9] 01:00PM BLOOD FDP-40-80 [2137-10-9] 03:45AM BLOOD Glucose-268* UreaN-50* Creat-3.1* Na-128* K-4.2 Cl-93* HCO3-20* AnGap-19 [2137-10-9] 03:45AM BLOOD ALT-4675* AST-[Numeric Identifier 68244]* CK(CPK)-260* AlkPhos-117 Amylase-197* TotBili-2.1* [2137-10-9] 03:45AM BLOOD Lipase-114* [2137-10-9] 03:45AM BLOOD CK-MB-14* MB Indx-5.4 [2137-10-9] 03:45AM BLOOD cTropnT-0.70* [2137-10-9] 08:25AM BLOOD CK-MB-17* MB Indx-6.4* cTropnT-0.72* [2137-10-9] 03:00PM BLOOD CK-MB-16* MB Indx-7.9* cTropnT-0.63* [2137-10-9] 10:21PM BLOOD CK-MB-14* MB Indx-8.4* cTropnT-0.53* [2137-10-10] 03:56AM BLOOD CK-MB-12* MB Indx-7.1* cTropnT-0.54* [2137-10-9] 03:45AM BLOOD Calcium-7.5* Phos-4.6* Mg-2.0 [2137-10-9] 08:25AM BLOOD calTIBC-173* Ferritn-GREATER TH TRF-133* [2137-10-9] 01:00PM BLOOD Ammonia-94* [2137-10-9] 03:45AM BLOOD Cortsol-351.7* [2137-10-9] 08:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2137-10-9] 01:00PM BLOOD AMA-NEGATIVE Smooth-POSITIVE - [2137-10-9] 03:45AM BLOOD CRP-GREATER TH [2137-10-9] 08:25AM BLOOD HCV Ab-NEGATIVE [2137-10-9] 04:22AM BLOOD Lactate-3.8* . ABDOMEN U.S. (PORTABLE) [2137-10-9] 1:10 PM DUPLEX DOPP ABD/PEL PORT; ABDOMEN U.S. (PORTABLE) Reason: Please assess liver and remainder abdomen, please assess por [Hospital 93] MEDICAL CONDITION: 75 year old woman with sepsis, shock liver REASON FOR THIS EXAMINATION: Please assess liver and remainder abdomen, please assess portal and hepatic veins with doppler flow studies INDICATION: 75-year-old woman with sepsis and shock liver. PORTABLE DUPLEX OF THE ABDOMEN: This is a limited study due to patient's intubated status. The gallbladder is not visualized. The liver shows normal echogenicity with no focal masses. The intrahepatic branches of the hepatic artery and hepatic vein are patent. The main portal vein is patent. The intrahepatic portal veins are difficult to assess. The pancreas is poorly visualized but shows no gross abnormality. The right kidney measures 12 cm. There is a cyst in the superior portion of the right kidney measuring 1.2 x 1.1 x 1.2 cm. The left kidney measures 12 cm, and there is a cyst in the mid to upper pole measuring 2.4 x 1.8 x 1.4 cm. The aorta is of normal caliber. The spleen is unremarkable. IMPRESSION: 1. Patent main portal vein and hepatic artery and vein. 2. Bilateral renal cysts. . DUPLEX DOPP ABD/PEL PORT [2137-10-9] 1:10 PM DUPLEX DOPP ABD/PEL PORT; ABDOMEN U.S. (PORTABLE) Reason: Please assess liver and remainder abdomen, please assess por [Hospital 93] MEDICAL CONDITION: 75 year old woman with sepsis, shock liver REASON FOR THIS EXAMINATION: Please assess liver and remainder abdomen, please assess portal and hepatic veins with doppler flow studies INDICATION: 75-year-old woman with sepsis and shock liver. PORTABLE DUPLEX OF THE ABDOMEN: This is a limited study due to patient's intubated status. The gallbladder is not visualized. The liver shows normal echogenicity with no focal masses. The intrahepatic branches of the hepatic artery and hepatic vein are patent. The main portal vein is patent. The intrahepatic portal veins are difficult to assess. The pancreas is poorly visualized but shows no gross abnormality. The right kidney measures 12 cm. There is a cyst in the superior portion of the right kidney measuring 1.2 x 1.1 x 1.2 cm. The left kidney measures 12 cm, and there is a cyst in the mid to upper pole measuring 2.4 x 1.8 x 1.4 cm. The aorta is of normal caliber. The spleen is unremarkable. IMPRESSION: 1. Patent main portal vein and hepatic artery and vein. 2. Bilateral renal cysts. . CT HEAD W/O CONTRAST [2137-10-9] 6:12 AM CT HEAD W/O CONTRAST Reason: UNRESPONSIVE. ? ICH [Hospital 93] MEDICAL CONDITION: 75 year old woman with unresponsiveness REASON FOR THIS EXAMINATION: eval for ICH CONTRAINDICATIONS for IV CONTRAST: creat INDICATION: Unresponsiveness. NONCONTRAST HEAD CT: No prior for comparison. Patient is markedly tilted within the scanner gantry. FINDINGS: No hydrocephalus, shift of normally midline structures, intra- or extra- axial hemorrhage, or acute major vascular territorial infarct is identified. Lacunar infarcts, chronic in age, are noted in both basal ganglia and subinsular cortices reflects chronic microvascular infarction. A few subcm. areas of low density are noted in the right temporal lobe- these may represent enlarged sulci v. chronic cortical infarcts. The patient is intubated. No fractures are seen. There is a small, probable retention cyst in the right maxillary sinus, with opacification of a few ethmoid air cells, and mild mucosal thickening in the frontal sinus. Mastoid air cells are poorly pneumatized and aerated. Sphenoid sinus shows moderate mucosal thickening. There is fluid and aerosolized secretions in the nasopharynx and oropharynx, likely due to intubation. IMPRESSION: No acute intracranial hemorrhage or mass effect. See above report for additional findings. Sinusitis, likely chronic in age. . Cardiology Report ECHO Study Date of [2137-10-10] PATIENT/TEST INFORMATION: Indication: Left ventricular function. BP (mm Hg): 117/67 HR (bpm): 72 Status: Inpatient Date/Time: [2137-10-10] at 09:50 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W052-0:00 Test Location: West MICU Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.6 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 6.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 3.9 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.0 cm Left Ventricle - Fractional Shortening: 0.23 (nl >= 0.29) Left Ventricle - Ejection Fraction: 50% (nl >=55%) Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm) Aorta - Ascending: 3.3 cm (nl <= 3.4 cm) Aorta - Arch: 3.1 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 1.1 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 0.86 Mitral Valve - E Wave Deceleration Time: 255 msec TR Gradient (+ RA = PASP): >= 33 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild global LV hypokinesis. No resting LVOT gradient. RIGHT VENTRICLE: Dilated RV cavity. Borderline normal RV systolic function. [Intrinsic RV systolic function likely more depressed given the severity of TR]. Abnormal septal motion/position consistent with RV pressure/volume overload. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. Mildly dilated aortic arch. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Significant PR. PERICARDIUM: No pericardial effusion. Conclusions: 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 mild global left ventricular hypokinesis. The right ventricular cavity is dilated. Right ventricular systolic function is borderline normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. Significant pulmonic regurgitation is seen. There is no pericardial effusion. . GI BLEEDING STUDY [2137-10-20] GI BLEEDING STUDY Reason: BRBPR AND RLQ PAIN ? SOURCE OF BLEED RADIOPHARMECEUTICAL DATA: 16.4 mCi Tc-[Age over 90 ]m RBC ([2137-10-20]); HISTORY: Recent bright red blood per rectum, in the setting of sepsis and multiorgan failure in the MICU. DECISION: INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[Age over 90 ]m, blood flow and dynamic images of the abdomen for minutes were obtained. A left lateral view of the pelvis was also obtained. Blood flow images are unremarkable. The iliac arteries are ectactic. Dynamic blood pool images show no definite early bleeding on images obtained over 0-60 minutes. Subsequently, after repositioning the patient over a [10-6] minute period, imaging shows evidence of hemorrhage in the sigmoid colon over the subsequent hour. IMPRESSION: Late dynamic images demonstrating extravasation into the sigmoid colon, but no evidence of brisk bleeding within the first hour. This is most suggestive of a slow intermittent hemorrhage in the sigmoid colon. These findings were discussed with Dr. [First Name (STitle) ] from the MICU shortly after the study. . EKG Cardiology Report ECG Study Date of [2137-10-17] 8:00:54 PM Sinus rhythm. Atrial ectopy. There is a late transition which is probably normal. Compared to the previous tracing atrial ectopy is now present. . OPERATIVE REPORT [Last Name (LF) ],[First Name3 (LF) ] Signed Electronically by [Last Name (LF) ],[First Name3 (LF) ] on WED [2137-10-23] 10:10 AM Name: [Known lastname ], [Known firstname ] E Unit No: [Numeric Identifier 68245] Service: Date: [2137-10-21] Date of Birth: [2062-1-27] Sex: F Surgeon: [First Name8 (NamePattern2) ] [Name8 (MD) ], [MD Number(1) 19187] ASSISTANT: [Last Name (NamePattern4) ], MD PREOPERATIVE DIAGNOSIS: Respiratory failure. POSTOPERATIVE DIAGNOSIS: Respiratory failure. OPERATION: Percutaneous gastrostomy tube placement. INDICATION: Nutrition. DESCRIPTION OF PROCEDURE: After informed consent was obtained, under general anesthesia, and with the patient already on Zosyn for antibiotic prophylaxis, she was placed at a 45 degrees angle. The gastroscope was inserted into the oral cavity and passed through the esophagus into the stomach. The mucosa was entirely normal with no obvious lesion. The stoma was insufflated. The skin over the left upper quadrant was palpated and a sharp indentation with 1 finger was seen. The skin was prepped with chlorhexidine and draped in a typical sterile fashion. 1% lidocaine was used for local anesthesia. An Angiocath was inserted under direct vision and a snare was lassoed and pulled back through the esophagus and into the oral cavity. A 20-French PEG tube was loaded and pulled back through the oral cavity into the esophagus and through the abdominal wall. The gastroscope was reinserted to confirm excellent placement with a mushroom cap against the abdominal wall cavity. Bolsters were placed at 3 cm to secure the PEG tube. . OPERATIVE REPORT [Last Name (LF) ],[First Name3 (LF) ] Signed Electronically by [Last Name (LF) ],[First Name3 (LF) ] on WED [2137-10-23] 10:41 AM Name: [Known lastname ], [Known firstname ] E Unit No: [Numeric Identifier 68245] Service: Date: [2137-10-22] Date of Birth: [2062-1-27] Sex: F Surgeon: [First Name8 (NamePattern2) ] [Name8 (MD) ], [MD Number(1) 19187] ASSISTANT: [First Name8 (NamePattern2) ] [Last Name (un) 68246] PREOPERATIVE DIAGNOSIS: Respiratory failure. POSTOPERATIVE DIAGNOSIS: Respiratory failure. PROCEDURE: Percutaneous tracheostomy tube placement. INDICATIONS FOR PROCEDURE: Respiratory failure. DESCRIPTION OF PROCEDURE: After informed consent was obtained, under general anesthesia, the patient's neck was prepped with chlorhexidine, draped in the usual fashion. The first tracheal ring was identified. Local anesthesia using 1.5 Xylocaine with epinephrine was used to anesthetize the area. A 2 cm horizontal skin incision was performed using a scalpel. Using [Initials (NamePattern4) ] [Last Name (NamePattern4) 1356] clamp we dissected the subcutaneous tissue until visualizing the tracheal rings. The 18 gauge needle with an attached syringe with lidocaine in the trachea was penetrated under bronchoscopic visualization. A guidewire was inserted through the needle, after which the needle was withdrawn. A punch dilator was inserted and using a blue Rhino kit, the trachea was dilated, after which an 8 Portex tracheostomy tube was inserted. The bronchoscope was introduced through the tracheostomy tube and midline position was confirmed with adequate volumes on mechanical ventilator. The tracheostomy tube was connected to the ventilator and was secured to the neck with a Velcro skin tie. . DISCHARGE LABS: [2137-10-23] 04:40AM BLOOD WBC-15.0* RBC-3.52* Hgb-10.6* Hct-31.1* MCV-88 MCH-30.2 MCHC-34.2 RDW-15.8* Plt Ct-172 [2137-10-22] 03:57AM BLOOD PT-15.2* PTT-33.9 INR(PT)-1.4* [2137-10-23] 04:40AM BLOOD Glucose-104 UreaN-85* Creat-3.7* Na-138 K-3.8 Cl-104 HCO3-24 AnGap-14 [2137-10-20] 03:53AM BLOOD ALT-123* AST-21 LD(LDH)-227 AlkPhos-74 Amylase-271* TotBili-0.3 [2137-10-23] 04:40AM BLOOD Calcium-8.4 Phos-4.9* Mg-1.9 Brief Hospital Course: 75 y/o female with PMH breast ca s/p R sided mastectomy, interstitial lung disease, h/o pna, presented w/ 1 week h/o cough, was intubated at [Hospital3 ], and transferred to [Hospital1 18] at family's request, septic with hypothermia, hypotensive on pressors, and with shock liver and renal failure. . # Respiratory Failure: She was intubated at [Hospital3 3583] for hypoxic respiratory failure. Her CT scan suggests interstitial lung disease. ECHO showed normal ejection fractio. She was intubated from admission on [2137-10-9], and had a tracheostomy placed on [2137-10-22]. Susupected cause for decompensation was underlying pneumonia . Sputum cultures were negative. Viral Bronchoalveolar lavage showed no increase number of macrophages or eosinophils. She completed a 14 day course of Vancomycin and Zosyn for empiric pneumonia. Prednisone 1 mg/kg was given for treatment of possible cryptogenic organizing pneumonia. Patient became progressively more hypercapnic and had a respiratory acidosis soon after trying to wean from Assist /Control Mechanical Ventilation and placed on PS ventilation. For this reason, a tracheostomy tube was placed on [2137-10-22] (day # 14 of intubation) with no complications. She tolerated BIPAP with optimal titration parameters between 15/5 cmH2O. She should continue Prednisone 1 mg/kg for 4 weeks and her outpatient Pulmonologist should taper Prednisone to 0.5 mg/kg after this period to continue for at least 6-8 weeks total. She will need Mechanical Ventilation at rehab facility. Current vent settings are BiPAP with pressure support of 10 and PEEP of 5 with .40 FiO2. . # Sepsis: She presented with hypotension, hypothermia (T 95.0 on admission), leukocytosis with bandemia, end-organ failure (shock liver c AST/ALT > [Numeric Identifier 2249], ARF). Initially required pressors (on levophed which were discontinued within 24 hours. Likely etiologies included infectious- PNA considering UA was not abnormal and a CT scan of the abdomen done at an OSH did not show abscess , diverticulitis, perforation, mesenteric ischemia. She was given broad spectrum antibiotics vancomycin and zosyn to cover infectious etiologies. Urine, sputum, and blood cultures did not grow out any organisms. She completed a 14 day course of antibiotics on [2137-10-23]. . # Leukocytosis/C Diff Infection: Patient had an elevated WBC count of 12 K c 10 % bands on admission . She received full course of broad spectrum atb. After D # 4 of admission WBC peaked at [Numeric Identifier ] despite atb treatment. Two C diff toxin A were negative but a second C diff toxin B came back positive. She was started on Flagyl [2137-10-13] and should complete a 14 day course on [2137-10-26]. . # ARF: She has no history of underlying renal disease. She presented with elevated Cr of 3 which peaked to 7 during admission. UA showed muddy brown casts. Urine lytes c/w ATN. US showed normal sized kidneys SHe had oliguria which resolved with time and her urine output is back to baseline. She had also received Gentamycin and contrast at the outside hosptial, which may have contributed. There was no need for dialysis. Creatinine was 3.6 on discharge , with normal Urine output. She should continue on phosphate binders until renal function returns to baseline. . # Altered mental status: Presented intubated, non-responsive. Likely Toxic/metabolic (renal failure with uremia, hepatic encephalopathy, infectious) vs Medication effect given renal failure and transaminitis as she received sedating medications at OSH. She regained responsiveness and was alert and oriented throughout most of her admission. . # Elevated Amylase/Lipase: Amylase/lipase trending up after tube feeds initiated. Enxymes came back to normal after improvement of renal function. . # Transaminitis: Presented with highly elevated LFT's, Bili, LDH. Likely due to shock liver. Acetamenophen level not elevated. Hepatitis serologies, EBV, CMV negative for acute infection. No evidence of portal vein or hepatic vein thrombosis on U/S. Anti-SM Ab positive. Enzymes trended down to normal on discharge. . # Metabolic Acidosis: Patient had elevated anion gap on admission . AFter fluid resuscitation her metabolic acidosis turned was worsened by respiratory acidosis. Both improved after treatment of sepsis and lung infection. . # Diverticular Bleed: Patient had massive hematochezia on HD # 11. Hc remained stable near 28-32 %.EGD wnl. Lower GI scope with diverticulosis and evidence of earlier bleeding. She received 2 U PRBC. HCT remained stable during rest of hospitalization. She should avoid NSAIDs and aspirin. High fiber diet recommended. . # NSTEMI: Pt w/out known h/o cardiac disease. Had demand ischemia in setting of sepsis, with elevated trop due to renal failure. Echo showed EF 50% with large LA and diated RV with Mod TR and Significant PR, PAP 33. ASA was started due to coagulopathy on admission and later GI bleed. [Month (only) 116] start ASA in th future if no further episodes of bleeding. . # Bradycardia: Patient's HR ranged from 40 -60 after sepsis treated. Patient was never symptomatic. EKG without conduction abnormalities. . # Anemia: Normocytic. Iron studies show elevated iron and ferritin levels, low TIBC. . # Nutrition: She has a PEG placed on [2137-10-22]. She should get Nepro full strength @ 30 cc /h. . #Communication: Daughter [First Name4 (NamePattern1) 553] [Last Name (NamePattern1) ]- H [Telephone/Fax (1) 68247], C [Telephone/Fax (1) 68248]. The patient has a hearing aid and wears glasses to comunicate. Medications on Admission: Unknown Discharge Medications: 1. Metronidazole 500 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO TID (3 times a day). 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 3. Prednisone 20 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical TID (3 times a day) as needed. 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [Last Name (STitle) ]: [5-30] Puffs Inhalation Q4H (every 4 hours). 6. Albuterol 90 mcg/Actuation Aerosol [Month/Day (3) ]: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 7. Calcium Acetate 667 mg Capsule [Month/Day (3) ]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS): can stop once renal function back to baseline. 8. Insulin Regular Human 100 unit/mL Solution [Month/Day (3) ]: Insulin by sliding scale while on Prednisone units Injection QACHS. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: PRIMARY 1. Multifactorial Respiratory Distress from etiologies including idiopathic pulmonary fibrosis, pneumonia, and hypercarbic respiratory failure requiring tracheostomy 2. Gastrointestinal Bleed 3. C. Diff colitis 4. Malnutrition 5. Sepsis with multiple organ failure, improved SECONDARY 1. Severe restrictive lung disease 2. Breast Cancer s/p Mastectomy Discharge Condition: afebrile, hemodynamically stable, comfortable, with tracheostomy and PEG Discharge Instructions: 1. Please take all medications as prescribed 2. Attend all follow-up appointments 3. If you develop fevers, chills, nausea, vomiting, gastrointestinal bleeding, or any other concerning signs/symptoms, please contact your provider or report to the Emergency Department 4. Your prednisone is being tapered - please follow instructions on medications list Followup Instructions: 1. Please follow-up with the respiratory care team at rehab regarding a Passy-Muir valve 2. Please follow up with a pulmonologist for Interstitial lung disease. 3. Please follow up with primary care doctor. Completed by:[2137-10-23]	[ "276.2", "428.0", "584.5", "414.8", "577.0", "038.9", "515", "401.9", "785.52", "427.89", "518.81", "V45.71", "486", "V10.3", "286.7", "V58.65", "349.82", "562.12", "008.45", "570", "535.50", "995.92" ]	icd9cm	[ [ [] ] ]	[ "99.04", "38.93", "96.6", "31.1", "38.91", "45.23", "96.05", "99.07", "45.13", "99.15", "93.90", "96.72", "43.11" ]	icd9pcs	[ [ [] ] ]	23566, 23638	16878, 20219	372, 467	24044, 24119	2527, 2527	24520, 24758	2000, 2009		22553, 23543	6794, 6834	23659, 24023		22520, 22530				24143, 24497			16410, 16855		8130, 16393				2024, 2508																										275, 334	6863, 6961						495, 1804					6970, 8104		2543, 4331				20234, 22494							1826, 1946	1962, 1984
3,394	107,080	15127	Discharge summary	report	Admission Date: [2172-9-11] Discharge Date: [2172-10-9] Date of Birth: [2123-11-21] Sex: M HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old gentleman who first noted rectal bleeding and underwent colonoscopy and was ultimately found to have a rectosigmoid carcinoma at approximately 12 cm. A CT angiography was the liver including two 2-cm masses in the medial segment of the left lobe, two small equivocal less than 5-mm lesions in the left lateral segment, an ablation adjacent to the falciform ligament (thought to represent focal fat), and six lesions in the right lobe of the liver including a less than 1-cm lesion near the dome of the liver. Additionally, demonstrated a cluster of five masses in the right HOSPITAL COURSE: On [2172-9-11], the patient underwent a right hepatic lobectomy, a cholecystectomy, a segment 4A resection, and a Infusaid pump placement. Please see the Operative Note per Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for details of this component of the operation. The patient also underwent a low anterior resection, a splenic flexure mobilization, and an omental flap. Please see the Operative Note per Dr. [Last Name (STitle) 1888] for details of this component of the operation. During the course of the operation, the patient received 3 units of packed red blood cells and 4 units of fresh frozen plasma. He was ultimately transferred to the Intensive Care Unit intubated. The patient was extubated in the Intensive Care Unit on postoperative day two. The remainder of his stay in the Intensive Care Unit was without any significant events. He was transferred to the floor on postoperative day four. His epidural was discontinued. Additionally, on this day, it also marked the completion of his postoperative Unasyn prophylaxis. On postoperative day five, an Infusaid pump study was undertaken. He was started on sips of clear liquids which he tolerated without difficulty. The impression from this study was that there was a nonhomogeneous pattern of uptake in the liver with relatively increased activity at the dome of the liver with considerably decreased activity in the remaining portions. On postoperative day seven, the patient was advanced to a full liquid diet and tolerated this without difficulty. On postoperative day eight, his intravenous line was hep-locked as he was taking in adequate orals. On postoperative day nine, the patient underwent an ultrasound of the abdomen because of increasing output from his surgical drain. The impression from this study was that the patency and appropriate flow was documented in the remaining hepatic and portal veins. A repeat study was recommended for better re-evaluation of the main portal vein. Fluid collections were noted additionally inferior and superior to the liver; consistent with post surgical changes. An ultrasound on postoperative day 10 indicated that there was excellent flow in all hepatic vessels. There were no focal hepatic lesions, and there was only a small postoperative fluid collection noted to the liver. On postoperative day 11, the patient was determined to have a seroma surrounding his Infusaid pump. The seroma was aspirated on postoperative day 12 without incident. On postoperative day 17, the patient reached tube feed goals at 50 cc per hour and was tolerating this without difficulty. On postoperative day 18, the seroma was again drained with aspiration of approximately 150 cc of clear yellow fluid. The procedure went without complications, and the patient tolerated the procedure. In consultation with Nutrition, tube feeds were advanced to 60 cc per hour which was the patient's goal feeds. The patient was ultimately discharged on postoperative day 28 with [Hospital6 407] services at home. He was continuing to receive tube feeds as his oral intake was less than adequate for maintaining his fluid and caloric requirements. The patient was scheduled for close followup with Dr. [Last Name (STitle) ]. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. DISCHARGE STATUS: His discharge status was to home with nursing services. DISCHARGE DIAGNOSES: 1. Metastatic colon cancer to the liver and rectosigmoid cancer. 2. Status post right hepatic lobectomy. 3. Status post cholecystectomy. 4. Status post segment 4A resection. 5. Status post Infusaid pump placement. 6. Status post low anterior resection and splenic flexure mobilization with omental flap. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Ursodiol 300 mg p.o. b.i.d. 2. Lansoprazole 30 mg p.o. q.d. 3. Percocet one to two tablets p.o. q.4-6h. as needed. 4. Colace 100 mg p.o. b.i.d. 5. Benadryl 50 mg p.o. q.4-6h. as needed. 6. Milk of Magnesia 30 cc p.o. q.4-6h. as needed. 7. Spironolactone 100 mg p.o. q.d. 8. Lasix 20 mg p.o. q.d. 9. Lactulose 30 cc p.o. t.i.d. 10. GoLYTELY 16 ounces p.o. b.i.d. DISCHARGE FOLLOWUP: Plans again for close follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. The patient was instructed to call his office for his initial appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], M.D.,Ph.D. 02-366 Dictated By:[Last Name (NamePattern1) 1752] MEDQUIST36 D: [2172-11-25] 18:08 T: [2172-11-28] 04:42 JOB#: [Job Number ]	[ "997.3", "782.3", "285.1", "154.0", "996.79", "197.7", "576.8", "780.6", "511.9" ]	icd9cm	[ [ [] ] ]	[ "86.06", "86.01", "50.3", "48.63", "51.22", "48.23" ]	icd9pcs	[ [ [] ] ]								4220, 4531				4558, 4976		772, 4058																												4073, 4199													4997, 5446				148, 754
14,311	198,441	51759	Discharge summary	report	Admission Date: [2107-10-21] Discharge Date: [2107-10-26] Date of Birth: [2035-7-9] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: SOB, intraperitoneal free air post ERCP Major Surgical or Invasive Procedure: ERCP/stent [10-21] History of Present Illness: 70 F w/ a h/o Roux en Y gastrojejunostomy for peptic ulcer disease sp lap CCY @ an OSH c/b by a bile leak presented to [Hospital1 18] for ERCP/stent placement [2107-10-21]. Post procedure, the patient developed SOB and CXR showed free intraperitoneal air. Pt pt denied abdominal pain at this time and was transferred to the ICU for close monitoring. Past Medical History: asthma, hypercholesterolemia, mild HTN, h/o peptic ulcer diseas. sp partial antrectomy, gastrojejunostomy, truncal vagotomy [2090], B total knee replacement [2090], TAH [2074], sp appy [2060] Physical Exam: NAD A & O X 3 PERRLA, EOMI RRR CTAB soft, NT/ND No R/G mildly distended umbilical wound open, packed with wet to dry Dx, no drainage/erythema 1 + E/no C/C Pertinent Results: [2107-10-21] 04:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2107-10-21] 04:19PM GLUCOSE-98 UREA N-19 CREAT-0.8 SODIUM-137 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-29 ANION GAP-14 [2107-10-21] 04:19PM ALT(SGPT)-64* AST(SGOT)-54* CK(CPK)-106 ALK PHOS-412* AMYLASE-13 TOT BILI-11.4* DIR BILI-8.4* INDIR BIL-3.0 [2107-10-21] 04:19PM LIPASE-32 [2107-10-21] 04:19PM CK-MB-5 cTropnT-<0.01 [2107-10-21] 04:19PM WBC-16.2* RBC-3.28* HGB-10.1* HCT-30.9* MCV-94 MCH-30.9 MCHC-32.7 RDW-15.3 [2107-10-21] 04:19PM PLT COUNT-406 [2107-10-21] 04:19PM PT-12.2 PTT-20.6* INR(PT)-0.9 [2107-10-21] 10:20AM WBC-13.3* RBC-3.08* HGB-9.3* HCT-28.6* MCV-93 MCH-30.2 MCHC-32.5 RDW-15.4 [2107-10-25] 05:35AM BLOOD WBC-10.7 RBC-3.46* Hgb-10.4* Hct-31.6* MCV-91 MCH-30.1 MCHC-33.0 RDW-14.5 Plt Ct-499* [2107-10-25] 05:35AM BLOOD Glucose-159* UreaN-15 Creat-0.4 Na-138 K-3.3 Cl-101 HCO3-28 AnGap-12 [2107-10-22] 10:14AM BLOOD ALT-46* AST-32 LD(LDH)-639* AlkPhos-355* Amylase-6 TotBili-6.9* [2107-10-23] 04:00AM BLOOD ALT-38 AST-27 AlkPhos-334* Amylase-7 TotBili-5.7* [2107-10-24] 02:34AM BLOOD ALT-31 AST-24 AlkPhos-301* Amylase-8 TotBili-4.2* [2107-10-25] 05:35AM BLOOD ALT-36 AST-31 AlkPhos-301* Amylase-8 TotBili-3.7* [2107-10-26] 04:01AM BLOOD ALT-38 AST-33 AlkPhos-277* TotBili-2.8* [2107-10-21] 03:41PM BLOOD Glucose-120* Lactate-1.3 Na-133* K-3.7 Cl-99* [2107-10-23] 04:21AM BLOOD Lactate-1.1 Brief Hospital Course: The pt was transferred from the ERCP suite to the ICU for close monitoring. A NGT, Foley, amd R CVL was placed. CT abdomen upon admission read the following: Large amount of free air within the peritoneum and in the porta hepatis region. ? duodenal perforation. No extravasation. Large amount of ascites tracking into the pelvis. Diverticulosis without diverticulitis. Bibasilar atelectasis. Clinically, the pt looked well and denied abdominal pain. Pt was hemodynamincally stable w/ O2 sats of 96% on RA. Abdominal exam was significant only for mild distention, NT, no R/G. See admission labs/PE. The pt was administered IVF, kept NPO, and started on Zosyn. HD1, the pt required 1 L bolus for decreasing urine output with a good response. The pt recieved 2 U PRBC and recieved prn hydralazine for hypertension. NGT was DC'd on HD 3 and the pt was kept NPO. On HD4, the pt was overall much improved. She was started on lopressor despite her hx of mild asthma and tolerated it well. Her HR and blood pressure was better controlled and the pt was ultimately DC'd on lopressor. The pt was started on clears and transferred to the floor. The pt tolerated clears without problems and was advanced to a regular diet on HD 6. Upon DC, the pt was passing flatus and voiding on her own. She was passing flatus and having bowel movements. She was afebrile with stable vital signs. Her PE was unremarkable. Please see DC labs. Her WBC was nl and LFT's were steadily trending down. The pt was DC's w/ VNA for umbilical dressing changes (pre admission) and PT on 7 days of PO levofloxacin. Medications on Admission: Albuterol inhaler, fosamax Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: abdominal free air post ERCP; ? post surgical vs perforation Discharge Condition: stable Discharge Instructions: Please call physician if experiencing fevers/chills, severe abdominal pain, nausea/vomiting, chest pain or shortness of breath. Followup Instructions: Please follow up with Dr. [First Name (STitle) ] in 2 weeks; call the office for an appointment. Completed by:[2107-10-26]	[ "998.2", "401.9", "E878.6", "997.4", "569.83", "493.90", "789.5", "272.0" ]	icd9cm	[ [ [] ] ]	[ "99.04", "51.87", "51.85" ]	icd9pcs	[ [ [] ] ]	4942, 5017	2736, 4341	354, 379	5122, 5130	1190, 2713	5306, 5439			4418, 4919		5038, 5101		4367, 4395				5154, 5283									1014, 1171																										275, 316							407, 767																		789, 999
18,357	110,903	53323	Discharge summary	report	Admission Date: [2184-9-12] Discharge Date: [2184-9-16] Date of Birth: [2118-12-6] Sex: F Service: MEDICINE Allergies: Trazodone / Risperdal / Indocin / Flexeril / Gantrisin / Coumadin Attending:[First Name3 (LF) 348] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: 65 yo F with h/o AF, diastolic HF, pulm HTN, chronic pain on narcotics and other medical issues admitted through the ED because of altered mental status and respiratory distress. . Per patient, she awoke this AM with urgency to have bowel movement. Tried to stand and fell because she was weak. She lying on her knees for some time (unclear total time). Pt hit head on ground however did no LOC. Remembered whole event. Called EMS who brought pt to [Hospital1 ]-N. Was given 2mg of narcan for unresponsiveness. Head/Neck CT was apparently completed and was reported negative. She was then transferred to [Hospital1 18] for further evaluation. Utox was negative . Of note, patient was reported had a similar event a few weeks ago which was thought to be been caused by an accidental overdose of oxycodone. . In [Hospital1 18] [Name (NI) ], pt was evaluated however given AMS, pt was admitted to ICU for further work-up. Prior to transfer, pt was given ceftriaxone. In ICU, patient appeared lethargic but answered questions appropriately. Past Medical History: Hypertension Atrial fibrillation Diastolic CHF Interstitial lung disease secondary to asbestosis COPD on chronic O2 on 2L NC Seizure disorder Obstructive sleep apnea Rheumatoid arthritis Osteoarthritis on heavy narcotic use chronically Chronic low back and shoulder pain s/p laminectomy Recurrent urinary tract infection s/p left TKR in [12-2] s/p laminectomy and periumbilical herniorrhaphy [12-3] Social History: The patient lives alone. She had just been discharged from rehab. Has a distant smoking history of 40 to 50 pack years. No alcohol use. Is retired. Limited function due to chronic pain and disability. Family History: Non-Contributory Physical Exam: Admission physical exam: General: Lethargic, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Bibasilar crackles with end expiratory wheezes CV: Bradycardic, irregular rate Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ edema. . Discharge physical exam: Vitals: Tm 99.0 BP 98-110/54-80 HR 65-83 RR 20 92-98% 3L General: Alert, oriented x 3, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: Supple, no LAD Lungs: Mild, diffuse wheeze but moving air CV: Irregularly irregular rhythm Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding. Ext: Warm, well perfused, 2+ radial/pedal pulses. Neuro: Coarse tremor of left hand. Patient reports it is longstanding. Pertinent Results: Admission labs: [2184-9-12] 08:49AM BLOOD WBC-9.3 RBC-3.23* Hgb-9.7* Hct-27.6* MCV-85 MCH-29.9 MCHC-35.1* RDW-14.4 Plt Ct-236 [2184-9-12] 08:49AM BLOOD PT-21.1* PTT-57.6* INR(PT)-1.9* [2184-9-12] 08:49AM BLOOD Glucose-135* UreaN-28* Creat-0.7 Na-125* K-3.1* Cl-84* HCO3-33* AnGap-11 [2184-9-12] 08:49AM BLOOD ALT-7 AST-19 LD(LDH)-196 CK(CPK)-55 AlkPhos-87 TotBili-0.4 [2184-9-12] 08:49AM BLOOD Albumin-3.7 Calcium-8.6 Phos-2.8 Mg-2.4 [2184-9-12] 06:01AM BLOOD Lactate-1.1 [2184-9-12] 05:10AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.005 [2184-9-12] 05:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG CT head FINDINGS: No hemorrhage, large territorial infarction, edema, mass, or shift of normally midline structures is present. There is evidence of mild sequelae of chronic small vessel ischemic disease in bihemispheric subcortical and periventricular white matter. The ventricles and sulci are appropriate size and configuration for age. The basal cisterns are widely patent. The visualized paranasal sinuses are well aerated. No fractures or soft tissue hematomas. IMPRESSION: No acute intracranial process. . EKG: [2184-9-12] Atrial fibrillation with controlled ventricular response. Q-T interval prolongtion. ST-T wave abnormalities. Since the previous tracing of [2184-8-23] the rate is slower and aberrantly conducted beats are no longer seen. . [2184-9-14] CXR: Pulmonary vascular congestion and dilated mediastinal veins are unchanged since [9-12], but severe cardiomegaly has improved and mild pulmonary edema persists. The heterogeneity of opacification in the lungs could obscure discrete pulmonary nodules. It is strongly recommended that conventional radiographs be obtained to make sure that what appear to be discrete opacities are instead asymmetric edema rather than nodules. . [2184-9-16] CXR: Vascular congestion has almost completely resolved. Cardiomegaly is stable. There are no large lung nodules. Opacity in the left mid lung is consistent with fluid in the fissure. There are moderate degenerative changes in the thoracic spine. Of note, the interpretation of this radiograph is limited due to technique and apical lordotic view in the frontal radiograph. . Discharge labs: [2184-9-16] 05:57AM BLOOD WBC-8.6 RBC-3.05* Hgb-9.2* Hct-26.9* MCV-88 MCH-30.2 MCHC-34.3 RDW-14.5 Plt Ct-178 [2184-9-16] 05:57AM BLOOD Glucose-147* UreaN-20 Creat-0.8 Na-132* K-4.4 Cl-91* HCO3-34* AnGap-11 Brief Hospital Course: The patient is a 65-year-old woman with a history of atrial fibrillation, diastolic dysfunction, found down at home and transferred to [Hospital1 18] with hyponatremia and altered, both of which quickly resolved in the MICU. The patient has been transferred to Medicine for likely placement in rehabilitation given her failure after just a few hours at home. . # Altered mental status: The patient's mental status appears to have cleared by the time of her transfer to Medicine from the MICU. The original differential diagnosis included medication-related v. head trauma v. hyponatremia (and dehydration with diarrhea) v. infection. Head trauma ruled out by CT. No sign of infection on imaging and labs. Hyponatremia cleared fairly quickly with normal saline. The patient may also have used too much of her dual nodal agents, which led to bradycardia and poor perfusion. The patient's clonazepam was also stopped. Medication and low sodium, possibly together, the lead suspects for her altered mental status. The patient's mental status has been appropriate during her entire Medicine stay. . # Atrial fibrillation: The patient originally had bradycardia, which may have been related to incorrect medication use of her dual nodal agents. The bradycardia resolved in the MICU. On the medicine floor, she instead became tachycardic. The patient had an episodes of poor rate control, for which she received IV metoprolol and diltiazem. The patient also had two episodes of symptomatic atrial fibrillation (shortness of breath), during which she had adequate blood pressure to uptitrate her nodal blockers. Control of her rate finally occurred with metoprolol 50mg TID and diltiazem 90mg QID. The patient was kept on dabigatran for stroke prevention. . # Leukocytosis: The patient's white blood cell count jumped to 11.6. She was not febrile, but she did sound more rhonchorous on physical exam on [2184-9-14]. The patient's white count resolved on Wednesday, [9-15]. No more rhonchi by [2184-9-16]. Urine culture not suggestive of infection. X-ray not suggestive of consolidation. By discharge, leukocytosis had resolved. . # Possible lung nodules: The radiologist [Location (un) 1131] the patient's chest X-ray, Dr. [Last Name (STitle) ], was concerned for possible lung nodules. Given her vascular congestion, however, possible nodules cannot be seen. Diuresis with furosemide was continued. The patient should have follow up X-ray to examine for nodules, although a final X-ray did not show any nodules. . # Respiratory status/COPD: The patient has a home O2 requirement. The patient reports chronic cough, likely secondary to COPD. No fevers but a leukocytosis developed. Her respiratory status may also be a result of symptomatic atrial fibrillation or pulmonary edema, given chext X-ray with vascular congestion. The patient was saturating well on nasal cannula at 2L by the end of the hospitalization. . # Hyponatremia: Likely related to hypovolemia, especially as hyponatremia resolved after patient received total of 4L NS. Patient has returned to slightly below normal baseline. . # Coronary artery disease: Continue aspirin. Simvastatin does reduced to 10mg, based on FDA guidelines for patients who are simultaneously on diltiazem. . # Acute-on-chronic diastolic CHF: Continued aspirin, furosemide, lisinopril. The patient received one dose of IV furosemide because of vascular congestion seen on exam. By discharge, final X-ray showed clearance of vascular congestion. . # Depression: Continued aripripazole and venlafaxine. Clonazepam was held, given recent AMS, and patient showed no evidence of withdrawal from benzodiazepine. . . TRANSITIONS OF CARE: - The patient will need a follow-up X-ray to determine if she does have lung nodules. - The patient's physician should determine if she needs clonazepam. This medication was stopped in the hospital and not restarted. Medications on Admission: 1. aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 5. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 8. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO once a day. 9. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 10. magnesium oxide 400 mg Tablet Sig: Two (2) Tablet PO twice a day. 11. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 inh Refills:2 12. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 13. furosemide 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO three times a day. 15. methocarbamol 750 mg Tablet Sig: One (1) Tablet PO three times a day. 16. lisinopril 5 mg Tablet Sig: One (1) Tablet PO twice a day. 17. clotrimazole 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) for 1 weeks. Disp:1 60 gram tube Refills:1 18. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for rash for 2 weeks. Disp:1 tube Refills:0 19. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 21. calcium carbonate 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 22. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO twice a day Discharge Medications: 1. aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) inhalation Inhalation once a day. 5. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO once a day. 9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. magnesium oxide 400 mg Tablet Sig: Two (2) Tablet PO twice a day. 11. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 12. furosemide 40 mg Tablet Sig: 1.5 Tablets PO twice a day. 13. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 14. lisinopril 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. dabigatran etexilate 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 16. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: [11-30] Tablet, Chewables PO QID (4 times a day) as needed for indigestion. 17. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. diltiazem HCl 360 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 ] Village - [Location 4288] Discharge Diagnosis: Altered mental status Hyponatremia Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [Known lastname 6330], It was a pleasure participating in your care at [Hospital1 771]. . You were admitted to the hospital because you had fallen and were not responsive. You briefly spent time in the Intensive Care Unit, where you were found to have low sodium, which was quickly fixed. Your confusion also cleared. On the medicine floor, your heart rhythm, which is called atrial fibrillation, was not controlled. We changed your medications to control that rate and to prevent you from having symptoms, such as feeling tired or short of breath. You will go to a rehabilitation facility to strengthen you before you return back home. They can also montior your medication, to make sure you do not take too many medications that can make you sleepy or confused. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. . We changed the doasges of these medications to help control your heart rate: START metoprolol 50mg three times per day. START diltiazem ER 360mg daily. . We changed the dosage of your cholesterol medication because it can interact badly with the diltiazem: START simvastatin 10mg daily. . We stopped your clonazepam because you arrived to the hospital confused, and this medication can add to confusion. STOP clonazepam. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [2184-10-5] at 10:00 AM With: [Name6 (MD) ] [Name8 (MD) 10828], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "338.29", "427.31", "428.0", "V58.69", "799.02", "793.11", "311", "794.31", "780.97", "428.33", "276.1", "416.8", "327.23", "496", "427.89", "780.96", "714.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13137, 13210	5649, 6024	347, 353	13309, 13309	3077, 3077	14807, 15100	2100, 2118		11567, 13114		13231, 13288		9584, 11544				13492, 14784			5411, 5626						2158, 2560																										286, 309							381, 1436							3093, 5395				13324, 13468		9340, 9558					1458, 1866	1882, 2084				2585, 3058
32,262	131,726	34450	Discharge summary	report	Admission Date: [2115-7-23] Discharge Date: [2115-7-27] Date of Birth: [2054-8-16] Sex: M Service: CARDIOTHORACIC Allergies: Tylenol/Codeine No.3 Attending:[First Name3 (LF) 1267] Chief Complaint: DOE/Fatigue Major Surgical or Invasive Procedure: [2115-7-23] - CABGx3 (left internal mammary->Left anterior descending artery, Saphenous vein graft(SVG)->Ramus, SVG->Posterior descending artery.) History of Present Illness: The patient is 61-year-old man with severe peripheral vascular disease status post above knee amputation who presents with severe vessel disease but preserved left ventricular function. The risks and the benefits of the procedure were explained to the patient and he wishes to proceed. Past Medical History: CAD s/p CABGx3 Hyperlipidemia PVD s/p revascularization x6 of right leg Claudication Right AKA Right arm surgery GERD Depression Hernia repair Prior ETOH abuse Social History: Married with 6 children. Currently unemployed. denies alcohol use. Active smoker for past 40 years. 1/2-1ppd. Family History: Mother and father both died from cardiovascular diseasein their 50's. Siblings with PVD and CVD. Physical Exam: Ht: 5 feet 6 inches Wt: 164 lbs GEN: NAD HEENT: NCAT, PERRL, Sclera anicteric, OP benign NECK: Supple with FROM HEART:RRR without R/G/M LUNGS:Clear to A+P ABDOMEN:Soft, nontender, +BS EXT:without C/C/E, pulses 2+= throughout bilat. NEURO:nonfocal Pertinent Results: [2115-7-23] ECHO PRE-BYPASS: 1. The left atrium and right atrium are normal in cavity size. 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. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. There is mild regional left ventricular systolic dysfunction with anterior apical hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The remaining left ventricular segments contract normally. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. 1. LVEF is preserved. 2. Aortic contours appear intact post decannulation. 3. Other findings are unchanged [2115-7-26] 06:30AM BLOOD WBC-13.9* RBC-3.30* Hgb-10.0* Hct-29.3* MCV-89 MCH-30.3 MCHC-34.2 RDW-14.3 Plt Ct-290 [2115-7-23] 12:19PM BLOOD PT-13.5* PTT-42.0* INR(PT)-1.2* [2115-7-26] 06:30AM BLOOD Glucose-106* UreaN-18 Creat-0.9 Na-138 K-4.7 Cl-100 HCO3-31 AnGap-12 [Known lastname ],[Known firstname ] J [Medical Record Number 79182] M 60 [2054-8-16] Radiology Report CHEST (PORTABLE AP) Study Date of [2115-7-25] 10:04 AM [Last Name (LF) ],[First Name7 (NamePattern1) 1112] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] FA6A [2115-7-25] SCHED CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 79183] Reason: Pleural effusion, pneumothorax. [Hospital 93] MEDICAL CONDITION: 60 year old man s/p CABG and CT removal REASON FOR THIS EXAMINATION: Pleural effusion, pneumothorax. Provisional Findings Impression: [First Name9 (NamePattern2) 79184] [Doctor First Name ] [2115-7-25] 2:51 PM Slightly increased basal atelectasis. Persistent left small pleural effusion. Low lung volumes. Final Report (Revised) FRONTAL CHEST RADIOGRAPH: INDICATION: 60-year-old man post-CABG, chest tube removal. COMPARISON: [2115-7-23]. FINDINGS: The patient is post-cardiac surgery. The endotracheal tube, Swan- Ganz catheter, chest tube, nasogastric tube, mediastinal drains have been removed in the interval. The lung volumes are slightly low. There is bibasal atelectasis and small left pleural effusion. Left retrocardiac density is probably due to atelectasis. Pulmonary vascularity is not increased. There is tiny left apical pneumothorx. The upper abdominal loops of bowel are distended with gas, and may correspond to a postoperative ileus. IMPRESSION: Possible left apical pneumothorax. Low lung volumes, bibasal atelectasis, and small left pleural effusion. 2) Interval removal of support devices. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Name (STitle) ] DR. [First Name8 (NamePattern2) 1569] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11006] Approved: [Doctor First Name ] [2115-7-25] 5:36 PM Brief Hospital Course: Mr. [Known lastname 1968] was admitted to the [Hospital1 18] on [2115-7-23] for surgical management of his coronary artery disease. He was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Within 24 hours, he awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. Later on postoperative day one he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. His chest tubes were d/c'd on POD 2 and his epicardial pacing wires were d/c'd on POD 3. He continued to progress and was discharged to home in stable condition on POD 4. All necessary appointments for follow up were discussed with Mr.[Known lastname 1968] prior to discharge. Medications on Admission: Simvastatin 80mg one tablet a day every morning Atenolol 50mg daily every morning Salsalate 750 one tablet twice a day Omeprazole 20mg one tablet twice a day Aspirin 325mg daily every morning Oxycodone 20mg 1-2 tablets a day as needed Percocet 5-325mg 1-2 tablets as needed for right leg phantom pain Gabapentin 600mg, one three times a day Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:180 Capsule(s) Refills:2 7. Chantix 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:10 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:20 Tab Sust.Rel. Particle/Crystal(s) Refills:0 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): x 1 month. Disp:30 Tablet(s) Refills:2 12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: .community health and hospice Discharge Diagnosis: CAD s/p CABGx3 Hyperlipidemia PVD s/p revascularization x6 of right leg Claudication Right AKA Right arm surgery GERD Depression Hernia repair Prior ETOH abuse Discharge Condition: Stable 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) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 1 month. ([Telephone/Fax (1) 78538] Please follow-up Paicopolous in 2 weeks. Please follow-up with Dr. [Last Name (STitle) 665] in [12-23] weeks. [Telephone/Fax (1) 250] Completed by:[2115-7-27]	[ "311", "496", "511.9", "414.01", "272.4", "443.9", "440.21", "530.81", "560.1", "305.1", "518.0" ]	icd9cm	[ [ [] ] ]	[ "36.15", "36.12", "39.61", "88.72" ]	icd9pcs	[ [ [] ] ]	7957, 8018	5055, 6068	299, 452	8222, 8231	1475, 3554	8974, 9246	1094, 1192		6460, 7934	3594, 3634	8039, 8201		6094, 6437				8255, 8951									1207, 1456																										248, 261	3666, 5032						480, 768																		790, 951	967, 1078
13,969	118,885	30550+57702	Discharge summary	report+addendum	Admission Date: [2143-3-31] Discharge Date: [2143-4-11] Date of Birth: [2077-6-8] Sex: M Service: VSU CHIEF COMPLAINT: Chronic nonhealing left first great toe ulceration for the last 7 weeks. Patient developed C diff while taking antibiotics and has been treated for his C difficile for the last 3 weeks. Patient now is admitted for vascular evaluation in consideration for lower extremity revascularization. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Include prednisone 48 mg daily, Celexa 28 mg daily, Coreg 25 mg daily, multivitamin tablet 1 daily, iron daily, B complex daily, Actos 45 mg daily, enteric coated aspirin 81 mg daily, Prilosec 20 mg daily, Zocor 40 mg daily, Avapro [Age over 90 ] m,g daily, hydrochlorothiazide 25 mg daily, vancomycin 500 mg q.i.d. for 3 weeks. His insulin is 50/50 55 units q a.m., 40 units at dinner and at lunch, Floriform 25 mg b.i.d. PAST MEDICAL HISTORY: Illnesses include temporal arthritis, prednisone dependent, history of depression, history of hypertension. History of type 2 diabetes x22 years, insulin- dependent with neuropathy. History of gastroesophageal reflux disease. History of hyperlipidemia on a statin. History of benign prostatic hypertrophy. History of chronic obstructive pulmonary disease. PAST SURGICAL HISTORY: Includes cystoscopy with bladder stone removal. Bilateral knee replacements, status post transurethral resection of the prostate. SOCIAL HISTORY: The patient is a former smoke, has not smoked for 17 years. Previously had greater than a 70-pack- year history of smoking. Patient denies alcohol or drug use. Patient lives with his spouse. PHYSICAL EXAMINATION: Vital signs: 97, 8, 84, 22, blood pressure 108/64, oxygen saturation 97% on room air. Fingerstick glucose on admission was 428. Patient weighs 247 pounds. General appearance: A gentleman in no acute distress. Heart is regular rate and rhythm. Normal S1 nd S2. Lungs are clear to auscultation bilaterally. Abdominal examination was soft, nontender, nondistended, obese. The left first toe is open ulcer with tissue loss distal to the nail. Pulse examination shows femoral pulses are palpable bilaterally. The popliteals are nonpalpable bilaterally. The right PT is [Name (NI) ]. The right DP and the left DP and PT are non- [Name (NI) ] signals. HOSPITAL COURSE: The patient was admitted to the vascular service. He was prehydrated for diagnostic arteriogram. He was begun on antibiotics for his toe ulceration. An x-ray of the left foot was obtained to rule out osteomyelitis. The initial culture grew staph coag positive of moderate growth, beta streptococcal group B, moderate growth, gram negative rods, rare of pre-colony morphology. The staph coag positive was sensitive to gentamicin, levofloxacin, oxacillin, resistant to penicillin. Sensitive to Bactrim. There were no anaerobe cultures growth. The patient's foot films showed extensive small artery calcification throughout the foot. There was mild subluxation and degeneration changes of both the first metatarsophalangeal and interphalangeal joint but no bone destruction to suggest osteomyelitis. The lateral view, however, shows an erosion that centers at the anterior inferior articulating surface of the calcaneus of his mid foot which is suggestive of osteoarticular infection. Two overhead views show rare fraction of bone at the bases of the third and fourth metatarsals. CT scanning is recommended for any further evaluation of the foot. The patient was continued on antibiotics considering the cultures and the link that is there for antibiotics these were discontinued. The patient underwent a diagnostic arteriogram on [2143-4-1] by Dr. [Last Name (STitle) ]. Patient tolerated the procedure well. There was a questionable small hematoma in the right groin. The pulse examination remained unchanged. The patient was prepared for surgery. The patient's urine was dirty and ciprofloxacin was instituted along with Vancomycin and Flagyl. The patient had vein mapping obtained to assess for conduit for surgery. The angiography demonstrated patent inflow. Left superficial femoral artery was diseased with a patent anterior tibial with proximal and distal disease and a patent dorsalis pedis. Patient underwent on [2143-4-3] a left femoral DP bypass with in situ saphenous vein graft. The patient tolerated the procedure well, was extubated in the operating room and was transferred to the post anesthesia care unit for continued care. Patient did return because of a hematoma development which required evacuation under anesthesia in which there was an avulsion on the vein graft tie and this was repaired and bleeding was controlled. The patient was transfused 2 units of packed cells. The patient's graft was palpable at the end of the hematoma evacuation. Patient was then transferred to the post anesthesia care unit for continued monitoring and care. Patient's hematocrit was 24.5. He was transfused. He continued to do well from a hemodynamic standpoint. Because the patient remained intubated after undergoing the hematoma evacuation he was transferred to the Surgical Intensive Care Unit for continued postoperative care. His post transfusion hematocrit was 27.7. BUN 16, creatinine 0.7. The patient's respiratory wean was initiated to extubate. The patient's Swan was discontinued. His [First Name8 (NamePattern2) 1661] [Last Name (NamePattern1) 1662] drain in the hematoma area remained in place. Total [First Name8 (NamePattern2) 1661] [Last Name (NamePattern1) 1662] drainage for the first 24 hours was 80 cc. Patient's graft was palpable. Patient had persistent hypotension. He was given IV steroids for adrenal insufficiency with improvement in his hemodynamic status and he was able to be extubated. Antibiotics were discontinued. Postoperative day 2 there were no overnight events. Patient was transfused a unit of packed cells on [2143-4-6]. Patient's Lopressor was increased secondary to poor heart rate control and systolic blood pressure control. Patient was transferred to the VICU for continued monitoring and care. Postoperative day 3 he did require Lasix x2. He was put back on his oral steroids. Blood pressures were under better control. Aggressive pulmonary toiletry was begun. His right internal jugular was discontinued on postoperative day 5 for temperature elevation of 101.8. The blood cultures were no growth. Urine cultures were negative. The Foley was discontinued. [Initials (NamePattern4) ] [Last Name (NamePattern4) 1661] [Last Name (NamePattern1) 1662] drain remained in place. Postoperative day 6 repeat urine culture was done and the patient was started on ciprofloxacin, that was [2143-4-8]. Ambulation was begun and diuresis was continued. The patient had [Year (4 digits) ] pedal pulses bilaterally. The remaining hospital course was unremarkable. The patient will be assessed by physical therapy in determination whether he will require rehabilitation screening. Case management was consulted for discharge planning. Patient will be discharged when medically stable and bed available. DISCHARGE DIAGNOSES: 1. Arterial insufficiency with nonhealing left first toe ulceration x7 months. 2. History of temporal arthritis, prednisone dependent. 3. History of depression, stable. 4. History of hypertension uncontrolled. 5. History of diabetes type 2, insulin dependent, stable. 6. History of hyperlipidemia on a statin. 7. History of bladder stones, status post cystoscopy. 8. History of arthritis, status post bilateral knee replacement. 9. History of benign prostatic hypertrophy, status post transurethral resection of the prostate. 10. History of chronic obstructive pulmonary disease. 11. Postoperative blood loss anemia, transfused. 12. Postoperative renal insufficiency, treated. DISCHARGE INSTRUCTIONS: Patient should ambulate essential distances and progress as tolerated. He may shower but no tub baths. He should keep the leg elevated when ambulating. An Ace wrap should be applied from foot to knee on the operative site and legs should be kept elevated when sitting in a chair. Patient should continue all medications as directed. He should follow up with Dr. [Last Name (STitle) 1391] in 2 weeks time for an appointment at [Telephone/Fax (1) 1393]. DISCHARGE MEDICATIONS: Ditropan 20 mg daily, aspirin 81 mg daily, tiotropium bromide 18 mcg capsule with inhalant device daily, simvastatin 40 mg daily, Protonix 40 mg daily, prednisone 45 mg daily, metoprolol tartrate 50 mg b.i.d., ciprofloxacin 500 mg q 12 hours, miconazole nitrate powder to topical areas p.r.n., hydromorphone 2 mg tablets 1 to 2 hours p.r.n. for pain, insulin is NPH/regular insulin 70/30. She gets 27 units at breakfast, 20 units at dinner and lunch. Will also get regular insulin U100 prior to meals - breakfast 27 units, lunch and dinner 20 units, along with an insulin regular Humulin scale. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2143-4-9] 12:04:04 T: [2143-4-9] 13:28:33 Job#: [Job Number 72538] Name: [Known lastname 12086],[Known firstname ] D Unit No: [Numeric Identifier 12087] Admission Date: [2143-3-31] Discharge Date: [2143-4-11] Date of Birth: [2077-6-8] Sex: M Service: SURGERY Allergies: Morphine Attending:[First Name3 (LF) 231] Addendum: [2143-4-10] discharge delayed secondary to onset of c. diff by stool culture.Patient began on flagyl. Bed search continues, since patient will require private room. [2143-4-11] Private room availbe patient transfered to rehab for continued care. Stable Discharge Disposition: Extended Care Facility: [Hospital6 5025] & Rehab Center - [Location (un) ] [First Name11 (Name Pattern1) 77] [Last Name (NamePattern1) 237] MD [MD Number(1) 238] Completed by:[2143-4-11]	[ "707.15", "996.74", "518.0", "446.5", "008.45", "458.29", "V58.65", "112.2", "997.3", "E878.2", "V43.65", "998.11", "041.11", "285.1", "272.4", "496", "V15.82", "311", "250.60", "401.9", "V58.67", "440.24", "997.1", "530.81", "427.89", "255.4", "041.02", "998.12" ]	icd9cm	[ [ [] ] ]	[ "39.32", "99.23", "88.48", "83.09", "99.04", "39.29", "89.64", "88.42", "88.47" ]	icd9pcs	[ [ [] ] ]	9888, 10130							7189, 7888	8398, 9865				509, 937	2376, 7168			7913, 8374								1341, 1472																1704, 2358											153, 482																									960, 1317	1489, 1681
32,692	103,978	51945	Discharge summary	report	Admission Date: [2136-8-14] Discharge Date: [2136-9-16] Date of Birth: [2058-10-11] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Cognitive decline Major Surgical or Invasive Procedure: bifrontal craniotomy peg placement tracheostomy History of Present Illness: The patient is a 73-year-old female who recently presented to my outpatient clinic. She had been followed for decreasing cognitive decline. The patient was worked up including imaging. A bifrontal large olfactory groove meningioma measuring 7 x 6 cm was found. The patient was extensively counseled. Given the family history and the large extent of the lesion, the decision was made by the brain tumor conference to resect the lesion for a better prognosis. The patient was extensively counseled. The patient was consented. The patient was taken electively to the OR. Preoperative films had been obtained. The patient was taken to the operating room on [2136-8-16]. Past Medical History: 1. macular degeneration 2. HTN 3. Hypercholesterolemia 4. meningioma Social History: Retired dental hygienist. She is married. She lives with her spouse and her daughter. She does not smoke, She drinks wine with dinner. Denies any recreational drugs. Family History: Mother died at age [Age over 90 ] of old age. Father died at age [Age over 90 ] with heart disease. Her sister is 71 in good health. She has two children both in good health. Physical Exam: Exam [2136-9-16]: Patient opens eyes to voice. She does not speak but attempts to stick out her tongue to command. PERRL. 3-2 mm bilaterally. The left one is larger initially but when rechecked is equal to the left. Motor: Moves left arm spontaneously and squeezes to command. Moves right arm with noxious stimuli. Withdraws both legs to noxious stimuli. Toes upgoing bilaterally. Her incision has healed well. Pertinent Results: RADIOLOGY Final Report [Numeric Identifier 82379] EXT CAROTID BILAT [2136-8-14] 7:55 AM Reason: angio w/embolization for bifrontal planum sphenoidale mening Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 77 year old woman with bifrontal planum sphenoidale meningioma. REASON FOR THIS EXAMINATION: angio w/embolization for bifrontal planum sphenoidale meningioma. TYPE OF STUDY: Cerebral angiogram. CLINICAL HISTORY: A 77-year-old female with bifrontal planum sphenoidale meningioma presents for evaluation with angiogram with possible embolization. Comparison is made with CT angiogram of the head performed [2136-7-3] and MRI of the brain performed [2136-7-2]. TECHNIQUE: Informed consent was obtained from the patient and the patient's family after explaining the risks, indications, and alternative management. Risks explained included bleeding, hemorrhage, stroke, loss of vision and/or speech, injury to blood vessels and/or nerves, allergic reaction to contrast material, renal failure, and death. Additionally possible use of embolization coils if needed was discussed. The patient was brought to the interventional neuroradiology suite and placed on the biplane table in the supine position. Prior to the start of the procedure, a timeout was performed to verify the patient's identity using two patient identifiers and the procedure to be performed. Both groins were prepped and draped in the usual sterile fashion. General anesthesia was provided by the anesthesiology service. Access to the right common femoral artery was obtained using a 19-gauge single-wall needle, under local anesthesia using 1% lidocaine mixed with sodium bicarbonate with aseptic precautions. Through the needle, a 0.35 [Last Name (un) 7648] wire was introduced and the needle was taken out. Over the wire, a 5-French vascular sheath was placed and connected to a saline infusion (mixed with heparin 500 units and 500 cc of saline) with a continuous drip. Through the sheath, a 4 French Berenstein catheter was introduced and connected to the continuous saline infusion (with heparin mixture: 1000 units of heparin and 1000 cc saline). The following vessels were selectively catheterized and arteriograms were performed from these locations. After review of the study, the catheter and the sheath were withdrawn and pressure was applied on the groin until hemostasis was achieved. The procedure was uneventful and the patient tolerated the procedure well without immediate post-procedure related complications. The patient was sent to the floor with post-procedure orders. The following blood vessels were selectively catheterized and arteriograms were obtained in the AP and lateral projections: 1. Right external carotid artery. 2. Right internal carotid artery. 3. Right common carotid artery. 4. Left external carotid artery. 5. Left internal carotid artery. 6. Left common carotid artery. FINDINGS: Evaluation of the above blood vessels demonstrates no evidence of aneurysm or vascular malformation. Upon injection of the right internal carotid artery there is a large hypervascular mass with a large tumoral blush identified in the bifrontal region which is largely supplied by the right anterior ethmoidal and right ophthalmic arteries. Additionally, upon injection of the left internal carotid artery, there is identification of this large hypervascular mass to be supplied by a branch arising from the left paricallosal branch on the anterior cerebral artery. Additionally, upon injection of the bilateral external carotid arteries there is minimal tumor-related blush seen to supply from branches of the bilateral middle meningeal arteries. Also, additionally upon injection of the left external carotid artery there is a hypervascular mass with a prominent tumor-related blush seen overlying the left frontal lobe. This hypervascular mass appears to be largely supplied by branches from the left middle meningeal artery. IMPRESSION: 1. Large bifrontal hypervascular mass is consistent with meningioma as reported on prior cross-sectional images which is larger beings supplied by the right anterior ethmoidal and ophthalmic arteries and a left branch arising from the left callosal artery. 2. Large hypervascular mass overlying the left frontal lobe consistent with a meningioma as correlated with prior cross-sectional images largely being supplied by branches from the left middle meningeal artery. These findings were discussed with Dr. [Last Name (STitle) ] at the time of the examination. Dr. [Last Name (STitle) ], attending interventional neuroradiologist, was present and performed the procedure. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 815] DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Approved: TUE [2136-8-21] 3:13 PM RADIOLOGY Final Report [Numeric Identifier 7649] CAROTID/CERVICAL BILAT [2136-8-14] 7:55 AM Reason: angio w/embolization for bifrontal planum sphenoidale mening Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 77 year old woman with bifrontal planum sphenoidale meningioma. REASON FOR THIS EXAMINATION: angio w/embolization for bifrontal planum sphenoidale meningioma. TYPE OF STUDY: Cerebral angiogram. CLINICAL HISTORY: A 77-year-old female with bifrontal planum sphenoidale meningioma presents for evaluation with angiogram with possible embolization. Comparison is made with CT angiogram of the head performed [2136-7-3] and MRI of the brain performed [2136-7-2]. TECHNIQUE: Informed consent was obtained from the patient and the patient's family after explaining the risks, indications, and alternative management. Risks explained included bleeding, hemorrhage, stroke, loss of vision and/or speech, injury to blood vessels and/or nerves, allergic reaction to contrast material, renal failure, and death. Additionally possible use of embolization coils if needed was discussed. The patient was brought to the interventional neuroradiology suite and placed on the biplane table in the supine position. Prior to the start of the procedure, a timeout was performed to verify the patient's identity using two patient identifiers and the procedure to be performed. Both groins were prepped and draped in the usual sterile fashion. General anesthesia was provided by the anesthesiology service. Access to the right common femoral artery was obtained using a 19-gauge single-wall needle, under local anesthesia using 1% lidocaine mixed with sodium bicarbonate with aseptic precautions. Through the needle, a 0.35 [Last Name (un) 7648] wire was introduced and the needle was taken out. Over the wire, a 5-French vascular sheath was placed and connected to a saline infusion (mixed with heparin 500 units and 500 cc of saline) with a continuous drip. Through the sheath, a 4 French Berenstein catheter was introduced and connected to the continuous saline infusion (with heparin mixture: 1000 units of heparin and 1000 cc saline). The following vessels were selectively catheterized and arteriograms were performed from these locations. After review of the study, the catheter and the sheath were withdrawn and pressure was applied on the groin until hemostasis was achieved. The procedure was uneventful and the patient tolerated the procedure well without immediate post-procedure related complications. The patient was sent to the floor with post-procedure orders. The following blood vessels were selectively catheterized and arteriograms were obtained in the AP and lateral projections: 1. Right external carotid artery. 2. Right internal carotid artery. 3. Right common carotid artery. 4. Left external carotid artery. 5. Left internal carotid artery. 6. Left common carotid artery. FINDINGS: Evaluation of the above blood vessels demonstrates no evidence of aneurysm or vascular malformation. Upon injection of the right internal carotid artery there is a large hypervascular mass with a large tumoral blush identified in the bifrontal region which is largely supplied by the right anterior ethmoidal and right ophthalmic arteries. Additionally, upon injection of the left internal carotid artery, there is identification of this large hypervascular mass to be supplied by a branch arising from the left paricallosal branch on the anterior cerebral artery. Additionally, upon injection of the bilateral external carotid arteries there is minimal tumor-related blush seen to supply from branches of the bilateral middle meningeal arteries. Also, additionally upon injection of the left external carotid artery there is a hypervascular mass with a prominent tumor-related blush seen overlying the left frontal lobe. This hypervascular mass appears to be largely supplied by branches from the left middle meningeal artery. IMPRESSION: 1. Large bifrontal hypervascular mass is consistent with meningioma as reported on prior cross-sectional images which is larger beings supplied by the right anterior ethmoidal and ophthalmic arteries and a left branch arising from the left callosal artery. 2. Large hypervascular mass overlying the left frontal lobe consistent with a meningioma as correlated with prior cross-sectional images largely being supplied by branches from the left middle meningeal artery. These findings were discussed with Dr. [Last Name (STitle) ] at the time of the examination. Dr. [Last Name (STitle) ], attending interventional neuroradiologist, was present and performed the procedure. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 815] DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Approved: TUE [2136-8-21] 3:13 PM RADIOLOGY Final Report MR HEAD W/ CONTRAST [2136-8-15] 5:23 AM MR HEAD W/ CONTRAST Reason: Please do at 6 am for pre-op Contrast: MAGNEVIST [Hospital 93] MEDICAL CONDITION: 77 year old woman with bifrontal meningioma who will have surgery [8-15] REASON FOR THIS EXAMINATION: Please do at 6 am for pre-op CONTRAINDICATIONS for IV CONTRAST: None. MRI HEAD HISTORY: 77-year-old woman with meningiomas, here for pre-op evaluation. TECHNIQUE: Triplanar post-gado T1-weighted images of the head as well as post-gado MP-RAGE of the head were obtained with fiduciary markers in place. FINDINGS: Comparison is made to a prior head MR from [2136-7-2] as well as a CTA from [2136-7-3] and a cerebral angiogram from [2136-8-14]. Again seen is a large extra-axial enhancing mass consistent with a planum sphenoidale meningioma which is compressing and distorting the frontal lobes bilaterally. There is surrounding vasogenic edema of the frontal lobes extending into the right side of the corpus callosum with marked compression of the frontal horns of the lateral ventricles. There is also a approximately 3.4 x 2.8 cm extra-axial mass with underlying hyperostosis overlying the left frontal parietal lobe consistent with a second meningioma. This meningioma shows new internal necrosis which is new compared to the prior study. No new lesions are identified. IMPRESSION: Two large meningiomas as described above with a smaller meningioma over the left frontoparietal lobe showing some internal necrosis which is new. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: [Doctor First Name ] [2136-8-16] 8:53 AM RADIOLOGY Final Report CT HEAD W/O CONTRAST [2136-8-15] 9:01 PM CT HEAD W/O CONTRAST Reason: Follow up blood products [Hospital 93] MEDICAL CONDITION: 77 year old woman with meningioma resection REASON FOR THIS EXAMINATION: Follow up blood products CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Status post meningioma resection. COMPARISON: [2136-7-3]. TECHNIQUE: Non-contrast head CT scan. FINDINGS: Patient is status post resection of previously seen large bifrontal extra-axial mass. Large amount of expected post-surgical pneumocephalus seen in the bifrontal region. Heterogeneous appearance in the resection bed is seen, with high-density material consistent with acute blood in the resection bed. Scattered foci of gas also seen in the resection bed. Hypodensity again seen in this region consistent with edema. Configuration of the ventricles appears relatively unchanged. No new hydrocephalus. Second calcified extra-axial mass along the lateral aspect of the left frontal lobe appears unchanged from prior. High-density material now also seen within the nasopharynx. Bone windows demonstrate frontal craniotomy defects and post-surgical hardware. Subcutaneous emphysema noted with multiple staples in the frontal scalp. Minimal mucosal thickening seen within the ethmoid, maxillary and sphenoid sinuses. IMPRESSION: 1. Status post resection of previously seen large bifrontal extra-axial mass, with expected pneumocephalus. Heterogeneous appearance of the resection bed, with multiple pockets of gas and high density material consistent with blood in the resection bed. 2. Unchanged appearance of calcified left meningioma. 3. High-density material is seen within the nasopharynx consistent with blood. Clinical correlation recommended. Findings were discussed with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at 10:45 p.m., [2136-8-15]. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 7415] Approved: [Doctor First Name ] [2136-8-16] 10:18 AM RADIOLOGY Final Report PORTABLE ABDOMEN [2136-8-25] 12:07 PM PORTABLE ABDOMEN Reason: eval for dilated loops [Hospital 93] MEDICAL CONDITION: 77 year old woman s/p craniotomy s/p dobhoff pneumonia, now w/ b/l rhonci, distended abdomen REASON FOR THIS EXAMINATION: eval for dilated loops HISTORY: Abdominal distention. Single supine radiograph of the abdomen demonstrates air and stool projecting over a normal caliber rectum. Small amount of air and stool are seen along the descending colon as well. Multiple loops of normal caliber air-distended small bowel are seen to collect in the middle of the abdomen. There is a featureless collection of air within a viscus projecting over the epigastrium. Given the presence of the patient's Dobbhoff tube on chest radiographs both prior and subsequent to this study the finding does not represent the stomach. IMPRESSION: Nonspecific bowel gas pattern. A single collection of air within a viscus projecting over the upper mid abdomen is unlikely to represent the stomach. Close clinical followup is requested. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 6892] Approved: SAT [2136-9-1] 12:24 AM RADIOLOGY Final Report CT HEAD W/O CONTRAST [2136-8-25] 7:43 AM CT HEAD W/O CONTRAST Reason: assess for herniation, progression of lesion [Hospital 93] MEDICAL CONDITION: 77 year old woman with large meningioma, now more somnolent, with dilated left pupil REASON FOR THIS EXAMINATION: assess for herniation, progression of lesion CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 77-year-old female with large meningioma with dilated left pupil, assess for herniation. COMPARISON: [2136-8-20]. TECHNIQUE: Non-contrast head CT scan. FINDINGS: Again seen is a large calcified left frontal parietal mass previously described as a meningioma. Hyperdensity at the anterior medial aspects is consistent with hemorrhage and is unchanged. Vasogenic edema has increased resulting in increased rightward subfalcine herniation, now 6 mm and compression of the left lateral ventricle. Suprasellar cistern is effaced and there is mild compression on the brainstem indicating transtentorial herniation. Fourth ventricle is largely similar in appearance. Patient is status post bifrontal craniotomy with small amount of expected pneumocephalus and extraaxial fluid, which represents hemorrhage. Evolving intraparenchymal hemorrhage with associated edema and local sulcal effacement is seen in the bifrontal lobes anteriorly. IMPRESSION: 1. Increased mass effect from vasogenic edema and hemorrhage surrounding calcified left frontal parietal meningioma has resulted in an increased rightward subfalcine herniation and compression on the left lateral ventricle and near complete effacement of the suprasellar cistern resulting in new transtentorial herniation. There may be mild compression of the brainstem. These findings were discussed with Dr. [Last Name (STitle) 877] on [2136-8-25], at 9:35 a.m. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Doctor Last Name ] DR. [First Name (STitle) 3905] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3906] Approved: SAT [2136-8-25] 12:16 PM Neurophysiology Report EEG Study Date of [2136-9-1] OBJECT: HX OF MENINGIOMA WITH ALTERED MENTAL STATUS. EVALUATE FOR SEIZURES. REFERRING DOCTOR: DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] FINDINGS: ABNORMALITY #1: Throughout the recording there is persistent mixed frequency theta and delta frequency slowing seen over the right frontal and central regions. ABNORMALITY #2: There is some voltage asymmetry between the two hemispheres with decreased voltage noted over the left anterior quadrant. ABNORMALITY #3: Throughout the recording the background rhythm is slow typically in the 6 Hz frequency range slightly disorganized and poorly reactive. ABNORMALITY #4: Intermixed with the already slow and disorganized background are brief intermittent bursts of moderate amplitude mixed frequency slowing. 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: There were no clear transitions or change in state noted. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 78 bpm. IMPRESSION: This is an abnormal portable EEG due to persistent focal slowing in the right fronto-central region suggestive of an area of underlying subcortical dysfunction. In addition, there was a voltage asymmetry of decreased amplitudes noted over the left anterior quadrant suggestive of a structural or destructive process in that region. The background rhythm was also slow, disorganized, and poorly reactive with admixed bursts of generalized mixed frequency slowing suggestive of a mild global diffuse encephalopathy. This suggests ongoing bilateral subcortical or deeper midline dysfunction. Medications, metabolic disturbances, infection, and anoxia are among the most common causes of encephalopathy but there are others. There were no clearly epileptiform discharges and no electrographic seizures were seen. INTERPRETED BY: [Last Name (LF) ],[First Name3 (LF) ] L. ([5-/3059]B) RADIOLOGY Final Report CT HEAD W/O CONTRAST [2136-9-5] 12:37 PM CT HEAD W/O CONTRAST Reason: eval interval change [Hospital 93] MEDICAL CONDITION: 77F with large bifrontal meningioma, now s/p bifrontal crani, partial resection of tumor; returned to ICU for s/s of herniation, ameliorated w/ mannitol and decadron, persistent hyponatremia s/p tx w/ hypertonic saline REASON FOR THIS EXAMINATION: eval interval change CONTRAINDICATIONS for IV CONTRAST: None. CT SCAN OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST HISTORY: Large bifrontal meningioma. Status post bifrontal craniotomy and partial resection of tumor, returned into the ICU for signs and symptoms herniation ameliorated with mannitol and Decadron. Persistent hyponatremia, status post treatment with hypertonic saline. Evaluate for interval change. TECHNIQUE: Non-contrast head CT scan. COMPARISON STUDY: [2136-8-30] non-contrast head CT scan interpreted by Dr. [Last Name (STitle) ] as revealing "evolution of blood products in the left frontal lobe adjacent to the meningioma. The edema and midline shift associated with this lesion are unchanged." FINDINGS: The large heavily calcified lesion within the left frontal region as well as the marked surrounding edema unaltered in extent. There is little change in the mass effect exerted upon the frontal [Doctor Last Name 534] and body of the left lateral ventricle. There is approximately 5 mm rightward subfalcine herniation seen. The subfrontal lesion, as before, is quite difficult to discern, but there does appear to be residual edema, which persists after the extensive resection. A small bifrontal extraaxial fluid filled compartment, which appears contiguous to and subjacent to the large frontal craniotomy flap appears unaltered in size. No other new extracranial abnormalities are discerned. CONCLUSION: Relatively little change in the appearance of the postoperative CT scan, as noted above. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9987] Approved: WED [2136-9-5] 3:17 PM RADIOLOGY Final Report CHEST (PORTABLE AP) [2136-9-5] 5:31 AM CHEST (PORTABLE AP) Reason: Fever, question PNA [Hospital 93] MEDICAL CONDITION: 77 year old woman s/p craniotomy s/p dobhoff HIT+, awaiting trach and PEG REASON FOR THIS EXAMINATION: Fever, question PNA INDICATION: 77-year-old woman status post craniotomy status post Dobbhoff; fever; evaluate for pneumonia. COMPARISONS: Chest radiograph dated [2136-8-30]. FINDINGS: A single AP portable upright view of the chest was obtained. An endotracheal tube terminates 4 cm above the carina. The nasogastric tube terminates in the pyloric region. A left internal jugular catheter terminates at the confluence of the brachiocephalic veins, as before. There is increased left basilar opacity, without pneumothorax or pulmonary vascular congestion. The cardiac silhouette is stable. IMPRESSION: 1. Increased left basilar opacity, compatible with a pleural effusion and adjacent atelectasis or pneumonia. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 7805] [Name (STitle) ] DR. [First Name (STitle) 3901] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3902] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Approved: [Doctor First Name ] [2136-9-6] 7:40 AM Cardiology Report ECG Study Date of [2136-8-15] 1:32:28 AM Normal sinus rhythm, rate 61. Left ventricular hypertrophy. Non-specific lateral repolarization changes consistent with left ventricular hypertrophy and/or ischemia. Compared to the previous tracing of [2136-7-24] probably no significant change. Read by: [Last Name (LF) ],[First Name3 (LF) ] S. Intervals Axes Rate PR QRS QT/QTc P QRS T 61 128 90 458/459 23 -12 115 [Hospital1 69] [Location (un) 86], [Telephone/Fax (1) 15701] Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 106730],[Known firstname ] [2058-10-11] 77 Female [-5/3667] [Numeric Identifier 107533] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] Gross Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ], DR. [Last Name (STitle) ]. ROBENS/cofc SPECIMEN SUBMITTED: FS FRONTAL TUMOR, FRONTAL TUMOR (2). Procedure date Tissue received Report Date Diagnosed by [2136-8-15] [2136-8-15] [2136-8-20] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/cma?????? Previous biopsies: [Numeric Identifier 107534] BACK/st. DIAGNOSIS: Specimen #1: "Frontal tumor, ? meningioma", craniotomy (A, B-C): Meningioma meningothelial subtype (WHO grade I) (see note). Note: The tumor lacks any atypical features including necrosis, sheeting and prominent nucleoli. Mitotic rate is less than 1 per 10 hpf. Specimen #2: "Frontal tumor, ? meningioma", craniotomy (D-H): Meningioma, meningothelial subtype (WHO grade 1). Clinical: ? Meningioma. Gross: This specimen has been received in two parts. Specimen 1, is received fresh for intraoperative consult labeled with the patient's name "[Known lastname ], [Known firstname ]", and the [Hospital 228] medical record number. The specimen consists of an aggregate of soft tan tissue measuring 3.5 x 2 x 0.6 cm. 20% of the tissue is consumed for intraoperative frozen section (FS1) smear, (SM1 and touch preps), (PP1). The frozen section diagnosis by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4223] is: "Meningioma with no atypical features". The specimen is entirely submitted as follows: A=frozen section remnant, B-C = Nonfrozen portion of specimen. Specimen 2, is received fresh labeled with "[Known firstname ] [Known lastname ]", the medical record number and "frontal tumor ?meningioma", and consists of multiple tan pink soft tissue fragments measuring approximately 9.0 x 4.6 x 1.8 cm in aggregate. Representative sections are submitted in D-H. Brief Hospital Course: Pt was admitted through SDA for Bifrontal craniotomy for mengioma resection / elective. [8-17] pt was extubated and was noted to be abulic. [8-20] Pt noted with Right facial droop and right pronator drift with R hemiparesis. CT revealed that second known meningioma in left parietal region with spontaneous hemorrhage. The bleed was considered to be non surgical. [8-23] CXR revealed CHF and PNA, lasix and abx started. [8-25] pt with unilateral pupillary enlargement / mannitol and decadron given emergently / re-intubated /exam followed closely. Hyponatremia treated with 23% (twenty three) normal saline which was then converted to 3% NS. [8-30] pt with thrombocytopenia - HIT antibodies sent and were inconclusive. All heparin products held. Trach and peg placed on hold until plts recovered. hematology consult obtained. [9-1] exam continues to fluctuate / eeg ordered / no sz activity noted / CT scans followed. Keppra decreased [12-30] possible cause of [Month (only) ]. mental status. [9-5] repeat CT stable. Decadron wean complete. Vanco started for GNR, GPC, GPR in sputum. [9-8] trach and peg complete/ off ventilator [9-9] neuro exam improving / following commands / eyes open [9-12] transferred to step down unit. PT and OT have evaluated the patient and both recommended rehab. She was accepted at [Hospital 100] Rehab and was supposed to go on [9-14] but the bed was unavailable. On [9-16] the bed was available and she was transferred to [Hospital 100] Rehab. Her exam prior to discharge was stable. See physical exam section above. Medications on Admission: [Last Name (un) 1724]: 1. Toprol 25 mg 2. Lipitro 20 mg 3. Prozac 20 mg Discharge Medications: 1. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Colace 50 mg/5 mL Liquid Sig: Two (2) PO twice a day. 5. Keppra 100 mg/mL Solution Sig: 10 ml PO twice a day. 6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 7. heparin Sig: 5,000 units Subcutaneous three times a day. 8. Ketoconazole 2 % Cream Sig: One (1) Topical Q 12 hours PRN: Please apply under breasts. 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) PO QID PRN. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Intracranial meningioma s/p resection Discharge Condition: Neurologically stable Discharge Instructions: ?????? Have your incision checked for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed. 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) ] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) ] TO BE SEEN IN 4 WEEKS. YOU WILL NEED AN MRI OF THE BRAIN WITH AND WITHOUT GADOLINIUM PRIOR TO YOUR VISIT. Completed by:[2136-9-16]	[ "482.41", "285.9", "276.1", "401.9", "287.4", "E934.2", "518.5", "V09.0", "999.9", "225.2" ]	icd9cm	[ [ [] ] ]	[ "96.6", "88.41", "31.1", "43.11", "38.93", "03.90", "02.06", "02.12", "96.72", "38.91", "01.51" ]	icd9pcs	[ [ [] ] ]	29881, 29947	27471, 29089	338, 388	30029, 30053	2020, 2208	31051, 31288	1381, 1566		29215, 29858	23522, 23596	29968, 30008		29115, 29192				30077, 31028									1581, 1998																										281, 300	23625, 27448						416, 1088																		1110, 1181	1197, 1365
24,178	181,155	7739	Discharge summary	report	Admission Date: [2107-1-21] Discharge Date: [2107-3-17] Date of Birth: [2061-7-18] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Doxycycline / Ofloxacin Attending:[First Name3 (LF) 2485] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubated. ICU procedures including central venous line, arterial line, and lumbar puncture. History of Present Illness: Mrs. [Known lastname 28082] is a 45 year old female with a history of alcoholic cirrhosis who presented to an OSH with a chief complaint of 1 week duration of SOB and productive cough for the past 2 days. She was found to have a temp of 102, tachy to 120, BP stable 120/80. O2 sat 84% on RA, 95% on 2 liters with severe orthopnea. She was found to have a large R pleural effusion and given azithro, ceftriaxone and transferred to [Hospital1 18]. At the [Hospital1 18] ED she was found to be profoundly hypoxic (7.43/30/56 on 100% FiO2), and RR of 40+ and in acute resp distress and therefore she was intubated. In addition she was started on hydrocort and fludricort and sent to the ICU. ROS: Cough, Chills, Night sweats, Green sputum, Past Medical History: 1. Etoh Cirrhosis 2. Migraines 3. Pancreatitis 4. Chronic back pain/spasm Social History: History of EtOH abuse, unclear recent use, no tobacco. Family History: Brother with AS, ?father with AS. Physical Exam: [Name (NI) 2420] Pt arrived intubated in NAD VS: 101.1 96 98/65 AC 450 x 25 100% PEEP 10 HEENT: NC/AT, PERRL, Icteric, MMM Neck: Supple, unable to assess JVD, no LAD, no Thyromegaly Chest: Clear to Ausc ant on Left, R sided dullness to perc [12-31] up and crackles. CV: RRR, distant, no M/R/G Abd: Mildly distended, + BS, NT, + caput, + shift in dullness Extr: B/L LE trace edema, Peripheral pulses 2+ Skin: + spider angiomata, Caput on abdomen Neuro: + Clonus of RLE, diminished reflexes b/l, difficult to assess on propofol gtt Pertinent Results: Labs: Microbiology: [1-22] Pleural fluid: gram stain 2+ PMNs, no organisms, negative culture. [1-22] Peritoneal fluid: gram stain no PMNs, no organisms, negative culture. [1-22] BAL: negative culture, negative flu. [1-29], 9, 10, 13 stool: c. diff negative. [2-3] CSF: negative. [2-3] Pleural fluid: negative. [2-7] BAL: negative culture. [3-14] Sputum culture: I to cefepime, S to Zosyn, S ceftazidime [3-14] pleural fluid cultures NGTD [3-14] urine culture: yeast [3-11] peritoneal fluid culture negative [3-11] stool culture and c. diff negative [3-11] sputum culture: I to ceftazidime, I to meropenem, S to zosyn and S cefepime [3-10] blood culture [3-10] urine culture yeast [3-10] stool culture c. diff negative [2111-3-1] blood cultures negative [2-27] sputum culture MRSA [Date range (1) 28083] blood culture negative [2-23] blood culture VRE [2-16] EBV IgG VCA, EBNA positive, IgM negative [2-16] toxo IgG and IgM ab negative [2-16] CMV IgG positive, IgM negative Cytology: [2-3] Pleural fluid: negative for cytology. [2-7] Bronchial washings: negative for cytology. [3-14] pleural fluid cytology pending [3-11] peritoneal fluid negative Imaging: CT CHEST [1-22]: 1. Diffuse bilateral ground glass and consolidative opacities within both lungs consistent with multifocal pneumonia. 2. Large right pleural effusion with compressive atelectasis of the right middle and right lower lobes. 3. Cholelithiasis. 4. Findings compatible with cirrhosis and moderate amount of ascites. 5. Stranding and soft tissue density adjacent to the right internal jugular vein consistent with a small hematoma from recent central venous attempt. No pneumothorax. CT HEAD [1-22]: 1. No intracranial hemorrhage. ABD U/S [2-2]: Directed son[Name (NI) 493] examination over the four abdominal quadrants demonstrates a small amount of ascites which is insufficient for both marking a spot for tap and ultrasound-guided paracentesis. There is a large right pleural effusion. CT HEAD [2-2]: No evidence of acute intracranial hemorrhage. CXRs showed persistent right sided opacities. CT ABDOMEN W/O CONTRAST [2107-3-17] 10:29 AM IMPRESSION: 1. No evidence of retroperitoneal hemorrhage. 2. Unchanged large amount of ascites and soft tissue anasarca. 3. Increased amount of air within the bladder. The patient does have a Foley in place. CHEST (PORTABLE AP) [2107-3-14] 8:09 AM CHEST AP: Motion artifact is present. Tracheostomy tube is in place. An NG tube is seen with its tip below the diaphragm. There is a persistent loculated right pleural effusion. Multifocal opacities are present in the right lung, unchanged from the previous study. There is some interval clearing of the left lung opacities. IMPRESSION: Persistent right lung airspace opacities with a loculated right effusion. Improving left lower lobe opacity. CT ABDOMEN W/CONTRAST [2107-3-11] 1:05 PM IMPRESSION: 1. Large right pleural effusion causing contralateral mediastinal shift. Multiple opacities in the lungs consistent with ARDS. 2. Ascites, pericardial effusion, and soft tissue anasarca. 3. No evidence for abscess. UNILAT UP EXT VEINS US PORT RIGHT [2107-3-3] 5:11 PM FINDINGS: Grayscale and Doppler son[Name (NI) 867] was performed of the right subclavian, axillary, brachial, and cephalic veins. There is evidence of filling defect within a right brachial/axillary vein. However, when compared to prior study, the subclavian vein now demonstrates wall-to-wall flow on Doppler study. Compression of the subclavian was difficult to assess secondary to the clavicle. Right cephalic vein now demonstrate compressibility and wall-to-wall Doppler flow with normal waveforms. Internal jugular was not assessed secondary to patient's tracheostomy and overlying equipment. IMPRESSION: Again seen is evidence of deep venous thrombus within the right brachial/axillary vein. Flow now seen within the cephalic and subclavian veins. Cardiology Report ECHO Study Date of [2107-2-14] PATIENT/TEST INFORMATION: Indication: cirrhosis. Right hydrothorax. Weight (lb): 157 BP (mm Hg): 108/34 HR (bpm): 66 Status: Inpatient Date/Time: [2107-2-14] at 15:41 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006E000-0:00 Test Location: East MICU Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.6 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.5 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.7 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.5 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.0 cm Left Ventricle - Fractional Shortening: 0.33 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 65% (nl >=55%) Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm) Aortic Valve - Peak Velocity: 1.8 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 1.57 Mitral Valve - E Wave Deceleration Time: 184 msec TR Gradient (+ RA = PASP): 21 to 25 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Normal regional LV systolic function. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PERICARDIUM: No pericardial effusion. Conclusions: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 2. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1445], MD on [2107-2-14] 16:29. [Location (un) ] PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. ([Numeric Identifier 28084]) LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [2107-2-14] 1:08 PM ABDOMINAL ULTRASOUND: The liver is diffusely echogenic, with a nodular contour. A right-sided pleural effusion as well as ascites fluid is seen. The gallbladder is not clearly identified. There is an irregularly-shaped structure adjacent to the liver, which likely represents bowel, although an unusually contoured gallbladder with sludge within its lumen cannot be excluded. There is no evidence of intra- or hepatic biliary ductal dilation. The right kidney appears unremarkable, without evidence of hydronephrosis or nephrolithiasis. The main portal vein, left portal vein, right anterior portal vein, and right posterior portal vein are patent, with normal waveforms, and flow in an appropriate direction. The left, right, and middle hepatic veins are patent with normal waveforms. The left and right hepatic arteries are patent with normal waveforms. The inferior vena cava, superior mesenteric vein, and splenic vein also demonstrate normal waveforms. IMPRESSION: 1. Echogenic nodular liver consistent with history of cirrhosis. 2. No evidence of portal vein thrombosis. 3. Right-sided pleural effusion and right upper quadrant ascites. Brief Hospital Course: Ms. [Known lastname 28082] is a 45 yo woman with known Alcoholic Cirrhosis who presented to the ED on [2107-1-21] with worseining SOB, non producive cough and fever. She was found to be tachypnic and in respiratory distress with an ABG of 7.43/30/56 and was subsequently intubated in the setting of sepsis with leukocytosis to 20.6 and lactate of 4.0.. [Hospital Unit Name 13533]: The patient was admitted to the medical ICU for further treatment and management. Chest CT showed bilateral ground glass opacities and she was treated for a multifocal pneumonia initially with zosyn, vancomycin, and levaquin. PCP was also considered given her history of steroid use but a BAL was negative for PCP as well as for other infectious etiologies. In addition to the antibiotics, she was initially treated with ARDS net ventilation and her large right sided pleural effusion was tapped on two separate occasions. This was transudative and was thought to likely be a hepatic hydrothorax due to her history of cirrhosis. Antibiotics were stopped on [1-29] after a nine day course as all studies were negative. She was extubated on [1-31] and maintained her O2 sats. She required re-intubation on [2-3] for increased agitation and LP, thoracentesis, and head CT were all performed and were all essentially negative. She remained intubated until [2-10] and during this time she was treated with lactulose and rifaximin to treat hepatic encephalopathy as a possible cause for mental status change. She developed a suspected vent-associated pneumonia for which she was treated with levofloxacin (finished [2-14]). She was extubated on [2-10] but required reintubation secondary to respiratory failure and hypoxia. After a third extubation the patient's respiratory status seemed stable and her mental status was clear. She was conversing normally and was even cleared by speech and swallow study for a regular diet, however after a few days she developed an acute hypoxic episode, most likely secondary to aspiration. She was re-intubated at this time and transferred back to the ICU. Discussion was begun regarding the need for tracheostomy given the patient's repeated intubations and likely scar tissue. This was postponed given the patient's persistent fevers (see below), however she was trached on [3-3] and did quite well, quickly weaning to pressure support and then trach mask ventilation. She was given a Passy muir valve and was seen by speech therapy. Given her ascites, PEG was contraindicated for Gtube and instead postpyloric (nasointestinal) tube was placed for tube feeds. The patient was found to have persistent fevers during her stay in the unit. She was ultimately treated initially for her multifocal pneumonia, then for aspiration pneumonia. Sputum later grew out MRSA and blood cultures later grew out VRE. The patient was treated with linezolid for 14 days to cover both of these infections and all lines were removed (R PICC, aline, L SC central line). A new L antecubital PICC was placed after blood cultures were repeatedly negative. As the patient continued to spike temperatures she was started on zosyn empirically for ventilator asociated pneumonia nad completed a 10 day course. The patient was also found to develop a large right upper extremity DVT which extended from the subclavian through the axillary and into the cephalic vein in the setting of having a right sided PICC line. She was started on a heparin drip, and transitioned to coumadin with goal INR [12-31]. Follow up ultrasound showed persistent DVT with some reinitiation of flow in the subclavian and cephalic veins. The patient was seen by the liver team for her cirrhosis, a diagnosis she carried prior to admission and this was thought to be due to EtOH. A paracentesis done on admission was consistent with cirrhosis and was negative for SBP. She was maintained on lactulose, titrated to several bowel movements per day. Her lasix and aldactone were initially held due to low blood pressures but were gradually reinitiated as her blood pressure could tolerate. On admission, the patient was taking prednisone as an outpatient for a ?COPD diagnosis and she was initially treated with hydrocortisone due to her acute illness initially. This was gradually weaned down and she finished prednisone taper on [2-11]. The patient was stable on trach mask with nasointestinal (postpyloric) tube feeds. She finished her course of linezolid as well as zosyn and continued on coumadin for DVT treatment. On [3-11] she redeveloped fevers and a lactic acidosis to 12.1 and was started on meropenem and placed on the ventilator. Her fever workup included a CT scan that was negative for abscess, a R thoracentesis of 2.2 L that was negative for infection and consistent with hydorhepatothroax, negative blood cultures, urine cultures which only showed yeast, and sputum cultures which showed a pseudomonal pneumonia with intermediate sensitivity to meropenem and ceftazidime, but sensitive to zosyn and cefepime. She was started on cefepime on [3-14]. On [3-17], the sensitivities on her repeat sputum culture returned and showed pseudomonas with intermediate sensitivity to cefepime, but sensitive to zosyn and ceftazidime. She was started on zosyn [3-17] to complete a 7 day course ending on [3-21]. Her lactic acid fell to 2.5 with appropriate antibiotic therapy and she defervesced. Also on [3-11], she had an 8 point hct drop from 23 to 15. She was given 3 units of blood with an increase in her hct to 28 and her coumadin was stopped. Her stools were guaiac negative and 2 CT scans were negative for retroperitoneal abscesses. Her hct remained stable, ranging between 25.6-29. Hematology was curbsided. Given that her DVT was in an upper extremity which has a very low incidence of causing PE, that her PICC line in that arm has been removed, that she has a baseline elevated INR and that she is at risk for bleeding, the risks of futher anticoagulation outweighed the benefits. Her RUE was also no longer erthematous, warm or tender at time of discharge with proven re-establishment of flow. At time of discharge, she had been weaned down to pressure support of 10, PEEP 5 and had tidal volumes in the low 400s, RR in the 20s. She will need to continue being weaned on the vent as an outpatient as tolerated. She will also need continued diuresis with lasix [Hospital1 ] and as needed for her pulmonary and lower extremity edema. She has a postpyloric tube in place for tube feeds and will need a speech and swallow evaluation once she is weaned off the ventilator. She is discharged to rehab for trach care, tube feeds, general medical care, monitoring of her hematocrit, and monitoring of mental status. The patient should continue on lactulose TID prn for 3 bowel movements (or 1000mL of stool) per day) as well as rifaximin for her mental status. She may need an outpatient GI evaluation at some point to determine the source of her bleed. She will need a follow-up appointment with a hepatologist on discharge from the rehab for following of her alcoholic cirrhosis and possible liver transplant. Medications on Admission: Prozac 20 mg po qd Prednisone 10 mg po bid Lasix 40 mg po qd Protonix 40 mg po qd Aldactone 25 mg po qd Zyrtec 10 mg po bid Imitrex prn flexeril 10 mg po qhs prn Lidoderm patch Qd 12 hrs on 12 Hrs off Nortriptyline 10 mg [Hospital1 ] Discharge Medications: 1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 5. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral ASDIR (AS DIRECTED) as needed for to bottom. 6. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed) as needed for for bottom. 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 8. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 10. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 12. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Ascorbic Acid 90 mg/mL Drops Sig: Five Hundred (500) mg PO BID (2 times a day). 14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 15. Insulin Lispro (Human) 100 unit/mL Solution Sig: see sliding scale Subcutaneous ASDIR (AS DIRECTED). 16. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed. 18. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 19. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): to erythematous areas in axilla, chest and arms. 21. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed. 23. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: 10 ml of NS followed by 1 ml of 100 units/ml heparin each lumen QD and PRN. 24. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. 25. Furosemide 10 mg/mL Solution Sig: One (1) Injection TID (3 times a day). 26. Zosyn 4.5 g Recon Soln Sig: One (1) Intravenous every eight (8) hours for 4 days. Discharge Disposition: Extended Care Facility: [Hospital6 23973] [Hospital1 ] Discharge Diagnosis: Alcoholic Cirrhosis Bacteremia Ventilator Associated Pneumonia Hepatohydrothorax Right upper extremity deep vein thrombosis Hepatic encephalopathy Discharge Condition: Hemodynamically stable, tracheostomy in place on a ventilator with pressure support=10, PEEP=5. Discharge Instructions: 1. Please check her hematocrit every other day for the first week to ensure stability. Her discharge hematocrit is 25.6. 2. Please monitor her electrolytes, especially potassium and magnesium, while diuresing her. She will need electrolyte checks every day for the first week. 2. Please continue to wean her off the ventilator as tolerated. Followup Instructions: Please have her follow-up with her primary care doctor, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 22763], at time of discharge from rehabilitation. She should ask her primary care doctor [First Name (Titles) ] [Last Name (Titles) 28085] to a hepatologist or call [Telephone/Fax (1) 2422] for an appointment with a hepatologist at the Liver Center at [Hospital1 827]. She was seen by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] as an inpatient. Completed by:[2107-3-18*]	[ "287.5", "041.04", "507.0", "348.31", "789.5", "286.7", "518.81", "117.9", "482.41", "790.7", "571.2", "451.82", "V09.0", "V58.65", "482.1", "112.0", "707.14", "496", "511.8", "428.0", "038.9", "996.62" ]	icd9cm	[ [ [] ] ]	[ "03.31", "54.91", "96.72", "00.14", "96.6", "96.04", "31.1", "38.91", "38.93", "33.24", "34.91" ]	icd9pcs	[ [ [] ] ]	19798, 19863	9820, 17058	315, 409	20054, 20152	1982, 6085	20543, 21115	1373, 1408		17346, 19775		19884, 20033		17084, 17323				20176, 20520					6111, 8434				1423, 1963																										268, 277							437, 1188			8466, 9797															1210, 1285	1301, 1357
32,419	134,909	22429	Discharge summary	report	Admission Date: [2199-8-24] Discharge Date: [2199-8-27] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 425] Chief Complaint: near syncope Major Surgical or Invasive Procedure: Pacemaker replacement History of Present Illness: 86M with h/o DM2, CAD s/p CABG, carotid stenosis, CHB s/p pacer presents after episode of near syncope at home today. Recently he has been feeling more fatigued, although this is variable. The morning of admission, he was able to exercise on his eliptical bike for 18 minutes (about 1 mile), longer than is usual for him (13 minutes). After returning to his apartment, he felt his legs give out as he was unlocking his door. He did not lose consciousness or hit his head, but he lacked the energy to pick himself up. He was able to push himself inside and call for help. There were no preceding symptoms of vision changes, chest discomfort, shortness of breath, palpitations, recent fevers or chills. He has not recently had vomiting or diarrhea. His PO intake has not been as good over the course of the summer secondary to weakness in his arms (ulnar neuropathy, followed by neuropathy) that limits his comfort cooking for himself. Of note, he was recently seen by his NP on [8-21] for c/o dizziness and gait unsteadiness. Physical exam at that time was notable for BP 132/60 and P82, with no focal neurologic deficits. In addition, he had previously been seen at EP device clinic [2198-9-18] at which time his pacer was functioning properly. Upon evaluation by EMS, his vitals were BP 140/60 P 36 RR 16 O2 100% on room air. He was decribed as pale appearing and mildly diaphoretic, but was awake and mentating clearly. His EKG showed complete heart block with intermittent pacer capturing. He was administered atropine 0.5mg once, with transient rise in his heart rate to 72, subsequently returning to 20's-30's. At the [Hospital1 18] ED, his vitals were T 98 P 28 BP 119/52 RR 18 100% RA. His physical exam was unremarkable aside from bradycardia. He was given 1L normal saline, pacer plads were placed, and he was admitted to the CCU for temporary pacer wire. . Review of systems is positive for stroke and TIA. There is no history of thrombosis, PE, or bleeding diathesis. He occasionally has blood on his toilet paper without hematochezia or melena. He has night time leg pains due to neuropathy but denies claudications. Past Medical History: 1. DM2 --c/b peripheral neuropathy, last HbA1c 7.5 [4-15] 2. CAD --s/p CABG [2163] --h/o MI [2183] 3. Complete heart block, s/p dual chamber St. [Male First Name (un) 923] pacer [2194] --seen at [Hospital ] clinic [2197] 4. Bilateral carotid stenosis --s/p L sided stent [5-16] --s/p R CEA c/b R vocal cord paralysis 5. TIA 6. Stroke, frontoparietal [2184] 7. Lower back pain 8. Glaucoma 9. Anemia, h/o colon polyps 10. GERD 11. Hyperlipidemia 12. h/o Bell's palsy 13. h/o hematuria 14. h/o chronic dizziness 15. s/p hip and arm fractures 16. s/p cataract surgery Cardiac Risk Factors: +Diabetes, +Dyslipidemia, -Hypertension . Cardiac History: CABG, in [2163] . Pacemaker/ICD placed in [2163]. Vincents ([Hospital1 1559]) Social History: He quit smoking ~40 years ago, but intermittently smoked for ~20 years sometimes heavily (3ppd). He denies drinking alcohol in 50 years. Father had stroke in his 80's. No known MI or sudden death. Family History: Non-contributory Physical Exam: T98 P28 BP 119/52 RR 18 O2 100% room air (pre transvenous pacer) General: Pale but well appearing elderly man in no acute distress HEENT: RIJ with transvenous pacer in place, moist mucous membranes CV: Regular rate S1 S2 no m/r/g Pulm: Lungs with few crackles at left base that persist after coughing Abd: Soft, +BS, nontender Extrem: Warm, trace ankle edema bilaterally. 2+ radial pulses, 1+DP, 2+ PT pulses Neuro: Alert and oriented, somewhat tangential speech but re-directable, no gross deficits, moving all extremities Pertinent Results: EKG left axis, Complete heart block with occasional pacer capture, ventricular rate approximately 36bpm, atrial rate ~130, inverted T's 2D-ECHOCARDIOGRAM performed on [4-15] demonstrated: EF 50% mildly dilated LA, 1+ MR, 1+AR, trivial TR. PA systolic BP could not be estimated on this study. . ETT performed on [4-15] demonstrated: reached 77% predicted HR on [Doctor Last Name ] protocol, stopped secondary to fatigue, no anginal symptoms. MIBI negative . LABORATORY DATA: CBC: 8.0 > 35.8 < 271 Chem: 142/4.4/105/29/18/1.6<155 INR 1.0, PTT 34.9 CK 61, MB not done, Tropn<0.01 CXR SINGLE VIEW CHEST, AP: The cardiac and mediastinal contours are stable and within normal limits. The patient is status post median sternotomy and CABG. A dual-lead right-sided pacer is in place with unchanged appearance of pacer wires. A left perihilar opacity seen on the previous exam is no longer visualized and may have represented loculated pleural effusion. There are small, bilateral pleural effusions with bibasilar atelectasis. Otherwise, no evidence of pneumonia or pulmonary edema. IMPRESSION: No acute cardiopulmonary disease. Brief Hospital Course: This 86M with history of CAD, DM2 c/b neuropathy, and CHB s/p pacer presented after near-syncope episode at home today and subsequently found to have malfunctioning pacer, likely the etiology of his symptoms. CARDIAC 1. Rhythm, CHB: Upon admission patient had transvenous pacer placement without complications. Nodal blocking agents were held. Permanent pace maker battery found to be dead, and patient ultimatly brought to cath lab for generator replacement without complication. Pt to follow up in device clinic 2 weeks afte d/c. 2. Pump: EF 50% with history of diastolic heart failure, clinically euvolemic. Did not start beta-blocker given history of orthostatic hyoptension 3. Ischemia: Continued ASA, statin. ENDO 1. Diabetes: patient maintained on insulin sliding scale. Restarted on home glipizide on discharge. NEURO 1. h/o postural hypotension, h/o neuropathy: continue outpatient florinef 2. chronic back pain: continue neurontin, tylenol as per home OPTHAL 1. glaucoma: continue eyedrops but hold beta blocker Shoulder Pain: No signs of ischemia on EKG, patient with history of neuorpathic pain. Neurotin dose increase with good effect. Dispo: After being evaluated by physical therapy, patient felt to benefit from a short stay in rehab due to concerns for falls and for occupational therapy rehabilitation. Medications on Admission: ALPHAGAN P (brimonidine) 0.15 %--1 drop as directed twice a day CARMOL (topical urea) 40 40%--Apply to affected area every day COLACE 100 mg--1 capsule(s) by mouth once a day as needed for as needed COSOPT (dorzolamide/timolol) 2-0.5 %--1 drop in each eye twice a day Caltrate-600 Plus Vitamin D3 600-200 mg-unit--1 tablet(s) by mouth once a day ECOTRIN 325 mg--1 (one) tablet(s) by mouth once a day FOSAMAX 70 mg--1 tablet(s) by mouth qweek Florinef 0.1 mg--1 (one) tablet(s) by mouth once a day in the morning GLIPIZIDE 5 mg--1 tablet(s) by mouth once a day entered for web omr conversion LIPITOR 10 mg--1 (one) tablet(s) by mouth once a day entered for web omr conversion LISINOPRIL 2.5 mg--1 (one) tablet(s) by mouth bedtime LUMIGAN (bimatoprost) 0.03 %--1 (one) drop in each eye at bedtime entered for web omr conversion NEURONTIN 100 mg--1 capsule(s) by mouth at bedtime VIACTIV 500 mg-100 unit-[Unit Number ] mcg--2 tablet(s) by mouth daily Tylenol, at bedtime with neurontin Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 3. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic qhs (). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Cosopt 2-0.5 % Drops Sig: One (1) Ophthalmic twice a day. 9. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 11. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One (1) Tablet PO once a day. 12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) ] - [Location (un) 620] Discharge Diagnosis: Primay dx: Complete Heart Block Secondary dx: DM2 CAD HTN Orthostatic hypotension Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital after an admission for unsteadyness and near syncope. You were found to have a dead battery on your pacemaker. Your pacemaker was replaced. Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2199-9-4] 10:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name12 (NameIs) 280] Phone:[Telephone/Fax (1) 719] Date/Time:[2199-9-13] 10:05 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 722], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2199-10-24] 9:20	[ "427.31", "458.0", "V53.31", "428.30", "354.2", "426.0", "401.9", "357.2", "250.60", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "37.87", "37.78" ]	icd9pcs	[ [ [] ] ]	8495, 8568	5237, 6573	274, 298	8694, 8703	4073, 5214	8927, 9357	3495, 3514		7610, 8472		8589, 8673		6599, 7587				8727, 8904									3529, 4054																										222, 236							326, 2471																		2493, 3265	3281, 3479
53,677	131,235	44467	Discharge summary	report	Admission Date: [2154-3-27] Discharge Date: [2154-3-29] Service: MEDICINE Allergies: Amoxicillin / Roxicet / Bactrim Ds / Ciprofloxacin Hcl / Streptomycin Sulfate Attending:[First Name3 (LF) 4588] Chief Complaint: Vomiting Major Surgical or Invasive Procedure: none History of Present Illness: This is a 87 year-old female with a history of Diastolic heart failure, pulmonary hypertension, Chronic kideny disease, and atrial fibrillation on Coumadin who presents with vomiting. Pt lives at [Hospital 100] Rehab. She reports having a cough with productive sputum and fever about 2 weeks ago. This resolved and then she developed nausea and vomiting over the past few days. She has had decreased PO intake, only tolerating tea and crackers. No fever, chills, CP, SOB, abdominal pain, hematemesis, diarrhea. Labs at [Hospital 100] Rehab today revealed Na 128 and K 2.5. She was transferred from [Hospital 100] Rehab to the [Hospital1 18] for further evaluation. . In the ED initial vitals were: T 98.1, BP 152/49, HR 53, RR 20, O2sat 100%. She received a CT scan which incidentally showed a pericardial effusion. This was evaluated by Cardiology who performed a bedside ECHO which confirmed the effusion but did not show tamponade. In the ED, she received 40mEq potassium PO and 40mEq IV, 1 litre normal saline, and zofran. ECG showed PVC's but no acute ischemic changes. She is admitted to the MICU for electrolyte abnormalities of Na 123, K 2.8, and pericardial effusion. . Past Medical History: -Diastolic heart failure with preserved ejection fraction. -Hypertension. -Hyperlipidemia. -Aortic stenosis with aortic valve area from 1-1.2. -Pulmonary hypertension. -Renal cell carcinoma s/p R nephrectomy '[39] -Chronic kidney disease with baseline creatinine of 2.6. -s/p cholecystectomy for porcelain gall bladder '[39] -Restrictive lung disease. -Chronic constipation. -Degenerative joint disease. -Atrial fibrillation. -Renal artery stenosis. -on home O2, 2-3 L as needed -Cystic lesions on pancreas with chronic intra- and extra-hepatic dilatation Social History: Lives at [Hospital ] rehab. She is a lifelong nonsmoker. She ambulates with a walker. She denies any history of alcohol or drug use. . Family History: NC Physical Exam: On admission per ICU team: VS - T 96.8; BP 144/45; HR 58; RR 20; O2sat 98% on 2L Gen: elderly female, speaks Russian mainly but fairly fluent in English, no acute respiratory distress. HEENT: NCAT. Sclera anicteric. Blind in L eye. R eye with cataract. mildy dry MM. Neck: supple, no cervical or supraclavicular LAD CV: irreg irreg, [1-11] harsh systolic murmur throughout precordium, loudest at RUSB with radiation to the carotids. Chest: No chest wall deformities. Respirations were unlabored, no accessory muscle use. Mild diffuse expiratory wheezes, but good air movement throughout. No crackles or rhonchi. Abd: Soft, tender to palpation at the LUQ/epigastrium, non-distended. No HSM or tenderness. No rebound or guarding. Ext: No clubbing, cyanosis or edema. Radial and DP pulses 2+ Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: A+O x3, grossly intact Pertinent Results: [2154-3-27] 04:37PM WBC-8.3 RBC-4.50 HGB-12.2 HCT-36.7 MCV-82 MCH-27.1 MCHC-33.3 RDW-16.8* [2154-3-27] 04:37PM NEUTS-85.1* LYMPHS-11.0* MONOS-3.5 EOS-0.2 BASOS-0.2 [2154-3-27] 04:37PM PLT COUNT-271 . [2154-3-27] 05:30PM PT-40.1* PTT-39.4* INR(PT)-4.4* . [2154-3-27] 05:30PM ALBUMIN-3.9 CALCIUM-8.6 PHOSPHATE-4.6* MAGNESIUM-2.6 . [2154-3-27] 05:30PM CK-MB-6 [2154-3-27] 05:30PM cTropnT-0.03* [2154-3-28] 03:00AM BLOOD CK-MB-6 cTropnT-0.03* [2154-3-28] 03:00AM BLOOD CK(CPK)-172* [2154-3-28] 08:39AM BLOOD CK-MB-6 cTropnT-0.03* [2154-3-28] 08:39AM BLOOD CK(CPK)-162* . [2154-3-27] 09:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2154-3-27] 09:40PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007 . ECG official read: Atrial fibrillation with ventricular premature complexes including a triplet Nonspecific ST-T abnormalities. Since previous tracing of [2153-1-22], further ST-T wave changes suggested but baseline artifact makes comparison difficult. Intervals Axes Rate PR QRS QT/QTc P QRS T 78 258 100 438/469 82 39 88 . [2154-3-27] CXR: IMPRESSION: No evidence of consolidation. Mild fluid overload. . [2154-3-27] CT HEAD: IMPRESSION: No evidence of acute hemorrhage. Enlarged ventricles out of proportion to the sulci which likely represents central atrophy given stability over time. . [2154-3-27] CT ABD/PELV: IMPRESSION: 1. Moderate pericardial effusion and signs of fluid overload concerning for heart failure. Recommend clinical correlation. 2. Pancreatic cysts, better evaluated on recent MRCP. 3. Left kidney hypo- and hyperdense lesions, similar in appearance. 4. Vascular calcifications. 5. Normal appendix. 6. Lucency within the sacrum, stable and likely benign etiology. . [2154-3-28] [Month/Day/Year ]: The left atrium is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Diastolic function could not be assessed. The right ventricular cavity is mildly dilated with normal free wall contractility. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-7]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Pericardial constriction cannot be excluded. IMPRESSION: Image quality and frequent ectopy make interpretation difficult. There is a small circumferential effusion without tamponade (signs of tamponade may be absent in the presence of elevated right sided pressures). Pericardial constriction cannot be excluded. LV function is probably normal. Mild to moderate mitral regurgitation. Moderate pulmonary artery systolic hypertension. Brief Hospital Course: 87 F with a history of diastolic heart failure, pulmonary HTN, CKD, and a-fib on Coumadin who presents with vomiting, right lower quadrant tenderness, and incidental pericardial effusion. . #. Nausea/Vomiting: Unclear etiology. Possibly gastroenteritis vs primary electrolyte abnormality contributing to nausea. Obstruction much less likely as patient had BM on day prior to admission. Patient ruled out for MI. No acute pathology on CT scan. Pt has known chronic biliary dilatation and AP is elevated, but not far from baseline. Currently denies nausea and no vomiting since admit. Appears euvolemic now and has improving crackles on lung exam. Tolerating PO well. . #. Pericardial effusion: Evaluated by cardiology in the ED who performed a bedside ECHO which did not show tamponade. The patient is currently hemodynamically stable. Pericardial effusion was also noted on TTE from [3-13] and can be seen on CT chest from [2150] indicating this is likely a chronic effusion. Patient has ruled out for MI. . #. Hyponatremia: Patient arrived with Na of 123 and appeared hypovolemic on exam likely [1-7] N/V above. Urine lytes were not sent until she was repleted/given lasix. She was given 2 L total of NS with correction of her Na to 133 by day of discharge. . #. Afib: INR is supratherapeutic at 4.3 on day of discharge. - held coumadin while in house . #. Chronic diastolic heart failure: She was given 2 L NS in ED/MICU and lasix was restarted when her N/V and hyponatremia resolved. Currently appears euvolemic on exam. - Furosemide daily . #. CKD: Cr remained at baseline during hospitalization. - renally dose all medications . #. Hypertension: Currently normotensive. - re-start amlodipine - consider re-starting hydral, imdur, metoprolol in AM . #. Hyperlipidemia: cont simvastatin . #. Optho: cont eye gtt . #. FEN: - Cardiac diet. - replete lytes prn . Medications on Admission: Omeprazole 40mg PO BID Hydralazine 25mg PO BID Simvastatin 80mg PO qHS Dorzolamide eye gtt 2% 1 drop OD TID Tobramycin/Dexamethasone eye ointment OU qHS Metoprolol XL 25mg PO daily Lorazepam 0.5mg PO qHS prn Homatropine 5% 1 drop [Hospital1 ] OD Allopurinol 100mg PO daily Latanoprost 1 drop OD qHS Tylenol 650mg q6 prn Amlodpine 10mg PO daily Imdur 30mg PO daily Spiriva 18 mcg cap 1 inh daily Sertraline 50mg PO daily Ca Carb 650mg PO BID Vit D 1000u daily Flovent 110mcg inh 2 puffs [Hospital1 ] Dulcolax 10mg PO daily Coumadin Aspirin 81mg PO daily Bethenacol 10mg PO TID Lasix 80mg PO daily Senna 1 tab PO BID Compazine 5mg PO q8 prn . Discharge Medications: 1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 3. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 4. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic QHS (once a day (at bedtime)). 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 6. Homatropine HBr 5 % Drops Sig: One (1) drop Ophthalmic twice a day. 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 10. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Calcium Carbonate 650 mg (1,625 mg) Tablet Sig: One (1) Tablet PO twice a day as needed. 15. Cholecalciferol (Vitamin D3) 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 16. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 17. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 19. Bethanechol Chloride 10 mg Tablet Sig: One (1) Tablet PO three times a day. 20. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 22. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 23. Warfarin 5 mg Tablet Sig: as directed Tablet PO once a day: Start on [2154-3-30]. Please take coumadin as directed based on INR. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Primary: Gastroenteritis Hypovolemic hyponatremia Stable chronic pericardial effusion . Secondary: Chronic Diastolic heart failure Discharge Condition: good, VSS, afebrile, tolerating PO, on baseline 2-3 L oxygen as needed. Discharge Instructions: You came to the hospital for nausea and vomiting for 3 days. Your sodium and potassium levels were very low and a CT scan indicated you may have fluid around your heart. The cardiologists evaluated you and stated that the fluid around your heart is chronic and not dangerous at this time. You were given IV fluids and supplemental potassium which have corrected your electrolyte abnormalities. . Medication changes: - Your hydralizine and metoprolol were stopped for low blood pressures and may be added back as needed at [Hospital1 ]. - Please take your other medications as prescribed. . Please call your doctor or return to the ED if you have nausea, vomiting, dizzyness/confusion, chest pain, shortness of breath, increasing leg swelling, diarrhea, constipation, or other concerns. Followup Instructions: Provider: [Name10 (NameIs) ] Phone:[Telephone/Fax (1) 62] Date/Time:[2154-12-24] 1:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2154-12-30] 1:40 Completed by:[2154-3-29]	[ "423.9", "276.1", "585.9", "577.2", "416.8", "403.90", "427.31", "V10.52", "428.0", "041.12", "424.1", "428.32", "008.69" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11097, 11162	6471, 8352	294, 301	11337, 11411	3206, 4488	12251, 12525	2286, 2290		9052, 11074		11183, 11316		8378, 9029				11435, 11833									2305, 3187																							11853, 12228			246, 256							329, 1526		4497, 6448																1548, 2114	2130, 2270
24,262	198,453	22332	Discharge summary	report	Admission Date: [2116-11-18] Discharge Date: [2116-12-15] Date of Birth: [2057-4-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 18369] Chief Complaint: Shortness of Breath and Hypoxia Major Surgical or Invasive Procedure: Thoracentesis Chest tube placement Intubation and Mechanical Ventilation History of Present Illness: Pt is a 59 yo greek speaking male with aggressive metastatic RCC (diagnosed recently in [4-12]), s/p Left nephrectomy, INF, on adriamycin and Gemzar since [2116], who presented to clinic after 1-2 days of productive (yellow sputum) cough, and progressive shortness of breath. He was found to be hypoxemic with an O2 sat of 88% on room air. He received part of 4th chemo cycle then coughed up a big mucus plug with associated congestion. + desaturation to 84% with no improved with albuterol. . In the emergency room: T 101.1F, HR 130s, BP: 132/80, RR: 15, O2: 98% on NRB initially. Leucocytosis WBC 27. HCT 25 (baseline 30, guiac negative, LDH, T bili okay). CXR showed a left massive effusion vs. collapse. Mr. [First Name (Titles) 58165] [Last Name (Titles) 12368] suddenly to 82% on NRB with solmnolence. He was intubated and ABG (30 minutes later) showed 7.14/89/209. The patient was admited to the Medical ICU. Past Medical History: 1) Renal cell cancer, s/p left nephrectomy and Interferon therapy in [Country 5881] [4-12] as well as Gemzar/Adriamycin. 2) Hypertension 3) Diabetes Mellitus II 4) Iron deficiency anemia Social History: Patient lives in [Country 5881]. He is currently visiting family in the United States. He is accompanied by his wife. Denies use of tobacco or drugs. Drinks ETOH socially. Family History: NC - no cancers in family Physical Exam: On Admission to MICU: VS: Tc: 101.1; BP: 132/80; HR: 130s; RR: 15; SaO2: 99% Ventilator settings: AC: 15/500/5/1 Gen: intubated HEENT: pupils 2mm bilateral, equal and reactive to light Neck: larg, superficial left neck mass Chest: [Month (only) ]. BS on Left, crackles on right CV: tachy, regular rhythm, S1, S2, no murmurs, rubs, gallops Abd: soft, NT/ND Ext: no c/c/e . On transfer to the OMED team: VS: Tc: 96.3; BP: 113/76; HR: 80; RR: 22; SaO2: 100 RA Gen: Eldely male looking up at ceiling, in NAD HEENT: Multiple nodules on scalp and one on left forehead. Red appearing growths. PERRL; EOMI; OP dry without exudate. Sclera anicteric. Neck: No JVD CV: RRR S1S2. No Murmurs appreciated. Lungs: Decreased BS b/l L>>R. Slight rales at right base. Abd: +BS. Soft, NT, ND. [Last Name (un) 8314] scar. No rebound. No guarding. Ecchymoses lower abdomen b/l. Ext: 2+ Pitting edema in lower ext b/l mid-calf down. DP palpable 1+. Left arm swollen. Pertinent Results: Labs on admission: [2116-11-18] 11:56PM TYPE-ART TIDAL VOL-500 O2-100 PO2-55* PCO2-61* PH-7.23* TOTAL CO2-27 BASE XS--3 AADO2-622 REQ O2-98 [2116-11-18] 11:56PM LACTATE-1.9 [2116-11-18] 11:56PM freeCa-1.06* [2116-11-18] 10:18PM GLUCOSE-227* UREA N-20 CREAT-0.6 SODIUM-139 POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-23 ANION GAP-11 [2116-11-18] 10:18PM CORTISOL-29.2* [2116-11-18] 09:32PM PT-15.1* PTT-28.4 INR(PT)-1.4 [2116-11-18] 08:26PM TYPE-ART PO2-209* PCO2-89* PH-7.14* TOTAL CO2-32* BASE XS--1 INTUBATED-INTUBATED [2116-11-18] 08:26PM K+-4.6 [2116-11-18] 07:50PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.022 [2116-11-18] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG [2116-11-18] 07:50PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 TRANS EPI-0-2 [2116-11-18] 05:54PM LACTATE-2.0 [2116-11-18] 05:39PM GLUCOSE-189* UREA N-18 CREAT-0.6 SODIUM-135 POTASSIUM-5.5* CHLORIDE-99 TOTAL CO2-25 ANION GAP-17 [2116-11-18] 05:39PM CALCIUM-8.0* PHOSPHATE-3.4 MAGNESIUM-1.7 [2116-11-18] 05:39PM WBC-26.8* RBC-3.09* HGB-7.8* HCT-25.6* MCV-83 MCH-25.1* MCHC-30.3* RDW-16.4* [2116-11-18] 05:39PM NEUTS-83* BANDS-13* LYMPHS-3* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2116-11-18] 05:39PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL [2116-11-18] 05:39PM PLT SMR-VERY HIGH PLT COUNT-796* [2116-11-18] 02:00PM UREA N-15 TOTAL CO2-28 [2116-11-18] 02:00PM ALT(SGPT)-45* AST(SGOT)-31 LD(LDH)-159 ALK PHOS-141* TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1 [2116-11-18] 02:00PM ALBUMIN-2.4* CALCIUM-9.0 [2116-11-18] 02:00PM WBC-24.9# RBC-3.52 HGB-9.1* HCT-29.2* MCV-83 MCH-25.7* MCHC-31.0 RDW-17.4* [2116-11-18] 02:00PM PLT COUNT-831* [2116-11-18] 02:00PM GRAN CT-[Numeric Identifier 58166]* . . [2116-11-19] Cytology of Thoracentesis fluid: "Atypical cells favor reactive mesothelial cells and inflammtory cells." . [2116-11-20]: TTE: "The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion." . [2116-11-25] Cytology of Thoracentesis fluid: "NEGATIVE FOR MALIGNANT CELLS. Scattered lymphocytes and proteinaceous material." . [2116-11-27] Video Swallow Study: "Single episode of aspiration of nectar thickened liquids on the initial bolus during premature spillover. Prominent residual worse with thick liquids." . [2116-11-28] CT Chest: "1. Bulky adenopathy within the mediastinum and both hila resulting in compression of left lower lobe bronchus 2. New bilateral moderate/large pleural effusions. 3. Right upper lobe patchy pulmonary parenchymal opacity which could represent the patient's known pneumonia or metastatic disease. 4. Unchanged retroperitoneal adenopathy, left chest wall and scapular masses 5. A lytic lesion of the T12 vertebral body extends to the osseous margins of the central spinal canal and results in possible spinal cord compression at this level." . [2116-11-29] Unilateral US of UE: "No evidence of venous thrombosis." . [2116-11-30] Cytology of Thoracentesis fluid: "NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells and blood." . [2116-12-7] Portable CXR: "Interval improved aeration in left upper lobe and left perihilar region, corresponding to reduction in left effusion and adjacent atelectasis, with residual moderate to large loculated left effusion. Stable right sided effusion" . Brief Hospital Course: The patient was intubated in the ED for respiratory distress and hypoxia. He was immediately admitted to the MICU on [2116-11-18] where he was found to require dopamine for maintenance of blood pressure. . 1. Respiratory distress: On admission, the respiratory distress was thought to be secondary to mixed hypoxic hypercarbic failure secondary to pneumonia and left pleural effusion. While pending work up for his respiratory distress, the patient self extubated himself on [11-20]. He was relatively stable from a respiratory standpoint until the 15th when he experienced acute respiratory distress requiring BIPAP. This was thought to be secondary to fluid overload after mobilization of fluids after receiving several liters of hydration as per the sepsis protocol and pressure support. The patient was given a ten day course of Zosyn which he tolerated well for the PNA and a thoracenetesis with chest tube placement for the presumed malignant pleural effusion (2.5L of exudative fluid was removed, however 3 sets of cytology all returned negative for malignant cells). The patient subsequently recieved a pleurodiesis from interventional pulmonary as well. After pleurodesis, pt became tachycardic and tachypnic (to 120s and 30s) and was third spacing all of his fluid. However this was transient and resolved with supportive measures. The pt gradually improved with decreasing oxygen requirement and was eventually weaned down to 3L NC at which point the pt was transferred to the floors to the OMED team on [2116-11-26]. On the floor, the patient has been stable on 3L NC, maintaining oxygen saturation between 95-98%. A CXR taken on the [8-6], demonstrated interval improvement in left lung with stable pleural effusions. As per interventional pulmonology, there are no further interventions planned. We would recommend continuation of the oxygen supplementation via nasal canula for comfort. . 2. PNA: The patient was thought to have a Community Acquired PNA vs post-obstructive PNA. He was not neutropenic and was started on zosyn and finished an 11 day course on [2116-11-29]. The abx course was not complicated. He finished his abx and remained afebrile with normal WBC count on the floors. . 3. Hypertension/hypotension: The patient was admitted to the MICU on dopamine for pressure support. His hypertensive medications - metoprolol were held. The patient was given several liters of IVF as pt was intravascularly depleted. The patient was also given 2 units prbcs to replete intravasc volume on [2116-12-1]. On the floors, the patient was hemodynamically stable, maintaining good BP, and his normal hypertensive medications were re-started without complications. . 4. Progressive Renal Cell Carcinoma: Pt is s/p nephrectomy, interferon, cranial bone met XRT ([8-12]), skin/bone involment. Last CT Scan ([8-31]) with diffuse metastatic disease involving the mediastinum, hila, lungs, posterior left chest wall, resection bed, retroperitoneal lymph nodes, and right superior pubic ramus, multiple pulmonary nodules are also seen in both lungs, and right kidney. Review of his path report from skin sample (from [7-12]) revealed sarcomatoid features. Started Gemcytabine/Doxorubicin this summer. There are no further treatment planned due to the advanced stat of his disease. The family has agreed to supportive measures. Calcium levels remained stable despite bone mets. . 5. DM: Pt was on an regular nsulin sliding scale and FS were well controlled for >1week. The QID FS checked were discontinued. Interval lab test including chemistries showed the glucose level to be stable. . 6. ANEMIA: The etiology of the patient's anemia is multifactorial including both Fe deficiency + thalassemia minor (dx via electropheresis). The patient was on darvopoeitin q 2weeks and he received two units of PRBC on [2116-11-28] and was transfused again on [2116-12-1] (2 units) as pt was intravascularly depleted with low protein state. His Hct remained stable since transfer to the floors. . 7. PAIN: was on fentanyl patch pre-admit. We restarted the fentanyl patch at 25 mcg.hr. Also had Morphine prn for pain control. The patient denies any pain or discomfort since admission to the floor. . 8. PPx: pneumoboots, H2 blocker 9. Code status: Pt initially DNR/DNI but family changed mind in MICU. Again, made DNR/DNI after several family talks between pt's family and his primary oncological team. Pt and family agreed to hospice care. 10. Communication: sister, [Name (NI) ] (speaks english) wife, [Female First Name (un) 58167] (does not speak english). Medications on Admission: 1. darvopoetin 2. darvocet 3. FeSo4 4. colace Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours). 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:10 Patch 72HR(s) Refills:2 8. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 9. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4-6H (every 4 to 6 hours) as needed. 10. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane TID (3 times a day) as needed. 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Roxicet 5-325 mg/5 mL Solution Sig: [5-28] ml PO q1-3hours PRN as needed for pain and shortness of breath for 1 days. Disp:60 ml Refills:0 15. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: 2-3 puffs Inhalation every 6-8 hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: VNA [Location (un) 270] East / Visitng Nurse Hospice Discharge Diagnosis: Primary: Respiratory distress secondary to malignant pleural effusion Secondary: Metastatic Renal Cell Carcinoma, HTN, DMII Discharge Condition: Stable Discharge Instructions: Please take all of your medication. Followup Instructions: None. Completed by:[2116-12-15]	[ "V10.52", "518.0", "486", "V58.67", "V45.73", "995.92", "198.5", "707.03", "038.9", "518.81", "197.2", "250.00", "198.2", "785.59", "401.9" ]	icd9cm	[ [ [] ] ]	[ "34.91", "99.04", "34.04", "38.93", "96.6", "34.92", "96.71", "96.04", "99.25" ]	icd9pcs	[ [ [] ] ]	13176, 13259	6951, 11588	349, 424	13427, 13435	2836, 2841	13520, 13557	1820, 1847		11684, 13153		13280, 13406		11614, 11661				13459, 13497									1862, 2817																										278, 311							455, 1392									2855, 6925									1414, 1610	1626, 1804
14,975	127,677	20032	Discharge summary	report	Admission Date: [2182-5-1] Discharge Date: [2182-5-6] Date of Birth: [2099-9-16] Sex: M Service: MEDICINE Allergies: Amoxicillin Attending:[First Name3 (LF) 1990] Chief Complaint: Shortness of [First Name3 (LF) ] Major Surgical or Invasive Procedure: None History of Present Illness: Identifer: Dr. [Known lastname 4901] is an 82 y/oM with a h/o CAD s/p NSTEMI, advanced Parkinson's Disease, recently diagnosed moderate-poorly differentiated adenocarcinoma of the liver (cholangio vs. met of unknown primary) with lymphatic invasion, history of recent hematuria, and history of prior UTIs with ESBL producing organisms. He presents to the [Hospital1 18] from [Hospital1 5595] with shortness of [Hospital1 1440], found at [Hospital1 5595] to have RLL pneumonia. He has had several days of profound fatigue. He states that he regularly has some chest pain, both on exertion and at rest, typically once a day, including the morning of admission, though he does not think this has changed recently. He does have some worsening shortness of [Hospital1 1440], and some cough. He developed leukocytosis on [2182-4-30] from 7.1 -> 12.7 with 91% PMN no bands. He had a U/A (unknown date) obtained that grew Klebsiella, and he was restarted on ertapenem. He had a cxr on [2182-4-30] that showed suspected RLL pneumonia, and he was transferred to [Hospital1 18] for further management. In the ED, he was 99.6 107 177/95 32 96 at triage. CXR showed suspected multifocal pneumonia, and he received vancomycin 1gm, levofloxacin 750mg, and ceftriaxone 1gm all IV x1. Influenza Viral DFA was sent and is pending. His peak temperature was 104 rectally in the ED, and he was found to be guaiac positive. ECG showed appreciable inferolateral ST depressions, and a troponin was checked and was elevated at 2.18. Cards was consulted, but given his overal condition felt he was not a candidate for early revascularization and recommended heparin gtt. He was also on labs found to he hyperkalemic, and received bicarb, and kayexelate. Past Medical History: 1)Parkinson's disease/Autonomic dysfunction 2)3-Vessel Coronary Artery Disease - medically managed-[2180] for NSTEMI 3)Hypertension - hypertensive urgency in [2180] with NSTEMI 4)Hx of recurrent ESBL - Klebsiella Urinary Tract Infection with hx of Sepsis in [11-9] 5)Chronic renal insufficiency (baseline creat 1.2-1.5) 6)Chronic lower back pain 8)h/o melanoma s/p resection 20yrs ago 9)GERD 8)BPH 9)Chronic Systolic Heart Failure, EF~50%. 10)Hyperlipidemia. 11)4.4 X 4.2 X 4.1 cm Left Renal Cyst. 12)Dysautonomia with Syncope. 13)Hx MRSA Pneumonia. 14)Depression. 15)S/P Open Cholecystectomy. 16)Spinal Stenosis partial paralysis. Poor Functional Status Social History: Lives at [Hospital 100] Rehab with his wife. [Initials (NamePattern4) ] [Last Name (NamePattern4) 53949] Relations professor. Walks with a walker. Smoked previously, but quit 45 years ago, had 5 years of 1ppd. Occasional alcohol at special occasions, dinner. No IVDA. . ADLS: over the last month he needs assistance with dressing, ambulating, incontinent care previously was independent. Up until this week he has been going to the dining room for meals. Lives with wife at [Name (NI) 5595] Walks with walker in his room when well and then largely wheelchair bound Recent falls + Unsteady gait + Visual aides Family History: son and daughter have renal cysts. Physical Exam: performed by ICU team on arrival - not documented here. This summary completed by [Hospital1 ] attending. Pertinent Results: [2182-5-1] 09:57PM GLUCOSE-307* UREA N-47* CREAT-1.9* SODIUM-133 POTASSIUM-5.3* CHLORIDE-97 TOTAL CO2-23 ANION GAP-18 [2182-5-1] 09:57PM GLUCOSE-307* UREA N-47* CREAT-1.9* SODIUM-133 POTASSIUM-5.3* CHLORIDE-97 TOTAL CO2-23 ANION GAP-18 [2182-5-1] 09:57PM CK-MB-6 cTropnT-2.27* [2182-5-1] 09:57PM ALBUMIN-3.2* CALCIUM-8.5 PHOSPHATE-4.0# MAGNESIUM-2.2 [2182-5-1] 04:45PM URINE COLOR-Red APPEAR-Cloudy SP [Last Name (un) 155]-1.019 [2182-5-1] 04:45PM URINE RBC->50 WBC->50 BACTERIA-NONE YEAST-NONE EPI-0 [2182-5-1] 04:23PM LACTATE-2.4* [2182-5-1] 04:19PM GLUCOSE-307* UREA N-46* CREAT-2.0* SODIUM-131* POTASSIUM-5.8* CHLORIDE-95* TOTAL CO2-23 ANION GAP-19 [2182-5-1] 04:19PM estGFR-Using this [2182-5-1] 04:19PM CK(CPK)-224* [2182-5-1] 04:19PM CK(CPK)-224* [2182-5-1] 04:19PM CK-MB-6 [2182-5-1] 04:19PM CK-MB-6 [2182-5-1] 04:19PM WBC-14.9# RBC-3.54 HGB-10.4* HCT-31.2* MCV-88 MCH-29.4 MCHC-33.4 RDW-17.3* [2182-5-1] 04:19PM NEUTS-90.6* LYMPHS-5.0* MONOS-3.5 EOS-0.6 BASOS-0.2 [2182-5-1] 04:19PM PLT SMR-NORMAL PLT COUNT-273# [2182-5-1] 04:19PM PT-13.9* PTT-25.1 INR(PT)-1.2* <br> [2182-5-1] 4:45 pm URINE Site: CATHETER FINAL REPORT [2182-5-2] URINE CULTURE (Final [2182-5-2]): GRAM NEGATIVE ROD(S). ~1000/ML. GRAM POSITIVE BACTERIA. ~1000/ML. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. <br> [Known lastname ],[Known firstname ] DR [Medical Record Number 53950] M 82 [2099-9-16] Radiology Report CHEST (PORTABLE AP) Study Date of [2182-5-1] 4:52 PM [Last Name (LF) ],[First Name3 (LF) ] EU [2182-5-1] 4:52 PM CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 53951] Reason: Evaluate for infiltrate/edema [Hospital 93] MEDICAL CONDITION: 82 year old man with sob REASON FOR THIS EXAMINATION: Evaluate for infiltrate/edema Final Report CHEST RADIOGRAPH PERFORMED ON [2182-5-1] Comparison is made with a prior chest radiograph from [2182-3-15]. Prior chest CT from [2178-10-30] is also available for comparison. CLINICAL HISTORY: 82-year-old man with shortness of [Month/Day/Year 1440]. Evaluate for pneumonia or edema. FINDINGS: Single portable AP chest radiograph is obtained. Slight motion blur limits evaluation. There are increased patchy opacities involving both lungs which is most compatible with multifocal pneumonia, though mild superimposed congestion cannot be excluded. There may be small bilateral pleural effusions. Heart size is at the upper limits of normal. Mediastinal contour is unremarkable. Atherosclerotic calcifications of the aortic knob are noted. There is no pneumothorax. Bony structures appear grossly intact. IMPRESSION: Findings most compatible with multifocal pneumonia with possible superimposed mild congestion, bilateral small pleural effusions. <br> [5-5] EKG - sinus, 1st degree block - noted ST/TW changes from admission - without changes, mild prolonged Qtc <br> [5-2] Echo - EF noted 45-50% <br> The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with akinesis of the inferior wall and hypokinesis of the inferior septum. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [2181-2-1], the inferior septum appears mildly hypokinetic on the current study and the inferior wall is frankly akinetic. Overall EF is correspondingly lower. Brief Hospital Course: 82M with metastatic adenocarcinoma of unknown prior, CAD, advanced Parkinson's Disease p/w PNA and UTI from [Hospital 100] Rehab - found also to have positive biomarkers for NSTEMI (due to demand stress) - admitted to [Hospital Unit Name 153] - cardiology notified - tx with hep gtt - otherwise just medical management, and with abx for PNA. Pt infx improving slowly with details below - transfered to floor early am of [2182-5-3]. Pt overall severely dehabilitated - otherwise clinically improving from infectious standpoint on floor. Geriatrics service consulted (Dr. [Last Name (STitle) ] over weekend) for assistance - note after full discussion with pt and family - pt wants aggressive treatment as possible (including full onc evaluation that is planned for [2182-5-13] as outpt with Dr. [Last Name (STitle) ] (has been notified and aware of patient's concerns). Pt without CP complaints past 48h with EKGs without changed today from initial admission - however trop further elevated than admission levels (mid 2 range) now at 4.37 - with lack of sx or ekg changes will cont current managment acutely but asking for full cardiology evaluation for further assistance (as pt is interested in aggressive treatment options after full discussion). Dispo: await cardiology assessment, noted mid-line access lost over weekend, PICC nurse unable to access - awaiting IR PICC access in am - once PICC placed and cardiology eval completed - can transfer to back to [Hospital ] rehab. <br> 1. PNA, treating hospital acquired: Patient had started treatment for PNA at [Hospital 100] Rehab. Was started with ertepenem at rehab center with pt with resistant klebsiella UTI -tx to [Hospital1 18] for further eval of high fevers/sob - where additional NSTEMI dx as noted. Pt tx with vanc/[Last Name (un) 2830]/levoflox with double coverage for gram negatives in ICU - on [5-3] on floor - with pt doing better - d/c levoflox - BCx without growth to date - no sputum sent for cx prior - given [Hospital ] hospital stay and from NH - will cont coverage for HAP with vanc - and cont meropenum course. However on [5-5] - pt lost complete access - PICC nurse unable to attain any access, and unable to locate site for EJ attempt - given clinical stability AND that pt with PNA process not UTI - will cont treatment with just levofloxacin po - and restart today - and d/c meropenem as a result. Pt will still need access for cont treatment with vanc (will 3 more days) - IR consult placed (placed as urgent). Changed vanc dosing to q24H on [5-5] with low trough (improved renal fx). - Change IV vanc to q24h (dose given this am) - due to now access lost - will d/c meropenem - start levofloxacin PO - monitor overnight - needs total of 3 more days of treatment - trying to obtain sputum cx if possible but cont treatment as above - noted [5-1] blood cx with no growth to date, and [4-30] culture from HRC. - (urine legionella neg) - to complete total of 8 days of Rx. then PICC line can be removed. <br> # UTI: h/o ESBL Klebsiella in the last. However with 5/27 UCx results - no active infection from urinary tract - so abx for PNA process as above (thus ok to change to levofloxacin from meropenem). <br> # NSTEMI: positive biomarkers, ST depressions on ECG and new inferior akinesis on echo. AMI is likely a couple of days prior to admission given the relatively low CK and more elevated troponins vs more demand effects from infection. Pt initially tx with hep gtt- cardiology involved prior - now just cont medical mgmt. However with trop increase - pt's interest in aggressive treatment options. - cardiology consulted - medical management recommended and enacted. - continued asa, simvastatin, metoprolol, isosorbide as per cardiology recommendation. <br> # hematuria: Patient has been evaluated for this over the past several weeks at [Hospital 100] Rehab. He required 3 way foley with bladder irrigation while on heparin gtt in [Hospital Unit Name 153]. Sx improving - pt today more agreeable to d/c foley - hematuria resolved and foley discontinued. <br> # metastatic CA: Patient was recently diagnosed with metastatic adenocarcinoma of unknown primary. He was followed by Dr. [Last Name (STitle) ] in onc clinic at [Hospital1 18] - outpt hem/onc follow-up - noted pt and family still interested in full treatment options - geriatrics consulted - assisting dicussions: o/p evaluation arranged. <br> # anemia: likely due to hematuria. Stable, hematuria resolved. # CKD, stage III Cr at baseline (1.3 - 1.6) # Hyponatremia - mild - and more hypervolemia per exam. -gave 1x dose lasix 40mg IV [5-4] with improvement today - remained stable, only mildly low at 130 # [Month/Year (2) 53947]: c/w sinemet/mirapex Medications on Admission: oxyCONTIN 20mg PO BID Miralax 17gm po qOD pramipexole 0.125mg PO TID Norvasc 5mg PO daily Sinemet 25/100 PO BID 9am 2pm, 6,11, 16h vitamin d 1000 units daily docusate sodium iron 325mg PO BID finasteride 5mg PO daily Gabapentin 300mg PO qhs imdur 60mg PO daily mrimidone 25mg PO qHS Senna 1 tablet PO daily [Hospital1 ] Sertraline 12.5mg PO daily Simvastatin 40mg pO qHS flomax 0.4mg PO qhs lisinopril 10mg PO daily prilosec 20mg po daily Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 3 days. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO FIVE TIMES DAILY (). 4. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): at 0600, 1100, 1600 . 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO QHS (once a day (at bedtime)). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 10. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Primidone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 12. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 14. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 18. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 19. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 20. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Insulin Regular Human 100 unit/mL Solution Sig: as per sliding scale units, insulin Injection ASDIR (AS DIRECTED): see attached sliding scale. 22. 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. 23. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection three times a day: sub cutaneuous, for DVT prophylaxis. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: # Hospital Acquired Pneumonia # NSTEMI/CAD # metastatic cancer of unknown primary # chronic kidney disease # parkinson's disease Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet <br> Your diagnoses are as below - you are going to be finish your antibiotic treatment for your infection as below. Your overall weakness currently as we had discussed is related to your severe dehabilitation from the recent infection in setting of all your on-going chronic medical problems including the cancer. You are to participate with rehab to the best of your ability, and as you have arranged prior will be seeing your oncologist as below on [2182-5-13]. <br> If you re-develop a fever, worsening shortness of [Date Range 1440] or chest pain, or any other concering symptom - have your provider evaluate you and/or return to the hospital. Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2502], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2182-5-13] 10:00 <br> Please call your PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 38919] to arrange a follow-up appointment in 2 weeks - though you will be seen by your provider at [Hospital 100] rehab for now.	[ "995.92", "332.0", "276.1", "600.00", "199.1", "276.7", "530.81", "414.01", "585.3", "482.9", "197.7", "599.71", "412", "428.0", "599.0", "V10.82", "410.71", "038.9", "428.22" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	15378, 15444	7844, 12655	307, 313	15617, 15626	3656, 5542	16434, 16846	3474, 3510		13166, 15355	5582, 5607	15465, 15596		12681, 13143				15650, 16411									3525, 3637																										231, 269	5639, 7821						341, 2123																		2145, 2813	2829, 3458
43,770	193,987	43963	Discharge summary	report	Admission Date: [2200-4-10] Discharge Date: [2200-4-17] Date of Birth: [2135-7-29] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 78] Chief Complaint: CC:[CC Contact Info ] Major Surgical or Invasive Procedure: [2200-4-11] Bilateral Craniotomies for evacuation of bilateral subdural hematomas [2200-4-14] Return to OR for removal of left drain History of Present Illness: HPI: This is a 64 year old woman who came to the neurosurgery clinic in [Month (only) 956] for follow up on chronic left sided SDH. She developed a new R SDH and was admitted for observation. She was eventually discharged with 24 hr supervision. She had a follow up CT today that showed enlargement of the bilateral SDH. She is having difficulty with headaches, memory and cognitive functioning. She slid off the bed this week but did not hit her head. She and her HCP, her daughter, agreed to proceed with craniotomies for evacuation. She was admitted from our clinic due to her cognitive impairment. Past Medical History: depression hypercholesterolemia Recent weight loss Social History: Lives alone in [Hospital1 392], MA. Has been separated from her husband for several years. The husband is health Care proxy. The patient and husband continue to file taxes together and share medical insurance. Daughter away at second year of college. Retired in [2199-6-26] from a position with the Dept of Public Health as a social worker with the [Hospital1 ] Family Support Group. No smoking. Alcohol 1-2 drinks per year. No illegal drug use Family History: No family history of strokes or dementia. Mother deceased from lung cancer. Father with coronary artery disease and deceased from MI. Physical Exam: PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD. Slow speech, tangential thinking HEENT: Pupils: [3-28] EOMs intact Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. RLE [2-28]+ pitting edema in lower extremities Neuro: Mental status: Awake and alert, cooperative with exam, flat affect Orientation: Oriented to person, place, month. Language: Speech slow. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: No abnormal movements, tremors. Strength full power [5-31] throughout. No pronator drift Sensation: Intact to light touch Handedness Left On Discharge: She is pleasant and awake. She Oriented x 3, slow to answer but appropriate. speech is fluent and slow. PERRL 3-1.5 b/l. EOMs full. Face symmetric, tongue is midline with good palatal rise. Motor is [5-31] b/l. sensory is intact to light touch. no pronator drift. Pertinent Results: CT head [2200-4-10] Acute on chronic subdural hematomas, increased in size compared to prior study on [2200-3-6]. No evidence of herniation, infarction, or midline shift. CT head [2200-4-11] 1. Interval bilateral craniotomies with placement of bilateral subdural drains. Decreased size of bilateral subdural collections with persistent sulcal effacement and increased effacement of the ventricular system without evidence for herniation. 2. Large amount of post-procedural pneumocephalus CT head [2200-4-12] 1. Since the CT of roughly 17 hours earlier, there is decreased pneumocephalus but no interval change in the bilateral subdural fluid collections or the position of the subdural drains. 2. No shift of midline structures and no evidence of central herniation CT head [2200-4-13] Stable appearance compared to previous scan Chest xray [2200-4-13]: IMPRESSION: AP chest compared to [4-10]: As before lungs are hyperinflated, suggesting COPD or small airways obstruction, but clear of any focal abnormality. There is no pulmonary edema. Heart size is normal, and there is no pleural effusion. Incidental note made of azygos fissure, clinically insignificant anatomic variant. Ct head [4-15] - Status post interval removal of bilateral subdural drains with stable pneumocephalus and bilateral subdural fluid. Persistent bilateral dense foci within subdural fluid collections may be related to acute -subacute blood products , similar to prior. Brief Hospital Course: Ms. [Known lastname ] was admitted from neurosurgery clinic with enlarging chronic bilateral SDH, larger on the left than the right. On [4-11] she underwent bilateral craniotomies for evacuation of hematomas. Two subdural drains were placed. THe patient tolerated the procedure well, was extubated and transferred to the ICU for Q1 hour neuro checks and systolic blood pressure control less than 140. She was placed on flat bed rest x 24 hours. Postoperative head CT decrease in bilateral SDH and post operative pneumocephalus. On [4-12], bilateral subdural drains continue to have significant output. Patient on exam is stable. A repeat head CT was done and showed appropriate placement of bilateral subdural drains and decreased size of bilateral SDH. CT on [4-13] did not show much expansion of her brain and the drains were left in place. She wa OOB to chair and her diet was advanced. On [4-14], bilateral subdural drains were removed. R drain at bedside and L drain in OR due to position of catheter. Patient remained stable throughout the day. Head CT on [4-15] showed stable post operative changes. Social work met with the husband and the daughter along with the neuropsychiatry to discuss patients underlying dementia and defecits. We will have ongoing conversations with the family about patient's new diagnosis. Neurology recommends follow up as an outpatient in the Cognitive [Hospital 878] clinic in 2 months. The patient was seen and evaluated by physical and occupational therapy. They recommended acute rehab at [Hospital1 ]. She is afebrile, VSS and neuro stable. She is tolerating POs and pain is well controlled. Incision is clean, dry and intact. She is set for d/c in stable condition. Medications on Admission: Citalopram 10 mg po daily Keppra 500 mg [Hospital1 ] Crestor 10 mg po QD Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for headache. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Bilateral Chronic Subdural hematoma Confusion Dementia - [Last Name (un) 309] Body post-op fever constipation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [8-5] days(from your date of surgery) for removal of your staples and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. HOWEVER, If you are at rehab/nursing facility, please remove sutures/staple on [2200-4-21]. Call above with questions. ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. ??????Call to schedule your follow up appointment with Neurology, to be seen in 2 months: [Telephone/Fax (1) 1690]. - Please see your primary care upon discharge from hospital Completed by:[2200-4-17]	[ "311", "272.0", "V15.88", "564.00", "294.9", "432.1", "783.21", "780.62" ]	icd9cm	[ [ [] ] ]	[ "86.05", "01.31" ]	icd9pcs	[ [ [] ] ]	7105, 7175	4591, 6346	332, 474	7333, 7333	3082, 4568	9075, 9903	1675, 1813		6474, 7082		7196, 7312		6372, 6451				7518, 9052									1843, 2053																	2787, 3063									267, 294							502, 1110	2207, 2773										7348, 7494							1132, 1185	1201, 1659
30,887	114,428	9618	Discharge summary	report	Admission Date: [2146-5-8] Discharge Date: [2146-5-13] Date of Birth: [2091-8-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 10293] Chief Complaint: Recurrent altered mental status . Major Surgical or Invasive Procedure: Paracentesis . History of Present Illness: 54 year old man with history of ETOh induced cirrhosis with complications of esophageal varices, refractory ascites s/p TIPS and subsequent closure p/w altered mental status. Of note the patient was just discharged from [Hospital1 18] on [2146-5-1] for an admission for hepatic encephalopaty at which time he was found to have a UTI and he completed 7 days of antibiotics. He had his lactulose regimen titrated up during the admission. He had an outpatient liver u/s on [5-6] but the read is still pending. On the afternoon of the 24th his wife noted him to be less interactive and more somnolent. He was at home and leaned down onto floor from his recliner and did not get up. He had a small abrasion on his head. She gave him an additional dose of lactulose. However his somnolence persisted and she had him brought to [Hospital3 3583]. His vitals there were unremarkable and he was breathing comfortably on room air. He received an additional 20 gm of lactulose prior to transfer to [Hospital1 18]. . In the ED his initial vital signs were afebrile 110/79 90 19 97%RA. He received an additional dose of lactulose PO. A head CT was unremarkable for hemorrhage. He was transfered to the floor. . Past Medical History: 1. EtOH induced cirrhosis with portal HTN and esophageal varices, refractory ascites. h/o encephalopathy. previously not candidate for txp due to obesity, but lost 40 lbs and put on list in [10-21]. 2. s/p TIPS [2137] with frequent revisions, [8-4] and TIPS redo [2145-11-19], now s/p closure [4-21] 3. CKD with baseline Cr 1.6 4. DM2 5. s/p ccy for porcelain gallbladder in [10/2145] 6. neuroendocrine tumor in stomach 7. obesity 8. OSA on BiPAP at home c/b mild pulmonary hypertension 9. Squamous cell skin ca on left shoulder 10. s/p rhinoplasty after broken nose 11. s/p surgery for R cheek infection 12. s/p TIPS closure due to frequent encephalopathy [4-/2146] . Social History: Married to wife [Name (NI) ] and living in [Name (NI) 3320]. 16 py h/o smoking, quit 27 years ago. H/O alcohol abuse, quit 10 yrs ago. Remote marijuana/cocaine use in the 60s-70s, no IVDU. Umemployed at present. He previously worked as the Director of food & beverage services on a cruisline in the Hawaiian islands. . Family History: # Mother, d 56: CVA # Father, d 84: Alzheimer's # Sister: DM2, seizures # Brother, older: [Name2 (NI) 3495] disease # Brother, younger: [Name2 (NI) ] known disease . Physical Exam: VS: 97.5 94 129/93 15 97%2L GEN: minimally arousable to voice or noxious stimuli. HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, mild icteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: [Last Name (un) 25359] open ccy scar, pendulous, NT, distended with ascites, + BS, no HSM. marked scrotal edema (inguinal hernia with ascites tracking down). non-visible urethral meatus. EXT: warm, dry, +2 distal pulses BL, no femoral bruits NEURO: awake. arousable to voice and noxious stimuli, not following commands, CN II-XII grossly intact, withdrawals all 4 ext symmetrically. No sensory deficits to light touch appreciated. +asterixis . Pertinent Results: CT head [5-8]: There is no hemorrhage, hydrocephalus, shift of normally midline structures, or evidence of major vascular territorial infarct. The [Doctor Last Name 352]-white matter differentiation is preserved. Hyperdensities are seen within the periventricular and subcortical white matter consistent with chronic microvascular ischemic disease. The visualized paranasal sinuses and mastoid air cells remain normally aerated. The surrounding soft tissue and osseous structures are within normal limits. . CXR [5-8] Portable radiograph of the lower lung and upper abdomen is demonstrated. The NG tube tip is in the stomach. The TIPS catheter is demonstrated in expected unchanged location. The limited evaluation of the upper abdomen is unremarkable. The evaluation of the lung bases demonstrates left pleural effusion and left lower lobe atelectasis. . RUQ US w/doppler [5-9]: Complete occlusion of the TIPS catheter compatible with recent TIPS closure procedure performed on [4-14], 08, no change from [2146-4-27]. . Brief Hospital Course: 54 year old man with history of alcoholic cirrhosis complicated by refractory ascites s/p TIPS c/b recurrent hepatic encephalopathy with TIPS closure, who presented to ICU from OSH for somnolence, now mental status improved with lactulose but still not at baseline. . # Recurrent hepatic encephalopathy: The patient presented with sudden decline in mental status and an unwitnessed fall at home. He was somnolent when he arrived from OSH so was admitted to ICU and improved with lactulose per NGT. Mental status slowly improved back to baseline. We will also evaluate whether the TIPS is still closed. No indication of infection - diagnostic para negative for SBP, UCx negative, CXR without evidence of infection. He was continued on lactulose and rifamixin. RUQ [Month (only) 950] with doppler confirmed TIPS is closed. . # Etoh cirrhosis: He is awaiting liver [Month (only) ]. MELD on admission was 20. Patient has had issues with recurrent hepatice encephalopathy so TIPS was closed on [2146-4-16]. Patient also with h/o esophageal varices but Hct stable and no evidence of bleed. Lactulose and rifamixin were continued as above. Nadolol and diuretics were held initially and then re-started prior to discharge at his pre-admission doses. . # s/p unwitnessed fall: Patient has abrasions on forehead and knees bilaterally when he was encephalopathic prior to admission. CT head negative. Wounds all looked superficial and there was no evidence for more serious injury. . # s/p UTI: Patient finished 7 day course of amoxicillin for enterococcal UTI on [2146-5-5]. Patient had difficult foley placement by urology in ICU so started on a course of CTX but this was discontinued after 2 days as there was no evidence for UTI. Foley was discontinued when his mental status cleared. . #) Pancytopenia: This is chronic and likely [1-15] liver disease. He is known to be guaiac positive, presumed to be from his neuroendocrine tumor in his stomach. Hct at last discharge on [5-6] was 30.2, currently 27-28. . #) DM2: DM regimen at home is NPH 75 units qAM, 70. His regimen was decreased in the ICU as patient was NPO. Once he started eating, his NPH regimen was titrated up to his home doses. He was also covered with a humalog insulin sliding scale. . #) Neuroendocrine tumor: Patient has known 1.5cm mass in gastric cardia from [12/2145], not much increase in change from last EGDs in [2144]. Pathology consistent with carcinoid tumor. No evidence of flushing, increased urination. Patient can follow up as outpatient for further workup of carcinoid syndrome . #) Code status: FULL, confirmed with wife and patient at time of admission. . Medications on Admission: Pantoprazole 40 mg Q24H Magnesium Oxide 400 mg [Hospital1 ] Spironolactone 100 mg [Hospital1 ] Furosemide 100 mg DAILY Rifaximin 400 mg TID Nadolol 10 mg DAILY Lactulose 10 gram/15 mL Syrup Sig: One [Age over 90 ]y (120) ML PO QAM (once a day (in the morning)). Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QNOON. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO QPM (once a day (in the evening)). Insulin NPH 75U QAM;70U QPM 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. Furosemide 20 mg Tablet Sig: Five (5) Tablet PO once a day. 3. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO once a day. 7. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Seventy Five (75) units Subcutaneous qAM. 8. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Seventy (70) units Subcutaneous qPM. 9. Glucerna Shake Liquid Sig: One (1) bottle PO twice a day. Disp:60 bottles Refills:2 . Discharge Disposition: Home With Service Facility: [Age over 90 269] Assoc. of [Hospital3 ] Discharge Diagnosis: Final diagnosis: Hepatic encephalopathy . Secondary diagnosis: EtOH-induced cirrhosis CKD with baseline Cr 1.2-1.5 DM 2 Neuroendocrine tumor in stomach with chronic low grade GIB . Discharge Condition: Stable . Discharge Instructions: You were admitted for confusion and an unwitnessed fall at home due to your hepatic encephalopathy. Initially you were in the intensive care unit as you were very sleepy and required a nasogastric tube for lactulose. You improved with lactulose and were transferred to the medical floor. You had a paracentesis on the day of discharge for increasing ascites with 5L removed. . Please continue all your home medications and keep all scheduled follow-up appointments. . Please call your physician or return to the emergency room if you have any increased confusion, decreased bowel movements despite increased lactulose, fever, chills, pain on urination, or any other new or worrisome symptoms. . Followup Instructions: Provider [Name9 (PRE) ],[Name9 (PRE) 8754] DERMATOLOGY GEN-[Doctor First Name 8754] (NHB) Date/Time:[2146-5-11] 10:00 . Provider [Name9 (PRE) 1382] [Name9 (PRE) 1383], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2146-5-20] 10:00 . Provider PULMONARY FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2146-7-19] 11:10 .	[ "571.2", "572.2", "585.9", "284.1", "327.23", "250.00", "599.0", "303.93", "789.59", "572.3", "V49.83", "584.9", "403.90", "235.2", "608.86", "278.00" ]	icd9cm	[ [ [] ] ]	[ "99.05", "54.91", "96.07" ]	icd9pcs	[ [ [] ] ]	8661, 8740	4715, 7385	349, 365	8964, 8975	3645, 4692	9718, 10083	2693, 2868		7885, 8638		8761, 8761		7411, 7862		8778, 8803		8999, 9695									2883, 3626																										276, 311							393, 1612				8824, 8943														1634, 2333	2349, 2677
26,107	187,321	48582	Discharge summary	report	Admission Date: [2155-4-12] Discharge Date: [2155-4-12] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 106] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: intubation History of Present Illness: [Age over 90 ] year old female who initially presented to ED with worsening chest pain and shortness of breath for 10 to 14 days. In the ED the patient was found to be hypotensive with BP of 77/36 and subsequently went into witnessed arrest. ECG was performed in the ED which initially showed NSR, RBBB with left axis deviation with ST elevations in v1, v2 with lateral ST depression. The patient was given ASA and the ECG progressed to vtach at which point lidocaine and amiodarone was loaded. The patient went into asystole after the lidocaine was given and the patient received atropine and was intubated. The patient subsequently developed junctional rhythm and return to NSR with LBBB and AV prolongation. A bedside TTE was performed which demonstrated an EF of 10% with severe global hypokinesis. 1st set of CE were as follows: CK: 179, MB: 12, MBI: 6.7. The patient was transferred to the CCU for further management. Past Medical History: 1. Hypertension 2. CVD 3. PVD 4. S/p splenectomy 30yrs prior due to thrombocytopenia 5. Cataracts s/p bilateral eye surgery with corneal damage due to hard contact lenses 6. Neuropathy Social History: The patient immigrated from [Country 4754] in [2084], she was widowed in [2141]. She moved to senior housing 6 years ago. Three sisters live locally including her sister, [Name (NI) ], who accompanies her today and one lives in [Location ]. She has no children. She worked as a housekeeper, retiring approx. 2 years ago. No use of alcohol or tobacco. The patient is functionally independent in ADL's and IADL's. She does not drive, but takes public transport, including the T and taxis. Family History: noncontributory Physical Exam: The patient was unresponsive and found to be breathless, pulseless, and without heart tones, blood pressure, and corneal reflexes. The patient was pronounced dead at 1735 on [2154-4-12]. The patient's physician and family were notified. They refused anatomic gifts and autopsy. Pertinent Results: [2155-4-12] 04:20PM CK(CPK)-1611* [2155-4-12] 04:20PM CK-MB-120* MB INDX-7.4* cTropnT-12.46* [2155-4-12] 04:20PM PT-19.4* PTT->150* INR(PT)-2.4 [2155-4-12] 12:35PM LACTATE-7.3* [2155-4-12] 12:35PM freeCa-1.08* [2155-4-12] 09:06AM ALT(SGPT)-764* AST(SGOT)-1028* LD(LDH)-1265* CK(CPK)-367* ALK PHOS-103 TOT BILI-1.0 [2155-4-12] 09:06AM CK-MB-31* MB INDX-8.4* cTropnT-0.98* [2155-4-12] 09:06AM ALBUMIN-3.2* CALCIUM-7.3* PHOSPHATE-5.0* MAGNESIUM-2.8* [2155-4-12] 09:06AM WBC-16.2* RBC-4.17* HGB-12.9 HCT-40.4 MCV-97 MCH-30.9 MCHC-31.9 RDW-14.0 [2155-4-12] 05:29AM GLUCOSE-339* LACTATE-8.7* NA+-141 K+-3.5 CL--115* [2155-4-12] 05:29AM HGB-10.3* calcHCT-31 O2 SAT-98 CARBOXYHB-0.0 MET HGB-0.9 [2155-4-12] 04:45AM GLUCOSE-221* UREA N-20 CREAT-0.9 SODIUM-139 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-20* ANION GAP-19 [2155-4-12] 04:45AM CK(CPK)-179* [2155-4-12] 04:45AM cTropnT-0.21* [2155-4-12] 04:45AM CK-MB-12* MB INDX-6.7* [2155-4-12] 04:45AM WBC-12.5* RBC-4.17* HGB-13.0 HCT-39.5 MCV-95 MCH-31.1 MCHC-32.8 RDW-14.1 [2155-4-12] 04:45AM PLT COUNT-279 [2155-4-12] 04:45AM PT-13.2 PTT-25.6 INR(PT)-1.1 . Echocardiogram The left atrium is dilated. The left ventricular cavity is mildly dilated with severe global hypokinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with mild global free wall hypokinesis (?apical dysfunction more prominent?). The aortic leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . CXR Congestive heart failure. . Brief Hospital Course: [Age over 90 ] year old female with hypertension, cerebrovascular disease, and peripheral vascular disease who presented after 10-14 days of progressive chest pain and shortness of breath with witnessed cardiac arrest in ED resulting in cardiopulmonary resuscitation. She presented intubated and unconscious off sedation to the cardiac care unit. The patient was started on dopamine infusion for inotropic pressure support in the ED but had reached maximum dose available. She was switched to levophed and dobutamine for better blood pressure control assessed by a peripheral arterial line that was placed in the CCU. Beta blockade was held for hypotension. She received aspirin and was started on intravenous heparin. She had been given amiodarone and lidocaine for her arrhythmia, which were discontinued. By echocardiogram, her LVEF was 10%, suggesting she had experienced significant cardiac dysfunction. Additionally, her CK and troponin T continued to climb, indicating large scale, ongoing cardiac damage. On telemetry, the patient exhibited various conduction blockade, including eposodic Weinkebach grouped beating. . The patient likely developed anoxic brain damage due to signficant cardiac arrest in the setting of baseline cerebrovascular disease. She was at presentation nonresponsive without any sedation with decorticate posturing to painful stimuli without evidence of normal withdrawal response. Babinski sign was postive bilaterally but more pronounced on the left. Pupils were fixed and dilated. She had ittle spontaneous limb movement and poor peripheral capillary refill. . She became febrile to >105 rectally during her [Last Name (un) 102218] CCU course. Blood cultures were obtained and results were pending at time of death. The patient's sister, [Name (NI) 13118], and several other family members were present at the time of death. They had opted on the telephone earlier in the day to apply DNR/DNI status per the patient's wishes expressed to multiple family members. The patient was kept intubated on pressors until the family made the decision to withdraw aggressive care, pursuing comfort measures only instead. The patient was successfully extubated without complication and the IV infusions were discontinued. IV morphine was given for comfort without overly reducing respiratory rate. The patient expired within an hour later with family present and last rites were obtained. Medications on Admission: 1. Atenolol 50 mg once daily 2. Ecotrin 81mg once daily 3. ELAVIL 10MG QHS 4. IBUPROFEN 400 MG [Hospital1 ] 5. NEURONTIN 800MG TID 6. NORVASC 5MG QD 7. VITAMIN E 400 INT. UNITS TID Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: congestive heart failure anoxic brain injury cardiac arrest myocardial infarction leukocytosis transaminitis hypocalcemia Secondary 1. Hypertension 2. Cerebrovascular disease 3. Peripheral vascular disease 4. S/p splenectomy 30yrs prior due to thrombocytopenia 5. Cataracts s/p bilateral eye surgery with corneal damage due to hard contact lenses 6. Neuropathy Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired	[ "443.9", "401.9", "427.5", "437.9", "275.41", "348.1", "790.4", "428.0", "410.11" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	6901, 6910	4208, 6636	272, 284	7315, 7324	2329, 4185	7380, 7390	1993, 2010		6872, 6878		6931, 7294		6662, 6849				7348, 7357									2025, 2310																										222, 234							312, 1243																		1265, 1452	1468, 1977
5,450	116,822	21539	Discharge summary	report	Admission Date: [2126-11-16] Discharge Date: [2126-11-22] Date of Birth: [2047-2-18] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3266] Chief Complaint: Hepatic failure Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [Known lastname 56774] is a 79 year-old woman with a history of essential thrombocytosis, chronic anemia, and recently diagnosed ([9-21]) cirrhosis, ascites, and splenomegaly who presents with a several day history of black tarry stools and one episode of brown emesis. Mrs. [Known lastname 56774] first began feeling fatigued 2 weeks prior to admission, and missed a full week of work ([2044-11-2]) secondary to this fatigue. On [11-10] she continued to feel tired and lightheaded, but went to work anyway. On [11-14] she returned home from bingo in the evening and threw-up watery brown emesis with food. Though she cannot specify which day it began, at some point over this week her stools began to appear black and tarry, as they had when she was on iron therapy for anemia. On [11-15] she came home from work so tired that she was unable to climb the stairs in her home, and her family brought her to an outside hospital later that evening. Of note, per her medical record, in [9-21] Mrs. [Known lastname 56774] presented to her PCP with [Initials (NamePattern4) ] [Last Name (NamePattern4) 19341] history of bilateral lower extremity swelling and increased abdominal girth. Abdominal CT ([9-21]) at an outside institution was read as massive ascites with a small nodular liver and splenomegal. Endoscopy ([2-20]) report includes hiatal hernia but no varices. Colonoscopy at this time was reportedly negative. Therapeutic paracentesis revealed a transudate suggestive of portal hypertension, with negative cytology. Serology for Hep B and C were negative, the patient does not drink alcohol or use tylenol regularly. Work-up for autoimmune hepatitis was started. She was started on lasix and aldactone, but could not tolerate the aldactone since she felt ??????dry??????. At the outside hospital on [11-15] Mrs. [Known lastname 56774] was found to have an elevated INR and HCT of 28.6 on admission that dropped to 21.5. She could not be immediately transfused secondary to difficulty matching packed red blood cells. She was given four units of fresh frozen plasma, 2 units of packed red blood cells, and started on prednisone 80 mg for supposed autoimmune hemolysis, as well as folic acid. On [11-16] she was admitted to the [Hospital1 18] MICU, where her intial HCT post-transfusion was 28.5. The MICU course included banding of esophageal varices and medical treatment with octreotide, pantoprazole, and sucralfate. Prophylactic antibiotics were started (metronidazole and levofloxacin, then changed to ciprofloxacin at 500 mg PO q12 hours) to try to avoid spontaneous bacterial peritonitis. EKGs were followed secondary to a slight increase in troponin at outside hospital thought to be due to demand ischemia secondary to blood loss, and an echo was done secondary to a newly perceived heart murmur. The labs sent from the MICU course are listed below. Past Medical History: 1. Essential thrombocytosis 2. Anemia 3. Hepatosplenomegaly with ascites 4. Cystocele Social History: 1. Cook at local school 2. No tobacco, EtOH, IVDA Family History: 1. Mother - metastatic abdominal cancer 2. Father - bone cancer 3. Sister - breast cancer 4. Brother - stroke 5. Sister - liver transplant Physical Exam: T 97.1 HR 54 BP 110/60 RR 18 Sat 91% RA GEN: Alert, awake, oriented, chatty, sitting in chair talking with daughter. Thin [Name2 (NI) 56775] face not in proportion with swollen appearance of extremities and abdomen. HEENT: Head NC/AT. Sclerae anicteric, conjunctiva pale. PERRLA, EOMs intact, VFs full. Nasal mucosa pink, without polyps. No sinus tenderness. Oropharynx clear and nonerythematous. Mucous membranes moist. Trachea midline. Neck supple. Thyroid not enlarged and without nodules. No LAD. CARDIO: JVP 4 cm above the sternal angle at 30?????? elevation. Carotid pulses 2+ bilat.; upstrokes brisk; without bruits. PMI appreciated at 4th-5th IC space on midaxillary line. Holosystolic murmur obscuring S1 best heard at right upper sternal border and lower left sternal border. Otherwise, S1 & S2 normal. No rubs, gallops, heaves or thrills. PULM: Soft crackles at bases bilaterally. No wheezes or rhonchi. [Last Name (un) ]: Distended/obese, nontender. BS present in all 4 quadrants. No bruits. Shifting dullness. Liver edge not felt, but abdomen firm throughout right upper quadrant. Spleen tip felt at umbilicus with splenic body extending to pelvic brim. Bandages covering site of peritoneal tap. No CVA tenderness. EXTR: Warm and well perfused bilaterally. Radial pulses 2+. Post tib. and DP pulses 1+ bilat. Good capillary refill bilat. 1+ pitting lower extremity edema to mid-calf bilaterally. Thickened DIP joints consistent with osteoarthritis bilaterally. NEURO: AOx3. Rest of MMSE not performed. CNs II-XII intact to direct testing. Light touch intract UEs and [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]. No asterixis. No clonus. SKIN: Skin fragile, warm, and moist. Facial skin appears tanned, but difficult to assess presence of jaundice in overhead lighting. Nails without clubbing or cyanosis. Hair of average texture. No spider angiomata. No suspicious nevi. No rashes or petechiae. Several large ecchymoses on arms, burn on right inner wrist. No palmar erythema. Pertinent Results: [2126-11-16] 11:11PM BLOOD WBC-6.4 RBC-2.92* Hgb-9.6* Hct-28.5* MCV-98 MCH-32.9* MCHC-33.6 RDW-20.3* Plt Ct-553* [2126-11-18] 04:44AM BLOOD WBC-8.4 RBC-3.26* Hgb-10.7* Hct-32.8* MCV-101* MCH-33.0* MCHC-32.7 RDW-19.8* Plt Ct-538* [2126-11-16] 11:11PM BLOOD Neuts-92.0* Bands-0 Lymphs-6.5* Monos-1.0* Eos-0.3 Baso-0.2 [2126-11-16] 11:11PM BLOOD PT-15.1* PTT-33.1 INR(PT)-1.4 [2126-11-18] 04:44AM BLOOD PT-15.5* PTT-31.2 INR(PT)-1.5 [2126-11-18] 04:44AM BLOOD Glucose-121* UreaN-41* Creat-0.8 Na-141 K-4.0 Cl-102 HCO3-33* AnGap-10 [2126-11-16] 11:11PM BLOOD Glucose-119* UreaN-41* Creat-0.8 Na-140 K-3.5 Cl-101 HCO3-32* AnGap-11 [2126-11-18] 04:44AM BLOOD ALT-27 AST-33 LD(LDH)-238 AlkPhos-65 TotBili-1.5 DirBili-0.6* IndBili-0.9 [2126-11-16] 11:11PM BLOOD ALT-30 AST-41* LD(LDH)-256* CK(CPK)-62 AlkPhos-69 TotBili-2.8* DirBili-1.0* IndBili-1.8 [2126-11-18] 04:44AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.1 [2126-11-16] 11:11PM BLOOD Albumin-3.1* Calcium-8.9 Phos-3.0 Mg-1.9 UricAcd-7.9* Iron-87 Brief Hospital Course: Mrs. [Known lastname 56774] is a 79 year-old woman with history of essential thrombocytosis, chronic anemia, and recently diagnosed ([9-21]) cirrhosis, ascites, and splenomegaly who presents with a several day history of black tarry stools and one episode of brown emesis. 1. GI bleed, source unknown, but thought to be secondary to esophageal varices. After receiving packed red blood cells and fresh frozen plasma, her hematocrit has stabilized. EGD revealed varices, subsequently banded, but no active bleeding. Negative colonsopy reported from [2-20]. HCT over past 24 hours have been stable > 29. She was treated with sucralfate, nadolol, octreotide and antibiotic prophylaxis. She remained stable in that respect throughout her stay. 3. Decompensated chronic liver failure, unknown etiology: The patient has cirrhosis diagnosed by CT, ascites, esophageal varices, decreased synthetic function (increased INR, low albumin). THe patient underwent a diagnostic/therapeutic paracentesis on [11-17], [2082] cc of fluid consistent with ascites (no malignant cells, serum-ascites albumin gradient = 2.0). Various diagnoses were excluded both during this stay and prior to arrival. These included infectious, alcoholic, NASH, autoimmune, metabolic. A liver biopsy was performed on [2126-11-20] which revealed cirrhosis but no evident causes. She underwent a second therapeutic paracentesis prior to her discharge which produced large amounts of fluid and relieved her mild shortness of breath and hypoxia (sats. 91-92). 4. Anemia: There are multiple possible origins to Mrs. [Known lastname 56774]?????? anemia. Her anemia diagnosed in [2-20] was treated with iron and transfusion, and is now exacerbated by her GI bleed. In contradiction to her original treatment with iron and labs at the outside hospital that indicate iron deficiency anemia, her current anemia is macrocytic, the differential diagnosis of which primarily includes deficiencies of folate or B12 secondary to malnutrition or absorption disorders; however, Mrs. [Known lastname 56774]?????? lab values for both folate and B12 are elevated, most likely due to supplementation. It is also possible that the macrocytosis and elevated RDW were secondary to liver failure. Her reticulocyte level is not high enough (2.9%) to cause such a high MCV. Another possible cause of her anemia could be her ten-year treatment with hydroxyurea. Data from the OSH included a positive Coombs antibody test combined with the elevated indirect bilirubin could indicate hemolysis, but in the setting of cirrhosis with a normal haptoglobin level and normal LDH significant hemolysis is unlikely. Thus, for treatment we deferred from continuing the prednisone and folate started at the OSH. As her iron levels are low, we restarted iron supplementation. 5. Essential thrombocytosis: Has been taking hydroxyurea for at least ten years. Platelets 538 on admission. The hematologist advised to hold her hydroxyurea until her platelet count reached 800. 6. New murmurs: New murmurs of mitral and tricuspid regurgitation and aortic stenosis auscultated and validated by echocardiography. Mrs. [Known lastname 56774] was discharged after an uncomplicated [Hospital 56776] hospital stay with a diagnosis of decompensated liver failure and gastrointestinal bleed. She was sent home in stable condition and with close follow up with the GI service. Medications on Admission: 1. Hydroxyurea 10 mg once daily 2. Aspirin 81 mg once daily 3. Lasix 4. Multivitamins Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day): Please stop sunday night [11-24]. Disp:20 Tablet(s) Refills:0 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily) as needed for PRN bowel mov't: Please ttitrate to [2-19] bowel mov't per day if patient is showing signs of confusion. Disp:qs bottle Refills:1 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Decompensation of liver failure with GI bleed Discharge Condition: good Discharge Instructions: Please take all medications as directed. Sucralfate should be taken through Sunday [11-24], and Pantoprazole until your procedure with Dr. [Last Name (STitle) ]. Otherwise, the prescriptions are on-going. Continue with incentive spirometry and ambulation at home. Please call Dr. [Last Name (STitle) ] and return to the ED immediately if there you have vomit with dark material or blood, dark tarry stools or blood per rectum, confusion that is not relieved by lactulose, shortness of breath, dizziness, or any other concerning symptoms. Please maintain a low-salt diet and restrict fluids to 1.5L max per day. Your medications will need to be adjusted in the near future by Dr. [Last Name (STitle) ] according to how much fluid you are retaining and future procedures. Followup Instructions: Please follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2126-11-24] for EGD/banding procedure. Her office will call you with the time of the appointment. Please follow-up with PCP within [Name9 (PRE) 56777] of discharge. Completed by:[2126-12-11]	[ "789.5", "289.9", "572.3", "456.20", "572.2", "280.0", "571.5" ]	icd9cm	[ [ [] ] ]	[ "45.13", "54.91", "50.11", "42.33", "99.07" ]	icd9pcs	[ [ [] ] ]	11298, 11304	6746, 10187	333, 339	11394, 11400	5692, 6723	12234, 12535	3497, 3637		10323, 11275		11325, 11373		10213, 10300				11424, 12211									3652, 5673																										278, 295							367, 3305																		3327, 3414	3430, 3481
66,256	187,869	13112	Discharge summary	report	Admission Date: [2169-11-29] Discharge Date: [2169-12-2] Date of Birth: [2105-9-19] Sex: F Service: MEDICINE Allergies: Aspirin / Ciprofloxacin / Procardia / Niacin / Biaxin / Niaspan / Ibuprofen / Crestor / Quinolones / Neosporin / Adhesive Tape Attending:[First Name3 (LF) 1257] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: bronchoscopy PICC placement History of Present Illness: This is a 64F with sarcoidosis, h/o left lower lobe wedge resection for pulmonary nodules, and tracheobronchomalacia who was recently admitted ([Date range (1) 40041]) for removal of Y stent and debridement of granulation tissue in the L mainstem bronchus who now presents with increased shortness of breath--could not walk to bathroom without severe dyspnea--went to OSH, found to be in rapid afib; started dilt gtt at OSH, and transferred here, where she was in sinus rhythm on dilt gtt. However, still dyspneic. In the ED, still on dilt gtt. CTA looks like collapse of LLL (no PE); IP aware, and plan bronch tomorrow (NPO p MN, coags buffed). 85, 102/65, 25, 93-6% 3L. ROS: Had been constipated during recent hospital stay, then had large BM at home. The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, melena, hematochezia, chest pain, orthopnea, PND, lower extremity oedema, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: 1. Obesity. 2. History of pericarditis/tamponade secondary to polyserositis. She has been on steroids for this for the past 17 years. 3. History of pleural effusion. 4. Sarcoidosis. 5. GERD. 6. History of lung nodule status post thoracotomy with left lower lobe wedge resection ([Hospital1 2025] [2160]). 7. Asthma. 8. Hiatal hernia. 9. OSA on nocturnal CPAP (plus 12) 10. Hypertension. 11. Lactose intolerance. 12. Tracheobronchomalacia; had Y stent placed [2169-11-6], with no improvement in dyspnea but worse [Last Name (LF) ], [First Name3 (LF) ] it was removed [2169-12-4]. Social History: The patient is divorced. She lives alone in [Location (un) ], [State 350]. She has one son who lives close by. She has been on disability since [2149]. Prior to that, she worked as a financial analyst. She has a rare glass of wine. She quit smoking in [2160]. Prior to that she smoked a pack a day for 40 years. She has never used any illicit drugs. She denies asbestos exposure and reports no known TB exposures. She had a negative PPD test last year prior to starting Enbrel therapy. Family History: There is no family history of lung disease or sarcoid. Her mother died secondary to rectal cancer 82 years old. Notably she did have lupus. Her father died secondary to an MI at 72 years old. Her son is healthy. Physical Exam: Vitals: T:98.5 BP:154/39 HR:75 RR:12 O2Sat:97% 3L GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses Pertinent Results: [2169-11-29] 03:53PM GLUCOSE-135* NA+-139 K+-4.5 CL--94* TCO2-31* [2169-11-29] 03:45PM UREA N-13 CREAT-0.5 [2169-11-29] 03:45PM CK(CPK)-24* [2169-11-29] 03:45PM cTropnT-<0.01 [2169-11-29] 03:45PM CK-MB-NotDone [2169-11-29] 03:45PM WBC-18.8* RBC-4.52 HGB-12.0 HCT-35.5* MCV-79* MCH-26.5* MCHC-33.7 RDW-14.9 [2169-11-29] 03:45PM NEUTS-91.0* LYMPHS-5.6* MONOS-1.9* EOS-1.1 BASOS-0.3 [2169-11-29] 03:45PM PLT COUNT-778* [2169-11-29] 03:45PM PT-14.1* PTT-28.5 INR(PT)-1.2* [2169-11-29] 04:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Laboratories: OSH labs this morning notable for TnI 0.04, BNP 17, CBC and lytes similar to ED labs here. ECG: Sinus rhythm at 91 bpm, nml axis, incomplete RBBB, ant T waves are flat, similar to [2169-11-26]. Imaging: CXR: There is atelectasis at the left lung base. There is stable cardiomegaly. The right lung is clear. CONCLUSION: Minimal stable atelectasis in the left lower lobe with no acute cardiopulmonary process. CTA Chest [2169-11-29]: IMPRESSION: 1. No pulmonary embolism. 2. Worsening left basilar collapse, presumably secondary to collapse of the left mainstem bronchus, likely due to the patient's known diagnosis of tracheobronchomalacia. Extrinsic compression is less likely, though there is some increased soft tissue surrounding the area of the collapsed left mainstem bronchus, and scattered borderline mediastinal lymph nodes as previously described. TTE [2169-12-1]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 64yoF with tracheobronchomalacia, recently admitted for removal of Y stent in the L mainstem, now with LLL collapse, likely from mucus plugging, pt was admitted to the [Hospital Unit Name 153] for new onset afib requiring a Diltiazem drip. . # Dyspnea/LLL collapse: [11-30] bronchoscopy revealed reaccumulation of granulation tissue and mucous which appeared purulent. BAL could not be sent due to limited size of her airways. She was started on Vanc/Cefepime day 1=[12-1], 7 day course complete on [2169-12-7] for healthcare associated pneumonia. PICC line was placed [2169-12-1]. Pt was continued on [Month/Day/Year ] suppressants, supplemental oxygen as needed, and nebulizer treatments. Sats remained stable throughout this hospitalization on 2-3L oxygen via nasal cannula. . # afib: Pt has had new afib observed over a few days prior to her unit admission, with poor rate control on arrival from OSH. Pt was initially transferred from the ED to the ICU on a diltizaem however several hours into admission was able to be weaned to PO Diltiazem and Metorpolol. Given her CHADS2 score of 1, pt was not started on anticoagulation. Noted to be in sinus rhythm on day of transfer so no DCCV was initiated. A TSH was checked for the a. fib work up and was 0.081 with a free T4 of 1.9. She had no further episodes of atrila fibrillation HD [12-19]. TTE on [2169-12-1] revealed mildly dilated left atrium. LVEF 70%. # HTN: on micardis 40/12.5 at home, as well as lasix and toprol XL 25mg daily. Her Toprol was continued at her home dose, but her outpatient micardis was held. She was started on diltiazem 30mg QID for control of her atrial fibrillation as well as control of her blood pressure. Her blood pressure was stable on this regimen. # asthma: Pt was continued on montelukast, advair 250-50 [Hospital1 ] . # allergic rhinitis: Pt was continued on fluticasone nasal, zyrtec . # sarcoidosis, h/o serositis: not active. Continued prednisone taper and bactrim for PJP prophylaxis. . # chronic pain: continued cyclobenzaprine, oxycodone . # OSA: continued home CPAP of 12 cm H20 In the out patient: Diltiazem can be changed to long acting formulation, or alternatively, discontinued, and her BBloker dose can be increased to 50 Mg daily to minimize her medications. Medications on Admission: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 8. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 12. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day for 2 days. Disp:25 Tablet(s) Refills:0 13. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 3 days. 14. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 3 days: then 1 x days, then [11-17] tablet (5mg) x 3 days. 15. Saline Solution Sig: Three (3) ML Miscellaneous three times a day: Nebulizers.Disp:300 Refills:2 16. Micardis HCT 40-12.5 mg Tablet Sig: One (1) Tablet PO once a day. 17. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day. 18. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day. 19. Cyproheptadine 4 mg Tablet Sig: One (1) Tablet PO twice a day. 20. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as needed. 21. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO once a day.Disp:15 Tablet Sustained Release 24 hr(s) Refills:2 Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 7. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO daily () for 1 days: [12-3]. 8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 3 days: [Date range (1) 40042]. 9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 3 days: [Date range (1) 23500]. 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 3 days: [Date range (1) 23501]. 11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 12. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 13. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO every twelve (12) hours. 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Cyproheptadine 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 21. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 22. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 23. Chlorpheniramine-Hydrocodone 8-10 mg/5 mL Suspension, Sust.Release 12 hr Sig: Five (5) ML PO Q12H (every 12 hours) as needed. 24. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 25. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 26. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours). 27. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): see attached insulin sliding scale. 28. Ondansetron 4 mg IV Q8H:PRN 29. CefePIME 2 g IV Q12H 30. Vancomycin 1000 mg IV Q 12H 31. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day as needed for fluid overload. 32. Saline Mist 0.65 % Aerosol, Spray Sig: One (1) Nasal four times a day as needed. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: primary: left lower lobe collapse tracheobronchomalacia atrial fibrillation secondary: sarcoidosis obstructive sleep apnea hypertension obesity Discharge Condition: stable Discharge Instructions: You were admitted for collapse of your left lower lobe due to your tracheobronchomalacia. While you were here, you had bronchoscopy which revealed granulation tissue and mucous plugging. You were started on antibiotics to treat a hospital acquired pneumonia, you should continue these until a 7 day course is complete on [2169-12-7]. While you were here, you had atrial fibrillation. You were started on a new medication called diltiazem to control your heart rate. This also helps to control your blood pressure. You should continue to take this medication outpatient. Also, because it helps to control your blood pressure, your other blood pressure medication, Micardis, was held. If necessary, this can be restarted outpatient. If you should have worsening shortness of breath, fever/chills, headache/dizzyness, you should call your regular doctor or present to the emergency department. It is very important that you take all of your medications as directed and follow up with your appointments. Followup Instructions: You have the following appointments: Antibiotic regimen complete [2169-12-7](day 1 of CTX/Vanc= [2169-12-1]) Provider: [Name10 (NameIs) 12554] CLINIC INTERVENTIONAL PULMONARY (SB) Phone:[Telephone/Fax (1) 3020] Date/Time:[2169-12-12] 10:30 Provider: [Name10 (NameIs) 1532] [Last Name (NamePattern4) 8786], MD Phone:[Telephone/Fax (1) 3020] Date/Time:[2169-12-12] 10:00	[ "271.3", "518.0", "427.31", "327.23", "423.2", "517.8", "278.00", "486", "530.81", "553.3", "135", "401.9", "493.00", "V58.65", "519.19", "338.29" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.05", "33.22" ]	icd9pcs	[ [ [] ] ]	13037, 13084	5925, 8231	396, 426	13273, 13282	3664, 5902	14334, 14742	2677, 2890		10227, 13014		13105, 13252		8257, 10204				13306, 14311									2905, 3645																										349, 358							454, 1515																		1537, 2141	2157, 2661
1,603	193,740	18529	Discharge summary	report	Admission Date: [2174-1-19] Discharge Date: [2174-2-1] Date of Birth: [2102-7-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 759] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 71 yo male with metastatic esophageal carcinoma currently being docetaxil and bevacizumab. He underwent a BAL on [1-11] which showed strep pneumo. He was then recently admitted on [1-13]- [1-14] with dehydration and pneumonia, was treated, and discharged with an appointment for a video swallowing study on [1-19] to evaluate for aspiration. He underwent this study today and per patient this went well. He then went back to his house, sat on the stairs because he felt weak, and then lost consciousness and slumped to the side witnessed by his son and wife. There was no head trauma or falls. He was also reported to have cyanotic lips and fingers and chills. His wife called EMS to the [Hospital1 18] [Name (NI) ]. On arrival he had a temp of 100.8, HR in the 140 - 160s, BP 70 - 90 systolic. He had an elevated white count and a lactate of 8.9. Sepsis protocol was instutited, RIJ was placed, and he was given vanco, ceftriaxone, azithromycin, cefepime, potassium repletion, and 2.5 liters of fluid. Since his BP was labile, he was placed on Levophed. His Hb decreased from 12 to 8 after fluids and he was transfused 1 unti of PRBC in the ED. During the past few weeks, the patient reports that he has not been eating due to lack of appetite. He denies N/V/D. He has not had a BM in 4 days. He has been drinking lots of water he reports. + rhinorrhea. Past Medical History: 1. metastatic adenocarcinoma of the GE junction T3/N1, s/p chemo (irinotecan and cisplatin-->carboplatin [2-23] tox). chemo d/c'd 22 disease progression [10-25] 2. emphysema/COPD Social History: quit tobacco 4 years ago, previously smoked one pack per day for 30 years, occasional EtOH, no drugs, lives at home with his wife and is a retired air conditioning business owner. Normally able to walk up stairs, however in the last few days, he has been requiring assistance walking around. Family History: no CAD, cancer, or pulmonary disease Physical Exam: Vitals: T=100.8, HR = 115, BP = 120/60 -> 78/43 -> 100/60 with Levophed, RR =20 , SaO2 = 96% on 4L NC in ER, 98% on RA in ICU General: Pleasant male, appears comfortable, NAD. HEENT: Normocephalic and atraumatic head, no nuchal rigidity, anicteric sclera, moist mucous membranes. Neck: No thyromegaly, no lymphadenopathy, no carotid bruits. Chest: chest rose and fell with equal size, shape and symmetry, lungs were clear to auscultation bilaterally, though with decreased breath sounds. No erythema around Portacath, non tender. CV: PMI appreciated in the fifth ICS in the midclavicular line without heaves or thrills, RRR, normal S1 and S1 no murmurs rubs, distant heart sounds Abd: Normoactive BS, NT and ND. No masses or organomegaly Back: No spinal or CVA tenderness. Ext: No cyanosis, no clubbing or edema with 2+ dorsalis pedis pulses bilaterally Integument: no rash Neuro: CN II-XII symmetrically intact, PERRLA. Strength 5/5 throughout. Pertinent Results: [2174-1-19] 08:33PM GLUCOSE-87 UREA N-12 CREAT-0.7 SODIUM-137 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-21* ANION GAP-13 [2174-1-19] 08:33PM WBC-9.3 RBC-3.31* HGB-10.1* HCT-30.8* MCV-93 MCH-30.5 MCHC-32.8 RDW-16.9* [2174-1-19] 12:24PM GLUCOSE-163* UREA N-19 CREAT-1.1 SODIUM-137 POTASSIUM-7.1* CHLORIDE-97 TOTAL CO2-16* ANION GAP-31* [2174-1-19] 12:24PM WBC-14.0* RBC-4.11* HGB-12.5* HCT-40.8# MCV-99# MCH-30.4 MCHC-30.6 RDW-16.1* CHEST (PORTABLE AP) Reason: eval for Right IJ line placement, PTX [Hospital 93] MEDICAL CONDITION: 71 year old man with s/p endoscopy with syncope REASON FOR THIS EXAMINATION: eval for Right IJ line placement, PTX INDICATION: Evaluate right IJ placement, rule out pneumothorax. AP SUPINE PORTABLE CHEST: Comparison to AP upright chest of two hours [Known lastname ]. There has been interval placement of right-sided IJ line, with its tip in the inferior SVC. No pneumothorax. PortaCath tip unchanged in position. There has been no other significant interval change. IMPRESSION: Right-sided IJ with its tip in the SVC; no pneumothorax. No other significant interval change CT chest/abdomen/pelvis: IMPRESSION: 1) Interval development of small bilateral pleural effusions and free fluid within the abdomen and pelvis without abscess identified. 2) No significant interval change in previously described patchy pulmonary opacities. 3) Unchanged liver lesions and celica axis and mesenteric lymph nodes. 4) No new lesions identified. 4) Interval development of nonspecific colon wall thickening, which is not well distended. Clinical correlation is recommended as this could represent an infectious colitis. Ischemic colitis is considered less likely given distribution. Brief Hospital Course: A/P: 71 yo male, h/o metastatic adenocarcinoma of the GE junction, s/p irinotecan/carboplatin, now on experimental chemotherapeutic regimen, admitted with hypotension (?sepsis), currently stable, being treated for ?pneumonia and poor PO intake. . 1. Hypotension: Initially, sepsis by protocol was instituted in the setting of increased lactate, hypotension, hyperthermia, tachycardia, and an elevated white count. However, most likley not an infectious process, but rather dehydration from paucity of PO intake. The patient was hypotensive in the ED which respondeed to fluid boluses. Other causes: pneumonia, sinusitis, line infection, or autonomic dysfxn [2-23] cisplain therapy. The patient was admitted to the [Hospital Unit Name 153]. He was treated witht he sepsis protocol. His lactate continue to be low, his pressure increased with fluid boluses and his Levophed was weaned to off. GIven his nasal conjestion, cough, and weakness, he was placed on precautions and evaluated for influenza which was negative. Screening for adrenal insuffiency was negative. Blood and urine cultures were also taken which were also negative. Vancomycin, azithromycin, and cefepime was stopped and the Levofloxacin was contined for strep pneumo coverage that had previously been documented via bronch. He completed his Levaquin on [2174-1-26]. Pt subsequently transferred to regular medical service from ICU. On the floor the pt continued to be baseline hypotensive to the 80s systolic. Review of the pt's OMR chart shows that this was his baseline bp [Known lastname ] to any chemotx. . On the floor, he continued to be stable hemodynamically. The levofloxacin was continued until [2174-1-24] for empiric pneumonia coverage (and given history of strep pneumo on bronch recently). He was continued on IVF for poor PO intake (was hemodynamically/had adequate SBP's). CT of the chest/abdomen/pelvis was negative for any obvious source of infection, and he remained afebrile with a normal WBC. . 2. Syncope/orthostasis: there was a question of whether he syncopized on day of admission. He was persistently hypotensive (SBP's 80-100) while in-house, although this appears to be close to his baseline when old OMR notes were referenced. He was maintained on telemetry with no significant events. Pt also had TTE showing mild diastolic dysfunction but o/w no signficant structural heart disease to account for syncope. Later in hospital course, pt was found profoundly orthostatic with systolic pressure going from 100 to 50 w/ supine to standing. Although syncope was not induced, pt was quite symptomatic w/ these changes. The etiology of this orthostasis remains unclear. As mentioned below, pt has had difficulties w/ adequate po intake secondary to anorexia - however, he was not felt to be profoundly dehydrated. It was theorized that there may be component of autononic dysfunction (for unclear reasons) causing orthostasis and tilt test was performed. Preliminary results from the tilt were equivocal and after discussions w/ oncology, it was decided to start patient on florinef 0.1 mg po bid, with some objective decrease in the degree of his orthostatis. Midodrine was added as well. Plan for pt to go to rehab for further stabilization w/ neuro and autonomic f/u. . 3. Esophageal Cancer: Team was in communication with Dr. [Last Name (STitle) 3274]. Torso CT was obtained to evaluate fo disease progression as his degree of FTT is out of proportion to his chemotherpy and known stage of his disease. CT did not show any significant interval change in his disease. Chemotherpy has been held for a few weeks given his degreee of weight loss and lethargy (currently on ?experimental bevacizumab and doxetaxol; His irinotecan/carboplatin was stopped in [10-25] secondary to disease progression). He was seen by oncology consult team while in-house but had no active oncologic issues. Of note, the oncology team thought his level of anorexia was not likely solely due to his disease or chemotherapeutic regimen. He has been asked to call dr. [Last Name (STitle) ] following d/c for f/u to discuss further managment of esophageal cancer. . 4. Anorexia: As per patient and his wife, he has had a [Last Name 19390] problem with poor PO intake. He was recently started on megace without much success. Psychiatry was consulted and did not feel the anorexia was secondary to depressive symptoms. As above, oncology felt neither his disease nor chemotherapeutic regimen could account for his level of anorexia. Nutrition was consulted, and IVF were continued as needed for poor PO intake. Psych had suggested remeron for improved appetite but oncology recommended on holding on further medications at this time. Ultimately, pt has shown improved po intake over the remainder of his hospital course. Nutrition has recommended continued supplement w/ carnation instant breakfast 3x day. . 5. ?Colonic Thickening with free fluid: This was seen incidentally on staging CT of chest and abdomen. Pt had no symptoms of diarrhea or abdominal pain, and he had a benign abdominal exam. C. difficile sample was sent (given pt hospitalized, on antibiotics) and was negative. . 6. Dispo: It was felt that an acute rehabilitation facility was more appropriate than returning home given pt's poor PO intake, debilitation, and generalized wekaness. For this reason, will be transfered to [Hospital 100] Rehab. . 7. Code: full per initial discussions w/ wife. Medications on Admission: Megace 40 QID Compazine prn reglan 10 QID and prn ativan 0.5mg q8 prn advair 250-50 [Hospital1 ] ipratrop 2puff QID levofloxacin 500 ending on [1-24] colace, senna tylenol #2 [1-23] tab prn Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. Fludrocortisone Acetate 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Megestrol Acetate 40 mg/mL Suspension Sig: Twenty (20) cc PO DAILY (Daily). 9. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 10. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain, insomina. 11. heparin 5000 units sc tid while lying in bed Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: hypotension, unclear etiology resolved orthotasis syncope presumed secondary to orthostasis metastatic esophageal carcinoma Discharge Condition: fair Discharge Instructions: please return to ed or [Name8 (MD) 138] md [First Name (Titles) ] [Last Name (Titles) 5162], chills, shortness of breath, palpitations, chest pain, syncope. please take medications as directed please be sure to rise slowly while standing. Followup Instructions: Please call PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] after d/c'd from rehab Provider: [Name10 (NameIs) ],[First Name3 (LF) ] MULTI-SPECIALTY MULTI-SPECIALTY THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI Date/Time:[2174-2-17] 10:00 Provider: [Name10 (NameIs) ] [Name8 (MD) 4777], MD Where: [Hospital6 29] NEUROLOGY Phone:[Telephone/Fax (1) 44] Date/Time:[2174-3-10] 10:00 Autonomic Lab [2174-3-10] at 10am, Palmes III, [Hospital Ward Name 517], Autonomic Lab. Repeat TSH in 6 weeks.	[ "780.2", "199.1", "458.0", "793.4", "780.79", "783.0", "197.8", "276.5", "492.8", "458.9", "482.30" ]	icd9cm	[ [ [] ] ]	[ "00.17", "89.59", "99.04", "38.93" ]	icd9pcs	[ [ [] ] ]	11881, 11954	5057, 10547	325, 331	12122, 12128	3295, 3816	12428, 12989	2275, 2314		10799, 11858	3853, 3901	11975, 12101		10573, 10776				12152, 12405									2329, 3276																										274, 287	3930, 5034						359, 1740																		1762, 1950	1966, 2259
19,038	131,354	51567	Discharge summary	report	Admission Date: [2182-8-15] Discharge Date: [2182-8-21] Date of Birth: [2133-12-20] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: s/p renal transplant over 20 years ago, now failed, ESRD, here for renal transplant Major Surgical or Invasive Procedure: [2182-8-15] renal transplant History of Present Illness: Pt is a 48 year old male s/p renal transplant over 20 years ago. The native kidney failed [2-11] glomerulonephritis. The transplanted kindey failed 3 - 4 years ago since which time patient has been on hemodialysis three times a week, Tue/Thr/Sat. He is dialyzed through right upper arm AV fistula. Past Medical History: -h/o fistula s/p repair, c/b seizures and cord compression -Hypertension -Dyslipidemia -History of gloerulonephritis, then received cadaveric renal transplant, ~20 yrs ago, on immunosuppressants in past, transplant failed 2 years ago and now on hemodialysis. -[2182-8-15] renal transplant -Anemia -Coagulase negative staphylococcal bacteremia -Community-acquired pneumonia -Duodenal ulcers status post thermal therapy/injection -Pericardial effusion -Obesity -Osteopenia Social History: Has lived with his mother and children in the past, now living with sons. Former businessman, not working because he remains on dialysis. He denies use of tobacco, alcohol or using illicit substances, though a he has had toxicology screens positive for cocaine and opioids in the past. Family History: No history of seizure or stroke Physical Exam: gen: WD/WA, NAD HEENT: PERRL, EOMI, non-icteric CV: RRR, nl S1, S2, [3-15] ejection murmur appreciated pulm: CTA B abd: obese, NT/ND, NBS, soft neuro: deferrred, pt with generalized weakness on L side Pertinent Results: [2182-8-21] 05:32AM BLOOD WBC-5.7 RBC-3.09* Hgb-9.6* Hct-28.6* MCV-93 MCH-31.1 MCHC-33.7 RDW-15.7* Plt Ct-148* [2182-8-21] 05:32AM BLOOD PT-16.6* INR(PT)-1.5* [2182-8-21] 05:32AM BLOOD Glucose-102 UreaN-44* Creat-2.7* Na-142 K-4.0 Cl-107 HCO3-26 AnGap-13 [2182-8-15] 10:14AM BLOOD ALT-24 AST-25 AlkPhos-155* TotBili-0.5 [2182-8-20] 06:17AM BLOOD tacroFK-9.5 Brief Hospital Course: On [2182-8-15], Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] performed a renal transplant into the left iliac fossa with placement of a 6-French double-J stent. Please refer to operative note for details. Induction immunosuppression was administered (solumedrol, cellcept, ATG). Postop, urine output was on the low side averaging 6-25cc per hour. SBP was on the low side (80s). Two units of prbc were administered for hct 28.6. He was transferred to the SICU for management. He was started on low dose neo for BP support, but this was quickly weaned off. Hemodialysis was done on postop day 1 for hyperkalemia and volume overload. He was transferred out of the SICU as BP stabilized. Urine output increased daily and creatinine trended down each day to 2.7 by postop day 6 ([8-21]). A total of 3 doses of ATG were given. Prograf was started and increased to 6mg [Hospital1 ] with trough reaching a level of 12.7 by postop day 6. Steroids were weaned off and cellcept 1 gram [Hospital1 ] was well tolerated. The foley was removed without incident. The incision remained clean, dry and intact. JP was removed. Coumadin (for h/o cva [1-18]) was resumed at home dose (8mg qd) on [8-19]. INR was 1.5 on [8-21]. Coumadin had been managed previously by nephrology at his dialysis unit. This will be managed by [Hospital1 18] Transplant nephrology until he acquires a PCP. [Name10 (NameIs) ] will be drawn every Monday and Thursday per transplant protocol. PT was consulted and felt that he was safe to go home. PT recommended resumption of outpatient PT that he had been doing as long as no straining or heavy lifting was involved. ID saw him post transplant for h/o cervical osteo [11-16] recommending continuing minocycline as previously taken. A f/u appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 106886] was to be arranged. Medications on Admission: metoprolol 50 mg qday nephrocaps 1 tab qday minocycline 50mg [Hospital1 ] omeprazole 20mg qday (?[Hospital1 ]) renagel 800mg tid warfarin 8mg qday fish oil Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 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. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 7. Minocycline 50 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 8. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a day. 9. Warfarin 4 mg Tablet Sig: Two (2) Tablet PO once a day. 10. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 11. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:1 13. Outpatient Physical Therapy OK to resume previous outpatient PT 3-4x/week to improve strength left side. no heavy lifting/no straining. has RLQ incision Discharge Disposition: Home Discharge Diagnosis: esrd s/p renal transplant h/o cva h/o cervical osteo Discharge Condition: good Discharge Instructions: Please call the Transplant Office [Telephone/Fax (1) 673] if fever, chills, nausea, vomiting, increased abdominal distension, decreased urine output, weight gain of 3 pounds in a day, edema, incision redness/bleeding/drainage. [Telephone/Fax (1) ] every Monday and Thursday at [Last Name (NamePattern1) 439], [Location (un) 86] [Month (only) 116] shower No heavy lifting No driving while taking pain medication Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] TRANSPLANT SOCIAL WORK Date/Time:[2182-8-27] 10:30 Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2182-8-27] 11:20 Completed by:[2182-8-21]	[ "285.21", "996.81", "403.91", "E878.0", "458.29", "E849.7", "583.9", "585.6" ]	icd9cm	[ [ [] ] ]	[ "39.95", "00.93", "55.69" ]	icd9pcs	[ [ [] ] ]	5637, 5643	2262, 4193	399, 434	5740, 5747	1860, 2239	6227, 6521	1586, 1619		4408, 5614		5664, 5719		4219, 4385				5771, 6204									1634, 1841																										275, 361							462, 766																		788, 1264	1280, 1570
29,098	102,534	33368	Discharge summary	report	Admission Date: [2110-4-9] Discharge Date: [2110-4-21] Date of Birth: [2063-12-27] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 5188] Chief Complaint: abdominal pain, constipation x 10 days Major Surgical or Invasive Procedure: [2110-4-10] colonoscopy, rigid sigmoidoscopy [2110-4-14] sigmoid colectomy History of Present Illness: 46M with mental retardation presented to [Hospital1 18] [Location (un) 620] with abdominal pain and constipation x 10 days. The pain was described as diffuse, crampy, and intermittent. He has had no prior episodes of this pain. He took ExLax 1 day prior to admission, which resulted in multiple episodes of non-bloody diarrhea. He had nausea with 5 episodes of non-bloody emesis on the day of admission. No fevers, chills, chest pain, SOB, dysuria. He was found to have a sigmoid volvulus on CT scan at [Hospital1 18] [Location (un) 620] and was subsequently transferred to the TSICU. Past Medical History: mental retardation, seizure disorder Social History: Mentally retarded. Lives with mother. [Name (NI) ]-ADL. No EtOH, tobacco, or recreational drugs. Family History: Non-contributory. Physical Exam: On admission: 99.6 90 132/85 18 95%RA Gen: NAD, A&O, no jaundice CVS: RRR, nl S1S2, I/VI systolic murmur at apex radiating to LUSB Pulm: CTA b/l Abd: markedly distended, tympanitic, diffusely tender, +BS, guiaic negative On discharge: 99.7 90 120/66 16 97%RA Gen: NAD, A&O CVS: RRR, no m/r/g Pulm: CTA b/l Abd: soft, ND, appropriately tender, +BS Incision: c/d/i, + ecchymosis lateral & inferior to wound, open area packed with gauze, serosanguinous drainage Ext: no c/c/e Pertinent Results: On admission: [2110-4-9] 11:00PM BLOOD WBC-12.1* RBC-4.54* Hgb-13.8* Hct-39.1* MCV-86 MCH-30.5 MCHC-35.4* RDW-12.7 Plt Ct-344 [2110-4-9] 11:00PM BLOOD Neuts-83.7* Lymphs-10.2* Monos-5.3 Eos-0.3 Baso-0.4 [2110-4-9] 11:00PM BLOOD Glucose-95 UreaN-17 Creat-0.7 Na-144 K-3.4 Cl-105 HCO3-25 AnGap-17 [2110-4-9] 11:10PM BLOOD Lactate-1.2 [2110-4-18] 09:10AM BLOOD WBC-7.9# RBC-3.78* Hgb-11.6* Hct-33.2* MCV-88 MCH-30.6 MCHC-34.8 RDW-13.1 Plt Ct-426 [2110-4-10] 4:13 AM SUPINE ABDOMEN, TWO VIEWS: A gas-filled markedly dilated loop of likely sigmoid colon, arises out of the pelvis into the left upper quadrant, with "coffee bean" appearance conistent with sigmoid volvulus, as suggested in the history. The more proximal large bowel is gas-distended with gas- filled loops of small bowel also observed. A nasogastric tube is in place. The bladder likely contains contrast, perhaps from recent intravenous administration, as well as a foley balloon. IMPRESSION: Sigmoid volvulus consistent with provided history. [2110-4-10] 9:35 AM PORTABLE SUPINE ABDOMEN: Evaluation of this single supine portable view of the abdomen is severely limited due to extreme motion artifact. A rectal tube has been inserted with its tip projecting over the left upper abdomen. Although limited, there is a persistent dilated loop of colon arising out of the pelvis into the mid-left upper quadrant, with "coffee bean" appearance, suggestive of persistent sigmoid volvulus. IMPRESSION: Suggestion of persistent sigmoid volvulus, despite rectal tube placement (evaluation is severely limited due to motion). [2110-4-14] SPECIMEN SUBMITTED: Sigmoid Colon. Markedly dilated segment of colon with vascular congestion consistent with volvulus. No evidence of malignancy. [2110-4-17] 6:23 am SWAB Source: abdominal inc. FINAL REPORT [2110-4-21] GRAM STAIN (Final [2110-4-17]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. WOUND CULTURE (Final [2110-4-20]): ESCHERICHIA COLI. SPARSE GROWTH. ENTEROCOCCUS SP.. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| ENTEROCOCCUS SP. \| \| AMPICILLIN------------ =>32 R <=2 S AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PENICILLIN------------ 2 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 2 S ANAEROBIC CULTURE (Final [2110-4-21]): NO ANAEROBES ISOLATED. On discharge: [2110-4-17] 05:25PM BLOOD Glucose-112* UreaN-12 Creat-0.6 Na-135 K-3.8 Cl-102 HCO3-26 AnGap-11 [2110-4-17] 05:25PM BLOOD Calcium-8.9 Phos-1.9* Mg-2.1 [2110-4-19] 09:05PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.015 [2110-4-19] 09:05PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-7.0 Leuks-NEG [2110-4-19] 09:05PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-1 [2110-4-19] 09:05PM URINE Mucous-RARE Brief Hospital Course: Patient was transferred from [Hospital1 18] [Location (un) 620] after CT abdomen demonstrated sigmoid volvulus. He underwent bedside colonoscopy & rigid sigmoidoscopy in the TSICU. He was successfully decompressed, but his colon was noted to be reforming the loops of volvulus upon withdrawal of the scope following 2 separate attempts. An AXR demonstrated a persistent volvulus. A rectal tube was placed. He was kept NPO, on maintenance IVF, in preparation for a sigmoid resection over the next several days. On HD 2, his NGT was d/c'd. On HD 5, he underwent sigmoid colectomy. Please see operative note for further details. His Foley was d/c'd on POD 1. His pain was controlled with Toradol and ...On POD 2, he was started on clears, which he tolerated. His temperature reached 102.3 and he was pan-cultured. His wound was noted to be erythematous at the inferior aspect and was opened. Keflex was started. On POD 3, he passed flatus, but had 2 episodes of bilious emesis; he was maintained on clears. On POD 5, Keflex was d/c'd. He was advanced to regular diet. On POD 6, he had a bowel movement. On POD 7, his staples were removed and Steri-Strips were applied. He was afebrile with stable vital signs, ambulating, tolerating regular diet without nausea or vomiting, and continuing to have bowel function. He was discharged home with VNA for wet-to-dry dressing changes. Medications on Admission: Keppra 500', Dilantin 100" Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 months: Take with Vicodin. Disp:60 Capsule(s) Refills:0 4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:25 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: sigmoid volvulus post-op wound dehiscience . Secondary: mental retardation, seizure d/o Discharge Condition: Afebrile, vital signs stable, tolerating regular diet, ambulating, pain well controlled on PO medication. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -You incision should be packed with sterile gauze at least twice a day. Keep surrounding skin clean & dry. VNA will assist with dressing management. -Your remaining steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: 1. Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 5189] Call to schedule appointment in 1 week to check your incision. 2. Make a follow-up appoinment with your PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 518] [Last Name (NamePattern1) ], [Telephone/Fax (1) 8927], in 1 week or as needed. [Name6 (MD) ] [Last Name (NamePattern4) ] MD, [MD Number(3) 5190] Completed by:[2110-4-21]	[ "E878.6", "319", "345.90", "998.32", "560.2" ]	icd9cm	[ [ [] ] ]	[ "45.76", "45.23" ]	icd9pcs	[ [ [] ] ]	7463, 7521	5481, 6883	354, 439	7662, 7770	1808, 1808	9455, 9979	1272, 1291		6960, 7440		7542, 7641		6909, 6937				7794, 8936							8951, 9432		1306, 1306																	4972, 5458									276, 316							467, 1075									1822, 4958									1097, 1135	1151, 1256
29,786	151,025	10864	Discharge summary	report	Admission Date: [2151-8-6] Discharge Date: [2151-8-14] Date of Birth: [2094-11-16] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: Palpitations Major Surgical or Invasive Procedure: [2151-8-7] Cardiac catheterization [2151-8-10] 1. Four Vessel Coronary Artery Bypass Grafting(left internal mammary to left anterior descending artery, vein grafts to obtuse marginal, PLV branch and right coronary artery) 2. Cryoablation of posterior lateral wall for VT focus History of Present Illness: 50 year old man with prior MI and Cx stenting in [2145], HTN, + chol, GERD, admitted to Sturdy ER with complaints of palpitations since thursday. The palpitations are associated with pain in his throat and neck, and worsen with even mild exertion. He also describes worsening dyspnea on exertion over the past 2 weeks. He felt lightheaded while walking today. Today the palpitations seemed to be more frequent, occuring for minutes at a time. He had similar palpitations 6 months after his MI/Cath in [2146], that resolved spontaneously. He was seen by Dr. [Last Name (STitle) 3100] recently and had an outpatient stress test that was notable for inferolateral ischemia by pt report. In the OSH ER on telemetry, the patient was found to have multiple PVCs, including periods concerning for non-sustained V-Tach. Upon admission, he denies chest or throat pain. He does feel intermittant fluttering. He does not feel short of breath at rest. Past Medical History: 1. Coronary Artery Disease - history of myocardial infarction and s/p PCI/stening to circumflex in [2145]. 2. Hypertension 3. Hyperlipidemia 4. Bifasicular block 5. GERD 6. Cholecystectomy Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. HI father had a heart attack at age 50 Family History: His father had a heart attack at age 50 Physical Exam: Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, no JVD CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Non-tender. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. Pertinent Results: [2151-8-7] 06:50AM BLOOD WBC-5.5 RBC-4.58* Hgb-15.2 Hct-42.6 MCV-93 MCH-33.2* MCHC-35.7* RDW-14.3 Plt Ct-187 [2151-8-7] 06:50AM BLOOD PT-11.5 PTT-24.3 INR(PT)-1.0 [2151-8-7] 06:50AM BLOOD Glucose-109* UreaN-16 Creat-1.2 Na-140 K-4.6 Cl-105 HCO3-28 AnGap-12 [2151-8-6] 09:51PM BLOOD CK-MB-1 cTropnT-<0.01 [2151-8-7] 06:50AM BLOOD CK-MB-1 cTropnT-<0.01 [2151-8-9] 12:35PM BLOOD %HbA1c-5.4 [2151-8-9] TTE: The left atrium is mildly dilated. The interatrial septum is aneurysmal. A color Doppler signal of near-continuous left-to-right shunt is seen across the interatrial septum c/w a secundum type atrial septal defect. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: Mr. [Known lastname 35389] was admitted under cardiology. Prior to cardiac catheterization, he was loaded with Plavix. He remained pain free on medical therapy but continued to experience symptomatic runs of non-sustained ventricular tachycardia. Cardiac catheterization on [8-7] revealed severe three vessel coronary artery disease for which cardiac surgery was consulted. Routine preoperative evaluation was performed including an EP consult given his ventricular ectopy. It was felt that the ventricular tachycardia was ischemia related and agreed with plans for surgical revascularization. Cryoablation was also recommended at time of surgical revascularization. A preoperative echocardiogram was obtained which showed normal left ventricular wall thickness, cavity size, and systolic function. There was [2-16]+ mitral regurgitation and no aortic valve disease. It was also notable for a left-to-right shunt across the interatrial septum at rest, consistent with secundum atrial septal defect. His preoperative course was otherwise uneventful and he was eventually cleared for surgery. On [8-10], Dr. [Last Name (STitle) ] performed coronary artery bypass grafting along with cryoablation. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and weaned from inotropic support without difficulty. Low dose beta blockade was resumed and he transferred to the SDU on postoperative day two. He remained in a normal sinus rhythm. [8-11], pt was transfered to the regular cardiax floor. Here he remained stable. Chest tubes were DC'd in the usual fashiom. Pacing wires were zDC'd in the usual fashion. There was no sequele. Pt progressed with PT to a state that he could go home with VNA services To note pt did have post operative Afib on the 28th. His Bp was borderline. We stopped his ace inhibitor and increased his BB. Pt converted back to NSR. EP was consulted. They confered with the aforementioned plan. Medications on Admission: Atenolol 12.5 QD Zestril 2.5 QD Lipitor 20 QD Prilosec 20 QD B6-B12-folic acid Ecotrin 325mg Discharge Medications: 1. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day for 30 days. Disp:30 Tablet(s) Refills:0 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day for 4 weeks. Disp:28 Tablet(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO twice a day. 7. Zestril 2.5 mg 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. 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:3 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Community VNA Discharge Diagnosis: Coronary Artery Disease - s/p CABG Ventricular Tachycardia - s/p Cryoablation Atrial Septal Defect Mild Mitral Regurgitation Ventricular Tachycardia History of MI [2145] History of PCI/stenting to circumflex system [2145] Hypertension Hyperlipidemia Bifasicular Block Discharge Condition: Good Discharge Instructions: Patient should shower daily, 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 cardiac surgeon if start to experience fevers, sternal drainage and/or wound erythema. Followup Instructions: Cardiac surgeon, Dr. [Last Name (STitle) ] in [5-20] weeks. Local PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ] in [3-20] weeks. Local cardiologist, Dr. [Last Name (STitle) 6203] in [3-20] weeks. Completed by:[2151-8-14]	[ "412", "745.5", "V45.82", "410.71", "401.9", "427.0", "414.01", "272.4", "327.23", "530.81", "426.53" ]	icd9cm	[ [ [] ] ]	[ "37.22", "88.53", "88.72", "39.61", "88.56", "37.34", "36.13", "36.15" ]	icd9pcs	[ [ [] ] ]	7022, 7066	3861, 6012	334, 621	7385, 7391	2554, 3838	7774, 8038	1999, 2040		6156, 6999		7087, 7364		6038, 6133				7415, 7751									2055, 2535																										282, 296							649, 1603																		1625, 1819	1835, 1983
28,099	159,412	45386	Discharge summary	report	Admission Date: [2180-7-14] Discharge Date: [2180-8-25] Date of Birth: [2132-1-24] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1493] Chief Complaint: weakness, confusion Major Surgical or Invasive Procedure: blood transfusion ultrasound-guided paracentesis esophagogastroduodenoscopy colonoscopy History of Present Illness: Mr [Known lastname 96897] is a 48 yo male with EtOH abuse and chronic HCV infection, who presented to his PCP with complaints of generalized weakness, lightheadedness and yellow eyes. Per her note, he was in detox several days prior to presenting and he states that he has not had a drink now in [4-18] days. He states that his last episodes of drinking were not above average. Denies any recent sexual contacts and denies any IVDU. Given his clear jaundice on exam, his PCP sent him to [Hospital1 18] for further evaluation. She was also concerned about encephalopathy. He was admitted to the floor on [2180-7-14] with likely alcoholic hepatitis. Liver service followed him there and was concerned about his high discriminant function and poor level of consciousness. He was evaluated by the MICU team and transferred to the MICU for continued encephalopathy. During course there was also concern of pericholecystic fluid/acute cholecystitis and he has been followed by surgery. Past Medical History: 0. Likely hepatic cirrhosis 1. EtOH abuse, h/o DTs / withdrawal seizures 2. Hepatitis C (not confirmed here [1-15] RNA neg) 3. hypertension 4. h/o pancytopenia 5. ? h/o seizures in setting of head trauma 6. childhood asthma 7. depression 8. orbital fracture and small SDH s/p fall [3-/2180] Social History: Pt has been homeless for many years, lived in shelters, with his mother, siblings and friends at times. He smokes one pack per day of tobacco. No intravenous drug use. Regular alcohol use for many year. Family History: Non contributory Physical Exam: Vitals: 98.9, 107/63, 93, 96% RA GEN: Well-appearing, NAD, sleepy but arousable HEENT: Sclera grossly icteric, PERRL, EOMI, OP clear, MMM, sublingual icterus as well NECK: Supple, no LAD CV: RRR, no M/G/R PULM: CTAB, no W/R/R ABD: Soft, NT, ND, +BS, liver edge palpable 2cm below costal margin EXT: No C/C/E NEURO: AAO to place, year, month, day and situation. CN II-XII grossly intact, moving all extremities well. + asterixis. Pertinent Results: <b> LABS ON ADMISSION: ([2180-7-14]) </b> HEMATOLOGY: [2180-7-14] 06:50AM BLOOD WBC-5.5 RBC-2.48* Hgb-9.4* Hct-26.3* MCV-106* MCH-37.8* MCHC-35.8* RDW-18.6* Plt Ct-113* [2180-7-14] 06:50AM BLOOD Neuts-76.1* Lymphs-15.9* Monos-6.7 Eos-0.9 Baso-0.4 [2180-7-14] 06:50AM BLOOD PT-20.0* PTT-43.1* INR(PT)-1.9* CHEMISTRY: [2180-7-13] 04:00PM BLOOD Glucose-84 UreaN-11 Creat-0.8 Na-133 K-4.1 Cl-97 HCO3-29 AnGap-11 [2180-7-14] 06:50AM BLOOD ALT-67* AST-185* LD(LDH)-174 AlkPhos-94 Amylase-44 TotBili-21.7* [2180-7-14] 06:50AM BLOOD Lipase-19 [2180-7-14] 06:50AM BLOOD Albumin-2.5* Calcium-8.9 Phos-2.5* Mg-1.8 Iron-111 [2180-7-14] 06:50AM BLOOD Ammonia-81* OTHER: [2180-7-14] 06:50AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2180-8-4]: HCV VIRAL LOAD: HCV-RNA NOT DETECTED. [2180-7-14] 10:03AM BLOOD AMA-NEGATIVE Smooth-POSITIVE [2180-7-14] 10:03AM BLOOD [Doctor First Name ]-NEGATIVE [2180-7-14] 06:50AM BLOOD AFP-5.7 [2180-7-13] 04:00PM BLOOD Phenyto-3.1* TOX: [2180-7-13] 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [2180-7-14] 01:21PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-POS mthdone-NEG <b> DISCHARGE LABS: </b> [8-23] Hct 25.3 Plt 92 [8-18] INR 2.0 [8-18] Glc 91 BUN 5 Cr 1.3 Na 136 K 3.5 Cl 103 HCO3 26 [8-20] ALT 27 AST 65 LDH 196 AP 117 TBili 8.8 <b> OTHER LABS: </b> ANEMIA WORKUP: [2180-7-27] 05:35AM BLOOD Ret Aut-5.3* [2180-7-14] 06:50AM BLOOD calTIBC-120* Ferritn-1100* TRF-92* [2180-7-19] 06:50AM BLOOD Hapto-49 [2180-7-24] 05:47AM BLOOD VitB12-1668* Folate-12.0 PERITONEAL FLUID: [2180-8-1] 09:45AM ASCITES TotPro-0.6 Glucose-100 LD(LDH)-34 Albumin-LESS THAN 1 [2180-8-1] 09:45AM ASCITES WBC-111* RBC-46* Polys-6* Lymphs-3* Monos-8* Mesothe-1* Macroph-82* [2180-8-7] WBC 23 RBC [Numeric Identifier 7781] Polys 42% Alb < 1.0 <B> MICROBIOLOGY </b> [2180-7-30] 1:30 pm BLOOD CULTURE Source: Line-PICC. Anaerobic Bottle Gram Stain (Final [2180-8-1]): GRAM POSITIVE ROD(S) C/W CORYNEBACTERIUM AND PROPIONIBACTERIUM SPECIES. Otherwise multiple blood, urine, and peritoneal fluid cultures were all negative. <B> RADIOLOGY </b> [2180-7-14] 12:20 AM # [Telephone/Fax (1) 96898] CHEST (PA & LAT) Somewhat limited examination secondary to low lung volumes. No definite superimposed acute cardiopulmonary process. [2180-7-13] 5:01 PM # [Telephone/Fax (1) 96899] CT HEAD W/O CONTRAST No acute intracranial process. [2180-7-13] Radiology CT ABD W&W/O C IMPRESSION: 1. Heterogenous liver attenuation in addition to striking portal adenopathy may indicate an acute hepatitis. Conversely, an infiltrative liver malignancy cannot be excluded. This could be further assessed with multi-phasic MRI. 2. Mildly distended gallbladder, wall edema, and pericholecystic fluid. Gallstones were visualized on previous ultrasound examination. However, in the setting of no significant right upper quadrant symptoms and no elevated white blood cell count, this seems unlikely to be consistent wtih acute cholecystitis. [2180-7-16] Radiology MRI ABDOMEN W/O & W/CON IMPRESSION: 1. Fatty infiltration of the liver. 2. Mild gallbladder wall edema, which is nonspecific in the setting of trace ascites. 3. Extensive periportal lymphadenopathy. 4. Stigmata of portal hypertension including recanalized paraumbilical vein and anterior abdominal wall varices. 5. No focal pancreatic or liver lesions identified. [2180-7-14] Radiology DUPLEX DOP ABD/PEL LIMI IMPRESSION: 1. Echogenic liver which is suggestive of fatty infiltration; however, liver fibrosis/cirrhosis cannot be entirely excluded. 2. Portal venous, hepatic venous, and hepatic arterial systems are patent with appropriate flow. 3. No evidence of intra- or extra-hepatic bile duct dilation. [2180-8-3] RUQ U/S IMPRESSION: 1. No evidence of cholecystitis. Normal appearing gallbladder without stones. No intra- or extra-hepatic biliary ductal dilation. 2. Unchanged echogenic and heterogeneous liver parenchyma, without a focal mass seen. 3. Small amount of ascites. [2180-8-9] Renal U/S IMPRESSION: Normal renal son[Name (NI) ] without hydronephrosis. [2180-8-8] EGD 2 cords of grade 1 varices at the lower third of the esophagus Erythema in the stomach body and antrum compatible with gastritis Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum [2180-8-16] Colonoscopy Polyps in the sigmoid colon and ascending colon Diverticulosis of the whole colon Grade 2 internal hemorrhoids Unable to evaluate the cecum and valve because loop formation and patient's uncomfort and pain. Otherwise normal colonoscopy to cecum [2180-8-23] RUQ U/S IMPRESSION: 1. Mild heterogeneity in the liver echotexture, possibly slightly decreased from previous examination. No focal lesion detected. 2. No intra- or extra-hepatic biliary ductal dilation or gallstones. 3. Splenomegaly. Brief Hospital Course: 1) ACUTE ON CHRONIC LIVER FAILURE: Most likely acute alcoholic hepatitis given known history of alcohol abuse, AST/ALT > 2, and negative hepatitis viral serologies (negative viral load in the case of Hep C). His presentation was initially concerning for an obstructive lesion given the new perihepatic LAD on abdominal CT, but his AP was normal and a RUQ U/S showed no obstruction. He had no additional risk factors for aquisition of other hepatitis viruses (no recent unprotected sex or IVDU). His presentation was also concerning for hepatic vein/IVC thrombosis, but a liver U/S with doppler was negative for clot. His autoimmune work-up ([Doctor First Name ], anti-smooth muscle antibodies, soluble liver antigen, ceruloplasm, urine copper for Wilson's disease) was negative. His hepatitis serologies indicated previous exposure but no active infection (HBsAg neg, HBsAb pos, HBcAb pos, HBV DNA undetect, HCV RNA undetect, anti-HAV neg). On discharge his bilirubin improved to 8.2, INR stable at 2.0, platelets 92. He had a liver MRI that showed no focal lesions, but fatty infiltration, periportal LAD, and signs of portal HTN. He was started on prednisone 40mg PO daily and lactulose 30cc QID. He continued to complain of vague RUQ pain, so an U/S was repeated, with no changes noted. Furthermore, his LFTs have trended down and stabilized; his AST remained only slightly elevated at discharge, although his TBili was very high. He had elevated INRs (max 2.6, decreased to 2.0) which were treated w/ PO vitamin K. Outpatient liver clinic appointment scheduled to follow liver disease and consider transplant. 2) ENCEPHALOPATHY: Patient was encephalopathic when admitted, with an elevated ammonia level. He was treated with lactulose 30-45cc QID, but his dose was later decreased to 30cc TID due to exacerbation of hemorrhoids and pain and blood with bowel movements. He was often reluctant to take his lactulose and had to frequently be explained the reason for taking it. He was also treated with rifaximin. Overall his mental status has improved and he has been AAOx3, but with some residual confusion. Also, his gait is still slightly unsteady and he continues to have asterixis on exam. He is discharged on lactulose and rifaximin, which he must take regularly. 3) ANEMIA: The patient had macrocytic anemia on admission (Hct=27.7) and his hematocrit continued to slowly decrease during his stay. His B12 level was elevated and his folate level was normal. Iron studies showed normal Iron, decreased TIBC, increased Ferritin. Blood smear showed occasional schistocytes and 2+ target cells. He had a normal EGD and colonoscopy, although the cecum was not visualized. Given his history and labs, he was thought to have anemia from chronic liver disease and possible bone marrow suppression due to alcohol use. [Month (only) 116] have also been due to hemorrhoidal bleeding. He was transfused with pRBCs to keep him above Hct=21, receiving 9 units over the course of his admission. He had no s/sx of transfusion reaction and his Hct was 25.3 at discharge. 4) FEVER: The patient spiked a fever to 101.9 on [7-14] and was subsequently worked up for infection. CXR was negative for pneumonia x2, urine analysis and cultures were negative, and blood cultures were negative. Initial abdominal ultrasound was negative for cholecystitis and showed trace ascites (<1cc), although he did have ascites later on, and received two ultrasound-guided paracenteses, negative for SBP. His fevers resolved and he had been afebrile from [2180-7-19] to [7-29], when he started spiking fevers again. On [8-3], he spiked a fever up to 104.5 with hypotension to 80s and tachycardia to 110s. Pt was started on broad-spectrum antibiotics (vanc, levofloxacin, [Doctor Last Name ]), given copious IVFs and transfered to the MICU with SIRS criteria. On admission to the MICU he was severely anemic to Hb/HCT of 5.7/16.9. Pt was transfused 3U of pRBC and a 1L of NS. His Hb/HCT elevated to 8.3/23.5 and stabilized. He was restated on lactulose and antibiotics for GI PPX. All cultures were negative. His BP and mental status improved. He was transfered back to the floor in stable condition mentating at baseline with stable VSS and afebrile. 5) HYPONATREMIA: Patient had low-normal serum sodium at baseline, decreased to 131/132 at times during his stay. He appeared euvolemic with no evidence of third-spacing of fluid on exam. Serum osmolality was 285 (within reference range). It is possile that these low-normal levels are secondary to cirrhosis and intravascular volume depletion, leading to increased fluid retention. It could also be due to hypertriglyceridemia. Adrenal insufficiency is also possible, but less likely given his stable blood pressure. His sodium levels normalized prior to discharge. 6) ALCOHOL ABUSE: Patient had no signs of alcohol withdrawal during his hospital stay. He was continued on thiamine, folate, and multivitamin supplementation. Advised extensively to stop drinking. 7) ACUTE RENAL FAILURE: Patient had a creatinine spike to 2.6 from his baseline of around 0.8. Renal consult felt this was prerenal rather than HRS, so octreotide & midodrine were stopped. His creatinine gradually improved to 1.3 and remained stable. 8) SEIZURE HISTORY: Patient has an unclear history of seizures, in setting of EtOH withdrawal vs. head trauma vs. childhood issue. He was on phenytoin 100mg TID, but his drug level increased to 22.7, so he was decreased to [Hospital1 ] dosing, and a repeat level was 20.7. Medications on Admission: Dilantin 100mg TID Zantac 150mg [Hospital1 ] Albuterol INH PRN Atenolol 25mg PO daily Thiamine MVI Folate Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): Titrate to 3 BMs daily. 12. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal HS (at bedtime) as needed. 13. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal HS (at bedtime) as needed. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] House Discharge Diagnosis: Primary: Alcoholic Hepatitis Secondary: Alcohol Abuse History of hepatitis C infection Anemia Discharge Condition: Mental status has improved. Afebrile with stable vital signs. Discharge Instructions: You were admitted to the [Hospital1 18] with a diagnosis of acute on chronic liver failure and encephalopathy (changes in your mental status) due to the liver failure. You were kept in the hospital to watch your liver function tests, which have improved. You were started on lactulose and rifaximin, and must continue to take it and have at least 3 bowel movements a day. While in the hospital, you were found to be anemic. Because your red blood cells were low, we gave you transfusions to increase your red blood cells. You were also given IV fluids and octreotide and midodrine, medicines to improve your kidney function. Your kidney function has not yet returned to baseline but has improved. During your hospital stay, you also had fevers and low blood pressure. Because of concern for infection, you were sent to the ICU and your steroid treatments were stopped. No infection was found in your blood, urine, or the fluid in your abdomen. You were transferred back to the medicine service once your blood pressure normalized. You were given IV vancomycin, ciprofloxacin, and flagyl (antibiotics) for 7 days. Please keep all follow up appointments and take all medications as prescribed. We have lowered your dilantin to twice daily based on your blood levels. Please return to the hospital if you experience any of the following symptoms: - Temperature greater than 101.5 - fevers, chills, sweats, nausea, sweating - Increased confusion or flapping of your hands - Increase yellowing of your eyes or under your tongue - Increased weight gain or fluid in the abdomen/legs - Increasing abdominal pain Followup Instructions: Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 2270] [Last Name (NamePattern1) ], at [Hospital 12091] Health Center on Monday, [2180-9-4] @ 4:00pm. [Telephone/Fax (1) 6820]. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7128], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2180-11-8] 10:00 Completed by:[2180-8-25]	[ "789.59", "572.8", "303.90", "584.9", "571.3", "276.1", "456.21", "211.3", "571.1", "286.7", "401.9", "571.2", "305.1", "070.54", "995.91", "285.1", "285.29", "562.10", "572.2", "455.2", "570", "V60.0", "038.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "99.04", "45.23", "54.91", "45.13" ]	icd9pcs	[ [ [] ] ]	14551, 14653	7567, 13140	335, 424	14792, 14856	2492, 2501	16522, 16966	2010, 2028		13301, 14528		14674, 14771		13166, 13278				14880, 16499			3782, 3948						2043, 2473																										276, 297							452, 1450									2515, 3766									1472, 1773	1789, 1994			3960, 7544
16,786	199,888	16929	Discharge summary	report	Admission Date: [2122-8-2] Discharge Date: [2122-8-26] Date of Birth: [2082-7-26] Sex: F Service: MEDICINE Allergies: Amoxicillin / Sulfa (Sulfonamides) / Bactrim / Iodine; Iodine Containing / Abciximab Attending:[First Name3 (LF) 6169] Chief Complaint: Sudden onset low back pain Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 40 yo F with multiple medical problems including AML s/p [First Name3 (LF) 3242] 4 years ago c/b severe and extensive GVHD presents with low back pain, UTI and hypotension. Pt was in her USOH until [First Name3 (LF) 2974] when had acute onset low back pain. Per husband, pt was being transferred from bed to commode, she then let herself down onto the commode when suddenly felt acute onset of lower back pain. Throughout the course of the day her back pain improved with percocet and warm compresses. On sunday, however, her husband again was transferring pt from bed to commode when her legs acutely "gave out". She denied any LH/Dizziness, no CP/palpitations/SOB. She did not pass out or lose consciousness. Her legs felt weak. She denied any urinary or stool incontinence, no numbness or loss of sensation of her legs. Her husband called 911 and was brought to ED. . ED COURSE: Initial VS 98.6 BP 72/54 HR 85 99%RA. Pt received 1L NS, solumedrol 125mg x1, 2mg morphine IV x1, and ceftriaxone 1gm x1. BP responded to fluid which increased to 100/palp. Rectal exam did not suggest cord involvement due to normal rectal sensation and tone. She was admitted to [Hospital Unit Name 153] for closer monitoring for Hypotension. . ROS: Pt normally bed bound or wheelchair bound, denied fevers/chills/sweats. No recent travelling or sick contacts-recently hospitalized [6-/2122] for mastoiditis. No dysuria, no abdominal pain/N/V/Diarrhea. No HA, Confusion or word finding difficulties. Blurry vision-not new. Weight has been stable. Past Medical History: #. AML: diagnosed [4-14] s/p allo-related SCT [10-14] (sister was donor) Cytoxan/MTX/TBI--recently resumed cytoxan on [7-24] per Dr. [First Name (STitle) 1557] #. CAD s/p STEMI [11-16] with 2VD s/p DES in LAD, POBA D1 with BMS to mid D1. NSTEMI [2122] s/p PCI [4-/2122] noted below. #. STEMI [4-/2122] s/p CATH: 1. Subacute stent thrombosis of the LCX bare metal stent. 2. Hypotension requiring pressors consistent with hypovolemic and vasodilatory shock. 3. Possible anaphylactoid reaction to ReoPro. 4. Bleeding from left femoral arteriotomy and venotomy site with hemostasis achieved after Femstop applied. 5. Blood loss anemia status post 5 units of PRBC. 6. Successful thrombectomy and balloon angioplasty of the LCx. #. extensive chronic GVHD: skin, gut, left hand digit amps x4, chronic immune suppression cellcept, entocort, prednisone, rituxan (last [2121-8-22]) #. strep pneumo mastoiditis [4-18] #. Chronic left upper extremity brachiocephalic DVT #. ankle fracture in left ankle s/p surgical repair [8-17] #. asthma #. eczema #. migraine headaches #. history of oral HSV #. HTN, however most recent infusion note BP 90/50 and all BPs need doppler to measure (baseline SBP 90s-low 100s) #. Diabetes, Hgb A1C ([9-17]) 8.9 #. Weelchair bound #. performance status is 60% [6-/2122] Social History: - Immigrated from [Country 6257] at young age and lived in MA since. - Currently lives with husband and two sons (12yo, 15yo) mother-in-law on [Location (un) 1773]. -TOB: 1pack per 3 days down from 1/2ppd x 20yrs, No ETOH use. No illicits . Family History: - Mother died of cancer - No CAD, no sudden death - No family history of blood clots. . Physical Exam: VS: 97.6 BP 102/74 HR 74 RR 17 100%RA GEN: lying in bed, NAD, breathing comfortably, speaking in full sentences HEENT: + Cushingoid/moon facies, PERRL, no scleral icterus, mm dry, no lesions CV: Reg, nl S1,S2, No M/R/G, unable to assess JVD due to body habitus Pulm: CTA bilaterally, no wheezing or stridor Abd: soft, ND/NT +BS, hyperpigmentation at lovenox injection sites with inderation noted Ext: bilateral 2+ LE edema, LE's warm, LEU with digits x4 amputated. Neuro: alert and oriented x3, appropriate, moving all 4 extremities Skin: changes c/w GVH, hyperpigmentation of face Rectal (per ED): Normal rectal tone, normal perianal sensation Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2122-8-4] 04:50AM 8.3 2.91* 9.7* 29.5* 101* 33.2* 32.8 18.7* 322 [2122-8-3] 05:06AM 9.4 2.99* 9.7* 30.8* 103* 32.6* 31.6 18.6* 310 [2122-8-2] 03:10PM 10.8 3.23* 10.1* 33.5* 104* 31.3 30.3* 19.0* 359 Hematocrit decreased slightly while in the ICU, however baseline HCT is 33 . DIFFERENTIAL Neuts Bands Lymphs Monos Metas Myelos [2122-8-2] 03:10PM 76* 0 13* 9 1* 1* . URINALYSIS GENERAL URINE INFORMATION Type Color Appear Sp [Last Name (un) ] [2122-8-2] 04:00PM Amber1 Hazy 1.043* . Bld Nitr Pro Glu Ket Bili Urobiln pH [2122-8-2] 04:00PM TR NEG 30 NEG NEG SM NEG 6.5 MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE RenalEp [2122-8-2] 04:00PM 0-2 21-50* MOD NONE 0-2 OTHER URINE FINDINGS Mucous [2122-8-2] 04:00PM MOD . MICROBIOLOGY: Blood & Urine culture ([2122-8-2]) did not grow anything. . IMAGING: MRI LUMBAR SPINE [2122-8-3]: Moderate compression fracture of the T11 vertebral body and possibly also a minimal fracture of the L4 vertebral body. Perhaps these fractures relate to osteoporosis secondary to steroid administration, if this [Doctor Last Name 360] was administered on a chronic basis . MR THORACIC SPINE W/O CONTRAST [2122-8-20] 1. Diffuse altered signal intensity of the bone marrow in the cervical and thoracic vertebrae, indicating fatty replacement. This is concerning, given the history of AML with bone marrow transplantation. Please correlate clinically and with lab values. 2. No significant change in the wedge compression fracture noted at T12 level (not T11 as the patient has transitional vertebra at L5-S1). Significant change in the small fragment retropulsed with moderate indentation on the ventral thecal sac. 3. No new areas of compression fracture in the thoracic spine. . ECHO [2122-8-3]: - Mild Regional [Last Name (LF) 47663], [First Name3 (LF) ] 45-55% - 1+ MR, No AR - No pericardial effusion . UNILAT UP EXT VEINS US LEFT [2122-8-19] No evidence of DVT in the left upper extremity. Brief Hospital Course: Pt is a 40 yo F with AML s/p related allogenic bone marrow transplant in [10-14] with GVHD who presented for acute back pain and was found to have T11 compression fracture on MRI. She was admitted to the medical ICU for hypotension and transferred 2 days later to [Date Range 3242] service after stabilization. . 1. Back pain: MRI showed compression fracture of the T11 vertebral body and possibly also a minimal fracture of the L4 vertebral body, likely due to osteoporosis from chronic steroids use. There was no evidence of an infectious process or spinal canal compromise. There were no neurologic symptoms to suggest cord involvement and MRI showed no cord compression; neurology was consulted and agreed. Orthopedics was consulted, and recommended TLSO brace and possible vertebroplasty if pain persists. She was fitted for TLSO brace to support her back and minimize risk of cord transection. A repeat MRI for new onsent upper back pain (see below) showed a change of a small fragment retropulsed with moderate indentation on the ventral thecal sac. Orthopedics was reconsulted and, since there were no neurological symptoms, it was recommended that she wear the TLSO brace when HOB >45 degrees and for all transfers. Physical therapy has worked with her and her husband and was cleared for discharge. Pt was discharged on adequate pain regimen with narcotics. . 2. Hypotension upon admission: The patient was admitted to the ICU from the ED because of hypotension. Home antihypertensive medications were held because of low BP readings. She was initially ruled out for a myocardial infarction with cardiac enzymes x3 and EKG. An ECHO was also performed, which revealed mild regional [Date Range 47663] with EF 45-55%. Although the patient remained on a low-dose of prednisone 10mg daily, a cortisol stimulation test was performed, which showed a strong rise from the suppressed endogenous cortisol level of 0.6 to 19 one half hour after the test, making adrenal insufficiency unlikely. Pt did not have any indication of sepsis as she was afebrile without leukocytosis. Later, BP readings were found not to correlate between left arm (PICC line inserted in right arm) and the thighs, likely because of severe vascular disease. BP readings were subsequently taken from the thigh, and Metoprolol and Imdur were restarted as tolerated. . 3. Unstable angina with acute inferior posterior MI in a previously infarcted territory: On [2122-8-5], the patient developed substernal chest pressure, and an EKG was performed that showed a change from admission, with inferoseptal depressed and downward sloping ST segments. This was concordant with a slight rise in CK-MB and Troponin. The pain subsided with SL NTG, and the patient remained without clinical evidence of hypotension with the NTG. She was managed conservatively with SL NTG, Lopressor, which was titrated up as BP tolerated, [Date Range ] 325 mg, [Date Range ] 75 mg [Hospital1 ], and Lovenox 60mg SC BID. Pt continued to have episodes of chest pain, and troponin peaked to 0.27. Cardiology was consulted. The [Hospital1 3242] service and the Cardiology service felt that the risk of cardiac cath outweighed the benefits given the patient's history of the last cardiac cath. Medical management was maximized under the guidance of Cardiology. Pt was titrated back up to Metoprolol 200 mg po BID, and pt was started on Ranolazone and her EKGs were monitored daily for QT prolongation. . 4. UTI: Pt had a U/A suspicious for UTI and because of her hypotension and concern for sepsis was initially started on Ceftriaxone. This was changed to Cipro based on sensitivities from prior urine culture. Urine culture from [8-2] with NGTD and the Cipro was discontinued. . 5. AML s/p related allogenic bone marrow transplant in [10-14] with chronic GVHD: Cytoxan was initially held on admission but restarted after transfer from the [Hospital Unit Name 153]. Pt was continued on her outpatient prednisone dose of 10 mg po daily, budesonide 3 mg po TID, and Cellcept [Pager number ] mg po QID. For ppx, pt was maintained on acyclovir 400 mg po BID. . 6. DM: Pt was placed on a diabetic diet and continued on glargine 35 units daily per home regimen with an Humalog SS. . 7. MSK pain in upper back and bilateral scapula: On [8-19], left UE swelling was noted. As she was being transferred for an ultrasound study (negative for DVT), she developed acute back and scapular pain. Repeat MRI did not show a new fracture and no evidence for aortic dissection was noted on this nonideal study. Pain was relieved with muscle relaxants and narcotics and continued to improve. Medications on Admission: - Prednisone 10 mg po qd - Mycophenolate Mofetil 500 mg po qid - Acyclovir 400 mg po q 8hrs - Fluconazole 200 mg po bid - Folic Acid 1 mg po qd - Nexium 40 mg po qd - Clopidogrel 75 mg po BID - Aspirin 81 mg po qd - Lovenox 60mg [Hospital1 ] - Lasix 20 mg po daily - Toprol Xl 100 mg po bid - Lisinopril 5mg daily - Isosorbide Mononitrate 60mg daily - Budesonide 3 mg po tid - Insulin Glargine 35 units qam - Humalog per sliding scale. - MagOx 400 mg po bid - Rituxan monthly for GVHD last dose 6/8, IVIG monthly last dose [7-24], Pamidronate q6months Discharge Medications: 1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO TID (3 times a day). 10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 35 units Subcutaneous once a day. 11. Insulin Lispro 100 unit/mL Solution Sig: 1 - 10 units Subcutaneous four times a day: Please use sliding scale as directed. 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:30 Tablet, Sublingual(s) Refills:0 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:7 Adhesive Patch, Medicated(s) Refills:2 18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 19. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. 20. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 21. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: [1-13] Tablet Sustained Release 12 hrs PO twice a day. 22. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 23. Cyclophosphamide 50 mg Tablet Sig: One (1) Tablet PO once a day. 24. Tizanidine 4 mg Capsule Sig: One (1) Capsule PO three times a day as needed for muscle cramps. Disp:20 Capsule(s) Refills:0 25. Miralax 17 g (100%) Powder in Packet Sig: One (1) PO once a day as needed for constipation. Disp:10 Refills:1 26. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO at bedtime. Disp:30 Tablet Sustained Release 12 hr(s) Refills:0 27. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:70 Tablet(s) Refills:0 28. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain (for chest pain only if not relieved by SL NTG). Disp:50 Tablet(s) Refills:0 29. Outpatient line care PICC/Midline supplies per Critical Care Program protocol. Discharge Disposition: Home With Service Facility: All Care VNA Discharge Diagnosis: Primary: T11 vertebral compression fracture Unstable angina/Myocardial infarction . Secondary: Acute myleoid leukemia Graft versus host disease Diabetes mellitus type II Discharge Condition: Stable Discharge Instructions: You were admitted for acute low back pain and was found to have a compression fracture in the T12 vertebrae of your spine. Orthopedics evaluated you and recommended the TLSO brace, which you received. We have given you prescriptions for pain medications and muscle relaxants. . Your hospital stay was complicated by unstable angina/myocardial ischemia. We have changed your heart medications. We have discontinued your Lasix and Lisinopril. We have added Nitroglycerin sublingual tablets for chest pain and Ranolazine 500 mg twice a day; we have given you the prescriptions. Please stay on these medications until you are seen by your cardiologist. . Please continue to take the other medications as prescribed. In addition, we are recommending calcium and vitamin D supplements to help keep your bones strong. . Please keep all your appointments. . If you have any increase in back pain, sudden muscle weakness, numbness or tingling, urine or stool incontinence, chest discomfort, shortness of breath, or any other concerning symptoms, please call your primary care provider or go to the emergency room. Followup Instructions: Please keep the following appointments: . Provider: [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern4) 6175], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2122-8-31] 3:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11755], [MD Number(3) 1240]:[Telephone/Fax (1) 3241] Date/Time:[2122-8-31] 3:00 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. Phone:[Telephone/Fax (1) 920] Date/Time:[2122-9-1] 4:20	[ "996.85", "412", "272.4", "V12.51", "251.8", "E878.0", "414.01", "401.9", "205.00", "410.31", "733.09", "733.13", "599.0", "E932.0", "V58.65" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	14907, 14950	6616, 8022	371, 377	15164, 15173	4377, 6593	16332, 16851	3607, 3696		11931, 14884		14971, 15143		11347, 11908				15197, 16309									3711, 4358																										305, 333							405, 1957									8037, 11321									1979, 3323	3339, 3591
7,086	153,493	9487+56035+56036	Discharge summary	report+addendum+addendum	Admission Date: [2102-12-24] Discharge Date: [2103-1-9] Date of Birth: [2062-5-20] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [2103-1-3] IVC filter placement (Gunther Tulip retrievable filter) [2102-12-28] ORIF left acetabular fracture History of Present Illness: 40 yo male unrestrained passenger s/p motor vehicle crash vs. guard rail. ? LOC. Transported via EMS from scene to [Hospital1 18] for further care. Past Medical History: Obesity HIV + Hepatitis C Seizure disorder Social History: h/o IVDA Family History: Noncontributory Pertinent Results: [2102-12-24] 02:54PM GLUCOSE-103 UREA N-13 CREAT-0.6 SODIUM-135 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-26 ANION GAP-13 [2102-12-24] 02:54PM ALT(SGPT)-17 AST(SGOT)-30 LD(LDH)-207 ALK PHOS-94 AMYLASE-48 TOT BILI-0.5 [2102-12-24] 02:54PM CALCIUM-9.1 PHOSPHATE-3.2 MAGNESIUM-1.8 [2102-12-24] 02:54PM WBC-6.4 RBC-3.63* HGB-10.7* HCT-30.9* MCV-85 MCH-29.3 MCHC-34.5 RDW-16.6* [2102-12-24] 02:54PM PLT COUNT-150 [2102-12-24] 02:54PM PT-12.6 PTT-24.6 INR(PT)-1.1 [2102-12-24] 06:15AM WBC-5.8 RBC-3.76* HGB-11.1* HCT-31.6* MCV-84 MCH-29.6 MCHC-35.2* RDW-16.8* [2102-12-24] 06:15AM PLT COUNT-160 Cardiology Report ECG Study Date of [2102-12-26] 2:48:38 PM Sinus rhythm with ventricular premature beats. Compared to the previous tracing no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 67 180 110 420/435 24 -9 7 CT C-SPINE W/O CONTRAST [2102-12-23] Reason: Eval for fx/subluxation/dislocation IMPRESSION: 1. Teardrop compression fracture involving the anteroinferior C3 vertebral body. 2. Moderate prevertebral soft tissue swelling without encroachment upon the airway. 3. Subtle lucency through the left C2 transversalis foramen representing a possible fracture and raising concern for vascular injury. The above findings are concerning for possible ligamentous and vascular injury. Further characterization with a dedicated MRI/MRA is recommended. These findings were immediately discussed with Dr. [First Name4 (NamePattern1) 2031] [Last Name (NamePattern1) ] [Doctor Last Name ] on completion of the scan. CT PELVIS ORTHO W/O C Reason: Evaluate acetabulum, femoral head Field of view: 45 [Hospital 93] MEDICAL CONDITION: 40 year old man with L acetabular fx REASON FOR THIS EXAMINATION: Evaluate acetabulum, femoral head CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Left acetabular fracture. COMPARISON: Radiographs [2102-12-23]. TECHNIQUE: Non-contrast CT of the pelvis with coronally and sagittally reformatted images. FINDINGS: Intraarticular comminuted left acetabular fracture involves the posterior column, roof, and medial wall. The left femoral head appears to maintain a normal contour, without evidence of fracture. There is associated hematoma within the surrounding soft tissues. The right hip joint space is slightly narrowed, and moderate osteophyte formations are noted about the right hip. No fracture is seen on the right. The SI joints and pubic symphysis are within normal limits. Incidentally noted within the soft tissues of the pelvis is a 1 cm calcific density just superior to the bladder, of doubtful significance, which may represent a calcified lymph node. The contents of the pelvis are otherwise unremarkable on this noncontrast examination. IMPRESSION: Intraarticular left acetabular fracture. Brief Hospital Course: He was admitted to the Trauma Service and transferred to the Trauma ICU for close monitoring. Neurosurgery was consulted given his cervical spine fractures. These injuries were nonoperative. He was placed in a hard collar which will need to remain in place for a total of 6 weeks; at which time he will follow up with Dr. [Last Name (STitle) 548] for further CT imaging. Orthopedic surgery was consulted for his left acetabular fracture; he was taken to the operation room on [12-28] for ORIF of this injury. He is to remain non weight bearing in that extremity and will follow up with Dr. [Last Name (STitle) 1005] in 2 weeks. He is on Lovenox for DVT prophylaxis. An IVC filter was placed as well on [2103-1-3]. Acute & Chronic Pain service were consulted given his history with chronic pain and long standing narcotic use; his home medications for pain control include Methadone, MS Contin, Tizanidine and Neurontin. He was initially on a Ketamine infusion drip and later changed to PCA Dilaudid. His PCA was eventually discontinued and he was started on po Dilaudid 4-8 mg which seemed to be effective. He did have a drop in his hematocrit from 23.4 to 21 on [1-3] but remianed hemodynmaically stable despite this drop. His central line was removed earlier on that morning and given his poor access it was decided to start him on Niferex 150 [Hospital1 ]; his hematocrit rose from 20.1 on [1-4] to 23.5 on [1-8] without transfusion. On [1-8] @ 7:20 pm his hemaocrit was re-checked and was 26.1. Because of his injuries and very deconditioned status both Physical and Occupational therapy were consulted and have recommended short term rehab. Medications on Admission: Methadone 140' MC Contin 130 ''' Antiretrovirals Neurontin 400''' Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection four times a day: per sliding scale. 2. Methadone 40 mg Tablet, Soluble Sig: 3.25 Tablet, Solubles PO DAILY (Daily): For pain control. 3. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). 4. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every eight (8) hours: To be given with 100 mg MS Contin; total dose 130 mg q 8 hours. 5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 6. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold fro SBP <100; HR <60. 11. Clonazepam 1 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for PRN anxiety. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) dose Subcutaneous Q12H (every 12 hours). 15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 16. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. Tizanidine 2 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 18. HYDROmorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for break through pain. 19. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 21. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 22. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: s/p Motor vehicle crash Tear drop fracture C3 Left transverse process fracture C2 Comminuted left acetabular fracture Discharge Condition: Stable Discharge Instructions: DO NOT bear any weight on your left lower extremity. You must continue to wear your hard collar for 4 weeks until follow up with Dr. [Last Name (STitle) 548], Neurosurgery. Followup Instructions: Follow up in 2 weeks with Dr. [Last Name (STitle) 1005], orthopedics, call [Telephone/Fax (1) 1228] for an appointment. Follow up with Dr. [Last Name (STitle) 548], Neurosurgery, in 4 weeks. Call [Telephone/Fax (1) 1669] for an appointment. Inform the office that you will need a repeat CT scan of your cervical spine for this appointment. Completed by:[2103-1-9] Name: [Known lastname 4366],[Known firstname ] Unit No: [Numeric Identifier 5602] Admission Date: [2102-12-24] Discharge Date: [2103-1-9] Date of Birth: [2062-5-20] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 844] Addendum: After Foley removed on [2103-1-8] Mr. [Known lastname ] began to complain of dysuria and hematuria; he was noted to have pink tinged urine, no clots noted or reported. A U/A and urine culture were obtained and sent for analysis. The urine culture is still pending at time of this dictation; he is being treated empirically with Levofloxacin and Pyridium. Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection four times a day: per sliding scale. 2. Methadone 40 mg Tablet, Soluble Sig: 3.25 Tablet, Solubles PO DAILY (Daily): For pain control. 3. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). 4. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every eight (8) hours: To be given with 100 mg MS Contin; total dose 130 mg q 8 hours. 5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 6. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold fro SBP <100; HR <60. 11. Clonazepam 1 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for PRN anxiety. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) dose Subcutaneous Q12H (every 12 hours). 15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 16. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. Tizanidine 2 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 18. HYDROmorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for break through pain. 19. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 21. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 22. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 23. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 24. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Discharge Disposition: Extended Care Facility: [Hospital3 1174] [Hospital ] Hospital - [Location (un) ] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 845] MD [MD Number(1) 846] Completed by:[2103-1-9] Name: [Known lastname 4366],[Known firstname ] Unit No: [Numeric Identifier 5602] Admission Date: [2102-12-24] Discharge Date: [2103-1-9] Date of Birth: [2062-5-20] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 844] Addendum: See previous Addendum Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection four times a day: per sliding scale. 2. Methadone 40 mg Tablet, Soluble Sig: 3.25 Tablet, Solubles PO DAILY (Daily): For pain control. 3. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). 4. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO every eight (8) hours: To be given with 100 mg MS Contin; total dose 130 mg q 8 hours. 5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 6. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold fro SBP <100; HR <60. 11. Clonazepam 1 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for PRN anxiety. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) dose Subcutaneous Q12H (every 12 hours). 15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 16. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. Tizanidine 2 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 18. HYDROmorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for break through pain. 19. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 21. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 22. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 23. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. 24. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Discharge Disposition: Extended Care Facility: [Hospital3 1174] [Hospital ] Hospital - [Location (un) ] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 845] MD [MD Number(1) 846] Completed by:[2103-1-9]	[ "304.73", "805.03", "278.00", "808.0", "805.02", "788.1", "345.90", "E815.1", "V08", "070.70" ]	icd9cm	[ [ [] ] ]	[ "38.7", "79.39", "79.75", "38.93" ]	icd9pcs	[ [ [] ] ]	14529, 14778	3649, 5336	337, 457	7844, 7853	782, 2462	8078, 9215	746, 763		12230, 14506	2499, 2536	7703, 7823		5362, 5429				7877, 8055																																			274, 299	2565, 3626						485, 638																		660, 704	720, 730
64,819	159,799	37047	Discharge summary	report	Admission Date: [2156-6-9] Discharge Date: [2156-6-17] Date of Birth: [2087-9-19] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2156-6-10] Coronary Artery Bypass Graft x 4 (Left internal mammary artery to left anterior descending, Saphenous vein graft to diagonal, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery) History of Present Illness: The patient is a 68year old white male with a known history of coronary artery disease. He recently developed dyspnea on exertion and [Month/Day/Year 1834] cardiology work-up. Cardiac catheterization and coronary angiography revealed 3 vessel coronary artery disease, including a 90% left main stenosis. He was referred for surgical revascularization. Past Medical History: Coronary Artery Disease s/p Inferior Myocardial Infartion w/ RCA angioplasty '[41] Hypertension Hyperlipidemia Obesity Sleep apnea(bipap) Chronic Renal Insuffiecency(1.7) Barrett's Esophagus/Gastroesophageal reflux disease Diverticulosis Anxiety/Depression Skin CA s/p excision(top of sternum-midline) Renal mass-not yet worked up s/p Tonsillectomy s/p ORIF left arm Social History: Occupation: retired Last Dental Exam Lives with: alone Race: Caucaisian Tobacco: ETOH Enrolled in any clinical/research study? no Family History: non-contributory Physical Exam: Pulse: 54 Resp: 14 O2 sat: 94%-RA B/P Right: 164/87 Left: Height: 5'0" Weight: 143K General:NAD Skin: Dry [] [Year (2 digits) 5235] []Bilat foot fungal infection/also involves panus skin folds HEENT: PERRLA [x] EOMI [x] anicteric Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 2/6 SEM>RUSB Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Obese, no HSM Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly [Year (2 digits) 5235] [x] Pulses: Femoral Right: palp Left: trace DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: rad murmur bilat Pertinent Results: [2156-6-10] Echo: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. A patent foramen ovale is present. Because of poor gastric windows, there is limited ability to assess LV fxn and size. From esophageal windows, the LV appears moderately depressed, with an EF = 35 - 40%. Marked inferior wall hypokinesis. The RV appears to be mildly to moderately depressed. There are simple atheroma in the descending thoracic [Month/Day/Year 5236]. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is AV-Paced, on low dose NTG. Biventricular systolic fxn remains mildly to moderately depressed. Inferior HK. Trace AI. 1+ MR. [First Name (Titles) ] [Last Name (Titles) 5235]. Other parameters as pre-bypass. [2156-6-10] LE Vein mapping: Duplex evaluation was performed of bilateral lower extremity veins. The greater saphenous veins are patent from the groin to the ankle bilaterally. On the right greater saphenous diameters range from 0.30-0.63 cm. On the left, the greater saphenous diameters range from 0.27 to 0.55 cm. [2156-6-17] 02:34AM BLOOD WBC-9.3 RBC-4.03* Hgb-11.1* Hct-34.3* MCV-85 MCH-27.6 MCHC-32.4 RDW-15.4 Plt Ct-252 [2156-6-16] 02:51AM BLOOD WBC-8.0 RBC-3.70* Hgb-10.2* Hct-31.7* MCV-86 MCH-27.6 MCHC-32.2 RDW-15.6* Plt Ct-213 [2156-6-13] 03:48AM BLOOD PT-12.3 PTT-25.9 INR(PT)-1.0 [2156-6-17] 02:34AM BLOOD Glucose-104 UreaN-33* Creat-1.9* Na-141 K-3.8 Cl-102 HCO3-27 AnGap-16 [2156-6-16] 02:51AM BLOOD Glucose-103 UreaN-31* Creat-1.9* Na-144 K-4.1 Cl-106 HCO3-25 AnGap-17 [2156-6-17] 02:34AM BLOOD Calcium-9.0 Mg-2.3 Brief Hospital Course: Mr. [Known lastname ] [Last Name (Titles) 1834] cardiac cath at outside hospital which revealed severe three vessel and left main disease. He was transferred to [Hospital1 18] for surgical management. Upon admission he was medically managed and appropriately worked-up for bypass surgery. On [6-10] he was brought to the operating room where he [Month/Day (4) 1834] a coronary artery bypass graft x 4. He did receive vancomycin and cipro for perioperative antibiotic prophylaxis as his hospital stay was greater than 24 hours pre-op. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. He awoke neurologically [Month/Day (4) 5235] and was subsequently extubated on POD # 4. Chest tubes and pacing wires were discontinued without incident. The patient has a history of chronic renal insufficiency with a baseline creatinine of 1.6. Creatinine rose to 3.2, resulting in acute on chronic renal failure. The nephrology service was consulted, and renal function did return to baseline prior to discharge. Renal replacement therapy was not required. The patient did develop a left sided pleural effusion and received a chest tube for this. This tube was discontinued without complication. The patient was transferred to rehab on POD 7 with appropriate follow-up instructions. Medications on Admission: Lasix 20', Folate/B6/B12 2.5/25/2 1cap/qd, zoloft 150', Atenolol 100', Simvastatin 80', Lotrel 10/40 1cap/qd, Wellbutrin SR 150', Prilosec 40', Aldactone 50', Tricor 48', Fiber tabs, Fish oil 1000', ASA 500', MVI Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 8. Wellbutrin SR 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 16. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 18. HydrALAzine 20 mg IV Q6H:PRN sbp > 120 19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 20. Dextrose 50% 12.5 gm IV PRN glucose < 60 Recheck glucose q 30 minutes until glucose > 100 21. Metoclopramide 10 mg IV Q6H:PRN nausea/vomiting 22. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 23. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 24. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 26. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day). 27. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: dose according to sliding scale. 28. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): dose according to sliding scale. Discharge Disposition: Extended Care Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Inferior Myocardial Infartion w/ RCA angioplasty '[41] Hypertension Hyperlipidemia Obesity Sleep apnea(bipap) Chronic Renal Insuffiecency(1.7) Barrett's Esophagus/Gastroesophageal reflux disease Diverticulosis Anxiety/Depression Skin CA s/p excision(top of sternum-midline) Renal mass-not yet worked up s/p Tonsillectomy s/p ORIF left arm Discharge Condition: Good Discharge Instructions: no lotions, creams, powders or ointments to incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness, drainage, or weight gain of 2 pounds in 2 days or 5 pounds in one week shower daily at pat incison dry; no baths or swimming Call with any questions or concerns Followup Instructions: Dr. [Last Name (STitle) 914] in 2 weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 39975] in 4 weeks Dr. [Last Name (STitle) 77687] in 6 weeks please call for all appts. Completed by:[2156-6-17]	[ "511.9", "414.2", "403.90", "584.9", "518.0", "585.9", "530.81", "530.85", "414.01", "300.4", "272.4", "327.23", "703.8" ]	icd9cm	[ [ [] ] ]	[ "36.15", "39.61", "33.24", "38.93", "36.13", "88.73", "86.27", "34.04" ]	icd9pcs	[ [ [] ] ]	8591, 8606	4206, 5603	339, 576	9053, 9059	2407, 4183	9435, 9657	1586, 1604		5866, 8568		8627, 9032		5629, 5843				9083, 9412									1619, 2388																										280, 301							604, 964																		986, 1358	1374, 1570
17,269	184,954	25711	Discharge summary	report	Admission Date: [2189-9-18] Discharge Date: [2189-9-18] Date of Birth: [2129-4-2] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Morphine / Digoxin Attending:[First Name3 (LF) 330] Chief Complaint: maintain support in anticipation of organ donation Major Surgical or Invasive Procedure: subclavian and arterial line placement; organ retrieval History of Present Illness: 60yo woman with h/o afib on coumadin, HTN, CAD who was in her usual state of health when her family last spoke with her on the phone around 7pm on the night prior to admission. This morning she was found by her daughter in law in bed, unresponsive, with agonal breathing, and with a bucket of emesis at the bedside. EMS was called, and she was intubated and transferred to [Hospital3 ] hospital where head CT revealed a large right sided intracranial hemorrhage. She was given narcan, mannitol, and potassium, and transferred to [Hospital1 18] for neurosurgy evaluation. On presentation to [Hospital1 18] ED HR 65, BP 137/68, 100% on AC TV 400 x RR 20 100% FiO@, PEEP 5. In ED she received manitol, dilantin, nitro gtt. Repeat CT revealed significant midline shift and transtentorial herniation. Subsequent neurosurgery and neurology examinations were consistent with brain death. The patient's family was notified, and they wished to pursue organ donation. She is being admitted to the MICU for continued support while [Location (un) 511] Organ Center continues efforts for organ donation. Blood pressure is currently labile with SBP range 70s-170s on neosynephrine. Oxygentating well on ventilator AC TV 400 x RR 20 100% FiO@, PEEP 5. She is unresponsive to voice or pain Past Medical History: CAD s/p CABG [2177] Afib on coumadin Hypertension emphysema Social History: lives alone, has 4 grown children, quit smoking many years ago, no etoh, no drugs Family History: sister died of stroke in her 40's (unknown causes) . Physical Exam: T 97.0 HR 68 BP 130/59 RR 26 100% Gen: obese, intubated, unresponsive HEENT: pupils fixed and dilated, no doll's eyes, no corneal reflex, anicteric, ETT Neck: supple CV: RRR, no mrg Resp: coarse bilaterally Abd: +BS, soft, NT, ND, no HSM Ext: no edema, palpable diminished radial and DP pulses although, warm fingers Neuro: pupils unreactive, no response to pain or verbal stimuli, no corneal reflex Pertinent Results: [2189-9-18] 02:28PM TYPE-ART PO2-72* PCO2-38 PH-7.39 TOTAL CO2-24 BASE XS--1 [2189-9-18] 06:57AM TYPE-ART PO2-91 PCO2-37 PH-7.39 TOTAL CO2-23 BASE XS--1 [2189-9-18] 06:57AM LACTATE-2.6* [2189-9-18] 06:42AM GLUCOSE-123* UREA N-13 CREAT-0.8 SODIUM-156* POTASSIUM-4.1 CHLORIDE-122* TOTAL CO2-22 ANION GAP-16 [2189-9-18] 06:42AM ALT(SGPT)-51* AST(SGOT)-126* ALK PHOS-108 AMYLASE-30 TOT BILI-0.6 [2189-9-18] 06:42AM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-1.9* MAGNESIUM-2.5 [2189-9-18] 06:42AM PT-19.8* PTT-35.6* INR(PT)-2.6 [2189-9-18] 02:28AM TYPE-ART PO2-94 PCO2-38 PH-7.37 TOTAL CO2-23 BASE XS--2 [2189-9-18] 02:28AM LACTATE-3.3* [2189-9-18] 02:28AM O2 SAT-93 [2189-9-18] 02:28AM freeCa-1.27 [2189-9-18] 01:57AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.001 [2189-9-18] 01:56AM PT-18.7* PTT-28.4 INR(PT)-2.3 [2189-9-18] 12:42AM O2 SAT-86 [2189-9-18] 12:19AM O2 SAT-98 [2189-9-17] 03:06PM ALT(SGPT)-46* AST(SGOT)-52* CK(CPK)-285* TOT BILI-0.5 [2189-9-17] 03:06PM CK-MB-7 cTropnT-<0.01 [2189-9-17] 02:50PM CALCIUM-9.0 PHOSPHATE-2.8 MAGNESIUM-1.5* [2189-9-17] 02:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2189-9-17] 02:50PM URINE HOURS-RANDOM [2189-9-17] 02:50PM URINE HOURS-RANDOM [2189-9-17] 02:50PM WBC-18.6* RBC-5.13 HGB-11.4* HCT-36.4 MCV-71* MCH-22.3* MCHC-31.4 RDW-17.7* [2189-9-17] 02:50PM NEUTS-92* BANDS-1 LYMPHS-4* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2189-9-17] 02:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-3+ POLYCHROM-1+ OVALOCYT-2+ TEARDROP-OCCASIONAL [2189-9-17] 02:50PM PLT SMR-NORMAL PLT COUNT-303 [2189-9-17] 02:50PM PT-17.3* PTT-26.6 INR(PT)-2.0 [2189-9-17] 02:50PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.019 [2189-9-17] 02:50PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 Brief Hospital Course: The patient was admitted for monitoring prior to becoming an organ donor. She was declared brain dead after a complete neurologic examination revealed no brainstem activity including doll's eyes, cold caloric, and complete apnea testing. Blood pressure was supported during the night with levophed. She also received a dose of steroids. She continued on ventilator support. The following day organs were harvested; she was discharged to the care of the [Location (un) 511] Organ Bank and then to her family for funeral arrangements. Medications on Admission: enalapril 5mg daily zoloft 200mg daily premarin 0.625mg daily coumadin 2.5mg daily metoprolol 25mg [Hospital1 ] levothyroxine 200mg daily lipitor 40mg daily protonix 40mg daily lorazepam 1mg prn Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired	[ "431", "V45.81", "V58.61", "496", "427.31", "278.00" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	5252, 5261	4427, 4970	351, 408	5312, 5321	2422, 4404	5377, 5387	1931, 1986		5220, 5229		5282, 5291		4996, 5197				5345, 5354									2001, 2403																										261, 313							436, 1728																		1750, 1816	1832, 1915
46,923	152,216	40758+58395	Discharge summary	report+addendum	Admission Date: [2200-3-24] Discharge Date: [2200-3-27] Date of Birth: [2117-7-7] Sex: F Service: ORTHOPAEDICS Allergies: morphine / Erythromycin Base Attending:[First Name3 (LF) 8587] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: Open reduction internal fixation left femur and right tibia History of Present Illness: 82 yo Female who usually ambulates with walker s/p witnessed mechanical fall. No LOC, no head strike. Patient has a left leg motor neuropathy with drop foot that causes her much difficulty with ambulation and resulted in this fall. Neuropathy of unknown origin. Patient immediately felt pain in left knee and was taken to OSH. They were referred here for futher Orthopaedic Care. Past Medical History: 3V CABG ~ 7 years ago Hypothyroid HTN Left leg neuropathy with drop foot s/p olecranon and humerus ORIF Social History: Lives alone. Ambulates with walker. denies smoking, drinking, drugs. Family History: N/A Physical Exam: Admission Physical Exam: 98 84 111/63 18 93% RA A&O x 3 , NAD Cor: well perfused Pulm: No respiratory distress RLE: Compartments soft, skin intact. Full supple, painless ROM of hip, knee. + swelling at ankle. No joint effusions or crepitus appreciated. 5/5 strength to hf, kf, ke. 0/5 [Last Name (un) ], adf, apf - at baseline. foot is wwp, dp and pt pulses are 2+. SilT s/s/dp/sp/tn distributions. LLE:Compartments soft, skin intact. Full supple, painless ROM of hip, ankle. + swelling superior to knee. no crepitus appreciated. 5/5 strength adf, apf, [Last Name (un) ]. foot is wwp, dp and pt pulses are 2+. SilT s/s/dp/sp/tn distributions. Pertinent Results: TT Echo: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Xray films in ED revealed right distal tibia fracture and left distal femur fractures. [2200-3-27] 05:20AM BLOOD Hct-28.7* [2200-3-27] 12:40AM BLOOD Hct-29.3* [2200-3-27] 09:20AM BLOOD Glucose-144* UreaN-9 Creat-0.6 Na-135 K-3.2* Cl-95* HCO3-33* AnGap-10 Brief Hospital Course: Ms. [Known lastname ] was evaluated in the emergency room by the orthopaedic trauma service and found to have a left femur fracture and right tibia fracture. She was admitted to ortho and prepped for surgery. On HD 2, she was taken to the OR. See operative report for full details. She tolerated the procedure well, however post-operatively there were concerning EKG changes consistent with ischemia. A TTE was performed, see report for full details and cardiac enzymes were cycled. Cardiac enzymes were negative x3. Patient spent post-operative period in ICU for increased monitoring. During the peri-operative period she received 4 units of blood due to acute blood loss. On POD#2 she received an additional 2 units of blood and 1 of FFP. She was started on lovenox daily for DVT prophylaxis on POD#1. At the time of discharge, she was afebrile with stable vital signs, tolerating a regular diet, voiding spontaneously, and with her pain well controlled. Medications on Admission: Cymbalta 30 QD, alprazolam 0.5 mg QD, amitriptyline 10 mg QD, HCTZ 25 QD, Protonix 40 [Last Name (LF) 244], [First Name3 (LF) ] 81, Lisinopril 5 QD, Synthroid 25 mcg', simvastatin 40 QD, Metroprol 50 QD Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for Anxiety. 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 11. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40 mg Subcutaneous DAILY (Daily): Continue for 4 weeks post-op. 14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. Discharge Disposition: Extended Care Facility: Radius [Hospital 36748] HealthCare Center - [Hospital1 189] Discharge Diagnosis: Left distal femur fracture and Right distal tibia fracture Discharge Condition: Stable. Alert and Oriented. Discharge Instructions: Wound Care: - Keep Incision clean and dry. - Do not soak the incision in a bath or pool. Activity: - Continue to be non weight bearing on your left and right leg. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. - You have also been given Additional Medications to control your pain. Please allow 72 hours (Monday through Friday, 9am to 4pm) for refill of narcotic prescriptions, so plan ahead. There will be no prescription refils on Saturdays, Sundays, or holidays. 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. Physical Therapy: Non weight bearing bilateral lower extremity. Treatments Frequency: Dressing changes as needed. Followup Instructions: Please follow-up in [Hospital 1957] Clinic with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [MD Number(3) 49252] weeks. Please call [Telephone/Fax (1) 9769] for an appointment. Completed by:[2200-3-27] Name: [Known lastname 14127],[Known firstname 13025] Unit No: [Numeric Identifier 14128] Admission Date: [2200-3-24] Discharge Date: [2200-3-27] Date of Birth: [2117-7-7] Sex: F Service: ORTHOPAEDICS Allergies: morphine / Erythromycin Base Attending:[First Name3 (LF) 3564] Addendum: Please follow-up in [Hospital ] Clinic with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2577], [MD Number(3) 14129] weeks. Please call [Telephone/Fax (1) 14130] for an appointment. Please follow-up with your PCP and Cardiologist in the next [12-1] weeks for further evaluation of your cardiac status given EKG changes post-operatively. Discharge Disposition: Extended Care Facility: Radius [Hospital 14131] HealthCare Center - [Hospital1 1612] Followup Instructions: Please follow-up in [Hospital ] Clinic with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2577], [MD Number(3) 14129] weeks. Please call [Telephone/Fax (1) 14130] for an appointment. Please follow-up with your PCP and Cardiologist in the next [12-1] weeks for further evaluation of your cardiac status given EKG changes post-operatively. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3565] MD [MD Number(2) 3566] Completed by:[2200-3-27]	[ "401.9", "824.8", "285.1", "V45.81", "821.23", "244.9", "357.82", "E880.9", "736.79" ]	icd9cm	[ [ [] ] ]	[ "79.36", "79.35" ]	icd9pcs	[ [ [] ] ]	8017, 8112	2886, 3849	301, 363	5601, 5631	1698, 2863	8135, 8666	1005, 1010		4111, 5381		5519, 5580		3875, 4088				5655, 5655									1050, 1679	6889, 6935	6957, 6986																								253, 263					5667, 6871		391, 774																		796, 902	918, 989
27,084	162,264	33978	Discharge summary	report	Admission Date: [2193-5-21] Discharge Date: [2193-5-27] Date of Birth: [2124-3-28] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: CP Major Surgical or Invasive Procedure: [2193-5-21] - Coronary artery bypass graft times two with left internal mammary artery to left anterior descending coronary artery and reverse single vein graft from the aorta to the ramus coronary artery. History of Present Illness: This is a 69-year-old male with a history of coronary artery disease who over the last several months had developed some diffuse abdominal pain noticed with exertion. It had progressed to recent back pain and chest pain. He underwent evaluation. EKG showed changes. He underwent a stress test which was positive and he was referred for catheterization. Catheterization revealed a left main 50-60% stenosis as well as a left circumflex artery lesion of approximately 80-90%. Based on these findings, the patient was recommended to undergo coronary artery bypass graft. Past Medical History: CAD MI HTN Chronic low back pain Shingles Social History: Retired police officer. 10 pack year smoking history quitting 30 years ago. Lives with wife. 1 beer/day. Family History: Unremarkable Physical Exam: 70 118/69 73" 225lbs GEN: WDWN in NAD SKIN: Warm, dry, no clubbing or cyanosis. HEENT: PERRL, Anicteric sclera, OP Benign NECK: Supple, no JVD, FROM. LUNGS: CTA bilaterally. HEART: RRR, No M/R/G ABD: Soft, ND/NT/NABS EXT:warm, well perfused, no bruits, no varicosities, no peripheral edema NEURO: No focal deficits. Pertinent Results: [2193-5-21] ECHO PRE-BYPASS: 1. The left atrium is moderately dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. Mild spontaneous echo contrast is present in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with mid to apical anterior to anteroseptal hypokinesis. Overall left ventricular systolic function is moderately depressed (LVEF= 30 %). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is systolic doming of the aortic valve leaflets. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild to moderate ([1-9]+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including Milrinone and Norepinephrine and is is a sinus rhythm. 1. Biventricular function is unchanged. 2. Aorta is intact post decannulation 3. Other findings are unchanged [2193-5-27] 01:44PM BLOOD WBC-24.9* RBC-3.11* Hgb-9.6* Hct-28.8* MCV-93 MCH-30.8 MCHC-33.3 RDW-16.5* Plt Ct-170 [2193-5-27] 10:29PM BLOOD PT-43.4* PTT-58.5* INR(PT)-4.8* [2193-5-27] 10:29PM BLOOD Glucose-184* UreaN-32* Creat-2.3* Na-136 K-4.4 Cl-97 HCO3-15* AnGap-28* [2193-5-27] 10:11AM BLOOD ALT-3013* AST-5084* LD(LDH)-7900* CK(CPK)-416* AlkPhos-117 Amylase-130* TotBili-3.1* [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 78470], [Known firstname ] [Hospital1 18] [Numeric Identifier 78471]Portable TTE (Complete) Done [2193-5-27] at 12:29:40 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. Division of Cardiothoracic [Doctor First Name ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2124-3-28] Age (years): 69 M Hgt (in): 72 BP (mm Hg): 90/50 Wgt (lb): 220 HR (bpm): 100 BSA (m2): 2.22 m2 Indication: Coronary artery disease. Left ventricular function. Right ventricular function. ICD-9 Codes: 427.89, 799.02, 424.1 Test Information Date/Time: [2193-5-27] at 00:29 Interpret MD: [Name6 (MD) ] [Name8 (MD) 4082], MD Test Type: Portable TTE (Complete) Son[Name (NI) 930]: Cardiology Fellow Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2008W006-1:49 Machine: Other Echocardiographic Measurements Results Measurements Normal Range Findings LEFT ATRIUM: Dilated LA. No mass/thrombus in the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. Depressed LAA emptying velocity (<0.2m/s) RIGHT ATRIUM/INTERATRIAL SEPTUM: No thrombus in the RAA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate global LV hypokinesis. RIGHT VENTRICLE: Mildly dilated RV cavity. Severe global RV free wall hypokinesis. AORTA: Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild to moderate ([1-9]+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. [Male First Name (un) ] of the mitral chordae (normal variant). No resting LVOT gradient. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate [[1-9]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. The rhythm appears to be A-V paced. Emergency study. Echocardiographic results were reviewed by Conclusions The left atrium is dilated. No mass/thrombus is seen in the left atrium/left atrial appendage or right atrium/ right atrial appendage No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal with normal/small cavity size. There is moderate regional dysfunction with septal dyskinesis, and near akinesis of the distal half of the anterior wall and distal inferior wall and apex. The remaining segments contract well. The right ventricular cavity was mildly dilated with near akinesis of the free wall. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are thickened. Mild to moderate ([1-9]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2193-5-21], right ventricular cavity enlargement with near global akinesis is new and suggestive of primary right ventricular ischemia. The severity of tricuspid regurgitation is also increased. Dr. [Last Name (STitle) ] was notified by telephone on [5-27] at 01:00. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4083], MD, Interpreting physician [Last Name (NamePattern4) ] [2193-5-27] 15:09 RADIOLOGY Final Report CHEST (PORTABLE AP) [2193-5-27] 1:10 AM CHEST (PORTABLE AP) Reason: assess Swan Ganz placement [Hospital 93] MEDICAL CONDITION: 69 year old man s/p arrest, opening of his chest REASON FOR THIS EXAMINATION: assess Swan Ganz placement CHEST RADIOGRAPH INDICATION: Followup. COMPARISON: [2193-5-26]. As compared to the previous examination, a newly positioned endotracheal tube is 6 cm above the carina with its tip. A newly inserted left-sided chest tube is in standard position. Its tip at the left apex is surrounded by a small parenchymal opacity, potentially suggesting local bleeding. The tip of a newly inserted Swan-Ganz catheter projects over the outflow tract of the right ventricle. There is extensive cardiomegaly with subtle signs of over-hydration. There is no evidence of pleural effusions, and no evidence of pneumothorax. No focal parenchymal opacities suggestive of pneumonia. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] Approved: MON [2193-5-27] 10:03 AM Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2193-5-21] for surgical management of his coronary artery disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to two vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. He received FFP, platelets, cryo and packed red blood cells for postoperative bleeding with resolution. Within 24 hours, Mr. [Known lastname ] [Last Name (Titles) 5058] neurologically intact and was extubated. Plavix and aspirin were resumed given his previous cardiac stent. He developed atrial fibrillation and amiodarone and beta blockade were started. He subsequently converted back into a normal sinus rhythm. On postoperative day two, he was transferred to the step down unit for further recovery. Mr. [Known lastname ] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He was progressing and had gone into AF. He was being anticoagulated on coumadin and was progressing with PT. He was ready to be discharged on POD 5 when he had a syncopal episode. He did not lose consciousness. He was mildly hypotensive and had a HR in the 60's. His Amiodorone was discontinued. At 11PM he had a bradycardic arrest. CPR was initiated and he regained a rhythm and BP on pressors. He was transferred to the CVICU and then had an echo which showed RV hypokinesis. He had a cardiac cath which revealed an occluded RCA and RV failure. He then had a cardiac cath which showed a totally occluded RCA and RV failure. An IABP was placed and pt. remained on multiple pressors and was profoundly acidotic. He had low cardiac outputs throughout the following day and his pressor requirement increased. At 11:30 PM he had bradycardia and became hypotensive. He eventually was asystolic and could not capture with his V pacer. His BP was in the 20's despite fluid and wide open pressors. His chest dressing was opened and he had internal massage, but he was unable to be rescitated. Dr. [Last Name (STitle) ] and the pt.'s family were notified. Medications on Admission: Toprol Accupril Aspirin Lovenox Plavix Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: CAD s/p CABGx2 HTN MI Shingles Chronic low back pain Discharge Condition: Expired Discharge Instructions: None Completed by:[2193-5-28]	[ "584.9", "285.9", "780.2", "E879.9", "518.81", "424.1", "570", "414.01", "397.0", "348.1", "998.11", "401.9", "276.2", "272.0", "427.5", "427.31", "424.0" ]	icd9cm	[ [ [] ] ]	[ "88.72", "96.04", "39.61", "99.60", "89.68", "38.93", "99.06", "96.71", "89.64", "36.15", "99.04", "36.11", "37.61", "39.63", "93.90" ]	icd9pcs	[ [ [] ] ]	10853, 10862	8508, 10735	324, 536	10959, 10969	1704, 7556		1336, 1350		10824, 10830	7593, 7642	10883, 10938		10761, 10801				10993, 11028									1365, 1685																										282, 286	7671, 8485						564, 1133																		1155, 1198	1214, 1320
2,286	122,327	43078	Discharge summary	report	Admission Date: [2162-3-25] Discharge Date: [2162-4-12] HISTORY OF PRESENT ILLNESS: This is a [Age over 90 ]-year-old male who disease, recently started on hemodialysis and coronary artery disease, status post coronary artery bypass grafting. He was admitted to the medical service for further evaluation of the source of his fever and mental status changes. He was in his usual state of health until two days prior complained of abdominal cramping. He was taken to an outside hospital, and was noted to have a fever, hypoxia in the 80s, a potassium of 6, and a chest x-ray showing a right pneumonia. He was given Levaquin and sodium bicarbonate and was transferred to the [Hospital1 69]. On arrival, he was found to be increasingly lethargic. He was coughing and complaining of abdominal cramping. PAST MEDICAL HISTORY: 1. End- stage renal disease (on hemodialysis since [3-5]). 2. A coronary artery bypass graft in [2159] with an ejection fraction of 55%. 3. Type 2 diabetes. 4. Hypertension. 5. Peripheral vascular disease. 6. Benign prostatic hypertrophy. 7. Deep venous thrombosis in [2160]. 8. Pacemaker for complete heart block. PAST SURGICAL HISTORY: He had a femoral-tibial bypass and a ilial-femoral bypass in [2155]. ALLERGIES: He is allergic to CODEINE. MEDICATIONS ON ADMISSION: His medications were Phos-Lo, Calcitriol, Lopressor 50 mg p.o. b.i.d., Nephrocaps, and Imdur 30 mg p.o. q.d. SOCIAL HISTORY: He lives with his daughter. [Name (NI) ] has no history of tobacco or alcohol use. PHYSICAL EXAMINATION ON PRESENTATION: On examination, his temperature was 100.2, his pulse was 60, blood pressure was 105/78, respiratory rate of 26, O2 sat of 100% on 2 liters and 88% on room air. He was an elderly male lying in bed. His examination was remarkable for crackles at the bases bilaterally. There was a 3/6 systolic ejection murmur. Mild abdominal distention, but otherwise soft and nontender with tympany. He did have some guaiac-positive stool on rectal examination. No edema. Neurologically, he was somnolent but arousable, but did not answer questions appropriately. PERTINENT LABORATORY DATA ON PRESENTATION: His white blood cell count was 9.7, with a hematocrit of 26. Chemistry revealed a sodium of 139, potassium of 6, chloride of 101, bicarbonate of 24, blood urea nitrogen of 40, creatinine of 4.5, glucose was 159. His repeat potassium was 5.3. His coagulations revealed PT of 14.7, INR of 1.5, PTT of 31.2. RADIOLOGY/IMAGING: His KUB here showed air/fluid levels, nondistended loops, with no evidence of obstruction. Chest x-ray showed mild congestive heart failure with a right hemidiaphragm obscured by either an effusion versus an infiltrate. ASSESSMENT: He was admitted to the medical service for evaluation of his fever, abdominal pain and mental status changes. The differential diagnosis listed by the medical service included congestive heart failure, pneumonia, or toxic metabolic derangement as a result of the pneumonia. He was admitted for careful observation. HOSPITAL COURSE: He was transfused packed red blood cells for a HCT of 26 on [3-25]. He was complaining of occasional crampy abdominal pain, constipation, nausea, and some occasional emesis. He had Staphylococcus aureus from the outside hospital growing in [4-22] of his blood cultures. He was on levofloxacin and vancomycin. Dialysis and Renal were following. On [2162-3-28], a CT of the abdomen was obtained that showed free air and contrast extravasation into the peritoneal cavity. At that time, Surgery was consulted. At that time, he was non- arousable buthemodynamically stable. His abdomen was markedly distended. The review of the CT scan reveals no opacification of the small bowel and a large amount of contrast extravasation consistent with a gastric perforation. A long discussion occured with the family regarding his need for surgery including an extensive conversation about the morbidity and mortality associated with this diagnosis in a [Age over 90 ] yo male with DM, CAD, and ESRD. The family wanted to pursue all measures and he was brought to the OR emergently for intubation and exploratory laparotomy. On exploration, he was found to have a perforated ulcer measuring approximately 5cm involving the distal stomach across the pylorus to the level of the common bile duct. There was extensive contamination of the peritoneal cavity with visible food particles in the lesser sac. Another conversation with the family was entertained and the findings were discussed. Again, the family wanted to pursue all available means. He underwent a distal gastrectomy with a loop gastrojejunostomy. A JP drain was placed in the lesser sac. He was transferred to the Postanesthesia Care Unit intubated and stable. He was maintained on Levophed for blood pressure support. He required controlled ventilation. He could not tolerate hemodialysis secondary to hemodynamic instability. He was given Levophed, Flagyl, and fluconazole. The patient was given a very grim prognosis. The family was discussing code status, but continued to make him full code. The patient underwent CBV/HDF. He had a complicated Intensive Care Unit stay with worsening of his lactic acidosis and with complications of Levophed; mainly, necrotic digits of the fingers and toes. In the setting of his hypotension, sepsis, acidosis (on pressors), with respiratory alkalosis, he was kept on low tidal volumes and given bicarbonate. He was also continued on his antibiotics for his sepsis and supportive management. Further surgery was deemed not appropriate and the family agreed with this decision. The patient had all sedation stopped and remained obtunded. He had a Stroke consultation and had a head CT which showed right watershed infarcts. The Stroke team gave him a very poor prognosis given his right middle cerebral artery stroke. He was requiring increasing doses of pressors. He also was quite coagulopathic and was treated with vitamin K and fresh frozen plasma. He had multiple blood transfusions of packed red blood cells. Extensive daily conversations were held with the family. An ethics consult was obtained as the family wanted to continue all measures. On [4-12], on postoperative day 15, while he was in profound shock, he became apneic on the ventilatory, with loss of blood pressure. His pacemaker was functioning, but he had no other vital signs. He was declared dead and the family was present at the time of his death. DISCHARGE STATUS: Death. DISCHARGE DIAGNOSES: 1. Perforated duodenal ulcer. 2. Status post gastrectomy and gastrojejunostomy. 3. End-stage renal disease. 4. Peripheral vascular disease. 5. Large hemorrhagic middle cerebral artery stroke. 6. Coronary artery disease s/p CABG. 7. Sepsis, treated with multiple pressors. 8. Respiratory failure. 9. Gastrointestinal bleeding. 10. Methicillin-resistant Staphylococcus aureus pneumonia. 11. Diabetes. 12. Metabolic alkalosis. 13. Respiratory and metabolic acidosis as well. 14. Hypotension. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 13186], M.D. [MD Number(1) 13187] Dictated By:[Last Name (NamePattern1) 8344] MEDQUIST36 D: [2162-5-6] 15:16 T: [2162-5-6] 16:03 JOB#: [Job Number 92914]	[ "532.50", "531.50", "263.9", "E879.8", "403.91", "276.2", "996.62", "038.11", "250.00" ]	icd9cm	[ [ [] ] ]	[ "43.7", "03.31", "38.93", "39.95" ]	icd9pcs	[ [ [] ] ]								6589, 7378					1350, 1460	3098, 6567											1209, 1323																																		103, 827																		849, 1185	1477, 3080
14,334	173,033	4671	Discharge summary	report	Admission Date: [2112-8-1] Discharge Date: [2112-8-17] Date of Birth: [2039-6-19] Sex: F Service: MEDICINE Allergies: Levofloxacin Attending:[First Name3 (LF) 2387] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Renal artery stent History of Present Illness: 73 yo F with HTN, CRI, s/p left nephrectomy, right RAS s/p stenting in [2111-12-1], CHF, presented [8-2] with worsening dyspnea. Found to be in CHF in setting of hypertensive emergency. The renal artery was re-evaluated given high suspicion of restenosis. Taken for cath on [8-4], which revealed 95% right renal artery instent restenosis. The vessel was stented again. Post-stenting, the pt continued to have elevated BP, and worsening renal function. She was thought to have contrast nephropathy. Also, she had hct drop noted on [8-5] of 30 to 23. She was given 2U RBCs with bump in cr to 25. She then began complaining of RUQ pain. MRI/MRA showed large subcapsular hematoma with active bleeding. Transferred to CCU for closer monitoring. Past Medical History: 1. s/p Left sided nephrectomy for Renal cell CA - no chemo or XRT 2. Diabetes Mellitus x 20 years -- currently on glyburide and insulin 3. Hypertension 4. Chronic renal insufficiency - Cr 1.5 in [2111-12-1] 5. bilateral knee replacements 6. reports benign breast lump many years ago. 7. h/o admission for E coli UTI [2108] w/ ?urosepsis 8. h/o guaiac positive stool - colonoscopy with diverticulosis of sigmoid 9. renal artery stenosis on right - s/p stenting in [2111-12-1] - Doppler in [2112-3-30] showed normal arterial and venous waveforms and flow 10. clean coronaries on cath [12-4] Social History: Lives in [Location 6151]; originally from [Country 2045] but has lived here for 35 years. Not currently working but used to work in housekeeping. Denies any history of smoking, alcohol, or drug use. Widow. Has 7 children. Family History: Both parents w/ DM, daughter w/ DM; denies any other known family history. Physical Exam: VS - T 98.6, BP 168/50, HR 82, RR 22, O2 sat 96% 2L general - comfortable, resting in bed, NAD HEENT - PERRL, EOMI, OP clr, MMM, JVD not appreciated CV - RRR w/ ectopy, nl s1 s2, [3-7] syst mur at base chest - bibasilar crackles abdomen - NABS, soft, NT/ND, no g/r back - non-tender to palpation ext - L>R lower extremity edema, trace on R, 2+ on L (pt laying on L side) neuro - CN II-XII intact, strength 5/5 throughout, sensation intact to lt touch Pertinent Results: [2112-8-1] H c t - 3 3 . 7 - - > 3 0 . 0 ( 7 / 6 ) - - > 2 3 . 6 ( 7 / 7 ) - - > 2 3 . 3 - - > 2 5 . 9 ( 7 / 8 ) - - > 2 4 . 7 - - >25.3-->28.6([8-7])-->27.8-->27.1-->27.5-->29.2([8-8])-->28.8([8-12]) . [2112-8-1] C r e a t - 2 . 0 - - > 2 . 3 ( 7 / 5 ) - - > 3 . 1 ( 7 / 6 ) - - > 2 . 7 - - > 3 . 5 ( 7 / 7 ) - - > ( 7 / 8 ) - - > 3 . 1 ( 7 / 9 ) - - > 3 . 4 - - > 3 . 8 - - > 4 . 0 ( 7 / 1 0 ) - - > 4 . 1 - - > 4 . 4 ( 7 / 1 1 ) - - > 5 . 3 - - >5.6-->5.7([8-10])-->5.6([8-10])-->4.7([8-11])-->4.4([8-12])-->Creat-4.7 . [2112-8-1] proBNP-8986 . [2112-8-6] URINE RBC-[12-19]* WBC->50 Bacteri-MANY Yeast-NONE Epi-[7-9] [2112-8-6] URINE CX >100,000 E. coli . Renal cath ([2112-8-4]): 95% right renal artery in-stent restenosis. Successful PTCA/stent of right renal artery with a 6.0 x 18mm Racer stent . Renal MRI/MRA ([2112-8-6]): Large perinephric hematoma including mass effect on the lateral aspect of the right kidney. Active extravasation seen in the course of this exam though not accumulating at a very brisk rate. No abnormality of the visualized right renal artery and the extravasation is quite lateral to any of the extrarenal renal artery branches. . Echocardiogram: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. . Brief Hospital Course: 73 F with right renal artery stenosis s/p stenting complicated by subcapsular hemorrhage. . ## CVS: -Ischemia: Known CAD. --- Pt was initially only given ASA 81 mg PO as therapy in light of her capsular hemorrhage post-renal atery stenting. She was eventually started back on clopidogrel 75 mg PO qd once the bleeding ceased. -Pump: CHF on presentation likely secondary to hypertensive emergency. Pt was volume overloaded while in the CCU; however, became she became short of breath due to volume overload only once. Because of her volume overload in the setting of oliguric renal failure, she eventually required dialysis. She underwent two sessions of dialysis, and subsequently responded to well diuresis with furosemide and metolazone. Pt was started on daily diuretic therapy since she seemed to consistently develop LE edema & basilar crackles on lung exam when not recieving diuretics. -Valves: No known dz -Rhythm: no electrical abnormalities. Monitored on telemetry. . ## Renal: Pt's initial presentation with hypertensive urgency was attributed to re-stenosis of her renal artery stent. Even after PTCA & re-stenting of the renal artery the pt's BP remained elevated & her renal failure persisted. Her blood pressure was initially treated in the CCU with a nitro drip. Then changed to labetalol drip before converting to PO labetalol and being transfered to the floor. Multiple agents were required to lower the pt's BP. After trying numerous combinations the following meds seemed to control her pressure adequately: labetolol, hydralazine, nifedipine, and clonidine (initially PO then patch). Since stabilization on these medications, her SBP has remained mostly <140. Of note, pt's oral clonidine was tapered during the transition to the clonidine patch; however, she should be monitored for rebound hypertension as the taper has just been completed. Post-renal artery cath, the pt's renal function became progressively worse, peaking at a creatinine of 5.7. She became uremic. A tunneled catheter was placed for dialysis, which was performed twice with good effect. After dialysis, her Crt began to trend downward, leveling off at 2.7. Her acute renal failure was likely multifactorial (hypertensive emergency, dye load, ? constriction from hematoma). Her urine output improved after dialysis, though it was still low. Because of this and the associated signs of volume overload, we started her on daily diuretic therapy. -Pt's potassium was noted to be rising following cath (from 3.3 to 5.1 over two days). Has improved to 4.7 on loop diuretic. This needs to be monitored every few days. . ## ID: Pt was diagnosed with a foley catheter-associated UTI and treated with 10-day course of ceftriaxone 1 g IV qd because she has a levofloxacin allergy. The urine culture revealed pan-sensitive E. coli. Repeat urine culture revealed no growth. Pt's WBC has been rising slightly. On, [2112-8-18], WBC=12.9. Pt has been afebrile. If WBC continues to rise, she may need a repeat UCx. There was no evidence of lower extremity cellulitis, though there was concern that with her lower extremity swelling that she might develop this if the skin breaks. . ## DM: Pt was on NPH 7 qAM/7 qPM along with RISS. Since she had been requiring an additional 8units of insulin on top of her NPH at 7qAM/7qPM, we increased her NPH to 14 qAM / 7 qPM upon discharge. Her glyburide was held given her renal failure. . ## Anemia: Pt's anemia was attributed to her sub-capsular hematoma & also EPO deficiency in the setting of renal failiure. She received multiple units of PRBC's to stabilize her Hct. Overtime, her Hct improved, and the sub-capsular hematoma was found to be stable on repeat imaging. She was started on EPO per renal's recommendation. Hct has stabilized around 30. . ## LE edema: During hospitalization, pt was noted to have assymetric lower extremity edema (L>R). There was associated tenderness mild erythema. Despite getting DVT prophylaxis, there was still concern that this might be DVT given her prolonged bed-rest. She underwent lower extremity ultra-sound which was negative for DVT. Following negative U/S, she was diuresed. The swelling will likely improve with continued daily diuretic therapy. . ## ?Depression: the pt's mood seemed depressed. Though she denied being depressed, she did admit to feeling hopeless & helpless. She refused to talk to a psychiatrist while in hospital. We started her on Zoloft 50mg/day [2112-8-17]. Dr. [Last Name (STitle) ] will be following up on this issue with the pt within one week of discharge. . ## Activity: pt worked with physical therapy on a few occasions during hospitalization. She needed assistance ambulating, and they recommended [Hospital 3058] rehab to help improve her physical condition. . ## Skin: Pt was noted to have multiple small stage 1 ulcers on her bottom that were treated with Duo-derm. She will benefit from wound care and improved ambulation. . ## Social: pt's family came regularly to see pt. They took an active interest in her care. Medications on Admission: 1. Hydralazine 50 mg PO QD 2. Hydrochlorothiazide 25 mg PO DAILY 3. Metoprolol Tartrate 50 mg PO TID 4. Clopidogrel 75 mg PO DAILY 5. Atorvastatin 20 mg PO DAILY 6. Glyburide 10 mg PO DAILY 7. Aspirin 325 mg PO DAILY 8. Benicar 40 QD 9. Insulin N 10U QD 10. Procrit QWk Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day): Please hold if HR < 60 or SBP <100. 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily): Please hold if SBP <100. 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): Please hold if SBP <100. Tablet(s) 9. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 10. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) patch Transdermal once a week: Please apply every Monday, and change site of patch with each application. If pt experiences, burning at patch site, please remove & discontinue. Let Dr. [Last Name (STitle) ] know. 11. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 14. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) Subcutaneous twice a day: 14units in the AM 7units in the PM. 15. Zoloft 25 mg Tablet Sig: Two (2) Tablet PO once a day: Watch for signs of suicidality, as this is a new medication for the pt. 16. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital1 2670] - [Location (un) ] Discharge Diagnosis: Hypertensive urgency renal artery instent restenosis renal subcapuslar hematoma CHF Acute on chronic renal insufficiency Discharge Condition: Stable Discharge Instructions: If pt spikes a fever or if WBC is increasingly elevated, check a U/A and urine culture. Pt recently treated for a UTI. Also, watch for signs of cellulitis as pt's legs have been swollen in setting of volume overload. . -Please contact [First Name8 (NamePattern2) ] [Name (NI) ] [Name (NI) ] or return to the ER if the pt develops any of the following symptoms: chest pain, palpitations, shortness of breath, fever, or decreased urine output. Followup Instructions: -Wednesday [8-17] 4:30pm appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at his office at [Location (un) 8170], [Apartment Address(1) 19746], [Location (un) ], [Numeric Identifier 1415] Phone: [Telephone/Fax (1) 2394] . -Appointment scheduled on [9-15] at 1pm with [Hospital1 18] nephrologist [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1366], MD. Location: [Hospital Ward Name 516] of [Hospital1 18], [Hospital Ward Name 23] Building [Location (un) 436] Medical Specialties . Please arrange an appointment with your primary care [First Name8 (NamePattern2) ] [Doctor First Name ] [Doctor Last Name ] ([Telephone/Fax (1) 608]) within 1 wk of discharge from rehab.	[ "V10.52", "584.9", "996.74", "E947.8", "V43.65", "V45.73", "428.0", "428.30", "405.91", "250.00", "998.11", "V18.0", "285.1", "599.0", "276.1" ]	icd9cm	[ [ [] ] ]	[ "39.50", "38.95", "38.93", "39.95", "00.45", "39.90", "99.05", "00.40", "99.04" ]	icd9pcs	[ [ [] ] ]	11704, 11774	4544, 9618	292, 312	11939, 11948	2566, 4521	12453, 13244	1998, 2075		9939, 11681		11795, 11918		9644, 9916				11972, 12430									2090, 2547																										233, 254							340, 1101																		1123, 1734	1750, 1982
70,838	149,947	9535	Discharge summary	report	Admission Date: [2201-7-2] Discharge Date: [2201-7-6] Date of Birth: [2136-7-8] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1943] Chief Complaint: s/p falls Major Surgical or Invasive Procedure: None History of Present Illness: 64 yo female w/hx of DMII, polio (childhood; uses walker and cane at baseline), mod MR, CKD (beleived to be drug related to allopurinol or HCTZ, now stopped) associated w/edema, presented w/ 2 episodes of falling due to bilateral lower extremetiy weakness. Pt denies having LOC, no pain or head strikes. No chest pain or SOB. Pt woke this AM unable to get out of bed due to weakness; had leg numbness and fell x2 w/out LOC or head strike. Per report, tried to get up to use the bathroom, put feet in ground and was very weak and fell when she tried to stand. She had help standing and was ok for few seconds. Denied SOB, CP, blurry vision. No F/C/N/V, cough, SOB. Had similar episode 20 days ago that resolved on its own and had not had any issues since then. Awake and alert. Called EMT given significant weakness; at time of medic arrival pt was ambulatory. No pain or injury/numbness or tingling. In [Name (NI) ] pt's VS were 98.6 68 135/44 16 98% RA, afeb and normal HR. Initially, no pain anywhere when presented to ED. On exam, found to have weakness in straight leg raises bilateraly. Sensory intact. Lungs sounded clear. However, pressures were labile (SBP 70s-100s); BP 70s and bounce back up on repeat, then sustained in 80s so RIJ placed and gave 10mg decadron. HR stable. EKG was unchanged from prior, CE Trop: 0.07->0.05, CK: 1163, MB: 16 (but in setting of CKD) and no chest pain; pt was given ASA 325. Elevated LFTs on labs but bedside US or RUQ showed normal GB/biliary tree. Pt also had elevated WBC 21.7, CXR showed +LLL hazziness on prelim read and pt was started on vanc/zosyn (after also getting ceftriaxone). Lactate 1.2. Lipase 90. Given Cr elevated at 3.0 from baseline of 1.8-2.0 and labile BPs, pt received 2L IVF and also central line placed. Start on tamiflu. SBP to 50s with no mental status changes. Started on levophed BPs to 90s and started having increased work of breathing. Worse breathing put on bipap lowest to 92% on bipap at 350. Bedside echo looks like hyperdynamic function. Similar to yesterday routine echo. Pt was asymptomatic during this, felt fine. X-ray of lower extremeties and spine performed given symptoms; premil read does not show any acute process. Neuro consulted. Pt was admitted to ICU for continued management and treatment. Arms different BPs, labile in the past because of different arm pressures. Take BPs on right arm 130-140s. Making urine. On the floor, patient was on Bipap but quickly taken off. She was pleasant and in no distress. Denied complaints including CP, SOB, cough, fever, chills, N/V/D. She reported feeling improved since arriving in ED. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Diabetes type II hypertension hypothyrodism macroalbuminuria gout hyperlipidemia fibroids Polio as a child Social History: Per PCP note, native language cantonese. patient is retired, previously worked asa seamstress. She has never married nor does she have any children. She lives with her father in [Name (NI) 583]. She smoked 3 cigarettes a day for 20 years, but quit 3 weeks ago due to restrictions around where she lives. Family History: mom has HTN, CVA, and CAD Physical Exam: Vitals: T:97 BP:128/46 P:80 R:18 18 O2:97%2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: crackles b/l up to mid lung fields, no wheezes, rhonchi CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM best heard and RUSB,no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 1+ left DP and radial, 2+ right radiala nd DP, no clubbing, cyanosis or edema Neuro: AAOx3, strength 5/5 thoughout upper and lower ext exceot left lower ext [4-18], sensation intact, gait deferred, CN2-12 intact Pertinent Results: Admission labs: [2201-7-2] 10:40AM BLOOD WBC-21.7# RBC-3.83 Hgb-11.1* Hct-33.3* MCV-87 MCH-29.0 MCHC-33.3 RDW-14.1 Plt Ct-297 [2201-7-2] 10:40AM BLOOD Neuts-91.7* Lymphs-4.3* Monos-3.4 Eos-0.2 Baso-0.4 [2201-7-2] 11:36AM BLOOD PT-13.5* PTT-35.0 INR(PT)-1.1 [2201-7-2] 10:40AM BLOOD Glucose-203* UreaN-74* Creat-3.0# Na-140 K-4.5 Cl-112 HCO3-16* AnGap-17 [2201-7-2] 10:40AM BLOOD ALT-62* AST-53* LD(LDH)-432* CK(CPK)-1163* AlkPhos-97 TotBili-0.4 [2201-7-2] 10:40AM BLOOD Lipase-90* [2201-7-2] 10:40AM BLOOD CK-MB-16* MB Indx-1.4 [2201-7-2] 03:00PM BLOOD Calcium-7.8* Phos-3.3 Mg-2.0 UricAcd-9.4* [2201-7-2] 10:40AM BLOOD Cortsol-31.6* Imaging: TTE [2201-7-1]: Mild symmetric left ventricular hypertrophy with hyperdynamic left ventricular function and mild outflow tract obstruction. Moderate mitral regurgiatation. Moderate pulmonary hypertension. Elevated estimated left ventricular end diastolic pressure. Mild functional mitral stenosis due to annular calcification. Compared with the report of the prior study (images unavailable for review) of [2198-8-20], LV function is now hyperdynamic with accompanying outflow tract gradient. Pulmonary hypertension is identified. The severity of mitral regurgitation has increased. L-spine, pelvis [2201-7-1]: Profound osteopenia and degenerative change. If clinical concern for acute compression fracture is present, consider MRI for more sensitive evaluation. No gross malalignment is seen. There is no pelvic fracture. Hypoplastic left pelvis is stable. MRI Head: FINDINGS: There is extensive, confluent T2-/FLAIR-hyperintensity seen in the periventricular and deep white matter, consistent with sequelae of microvascular ischemia. In addition, there are scattered lacunar infarcts in the cerebral hemispheres, unchanged since the CT of [2198-8-17]. There is no evidence of acute infarction or hemorrhage. There is no mass, mass effect, edema or shift of normally-midline structures. Noted is a partially-empty sella turcica, a common variant. The paranasal sinuses and mastoid air cells are clear. There is no abnormality of bone marrow signal. IMPRESSION: Sequelae of chronic small vessel ischemic disease, without evidence of acute intracranial process. MR Chest: FINDINGS: Some of the images are degraded by motion artifact. Within limitations of a non-contrast study, no major aortic abnormality including dissection, aneurysm, or traumatic injury is identified. There is cardiomegaly with bilateral pleural effusions more prominent on the right, small to moderate in size. In addition, there is enlargement of the pulmonary artery up to 3.3 cm, denoting pulmonary arterial hypertension. Chest wall and mediastinum are unremarkable. IMPRESSION: No acute aortic syndrome, although study is limited due to motion artifact. Signs of pulmonary arterial hypertension and cardiomegaly. DISCHARGE LABS: CBC: [2201-7-6] 07:16AM BLOOD WBC-14.2* RBC-3.68* Hgb-10.7* Hct-32.3* MCV-88 MCH-29.1 MCHC-33.2 RDW-14.4 Plt Ct-359 [2201-7-6] 07:16AM BLOOD Neuts-80.5* Lymphs-10.9* Monos-5.2 Eos-2.7 Baso-0.6 [2201-7-6] 07:16AM BLOOD Plt Ct-359 CHEMISTRIES: [2201-7-6] 07:16AM BLOOD Glucose-103* UreaN-41* Creat-1.7* Na-146* K-4.8 Cl-114* HCO3-22 AnGap-15 [2201-7-2] 10:40AM BLOOD ALT-62* AST-53* LD(LDH)-432* CK(CPK)-1163* AlkPhos-97 TotBili-0.4 [2201-7-6] 07:16AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.3 CREATININE KINASE [2201-7-2] 03:00PM BLOOD CK(CPK)-1136* [2201-7-2] 06:00PM BLOOD CK(CPK)-1112* [2201-7-3] 03:40AM BLOOD CK(CPK)-746* [2201-7-4] 06:20AM BLOOD CK(CPK)-332* [2201-7-6] 07:16AM BLOOD CK(CPK)-146 [2201-7-2] 10:40AM BLOOD cTropnT-0.07* [2201-7-2] 03:00PM BLOOD cTropnT-0.05* [2201-7-2] 06:00PM BLOOD CK-MB-19* MB Indx-1.7 cTropnT-0.04* [2201-7-3] 03:40AM BLOOD CK-MB-15* MB Indx-2.0 cTropnT-0.03* ENDOCRINE LABS: [2201-7-4] 06:20AM BLOOD FSH-49* LH-53 Prolact-27* [2201-7-5] 05:25AM BLOOD TSH-2.4 [2201-7-5] 05:25AM BLOOD Cortsol-23.2* [2201-7-5] 05:55AM BLOOD Cortsol-31.4* [2201-7-5] 06:25AM BLOOD Cortsol-36.9* [2201-7-5] 05:25AM BLOOD ACTH - FROZEN-Test [2201-7-4] 03:24PM BLOOD INSULIN-LIKE GROWTH FACTOR-1-PND ABG: [2201-7-2] 05:20PM BLOOD Type-ART pO2-96 pCO2-28* pH-7.26* calTCO2-13* Base XS--12 Intubat-NOT INTUBA Brief Hospital Course: 64 year old cantonese-speaking only female with history of polio, insulin dependent type II diabetes, and chronic kidney disease presented with an episode of falling due to lower extremity weakness and was found to be hypotensive on admission with acute on chronic kidney failure and rhabdomyolysis. ## Hypotension: The etiology of her hypotension was likely multifactorial in the setting of potential blood pressure medication changes, sepsis, or hypovolemia from poor oral intake. The patient was initially admitted to the intensive care unit because of systolic blood pressure of 50 (although reportedly asymptomatic). She briefly required levophed and was aggressively fluid resuscitated with improvement of her blood pressures. Unfortunately the patient developed hypoxia secondary to pulmonary edema in this setting (see below) and required BiPAP. ## Pulmonary edema: In the setting of aggressive fluid hydration, the patient developed hypoxia with pulmonary edema shown on chest x-ray and required BiPAP. With diuresis the patient's hypoxia resolved. An echo showed a hyperdynamic left ventricular function with increased severity of known mitral regurgitation. ## Leukocytosis: Patient was admitted with a WBC 21K. She was started on antibiotics for possible pneumonia or sepsis in the setting of her hypotension. However no evidence of pneumonia was reported on repeat chest x-ray, and blood and urine cultures show no growth to date. On discharge patient was afebrile and WBC was downtrending at 14.2. Patient will follow-up with her PCP to [Name9 (PRE) 32385] her CBC in one week. ## Vascular stenosis: Patient had uneven blood pressures in her right and left arm (left SBP 90s, right SBP 130s) concerning for aortic dissection in the setting of her low blood pressures. An MRI chest however showed no evidence of aortic dissection. Vascular surgery thought this was most likely due to arterial stenosis and recommended no intervention at this time as patient was asymptomatic. ## Rule out hypopituitarism: MRI brain showed a partial empty sella, which was concerning for secondary adrenal insufficiency in the setting of her hypotensive episode. Patient received decadron in the ED initially. Patient however had normal AM cortisols (>20) and an adequate response to the cosyntropin test. Other pituitary hormones (LH/FSH/ACTH/prolactin/IGF-1) were also checked given the partial empty sella. LH and FSH were indicative of post-menopausal status. Prolactin slightly elevated which is difficult to interpret in the setting of illness. TSH normal. ACTH and IGF-1 will be followed-up as an outpatient. ## Rhabdomyolysis: Patient had mild rhabdomyolysis with elevated creatine kinase on admission secondary to prolonged time down after her fall. This was consistent with her urine analysis which showed gross hematuria but only 1 RBC. Her rhabdomyolys resolved resolved with hydration, and her creatine kinase and creatinine normalized. ## Acute on chronic kidney failure: Patient's creatinine was elevated on admission (3.0) from her baseline (1.6-2.1) likely secondary to prerenal azotemia. Her creatinine returned to baseline with fluid resuscitation. ## Lower extremity weakness/falls: Most likely this patient's fall was secondary to an exacerbation of her left leg weakness, which she has at baseline as a sequelae of polio. However due to concern for cerebrovascular accident, neurology was consulted and an MRI brain showed sequelae of chronic small vessel ischemic disease without any acute intracranial process. MR [Name13 (STitle) 2853] ruled out a cord lesion. Furthermore L-spine and pelvis was negative for any fractures. Patient was seen by physical therapy who recommended discharge with home PT. # DM2: Patient had high blood sugars on this admission, so her Levemir insulin was increased to 16 Units at night. Patient was discharged on [7-6] to her home. She will follow-up with her PCP. [Name10 (NameIs) ] that time, she should: (1) get bloodwork to ensure that WBC is downtrending, (2) follow-up final urine and blood cultures, (3) follow-up endocrine labs (ACTH, IGF, LH) (4) discuss medication adjustments. Namely the medication adjustment that were made during this hospitalization was: 1) increase Levemir to 16, 2) continue cefpodoxime and azithromycin until [7-7], and 3) decreased lasix to 20 mg. Medications on Admission: Per OMR [2201-6-8] PCP note ACARBOSE - (Prescribed by Other Provider) - 50 mg Tablet - 2 Tablet(s) by mouth three times a day AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day EZETIMIBE-SIMVASTATIN [VYTORIN 10-40] - 10 mg-40 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth once a day GLIPIZIDE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day INSULIN DETEMIR [LEVEMIR FLEXPEN] - (Prescribed by Other Provider) - 100 unit/mL Insulin Pen - 12 qd LEVOTHYROXINE - 50 mcg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth DAILY (Daily) Discharge Medications: 1. acarbose 50 mg Tablet Sig: Two (2) Tablet PO three times a day. 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. 4. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 weeks. Disp:21 Tablet(s) Refills:0 5. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Levemir Flexpen 100 unit/mL Insulin Pen Sig: One (1) 16 Subcutaneous once a day for 2 weeks. 7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 1 days. Disp:2 Tablet(s) Refills:0 10. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:1 Tablet(s) Refills:0 11. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital6 1952], [Location (un) 86] Discharge Diagnosis: Primary diagnoses: Fall, hypotension, community acquired pneumonia, hypoxic respiratory distress due to pulmonary edema, acute on chronic kidney failure, rhabdomyoloysis, diastolic heart failure, vascular stenosis Secondary diagnoses: Hypothyroidism, insulin dependent diabetes type II, hyperlipidemia, gout, uterine fibroids, polio, hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted because you fell at home. You had x-rays of your pelvis and spine, which showed no fractures. The neurologist saw you because they were concerned about your the weakness in your left side. A brain MRI was done, and no evidence of stroke was seen. However on the MRI they found a structural variant called "empty sella," which can be associated with low levels of hormones. We tested your hormones, and they all functioned appropriate. In particular we found no evidence of adrenal insufficiency, which we were most concerned about. Furthermore for your weakness, physical therapy worked with you on strenghtening and balance. They gave you a walker, which you should always use when you go home. On admission you had low blood pressure, so we gave you fluids. Unfortunately some of the fluid went to your lungs, so you had trouble breathing. You were admitted to the intensive care unit, where they helped you breath with a respiratory mask called BiPAP. We also gave you lasix, which is a medication that helps you urinate out the extra water, and your breathing improved. We also noticed that the blood pressure as measured in your left arm was lower than your right arm. A vascular surgeon saw you and believes that this difference is due to narrowing of the vessels in your left arm ("vascular stenosis"), which is likely related to your diabetes and hypertension. At this time, they recommended no interventions. Furthermore you had increased white blood count on admission, which can be a sign of infection. A chest x-ray showed possible pneumonia, so we treated you with antibiotics called cepodoxime and azithromycin. You should continue them for 1 more day (last dose 5/24). We also found that your kidney function was worse during this admission. This can occur when there is muscle breakdown from the fall as well as low blood pressure. With hydration your kidney function improved back to your normal level. Lastly we found blood in your urine. This can also be seen after a fall. We sent a urine sample, but the results are not back yet. You should follow-up with your PCP if further [Name9 (PRE) 8019] will be needed. In summary, when you leave the hospital, you will need to: - Follow-up with your PCP in one week to get the results of your urine sample, get bloodwork, and discuss any medication adjustments - Use your walker all the time - Observe the following medication changes: (1) During this admission you had high blood [Last Name (LF) 32386], [First Name3 (LF) ] we increased your Levemir insulin to 16 Units at night. (2) Continue your antibiotics cefpodoxime and azithromycin for 1 more day (last dose 5/24) (3) We decreased your furosemide dose to 20 mg because you did not have any leg swelling on this admission. You should speak to your PCP about whether to increase or keep at this dose. Followup Instructions: Please keep the following appointments: Department: [Hospital3 249] When: THURSDAY [2201-7-16] at 3:20 PM With: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]/[Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage 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. Completed by:[2201-7-9]	[ "244.9", "V15.88", "218.9", "317", "250.00", "138", "428.33", "038.9", "V15.82", "995.92", "584.9", "440.20", "428.0", "728.88", "274.9", "272.4", "V58.67", "253.8", "728.87", "403.90", "486", "288.60", "585.9", "276.2" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	15008, 15083	8937, 13303	311, 317	15474, 15474	4585, 4585	18536, 19205	3838, 3865		14070, 14985		15104, 15319		13329, 14047				15656, 18063			7498, 8914						3880, 4566			15340, 15453																		2988, 3367		18083, 18513			262, 273							345, 2969							4601, 7482				15489, 15632							3389, 3497	3513, 3822
58,928	154,276	37806	Discharge summary	report	Admission Date: [2186-10-27] Discharge Date: [2186-11-15] Date of Birth: [2106-8-22] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: Left temporal SAH/IVH, L ICA aneurysm Major Surgical or Invasive Procedure: EVD placement [2186-10-27] Coiling of L ICA [2186-10-28] Trach/PEG [2186-11-3] History of Present Illness: 80 yo RHF with hx HTN and likely CAD p/w SAH. On the day of admission she complained of generalized headache, but no nausea or vomiting. Later that day, she was found down by relatives (unwitnessed event) and she was taken to Good [Hospital 39888] Medical Center and found to have SAH on CT head. She was given 1g PHT and transferred to [Hospital1 18]. GCS was initially 13 and decreased to 6. She was promptly intubated upon arrival (after failed attempt to intubate en route). She was intubated with succinylcholine and etomidate and then started to bite the ETT and SBP was 80. She was given 4mg ativan as well. Past Medical History: HTN Pacemaker HLD ? CAD Social History: Pt lives in [Location ] and was visiting son in [State 350] to assist in caring for sons children while sons wife is hospitalized at [Hospital1 18] with complicated pregnancy. Family History: Unknown Physical Exam: VS; T 98.9 BP 100/60 P 70, on ventilator Gen; lying in bed, intubated CV; RRR, no murmurs Pulm; CTA b/l anteriorly Abd; soft, NT, ND Extr; no edema Neuro; (off sedation but had received succinylcholine, etomidate and ativan 4 mg) Eyes closed, does not arouse to noxious stimuli. PERRL 2.5-->2mm, corneals present bilateral, oculovestibular reflex present, gag present. Face appears symmetric. No spontaneous movement but withdraws to noxious stimuli in all extremities. Toes equivocal. Discharge exam has changed slightly from above admission exam: The patient is treached. She opens her eyes to voice, but does not follow commands. She does not move her extremities to nox stimuli Pertinent Results: CTA NECK W&W/OC & RECONS [2186-10-27] 1. CT head demonstrates extensive subarachnoid hemorrhage and ventricular dilatation. 2. CT angiography of the head demonstrates a posterior communicating artery aneurysm with some irregularity of the surface pointing posteriorly and slightly inferiorly. 3. No other intracranial aneurysms are seen. 4. No abnormalities on somewhat limited CT angiography of the neck. CT HEAD W/O CONTRAST [2186-10-27] 1. New placement of an intraventricular drain from a right frontal approach with the size of the ventricles appearing minimally changed from the most recent comparison. 2. Redemonstration of extensive subarachnoid hemorrhage CAROTID/CEREBRAL UNILAT [2186-10-28] Successful coiling of left supraclinoid internal carotid artery aneurysm. No additional aneurysm noted on the left internal carotid artery CT HEAD W/ & W/O CONTRAST [2186-10-31] 1. No new intracranial hemorrhage. 2. Metallic artifact limits assessment of potential vasospasm or new hemorrhage of nearby structures. 3. Stable areas of subarachnoid hemorrhage in the bilateral frontal lobes and within the occipital horns of the lateral ventricles. 4. Stable ventricle size. EEG [2186-11-6] This telemetry captured five pushbutton activations, as described above. There were no epileptiform features noted on these files. Routine sampling showed a background that was moderately encephalopathic with mixed theta and delta frequencies and occasional bursts of generalized high voltage delta slowing. There were no epileptiform features or electrographic seizures on this recording. EEG [2186-11-7] This telemetry captured one pushbutton activation which was not associated with any epileptiform features. Routine sampling continued to show a generally slow and disorganized background consisting of mixed theta and delta frequencies consistent with a moderate encephalopathy. There were also occasional bursts of higher voltage generalized delta activity. There were no epileptiform CT HEAD W/O CONTRAST [2186-11-8] 1. Subarachnoid and intraventricular hemorrhage, overall unchanged in appearance when compared to prior study. There is no evidence of new hemorrhage. 2. Stable appearance of coiled the left supraclinoid ICA aneurysm. Brief Hospital Course: Pt was admitted to the ICU for close monitoring s/p EVD placement in OR and then had a coiling of a L ICA aneurysm. She was then extubated on [10-29] and then required re-intubation on [10-30]. Her head CT was negative however her sputum then grew out Pseudomonas and was started on appropriate treatment. CTAs were negative for vasospasm. She was trached and PEG'd, She was found to have possible seizure activity and an EEG confirmed this. She was started on Dilantin along with her current Keppra medication. Her clinical exam however was poor although CTAs continued to be negative for vasospasm and subsequent EEGs showed no seizures and Dilantin was eventually weaned off. Due to her poor neurological status and poor progress a family meeting was conducted however family wanted to continue treatment. Her EVD was then d/c'd and she was transferred to SDU on [11-8]. She did spike a fever, CSF cx's were sent and were negative. Fever is thought to be attributed to PNA. On [11-10] she had episodes of tachypnea although her CXR was improved, sputum still has gram neg rods/psuedomonas for which she is being treated with Cefepine and Cipro which ends on [11-18]. Additionally her LENIs were negative and ABG showed no hypoxemia. [11-14] her exam improved slightly to include eye opening to voice, brief eye contact and attempt to protrude her tongue. Medications on Admission: ASA cozaar metoprolol diltiazem zocor MVT omeprazole docusate benadryl Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for const. 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [1-6] Drops Ophthalmic PRN (as needed) as needed for dryness. 9. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed for fever. 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. Levetiracetam 100 mg/mL Solution Sig: 1500 (1500) mg PO BID (2 times a day): 1500mg [Hospital1 ]. 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 15. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) for 4 days. 16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for yeast. 17. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for SBP > 180. 18. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours) for 4 days. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: Left teporal subarachnoid hemorrhage intraventricular hemorrhage left internal carotid artery aneurysm ventilator aquired pneumonia dysphagia respiratory failure hydrocephalus Discharge Condition: Stable Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. - you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[2186-11-15]	[ "787.20", "430", "272.4", "518.81", "414.01", "780.39", "997.31", "285.9", "431", "331.4", "041.7", "401.9", "V45.01" ]	icd9cm	[ [ [] ] ]	[ "96.6", "43.11", "89.19", "01.28", "38.93", "96.04", "39.72", "31.1", "88.42", "96.71", "96.72", "88.41" ]	icd9pcs	[ [ [] ] ]	7666, 7748	4401, 5787	357, 450	7967, 7976	2109, 4378	9068, 9431	1378, 1387		5909, 7643		7769, 7946		5813, 5886				8000, 9045									1402, 2090																										280, 319							478, 1109																		1131, 1157	1173, 1362

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