Split (1)

train · 26.9k rows

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31,039	153,249	50773	Discharge summary	report	Admission Date: [2147-4-5] Discharge Date: [2147-4-10] Service: MEDICINE Allergies: Proscar / Haldol Attending:[First Name3 (LF) 1711] Chief Complaint: shortness of breath. Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a [Age over 90 ] year old man with history of CAD s/p MI, dementia, depression, COPD who presents with acute shortness of breath. He presented from his [Hospital3 ] facility with shortness of breath. He was found to be wheezing and tachypneic with worsening lower extremity edema. He was referred to the ED for further evaluation. . Upon arrival in the ED, his initial vital signs were 97.7 78 130/96 24 88%RA -> 99%NRB. An CXR was read as pulmonary edema with potential multi-focal pneumonia. He was placed on BiPaP for oxygenation support. He received levofloxacin, ceftriaxone, solumedrol, atrovent, albuterol, and nitroglycerin. . He denies chest pain, cough, palpitations or fevers. On review of symptoms, he denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. . Past Medical History: s/p multiple mechanical falls [Hospital1 ] admission [3-6] with ARF due to dehydration, renal failure HTN Memory loss with dementia Essential tremor Glucose intolerance Depression CAD s/p NSTEMI [2132] Sciatica Gait disorder . . Cardiac Risk Factors: + Glucose Intolerance, -Dyslipidemia, +Hypertension . Cardiac History: CABG: N/A . Percutaneous coronary intervention: N/A . Pacemaker/ICD: N/A Anemia BPH Asbestosis with pleural plaques, +PPD Gout Cataracts, bilateral OA Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Pt lives in [Hospital 4382] home. Health care proxy and power of attorney is pt's nephew, who is supportive and involved. Family History: NC Physical Exam: VS: T 99.1, BP 136/90, HR 84, RR 19-28, O2 100% on BiPAP 10/5 FIO2 0.4 obs TV 707 Gen: WDWN elderly aged male in NAD. Oriented x2. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink Neck: Supple with JVP of 10 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. crackles [11-30] way up right chest, [12-2] way up on left chest Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: 2+ lower extremity edema to mid-shin. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; DP dopplerable Left: Carotid 2+ without bruit; Femoral 2+ without bruit; DP dopplerable Neuro: alert. orient to name, [Hospital3 ] Hospital not day or date. moving all 4 extremities symmetrically. . MEDICAL DECISION MAKING . EKG demonstrated sinus @ 81. RBBB. LAD. TWI V1-4. 1mm concave STE in V2-3 with significant change compared with prior dated [2146-5-5] including TWI and widening of QRS. . 2D-ECHOCARDIOGRAM performed on [2147-4-5] demonstrated: severe global hypokinesis (EF ~15-20%) est TR grad 21. RV function depressed. no sign valvular pathology. no pericardial effusion . Pertinent Results: [2147-4-5] 11:00AM CK-MB-16* MB INDX-7.1* proBNP-[Numeric Identifier 105608]* [2147-4-5] 11:00AM cTropnT-1.37* [2147-4-5] 08:10PM CK-MB-76* MB INDX-10.4* cTropnT-3.78* [2147-4-5] 08:10PM CK(CPK)-733* . [2147-4-5] 11:00AM WBC-13.7* RBC-4.26* HGB-12.3* HCT-35.4* MCV-83 MCH-28.9 MCHC-34.8 RDW-13.0 [2147-4-5] 11:00AM NEUTS-90.4* BANDS-0 LYMPHS-5.6* MONOS-3.9 EOS-0.2 BASOS-0 PLT COUNT-345 [2147-4-5] 08:10PM WBC-9.5 RBC-3.97* HGB-11.1* HCT-32.9* MCV-83 MCH-27.9 MCHC-33.7 RDW-12.9 PLT COUNT-308 . [2147-4-5] 11:00AM GLUCOSE-193* UREA N-33* CREAT-1.8* SODIUM-129* POTASSIUM-5.0 CHLORIDE-90* TOTAL CO2-21* ANION GAP-23* [2147-4-5] 11:00AM ALT(SGPT)-17 AST(SGOT)-45* LD(LDH)-459* CK(CPK)-224* ALK PHOS-63 TOT BILI-0.8 [2147-4-5] 08:36PM TYPE-[Last Name (un) ] PO2-32* PCO2-39 PH-7.35 TOTAL CO2-22 BASE XS--4 [2147-4-5] 08:36PM LACTATE-3.7* . [2147-4-5] 09:45PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2147-4-5] 09:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2147-4-5] 09:45PM URINE RBC-4* WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [2147-4-5] 09:45PM URINE HYALINE-21* Brief Hospital Course: [Age over 90 ] year old man with hx of CAD s/p distant MI, HTN, presenting with acute shortness of breath and CHF. . # CAD/Ischemia: new onset acute CHF with elevated biomarkers and new EKG abnormalities likely induced by recent ischemic event. In discussion with [Hospital 228] healthcare proxy, and to the extent possible, the patient himself, the team agreed that medical management rather than aggressive procedures was most consistent with the patient's goals of care. His cardiac enzymes declined during his admission and serial EKGs did not suggest a second event. He was diuresed and given ASA and statin. He was started on metoprolol but after having some wheezing was changed to carvedilol. He had a 48 hour heparin drip, and a nitro drip during the first day of his admission. The palliative care service was consulted, and together with palliative care, the [Hospital 228] healthcare proxy decided that hospice was the next appropriate place for care. He was discharged to hospice on [2147-4-10]. . # Pump: The patient came in with acute systolic congestive heart failure based on CXR, elevated BNP, and TTE findings; likely this was due to an ischemic trigger. With diuresis and carvedilol his breathing and comfort improved considerably. . # Rhythm: Mr [Known lastname 34210] was mostly in sinus rhythm; he had some overnight episodes of supraventricular tachycardia of unclear type but without ongoing consequences. . # Valves: There was no significant valvular pathology on TTE. . # Respiratory Distress/Hypoxia: He was having considerable difficulty with breathing when he first arrived, and as above this appeared to be most consistent with CHF. He did not have cough, fever or other abnormality to point toward pneumonia. Initially his chest x-ray could not rule out pneumonia but did begin to clear during his admission in a manner more consistent with resolution of pulmonary edema. Blood cultures did not suggest bacteremia though they were still "no growth to date" rather than final by the time the patient was discharged to hospice. . # Mental status: Mr [Known lastname 105609] lucidity waxed and waned and he had significant problems with sundowning and agitation at night, often trying to get out of bed at night and demanding to go home. He tended to be calmer at day, usually with evidence of dementia and memory and cognitive problems, but remaining pleasant and amiable. His seroquel dose was increased. He has had parkinsonian reactions to haloperidol in the past, so this medicine was not given. We avoided benzodiazepines in this elderly patient. . # Metabolic Acidosis: Anion gap was likely from mild renal failure; may be some contribution of inflammation/ischemia; electrolyte abnormalities resolved during his admission. . # Hyponatremia: He had sodium levels down to 128 during this admission, likely secondary to CHF, volume overload and poor forward flow, with this kidney poorly perfused and Cr clearance down. He had normal sodium level on discharge. . # Acute renal failure: His creatinine rose to 2.3 from a prior baseline of 1.2-1.3. This was most likely from poor forward flow from volume overload and CHF. His creatinine was declining again by the time of discharge, to 1.8 on day of discharge. . # FEN: Heart healthy diet . # Prophylaxis: PPI at home dose, heparin . # Code: DNR/DNI . # Communication: [Name (NI) ] [Name (NI) 105610] (nephew/HCP) h [Telephone/Fax (1) 105611] w [Telephone/Fax (1) 105612] [Name (NI) ] [Name (NI) 105610] (niece) c [Telephone/Fax (1) 105613] . . Medications on Admission: Aspirin 325 mg daily atenolol 50 mg daily hydrochlorothiazide 12.5 mg daily metamucil packet daily pantoprazole 20 mg daily nitroquick 0.3 mg SL prn . ALLERGIES: Haldol/Proscar Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q2H (every 2 hours) as needed for SOB or pain. 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital1 ] FAMILY HOSPICE Discharge Diagnosis: Myocardial infarction . Acute on Chronic Systolic Heart Failure . Dementia Discharge Condition: stable Discharge Instructions: You were seen in the hospital for treatment of heart failure. This was likley caused by a heart attack. Your breathing improved with removing fluid. . Please take your medications as prescribed. . You should follow up with your primary care physician [Last Name (NamePattern4) ] [11-30] weeks. He will need to follow your potassium levels as an outpatient. . Please call your primary care physician if you have chest pain, shortness of breath, or other concerns. Followup Instructions: Please call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 250] and make a follow up appointment in [11-30] weeks. Completed by:[2147-4-11]	[ "294.8", "412", "274.9", "501", "414.01", "428.21", "401.9", "584.9", "276.1", "428.0", "V66.7", "518.82", "715.90", "276.2" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9254, 9312	4733, 6815	244, 250	9431, 9440	3461, 4710	9961, 10120	2034, 2038		8543, 9231		9333, 9410		8341, 8520			9464, 9938									2053, 3442																			184, 206												278, 1256								6830, 8315						1278, 1766	1782, 2018
78,522	167,683	39275	Discharge summary	report	Admission Date: [2167-9-9] Discharge Date: [2167-9-27] Service: MEDICINE Allergies: Aspirin Attending:[First Name3 (LF) 2108] Chief Complaint: Respiratory Failure Afib w/ RVR Pleural Effusion Major Surgical or Invasive Procedure: Central line Arterial line Endotracheal intubation History of Present Illness: 89M with a chronic nonhealing LLE venous stasis ulcer transfered from [Hospital3 ] s/p a complicated course notable for complete opacification of the L lung, new Afib with RVR, and respiratory failure. For the past several months he has reported to his daughter a funny sensation in his ears at times, but no chest pain, palpitations, SOB, DOE, or other symptoms. He has been losing weight and not eating as much. For the past week or so he has had increasing malaise and complained about his chronic LLE ulcer. Ultimately his daughter convinced him to call his doctor, and he was referred to the ED at [Hospital3 ]. At [Hospital1 ] he was noted to have increased erythema and exudate around his chronic LLE ulcer. His initial ECG showed Afib with RVR. A chest Xray showed complete opacification of the L lung field. He was empirically started on vancomycin for his LLE ulcer in the ED. Given his multiple active medical issues, he was admitted to Medicine for management. The following day he underwent a diagnostic thoracentesis. Analysis of the fluid showed LDH 114, amylase of 69, and Tprotein of 4.0 consistent with an exudate. Several hours after the procedure he was noted to be hypoxic. CXR showed re-opacification of the L lung. He was intubated for hypoxic respiratory failure. A subsequent bronch showed thick, dark sputum. His L lung field remained persistently opacified and he remained intubated for respiratory failure. After several days without improvement he was transfered to [Hospital1 18] for further management. . Review of Systems: Not obtainable as intubated and sedated Past Medical History: - Chronic non-healing venous stasis ulcer on the LLE - Gout - Chronic renal insufficiency - Hypothyroidism - s/p tonsilectomy - s/p pilonidal cystectomy - s/p vein stripping for chronic venous insufficiency Social History: - Lives alone, independent with ADLs - Tobacco: Denies - etOH: Denies - Illicits: Denies Family History: Mother: RA - Father: healthy - Sister: Died of leukemia age 52 Physical Exam: On Admission: GEN: NAD VS: 98.9 106 113/54 21 92% on AC PEEP 5 FiO2 0.4 R 16 Vt 500 HEENT: Adentulous, dry MM, wound on L upper lip, no OP lesions, JVP 13cm, neck is supple, no cervical, supraclavicular, or axillary LAD CV: RR, NL S1S2 no S3S4 MRG PULM: Bronchial BS on the L and coarse rhonchi on the R, dense to percussion on the L relative to R ABD: BS+, soft, NTND, no masses or HSM, no stigmata of chronic liver disease LIMBS: 3+ LE edema bilat, no tremors or asterixis, no clubbing SKIN: Chronic venous stasis changes of the shins, 3cm x 4cm ulcer on L shin without exudates or erythema NEURO: Strength 5/5 of the upper and lower extremities, reflexes 1+ of the upper and lower extremities, toes down bilaterally Pertinent Results: Labs on admission: [2167-9-9] 08:09PM TYPE-ART TEMP-37.1 RATES-16/ TIDAL VOL-500 PEEP-5 O2-60 PO2-65* PCO2-41 PH-7.40 TOTAL CO2-26 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED [2167-9-9] 08:09PM LACTATE-0.8 [2167-9-9] 08:09PM O2 SAT-92 [2167-9-9] 08:09PM freeCa-1.20 [2167-9-9] 07:52PM estGFR-Using this [2167-9-9] 07:52PM ALT(SGPT)-29 AST(SGOT)-74* LD(LDH)-206 ALK PHOS-137* TOT BILI-0.5 [2167-9-9] 07:52PM ALBUMIN-2.4* CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.0 [2167-9-9] 07:52PM TSH-5.3* [2167-9-9] 07:52PM FREE T4-0.85* [2167-9-9] 07:52PM WBC-13.7* RBC-3.91* HGB-12.3* HCT-37.7* MCV-96 MCH-31.5 MCHC-32.7 RDW-13.7 [2167-9-9] 07:52PM NEUTS-87.7* LYMPHS-3.0* MONOS-7.0 EOS-2.2 BASOS-0.1 [2167-9-9] 07:52PM PLT COUNT-193 [2167-9-9] 07:52PM PT-14.2* PTT-67.0* INR(PT)-1.2* Pathology: [9-10] Pleural fluids: NEGATIVE FOR MALIGNANT CELLS. Scattered reactive mesothelial cells in a background of abundant polymorphous lymphocytes, favor reactive. Bronch [9-11]: Bronchial Lavage, Left Lower Lobe: NEGATIVE FOR MALIGNANT CELLS. Alveolar macrophages, lymphocytes, and neutrophils. No fungal organisms or viral cytopathic effect identified. Note: AFB and GMS stains will be performed and reported in an addendum. [2167-9-16]: Tissue phenotyping, Pleural Report not finalized. Assigned Pathologist [Last Name (LF) 21496],[First Name3 (LF) 35386] Logged in only. PATHOLOGY # [-1/3165] Immunophenotyping, Pleural [2167-9-16] Pleural Fluid: NEGATIVE FOR CARCINOMA. Mesothelial cells, lymphocytes, histiocytes, and blood. Imaging: [2167-9-10] TTE: The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 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 aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: poor technical quality due to patient's body habitus. Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen but is probably normal. No pathologic valvular abnormality seen. [2167-9-10] CT Chest without contrast: Dense pericardial calcification likely representing previous pericardial TB, large bilateral pleural effusions, worse on the left, with associated extensive compressive atelectasis, ascites and likely cirrhosis. The normal sized atrium is incongruous with the constellation of pulmonary, pericardial and abdominal findings that suggest right heart failure due to constrictive pericarditis. An echocardiogram may help clarify whether right heart failure and restrictive physiology is present. The study and the report were reviewed by the staff radiologist. [2167-9-11] Abdominal US 1. Cirrhotic liver without concerning focal lesion. Large amount of ascites and moderate right pleural effusion is noted. 2. Mild gallbladder wall edema is likely due to third spacing. No evidence of acute cholecystitis. 3. Portal triads are slightly echogenic, likely due to liver hypoechogenicity. These findings may be seen in hepatitis. Clinical correlation is advised. [2167-9-15] TTE IMPRESSION: There is a small filamentous mass on the mitral valve associated with mild mitral regurgitation and a focal area of thickening on the mitral valve leaflet, presenting a probable vegetation; however, a loose chordae cannot be ruled out and this is unlikely to be a fungal vegetation [2167-9-19] Portable Abdomen IMPRESSION: Nasogastric tube placement as described. It is somewhat high, apparently reaching below the diaphragm, as before. Brief Hospital Course: 89M with an infected chronic LLE venous stasis ulcer, new Afib with RVR, a large L side pleural effusion, and hypoxic respiratory failure transfered from an OSH for further management. Hypoxic respiratory failure / Right & Left pleural effusion / Left pneumothorax: The patient was transferred from an OSH intubated/sedated. Routine blood gases were drawn and the patient remained well ventilated and oxygenated. The etiology of his respiratory failure was unclear but was initially thought to be due to PNA vs. persistent effusions. The patient was empirically treated with Vanc/Pip/Tazo and transitioned to Vanc/Flagyl/Cefepime for a total antibiotic course of 10 days, ending on [2167-9-14]. OSH thoracentesis showed an exudative effusion. Recurrence of the effusion was thought to be due to re-expansion pulmonary edema vs. diffusion of ascites across the diaphragm. Left sided thoracostomy with chest-tube placement was performed and subsquently complicated by a pneumothorax that resolved after placing the chest tube to wall suction; analysis of the left sided effusion suggested it was transudative. Right sided thoracentesis showed a transudative effusion as well, and it improved with diuresis. In the setting of known pericardial calficication on imaging and volume overload, it was thought that constrictive heart physiology may have been the primary pathology; however TTE showed overall left ventricular systolic function is normal (LVEF>55%). Bacteremia / Fungemia / Endocarditis: Blood cultures drawn [9-10] grew [Female First Name (un) ] PARAPSILOSIS; subsequent surveillance cultures were negative for further fungi and bacteria, including mycobacteria. TTE showed a small filamentous mass on the mitral valve associated with mild mitral regurgitation and a focal area of thickening on the mitral valve leaflet, presenting a probable vegetation; however, a loose chordae was not ruled out and it was thought that it was unlikely to be a fungal vegetation. Cardiology and ID recommended a 14 day total course of fluconazole, day 1 = [2167-9-16] then repeat TTE in the future. Pericardial calcification: Chest CT showed calcified pericardium with potential restriction. Subsequent TTE showed no pericardial effusion. New Afib with RVR: Discovered at the OSH; EKG on admission showed RBBB. The patient was rate-controlled with metoprolol. He initially was placed on a heparin drip, which was stopped due to a low risk of stroke (CHADS = 2) and high risk of bleeding complication with recent chest tubes, acute illness, malnutrition. Rate control was attempted using ongiong titration of beta blocker and calcium channel blocker. Infected LLE ulcer: The patient was continued on broad-spectrum antibiotics until [2167-9-14] as above. His ulcer showed a clean base and routine dressing changes were made per wound care's recommendations. Wound care's recommendations on transfer to floor from [Hospital Unit Name 153] were: duoderm wound gel, adaptic dressing, 4x4's and wrap with kerlix, secure with paper tape, change dressing daily Rash: The patient developed a drug rash over the course of the hospitalization, which improved with topical antifungal therapy CODE BLUE was called on [2167-9-27], the patient was found in a PEA arrest, likely cause of death was due to an aspiration event; however his loss of pulse was unwitnessed and the exact cause cannot be confirmed. He was DNR / DNI based on previous discussions with his family during this hospital stay. Medications on Admission: Home Meds: - Allopurinol 300mg PO daily . Medications on transfer: - Piparcillin tazobactam 3.375g IV Q6H D1 [2167-9-3] - Vancomycin 1000mg IV Q24H D1 [2167-9-3] - Allopurinol 300mg PO daily - Lansoprazole 30mg PO daily - Heparin drip at 1000 units/H - Diltiazem drip at 10mg/H - Midazolam drip at 1mg/H - Tylenol PRN - Albuterol PRN - Chlorhexadine mouth care - Artificial tears . Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: Respiratory Failure requiring intubation and chest tube drainage Candidemia with ongoing concern for endocarditis Delerium Malnutrition,anasarca,dysphagia atrial fibrillation with rapid ventricular response Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired	[ "707.19", "682.6", "934.9", "459.81", "349.82", "423.8", "427.31", "518.81", "112.81", "E947.8", "244.9", "403.90", "372.30", "518.0", "112.3", "E915", "423.2", "585.9", "571.5", "511.9", "263.0", "486", "584.9", "276.0", "428.33", "693.0", "428.0", "789.59" ]	icd9cm	[ [ [] ] ]	[ "34.91", "33.24", "96.72", "88.72", "96.6", "34.04" ]	icd9pcs	[ [ [] ] ]	11289, 11298	7292, 10809	263, 315	11549, 11566	3136, 3141	11630, 11648	2313, 2377		11249, 11266		11319, 11528		10835, 10877			11590, 11607									2392, 2392														1914, 1955					175, 225												343, 1895							3156, 7269						10902, 11226	1977, 2186	2202, 2296
501	190,462	50754	Discharge summary	report	Admission Date: [2190-1-28] Discharge Date: [2190-2-4] Service: MEDICINE Allergies: Aspirin Attending:[First Name3 (LF) 613] Chief Complaint: SOB and Respiratory Failure Major Surgical or Invasive Procedure: None History of Present Illness: The pt is an 83-year-old woman w/ h/o COPD FEV1 0.93 FEV1/FVC 89% FVC 40% pred (PFTs [2176]). She is on Home O2 and BIPAP at night. Pt has h/o hypercapnic resp failure c multiple admissions for high COPD up to 125. Last admitted last time at [Hospital1 112] [2189-12-7]. She was intubated at that time for 36 hours. She presents w/ fever and productive cough x 4 days. Pt was seen by her primary pulmonologist and given Levofloxacin. She had taken it for 4 days without noticing improvement in her symtpoms. MICU team was called to evaluate pt for progressive hypoxemia in ED. In [Name (NI) ] pt was clearly tachypneic RR 35 bpm, SpO2 99% on 100% NRB, T 100. Her BP was elevated up to 140/72. She was given Solumedrol 125, Ceftriaxone, Zithromax, and started on NTG drip. She has also been on BIPAP 12/5 and 4 lt c Spo2 95%. ABGs in ED 7.29/72/81/36 Past Medical History: 1. COPD with hypoxia and CO2 retention, on home O2, patient aware of symptoms of hypoxia and CO2 retention. 2. Sleep apnea, using BiPAP at night. 3. Chronic lower back pain. 4. Osteoporosis. History of GI bleed 5. CAD 6 GERD 7. afib, not on coumadin for ~3 months per patient Social History: Patient has a 60-pack year history. Lives in same building as daughter. [Name (NI) ] EtoH Family History: NC Physical Exam: HR 119---99 BP 140/112 ---100/52 (NTG drip) RR 35 Spo2 99% T 100 . Gen: Obese lady on facial mask , not able to [Doctor First Name ], somnolent but arousable NECK no jvp Chest: decresed BS bilaterally , no clear crackles. CV: RRR no m/r/g Abdomen: large peiumbilical hernia, c no signs of strngulation Ext: + + edema Brief Hospital Course: 1. COPD: The pt presented w/ severe hypoxemia and hypercarbia. Elevated HcO3 indicates longstanding Hx of COPD. In the MICU, she was maintained on BiPap at night. IV steroids were continued and changed to po prednisone on [1-29]. Her mental status returned to normal as her respiratory status improved, and she was maintaining good SaO2 on NC. By the time she was called out of the MICU, she was maintaining SaO2 of 88-92% on 2L NC, her baseline at home. BiPAP was continued overnight for episodes of apnea (pt had her own machine). She was continued on her prednisone taper and nebulizers. Patient is to continue with Prednisone 40 mg QD for next 7 days and then continue the taper with decrease by 10 mg over next 7 days to her baseline of 10 mg QD . 2. possible CAP: CXR is negative although poor quality [1-7] pt's body habitus. A repeat PA and lateral [1-31] was unremarkable. She was started on CTX and azithro in the ED and the CTX was discontinued on [1-30]. Empiric treatment for CAP w/ azithro for 5 days was continued. Her DFA was positive for influenza A on [1-29] after which she was maintained on droplet precautions. Tamiflu was not started as the diagnosis was made 24-48 hr after the onset of symptoms. . 3. CV # Pump: Pt w/ hx of severe HTN. She was diuresed for mild fluid overload in her legs with IV Lasix in the MICU and then switched to her PO Lasix home dose of 120mg [Hospital1 ] after being transferred to the floor. A TTE showed normal EF. Patient was subsequently discharged with a lower dose of 80 mg of Lasix [Hospital1 ] as she appeared to have contraction alkalosis. Patient's edema appears to be at baseline as far as her lower extremity edema. The etiology of her total body volume remains unclear after discussion with patient's PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 23427] as she does not have overwhelming largePA pressures and no evidence of severe diastolic and nl systolic function. . # Ischemia: Pt not on ASA [1-7] prior hx of bleeding. No BB [1-7] COPD. . # Rhythm: - h/o PAF - not while in house, stable. Patient is on amiodarone which was continued. She states she has not been on Coumadin for the last several months due to presumed GIB. - h/o MAT - patient appeared to be in intermittent MAT. She was rate controlled with Diltiazem XR. Which she tolerated well. . # GI: Pt has hx of GERD. No signs of active GI bleeding. PPI was continued. . # Alkalosis and Hypochloremia - patient with alkalosis to HCO3 of 48, but her baseline pCO2 is in 70s. This perhaps was further exacerbated by aggressive diuresis with IV lasix. Patient's hypochloremia corrected while her lasix was held and reduced however restarting home dose she worsened again. Patient is thus being discharged on lower than her home dose in order to correct contraction alkalosis that may be contributing to her elevated bicarb. . Dispo - patient is to follow up with Dr. [Last Name (STitle) 23427] her PCP, [Name10 (NameIs) ] patient, she has an appointment on [2190-2-12]. . Medications on Admission: 1. [Last Name (un) ]-Vent 2 puffs b.i.d., 2. Serevent 2 puffs b.i.d. 3. Albuterol 2puffs b.i.d., 4 Atrovent, 5. Theophylline 600 mg p.o. q.d., 6. Fosamax 35 mg q. Sunday, 7. Calcium Carbonate 8. Lasix 80 mg p.o. q.d. 9. KcL 40 [Hospital1 ] 10.Advair 11.Diltiazem 30 qd 12.Lt4 50 qd 13.Prednisone 40 14.Amiodarone 100 15.Pantoprazole 40 qd Discharge Medications: 1. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 8. Insulin Regular Human 100 unit/mL Cartridge Sig: [12-10] units Injection four times a day: as directed per Insulin Sliding Scale. 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff Inhalation Q2H (every 2 hours) as needed. 11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-7] Puffs Inhalation Q6H (every 6 hours). 12. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 13. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): x 7 days, then 30 x 7 days, then 20 x 7 days then maintenance @ 10, unless instructed otherwise after her appt with Dr. [Last Name (STitle) 23427] on [2190-2-12]. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Outpatient Lab Work Please follow chem 7 over next 3 days as her lasix getting adjusted Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: 1. Influenza A infection 2. COPD - severe, oxygen dependent, on nocturnal BiPAP Secondary: 3. Diastolic CHF 4. Right heart failure 5. Diabetes Mellitus - Type 2, controlled with complications 6. Hypertension 7. Chronic Kidney Disease, Stage III 8. Osteoporosis 9. Multifocal Atrial Tachycardia 10. Report of history of GI bleed in past Discharge Condition: Stable. Ambulating on 2L with Sats of 95%. Tolerating PO. No fever. Discharge Instructions: Please take all your medications as instructed. Your prednisone is decreased today to 40 and you should continue @ 40 for next 7 days. It should be then further decreased by another 10 every 7 days until your baseline dose or as determined by your pulmonologist/PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 23427]. It's important that you follow up with him on [2190-2-12] and that appropriate transportation be arranged for your visit with him. . Please follow patient's chemistry 7 as her lasix gets adjusted. Patient is getting d/c on a lower than home dose of 120mg [Hospital1 ]. She is to continue on 80 mg QD in order to correct presumed contraction alkalosis. Please FOLLOW patient's chemistry 7: including chlrodie and bicarbonate over next few days as her lasix is getting titrated. Followup Instructions: Please follow up Dr. [Last Name (STitle) 23427] on [2190-2-12]. Please make sure you keep that appointment and arrange appropriate travel arrangements. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2190-2-4]	[ "428.0", "585.3", "403.91", "491.21", "250.00", "428.30", "487.1", "518.81" ]	icd9cm	[ [ [] ] ]	[ "93.90" ]	icd9pcs	[ [ [] ] ]	7070, 7149	1936, 5004	241, 248	7539, 7610		8478, 8790	1571, 1575		5402, 7047		7170, 7518		5030, 5379			7634, 8455									1590, 1913																			174, 203												276, 1143														1165, 1444	1460, 1555
63,706	188,753	39386	Discharge summary	report	Admission Date: [2172-6-18] Discharge Date: [2172-6-21] Date of Birth: [2147-8-10] Sex: F Service: MEDICINE Allergies: Penicillins / NyQuil D / Oxycodone Attending:[First Name3 (LF) 613] Chief Complaint: HEMOPTYSIS Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 24 year old female with PMH of DVT and PEx3 on lovenox, asthma, seizure hx, developmental delay, chronic right leg pain, who is presenting to the ED after she "passed out last night", woke up this morning with nausea, bloody emesis as well as hemoptysis. Per ACS note: "she reports walking in the kitchen at around 10 pm last night and the next thing she remembers is waking up this morning on the kitchen floor with her daughter crying and trying to wake her up. Her daughter is four years old. She reports multiple episodes of bloody emesis and hematochezia, also reports "blood coming out her ears". She denies any such episode happening in the past. She also reports a headaache at the back of her head and pain in her neck. She reports not being able to lift her right leg. She reports pain in the righ calf, foot and knee." In the ER she reported abdominal pain at the site where she injects lovenox." Per ACS note: Patient reports h/o seizures and states the she might have had a seizure last night. She reports loss of consciousness. Patient report h/o PE total of three times in the last year. She states she was initially treated with coumadin, then switched to lovenaox in [Month (only) 116] of this year. She denies non-compliance. Of note, patient provided inconsistent story to multiple health care providers. At some point she reported being nauseasted at night and experiencing hematochezia and hempoptysis as well as BRBPR. She reported feeling dizzy and as she was ready to ask for help she fell. Some of the history was corraborated with the patient's mother. In the ED she had a neg NG lavage, rectal neg and a CT abd/ pelvis, ct chest, ct head, leg cxrs and was given cipro, flagyl, and vanc for an subq abdominal infection. The patient's guardian since [Name2 (NI) 958] said that the patient is medically complicated, has narcotic and psych medicine seeking tendancies. The patient has a medical home [Hospital1 87067] Health Center that has a 24/7 urgent care clinic. The patient is supposed to go there to have all of her primary and urgent care issues. She has instead gone to [Hospital1 2177], [Hospital1 3278], [Hospital1 882], [Hospital1 ], [Hospital1 18] and [Hospital1 87068] ERs- the guardian knows this because she is contact[Name (NI) ] for consent at each. Per the guardian a home visit revealed "[Last Name (un) 2432] buckets of drugs." She is followed by outpatient by psyhiatry, endocrinology, neurology and several other specialist's. She is "invested in treatment," The [Doctor Last Name ] mother is not an accurate reporter and is paid to provide VMA servies. Thyroid has been "ruled out." Documentation from [Hospital1 2177]: CT/PA 1.Segmental and Subsegmental pulmonry emboliin the left lower lobe Psychiatry - "Known to psychiatry has tendancy to facricate issues" On arrival to the MICU, pt is lying in NAD, keeps eyes closed unless prompted. She says she does not remember what happened yesterday. She complains of neck pain that is similar to her previous pain. She also compalins of left abdominal pain, and right leg pain. She spit up some hemoptysis that is mixed with saliva, but she does have a tongue ring (placed years ago) that appears to be have some blood coming from it. She complains of chills, nausea, and wheezes. Review of systems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: Past Medical History: developmental delay depression asthma PEx3; [3-/2171], [7-/2171], [12/2171] w/ ivc filter [12/2171] possible seizures chronic right leg pain PSH: incisional umbilical hernia repair thymomectomy c-section times 2 appy chole Social History: Social History: Smoker Previous Cocaine Use EtOH socially 2 children lives at home [Hospital1 ] of the state Family History: Family History: Adpoted, but per record from [Hospital1 ] the [Doctor Last Name ] mom says her Biological Mother died w/ HTN, DM, IVDA, and multiple blood clots Physical Exam: Admission exam: Vitals: T: 98.3 BP: 136/37 P: 74 R: 13 O2: 100% on RA General: Obese alert, oriented in no acute distress, very slow to react HEENT: tongue ring with some blood near it, Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Indurated area 3 by 4 inches, soft, non-distended, bowel sounds present GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, [Last Name (un) 17610], grossly normal sensation Discharge exam: Pertinent Results: [2172-6-18] 10:20PM WBC-8.5 RBC-4.48 HGB-11.2* HCT-36.3 MCV-81* MCH-25.0* MCHC-30.8* RDW-15.4 [2172-6-18] 10:20PM NEUTS-67.1 LYMPHS-25.9 MONOS-4.5 EOS-2.1 BASOS-0.4 [2172-6-18] 10:20PM PLT COUNT-301 [2172-6-18] 02:59PM COMMENTS-GREEN TOP [2172-6-18] 02:59PM LACTATE-0.9 [2172-6-18] 11:55AM URINE HOURS-RANDOM [2172-6-18] 11:55AM URINE UCG-NEG [2172-6-18] 11:55AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2172-6-18] 11:55AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2172-6-18] 11:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2172-6-18] 08:30AM GLUCOSE-92 UREA N-8 CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15 [2172-6-18] 08:30AM estGFR-Using this [2172-6-18] 08:30AM ALT(SGPT)-36 AST(SGOT)-30 CK(CPK)-110 ALK PHOS-79 TOT BILI-0.3 [2172-6-18] 08:30AM LIPASE-37 [2172-6-18] 08:30AM ALBUMIN-4.3 [2172-6-18] 08:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [2172-6-18] 08:30AM WBC-7.9 RBC-4.85 HGB-12.1 HCT-39.0 MCV-80* MCH-24.9* MCHC-31.0 RDW-15.4 [2172-6-18] 08:30AM PLT COUNT-340 [2172-6-18] 08:30AM PT-13.0* PTT-150* INR(PT)-1.2* CXR: TECHNIQUE: Single PA view of the chest: The lungs are clear. Cardiomediastinal silhouette and hilar contours are unremarkable. No pleural effusion or pneumothorax is noted. Surgical clips are noted in the mediastinum. There is no evidence of free air. IMPRESSION: No acute intrathoracic process. CT Abd/Pelvis: IMPRESSION: 1. Substantial amount of air locules and adjacent stranding in the left lower quadrant subcutaneous tissue. Please correlate this with the history of injection to the site and physical exam in this area as findings suggest a soft tissue infection/cellulitis. No abscess. 2. Unusually aligned and rightward tilted IVC filter with the legs extending through the IVC and adjacent to the aorta. 3. The patient is status post cholecystectomy, appendectomy, and IUD placement. C-spine: IMPRESSION: 1. No evidence for fracture or dislocation. 2. Mild reversal of the usual expected lordotic curvature, which can be seen with collar placement. 3. Enlarged thyroid with asymmetric right-sided enlargement, possibly reflecting one or more nodules. When clinically appropriate, correlation with pertinent clinical history, laboratory data, and consideration of thyroid ultrasound are recommended. CT Head- Wet read: CT OF THE HEAD: There is no acute intracranial hemorrhage, edema, mass effect or large acute territorial infarction. The ventricles and sulci are normal in size and configuration. The [Doctor Last Name 352] and white matter differentiation is preserved. The paranasal sinuses and mastoids are clear. There is no acute fracture. There are no suspicious lytic or sclerotic bony lesions. IMPRESSION: No acute intracranial process. Brief Hospital Course: 24 year old female with PMH of DVT and PE on lovenox, asthma, seizure hx, developmental delay, and chronic right leg pain presented w/ hemoptysis after being found lying down and somnolent by her 4-year-old daughter. CT head in the ED could not rule out acute bleed as per ED attending due to the presence of IV contrast, so the patient was admitted to the MICU for Q1H neuro checks. . # Abdominal Pain: The patient also had a complaint of abdominal pain, which was likely related to cellulitis at her Lovenox injection site. In the ED, she was started on vancomycin, ciprofloxacin, and Flagyl. In the MICU, she was narrowed 7-day course of clindamycin (due to a PCN allergy). Ultrasound was performed at bedside and did not show any evidence of abscess. Her blood cultures were negative . # Hemoptysis: The patient has a hx of 3 PEs and is currently on Lovenox and has an IVC filter. There were no more episodes of hemoptysis, and we continued her anticoagulation continued due to 3 previous PEs. It was questionable whether patient had true hemoptysis or simply had bleeding of he tongue ring. . # Possible Seizure History: Pt possibly had a seizure prior to coming in; her CK was normal. Keppra was restarted, but she needs to follow-up with her neurolgist. . #s/p Fall: slipped and fell while showering on day of discharge, hit right posterior skull on edge of tub. Patient account of event inconsistent, reports loss of consciousness for a moment, but attending was present immediately after fall and witnessed patient alert and oriented immediately following. She had sm swelling 3cm dia on posterior skull, no focal neurological deficits including concentration, re-evaluated by PT who stated patient is safe for discharge and is not fall risk. # Psychiatric History: There is concern about her psychiatric health and we consulted psychiatry about multiple visits to different medical providers and concern about self-care issues. Per social work, patient has close follow up with psychiatric facility. . # Asthma: No SOB or breathing issues. Continued on home medications, no acute changes in hospital. . # Sleep: No issues home drug continued. No acute exacerbation. . # GERD: No issues home drug continued . # Chronic Right Leg Pain: Her home meds were held due to concern about somnolence. Complained of chronic pain to even light touch, however unlikely to be any acute process given benign exam. patient slept most of the day without complaints. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PharmacywebOMR [Hospital1 2177] records. 1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [Hospital1 ] 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 3. Aripiprazole 7.5 mg PO DAILY 4. Enoxaparin Sodium 80 mg SC Q12H 5. Docusate Sodium 100 mg PO BID constipation 6. Senna 2 TAB PO BID:PRN constipation 7. traZODONE 100 mg PO HS:PRN sleep 8. Omeprazole 20 mg PO DAILY 9. Loratadine NF 10 mg Oral daily 10. LeVETiracetam 500 mg PO BID 11. Fluticasone Propionate NASAL 2 SPRY NU DAILY 12. Quetiapine extended-release 150 mg PO DAILY 13. Ibuprofen 600 mg PO Q6H:PRN pain 14. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN severe pain 15. Citalopram 20 mg PO DAILY Discharge Medications: 1. Aripiprazole 7.5 mg PO DAILY 2. Citalopram 20 mg PO DAILY 3. Docusate Sodium 100 mg PO BID constipation 4. Enoxaparin Sodium 80 mg SC Q12H 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [Hospital1 ] 7. Ibuprofen 600 mg PO Q6H:PRN pain 8. LeVETiracetam 500 mg PO BID 9. Omeprazole 20 mg PO DAILY 10. Senna 2 TAB PO BID:PRN constipation 11. traZODONE 100 mg PO HS:PRN sleep 12. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 13. Loratadine NF 10 mg ORAL DAILY 14. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN severe pain 15. Quetiapine extended-release 150 mg PO DAILY 16. Outpatient Physical Therapy Evaluate and treat right knee Discharge Disposition: Home Discharge Diagnosis: right knee sprain History of pulmonary embolism x3 developmental delay Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 3924], You were treated at [Hospital1 18] to evaluate for a skin infection and for blood in your mouth. While you were here, we thought that you did not have an infection, and instead need to switch the site you inject Lovenox. The blood from your mouth likely came from your piercing. We're sorry you slipped in the bathroom. You were evaluated and did not appear to sustain additional injuries. Physical therapy worked with you again and felt you were steady on your feet and safe to go home. Please follow up with your primary care doctor and the [Hospital ] clinic in [2-3] days. Followup Instructions: Please follow up with your PCP and [Name9 (PRE) ] clinic. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2172-6-22]	[ "789.00", "780.39", "E885.9", "331.83", "311", "305.1", "530.81", "780.09", "780.52", "786.30", "416.2", "338.29", "V58.61", "315.9", "493.90", "844.9", "729.5", "V45.89" ]	icd9cm	[ [ [] ] ]	[ "96.34" ]	icd9pcs	[ [ [] ] ]	12272, 12278	8284, 10755	306, 312	12393, 12393	5242, 8261	13201, 13415	4395, 4550		11562, 12249		12299, 12372		10781, 11539			12546, 13178									4565, 5206					5223, 5223									3704, 3945					255, 268												340, 3685								12408, 12522						3989, 4231	4263, 4363
8,306	193,359	44868	Discharge summary	report	Admission Date: [2167-6-11] Discharge Date: [2167-6-23] Date of Birth: [2113-7-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 689] Chief Complaint: Fever Major Surgical or Invasive Procedure: none History of Present Illness: 53 yo male with PMH of htn, who presented with fever. He notes that he had back pain and l flank pain on Sunday, sharp in nature and worse with exhalalation. He was seen at [Hospital3 ] hospital and diagnosed with kidney stones when he had +RBC in urine. He was given percocet and sent home. Since then he has had fevers to 37.8. THe pain in his back was somewhat improved. He notes he does not take his antihypertensives regularly. He denies CP, SOB, dysuria, changes in vision, headache. He presented to the ED and was found to have elevated BP to 210/100. CTA was performed that showed extensive intramural thrombus of aorta. He was given Lopressor IV and PO initially and then started on esmolol and nipride drips. His BP decreased to 123/47Vascular [Doctor First Name ] and CT [Doctor First Name ] eval'd pt in ED. Type B dissection with no end organ malperfusion, rec BP control. Past Medical History: Hypertension Social History: Lives with wife, one son. FOrmer social smoker ([12-21]/wk), occasional ETOH, no drugs. Family History: Mother with htn Physical Exam: 99.6, 132, 219/108, 20, 97%RA GENL: NAD HEENT: PERL, normal discs, no LAD, no elev JVP CV: RRR no MRG Lungs: CTAB ABD: soft, nt, nd, +bs Ext: no C/C/E, 2+ pedal pulses Neur: A&Ox3 Pertinent Results: [2167-6-10] 09:45PM WBC-11.7* RBC-4.36* HGB-13.2* HCT-36.8* MCV-85 MCH-30.3 MCHC-35.8* RDW-12.6 [2167-6-10] 09:45PM PLT COUNT-157 [2167-6-10] 09:45PM NEUTS-75.0* LYMPHS-16.2* MONOS-7.3 EOS-1.3 BASOS-0.2 [2167-6-10] 09:45PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.020 [2167-6-10] 09:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2167-6-10] 09:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [2167-6-10] 09:45PM GLUCOSE-128* UREA N-32* CREAT-1.5* SODIUM-141 POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-26 ANION GAP-14 [2167-6-10] 09:54PM PT-13.0 PTT-25.7 INR(PT)-1.1 [2167-6-11] 12:20AM ALBUMIN-4.0 [2167-6-11] 12:20AM CK-MB-2 [2167-6-11] 12:20AM CK-MB-2 [2167-6-11] 12:20AM cTropnT-<0.01 [2167-6-11] 12:20AM LIPASE-19 [2167-6-11] 12:20AM ALT(SGPT)-22 AST(SGOT)-19 LD(LDH)-170 CK(CPK)-153 ALK PHOS-88 AMYLASE-53 TOT BILI-1.1 [2167-6-11] 05:54AM PLT COUNT-164 . EKG: Sinus rhythm, Left ventricular hypertrophy, Minor ST-T wave abnormalities. Since previous tracing of [2165-9-30], no significant change . [6-10] CTU: 1. Findings consistent with an intramural hematoma of the aorta extending from the upper most image acquired on this study above the diaphragmatic hiatus through to the level of the aortic bifurcation, possibly involving the right common iliac artery. The celiac artery, SMA, left renal artery, and [Female First Name (un) 899] appear patent. The right renal artery also appears patent although evaluation is considered suboptimal. 2. Multiple left-sided renal cysts and multiple hypodense lesions too small to characterize in the kidneys bilaterally that may represent cysts. No renal stones identified. No hydronephrosis. . [6-11] CTA: Aortic intramural hematoma that appears to extend proximally from the level of the take off of the left subclavian artery, and distally through to the level of the bifurcation of the aorta, also apparently involving the proximal right common iliac artery. The celiac artery, SMA, renal arteries, and [Female First Name (un) 899] all appear patent. . [6-12] CTA: Compared to the exam of [2167-6-11], no significant change in the appearance of the aortic intramural hematoma. No evidence of new retroperitoneal hemorrhage or fluid collections. . [6-13] MRI L-spine: 1. No evidence of epidural abscess. 2. Diffusely abnormal bone marrow signal, which appears nonspecific but may be seen in diffuse bone marrow infiltration or chronic illness. Clinical correlation suggested. 3. Distended bladder. Clinical correlation suggested. . CXR: No radiographic evidence of pneumonia . TTE: 1. The left atrium is mildly dilated. 2. The left ventricular cavity is mildly dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. 4. Mild (1+) aortic regurgitation is seen. 5. No evidence of endocarditis seen. . MRI C-SPINE ([6-18]) 1. No evidence of an epidural abscess. 2. Cervical spondylosis with mild central stenosis and severe narrowing of neural foramina at multiple levels. . MRI T-SPINE ([6-18]) No evidence of an epidural abscess Brief Hospital Course: 1) AORTIC DISSECTION: Intramural aortic hematoma seen on CT scan in ED. Vascular surgery consulted who felt it was consistent with a Type B Aortic dissection. He was admitted to the CCU for aggressive BP control. He was on a nipride and esmolol drip and eventually transitioned to PO agents. He had a repeat CT scan which revealed a stable appearance of the aorta. He was scheduled a follow up appoinmtent with Vascular surgery after discharge. He should also have a follow up CT scan after discharge which should be arranged by his primary care doctor. . 2) HYPERTENSION: His blood pressure was controlled with high dose Lisinopril, Labetalol, Norvasc. Labetalol was continually titrated up for difficult to control blood pressure. Eventually, clonidine was also added for better control, which was achieved prior to discharge. At the time of discharge, he was given a clonidine patch and transitioned off PO clonidine with a 3 day taper. He was instructed to have his blood pressure checked (by VNA and on his own), and call his doctor if he noticed that it was >140/90 or <90/50. He was also told to call his provider or go to the ER if he experienced chest pain, difficulty breathing, dizziness, or blurry vision. . 3) FEVER: Patient had a low grade temperature at admission and it continued throughout his hospital course. He had an extensive work-up including MRI spine (negative for epidural abscess), TTE (negative for vegetation), blood cultures (negative), urine cultures (negative), PPD (negative), Hepatitis panel, HIV test (negative). Ultimately, the infectious disease service felt that his fevers were due to his aortic intramural hematoma. Eventually, he became afebrile while off all antibiotics for several days. . 4) ANEMIA: Patient's HCT was in low thirties. Work-up revealed low iron, normal TIBC, and high ferritin, as well as a borderline low B12 level. The MRI of the L-spine commented on a diffusely abnormal signal pattern from the bone marrow. Heme/Onc was consulted who preformed a bone marrow biopsy. It was consistent with findings of anemia of chronic disease or inflammation. Medications on Admission: Lopressor 50 mg [Hospital1 ] (does not take regularly) Combination of ?HCTZ and ACEI (does not take regularly) ASA Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: 1) Fever 2) Aortic Dissection Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the ER if you experience fever, chills, chest pain, difficulty breathing, dizziness/lightheadedness, blurry vision, or difficulty walking. You should check your blood pressure daily and call Dr. [Last Name (STitle) 3357] if it is higher than 140/90 or lower than 90/50. Please take your medications as prescribed and follow up as scheduled below. Followup Instructions: 1) Please follow up with your Primary Care Physician (Dr. [Last Name (STitle) 95978] [Telephone/Fax (1) 4606]) on [7-2] at 12:45. . 2) Please follow up with Dr. [Last Name (STitle) ] in Vascular Surgery on [2167-7-7] at 3:00 PM. [Hospital 2577] Medical Office Building, [Hospital Unit Name ].	[ "441.02", "584.9", "280.9", "780.6", "403.91" ]	icd9cm	[ [ [] ] ]	[ "41.31" ]	icd9pcs	[ [ [] ] ]	7316, 7402	5020, 7146	319, 325	7476, 7484	1647, 4997	7923, 8247	1415, 1432				7423, 7455		7172, 7293			7508, 7900									1447, 1628																			274, 281												353, 1253														1275, 1290	1306, 1399
11,596	196,232	27425	Discharge summary	report	Admission Date: [2157-5-12] Discharge Date: [2157-6-17] Date of Birth: [2105-11-6] Sex: F Service: SURGERY Allergies: Penicillins / Aspirin / Acetaminophen Attending:[First Name3 (LF) 668] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: 1. Orthotopic liver and renal transplant [2157-6-6] 2. ERCP, common bile duct stent [2157-6-12] 3. EGD [2157-5-15] 4. TIPS 5. Central line placement 6. Paracentesis 7. tunneled hemodialysis line placement 8. Colonoscopy [2157-6-3] 9. Hemodialysis History of Present Illness: 51 y/o F w/alcoholic cirrhosis, s/p banding of varices in last year, who presented to [Hospital 1562] Hospital today after vomiting bright red blood. While there, she vomited initially 700 cc BRB and then 1500 cc during EGD. BP dropped as low as 80s but responded with volume (received 500 NS, 1500 Hespan, 3 U PRBCs). She was intubated for airway protection and a femoral line was placed for access. She was placed on octreotide gtt and given levofloxacin for prophylaxis. EGD demonstrated massive GI bleed near GEJ likely from grade IV esohpageal varices, large amt of fresh blood and clots. one column of varix had whitish spot. Placed five bands at distal esophagus. She was transferred here for ? TIPS. . Per her fiance, she was hospitalized one week ago for abdominal pain and swelling. She was told she had an infection and was on antibiotics, but never had a paracentesis. She had also been taking vitamin K. She has "coughed up" blood in the past and has had bands placed once in the past. Past Medical History: 1. Cirrhosis, diagnosed in last year per fiance. Initially there was a question of Hep C, per him tests were first positive and subsequently negative 2. Hx of VRE per chart 3. Hx "nonspecific colitis" 4. Hx C Diff 5. ? pancreatic mass Social History: Lives at home in [Location (un) ] with fiance and four children (ages 17, 15, 14, and 12). Works as a deli clerk at local Stop & Shop. Hx tobacco, 1 ppd but quit 3 years ago. Long alcohol hx, last drink in [Month (only) 404] per fiance. Family History: NC Physical Exam: VS - T 98.4, BP 130s/60s, HR 90s-100s, RR 16, sats 97% on RA Gen: Jaundiced, middle aged female, lying in bed. Minimally interactive. AAOx3, but ? confabulating answers to some questions. HEENT: Sclera hemorrhagic. PERRL. ? strabismus. Neck: No JVD. Central line on L. CV: Tachy, reg, normal S1, S2. No m/r/g. Lungs: CTA anteriorly, but decreased BS at bases. Abd: Soft, mildly distended, nontender. + BS. No masses appreciated. No rebound or guarding. Ext: Mild edema bilaterally in LE. Appears volume overloaded on exam, but not pitting edema. Feet very cool, 2+ DP/PT pulses bilaterally. No clubbing or cyanosis. Neuro: CN appear grossly intact, though able to fully assess. Grip strong and symmetric. L sided weakness - LUE 4-/5 on flexion/extension, vs 4+/5 on RUE. "too tired" to assess LE. Can wiggle toes. Babinski equivocal bilaterally. Skin: Profoundly jaundiced. No rashes Pertinent Results: LABS on admission: WBC 2.6, Hct 26.3, MCV 91, Plt 104* (DIFF: Neuts-68.5 Lymphs-21.5 Monos-3.9 Eos-5.9* Baso-0.2) PT 20.1, PTT 35.9, INR 1.9 Na 136, K 5.7, Cl 110, HCO3 22, BUN 22, Cr 0.6, Glu 117 ALT 22, AST 76, LDH 146, AlkPhos 252, TBili 3.4 Albumin 1.7, Calcium 6.6, Phos 3.8, Mg 1.4 ABG: 7.39/41/100 on AC, 40% FiO2, Tv 550, PEEP 5, RR 15 Lactate 1.2 UA: Clear, LtAmb, USG 1.025, Blood TR, Nit NEG, Prot TR, Glu NEG, Ket NEG, Bili NEG, Urobil NEG, pH 5.0, Leuks NEG, RBC 2, WBC 0, Bact NONE, Epi 0, CastHy 2* . LABS during hospitalization: [2157-5-23] 01:10PM BLOOD Vanco-53.6* [2157-5-28] 06:15AM BLOOD Vanco-13.8* . [2157-5-26] T cell subset: WBC-3.9* Lymph-9.3* Abs [Last Name (un) ]-363 CD3%-97 Abs CD3-352* CD4%-58 Abs CD4-209* CD8%-21 Abs CD8-77* CD4/CD8-2.7 . [2157-5-13] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2157-5-13] HCV Ab-POSITIVE [2157-5-19] HAV Ab-POSITIVE [2157-5-19] HERPES SIMPLEX (HSV) 2, IGG- [2157-5-19] HERPES SIMPLEX (HSV) 1, IGG-Test [2157-5-19] AFP 1.0 [2157-5-25] CEA 2.8 [2157-5-25] CA [70]-9 -Test [2157-5-26] VBG: 7.47/36/35/27 [2157-5-26] HEPATITIS Be ANTIBODY-PND [2157-5-26] STRONGYLOIDES ANTIBODY,IGG-PND [2157-5-26] HERPES 8 IgG ANTIBODY-PND [2157-5-26] HEPATITIS Be ANTIGEN-PND [2157-5-27] Serum Osmolality 317* [2157-5-28] Iron 141, calTIBC 148, Ferritin 871, TRF 114, Hapto <20 [2157-5-29] TSH PND [2157-5-29] Free T4 PND . Urine studies: [2157-5-23] URINE Osmolal-335 [2157-5-23] URINE Creat 36, Na 83, K 22, Cl 82 [2157-5-27] 11:22PM URINE HISTOPLASMA ANTIGEN-PND . Ascites fluid: [2157-5-19] WBC 125, RBC [Numeric Identifier 24869] (DIFF: Polys 23, Lymphs 35, Monos 10, Eos 3, Mesothe 1, Macrophages 28) TotProt 1.0, Glucose 154, LDH 54, Albumin LESS THAN ASSAY . . IMAGING: [2157-5-13] ABD U/S: Four-quadrant ultrasound shows a trace of fluid only, the largest pocket been identified in the right lower quadrant. This is not suitable for planned paracentesis and no spot was marked. Limited views of the liver show somewhat nodular outline consistent with cirrhosis. . [2157-5-13] LIVER U/S: Pulsatile flow is demonstrated in the IVC and major hepatic veins. The portal vein and hepatic arteries are patent. The liver is shrunken and nodular, and ascites is present. The common bile duct is not dilated, a stone is present within the neck of the gallbladder. A 3.2-cm cyst is present in the right lobe, unchanged. IMPRESSION: Cirrhotic liver with ascites. Patent portal and hepatic vessels . [2157-5-17] ABD U/S: Patent TIPS shunts with velocities ranging from 52-221 cm/sec. The hepatic venous velocities are rather high and consequently a short-term followup study is recommended to reevaluate and exclude the possibility of stenosis at the hepatic venous stent. . [2157-5-19] RUE U/S: Right cephalic and brachial vein thrombosis. . [2157-5-19] ECHO: 1. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 2. There is mild pulmonary artery systolic hypertension. . [2157-5-21] CXR: Endotracheal tube is approximately 3 cm above carina. NG tube is in body of stomach. Left jugular CV line is in mid SVC. No pneumothorax. Right lateral chest is not included on the film. Persistent opacity consistent with atelectasis in the left lower lobe is again demonstrated, slightly improved since prior film of same date. . [2157-5-22] CT a/p: 1. Cirrhotic liver with portal hypertension. 2. Peripheral wedge-shaped hypoenhancing areas within the spleen, likely infarcts. 3. There are no focal enhancing liver lesions. 4. Cholelithiasis. 5. TIPS in place. 6. Multiple enlarged portosystemic varices in the upper abdomen. 7. Replaced right hepatic artery arising from the SMA. 8. Enlarged lymph nodes as described much larger than we typically see in patients with cirrhosis, does the patient has any other underlying liver disease? 9. Hepatic cyst. 10. NG tube in place. . [2157-5-24] renal U/S: Normal-sized kidneys with no hydronephrosis. . [2157-5-30] CXR: 1. Worsening left retrocardiac opacity. Although possibly due to a combination of atelectasis and effusion, pneumonia should be considered in the appropriate clinical setting. 2. Minimal hazy opacity in right upper lobe, for which an early focus of pneumonia is not excluded. . [2157-5-31] PFTs: performed, report pending . [2157-5-31] LIVER U/S: There has been resolution/reabsorption of nearly all of the ascites and there is insufficient amount for ultrasound-guided paracentesis. . [2157-6-3] CXR: 1. Persistent left pleural effusion and left retrocardiac opacity. Although this may represent a combination of atelectasis and effusion, pneumonia should be considered in the appropriate clinical setting. 2. Mild pulmonary interstitial edema. 3. No pneumothorax. . [2157-6-3] MANDIBLE XR/PANOREX: Limited study. No evidence of fractures or gross bony abscess. Further characterization of the dentition could be performed with a Panorex view if clinically warranted. . [2157-6-3] COLONOSCOPY: Grade 1 external hemorrhoids, xanthomas in sigmoid (which were biopsied), other normal colonoscopy to cecum. Brief Hospital Course: 51yo F w/ EtOH cirrhosis, s/p upper GIB from esophageal varices. Underwent banding and TIPS procedure. MICU course complicated by hemolytic anemia due to incorrect blood type during transfusion, MRSA ventilator associated pneumonia, Klebsiella SBP, and now acute renal failure likely due to CIN. . # RESP: Ms. [Known lastname 67131] was originally intubated for airway protection at the OSH. After transfer here, while still intubated, she developed fevers and infiltrates on CXR. Endotracheal specimen revealed MRSA. A bronchoscopy was performed and cultures revealed GPC and yeast. She was treated with vancomycin and was able to be extubated on [2157-5-23]. Post-extubation, her respiratory status was stable. She had albuterol inhalers prn, but did not need them. She was able to use an incentive spirometer to help with her atelectasis. CXR showed a persistent retrocardiac opacity but she was afebrile and had no cough or sputum production, so antibiotics were never restarted. Post-colonoscopy, she had decreased O2 sats but her CXR showed only mild volume overload, so it was felt to be most likely due to atelectasis/sedation from the procedure. . # CV: Ms. [Known lastname 67131] has no known cardiac history. EKG showed sinus tach, with TWI in VI, TW flattening in III, aVF, but no ST changes. Her ECHO shows hyperdynamic walls, with EF 75%, but no WMA. . # ID: Ms. [Known lastname 67131] was febrile while in the MICU and the source was not known. Urine grew VRE as well as yeast. Yeast cultures were unable to be speciated. While in the MICU, she had a PICC line for access, but it appeared infected with presumed septic thrombi in superficial veins. Blood cultures were negative. The PICC line was removed and a left IJ was placed instead. Respiratory sources were considered, and she was treated with vancomycin for a MRSA ventilator-associated pneumonia. Vancomycin was used from [5-15] -> [5-24], and was discontinued once she developed persistent renal failure. Her Cr became elevated to such an extent that her vancomycin was able to be dosed by level. Other sources were felt to be possible SBP given that a peritoneal culture grew Klebsiella. For that, she was treated with cefepime for 14 days ([5-17] -> [5-31]). Repeat paracentesis was considered, but follow-up ultrasound showed that there was no ascites. Once she completed the course of cefepime, she was started on cipro per the liver team for SBP ppx. Both pneumovax and dT were given on [6-3] as her immunization status was unable to be obtained. She continued to have a retrocardiac opacity on CXR, but no signs or symptoms of pneumonia. Stool cultures were negative for Cdiff. . # RENAL: Ms. [Known lastname 67131] went into acute renal failure on [2157-5-23], after undergoing a CT with contrast. Renal consulted on the patient and felt that the most likely etiology to her acute renal failure was contrast induced nephropathy. Hepatorenal syndrome was considered, but was less likely given that her urine lytes showed that she was not sodium avid. Octreotide and midodrine were tried empirically, in case there was an element of hepatorenal syndrome, but there was no improvement in renal function with these medications so both were discontinued. A tunnelled HD line was placed on [6-3] and hemodialysis was started on [6-4]. On [2157-6-5] she underwent a combined liver/renal transplant. Her renal graft began functioning soon after implantation. Her creatinine trended down over time. . # HEME: On one transfusion, Ms. [Known lastname 67131] was given incorrectly typed blood and developed hemolysis which likely decreased her Hct and may have contributed to her jaundice. Her Hct reached a nadir of 23 on [6-1] so she was given 1u pRBC which increased her Hct appropriately to 27. However, it continued to slowly trend down. She was given epogen at dialysis, but it appeared that she was not responding to epogen. During the course of her transplant she recieved 3 L of cell [Doctor Last Name 10105], 18 units of FFP, 10 units of cells, 5 platelets, and 5 cryo. She was also transfused on POD 1 with 4 PRBCs, 2 FPP, and 4 platelets for her acute blood loss anemia. . #. Pancytopenia: This was felt to be due to a combination of marrow suppression from alcohol abuse and cirrhosis. Her anemia was also likely due to her massive GI bleed, hemolytic anemia, and possibly renal failure. Her thrombocytopenia was monitored daily and platelets were only transfused for bleeding or around times of procedures. On discharge her hematocrit, WBC, and platelet counts were stable and appropriate. . # GI: Ms. [Known lastname 67131] had a severe variceal bleed at the OSH, requiring 5u pRBC and 2u FFP. She underwent EGD and banding at OSH with repeat EGD here (5 bands placed) as well as a TIPS procedure. She was followed by the liver team here and was placed on the transplant list. Her MELD score was 40 and she was given supportive care while waiting for a transplant. Attempts were made to complete all testing prior to transplant. A dental evaluation was attempted on [6-3], but the patient was uanble to fully cooperate. A mammogram was scheduled for [6-6]. Equipment was needed in order to do a PAP, but was unable to be obtained prior to her transplant. A PAP from several years ago was negative. A colonoscopy was performed and was essentially normal. Xanthomas were biopsied and removed, but the results were pending upon transfer to the surgery service. A liver/renal transplant became available to her on [2157-6-5]. Please see the operative note for further details. The patient was taken intubed to the SICU from the OR. She was extubated on POD 2. Over time her LFT's trended down and her encephalopathy cleared. On POD6 her T Bili was acutely elevated and again rose to 20.8 on POD 7. An ERCP was performed which demonstrated a stricture at the common bile duct anasotomosis. A stent was placed during this procedure. The following day her T Bili was significantly decreased to 9.1 On dicharge her transaminases and T Bili had normalized. . # NEURO: After being extubated and having her sedation weaned, her mental status continued to be waxing and [Doctor Last Name 688]. It was unclear if this was related to uremia and/or encephalopathy (though she had no asterixis). She was continued on rifaximin and lactulose for prevention of encephalopathy. Any medications which could be altering her mental status were discontinued. In the post-op period her encephalopathy cleared has her liver function improved. On discharge she was alert, oriented, understood why she had been hospitalized, and was able to take an active role in her care. She continued to learn about her medications and long-term needs. . # ENDOCRINE: Her hyperglycemia was likely due to her severe illness. Her fingersticks were controlled with an insulin sliding scale. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Diabetes center consult was obtained post-opertively. Intermittantly she was on an insulin drip. On dishcarge her blood glucose was controlled with glargine and ISS. . # FEN: In the MICU, while intubated, she was given nutrition via tube feeds in OG/NG tube. Once she was extubated, she was able to take clears and her diet was advanced to solids upon transfer to the floor. She was given [First Name8 (NamePattern2) ] [Doctor First Name ], renal diet with supplements. She was not given IVF on the floor as her kidney function was worsening and she was total body volume overloaded. Her electrolytes were monitored daily and were repleted as needed to keep her K >4 and Mg >2. Post-operatively she was started on TPN on POD 1; however due to access issues as well as her ability to take PO's this was discontinued on POD 4. On discharge she was tolerating a regular diet with good PO intake. . # ACCESS: She had a PICC line originally in MICU, but it was removed due to concerns about infection. A left IJ was placed [5-19] in the MICU. A tunneled HD catheter was placed [6-2]. The LIJ was removed in the SICU once it stopped functioning. She was maintained with peripheral access for the remainder of her hospitalization. . # PPX: She was given pneumoboots for DVT prophylaxis (no heparin given her low platelets). She was also given a PPI q12. No bowel regimen was needed as she had profuse diarrhea. . # CODE: FULL . # DISPO: To rehab. . Medications on Admission: Antibiotic - unknown which one Vitamin K Discharge Medications: 1. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). Disp:15 Tablet(s) Refills:2 2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): single strength. Disp:30 Tablet(s) Refills:2 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 units Injection [Hospital1 ] (2 times a day): until ambulating. Disp:qs Refills:2 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:qs Refills:0 8. Ursodiol 300 mg Capsule Sig: 300 mg Capsules PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 9. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:120 Capsule(s) Refills:2 10. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:2 11. Insulin SS please see attached sliding scale 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. Outpatient Lab Work please draw labs every monday and thursday. needs ast,alt,ap,TB,cbc,chem10, tacro level Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: End-stage liver disease and end-stage renal disease. Discharge Condition: good Discharge Instructions: Take all medications as instructed. Regular diet. You may resume activity as tolerated. You may shower, then pat-dry incision. Do not rub incision. No tub baths or swimming for 3-4 weeks. You may leave the incision uncovered or use a light dressing for comfort. * Increasing pain * Fever (>101.5 F) or Vomiting * Inability to eat or drink * Inability to pass gas or stool * Redness/swelling/drainage from incisions * Decreased urine output * Other symptoms concerning to you Followup Instructions: [Hospital ] clinic [Telephone/Fax (1) 673] Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2157-6-23] 1:40 Provider: [Name10 (NameIs) 1344] [Last Name (NamePattern4) 3125], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2157-6-30] 2:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2157-7-7] 1:00 Completed by:[2157-6-17]	[ "250.00", "V09.0", "272.2", "403.91", "576.2", "567.23", "428.0", "285.1", "599.0", "999.8", "584.5", "518.81", "572.3", "482.41", "E947.8", "284.8", "303.93", "585.6", "570", "283.0", "518.0", "996.62", "571.2", "456.20" ]	icd9cm	[ [ [] ] ]	[ "55.69", "96.72", "99.06", "99.05", "45.13", "50.59", "51.87", "39.95", "99.04", "99.15", "38.95", "45.25", "39.1", "00.93", "54.91", "99.07", "96.6" ]	icd9pcs	[ [ [] ] ]	18370, 18449	8368, 16817	308, 573	18546, 18553	3067, 3072	19082, 19608	2143, 2147		16909, 18347		18470, 18525		16843, 16886			18577, 19058									2162, 3048																			257, 270												601, 1606							3086, 8345							1628, 1865	1881, 2127
26,964	170,782	10803	Discharge summary	report	Admission Date: [2147-1-9] Discharge Date: [2147-1-26] Date of Birth: [2065-10-24] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: Unstable angina/NSTEMI Major Surgical or Invasive Procedure: [2147-1-9] Cardiac Catheterization [2147-1-14] 1. Emergency coronary artery bypass graft x1 (saphenous vein graft to posterior descending artery) and mitral valve repair with a size 32 [Company 1543] MC3 complete ring. 2. Insertion of intra-aortic balloon pump, right femoral artery. History of Present Illness: The patient is an 81 year old male with a history of severe CAD s/p CABG in [2126] with LIMA-LAD and SVG-LCx c/b post-op tamponade, multiple subsequent catheterizations, last in [Month (only) 216] showing occlusion of his LMCA and his SVG-OM graft, occluded RCA s/p POBA, ischemic cardiomyopathy EF 45-50% initially presented on [2147-1-6] to an OSH with substernal chest discomfort with radiation to left arm associated with shortness of breath. The pain was abrupt, [5-16], and occured while he was watching television. He took SL NTG and Maalox without relief. The symptoms were similar to several prior episodes this year requiring hospitalization, and he called EMS. He ruled in for NSTEMI at OSH with peak troponin of 2.66 and was transferred to [Hospital1 18] for cardiac catheterization on a heparin drip. On cath on [1-9] at [Hospital1 18], he had a patent LIMA-LAD graft, occluded SVG-OM, and RCA with severe diffuse disease of the mid vessel and subtotal distal occlusion. It was recommended by Dr. [Last Name (STitle) ] that he go for CABG at that time. Was evaluated by CT [Doctor First Name ], who said he is a surgical candidate for redo; however, patient and patient's family does not want a CABG and are apparently pursuing second opinions for possible PCI. Beginning on the morning of [1-10], he began to have intermittent episodes of chest pain and SOB with subsequent wet lung sounds, for which he received 40 mg IV Lasix and was placed on a Nitro drip. At the time, he had inferior-lateral ST depressions which lessened with the Nitro and a slow heart rate. Overnight, the patient's symptoms resolved and the nitro gtt was turned off. Patient then triggered on the morning of [1-11] for 5/10 chest pain and SOB. Nitro gtt was resumed and patient given 40 mg IV Lasix with resolution. At 5:30 pm, patient had another episode of chest pain with Inferio-lateral ST depressions again present. Nitro gtt was increased to 2, 20 mg IV Lasix was given, and patient was [Hospital 35261] transferred to the CCU for further monitoring and management. On arrival to the floor, HR 94 BP 127/74 94% 2L, chest pain free with Nitro drip at 2. ST depressions had lessened. Past Medical History: CAD, MR s/p CABG, MVR PMH: s/p CABG in [2126] PCI's CHF Hypertension Dyslipidemia mild aortic regurgitation prostate cancer s/p XRT peripheral neuropathy Chronic kidney disease stage II CVA HOH with bilateral hearing aides Social History: - Tobacco history: Denies - ETOH: [3-10] glasses homemade wine/week - Illicit drugs: Denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Father died of MI at 82. Brother died at age 65 from MI. Mother had diabetes. Physical Exam: VS: HR 94 BP 127/74 94% 2L Gen: NAD. Alert and oriented x3. Mood and affect appropriate. Pleasant and cooperative. Resting comfortably in bed. Able to speak in full sentences. [Month/Day (3) 4459]: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP benign. Neck: Supple. JVP not elevated. No cervical lymphadenopathy. CV: RRR. Normal S1, S2. No M/R appreciated. Intermittent S3. Well healed sternotomy scar. Chest: Respiration unlabored, good air movement. Bibasilar crackles L>R about [1-8] and [1-9] respectively. No wheezes or rhonchi. Abd: BS present. Soft, NT, ND. No HSM detected. Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+. Skin: No rashes, ecchymoses, or other lesions noted. Pertinent Results: Admssion Labs: [2147-1-24] 04:45AM BLOOD PT-23.8* INR(PT)-2.3* [2147-1-23] 06:45AM BLOOD PT-20.9* INR(PT)-1.9* [2147-1-22] 06:30AM BLOOD PT-16.3* PTT-24.8 INR(PT)-1.4* [2147-1-21] 03:56AM BLOOD PT-14.5* PTT-25.5 INR(PT)-1.3* [2147-1-20] 03:00AM BLOOD PT-15.1* PTT-32.5 INR(PT)-1.3* [2147-1-19] 03:05AM BLOOD PT-15.0* PTT-30.1 INR(PT)-1.3* [2147-1-18] 04:03AM BLOOD PT-15.3* PTT-30.0 INR(PT)-1.3* [2147-1-16] 03:19AM BLOOD PT-14.7* PTT-32.0 INR(PT)-1.3* [2147-1-15] 04:41AM BLOOD PT-14.4* PTT-29.6 INR(PT)-1.2* [2147-1-14] 01:35PM BLOOD PT-16.5* PTT-37.9* INR(PT)-1.5* [2147-1-14] 12:00PM BLOOD PT-18.2* PTT-37.5* INR(PT)-1.6* [2147-1-14] 03:53AM BLOOD PT-14.8* PTT-59.7* INR(PT)-1.3* [2147-1-13] 05:15AM BLOOD PT-14.2* PTT-69.7* INR(PT)-1.2* [2147-1-12] 04:25AM BLOOD PT-14.6* PTT-63.6* INR(PT)-1.3* [2147-1-11] 06:10AM BLOOD PT-14.1* PTT-69.7* INR(PT)-1.2* [2147-1-25] 04:40AM BLOOD UreaN-72* Creat-1.9* Na-136 K-3.3 Cl-96 [2147-1-24] 04:45AM BLOOD Glucose-134* UreaN-74* Creat-2.0* Na-135 K-3.1* Cl-94* HCO3-31 AnGap-13 Discharge Labs: [2147-1-26] 04:35AM BLOOD WBC-14.9* RBC-3.55* Hgb-10.4* Hct-31.5* MCV-89 MCH-29.2 MCHC-33.0 RDW-15.6* Plt Ct-267 [2147-1-25] 04:40AM BLOOD WBC-16.5* RBC-3.52* Hgb-10.4* Hct-30.9* MCV-88 MCH-29.7 MCHC-33.8 RDW-15.4 Plt Ct-244 [2147-1-26] 04:35AM BLOOD Plt Ct-267 [2147-1-26] 04:35AM BLOOD PT-19.4* PTT-28.2 INR(PT)-1.8* [2147-1-26] 04:35AM BLOOD Glucose-118* UreaN-79* Creat-2.0* Na-135 K-3.7 Cl-96 HCO3-27 AnGap-16 [2147-1-26] 04:35AM BLOOD ALT-102* AST-46* AlkPhos-171* Amylase-177* TotBili-3.4* [2147-1-24] 04:45AM BLOOD ALT-139* AST-60* AlkPhos-156* Amylase-193* TotBili-3.5* [2147-1-26] 04:35AM BLOOD Lipase-194* [2147-1-24] 04:45AM BLOOD Lipase-211* CARDIAC CATH [2147-1-9]: 1. Selective coronary angiography of this right dominant system revealed three vessel native coronary artery disease. The LCA was not engaged and known occluded. The RCA showed severe diffuse disease of the mid vessel followed by a subtotally occluded distal RCA due to distal RCA stent ISRS. 2. Limited hemodynamics showed normotension of 132/63 mmHg. 3. Arterial conduit angiography showed a patent LIMA-LAD. The LIMA does appear to stay left of the midline. 4. Successful closure of right femoral arteritomy with 6F angioseal. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Normal blood pressure. 3. Patent LIMA-LAD 4. CT surgery eval for consideration of redo cabg of PDA. 5. Successful RFA angioseal. . - ECHO [2147-1-9]: The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %) with global hypokinesis and regional infero-septal, inferior and infero-lateral near akinesis (?CAD?). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal. with borderline normal free wall function. 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. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Radiology Report CHEST (PA & LAT) Study Date of [2147-1-22] 11:54 AM [Hospital 93] MEDICAL CONDITION: 81 year old man with s/p cabg and mv ring Final Report One view. Comparison with the previous study done [2147-1-20]. There is interval improvement in pulmonary vascular congestion and small pleural effusions. The heart and mediastinal structures are unchanged. An endotracheal tube, nasogastric tube, and right internal jugular sheath have been removed. RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in echotexture without focal lesions. The previously documented small segment VIII cyst is not seen on this study. There is no intrahepatic or extrahepatic biliary ductal dilatation. The CBD is normal in caliber, measuring 4 mm in diameter. There is no gallstone. Minimal sludge layers in the dependent portion of the otherwise normal gallbladder. There is no pericholecystic fluid. Normal hepatopetal portal venous flow is demonstrated. There is a small right pleural effusion. IMPRESSION: 1. Minimal gallbladder sludge in an otherwise normal gallbladder. No gallstones. 2. No intra- or extra-hepatic extrahepatic biliary ductal dilatation. 3. Small right pleural effusion. Radiology Report CHEST (PA & LAT) Study Date of [2147-1-22] 11:54 AM [Hospital 93] MEDICAL CONDITION: 81 year old man with s/p cabg and mv ring Final Report One view. Comparison with the previous study done [2147-1-20]. There is interval improvement in pulmonary vascular congestion and small pleural effusions. The heart and mediastinal structures are unchanged. An endotracheal tube, nasogastric tube, and right internal jugular sheath have been removed. Brief Hospital Course: The pt. was admitted [2147-1-9] to [Hospital Ward Name 121] 3 and cardiac surgery was consulted. He had a NSTEMI with a peak troponin of 2.66. The patient and his family were undecided about whether to proceed with surgery and he had a new episode of chest pain and was transferred to the CCU on IV NTG. His creatinine increased to 2.1 and surgery was delayed. On [2147-1-14] he underwent urgent Redo CABGx1(SVG->PDA)/MV repair/IABP placement. He had a VF arrest on induction and went urgently on bypass. His total bypass time was 140 minutes and cross clamp time was 65 minutes. He was transferred to the CVICU on Milrinone, Epi, Levo, Amiodorone, and Propofol. EP saw the patient and recommended discontinuation of Amio and Lido and to overdrive pace him so he was not bradycardic. He was gradually weaned off his drips and had his IABP d/c'd on POD#2. He became oliguric and did not respond to multiple diuretics. Eventually he started making urine when his SBP was greater than 140. His creatinine peaked at 3.9 and then came down fairly quickly. He was extubated on POD #3 and was extremely lethargic. He had copious secretions, but had good O2 sats and was not tachypneic. He was NT suctioned hourly and eventually on the AM of POD#4 he was reintubated. He underwent bronchoscopy and had his secretions evacuated. A culture was sent an grew out staph aureus. He was treated with Zosyn and Vanco and was extubated again on POD#5. He was much more alert and continued to progress and was transferred to the floor on POD#6. His IV antibiotics were d/c'd and he was started on Levaquin. He continued to make progress on the floor. Physical therapy evaluated the patient, and he was deemed a rehab candidate. He was discharged to NE [Hospital1 ] in [Location (un) 701] on POD 12. He remains on coumadin for post-op a-fib. He is to follow-up with Dr [Last Name (STitle) 7772] in 3 weeks Medications on Admission: ASA 325 mg daily Plavix 75 mg daily (Lat dose [2147-1-9]) Imdur 30 mg daily Lisinopril 2.5 mg daily Metoprolol tartate 12.5 mg twice daily MVI daily Lyrica 25 mg twice daily SL NTG prn Colace 100 mg [Hospital1 ] Mylanta prn MOM prn Tylenol prn Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 10 days. 12. warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily at 4 PM: Coumadin for AFib Target INR 2-2.5 check INR daily. 13. warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: [1-26] dose. 14. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: CAD, MR s/p CABG, MVR PMH: s/p CABG in [2126] PCI's CHF Hypertension Dyslipidemia mild aortic regurgitation prostate cancer s/p XRT peripheral neuropathy Chronic kidney disease stage II CVA HOH with bilateral hearing aides Discharge Condition: Alert and oriented x3 nonfocal exam Deconditioned; walks minimal distance with walker and assist Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. 2+ Edema bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [First Name (STitle) ] Phone:[Telephone/Fax (1) 170] [2147-2-20] 1:15 Cardiologist: Dr [Last Name (STitle) 7047] [Telephone/Fax (1) 8725] [2147-2-7] 1:00 Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) 2515] A. [Telephone/Fax (1) 3183] in [4-11] 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 Please arrange for coumadin/INR follow-up on discharge from rehab [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2147-1-26]	[ "584.9", "997.31", "410.71", "041.11", "287.49", "356.9", "V12.54", "424.0", "996.72", "403.90", "414.01", "428.0", "272.4", "414.8", "V10.46", "585.2", "427.5", "427.41", "428.33" ]	icd9cm	[ [ [] ] ]	[ "96.04", "88.56", "39.61", "35.33", "37.22", "96.71", "33.24", "36.11", "37.61", "96.6", "33.22", "99.60" ]	icd9pcs	[ [ [] ] ]	13299, 13371	9618, 11549	333, 648	13642, 13908	4289, 5379	14749, 15514	3297, 3494		11851, 13276	9234, 9595	13392, 13621		11575, 11828		6663, 7998	13932, 14726			5395, 6646						3509, 4270																			270, 295												676, 2914														2936, 3165	3181, 3281
12,039	143,397	9047+55995	Discharge summary	report+addendum	Admission Date: [2192-3-25] Discharge Date: [2192-4-2] Date of Birth: [2112-6-19] Sex: M Service: VSU CHIEF COMPLAINT: Non healing right foot infected ulcers with ischemic gangrene. HISTORY OF PRESENT ILLNESS: This is a 79 year old gentleman with a history of peripheral vascular disease, recently admitted [3-13] for gout and flare of cellulitis of the right foot. The patient also had a history of eschar of the lateral right foot. The patient was admitted for intravenous antibiotics, pre-hydration for arteriogram. The patient's arterial studies done on [2191-3-15] demonstrated an ABI of 0.52 on the right, with significant disease. The patient denies fever, chills, chest pain, shortness of breath, diaphoresis. Denies rest pain. PAST MEDICAL HISTORY: Allergies - Percocet causes delusions. Medications on admission included metformin 1000 mg b.i.d., Lopressor 12.5 mg b.i.d., Coumadin 2.5 mg daily alternating with 5 mg every other day, colchicine 0.6 mg daily, Levaquin 500 mg daily, dicloxacillin 500 mg q.i.d., vitamin B12 monthly, Lipitor 20 mg daily. Past medical history of type 2 diabetes, non insulin dependent. Peripheral vascular disease, coronary artery disease, history of gout, history of hypercholesterolemia, history of hypertension, history of pulmonary embolus. Past surgical history includes appendectomy in [2166], a left lower extremity bypass in [2190] (left SFA to DP with non reversed lesser saphenous vein), coronary artery bypasses in [2189]. Family history is significant for myocardial infarction. Father died at the age of 78. Both his sister and brother have coronary artery disease. The patient denies tobacco, alcohol or drug use. PHYSICAL EXAMINATION: The patient is afebrile, in no acute distress. Heart has a regular rate and rhythm. Lungs are clear to auscultation. Abdominal exam is benign. Carotids are palpable bilaterally, without bruits. The right plantar surface of the right toe is with dry eschar, and there is a dry lateral right foot ulceration. Pulse exam shows palpable femorals bilaterally, 1+. The right popliteal is 1+. The left popliteal is absent. The right dorsalis pedis is monophasic, with a triphasic PT. On the left, the dorsalis pedis is 1+, posterior tibialis is monophasic signal. The graft is palpable, 2+. There is 2+ edema on both lower extremities. HOSPITAL COURSE: The patient was admitted to the vascular service, placed on bedrest, oxacillin. Levofloxacin and Flagyl were instituted for antibiotics. The patient's white count was 7.3, hematocrit 32.6. BUN was 21, creatinine 0.8. Coags were normal. Electrocardiogram was normal sinus rhythm without ischemic changes, and old inferior wall MI unchanged from [2191-3-5]. Chest x-ray was unremarkable. The patient's cultures grew a staph which was oxacillin sensitive. The patient continued on his antibiotics. He was IV hydrated and underwent on [2192-3-26] an arteriogram by Dr. [Last Name (STitle) ] which was a diagnostic study. This revealed abdominal aorta with bilateral single renal arteries which were patent. The right lower extremity had a large, patent common iliac, external iliac and hypogastric arteries. There was no gradient across the iliac after augmentation. The common femoral, profunda femoris and superficial femoral are large, calcified and patent. The popliteal is patent to the tibioperoneal trunk, which occludes. AT is patent for 1 cm, then occludes. The peroneal occludes where it reconstructs at the ankle. The posterior tibialis reconstitutes at the ankle, but is very small and diseased. The dorsalis pedis reconstitutes, but is a very small and diseased vessel. The left lower extremity - the common iliac, external and hypogastric arteries are patent. The patient tolerated the arteriogram. There were no complications. The wound was clean, dry and intact without hematoma. Cardiology was requested to see the patient. They thought he was well beta blocked on his current medical management. Re- start his warfarin postoperatively as soon as it is judicious from the surgical standpoint. Would check his LDL and start him on a higher dose of statins to get an LDL less than 70. They felt that this gentleman was highly active, had a coronary artery bypass graft in [2189]. He was asymptomatic, which would suggest that the grafts are patent and no further cardiac evaluation was indicated. The patient proceeded to surgery on [2192-3-28]. He underwent a right below knee popliteal to dorsalis pedis non-reversed saphenous vein graft with a fibulectomy and exploration of the peroneal artery and angioscopy and valve lysis. The patient tolerated the procedure well and was transferred to the post anesthesia care unit in stable condition. Postoperatively, his hematocrit was 28.6, BUN 10, creatinine 0.9. His lactate was 1.3, his phosphorus was 1.7. He was replenished. He remained hemodynamically stable and was transferred to the VICU for continued monitoring and care. On postoperative day 1, the patient returned to surgery because of change in his graft pulse. An intraoperative arteriogram and exploration was done. There was no graft stenosis or occlusion. The patient was transferred to the post anesthesia care unit in stable condition. He was transfused 2 units of packed red blood cells for an hematocrit of 26. The patient was evaluated by Physical Therapy on postoperative day 4. They felt that he would require rehabilitation prior to being discharged to home. From a cardiac standpoint, the patient has done well, and Cardiology signed off on postoperative day 5. The patient was transferred to the regular nursing floor for continued care. On pulse exam, he had a dopplerable graft pulse. The foot was warm. The foot ulceration was healing. The patient was transferred to rehabilitation for continued care. Discharge medications include metformin 1000 mg b.i.d., colchicine 0.6 mg daily, acetaminophen 325 mg tablets [11-27] every 4-6 hours p.r.n., alrestatin calcium 20 mg daily, hydrocodone and acetaminophen 5/500 1-2 tablets every 4-6 hours p.r.n., Colace 100 mg b.i.d., aspirin 325 mg daily, albuterol actuated aerosol 1-2 puffs every 6 hours, metoprolol 25 mg b.i.d., warfarin 5 mg daily. The patient's INR should be monitored for a goal INR of [12-29]. He should follow up with his primary care physician regarding continuation of INR monitoring and warfarin dosing adjustment. The patient should follow up with Dr. [Last Name (STitle) ] in [11-27] weeks post discharge. DISCHARGE DIAGNOSES: 1. Right foot ischemia with gangrene and non healing ulceration secondary to arterial insufficiency. 2. Postoperative graft pulse change, status post exploration and arteriogram of the right leg on [2192-3-26]. 3. Status post right below knee popliteal to dorsalis pedis bypass graft with non-reversed saphenous vein, angioscopy through the left and exploration of the peroneal artery on [2192-3-28]. 4. Postoperative blood loss anemia, transfused. 5. History of gout, stable. 6. History of coronary artery disease, stable. 7. History of hypertension, controlled. 8. History of type 2 diabetes, non insulin dependent, controlled. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 17755], [MD Number(1) 17756] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2192-4-2] 13:55:23 T: [2192-4-2] 14:41:43 Job#: [Job Number 31281] Name: [Last Name (LF) 5445],[Known firstname ] Unit No: [Numeric Identifier 5446] Admission Date: [2192-3-25] Discharge Date: [2192-4-5] Date of Birth: [2112-6-19] Sex: M Service: SURGERY Allergies: Percocet Attending:[First Name3 (LF) 5447] Addendum: patient remained in the hospital until [2192-4-5] and continued to work with physical thearphy.Patient discharge to home [2192-4-5] stable condition. wound erythema much improved. will continue a total seven day course of dicloxcillin . Day [3-1] at discharge.Followup with Dr. [Last Name (STitle) 4107] in 2 weeks. call for appointment. Continue with bacitracint to toes on rt. foot. Discharge Disposition: Home With Service Facility: [Hospital 136] Homecare [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4108] MD [MD Number(1) 4109] Completed by:[2192-4-5]	[ "V70.7", "285.1", "274.9", "E878.2", "996.74", "707.14", "250.00", "440.24", "401.9", "V58.67", "V58.61", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "38.08", "88.42", "88.48", "86.22", "38.09", "99.04", "77.87", "38.22", "39.29" ]	icd9pcs	[ [ [] ] ]	8270, 8484							6578, 8247						2402, 6557																				1754, 2384										153, 217												246, 781														804, 1731
8,036	139,339	22231	Discharge summary	report	Admission Date: [2137-5-14] Discharge Date: [2137-5-22] Date of Birth: [2097-2-16] Sex: F Service: MEDICINE Allergies: Naproxen / Trazodone / Compazine / Motrin / Toradol Attending:[First Name3 (LF) 3705] Chief Complaint: change in mental status Major Surgical or Invasive Procedure: intubated on [2137-5-14] and extubated on [2137-5-15] with MICU stay from [2137-5-14]->[2137-5-19] History of Present Illness: Patient is a 46 yo woman with h/o Hep C and IVDA who is transfered from OSH, presented to the ED with altered mental status, neck stiffness, and petechial rash. She recieved vanco, ceftriaxone and acyclovir. LP deferred in ED secondary to thrombocytopenia. In ed, she was also given 2L ivf. Patient was recently admitted in [3-6] for headache thought to be either viral meningitis, post lp headache vs. more likely, pain seeking behavior. Past Medical History: 1. Fibroids 2. Chronic Pain 3. Opiate dependence 4. EtOh 5. Agoraphobia 6. Depression 7. Hepatitis C secondary to IVDU per notes, but patient reports due to blood transfusion 8. ?Renal stones 9. Splenomegaly and thrombocytopenia; per prior OMR notes, has been extensively evaluated in the past with viral serologies and BM biopsy 10. ? Bipolar affective disorder. History of psych hospitalization at age 20 following assault, at age 30 during parents separation and in [9-5] after OD attempt Social History: Widowed in [2135]- husband [Name (NI) 57985] w/basal cell carcinoma, heroin abuse- 1bag/day for 2y, but currently denies. occassional etoh, no tobacco. lives w/son, worked in customer relations for [Company 22957]. Family History: Father w/alcoholism Physical Exam: VS: 99.8 BP 184/107-->146/89 P 94 O2 ac 100% 500 14 5 GEN: intubated/sedated HEENT: No JVD, no LAD, OP clear with no thrush. upper back, arms, legs with excoriations. face with mild erythema. LUNGS: CTA B HEART: RRR, no m/r/g ABD: Soft, hypoactive bowel sounds, NT, vertical midline scar, RUQ scar EXTR: No c/c/e NEURO: opens eyes to commands Pertinent Results: Admission Labs: [2137-5-14] 08:25PM WBC-4.3# RBC-3.93* HGB-11.0* HCT-32.2* MCV-82 MCH-28.1 MCHC-34.3 RDW-17.9* [2137-5-14] 08:25PM PLT COUNT-55* [2137-5-14] 08:25PM NEUTS-64.3 LYMPHS-26.8 MONOS-5.9 EOS-2.3 BASOS-0.7 [2137-5-14] 08:25PM PT-16.5* PTT-37.9* INR(PT)-1.5* [2137-5-14] 08:25PM GLUCOSE-109* UREA N-4* CREAT-0.6 SODIUM-140 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-27 ANION GAP-10 [2137-5-14] 08:25PM ALT(SGPT)-16 AST(SGOT)-40 CK(CPK)-174* ALK PHOS-151* AMYLASE-47 TOT BILI-1.0 [2137-5-14] 08:33PM LACTATE-1.3 [2137-5-14] 08:25PM LIPASE-26 [2137-5-14] 08:25PM CK-MB-4 cTropnT-<0.01 [2137-5-14] 08:25PM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-3.9 MAGNESIUM-1.9 . CT Neck [5-14]: 1. No fluid collections or abscesses are identified within the neck. There are no pathologically enlarged lymph nodes. 2. Endotracheal tube cuff appears slightly overdistended, with no adjacent pneumomediastinum. 3. Bilateral hypodense thyroid nodules, with scattered coarse calcifications are likely benign. Thyroid ultrasound could be performed on a nonemergent basis if clinically indicated. . CT Chest/Abd/Pelvis [5-14]: 1. No evidence of pulmonary embolism, as clinically questioned. Enlarged pulmonary artery, compatible with pulmonary arterial hypertension. 2. Bilateral pleural effusions with adjacent airspace disease, likely representing atelectasis. 3. Findings consistent with cirrhosis with associated splenomegaly likely reflecting portal hypertension. . CT Head [5-14]: No intracranial hemorrhage or mass effect. . CXR [5-14]: 1. Recommend pulling the endotracheal tube at least 2 cm back. 2. Increased density of the retrocardiac space could represent atelectasis versus underlying hiatal hernia. Clinical correlation recommended. . CXR [5-16]: Probable worsening of bilateral pleural effusions with new left lower lobe opacity. Given rapidity of onset atelectasis or aspiration pneumonitis is favored over rapid developing pneumonia. . Renal US [5-17]: Unremarkable evaluation of bilateral kidneys without evidence for hydronephrosis, obstructing stone or renal mass. . KUB [5-18]: Ascites with retained oral contrast in the distal colon and rectum. No contrast seen corresponding to renal fossae or course of ureters. . X-ray of Right shoulder ([2137-5-19] FINDINGS: There is no fracture or dislocation. The glenohumeral and acromioclavicular joints are within normal limits. The coracoclavicular interval is appropriate. The regional soft tissues radiographically are unremarkable. The visualized adjacent lung is clear. . IMPRESSION: No radiographic evidence of traumatic bony injury to the shoulder. Please note, not mentioned above, there are very tiny curvilinear opacities in the region of the greater tuberosity which are likely due to calcific tendinitis and are not felt to be due to acute trauma. . ECG [2137-5-19]: sinus at 80, nl intervals and axis, no ST/T wave changes. . Microbiology: Blood cx - ngtd urine cx - negative RPR - pending . Discharge labs: [2137-5-22] 05:15AM BLOOD WBC-2.1* RBC-3.11* Hgb-8.6* Hct-25.5* MCV-82 MCH-27.7 MCHC-33.7 RDW-18.6* Plt Ct-75* [2137-5-22] 05:15AM BLOOD Glucose-94 UreaN-14 Creat-1.6* Na-140 K-3.9 Cl-107 HCO3-26 AnGap-11 [2137-5-22] 05:15AM BLOOD Calcium-8.3* Phos-4.6* Mg-1.6 Brief Hospital Course: Impression/Plan: Pt is a 46 yo woman hep C, splenomegaly & pancytopenia of unclear etiology, depression/anxiety, hx prescription narcotic abuse who p/w acute mental status changes intubated. She was successfully extubated on HD 2 and then developed acute renal failure (likely contrast induced nephropathy). 1. Altered mental status/delirium/possible benzodiazepine overdose - Unclear etiology for this. Toxicology screen at OSH was not done and here only positive for opiates (she was given then in ED)She was initially intubated for airway protection, and successfully extubated on HD#2. Pt was initially thought to have meningitis, though an LP could not be performed. She was initially treated with meningeal dosing abx (vancomycin and ceftriaxone). However, exam did not support meningitis and upon review on OMR records, patient has a history of neck pain (tension headache). Her altered mental status was thought to possibly be toxic metabolic in etiology or hepatic encephalopathy secondary to her underlying cirrhosis (elevated ammonia level on admission). Another concern was TTP in the setting of mental status changes, renal failure, anemia, and thrombocytopenia (see below). However, heme-onc saw pt and felt that this was unlikely secondary to smear. EEG showed nonspecific mild encephalopathy. Lactulose was started po. Panculture was negative for infection. Additionally, question of withdrawing from substances (clonazepam, antispasmotics, other drugs) are more likely as on the day of the call out, pt was found to have bottles of clonipin under her pillows; although she denies taking the pills, she appeared very sedated and the bottles were filled on [2137-5-14] (same day she was admitted to the [Hospital1 18]), prescribed at [Hospital ] Hospital. Called the pharmacy who filled the presciption [Telephone/Fax (3) 57986], unable to read the signature of the prescription as it was a hand written prescription. Called [Hospital ] hospital and on call psychiatrist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (3) 57987]), pt was admitted briefly (1-2 days) for GI symptoms thought to be pancreatitis at [Hospital1 ], and was discharged on clonipin (2mg PO bid) as this was her outpatient medications by one of the interns on the floor. Because of her sedation, benzos and dilaudid were discontinued (she was briefly kept on CIWA scale). Psychiatry evaluated pt, and recommended seroquel 25mg PO tid for agitation and anxiety, and continue haldol prn for agitation. She became more alert and less sedated after above regimen. Physical therapy and occupational therapy worked with the patient, and she did well, and cleared her to go home. Social worker were involved throughout her stay to provide support and resources for her substance abuses. 2. Fever: Initially had fever on admission to ICU. Likely source thought to be a new LLL pna (aspiration vs. hospital acquired). Ceftriaxone, vancomycin, and flagyl were started but d/c'd on HD #5 as CXR improved and pneumonitis was posibble. Pancultures were negative. Although she has ascites, she never had abdominal pain or asterixis suggesting spontanous bacterial peritonitis. Right shoulder xray done for pain was negative for acute fractures. 3. Non-oliguric Acute renal failure- Creatinine rose to peak of 4.1 from 0.7. Seen by nephrology who thought it to be consistent with a contrast induced nephropathy (ATN) given dates. Creatinine steadily decreased to 1.6 at the time of discharge. Cryoglobulin negative. ATN from dye is most likely. 4. s/p intubation: intubated for AMS and for ease of obtaining imaging studies. Extubated on HD #2. 5. Pancytopenia: Etiology was unclear and patient reports having a bone marrow biopsy with "inconclusive results". HIV negative in [2137-2-28]. Baseline platelets are around 55K. She had a brief platelet drop from her baseline, hem/onc was consulted for concerns of TTP (given that this episode occured around same time of her ARF). Peripheral smear on heme review with no evidence of hemolysis. Fibrinogen, FDP, and DAT negative per heme recommendations. Pt received vitamin K x 3 doses po. Her CBC remained stable around her baseline after that. 6. Neck pain - thought to be chronic as above; Muscle relaxants were d/c'd secondary to patients mental status and over sedation. Dilaudid was initially continued in the MICU, but was discontinued on the floor as pt was seen to hiding bottles of clonipin under pillow and appear extremently sedated on the day of the transfer to the floor. Her mental status improved after stopping sedating medications (narcotics, benzo, muscle relaxants, etc). 7. [Name (NI) 1622] pt reports pain all over and non-localizing except for neck pain as above. All workup were negative. More likely pain seeking behavior. Secondary to severe sedation, her muscle relaxant and dilaudid was d/c'ed. She was kept on tylenol for pain which she tolerated well, although she complained of pain, but after reassurance and for her safety (not wanting her to be oversedated), she didn't get further narcotics. 8. Chronic Hepatitis C- Not previously worked-up. No evidence of decompensation. Abdominal US in findings had evidence of cirrhosis, no portal vein thrombosis or clot. AFP is 4.9. We started lactulose as above. 9. Substance abuse (ETOH, opiates) - was on a CIWA which was d/cd. Continued thiamine and folate. [Last Name ] problem #1 above as pt was found to hide her clonipin bottles under her pillows, and all sedative meds were D/C'ed given severe sedation. Psych recommended seroquel 25mg PO tid for agitation and anxiety w/ haldo prn. She tolerated that regimen well. Medications on Admission: on recent d/c in [Month (only) ]: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY 2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Tizanidine 2 mg Capsule Sig: One (1) Capsule PO at bedtime. Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for titrate for [2-2] BMs per day. Disp:1 bottle Refills:0 4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation and anxiety for 2 weeks. Disp:42 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: altered mental status (improved, extensive work up negative, and most likely from sedative medications) pancytopenia (stable) acute renal failure from IV contrast (improving) radiolographic evidence of cirrhosis Discharge Condition: afebrile, vital sign stable, tolerating PO, and ambulating Discharge Instructions: You were admitted for altered mental status, and extensive workup for infectious causes were negative. EEG is negative for seizures. You mental status has improved after you were taken off a lot of the sedation medications, including clonopin or other benzodiazepam, dilaudid, muscle relaxant. Psychiatry team evaluated you inpatient, and recommended that instead of taking benzodiazepam (clonopin) for agitation and anxiety, try seroquel (less sedating) as needed for your anxiety, which you were given a presciption. Please follow up with your PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] (see appointment time below) regarding any adjustment of your medications from now on, as it is very important to coordinate all of your medical care in one place. . Please take your medications as prescribed. Do not exceed 2grams of tylenol every day for control of your pain. Do not take any NSAIDS (including ibuprofen, motrin, etc.) until your kidney function is close to your baseline. . Call 911 or go to the nearest emergency room if you have fever>101, chills, chest pain, shortness of breath, severe nausea, vomiting, abdominal pain, or diarrhea, or any other symptoms that are concerning to you. Followup Instructions: Please follow up with your PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 9251], on [2137-6-12] at 2:50pm (address: [Last Name (NamePattern1) 14305]). Completed by:[2137-5-22]	[ "486", "292.81", "E947.8", "E937.9", "304.01", "571.5", "518.0", "070.54", "287.5", "584.9", "311" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	12159, 12165	5465, 11194	336, 453	12421, 12482	2108, 2108	13791, 14061	1708, 1729		11637, 12136		12186, 12400		11220, 11614			12506, 13768			5168, 5442						1744, 2089																			273, 298												481, 929					2125, 5151									951, 1448	1464, 1692
57,579	117,176	38361	Discharge summary	report	Admission Date: [2178-6-11] Discharge Date: [2178-6-17] Date of Birth: [2154-12-19] Sex: F Service: MEDICINE Allergies: Dilaudid Attending:[Last Name (NamePattern1) 1136] Chief Complaint: chest pain, shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 23F HgSC disease who was recently admitted to the [Hospital 18] medical service [Date range (1) 29431]/10 with pain crisis presented to the ED with 1 day of shortness of breath and right-sided pleuritic chest pain. Had felt better after recent hospitalization until the day prior to this presentation when she developed progressive shortness of breath and sharp pleuritic right-sided chest pain that radiates "everywhere" and occurred at rest. She reports a brief episode of lightheadedness this morning and a productive cough (cannot characterize sputum) but denies fever, chills, diaphoresis, upper respiratory symptoms, palpitations, nausea, vomiting, diarrhea, abdominal pain, leg swelling or pain. No sick contacts or recent extended periods of immobilization (was treated with SQ heparin during her prior hospitalization). She does not identify a particular trigger for sickle crises. In the ED, initial V/S 97.2 88 109/80 14 98%RA. WBC# 14.2 with 67%PMN, Hct 27% MCV 83, retic 10.5, U/A/UCG neg. EKG unchanged. CXR showed possible bibasilar opacities. CTA (prelim) was suboptimal but did not show central or subsegmental PE but did show bibasilar opacities L>R. Given levoflox 750 mg IV, morphine IV, zofran IV, NS 1L. Vital signs prior to transfer to the medical floor were 98.1 88 116/80 16 98%RA. On the floor, her initial O2sat was in the 70s. Placed on NRB, O2sat up to 88% initially then 100% - ABG on 100%NRB 7.33/51/102 lactate 0.6. Transferred to ICU for further management. Upon arrival, she reports no significant improvement in persistent right-sided chest pain (rates [12-4]) and dyspnea. Additional history obtained as stated. Past Medical History: Hemoglobin SC disease; baseline white blood cell count ~13K, hematocrit 27-29 Social History: Recent graduate of [Doctor Last Name ] [Location (un) ]. No tobacco/ETOH/illicits. Family History: Aunt died of complicated of SSA. No known premature CAD or VTE Physical Exam: Vitals: T 98.1 HR 91 BP 119/53 RR 28 O2sat 100%NRB General: Awake, alert, splinting but no accessory muscle use, speaking in full sentences HEENT: Sclera anicteric, dry MM Neck: Supple, no JVD or LAD Lungs: Bibasilar rales clear with coughing, inspiratory effort limited due to pain but no wheeze or rhonchi CV: reg rate nl S1S2 no m/r/g Abdomen: Soft NTND normoactive BS Ext: Warm, dry, full distal pulses no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [2178-6-10] WBC 14.2 / hct 27 / Plt 555 Retic Count 10.5 DISCHARGE LABS: [2178-6-17] WBC 15.5 / Hct 28.7 / Plt 482 Na 137 / K 4.4 / Cl 101 / CO2 26 / BUN 7 / Cr .8 / BG 81 Ca 9.3 / Mg 1.7 / Phos 4.2 MICROBIOLOGY: [2178-6-11] Urine Legionella negative [2178-6-11] Blood Cx x 2 negative [2178-6-11] Rapid respiratory viral antigen panel negative STUDIES: [2178-6-11] CXR - Bibasilar atelectasis, pneumonia, or acute chest syndrome due to sickle cell anemia. [2178-6-11] CTA Chest - 1. No central PE and probably no subsegmental PE. 2. Bibasilar atelectasis, left greater than right is consistent with acute chest syndrome in the appropriate clinical context. 3. The visualized spleen is small consistent with autosplenectomy of sickle cell disease. [2178-6-15] CXR - Slight interval improvement of left lower lung consolidation and effusion as well as improved aeration of right lower lung. Brief Hospital Course: 23yo female with hemoglobin SC disease was admitted with acute chest syndrome with pneumonia. She was started on broad spectrum antibiotics initially with vancomycin, zosyn, and levofloxacin and required an ICU admission. Her symptoms gradually improved and her antibiotics were tapered to levofloxacin alone with continued improvement in her symptoms. She completed a 7 day course of antibiotics during her hospitalization and was discharged with PCP [Name9 (PRE) 702] within 3 days of discharge. Medications on Admission: Folate 1 mg daily Discharge Medications: 1. FoLIC Acid 5 mg PO/NG DAILY 2. Morphine Sulfate IR 15 mg PO Q6H:PRN pain This medication can make you drowsy. Do not drive or use heavy machinery while taking this medication. Disp #20 Dose(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Acute Chest Syndrome 2. Sickle Cell Disease 3. 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 with pain due to your sickle cell disease and pneumonia. Your symptoms improved with antibiotics and pain medications. Your fatigue and pain should continue to slowly improve as you continue to recover at home. Followup Instructions: Please follow-up with your primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2178-6-19] at 8:50am.	[ "486", "780.61", "282.64", "517.3" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	4542, 4548	3738, 4241	310, 317	4671, 4671	2770, 2770	5091, 5274	2232, 2296		4309, 4519		4569, 4569		4267, 4286			4822, 5068			2864, 3715						2311, 2751																			239, 272												345, 2007					2786, 2848	4588, 4650		4686, 4798						2029, 2108	2124, 2216
15,351	176,290	23069	Discharge summary	report	Admission Date: [2177-6-7] Discharge Date: [2177-6-17] Date of Birth: [2103-1-20] Sex: F Service: CARDIOTHORACIC Allergies: Ativan Attending:[First Name3 (LF) 2969] Chief Complaint: Transfer from OSH w/ c/o increasing SOB and rapid Afib- found to have pericardial effusion -admitted for management /pericardial window. Major Surgical or Invasive Procedure: pericardial window [6-9], intubated [6-10], extubated [6-13]. History of Present Illness: : Ms. [Known lastname ] is a 74-year-old patient treated by Dr. [First Name4 (NamePattern1) 951] [Last Name (NamePattern1) 952] in the past, where she was found to have a right hilar carcinoma likely arising in the middle lobe. Evaluation revealed pleural carcinomatosis rendering her stage T4 (3B). She underwent talc pleurodesis and has been treated with systemic chemotherapy. She was transferred emergently from [Hospital3 ] over the weekend with dyspnea on exertion, shortness of breath, and new atrial fibrillation. She was found to have a new pericardial effusion which progressed to hemodynamic significance requiring pericardiocentesis. A pericardial window was planned for management. Past Medical History: Stage IV lung cancer ([11-23]) s/p TALC and chemo, htn, hyperlipid, COPD, CAD, s/p L CEA Social History: Lives w/ sister- [Name (NI) ] [Name (NI) 59451] 1-[Telephone/Fax (1) 59452]. Has home O2 and home hospice prior to this admit. Former smoker -1pk q 2 weeks -quit [2172]. no Etoh. Family History: Mother CVA, Sister Cervical Ca, Physical Exam: VS: 98.4, 108(irreg), 138/84, 27. 96% on 5L. General: Alert, SOB on 5 liter O2 NP, pleasant and [Doctor Last Name ]. Lungs: decrease BS on right base, occas rhonchi Heart: Irreg, irreg Abd: soft, ND, Right tenderness -no [Doctor Last Name ] sign. remanider of abd exam w/o tenderness, rebound, or guarding w/ +BS. Extrem: no C/C/E Neuro A+OX3 Pertinent Results: RENAL U.S. PORT [2177-6-11] 8:20 AM FINDINGS: The kidneys are normal in contour and echogenicity with no evidence of hydronephrosis, masses, or stones. The right kidney measures 11.5 cm and the left kidney measures 12 cm. The bladder was emptied during the study. There is a small amount of ascites and gallstones are noted. Cardiology Report ECHO Study Date of [2177-6-10] :Conclusions: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are grossly normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. [2177-6-9] [-4/2337] PERICARDIAL FLUID :POSITIVE FOR MALIGNANT CELLS consistent with adenocarcinoma. LIVER OR GALLBLADDER US (SINGLE ORGAN) [2177-6-8] 12:13 AM:Transabdominal ultrasound examination of the right upper quadrant was performed. There is a 1.8 cm mobile gallstone. There is gallbladder wall thickening and a small amount of pericholecystic fluid. The common duct is not dilated and measures 3 mm. There is no intrahepatic biliary ductal dilatation. Limited images of the pancreas are grossly unremarkable. IMPRESSION: Findings worrisome for acute cholecystitis. If indicated, HIDA scan may be performed for further evaluation. Brief Hospital Course: Patient admitted to BICMC CCU [2177-6-7] from [Hospital 1562] HOspital after present to ED w/worsening shortness of breath, found to be in Afib@150. Echo showed ef 70%, moderate pericardial effusion, trace MR, mild pulm htn. Pt transferred for further management. Pt denied f/c, CP, SOB, abd pain, constipation, diarrhea. [2177-6-8]- HD#1--Cardiology and Surgery consult obtained, chest CT, CXRY, RUQ u/s to r/o cholycystitis done. HIDA scan scheduled Patient managed on diltiazem gtt, vanco and zosyn after pan culture, ivf. HD#2-12am- Increased SOB and confusion, ? ativan. Echo done STAT> partial collapse of RA, partial limited contraction of RV c/w early tamponade. Pericardialcentesis and drainage of 600cc done by Cardiology w/ local. Plan for pericardial window in am. Dilt gtt cont for Afib, digoxin load, autodiuresing w/ lytes repleated, vanco and zosyn. Left thoracotomy and pericardial window done; clot in atrial appendage> heparin to start. Chest tube and JP drain in place. Intubated, PA line placed, u/o low, somulent, CT drainage 170. Post-op admitted to SICU. HD#3/POD#1- Somulence, toradol and narcan given. Morphine, dilaudid, haldol d/c. Head CT done, then Heparin started @800/hr- goal PTT50-60. Diuresis w/ lasix. Neo started for MAP >60; cardiac enzymes and troponin neg, JP drain d/c; CPAP trial done; Renal consult done, renal u/s for increased Cr 2.5. POD#2- INtubated and sedated on CPAP; afib cont; wean pressor/NEO; zosyn and vanco d/c, levofloxacin started for UTI; good u/o- rnal u/s normal; TF started and held for residuals >300cc. POD#3- Family meeting, planned extubation after wean, tolerated well. Patient DNR/DNI. Plan for discharge to home w/ Hospice when stable. Planning started. Central line change, PA line d/c, triple lumen changed over wire for Neo. POD#4- Neo, dilt d/c; lopressor 25 [Hospital1 ]; CT to water seal. Transfer to floor, with some confusion- 1:1 sitter for safety of IV and CT. A&Ox2, OOB w/ assist. POD#5- Patient doing well, pain controlled, good po intake, ambulating. CT d/c, foley d/c, CXRAY s/p CT d/c wnl, no ptx.HR 100-12O afib, BP stable. Discharge planning for hospice cont. Plan for d/c in AM. POD#6- Central line d/c w/o complication. Patient ready for discharge to home w/ Hospice. Discharge instructions given and reviewed with patient and family by RN. Medications on Admission: Zoloft 50', Lipitor 40', Inderal 80' Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours). 9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:20 Tablet(s) Refills:0 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 15. Lopressor 50 mg Tablet Sig: [12-22] Tablet PO twice a day. Disp:30 Tablet(s) Refills:2 16. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain. Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Stage IV Non small cell lung cancer. Pericardial effusion-s/p pericardial window Discharge Condition: good Discharge Instructions: Call Dr.[Name (NI) 1816] office for: fever, chills, chest pain, or shortness of breath. [Telephone/Fax (1) 170]. YOu may resume your activity as you tolerate and is comfortable. No driving for 2 weeks. YOu may take motrin or tylenol or codeine for any pain or discomfort you might have. Refer to medication list. Followup Instructions: Call Dr.[Name (NI) 1816] office for a follow up appointment in [1-23] weeks. [Telephone/Fax (1) 170]. Completed by:[2177-6-17]	[ "496", "272.4", "401.9", "599.0", "197.2", "198.89", "427.31", "162.4" ]	icd9cm	[ [ [] ] ]	[ "96.71", "33.22", "96.6", "37.0", "96.04", "37.12" ]	icd9pcs	[ [ [] ] ]	7786, 7837	3768, 6118	409, 485	7962, 7968	1990, 3745	8338, 8483	1570, 1603		6205, 7763		7858, 7941		6144, 6182			7992, 8315									1618, 1971																			233, 371												514, 1226														1248, 1342	1358, 1554
76,835	126,620	14062	Discharge summary	report	Admission Date: [2172-6-29] Discharge Date: [2172-7-4] Date of Birth: [2097-10-28] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Increasing episodes of heart failure Major Surgical or Invasive Procedure: [2172-6-30] Redo sternotomy, Coronary artery bypass graft x2 (saphenous vein graft > RAMUS, saphenous vein graft > posterior descending artery) History of Present Illness: 74 year old gentleman with complex past medical history and multiple comorbidities who underwent coronary artery bypass surgery in [2143]. He suffered a reinfarction in [2155] and ICD placement for a ventricular fibrillation arrest. More recently he has been having multiple episodes of heart failure, a pulseless electrical activity arrest following anesthesia and recently suffered a myocardial infarction on [2172-4-29] following surgery to removed a squamous cell skin cancer from his left temporal region. He was admitted to [Hospital3 2576] [Hospital3 ] where he underwent a recatheterization revealing native left main and three vessel disease along with two of three vein grafts occluded. His vein graft to the left anterior descending artery was patent. Given that he needs further surgery with regards to his left temporal squamous cell skin cancer, he has been referred for evaluation for a redo CABG prior to any further surgical procedures. It is felt that he is rather high risk to undergo general anesthesia for any further surgery without his coronary disease first being addressed. Given the severity of his disease and complexity of his situation, he has been referred to Dr. [Last Name (STitle) ] for further evalutation. He is admitted today for further pre-op workup and heparin bridge. Last dose of coumadin was Wednesday, [2172-6-24]. Past Medical History: - Coronary artery disease - Hyperlipidemia - Myocardial infarction x3 ([2143], [2155], [2172]) - Hypertension - Urosepsis - PEA Arrest - Pneumonia - Respiratory failure following renal stenting - Ventricular arrythmias/Cardiac arrest - Atrial fibrillation - Rectal Cancer - Skin Cancer requiring resection and radiation (SCC) - Left occipital region. Needs further surgery and skin grafting. - Urinary tract infection - Congestive heart failure - Peripheral vascular disease - Nephrolithiasis - Episode of acute kidney injury following renal stenting - Colon cancer - s/p CABGx3 (SVG->LAD, Diag, RCA) in [2143] [Hospital6 41942] - s/p St. [Male First Name (un) 923] ICD placed in [2155] for VT arrest, only prior discharge in [2164] also for AF with RVR, device upgraded in [2158] and again in [2163] - Lithotripsy - left ureteral stent placement and removal of left nephrostomy tube - Fem [Doctor Last Name ] bypass in [2147] - Small bowel resection in [2155] Colon cancer Social History: Lives with: Wife in [Name2 (NI) 1468] Occupation: Retired Tobacco: 30pack years, quit in [2143]. ETOH: None Family History: non-contributory Physical Exam: Pulse: 53 SR Resp: 16 O2 sat: 99% B/P Right: 156/84 Left: Height: 68" Weight: 172 General: WDWN in NAD Skin: Warm, Dry, intact. Left upper chest AICD/PPM. Well healed sternotomy, well healed mid-line abdominal incision left occipital region- large surgical site with foam dressing HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP moist without lesions, +dentures Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR, II/VI systolic murmur at Left sternal border Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema: right- trace left- 1+ Varicosities: Left GSV harvested by open technique. Scar well healed. Right appears suitable. Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:NP Left:NP PT [Name (NI) 167]:1+ Left:NP Radial Right:2+ Left:2+ Carotid Bruit + bilateral bruits vs. transmitted cardiac murmur Brief Hospital Course: Mr. [Known lastname 25268] was admitted preoperatively for evaluation and on [6-30] was brought to the operating room for redo sternotomy, coronary artery bypass graft surgery. Please see the operative report for further details. He received Cefazolin for perioperative antibiotics and was transferred to the intensive care unit for post operative management. That evening he was weaned from sedation, awoke neurologically intact and was extubated without complications. His chest tubes and epicardial wires were removed. Coumadin was started for atrial fibrillation. By post operative day #4 he was discharged to home. All follow-up appointments were advised. Medications on Admission: Simvastatin 80mg daily *Coumadin 2mg daily* (LD [2172-6-24]) Metoprolol XL 25mg daily ?dose Lisinopril 2.5mg daily Fluorouracil 5% cream Xalatan 0.005% daily 1 gtt OU at bedtime Brimonidine 0.2% daily 1gtt OU Twice daily Amiodarone 200mg daily Lasix 20mg daily Nitroglycerin Imdur 30mg daily Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. 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 6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 10. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day: dose to be increased once amiodarone d/c'd. Disp:30 Tablet(s) Refills:2 11. fluorouracil Topical 12. Coumadin 1 mg Tablet Sig: as directed for afib Tablet PO once a day: INR goal 2.0-2.5 for Afib. Disp:60 Tablet(s) Refills:2 13. Outpatient Lab Work INR goal 2.0-2.5. First draw on [2172-7-6] with results to Dr. [Name (NI) 41943] office at [Hospital1 ] with attention to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 41944]. Fax ([Telephone/Fax (1) 41945]. Plan confirmed with [Doctor First Name 3742] on [7-3]. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Coronary artery disease s/p cabg Chronic systolic heart failure Hyperlipidemia Myocardial infarction Hypertension Urosepsis PEA Arrest Pneumonia Respiratory failure following renal stenting Ventricular arrythmias/Cardiac arrest Atrial fibrillation Rectal Cancer Skin Cancer Urinary tract infection Peripheral vascular disease Nephrolithiasis Colon cancer Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage. Edema 2+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [Last Name (STitle) ] on [7-23] at 1:45pm in the [Hospital ] medical office building [Hospital Unit Name ] [Telephone/Fax (1) 170] Cardiologist: Dr [Last Name (STitle) 6512] on [7-6] on 10:30pm Wound check on Wednesday [7-8] on [Hospital Ward Name ] 2A Please call to schedule appointments with your Primary Care Dr [Last Name (STitle) ] in [4-28] weeks INR goal for afib 2-2.5 First draw on [2172-7-5] with results to Dr.[Name (NI) 41946] office at [Hospital1 ] with attention to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 41944]. Fax ([Telephone/Fax (1) 41945]. Plan confirmed with [Doctor First Name 3742] on [7-3]. 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:[2172-7-4]	[ "428.0", "414.01", "428.22", "401.9", "173.4", "412", "443.9", "414.05", "V10.05", "V45.02" ]	icd9cm	[ [ [] ] ]	[ "39.61", "38.97", "36.12" ]	icd9pcs	[ [ [] ] ]	6795, 6852	4155, 4832	348, 498	7253, 7478		8319, 9283	3117, 3135		5184, 6772		6873, 7230		4858, 5161			7502, 8296									3150, 4132																			271, 310												526, 1916														1938, 2967	2983, 3101
4,397	189,024	53692+59543	Discharge summary	report+addendum	Admission Date: [2156-9-29] Discharge Date: [2156-10-22] Date of Birth: [2098-6-10] Sex: F Service: MED Allergies: Iodine; Iodine Containing / Augmentin / Imipenem / Bactrim Ds / Gentamicin Attending:[First Name3 (LF) 1055] Chief Complaint: Fatigue and Malaise Major Surgical or Invasive Procedure: Swan-[Last Name (un) 26645] Catheterization, Intubation and Cardiac Catheterization. History of Present Illness: 58 year old morbidly obese female with a history of multiple medical problems including coronary artery disease (s/p stent in proximal&ostial LAD), peripheral vascular disease, type II diabetes mellitus who presented to the emergency department with four days of fatigue, malaise and buttock pain from her skilled nursing facility. In the emergency department, she was afebrile but had systolic pressures in the 70's to 80's. Her chest x-ray was clear. She was given six liters of normal saline and eventually was started on vanco/levaquin/flagul on the suspicion of sepsis. After receiving fluids and being transferred to the floor, she was found to have O2 sats in the 70's. Noninvasive BiPAP was tried without improvement and she eventually required intubation. Initial ABG was 7.08/67/160. Her chest xray showed pulmonary edema. A total of 200mg of IV lasix was given with little effect. At the time, CK was 592, MB of 90, and MBI of 15 but because of her presumed sepsis, she was not a cath candidate. Past Medical History: DM2, CRI baseline Cr 1.7-2.2, morbid obesity, CAD s/p PTCA, [2-19] MI, PVD c/v chronic venous stasis ulcers, HTN, CVA [2150], PAF, [Female First Name (un) 564] skin infx, ACD, depression, bacteremia, MRSA, VRE, Cdiff PSHx: Lithotripsy, renal bx, deviated septum, debridement leg ulcers [9-17] by [Doctor Last Name ], left leg ulcer debridement w/wound vac placement [2156-8-10] by Dr. [Last Name (STitle) 1391] Social History: Pt is single, she receives support from her friend and her cousin. She has never smoked. She drinks ETOH rarely. No H/O drugs. Family History: Her sister had breast cancer. Physical Exam: VS T 97.2 BP 86/30 HR 115 RR 33 SpO2 90% intubated Vent: AC 450/23/10/1.0 Gen: arousable, morbidly obese F intubated. HEENT: PERRL, anicteric, MMM CV: RRR no m/r/g, distant s1/s2 Pul: coarse bs but clear anteriorly Abd: obese, non-tender Ext: RLE latereal linear ulcers, LLE w/ 8-10cm ulcer with yellow/pink granulation tissue, oozing. Neuro: responsive to voice/pain, moves all four ext Pertinent Results: [2156-9-29] 09:02PM BLOOD freeCa-1.17 [2156-9-29] 10:59PM BLOOD freeCa-1.11* [2156-9-30] 08:33AM BLOOD freeCa-1.01* [2156-10-1] 03:45AM BLOOD freeCa-1.00* [2156-9-29] 10:59PM BLOOD O2 Sat-98 COHgb-0 MetHgb-1 [2156-9-30] 06:46PM BLOOD O2 Sat-81 [2156-9-29] 12:25PM BLOOD Lactate-2.3* [2156-9-29] 07:32PM BLOOD Lactate-1.5 [2156-9-29] 08:12PM BLOOD Lactate-1.4 [2156-9-29] 09:02PM BLOOD Glucose-146* Lactate-2.0 Na-141 K-4.0 Cl-110 [2156-9-29] 10:59PM BLOOD Na-141 K-4.0 Cl-111 [2156-9-30] 02:34AM BLOOD Lactate-2.8* [2156-9-30] 08:33AM BLOOD Lactate-2.9* [2156-9-29] 12:25PM BLOOD Comment-GREEN TOP [2156-9-29] 10:59PM BLOOD Type-ART pO2-160* pCO2-67* pH-7.08* calHCO3-21 Base XS--11 -ASSIST/CON Intubat-INTUBATED [2156-9-30] 08:33AM BLOOD Type-ART Temp-38.1 Rates-28/ Tidal V-500 PEEP-10 O2-60 pO2-165* pCO2-29* pH-7.39 calHCO3-18* Base XS--5 Intubat-INTUBATED Vent-CONTROLLED [2156-10-1] 10:30AM BLOOD Type-ART Temp-36.7 Rates-/13 PEEP-5 O2-40 pO2-107* pCO2-46* pH-7.35 calHCO3-26 Base XS-0 Intubat-INTUBATED Vent-SPONTANEOU [2156-9-30] 10:38AM BLOOD Vanco-8.7* [2156-10-6] 11:27PM BLOOD Vanco-30.6 [2156-10-9] 07:34PM BLOOD Vanco-16.1* [2156-9-29] 11:21PM BLOOD Cortsol-29.5* [2156-10-13] 05:57AM BLOOD TSH-0.43 [2156-10-4] 04:06AM BLOOD Triglyc-153* HDL-31 CHOL/HD-2.7 LDLcalc-21 [2156-10-8] 11:05AM BLOOD Triglyc-111 HDL-41 CHOL/HD-2.1 LDLcalc-25 [2156-10-7] 03:22PM BLOOD %HbA1c-5.9* [2156-10-4] 04:06AM BLOOD Ferritn-64 [2156-10-8] 11:05AM BLOOD VitB12-724 [2156-10-14] 05:19AM BLOOD Ferritn-353* [2156-9-29] 12:27PM BLOOD Albumin-3.4 [2156-10-5] 05:02AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.4* [2156-10-15] 10:50AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8 [2156-10-20] 06:52AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.9 [2156-9-29] 08:47PM BLOOD CK-MB-90* MB Indx-15.2* cTropnT-0.73* [2156-9-30] 10:38AM BLOOD CK-MB-119* MB Indx-16.4* cTropnT-1.46* [2156-10-7] 11:48PM BLOOD CK-MB-NotDone cTropnT-1.16* [2156-10-20] 10:14PM BLOOD CK-MB-NotDone [2156-10-21] 04:47AM BLOOD CK-MB-NotDone cTropnT-0.03* [2156-9-29] 12:27PM BLOOD ALT-7 AST-22 AlkPhos-127* Amylase-33 TotBili-0.4 [2156-9-30] 05:26AM BLOOD ALT-10 AST-40 CK(CPK)-636* AlkPhos-118* TotBili-0.4 [2156-10-2] 03:54AM BLOOD ALT-10 AST-24 AlkPhos-95 TotBili-0.4 [2156-10-10] 05:40AM BLOOD CK(CPK)-85 [2156-10-20] 10:14PM BLOOD CK(CPK)-28 [2156-10-21] 04:47AM BLOOD CK(CPK)-30 [2156-9-29] 12:27PM BLOOD Glucose-102 UreaN-30* Creat-2.0* Na-143 K-4.9 Cl-106 HCO3-21* AnGap-21* [2156-9-30] 05:26AM BLOOD Glucose-149* UreaN-28* Creat-1.9* Na-145 K-3.5 Cl-110* HCO3-17* AnGap-22* [2156-10-1] 03:02PM BLOOD Glucose-121* UreaN-22* Creat-1.7* Na-143 K-3.9 Cl-109* HCO3-28 AnGap-10 [2156-10-2] 06:18PM BLOOD Glucose-118* UreaN-17 Creat-1.6* Na-144 K-4.2 Cl-108 HCO3-28 AnGap-12 [2156-10-8] 11:05AM BLOOD Glucose-130* UreaN-19 Creat-2.0* Na-142 K-4.7 Cl-103 HCO3-26 AnGap-18 [2156-10-15] 10:50AM BLOOD Glucose-106* UreaN-28* Creat-2.2* Na-144 K-5.0 Cl-108 HCO3-27 AnGap-14 [2156-10-19] 05:25AM BLOOD Glucose-95 UreaN-26* Creat-1.9* Na-144 K-4.5 Cl-108 HCO3-27 AnGap-14 [2156-10-22] 05:26AM BLOOD Glucose-60* UreaN-28* Creat-2.2* Na-140 K-4.0 Cl-100 HCO3-29 AnGap-15 [2156-10-1] 03:02PM BLOOD Ret Aut-2.0 [2156-9-29] 11:21PM BLOOD Fibrino-521# [2156-9-29] 12:27PM BLOOD Plt Ct-282 [2156-9-30] 05:26AM BLOOD PT-15.4 PTT-101.4* INR(PT)-1.5 [2156-9-29] 11:21PM BLOOD Plt Ct-353# [2156-10-1] 03:30AM BLOOD PT-14.3* PTT-60.1* INR(PT)-1.3 [2156-10-4] 04:06AM BLOOD PT-14.1* PTT-28.9 INR(PT)-1.3 [2156-10-7] 05:02AM BLOOD PT-14.1* PTT-29.4 INR(PT)-1.3 [2156-10-8] 11:05AM BLOOD PT-16.1* PTT-140.1* INR(PT)-1.6 [2156-10-10] 05:40AM BLOOD Plt Ct-239 [2156-10-16] 05:21AM BLOOD Plt Ct-251 [2156-10-17] 06:00AM BLOOD PT-13.7* PTT-41.9* INR(PT)-1.2 [2156-10-18] 05:30AM BLOOD PT-13.8* PTT-39.5* INR(PT)-1.2 [2156-10-18] 09:48AM BLOOD PT-13.6 PTT-36.6* INR(PT)-1.2 [2156-10-20] 06:52AM BLOOD PT-14.0* PTT-39.2* INR(PT)-1.2 [2156-10-20] 10:14PM BLOOD Plt Ct-228 [2156-9-29] 12:27PM BLOOD Neuts-73.7* Lymphs-17.0* Monos-6.1 Eos-2.7 Baso-0.5 [2156-10-2] 03:54AM BLOOD Neuts-67.4 Lymphs-20.8 Monos-4.8 Eos-6.6* Baso-0.3 [2156-10-8] 11:05AM BLOOD Neuts-78.5* Lymphs-13.8* Monos-2.7 Eos-4.6* Baso-0.4 [2156-9-29] 12:27PM BLOOD WBC-7.2 RBC-3.35* Hgb-9.9* Hct-30.3* MCV-90 MCH-29.4 MCHC-32.5 RDW-14.1 Plt Ct-282 [2156-9-30] 05:26AM BLOOD WBC-20.0* RBC-3.28* Hgb-9.7* Hct-30.4* MCV-93 MCH-29.5 MCHC-31.8 RDW-15.0 Plt Ct-321 [2156-10-1] 03:02PM BLOOD WBC-7.9 RBC-3.41* Hgb-9.9* Hct-30.3* MCV-89 MCH-29.1 MCHC-32.7 RDW-15.6* Plt Ct-257 [2156-10-3] 05:24AM BLOOD WBC-6.6 RBC-3.35* Hgb-9.9* Hct-30.7* MCV-92 MCH-29.5 MCHC-32.1 RDW-14.8 Plt Ct-271 [2156-10-10] 05:40AM BLOOD WBC-9.1 RBC-3.53* Hgb-10.5* Hct-32.2* MCV-91 MCH-29.7 MCHC-32.6 RDW-14.8 Plt Ct-239 [2156-10-16] 05:21AM BLOOD WBC-8.0 RBC-3.28* Hgb-9.7* Hct-29.9* MCV-91 MCH-29.6 MCHC-32.6 RDW-14.7 Plt Ct-251 [2156-10-20] 06:52AM BLOOD WBC-7.7 RBC-3.27* Hgb-9.6* Hct-30.2* MCV-92 MCH-29.5 MCHC-31.9 RDW-15.9* Plt Ct-229 [2156-10-22] 05:26AM BLOOD WBC-9.9 RBC-3.42* Hgb-10.1* Hct-31.1* MCV-91 MCH-29.7 MCHC-32.6 RDW-15.9* Plt Ct-262 Brief Hospital Course: Ms [Known lastname 43134] was admitted to [Hospital1 18] [Hospital Unit Name 153] with Septic Shock and no identifiable infectious source. In the setting of sepsis she had a NSTEMI. The patient then stablized, was transferred to the [Doctor Last Name ] [Doctor Last Name 22583] Medicine service and had a diagnostic cardiac catheterization revealing 2VD including LMCA. She then underwent successful stenting of LMCA/LAD/LCX. 1. Sepsis: Upon admission, the patient had severe maliase, mild confusion and was determinted to be in septic shock. Her presumed source was lower extremity ulcerations and cellulitis secondary to chronic peripheral vascular disease. She intially required maximal fluid resuciation, vasopressor therapy and intubation for a secondary respiratory failure from metabolic acidosis. She was started on Vancomycin and Levofloxacin and completed a two week course. Culture data was never revealing. As part of her sepsis syndrome, she developed acute renal failure in the background of a chronic kidney disease. Over her course, she was weaned from mechanical intubation and vasopressor therapy. Her kidney function steadily improved. Of note, her ACTH stimulation test was normal. 2. LE Ulcers and Cellutlits: Her ulcerations, as mentioned, were chronic and secondary to PVD. She was treated conservatively and was seen by Vascular Surgery and the RN Wound Care Team. Conservative treatment included Vitamin C and Zinc supplementation for wound healing. Over her course, her ulcers markedly improved with new epidermal growth noted. 3. NSTEMI/CAD: The patient had a recent MI and stent (LAD and OM) placement in [2155-12-18]. As mentioned, she then had a NSTEMI in the setting of septic shock. She was started on heparin and continued on beta-blocker, statin, clopidogrel, and aspirin. Once stable, a pMIBI revealed a likely reversible inferolateral myocardial perfusion defect. Her follow-up cardiac catheterization showed severe 2VD and she then underwent high-risk PCI/Stenting as she was not a surgical canidate (for CABG) based on CT Surgery evaluation. Her 2VD was successful and the patient remained symptom free and stable after this intervention. She was scheduled for a re-look cardiac catheterization for three weeks after discharge. Upon iodinated contrast dye exposure, she was prophylaxed with sodium bicarbonate solution along with acetlycysteine. 4. AF: The patient had brief and intermittent episodes of atrial fibrillation early in her course, in the setting of resolving infection. Once stable, with her infection resolved, she remained in sinus rhythm. She was not anti-cogulated for this reason. 5. Anemia: The etiology of her anemia was likely multifactorial: EPO deficiency, chronic inflammation via LE ulcers, and DM. Upon admission, the patient required PRBC transfusions after a likely hemodilutional effect of aggressive fluid resucitation. She had no known source of bleeding. She was later commenced on EPO therapy given her known CKD and DM. She responded well and her HCT remained stable in the low 30's. She was also tested for various vitamin deficiencies (folate, B12, B6, etc.) and was commenced on supplementation. 6. Diabetes Mellitus: The patient had known long-standing disease. She was continued on NPH and sliding scale regular Insulin. Once the patient was stable on the medicine floor, she had acheived euglycemia on her insulin regimen. 7. Depression: The patient was frequently tearful during her course. She had a known history of depression. She was seen by the social work services team, which she found to be helpful. She was advised to pursue outpatient therapy and was continued on Wellbutrin and Celexa. Medications on Admission: Plavix 75 [Last Name (LF) ], [First Name3 (LF) ] 81 qd, Protonix 40qd, Ambien qhs, Celexa, Oxycodone/Oxycontin Colace/Senna/Dulcolax, VitC/Zn, Lopressor 50 TID, Lipitor 10qd, Miconazole powder, Muprirocen, Tylenol, Heparin SC, Celexa Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary Dx: Septic Shock, Respiratory Failure, Acute Renal Failure, Non-ST Elevation Myocardial Infarction. Secondary Dx: Lower Extremity Ulcers, Two Vesssel Coronary Artery Disease, Congestive Heart Failure, Anemia, Diabetes Mellitus, Severe Obesity. Discharge Condition: Stable/Good. Discharge Instructions: 1) If you have any chest pain, shortness of breath, fevers, chills, nausea, vomiting, or any other concerning symptoms, please contact your doctor or return to the ER. 2) Please weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Please limit your fluid intake to 1.5 liters per day. 3) Please take your new medications as instructed. Followup Instructions: 1) Please follow-up with [Hospital1 18] Cardiology in the next two to three weeks. Please call [Telephone/Fax (1) 4451] to make an appointment with [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437]: [Telephone/Fax (1) 4451]. 2) The [Hospital1 18] Cardiologists have planned to perform another cardiac catheterization in three weeks. Please confirm this appointment with your [Hospital1 18] Cardiologist. 3) Please follow-up with your new primary care doctor, [First Name8 (NamePattern2) 2453] [Name8 (MD) ], MD [First Name (Titles) ] [Last Name (Titles) 18]: [Telephone/Fax (1) 250]. You have an appointment for [2156-11-19] at 2:00PM in the [Location (un) 8661] Building, [Location (un) 895], North Ste on the [Hospital Ward Name 516]. 4) Please have the doctors at your Rehab Facility check your SMA10 in one week. Please also have your CBC checked in two weeks to ensure that you are receiving the appropriate amount of EPO therapy. Name: [Known lastname 18064],[Known firstname ] Unit No: [Numeric Identifier 18065] Admission Date: [2156-9-29] Discharge Date: [2156-10-22] Date of Birth: [2098-6-10] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing / Augmentin / Imipenem / Bactrim Ds / Gentamicin Attending:[First Name3 (LF) 1852] Chief Complaint: SEE PREVIOUS DC SUMMARY Major Surgical or Invasive Procedure: SEE PREVIOUS DC SUMMARY History of Present Illness: SEE PREVIOUS DC SUMMARY Past Medical History: SEE PREVIOUS DC SUMMARY Social History: SEE PREVIOUS DC SUMMARY Family History: SEE PREVIOUS DC SUMMARY Physical Exam: SEE PREVIOUS DC SUMMARY Pertinent Results: SEE PREVIOUS DC SUMMARY Brief Hospital Course: ADDITION/CORRECTION TO PREVIOUS DC SUMMARY: NSTEMI: For Severe 2VD, patient had high-risk PCI and Stenting. Cypher stents were placed. The patient was continued on ASA and Plavix. For the remained of her course and managment, SEE PREVIOUS DC SUMMARY. Medications on Admission: SEE PREVIOUS DC SUMMARY Discharge Medications: SEE PREVIOUS DC SUMMARY Discharge Disposition: Extended Care Facility: [Hospital3 14] & Rehab Center - [Hospital1 15] Discharge Diagnosis: SEE PREVIOUS DC SUMMARY Discharge Condition: SEE PREVIOUS DC SUMMARY Discharge Instructions: SEE PREVIOUS DC SUMMARY Followup Instructions: SEE PREVIOUS DC SUMMARY [First Name11 (Name Pattern1) 77] [Last Name (NamePattern4) 692] MD [MD Number(2) 693] Completed by:[2156-10-22]	[ "585", "518.82", "584.9", "599.0", "278.01", "995.92", "785.52", "250.00", "038.9", "V58.67", "707.09", "682.6", "459.81", "410.71", "427.31", "428.0" ]	icd9cm	[ [ [] ] ]	[ "36.05", "88.56", "88.55", "96.6", "96.04", "96.71", "00.17", "99.04", "36.07", "38.93", "89.64", "37.22" ]	icd9pcs	[ [ [] ] ]	14897, 14978	14522, 14775	14208, 14233	15045, 15070	14474, 14499	15142, 15325	14390, 14415		14849, 14874		14999, 15024		14801, 14826			15094, 15119									14430, 14455																			14145, 14170												14261, 14286														14308, 14333	14349, 14374
11,961	136,082	3733	Discharge summary	report	Admission Date: [2153-11-19] Discharge Date: [2153-11-22] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2160] Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] year old Russian speaking F with chest pain and hypotension. On the night prior to admission, she reports band-like CP radiating around her chest bilaterally to the back with dizziness. She took medication similar to sl ntg (Russian med) and was CP free. Per daughter, patient took double dose of [Name (NI) 16828] (25->50 mg) as well. . In the ED SBP was 70s, A.fib with HR 90-120s. In the ED, given fluids 750 cc increased to 80's. Bedside echo negative for effusion, thought to be dry given slow fluid bolus. No evidence of infection, afebrile, U/A negative, CXR clear. she was admitted to the ICU for observation and fluid resuscitation. Her BP improved with IVF and with holding her BP meds. she was chest pain free till discharge. She was transferred to the floor for further management. was dizzy currently not, not able to walk very far due to her "heart". Past Medical History: CAD s/p MI at 69 and 71 y.o. ischemic cardiomyopathy ([5-15] ECHO with EF 40%) HTN Afib s/p pacemaker DM II with documented retinopathy (dx 4 years ago) Depression/anxiety (X 10 years) allergic rhinitis s/p cataract surgery bilaterally Asthma Social History: Lives alone in an apartment but her daughter lives in the same building, does not ambulate often (per daughter has had 2 falls in the past 2 years), no tob and no etoh. Has a nurse who comes home to help with medications. Family History: Father- TB, CAD, DM no history of cancer Physical Exam: Vitals: 98.4 68 129/48 98% 2L NC (in ICU) Gen: appears younger than stated age, speaking in full sentences, well groomed, NAD HEENT: OP clear, moist, anicteric Neck: supple, no JVD appreciated CVS: nl S1 S2, irregular, no m/r/g appreciated Pulm: CTA b/l no wheezines/rales, slightly decreased BS throughout, bases relatively clear Abd: obese, soft, NT, BS+ Ext: warm, no edema Pertinent Results: [2153-11-22] 05:50AM BLOOD WBC-6.5 RBC-3.81* Hgb-11.4* Hct-33.0* MCV-87 MCH-29.9 MCHC-34.5 RDW-15.0 Plt Ct-189 [2153-11-19] 11:35AM BLOOD WBC-8.5# RBC-4.07* Hgb-12.4 Hct-35.7* MCV-88 MCH-30.5 MCHC-34.8 RDW-14.9 Plt Ct-194 [2153-11-19] 11:35AM BLOOD Neuts-75.5* Lymphs-16.5* Monos-5.4 Eos-2.5 Baso-0.1 [2153-11-22] 05:50AM BLOOD PT-19.3* PTT-27.0 INR(PT)-1.8* [2153-11-19] 09:00PM BLOOD PT-45.2* PTT-32.0 INR(PT)-5.2* [2153-11-22] 05:50AM BLOOD Glucose-141* UreaN-16 Creat-0.8 Na-142 K-4.0 Cl-103 HCO3-34* AnGap-9 [2153-11-19] 11:35AM BLOOD Glucose-163* UreaN-21* Creat-0.8 Na-142 K-4.3 Cl-104 HCO3-28 AnGap-14 [2153-11-22] 05:50AM BLOOD Calcium-8.8 Mg-2.0 [2153-11-19] 11:35AM BLOOD Phos-3.5 Mg-1.7 [2153-11-19] 01:01PM BLOOD Lactate-2.6* [2153-11-19] 12:05PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.006 [2153-11-19] 12:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG URINE CULTURE (Final [2153-11-21]): Culture workup discontinued. Further incubation showed contamination with mixed fecal flora. Clinical significance of isolate(s) uncertain. Interpret with caution. GRAM NEGATIVE ROD #1. >100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML.. [2153-11-19] 12:52 pm BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): [2153-11-19] 12:50 pm BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending Atrial fibrillation with rapid ventricular response. Diffuse ST-T wave abnormalities which are non-specific. Low QRS voltage in the precordial leads. Compared to the previous tracing of [2153-10-7] atrially paced rhythm has changed to atrial fibrillation. Clinical correlation is suggested. Read by: [Last Name (LF) ],[First Name4 (NamePattern1) ] [Last Name (NamePattern1) 10592] Intervals Axes Rate PR QRS QT/QTc P QRS T 105 0 82 346/407.28 0 19 138 CXR: IMPRESSION: 1) Stable cardiomegaly without evidence of overt congestive heart failure. 2) Subtle right mid lung zone opacity, better seen on the chest CTA of [2153-10-5]. Brief Hospital Course: # Hypotension: Resolved with IV hydration. Given the patient's history, was likely due to overmedication with [Last Name (un) 11823] with sublingual nitroglycerin. BP was normal on the floor and gradually metoprolol and [Last Name (un) ] were introduced at lower doses, with good response. Isordil was not started given the recent hypotensive episode. This can be restarted in clinic if the patient can tolerate it. No further chest pain occured in the hospital and no cardiac enzyme changes or ECG changes were noted. A work-up for infection related sepsis was also done - except for UTI no clear source of infection found. Blood cultures were negative at discharge. # Coronary artery disease: ASA, statin, sotalol were continued. Beta blocker was restarted. [Last Name (un) ] was started a a once daily dose. I called Dr [Last Name (STitle) 3357], patient's PCP and cardiologist - he also mentioned that the patient was supposed to be on metoprolol 25mg [Hospital1 ] but was not taking it at home. He also recommended, that given the [Doctor First Name ] cardiac enzymes and unchanged ECG, he will prusue further CAD work-up in his clinic after discharge. # A.fib: she was initially tachycardic but with re-initiation of mediction, was rate controlled. Sotalol was continued. # INR was supratherapeutic on admission - though no acute bleeding was noted with hct remaining stable. INR decreased to 1.8 with withholding warfarin. warfarin was reinitiated on [2153-11-22] (4/week dose) . she was advised to see her PCP Dr [Last Name (STitle) 3357] to get another INR checked. . # CHF. was euvolemic on exam, no rales or edema. Meds as above. # UTI - was treated with ciprofloxacin and she should complete a 3-day course. (total) # Abnormal CT chest: tree and [Male First Name (un) 239] opacities in CT [10-5]. [10-8] AFB stain negative. TB culture (no growth x1 month to date). she missed the pulmonary clinic appointment. This was rescheduled and the patient is advised to keep her appointment. The final culture read may be followed up in primary care clinic. # DM - given her CHF (relative contraindication for metformin), metformin was stopped and he patient was transitioned to glipizide. No hypoglycemic episodes were noted. # COPD - on inhalers. Good o2 sat (>95%)on ambulation. She was evaluated by physical therapy. No rehab recommended. She has a walker at home. # Communication: Daughter [Telephone/Fax (1) 16829]. All of the above medication changes and the occurances in the hospital were conveyed to her daughter, [Name (NI) 8982]. Medications on Admission: - nitro - sotalol 80 [Hospital1 ] - metformin 1 g po AM; 500 mg po noon - ASA 81 - [Hospital1 16828] 25 mg daily - protonix 40 - lipitor 80 - trazadone 50 qhs prn - coumadin 2 mg 4x per week - ativan prn - isordil 10 TID - per old D/C summary [9-16] also on Albuterol and Celexa 20 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. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:30 Refills:0 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:10 Refills:0 6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 7. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 days. Disp:2 Tablet(s) Refills:0 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 11. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 4X/WEEK ([Doctor First Name ],TU,TH,SA). Disp:60 Tablet(s) Refills:0 13. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] family services Discharge Diagnosis: Hypotension - medication related Atrial fibillation Supratherapeutic INR Urinary tract infection Secondary diagnoses: Coronary artery disease Congestive heart failure, systolic Pacemaker Anemia Diabetes Mellitus , type 2, retinopathy Abnormal CT chest Chronic obstructive pulmonary disease s/p cataract surgery Discharge Condition: Stable Discharge Instructions: Return to the emergency room or call you rprimary doctor, Dr [Last Name (STitle) 3357] if you notice chest pain, shortness of breath, palpitations, bleeding or any other symptoms. Your medications have been changed and a list will be provided to you along with prescriptions. Please make a note of these changes and also show the medications to your home nurse who gives you the medications. Your INR was very high when you came to the hospital this time. It is now normal and coumadin(warfarin) has been restarted. Please follow up with Dr [Last Name (STitle) 3357] to get INR checked next week (as scheduled). Your blood pressure was low this time when you came to the hospital because of excess medication. Please avoid any self changes to your mediation doses and talk to your doctor before you take a higher dose. Metformin that you were taking has been stopped and another diabetic medication called glipizide is started. Do not take metformin after you return home. Monitor your blood sugars closely and report and abnormal values (<70 or >140) to your doctor. Also, you are advisd not to restart isordil unless you talk with Dr [Last Name (STitle) 3357]. You missed your last appointment with the pulmonary specialist in regards to the abnormal CT chest you had. Another appointment has been made for you and you are advised to keep that appointment. Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2154-2-26] 1:30 Provider: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 6197] Date/Time:[2154-2-26] 2:00 Dr [Last Name (STitle) 3357] ([Telephone/Fax (1) 4606]) on Tuesday [2153-11-27] at 3-30 pm for INR check. Pulmonary: Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ]/DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2153-12-10] 3:30 Provider: [Name Initial (NameIs) 9484]CC2 PULMONARY LAB-CC2 Date/Time:[2153-12-10] 3:00	[ "362.01", "786.59", "428.0", "414.8", "428.22", "E858.3", "790.92", "458.29", "V45.01", "493.20", "250.50", "972.9", "427.31", "401.9", "599.0", "V58.61" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8842, 8905	4408, 7018	275, 282	9261, 9270	2189, 3568	10695, 11379	1730, 1773		7362, 8819		8926, 9024		7044, 7339			9294, 10672									1788, 2170	9045, 9240																		225, 237							3701, 4385	3627, 3671				310, 1202														1224, 1473	1489, 1714
48,468	164,098	48776	Discharge summary	report	Admission Date: [2159-1-31] Discharge Date: [2159-2-27] Date of Birth: [2092-7-30] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2167] Chief Complaint: - left wrist erythema/edema, right hip pain Major Surgical or Invasive Procedure: - left wrist arthrocentesis - laminectomy and epidural abscess drainage (lumbar spine) - CT-guided drainage and drain placement for right psoas abscess - left wrist debridement and irrigation - laminectomy and epidural abscess drainage (cervical spine) - posterior spinal fusion with anterior and posterior hardware placement (cervical spine, C4-C7) - Left iliac crest debridement and evacuation of abscess History of Present Illness: On admission: 66 yo female with h/o HTN p/w worsening L hand swelling and erythema and R hip pain x 1 wk. Was seen at an ED in [State 1727] 2 wks ago for CP, r/o ACS. Had a negative w/u, including a stress test. Approx. 1 wk later presented to her PCP with [Name Initial (PRE) ] hip pain and L hand swelling and erythema; PCP reassured her and prescribed muscle relaxants and pain medications. Her sx have gradually worsened over the past wk, to the point that she has had to borrow her friend's walker for ambulation. Had an app't with her PCP today, but on the advice of a roofer (who used to be an EMT) came to the ED instead. . In the ED, initial vitals were as follows: T 97.9 P 84 BP 95/59 RR 12 O2sat 97%RA. She was started on vancomycin and Unasyn, and given morphine 4mg IV and Tylenol 500mg po x 1 for pain relief. CXR showed possible mild edema vs. atypical infection, and labs were significant for a negative U/A and a WBC count of 35.7 with 79%N and 2%bands. Vitals on transfer were as follows: T 98.0 BP 133/58 P 85 O2sat 98%RA . Review of sytems: (+) 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. Past Medical History: - HTN Social History: - denies T/E/D, retired 3rd-grade teacher, now runs a B&B in [State 1727] Family History: - father with MI at 80 Physical Exam: On admission: Vitals: T:99.5 BP:118/68 P:78 RR:18 O2sat:92%RA, 95%2L General: alert, oriented, no acute distress, mildly uncomfortable Derm: erythema over nasal bridge and L maxilla, erythema over hands b/l to the wrist L>R HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB CV: RRR, nml S1/S2, 2/6 systolic murmur (pre-existing per pt) Abdomen: soft, non-distended, no TTP, no rebound/guarding Ext: Warm/well-perfused, 2+ pulses, no C/C/E Pertinent Results: [2159-1-31] WBC-35.7 Hgb-11.8 Hct-33.4 Plt Ct-235 [2159-1-31] Neuts-79 Bands-2 Lymphs-13 Monos-3 Eos-0 Baso-0 Atyps-0 Metas-3 Myelos-0 [2159-2-2] Neuts-90 Bands-0 Lymphs-5 Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2159-2-4] WBC-26.2 Hgb-10.7 Hct-31.4 Plt Ct-422 [2159-2-6] WBC-25.6 Hgb-8.3 Hct-24.4 Plt Ct-511 [2159-2-8] WBC-17.9 Hgb-9.5 Hct-26.8 Plt Ct-555 [2159-2-9] WBC-13.8 Hgb-8.9 Hct-25.8 Plt Ct-595 [2159-2-9] WBC-9.4 Hgb-8.3 Hct-23.4 Plt Ct-487 [2159-2-10] WBC-13.7 Hgb-9.4 Hct-26.4 Plt Ct-563 [2159-2-13] WBC-15.8 Hgb-8.7 Hct-25.1 Plt Ct-520 [2159-2-14] WBC-16.6 Hgb-8.7 Hct-25.7 Plt Ct-607 [2159-2-16] WBC-16.5 Hgb-8.5 Hct-24.8 Plt Ct-676 . [2159-1-31] Glucose-130 UreaN-69 Creat-1.4 Na-135 K-3.6 Cl-98 HCO3-23 [2159-2-4] Glucose-102 UreaN-15 Creat-0.8 Na-134 K-3.9 Cl-95 HCO3-25 [2159-1-31] ALT-39 AST-55 LD(LDH)-479 CK(CPK)-292 AlkPhos-191 TotBili-0.5 . [2159-2-1] HBsAg-NEGATIVE HBsAb-NEGATIVE [2159-2-1] BLOOD HCV Ab-NEGATIVE . [2159-1-31] ANCA-NEGATIVE B [2159-2-1] dsDNA-NEGATIVE [2159-1-31] [Doctor First Name ]-NEGATIVE . BILATERAL HAND/WRIST: IMPRESSION: Within limitations above, bilateral hand and wrist are grossly unremarkable except for marked soft tissue edema along the dorsum of the left hand and the second digit of the right hand. . AP PELVIS/RIGHT HIP: IMPRESSION: Unremarkable right hip series. There may be very mild early osteoarthritis. . MRI PELVIS: IMPRESSION: 1. Large loculated fluid collection which involves the right iliacus, right obturator internus, right pelvic sidewall, and right piriformis muscles. Additional loculated fluid collection located left of the rectosigmoid junction. Given the history, these are compatible with infected fluid collections. In the absence of contrast, the precise extent of fluid vs inflamed tissue cannot be determined. 2. Small bilateral hip joint effusions, nonspecific in appearance. No surrounding marrow edema. 3. Small right- sided sacroiliac joint effusion with marrow edema on both sides of the SI joint. This is suyspicious for infection of the right si joint, with surrounding osteomyelitis. 4. Abnormal signal in the L3 vetebral body, not fully evaluated on this scan. The possibility of extension of infection to involve the lspine remains a significant concern. 5. Diffusely abnormal patchy changes in the marrow on the T1 images, atypical for someone of this age. ? chronic anemia versus infiltrative process of the marrow. . MRI L-SPINE: CONCLUSION: Findings suggesting intraspinal epidural abscess posterior to the L4 and L5 vertebral bodies. No findings to suggest spinal osteomyelitis. However, this imaging technique may have limited sensitivity for early osteomyelitis. Abscess collections also noted in the right iliopsoas muscle and posterior to the right sacrum. . MRI C-SPINE: IMPRESSION: Discitis osteomyelitis at C5-C6 and to a lesser extent C6-C7 with epidural and retropharyngeal abscesses, cord compression and cord edema. Possible osteomyelitis at T6/T7. . CT CHEST/ABDOMEN: IMPRESSION: 1. Several rounded fluid collections, suspicious for abscesses, with the largest anterior to right iliac bone measuring 2.2 cm x 2.9 cm, with additional ring-enhancing foci within the right iliacus muscle, as well as along the right pelvic sidewall. These are too small and also anatomically not amenable to percutaneous drainage. 2. Large bilateral pleural effusions, with associated atelectasis/consolidation of the adjacent lungs. 3. Pulmonary edema, with numerous bilateral pulmonary nodules, which may be infectious or inflammatory. Followup is recommended following resolution of acute symptoms to ensure resolution of the pulmonary nodules. 4. Post-surgical changes within the left iliac bone, and adjacent subcutaneous tissues. 5. Erosive changes of the right sacroiliac joint, could reflect sacroiliatis given the adjacent abscesses. . UNILAT UP EXT VEINS US LEFT Thrombosis of the left cephalic vein. No deep venous thrombosis in the left upper extremity. Basilic vein was not identified. CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST IMPRESSION: 1. Possible right striated nephrogram suggestive of possible pyelonephritis and would recommend clinical correlation with urinalysis. 2. Unchanged abscesses seen along the right iliac bone. 3. Unchanged appearance to a right posterior pelvic wall drain. 4. L5 laminectomy with associated postoperative changes, which appear stable. 5. Interval removal of posterior skin staples with a new 2 x 2 x 1.5 cm fluid collection which tracks inferiorly. 6.Unchanged large bilateral pleural effusions with associated atelectasis and consolidation. Improved pulmonary edema. 7. Area in the bladder and would recommend clinical correlation with recent instrumentation. C-SPINE NON-TRAUMA [1-2] VIEWS FINDINGS: In comparison with the study of [2-11], there is little change in the appearance of the anterior and posterior fusions. No evidence of hardware-related complication. There is some prominence of the prevertebral soft tissues, though this may merely reflect the relatively recent operative state. To evaluate for possible abscess formation, CT would be necessary. Brief Hospital Course: )Cellulitis/arthralgia - on presentation she had cellulitis and arthralgia, and was started on vancomycin and Unasyn. Her initial WBC count was significantly elevated to 35.7, although she was afebrile at the time. On the day after admission, she became febrile with a Tmax of 101.4F, and initial blood cultures drawn in the ED grew MSSA. Rheumatology was consulted and performed an arthrocentesis of the left wrist, which also grew MSSA. Sensitivities returned on HD#5, and her abx were changed from vancomycin/Unasyn to nafcillin. MRI's of the pelvis and L-spine were also done to assess for bony involvement, as significant arthralgias were part of her presentation. MRI of the pelvis demonstrated a large right psoas abscess extending into the piriformis, which was drained by IR under CT guidance, with placement of a drain on HD#4. MRI of the L-spine showed a likely L4-L5 epidural abscess on final read on HD#5, and Spine Surgery was consulted. She was taken to the OR on HD#6 for a laminectomy and drainage of the epidural abscess. On HD#7 the Orthopedics Trauma team took her to the operating room for wash-out of her left wrist. Please see the operative reports for full details. She received 2 units of PRBC post-operatively. . She did well post-operatively, but several days later her WBC count began to increase again and she became febrile. Infectious Disease was consulted, and recommended further imaging. They continued to follow her throughout her hospitalization. MRI's of the C-spine and T-spine were performed to assess for additional involvement of the spine, and were significant for several foci of osteomyelitis and discitis, as well as a C-spine epidural abscess causing cord compression. Spine Surgery was urgently consulted, and she went back to the operating room on HD#10 and HD#13 for drainage and debridement of the abscess as well as fusion of C4-C7. She received 2 units of PRBC intra-operatively. Please see the operative report for full details. Spine Surgery continued to follow her during her hospitalization for management of her drains and post-operative care. . CT scan of the chest and abdomen performed on HD#14 demonstrated resolution of the right psoas abscess, with abscesses in the right iliac fossa, right iliacus muscle, and right pelvic sidewall not amenable to percutaneous draiange. CT on HD#20 showed no significant change. . A TTE on [2-2] and a TEE on [2-8] did not demonstrate an endovascular site of infection . She was treated with Nafcillin throughout her course with a brief transition to vancomycin on HD#20 in the setting of fever and leukocytosis. She tolerated it well except for hypokalemia with initial fevers and leukocytosis resolving by the second week. . From HD#10 to HD#24 she demonstrated rising leukocytosis and low grade fevers. Blood culture on [2-17] was positive for E. Coli and the surgical site where her bone graft was obtained from the iliac crest began to show signs of infection. A wound culture was positive for Ecoli and she again returned to the operating room on HD#20 for debridement and washout of the site. Culture of tissue and bone from the area were positive for E coli. A drain was placed which was discontinued on the day of discharge. She was treated with ciprofloxacin and began showing improvement immediately in fever and leukocytosis. On discharge she remains on nafcillin and Cipro pending resolution of symptoms and inflammatory markers. . . ) Pleural Effusions- She was noted to have bilateral pleural effusions, as well as several pulmonary lesions consistent with septic emboli. Her oxygen saturation was good and she had mild respiratory complaints, so the decision was made to treat her pleural effusions medically rather than by thoracentesis. She was gently diuresed with furosemide as needed. . . ) Hypokalemia - Potassium was as low as 2.6 while the patient was on nafcillin improving immediately when nafcillin was temporarily stoppped. She was managed with daily potassium repletion with up to a total of 120 mEq / day of intravenous and oral potassium. On discharge her potassium was 3.3. . . )ARF - creatinine on admission was elevated to 1.4, which resolved with IV hydration. Her creatinine subsequently has several transient elevations, which were most likely due to volume depletion, and normalized with hydration. On discharge, her creatinine was 0.9 . . )HTN - BP was initially well-controlled on her outpatient medication regimen. However, hydrochlorothiazide was subsequently held due to an elevation of her creatinine, and after her multiple surgeries blood pressure control was more difficult. She was started on hydralazine post-operatively, and her amlodipine and atenalol were titrated up. She continued to have elevated blood presssures despite this and lisinopril was added and titrated up. Her blood pressure on the morning of discharge was 155/80. Medications on Admission: - atenalol 50mg daily - HCTZ 25mg daily - amlodipine (unknown dose) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4-6H () as needed for Pain. 4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. 6. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO every six (6) hours. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. Cipro 750 mg Tablet Sig: One (1) Tablet PO twice a day: Continue until [2159-4-1]. 9. Nafcillin 2 gram Recon Soln Sig: Two (2) grams Intravenous every four (4) hours: Continue until [2159-4-1]. 10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day: Please discontinue after completion of Nafcillin course on [2159-4-1]. 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary Diagnoses - Methicillin sensitive Staphylococcus aureus septicemia and multiple abscesses - Left wrist septic arthiritis - Lumbar osteomyelitis - Right sacroiliitis - Cervical discitis/osteomyelitis and spinal epidural abscess - Septic pulmonary embolic disease - right psoas abscess; Intra-abdominal/pelvic abscesses - E.coli septicemia and iliac crest post-surgical site abscess with osteomyelitis - Hypokalemia - Hypertension - Anasarca - Acute renal failure - Anemia Discharge Condition: Afebrile. Discharge Instructions: You were admitted to the hospital for a bacterial infection. This improved with antibiotics through your IV. Because you had many serious infections, including in your spine and bones, you will need to be on antibiotics for several weeks. A long-term IV (PICC) was placed in your right arm for this purpose. You are being discharged to a rehabilitation facility to help you to get stronger after your long hospitalization, and so that you can continue to receive IV antibiotics. . Medication Changes: - nafcillin was started - ciprofloxacin was started - hydralizine was started - Lisinopril was started and increased to 20mg daily - amlodipine was increased to 10mg daily - atenalol was increased to 100mg daily . Please follow up with your primary doctor after you leave the rehabilitation facility. . Please call your doctor for the following: fever, severe or increasing pain, new areas of rash/redness or spreading redness, chest pain, difficulty breathing, nausea/vomiting, any other new or concerning symptoms. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Last Name (NamePattern1) ], MD DEPARTMENT OF ORTHOPAEDIC SURGERY [Hospital Ward Name 23] Building [Location (un) 551], [Hospital1 18] [Hospital Ward Name 516] Phone:[Telephone/Fax (1) 3736] Date/Time:[2159-3-5] 7:40 AM Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 111] DIVISION OF INFECTIOUS DISEASE [Hospital Ward Name ] BLDG ([Doctor First Name ]), BASEMENT FLOOR [2159-3-23] 10:30 AM Please follow-up with your primary care doctor 2 to 3 days after discharge from rehab: [Doctor First Name 1698] [Initials (NamePattern4) ] [Last Name (NamePattern4) 1699], [Telephone/Fax (1) 1701] Completed by:[2159-2-27*]	[ "E878.8", "711.03", "276.50", "511.9", "682.3", "720.2", "567.22", "567.31", "614.3", "453.8", "276.8", "998.59", "324.1", "E930.0", "730.08", "415.12", "584.9", "722.91", "995.92", "038.12", "401.1", "998.12", "038.42", "285.9", "276.6", "V88.01" ]	icd9cm	[ [ [] ] ]	[ "81.03", "84.51", "02.94", "77.49", "77.79", "80.13", "54.91", "38.93", "81.91", "03.09", "83.21", "77.69", "80.51", "81.02", "03.4", "81.63" ]	icd9pcs	[ [ [] ] ]	14310, 14380	8163, 13064	359, 768	14903, 14915	2903, 8140	15981, 16755	2355, 2379		13183, 14287		14401, 14882		13090, 13160			14939, 15420									2394, 2394																15440, 15958			276, 321						1866, 2214						796, 796							2408, 2884							2236, 2243	2259, 2339
4,113	176,856	4894	Discharge summary	report	Admission Date: [2144-6-15] Discharge Date: [2144-6-21] Date of Birth: [2103-6-23] Sex: F Service: MEDICINE Allergies: Codeine / Amoxicillin / Blood-Group Specific Substance Attending:[First Name3 (LF) 30] Chief Complaint: nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: EGD History of Present Illness: 41 yo F with DM1, s/p renal transplant in [2140], CAD s/p [Hospital ] transferred from OSH for DKA. . Initially presented to OSH (Southern [Hospital ] Medical center) with n/v, altered mental status on [6-14] x 2-3 days. Her initial VS were: T 91.4, BP 82/53, RR 32, O2 sat 95% on RA. Her inital glu was 1148, AG 36, PH 6.9, bicarb was 4. She was given NS and started on an insulin gtt and admitted to the ICU. Anion gap at 2PM on day of transfer was 13. Pt arrived with insulin gtt running. Total amount of fluid she recieved at OSH is unclear. Pt has history of frequent recurrent DKA episodes with no known precipitating factors. She states that she stopped taking her insulin because she was feeling sick from her menses with diarrhea. . Of note, her Creatinine, which runs 0.9- 1.0 at baseline, was 2.1 on admission. Repeat CRT at 2PM on day of transfer was 1.2. . She was also initially noted to be in Aflutter and spontaneuously converted to NSR. Her EKG showed TW-inversions in lateral leads. Her troponin I was 0.11 on admission and increased to 12.0. This was felt to be due to demand ischemia by the OSH ICU team. A cardiology consult was obtained at the OSH and the pt was started on Lovenox, ASA, Plavix, Integrellin. . Recently admitted [4-25]/- [2144-4-26] to [Hospital1 18] for CHF exacerbation due to dietary non-complaince. She was ruled our for MI by enzymes x 3. Past Medical History: 1.ESRD s/p living related donor [10-31] 2.Diabetes Mellitus type I with retinopathy, gastroparesis and neuropathy 3.CAD s/p CABG [5-2] (LIMA-LAD, SVG-PDA, OMI-Diag). (Echo at [Hospital1 ] [First Name (Titles) ] [2143-8-1] showed mild symmetric LVH with a normal EF of greater than 55%. There were subtle apical, anterior, and lateral areas of hypokinesis. There was also moderate 2+ mitral regurg and moderate pulmonary artery hypertension. She had a stress test and exercise MIBI in [2144-1-1] that showed reversible defects in the territory ofthe LAD and left circumflex similar in appearance to a prior study in [2142-5-31]. A normal ejection fraction of 51% was reported.) 4.PVD s/p bypass fem-[Doctor Last Name ] 5.CHF EF = 45-50% 6.HTN 7.Chronic ulcers 8. Sarcoidosis 9. Depression 10. Blindness bilaterally. L eye prosthesis. . Medications on Admission to OSH: 1. Bactrim double strength one tab every Monday, Wednesday and Friday. 2. Aspirin 81 mg daily. 3. Prednisone five milligrams daily. 4. Reglan ten milligrams four times a day before meals and at bedtime. 5. Zoloft 75 mg at bedtime. 6. Sirolimus three milligrams daily. 7. Lopressor 150 mg t.i.d. 8. Plavix 75 mg daily. 9. Ramipril 2.5 mg daily. 10. Tacrolimus two milligrams b.i.d. 11. Insulin Lantus 22 units qhs 12. Humalog insulin sliding scale. 13. Zantac 75 mg b.i.d. 14. Lipitor 80 mg daily. 15. Compazine 20 mg p.o. q. 4h. as needed for nausea. 16. Remeron 15 mg p.o. at bedtime as needed for sleeplessness. 17. Calcium 500 mg b.i.d. 18. Vitamin D 425 mg daily. 19. Fosamax 70 qweek on WEDs 21. Ranitidine 150 [Hospital1 ] . MEDS on TRANSFER: 1. Insulin gtt 2. Integrilin gtt at 1 mcg/kg/min 3. Rocephon 1g IV qd 4. Ranitidine 150mg PO bid 5. Solucortef 100mg IV q8h x 2 doses, then 50mg IV x 1 dose 6. Protonix 40mg qd 7. Lovenox 60mg SC qd 8. Lopressor 5mg IV q6h 9. Prograft 2mg [Hospital1 ] 10. Ramamune 3mg PO qd 11. ECASA 81mg po qd 12. Plavix 75mg qd . Allergies: Codeine / Amoxicillin Social History: Lives with her mother in [Name (NI) ]. Quit tobacco 3 months ago; prior, smoked 1/2ppd - 1 ppd for about 15 years. No alcohol or IVDU. Family History: no diabetes "heart trouble" in father and mother of unknown type F - MI at 74y/o M - HTN Physical Exam: Physical Exam: 102 154/48 54 40 100%2LNC GEN: Ill appearing but in in NAD HEENT: Mucous membranes dry. Lips dry and cracked. OP clear, JVP 8 cm, L eye prosthesis. R eye blind reactive to light. CV: RR, 4/6 systolic murmur across precordium Lungs: crackles at bases bilaterally Abd: S/nd. +BS, minimal tender diffusely, no rebound or guarding Ext: Trace edema bilaterally. 1+ DP/PT pulses bilaterally. Neuro: A&OX3. Pertinent Results: LABS ON XFER: . WBC 24.2 N82 B13 L3 HCT 47.3 MCV: 103 PLT: 442 . INR 1.03 PTT 32 . UA: 3+ glucose, 3+ ketones, Neg LE, nitrites . Na: 145 Cl: 117 BUN: 19 Glu: 138 K: 4.0 HCO3: 15 CR: 1.3 . Ca: 8.3 Mg: 1.7 Ph: 1.6 . CK: 240 TropI 12.15 . Lipase 399, [Doctor First Name ] 182 Hcg neg. . ABG: 7.38/20/103 [2144-6-15] 08:10PM GLUCOSE-55* UREA N-17 CREAT-1.0 SODIUM-147* POTASSIUM-3.7 CHLORIDE-120* TOTAL CO2-15* ANION GAP-16 [2144-6-15] 08:10PM ALT(SGPT)-11 AST(SGOT)-39 CK(CPK)-233* ALK PHOS-82 TOT BILI-0.2 [2144-6-15] 08:10PM CK-MB-19* MB INDX-8.2* cTropnT-0.72* [2144-6-15] 08:10PM CALCIUM-8.5 PHOSPHATE-2.3* MAGNESIUM-1.6 [2144-6-15] 08:10PM WBC-20.8# RBC-3.78 HGB-11.1* HCT-32.6* MCV-86 MCH-29.5 MCHC-34.2 RDW-13.6 [2144-6-15] 08:10PM NEUTS-93.1* BANDS-0 LYMPHS-3.8* MONOS-1.6* EOS-1.3 BASOS-0.1 [2144-6-15] 08:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2144-6-15] 08:10PM PLT SMR-NORMAL PLT COUNT-287 [2144-6-15] 08:10PM PT-12.5 PTT-30.3 INR(PT)-1.0 CMV Viral Load (Final [2144-6-17]): CMV DNA not detected. Performed by PCR. MRA: 1. No evidence of aortic pathology. 2. Calcified left common carotid plaque < 50% Esophagus mucosal biopsy: Active esophagitis with fibrinopurulent exudate consistent with ulceration. GMS stain for fungal organisms is negative with satisfactory control. No viral cytopathic effect identified Blood Cultures ([2144-6-16]): no growth Brief Hospital Course: 41 year old female with type 1 DM, s/p renal transplant transferred from OSH with DKA, NSTEMI, possible left lingular PNA. . DKA: secondary to pneumonia and dietary/insulin non-compliance. AG gap closed with IVF and insulin, and presenting symptoms resolved [Last Name (un) ] followed Pt through course. . NSTEMI: Pt with h/o CAD s/p CABG [5-2]. TropT 0.72 on admission, trended down to 0.27. EKG at [Hospital1 18] unremarkable. Continued ASA, plavix, BB, statin, acei . BACK PAIN: MRA failed to show disection. Diminished with resolving DKA. Given Morphine Sulfate 2 mg IV Q3-4H:PRN . MELENA: in setting of lovenox and integrillin, stopped soon after admission. Still on aspirin and plavix. EGD showed erosion in the fundus, esophageal candidiasis, but otherwise normal egd to second part of the duodenum . NEPHROPATHY: s/p cadaveric renal transplant: Creatinine improved from admission suggests likely prerenal failure. Continue prednisone/sirolimus/tacrolimus + ACEi + bactrim. Renal transplant floowed Pt's course. . LEUKOCYTOSIS/LEFT LINGULA PNA. R/o infection. Elevated WBCs may be due to stress-dose steroids started on admission. Blood cultures negative. Given levofloxacin to cover for community-acquired PNA. . D/N/V: Patient with gastroparesis. No concerning abdominal exam. Given antiemetics prn and reglan standing Medications on Admission: Medications on Admission to OSH: 1. Bactrim double strength one tab every Monday, Wednesday and Friday. 2. Aspirin 81 mg daily. 3. Prednisone five milligrams daily. 4. Reglan ten milligrams four times a day before meals and at bedtime. 5. Zoloft 75 mg at bedtime. 6. Sirolimus three milligrams daily. 7. Lopressor 150 mg b.i.d. 8. Plavix 75 mg daily. 9. Ramipril 2.5 mg daily. 10. Tacrolimus two milligrams b.i.d. 11. Insulin Lantus 22 units qhs 12. Humalog insulin sliding scale. 13. Zantac 75 mg b.i.d. 14. Lipitor 80 mg daily. 15. Compazine 20 mg p.o. q. 4h. as needed for nausea. 16. Remeron 15 mg p.o. at bedtime as needed for sleeplessness. 17. Calcium 500 mg b.i.d. 18. Vitamin D 425 mg daily. 19. Fosamax 70 qweek on WEDs 21. Ranitidine 150 [Hospital1 ] . MEDS on TRANSFER: 1. Insulin gtt 2. Integrilin gtt at 1 mcg/kg/min 3. Rocephon 1g IV qd 4. Ranitidine 150mg PO bid 5. Solucortef 100mg IV q8h x 2 doses, then 50mg IV x 1 dose 6. Protonix 40mg qd 7. Lovenox 60mg SC qd 8. Lopressor 5mg IV q6h 9. Prograft 2mg [Hospital1 ] 10. Ramamune 3mg PO qd 11. ECASA 81mg po qd 12. Plavix 75mg qd Discharge Medications: 1. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 2. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 7. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:10 Tablet(s) Refills:0 12. Sertraline HCl 50 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 14. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 weeks. Disp:21 Tablet(s) Refills:0 15. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO once a day. Disp:120 Tablet(s) Refills:2 16. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous at bedtime. Disp:qs Refills:2 17. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:120 Tablet(s) Refills:2 18. Outpatient Lab Work Please check chem 7 panel on [2144-6-22]. [Date Range ] results to Dr. [First Name8 (NamePattern2) 3122] [Name (STitle) 1860] at [Telephone/Fax (1) 434] (phone [Telephone/Fax (1) 20422]) Discharge Disposition: Home Discharge Diagnosis: 1. DMI 2. DKA 3. CAD s/p CABG 4. s/p Renal transplant [2140] 5. Pneumonia Discharge Condition: Stable Discharge Instructions: You are discharged to home and should continue all medication as prescribed. Try soft foods given your swallowing discomfort. Please call your primary care physician or present to the ER if you experience chest pain, shortness of breath, bright red blood from your rectum, black tarry stools, increasing finger stick glucose measurements or other concerns. Please keep all of your appointments. Followup Instructions: You should have your blood drawn tomorrow to check your creatinine (kidney function) and the results faxed to Dr. [First Name8 (NamePattern2) 3122] [Name (STitle) 1860] [Telephone/Fax (1) 434]. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Name8 (MD) ], MD Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2144-7-2] 1:30 You should follow-up with your Cardiologist Dr. [Last Name (STitle) ] within 1-2 weeks after discharge. Please call [Telephone/Fax (1) 6197]. Provider: [Name Initial (NameIs) ] Where: RA [Hospital Unit Name ] ([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX) HMFP Phone:[Telephone/Fax (1) 1387] Date/Time:[2144-6-30] 10:20 Provider: [Name10 (NameIs) ] SACKS, LICSW Where: RA [Hospital Unit Name ] ([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX) HMFP Phone:[Telephone/Fax (1) 1387] Date/Time:[2144-6-30] 11:00 You will also need a Colonoscopy in [7-8] weeks. You should follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3815] (phone number: [Telephone/Fax (1) 16315]). You can schedule this Colonocopy by calling [Telephone/Fax (1) 463]. You should also schedule a follow-up appointment with Dr. [Last Name (STitle) 2262] in Nephrology in two weeks. His office number is [Telephone/Fax (1) 20423].	[ "V45.81", "250.63", "578.9", "112.84", "135", "996.81", "250.53", "584.9", "357.2", "250.13", "362.01", "486", "E879.0", "401.9", "276.5", "410.71", "428.0", "536.3" ]	icd9cm	[ [ [] ] ]	[ "45.16", "38.93" ]	icd9pcs	[ [ [] ] ]	10470, 10476	6065, 7414	340, 346	10598, 10607	4537, 6042	11051, 12490	3995, 4085		8570, 10447		10497, 10577		7440, 8208			10631, 11028									4115, 4518																			274, 302												374, 1788														1810, 3448	3838, 3979		8226, 8547
18,852	142,775	11120+11121	Discharge summary	report+report	Admission Date: [2122-9-21] Discharge Date: [2122-9-30] Service: MEDICINE anemia of unclear etiology who was admitted to the MICU on [9-21] with type B aortic dissection complicated by left hemothorax, after presenting with an episode of acute infrascapular back pain and nausea. CT scan at outside hospital suggested aortic dissection with left hemothorax. intramural hematoma at the superior aspect of the aortic arch felt likely secondary to an ulcerated aortic plaque. The patient was evaluated by Cardiothoracic Surgery at presentation, who recommended medical management of her type B dissection. She was thus admitted to the Medical Intensive Care Unit for careful hemodynamic control with IV labetalol and nitroprusside. Chest tube drainage of her left hemothorax was performed. mediated asystolic episodes. The EP service was consulted and upon review of these episodes ultimately did not feel that pacemaker was indicated. She also developed fever in the Intensive Care Unit felt likely secondary to an infected arterial line insertion site, with subsequent blood cultures positive for MRSA. PAST MEDICAL HISTORY: Anemia of unclear etiology. Per the patient, she had a history of bone marrow biopsy which was unremarkable. She is status post total abdominal hysterectomy. MEDICATIONS ON TRANSFER FROM MICU: Labetalol 400 mg p.o. b.i.d., Amlodipine 10 mg p.o. q.d., Dicloxacillin 500 mg q.6, Protonix, Reglan, Lasix p.r.n. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: She is married. She denied history of smoking or alcohol use. FAMILY HISTORY: Positive for cancer. PHYSICAL EXAMINATION: Vital signs: Temperature 97.0??????, heart rate 66, respirations 14, blood pressure 122/55, oxygen saturation 100% on 5 L nasal cannula. General: The patient was in no acute distress. She was mildly pale. HEENT: Oropharynx clear. Dry mucous membranes. Neck: Supple. There was no lymphadenopathy. No jugular venous distention. Cardiovascular: S1 and S2. There was a 2 out of 6 holosystolic murmur. Regular, rate and rhythm. Lungs: Decreased breath sounds on the left up to half of her lung, some respiratory breath sounds on the right side. Abdomen: Nontender and nondistended abdomen with positive bowel sounds. Extremities: Left arm cellulitis with erythema and focal forearm edema. Neurological: She was well oriented times three. She had normal language and memory function. Motor: Normal tone. Normal strength except mild weakness of her left iliopsoas. Deep tendon reflexes 2+ in upper extremities and 1+ in lower extremities. Toes downgoing. Sensory and coordination: Within normal limits. HOSPITAL COURSE: This was an 86-year-old woman with type B aortic dissection, transferred to the general medical [Hospital1 ] for further medical management s/p acute hemodynamic control in the MICU. 1. Cardiovascular: Status post aortic dissection type B. Medical management with multiple anti-hypertensive agents was continued with goal systolic blood pressures of roughly 100-110, though this goal was difficult to maintain. During this time, the patient's left-sided effusion re-accumulated. Initial diagnostic thoracentesis demonstrated a bloody-appearing exudative effusion which did not meet criteria for hemothorax. Follow-up therapeutic thoracentesis, performed because the patient continued to have significant O2 requirement, demonstrated bright red blood which promptly clotted in the collection bottle. Pt's case was urgently reviewed with the cardiothoracic team given concern for recurrent aortic leak. Upon review, the CT surgery team felt that an open operative repair would be too high-risk in this elderly patient. The case was further reviewed with Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 35852], [First Name3 (LF) ] interventional radiologist at [Hospital6 1129], who commented that an endovascular stent was not a feasible repair option because of the specific location of her aortic lesion based on primary review of the patient's CT angiogram findings. The patient was thus transferred back to the MICU for further medical management of a potentially unstable type B aortic dissection. Infectious disease: The patient developed staph aureus bacteremia, presumed a-line source, and was started on Vancomycin IV on [Month (only) 359] with plans to continue for a total of a two-week course via PICC line. She was also treated for E. coli urinary tract infection with Levofloxacin, and this was started on [2122-9-29] for a planned five day course. total course of five days should be Hematologic: The patient has a history of chronic anemia, and her iron studies and reticulocyte count were consistent with anemia of chronic disease. LABORATORY DATA: On admission white blood cell count 10.5, hemoglobin 7.9, hematocrit 23.9, MCV 88, MCH 29.2, RBW 13.5; white blood cell count on discharge 10.8, hemoglobin 12.1, hematocrit 35.7, platelet count 223,000; coags with a PTT of 28.5, INR 1.3; reticulocyte count of 1.9, iron 22, TIBC 147, ferratin 187, DRF 113; urinalysis [6-7] WBC, many bacteria, [3-2] epithelial cells; CHEM7 on discharge with glucose of 90, BUN 16, creatinine 0.6, sodium 138, potassium 3.7, chloride 102, bicarb 24, CK 61; LFTs within normal limits; calcium 7.9, magnesium 1.6, phosphate 2.7; culture revealed staph aureus positive with sensitivity to Vancomycin; RPR still pending on the day of discharge; E. coli from urine culture with 200,000 organisms, sensitive to Levofloxacin. Chest x-ray on admission revealed fairly marked ventricular enlargement, widening of the superior mediastinum and loss of clearly defined aortic arch, blunting of the left costophrenic angle, possibly due to effusion or hemithorax, collapse and consolidation of the left lower lobe. The right lung appeared clear. Chest CT with findings consistent with type B aortic dissection complicated by left hemothorax, as above. Repeat chest x-ray on [9-28] revealed stable widened mediastinum consistent with known aortic dissection, persistent bilateral pleural effusion, left greater than right, but no evidence of pneumothorax. Echocardiogram revealed normal ejection fraction, more than 50%, mild mitral regurgitation, mild aortic regurgitation, borderline hypertrophy of left ventricle, normal left ventricular systolic function, normal size of right ventricle, no pericardial effusion. Electrocardiogram revealed normal sinus rhythm, no ischemic changed. DISCHARGE DIAGNOSIS: 1. Type B aortic dissection, medically treated. 2. Anemia of chronic disease. 3. Hypertension. 4. Staphylococcus aureus bacteremia. 5. Escherichia coli urinary tract infection. DISCHARGE MEDICATIONS: Labetalol 600 mg p.o. b.i.d., Lasix 20 mg p.o. q.d., Vancomycin 750 mg IV q.12 hours for a total of 2 weeks (started on [2122-9-29]), Levofloxacin 500 mg p.o. q.d. total of 5 days (started on [2122-9-29]), Dulcolax 10 mg p.o. q.d. p.r.n., Lactulose 30 cc p.o. p.r.n., Amlodipine 10 mg p.o. q.d., Protonix 40 mg p.o. q.d. DISPOSITION: Transferred back to MICU. DR.[First Name (STitle) ],[First Name3 (LF) 734] 12-944 Dictated By:[Last Name (NamePattern1) 6063] MEDQUIST36 D: [2122-9-30] 13:47 T: [2122-9-30] 13:55 JOB#: [Job Number 35853] Admission Date: [2122-9-21] Discharge Date: [2122-10-4] Service: [Company 191] HISTORY OF PRESENT ILLNESS: The patient is an 86 year-old female without a significant past medical history who presented to the MICU for blood pressure management for type B aortic dissection with left hemothorax. The patient initially presented to the [Hospital3 4527] with complaints approximately one week prior to admission. She described onset of vigorous emesis without any fevers or chills, headaches, or prodrome. At that time she felt an acute, sharp infrascapular back pain, which was intermittent and slowly resolving. Today at approximately 1:00 p.m. the patient was raking her back pain. This time it was associated with diaphoresis, but without radiation. The patient's states her symptoms were worse then her prior episode, associated with nausea, and not relieved by lying down. In the Emergency Room of the [Hospital3 4527], the patient's chest x-ray demonstrated a left hemothorax. CT of the chest with contrast demonstrated a 5 mm aortic dissection with questionable distinguishment of type A verses type B. The patient was therefore transferred to [Hospital1 69] for further [Hospital1 2742]. At [Hospital3 ], an aortogram demonstrated a type B dissection. Cardiothoracic surgery evaluated the patient and recommended medical management with serial hematocrit checks. PAST MEDICAL HISTORY: Total abdominal hysterectomy, anemia. MEDICATIONS: Calcium supplements, Tylenol prn. No history of aspirin use. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies tobacco history. FAMILY HISTORY: Noncontributory. PRIMARY CARE PHYSICIAN: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Hospital3 4527] Hospital. PHYSICAL EXAMINATION: Vital signs temperature max 95.6, heart rate 70. Blood pressure 130 to 140 over 60 to 70. Respiratory rate 23. Saturation 93% on 3 liters nasal cannula. General, lying in bed, pleasant. HEENT normocephalic, atraumatic. Mucous membranes are moist. Pale. Cardiovascular, regular rate and rhythm, 2/6 systolic ejection murmur radiating into the apex. Pulmonary, decreased breath sounds on the left, right clear to auscultation. Abdomen soft, nontender. Extremities, no clubbing, 1+ bilateral distal pedal pulses, 2+ bilateral radial pulses. LABORATORY: White blood cell count 10.5, hematocrit 23.9, platelets 88, sodium 136, potassium 3.4, chloride 103, bicarb 24, BUN 23, creatinine 0.7, glucose 222, CK 79, MB 2, troponin less then .3. PT 14.9, PTT 25.3, INR 1.5. CHEST X-RAY: Left large pleural effusion with wide mediastinum. CT CHEST: Large left blowing effusion. AORTOGRAM: Type B dissection with mural irregularity, questionable thrombus. HOSPITAL COURSE: The patient is an 86 year-old female without a significant past medical history who presented to the [Hospital1 ] [First Name (Titles) ] [Last Name (Titles) 2742] and management of a type B aortic dissection. 1. Cardiovascular: The patient was evaluated by cardiothoracic surgery who decided that optimal management would be to avoid surgery and to manage medically. A blood pressure goal of a systolic blood pressure of 100-120 mmHg was set. The patient was treated with intravenous, nitroglycerin and Esmolol in the Emergency Department and was started on IV Labetalol in order to obtain blood pressure control. During medical management the patient was monitored for any development of increased pain, asymmetric poles, or increasing aortic murmur, which would have prompted a repeat CT scan. Following admission the patient's blood pressure was controlled with a Labetalol drip to a goal of a systolic blood pressure to 100 - 120. However, on the day following admission as a chest tube was being inserted to drain her left hemithorax, the patient experienced an episode of bradycardia, which resulted in asystole and unresponsiveness. Ambu bagging was initiated. Fluid resuscitation was initiated and her Labetalol was discontinued. The patient's heart rate quickly returned and though she remained somnolent she became responsive and oriented. The patient experienced two more similar episodes of bradycardia while her hemothorax was being drained without significant change in her blood pressure. It was thought that she most likely had vagal episodes as an etiology of her bradycardia possibly exacerbated by her Labetalol drip, therefore she was started on Nipride drip for a systolic blood pressure goal of 100 to 110. The patient was evaluated by the electrophysiology Service who also recommended that her bradycardic events were most likely vagally mediated. They recommended continuing beta blocker on the patient and using Atropine should the episodes recur. At this time the patient's chest tube was in a good position and draining appropriately. The patient's blood pressure proved difficult to control despite initiation of Esmolol, Nipride, Captopril and Lopressor. Her medications were altered over the course of the next few days in an attempt to find an appropriate regimen. An echocardiogram was also performed, which demonstrated left ventricular ejection fraction of 50% and no other significant findings. The patient was slowly weaned off of Nipride and then switched from intravenous Labetalol to po Labetalol. The possibility of cardiothoracic surgical procedure was revisited while the patient was being managed medically. Interventional radiology was also consulted for the possible placement of an intravascular stent. However, given involvement of the aortic arch it was felt that an intravascular stent was not appropriate. In addition, it was felt that the morbidity and mortality associated with surgical intervention was too high for this to be a consideration. The patient had obtained sufficient blood pressure control by the first of [Month (only) 359] to be transferred from the MICU to a floor unit. There she continued to have medical management of aortic dissection while final decisions from interventional radiology and cardiothoracic surgery were discussed with the family. However, on the [10-2] the patient was noted to be short of breath once again associated with some infrascapular back pain. A thoracentesis was performed for her shortness of breath, which revealed left sided effusion of clots and blood. The patient was subsequently transferred back to the Intensive Care Unit. A chest tube was not placed at this time given the risk of further destructing the thoracic vasculature. At this point a family group discussion was held to discuss the last possible options for management of this patient's aortic dissection. It was explained to the patient that while surgical correction was an option the mortality rate associated with the procedure was very high, and a high rate for post-procedure paralysis . It was also explained to her that an intravascular stent would not be appropriate management given the location of the dissection. In addition it was also explained to the patient that should she have no further surgical management that her dissection would likely rebleed some time in the future and treatment at that time would likely not be able to sustain her life. Following extensive discussions of the possible risks and benefits, the patient made the final informed decision to decline any surgical management and to return home under the care of hospice. This decision was discussed with her family and with her primary care physician. At the time of discharge the patient's blood pressure was relatively stable at approximately 120/70. Her blood pressure medications will be continued when she is at home. The patient was discharged home under hospice care. 2. Pulmonary: The patient demonstrated a type B aortic dissection with a large left pleural effusion at the time of admission. It was presumed that the patient had a large left hemothorax secondary to her aortic dissection. Her saturations were monitored and she maintained saturations of 92 to 95% on 4 liters of oxygen by nasal cannula. Cardiothoracic if surgery was consulted, placement of a chest tube to drain her left hemothorax. During placement of the chest tube the patient had three episodes of bradycardia, which were thought secondary to vagal tone. However, she maintained appropriate saturations. Following placement of the chest tube an A line was placed and an arterial blood gases showed 7.41/33/63. Over the course of the next few days the patient required oxygen supplementation by a face mask. This was thought likely secondary to an element of volume overload possibly with a combination of congestive heart failure. Therefore she was diuresed with Lasix. The patient did demonstrate some improvement of her saturations following diuresis. The chest tube was discontinued on the [10-26]. The patient had some increased tachypnea and increased O2 requirements following pulling of the chest tube. The chest x-ray demonstrated that the lung had expanded well and did not show any evidence of congestive heart failure. An echocardiogram was obtained, which showed a normal ejection fraction. Doppler ultrasound of the lower extremities were obtained to rule out deep venous thrombosis in case the patient's tachypnea would be secondary to a pulmonary embolus. However, the doppler ultrasound was negative and the patient appeared to stabilize on 5 liters of nasal cannula. The hypoxemia was thought in part related to the pulmonary vascular effects of Nitroprusside, as the hypoxemia resolved most rapidly upon discontinuation of the Nitroprusside infusion. Over the course of the next few hospital days the patient continued to maintain an O2 requirement. Her episodes of shortness of breath appeared to respond well to gentle diuresis. However, the patient did demonstrate worsening of her left pleural effusion over subsequent chest x-rays. A thoracentesis was performed, which was negative for empyema and negative for a primary hemorrhage. However, a chest tube was not placed secondary to wanting to avoid disruption of the thoracic vasculature. At that point it was felt that the patient's shortness of breath was most likely secondary to multi factorial causes. Once the decision was made for the patient to go home on hospice care, home O2 was arranged. It was also determined not to perform any further therapeutic or diagnostic taps of her pleural effusion. 3. Hematology: The patient demonstrated a drop in her baseline hematocrit on presentation in the Emergency Room thought secondary to bleeding from her aortic dissection. The patient was transfused two units of packed red blood cells and a post transfusion hematocrit demonstrated a bump from 23.9 to 28.7. It was also noted that the patient's coagulation studies were mildly elevated, therefore she was given vitamin K to increase her coagulability. The patient's hematocrit subsequently remained stable and she required no further blood transfusions. The patient was subsequently transferred to the floor, however, developed a second left sided pleural effusion on the [10-2]. It was felt that this pleural effusion was most likely a hemothorax, however, the patient's hematocrit remained relatively stable and she required only two units of packed red blood cells. Following this episode the patient had no further episodes of bleeding over the course of the hospital stay. 4. Infectious disease: At the time of presentation the patient was afebrile with a normal white blood cell count. However on the [10-26] the patient developed a new low grade temperature to 100.4 and her arterial line site demonstrated some mild erythema. Therefore this line was discontinued and she was started on Dicloxacillin for a likely cellulitis. In addition, the patient was pan cultured and a chest x-ray was checked. Over the course of the next couple of days, the patient demonstrated two blood cultures, which were positive for MRSA. The source of her MRSA was unclear but concerns included line-related infection or (less likely) mycotic aneurysm. Vancomycin 1 gram b.i.d. was started on the second of [Month (only) 359] to be continued for a total of fourteen days. The patient also completed her Dicloxacillin treatment. At the time of discharge the patient will continue her intravenous Vancomycin to be discontinued on the [10-13]. At the time of discharge the patient had been afebrile with a normalized white blood cell count. 5. Renal: The patient was admitted with a baseline creatinine of 0.8. There was no evidence of her aortic dissection compromising her renal perfusion. The patient's renal status remained stable over the course of her hospital stay. 6. GI: The patient had no gastrointestinal complaints over the course of her hospital stay. She was maintained on a regular diet, which she tolerated without difficulty. There were no further gastrointestinal issues. The patient was also maintained on Protonix for gastrointestinal prophylaxis over the course of the hospital stay. 7. Fluids, electrolytes and nutrition: The patient was able to tolerate po over the course of the hospital stay. Fluid boluses were provided on a prn basis in order to maintain urine output. Electrolytes were checked and replaced as needed. In addition, Lasix was provided on a prn basis in order to obtain optimal pulmonary function. The patient's nutritional status was maintained over the course of the hospital stay. She was discharged home with instructions to assume a cardiac diet at home. 8. Access: The patient has a PICC placed in her right arm for intravenous access. 9. Prophylaxis: Prophylaxis was maintained with pneumoboots and Protonix. 10. Code status: The patient was full code over the course of the hospital stay. However, at the final family discussion on the day prior to discharge, the patient changed her code status to DNR/DNI. This change was communicated both to the patient's family and to the patient's primary care physician. DISPOSITION: The patient was discharged to home in stable, but guarded condition. She will be under the care of hospice. MEDICATIONS ON DISCHARGE: Labetalol 600 mg po b.i.d., Lasix 20 mg po q day, Vancomycin 750 mg IV q 12 hours for a total of two weeks started on [2122-9-29]. Dulcolax 10 mg po q.d. prn, Amlodipine 10 mg po q day, Zestril 5 mg po q.d. DR.[Last Name (STitle) 2437],[First Name3 (LF) ] 12-664 Dictated By:[Name8 (MD) 8860] MEDQUIST36 D: [2122-10-3] 22:44 T: [2122-10-5] 10:51 JOB#: [Job Number 35854] cc:[Telephone/Fax (1) 35855]	[ "427.89", "285.9", "511.8", "996.62", "041.4", "511.9", "599.0", "441.00", "790.7" ]	icd9cm	[ [ [] ] ]	[ "38.93", "34.91", "34.04" ]	icd9pcs	[ [ [] ] ]							9038, 9182		6754, 7468		6547, 6730	21641, 22116		10185, 21614																				9205, 10167																						7497, 8790														8813, 8967	8984, 9021
22,143	139,997	26158	Discharge summary	report	Admission Date: [2113-1-30] Discharge Date: [2113-2-24] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: AAA with ischemic left foot changes Major Surgical or Invasive Procedure: profunda femris endartectomy,ax-profunda femoris bypass graft with PTFE,angioscopy and valvelysis of GSV,AX-femoral-AT byp with GSV issvg, lt. 3rd toe amputation [2113-2-3] angiogram of aabdominal and pelvic vessels with left leg runoff,via left femoral artery [2113-2-1] intubation History of Present Illness: 83 y M with complicated medical history including CAD a/p CABG, PVD, CHF, AF and known AAA who originally presented to surgical service as a direct admit for apparent LE graft/bypass for worsening PVD and necrotic 3rd toe of 5 days duration. He was refered to Dr. [Last Name (STitle) 1391] for evaluation for vascular surgery after being told was to high risk for surgical intervention. Past Medical History: hypertension hyper cholestremia AF, anticoagulated CHF (~35%) COPD, at baseline no inhaler or O2, no pulmonologist CAD s/p CABG ([2-/2107] LIMA->LAD, SVG->PDA, SVG->RAmus) h/o VT Social History: married lives with spouse denies smoking ETOH, socially Family History: unknown Physical Exam: Vital signs: 97.6-65-20 90/50 955 O2 room air Gen: no acute distress. HEENT: no carotid bruits Lungs: clear to auscultation Heart: Irregular, irregular rythmn ABD: sot nontender with pulsitle mass Left foot: 3rd toe necrosis with dorsal foot ischemic chamges Pulses: radial,femoral pulses palpable, popliteal dopperable monophasic signals bilaterally,left pedal pulses absent. rt. pedal pulses dopperable signa; monophasic signals Neuro intact. Pertinent Results: [2113-1-30] 10:30PM WBC-13.1* RBC-3.37* HGB-11.4* HCT-33.3* MCV-99* MCH-33.9* MCHC-34.3 RDW-13.4 [2113-1-30] 10:30PM PLT COUNT-183 [2113-1-30] 10:30PM PT-25.3* PTT-58.7* INR(PT)-4.7 [2113-1-30] 09:27PM URINE TYPE-RANDOM COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.018 [2113-1-30] 09:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2113-1-30] 09:27PM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0 Brief Hospital Course: Patient flashed on the floor. He was transferred on the unit [2-23] for pulmonary edema. The patient diuresed well with lasix gtt but still was having difficulty ventilating. In the early morning of [2-24] the patient became tired from effort of breathing. Anesthesia was called and he was intubated. Peri intubation the patient dropped his BP and pulse to 70's and 60's respectively. Likely suffered a cardiac event. He continued to decline despite fluids and pressors. Family was informed. Given his status as DNR the patient was not resucitated and he expired at 4:12 am. Family refused autopsy. Medications on Admission: lasix 40mgm qd digoxin 0.25mgm qd toprol xl 50mgm qd,coumadin 2mgm qd lipitor 20mgm qd benicar 20mgm qd,zoloft 25mgm qd, detrol 4mgm qd ariecept qd asa 81mgm qd Discharge Medications: none Discharge Disposition: Extended Care Facility: [Hospital6 54351] - [Location (un) 5503] Discharge Diagnosis: abdoniminal aortic aneurysm with foot ischemic changes postoperative blood loss anemia, transfused postoperative hypotension,resolved postoperative CHF,resolved postoperative confusion, resolved postoperative LLL pneumonia history of CAD s/p CABG"S: Lima-lad,SVG-RCA distal [2107],NQWMI [11-7] history of hypertension history of hyperlipdemia history of chronic AF history of COPD Discharge Condition: stable Discharge Instructions: none Followup Instructions: none	[ "507.0", "276.0", "427.31", "441.4", "440.1", "401.9", "518.84", "440.0", "285.1", "263.9", "V45.81", "428.0", "427.1", "730.07", "440.24", "458.29", "486", "496", "286.7" ]	icd9cm	[ [ [] ] ]	[ "00.17", "96.6", "39.29", "99.07", "38.93", "88.48", "88.42", "38.18", "99.04", "99.15", "96.71", "84.11", "96.04", "00.40" ]	icd9pcs	[ [ [] ] ]	3185, 3260	2328, 2945	297, 590	3693, 3702	1794, 2305	3755, 3762	1305, 1314		3156, 3162		3281, 3672		2971, 3133			3726, 3732									1329, 1775																			222, 259												618, 1010														1032, 1216	1232, 1289
43,314	133,852	40656	Discharge summary	report	Admission Date: [2110-5-16] Discharge Date: [2110-5-21] Date of Birth: [2028-12-13] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4679] Chief Complaint: Interstitial Lung Disease with home oxygen requirement Major Surgical or Invasive Procedure: Right sided Thoracotomy, open lung biopsy History of Present Illness: 81 yoF seen in clinic as a consult from Dr. [Last Name (STitle) ], who presented with a long standing history ( greater than 2 years ) of lung disease, recurrent bronchitis, and pulmonary infections, requiring recently escalating cyclical doses of antibiotics in order to prevent respiratory decompensation. She has been treated with multiple antibiotics, including Bactrim, and has been on ciprofloxacin and doxycycline in the past. She has had multiple bronchoscopies, and endobronchial biopsies, which have not revealed a diagnosis. She complains of multiple episodes of fever, as well as 'day sweats and hot flashes.' She denies nausea, vomiting, diarrhea. No headache, no vision changes. She reports 4 L oxygen requirement, which is up from prior weeks. She also reports requiring sitting up in order to sleep. Past Medical History: PAST MEDICAL HISTORY: - recurrent pneumonia - bronchiectasis / severe COPD - HTN - GERD - hiatal hernia Social History: She is supported by her extensive family who is with her at the bedside. She has a long standing history of second hand smoke (> 60 years). She denies alcohol or illicit drug use. Family History: Mother: breast cancer Father: lung cancer Siblings: breast cancer, lung cancer Offspring: breast cancer Physical Exam: Temp: 98.1 HR: 78 BP: 101/65 RR: 22 O2 Sat: 92% 4L GENERAL: NAD HEENT: normal exam. PERRLA, EOMI, neck soft, supple, trachea midline CV: RRR no MRG RESPIRATORY: Rales, expiratory wheeze, ronchi bilaterally ABD: soft, NT, ND no masses EXT: No CCE, extremities warm. Pertinent Results: [2110-5-16] 06:00PM BLOOD WBC-32.9* RBC-3.86* Hgb-9.9* Hct-33.0* MCV-86 MCH-25.8* MCHC-30.1* RDW-15.9* Plt Ct-695* [2110-5-21] 01:53AM BLOOD WBC-16.0* RBC-3.00* Hgb-7.8* Hct-25.4* MCV-85 MCH-26.0* MCHC-30.7* RDW-16.4* Plt Ct-544* [2110-5-16] 06:00PM BLOOD PT-11.7 PTT-23.8 INR(PT)-1.0 [2110-5-21] 01:53AM BLOOD Plt Ct-544* [2110-5-16] 06:00PM BLOOD Glucose-212* UreaN-13 Creat-0.5 Na-139 K-4.7 Cl-97 HCO3-34* AnGap-13 [2110-5-21] 01:53AM BLOOD Glucose-126* UreaN-18 Creat-0.3* Na-140 K-4.1 Cl-98 HCO3-36* AnGap-10 [2110-5-16] 06:00PM BLOOD ALT-39 AST-31 CK(CPK)-47 AlkPhos-105 Amylase-48 TotBili-0.2 [2110-5-16] 06:00PM BLOOD Albumin-2.9* Calcium-8.6 Phos-5.1* Mg-1.9 [2110-5-21] 01:53AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.1 [2110-5-16] 04:46PM BLOOD Type-ART pO2-194* pCO2-91* pH-7.16* calTCO2-34* Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [2110-5-18] 11:53PM BLOOD Type-ART pO2-77* pCO2-70* pH-7.31* calTCO2-37* Base XS-5 Intubat-INTUBATED [2110-5-21] 02:39PM BLOOD Type-ART pO2-63* pCO2-50* pH-7.45 calTCO2-36* Base XS-8 Brief Hospital Course: Patient was initally seen in clinic. Please see clinic note for details. Patient was then seen in the pre-operative area, and once again the severe risks associated with the procedure were discussed with her and her family. Seh again consented to the procedure as she stated that she could no longer live comfortably as she was, and wanted to do anything to get to a better state of health, despite the risks. In the operating room the planned procedure was carried out (see operative note) however, the patient became asystolic and ACLS protocol was carried out. She was asystolic for approximately 1 minute and underwent chest compressions. She was intubated and taken to the ICU. B/L chest tubes were placed, the right sided for the operative site and the left for inspriatory deficit. Her course from there on out was complicated mainly by a massive air leak and was unable to take adequate inspiratory volumes in order to maintain her oxygenation ad respiration. She was awake and alert for the majority of her stay. A second right sided chest tube was placed on POD 1, for residual apical pneumothorax, which improved with decompression. Tube feedings were maintained for nutrition. Her urine output was normal with a normal creatinine. She did have a large amount subcutaneous emphysema, which was lessened somewhat with chest tube suction on the right side. By POD 5, she was still unable to wean off the ventilator. Despite other organ systems being stable, she decided, after multiple conversations with the housestaff, Dr. [First Name (STitle) ] and the ICU team, that she did not want to continue on a respirator and did not want a tracheostomy if there was little hope of improving to the point of weaning off ventilatory support. After conversation to this effect, she decided that she wanted to be extubated and made Comfort Measures Only. This was done in the afternoon of [5-21]. She expired shortly thereafter. Medications on Admission: MEDICATIONS: Prednisone 40' Spiriva 18mcg' Acidophilus Herbal laxative Diltiazem 15" Flovent 220mcg' mucinex 600" Cal-[Last Name (un) ] 500"' Ventolin 90mcg 2 puffs"" B complex vitamins 1 tab' Eye Vitamins 1 tab' Fish oil 1000' Ensure " Bactrim DS 1 tab" Omeprazole 20' Ferrous Sulfate 325' Biscadoyl 10' MoM 400/50' Zolpidem 5' QHS Fleet Enema Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Interstitial lung disease Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired	[ "V49.86", "V58.65", "486", "933.1", "512.1", "427.5", "997.1", "E912", "E849.7", "V46.2", "515", "714.0", "V66.7", "530.81", "494.0", "518.81", "E878.8", "553.3" ]	icd9cm	[ [ [] ] ]	[ "96.6", "34.04", "96.04", "33.28", "99.60", "33.24", "96.72", "96.05" ]	icd9pcs	[ [ [] ] ]	5513, 5522	3127, 5081	366, 409	5591, 5600	2031, 3104	5656, 5666	1609, 1715		5481, 5490		5543, 5570		5107, 5458			5624, 5633									1730, 2012																			272, 328												437, 1266														1310, 1394	1410, 1593
890	171,089	29544	Discharge summary	report	Admission Date: [2177-12-18] Discharge Date: [2178-1-5] Date of Birth: [2113-11-30] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: transfer from [Hospital 10315] Hospital in [Location (un) 14078], CT/referring Dr. [Last Name (STitle) 5686] and Dr. [Last Name (STitle) 22956] Major Surgical or Invasive Procedure: CABG X 3, Maze, IABP placement on [2177-12-23] History of Present Illness: Mr. [Known lastname 70851] is a 64 yo gentleman who suffered a VF arrest while at a Casino. A Subsequent cardiac catheterization revealed three vessel disease. He was transferred to [Hospital1 771] for surgial evaluation. Past Medical History: PMH: Cardiomyopathy, DM, CRI, MI, CAD, CHF, +chol, Chronic Afib, HTN, Pancreatitis, Bile duct tumor PSurgH: Bile duct tumor removal Cholecystectomy Social History: 50 pack year smoking history but quit 20 yrs ago, no ETOH X 20 yrs, retired, used to work for GE, lives independently with his wife. Family History: Mother died of an unknown cancer. Father died of an MI at 65. Brother had an MI at 66. Another brother had a CABG at 55. He has 2 healthy children. Physical Exam: Vitals: P: 106 BP: 142/98 R: 16 SaO2: 93% on RA General: Awake, alert, NAD although tearful at times when discussing his near death HEENT: NC/AT, PERRL, EOMI without nystagmus, ? scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD appreciated Pulmonary: Lungs CTA bilaterally, breathing comfortably Cardiac: irreg irreg, 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 and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact Pertinent Results: [2178-1-1] 06:25AM BLOOD Hct-33.1* [2178-1-1] 06:25AM BLOOD PT-29.9* PTT-40.5* INR(PT)-3.1* [2178-1-1] 06:25AM BLOOD Glucose-63* UreaN-24* Creat-1.5* Na-138 K-4.7 Cl-98 HCO3-34* AnGap-11 [2178-1-4] 05:05AM BLOOD WBC-7.0 RBC-3.43* Hgb-10.1* Hct-31.0* MCV-90 MCH-29.6 MCHC-32.7 RDW-14.2 Plt Ct-299 [2178-1-5] 09:00AM BLOOD PT-32.0* INR(PT)-3.4* [2178-1-4] 05:05AM BLOOD PT-29.9* INR(PT)-3.1* [2178-1-3] 05:10AM BLOOD PT-29.5* PTT-36.9* INR(PT)-3.1* [2178-1-5] 09:00AM BLOOD Glucose-159* UreaN-30* Creat-1.8* Na-135 K-4.8 Cl-98 HCO3-30 AnGap-12 [2178-1-4] 05:05AM BLOOD Glucose-124* UreaN-36* Creat-2.2* Na-135 K-4.8 Cl-95* HCO3-30 AnGap-15 [2178-1-3] 05:10AM BLOOD Glucose-45* UreaN-32* Creat-2.0* Na-133 K-4.4 Cl-92* HCO3-31 AnGap-14 [2178-1-2] 06:50AM BLOOD UreaN-28* Creat-1.7* K-4.1 Brief Hospital Course: Mr. [Known lastname 70851] was brought to the operating room on [2177-12-23] and underwent a coronary artery bypass grafting times three, RF MAZE, and balloon placement. This procedure was performed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD. He was hypotensive and required the placement of a balloon pump before he was transferred to the surgical intensive care unit. His epineprhine was weaned to off and his IABP was weaned and removed on POD #2. He was extubated on POD #2. He remained in atrial fibrillation. He was transferred to the floor on POD #4. He was started on heparin and coumadin for a fib. He was seen by [Last Name (un) ] for his DM and elevated blood sugars and was restarted on his metformin and glyburide as well as set up for post op follow up and teaching. He was seen in consultation by electrophysiology for his preoperative v fib arrest. They recommended TEE and possible EP study. TEE on [1-1] showed an LAA thrombus, precluding an EP study, he will follow up as an outpatient.Also on [1-1] he developed a fever to 103. He was pancultured and placed on vanco and cipro empirically. His creatinine began to rise and his ace inhibitor was dc'd. He subsequently remained afebrile, his creatinine began to normalize, and his blood sugars improved. He was ready for discharge home on [1-5]. Medications on Admission: Home Medications: Coumadin 2.5 mg daily Enalapril 20 mg po daily Dig 0.25 Atenolol 25 mg po daily Lipitor 20 mg po daily Glyburide 10 mg po daily HCTZ 12.5 mg po daily Ranitidine 300 mg po daily Creon 10,000 tid Metformin 1000 mg po bid Viagra prn . Meds on transfer: Heparin drip stopped ASA Clonidine 0.1 mg po tid Furosemide 40 mg po daily SSI Glargine 20 U daily Metop 50 mg po bid pantoprazole 40 mg po daily Discharge Medications: 1. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day for 7 days. Disp:7 pkts Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day (with meals and at bedtime)). Disp:120 Cap(s) Refills:0 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 2 doses: Check INR [1-7] with results to Dr. [Last Name (STitle) 5686]. Disp:90 Tablet(s) Refills:0 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:270 Tablet(s) Refills:0 12. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Check INR [1-7]. Take as directed by Dr. [Last Name (STitle) 70852] for INR goal of [1-17]. Disp:30 Tablet(s) Refills:0 13. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO DINNER (Dinner): hold for blood sugar less than 80. Disp:30 Tablet(s) Refills:0 14. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BREAKFAST (Breakfast): hold for blood sugar less than 80. Disp:30 Tablet(s) Refills:0 15. Lancets 16. Glucose Test Strips Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: CAD DM CRI Chronic AF HTN Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no driving for 1 month no lifting > 10# for 10 weeks Followup Instructions: with Dr. [Last Name (STitle) 5686] in [1-17] weeks with Dr. [Last Name (STitle) ] in [3-19] weeks with Dr. [Last Name (STitle) ] in [1-17] weeks Make an appointment for education classes at [Last Name (un) ] @ [Telephone/Fax (1) 70853] Make an appointment with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1557], NP or Dr. [Last Name (STitle) 70854], or Dr. [Last Name (STitle) ] at [Last Name (un) ] for 1 [Telephone/Fax (1) 70855], and also amke an appointment with [Last Name (un) ] Vision Network at the same number. Make an appointment with Dr. [First Name (STitle) ] for 1-2 weeks Completed by:[2178-1-5]	[ "414.01", "511.9", "427.31", "410.71", "428.0", "425.4", "427.1", "518.5", "V58.61", "250.92", "585.9", "424.0", "577.8", "401.9", "412", "V10.09", "272.4", "V17.3" ]	icd9cm	[ [ [] ] ]	[ "88.72", "88.56", "37.33", "88.53", "39.61", "36.15", "37.22", "97.44", "37.61", "36.12" ]	icd9pcs	[ [ [] ] ]	6767, 6825	2935, 4308	483, 536	6895, 6902	2082, 2912	7097, 7789	1135, 1287		4773, 6744		6846, 6874		4334, 4334			6926, 7074					2047, 2063				1302, 1951			4352, 4584																283, 445												564, 797								1966, 2030						819, 969	985, 1119		4602, 4750
23,849	140,527	17422	Discharge summary	report	Admission Date: [2189-11-16] [Month/Day/Year ] Date: [2189-12-8] Date of Birth: [2123-7-19] Sex: F Service: MEDICINE Allergies: Codeine / Plavix / Aspirin Attending:[First Name3 (LF) 3913] Chief Complaint: B/L knee replacement Major Surgical or Invasive Procedure: B/L knee replacement intubation a-line placement central line placement History of Present Illness: Pt is a 66 y/o woman w/ a PMH of CMML, HTN, DM, AS (s/p bio-prosthetic AVR), and CVA who was admitted for bilateral total knee replacements. One day post-op she was found to be tachycardic, hypoxic, and hypotensive. She had awoken that morning feeling well and worked with PT but was subsequently found by the nurse to have a spo2 in the 70's, tachycardic to the 130's, and hypotensive to the 70's. She was coded w/ little BP response to NS/PRBC infusion. She was bagged with 100% fio2 and an ABG at the time was 7.35/26/256. She was transferred to the [Hospital Unit Name 153] where her respiratory and mental status declined and she was intubated. She was found to be in PEA on transfer to the [Hospital Unit Name 153] and received atropine and epi w/ return of a perfusing rhythm. She was started on pressors at this time. In the [Hospital Unit Name 153], she was noted to have a 20pt HCT drop w/out obvious source of bleeding other than weakly guaiac positive stools. She responded to PRBC infusions and has been stable afterwards. ECHO after transfer to the unit showed new wall motion abnormalities whereas a cath in [2188] had been normal. She developed severe CHF and required lasix gtt but had been auto-diuresing prior to call-out and her respiratory status has improved significantly w/ diuresis. Her pressors were slowly weaned and she was eventually started on an ace-i and bb secondary to her new dx of CHF and low EF. She was originally started on vanco/zosyn when she developed hypotension [2-18] concerns of sepsis but these were d/c'ed after her BP improved and all her cultures remained negative. Past Medical History: 1. CMML (Chronic Myelomonocytic Leukemia): Diagnosed in [2184], status post splenic radiation total 750 rads in 15 treatments 2. S/p AVR [8-20] 3. Type 2 diabetes. 4. Hypertension. 5. GERD/hiatal hernia. 6. Thyroid cancer, status post total thyroidectomy. 7. CVA times two. 8. Total abdominal hysterectomy for menorrhagia 9. S/p Cholecystectomy [94]. S/p benign breast mass excisionx 2 Social History: Denied any tobacco, alcohol, or intravenous drug abuse. Lives with her husband. Children are very involved in her care but all live in NC. Former bookeeper, retired after illness. Family History: The patient's father's side has had multiple MIs and coronary artery disease. No FH cancers. Physical Exam: Overweight woman lying in bed in NAD, raspy voice, - rashes HEENT: EOMI, PERRLA, MMM, O/P clear Neck: - LAD Lungs: CTA b/l CV: RRR, S1/S2 intact, 2/6 SEM at the USB Abd: S/NT/ND, +BS Ext: B/L knee surgical sites C/D/I w/out sign of infection, + LE edema Neuro: CN 2-12 grossly intact, AAO x3 Pertinent Results: [2189-11-16] 07:00PM CK(CPK)-49 [2189-11-16] 07:00PM CK-MB-2 [2189-11-16] 01:28PM CK(CPK)-36 [2189-11-16] 01:28PM CK-MB-2 cTropnT-0.03* TTE [2189-11-20] The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is moderately-to-severely depressed (ejectoion fraction 30 percent) secondeary to severe hypokinesis of the anterior septum, anterior free wall, and apex. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. A bioprosthetic aortic valve prosthesis is present. The aortic prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. There is moderate thickening of the mitral valve chordae. There is a minimally increased gradient consistent with trivial mitral stenosis. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the findings of the prior study (tape reviewed) of [2189-11-17], the heart rate and left ventricular ejection fraction are reduced. CT C/A/P [2189-11-18] IMPRESSION: 1. No evidence of retroperitoneal hematoma. 2. Stable pelvic lymphadenopathy. 3. Stable soft tissue mass in the left pelvis, which may represent a duplication cyst, enlarged lymph node, or left ovary/mass as stated on the previous examinations. 4. Enlarged right axillary and mediastinal lymph nodes of uncertain clinical significance. 5. Bilateral pleural effusions. Ultrasound R upper extremity [2189-11-26] IMPRESSION: No DVT. Thrombus within the distal right cephalic vein. DUPLEX DOPP ABD/PEL [2189-11-20] 3:54 PM LIVER ULTRASOUND WITH DOPPLER: The patient is status post cholecystectomy. There is no intrahepatic bile duct dilatation. The common bile duct measures 6 mm, which is normal for a post-cholecystectomy state. The portal vein is patent with normal direction of flow. The hepatic veins and main hepatic artery are patent. No ascites is seen. IMPRESSION: 1. No evidence of intra- or extra-hepatic bile duct dilatation. 2. The hepatic vessels are patent. 3. No evidence of ascites. KNEE 2 VIEW PORTABLE BILAT [2189-11-16] 1:33 PM BOTH KNEES: Two nonstandard views show bilateral new total knee prostheses. Skin staples and drains are in place. There is post surgical air within the soft tissues. IMPRESSION: Status post bilateral total knee arthroplasty. Brief Hospital Course: A/P: 66 y/o f with CMML, AVR, DM2, HTN admitted for bilateral total knee replacements who developed shock and hypoxemic respiratory failure on post-op day 1 . #Shock -- On transfer to the [Hospital Unit Name 153], had a 20 point Hct drop. Was evaluated extensively and pan scanned but no etiology of bleeding found. Required 7 units PRBC to increase her Hct. A STAT echo on transfer to the [Hospital Unit Name 153] showed a possible new wall motion abnormality (after being coded) but no effusion, no evidence of tamponade, no changes in AVR, and an EF of 35-40% Repeat echo [11-25] showed persistant EF of 35%. Cardiology was consulted and they felt that her decreased LV systolic dysfunction was post-arrest given her clean coronaries in [2188] in cath for pre-op for her AVR. They recommended a follow-up echo at some point in the next few months. . 1. Hct drop -- No clear source. Ortho evaluated and didn't feel it's her knees. She is not hemolyzing by labs. An NG lavage was negative though she was trace guaiac positive (though no melena/hematochezia). Imaging did not reveal the source of the bleed and she remained stable for the remainder of her stay. . 2. Respiratory failure- Unclear what the etiology of the pt's respiratory failure was on admission to the [Hospital Unit Name 153]. Was able to be weaned down and was extubated on [11-20]. However, later that night, she developed increased work of breathing and was unable to clear her secretions so pt was reintubated. Extubated [11-30] after a prolonged wean and difficulty getting off the vent. She was thought to have difficult extubation due to volume overload and improved once she was diuresed with a lasix gtt. Pt was transfered to the floor on 4L NC. The patient autodiuresed well on the floor and was eventually weaned off her O2 requirement. . 3. New LBBB and [Name (NI) 48688] Pt had clean coronaries on cath 4/[2188]. New wall motion abnormalities following cardiac arrest on transfer to the [Hospital Unit Name 153]. Had chest pain [11-24] with unchanged ECG. Pain worse with palpation, c/w musculoskeletal injury. She was started on both a bblocker and acei when her bp tolerated. Cardiology was consulted who recommended lasix 40 mg PO QD for fluid overload. They recommended a follow-up Echo in the next few months. . 4. CMML -- Was followed by BMT service. WBC count rising so restarted on hydroxyurea on [11-22], and prednisone on [12-2]. Her hydrea dose was titrated daily until her wbc remained stable ~ 20 and her platelets also remained stable. . 5. Knees - Pt received her bilateral knee replacement for her DJD and was followed by ortho throughout her course. she was started on lovenox. she did well with PT and her wound remained c/d/i. she will be d/c'ed to long term rehab for PT. . 6. Stage 2-3 ulcer R heel - Patient developed ulcer from CPM machine as part of her rehab for her s/p TKR, which remained uninfected. Wound management followed, and it was cleaned with sterile water, pat dried and dressed with a duoderm bandage and Kerlex bandage QD. Medications on Admission: 1. Pantoprazole 40 mg Tablet [Hospital1 ] 2. Danazol 200 mg Capsule Sig: PO Q12H 3. Hydroxyurea 500 mg Capsule PO DAILY 4. Prednisone 2.5 mg Tablet Three Tablet PO DAILY 5. Captopril 12.5 mg Tablet 1 Tablet PO BID 6. Allopurinol 100 mg Tablet 1 Tablet PO DAILY 7. Levothyroxine Sodium 112 mcg 1 Tablet PO DAILY 8. Furosemide 20 mg Tablet 1 Tablet PO DAILY 9. Ergocalciferol (Vitamin D2) 50,000 unit [Unit Number ] PO ONCE ON WED AND SUN 10. Multivitamin 11. Vitamin E 400 unit [Unit Number ]. Zyrtec 10 mg Tablet 13. Reglan 10 mg Tablet 1 PO TID [Unit Number ] Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 3. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for a total of 12.5 mg PO QD. 5. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day: for total dose of 12.5 mg PO QD. 6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 7. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 12. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 14. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for [Female First Name (un) ] skin infection. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 19. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 21. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO once a day. 22. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO QD with meal. [Female First Name (un) ] Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] [Location (un) ] Diagnosis: Primary: Shock Hypoxic respiratory failure S/p bilateral total knee replacements Probable myocardial infarction with new left bundle branch block and wall motion abnormalities Chronic Myelomonocytic Leukemia status post radiation therapy and splenectomy Stage II-III pressure ulcer on Right heel Secondary: Aortic stenosis status post bio-prosthetic Aortic Valve Replacement Hypertension Diabetes Mellitus 2 Hypertension Thyroid cancer status post thyroidectomy Cerebral Vascular Accident x 2 Gastroesophageal Reflux Disease status post cholecystectomy [Location (un) ] Condition: Fair [Location (un) ] Instructions: 1. Please take all medications as prescribed. 2. Please attend all follow-up appointments. 3. Seek medical attention if you develop fevers, chills, nausea, vomiting, shortness of breath, chest pain or any other concerning symptoms. Followup Instructions: Please make a follow-up appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1557] at [Telephone/Fax (1) 3237] in the next 1-2 weeks. Please call to make an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 2 weeks at [Telephone/Fax (1) 1113]. Completed by:[2189-12-8]	[ "205.10", "428.40", "401.9", "V10.87", "786.3", "E878.1", "E849.7", "250.00", "998.0", "428.0", "427.5", "707.07", "997.1", "530.81", "518.81", "V42.2", "276.2", "275.41", "715.36", "285.1" ]	icd9cm	[ [ [] ] ]	[ "96.04", "33.22", "99.60", "88.72", "96.72", "81.54", "99.04", "38.93", "38.91" ]	icd9pcs	[ [ [] ] ]		6004, 9112	321, 395		3133, 5981	12659, 13015	2711, 2806						9138, 11741												2821, 3114																	11773, 12329		261, 283		12361, 12368	12403, 12636									423, 2074														2096, 2496	2512, 2695
20,124	101,852	49717	Discharge summary	report	Admission Date: [2189-4-15] Discharge Date: [2189-4-17] Date of Birth: [2133-2-8] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: Right arm swelling. Major Surgical or Invasive Procedure: Venography of right arm/chest. Angioplasty of right subclavian/brachiocephalic thrombus. TPA infusion. History of Present Illness: Patient is well-known to the Transplant service. He has ESRD secondary to anti-GBM disease, and recently was admitted for thrombectomy of his left AV Vectra graft. Ultimately, that failed and a right subclavian Permacath was placed for dialysis access. He now returns having been seen at his dialysis center after successful dialysis, but with noticeable pain-free right arm swelling. Past Medical History: 1. ESRD: [2-5] anti-GBM disease, on HD since [3-7] 2. DM2: dx [2177] 3. HTN 4. Chronic low back pain [2-5] herniated discs 5. CHF 6. Peripheral neuropathy 7. Anemia 8. h/o nephrolithiasis 9. s/p cervical laminectomy 10. h/o depression 11. h/o MSSA bacteremia 12. s/p L AV graft: [7-7] Social History: Lives w/ wife, son, daughter-in-law, and three grandchildren in [Name (NI) 86] area, has been unemployed [2-5] disability, smokes tobacco 1 ppd x45 years, past alcohol, no recreational drug use. Family History: 1. DM 2. Renal failure Physical Exam: AVSS. Gen: NAD, A&O x3 Chest: CTA, RRR Abd: S, NT, ND Ext: trace RUE edema, otherwise warm and well-perfused Pertinent Results: [2189-4-15] 07:00AM BLOOD PT-27.6* INR(PT)-2.8* [2189-4-17] 02:18AM BLOOD WBC-6.7 RBC-2.81* Hgb-8.4* Hct-26.8* MCV-95 MCH-30.0 MCHC-31.5 RDW-17.5* Plt Ct-432 [2189-4-17] 02:18AM BLOOD PT-22.3* PTT-35.2* INR(PT)-2.2* [2189-4-17] 02:18AM BLOOD Glucose-120* UreaN-40* Creat-9.3* Na-142 K-4.8 Cl-100 HCO3-29 AnGap-18 [2189-4-17] 02:18AM BLOOD Calcium-8.9 Phos-6.0* Mg-1.7 Brief Hospital Course: Patient was seen in the ER and ultrasound revealed that he had a right IJ thrombus, and that the tip of the Permacath was in the right IJ. This is despite having an admission INR of 2.8. He was admitted for work-up of the thrombus and possible resiting of the dialysis line. On HD #2, patient went to IR for venography to delineate the extent of thrombus and catheter position, as well as to look for central stenoses or other reasons for his failed left arm AV graft and new clot in right system. IR found an occlusion of the right subclavian/brachiocephalic, performed angioplasty of the presumed thrombus and left a venous sheath in place for TPA thrombolysis with the intention of follow-up venography on HD #3. Incidentally, the Permacath was seen to be in good position. Subsequent to this, discussion between Dr. [First Name (STitle) ] and the patient's nephrologist concluded that the risk of bleeding outweighed the possible benefit of thrombolysis; TPA administration was stopped. On HD #3, the patient had his sheath removed, was dialyzed successfully through the Permacath and he was discharged home. Medications on Admission: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QHD (each hemodialysis). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. Sevelamer 400 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 13. Choline & Magnesium Salicylate 750 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QHD (each hemodialysis). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. Sevelamer 400 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 13. Choline & Magnesium Salicylate 750 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: DVT of right internal jugular/subclavian/brachiocephalic veins. Discharge Condition: Stable. Mild residual swelling of right arm. Discharge Instructions: DC to home. Continue with hemodialysis via right subclavian Permacath. Continue with outpatient Coumadin and INR checks with goal INR 2 - 3. Elevate right arm when possible to reduce swelling. Followup Instructions: Follow-Provider: [Name10 (NameIs) 1344] [Last Name (NamePattern4) 3125], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2189-4-23] 10:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 544], M.D. Date/Time:[2189-6-12] 11:30 Completed by:[0-0-0]	[ "996.73", "403.91", "583.89", "722.10", "250.00", "585.6", "285.21", "453.8", "V13.01", "428.0", "356.9" ]	icd9cm	[ [ [] ] ]	[ "00.41", "39.50", "99.10", "39.95", "88.67" ]	icd9pcs	[ [ [] ] ]	5417, 5423	2001, 3129	332, 438	5530, 5577	1588, 1978	5821, 6118	1420, 1444		4286, 5394		5444, 5509		3155, 4263			5601, 5798									1459, 1569																			273, 294												466, 855														877, 1183	1199, 1404
32,381	118,260	7972	Discharge summary	report	Admission Date: [2173-4-13] Discharge Date: [2173-4-21] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor Last Name 10493] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Endotracheal Intubation Bronchoscopy History of Present Illness: 89 year old man with hx atrial fibrillation, HTN, BPH, bronchiectasis presenting with cough for the past week. Per family member, he was having a worsening productive cough. He was evaluated by his PCP who thought it was an sinus allergy and prescribed a nasal spray. She denied his having a fever. She denied he had chest pain or particular shortness of breath. He had a mild headache yesterday. Today, he said to her that he did not feel well which prompted a trip to the ED. In the ED, his initial vital signs were notable for 98.5 (100.2rec) 178/128 22 94%4L. He subsequently stated that he had shortness of breath. A CXR was unchanged from prior. He had progressive respiratory fatigue and was intubated with etomidate prior to having a CTA chest. Following intubation, he dropped his blood pressure to 70s systolic which improved following IVF and removal of the propofol. . ROS: per the patient's wife: denies chest pain, abd pain, dysuria, back pain. no leg swelling. Past Medical History: 1. Newly diagnosed Atrial fibrillation 2. HTN 3. CAD s/p RCA PTCA '[59]. Repeat cath [2163]: 40% mid LAD, 40% mid LCX, luminal irregularities RCA. Last stress mibi [3-23]: No ECG or anginal sxs. Normal myocardial perfusion at the level of stress achieved, Calculated LVEF of 56%. 4. Hypercholesterolemia 5. BPH s/p TURP 6. s/p tympanomastoidectomy Social History: The patient lives with a girlfriend. [Name (NI) 4084] smoked. Drink socially, no illicit drugs. He is a retired salesman. A possible asbestos exposure in the past. Family History: Notable for a mother who died of a myocardial infarction in her 80's. Father died of a myocardial infarction in his 80's. Physical Exam: VS: 98.5 129/63 80 22 100% initial vent: AC 500 x 16 FIO2 1 PEEP 5 PIP 28 Plat 20 GEN: intubated, sedated HEENT: AT, NC, pupils 2->1 bilat, normal response to oculocephalics, no conjuctival injection, anicteric, MMM, Neck supple, no LAD, no carotid bruits. IJ to mid thyroid cart CV: irreg irreg, nl s1, s2, no m/r/g PULM: inspiratory wheeze bilat. crackles at bases. good ABD: soft, NT, ND, + BS, no HSM EXT: warm, dry, +1 distal pulses BL, no femoral bruits NEURO: sedated. moving all 4 extremities in response to noxious stimuli PSYCH: unable to assess Pertinent Results: [2173-4-13] 09:30AM WBC-8.5# RBC-5.19 HGB-15.0 HCT-46.4 MCV-89 MCH-29.0 MCHC-32.4 RDW-13.5 [2173-4-13] 09:30AM NEUTS-70 BANDS-14* LYMPHS-10* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2173-4-13] 09:30AM PLT SMR-NORMAL PLT COUNT-221 [2173-4-13] 09:30AM GLUCOSE-134* UREA N-24* CREAT-0.8 SODIUM-144 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-31 ANION GAP-14 [2173-4-13] 09:30AM ALT(SGPT)-45* AST(SGOT)-48* LD(LDH)-323* CK(CPK)-67 ALK PHOS-104 TOT BILI-1.1 [2173-4-13] 11:13AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG [2173-4-13] 05:38PM DIGOXIN-0.3* [2173-4-13] 05:38PM CK-MB-NotDone cTropnT-<0.01 [2173-4-13] 05:38PM CK(CPK)-34* . CXR - Bilateral lower lung pleural plaques are consistent with prior asbestos exposure. An apparent interstitial abnormality is better evaluated on recently performed CTA chest ([2172-3-8]). There is no focal airspace consolidation or pleural effusion. The bony thorax is unremarkable. . CTA chest - (wet read) No PE. Again cardiomegaly, pleural and interstitial abnormalities c/w asbestosis exposure and mild asbestosis. . CXR - (post-intubation) - Post-intubation with endotracheal tube and orogastric tube in satisfactory position. . Echo: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is markedly dilated with borderline normal free wall function. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([11-18]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Severely dilated right ventricle with at least mild pulmonary artery systolic hypertension (may be underestimated as right atrial pressures are probably elevated). Moderate tricuspid regurgitation. Mild to moderate mitral regurgitation. Brief Hospital Course: 89 year old man with history of CAD, HTN, atrial fibrillation, and bronchiectasis who presented dizziness to have progressive hypoxic respiratory failure from presumed pneumonia who also developed urinary tract infection and traumatic hematuria. . 1 Hypoxic respiratory failure: Leading cause given low grade fever and bandemia would be CAP although he did not have an impressive chest xray for infection on admission. After intubation with fluid resuscitation, the patient had bilateral patchy infiltrates superimposed on evidence of chronic parenchymal disease on prior films. The patient was intubated for 4 days. He was treated with double coverage (levo/CTX) for CAP requiring ICU admission. He was extubated and did well, aided by one day of diuresis with lasix, but has been auto-diuresing since. His EKG was not significantly changed from prior. CT was also negative for PE. He completed 5 days of levofloxacin 750mg qdaily and 8 days of ceftriaxone 1g q24hours. He was noted to be deconditioned after extubation and felt to have difficulty clearing secretions so was aided with the use a flutter valve, incentive spirometer, chest pt, regular pt, albuterol and ipratropium nebs, and guaifenesin. He was slowly weaned from supplemental oxygen, with sats in the low 90's on RA. . 2 Rising leykocytosis: After being transferred from the MICU, the patient was noted to have a rising WBC. After a UA came back with moderate bacteria and >1000 WBC, a UTI was suspected and a course of Cipro 500mg PO Q12 hours was started. This was later discontinued after 1 dose and a repeat UA was completely negative. He developed loose stool and was started on empiric Flagyl 500mg PO TID on [2173-4-19] out of concern for C. Difficile (sample negative x1 on discharge; 2nd sample pending). His diarrhea was improving by time of discharge and his WBC had decreased from 15k to 12k after one day of metronidazole. He will continue metronidazole through [2173-5-4]. . 3 Atrial fibrillation: Beta blocker was titrated up in MICU. Digoxin was initially held then restarted, with level noted to be 0.4. Aspirin 325mg was continued throughout. He is chronically not anticoagulated due to fall risk per Dr. [Known lastname 1007]. Before discharge,his BP's were running low (systolic high 90's and low 100's) necessitating holding of the metoprolol and HCTZ. It was decided to decrease the metoprolol to 50mg PO BID, closer to his initial home dose of 50mg PO daily. . 4 Hematuria: He was noted to develop hematuria, presumably from foley placment. Once the foley was removed he continued have bloody urine but never became obstructed. This should be followed up as an outpatient to determine resolution. . 5 Dementia: Alzheimer's type per Dr. [Known lastname 1007]. He was continued on donepizil. He became delerious at night in the icu but improved with haldol/trazadone. On the floor he only needed haldol and remained lucid with good attention. . #CODE: FULL . #COMMUNICATION: patient, [Name (NI) 2013] [Name (NI) 28573] (wife) [Telephone/Fax (1) 28574], [First Name5 (NamePattern1) 553] [Last Name (NamePattern1) 28575] (youngest daughter) [Telephone/Fax (1) 28576] . #DISPO: Stable respiratory status and requiring respiratory rehab. Diarrhea and WBC are improving, and patient ready to be transferred to [Hospital1 100] Senior Life. Medications on Admission: aricept 10 mg daily hctz 12.5 mg daily zocor 20 mg daily zestril 5 mg qAM digoxin 125 mg daily metoprolol 25 mg [Hospital1 ] Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Primary: Hypoxic respiratory failure from pneumonia, chronic congestive heart failure with diastolic dysfunction, traumatic hematuria, urinary tract colonization, suspected C. Difficile colitis. . Secondary: Dementia, bronchiectasis, benign prostatic hypertrophy, hypertension, atrial fibrilation. Discharge Condition: Ambulating with assistance, eating. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your doctor or return to the emergency department if you experience chest pain, shortness of breath, abdominal pain, diarrhea, or any symptoms that concern you. Followup Instructions: Please follow-up with Dr. [First Name4 (NamePattern1) ] [Known lastname 1007] within 1-2 weeks of discharge. [First Name11 (Name Pattern1) ] [Known lastname 10491] MD, [MD Number(3) 10495]	[ "294.10", "600.00", "599.7", "501", "401.9", "787.91", "518.81", "428.32", "427.31", "008.45", "331.0", "486" ]	icd9cm	[ [ [] ] ]	[ "33.24", "96.6", "96.72", "96.04" ]	icd9pcs	[ [ [] ] ]	8491, 8576	4934, 8311	283, 321	8918, 8956	2630, 4911	9262, 9503	1914, 2038				8597, 8897		8337, 8468			8980, 9239									2053, 2611																			224, 245												349, 1327														1349, 1712	1728, 1898
9,267	155,455	5902	Discharge summary	report	Admission Date: [2147-10-2] Discharge Date: [2147-11-3] Date of Birth: [2096-3-15] Sex: F Service: MEDICINE CHIEF COMPLAINT: Seizure with respiratory distress. HISTORY OF PRESENT ILLNESS: This is a 51 year old female with Down syndrome, dementia, seizure disorder and paraparesis, and aphasic since cervical cord surgery, who has been living in a nursing home and attending day care. At day care, ten days prior to her transfer to the [Hospital1 346], the patient had a witnessed seizure involving the upper extremities lasting for fifteen minutes. The patient was shifted to the [Hospital6 33] where she was found to have respiratory distress. Chest x-ray showed right infiltrate which was consistent with aspiration. The patient was admitted to Intensive Care Unit and started on antiepileptics. She became toxic at very low doses of Dilantin and then on Tegretol and was successfully put on Trileptal. The dose of Trileptal was titrated up in relation to the occurrence of myoclonus. The patient was started on a course of intravenous Clindamycin and Tequin and supplemental oxygen to maintain saturation between 96 and 98% and physiotherapy, pulmonary toilette and inhalers. Blood cultures were negative and sputum cultures grew out Methicillin resistant Staphylococcus aureus sensitive to Tequin, Gentamicin, Bactrim, Tetracycline and Vancomycin. On [2147-9-22], the patient developed mild congestive heart failure and was diuresed with Lasix 40 mg p.o. The patient continued to be lethargic without return to her previous mental status maintaining inadequate oral intake of pureed diet and needing supplemental oxygen. Laboratories showed an increase in TSH and the dose of Synthroid was increased to 0.15 mg q.d. The patient was transferred to the [Hospital1 69] further management. PAST MEDICAL HISTORY: 1. Down syndrome. 2. Dementia likely due to Down syndrome. 3. Seizure disorder about once monthly seizures which last only a minute or two but in which her postictal state would last for about 24 hours. She was not on any antiseizure medicines at the time of admission to the [Hospital6 3426]. 4. C3-C4 spinal fusion, paraparesis, minimally responsible, unable to do activities of daily living, status post spinal cord surgery. 5. Dysphagia and previous gastrostomy tube, now eating soft foods with recent swallowing study felt to be encouraging. 6. Hypothyroidism, recent TSH with increase in the Synthroid dose. 7. History of diverticulitis. 8. Chronic incontinence of urine and stool for which she wears diapers. 9. Urinary tract infections are frequent. 10. Chronically loose stools. 11. History of Methicillin resistant Staphylococcus aureus in sputum. ALLERGIES: Penicillin, Sulfa, Erythromycin and Dilantin. MEDICATIONS ON ADMISSION: 1. Folic Acid 1 mg q.d. 2. Vitamin C 500 mg q.d. 3. Zinc 200 mg q.d. 4. Aspirin 81 mg q.d. 5. Beconase one spray each nostril b.i.d. 6. Ventolin MDI q.i.d. 7. Synthroid 0.125 mcg q.d. 8. Colace 100 mg b.i.d. 9. Trileptal 150 mg b.i.d. The patient is nonverbal and the history was obtained from records and the brother, [Name (NI) ] [Name (NI) 23306], who is her health care proxy, and the rest of the family who are very supportive. PHYSICAL EXAMINATION: On examination, the patient was alert, afebrile, vital signs stable, saturation in mid 90s on blow by mask at 40%. Skin no rashes. Mucous membranes are dry. The pupils are equal, round, and reactive to light and accommodation. Conjunctiva anicteric. Oropharynx is dry. The neck is supple with no lymphadenopathy. Chest - coarse breath sounds anteriorly. Cardiovascular - distant, regular rate and rhythm, no murmur appreciated. The abdomen is soft, bowel sounds present. Extremities - no edema or cyanosis. Back - small decubitus ulcer. LABORATORY DATA: White blood cell count 6.3, hematocrit 46.4, platelets 343,000. Prothrombin time 13.2, partial thromboplastin time 27.7, INR 1.2. Sodium 142, potassium 4.0, chloride 101, CO2 32, blood urea nitrogen 11, creatinine 0.9, glucose 112. Albumin 2.9, calcium 8.6, magnesium 2.2, phosphate 3.1. HOSPITAL COURSE: The patient was admitted to the Medical Service and placed on supplemental oxygen and course of Tequin and Clindamycin was continued. After admission to the hospital, the patient underwent a swallow study which showed that the patient aspirated pureed food and was made NPO. CAT scan of the chest was done on [2147-10-4], which was negative for primary embolus and the chest x-ray showed mild chronic heart failure and the patient was started on Captopril. Code status was discussed with the brother and the patient's code status was changed from full code to no shock but intubation was permitted. A gastric tube was passed on [2147-10-4], and the patient was started on her prehospitalization medications. Enteral feeds were started on [2147-10-5]. The patient was weaned to two liters of oxygen via nasal prong but had intermittent periods of desaturation with tachycardia of unknown origin. The patient continued to deteriorating and was intubated for respiratory distress on [2147-10-6], and was put on mechanical ventilation, placed empirically on Vancomycin and Gentamicin while the results of the culture were awaited. The patient had an episode of hematuria on [2147-10-6]. Genitourinary services were consulted and thought it was traumatic due to the Foley or due to chronic Foley catheter placement and did not deem any intervention necessary at this time. The patient also had severe yeast infection of the labia and groin and was treated with antifungal powder, with suppositories. The decubitus ulcer on the left lateral malleolus and sacrum was treated with Duoderm and waffle boots. The patient became hypertensive to 180/122 with tonic seizures. The seizures resolved with Ativan administration and the patient's pressure normalized and showed downward trend and required pressor infusion to maintain adequate blood pressure. The patient was ruled out for myocardial infarction. An electroencephalogram done on [2147-10-7], showed evidence of burst suppression with right hemispheric spikes which were asymmetric suggestive of encephalopathy due to anoxia, benzodiazepines, barbiturates or other interictal states but structural lesions could not be ruled out as the patient looked more alert but was hemodynamically unstable and would have been a poor surgical candidate. Further studies were not carried out at that time. The patient remained stable and underwent delayed pressors over the course of the next few days and initially did not show much respiratory effort when weaning was attempted. Over the next few days, the patient was weaned to pressor support and then extubated on [2147-10-15]. The patient was weaned off the pressors on [2147-10-12]. The systolic pressures tended to drop into the 70s and 80s when the patient was asleep but there was no evidence of decreased perfusion and the pressures were returned to the 90s to 100s systolic when the patient was aroused. The patient continued to have peak copious secretions which required frequent suctioning and aggressive pulmonary toilette. On [2147-10-17], the patient had three small consecutive seizure episodes witnessed by the neurology team and hypoxia with decreased saturation over the course of the day. There was a suspicion of repeat aspiration and the patient was reintubated after a discussion with the family. The patient continued to be intubated and ventilated for the next week and showed minimal spontaneous effort. The course of antibiotics, Levofloxacin and Vancomycin, was completed on [2147-10-20], and the patient had a percutaneous endoscopic jejunostomy tube placed on the same day. On [2147-10-24], the patient had increased thick tan colored secretions, a spike in temperature and an increase in the white blood cell count. The patient was pancultured and stool sent for Clostridium difficile analysis. The patient was started empirically on Ceftriaxone and Flagyl for wide spectrum coverage. The preliminary sputum culture showed heavy growth of guaiac positive staphylococcus aureus and the antibiotics were changed to Vancomycin for one week after infectious disease consultation. The patient was evaluated by ENT team for a tracheostomy which was placed under general anesthesia without untoward events on [2147-10-24]. Due to poor intravenous access, a PICC line was placed by interventional radiology on [2147-10-27]. The patient had a decrease in the sodium level at 130. Her tube feeds were changed from ProMod with fiber to Respalor at 35 ml/hour at goal. She finished her antibiotic course on [2147-11-3], and was discharged to [Hospital1 13199] Rehabilitation Center on [2147-11-3], in stable condition on a tracheostomy mask. Laboratories at discharge included white blood cell count 12.9, hematocrit 30.0, platelets 469,000. Sodium 130, potassium 4.5, chloride 102, CO2 25, blood urea nitrogen 8, creatinine 0.7, glucose 97. The patient was discharged to [Hospital1 13199] Rehabilitation Center in stable condition with a #4 Shiley tracheostomy in place and a percutaneous endoscopic jejunostomy tube. The patient was on tracheostomy mask with humidified oxygen at 40%. MEDICATIONS ON DISCHARGE:: 1. Trileptal 150 mg at 7:00 a.m. and 300 mg at 7:00 p.m. per percutaneous endoscopic jejunostomy tube. 2. Synthroid 0.25 mg per percutaneous endoscopic jejunostomy tube. 3. Respalor at 35 ml/hour through percutaneous endoscopic jejunostomy tube. 4. Heparin 5000 units subcutaneous b.i.d. 5. Albuterol/Atrovent one to two puffs q4hours p.r.n. 6. Zinc Sulfate 220 mg per percutaneous endoscopic jejunostomy tube. 7. Vitamin C 500 mg per percutaneous endoscopic jejunostomy tube b.i.d. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Name8 (MD) 23307] MEDQUIST36 D: [2147-11-3] 13:46 T: [2147-11-3] 14:30 JOB#: [Job Number 23308] and [Numeric Identifier 23309] and [Numeric Identifier ]	[ "518.81", "482.41", "244.9", "507.0", "428.0", "758.0", "780.39", "V45.4", "707.0" ]	icd9cm	[ [ [] ] ]	[ "31.29", "96.6", "96.04", "96.72", "44.32" ]	icd9pcs	[ [ [] ] ]												9405, 10191	2834, 3286	4182, 9379																				3309, 4164										159, 195												224, 1854														1876, 2808
27,343	149,718	32770	Discharge summary	report	Admission Date: [2178-12-17] Discharge Date: [2178-12-24] Date of Birth: [2135-12-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 134] Chief Complaint: Vfib arrest Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: Mr. [Known lastname 11041] is a 42 yo male with a history of hyperlipidemia who collapsed while playing soccer on the evening of admission. 911 was called at approx 9:30pm after the patient had collapsed. The fire department arrived first, and initiated CPR. ACD was applied, and reportedly the patient was shocked x 1 for VFIB (strip not available). EMS team arrived at 9:40 PM, pt in asystole at that time. CPR continued, ACLS started and pt given epi x 2 and atropine x 1 at which point he developed sinus brady at 57 and SBP 110/70. He was intubated in the field and transported to OSH. . The patient's wife reports that the patient had complained of chest pain during exercise over the past few months. No reports of pain today. Wife reports he had no recent complaints of fever/chills at home. No complaints of dyspnea. No significant PMH with the exception of hyperlipidemia for which he took medication. . At the OSH: Initial Vitals: HR 50-60, BP 100-110/60-70s, afebrile. WBC: 11, Hct 43.4, Plt 211, Na 138, K 3.5, Cl 100, CO2 17, Glc 272, BUN 31, Cr 1.4, CK 426, MB 3.8, I 0.8, TropI 0.09 (nl 0-0.3). Started on lidocaine gtt, propofol gtt, given ASA 325 PR, ativan 1 mg IV, 1 L NS. GCS = 4 per [Location (un) ] note. . [Location (un) 7622] to [Hospital1 18] CCU at request of family. . ROS: Unable to obtain. Past Medical History: Hyperlipidemia No history of hypertension or diabetes Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse or drug use. Family History: There is no family history of premature coronary artery disease or sudden death. Father died of MI at age 60s, grandfather age 80s. [Name2 (NI) ] history of arrhythmia. No recent travel. Pt moved to the US at age 20. Physical Exam: ADMISSION PHYSICAL EXAM VS: T 99.8, HR 80 BP 117/75, RR 19, O2 100% on AC 500x20, 60%, PEEP 5. Gen: intubated, sedated, nonresponsive. HEENT: NCAT. Sclera anicteric. PERRL 4->2 b/l. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple without JVD CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, ND, No HSM. No abdominial bruits. Ext: Cool to touch. 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 NEURO: PERRL. Moves b/l LE in response to pain. Did not see any UE movement, (though UE movement documented in OSH note). Babinski mute b/l. No clonus. +cough, uncertain if gag reflex. Pertinent Results: OSH EKG: NSR at 63, TW depression V3, TW depression V4 V5, unable to interpret leads aVR, aVL, aVF. EKG on admission to CCU: NSR at 67, nl axis, nl intervals, QTc = 374. TWI III, Q in III. ?J point elevation in V2, V3. biphasic T waves V3, V4. No prior available for comparision. . [2178-12-17] 02:30AM WBC-10.7 RBC-4.76 HGB-15.1 HCT-42.6 MCV-89 MCH-31.6 MCHC-35.4* RDW-12.8 [2178-12-17] 02:30AM NEUTS-82.9* LYMPHS-11.5* MONOS-5.2 EOS-0.3 BASOS-0.1 [2178-12-17] 02:30AM PLT COUNT-203 [2178-12-17] 02:30AM PT-13.5* PTT-23.5 INR(PT)-1.2* [2178-12-17] 02:26AM GLUCOSE-114* LACTATE-1.8 NA+-138 K+-5.0 [2178-12-17] 02:26AM freeCa-1.19 [2178-12-17] 02:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2178-12-17] 02:30AM TRIGLYCER-74 HDL CHOL-49 CHOL/HDL-2.9 LDL(CALC)-80 [2178-12-17] 02:30AM ALBUMIN-4.0 CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-2.1 CHOLEST-144 [2178-12-17] 02:30AM CK-MB-41* MB INDX-6.1* cTropnT-2.43* [2178-12-17] 02:30AM ALT(SGPT)-115* AST(SGOT)-126* LD(LDH)-278* CK(CPK)-670* ALK PHOS-96 TOT BILI-0.4 [2178-12-17] 02:30AM GLUCOSE-116* UREA N-31* CREAT-1.4* SODIUM-140 POTASSIUM-5.6* CHLORIDE-106 TOTAL CO2-27 ANION GAP-13 [2178-12-17] 03:53AM URINE RBC-[1-27]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 TRANS EPI-0-2 [2178-12-17] 03:53AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2178-12-17] 03:53AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2178-12-17] 08:06AM CK-MB-49* MB INDX-7.5* cTropnT-0.76* [2178-12-17] 08:06AM CK(CPK)-651* [2178-12-17] 04:39PM CK-MB-80* MB INDX-9.1* cTropnT-1.11* [2178-12-17] 04:39PM CK(CPK)-877* . [2178-12-17] TTE: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is severe global left ventricular hypokinesis. Quantitative (biplane) LVEF = 20%. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) 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 symmetric left ventricular hypertrophy with severe global systolic dysfunction. Mild right ventricular systolic dysfunction. No asymmetric septal hypertrophy, marked regional variability in LV wall motion, or significant valvular disease seen. . [2178-12-18] CT Head: There is no evidence of hemorrhage, masses, shift of normally midline structures, hydrocephalus, or major vascular territorial infarct. No abnormalities are seen in the globus pallidi, hippocampal region, or watershed areas of the cortex. Ventricles and sulci are normal in contour and configuration. No fractures are identified. Air-fluid levels are seen in the sphenoid, ethmoid, and maxillary air cells. Endotracheal intubation is noted on the scout film. IMPRESSION: No intracranial abnormalities. [2178-12-18] Cardiac Catheterization 1. Selective coronary angiography of this right dominant system demonstrated a single vessel CAD. The LMCA had a 20% distal stenosis. The LAD had a 90% stenosis at the bifurcation with a moderately sized D1. The mid LAD had a 30% stenosis. The LCX was patent. The RCA had a 20% distal vessel stenosis. 2. Limited resting hemodynamics revealed an elevated left sided filling pressure with an LVEDP of 19 mmHg. 3. Left ventriculography was deferred. 4. Successful PTA of the first diagonal with a 2.5x12mm voyager balloon. Successful ptca and stenting of the proximal LAD with a 3.0x18mm cypher stent which was post-dilated to 3.25mm. Final angiography revealed 0% residual stenosis in the LAD, 20% residual stenosis in the ostium of D1. The patient left hemodynamically stable and back to the CCU for further treatment. Brief Hospital Course: ACUTE MYOCARDIAL INFARCTION The patient had a myocardial infarction while playing soccer on [2178-12-17]. He also suffered from VFib arrest and was given CPR on the field. On [2178-12-18], he underwent cardiac catheterization and was found to have a 90% stenosis of the LAD; he received a cypher stent in this vessel. He was started on atorvastatin 80 mg QD as well as aspirin and plavix. Echo on [12-18] showed an EF of 20% with global hypokinesis, but repeat echo on [12-22] showed an EF 60% likely reflecting recovery of the stunned myocardium. There was no evidence of structural heart disease. During his event, he was intubated for airway protection and likely suffered some degree of anoxic brain injury from the VFib arrest. He was initially very confused and agitated after his extubation, but these symptoms resolved by the time of discharge. He did seem to have short term memory deficits at the time of discharge, and it was thought he would benefit from OT and PT in short term rehab before returning home. HYPERTENSION His high blood pressure was initially managed with metoprolol 37.5 mg TID; he was switched to metoprolol XL 100 mg QD with good effect and discharged on that medicine. He was also started on lisinopril 5mg QD. FEVERS During his hospitalization, he had several low grade temperatures and was found to have heavy growth of MSSA in his sputum. He was also found to have [11-27] vials of coagulase negative staph in his blood cultures, likely a contaminant. He was started on a seven day course for the MSSA in his sputum beginning on [2178-12-22] and defervesced. Medications on Admission: Unknown medication for high cholesterol Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 days: Continue through [2178-12-28]. Discharge Disposition: Extended Care Facility: [Hospital 5503] [Hospital ] Hospital Discharge Diagnosis: Acute myocardial infarction Discharge Condition: Stable-- with improved cardiac function; not short of breath or dyspneic. Still with some short term memory deficits from likely anoxic brain injury but overall improved. Discharge Instructions: You should not do any running or exercise for the next several weeks and until further advised by your cardiologist. This is because you had a mild heart attack should be reevaluated before returning to your normal activity level. There are several medications for your heart that you have been started on because you had a heart attack. You need to take these until told to do so otherwise by your cardiologist. Followup Instructions: You should make an appointment to see your primary care doctor in the next 1 - 2 weeks. You should make an appointment to see a cardiologist at [Hospital1 ] Hospital in the next 2 - 3 weeks-- you can call ([Telephone/Fax (1) 2037] to make an appointment.	[ "E884.4", "401.9", "427.41", "272.4", "787.02", "414.01", "E849.7", "780.6", "V17.3", "910.8", "410.91" ]	icd9cm	[ [ [] ] ]	[ "00.40", "88.53", "36.07", "88.56", "96.04", "00.45", "00.66" ]	icd9pcs	[ [ [] ] ]	9685, 9756	7413, 9044	329, 354	9828, 10002	3195, 6011	10466, 10733	1955, 2177		9134, 9662		9777, 9807		9070, 9111			10026, 10443									2192, 3176																			278, 291												382, 1725		6020, 7390												1747, 1802	1818, 1939
25,928	128,740	53246	Discharge summary	report	Admission Date: [2110-8-27] Discharge Date: [2110-9-6] Date of Birth: [2050-6-29] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tear Major Surgical or Invasive Procedure: EGD History of Present Illness: 60 year old female with COPD and psoriatic arthritis admitted [8-27] with hematemesis over one day. She reported a 2 week productive cough with post-tussive emesis that was initially nonbloody. The day of admission, pt experienced post-tussive emesis and noticed that vomit was brown. By the afternoon of the day of admission, pt noted hematemesis which she attributed to a self-limited episode of epistaxis, but the blood increased in volume with two subsequent occurences of emesis, with clots in the third. This prompted her to get to [Hospital3 ], where they found her hct to be 31 and plt 146. She was lightheaded without any syncope. She's also had increasing dyspnea on exertion and some right sided abdominal pain. This pain has been present for five days, constant, though with fluctuating intensity; she has no idea what makes the pain better or worse, specifically denying eating as a trigger. She denies jaundice. She was sent to [Hospital1 18] for further evaluation, and in the ED her hct was found to be 27 and plt down to 75 with an INR of 1.6. Her stool was dark and guaiac positive, and an NGL lavage initially showed coffee grounds and clot but cleared with 100cc lavage. She was given 1unit of pRBCs, 3units of FFP, and vitamin K and transferred to the MICU. In the MICU, she underwent EGD which showed [Doctor First Name 329] [Doctor Last Name ] tear at GE juncion. No intervention done. She was given IV ppi [Hospital1 ] and antiemetics. Hct remained stable after 3 unit transfusion [8-27] and [8-28] and now being called out to the floor. Floor course (#1): As pt also complained of a severe cough and was noted to have a h/o + PPD, her sputum was sent for AFBx3, which were ultimately negative. While on the floor, she began to develop malaise, fevers, and chest and back pain. Two sets of cardiac enzymes (checked [2-6] depressions in V5-6) were negative. CT angio was negative for PE. Pt also developed a rising fever curve, from 99's, then up to 102 and 104 with rigors and hypotension (SBP 90s, baseline in 130s), and tachycardia (110s-130s). BP responded modestly to fluids, but continued to drop to 90s between boluses, so she was transferred back to the MICU. MICU course (#2): Urine and blood Cx eventually grew pansensitive E. coli. Pt was transiently on levophed (right IJ placed on [9-2]), but was able to be weaned quickly. She received cefepime ([Date range (1) 15152]) and levofloxacin ([9-2] - current). Cefepime was discontinued on [9-4]. She was hemodynamically stable and called out to the floor. Here, she states that she feels much improved at this time. She denies dysuria, noting that her urine has gotten more clear; she does have some urinary frequency. No shakes or chills. She is starting to have some of the achiness in her back and neck, which is chronic and has been relieved by oxycodone. Has been constipated - last BM was earlier this week, is starting to feel distended. Notes that after her last drink prior to admission, she has not felt shaky. Past Medical History: -COPD -Psoriatric Arthritis -Muscle cramps -PAT Social History: EtOH: One bottle of wine a day. She has had periods of abstinence of up to "months"; she has never had seizures or withdrawn. She states a desire to quit and feels confident that she can. Tobacco: 1ppd x 45yrs. Plans to quit and is currently on patch. Drugs: Remote history of IVD (60s; denies any since then); also history of cocaine use - has done a "couple of lines" in last few years but nothing in last few months. Former RN. Lives alone on [Hospital1 6687]. No children. Family History: Both parents died of lung CA Physical Exam: Vitals: T max 100, Tc 98.3 BP 123/67 range: 122-142/62-77 HR 74-95 RR 19 O2sat 100%RA I/O 1060/2800(24 hr). GEN: elderly thin lady sitting in bed itching her left arm. HEENT: NCAT, EOMI, perrl, MMM, OP clear CVR: RRR, nl s1, s2. no r/m/g Chest: CTAB, no crackles. no wheezing Abd: soft, nt, nd, no masses, no hsm Ext: no edema, pedal pulses 2+ bl, bleeding cut on left lower leg-bandaged Pertinent Results: LABS ON ADMISSION: Chemistries: [2110-8-27] 07:35PM GLUCOSE-98 UREA N-24* CREAT-0.6 SODIUM-139 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-28 ANION GAP-10 CBC: [2110-8-27] 07:35PM WBC-4.4 RBC-2.32* HGB-9.0* HCT-27.4* MCV-118* MCH-38.9* MCHC-33.0 RDW-13.7 [2110-8-27] 07:35PM NEUTS-74* BANDS-0 LYMPHS-22 MONOS-3 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [2110-8-27] 07:35PM PLT SMR-VERY LOW PLT COUNT-75* Coags: [2110-8-27] 07:35PM PT-17.5* PTT-30.6 INR(PT)-1.6* [2110-8-27] 07:35PM FIBRINOGE-137* D-DIMER-646* LFTS: [2110-8-27] 07:35PM ALT(SGPT)-33 AST(SGOT)-142* LD(LDH)-184 ALK PHOS-103 TOT BILI-1.7* Other Labs: [2110-8-27] 07:35PM calTIBC-233* VIT B12-739 FOLATE-5.7 HAPTOGLOB-79 FERRITIN-256* TRF-179* [2110-8-27] 07:35PM TOT PROT-6.6 IRON-213* LABS ON DISCHARGE: EGD ([8-28]): 1. [Doctor First Name ]-[Doctor Last Name ] tear 2. Healed ulcer was seen in the antrum 3. Normal mucosa in the duodenum 4. Abnormal mucosa in the stomach . Abdominal US ([8-28]): 1. Normal hepatic arterial, portal and hepatic venous waveforms. 2. Small ascites. 3. Splenomegaly. 4. Gallbladder wall edema, concordant with this patient's hypoalbuminemia. . CT abd/pelvis [9-3]: 1. No discrete abscess collection, as clinically questioned. 2. Ascites. 3. Small bilateral pleural effusions. 4. Diffuse interlobular septal thickening, probably related to CHF, less likely infectious or inflammatory. 5. Cannot exclude cecal neoplasm. Consider direct visualization, if no recent colonic evaluation has been performed. 6. Grade 1 anterolisthesis of L5 on S1. . [9-1] echo: EF 60-65%, mild [Name Prefix (Prefixes) ] [Last Name (Prefixes) 1915] and aortic dilation . CXR [9-4]: Stable appearance of prominent interstitial markings which represent emphysema and bronchiectasis. CVL in proper position. . LABS: Herediatory hemochromatosis - pending EHRLICHIA ANTIBODY PANEL (HME AND HGE)- pending Micro - pertussis culture and pcr - pending [8-30] AFB - prelim negative gram stain < 10 pmn, g+ cocci in pairs/chains [8-30] HCV VL - pending . Hepatitis B Surface Antigen NEGATIVE Hepatitis B Surface Antibody POSITIVE Hepatitis B Virus Core Antibody NEGATIVE Hepatitis A Virus Antibody NEGATIVE Pos/Neg Hepatitis B Core Antibody, IgM NEGATIVE Hepatitis A Virus IgM Antibody NEGATIVE HEPATITIS C SEROLOGY *Hepatitis C Virus Antibody POSITIVE* Brief Hospital Course: A/P: 60f with pmhx of COPD and psoriatic arthritis admitted with cough and UGIB noted to have [Doctor First Name ]-[Doctor Last Name ] tear on EGD with new dx of Hepatitis C. 1. UGIB: Recent GIB [2-6] [Doctor First Name ]-[Doctor Last Name ] tear seen on EGD; patient also had healed ulcer in the antrum. UGIB Received 3 units PRBC here total. HCT stable after EGD and pt symptom free. No vomiting since admission to hospital. This may be related to her use of high dose NSAIDs (up to 2800mg daily). She is h.pylori negative. Her INR was 1.6 at presentation and is currently 1.3; this may be related to underlying liver disease. She has not recieved any transfusions since [8-28]. PPI (40 mg [Hospital1 ]) and antitussives were used. 2. Urosepsis: Patient had episodes of fever and hypotension described above. Intially she was on double coverage (levofloxacin and cefepime), now just on levofoxacin. Blood and urine culture from [9-1] showed e.coli (pansensitive). Repeat blood and urine have been negative thus far (most recent blood/urine drawn: [9-4] at ~9:30 for low grade temp). Will be discharged on levofloxacin for a total of 14 days (Day 1 = [9-2]). 3. Cough: Had a history of cough for > 2 weeks; she has cough at baseline, which may be related to her tobacco use. Was also initially concerning for TB given history of +PPD, but AFB was (-) x3 with a negative CXR. Pertussis was entertained and the culture and PCR are pending as of discharge. Also question mold allergy given mold in her house and the fact that her cough has improved since coming to hospital. GERD may have been a contributor. She was treated with antitussives and PPI with improvement in her cough. She states a plan to quit smoking. 4. RUQ pain/elevated LFTs: RUQ pain on admission, pain now resolved. Maybe secondary to HepC and alcoholic hepatitis. The LFT ratio was ~2:1 AST:ALT. Given history of living in an area with endemic ehrlichia, antibody was sent and is pending upon discharge. 5. Hep C: This is a new diagnosis. Viral load 629,000. Transmission may have been in the 60s as the patient states she does not have any use of IVD since then. She does have some transaminities (with AST:ALT ratio >2:1), an elevated INR, low albumin (currently 3.1) and platelets (70s) and some ascites, all indicative of liver pathology. The patient is aware and has follow-up with GI on [2110-9-26]. She also recieved hepatitis A vaccine while here. 6. Anemia: Macrocytic anemia. Has high iron, low TIBC, and a high ferritin. Normal B12/folate. Likely due to UGIB but may also have some degree of chronic anemia, possibly due to bone marrow effects of alcohol. Hematocrits were followed and were stable upon discharge. 7. Thrombocytopenia: Platelets in the 70s. Likely due to chronic liver, given alcohol and hep C. Also has splenomegaly on CT; may represent sequestration. Patient takes quinine - this may be somewhat related, although secondary. Quinine was held and platelets were followed. 8. Coagulopathy: The patient had an elevated INR on admission. Given vit K and FFP in setting of bleeding. Now stable at 1.3. Again likely due to liver disease. . 9. Etoh abuse: Patient has history of drinking one bottle of wine per day. She denies ever withdrawing with periods of abstinence of up to "months". Initially, CIWA scale was used and per ICU she did not require much ativan. Thiamine, folate, MVI given daily. Patient states planned abstinence upon discharge. 10. COPD: Was stable in house. She was continued on fluticasone/salmeterol with PRN tiotropium. 11. Psoriatic arthritis: Patient initially had pruritis of left upper arm c/w her usual psorias flare. She uses high dose NSAIDs and percocet at home. NSAIDs were help in house and oxycodone was used for analgesia. Given oxycodone upon discharge with clear instructions to not use NSAIDs. Medications on Admission: -Quinine -Ranitidine -Fluticasone/salmeterol -Percocet -NSAIDS (up to 2,800mg daily) PRN Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:10 Tablet(s) Refills:0 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:60 Disk with Device(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. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 5. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:4 Patch 24HR(s) Refills:0 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tear Urosepsis Hepatitis C COPD Psoriatic arthritis Discharge Condition: stable Discharge Instructions: Please take all your medications and follow up with all your appointments. Please report to the ED or to your PCP if you have any worsening symptoms of abdominal pain, nausea, vomiting, blood in vomit or in stools or any other concerns. Also, do NOT use ANY NSAIDs (e.g. Motrin, Advil, Ibuprofen, Naproxen). Use oxycodone (as directed) for pain and follow-up with your PCP. Please be sure to have booster hepatitis A vaccine in 6 months. Followup Instructions: 1. Please make an appointment to see your primary care physician [Last Name (NamePattern4) ] [1-6] weeks. 2. Follow-up with gastroenterology on [2110-9-26] at 3:30 (Nantuckett office); call [Telephone/Fax (1) 1983] for directions. 3. You need a booster hepatitis A vaccine in 6 months (you recieved one dose here).	[ "038.40", "287.5", "599.0", "285.1", "070.70", "530.7", "496", "696.0" ]	icd9cm	[ [ [] ] ]	[ "45.13", "38.93" ]	icd9pcs	[ [ [] ] ]	11834, 11840	6962, 10866	384, 389	12003, 12012	4520, 4525	12501, 12837	4066, 4096		11005, 11811		11861, 11982		10892, 10982			12036, 12478									4111, 4501																			274, 346					5340, 6939							417, 3479							4540, 5160							3501, 3550	3566, 4050			5172, 5320
76,007	152,737	12873	Discharge summary	report	Admission Date: [2194-10-27] Discharge Date: [2194-10-31] Date of Birth: [2130-10-28] Sex: M Service: CARDIOTHORACIC Allergies: metformin / niacin Attending:[First Name3 (LF) 165] Chief Complaint: shortness of breath and chest burning with exertion Major Surgical or Invasive Procedure: [2194-10-27] Coronary artery disease (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA) History of Present Illness: Mr. [Name13 (STitle) 4027] is a 64 year old man with a history of multiple PTCA and a right coronary artery stent in [2186]. He complains of chest burning, shortness of breath, tightness in his neck, and burning in his upper thighs after walking up 3-4 flights of stairs for the past couple of months. Occasionally during these episodes, he experiences lightheadedness. The discomfort subsides within 30 seconds after slowing down. On cardiac catheterization, he was found to have two vessel disease; he is now being referred to cardiac surgery for revascularization. Past Medical History: CAD s/p multiple PCTA in [2174] for three vessel disease, repeat catheterization in [2186] with stent placed to RCA Retinal detachment R eye s/p closure Hyperlipidemia Diabetes (not on medications currently, had a reaction to metformin) Restless leg syndrome Cardiomyopathy Depression GERD Arthritis Past Surgical History: R retinal detachment closure Past Cardiac Procedures: -multiple PCTA for three vessel disease ([2174]) -repeat catheterization w/ stent placed to RCA ([2186]) Social History: Mr. [Name13 (STitle) 4027] lives with his wife [Name (NI) 501] and works as a civil engineer. He denies having ever smoked and drinks 2-7 alcholic beverages per week. Family History: His father had coronary artery disease in his 40's. Physical Exam: Pulse: 49 Resp: 18 O2 sat: 100/RA B/P Right: 118/72 Left: 129/90 Height: 5'7" Weight: 177 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [] Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: none Left: none Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 3240], [Known firstname ] [Hospital1 18] [Numeric Identifier 39592] (Complete) Done [2194-10-27] at 9:10:53 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] Division of Cardiothoracic [Doctor First Name ] [First Name (Titles) ] [Last Name (Titles) ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 39593] Status: Inpatient DOB: [2130-10-28] Age (years): 63 M Hgt (in): 68 BP (mm Hg): 145/78 Wgt (lb): 168 HR (bpm): 56 BSA (m2): 1.90 m2 Indication: Chest pain. Coronary artery disease. Shortness of breath. Intraoperative TEE for CABG. Aortic valve disease. Left ventricular function. Mitral valve disease. Preoperative assessment. Right ventricular function. ICD-9 Codes: 785.2, 786.05 Test Information Date/Time: [2194-10-27] at 09:10 Interpret MD: [Name6 (MD) 1509] [Name8 (MD) 1510], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 1510], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2012AW 6-: Machine: 6 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: 4.5 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Left Ventricle - Stroke Volume: 87 ml/beat Left Ventricle - Cardiac Output: 4.90 L/min Left Ventricle - Cardiac Index: 2.58 >= 2.0 L/min/M2 Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Arch: 3.1 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 6 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 3 mm Hg Aortic Valve - LVOT VTI: 23 Aortic Valve - LVOT diam: 2.2 cm Aortic Valve - Valve Area: 2.8 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.4 m/sec Mitral Valve - E/A ratio: 1.50 Mitral Valve - E Wave deceleration time: 211 ms 140-250 ms Findings LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Simple atheroma in ascending aorta. Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Mild PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the patient. A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Pre-Bypass: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen by color flow doppler. 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. There are simple atheroma in the ascending aorta, aortic arch, and in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is Mild (1+) pulmonic valve regurgitation. There is no pericardial effusion. Post-Bypass: The patient is A-V Paced on a phenylephrine infusion s/p CABG. Left ventricular function is preserved with an estimated EF-55%. There are no apparent wall motion abnormalities. There is no echocardiographic evidence of aortic dissection s/p decannulation. The remainder of the exam is unchanged. [2194-10-31] 06:00AM BLOOD WBC-9.6 RBC-3.25* Hgb-11.0* Hct-31.2* MCV-96 MCH-33.9* MCHC-35.3* RDW-13.4 Plt Ct-201 [2194-10-31] 06:00AM BLOOD Plt Ct-201 [2194-10-31] 06:00AM BLOOD Glucose-136* UreaN-19 Creat-0.9 Na-140 K-4.4 Cl-100 HCO3-29 AnGap-15 [2194-10-31] 06:00AM BLOOD Mg-2.4 Brief Hospital Course: Mr. [Name13 (STitle) 4027] was brought to the operating room on [2194-10-27] where he underwent a coronary artery bypass grafting performed by Dr. [Last Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He arrived initially atrially paced for hypotension and on a Neosynepherine infusion but then transitioned to a Nitroglycerin infusion for hypertension. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward his preoperative weight. He was transferred to the telemetry floor for further recovery on POD #1. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He had an elevated HbA1c preoperatively and postoperatively was started on glipizide with stabilization of his blood sugars. By the time of discharge on POD #4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Lisinopril 5 mg PO DAILY 2. BuPROPion 100 mg PO BID 3. Fish Oil (Omega 3) 1000 mg PO BID 4. Metoprolol Tartrate 50 mg PO BID 5. Rosuvastatin Calcium 10 mg PO DAILY 6. Nitroglycerin SL 0.4 mg SL PRN cp 7. Clopidogrel 75 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Aspirin 325 mg PO DAILY 10. Fluvoxamine Maleate 100 mg PO DAILY 11. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. BuPROPion 100 mg PO BID 3. Fish Oil (Omega 3) 1000 mg PO BID 4. Fluvoxamine Maleate 100 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Rosuvastatin Calcium 10 mg PO DAILY 8. Acetaminophen 650 mg PO Q4H:PRN pain, fever 9. Docusate Sodium 100 mg PO BID 10. GlipiZIDE 2.5 mg PO BID RX glipizide 5 mg 0.5 (One half) tablet(s) by mouth two times daily Disp #30 Tablet Refills:2 11. Oxycodone-Acetaminophen (5mg-325mg) [2-10] TAB PO Q4H:PRN pain RX oxycodone-acetaminophen [Percocet] 5 mg-325 mg one tablet(s) by mouth every four hours Disp #30 Tablet Refills:0 12. Furosemide 40 mg PO DAILY Duration: 5 Days RX furosemide 40 mg one tablet(s) by mouth daily Disp #5 Tablet Refills:2 13. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days Hold for K > RX potassium chloride 20 mEq one tablet by mouth daily Disp #5 Tablet Refills:2 14. Metoprolol Tartrate 25 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. [Last Name (NamePattern4) 9641] metoprolol tartrate 25 mg one tablet(s) by mouth two times daily Disp #60 Tablet Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: coronary artery disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours* Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [Telephone/Fax (1) 170] Surgeon Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] [2194-12-2] at 1:00pm [Telephone/Fax (1) 170] Cardiologist/PCP [Last Name (NamePattern4) ].[Known firstname ] [Last Name (NamePattern1) 4469] [2194-11-27] at 11:00am Wound Check at [Hospital Unit Name ] Cardiac Surgery Office, [Hospital Unit Name ] [2194-11-11] at 10:00am Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2194-10-31]	[ "414.01", "V45.82", "530.81", "425.4", "250.00", "272.4" ]	icd9cm	[ [ [] ] ]	[ "36.15", "39.61", "36.13" ]	icd9pcs	[ [ [] ] ]	10794, 10851	7750, 9143	340, 433	10919, 11075	2513, 6091	11947, 12725	1771, 1825		9649, 10771		10872, 10898		9169, 9626			11099, 11924							1393, 1562	6140, 7727	1840, 2494																			248, 302												461, 1040														1062, 1370	1578, 1755
29,434	175,799	34418	Discharge summary	report	Admission Date: [2189-9-15] Discharge Date: [2189-9-23] Date of Birth: [2125-4-9] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: Crescendo Angina Major Surgical or Invasive Procedure: [2189-9-18] - CABGx4 (Left internal mammary-> left anterior descending artery, Saphenous vein graft(SVG)->Obtuse marginal artery 1, SVG->Obtuse marginal artery 3, SVG->Posterior descending artery.) [2189-9-15] - Left heart catheterization and coronary angiography History of Present Illness: Presented to outside hospital with 3-4 weeks of exertional back and right shoulder pain. He had an episode of nocturnal angina that awoke him the night of admission. NSTEMI was diagnosed elsewhere (TropI 9,12.3) and tranferred, painfree, to [Hospital1 18] for definitive care. Past Medical History: Hypertension Appendectomy benign testicular tumor 15 yrs ago Social History: Never smoked. Works as a dialysis technician lives with his wife Rare ETOH Family History: Father died of Cancer Mother died of MI age 72 Brother A & W. Physical Exam: A &O x 3.Afebrile Lungs- clear Cor- NSR 70s. BP usually 120s/80s Exts- trace edema. Wounds clean and dry. Fully ambulatory. Sternum stable and healing well. Pertinent Results: [2189-9-22] 05:45AM BLOOD WBC-6.1 RBC-3.11* Hgb-9.8* Hct-27.2* MCV-87 MCH-31.5 MCHC-36.0* RDW-13.0 Plt Ct-216 [2189-9-22] 05:45AM BLOOD Glucose-121* UreaN-13 Creat-0.8 Na-141 K-3.8 Cl-104 HCO3-25 AnGap-16 [2189-9-22] 05:45AM BLOOD Mg-2.1 Brief Hospital Course: Catheterization showed 70% distal LM, 80% LAD, mild origin OM1,40-50% OM2, 50% OM3,prox.RCA 60%. Echo demonstrated LVEF ~50%. he was Heparinized and remained painfree. On [9-18] he underwent CABG X 4 as noted. See operative note for details. He was weaned from CPB easily in SR. He remained stable and was easily extubated that day. Beta blockers were begun and he was diuresed towards his preoperative weight. CTs and wires were removed and he progressed nicely. he was preparing for discharge on [9-22] (POD4) when he had a vagal episode in the bathroom. He was diaphoretic transiently but quickly recovered and felt fine. His BP and pulse were normal immediately after this episode.he subsequently remained stable. Wounds were clean and dry and he was ready for discharge on [9-23]. Medications on Admission: Plavix 75mg ASA 325mg lisinopril 10mg MVI Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day. Disp:30 Packet(s) Refills:2 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:100 Tablet(s) Refills:0 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: coronary artery disease s/p CABG x4 Hypertension Discharge Condition: good Discharge Instructions: 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) 4044]. Report any fever greater then 100.5. Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. No lotions, creams or powders to incision until it has healed. Shower daily. No baths or swimming.Gently pat the wound dry. o lifting greater then 10 pounds for 10 weeks. No driving for 1 month and off all narcotics Take all medications as directed Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 4 weeks. ([Telephone/Fax (1) 1504] Please follow-up with Dr. [Last Name (STitle) ] in 2 weeks. ([Telephone/Fax (1) 18658] Please follow-up with Dr. [Last Name (STitle) 7047] in [2-15] weeks. [Telephone/Fax (1) 8725] Completed by:[2189-9-23]	[ "414.01", "414.8", "780.2", "401.9", "410.71" ]	icd9cm	[ [ [] ] ]	[ "36.13", "88.56", "88.53", "37.22", "39.61", "36.15" ]	icd9pcs	[ [ [] ] ]	3432, 3487	1605, 2410	294, 569	3580, 3587	1331, 1582	4220, 4546	1074, 1137		2502, 3409		3508, 3559		2436, 2479			3611, 4197									1152, 1312																			238, 256												597, 882														904, 966	982, 1058
43,400	124,673	17606	Discharge summary	report	Admission Date: [2130-12-21] Discharge Date: [2130-12-22] Date of Birth: [2077-6-14] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 1402] Chief Complaint: s/p PVI c/b post op hypotension and bradycardia Major Surgical or Invasive Procedure: Pulmonary Vein Isolation History of Present Illness: 53 yo male a history of mild Ebstein??????s anomaly, atrial tachycardia and recently diagnosed atrial fibrillation. He has had a TEE cardioversion and subsequently discharged. Then, in [2130-11-5] he ad palpitations again and had another cardioversion, started on sotalol, but couldn't tolerate due to bradycardia and was referred in for PVI. Today, the patient underwent successful PVI, but postoperatively he was bradycardic to the high 30s/low 40s, and was hypotensive to the 80s/90s. He was given IVF bolus with improvement of his SBP. The rhythm appeared to be intermittent junctional bradycardia, thought to be due to sinus dysfunction post PVI. At the time of transfer to the CCU for monitoring, he was hemodynamically stable and otherwise doing well. He had an ECHO in the PACU which did not show any pericardial effusion. HCT was stable. CT abdomen/pelvis without evidence of RP bleed. . On review of systems, he denies deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (-)Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: cardioversion x 2 3. OTHER PAST MEDICAL HISTORY: Atrial fibrillation Atrial tachycardia Ebstein??????s anomaly H/O TIA/RIND Abnormal EKG-sinus brady, RBBB, t wave inversion III, avf Dyslipidemia Heart murmur Social History: -Tobacco history: denies -ETOH: 2 drinks/week -Illicit drugs: none Family History: No family history of early MI, otherwise non-contributory. Physical Exam: 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 * 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: [2130-12-22*] 04:16AM BLOOD WBC-7.9 RBC-3.81 Hgb-11.9# Hct-32.3 MCV-85 MCH-31.3 MCHC-36.9* RDW-13.1 Plt Ct-219 [2130-12-21] 07:45AM BLOOD PT-16.2* PTT-25.5 INR(PT)-1.5* [2130-12-22] 04:16AM BLOOD Glucose-109* UreaN-13 Creat-0.8 Na-140 K-3.8 Cl-107 HCO3-28 AnGap-9 . [2130-12-20] CTA Chest: 1. Two left sided and a single, common right sided pulmonary vein with no evidence of anomalous pulmonary venous return or focal stenosis (dimensions listed above). 2. Dilated right atrium and right ventricle. 3. Less than 4-mm lung nodules, do not warrant further followup is the patient has no risk factor for malignancy. If risk factors are present, followup is recommended in 1 year. 4. Signs of small airway disease. . [2130-12-21] Echocardiogram: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. The right ventricular cavity is markedly dilated with normal free wall contractility. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The septal insertion of the tricuspid valve is apically displaced, consistent with Ebstein's anomaly. Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild Ebstein's anomaly with dilated right ventricle and moderate TR. Normal regional and global left ventricular systolic function. Mild aortic and moderate tricuspid regurgitation. No pericardial effusion seen. . [2130-12-21] CT Abd/Pelvis: 1. No evidence of retroperitoneal hematoma. 2. Transitional lumbosacral anatomy. Brief Hospital Course: The patient was admitted with difficult to control atrial fibrillation, s/p pulmonary vein isolation with post-operative bradycardia and hypotension. Nodal agents were held and no pressors were needed. Blood pressures on admission were in the 100s systolic with HR in the 60s. The patient did well and was discharged the following day. He was initially put on a heparin drip, then started on Coumadin and given Lovenox for a bridge. He was discharged with follow-up with Dr. [Last Name (STitle) ] and [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts monitor. He remained in sinus rhythm post-procedure. Medications on Admission: Lipitor 20mg PO qday MVI Lysine 1,000 mg PO qday Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily). 3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: at 5 PM. 4. Lysine 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 5. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous [Hospital1 ] (2 times a day): please use until INR > 2.0. Disp:14 syringe Refills:2 Discharge Disposition: Home Discharge Diagnosis: Atrial fibrillation Ebstein's anomaly Dyslipidemia Discharge Condition: VS: stable Groins: stable Labs: stable Discharge Instructions: You were admitted to the hospital to undergo a pulmonary vein isolation procedure to treat atrial fibrillation. You has a short period of low blood pressure and slow heart rate after the procedure. No changes were made to your medications, except that you should take 5 mg of coumadin daily for now while your INR is subtherapeutic as your coumadin was held for the procedure. You will need to have your INR checked on Monday, [12-25] and adjust your dose of coumadin for Monday based on the INR. Continue the Lovenox until your INR is between 2.0 and 3.0 Go to the emergency room or call your primary doctor if you experience fevers, chills, chest pain, shortness of breath, dizziness, blood in your stool, or black stool. Followup Instructions: An appointment was made for you to follow up with your cardiologist: 2 weeks - 3 weeks Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2131-1-12] 1:40	[ "746.2", "458.29", "427.31", "427.89", "272.4" ]	icd9cm	[ [ [] ] ]	[ "37.34" ]	icd9pcs	[ [ [] ] ]	6397, 6403	5204, 5841	366, 393	6497, 6538	3217, 5181	7318, 7560	2316, 2376		5940, 6374		6424, 6476		5867, 5917			6562, 7295									2391, 3198		1935, 2023																	279, 328												421, 1822										2054, 2214				1844, 1915	2230, 2300
27,163	111,820	22735	Discharge summary	report	Admission Date: [2128-12-30] Discharge Date: [2129-1-12] Service: MEDICINE Allergies: Sulfur / Loperamide Attending:[First Name3 (LF) 710] Chief Complaint: CHF, COPD, NSTEMI, GI Bleed while anti-coagulated for NSTEMI Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a [Age over 90 ] yo F w/ COPD, CRI, hypothyroidism, and hyperlipidemia who initially presented to [Hospital1 18] on [2128-12-30] with COPD exacerbation; her hospital course was complicated by an NSTEMI on [1-2] which was treated medically with heparin gtt, ASA and plavix - she now has had BRBPR, melenotic stool and report of black vomit for several hours. . The patient initially presented with SOB and LE edema similar to two other COPD flares she has had over the last two months. During both admissions she was found to have EKG changes but negative cardiac enzymes. Recent clinic notes document increaing dyspnea despite diuresis, and increased use of supplemental O2 (at first only used intermittently, then usuing it all day) with persistent SOB despite O2 sats in the upper 90's. She was sent to ED by her PCP. . In the [Last Name (LF) ], [First Name3 (LF) ] EKG showed TWI in avl, V5, V6 and slight STE in V1-V3, all stable from previous. Overall stable EKG from [11-29]. BNP was > 15,000 (12,000 in [10-30],000 in [11-30]). She was admitted for COPD exacerbation and being treated with nebs, diuresis, O2. She initially had elevated troponin with flat CK and CKMB; the troponin (0.09-0.2) was thought to be [12-25] renal failure. . On [1-2] patient triggered with episode of chest pain, found to have elevated CK (peak 86), MBIndex (16) and Troponin (2.08) but no new changes on EKG. She was seen by cardiology and placed on heparin gtt, ASA 325, plavix 600mg as well as beta blocker, continued on lipitor 80mg for medical treatment of NSTEMI. TTE ([1-3], full report below) showed EF >60%, mod LVH, Increased PCWP, 1+MR, 1+TR, mod APH, sma pericardial effusion. . On [1-4] patient's heparin was discontinued for PTT 149, she was also orthostatic so lasix, imdur, b-blocker were also held. In the afternoon/evening she had three episodes of BRPBR as well as large melanic stool. Later on the patient's daughter reported an episode of black colored emesis, she later vomited food material. VS were: SBPs in the low 100's, HR in 80's (beta blocked) with O2 sat low 90's on 3-4L nc. Her HCT dropped from 28 on am labs -> 24; received 1L fluids on floor. Multiple attempts at NGT and OGT were unsuccessful, and IV access was tenuous, prompting admission to ICU. . GI fellow was consulted - Patient received 2 units of PRBCs and 1 unit of FFP. Her HCT has been stable in MICU. Her vitals were stable as well. Received lasix IV volume overload after PRBCs. CT abdomen was suspicous for ischemic colitis in [Female First Name (un) 899] region, and tagged red cell scan was negative. Patient and family has refused surgery. Empirically started treating with vanc/levo/flagyl. She was started on Clear diet and is tolerating it. . On transfer to the floor patient denies chestpain, abdominal pain, nausea, vomitting, dizziness, headache, change in vision/hearing, weakness. States that she felt slight SOB during trasportation. Otherwise feels 'fine'. Past Medical History: COPD Hypercholesterolemia depression Right breast cancer s/p R mastectomy 40 y ago Orthostatic hypotension Hypothyroidism Arthritis Age-related hearing loss Urethral stricture Internal and external hemorrhoids GERD s/p hysterectomy s/p appendectomy s/p R carotid endarterectomy Social History: She was a long time smoker with approximately a 40-pack-year history; however, she quit about 20 years ago. There is no alcohol, drug or herbs usage. She lives with her daughter and son in law who help her with medications. She is able to walk on her own and walks to the end of block and back before she gets tired normally. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: Temp: 96.6 BP: 150/70 HR: 85 RR: 24 O2sat 93% on 2L GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, OP clear NECK: JVP not elevated, carotid pulses [12-26] RESP: [Hospital1 ]-basilar crackles. no wheezes CV: RRR, S1 and S2 wnl, 2/6 systolic murmur heard best a LUSB. ABD: positive BS, soft, tender to palpate in LLQ, no masses or hepatosplenomegaly EXT: warm, DP 2+, trace edema SKIN: multiple echymosis NEURO: Alert and awake. Able to say name, date. Unable to recall the hospital's name. Able to say the city. Able to name president. DF/PF [3-28]. Spontaneously moves BUE. sensation intact. muscle tone wnl. Pertinent Results: Admit Labs: [2128-12-30] 04:05PM BLOOD WBC-9.2 RBC-3.38* Hgb-11.2* Hct-32.8* MCV-97 MCH-33.3* MCHC-34.3 RDW-15.5 Plt Ct-303 [2128-12-30] 04:05PM BLOOD Neuts-79.5* Lymphs-13.1* Monos-5.3 Eos-1.8 Baso-0.3 [2128-12-30] 04:05PM BLOOD Glucose-103 UreaN-35* Creat-2.0* Na-138 K-4.0 Cl-98 HCO3-28 AnGap-16 [2128-12-30] 04:05PM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.6 Mg-2.002/07/08 04:20PM BLOOD TSH-3.3 Cardiac enzymes: [2128-12-30] 04:05PM BLOOD CK-MB-NotDone cTropnT-0.21* proBNP-[Numeric Identifier 58855]* [2128-12-30] 04:20PM BLOOD CK-MB-NotDone cTropnT-0.20* proBNP-[Numeric Identifier 58856]* [2128-12-30] 11:50PM BLOOD CK-MB-NotDone cTropnT-0.14* [2128-12-31] 06:35AM BLOOD CK-MB-NotDone cTropnT-0.14* [2129-1-2] 10:24AM BLOOD CK-MB-NotDone cTropnT-0.09* proBNP-6439* [2129-1-2] 04:45PM BLOOD CK-MB-27* MB Indx-16.0* cTropnT-0.25* [2129-1-3] 02:00AM BLOOD CK-MB-86* MB Indx-15.8* cTropnT-0.76* [2129-1-3] 06:50AM BLOOD CK-MB-80* MB Indx-15.6* cTropnT-1.08* proBNP-6600* [2129-1-3] 04:00PM BLOOD CK-MB-52* MB Indx-13.2* cTropnT-1.90* [2129-1-3] 11:15PM BLOOD CK-MB-29* MB Indx-10.6* cTropnT-2.08* [2129-1-4] 06:58AM BLOOD CK-MB-20* MB Indx-9.7* cTropnT-1.89* [2129-1-5] 06:30AM BLOOD Lactate-1.4 [2129-1-6] 09:14AM BLOOD Lactate-0.8 . ECHO ([1-3]): The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is borderline low (2.4 L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. In the absence of a prominent history of systemic hypertension, an infiltrative process (e.g., amyloid, etc.) should be considered. . CXR ([1-2]): Mild cardiomegaly is unchanged. Small bilateral pleural effusions greater on the left have mildly increased. There has been also mild interval increase in left lower retrocardiac opacity, likely atelectasis. There is no overt CHF or pneumothorax. Surgical clips are noted in the neck. Patient post right mastectomy. . GI BLEEDING STUDY [2129-1-5]: No evidence of active GI bleeding. . CT ABD/PELVIS W/O CONTRAST [2129-1-5]: 1. Circumferential thickening of the descending colon extending from the splenic flexure to the descending/sigmoid colon junction, indicating colitis. The differential diagnosis includes ischemia, especially given the degree of calcified atherosclerotic plaque in the abdominal aorta, as well as infectious and other inflammatory causes. The mesenteric vasculature cannot be assessed on this non-contrast exam. There are small amounts of fluid in the left paracolic gutter, but no pneumatosis or free air at this time. 2. Moderate bilateral pleural effusions and small-to-moderate pericardial effusion are not significantly changed since [Month (only) 404] [2128]. 3. Ground-glass opacity in the periphery of the right lower lobe, for which interval CT followup is recommended. 4. Evidence of prior granulomatous infection. 5. Mildly dilated CBD. 6. Left internal iliac artery aneurysm measuring 11 mm. Brief Hospital Course: [Age over 90 ] yoF w/COPD, CRI and cardiac risk factors who initially presented with CHF/COPD exacerbation; she was admitted to MICU with GI Bleed in the setting of anticoagulation for treatment of NSTEMI. ?Ischemic colitis but patient and family does not want surgery. Transfered to floor as her HCT has stabilized. . # GI Bleed: unclear source - patient with BRBPR, melanic stools and report of black emesis; black vomit and melanic stools support an upper GI source whereas bright red blood, history of diverticulosis seen on last colonscopy ([8-30]) as well as internal and external hemorrhoids point towards a lower GI source. CT ABD showed likely ischemic colitis in [Female First Name (un) 899] distribution with fluid in pelvis, negative tagged red cell scan. Ischemic colitis could be [12-25] vascular disease. Unlikely embolic given anticoagulation for NSTEMI. Perhaps also a bleeding diverticula. She has received 1L fluids, 2 BRBC, 1 unit FFP; HCT now stable around 30. Lacate is 0.8. Patient and family agree that she does not want surgery. Appreciated surgery recs. Patient was intially treated with PPI [Hospital1 ]. Held all anticoagulants and antiplatellets. Antibiotics, ampicillin, levofloxacin and flagyl were administered for 2 days. Diet advanced to regular prior to discharge. She does not have active bleeding at the time of discharge. She is hemodynamically stable with benign abdominal exam at the time of discharge. Follow up appointment with primary care doctor [First Name (Titles) ] [Last Name (Titles) 19379]d in one week prior to discharge. Geriatric team, Dr.[Last Name (STitle) ] to follow the patient at [Hospital1 ]. . # NSTEMI: Ruled in by CEs, MB trended down prior to discharge. HCP has preferred medical management to cath. No motion abnormality by ECHO, though marked hypertrophy and likely diastolic dysfunction. Heparin, ASA, and plavix held for GIB as mentioned above. Patient was tolerating metoprolol prior to discharge. . # SOB: patient with recent worsening of dyspnea prior to this admission, in the setting of progressive decline since at least [Month (only) 1096]. Likely component of diastolic dysfunction and COPD exacerbation. Currently saturating well in 2L NC. Restarted on diuretics and tolerated it well. Continued Ipratropium Bromide Neb. Systemic steroids started for COPD flare to be weaned off as out patient. Started on Vantin for possible bronchitis. . # Leukocytosis: Started after receiving systemic steroids. No signs of infection. UA not suspicous for UTI. Urine culture showed no growth. Will start on Vantin for possible bronchitis. Geriatric team, Dr.[Last Name (STitle) ] to follow the patient at [Hospital1 ]. . # Orthostasis: noted on floor [1-4], managed with midodrine chronically. Midodrine discontinued per cardiology recs. . # CRI: baseline Cr of 1.5. At baseline prior to discharge. . # Chronic diarrhea: Resolved prior to discharge. C diff negative. On entecort at home. Started on low dose cholestyramine, to be adjusted according to Geriatrics team as out patient. . # Depression: Continued on out patient celexa. . # Hyperlipidemia: Lipitor uptitrated in the setting of NSTEMI. . # Hypothyroidism: Continued levoxyl . # Code Status: DNR/DNI but otherwise aggressive intervention (central access, pressors ok). . # Communication: with patient and daughter, [Name (NI) ] [Last Name (NamePattern1) ], who is HCP. Phone [Telephone/Fax (1) 58854]. Medications on Admission: Medications at Home: Celexa 10mg qday entocort EC 9 mg q am lasix 20mg qday ipratropium bromide tid levoxyl 88mcg qday lipitor 10 qday midodrine 2.5 mg [Hospital1 ] omeprazole 20 mg qday Discharge Medications: 1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Three (3) Capsule, Sust. Release 24 hr PO once a day. 3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:40 Tablet(s) Refills:2 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day): Hold for SBP < 100 or HR < 60. 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP < 100. 10. Ondansetron 4 mg IV Q8H:PRN 11. Cholestyramine-Sucrose 4 gram Packet Sig: 0.5 Packet PO DAILY (Daily): Please DO NOT admininster this medications with other medications. Packet(s) 12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for abdominal bloating. 14. Prednisone 5 mg Tablet Sig: as directed below Tablet PO once a day for 10 days: Please administer prednisone 40 mg daily for 2 days ([1-13] to [1-14]) followed by 30 mg for two days ([1-15] to [1-16]) followed by 20 mg daily for two days ([Date range (1) 58857]) followed by 10 mg ([1-19] to [1-20]) followed by 5 mg ([12/2049] to [1-22]) and then stop. 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day: hold for SBP < 100 and HR < 60. 16. Vantin 200 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) 55] Discharge Diagnosis: Non ST elevation Myocardial Infarction Gastrointestinal bleed Congestive Heart Failure Chronic Obstructive Lung Disease Chronic Renal Insufficiency Discharge Condition: Stable to be discharged to [Hospital1 ] Discharge Instructions: You were admitted with mild volume overload and congestive heart failure. You had a heart attack during this hospital stay. You were started on blood thinners to treat this heart attack. You had gastrointestinal bleeding while on blood thinners. Please continue to follow up with Dr. [Last Name (STitle) 36656] after discharge as below. . Please take medications as instructed below. . If you develop worsening chest pain, shortness of breath, lower extremity swelling, weight gain >2 lbs, bleeding or any other concerning symptoms, please call Dr. [Last Name (STitle) ] or report to the nearest ER. Followup Instructions: You have a follow up appointment made with your primary care doctor, DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] [Telephone/Fax (1) 719], on [1-20], [2128] at 4.30 pm. . PREVIOUSLY SCHEDULED APPOINTMENTS: Provider: [Name10 (NameIs) 161] [Name8 (MD) 6476], MD Phone:[Telephone/Fax (1) 2998] Date/Time:[2129-2-3] 11:45 . Please call if you need to reschedule. Completed by:[2129-1-12]	[ "410.71", "285.9", "491.21", "585.9", "244.9", "428.0", "428.30", "272.0", "416.0", "578.9", "V10.3" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	14137, 14209	8477, 11992	288, 294	14401, 14447	4783, 5196	15107, 15582	4013, 4096		12233, 14114		14230, 14380		12018, 12018			14471, 15084				12039, 12210					4111, 4764															5213, 8454				188, 250												322, 3349														3371, 3651	3667, 3996
30,099	106,857	31319	Discharge summary	report	Admission Date: [2150-8-16] Discharge Date: [2150-8-22] Date of Birth: [2095-2-28] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5880] Chief Complaint: s/p 20 foot fall from construction lift Major Surgical or Invasive Procedure: ORIF right femur fracture History of Present Illness: Mr. [Known lastname 68525] is a 55 year-old man who was transferred by [Location (un) ] after 20-foot fall off of a construction lift. GCS was 15 at the scene but he was amnestic to the event. He reported back pain on arrival to the trauma bay. Past Medical History: None Social History: Married. Self-employed Family History: Non-contributory Physical Exam: Exam on Admission: Vitals: HR 105 BP 100/P repeat 121/78 RR 15 O2: 96% NC GCS 15 Gen: Awake, alert and oriented. HEENT: Abrasion to left maxilla. Blood in nares. Neck: C-collar in place Chest: Equal bilateral breath sounds. No crepitus. CVS: RRR. Abd: Soft. NT/ND. Rectal: Normal tone. No gross blood. Normal prostate. GU: Normal scrotum. + hematuria Musculoskeletal: Right leg splint. Thigh deformity. Pertinent Results: Portable Chest X-ray [2150-8-26]-IMPRESSION: Right seventh lateral rib fracture, with subcutaneous emphysema better seen on CT. The prominence of the mediastinum may be related to technique. Please refer to the CT torso exam for details. . Non-Contrast Head CT [2150-8-16]- 1. No evidence of hemorrhage detected although study is limited given motion artifact. 2. Lobulated mucosal thickening within the left maxillary sinus and a small amount of fluid within it- ? inflammatory in origin. No definite fracture is detected. . CT Torso [2150-8-16]- 1. Moderate sized right traumatic pneumothorax with mild shift of the mediastinum suggesting a minor component of tension. 2. Multiple acute fractures including sternal, pelvic, sacral and right lateral rib as described above. There is no evidence of active extravasation from the pelvic arterial system. 3. No evidence of contrast or urine extravasation from the bladder although given mechanism and history of hematuria, bladder injury should be considered. Right Femur 14 Views [2150-8-16]- 14 fluoroscopic intraoperative spot radiographs are submitted for interpretation. An intermedullary rod traverses a severely comminuted segmental fracture of the proximal femoral shaft. The rod is transfixed by two proximal screws through the femoral neck and two distal interlocking screws through the distal metadiaphysis of the femur. The fracture fragments are in near anatomic alignment. Please refer to the operative note for full details. [2150-8-16] 11:26PM GLUCOSE-257* UREA N-16 CREAT-1.6* SODIUM-145 POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-16* ANION GAP-24* [2150-8-16] 11:26PM CALCIUM-7.4* PHOSPHATE-6.0* MAGNESIUM-1.9 [2150-8-16] 11:26PM WBC-11.8# RBC-3.49# HGB-10.9# HCT-32.3# MCV-93 MCH-31.1 MCHC-33.6 RDW-14.3 [2150-8-16] 11:26PM PLT COUNT-181# [2150-8-16] 11:13AM HGB-12.2* calcHCT-37 [2150-8-16] 10:40AM LACTATE-4.5* [2150-8-16] 10:30AM UREA N-16 CREAT-1.7* SODIUM-140 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-18* ANION GAP-21* [2150-8-16] 10:30AM estGFR-Using this [2150-8-16] 10:30AM AMYLASE-47 [2150-8-16] 10:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2150-8-16] 10:30AM URINE HOURS-RANDOM [2150-8-16] 10:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2150-8-16] 10:30AM WBC-6.0 RBC-1.68* HGB-5.2* HCT-15.5* MCV-93 MCH-31.0 MCHC-33.5 RDW-13.9 [2150-8-16] 10:30AM PLT COUNT-108* [2150-8-16] 10:30AM PT-13.1 PTT-25.5 INR(PT)-1.1 [2150-8-16] 10:30AM FIBRINOGE-298 [2150-8-16] 10:30AM URINE COLOR-[Location (un) ] APPEAR-Cloudy SP [Last Name (un) 155]-1.021 [2150-8-16] 10:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [2150-8-16] 10:30AM URINE RBC->50 WBC-[5-24]* BACTERIA-MANY YEAST-NONE EPI-0-2 Brief Hospital Course: Mr. [Known lastname 68525] was admitted to the trauma surgery service with the following injuries: right-sided pneumothorax, right rib fractures, sternal fractures, multiple pelvic fractures, right femur fracture. . #) Femur Fracture- Mr. [Known lastname 68525] was taken to the operating room by orthopedics for an open reduction intramedullary fixation of his right femur fracture. He was started on Ancef postoperatively, Lovenox and a Dilaudid PCA. He later was started on oral pain medication. He was seen by physical and occupational therapy. He should continue Lovenox and follow-up with Dr. [First Name (STitle) ]. . #) Pelvic fractures- Orthopedics was consulted regarding his right saral fracture and left inferior pubic ramus fracture and non-operative treatment was recommended. His activity status is non-weight bearing of the right lower extremity, weight-bearing as tolerated on the left lower extremity. . #) Urinary Tract Infection- On hospital day 5, he was noted to have a urinary tract infection and was started on ciprofloxacin for three days. . #) Disposition- Mr. [Known lastname 68525] was discharged to a rehabilitation facility. Medications on Admission: None Discharge Medications: 1. Enoxaparin 30 mg/0.3 mL Syringe Sig: 0.3 ML's Subcutaneous Q12H (every 12 hours). 2. Acetaminophen 1,000 mg Packet Sig: One (1) PO Q6H (every 6 hours). 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 8. Phenol-Phenolate Sodium Mouthwash Sig: One (1) Spray Mucous membrane QID (4 times a day). 9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 10. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 11. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain. 12. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insominia. 13. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-16] Sprays Nasal TID (3 times a day) as needed for allergy symptoms. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. 16. Loratadine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: s/p Fall Right pneumothorax Right 3rd, 4th, and 6th rib fractures Right pulmunary contusion Pelvic fracture Sternal fracture Right femur fracture Urinary tract infection Discharge Condition: Good Discharge Instructions: You were admitted to the hospital after a 20 foot fall. You were found to have the following injuries: Right pneumothorax Right 3rd, 4th, and 6th rib fractures Right pulmunary contusion Pelvic fracture Sternal fracture Right femur fracture You had a surgical repair of your femur fracture. Orthopedic surgery also evaluated your pelvic fractures and did not recommend further surgery. You should NOT bear any weight on your right leg for the next eight weeks. You should continue taking the medication Lovenox to prevent blood clots until otherwise advised by Dr. [First Name (STitle) ]. You were also treated for a urinary tract infection during this hospitalization. Your scrotal swelling and bruising is likely related to your pelvic fractures. You should continue to apply ice as needed to your scrotum. If you have increasing pain or swelling of your scrotum, you should call your doctor or report to the hospital. . You should call your doctor or return to the hospital for: * Chest pain, shortness of breath * Fevers, chills, cough * Abdominal pain, nausea or vomiting * Worsening of your scrotal swelling Followup Instructions: Follow up with Dr. [First Name (STitle) ], Orthopedics, in 2 weeks, call [Telephone/Fax (1) 1228] for an appointment. Follow up with Dr. [Last Name (STitle) 18191] in 2 weks for your pelvic fractures, call [Telephone/Fax (1) 1228] for an appointment. Follow up with Dr. [Last Name (STitle) ] in Surgery Clinic in 2 weeks, call [Telephone/Fax (1) 6429] for an appointment.	[ "E884.9", "808.2", "861.21", "860.0", "821.00", "807.03", "807.2", "599.0", "805.6" ]	icd9cm	[ [ [] ] ]	[ "79.35" ]	icd9pcs	[ [ [] ] ]	7065, 7135	4169, 5345	354, 382	7349, 7356	1206, 4146	8528, 8929	749, 767		5400, 7042		7156, 7328		5371, 5377			7380, 8505									782, 787																			275, 316												410, 665							802, 1187							687, 693	709, 733
66,894	157,688	3037	Discharge summary	report	Admission Date: [2126-8-10] Discharge Date: [2126-8-11] Date of Birth: [2069-3-7] Sex: F Service: MEDICINE Allergies: Zanaflex / Aspirin / Premphase / lisinopril Attending:[First Name3 (LF) 2297] Chief Complaint: abdominal pain, tenesmus Major Surgical or Invasive Procedure: intubation and mechanical ventillation arterial line internal jugular central venous line History of Present Illness: 57 year old female with stage 1 breast cancer s/p initiation of docetaxel and carboplatin on [2126-8-2], now presenting with abdominal pain and dysuria. Most of the following history was obtained by the ED team, prior to her decompensation. Her symptoms started this AM, with frequency and urgency. She characterizes the suprapubic pain as sharp and radiating to back and right flank. Symptoms notable for intermittent chills and diaphoresis, nausea with one episode of vomitous. Her last bowel movement was this morning without bright red blood. She has been passing flatus. As her pain worsened throughout the day, she called the [Hospital ] clinic and proceeded to the ED. She did contact her oncologist ([Name (NI) ]) on [8-5] with multiple issues, including hyperglycemia to the 300s-400s, acute on chronic back pain, and constipation with mild abdominal pains. She was instructed to report to the ED for insulin administration if her FSBGs were > 400. She was started on acetaminophen 1000mg TID for her pain. She attributed her abdominal pain at that time to constipation because she had not stooled in 2 days. In the ED, initial vitals were: 98 115 97/51 16 100%, pain [9-11]. Exam was notable for right CVA and suprapubic tenderness, without peritoneal signs. IVFs were started at this point when the lactate returned at 7.0. With neutropenia of 0.5, she was covered with Vancomycin and Cefepime. Her blood pressures then started to decline and she became more tachypneic and in increasing respiratory distress. She was then intubated for airway protection and levophed was started for her hypotension. She was given vecuronium earlier in the evening due to overbreathing the vent. CT abdomen showed extensive inflammatory mural thickening/stranding of the distal descending colon/sigmoid and rectum with free intraperitoneal fluid, not likely ischemic colitis. Surgery was consulted and did not feel she was a surgical candidiate. When she maxed out on levophed, dopamine was added and both pressors are running through her port-a-cath. She is tolerating the ventilator, sedated on fentanyl/midazolam with most recent ABG of 7.21 / 36 / 78 (450/20/5/100%). Bedside TTE did not suggest cardiac involvement, without any RV strain. Total IVF 7L. On arrival to the MICU, the patient is intubated, sedated, and requiring a 3rd pressor. Past Medical History: -Breast cancer: Stage 1, ER/PR negative, Her2/neu positive (see Oncologic history below) -HTN -hypothyroidism -Diabetes mellitus, A1C 11 in [4-/2126] -GERD -osteopenia -obesity and OSA -fibromyalgia -depression/anxiety -asthma -s/p c-section X3 -nephrolithiasis -s/p tonsillectomy GYN/OB HISTORY: Menarche at age 13 with menopause at age 51. G3P3 with first birth at age 26. She has been on hormonal therapy for 3 weeks at age 51 but had alopecia so stopped. On OCPs for a few years in between her children. Had a cyst removed from ipsilateral breast six years ago. ONCOLOGIC HISTORY: - [2126-5-17]: mammogram and ultrasound due to left axillary pain with left breast 1 cm mass in the inferomedial breast, measured 0.8X0.6X0.6cm with irregular margins with ultrasound. Had a negative screening mammogram in 3/[2124]. - [2126-5-21]: left breast core biopsy - [2126-6-26]: lumpectomy and sentinel node biopsy with 1.1cm tumor with single focus of invasive ductal carcinoma, grade 3 without LVI, CIS. [1-3] lymph nodes were without disease. Closest margin was 0.1cm. Tumor was ER/PR negative, Her-2/neu positive. - [2126-8-2]: initiation of chemotherapy - docetaxel, carboplatin every 21 days for 6 cycles with Trastuzumab 4mg/kg week 1 followed by 2mg/kg for 17 weeks followed by 6mg/kg IV Q3 weeks to complete 1 year. Social History: Initially from [Male First Name (un) 1056], then FL, moved to MA in [2092]. -Work: Not working currently. Used to do nail manufacturing in PR and then boat decorating in FL. -Support: Lives with son who works at the aquarium full-time. She has support and friends through her church. A daughter lives nearby and another one is out in [State 4565] with her only grand-child. -Tobacco history: <1ppd for a few years in her 30s. -ETOH: Last 20 years ago. -Activity: No current regular activity. Will walk a lot of places during the day. Family History: Mother: living at age 84 with DM, HTN Father: unknown siblings: 1 sister, 1 [12-3] sister and 2 brothers: health unknown children: healthy. No family history of breast or ovarian cancer. Had an uncle who may have had a severe skin cancer of the face. Physical Exam: Admission Physical Exam: Vitals: T: 97.7 BP: 62/41 P: 155 R: 24 18 O2: 97% on AC 400/24/5/100% General: intubated and sedated HEENT: pupils minimally responsive, sclera anicteric, MMM, oropharynx not visualized Neck: supple, JVP not elevated, no LAD CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: tense and quite distended, bowel sounds present, no organomegaly appreciated GU: foley in place Ext: cool, weak pulses bilaterally, no clubbing, cyanosis or edema Neuro: corneal reflexes not intact by eyelash stimulation, responds to pain without sedation Patient expired during hospitalization: Cardiac sounds absent, pulses absent. Breath sounds absent. Corneal reflexes negative. Pertinent Results: Admission Labs: [2126-8-10] 04:30PM BLOOD WBC-0.5# RBC-4.65 Hgb-14.6 Hct-41.5 MCV-89 MCH-31.4 MCHC-35.2 RDW-12.3 Plt Ct-204 [2126-8-10] 04:30PM BLOOD Neuts-7* Bands-0 Lymphs-87* Monos-4 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 [2126-8-10] 04:30PM BLOOD Plt Ct-204 [2126-8-10] 04:30PM BLOOD Glucose-325* UreaN-13 Creat-0.9 Na-140 K-3.0* Cl-99 HCO3-20* AnGap-24* [2126-8-11] 12:02AM BLOOD ALT-45* AST-143* LD(LDH)-760* CK(CPK)-1096* AlkPhos-95 TotBili-0.8 [2126-8-11] 12:02AM BLOOD Albumin-1.7* Calcium-5.6* Phos-4.0 Mg-1.2* [2126-8-10] 05:53PM BLOOD Type-[Last Name (un) ] Temp-36.7 pO2-41* pCO2-49* pH-7.22* calTCO2-21 Base XS--7 Intubat-NOT INTUBA [2126-8-10] 05:00PM BLOOD Lactate-6.9* Labs prior to expiration: [2126-8-11] 01:52PM BLOOD WBC-1.1* RBC-4.08* Hgb-13.0 Hct-38.5 MCV-95 MCH-31.8 MCHC-33.6# RDW-12.8 Plt Ct-108* [2126-8-11] 01:52PM BLOOD Neuts-4* Bands-3 Lymphs-76* Monos-13* Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-0 NRBC-2* [2126-8-11] 01:52PM BLOOD PT-20.7* PTT-78.5* INR(PT)-2.0* [2126-8-11] 01:52PM BLOOD Glucose-359* UreaN-15 Creat-1.7* Na-144 K-3.6 Cl-118* HCO3-15* AnGap-15 [2126-8-11] 01:52PM BLOOD ALT-204* AST-473* LD(LDH)-1322* AlkPhos-57 TotBili-0.4 [2126-8-11] 01:52PM BLOOD Calcium-6.1* Phos-2.2# Mg-1.8 [2126-8-11] 09:25AM BLOOD Type-ART pO2-102 pCO2-30 pH-6.98* calTCO2-8* Base XS--24 [2126-8-11] 12:51PM BLOOD Type-ART pO2-82* pCO2-34* pH-7.17* calTCO2-13* Base XS--15 [2126-8-11] 12:51PM BLOOD Lactate-8.5* [2126-8-10] 5:30 pm BLOOD CULTURE in all bottles Blood Culture, Routine (Preliminary): PRESUMPTIVE CLOSTRIDIUM SEPTICUM. Anaerobic Bottle Gram Stain (Final [2126-8-11]): GRAM NEGATIVE ROD(S). CT abdomen: IMPRESSION: Extensive inflammatory mural thickening and stranding involving the distal descending colon, sigmoid and rectum with accompanying free intraperitoneal fluid, but no free air. The differential considerations for this process given the patient's history include chemotherapeutic drug toxicity, infectious process and vasculitis. Ischemia is less likely given the distribution. Brief Hospital Course: 57 year old female with stage I ER/PR negative, Her2-neu positive breast cancer s/p initiation of docetaxel/carboplatin + trastuzumab regimen admitted with abdominal/flank/rectal pain; found to have severe septic shock requiring intubation and pressors with CT abdomen showing severe colonic thickening in the setting of neutropenia. # Septic shock [1-3] neutropenic enterocolitis/typhlitis: Her abdominal/rectal pain may be secondary to the colitis seen in the distal colon (sigmoid and rectum) and this inflammatory/infectious process combined with her profound neutropenia may have lead to her sepsis. This GI process would explain the elevated lactate and subsequent hypotension from septic shock, though the pattern is strange and does not coincide with an ischemic pattern or any particular disease process. Blood cultures ended up growing CLOSTRIDIUM SEPTICUM, which causes clostridial myonecrosis or a condition called "spontaneous gas gangrene", usually seen in those with risk factors of immunocompromise including colonic malignancy, neutropenia, or chemotherapy. As we began to support her with mechanical ventilation and 3 pressors (norepinephrine, phenylephrine, and vasopression), her initial bladder pressure was 31, indicating a brewing intra-abdominal process. Surgery was involved and believed that an ex-lap or any other intra-abdominal procedure would have been extremely risky and likely hasten her death. She was aggressively resuscitated with IVF, diabetic ketoacidosis was treated with insulin gtt and aggressive IVF resuscitation with potassium repletion, and she was covered with antibiotics initially with vancomycin IV, cefepime, metronidazole, as well as PO and PR vancomycin for presumed severe C. diff infection. Epinephrine was added as 4th pressor and extended GNR coverage was added, given the presumed GNRs report on the blood cultures. ID team also recommended checking for Strongyloides infection in the setting of her immunocompromise, which was ultimately negative. She was also given stress-dose steroids with the recent history of dexamethasone with chemotherapy, but the blood pressure did not respond. She was also given Neupogen to held with her WBC count, per Oncology team recs. Bicarbonate and calcium were pushed to support her rapidly declining blood pressure. However, she decompensated thereafter. Her condition did not improve and her family decided not to escalate any further care and eventually transitioned her to comfort care only. She passed away shortly thereafter. Her family declined a post-mortem examination. Medications on Admission: ALBUTEROL SULFATE [VENTOLIN HFA] - Ventolin HFA 90 mcg/actuation Aerosol Inhaler 2 puffs by mouth every six (6) hours as needed for cough, wheeze -AZELASTINE [ASTELIN] - Astelin 137 mcg Nasal Spray Aerosol 2 puffs(s) each nostril twice a day before fluticasone spray -BACLOFEN - baclofen 10 mg tablet 1 Tablet(s) by mouth at bedtime -CHLORHEXIDINE GLUCONATE - chlorhexidine gluconate 0.12 % Mouthwash 15 mL (1 tablespoon) oral rinse 0.12% swish and spit for 30 seconds twice daily -DEXAMETHASONE - dexamethasone 4 mg tablet 1 tablet(s) by mouth twice a day take day before, day of and day after chemotherapy. START morning of Thursday [8-1]. -GLIPIZIDE - glipizide 10 mg tablet 1 Tablet(s) by mouth twice a day before breakfast and supper - diabetes -IBUPROFEN - (has rx for now) - ibuprofen 800 mg tablet 1 Tablet(s) by mouth twice a day as needed for pain -LEVOTHYROXINE - levothyroxine 125 mcg tablet 1 Tablet(s) by mouth once a day before breakfast - thyroid -LOSARTAN - losartan 50 mg tablet 1 Tablet(s) by mouth once a day in morning - blood pressure, protects kidneys -METFORMIN - metformin 500 mg tablet 1 Tablet(s) by mouth twice a day with breakfast and supper - diabetes -ONDANSETRON - ondansetron 4 mg disintegrating tablet 1 tablet(s) by mouth three times a day as needed for nausea -OXYCODONE-ACETAMINOPHEN [PERCOCET] - Percocet 5 mg-325 mg tablet [12-3] tablet(s) by mouth every four (4) hours as needed for as needed for pain -PANTOPRAZOLE - pantoprazole 40 mg tablet,delayed release 1 Tablet(s) by mouth once a day with supper as needed for reflux, gastritis -PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg tablet 1 tablet(s) by mouth every six (6) hours take day of and day after chemotherapy than after as needed for nausea -SCALP PROTHESIS - -SITAGLIPTIN [JANUVIA] - Januvia 50 mg tablet 1 Tablet(s) by mouth once a day - diabetes -VENLAFAXINE - venlafaxine ER 37.5 mg capsule,extended release 24 hr 1 Capsule(s) by mouth at bedtime - depression Medications - OTC -ACETAMINOPHEN - acetaminophen 500 mg tablet [12-3] tablet(s) by mouth three times a day as needed for pain -ASCORBIC ACID [VITAMIN C] - (OTC) - Dosage uncertain -CALCIUM CARBONATE [TUMS E-X] - (OTC) - Tums E-X 300 mg (750 mg) chewable tablet 2 Tablet(s) by mouth once a day with supper -CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) 2,000 unit capsule 1 Capsule(s) by mouth twice a day Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A	[ "733.90", "995.92", "785.52", "288.00", "174.8", "530.81", "493.90", "250.12", "244.9", "401.9", "038.3", "009.1", "327.23", "276.8", "518.81", "729.1", "278.00", "E933.1", "V87.41" ]	icd9cm	[ [ [] ] ]	[ "96.04", "38.97", "38.91", "96.71" ]	icd9pcs	[ [ [] ] ]	13084, 13093	8000, 10592	328, 419	13140, 13145	5842, 5842	13197, 13203	4777, 5034		13056, 13061		13114, 13119		10618, 13033			13169, 13174									5074, 5823				7456, 7977															264, 290												447, 2827					5858, 7412									2849, 4197	4213, 4761
52,448	115,905	41802	Discharge summary	report	Admission Date: [2104-11-21] Discharge Date: [2104-11-26] Date of Birth: [2035-3-21] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[First Name3 (LF) 1515] Chief Complaint: NSTEMI transferred for cardiac catherization Major Surgical or Invasive Procedure: Cardiac Catherization [2104-11-24] with drug eluting stents to the right coronary artery x1 and to the obtuse marginal artery x2. History of Present Illness: Pt is a 68 year old M with PMHx HTN, HLD, CAD s/p MI with 4 vessel CABG x4 at [Hospital 4415]. He presented to [Hospital6 3105] with chest pain. He initially presented to [Hospital6 5016] with SOB and chest tightness in 9/[2104]. TTE at the time revealed mild TR, mildly elevated [Last Name (un) 6879] 38 mmHg, LVEF 55% and stress test with nuclear imaging showed abnormal myocardia perfusion with a fixed posterior lateral defect, without evidence of ischemia or reversibility. He was discharged but then later presented to Cardiologists office on [2104-10-6] with intermittent chest pain, which did not appear to be anginal in nature. Patient reports that he has been having chest pain at night when he lays down in bed and that the pain is relieved with Maalox. Given perfusion study only few weeks prior his symptoms were thought to be GERD and he was started on PPI. Patient returned to cardiologist for follow up appointment when he was found to be hypertensive with CP c/w angina. CP occuring with exertion, relieved at rest and radiating to left arm. . Per discussion with patient, he denies ever having CP with exertion and he is able to ambulate and do light work without symptoms. He is adament that he only has chest pain when going to bed at night laying down. The pain requires him to sit up and maalox relieves symptoms. He describes the pain as pressure like and also involving his back. He has never had N/V, diaphoresis with these episodes. The pain is not radiating and is does not change with position or with respirations. . Patient presented to LGH ED after referral from Cardiologist for CP/SOB. EKG done in ED showed RBB, LAFB, Q waves in inteferior lead c/w old MI. First topinin came back elevated at 6.29. At that time he was given chewable aspirin, plavix, and started on heparin drip. TSH was normal. Met panel was normal except for AST of 50. CXR without acute process, Trop peaked at 7.17. . Cardiac Catherization (L wrist) was performed on [2104-11-21] which showed LIMA to LAD patent, SVG to RCA with tight stenosis at the ostium/graft and bifurcation (thought to be culprit lesion). Patient had some chest pain at end of procedure, given 2 mg morphine, 2 sprays of ntg with improvement in his symptoms. He was transiently placed on a nitro drip for CP but this was stopped prior to transfer. . Plan was transfer directly to [Hospital1 18] cath lab for intervention today, however the patient was fed beef stew at around 1pm, so he was transferred to [Hospital Ward Name 121] 3 directly. On transfer, patient off nitro drip and vitals 104/58. Telemetry showed sinus rhythm with 1st degree/bundle hr 50s, 97%RA . Cardiac review of systems is notable for current absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. He does described dyspnea with heavy exertion but denies SOB with light slow walking (COPD has been an issue in terms of functional limitations Past Medical History: - CAD: MI s/p 4 vessel CABG at [Hospital1 336] in [2089] - HLD - HTN - COPD - Glucose Intolerance - Former Smoker Social History: -Semi-Retired Fence Builder -Tobacco history: Former 40 pack-yr smoker, Quit in [Month (only) ] -ETOH: None -Illicit drugs: None Family History: - CAD - Mother lived until [Age over 90 ]yo - Father had MI, lived until 85yo Physical Exam: ADMISSION PHSYICAL EXAM: Afebrile 109/54 56 22 94%RA W: 180lbs H 5'3" GENERAL: Well appearing 69yo M who appears stated age. Comfortable, appropriate and in good humor HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with low JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. NO lower extremity edema, LLE has chronic skin change over medial aspect over tibia, pink-red with some scabbed scratched. 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+ . DISCHARGE PHYSICAL EXAM: VS: 98.6 81 104-116/60-68 18 98%RA GENERAL: NAD, comfortable, appropriate HEENT: PERRL, EOMI, OP clear NECK: Supple, no JVD CARDIAC: RRR, nlS1S2, no mrg LUNGS: Resp unlabored, CTA b/l, no crackles, wheezes or rhonchi. ABDOMEN: Soft, obese, nontender naBS EXTREMITIES: Warm and well perfused, no cyanosis/edema; R groin c/d/i, L groin c/d/i, R radial c/d/i, no hematoma or ecchymosis at any site PULSES: feet warm Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: . [2104-11-21] 05:45PM BLOOD WBC-12.2* RBC-4.16* Hgb-14.0 Hct-40.3 MCV-97 MCH-33.6* MCHC-34.8 RDW-12.4 Plt Ct-243 [2104-11-22] 07:26AM BLOOD WBC-8.6 RBC-3.97* Hgb-13.2* Hct-38.3* MCV-96 MCH-33.3* MCHC-34.5 RDW-12.6 Plt Ct-183 [2104-11-21] 05:45PM BLOOD PT-12.1 PTT-24.3 INR(PT)-1.0 [2104-11-21] 05:45PM BLOOD Glucose-129* UreaN-18 Creat-0.9 Na-139 K-4.8 Cl-100 HCO3-31 AnGap-13 [2104-11-21] 05:45PM BLOOD Calcium-9.1 Phos-2.7 Mg-2.4 [2104-11-21] 05:45PM BLOOD CK-MB-6 cTropnT-0.89* . PERTINENT LABS: . [2104-11-21] 05:45PM BLOOD CK-MB-6 cTropnT-0.89* [2104-11-25] 01:16AM BLOOD CK-MB-7 cTropnT-0.58* [2104-11-25] 06:16AM BLOOD CK-MB-17* MB Indx-6.7* cTropnT-0.77* [2104-11-26] 07:25AM BLOOD CK-MB-10 MB Indx-3.3 cTropnT-1.10* [2104-11-24] 08:00AM BLOOD %HbA1c-5.8 eAG-120 . DISCHARGE LABS: . [2104-11-26] 07:25AM BLOOD WBC-9.1 RBC-3.79* Hgb-12.7* Hct-36.2* MCV-96 MCH-33.6* MCHC-35.1* RDW-12.6 Plt Ct-194 [2104-11-26] 07:25AM BLOOD Glucose-110* UreaN-24* Creat-0.9 Na-138 K-4.1 Cl-100 HCO3-28 AnGap-14 [2104-11-26] 07:25AM BLOOD CK-MB-10 MB Indx-3.3 cTropnT-1.10* [2104-11-26] 07:25AM BLOOD Calcium-9.3 Phos-3.4 Mg-1.9 . MICRO/PATH: . MRSA SCREEN (Final [2104-11-27]): No MRSA isolated. . IMAGING/STUDIES: . TTE [2104-11-24]: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the inferior and inferolateral walls and near akinesis of the mid lateral wall. The remaining segments contract normally (LVEF = 40-45 %). Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction c/w multivessel CAD. Mild mitral regurgitation with normal valve morphology. . C.CATH [11-24]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe ostial SVG-RCA stenosis. 3. Severe distal SVG-OM stenosis at touchdown. 4. Successful PTCA and stenting of ostial SVG-RCA with endeavor stent 5. Successful PTCA and stenting of distal SVG-OM with two overlapping endeavor [Name Prefix (Prefixes) ] [Last Name (Prefixes) 10157]. No-reflow improved by end of case. 6. Please see full report in OMR for full details of angiography and PCI. 7. Successful RRA TR band. 8. Successful RFA angioseal. . C.CATH [11-24]: FINAL DIAGNOSIS: 1. No acute angiographically aparant occlusion to explain the patient's ST elevations. 2. Patent SVG to RCA 3. Patent SVG to OM with slow flow, a side branch occlusion and a 40% proximal hazy lesion. Brief Hospital Course: 69M with hx of HTN, HLD, CAD, COPD, an MI s/p 4 vessel CABG in [2089] who presents to LGH with [Hospital 39700] transferred to [Hospital1 18] now s/p high-risk PCI with [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 3 complicated by subsequent chest pain and vagal episode without significant findings on repeat cath. . ACTIVE DIAGNOSES: . # NSTEMI: Patient admitted to LGH with CP, SOB and elevation in troponins consistent with NSTEMI. Cardiac catherization at LGH showed LIMA to LAD patent, but with severe disease of grafts: 95% SVG to OM, 99% RCA and total occlusin of SVG to Diag with a bifurcation lesion suspected as the culprit lesion causing his NSTEMI. He was loaded with plavix 300mg at OSH and was given ASA 325 as well as heparin drip and transferred to [Hospital1 18] for further evaluation and treatment in the CCU. He had a TTE which showed LVEF of 40-45% and regional systolic dysfunction c/w multivessel CAD. He was taken to the cath lab where he was found to have severe three vessel disease with severe ostial SVG-RCA stenosis and severe distal SVG-OM stenosis. He had [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 1 to ostial SVG-RCA and overlapping [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2 to SVG-OM lesion. Several hours following the procedure he had a vagal event and increased chest pain concerning for in-stent thrombosis and was taken to the cath lab without acute angiographically apparent occlusion to explain the patient's symptoms. Following this his symptoms resolved. He was discharged on atorvastatin, metoprolol, plavix, full dose aspirin, and imdur and had follow-up appointments arranged. . CHRONIC DIAGNOSES: . # Hypertension: Chronic and stable with BPs in 140s as an outpatient. He was switched from atenolol to metoprolol, started on imdur, and continued on his home diovan. . # COPD: Chronic, stable without recent acute exacerbations or intubations or need for home oxygen. He was continued on his home advair, and albuterol/ipratropium inhalers as needed. . # Glucose Intolerance: Chronic and Stable with A1c of 5.8 this admission. He will benefit from lifestyle counseling as an outpatient. . # Hyperlipidemia: Chronic, Stable, LDL <100 but not at goal <70 given extent of CAD. His home atorvastatin was increased to 80mg daily. . TRANSITIONAL ISSUES: -He was arranged with outpatient follow-up at discharge -He will need to be on aspirin and plavix until his cardiologist tells him to discontinue either medication -He would benefit from lifestyle counseling in the outpatient setting Medications on Admission: HOME MEDICATIONS: confirmed with pt -Aspirin 81 mg Daily -Diovan 160 mg Daily -Simvastatin 40 mg QHS -HCTZ 25 mg Daily -Lasix 20 mg Daily -Atenolol 25 mg [Hospital1 ] -Advair Diskus 250/50 i inh Daily -Albuterol sulfate 2 puff Q4H PRN -Atrovent 2 puff QID pnr -Econazole cream applied to feet daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:30 Tablet Extended Release 24 hr(s) Refills:0 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:2 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 10. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. econazole Topical Discharge Disposition: Home Discharge Diagnosis: Active: - Non ST elevation myocardial infarction Chronic: - Coronary artery disease - Hyperlipidemia - Hypertension - Chronic obstructive pulmonary disease - Glucose Intolerance - Former Smoker Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [Known lastname 90789], It was a pleasure treating you during this hospitalization. You were transferred to [Hospital1 69] for cardiac catherization after you were found to have severe coronary artery disease at [Hospital6 3105]. Your history and lab work suggested that you had a small heart attack and you were treated with IV blood thinners. You received a cardiac catherization that showed a tight blockage in two of your arteries that were opened and three drug eluting stents were placed. Your repeat echocardiogram showed an area that was still weak but your overall heart function is OK. You are being discharged in stable condition and with the following changes made to your home medications. - START Imdur 30mg by mouth daily to prevent further chest pain - START Clopidogrel 75mg Daily and Aspirin 325 mg daily to keep the stent open. Do not stop taking clopidogrel or aspirin for any reason or miss [First Name (Titles) 691] [Last Name (Titles) 4319] unless Dr. [Last Name (STitle) ] says it is OK to do so. - START Atorvastatin 80mg daily to prevent further blockages instead of simvastatin - START Metoprolol 100mg Daily instead of Atenolol to lower your heart rate - STOP Furosemide, simvastatin, and atenolol Followup Instructions: Name: STUPNYTSKYI,OLEKSANDR Specialty: PRIMARY CARE Address: [Street Address(2) ] [Apartment Address(1) 3882], [Hospital1 ],[Numeric Identifier 66038] Phone: [Telephone/Fax (1) 83705] We were unable to contact your PCP to schedule [Name Initial (PRE) ] follow up appointment. It is recommended you see your PCP [Name Initial (PRE) 176] 1 week of your discharge from the hospital. Please contact your PCP at the number above. Name: [Last Name (LF) 5423],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD Location: [Location (un) ] CARDIOLOGY Address: [Last Name (un) 39144], STE#404 [Hospital1 ], [Numeric Identifier 39146] Phone: [Telephone/Fax (1) 5424] Appointment: WEDNESDAY [12-31] AT 2:45PM Completed by:[2104-11-29]	[ "401.9", "794.31", "V15.82", "414.05", "272.4", "410.71", "496", "790.29", "414.2", "780.2", "412" ]	icd9cm	[ [ [] ] ]	[ "00.47", "88.55", "00.41", "99.20", "37.21", "88.56", "36.07", "00.66" ]	icd9pcs	[ [ [] ] ]	12941, 12947	8703, 9046	315, 451	13186, 13186	5513, 5513	14615, 15423	3779, 3862		11649, 12918		12968, 13165		11321, 11321		8479, 8680	13337, 14592			6363, 7922						3877, 5016			11339, 11626								11060, 11295								231, 277												479, 3468					5529, 6037			13201, 13313	6053, 6347			9064, 11039		3490, 3613	3629, 3763				5041, 5494
45,817	161,097	54477	Discharge summary	report	Admission Date: [2197-3-2] Discharge Date: [2197-3-7] Date of Birth: [2116-12-7] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: history of aortic stenosis. She has been followed by echo by her PCP. [Name10 (NameIs) ] remains asymptomatic Major Surgical or Invasive Procedure: [2197-3-2] 1. Aortic valve replacement with a size 21 [Last Name (un) 3843]-[Doctor Last Name ] Magna tissue valve. 2. Coronary artery bypass graft x1 saphenous vein graft to ramus artery. 3. Endoscopic harvesting of the long saphenous vein. History of Present Illness: The patient is a 79 year old [Location 7972] female with a history of aortic stenosis. She has been followed by echo by her PCP. [Name10 (NameIs) ] remains asymptomatic, caring for her grandchildren and carrying grocery bags without limitation. Echo [2195-12-17] reveals severe AS with [First Name8 (NamePattern2) ] [Location (un) 109] 0.8-1.0 cm2, worsening from [Location (un) 109] 1.2cm2 in [2192]. She is referred for surgical evaluation Past Medical History: hypertension hypercholesterolemia diabetes mellitus -Type II mild BLE varicosities tubal ligation R Cataract [Doctor First Name ] Social History: Race: [Location 7972] Last Dental Exam: none recently Lives with: husband Occupation: retired housekeeper- CHB Tobacco: chewed tobacco- quit 10 yrs.ago ETOH: none Family History: non-contributory, parents died of "old age" Physical Exam: Pulse: 64 Resp: O2 sat: B/P Right: 178/85 Left: 178/81 Height: Weight: General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP with dentures ( has some prosthetic teeth missing from plate) Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur : 3/6 SEM- radiates to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]; no HSM Extremities: Warm [x], well-perfused [x] Edema trace edema b/l ; lealed lac. anterior RLE Varicosities: None [] small/minor varicosities BLEs Neuro: Grossly intact X; MAE 5.5 strengths; nonfocal exam Pulses: Femoral Right: 2+ Left: 1+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: radiation of cardiac murmur to carotids Pertinent Results: [2197-3-7] 09:42AM BLOOD WBC-8.0 RBC-2.95* Hgb-9.1* Hct-26.9* MCV-91 MCH-30.9 MCHC-33.8 RDW-14.4 Plt Ct-168 [2197-3-2] 10:17AM BLOOD WBC-8.7 RBC-2.60# Hgb-8.2# Hct-23.0# MCV-89 MCH-31.6 MCHC-35.7 RDW-12.4 Plt Ct-112* [2197-3-7] 09:42AM BLOOD Plt Ct-168 [2197-3-7] 09:42AM BLOOD PT-12.1 INR(PT)-1.0 [2197-3-2] 10:17AM BLOOD Plt Ct-112* [2197-3-2] 10:17AM BLOOD PT-14.6* PTT-36.0* INR(PT)-1.2* [2197-3-2] 10:17AM BLOOD Fibrino-144* [2197-3-7] 09:42AM BLOOD Glucose-154* UreaN-17 Creat-0.7 Na-138 K-4.0 Cl-99 HCO3-32 AnGap-11 [2197-3-2] 11:37AM BLOOD UreaN-9 Creat-0.6 Na-141 K-3.7 Cl-109* HCO3-25 AnGap-11 [2197-3-7] 09:42AM BLOOD Mg-2.2 [2197-3-4] 09:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Negative echocardiogram Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS (area 0.8-1.0cm2). Trace AR. 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. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS Biventricular systolic function is preserved. There a well seated, well functioning bioprosthesis in the aortic position. No AI is visualized. The MR is now trace. The remaining study is unchanged from prebypass. Brief Hospital Course: Admitted same day surgery and was taken to the operating room for aortic valve replacement and coronary artery bypass graft surgery. See operative report for further details. She received cefazolin for perioperative antibiotics. Postoperatively she was transferred to the intensive care unit for post operative management. In first twenty four hours she was weaned from sedation, awoke neurologically intact and was extubated without complications. She went into atrial fibrillation that was treated with betablockers and amiodarone. She has been in sinus rhythm for greater than 24 hours prior to discharge. Coumadin was started for anticoagulation with goal INR 2-2.5 for atrial fibrillation. Physical therapy worked with her on strength and mobility. She was ready for discharge to rehab on post operative day 5 to rehab at [Hospital 111488] healthcare center at [Location (un) ]. Medications on Admission: glyburide 2.5mg daily HCTZ 25 mg daily lisinopril 40 mg daily ranitidine 150 [Hospital1 ] simvastatin 40 mg daily asa 81 mg daily MVI daily zetia 10 mg daily Discharge Disposition: Extended Care Facility: [Hospital 4470] HealthCare Center at [Location (un) 38] Discharge Diagnosis: Aortic Stenosis-s/p AVR Coronary Artery Disease-s/p CABG post-operative atrial fibrillation-now sinus rhythm PMH: hypertension, hypercholesterolemia, diabetes mellitus -Type II mild BLE varicosities PSH:tubal ligation, Right Cataract excision Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Edema- none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Goal INR 2.0-2.5 First draw [3-8] To be dosed by rehab physician Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [Last Name (STitle) 7772] on [4-3] at 1:30pm Cardiologist:none Primary Care Dr.[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [4-4] at 10:30am Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Goal INR 2.0-2.5 First draw [3-8] To be dosed by rehab physician Please check PT/INR monday and wednesday and friday for 2 weeks and prn and then may decrease to twice a week Please arrange coumadin follow prior to discharge from rehab [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2197-3-7]	[ "427.31", "250.00", "424.1", "V26.51", "454.9", "997.1", "401.9", "414.01", "V15.82", "272.0", "E878.2" ]	icd9cm	[ [ [] ] ]	[ "36.11", "35.21", "39.61" ]	icd9pcs	[ [ [] ] ]	6264, 6354	5152, 6052	422, 678	6641, 6814	2491, 4154	7871, 8698	1539, 1585				6375, 6620		6078, 6241			6838, 7848								4193, 5129	1600, 2472																			268, 384												706, 1180														1202, 1338	1354, 1523
60,295	122,434	41734	Discharge summary	report	Admission Date: [2201-3-6] Discharge Date: [2201-3-15] Date of Birth: [2160-11-28] Sex: F Service: MEDICINE Allergies: Penicillins / morphine Attending:[First Name3 (LF) 603] Chief Complaint: tracheal stenosis Major Surgical or Invasive Procedure: Microsuspension laryngoscopy, CO2 laser excision of tracheal stenosis, rigid dilation, tracheostomy change [2201-3-6] History of Present Illness: 40 yo F with Crohn's disease, DM2, HTN, CAD with h/o STEMI s/p CABGx5, tracheal stenosis, s/p trach, initially presenting for microsuspension laryngoscopy and CO2 laser reexcision of subglottic stenosis with dilation by ENT, now transferred to medicine post-operatively for consideration of tracheal resection by thoracic surgery. . The patient had a STEMI in [6-/2200], and underwent emergency CABG. She was intubated for 7 days due to cardiogenic shock. She was successfully extubated, but subsequently developed tracheitis and eventually needed a tracheostomy. She was found to have complete tracheal stenosis. On [2200-9-11], re-canalization of stenotic area was attempted via flexible and rigid bronchoscopies, but was unsuccessful. Additional attempts to alleviate the tracheal stenosis were made by ENT on [2201-2-20] and again today, with the goal of placing a T-tube, but without success. . Today, the patient underwent microsuspension laryngoscopy and CO2 laser reexcision of subglottic stenosis with dilation by ENT. She received general anesthesia and remained hemodynamically stable throughout the case. She developed hyperglycemia in the PACU, for which she was given regular insulin 8 units. She is now transferred to medicine further further management while consultants from interventional pulmonology, thoracic surgery, and ENT consider surgical options. . On the medical floor, the patient had no complaints. Past Medical History: CAD with h/o STEMI s/p CABG x 5 [2200-7-8] (LIMA->LAD, SVG->OM, RCA, sequential SVG to rPDA, R post LV branch) CHF EF 20-30% Diabetes HTN Hyperlipidemia Asthma Fibromyalgia Obesity Tracheal stenosis Crohn's disease h/o MRSA pneumonia s/p appendectomy s/p ventral hernia repair [5-11] s/p cholecystectomy s/p C-section with tubal ligation Social History: -tobacco: former smoker -EtOH: none -Drugs: none Family History: non-contributory Physical Exam: Vital signs: T 98.8, HR 85, BP 111/75, RR 20, O2 Sat 98%/RA Gen: No acute distress. HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. Neck: Trach in place. Resp: Normal respiratory effort. CTAB. CV: RRR. Normal s1 and s2. No M/G/R. Abd: +BS. Soft. NT/ND. No rebound or guarding. Ext: Warm and well-perfused. Radial and DP pulses 2+ bilaterally. Neuro: A+Ox3. PERRL. EOMI, with no nystagmus. Face symmetric. Palate elevates symmetrically. Tongue protrudes in midline. Strength 5/5 throughout upper and lower extremities. Pertinent Results: Admission labs: [2201-3-6] 01:05PM BLOOD WBC-11.8* RBC-4.76 Hgb-12.6 Hct-41.8 MCV-88 MCH-26.4* MCHC-30.1* RDW-16.2* Plt Ct-317 [2201-3-6] 01:05PM BLOOD Glucose-283* UreaN-20 Creat-0.7 Na-136 K-5.3* Cl-99 HCO3-27 AnGap-15 Blood cultures x 2 [2201-3-11]: pending . CXR (portable AP) [2201-3-6]: No pneumothorax or pneumomediastinum. . CT trachea [2201-3-9]: 1. Suboptimal inspiration, limiting evaluation of tracheal caliber with persistent tracheal wall thickening. 2. Interval improvement in bilateral pulmonary consolidations with residual ground glass opacity, which may be exaggerated by expiratory phase imaging. 3. Stable mediastinal and hilar lymphadenopathy. 4. Possible right thyroid nodule for which non-urgent ultrasound is recommended. Brief Hospital Course: 40 yo F with Crohn's disease, DM2, HTN, CAD with h/o STEMI s/p CABGx5, tracheal stenosis, s/p trach, initially presenting for microsuspension laryngoscopy and CO2 laser reexcision of subglottic stenosis with dilation by ENT. The patient was transferred to medicine post-operatively for management of her diabetes, HTN, and CHF while the various surgical services developed a plan. Her course was complicated by respiratory depression from morphine, requiring a brief ICU stay. She was discharged with a plan for outpatient thoracic surgery, ENT, and interventional pulmonary follow-up for consideration of tracheal resection. . # Tracheal stenosis: The patient underwent microsuspension laryngoscopy and CO2 laser reexcision of subglottic stenosis with dilation on [2201-3-6]. The procedure was not successful in alleviating the patient's tracheal stenosis. She was transferred to medicine post-operatively while ENT, interventional pulmonary, and thoracic surgery evaluated how to address the tracheal stenosis. CT was performed to determine the length of the stenosis. The thoracic surgery service recommended consideration of tracheal resection, and asked cardiology to consult for pre-operative evaluation. Cardiology was consulted and noted that the patient has a high risk for peri-operative cardiac complications, but felt that no further cardiac testing or interventions were required prior to surgery. The patient continue benzonatate, mucinex, albuterol, and duonebs. She was discharged with a plan to follow up with thoracic surgery, interventional pulmonology, and ENT as an outpatient for further discussion of tracheal resection. The patient is trach-dependent and cannot be intubated from above. . # Hypotension/somnolence/respiratory depression: Post-operatively, the patient complained of chest and throat discomfort. The chest discomfort is a chronic complaint, was highly reproducible on exam, and was felt to be musculoskeletal in origin (see below). The patient requested liquid morphine rather than her home oxycodone due to ease of swallowing, and the dose was uptitrated as she continued to complain of pain. On [2201-3-10], the patient developed a mucus plug, followed by respiratory depression, and hypotension. She was transferred to the MICU, where she was treated with a narcan gtt. The patient's symptoms were attributed to morphine. The patient's condition improved, and she was weaned off of the narcan gtt and transferred back to the medical floor. Future providers should be aware that Mrs. [Known lastname ] is very sensitive to the accumulation of morphine and its metabolites. . # Hyperkalemia: The patient present with K 5.3, likely related to lisinopril + potassium supplementation. Potassium supplementation was stopped. The patient was discharged off of lisinopril due to low-normal blood pressure, but this can likely be restarted (without any potassium supplementation and with close electrolyte monitoring) in the outpatient setting. . # ?Right thyroid nodule: Noted incidentally on CT trachea. This was discussed with the patient's primary care doctor Dr. [Last Name (STitle) 90669] [Name (STitle) 65534] on [2201-3-17]. Dr. [Last Name (STitle) 65534] will arrange for a non-urgent thyroid ultrasound to further characterize the possible nodule. . # Chest pain: The patient had chest pain that was highly reproducible with palpation and started with cough, with EKG unchanged and cardiac enzymes normal. The pain was felt to be of musculoskeletal etiology. . # Diabetes mellitus: The patient presented for her elective ENT procedure on [2201-3-6] with blood sugar >400. She was transferred to medicine post-operative, and was managed with her home dose of Lantus 38 units QHS, with a Humalog insulin sliding scale. She was discharged on her pre-admission insulin regimen of Lantus 38 units at night, with sliding scale. . # CAD s/p CABG: Continued aspirin, Plavix, metoprolol. Held lisinopril in the setting of hyperkalemia, then restarted lisinopril as hyperkalemia resolved. Subsequently held lisinopril due to hypotension. Lisinopril can likely be titrated back on by the patient's primary care physician at the time of follow-up . # Chronic systolic heart failure: EF 35-40% per TTE [2200-8-4]. The patient was euvolemic at the time of discharge. Lasix was held, with a plan to restart, likely at a lower dose, at the time of PCP [Last Name (NamePattern4) 702]. Lisinpril was held due to low-normal blood pressure and will need to be restarted after discharge. . # HTN: The patient was discharged on metoprolol but off of lisinopril and Lasix due to low-normal blood pressures. Lisinopril and Lasix can be readded as tolerated in the outpatient setting. . # Fever: The patient had a single fever to 101 in the ICU. The etiology was unclear, but the fever resolved and did not recur. . # Chronic chest/throat pain: Continued lidoderm patch, gabapentin. Initially changed oxycodone to morphine per patient request, but then the patient developed complications of oversedation and respiratory depression (see above). She was subsequently started on a regimen of oxycodone 10 mg Q6 hours PRN. . # Intertriginous rash: The patient developed a rash under her breasts that was felt to be fungal in etiology and was treated with miconazole powder. . # Communication: HCP husband [Name (NI) 13291] [Name (NI) ] and sister [Name (NI) ] [Name (NI) 57301] [Telephone/Fax (1) 90676] . # Code status: FULL CODE Medications on Admission: protonix 40 mg daily paxil 40 mg daily Humalog 18 units TID before meals Lantus 38 units SC at bedtime Tylenol 650 mg Q4-6 hours PRN pain benzonatate 100 mg TID PRN cough aspirin 325 mg daily Duoneb 3L PRN wheezing Lidoderm patch Seroquel XR 150 mg QHS albuterol 2 puffs Q4H PRN wheezing, shortness of breath gabapentin 400 mg QID zofran 4 mg PRN nausea, vomiting lisinopril 15 mg daily lipitor 40 mg daily Plavix 75 mg daily furosemide 60 mg daily mucinex ER 600 mg Q12 PRN vitamin B12 100 mcg daily asacol 800 mg [Hospital1 ] vitamin D 5000 units daily Klonopin 1 mg [Hospital1 ] oxycodone 5 mg Q6H PRN pain metoprolol tartrate 25 mg [Hospital1 ] Klor-Con M10 ER 10 meq every other day 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. Paxil 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. insulin glargine 100 unit/mL Solution Sig: Thirty Eight (38) units Subcutaneous at bedtime. 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [3-6] hours as needed for pain. 5. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 9. Seroquel XR 150 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO at bedtime. 10. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 11. gabapentin 400 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). 12. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 13. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Asacol 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO twice a day. 17. Vitamin D3 5,000 unit Tablet Sig: One (1) Tablet PO once a day. 18. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:10 Tablet(s) Refills:0 21. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): Apply to affected area under breasts twice daily. Disp:30 grams Refills:0 22. Mucinex 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1) Tablet, ER Multiphase 12 hr PO twice a day. Disp:60 Tablet, ER Multiphase 12 hr(s) Refills:2 23. insulin glargine 100 unit/mL Solution Sig: Thirty Eight (38) units Subcutaneous at bedtime. 24. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous as directed: Please use the sliding scale you were using prior to admission. Discharge Disposition: Home With Service Facility: [Hospital ] Home Health Discharge Diagnosis: Primary: 1. Tracheal stenosis. 2. Diabetes mellitus. 3. Hypotension. 4. Respiratory depression, secondary to morphine. 5. Intertriginous tinea corporis under breasts . Secondary: 1. Coronary artery disease 2. Chronic systolic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital after a surgery, which was done to try to open of the narrowing of your trachea. The surgery was not able to open up the narrowing. You were admitted to the medical service, and evaluated by the thoracic surgery for possible tracheal resection. You were seen by cardiology, who felt that this would be a high-risk procedure, but did not recommend any further cardiac testing prior to surgery. . You had an episode of sleepiness, respiratory depression, and low blood pressure, that was thought to be related to morphine, and required a brief ICU stay. As the morphine wore off, your condition improved. . You will follow up with thoracic surgery, interventional pulmonology, and ENT as an outpatient to discuss surgical options for your tracheal stenosis. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. . There are some changes to your medications: 1. STOP potassium supplement, as your potassium was too high on admission. 2. STOP lisinopril and Lasix (furosemide) for now and discuss restarting these when you see your primary care doctor. 3. INCREASE Mucinex (guaifenisen) to 1200 mg twice daily 4. START miconazole powder for fungal rash under breasts. . You have been given a prescription for oxycodone. Never take this more than prescribed, as it can cause dangerous sedation and breathing problems. [Name (NI) ] not drive or participate in hazardous activities after taking oxycodone. Followup Instructions: Name: [Last Name (un) ],[Last Name (un) ] L. Location: COOS COUNTY FAMILY HEALTH SERVICES Address: [Street Address(2) ], [Location (un) ],[Numeric Identifier 90671] Phone: [Telephone/Fax (1) 90673] When: Wednesday, [3-18], 9:45 AM . We are working on a follow up appt in the Thoracic Surgery department with Dr. [Last Name (STitle) ] within 2 weeks. You will be called at home with the appointment. If you have not heard or have questions, please call ([Telephone/Fax (1) 29075]. . Please call the [Hospital ] clinic at ([Telephone/Fax (1) 6213] to schedule an appointment with Dr. [Last Name (STitle) ] for the same day that you come to see Dr. [Last Name (STitle) ] in thoracic surgery. You should see them within the next 2 weeks. . Please call Dr.[Name (NI) 5070] office at ([Telephone/Fax (1) 17398] to schedule an appointment for the same day that you come to see Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) ].	[ "414.00", "519.19", "933.1", "780.60", "555.9", "241.0", "276.7", "V58.67", "E849.7", "428.0", "E935.2", "V44.0", "338.4", "276.2", "428.22", "250.92", "311", "729.1", "110.5", "V45.81", "458.9", "478.74", "V15.82", "786.59", "E912", "493.90", "401.1" ]	icd9cm	[ [ [] ] ]	[ "31.99", "31.5", "97.23" ]	icd9pcs	[ [ [] ] ]	12528, 12586	3716, 9223	300, 424	12881, 12881	2925, 2925	14521, 15521	2345, 2363		9973, 12505		12607, 12860		9249, 9950			13032, 13921									2378, 2906													13950, 14498						243, 262												452, 1893					2941, 3693			12896, 13008						1915, 2262	2278, 2329
28,968	102,894	32621	Discharge summary	report	Admission Date: [2179-10-30] Discharge Date: [2179-11-5] Date of Birth: [2104-2-18] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: chest pain Major Surgical or Invasive Procedure: emergent CABGx3 (LIMA->LAD, SVG->, SVG->) [10-30] History of Present Illness: 75 y.o. female that presented to OSH with chest pain and shortness of breath. She was found to have 2mm ST segment depressions in I, aVL, II, aVF, V4 and V6 with reportedly old LBBB. She was started on heparin, eptifibatide, clopidogrel 600mg and underwent left-heart cath and found to have 95% LCx, 90% LMCA, 90% LAD, and occluded RCA with collaterals from LAD. LCx was stented with Voyager 2.5x15mm. Patient was felt to have worsened MR secondary to papillary muscle dysfunction that seemed to improve with stenting of LCx. IABP was placed, and she was started on dopamine and transferred to [Hospital1 ] for further management and possible CABG. Past Medical History: HTN, DM, Osteoarthritis, Dyslipidemia Social History: denies tobacco, etoh Family History: unknown Physical Exam: On admission: BP 126/56 HR 82 RR 20 Elderly F intubated and sedated CV RR, IABP Lungs clear anteriorly Abdomen obese, soft, NTND Extrem cool, no edema Pertinent Results: [2179-11-5] 06:25AM BLOOD WBC-17.1* RBC-3.62* Hgb-11.7* Hct-34.6* MCV-96 MCH-32.2* MCHC-33.7 RDW-15.0 Plt Ct-575* [2179-11-5] 06:25AM BLOOD Plt Ct-575* [2179-11-2] 02:14AM BLOOD PT-13.2* PTT-30.0 INR(PT)-1.2* [2179-11-5] 06:25AM BLOOD Glucose-133* UreaN-24* Creat-0.9 Na-139 K-4.5 Cl-96 HCO3-33* AnGap-15 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 76038], [Known firstname 4617] [Hospital1 18] [Numeric Identifier 76039]TTE (Complete) Done [2179-11-4] at 3:09:03 PM 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: [2104-2-18] Age (years): 75 F Hgt (in): 65 BP (mm Hg): 123/493 Wgt (lb): 156 HR (bpm): 105 BSA (m2): 1.78 m2 Indication: s/p CABG. ICD-9 Codes: 414.8, 424.2 Test Information Date/Time: [2179-11-4] at 15:09 Interpret MD: [First Name11 (Name Pattern1) 449] [Last Name (NamePattern4) ], MD Test Type: TTE (Complete) Son[Name (NI) 930]: [First Name4 (NamePattern1) 1022] [Last Name (NamePattern1) ], RDCS Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Suboptimal Tape #: 2007W046-1:12 Machine: Vivid [7-4] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.4 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.4 m/s Left Atrium - Peak Pulm Vein D: 0.3 m/s Right Atrium - Four Chamber Length: 4.7 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.4 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% >= 55% Left Ventricle - Lateral Peak E': 0.07 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.05 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 13 < 15 Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.14 Mitral Valve - E Wave deceleration time: 140 ms 140-250 ms TR Gradient (+ RA = PASP): 26 to 29 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Elongated LA. LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Mildly depressed LVEF. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV wall thickness. Mildly dilated RV cavity. Borderline normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Characteristic rheumatic deformity of the mitral valve leaflets with fused commissures and tethering of leaflet motion. No MVP. Mild mitral annular calcification. Moderate thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Trivial MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic tricuspid valve supporting structures. No TS. Mild [1+] TR. Borderline PA systolic hypertension. PERICARDIUM: Small pericardial effusion. Effusion circumferential. No echocardiographic signs of tamponade. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor apical views. Left pleural effusion. Conclusions The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %) secondary to hypokinesis of the anterior septum and posterior wall. There is no ventricular septal defect. The right ventricular cavity is mildly dilated. Right ventricular systolic function is borderline normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve shows characteristic rheumatic deformity. There is no mitral valve prolapse. There is moderate thickening of the mitral valve chordae. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is borderline pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Brief Hospital Course: She was admitted to the CCU. She was taken to the operating room emergently for cardiogenic shock where she underwent a CABG. She was started on vancomycin periop for prophylaxis was she was in house preoperatively. She was transferred to the ICU in critical but stable condition on epinephrine, neosynephrine and propofol. She was transfused 3 units post op for anemia/hypotension and shock. She remained intubated with IABP overnight. Her IABP was dc'd in the morning of post op day 2. Her epi was weaned to off and she was extubated on the morning of post op day 3. She was transferred to the floor on POD #4. She was seen by physical therapy who [Hospital 24260] rehab placement, and she was ready for discharge on POD #6. Her white count on discharge was 17, her incisions appear to be healing well, and her white count should be rechecked on [11-8]. Medications on Admission: Simvastatin 40', Ezetimibe 10', Lisinopril 40', Atenolol 50', Metformin 500' 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:225 Tablet(s) Refills:0 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Discharge Disposition: Extended Care Facility: [Hospital 2971] Rehabilitation and Nursing Center - [Hospital1 1474] Discharge Diagnosis: CAD now s/p CABG HTN, DM, Osteoarthritis, Dyslipidemia 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 lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [Last Name (STitle) 3314] (PCP) 2 weeks Dr. [Last Name (STitle) ] (cardiologist) 2 weeks Dr. [Last Name (STitle) ] 4 weeks Completed by:[2179-11-5]	[ "584.9", "428.0", "285.9", "428.42", "414.01", "410.91", "424.0", "401.9", "785.51", "518.81", "250.00", "E878.2", "272.4" ]	icd9cm	[ [ [] ] ]	[ "96.71", "00.17", "39.61", "99.04", "36.12", "36.15" ]	icd9pcs	[ [ [] ] ]	8233, 8336	6123, 6988	333, 389	8435, 8443	1381, 6100	8743, 8913	1186, 1195		7115, 8210		8357, 8414		7014, 7092			8467, 8720									1210, 1210																			283, 295												417, 1071							1224, 1362							1093, 1132	1148, 1170
30,575	114,848	7353	Discharge summary	report	Admission Date: [2201-1-31] Discharge Date: [2201-2-4] Date of Birth: [2154-5-25] Sex: M Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 689] Chief Complaint: Altered mental status s/p fall, drowsiness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 46 yo male with a history of bilateral AVN s/p hip replacement x2, DM2, depression, and OSA on CPAP who presented s/p 2 falls at home. 2 days prior to admission, he was walking at home at 2 am, and reports a mechanical fall in which he hit the side of a cabinet while walking, and fell back and hit the back of his head. The fall was unwitnessed, and the patient is unsure if he had LOC. He denied palpitations, prodrome, or loss of bowel or bladder function. He believes the fall may be secondary to cold symptoms vs. his diabetes. He reports that he had not been checking FSBGs, but he had felt a little diaphoretic. During the 2 days s/p the fall, his family reported that he was more confused and lethargic than usual. Then on the day of admission, he was walking and again fell. He landed on his knees but did not hit his head. He called out to his mother for help, but she did not respond so he pushed his life line button for EMS. Of note, he has had several falls in the past year secondary to his obesity and chronic pain. . Mother reports that patient put on Wellbutrin in past 2 weeks for smoking cessation. Last year, was at [Location (un) 38] at which time started celexa, buspar, and haldol. . His SaO2 was 83% on RA in ambulance. Vital signs in the ED were temp 96.9, HR 96, bp 154/83, RR 13, SaO2 up to 91% on 4L NC, FSBG 143. He was found to be Pickwickian, and was alert and oriented x2. EKG showed NSR at a rate of 83. Head CT showed no acute intracranial process, and CT C-Spine showed no cervical spine fracture or malalignment. Blood cultures were sent, CXR was a l imited study given low lung volume but no definite acute cardiopulmonary process detected, and he was given Levaquin 750 mg IV x1. ABG showed 7.28/74/63, and he was put on BiPAP and given Narcan 0.4 mg IV x1. He was admitted for hypercarbic respiratory acidosis. . The patient was initially admitted to the floor, and on the evening of admission felt agitated as if he was withdrawing from his medications. He was A&Ox3. He was given Ativan 1 mg PO x2, Oxycodone 5 mg PO x1, and Dilaudid 0.5-1 mg IV x1. Psych was consulted and recommmended continuing short-acting opioids and withholding long-acting opioids. He was started on Oxycodone 5-10 mg PO q4 hr prn, Ativan 1 mg PO q6hr prn, and Morphine 2 mg IV q2 hr prn. He then developed altered mental status and somnolence, and ABG showed 7.41/60/40. He received Narcan 0.4 mg IV x1 then 2 mg IV x2. He was transferred to the MICU, and his mental status improved with CPAP and brief Narcan gtt. He remained hemodynamically stable, and ABG improved to 7.47/53/79. . The patient currently reports [3-28] pain, and localizes his pain to his back, hips, and knees. He denies nausea. Past Medical History: -DM2 has been followed at [Last Name (un) ] -OSA on CPAP at home -Hepatits C - s/p aborted course of interferon -Major depressive disorder, ? of schizophrenia and bipolar disorder -Hypertension -Bilateral avascular necrosis of femoral heads s/p hip replacements in '[79] and '[85] -s/p L1/L2 kyphoplasty after fall [6-25] -s/p left distal radius fracture after fall [6-25] -Bilateral lower extremity edema, thought to be secondary to venous stasis -DJD of his back -Osteoporosis -Morbid Obesity Social History: - On disability, lives with his mother, attends a day program. - Smokes 1.5 ppd for > 10yrs, no EtoH for 15 years or illicits for the past 13 years - Stopped IVDA in [2186] aver 3 years of use, cocaine with heroin use. - Has been in psychiatric partial hospitalization program in [Location 1268] for the past six years. Family History: Non contributory Physical Exam: vitals- T 99.4F, BP 142/96, HR 90, RR 22, O2 96% 3L, Weight: 350 lbs gen- morbidly obese, sitting in chair, in mild discomfort secondary to leg pains. heent- EOMI. OP clear. pulm- CTA b/l. no r/r/w cv- RRR. normal S1/S2. no m/r/g abd- soft, NT/ND. well healed surgical scars. Normal active bowel sounds ext- 2+ pitting edema b/l LEs. + Erythema anterior shins b/l LEs, warm to touch, w/o associated ulceration; symmetric. no evidence of lymphangitic spread or palpable cords; distal pulses palpable 1+ b/l. neuro- alert and oriented x 3. motor strength 5/5 b/l. unable to flex or extend hips due to previous surgeries. Pertinent Results: LABS: [2201-2-1] 08:00AM BLOOD WBC-7.1 RBC-4.43* Hgb-13.4* Hct-40.9 MCV-92# MCH-30.3 MCHC-32.9 RDW-15.8* Plt Ct-133* [2201-2-4] 07:15AM BLOOD WBC-5.1 RBC-4.43* Hgb-13.3* Hct-40.9 MCV-92 MCH-30.0 MCHC-32.5 RDW-16.6* Plt Ct-117* [2201-2-1] 08:00AM BLOOD Neuts-84.8* Lymphs-12.7* Monos-2.2 Eos-0.1 Baso-0.2 [2201-2-1] 01:23PM BLOOD Neuts-86.2* Lymphs-11.8* Monos-1.7* Eos-0.1 Baso-0.1 [2201-2-1] 08:00AM BLOOD PT-13.5* PTT-25.9 INR(PT)-1.2* [2201-2-1] 01:23PM BLOOD Fibrino-305 [2201-1-31] 10:15AM BLOOD ESR-8 [2201-1-31] 10:15AM BLOOD Glucose-113* UreaN-11 Creat-0.7 Na-140 K-4.6 Cl-96 HCO3-38* AnGap-11 [2201-2-4] 07:15AM BLOOD Glucose-231* UreaN-9 Creat-0.6 Na-136 K-3.3 Cl-94* HCO3-35* AnGap-10 [2201-1-31] 10:15AM BLOOD ALT-143* AST-134* LD(LDH)-193 CK(CPK)-63 AlkPhos-83 Amylase-26 TotBili-0.3 [2201-2-1] 01:23PM BLOOD ALT-119* AST-90* LD(LDH)-210 CK(CPK)-176* AlkPhos-75 Amylase-34 TotBili-0.6 [2201-1-31] 10:15AM BLOOD Lipase-20 [2201-2-1] 01:23PM BLOOD Lipase-21 [2201-1-31] 10:15AM BLOOD cTropnT-<0.01 [2201-2-1] 01:23PM BLOOD CK-MB-6 cTropnT-<0.01 [2201-2-1] 08:00AM BLOOD Calcium-9.5 Phos-2.2* Mg-1.0* [2201-2-1] 01:23PM BLOOD Albumin-3.7 Calcium-9.9 Phos-2.7 Mg-1.0* UricAcd-5.0 Iron-72 Cholest-132 [2201-2-4] 07:15AM BLOOD Calcium-9.1 Phos-2.5* Mg-1.5* [2201-2-1] 01:23PM BLOOD calTIBC-471* Ferritn-94 TRF-362* [2201-2-3] 08:10AM BLOOD %HbA1c-6.5* [2201-2-1] 01:23PM BLOOD Triglyc-86 HDL-56 CHOL/HD-2.4 LDLcalc-59 [2201-2-1] 01:23PM BLOOD TSH-0.16* [2201-2-1] 01:23PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2201-1-31] 10:26AM BLOOD Type-ART pO2-63* pCO2-74* pH-7.28* calTCO2-36* Base XS-4 [2201-2-1] 01:07PM BLOOD Type-ART Temp-37 pO2-45* pCO2-54* pH-7.43 calTCO2-37* Base XS-9 Intubat-NOT INTUBA Comment-NON-REBREA [2201-2-1] 01:12PM BLOOD Type-ART Temp-37 pO2-40* pCO2-60* pH-7.41 calTCO2-39* Base XS-10 Intubat-NOT INTUBA Comment-NON-REBREA [2201-2-1] 05:12PM BLOOD Type-ART PEEP-11 pO2-79* pCO2-53* pH-7.47* calTCO2-40* Base XS-12 Intubat-NOT INTUBA [2201-1-31] 10:42AM BLOOD Lactate-2.5* [2201-1-31] 01:12PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 [2201-2-1] 10:33PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.018 [2201-1-31] 01:12PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2201-2-1] 10:33PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [2201-2-1] 10:33PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . MICRO: Blood Cx ([1-31]): No growth x2 Blood Cx ([2-1]): No growth Urine Cx ([2-1]): <10,000 organisms/ml . IMAGING: ECG ([1-31]): Sinus rhythm at a rate of 83. Compared to the previous tracing of [2200-9-8] no change. . CXR Portable ([1-31]): Study is limited secondary to lordotic positioning and low lung volumes. The cardiomediastinal silhouette is grossly within normal limits given AP and lordotic positioning. Perihilar vascular crowding is believed secondary to low lung volumes. No focal consolidation is appreciated. Degenerative changes are noted at the left acromioclavicular joint and a well-corticated ossific density is present superior to this joint. IMPRESSION: Limited study given low lung volume, AP technique and lordotic positioning. No definite acute cardiopulmonary process detected. . Head CT ([1-31]): There is no evidence of hemorrhage, edema, mass, mass effect or infarction. The ventricles and sulci are normal in size and configuration. There is no fracture. IMPRESSION: No acute intracranial process. . CT C-Spine ([1-31]): There is no cervical spine fracture or malalignment. There is minimal straightening of normal cervical spine lordosis. Prevertebral and paraspinal soft tissues are not enlarged. Visualized outline of the thecal sac appears unremarkable, please note however, that CT is unable to provide intrathecal detail comparable to MRI. Incidental note is made of increased ground-glass attenuation, and interlobular septal thickening at the lung apices, which could be suggestive of increased volume status. IMPRESSION: No cervical spine fracture or malalignment. . CXR Portable ([2-1]): There are low lung volumes. There is prominence of the central pulmonary vasculature, but the lungs are probably clear, with the exception of mild atelectasis at the left costophrenic angle. IMPRESSION: Atelectasis left costophrenic angle, otherwise probably clear. Brief Hospital Course: # Altered Mental Status: The patient presented with increased lethargy and confusion s/p 2 falls at home. The falls sounded mechanical as he reported hitting the side of a cabinet, but he did hit the back of his head during the first fall. Head CT showed no acute intracranial process, and CT C-Spine showed no cervical spine fracture or malalignment. Blood cultures showed no growth, and Urine culture showed <10,000 organisms/mL. The patient became agitated on the night of admission possibly secondary to withdrawal from his medications, and received Ativan 1 mg PO x2, Oxycodone 5 mg PO x1, and Dilaudid 0.5-1 mg IV x1. He then developed altered mental status and somnolence, and ABG showed 7.41/60/40. He received Narcan 0.4 mg IV x1 then 2 mg IV x2. He was transferred to the MICU for oversedation, and his mental status improved with CPAP and a brief Narcan gtt. He remained hemodynamically stable, and ABG improved to 7.47/53/79. His altered mental status was thought to be due to a combination of fall (post-concussion) with polypharmacy from his home narcotic medications. His mental status was clear at the time of discharge. He was discharged on his home doses of Oxycontin 100 mg PO q8hr, Percocet 5-325 mg, 1-2 Tablets PO q6 hr prn, Alprazolam 2 mg PO qid, Buspirone 10 mg tid, Citalopram 40 mg daily, Haldol 5 mg PO bid, and Quetiapine 200 mg PO qhs. His Temazapam and Wellbutrin were held during this admission, and can be added back as an outpatient. . # Pain management: The patient is on multiple pain medications at home given his chronic back, hip, and knee pain. The pain service was consulted during this admission. He was placed on a Clonidine patch TTS 1 qweekly during this admission, but this was not continued at the time of discharge. His other pain medications include Oxycontin 100 mg PO q8 hr and Percocet [11-19] tabs q6 hr prn breakthrough pain. . # OSA: The patient has a history of OSA and is intermittently on CPAP at home. He may have a component of obesity hypoventilation leading to hypoxia and wheezing. TTE [8-25] showed borderline pulmonary artery systolic hypertension. The patient was given Nasal BiPap at night, and satted well on room air. He was given Albuterol and Atrovent nebs prn. He was scheduled for an outpatient follow up appointment with Pulmonary in the Sleep Clinic. . # Hypertension: The patient was continued on Toprol XL 100 mg daily. He was started on Lisinopril 5 mg daily, and this can be titrated up as an outpatient for further blood pressure control. . # Diabetes Mellitus Type 2: His last HgA1c was 6.2% in [6-25], and a repeat HgA1c during this admission was 6.5%. He was continued on Metformin 1000 mg [Hospital1 ]. . # Depression/Anxiety: The patient has a history of depression and has had auditory hallucinations for the past 3 years. During this admission he continued to have auditory hallucinations of voices telling him he is a fraud and that he should be able to walk. He denied visual hallucinations. He denied suicidal ideation, but does wonder "what will my life become" given his frequent pain. Psychiatry was consulted during this admission. He was continued on Haldol 5 mg [Hospital1 ], Seroquel 200 mg qhs, Celexa 40 mg daily, Xanax 2 mg qid, Buspar 10 mg tid. His Temazapam and Wellbutrin were held per psychiatry recommendations, and these can be added back as an outpatient as needed. His TSH was slightly low at 0.16 during this admission, and will need to be rechecked as an outpatient. . # Tobacco Abuse: He was started on a Nicotine patch 14 mg daily. Medications on Admission: Medications on Admission (Psych confirmed with Strand Pharmacy) -Alprazolam 2 mg QID -Buspirone 10 mg tid -Celexa 40 mg daily vs. 30 mg [Hospital1 ] -Docusate Sodium 100 mg Capsule [Hospital1 ] -Haloperidol 5 mg Tablet [Hospital1 ] -Magnesium Oxide 400 mg [Hospital1 ] -Metoprolol Succinate (Toprol XL) 100 mg daily -Metformin 1000 mg [Hospital1 ] -Hexavitamin daily -Oxycodone 100 mg Tablet Sustained Release q8hr -Quetiapine 200 mg qhs -Tylenol 1000 mg qid prn pain -Wellbutrin SR 100 mg [Hospital1 ] -Temazapam 30 mg qhs -Zocor 80 mg daily . Allergies: Codeine Discharge Medications: 1. Alprazolam 1 mg Tablet Sig: Two (2) Tablet PO four times a day. 2. Buspirone 10 mg Tablet Sig: One (1) Tablet PO three times a day. 3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for constipation. Disp:30 Tablet(s) Refills:2 6. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Oxycodone 60 mg Tablet Sustained Release 12 hr Sig: 1.5 Tablet Sustained Release 12 hrs PO Q8H (every 8 hours). **** Please note: This should actually read Oxycodone 100 mg PO q8 hr (not 90 mg PO q8hr). The patient was aware of this at the time of discharge. 12. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for breakthrough pain. 14. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:2 15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: PRIMARY: Altered Mental Status Respiratory Depression Hypertension . SECONDARY: Diabetes Mellitus Obstructive Sleep Apnea Depression Anxiety Tobacco Abuse Discharge Condition: Afebrile, awake and alert, ambulating with PT Discharge Instructions: 1. If you develop chest pain, shortness of breath, fever >101.5, confusion or mental status changes, falls, loss of consciousness, lightheadedness or dizziness, weakness or numbness, or any other symptoms that concern you, call your primary care physician or return to the ED. 2. Take all medications as prescribed. 3. Attend all follow up appointments. 4. Your Temazapam and Wellbutrin were held during this admission. You should ask your primary care physician or psychiatrist if and when these medications should be restarted. 5. You were started on Lisinopril 5 mg daily to help with your blood pressure. 6. You were started on a Nicotine Patch to help you stop smoking. Followup Instructions: You will need to follow up with Dr. [Last Name (STitle) 2204], you primary care physician ([Telephone/Fax (1) 2205]) in the next 1-2 weeks. His office will call you in the next few days with an appointment date and time. . You have a follow up appointment with [Doctor First Name ] in Vascular ([Telephone/Fax (1) 1237]) on [2201-2-16] at 1:00 in VASCULAR [Apartment Address(1) 871] of the [Hospital Unit Name ], [Location (un) ]. You then have an appointment with Dr. [Last Name (STitle) ] in Vascular ([Telephone/Fax (1) 1237]) on [2201-2-16] at 2:00. . You have a follow up appointment with Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) ] in the Pulmonary Sleep Clinic ([Telephone/Fax (1) 612]) on [2-17] at 9:30 in the [Hospital Ward Name 23] Center [Location (un) 858].	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17,196	140,908	50914	Discharge summary	report	Admission Date: [2152-11-21] Discharge Date: [2152-10-29] Date of Birth: [2086-7-27] Sex: M Service: [Location (un) 259] HISTORY OF THE PRESENT ILLNESS: The patient is a 66-year-old gentleman with a three-day history of increasing difficulty with gait and strength, especially in the lower extremities. He also had a headache. He had a CT in the ER, which showed intracranial hematoma on [2152-10-20]. Today, the CT revealed enlargement of the bilateral subdural fluid collection with old and new blood with mass effect and effacement of the sulci in the frontal and parietal region. PAST MEDICAL HISTORY: 1. Prostate cancer. 2. Myocardial infarction in [2152]. 3. Hypertension. 4. Increased cholesterol. 5. Tonsillectomy. 6. Colon resection. 7. Stent placement just recently after the most recent myocardial infarction PHYSICAL EXAMINATION: Examination revealed the following: Temperature 96.5, heart rate 63, blood pressure 116/54, respiratory rate 14, saturations 99% on room air. He was awake, alert, and oriented. Pupils equal, round, and reactive to light. Extraocular muscles were full. Chest was clear to auscultation. CARDIAC: Regular rate and rhythm. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Warm. Strength was [6-11] in the upper extremities. Lower extremity strength: Ankles [5-12] and the left ankles were [6-11]. Sensation was intact bilaterally. He moved all extremities and followed commands. HOSPITAL COURSE: The patient was admitted for observation to the ICU and possible subdural drainage at the bedside, which was eventually done on [2152-11-22] under sterile conditions. He had bilateral frontal subdural drains placed, which remained in place. Followup head CT on [2152-10-24] showed new collection. Drains remained in place until [2152-10-25] at which time they were discontinued and the patient was transferred to the regular floor. He is out of bed, ambulating. He was seen by the Department of Physical Therapy and Occupational Therapy. It was found that the patient would be safe for discharge to home with home safety evaluation. He was discharged to home in stable condition. MEDICATIONS ON DISCHARGE: 1. Metoprolol 12.5 mg PO b.i.d.; hold for heart rate less than 60, blood pressure less than 100. 2. Zantac 150 mg PO b.i.d. 3. Moexipril 15 mg PO q.d. 4. Atorvastatin 40 mg PO q.h.s. 5. Hydromorphone 2 mg PO q.4h. to 6h. p.r.n. pain. The patient was stable with suture removal on post-procedure day #10. Vital signs were stable. The patient will followup with Dr. [Last Name (STitle) 6910] in one month for repeat head CT and with the cardiologist, primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ] in one to two weeks. [Name6 (MD) 6911] [Name8 (MD) ], MD [MD Number(1) 6913] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2152-11-28] 10:31 T: [2152-11-28] 11:43 JOB#: [Job Number 54945]	[ "401.9", "432.1", "185", "412", "272.0", "V45.82", "781.3" ]	icd9cm	[ [ [] ] ]	[ "01.09" ]	icd9pcs	[ [ [] ] ]												2247, 3059		1522, 2221																				900, 1504																																				651, 877
10,743	100,560	17429+17430	Discharge summary	report+report	Admission Date: [2134-5-27] Discharge Date: [2134-6-3] Date of Birth: [2059-11-12] Sex: M Service: HISTORY: The patient is a 74-year-old gentleman with right hemifacial paralysis status post posterior fossa decompression on [2134-5-14] complicated by postoperative delirium and bilateral subdural hygromas. The patient was operated on at [Hospital3 ] Hospital. Postoperatively, he was transferred to the ICU down at [Hospital3 ] Hospital and the family requested transfer to [Hospital1 69] for further management. PHYSICAL EXAMINATION: The patient is pleasant, sleepy, but arousable. Pupils are under 3 mm. His chest is clear to auscultation. His cardiac status is regular rate and rhythm, no murmur, rub or gallop. He is awake, alert, oriented times one. He has a left-sided weakness, left upper greater than lower extremity weakness, with right facial due to the Bell's palsy and facial paralysis. He moves the right side purposely and spontaneously. The left upper extremity is now anti-gravity strength with poor fine motor coordination. Left lower extremity is anti-gravity strength on the left side as well. HOSPITAL COURSE: The patient was monitored in the ICU for four or five days. Initially had drains in place from his subdural hygroma incisions. Those were DC'd. His operative incision is clean, dry, and intact, and the staples will be removed prior to discharge. Mental status: He was lethargic, but easily arousable, confused at times. Would follow commands on the right side. Had some garbled speech which has greatly improved. His heart rate was in the 50's to 60's, normal sinus rhythm with episodes of sinus tachycardia up to the 140's. He was started on PO Lopressor for that. CPK's were sent and they were negative. He was in the ICU until [2134-5-28]. He was sent to the regular floor. He opened his eyes spontaneously and his pupils were 5 down to 3 mm. He has a right ptosis. He, again, had anti-gravity strength on the left side, which was improved from a pretty dense paralysis on admission. Head MRI was negative for stroke. Head CT showed inproved bilateral subdural hygromas. He was seen by Physical Therapy and Occupational Therapy and found to require acute rehab. He was discharged in stable condition with improving neurologic status. DISCHARGE MEDICATIONS: 1. Famotidine 20 mg PO b.i.d. 2. Metoprolol, 50 mg PO b.i.d. 3. Heparin, 5,000 units SQ q 12 hours. 4. Tylenol, 650 PO q 4 hours p.r.n.. CONDITION ON DISCHARGE: Stable. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2134-6-4] 09:36 T: [2134-6-4] 10:14 JOB#: [Job Number 48702] Admission Date: [2134-5-27] Discharge Date: [2134-6-4] Date of Birth: [2059-11-12] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old gentleman with a past medical history of coronary artery disease and myocardial infarction, bilateral carotid stenosis status post a left carotid endarterectomy, who developed a right Ball's palsy and hemifacial paralysis treated with Botox and status post a posterior fossa microvascular decompression on [2134-5-14] at [Hospital3 ] Hospital. Postoperatively there was a question of the patient being in delirium tremens on the floor. The patient fell out of his wheelchair in his room and was transferred to the intensive care unit. The patient had a CT/MRI that showed bilateral subdural hygromas. The patient was status post evacuation of the hygromas on [2134-5-26] and had drains placed and had persistent altered mental status and confusion, and the patient's family requested that the patient be transferred to [Hospital1 69] for further management. PAST MEDICAL HISTORY: 1. Coronary artery disease and myocardial infarction. 2. Bilateral carotid stenosis. 3. Peptic ulcer disease. 4. Hypertension. 5. Increased lipids. 6. History of right Bell's palsy and hemifacial paralysis. PAST SURGICAL HISTORY: Coronary artery bypass grafting and left carotid endarterectomy. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: His blood pressure was 152/74, heart rate 77, respiratory rate 18, saturations 100% on three liters. Pupils were equal, round and reactive to light. Extraocular movements were full. Cardiac examination showed regular rate and rhythm, S1 and S2. Lungs showed decreased breath sounds bilaterally, no crackles. Abdomen was soft with no masses. Extremities had 4+/5 strength in the bilateral lower extremities and right grasp. The patient has a left upper extremity hemiparesis. He moves the right arm and leg purposely and spontaneously. He continues to have a right facial droop. Pupils were 4 down to 2 mm and brisk. HOSPITAL COURSE: He was admitted to the intensive care unit for close monitoring. INCOMPLETE DICTATION. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2134-6-4] 09:30 T: [2134-6-4] 10:27 JOB#: [Job Number ]	[ "401.9", "412", "852.20", "351.0", "E884.3", "V45.81", "427.31" ]	icd9cm	[ [ [] ] ]	[ "03.31" ]	icd9pcs	[ [ [] ] ]									2371, 2513					4950, 5312									4163, 4283											4306, 4932																						2997, 3904								1454, 2348						3927, 4139		2538, 2968
79,078	184,841	17053+56820	Discharge summary	report+addendum	Admission Date: [2146-7-17] Discharge Date: [2146-8-1] Service: MEDICINE Allergies: Remeron Attending:[First Name3 (LF) 8104] Chief Complaint: status post fall Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ] yo M with h/o dementia, BPV, bronchiectasis, coloniztion w/ MAC, afib, PM [2-26] sss, and multiple falls s/p unwitnessed fall at [Hospital3 ]. In ED, had difficulty obtaining O2 sat, placed on NRB and ABG pO2-207/pCO2-46/7.37. All imaging was negative: head & spine CT, elbow & pelvis xray. Given levo, cefepime, and flagyl [2-26] thick green sputum. Admitted to ICU, where o2 sats were at baseline per prior reports, using toe o2 sat monitor. Sputum smear positive for AFB - spec sent to state lab, neg for TB per GEN-PROBE AMPLIFIED M. TUBERCULOSIS DIRECT TEST (MTD). Given IVF for low BP, repeat cxr revealed mild pulm edema. Sent to 11R on [7-18] & ruled in for a NSTEMI by enzymes. Past Medical History: Mixed Alzheimer's/Vascular Dementia h/o Multiple falls (? mechanical falls x 3 recently at ALF) Severe Bronchiectasis, PFTs ([1-/2145]) c/w restrictive ventilatory defect, followed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD h/o MAC & Mycobacterium abscessus Atrial fibrillation (on ASA, [2-26] hemoptysis while on coumadin) SSS, s/p Pacemaker Anemia (hct mostly mid-30's per OMR) Hiatal hernia h/o Colon CA, s/p partial colectomy Benign positional Vertigo CKD (baseline Cr 1.0) Osteoarthritis BPH Glaucoma, blind in left eye, glasses to read HOH Depression . PSHx s/p bilat cataract excision, [2144] s/p partial colectomy s/p chole, due to gallstones Social History: Retired from family owned car business. Lives in dementia unit of [Hospital3 ] (The Falls at Cordingly [Last Name (LF) ], [First Name3 (LF) 745]). Widowed (was married 64 years), two sons and daughter-in-laws who are very involved. [Name (NI) 47951] HCPs - [Name (NI) 122] (son), cell [Telephone/Fax (1) 47952] (his wife [Name (NI) 5036], cell [Telephone/Fax (1) 47953]); and [Name (NI) ] (son), home [Telephone/Fax (1) 47954], cell [Telephone/Fax (1) 47955], work [Telephone/Fax (1) 47956] (his wife [Name (NI) ] cell [Telephone/Fax (1) 47957]). . ADLs: RW @ baseline - independent in feeding and eating, but pushes food around plate. Clothes are laid out for him and he dresses himself. Assistance with bathing. [Name (NI) 4461] - son [Doctor Last Name 122] manages all. . Smoking, EtOH: Quit smoking over 20 years ago. 1PPD x 10+yrs, denies any alcohol use or IVDU. . Vision/Hearing: Blind in left eye [2-26] glaucoma. Wears glasses to read, is HOH but no hearing aides. . Functional Baseline ADLs: walks with walker at baseline. Is independent in feeding and eating, but pushes food around plate. Clothes are laid out for him and he dresses himself. Assistance with bathing . [Month/Day (2) 4461]: Son [Name (NI) 122] [Name (NI) 47958] manages all. Family History: Noncontributory Physical Exam: ADMISSION EXAM: =============== Gen: Thin elderly gentleman in no acute distress. HEENT: PERRL. CV: Distant heart sounds. No M/R/G. Pulm: Scattered crackles worse at the bases bilaterally. Abd: Soft, nontender, no organomegaly. Ext: No edema. Neuro: A&Ox1. Pertinent Results: Admission labs: =============== [2146-7-18] BLOOD WBC-9.3 RBC-3.62* Hgb-9.8* Hct-31.3* MCV-86 MCH-26.9* MCHC-31.2 RDW-15.6* Plt Ct-216 [2146-7-18] BLOOD Glucose-108* UreaN-28* Creat-0.8 Na-142 K-4.3 Cl-111* HCO3-23 AnGap-12 [2146-7-18] BLOOD CK-MB-7 cTropnT-0.10* [2146-7-17] BLOOD CK-MB-4 cTropnT-0.05* [2146-7-17] BLOOD cTropnT-0.02* [2146-7-17] URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2146-7-17] LACTATE-3.0* . Cardiac: ======== [2146-7-17] 06:20PM cTropnT- 0.02 [2146-7-17] 11:09PM cTropnT- 0.05 [2146-7-18] 05:18AM cTropnT- 0.10 [2146-7-18] 06:05PM cTropnT- 0.14 [2146-7-19] 08:50AM cTropnT- 0.10 [2146-7-20] 06:20AM cTropnT- 0.08 MICRO: ====== [2146-7-17] 11:09 pm SPUTUM Source: Expectorated. ACID FAST SMEAR (Final [2146-7-19]): ACIDFAST BACILLI, MODERATE SEEN ON CONCENTREATED SMEAR; GEN-PROBE AMPLIFIED M. TUBERCULOSIS DIRECT TEST (MTD) (Preliminary): NEGATIVE FOR M. TUBERCULOSIS BY MTD. [Last Name (un) ] RESULTS. MTD PERFORMED AT [State ] STATE LABORATORY, [Location (un) ], MA. [2145-5-31] SPUTUM (Expectorated, Final [2145-7-16]) - MYCOBACTERIUM AVIUM COMPLEX, Identified by State Laboratory; MYCOBACTERIUM ABSCESSUS, Identified by State Laboratory. . IMAGING: ======== [2146-7-23] CT HEAD W/O CONTRAST - No evidence of acute hemorrhage, mass lesion, hydrocephalus, or major territorial infarction. [2146-7-21] CT HEAD W/O CONTRAST - no evidence of acute intracranial hemorrhage or subdural hematoma, mild right parietal soft tissue swelling without evidence of underlying fracture, no significant changes in comparison with the prior CT of the head dated [2146-7-17]. [2146-7-18] CHEST (PORTABLE AP)- Mild pulmonary edema, small nodules within the upper lobes likely secondary to pulmonary edema, large hiatal hernia with associated atelectasis in the LLL. [2146-7-17] CT HEAD W/O CONTRAST - No acute intracranial hemorrhage, chronic small vessel ischemia. [2146-7-17] CT C-SPINE W/O CONTRAST - No acute fracture or dislocation involving the cervical spine. Multilevel degenerative disease, stable. [2146-7-17] ELBOW (AP, LAT & OBLIQUE) LEFT - no acute fracture, dislocation or joint effusion. [2146-7-17] PELVIS (AP ONLY) - No acute fracture. . EKG: ==== [2146-7-19] - A-V sequential pacing with occasional ventricular premature beats. Compared to the previous tracing of [2146-7-17] A-V sequential pacing at a rate of 60 beats per minute is seen. QT/QTc 460/465 . Discharge Labs: ================ [2146-7-24] BLOOD WBC-6.8 RBC-3.83* Hgb-10.7* Hct-32.5* MCV-85 MCH-27.9 MCHC-32.9 RDW-16.5* Plt Ct-289 [2146-7-24] BLOOD Glucose-101 UreaN-12 Creat-0.7 Na-140 K-3.4 Cl-105 HCO3-27 AnGap-11 Brief Hospital Course: [Age over 90 ] year old man s/p unwitnessed fall at [Hospital3 ]. Normally he can get himself up, but this time was not able. He is unable to provide history but no report of dizziness, chest pain, sob after according to ALF staff. All imaging was negative in ED, he was given levo, cefepime, and flagyl [2-26] thick green sputum. Admitted to ICU. In the [Hospital Unit Name 153], the patient saturated well on room air and low nasal cannula oxygen supplementation overnight. He had some relative hypotension that improved without intervention and was afebrile. # NSTEMI: On arrival to floor troponin continued to rise with peak 0.14 on [2146-7-18], then trended down. No changes on ECG. Patient never complained of any pain. Discussion with family confirmed did not want intervention and to maintain comfort. No anticoagulation due to h/o hemoptysis & frequent falls. Sotalol 80 mg PO DAILY, was continued for rhythm control # Positive AFB smear: was sent in setting of concern for respiratory status. He has a known h/o of bronchiectasis and colonization with MAC ([6-1]). Was placed in respiratory isolation for r/o TB which was d/c'd on [2146-7-25], after negative MTD by State Lab. No signs of worsening respiratory status. # Bronchiectasis: initially received broad antibiotics in ED for green sputum & low BP. No fever, PNA per CXR, leukocytosis or signs of worsening respiratory function. He continued on ipatropium nebs with albuterol PRN and has had an intermittent congested sounding but non-prod cough with stable o2 sats on RA. # Delirium over accelerating mixed dementia in setting of environment change and nstemi. Family & PCP give [Name Initial (PRE) ]/o accelerating decline as evidenced by weight loss, freq falls & deterioration of former self-care abilities. Had occasional visual hallucinations in hospital. Supportive measures. Foley and telemetry quickly discontinued. Zoloft was tapered and discontinued, Protonix stopped for possible confusion. Failed trial of traZODONE for sleep. Quetiapine Fumarate 12.5mg PO HS prn sleep started on [7-26]. This sedated him for several days and was discontinued. The patient did not experience agitation during the remainder of the hospitalization and was off 1:1 sitters for several days prior to discharge. # s/p Multple falls: no evidence of injury. Most likely blindness contributing, but family does report he has been less active lately. Head ct and c-spine negative for fracture or bleed. He was evaluated by physical therapy who recommended 24 hour supervision. Prior to admission he was ambulating with a rolling walker. Fell out of bed on general care unit [7-20], [7-21] & [7-23]. Slight bruising to trochanter, normal ROM without pain. Was able to walk without gait disturbance or pain. Head CT w/out contrast neg. Has low bed with pads on floor. All anticoags held [2-26] risk of falls. # Weight loss: [11-9] lb weight loss over past three months. Digoxin recently stopped. Continue supplements. 1:1 assistance with feeding. Appears to forget to swallow food that is placed in mouth. Diet: ground consistency & nectar-thickened liquids. Despite frequent mouth care, upright position, encouragement & supervision -pt often refuses to eat/drink & has min PO intake. Maintained on Aspiration Precautions (S&S consult not obtained). # Afib: had hemoptysis on coumadin, ASA held given falls & risk of bleeding, on sotalol for rate/rhythm control. AV paced. # CKD: slightly elevated on admission (1.1), has trended down (0.7 on [7-24]). No ACE-I given CRI at this time # Skin, Stage II ulcers right scapula & left lateral thoracic spine, skin tears left FA & posterior head - sequential air matress to go on low bed - attempt to maintain out of supine position - barrier cream to peri-rectal area - check for incont/toilet & turn S->S q2h - keep heels off of bed - dsgs per orders #Advance Directives: HCP- joint [Name2 (NI) 2759] - [Name (NI) 122] (son), cell [Telephone/Fax (1) 47952] (his wife [Name (NI) 5036], cell [Telephone/Fax (1) 47953]); and [Name (NI) ] (son), home [Telephone/Fax (1) 47954], cell [Telephone/Fax (1) 47955], work [Telephone/Fax (1) 47956] (his wife [Name (NI) ] cell [Telephone/Fax (1) 47957]) . Code Status- Family meeting ([2146-7-26]) with PCP [Name Initial (PRE) ]: - DNR/DNI, no feeding tubes or artificial nutrition re-confirmed; - goals of care to be maintaining pt's dignity, emphasizing comfort & family enjoying whatever time remains with the patient; - Comfort Measures Only, food/drink will be offered, meds continued as rx, no IV's, no routinue VS or blood draws. Medications on Admission: Albuterol prn Digoxin 0.125mg daily (recently discontinued as level 1.3 and may have negative effect on appetite) Prilosec 20mg daily Sertraline 50mg daily Sotalol 80mg daily Timolol 0.5% 1 drop both eyes daily Travoprost 0.004% drops 1 drop both eyes daily ASA 325mg dasily Colace 100mg po bid MVI daily Aleve 220mg daily prn pain Discharge Medications: DNR/DNI/CMO - Sotalol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). - Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). - Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. - Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One Inhalation Q4H (every 4 hours) as needed. - Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. - Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Last Name (un) 14710] House (Hospice Home) - [Location (un) 620] Discharge Diagnosis: Primary Diagnoses: Dementia with Delirium NSTEMI Secondary Diagnoses: Mixed Alzheimer's/Vascular Dementia h/o Multiple falls (? mechanical falls x 3 recently at ALF) Severe Bronchiectasis (followed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD) h/o +MAC Atrial fibrillation (on ASA, due to hemoptysis while on coumadin) SSS, s/p Pacemaker Anemia (hct mostly mid-30's per OMR) Hiatal hernia h/o Colon CA, s/p partial colectomy Benign positional Vertigo CKD (baseline Cr 1.0) Osteoarthritis BPH Glaucoma, blind in left eye, glasses to read HOH Depression . PSHx s/p bilat cataract excision, [2144] s/p partial colectomy Discharge Condition: Poor Discharge Instructions: Comfort measures only, DNR/DNI Followup Instructions: Hospice Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1239], [Name Initial (NameIs) ].O. Phone:[Telephone/Fax (1) 719] Date/Time:[2146-10-5] 2:30 Completed by:[2146-7-28] Name: [Known lastname 8849],[Known firstname ] Unit No: [Numeric Identifier 8850] Admission Date: [2146-7-17] Discharge Date: [2146-8-1] Date of Birth: [2051-5-28] Sex: M Service: MEDICINE Allergies: Remeron Attending:[First Name3 (LF) 8851] Addendum: Mr. [Known lastname ] developed a new l facial swelling on [7-30]. Chief Complaint: swelling on Left side of face Major Surgical or Invasive Procedure: none History of Present Illness: A new swollen area developed on the left face on [7-30] which is tender to palpation. We are treating it with hot soaks and tylenol. We are starting him on Keflex for comfort. Past Medical History: Mixed Alzheimer's/Vascular Dementia h/o Multiple falls (? mechanical falls x 3 recently at ALF) Severe Bronchiectasis, PFTs ([1-/2145]) c/w restrictive ventilatory defect, followed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD h/o MAC & Mycobacterium abscessus Atrial fibrillation (on ASA, [2-26] hemoptysis while on coumadin) SSS, s/p Pacemaker Anemia (hct mostly mid-30's per OMR) Hiatal hernia h/o Colon CA, s/p partial colectomy Benign positional Vertigo CKD (baseline Cr 1.0) Osteoarthritis BPH Glaucoma, blind in left eye, glasses to read HOH Depression . PSHx s/p bilat cataract excision, [2144] s/p partial colectomy s/p chole, due to gallstones Social History: Retired from family owned car business. Lives in dementia unit of [Hospital3 2065] (The Falls at Cordingly [Last Name (LF) ], [First Name3 (LF) ]). Widowed (was married 64 years), two sons and daughter-in-laws who are very involved. [Name (NI) 8852] HCPs - [Name (NI) ] (son), cell [Telephone/Fax (1) 8853] (his wife [Name (NI) 3291], cell [Telephone/Fax (1) 8854]); and [Name (NI) ] (son), home [Telephone/Fax (1) 8855], cell [Telephone/Fax (1) 8856], work [Telephone/Fax (1) 8857] (his wife [Name (NI) ] cell [Telephone/Fax (1) 8858]). . ADLs: RW @ baseline - independent in feeding and eating, but pushes food around plate. Clothes are laid out for him and he dresses himself. Assistance with bathing. [Name (NI) 8859] - son [Doctor Last Name ] manages all. . Smoking, EtOH: Quit smoking over 20 years ago. 1PPD x 10+yrs, denies any alcohol use or IVDU. . Vision/Hearing: Blind in left eye [2-26] glaucoma. Wears glasses to read, is HOH but no hearing aides. . Functional Baseline ADLs: walks with walker at baseline. Is independent in feeding and eating, but pushes food around plate. Clothes are laid out for him and he dresses himself. Assistance with bathing . [Month/Day (2) 8859]: Son [Name (NI) ] [Name (NI) ] manages all. Family History: Noncontributory Physical Exam: L anterior ear swelling 5 cm x 3 cm, firm, eythematous and tender. Pertinent Results: [2146-7-24] 07:10AM BLOOD WBC-6.8 RBC-3.83* Hgb-10.7* Hct-32.5* MCV-85 MCH-27.9 MCHC-32.9 RDW-16.5* Plt Ct-289 Brief Hospital Course: Mr. [Known lastname ] is brighter and less agitated. He recognizes his family and is cooperative most of the time. He does not require a sitter and has been eating and drinking mimimally. On [2146-7-30] he developed an erythematous and tender area on the left side of his face. He is afebrile. We are treating it with warm compresses and around the clock Tylenol. He appears comfortable. We also decided to add Keflex for comfort, he has not received any keflex yet. Medications on Admission: see d/c summary Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 2. Sotalol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 7. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 9. DNR/DNI/CMO 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 11. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): for 7 days. Disp:28 Capsule(s) Refills:0 12. Morphine Concentrate 20 mg/mL Solution Sig: 5 mg PO q 4 hours prn as needed for pain: give 5 mg (0.25ml) by mouth or under tongue every 4 hours as needed for mild pain (rating of [1-27] on a scale of 0-10) that is persistent or increasing and not responding to acetaminophen suppositiories; or for moderate to severe pain (rating of [5-5] on a scale of 0-10); or for breathlessness. Disp:30 cc Refills:0 13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO q 6 hours prn anxiety as needed for anxiety. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Last Name (un) 8860] House (Hospice Home) - [Location (un) 407] Discharge Diagnosis: Left facial swelling Discharge Condition: Stable, with poor prognosis Discharge Instructions: You were admitted to the hospital after falling at the [Hospital 8861] Facility and developed delirium in the hospital. You are being discharged to an in patient hospice facility for comfort care. Followup Instructions: Hospice Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].O. Phone:[Telephone/Fax (1) 7151] Date/Time:[2146-10-5] 2:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8862] MD [MD Number(2) 8863] Completed by:[2146-8-1]	[ "285.21", "369.8", "V10.05", "365.9", "290.41", "707.02", "V66.7", "427.31", "386.11", "784.2", "V45.01", "410.71", "518.82", "437.0", "600.00", "585.2", "783.21", "707.8", "V15.88", "715.90" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	18108, 18207	16092, 16573	13550, 13557	18271, 18301	15953, 16069	18551, 18893	15834, 15851		16639, 18085		18228, 18250		16599, 16616			18325, 18528			5995, 6211						15866, 15934	12146, 12727																		13481, 13512												13585, 13768					3402, 5979									13790, 14485	14501, 15818
3,779	175,662	6630	Discharge summary	report	Admission Date: [2126-4-30] Discharge Date: [2126-5-5] Service: ACOVE CHIEF COMPLAINT: Melena. HISTORY OF THE PRESENT ILLNESS: The patient is a [Age over 90 ]-year-old woman without a history of GI bleed who presents with new onset melena at approximately 3:00 a.m. on the day of presentation. She denied nausea or vomiting but states that she has had crampy abdominal pain. She has been taking Vioxx 50 mg p.o. q.d. episodically over the last few weeks for right shoulder pain. She denied dizziness or lightheadedness. No chest pain or shortness of breath. She came to [Hospital1 18] ED where NG lavage in the Emergency Room reportedly was negative. No signs of orthostatic changes in blood pressure were noted. She was then admitted to the Medicine ICU for further evaluation. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hiatal hernia. 3. Meniere's disease. 4. DJD. 5. Diverticulitis. 6. Chronic renal insufficiency with a baseline creatinine of 2.2. 7. Osteoporosis. 8. GERD. 9. Glaucoma. 10. Hyperlipidemia. 11. Status post bilateral total hip replacement. ADMISSION MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Lasix, dose unknown. 3. Metoprolol 50 mg p.o. b.i.d. 4. Vioxx 50 mg p.o. q.d., although the patient states that she has only taken a few pills. SOCIAL HISTORY: No tobacco or alcohol use. She was never married and lives alone. She is independent in all activities of daily living. The patient walks with a walker and cane while at home. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood pressure 187/90, heart rate 64, respiratory rate 18, oxygen saturation 100% on 2 liters nasal cannula. General: The patient is pleasant and conversant. She was in no apparent distress. She was well nourished and well developed. HEENT: The head was normocephalic, atraumatic. The extraocular muscles were intact. The pupils were equal, round, and reactive. The oropharynx was dry. The sclerae were anicteric and were not pale. Neck: Supple, no lymphadenopathy. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate, no murmurs, rubs, or gallops noted. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds. Extremities: No clubbing, cyanosis or edema. Neurologic: She was alert and oriented times three. Cranial nerves II through XII were intact. Motor strength was 4+-[6-17], symmetrical lower extremities. LABORATORY VALUES ON PRESENTATION: White blood cell count 9.7, hematocrit 40.5, MCV 93, platelets 189,000. PT 12.7, PTT 27.1, INR 1.1. Sodium 139, potassium 3.4, chloride 99, bicarbonate 26, BUN 60, creatinine 3.2, glucose 112, ALT 9, AST 14, LDH 201, alkaline phosphatase 105, amylase 107, total bilirubin 0.6, lipase 48, calcium 10.3, albumin 4.3. H. pylori antibody test negative. IMPRESSION: The patient is a [Age over 90 ]-year-old female with multiple medical problems and no history of gastrointestinal bleed who presents with new onset melena starting on the date of admission. HOSPITAL COURSE: 1. GASTROINTESTINAL: Mrs. [Known lastname 25345] was admitted to the Intensive Care Unit for emergent endoscopy. The initial EGD showed a single ulcer in the prepyloric region with clotted blood adherent to the ulcer; 4 cc of 1:10,000 epinephrine was injected at the ulcer site with good hemostasis. She was monitored overnight in the Intensive Care Unit with hemodynamic stability and stable crit between 36-40. She was then transferred to the ACOVE Service for further observation. On the day after transfer, hospital day number three, she was noted to have a drop in her hematocrit from 37 to 31 and a repeat endoscopy was performed which showed a visible vessel in the prepyloric region suggestive of recent bleeding. Again, 1-2 cc of 1:10,000 epinephrine was injected for hemostasis. BICAP electrocautery was applied as well. Her hematocrit was followed q. six hours thereafter and found to remain stable in the 30-32 range. She continued to have melena throughout the hospitalization. She was started on Protonix 40 mg p.o. b.i.d. and instructed to avoid all NSAIDs, [Doctor Last Name ]-2 inhibitors, or aspirin. An H. pylori antibody was sent and found to be negative. 2. CARDIOVASCULAR: Once hemodynamic stability was proven, she was restarted on her Lopressor 25 mg p.o. b.i.d. with moderate control of blood pressure. She had no episodes of hypotension. Her Lasix was not restarted at this time secondary to evidence of dehydration. 3. RENAL: Ms. [Known lastname 25345] has evidence of chronic renal insufficiency with a baseline creatinine of 2.2. On admission, her creatinine was mildly elevated to 3.2 which responded to intravenous fluids. It was likely that she was dehydrated secondary to blood loss. Her creatinine remained stable around baseline for the remainder of the hospitalization. 4. FLUIDS, ELECTROLYTES, AND NUTRITION: Following second endoscopy, a clear liquid diet was initiated and was advanced as tolerated. She had no difficulties. 5. DISPOSITION: Physical Therapy evaluated the patient while hospitalized and found some evidence of deconditioning and unsteadiness. She was determined safe to be discharged to home with home PT and home safety evaluation. 6. HEMATOLOGY: Acute blood loss from GI bleeding as described above. She required no transfusions during this hospitalization. 7. PAIN CONTROL DUE TO OSTEOARTHRITIS AND DEGENERATIVE JOINT DISEASE: She was taking NSAIDs medication namely Vioxx while at home. She was instructed to continue taking Tylenol only for pain relief. She is to follow-up with Dr. [Last Name (STitle) 16258] for further decisions concerning pain medication. DISCHARGE CONDITION: Stable and improved. DISCHARGE DIAGNOSIS: 1. Gastrointestinal bleed secondary to prepyloric ulcers thought secondary to NSAID use. 2. Deconditioning. 3. Hypertension. 4. Degenerative joint disease. 5. Acute on chronic renal insufficiency, resolved. 6. History of gastroesophageal reflux disease. 7. History of hyperlipidemia. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. b.i.d. 2. Lopressor 50 mg p.o. b.i.d. 3. Tylenol 500 mg q. six hours p.r.n. 4. Lasix at unknown dose. DISCHARGE DISPOSITION: Ms. [Known lastname 25345] is to be discharged home with follow-up with home physical therapy and safety evaluation. She is to follow-up with Dr. [Last Name (STitle) 16258] in one week. Additionally, she is to follow-up with [First Name8 (NamePattern2) 1586] [Doctor Last Name ] in GI for repeat endoscopy in four to six weeks. [First Name8 (NamePattern2) 11595] [Last Name (NamePattern1) ], M.D. [MD Number(1) 17144] Dictated By:[Last Name (NamePattern1) 6240] MEDQUIST36 D: [2126-5-3] 06:39 T: [2126-5-4] 19:00 JOB#: [Job Number 25346]	[ "280.0", "272.4", "531.40", "E935.9", "530.81", "401.9", "530.2", "553.3", "715.90" ]	icd9cm	[ [ [] ] ]	[ "45.13" ]	icd9pcs	[ [ [] ] ]	6246, 6868			5734, 5756					6092, 6222		5777, 6069			3037, 5712				1129, 1308																										106, 816																			1541, 3019							838, 1106	1325, 1526
42,860	160,594	45669	Discharge summary	report	Admission Date: [2113-1-20] Discharge Date: [2113-1-27] Date of Birth: [2051-1-25] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [2113-1-20] - Right and left heart catheterization [2113-1-23] - 1. Minimally invasive mitral valve repair with size #30 CG Future band. 2. Closure of patent foramen ovale. History of Present Illness: 61-year-old male with history of MVP, moderate MR p/w worsening dyspnea and worsening MR. . Patient presented to his cardiologist with c/o dyspnea on exertion. He was being followed by cardiology for moderate mitral valve insufficiency that for the most part had been asymptomatic. Recently, he complained of DOE and orthopnea. He denied CP, palpitations, LH, and syncope. . As an outpatient: ECG showed left ventricular hypertrophy with sinus rhythm. Labs were notable for: wbc 6.6, hgb 14.2, hct 43, plt 181, na 142, k4.7, cl 104, bun 16, cr 1.27, ap 75, ast 21, alt 24, t bili 0.7, albumin 3.7, bnp 199. CXR showed small bilateral pleural effusions. He was started on lasix 20mg po. He then had an echo done at [Hospital1 112] that showed normal LV systolic function EF 65%, LV mildly enlarged at 5.6cm, mild PA pressure elevation of 35 mmHg plus RA pressure, and severe MR. . He was admitted for cardiac catheterization. Cardiac cath demonstrated clear coronaries, with elevated wedge pressure in the 20s. . On arrival to the floor, VSS and patient sitting comfortably in chair, satting at 100%RA. Denies chest pain, nausea, vomiting . REVIEW OF SYSTEMS: as above, otherwise negative Past Medical History: - Severe MR - MV Prolapse - Sensorineural hearing loss - BPH Social History: He is [Initials (NamePattern4) ] [Last Name (NamePattern4) 86] police officer. He is married with no children. Denies cig use. Infrequent ETOH. Family History: He has a family history of diabetes and hypertension but no heart disease (early MI, arrhythmia, cardiomyopathies, or sudden cardiac death). Physical Exam: Admission PEx: VS: 97.9 126/88 88 18 100%RA GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. speaking in full sentences, comfortably HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, difficult to appreciate any JVD CARDIAC: RRR, normal S1, S2, [3-31] HSM at apex. LUNGS: CTAB, crackles bilat at bottom [12-27] lungs. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. +2DP SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: non-focal, moving all extremities spontaneously Pertinent Results: Labs on admission: [2113-1-21] 07:29AM BLOOD WBC-5.8 RBC-4.52* Hgb-13.0* Hct-37.0* MCV-82 MCH-28.8 MCHC-35.1* RDW-13.8 Plt Ct-164 [2113-1-20] 11:15AM BLOOD PT-11.7 INR(PT)-1.1 [2113-1-21] 07:29AM BLOOD Glucose-112* UreaN-22* Creat-1.2 Na-139 K-3.7 Cl-106 HCO3-28 AnGap-9 [2113-1-21] 07:29AM BLOOD ALT-22 AST-16 LD(LDH)-180 AlkPhos-68 TotBili-0.6 [2113-1-21] 07:29AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.6 Mg-2.2 Cholest-PND Imaging/Procedures: . Cardiac Cath [2113-1-20]: 1. Selective coronary angiography of this right-dominant system demonstrated no angiographically apparent flow-limiting disease. The LMCA, LAD, LCx, and RCA had no angiographically apparent flow-limiting disease. 2. Limited resting hemodynamics revealed an elevated left-sided filling pressure with a mean PCWP of 19mmHg and prominent v-waves to 27mmHg. RVEDP was normal at 7mmHg. There was mild pulmonary hypertension with a PA pressure of 34/11mmHg. Systemic arterial pressures were low at 77/55mmHg. FINAL DIAGNOSIS: 1. No angiographically apparent coronary disease. 2. Elevated left-sided filling pressure. 3. Low systemic arterial pressures. . CXR [2113-1-20]: Findings suggesting mild vascular congestion. Calcified lymphadenopathy suggestive of prior granulomatous exposure. MICROBIOLOGY: Urinalysis: [2113-1-20] 09:20PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.010 [2113-1-20] 09:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG MSSA swab: prelim positive Brief Hospital Course: 61-year-old male with history of mitral valve prolapse and moderate regurgitation who presented with worsening dyspnea and was found to have worsening regurgitation which was now severe. He was taken to cath lab which was notable for clean coronaries and elevated wedge pressure. Given the severity fo his disease, the cardiac surgerical service was consulted. On [2113-1-23] Mr. [Known lastname ] was taken to the operating room where he underwent a minimally invasive repair of his mitral valve with closure of a patent foramen ovale. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next few hours, he awoke neurologically intact and was extubated. On postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. He was started on betablockade and lisinopril which he is tolerating well. He has remained hemodynamically stable. PW and CT'w were remove in timely fashion and without incident. The physical therapy service was consulted for assistance with her postoperative strength and mobility. At the time of discharge rigth sided CT site was draining small to moderate amount of serosang drainage. He was discharged with dressing in place. All patients questions and concerns addressed. Discharge instructions revieved. Medications on Admission: FUROSEMIDE 20 mg daily (started last couple of days) SILDENAFIL [VIAGRA] 50 mg prn Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:7 Tablet(s) Refills:0 2. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 1 weeks. Disp:7 Tablet, ER Particles/Crystals(s) Refills:0 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks: until mortrin dc'd. Disp:60 Tablet(s) Refills:0 6. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks. Disp:120 Tablet(s) Refills:0 7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 10. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [3-31] hours as needed for pain. Disp:30 Tablet(s) Refills:0 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). Disp:1 Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: BPH Hearing loss left ear Mitral valve insufficiency s/p appendectomy as a child athletes foot granulomas of the lungs seen 15yrs ago Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Thoracotomy - healing well, no erythema or drainage Right Groin - Healing well Edema: trace generalized Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [First Name (STitle) ] [2113-2-21]@ 1:15pm Cardiologist: Dr. [Last Name (STitle) 2257] [2113-2-15] 11:10am Wound Check:[2113-2-2] @10AM Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ] in [3-30] 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 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2113-1-27]	[ "285.1", "600.00", "338.18", "511.9", "429.5", "424.0", "389.17", "747.0", "401.9", "416.8", "428.0" ]	icd9cm	[ [ [] ] ]	[ "05.31", "39.61", "37.21", "35.12", "35.32", "35.71", "88.56" ]	icd9pcs	[ [ [] ] ]	7365, 7422	4456, 5843	329, 512	7600, 7821	2878, 2883	8709, 9323	2008, 2150		5976, 7342		7443, 7579		5869, 5953		3897, 4433	7845, 8686									2165, 2859														1708, 1739					270, 291												540, 1689							2897, 3880							1761, 1823	1839, 1992
75,451	172,110	5231	Discharge summary	report	Admission Date: [2128-2-22] Discharge Date: [2128-2-29] Date of Birth: [2056-4-26] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4679] Chief Complaint: Squamous cell carcinoma of the right upper lobe. Major Surgical or Invasive Procedure: [2128-2-23]: 1. Right thoracotomy. 2. Lysis of adhesions. 3. Right upper lobectomy with en bloc resection of ribs 2, 3 and 4. 4. Mediastinal lymphadenectomy. History of Present Illness: The patient is a 71-year-old male with end-stage renal disease. A workup for possible renal transplantation disclosed an upper lobe nodule very concerning for cancer. Biopsy demonstrated squamous cell carcinoma. His metastatic survey was negative. However, the CT scan suggested the possibility of both chest wall involvement as well as possible involvement of the vena cava and/or the subclavian artery. He was admitted for right upper lobectomy with chest wall reconstruction. Past Medical History: Hypertension COPD Polycystic Kidney Disease on HD since [1-5] 3x week M-W-F Left leg claudication Ventral Hernia Hypercholesterolemia Cardiac Arrest [2124] GERD Arthritis Past Surgical History Cerebral artery aneurysm clipping [2114] Abdominal Aortic aneurysm repair [2124] at [Hospital1 112] Social History: Lives with:Married with a son and daughter [Name (NI) 2270] who is his health care proxy, his wife has [Name (NI) 2481]. Occupation:retired Tobacco:denies (quit 3 years ago), smoked 1ppd for 50 yrs ETOH:denies (quit 3 yrs ago) Family History: Family History:adopted, family history unknown Physical Exam: Gen: NAD, AOx3 CVS: RRR, no m/r/g Resp: slightly diminished breath sounds on the right mid/lower lung fields, cta on the left. Incision c/d/i Abd: soft, NT/ND Ext: WWP, no edema Pertinent Results: [2128-2-25] 11:40PM BLOOD WBC-6.8 RBC-3.24* Hgb-10.5* Hct-30.7* MCV-95 MCH-32.5* MCHC-34.4 RDW-16.0* Plt Ct-119* [2128-2-26] 08:10AM BLOOD WBC-7.1 RBC-3.06* Hgb-9.8* Hct-29.0* MCV-95 MCH-32.1* MCHC-33.9 RDW-16.1* Plt Ct-120* [2128-2-27] 07:30AM BLOOD WBC-8.1 RBC-3.30* Hgb-10.5* Hct-32.0* MCV-97 MCH-31.8 MCHC-32.7 RDW-15.8* Plt Ct-137* [2128-2-28] 06:29AM BLOOD WBC-6.7 RBC-3.11* Hgb-10.2* Hct-29.9* MCV-96 MCH-32.9* MCHC-34.1 RDW-15.8* Plt Ct-164 [2128-2-27] 07:30AM BLOOD PT-13.6* PTT-24.5 INR(PT)-1.2* [2128-2-27] 07:30AM BLOOD Plt Ct-137* [2128-2-28] 06:29AM BLOOD PT-13.5* PTT-24.5 INR(PT)-1.2* [2128-2-28] 06:29AM BLOOD Plt Ct-164 [2128-2-26] 08:10AM BLOOD Glucose-129* UreaN-67* Creat-8.2* Na-140 K-3.5 Cl-94* HCO3-30 AnGap-20 [2128-2-27] 07:30AM BLOOD Glucose-122* UreaN-50* Creat-5.7# Na-142 K-4.7 Cl-98 HCO3-30 AnGap-19 [2128-2-28] 06:29AM BLOOD Glucose-155 UreaN-76* Creat-7.5# Na-140 K-3.9 Cl-96 HCO3-28 AnGap-20 [2128-2-29] 07:30AM BLOOD Glucose-124 UreaN-49* Creat-5.7# Na-142 K-4.9 Cl-98 HCO3-31 AnGap-18 [2128-2-27] 07:30AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.3 [2128-2-28] 06:29AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.4 [2128-2-29] 07:30AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.4 Brief Hospital Course: Mr. [Known lastname ] was admitted on late sunday evening, [2128-2-22] for hemodialysis prior to planned right upper lobectomy for squamous cell carcinoma. On [2128-2-23] he was taken to the operating by Dr. [First Name (STitle) ]. for Right thoracotomy. Lysis of adhesions. Right upper lobectomy with en bloc resection of ribs 2, 3 and 4. and Mediastinal lymphadenectomy. He was transfer to the TSICU intubated and sedated. He had 3 chest tubes to suction, Foley and Epidural managed by the acute pain service. On [2128-2-24] he was successfully extubated. Aggressive nebs and pulmonary toilet his oxygen requirements improved to room air prior to discharge. He was followed by renal for ESRD and underwent dialysis which was discontinued secondary to hypotension after removal of 1 Liter. His hypotension improved with SBP 140's. His chest tubes were placed to water-seal and 4hr f/u CXR showed increase right apical pneumothorax. They were placed back to suction with f/u CXR showing lung re-expansion. His diet was advanced as tolerated. On [2128-2-25] he transfer to the floor in stable condition. Respiratory: incentive spirometer, nebs and good pain control his oxygen requirments improved. Chest-tubes: 3 chest tubes, 2 apically and 1 along the right hemidiaphragm with persistent air-leak. On [2128-2-25] the suction was decreased to 10 cm H20 from 20. Chest tube were changed to water-seal [2128-2-26] without persistent airleak. Right hemidiaphragm chest tube was removed on [2128-2-26]. [2128-2-27] another apical chest tube was discontinued without airleak. On [2-28] the final chest tube was dc'd with postpull chest film revealing stable R apical air space. Cardiac: Beta-blockers were initially continued. On [2128-2-26] he developed rapid atrial fibrillation in the 140's and was given metoprolol 5 mg IV x 3, with transient decrease in heart rate. He then received amiodarone 150 mg IV, followed by amiodarone gtt at 1 mg/min, with conversion to sinus rhythm. Amiodarone gtt was stopped at around 3 a.m., and the patient was started on amiodarone at a dose of 400 mg TID. He then went back into rapid AF with ventricular rate 140s, for which he received diltiazem 10 mg IV, however then had conversion pauses, up to 8 seconds. . Cardiology was consulted, and given the 8 second pauses the patient was watched over the night in CCU. The patient remained in sinus rhythm once converting, however had 2 minutes of rapid afib on [2128-2-27] without hemodynamic instablity. He will followup with cardiology as an outpatient. All other nodal blockers were held, until [2128-2-27], when labetolol 150mg po bid restarted, and titrated to 300mg [Hospital1 ] on [2128-2-28], which he tolerated well. His blood pressures were also high which we slowly worked on adding home BP medications for control. Cardiology recommended that patient be sent home with all of his home medications, amiodarone will not be continued upon discharge. GI: Advanced diet to regular renal and tolerated. Renal: ESRD followed by renal. HD continue, last on Saturday [2128-2-28]. Chemistries watched closely. Home renal medications were restarted. Extremity: Right arm edema noted Upper Extremity US showed no DVT on [2128-2-27]. Heme: He received a transfusion for 2 units of PRBC's intraoperatively. Pain: Hydromorphone and bupivicaine Epidural was used for postoperative pain management, with good effect. The patient self dc'd on accident the epidural [2128-2-27] a few hours prior to planned dc of epidural by APS. Heparin was held. The patient's pain was controlled with oxycodone and tylenol thereafter. Disposition: He was seen by physical therapy on [2128-2-27] who recommended home with PT. At the time of discharge on [2128-2-29] Mr [Known lastname ] was afebrile, vital signs were stable, he was tolerating a regular diet, ambulating and voiding without assistance. He received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: ALBUTEROL SULFATE IH, , AMLODIPINE 5 mg daily, Nephrocaps, Ca acetate 1334 TID w/meals, Plavix 75 mg daily, Epogen 2400 3x/week, LABETALOL 300 mg [Hospital1 ], ZEMPLAR 3mcg 3x/week, REMVELA 2 tabs tid, SIMVASTATIN 40 mg daily, TRAZODONE 150 mg prn Discharge Medications: 1. Home oxygen 2 L NC continuous pulse dose for portability. Dx: lung cancer, COPD 2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:120 Tablet(s)* Refills:0 10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain, fever. 11. labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day. 12. verapamil 180 mg Cap,Ext Release Pellets 24 hr Sig: 0.5 Cap,Ext Release Pellets 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 2256] Discharge Diagnosis: Right upper lobe, lung Squamous cell carcinoma. Polycystic Kidney Disease on HD since [1-5] 3x week M-W-F Postoperative atrial fibrillation CAD, s/p CABG x 3, [12-4] COPD Left leg claudication Arthritis hypercholesterolemia, hypertension Cardiac Arrest [2124] GERD Cerebral artery Ventral Hernia Aneurysm clipping [2114] Abdominal Aortic aneurysm repair [2124] at [Hospital1 112] 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: Call Dr.[Name (NI) 5067] office [Telephone/Fax (1) 2348] if you experience: -Fevers > 101.5 or chills -Increased shortness of breath, cough or chest pain -Incision develops drainage or increased redness -Chest tube sites: cover with gauze and tape x 48 hours then a bandaid until healed. Should site drain cover with a clean dry dressing and change as needed -Shower daily after initial gauze bandage removed. Wash incision with mild soap and water, rinse, pat dry Do not drive while taking narcotics. Take stool softeners while on narcotics to avoid constipation. Hemodialysis: continue as previous Followup Instructions: Follow-up with Dr. [First Name (STitle) ] [0-0-] Date/Time:[2128-3-16] 10:00 on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center, [Location (un) ]. Chest X-Ray [Location (un) 861] Radiology 30 minutes before your appointment Hemodialysis M-W-F as previous DIALYSIS,SCHEDULE HEMODIALYSIS UNIT Date/Time:[2128-3-1] 7:30 Followup with cardiologist in 2 weeks for followup of atrial fibrillation and medications. Completed by:[2128-2-29]	[ "414.00", "530.81", "198.89", "162.3", "198.5", "272.0", "403.91", "753.12", "997.1", "V45.11", "427.31", "585.6", "V45.81", "496" ]	icd9cm	[ [ [] ] ]	[ "33.39", "33.22", "39.95", "34.4", "40.3", "32.49", "77.61" ]	icd9pcs	[ [ [] ] ]	8658, 8758	3180, 7281	360, 528	9206, 9206	1907, 3157	10025, 10519	1660, 1694		7584, 8635		8779, 9185		7307, 7561			9389, 10002									1709, 1888																			271, 322												556, 1039								9221, 9365						1061, 1376	1392, 1629
9,263	129,773	30342	Discharge summary	report	Admission Date: [2179-5-31] Discharge Date: [2179-6-7] Date of Birth: [2109-12-16] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Redness along sternal incision Major Surgical or Invasive Procedure: [2179-6-1] Sternal Debridement and re-wiring History of Present Illness: 69 y/o male s/p CABG on [2179-5-14] who was discharged from [Hospital1 18] on [5-19]. He had been doing well, but presented today with erythema along sternal incision site. He also noticed some discharge of fluid after coughing several days ago, but denies fluid discharge since then. Denies fever or chills. Past Medical History: Coronary Artery disease s/p Coronary Artery Bypass Graft x 4 on [2179-5-14] elevation myocardial infarction [2179-5-12] Atrial Fibrillation Hypertension Social History: Social history is significant for the absence of current tobacco use. Family History: There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death. Physical Exam: NAD Lungs CTAB Irreg-reg with -murmur Lower [2-17] of incision with erythema abd. soft NT/ND +BS -c/c/e Pertinent Results: [5-31] Chest CT: Retrosternal fluid collection which extends cephalocaudally for approximately 8 cm and communicates to the anterior chest wall at the level of the inferior sternotomy. Moderate left pleural effusion. Findings suggestive of asymmetric pulmonary edema in the left. [6-7] CXR: There is no appreciable air or fluid is accumulated in the right pleural space following removal of the right thoracostomy tube. Small left pleural effusion and basilar atelectasis have decreased. Focus of upper lobe atelectasis is unchanged. Cardiomediastinal silhouette has a normal postoperative appearance, unchanged. [2179-5-31] 01:25PM BLOOD WBC-7.1 RBC-3.07* Hgb-8.9* Hct-26.9* MCV-88 MCH-28.8 MCHC-33.0 RDW-14.4 Plt Ct-501# [2179-6-6] 05:20AM BLOOD WBC-6.1 RBC-3.09 Hgb-8.9* Hct-26.3* MCV-85 MCH-28.6 MCHC-33.7 RDW-14.8 Plt Ct-349 [2179-6-1] 03:41PM BLOOD PT-14.4* PTT-27.6 INR(PT)-1.3* [2179-5-31] 01:25PM BLOOD Glucose-112* UreaN-16 Creat-1.1 Na-137 K-4.4 Cl-103 HCO3-27 AnGap-11 [2179-6-6] 05:20AM BLOOD Glucose-94 UreaN-20 Creat-1.1 Na-140 K-3.7 Cl-105 HCO3-26 AnGap-13 [2179-6-6] 05:20AM BLOOD Calcium-7.8* Phos-3.8 Mg-2.5 Brief Hospital Course: Mr. [Known lastname ] was admitted on [5-31] for suspected sternal wound infection. He underwent a chest CT which revealed retrosternal fluid collection that extends cephalocaudally for approximately 8 cm and communicates to the anterior chest wall at the level of the inferior sternotomy. He was started on empiric antibiotics and then on [6-1] he was brought to the operating room where he underwent a sternal debridement and re-wiring. Please see dictated surgical report. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was transferred to the telemetry floor for further care. He was continued on antibiotics and re-started on his pre-op medications. On post-op day two ID was consulted secondary to positive bone culture. Left pleural chest tube was removed on post-op day three and the remainder of the chest tubes were removed on [6-7]. During this time he appeared to be doing well and was discharged home with VNA services and antibiotic therapy per ID on post-op day six. Medications on Admission: Aspirin, Lopressor, Lipitor, Colace, Amiodarone, Lisinopril, Iron, MVI Discharge Medications: 1. PICC line PICC line care per NEHT protocol 2. Outpatient Lab Work Weekly CBC, BUN/Cr, Vanco trough with results to Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Hospital ] clinic [Hospital1 18] fax ([Telephone/Fax (1) 1353] office #([Telephone/Fax (1) 10] 3. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours): until [2179-7-7] . Disp:qs qs Refills:0 4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks. Disp:42 Tablet(s) Refills:0 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 6. 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 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 11. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 17. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 18. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home with Service Discharge Diagnosis: Sternal wound infection/dehiscence s/p Sternal Debridement and re-wiring PMH: Coronary Artery disease s/p Coronary Artery Bypass Graft x 4 on [3-30] elevation myocardial infarction [2179-5-12] Atrial Fibrillation Hypertension Discharge Condition: good Discharge Instructions: Please resume instructions from prior discharge following your bypass surgery: Do not drive for 1 month. Do not lift more than 10 pounds for 8-10 weeks. No lotions, creams, or powders on any incision. Call for fever greater than 100.5, redness or drainage from incision. [Month (only) 116] shower over incision and pat dry. Followup Instructions: Dr. [Last Name (STitle) 914] in 4 weeks Primary Care Physician [Last Name (NamePattern4) ] [2-16] weeks Wound Check - [2179-6-16] on [Hospital Ward Name ] 2Provider: DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 457] Date/Time:[2179-7-19] 10:00 Weekly Lab: CBC, BUN, Cr, Vanco trough first draw [6-10] with results to Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] fax [Telephone/Fax (1) 432] Completed by:[2179-6-25]	[ "998.59", "V45.81", "285.9", "998.31", "414.00", "401.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "77.61", "34.79" ]	icd9pcs	[ [ [] ] ]	6058, 6077	2486, 3641	351, 401	6354, 6360	1301, 2463	6736, 7267	1038, 1158		3762, 6035		6098, 6333		3667, 3739			6384, 6713									1173, 1282																			281, 313												429, 751														773, 935	951, 1022
59,318	125,953	2923	Discharge summary	report	Admission Date: [2127-9-29] Discharge Date: [2127-10-3] Date of Birth: [2052-7-16] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2880] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: This is a 75M with Stage IV lung adenocarcinoma s/p wedge resection of the left upper lobe in [6-/2125], DM, HL, PVD, CAD s/p 3 stents to the RCA in [2125], NSTEMI in [7-/2126] with medical management and known 70% LMCA stenosis who p/w chest pain during alternative medicine of vitamin C infusion. Pain substernal, [3-20], non-radiating, similar to previous NSTEMI. During the episode of chest pain, his blood pressure was noted to be 180/60 and he took two SL NRG which resolved his chest pain. He was evaluated at [Hospital6 7472] ED with no recurrence in chest pain. In the past 3 months, patient has had similar pain 2-3x/week with exertion and 2-3x/month at rest, relieved by SL NTG. At the OSH ED, vitals were T98 P93 BP128/76 RR20 92%RA. CXR showed no acute findings. Labs were sent with a Trop <0.01, BNP 82, CRP <0.1, INR <1.08. Patient remained chest pain free and was transfered to [Hospital1 18]. He took two 81mg ASA this AM. On the floor, he reports being CP free at this time and he is without additional complaint at this time. On review of systems, He denies any recent illnesses, and ROS negative for cough, sore throat, rhinorrhea, abdominal pain or diarrhea. 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. All of the other review of systems were negative. Cardiac review of systems is notable for absence of orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS:(+)Diabetes,(+)Dyslipidemia,(-)Hypertension 2. CARDIAC HISTORY: -CAD with 3VD (70% LMCA), s/p NSTEMI [7-20] treated medically -CABG: Not a candidate given Stage IV Lung Ca -PERCUTANEOUS CORONARY INTERVENTIONS: in [11/2125] with 3 stents to RCA. 3. OTHER PAST MEDICAL HISTORY: --NSCLC Stage IV [2124] s/p wedge resection [6-/2125] --h/o Intraductal papillary mucinous tumor of the pancreas and chronic pancreatitis s/p pylorus sparing Whipple procedure in [2117-12-11] --DM2, insulin dependent --GERD --peripheral [Year (4 digits) 1106] disease --hypothyroidism --hypogonadism --BPH --depression SURGICAL HISTORY: -- lung wedge resection in [6-/2125] --Incisional hernia repair [2119] --Primary umbilical herniorrhaphy [2123] --CCY --Biliary stent --status post right and left-sided femoral bypass surgeries --femoral endarterectomy and iliac stenting [2123-5-11] Social History: 35-pack-year history of smoking, no IVDU. Physically active, lives with his wife. Family History: Mother died of MI at age 63. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: VS: T=98.3 BP=134/75 HR=79 RR=20 O2 sat=94% on RA GENERAL: AOx3, NAD, Comfortable HEENT: PERRL, EOMI. OP clear, MMM NECK: Supple without elevation of JVP CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, mild epigastric tenderness which pt reports is chronic. 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+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+ DISCHARGE EXAM: Afebrile. VSS HEENT: PERRL, EOMI. OP clear, MMM NECK: Supple without elevation of JVP CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, mild epigastric tenderness which pt reports is chronic. 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+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Pertinent Results: ADMISSION LABS: [2127-9-29] 11:23PM BLOOD WBC-7.3 RBC-5.04 Hgb-13.7* Hct-42.5 MCV-84 MCH-27.1 MCHC-32.2 RDW-15.8* Plt Ct-169 [2127-9-29] 11:23PM BLOOD PT-13.6* PTT-26.4 INR(PT)-1.2* [2127-9-29] 11:23PM BLOOD Plt Ct-169 [2127-9-29] 11:23PM BLOOD Glucose-285* UreaN-8 Creat-0.8 Na-137 K-4.3 Cl-100 HCO3-30 AnGap-11 [2127-9-29] 11:23PM BLOOD CK(CPK)-123 [2127-9-29] 11:23PM BLOOD Calcium-9.2 Phos-2.4* Mg-1.7 CARDIAC ENZYMES: [2127-9-29] 11:23PM BLOOD CK-MB-8 cTropnT-0.06* [2127-9-30] 07:00AM BLOOD CK-MB-10 MB Indx-8.5* cTropnT-0.14* [2127-10-1] 02:08AM BLOOD CK-MB-5 cTropnT-0.14* Cardiac Cath [2127-9-30]: LMCA: diffuse 60-70% LAD: Proximal 60-70% LCX: TO; Ramus 80% origin- moderate RCA: diffuse prox 80%, mid 90%, distal 80%, in stent and gap in mid vessel Assessment and Recs: 1. 3 vessel CAD 2. Successful [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 3. ASA 81 mg [Last Name (un) ]; Plavix 75mg daily indefinitely ECHO [10-1]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %) secondary to hypokinesis of the basal-mid inferior and infero-lateral walls. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. DISCHARGE LABS: [2127-10-2] 06:20AM BLOOD WBC-7.0 RBC-4.25* Hgb-11.4* Hct-35.0* MCV-82 MCH-26.8* MCHC-32.5 RDW-15.1 Plt Ct-181 [2127-10-2] 06:20AM BLOOD Plt Ct-181 [2127-10-2] 06:20AM BLOOD Glucose-119* UreaN-17 Creat-1.0 Na-139 K-4.5 Cl-101 HCO3-33* AnGap-10 [2127-10-2] 06:20AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.9 Brief Hospital Course: 75 year old male with Stage IV NSC Lung Cancer, CAD (NSTEMI in [2126], PCI to RCA in [2125]) admitted with chest pain during vitamin C infusion at OSH with CE neg x1, EKG stable, admitted for suspicion of ACS. # NSTEMI: Patient developed chest pain with precordial T wave inversions while receiving a vitamin C infusion. Enzymes were initially negative, but troponin trended up to 0.14 and CKMB 8.5, so patient ruled in for NSTEMI. Patient started heparin drip and atorvastatin 80mg (DCed home simvastatin). Continued home Plavix, metoprolol, Imdur, lisinopril. Patient was taken to the cath lab where 3 stents were placed in the RCA. During procedure patient had Vfib arrest and was resusitated with ROSC (see below). # VFIB Arrest: During cardiac cath, patient developed VFib arrest in the setting of balloon inflation. Patient recieved epinephrine, lidocaine, CPR and transcutaneous defibrillation with ROSC. Patient was then transfered to the CCU where he was stable, neurologically intact with no additional evidence of ventricular arrythmia on telemetry. He was transfered to the floor in stable condition prior to discharge. # PUMP/ISCHEMIC CARDIOMYOPATHY: His last ECHO showed EF of 40-45% chronic systolic CHF with inferior and inferolateral hypokinesis (post cath ECHO unchanged). Pt appeared euvolemic on exam without pulmonary edema on CXR. Continued metoprolol and lisinopril as above. # Elevated INR/PT: INR was mildly elevated to 1.3-1.4. In the past it has been elevated to 1.2 as well. This etiology unclear, but is most likely [2-12] to the large volume of homeopathic medications he is on as an outpatient. His LFTs were wnl on admission, making liver failure [2-12] metastatic burden unlikely. # DM II: Last A1c 6.9 in [5-21]. He was continued on his home insulin regimen. # Stage IV lung adenocarcinoma. Stable, no evidence of metastasis. # PVD: Continued cilostozol. # HL: Atorvastatin 80mg in the setting of ACS. # Hypothyroidism: Continue synthroid # BPH: continue tamsulosin # Depression: continue venlafaxine Medications on Admission: 1. aspirin 81 mg Daily 2. cilostazol 100 mg PO daily 3. clopidogrel 75 mg PO Daily 4. Insulin SC Lantus 30-40U HS and Novolog TID SSI 5. levothyroxine 50 mcg Daily 6. metoprolol succinate 50mg daily 7. ranitidine HCl 150 mg PO HS 8. simvastatin 20 mg HS 9. tamsulosin 0.4 mg HS 10. venlafaxine 75 mg PO daily 11. pancrease TID qMeals 12. isosorbide mononitrate 60 mg Sustained Release HS 13. lisinopril 2.5 mg Tablet HS 14. Naltrexone 4.5mg QHS 15. NTG SL 0.3mg PRN 16. testosterone cream 50 [Hospital1 ] Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cilostazol 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Lantus 100 unit/mL Solution Sig: 30-40 units Subcutaneous at bedtime: as directed per your PCP. 5. Novolog 100 unit/mL Solution Sig: as directed units Subcutaneous three times a day: prior to meals as directed per PCP. 6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 10. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. pancrease Sig: One (1) three times a day: with meals. 12. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO HS (at bedtime). 13. naltrexone Oral 14. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual as directed as needed for chest pain: repeat every 5 minutes, up to 3 times. 15. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 16. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 17. testosterone 1 %(50 mg/5 gram) Gel in Packet Sig: One (1) Transdermal daily (). 18. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain for 7 days: do not drive or operate machinery while on this medication as it can make you sleepy. Disp:35 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: NSTEMI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 14082], It was a pleasure taking care of you during your hospitalization at [Hospital1 18]. You were admitted because you had chest pain. Your blood work showed elevated troponins (an enzyme leaked from damaged heart muscles). For your heart attack, you underwent cardiac catheterization and had 3 additional stents placed in the right coronary artery to open up the artery. During this procedure, your heart temporarily stopped pumping, so you received CPR and 2 shocks to bring your heart back to normal activity. You have a few fractured ribs from chest compression, which should heal on its own. We made the following changes to your medications: ADDED Tylenol #3- as needed for rib pain ADDED Atorvastatin STOPPED Simvastatin Your oxygen levels dropped when you walked which is probably due to your lung disease. We offered you oxygen to take home with you, however since you were not having any symptoms, you declined. If you have further difficulty with your breathing, please contact your PCP. Followup Instructions: Name: BROWN,[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Location: FAMILY MEDICINE ASSOCIATES Address: [State 14083], [Location (un) 14084],[Numeric Identifier 14085] Phone: [Telephone/Fax (1) 14086] Appointment: Friday [2127-10-10] 9:45am Department: CARDIAC SERVICES When: TUESDAY [2127-10-14] at 10:40 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4511], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) 900] [Last Name (NamePattern1) 2882] MD, [MD Number(3) 2883] Completed by:[2127-10-4]	[ "412", "530.81", "414.01", "250.00", "428.22", "V10.11", "410.71", "V45.82", "272.4", "428.0", "244.9", "997.1", "E879.0", "427.41", "443.9", "V58.67" ]	icd9cm	[ [ [] ] ]	[ "36.07", "00.40", "99.62", "88.56", "00.66", "37.22", "00.45" ]	icd9pcs	[ [ [] ] ]	10845, 10851	6440, 8519	315, 340	10910, 10910	4381, 4381	12124, 12866	3042, 3187		9078, 10822		10872, 10889		8545, 9055			11060, 11717			6102, 6417						3202, 3816		2086, 2275			3832, 4362								11746, 12101		4829, 6086				265, 277												368, 1976					4397, 4812			10925, 11036		2306, 2927				1998, 2066	2943, 3026
53,714	145,398	40110	Discharge summary	report	Admission Date: [2145-5-19] Discharge Date: [2145-6-1] Date of Birth: [2073-9-20] Sex: M Service: SURGERY Allergies: scallops Attending:[First Name3 (LF) 2597] Chief Complaint: 7.2- cm infrarenal aortic aneurysm Major Surgical or Invasive Procedure: [2145-5-19] Endovascular AAA repair [2145-5-21] cardiac L main, RCA stents, L SFA thromb, CFA vein followed by L SFA thrombectomy, CFA vein patch angioplasty History of Present Illness: The patient is a 71-year-old male with a known infrarenal abdominal aortic aneurysm. He has a past medical history significant for COPD with home oxygen, hypertension and obesity. Do this the patients high risk of rupture the decision was made to intervene and fix the aneursym. He was scheduled outpatient for an endoluminal repair of abdominal aortic aneurysm on [2145-5-19]. Past Medical History: - COPD- baseline home O2 3LCN - Morbid Obesity - HTN - HL - AAA - Pulm. nodule - Edema - S/P abd. hernia repair Social History: Lives at home with wife, daughter, son-in-law and 3 grandchildren. Used to work as a office equipment repairman. Tobacco - quit [2136], was a lifetime smoker - 1-2ppd for 43 years EtOH - occasional ethanol drug use - denies. Family History: CAD/PVD - father and mother, died in their 70s CVA - brother in 60s. Brother diagnosed with alzheimers at age 60. Physical Exam: VS: T: 98 HR: 89 BP: 103/51 RR: 20 Spo2: 94% 2LNC Gen: NAD, alert and oriented x 3 Neuro: CN II-XII intact CV: RRR, no mrg, + S1 + S2 Lungs: CTA bilaterally Abd: soft, NT, obese, no rebound or guarding Wound: Left groin with some erythema in skin folds JP drain with minimal serous drainage Bilateral lower extremities warm and dry. Signals per doppler bilaterally. Pertinent Results: [2145-6-1] 07:08AM BLOOD WBC-9.9 RBC-4.25* Hgb-12.3* Hct-37.6* MCV-89 MCH-29.0 MCHC-32.7 RDW-15.7* Plt Ct-372 [2145-5-29] 06:13AM BLOOD WBC-8.0 RBC-3.95* Hgb-11.7* Hct-35.3* MCV-89 MCH-29.6 MCHC-33.1 RDW-16.0* Plt Ct-302 [2145-5-28] 04:28AM BLOOD WBC-7.2 RBC-3.73* Hgb-11.2* Hct-33.2* MCV-89 MCH-29.9 MCHC-33.6 RDW-16.1* Plt Ct-257 [2145-5-27] 02:09AM BLOOD WBC-6.9 RBC-3.72* Hgb-11.2* Hct-33.7* MCV-91 MCH-30.1 MCHC-33.3 RDW-16.3* Plt Ct-225 [2145-6-1] 07:08AM BLOOD Plt Ct-372 [2145-5-29] 06:13AM BLOOD Plt Ct-302 [2145-5-28] 06:19AM BLOOD PT-13.5* PTT-29.0 INR(PT)-1.2* [2145-5-28] 04:28AM BLOOD Plt Ct-257 [2145-6-1] 07:08AM BLOOD Glucose-97 UreaN-33* Creat-1.1 Na-135 K-4.1 Cl-96 HCO3-28 AnGap-15 [2145-5-30] 07:55AM BLOOD Glucose-96 UreaN-25* Creat-0.9 Na-138 K-4.5 Cl-98 HCO3-31 AnGap-14 [2145-5-29] 06:13AM BLOOD Glucose-105* UreaN-22* Creat-0.9 Na-136 K-4.1 Cl-100 HCO3-30 AnGap-10 [2145-5-28] 04:28AM BLOOD Glucose-108* UreaN-23* Creat-0.9 Na-135 K-3.7 Cl-100 HCO3-27 AnGap-12 [2145-5-24] 03:13AM BLOOD ALT-23 AST-38 LD(LDH)-532* CK(CPK)-78 AlkPhos-80 Amylase-25 TotBili-1.4 [2145-5-23] 02:13AM BLOOD ALT-32 AST-91* LD(LDH)-701* CK(CPK)-223 AlkPhos-58 Amylase-16 TotBili-1.1 [2145-5-24] 03:13AM BLOOD CK-MB-6 [2145-5-23] 02:13AM BLOOD CK-MB-17* MB Indx-7.6* cTropnT-2.44* [2145-5-22] 06:31AM BLOOD CK-MB-99* MB Indx-10.4* cTropnT-2.59* [2145-5-21] 11:37PM BLOOD CK-MB-175* MB Indx-12.7* cTropnT-3.08* [2145-6-1] 07:08AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.4 [2145-5-30] 07:55AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.3 [2145-5-29] 06:13AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.3 [2145-5-27] 02:19AM BLOOD Type-ART pO2-88 pCO2-51* pH-7.34* calTCO2-29 Base XS-0 [2145-5-27] 02:19AM BLOOD Glucose-86 K-4.4 [2145-5-26] 10:53PM BLOOD Glucose-81 K-3.8 [2145-5-26] 05:27PM BLOOD Glucose-81 K-3.5 [2145-5-27] 02:19AM BLOOD O2 Sat-95 [2145-5-27] 02:19AM BLOOD freeCa-1.27 [2145-5-26] 10:53PM BLOOD freeCa-1.23 CXR: [2145-5-28] INDICATION: Abdominal aortic aneurysm stent, acute myocardial infarct, followup for resolution of congestive cardiac failure. COMPARISON: Radiographs dating back to [2145-2-3] and most recently [2145-5-26]. FINDINGS: A narrow tracheal coronal diameter is consistent with a saber sheath configuration. Indistinctness of the perihilar vasculature bilaterally with generalized ground-glass opacity has slightly improved since [2145-5-26] suggesting improving pulmonary venous congestion. The left hilum is prominent, but this most likely relates to mild pulmonary arterial enlargement, better characterized on CT of [2145-2-4]. Mild cardiomegaly is stable. A right internal jugular central venous catheter tip is projected over the expected location of the brachiocephalic confluence. Since [2145-5-26], an endotracheal tube has been removed. IMPRESSION: Improving pulmonary edema. The study and the report were reviewed by the staff radiologist. Echo [2145-5-24] Conclusions The left atrium is mildly elongated. 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%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen (images suboptimal). The mitral valve is grossly normal. No definite mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. Compared with the prior study (images reviewed) of [2145-5-10], moderate pulmonary artery systolic hypertension is now identified. Global biventricular systolic function is similar. Brief Hospital Course: On [2145-5-19] the patient presented to [Hospital1 18] for a scheduled endovascular AAA repair by Dr. [Last Name (STitle) ]. He was kept intubated post operatively due to COPD history and transferred to the VICU on a Neo-Synephrine gtt. Overnight in the ICU the patient developed an acutely cold left foot without pedal signals. An [2145-5-20] ECG obtained also showed changes in lateral lead with elevated troponins which was concerning for coronary ischemia. Bedside echo showed normal LF function. Cardiology recommended medical management of heparin drip, serial ECGS and enzymes with plavix, beta blocker,aspirin and lipitor. The decision was made to extubate the patient which he tolerated for a few hours. By mid afternoon the patient continues to have a cold, pulseless foot on heparin drip. He required re-intubation and the decision was made to return the patient to the cath lab for a coronary intervention for STEMI as well as an attempt to revascularize his left leg. [2145-5-21] Taken to the Cath lab and the Cardiology team placed PTCA/stent of the LM and RCA (the patient will need to remain on plavix for at least 3 months). He subsequently had a left common iliac thrombectomy and vein patch of the common femoral artery. Transferred back to ICU on levo and nitro gtt and fluid boluses for hypotension. Kept in ICU on heparin gtt. Foot perfusion improved and hct stable. 4/16-222 Remained in ICU with BP management and vent support. Required days of weaning to extubation. Cardiac enzymes continued to trend down. Continued on heparin gtt. Continued to diuresis in the ICU. Levo weaned for BP management. On [5-26] the patient was extubated, OOB with physical therapy as a max assist. Continued on heparin gtt. On [2145-5-28] the patient was transferred to the Vascular stepdown. OOB with PT. Continued diuresis. [2145-5-30] Stable in VICU on nasal cannula. Dermatology saw patient in VICU for left shin skin lesion. Recommended biopsy as an outpatient- patient is aware but refused presently. Physical therapy recommended Rehab. Patient awaiting bed placement. No acute issues. [2145-6-1] Discharged to Rehab. Family aware of plan. Will be sent with JP drain. Will follow up with Dr. [Last Name (STitle) ] in 1 week for drain and staple removal and wound check. Atrius Cards office was notified of patient's discharge and will call [Location (un) 2199] Lifecare with a time. Medications on Admission: asa, enalapril, flovent, lasix, spiriva, simvastatin, home oxygen 3L Discharge Medications: 1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for left groin fold. 2. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 3. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): while decreased mobility. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 12. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 13. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Four (4) Puff Inhalation QID (4 times a day). 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 15. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: may increase to twice daily if needed . 18. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): new med . 19. Insulin Sliding Scale- Regular Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-159 mg/dL 2 Units 2 Units 2 Units 0 Units 160-199 mg/dL 4 Units 4 Units 4 Units 2 Units 200-239 mg/dL 6 Units 6 Units 6 Units 4 Units 240-280 mg/dL 8 Units 8 Units 8 Units 6 Units > 280 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: Life Care Center at [Location (un) 2199] Discharge Diagnosis: AAA (preop) PMH: COPD on home oxygen (3L) Morbid Obesity Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [3-11] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [5-12] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Division of Vascular and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [3-11] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [4-9] weeks for post procedure check and ultrasound What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [Telephone/Fax (1) 1237]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2145-6-7] 1:15 Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2145-6-21] 1:30 Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2145-6-21] 2:15 You should follow up with [Location (un) 2274] Cardioligy in 1 month at the [Location (un) 1468] Office with Dr. [Last Name (STitle) 6512]. The Cardiology office has been notified and will call your Rehab with the time of your appointment. It was recommneded that you follow up with [Hospital1 18] Dermatology for a skin biopsy of your growth on your leg. Please call if you decide you would like this done: [Location (un) 830] [Location (un) 86], [Numeric Identifier 718] ([Telephone/Fax (1) 8132] Completed by:[2145-6-1]	[ "998.12", "444.22", "401.9", "518.5", "496", "441.4", "997.2", "414.01", "V15.82", "278.01", "285.1", "272.4", "V46.2", "997.1", "709.9", "785.51", "410.71", "E878.2", "518.89" ]	icd9cm	[ [ [] ] ]	[ "00.24", "39.71", "36.06", "33.24", "96.72", "00.66", "38.18", "00.41", "00.46" ]	icd9pcs	[ [ [] ] ]	10655, 10726	5733, 8177	302, 471	10841, 10841	1819, 5710	16137, 17114	1283, 1400		8296, 10632		10747, 10820		8203, 8273			10992, 12995	15566, 16114								1415, 1800																			228, 264												499, 883								10856, 10968						905, 1019	1035, 1267
15,084	187,562	28000	Discharge summary	report	Admission Date: [2137-3-25] Discharge Date: [2137-4-18] Date of Birth: [2077-7-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 25876] Chief Complaint: Admission for IL-2 Major Surgical or Invasive Procedure: s/p central line placement emergent tracheotomy picc line placement JP drain placed History of Present Illness: HPI and Brief Hospital Course: Mr. [Known lastname 2405] is a 59 yo M w/ PMH Left renal cell carcinoma s/p resection 8 [Last Name (un) ] w/ recurrence in the gallbladder and possibly a second right renal primary who started high dose IL-2 therapy on [2137-3-25]. He tolerated [1-24] doses with minimal complications. He finished his last dose at 3 pm on [3-29]. As of [3-29] he was positive 3 Liters. On the day of [3-30], he was more confused and agitated trying to pull out his lines. He was also noted to be more short of breath. A CXR was notable for low lung volumes contributing to increased IS and vascular markings. He was given 20 IV lasix with ~200 cc UO. At 5:30 pm, he continued to be short of breath. His sats were noted to be 80% NRB. A Code Blue was called. ABG was 7.06/83/119/25. Multiple attempts were made at intubation without success. After one intubation his HR was noted to be in the 30s so he was given 1 dose of atropine with an increase in his heart rate to 150s afib w/ rvr. The surgery team was called and multiple attempts were made at a surgical airway without definite success. Eventually anesthesia felt they had an oral airway and his sats increased to high 80s with bagging. A femoral A line was placed. He received 40 mg Lasix IV w/ ~200-300 cc UO. The course was also complicated by persistent hypotension requiring dopamine and neosynephrine and continued afib w/ RVR with rates 120s-180s. He was then taken to the OR for EGD and bronchoscopy. In the OR, he underwent neck exploration, bronchoscopy, repair of laryngeal laceration and EGD. His superior airway was noted to be edematous. On arrival to the [Hospital Unit Name 153], he was intubated, sedated. . Past ONC Hx: Mr. [Known lastname 2405] was diagnosed with left renal cell carcinoma approximately 8 years ago. He reportedly underwent nephrectomy revealing a T2 renal cell carcinoma. He was well until approximately [6-15], when he developed chest pain and difficulty swallowing with endoscopy revealing oral candidiasis. Approximately 6 months later, he underwent repeat endoscopy with stomach biopsy showing a lymphoid infiltrate. The presence of the gastric lymphoid infiltrate lead to a CT scan which revealed a 10 x 10 mm lesion in the gallbladder fundus. He underwent cholecystectomy on [2136-6-21] by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at the [Hospital1 ]. Pathology revealed metastatic clear cell carcinoma involving the gallbladder consistent with metastasis from renal primary. Restaging CTs on [2136-6-27], revealed indeterminant tiny 2 to 3 mm nodules in the right subpleural lung, a 1.8 cm mass in the right kidney, 2 subcentimeter perinephric nodules, and 3 perisigmoid nodules. On follow-up CTs, the right kidney mass was stable and felt to be a 2nd primary. In [2-17], CT abd was notable for enlarging LN near the uncinate process. On [2137-3-25], he was admitted to start high dose IL-2 therapy. He received [1-24] doses as of [2138-1-26]. Past Medical History: PMH: renal cell carcinoma HTN Anxiety . PSH: Nephrectomy as above Tonsillectomy Appendectomy CCY Social History: Married with 3 daughters. [Name (NI) ] is an executive at a tech company working here in [Location (un) 86] with his residence in [State 3908]. He smokes half a pack per day and has smoked for the past 25 years. He denies ETOH. Family History: He denies history of cancer in his parents or siblings. Father has diabetes. Mother with thyroid issues. Two brothers are alive and well. Physical Exam: PE: VS Tc98.7 99.5 74 65-83 107/63 107-114/63-72 99% FiO2 .4 I/O 2[Telephone/Fax (5) 68173] GENL: PMV HEENT: PERRL, Sclera anicteric NECK: no JVD, JP drain on R side CV: RRR no mrg PULM: diffuse rhonchi ABD: soft, ND, NABS, No HSM appreciated, LQ scar EXT: 2+ edema, feet warm, trace radial and dp pulses b/l NEURO: awake and alert, talking without problem, moves all extrem, CN 2-12 intact, FROM Pertinent Results: Initial labs: [2137-3-26] 12:00AM GLUCOSE-68* UREA N-17 CREAT-1.3* SODIUM-143 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-21* ANION GAP-17 [2137-3-26] 12:00AM ALT(SGPT)-29 AST(SGOT)-41* LD(LDH)-185 CK(CPK)-54 ALK PHOS-80 TOT BILI-0.3 DIR BILI-0.1 INDIR BIL-0.2 [2137-3-26] 12:00AM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-2.0* MAGNESIUM-1.9 [2137-3-26] 12:00AM WBC-9.6 RBC-4.97 HGB-14.8 HCT-42.9 MCV-86 MCH-29.7 MCHC-34.5 RDW-14.6 [2137-3-26] 12:00AM NEUTS-93* BANDS-3 LYMPHS-1* MONOS-2 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [2137-3-26] 12:00AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ BURR-OCCASIONAL [2137-3-26] 12:00AM PLT COUNT-278 [2137-3-25] 06:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2137-3-25] 01:30PM GLUCOSE-154* UREA N-14 CREAT-1.2 SODIUM-143 POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-26 ANION GAP-12 [2137-3-25] 01:30PM ALT(SGPT)-13 AST(SGOT)-12 LD(LDH)-117 CK(CPK)-51 ALK PHOS-76 TOT BILI-0.2 DIR BILI-0.0 INDIR BIL-0.2 Discharge labs: [2137-3-25] 01:30PM ALBUMIN-3.7 CALCIUM-8.7 PHOSPHATE-2.5* MAGNESIUM-2.1 [2137-3-25] 01:30PM WBC-8.5 RBC-5.00 HGB-14.7 HCT-42.2 MCV-84 MCH-29.3 MCHC-34.7 RDW-14.4 [2137-3-25] 01:30PM NEUTS-52.2 LYMPHS-38.4 MONOS-5.0 EOS-3.7 BASOS-0.7 [2137-3-25] 01:30PM PLT COUNT-278 [2137-3-25] 01:30PM PT-11.4 PTT-29.7 INR(PT)-1.0 [2137-4-18] 12:00AM BLOOD WBC-11.9* RBC-3.41* Hgb-9.9* Hct-30.7* MCV-90 MCH-29.0 MCHC-32.3 RDW-15.9* Plt Ct-389 [2137-4-18] 12:00AM BLOOD Plt Ct-389 [2137-4-18] 12:00AM BLOOD Glucose-120* UreaN-11 Creat-1.5* Na-137 K-4.1 Cl-102 HCO3-25 AnGap-14 [2137-4-16] 12:00AM BLOOD ALT-28 AST-27 LD(LDH)-193 AlkPhos-113 TotBili-0.7 [2137-4-18] 12:00AM BLOOD Calcium-7.6* Phos-4.0 Mg-1.9 Echo: Conclusions: The left atrium is normal in size. 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) 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 moderate pulmonary artery systolic hypertension. There is no pericardial effusion.IMPRESSION: Moderate pulmonary artery systolic hypertension. Preserved global and regional biventricular systolic function. These findings are suggestive of a primary pulmonary process (primary pulmonary hypertension, chronic pulmonary embolism, COPD, etc.). . Brief Hospital Course: Impression/Plan: 59 yo M w/ metastatic renal cell carcinoma s/p dose 12/14 of IL-2 at 3pm on [3-29] with acute onset of hypoxia and hypotension transferred to unit with respiratory code. . # Hypoxic respiratory failure - Most likely due to pulmonary edema/ capillary leak in the setting of the pt receiving IL-2 and being 3-4L positive. CT showed multifocal pna and loculated parapneumonic effusion, positive for exudate. Chest tube placed and pulled the day before leaving the ICU. Patient was trached. Bronchoscopy done before discharge showed good repair. Since the patient was satting mid 90s on room air the trach was capped. Patient found to have serratia and proteus pneumonia and was treated for 7 days with aztreonam, 7 days of ceftriaxone. On [4-12] his sputum cx showed sparse growth of serratia which was pan-sensitive. Patient was put on levaquin for another week. Will follow-up with Dr. [Last Name (STitle) 1729] and thoracics for trach removal. . #Acute Renal Failure: Most likely due to IL-2 +/- Naproxen use or ATN in setting of hypotension. Decreased UO common with IL-2. Renal status stabilized and patient had good UO on discharge. . #Afib w/ RVR - on return to the floor, patient was in sinus rhythm with rates in 80s. He was started back on his toprol as his blood pressure was normal to elevated. . #Renal Cell Ca - Per primary team . #. Hyperglycemia- initially thought to be due to tube feeds and pt was put on lantus and humalog sliding scale. Sugars improved, but still elevated. Should f/u with PCP regarding diabetes. Not discharged on insulin. HbA1C was 6.5. Medications on Admission: Klonopin Toprol XL 50 Avapro 300 mg daily Discharge Medications: 1. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:qs qs Refills:0 4. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:qs qs Refills:0 5. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:10 Patch 72HR(s) Refills:2 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:4 Tablet(s) Refills:0 7. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 9. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 11. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Caregroup VNA Discharge Diagnosis: Metastatic renal cell CA - s/p C1W1 HD IL-2 Discharge Condition: HD stable and afebrile. Discharge Instructions: You were admitted for IL-2 therapy for renal cell carcinoma. During your stay, you had a respiratory code and transferred to the ICU for emergent tracheotomy and JP drain placement. Please take all medications as directed. Please follow-up with all outpatient appointments. Notify Dr. [Last Name (STitle) 24699] office for fever, chills, shortness of breath or inability to take oral fluids, diarrhea, chest pain or any other concerning symptoms. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] on [4-30] at 2:00. His office is located on the [Location (un) ] of the [Hospital Ward Name 23] building. You should also see Dr. [Last Name (STitle) 1729] on Tuesday [4-23] at 2:00.	[ "693.0", "E935.6", "518.81", "275.3", "785.51", "E879.8", "300.00", "799.02", "458.29", "584.5", "427.31", "276.0", "E849.7", "782.4", "427.1", "287.5", "518.0", "511.9", "197.0", "428.0", "276.4", "275.2", "482.83", "416.8", "E933.1", "E870.5", "787.01", "V58.12", "998.2", "189.0", "348.1", "790.29", "528.09", "196.8" ]	icd9cm	[ [ [] ] ]	[ "06.09", "31.61", "00.15", "99.60", "96.07", "31.1", "34.91", "34.04", "96.72", "96.04", "42.23", "38.93", "99.04", "33.22", "38.91" ]	icd9pcs	[ [ [] ] ]	10426, 10470	7309, 8912	335, 421	10558, 10584	4488, 5592	11086, 11345	3907, 4050		9005, 10403		10491, 10537		8938, 8982			10608, 11063			5609, 7286						4066, 4469																			277, 297												449, 457														3531, 3630	3646, 3891
80,274	198,989	51425	Discharge summary	report	Admission Date: [2168-11-5] Discharge Date: [2168-11-24] Date of Birth: [2089-3-25] Sex: F Service: MEDICINE Allergies: Morphine / Demerol / Levaquin / Benadryl / Cymbalta / Celexa / Remeron / Sulfa (Sulfonamide Antibiotics) / Quinolones / Vancomycin Attending:[First Name3 (LF) 1145] Chief Complaint: Hypotension/Afib w/RVR Major Surgical or Invasive Procedure: Central Venous Line placed History of Present Illness: 79 yo F w/ nonischemic cardiomyopathy EF 20% s/p BiV pacer [8-31], PAF, DMII, h/o DVT, PE [2-1] on coumadin, recurrent C.diff presents as OSH transfer with hypotension from presumed urosepsis, atrial fibrillation with RVR, NSTEMI, and acute on chronic renal failure. . At the OSH, she presented on [2168-11-4] with chief complaint of weakness and fatigue. The was found to be hypotensive with SBP 70s with a UA consistent with UTI, WBC 18.1 and she was started on zosyn initially due to her multiple drug allergies which was then switched to Primaxin and she was fluid resuscitated. On the day of transfer, Tm 104, and she was found to be in atrial fibrillation with RVR to 180s. Amiodarone bolus (50mg IV x1)and gtt(1mg/min x6 hours then 0.5mg/min) were initiated and she received 250mcg digoxin IV x2. She was found to be hypotensive and a CVL was placed and levophed was started. She also received stress dose steroids with IV hydrocort 100mg. She was noted to have a hematocrit drop from 29.1 on admission to 27.3 on the day of transfer. Guiac stool was negative. Flu swab was negative. Creatinine found to be 2.6 from baseline of 1.3-1.5. Troponin was elevated with peak at 0.24 with CK 18 . On review of systems, she denies any prior history of stroke, TIA, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies exertional buttock or calf pain and has no limitation in walking. 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: - Paroxysmal atrial fibrillation on coumadin - Left bundle branch block - sub-massive Pulmonary embolism - S/p admission to [Hospital1 18] [3-31] with C.diff (WBC in the 20's) - CKD - baseline 1.3-1.5 - Type II diabetes - NID - Rhuematoid Arthritis- the patient previously was on methotrexate for about 3 years and more recently has been on prednisone 5mg daily. Had been on Enbrel but has not taken that for several months. - Aortic sclerosis - Systolic chronic congestive heart failure - Severe global hypokinesis and inferior akinesis (LVEF=25-30%) by TEE ([2-1]), s/p BiV placement [8-31] - Hypertension - Obesity - Hyperlipidemia - DVT/PE - First in [2150]/93, and recurrent as of [2-1] - Right carotid artery 60% stenosis - ASA allergy--> anaphylaxis in [2128]. Presently on ASA - Multiple episodes of C. Diff - Recent hospitalization [8-31] for ICD implantation c/b C.diff, abdominal wall hematoma - Hypothyroidism . 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS:None -PACING/ICD: s/p BiV ICD Social History: -Tobacco history: Reports 50 pack-year tobacco history, quit [2138]. -ETOH: Occasional alcohol. -Illicit drugs: None Transferred from [Hospital3 7571]Hosp. Was discharged to [Hospital3 106633] - [Location (un) ] from [Hospital1 18] [8-31] and was at home prior to this admission. Family History: Mother and father with CAD in their 50s, one sister with CHF and another sister died with AS (in twenties after surgery in teens), sister with DM. Physical Exam: VS: T= 97.6 BP= 102/38 HR=73 RR=18 O2 sat=96% on RA GENERAL: WDWN elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 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, few b/l crackles at bases, no wheezes or rhonchi. ABDOMEN: b/l breast implants. 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 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Pertinent Results: ADMISSION LABS: [2168-11-5] 09:32PM TYPE-MIX [2168-11-5] 09:32PM LACTATE-1.5 [2168-11-5] 09:32PM O2 SAT-55 [2168-11-5] 09:14PM GLUCOSE-175* UREA N-56* CREAT-2.3* SODIUM-139 POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-19* ANION GAP-15 [2168-11-5] 09:14PM estGFR-Using this [2168-11-5] 09:14PM CALCIUM-6.3* PHOSPHATE-3.5 MAGNESIUM-1.8 [2168-11-5] 09:14PM WBC-14.5* RBC-2.94* HGB-9.1* HCT-27.4* MCV-93.1 MCH-30.8 MCHC-33.0 RDW-16.5* [2168-11-5] 09:14PM NEUTS-62 BANDS-24* LYMPHS-5* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-6* MYELOS-2* [2168-11-5] 09:14PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ TEARDROP-OCCASIONAL [2168-11-5] 09:14PM PLT SMR-LOW PLT COUNT-101* [2168-11-5] 09:14PM PT-18.9* PTT-32.0 INR(PT)-1.7* OTHER PERTINENT RESULTS: fibrinogen: 622 Inhibitor screen: negative HIT panel: negative Cryoglobulin: negative Ammonia 14 TSH 2.1 T3 37 freeT4 0.70 Cortisol 23 . [2168-11-7] CT abd/pelvis IMPRESSION: 1. Bilateral pleural effusions and interstitiell changes in the lungs consistent with CHF. 2. abnormality in the right rectus muscle most consistent with subacute rectus sheet hematoma (correlate with history of anticoagulation) 3. Anasarca. 4. Vertebral body deformity of L3, stable. Vertebral body deformity of T12 with interval worsening and now appears completely collapsed. 5. Scout image of chest suboptimal for evaluation of left IJ placement due to multiple overlying lines. . [11-9]: Echo The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 20-25 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2168-4-20], the left ventricular cavity appears dilated on the current study. The degree of mitral regurgitation has increased significantly. The degree of aortic stenosis has incrased slightly. LV systolic function remains severely depressed, although the ventricle does not appear as dyssynchronous as on the prior study. . [2168-11-10] CT head: 1. No acute hemorrhage, no acute vascular territorial infarction. [2168-11-14] LUE U/S: No evidence of deep vein thrombosis in the left arm [2168-11-14] CT chest/abd/pelvis: 1. No evidence of pancreatitis. 2. Moderately large bilateral pleural effusions, increased in size since the prior study, most c/w CHF. Bibasilar atelectasis, left greater than right. 3. Subacute rectus sheath hematoma remains stable in size and appearance. 4. Anasarca. [2168-11-19] B/L LENIs: 1. No DVT of either lower extremity. 2. Calf veins not visualized of either leg. [2168-11-22] EEG: This is a mildly abnormal routine EEG in the waking and drowsy states due to a background that was mildly slow and disorganized with occasional bursts of generalized delta slowing. This is consistent with a mild encephalopathy. There were no focal, lateralized, or epileptiform abnormalities noted . MICROBIOLOGY: [2168-11-5] MRSA screen: negative [2168-11-6] BCx x2: negative [2168-11-6] Stool Cx: negative for salmonella, shigella, campylobacter, Cdiff toxin [2168-11-6] UCx: negative [2168-11-7] Cdiff: negative [2168-11-7] BCx x2: negative [2168-11-7] OSH Cath tip: negative [2168-11-7] Cdiff: negative [2168-11-7] DFA Influenza: negative [2168-11-8] [Last Name (un) ] Legionella: negative [2168-11-8] Lyme: negative [2168-11-8] Erlichia: negative [2168-11-8] Aspergillus Ag: negative [2168-11-8] Beta glucan: negative [2168-11-9] RPR: non-reactive [2168-11-9] UCx: negative [2168-11-10] UCx: negative [2168-11-10] Cdiff: negative [2168-11-15] Cdiff: negative [2168-11-15] BCx x2: negative [2168-11-19] Cdiff: negative [2168-11-21] Wound Cx (sacral decub): mixed flora DISCHARGE LABS [2168-11-24]: WBC 17.2 H/H 9.1/28.0 Plt 161 PT 24 PTT 96.5 INR 2.3 Na 137 K 4.3 Cl 102 HCO3 30 BUN 54 Cr 1.2 Glc 86 Ca 7.6 Mg 1.9 P 4.1 [2168-11-22] Alb 1.6 Brief Hospital Course: 79 yo F w/ a h/o CHF (EF of 20-30%), carotid stenosis, no CAD from cath [2-1], and h/o LBBB s/p BiVpacer presents as OSH transfer with urosepsis, atrial fibrillation w/ RVR and demand ischemia. . # Infection: FUO, Complicated by Afib w/ RVR in setting of EF 20%. Pt with history of urine enterobacter sensitive to [Last Name (un) 2830]/cefepime. Was started on zosyn and switched to imipenem at OSH. Appears euvolemic on exam. On meropenem x 10d and azithromycin x 5d given prior cx data and multiple drug allergies. OSH Urine cx, blood Cx data ?????? no growth. Infiltrate on CXR but after d/w rads, felt that CXR probably not indicative of PNA, likely edema instead. ID consulted but don't believe there is infectious etiology. All cultures and CT A/P showed no infectious source. Given patient's h/o C. difficile infection, strong suspicion for this as etiology but patient's stool cultures were repeatedly negative for C. diff (x5). After exhausting all other obvious sources of infection, and after discussion with ID, empiric treatment for C. diff was started with IV flagyl + PO vancomycin. After commencing this treatment, the patient's significant leukocytosis began to decline. MS improved as well. Flagyl was discontinued when pt improved clinically. Will remain on PO Vanc for extended course with taper - 125mg PO q8h x 14d, taper to 125mg po q12 x7d, 125mg po q24h x7d, 125mg po q48h X 7d, 125 mg po q72h X 14d. . # Altered/Depressed MS ?????? Started after being given 1mg ativan for line placement. No CO2 retention. C/w toxic-metabolic picture but not improving with broad spectrum Abx. Head CT -> WNL. Lactulose was trialed [11-10] with no improvement. No appreciable response to stress dose steroids x 2d and d/ced [11-12]. TSH WNL; fT4, T3 slightly low but doubtful to be responsible for this clinical picture. Neuro consult agreed with current workup and treatment plan and did not feel non-convulsive status epilepticus was likely. EEG showed mild encephalopathy. MS [First Name (Titles) 21299] [Last Name (Titles) 58985] with treatment for Cdiff. Pt is currently AOx3. She should have TSH followed up in 4 weeks as an outpatient. . # Acute on Chronic Renal Failure: Baseline 1.3-1.5, creatinine 2.6 on presentation to OSH. Cr has improved with hydration but azotemia continued for unclear reasons. No GI bleed. Renal was consulted and initially considered dialysis but as azotemia began to resolve (after peaking at 104), held off on HD. Good UOP during hospitalization. Discharge BUN/Cr 55/1.2. . # Supertherapeutic INR: Likely due to drug drug interaction (amio vs. flagyl vs abx). Amio d/ced. Inhibitor screen negative. After clinical picture was of less acuity, patient was rebridged to therapeutic INR with heparin/warfarin. Discharge INR 2.3. . # Thrombocytopenia: Pt's platelets dropped to low 100s, lowest 92. Heparin SC was held during this time until HIT panel was negative. She was then started on Heparin gtt bridge to Coumadin for paroxysmal afib. Platelets improved to 160s prior to discharge. . # RHYTHM: Though paced, underlying rhythm is Afib, rate controlled with amiodarone and metoprolol. Likely worsened by underlying sepsis. Anticoagulated with therapeutic INR since admission at OSH. Amio discontinued [1-25] to possible contributions to AMS. Continued rate control with BB. Pt was restarted on Coumadin with Heparin bridge. Discharge INR 2.3. . # PUMP: s/p BiV placement [8-31]. Reports using lasix 20mg [Hospital1 ] at home although no record from OSH. Euvolemic on admission. Initially given fluids for hypotension and renal failure. Had oxygen requirement and anasarca, so pt had evidence of volume overload - +17L during length of stay. Pt has been getting diuresis - Lasix 80mg IV daily for goal negative 500cc/day. Pt is also on Captopril and BB. . # CORONARIES: No known CAD as per cath [2-1]. Likely had demand ischemia in setting of urosepsis compounded by acute on chronic renal failure. Aspirin held. Metoprolol 12.5 mg [Hospital1 ] was started. . # Hypothyroidism - continued home synthroid dose, TSH WNL. Should have TSH followed as outpatient in 4 weeks. . # LE Edema - Pt noted to have LE edema, likely [1-25] to fluid overload. B/l LENIs were negative for DVTs. # Rheumatoid Arthritis: Chronic 5mg prednisone steroid use, although not completely clear most recent use. No evidence of adrenal insufficency from this low dose. Did receive hydrocort 100mg IV x1 at OSH on day of transfer. Received 2 doses of 125mg IV daily of solumedrol but discontinued as did not improve her clinically although did cause leukocytosis. Continued on home dose Prednisone 5mg PO. . # DMII - Managed with lifestyle modification at home. FS elevated while hospitalized. The patient is currently on Lantus 10 units daily with sliding scale coverage. . # Pressure ulcer/Nutrition - Pt developed a stage III pressure ulcer during hospitalization. She was started on Vitamin C and Zinc Sulfate for 10 day course, ending on [11-26]. She was started on Vitamin A [2168-11-24] (could not be crushed - pt now able to tolerate whole pills), which should be continued for a 10 day course. She should remain on tube feeds in addition to PO intake, as she is malnourished and needs calories to help with wound healing. She should be re-evaluated by nutrition in several days to determine if she can be weaned off tube feeds. . # FEN - tube feeds during hospitalization - Renal tube feeds were switched to Fibersource HN [1-25] to high concentration of Na in Renal TF and resultant hypernatremia. Hypernatremia has resolved. . # ORAL CARE - Pt was resistant to oral care when she had AMS. She was noted to have a mass attached to her palate. ENT was consulted and removed a piece of dried mucous. They noted an area of discoloration on her hard palate, which should be followed up in outpatient clinic - [Telephone/Fax (1) 41] fellows clinic. Medications on Admission: Aspirin 325mg daily Ferrous Sulfate 325mg po daily Synthroid 25mg po daily Humalog SS Zocor 10mg po QHS Primaxin 500mg IV Q12H Prilosec 20mg po daily Amiodarone IV gtt 0.5mg IV Hydrocortisone 100mg IV daily Levophed gtt NS 75cc/hr coumadin 3mg po QHS . At home: per patient, unclear if accurate Carvedilol 3.125mg po BID Coumadin 3mg po daily Aspirin 325mg po daily Prednisone 5mg po daily Synthroid 25mcg daily Simvastain 10mg daily lasix 20mg po BId Discharge Medications: 1. Levothyroxine 25 mcg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet [Telephone/Fax (1) ]: 0.5 Tablet PO BID (2 times a day). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 4. Prednisone 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 7. Captopril 12.5 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO TID (3 times a day): please hold for SBP < 100. 8. Warfarin 1 mg Tablet [Last Name (STitle) ]: Three (3) Tablet PO Once Daily at 4 PM. 9. Furosemide 10 mg/mL Solution [Last Name (STitle) ]: Eight (8) mg Injection once a day. 10. Vancomycin 125 mg Capsule [Last Name (STitle) ]: One (1) Capsule(s)-> please use suspension PO see below: [Date range (1) 106112]: 125mg every 8hrs; [Date range (1) 66521]: 125mg every 12 hrs; [Date range (1) 65518]: 125mg every 24 hrs; [Date range (1) 25254]: 125mg every 48hrs; [Date range (1) 105174]: 125mg every 72 hrs . 11. Insulin Glargine 100 unit/mL Cartridge [Date range (1) ]: Ten (10) Units Subcutaneous once a day. 12. Zinc Sulfate 220 mg Capsule [Date range (1) ]: One (1) Capsule PO DAILY (Daily) for 3 days. 13. Vitamin A 10,000 unit Capsule [Date range (1) ]: One (1) Capsule PO DAILY (Daily) for 10 days. 14. Calcium Carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension [Date range (1) ]: One (1) PO TID (3 times a day). 15. Ascorbic Acid 90 mg/mL Drops [Date range (1) ]: One (1) PO BID (2 times a day) for 3 days. 16. Insulin Lispro 100 unit/mL Cartridge [Date range (1) ]: according to sliding scale units Subcutaneous QACHS. 17. Outpatient Lab Work please monitor electrolytes while patient is being diuresed and check PT/INR to maintain an INR [1-26] for atrial fibrillation Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis: urosepsis NSTEMI acute on chronic renal failure atrial fibrillation with rapid venticular response clostridium difficile infection sacral decubitus ulcer Secondary Diagnosis: HTN type 2 Diabetes Discharge Condition: hemodynamically stable, alert and oriented x 3; non-ambulatory (wheelchair bound at baseline) Discharge Instructions: You came to the hospital with fatigue and weakness. You were found to have a severe urinary tract infection, a rapid/ unstable heart rate with evidence of a small heart attack. We treated you with antibiotics and started you on medications to help control your heart rate. Your hospital course was complicated by low blood pressure, confusion and a high white blood cell count. An extensive evaluation for an infectious cause of your symptoms was negative. Your symptoms began to resolve once we treated you for infectious diarrhea caused by a bacteria, clostridium difficile. You will need to take the antibiotic vancomycin for a prolonged course to treat this infection appropriately. Because your oral intake was not good, you were also started on supplemental nutrition through a nasogastric tube. By the time of discharge, you were improving. Because your hospital course was so complicated, you may take a long time to recover. There were a lot of changes to your medication regimen. Please see the attached medication administration record. Followup Instructions: Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 6955], in [12-25] weeks. please follow up with the otolaryngologists for hard palate discoloration within 2 months. Please call [Telephone/Fax (1) 41] to schedule an appointment	[ "244.9", "995.92", "403.90", "433.10", "707.03", "426.3", "440.0", "428.23", "V58.61", "707.23", "263.9", "038.9", "410.71", "584.9", "528.9", "599.0", "276.0", "250.00", "287.5", "V45.02", "008.45", "780.65", "427.31", "790.92", "428.0", "425.4", "428.22", "714.0", "585.9", "348.31" ]	icd9cm	[ [ [] ] ]	[ "38.93", "31.42", "96.6" ]	icd9pcs	[ [ [] ] ]	18152, 18223	9576, 15534	415, 443	18482, 18578	5577, 7609	19685, 19984	3641, 3789		16036, 18129		18244, 18244		15560, 16013			18602, 19662									3804, 4714		3219, 3300																	353, 377												471, 2159		7618, 9553	18439, 18461		4749, 5558	18263, 18418								2181, 3199	3316, 3625
42,919	112,192	39874	Discharge summary	report	Admission Date: [2140-7-29] Discharge Date: [2140-8-3] Date of Birth: [2100-11-24] Sex: M Service: MEDICINE Allergies: Propoxyphene / Methadone / pseudoephedrine / Peanut / Adhesive Bandage / Banana Attending:[First Name3 (LF) 2195] Chief Complaint: fever Major Surgical or Invasive Procedure: IR guided HD line placement History of Present Illness: Mr. [Known lastname 15532] is a 39 y.o incarcerated male w/ HIV, ESRD M/W/F HD, last got it Weds, presenting with fevers. On Monday had erythema around his catheter site (in the groin) at HD. He finished HD and got a dose of vanc. On Wed he continued to feel fatigue and had more fevers so go dialyzed completely, got a dose of vanc and then had his catheter pulled. They packed the wound and he went home. He came back today and the site looked much worse after the packing was taken out and the cath site was indurated with concern for an abscess. In addition he was complaining of SOB and couldn't lay flat in HD which they called "respiratory distress". In the ED, VS: 9 98.4 85 173/102 18 87%. he triggered for hypoxia to 87% RA. Responded to upright position and supplemental O2. Also given morphine and 80mg IV lasix. Now sat 94-95 4 L NC In addition he was hypertensive to the 200's and got 10mg IV hydral which dropped the BP to 170s (pt reports this is his baseline). On labs he was noted to have a mild troponin leak. EKG with peaked T waves concerning for hyperkalemia although K 4.7. Got calcium gluconate prior to seeing Ca which was wnl. CXR with diffuse infiltrate suggestive of fluid overload. Exam correlated. Patient had no HD access and a 16 gauge EJ placed and IR was called so patient could get an HD line. Only access site is right groin. Called renal who will evaluate. Also on exam groin site: Erythemaotous, warm, cellulitic, had U/S looks like small ? complex collection--> got IV vanc and pipercillin tazobactam Attempting to obtain more records from federal prison. Contact [Name (NI) ] at number in RN comments. . On the floor, patient was breathing comfortably. He re-iterated the above story including feeling unwell for the last few days starting Monday. . 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: HIV (CD4 308 in [Month (only) 958] with undetectable VL) End Stage Renal Disease H/O ESBL sepsis last year AV graft failure complicated by amputation of right forearm and hand HTN DMII Asthma GERD Chronic phantom limb pain Social History: Incarcerated - Tobacco: Denies - Alcohol: Denies - Illicits: Endorses marijuana approximately 7 years ago Family History: Father with ESRD and CAD w/ death of MI at 56. Physical Exam: Vitals: T: 96.9 BP:175/98 P:86 R: 24 O2: 93 on 3L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, 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 Discharge exam: GEN: Lying in bed in NAD HEENT: NCAT, EOMI. COR: +S1S2, no m/g/r. PULM: Diminished breath sounds bilaterally secondar to habitus & posture, however CTAB, no c/w/r . [Last Name (un) ]: +NABS in 4Q. Slight transient tenderness is right lower quadrant, no tenderness to percussion or rebound tenderness. EXT: Left groin site markedly improved, without any surrounding erythema. Area is still firm/scarred. Right tunneled groin catheter tender to palpation over tunneled aspet, but without erythema. NEURO: Awake & alert, MAEE. Pertinent Results: [2140-7-29] 09:35PM VANCO-22.5* [2140-7-29] 11:54AM COMMENTS-GREEN TOP [2140-7-29] 11:54AM LACTATE-0.8 K+-4.7 [2140-7-29] 11:50AM GLUCOSE-123* UREA N-89* CREAT-11.2* SODIUM-135 POTASSIUM-4.9 CHLORIDE-91* TOTAL CO2-24 ANION GAP-25* [2140-7-29] 11:50AM CK(CPK)-98 [2140-7-29] 11:50AM cTropnT-0.09* [2140-7-29] 11:50AM CK-MB-2 [2140-7-29] 11:50AM CALCIUM-9.8 PHOSPHATE-6.8* MAGNESIUM-2.5 [2140-7-29] 11:50AM VANCO-9.0* [2140-7-29] 11:50AM WBC-11.6* RBC-4.56* HGB-9.8* HCT-30.7* MCV-67* MCH-21.4* MCHC-31.8 RDW-19.2* [2140-7-29] 11:50AM NEUTS-84.0* LYMPHS-9.4* MONOS-3.5 EOS-2.5 BASOS-0.7 [2140-7-29] 11:50AM PLT COUNT-310 [2140-7-29] 11:50AM PT-13.9* PTT-32.9 INR(PT)-1.2* Micro: Blood Cultures 6/25 NGTD; MRSA Nasal Screen positive . EKG: NSR. Nl Axis, intervals. Peaked Twaves in V2-V4 and TW inversions I, II. LVH. Probably [Name Prefix (Prefixes) ] [Last Name (Prefixes) 6192]. . RADIOLOGY: LENI: 1. No left lower extremity deep venous thrombosis. 2. 1.3 cm complex fluid collection reflects hematoma with or without superinfection or abscess with reactive lymphadenopathy. . CXR: Moderate pulmonary edema with probable small bilateral pleural effusions. No pneumothorax. Brief Hospital Course: Mr. [Name13 (STitle) ] is a 39 year old gentleman with End Stage Renal Disease on Dialysis admitted with a catheter site infection, transferred to the MICU for volume overload/hypoxia. Dyspnea: The patient was dyspneic and hypoxic on presentation to the MICU. He was treated with several hours of Ultrafiltration and Hemodialysis and his symptoms resolved. Groin/catheter site infection: The patient developed an area of induration and erythema at his groin catheter site. Surgery was consulted and did not intervene. He was started on Vancomycin and Meropenem given a history of Resistant organisms and MRSA. The patient's dialysis catheter was moved under interventional radiology guidance. A PICC was also placed for antibiotic administration. ESRD: The patient was dialyzed while admitted through his newly placed catheter. He did develop asymptomatic hyperkalemia while admitted. He will continue a Monday, Wednesday, Friday scheduled for Dialysis. # HIV: continued home regimen. # Communication: Patient and [First Name8 (NamePattern2) 8254] [Known lastname 15532] [Telephone/Fax (1) 87718] (we cannot contact her she needs to be called by the policemen) # Code: Full (discussed with patient) Transitional issues: Complete Vancomycin/Ertapenem (switched for availability of pharmaceutical [Doctor Last Name 360]) until [2140-8-7]. Medications on Admission: Nifedipine CR 60 mg PO daily Emtricitabine 200 mg PO 2/wk (MO, FR) Insulin SC PRN for BG>200 Sevelamer Carbonate 3200 mg PO TID Sertraline 200 mg PO daily Omeprazole 20 mg PO daily Mom[Name (NI) 6474] inhaled [Hospital1 ] Minoxidil 10 mg PO BID Metoprolol Succinate 200 mg PO daily Ferrous gluconate 324 mg PO BID Lisinopril 40 mg PO daily Efavirenz 600 mg PO QHS Docusate 100 mg PO BID Diphenhydramine 25 mg PO Q8hr: PRN itching Amitriptyline 100 mg PO HS Albuterol inhalers Q4hrs Abacavir 600 mg PO daily Discharge Medications: 1. nifedipine 60 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 2. emtricitabine 200 mg Capsule Sig: One (1) Capsule PO 2X/WEEK (MO,FR). 3. sevelamer carbonate 800 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. mom[Name (NI) 6474] 110 mcg (30 doses) Aerosol Powdr Breath Activated Sig: One (1) puff Inhalation twice a day. 7. minoxidil 10 mg Tablet Sig: One (1) Tablet PO twice a day. 8. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 9. ferrous gluconate 324 mg (36 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. efavirenz 600 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. insulin lispro 100 unit/mL Solution Sig: As directed Subcutaneous three times a day: As directed per attached sliding scale. 14. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO every eight (8) hours as needed for itching. 15. amitriptyline 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. ertapenem 1 gram Recon Soln Sig: Five Hundred (500) mg Intravenous every twenty-four(24) hours for 5 days: To be given after dialysis on dialysis days. Last dose [8-7]. Disp:5 doses* Refills:0 17. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 18. abacavir 300 mg Tablet Sig: Two (2) Tablet PO once a day. 19. vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous Daily after dialysis for 5 days: To be given on dialysis days only, last dose [8-9]. Disp:3 grams Refills:0 20. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain for 3 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnoses: - Left groin Cellulitis catheter infection - ESRD Secondary Diagnoses: - HIV infection - Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 15532], You have been admitted to the hospital with an infection around your dialysis line. While you were here we replaced a new dialysis line, and treated you with ultrafiltration and hemodialysis to allievate your shortness of breath. You have been evaluated by Surgery and your Kidney team and you are now safe for discharge. New Medications: We have added the following Antibiotics: Ertapenem & Vancomycin for 5 more days. Followup Instructions: Please follow up with your primary care doctor: [Last Name (LF) ],[First Name8 (NamePattern2) 3679] [Last Name (NamePattern1) ] [Telephone/Fax (1) 87719] within 1-2 weeks.	[ "V49.65", "E849.7", "428.33", "403.91", "250.00", "585.6", "353.6", "682.2", "041.12", "E879.1", "996.62", "790.7", "530.81", "428.0", "V08", "493.90", "V02.54" ]	icd9cm	[ [ [] ] ]	[ "38.95", "38.97", "39.95" ]	icd9pcs	[ [ [] ] ]	9575, 9590	5512, 6738	346, 375	9756, 9756	4224, 5489	10391, 10582	3072, 3121		7452, 9552		9611, 9681		6911, 7429			9907, 10368									3136, 3656	9702, 9735				3672, 4205						6759, 6885			2230, 2678					301, 308												403, 2211								9771, 9883						2700, 2929	2945, 3056
766	183,370	24738	Discharge summary	report	Admission Date: [2178-3-3] Discharge Date: [2178-3-27] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4111] Chief Complaint: LE cellulitis/R hand weakness/L carotid stenosis Major Surgical or Invasive Procedure: none History of Present Illness: 85yo female with multiple medical problems presents to [Hospital1 18] on [3-3] with LLE cellulitis and new-onset RUE weakness. At OSH, found to have >70% L carotid stenosis and transferred to [Hospital1 18] for further management. Past Medical History: hyperchol, lung CA s/p R wedge resection, h/o CVA w/visual deficit, gastritis, h/o endocarditis, s/p aortic aneurysm repair, bilateral cataracts, h/o GIB Social History: widowed, lives in [Hospital3 ] prior 70 pack year smoking history, no EtOH. Family History: DM, CAD Physical Exam: Gen somnolent, minimally responsive CV RRR Resp +BS bilaterally Abd soft, NTND Ext 1+ LE edema bilaterally Pertinent Results: [2178-3-27] 01:55AM BLOOD WBC-20.7# RBC-3.19 Hgb-10.0* Hct-31.8* MCV-100* MCH-31.4 MCHC-31.5 RDW-18.3* Plt Ct-252 [2178-3-26] 02:15AM BLOOD WBC-11.7# RBC-3.24 Hgb-10.1* Hct-30.9* MCV-95 MCH-31.0 MCHC-32.6 RDW-18.1* Plt Ct-270 [2178-3-27] 01:55AM BLOOD Plt Ct-252 [2178-3-27] 01:55AM BLOOD PT-13.0 PTT-35.0 INR(PT)-1.1 [2178-3-26] 02:15AM BLOOD Plt Ct-270 [2178-3-27] 01:55AM BLOOD Glucose-159* UreaN-98* Creat-2.4* Na-137 K-5.8* Cl-97 HCO3-33* AnGap-13 [2178-3-26] 02:15AM BLOOD Glucose-75 UreaN-86* Creat-1.6* Na-138 K-5.0 Cl-97 HCO3-38* AnGap-8 [2178-3-25] 03:19AM BLOOD Glucose-121* UreaN-65* Creat-1.1 Na-140 K-4.1 Cl-97 HCO3-40* AnGap-7* [2178-3-26] 02:15AM BLOOD CK(CPK)-14* [2178-3-27] 01:55AM BLOOD Calcium-8.8 Phos-10.7# Mg-2.3 [2178-3-26] 02:15AM BLOOD Calcium-9.5 Phos-6.5 Mg-2.3 [2178-3-25] 03:19AM BLOOD Calcium-9.7 Phos-5.1* Mg-2.1 [2178-3-27] 02:19AM BLOOD Type-ART pO2-33* pCO2-145* pH-6.96* calHCO3-35* Base XS--5 [2178-3-26] 03:07AM BLOOD Type-ART pO2-158* pCO2-85* pH-7.28* calHCO3-42* Base XS-9 Brief Hospital Course: Patient admitted for evaluation of new right sided weakness. Neurology consulted for the possibility of a new CVA. Carotid duplex from OSH demonstrated > 70% stenosis of patient's L carotid for which vascular surgery was consulted. During this time, patient noted to have guiac+ stool and a dropping hematocrit. A GI consult was obtained, and an EGD was performed which demonstrated blood in the duodenum from a AVM. The patient was maintained supportively despite continued bleeding and she was transfused with PRBC's to maintain a Hct >30. A repeat EGD was performed on HD 6 which demonstrated actively bleeding again in the duodenum. A tagged RBC scan confirmed bleeding in the distal duodenum. Patient continued to receive transfusions in order to maintain her Hct. Another EGD was performed HD7 where a BICAP probe was applied to the bleeding portion of the lesion with cessation of the bleeding. After this procedure, the pt's Hct stabilized but did drift down slowly. Over the next few days, patient stabilized and was tolerating a regular diet. She was transferred to the floor from the ICU and rehab screening was begun. On HD10 patient noted to be more somnolent with +tarry stool. She was transferred to the ICU and transfused and a stat EGD was performed which demonstrated fresh blood in the duodenum. Patient continued to deteriorate from a mental status standpoint with both psychiatry and neurology following. Patient did develop hypercarbia and Bipap was started as the patient was DNR/DNI at this point in time. Despite attempts at diuresis, patient's mental and respiratory status did deteriorate over the next few days. Any opportunities for operative repair of her bleeding duodenal ulcer were put on hold secondary to these more urgent events. Patient did improve briefly, was once again transferred to the floor. However, she continued to have respiratory difficulties and hypercarbia likely stemming from her previous transfusions. Her mental status waxed and waned but she eventually did deteriorate on the floor necessitating transfer to the ICU. Over the next few days, her family at her bedside, the patient experienced episodes of hypotension, altered mental status and hypercarbia. Her DNR/DNI status was confirmed with her family. An infectious workup was initiated for potential sources of her hypotension and altered mental status and the pt was maintained on antibiotics and parenteral nutrition. The patient became more somnolent with increasing labored breathing and on HD25 she expired. Medications on Admission: albuterol, amio 200', advair 150'', lasix 80', lopressor 12.5'', prilosec 20' Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: GI bleed respiratory failure Discharge Condition: expired	[ "285.1", "780.09", "311", "403.91", "433.30", "427.89", "396.2", "458.8", "280.9", "441.2", "V12.59", "354.3", "427.31", "599.7", "276.51", "537.83", "682.6", "276.2", "707.03", "398.91", "537.84" ]	icd9cm	[ [ [] ] ]	[ "38.93", "44.43", "99.15", "99.04", "45.13", "93.90" ]	icd9pcs	[ [ [] ] ]	4809, 4818	2129, 4654	309, 315	4890, 4900	1028, 2106		877, 886		4782, 4786		4839, 4869		4680, 4759												901, 1009																			221, 271												343, 587														609, 764	780, 861
25,115	123,101	43874	Discharge summary	report	Admission Date: [2200-8-12] Discharge Date: [2200-8-15] Date of Birth: [2131-4-11] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: This is a 69-year-old Caucasian male with past medical history significant for hypertension, coronary artery disease status post multiple myocardial infarctions and ICD placement secondary to V-fib arrest, systolic CHF with an EF of 20%, AFib status post cardioversion [2200-5-15] and currently on Coumadin, peptic ulcer disease status post partial gastrectomy in [2162], colonic polyps, and diverticuli, who now presents with a two week history of painless hematuria followed by presyncope and bright red blood per rectum x1 day. The patient, as stated above, has been having two weeks of painless hematuria prior to admission. On the morning of admission, he underwent an outpatient cystoscopy without any complications, which failed to reveal any significant findings. About two hours after lunch, he began to feel quite lightheaded, weak, and diaphoretic. His symptoms were relieved after lying down. Soon thereafter, he had a large loose bowel movement. It was unclear whether there was any bright red blood per rectum or whether the stool was melanotic at this time. After the bowel movement, he again had an episode of presyncope. At that time, his daughter called EMS. His blood pressure on the field was noted to be 80/42 with a pulse of 60. He was brought to the [Hospital1 346] Emergency Department, where his blood pressure was confirmed to be 85/40 with a pulse of 53. He was given about 2 liters in the Emergency Department with a rise in his pressure to 150/85. Nasogastric lavage in the ED was negative, but the patient did have three large loose maroon guaiac positive bowel movements. His hematocrit dropped from 42.4 to 39.3 after both the bowel movement and hydration. He was thus transferred to the Medical ICU for closer monitoring. The patient reports that his last episode of bright red blood per rectum was in [2162]. He denied any foreign travel, sick contacts, unusual foods, chest pain, shortness of breath, abdominal pain, nausea, vomiting, palpitations. PAST MEDICAL HISTORY: 1. CAD status post anterior wall MI in [2188], status post PTCA/stent of LAD with restenosis leading to a repeat PTCA in [2197]. 2. Persantine thallium test in [2199-5-15] negative for ischemia, but revealed an EF of 20%. 3. V-fib arrest [2198-4-15] leading to placement of an AICD. 4. Pneumococcal pneumonia and respiratory failure. 5. Duodenal ulcer status post partial gastrectomy in [2162] complicated by splenic injury leading to a splenectomy at that time. 6. Hypertension. 7. Hypercholesterolemia. 8. Prostate cancer. 9. Atrial fibrillation on Coumadin since [2198-4-15]. 10. Colonic polyps. 11. Sigmoid and transverse colon diverticuli. 12. Squamous cell cancer. 13. Basal cell cancer. MEDICATIONS ON ADMISSION: 1. Amiodarone. 2. Aspirin. 3. Coumadin. 4. Atenolol. 5. Lipitor. 6. Flomax. 7. Lasix. 8. Prevacid. 9. Lisinopril. 10. Vitamin C. 11. Vitamin E. 12. Nitroglycerin prn. ALLERGIES: Penicillin which results in a rash. FAMILY HISTORY: Father died of prostate cancer. Son died of melanoma. Uncle had a MI in his 60s. SOCIAL HISTORY: The patient lives with his daughter. [Name (NI) ] quit tobacco in [2162]. He drinks about one drink every two weeks. He is a funeral home director and denies any IV drug use. PHYSICAL EXAMINATION: Temperature 97.7, blood pressure 128/64, pulse 58, respirations 16, and sating 100% on room air. In general, this is a well-developed, well-nourished, and well-appearing pleasant gentleman, who is alert and oriented times three and appeared to be in no apparent distress. Pupils are equal, round, and reactive to light. Mucous membranes were dry. Neck was without any jugular venous pressure or lymphadenopathy. Lungs were clear. Cardiovascular revealed normal S1, S2 without any murmurs, rubs, or gallops. Abdomen was obese, but soft. There was mild right lower quadrant tenderness to palpation, but no rebound or guarding. Bowel sounds were normal. There was a well-healed surgical scar in the midline. There is no hepatosplenomegaly or palpable masses. Extremities were warm with 2+ pulses, no edema. Neurologic was nonfocal, symmetric, and the patient displayed appropriate mentation. LABORATORIES ON ADMISSION: Notable for a white count of 16.8, hematocrit 39.3, platelets of 323. Differential of 65 polys, 28 lymphocytes, 5 monocytes, INR of 2.5. Creatinine 1.4 up from a baseline of 1.1. BUN 31. Urinalysis showed 30 protein, greater than 50 red cells, [3-19] white cells, and occasional bacteria. EKG showed sinus bradycardia at 54, left axis deviation, old Q's in the inferior leads, and poor R-wave progression, old T-wave inversions in lateral and precordial leads. Prolonged QTc interval at 510, but no acute ST changes. HOSPITAL COURSE BY PROBLEMS: [Name2 (NI) ] gastrointestinal bleed: The patient's lower GI bleed was most likely thought to be due to the patient's known diverticuli in the setting of anticoagulation on Coumadin. Two large bore IVs were placed at all times, and the patient was placed on telemetry. His hematocrits were checked on a q.4. basis initially until they were deemed to be stable. The patient did not require any blood transfusions during his hospital stay. He was placed on IV Protonix b.i.d. for adequate prophylaxis. He was initially kept NPO and given maintenance IV hydration. His Coumadin and aspirin were both held for about 24 hours. The GI team was consulted, but it was felt that there was no role for either any further imaging at this time. After about 24 hours, the patient stopped having any further bloody bowel movements. At that time, his diet was slowly advanced and well tolerated. Hypotension: The patient had transient hypotension with a systolic pressure in the 80s on initial presentation likely secondary to decreased intervascular volume in the setting of diarrhea. After about 2 liters of normal saline, the patient's blood pressure returned back to his baseline and he remained hemodynamically stable thereafter. His atenolol and lisinopril were changed to shorter acting metoprolol and captopril while he was in-house. His Lasix was held for one day as well. Leukocytosis: Patient presented with a white count of 16.8 with no left shift. Clostridium difficile toxin, blood cultures, urine cultures, and chest x-ray were all unremarkable. The patient remained afebrile throughout his hospital stay. His white count at the time of discharge was still elevated at 12 with no clear etiology. Coronary artery disease: The patient was continued on his statin, beta blocker, and ACE inhibitor. His aspirin was placed on hold transiently. It was decided not to reverse his INR as the patient is at high risk for thromboembolic disease. Atrial fibrillation: Even though the patient has a history of AFib, he remained in sinus bradycardia throughout this hospital stay. His amiodarone was continued. Given the patient's history of recurrent instent restenosis while off Coumadin, it was decided to restart his Coumadin on hospital day #2 with a goal to keep his INR between 1.7 and 2. It was also decided to start him on a baby aspirin instead of a full dosed aspirin. Acute renal failure: Patient's initial creatinine at the time of this presentation was 1.4, elevated from his baseline of 1.1, which is thought to be secondary to prerenal azotemia in the setting of diarrhea. After gentle hydration, the patient's creatinine returned to [Location 213] range. At the time of discharge, it had recovered to 0.9. CHF: The patient's weight was checked daily and remained stable for the most part. He had no signs or symptoms of hypoxia or fluid overload. His outpatient Lasix was resumed on hospital day #3. Hematuria: The patient underwent an abdominopelvic CT immediately prior to discharge, which revealed a 1 x 0.6 cm stone in the left ureteropelvic junction. There was no evidence of hydronephrosis visualized. As a result, the patient will be scheduled for an outpatient laser lithotripsy to take care of the stone and resolve his hematuria. Benign prostatic hypertrophy: The patient was continued on his outpatient Flomax when it was deemed that he was hemodynamically stable. Prophylaxis: The patient was initially kept on b.i.d. Protonix IV until he was able to tolerate p.o. He was placed on pneumoboots for adequate DVT prophylaxis until he started ambulating. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg q.d. 2. Lipitor 20 mg q.d. 3. Flomax 0.4 mg q.h.s. 4. Aspirin 81 mg q.d. 5. Coumadin 2 mg q.d. (goal INR 0.7-2). 6. Atenolol 25 mg q.d. 7. Lisinopril 10 mg q.d. 8. Protonix 40 mg q.d. DISCHARGE CONDITION: The patient was discharged in good condition to home. He is to followup with his cardiologist, Dr. [Last Name (STitle) 3302] on [8-27]. He is also to followup with his PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 4844] as well as his urologist, Dr. [Last Name (STitle) 986]. An outpatient laser lithotripsy will be performed by Dr. [Last Name (STitle) 986]. In addition, he is to followup at [Hospital 197] Clinic on [Last Name (LF) 766], [8-18] for an INR check. He is to resume all of his preadmission medications with the only exception being aspirin 81 mg instead of 325 mg q.d. It is important, given his history of diverticular bleeding, that the INR be maintained between 1.7 and 2.0. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437], M.D. [MD Number(1) 2438] Dictated By:[First Name (STitle) 47744] MEDQUIST36 D: [2200-10-6] 19:58 T: [2200-10-10] 10:09 JOB#: [Job Number 94201]	[ "427.31", "428.0", "276.5", "V45.02", "428.22", "414.01", "V45.82", "592.0", "562.12" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]				8847, 9863			3179, 3263		8619, 8825				2945, 3162																					3490, 4404																						162, 2178							4419, 8596							2200, 2919	3280, 3467
41,389	178,922	41967	Discharge summary	report	Admission Date: [2101-9-24] Discharge Date: [2101-9-30] Date of Birth: [2031-7-23] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Known firstname 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2101-9-26] - Coronary artery bypass graft x4 (Left internal mammary 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 first obtuse marginal coronary artery; reverse saphenous vein single graft from aorta to posterior descending coronary artery) History of Present Illness: 70 year old male with hyperlipidemia and Type 2 diabetes has been bothered by several months of exertional chest tightness that has been associated with shortness of breath. This has occured with as little as gardening and seems to respond quickly to SL nitroglycerin. He has not had any discomfort at rest. Recent stress testing has been notable for a large area of ischemia involving the LAD territory. He was found to have coronary artery disease upon cardiac catheterization and is now being referred to cardiac surgery for revascularization. He was originally scheduled for CABG [2101-10-4] and presented [9-24] with repeat chest pain. Past Medical History: Hyperlipidemia Non Insulin dependent diabetes Obesity GERD s/p Appendectomy Social History: Race: Caucasian Last Dental Exam: 2 months ago Lives with: wife Contact: [Name (NI) 91091] [Name (NI) 284] (wife) Phone #[Telephone/Fax (1) 91092] home Occupation: professor [First Name (Titles) ] [Last Name (Titles) 14925]teaching literature Cigarettes: Smoked no [x] Other Tobacco use: has smoked pipes and cigars daily for approximately 15 years. He quit 3-4 weeks ago ETOH: < 1 drink/week [x] Illicit drug use:denies Family History: No premature coronary artery disease Physical Exam: Pulse:65 Resp:18 O2 sat:99/RA B/P Right:154/74 Left:151/74 Height:5'[00]" Weight:220 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] __none___ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [Name (NI) 167]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Right:N Left:N Pertinent Results: Admission Labs: [2101-9-24] 01:00AM PT-11.5 PTT-26.0 INR(PT)-1.0 [2101-9-24] 01:00AM PLT COUNT-232 [2101-9-24] 01:00AM WBC-10.4 RBC-4.36* HGB-13.7* HCT-39.1* MCV-90 MCH-31.4 MCHC-35.0 RDW-13.1 [2101-9-24] 01:00AM CALCIUM-9.6 PHOSPHATE-3.2 MAGNESIUM-2.2 [2101-9-24] 01:00AM cTropnT-<0.01 [2101-9-24] 01:00AM GLUCOSE-145* UREA N-24* CREAT-1.2 SODIUM-141 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17 [2101-9-24] 10:31PM %HbA1c-6.9* eAG-151* [2101-9-24] 11:47PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [2101-9-24] 11:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2101-9-24] 11:47PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.024 Discahrge Labs: [2101-9-29] 05:02AM BLOOD WBC-12.2* RBC-3.86* Hgb-12.1* Hct-33.9* MCV-88 MCH-31.3 MCHC-35.6* RDW-13.4 Plt Ct-183 [2101-9-29] 05:02AM BLOOD Plt Ct-183 [2101-9-26] 01:17PM BLOOD PT-13.9* PTT-31.2 INR(PT)-1.2* [2101-9-29] 05:02AM BLOOD Glucose-125* UreaN-21* Creat-1.2 Na-139 K-4.4 Cl-102 HCO3-29 AnGap-12 [2101-9-24] ECHO: The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Chest CT [2101-9-25]: 1. No acute intrathoracic process. 2. No significant tortuosity of the thoracic aorta, with common trunk of the innominate artery and left common carotid (normal variant). Radiology Report CHEST (PORTABLE AP) Study Date of [2101-9-28] 4:50 PM Final Report: As compared to the previous radiograph, the right-sided chest tube has been removed. There is unchanged appearance of the right lung bases. No evidence of pneumothorax. Mild areas of atelectasis. Moderate cardiomegaly without pulmonary edema. Moderate tortuosity of the thoracic aorta. Brief Hospital Course: Mr. [Known lastname 284] is a 70 year old male who was originally scheduled for coronary bypass grafting on [2101-10-4], he presented to the emergency room on [9-24] with repeat chest pain. He received medical management and was worked up and ruled out for myocardial infarction. On [9-26] he was brought to the operating room where he underwent a coronary artery bypass graft x4. Please see operative report for surgical details. In summary he had: 1. Coronary bypass grafting x4: with Left internal mammary 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 first obtuse marginal coronary artery; reverse saphenous vein single graft from aorta to posterior descending coronary artery. 2. Endoscopic left greater saphenous vein harvesting. 3. Epiaortic duplex scanning. His bypass time was 106 minutes with a crossclamp time of 91 minutes. He tolerated the operation well and 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 beta blockers and diuretics were started. Later on day one he was transferred to the step-down floor for further recovery. One on the floor his post operative course was uneventful, all tubes, lines and epicardial pacing wires were removed per cardiac surgery protocol. The patient worked with physical therapy to increase his activity level and improve endurance. He had bursts of A Fib and was started on amiodarone. His BBlockers were titrated as tolerated hemodynamically, and his oral diabetes meds were resumed. On POD #5 he was discharged home with visiting nurses. He is to follow up with Dr [Last Name (STitle) 914] in one month. Medications on Admission: glipizide - (prescribed by other provider) - 10 mg tablet - 1 tablet(s) by mouth every morning metformin - (prescribed by other provider) - 850 mg tablet - 1 tablet(s) by mouth twice a day metoprolol tartrate - (prescribed by other provider) - 25 mg tablet - 1 tablet(s) by mouth twice a day nitroglycerin - (prescribed by other provider) - dosage uncertain pravastatin - (prescribed by other provider) - 40 mg tablet - 1 tablet(s) by mouth daily every morning isosorbide mononitrate - 30mg tablet - 1 by mouth daily (recently started) medications - otc aspirin - (prescribed by other provider) - 325mg daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day: start PM [9-30]. Disp:60 Tablet(s) Refills:1 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:28 Tablet(s) Refills:0 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 6. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:1 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days: 200 mg [Hospital1 ] through [10-5]; then 200 mg daily starting [10-6]. Disp:60 Tablet(s) Refills:1 9. glipizide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:1 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:5 Tablet(s) Refills:0 11. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day for 5 days. Disp:5 Capsule, Extended Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 4(LIMA-LAD, SVG->OM1,Diag,PDA) postop A Fib PMH: Hyperlipidemia Non Insulin dependent diabetes Obesity GERD s/p Appendectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg - Left - healing well, no erythema or drainage. Edema: trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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 [11-1] @ 2:15 pm [Hospital Ward Name ] [Hospital Unit Name ] Wound check office nurse [Last Name (Titles) ] 2A [10-11] @ 10:00 AM Cardiologist: Dr. [First Name (STitle) ] [Name (STitle) 2257] on [10-14] @ 8:30 AM Please call to schedule appointments with your Primary Care Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 30186] in [5-3] 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:[2101-9-30]	[ "E878.2", "997.1", "250.00", "530.81", "V15.82", "411.1", "278.00", "427.31", "272.4", "414.01", "V45.89" ]	icd9cm	[ [ [] ] ]	[ "36.13", "36.15", "39.61" ]	icd9pcs	[ [ [] ] ]	9209, 9267	5218, 7083	319, 697	9494, 9717	2668, 2668	10557, 11250	1949, 1987		7743, 9186		9288, 9473		7109, 7720			9741, 10534									2002, 2649																			269, 281												725, 1376					2684, 5194									1398, 1475	1491, 1933
29,774	151,162	33850	Discharge summary	report	Admission Date: [2108-6-1] Discharge Date: [2108-6-9] Date of Birth: [2061-9-2] Sex: M Service: MEDICINE Allergies: Tramadol Attending:[First Name3 (LF) 458] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catherization. History of Present Illness: Patient is a 46 year old male with a history of rheumatic heart disease s/p MVR [2095], CAD s/p MI and PCI with EF 25% on recent LV gram, drug abuse, medication non compliance who presented as a transfer from [Hospital6 ] with severe chest pain. . The patient used cocaine at approximately 8am. He reports that the chest pain started in the afternoon worse than his prior episodes, and radiated down both arms. He took 3 nitroglycerine without relief. Patient presented to [Hospital6 33]. HR 97, BP 133/96, 100%RA. EKG showed NSR with nl axis/intervals, prominant T-waves in precordial leads but unchanged from prior studies. Labs were notable for CK 689, MB 72.9, Troponin T 0.32. He was given 325 aspirin, 300mg plavix, metoprolol 5mg IV, morphine 10mg IV x 2, and was started on heparin and nitroglycerin drips. He was transfered for evaluation and possible intervention. . In the emergency room @ [Hospital1 18] his vitals were HR 86, BP 126/83, RR 16 O2sat 98%. Seen by cardiology and desicion was made not to emergently cath but to admit for NSTEMI. IIbIIIa was not administered. He was ruled out for PE/Dissection with a CTA. Of note, his heparin gtt was held during the CTA and while awaiting the read. . Upon arrival to the floor, patient reports continued chest pain. Further review of systems was difficult to obtain as the patient intermitently fell asleep during the history Past Medical History: # Rheumatic Heart Disease s/p MVR - [First Name8 (NamePattern2) ] [Male First Name (un) 923] [2095] - reportedly @ [Hospital1 2177] # CAD - history obtained from [Hospital3 ] Records, not verified -cocaine induced MI [2095] -? MI w/PCI [2104] @ [Hospital1 112] (95% diagonal, 75% circumflex, 80% OM) -Cath @ [Hospital3 ] [12/2107] w/ 100% D1 occlusion, severe ostial OM stenosis. Circumflex w/30% proximal, 40% distal. No sig LM or LAD dz. LV gram showed globally preserved EF @ 55%. Unclear from documentation if these were intervened on @ [Hospital3 ] -Cath @ [Hospital3 ] [3-/2108] w/100%D1, patent stents in circumflex, 65% OM stenosis @ site of prior stent. nl RCA, 30% prox LAD, right dom. EF changed @ that time to 25-33% with global hypokinesis. # Drug Abuse # Hep C (not verified) # Hypercholesterolemia # Anxiety # Depression # GERD Social History: Smokes [12-28] ppd, +etoh, +cocaine. Denies other drug use. Born in [Country 3587], moved to US in [2070]. Lived in [Location 86], but moved to [Location (un) ] recently. Does not have a PCP. [Name10 (NameIs) ] not had his INR checked regularly Family History: Non-contributory Physical Exam: VS: T 96.4, BP 118/80 , HR 86 , RR 16, O2 100% onRA Gen: sleepy, but arousable HEENT: poor dentition, white coating noted around oropharynx CV: RRR mechanical s1 noted when auscultating over mitral position RESP: CTA b/l ABD: soft, NT/ND, no masses EXT: no stigmata of distal embolization NEURO: CN intact II-XII, strength preserved upper and lower extremities, finger to nose testing showed no ataxia. Pertinent Results: ========== CARDIOLOGY ========== EKG demonstrated Sinus rhythym, nl axis, left atrial abnormalitiy, prominent T-waves in precordium. . TELEMETRY demonstrated: reportedly 7 beat run of ventricular tachycardia on tele in ED. . =============== LABORATORY DATA =============== ADMISSION LABORATORIES Sodium 141 Potassium 4.0 Chloride 105 HCO3 21 BUN 8 Crt 1.0 Glucose 102 AGap=19 CK: 799 MB: 106 MBI: 13.3 Trop-T: 0.44 CBC: 10.4>36.8<342 N:67.4 L:25.5 M:5.1 E:1.5 Bas:0.6 PT: 14.5 PTT: 135.7 INR: 1.3 . ========= RADIOLOGY ========= Chest X-ray: CHEST: Patient is status post median sternotomy and CABG. The cardiac, mediastinal and hilar contours are normal. There is slight crowding of the pulmonary vasculature likely secondary to low lung volumes. The lungs are otherwise clear without consolidation or edema. There is no pleural effusion or pneumothorax. Surgical clips are seen in the mid abdomen. IMPRESSION: Low lung volumes. No radiographic evidence of pneumonia or CHF. Brief Hospital Course: # CAD/Ischemia: The patient presented with an NSTEMI in setting of cocaine abuse. While acute plaque rupture, stent thrombosis, in-stent restenosis or thrombus form mitral valve also possible, desicion was made for non-urgent cath as pain was controlled, and EKG without acute ST elevations or change from prior. Heparin drip and ASA 325 mg PO daily was continued. The patient was also administered plavix 75mg po daily. A low dose ACE-I was started. Home metoprolol was held given risk of unopposed alpha adrenergic stimulation with a beta-blocker. The decision was subsequently made to go to the cath lab. Cath showed LCX 100% occluded at site of prior stent and had POBA at the site. His D1 was totally occluded at the site of the prior stent. He remained on aspirin and plavix. Labetolol was ultimately started. . # Pump: EF per prior records is depressed. There were no clinical or radiographic signs of failure on admission. ECHO was done post cath which showed mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with akinesis/dyskinesis of the basal halves of the inferior and inferolateral walls. The remaining segments contract well (LVEF 35%). . # Valves: Patient has a history of MVR. He was continued on a heparin drip as a bridge to coumadin. He remained in the hospital until his INR was therapeutic (goal 2.5-3.5) and follow up was arranged in coumadin clinic for ongoing monitoring on discharge. He was discharged on coumadin 5mg daily. . # Splenic infarct on CT Likely due to embolic event possibly d/t emboli from mechanical valve on non-therapeutic anticoagulation, unclear if acute. No further intervention done as pt remained asymptomatic and labs were wnl. . # Pain: Pt complained of a headache. Patient reported headache which has been intermittent during hospital stay. Normal neurologic exam. Upon further discussion patient revealed that he has a history of head trauma with baseball bat several years ago, and has had headaches since that time. Headaches may last for minutes to days, come and go. He has had prior head imaging as well. CT head was within normal limits. Attempted to use non-narcotics (Ultram), however patient reports itching to this medication. Will aim to arrange follow-up with new PCP, [Name10 (NameIs) 1023] may then coordinate any treatment for migraines versus neurology follow up. Pt was given tylenol #3 while in house for pain control. Medications on Admission: *per patient med list, unclear if taking Coumadin 5mg/10mg (unclear how he takes it) [Name (NI) *] 80mg po Qday Lisinopril 40mg po Qday nitro 0.4sl prn HCTZ 25mg po Qday Ultram 50mg po prn Imdur 30mg po Qday Toprol XL 100mg po Qday ASA 81 mg po qday MVI, Folic Acid, Thiamine Prilosec 20mg po BID nicotine patch celexa 20mg po Qday Naproxyn 500mg po BID Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:2 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed): Take for chest pain, if no response, may repeat twice, if no improvement, please call 911. Disp:30 Tablet, Sublingual(s) Refills:2 5. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:2 7. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed: As needed for headache. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary diagnosis: - NSTEMI Secondary diagnoses: - Cocaine use - Mitral valve replacement - Coronary artery disease Discharge Condition: Stable, ambulating without any difficulties. Discharge Instructions: You were admitted after having chest pain, and had evidence of a heart attack. You underwent cardiac catherization and a balloon was used to open one of your arteries. It was also found that your coumadin level (INR) was low, and you were treated with heparin until it was at the goal level to protect your mechanical valve. . It is VERY important that you continue to take you coumadin (for protection of your heart valve), aspirin, and Plavix. Do NOT stop these medications unless instructed by your cardiologist. If you do not take your aspirin or Plavix, you are at risk of another heart attack, or even death. It is also very important that you not use cocaine, as it can cause further heart damage and heart attacks. . Several medication changes have been made: - Labetalol has been started for your blood pressure and heart rate, 100 mg twice daily. - Plavix 75 mg daily to keep your heart stents open. - Aspirin 325 mg daily - Coumadin (also called Warfarin) 10 mg daily. You need to have levels of this monitored weekly by Dr.[Name (NI) 78237] office. - Atorvastatin 80 mg for your cholesterol. - Tylenol #3 for your headaches. - Other medications, such as HCTZ, Toprol XL, Lisinopril, Imdur, and Naproxyn have been stopped. . Based on the echocardiogram of your heart and your valve replacement, and endocarditis prophylaxis recommendations, prophylaxis with antibiotics prior to any dental procedures IS recommended. . Please contact your cardiologist, primary care physician, [Name10 (NameIs) ] go to the emergency room if you experience any chest pain, shortness of breath, bleeding, fevers, weight gain more than 2 pounds in one day, leg swelling, or other concerning symptoms. . Please follow up at an appointment made for you in the cardiology department with Dr. [Last Name (STitle) 78238] [Name (STitle) ] (you saw her in [Month (only) 116]). Her office is located on [Street Address(2) 52499] in [Location (un) ], [Numeric Identifier 31449]. The phone number for her office is ([2070], and her fax number is ([Telephone/Fax (1) 78239]. . An appointment has been made for you at 11:30 AM, on Friday [6-15]. Her office will follow your INR (Coumadin level). . You should establish a primary care provider in your home town. You may call any of the following locations to set up an appointment: ([Telephone/Fax (1) 32468] [Hospital3 ]; ([Telephone/Fax (1) 78240]; [Hospital 3501] Medical Foundation ([Telephone/Fax (1) 57366], or [Hospital ] Community Health Center in [Location (un) 7913] ([Telephone/Fax (1) 78241]. Followup Instructions: Please follow up at an appointment made for you in the cardiology department with Dr. [Last Name (STitle) 78238] [Name (STitle) ] (you saw her in [Month (only) 116]). Her office is located on [Street Address(2) 52499] in [Location (un) ], [Numeric Identifier 31449]. The phone number for her office is ([2108], and her fax number is ([Telephone/Fax (1) 78239]. . An appointment has been made for you at 11:30 AM, on Friday [6-15]. Her office will follow your INR (Coumadin level). . You should establish a primary care provider in your home town. You may call any of the following locations to set up an appointment: ([Telephone/Fax (1) 32468] [Hospital3 ]; ([Telephone/Fax (1) 78240]; [Hospital 3501] Medical Foundation ([Telephone/Fax (1) 57366], or [Hospital ] Community Health Center in [Location (un) 7913] ([Telephone/Fax (1) 78241].	[ "410.71", "070.70", "444.89", "V45.82", "300.4", "346.90", "V58.61", "427.1", "V43.3", "414.01", "412", "V15.81", "305.60", "272.0", "305.1" ]	icd9cm	[ [ [] ] ]	[ "88.56", "00.66", "00.40", "37.22" ]	icd9pcs	[ [ [] ] ]	8229, 8280	4415, 6913	277, 302	8440, 8487	3413, 4392	11145, 12056	2957, 2975		7323, 8206		8301, 8301		6939, 7300			8511, 11122									2990, 3394	8350, 8419																		226, 239												330, 1736						8320, 8329								1758, 2654	2670, 2941
52,482	178,517	53155	Discharge summary	report	Admission Date: [2167-4-27] Discharge Date: [2167-5-2] Date of Birth: [2106-7-14] Sex: M Service: CARDIOTHORACIC Allergies: Latex Gloves Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2167-4-27] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending artery, and saphenous vein grafts to obtuse marginal and posterior descending arteries. History of Present Illness: Mr. [Known lastname 11791] is a 60 year old male with multiple cardiac risk factors. Over the last several months, he admitted to chest pain with minimal exertion. His chest pain did improve with sublingual Nitroglycerin. He underwent elective cardiac catheterization which revealed severe three vessel coronary artery disease. Preoperative echocardiogram showed an ejection fraction of 55%. Given the above results, he was referred for surgical revascularization. Past Medical History: Coronary Artery Disease Hypertension Type II Diabetes Mellitus Dyslipidemia Chronic Renal Insufficiency Gastroesophogeal Reflux Disease Left Shoulder Arthritis/Rotator Cuff Injury History of Detached Retina Social History: Lives with wife. Several children, present at bedside. Smoked a few cigs/day for 2-3 years, stopped in [2117]. Works at [Hospital1 18] in environmental services. He only rarely drinks beer once in a while for holidays. Family History: Parents with CAD in their 70s. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Vitals: bp 145/68 hr 50 General: well appearing male in no acute distress Skin: unremarkable HEENT: oropharynx benign Neck: supple, no jvd Chest: lungs clear bilaterally Heart: regular rate and rhythm, normal s1s2, no murmur or rub Abdomen: benign Ext: warm, no edema Neuro: non-focal Pulses: 1+ distally, no carotid or femoral bruits Pertinent Results: [2167-4-27] Intraop TEE: PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%).Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in thedescending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylehrine at 0.3mcg/kg/min. Thoracic aorta is intact.Mild MR [First Name (Titles) ] [Last Name (Titles) ]. LVEF 55%. Normal RV systolic funciton. [2167-5-1] 05:25AM BLOOD WBC-8.8 RBC-3.08* Hgb-9.1* Hct-27.8* MCV-90 MCH-29.6 MCHC-32.9 RDW-14.3 Plt Ct-219# [2167-5-1] 05:25AM BLOOD Glucose-131* UreaN-19 Creat-1.2 Na-137 K-4.4 Cl-97 HCO3-29 AnGap-15 [2167-5-1] 05:25AM BLOOD Mg-2.3 Brief Hospital Course: Mr. [Known lastname 11791] was admitted and underwent coronary artery bypass grafting surgery by Dr. [Last Name (STitle) 914]. Given he was a same day admit, Cefazolin was used for perioperative antibiotic coverage. For surgical details, please see operative note. Following the procedure, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. His CVICU course was otherwise uneventful and he transferred to the telemetry floor on postoperative day one. Chest tubes and pacing wires were removed without complication. On POD#4 Mr. [Known lastname 11791] developed brief episode of self-limiting Afib. He was staretd on po amiodarone and has maintained NSR. He was discharged in good conditon on POD 5. Medications on Admission: Zestoretic 20/12.5 tabs, 2 daily Metformin 500 daily Toprol XL 100 daily Nambutone 750 daily Protonix 40 daily Nitro prn Aspirin 81 daily Simvastatin 40 daily Tylenol #3 prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day for 2 weeks. Disp:28 Tablet Sustained Release(s) Refills:0 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. Nabumetone 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. 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 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): 400mg 3x/day x 7 days, then 400mg 2x/day x 7 days, then 400mg/day x 7 days, then 200mg daily until further instructed . Disp:180 Tablet(s) Refills:2 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease, s/p CABG Hypertension Type II Diabetes Mellitus Dyslipidemia Chronic Renal Insufficiency Discharge Condition: Good Discharge Instructions: - Shower daily, no baths or swimming - No lotions, creams or powders to incisions - No driving for at least 4 weeks and off all narcotics - No lifting more than 10 pounds for 10 weeks - Report any redness or drainage from incisions - Report any fever greater than 100.5 - Report any weight gain greater than 2 pounds a day or 5 pounds a week - Take all medications as directed Followup Instructions: Dr. [Last Name (STitle) 914] in [4-5] weeks, call for appt Dr. [Last Name (STitle) 1789] in [2-3] weeks, call for appt Wound check on [Hospital Ward Name 121] 6 in 2 weeks Completed by:[2167-5-2]	[ "272.4", "530.81", "427.31", "414.01", "403.90", "411.1", "250.00", "585.9" ]	icd9cm	[ [ [] ] ]	[ "39.61", "36.12", "36.15" ]	icd9pcs	[ [ [] ] ]	5878, 5936	3250, 4049	288, 510	6094, 6101	2017, 3227	6526, 6748	1500, 1646		4273, 5855		5957, 6073		4075, 4250			6125, 6503									1661, 1998																			238, 250												538, 1008														1030, 1239	1255, 1484
51,027	172,000	2950	Discharge summary	report	Admission Date: [2165-1-10] Discharge Date: [2165-1-26] Date of Birth: [2094-11-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2751] Chief Complaint: hypoglycemia/ARF Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 12543] is a 70 yo M with DM2 and CKD baseline Cr 3.5-4.2 up to 9.0 [6-28] not on dialysis found by family to be altered with hypoglycemia now with ARF. He was given orage juice and milk by family. Pt vomited, unable to hold down food and fluid. [Hospital ]hosp fsbs 38, got 1mg IM glucagon. Repeat FSBS 58. Has not seen PCP [Name Initial (PRE) 14169] [6-28]. Has been feeling in normal state of health up until today. His medications have been managed by a nurse and one of his sons. H . In ED 95.4 51 146/100 17 96% on RA found to be cool and dry and awake to voice. Pt has chronic edema, noted to be worsening. CXR found new left sided pleural effusion. Prior to leaving ED,9 7.2 52 125/77 17 100% on RA. Access 22 and 18 G access. Got 700cc IV. EKG sinus brady, TWI in v4-v6. Per ED makes urine. BCx drawn. . Currently, patient feels well. He denies chest pain, shortness of breath, cough, fever, chills, nausea/vomiting or abdominal pain. Endorsed diarrhea that started this am. He says he feels cold but usually feels this way. He denies orthopnea and PND. He is wheelchair bound at baseline. Patient was informed of kidney failure and refused to accept dialysis. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -5/08 L BKA for gangrene -DM2 -Hypertension -CKD baselin 3.5-4.2, up to 9 in [6-28] -blindness -neuropathy, possibly demyelinating polyneuropathy -systolic CHF EF 50% as of [4-28] Social History: originally from [Location (un) 4708]. Remoted history of smoking in 20s and rare alcohol use. Denies drugs. Wheelchair bound, has nurse visit 3x/day and supportive family Family History: 2 sons with DM2, one who died from MI Physical Exam: Vitals - T: rectal BP:150/88 HR:79 RR:16 02 sat:97%RA GENERAL: Pleasant, frail and chronically ill elderly male in NAD HEENT: Normocephalic, atraumatic. + conjunctival pallor. Left eye sealed shut. No scleral icterus. Unable to assess pupils [1-22] blindness. dryMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or gallops. JVP=jaw 14cm water LUNGS: crackles b/l bases, decreased BS b/l ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: Anasarca, 2+ edema throughout body including forearms and abdomin. L knee bka. Ext cool throughout. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact except blindess and EOMI. Preserved sensation throughout. 5/5 strength throughout. 1+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Rectal: guaic neg brown stool GU: Extreme scrotal edema Pertinent Results: [2165-1-10] 04:20PM POTASSIUM-5.4* [2165-1-10] 12:40PM URINE EOS-POSITIVE [2165-1-10] 12:39PM URINE HOURS-RANDOM UREA N-460 CREAT-69 SODIUM-39 [2165-1-10] 12:39PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.011 [2165-1-10] 12:39PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2165-1-10] 12:39PM URINE RBC-0-2 WBC-[2-22] BACTERIA-FEW YEAST-FEW EPI-0-2 [2165-1-10] 12:39PM URINE GRANULAR-0-2 [2165-1-10] 12:39PM URINE AMORPH-MOD [2165-1-10] 12:25PM POTASSIUM-6.8* [2165-1-10] 12:25PM CK(CPK)-677* [2165-1-10] 12:25PM CK-MB-15* MB INDX-2.2 cTropnT-0.47* [2165-1-10] 08:35AM %HbA1c-6.5* [2165-1-10] 06:30AM K+-4.7 [2165-1-10] 06:20AM GLUCOSE-80 UREA N-101* CREAT-11.1* SODIUM-144 POTASSIUM-4.9 CHLORIDE-112* TOTAL CO2-12* ANION GAP-25* [2165-1-10] 06:20AM ALT(SGPT)-63* AST(SGOT)-58* LD(LDH)-335* CK(CPK)-430* ALK PHOS-211* TOT BILI-0.3 [2165-1-10] 06:20AM CK-MB-11* MB INDX-2.6 proBNP-[Numeric Identifier 14170]* [2165-1-10] 06:20AM ALBUMIN-3.3* CALCIUM-6.7* PHOSPHATE-7.5* MAGNESIUM-2.4 IRON-46 [2165-1-10] 06:20AM calTIBC-173* FERRITIN-174 TRF-133* [2165-1-10] 06:02AM GLUCOSE-339* LACTATE-1.6 K+-7.4* [2165-1-10] 05:55AM GLUCOSE-354* UREA N-102* CREAT-11.1# SODIUM-137 POTASSIUM-9.4 CHLORIDE-108 TOTAL CO2-15* ANION GAP-23* [2165-1-10] 05:55AM estGFR-Using this [2165-1-10] 05:55AM cTropnT-0.44* [2165-1-10] 05:55AM CALCIUM-6.9* PHOSPHATE-8.2# MAGNESIUM-2.6 [2165-1-10] 05:55AM WBC-5.5 RBC-3.80 HGB-9.5* HCT-31.4* MCV-82 MCH-24.9* MCHC-30.2* RDW-18.0* [2165-1-10] 05:55AM NEUTS-64 BANDS-0 LYMPHS-26 MONOS-8 EOS-1 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [2165-1-10] 05:55AM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-3+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ TARGET-1+ SCHISTOCY-1+ BURR-2+ TEARDROP-1+ BITE-OCCASIONAL ACANTHOCY-OCCASIONAL ELLIPTOCY-1+ [2165-1-10] 05:55AM PLT SMR-NORMAL PLT COUNT-320 LPLT-2+ . MICROBIOLOGY: [1-9] bcx pending, urine culture . Cdiff: negative . EKG: sinus bradyarrhythmiaat 55, NA, QT prolonged, TWI in I, II, L, F, V4-V6 that are unchanged from prior. No ST changes. repeat low voltages in limb leads, small Q in III and AvF,Twave now flat in II . [1-10] CXR Large left and moderate right pleural effusions are new from [2161]. Enlargement of the cardiac silhouette may indicate a pericardial effusion. Retrocardiac opacity is concerning for infection. Irregularity of the left aspect of the trachea may indicate an invasive lesion. Hilar contours appear normal. [1-16] CXR: The current study demonstrates unchanged bilateral pleural effusions and bibasal opacities, left more than right that might represent a combination of atelectasis and infectious process potentially hidden by combination of pleural effusion and atelectasis. Cardiomediastinal silhouette is stable. Note again is made of the significant deviation of the trachea to the right with focal narrowing of the AP diameter of the trachea up to 9 mm compared to 24 mm below that point, findings that can be seen dating back to [2162-5-7], but significantly increased since then and might be consistent with enlarging thyroid lesion in the left lobe of the thyroid as well as other potentially present upper mediastinal process, correlation with thyroid ultrasound and chest CT is highly required . here is no pneumothorax. There is no interval progression of pulmonary edema. . [1-10] Echo: The left atrium is moderately dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 30-35%). The estimated cardiac index is depressed (<2.0L/min/m2). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([12-22]+) aortic regurgitation is seen. The is mild (1+) mitral regurgitation. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Moderate symmetric LVH with moderate to severe biventricular systolic dysfunction. Mild to moderate aortic regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [2162-5-11], right ventricle has dilated. Biventricular systolic function has significantly deteriorated and there is more polyvalvular regurgitation. There is now moderate pulmonary hypertension. Are there clinical features to suggest an infiltrative process, such as amyloidosis? CT HEAD: ([2165-1-14]) FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, or acute infarction. The [Doctor Last Name 352]-white matter differentiation is preserved. The ventricles and sulci are stable in caliber and configuration, emonstrating prominence most compatible with atrophic change. There is periventricular hypodensity, compatible with chronic small vessel ischemic changes. The basal ganglia do not demonstrate hypodensity that would be concerning for a global anoxic event. There are atherosclerotic calcifications involving the bilateral internal carotid arteries and vertebral arteries. Visualized portions of the paranasal sinuses are well aerated. Redemonstrated are post- surgical changes involving the right orbit. IMPRESSION: No intracranial hemorrhage or evidence of acute infarction. Brief Hospital Course: Mr. [Known lastname 12543] is a 70 yo M with DM2 and CKD baseline Cr 3.5-4.2 up to 9.0 [6-28] not on dialysis who presented with altered mental status, hypoglycemia, and acute on chronic renal failure. . # PEA arrest and Unresponsive episodes: Initial episode remains of unclear etiology. Patient was not intubated and responded quickly to ACLS protocol. Second episode felt to be secondary to sensitivity to narcotics and compazine. Although there were conflicting resports regarding absence of a pulse during one of these episodes, the patient was noted to be hypertensive at time of code team arrival. The second episode also coincided with narcotic medication use (oxycodone) and post prandial period. Patient was intubated for airway protection on both ocasions however was quickly extubated. It is unclear if this was due to metabolite accumulation of narcotics (although oxycodone is not renally cleared) and naloxone was not given during uresponsive event. On [2165-1-14] patient was noted to be bradycardic, hypopneic and hypertensive. CT head was unremarkable and no other cause of events was found. Patient was re-extubated on [1-15] without difficulty but had some recurrent episodes of depressed mental status where he was minimally responsive but hemodynamically stable and without any arrythmia or secondary metablic derrangement. Other etiologies on the differntial for unresponsive episodes were seizures vs. apneic episodes (MICU documented 8 second apneic episodes with desats to 70%). Thorough workup was performed including serial ABG's which revealed mild CO2 retention during the day. Night time CPAP was intiated, but soon discontinued secondary to patient refusal. Hemodialysis was also initiated during the admission, and narcotics/sedating medications avoided. In this context, the patient's mental status improved back to baseline and he had no have further unresponsive episodes. . # Acute on Chronic Kidney Disease: Patient presented with severely depressed renal function during this hospitalization with severe volume overload and with metabolic acidosis refractory to lasix. He initially refused initiation of hemodialysis. However, after several family meetings HD was started via Tunneled RIJ placed on [2164-1-15]. The patient continued to refuse hemodialysis intermittently during the course of his hospitalization. However, he did agree to continue with outpatient dialysis at discharge. He was discharged with a plan for outpatient dialysis on a Tu/[Doctor First Name ]/Sat schedule to by followed by Dr. [Last Name (STitle) 118] of nephrology. . # Hypoxemia: The patient had an intermittent O2 requirement during the hospitalization, thought to be secondary to severe fluid overload and pulmonary edema. CXR showed bilateral pleural effusions that improved slightly with several sessions of dialysis. However, given the degree of fluid seen on CXR, it was difficult to distinguish whether patient also had concurrent mass or consolidation. The patient should have repeat CXR in 6 weeks to reexamine lung fields after significant fluid removal is accomplished with dialysis. At discharge, the patient's oxygen saturation was in the mid-90s on room air. Oxygen saturation monitors were felt to be most accurate on the forehead or earlobe; monitors on the fingers would consistently show decreased saturation with poor plethysmograph. . # Thyroid mass - large left mediastinal mass extending from left lobe of thyroid was initially discovered on CXR and further evaluated with CT. Thyroid function tests were within normal limits. Patient was provided with any appointment for an outpatient thyroid biopsy at discharge. . # Penile and Scrotal pain: At admission the patient complained of scrotal pain that was felt to be secondary to significant scrotal edema from fluid overload. His scrotal edema responded well to fluid removal with dialysis, and was improved at discharge. He was initially evaluated by urology in the MICU, who felt there was no evidence of penile or scrotal ischemia but he did have a glans ulcer. This was treated with bacitracin ointment, and healed well. However, toward the end of his hospitalization, the patient had developed dry gangrene of the penile head. Urology again evaluated the patient, and did not feel that any surgical intervention was indicated. Urology . # Hypoglycemia: Likely occurred in setting of lantus not being cleared well by failing kidneys. Patient did not experience any further episodes of hypoglycemia during hospitalization. # Anemia: Hct at baseline ~30, no signs of bleeding, likely [1-22] chronic disease. Guaic negative. Iron studies consistent with anemia of chronic disease, and no evidence of concurrent iron deficiency. The patient received epogen with dialysis, to be continued at discharge. . # HTN: Patient was intermittently hypertensive this admission, thought to be chiefly secondary to massive fluid overload. Antihypertensive medications were held during the per-code period, and restarted thereafter. He was titrated up to metoprolol 25 mg [Hospital1 ] and Amlodipine 10 mg daily ad discharge. . # CHF EF now 30-35%: Repeat echo on admission showed worsening heart biventricular heart failure. Has polyvalvular regurgitation as a result. HE was continued on ASA 325, Metoprolol and amlodipine. He was not started on ACE-I this admission given his decompensated renal failure. . # DM2: Last A1c<7%, likely improved control with worsening renal failure and poor clearance of lantus. Lantus was initially held secondary to hypoglycemia at admission and patient maintained on HISS. Prior to discharge, patient was restarted on low dose lantus once daily, with HISS to continue QID. . # Nausea/vomiting: The patient had persistent nausea and vomiting early in hospitalization, likely secondary to uremia. He was treated with antiemetics, and CT head was unrevealing. Nausea and vomiting improved with dialysis and he was symptom-free at discharge. . # Transaminitis: LFTS elevated likely [1-22] to congestive hepatopathy. Theses were trended and were stable. Viral hepatitis panel was negative for hepatitis B and C. . # HL: continued on home atorvastatin. . # CODE: FULL confirmed in family meeting, . # CONTACT: HCP son [Name (NI) 14171] [Telephone/Fax (1) 14172] Medications on Admission: AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day for pressure ASPIRIN - 325 MG TABLET (ENTERIC COATED) - TAKE ONE TABLET EACH DAY ATORVASTATIN [LIPITOR] - 40 mg Tablet - [12-22] Tablet(s) by mouth once a day for cholesterol FUROSEMIDE [LASIX] - 40 mg Tablet - 3 Tablet(s) by mouth qam IBUPROFEN - 600 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for pain Same as MOTRIN INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 35 q am INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - sliding scale before breakfasst, lunch and supper sugar greater than 150 give 6 units BS >200 give 8 units BS>250-300 give 10 units METOPROLOL SUCCINATE [TOPROL XL] - 200 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day ONE TOUCH ULTRA MINI - - test Three times daily ONE TOUCH ULTRA MINI TEST STRIPS - - test blood sugar three times a day no substitution SOCK SHRINKER - - use once a day for fluid one for foot, one for bka leg Medications - OTC ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - take one Tablet by mouth daily Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO once a day. 4. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale units Subcutaneous four times a day. Disp:1 vial Refills:2 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Insulin Glargine 100 unit/mL Solution Sig: Two (2) Subcutaneous once a day: can give either in AM or PM (whenever is convenient for family dispensing medication). Disp:1 vial Refills:2 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: Acute on chronic renal failure Biventricular systolic heart failure Anasarca Hypoglycemia . Secondary: Diabetes Mellitus Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to the hospital because of low blood sugars. We found you to had a lot of extra fluid on your body and that you had heart failure and kidney failure. You were initiated on dialysis in order to treat your overall fluid overload. Additionally, we made some adjustments to your outpatient medications. . You are scheduled for dialysis on a Tuesday/Thursday/Saturday schedule. It is EXTREMELY important that you go to all of your dialysis appointments. Missing dialysis could result in difficulty breathing, abnormal electrolytes and even death. . . Medication changes: 1) Decrease lantus and humalog sliding scale; please see medication list for details. Please record finger stick values four times daily for the next week and bring values to your next PCP appointment with Dr. [Last Name (STitle) 11528]. 2)We started you on nephrocaps (B Complex-Vitamin C-Folic Acid) daily 3)Start Ranitidine 150 mg daily for reflux symptoms. 4)Please stop the ibuprofen as it can damage your kidneys. You may use tylenol as needed for pain. 5)We decreased your Toprol XL to 50 mg daily. 6)Please stop Lasix and any other diuretics that you may have taken in the past. All other medications remain unchanged. . If you develop any of the warning signs listed below or any other symptom that is concerning to you, please call your primary care doctor or got your local emergency room. Followup Instructions: Appointment #1 MD: Dr [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) 11528] Specialty: Primary Care Date/ Time: [2167-2-5]:15pm Location: [Hospital1 ], CHC [Hospital1 14173]Phone number: [Telephone/Fax (1) 7976] . Your Kidney specialist, Dr. [Last Name (STitle) 118] will see you during dialysis. He can also be reached at ([Telephone/Fax (1) 10135]. . Thyroid Nodule [Hospital 14174] Clinic, 10:30 AM Thursday [2-14] [Location (un) ] [Hospital Ward Name 23] Building with Clinical Specialties Dr. [Last Name (STitle) 5182]	[ "V02.54", "272.4", "250.80", "782.3", "584.9", "427.5", "794.31", "428.0", "585.6", "285.21", "787.01", "V58.67", "608.9", "428.22", "786.6", "564.00", "790.4", "607.9", "348.30", "E932.3", "276.2", "403.11" ]	icd9cm	[ [ [] ] ]	[ "39.95", "96.38", "38.95", "38.91", "99.60" ]	icd9pcs	[ [ [] ] ]	18142, 18199	9217, 15559	333, 340	18373, 18373	3301, 8355	19961, 20553	2252, 2291		16679, 18119		18220, 18352		15585, 16656			18543, 19110									2306, 3282																19130, 19938			277, 295												368, 1832		8364, 9194						18387, 18519						1854, 2043	2059, 2235
11,276	108,792	13449	Discharge summary	report	Service: Date: [2117-6-3] Surgeon: [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] DATE OF ADMISSION: [2117-6-3]. DATE OF DISCHARGE: [2117-7-5]. HISTORY OF THE PRESENT ILLNESS: The patient is an 84-year-old male with known aortic stenosis, who came in with acute exacerbation of his symptoms requiring admission. He underwent an echocardiogram and he is scheduled for an AVR. PAST MEDICAL HISTORY: History is significant for mitral valve prolapse, aortic stenosis, hypertension, status post cholecystectomy and appendectomy, status post tonsillectomy, adenoidectomy, macular degeneration, and recent onset chronic atrial fibrillation and congestive heart failure. MEDICATIONS AT HOME: 1. Dyazide once a day. 2. Quinine p.r.n. for cramps. 3. Lopressor 12.5 mg b.i.d. 4. Protonix 40 mg once a day. 5. Coumadin 2.5 mg every day. The patient's echocardiogram in [2117-4-5], had an ejection fraction of 45% to 55%. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient is a former smoker with 20 pack- per-year-history. PHYSICAL EXAMINATION: On initial examination, he was a pleasant elderly male. Chest was clear, irregular heart rate with bilateral 1+ to 2+ pitting edema and no JVD. The patient was admitted to the Cardiothoracic Surgery Service, Dr. [Last Name (Prefixes) 40779] for AVR. The patient underwent AVR on [2117-6-4]. He underwent an AVR with #23 CE pericardial valve and a TV repair using a #32 CE ring. Bypass time: 112 minutes. Cross-clamp time: 63 minutes. The patient was postoperatively transferred to the Cardiothoracic Intensive Care Unit, A-paced with a rate of 82 beats per minute requiring Neo-Synephrine for pressor support. The patient was transfused several units of blood cells and FFP on the day of operation. TEE immediately within the perioperative area showed normal systolic function and a dilated RV. The patient was still intubated on postoperative day #1 and on pressor support. On postoperative day #2, he was weaned off pressors and thus sedated. Chest tubes were discontinued. He was weaned and on [6-6], [2117], postoperative day #2, he was extubated. Cardiovascularly, he remained in atrial fibrillation, which he was in preoperatively for which he was receiving Amiodarone. On postoperative day #3, [2117-6-7], the patient still required some .................... for pressor support. Renal function and pulmonary function were within normal limits at this time. On postoperative day #4, [2117-6-8], the patient had Amiodarone restarted, p.o. basis as well as a drip. By postoperative day #5, we had noticed a bump in the creatinine to 1.2. We will continue aggressive diuresis using Lasix. The patient was having fluid overload. EP was consulted regarding for TE, which showed no evidence of a thrombus. We obtained consent for cardioversion. The Pulmonary Department was consulted on [2117-6-9] for pulmonary status. This showed interstitial space disease. At that time, the Pulmonary Service [2117-6-9] thought that this was due to a fluid overload on top of his disease. They continued aggressive diuresis of the patient. On [2117-6-10], the patient was, despite cardioversion, back in atrial fibrillation. The patient was, at this point, intubated due to reversing respiratory status and sedated. He was, at this point, on a procainamide drip to attempt control of the atrial fibrillation. Lasix drip was continued in attempt to aggressively diurese him. We were attempting to wean him off pressor support. The Electrophysiology Service agreed with our procainamide. We continued to have difficulty ventilating him. The Pulmonary Department was following and agreed with our management. On postoperative day #7, [6-11], [2117], the patient was stable. Plan remained the same. The Department of Nutrition was involved and tube feeds were started at 30 cc an hour previously. We were attempting goal rate of ....................calories using tube feeds. The Pulmonary Department continued to follow, Electrophysiology Service as well. On postoperative day, [2117-6-12], the patient remained in atrial fibrillation and sedated. The patient was, at this point, on heparin drip secondary to atrial fibrillation. Pulmonary consultation was called. They continued to follow. We were attempting to extubate the patient and weaning his respiratory support. On postoperative day #9, [2117-6-13], we stopped the Lasix and started Bumex, which increased his urine output. He still required pressor support. Tube feeds were taken to goal. With aggressive diuresis, we noticed that the creatinine had jumped as high as 1.6 during this postoperative period. On postoperative day #10, the patient was doing better on [6-14]. He still required Nitroglycerin support. We continued diuresing with Lasix. At this point, the creatinine was done to 1.1. The atrial fibrillation continued and we were continuing to anticoagulate the gentleman. The Department of Nutrition continued to follow the patient and advised. On postoperative day #11, [2117-6-15], the patient's mental status was improving. EF was better with invasive monitoring. We were able to reduce his pressor support down to 5. He had a lowered requirement from 0.8 to 0.4. On postoperative day #12, the patient continued on heparin drip and on tube feeds and Ceftazidime and Lovenox for prior diagnosed sputum infection. The patient remained intubated. Mental status was improving. Chest x-ray showed feeding tube remaining in the stomach. He had interstitial lung disease with worsening. Of note, the creatinine was stable at 1.1. The vasopressor support was continuing. On postoperative day #13, [2117-6-17], the patient remained in atrial fibrillation. The patient remained intubated and pressor support was done, reconsidered extubation. He was still on heparin drip tube feeds. Neo was weaned off slowly. On postoperative day #14, [2117-6-18], the patient was in atrial fibrillation again. The patient still had copious secretions. Pressor-support ventilation, we were unable to extubate. The patient was anticoagulated well. The patient is now receiving free water. Creatinine was stable at 0.9. On postoperative day #16, [2117-6-20], the patient continued with Ceftazidime and heparin drip, nourishes. The patient was extubated. Wires were discontinued. heparin was continued. The patient was doing well. Ceftazidime and Levofloxacin were continued. The Speech Department was consulted on the 17th. They cautioned us regarding allowing him p.o. intake. Of note, during the rest of the hospital stay, the patient was evaluated and it was thought he would not be able to tolerated p.o. On postoperative day #18th, the respiratory status was tenuous. The patient was continued on the Ceftazidime. We continued the Ceftazidime and Levofloxacin. Pulmonary consultation was called for question of chest CT, repeat sputum cultures, chest PT. PT was involved in his care at this point. On [6-17], [2117], at this point, he had failed a swallow evaluation and he was being diuresed. Respiratory status remained tenuous. Kidney function was okay. We continued him Amiodarone and heparin. We discontinued the Levofloxacin and Ceftazidime. On postoperative day #20, [2117-6-24], the patient was stable with aggressive pulmonary toilet. The heparin drip was continued. On the 20th, we attempted a percutaneous endoscopic gastrectomy, which was unsuccessful. On postoperative day #21, we continued aggressive respiratory status. The Department of Neurology was consulted on [2117-6-25] for confusion. They felt that the patient had mild encephalopathy possibly due to an increasing sodium, which at this point, had reached 150, and asked us to consider doing MRI to rule out any further pathology. On postoperative day #22, [2117-6-26], the patient was continued on heparin and SSRI. We continued diuresing with Bumex. We started the patient on Diflucan for yeast in the sputum. On [2117-6-28], the patient was stable. No changes were made. .................... was asked to see him again seen and it was decided that the patient would not be able to take p.o.'s for some time. In accordance with that an open gastrostomy and open tracheostomy was scheduled. Open tracheostomy indication was pulmonary care and PEG was because we failed to do the percutaneous wound safely. The patient was taken to the operating room on [6-29] and had that done successfully without complications. We had shut off the heparin before the operation. Postoperatively, the patient had some SIMV pressor support, which we were then able to wean down to CPAP. On [2117-7-1] no major events happened. The patient was continued on Fluconazole and heparin drip. On [2117-7-1], the patient was agitated and given some sedation. On [2117-7-2], postoperative #28, the patient was given Lopressor. Chest PT was continued. Tube feeds were continued. We continued Fluconazole. The respiratory status remained concerning and we continued to diurese. The Department of Psychiatry was involved. Regarding to recommendations, we discontinued all the benzodiazepines, opiates, and anticholinergics and started him on Haldol. On [2117-7-3], the patient was having hypercapnia. He was put back on the CPAP pressor support, which was then later weaned off. He continued Fluconazole. The heparin drip was continued, anticoagulation for chronic atrial fibrillation. On [7-4], [2117] the patient was therapeutic on Coumadin, which has been started and heparin drip was discontinued. The patient was doing well. In accordance with the family's wishes, the patient was arranged for hospice. The patient, at this point, was DNR. The issues upon discharge are as follows: The patient is some delirious. The patient should await all anticholinergics, no opioids, benzodiazepines. He is being sent home on Haldol per the Department of Psychiatry/patient. CARDIOVASCULAR: The patient is on Lopressor 12.5 mg p.o. b.i.d. GASTROINTESTINAL: The patient is getting tube feeds of Promote with fiber at 75 cc an hour. He will get Prevacid at 30 mg q.d for G-tube, Fluconazole 20 mg until the 5th of this month, Albuterol nebulizers for the respiratory status. FLUIDS, ELECTROLYTES, AND NUTRITION: For diuresis, he will receive Lasix 20 mg q.d. along with potassium supplementation. For anticoagulation, he will receive Coumadin 1 mg today and tomorrow. INR is therapeutic at 2.7 and it is to be checked tomorrow. Dr. [Last Name (STitle) ] of the Department of Cardiology will follow the INR dosing for a goal target of 2 to 2.5. He is aware of this, and he will do so. The patient is to have nothing orally. We are to maintain his comfort and optimal level of function with hospice at home. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 28973] D: [2117-7-5] 10:22 T: [2117-7-5] 10:31 JOB#: [Job Number 40780]	[ "398.91", "401.9", "276.0", "515", "396.2", "427.31", "397.0" ]	icd9cm	[ [ [] ] ]	[ "39.61", "96.72", "35.14", "96.04", "96.6", "35.21", "33.22", "31.1", "43.19" ]	icd9pcs	[ [ [] ] ]																				799, 1090																																																			1107, 11845
54,145	134,739	482	Discharge summary	report	Admission Date: [2187-12-24] Discharge Date: [2187-12-28] Date of Birth: [2108-9-21] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain, lightheadedness and dsypnea on exertion Major Surgical or Invasive Procedure: [2187-12-24] - Aortic valve replacement (21mm St. [First Name5 (NamePattern1) 923] [Last Name (NamePattern1) 4041] tissue valve)/Coronary artery bypass grafting x 1 (Left internal mammary artery->Left anterior descending artery) History of Present Illness: Mrs. [Known lastname 4042] is a 79 year old female who has been followed with serial echocardiograms for aortic stenosis. She has recently developed exertional angina and dyspnea. In addition, she reports easy fatiguability and cutting back her activities over the past few months. She presents today for surgical evaluation. Past Medical History: Aortic stenosis Coronary artery disease Hypertension insulin-dependent Diabetes mellitus Hyperlipidemia Colon cancer s/p resection Osteoporosis AV Block s/p PPM vertigo osteoarthritis chronic renal insufficiency (1.3) Social History: Last Dental Exam:[2183] Lives with: husband Contact: Phone # Occupation:retired Cigarettes: Smoked no [] yes [X] last cigarette 48 yrs ago Hx:15 PYHx Other Tobacco use:none ETOH: < 1 drink/week [x] [1-8] drinks/week [] >8 drinks/week [] Illicit drug use-none Family History: 2 siblings with CABG Physical Exam: Pulse:76 Resp: 16 O2 sat: B/P Right: 148/62 Left: 133/58 Height: 61" Weight: 130 lbs Five Meter Walk Test #1_______ #2 _________ #3_________ General:NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable Neck: Supple [x] Full ROM []no JVD appreciated Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade ___4/6 SEM___ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no HSM/CVA tenderness Extremities: Warm [x], well-perfused [x] Edema [] none Varicosities: None [x] Neuro: Grossly intact [x]MAE [3-6] strengths;; nonfocal exam Pulses: Femoral Right:1+ Left:1+ DP Right:1+ Left:1+ PT [Name (NI) 167]: NP Left:NP Radial Right: 2+ Left:2+ Pertinent Results: [2187-12-24] ECHO PRE-CPB: 1. The left atrium is normal in size. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic root. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. 7. Mild (1+) mitral regurgitation is seen. 8. There is a trivial/physiologic pericardial effusion. Drs. [Last Name (STitle) ] and [Doctor Last Name 4043] notified in person of the results. POST-CPB: On infusion of phenylephrine, epi. AV pacing. Well-seated bioprosthetic valve in the aortic position with trivial central AI, no paravalvular leak. The aortic gradient is now 11 mmHg. LVEF = 70% on inotropic support. MR remains 1+. The aortic contour is normal post decannulation. Brief Hospital Course: Mrs. [Known lastname 4042] was admitted to the [Hospital1 18] on [2187-12-24] for surgical management of her coronary artery disease and aortic stenosis. She was taken to the operating room where she underwent coronary artery bypass grafting to one vessel and replacement of her aortic valve with a 21mm [Date Range 4041] tissue valve. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Over the next few hours, she awoke neurologically intact and was extubated. She was transfused 2 units of red blood cells for postoperative anemia. On postoperative day one, she was transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. Her internal pacemaker was interrogated by the electrophysiology service. She continued to make steady progress and was discharged to [Hospital 100] Rehab on postoperative day 4. She will follow-up with Dr. [Last Name (STitle) ], her cardiologist, the electrophysiology service and her primary care physician as instructed. Medications on Admission: INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 35-40 units sc at bedtime INSULIN LISPRO [HUMALOG KWIKPEN] - 100 unit/mL Insulin Pen - 8 units sc 3 times a day as needed for or as needed INSULIN SYRINGE-NEEDLE U-100 [BD SAFETYGLIDE INSULIN SYRINGE] - 30 gauge X [4-16]" Syringe - Use to inject insulin once daily IRBESARTAN [AVAPRO] - 300 mg Tablet - 1 (One) Tablet(s) by mouth once a day METOPROLOL TARTRATE 25 mg [Hospital1 ] PRAVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth daily "NO SUBSTITUTION" SCOPOLAMINE BASE [TRANSDERM-SCOP] - 1.5 mg/72 hour Patch 72 hr - apply behind ear every 3 days as needed for vertigo ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day BLOOD SUGAR DIAGNOSTIC, DRUM [ACCU-CHEK COMPACT TEST] - Strip - use to check sugar 4 times daily and as needed INSULIN NEEDLES (DISPOSABLE) [BD INSULIN PEN NEEDLE UF ORIG] - 29 gauge X [12-3]" Needle - use for insulin pen 3 times daily Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 3. Pravachol 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. 7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days: Take for a week then stop. 8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. Insulin Order Please see flowsheet: Glargine 40units at bedtime Humalog sliding scale. Fingersticks QACHS. Discharge Disposition: Extended Care Facility: tbd Discharge Diagnosis: Aortic stenosis/coronary artery disease Hypertension insulin-dependent Diabetes mellitus Hyperlipidemia Colon cancer s/p resection Osteoporosis AV Block s/p PPM vertigo osteoarthritis chronic renal insufficiency (1.3) Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with percocet Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage. 1+ Lower extremity Edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 2) Please NO lotions, cream, powder, or ointments to incisions 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive 5) No lifting more than 10 pounds for 10 weeks 6) Take lasix 20mg and potassium 20mEq for 7 days then stop. 7) Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [Last Name (STitle) ] on [2188-1-30] at 1:15PM Cardiologist: Dr. [Last Name (STitle) 911] on [2188-1-30] at 2:40p Wound Check: [2188-1-3] 11:15AM [Hospital ] Medical Building 2A ([Telephone/Fax (1) 4044] Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 62] Date/Time:[2187-12-31] 3:00 Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ] in [3-6] weeks Please call for appointment [Telephone/Fax (1) 133] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours You are scheduled for the following appointments: Surgeon: Dr. [Last Name (STitle) ] on [2188-1-30] at 1:15PM Cardiologist: Dr. [Last Name (STitle) 911] on [2188-1-30] at 2:40p Wound Check: [2188-1-3] 11:15AM [Hospital ] Medical Building 2A ([Telephone/Fax (1) 4044] Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 62] Date/Time:[2187-12-31] 3:00 Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ] in [3-6] weeks Please call for appointment [Telephone/Fax (1) 133] 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:[2187-12-28]	[ "V45.01", "V10.05", "250.00", "V17.3", "287.5", "780.4", "413.9", "272.4", "V58.67", "585.9", "733.00", "715.90", "285.1", "305.1", "403.90", "424.1", "414.01" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.21", "36.15" ]	icd9pcs	[ [ [] ] ]	6990, 7020	3720, 4916	364, 607	7282, 7516	2369, 3697	8518, 10019	1534, 1557		5957, 6967		7041, 7261		4942, 5934			7540, 8495									1572, 2350																			273, 326												635, 967														989, 1209	1225, 1518
27,167	157,185	42971	Discharge summary	report	Admission Date: [2136-8-1] Discharge Date: [2136-8-17] Date of Birth: [2060-10-9] Sex: F Service: SURGERY Allergies: Tape Attending:[First Name3 (LF) 1] Chief Complaint: Colonic polyp not amendable to endoscopic removal Major Surgical or Invasive Procedure: [8-1]: Low anterior resection with mobilization of the splenic flexure [8-5]: exploratory laparotomy, washout of abdomen and loop ileostomy History of Present Illness: The patient is 75 yo female who was found to have a colonic polyp on colonscopic recently that was not amendable to endoscopic removal. The pathology was negative for cancer; however, she was recommended to have the lesion surgically remove due to the risk for converting to carcinoma. Patient was referred to see Dr. [Last Name (STitle) ] for surgical removal. She has no GI complaint before admission. She did report having an episode of GI bleed in past on Coumadin. Otherwise, she's relatively healthy and still working full-time. Past Medical History: PMHx: Paroxysmal atria tachycardia HTN Osteoarthritis Depression PSHx: Right total hip replacement Social History: Lives at home with daughters nearby. [Name2 (NI) 1403] as a social worker with specialty in psychotherapy. Does not drink or smoke. Family History: No history of stroke. Father died of CHF complicated by atrial fibrillation. Physical Exam: Vitals: Tm 98.9, Tc 98.9, HR 57, BP 116/56, RR 20, SaO2 98% on RA General: NAD, A/Ox3 Cardiac: RRR Lungs: no respiratory distress Abd: soft, nt/nd, non-distended, no rebound/guarding; macular rash under ostomy bag reduced in size & nontender. Stoma pink, soft stool (nonbloody) in ostomy bag. Wound: CD&I, no erythema/induration. Staples our, 2x portions of incision still packed w/wicking and draining small amount of purulent/serosang Extremities: WWP, 1+edema Pertinent Results: [2136-8-5] COLON (GASTROGRAF): anastomotic leak [2136-8-16] 05:05AM BLOOD WBC-16.0* RBC-3.60* Hgb-10.5* Hct-31.2* MCV-87 MCH-29.1 MCHC-33.6 RDW-14.2 Plt Ct-1039* [2136-8-16] 09:10PM BLOOD PT-19.0* PTT-85.9* INR(PT)-1.7* [2136-8-16] 05:05AM BLOOD Plt Ct-1039* [2136-8-10] 05:22AM BLOOD Glucose-91 UreaN-9 Creat-0.4 Na-139 K-3.9 Cl-102 HCO3-29 AnGap-12 [2136-8-7] 04:27AM BLOOD ALT-50* AST-41* AlkPhos-55 TotBili-0.5 [2136-8-6] 08:33PM BLOOD CK-MB-7 cTropnT-0.09* [2136-8-10] 05:22AM BLOOD Calcium-7.2* Phos-2.6* Mg-1.8 [2136-8-14] 08:15PM BLOOD Vanco-6.5* Brief Hospital Course: Ms. [Known lastname 92753] was admitted for sigmoidectomy for colonic polyps. The surgery was performed electively and occurred without complications. She was admitted to the surgical service for postoperative care and arrived in stable condition. On POD1 the patient developed hypotension and bradycardia with blood pressures as low as 60's/40'2 with a heart rate in the low 50s despite being completely asymptomatic. She was aggressively resuscitated with IV fluids and were stabilized overnight with blood pressures in the 120s-140s. At that time she began having loose bowel movements. On POD 2 she had blood pressures in the normal range but continued to have very loose/watery bowel movements over 20 times that day. The patient remained afebrile and C.diff cultures were negative. POD3 the patient developed fever to 103.8, tachy to the 130s, and increased tachypnea all with a stable BP. Ms. [Known lastname 92753] was worked up for causes of fever but continued to look poor clinically and was transferred to the ICU for more highly monitored care. UrCx and BlCx were positive for GNRs (aerobic and anaerobic) and she was started on cefepime/flagyl. POD 4 she underwent barium enema with fluoroscopy and was found to have a colonic leak at/near the site of anastomosis. The patient was taken urgently to the OR and underwent ex lap with washout and diverting loop ileostomy. On POD 5, she went into atrial fibrillation which did not respond to medical cardioversion. She remained hemodynamically stable and asymptomatic throughout, and was successfully electrically cardioverted into normal sinus rhythm the afternoon of POD 7. The patient was transferred back to the surgical service the afternoon of POD 8. Her WBC became elevated and remained elevated despite antibiotic therapy; chest xray was negative for pulmonary causes of infection, but urine studies were positive for a coagulase negative staph sensitive to vancomycin. She stayed on vancomycin, cefepime and flagyl but continued to have persistent elevated WBC; a CT scan of her pelvis revealed a pericolic abscess that could be the culprit. On POD 11 white blood count decreased to 16.0 and she was transitioned to PO augmentin. CT guided drainage of the pericolic abscess was placed on hold indefinitely as she remained asymptomatic with downtrending WBC. The patient was bridged to coumadin with a heparin drip, which was discontinued prior to discharge. Wound culture of Ms. [Known lastname 92754] incision grew enterococcus, susceptible to ampicillin, penicillin and vancomycin; she will continue augmenting for a total of 3 weeks. Ms. [Known lastname 92753] was discharged to an extended care facility on POD 12 in stable condition. Medications on Admission: diltiazem SR 240', warfarin 6', flecainide 100'', albuterol Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB. 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 3.5 weeks: Continue 400mg daily until [2136-9-11]. Then 200mg indefinitely. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 9. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 20 days. Disp:60 Tablet(s) Refills:0 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain . Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: sigmoid colectomy for polyp not amenable to polypectomy complicated by anastamotic leak requiring loop ileostomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service following a sigmoid colectomy, which was complicated by an anastamotic leak requiring a loop ileostomy. Please call your doctor or go to the emergency department if: You experience new chest pain, pressure, squeezing or tightness. You develop new or worsening cough, shortness of breath, or wheeze. You are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. Your pain is not improving within 12 hours or is not under control within 24 hours. Your pain worsens or changes location. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until cleared by your surgeon. You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Monitoring Ostomy Output: Keep well hydrated. Replace fluid loss from ostomy daily. Avoid drinking only 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 exceeds 1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16 mg in one day. Warfarin (Coumadin): What is this medicine used for? This medicine is used to thin the blood so that clots will not form. How does it work? Warfarin changes the body's clotting system. It thins the blood to prevent clots from forming. What you should contact your healthcare provider [Name Initial (PRE) ]: Signs of a life-threatening reaction. These include wheezing; chest tightness; fever; itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat, severe dizziness or passing out, falls or accidents, especially if you hit your head. Talk with healthcare provider even if you feel fine, significant change in thinking clearly and logically, severe headache, severe back pain, severe belly pain, black, tarry, or bloody stools, blood in the urine, nosebleeds, coughing up blood, vomiting blood, unusual bruising or bleeding, severe menstrual bleedin, or rash. Call your doctor if you are unable to eat for several days, for whatever reason. Also call if you have stomach problems, vomiting, or diarrhea that lasts more than 1 day. These problems could affect your Coumadin/warfarin dosage. Coumadin (Warfarin) and diet: Certain foods and beverages can impair the effect of warfarin. For this reason, it's important to pay attention to what you eat while taking this medication. Until recently, doctors advised [Name5 (PTitle) ] taking warfarin to avoid foods high in vitamin K. This is because large amounts of vitamin K can counteract the benefits of warfarin. However, recent research shows that rather than eliminating vitamin K from your diet, it is more important to be consistent in your dietary vitamin K intake. These foods contain vitamin K: Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli, Cabbage, [Location (un) 2831] sprouts, Green onions, Asparagus, Cauliflower, Peas, Lettuce, Spinach, Turnip, collard, and mustard greens, Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver. Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins, Soybeans and Cashews. Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage but it does not mean you must avoid all alcohol. Serious problems can occur with alcohol and Coumadin??????/warfarin when you drink more than 2 drinks a day or when you change your usual pattern. Binge drinking is not good for you. Be careful on special occasions or holidays, and drink only what you usually would on any regular day of the week. Monitoring: The doctor decides how much Coumadin??????/warfarin you need by testing your blood. The test measures how fast your blood is clotting and lets the doctor know if your dosage should change. If your blood test is too high, you might be at risk for bleeding problems. If it is too low, you might be at risk for forming clots. Your doctor has decided on a range on the blood test that is right for you. The blood test used for monitoring is called an INR. Use of Other medications: When Coumadin/warfarin is taken with other medicines it can change the way other medicines work. Other medicines can also change the way Coumadin??????/warfarin works. It is very important to talk with your doctor about all of the other medicines that you are taking, including over-the-counter medicines, antibiotics, vitamins, or herbal products. Followup Instructions: Please call Dr. [Last Name (STitle) ] for a follow-up appointment: [Telephone/Fax (1) 9] Provider: [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1849], M.D. Date/Time:[2136-10-16] 2:20	[ "569.5", "562.11", "038.8", "211.3", "427.31", "995.92", "584.9", "410.71", "E878.2", "311", "997.4", "599.0", "V58.61", "V43.64", "401.9", "998.59", "785.52" ]	icd9cm	[ [ [] ] ]	[ "99.62", "45.75", "46.01" ]	icd9pcs	[ [ [] ] ]	6341, 6411	2516, 5248	310, 459	6568, 6568	1900, 2493	12749, 12797	1322, 1401		5358, 6318		6432, 6547		5274, 5335			6719, 7754						8548, 12726			1416, 1881																		7786, 8533	221, 272										12820, 12973		487, 1027								6583, 6695						1049, 1150	1166, 1306
47,829	175,022	37766	Discharge summary	report	Admission Date: [2102-9-27] Discharge Date: [2102-10-27] Date of Birth: [2039-6-1] Sex: M Service: MEDICINE Allergies: Ativan / Ibuprofen Attending:[First Name3 (LF) 3556] Chief Complaint: Progressive Right-Sided Weakness Major Surgical or Invasive Procedure: PEG tube placement Tracheostomy Endotracheal intubation PICC line placement x 2 Bronchoscopy History of Present Illness: PER ADMITTING RESIDENT: The history was obtained from Mr [Known lastname 84568] son [Name (NI) ], as the patient was confused and agitated. Mr [Known lastname ] is an ambidextrous man who writes with his left hand with a hitherto unremarkable medical history, who presents with progressive right sided weakness. It started off 5 weeks ago with a right facial palsy, which his PCP, [Name10 (NameIs) ] [Last Name (STitle) 10851] in NH thought was a Bells palsy. However, the symptoms did not improve, and he started to complain of severe back pain, so much so that he resorted to sleeping in a Jacuzzi for 20 mins at a time. He went back to his PCP, [Name10 (NameIs) ] according to [Doctor First Name ], he was given analgesia and sent home. On [8-23], his PCP ordered an MRI of the brain which showed a 1.5 cm soft tissue mass in the midbrain and a question of a small acute infarct in the right posterior part of the pons. Mr [Known lastname ] then started to develop right sided arm weakness accompanied by numbness two weeks ago, which has become progressively worse. Last week, his right leg started to become involved in a similar manner. In addition to these symptoms, [Doctor First Name ] mentioned that his father weighed ~220 lb 5 weeks ago, and then a few days ago he was weighed at ~185 lb in an OSH. Last week on [Last Name (LF) 2974], [First Name3 (LF) ] took his father to CMC [Location (un) 5450] [Name (NI) ], and he had a CT scan of his brain which he was told showed nothing, and the MRI of his entire spine w/o contrast showed a questionable lesion (probable hemangioma) at T7, otherwise there was a minor disc protrusion at T9/10. He was discharged home, however, he got worse over the weekend, and his son took him into [Hospital6 204] yesterday, and they transferred him to the [Hospital1 ] ER for a stroke evaluation. At [Hospital1 189] he had a CXR which showed atelectasis of the R middle lobe which could be due to a lesion or infection, and his CT head scan had a lot of movement artifact. ROS: no fevers or chills according to his son, no other neurological or systemic symptoms obtainable from Mr [Known lastname ] due to his mental status. Past Medical History: - Alcohol Dependence - Nicotine/Tobacco dependence - Esophageal Strictures requiring regular dilatations - HTN - ITP treated with steroids in the past Social History: HABITS - Tobacco: smokes 1 PPD x 35 years - ETOH" drinks 6-12 beers/night or 1 liter vodka/night (for "all life") - Recreational Drug Use: remote marijuana use Family History: - negative for autoimmune d/o - negative for neurological d/o - negative for muscle d/o Physical Exam: On ADMISSION: T-98.2 BP-154/109 HR-86 RR-18 O2Sat-96% Gen: Trying to crawl out of bed. There is marked asymmetry from the back between the right and left side. At one point he had almost a pill rolling movement in his left hand. HEENT: NC/AT, wearing an eye patch over the right eye, the right side of his face almost looks as if it has "caved in", moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Rhonchi heard in the right mid zone aBd: +BS soft, has two subcutaneous lipomas in the right upper quadrant, nontender ext: no edema Neurologic examination: Mental status:Confused, agitated, thinks that he is in [Country 480], then states that he knows that he is in America, somewhere. Knows who he is, and can identify his son. Cranial Nerves: Right eye looks ecchymotic, cornea looks cloudy, pupil unreactive, in fundoscopy, question of debris in the anterior chamber. Left eye 3-->2 mm. Blinks to threat. EOMS appear full. Corneals in tact bilaterally. Right lower motor facial nerve palsy with a positive Bell's phenomenon. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Shoulder shrug looks asymmetric. Tongue deviates to the left. Motor: Evidence of weight loss. Tone increased in the right arm and right leg. No observed myoclonus or tremor right pronator drift Left side appears strong, can keep his left arm and leg up for 30 s, will not comply with formal testing Right side arm can stay antigravity for 5 s, and the right leg for 10 s. Sensation: Moves all 4 limbs symmetrically away from noxious stimuli Reflexes: 1 and symmetric throughout, apart from absent ankle jerks. Right - Babinski Left - downgoing Coordination: he would not attempt this, he could grab my neuro tools to try and prevent me from his left hand, but could not do this easily on the right side. Gait: when he stands, he keels over to the right Pertinent Results: Admission Lab Data: . WBC-8.4 RBC-4.14* HGB-14.0 HCT-40.2 MCV-97 MCH-33.8* MCHC-34.9 RDW-13.6 GLUCOSE-95 UREA N-17 CREAT-0.7 SODIUM-135 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-29 ANION GAP-14 CK-MB-4 cTropnT-<0.01 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-40 BILIRUBIN-SM UROBILNGN-1 PH-5.5 LEUK-NEG UPEP: Neg . CSF ([2102-9-27]): Tube 1: WBC-45 RBC-1450* POLYS-1 LYMPHS-91 MONOS-5 OTHER-3 Tube 4: WBC-200 RBC-3* POLYS-0 LYMPHS-87 MONOS-9 OTHER-4 PROTEIN-246* GLUCOSE-42 Cytology: Hypercellular specimen with many lymphocytes and monocytes. Gram Stain: No PMNs, No microorganisms Fluid Cx: Neg AFB: Negative HSV PCR: Negative EBV: Negative HHV-6: Negative Enterovirus: Negative Listeria: P Lyme: Equivocal VDRL: P West Nile Virus: P . CSF ([2102-10-4]): Tube 1: WBC-10 RBC-7 POLYS-0 LYMPHS-88 MONOS-5 OTHER (plasma) -2 Tube 4: WBC-195 RBC-55 POLYS-0 LYMPHS-90 MONOS-6 OTHER (plasma) -4 PROTEIN-73 GLUCOSE-63 Cytology: Gram Stain: No PMNs, No microorganisms Fluid Cx: Neg Lyme: . SERUM: Lyme IgM: POSITIVE; IgG: Negative Listeria: Negative HIV: Negative [Doctor First Name ]: Negative ANCA: Negative ESR: 21 CRP: ([2102-9-28]) 43.3, ([2102-10-3]): 65.9 SPEP: Neg CEA: 5.1 Ca [11]-9: 14 . BAL AFB: Negative Cx: No growth Gram Stain: 4+ PMN, no microorganisms . Resp Viral Cx: Negative . Discharge Lab Data: . IMAGING: . CT Head ([2102-9-27]): IMPRESSION: No acute intracranial process. . CT C-spine, Chest, Abdomen, Pelvis ([2102-9-27]): IMPRESSION: 1. Large left lower lobe atelectasis. An obstructive endobronchial lesion cannot be excluded. Other etiologies would include mucous plugging. 2. Gastric, cardiac and fundus mural thickening of unclear etiology. Differential considerations include inflammatory/neoplastic infiltration. Further evaluation with endoscopy may be considered. 3. Hepatic steatosis. 4. Splenic low attenuation lesions, not seen before. These could represent splenic infarcts. In the current clinical setting can not exclude an infectious component. 5. Moderate hiatal hernia. . MRI Brain ([2102-9-27]: IMPRESSION: 1. Abnormal cranial nerve enhancement most likely secondary to the patient's diagnosis of Lyme Disease. 2. Abnormal signal surrounding the obex at the cervicomedullary junction may also relate to the patient's Lyme disease but is of unclear etiology. . Right Shoulder X-ray ([2102-10-1]): No fracture, dislocation, or gross degenerative change is identified. Mild degenerative changes of the AC joint are noted. . CXR ([2102-9-28]): ET tube tip is 3.2 cm above the carina. NG tube tip is out of view below the diaphragm. There is no pneumothorax or enlarging pleural effusions. There are low lung volumes. Bibasilar opacities consistent with atelectasis have improved on the right and probably increased on the left. Cardiac size is top normal. . CXR ([2102-9-28]): FINDINGS: The patient is post extubation. New left lower lobe collapse and volume loss in the left hemithorax in a short time interval is most likely due to mucus plugging. The right lung is grossly clear. . CXR ([2102-10-1]): FINDINGS: In comparison with the study of [9-30], there is some decrease in the degree of left lower lobe atelectasis. The mediastinal contours are substantially less shifted to the left. Right lung is clear. . Transthoracic Echocardiogram ([2102-9-29]): The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. 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). 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 masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. No obvious vegetations or masses seen. Brief Hospital Course: Mr. [Known lastname ] 63 year old male smoker with a past medical history significant for alcohol dependence, esophageal stricture, hypertension and ITP who was admitted on [9-27] with a 5-wk history of progressive right-sided weakness (face --> wrist drop --> leg) in the setting of 35# unintentional weight loss in 5 weeks and was found to have a positive serum LYME titer. . 1. Lyme encephalitis: Diagnosed based MRI, CSF lymphocytic pleocytosis, positive serum serology with equivocal CSF serology. He was initially admited to the neurology service. In brief, per the patient's son, the patient developed right facial palsy 5 weeks prior to admission and was diagnosed as Bell's palsy. He also developed back pain and was given analgesia. MRI brain was ordered with demonstated a possible pontine acute infarct and midbrain mass. He then developed R sided progressive arm and leg numbness and weakness as well as confusion at home. There is also report of previous bulls eye rash. The patient was admitted to the SICU/Neuro ICU. He was diagnosed with probable Lyme encephalitis and started on ceftriaxone. Patient recieved a full 4 week course of ceftriaxone (28 days). He was followed by the neurology service throughout his admission. Patient did have improvement in his neurologic status, but it is unclear which of his deficits are permanent. . 2. Agitation/altered mental status. Patient had multifactorial delerium thought to be secondary to encephalitis as well as electrolyte abnormalities and med related. Patient had had some chronic narcotic use, and methadone was started by the SICU team for pain control. When patient was transfered to MICU he was no longer experiencing pain, so methadone was slowly tapered down with some improvement noted in his confusion. He was also started on Seroquel for agitation which was noted to help. Patient had hypernatremia on transfer to MICU service and was treated with free water boluses in his PEG feeds, which improved his hypernatremia. It was noted that his mental status was much improved with improvement of his hypernatremia, and therefore his sodium was maintained as close to 140 as possible. . 3. Respiratory failure. Patient had difficulty weaning off ventilator so had trach and PEG placed [10-10]. There was concern for pneumonia based on CXR, however the patient had a BAL and sputum cultures which were both negative for any growth. The patient was afebrile without elevation in WBC count without treatment. Patient thought to have difficulty clearing secretions, with significant suctioning of secretions. Also had periods of apnea, thought to be related to sedating effects of medications. Once his mental status cleared and he was able to clear his secretions, he was placed on trach mask trial which he did well with and tolerated for a full 5 days prior to discharge. Patient was treated throughout his hospitalization with inhaled medications for bronchospasm as there was thought to be a COPD component to his respiratory failure as he had a significant prior smoking history. . 4. Fever: Patient had multiple low grade temperatures throughout the hospitalization. He has been afebrile since [10-15] without any treatment. All blood, sputum and urine cultures were negative. He had a PICC line in place at the time of the fever, which was discontinued, and nothing grew from the catheter tip. He had negative C. diff cultures. The source was thought to be likely Lyme, which was treated with Ceftriaxone. . 5. Abdominal Pain: Patient had an episode of severe abdominal pain on the morning of [10-26]. He had also had a bloody bowel movement the evening of [10-25], which was attributed to hemerhoids as the blood was surrounding the bowel movement without mixing and was red. He was seen by surgery, who felt that the patient did not have a surgical abdomen. He had a PEG tube lavage which was negative for any upper GI bleeding source. His hematocrit remained stable. He was also seen by gastroenterology who did not perform either an EGD or colonoscopy as his bleeding had resolved. His LFTs, amylase and lipase were all normal. He had a right upper quadrant ultrasound which was normal. He had a normal lactate, which ruled out ischemia. His KUB showed a significant amount of stool, so constipation was thought to be the major source of his pain. He was maintained on a bowel regimen for stooling and his tube feeds were restarted without evidence of pain. 7. Hypernatremia thought to be likely iatrogenic as patient was not getting free water flushes with his tube feeds. This corrected with free water flushes. Free water via PEG tube may need to be adjusted at rehab based on regular sodium checks. . 8. Corneal ulcer. Patient was noted to have a corneal ulcer, seen by ophthalmology who performed eyelid suturing on [10-13]. Likely related to inability to protect eye with neurologic deficits. Patient was given a 10 day course of Vigamox antibiotic eye oitment. He was also given bacitracin ointment and artificial tears per ophthalmology, which should be continued until he is seen in 1 week by an outpatient ophthalmologist. . 9. Accelerated idioventricular rhythm. Patient had an episode of an accelerated idioventricular rhythm, and was seen by cardiology. They felt that this was likely benign and not related to Lyme disease. He was started on Metoprolol and there was no reoccurance of the accelerated idioventricular rhythm. . 10. Hypotension: Patient had periods of hypotension, thought to be likely iatrogenic as patient had clonidine given for aggitation. The clonidine was tapered off and this improved his hypotension. His medications were also spaced out so that his lopressor was not given with his seroquel, which also resolved his hypotension. He has had no periods of hypotension in the past 4 days since these medication changes were made. . 11. Nutrition: Patient is recieving tube feeding via PEG tube for nutrition as well as free water flushes with 300 mL every 4 hours for free water repletion. . 12: DVT prophylaxis was given for the course of his hospital stay with subcutaneous heparin. . 13. Patient was full code throughout his hospital stay HCP: son [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 84569] Medications on Admission: - oxycodone 5/325 mg po q 4-6h prn pain - hydromorphone 2 mg po q4h prn pain - cyclobenzaprine 10 mg po TID prn pain - lorazepam 0.5 mg po q 12h - neurontin 300 mg po tid - hctz 25 mg po daily - theratears - mvi po daily ALLERGIES: - motrin - GI distress - ativan - paradoxical reaction Discharge Medications: 1. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q6H (every 6 hours). 2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic Q2H (every 2 hours). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): HOLD for SBP <100, Hr <60. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 5. Methadone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) for 1 days: patient will complete methadone taper on [2102-10-28]. 6. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation. 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS;PRN () as needed for agitation . 9. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One (1) inhalation Inhalation [Hospital1 ] (). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for sob, wheezing. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Discharge Diagnosis: Lyme encephalitis . Respiratory failure Delerium Corneal ulcer Accelerated idioventricular rhythm Hypotension Hypernatremia Atelectasis Lower Gi bleed Fever Discharge Condition: Stable, off ventilator on trach mask oxygen, ongoing delerium with some delusional and paranoid features. Persistent R sided facial droop and R sided weakness that has been gradually improving. Discharge Instructions: You were admitted after having neurologic changes due to a severe Lyme disease infection. You have completed a course of antibiotics and are improving. You also had difficulties getting off the ventilator, but this has also improved. You will need to go to rehab following your hospitalization to improve your physical strength and allow time for your thinking to improve. . Please return to the hospital or call your doctor if you have weakness or other changes in your neurologic function, increasing confusion, headache, fever greater than 101, chest pain, abdominal pain, or any new symptoms that you are concerned about. . You had a number of medication changes during your hospital stay here. Please take all medications as prescribed. Followup Instructions: Followup with your primary care physician will be arranged after your discharge from rehab. . Please followup with ophthalmology available at your rehab facility within one week. Please continue your eyedrops as prescribed until that followup appointment. . In the future you should followup with gastroenterology due to a single episode of bloody stool that occurred on [2102-10-25]. . You should see a speech therapist for swallowing evaluation while at rehab. Until that time, we do not feel it is safe for you to take food or drink by mouth. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560] Completed by:[2102-10-27]	[ "518.0", "323.41", "293.0", "458.9", "455.2", "370.00", "401.9", "564.09", "491.21", "427.89", "303.91", "553.3", "305.1", "276.0", "287.31", "518.81", "088.81" ]	icd9cm	[ [ [] ] ]	[ "08.52", "31.1", "33.22", "43.11", "96.72", "96.04", "38.93", "03.31", "96.6", "33.24" ]	icd9pcs	[ [ [] ] ]	17786, 17801	9718, 15986	312, 407	18002, 18199	5185, 9695	18993, 19706	3047, 3137		16324, 17763		17822, 17981		16012, 16301			18223, 18970									3152, 3152																			240, 274												435, 2680	4046, 5166						3166, 3828	3866, 4030			3852, 3852			2702, 2854	2870, 3031
24,657	186,160	1893	Discharge summary	report	Admission Date: [2196-11-9] Discharge Date: [2196-11-13] Date of Birth: [2136-6-9] Sex: M Service: MEDICINE/[Location (un) 259] HISTORY OF PRESENT ILLNESS: The patient is a 60 year old male with past medical history significant for nonHodgkin's lymphoma and Stage IV nonsmall cell lung cancer with progressive bony metastases for which the patient has been using nonsteroidal anti-inflammatory drugs, who presented with bright red blood per rectum on [2196-11-9], and had a hematocrit of 33.0 down from 39.3. The patient had a negative nasogastric lavage in the Emergency Department and was subsequently transferred to the Medical Intensive Care Unit with hypotension and hematocrit drop from 33.6 to 26.5. The patient had a positive tagged red blood cell scan localizing to the distal small bowel but had a negative angiogram. The patient is now status post esophagogastroduodenoscopy showing ulcer in the proximal duodenal bulb, status post injection, and multiple erosions in the duodenal bulb and proximal portion of the second part of the duodenum consistent with nonsteroidal anti-inflammatory drug induced duodenitis. The patient is also status post colonoscopy showing external hemorrhoids and single diverticulum in the sigmoid colon. The patient is now transferred to the general floor. PAST MEDICAL HISTORY: 1. Nonsmall cell lung cancer, Stage IV diagnosed by thoracoscopy and wedge resection in [4-26]. The patient is status post Taxol/Carboplatin times four cycles, finished on [2196-7-7]. Right hip metastases, status post radiation therapy times three cycles. Known diffuse bony metastases, getting Zometa q1month. 2. B-cell nonHodgkin's lymphoma with axillary, mediastinal and retroperitoneal lymphadenopathy. 3. Hiatal hernia. 4. Neuropathy secondary to chemotherapy. MEDICATIONS ON ADMISSION: 1. Aspirin. 2. Multivitamin. 3. Oxycodone. 4. Aleve. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient works as a draftsman, married, has two children, and two grandchildren. No smoking and no illicit drugs. Alcohol use approximately one drink a day. PHYSICAL EXAMINATION: Vital signs revealed temperature 98.9, blood pressure 150 to 170 over 70 to 80, pulse 100 to 109, oxygen saturation 97% in room air. Generally, a pleasant gentleman in no apparent distress. Head, eyes, ears, nose and throat examination - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Moist mucous membranes. Neck - supple with no lymphadenopathy, no jugular venous distention. Pulmonary is clear to auscultation bilaterally. Cardiovascular is tachycardia, regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. The abdomen is benign. Extremities - no cyanosis, clubbing or edema. Neurologic examination was nonfocal. LABORATORY DATA: White blood cell count was 8.6, hematocrit 32.8, platelet count 117,000. INR 1.2. Normal Chem10. Esophagogastroduodenoscopy showed 8.0 millimeter benign appearing duodenal ulcer, erosive gastritis and duodenitis consistent with nonsteroidal anti-inflammatory drug induced gastropathy. Colonoscopy showed a single sigmoid diverticulum. Bleeding scan showed active bleeding in upper pelvic region, sigmoid bleed less likely distal small bowel. Mesenteric angiogram negative study, normal SMA and [Female First Name (un) 899]. HOSPITAL COURSE: 1. Upper gastrointestinal bleed - The patient has undergone a bleeding scan, mesenteric angiogram, colonoscopy and esophagogastroduodenoscopy. The patient was in the Medical Intensive Care Unit for two days for which he was admitted for hypotension and hematocrit drop from 33.6 to 26.5. The patient was transfused and remained hemodynamically stable. The patient tolerated colonoscopy and esophagogastroduodenoscopy well without complications. Nonsteroidal anti-inflammatory drugs were held. There was no evidence of rebleeding. The patient was continued on Protonix and was subsequently transferred to the general Medicine floor. Diet was advanced without difficulty. The patient was reevaluated by the gastroenterology team after colonoscopy and has continued to do well. 2. Hematology/Oncology - Known nonHodgkin's lymphoma and Stage IV nonsmall cell lung cancer with bony metastases. The patient's pain was controlled with Oxycodone and Tylenol. Nonsteroidal anti-inflammatory drugs were avoided. Last dose of Zometa was on [2196-11-3]. The patient is to follow-up as an outpatient with Hematology/[Hospital ] Clinic. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed. 2. NonHodgkin's lymphoma. 3. Nonsmall cell lung cancer with bony metastases. FOLLOW-UP PLANS: The patient is to follow-up with the [Hospital ] Clinic within the next three weeks. The patient is also to follow-up with his primary care physician within the next week after the hospitalization. The patient is to also follow-up with his hematologist/oncologist as previously arranged. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5613], M.D. [MD Number(2) 5614] Dictated By:[Name8 (MD) 4937] MEDQUIST36 D: [2196-11-14] 11:34 T: [2196-11-19] 12:04 JOB#: [Job Number 10557]	[ "562.10", "E849.0", "455.5", "E935.9", "V10.11", "553.3", "532.00", "198.5", "202.88" ]	icd9cm	[ [ [] ] ]	[ "38.91", "99.04", "44.43", "88.47", "45.23" ]	icd9pcs	[ [ [] ] ]							1945, 1963	4663, 4777					1870, 1928	3437, 4581																				2166, 3420			4795, 5354																			190, 1340														1362, 1844	1980, 2143	4606, 4642
31,503	184,692	25029	Discharge summary	report	Admission Date: [2157-6-8] Discharge Date: [2157-6-19] Date of Birth: [2135-5-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 134] Chief Complaint: Cardiac arrest Major Surgical or Invasive Procedure: central lines, intubation with mechanical ventilation History of Present Illness: 22M h/o surgery for transposition of the great vessels, brought by ambulance to the ED in PEA arrest. He was reportedly in the process of being arrested for alcohol intoxication, and became unresponsive - details unclear. EMS flagged down by police, found face-down with abrasions on his face. Police told EMS that patient fell from standing position. Received epi x 2 and atropine in field. "No shock" rhythm x 2 on defibrillator. AED transiently showed VF, but before could shock, went into wide-complex tachycardia with pulse. Intubated in field with difficulty. On arrival to ED, lost pulse, in PEA arrest with wide-complex tachycardia. Received additional epi x 1, atropine x 1, vasopressin, CaCl, 1 amp bicarb, narcan, and one 3mg dose epi. Pulseless for approximately 10 minutes, after which patient regained pulse and pressure, which rose to SBP 150. Initial labs notable for lactate 10.9, wbc 13.7, EtOH 137. ECG with sinus tachycardia, no acute ST or T-wave changes. Head CT showed no bleed, C-spine CT showed no fracture, chest CT showed no PE or acute dissection. Adjunctive hypothermia was induced using the Arctic Sun System, and given a dose of vecuronium, started on fentanyl/versed. Prior to vecuronium, pupils noted to be 6mm and non-reactive. Transferred to ICU for further management. Past Medical History: Transposition of great vessels, s/p Senning repair [2134], did not undergo arterial switch. When pt was 15yo, found to have evidence of significant RV failure. He was treated with afterload reduction but was not compliant. For the past several years he has not had significant medical follow-up. Social History: Per family, patient social ethanol drinker. Tobacco user intermittently over past years. Was student at [Hospital1 ], currently taking semester off. Lives in [Location ] with friends/classmates. Played baseball, currently plays basketball. Family History: Noncontributory Physical Exam: T: 95.9F BP: 98/56 HR: 104 SaO2: 96% on AC 500x20/5/100% Gen: Caucasian male, intubated and sedate HEENT: pupils 6mm -> 4mm, reactive to light and accommodation. Neck: No LAD Chest: CTA anteriorly, median sternotomy scar visible, Arctic Sun in place Abd: Cannot examine due to Arctic Sun Extr: No LE edema, DPs 2+ and symmetric Neuro: PERRL 6->4mm, normal doll's eyes, DTRs sluggish, symmetric Toes downgoing. +irregular jerking of jaw. No clonus. Pertinent Results: ****** STUDIES: **** . ECG Study Date of [2157-6-8] Sinus tachycardia. Marked right axis deviation. Right bundle-branch block. P-R interval prolonged for rate. ST-T wave abnormalities. No previous tracing available for comparison. CT HEAD W/O CONTRAST [2157-6-8] NON-CONTRAST CT HEAD: There is no acute intra- or extra-axial hemorrhage, edema, mass effect, shift of normally midline structures or major vascular territorial infarction. There is complete opacification of the frontal, ethmoid, and maxillary sinuses, with hyperdense inspissated material noted within the sinuses bilaterally. There is no evidence of fracture. Soft tissues are normal. IMPRESSION: 1. No intracranial hemorrhage or fracture. 2. Sinus disease with opacification of the paranasal sinuses. . EEG Study Date of [2157-6-8] FINDINGS: ABNORMALITY #1: Throughout the recording, the background was of extremely low voltage with minimal, if any, cerebral activity noted at a gain of 3 uV sensitivity. The background was poorly reactive. There are no clearly epileptiform features. BACKGROUND: As above. HYPERVENTILATION: Could not be performed as this was a portable study. INTERMITTENT PHOTIC STIMULATION: Could not be performed as this was a portable study. SLEEP: No normal waking or sleeping morphologies were noted. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 60 bpm. IMPRESSION: Abnormal portable EEG due to the extremely low voltage and poorly reactive background with minimal, if any, cerebral activity evident. There were no areas of prominent focal slowing. There were no clearly epileptiform features. . TTE (Congenital, complete) Done [2157-6-8] Findings LEFT ATRIUM: Dilated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. LEFT VENTRICLE: Small LV cavity. Depressed LVEF. RIGHT VENTRICLE: RV hypertrophy. Markedly dilated RV cavity. Severe global RV free wall hypokinesis. Cannot exclude RV mass. Prominent moderator band/trabeculations are noted in the RV apex. AORTIC VALVE: No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate to severe [3+] TR. PERICARDIUM: No pericardial effusion. Conclusions There is evidence for D-Transposition of the Great Arteries with ventriculo-arterial discordance. The patient is s/p palliative inter-atrial baffle (Senning). The right ventricle is anterior and appears systemic. The systemic ventricle (RV) is markedly dilated with severe global hypokinesis. RV thrombus cannot be excluded. There is moderate to severe tricupsid regurgitation. The interatrial baffles appear patent without leakage (vena cava to LA and pulmonary venous to RA baffles well visualized). The left ventricle is connected to the pulmonary artery. It is small and hypokinetic. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. IMPRESSION: D-Transposition of the Great Arteries s/p interatrial baffle palliative surgery. Baffles appear patent without leakage. The systemic ventricle is markedly dilated with severe hypokinesis c/w systemic ventricular failure. . CT PELVIS W/CONTRAST Study Date of [2157-6-8] 1:32 AM CTA CHEST: There is no PE. The heart is enlarged with Right ventricular hypertrophy noted. Subcarinal and medistinal hypodensity is likley post surgical. The lungs demonstrate patchy airpace disease, worse on the right with adjacent atelectesis. abberrent anatomy including drainage of the pulmonarty veins into the left ventricle. CTA ABDOMEN: The liver, spleen, and adrenals are unremarkable. Thin, hyperdense material in the right lobe of the liver is of uncertain significance or etiology. The liver is otherwise unremarkable. The large and small bowel are unremarkable. There is no free fluid or free air. Bone windows demonstrate no suspicious lesions IMPRESSION: 1. No PE or dissection. 2. Aspiration pneumonia. 3. ? repaired transposition of the great vessels. . CT C-SPINE W/O CONTRAST Study Date of [2157-6-8] NON CONTRAST CT C-SPINE: There is no fracture or malalignment to the level of T1. Straightening of the normal lumbar lordosis is noted. 4-mm low attenuation focus within the left lobe of the thyroid gland likely represents a thyroid cyst. A dedicated thyroid ultrasound examination could be performed to further evaluation this finding as clinically indicated on a nonemergent basis. The evaluation of the prevertebral soft tissues is limited due to intubation. IMPRESSION: No fracture or malalignment. . CT HEAD W/O CONTRAST Study Date of [2157-6-8] HEAD CT WITHOUT IV CONTRAST: There is no hemorrhage, edema, mass effect, or shift of normally midline structures. The ventricles and sulci are normal in size and configuration for the patient's age. There is again sinus opacification involving the maxillary, ethmoid, and sphenoid sinuses, which may represent polypoid opacification or chronic sinusitis. IMPRESSION: No hemorrhage or cerebral edema. . CHEST (PORTABLE AP) Study Date of [2157-6-8] FINDINGS: The heart size is enlarged. The mediastinal and hilar contours are normal. The left lung is clear. Increased opacification of the right lung is related to the combination of the positioning and right lung base infiltrate. No pneumothorax and no pulmonary vascular congestion. The endotracheal tube projects 7.3 cm above the carina. IMPRESSION: 1. No pulmonary edema. 2. Opacification of the right lung base compatible with aspiration or atelectasis. . MR CERVICAL SPINE W/O CONTRAST Study Date of [2157-6-10] MR OF THE CERVICAL SPINE WITHOUT IV GADOLINIUM: Vertebral height, signal characteristics and alignment are preserved. There is no evidence of acute fracture or spondylolisthesis. There is no STIR evidence of edema of the ligaments or vertebral bodies. Cervical spinal cord has normal signal characteristics. Mild disc bulges are noted at C4-5 and C5-6 but there is no significant central canal or neural foraminal stenosis. Paraspinal soft tissues are unremarkable. IMPRESSION: No evidence of ligamentous injury of the cervical spine. . MR HEAD W/O CONTRAST Study Date of [2157-6-10] There is increased signal and restricted diffusion in bilateral putamen, caudae and cortex of the calcarine fissure, right greater than left, right parietal cortex and bilateral rolandic fissures. Findings are compatible with hypoxic injury to the brain. Ventricles are not enlarged. Extensive pansinus opacification is unchanged. There is also right mastoid opacification. Intracranial flow voids are maintained. MRA of the circle of [Location (un) 431] demonstrates no evidence for aneurysm or stenosis. IMPRESSION: Findings compatible with diffuse hypoxic injury to the brain. Findings were discussed with Dr. [First Name (STitle) ] at the time of attending interpretation. . CHEST (PORTABLE AP) Study Date of [2157-6-9] The endotracheal tube is in the thoracic inlet projecting 9 cm above the carina and needs to be advanced. Heart size is enlarged. The mediastinal and hilar contours are normal. The left lung is clear. Opacification of the right lung base is unchanged consistent with atelectasis at the right lung base. No pleural effusion or pneumothorax. IMPRESSION: ET tube in thoracic inlet. Unchanged right lung consolidation compatible with atelectasis/aspiration. The study and the report were reviewed by the staff radiologist. . CHEST (PORTABLE AP) Study Date of [2157-6-11] Endotracheal tube terminates about 3.3 cm above the carina. A feeding tube has been removed. Unusual configuration of cardiomediastinal contours is consistent with the patient's history of congenital heart disease. Minimal residual hazy opacity persists within the right lung, but has markedly improved compared to earlier study of [2157-6-9]. . CHEST XRAY - [6-13] - Cardiomegaly, specifically the right [Doctor Last Name 1754], with upturning of the cardiac apex. Complete resolution of the pulmonary edema. The patient was extubated. . EKG - [6-14] - Sinus rhythm. Biatrial abnormality. Right axis deviation. Incomplete right bundle-branch block. Diffuse repolarization abnormalities. Possible right ventricular hypertrophy. Compared to the previous tracing of [2157-6-11] multiple abnormalities as noted persist without major change. . CXR - [6-14] - AP chest radiograph compared to [2157-6-13] shows no significant change allowing for patient rotation. No consolidation, pneumothorax or pleural effusion is detected. The heart remains moderately enlarged, unchanged from prior exam. There is no evidence of pulmonary edema. Post-surgical changes related to median sternotomy are demonstrated. NG tube terminates within the stomach. . CXR - [6-19] - Endotracheal tube has been placed. The tube terminates just above the thoracic inlet. The heart is mildly enlarged. The lungs appear grossly clear. The right costophrenic angle has been omitted from the study. . [2157-6-19*] 01:18AM BLOOD WBC-12.3 RBC-4.38* Hgb-13.3* Hct-42.1 MCV-96# MCH-30.3 MCHC-31.6 RDW-13.8 Plt Ct-169 [2157-6-16] 04:42AM BLOOD WBC-9.3# RBC-4.93 Hgb-14.7 Hct-43.9 MCV-89 MCH-29.7 MCHC-33.4 RDW-14.5 Plt Ct-186 [2157-6-15] 04:10AM BLOOD WBC-5.7 RBC-4.69 Hgb-14.3 Hct-42.4 MCV-90 MCH-30.4 MCHC-33.7 RDW-14.0 Plt Ct-165 [2157-6-14] 04:03AM BLOOD WBC-6.7 RBC-4.96 Hgb-14.8 Hct-44.2 MCV-89 MCH-29.9 MCHC-33.5 RDW-14.1 Plt Ct-173 [2157-6-12] 05:44AM BLOOD WBC-6.4 RBC-4.33* Hgb-13.0* Hct-39.8* MCV-92 MCH-30.1 MCHC-32.8 RDW-13.8 Plt Ct-140* [2157-6-11] 03:25AM BLOOD WBC-6.3 RBC-4.07* Hgb-12.5* Hct-37.6* MCV-92 MCH-30.6 MCHC-33.1 RDW-13.7 Plt Ct-133* [2157-6-11] 03:25AM BLOOD WBC-6.3 RBC-4.07* Hgb-12.5* Hct-37.6* MCV-92 MCH-30.6 MCHC-33.1 RDW-13.7 Plt Ct-133* [2157-6-9] 05:28AM BLOOD WBC-10.2 RBC-5.38 Hgb-16.2 Hct-49.1 MCV-91 MCH-30.2 MCHC-33.0 RDW-13.7 Plt Ct-158 [2157-6-8] 08:58AM BLOOD WBC-18.7* RBC-5.52 Hgb-16.6 Hct-51.0 MCV-92 MCH-30.1 MCHC-32.6 RDW-13.4 Plt Ct-206 [2157-6-8] 01:17AM BLOOD WBC-13.7* RBC-5.42 Hgb-16.3 Hct-52.7* MCV-97 MCH-30.1 MCHC-31.0 RDW-13.0 Plt Ct-221 [2157-6-8] 08:58AM BLOOD Neuts-94.7* Bands-0 Lymphs-3.1* Monos-1.9* Eos-0.2 Baso-0.1 [2157-6-8] 08:58AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2157-6-19] 01:18AM BLOOD Plt Ct-169 [2157-6-13] 06:09AM BLOOD Plt Ct-154 [2157-6-13] 06:09AM BLOOD PT-14.1* PTT-27.9 INR(PT)-1.2* [2157-6-10] 04:36AM BLOOD PT-16.2* PTT-31.7 INR(PT)-1.4* [2157-6-9] 08:03AM BLOOD PTT-29.6 [2157-6-8] 03:43PM BLOOD Plt Ct-224 [2157-6-8] 03:43PM BLOOD PT-15.9* PTT-29.3 INR(PT)-1.4* [2157-6-8] 01:17AM BLOOD Fibrino-333 [2157-6-19] 01:18AM BLOOD Glucose-319* UreaN-19 Creat-1.3* Na-144 K-4.1 Cl-102 HCO3-26 AnGap-20 [2157-6-18] 04:56AM BLOOD Glucose-96 UreaN-19 Creat-1.0 Na-144 K-4.1 Cl-108 HCO3-26 AnGap-14 [2157-6-14] 05:00PM BLOOD Glucose-127* UreaN-18 Creat-1.4* Na-143 K-3.9 Cl-109* HCO3-24 AnGap-14 [2157-6-14] 04:03AM BLOOD Glucose-113* UreaN-16 Creat-1.3* Na-146* K-4.1 Cl-109* HCO3-25 AnGap-16 [2157-6-12] 03:56PM BLOOD Glucose-129* UreaN-14 Creat-1.2 Na-145 K-4.0 Cl-111* HCO3-23 AnGap-15 [2157-6-10] 04:36AM BLOOD Glucose-137* UreaN-24* Creat-1.2 Na-141 K-4.2 Cl-109* HCO3-24 AnGap-12 [2157-6-9] 07:41PM BLOOD Glucose-152* UreaN-25* Creat-1.4* Na-142 K-4.9 Cl-109* HCO3-21* AnGap-17 [2157-6-9] 05:28AM BLOOD Glucose-112* UreaN-19 Creat-0.8 Na-139 K-4.8 Cl-107 HCO3-21* AnGap-16 [2157-6-8] 08:58AM BLOOD Glucose-138* UreaN-17 Creat-0.9 Na-142 K-3.7 Cl-106 HCO3-18* AnGap-22* [2157-6-8] 08:33AM BLOOD Glucose-119* UreaN-16 Creat-1.1 Na-141 K-4.2 Cl-103 HCO3-20* AnGap-22* [2157-6-8] 04:40AM BLOOD Glucose-600* UreaN-12 Creat-1.0 Na-128* K-3.6 Cl-89* HCO3-19* AnGap-24 [2157-6-8] 01:17AM BLOOD UreaN-14 Creat-1.4* [2157-6-10] 04:36AM BLOOD ALT-21 AST-38 LD(LDH)-191 AlkPhos-83 TotBili-1.2 [2157-6-9] 05:28AM BLOOD ALT-30 AST-46* LD(LDH)-224 AlkPhos-104 TotBili-1.4 [2157-6-8] 03:43PM BLOOD ALT-34 AST-59* LD(LDH)-299* AlkPhos-111 TotBili-0.8 [2157-6-8] 08:58AM BLOOD ALT-35 AST-60* LD(LDH)-284* AlkPhos-124* Amylase-57 TotBili-0.7 [2157-6-8] 01:17AM BLOOD CK(CPK)-115 Amylase-37 [2157-6-8] 08:58AM BLOOD Lipase-18 [2157-6-8] 01:17AM BLOOD CK-MB-4 cTropnT-<0.01 [2157-6-19] 01:18AM BLOOD Calcium-9.7 Phos-6.5# Mg-3.4 [2157-6-14] 04:03AM BLOOD Mg-2.0 [2157-6-9] 08:03AM BLOOD Calcium-9.0 Phos-4.9# Mg-2.2 [2157-6-9] 05:28AM BLOOD Albumin-3.9 Calcium-8.7 Phos-3.1 Mg-2.3 [2157-6-8] 04:40AM BLOOD Calcium-6.3 Phos-4.5 Mg-1.6 [2157-6-8] 03:43PM BLOOD TSH-2.9 [2157-6-13] 06:07PM BLOOD Vanco-14.2 [2157-6-12] 05:44AM BLOOD Vanco-12.1 [2157-6-8] 01:17AM BLOOD ASA-NEG Ethanol-137* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2157-6-19] 02:07AM BLOOD Type-ART pO2-194* pCO2-30* pH-7.33* calTCO2-17* Base XS--8 [2157-6-14] 12:48AM BLOOD Type-ART pO2-88 pCO2-36 pH-7.44 calTCO2-25 Base XS-0 [2157-6-13] 11:47PM BLOOD Type-ART pO2-84* pCO2-56* pH-7.43 calTCO2-38* Base XS-10 [2157-6-13] 12:46AM BLOOD Type-ART PEEP-5 pO2-79* pCO2-38 pH-7.42 calTCO2-25 Base XS-0 Intubat-NOT INTUBA [2157-6-12] 10:18PM BLOOD Type-ART pO2-73* pCO2-34* pH-7.43 calTCO2-23 Base XS-0 Intubat-NOT INTUBA [2157-6-12] 06:14PM BLOOD Type-ART pO2-62* pCO2-38 pH-7.41 calTCO2-25 Base XS-0 Intubat-NOT INTUBA Comment-QNS [2157-6-12] 05:35PM BLOOD Type-ART pO2-48* pCO2-38 pH-7.41 calTCO2-25 Base XS-0 [2157-6-11] 02:49PM BLOOD Type-ART PEEP-5 FiO2-50 pO2-84* pCO2-42 pH-7.39 calTCO2-26 Base XS-0 [2157-6-11] 02:13PM BLOOD Type-ART PEEP-5 FiO2-50 pO2-41* pCO2-45 pH-7.38 calTCO2-28 Base XS-0 [2157-6-11] 10:16AM BLOOD Type-ART pO2-87 pCO2-40 pH-7.39 calTCO2-25 Base XS-0 [2157-6-11] 03:40AM BLOOD Type-ART Temp-37.3 pO2-113* pCO2-39 pH-7.42 calTCO2-26 Base XS-0 Intubat-INTUBATED [2157-6-10] 03:44AM BLOOD Type-ART pO2-150* pCO2-33* pH-7.45 calTCO2-24 Base XS-0 [2157-6-9] 08:03PM BLOOD Type-ART pO2-81* pCO2-35 pH-7.43 calTCO2-24 Base XS-0 [2157-6-9] 03:43PM BLOOD Type-ART Rates-0/22 Tidal V-550 PEEP-10 FiO2-70 pO2-91 pCO2-31* pH-7.42 calTCO2-21 Base XS--2 Intubat-INTUBATED [2157-6-9] 11:48AM BLOOD Type-ART Temp-38.0 PEEP-10 FiO2-70 pO2-78* pCO2-35* pH-7.41 calTCO2-23 Base XS--1 -ASSIST/CON Intubat-INTUBATED [2157-6-9] 08:20AM BLOOD Type-ART Temp-36.8 Rates-22/ Tidal V-550 PEEP-10 FiO2-60 pO2-44* pCO2-39 pH-7.32* calTCO2-21 Base XS--5 -ASSIST/CON Intubat-INTUBATED [2157-6-9] 05:37AM BLOOD Type-ART pO2-84* pCO2-33* pH-7.40 calTCO2-21 Base XS--2 [2157-6-9] 12:17AM BLOOD Type-ART pO2-69* pCO2-33* pH-7.38 calTCO2-20* Base XS--4 [2157-6-8] 04:13PM BLOOD Type-ART Temp-34.4 Rates-20/2 Tidal V-500 PEEP-5 FiO2-40 pO2-76* pCO2-39 pH-7.32* calTCO2-21 Base XS--5 Intubat-INTUBATED Vent-CONTROLLED [2157-6-8] 12:48PM BLOOD Type-ART Temp-34.3 Rates-20/2 PEEP-5 FiO2-50 pO2-96* pCO2-36 pH-7.34* calTCO2-20* Base XS--5 Intubat-INTUBATED Vent-CONTROLLED [2157-6-19] 02:07AM BLOOD Glucose-298* Lactate-9.1* Na-142 K-3.3* Cl-109 [2157-6-13] 12:46AM BLOOD K-3.5 [2157-6-12] 06:14PM BLOOD Glucose-119* Lactate-1.1 Na-141 K-3.9 Cl-108 [2157-6-12] 05:35PM BLOOD Glucose-119* Lactate-1.2 Na-142 K-4.0 Cl-107 [2157-6-8] 12:48PM BLOOD Lactate-1.3 [2157-6-8] 09:03AM BLOOD Lactate-1.9 [2157-6-8] 05:28AM BLOOD Lactate-2.5* [2157-6-8] 01:25AM BLOOD Glucose-103 Lactate-10.9* Na-145 K-4.0 Cl-104 calHCO3-20* [2157-6-19] 02:07AM BLOOD O2 Sat-100 [2157-6-13] 06:42AM BLOOD O2 Sat-96 [2157-6-12] 06:14PM BLOOD Hgb-.0* calcHCT-0 O2 Sat-QNS COHgb-QNS MetHgb-QNS [2157-6-9] 08:03PM BLOOD O2 Sat-95 [2157-6-9] 03:43PM BLOOD O2 Sat-96 [2157-6-9] 01:02AM BLOOD O2 Sat-98 [2157-6-8] 11:09PM BLOOD O2 Sat-93 [2157-6-19] 02:07AM BLOOD freeCa-1.57* [2157-6-13] 12:46AM BLOOD freeCa-1.12 [2157-6-12] 06:14PM BLOOD freeCa-1.16 [2157-6-12] 05:35PM BLOOD freeCa-1.15 [2157-6-12] 08:58AM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.014 [2157-6-9] 02:48PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 [2157-6-8] 02:15AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.032 [2157-6-12] 08:58AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2157-6-9] 02:48PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2157-6-8] 02:15AM URINE Blood-MOD Nitrite-NEG Protein-500 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2157-6-12] 08:58AM URINE RBC-7* WBC-<1 Bacteri-FEW Yeast-NONE Epi-<1 [2157-6-9] 02:48PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0-2 [2157-6-8] 02:15AM URINE RBC-[2-23]* WBC-[5-31]* Bacteri-MANY Yeast-OCC Epi-<1 [2157-6-12] 08:58AM URINE CastGr-2* [2157-6-9] 02:48PM URINE CastHy-0-2 [2157-6-12] 08:58AM URINE AmorphX-FEW [2157-6-8] 02:15AM URINE AmorphX-OCC [2157-6-8] 02:15AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . [2157-6-12] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [2157-6-12] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2157-6-12] URINE URINE CULTURE-FINAL INPATIENT [2157-6-12] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2157-6-12] URINE URINE CULTURE-FINAL INPATIENT [2157-6-10] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [2157-6-10] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [2157-6-9] SPUTUM NOT PROCESSED INPATIENT [2157-6-9] URINE URINE CULTURE-FINAL INPATIENT [2157-6-9] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2157-6-9] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2157-6-9] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [2157-6-8] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} INPATIENT [2157-6-8] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2157-6-8] URINE URINE CULTURE-FINAL Brief Hospital Course: 22M h/o Senning procedure for D-transposition of the great vessels, brought by ambulance to the ED in PEA arrest, mechanically intubated and placed on cooling protocol, successfully extubated with MRI findings and clinical findings of anoxic brain injury, with subsequent cardiac arrest with ventricular dysarrythmia on hospital day #11 with ultimate result of death. 1. PEA cardiac arrest/Rhythm/cardiac arrest - Unclear etiology with conflicting reports regarding circumstances and timing of CPR initiation. Arrest thought secondary to increased catecholinergic state, acute RV failure, hypoxia, or possibly other cause (eg. commotio cordis). Patient was at increased risk arrythmia due to his baseline congenital heart disease, specificially at an increased risk for a junctional rhythm and atrial arrythmia, especially atrial flutter, or ventricular arrythmias are not uncommon. Unclear initial presenting rhythm at onset of event. As per HPI, BLS/ACLS continued in field and into [Hospital1 18] ED with endotracheal intubation with reacquisition of pulse and pressure. Patient was transferred to CCU and initiated on Arctic Sun cooling protocol for 36-hour period and remained on mechanical ventilation, without complication. Patient was cooled without complication. Telemetry throughout hospitalization did not show any abnormal runs of ventricular tachycardia. On [2157-6-15] consultation was requested of the Electrophysiology Service. Their plan was to perform an EP study the following week with the asistance of an electrophysiologist from [Hospital1 11900]. At 12:47 AM on [6-19] (morning of death), patient found to be hypoxic and without a pulse (1:1 sitter noted upper extremity arm movement just prior to event). Code blue initiated with initial rhythm of PEA for 4 minutes, then subsequent pulseless ventricular tachycardia/ventricular fibrillation for next thirteen minutes. BLS/ACLS algorithms followed with anesthesia placement of endotracheal intubation and surgical placement of femoral central venous line. Patient reacquired perfusing pressure, pulse, with tachycardia narrow-complex rhythm at 1:00am, with subsequent re-transfer to CCU. At 1:10am, patient converted into pulseless ventricular tachycardia and received ACLS algorithm, with reacquisition of pressure and pulse at 1:14 AM. From 1:14 AM to 2:02 AM, patient had perfusing pressure, pulse, and narrow complex tachycardia with periods of bradycardia. At 2:02 AM, patient again converted into pulseless ventricular tachycardia and ventricular fibrillation, prompting ACLS algorithm until 2:28AM. Resuscitive efforts were discontinued at 2:28 AM with agreement from participating team members. Members of team present throughout code were ICU intensivist, cardiology fellow, anesthesia resident and intern, anesthesia attending, respiratory therapist, and CCU nursing staff. Attending of record, Dr. [Last Name (STitle) ] was several times contact[Name (NI) ] during code. Patient's family was called on two occasions, once upon transfer to CCU after 1AM and at 2:40 AM. Medical examiner was called at 3:30 AM, with case accepted. Family arrived at room at 5:30 AM, all questions answered by medicine housestaff and CCU nursing staff. 2. Cardiac function - as above, patient had congenital transposition of the great vessels, s/p Senning reparin in [2134] with severe RV dilation (increased in severity since prior ECHOs obtained from [Hospital1 ]--by report, then re-verified after retrieval of echocardiogram images). Patient's previous cardiac MR reviewed from 2 years ago as compared to echocardiogram here suggested similar cariac function. Patient did not show evidence of fluid overload throughout his hospitalization, and aside from intial diuresis on D#2 of hospitalization, patient was kept euvolemic throughout his stay. . 3. Neurologic Status - as above, patient received Arctic sun cooling protocol on admission for duration of 36 hours. From [6-8] to [6-11] patient remained intubated, limiting adequate neurological evaluation; when sedation was lessened, we would open his eyes, move his trunk, and gag vigourously, without clear evidence if these movements were purposeful. Upon transfer to the medicine floor, patient was able to answer some simple questions appropriately, but with significant dysarthria, with muscoloskeletal deficits in upper trunk and left upper extremity. Initial CT of the head upon admission showed no acute abnormalities. Subsequent MRI of the head post-intubation was consistent with diffuse anoxic brain injury; however, the long-term implications of the anoxic injury were unclear. [Name2 (NI) 62847] consult followed patient throughout his stay. . 4. Respiratory failure/aspiration pneumonia - patient initially intubated for airway protection during cardiac arrest and remained intubated through cooling protocol. Patient's chest imaging initially demonstrated bilateral opacities, right greater than left and was initiated upon Unasyn empirically for aspiration pneumonia. Following discontinuation of cooling protocol, patient was extubated on [6-12] with adequate gag reflex and alertness without event. Due to temperature to 101.9, antibiotics were changed to Vancomycin and Zosyn, with completion of a ten-day course of these antibiotics with resolution of fevers with markedly improved secretions. On days following extubation, patient was noted to have apneic periods of variable durations with stable oxygen saturations >90%. ABGs did demonstrate pO2 decreases during apneic periods to 50s, despite maintaining adequate peripheral oxygen saturations. A pulmonary consult was placed, with a modified sleep study being performed while still in the CCU, with recommendations for CPAP support. Plan was for outpatient sleep study. . 5. ETOH withdrawal - undetermined chronicity or quantity of alcohol ingestion prior to hospitalization. Patient initially with ethanol level upon admit, with midazolam utilization for sedation for intubation. Patient showed no signs of withdrawal following extubation. . 6. fEN - patient was initially started on tube feeds while still intubated, then advanced to softs/pureed prior to transfer to floor, without apparent issue. One hour prior to ultimate cardiac arrest, patient had eaten applesauce with crushed pills without apparent difficulty, fed by nursing staff. . 7. PPX - patient was kept upon H2 blockade and SC heparin for GI stress ulcer and DVT prophylaxis. . 8. Contacts - mother - [Name (NI) ]: [Telephone/Fax (1) 62848], [Name2 (NI) ]r: [Name (NI) ]: [Telephone/Fax (1) 62849] Legal services involved with case from onset. No communication with any individuals other than family was upheld througout hospitalization. Medications on Admission: Unknown - parents believe not on any meds Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Primary: Congenital heart disease- D-Transposition of the great vessels Right ventricular hypertrophy anoxic brain injury aspiration pneumonia central sleep apnea cardiac arrest with result of death Discharge Condition: Patient expired. Discharge Instructions: Patient expired. Followup Instructions: Patient expired.	[ "745.12", "427.5", "305.1", "348.30", "429.3", "305.00", "327.27", "507.0", "E888.9", "276.2", "348.1", "427.1", "910.0" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.91", "96.72", "96.04", "99.60", "93.90" ]	icd9pcs	[ [ [] ] ]	28102, 28111	21130, 27968	328, 383	28353, 28371	2828, 3121	28436, 28455	2326, 2343		28061, 28079		28132, 28332		27994, 28038			28395, 28413									2358, 2809																			274, 290												411, 1718		3130, 21107												1740, 2041	2057, 2310
66,595	128,710	43602	Discharge summary	report	Admission Date: [2160-6-8] Discharge Date: [2160-6-16] Date of Birth: [2097-6-1] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1390] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [2160-6-9] Exploratory laparotomy, loop terminal ileostomy, omentectomy. History of Present Illness: Mr. [Known lastname ] is a 63 year old man with h/o metastatic colon ca, on 5-FU/Leucovorin (Oxaplatin d/c'd [1-30] to neuropathy), peritoneal carcinomatosis, who presents with abdominal pain. The patient had onset of intermittent abdominal pain starting 2 days ago. It was periumbilical with no radiation, worsened on Saturday. Noted to be worse with food, so had decreased PO intake yesterday. Similar in nature to abdominal pain in [2-8], when he was found to have a UTI. Associated with lightheadedness with standing. No nausea, vomiting, constipation, diarrhea, melena, BRBPR. The patient had been feeling quite well up to this point. His family notes that his energy was improved and that he was going for walks outside. In the ED, initial VS: 100.2 97 107/68 20 100%. Exam was remarkable for suprapubic tenderness. Labs notable for WBC 14.2, mild transaminitis, Cr at baseline 1.3. UA dirty, but no bacteria. He had a renal u/s to rule out hydronephrosis. CT torso was done (wanted to eval abd/pelvis, patient was due for CT torso in a week), which showed colitis. Pain was controlled with Morphine 4mg IV x3. He was given Cipro IV for presumed UTI, then added Flagyl when CT showed e/o colitis. Tylenol given for T 101.8, cultures drawn. Given 3L NS. Vitals prior to transfer: 101.8 117 124/77 16 96%RA. On the floor, intial vitals: 100.7 130/82 114 20 95%RA. The patient was still having [7-6] abdominal pain in the periumbilical region and lower quadrants, up to [10-6] with palpation. No nausea, vomiting. +Dysuria. Past Medical History: [8-/2158] Initial presentation with nocturia, nausea and LUQ pain weight loss (16lb over 2mo). Imaging revealed extensive peritoneal and omental nodularity which appearance was consistent with carcinomatosis as well as right hydronephrosis and hydroureter secondary to a mass versus lymphadenopathy at the base of the right ureter. The largest lesion was at the right lower quadrant/inseperable from bowel loops. Numerous lesions medial to the right psoas. Right lower lobe pulmonary nodule. A CT-guided biopsy of the omentum revealed malignant cells, consistent with well-differentiated adenocarcinoma, favoring a colorectal / appendiceal origin, supported by positive AE [12-31] and CDX2 immunostains. CEA was 147. [2158-11-9]: Start FOLFOX chemotherapy (dose-reduced 25% for C2 due to side effects). [2159-7-23]: Cycle # 8, D# 15 : discontinue Oxaliplatin due to neuropathy [12/2159] CT torso: stable disease. - Currently C19D13 of 5FU/Leucovorin - Plan for internalization of R ureter stent in near future Other Past Medical History: HTN DM2 HLD Social History: The patient is married, has three daughters, lives in [Name (NI) 1474]. His is expecting a grand kid in [Month (only) 958]. He emigrated from [Country 2045] in [2122] and worked for [Company 2267] in the sitting and receiving department. He is a lifelong nonsmoker. Tobacco use: None. Alcohol use: Rarely. Recreational drug use: None. Family History: Mother with h/o DM. No family h/o cancer. Physical Exam: Temp 100.7 BP 130/82 HR 114 RR 20 O2 sat 95%RA. GEN: AOx3, NAD HEENT: PERRLA. dry MM. OP clear. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: tachycardic, S1/S2 normal. no murmurs/gallops/rubs. Pulm: No dullness to percussion, CTAB no crackles or wheezes Abd: BS+, soft, tender to palpation in lower quadrants, ND, no rebound/guarding, no HSM, no [Doctor Last Name 515] sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: AOx3, no focal deficits Pertinent Results: ADMISSION LABS: [2160-6-8] 03:45AM BLOOD WBC-14.2# RBC-4.43 Hgb-13.7* Hct-38.4* MCV-87 MCH-30.9 MCHC-35.6* RDW-16.3* Plt Ct-170 [2160-6-8] 03:45AM BLOOD Neuts-68 Bands-1 Lymphs-19 Monos-11 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [2160-6-8] 03:45AM BLOOD Glucose-138* UreaN-17 Creat-1.3* Na-134 K-3.6 Cl-97 HCO3-25 AnGap-16 [2160-6-8] 03:45AM BLOOD ALT-52* AST-47* AlkPhos-106 TotBili-0.8 [2160-6-8] 03:45AM BLOOD Lipase-19 [2160-6-8] 03:48AM BLOOD Lactate-2.2* URINE: [2160-6-8] 03:45AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.012 [2160-6-8] 03:45AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [2160-6-8] 03:45AM URINE RBC-14* WBC-13* Bacteri-NONE Yeast-NONE Epi-1 TransE-<1 MICRO: [2160-6-8] BC x 2 NG [2160-6-8] UCx: neg [2160-6-9] Peritoneal fluid: NG STUDIES: [2160-6-8] CT Torso: IMPRESSION: 1. Hyperemia, wall thickening and fat stranding in the sigmoid colon could be due to a primary colitis of inflammatory or infectious etiology with reactive changes in the distal ileum. A small bowel etiology is considered less likely. Direct visualization with sigmoidoscopy should be considered. 2. Unchanged left upper lobe pulmonary nodule. Non-visualization of the previously noted right pulmonary nodule secondary to atelectasis. No new pulmonary nodules noted. 3. No evidence of hydronephrosis in the right kidney and normal appearance of the nephroureteral stent. 4. Diffuse fatty infiltration of the liver. . [2160-6-8] Renal U/S: 1. Nephrostomy tube not clearly seen within the renal pelvis, but well seen within the bladder; however, please note that nephrostomy tube was seen in appropriate position on the same day CT scan. 2. Bilateral renal cysts. Brief Hospital Course: Mr. [Known lastname ] is a 63 year old man with h/o metastatic colon ca, peritoneal carcinomatosis, on 5-FU/Leucovorin C19D13, who presented with acute onset of abdominal pain, fever empirically treated for infectious colitis with ciprofloxacin and Flagyl with hospital course complicated by SBO requiring surgical intervention. . #. Abdominal pain. On presentation patient with acute onset of abdominal pain 2 days ago and associated fever. Admission CT torso with findings concerning for sigmoid colitis. Patient empirically stated on ciprofloxacin and Flagyl in setting of. leukocytosis and fever. On HD2 patient developed acute worsening of abdominal pain with associated abdominal distension and inability to pass flatus or stool. Exam concern for rebound. STAT KUB/CXR obtained which was negative for free air but demonstrated distended loops of small bowel. NGT placed to suction. Surgery consulted and decision made to treat patient urgently to the OR for operative mgmt of SBO. He was taken to the Operating Room on [2160-6-9] and underwent an exploratory laparotomy with loop ileostomy and omentectomy. He tolerated the procedure well and returned to the PACU in stable condition. He maintained stable hemodynamics and his pain was adequately controlled. Following transfer to the Surgical floor he remained NPO until bowel function returned. He transiently required Toradol in addition to narcotics for pain relief and was then able to get out of bed and try to participate in Physical Therapy. He initially required maximal assist but as his hospitalization lengthened he was improving daily and will have some home physical therapy. A diet was started on POD # 5 and he gradually increased to a regular diabetic diet which was well tolerated though modestly. He was seen on multiple occasions by the Ostomy nurse for care and teaching with both Mr. [Known lastname ] and his family. He has a bridge under his ostomy which will be removed at his first post op visit and his staples will also be removed at that time. Blood sugars post op were variable and he was placed on his pre op Lantus though at a lower dose. This was increased to 30 units as his sugars were in the 120 - 200 range. He will continue to follow his sugars QID at home and follow up with Dr. [Last Name (STitle) ] in case further adjustment is needed. He had metastatic involvement of proximal R ureter and is now s/p nephrostomy tube placement on the right. Per outpatient provide plans to internalize the stent in the coming months. Renal US obtained which demonstrated patency of stent without hydronephrosis of right kidney and at discharge his creatinine was 1.2. After an uncomplicated recovery he was discharged to home on [2160-6-16] and will follow up in the [Hospital 2536] Clinic in 1 week. Medications on Admission: Amlodipine 10mg PO daily Lantus 42units daily Humalog sliding scale Methylphenidate 5mg PO daily Metoclopramide 5mg PO QACHS Pyridoxine 100mg PO daily Discharge Medications: 1. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. 2. insulin regular human 100 unit/mL Solution Sig: 0-10 units Injection four times a day as needed for per sliding scale coverage. 3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 6. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Carcinomatosis, small-bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [5-6] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. * Your staples will be removed at your follow-up appointment. * Continue to follow the instructions given to you by the ostomy nurse and the VNA will also help you with ostomy care. Followup Instructions: Call the Acute care Clinic at [Telephone/Fax (1) 600] for a follow up appointment in 1 week for staple removal and bridge removal. Call Dr. [Last Name (STitle) ] for a follow up appointment in [12-30] weeks. Provider: [First Name4 (NamePattern1) 4912] [Last Name (NamePattern1) 4913], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2160-6-23] 10:00 Provider: [First Name4 (NamePattern1) 4617] [Last Name (NamePattern1) 4618], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2160-6-23] 11:00 Provider: [Name10 (NameIs) 706] CARE,ONE [Name10 (NameIs) 706] CARE UNIT Phone:[Telephone/Fax (1) 446] Date/Time:[2160-6-24] 7:30 Completed by:[2160-6-17]	[ "593.4", "272.0", "567.89", "560.89", "585.9", "338.3", "558.9", "250.00", "591", "198.1", "599.0", "197.6", "584.9", "V10.05", "403.90" ]	icd9cm	[ [ [] ] ]	[ "54.4", "46.01" ]	icd9pcs	[ [ [] ] ]	9604, 9659	5890, 8713	316, 395	9743, 9743	4069, 4069	11871, 12576	3466, 3509		8915, 9581		9680, 9722		8739, 8892			9894, 11351						11367, 11848			3524, 4050																			262, 278												423, 1976					4085, 5867			9758, 9870						3059, 3073	3089, 3450
54,438	176,725	19259	Discharge summary	report	Admission Date: [2198-5-16] Discharge Date: [2198-6-2] Date of Birth: [2148-6-17] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 922] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [2198-5-17] 1. Mitral valve repair with a [Company 1543] Profile 3-D annuloplasty ring cyst, model #680R, serial #[Serial Number 52467]. 2. Tricuspid valvuloplasty with an [Doctor Last Name ] MC3 annuloplasty system, model #4900, size is 30 mm, serial #[Serial Number 52468]. The size of the [Company 1543] Profile 3-D was 32 mm. 3. Full left and right-sided Maze procedure with a combination of the [Company 1543] Irrigated BP-2 bipolar RF system as well as the CryoCath. [2198-5-16] Cardiac Cath History of Present Illness: 49 year old gentleman who has been followed for mitral regurgitation since [2191-3-6]. He has severe hypertension that resulted in left ventricular dilatation and mitral regurgitation. Over the course of six years, the mitral regurgitation has worsened (left ventricular ejection fraction has not changed from 30%) despite attempts to gain control over his systemic blood pressure. Follow up echocardiograms revealed severe mitral regurgitation with similiar left ventricular function and a severely dilated left ventricle. He continues to be relatively asymptomatic of his mitral disease. He has seen Dr [Last Name (STitle) 914] for an operation and is here today for a catheterization before proceeding. Past Medical History: Mitral Regurgitation Tricuspid Regurgitation Hypertension Atrial fibrillation (since [2191]) Social History: Lives with: He is initially from [Country 3594]. He lives with his girlfriend. Occupation: [Name2 (NI) ] previously worked on a cruise ship, and did carpentry. Currently unemployed Tobacco: Denies ETOH: Rare use Family History: Father who died of a stroke at the age of 48. Mother died at 56yo, possibly of MI Physical Exam: Pulse: 62 Resp: 18 O2 sat: 100% B/P Right: 151/114 Left: 165/107 Height: 5'7" Weight: 178lb General: NAD, WGWN, appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur -no murmur appreciated Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] no Edema; On the right medial side of the calf has large area of varicous veins, which are soft and non painful. Right leg is w/o any varicosities. 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: no Left: no Pertinent Results: [2198-5-16] Cath: 1. Selective coronary angiography of this right dominant system demonstrated angiographically apparent flow-limiting coronary artery. The LMCA, LAD, LCx, and RCA had no angiographically significant disease. 2. Resting hemodynamics revealed mildly elevated left- and right-sided filling pressures with a mean PCWP of 16 mmHg and an RVEDP of 14 mmHg. Pulmonary arterial pressures were mildly elevated at 35/27 mmHg. Cardiac output was significantly decreased at 2.4 L/min with an index of 1.3 L/min/m2. [2198-5-17] TEE: PRE-CPB:1. The left atrium is markedly dilated. Moderate to severe spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 30 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 4. The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with normal free wall contractility. 5. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are elongated. No mass or vegetation is seen on the mitral valve. There is bilateral leaflet restriction. Moderate to severe (3+) mitral regurgitation is seen. There is dilatation of the annulus, which measures 5.1 cm 8. The tricuspid valve leaflets fail to fully coapt. The tricuspid annulus is enlarged and measures 4.2 cm. Dr. [Last Name (STitle) 914] was notified in person of the results. POST-CPB: On infusions of milrinone, norepinephrine, amiodarone. AV pacing ,then apacing for slow JR. [Name (NI) ]-seated annuloplasty rings in the mitral and tricuspid positions. Trivial MR [First Name (Titles) ] [Last Name (Titles) ]. No gradient across mitral or tricuspid valves with CO= 7 L/min. LVEF is now 35% on inotropic support. Normal RV systolic function on inotropic support. AI remains trace. Aortic contour is normal post decannulation. Brief Hospital Course: The patient was brought to the operating room on [2198-5-17] where the patient underwent Mitral Valve Repair, Tricuspid Valve annuloplasty and full Maze procedure. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. He was found to be in junctional escape rhythm and EP was consulted. Beta blocker was held initially and the patient was gently diuresed toward the preoperative weight. He was started on IV Nitro for hypertension and oral agents were titrated. Anti-coagulation was resumed with Coumadin for atrial fibrillation. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He was planned for discharge on post-op day nine but spiked a temperature. Incision was clean without erythema or drainage. Blood cultures and U/A were negative. In addition he developed abdominal discomfort with elevated LFT's. Transplant Surgery was consulted and the underwent multiple imaging studies which were all negative. LFTs were normalizing by the time of discharge. He did develop some runs of ventricular tachycardia. He remained hemodynamically stable. EP evaluated the patient and recommendations were made. Ultrasound was performed on the RLE for tenderness and swelling that would return negative for DVT. By the time of discharge the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA in good condition with appropriate follow up instructions. [Company 191] anti-coagulation to continue managing Coumadin/INR. Medications on Admission: AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily CARVEDILOL [COREG] - 25 mg Tablet - 1 Tablet(s) by mouth twice daily FUROSEMIDE - 80 mg Tablet - one Tablet(s) by mouth every other day (prn) LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily WARFARIN - 5 mg Tablet - 1 Tablet by mouth daily five days per week; one & one-half tablets twice per week; or as directed by [Hospital 263] clinic Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR Coumadin for A-fib Goal INR 2-2.5 First draw [2198-6-3] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by [Hospital 191] [Hospital ] clinic Results to phone [Telephone/Fax (1) 2173] 2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 4. 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 5. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 6. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Dose may change for goal INR 2-2.5, managed by [Hospital 191] [Hospital ] clinic. Disp:60 Tablet(s) Refills:0 7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 13. white petrolatum-mineral oil Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for lower extremities . Disp:qs Refills:0 14. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Mitral Regurgitation s/p MV repair Tricuspid Regurgitation s/p TV repair Atrial fibrillation s/p MAZE procedure and LAA ligation Post operative junctional rhythm Hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with Dilaudid Sternal Incision - healing well, no erythema or drainage Edema: trace, R>L Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: The following appointments are already scheduled for you Surgeon: Dr. [Last Name (STitle) 914] [Telephone/Fax (1) 170] on [6-19] at 1:15pm Cardiology/heart failure [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] NP [Telephone/Fax (1) 62] [7-3] 2:30 Please call to schedule the following: Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) ] T. [Telephone/Fax (1) 52469] in [5-8] weeks Labs: PT/INR Coumadin for A-fib Goal INR 2-2.5 First draw [2198-6-4] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by [Hospital 191] [Hospital ] clinic Results to phone [Telephone/Fax (1) 2173] Completed by:[2198-6-6]	[ "428.23", "425.4", "577.0", "427.31", "424.2", "427.1", "401.9", "V58.61", "575.0", "424.0", "E878.8", "428.0" ]	icd9cm	[ [ [] ] ]	[ "39.61", "37.33", "35.33", "88.56", "37.21", "37.36" ]	icd9pcs	[ [ [] ] ]	9684, 9690	5372, 7372	321, 853	9908, 10075	2888, 5349	10862, 11597	1972, 2055		7827, 9661		9711, 9887		7398, 7804			10099, 10839									2070, 2869																			269, 283												881, 1598														1620, 1718	1734, 1956
16,560	109,090	49940	Discharge summary	report	Admission Date: [2113-1-30] Discharge Date: [2113-2-17] Date of Birth: [2027-9-7] Sex: F Service: MEDICINE Allergies: Codeine / Keflex / Clindamycin / adhesive tape / Gentamicin / Zosyn / Cefepime Attending:[First Name3 (LF) 99] Chief Complaint: N/V/Hypotension/Upper GI bleed Major Surgical or Invasive Procedure: Upper endoscopy x 2 intubation/extubation History of Present Illness: Ms [Known lastname 104301] is a 85 year-old female with hx of dyphagia and aspiration s/p G-tube placement 1.5 months ago sent in from [Known lastname ] to the ED with hypotension, nausea, and vomiting. She had been in rehab for a month after her G-tube placement until 2 weeks prior to this presentaiton. She presented to [Known lastname ] on the day of admission with decreased intake via PEG tube secondary to nausea. She states she had slightly decreased intake the day prior to admission, but became extremely nauseous the day of admission and could not tolerate intake through her G-tube. She denies abdominal pain, bright red blood in her stool, or melena. In the ED, initial VS: BP 75/40. She was guaiac negative on exam. Surgery was consulted and evaluated her. She was noted to have bright red blood from the G-tube when it was flushed. Her Hct was in the mid 20's (from mid to high 30's). GI was contact[Name (NI) ] and plan to scope once in the MICU. She was started on a prontonix gtt. She has two PIVs (20-guage) placed. She was given 2 L NS and ordered for 1 unit of PRBC. Right as she was going to be taken up to the MICU, her pressure dropped to a SBP of 60. She was symptomatic. She was laid flat with improvement to 79/44. Her unit of PRBC had just been started when her pressure dropped. She was also nuaseous and was given some zofran. A third liter of NS was started. Most recent pressure prior to transport was 91/38. When the patient arrived in the MICU peripheral levophed was running. She was maintaining BP in the 90's. She denied pain. On ROS she denies fevers, chills, dizziness, CP, shortness of breath, dysuria or other symptoms. Past Medical History: Diastolic CHF Atrial Fibrillation s/p Ablation Dilated Ascending Aorta Osteoporosis Hypothyroidism Dysphagia for several years with Weight Loss s/p G-tube placement History of PNA requiring VATS pleural effusion drainage and decortication on the right side Diverticulosis/Diverticulitis Cerebral Palsy Macular degeneration Ventral Hernias Rosacia Past Surgical History: 1. Status post removal of bowel obstruction due to diverticulitis requiring a temporary colostomy 2. Status post surgical repair of a prolapsed uterus 3. Status post total hysterectomy 4. Status post abdominal surgery secondary to complications of prolapsed uterus surgery - The patient developed multiple hernias. 5. Status post surgery for exposed keratoses 6. Status post G-tube placement Social History: She lives alone in [Location (un) ]. No tobacco, alcohol, or drug use. Family History: non-contributory Physical Exam: Initial exam: GEN: Elderly female laying in bed in NAD. Difficult to understand. HEENT: Pupils cloudy, EOMI, anicteric, MM dry, op without lesions, no jvd RESP: Breathing comfortably. CTAB. CV: [Location (un) 8450], 3+ systolic murmur heard best at the LUSB. ABD: +BS, soft, NTND, large ventral hernia present. G-tube present with bright red blood in the tube with dressing around it. EXT: no c/c/e NEURO: Alert and oriented to person, place, and time. Grossly nonfocal. Discharge exam: General Appearance: extubated, AOx3 Cardiovascular: normal S1/S2, murmur Respiratory / Chest: clear to auscultation bilaterally Abdominal: mildly distended, Non-tender, multiple surgical sites, ventral hernias Neurologic: answering questions, responding appropriately Pertinent Results: Admission Labs: Na 142 K 4.4 Cl 105 BUN 88 Cr 0.5 Glu 242 . WBC 10.3 Hct 26.7 Plt 227 N 90.7% L 6.3% M 2.2% . PT 15.3 PTT 25.7 INR 1.3 . Lactate 2.4 . Hct 26.7 --> 26 --> 25.2 --> 19.1 . UA neg leuk, neg nitr . Micro: BCx - pending . EKG: normal sinus rhythm with 1st degree AV delay. No STE or STD TWI in 1 Imaging: CXR: IMPRESSION: No acute intrathoracic process. KUB: IMPRESSION: 1. No evidence of obstruction. 2. Limited assessment for free air. EGD [1-30]: Stomach: Contents: Red blood was seen in the stomach. Large clots present in fundus below GE junction. PEG site with balloon [Month/Year (2) 48613] without active bleed or [Month/Year (2) ] from site. Despite lavage for over two hours unable to clear field for optimal look at fundus. Potential ulceration on greater curvature but unclear and no visible vessel or active bleeding from that site. Clot re-formed after suction given active bleed. Impression: Blood in the stomach Blood in the duodenum Blood in the esophagus Otherwise normal EGD to second part of the duodenum EGD [1-31]: Stomach: Excavated Lesions A single cratered [Month/Year (2) ] was found in the fundus just distal to GE junction at the greater curvature across from the ballon, which appeared to be the source of bleeding. Dimensions 2cm x 4 cm. No visible vessel or active bleeding therefore no intervention performed. Small amount of red blood in stomach. No [Month/Year (2) ] beneath PEG site. Duodenum: Other Small amount of old blood seen in duodenum. Impression: [Month/Year (2) ] in the fundus just distal to GE junction Small amount of old blood seen in duodenum. Otherwise normal EGD to second part of the duodenum CXR [2-17]: Cardiomediastinal contours are stable in appearance. Persistent left lower lobe collapse and adjacent small left pleural effusion. Linear atelectasis present at right base with otherwise clear appearance of right lung. Brief Hospital Course: # Upper GI Blood: Patient has a baseline Hct in the high 30's (most recently in [Month (only) ] during her recent hospitalization it was in the mid 30's). On admission Hct of 26 which was an acute decline. Guaiac negative on rectal exam, however bright red blood was noted to come from the G-tube concerning for an upper GI bleed. She was admitted to the MICU. Prior to admission, she became hyotensive to the ED requiring levophed. EGD in the MICU initially showed voluminous bleeding. Her hematocrit continued to fall to as low as 19. Massive trasnfusion protocol was activated. The patient received 9 units packed RBCs, 2 units FFP, 1 unit of platelets, and 4 L NS. Her hematocrit stabilized and levophed was weaned as she was volume resuscitated. Patient received several units prbcs and GI was consulted and performed EGD which revealed large clot in the fundus just distal to GE junction with pulsation seen near the clot and oozing. PEG site with no evidence of bleeding. She was initially on a protonix gtt and then transition to PPI [Hospital1 ] with planned 8 week course. Overnight on [2-5] she was noted to have hypotension and tachycardia in the context of bright red blood output per her G-tube. Her HCT dropped from 39 to 31 and she became tachycardic and hypotensive. In this context she had altered mental status with confusion and delirium. In the ICU a subclavian line was placed as peripheral access was lost. The patient was evaluated by IR, surgery, and GI and sent to the IR suite for further management. In the IR suite she had embolization of her left gastric artery, which was bleeding, leading to her stabilization. She subsequently had a stable hct with several days of melena but no bright red blood per rectum or g-tube. She is continued on lansoprazole 30mg [Hospital1 ]. In total she required 6U PRBCs, but has not required a transfusion for over a week at the time of discharge. # Respiratory Failure: Patient was electively intubated for EGD because had had difficult EGDs in past. She remained ventilated for one day and then was extubated on [2113-2-1]. However, in the second admission to the ICU, on [2-6] pt was found to have a PEA arrest requiring rapid reintubation. Pt subsequently had difficulty with extubation requiring increasing pressure support and having difficulty producing negative inspiratory force. Respiratory failure was felt to be [2-22] hypervolemia and HAP. HAP was treated with vancomycin x10d for staph aureus found on sputum cx. Pt was also diuresed to pre-admission wait. With improvement of pna and volume status the pt continued to have difficulty with extubation so neurology was consulted and felt that her inability to be extubated could be [2-22] underlying chronic dystrophy(possibly [Last Name (un) 52373]-scapulo-humeral)which was exacerbated by neuromuscular blockade from gentamicin. Patient slowly improved and was subsequently able to be successfully extubated. . # Hypotension: Pt was hypotensive in the setting of GI bleed and sedation for intubation as above. Pt required pressor support with Neosynephrine followed by Levophed. Pressors were weaned as pt stabilized and sedation was weaned. Home blood pressure meds were held at discharge, and should be restarted at her rehab facility. # Chronic diastolic heart failure: Most recent TTE in [9-29] showed EF >70%. Held metoprolol and lisinopril in the setting of hypotension. . # History of atrial fibrillation s/p ablation: Held ASA and metoprolol in the setting of GI bleed and recent hypotension. Aspirin will be held at least 2 weeks per GI recs, to be restarted on [2-19]. # Chronic Dysphagia: The patient has chronic dysphagia and problems clearing secretions. She was started on atropine drops by mouth to help decrease secretions. Those were subsequently held and she was continued on tube feeds. # The patient's hypothyroidism and osteoporosis were stable and she is discharged on home levothyroxine, boniva, calcium, and vitamin d. # Osteoporosis: On Boniva q3 months. Initially held ca/vit d but restarted once stabilized. . # Comm: Daughter, [Name2 (NI) ] [Name (NI) 79] cell: [Telephone/Fax (1) 104302]. HCP son [Name (NI) ]. [Name2 (NI) 7092] Status: Full code Dispo: Pt discharged to [Hospital 100] Rehab on [2113-2-17]. Medications on Admission: Levothyroxine 50mcg po by mouth daily Ferrous Sulfate 220 mg (44 mg Iron)/5ml solution - 7.5 ml po daily Ranitidine HCl 15 mg/ml syrup - 10 ml by mouth [Hospital1 ] Docusate Sodium 60 mg/15mL syrup - 30 mL(s) by mouth [Hospital1 ] Calcium carbonate 1250mg daily Metoprolol 25mg [Hospital1 ] (no PM dose if systolic <100) Lisinopril 40mg daily Diazepam - 1mg daily at bedtime Senna 8.6 mg tab - 1 tab TID PRN Aspirin 325mg - 1 tab daily Vitamin D 500 mg [Hospital1 ] Zymar (Gatifloxacin) 0.3% eye drops - Four times/day MWF Erythromycin ointment - 5mg/gram ointment in her eyes - daily at bedtime Bacitracin Zinc Polymycin B Sulfate - 3.5mg ointment po qhs Boniva q3 months Multivitamin Miralax prn Discharge Medications: 1. erythromycin 5 mg/gram (0.5 %) Ointment [Hospital1 ]: One (1) drops Ophthalmic QHS (once a day (at bedtime)): one drop in each eye. 2. bacitracin-polymyxin B 500-10,000 unit/g Ointment [Hospital1 ]: One (1) Appl Ophthalmic QHS (once a day (at bedtime)): apply to both eyes. 3. diazepam 2 mg Tablet [Hospital1 ]: 0.5 Tablet PO QHS (once a day (at bedtime)). 4. levothyroxine 50 mcg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 6. guaifenesin 100 mg/5 mL Syrup [Last Name (STitle) ]: Ten (10) ML PO Q6H (every 6 hours). Disp:1200 ML(s) Refills:2 7. quetiapine 25 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO QHS PRN () as needed for agitation, insomnia. 8. acetaminophen 325 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, headache, fever. 9. cholecalciferol (vitamin D3) 400 unit Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 10. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid [Last Name (STitle) ]: Five (5) ml PO DAILY (Daily). 11. moxifloxacin 0.5 % Drops [Last Name (STitle) ]: One (1) drop both eyes Ophthalmic TID (3 times a day) as needed for eye redness/irritation. 12. atropine 1 % Drops [Last Name (STitle) ]: One (1) drop Ophthalmic four times a day as needed for oral secretions. 13. therapeutic multivitamin Liquid [Last Name (STitle) ]: Five (5) ML PO DAILY (Daily). 14. zinc sulfate 220 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO DAILY (Daily). 15. ascorbic acid 500 mg/5 mL Syrup [Last Name (STitle) ]: Five (5) ml PO DAILY (Daily). 16. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization [Last Name (STitle) ]: One (1) nebulization Inhalation every six (6) hours as needed for shortness of breath or wheezing. 17. ipratropium bromide 0.02 % Solution [Last Name (STitle) ]: One (1) nebulization Inhalation every six (6) hours as needed for shortness of breath or wheezing. 18. Artificial Tears Drops [Last Name (STitle) ]: 1-2 drops Ophthalmic every four (4) hours as needed for dry eyes. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: Upper GI Bleed secondary to Gastric [Hospital6 ] PEA arrest Hospital Acquired Pneumonia Secondary: Hyperlipidemia Hypertension Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital for a large bleed from an [Hospital6 ] in your stomach. The GI doctors [Name5 (PTitle) 48613] the [Name5 (PTitle) ] and confirmed that it was the cause of your bleed, but it had stopped bleeding. You were treated with a medicine to reduce the amount of acid in your stomach and help your stomach heal. Your were transfused blood as your large bleed had caused your blood levels and blood pressure to get quite low. During your stay, you had an event where your heart stopped beating, but your heartbeat returned with medications. You were intubated at that time to help you breathe. You were diagnosed with a pneumonia, and received a full course of antibiotics. You were given medications to help reduce the fluid in your lungs. Your breathing tube was removed on [2-16], and you have done very well since that time. At the time of discharge your blood levels were stable, you were breathing well on low levels of oxygen, and you were tolerating your tube feeds. . The following changes were made to your medications: -You were started on lansoprazole twice per day. -You were started on seroquel 12.5mg at night as needed to help you sleep -Please restart aspirin 325mg daily on [2113-2-19] -You are being given albuterol and ipratropium nebulizers to help with your breathing as needed. -You were started on multivitamin, ascorbic acid, and zinc. -Your blood pressure medications (lisinopril and metoprolol) were held due to low blood pressures. They will restart these at your rehab facility once your blood pressures are back to your baseline. -The eye medication Zymar was held due to the fact that you were on multiple eye medications. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [2113-2-22] at 1:20 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: INFUSION/[Hospital Ward Name 1248] UNIT When: THURSDAY [2113-3-2] at 10:15 AM [Telephone/Fax (1) 14067] Building: GZ [Hospital Ward Name ] BUILDING (FELBEERG/[Hospital Ward Name ] COMPLEX) [Location (un) ] Campus: EAST Best Parking: Main Garage Endoscopy appointment: [2113-4-21] at 1pm Please call Dr.[Name (NI) 104303] office next week to find out when the anesthesia appointment will be (usually one week before the endoscopy appointment). Completed by:[2113-2-17]	[ "276.52", "343.9", "428.0", "998.30", "486", "733.00", "276.0", "428.32", "276.3", "518.81", "531.00", "553.20", "426.11", "518.0", "362.50", "V55.1", "787.01", "427.5", "276.7", "244.9", "V70.7", "562.10", "285.1" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.72", "99.60", "96.6", "45.13", "96.04", "88.47", "44.44", "38.93" ]	icd9pcs	[ [ [] ] ]	13189, 13255	5821, 10195	367, 410	13455, 13455	3854, 3854	15450, 16265	3036, 3054		10959, 13166		13276, 13434		10221, 10936			13631, 15427							2533, 2926		3069, 3549					3565, 3835														297, 329												438, 2140					3870, 5798			13470, 13607						2162, 2510	2942, 3020
2,779	113,282	30164	Discharge summary	report	Admission Date: [2161-3-28] Discharge Date: [2161-4-17] Date of Birth: [2108-1-8] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1384] Chief Complaint: Transfer from OSH with acute renal failure Major Surgical or Invasive Procedure: Renal biopsy [2161-4-2] left nephrectomy [2161-4-3] tunnelled HD line [2161-4-16] History of Present Illness: 53M etoh cirrhosis (MELD 37), CAD, COPD, presents from OSH with acute renal failure and confusion. He was diagnosed with cirrhosis about a year ago. He has been followed by hepatology at [State 792]Hospital. Recent meld was 24 in [12-10] with cr 1.2, INR 1.8, and t. bili 9.1. The patient routine labs drawn on [3-23] which showed a Cr of 5.5. He was called by his physician and asked to come to the ED on [3-24]. At OSH, he was being treated with vanc, although uncleear about the actual or suspected source of infection. Paracentesis was considered but not done as he did not have obvious ascites on exam. The pt arrived in stable condition, satting 100 on RA, appearing comfortable. He was A+O x3 and appropriate with very mildly slurred speech, though no asterixis. Seen and evaluated by transplant medicine team on [3-28]. The patient states that he was feeling at his baseline. However, he was unable to provide detailed history about his medical problems. [Name (NI) ] wife, he has been very forgetful over the past few months with increasing confusion. He is fairly independent at home and able to carry out routine ADLs. He always complains of thirst and has been staying well hydrated with fluids. However, he has had tea-colored urine for the past few months. Over the last few weeks, he began to have decrease in appetite with intermittent episodes of nausea, non-bilious, non-bloody emesis. The wife feels the increased fullness is from an increase in abdominal girth also over the same period of time. He has not had alcohol since he stopped about 1 year ago. He denies any SOB, fevers, chills, myalgias. ROS is positive for BRBPR which has intermittently although he has had a negative w/u including EGD/[Last Name (un) ] which showed only hemorrhoids, adenomas and portal gastropathy. Past Medical History: Cirrhosis Hepatic encephalopathy CAD COPD Social History: Married, lives with wife. Worked as mechanic until he became sick smoker for 30 years. Abstinent from EtOH for 1 year, no drug use. Family History: Father had EtOH cirrhosis, mother died from CA Physical Exam: 97.3 142/64 58 22 98RA 86.5 kg I/O = [Telephone/Fax (1) 71883] GEN: A+O x2, slurred speech, no asterixis HEENT: scleral icterus, PERRL, EOMI, dry MM, OP clear RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g, JVP +12 ABD: soft, NT, no ascites, no caput medusae, no shifting dullness EXT: trace edema, 2+ DP pulses SKIN: mild jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps Brief Hospital Course: Patient transferred from [Hospital ] Hospital for further evaluation of ARF, MELD 32. Patient seen by Renal, Hepatology while on Medicine service. Patient remained confused since his admission (encephalopathic). Urine ouptut was low. Lasix was not helpful. He required intermittent hemodialysis via temporary hemodialysis catheter. On [4-2] (HD6) a renal biopsy was performed. He received 3 bags of platelets and 3 units of FFP prior to the biopsy on [4-2] with a platelet count of 86,000, INR 1.7. Following the biopsy, he became diaphoretic with chest pain. His Hct was 23.9% and dropped to 21% post-procedure with a platelet count of 107,000. He received 2 more units of PRBC, 2 units of plt, and DDAVP and was then transferred to the ICU. In the first 24 hours of being in the ICU, he received 8 units of PRBCs without any response in his Hct (stable at 24%), 10 units of FFP, 4 bags of platelets, DDAVP 75mcg (total), Vit K (5mg), and cryoprecipitate administered. He went to IR for embolization of suspected renal bleed, but tolerated this poorly with 9/10 chest pain with ST depression in anterior leads. A nitro drip was started. CK was 1326, MB 163 and troponin 5.[Street Address(2) ] depression. He sustained an anterior NSTEMI. CT of abdomen done on [4-3] showed an unchanged large left perinephric hematoma. Due to his continued blood requirement, he was brought to the operating room for urgent left nephrectomy. Patient transferred back to the ICU post-op. PLease see the operative [Last Name (un) ] for further details. No obvious area of bleeding could be found on the kidney. For further details of the procedure, see operative dictation. Hct remained stable post nephrectomy. JP fluid output was initially high. This decreased over time. Of note, the kidney biopsy demonstrated IgA nephropathy.There was also ongoing transplant evaluation for liver transplant. At issue was cardiac clearance given PMH of angina. Cardia echo revealed mild (1+) mitral regurgitation is seen. There was mild pulmonary artery systolic hypertension. LVEF was >55%. Cardiac cath was deferred. Stress MIBI was performed on [4-15]. Findings showed no evidence of reversible ischemia or clinical symptoms of angina. Recommendations included continuation of asa qd, continuation of beta blockers, and initiation of captopril with up titration of dose. If tolerated, captopril could be switched to lisinopril 5mg qd. IV BB was recommended perioperatively should he undergo further surgery. Tube feedings were administered via an NG tube that was in place postop nephrectomy. The nasogastric tube was self d/c'd. Calorie counts suggested that he was only meeting 50% of his needs. Ensure plus was given tid. Calorie counts were continued for eval of further need for tube feedings. Calorie counts ________. Neurologically he experienced varying degrees of encephalopathy. Lactulose was given. A psyche consult was obtained for evaluation of judgement given that he refused treatments on [4-13]. Recommendations included 1:1 sitter, identification of source of delerium and prn haldol. Haldol was not given. Rifaximin was resumed to decrease encephalopathy. He continued to present with a waxing/[Doctor Last Name 688] delerium/encephalopathy. During this time he was verbally abusive to his wife and staff. On [2161-4-16] The temporary hemodialysis catheter was changed to a tunnelled HD line without complications. An outpatient hemodialysis center was located in [Last Name (un) 30514], R.I. ([Telephone/Fax (1) 71884]). Patient received hemodialysis on Friday [4-17] prior to discharge. Medications on Admission: Vancomycin Metoprolol 50" Asa 81' HCTZ 25' Imdur 30' Lipitor 10' NTG SL Protonix 40' Lactulose Thiamine Mupirocin nares Advair 250/50" Combivent inahler Lexapro 10' Colace Discharge Medications: 1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:1 Refills:1 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 Refills:2 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): adjust to have [3-8] bowel movements per day. Disp:2700 ML(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 7. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home With Service Facility: [Doctor Last Name 792]VNA Discharge Diagnosis: Primary: Renal failure EtOH cirrhosis Hepatic encephalopathy Anemia Thrombocytopenia Coronary artery disease . Secondary: COPD Discharge Condition: fair Discharge Instructions: Please call your doctor or return to the emergency room if you develop chest pain, shortness of breath, decrease in or loss of urination, fevers, chills, confusion, increasing abdominal girth or significant weight gain, blood in your stool or dark, tarry colored stools. . Please follow up with your appointments as outlined below. Followup Instructions: [Name6 (MD) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2161-4-30] 10:30 [Last Name (LF) ],[First Name3 (LF) 156] TRANSPLANT SOCIAL WORK Date/Time:[2161-4-30] 11:00 Completed by:[2161-4-17]	[ "998.12", "285.1", "572.2", "496", "278.00", "571.2", "428.0", "286.7", "518.81", "410.11", "998.11", "599.7", "997.1", "584.8", "572.3", "303.93", "572.4", "585.6" ]	icd9cm	[ [ [] ] ]	[ "38.95", "55.23", "88.45", "99.07", "99.04", "96.72", "55.51", "96.04", "39.79", "96.6", "99.05", "99.06", "38.93", "50.11", "39.95" ]	icd9pcs	[ [ [] ] ]	8043, 8103	3170, 6815	356, 452	8274, 8281		8661, 8902	2544, 2592		7038, 8020		8124, 8253		6841, 7015			8305, 8638									2607, 3147																			274, 318												480, 2313														2335, 2379	2395, 2528
12,599	124,664	8902	Discharge summary	report	Admission Date: [2125-1-31] Discharge Date: [2125-2-10] Date of Birth: [2068-7-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2186] Chief Complaint: Back pain Major Surgical or Invasive Procedure: NA History of Present Illness: For full H&P, please see nightfloat and [Doctor Last Name 3271]-[Doctor Last Name 679] admission notes. In brief, the patient is a 56 yo man with h/o EtOH abuse, reported HepB/C positive, who presented to the ED yesterday with low back pain. The patient states that he woke up yesterday morning with low back pain, located around "L3." The patient admits to drinking 15 beers the previous night, and he does not remember any trauma, but notes that he could have "jumped out a window and not known". The patient apparently endorsed mild abdominal pain last night, but he denies nausea, vomiting, abdominal pain this morning. . In the ED, the patient was afebrile, BP dropped from 107/64 to 95/43, P 100. He was found to have a leukocytosis to 16K and a U/A which was negative. He had a plain film of his lower back, which did not show any evidence of fracture. He was placed on a CIWA scale. Because of the leukocytosis blood cultures were taken and he was started on CTX for SBP ppx and a liver U/S was obtained. The ultrasound showed coarsened echo-texture with no ascites. His hypotension resolved with 3L NS in the ED. . This morning, the patient stated that he continued to have back pain, though it is improved after Morphine and a Lidocaine patch. He denied weakness in his legs, but he did endorse distal peripheral neuropathy that he says is from his ETOH use. . Plan from [Doctor Last Name ]-[Doctor Last Name ] team was for MRI L-spine today after a CTA to r/o dissection because more epigastric pain. The CTA was negative and he was transferred to the medicine floor. . On the floor the patient was found to have HR 140s with no IV access. The patient had [9-15] lower back pain and "burning" pain with swallowing. He also c/o thirst. He denied SOB, chest pain, abdominal pain, bowel or bladder irregularities, fevers, chills, or weakness of his extremities. He notes that he has neuropathy caused from EtOH that is not worse than previous. Past Medical History: 1. Anxiety/depression. Denies history of bipolar disorder. (patient says takes seroquel 50mg twice per day and 200mg at night) 2. EtOH abuse 3. Hepatitis B positive per patient - but also hepatitis c? - denies treatment. 4. COPD - on inhalers at home Social History: Divorced twice, with three children. Alcoholism made him lose his family and two businesses. Former carptenter. EtOH x years. Smokes 1 ppd x 39 years. No drug (IV or otherwise). Reports recent period of sobriety (>2 months) started drinking again 2 weeks ago, everyday "as much as he could get". Was recently at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 23752] house after d/c from [Hospital1 392] and has been getting help with housing from a housing service in his area. Family History: 3 brothers, 1 sister: alcoholism. Sister with psychiatric problems/anxiety. Physical Exam: VS: T 98.7, BP 97/64, P 129, R 22, O2 93% on RA GEN: Discheveled, middle aged man, in pain HEENT: EOMI, PERRL, oropharynx dry and without exudate CARDIAC: Tachycardic, regular Nl S1 and S2. No r/m/g CHEST: Scattered wheezing esp in upper lobes bilaterally ABD: + BS Distended. TTP in RUQ. No rebound or guarding. EXT: No edema. Decreased sensation in lower extremities. Positive straight leg test in bilateral [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]: TTP across lower back inc. CVA tenderness and para-spinal tenderness but no point tenderness along spine. NEURO: alert and appropriate. CN II-XII intact. Reports bilat stocking pattern decreased senstaion to knee (old). No asterixis. Pertinent Results: ADMISSION LABS: . [2125-1-31] 06:55PM BLOOD WBC-16.6# RBC-5.20# Hgb-15.4 Hct-42.9 MCV-83# MCH-29.7 MCHC-36.0 RDW-14.9 Plt Ct-255 [2125-1-31] 06:55PM BLOOD Neuts-82.7* Bands-0 Lymphs-12.4* Monos-4.4 Eos-0.3 Baso-0.1 [2125-1-31] 06:55PM BLOOD Plt Ct-255 [2125-2-1] 06:30AM BLOOD PT-13.2 PTT-29.5 INR(PT)-1.1 [2125-1-31] 06:55PM BLOOD Glucose-106* UreaN-10 Creat-0.8 Na-125* K-3.8 Cl-88* HCO3-16* AnGap-25* [2125-1-31] 06:55PM BLOOD ALT-48* AST-159* AlkPhos-93 TotBili-0.6 [2125-1-31] 06:55PM BLOOD Lipase-13 [2125-1-31] 06:55PM BLOOD Calcium-9.2 Phos-2.7# Mg-2.3 [2125-1-31] 06:55PM BLOOD ASA-NEG Ethanol-86* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2125-1-31] 08:37PM BLOOD Lactate-3.9* . . PERTINENT STUDIES: . L-Spine XRay ([1-31]): AP and lateral views of the lumbar spine are btained. There are five non-rib-bearing lumbar-type vertebrae. Vertebral bodies maintain normal alignments. There is no evidence of compression fracture. Degenerative disc disease is most notable at T12-L1 with endplate spur formation seen. The posterior elements are suboptimally assessed given exclusion on the second image of the series and underpenetrated technique on the third image of the series. Extensive vascular calcifications are seen along the distal aorta on the lateral projection. SI joints and visualized portions of the hip joints appear unremarkable. EKG: Sinus tachycardia with rate ~120s. ST depressions II, V3-V5 and TWF in III CTA Chest: Prelim read: Esoph thickening, no PE, no dissection CXR: No acute C-P process ABD U/S: FINDINGS: There is a single adherent subcentimeter stone along the wall of the gallbladder, which is otherwise unremarkable. The liver has an increased echogenic appearance since the prior study, suggesting worsening liver disease. Flow in the main portal vein is hepatopetal. The spleen is not enlarged, measuring 12.2 cm in length. The pancreas is not well visualized because of overlying bowel gas. No ascites is present. Brief Hospital Course: In brief this is a 56 yo man presenting with back pain, alcohol intoxication, and elevated creatinine kinases. # Rhabdomyolysis: Patient had elevated CK on admission. The exact cause for this process is unclear but it is suspected that he must have suffered trauma while intoxicated. He was treated with IVF and urine alkalinization. His CK trended down with this intervention. # Back pain: He was noted to have small T12 and L1 compression fractures. Neurosurgery evaluated the patient. His pain was managed with Morphine. # EtOH Abuse: The patient has a significant history of EtOH abuse and EtOH withdrawal seizures, with a recent drinking binge for two weeks prior to admission with last drink the night prior to admission. Patient was placed on valium withdrawl protocol. He required high doses of valium in order to prevent withdrawl symptoms. # Agitation: This was attributed to a paradoxical valium effect. This medication was discontinued and his aggitation improved. While agitated he was places on restrains, temporarily, because he exhibited aggressive behaviour toward house staff. He was placed on haldol standing and prn. His electrolytes and QTc remained within normal levels during haldol administration. Psychiatry saw the patinent. When his aggitation decreased haldol was stopped and his home seroquel was restarted. # Elevated lactate, hypotension: The patient was hypotensive in the ED and he had a lactate which was elevated. These resolved with IVFs. There was a concern for thiamine deficiency, given the patient's history of alcoholism. He was started on thiamine supplements. # COPD: Patient has significant smoking history and reports h/o COPD for which he takes inhalers including advair at home. He was placed on nebulizer treatments for the duration of his stay. Medications on Admission: Thiamine HCl 100 mg daily Folic Acid 1 mg daily Hexavitamin 1 mg daily Pantoprazole 40 mg daily Albuterol inhaler q6h prn Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:1 bottle Refills:0 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:1 bottle Refills:0 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: please place to low back: 12 hours on 12 hours off. Disp:30 Adhesive Patch, Medicated(s) Refills:0 8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 9. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:30 Tablet(s) Refills:2 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:60 Disk with Device(s) Refills:2 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:30 Tablet(s) Refills:0 12. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO twice a day for 2 weeks. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: EtOH withdrawal COPD Discharge Condition: stable Discharge Instructions: You were admitted to the hospital with back pain. We got MRIs of your back that showed small fractures. We gave you pain medications to help relieve the pain. While you were in the hospital you requested detox from alcohol. You were treated with medications for this and you got better. You have seen the social work team and will follow up with the services they provided for you as an outpatient. Medication Changes: We added the following medications to your regimen: - folate and thiamine - oxycodone and ibuprofen for pain - seroquel for your agitation - advair for your COPD - clonidine for your blood pressure Please come back to the hospital or call your pcp if you have fevers, chills, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, blood in your stools, black stools, leg weakness, difficulty urinating, pain with urination, or any other concerning symptoms. Followup Instructions: Please call to make an appointment with your regular doctor [First Name8 (NamePattern2) ] [Last Name (STitle) 30948],[First Name3 (LF) ] T. [Telephone/Fax (1) 250] and your psychiatrist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 5139], at [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] House Completed by:[2125-2-15]	[ "V02.62", "V02.61", "291.81", "276.2", "E888.9", "728.88", "305.1", "530.10", "303.91", "805.4", "276.1", "300.00", "805.2", "292.81", "E939.4", "V12.04", "496" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	9644, 9650	5994, 7799	325, 330	9715, 9724	3960, 3960	10673, 11085	3143, 3221		7972, 9621		9671, 9694		7825, 7949			9748, 10148									3236, 3941																10168, 10650			276, 287												358, 2335					3976, 5971									2357, 2610	2626, 3127
51,891	172,241	37636	Discharge summary	report	Admission Date: [2192-11-9] Discharge Date: [2192-11-21] Date of Birth: [2108-7-8] Sex: F Service: MEDICINE Allergies: Prinivil / Keflex Attending:[First Name3 (LF) 10842] Chief Complaint: Elective admission for Plasmaphoresis Major Surgical or Invasive Procedure: IVC filter placement ([2192-11-16]) History of Present Illness: Ms. [Known lastname ] is a lovely 84 y/o right handed woman with a PMH significant for HTN, HLD, atrial fibrillation (s/p cardioversion, currently on Coumadin) and a diagnosis of CIDP that has recently come into question and is now believed to be multifocal motor neuropathy with conduction block by her outpatient neuromuscular attending (Dr. [Last Name (STitle) 1206], who presents to [Hospital1 18] today for a direct admission for plasmapheresis for MMNCB. As a result of her neuromuscular conditon, she is currently paraplegic with no movement of her lower extremities and minimal movement of her upper extremities. She says that she "can't move, can't sit and can't turn over by herself." Her symptoms began with a fall in [2191-2-10]. Prior to that, she was able to live independently and conduct all of her own ADLs; however, she had noted some difficulty with walking and especially climbing stairs or getting up from a seated position in the previous few years prior to her first fall. The first time she fell was in the snow outside; however, her subsequent falls occurred because of loss of balance; she says her legs would give out on her and then she would fall backwards. She had 11 falls between [2191-2-10] and [2192-2-10]. In [2191-12-11], she was able to still get around the house with a wheelchair and a walker. However, since her last fall in [2192-2-10], she has been in a rehab facility with her lower extremity weakness. She was admitted to the Neurology Service in [2192-4-9] as a direct admission from [Hospital 878] Clinic as she was noted to be paraplegic; she have no movement in her LE at that time, though had perserved sensory findings and LE reflexes. During that admission, she had an LP that showed 1 wbc, 2 rbc, protein 30, glucose 73 as well as an EMG/NCS which showed conduction block and was considered to be consistent with CIDP. She was then started on a 5 day course of IVIG (2g/kg total dose) and discharged back to rehab. While at rehab, she remained wheelchair bound, but there was actually some improvement noted after the IVIG as she and her son noted that by the middle of [Month (only) 116], she was able to stand with assistance and using the parallel bars. During this time, her upper extremity strength was mostly preserved, though she did note some left greater than right upper extremity weakness. She says that she has never noted any twitching of her muscles. In the middle of [Month (only) 116] she developed a left thigh hematoma (after a fall while on Coumadin) and has not been able to return to that level of lower extremity progress since. Subsequent to the hematoma, she underwent what her son called aggressive IVIG infusions- he had one week of IVIG infusions (2 g/kg divided over 5 sessions) a month for 3 months ([Month (only) ], [Month (only) 205] and [Month (only) 216]). There was no improvement with these IVIG treatments. She had a repeat EMG after the last series of IVIG treatments; this showed a severe chronic motor greater than sensory axonal polyneuropathy with ongoing axonal loss. The conduction block was no longer noted; sensory responses improved compared to the earlier EMG but motor amplitudes decreased. This did not confirm or rule out CIDP; however, it was thought that with the progressive weakness, preserved reflexes and sensation on exam (and improved sensory nerve conduction studies) and the conduction block that was no longer noted compared to previous EMG (possible improvement with IVIG treatment) that this may be MMNCB. She was subsequently started on Prednisone 60 mg daily with no improvements noted. Plasampheresis had been planned for later in [Month (only) 359]; however, she said that she has been continuing to get worse-- her left arm, which has consistently been weaker than her right, has gotten much worse (she can no longer move proximal left arm against gravity and also has been having difficulty moving/using her left hand i.e. cutting food) and her right arm has been getting weaker as well. Due to this weakness, her planned admission for plasmapheresis was expedited. Past Medical History: -CIDP, on monthly IVIG, received 30g infusion [2192-6-7] and [2192-7-30] -HTN -HLD -afib on coumadin, s/p TEE/cardioversion [11-17]. Coumadin discontinued after admission in [2192-6-9] with left thigh hematoma -left carotid plaque (unknown severity) -aortic stenosis -remote history of DVT -asthma, ? COPD -arthritis -sciatica -esophagitis -tinnitus Social History: -retired funds manager of health/welfare for Teamsters [Hospital1 ], lives with husband and son in [Name (NI) 4628]. No history of tobacco, etoh, or drugs. Family History: -mother with MI at 63. Sister and son with DM2. Physical Exam: On Admission: Mental Status: awake, alert, orientedx3. Attentive- able to [First Name8 (NamePattern2) ] [Doctor Last Name 1841] backwards rapidly. Able to perform simple calculation and follow midline and axial commands. [4-11] registration and recall at 5 minutes. No evidence apraxia or neglect. Language: clear, fluent, nondysarthric. No paraphasic errors. Intact naming/repetition/comprehension. Cranial Nerves: CN II-XII intact. PERRL 3-->2 ml. VFF. EOMI without nystagmus. Facial sensation intact. Face symmetric. Palate elevates symmetrically. Tongue protrudes in midline. Motor: Decreased muscle bulk LE b/l. No tremor. Unable to assess drift secondary to weakness. Occasional UE fasiculations. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 2 4- 4- 4- 4- 4- 4- 0 0 0 0 0 0 0 R 2 4 4 4 4 4 4 0 0 0 0 0 0 0 She has Hx of a right foot drop. DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 1 0 R 2 2 2 1 0 Unable to assess plantar response (toes mute and atrophied tensor fascia [Last Name (un) 80640]) Sensory: Intact light touch. Intact proprioception in great toe b/l but not fifth toe b/l. Decreased vibration UE b/l and no vibratory sense at feet and knees. Diminished pin prick sensation proximally in b/l UE and distally in b/l LE. No extinuishing to DSS. Coordination: unable to assess secondary to weakness. Gait/Romberg: deferred as she is paraplegic . On discharge VS: afebrile, 97.6, 150/60 (147-176/60-80), p69, rr18 Sa0298% RA GENERAL: Overweight elderly female laying supine in NAD HEENT: [Last Name (un) 84420] tube in place PERRL, no pharyngeal erythema, mucous membranes moist CHEST: CTA anteriorly no wheezes, no crackles, no rhonchi CV: Holosystolic blowing murmur at LLSB no gallops ABD: Non-distended, BS normoactive, Soft, non-tender EXT: Ecchmosis overlying right postrior forarm, left anticubital fossa, right gleutual ecchymosis extending ~20x30cm. warm, well perfused, + SCDs & multipodus boots NEURO: AAOx3 Cranial Nerves: CNII-CNXII intact BL, Motor 0/5 BL in lower extremities, [2-14] Triceps BL, [3-16] left biceps in upper extremities with L>R weakness. Pertinent Results: [2192-11-9] 12:45PM BLOOD WBC-9.5# RBC-4.27 Hgb-14.0 Hct-42.5 MCV-99* MCH-32.7* MCHC-32.9 RDW-14.4 Plt Ct-162 [2192-11-10] 05:50AM BLOOD WBC-7.9 RBC-3.83* Hgb-12.7 Hct-37.2 MCV-97 MCH-33.2* MCHC-34.2 RDW-14.4 Plt Ct-152 [2192-11-12] 05:25AM BLOOD WBC-7.2 RBC-3.29* Hgb-11.1* Hct-32.8* MCV-100* MCH-33.7* MCHC-33.8 RDW-14.5 Plt Ct-160 [2192-11-12] 05:20PM BLOOD WBC-11.5# RBC-2.63 Hgb-8.6* Hct-26.0* MCV-99* MCH-32.8* MCHC-33.3 RDW-13.8 Plt Ct-183 [2192-11-13] 02:04AM BLOOD WBC-12.1* RBC-3.56# Hgb-11.3# Hct-31.8* MCV-89# MCH-31.7 MCHC-35.5* RDW-16.4* Plt Ct-112* [2192-11-14] 03:15AM BLOOD WBC-9.2 RBC-2.85* Hgb-9.1* Hct-25.4* MCV-89 MCH-32.0 MCHC-35.9* RDW-16.8* Plt Ct-103* [2192-11-15] 05:10AM BLOOD WBC-9.3 RBC-2.46* Hgb-7.9* Hct-22.5* MCV-92 MCH-32.3* MCHC-35.2* RDW-16.6* Plt Ct-111* [2192-11-16] 02:20AM BLOOD WBC-8.8 RBC-3.01* Hgb-9.7* Hct-26.9* MCV-89 MCH-32.1* MCHC-36.0* RDW-16.9* Plt Ct-106* [2192-11-17] 05:08AM BLOOD WBC-7.7 RBC-3.08* Hgb-9.7* Hct-27.8* MCV-90 MCH-31.5 MCHC-35.0 RDW-16.8* Plt Ct-117* [2192-11-18] 05:34AM BLOOD WBC-8.0 RBC-3.12* Hgb-10.1* Hct-28.9* MCV-92 MCH-32.4* MCHC-35.1* RDW-16.3* Plt Ct-149* [2192-11-19] 06:38AM BLOOD WBC-7.3 RBC-3.01* Hgb-9.6* Hct-27.9* MCV-93 MCH-32.0 MCHC-34.6 RDW-16.5* Plt Ct-156 [2192-11-20] 05:54AM BLOOD WBC-7.4 RBC-3.08* Hgb-9.8* Hct-28.8* MCV-94 MCH-32.0 MCHC-34.2 RDW-16.8* Plt Ct-175 [2192-11-21] 04:32AM BLOOD WBC-7.9 RBC-3.15* Hgb-10.1* Hct-30.0* MCV-95 MCH-32.0 MCHC-33.6 RDW-16.5* Plt Ct-194 [2192-11-9] 12:45PM BLOOD PT-24.6* PTT-21.7* INR(PT)-2.4* [2192-11-9] 03:10PM BLOOD PT-25.5* PTT-21.6* INR(PT)-2.5* [2192-11-10] 05:50AM BLOOD PT-26.5* PTT-150* INR(PT)-2.6* [2192-11-10] 08:40AM BLOOD PT-24.7* PTT-75.6* INR(PT)-2.4* [2192-11-10] 08:28PM BLOOD PT-20.4* PTT-45.2* INR(PT)-1.9* [2192-11-11] 04:30AM BLOOD PT-19.4* PTT-71.7* INR(PT)-1.8* [2192-11-11] 06:40PM BLOOD PT-17.3* PTT-59.7* INR(PT)-1.6* [2192-11-12] 01:47AM BLOOD PT-16.8* PTT-71.7* INR(PT)-1.5* [2192-11-12] 05:25AM BLOOD PT-16.1* PTT-74.1* INR(PT)-1.4* [2192-11-12] 05:20PM BLOOD PT-15.2* PTT-48.0* INR(PT)-1.3* [2192-11-13] 02:04AM BLOOD PT-13.3 PTT-20.8* INR(PT)-1.1 [2192-11-13] 02:04AM BLOOD PT-13.3 PTT-20.8* INR(PT)-1.1 [2192-11-14] 03:15AM BLOOD PT-11.9 PTT-18.9* INR(PT)-1.0 [2192-11-18] 05:34AM BLOOD PT-11.2 PTT-18.9* INR(PT)-0.9 [2192-11-19] 06:38AM BLOOD PT-11.0 PTT-19.7* INR(PT)-0.9 [2192-11-20] 05:54AM BLOOD PT-10.8 PTT-18.7* INR(PT)-0.9 [2192-11-21] 04:32AM BLOOD PT-10.9 PTT-18.3* INR(PT)-0.9 [2192-11-12] 05:20PM BLOOD CK(CPK)-15* [2192-11-13] 02:04AM BLOOD CK(CPK)-46 [2192-11-12] 05:20PM BLOOD CK-MB-3 cTropnT-0.02* [2192-11-13] 02:04AM BLOOD CK-MB-4 cTropnT-0.01 [2192-11-14] 03:15AM BLOOD TSH-0.51 [2192-11-12] 06:58PM BLOOD Type-ART pO2-30* pCO2-48* pH-7.36 calTCO2-28 Base XS-0 . ............Imaging.......................... echo [2192-11-13]: The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no left ventricular outflow obstruction at rest or with Valsalva. A mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Trivial mitral regurgitation is seen. There is no pericardial effusion. . HISTORY: Known spontaneous right gluteal/posterior thigh hematoma. Evaluate for findings of active extravasation. . Comparison is made to CT examination from one day prior. . TECHNIQUE: MDCT-acquired axial images were initially obtained through the pelvis and lower extremities through the knees without contrast. Post-contrast sequences were then attempted; however, there was extravasation of contrast through to patient's indwelling IV with instillation of approximately 100 cc of Optiray contrast. Repeat scout tomogram was obtained demonstrating contrast within the subcutaneous tissues extending from the antecubital fossa superiorly to the mid humerus. The patient was examined by Dr. [Last Name (STitle) ] from radiology and no significant paresthesias or loss of pulses was identified. Dr. [Last Name (STitle) 84421] was notified immediately after the exam was completed via telephone and a plastic surgery consult was recommended given the volume of contrast extravasated. . CT OF THE PELVIS/LOWER EXTREMITIES WITHOUT CONTRAST: There has been continued interval evolution of the known hematoma in the right gluteal region with decreased size to the collection and increased density. For example, where the collection previously spanned 6.4 cm and currently spans only 4.3 cm (4:27). No new sites of hemorrhage are identified and there are no internal low-attenuation regions within the collection to suggest ongoing active hemorrhage, although evaluation is suboptimal without intravenous contrast administration. No other new findings are noted from the exam completed one day prior, other than some mild degenerative changes also present within the knees and there is suggestion of an old fracture with slight stepoff and sclerotic fracture line involving the medial distal left femoral condyle, which appears little changed from the prior [2192-6-26] radiograph. Moderate osteoarthritic changes are noted bilaterally, slightly greater on the left including osteoarthritic changes involving the hips bilaterally as well. . IMPRESSION: . 1. Interval organization and decreased size to right gluteal/posterior thigh subcutaneous hematoma. No findings of increased size to the collection are noted to suggest continued bleeding. 2. Degenerative changes involving both hips and knees with suggestion of an old fracture involving the medial left femoral condyle. Brief Hospital Course: Ms. [Known lastname ] is an 84 y/o woman who presented as a direct admission for plasmapheresis for what is believed to be multifocal motor neuropathy with conduction block and developed hypotension and was admitted to the intensive care unit. # Glueteal hematoma: On admission, coumadin for a-fib, which was held, and heparin drip started while INR normalized. On [11-12], INR had trended from 2.4 t to 1.4 and she had a plasmaphresis line placed by interventional radiology, that day, she went for plasmaphoresis and became unresponsive, and hypotensive. CT scan showed large gluteal hematoma and she was admitted to the ICU. On ICU day 1 she was transfused 4 units pRBC and had 2 more units over the course of her stay. Throughout stay in the ICU, NIF was measured at 28-30, VC 0.55-0.66L, she did not require ventilatory support. She failed speech and swallow and [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Doctor Last Name ] was placed and tube feeds initiated. Given history of DVT, and immobility secondary to paralysis and inability to resume anticoagulation in the face of recent bleed, an IVC filter was placed. Her hematocrit remained stable throughout the remainder of her hospitalization and she did not require further transfusion. . # Multifocal motor neuropathy: Patient has a history of an incompletely described progressive motor weakness involving her extremities. On admission, she had lower extremity paralysis and partial bilateral upper extremity paralysis, retaining 3/5 L>R motor strength in the biceps. As an outpatient, she had been on prednisone 40mg x 3 weeks. She was admitted for plasmaphoresis which was not initiated due to hypotension and gluteal bleed. Given her long term steroid use, she was started on Bactrim DS for PCP [Name Initial (PRE) 1102]. In her hospital course she noted worsening upper extremity weakenss. It was determined that the disease was progressing despite prednisone therapy and a taper was initiated which will be complete three weeks after discharge. She is being discharged to rehabilitation with follow up with Dr. [Last Name (STitle) 1206] who will initiate therapy with rituxan. . # Hx of DVT: Patient was admitted on on Coumadin and transitioned to heparin drip which was held in the setting of her hematocrit drop and gluteal bleed. An IVC filter was placed [11-16] and anticoagulation was not resumed due to bleeding risk. . # Afib: Throughout admission, home regimen of amiodarone and metoprolol was continued and she remained rate controled and in sinus rhythm. Coumadin was discontinued due to bleeding risk, and was not restarted given history of bleeds and sinus rhythm. . Medications on Admission: Amiodarone 200 mg daily Amlodipine 5 mg daily Metoprolol 12.5 mg [Hospital1 ] Colace 100 mg [Hospital1 ] Senna one tab [Hospital1 ] Prednisone 60 mg daily Vit D 50,000 Units weekly x 4 weeks (this is week 1) Ranitidine 150 mg [Hospital1 ] HCTZ 25 mg daily Miralax 17 gm daily Rosuvastatin 5 mg daily Coumadin 4.5 mg daily Tylenol 500 mg tid Lidocaine patch 5% one patch topically as needed for back pain Ultram 500 mg q4h prn pain Ipratropium nebs q6h prn SOB Celexa 20 mg daily Calcium 600 with Vitamin D [Hospital1 ] Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY AT 9PM (). 2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. prednisone 10 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily): take three tablets daily then change to 2 tabs daily on [2192-11-24]; then change to 1 tab daily on [2192-11-28]; then change to 0.5 tabs daily [2192-12-3], then discontinue [2192-12-7]. 7. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (FR) for 3 weeks. 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 10. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) g PO DAILY (Daily). 11. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day. 12. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): do not exceed 4000mg acetaminophen in one day. 13. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day: apply to affected area on back. 14. ipratropium bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for shortness of breath. 15. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,SA) for 3 weeks. 17. insulin lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous ASDIR (AS DIRECTED): 71-100 mg/dL =0 Units. 101-150mg/dL = 2 Units. 151-200mg/dL = 4 Units. 201-250mg/dL = 6Units. 251-300 mg/dL = 8Units. 301-350mg/dL = 10 Units. 351-400 mg/dL = 12 Units. >400 mg/dL Notify M.D. . 18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection PRN (as needed) as needed for catheter maintenance: 1000 UNIT DWELL PRN catheter maintenance 1000 units /1cc . 19. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 20. miconazole nitrate 2 % Powder Sig: One (1) application Topical twice a day: Apply to affected area in skin folds. Discharge Disposition: Extended Care Facility: [Hospital1 4860] - [Location (un) 4310] Discharge Diagnosis: Primary - CIDP VS Seconadry - Gluteal Hematoma - Paroxysmal A-fib - Hyperlipidimia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Ms. [Known lastname ] [Last Name (Titles) ] were admitted for plasmapharesis. You have a progressive neuromuscular disease that is causeing your weakness. We believed that plasmapharesis may help with this. During the course of organizing this you developed a gluteal hematoma that required acutly a transfusion of 4 units of packed red blood cells. You were monitored in the ICU for this. We disconitinued your warfarin because you have had multiple bleeding events and have not been in atrial fibrillation. Because of your risk for developing clots and your bleeding issues you had an IVC filter placed to prevent pulmonary embolisim. After leaving the intensive care unit, your blood level remained stable and you did not show any other signs of bleeding. - Dr. [Last Name (STitle) 1206] [Name (STitle) 80844] that you follow up with him to initiate therapy with rituxan after discharge. He will contact you to set up the appointment. - We made the following changes to your medications - Stop Warfarin - Continue prednisone tapering as directed - continue bactrim for 3 three weeks after discharge Followup Instructions: Dr. [Last Name (STitle) 1206] will contact you at [Name (NI) ] rehabilitation to schedule an appointment for Rituxan treatment	[ "357.89", "V12.51", "V58.61", "344.00", "427.31", "V58.65", "401.9", "729.92", "V15.88", "458.29" ]	icd9cm	[ [ [] ] ]	[ "38.97", "96.6", "38.7" ]	icd9pcs	[ [ [] ] ]	19263, 19337	13727, 16419	317, 358	19465, 19465	7516, 13704	20742, 20880	5138, 5189		17009, 19240		19358, 19444		16445, 16986			19600, 20719									5204, 5204																			240, 279												386, 4548	7353, 7497						5218, 5218	19480, 19576						4570, 4939	4955, 5122
67,814	126,376	32614	Discharge summary	report	Admission Date: [2185-6-30] Discharge Date: [2185-7-4] Date of Birth: [2130-5-22] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 30] Chief Complaint: Nausea, abdominal pain, hyperglycemia Major Surgical or Invasive Procedure: none History of Present Illness: 55 yo M with history of recently diagnosed DM ([2184-9-11]) that has been diet controlled who presented to the ED with complaint of polyuria, polydypsia, nausea, abdominal pain, and blood sugar of 700 (measured at PCP [Name Initial (PRE) 3726]). Per patient, had been feeling unwell for about 2 weeks. Noted poorer dietery changes recently. Given new abdominal pain today, presented to work and got blood sugar checked (by school nurse and was found to be > 700). Went to PCP where recieved 2L NS and 10U insulin SC. Then presented to our ED. . Initial ED VS 97.7, 75, 159/100, 18, 99/RA, 280 lb. Per ED physical exam, patient appeared fatigued, lungs were clear to auscultation, no abdominal pain. He did have decreased sensation in his left great toe. Initial blood glucose 713 with elevated Cr. UA negative. EKG with SR with TWI unchanged from prior. CXR without an acute process. He then developed agitation. Concern for cerebral edema. Given 1mg Ativan, FS 400s. Noncontrast head CT did not reveal any acute changes. Given 1L additional NS and started on insulin gtt. . Upon arrival to ICU, patient confirms history as above. Notes intermittent muscle spasms for weeks, like he's been exercising but hasn't been. Very fatigued. Thinks may have lost '[05] lbs'. Also with visual changes like 'taking pictures'. Confirms intermittent chills. Also endorses drinking upwards of 1L [Company 76027] daily. Past Medical History: Carotid tumor s/p resection Diabetes Mellitus, type 2 h/o Cervical injury and surgery h/o knee surgery HTN - not treated Social History: Works as a police officer. Denies any significant alcohol use. No tobacco use or illicit drug use. Family History: Family history of DM in maternal grandmother Physical Exam: VS: 97.8, 82, 144/81, 17, 96/RA 6'4" 119 Kg GEN: Appears sleepy, mildly slurred speech. HEENT: NCAT, PERRLA, MMM, JVP at clavicle at 80 degrees upright CV: RRR with m/g/r PULM: CTAB, w/r/r ABD: Active bowel sounds, soft, nontender LIMBS: Mildly cool feet, but [3-17] DP/PT pulses SKIN: Without lesions Pertinent Results: CBCs [2185-6-30] 02:40PM BLOOD WBC-6.4 RBC-6.22* Hgb-13.4* Hct-42.0 MCV-68* MCH-21.5* MCHC-31.9 RDW-18.3* Plt Ct-230 [2185-7-1] 04:20AM BLOOD WBC-8.5 RBC-5.67 Hgb-11.8* Hct-36.8* MCV-65* MCH-20.9* MCHC-32.2 RDW-17.8* Plt Ct-241 [2185-7-2] 04:24AM BLOOD WBC-7.0 RBC-5.18 Hgb-10.8* Hct-33.4* MCV-65* MCH-20.9* MCHC-32.4 RDW-18.0* Plt Ct-196 . COAGS: [2185-7-2] 04:24AM BLOOD PT-11.6 PTT-22.5 INR(PT)-1.0 . CHEMISTRIES: [2185-6-30] 02:40PM BLOOD Glucose-713* UreaN-41* Creat-2.0* Na-123* K-5.6* Cl-83* HCO3-22 AnGap-24* [2185-6-30] 07:00PM BLOOD Glucose-407* UreaN-35* Creat-1.8* Na-129* K-4.2 Cl-92* HCO3-22 AnGap-19 [2185-6-30] 11:14PM BLOOD Glucose-442* UreaN-38* Creat-1.7* Na-129* K-5.2* Cl-96 HCO3-22 AnGap-16 [2185-7-1] 04:20AM BLOOD Glucose-175* UreaN-34* Creat-1.6* Na-135 K-3.9 Cl-99 HCO3-24 AnGap-16 [2185-7-1] 11:08AM BLOOD Glucose-231* UreaN-28* Creat-1.4* Na-133 K-3.9 Cl-100 HCO3-24 AnGap-13 [2185-7-1] 03:15PM BLOOD Glucose-325* UreaN-30* Creat-1.3* Na-131* K-4.7 Cl-101 HCO3-23 AnGap-12 [2185-7-1] 10:02PM BLOOD Glucose-481* UreaN-32* Creat-1.2 Na-130* K-4.6 Cl-103 HCO3-20* AnGap-12 [2185-7-2] 04:24AM BLOOD Glucose-248* UreaN-25* Creat-1.2 Na-134 K-3.8 Cl-100 HCO3-22 AnGap-16 . CKs: [2185-6-30] 02:40PM BLOOD CK(CPK)-566* [2185-6-30] 07:00PM BLOOD CK(CPK)-544* [2185-7-1] 04:20AM BLOOD CK(CPK)-475* [2185-7-2] 04:24AM BLOOD CK(CPK)-303 . CK-MB/TROPONIN: [2185-6-30] 02:40PM BLOOD CK-MB-10 MB Indx-1.8 [2185-6-30] 02:40PM BLOOD cTropnT-<0.01 . HBG A1c: [2185-6-30] 07:08PM BLOOD %HbA1c-12.2* eAG-303* . MICROBIOLOGY: U/A clean . IMAGING: [6-30] CT HEAD IMPRESSION: No acute intracranial process [6-30] CXR IMPRESSION: No acute cardiothoracic process including no pneumonia. Brief Hospital Course: 55 yo M with PMH of DM2, reportedly diet controlled, admitted with hyperglycemia. . # DM with hyperglycemia: The pt presented with hyperglycemia > 700 and an anion gap. He was admitted to the ICU where he was administered an insulin gtt and 3 L of IVF and his gap closed. His insulin was converted over to sQ long acting glargine with humulog sliding scale. CBC, UA, CXR did not reveal evidence of infection. However, collateral information was obtained by the patient's wife that the pt engages in excessive alcohol intake upwards of 6 beers plus bottles of wine and/or hard liquor every day for the past few months. HbA1c was found to be elevated at 12.2%. [Last Name (un) ] was consulted and recommended an insulin regimen of 64 units glargine QAM, aggressive humalog sliding scale, as well as starting metformin [Hospital1 ]. Of note, he persistently had elevted bg > 250 for his am fingerstick. He was also started on an ACE inhibitor given his hypertension and 81 mg aspirin for primary prevention of cardiac events. [Hospital1 ] was consulted and provided diabetes diet education. The patient previously managed his diabetes with diet only, and did not check his finger sticks at home. He was given a Rx for glucometer and received instruction on how to check his blood glucose as well as administer insulin. He was given follow up appointments with his PCP the day following discharge (group session) and again on [2185-7-8]. He was also given an appointment with endocrinology. As he is new to insulin and medication management of his diabetes, he will need continued [Date Range ] and lifestyle education and will benefit from an outpatient [Date Range ] consult. He will also need his fingersticks monitored and his insulin to be titrated accordingly. . # Microcytic anemia ?????? The patient was found to have a Hct of 33.4 His MCV was low at 65. Iron studies were not consistent with iron deficiency anemia and there was no evidence of bleeding. . # Renal insufficiency: The pt presented with cr 2.0 which was thought to be secondary to volume depletion and renal hypoperfusion and possibly from his recent use of daily ibuprofen. His UA revealed only ketones and glucose. His NSAIDS were held and after IV fluids the patient's creatinine normalized to 1.2. . # Hypertension: The patient was started on lisinopril 10 mg once a day. He should have his creatinine and electrolytes monitored during his follow up with his PCP. Medications on Admission: Lavoza (Omega-3-Acid Ethyl Esters) or Fish oil daily Ibuprofen PRN Discharge Medications: 1. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 4. Insulin Glargine 100 unit/mL Solution Sig: Sixty Four (64) units Subcutaneous once a day. Disp:1000 units Refills:2 5. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous TIDAC HS. Disp:1000 units Refills:2 6. Lancets Misc Sig: One (1) box Miscellaneous four times a day. Disp:1 box Refills:2 7. Blood Glucose Test Strip Sig: One (1) strip In [Last Name (un) 5153] four times a day. Disp:1 box Refills:2 8. Syringe with Needle, Safety 3 mL 23 x 1 Syringe Sig: One (1) syringe Miscellaneous four times a day. Disp:1 box Refills:2 9. equipment one touch ultra glucometer 10. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: - Diabetic ketoacidosis - Acute renal failure - Hypertriglyceridemia - Hypercholesterolemia Secondary: - Hypertension - Microcytic anemia - Alcohol use Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital because you were not feeling well and were very thirsty. You were found to have extremetly elevated blood sugars. You were admitted to the intensive care unit for monitoring and you were started on insulin. You were also started on another medicaiton for your diabetes, called metformin. You received teaching on how to give yourself insulin injections. Please check your blood sugars four times a day (before meals and before bed) and administer insulin based on the sliding scale you were given. You will need to see your primary care doctor [First Name (Titles) ] [Hospital1 ]. we have made this appointment. It is very important that you go to this appointment so that they can monitor your sugars and adjust your insulin regimen. You should talk to your doctor [First Name (Titles) ] [Last Name (Titles) ] counseling and your insulin regimen. Please try to document your blood sugar levels. It is important that you also monitor your alcohol intake as excessive alcohol can precipitate life threatening conditions such as diabetic ketoacidosis in the future. We recommend that men do not take more that two alcoholic beverages a day. The following changes have been made to your medications: START Glargine (long acting) insulin 64 units before breakfast. If your blood glucose is under 150 do not give any insulin and call your primary care doctor regarding what to do next. START Humalog (short acting) insulin following the insulin sliding scale START Metformin 850 mg twice a day START Lisinopril 10 mg once a day START baby aspirin (81 mg ) once a day STOP Ibuprofen If you develop sweating, trembling, racing heart, confusion, or any other symptoms of concern, please call your primary care doctor and drink some [Location (un) 2452] juice. Followup Instructions: Primary Care Doctor Appointment When: Tuesday, [7-5] at 1 pm With: [Last Name (LF) 38274],[First Name3 (LF) ] X. Location: [Location (un) 2274] [Location (un) 2277] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 19604] Phone: [Telephone/Fax (1) 3530] Diabetes/Endocrinology Appointment When: THURSDAY, [7-7], 10AM With: [Last Name (LF) 6810],[Name8 (MD) 6811] MD Address: [Location (un) ], [Location (un) ],[Numeric Identifier 718], [Hospital ] Medical Specialities Phone: [Telephone/Fax (1) 2296] Primary Care Doctor Appointment When: [Last Name (LF) ], [2185-7-8]:50AM With: [Last Name (LF) 38274],[First Name3 (LF) ] X. Location: [Location (un) 2274] [Location (un) 2277] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 19604] Phone: [Telephone/Fax (1) 3530]	[ "357.2", "338.29", "276.1", "584.9", "530.81", "300.4", "782.4", "305.00", "V58.67", "250.62", "250.12", "285.9", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7870, 7876	4233, 6712	307, 313	8092, 8092	2435, 4210	10091, 10999	2041, 2087		6830, 7847		7897, 7897		6738, 6807			8243, 10068									2102, 2416																			230, 269												341, 1763						7916, 8071		8107, 8219						1785, 1908	1924, 2025
4,187	138,958	16842	Discharge summary	report	Admission Date: [2194-4-6] Discharge Date: [2194-4-17] Date of Birth: [2148-6-18] Sex: M Service: [Last Name (un) ] CHIEF COMPLAINT: Thrombocytopenia. HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old male with a history of hepatitis C cirrhosis, status post liver transplant in [2192-9-12] with recurrent hep C who presents with asymptomatic thrombocytopenia. The patient had a recent hospitalization from [2-17] through [2194-2-26] and again from [3-4] through [2194-3-7]; both for thrombocytopenia. On his first admission he had an extensive workup including a bone marrow biopsy. His thrombocytopenia was ultimately thought to be secondary to ITP, likely from tacrolimus. He was discharged after changing his immunosuppression from FK for Rapamune. On subsequent admission his platelets remained low despite discontinuation of Prograf, Bactrim and CellCept. He was therefore started on prednisone with an increase in his platelets from 13,000 to 22,000. He was continued on steroids and followed in the clinic. However, his platelet count only reached 37,000. He was given IVIG, with improvement in his platelets to 66,000. However, he was also noted to have worsening LFTs; thought to be due to activation of hepatitis C virus. Otherwise, he has been asymptomatic. No easy bruising, petechiae, bleeding gums, epistaxis, hemoptysis, hematemesis, hematuria, bright red blood per rectum, or melena. He did sustain some scrapes and scratches from gardening. He also notes some discomfort at the site of his ventral hernia repair. PAST MEDICAL HISTORY: Significant for hep C virus cirrhosis; liver transplant on [2192-9-24]; recurrent hepatitis C infection; vertebral hernia, status post repair in [2193-12-12]; one episode of mild acute rejection in [2193-5-12]; anastomotic biliary stricture, status post dilatation and stenting; hypertension, well controlled; post transplant diabetes; history of anemia of chronic illness; history of renal insufficiency, resolved; thrombocytopenia thought to be drug induced. SOCIAL HISTORY: He lives with wife. [Name (NI) ] kids. History of alcohol abuse, most recent use in [2193-8-12]. No tobacco or drug use. FAMILY HISTORY: Father with liver problems, died of cirrhosis. Mother with hypertension/diabetes, and died of intestinal cancer. Brother with [Name (NI) 4522]. Sister with hypertension. PHYSICAL EXAMINATION: T-max was 97.8, BP 124/78, heart rate 76, respiratory rate 20, O2 saturation 95% on room air. He was comfortable, in no acute distress, non-jaundiced. HEENT revealed NCAT. Sclerae anicteric. Pupils equal, round and reactive to light. EOMs intact. Mucous membranes moist. No lymphadenopathy. Heart with regular rate and rhythm. No murmurs, regurg, gallop. Chest was clear to auscultation. Abdomen with well-healed incisional scar, nondistended, no CVA tenderness, normal active bowel sounds. Extremities with 2+ pitting edema. No petechiae. Neuro revealed alert and oriented, nonfocal. LABORATORY DATA ON ADMISSION: White count 3.6, hematocrit 43.1, platelet count 51, BUN 14, creatinine 0.9, AST 232, ALT 275, alkaline phosphatase 201, total bilirubin 0.8, PT 10.9, PTT 24, INR 0.9. BRIEF HISTORY OF HOSPITAL COURSE: The patient was admitted to the hospital. He was continued on oral prednisone 40 mg p.o. daily. He received meningococcal, pneumococcal, and hemophilus vaccines preop for splenectomy. He received sliding-scale insulin for his hyperglycemia. He was taken to the OR on [2194-4-9] by Dr. [First Name (STitle) ] [Name (STitle) ] for open splenectomy with a wedge biopsy of the liver. Assisting resident was Dr. [First Name8 (NamePattern2) 32712] [Name (STitle) ]. Under general anesthesia. EBL was 500 cc. The patient was extubated and transferred to the recovery room in stable condition. Postop, he was stable. Please see operative note for further details. Postop, the patient was found to be somewhat somnolent, and hypotensive, and oliguric despite 3 liters of crystalloid. His hematocrit postop dropped down to 16.3 from 34.7. He received transfusion with 1 unit of packed red blood cells and 1 bag of platelets for a platelet count of 43. He returned to the OR under anesthesia for postop bleeding. The procedure was exploratory laparotomy with a washout. The surgeon was Dr. [First Name (STitle) ] [Name (STitle) ]. Assisted by Dr. [First Name8 (NamePattern2) 32712] [Name (STitle) ] and Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] under general anesthesia. EBL was 1000 cc. He received 8 units of packed red blood cells, 3 units of FFP, and 2 units of platelets, and 5 liters of IV crystalloid. Findings were approximately 1 liter of blood and fluid which were aspirated out the surgical site. Please see operative report for further details. Towards the end of the case, the patient was hemodynamically stable. Making good urine. The patient was intubated and transferred to the ICU where he did well. His pain was controlled. He did have a JP draining approximately 310 cc of serosanguineous fluid. His hematocrit remained stable at 31.6 to 28.1. His JP drain output increased to approximately 1 liter. Hematocrit was 26.1. Hematocrit started to trend up, and JP drainage diminished. His JP drain was removed on [2194-4-16]. Platelet count increased to the 140s. He continued on a hydrocortisone taper and then was transitioned to prednisone 20 mg p.o., and this was decreased to 15 mg p.o. daily. His diet was gradually advanced. Vital signs were stable. His liver function tests remained stable. There was a slight increase in his alkaline phosphatase from 75 to 124. Total bilirubin remained stable at 0.6. Prograf dosage was adjusted per level, and Rapamune was discontinued. He was restarted on Prograf on [2194-4-9]. Hepatology followed the patient during this hospital course as well as hematology. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] consult was obtained for management of hyperglycemia secondary to the steroids. Physical therapy followed the patient. The patient was found to be stable and independent, and did not require home PT. On postop days #8 and #7, he was well. Afebrile, blood pressure 148/70, heart rate 73. His JP drain was removed. He was tolerating regular food. Voiding without any difficulty. Incision was open to air with clips. Of note, the patient was started on an antibiotic - vancomycin - for 3 days. On postop day #6, the patient was started on IV vancomycin for a cellulitis around the incision. This improved significantly. DISCHARGE STATUS: He was discharged home in stable condition. MEDICATIONS ON DISCHARGE: Included Percocet 1 to 2 tablets p.o. p.r.n. q.4-6h.; metoprolol 25 mg p.o. b.i.d.; prednisone 15 mg p.o. daily; Protonix 40 mg p.o. daily; Lasix 40 mg p.o. daily; Lopressor 25 mg p.o. b.i.d.; tacrolimus 1 mg p.o. b.i.d.; insulin Glargine 15 units subcutaneously with supper and Humalog sliding scale p.r.n. q.i.d.. He was to resume his calcium at home. Also the Norvasc and lisinopril that he was on preop was to be reassessed in the outpatient clinic for resumption. DISCHARGE DIAGNOSES: Idiopathic thrombocytopenic purpura likely secondary to Prograf; splenectomy on [2194-4-9]; and exploratory laparotomy with washout of hematoma on [2194-4-10]. DISCHARGE FOLLOWUP: The patient was scheduled to follow up in the output clinic with Dr. [Last Name (STitle) ] in 1 week. DISCHARGE CONDITION: Stable. [Name6 (MD) ] [Name8 (MD) ], [MD Number(1) 4841] Dictated By:[Name8 (MD) 4664] MEDQUIST36 D: [2194-4-23] 16:23:53 T: [2194-4-23] 19:37:50 Job#: [Job Number 47484]	[ "070.70", "998.11", "401.9", "E878.6", "E878.0", "E933.1", "285.1", "996.82", "287.31", "585.9", "250.00" ]	icd9cm	[ [ [] ] ]	[ "41.5", "54.12", "50.12", "99.04", "99.07", "99.05" ]	icd9pcs	[ [ [] ] ]				7540, 7770			2261, 2436	7221, 7390				6729, 7199		3280, 6702																				2459, 3061										171, 190				7411, 7518								219, 1600							3076, 3262							1623, 2097	2114, 2244
4,800	106,976	43718	Discharge summary	report	Admission Date: [2121-10-13] Discharge Date: [2121-10-16] Date of Birth: [2049-3-5] Sex: M Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7729] Chief Complaint: L parotid mass Major Surgical or Invasive Procedure: L parotidectomy History of Present Illness: 72M with h/o L parotid mass. FNA revealed malignant cells. Pt presents for elective left parotidectomy. Past Medical History: DM CAD s/p CABG h/o atrial fibrillation HTN CRI w/Cr 2.0 h/o SCC L leg/R ear Social History: Occasional EtOH, no tobacco Family History: NK Physical Exam: NAD EOMI, nares patent, oropharynx clear without exudates/erythema L face and neck incision intact without overlying erythema or swelling. Neck otherwise flat and soft. CN VII intact to testing Pertinent Results: [2121-10-13] 03:48PM GLUCOSE-160* UREA N-43* CREAT-1.9* SODIUM-139 POTASSIUM-5.1 CHLORIDE-108 TOTAL CO2-23 ANION GAP-13 [2121-10-13] 03:48PM CK(CPK)-38 [2121-10-13] 03:48PM CK-MB-2 cTropnT-<0.01 [2121-10-13] 03:48PM CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-1.7 [2121-10-13] 03:48PM DIGOXIN-1.6 [2121-10-13] 03:48PM WBC-7.3 RBC-4.15* HGB-12.6* HCT-37.4* MCV-90 MCH-30.5 MCHC-33.8 RDW-15.0 [2121-10-13] 03:48PM PLT COUNT-159 [2121-10-13] 02:18PM TYPE-ART PO2-325* PCO2-44 PH-7.34* TOTAL CO2-25 BASE XS--2 VENT-CONTROLLED [2121-10-13] 02:18PM GLUCOSE-197* LACTATE-2.1* NA+-137 K+-5.4* CL--106 [2121-10-13] 02:18PM HGB-13.7* calcHCT-41 [2121-10-13] 02:18PM freeCa-1.17 Brief Hospital Course: Pt underwent a left parotidectomy. Intraoperatively, anesthesia noted that the patient was likely in atrial flutter. He was kept intubated overnight as anesthesia was concerned regarding the need for reintubation as the patient has a h/o of difficult intubation and required a fiberoptic intubation for this operation. Postoperatively, he was transferred to the MICU where he was electrically cardioverted successfully. He was stable overnight and on POD 1, he was extubated without difficulty. He tolerated po intake, and remained in normal sinus rhythm. On POD 2 he continued to do well and remained in NSR. He was transferred to the floor. Cardiology recommended no further interventions for Mr. [Known lastname 23657] regarding his episode of a-fib/a-flutter. On POD 3, his JP drain was discontinued and he was discharged home in good condition. 1. L parotidectomy -pt did well post operatively -L JP drain removed prior to discharge -CN VII intact -pathology pending 2. A-fib/a-flutter -started intra-op, pt electrically converted in the MICU and remained in NSR for the remainder of his hospital stay -cardiology recommended no further intervention above pt's home dose of digoxin and atenolol 3. DMII -BS well controlled during his stay with regular insulin SS and glargine 4. Dispo -discharged to home -pt to f/u with Dr. [Last Name (STitle) 1837] Medications on Admission: digoxin, atenolol, diovan, nitrodur, amaryl, glargine, lipitor Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 2. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a day for 5 days. Disp:15 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left parotid mass Discharge Condition: good Discharge Instructions: Please take your antibiotcs as directed. Do not drive while taking pain medications. Please call the clinic or come to the emergency room if you have fever or increased swelling and pain in your neck. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 1837] in [7-6] days. Call [Telephone/Fax (1) 7732] for an appointment.	[ "142.0", "427.31", "401.9", "250.00", "427.32", "V45.81", "585.9" ]	icd9cm	[ [ [] ] ]	[ "26.32" ]	icd9pcs	[ [ [] ] ]	3394, 3400	1632, 3002	337, 355	3462, 3469	882, 1609	3718, 3850	649, 653		3115, 3371		3421, 3441		3028, 3092			3493, 3695									668, 863																			283, 299												383, 488														510, 588	604, 633
16,370	109,191	29010	Discharge summary	report	Admission Date: [2185-1-3] Discharge Date: [2185-1-15] Date of Birth: [2124-7-21] Sex: M Service: MED HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 60-year-old male with metastatic melanoma, admitted to begin cycle 1, week 1 high-dose IL-2 therapy. His oncologic history began in [2184-7-27], when he noted a right groin skin tag which grew quickly over 2 months. Excisional biopsy in [2184-10-27] revealed a greater than 11 mm thick, ulcerated melanoma with perineural invasion and mitotic rate of 8 per meters squared. He was referred to Cutaneous [Hospital ] Clinic, at which point 2 subcutaneous nodules along the right groin scar were noted and a left posterior shoulder subcutaneous nodule was noted. Fine needle aspiration confirmed a melanoma at the site. PET CT revealed widespread metastases in the lung, liver, subcutaneous tissues and bone. Brain MRI was negative. He was evaluated for high-dose IL-2 and passed eligibility testing to begin therapy. PAST MEDICAL HISTORY: BPH, status post laparoscopic cholecystectomy in [2178], left knee arthroscopic surgery complicated by left DVT, hypertension, sleep apnea, osteoarthritis of the right knee, melanoma as above, benign positional vertigo, history of pseudogout, history of C-7 narrowing with occasional nerve pain. ALLERGIES: No known drug allergies. MEDICATIONS: Lisinopril 20 mg daily, on hold, Flomax 0.4 mg daily, Proscar 5 mg daily, Naprosyn 500 daily to b.i.d. p.r.n. PHYSICAL EXAMINATION: GENERAL: Well-appearing male in no acute distress. Performance status 1. VITAL SIGNS: 97.5, 130, 18, 133/80, O2 saturation 94% in room air. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Moist oral mucosa without lesions, multiple scalp nodules present. NECK: Supple. LYMPH NODES: No cervical, supraclavicular, bilateral axillary or bilateral inguinal lymphadenopathy. Right groin subcutaneous nodules noted. HEART: Regular rate and rhythm, S1 and S2. CHEST: Clear to percussion and auscultation bilaterally. ABDOMEN: Rounded, positive bowel sounds, soft, nontender, no HSM or masses. EXTREMITIES: No lower extremity edema. NEURO EXAM: Nonfocal. SKIN: Right groin biopsy site healed without nodularity. There are subcutaneous nodules above and below the biopsy site as well as scattered scalp nodules. There is a left shoulder subcutaneous nodule measuring approximately 4 x 3 cm and a left low axillary chest wall subcutaneously nodule measuring approximately 1 cm. ADMISSION LABS: WBC 10.6, hemoglobin 11.7, hematocrit 34.5, platelet count 237,000, INR 1.2, BUN 20, creatinine 1, sodium 138, potassium 4.5, chloride 99, CO2 24, glucose 138, ALT 40, AST 41, LDH 970, alkaline phosphatase 179, amylase 35, total bilirubin 0.8, lipase 39, albumin 3.8, calcium 9.3, phosphorus 3.6, magnesium 2.3. HOSPITAL COURSE: Mr. [Known lastname ] was admitted and underwent central line placement to begin therapy. His admission weight was 106.6 kg, and he received interleukin-II 600,000 international units per kilogram, equaling 64 million units IV q.8h. x14 potential doses. During this week, he received 10 of 14 doses, with 1 dose held for questionable neurotoxicity and 3 doses held due to development of tachypnea, stridor and respiratory distress, requiring mechanical ventilation. This event occurred in early morning hours of treatment day #5 and he was transferred emergently to the ICU and intubated, given stridor and tachypnea. He was not having significant hypoxia at this time. He then became hypotensive, requiring initiation of phenylephrine and Levophed. At the time of his intubation, his bicarbonate was 15 and he was aggressively treated with bicarbonate repletion. The patient was intubated x4 days and was eventually extubated on [1-11]. He continued to recover and was recovering was transferred back to the floor on [1-12], where rehab was initiated. He developed Clostridium difficile diarrhea, improved on Flagyl. He was eventually discharged to home on [2185-1-15] with physical therapy. Other side effects during IL-2 therapy included mild chills; development of an erythematous skin rash; nausea, improved with lorazepam; diarrhea, improved with Lomotil, and fatigue During this week, he developed acute renal failure with a peak creatinine of 7.3, improved to 1.3 at the time of discharge. He developed hyperbilirubinemia with a peak bilirubin of 7.1, improved to 1.1 upon discharge. He also developed transaminitis with a peak ALT of 100 and peak AST of 117, improved to within normal limits at the time of discharge. He was anemic with hemoglobin of 7.2, improved to 11.7 after packed red blood cell transfusion. He was thrombocytopenic with a platelet count low of 55,000, without evidence of bleeding. As noted above, he developed metabolic acidosis, felt to be at least partially responsible for his respiratory failure, with a minimum bicarbonate of 14, improved with bicarbonate repletion. He had no evidence of coagulopathy or myocarditis. By [2185-1-15] he was discharged to home. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: Metastatic melanoma, status post cycle 1, week 1 high-dose IL-2 complicated by respiratory failure and acute renal failure. DISCHARGE MEDICATIONS: Lorazepam 1 mg q.4-6h. p.r.n. nausea/vomiting, Compazine 10 mg q.6h. p.r.n. nausea/vomiting, Proscar 5 mg daily, Flagyl 500 mg p.o. t.i.d. oxycodone 5 to 10 mg q.4h. p.r.n. pain, Zantac 150 mg p.o. t.i.d. FOLLOWUP PLANS: Mr. [Known lastname ] will be seen in clinic in 1 week and the 2nd week of IL-2 therapy will be determined at that time. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 26819], [MD Number(1) 26820] Dictated By:[Last Name (NamePattern1) 18853] MEDQUIST36 D: [2185-4-1] 16:17:52 T: [2185-4-3] 09:22:18 Job#: [Job Number 69910] cc:[Numeric Identifier 69911] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 29848], MD [First Name (Titles) ] [Last Name (Titles) 159] Associates 50 [Location (un) 69912], [Numeric Identifier 43858]	[ "715.96", "E949.9", "038.9", "275.3", "V58.12", "785.59", "584.5", "198.89", "198.5", "518.81", "112.0", "284.8", "780.57", "008.45", "197.7", "428.0", "276.7", "197.0", "276.2", "276.0", "196.2", "172.8" ]	icd9cm	[ [ [] ] ]	[ "93.90", "96.72", "00.17", "99.04", "00.15", "38.93", "96.04", "96.6" ]	icd9pcs	[ [ [] ] ]									5285, 6144		5136, 5261			2859, 5080																				1532, 2511																						164, 1022					2528, 2841									1045, 1509		5105, 5114
32,063	197,146	33805	Discharge summary	report	Admission Date: [2123-4-20] Discharge Date: [2123-4-25] Date of Birth: [2049-7-27] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1232] Chief Complaint: Metastatic renal cell carcinoma Major Surgical or Invasive Procedure: Right adrenalectomy and prostate needle biopsy. History of Present Illness: 73-year-old white male, retired fire fighter, who is referred for evaluation of metastatic renal cell cancer to his right adrenal. This has been known to be positive for renal cell cancer since biopsy of [2122-1-5]. Thusfar staging studies have revealed that this is the only metastases from his original tumor. He originally was found to have bilateral renal tumors in the form of a 2.5 cm mass in the lower pole of his right kidney and a 6.5 cm mass in the left kidney. A right partial nephrectomy was performed on [2119-10-30] followed by a total left nephrectomy on [2119-12-18]. In both cases, the adrenal glands were left in place, that is to say the left adrenal gland from his left total nephrectomy was left in situ. He has undergone courses of biologic therapy, which have not resolved the metastases. Presently, he has no difficulties with voiding and there is no history of hematuria or urinary tract infection. Past Medical History: Past medical history is significant for hypertension and negative for myocardial infarction, angina, diabetes, colitis, stroke, ulcer, lung disease, thyroid disease, hepatitis, gout, sciatica, and glaucoma. Past surgical history includes a TUR prostate as well as the above noted left radical nephrectomy and right partial nephrectomies. He has also undergone a needle biopsy of the prostate on [2120-12-10] which was negative for malignancy in 15 cores. Finally, he has undergone an appendectomy in [2068] and a TUR prostate at a remote time. Physical Exam: General: comfortable Abd: soft, non tender, non distended Incisions: clean, dry, intact; no signs of infection Brief Hospital Course: Patient was admitted to Urology after undergoing right adrenalectomy and prostate needle biopsy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. He was kept NPO until he passed flatus on POD4, diet was advanced conservatively. Foley removed the day prior to discharge and patient passed voiding trial without difficulty. The remainder of the hospital course was relatively unremarkable. The patient's pain control was excellent throughout. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic with Dr. [Last Name (STitle) 261]. Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: 0.5-1 Tablet PO every 4-6 hours as needed for pain for 1 weeks: No alcohol or driving on this medication. Disp:30 Tablet(s) Refills:0 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation for 1 weeks: Take while on percocet. Stop when having regular bowel movements. Disp:20 Capsule(s) Refills:0 3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:0 Tablet(s) Refills:0 4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:0 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Metastatic renal cell carcinoma Discharge Condition: Stable Discharge Instructions: -You may shower, but do not tub bathe, swim, soak, or scrub incision for 2 weeks. -Allow bandage strips to fall off over time -No heavy lifting for 4 weeks (no more than 10 pounds) [Hospital 16237] medical attention for fevers (temp>101.5), worsening pain, drainage or excessive bleeding from incision, chest pain or shortness of breath. -Follow up in 1 week for wound check/foley removal -Please do not drive or consume alcohol while taking pain medications. Followup Instructions: Dr. [Last Name (STitle) 261], call for appt, [Telephone/Fax (1) 277]	[ "288.60", "V10.52", "799.02", "198.7", "V45.89", "790.93", "401.9" ]	icd9cm	[ [ [] ] ]	[ "07.22", "60.11" ]	icd9pcs	[ [ [] ] ]	3693, 3699	2098, 3085	346, 396	3775, 3784		4302, 4382			3108, 3670		3720, 3754					3808, 4279									1962, 2075																			275, 308												424, 1368														1390, 1947
58,264	185,752	44689	Discharge summary	report	Admission Date: [2130-4-11] Discharge Date: [2130-4-15] Date of Birth: [2086-5-3] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 896] Chief Complaint: Fever, Abdominal pain, SOB Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: The patient is a 43-year-old man with HIV, Hep C, cardiomyopathy, hypertension, polysubstance abuse including cocaine in addition to membranous GN (MPGN from Hep C) now ESRD on HD (T/Th/Sat, last on Saturday), heavy smoker who presented to the ED with abdominal pain, fever, dyspnea. . Pt reports he was in his usualy state of health until this morning at 2am when he awoke feeling SOB. His BP at that time was "very high." and he had abdominal pain. Notes 5 bm yesterday, formed stool with no blood. He reported to the ED. He had missed some of his doses of his blood pressure medications. . In the ED, initial VS were: T 102.9, BP 179/95, HR 110, RR 23, 98% RA. Given 1g tylenol, ASA 325, 5mg IV morphine, Vancomycin 1g, ceftriazone 1g, azithromycin 500mg IV. Labs in ED: WBC 10, HCT 27, PLT 211. INR 1.1, PTT 34. Na 142, K 4.5, Cl 105, HCO3 20, BUN 70, Cr 7.3, glucose 112. ALT 13, AST 19, AP 105, TBilli 0.2, Alb 4, lipase 48, Ca 8.3, Mg 2.2, Phos 4. CXR showed RLL pna. CT abd performed for abd pain. . The patient was sent directly to dialysis for HD session since he was 4 kilograms above his dry weight. Per fellow, he had episode of small hemoptysis, confirmed by RN. However, according to patient, he felt it was from the grape juice he was given earlier in the day. Denies any history of hemoptysis. While in HD, patient became suddenly hypertensive up to the 200s/120s and has sudden acute worsening of his dyspnea, RR 40s, hypoxemic satting in 70s on RA. Concern for flash pulmonary edema. He continued HD to remove 4-5 L fluid. He was given a nebulizer with no improvement. Placed on non-rebreather and satting in 93-95%. He looked uncomfortable, sitting upright, using accessory muscle use to breath. Vitals in HD on initial evaluation of patient 226/128, HR 136, RR 40s, satting mid 90s on non-rebreather. While in HD he was given hydralazine 10mg IV (did not improve BP), tylenol 325mg, Epo 7600, Zemplar 3mcg, topical nitro-paste 1.2 inch, Lopressor 5mg IV. Then given nitropaste 0.5 inch and BP improved to 160s. Vitals prior to transfer to MICU: BP 161/102, HR 124. Following his dialysis, the patient felt substantially better and was breathing more easily. . In the MICU, the patient's vitals were T 98.7 HR 116 BP 179/90 RR 23 98% 3L. He complained of pain in his jaw, neck, hips, and left upper quadrant on exam. The patient did think that he was breathing more freely than the event in hemodialysis. In MICU, pt's hypertension was controlled with nitro drip, carvedilol, clonidine, nifedipine, hydral and terazosin. . On transfer to medicine, his vitals are 97.8, 146/86, 102, 21 98% 2L. He reports that he is still having some hemoptysis and he was complaining of continued RUQ pain. Pt reports that he thinks his pain has been inadequately controlled. He is currently being dialysed. Past Medical History: 1. HIV - He was diagnosed with HIV in [2112]. Risk factors included unprotected heterosexual sex as well as intravenous drug use. His nadir CD4 count is 91 and he has no known opportunistic infections. Last viral load undetectable, CD4 556 ([11-1]). 2. Hepatitis C. Genotype 1B. Viral load 187,000 in [12-29]. 3. Cryoglobulinemia 4. Cardiomyopathy with an EF of 45-50%. 5. Chronic renal insufficiency - MPGN by biopsy in [2123] and hypertensive nephrosclerosis 5. GERD. 6. Hypertension. 7. Gynecomastia; s/p bilateral gynecomastia excision with liposuction [2126-7-23]. 8. Polysubstance abuse, including cocaine and alcohol. 9. Anemia, hematocrit 20-24. 10. Hypertriglyceridemia - TG 282 in [3-/2126] 11. Right hydrocele. 12. A subacute infarct in the right caudate head seen on MRI in [1-29] 13. Influenza B, [2126-2-22]. 14. Erectile dysfunction. 15. Depression 16. Inguinal hernia repair in [2123]. 17. Left ankle ORIF in [2122]. 18. Appendectomy in [2101]. Social History: History of incarceration for 4 yrs. Is self-employed, unmarried. He has three children. Denies alcohol. Reports marijuana use daily, denies tobacco or cocaine. Lives with friend [Name (NI) 1787]. Family History: Mother and father have hypertension; has 3 brothers, 3 sisters: all healthy, none with HTN. There is also a family history of type 2 diabetes mellitus. No family history of sudden death and premature atherosclerotic cardiovascular disease. Physical Exam: General: Alert, oriented, comfortable HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP around 12 CV: S1, S2, no murmurs auscultated Lungs: Crackles heard at bases Abdomen: Soft, slightly tender in RUQ, non-distended, bowel sounds present, no organomegaly GU: No foley Ext: Warm, well perfused, trace pedal edema. Neuro: A+Ox3, 5/5 strength in all extremities discharge 98.5 (99.2) 148/87 (120s-190s) 86 18 99%RA FS 112 General: Alert, oriented, comfortable HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP 10 CV: S1, S2, systolic murmur over LLSB Lungs: rhonchorus breath sounds bilaterally Abdomen: soft, mildly tender to palpation abdomen, no peritoneal signs GU: No foley Ext: Warm, well perfused, trace pedal edema Neuro: A+Ox3, 5/5 strength in all extremities Pertinent Results: [2130-4-11] 05:15AM BLOOD WBC-10.0 RBC-2.59# Hgb-8.7 Hct-27.1* MCV-105# MCH-33.4 MCHC-31.9 RDW-13.4 Plt Ct-211 [2130-4-11] 05:15AM BLOOD Neuts-89.8* Lymphs-5.2* Monos-3.6 Eos-1.1 Baso-0.2 [2130-4-11] 05:15AM BLOOD PT-11.4 PTT-34.0 INR(PT)-1.1 [2130-4-11] 05:15AM BLOOD Glucose-112* UreaN-70* Creat-7.3# Na-142 K-4.5 Cl-105 HCO3-20 AnGap-22* [2130-4-12] 03:52AM BLOOD Glucose-118* UreaN-70* Creat-6.8* Na-136 K-5.0 Cl-99 HCO3-19* AnGap-23* [2130-4-11] 05:15AM BLOOD ALT-13 AST-19 AlkPhos-105 TotBili-0.2 [2130-4-11] 05:15AM BLOOD Lipase-48 [2130-4-11] 05:15AM BLOOD cTropnT-0.04* [2130-4-11] 05:15AM BLOOD Albumin-4.0 Calcium-8.3* Phos-4.0 Mg-2.2 [2130-4-11] 05:24AM BLOOD Lactate-1.5 CTA abd/pelv/chest: IMPRESSION: IMPRESSION: 1. No pulmonary embolism or aortic pathology. 2. Enlarged main pulmonary artery suggestive of pulmonary arterial hypertension. 3. Mediastinal lymphadenopathy. 4. Right middle and right lower lobe opacifications concerning for pneumonia on a background of pulmonary edema. 5. Small right pleural effusion, periportal and pericholecystic edema as well as hazy mesentery, unchanged compared to [2129-4-22] and likely due to HIV diagnosis. 6. Nonspecific bowel wall thickening in distal ileum likely exaggerated by collapse, though a mild ileitis is a consideration. . [4-12] Echo The left atrium is mildly dilated. The left atrium is elongated. The right atrium is moderately dilated. The estimated right atrial pressure is 5-10 mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. [4-14] CXR There has been interval improvement of pulmonary edema, substantial with only minimal residual Kerley B lines demonstrated. Right lower lung opacity is still present, consistent with known right middle lobe and right lower lobe infectious process. Mild vascular engorgement is still demonstrated. Cardiomegaly is moderate to severe, unchanged. No pneumothorax is seen. Micro: bcx [2130-4-11] -[2130-4-13]: no growth legionella urine is negative discharge [2130-4-15] 12:45PM BLOOD WBC-6.9 RBC-2.93* Hgb-9.2* Hct-31.0* MCV-106* MCH-31.4 MCHC-29.7* RDW-12.7 Plt Ct-345 [2130-4-15] 12:45PM BLOOD Plt Smr-NORMAL Plt Ct-345 [2130-4-15] 12:45PM BLOOD Glucose-117* UreaN-54* Creat-6.9* Na-140 K-5.3* Cl-100 HCO3-23 AnGap-22* [2130-4-15] 12:45PM BLOOD Calcium-8.7 Phos-4.5 Mg-2.7* [2130-4-15] 01:30PM BLOOD Vanco-12.6 Brief Hospital Course: 43 year old gentleman with HIV (CD4 619 on [2129-11-9], HIV-1 RNA undetectable [2129-11-30]), HCV (viral load 61,900 IU/mL [2129-11-11]), MPGN now with ESRD on dialysis Tues-Thurs-Sat, history of cryoglobulinemia, who is admitted to hospital for dyspnea and abdominal pain. Chest X-ray and CT suggest RLL pneumonia. The patient appeared to have an episode of flash pulmonary edema in the setting of hypertensive emergency. # Respiratory distress/HCAP: (RLL/RML) and acute-on-chronic diastolic heart failure. Likely flashed in setting of PNA and volume overload. In HD in setting of hypertension up to 220/120s. Opportunistic infections considered but given recent CD4 count of 422, unlikely. He was started on cefepime, vancomycin, levofloxacin and nebulizers. With this treatment, respiratory status improved to 2L NC requirement. Sputum culture, blood cultures, urine culture, C. diff toxin were pending at time of transfer from MICU, but all returned negative. Pt was dialysed an additional 2 times before discharge and was euvolemic at discharge. He was continued on levaquin and vanco and transitioned to ceftazadime for HD dosing. He was discharged on these medications for his pna until [2130-4-21]. # Abdominal pain: LFTs wnl, CT shows ?ileitis? (unchanged from prior) EGD in [2124] was normal. Another possibility considered was hepatic congestion or gut edema in setting of acute on chronic CHF. Final CT abdomen read was equivocal for ileitis but pt's pain improved over hospital course. Pain could have been referred pain from RLL pna. He did have constipation that was relieved with aggressive bowel reg. # Hypertensive emergency: Has history of difficult-to-control hypertension. Pts BP 220/120s in HD room in setting of missing his medications. Restarted patient's substantial home PO regimen, and SBPs on discharge improved to 150's-160s. He was discharged on home medication regimen. # HCV/HIV: Repeat CD4 count 422, makes opportunistic infection less likelt. Continued home regimen of antiretroviral therapies. # CKD, stage V, ESRD on HD: Received partial HD today, although mainly removed fluid. Removed 4L fluid on day of admission. Removed an additional 4L over next two days. Transitional: home BP monitoring, will need close follow up with PCP or nephrologist for bp control Medications on Admission: 1. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. 3. clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. emtricitabine 200 mg Capsule Sig: One (1) Capsule PO 2X/WEEK (TU,SA): after dialysis, every tuesday and saturday . 6. hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 8. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 10. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea: take 30 minutes prior to Sustiva/Ziagen/Epivir 11. terazosin 1 mg Capsule Sig: Three (3) Capsule PO at bedtime. 12. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day. 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. B complex-vitamin C-folic acid 0.8 mg Tablet Sig: One (1) Tablet PO once a day. 15. docusate sodium 100 mg Capsule Sig: [1-23] Capsules PO BID (2 times a day). Discharge Medications: 1. carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 2. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 4. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 6. prochlorperazine maleate 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as needed for nausea. 7. terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 8. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 12. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. emtricitabine 200 mg Capsule Sig: One (1) Capsule PO 2X/WEEK (TU,SA). 14. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. 15. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 17. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 6 days: take after dialysis (through [4-21]). Disp:3 Tablet(s) Refills:0 19. ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln Injection QHD (each hemodialysis) for 6 days: after HD for 6 more days (through [4-21]). 20. vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous PER HD PROTOCOL for 6 days: Continue for six more days (through [4-21]). Discharge Disposition: Home Discharge Diagnosis: Healthcare Associated Pneumonia Flash pulmonary edema ESRD - requiring emergent dialysis 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 hospital acquired pneumonia. Your course was complicated by flash pulmonary edema. We treated your pneumonia with IV antibiotics and your pulmonary edema with dialysis and blood pressure control. . We have made the following changes to your home medications: -start levaquin 500mg 1 tab by mouth every 48hrs. take after dialysis. -start ceftazadime and vancomycin to be given IV when you are at dialysis. -Continue the remainder of your home medications. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Please call your PCP to make an appointment within one week of discharge. . Also, please resume dialysis at your normal schedule. . Below are some additional appointments you have already scheduled Department: [Hospital3 249] When: WEDNESDAY [2130-5-17] at 11:00 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ADVANCED VASC. CARE CNT When: MONDAY [2130-7-3] at 1 PM With: [Name6 (MD) 5536] [Name8 (MD) ], MD [Telephone/Fax (1) 5537] Building: [Street Address(2) 7298] ([Location (un) 583], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: WEDNESDAY [2130-8-9] at 11:30 AM With: [First Name8 (NamePattern2) 1903] [Last Name (NamePattern1) 1904], NP [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "585.6", "V45.11", "428.33", "285.9", "V08", "070.54", "486", "428.0", "403.91" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	14467, 14473	8787, 11124	329, 343	14606, 14606	5553, 8764	15367, 16514	4452, 4694		12490, 14444		14494, 14585		11150, 12467			14757, 15038									4709, 5534			15056, 15344																263, 291												371, 3188								14621, 14733						3210, 4217	4233, 4436
71,311	109,349	9433	Discharge summary	report	Admission Date: [2146-1-2] Discharge Date: [2146-1-4] Date of Birth: [2080-12-30] Sex: M Service: MEDICINE Allergies: lisinopril Attending:[Doctor First Name 2080] Chief Complaint: Tongue swelling Major Surgical or Invasive Procedure: Laryngoscopy History of Present Illness: 65-year-old male with history of coronary artery disease, diabetes and hypertension who presenting following discharge [1-1] following burhole evacuation of subdural hemorrhage presenting to the [Hospital1 18] ED with left sided tongue swelling and dyspnea which began overnight on New Years. He was recently discharged from [Hospital1 18] after a hospitalization for evacuation of subdural hematoma. New medications on discharge include: codeine, Admitted [Date range (1) 32177] for subdural hemorrhage, was stable although did have some nausea and vomiting, was not intervened upon and discharged although did not follow up in clinic. Patient represented [12-29] with increased confusion and right facial droop and on [12-30] underwent a left frontal burr hole evacuation of chronic SDH and discharged [2145-12-31] following operation. Of note, while in house, initially, patient was not taking lisinopril, however, this was restarted 12/27 per the orders, although a medicine consult on [12-30] asked it to be restarted. Also of note, in [12-29], patient was given FFP/platelet transfusion although he had normal PT/INR and platelet levels. He had adverse reaction to transfusion with hives/itching and required benadryl and monitoring for airway compromise. In the ED, initial VS were: 11:29 Temp: 97.6 HR: 102 BP: 183/115 RR: 20 97% RA. He was not stridorous or wheezing. He was given Diphenhydramine 50mg IV, Famotidine 20mg IV, and Methylprednisolone 125mg IV. He was seen by ENT who performed laryngosocpy and noted a swollen glossus, and no laryngeal or epiglotteal edema. A size 7 nasopharyngeal airway and endotracheal intubation was deferred. Given severity of tongue sweling and concern for the possible need for intubation, he was admitted to the MICU for close monitoring. Vitals on transfer were P;89 BP:163/87 rr:17 SaO2:97% RA. On arrival to the MICU, patient is [Last Name (un) 664] and in no acute distress. Past Medical History: Hypertension Hyperlipidemia ABNORMAL LIVER FUNCTION TESTS DIABETES MELLITUS Type II ANEMIA CHRONIC PARANOID SCHIZOPHRENIA CORONARY ARTERY DISEASE - angioplasty 6 years ago in NJ EXERTIONAL DYSPNEA EYE ALLERGY NECROBIOSIS DIABETICORUM R ARM PAIN Barrett's esophagus (biopsy) Social History: Single, has six children (4 daughters) lives alone but stays with daughter occasionally. Quit tobacco 5yrs ago after 40pack yrs - Alcohol: Patient denies currently, but does report drinking in [Month (only) 359] when he fell - Illicits: denies Family History: No history of heeridetary angioedema, daughter with diabetes. Otherwise non-contributory. Physical Exam: Admission: Vitals: T: 98.2 BP:165/80 P:89 R: 18 O2:98% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, tongue is enlarged inferiorly with evidence of clear fluid filled bubbles, appearing like a jellyfish. oropharynx unable to see due to tounge enlargement, EOMI, PERRL, surgical scar with staples over left frontal/ parietal bone. Well healed wound over right occiput. Neck: evidence of swelling under central mandible, supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, Skin: no evidence of hives or rashes Pertinent Results: Admission: [2146-1-2] 12:00PM BLOOD WBC-10.2 RBC-4.26* Hgb-11.9* Hct-36.1* MCV-85 MCH-27.9 MCHC-32.9 RDW-13.4 Plt Ct-251 [2146-1-2] 12:00PM BLOOD Neuts-73.4* Lymphs-18.6 Monos-5.1 Eos-2.3 Baso-0.5 [2146-1-2] 12:00PM BLOOD PT-11.6 PTT-27.1 INR(PT)-1.1 [2146-1-2] 12:00PM BLOOD Glucose-234* UreaN-30* Creat-1.0 Na-137 K-4.2 Cl-99 HCO3-25 AnGap-17 [2146-1-2] 12:00PM BLOOD ALT-21 AST-20 AlkPhos-80 TotBili-0.3 [2146-1-2] 12:00PM BLOOD Albumin-4.4 [2146-1-2] 12:00PM BLOOD C3-PND C4-PND [2146-1-2] 12:00PM BLOOD Phenyto-14.6 Brief Hospital Course: 65-year-old male with history of coronary artery disease, diabetes and hypertension who presenting following discharge [1-1] following burhole evacuation of subdural hemorrhage presenting to the [Hospital1 18] ED with left sided tongue swelling and dyspnea which began overnight on New Years. # Angioedema with marked inferior aspect tongue swelling likely secondary to lisinopril which patient has been taking since [2143] and filled in pharmacy early [2145-12-2]. Also possible is reaction to dilantin. Patient was managed with a nasal trumpet initially and no intubation. Patient was admitted to the ICU for airway monitoring. LFTs were normal and at time of ICU transfer, C4, C3 were pending. We held lisinopril and started HCTZ 25mg daily for HTN control (patient was on HCTZ in the past, held for "hypotension"). We also stopped dilantin (level was 14.6 and therapeutic) and switched over to keppra 750mg [Hospital1 ] to be continued until seen in neurosurgery clinic. We also started methylprednisolone 125mg q8h for a day and then switched to PO decadron 10mg q8h to continue for a total of 6 days and no taper. We also started famotidine 20mg q12h and diphenhydramine 50mg TID in the peri-angioedema period. Within 24 hours of arrival to the ICU, the patient's tongue inflammation reduced considerably. Patient was initially kept NPO, but was then transitioned to full diet without difficulty. He was then transferred to the floor. He improved significantly with dexamethasone therapy. His daughter confirmed that she would throw out his lisinopril and dilantin at home and ensure he follows up to his PCP appointment the following day. # Recent subdural hematoma with evacuation [2145-12-29]: no neurologic defecits at this time. As above, we held dilantin given possible SJS with dilantin (maybe appearing as angioedema in this instance) and switched to keppra 750mg [Hospital1 ] after talking with the neurosurgery team. We held dilantin and patient will continue keppra until following up with neurosurgery clinic. Patient needed staples removed either by neurosurgery as an outpatient or in house between [Date range (1) 32178]/12 and was told to schedule a follow up with them. # Diabetes, type 2 uncontrolled - A1C 9.3, prior to previous admission, patient on glyburide, metformin and insulin detemir. Glyburide discontinued on discharge and decrease dose to 25U at bedtime (approx [2-4] of home dose of 35U at bedtime) and started insulin sliding scale. In the unit, patient was given insulin sliding scale as well as glargine 20Units while NPO q24h. On the floor he had some sugars in the 200s, occasionally 300s due to steroids which we felt would improve after stopping steroids in 2 days. He will go to 35 Units on discharge/ when eating, which is identical to his home dose. His PCP will continue to follow his blood sugars. # Hypertension - patient hypertensive at admission 183/115 and was on lisinopril since [2143] (confirmed by pharmacy). We started HCTZ as above 25mg qd with permissive hypertension to the 150s while the patient on steroids. His PCP can follow up his blood pressures and a chem 7. # Schizophrenia/ psych/ neuro: We continued perphenazine 12mg PO qhs and benztropine 2mg [Hospital1 ]. Held alprazolam 2mg PO qhs, given diphenhyrdamine. Medications on Admission: 1. docusate sodium 100 mg Capsule [Hospital1 ] 2. alprazolam 2 mg PO QHS 3. betamethasone dipropionate 0.05 % Cream Appl Topical [Hospital1 ] 4. benztropine 2 mg [Hospital1 ] 5. perphenazine 12 mg Tablet PO QHS 6. lisinopril 40 mg Tablet PO DAILY 7. phenytoin 125 mg/5 mL Suspension PO TID 8. simvastatin 40 mg Tablet DAILY 9. Tylenol-Codeine #3 300-30 mg 1 Tablet PO q6 hours PRN pain. 10. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puff Inhalation four times a day as needed for shortness of breath or wheezing. Discharge Medications: 1. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 3 days. Disp:9 Capsule(s) Refills:0 3. perphenazine 8 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)). 4. benztropine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. dexamethasone 4 mg Tablet Sig: 2.5 Tablets PO Q8H (every 8 hours) for 2 days. Disp:18 Tablet(s) Refills:0 6. levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. insulin glargine 100 unit/mL Solution Sig: Thirty Five (35) UNITS Subcutaneous at bedtime. 11. alprazolam 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) 2 PUFFS Inhalation every six (6) hours as needed for shortness of breath or wheezing. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Angioedema Anemia Diabetes mellitus type II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to take care of you here at [Hospital1 18]. You were admitted for tongue swelling called "angioedema". This was thought to be due to lisinopril, which can happen any time while on this medication. A much less likely possibility is a reaction from your new seizure medication Dilantin, therefore, to be safe, we also changed you to a different seizure medication called Keppra. If you develop worsening swelling or difficulty breathing, please go to the emergency room immediately. Also, we noted your blood counts are low, you will need an endoscopy for your Barrett's esophagus screening and a repeat colonscopy given your polyp. We have made the following changes to your medications: STOP lisinopril (your daughter will throw away all your pills) STOP dilantin (your daughter will throw away all your pills) For seizure prevention due to your recent head injury: START Keppra 750mg by mouth twice daily For your angioedema: START dexamethasone 12mg by mouth every 8 hours for two more days (last dose [2146-1-6]) START benadryl 25mg by mouth three times daily for 2 more days For your alcohol use: START multivitamin, folate, and thiamine Followup Instructions: Please set up an appointment with neurosurgery within 2 weeks: ([Telephone/Fax (1) 88]. Department: [Hospital1 7975] INTERNAL MEDICINE When: WEDNESDAY [2146-1-5] at 11:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10134], MD [Telephone/Fax (1) 7976] Building: [Hospital1 7977] ([Location (un) 686], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: [Hospital 7975] [Hospital ] HEALTH CENTER When: MONDAY [2146-2-7] at 10:00 AM With: [Doctor First Name 674] BROW [Telephone/Fax (1) 7976] Building: [Hospital1 7977] ([Location (un) 686], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: [Hospital 7975] [Hospital ] HEALTH CENTER When: TUESDAY [2146-2-22] at 10:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 22387], MD [Telephone/Fax (1) 7976] Building: [Hospital1 7977] ([Location (un) 686], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site Completed by:[2146-1-5]	[ "E936.1", "414.01", "V45.82", "295.32", "V12.54", "250.02", "285.9", "E942.9", "401.1", "995.1", "303.90" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9822, 9879	4541, 7887	287, 302	9967, 9967	3962, 4518	11314, 12449	2887, 2979		8473, 9799		9900, 9946		7913, 8450			10118, 10799									2994, 3943													10828, 11291						232, 249												330, 2308								9982, 10094						2330, 2605	2621, 2871
29,377	191,924	54566	Discharge summary	report	Admission Date: [2159-12-30] Discharge Date: [2160-1-8] Date of Birth: [2109-7-1] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5547] Chief Complaint: Perforated Duodenal Ulcer Major Surgical or Invasive Procedure: [2159-12-30]: Exploratory laparotomy, Omental [Location (un) ] patch repair of perforated duodenal ulcer & Core needle biopsies of left lobe of liver. History of Present Illness: 50F with multiple medical problems presented to the [Hospital1 18] [Name (NI) ] 1 day after acute onset of epigastric pain radiating to RLQ, [10-11] in severity, which then became diffuse. She also recalled nausea and vomiting and denies any BM x2days. She had one episode of fever but denies chills, CP, SOB or changes in urinary habits. Past Medical History: 1. asthma -does not use inhalers 2. HTN -off meds for several years 3. rheumatoid arthritis -seronegative 4. chronic severe back pain 5. 4 C-sections. 6. History of secondary syphilis, treated. 7. Polysubstance abuse, notably cocaine 8. Depression 9. Pulmonary hypertension 10. Restrictive lung disease 11. Seizures in childhood Social History: Lives with boyfriend. 4 children. Smokes [3-5] cigarettes per day. Drinks 3 drinks most nights Family History: Noncontributory Physical Exam: VS: T98.6, HR134, BP139/46, RR30, POx96%RA GEN: in acute distress, tachypnic [2-4] abdominal pain CVS: RRR, sinus tachycardia RESP: CTAB/L GI: TTP, +rebound, +guarding Rectal: tender on exam, c/w peritoneal irritation Pertinent Results: [2159-12-29] 08:40PM BLOOD WBC-17.0# RBC-3.87 Hgb-13.1 Hct-40.2 MCV-104# MCH-34.0# MCHC-32.7 RDW-18.0* Plt Ct-325 [2159-12-30] 02:30AM BLOOD WBC-17.7* RBC-2.55# Hgb-8.9# Hct-27.1# MCV-106 MCH-35.0* MCHC-32.9 RDW-17.7* Plt Ct-245 [2159-12-31] 01:51AM BLOOD WBC-18.0* RBC-2.49* Hgb-8.5* Hct-26.2* MCV-105* MCH-34.4* MCHC-32.6 RDW-17.7* Plt Ct-218 [2160-1-1] 11:51PM BLOOD WBC-12.0* RBC-2.47* Hgb-8.4* Hct-27.4* MCV-111* MCH-34.1* MCHC-30.8* RDW-17.2* Plt Ct-215 [2159-12-30] 12:05AM BLOOD PT-21.7* PTT-44.0* INR(PT)-2.1* [2160-1-3] 05:12AM BLOOD PT-22.2* PTT-41.6* INR(PT)-2.1* [2159-12-29] 08:40PM BLOOD Glucose-90 UreaN-13 Creat-0.9 Na-137 K-3.5 Cl-110* HCO3-18* AnGap-13 [2159-12-30] 03:40AM BLOOD Glucose-114* UreaN-12 Creat-0.6 Na-143 K-3.0* Cl-119* HCO3-17* AnGap-10 [2160-1-1] 11:51PM BLOOD Glucose-94 UreaN-14 Creat-1.0 Na-139 K-5.0 Cl-114* HCO3-14* AnGap-16 [2160-1-6] 07:25AM BLOOD Glucose-68* UreaN-7 Creat-0.6 Na-136 K-3.2* Cl-106 HCO3-22 AnGap-11 [2160-1-7] 07:35AM BLOOD Glucose-113* UreaN-6 Creat-0.7 Na-133 K-3.5 Cl-105 HCO3-22 AnGap-10 [2159-12-29] 08:40PM BLOOD ALT-10 AST-18 AlkPhos-102 TotBili-1.2 [2159-12-30] 03:40AM BLOOD ALT-17 AST-57* AlkPhos-60 TotBili-1.2 [2160-1-3] 05:12AM BLOOD ALT-19 AST-55* AlkPhos-58 Amylase-19 TotBili-1.4 [2159-12-29] 08:40PM BLOOD Albumin-2.4* Calcium-9.1 Phos-3.8 Mg-1.3* [2160-1-5] 08:00AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE [2160-1-4] 02:32AM BLOOD CRP-95.7* [2160-1-1] 11:51PM BLOOD Vanco-12.2 [2160-1-5] 08:00AM BLOOD HCV Ab-NEGATIVE [2159-12-30] 12:40AM BLOOD pO2-67* pCO2-27* pH-7.30* calTCO2-14* Base XS--11 Comment-GREEN TOP [2159-12-29] 10:09PM BLOOD Lactate-2.5* [2159-12-30] 02:42AM BLOOD Glucose-134* Lactate-2.9* Na-142 K-3.3* Cl-117* [2160-1-2] 12:59AM BLOOD Lactate-6.9* [2160-1-2] 05:13AM BLOOD Lactate-2.4* [2159-12-30] Needle Biopsy Liver: 1) Focal mild to moderate portal chronic inflammation including plasma cells and eosinophils with focal periportal extension (grade [1-4]). 2) Focal mild portal/periportal and lobular fibrosis on trichrome stain (stage 2). 3) Focal mild fatty change. 4) Focally prominent increased iron in periportal hepatocytes on iron stain. 5) Focal mild cholestasis. [2159-12-29] CT A/P: 1. Large amount of intraperitoneal free air indicating a perforated viscus. Given the distribution in the upper abdomen and quantity, it is likely related to perforation of the stomach or duodenum, the latter being statistically favored. Note is made of a defect in the gastric fundus and duodenum, which may represent focal ulcerations. 2. Gallbladder wall edema, which is a nonspecific finding in the setting of large amount of ascites. Recommend correlation with physical exam and history. 3. Patchy opacities within the lung bases, which likely represents atelectasis; however, aspiration can have a similar appearance [2159-12-31] CXR: FINDINGS: Again noted are bibasilar opacities which now appears worse on the right and better on the left. There is no evidence of pulmonary edema. Right and left hilar fullness corresponding with lymphadenopathy as seen on prior chest CT is unchanged. The cardiomediastinal silhouette is stable. [2159-1-5] CXR: There has been no significant change since the prior chest x-ray of [1-5] or [1-4]. Diffuse interstitial opacities are again seen, particularly in the right lung and small posterior effusions are present on both sides. [2160-1-7] ECG: Sinus rhythm. Right ventricular hypertrophy. Low QRS voltage in the limb leads. Compared to the previous tracing of [2160-1-3] there is no significant diagnostic change. Clinical correlation is suggested. Brief Hospital Course: [12-28]: Pt presented to [Hospital1 18] ED with 10/10 abdominal pain. CT scan showed extensive free air in the abdomen, free fluid and debris. [12-29]: Pt taken urgently to the OR for aforementioned procedure. Please see dictated operative note in OMR. [Name (NI) ], pt admitted to SICU, intubated, sedated. TTE done confirming TR and pulm HTN. Albumin x2 to help UOP. Weening vent. slight left thigh swelling. [12-30]: attempting to wean vent, became very tachypnic on CPAP, persistent hyperchloremic metabolic acidosis, central line placed. [12-31]: extubated, NGT d/c'd, started on sips, lopressor d/c'd due to hypotension, changed to DPCA, ABx continued for fever. UOP decr, prerenal, given 3L fluid and albumin, lasix 20 and diureses well [1-1]: Added gabapentin and oxycodone; weening off NRB mask; lasix added in PM for UOP tapering off; develop wheezing in AM, xopenix ordered. KVO fluid. [1-3]: lasix 20 bolus, ppi changed to h2 blocker, fever, blood and urine sent [1-4]: Central line removed and pt transfered to floor, PCA d/ce'd and pt tolerating pain control w/PO meds [1-5]: Diet advanced to regular, diuresed with IV Lasix 40 mg. [1-6]: JP drain removed, pt OOB to chair with max assist [1-8]: Pt discharged to rehab in stable condition Medications on Admission: Gabapentin 800mg PO TID, ibuprofen 800mg TID, omeprazole 20mg PO daily, oxycodone 5mg 1-2 tabs PO q6hrs, trazadone 50mg PO qhs, colace 100mg PO bid, magnesium oxide 800mg PO bid Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain: Do not exceed 4000mg in 24hrs. 2. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 3. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: [1-4] PO BID (2 times a day) as needed for constipation. 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Furosemide 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. 11. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q8 PRN () as needed for Wheeze. 12. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: [1-4] PO Q6H (every 6 hours) as needed for insomnia. 13. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): to skin lesions on neck, back, abdomen and extremities; do not use on face or groin . Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary: Perforated Duodenal Ulcer Nodular appearing liver (likely cirrhotic)- biopsies obtained, and hepatology serolgies collected Toxicology screen positive for cocaine Pulmonary hypertension post-op pneumonia post-op atelectasis persistent hyperchloremic metabolic acidosis-managed with CPAP in ICU, weaned from vent gradually. Post-op low urine output-managed with IV albumin and IV fluid hydration . Secondary: [First Name9 (NamePattern2) 30065] [Location (un) ] syndrome, asthma, HTN, RA, chronic back pain, secondary syphilis (treated), cocaine abuse, depression, pulm HTN, childhood seizures Discharge Condition: Stable Tolerating a regulardiet Adequate pain control with oral 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: -Your staples will be removed at [Hospital3 ] on Wed [2160-1-16]. Steri Strips will be applied. -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. . Resp status: -Wean oxygen as tolerated. Sats >90% in absence of Respiratory/Neurologic symptoms is acceptable. -Oxygen set-up at home. Patient denies using home oxygen for years. . Hepatology (Liver doctor): -Please follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital ] Health Center to follow-up results of liver biopsy and remaining hepatitis serologies. ([Hospital1 18] Liver center [Telephone/Fax (1) 2422] will call with appointment for follow-up in [1-4] weeks). . Pulmonology: -Follow-up with Dr. [First Name (STitle) ] ([Telephone/Fax (1) 612]) Followup Instructions: 1. Please follow-up with Dr. [Last Name (STitle) 1924] [Telephone/Fax (1) 7508] on [2160-1-22] at 10am. 2. Follow-up with your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) 4223] [Telephone/Fax (1) 7976] in 1 week. . Previous appointments: 1.Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2160-1-14] 1:40 2. Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2160-1-14] 2:00 3. Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] & DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2160-1-14] 2:00 Completed by:[2160-1-8]	[ "714.0", "416.8", "532.50", "518.0", "593.9", "276.2", "696.2", "286.9", "305.60", "789.59", "567.9", "493.90", "692.9", "518.81", "571.5", "486" ]	icd9cm	[ [ [] ] ]	[ "50.11", "44.42", "86.11" ]	icd9pcs	[ [ [] ] ]	8241, 8311	5400, 6705	339, 499	8963, 9039	1641, 5377	11297, 12078	1367, 1384		6933, 8218		8332, 8942		6731, 6910			9065, 10207						10222, 11274			1399, 1622																			274, 301												527, 881														903, 1233	1249, 1351
82,494	146,806	49621	Discharge summary	report	Admission Date: [2109-10-17] Discharge Date: [2109-11-1] Date of Birth: [2031-7-29] Sex: M Service: MEDICINE Allergies: Aspirin / Iodine / Bactrim / Sulfa(Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2782] Chief Complaint: fall w/ multiple facial and cervical fractures Major Surgical or Invasive Procedure: 1. Application and removal of [Location (un) 8766] tongs. 2. Application of allograft. 3. Application of morselized autograft. 4. Posterior cervical arthrodesis C2-C7. 5. Posterior instrumentation C2-C7. 6. Bilateral laminotomy C3 with medial facetectomy. 7. Bilateral laminectomy and medial facetectomy of C4, C5, C6, C7. History of Present Illness: 78 yo M with CAD, ESRD, HTN, HL, DM and dCHF, presenting to the ED after a fall at home. He was trying to grab his grandson near the bed and fell out of bed, hitting his face on the dresser. On arrival to the ED, he was found to multiple facial fractures and an exam concerning for central cord compression. On [2109-10-16] underwent an MRI which showed severe spinal canal stenosis, similar to the prior examination, with developing increase in spinal cord abnormal signal at C4-C5, which may reflect cord edema or myelomalacia. Prior to his surgery, CCU was consulted for advice regarding evaluation and management of emergent need for surgery in the setting of multiple cardiac risk factors, and indicated that no further cardiac testing needed prior to surgery, and to resume plavix when safe post-surgery. As such, HMFP Ortho Spine operated on [10-18], performing a posterior cervical arthrodesis C2-C7, bilateral laminotomy C3 with medial facetectomy, and bilateral laminectomy and medial facetectomy of C4, C5, C6, C7. A CT of his head showed comminuted nasal bone fx with air tracking in overlying subcutaneous tissue, for which plastics was consulted, and recommended follow-up in their clinic, as well as stitches out on [2109-10-22]. Additionally, on [2109-10-21] Neurology was consulted for acute onset of dysarthria on [2109-10-19]; an MRI showed mild small vessel changes and no stroke or other significant FLAIR abnormality and no significant stenoses or occlusion on MRA head and neck. They believed he had toxic metabolic encephalopahty, but no focal abnormalities on examination, so signed off. Also of note, patient had a fever on [2109-10-21] to 101.5 and was pan-cultured. Increased drainage from cervical incision site was evaluated by ortho spine-thought to be appropriate. His ICU course has also been complicated by occasional hypertension requiring hydralazine. Patient upon request for transfer from ACS to Orthopedics was decline by orthopedics secondary to concern regarding management of multiple comorbidities. Transfer to medicine for further mangement of multiple medical issues as well as monitoring for complications from partial cord compression. . Review of sytems: (+) 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: Type II DM HTN CKD - bl Cr 2.5 Gout Gastritis/ulcer/GERD -> last EGD in [2105] with gastritis presumed CAD Dyslipidemia LE DVT in [2095] NSTEMI in [2104] Social History: His social history is significant for the absence of current tobacco use, was former smoker. No EtOH abuse. Wife takes care of him. Family History: Mother with CAD s/p CABG Physical Exam: Admission Physical: GEN - laying flat on stretcher, in C-collar, comfortable, hypoactive [Year (4 digits) 4459] - dry MM without obvious thrush, in C-collar so unable to assess CV - RRR, no murmurs rubs gallops LUNGS - clear bilaterally ABD - soft non tender EXT- left upper extremity edema comapared to the right, PICC was removed; Patient has an IV in the right forearm NEURO - A+Ox2 (didn't know date, slow to respond), CN 2-12 grossly intact, sensation to light touch intact throughout, motor grossly intact Discharge Physical: GEN - in C-collar, comfortable [Year (4 digits) 4459] - MMM, EOMI CV - RRR NECK - staples intact in posterior neck with good approximation of edges, no evidence of erythema or discharge; pt to maintain c-collar at all times LUNGS - clear bilaterally ABD - soft non tender, NABS EXT- warm, dry, no [Location (un) ] NEURO - Alert, oriented to person, place, month & year, CN 2-12 grossly intact, toes downgoing strength: Left - UE: proximal deltoid, triceps & biceps [2-25]; handgrip [12-27], wrist extension [12-27], wrist flexion [1-27], LE: hip flexion [2-25], able to wiggle toes, unable to lift heel off bed Right - UE: proximal deltoid, triceps & biceps [2-25]; handgrip [12-27], wrist extension [12-27], wrist flexion [1-27], LE: hip flexion [2-25], able to wiggle toes, unable to lift heel off bed Pertinent Results: Admission Labs: [2109-10-16] 07:50PM BLOOD WBC-7.8 RBC-3.48* Hgb-10.1* Hct-30.2* MCV-87 MCH-28.9 MCHC-33.3 RDW-16.5* Plt Ct-182 [2109-10-16] 07:50PM BLOOD Neuts-73.9* Lymphs-18.7 Monos-4.6 Eos-2.4 Baso-0.3 [2109-10-16] 10:22PM BLOOD PT-10.5 PTT-28.3 INR(PT)-1.0 [2109-10-16] 07:50PM BLOOD Glucose-184* UreaN-40* Creat-2.5* Na-137 K-5.5* Cl-109* HCO3-19* AnGap-15 [2109-10-16] 07:50PM BLOOD Calcium-8.8 Phos-2.6* Mg-2.1 Discharge Labs: [2109-11-1] 05:45AM BLOOD WBC-9.8 RBC-2.72* Hgb-7.8* Hct-23.9* MCV-88 MCH-28.6 MCHC-32.6 RDW-16.0* Plt Ct-375 [2109-11-1] 05:45AM BLOOD PT-28.3* PTT-34.6 INR(PT)-2.6* [2109-11-1] 01:05PM BLOOD Na-135 K-5.4* Cl-104 [2109-11-1] 05:45AM BLOOD Calcium-8.8 Phos-5.5* Mg-2.7* INR: [2109-10-28] 09:20AM BLOOD PT-15.5* PTT-61.5* INR(PT)-1.4* [2109-10-28] 09:20AM BLOOD Plt Ct-252 [2109-10-28] 03:50PM BLOOD PT-17.3* PTT-63.0* INR(PT)-1.6* [2109-10-29] 06:05AM BLOOD PT-26.5* PTT-88.4* INR(PT)-2.4* [2109-10-29] 11:45AM BLOOD PT-28.2* PTT-57.6* INR(PT)-2.6* [2109-10-29] 07:10PM BLOOD PT-36.7* PTT-150* INR(PT)-3.4* [2109-10-30] 06:10AM BLOOD PT-43.1* PTT-58.4* INR(PT)-4.0* [2109-10-31] 06:00AM BLOOD PT-40.0* PTT-39.6* INR(PT)-3.7* [2109-11-1] 05:45AM BLOOD PT-28.3* PTT-34.6 INR(PT)-2.6* Microbiology: Blood Culture, Routine (Final [2109-10-27]): NO GROWTH. URINE CULTURE (Final [2109-10-22]): NO GROWTH. Blood cultures [2109-10-28] and [2109-10-29] pending x2 URINE CULTURE (Final [2109-10-29]): NO GROWTH. Blood cultures [2109-10-29] pending Imaging: CT head/sinus [2109-10-16]: IMPRESSION: Comminuted fractures of the right nasal bone and nasal septum. Minimally displaced fracture of the left nasal bone. Nasal and right premaxillary STS with ST gas raising concern for open fractures. MRI c-spine [2109-10-16]: IMPRESSION: Severe spinal canal stenosis, similar to the prior examination, with developing increase in spinal cord abnormal signal at C4-C5, which may reflect cord edema or myelomalacia. SPECT IMPRESSION: Only rest perfusion images were obtained, which reveal uniform tracer uptake throughout the left ventricular myocardium. Mildly enlarged left ventricular cavity size, unchanged from prior study on [2108-9-14]. CT head w/o [2109-10-19]: IMPRESSION: No acute intracranial abnormality. Stable nasal bone and septal fractures. MRA brain/neck [2109-10-19]: IMPRESSION: No evidence of acute infarct. No mass effect or hydrocephalus. MRA of the head and neck are limited by motion but demonstrate no vascular occlusion. Fluoroscopic guided drainage of hematoma [2109-10-22]: IMPRESSION: Successful fluoroscopic-guided lumbar drainage placed without complications L Upper Extremity u/s [2109-10-26]: IMPRESSION: Extensive left upper extremity thrombus, as above, surrounding the left PICC and the non-cannulated basilic vein. Proximal extent can not be visualized proximal to the subclavian vein on this ultrasound examination CXR [2109-10-27]: IMPRESSION: AP chest compared to [10-16] through [10-22]: New left perihilar opacification could be a small pneumonia developed since [10-22]. Heart size is borderline enlarged. Distention of the azygos vein suggests elevated central venous pressure or volume, or alternatively supine positioning. CXR [2109-10-29]: FINDINGS: In comparison with study of [10-27], the azygos vein is less prominent, reflecting either improved vascular status or possibly a more upright position. Cardiac silhouette is within normal limits and there is no evidence of acute pneumonia or definite pulmonary vascular congestion. The prominence in left perihilar region also has decreased. Minimal atelectatic change is seen in the retrocardiac region Brief Hospital Course: Mr. [Known lastname 805] is a 78 yo M with CAD, ESRD, HTN, HLD, DM and dCHF, presenting on [2109-10-17] after fall, went to OR for C4-C7 laminectomy on [10-18] complicated by CSF leak. Course was further complicated by catheter-induced DVT, delirium, hyperkalemia, non-gap acidosis, and transfered to medicine for management multiple medical conditions. # C-spine fractures: Secondary to mechanical fall. Fractures demonstrated by imaging on presentation, complicated by cord compression with severe weakness. Evaluated by orthopedics who performed a posterior cervical arthrodesis C2-C7, bilateral laminotomy C3 with medial facetectomy, and bilateral laminectomy and medial facetectomy of C4, C5, C6, C7 on [10-18]. Course then complicated by CSF leak requiring LP drain placement on [2109-10-22] with IR. Drain was left in place until removed on [2109-10-28]. Orthopedics recommended continued [Location (un) 2848] J collar for 8-12 weeks and follow-up in clinic within 1 week of discharge, scheduled for [2109-11-8]. He worked with PT during this admission pending discharge to rehab to help improve strength (strength documented under discharge physical). # Nasal bone fractures: Seen on CT sinus imaging. Plastics was consulted who recommended conservative management, placed several stitches, which were removed on [2109-10-30]. He will follow-up in clinic on [2109-11-8]. # UTI: Pt was found to be delirious and having low grade fevers. Cultures were sent, and UA was suggestive of UTI. He was started on Ceftriaxone and foley catheter was removed. Attempted voiding trial, but had to be replaced on [10-30] in evening given unable to void (likely [1-24] narcotics, BPH, lack of mobility). UCx showed no growth but was sent after started treatment of antibiotics. He was switched to Cipro to complete a 7 day total course for catheter-associated UTI, to be completed on [2109-11-3]. If patient develops confusion, would consider rechecking for infection. Would recommend discontinuing foley catheter with voiding trial once able. # Catheter-induced upper extremity venous thrombosis: s/p removal of PICC. Started on heparin gtt until therapeutic on coumadin. Pt was bridged to Coumadin. He will be managed by the [Hospital 191] [Hospital3 ] on discharge from rehabilitation. His dose will likely need to be adjusted after completing his course of antibiotics for the UTI. # Hypertension: Blood pressures have been elevated. His initial regimen was Amlodipine 10 mg PO/NG DAILY, Valsartan 160 mg PO/NG DAILY, and Torsemide 5 mg PO daily. Hydralazine was started in house at 10mg TID, and Carvedilol was initially held and then restarted with improved blood pressure control. HCTZ was discontinued as pt appeared dry. Valsartan was then held on [11-1] given hyperkalemia and continued poor po intake. His BP should be monitored and adjusted as needed. Recommend uptitration of hydralazine as needed for BP control. Consideration of restarting Valsartan once hyperkalemia improves. # Metabolic Encephalopathy: Pt had worsening confusion post-op. Most likely multifactorial secondary to pain medications, UTI, and pain. Considered also secondary meningitic infection given recent lumbar drain, though pt improved with treatment of pain and UTI. He was treated for UTI as above. He was started on Seroquel qhs with improvement. As below, pt had had previous workup for dysarthria which was negative (see below). On discharge, his mental status was that he was oriented to person, place, month and year. # Hyperkalemia: Likely secondary to potassium intake (in IVFs inintially), slight worsening renal failure, as well as possible RTA secondary to diabetes given non-gap acidosis. As above, pt appeared mildly dry. On [11-1], his Valsartan was discontinued and he was given 500cc fluids in addition to one dose of kayexalate. His potassium was rechecked and was 5.4 at time of discharge. Pt was placed on a low potassium diet. # Non-anion gap metabolic acidosis: Multiple etiologies, although likely RTA as possible etiology. RTA type would be a Type IV likely secondary to diabetes. Urine pH was 5.0, with HCO3 <5. Lytes were trended and improved, stable on discharge with HCO3 of 20. # Acute on chronic renal failure: His creatinine briefly increased to 3.1 at maximum, likely secondary to mild dehydration and poor po intake. He continued on Calitriol and treatment for HTN as above. # Dysarthria: On [2109-10-21] Neurology was consulted for acute onset of dysarthria on [2109-10-19]. CT head showed no changes. An MRI showed mild small vessel changes and no stroke or other significant FLAIR abnormality and no significant stenoses or occlusion on MRA head and neck. Pt's change in mental status and ? dysarthria was believed he had toxic metabolic encephalopahty, but no focal abnormalities therefore no more recommendations from neurology. # Elevated BUN: Considered uremia vs. UGIB. Pt's Hct remained stable. Pt appeared dry on examination, and HCTZ was discontinued on [10-31]. He was given gentle IVF's on [11-1] given pt appeared dry. Inactive issues: # CAD: Pt had cardiology consult for pre-op clearance. Nuclear scan showed no defects, though this study was done at rest. Pt's plavix held for surgery and lumbar drain. Given that pt was started on Coumadin for anticoagulation as above, discussed risks and benefits of restarting plavix with pt's outpatient cardiologist. Decision was made to hold plavix for now while on anticoagulation given risks for bleeding. He was continued on [Last Name (un) ], statin, and Carvedilol. # Chronic Diastolic congestive heart failure: No evidence of decompensation. Continued on Valsartan, Torsemide initially. Carvedilol held initially and then restarted. As above, Valsartan was discontinued at discharge given hyperkalemia. Discharge weight is 217.4lbs. # Diabetes mellitus: Per his wife, pt's BG had been well-controlled completely off all medications. He had been on Actos prior but that had been discontinued prior to admission. Pt was placed on insulin while in house. He should follow-up with this [Last Name (un) ] physician after discharge from rehab for continued management. # Gastritis: Continued on Ranitidine. TRANSITIONAL CARE: # CODE: FULL # CONTACT: WIFE, HCP - [Name (NI) ] [Name (NI) 805] Phone number: [Telephone/Fax (1) 103765]; Cell phone: [Telephone/Fax (1) 103766] # FOLLOW-UP: - PLASTICS [11-8] - ORTHO SPINE [11-8] - Pt will need f/u with PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 4427] after discharge from rehab # Pending studies: - Blood cultures 11/4, [10-28], [10-29] pending at time of discharge # medication changes: - STARTED Coumadin for DVT - STARTED Hydralazine - STARTED Cipro for UTI - STARTED Oxycodone for pain control - INCREASED dose of Carvedilol - DISCONTINUED PLAVIX - DISCONTINUED HCTZ, VALSARTAN Consider restarting Valsartan if hyperkalemia improves Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO DAILY 2. Tamsulosin 0.8 mg PO HS 3. Docusate Sodium 100 mg PO BID:PRN constipation 4. Torsemide 5 mg PO DAILY 5. Amlodipine 10 mg PO DAILY HOLD for sbp<100 6. Ranitidine 300 mg PO HS 7. Clopidogrel 75 mg PO DAILY 8. Acetaminophen 650 mg PO Q6H:PRN pain, fever 9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, SOB 10. Calcium Carbonate 500 mg PO QID 11. Cyclobenzaprine 10 mg PO TID:PRN spasms HOLD for sedation, confusion 12. Calcitriol 0.25 mcg PO DAILY 13. Fluticasone Propionate NASAL 2 SPRY NU [Hospital1 *] 14. FoLIC Acid 1 mg PO DAILY 15. Sertraline 25 mg PO DAILY 16. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 17. Diovan HCT NF* (valsartan-hydrochlorothiazide) 160-25 mg Oral daily 18. Cyanocobalamin 1000 mcg PO DAILY 19. Polyethylene Glycol 17 g PO DAILY:PRN constipation 20. Senna 1 TAB PO BID:PRN constipation 21. Carvedilol 1.56 mg PO BID taking [12-24] tablet Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain, fever 2. Amlodipine 10 mg PO DAILY HOLD for sbp<100 3. Atorvastatin 40 mg PO DAILY 4. Cyclobenzaprine 10 mg PO TID:PRN spasms HOLD for sedation, confusion 5. Docusate Sodium 100 mg PO BID 6. Torsemide 5 mg PO DAILY 7. Cyanocobalamin 1000 mcg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Senna 1 TAB PO BID:PRN constipation 11. Sertraline 25 mg PO DAILY 12. Fluticasone Propionate NASAL 2 SPRY NU [Hospital1 ] 13. Calcitriol 0.25 mcg PO DAILY 14. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain HOLD for sedation, confusion, RR<10 15. Calcium Carbonate 500 mg PO QID 16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing, SOB 17. Ranitidine 300 mg PO HS 18. Quetiapine Fumarate 12.5 mg PO HS HOLD for sedation 19. Carvedilol 3.125 mg PO BID HOLD for SBP<100, HR<50 20. HydrALAzine 10 mg PO Q8H HOLD for SBP<100 21. Tamsulosin 0.8 mg PO HS 22. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days last day is [11-3] 23. Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 24. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 25. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS glaucoma 26. Warfarin 2.5 mg PO DAILY16 to be adjusted daily based on INR, goal is [1-25] Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary: C-spine fractures complicated by central cord syndrome, s/p Application and removal of [Location (un) 8766] tongs. 2. Application of allograft. 3. Application of morselized autograft. 4. Posterior cervical arthrodesis C2-C7. 5. Posterior instrumentation C2-C7. 6. Bilateral laminotomy C3 with medial facetectomy. 7. Bilateral laminectomy and medial facetectomy of C4, C5, C6, C7. metabolic encephalopathy Urinary tract infection Deep venous thrombosis Secondary: Diabetes Chronic renal insufficiency Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Must maintain C-collar at all times and keep HOB >40 Discharge Instructions: Dear Mr. [Known lastname 805], It was a pleasure taking care of you this admission. You were admitted after a fall, and had multiple fractures. You had extensive spinal surgery and were followed closely by the surgeons. After the surgery you became confused and were found to have a urinary tract infection and transferred to the medicine team. You improved with antibiotics. You are very weak and need rehabilitation to improve your strength. Please see the attached medication list. Followup Instructions: Please follow-up with the following appointments: Department: SPINE CENTER When: FRIDAY [2109-11-8] at 8:00 AM With: DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] [Telephone/Fax (1) 8603] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please arrive about 20 mins prior to your appointment for Xrays. Department: DIV. OF PLASTIC SURGERY When: FRIDAY [2109-11-8] at 9:15 AM With: [First Name11 (Name Pattern1) 1216] [Last Name (NamePattern4) 2612], MD [Telephone/Fax (1) 6331] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2109-11-1]	[ "276.7", "276.2", "428.32", "412", "873.20", "997.09", "272.4", "996.64", "599.0", "802.0", "E878.1", "250.40", "585.3", "349.82", "403.10", "V15.82", "414.01", "535.50", "285.21", "600.00", "453.81", "E884.4", "428.0", "331.9", "873.43", "588.89", "E849.0", "952.03", "584.9", "952.08", "274.9", "276.51", "996.74" ]	icd9cm	[ [ [] ] ]	[ "03.59", "81.03", "38.97", "27.51", "03.09", "81.63", "21.81" ]	icd9pcs	[ [ [] ] ]	18334, 18404	8980, 14122	369, 702	18966, 18966	5146, 5146	19712, 20536	3695, 3721		17019, 18311		18425, 18945		16020, 16996			19197, 19689			5602, 8957						3736, 5127																15742, 15994			282, 331						2960, 3340						730, 2942				14139, 15722	5162, 5586			18981, 19173						3362, 3529	3545, 3679
31,284	142,084	3563	Discharge summary	report	Admission Date: [2131-7-31] Discharge Date: [2131-8-16] Date of Birth: [2069-7-15] Sex: M Service: MEDICINE Allergies: Risperdal / Lisinopril Attending:[First Name3 (LF) 2181] Chief Complaint: found down Major Surgical or Invasive Procedure: intubation CVL placement History of Present Illness: 62 y/o M with PMHx of major depression with multiple suicide attempts by overdose, DMII, seronegative RA, HTN was found unresponsive today at 5pm. He was seen this AM without any c/o; no hx of depression or recent relationship problems. Around [Name2 (NI) ] today, was seen lying in his room, and was slightly slowed, ? sedated. Then around 5:30pm, he was found by his wife in his room unresponsive, "turning blue." EMS was called (no sheet) but appears to have found him unresponsive and not breathing. BS was 170 in the field. . His duagher later found empty pill bottles in teh basement where he was found with 40 pills of Seroquel missing, 22 pills of Diovan missing, 33 pills of Lipitor missing and ~15 pills of Glucophage missing. . He was intubated upon arrival to the ED with 20mg IV Etomidate, 120 mg IV succinylcholine. His initial VS were temp 96 rectal, HR 126, BP 60/p, 100% on the vent. He was given 4L NS in boluses as his BP continued to dip into the 70s-80s/40s. Prior to his arrival in the MICU, his temp dropped to 92, and he was placed on a bair hugger. Past Medical History: 1) Major depression with psychotic features; attempted SI with overdose in [2126]; admitted at the time. Began after son committed suicide in [2119]. 2. Hypertension. 3. Diabetes mellitus type 2. 4. Hypercholesterolemia. 5. Seronegative RA 6. Lumbar disc disease. Social History: He was born in [Location ] and moved to the United States 25 to 30 years ago. Retired nine years ago from his job as a machine operator due to work related injury. Now lives with wife, 25 year old daughter and the daughter's two children. [Name (NI) ] son is 31 and married with children. [Name (NI) ] son was 21 and committed suicide in [2118], after an argument with girlfriend. The patient denied any history of mental illness in the family despite the son's suicide. As well, the family revealed that the patient's father as well made suicide attempt. Family History: son and father committed suicide Physical Exam: Initial Exam: VS: Temp:95.0 BP:77/33 HR:120 RR:15 O2sat: 100% on vent VENT: AC 600x14; PEEP 5, 50% Fi02 GEN: Intubated, retracts to pain HEENT: Pupils minimally reactive, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps Pertinent Results: Labs: Imaging: CT c-spine [7-31]: IMPRESSION: No acute fracture or alignment abnormality . CT Head [7-31]: IMPRESSION: No intracranial hemorrhage or edema . pCXR [7-31]: ET tube terminates 5.4 cm above the carina, at the level of the inferior clavicular heads, in standard position. NG tube is seen with tip in the stomach. Mild perihilar haziness is likely due to supine positioning rather than pulmonary edema. There are no effusions or pneumothorax. Cardiac, mediastinal, and hilar contours are normal. . Cardiac enzymes: Trop 0.15, Trop 0.06, Trop 0.04 . Discharge CBC: WBC-9.0 RBC-3.33* Hgb-10.5* Hct-30.5* MCV-92 MCH-31.6 MCHC-34.4 RDW-15.0 Plt Ct-113* . Coags [2131-8-8] BLOOD PT-13.6* PTT-76.0* INR(PT)-1.2* [2131-8-7] BLOOD Glucose-104 UreaN-38* Creat-2.1* Na-145 K-4.3 Cl-112* HCO3-22 AnGap-15 . LFT's [2131-8-6] BLOOD ALT-71* AST-102* CK(CPK)-160 AlkPhos-157* Amylase-284* TotBili-0.4 [2131-8-6] BLOOD Lipase-293* Brief Hospital Course: On admission, Mr [Known lastname 16267] was profoundly hypotensive and tachycardic and was admitted to the MICU. In the MICU, he was intubated, received volume rescusitation, pressors and received empiric antibiotics although his respirator depression and hypotension wer thought to be due to Seroquel and Diovan overdoses. He received 8 days of levofloxacin and flagyl for possible aspriation PNA. He was also found to have ARF with ATN, peak Cr 4.0 His MS, BP and respiratory drive imropoved in the first 36 and he was transfered to the floor. On the hospital wards, he developed bradycardia with HR in 30's for two days. Pt was placed on telemetry and cardiology was consulted. Per cardiology, pt's bradycardia was due to Mobitz Type 1 secondary to high vagal tone w/ hypertension and nausea. Pt's hypertension was treated with hydralazine and came down from systolic BP 170's to 130's/140's. Pt's nausea was treated with full resolution with Phenergan. The patients bradycardia resolved with HR in 80's. One week after admission, the patient began developing abdominal pain and a few episodes of diarrhea. C. diff and GI infection were ruled out. LFT's and amylase/ lipase were obtained - they were found to be significantly elevated, suggestive of biliary colic vs cholecystis although the patient was never febrile, no leukocytosis. The patient received a RUQ U/S showing a distended gall bladder with a lot of echogenic material thought to be sludge; there was no pericholecystic fluid, wall thickening or abnormalities of the ducts, liver or CBD. A CT of the abd was unrevealing as to the material in the gall bladder. The patient continued to have + [Doctor Last Name 515] sign although LFT's began trending down slowly suggestive of a gallstone or sludge that had passed. The pt received an ERCP without any sphincterotomy or stent placement. General surgery was consulted for elective cholecystectomy within the next month. During his hospital stay, the patient was followed by phsyciatry who recommended inpatient psych hospitalization for further treatment. After resolution of the patients elevated LFT's and abd pain, the patient was transfered to the psychiatry [Hospital1 ]. The patient will need to schedule an elective cholecystectomy sometime this month. Medications on Admission: Tylenol 500MG PO qdaily Seroquel 50 mg [Hospital1 ] Diovan 80 mg qDaily Lipitor 20mg qD Naprosen 375mg PO BID Diovan 80mg qD Metformin 500 qD Lexapro 10mg qD (?) Prilosec Remeron 30 qhs (?) 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. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)) as needed. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: do not exceed 6 tablets per 24 hour period. 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 6. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO four times a day. Discharge Disposition: Extended Care Facility: [Hospital1 18] Discharge Diagnosis: Intentional drug overdose Acute tubular necrosis Bradycardia Biliary colic Discharge Condition: good Discharge Instructions: Please return to emergency department if you have bleeding at your central line site, worsening abdominal pain, fevers, chills, or other concerning symptoms. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, MPH[MD Number(3) 708]:[Telephone/Fax (1) 7976] Date/Time:[2131-8-14] 12:15. Your primary care doctor should check your renal function. We have stopped your diovan, you should not be taking this medication until you kidney function improves. We have started a medication called hydralazine in its place. Once you renal function improves, your doctor may wish to restart you diovan. You will need to schedule an elective cholecystectomy (gall bladder removal) sometime this month. Please call ([Telephone/Fax (1) 15807] to shedule an appointment for evaluation with Dr. [Last Name (STitle) ].	[ "969.3", "722.52", "584.5", "962.3", "518.81", "E950.3", "972.9", "272.0", "972.2", "401.9", "507.0", "250.00", "E950.4", "714.0", "296.34", "573.3", "577.0", "427.89", "426.13" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	7163, 7208	4057, 6345	294, 320	7327, 7334	3078, 3599	7540, 8235	2330, 2364		6590, 7140		7229, 7306		6371, 6567			7358, 7517									2379, 3059															3616, 4034				244, 256												348, 1428														1451, 1725	1741, 2314
29,288	147,583	45796	Discharge summary	report	Admission Date: [2124-11-14] Discharge Date: [2124-11-21] Date of Birth: [2059-11-27] Sex: M Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 2736] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 64 M h/o obesity, PVD, CKD (baseline unknown), DVT ~6-10y ago, recently d/c'd [11-9] from [Hospital3 417] after presenting s/p fall x 2 (described SSCP 15m prior, non-radiating, in AM, then LH/dizzy after leaving the shower, fell x 2 10 min apart, no LOC, preceding SOB, PALP, N/V), with negative p-mibi and TTE with normal valves, EF. . Pt in his USOH at home until ~7PM [11-14], went outside, slid on ice, fell, landing on both knees, then falling towards right, bruised R elbow. no LOC, no head trauma. No antecedent CP/SOB/PALP/LH/N/V/diaphoresis. Neighbors brought him inside, ~1hr later, pt started c/o mid-back and central chest pain with some radiation to both shoulders, dull, no sob/n/v/diaphoresis, starting ~7PM, at 930pm pain persisted, pt called EMS. no pain with inspiration, no pain with exertion (though pt not moving much). states pain worse with bending over. . EMS initial VS= BP 126/80 99%RA, EKG per report, sinus arrythmia, nonspecific ST changes, poor r-wave progression. given nitro with resolution of CP prior to arrival at OSH ~1030 (unclear if before or after nitro). At OSH, CK 421 MB TROP 7.16, INR 2.3, heparin gtt ordered however not given [12-23] pharmacy refused due to INR. Per report, Dr. [Last Name (STitle) 7047] decided against heparin gtt today, instead pt given plavix 300mg 6am on [11-15], and again at 10:30. no other meds given o/n. . On morning of transfer [11-15], 7AM VS= NSR, 97.7, 75-68, RR 20, BP 108/54 (108/54-124/84), 96%RA->100%2L, pt given asa 325, lopressor 25mg po x 1, mucomyst 600mg x 1, percocet for bilateral feet pain, IVF= 2ampHCO3 + 1/2 NS @ 11:15AM 100/hr. [Name8 (MD) ] RN pt denied CP, though reported intermittent pain to cardiologist. Pt being transferred to CCU for further workup of chest discomfort, described as radiating from the back towards chest. . With regard to cardiac review of systems, pt denies any h/o regular angina or chest pain with exertion. He has stable DOE with occasionally with dressing himself more often with a flight of stairs. His bilateral ankle edema is chronic and unchanged of late, with chronic venous stasis changes. He denies PND/orthopnea, but notes an episode of syncope prior to his most recent hospilazation, though it is unclear if he truly lost consciousness. He denies any preceding cp/sob/palpitation/n/v/diaphoresis, and states he slipped getting out of the tub. Of note, ~15min later, he admits to falling again in his bedroom. At that time he endorses lh/dizzy prior to fall, but cannot recall if he lost consciousness. . ROS: +cough, non-productive, +DOE, claudication - after walking 20-30 feet, bilateral calf pain, improves within 10-15min, no rest pain, but + "numbness" bilateral feet with "pins and needles" which improves with walking. . 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, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock pain. All of the other review of systems were negative. Past Medical History: - CKD (bl creatinine 1.6 - 1.8, stable over the past 10 years) - h/o DVT on coumadin (date=6-10y ago) with low protein C - morbid obesity s/p gastic bypass [2088] - h/o b knee pain [12-23] OA - scheduled for R knee replacement [2124-12-1] - spinal stenosis - h/o falls x 1/month x 1 yr [12-23] "balance" - h/o hypokalemia - s/p appendectomy as child. Social History: Social history is significant for the absence of current tobacco use. +etoh, drink 2 beers/day Family History: Mother died at 60 of MI, father died at 73 "from diabetes." Physical Exam: VS: 97.1 70 100/74 20 99%[Last Name (LF) ], [First Name3 (LF) ] LUE BP 95/68, RUE 89/78. Gen: obese middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. anxious. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 12 cm @ 90 degrees. CV: unable to appreciate PMI. RR, normal S1, S2. ?S4, no S3. no m/r Chest: 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. midline vertical scar RLQ (appy), epigastric horizontal well healed scar. no palpable aorta, no renal bruit. Ext: No c/c. No femoral bruits. 2+ B LE EDEMA to knee. Skin: +chronic venous stasous changes. Pulses: Right: Carotid 2+ w/o bruit; Femoral 2+ without bruit; 1+ DP, dopplerable PT. Left: Carotid 2+ w/o bruit; Femoral 2+ without bruit; dopplerable DP, PT Pertinent Results: LABS: [2124-11-14] 11:00PM BLOOD WBC-10.2 RBC-3.65* Hgb-11.7* Hct-36.8* MCV-101* MCH-32.1* MCHC-31.9 RDW-14.4 Plt Ct-292 [2124-11-15] 07:15AM BLOOD WBC-8.3 RBC-3.26* Hgb-10.5* Hct-32.6* MCV-100* MCH-32.2* MCHC-32.2 RDW-14.5 Plt Ct-256 [2124-11-16] 06:25AM BLOOD WBC-7.0 RBC-3.05* Hgb-10.0* Hct-29.8* MCV-98 MCH-32.7* MCHC-33.4 RDW-14.6 Plt Ct-203 [2124-11-14] 11:00PM BLOOD PT-27.8* PTT-61.0* INR(PT)-2.8* [2124-11-15] 07:15AM BLOOD PT-30.3* PTT-37.5* INR(PT)-3.1* [2124-11-15] 07:10PM BLOOD PT-20.7* PTT-77.6* INR(PT)-1.9* [2124-11-16] 06:25AM BLOOD PT-17.7* PTT-65.5* INR(PT)-1.6* [2124-11-14] 11:00PM BLOOD Glucose-98 UreaN-25* Creat-1.7* Na-142 K-4.2 Cl-109* HCO3-20* AnGap-17 [2124-11-16] 06:25AM BLOOD Glucose-96 UreaN-24* Creat-1.6* Na-139 K-4.4 Cl-109* HCO3-20* AnGap-14 [2124-11-14] 11:00PM BLOOD ALT-28 AST-56* CK(CPK)-1104* AlkPhos-75 Amylase-51 TotBili-0.4 [2124-11-15] 07:15AM BLOOD ALT-24 AST-43* CK(CPK)-731* AlkPhos-64 TotBili-0.3 [2124-11-15] 07:10PM BLOOD CK(CPK)-871* [2124-11-14] 11:00PM BLOOD CK-MB-14* MB Indx-1.3 cTropnT-0.38* [2124-11-15] 07:15AM BLOOD CK-MB-9 cTropnT-0.25* [2124-11-15] 07:10PM BLOOD CK-MB-7 cTropnT-0.18* [2124-11-15] 07:15AM BLOOD VitB12-434 Folate-6.9 [2124-11-14] 11:00PM BLOOD %HbA1c-5.3 [2124-11-14] 11:00PM BLOOD Triglyc-89 HDL-64 CHOL/HD-1.7 LDLcalc-28 [2124-11-14] 11:00PM BLOOD TSH-5.1* [2124-11-15] 07:15AM BLOOD Free T4-0.88* [2124-11-15] 07:33AM BLOOD Lactate-0.7 . OSH LABS: [2124-11-13] @ 11:45PM: (no labs [11-15] except cardiac enzymes). na 139 k 4.3 cl 113 co2 20 bun 25 cre 1.6 glucose not done . cpk 421 -> 712 cpk mb 20.6 -> 23.5 mbi 4.9 -> 4.3 tropI (0.02-0.50) 7.16 -> 5.31 (@8:45AM) . wbc 9.1 hct 36.7 plt 249 mcv 98 . ptt 40 on [11-14]. pt 24.8->26.4 @ 9AM [11-15] inr 2.3->2.5 . . STUDIES: [2124-11-15] TTE: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal half of the inferior, septal and anterior walls, and apex. The remaining segments contract normally (LVEF = 30 %). No defininte left ventricular thrombus is seen, but views of the apex are suboptimal. 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 appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w multivessel CAD (mid-LAD and PDA lesions). . . [2124-11-16] LHC: . . . [2124-11-14] 0100 OSH EKG demonstrated: NSR, nl axis, prolonged PR 180s, normal QRS (some notching on downstroke of V3), QTc 500s, but QT normal on inspection, ~1mm STE in I, biphasic TW V1, III, no STD. . [2124-11-14] 1053 OSH EKG demonstrated: NSR, nl axis, prolonged PR, normal QRS, QTc 500s, but QT normal on inspection, <1mm STE in I, II, biphasic TW V1, III, no STD. . [2124-11-14] 1424 OSH EKG demonstrated: NSR, nl axis, prolonged PR 182, normal QRS, QTc 484, but QT normal on inspection, <1mm STE in I, II, biphasic TW V1, III, no STD. decreased S wave amplitude in V1-2. . [2124-11-4] OSH TTE demonstrated: EF 55-60%. LV size normal. mild LVH. left [Male First Name (un) 4746]/contractility wnl RA nl. no AR/AS. no MR. tricuspid not well visualized. pericardium normal. aortic root appears normal. AoRootDiam 35mm. Impression: Technically liited study [12-23] pt's COPD and obesity. . [2124-11-6] OSH P-MIBI demonstrated: appropriate HR increase 67->77, BP dropped 128/54->113/63. no cp, no diagnostic ECG chagnes, no arrythmias. inferior wall defect on rest and [Last Name (un) ], most liekly [12-23] diaphragmatic attenuation. no definitive evidence of ischemia or prior infract. normal EF 61%. Brief Hospital Course: 64 M h/o CKD, PVD, morbid obesity, transferred from OSH after presenting with CP s/p fall, with positive CE. . # Chest pain - initial differential included ACS, PE, dissection, or mechanical pain [12-23] fall. Given cardiac risk factors, +enzymes, and TTE with new wall motion abnormality on TTE, felt ACS more likely, pt hydrated with 1L IVF bolus, bicarb, and mucomyst. Left heart catheterization revealed clean coronaries on [11-17], EF=20%, with severe HK and AK apically more suggestive of ?takasubo's [12-23] pain from fall. Continued asa 325 qd. Discontinued plavix given clean coronaries. Continued betablocker, statin, ACE inhibitor. . # CAD/Ischemia: no frank h/o CAD, TTE [11-16] c/w multivessel CAD, however clean coronaries on cath. Asa/plavix/metoprolol/statin/ACE inhibitor. . # Pump: pt grossly euvolemic currently, EF > 55% on TTE and PMIBI [2124-11-8] discharge, now with EF 20% on LV gram, severe HK and AK. Transitioned from heparin to coumadin for akinetic wall segments as well as history of deep vein thrombosis. Started on ace inhibitor, lasix for afterload/preload reduction. . # Rhythm: Normal Sinus rhythm . # Valves: f/u TTE. . # HTN: normotensive currently. . # PVD - dopplerable pulses bilaterally, and palpable on R LE. unclear if LE pain is clearly claudication or more neuropathy, esp given h/o DM, and B12 injections. . # CKD - baseline 1.6-1.8 per PCP, [Name10 (NameIs) 46296] unclear no known HTN or DM. Initially held ACE [12-23] cre 1.7, improved over course. A1c <6, no obvious HTN, SPEP and UPEP negative. . # ? rhabdo - pt on ground for ?1hr, CKs trending down (peak 1100), with renal failure. Given IV fluid hydration and CK trended down. Urine negative for myoglobin. . # knee pain - likely OA [12-23] weight, with recent meniscal tear. - continued percocet prn. . # FEN: - cardiac diet for now, npo p mn for cath [11-17]. . # Prophylaxis: - heparin gtt -> will transition back to coumadin. - ppi given heparin gtt. - bowel regimen. . # Code: FULL CODE - discussed with pt [2124-11-14]. . # Communication: - [Hospital3 ] - floor = [Telephone/Fax (1) 97561], main = [Telephone/Fax (1) ]. - brother-in-law [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 97562]. . # DISPO - needed home services, currently lives alone, PT consult cleared to home, set up home VNA, arranged for INR check. Medications on Admission: CURRENT MEDICATIONS: UPON TRANSFER: aspirin 325mg po qdaily plavix 300mg x 2 po given [11-15] 10AM lopressor 25mg po bid mucmyst 600mg po bid ativan 0.5mg prn . . HOME MEDS: (FROM [11-9] DISCHARGE SUMMARY) prozac 10mg po qdaily coumadin 4mg po qdaily b12 1000mcg qmonthly percocet prn (foot pain) Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for knee pain. 2. Aspirin 325 mg 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. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once Daily at 16). Disp:60 Tablet(s) Refills:2 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Outpatient Lab Work Please draw PT/PTT/INR on [2124-11-22]. Fax results to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 25041] Discharge Disposition: Home With Service Facility: [Location (un) 701] VNA Discharge Diagnosis: Primary: Stress cardiomyopathy Secondary: Chronic kidney disease, h/o DVT on anticoagulation Discharge Condition: Good, chest pain free, vital signs stable Discharge Instructions: You were admitted to the hospital with chest pain. You were noted to have poor pumping function of the heart secondary to stress. You did not have a heart attack. . You were started on new medications including: Toprol XL 25mg daily Lisinopril 2.5mg daily Furosemide (lasix) 40mg daily Citalopram 20mg daily . You will have a visiting nurse [First Name (Titles) ] [Last Name (Titles) ] you with medications. . You need to have your blood drawn on [11-22] to make sure your dose of coumadin is correct. . Dr.[Name (NI) 8716] office will contact you to set up an appointment. Please follow up with your new cardiologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] as below. . Call your doctor or return to the emergency room if you develop worrisome symptoms such as chest pain, shortness of breath, fluttering in your chest, etc. Followup Instructions: Please followup with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], a cardiologist recommended by Dr. [Last Name (STitle) ]. His phone number is [Telephone/Fax (1) 3183]. Dr.[Name (NI) 8716] office will call you to schedule followup. If you do not hear from them on wednesday [11-22], please call his office.	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77,500	196,619	45731	Discharge summary	report	Admission Date: [2165-4-26] Discharge Date: [2165-5-3] Date of Birth: [2105-4-28] Sex: F Service: CARDIOTHORACIC Allergies: Hydrochlorothiazide Attending:[First Name3 (LF) 5790] Chief Complaint: Post tracheostomy and tracheal stenosis. Major Surgical or Invasive Procedure: [2165-4-26]: Flexible bronchoscopy with bronchoalveolar lavage and cervical tracheal resection and reconstruction. [2165-5-3]: Bronchoscopy History of Present Illness: 59 y/o female with complicated medical history c/w morbid obesity s/p Lap Gastric Bypass, sleep apnea, who has been diagnosed with adult onset asthma 9 or 10 years ago. Her SOB has been progressively getting worse over the years, although it improved substantially after her bypass in [2159], when she was able to come off home O2 after loosing around 80lbs (from 280 to 201lbs currently). She was recently admitted to an OSH with pneummonia and she required iv antibiotics and prednisone taper for "asthma exacerbation". A CT scan of the chest was done and was suggestive of tracheal stenosis and TBM. She was then referred from Dr. [Last Name (STitle) 64744], her pulmonologist at [Hospital3 ], to Dr. [Last Name (STitle) ] who performed a flexible bronchoscopy comfirming an A shaped short tracheal stenosis with evidence of TBM. The pt also reports occasional coughing with white phlegm, only yellow when she has a concurrent pneumonia. She also reports mild heartburn, but no fever, chills or recent weight loss. She report a voice change since her thyroidectomy for [Doctor Last Name 933] disease in [2157]. She currently is disabled, has SOB with mild exertion such as walking, going up the stairs or attempting to do the laundry. She has minimal SOB at rest, and cannot lay flat at night (she has to use at least 2 pillows). She uses CPAP at night for her sleep apnea as well. She was admitted for tracheal resection and reconstruction for tracheal stenosis. Past Medical History: 1. [Doctor Last Name 933] disease status post radioactive ablation with subsequent thyroidectomy and hypothyroidism. 2. T12-L1 disk herniation. 3. Status post cholecystectomy. 4. Right groin cyst removal 5. History of gastric bypass. 6. Diabetes mellitus type 2. 7. Osteopenia 8. Sleep apnea 9. Pancreatitis 10. Silent MI [65]. GERD 12. tracheostomy Social History: Married with 3 children, quit smoking 15 years ago. Family History: NC Physical Exam: Vital signs: VS: T98.4, HR 74 SR, BP 124/70, RR 18, O2 sats 97% RA Physical Exam: Gen: pleasant, in NAD Neck: incision healing without redness, purulence or drainage. CV: RRR S1, S2, no MRG or JVD Abd: soft, NT, ND Ext: warm, no edema Pertinent Results: Pathology - Tracheal rings 1, 2, 3: Respiratory mucosa, squamous metaplasia, and minor salivary gland. Tracheal cartilage. CXR [2165-4-28]: Right mid lung atelectasis is unchanged otherwise the lungs are grossly clear. Moderate-to-severe cardiomegaly is stable. There is no evident pneumothorax. If any there is a small right pleural effusion. A drain projects in the upper mediastinum. CXR [2165-4-30]: 1. Interval improvement in the atelectasis in the right middle lobe. 2. Left mid lung linear atelectasis and small left pleural effusion are unchanged. [2165-4-28] 02:17AM BLOOD WBC-10.7 RBC-3.60* Hgb-10.2* Hct-32.0* MCV-89 MCH-28.4 MCHC-32.0 RDW-15.5 Plt Ct-174 [2165-5-3] 07:20AM BLOOD Glucose-114* UreaN-15 Creat-1.2* Na-142 K-4.5 Cl-104 HCO3-29 AnGap-14 Brief Hospital Course: The patient was taken to the Operating Room on [2165-4-26] by Dr. [Last Name (STitle) ] for flexible bronchoscopy with bronchoalveolar lavage and cervical tracheal resection and reconstruction. There were no complications to the procedure. Please see operative report for more details. She was directly admitted to the surgical ICU post-operatively and transferred to the floor POD3. Her hospital course can be summmarized by the following review of systems: Neuro: Patient pain was controlled with a PCA of dilaudid. She was transitioned to an oral regimen once tolerating diet. By discharge, her pain was well-controlled on Roxicet. She had no neurological deficits. Cardio: She was hemodynamically stable. Her beta-blockade was resumed immediately post-operatively. Her oral regimen was maintained and adjusted to lower dosing of atenolol 25mg po daily. She had sinus bradycardia in the mid 40's occasionally but was assymptomatic. She had no other issues. Her lisinopril and norvasc dosed were also halved due to excellent blood pressure. Pulm: S/p tracheal resection with reconstruction. She was taken directly to the surgical ICU post-operatively and extubated later that evening. She maintained her airway with no respiratory distress. Her Lasix was resumed on POD6 due to slight shortness of breath and pedal edema. She did not require any oxygen on discharge. Bronchoscopy performed POD 7 showed intact anastomosis and patent airway. Sutures were cut. GI: Patient was kept NPO for 3 days for aspiration precautions. She was then advanced to a soft regular diet. PPI was resumed. No other issues. FEN/Renal: As she is on daily lasix, her fluid status was closely monitored. She made adequate urine t/o this hospital stay. Lasix was resumed on POD6. No other issues. Heme: She was started on SQH and had no other issues. ID: Pre-operative antibiotics of ancef. No infectious issues or concerns. Endo: Blood sugars were watched closely, and the patient was placed on lantus 10 units which kept her sugars controlled below 130 mostly. She will followup with outpatient endocrinologist for further uptitration of her lantus insulin if her glucoses are >150, as she was discharged well below her home dose of 52 units qhs. She was also resumed on her metformin. Dispo: The patient was deemed safe by Dr. [Last Name (STitle) ] for discharge home today. VNA was ordered to visit her once. Medications on Admission: Norvasc 10mg po daily, Levoxyl 250 (5x/week), Prilosec 20'', Lantus 52units qhs, Atenolol 50mg po daily, lisinopril 40 mg po daily, Doxazocin 4mg po daily, Vit D, Albuterol prn, lasix 40 mg po daily Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for sob, wheeze. 3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: check electrolytes in one week with your PCP. 4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:500 ML(s) Refills:0 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): NOTE DOSE CHANGE. 7. Levothyroxine 100 mcg Tablet Sig: 2.5 Tablets PO 5X/WEEK (MO,TU,WE,TH,FR). 8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): NOTE DOSE CHANGE. 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): NOTE DOSE CHANGE. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 12. Metformin 500 mg Tablet Sig: One (1) Tablet PO three times a day. 13. Calcium 500 mg Tablet Oral 14. Ergocalciferol (Vitamin D2) Oral 15. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime: if blood sugars >150 consistently discuss increasing lantus with your endocrinologist. Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Post tracheostomy, tracheal stenosis. [Doctor Last Name 933] disease status post radioactive ablation with subsequent thyroidectomy and hypothyroidism. T12-L1 disk herniation. Diabetes mellitus type 2 on insulin Osteopenia Sleep apnea Pancreatitis Silent MI GERD PSH: History of gastric bypass. Status post cholecystectomy. Right groin cyst removal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 2348] if you experience -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Hoarsness or difficulty breathing -You may shower. No swimming or bathing -No driving while taking narcotics - NOTE YOU ARE ON DIFFERENT MEDICATION DOSING COMPARED WITH ADMISSION MEDICATIONS: PLEASE TAKE NEW MEDICATIONS WITH DOSING. CALL IF ?'S. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] [5-21] at 9:00 am in the [Hospital Ward Name 121] Building Chest Disease Center [Hospital1 ] 116 Chest X-Ray [Hospital Ward Name 517] Clinical Center [Location (un) ] Radiolgoy 30 minutes before your appointment. Follow up with your endocrinologist regarding your lantus dosing. If blood glucose greater than 150 you will need to have lantus dose adjusted. Check you blood pressure sporadically and if it is staying higher than 130/80 please discuss increasing some of your blood pressure medications with your primary care physician. Completed by:[2165-5-3]	[ "577.1", "278.01", "511.9", "V58.67", "733.90", "244.1", "250.80", "E932.3", "V15.82", "V45.86", "427.89", "722.10", "519.02", "722.11", "519.19", "327.23", "493.90", "518.0", "E878.3", "412" ]	icd9cm	[ [ [] ] ]	[ "33.21", "33.24", "31.79" ]	icd9pcs	[ [ [] ] ]	7610, 7665	3553, 5966	327, 477	8063, 8063	2748, 3530	8653, 9285	2474, 2478		6215, 7587		7686, 8042		5992, 6192			8214, 8551		8574, 8630							2575, 2729																			246, 289												505, 1998								8078, 8190						2020, 2389	2405, 2458
65,401	156,518	50515	Discharge summary	report	Admission Date: [2167-5-30] Discharge Date: [2167-6-2] Date of Birth: [2105-6-17] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 8404] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: 61 female with h/o HATN, CAD, DM and recently now C6 [Female First Name (un) ] B [Female First Name (un) 39850] developed s/p C6 discectomy and C7-T1 anterior cervical discectomy and fusion (ACDF)ACDF. She had a complicated hospital course and was discharged to [Hospital1 ] on [5-29] and was there for less than 8 hours. She complained of chest pain [11-16]. Her trach gauze had also required changing four times with increased clear secretions. The summary of her hospital course is detailed in the discharge summary from [5-29]. Briefly: ?????? Admitted electively for C6 corpectomy and C7-T1 ACDF after being seen in referral for difficulty buttoning blouse and found to have compression of C5-C6 and C6-C7. ?????? Post noted to have motor defecits ?????? MRI showed new signal abnormality in cord ?????? Respiratory falure [5-4] ?????? intubation and bronch ?????? Persistant fevers ?????? Started on vanc/cefepime cipro for VAP ?????? Cefepime changed to ceftriaxone for better coverage of H flu in sputum [5-8] ?????? Pseudomeningocele on MRI ?????? DVT LUE ?????? Still febrile ?????? abx ceftriaxone and linezolid ?????? [5-12] attempted trach?????? aborted due to encountering CSF ?????? JP drain at CSF ?????? [5-14] JP removed and lumbar drain placed ?????? [5-15] trach + peg ?????? [5-17] lumbar drain not working ?????? [5-18] 2 lumbar drains placed ?????? [5-19] abx for VAP d/c??????d, ancef for drain ppx ?????? [5-24] lumbar drain removed ?????? Transistioned to Coumadin . On arrival to ED, initial vitals were 101.2 90 144/60 18 100%. She was given Vancomycin, Zosyn, 2 g ceftriaxone and Tylenol for fever. CTA with no PE, + bibasilar consolidation. NS consulted, wound site looks good; drain sites in place look well. No further imaging necessary per Dr. [Last Name (STitle) 548]. No new neurosurgical issues so did not feel admission to Neurosurgery was indicated. She was hemodynamically stable but admitted to the due to concern for increased nursing care. . Currently she denies pain. Past Medical History: C5 [First Name7 (NamePattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 39850] Chronic respiratory failure with trach s/p C6 corpectomy and ACDF C7T1 c allograft and plate c/b CSF leak stage II pressure ulcers MRSA/Hflu VAP LUE DVT Neurogenic bowel Neurogenic bladder h/o HTN h/o MI in 03 s/p BMS to LCcx DM (diet controlled) hypercholesterolemia s/p TAH-BSO [2146] hypotension, on florinef/MICU and glycopyrrelate Social History: Occupation: Drugs: Tobacco: prior (30-40 years) 1+ pack/day smoker Alcohol: Other: used to work as [Hospital1 112] clerk . She smokes approximately a third of a pack per day. Family History: HTN Physical Exam: On Admission: Gen: sleepy, NAD HEENT: tach in place on trach mask PULM: rhonchi bilaterally CV: RR, SM LSB ABD: s/nt/nd nabs EXT: no c/c/e Neuro: alert but drowsy appearing. B UE weakness R>L but able to move left extremity. BLE paralysis . On discharge: Gen: alert and oriented x 3, NAD HEENT: PERRL, trach in place CV: RRR, no m/r/g Pulm: CTA bilaterally Abd: soft, NTND Extrem: no edema Pertinent Results: On Admission: [2167-5-29] 02:40AM BLOOD WBC-4.9 RBC-2.63* Hgb-8.2* Hct-26.1* MCV-99* MCH-31.2 MCHC-31.5 RDW-16.7* Plt Ct-116* [2167-5-29] 02:40AM BLOOD PT-26.3* PTT-37.7* INR(PT)-2.5* [2167-5-29] 02:40AM BLOOD Glucose-93 UreaN-15 Creat-0.3* Na-142 K-4.1 Cl-106 HCO3-28 AnGap-12 [2167-5-29] 02:40AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.2 . On Discharge: [2167-5-31] 03:15AM BLOOD WBC-4.8 RBC-2.50* Hgb-7.8* Hct-24.8* MCV-99* MCH-31.0 MCHC-31.2 RDW-16.8* Plt Ct-163 [2167-5-31] 03:15AM BLOOD Neuts-61.8 Lymphs-27.1 Monos-6.8 Eos-3.9 Baso-0.5 [2167-5-31] 03:15AM BLOOD PT-23.7* PTT-81.4* INR(PT)-2.2* [2167-5-31] 03:15AM BLOOD Glucose-94 UreaN-12 Creat-0.5 Na-144 K-4.1 Cl-110* HCO3-25 AnGap-13 [2167-5-31] 03:15AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3 [2167-5-31] 03:12AM BLOOD Lactate-0.8 . Troponin trend: [2167-5-31] 03:15AM BLOOD cTropnT-<0.01 [2167-5-30] 12:14PM BLOOD cTropnT-<0.01 [2167-5-30] 02:15AM BLOOD cTropnT-<0.01 . Microbiology: [2167-5-30] 02:35AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [2167-5-30] 02:35AM URINE RBC-42* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 URINE CULTURE (Pending): ngtd Blood Culture, Routine (Pending): ngtd . Imaging: CTA on admission: 1. No evidence of PE or acute abdominal process. 2. Bibasilar atelectasis, with small pleural effusions. Brief Hospital Course: 61 y/o F recent [First Name7 (NamePattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] s/p C6 corpectomy with C7-T1 ACDF and complicated post-op course admitted after <24h in rehab with fevers and a report of chest pain. . # Chest Pain: Chest pain free on admission. No EKG changes on admission. Patient does have history of inferior MI [2159]. Had an ECHO [Month (only) 547] with normal EF. Patient ruled out for ACS with Troponin x 3 negative. CTA negative for PE. Patient was restarted on her cardiac medications including. ASA 81, Simvastatin and Lisinopril. We did not restart her Beta-blocker as she has recent bradycardia from autonomic dysfunction. -ACE and statin should be up-titrated as needed. -ASA use discussed with neurosurgery team, and no contraindications to proceed -If patient recovers her autonomic dysfunction and is felt unlikely to be at risk for bradycardia, she can restart low dose metoprolol and uptitrate as indicated. . # Fever: No leukocytosis. Tmax during admission 100.1. No localized source. No diarrhea to suggest C. Diff. No altered mental status to suggest CSF etiology. CTA no evidence of pneumonia. Ua negative. However, due to the report of increasing secretions, the patient was started on broad coverage Vanc/Cefepime. Once the patient's blood cultures negative for 48 hours and she had no further fever, leukocytosis or other sign of infection, these antbiotics were stopped. - Will f/u blood cultures and call [Hospital1 ] if negative tomorrow - our contact number is [Telephone/Fax (1) 105208] if you do not hear from us. . # Recent LUE DVT: CTA negative for PE on admission. She was therapeutic on coumadin and INR was 2.1 on the day of discharge. Coumadin dose is 5mg daily. -recheck INR on Wednesday [2167-6-4] and if stable will need weekly INR checks -patient's coumadin should continue for 3-6 months. After that she will require DVT prophylaxis with SQ heparin or lovenox ongoing given her [First Name7 (NamePattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] state. . # Anemia: Stable . # Lactic acidosis: Lactate elevated on admission resolved with IVF. . # H/O respiratory failure s/p trach: Stable on trach mask. No notable increase during admission. CTA demonstrates no infiltrate or evidence of pneumonia. Patient admitted to the ICU but required no vent support. Patient continued on prn albuterol and standing ipratropium. Acetylcysteine nebs were not needed or continued. . # stage II pressure ulcers: Continued wound care. No evidence of infection. . # C5 [First Name7 (NamePattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] with Neurogenic bowel/bladder, hypotension: This appears unchanged from recent discharge. Patient was continued on her bowel regimen, foley was kept in place. Patient was hypertensive so her midodrine was decreased to [Hospital1 ] and florinef was continued. - Midodrine can be further weaned for SBP >140 . # DM: Sliding scale while in house but did not require any insulin. Can be considered diet controlled. . # hypercholesterolemia: restarted on statin as above. . # Recent hospital stay: Patient with recent complicated stay (see HPI) - please refer to recent d/c summary. Printed out extra copy and sent with patient. . # Trach care: Inner cannula was changed on [2167-6-1]. Discussed with Dr. [Last Name (STitle) ] [Name (STitle) ] who placed trach and confirmed trach is ok to proceed with down-sizing as the fibrous track of the tracheotomy will be well sealed off from the neck tissues in general. In addition CSF collection in the neck dried up after placement of the lumbar drains and the dural injury has no doubt long since sealed. Secretions are not CSF they are sputum. Medications on Admission: 1. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 3. fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. glycopyrrolate 1 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 6. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 7. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 9. oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q4H (every 4 hours) as needed for pain. 10. midodrine 2.5 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours). 11. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): goal INR 2.5 - 3.0. 12. acetaminophen 650 mg/20.3 mL Solution Sig: Six [Age over 90 1230]y (650) mg PO Q6H (every 6 hours) as needed for pain/fever. 13. acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs Miscellaneous Q6H (every 6 hours) as needed for thick secretions. Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. glycopyrrolate 1 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 6. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation every four (4) hours. 7. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 9. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for pain. 10. alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every Tuesday). 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 15. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. midodrine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. psyllium Packet Sig: One (1) Packet PO DAILY (Daily) as needed for constipation. 18. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: Thirty (30) ML PO QID (4 times a day) as needed for dyspepsia. 19. acetaminophen 650 mg/20.3 mL Solution Sig: Six [Age over 90 1230]y (650) mh PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Atypical cardiac pain Fever Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted for chest pain. You did not have a heart attack. You were also ruled out for a blood clot in your lung. . You were covered with antibiotics until your blood cultures returned negative. . Please follow your medications as listed. Followup Instructions: Please follow recommended follow-up according to last discharge: YOUR SUTURES ARE UNDER THE SKIN YOU WILL NOT NEED TO BE SEEN UNTIL THE FOLLOW UP APPOINTMENT PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) ] TO BE SEEN IN 6 WEEKS. YOU WILL NEED AP AND LATERAL C SPINE XRAYS PRIOR TO YOUR APPOINTMENT [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 8405]	[ "518.83", "414.01", "305.1", "596.54", "V44.0", "786.59", "285.9", "344.00", "564.81", "V58.61", "401.9", "250.00", "276.2", "V45.4", "780.60", "272.0", "V12.51" ]	icd9cm	[ [ [] ] ]	[ "96.6" ]	icd9pcs	[ [ [] ] ]	11895, 11965	4952, 8750	314, 320	12036, 12036	3539, 3539	12484, 12928	3109, 3114		10123, 11872		11986, 12015		8776, 10100			12213, 12461									3129, 3129								4789, 4809		3903, 4755									264, 276												348, 2429							4823, 4929	12051, 12189						2451, 2897	2913, 3093
27,143	177,210	33204	Discharge summary	report	Admission Date: [2189-12-29] Discharge Date: [2190-1-8] Date of Birth: [2142-11-15] Sex: F Service: CARDIOTHORACIC Allergies: Benadryl Attending:[First Name3 (LF) 5790] Chief Complaint: abdominal wound drainage Major Surgical or Invasive Procedure: [2189-12-29] EGD, revision of gastrostomy tube History of Present Illness: 47F with h/o obesity hypoventilation syndrome, sleep apnea on CPAP, COPD, recently discharged to rehab on [2189-12-24]. She had been admitted for COPD exacerbation and MRSA PNA, failed to wean from ventilation, and, on [2189-12-15], underwent tracheostomy and open gastrostomy tube placement with Dr. [Last Name (STitle) ]. On [2189-12-21], she returned to the OR for fascial dehiscence. Prior to discharge, she was tolerating goal tube feeds without difficulty and her incision was intact. She was transferred back to [Hospital1 18] on [2189-12-29] with gastric contents draining from her abdominal incision. Past Medical History: PMH: h/o childhood asthma, morbid obesity, obesity hypoventilation syndrome, sleep apnea, COPD, hyperlipidemia, DMII, HTN PSH: tracheostomy, gastrostomy tube ([2189-12-15]); abdominal wash out, closure of fascial dehiscence ([2189-12-21]) Social History: 1 PPD smoker. Lives w/husband. Family History: non-contributory Physical Exam: On admission: 99.5 92 131/93 27 98%TM Gen: NAD HEENT: NC, EOMI, MMM Neck: midline trachea with tracheostomy in place CVS: RRR, nl S1S2, no m/r/g Pulm: coarse breath sounds diffusely, diminished breath sounds at b/l bases Abd: obese, soft, diffuse tenderness, no peritoneal signs, midline surgical incision, open superiorly with brown gastric drainage Ext: no c/c/e On discharge: 98.9 88 126/71 20 93%TM Gen: NAD HEENT: NC, EOMI, MMM Neck: midline trachea with tracheostomy in place CVS: RRR, nl S1S2, no m/r/g Pulm: CTA b/l Abd: obese, soft, NT, ND, +BS, midline incision with VAC dressing (last changed [1-8]), no leak, G tube without erythema Ext: no c/c/e Pertinent Results: On admission: [2189-12-30] 12:52AM BLOOD WBC-15.8* RBC-3.80* Hgb-12.2 Hct-37.0 MCV-97 MCH-32.1* MCHC-32.9 RDW-12.5 Plt Ct-560* [2189-12-30] 12:52AM BLOOD PT-12.8 PTT-24.9 INR(PT)-1.1 [2189-12-30] 12:52AM BLOOD Glucose-157* UreaN-16 Creat-0.7 Na-142 K-4.2 Cl-99 HCO3-37* AnGap-10 [2189-12-30] 12:52AM BLOOD Calcium-9.8 Phos-5.1* Mg-2.3 [2189-12-30] 01:03AM BLOOD Type-ART pO2-85 pCO2-63* pH-7.39 calTCO2-40* Base XS-9 On discharge: [2190-1-7] 04:10PM BLOOD WBC-9.6 RBC-3.42* Hgb-11.0* Hct-32.9* MCV-96 MCH-32.3* MCHC-33.5 RDW-13.2 Plt Ct-258 [2190-1-7] 04:10PM BLOOD Glucose-131* UreaN-9 Creat-0.5 Na-141 K-4.4 Cl-100 HCO3-34* AnGap-11 [2190-1-7] 04:10PM BLOOD Calcium-9.4 Phos-3.9 Mg-2.0 Brief Hospital Course: Patient was admitted with gastric contents draining from abdominal wound. She was started on vancomycin and Zosyn and was taken to the OR. On EGD, the G tube was found to be leaking and was replaced. Please see operative note for further details. Postoperatively, she was transferred to the TSICU. On POD 1, she was transferred to the floor. On POD 2, tube feeds were started. Nutrition was consulted for recommendations on tube feeds. On POD 3, the wound was opened and a VAC dressing was placed. On POD 4, her regular insulin sliding scale and Glargine were restarted with improved glucose control. On POD5, her vanco and Zosyn were d/c'd. She was started on Augmentin. On POD 6, her VAC was changed and her wound was debrided. On POD 8, she was evaluated by Speech & Swallow and cleared for regular diet. Her trach was deemed too large for a Passy Muir valve. Plans were made to downsize it; however, later in the day, she had an episode of mucous plugging, for which a Code Blue was called, and which resolved following suctioning. On POD 7, as she had tolerated regular diet, her tube feeds were discontinued. On POD 8, the VAC dressing was changed and the wound debrided. It was clean with serosanguinous drainage. She was stable for discharge to rehab. She will complete a 7 day course of Augmentin on [2190-1-9]. Medications on Admission: Humalin SS, Combivent q6h, Crestor 10', Diovan 160', Colace, fentanyl patch 25 mcg q72h, MVI, SQH, Lantus 60", miconazole powder, Beclovent 2puffs", Senna, Tylenol, diazepam 2 prn, Atrovent q6h prn, MOM prn, morphine 4 q3h prn Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [Date Range ]: One (1) Injection TID (3 times a day). 2. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [Date Range ]: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 3. Fentanyl 75 mcg/hr Patch 72 hr [Date Range ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Miconazole Nitrate 2 % Powder [Date Range ]: One (1) Appl Topical PRN (as needed). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Date Range ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Lactulose 10 gram/15 mL Syrup [Date Range ]: Fifteen (15) ML PO BID (2 times a day) as needed for constipation. 7. Docusate Sodium 50 mg/5 mL Liquid [Date Range ]: Five (5) ML PO BID (2 times a day). 8. Hydrocodone-Acetaminophen 5-500 mg Tablet [Date Range ]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: crushed . 9. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for Reconstitution [Date Range ]: Ten (10) ML PO TID (3 times a day) for 2 days: through [2190-1-9]. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] once a day: . 11. Hydromorphone 2 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for breakthough pain: crushed . 12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [Last Name (STitle) ]: Two (2) ML Intravenous DAILY (Daily) as needed. 13. Insulin Insulin SC Fixed Dose Orders Glargine 60 Units qHS Regular Insulin SC Sliding Scale QACHS Glucose Regular Insulin Dose 0-60 mg/dL [11-18] amp D50 61-110 mg/dL 0 Units 111-160 mg/dL 30 Units 161-200 mg/dL 33 Units 201-240 mg/dL 36 Units 241-280 mg/dL 39 Units 281-310 mg/dL 42 Units 311-350 mg/dL 45 Units 351-400 mg/dL 48 Units > 400 mg/dL Notify M.D. 14. Morphine Sulfate 2-4 mg IV DAILY PRN DRESSING CHANGE 15. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [Month/Day (2) ]: 2.5mg/3 ML Inhalation Q2H (every 2 hours) as needed. 16. Ipratropium Bromide 0.02 % Solution [Month/Day (2) ]: 0.02% Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 17. Lorazepam 0.5 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day) as needed: crushed. 18. Fluticasone 110 mcg/Actuation Aerosol [Month/Day (2) ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 38] Discharge Diagnosis: s/p trach, open G tube ([12-15]); c/b dehiscence s/p abdominal washout and fascial closure ([12-21]); s/p EGD, revision of gastrostomy tube ([12-29]); morbid obesity; hypoventilation syndrome; OSA (home CPAP); COPD; DM2; HTN; hyperlipidemia Discharge Condition: Afebrile, vital signs stable, tolerating regular diet (cleared for PO by speech & swallow), deconditioned and requires intensive physical therapy. Discharge Instructions: Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 170] if experience: -Fever > 101.5 or chills -Trach complications, difficulty with ventilation -Abdominal wound complications (e.g. increased or purulent drainage, erythema) -G-tube complications Wound VAC dressing change Q3D Right PICC line flush per protocol Followup Instructions: On the day of appointment with Dr. [Last Name (STitle) ], take off VAC dressing and apply wet to dry gauze. Reapply VAC upon return from clinic. Provider: [Name10 (NameIs) 1532] [Last Name (NamePattern4) 8786], MD Phone:[Telephone/Fax (1) 3020] Date/Time:[2190-1-12] 10:30 Provider: [Name10 (NameIs) 1532] [Last Name (NamePattern4) 8786], MD Phone:[Telephone/Fax (1) 3020] Date/Time:[2190-1-21] 10:30 Completed by:[2190-1-8]	[ "V55.1", "V44.0", "272.4", "250.00", "780.57", "518.82", "493.20", "934.0", "536.42", "401.9" ]	icd9cm	[ [ [] ] ]	[ "96.6", "97.02", "38.93", "86.28", "44.13", "93.59" ]	icd9pcs	[ [ [] ] ]	6950, 7031	2826, 4152	301, 353	7328, 7477	2081, 2081	7846, 8314	1356, 1374		4429, 6927		7052, 7307		4178, 4406			7501, 7823									1389, 1389										2533, 2803									237, 263												381, 1020							2095, 2519							1042, 1291	1307, 1340
46,366	195,169	50335	Discharge summary	report	Admission Date: [2124-12-11] Discharge Date: [2124-12-16] Date of Birth: [2072-9-30] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2840] Chief Complaint: shortness of breath pna, asthma exacerbation Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: 52 y/o F with hx of asthma, sinusitis and hx of CVA presented with three day history of shortness of breath on [12-11]. The shortness of breath was progressive and felt like she just couldn't catch her breath. She did endorse some wheeziness. Patient denied fevers, chills, night sweats. She did not have a cough. She had been struggling with a year of sinus pain and pressure and trouble breathing through her nose. . In the ED, vitals were 99.6, 101 axillary, 130, 135/68, 95% on neb. CXR showed bilateral upper lobe infiltrates concerning for pneumonia vs. bronchitis. Patient was thought to be at least somewhat immune compromised due to hx of steroid use per ENT treatment of sinusitis. Patient was admitted directly to MICU Green. . During her hospitalization, she was initially treated for CAP with clinda and levo. Also initally recieved methylprednisone for diffuse wheezing. Her abx were then broadened to levo and ceftriaxone. While in the ICU, patient had bronchoscopy which showed a 40% eosinophilia (she also had serum eosinophilia). She had no risk factors for TB and AFB x1 was negative. PCP smear was negative and LDH was normal. Due to eosinophilia, it was thought that patient may have Churg-[Doctor Last Name 3532]. ANCA was sent, but negative (although approx 50% of cases ar ANCA neg). All culture data came back negative so all antibiotics were stopped on [12-13]. Of note, patient had been on IV solumedrol since admission, with plan to start taper of steroids to PO once transferred to the floor. . On admission to the floor, the patient is feeling better than she has. Still feels very congested in her sinuses and does not think the O2 is helping through the NC because she can't breath through her nose. Has dry mouth and is thirsty. Breathing has improving, is still mildly dyspneic, but better. She is having a hard time sleeping and seeing some bright colors and shapes when she closes her eyes. These symptoms started when she was started on steroids. Denies abdominal pain, nausea, vomitting, but is contipated and hasn't had a BM since being in the hospital. Past Medical History: 1. cva [2-26] to ruptured aneurysm - remote, with R-sided residual weakness 2. asthma hx - no PFTs 3. R-distal radius fracture 4. pansinusitis - followed by ENT - pseudomonas on nasal swab 5. allergic rhinitis 6. anxiety disorder 7. migraine headaches 8. iron deficiency anemia Social History: independent ADLs, does have some help from family members. Denies tobacco or ethanol use currently. Family History: non-contributory currently Physical Exam: PE on admission afebrile, sbp 110/60, hr 110, nrb satting 98% 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: [2124-12-11] 08:00PM BLOOD WBC-9.8# RBC-5.28 Hgb-15.5 Hct-44.4 MCV-84 MCH-29.3 MCHC-34.8 RDW-13.5 Plt Ct-256 [2124-12-13] 05:08AM BLOOD WBC-17.1# RBC-4.40 Hgb-12.6 Hct-37.5 MCV-85 MCH-28.7 MCHC-33.7 RDW-13.9 Plt Ct-261 [2124-12-16] 07:10AM BLOOD WBC-8.9 RBC-4.33 Hgb-12.3 Hct-37.0 MCV-85 MCH-28.3 MCHC-33.2 RDW-13.9 Plt Ct-261 [2124-12-11] 08:00PM BLOOD Neuts-92.0 Lymphs-3.8* Monos-1.4* Eos-2.5 Baso-0.3 [2124-12-13] 05:08AM BLOOD Neuts-94.0* Lymphs-3.7* Monos-1.5* Eos-0.4 Baso-0.5 [2124-12-11] 08:00PM BLOOD Glucose-148* UreaN-13 Creat-0.8 Na-132* K-4.4 Cl-95* HCO3-26 AnGap-15 [2124-12-13] 05:08AM BLOOD Glucose-120* UreaN-19 Creat-0.6 Na-141 K-3.7 Cl-109* HCO3-23 AnGap-13 [2124-12-16] 07:10AM BLOOD Glucose-86 UreaN-13 Creat-0.6 Na-141 K-4.0 Cl-106 HCO3-28 AnGap-11 [2124-12-12] 05:41AM BLOOD ALT-15 AST-21 LD(LDH)-234 CK(CPK)-292* AlkPhos-104 TotBili-0.2 [2124-12-12] 05:41AM BLOOD proBNP-481* [2124-12-16] 07:10AM BLOOD Calcium-8.8 Phos-1.7# Mg-2.1 [2124-12-11] 09:00PM BLOOD Type-ART Temp-39.7 pO2-173 pCO2-37 pH-7.41 calTCO2-24 Base XS-0 Intubat-NOT INTUBA Comment-GREEN TOP [2124-12-11] 08:07PM BLOOD Lactate-1.5 [2124-12-12] 11:19AM BLOOD IGE-Test [2124-12-12] 08:17AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- TEST [2124-12-12] 08:17AM BLOOD B-GLUCAN-Test . Imaging: CXR on admission: There is stable mild biapical pleural thickening. There is mild peribronchial thickening, unchanged since the prior examination. There is no focal pulmonary consolidation. The cardiomediastinal silhouette is unremarkable. CONCLUSION: 1. Mild peribronchial thickening may indicate reactive airway disease/bronchitis. 2. Stable minimal biapical pleural scarring. . CTA chest: IMPRESSION: 1. Limited study due to respiratory motion. No central or large segmental pulmonary embolism. No dissection. 2. Right upper lobe and left upper lobe pneumonia. . Echo: The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. The mitral valve leaflets are elongated. There is mild mitral valve prolapse. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . CXR on discharge: A region of consolidation in the suprahilar right upper lobe is shrinking, perihilar consolidation on the left is not. Followup advised for presumed pneumonia, alternatively pulmonary hemorrhage. Lower lungs clear. Heart size normal. No pleural effusion or evidence of central adenopathy. Brief Hospital Course: 52 y/o F with hx of asthma and chronic pansinusitis who presents with three day history of shortness of breath. Treated for pneumonia, but all cultures negative. Bronchoscopy showed eosinophilia predominance. Most likley diagnosis is ANCA (-) Churg-[Doctor Last Name 3532]. . # Churg [Doctor Last Name 3532] - based on esoinophils seen in bronchoscopy and negative cultures, is the most likely diagnosis. Did have history of severe sinusitis and questionable asthma. Biopsy from bronchoscopy was still pending at the time of discharge. With upper lobe opacities and recent steroids could be an rare infectious process like fungal or aspergillosis or silicosis, but based on all the negative smears and cultures, makes it less likely. Abx were stopped after three days, was monitored for fevers, and remained afebrile and stable. Was initially treated with IV steroids which were transitioned to orals while on the floor. She was sent out on a long 6+ week taper, which will be followed by her pulmonologist. She was started on bactrim for PCP [Name Initial (PRE) ]. She will also need careful monitoring of her blood sugars while on steroids. Her PCP was called and we discussed outpatient plan before she was discharged. Evenutally will need PFTs and pulmonary follow up as an outpatient. . # Shortness of breath - see above, likely secondary to Churg-[Doctor Last Name 3532]. Was satting fine on room air at the time of discharge. Continued albuterol and advair as an outpatient. PT worked with the patient and was able to see that her ambulatory sats were within normal limits and she was moving around at her baseline. . # Sinusitis - on recent CT, patient with total opacification of sinuses. Is s/p steroids and cipro course for these with plan for outpatient ENT surgery this week. Has had long standing sinusitis and hx of psuedomonas. Sinusitis is at baseline and does not appear to be infected at this time. She will f/u with her ENT doctor as an outpatient to discuss the need for surgery for the impacted sinuses. . # Asthma - again, likley related to Churg-[Doctor Last Name 3532], often precedes the diagnosis by 5-10 years (from Uptodate). Will continue with advair and albuterol nebs as needed. . # Elevated Blood sugars - likely was from the steroids, was on insulin sliding scale while an inpatient, but decided not to treat as an outpatient. She will follow up closely and have VNA to help check her sugars the first few days after she is discharged home. Hope with the taper that they will begin to normalize. . # Insomnia - likely a side effect of the steroids, trazadone was used for treatment. . # Discharge - was sent home in good condition, feeling well with close followup. Medications on Admission: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) prn AMITRIPTYLINE - 50 mg qhs AZELASTINE [ASTELIN] - 137 mcg intranasal [Hospital1 ] CIPROFLOXACIN [CIPRO] - 500 [Hospital1 ] for 20 days (?start [11-30]) FLUTICASONE-SALMETEROL 250/50 HYDROCORTISONE - cream prn for rash IMITREX - 50 prn MONTELUKAST - 10qhs OXYCODONE - 5 prn PREDNISONE - taper on [11-30] by ENT Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): Please take while you are on prednisone. . Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Disp:15 Tablet(s) Refills:2 3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [1-26] Sprays Nasal QID (4 times a day) as needed. 4. Calcium Citrate-Vitamin D3 315-200 mg-unit Tablet Sig: Two (2) Tablet PO twice a day: You need to take two twice a day so that you get 1200 mg of calcium per day and 800 IU of Vitamin D per day. 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:0 7. Singulair 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Astelin 137 mcg Aerosol, Spray Sig: One (1) spray Nasal twice a day. 9. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime: Please discuss with Dr. [Last Name (STitle) 713] whether you should restart this medication. 10. Imitrex 50 mg Tablet Sig: One (1) Tablet PO once and than repeat in one hour as directed as needed for migraines. 11. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day: You will be taking 60 mg for about 6-12 weeks. . Disp:90 Tablet(s) Refills:2 12. Trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO at bedtime as needed for insomnia: Only take if you need it while you are on the prednisone. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Churg-[Doctor Last Name 3532] Disease - biopsy pending 2. Sinusitis 3. Asthma Discharge Condition: stable Discharge Instructions: You were admitted for 3 days of very severe shortness of breath. You were admitted to the Intensive Care Unit and monitored very closely. Initially it was thought you might have a pneumonia, so you started on antibiotics. The pulmonologists did a bronchoscopy and found that you had a large amount of cells called eosinophils. This is sometimes associated with a disease called Churg-[Doctor Last Name 3532] disease. Churg-[Doctor Last Name 3532] disease is sometimes associated with asthma and sinusitis. It is an autoimmune disease. The best treatment for this type of disease is steroids, so you will need to go home on a pill called prednisone. This pill has some side effects for which you will need to take even more medicines. Please start taking Calcium and Vitamin D. Also take Bactrim to prevent any other lung infections. Please follow up with Dr. [Last Name (STitle) 713] and the other doctors listed below. You can continue to use your own albuterol nebulizer or inhaler but we also gave you a script for levoalbuterol (Xopenex) which helps decrease the increased heart rate. If you don't feel palpitations or that your heart rate is fast with your own albuterol then you don't need to fill the Xopenex script. Please return to the hospital for any worsening shortness of breath, increased cough, fevers, chills, chest pain, fainting, headaches, or any other concerns. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 713] in the next 1-2 weeks. Please call [Telephone/Fax (1) 6935] to make this appointment. Please make sure you take the calcium and vitamin D as prescribed and talk to Dr. [Last Name (STitle) 713] about scheduling a bone density exam and whether or not you should take a bisphosphonate to strengthen your bones. Please follow up with Dr. [Last Name (STitle) ] for further evaluation of your broken wrist. You Xray is at 9am, your appointment with the doctor is at 920. Please call [Telephone/Fax (1) 1228] if any questions. Please follow up with the pulmonologist Dr. [First Name (STitle) ] [Name (STitle) ], [Hospital Ward Name 23], [Location (un) ] on [1-10] at 8:30 am. You will have pulmonary function tests first. Tel ([Telephone/Fax (1) 513]. Please make an appointment with Dr. [First Name8 (NamePattern2) 2602] [Name (STitle) 2603], [First Name3 (LF) ] Allergist at ([Telephone/Fax (1) 14583]. Please call your ENT doctor [First Name (Titles) ] [Last Name (Titles) 44388] your possible surgery to have your sinuses drained. Completed by:[2124-12-20]	[ "300.00", "292.85", "E932.0", "280.9", "790.29", "346.90", "446.4", "493.00", "473.8", "785.0" ]	icd9cm	[ [ [] ] ]	[ "33.27", "33.24" ]	icd9pcs	[ [ [] ] ]	11706, 11712	6820, 9564	362, 376	11860, 11869	3770, 5121	13324, 14512	2953, 2981		9986, 11683		11733, 11733		9590, 9963			11893, 13301									2996, 3751										6506, 6797									278, 324												406, 2513						11752, 11839	5135, 6492							2535, 2819	2835, 2937
51,174	106,446	47548	Discharge summary	report	Admission Date: [2179-4-22] Discharge Date: [2179-4-26] Date of Birth: [2100-7-27] Sex: F Service: MEDICINE Allergies: Erythromycin Base / IV Dye, Iodine Containing Contrast Media Attending:[First Name3 (LF) 5893] Chief Complaint: Weakness, falls, fever Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: 78 year old female with metastatic invasive lobular breast cancer on gemcitabine with peripheral neuropathy who presents with fever and multiple falls. Patient was admitted to OMED from [4-16] - [4-17] for bilateral LE cellulitis. She was given Vancomycin and showed improvement and was discharged on Keflex for 8 days. She reports comliance with this medication and some reduction in swelling of her legs but claims that they are still "hard" (swollen) and red (L > R). She also reports having multiple falls, [3-11] the day of admission, where she had to crawl on the ground to get to her phone. He complains of left ankle pain; she says she fell on her rear but never hit her head or lost consciousness. . In the ER, initial vitals T 103 102 147/62 18 94% RA., She received Tylenol, Vancomycin, and Cefepime, and admitted for further evaluation. She was not aware she had a fever but reports she has felt "cold" but no rigors. . Review of Systems: (+) Per HPI, nausea, poor appetite, fatigue (-) Denies night sweats. Denies blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. . Past Medical History: PAST ONCOLOGIC HISTORY: [2156] carcinoma of the right breast treated with excision, axillary sampling and radiation to breast and axilla. In [Month (only) 205] [2169] she was diagnosed with an invasive lobular carcinoma of the same breast. The tumor was ER,PR + and HER2 negative. On [8-5] [2169] she underwent a right mastectomy for a greater than 5 cm tumor. She was therefore staged as T3N?M0. The nodes were not evaluable because of prior excision and radiation. She elected not to have chemotherapy and took Arimidex as adjuvant therapy beginning in [2170-8-6]. Because of a rising CA [93]-29 a PET scan was done on [2174-5-16] which revealed: There is focal abnormal uptake of FDG throughout the spine, bilateral ribs, bilateral clavicles, left scapula, left humerus, sternum, bilateral iliac bones. There is also uptake within subcentimeter left hilar lymph nodes (SUV 4.8), and asymmetrically within the right lingual tonsil (SUV 4.8). There are bilateral maxillary retention cysts/polyps, colon diverticulosis, a 5mm right lower lobe nodule (not FDG avid but may be due to small size), and a nodular component to a left lower lobe scar. The Arimidex was discontinued in the hope of seeing a withdrawal response. It did not occur so on [2174-7-15] she was begun on Aromasin with monthly Faslodex injections. A PET scan done on [2176-5-21] showed dramatic improvement in osseous metastatic disease and resolution of FDG avidity and increased sclerosis of the previously FDG avid skeletal metastases. There was no new skeletal lesion. She was hospitalized at [Hospital1 18] from [11-30]-30, [2176] because of severe diarrhea. On [2177-9-2] she had a PET scan which showed: 1. Widespread new osseous metastatic disease throughout ribs, vertebral bodies, scapulae, and several new lesions in pelvis, all FDG-avid. 2. Stable non-FDG-avid right lower lobe 7 mm pulmonary nodule. She was treated initially with Capecitabine to which she was intolerant. She was started on weekly Taxol in [2177-12-6]. On [2178-10-1] she had a PET scan which shows: 1. Mixed response, with overall improvement in the multi-focal osseous metastasis. A majority of the FDG avid lesions seen in the prior study, are now non FDG avid. However a few new FDG avid lesions are present. 2. Stable non FDG avid right lower lobe pulmonary nodule. Per Neuro-Onc Note: [2156] Carcinoma of the right breast treated with excision, axillary sampling and radiation to breast and axilla [2158-1-6] Re-excision of right breast mass and right axillary LAD by Dr. [Last Name (STitle) ] [6-/2170] Right breast mass found [2170-7-4] Biopsy of right breast Pathology: invasive lobular carcinoma, ER/PR positive and HER2 negative [2170-7-30] Right total mastectomy by Dr. [Last Name (STitle) ], Pathology: greater than 5.0 cm tumor ( T3), ER/PR+,HER2- [8-9] - [7-13]: Anastrozole, stopped due to rising CA [93]-29, [2174-5-16] PET-CT showed progression [7-13] - [2177-8-12] Exemestane-fulvestrant [2177-9-2] PET-CT showed progression [9-15] Started capecitabine, had a response, but stopped for diarrhea [2177-12-13] - [2179-2-9] Paclitaxel x15 [2178-10-1] PET-CT showed progression [2-14] -[12-17] Monthly zoledronate and vinorelbine, 3-weeks-on/1-week-off [2179-2-16] PET-CT showed progression [2179-3-2] Vinorelbine restarted PAST MEDICAL HISTORY: Breast cancer as above Post-auricular revision mastoidectomy with tympanoplasty, right ear, with split thickness skin grafting [2164-1-24] Dilatation and curettage, polypectomy [2166-6-19] and [2169-5-11] Chronic constipation Hypertension DM2, diet controlled Poor hearing, has bilateral hearing aids Cholecystectomy GERD asthma hyperlipidemia D&C for endometrial polyp, [2165] and [2168]. Her previous colonoscopy on [2174-8-31] only showed Diverticulosis of the sigmoid colon and descending colon. But in [2170], she had two adenomas . Social History: She lives alone, and has been using Meals on Wheels since her husband died. She has two children, a daughter in [Name (NI) 4310] ([Doctor First Name 1785]) and a son in [Name (NI) 1459]. She has six grandchildren and two great grandchildren. She quit smoking 3ppd 25yrs ago and does not drink alcohol. She says she has family who live upstairs from her and she has VNA 2-3x/week. Family History: Mother died of colon cancer. Father died of complications of lead poisoning. Physical Exam: Vitals: T 102.9 bp 111/42 HR 95 RR 16 SaO2 99RA GENERAL: NAD, animated and conversant HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, patent nares, MMM, wears dentures, dry mucous membranes CARDIAC: RRR with III/VI systolic murmur LUNG: CTAB, normal effort ABDOMEN: Nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well NEURO: proprioception in lower extremities and pinprick sensation is intact. Able to move all extrmities. Gait not tested nor full strength in LE not tested secondary to pain and instability. CN grossly intact SKIN/EXT: Warm and erythema of LLE with some mild underlying edema, also mild erythma and warmth of RLE as well which is improved from the faint line drawn of margin previously. Erythema on LLE does not have distinct borders and is difficult to trace. Substantial onychomycosis of nails on RLE. PSYCH: Cooperative Pertinent Results: Admission labs: [2179-4-22] 06:02PM PT-14.6* PTT-29.9 INR(PT)-1.4* [2179-4-22] 06:02PM PLT COUNT-148* [2179-4-22] 06:02PM NEUTS-86.6* LYMPHS-8.6* MONOS-4.3 EOS-0.4 BASOS-0.1 [2179-4-22] 06:02PM WBC-8.4# RBC-2.92* HGB-8.6* HCT-27.2* MCV-93 MCH-29.5 MCHC-31.7 RDW-15.7* [2179-4-22] 06:02PM GLUCOSE-147* UREA N-24* CREAT-1.2* SODIUM-134 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-20* ANION GAP-17 [2179-4-22] 07:03PM LACTATE-0.8 [2179-4-22] 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2179-4-22] 08:45PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.008 Micro: -BCx (x5) - NGTD -C. diff ([2179-4-24]) - PCR positive for C. diff Imaging: -LENIs ([2179-4-22]): 1. No evidence of deep venous thrombosis in the left common femoral, superficial femoral or popliteal veins. 2. Limited evaluation of the calf veins due to subcutaneous edema. -CXR ([2179-4-22]): No acute cardiopulmonary process. -Renal US ([2179-4-24]): No stones or hydronephrosis. -KUB ([2179-4-25]): Supine and left decubitus views of the abdomen show considerable increase in distention and wall thickening of the large bowel consistent with pancolitis. There is no free intraperitoneal gas. Presence of intraperitoneal fluid is can only be assessed by abdominal CT scanning, performed subsequently and reported separately. -CT abd/pelvis ([2179-4-25]): 1. Diffuse thickening and wall edema with stranding of the colon consistent with severe pancolitis, most likely infectious in etiology; however, inflammatory or ischemic causes cannot be excluded. Borderline dilated transverse colon, which in the right clinical setting is a sign of toxic megacolon. There is no evidence for perforation. Small-to-moderate ascites. 2. Small bilateral pleural effusions with atelectasis, worse on the right. 3. Multiple sclerotic bony lesions consistent with patient's known bony metastatic disease. No acute fractures. 4. Small hiatal hernia. Brief Hospital Course: 78F with met breast CA on gemcitabine, initially admitted for fevers, abdominal pain and leukocytosis, subsequently found to have C. diff colitis, [Last Name (un) ] and and concern for toxic megacolon #C. diff colitis with toxic megacolon and sepsis: While on the medicine floor, she was found to have worsening abdominal pain and distention in the setting of C. diff, which was likely related to her recent antibiotics during prior admission for cellulitis. She was treated with PO vancomycin and IV Flagyl. She was transferred to the [Hospital Unit Name 153] for hypotension and hypoxia, the latter of which is discussed below. KUB was suggestive of pancolitis. She had a CT abd/pelvis which confirmed pancolitis and suggested borderline toxic megacolon. An NG tube was placed for decompression which the patient removed. Her blood pressure improved with multiple fluid boluses and she did not require pressors. Surgery was consulted and felt that there was no surgical intervention indicated given that her surgical mortality would be extremely high. On HD5, she became increasingly lethargic and confused. The worsening of her clinical condition raised concern for worsening of her sepsis and progression of her toxic megacolon. A meeting between the family, [Hospital Unit Name 153] team and surgical team was held during which it was decided to make the patient comfort-measures only. She expired on [4-26] at [2096]. #[Last Name (un) ]: Initially presumed to be pre-renal given her diarrhea and poor PO intake. However, it is likely she progressed to ATN given her poor urine output despite fluid challenge. Lisinopril was held and renal was consulted. Cr continued to rise during her ICU stay and she remained oliguric. Bladder pressure was also elevated to 16 in the setting of her C. diff pancolitis and toxic megacolon, indicating potential for early abdominal compartment syndrome. #Hypoxia: She was initially transferred to the [Hospital Unit Name 153] for the above findings as well as hypoxia with O2 sat of 70s on RA. There was concern for aspiration and she was empirically treated with Vanc/Zosyn for aspiration PNA as well as HCAP given her recent admission. In the [Hospital Unit Name 153], her hypoxia had resolved and she was satting well on RA. It is unclear whether the hypoxia prior to transfer was due to poor O2 sat [Location (un) 1131]. #Thrombocytosis: Plt elevated to over 1,000,000 during her [Hospital Unit Name 153] stay, thought to be reactive thrombocytosis in the setting of her sepsis and toxic megacolon. She was continued on ASA 81mg. #Pseudohyperkalemia: [1-7] her thrombocytosis as above, potassium was wnl when checked as whole blood sample in green top tube. #Metabolic acidosis: Both anion gap (from her lactic acidosis) and non-anion gap (likely from GI losses as well as fluid resuscitation with NS). She was given bicarbonate in her fluids in an attempt to improve her acidosis. Renal was also consulted prior to her transition to CMO. #Death: After transition to CMO care, as discussed above, the patient died on [4-26] at [2096]. --Inactive issues-- #Metastatic breast cancer: Followed by oncology as an outpatient, recently received gemcitabine. #Hypertension: Home BP meds held in the setting of sepsis and hypotension. #Hyperlipidemia: Cont home simvastatin Medications on Admission: 1. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day. 3. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. smooth move tea Sig: One (1) once a day. 8. calcium Oral 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. 11. vitamin d3-K-berberine-hops Sig: One (1) once a day. 12. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 8 days (start date [4-17]) Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Primary diagnoses: Clostridium difficule colitis Sepsis Toxic megacolon Acute kidney injury Secondary diagnoses: Metastatic breast cancer Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "556.6", "E885.9", "V12.72", "507.0", "V87.41", "276.7", "793.11", "401.9", "584.5", "530.81", "799.02", "V45.71", "788.5", "038.9", "276.2", "780.60", "V66.7", "V10.3", "995.92", "719.47", "272.4", "564.00", "198.5", "511.9", "458.9", "V49.86", "V15.88", "682.6", "389.9", "250.00", "493.91", "557.0", "008.45", "238.71", "356.9", "V15.82" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13908, 13917	9559, 12951	344, 350	14099, 14108	7474, 7474	14164, 14174	6428, 6508		13876, 13885		13938, 14031		12977, 13853			14132, 14141									6523, 7455	14052, 14078													1376, 1927					282, 306												406, 1357					7490, 9536									5428, 5997	6013, 6412
21,523	184,817	52149	Discharge summary	report	Admission Date: [2127-2-14] Discharge Date: [2127-2-20] Date of Birth: [2089-4-11] Sex: F Service: [Last Name (un) ] CHIEF COMPLAINT: Increased shortness of breath, chest pain, lethargy and difficulty ambulating. The patient came in through the emergency department. HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old female, status post cadaver kidney transplant, complicated by humeral rejection, status post cadaver renal transplant on [2127-2-4]. She has been receiving plasmapheresis up until [2127-2-11]. Hematocrit had trended down since surgery on [2-4]. Her hematocrit was 36. This decreased to 27 on [2-12] and to 22 on [2-13]. Repeat hematocrit was 18 on admission. PAST MEDICAL HISTORY: Significant for focal segmental glomerulosclerosis, hypertension. ALLERGIES: Vancomycin, penicillin, iodine and Benadryl. MEDICATIONS ON ADMISSION: 1. Bactrim single strength once a day 2. Nystatin 5 mL q.i.d. 3. Coumadin 5 mg at bedtime 4. CellCept [Pager number ] mg p.o. b.i.d. 5. Protonix 40 mg p.o. b.i.d. 6. Valcyte 450 mg p.o. b.i.d. 7. Colace 100 mg p.o. b.i.d. 8. Prograf 9 mg p.o. b.i.d. 9. Metoprolol 35 mg p.o. b.i.d. PHYSICAL EXAMINATION: On admission, the patient's physical exam, T-max 99.3, heart rate 103, BP 128/87, respiratory rate 18, and O2 saturation 98% on room air. The patient appeared obese. Pupils equal, round and reactive to light and accommodation. OP was clear. Neck supple. Lungs clear to auscultation. Heart: Tachycardiac, regular rate and rhythm, no murmurs, rubs or gallops. Abdomen: Tender only around the transplant incision site, positive bowel sounds, guaiac negative. No CVA tenderness. LABORATORY DATA: UA was done. This demonstrated 0 to 2 RBCs, 0 to 2 WBCs, rare bacteria, no yeast and 3 to 5 epithelial cells, negative nitrite. Urine sodium was 117 and urine creatinine 63. Renal ultrasound was done and this demonstrated small organizing fluid collection anterior to the transplanted kidney. Concern was for a small postoperative seroma or localizing hematoma. Otherwise, the Doppler evaluation was unremarkable. A chest x-ray done demonstrated left central line tip in the distal SVC, no pneumothorax and interval resolution of the right-sided pleural effusion. The patient was transferred to the SICU where she received 2 units of packed red blood cells for a hematocrit of 22.5 and 2 units of FFP for INR of 12.3. Creatinine on admission was 2.5. Prograf level was 14 and her Prograf was placed on hold. INR decreased to 1.3. Hematocrit increased to 21. She received another 2 units of packed red blood cells and a total of 4 bags of FFP. Fibrinogen was 263. Creatinine was 2.4. AST was 104, ALT 161, alkaline phosphatase 128 and total bilirubin 2.0. She was n.p.o. She continued to receive IV fluid. Nephrology was consulted. There was concern for TTP- HUS secondary to Prograf or humeral rejection. CT of the abdomen was done. This demonstrated hemorrhage within the lower [2-10] of the left rectus abdominis muscle. There was no significant change in the appearance of the peritransplant fluid collection, likely postoperative seroma or organizing hematoma. There was a small amount of low attenuating free fluid in the pelvis and bilateral atrophic native kidneys were demonstrated containing several lesions, not completely characterized on the current exam. Further evaluation was recommended with either ultrasound or MRI to exclude solid neoplasms. The patient continued to receive plasmapheresis. Dr. [First Name (STitle) ] from pathology followed the patient. Two-volume exchange using FFP was used as replacement fluid. This was continued daily. A kidney biopsy was done on [2127-2-15]. This demonstrated under light microscopy the specimen consisted of a renal cortex containing approximately 6 glomeruli of which 1 was globally sclerotic. The remainder all appeared bloodless, with thrombosis and occasional intercapillary neutrophil margination. There was minimal interstitial fibrosis and tubular atrophy. The tubules appeared mildly dilated. Mild interstitial edema was present. There was minimal chronic inflammation accompanying the scarring. No significant tubulitis was noted. Tubular capillaries were dilated with prominent neutrophils. Acute antibiotic-mediated humeral rejection, type 2, was noted. Please refer to original pathology report. Thirty tubular capillaries were diffusely positive for C4D. She received a total of 4 treatments of plasmapheresis on 4 separate days. During this time, her creatinine trended down to 2.0. Valcyte was changed to 450 mg p.o. once a day as the creatinine decreased to 1.9 on hospital day 3. She did complain of some nausea and vomiting. She was better after being treated with Anzemet Her diet was advanced slowly. Hematocrit was stable in the range of 29 to 30. Platelet count remained 58 to 59. INR was 1.1. Creatinine decreased to 1.9. She complained of a productive cough, slightly thick. The patient was able to self-suction with a Yankauer suction. The abdomen appeared soft with positive bowel sounds. She was tolerating her diet fairly well. She was able to get out of bed with assist. Nutrition services followed the patient and recommended Boost Plus t.i.d. She was given ATG 100 mg and Solu-Medrol for high class match titers. She tolerated this without problems. On hospital day 4, it was noted the patient had right breast swelling with tenderness. She complained of facial swelling as well. This was demonstrated on physical exam. Her right breast was significantly swollen as well as her right arm. She also had a left chest tunnel-line catheter. Her right arm was elevated. She was medicated for discomfort with fair relief. Coumadin was restarted at 5 mg p.o. once a day. Of note, her blood pressure had decreased to 114/71. Her Lopressor was held. BP ranged between 116/79 to 142/88 with a heart rate of 74. She remained afebrile. Urine output gradually increased to 1880 cc per day. Hematocrit trended down to 25. This remained stable in the 25.2 to 26 range. Prograf was decreased to 6 mg b.i.d. The Prograf level was 14.6 on [2127-2-19]. Physical therapy was consulted. The patient was noted to be deconditioned with decreased endurance. Outpatient physical therapy was recommended. On hospital day 6, she was discharged home in stable condition, alert and oriented, comfortable, with clear lungs, voiding QS without difficulty. Her abdominal incision was covered by a dry sterile dressing for minimal serosanguineous drainage with clip still present. She was out of bed ambulatory in the [Doctor Last Name ] with supervision. She was discharged home with visiting nurse with PT services at home. DISCHARGE MEDICATIONS: 1. Bactrim single strength p.o. once a day 1 tablet once a day 2. Nystatin 5 mL p.o. q.i.d. 3. Colace 100 mg p.o. b.i.d. 4. Protonix 40 mg p.o. once a day 5. Metoprolol was changed to 37.5 mg p.o. t.i.d. 6. Valcyte 450 mg p.o. q.i.d. 7. CellCept [Pager number ] mg p.o. q.i.d. 8. Prednisone 20 mg p.o. once a day 9. Coumadin 5 mg p.o. at bedtime 10. Prograf 6 mg p.o. b.i.d. 11. Dilaudid 2 mg p.o. p.r.n. q.4-6h. for discomfort DISCHARGE DIAGNOSES: Humeral rejection of the kidney transplant, supratherapeutic INR, anemia, deep venous thrombosis right arm, old incision wound, chronic, healing, asthma and hypertension. The patient was scheduled to follow up in the outpatient clinic. She had a followup appointment with Dr. [First Name (STitle) ] [Name (STitle) ] on [2127-2-21], as well as [Year (4 digits) ] on [2127-2-21]. DISCHARGE CONDITION: Stable. DISCHARGE INSTRUCTIONS: Also included elevation of the right arm as much as possible and to avoid Motrin-like medications as well as aspirin. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 3432] Dictated By:[Name8 (MD) 4664] MEDQUIST36 D: [2127-3-26] 14:36:19 T: [2127-3-26] 16:08:29 Job#: [Job Number 107897]	[ "584.9", "283.11", "585.6", "403.91", "511.9", "996.81", "E878.0", "E849.8", "790.92" ]	icd9cm	[ [ [] ] ]	[ "99.04", "99.07", "55.23", "38.93", "99.71" ]	icd9pcs	[ [ [] ] ]				7656, 7666				7234, 7634	6766, 7212				919, 1215			7691, 8064																		1238, 6743										172, 307												336, 745														768, 893
23,417	102,513	14220	Discharge summary	report	Admission Date: [2157-4-28] Discharge Date: [2157-5-16] Date of Birth: [2098-5-16] Sex: F Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: This is a 58-year-old female with a known descending thoracic aneurysm who was referred to [Hospital6 256] for cardiac catheterization as part of her preoperative work up. The patient reports a history of a myocardial infarction appropriately 10 years ago with occasional chest discomfort. It should be noted that the patient preoperatively was a poor historian. The patient reported this was due to prior CVAs. PAST MEDICAL HISTORY: 1. Hypertension 2. Hypercholesterolemia 3. Positive tobacco 4. Status post myocardial infarction approximately 10 years ago 5. Anxiety 6. Chronic obstructive pulmonary disease 7. Chronic back pain 8. Status post multiple CVAs, most recently one year ago 9. Rheumatoid arthritis 10. Descending thoracic aneurysm approximately 6.3 cm PAST SURGICAL HISTORY: 1. Status post cholecystectomy 2. Status post appendectomy 3. Status post tonsillectomy 4. Status post bilateral carotid endarterectomies 5. Status post hysterectomy Preoperatively, the patient reported the residual deficits from her CVA were occasional aphasia and poor memory. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1. Celebrex 200 mg po qd 2. Lopressor 100 mg po q a.m., 50 mg q p.m. 3. Plavix 75 mg po qd 4. Norvasc 5 mg po qd 5. Celexa 20 mg po qd 6. Hydrochlorothiazide 25 mg po qd 7. Darvocet prn 8. Alprazolam 0.5 mg po bid 9. Albuterol inhaler prn 10. Vanceril inhaler prn PREOPERATIVE LABORATORY DATA: White blood cell count 10.2, hematocrit 38.7, platelet count 271. Sodium 142, potassium 4.5, chloride 107, bicarbonate 30, BUN 17, creatinine 1.2, glucose 128. PREOPERATIVE Physical exam VITAL SIGNS: Pulse 72, blood pressure 112/80, respiratory rate 12. HEAD, EARS, EYES, NOSE AND THROAT: Negative NECK: Bilateral surgical scars. Carotids without bruit. CHEST: Clear to auscultation. The patient was noted to have erythema under both breasts and over the lower aspect of the sternum thought to be due to fungal infection. HEART: Regular rate and rhythm without murmur. ABDOMEN: Obese, positive bowel sounds, nontender, nondistended. HO[Last Name (STitle) ] COURSE: The patient was admitted to [Hospital6 1760] on [2157-4-28] for cardiac catheterization. Cardiac catheterization showed left ventricular ejection fraction of approximately 50%, 70% to 80% LAD lesion, 80% LCX lesion, 70% OM2 lesion, 90% RCA lesion. The patient was taken to the Operating Room on [2157-4-29] with Dr. [Last Name (Prefixes) ] for a coronary artery bypass graft x3, left internal mammary artery to ramus, saphenous vein graft to PDA, saphenous vein graft to PL. Please see operative note for further details. The patient as transferred to the Intensive Care Unit on nitroglycerin, milrinone and liquefied infusions. On the evening of postoperative day 0, the patient was noted to have a significant respiratory acidosis. Chest x-ray revealed a left upper lobe collapse. The patient underwent bronchoscopy which revealed a left upper lobe mucous plug which was removed. Post bronchoscopy chest x-ray revealed mild improvement in the aeration of the left upper lobe. The patient initially had a low cardiac index which responded to volume resuscitation and increasing the milrinone infusion. On postoperative day #1, the patient underwent repeat bronchoscopy which showed mild bilateral tracheobronchitis and again a mucous plug in the left upper lobe which was removed. The patient was continued on a propofol infusion through the first postoperative day due to patient tenuous respiratory status. On postoperative day #2, the patient's propofol was weaned to off at which time the Levophed infusion was discontinued as patient's blood pressure increased and the patient was subsequently placed on nitroprusside infusion to maintain her systolic blood pressure less than 130. The patient was noted to have a cough and gag with suctioning. The patient was noted to move head with noxious stimuli and pupils were 3 cm equal and reactive to light, but it was noted that there was no movement of arms or legs. On postoperative day #3, the milrinone was weaned to off with a continued adequate cardiac output and index. The patient continued on nitroprusside infusion for blood pressure control. The patient had been started back on Plavix for her previous carotid endarterectomies and patient had improving respiratory status and was able to decrease the ventilatory support, however the patient continued to have decreased neurologic function and a neurology consult was obtained and a head CT scan was obtained. CT scan of the head showed a ACA hypodensity bilateral watershed hypodensity extending posteriorly on the left and an old cerebellar stroke. Her neurologic exam on postoperative day #3 was no spontaneous eye opening, however opened eyes to noxious stimuli. The patient had positive corneal reflex, positive gag reflex, withdrew all limbs weakly to noxious stimuli. Neurology felt that it was unclear whether or not that patient's status was due to her preoperative neurologic findings or a new neurologic event and requested an EEG to rule out subclinical seizure activity. On postoperative day #4, the patient underwent EEG study which showed no epileptic features, generalized swelling with suggestion of encephalopathic condition. On neurologic exam, it was noted that the patient had bilateral Babinski sign. The patient was started on enteral nutrition on postoperative day #4. The patient had a sputum culture sent for increasing tracheal secretions which subsequently are positive for Haemophilus influenza and Pseudomonas. The patient was started on levofloxacin and ceftazidine for double coverage of the Pseudomonas. On postoperative day #4, the patient was started on Lopressor for control of hypertension, as well as placed on Isordil. The patient's neurologic status slowly progressed on postoperative day #6. Patient opened eyes to voice, but did not track. On postoperative day #9, it was noted that the patient stuck out her tongue to command and was able to track movement with her eyes. It was felt by the neurology service that due to the patient's early improvement in the first week, substantial recovery over the next few weeks to months was possible and it was decided that the patient would undergo tracheostomy and PEG placement and would be evaluated for neurologic rehabilitation. On [2157-5-9], the patient underwent placement of tracheostomy percutaneously by Dr. [Last Name (STitle) 952]. A 7.0 Portex as well as a PEG placement. After the tracheostomy placement, the patient as noted on chest x-ray to again have a whiteout of the left side and underwent bronchoscopy for large amounts of bloody secretions. Subsequent chest x-ray was improved. On postoperative day #11, the patient underwent a psychiatry consultation. As the patient has a history of anxiety, it was thought that the patient has a combination of delirium and dementia complicated by encephalopathy and it was recommended to continue the present management. The patient underwent repeat bronchoscopy on postoperative day #11 which showed relatively clear airways, clear secretions, no plugs in the left upper lobe. On postoperative day #12, the patient was tracking with her eyes, inconsistently following commands, non purposeful upper body movement. The patient remained hemodynamically stable and weaning on the ventilator. On postoperative day #12, neurology evaluated the patient and felt that she would continue to improve over the next several weeks and recommended once the patient was in a rehabilitation facility she could benefit from a dopamine agonist such as bromocriptine 2.5 mg q day and slowly titrate over several weeks to about 20 mg per day. The patient's ventilator had been weaned down to pressure support ventilation which she has tolerated well. On [5-16], postoperative day #17, the patient was accepted at a rehabilitation facility and was clear for discharge to rehabilitation facility. DISCHARGE CONDITION: T-max 99.3??????, pulse 84 in sinus rhythm, blood pressure 139/83, respiratory rate 23, oxygen saturation 95%. The patient is on the ventilator via tracheostomy. Pressure support ventilation 50% FIO2, PEEP of 5, pressure support of 12. Tidal volumes about 400. Neurologically, the patient opens eyes to voice, tracks visual stimuli, occasionally will follow commands by sticking out tongue, although inconsistently. The patient has non purposeful movements of her upper extremities and will withdraw her lower extremities to pain. Cardiovascular regular rate and rhythm without rub or murmur. Lungs - breath sounds are coarse with scattered wheezes and rhonchi throughout. The patient is being intermittently suctioned for small amounts of yellow secretions. The patient's last sputum culture from [5-6] showed sparse growth of Pseudomonas. Abdomen is obese, positive bowel sounds, nondistended. PEG tube is in place without erythema or drainage. The patient is tolerating tube feeds ProMod with fiber at 55 cc an hour. LABORATORY DATA FROM [2157-5-16]: White blood cell count 8.8, hematocrit 32.6, platelet count 356. Sodium 138, potassium 4.4, chloride 102, bicarbonate 25, BUN 23, creatinine 0.6, glucose 138. The patient's sternal incision is clean and dry without erythema. Sternum is stable. The patient's vein harvest site is clean and dry without erythema or drainage. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg per PEG qd 2. Celexa 20 mg quit 3. Combivent metered dose inhaler 2 puffs qid 4. Isordil 15 mg qd 5. Colace 100 mg qd 6. Prevacid 30 mg qd 7. Plavix 75 mg qd 8. Lopressor 50 mg tid 9. Levofloxacin 500 mg q 24 hours x5 days 10. Heparin 5000 units subcutaneous q 12 hours 11. Aspirin 325 mg qd 12. Ceftazidime 1 gm intravenous q8h x5 days 13. Nystatin swish and swallow 5 cc to mouth qid 14. Regular insulin sliding scale for blood sugar 150 to 200 give 3 units subcutaneous, for blood sugar 201 to 250 give 6 units subcutaneous, for blood sugar 251 to 300 give 9 units subcutaneous, for blood sugar 301 to 350 give 12 units subcutaneous. VENTILATOR SETTINGS: CPAP FIO2 50%, PEEP 5, pressure support 12. Th[Last Name (STitle) 1050] is to receive all medications via PEG tube. The patient is to receive tube feeds ProMod with fiber at 55 cc an hour via PEG tube. The patient is to follow up upon discharge from rehabilitation with Dr. [Last Name (Prefixes) ], as well as her cardiologist. The patient is to be discharged to rehabilitation in stable condition. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 3870] MEDQUIST36 D: [2157-5-16] 10:57 T: [2157-5-16] 11:03 JOB#: [Job Number 42284]	[ "414.01", "276.2", "490", "041.5", "441.2", "780.09", "997.02", "518.0", "518.5" ]	icd9cm	[ [ [] ] ]	[ "88.53", "31.1", "36.15", "36.12", "39.64", "88.56", "89.64", "37.23", "39.61" ]	icd9pcs	[ [ [] ] ]				8245, 9648					9671, 11032														983, 1307								1333, 8223																									177, 596														618, 960
15,133	100,938	11290+56224	Discharge summary	report+addendum	Admission Date: [2197-12-8] Discharge Date: Date of Birth: [2173-2-23] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: This is a 24-year-old male helmeted motorcyclist who sustained injury on [2197-12-8] with positive loss of consciousness at the scene. He was alert and oriented times three upon transfer via [Location (un) ] to the [Hospital1 69]. His only complaints were decreased sensation of the lower extremities and some shoulder pain. PHYSICAL EXAMINATION: Examination, upon arrival to the Emergency department at [Hospital1 69] was as follows: GENERAL: The patient was alert and oriented times three. The [Location (un) 2611] Coma Scale was 15. HEENT: Pupils equal, round, and reactive to light. Pupils were 4-mm to 2 -mm with brisk reflex. Extraocular muscles were intact. There was no JVD. Trachea was midline. RESPIRATORY: Lungs were clear to auscultation. Breath sounds were equal bilaterally. CARDIOVASCULAR: Regular rate and rhythm, normal sinus at 55. No murmurs, rubs, or gallops appreciated. Pelvis was stable with no deformities and no abrasions noted. ABDOMEN: Flat, soft, nontender and nondistended. Bowel sounds were present. EXTREMITIES: Bilateral shoulder pain, no obvious deformities noted. He was moving his upper extremities. There was some movement noted of the left lower extremity. RECTAL: Rectal tone revealed good rectal tone and he was guaiac negative in the Trauma Bay. LABORATORY DATA: Laboratory data upon admission revealed the following: White count of 8.8, hematocrit 44.8, platelet count 259, PT 13, PTT 28.8, INR 1.2. Chem 7 revealed the sodium of 139, potassium of 4.1, chloride of 102, BUN 14, creatinine 1.2, glucose 102. Amylase was found to be 76. Toxicology screen was negative. Alcohol screen was negative. Initial studies revealed the CAT scan of the head, which was read as negative, with no findings, no evidence of bleed. CAT scan of the neck was also read as negative. There was no evidence of deformity or fractures. CAT scan of the thoracic region, however, revealed that he was noted to have a T5, T6, and T7 vertebral body fracture. These were thought to be pressure injuries and they were found to be bony fragments, compressing on the spinal cord. From the CAT scan, he was taken to the Intensive Care Unit. Hospital course from the Intensive Care Unit was as follows: On [2197-12-10], at about 2300 hours he developed hypoxia, requiring intubation. A chest x-ray and repeat CAT scan revealed increasing severe pulmonary contusions in the beginning development of ARDS. He was intubated without incident and placed on a ventilator. At that time he was paralyzed and sedated using propofol. On [2197-12-12] he was started on total parenteral nutrition. He also had an IVC filter placed because it was felt that he was at risk for increased deep vein thrombosis and possible resulting pulmonary embolism. He also was felt to have a left pneumothorax. This was found with decreasing oxygen saturations, increasing respiratory difficulty and a chest tube was placed on the left side without incident. On [2197-12-16], cultures from the sputum, which were sent on [2197-12-13] grew out Moraxella and Staphylococcus aureus. At this time Vancomycin was added to his regimen, pending further speciation of the cultures. He continued to be sedated and intubated throughout this time. The medications being used were Ativan and Dilaudid drips. On [2197-12-17], the final cultures were speciated and found to be Moraxella and methicillin sensitive Staphylococcus aureus. Vancomycin was subsequently changed to Oxacillin. On [2197-12-19], there was worsening of the pleural effusions and he continued to be spiking increased temperatures. He continued to have broad antibiotic coverage. The increasing temperatures were thought to be due to the worsening pneumonia. Also, on [2197-12-19], he was brought to the operating room and had stabilization of his spine by the Orthopedic Spine Surgery. The spinal surgery was recorded to be a T5-T6 anterior vertebrectomy with anterior rod stabilization as well as posterior stabilization of the cords via instrumentation. This was done removing the left 4th rib in posterior position in order to gain access. On [2197-12-20], once the C-spine stabilization had been completed, the patient was evaluated by the Department of Physical Therapy. It was found that at that point he had a stage II decubitus ulcer on his sacrum, as well as a stage I to II decubitus ulcer on his right heel. Again, he continued to be intubated and sedated, again, using Ativan and Dilaudid drips. From [12-21] to [12-23] attempts to light sedation and weaning from ventilation continued. We continued the physical therapy. He was following commands and we found improvement in his oxygen saturation. On [2197-12-23], the chest tube was discontinued. He continued to require pain control for increased agitation, although we continued ventilator weaning. From [2197-12-24] to [2197-12-26], he had bronchoscopy for increased secretions, again, still attempting to wean him from ventilation. On [2197-12-27] he was found to have decreased oxygen saturations, increased respiratory distress. Chest x-ray revealed a left lower lobe lung collapse. Again, he underwent bronchoscopy finding increased secretions. Ventilator settings were changed over to pressure support. The lung was found to be reinflated after bronchoscopy. On [2197-12-28], the patient was extubated. At this time, he continues to be off the ventilator. He has been found to have increased secretions, although he has been able to maintain the oxygen saturation above 98% with the face mask. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [MD Number(1) 36234] Dictated By:[Last Name (NamePattern1) 22640] MEDQUIST36 D: [2197-12-29] 08:20 T: [2197-12-29] 10:30 JOB#: [Job Number 36235] Name: [Known lastname 32], [Known firstname ] Unit No: [Numeric Identifier 6452] Admission Date: [2197-12-8] Discharge Date: PENDING Date of Birth: [2173-2-23] Sex: M The patient's current Discharge Summary includes his course of care from his date of admission up to the 24th. This should be addendum immediately after paragraph marked on [2197-12-28]. On [2197-12-29], the patient remained extubated although due to significant pulmonary secretions and inability to clear secretions. He required re-intubation. Once the patient was reintubated, he immediately weaned to minimal ventilator support, however, this was deemed a failure of extubation and on the following day, the patient underwent a percutaneous tracheostomy at the bedside. The patient complications. Following this, his ventilatory status continued to improve significantly on C-PAP and minimal support with decreasing FIO2 requirements. Two days following his tracheostomy the site around the tracheostomy was noted to be erythematous and painful to touch, so the patient was started on Unasyn for this wound infection. Over the next couple of days the erythema continued to improve. However, on day of discharge, the tracheostomy continues to be erythematous and this infection is not yet resolved. Additionally, Unasyn was added to combat this wound infection because of a sputum culture taken on [2198-1-3], which is growing Gram negative rods not yet speciated. After starting the Unasyn, the patient's secretions related to this continued to improve. The patient was also noted on the 31st and [1-5], to have a significant amount of diarrhea, however, stools sent for Clostridium difficile tested negative. LABORATORY: On [1-5], the day of discharge, the patient's laboratory values were as follows: White blood cell count was 8.0, down from 12 the day before. Hematocrit was 29.5 and his platelet count was 604. These were all stable values. His chemistries on the morning of discharge: Sodium 137, potassium 3.8, chloride 97, bicarbonate 32, BUN 20, creatinine 0.6 and a glucose of 86. The patient's magnesium was 1.8. His INS calcium is 1.18. Chest x-ray on day of discharge revealed persistent bilateral blister essential alveolar opacities. These are felt to be consistent with either a aspiration pneumonia or possibly just atelectasis. Given the patient's low-grade fevers over the past two days, it is felt that we will assume that this is a pneumonia and continue his course of Unasyn. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1743], M.D. [MD Number(1) 1744] Dictated By:[Last Name (NamePattern1) 6453] MEDQUIST36 D: [2198-1-5] 10:37 T: [2198-1-5] 10:45 JOB#: [Job Number 6454]	[ "805.2", "707.0", "518.5", "860.0", "482.83", "E815.2", "810.00", "861.21", "998.59" ]	icd9cm	[ [ [] ] ]	[ "96.04", "77.81", "81.04", "99.15", "96.72", "38.7", "34.09", "77.89", "31.1" ]	icd9pcs	[ [ [] ] ]																																		510, 8929
25,071	104,335	15985	Discharge summary	report	Admission Date: [2114-12-23] Discharge Date: Date of Birth: [2076-5-17] Sex: F Service: HISTORY OF PRESENT ILLNESS: Miss [Known lastname 17811] is a 38-year-old female who originally had a lesion in the mid-sigmoid region, which had been diagnosed as a diverticulitis. For this she underwent a cecostomy. Postoperatively she underwent a colonoscopy. However, the scope could not pass through and biopsy revealed a carcinoma. A CT scan performed at this hospital prior to surgery revealed no evidence of any liver metastasis and a barium enema still showed an obstructing lesion in the sigmoid. The gastrografin through the cecostomy showed multiple large amounts of stool collection without obvious lesions. Of note, is that in the past the patient was difficult to intubate/extubate and she is status post repair of the cleft palate a long time ago. It was felt that a subtotal colectomy of this obstructing lesion would be appropriate, since it was difficult to prep the bowel. We discussed with the mother and the patient at the time the benefit of getting rid of the cecostomy, which was poorly functioning with skin complications. PAST MEDICAL/SURGICAL HISTORY: 1. Colon cancer. 2. Cecostomy performed for obstructing diverticulitis. 3. Palate reconstruction. 4. Tracheal stenosis. 5. Hearing impairment. MEDICATIONS: None. ALLERGIES: None. SOCIAL HISTORY: History of tobacco use. No history of alcohol or drug use. PHYSICAL EXAMINATION: Temperature 97.4, heart rate 68, blood pressure 134/56, respiratory rate 20. 95% on room air. General: Alert and oriented in no acute distress. Young female. Head, eyes, ears, nose and throat exam within normal limits. Lungs clear to auscultation bilaterally. Cardiac: Regular rate and rhythm. No murmurs. Abdomen soft, nontender. Cecostomy present. Bowel sounds present. Rectal exam is within normal limits. SUMMARY OF HOSPITAL COURSE: The patient was admitted to the General Surgery service. On [2114-12-23] she underwent subtotal colectomy and take down of the cecostomy. She tolerated the procedure well. There were no complications. Please see the full operative note for detail. She remained intubated and was kept in the Post Anesthesia Care Unit, then transferred to the Intensive Care Unit. She was maintained on intravenous fluids. Her white count decreased. An attempt was made to extubate the patient, however, there was no cuff leak and she did not tolerate it, requiring re-intubation. Her hematocrit was noted to decrease and she was transfused with packed red blood cells. Otolaryngology was consulted and a CT scan of the neck was done showing single enlarged left paratracheal lymph node, numerous small lymph nodes throughout mediastinum and neck, left lower lobe collapse and left pleural effusion as well as incidental node of right aortic arch with possible apparent left subclavian artery. The ENT service also did a fiberscopic study, showing abnormal abduction of the vocal cords and also a narrowing. The patient was started on tube feeds and also transparenteral nutrition. She spiked a fever to 103.7 with blood cultures positive for staph aureus as well as the central line tip. She was started on Vancomycin, Levaquin and Flagyl. The patient continued to improve however. Unfortunately she failed a second extubation attempt and there still was no cuff leak. As a result on [2115-1-3] the patient underwent tracheostomy. She tolerated the procedure well. She was eventually transferred to the regular floor. She continued to receive tracheostomy care as instructed. She received an antibiotic course for a pneumonia diagnosed on scan. She had a clot in the left internal jugular vein. A PICC line was placed on the other side and the central line was removed. A repeat ultrasound of the internal jugular vein showed partial resolution of the clot in the left internal jugular. She was started on Lovenox 60 mg twice a day injections. She was having diarrhea but C. difficile stool test remained negative. A swallow examination was performed and the patient was thought to be able to tolerate regular consistency diet. A Passy/Muir valve was placed. She was started on clear liquids and advanced to a regular diet which she tolerated well. The tube feeds were discontinued and feeding tube was removed. The TPN was stopped. She was ambulating without difficulty. She remained afebrile. Physical therapy consult recommended [Hospital 3058] rehabilitation. The patient was discharged on [2115-1-14]. CONDITION ON DISCHARGE: Good. DISPOSITION: Rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Colon cancer. 2. Subtotal colectomy. 3. Respiratory failure and vocal cord abnormality, Status post tracheostomy. 4. Left internal jugular thrombosis. 5. Pneumonia. DISCHARGE MEDICATIONS: 1. Percocet one to two tabs p.o. q 4 to 6 hours p.r.n. pain. 2. Lovenox 60 mg subcutaneously q 12 hour injection times one month. 3. Miconazole powder p.r.n. 4. Reglan 10 mg intravenous q 6. 5. Insulin sliding scale. 6. Tylenol 650 mg q 6 p.r.n. 7. Zofran p.r.n. DISCHARGE INSTRUCTIONS: The patient is to follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1837] (ENT) in 7 to 10 days for tracheostomy check. The patient is to follow-up with Dr. [First Name8 (NamePattern2) 1312] [Last Name (NamePattern1) 3314], her surgeon, in approximately two weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5014], M.D. [MD Number(1) 35804] Dictated By:[Last Name (NamePattern1) 1741] MEDQUIST36 D: [2115-1-14] 21:44 T: [2115-1-14] 19:20 JOB#: [Job Number 45780]	[ "568.0", "153.2", "996.74", "997.3", "453.8", "211.3", "482.41", "790.7", "518.5" ]	icd9cm	[ [ [] ] ]	[ "99.15", "96.72", "31.1", "97.23", "45.73", "54.59", "45.93", "96.04", "59.8", "96.6", "38.93", "46.52" ]	icd9pcs	[ [ [] ] ]									4880, 5159		4679, 4857					5184, 5774																1947, 4585		1497, 1918																						144, 1397															1414, 1475	4610, 4658
19,119	168,436	50380	Discharge summary	report	Admission Date: [2139-4-6] Discharge Date: [2139-5-14] Date of Birth: [2088-4-5] Sex: F Service: CARDIOTHORACIC Allergies: Zestril / Fioricet / Codeine / Ibuprofen Attending:[First Name3 (LF) 1283] Chief Complaint: nausea Major Surgical or Invasive Procedure: liver biopsy History of Present Illness: 50F w/recurrent MRSA endocarditis on rifampin and vancomycin p/w transaminitis, jaundice, and decreased hepatic synthetic function. History of MVR [12-27] for severe mitral stenosis, complicated by readmission for serious sternal wound infection that led to seeding of her porcine valve with MRSA. TEE showing mobile MV mass in [1-28] that has persisted [2-10] despite vancomycin via PICC. s/p vancomycin x8 wks and rifampin/gentamycin x2wks. Bacteremia w/ +BCx [1-29] that have been negative since [2-7]. Admission [Date range (1) 29260] for anasarca due to CHF that resolved w/diuresis. Presented to [Hospital ] clinic [4-2] from rehab w/nausea on rifampin and hemolytic anemia requiring transfusion. Admitted to OSH from rehab and found to have elevated LFTs (AST 69, ALT 67, AP 161) and creatinine (1.1). Tx to [Hospital1 18] for further evaluation. C/O nausea with dry heaves and mild pain. Past Medical History: prosthetic valve endocarditis diagnosed by TEE on [2139-1-28], present [2139-2-10] and [2139-3-25] (EF 60%, 3+TR, mod pulm HTN,sig worsened pulm regurg) sternal wound infxn s/p bilateral pectoral flap on [2139-2-4] by plastics s/p MVR on [2139-1-6] [2-25] severe mitral stenosis NQWMI [8-27] diabetes type I (age 19, mult DKA,peripheral neuropathy, gastroparesis w/reflux esophagitis,retinopathy s/p laser s/p B vitrectomy) hypertension hypercholesterolemia migraine osteoporosis depression/anxiety chronic hyponatremia h/o foot ulcers ? osteo s/p TAH/BSO, s/p appy/peritonitis, s/p cataract removal, s/p B carpal tunnel release Social History: Patient lives alone, smoke 1 pack/day, no alcohol or recreational drug use. Family History: Father died from MI at age 45 Physical Exam: 97 132/72 93 20 70kg (66kg) 2470/1725 FS 298/168/154/101 Gen - NAD, AOX3, resting comfortably in bed HEENT - MMM, no oropharyngeal lesions, JVP at jawline Heart - RRR, SEM Lungs - b-crackles to mid lung zones Abdomen - no increased distention, active BS, NT, palpable liver edge Ext - 3+ BLE edema bilaterally, +1 pedal pulses, symmetric Neuro - AOx3, responding appropriately, no asterixis, ambulating Pertinent Results: [2139-4-6] Admission Labs: GLUCOSE-171* UREA N-62* CREAT-1.7* SODIUM-126* POTASSIUM-5.0 CHLORIDE-84* TOTAL CO2-29 ANION GAP-18 ALT(SGPT)-755* AST(SGOT)-628* ALK PHOS-201* AMYLASE-17 TOT BILI-0.8 LIPASE-11 ALBUMIN-3.7 MAGNESIUM-2.9* TSH-3.7 WBC-14.1* RBC-3.70* HGB-11.1* HCT-34.9* MCV-94 MCH-30.1 MCHC-31.9 RDW-19.6* PLT SMR-VERY LOW PLT COUNT-48# PT-23.3 PTT-36.3* INR(PT)-3.4 . ECHO Study Date of [2139-4-8] 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. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricle appears dilated. Right ventricular systolic function is normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present with lateral rocking/separation from the mitral annulus consistent with dehiscense with associated paravalvular mitral regurgitation. There are small echodense structures associated with the prosthetic ring which may represent suture material. No definite vegetation is seen on the mitral valve. Moderate to severe (3+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The tricuspid valve leaflets are moderately thickened. Moderate to severe [3+] tricuspid regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared to the prior transesophageal study of [2139-2-10], the previously noted vegetations are not present in the current study. Dehiscense of the lateral border of the prosthetic mitral valve is new. . US Liver: The liver is normal in echotexture without evidence of focal hepatic masses. There is no intrahepatic biliary duct dilatation. The left, middle, and right hepatic veins are all patent and demonstrate normal venous waveforms. The portal vein is patent and demonstrates normal hepatopetal flow. The main hepatic artery, and branches of the left and right posterior hepatic arteries are all patent and demonstrate normal arterial waveforms. . Liver Bx [2139-4-15] 1. Prominent centrolobular hemorrhage with associated hepatocellular necrosis, hemosiderin-laden macrophages and nodular regenerative hyperplasia; see note. 2. Necrotic hepatocytes compose approximately 20% of the biopsy. 3. Trichrome stain shows minimal centrivenular fibrosis, no significant portal fibrosis. 4. No stainable iron seen on iron stain. [2139-5-11] 05:12AM BLOOD WBC-10.8 RBC-4.03* Hgb-11.8* Hct-35.2* MCV-87 MCH-29.3 MCHC-33.6 RDW-16.2* Plt Ct-336 [2139-5-12] 03:04AM BLOOD Glucose-161* UreaN-21* Creat-0.6 Na-128* K-4.8 Cl-89* HCO3-34* AnGap-10 [2139-5-7] 02:01AM BLOOD ALT-16 AST-32 LD(LDH)-372* AlkPhos-129* Amylase-45 TotBili-0.6 Brief Hospital Course: 51F with porcine MVR dehiscence s/p MRSA endocarditis [2-25] sternal wound infection after MVR 3 months ago. MRSA Endocarditis: Now cleared on [4-8] TEE after vanco x8wks and gent & rifampin x2wks; however, dehiscence of porcine appeared. Pt p/w heart failure and hepatic failure that has been treated. Heart and hepatic function are now optimized with reversal of coagulopathy and improvement in thrombocytopenia. BCx [4-6] x3 and [4-8] negative,including mycolytic. C. diff negative x3. Hepatic Failure/Encephalopathy: Transaminitis, hyperuricemia, coagulopathy, reduced synthetic fxn all improved. Likely [2-25] worsening dCHF. Abd u/s with normal appearing liver and patent vessels. Hepatitis serologies and HCV viral load. AFP and IgG normal. [Doctor First Name ] negative. [Last Name (un) 15412] positive. -liver bx consistent with recovery from episode of CHF induced hepatocellular damage from which complete recovery may be expected. Mrs. [Known lastname ] underwent aggressive diuresis and treatment of her heart failure preoperatively, which included an intra aortic balloon pump and inotropic therapy. Once she was cleared by the hepatology service, she was taken to the operating room on [4-28] with Dr. [Last Name (STitle) ] for a redo MVR via R thoracotomy with a 27mm mosaic valve. She also required a R femoral artery thrombectomy by vascular surgery. Post operatively she was started on epinephrine, milrinone and inhaled nitric oxide, continued with her IABP and transferred to the ICU in stable condition. She was seen by vascular surgery on POD#1 because her L foot was cool. It was recommended that the IABP be removed, this was done with improvement in her vascular exam. She was started on heparin for anticoagulation. She was started on fluconazole postoperatively because it was noted that she had a rash consistent with yeast on her chest, this was continued for 14 days postoperatively per the infectious disease team. Her nitric oxide and milrinone were weaned over the next several days, her support from the ventilator was decreased, and she was extubated on POD#4 without difficulty. She was started on Natrecor and aggressive diuretic therapy to achieve diuresis. She had been started on amiodarone for atrial fibrillation, which she had a few short episodes postoperatively. She was transferred from the ICU on POD#9. Her anticoagulation was discontinued on POD#14. She underwent an echocardiogram on [5-7] which showed an LVEF of 60, mildly dialated LA/RA, LVH dialated RV with normal function and abnormal septal motion consistent with RV overload, moderate to severe TR, and normal MV prosthesis. Although she remained volume overloaded, it was felt by the cardiology service, the cardiac surgery service and the medicine service that she could continue diuresis at rehab. On [5-12], she was cleared for discharge to rehab, and on [5-14] she was dischared to rehab. Medications on Admission: METOPROLOL ATORVASTATIN CALCIUM 20 MG daily BENZOYL PEROXIDE 5 %--Apply qd - [Hospital1 ] CALCIUM-600 600MG--One by mouth every day COZAAR 100MG--One by mouth every day DOCUSATE SODIUM 100MG--One by mouth four times a day ENTERIC COATED ASPIRIN 81 MG--One every day FOSAMAX 70MG--One by mouth qwk HUMULIN R 100U/ML--Sliding scale with breakfast and dinner HYDROXYZINE HCL 10MG--One to 3 by mouth q 8h as needed for nausea INSULIN, LANTUS AS DIRECTED BY DR [Doctor Last Name 105000] directed LANTUS 100 U/ML--20 units sq at bedtime or as directed LASIX 40MG--One by mouth [Last Name (LF) ], [First Name3 (LF) ] take additional 40mg dose 4 xweek. MAGNESIUM OXIDE 400MG--One by mouth every day METOCLOPRAMIDE 10 MG--One by mouth four times a day as needed MORPHINE SULFATE 15 mg--1 tablet(s) by mouth [Hospital1 ] MS CONTIN 15MG--TID MULTIVITAMIN WITH IRON --One by mouth every morning NICOTROL 10MG--Use 6 cartidges/day PROTONIX 40MG--One by mouth every day SENNA 1 TABLET--Use 4 pills a day with plenty of water TEGRETOL 200MG--3 by mouth qd, rxed by dr [Last Name (STitle) ] TERAZOSIN HCL 2MG--One by mouth at bedtime TRAZODONE HCL 100MG--2 by mouth at hs, per dr [Last Name (STitle) ] VITAMIN D [Numeric Identifier 1871] UNIT--One by mouth q wk Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Sertraline HCl 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 11. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 14. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 16. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 4 weeks: thru LD [6-9]. 17. Vancomycin HCl 500 mg Recon Soln Sig: 750 mg Recon Solns Intravenous Q24H (every 24 hours) for 4 weeks: LD [6-9]. 18. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 19. Heparin Lock Flush 10 unit/mL Syringe Sig: 5 cc MLs Intravenous PRN (as needed): for PICC care. 20. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 21. Insulin Glargine 100 unit/mL Solution Sig: Eighteen(18) units Subcutaneous at bedtime. 22. Insulin Regular Human 300 unit/3 mL Syringe Sig: as directed Subcutaneous four times a day: see attached sliding scale. Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) ] Discharge Diagnosis: s/p redo MVR prosthetic valve endocarditis Type I DM s/p liver biopsy chronic hyponatremia 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:1200cc you may wash your incisions with mild soap and water do not apply lotions, creams, ointments or powders to your incision do not swim or take a bath for 1 month do not drive for 1 month Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 59700], MD Where: LM [Hospital Unit Name 4341] DISEASE Phone:[Telephone/Fax (1) 457] Date/Time:[2139-5-21] 10:00 Provider: [First Name8 (NamePattern2) 1903] [Last Name (NamePattern1) 1904], [MD Number(3) 3670]: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 3512] Date/Time:[2139-6-3] 9:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Where: [Hospital6 29] [Hospital ] Phone:[Telephone/Fax (1) 250] Date/Time:[2139-5-18] 10:50 follow up with Dr. [Last Name (STitle) ] in [3-27] weeks follow up with the [Hospital ] clinic in 1 month Completed by:[2139-5-14]	[ "401.9", "996.61", "250.61", "427.31", "997.2", "997.1", "570", "424.0", "286.9", "599.0", "276.1", "444.22", "428.30", "584.9", "357.2", "287.5", "285.9", "428.0", "E878.1" ]	icd9cm	[ [ [] ] ]	[ "50.11", "38.93", "38.08", "39.61", "35.21", "88.72", "37.61", "00.13" ]	icd9pcs	[ [ [] ] ]	12123, 12193	5718, 8689	312, 326	12328, 12334	2549, 2564	12692, 13470	2078, 2109		10018, 12100		12214, 12307		8715, 9995			12358, 12669									2124, 2530																			266, 274												354, 1288					2580, 5695									1310, 1969	1985, 2062
10,581	123,247	1366	Discharge summary	report	Admission Date: [2135-12-21] Discharge Date: [2135-12-28] Date of Birth: [2053-7-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2291] Chief Complaint: Community Acquired Pneumonia Major Surgical or Invasive Procedure: none History of Present Illness: The pt is an 82yo male PMHx COPD, Systolic CHF (EF25%). The pt is a poor historian but he felt short of breath for several days--he is not sure how long. He also endorsed a productive cough with green sputum and subjective fevers. He is not sure about dysuria/frequency. Few days before the admission, he suffered a mechanical fall, after which he developed the cough w/ sputum, subj fevers. In the ED, initial VS were: 101.1 89 112/55 18 97% RA. Due to a pressure of 89/51, he was given 1L of IVF. A rll infiltrate was found. His ua showed evidence of a uti. He was treated with iv levofloxacin, ctx, and vancomycin. The pt was admitted to the MICU on [2135-12-21] and underwent treatment for HCAP/CAP and COPD exacerbation w IV prednisone, levofloxacin, vancomycin, zosyn, with improvement in respiratory status. In last 36 hrs in the MICU, pt's sbps were better (in the low 100s), remained afebrile, and his wheezing improved w/ nebs/steroids. He is due for a video swallow on [Year (4 digits) ]. Review of systems: (+) Per HPI (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies 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: COPD (not on oxygen) with moderately severe obstructive defect on PFT's - Systolic HF with LVEF 25% in [9-/2135] - Aortic stenosis with [Location (un) 109] 1.1 in [9-/2135] echo - CAD s/p CABG x4 in [2118] c/b NSTEMI in [11/2131] and unsuccessful RAMUS revascularization - History of [Company 1543] Sigma dual-chamber permanent [Company 4448] implant secondary to high-grade AV block in [2124] - PVD w/ Bilateral aortoiliac occlusive disease s/p bilateral lower extremity revascularizations (left SFA, right TPT/PT); ABIs are 1.2 on the right and 0.6 on the left ([2134-11-17]) - Carotid stenosis: Last duplex [2134-11-17]: Right ICA less than 40% stenosis. Left ICA 70-79% stenosis by velocity criteria - Hypertension - Hyperlipidemia - History of asthma - Right renal artery stenosis (76% by angiogram [6-/2130]) randomized to medical therapy as part of CORAL trial. The patient has since dropped out of the study; baseline cre is 1.5 - Gout - Hypothyroidism - Depression (?[1-19] death of son in [Name2 (NI) 116]) - Hearing loss: Does not use hearing aids. Unclear if SNHL or conductive. Social History: Pt currently living at the [First Name4 (NamePattern1) 533] [Last Name (NamePattern1) ]; he can walk with a walker but does get very SOB and wheezy after exertion - this is his current baseline. Pt retired, former art teacher. History of tobacco use but now quit, 10 pack years or so. Endorses occasional alcohol but no illicit drugs. SON, MAX [Telephone/Fax (1) 8292]. [Name2 (NI) ] is DNR/DNI as discussed with his son. Family History: - Father: died age 49 of a "leaky heart" valve - Mother: died 88 of unknown causes Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: General Appearance: Well nourished Eyes / Conjunctiva: PERRL Cardiovascular: (S1: Normal), (S2: Normal), no jvd Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Breath Sounds: Crackles : left base, Wheezes : diffuse) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): , Movement: Not assessed, Tone: Not assessed, finger to nose in tact, cn2-12 in tact, strength 5/5 in upper, lower exts bilat PHYSICAL EXAMINATION ON DISCHARGE: VS: Tc 97.6 BP 116-121/65-75 HR 72 RR 18 Satting 94% on RA General: alert, oriented X 3, in no acute distress on RA Resp: CTA bilaterally. No rales/crakcles/wheezes. Speaking in full sentences; no accessory muscle use. CV: nl s1 + s2; 2+ ejection systolic murmur Pertinent Results: LABS ON ADMISSION: [2135-12-21] 04:20PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.011 [2135-12-21] 04:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG [2135-12-21] 04:20PM URINE RBC-3* WBC->182* BACTERIA-MANY YEAST-NONE EPI-0 [2135-12-21] 04:20PM URINE MUCOUS-RARE [2135-12-21] 03:46PM LACTATE-1.7 [2135-12-21] 03:40PM GLUCOSE-93 UREA N-27* CREAT-1.7* SODIUM-132* POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-21* ANION GAP-17 [2135-12-21] 03:40PM estGFR-Using this [2135-12-21] 03:40PM CK-MB-4 cTropnT-0.12* [2135-12-21] 03:40PM WBC-10.3 RBC-4.34* HGB-12.7* HCT-36.9* MCV-85 MCH-29.4 MCHC-34.5 RDW-14.7 [2135-12-21] 03:40PM NEUTS-84.9* LYMPHS-8.2* MONOS-6.0 EOS-0.3 BASOS-0.5 [2135-12-21] 03:40PM PLT COUNT-197 [2135-12-21] 03:40PM PT-13.3* PTT-26.4 INR(PT)-1.2* LABS ON DISCHARGE: [2135-12-27] 06:33AM BLOOD WBC-13.8* RBC-4.14* Hgb-12.3* Hct-37.1* MCV-90 MCH- [2135-12-28] 05:40AM BLOOD Creat-1.8* [2135-12-27] 06:33AM BLOOD Glucose-117* UreaN-40* Creat-1.7* Na-147* K-4.2 Cl-108 HCO3-27 AnGap-16 [2135-12-24] 07:21AM BLOOD Lactate-1.8 IMAGING: [2135-12-21] - cxr - Patchy right lower lobe opacity is seen, worrisome for consolidation which could be due to infection or aspiration. [2135-12-21] - CT HEAD W/O CONTRAST - 1. No intracranial hemorrhage. 2. Sinus disease with hyperdense fluid level in the left maxillary sinus likely represents blood. No signs of facial fracture. 3. Chronic microvascular ischemic disease. [2135-12-26] - VIDEO SWALLOW - Penetration with trace aspiration on multiple sips of thin liquids. Residue in the valleculae. MICRO: - Blood Culture, Routine (Final [2135-12-27]): NO GROWTH. - URINE CULTURE (Final [2135-12-22]): GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. - MRSA SCREEN (Final [2135-12-23]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. - Legionella Urinary Antigen (Final [2135-12-22]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Brief Hospital Course: HOSPITAL COURSE: 82yo M w/ history of multiple medical problems including COPD and CHF with EF 25% who is admitted to the medicine floor from the MICU for managment of hypotension and pneumonia. Now comfortable on RA after complete course of levofloxacin and po steroids. ACTIVE ISSUES: # Pneumonia: Pt had a RLL infiltrate on lat CXR, 101.1 F in the ED, productive cough. Given recent prior hopsitalization, patient was started on HCAP treatment. However, pt improved considerably from a respiratory point of view, was afebrile, tolerating RA with wheezes much improved. So was given levofloxacin (days [7-25]) # COPD Exacerbation: Pt was treated for COPD exacerbation w/ prednisone po, albuterol and ipratropium nebs d/t pna possibly [1-19] aspiration event. Now tolerating RA with minimal wheezing. We continued albuterol/ipratropium nebs, fluticasone inhaler but held tiotropium # Cr Bump: baseline Cr 1.6. Cr peaked at 1.9, possibly [1-19] IV lasix but down trending to 1.7 on d/c. We held losartan, and continued lasix 20mg daily #Hypertension: We continued metoprolol and isosorbide, holding losartan INACTIVE ISSUES: # Chronic Systolic CHF: pt has an EF of 25% indicating poor forward flow. We continued metoprolol and lasix , but held losartan in the setting of Cr bump # CAD: minimally elevated troponins which trend with renal functions, flat MB's. We continued ASA, simvastatin, clopidogrel and isosorbide mononitrate # GERD: We continued omeprazole #Hyperlipidemia: We continued home simvastatin #Hypothyroidism: We continued synthroid #Depression: We continued home citalopram # FEN: aspiration precautions, thiamine # Prophylaxis: Subcutaneous heparin # Access: peripherals # Diet as tolerated # Communication: Patient / SON, MAX [Telephone/Fax (1) 8292]. # Code: DNR/DNI - confirmed with pt's son. # Disposition: discharge [Doctor Last Name 8310] Warraich, PGY-1 [Pager number 8311] TRANSITIONAL ISSUES: We started the pt on prednisone taper on discharge - 40mg for 3d, 20mg for 3d and 10mg for 3 days. We held losartan and reduced ;asix dose given Cr bump from 1.3 to 1.9. Please restart losartan, increase lasix to 40 qdaily after Cr is 1.3. Requires evaluation from physical therapy with regards to ambulation etc. Medications on Admission: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB, wheezes. 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 13. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 15. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO once a day as needed for constipation. 17. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 19. [Hospital1 ] HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 20. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [12-19] Tablet, Delayed Release (E.C.)s PO once a day as needed for constipation. . Allergies: nkda Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 9. ipratropium bromide 0.02 % Solution Sig: [12-19] Inhalation QID (4 times a day) as needed for shortness of breath or wheezing. 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [12-19] Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 15. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 17. prednisone 20 mg Tablet Sig: as directed Tablet PO once a day for 12 days: Take 3 tablets for 3 days, 2 tablets for 3 days then 1 tablet for 3 days. Disp:20 Tablet(s) Refills:0 18. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 19. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 20. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [12-19] Tablet, Delayed Release (E.C.)s PO once a day as needed for constipation. 21. [Month/Day (2) ] HCl 120 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 599] Senior Healthcare of [Location (un) 55] Discharge Diagnosis: - Community acquired pneumonia - COPD exacerbation - Cardiogenic Heart Failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr [Known lastname 8291], It was a pleasure taking care of you in [Hospital1 18]. You were admitted for difficulty breathing, which was because of an infection in your lungs and worsening of your lung disease. You were initially taken care of in the ICU, after which you were transferred to a medicine [Hospital1 ]. You were treated here with antibiotics and steroids. NEW MEDICATIONS: - Prednisone (a steroid): please take as directed for 12 days. MEDICATION CHANGES: - Lasix: dose was reduced to 20mg once a day. Please increase to previous dose of 40mg once a day after Cr is back to baseline (1.3) - Losartan: losartan was not given because of pt's worsening renal function. Restart losartan after patient's Cr is back to baseline (1.3) Followup Instructions: Department: CARDIAC SERVICES When: [Hospital1 ] [2136-1-9] at 1 PM With: ICD CALL TRANSMISSIONS [Telephone/Fax (1) 59] Building: None None Campus: AT HOME SERVICE Best Parking: None Department: CARDIAC SERVICES When: [Telephone/Fax (1) ] [2136-1-16] at 10:30 AM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: FRIDAY [2136-4-13] at 1 PM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "V45.01", "493.22", "412", "461.0", "787.20", "458.9", "V49.86", "440.0", "599.0", "507.0", "272.4", "244.9", "414.00", "428.23", "424.1", "403.90", "584.9", "311", "440.1", "V45.81", "274.9", "428.0", "530.81", "585.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13199, 13289	6869, 6869	335, 341	13412, 13412	4611, 4616	14374, 15157	3440, 3525		11049, 13176		13310, 13391		9173, 11026	6886, 7142		13588, 14057									3540, 3561										4327, 4592	8832, 9147			1399, 1799		14077, 14351			267, 297	7157, 7994				5534, 6846							369, 1380				8011, 8810			4631, 5514	13427, 13564						1822, 2968	2984, 3424
25,329	152,082	49961	Discharge summary	report	Admission Date: [2122-10-13] Discharge Date: [2122-10-16] Date of Birth: [2079-7-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 43 yo M w/ T1DM, ESRD on HD, HTN, depression presented to ED this AM with SOB. He had missed [First Name3 (LF) 2286] on Saturday and was driving to [First Name3 (LF) 2286] today when he noticed he was becoming more short of [First Name3 (LF) 1440] and had difficulty breathing. Per ED resident, no chest pain, dizziness or syncope. Patient came to the ED, where his O2 sats on RA were in the low 80s and his RR was 35. His BP was 240/120, he was nitro SL and then started on nitro gtt with good BP response. He was afebrile. A CXR showed bilateral pulmonary edema w/ small effusions. Renal was contact[Name (NI) ] for emergent [Name (NI) 2286], patient was started on BiPAP and admitted to MICU for [Name (NI) 2286] / BP control. . Of note, patient was recently admitted in [Month (only) ] with hypertensive emergency and pulmonary edema. He is currently off [Month (only) ] list due his untreated depression. When asked why he missed [Month (only) 2286] on saturday, he replied he did not feel well. He also he did not take his BP meds this AM. He does have a h/o admissions for med non-compliance and HTN/SOB. Patient makes little urine. . ROS: (+) nausea, dry heaves, headache (frontal), muscle aches since saturday, negative for F/C/syncopy, chest pain, diarrhea, dysuria. Past Medical History: 1. End-stage renal disease on hemodialysis for the past year and a half. Tu/Th/Sa. 2. Insulin-dependent diabetes for the past 22 years with retinopathy. 3. Hypertension. 4. Right foot ulcer status post surgery. 5. Depression with apparent history of suicide. 6. Gastroesophageal reflux disease. 7. Stress test in [2121-9-16] showing mild fixed inferior perfusion defect and left ventricular ejection fraction of 40%, last ECHO in [7-23] with EF 70%. 8. Left arm AV fistula. 9. h/o L flank pain since [2119] with multiple admissions and extensive work-up and no organic etiology for pain found. Social History: Lives with mother in subsidized housing. Has four children. Former floor tech. No smoking, EtOH, drugs. Family History: Diabetes in multiple relatives on both sides Physical Exam: PE: VS T 98.6, HR 86, BP 186/95, RR 22, O2 Sat 94% on CPAP PEEP8/PS10 FiO2 0.5 Gen: mild distress, AO, c/o HA HEENT: MMM, anicteric, PEERLA, JVD difficult to assess CV: RRR, no r/m/g Chest: crackles b/l at least 2/3 up, no wheezing Abd: soft, non-distended, mild TTP epigastric, no guarding, no rebound, + BS Ext: no edema Neuro: AOx3, [Year (4 digits) 20691] [Year (4 digits) 5235] . Pertinent Results: [2122-10-13] WBC-9.3 HGB-11.7* HCT-35.3* MCV-81* RDW-16.5* PLT-189 NEUTS-78.6* LYMPHS-15.1* MONOS-3.1 EOS-3.0 BASOS-0.2 PT-12.6 PTT-29.2 INR(PT)-1.1 GLUCOSE-58* UREA N-89* CREAT-16.6# SODIUM-138 POTASSIUM-5.9 CHLORIDE-97 TOTAL CO2-19* ANION GAP-28* CALCIUM-9.4 PHOSPHATE-8.3* MAGNESIUM-2.6 1st set: CK-778* CK-MB-19* MB INDX-2.4 cTropnT-0.22* proBNP-[Numeric Identifier ]* 2nd set: CK-654* CK-MB-16* MB INDX-2.4 cTropnT-0.22* 3rd set: CK-418* CK-MB-10 MB INDX-2.4 cTropnT-0.15* . ECG: NSR 87/[Last Name (LF) ], [First Name3 (LF) ] elevation less than 1mm in V2-3, TWI aVL, (no change to prior [9-22]) . CXR: Findings consistent with pulmonary edema and bilateral small pleural effusions. Brief Hospital Course: A&P: 43 yo M w/ T1DM, ESRD on HD, HTN, depression presented to ED with SOB in setting of volume overload [3-20] missing HD and hypertensive urgency. . #) Dyspnea: clinical findings c/w pulmonary edema, likely [3-20] missing HD and hypertensive urgency. He had urgent [Month/Day (2) 2286] and admitted to the MICU. He was ruled out for MI (baseline elevated troponin but flat). After control of BP and HD, he had no complaints of dyspnea. He initially required CPAP but was soon off oxygen. Compliance issues were addressed with the patient, primary team, and psych consult. . #) HTN: He has h/o med non-compliance with other admissions for hypertensive urgency. He was briefly on nitro gtt. His actual home medication regimen was investigated via communication with his PCP's office and pharmacy; it appeared that his home regimen was different from that which he has been put on in the hospital on past admissions (see medication list). For example, clonidine is always listed as one of his home medications. However, he is not using this at home and does not like this side effects; he therefore discretely removes it while admitted, resulting in rebound hypertension. In general, he does not trust medications not given by his PCP and will not take them post discharge without first talking to him. . #) ESRD: [3-20] T1DM, on HD x 1.5 years. He missed HD prior to admission (had had no HD x 5 days). He was dialyzed the first three days of his admission and will resume his regular schedule as an outpatient. He expresses great frustration with HD and is eager for renal [Month/Day (2) ]. However, he is currently off the [Month/Day (2) ] list [3-20] unstable mental state and depression. He has an upcoming appointment with the [Month/Day (2) ] psychology team. His phosphate binders were continued. . #) DM: on insulin x22y, last A1c in [6-22] was 7.0. We continued his home regimen of 70/30 with additional sliding scale coverage which he intermittently refused to take (does not do a sliding scale at home.) Glucose control overall was good. . #) Depression: He admits to having a lot of sadness and frustration related to multiple medical problems and the role that hemodialysis plays in his life. Psychiatry was consulted (there was also concern that his missing HD was in some way a suicidal gesture). It was felt that his moods were more consistent with dysthymia rather than major depression. Mirtazepine was restarted. He will followup with his counselor and PCP with further referral to psychiatry through their offices. He will also followup with [Date Range ] psychology as above. Medications on Admission: PER OMR/DISCHARGE SUMMARIES: 1.Lisinopril 40 mg Tablet DAILY 2.Aspirin 325 mg Tablet DAILY 3.Nifedipine 120 mg Tablet DAILY 4.Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD 5.Pantoprazole 40 mg Q24H 6.Calcium Acetate 667 mg Capsule Sig: Two Capsule PO TID 7.Mirtazapine 15 mg Tablet HS 8.Citalopram 20 mg Tablet DAILY 9.Metoprolol Succinate 100 mg: Two (2) Tablet Sustained Release DAILY 10.Doxepin 50 mg HS 11.Clonazepam 0.5 mg TID 12.Clonidine 0.2 mg/24 hr Patch Weekly QTUES 13.Lanthanum 500 mg Tablet, Two (2) Tablet, TID W/MEALS 14.Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QID 15.Colace 100 mg twice a day. 16.Insulin (70-30) suspension 15units before breakfast and 15 units before dinner . PER PATIENT REPORT/PHARMACY/PCP [Name Initial (PRE) ]: 1. Calcium Acetate 667 mg Three (3) Capsule PO TID W/MEALS 2. Lisinopril 40 mg Tablet once a day. 3. Nifedical XL 30 mg Tab,Sust Rel Osmotic Push 24hr PO once a day. 4. Labetalol 300 mg Tablet twice a day. 5. Aspirin 81 mg Tablet once a day. 6. Nexium 40 mg once a day. 7. Colace 100 mg twice a day. 8. Insulin (Insulin 70/30, 10 units every morning, 20 units every evening, by subcutaneous injection) Discharge Medications: 1. Calcium Acetate 667 mg Tablet Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. Nifedical XL 30 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 5. Labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 7. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. Insulin Please take your insulin as per your prior schedule (Insulin 70/30, 10 units every morning, 20 units every evening, by subcutaneous injection) Discharge Disposition: Home Discharge Diagnosis: Pulmonary edema End stage renal disease Diabetes type I Depression Discharge Condition: Stable Discharge Instructions: You were admitted for very high blood pressure and trouble breathing. This happened after missing [Name Initial (PRE) 2286]. You needed [Name Initial (PRE) 2286] here. Your blood pressure and breathing problems improved. . It is very important the you do not miss [First Name (Titles) 2286] [Last Name (Titles) 4314], even if you are not feeling well. . Please call your doctor or return to the hospital if you are having difficulty breathing, chest pain, severe headache, or any new symptoms that you are concerned about. . Please keep all of your [Last Name (Titles) 4314] with your doctors and take [Name5 (PTitle) ] of your medications as prescribed. We have made the following medication changes: We added a medication for depression called Remeron (Mirtazapine). Take this as prescribed. . You have taken all of your medications already today with the exception of Remeron. Please take this medication tonight and resume all of your usual medications tomorrow. Followup Instructions: You have the following upcoming [Name5 (PTitle) 4314] at [Hospital3 ]: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2122-10-23] 8:30 [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] CENTER - NON BILLING Phone:[Telephone/Fax (1) 673] Date/Time:[2122-10-23] 9:00 . You also have an appointment with your regular psychiatry team [Hospital1 87067] Health Care on [11-2] at 1 pm. Please call [Telephone/Fax (1) 104324] if you have any questions about this. . You also have an appointment with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ], on [11-4] (also [Hospital1 104325] Health care). . Please visit your primary care office ([Hospital1 ]) at your convenience on Tuesday, [10-20] to have your blood pressure checked by a nurse. . Your next [Month (only) 2286] session will be as usual on this Saturday. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "403.91", "362.01", "311", "250.51", "V45.1", "530.81", "428.0", "585.6" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	8389, 8395	3673, 6327	324, 331	8506, 8515	2923, 3650	9560, 10725	2448, 2494		7547, 8366		8416, 8485		6353, 7524			8539, 9249									2509, 2904																9269, 9537			277, 286												359, 1679														1701, 2310	2326, 2432
81,849	168,293	54786	Discharge summary	report	Admission Date: [2148-9-8] Discharge Date: [2148-9-11] Date of Birth: [2062-9-26] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2297] Chief Complaint: s/p cardiac arrest Major Surgical or Invasive Procedure: intubation and mechanical ventilation History of Present Illness: 85 year-old Mandarin-speaking woman with a history of recent hip fracture (discharged to rehab [8-30]) and pulmonary mycobacterium avium intracellulare infection (on Ethambutol and Azithromycin) admitted post cardiac arrest. The patient was eating breakfast with her daughter this AM and became unresponsive. No choking episode observed, but patient presumed to have an aspiration event. The patient was found to be in asystole with non-shockable rhythm on AED, and CPR was started by EMS. She received 4 rounds of epinephrine. She was intubated and an I/O was placed in the field. Presumed time in asystole 10 minutes. . On arrival to the ED, pulses were present. The patient was hypotensive, with BP 80s/40s and HR 80s. She received 2L NS. Right IJ was placed, but no pressors were initiated as blood pressure increased to SBP 90s. The patient underwent head CT that did not show any acute event. CT cervical spine negative. CTA chest demonstrated left bronchiectasis, supporting aspiration. No PE observed. The patient was started on the post-arrest cooling protocol. She did become bradycardic following initiation of cooling. VS at time of transfer to the MICU BP 97/47 HR 41 Temp 32.2. Current vent settings FIO2 50% Vt 400 RR 16 peep 5. . On arrival to the MICU, the patient displayed 4-5 episodes of activity that began with opening her eyes, followed by rhythmic movements of upper extremities bilaterally. Otherwise non-responsive while not on sedation. Past Medical History: 1. Hypertension (ambulatory BP range 140-160 mmHg systolics) 2. Chronic renal insufficiency (stage III), creatinine clearance 35 mL/min/1.73 m^2 most recently in [7-/2148]; GFR has fluctuated between 35-60 per Nephrology notes; followed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Hospital1 3278] - likely secondary to hypertensive nephrosclerosis and diabetic nephropathy with proteinuria (no history of biopsy) 3. Chronic vision loss 4. Non-insulin dependent diabetes (last HbA1c 6.7% in [6-/2148], home blood glucose well-controlled in 120-130 mg/dL range) 5. Pulmonary mycobacterium avium intracellulare infection (diagnosed in [11/2145] with CXR showing prominent interstitial markings and scarring; PFTs noted a restrictive pattern; PPD negative, AFB positive - started triple therapy with Azithromycin, Ethambutol and Rifabutin; followed by Pulmonology and Infectious Disease. Rifambutin stopped in [2147-8-7] - planning to maintain her on suppressive therapy indefinitely) 6. Iron deficiency anemia 7. Multiple liver masses (likely cysts per records) 8. Left occipital infarct ([11/2133]) 9. Malnutrition 10. s/p excision of left breast mass ([1-/2135]) 11. s/p left vitrectomy and endolaser ([4-/2143]) 12. s/p excision of left forearm mass ([12/2144]) 13. s/p right inguinal hernia repair ([3-/2145]) 14. Recent left hip fracture - discharged to rehab [2148-8-30] Social History: Patient in rehab since recent admission for hip fracture. She normally lives at home with her husband and is [Name (NI) 53881] only; she has 2 daughters and 1 son. She immigrated from [Country 651] over 20 years ago. No history of tobacco use or alcohol use; no recreational substance use. Patient is independent in ADLs and ambulates unassisted at baseline. Family History: Per daughter, no significant family history of early MI, arrhythmia or sudden cardiac death. Physical Exam: Admission Physical Exam: Vitals: T: 32.2 BP: 110/61 P: 83 R: 16 O2: 100% on FIO2 50% Vt 400 RR 16 peep 5 General: Intubated, unarousable to painful stimuli; does exhibit intermittent clonic movements of upper extremities preceeded by eye opening HEENT: Sclera anicteric, MMM, intubated Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased breath sounds in bases bilaterally Abdomen: cooling packs in place GU: foley in place draining yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Dolls eyes abnormal; corneal reflexes negative; does not withdraw to painful stimuli in all 4 extremities . Physical Exam at time patient expired: Neuro: Pupils fully dilated and unresponsive; corneal reflexes negative CV: No cardiac sounds; carotid and femoral pulses absent Lungs: No breath sounds Pertinent Results: Admission Labs: [2148-9-8] 09:08AM BLOOD WBC-8.1 RBC-2.73* Hgb-8.7* Hct-29.7* MCV-109* MCH-32.0 MCHC-29.4* RDW-15.8* Plt Ct-399 [2148-9-8] 01:45PM BLOOD Neuts-94.2* Lymphs-2.4* Monos-3.2 Eos-0.1 Baso-0.1 [2148-9-8] 01:45PM BLOOD PT-9.9 PTT-54.8* INR(PT)-0.9 [2148-9-8] 09:08AM BLOOD Glucose-738* UreaN-50* Creat-1.5* Na-138 K-8.0* Cl-112* HCO3-15* AnGap-19 [2148-9-8] 01:45PM BLOOD ALT-64* AST-104* CK(CPK)-274* AlkPhos-86 TotBili-0.3 [2148-9-8] 01:45PM BLOOD CK-MB-14* MB Indx-5.1 cTropnT-0.07* [2148-9-8] 01:45PM BLOOD Calcium-6.7* Phos-4.9# Mg-2.9 . Labs 1 day prior to when patient expired: [2148-9-10] 03:14AM BLOOD WBC-17.8* RBC-2.76* Hgb-8.5* Hct-27.2* MCV-99* MCH-30.9 MCHC-31.4 RDW-16.4* Plt Ct-382 [2148-9-10] 03:14AM BLOOD PT-10.9 PTT-31.2 INR(PT)-1.0 [2148-9-10] 03:14AM BLOOD Glucose-148* UreaN-54* Creat-2.0* Na-144 K-5.5* Cl-115* HCO3-17* AnGap-18 [2148-9-10] 03:14AM BLOOD CK-MB-7 cTropnT-0.06* [2148-9-10] 03:14AM BLOOD Calcium-7.7* Phos-6.6* Mg-2.9* Brief Hospital Course: 85 year-old Mandarin-speaking woman with a history of recent hip fracture admitted s/p PEA cardiac arrest. She underwent ACLS for 10 minutes and received 4 rounds of epinephrine prior to admission. Unclear etiology of arrest, although likely due to hypoxemia secondary to aspiration as patient was eating breakfast at time of arrest, and had bronchiectasis on CTA indicating likely chronic aspiration. She was treated with vancomycin and Zosyn to cover for aspiration pneumonia. No evidence of ischemia or new infarct on EKG. No PE on CTA. On admission, the patient was started on the Arctic Sun cooling protocol, with goal temperature 33 degrees C. She began to warm prematurely against the machine to 35.8 degrees, and was started on midazolam, cisatracurium, Keppra, and Tylenol to cover for fevers, subclinical shivering, and potential seizures. Temperature returned to goal. During the re-warming phase, the patient exhibited poor neurologic return, with absent corneal reflexes and increasing burst-suppression on EEG. She also exhibited myoclonic jerks. She was evaluated by neurology, who discussed the patient's poor neurologic status with the family in detail. On the ventilator, the patient showed markedly poor respiratory drive when placed on pressure support. The patient's neurologic and respiratory status was discussed with the family, and per the family's request, goals of care were transitioned towards comfort. The patient was extubated per the family's request, and expired within 10 minutes of extubation. Medications on Admission: 1. Amlodipine 5 mg PO BID hold for SBP<100 2. Azithromycin 250 mg PO Q24H 3. Carvedilol 12.5 mg PO BID 4. CloniDINE 0.3 mg PO BID 5. Docusate Sodium 100 mg PO BID constipation 6. Ethambutol HCl 400 mg PO BID 7. Furosemide 20 mg PO DAILY 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Ranitidine 150 mg PO BID 10. Valsartan 80 mg PO BID hold for SBP <100 11. Acetaminophen 1000 mg PO Q8H 12. Heparin 5000 UNIT SC BID last day [2148-9-10] 13. Alendronate Sodium 35 mg PO 1X/WEEK (MO) 14. Nateglinide 120 mg PO BID 15. Non-Aspirin Extra Strength NF (acetaminophen) 500 mg Oral QID:PRN 1 tablet 4 times a day as needed 16. Proctosol HC NF (hydrocorTISone) 2.5 % Rectal [Hospital1 ] 17. Sodium Polystyrene Sulfonate 15 gm PO 3X/WEEK (MO,WE,FR) Mon/wed/fri. hold for K<3.4 18. Zolpidem Tartrate 5 mg PO DAILY 1.5 tablets once a day 19. TraMADOL (Ultram) 25 mg PO BID:PRN pain hold for sedation Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Status Post Pulseless Electrical Activity Cardiac Arrest Discharge Condition: Expired	[ "031.0", "403.90", "780.01", "V12.54", "585.3", "427.5", "507.0", "348.1", "427.1", "V54.13", "583.81", "780.39", "V49.86", "427.89", "250.42", "333.2", "276.0" ]	icd9cm	[ [ [] ] ]	[ "38.97", "38.91", "96.71" ]	icd9pcs	[ [ [] ] ]	8368, 8377	5825, 7367	322, 361	8477, 8487	4783, 4783		3753, 3848		8327, 8345		8398, 8456		7393, 8304												3888, 4764																			264, 284												389, 1875					4799, 5802									1897, 3351	3367, 3737
2,015	162,267	28061	Discharge summary	report	Admission Date: [2134-9-15] Discharge Date: [2134-9-27] Date of Birth: [2087-3-21] Sex: M Service: SURGERY Allergies: Hydromorphone Attending:[First Name3 (LF) 5880] Chief Complaint: Extra-adrenal mass Major Surgical or Invasive Procedure: Surgical resection of extra adrenal mass. History of Present Illness: The patient is a 47-year-old white male who is referred by Dr. [Last Name (STitle) ] from [Location (un) ] for evaluation of a right retroperitoneal mass. This patient has had pain for about two months and a CT scan demonstrated a large mass in the retroperitoneal area. The patient had a paraspinous biopsy, which suggested that this was a periganglioma. On further testing, however, at [Location (un) ], his norepinephrine level was 1382, his epinephrine level was 692, and his total catecholamines were 2074. These are all well over the normal range. The patient has chronic history of back pain and has recently had hypertension and diaphoresis. He also notes a 30-pound weight loss. He is on lisinopril for his hypertension. He was found to have fatty liver and so he has stopped drinking. Social History: The patient reports that he is under considerable stress as his family is coming in for his surgery and his wife does not get along well with the rest of his family. Physical Exam: VITAL SIGNS: Blood pressure 150/90, pulse 90, respiratory rate 12. CHEST: Clear. CARDIOVASCULAR: Regular sinus rhythm without murmur. ABDOMEN: He is somewhat tender in the right flank. He has a small umbilical hernia. Pertinent Results: [2134-9-25] 05:20AM BLOOD WBC-9.4 RBC-2.50* Hgb-7.7* Hct-22.0* MCV-88 MCH-30.7 MCHC-34.9 RDW-13.8 Plt Ct-522* [2134-9-24] 07:00AM BLOOD WBC-8.5 RBC-2.51* Hgb-7.6* Hct-22.2* MCV-88 MCH-30.3 MCHC-34.4 RDW-13.8 Plt Ct-411 [2134-9-23] 03:24AM BLOOD WBC-9.2 RBC-2.46* Hgb-7.7* Hct-21.8* MCV-89 MCH-31.2 MCHC-35.1* RDW-14.1 Plt Ct-284 [2134-9-22] 03:17AM BLOOD WBC-7.3 RBC-2.64* Hgb-8.2* Hct-23.2* MCV-88 MCH-31.2 MCHC-35.4* RDW-14.0 Plt Ct-239 [2134-9-21] 01:29PM BLOOD Hct-23.7* [2134-9-21] 03:01AM BLOOD WBC-5.6 RBC-2.69* Hgb-8.3* Hct-23.5* MCV-88 MCH-31.1 MCHC-35.4* RDW-14.2 Plt Ct-167 [2134-9-20] 07:53PM BLOOD Hct-24.4* [2134-9-20] 09:30AM BLOOD WBC-5.1 RBC-2.35* Hgb-7.4* Hct-21.1* MCV-90 MCH-31.5 MCHC-34.9 RDW-13.9 Plt Ct-163 [2134-9-20] 02:22AM BLOOD WBC-5.7 RBC-2.36* Hgb-7.4* Hct-21.2* MCV-90 MCH-31.6 MCHC-35.0 RDW-14.0 Plt Ct-158 [2134-9-19] 09:16PM BLOOD WBC-6.6 RBC-2.47* Hgb-7.8* Hct-22.3* MCV-90 MCH-31.4 MCHC-34.9 RDW-14.0 Plt Ct-143* [2134-9-19] 02:30PM BLOOD WBC-7.2 RBC-2.54* Hgb-8.0* Hct-22.3* MCV-88 MCH-31.3 MCHC-35.7* RDW-14.0 Plt Ct-128* [2134-9-19] 08:55AM BLOOD WBC-8.0 RBC-2.56* Hgb-8.1* Hct-22.6* MCV-88 MCH-31.9 MCHC-36.1* RDW-14.1 Plt Ct-113* [2134-9-19] 02:57AM BLOOD WBC-9.4 RBC-2.68* Hgb-8.3* Hct-23.8* MCV-89 MCH-31.0 MCHC-34.9 RDW-14.1 Plt Ct-120* [2134-9-18] 10:11PM BLOOD WBC-9.9 RBC-2.73* Hgb-8.7* Hct-24.0* MCV-88 MCH-31.7 MCHC-36.1* RDW-14.0 Plt Ct-111* [2134-9-18] 03:10PM BLOOD WBC-10.2 RBC-2.78* Hgb-8.9* Hct-24.8* MCV-89 MCH-31.9 MCHC-35.8* RDW-13.8 Plt Ct-126* [2134-9-18] 07:24AM BLOOD Hct-24.4* [2134-9-18] 02:48AM BLOOD WBC-12.7* RBC-2.89# Hgb-9.3# Hct-25.4* MCV-88 MCH-32.1* MCHC-36.5* RDW-14.0 Plt Ct-147* [2134-9-17] 03:21AM BLOOD WBC-13.5* Hct-32.6* Plt Ct-200 [2134-9-16] 11:46PM BLOOD Hct-31.6* [2134-9-16] 07:27PM BLOOD Hct-31.2* [2134-9-16] 02:33AM BLOOD WBC-6.9 RBC-4.62 Hgb-13.8* Hct-40.7 MCV-88 MCH-30.0 MCHC-34.0 RDW-13.2 Plt Ct-284 [2134-9-25] 05:20AM BLOOD Plt Ct-522* [2134-9-24] 07:00AM BLOOD Plt Ct-411 [2134-9-23] 03:24AM BLOOD Plt Ct-284 [2134-9-22] 03:17AM BLOOD Plt Ct-239 [2134-9-21] 08:37AM BLOOD PTT-31.7 [2134-9-21] 05:00AM BLOOD PTT-31.1 [2134-9-21] 03:01AM BLOOD Plt Ct-167 [2134-9-21] 12:53AM BLOOD PTT-30.8 [2134-9-20] 07:53PM BLOOD PTT-31.7 [2134-9-20] 09:30AM BLOOD Plt Ct-163 [2134-9-20] 02:22AM BLOOD Plt Ct-158 [2134-9-19] 09:16PM BLOOD Plt Ct-143* [2134-9-16] 02:33AM BLOOD PT-12.9 PTT-25.6 INR(PT)-1.1 [2134-9-16] 03:15PM BLOOD Fibrino-90* [2134-9-27] 03:30PM BLOOD Creat-2.8* Na-136 K-5.0 [2134-9-27] 05:59AM BLOOD Glucose-86 UreaN-72* Creat-3.2* Na-140 K-5.4* Cl-105 HCO3-26 AnGap-14 [2134-9-26] 04:34PM BLOOD Glucose-92 UreaN-78* Creat-3.8* Na-138 K-5.3* Cl-101 HCO3-26 AnGap-16 [2134-9-16] 07:27PM BLOOD Glucose-110* UreaN-16 Creat-1.8* Na-141 K-4.8 Cl-108 HCO3-22 AnGap-16 [2134-9-16] 04:52PM BLOOD Glucose-178* UreaN-15 Creat-1.6* Na-142 K-4.4 Cl-105 HCO3-22 AnGap-19 [2134-9-16] 02:33AM BLOOD Glucose-123* UreaN-13 Creat-0.8 Na-142 K-3.9 Cl-104 HCO3-27 AnGap-15 [2134-9-20] 09:30AM BLOOD ALT-26 AST-59* AlkPhos-231* [2134-9-19] 09:16PM BLOOD ALT-38 AST-82* AlkPhos-118* [2134-9-18] 10:11PM BLOOD ALT-73* AST-182* AlkPhos-75 TotBili-0.5 [2134-9-18] 03:10PM BLOOD ALT-77* AST-183* AlkPhos-64 TotBili-0.5 [2134-9-26] 06:17AM BLOOD Calcium-8.7 Phos-7.5* Mg-2.4 [2134-9-25] 04:26PM BLOOD Calcium-9.0 Phos-7.0* Mg-2.6 [2134-9-16] 04:52PM BLOOD Phos-2.9 Mg-3.6* [2134-9-16] 02:33AM BLOOD Calcium-9.6 Phos-4.4 Mg-1.9 [2134-9-21] 03:01AM BLOOD Osmolal-303 [2134-9-18] 12:29PM BLOOD Cortsol-18.7 [2134-9-18] 11:58AM BLOOD Cortsol-18.5 [2134-9-18] 11:19AM BLOOD Cortsol-18.2 [2134-9-17] 08:57AM BLOOD Cortsol-15.9 [2134-9-21] 08:49AM BLOOD Type-ART Temp-37.3 O2 Flow-4 pO2-95 pCO2-51* pH-7.35 calTCO2-29 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2134-9-21] 03:18AM BLOOD Glucose-111* Na-135 K-4.3 Cl-105 [2134-9-20] 09:07PM BLOOD Glucose-98 Lactate-0.7 Na-136 K-4.2 Cl-104 [2134-9-20] 03:37PM BLOOD Glucose-91 Na-136 K-4.5 Cl-106 [2134-9-16] 02:19PM BLOOD Glucose-289* Lactate-11.9* Na-138 K-3.9 Cl-110 calHCO3-15* [2134-9-16] 01:52PM BLOOD Glucose-209* Lactate-12.7* Na-140 K-3.0* Cl-102 [2134-9-16] 12:07PM BLOOD Glucose-184* Lactate-4.9* Na-142 K-2.8* Cl-106 calHCO3-23 [2134-9-18] 03:28PM BLOOD O2 Sat-98 [2134-9-16] 03:52PM BLOOD Hgb-9.8* calcHCT-29 [2134-9-16] 03:26PM BLOOD Hgb-9.4* calcHCT-28 [2134-9-16] 01:52PM BLOOD Hgb-12.8* calcHCT-38 [2134-9-16] 12:07PM BLOOD Hgb-11.8* calcHCT-35 [2134-9-21] 08:49AM BLOOD freeCa-1.27 [2134-9-21] 03:18AM BLOOD freeCa-1.21 [2134-9-16] 01:52PM BLOOD freeCa-1.07* [2134-9-16] 12:07PM BLOOD freeCa-1.08* [2134-9-25] 05:20AM BLOOD CHROMOGRANIN A-Test [2134-9-18] 02:48AM BLOOD cortisol, free-Test [2134-9-17] 11:28AM BLOOD cortisol, free-Test Brief Hospital Course: The patient was admitted to the SICU post-operativly. He was intubated and was requiring a neosenephrine drip for preassure support but otherwise he was stable. He remained in the SICU for 7 days after which he was transfered to the floor. The neosenephrine drip was weaned to off on post-operative day 3 and he was extubated on post-operative day 4. His SICU course was complicated by ATN for which he required CVVHD. This was started POD 1 and he remained on CVVHD until POD 5 when his renal function had begun to return. On POD 7 he was transfered to the floor in stable condition. Medications on Admission: Nifedipine XR 60 mg in the morning, Toprol-XL 25 mg at bedtime, and Cardura 2 mg at bed time as well as Vicodin p.r.n.. He does not take any vitamins or supplements. 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. Hydrocodone-Acetaminophen 5-500 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: Pheochromocytoma Discharge Condition: Good Discharge Instructions: You may shower. Do not remove your steri-strips. However, when they fall off, you need not replace them. Please call or return to the ER if you develop fever, chills, night sweats, dizziness, vomiting, severe diarrhea or constipation, urinary problems, palpitations, or any other concern. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] on Tuesday, [10-5]. Please call ([Telephone/Fax (1) 6449] to schedule your appointment. Please follow-up with your primary care physician [Name Initial (PRE) 176] 3 days to have your potassium and creatinine checked.	[ "158.0", "274.9", "998.2", "E878.6", "496", "197.7", "584.5", "327.23", "401.9" ]	icd9cm	[ [ [] ] ]	[ "07.22", "54.4", "38.93", "96.6", "50.12", "99.04" ]	icd9pcs	[ [ [] ] ]	7713, 7719	6634, 7223	292, 336	7780, 7787	1624, 6611	8126, 8412			7441, 7690		7740, 7759		7249, 7418			7811, 8103									1380, 1605																			234, 254												364, 1181															1197, 1365
30,075	175,900	30830	Discharge summary	report	Admission Date: [2110-11-4] Discharge Date: [2111-1-7] Date of Birth: [2041-5-21] Sex: M Service: CARDIOTHORACIC Allergies: Ativan / Piperacillin Sodium/Tazobactam Attending:[First Name3 (LF) 2969] Chief Complaint: Fever Major Surgical or Invasive Procedure: [2110-11-7] PROCEDURE PERFORMED: 1. Bronchoscopy. 2. Flexible esophagoscopy. 3. Right posterior thoracotomy with creation of [Last Name (un) 72968] window and primary suture repair of esophagogastric leak. [2110-12-22] PROCEDURE: Left thoracentesis, ultrasound of the chest. [2110-12-24] PROCEDURES PERFORMED: 1. Tracheostomy. 2. Bronchoscopy with aspiration of secretions. 3. Esophagogastroduodenoscopy. History of Present Illness: Mr. [Known lastname ] is a 69-year-old gentleman now almost 3 months after [First Name9 (NamePattern2) 12351] [Doctor Last Name ] esophagectomy complicated by leak. He has required 1 prior re-operation for anastomotic dehiscence. This was repaired primarily, and he has had a long convalescence with both a small esophagogastric fistula as well as a pancreatic fistula. Most recently, he was re-admitted from rehab with a white count of 20,000 and a fever to 102 with bilious drainage from his residual chest tube. CT scan suggested undrained collection up near the anastomosis, with moth-eaten bone in the posterior ribs. This suggested a possible osteomyelitis or a sequestrum. As the tube was not providing definitive drainage, I recommended creation of a posterior [Last Name (un) 72968] window, and the patient agreed to proceed. Past Medical History: 1. Invasive CA of GE junction, Barrett's esoph s/p remote fundoplication (20 yrs ago @[Hospital1 ]) 2. Open CCK 3. Diverticulitis 4. Benign colon polyps 5. B/L cataracts Social History: Mr. [Known lastname ] is a retired groundskeeper for [University/College ]. Family History: non contributory Physical Exam: Pt Expired [2111-1-7] Pertinent Results: Autopsy results pending Brief Hospital Course: Mr. [Known lastname ] is well-known to the thoracic service. He returned from rehab after spiking a temp of 102. Pt was admitted to the thoracic surgery service on [2110-11-4] with a complicated hospital course after which the pt expired on [2111-1-7]. On [11-4] empyema tube fell out and was replaced. On [2110-11-7] pt went to the operating room for bronchoscopy, flexible esophagoscopy, and right posterior thoracotomy with creation of [Last Name (un) 72148] window and primary suture repair of esophagogastric leak. On [2110-12-24] pt underwent a tracheostomy, bronchoscopy with aspiration of secretions and esophagogastroduodenoscopy. During his hospital course the pt was placed on multiple antibiotic regimens due to spiking fevers, diarrhea, and multiple positive cultures from blood, wounds, sputum and drainage. He remained ventilator dependant and was eventually fitted with a tracheostomy tube for comfort. The pt received tube feeds through a jejunostomy feeding tube. Hypercalcemia was present throughout most of his hospital course for which he was followed closely by the endocrine service. Calcitonin was ultimately given with good effect in decreasing free calcium levels although the etiology of the hypercalcaemia was never discovered. Renal function was variable as monitored by BUN and Cr levels. Antibiotics were renally dosed and adjusted as necessary for renal function. The pt continued to require large volumes of both crystalloid and colloid to maintain appropriate cardiodynamics and eventually was placed on pressors. On [2111-1-7] during a family meeting, in light of respiratory failure, acute renal failure, and decreasing cardiac function, it was decided to withdraw vasopressor support and make the pt comfort measures only. After pressors were withdrawn, the pt expired within hours. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary arrest as late complication of esophagectomy Discharge Condition: none Discharge Instructions: none Followup Instructions: none	[ "V10.03", "V66.7", "790.7", "427.89", "510.0", "293.0", "482.82", "998.6", "518.81", "584.9", "782.1", "997.4", "787.91", "275.42", "285.9" ]	icd9cm	[ [ [] ] ]	[ "00.14", "96.56", "42.89", "99.04", "42.23", "96.6", "33.23", "33.22", "34.09", "45.13", "31.1", "34.72", "34.91" ]	icd9pcs	[ [ [] ] ]	3970, 3979	2064, 3918	311, 743	4084, 4090	2016, 2041	4143, 4151	1937, 1955		3941, 3947		4000, 4063					4114, 4120									1970, 1997																			266, 273												771, 1623														1645, 1820	1836, 1921
79,262	122,580	36356+36357	Discharge summary	report+report	Admission Date: [2157-9-13] Discharge Date: [2157-9-14] Date of Birth: [2076-1-15] Sex: M Service: PSYCHIATRY Allergies: Lisinopril Attending:[Last Name (NamePattern1) 11146] Chief Complaint: "Please give me medicine for my depression." (per translator) Major Surgical or Invasive Procedure: Prior to being transferred to the MICU, patient had a peripheral venous line placed by the medical consult service. History of Present Illness: Briefly, this is a 81 year old married spanish-speaking man w/ multiple medical problems who was admitted to medicine [9-5] for chest pain and hyponatremia, found to be confused and c/o depressoin and anxiety which prompted psychiatry to become involved. Due to his past history of polysubstance dependence and becoming confused on clonazepam, patient was started on seroquel, titrated up to 100mg po qhs + 50mg po bid (all standing) with very little benefit, also was getting zolpidem at night but continued to sleep very poorly. It would appear that patient has been troubled by a number of psychosocial stressors, causing him fits of "depression", and at times make him wish to fall asleep and never wake up - but denies any formal history of SI. While on the medical floor, his son was found to be intoxicated and smelling of ETOH, patient had been living with his grandson, together w/ his wife who is also suffering from multiple medical problems including cancer, emphasema and arthritis, and has been traveling back & forth to CA while spending time w/ his daughter who lives there. Remote history of physical abuse and neglect as a child after his father passed away and patient was forced to go to work as a farmer at age 14, as an adult became involved in drugs - using cocaine and morphine, as well as ETOH, however reports being completely sober x 30 years. Seen by medicine consult at the start of the shift due to very elevated BP readings which were taken this morning, and his medications were adjusted according to their recommendations. Patient gave consent to Social Work to speak w/ his family. Plans in place for grandson and wife to visit later this evening in order to provide comfort. Patient also requesting to speak with a pastor or priest if available. Per translator, patient is not confused although repetitively asks for help ("medicine") and does not report any relief caused by talking about his problems. Frequently at the nursing station door during the day requesting attention, c/o chest pain/pressure, and recieved EKG. Around 3:30 reported new-onset blurred vision, BP taken manually by this writer, found to be 220/112, somewhat irregular rhythm. Past Medical History: Diabetes Mellitus type II without complicatoins Aortic Stenosis with valve area of 1.0 Afib/flutter (not anticoagulated due to fall risk & non-compliance) Diastolic CHF (EF of 55%) CAD s/p cath in [5-28] with 2VD and BMS placed to distal RCA Orthostatic hypertension Obstructive Sleep Apnea: uses cpap at home Peptic Ulcer Disease History of prostate cancer Anxiety L ACA CVA: hypotensive washout stroke Neurocysticercosis: dx on CT with with mult extra calcifications. LE neuropathy S/P left ACL tear H/o Seizure d/o, last episode [2147], maintained on Carbamazepine LLL lung nodule [2151] Fe deficiency anemia Restless leg syndrome, insomnia, nightmares Vit D deficiency Remote h/o etoh abuse Social History: B&R in El [Country 19118], moved to US at age 60, prior to that married to his wife who he met when he was 8 years old. Finished high school. Had 5 children, one died in MVA, one lives with him currently, other are girls living elsewhere. Grandson recently relocated from [Location (un) 5354] to help, speaks english. Has support from family. Married 57 years. Lives with wife and grandson, [Name (NI) ]. [Name2 (NI) 3003] heavy etoh with withdrawal seizures but quit 30 years ago (son confirmed not actively drinking). Prior cocaine and morphine but quit 30y ago. Tobacco: quit 40 years ago. Family History: Father w CAD; died of MI age 41. Mother died of 'sepsis' in 30s. 5 brothers & sisters died at very young age(kids), but he does not know etiology. Pertinent Results: [2157-9-13] 07:58PM GLUCOSE-138* UREA N-17 CREAT-1.0 SODIUM-134 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-23 ANION GAP-16 [2157-9-13] 07:58PM ALT(SGPT)-20 AST(SGOT)-16 ALK PHOS-103 TOT BILI-0.5 [2157-9-13] 07:58PM CALCIUM-9.6 PHOSPHATE-3.9 MAGNESIUM-2.1 [2157-9-13] 07:58PM TSH-4.5* [2157-9-13] 07:58PM WBC-6.7 RBC-4.09* HGB-11.2* HCT-33.1* MCV-81* MCH-27.4 MCHC-33.8 RDW-17.5* [2157-9-13] 07:58PM NEUTS-66.4 LYMPHS-25.9 MONOS-4.8 EOS-2.7 BASOS-0.3 [2157-9-13] 07:58PM PLT COUNT-365 [2157-9-13] 11:15AM GLUCOSE-205* UREA N-14 CREAT-1.0 SODIUM-133 POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17 [2157-9-13] 11:15AM CALCIUM-9.1 PHOSPHATE-3.0 MAGNESIUM-2.0 [2157-9-13] 11:15AM WBC-7.2 RBC-4.05* HGB-11.0* HCT-33.3* MCV-82 MCH-27.1 MCHC-32.9 RDW-17.1* [2157-9-13] 11:15AM PLT COUNT-361 [2157-9-12] 06:50AM GLUCOSE-120* UREA N-14 CREAT-1.0 SODIUM-135 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15 [2157-9-12] 06:50AM CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-2.1 [2157-9-12] 06:50AM WBC-6.9 RBC-3.94* HGB-10.6* HCT-32.8* MCV-83 MCH-27.0 MCHC-32.5 RDW-17.3* [2157-9-12] 06:50AM PLT COUNT-332 Brief Hospital Course: Legal: patient signed into the hospital on a sec. 10,11 (c.v). Psychiatric: patient was interviewed with interpreter and reported disabling periods of depression which appeared to be related to his worries about his medical health and the well being of his family. Repeatedly asked for medicine to help him with his depression, and was extremely thankful when given any oral pills regardless of their purpose. Spent much of his spare time hanging around outside the nurses' station, attempting to make eye contact with his doctors and [Name5 (PTitle) ], in order to ask for "medicine". At the point of his transfer to the MICU, patient was extremely anxious about his failing health, and communicated these feelings to the clinical staff. Interpersonal: Patient permitted social work to contact his family, and spoke with his grandson, with whom patient lives together w/ his wife. The grandson reported his willingness to come in that evening w/ his grandmother (patient's wife) in order to visit and provide their emotional support. Medical: On the first night on the unit, patient was found to be having systolic blood pressures of >220mmHg, and diastolic BPs >120mmHg. In the morning a medical consult was obtained, and patient's antihypertensive regimen was adjusted. Pt. received an EEG after c/o chest pain/pressure, and later in the afternoon medical consult was again called to the floor when patient began c/o bibasilar HA and tunnel vision, w/ worsening dizziness and ataxia. He was transferred to the MICU for medical stablization. Medications on Admission: (psychiatric medications) 1) zoloft 125mg po qd 2) seroquel 200mg po qhs 3) seroquel 100mg po bid Discharge Medications: (psychiatric medications) 1) sertraline 125mg po qd 2) ativan 1mg po tid, hold for sedation Discharge Disposition: Extended Care Facility: transferred to the [Hospital1 18] MICU (Green) Discharge Diagnosis: Axis I: depressive disorder not otherwise specified anxiety disorder not otherwise specified rule out anxiety disorder due to general medical condition rule out hypertensive encephalopathy with anxiety and confusion history of polysubstance dependence (alcohol, cocaine, opiates, benzos) Discharge Condition: medically unstable and transferred to the MICU for medical management. MSE upon discharge: overweight Hispanic man laying in bed, making good eye contact and speaking in a grossly normal fashion (per translator); mood is depressed; affect is somewhat labile, dysphoric, very difficult to reassure; TC: denies SI but has limited future orientation; TP: generally linear and goal-directed; cog: limited exam, grossly attentive, command of remote and recent history appears intact; insight: poor; judgement: fair. Discharge Instructions: Please follow-up with your new medical service Followup Instructions: to be arranged by his new treatment team on the medical service Admission Date: [2157-9-14] Discharge Date: [2157-9-21] Date of Birth: [2076-1-15] Sex: M Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 1973] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: none History of Present Illness: 81 year old Spanish speaking man with history of Type 2 DM, CAD, poorly controlled hypertension, diastolic HF and aortic stenosis with multiple hospitalizations for hypertensive urgency/emergency, transferred from medicine service where he was admitted [Date range (1) 82401] with hypertension and chest pain. He was transferred to [Hospital1 ] 4 Inpatient Psychiatry the day prior to admission for management of his anxiety. He was initially admitted to the medical service with chest pain in the setting of hypertension. For his hypertension, cardiology was consulted and recommended the addition of spirnolactone and lorsartan. His BP control improved with the above regimen and management of his anxiety which was felt to keep him from adequately taking care of himself at home. On admission, he was also noted to be hyponatremic to 120. This was felt to be related to HCTZ that was recently started. His HCTZ was discontinued and he was placed on a fluid restriction with normalization of sodium. On [9-14], Medicine was consulted for blood pressure [Location (un) 1131] of 223/113. On repeat, he is noted to have a SBP 160/80 without intervention. The patient was noted to have headache, shortness of breath and chest pain. He received his BP medications, and his symptoms resolved. At approximately 3 PM, the patient had recurrence of his symptoms. At this time, he complained of bibasilar headache, as well as darkened vision, which he states is new for him. He was given Hydralazine 20 mg, Norvasc 10 mg. ECG showed AFib with ST depressions laterally, unchanged from prior. Given concern of the new headaches and vision changes, he was thus admitted to the MICU for further workup and evaluation. On arrival to the MICU, the patient states that he continues to have pressure in his left chest. He states that it is non-radiating, and he denies associated symptoms. The pain is mid-epigastric, and he says that it has been present since earlier this morning. This resolved prior to discharge from the MICU, Ultimately he was called out to the floor, with plans for continued management. On the floor he was noted occaisionally removing his clonidine patch, whic hwas moved onto his back. His blood pressure was markedly high prior to getting his morning medications and when he becomes severely anxious. This was particularly true when his son is present on the [Hospital1 ]. Past Medical History: Diabetes Mellitus type II without complications Aortic Stenosis with valve area of 1.0 Afib/flutter (not anticoagulated due to fall risk & non-compliance) Diastolic CHF (EF of 55%) CAD s/p cath in [5-28] with 2VD and BMS placed to distal RCA Orthostatic hypertension Obstructive Sleep Apnea: uses cpap at home Peptic Ulcer Disease History of prostate cancer Anxiety L ACA CVA: hypotensive washout stroke Neurocysticercosis: dx on CT with with mult extra calcifications. LE neuropathy S/P left ACL tear H/o Seizure d/o, last episode [2147], maintained on Carbamazepine LLL lung nodule [2151] Fe deficiency anemia Restless leg syndrome, insomnia, nightmares Vit D deficiency Remote h/o etoh abuse Social History: B&R in El [Country 19118], moved to US at age 60, prior to that married to his wife who he met when he was 8 years old. Finished high school. Had 5 children, one died in MVA, one lives with him currently, other are girls living elsewhere. Grandson recently relocated from [Location (un) 5354] to help, speaks english. Has support from family. Married 57 years. Prior heavy etoh with withdrawal seizures but quit 30 years ago (son confirmed not actively drinking). Prior cocaine and morphine but quit 30y ago. Tobacco: quit 40 years ago. Family History: Father w CAD; died of MI age 41. Mother died of 'sepsis' in 30s. 5 brothers & sisters died at very young age(kids), but he does not know etiology. Physical Exam: Vitals: T: 97.6, P: 72, BP 205/83, R: 21 O2: 98% on RA General: Elderly man, markedly anxious, in NAD. HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition Neck: Supple, JVP not elevated, no LAD Lungs: CTA BL CV: RRR, 2/6 systolic murmur Abdomen: +BS, distended [2-21] obesity, non-tender GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: . [2157-9-13] 11:15AM BLOOD WBC-7.2 RBC-4.05* Hgb-11.0* Hct-33.3* MCV-82 MCH-27.1 MCHC-32.9 RDW-17.1* Plt Ct-361 [2157-9-13] 07:58PM BLOOD Neuts-66.4 Lymphs-25.9 Monos-4.8 Eos-2.7 Baso-0.3 [2157-9-13] 11:15AM BLOOD Plt Ct-361 [2157-9-13] 11:15AM BLOOD Glucose-205* UreaN-14 Creat-1.0 Na-133 K-3.9 Cl-97 HCO3-23 AnGap-17 [2157-9-13] 07:58PM BLOOD ALT-20 AST-16 AlkPhos-103 TotBili-0.5 [2157-9-14] 05:34PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2157-9-13] 11:15AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.0 [2157-9-13] 07:58PM BLOOD TSH-4.5* PERTINENT LABS/STUDIES: CT HEAD ([9-15]): A non-contrast CT of the head was obtained. The [Doctor Last Name 352]-white matter differentiation is preserved. There is no intraparenchymal hemorrhage, mass, or mass effect. There are periventricular white matter hypodensities which are likely related to chronic ischemic microvascular disease. Again noted are coarse calcifications within the right frontal lobe, left frontal lobe, and left cerebellar hemisphere. Prominent bifrontal extra-axial spaces are again noted and may be related to atrophy. The calvarium is intact. Vascular calcifications are noted along the carotid siphons and basilar artery. CXR ([9-14]): As compared to the previous examination, the fluid marking of the minor fissure has decreased. The pre-existing right basal opacities have completely resolved. The extent of the pre-existing left basal opacities appears to be unchanged. Unchanged mild cardiomegaly, minimal signs indicating overhydration. Apparent blunting of the left costophrenic sinus could be projectional, however, a small left-sided pleural effusion cannot be excluded. RENAL U.S. Study Date of [2157-9-15] 10:10 AM IMPRESSION: 1. Technically limited Doppler examination due to the patient's inability to hold his breath. Tardus parvus waveform seen in the main renal artery bilaterally which may indicate a bilateral renal artery stenosis or could also indicate intrinsic renal disease. We also note that the prior scan from [2157-6-3] showed normal waveforms, quite different from today's exam. A CTA or MRA could be performed if clinically appropriate to further assess the renal arteries. 2. No hydronephrosis. 3. Stable bilateral renal cysts. CTA ABD W&W/O C & RECONS Study Date of [2157-9-16] 6:40 PM IMPRESSION: 1. Atherosclerotic disease of the descending aorta and branch vessels with no evidence of significant renal artery stenosis bilaterally. There is an early branching of the mid to lower pole right renal artery with very mild narrowing at the take-off of less than 50% stenosis. 2. Stable nodular thickening of the left adrenal gland. 3. Increased pelvic sclerosis, partly visualized, suggesting Paget's disease. A pelvic CT with a bone protocol is recommended when clinically feasible. 4. Follow-up of adrenal nodules and multiple renal hypodense lesions recommended in one year by CT in order to establish stability, given that several are either too small to characterize but incompletely characterized, while two show calcifications. ECG Study Date of [2157-9-14] 1:35:08 PM Atrial fibrillation, average ventricular rate 76. Diffuse non-diagnostic repolarization abnormalities. Compared to the previous tracing of [2157-9-8] thereis no diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 76 0 106 414/442 0 50 135 RAPID PLASMA REAGIN TEST (Final [2157-9-14]): NONREACTIVE. Reference Range: Non-Reactive. MRSA SCREEN (Final [2157-9-17]): No MRSA isolated. [2157-9-21] 08:00AM BLOOD WBC-7.5 RBC-4.40* Hgb-12.1* Hct-35.9* MCV-82 MCH-27.6 MCHC-33.8 RDW-17.0* Plt Ct-306 [2157-9-15] 01:55AM BLOOD PT-13.2 PTT-28.7 INR(PT)-1.1 [2157-9-21] 08:00AM BLOOD Glucose-121* UreaN-10 Creat-0.8 Na-131* K-4.2 Cl-95* HCO3-24 AnGap-16 [2157-9-20] 06:45AM BLOOD Glucose-109* UreaN-13 Creat-0.9 Na-127* K-4.4 Cl-95* HCO3-21* AnGap-15 [2157-9-19] 06:20AM BLOOD Glucose-100 UreaN-12 Creat-1.0 Na-132* K-4.1 Cl-97 HCO3-22 AnGap-17 [2157-9-16] 06:45AM BLOOD Glucose-99 UreaN-15 Creat-0.9 Na-134 K-4.1 Cl-98 HCO3-24 AnGap-16 [2157-9-15] 12:32PM BLOOD CK(CPK)-62 [2157-9-15] 01:55AM BLOOD CK(CPK)-67 [2157-9-14] 05:34PM BLOOD CK(CPK)-78 [2157-9-13] 07:58PM BLOOD ALT-20 AST-16 AlkPhos-103 TotBili-0.5 [2157-9-15] 12:32PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2157-9-15] 01:55AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2157-9-14] 05:34PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2157-9-21] 08:00AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.3 [2157-9-13] 07:58PM BLOOD TSH-4.5* [2157-9-15] 01:55AM BLOOD Cortsol-14.3 Brief Hospital Course: The patient is a 81 yo man with h/o HTN, CAD, DM2, AFib, who has had difficult to control hypertension exacerbated by anxiety. 1. Benign Hypertension/Malignant Hypertension: Two days prior to readmission to this unit, he was discharged to the inpatient psych [Hospital1 ] but ended up requiring transfer to the ICU for hypertensive urgency. His blood pressure was controlled with IV Ativan as well as IV hydralazine. His clonidine patch was increased to 0.3mg. The patient was subsequently transferred back to the [Hospital Ward Name ]. He was incidentally found to have an adrenal mass of abdominal CT in [5-28], though recent serum metanepherines, aldosterone and random cortisol were negative. He had a renal U/S [9-15] to assess for RAS, this was techinically difficult. The waveform that was seen may indicate intrinsic renal disease v bilateral renal artery stenosis, follow-up MRA or CTA was recommended and CTA showed no evidence of renal artery stenosis. He did however have a thickened adrenal gland and his pelvis looked like he may have Paget's disease. These will need to be followed up as an outpatient. He was continued on the following BP regimen: Carvedilol 25 mg po bid at 0600 and 1800 Hydralazine 25mg po q 6hours at 0000 0600 1200 1800 Spironolactone 25mg po qhs at 2200 Losartan 200mg po qhs at 2200 Amlodipine 10 mg po qd at 1800 Isosorbide mononitrate 90 mg po qd given at 0600 Clonidine patch 0.3mg/24hour 1 patch, changed every thursday His blood pressure on the floor was mostly related to his morning pre-medication state, and anxiety attacks. 2)Diastolic heart failure, acute on chronic, Aortic Stenosis: The patient has a history of diastolic CHF, with EF 55%. Per recent D/C summary, When the patient has high pressures (>200 systolic), he develops shortness of breath which responds to nitroglycerin paste and Lasix. 3) CAD Native Vessle: The patient has a history of CAD s/p BMS to the RCA. Continued on aspirin, [Last Name (un) ], beta blocker, statin. 4) Epilepsy: Continued his home Carbamazepine 300mg [Hospital1 ] and pregabalin 100mg TID. 5) Diabetes, type II, controlled. - Metformin held in house. Given an insulin sliding scale. 6) Atrial fibrillation: Continued Beta-Blocaker, aspirin. He is not anticoagulated at baseline due to fall risk and lack of compliance. 7) Hyponatremia - Managed with 1500ml Fluid Restriction 8) Obstructive Sleep Apnea - CPAP was continued 9) GERD - Zantac #) Code: DNR/DNI discussed with patient in Spanish Medications on Admission: Aspirin 325 mg daily Isosorbide Mononitrate 90 mg Sustained Release 24 hr daily Carbamazepine 300 mg [Hospital1 ] Sertraline 125 mg daily Pregabalin 100 mg TID RISS Latanoprost 0.005 % Drops qhs Clonidine 0.2 mg/24 hr Patch Weekly every Thursday Carvedilol 25 mg [Hospital1 ] Atorvastatin 20 mg daily Hydralazine 25 mg q6h Ranitidine HCl 150 mg daily Acetaminophen 325 mg q6h Ferrous Sulfate 325 mg daily Docusate Sodium 100 mg [Hospital1 ] Senna 8.6 mg Tablet [Hospital1 ] Spironolactone 25 mg qhs Losartan 200 mg qhs Amlodipine 10 mg daily Ipratropium Bromide 0.02 % Solution q6h prn Ativan 1 mg TID Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Carbamazepine 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 5. Sertraline 50 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 6. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 16. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 18. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 19. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): at 1800. 20. Losartan 50 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime): at 2200. 21. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily): give at 6 am. 22. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): give at 0600 and 1800. 23. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): give at 0000 0600 1200 1800. 24. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)): at 2200. Discharge Disposition: Extended Care Facility: Radius [Location (un) 86] Discharge Diagnosis: Primary diagnoses: 1. Hypertension 2. Anxiety Secondary diagnoses: 1. Diabetes mellitus 2. Congestive heart failure, chronic, diastolic 3. Coronary Artery disease 4. Seizure disorder 5. Aortic stenosis 6. Atrial Fibrillation 7. Restless Legs syndrome 8. Obstructive Sleep Apnea 9. Prior cerebrovascular accident Discharge Condition: stable Discharge Instructions: You were admitted for high blood pressure. It is very important that you take you blood pressure medications exactly as prescribed. You also have severe anxiety and you are being transferred to a psychiatric floor for further management of this. With better control of your anxiety your blood pressure may also improve. With regard to your congestive heart failure, please weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Followup Instructions: After discharge, please follow-up with: Your PCP: [Last Name (NamePattern4) ]. [Hospital1 30727] on [2157-9-23] at 1pm at [Hospital ] Community Health Center, tel [Telephone/Fax (1) 13770] Cardiology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2157-10-13] at 3:20 pm, [Hospital Ward Name 23] center, [Location (un) 436], tel [Telephone/Fax (1) 9832] If you are unable to make these appointments, please call ahead of time to reschedule them	[ "268.9", "276.1", "428.33", "428.0", "345.90", "427.31", "424.1", "327.23", "530.81", "V45.82", "357.2", "427.32", "V10.46", "V15.82", "V15.81", "518.89", "250.60", "V12.54", "533.90", "280.9", "414.01", "300.4", "401.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	22986, 23042	17630, 20212	8631, 8638	23398, 23407	12963, 12963	23952, 24461	12394, 12542		20881, 22963		23063, 23109		20238, 20858			23431, 23906									12557, 12944	23130, 23377																		8571, 8593											7755, 8177	8666, 11083					12979, 17607									11105, 11814	11830, 12378
18,898	157,697	45697	Discharge summary	report	Admission Date: [2179-12-30] Discharge Date: [2180-1-14] Date of Birth: Sex: F Service: Surgical HISTORY OF PRESENT ILLNESS: This 66-year-old woman with carcinoma of the esophagus presents with dysphagia. She has been having increasing amounts of dysphagia. She has been scheduled for surgery but now presents because of difficulty eating. An endoscopy done on [11-18] showed a mass in the mid esophagus causing partial obstruction. Surgery was planned for [1-4], however, she has had difficulty with eating and taking and keeping down liquids. The patient does have a history of coronary disease and has had an exercise thallium test which shows some ischemia. The patient is admitted for hydration and further work-up before surgery. PAST MEDICAL HISTORY: Notable for hypertension, hypercholesterolemia and peripheral vascular disease. She is status post below knee amputation on the left. MEDICATIONS: Include Verapamil 180 mg tid, Lipitor, Zestril, Amitriptyline, Atenolol 50 mg once per day. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: She is a well developed woman who has lost some weight recently. The heart sounds were regular. The abdomen was soft without masses or tenderness. Her below knee amputation site is well healed. LABORATORY DATA: Admission laboratory showed hematocrit of 34, white blood cells 6,500, BUN 16, creatinine 1. HOSPITAL COURSE: The patient was admitted to the medical service for cardiology work-up and hydration. She was hydrated. She was seen in consultation by the cardiologist who thought the patient was an intermediate risk for perioperative cardiac events and would proceed with surgery without cardiac catheterization. She was given beta blockade. She was prepared for surgery. She was placed on TPN. On [2180-1-4] the patient underwent an Ivor-[Doctor Last Name ] esophagogastrectomy with bronchoscopy and feeding jejunostomy. Surgery itself was uncomplicated with the exception of some ST changes when the patient's saturation dropped. The patient was admitted to the surgical Intensive Care Unit and followed closely. She had a small troponin leak and elevated MB fraction consistent with a small perioperative myocardial infarction. She was seen by cardiology who recommended Lopressor and Aspirin as soon as possible. Her enzymes actually increased to a CPK of 1528 with MB of 32 and MB index of 2.1. The patient was intubated and ventilated. Tube feedings were begun. She was extubated on postoperative day #3. She remained on a small amount of vasopressors, especially with her epidural in place and remained in the Intensive Care Unit for observation. Her pain was under reasonable control. The patient had a swallow which showed no leak. She was then discharged on [2180-1-14]. FINAL DIAGNOSIS: 1. Esophageal cancer. 2. Perioperative myocardial infarction. 3. Hypertension. 4. Peripheral vascular disease. 5. Hypercholesterolemia. SURGICAL PROCEDURES: Ivor-[Doctor Last Name ] esophagogastrectomy [2180-1-4]. DISCHARGE MEDICATIONS: Verapamil 180 mg tid, Lipitor, Zestril, Amitriptyline, Atenolol 50 mg [Hospital1 ], Percocet for pain. DISPOSITION: The patient was discharged with approval and will be followed with nursing services. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 6066] Dictated By:[Last Name (NamePattern4) 9706] MEDQUIST36 D: [2180-7-10] 11:24 T: [2180-7-12] 10:44 JOB#: [Job Number ]	[ "150.3", "997.1", "196.1", "401.9", "272.0", "410.91", "443.9" ]	icd9cm	[ [ [] ] ]	[ "33.23", "42.41", "96.6", "99.15" ]	icd9pcs	[ [ [] ] ]									3111, 3589					1442, 2840	2857, 3087																			1115, 1424																						162, 788														811, 1092
45,308	193,332	35522	Discharge summary	report	Admission Date: [2190-9-2] Discharge Date: [2190-9-9] Date of Birth: [2116-7-3] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: [2190-9-3] - AVR(25 [Company 1543] Mosaic Tissue)/Coronary artery bypass grafting to one vessel (Left internal mammary->Left anterior descending artery). History of Present Illness: 74 year old female with known aortic valve stenosis whoe developed chest pain recently with exertion. Follow-up echocardiogram revealed progression of her aortic stenosis with now higher gradients and a smaller aortic valve area. She was referred for cardiac cath which showed one vessel coronary artery disease. Given the progression of her aortic stenosis and new finding of coronary artery disease, she is being admitted today for pretesting/heparin with plans for AVR/CABG in AM. Past Medical History: Aortic stenosis Myocardial Infarction [2187] Coronary Artery Disease Coronary PTCA/Stent [2180] Permanent atrial fibrillation Diabetes Mellitus Hypertension Hyperlipidemia CVA [2187] - Continues with mild word finding difficulty Non-hodgkin's lymphoma s/p Oral and Abdominal radiation + Chemo Tachybrady syndrome Myelodysplastic syndrome Anemia (heme positive stools with endoscopy done at [Hospital3 ] which showed gastritis but no active bleeding) Prolapsed bladder Urinary incontinence Vertebral compression fracture PVD Spinal stenosis Past Surgical History: Pacemaker insertion - [6-23] Dr. [Last Name (STitle) 23246] Laparotomy with resection of abdominal tumor [2185] Cholecystectomy (open) [2167] Hysterectomy Incisional hernia repair Hemorrhoidectomy Appendectomy Bilateral greater saphenous vein stripping/ligation Repair of prolapsed bladder which failed Bilateral femoral artery vs. Iliac stents Back surgery for Spinal stenosis Social History: Occupation: Retired. Worked in admitting at [Hospital ] Hospital Last Dental Exam: Last year Lives with: Husband in [Name2 (NI) 2624] Race: Caucasian Tobacco: Never ETOH: Rarely if ever has a drink Family History: Father died of MI at age 65 and Mother died at age 82 of stroke Physical Exam: Pulse: Resp:12 O2 sat:98% RA Temp 97.7 B/P Right: Left:131/84 Height:5'3" Weight:172# General:AAox3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur IV/VI SEM at LLSB Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities:1+ LE edema B/L with superficial veins B/L None [] Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:1+ Left:1+ PT [Name (NI) 167]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right:murmur Left:murmur Pertinent Results: [2190-9-2] 06:52PM URINE RBC-0 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [2190-9-2] 05:32PM GLUCOSE-169* UREA N-44* CREAT-1.5* SODIUM-142 POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-24 ANION GAP-16 [2190-9-2] 05:32PM ALT(SGPT)-17 AST(SGOT)-18 ALK PHOS-60 AMYLASE-40 TOT BILI-0.6 [2190-9-2] 05:32PM LIPASE-39 [2190-9-2] 05:32PM ALBUMIN-4.6 CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-1.6 [2190-9-2] 05:32PM %HbA1c-6.5* [2190-9-2] 05:32PM WBC-4.9 RBC-3.60* HGB-9.9* HCT-31.7* MCV-88 MCH-27.3 MCHC-31.1 RDW-17.6* [2190-9-2] 05:32PM PLT COUNT-158 [2190-9-2] 05:32PM PT-14.9* PTT-24.4 INR(PT)-1.3* [2190-9-7] 06:30AM BLOOD WBC-7.3 RBC-3.35* Hgb-9.5* Hct-29.2* MCV-87 MCH-28.2 MCHC-32.4 RDW-17.2* Plt Ct-126* [2190-9-9] 06:03AM BLOOD PT-22.1* INR(PT)-2.1* [2190-9-9] 06:03AM BLOOD UreaN-42* Creat-1.3* K-4.5 [2190-9-7] 06:30AM BLOOD Glucose-77 UreaN-44* Creat-1.6* Na-135 K-4.2 Cl-104 HCO3-23 AnGap-12 /24/09 Carotid Ultrasound There is less than 40% stenosis within the internal carotid arteries bilaterally. [2190-9-3] ECHO PRE BYPASS The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with moderate hypokinesis of the distal anterior, anterolateral, anteroseptal, apical and mid septal walls. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The right ventricular cavity is dilated with borderline normal free wall function. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area = 0.5 cm2). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is v paced. Right ventricular systolic function remains low normal. The left ventricle displays a septal "bounce" consistent with ventricular pacing. There is some distal anteroseptal dyskinesis they may also be due to ventricular pacing. The distal anterior and anterolateral walls display improved function relative to the pre bypass study. The overall ejection fraction is in the 50% range. There is a bioprosthesis located in the aortic position. It is well seated. The ;eaflets are only poorly seen. The maximum pressure gradient through the valve is 12 mmHg with a mean pressure of 7 mmHg and an area calculated to be 1.7 cm2. No aortic regurgiation is seen. The thoracic aorta appears intact. No other changes from the pre-bypass study. Radiology Report CHEST (PA & LAT) Study Date of [2190-9-7] 2:06 PM Final Report TYPE OF EXAMINATION: Chest PA and lateral. INDICATION: Female patient status post aortic valve replacement and bypass surgery, evaluate for interval change. FINDINGS: Patient's condition did not permit examination in standard view therefore changed to AP and lateral view in sitting semi-upright position. Comparison is made with the next preceding AP single chest view of [9-5], [2189]. Previously described permanent pacer with single intracavitary electrode terminating in right ventricle unchanged. The same holds for the metallic components of a [Company 80889] aortic valve prosthesis. Right internal jugular vein approach central venous line in unchanged position and no pneumothorax has developed. The lateral view demonstrates some mild degree of bilateral pleural effusions in the posterior pleural sinuses. No new parenchymal abnormalities besides the previously described plate atelectasis on the bases. IMPRESSION: No significant interval change. DR. [First Name (STitle) ] [Initials (NamePattern5) 3250] [Last Name (NamePattern5) 3251] Approved: TUE [2190-9-7] 5:50 PM Brief Hospital Course: Ms. [Known lastname 7435] was admitted to the [Hospital1 18] on [2190-9-2] for surgical management of her aortic stenosis and coronary artery disease. Heparin was started as she had been off of her coumadin for several days. She was worked-up in the usual preoperative manner including a carotid duplex ultrasound which showed less then 40% stenosis bilaterally. On [2190-9-3], Ms. [Known lastname 7435] was taken to the opertaing room where she underwent cornary artery bypass grafting to one vessel with and aortic valve replacment. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Over the next 24 hours, she awoke neurologically intact and was extubated. She developed non-oliguria acute tubular nephrosis post operatively and creatinine peaked at 2.2. All diuretics were discontinued and her creatinine had decreased to 1.6 (which was her baseline) at the time of discharge. Chest tubes and pacing wires were removed per cardiac surgery protocol. Coumadin was restarted at home dose for atrial fibrillation and her INR was monitored. Dr [Name (NI) 80890] office was contact[Name (NI) ] and will be following her INR levels on discharge from rehab. Results are to be called into [Telephone/Fax (1) 77064] She was discharged to rehabilitation at [Location (un) 931] House inWalpole on on post operative day 6 in stable condition. Medications on Admission: Coumadin followed by Dr. [Last Name (STitle) 3497] Lisinopril 20mg qd Labetalol 200mg qd Simvastatin 20mg qd HCTZ 25mg qd or prn given lower extremity edema Procrit q4wks Folic acid 0.4mg QD Metformin 1000mg twice daily Aspirin 81mg daily Calcium with Vitamin D Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Warfarin 5 mg Tablet Sig: as directed below Tablet PO once a day: 5mg on sat/sun 7.5mg on mon-fri. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) 931] House Nursing & Rehabilitation Center - [Location (un) 932] Discharge Diagnosis: CAD/AS s/p CABG/AVR Aortic stenosis Myocardial Infarction [2187] Coronary Artery Disease Coronary PTCA/Stent [2180] Permanent atrial fibrillation Diabetes Mellitus Hypertension Hyperlipidemia CVA [2187] - Continues with mild word finding difficulty Non-hodgkin's lymphoma s/p Oral and Abdominal radiation + Chemo Tachybrady syndrome Myelodysplastic syndrome Anemia (heme + stools. endoscopy @ [Hospital3 ]-gastritis no active bleeding) Prolapsed bladder Urinary incontinence Vertebral compression fracture PVD Spinal stenosis Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These inlcude redness, drainage or increased pain. Report all wound issues to your surgeon 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) Shower daily and was incision with soap and water. No lotions, creams or powders to incision for 6 weeks. 5) No driving for 1 month. 6) No lifting more then 10 pounds for 10 weeks from date of surgery. 7) Call with any questions or concers. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 1 month. ([Telephone/Fax (1) 1504] Please follow-up with Dr. [Last Name (STitle) 3497] in [1-12] weeks. Please follow-up with Dr. [Last Name (STitle) 32496] in [1-12] weeks. [Telephone/Fax (1) 42946] Call all providers for appointments. Completed by:[2190-9-9]	[ "424.1", "238.75", "202.80", "V45.01", "427.31", "599.0", "412", "438.11", "250.00", "401.9", "584.5", "272.4", "443.9", "V58.61", "414.01" ]	icd9cm	[ [ [] ] ]	[ "88.72", "39.63", "39.61", "36.15", "35.21" ]	icd9pcs	[ [ [] ] ]	10342, 10456	7425, 8864	335, 499	11042, 11051	3046, 7402	11623, 11969	2250, 2316		9181, 10319		10477, 11021		8890, 9158			11075, 11600							1614, 2010		2331, 3027																			279, 297												527, 1013														1035, 1591	2026, 2234
30,530	166,486	32168	Discharge summary	report	Admission Date: [2134-7-7] Discharge Date: [2134-7-13] Date of Birth: [2061-4-30] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Aleve / Ibuprofen / Valium / Codeine / Morphine / Oxycodone Hcl/Acetaminophen / Darvocet-N 100 / Vicodin / Levaquin / Rocephin / Cipro Attending:[First Name3 (LF) 2724] Chief Complaint: Headache Major Surgical or Invasive Procedure: R frontal and parietal burr hole drainage of SDH History of Present Illness: 73 yo F with DM, neuropathy, HTN presented to an OSH on [7-7] with 5 days of headache, denied any trauma to head. OSH CT noted to have bilateral chronic subdural hematomas with mild midline shift so patient was transferred to [Hospital1 ]. In the ER given dilaudid and labetelol for high BP, and she was initially admitted to neurosurgery. On the floor, she had an episode of bradycardia to 30 and a brief low BP. She was seen by neurosurg and was thought to have this from high vagal tone in setting of vomiting. Repeat head CT did not show acute change. . Patient was transferred to medicine for further work up. At time of transfer she did not have any complaints. Denies ha/nausea/f/chills. No change in bowel habbits. States "feels like how she was at home". Per her family, she is considerably more confused and disoriented than three months ago. Of note recently, she had a PICC placed for cellulitis treatment and during the Heparin flushes her daughter reported that her head felt funny. Around this time, it was noticed that her thinking became less clear. . Past Medical History: 1.DMII-insulin dependent 2.Osteoporosis 3.chronic low back pain 4.R sciatica pain Social History: Lives with daughter and husband in [Name (NI) 1475] Family History: Mother and sister both had intracranial aneurysms Physical Exam: VSS T 98.5 HR 91 BP 130/48 RR 16 O2 100% 3L General Lying in bed, oriented to person and time, place "hospital....[Hospital1 1872]?" Slightly confused, when answering questions will often start talking about her blood sugars, but easily redirectable HEENT PERRL, EOMI, CNII-XII intact grossly, MMM, no lesions in her oropharynx, anicteric sclera Neck: Supple, no lymphadenopathy, no carotid bruits, JVP 8-10 cm Card: RRR S1 and S2 no m/r/g Pulm: CTAB Abd: obese, +BS, soft, non-tender, non-distended Ext: 1+ bilateral ankle edema going 1/2 up her shins, 2+ DP pulses bilaterally Skin: no rashes or lesions noted. pressure ulcer Neurologic: -motor: normal bulk, strength and tone throughout. -sensory: No deficits to light touch throughout. -cerebellar: No nystagmus, dysarthria, intention or action tremor, dysdiadochokinesia noted. FNF and HKS WNL bilaterally. -DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: [2134-7-7] 08:13PM WBC-8.4 RBC-4.31 HGB-13.5 HCT-38.7 MCV-90 MCH-31.3 MCHC-35.0 RDW-13.6 [2134-7-7] 08:13PM ASA-NEG ETHANOL-NEG ACETMNPHN-10.0 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2134-7-7] 08:13PM PHENYTOIN-<0.6* [2134-7-7] 08:13PM CK-MB-4 cTropnT-<0.01 [2134-7-7] 08:13PM CK(CPK)-164* [2134-7-7] 08:13PM GLUCOSE-131* UREA N-19 CREAT-1.0 SODIUM-137 POTASSIUM-5.6* CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 [2134-7-7] 08:13PM PT-10.7 PTT-23.6 INR(PT)-0.9 . Head CT [2134-7-7] Bilateral chronic subdural hematomas, right greater than left. Associated leftward midline shift of 6 mm max. A tiny focus of high-density material on the right indicates a small acute component. No evidence of transtentorial herniation . [2134-7-10] Bilateral subdural hematomas, right greater than left side, with subfalcine herniation to the left and signs of early central herniation. Small area of slow diffusion in the distribution of left anterior cerebral artery, which could indicate acute infarct related to subfalcine herniation. . EKG Sinus rhythm. Left atrial enlargement. Right bundle-branch block. No previous tracing available for comparison. Brief Hospital Course: Mrs. [Known lastname 1458] is a 73 year old female who presented to an OSH on [7-7] with a 5 day history of atraumatic headache. At the OSH, her head CT showed bilateral chronic subdural hematomas with mild midline shift so she was transferred to [Hospital1 18] on [7-7] for further evaluation and care. In the [Hospital1 18] ER she was given dilaudid and labetelol for high BP, and she was initially admitted to neurosurgery. On the neurosurgery floor, she had an episode of bradycardia and hypotension that coincided with bouts of vomiting. These findings were thought to have resulted from high vagal tone, and a repeat head CT did not show any acute changes. The patient was then transferred to geriatric medicine for further work up of her hypotension and bradycardia. At the time of transfer she did not have any complaints. She denies ha/nausea/f/chills, reports no change in bowel habbits, and states she "feels like how she was at home". Per her family, she is considerably more confused and disoriented than three months ago. Of note recently, she had a PICC placed for cellulitis treatment and during the Heparin flushes her daughter reported that her head felt funny. Around this time, it was noticed that her thinking became less clear. The neurosurgery team continued to follow her and monitor her clinical course daily. On [7-10] she was admitted to the medical ICU for further monitoring of her SDH. Upon further evaluation, her course was suggestive of a worsening SDH with symptoms from herniation. As a result, she underwent emergent R frontal and parietal burr hole SDH evacuation on [7-10]. She tolerated this procedure well and was monitored overnight in the surgical ICU. On POD#1 she was transferred to the floor. Her diet and activity were advanced, and her surgical incision remained clean and dry. She was seen by PT and OT and recommended for discharge home with physical therapy. She is being discharged today in stable condition, tolerating a regular diet, with prescriptions written. Medications on Admission: unknown 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. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:120 Capsule(s) Refills:2 6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection four times a day: please take your insulin sliding scale as previously prescribed. Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Subdural hematoma Diabetes Mellitus Type II Osteoporosis Discharge Condition: Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY ?????? 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 today ?????? 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 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 return to the office in 7 days to have your staples removed. Call [Telephone/Fax (1) ] to schedule an appointment. You will then need to be seen in 4 weeks by Dr. [Last Name (STitle) 548] at [Telephone/Fax (1) ] with a CT scan of the brain.	[ "724.3", "357.2", "733.00", "432.1", "276.51", "401.9", "292.81", "427.89", "250.60", "E935.2" ]	icd9cm	[ [ [] ] ]	[ "01.31" ]	icd9pcs	[ [ [] ] ]	6843, 6898	4065, 6128	421, 471	6999, 7008	2855, 4042	8157, 8422	1775, 1826		6186, 6820		6919, 6978		6154, 6163			7032, 8134									1841, 2836																			373, 383												499, 1580														1602, 1686	1702, 1759
76,376	195,583	39948	Discharge summary	report	Admission Date: [2174-12-20] Discharge Date: [2174-12-28] Date of Birth: [2115-1-19] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath, chest pain Major Surgical or Invasive Procedure: [2174-12-20] Cardiac Catheterization [2174-12-23] Coronary artery bypass graft x3 (Left internal mammary to left anterior descending, Saphenous vein graft > obtuse marginal, saphenous vein graft > posterior descending artery) History of Present Illness: 59 year old male with shortness of breath and discomfort in his chest x 3 month. He states that he noticed that whenever he exerted himself, such as walk up a flight of stairs, he developed shortness of breath as well as chest discomfort that he finds hard to describe. Not pain per say, but discomfort. He had actually first noticed this pain occurring several years ago when he played tennis, but he had attributed it to being out of shape when starting the season and he had gotten used to it once the tennis season started. Due to increasing symptoms of chest discomfort and shortness of breath, he decided to go to his primary care doctor to get evaluated yesterday. He was arranged for a stress echo today, which demonstrated marked dynamic changes on EKG with exertion as well as inducible ischemia in the apex, anterior and antero-septal walls, and inferiorly. He was then referred to [Hospital1 ] for cardiac catherization. Past Medical History: Dyslipidemia migraine headaches colonic adenoma BPH with elevated PSA Social History: Lives with wife. [Name (NI) ] genetics researcher. -Tobacco history: 1/2ppd x 10 years, quit 20 years ago. -ETOH: denies -Illicit drugs: denies Family History: Father - MI at age 59, angina in 50s. Died at age 71. Physical Exam: On admission: VS: 98.4 97/64 67 18 96% RA 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. 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. TR band in place on right radial artery SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [2174-12-28] 04:15AM BLOOD WBC-10.1 RBC-3.60* Hgb-10.4* Hct-30.5* MCV-85 MCH-28.8 MCHC-34.0 RDW-15.5 Plt Ct-270 [2174-12-27] 10:35AM BLOOD WBC-13.3* RBC-4.01* Hgb-11.9* Hct-34.5* MCV-86 MCH-29.6 MCHC-34.4 RDW-14.8 Plt Ct-266 [2174-12-28] 04:15AM BLOOD Na-135 K-3.5 Cl-104 [2174-12-27] 10:35AM BLOOD Glucose-164* UreaN-12 Creat-1.0 Na-135 K-3.9 Cl-102 HCO3-23 AnGap-14 Intra-op TEE Prebypass No atrial septal defect is seen by 2D or color Doppler. 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 and no aortic stenosis. Mild (1+) aortic regurgitation is seen. Mild to moderate ([1-22]+) mitral regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results on [2174-12-23] at 1030 am. Post bypass Patient is in sinus rhythm and receiving an infusion of phenylephrine. Mild hypokinesia of the apical and mid portions of the anterior and anterospetal walls noted. Mild mitral regurgitation persists. Aorta is intact post decannulation. Dr [Last Name (STitle) ] aware of post bypass findings as well Brief Hospital Course: Presented to emergency department after positive stress test and was admitted for cardiac evaluation. He underwent cardiac catheterization that revealed coronary artery disease. He was referred to cardiac surgery for surgical evaluation and underwent preoperative workup. He was then taken to the operating [***] for coronary artery bypass graft surgery, see operative report for further details. He received vancomycin for perioperative antibiotics and was taken to the intensive care unit for postoperative management. In the first twenty four hours he was weaned from sedation, awoke neurologically intact, and was extubated without complications. He continued to do well and was started on beta blockers and this was titrated up for hypertension and techycardia. On the morning of post operative day two he had visual changes which resolved quickly and CT head was negative. Physical therapy saw him for strength and mobility. He continued to progress and was discharged home with VNA on POD 5. All follow-up appointments advised. Medications on Admission: Avodart 0.5mg daily Lipitor 20mg daily flomax 0.4mg daily aspirin 81mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s)* Refills:0 2. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:0 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:30 Capsule, Sust. Release 24 hr(s) Refills:0 5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO twice a day. Disp:90 Tablet Sustained Release 24 hr(s) Refills:2 6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. acetaminophen-codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 8. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Coronary artery disease s/p CABG Dyslipidemia Benign Prostatic hypertrophy migraine headaches colonic adenoma Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema LLE trace, RLE none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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) ] Thursday, [2175-2-2], 1pm Please call to schedule appointments with your Cardiologist: Dr. [Last Name (STitle) 19] in 4 weeks Primary Care Dr [Last Name (STitle) ] [Name (STitle) ] [Telephone/Fax (1) 31019] in [4-25] 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:[2174-12-28]	[ "V17.3", "411.1", "272.4", "511.9", "346.90", "780.62", "414.01", "600.00", "998.12" ]	icd9cm	[ [ [] ] ]	[ "36.15", "37.22", "88.56", "36.12", "39.61" ]	icd9pcs	[ [ [] ] ]	6221, 6296	4002, 5047	344, 580	6450, 6675	2646, 3979	7516, 8046	1821, 1876		5174, 6198		6317, 6429		5073, 5151			6699, 7493									1891, 1891																			273, 306												608, 1547							1905, 2627							1569, 1640	1656, 1805
20,356	120,216	51289	Discharge summary	report	[ ] Date: [2155-9-12] Discharge Date: [2155-9-26] Date of Birth: [2096-2-29] Sex: F Service: MEDICINE Allergies: Milk / Dilantin Attending:[First Name3 (LF) 5827] Chief Complaint: Decreased urine output Major Surgical or Invasive Procedure: Intubated on ventilator briefly History of Present Illness: 59 F with ceftriaxone-sensitive Proteus mirabilis UTIs, L MCA CVA with residual R hemiplegia/aphasia at baseline, DM1, G tube, seizures, was sent from [Hospital ] rehab with decreased UO x 12 hours and Cr 4.1 from baseline 1.0. According to Stonehedge papers, on [9-9], BUN/Cr 88/3.3, Na 128, and urine grew out Proteus mirabilis. She was given 4 L IVF and Ceftriaxone 1 g daily from [9-9] to 9/14m and her foley was changed. On [9-11], her Na 123, K 5.7, Cl 91, HCO3 17, BUN/Cr 94/3.6. Starting on [9-12], she had <200 ml UO in 8 hours, BG 53 increased to 76 after glucagon. Her vitals were BP 112/75, HR 70, 98% RA. She was transferred to [Hospital1 18] for further care. . In the [Hospital1 18] ED, she was hypothermic to 32 C, hypotensive with SBP 80s, V paced at 60, 98% 2L nc, WBC 13, Bands 5. RIJ was placed, pulled back per CXR. CXR negative for infiltrate. Received levo/flagyl/vanco, BNP [Numeric Identifier 7206], lactate 1.4 to 1.9. Could not send a UA in the ED since she was anuric at the time. CT abdomen without contrast was not read by the time the patient was transferred to the MICU. . On MICU [Numeric Identifier ], ABG 7.19/36/99, and patient was intubated, became transiently hypotensive with SBP 70 in response to sedation meds, was given 500 ml NS bolus and started on Levophed which was weaned 30 min later with normotension. Urine output was several drops. EKG showed V pacing 60 resulting in RBBB with no signs of ischemia. . For her recent medical history, she was discharged from [Hospital1 18] in [3-5], went to [Hospital ] Rehab, was transferred to Stonehedge from [Hospital1 ] in mid-[Month (only) 205] for "increased medical needs" per patient's son. She was admitted at [Hospital 882] Hospital [Date range (1) 74679]/07 with ARF and ceftriaxone-sensitive Proteus UTI. Has MRSA, VRE, Cdiff history in [3-4]. Past Medical History: --L sided MCA stroke with aphasia/hemiplegia --Type 1 Diabetes Mellitus w/ h/o DKA and poor compliance --HTN --asthma --dyslipidemia --fibroids --cataracts --adenomatous polyps --CRI --Skin excoriations from itching --VRE, MRSA, Cdiff in [3-4] Social History: Used to live at [Hospital ] rehab until mid [7-5], moved to [Hospital ] rehab. Legal guardian is son [Name (NI) ] (only child), is unmarried. Prior to CVA, one 6 pk beer/wk, no smoking history, no illicit drug history. Family History: Aunt with type 2 diabetes. Her mom had a fatal MI at the age of 54. Her dad had ?COPD. Physical Exam: T 95.6, 110/40, 119, 19, 98% RA GENERAL: Use of accessory muscles to breathe, mildly labored, not speaking, not directing eyes appropriately to name, short height, shield like chest HEENT: Anicteric sclerae, cannot assess JVD because of neck habitus, RIJ TPL LUNGS: Secretions/rhonchi anteriorly HEART: AV paced, RRR, 2/6 SEM, no rub, no g ABDOMEN: Firm, mildly distended, obese, normoactive BS, PEG tube site clean with no erythema EXTR: No c/c/e, 2+DP pulses bilaterally NEURO: Does not follow commands, weak recoil to pain on left side SKIN: Excoriations from scratching and desquamation throughout skin Pertinent Results: [Name (NI) ] Labs: [2155-9-12] 11:29PM TYPE-ART PO2-187* PCO2-36 PH-7.25* TOTAL CO2-17* BASE XS--10 [2155-9-12] 10:29PM GLUCOSE-89 UREA N-95* CREAT-3.8* SODIUM-128* POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-14* ANION GAP-23* [2155-9-12] 10:29PM CALCIUM-7.7* PHOSPHATE-8.1* MAGNESIUM-3.1* [2155-9-12] 10:29PM OSMOLAL-298 [2155-9-12] 10:29PM CORTISOL-30.4* [2155-9-12] 09:55PM CK(CPK)-218* [2155-9-12] 09:55PM CK-MB-12* MB INDX-5.5 cTropnT-0.04* [2155-9-12] 09:55PM CORTISOL-27.6* [2155-9-12] 07:14PM TYPE-ART PO2-217* PCO2-31* PH-7.23* TOTAL CO2-14* BASE XS--13 [2155-9-12] 06:52PM ALT(SGPT)-18 AST(SGOT)-21 LD(LDH)-167 ALK PHOS-82 AMYLASE-21 TOT BILI-0.1 [2155-9-12] 06:52PM LIPASE-10 [2155-9-12] 06:52PM ALBUMIN-2.8* [2155-9-12] 06:52PM CORTISOL-30.1* [2155-9-12] 06:52PM URINE HOURS-RANDOM UREA N-267 CREAT-103 SODIUM-21 POTASSIUM-35 TOT PROT-364 PROT/CREA-3.5* [2155-9-12] 06:52PM URINE OSMOLAL-312 [2155-9-12] 06:52PM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.021 [2155-9-12] 06:52PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2155-9-12] 06:52PM URINE RBC-[6-8]* WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0-2 [2155-9-12] 06:52PM URINE EOS-POSITIVE [2155-9-12] 05:37PM TYPE-ART TEMP-26.7 PO2-518* PCO2-32* PH-7.24* TOTAL CO2-14* BASE XS--12 [2155-9-12] 05:37PM LACTATE-1.1 [2155-9-12] 05:37PM freeCa-1.07* [2155-9-12] 05:22PM GLUCOSE-83 UREA N-96* CREAT-3.8* SODIUM-126* POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-12* ANION GAP-23* [2155-9-12] 05:22PM CALCIUM-7.8* PHOSPHATE-8.1* MAGNESIUM-3.1* [2155-9-12] 05:22PM WBC-11.2* RBC-2.85* HGB-8.4* HCT-25.5* MCV-89 MCH-29.4 MCHC-32.9 RDW-16.0* [2155-9-12] 05:22PM PLT COUNT-306 [2155-9-12] 04:12PM TYPE-ART PO2-99 PCO2-36 PH-7.19* TOTAL CO2-14* BASE XS--13 [2155-9-12] 04:12PM GLUCOSE-115* LACTATE-1.9 NA+-123* K+-4.9 CL--99* [2155-9-12] 04:12PM freeCa-1.12 [2155-9-12] 12:53PM LACTATE-1.5 [2155-9-12] 12:40PM GLUCOSE-59* UREA N-101* CREAT-4.1* SODIUM-125* POTASSIUM-5.1 CHLORIDE-93* TOTAL CO2-15* ANION GAP-22* [2155-9-12] 12:40PM estGFR-Using this [2155-9-12] 12:40PM CK-MB-10 MB INDX-4.3 proBNP-[Numeric Identifier ]* [2155-9-12] 12:40PM CK(CPK)-230* [2155-9-12] 12:40PM cTropnT-0.04* [2155-9-12] 12:40PM CALCIUM-8.5 PHOSPHATE-9.0* MAGNESIUM-3.4* [2155-9-12] 12:40PM WBC-13.1* RBC-2.95* HGB-8.9* HCT-27.0* MCV-91 MCH-30.3 MCHC-33.2 RDW-15.9* [2155-9-12] 12:40PM NEUTS-73* BANDS-5 LYMPHS-11* MONOS-8 EOS-3 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [2155-9-12] 12:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL BURR-OCCASIONAL [2155-9-12] 12:40PM PLT COUNT-352 . Other Labs: PTH 376 Iron 39 Discharge hematocrit 28.1 Discharge creatinine 2.4 Discharge WBC 11.5 Eosinophils upon discharge 15.8 Discharge potassium 4.0 Vit D 1,25 pending . Other: [2155-9-16] 04:08AM BLOOD TSH-3.0 . Studies: US ABD LIMIT, SINGLE ORGAN PORT [2155-9-12] 6:38 PM IMPRESSION: 1. Small amount of pericholecystic fluid. No evidence of acute cholecystitis. 2. Echogenic bilateral renal parenchyma, compatible with medical renal disease. . CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST [2155-9-12] IMPRESSION: 1. Gallbladder distension with pericholecystic fluid, sludge and equivocal stones and mural thickening. Would recommend further evaluation for possible acute cholecystitis by ultrasound or HIDA scan. 2. Generalized anasarca. 3. Bilateral pleural effusions with associated atelectasis; with the air bronchograms that the patient has, cannot rule out basilar pneumonia. 4. Pancreatic calcifications consistent with chronic pancreatitis. 5. No evidence of a large mass, colitis or free air. . ECHO Study Date of [2155-9-13] Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The aortic valve leaflets are mildly thickened with focal calcification of the non-coronary cusp. There is no aortic valve stenosis. Trace 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. Moderate (2+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: No echocardiographic evidence of endocarditis. Focal thickening of non-coronary cusp of aortic valve with trivial aortic regurgitation. Moderate mitral regurgitation. Moderate to severe tricuspid regurgitation. Mild left ventricular hypertrophy with preserved regional and global left ventricular function but evidence of elevated left ventricular filling pressures.. Mild right ventricular dilation with normal systolic function. Moderate pulmonary hypertension. Small pericardial effusion. Compared with the prior study (images reviewed) of [2155-3-7], the severity of mitral and tricuspid regurgitation have increased. The right ventricle now appears mildly dilated. The other findings are similar. . ECG Study Date of [2155-9-22] 8:30:50 AM Baseline artifact. Probable atrial and ventricular sequential pacing. Compared to the prior tracing sinus tachycardia is no longer present. Read by: [Last Name (LF) 2194],[First Name3 (LF) ] H. Intervals Axes Rate PR QRS QT/QTc P QRS T 65 0 156 472/480 0 -72 94 Brief Hospital Course: 59 F rehab patient with ceftriaxone-sensitive Proteus mirabilis UTIs, L MCA CVA with residual R hemiplegia/aphasia at baseline, DM1, G tube, with resolved pna, resolved urosepsis, ongoing ARF from ATN. In the MICU, she was briefly on pressors and intubated intubated in the unit, now off pressers, extubated, and on 2L NC. Her Cr peaked at 4.1. Renal was consulted and felt this was [1-31] ATN/hypoperfusion. Cr has improved to 2.7 without further improvement. LOS +20 L, 2L positive yesterday. Not diuresing well with lasix and metolazone. UO in teens/hr, no post-ATN diuresis. Renal reconsulted, recommending diuril, 160 mg IV lasix. Also, she is s/p vanc/zosyn for urosepsis and subsequently developed peripheral eosinophilia, so she was switched to vanc/meropenem and completed a 10 day course of abx and 7 day course of fluconazole for yeast in her urine. She has had a Hct in the low to mid 20's for most of her MICU stay, but she was transfused 2 units upon transfer to the floor and her HCT remained stable around 30 therafter. . # ATN/acute renal failure: Baseline Cr 2.0 per PCP, [Name10 (NameIs) ] Cr was 4.1. Likely ATN but may have had a component of AIN given eosinophilia. Ulytes show prerenal etiology, renal consult detected many WBC and yeast, no white cell casts, no red cell casts in urine, diagnosed as ATN. Her acute on chronic renal insufficiency was attributed to hypotension associated with sepsis and decreased perfusion of kidneys. Cr rapidly improved with aggressive fluid resuscitation but plateaud around 2.6-2.7. Renal US showed no hydronephrosis. Meds were renally dosed. Renal was reconsulted and diuretics were held while she was on the floor. She likely has very large insensible losses and while she was 20L positive during her first 10 days, she was euvolemic at that point and she continued to be euvolemic for the rest of her stay. Her free water was increased for hypernatremia which resulted in improvement in hypernatremia. Her Cr never improved better than 2.6 for the rest of her stay. . # Urosepsis and Pneumonia: She was intubated on [Name10 (NameIs) ] for pH 7.19. Patient was treated for urosepsis and pneumonia with meropenem and vancomycin. Positive urine culture for Proteus mirabilis on [9-9] at rehab, but urine cultures were negative at [Hospital1 18]. Patient has a history of VRE and MRSA, and since she has DM, broad coverage antibiotics were used. CXR was negative on [Hospital1 ] and thereafter showed small effusions after fluid resuscitation of > 20L, with only very mild fluid overload overall. She was extubated on [9-16] without complication. For alternative infection sources, CT abd without contrast showed cholelithiasis/sludge with 3 mm gallbladder thickening but no cholecystitis, mild ascites. Abd US showed too little ascites to [Month/Year (2) ] for paracentesis, no hydronephrosis, and again cholelithiasis with no cholecystitis. For her complete antibiotic course, she was given Ceftriaxone from [Date range (1) 9846], Levo/Flagyl/Vanc x1 in ED, Zosyn/Vanc Day 1 [9-12]. Due to peripheral hypereosinophilia to maximum 22, zosyn was stopped and changed to Meropenem/Vanc Day 1 [9-16]. Blood cultures, urine cultures were negative, likely since the patient had been treated with Ceftriaxone before [Month/Year (2) ]. . For her pneumonia, sputum culture showed ESBL Klebsiella and pan-resistant Pseudomonas (except to Zosyn). It was undetermined whether this was due to colonization or a true infectious etiology, but the patient continued to clinically improve on antibiotics. She was continued on a total of a 10 day course of antibiotics, which were stopped on [9-22]. She remained afebrile for the rest of her stay . #Skin excoriation: Ms. [Known lastname 106413] was scratching her skin excessively, causing significant excoriation and bleeding. She was given a mitt and restraints. Dermatology was consulted and diagnosed Xerosis Cutis. She was given a 1:1 mixture of eucerin cream and 2.5% hydrocortisone. In addition, she was kept mildly sedated with morphine and Benadryl. When restraints were released, her mitt was enough to keep her from doing any more physical damage to her skin. . # Hypertension: On the floor she was moderately well controlled on labetalol 400mg PO bid. Her SBP was noted to be in the 170s, so her labetalol was titrated to 300mg PO tid. This resulted in brief SBP in the 90's, so her labetalol was titrated back to 400mg PO bid and she was discharged on that dose. . # Gap metabolic acidosis: Patient had a gap metabolic acidosis on [Known lastname ] that resolved by discharge, likely due to uremia and lactic acidosis. Urine was negative for glucose and ketones. . # DM1: Patient has a history of DKA episodes, is insulin-dependent. It was unknown at what age DM started. She was maintained on insulin sliding scale with good control of BG. . # Anemia: Baseline Hct 25, attributed to anemia of chronic disease. Patient received several RBC transfusions to maintain Hct in setting of fluid resuscitation. She has a history of guaiac positive stools, but her stools were guaiac negative during [Known lastname ]. Her Hct stabilized at 29-30 for the last 5 days of her stay. . # Left MCA CVA [12-4] with residual R hemiparesis/aphasia at baseline: Her home regimen includes ASA, statin, and oxcarbazepine for seizure prophylaxis. She was maintained on half dose oxcarbazepine per Neuro recommendations since this medication is partly metabolized renally. . # Asthma: She is not on a steroid inhaler at baseline. Albuterol and atrovent inhalers were administered during pneumonia, but were not needed after pneumonia resolved. . # Nutrition: She was on TF Glucerna 60 ml/hr at rehab, was assessed by Nutrition as being mildly overfed, and was maintained on TF Glucerna 25 ml/hr during [Year (2 digits) ]. . # Prophylaxis: She was maintained on PPI, heparin sc TID, and a bowel regimen. . # Code status: Full, discussed multiple times with son [Name (NI) ], who states that he had multiple extensive conversations with his mother regarding code status. According to [Doctor First Name ], she stated her wish before her CVA in [12-4] that if she was not able to speak for herself, that she wished to be kept full code even if she is to be chronically vented or in a chronically debilitated or vegetative state. Medications on [Date Range ]: Lantus 14 units daily Glucerna 65 ml/hr continuous Norvasc 10 mg daily Clonidine 0.1 mg [Hospital1 ] Avapro 75 mg daily Labetalol 400 mg [Hospital1 ] Isosorbide DN 90 TID Loratadine 10 daily Ranitidine 75 [Hospital1 ] Simvastatin 40 daily ASA 81 daily Oxcarbazepine 900 QAM, 600 [Hospital1 ] Iron 220 mg daily Senna Colace Lactulose Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: Two (2) PO BID (2 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection TID (3 times a day). 6. Ranitidine HCl 150 mg Tablet [Hospital1 ]: 0.5 Tablet PO BID (2 times a day). 7. White Petrolatum-Mineral Oil Cream [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 8. Hydrocortisone 2.5 % Cream [Hospital1 ]: One (1) Appl Rectal [Hospital1 ] (2 times a day). 9. Metronidazole 500 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day): Continue until [2155-10-7]. 10. Lactulose 10 g/15 mL Syrup [Month/Day/Year ]: Thirty (30) ML PO TID (3 times a day) as needed. 11. Ipratropium Bromide 0.02 % Solution [Month/Day/Year ]: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [Month/Day/Year ]: One (1) Inhalation Q6H (every 6 hours) as needed. 13. Diphenhydramine HCl 25 mg Capsule [Month/Day/Year ]: One (1) Capsule PO Q6H (every 6 hours) as needed. 14. Morphine 10 mg/5 mL Solution [Month/Day/Year ]: One (1) PO q6hr:prn as needed. 15. Oxcarbazepine 300 mg Tablet [Month/Day/Year ]: One (1) Tablet PO BID (2 times a day). 16. insulin Please see attached sheet for directions on fixed dose and sliding scale coverage. 17. Oxcarbazepine 300 mg Tablet [Month/Day/Year ]: 1.5 Tablets PO QAM (once a day (in the morning)). 18. Quetiapine 25 mg Tablet [Month/Day/Year ]: 0.5 Tablet PO BID (2 times a day) as needed. 19. Labetalol 200 mg Tablet [Month/Day/Year ]: Two (2) Tablet PO BID (2 times a day). 20. Outpatient Lab Work Please check chem10 and CBC with differential 2 times per week. Discharge Disposition: Extended Care Facility: [Hospital6 4657] - [Location 1268] Discharge Diagnosis: Primary: --L sided MCA stroke with aphasia/hemiplegia --ARF - ATN +/- AIN --xerosis cutis . Secondary: --Type 1 Diabetes Mellitus w/ h/o DKA and poor compliance --HTN --asthma --dyslipidemia --fibroids --cataracts --adenomatous polyps --CRI --Skin excoriations from itching --VRE, MRSA, Cdiff in [3-4] Discharge Condition: hemodynamically and medically stable Discharge Instructions: 59 F with ceftriaxone-sensitive Proteus mirabilis UTIs, L MCA CVA with residual R hemiplegia/aphasia at baseline, DM1, G tube, seizures, was sent from [Hospital ] rehab with decreased UO x 12 hours and Cr 4.1 from baseline 1.0. According to Stonehedge papers, on [9-9], BUN/Cr 88/3.3, Na 128, and urine grew out Proteus mirabilis. She was given 4 L IVF and Ceftriaxone 1 g daily from [9-9] to 9/14m and her foley was changed. On [9-11], her Na 123, K 5.7, Cl 91, HCO3 17, BUN/Cr 94/3.6. Starting on [9-12], she had <200 ml UO in 8 hours, BG 53 increased to 76 after glucagon. Her vitals were BP 112/75, HR 70, 98% RA. She was transferred to [Hospital1 18] for further care. . In the [Hospital1 18] ED, she was hypothermic to 32 C, hypotensive with SBP 80s, V paced at 60, 98% 2L nc, WBC 13, Bands 5. RIJ was placed, pulled back per CXR. CXR negative for infiltrate. Received levo/flagyl/vanco, BNP [Numeric Identifier 7206], lactate 1.4 to 1.9. Could not send a UA in the ED since she was anuric at the time. CT abdomen without contrast was not read by the time the patient was transferred to the MICU. . On MICU [Numeric Identifier ], ABG 7.19/36/99, and patient was intubated, became transiently hypotensive with SBP 70 in response to sedation meds, was given 500 ml NS bolus and started on Levophed which was weaned 30 min later with normotension. Urine output was several drops. EKG showed V pacing 60 resulting in RBBB with no signs of ischemia. . She finished her course of antibiotics. She was found to have C-diff and started on flagyl. Her renal failure remained stable and she was given free water and D5W for her hypernatremia, which resolved by the day of discharge. . She should have labwork twice weekly to assess her creatinine, sodium, hematocrit, and eosinophilia, and electrolytes (chem10 and CBC with differential). . She will be continued on flagyl until [2155-10-7]. She will need subQ heparin. . She scratches if she the mitt is taken off. She seems to have improved with 1:1 mixture of eucerin cream and 2.5% Hydrocortisone. Morphine and diphenhydramine helped with this too. Followup Instructions: Please follow up with her primary care provider.	[ "438.20", "V58.67", "995.92", "919.8", "518.81", "038.43", "585.9", "706.8", "397.0", "695.89", "577.1", "584.5", "789.5", "424.0", "038.9", "574.20", "V15.81", "250.01", "V18.0", "426.4", "V55.1", "112.2", "403.90", "288.3", "493.90", "486", "707.04", "285.29", "438.11", "458.9", "276.2" ]	icd9cm	[ [ [] ] ]	[ "93.96", "99.04", "96.6", "96.04", "96.71", "38.91", "38.93", "99.21" ]	icd9pcs	[ [ [] ] ]	18401, 18470	9509, 16306	297, 330	18820, 18859	3539, 6430	21050, 21102	2808, 2897		16329, 18378		18491, 18799					18883, 21027									2912, 3520																			235, 259												358, 2268														2290, 2540	2556, 2792			6442, 9486
81,100	197,268	8830	Discharge summary	report	Admission Date: [2164-1-3] Discharge Date: [2164-1-11] Date of Birth: [2115-10-10] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2164-1-3] Emergency coronary artery bypass graft x4, left internal mammary artery to left anterior descending artery and saphenous vein graft to diagonal artery and saphenous vein sequential graft to posterior left ventricular branch and posterior descending arteries. Endoscopic harvesting of the long saphenous vein. History of Present Illness: 48 year old male who was in his usual state of health until [1-1] when he developed acute onset of substernal chest pain which radiated to arms followed by tonic-clonic seizure. After his seizure he continued with chest heaviness. He was admitted to MWMC had a persantine nuclear perfusion scan. Cardiac enzymes flat. Subsequent catheteriztion [1-3] revealed coronary artery disease and he had chest pain and received SL NTG x 2 which dropped his SBP to 80's. He was transferred to [Hospital1 18] for emergent surgery Past Medical History: Coronary artery disease s/p CABG Multiple sclerosis Seizure disorder Coronary artery disease s/p RCA stent Hyperlipidemia Amnesia/memory disorder Chronic headaches Bilateral knee surgeries x 5 Social History: Lives with: Wife [Name (NI) 1139]: previously smoked [1-15] ppd Quit [2159] ETOH:Denies Walks with cane Family History: Mother died of heart disease in 50's s/p CABG Physical Exam: Pulse:74 Resp:17 O2 sat: 99% B/P Right: Left: 93/61 per A line Height: 5'[64]" Weight: 149 General:AAO x 3 in 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 Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact, slight right hand weakness Pulses: Femoral Right:right sheath in place Left: 2+ DP Right:2+ Left:2+ PT [Name (NI) 167]:2+ Left:2+ Radial Right:2+ Left:2+ Pertinent Results: [2164-1-9] 06:35AM BLOOD WBC-7.2 RBC-3.91* Hgb-11.4* Hct-32.9* MCV-84 MCH-29.2 MCHC-34.6 RDW-13.8 Plt Ct-432 [2164-1-3] 02:00PM BLOOD WBC-3.5# RBC-3.65 Hgb-10.8* Hct-30.3* MCV-83 MCH-29.6 MCHC-35.7* RDW-13.1 Plt Ct-263 [2164-1-9] 06:35AM BLOOD Plt Ct-432 [2164-1-3] 02:00PM BLOOD PT-15.3* PTT-150* INR(PT)-1.3* [2164-1-3] 05:52PM BLOOD PT-15.0* PTT-26.2 INR(PT)-1.3* [2164-1-9] 06:35AM BLOOD Glucose-112* UreaN-14 Creat-0.7 Na-140 K-3.9 Cl-105 HCO3-26 AnGap-13 [2164-1-3] 02:00PM BLOOD Glucose-160* UreaN-12 Creat-0.6 Na-140 K-3.4 Cl-108 HCO3-22 AnGap-13 [2164-1-3] 02:00PM BLOOD ALT-27 AST-18 AlkPhos-46 Amylase-38 TotBili-0.2 [2164-1-3] 02:00PM BLOOD Lipase-21 [2164-1-8] 06:30AM BLOOD Mg-2.2 [2164-1-3] 02:00PM BLOOD Calcium-8.0* Phos-3.0 Mg-1.8 [2164-1-3] 02:00PM BLOOD %HbA1c-6.0* eAG-126* [2164-1-3] 09:26PM BLOOD Phenyto-6.0* CHEST RADIOGRAPH INDICATION: Status post CABG, evaluation for pleural effusion. COMPARISON: [2164-1-5]. FINDINGS: The frontal radiograph appears normal, except for a moderate elevation of the left hemidiaphragm. On the lateral radiograph, bilateral small pleural effusions are visible. Status post CABG. No focal parenchymal opacity suggesting pneumonia. Minimal retrocardiac atelectasis. No pulmonary edema. Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Peak Pulm Vein S: 0.6 m/s Left Atrium - Peak Pulm Vein D: 0.4 m/s Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Ascending: 3.2 cm <= 3.4 cm Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 3 mm Hg < 20 mm Hg Findings LEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+] TR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions Prebypass No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. Dr. [Last Name (STitle) ] was notified in person of the results on [2164-1-3] at 1530 hours. Post bypass Patient is AV paced and receiving an infusion of phenylephrine. Very poor views on TEE at the mid esophagus. Transgastric views shows normal LV function. Aorta appears intact post decannulation. Brief Hospital Course: Transferred in from outside hospital with chest pain and brought emergently to the operating room on [1-3] for coronary artery bypass graft surgery, see operative report for further details. He received cefazolin for perioperative antibiotics and was transferred to the intensive care unit for postoperative management. In the first twenty four hours he was weaned from sedation, awoke neurologically at baseline, and was extubated without complications. On post operative day one he was started on betablockers and diuretics. He continued to do well and was transferred to the floor for the remainder of his stay. Physical therapy was consulted to assist with strength and mobility. Occupational therapy was consulted for evaluation. He was transfused with packed red blood cells for post operative anemia. He continued to progress and was ready for discharge post operative day seven to [Hospital3 ] in [Location (un) 1294]. Medications on Admission: Lofibra 200 daily ASA 325 daily Aricept 10 daily Niacin daily Namenda 10 mg [Hospital1 ] Dilantin 400 daily (missed doses x past 4 days) Crestor 20 mg daily Vesicare 5 mg daily Detrol LA 4 mg daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. phenytoin sodium extended 200 mg Capsule Sig: Two (2) Capsule PO once a day. Disp:60 Capsule(s) Refills:0 4. donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain . Disp:70 Tablet(s) Refills:0 8. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gram PO DAILY (Daily). Disp:qs qs Refills:0 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Tablet(s) 10. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 11. Lofibra 200 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 12. Namenda 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 13. solifenacin 5 mg Tablet Sig: One (1) Tablet PO once a day. 14. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Coronary artery disease s/p CABG Multiple sclerosis Seizure disorder Hyperlipidemia Amnesia/memory disorder Chronic headaches Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage. Edema none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [First Name (STitle) ] [Telephone/Fax (1) 170] Monday [2-6] at 1:30 pm Cardiologist: Dr [Last Name (STitle) 5874] [Telephone/Fax (1) 3658] [2-2] 2:00 pm Please call to schedule appointments with your Primary Care Dr [Last Name (STitle) 27187] in [4-18] weeks [Telephone/Fax (1) 3658] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2164-1-10]	[ "V45.82", "272.4", "411.1", "784.0", "345.90", "340", "414.01", "285.1" ]	icd9cm	[ [ [] ] ]	[ "36.13", "36.15", "39.61" ]	icd9pcs	[ [ [] ] ]	8610, 8684	5925, 6869	320, 645	8854, 9074	2306, 5902	9915, 10582	1578, 1626		7122, 8587		8705, 8833		6895, 7099			9098, 9892									1641, 2287																			270, 282												673, 1210														1232, 1428	1444, 1562

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