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80,254	134,373	37954	Discharge summary	report	Admission Date: [2165-8-20] Discharge Date: [2165-8-23] Service: MEDICINE Allergies: Lomefloxacin Attending:[First Name3 (LF) 106] Chief Complaint: VT storm Major Surgical or Invasive Procedure: Ventricular tachycardia ablation History of Present Illness: 85 year old man with chronic AF on coumadin, hypertension, non-ischemic cardiomyopathy with LVEF 30%, s/p BiV ICD, hx of VT with recent admission to CCH [2165-7-28] with VT storm s/p amio load presented to OSH on [2165-8-12] after his telemed monitor noted a HR of 130. At the OSH he converted spontaneously to a paced rhythm. He was continued on Amio as he had intermittent bursts of VT - always asymptomatic and hemodynamically stable while in VT. Seen by Dr. [Last Name (STitle) 19911] on that admission and ICD was reprogrammed with antitachycardia pacing at 115-150bpm without shock, 150-200 low dose shock, and thereafter high dose shock. He had an episode of acute systolic heart failure treated successfully with diuresis on this admission as well. He was then discharged home. Over the weekend he remained asymptomatic and then on [2165-8-20] he felt light-headed and felt his ICD fire X 2. He called EMS who recorded initially Vtach with a pulse although intermittently was paced as well. He denied chest pain, palpitations, syncope, SOB. He received valium for anxiety and was transferred to CCH. In the ER at CCH, he was having runs of NSVT from 15-20 beats per minute. He was seen by cardiology who recommended transfer to [Hospital1 18] for VT ablation. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia (+) Hypertension (+) 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: Non-ischemic CM with [Company 1543] ICD on [2-17] with upgrade to A-lead on [9-19] with upgrade to [Hospital1 ]-V ICD in [10-23]. Generator change [2162]. Trial of amio for recurrent VT with shocks [8-20]. Stopped Amio in [2159]. 3. OTHER PAST MEDICAL HISTORY: Chronic AFib Non-ischemic CM with EF 30% Hypothyroidism after Amio use in the past Left total hip replacement Diverticulosis Gout Social History: Married. lives with his wife. Non-[Name2 (NI) 1818], non-drinker. Family History: Non-contributory Physical Exam: VS: T=97.8 BP=96/56 HR= 130s->70s RR=16O2 sat= 97% 3L NC GENERAL: WDWN M in NAD. Sleeping but arousable. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no elevation of JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. Groin site bandaged without evidence of oozing PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Pertinent Results: Labs on admission: [2165-8-20] 11:15PM BLOOD WBC-10.1 RBC-3.61* Hgb-11.2* Hct-35.9* MCV-99* MCH-31.1 MCHC-31.3 RDW-15.3 Plt Ct-161 [2165-8-21] 05:07AM BLOOD PT-17.0* PTT-29.8 INR(PT)-1.5* [2165-8-20] 11:15PM BLOOD Glucose-124* UreaN-64* Creat-2.0* Na-139 K-5.2* Cl-109* HCO3-21* AnGap-14 [2165-8-20] 11:15PM BLOOD Calcium-8.9 Phos-3.0 Mg-2.6 . Labs on discharge: [2165-8-23] 07:30AM BLOOD WBC-9.6 RBC-3.42* Hgb-10.7* Hct-34.4* MCV-100* MCH-31.2 MCHC-31.1 RDW-15.9* Plt Ct-175 [2165-8-23] 07:30AM BLOOD Neuts-77.5* Lymphs-12.1* Monos-6.1 Eos-3.7 Baso-0.5 [2165-8-23] 07:30AM BLOOD Plt Ct-175 [2165-8-23] 07:30AM BLOOD Glucose-113* UreaN-67* Creat-2.1* Na-137 K-5.0 Cl-104 HCO3-25 AnGap-13 [2165-8-23] 07:30AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.4 [2165-8-22] 04:07AM BLOOD TSH-7.2* [2165-8-23] 08:19AM BLOOD QUINIDINE-PND . Brief Hospital Course: 85 year old man with history of non-ischemic cardiomyopathy with EF 30% and recurrent VT despite Amiodarone treatment in past admitted post-VT ablation to CMI service now transferred to CCU with sustained VT and hypotension. . # RHYTHM: Patient with VT s/p ablation procedure, who experienced VT of different morphology post-ablation. Per EP, the patient's original VT was likely ablated, unmasking another focus of VT. Prior to transfer to CCU patient was in sustained VT not responsive to anti-tachycardia pacing from his ICD X 6 trials. In the CCU, he was successfully V-paced and initially treated with amiodarone. Quinidine gluconate was added with good rhythm control, and serial ECGs showed no signifant prolongation of QTc. In addition, his coreg was switched to metoprolol and he was continued on his home dose of coumadin with close monitoring of INRs. . # HYPOTENSION: Initially felt to be medication induced as the patient had received multiple blood pressure medications along with lasix prior to CCU transfer. Hypotension initially persisted after the patient was converted to a paced rhythm. BP medications and lasix were intially held, and the hypotension resolved. The patient remained asymptomatic throughout with no orthostasis, dizziness, or chest pain. . # CORONARIES: The patient has no known history of CAD. Troponins were negative X 1 at OSH ED. He was continued on home dose of enalapril, and coreg changed to metoprolol as above. . # PUMP: The patient has a history of non-ischemic cardiomyopathy and systolic heart failure with TTE showing an LVEF of 30%. He was continued on home dose of enalapril and lasix, coreg changed to metoprolol as above. . #. Chronic Renal insufficiency: Cr 1.9-2.1, which is his baseline per OSH records. All medications were renally dosed and his creatinine was monitored daily while inpatient. . # Hypothyroidism: Continued on home dose synthroid. . # Gout: Continued on home dose allopurinol. . # FEN/GI: Low sodium / Heart healthy, Diabetic/Consistent Carbohydrate Diet. Bowel regimen with senna and colace. . # CODE: Full Code. Medications on Admission: Amiodarone 400mg [Hospital1 ] Coreg 12.5mg [Hospital1 ] Enalapril 10mg daily Lasix 40mg daily MVI Magnate Synthroid 100mg Daily Warfarin Allopurinol 100mg daily Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 2. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Take one full tablet 2 times per week and [12-21] tablet 5 times per week. . Disp:30 Tablet(s) Refills:2 3. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release(s) Refills:2 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Outpatient Lab Work Check PT/INR on [First Name8 (NamePattern2) 1017] [8-25] and call results to Dr. [Last Name (STitle) 14890] at [Telephone/Fax (1) 84818] Discharge Disposition: Home With Service Facility: VNA Assoc. of [Hospital3 ] Discharge Diagnosis: Ventricular tachycardia Acute on chronic Systolic congestive Heart Failure Non-ischemic Cardiomyopathy Discharge Condition: Stable. Quinidine level pnd. INR 2.4. Discharge Instructions: You were transferred for a procedure called ventricular tachycardia ablation. Two new medicines were started to control the ventricular tachycardia. Activity restrictions as per discharge instructions. Please watch your groin areas for any signs of bleeding, swelling or redness. . Contact Dr [Last Name (STitle) 14890] if you have symptoms of cheat pain, shortness of breath, if you receive a shock, dizziness, nausea or concerns about healing at the groin site. Coumadin has been restarted. Please have a coumadin level (INR) done on [First Name8 (NamePattern2) 1017] [8-25] with results to Dr. [Last Name (STitle) 14890]. A Qunidine level was sent and is pending at the time of your discharge. Dr. [Last Name (STitle) ] will be able to look up the result. . Medication changes: 1. Start Quinidine gluconate twice daily to prevent irregular ventricular tachycardia. 2. STOP your Carvedilol 3. START Metoprolol to prevent ventricular tachycardia 4. Restart your coumadin at your previous dose . Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet. Fluid Restriction 1500 ml daily Followup Instructions: Cardiology: Dr [Last Name (STitle) 14890] Phone:([Telephone/Fax (1) 84819] Date/time: Please keep any regularly scheduled appts. Primary Care: [Last Name (LF) ],[First Name3 (LF) ] F Phone: [Telephone/Fax (1) 30879] Date/time: Please keep any regularly scheduled appts. Electrophysiology: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]/[First Name8 (NamePattern2) 33718] [Last Name (NamePattern1) 36055] NP[MD Number(3) 708]: ([Telephone/Fax (1) 84819] Date/time: [8-30] at 3:30pm	[ "427.1", "458.9", "274.9", "244.9", "427.31", "403.90", "425.4", "V58.61", "428.0", "428.23", "V43.64", "585.9" ]	icd9cm	[ [ [] ] ]	[ "37.34" ]	icd9pcs	[ [ [] ] ]	7254, 7315	3826, 5925	228, 263	7462, 7502	2938, 2943	8730, 9283	2269, 2287		6145, 7231		7336, 7441		5951, 6122			7526, 8307								2302, 2919		1682, 2002																			8327, 8707	180, 190					3317, 3803						291, 1581									2957, 3298				2033, 2165				1603, 1662	2182, 2253
63,992	149,191	38884	Discharge summary	report	Admission Date: [2169-5-15] Discharge Date: [2169-6-15] Date of Birth: [2113-6-7] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 32612] Chief Complaint: Colocutaneous fistula Major Surgical or Invasive Procedure: [2169-5-18]: PICC line placement . [2169-5-31]: 1. Exploratory laparotomy. 2. Complex lysis of adhesions, exploration of the right colon with drainage of mesenteric micro perforation. 3. Irrigation and drainage of the colocutaneous fistula. 4. Diverting loop ileostomy. History of Present Illness: 55M with recent diagnosis of gastric cancer who underwent a total gastrectomy with J-tube placement on [2169-4-5]. His post-operative course was complicated by a splenic artery pseudoaneurysm (which was coiled) and an infected perisplenic hematoma which failed non-operative management (IR drained twice on [4-16] and [4-30]) and ultimately required open drainage in the OR on [2169-5-8]. He was discharged to rehab on [2169-5-12] with a wound vac over his left abdominal wound. He returns from rehab today as he was noted to have stool output through his wound vac. It was removed and replaced with an ostomy appliance and has been collecting stool. Of note, a possible fistula between the descending colon and the inferior portion of the fluid collection was seen on [2169-5-5] CT scan (prior to the open drainage procedure). A fistulogram was obtained to further assess but did not show evidence of communication with the fistula. Past Medical History: PMH: BPH, hemorrhoids PSH: Total gastrectomy, feeding J tube [2169-4-5], drainage left flank abscess [2169-5-8] Social History: He has never smoked, and does not drink alcohol. He works as a cook, and lives in an extended family with his son. Was previously at rehab after recent hospitalization. Family History: His family history is unrevealing for any history of carcinoma, he has 3 brothers and 1 sister all in good health. Physical Exam: Upon discharge: VS: 98.5, 90, 100/70, 12, 99% RA GEN: NAD CV: RRR RESP: Deminished bilaterally ABD: Midline abdominal incision open to air with steri strip and healed well. Stoma with appliances in RLQ, pink, 1 [1-4]" x 1 [1-2]" oval, proximal limb center, mucocutaneous junction intact, and peristomal skin intact. LLQ fistula site with minimal amount of yellow pasty stool, covered with DSD. Left to medial J-tube patent and site c/d/i. EXTR: RUE PICC line, dressing c/d/i Pertinent Results: MICROBIOLOGY: [2169-5-17] 3:50 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Final [2169-5-23]): NO GROWTH. [2169-5-15] 2:00 pm BLOOD CULTURE Blood Culture, Routine (Final [2169-5-21]): NO GROWTH. [2169-5-20] 8:30 pm SWAB Source: right port site- subQ collection. GRAM STAIN (Final [2169-5-21]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Preliminary): [Doctor First Name 86292] ([Numeric Identifier 85953]) REQUESTED Piperacillin/Tazobactam SENSITIVITIES [2169-5-23]. KLEBSIELLA OXYTOCA. MODERATE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. ESCHERICHIA COLI. MODERATE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA \| ESCHERICHIA COLI \| \| AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R =>32 R CEFAZOLIN------------- =>64 R =>64 R CEFEPIME-------------- <=1 S 2 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- 4 R 16 R CIPROFLOXACIN---------<=0.25 S 0.5 S GENTAMICIN------------ <=1 S =>16 R MEROPENEM-------------<=0.25 S <=0.25 S TOBRAMYCIN------------ <=1 S 8 I TRIMETHOPRIM/SULFA---- <=1 S =>16 R ANAEROBIC CULTURE (Preliminary): [2169-6-2] 8:24 pm FLUID,OTHER Source: JP fluid. GRAM STAIN (Final [2169-6-2]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): ENTEROCOCCUS SP.. SPARSE GROWTH. WORK UP PER DR.[Last Name (STitle) 86293] #[Numeric Identifier 86294] [2169-6-4]. Daptomycin SENSITIVITY REQUESTED BY DR. [Last Name (STitle) 86293] [2169-6-5] 9-5788. SENT TO [Hospital3 ] FOR DAPTOMYCIN SENSITIVITIES. NON-SUSCEPTIBLE TO DAPTOMYCIN MIC = 128MCG/ML, SENSITIVITY [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ]. SPARSE GROWTH. ID PER DR.[First Name (STitle) 8021],S #[Numeric Identifier 8022] [2169-6-5]. SENT TO [Hospital3 ] FOR FLUCONAZOLE TESTING. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R [2169-6-5] 11:28 am CATHETER TIP-IV Source: RIJ. WOUND CULTURE (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies. [2169-6-5] 9:50 am STOOL CONSISTENCY: WATERY FINAL REPORT [2169-6-5] C. difficile DNA amplification assay (Final [2169-6-5]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). DIAGNOSTICS: [2169-5-22]: CT A/P: 1. Multiple previously visualized rim-enhancing fluid collections have resolved. Only two collections persist and are at the site of the jejuno-jejunostomy site with one measuring 1.8 x 1.2 cm and the other measuring 1.7 x 0.6 cm. 2. Extensive decrease in size of previously visualized bilobed perisplenic hematoma with a drain which appears in place. The more inferior portion of this collection now measures 8.7 x 2.2 cm compared to 13.2 x 6.6 cm previously. 3. Previously visualized hematoma in the left lateral abdominal wall appears decreased in size and this area appears open to air. 4.Persistent small left pleural effusion with adjacent air space atelectasis. [2169-5-30] CT ABD: IMPRESSION: 1. New collection of extraluminal gas and/or stool in association with marked edema involving a segment of hepatic flexure of colon, with pericolic stranding. Findings are worrisome for a necrotic portion of bowel or a perforation of bowel. 2. Small bowel distention with transition to smaller caliber bowel within the right lower quadrant. Findings may represent early small-bowel obstruction versus ileus. 3. Slight increase in size of the perisplenic air and fluid collection along the track since the interval removal of the surgically placed catheter. 4. Numerous hypodensities throughout the liver previously characterized on MR [First Name (Titles) 3] [Last Name (Titles) 83432]. [2169-5-31] ECG: Baseline artifact. Probable sinus tachycardia. Marked vertical axis. Low limb lead voltage. ST-T wave abnormalities. Since the previous tracing of [2169-5-26] the axis is more leftward at a much faster rate. ST-T wave abnormalities are new. Clinical correlation is suggested. [2169-6-1] ECG: Sinus tachycardia. Leftward axis. Borderline low voltage. Since the previous tracing of [2169-5-31] the rate is slower. Otherwise, probably unchanged. [2169-6-6] ECHO: The left atrium is normal in size. 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. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. [2169-6-13] 04:56AM BLOOD WBC-7.8 RBC-3.51* Hgb-10.0* Hct-31.1* MCV-89 MCH-28.3 MCHC-32.0 RDW-16.5* Plt Ct-840* [2169-6-13] 04:56AM BLOOD Glucose-112* UreaN-16 Creat-0.4* Na-135 K-4.4 Cl-101 HCO3-26 AnGap-12 Brief Hospital Course: The patient was admitted to the Surgical Oncology Service for evaluation and treatment of his colocutaneous fistula. The patient was managed conservatively with IV antibiotics (Vanc, Zosyn), and his fistula fitted with an ostomy appliance. The patient continue to be febrile, with high fistula output. On [5-18], PICC line was placed and patient was started on TPN for bowel rest. On [5-20], fistula output started to downward, patient still spiking fever. CT abdomen on [5-22] revealed decrease in size of previously visualized bilobed perisplenic hematoma. The patient was continued on IV antibiotics per ID, TPN and IV fluids. On [5-30] patient reported increased abdominal pain and CT scan was obtained. CT demonstrated new collection of extraluminal gas and/or stool in association with marked edema involving a segment of hepatic flexure of colon, with pericolic stranding, which were worrisome for a necrotic portion of bowel or a perforation of bowel. On [5-31] patient went in OR, the patient underwent exploratory laparotomy, complex lysis of adhesions, exploration of the right colon with drainage of mesenteric micro perforation, irrigation and drainage of the colocutaneous fistula and diverting loop ileostomy, which went well without complication (reader referred to the Operative Note for details). Post operatively patient was transferred in ICU, intubated secondary for hypotension and persistent tachycardia. He received 1 unit of RBC and 750 mg of albumin, the patient was hemodynamically stable. [6-1]: worsening tachycardia (ST to 150-160) and hypotension, fever spike (102), given 1L fluid bolus, neo gtt restarted, repeat Hct sent (27->24), given 1 unit PRBCs; neo gtt able to be weaned [6-2]: Persistent tachycardia (120s) Received 500ml albumin & 1u pRBC w/o change in heart rate. [6-3]: Persistent tachy (100's), received 5mg metoprolol IV. Went for B/L LE ultrasounds that were neg for DVT but noticed complex loculated fluid collections within the lower abdomen, surgery notified but do not want further workup at this time as this may be post-surgical changes. [6-4]: off pressors, + flatus, stool in ostomy, hemodynamically stable [6-5]: SQH restarted, stool sent for c diff, TEE ordered to evaluate for vegetation per ID, and was negative for valvular vegetations. [6-6]: Transferred to the floor in stable condition. Fluconazole was changed to Micafungin to treat [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ]. [6-7]: Afebrile, fiber added to the tube feed secondary to persistent diarrhea. Stool negative for C-diff. [6-8]: Stable, screened for Rehab [6-15]: Discharged in Rehab By system: Neuro: The patient received PO oxycodone with good effect and adequate pain control. Though very limited in fluency in English, he was able to communicate in his native language and remained alert, oriented to person, place and time. Post op patient was started on Dilaudid PCA, which was weaned off. The patient was transitioned to PO Dilaudid. CV: In his previous hospitalization, the patient was noted to be borderline tachycardic to the low 100s with stable systolic blood pressures. This was managed with IV Lopressor, and was thought to be related to his underlying infectious process. His heart rate would intermittently spike to 140s, remaining in sinus rhythm, when ambulating, which would eventually settle back to his baseline. Post op, patient was persistently tachycardic with HR and hypotensive, he required short period of neo gtt. The patient's hypotension was treated with pRBC, albumin and fluid boluses. The hypotension and HR returned to [Location 213] baseline. Prior discharge, patient was started on PO Lopressor. He remained hemodynamically stable throughout; vital signs were routinely monitored. Pulmonary: He was found to have a stable left-sided pleural effusion on CT scan with no evidence of loculation or pneumonia. The patient otherwise remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially placed NPO due to his noted stool output from his left flank wound, which previously was suspicious for a fistula but was found not to be so on fistulogram during his previous hospitalization. A colocutaneous fistula in this area was present on initial CT when he re-presented on [2169-5-15]. He was fitted with an ostomy appliance, and provided TPN given his decreased oral intake. The TPN was weaned off on [6-7] as fistula output subsided, and patient was started on tube feeds. The ostomy nurses were follow the patient for both fistula appliance change and new ileostomy teaching/change. The patient also was maintained on a regular diet, he able to tolerate small PO intake only. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. He did not develop a leukocytosis, with a stable WBC between [5-8]. He intermittently spiked temperatures to 102F with negative urine and blood cultures. His wound culture, however, was noted to grow Klebsiella and E coli which were resistant to Zosyn, which was discontinued;he was previously discharged on daptomycin and Zosyn for known VRE in his abdominal collections, and this was modified to include these antibiotics as well as Flagyl per ID recommendations. The ID followed the patient during hospitalization, his current list of antibiotics included Ciprofloxacin, Flagyl and Daptomycin. He received Fluconazole for positive [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) ] infection, which was changed to Micafungin on [6-7]. The VRE sensitivity test came back resistant to Daptomycin and antibiotic was discontinued. ID was re consulted and secondary to low fistula output and good clinical picture, patient was discharged on Flagyl, Cipro and Micafungin. He will follow up with ID as outpatient. His most recent blood and stool cultures were negative prior to discharge. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly in both his sliding scale and through his TPN. Hematology: The patient received total 3 units of pRBC during this admission for low HCT level and hypotension. The patient also received 2 units of plasma and 6 vials of albumin during hospitalization. Prior discharge patient's HCT was stable within 30-31 range. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was stable, afebrile with stable vital signs. The patient was tolerating some intake of a regular diet with Tube feeds supplementation, ambulating with some assistance, voiding without assistance, and pain was well controlled with oral agents. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Medications at rehabiliation: metoprolol 2.5Q6, zosyn, daptomycin, doxazosin 8', trazodone 25', tylenol, percocet, zofran Discharge Medications: 1. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 2. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for fever. 3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. Cepacol Sore Throat 15-4 mg Lozenge Sig: One (1) Mucous membrane prn as needed for throat pain/discomfort. 5. cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day). 6. Ondansetron 4 mg IV Q8H:PRN nausea 7. Micafungin 100 mg IV Q24H 8. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 9. loperamide 2 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 12. hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4 hours) as needed for pain. 13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: 1. Colocutaneous fistula 2. Infected infected hematoma 3. Right colonoc perforation 4. Tachycardia 5. Hypotension 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 a fistula between your skin and colon, which was managed conservatively with an ostomy appliance and changed regularly. CT scan on [5-30] was suspicious for bowel perforation and you were taken in OR for exploratory laparotomy and diverting loop ileostomy. You have done well in the post operative period and are now safe to be discharge in Rehab to complete your recovery with the following instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. . PICC Line: Please monitor the site regularly, and [Name6 (MD) 138] your MD, nurse practitioner, or [Name6 (MD) 269] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. [Name6 (MD) ] your MD [First Name (Titles) ] [Last Name (Titles) 10836] to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry. Contact your [Name2 (NI) 269] Nurse if the dressing comes undone or is significantly soiled for further instructions. . Monitoring Ostomy output/Prevention of Dehydration: Keep well hydrated. Replace fluid loss from ostomy daily. Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. Try to maintain ostomy output between 1000mL to 1500mL per day. If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Change ostomy appliances every 72 hours or as needed. . J-tube: Flush with 30 cc of tap water before and after every use. Monitor for signs and symptoms of infection, dislocation. . LUQ fistula care: Change dressing daily and prn, wash incision with warm water and pat dry prior dressing change. Monitor for signs and symptoms of infection; fever, redness, bad odor. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2169-6-22] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: SURGICAL SPECIALTIES When: FRIDAY [2169-6-23] at 3:15 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 79168], MD [Telephone/Fax (1) 274] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: OSTOMY/[Hospital ] CLINIC When: FRIDAY [2169-6-23] at 3:15 PM With: WOUND/OSTOMY NURSE [Telephone/Fax (1) 23664] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . DEPARTMENT: Infectious diseases When: [2169-6-26] 09:30a With: [Last Name (LF) ],[Name8 (MD) ] MD Where: [Hospital Unit Name ], BASEMENT Completed by:[2169-6-15]	[ "995.91", "038.9", "998.6", "V45.75", "E878.8", "998.12", "285.9", "458.29", "998.59", "568.0", "286.7", "511.9", "V10.04", "998.2" ]	icd9cm	[ [ [] ] ]	[ "96.6", "99.15", "54.59", "45.03", "96.71", "46.01", "38.93" ]	icd9pcs	[ [ [] ] ]	17453, 17524	8938, 16214	325, 605	17682, 17682	2581, 3039	20599, 21701	1945, 2062		16387, 17430		17545, 17661		16240, 16364			17833, 18710					18725, 20576			2077, 2077																						264, 287			5520, 8915							2093, 2562	633, 1598										4266, 4441	17697, 17809						1620, 1742	1758, 1929		4476, 5485
62,345	100,292	37763	Discharge summary	report	Admission Date: [2122-9-16] Discharge Date: [2122-9-25] Date of Birth: [2056-8-21] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 398] Chief Complaint: Transfer from OSH with fevers, back pain, and pathologic evidence of Sweet Syndrome Major Surgical or Invasive Procedure: Intubation and mechanical ventilation Bone marrow biopsy Central venous line placement History of Present Illness: (Primary historians: wife & daughter): 66 y/o male with lung cancer s/p RUL lobectomy, back pain w/ spondylolisthesis, s/p lumbar laminectomes x2, initially admitted to OSH with back pain, now transferred to [Hospital1 18] with fevers, leukocytosis, and delirium. . Patient was in his usual state of health until mid-[8-11]-2 weeks after returning to [State 350] from [State 8842]. He initially complained of acute onset R lower back pain that started after leaning over quickly. He went to see his chiropractor. Pain worsened and developed L sided back pain as well. Also with + constipation and LE weakness. Around this same time, the patient started developing a productive cough and fevers. . He presented to [Hospital ] Hospital on [9-2]. Initially alert and oriented x 3, but noted to "say odd things". He was febrile to 101 in the ED, and was intermittently confused. MRI back showed L5-S1 central disc protrusion without mass effect or abnormal enhancement. CT of the head showed diffuse mild cerebral atrophy with no evidence of intracranial hemorrhage. MRI with and without contrast showed no evidence for meningitis and no enhancing mass lesion. Neurosurgery was consulted and felt no intervention needed based on lumbar imaging. ID consulted, and felt the patient had no clear signs of infection, aside from fevers, so antibiotics have been generally held. Neurology assessment was to assess the patient for viral illness, including viral meningitis, less likely paraneoplastic disorder. Lumbar puncture was attempted x 4, with records indicating that one attempt may have yielded venous blood. Acyclovir was temporarily started and then d/c'd when LP fluid was negative for HSV PCR. Heme/onc consulted for leukocytosis, bone marrow aspirate revealed myelodysplasia with no evidence of leukemia. Chromosomal and cytogenetic studies were sent. . Required ICU stay for angioedema of tongue with rash of neck and cheek. He did not require intubation, and the angioedema resolved with dexamethasone. He developed nodules on his face and neck; biopsies revealed neutrophilic dermatosis, c/w Sweet Syndrome (acute febrile neutrophilic dermatosis. . Found to be hypercalcemic with low albumin levels and ionized calcium of 1.61 on day prior to transfer. PTHrP and PTH were sent with Vitamin D studies. These were pending at the time of transfer. . Timeline: [9-3]: Tmax 102. LP under fluoro - ?was this venous blood per dc summary. Acyclovir. [9-4]: Tmax 102.7. Joint arthrocentesis of ? - culture neg and crystals neg. [9-5]: Tmax 102.2. [9-6]: Tmax 102.6. WBCs 18.2K. skin biopsy with neutrophilic dermatosis (Sweet). AFB negative. Started IV decadron 6mg Q6H. Vanco and ceftriaxone started. [9-7]: Tmax 99.2. Antibiotics stopped. [9-8]: afebrile. BMBx performed - aspirate c/w myelodysplasia, no leukemia. [9-11]: decadron decreased to 3 mg Q8H. Tmax 101.9. WBC 20.5K. [9-12]: Tmax 102.2 [9-13]: Tmax [9-14]: Tmax 101.4. WBC 34.8K. [9-15]: Tmax 100.8. WBC 33.1K. Ca [23].9/alb 2 (corrected 13.8) ionized 1.61. Received pamidronate IV 60 mg. PTH and PTHrP pending. . Review of sytems: (+) Per HPI; feels clammy. Wife believes the patient has been hallucinating and seeing people that aren't in the room. When asked who is in the room with him, the patient states "just my family." (-) Deniesheadache, sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Lung ca, unknown path, s/p RUL lobectomy 6 years ago - Chronic back pain s/p back surgery x 2 for disc herniation - Hyperlipidemia - s/p L TKR Social History: Recently quit smoking. No EtOH. Lives in [State 8842] with wife. Former [Name2 (NI) ] welder Family History: Mother died of unknown cancer, potentially GI. Grandmother had DM. Physical Exam: Vitals: T:96.5 BP:98/64 P:84 R:20 O2:92% RA General: Caucasian well nourished male in NAD, but with unclear mental status. HEENT: Mildly icteric conjunctivae. MMM without OP exudate or hyperemia. No appreciable JVD. Sclera anicteric, MMM, oropharynx clear. PERRLA 3 mm -> 2mm. Lungs: Dry crackles at bilateral lung bases. No wet crackles or wheeze. Good inspiratory effort. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: softly distended, non-tender, bowel sounds present, no rebound tenderness or guarding, no organomegaly. No pulsatile masses. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. No asterixis. Skin: Scattered small telangiectasias over face Neuro: Speech is halting, with long pauses mid-sentence. Able to repeat three words immediately but cannot recall at one minute. Oriented to person and time ("Football season"), and oriented to "hospital" but does not know city. Cranial nerves II-XII grossly intact. No nystagmus. Motor: 5/5 strength upper/lower extrems proximally & distally. Sensation: Grossly intact to touch, pinprick. DTR: 2+ biceps/brachoradialis/patellar reflexes bilaterally. Coordination: Intact finger-to-nose test. Gait: Deferred. Pertinent Results: Admission labs: [2122-9-16] 09:00PM BLOOD WBC-38.9* RBC-3.58* Hgb-11.6* Hct-35.5* MCV-99* MCH-32.4* MCHC-32.6 RDW-15.4 Plt Ct-180 [2122-9-16] 09:00PM BLOOD Neuts-65 Bands-4 Lymphs-8* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-8* Promyel-2* [2122-9-16] 09:00PM BLOOD PT-14.4* PTT-27.3 INR(PT)-1.3* [2122-9-16] 09:00PM BLOOD ESR-124* [2122-9-16] 09:00PM BLOOD Glucose-145* UreaN-41* Creat-1.1 Na-136 K-4.3 Cl-103 HCO3-26 AnGap-11 [2122-9-16] 09:00PM BLOOD ALT-47* AST-26 LD(LDH)-600* AlkPhos-186* TotBili-0.7 [2122-9-17] 08:40AM BLOOD Lipase-25 [2122-9-16] 09:00PM BLOOD TotProt-5.9* Albumin-2.6* Globuln-3.3 Calcium-12.1* Phos-3.7 Mg-2.6 [2122-9-16] 09:00PM BLOOD PTH-106* [2122-9-16] 09:00PM BLOOD TSH-0.27 [2122-9-16] 09:00PM BLOOD CRP-GREATER TH [2122-9-16] 09:00PM BLOOD ASA-NEG Ethanol-NEG Bnzodzp-NEG Barbitr-NEG [2122-9-17] 09:03AM BLOOD freeCa-1.54* ------------ [2122-9-16] Chest X-ray: FINDINGS: Lung volumes are low, and apical lordotic projection and portable technique also contribute to an accentuation of the cardiomediastinal contours. Patchy opacities are present at both lung bases, and may reflect atelectasis in the setting of low lung volumes. Differential diagnosis includes aspiration and early infectious pneumonia. Followup PA and lateral radiographs are suggested when the patient's condition permits. ----------- CSF: Cytology-NEGATIVE FOR MALIGNANT CELLS. [2122-9-17] 02:31PM CEREBROSPINAL FLUID (CSF) WBC-288 HCT,Fl-5.5* Polys-60 Lymphs-33 Monos-4 Other-3 [2122-9-17] 02:31PM CEREBROSPINAL FLUID (CSF) TotProt-363* Glucose-76 --------------- [2122-9-17] CT Head: No evidence of acute hemorrhage [2122-9-17] CT Abdomen/Pelvis: 1. No evidence of spinal or paraspinal abscess. Note that if concern exists for focal discitis or osteomyelitis, MR would be the more sensitive modality for evaluation. 2. Nodularity of the pancreas and left adrenal gland. Given history of previous lung malignancy, metastatic disease is the primary consideration at the pancreas. Additionally, though the adrenal nodule is statistically likely an adenoma, metastatic disease must be considered. Ongoing followup is recommended with repeat CT within 6 months, or with comparison to prior imaging. 3. Large bilateral consolidations in the lower lobes bilaterally. Given the history of fever and cough reported on the previous chest radiograph, these are concerning for infectious pneumonia. Nevertheless underlying mass is not excluded. Followup to resolution is recommended. 4. Large mediastinal lymphadenopathy as detailed above. 5. Numerous healing left lateral rib fractures as well as deformity in the right sixth rib, presumably post-surgical. ---------------- [2122-9-18] EEG: This is an abnormal routine EEG due to reduced voltage, slowing, and disorganization of the background rhythm. These findings are suggestive of a mild to moderate encephalopathy involving both cortical and subcortical structures. Medications, toxic/metabolic disturbances, and infection are among the most common causes. There were no areas of prominent focal slowing although encephalopathies can obscure focal findings. There were no clearly epileptiform features. --------------- [2122-9-18] Echo: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. Trace aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Limited study. No significant aortic or mitral regurgitation seen. Grossly preserved biventricular systolic function Brief Hospital Course: # Fevers: Transferred from outside hospital with pathologic diagnosis of Sweet's Syndrome, based on skin biopsy and persistent fevers/leukocytosis. The patient was febrile from his first day on the floor. Initial infectious workup including blood and urine cultures was unrevealing. Stable infiltrate opacities on OSH CXR may represent PNA, especially in setting of productive cough. CT of the chest revealed large bilateral consolidations, and the patient was started on broad antibiotic coverage for hospital acquired pneumonia, including vancomycin and ceftriaxone. The patient underwent lumbar puncture with IR guidance, which yielded ~15 cc of bloody CSF. Initial gram stain on the CSF revealed gram negative rods, and ampicillin was added for potential listeria meningitis, in the event that the gram negative rods reported on gram stain were actually gram variable. The CSF gram stain findings were subsequently changed from gram negative rods to "no organisms." Infectious disease was consulted prior to the above CT findings, and initially recommended holding antibiotic therapy, as well as sending a number of serologic infectious studies (HSV PCR in CSF, VZV PCR, West [Doctor First Name ] PCR, Eastern Equine Encephalitis PCR, enteroviral PCR, mycoplasma PCR, VDRL per ID). He was treated with broad spectrum antibiotics that were eventually tapered to doxycyline. The patient underwnet TTE, to evaluate for fever of unknown origin. No vegetations were noted. Rheumatology was also consulted, and they recommended tapering the patient's dexamethasone, as the patient's fevers were clearly not responding to the steroid treatments. He also underwent bone marrow biopsy; pathology is pending. # Mental status changes/Delirium: The patient was clearly confused and disoriented, which--per the family's report--was strikingly different from his baseline cognition/personality. Potential etiologies were thought to include infectious (meningoencephalitis, abscess or non-CNS infection), metabolic/endocrine (hypercalcemia), renal failure/uremia, hepatic encephalopathy, or persistently febrile state. It was thought unlikely to be hydrocephalus or brain metastases from unknown primary (hx of lung CA), given reportedly normal OSH imaging. Toxicology screens were negative. Liver function tests were benign. EEG revealed mild to moderate encephalopathy involving both cortical and subcortical structures, without epileptiform features. The patient's mental status seemed to wax and wane somewhat in proportion to his fevers; he would be more engaged and responsive to questioning when afebrile. # Leukocytosis: The patient had reportedly undergone bone marrow aspiration at the OSH, with findings consistent with myelodysplastic syndrome. His WBC count increased rapidly to 47,000. Hematology/oncology was consulted and performed another bone marrow aspiration to further assess the leukocytosis. Marrow analysis is pending. # Hypercalcemia: Calcium was highly elevated at OSH, where he received pamidronate treatment prior to transfer. On arrival initial calcium levels were measured at 12.1, with an albumin of 2.6. PTH levels were elevated at 106. PTHrP was sent off to an outside lab. His calcium trended downwards after receiving pamidronate. Endocrine was following and suspect primary hyperparathyroidism. . # Hypotension: Per patient's family, he has never had difficulty with high or low blood pressures, and was not on home anti-hypertensives. He had had very limited PO intake over the 2-3 weeks prior to admission. He was initially placed on maintenance IV fluids, and subsequently had the rate of infusion increased. He transiently required vasopressors while in the unit. . # History of carcinoid syndrome: His lung cancer was found to be carcinod. Endocrine was consulted and felt his symptoms were unlikely to be carcinoid-mediated. Chromogranin A and 5-HIAA were sent and are pending. . # HIT: His HIT antibody returned positive and he was started on Argatroban. SRA was sent and is pending. LENIs were negative for clot. . # Respiratory failure: Patient required intubation on [9-19]. This was due to ARDS; he was initiated on ARDSnet ventilation. He had difficultly oxygenating and required high PEEPs directed by balloon. . # Mediastinal lymphadenopathy: Unclear etiology. Patient was not stable enough for biopsy. . Patient acutely decompensated on morning of [9-25]. Patient was made CMO by family. He died that day. Autopsy is pending. Medications on Admission: UPON TRANSFER FROM OSH - omeprazole 20 mg daily - nystatin susp QID - heparin SQ 5000 TID - bisacodyl 10 mg daily - ibuprofen 600 mg QID prn - acetaminophen rectal 650 mg Q6H prn - NS at 75 cc/hr - dexamethasone 3 mg IV Q8H Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Primary: Fevers of unknown origin Concern for MDS Hypoxemia respiratory failure Acute Respiratory Distress Syndrome Acute renal failure Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A	[ "272.4", "518.81", "577.9", "255.9", "V10.11", "584.9", "780.60", "799.02", "274.00", "458.9", "289.84", "785.6", "252.00", "695.89", "486", "238.75" ]	icd9cm	[ [ [] ] ]	[ "96.72", "41.31", "38.93", "03.31", "96.04", "33.24" ]	icd9pcs	[ [ [] ] ]	14411, 14420	9611, 14109	359, 447	14600, 14609	5779, 5779	14661, 14667	4456, 4525		14383, 14388		14441, 14579		14135, 14360			14633, 14638								4540, 5760																						235, 321						3660, 4152					475, 3642			7441, 9588			5796, 7432											4174, 4321	4337, 4440
41,638	113,770	19495	Discharge summary	report	Admission Date: [2199-2-1] Discharge Date: [2199-2-9] Date of Birth: [2146-4-2] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2534] Chief Complaint: S/P Laparoscopic appendectomy presents with LLQ pain and abdominal distension. Major Surgical or Invasive Procedure: Sigmoid colectomy and sigmoid colostomy and Hartmann's procedure, drainage of retroperitoneal and peritoneal abscesses. History of Present Illness: Patient is a 52 yo male s/p laparoscopic appencedtomy [2199-1-25]. Patient with abdominal pain in the left lower quadrant and abdominal distension. He was transferred to [Hospital1 18] one week post op for further evaluation and treatment. CT scan reveals perforated sigmoid colon and retroperitoneal intraperitoneal abscess. Past Medical History: PMH: Prostate CA Hyperlipidemia CAD s/p cath HTN GERD Social History: No tobacco, daily ETOH, married, lives with family Family History: non contributory Physical Exam: Temp 98.5 HR 84 BP 121/76 RR 20 O2 sat 98% RA Exam: Gen: NAD, Awake, alert Ox3 CVS: RRR S1& S2 Lungs: CTA BL Abd: Soft, greatly distended, hypertympanic, Tender LLQ,no guarding or rebound Ext: No edema Pertinent Results: [2199-2-1] 09:45PM WBC-14.8* RBC-3.99* HGB-12.2* HCT-34.0* MCV-85 MCH-30.6 MCHC-35.9* RDW-12.9 [2199-2-1] 09:45PM NEUTS-81.8* LYMPHS-10.6* MONOS-4.6 EOS-2.2 BASOS-0.8 [2199-2-1] 09:45PM PLT COUNT-386 [2199-2-1] 09:45PM PT-13.4 PTT-34.4 INR(PT)-1.1 [2199-2-1] 09:45PM CALCIUM-7.8* PHOSPHATE-4.3 MAGNESIUM-2.5 [2199-2-1] 09:45PM GLUCOSE-115* UREA N-23* CREAT-0.8 SODIUM-136 POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-27 ANION GAP-16 [2199-2-2] 7:20 pm SWAB PERITONEAL FLUID CULTURE. FINAL REPORT [2199-2-6] GRAM STAIN (Final [2199-2-2]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN SHORT CHAINS. WOUND CULTURE (Final [2199-2-6]): A swab is not the optimal specimen collection to evaluate body fluids. Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. Work-up of organism(s) listed below discontinued (excepted screened organisms) due to the presence of mixed bacterial flora detected after further incubation. ESCHERICHIA COLI. SPARSE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. ENTEROCOCCUS SP.. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| ENTEROCOCCUS SP. \| \| AMPICILLIN------------ <=2 S =>32 R AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S LINEZOLID------------- 2 S MEROPENEM-------------<=0.25 S PENICILLIN G---------- =>64 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final [2199-2-6]): NO ANAEROBES ISOLATED. [2199-2-2] CT Abdomen/pelvis : Findings compatible with perforated viscus with likely source at the sigmoid colon/descending colon junction. At this junction, a fluid collection measuring up to 6.6 cm, containing air, enteric contrast and fluid is demonstrated. This collection tracks and involves to the retroperitoneum anterior to the psoas muscle where another discrete collection is demonstrated measuring up to 6.7 cm in its greatest dimension (SI). A third discrete collection is demonstrated within the lateral intraperitoneal cavity (series 2, image 48) measuring up to 4.9 cm in its greatest dimension (AP). Extensive associated pneumoretroperitoneum tracking to dissecting to involve the mediastinum. There is also a moderate amount of pneumoperitoneum. Brief Hospital Course: Patient is a 52 yo male s/p laparoscopic appendectomy at an OSH on [2199-1-25]. Patient's post operative course was complicated by SOB, abdominal distension, and LLQ pain. Patient with pain in his LLQ that is constant and worsens with movement. Patient was kept in the hospital and placed on TPN and IV ABX. Patient with no nausea or vomiting. No fevers or chills. Patient having bowel movements and passing flatus. He was transferred to [Hospital1 18] for further evaluation and management. Patient with repeat CT scan showing perforated sigmoid colon and retroperitoneal intraperitoneal abscess. He underwent a sigmoid colectomy and sigmoid colostomy and Hartmann's procedure, drainage of retroperitoneal and peritoneal abscesses on [2199-2-2]. Post operatively patient sent to the ICU intubated. He had a PCA for pain. He was extubated on [2-3]. He remained NPO/LR with an NGT to low continuous wall suction. Foley is in place with adequate urine output. He stayed on Cipro/Flagyl x 10 days for peritonitis and intra/RP abscesses. He was transferred to a regular nursing floor on [2198-2-4]. Culture grew VRE, and in consultation with ID, he was started on linezolid. Following transfer to the Surgical floor he continued to make good progress. As his bowel function returned his nasogastric tube was removed and he began a liquid diet which was gradually advanced to regular and tolerated well. He was seen on a regular basis by the ostomy nurse for general care and teaching and was slowly understanding the necessary treatments although he did wax and wane in his ability to care for the ostomy. Prior to discharge, he did demonstrate adequate understanding and ability to care for the ostomy. Medications on Admission: Amlodipine Besylate 10 mg QD Metoprolol Succinate ER 75 mg QD Hydrochlorothiazide 25 mg QD Quinapril 40 mg QD Aspirin 81 mg QD Citalopram HBR 10 mg QHS Simvastatin 40 mg QHS Alprazolam 0.5 mg PRN Claritan 10 mg PRN Famotidine 20 mg PRN Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). 4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. citalopram 20 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)): STOP taking this medication and do not restart until 2 weeks after finishing linezolid. 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours as needed for pain. 9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): thru [2199-2-12]. Disp:11 Tablet(s) Refills:0 10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): thru/[2199-2-12]. Disp:7 Tablet(s) Refills:0 11. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Perforated sigmoid colon retroperitoneal intraperitoneal abscess. 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 abdominal pain from a hole in your sigmoid colon. Surgery was done which entailed a temporary colostomy. Hopefully when the inflammation resolves and you have lost some weight (30-40 pounds), you can have the colostomy reversed, probably not for 3-4 months. It is very important that you start a weight loss program after you have recovered from this operation. * Your incision is healing from the inside out therefore you will need to have dressing changes daily while it heals. You will also need to continue to learn how to care for your colostomy. The VNA will be able to help you with that. Please take the three antibiotics as prescribed. The linezolid has been pre-approved by your insurance company. If there are any issues, the approval number is #[Numeric Identifier 52931]. The linezolid can interact with citalopram (Celexa), so STOP taking citalopram, and do not restart it until 2 weeks after finishing the linezolid. 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 [4-30] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Continue packing wound daily with saline damp gauze followed by a dressing on top. Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. Monitoring Ostomy output/Prevention of Dehydration: Keep well hydrated. Replace fluid loss from ostomy daily. Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. Continue all of your instructions from the Ostomy nurse. Followup Instructions: Call the Acute Care Clinic at [Telephone/Fax (1) 600] for a follow up appointment in 2 weeks. Call Dr. [Last Name (STitle) ] for an appointment in [2-22] weeks to help with a safe weight loss program.	[ "V45.79", "562.11", "567.22", "V09.81", "272.4", "530.81", "V55.1", "041.04", "567.38", "V10.46", "414.01", "401.9" ]	icd9cm	[ [ [] ] ]	[ "46.03", "96.6", "38.93", "45.75" ]	icd9pcs	[ [ [] ] ]	7663, 7719	4484, 6222	379, 501	7829, 7829	1295, 4461	11189, 11406	1029, 1047		6509, 7640		7740, 7808		6248, 6486			7980, 10424					10439, 11166			1062, 1276																						261, 341											529, 867											7844, 7956						889, 945	961, 1013
6,526	184,677	44612	Discharge summary	report	Admission Date: [2155-1-1] Discharge Date: [2155-1-9] Date of Birth: [2080-3-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 689] Chief Complaint: ARF, Hypernatremia, Altered MS Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 74 y/o m w h/o prostate ca s/p radical prostatectomy, h/o DVTs, ICH, htn recently admitted for decreased uop p/w n/v/diarrhea for past several days at rehab facility, and new altered MS, found to be in ARF in ED, with Cr. 2.2, Na 158. He was recently admitted [Date range (1) 58794] for episodes of diaphoresis, decreased urine output, and ARF with a Cr 2.5, which improved with IVF. He was also treated with 5 days of azithromycin at this time for concern of R hilar PNA on CXR and leukocytosis. . According to his wife he began having nausea and vomiting over the weekend at the rehab and seemed slightly drowsy on Monday but was oriented and communicating fully. Since Monday he has progressed to only intermittently responding to questions with yes/no answers, and he began having diarrhea in addition to nausea/vomiting. Prior to his last admission he was walking unassisted with a spastic gait, however he was bedridden during this last admission and since being at rehab had only progressed to getting into a wheelchair. . In the ED he was also noted to have an amylase 666 and lipase 733, with a noraml T bili. He was not noted to have any clear evidence of abdominal pain. His CT abd showed cholelithiasis without evidence of cholecystitis, and some evidence of proctitis, with concern for infectious proctitis, but no other intra-abdominal pathology. His head CT was negative for bleed or CVA, CXR showed improvement in R perihilar PNA, but his U/A was grossly positive. He was given vanc/levo/flagyl to cover broadly for the possibility of infection and UTI. He has remained hemodynamically stable with HR 60s in afib, and BP 120/70s. Past Medical History: 1) prostate CA s/p radical prostatectomy with lymph node dissection [2143] - incontinent at baseline - urinary retention, s/p urethral thrombus removed during cystoscopy [8-/2154] 2) bilateral DVT, s/p IVC filter [8-/2153] 3) C3-C7 spinal stenosis 4) pinned L. wrist 5) cerebral bleed [8-4] 6) HTN 7) depression 8) Newly diagnosed atrial fibrillation Social History: Lives with wife. [Name (NI) 3003] pipe smoker X 40 yrs ago, quit [2138]. No alcohol or other drug use. Family History: FmHx: non-contrib. Physical Exam: Exam: T 97.5 HR 62 afib BP 122/70 RR 16 sat 97% RA gen: lethargic, rousable to sternal rub, mostly unresponsive to questions but at times answers yes/no to simple questions HEENT: mmdry, no JVD CV: irreg irreg [1-6] sys m at apex pulm: CTAb ant abd: soft, unclear if slight [Name (NI) 25714] TTP, no guarding/rebound +BS ext: 1+ edema [Name (NI) ] to knee, trace RLE edema rectal: trace guaiac positive Pertinent Results: Labs: noted for Cr 2.2, Na 153 (down from 158 at presentation), amylase 666, lipase 733, See below . EKG: afib at 62/nml axis, int/ TWF in III and aVF (old)/no ST changes . CXR: Interval improvement in right perihilar consolidation . Head CT: negative . Abd CT: 1. Opacities at the left lung base are concerning for aspiration or pneumonia. 2. Thickening of the rectum which could be secondary to prior radiation therapy. If the patient has not had radiation, this could represent an infectious proctitis. 3. Small amount of pelvic free fluid. 4. Bilateral renal cysts. 5. Cholelithiasis without evidence of cholecystitis. [2155-1-1] 10:00PM UREA N-40* CREAT-1.7* SODIUM-150* POTASSIUM-4.0 CHLORIDE-121* TOTAL CO2-21* ANION GAP-12 [2155-1-1] 10:00PM MAGNESIUM-1.7 [2155-1-1] 04:48PM UREA N-39* CREAT-1.6* SODIUM-144 POTASSIUM-3.6 CHLORIDE-116* TOTAL CO2-20* ANION GAP-12 [2155-1-1] 04:48PM cTropnT-0.10* [2155-1-1] 02:51PM LACTATE-1.2 [2155-1-1] 12:22PM URINE HOURS-RANDOM UREA N-683 CREAT-81 SODIUM-26 [2155-1-1] 12:22PM URINE OSMOLAL-463 [2155-1-1] 12:22PM URINE EOS-POSITIVE [2155-1-1] 05:44AM GLUCOSE-102 UREA N-48* CREAT-1.9* SODIUM-147* POTASSIUM-4.8 CHLORIDE-115* TOTAL CO2-19* ANION GAP-18 [2155-1-1] 05:44AM ALT(SGPT)-52* AST(SGOT)-37 LD(LDH)-324* ALK PHOS-68 AMYLASE-325* TOT BILI-0.3 [2155-1-1] 05:44AM LIPASE-160* [2155-1-1] 05:44AM ALBUMIN-3.1* CALCIUM-8.9 PHOSPHATE-4.1 MAGNESIUM-2.0 [2155-1-1] 05:44AM WBC-12.5* RBC-3.11* HGB-9.5* HCT-28.9* MCV-93 MCH-30.5 MCHC-32.8 RDW-14.7 [2155-1-1] 05:44AM NEUTS-86* BANDS-0 LYMPHS-8* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2155-1-1] 05:44AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ ACANTHOCY-OCCASIONAL [2155-1-1] 05:44AM PT-33.0* PTT-37.7* INR(PT)-3.6* [2155-1-1] 05:44AM PLT COUNT-177 [2155-1-1] 04:13AM LACTATE-1.3 [2155-1-1] 04:13AM TYPE-ART PO2-110* PCO2-39 PH-7.36 TOTAL CO2-23 BASE XS--2 INTUBATED-NOT INTUBA [2155-1-1] 04:13AM O2 SAT-97 [2155-1-1] 03:05AM PO2-113* PCO2-38 PH-7.39 TOTAL CO2-24 BASE XS--1 INTUBATED-NOT INTUBA [2155-1-1] 03:05AM GLUCOSE-104 LACTATE-1.5 NA+-150* K+-4.6 CL--116* [2155-1-1] 03:05AM HGB-9.1* calcHCT-27 [2155-1-1] 03:05AM freeCa-1.26 [2154-12-31] 08:30PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.015 [2154-12-31] 08:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [2154-12-31] 08:30PM URINE RBC->50 WBC-[5-10]* BACTERIA-MOD YEAST-NONE EPI-0-2 [2154-12-31] 08:30PM URINE HYALINE-0-2 [2154-12-31] 08:13PM PH-7.33* [2154-12-31] 08:13PM GLUCOSE-114* LACTATE-1.4 NA+-153* K+-4.7 CL--114* TCO2-22 [2154-12-31] 07:00PM GLUCOSE-112* UREA N-54* CREAT-2.2* SODIUM-155* POTASSIUM-4.6 CHLORIDE-118* TOTAL CO2-23 ANION GAP-19 [2154-12-31] 07:00PM ALT(SGPT)-65* AST(SGOT)-40 CK(CPK)-136 ALK PHOS-86 AMYLASE-666* TOT BILI-0.2 [2154-12-31] 07:00PM LIPASE-733* [2154-12-31] 07:00PM WBC-11.5# RBC-3.41 HGB-10.9* HCT-31.6* MCV-93 MCH-32.0 MCHC-34.5 RDW-14.3 [2154-12-31] 07:00PM NEUTS-87* BANDS-3 LYMPHS-6* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2154-12-31] 07:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL ELLIPTOCY-1+ [2154-12-31] 07:00PM PLT SMR-NORMAL PLT COUNT-204 [2154-12-31] 07:00PM PT-26.5* PTT-31.9 INR(PT)-2.7* Brief Hospital Course: 1. UE weakness: The patient has a history of cervical stenosis that resulted in diffuse weakness in the past. On his last d/c, the patient was unable to walk or feed himself and returned from rehab in much the same condition. He was evaluated by neurology who felt that his weakness was likely [1-2] cervical stenosis seen on MRI and mild cord enhancement below this level. He was evaluated by ortho-spine who did not recommend acute surgical intervention and felt that he would be best served by a soft cervical collar and intensive PT. He was d/c to [Hospital 81068] rehab. . 2. Hypernatremia: Pt was hypernatremic on admission to the [Hospital Unit Name 153] and his urine osms/lytes were checked. He was repleted with 1/2 NS and his sodium corrected quickly with this regimen . 3. Altered MS: The patient was disoriented w/ AMS on admission. He was covered broadly w/ zosyn/vanco/flagyl in the [Hospital Unit Name 153] but these were stopped on the floor as his cultures returned negative. His hypernatremia was corrected as above and his mental status improved with this therapy. By the time he was called out to the floor, he was mentating normally and was AAO x3. . 4. ARF: His ARF on admission was attributed to his dehydration and he was fluid repleted as above. His dehydration was corrected w/ IVF as above and his renal failure corrected with IVF. He had a renal U/S that showed no evidence of hydronephrosis. His ace-i was initially held [1-2] this ARF but this was added back on as his failure corrected. . 5. GI: The patient had an elevation of his pancreatic enzymes on admission. RUQ u/s showed no CBD dilation but did show retained stones in the GB. His enzymes trended downwards throughout his admission and the patient was not interested in surgical evaluation for his cholelithiasis. . 6. CV: The patient has a history of afib and is anticoagulated as an outpatient. HIs INR was supratherapeutic on admission and his coumadin was held [1-2] this. It was added back as his INR trended downwards. His HTN was treated with metoprolol and lisinopril . 7. Heme: The patient has a hx of DVTs s/p IVC filter. His coumadin was handled as above. Medications on Admission: 1. Metoprolol Tartrate 12.5 mg PO BID 2. Sertraline 25 mg PO DAILY (Daily). 3. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID 4. Bethanechol Chloride 25 mg Tablet Sig: Two (2) Tablet PO TID 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg PO BID 7. Senna 8.6 mg Tablet PO BID as needed. 8. Lisinopril 10 mg PO once a day. 9. UROXATRAL 10 mg Tablet Sustained Release 24HR PO once a day. 10. Multi-Vitamin Tablet PO once a day. 11. Lidocaine 5 %(700 mg/patch) Topical DAILY (Daily). 12. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets 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 Q24H (every 24 hours). 14. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 15. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Coumadin as needed for goal INR [1-3]. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 2. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Bethanechol Chloride 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): please have your INR checked twice a week and titrate your INR to between [1-3]. 15. Baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day. Capsule(s) Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Sepsis, cervical spinal stenosis, AMS, pancreatitis, afib, DVT, Disconditioning, ARF Discharge Condition: Fair- not able to feed himself, unable to walk without assistance. Upper extremities are contracted. Discharge Instructions: PLease take all medications as prescribed. Please keep your follow-up appointments Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] by calling [Telephone/Fax (1) 693] once your are discharged from rehab Please have your INR followed twice a week while in rehab	[ "584.9", "577.0", "574.20", "V10.46", "276.0", "285.29", "427.31", "401.9", "721.1", "276.51", "V58.61", "496" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11358, 11437	6624, 8823	344, 351	11566, 11670	3058, 3292	11802, 11991	2572, 2593		9865, 11335		11458, 11545		8849, 9842			11694, 11779								2608, 3039																						273, 306											379, 2036					3301, 6601												2058, 2427	2443, 2556
18,673	142,361	26387	Discharge summary	report	Admission Date: [2132-3-3] Discharge Date: [2132-3-7] Date of Birth: [2058-10-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4760] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: BIPAP History of Present Illness: 73 y/o woman with Diabetes, Chronic obstructive pulmmonary disease on home o2 and bipap, complicated by multiple admissions for dyspnea and altered mental status, is admitted to the [Hospital Unit Name 153] from the emergency department where she was brought by EMS after being found with altered mental status and low peripheral blood oxygenation. . She was most recently admitted from [Date range (1) 65265] where her Bipap titration was increased from 14/10 to 16/12. She was also started on lisinopril and had her oxycodone discontinued during that admission. . In the Emergency Department, they confirmed SaO2 of 80s on room air, and she was placed on a non-rebreather. An ABG performed on the non-rebreater was 7.25/95/195. The patient was confirmed DNR/DNI but per her daughter she has done well on BiPap in the past. Bipap was initiated in the ED. A LLL consolidation was noted on chest Xray and she was given levofloxacin and ceftriaxone. . Further history and review of systems is obtained from her daughter, who was at the patients bedside. She reports the patient feeling ill for the last several days, with increased coughing, weakness, and confusion. Her daugher notes she was not delusional (as she can be), but more delerious, not knowing what a remote control was, or stating that she was in the water when she was not. Her daughter also reports that she has been lying in bed, fatigued, and has had difficulty getting up. At baseline, she in fact lives alone with 3x/day help and can ambulate and occasionally cook something. She has been unable to do these things of late. . Due to increased cough, she was started on levofloxacin by her pcp [Last Name (NamePattern4) ] [2132-3-1]. Past Medical History: 1. CAD: s/p 4-vessel CABG [2119] 2. CHF: ECHO [1-3] w/ 1+ MR, minimal AS, EF 40% w/ regional wall motion abnormalities 3. DM Type 2 4. HTN 5. COPD: on home O2 3.5L/m, BIPAP (settings 14/10) with multiple past admissions w/ pCO2 in the 70-80 range 6. Schizophrenia: initially symptomatic w/ paranoia and hallucinations, well controlled w/ meds 7. L3 fracture: [2127] 8. Symptomatic VT: s/p ICD in [1-2] 9. Hypothyroidism Social History: lives alone in [Hospital3 ] apartment; has home health aide daily; meals are prepared by the pt's daughter; walks independently but sometimes uses walker; uses home O2 at all times and BiPAP at night; smoked 60 pack-years but quit in [2123]; no alcohol, IVDU, or cocaine use. Family History: CAD: mother died of MI at unknown age Physical Exam: VS: T 99 HR 60 RR 24 91/40 92% venti mask GEN: Elderly woman, obese in NAD HEENT: EOMI, PERRL, anicteric NECK: Supple, tender to palpation; no nuchal rigidity CHEST: CTA anteriorly, no w/r/r CV: RRR, S1S2, III/VI systolic murmur at LLSB ABD: Soft/NT/ND, OBESE, +BS EXT: NO c/c/e, warm, 2+ DP/PT SKIN: no rashes Pertinent Results: CXR [2132-3-3]: Portable AP chest radiograph was compared to [2132-3-3]. The patient is rotated, which slightly decrease the sensitivity of this study. The patient is after median sternotomy. The lowest sternal wire is broken, although no displacement is demonstrated. The cardiomediastinal silhouette is unchanged. There is mild pulmonary edema that appears to be not significantly changed compared to the prior study. Small amount of pleural effusion cannot be excluded. There is no pneumothorax. IMPRESSION: Mild pulmonary edema. No significant change in the appearance of the chest radiograph compared to the prior study. . TTE [2132-3-5]: The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45%). The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: poor technical quality due to patient's body habitus. Left ventricular function is mildly hypokinetic, a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen. No pathologic valvular abnormality seen. Moderate pulmonary artery systolic hypertension. A bubble study was performed but the suboptimal technical quality means that the presence or absence of a PFO/ASD could not be determined. Compared with the report of the prior study (images unavailable for review) of [2129-1-10], the previously seen focal anterior wall hypokinesis, mitral regurgitation and tricuspid regurgitation cannot be clearly seen on the current study due to technical limitations. . CXR [2132-3-6]: REASON FOR EXAM: Respiratory distress, COPD. Comparison is made with prior study [3-4]. Increased opacity in the left lower lobe in the retrocardiac area is new, could be due to atelectasis but pneumonia cannot be totally excluded. Moderate cardiomegaly is stable. Left transvenous pacemaker leads terminate in standard position. Sternal wires are aligned. Mild fluid overload is unchanged as is the prominence of the hila bilaterally. [2132-3-3] 10:19PM TYPE-ART PO2-195* PCO2-95* PH-7.26* TOTAL CO2-45* BASE XS-11 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA [2132-3-3] 10:06PM PH-7.28* COMMENTS-GREEN TOP [2132-3-3] 10:06PM GLUCOSE-172* LACTATE-0.6 NA+-139 K+-4.1 CL--86* TCO2-40* [2132-3-3] 10:06PM HGB-9.8* calcHCT-29 [2132-3-3] 10:06PM freeCa-1.20 [2132-3-3] 10:00PM GLUCOSE-182* UREA N-27* CREAT-1.0 SODIUM-141 POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-40* ANION GAP-11 [2132-3-3] 10:00PM estGFR-Using this [2132-3-3] 10:00PM CK(CPK)-34 [2132-3-3] 10:00PM CK-MB-NotDone [2132-3-3] 10:00PM cTropnT-<0.01 [2132-3-3] 10:00PM WBC-6.1 RBC-3.04* HGB-9.0* HCT-27.3* MCV-90 MCH-29.7 MCHC-33.1 RDW-14.4 [2132-3-3] 10:00PM NEUTS-71.0* LYMPHS-19.7 MONOS-6.6 EOS-2.3 BASOS-0.6 [2132-3-3] 10:00PM PLT COUNT-228 Brief Hospital Course: 73 y/o woman w/Diabetes, Chronic obstructive pulmonary disease, coronary artery disease, admitted to the the ICU initially with hypercarbic respiratory failure. . # Hypercarbic Respiratory Failure/Hypoxemia/COPD/Community Acquired PNA/acute diastolic CHF: The patient has known COPD, chronic respiratory failure, and OSA. The patient had hypercarbic respiratory failure in ED initially with initial ABG 7.26/95/195. From previous adissions and ABGs it appears that pt is a chronic retainer of CO2, with lowest recorded pCO2s in the 60s. Pt is on 3.5 L NC O2 at home and BIPAP at night. Suspect BIPAP noncompliance at home. In addition, pt was noted to have a PNA and acute diastolic CHF complicating her picture. She had noted wheezing, triggered by either pulmonary edema or frank reactive airways disease. On BIPAP she had some worsening hypoxemia, so there was concern of possible extrpulmonary shunt or worsening pulmonary HTN. TTE was performed with a bubble study, but this was of poor quality due to body habitus (unable to eval for PFO). Per cardiology, next step would be TEE, but no one would likely wish to pursue fixing any shunt and question usefulness of further data. However, her hypoxemia began to resolve, so further workup was not pursued. The patient was treated with BIPAP, diuresis with lasix/diuril, and levofloxacin. Given standing nebs/inhalers; spiriva being held while on atrovent nebs. She completed her 5 day course of levofloxacin. She was started on steroids as well, but became notably agitated. Upon attempt to wean her steroids her symptoms again worsened, so these were resumed. She is currently on 10 mg daily of prednisone (down from 60 mg a day) which we recommend continuing for another 2 days (which would complete a 6 day course). The patient was titrated on BIPAP last admission to 16/12 at 15L/min O2, which should be resumed at night after discharge. Currently pt can maintain sat of 88-95% RA on 3.5 L NC. . # Altered Mental Status: Slowly improving, although pt is still mildly confused. Appears that respiratory insult was primary event, as well as PNA. Urine cultures and blood cultures were negative. Would avoid sedating medications and narcotics. Pt has had worsening respiratory failure in the past on oxycodone. . # Acute on Chronic Diastolic Congestive Heart Failure: Treated in the ICU with Lasix 40 mg IV BID and diuril 250 mg twice daily (given her metabolic alkalosis). The patient diuresed over 3 L in the ICU, and then she was resumed on her home dose of lasix 80 mg daily. Pt was not restarted on lisinopril as she has a prior history of hyperkalemia and cough with ACE inhibitors. Can consider starting [First Name8 (NamePattern2) ] [Last Name (un) ] (especially given mildly depressed EF of 40-45%). . # Hypernatremia: Na rose to 148 on [3-6] after diuresis, improved to 138 on [3-7] with D5W. Would continue to monitor. . # Metabolic Alkalosis: Pt was noted to have elevated urine Chloride, so unlikely contraction alkalosis. Likely due to CO2 retention. Pt received several days of diamox, with bicarb correcting from 46 to 40, which is her baseline. . # Coronary Artery Disease: Continued asa, lipitor, and metoprolol . # DM II, uncontrolled, no complications: The patient is on glyburide at home, which we have been holding. She is on sliding scale insulin. On day of discharge, fingerstick was up to 430, received 10 U Regular insulin, with FS in 100s prior to discharge. Would recommend starting lantus 10 U at night for basal coverage until she is off prednisone. Will also continue sliding scale insulin. . # Neck pain/DJD: Likely musculoskeletal vs. DJD changes. Patient being followed by PCP for this reason. Suspect pt may have nerve impingement in the C2 region based on her pain. CT C spine done on [10-25] as outpatient (ordered by PCP) which showed degenerative changes and limited study due to cervical positioning in lateral film. Pt cannot have MRI of her C spine due to her ICD. Oxycodone was stopped last admission when pt had hypercarbic respiratory failure and somnolence. In addition, neurontin had been started in the past to treat pts pain, but this was also stopped in the setting of recurrent episodes of somnolence and hypercarbic failure. She seems to tolerate ultram as needed. Would avoid all other sedating medications. Pt was treated here with tylenol, ultram as needed, lidoderm patch, motrin, and heat packs. Given a 1 time dose of Toradol prior to discharge which significantly helped her pain. If she continues to have pain, consideration in the future can be given to a steroid injection at a pain clinic (for the cervical spine). . # Hypothyroidism: Continued levothyroxine . # Schizophrenia: continued aripiprazole and risperdal; depakote had been stopped after last admission due to somnolence per daughter . # Anemia: Currently stable in 30s. Patient has previously had work-up in [2128] which showed normal iron, tibc, transferrin. No evidence of acute bleed. Would consider outpatient follow-up as per her PCP. [Name10 (NameIs) ] should undergo routine colonscopy screening (although high risk given her pulmonary status, so this needs to be taken into consideration). . DNR/DNI Medications on Admission: parin 5000 SCTID Sertraline 75mg po Qday Divalproex 500 mg SR 1 po qday Risperidone 2 mg po HS Atorvastatin 10 mg po Qday Aspirin 81 mg po Qday tiotroprium Bromide 18mcg IH Qday Albuterol prn Pantoprazole 40 mg po qday Levothyroxine 125 mcg po qday Lisinopril 5 mg Tablet po qday Furosemide 80 mg 1 tablet Qday Glyburide 5 mg po qday Tramadol 25mg po Q4-6h pain Calcium Acetate 667 mg 2 cpas TID w/ meals Toprol XL 25mg po Qday Advair Diskus Inhalation Aripiprazole 10 mg po qday Docusate Sodium 100 mg po BID Olanzapine 5 mg Tablet qhs prn Gabapentin 100 mg po TID Insulin Lispro sliding scale Psyllium 1 packet TID Bisacodyl prn Lidocaine patch to neck Acetaminophen prn Discharge Medications: 1. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for prn agitation. 12. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 14. Ultram 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 15. Aripiprazole 10 mg Tablet Sig: Four (4) Tablet PO QPM (once a day (in the evening)). 16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO QAM (once a day (in the morning)). 20. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [Hospital1 ] (2 times a day). 21. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply to back of neck. 22. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 23. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime). 24. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 25. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 26. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous as directed: For fingerstick of: 150-199 give 2U, 200-249 give 4U, 250-299 give 6 U, 300-349 give 8 U, 350-400 give 10 U. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Acute on chronic diastolic CHF Community acquired pneumonia Delirium Hypercarbic respiratory failure Hypoxemia Hypernatremia Metabolic Alkalosis Discharge Condition: stable, satting 88-95% on 3.5 L NC Discharge Instructions: You were admitted with high carbon dioxide retention, respiratory failure, a pneumonia, heart failure, and confusion. You have been treated with BIPAP, Lasix, antibiotics, and steroids. Your symptoms have been improving. You are also less confused. It is very important that you wear your BIPAP at home. . Call your doctor or return to the ER for any worsening shortness of breath, confusion, chest pain, fevers, respiratory distress, or any other concerning symptoms Followup Instructions: Please follow up with Dr. [Last Name (STitle) 4922] after your discharge from rehab.	[ "V46.2", "414.00", "428.33", "295.60", "244.9", "518.84", "428.0", "V15.82", "401.9", "496", "780.09", "276.3", "250.00", "486", "276.0", "V45.81" ]	icd9cm	[ [ [] ] ]	[ "93.90" ]	icd9pcs	[ [ [] ] ]	14968, 15039	6662, 8626	336, 344	15228, 15265	3255, 6639	15782, 15874	2868, 2908		12605, 14945		15060, 15207		11907, 12582			15289, 15759								2923, 3236																						275, 298											372, 2091											8641, 11881						2113, 2551	2567, 2852
9,726	150,742	23705	Discharge summary	report	Admission Date: [2114-3-18] Discharge Date: [2114-3-24] Date of Birth: [2068-7-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: n/v/abd pain Major Surgical or Invasive Procedure: None History of Present Illness: 45M DM1 (dxed 3 yrs ago), HTN, CAD (s/p stent x 2 last year), hypercholesterolemia transfer from OSH for DKA. . Pt presented to OSH ED [3-17] with N/V/epigastric abdominal pain, weakness and decreased PO intake. Pt had KUB done at that time which was negative, a negative amylase/lipase and was d/c home with dx gastroenteritis. . On day of admission, pt had persistent sx and re-presented to OSH ED. Labs at that time were notable for blood glucose=599/HCO3=6/K=5.9/BUN=30/Cr=2.5 (unclear baseline)/AG=28/ WBC=26; ABG=7.03/9/137. Pt put on insulin gtt, given NS 1L, pain meds/anti-emetics. Had persistent sx and transferred to [Hospital1 18] [Hospital Unit Name 153] for further monitoring. . On presentation to the [Name (NI) 153], pt had decreased abdominal pain/nausea, although still lethargic. Labs were somewhat improved from presentation: AG 23/HCO3 9/BS 347/BUN 36/Cr 2.2/WBC 27.2. . In the [Name (NI) 153], pt remained on insulin gtt x 2 days. Had persistent abdominal pain, unclear if related to DKA or if another primary process. Had CT abd which showed mild thickening in the ascending colon, ? mild colitis. Surgery was consulted, who recommended empiric coverage with flagyl/zosyn for possible translocation of bacteria with hypotension/ischemic colitis from prior DKA. Past Medical History: 1. DMI, dxed 3 yrs ago, followed by [Last Name (un) ] as outpatient. No previous episodes of DKA or similar symptoms per pt. 2. HTN 3. CAD s/p stent x 2 last year (per pt) - no records available 4. Hypercholesterolemia Social History: Divorced, lives with his 18 yr old daughter; has 2 other daughters [Name (NI) 1139] use - 1.5 ppd x 30 yrs. EtOH use-every other week, drinks 3 beers/day and drinks only at night after working day shifts; last drink 1 wk prior to admission. Works as a paper distributor. Family History: Father deceased of leukemia at 59. No FH of diabetes. Physical Exam: PE: T 99.2 BP 111/68 P 73 R 28 Pox 93%RA General: pleasant M appearing above his stated age in NAD HEENT: dry MM; no OP lesions; no LAD Skin: warm, no rashes Neck: supple Lungs: fine RLL crackles, o/w CTA with good air movement; no accessory muscle use; no paradoxical breathing Heart: RRR s1 s2 no m/g/r Abd: soft, tender focally in the LUQ, ND, BS(+) Ext: warm, no edema; 2(+)DP pulses Pertinent Results: CXR here: poor quality AP film; increased interstitial markings, no focal infiltrate . EKG: sinus tach at 105 bpm, LAD, <1mm ST elev V2, <1mm ST dep V4, hyperacute T wave V3 . [2114-3-18] CXR: No definite acute cardiopulmonary process. . [2114-3-19] GALLBLADDER U/S Cholelithiasis in a distended gallbladder without any definite evidence of acute cholecystitis. . [2114-3-19] CT TORSO: Diffuse air space consolidation throughout visualized lung bases, ? pneumonia/pulmonary edema/ARDS. Mild wall thickening in the ascending colon, ? mild colitis. . [2114-3-19] ABDOMINAL XRAY: No evidence of free air, though right diaphragm not optimally visualized. . [2114-3-20] TTE: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . [2114-3-21] CXR: Improving bilateral patchy opacities, associated with bilateral pleural effusions and atelectasis, probably representing improving pneumonia versus aspiration pneumonia. . [2114-3-18] 07:54PM BLOOD WBC-22.2* RBC-5.30 Hgb-14.5 Hct-46.6 MCV-88 MCH-27.3 MCHC-31.0 RDW-13.8 Plt Ct-240 [2114-3-21] 04:22AM BLOOD WBC-7.3 RBC-4.17* Hgb-11.7* Hct-33.1* MCV-79* MCH-28.0 MCHC-35.3* RDW-13.9 Plt Ct-137* [2114-3-18] 07:54PM BLOOD Neuts-72* Bands-14* Lymphs-7* Monos-6 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [2114-3-19] 05:10AM BLOOD Neuts-80* Bands-7* Lymphs-8* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2114-3-18] 07:54PM BLOOD PT-15.2* PTT-27.6 INR(PT)-1.5 [2114-3-18] 07:54PM BLOOD Glucose-347* UreaN-36* Creat-2.2* Na-137 K-4.6 Cl-105 HCO3-9* AnGap-28* [2114-3-21] 04:22AM BLOOD Glucose-174* UreaN-6 Creat-0.8 Na-138 K-2.7* Cl-101 HCO3-31* AnGap-9 [2114-3-18] 07:54PM BLOOD ALT-34 AST-39 AlkPhos-96 Amylase-63 TotBili-0.3 [2114-3-20] 05:29AM BLOOD ALT-30 AST-44* LD(LDH)-322* AlkPhos-92 TotBili-0.5 [2114-3-19] 01:55AM BLOOD CK-MB-9 cTropnT-<0.01 [2114-3-19] 10:02AM BLOOD CK-MB-11* MB Indx-3.0 cTropnT-<0.01 [2114-3-19] 01:58PM BLOOD CK-MB-10 MB Indx-2.9 cTropnT-<0.01 [2114-3-18] 07:54PM BLOOD Calcium-8.5 Phos-2.9 Mg-2.1 [2114-3-19] 05:21AM BLOOD Type-ART pO2-100 pCO2-12* pH-7.06* calHCO3-4* Base XS--25 [2114-3-21] 08:15AM BLOOD Type-ART Temp-37.8 Rates-/24 O2 Flow-6 pO2-83* pCO2-36 pH-7.50* calHCO3-29 Base XS-4 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NASAL [Last Name (un) 154] [2114-3-18] 08:27PM BLOOD Lactate-2.2* [2114-3-20] 05:40AM BLOOD Lactate-1.1 Brief Hospital Course: 45M DM1, CAD s/p PCI, HTN, hypercholesterolemia admitted with DKA ? [1-24] colitis, with hospital course c/b hypoxia [1-24] aspiration pneumonia. . 1. DM1-Precipitant unclear; ? URI per ROS on presentation. s/p [Hospital Unit Name 153] course for insulin gtt now on home regimen (Lantus/Humalog) with reasonable blood glucose control. Pt was followed by [Last Name (un) ] during his hospitalization to assist in his blood glucose control. . 2. Abd pain-Etiology thought [1-24] DKA vs. colitis as seen on Abd CT. Unclear whether patient had an infectious colitis vs. ischemic colitis from relative hypotension from DKA causing translocation of gut bacteria. Given the degree of patient's symptoms, pt had a surgical consult, who recommended empiric broad spectrum antibiotics with zosyn/flagyl (2 days, later abx changed to cover asp pna, see below). Pts abd pain improved through his [Hospital Unit Name 153] course, although was still present to a much milder degree upon discharge. Pt also reports h/o reflux type symptoms, had trace guaiac (+) stool in ICU and ? hematemesis by history. ? abdominal pain related to GERD/PUD. Would recommend further w/u with outpatient EGD as not acutely indicated. Patient had H.pylori Ab checked; should f/u results as an outpatient and Rx with prevpac if (+). . 3. Hypoxemia-Patient was noted to have increased work of breathing during his [Hospital Unit Name 153] stay, which was attributed to respiratory compensation for his metabolic acidosis from DKA. However, he also had progressive hypoxia, confirmed by air space disease seen on CT torso. It was felt that he had an aspiration pneumonia. He started a 10 day course of levofloxacin and flagyl on [2114-3-22]. Symptoms improved over course of hospitalization. . 4. CAD-Patient had no EKG changes on admission and no ischemia by enzymes. He was continue on ASA, metoprolol 12.5 mg PO BID (on Toprol XL 25 mg PO QD at home), plavix 75 mg PO QD. . 5. FEN-Patient had aggressive repletion of his electrolytes. . 6. Family-Mother [Name (NI) 1494] [Name (NI) 4249] ([Telephone/Fax (1) 60580] Medications on Admission: 1. Lipitor 20 QD 2. Plavix 75 QD 3. Metoprolol XL 25 QD 4. HISS 5. ASA 325 QD 6. Lantus 22 units QHS Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days. Disp:24 Tablet(s) Refills:0 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. Disp:8 Tablet(s) Refills:0 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25) Units Subcutaneous once a day: Please take as directed. Please cover daytime sugars with humalog sliding scale. Discharge Disposition: Home With Service Facility: Diversified VNA [Location (un) 1157] Discharge Diagnosis: Diabetic ketoacidosis Aspiration Pneumonia Colitis Discharge Condition: Patient is ambulating, tolerating POs, urinating and having bowel movements without difficulty. Discharge Instructions: Patient should take his medications as prescribed. He should not stop taking his insulin; if he has any questions, he should call his primary care provider regarding changes in his insulin. Followup Instructions: Patient should follow up with: 1. [Last Name (un) ] Diabetes Center ([Telephone/Fax (1) 4847] 2. Gastroenterology ([Telephone/Fax (1) 2233] (Please call to schedule a colonoscopy to evaluate colitis and an upper endoscopy to assess for ulcer disease) 3. Primary Care Provider [Last Name (NamePattern4) ]. [Last Name (STitle) 60581] (Please have your PCP check [Name Initial (PRE) ] urinalysis at your next office visit with him. You had some blood in your urine that was likely related to the foley catheter you had while getting blood thinners, but this should be followed up on to make sure it has cleared.)	[ "507.0", "272.0", "557.9", "518.81", "401.9", "250.11", "276.5", "V58.67", "276.2", "414.01", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "38.91", "38.93" ]	icd9pcs	[ [ [] ] ]	8977, 9048	5743, 7882	328, 335	9143, 9240	2711, 5720	9479, 10117	2233, 2288		8033, 8954		9069, 9122		7908, 8010			9264, 9456								2303, 2692																						275, 290											363, 1677																	1699, 1924	1940, 2217
25,933	145,785	4342	Discharge summary	report	Admission Date: [2149-5-28] Discharge Date: [2149-6-2] Date of Birth: [2115-3-12] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfonamides Attending:[First Name3 (LF) 1055] Chief Complaint: Benzo overdose Major Surgical or Invasive Procedure: Intubation for airway protection History of Present Illness: HPI: Ms. [Known lastname ] is a 34-year-old woman with Bipolar disorder and group home resident who by way of EMS for apparent alprazolam overdose. In the [Hospital1 18], the patient was lethargic and unable to give a history. She was promptly intubated for airway protection and in order to administer charcoal. Patient was found at group home in am laying on floor by bed unresponsive, last seen awake 8 hours prior at dinner. Group home states that patient "may have taken too many Xanax. Patient has a history of suicidal ideations and self mutilation. Later patient told psych that she was feeling down and impulsively ingested 5 days worth of medications, she states that her intent at that time was to end her life. Past Medical History: 1. Bipolar disorder. 2. Asthma. 3. Posttraumatic stress disorder. 4. GERD 5. Chronic constipation from laxative abuse. Social History: Denies any recent use of EtOH or illicit drugs. Per OMR, h/o sporadic marijuana use. Now living at the DBT House on [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [Location (un) ]. In currently in a relationship with a man whom she met during a previous inpt admission. Per OMR, the patient is currently not in contact with her family. She was raised in multiple [Doctor Last Name ] care homes because her mother could not care for her. She was physically abused and severely neglected as a child and been sexually assaulted. She has no current romantic relationship. She has never been married. She has completed up to the tenth grade of high school. She has no current legal issues. Family History: Substance abuse in mother and brother. Two sisters with h/o depression and suicidality. Physical Exam: VS 95.4 HR 62 BP 99/70 RR 20 O2Sat 100% Gen: Intubated and sedated HEENT: ATNC, Pupils dialted at 5 mm but minimally reactive, anicteric Chest: CTA ant/lat Cor: RR nl S1 S2 no m Abd: Soft, nd, hypoactive bowel sounds Ext: WWP, multiple linear scars and burns on hands and arms Neuro: Sedated, DTRs: Skin: No rashes or petechiae, linear and burn scars as above Pertinent Results: [2149-5-28] 07:56AM WBC-9.4# RBC-4.75 HGB-14.7 HCT-42.2 MCV-89 MCH-30.9 MCHC-34.8 RDW-13.6 [2149-5-28] 07:56AM PLT COUNT-330 [2149-5-28] 07:56AM NEUTS-73.0* LYMPHS-21.8 MONOS-3.8 EOS-1.1 BASOS-0.3 [2149-5-28] 07:56AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-POS [2149-5-28] 07:56AM LITHIUM-LESS THAN [2149-5-28] 07:56AM DIGOXIN-<0.2* [2149-5-28] 07:56AM GLUCOSE-116* UREA N-14 CREAT-1.0 SODIUM-137 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-20* ANION GAP-17 [2149-5-28] 07:56AM CALCIUM-9.7 PHOSPHATE-3.7 MAGNESIUM-2.1 [2149-5-28] 07:56AM ALT(SGPT)-21 AST(SGOT)-40 ALK PHOS-70 AMYLASE-59 TOT BILI-0.4 [2149-5-28] 07:56AM LIPASE-66* [2149-5-28] 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2149-5-28] 08:13AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2149-5-28] 01:38PM CK(CPK)-4713* [2149-5-28] 03:45PM URINE UCG-NEGATIVE [2149-5-28] 03:56PM D-DIMER-7998* CXR: Probable ateletasis of lingula, consistent with pneumonitis EKG: NSR R 60 Normal axis, intervals, incomplete RBBB, flat T aVL, V2, TWI V1 CT Chest- shows bilateral segmental, subsegmental PEs B/L LE LENIs - negative Brief Hospital Course: MICU Course: Patient was intubated in ED for airway protection and administation of charcoal. Toxicology consulted and felt that patient most likely had benzo overdose. ABG revealed widened A-a gradient so a d-dimer was sent which was elevated. Patient had CTA which showed bilateral pulmonary embolisms. Patient was started on heparin drip and bilateral lower extremeties were done which were negative for DVT. Patient was exubated after 1 day in ICU after waking up. Overnight in the ICU patient was noticed to have painful bullae on hands and arm along with swelling. Dermatology and plastic surgery were consulted who felt that symptoms were due to trauma; it was not felt that patient had compartment syndrome. Patient was splinted and UE were kept elevated. Patient was gradually put back on her outpatient xanax dose of 1mg qid and clozaril was restarted. Patient was transferred to floor after spending 1 day in the ICU. . Once on the floor patient stable. Plastic did not feel that patient had any compartment syndrome and recommended aggresive upper extremity elevation for swelling reduction. While on the floor patient's hands improved with good range of motion of left hand, however [Known lastname ] some poor range of motion of right. X-ray of the hands and wrist were obtained which were negative. Patient seen by PT and OT who recommended hand exercises and splints for patient. Patient was put on coumadin that was bridged with lovenox unti lINR theraputic [2-27]. Patient conitnued to have SI while on floor and was transferred to psychiatry. While on the floor patient's urinalysis suggestive of UTI and was put on 6 day course of levofloxacin. Medications on Admission: Propanolol XL 80mg qd Modifinal 100 mg po qd Lamictal 100 mg po bid Alprazolam 1 mg po qid Senna Trazadone 200 mg po qhs Clomipramine 100 mg po qhs Pantopraozle 40 mg po qd Clozapine 300 mg po qhs Folate 1 mg po qd Multivitamin Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Clozapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Warfarin Sodium 3 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Trazodone HCl 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 11. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 14. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: Benzodiazapine Overdose Traumatic/pressure bullae Bipolar Disorder Discharge Condition: Stable - Swelling in hands reduced and range of motion continue to improve. Discharge Instructions: Please continue to take coumadin as directed by your doctors until told to stop for clots found in your lungs. Please continue to take antibiotics as directed for urinary tract infection for 3 more days. Please conitnue to keep hands elevated in bed until follow up appointment with plastic surgery. Followup Instructions: Patient will be admitted to psychiatry service Patient should follow up with at plastic surgery clinic in 2 weeks. Appointment setup for Tues. [6-17] at 10am. [Location (un) 470] [Hospital Ward Name 23] Building with Dr. [Last Name (STitle) 18740] [Telephone/Fax (1) 274]	[ "709.8", "728.88", "301.83", "296.7", "493.90", "415.19", "599.0", "530.81", "309.81", "564.00", "E950.3", "969.4" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	6945, 6960	3804, 5492	301, 336	7071, 7148	2481, 3781	7498, 7796	1994, 2085		5771, 6922		6981, 7050		5518, 5748			7172, 7475								2100, 2462																						247, 263											364, 1098																	1120, 1241	1257, 1978
52,901	131,634	36211	Discharge summary	report	Admission Date: [2184-8-30] Discharge Date: [2184-9-16] Date of Birth: [2109-12-23] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath/Fatigue/Chest pain Major Surgical or Invasive Procedure: Aortic valve replacement with 21-mm St.[Hospital 923] Medical Biocor Epic Tissue Valve. History of Present Illness: This is a 74 year old male with known coronary artery disease and aortic stenosis who presents today for surgical evaluation. Past medical history notable for prior myocardial infarctions and RCA stenting at [Hospital6 ] in [2172](bare metal) and stenting at [Hospital1 18] in [2182](drug-eluting). He also has severe COPD on chronic steroids and intermittant home oxygen use. He was recently admitted to OSH with worsening shortness of breath and COPD exacerbation. He ruled out for an MI. There was no history of chest pain, syncope, diaphoresis or lightheadedness. He admits to severe dyspnea at less than 20 feet and he is often unable to walk up a flight of stairs. Extensive cardiac evaluation showed worsening aortic stenosis. Given the findings, he was referred for cardiac surgical evaluation and seen by Dr, [Name (NI) ] [2184-7-29]. He returns today for preadmission testing and surgical correction. Past Medical History: Coronary Artery Disease Myocardial infraction x2 Aortic Stenosis Hypertension Dyslipidemia Emphysema Chronic Obstructive Pulmonary Disease - on chronic oxygen therapy History of GI Bleed(aspirin associated) Benign Prostatic Hypertrophy Gastroesophageal Reflux Disease - H. Pylori Anemia Infrarenal Abdominal Aortic Aneurysm Vertigo - ? Viral tinitus Diverticulosis Osteoporosis Past Surgical History RCA stent ([2172] Bare metal), ([2182] Drug Eluting) Appendectomy Right inguinal hernia repair Bilateral cataract surgery Social History: Race: Greek Last Dental Exam: Edentulous Lives with: Wife in [Name2 (NI) 17065] Occupation: Retired Tobacco: Former smoker, quit approximately 6 years ago. 1.5ppd x 60 yrs. ETOH: No history of abuse Family History: Father with MI at age 75 Physical Exam: Admission Physical Exam Pulse: 90 SRResp: 16 O2 sat: 98% B/P Right: 131/79 Left: 128/74 Height: 68" Weight: 137 General: Well appearing in NAD Skin: Dry [X] intact [X]. Eczema/psoriasis on legs. Legs with dry skin and alopecia. HEENT: NCAT, PERRLA, EOMI sclera anicteric, OP benign Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally with delayed inspiration/expiration. Lipoma vs cyst located on left breast at inner lower quadrant. Heart: RRR, Nl S1-S2, III/VI high pitched systolic murmur Abdomen: Soft, mild mid/left lower quadrant, slightly distended, NABS, no palpable masses, + Ventral hernia Extremities: Warm [X], well-perfused [X] Trace Edema. Psoriasis noted on lower extremities. ?areas of impetigo. Varicosities: None [X] Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:Trace Left:trace PT [Name (NI) 167]:Trace Left:trace Radial Right:2 Left:2 Carotid Bruit Transmitted vs. Bruit Pertinent Results: [2184-9-13] 06:53PM BLOOD WBC-19.1* RBC-4.19# Hgb-10.5# Hct-32.9# MCV-78 MCH-25.0* MCHC-31.9 RDW-18.8* Plt Ct-344 [2184-9-13] 01:54AM BLOOD Glucose-107* UreaN-40* Creat-0.8 Na-142 K-3.3 Cl-103 HCO3-32 AnGap-10 [2184-9-15] 02:10AM BLOOD WBC-13.8* RBC-3.56* Hgb-9.1* Hct-28.0* MCV-79* MCH-25.6* MCHC-32.4 RDW-19.0* Plt Ct-313 [2184-9-15] 02:10AM BLOOD Glucose-108* UreaN-36* Creat-0.8 Na-141 K-3.6 Cl-100 HCO3-35* AnGap-10 [2184-9-14] 01:48AM BLOOD ALT-21 AST-29 LD(LDH)-271* AlkPhos-57 Amylase-38 TotBili-0.4 [2184-9-1] 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%). with borderline normal free wall function. The aortic valve prosthesis leaflets appear to move normally. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. IMPRESSION: Normal LV function and borderline RV function. No evidence of vegetations or abscess on the valves or perivalvular regions. Bioprosthetic aortic valve well seated without perivalvular leak or significant stenosis. No pericardial effusion or evidence of tamponade physiology. Brief Hospital Course: The patient is a 74-year-old male with worsening symptoms related to critical aortic stenosis presenting for aortic valve replacement. He also has coronary artery disease and had multiple interventions to his coronaries. [2184-8-30] Mr.[Known lastname 82095] went to the operating room and underwent an Aortic valve replacement with 21-mm St. [Hospital 923] Medical Biocor Epic Tissue Valve with Dr.[Last Name (STitle) ]. Please refer to the operative report for further surgical details. He tolerated the procedure well and was transferred to the CVICU intubated and sedated on Neosynephrine for blood pressure support. He awoke neurologically intact and was extubated on POD#1. Preoperative steroids were resumed for his significant COPD history. Nicardipine, as opposed to beta-blocker was utilized for increased cardiac selection and to minimize bronchospasm. He remained hemodynamically stable and was weaned off all drips. Coreg/Statin/Aspirin/home dose of Theophylline and diuresis was initiated. General surgery was consulted for concern of bowel ischemia and rising lactate.His respiratory status remained tenuous post extubation and on POD#2 he was reintubated for worsening respiratory distress and lactic acidosis. He was pan cultured for a rising WBC count. Empiric antibiotics were initiated. CT scan of his abdomen revealed dilated loops of bowel but no evidence of bowel ischemia per General Surgery. He was kept NPO and serial lactates followed. His abdominal exam improved and the acidosis corrected. POD# 5 he was extubated for the second time. His rhythm went into an SVT 170s. Adenosine was administered to assess the acutely rapid rhythm which was revealed to be atrial fibrillation. Amiodarone and Lopressor were administered with conversion to normal sinus rhythm with premature atrial contractions. He was intermittently between sinus rhythm and atrial fibrillation and was started on Coumadin. His pulmonary status remained tenuous postoperatively requiring ventilatory support with noninvasive biphasic positive airway pressure intermittently. He was reintubated on [2184-9-7] for respiratory failure and aggressively diuresed with a Lasix drip. Epinephrine and Levophed drips were started for hypotension and they were weaned off in the following 2 days. He had a right upper quandrant ultrasound which was negative for choleycystis due to abdominal distention and hypotension. He was extubated on [2184-9-10] and did well with aggressive pulmonary toilet. His steroids were weaned and he was started on a standing oral steroid dose. Nutritional support was provided via tube feeds, which were cycled from 7 pm to 7 am after he passed a speech and swallow evaluation on POD# 14 for puree solids with thin liquids. The infectious disease team was consulted for a leukocytosis and recommended discontinuing the Cefepime (which he was on for Serratia in the sputum) and continuing Vancomycin for a total of 7 days for coag negative staphylococcus in [12-1] blood cultures. New blood cultures were drawn as well as C diff on [9-13] and these were pending at the time of discharge. Once these are finalized as negative, all antibiotics should be stopped [2184-9-19]. We will follow up with the rehab if blood cultures turn positive to recommend a longer course. A new PICC was placed [2184-9-13]. Coumadin stopped per Dr. [Last Name (STitle) ] on [9-14]. His dobhoff tube was removed on POD number 16 and calorie counts were begun. He was cleared for discharge to Kidred of [Hospital 86] rehab on POD #17. Medications on Admission: Theophylline SR 200mg [Hospital1 ] Acyclovir 400mg three times daily for 10 days Diphenhydramine-Phenylephrine 10mg-25mg qhs/PRN Albuterol 90mcg HFA inhaler every four hours PRN Atrovent inhaler 17mcg HFA 1 puff every four hours Calcarb 600 with vitamin D 600-200 2 tablets twice daily Colace 100mg [Hospital1 ] Flomax 0.4mg qd Lasix 40mg qd * Plavix 75mg qd* Stop [2184-8-23] Protonix 40mg qd Prednisone 5mg qod Tapering (After one week, he will drop to five milligram every other day and will hopefully come off of that-per pulmonary). Zocor 20mg qhs Aspirin 81mg daily Ferrous sulfate 325mg daily Flovent 220 two puffs twice a day Spiriva inhaler daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 4. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 7. theophylline 80 mg/15 mL Elixir Sig: Eighty (80) mg PO Q6H (every 6 hours). 8. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for dyspnea. 9. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. 10. guaifenesin 100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for mucous plugs. 11. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks: 400 mg daily through [9-20]; then 200 mg daily starting [9-21]. 12. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: 4-6 Puffs Inhalation QID (4 times a day). 13. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP <95 or HR <55 and notify provider at rehab. 14. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 17. Pantoprazole 40 mg IV Q24H 18. vancomycin 750 mg Recon Soln Sig: One (1) Intravenous twice a day for 4 days: Stop date [9-19]. Disp:10 10 Refills:0 19. lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. 21. nystatin 100,000 unit/mL Suspension Sig: One (1) PO three times a day for 4 days. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Critical symptomatic aortic stenosis. s/p AVR (porcine #21mm)[2184-8-30] PMH: Coronary Artery Disease Myocardial infraction x2 Aortic Stenosis Hypertension Dyslipidemia Emphysema Chronic Obstructive Pulmonary Disease - on chronic oxygen therapy History of GI Bleed(aspirin associated) Benign Prostatic Hypertrophy Gastroesophageal Reflux Disease - H. Pylori Anemia Infrarenal Abdominal Aortic Aneurysm Vertigo - ? Viral tinitus Diverticulosis Osteoporosis postop A Fib SVT Past Surgical History RCA stent ([2172] Bare metal), ([2182] Drug Eluting) Appendectomy Right inguinal hernia repair Bilateral cataract surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tramadol Incisions: Sternal - healing well, no erythema or drainage Edema -trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] Thursday [10-7] @ 1:00 pm Cardiologist:Dr. [Last Name (STitle) ] [9-29] @ 1:30 pm [Telephone/Fax (1) 7960] Please call to schedule appointments with your Primary Care Dr.[Last Name (STitle) 13983] in [11-29] 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 Dr. [First Name8 (NamePattern2) 450] [Last Name (NamePattern1) 437] [2184-9-27] @ 1:00 pm [Telephone/Fax (1) 612] Completed by:[2184-9-16]	[ "276.2", "285.9", "V45.82", "041.19", "562.10", "492.8", "511.9", "V58.65", "272.4", "518.0", "441.4", "482.83", "600.00", "V46.2", "458.29", "518.81", "414.01", "424.1", "412", "401.9", "427.31", "557.0", "276.52", "276.0", "530.81", "733.00" ]	icd9cm	[ [ [] ] ]	[ "96.04", "88.72", "33.24", "38.97", "96.71", "38.91", "38.93", "35.21", "39.61", "96.6" ]	icd9pcs	[ [ [] ] ]	11046, 11117	4650, 8237	362, 456	11790, 11962	3254, 4627	12886, 13544	2211, 2238		8960, 11023		11138, 11769		8263, 8937			11986, 12863								2253, 3235																						283, 324											484, 1421																	1443, 1974	1990, 2195
24,927	155,622	11240	Discharge summary	report	Admission Date: [2113-9-28] Discharge Date: [2113-10-2] Date of Birth: [2078-3-10] Sex: M Service: [Location (un) 259] HISTORY OF PRESENT ILLNESS: The patient is a 35 year-old male with a history of noninsulin dependent diabetes mellitus, chronic pancreatitis with one previous hospital admission three years ago at [Location (un) 2498] who presents with left upper quadrant pain, bilious nausea and vomiting consistent with previous episodes of pancreatitis. The patient states the symptoms began two days prior to hospitalization with pain, nausea and vomiting. The patient was unable to hold down po even water. Usually the patient does not come to the hospital and the pancreatitis resolved with increased po hydration and bowel rest. Workup in the past has only included triglyceride and cholesterol monitoring. The patient gets these episodes every two to three months. The current episode is worse in severity then previous admission at [Location (un) 2498]. The patient was not admitted to the MICU at that time. The patient denies any fevers or chills, diarrhea, bright red blood per rectum or hematemesis. No chest pain or shortness of breath. The last episode of vomiting was the a.m. of [9-28], which was the morning of admission. The patient initially presented to the Emergency Room at 11:00 a.m. Laboratories at that time were significant for a white blood cell count of 22,000 with 89% neutrophils and no bands, glucose 434, and anion gap of 29. Abdominal CT showed chronic pancreatitis changes with dilatation of the pancreatic duct, pseudocyst with superimposed acute pancreatitis. PAST MEDICAL HISTORY: 1. Noninsulin dependent diabetes. 2. Chronic pancreatitis. 3. Hypercholesterolemia with elevated triglycerides. MEDICATIONS: Glyburide 10 mg po q.d. 2. Lopid 600 mg po b.i.d. ALLERGIES: 1. Narcotics, which includes a bad reaction with insomnia and nightmares. 2. Penicillin. FAMILY HISTORY: Negative for pancreatic disease. SOCIAL HISTORY: Denies any alcohol or tobacco use. He is a dentist. PHYSICAL EXAMINATION: Temperature 96. Pulse 120. Blood pressure 124/95. Respiratory rate 19. O2 sat 97% on room air. General, he is awake, alert and in some discomfort, but in no acute distress overall. HEENT normocephalic, atraumatic. Pupils are equal, round and reactive to light. Extraocular movements intact. Sclera anicteric. Oropharynx clear. Mucous membranes are dry. Neck is supple. No lymphadenopathy. No jugulovenous distention. Chest is clear to auscultation bilaterally. Cardiovascular tachycardiac with normal S1 and S2. No murmurs, rubs or gallops. Abdomen soft, mild tenderness in the left upper quadrant and mid epigastric region with no rebound or guarding. Bowel sounds present, but diminished and guaiac negative per the Emergency Department. Extremities revealed no clubbing, cyanosis or edema. Pulses were intact. Neurologically, he was alert and oriented times three. Cranial nerves II through XII are intact with motor and sensory function intact. LABORATORIES ON ADMISSION: White blood cell 22.4, hematocrit 46.4, platelets 411. Differential 89% neutrophils, 0 bands, 4% lymphocytes, 5% monocytes. AST 34, ALT 30, alkaline phosphatase 107, amylase 71, lipase 216, triglycerides 1136, total bilirubin 0.7. Sodium 134, potassium 5.3, chloride 96, bicarbonate 9, BUN 22, creatinine 1.2, glucose 434. HOSPITAL COURSE: Mr. [Known lastname ] was admitted to the [Hospital1 346] Medical Intensive Care Unit on [2113-9-29] for ongoing workup and treatment of chronic pancreatitis and diabetic ketoacidosis. The rest of the hospital course will be dictated by problem: 1. Gastrointestinal: The patient presented with acute on chronic pancreatitis by laboratories, physical examination and radiologic studies. He was made strict NPO and given aggressive intravenous fluid hydration. He was started on Ativan and Compazine prn for nausea with his liver function tests, amylase and lipase and white blood cell count being followed everyday. The general surgery team was consulted and recommended conservative treatment with the above measures at that time and no indication for surgery. He was continued NPO for two days after hospitalization and aggressive intravenous fluids were continued. His amylase and lipase rose to 156 and 336. The patient complained vigorously multiple times that he was thirsty and wanted to try oral feeding. He was started gently on clear liquids, however, his abdominal pain worsened. On [2113-10-2] the patient continued to be frustrated with his medical care and asked to leave AMA. We discussed with the patient that he was not ready to leave given that he was unable to tolerate po and he was still experiencing pancreatitis. Mr. [Known lastname ] appeared to understand that he was leaving against medical advise and that he was endangering his life and that he was endangering his life in this situation. He was given a prescription for Toradol and Ultram for pain and asked to follow up with his [Last Name (un) ] attending in two days. He was asked to continue good oral intake if he could tolerate it with his abdominal pain. The patient signed the AMA form and it was left on the chart. 2. Endocrine: The patient was admitted in diabetic ketoacidosis. An arterial blood gases at that time and blood gas revealed a pH of 7.29, PCO2 23, PO2 88. He was felt to be in diabetic ketoacidosis with good respiratory compensation. He was started on an insulin drip with q 2 hour finger sticks and the drip was titrated as needed. Over the course of the following two days his bicarbonate responded and his anion gap closed at the time of transfer to the MICU, and his bicarbonate was 17 and his anion gap was 15. He was continued on the insulin drip at 4 units an hour and this was transitioned over to NPH insulin in which the patient received NPH 26 units subcutaneous q.a.m. and 14 units subcutaneous q.p.m. with a very tight regular insulin sliding scale. The patient continued to have finger sticks i the high 100s to low 200s. On the morning of hospital discharge his anion gap was approximately 16 with a bicarbonate of 22. Given the patient left AMA it was not deemed that he had an optimal insulin regimen, however, he was discharged with 26 units of NPH q.a.m. and 26 units q.p.m. and a regular insulin sliding scale. The patient was asked to follow up with Dr. [Last Name (STitle) ] within two days after discharge and to return to the Emergency Room if his symptoms worsened. 3. FEN: The patient presented with chronic pancreatitis and appeared completely volume contracted. He was given aggressive intravenous fluids in the first few days of his hospitalization. On hospital day two the patient attempted oral po intake with clear liquids, however, continued to have abdominal pain. At the time of the patient leaving AMA he was still not tolerating po and it was deemed not in his best medical interest to leave, however, the patient was adamant in his leaving. He was asked to continued to encourage po intake as an outpatient and if his abdominal pains worsened and he was unable to hold down any home medication to return to the Emergency Room. 4. Psychiatric: Mr. [Known lastname ] remained very angry toward the house staff during his hospitalization. The issues with his anger were related to his pain control as well as the house staff being reluctant to advance his diet while he was continuing to receive intravenous fluids for his chronic pancreatitis. He also was angry toward the house staff at keeping him in the hospital given that he has many loans from dental school and he recently was bankrupt and does not have medical insurance at this time. This was the major emphasis toward him leaving AMA. DISCHARGE MEDICATIONS: Same as admission with the addition of NPH insulin 26 units q.a.m. and 26 units q.p.m., regular insulin sliding scale. Toradol 10 mg po q 4 to 6 hours prn pain and Ultram 50 mg po q 4 to 6 hours prn. DISCHARGE STATUS: The patient left AMA. He was given prescriptions for insulin, Ultram and Toradol as outlined above. There were multiple attempts to page the [Last Name (un) ] attending on call were unsuccessful. The patient signed the AMA form and expressed the understanding that he was endangering his life by leaving the hospital. He was asked to follow up with Dr. [Last Name (STitle) ] within two days prior to discharge and asked to return to the Emergency Room if his symptoms worsened. DISCHARGE DIAGNOSES: 1. Diabetic ketoacidosis. 2. Type 2 diabetes. 3. Chronic pancreatitis. CODE STATUS: The patient is full code. [First Name11 (Name Pattern1) 5257] [Last Name (NamePattern4) 19982], M.D. [MD Number(1) 16892] Dictated By:[Last Name (NamePattern1) 14434] MEDQUIST36 D: [2113-12-6] 15:03 T: [2113-12-10] 09:35 JOB#: [Job Number 36114]	[ "577.1", "272.0", "250.12", "577.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]							1989, 2023	8627, 9031	7894, 8606					3461, 7870																					2117, 3101																						181, 1660									3116, 3443								1683, 1972	2040, 2094
9,341	181,810	44950	Discharge summary	report	Admission Date: [2119-7-2] Discharge Date: [2119-7-10] Date of Birth: [2048-12-26] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 425] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 70 year old woman with a history of hypertension, stage III CKD, and COPD who was admitted [2119-7-2] with nausea and vomiting and found to have NSTEMI and hypoxia requiring admission to the CCU. . She reports acute onset of nausea/vomiting and dry heaving this morning. Vomitus was non-bloody, yellow in color. Also assocaited with diarreha, 4 movements in last 24 hours. She reported subjective fevers and chill but no abdominal cramping or pain. She denies sick contacts or unusual foods. Of note, patient was recently seen in the ED for bloody diarrhea and upper respiratory symptoms. She was diagnosed with infectious colitis and was given moxifloxacin and metronidazole. Also a recent admission to [Hospital1 18] for acute on chronic kidney injury (1.5 to 3.4). . In the ED, initial vitals were 98.1, 141/99, 112, 22, 100%RA. Exam significant for ill-appearing female that was dry heaving multiple times, hemoccult negative. Labs notable for WBC 15.7 (93%N), K 3.0 (repleted) , Phos 2.2, Mg 1.4 (repleted on floor), lactate 3.2 (repeat 1.9), AG 21. Normal LFTs, lipase, and UA, utox. KUB and CT ABD showed no acute cardiopulmonary process. EKG similar to prior. She was given IVF (1 L NS), zofran x 2, ativan 1 mg IV x 1, 40 meQ KCL in 1L D%4, Reglan 10 mg IV x 1. She was admitted as unable to tolerate PO, continuing n/v. . On arrival to the floor, she as tachycardic and 110 with bursts to 140 with vomiting. She developed sustained tachycardia to 140-150 and triggered for increasing oxygen requriement to 90% on 4-5LNC and hypotension on . She was given 500cc bolus IVNS. She was given metoprolol 5 mg IV x 1 and diltiazem 10 mg IV x 1 without effect. EKG showed sinus tachycardia STD V3-V5. CXR showed worseing pulmonary edema. STAT labs cardiac biomarkers returned CK-MB 18 MB 6.3 TropnT 0.90. . On arrrival to the CCU, Vitals were 134/57 p77 rr24 97% on 50% facemask. She reported that her breathing was comfortable, nausea resolved. Denies chest pain, palpatations, dyspena, cough, orthopnea, ankle edema, palpitations, syncope or presyncope. Repeat EKG showed sinus tachycardia at 103BPM, PR depressions in II, III, aVF, previously seen STD in V3-V5 resolved. Past Medical History: Past Medical History: 1. Hypertension 2. CKD 3. COPD - not on home oxygen 4. Lobular breast cancer s/p lumpectomy 5. Osteoporosis Social History: Works at stop and shop. Lives with husband and has 6 children. Use to smoke - 30 pack year history, quit 15 years ago. Denies alcohol and illicits. Family History: Father - hypertension Mother died at 93 5 brothers and 1 sister died (does not know cause) No kidney disease or kidney stones. No known cancers. Physical Exam: ADMISSION EXAM: VS: BP:134/57 P77 RR:24 SaO2 97% on 50% facemask. GENERAL: Elderly female breathing with pursed lips, appearing moderately uncomfortable. HEENT: mucous membs moist, JVP non elevated. CARDIAC: Distant heart sounds, s1/s2 tachycardic, no MRG. LUNGS: Inspiratory rales L>R, faint inspiratory wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No peripheral edema. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ DISCHARGE EXAM: Temp Max: 99.3 Temp current: 98.5 HR: 92-116 RR: 20 BP: 112-154/70-89 O2 Sat: 98% on RA FS: none Tele: ST, rate 100-120, no VEA Gen: NAD, comfortable CV: tachycardic, no murmurs, no JVD Lungs: CTAB, [Month (only) ] BS overall Abd; soft Ext: no edema, DP pulses 2+ Pertinent Results: ADMISSION LABS: [2119-7-2] 02:30PM BLOOD WBC-15.7# RBC-4.44 Hgb-13.0 Hct-36.8 MCV-83 MCH-29.3 MCHC-35.4 RDW-13.5 Plt Ct-337 [2119-7-2] 02:30PM BLOOD Neuts-92.6* Lymphs-4.8* Monos-2.3 Eos-0.1 Baso-0.2 [2119-7-3] 03:27AM BLOOD PT-12.4 PTT-26.4 INR(PT)-1.0 [2119-7-2] 02:30PM BLOOD Glucose-202* UreaN-19 Creat-1.1 Na-139 K-3.0* Cl-97 HCO3-21* AnGap-24* [2119-7-2] 02:30PM BLOOD Albumin-4.5 Calcium-9.4 Phos-2.2* Mg-1.4* [2119-7-2] 02:30PM BLOOD ALT-14 AST-16 AlkPhos-71 TotBili-0.4 [2119-7-4] 05:30PM BLOOD proBNP-[Numeric Identifier 96134]* [2119-7-7] 05:54AM BLOOD %HbA1c-6.2* eAG-131* [2119-7-3] 01:35AM BLOOD Type-ART FiO2-3 pO2-77* pCO2-59* pH-7.28* calTCO2-29 Base XS-0 CARDIAC ENZYMES [2119-7-2] 09:30PM BLOOD CK(CPK)-288* [2119-7-3] 09:50AM BLOOD CK(CPK)-640* [2119-7-4] 05:02AM BLOOD CK(CPK)-488* [2119-7-2] 09:30PM BLOOD CK-MB-18* MB Indx-6.3* cTropnT-0.90* [2119-7-3] 03:27AM BLOOD CK-MB-30* MB Indx-5.5 cTropnT-2.27* [2119-7-3] 06:28PM BLOOD CK-MB-22* MB Indx-3.5 cTropnT-1.16* [2119-7-4] 05:02AM BLOOD CK-MB-14* MB Indx-2.9 cTropnT-1.04* [2119-7-4] 04:26PM BLOOD CK-MB-10 MB Indx-2.7 cTropnT-0.65* IMAGING/STUDIES: CT ABDOMEN/PELVIS [2119-7-2]: IMPRESSION: 1. Radiographic lucency corresponds to colon interposed between the liver and diaphragm. 2. Fluid-filled cecum and ascending colon is compatible with history of diarrhea. Normal appendix. 3. Scattered diverticula without diverticulitis. CHEST, SINGLE AP PORTABLE VIEW [2119-7-2]: The heart is not enlarged. There is no [Month/Day/Year 1902], focal infiltrate, or effusion. The right hemidiaphragm is slightly elevated. Minimal atelectasis at both bases. Linear calcification overlying the right lung apex likely represents vascular calcification. Right upper quadrant surgical clips noted. No free air is seen beneath the diaphragm. Visualized portion of the bowel shows a nonspecific gas pattern. IMPRESSION: No acute pulmonary process identified. ECG [2119-7-2]: Sinus rhythm with premature atrial contractions. Normal tracing. Compared to the previous tracing no diagnostic interim change. ECHOCARDIOGRAM [2119-7-3]: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferior, inferolateral and inferoseptal segments. The remaining segments contract normally (LVEF = 40-45%). Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen; it is likely ischemic in nature. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Moderate mitral regurgitation. Compared with the report of the prior study (images unavailable for review) of [2112-3-23], regional left ventricular systolic dysfunction is new. ECHOCARDIOGRAM [2119-7-5]: The left atrium is mildly dilated. The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal-mid inferior and inferolateral walls. The remaining segments contract normally (LVEF = 40-45 %). Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared to the study dated [2119-7-3] (images reviewed), the patient is more tachycardic. Pulmonary pressures are now in the moderate range (undetermined on the prior study). Other findings are similar. SINGLE AP PORTABLE VIEW OF THE CHEST [2119-7-8]: Comparison is made with prior study performed a day earlier. Cardiomediastinal contours are normal. Aeration of the right lung has improved. There are no new lung abnormalities. Right PICC remains in place. The tip is difficult to visualize, can be followed at least to the cavoatrial junction. There is no pneumothorax or pleural effusion. MICROBIOLOGY: URINE CULTURE [2119-7-2] _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S C. DIFFICILE TOXIN [2119-7-3] - negative Brief Hospital Course: 70 year old woman with a history of hypertension, stage III CKD, and COPD is admitted for nausea/vomiting and found to have NSTEMI with hypoxia and tachycardia requiring admission to the CCU. #NSTEMI - Initial troponin T was 0.90 and peak was 2.27. EKG showed STD in V3-V5 consistnt with anterior septal MI. Repeat EKG showed resolution of previously seen STD and new PR depressions in II, III and aVF, which can be seen in RV infarct. Nitro was therefore held. Her initial N/V may have been related to myocardial ischemia. She was started on heparin drip, ASA, loaded with plavix. Started on metoprolol which was titrated to 100 mg [Hospital1 ]. Echo showed evidence of mild LV dysfunction (EF 40-45%) c/w CAD, moderate mitral regurgitation. Cardiac catheterization was deferred given respiratory distress likely secondary to heart failure and/or pneumonia, as well as the fact that she had persistent tachycardia equivalent to a stress test which she tolerated without recurrence of symptoms. [Month (only) 116] consider outpatient cardiac catheterization. Simvastatin was changed to atorvastatin at 80 mg, aspirin and plavix were started to minimize coronary artery thrombus. Pt should have nitroglycerin at home to take for chest pain. #Hypoxia - On arrival to CCU, CXR showed evidence of worsening pulmonary edema since admission after receiving fluids. Pt with labored breathing and pursed lips. ABG showed 77/59/7.28/29. Hypoxia thought to be due to volume overload as result of NSTEMI vs COPD exacerbation. Pt treated with albuterol/ipratripium nebs and advair. Also initially started on prednisone. She was diuresed with lasix. Repeat CXR concerning for early infiltrate vs. aspiration pnuemonia. Given recent hospitalization, fever, and elevated white count coverage for HAP was also initiated with vanc/cefepime and azithromycin for atypical coverage. Pulmonary service was consulted and recommended further diuresis and to stop the steroids as they felt SOB was more likely due to combination of UTI, lung inflammation/aspiration pneumonia, and/or low EF and MR [First Name (Titles) 767] [Last Name (Titles) 1902]/ACS. Pt completed antibiotics on [7-10]. At the time of discharge, she was comfortable on RA and denied cough or sputum production. She was not discharged on diuretics because of her [Last Name (un) ], but this may be considered in the future if she has evidence of fluid retention. Lisinopril was held because of [Last Name (un) ] but should be restarted once creat < 1.5. #Tachycardia: Likely multifactorial and related to hypovolemia agitation from respiratory distress, and possibly depressed LVEF. Patient remained tachycardic in the 120s. Initially thought pt was over-diuresed and was given fluids without response. Pt did have short episode of Afib, and converted with ibutilide. She remained tachycardic in low 100s throughout admission despite euvolemic, adequate pain control, no O2 requirements. Metoprolol sucinate was uptitrated to 150 mg [Hospital1 ] #Afib: Pt had episode of Afib on [7-4] treated with ibutilide 1 mg x 1 and converted to sinus. Again, went into Afib the following day and converted to sinus with metoprolol. Pt was bridged to coumadin, however remained in sinus through the rest of admission. Afib with RVR likely occured in the setting of acute infarction/respiratory distress. Given a drop in HCT and guaiac positive stools, anticoaguluation was discontinued. Pt still receiving ASA and plavix which offers some degree of anticoagulation. #UTI: Pt had urine culture showing > 100,000 org/ML of enterococcus sensitive to vancomycin, which she was already receiving for aspiration PNA. #Hypertension: Patient admitted with SBP 130's, and became hypotensive in the setting of tachycardia and NSTEMI. Hypotension resolved and is now normo to hypertensive. BPs controlled with metoprolol. Held home clonidine and nifedipine. Would like to add lisinopril when renal function improves. #Hyperglycemia - Initial chemistry significant for glucose of 222. patient is without history of diabetes, possibly stress response to acute myocardial infarction. Also may have been elevated from steroid use. Continued to check finger sticks though admission which improved. By discharge FS in low 100s and no insulin required. #Nausea/vomiting - Pt was initially started on Cipro/Flagyl when admitted to the floor given n/v/d and recent history of infectious colitis. However, nausea/vomiting likely anginal equivalent. patient afebrile. infectious colitis unlikely. Cipro/flagyl discontinued. Pt treated with zofran prn during admission. Also on ranitidine for GERD. N/V resolved by time of discharge. CHRONIC ISSUES: #Insomnia - continued trazodone 50 mg po qhs TRANSITIONAL ISSUES: #Pt will need follow up with primary care and cardiology after discharge. These have been scheduled. #Will need blood pressure modifications and possible adjustments given that now only on metoprolol and discontinued home clonidine, nifedipime and lisinopril. Would recommend lisinopril if additional blood pressure control needed and renal function allows, creat < 1.5. #Pt had episodes of Afib on admission. Is currently on ASA and plavix. However, did not start Coumadin at this time given that patient had drop in HCT and guaic positive stools. Given that sinus rhythm for majority of admission, it was felt that the risks outweighed the benefits to start Coumadin. Should the patient continue to have Afib in the future, can readdress need for coumadin and/or amiodarone. # HCP is daughter [Name (NI) ] [Name (NI) ] # Full code Medications on Admission: HOME MEDICATIONS: Alendronate 70 mg Q week Amitriptyline 10 mg daily Atenolol 100 mg Daily Clonidine 0.2 mg [Hospital1 ] Nifedipine 90 mg ER Daily Simvastatin 10 mg Daily Trazodone 75 mg QHS PRN insomnia Cholecalciferol (vitamin D3) 800 units daily Calcium carbonate 500mg [Hospital1 ] Solifenacin 5 mg Daily PRn as needed for urge incontinence. Lactobacillus rhamnosus GG 10 billion cell Cap [Hospital1 ] Fluticasone-salmeterol 250-50 mcg/dose 1 Inhalation twice a day. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [1-1] Inhalation every 4-6 hours. Lisinopril 40 mg daily (was held at discharge [2-1] [Last Name (un) ]) Discharge Medications: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 2. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO twice a day. 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as needed for insomnia. 6. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 8. lactobacillus rham. GG-inulin 10 billion-245 cell-mg Capsule, Sprinkle Sig: One (1) Capsule, Sprinkle PO twice a day. 9. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 10. ipratropium bromide 0.02 % Solution Sig: One (1) vial Inhalation Q8H (every 8 hours) as needed for SOB. 11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 14. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 15. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. Discharge Disposition: Extended Care Facility: [Hospital 392] Rehabilitation & Nursing Center - [Hospital1 392] Discharge Diagnosis: Acute on Chronic Kidney Injury Acute on Chronic Diastolic congestive heart failure Non ST elevation myocardial infarction Aspiration Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had trouble breathing and a low oxygen level that was due to a heart attack. This heart attack has made your heart weak and caused fluid to back up into your lungs. You received furosemide (lasix) to get rid of the extra fluid. At the same time, you have a pneunomia for which you received one week of antibiotics. You now do not need any oxygen and have no fever or other signs of infection. Your heart rate has been high and we adjusted your medicines to slow it down and lower your blood pressure. You were in an irregular rhythm called atrial fibrillation and are now in a normal rhythm again. We started warfarin (coumadin) but you developed some blood in your stool and this was stopped. You should check your pulse regularly to see if it is irregular which could mean the atrial fibrillation has returned. Until your heart recovers from the heart attack, weigh yourself every morning before breakfast and call Dr. [Last Name (STitle) ] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . We made the following changes to your medicines: 1. Stop taking Atenolol, clonidine, nifedipine, solifenacin, and simvastatin 2. Take atorvastatin to lower your cholesterol instead of simvastatin. You can restart simvastatin in a few months once you don't need a high dose. 3. Take Metoprolol succinate instead of atenolol to lower your heart rate and blood pressure 4. Start aspirin and plavix to prevent blood clots in your heart arteries. 5. Start tylenol as needed for pain 6. STart ranitidine to prevent stomach upset from the aspirin and plavix. 7. Stop taking combivent with the salmeterol. This could cause a rapid heart rate. Followup Instructions: Cardiology: Department: CARDIAC SERVICES When: FRIDAY [2119-8-4] at 9:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Primary Care: Provider: [Name10 (NameIs) 10160] [Name11 (NameIs) 10161], [MD Number(3) 1240]:[Telephone/Fax (1) 250] Date/Time:[2119-7-14] 1:50 Please cancel this appt if you are in rehabilitation. . Department: RADIOLOGY When: THURSDAY [2119-8-3] at 10:30 AM With: RADIOLOGY [Telephone/Fax (1) 327] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: THURSDAY [2119-11-2] at 1:45 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 16202], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: WEST [Hospital 2002] CLINIC When: THURSDAY [2120-6-13] at 1 PM With: [First Name11 (Name Pattern1) 1877] [Last Name (NamePattern1) 1878], M.D. [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Completed by:[2119-7-11]	[ "780.52", "041.04", "428.0", "428.33", "507.0", "599.0", "427.31", "585.3", "530.81", "410.71", "496", "733.00", "584.9", "V10.3", "403.90", "790.29" ]	icd9cm	[ [ [] ] ]	[ "38.97" ]	icd9pcs	[ [ [] ] ]	16253, 16352	8548, 13240	311, 332	16539, 16539	3787, 3787	18400, 19895	2884, 3030		14875, 16230		16373, 16518		14193, 14193			16722, 18377								3045, 3482			14211, 14852			3498, 3768										13325, 14167						252, 273											360, 2548						3803, 8525					16554, 16698			13257, 13303			2592, 2702	2718, 2868
80,029	187,592	16503	Discharge summary	report	Admission Date: [2127-7-14] Discharge Date: [2127-8-1] Date of Birth: [2054-1-30] Sex: F Service: NEUROSURGERY Allergies: Plavix / Meclizine Attending:[First Name3 (LF) 78] Chief Complaint: Transferred from OSH with dizziness, nausea Major Surgical or Invasive Procedure: External ventriculostomy drain History of Present Illness: 73F awoke this morning at [Hospital3 ] center c/o dizziness and nausea. Brought to [Last Name (un) 1724] and found R cerebellar hemorrhage. Pt became lethargic, was intubated and transferred to [Hospital1 18] for further management. She has h/o R MCA stroke [2114] which left her with left sided weakness but was living independently until end of last year when had fall at home requiring long rehab stay ultimately ending in moving to [Hospital3 ]. At baseline walks with walker and uses wheelchair for longer distances. Information obtained from daughter who is at bedside; she also states pt is full code. Past Medical History: R MCA CVA [2114], hemorrhage into R cva [2126] tx'd conservatively, CAD, subclavian steel syndrome (R UE SBP> L UE SBP),?TIAs, gastroparesis,bilat CEA,L fem-[Doctor Last Name ] [3-17] Social History: lives in [Hospital3 ], widowed - husband died 2 [Name2 (NI) 1686] ago, has one daughter Family History: Family Hx:noncontributory Physical Exam: PHYSICAL EXAM: O: BP: 165/58 HR:73 R O2Sats100 Gen: WD/WN, intubated HEENT: Pupils: 3mm min reactive R 2.5 reactive left, unable to assess EOMs Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: intubated, sedated but opens eyes to command and follows commands all 4 extremities Toes downgoing right, upgoing left Exam on discharge: Patient Awake and Alert, mouths words and is at times oriented to self and place. Pupils: Right 6mm and cloudy, Left 4mm to 2mm Trach and J tube Moves all ext spontaniously, rarely follows commands. Pertinent Results: [2127-7-14] 11:40AM BLOOD WBC-6.8 RBC-4.37 Hgb-15.3 Hct-45.5 MCV-104* MCH-35.0* MCHC-33.6 RDW-13.6 Plt Ct-157 [2127-7-15] 08:15AM BLOOD WBC-9.6 RBC-3.20# Hgb-10.8# Hct-33.1# MCV-103 MCH-33.7* MCHC-32.6 RDW-13.6 Plt Ct-178 [2127-7-16] 02:30AM BLOOD WBC-10.4 RBC-3.17* Hgb-10.8* Hct-32.1* MCV-101* MCH-34.2* MCHC-33.7 RDW-13.4 Plt Ct-197 [2127-7-16] 10:58AM BLOOD WBC-10.4 RBC-3.43* Hgb-11.5* Hct-35.4* MCV-103* MCH-33.5* MCHC-32.5 RDW-13.1 Plt Ct-208 [2127-7-17] 03:55AM BLOOD WBC-8.9 RBC-2.85* Hgb-9.2* Hct-29.3* MCV-103* MCH-32.5* MCHC-31.6 RDW-13.2 Plt Ct-171 [2127-7-18] 01:34AM BLOOD WBC-9.8 RBC-3.16* Hgb-10.5* Hct-32.1* MCV-102* MCH-33.2* MCHC-32.7 RDW-13.3 Plt Ct-212 [2127-7-14] 11:40AM BLOOD Neuts-89.3* Lymphs-8.0* Monos-2.3 Eos-0.3 Baso-0.1 [2127-7-14] 11:40AM BLOOD PT-12.0 PTT-24.6 INR(PT)-1.0 [2127-7-15] 08:15AM BLOOD PT-13.7* PTT-30.1 INR(PT)-1.2* [2127-7-18] 01:34AM BLOOD PT-13.4 PTT-29.0 INR(PT)-1.1 [2127-7-14] 11:40AM BLOOD Glucose-174* UreaN-19 Creat-0.7 Na-139 K-4.7 Cl-103 HCO3-27 AnGap-14 [2127-7-16] 10:58AM BLOOD Glucose-175* UreaN-16 Creat-0.6 Na-138 K-4.2 Cl-106 HCO3-21* AnGap-15 [2127-7-18] 01:34AM BLOOD Glucose-125* UreaN-15 Creat-0.6 Na-140 K-4.1 Cl-105 HCO3-25 AnGap-14 [7-14] Head CT IMPRESSION: 1. Large right cerebellar intraparenchymal hemorrhage with associated edema and mass effect including early upward transtentorial herniation and hydrocephalus. 2. Intraventricular hemorrhage involving the right lateral, third, and fourth ventricles. 3. Old right MCA infarct. MPRESSION: 1. Interval increase in right frontoparietal hemorrhage (2:21), now measuring 9 x 11 mm; no new hemorrhage seen. 2. Minimally changed appearance of right cerebellar hemispheric hematoma, with right-sided upward transtentorial herniation, unchanged. 3. Intraventricular hemorrhage with associated hydrocephalus, s/p placement of right transfrontal ventriculostomy catheter with expected tiny foci of right frontal extra-axial pneumocephalus. [7-17] Head CT IMPRESSION: 1. No significant interval change in right cerebellar hemorrhage with upward transtentorial herniation. Stable right frontoparietal hemorrhage and previously noted left-sided subarachnoid hemorrhage on current exam. 2. Stable amount of intraventricular hemorrhage within the occipital horns with slight interval decrease in the amount of hemorrhage within the fourth ventricle. Slight decrease in ventricular size as detailed above. [2127-7-17] EKG [Known lastname 46890],[Known firstname ] [Medical Record Number 46891] F 73 [2054-1-30] Cardiology Report ECG Study Date of [2127-7-17] 5:01:48 AM Sinus rhythm with atrial premature beats. Compared to the previous tracing the rhythm has changed. Read by: [Last Name (LF) ],[First Name3 (LF) ] Intervals Axes Rate PR QRS QT/QTc P QRS T 70 128 86 [Telephone/Fax (2) 46892]8 [7-30]: IMPRESSION: Uncomplicated placement of a 14 French [Doctor Last Name 9835] gastrojejunostomy tube with tip in the jejunum. Please note that the tube should be ready to use in approximately 24 hours. Brief Hospital Course: This patient is a 73F awoke the morning of [2127-7-14] at her [Hospital3 ] center c/o dizziness and nausea. She was taken to [Last Name (un) 1724] and found to have a R cerebellar hemorrhage. Pt became lethargic, was intubated and transferred to [Hospital1 18] for further management. Given her posterior fossa hemorrhage, she quickly developed hydrocephalus requiring an EVD on the 7th. On [7-16], the patient had brief episodes of SVT and troponin leak, with systolic blood pressure above 200 accompanied with hypoxia, an PE workup was negative. A cardiology evaluation was also obtained for persistent hypertension, an Echo was obtained to evaluate cardiac function. Patient clinically appeared to by in heart failure and improved with aggressive diuresis. The patient was extubated on [7-20] and was following commands on the right, but remained weak on the left. She was reintubated on [7-22] for respiratory failure and had a troponin leak with a Nstemi. A follow up MRI/MRA revealed a R MCA infarct. on [7-25] she had a bedside tracheostomy performed. On [7-27] she was diagnosed with right wrist cellulitis and seen by plastic surgery and started on Ancef. on [7-29] she went to interventional radiology for placement of a gastrojejunostomy tube with the tip in the jejunum. Medications on Admission: aggrenox200/25'',colace 100'',Iron 325', folic acid 1', lexapro 10',vitamin B12',trazadone 25', tylenol prn Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 1110] Discharge Diagnosis: Intracranial hemorrhage UTI Hydrocephalus Respiratory failure Malnutrition Hypertension Altered mental status CHF Cellulitis Electrolyte imbalance Troponin leak Discharge Condition: stable Discharge Instructions: . General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast this can be arranged by calling the above number as well. Completed by:[2127-8-1]	[ "272.0", "427.31", "401.9", "428.0", "430", "435.2", "410.71", "682.3", "348.4", "434.91", "599.0", "263.9", "331.4", "536.3", "518.81", "348.5", "428.21" ]	icd9cm	[ [ [] ] ]	[ "96.04", "33.22", "38.93", "02.39", "31.1", "46.32", "96.72" ]	icd9pcs	[ [ [] ] ]	6646, 6729	5156, 6487	325, 357	6934, 6942	1994, 5133	8186, 8503	1371, 1398				6750, 6913		6513, 6623			6966, 8163								1428, 1754																						241, 287											385, 1017		1774, 1975															1039, 1241	1257, 1355
27,727	133,733	32672	Discharge summary	report	Admission Date: [2121-11-18] Discharge Date: [2121-12-3] Date of Birth: [2052-10-5] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: CABGx3(LIMA->LAD, SVG->OM, RCA)/MV repair(26mm Physio ring)/ASD closure, IABP removal [11-21] History of Present Illness: 69yo woman with new onset angina associated with vomiting started [10-15]. After visit to PCP [Last Name (NamePattern4) ] [11-17] she was referred to ED for evaluation. In ER ruled in for MI. Had cardiac catheterization at OSH which revealed 3 VD an IABP was placed. A subsequent echo revealed 3+MR. She was then transferred to [Hospital1 18] for cardiac surgery Past Medical History: PVD Lupus DVT s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter HTN Sjogren's Chronic sinusitis Osteoporosis ^chol Hypothyroid s/p Tubal Ligation s/p Csection x3 s/p Tonsillectomy Social History: Retirerd school teacher. Lives with spouse. Denies tobacco Occaisioanl ETOH [5-11] drinks/year Family History: noncontributory Physical Exam: Admission: Neuro A&Ox3, nonfocal exam HEENT: unremarkable, EOMI,PERRL Neck-supple, full ROM, no lymphadenopathy CV RRR 1/6SEM Pulm: CTA-bilat Abdm: soft NT/ND +BS Ext: warm palpable pulses. IABP rt groin Pertinent Results: [2121-11-30] 06:45AM BLOOD WBC-8.9 RBC-4.17* Hgb-13.0 Hct-37.9 MCV-91 MCH-31.3 MCHC-34.4 RDW-16.1* Plt Ct-410 [2121-12-2] 09:20AM BLOOD PT-16.2* INR(PT)-1.4* [2121-12-1] 06:15AM BLOOD PT-27.4* PTT-33.0 INR(PT)-2.7* [2121-12-2] 06:30AM BLOOD Glucose-83 UreaN-9 Creat-0.7 Na-134 K-3.9 Cl-92* HCO3-28 AnGap-18 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2121-11-30] 06:45AM 8.9 4.17* 13.0 37.9 91 31.3 34.4 16.1* 410 RADIOLOGY Final Report ABDOMEN U.S. (COMPLETE STUDY) [2121-11-28] 3:31 PM ABDOMEN U.S. (COMPLETE STUDY) Reason: evaluation for RUQ with elevated lipase and amylase [Hospital 93] MEDICAL CONDITION: 69 year old woman with s/p cabg REASON FOR THIS EXAMINATION: evaluation for RUQ with elevated lipase and amylase INDICATION: Status post CABG with elevated lipase and amylase. COMPARISONS: None. ABDOMINAL ULTRASOUND: The gallbladder is unremarkable without evidence of stones. The liver shows no focal or textural abnormalities. There is no intra- or extra-hepatic biliary dilatation. The portal vein is patent with appropriate hepatopetal flow. The right kidney measures 12.0 cm. The left kidney measures 11.9 cm. There are no stones or hydronephrosis. Evaluation of the pancreas is limited as only the head was visualized. The spleen is unremarkable. IMPRESSION: 1. No cholelithiasis. 2. Unremarkable but limited examination of the abdomen as the pancreatic body and tail were not evaluated. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Doctor Last Name ] [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 5259], [Known firstname ] [Hospital1 18] [Numeric Identifier 76129] (Congenital) Done [2121-11-21] at 2:45:23 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2052-10-5] Age (years): 69 F Hgt (in): 63 BP (mm Hg): 120/40 Wgt (lb): 150 HR (bpm): 70 BSA (m2): 1.71 m2 Indication: Intraoperative TEE for CABG/MVR ICD-9 Codes: 745.5, 410.91, 786.05, 440.0, 424.0, 424.2 Test Information Date/Time: [2121-11-21] at 14:45 Interpret MD: [Name6 (MD) 3892] [Name8 (MD) 3893], MD Test Type: TEE (Congenital) 3D imaging. Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5740], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW4-: Machine: 4 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Aorta - Annulus: 1.8 cm <= 3.0 cm Aorta - Sinus Level: 2.6 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.3 cm <= 3.0 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. 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: Mild symmetric LVH. Normal LV cavity size. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Eccentric MR jet. Severe (4+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. 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. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: 1. The left atrium is dilated. 2. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum type ASD IS SEEN 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. Echogenicity noted in the descending aortic distal to the arch, consistent with a intra-aortic balloon pump. 6. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of Severe (4+) mitral regurgitation is seen with noted restricted posterior leaflet motion. Anterior leaflet length in 2.0cm and the Posterior leaflet length in 1.0cm with a C-[Month (only) ] distance of 2.4 cm. 8. The tricuspid valve leaflets are mildly thickened. 9. There is a small pericardial effusion. 10. There is a large right sided pleural effusion. POST-BYPASS: 1. Patient is on an epinephrine infusion along with small doses of phenylephrine. 2. Normal RV systolic function. 3. Overall LVEF is 40%. There is some mild improvement of lateral wall functions. 4. There is a mitral annulus ring seen and it is stable and functioning well with no residual MR [First Name (Titles) ] [Last Name (Titles) ]. 5. Thoracic Aortic contour is intact. 6. Intact interatrial septum. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 3892] [Name8 (MD) 3893], MD, Interpreting physician [Last Name (NamePattern4) ] [2121-11-21] 19:01 CHEST (PA & LAT) [2121-11-30] 2:20 PM CHEST (PA & LAT) Reason: evaluate effusion [Hospital 93] MEDICAL CONDITION: 69 year old woman s/p CABG MV repair REASON FOR THIS EXAMINATION: evaluate effusion STUDY: AP chest, [2121-11-30]. HISTORY: 69-year-old woman with CABG and mitral valve repair. FINDINGS: Sternotomy wires and aortic valve prosthesis are again seen. The cardiac silhouette and mediastinum are within normal limits. There is a left retrocardiac opacity and left-sided pleural effusion. There is some atelectasis at the right lung base. There is again seen a calcified lesion within the right proximal humerus that likely represents _____ bone infarct or calcified enchondroma as described on the prior study. Comparison with more remote films would be helpful. Otherwise, dedicated shoulder radiographs would be helpful. Brief Hospital Course: Admitted to [Hospital1 18] on [11-18] from [Hospital 5279] Hospital for coronary bypass surgery, IABP placed at OSH. She was seen by ID and Treated initially for klebsiella UTI then brought to OR on [11-21], please see OR note for details. In summary the patient had CABGx3(LIMA-LAD,SVG-OM,SVG-RCA)MVRepair(#26 Physio ring)ASD closure. Her bypass time was 161 minutes with a crossclamp time of 126 min. She tolerated the operation well and was transferred to the cardiac ICU in stable condition. The patient was kept sedated and intubated on the day of surgery and on POD1 her IABP was removed and she was extubated. The patient remained in the ICU for several days to wean from her iv medications, her course was also complicated by intermittant Atrial fibrillation for which she was started on Amiodarone both IV and PO. On POD8 she was transferred to the step down floor for further care. She was started on erythromycin eye ointment for supposed conjunctivitis. On the floor her po medications were further adjusted, her activity level was advanced with PT and on POD#12 it was decided she was stable and ready for discharge to rehab. Medications on Admission: HCTZ/Diovan Fosamax 70 Qwk ASA 81 QD MVI Calcium Imuran 50 QD Medrol 2 QD Norvasc 10 QD Synthroid 100 QD Lopressor 25 [Hospital1 ] Coumadin 5 QW-Sun 2.5 other 5 days Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours): while on Lasix. 5. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Methylprednisolone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days: then re-evaluate need for diuresis. 10. Erythromycin 5 mg/g Ointment Sig: One (1) u Ophthalmic TID (3 times a day) for 4 days. 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: 2mg on [12-2] & [12-3], then check INR for continued dosing for PE/IVC filter, target INR 2.0-3.0. Discharge Disposition: Extended Care Facility: [Location 55717] at [Location (un) 5450] NH Discharge Diagnosis: s/p MVRepair(#26 ring)CABGx3(LIMA-LAD,SVG-OM,SVG-RCA)ASD closure [11-21] PMH: CAD, ^chol, HTN, Sjogren's, Lupus, Osteoporosis, Hypothyroid, s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter, tonsillectomy, tubal ligation Discharge Condition: good Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage of wounds Followup Instructions: Dr. [Last Name (STitle) 914] in 2 weeks Dr. [Last Name (STitle) 39975] in 4 weeks Dr. [Last Name (STitle) 76130] in 6 weeks Completed by:[2121-12-3*]	[ "244.9", "414.01", "710.0", "427.31", "427.32", "285.9", "424.0", "584.9", "790.92", "998.0", "745.5", "997.1", "V12.51", "570", "599.0", "428.0", "410.71" ]	icd9cm	[ [ [] ] ]	[ "36.15", "97.44", "35.33", "36.12", "89.60", "35.71", "99.04", "39.61" ]	icd9pcs	[ [ [] ] ]	11749, 11827	8916, 10072	298, 398	12121, 12128	1423, 2063	12327, 12495	1167, 1184		10292, 11726	8167, 8204	11848, 12100		10098, 10269			12152, 12304							6150, 8130	1199, 1404																						248, 260	8233, 8893										426, 806																	828, 1035	1051, 1151
25,440	185,621	26565	Discharge summary	report	Admission Date: [2166-1-20] Discharge Date: [2166-1-20] Service: NEUROLOGY Allergies: Penicillins / Iodine Attending:[First Name3 (LF) 5018] Chief Complaint: tranfer from OSH for intracranial hemorrhage Major Surgical or Invasive Procedure: none History of Present Illness: Pt is an 83 yo male with complex PMH sig for IDDM, HTN, s/p several MIs, and ? atrial fibrillation who is transferred from [Hospital3 ] with a spontaneous ICH. . He was in his usual state of fairly high functioning health today and was on a tractor moving snow today. His wife then looked out and he had stopped the tractor. She went out to see him and he told her he had a headache and she noticed that his left side was not moving normally. EMS was called and brought him to [Location (un) ]. By the time he got there, his wife reports that he was no longer lucid. The initial event was at ~5 pm. At [Location (un) ], he had a seizure by report(unknown quality), was unresponsive, and was intubated and paralyzed there. He then had a head CT which shows an ~20 cc ICH in the right corona radiata of the frontal lobe, with extension into the deep temporal lobe and a question of baseal ganglia involvement. No IV spread is noted. He is on coumadin and his INR was initially 2.8. He was given 2 units FFP and vitamin K at [Location (un) ] and then transferred here. Since arriving here, he has received additional FFP, mannitol, hyperventilation, and was started on a labetalol gtt due to SBPs in the 200-210 range. Repeat head CT showed severe worsening with blood in all ventricles. Bleed size of 138 cc with subfalcine herniation, dilated left lateral ventricle, and effaced cisterns. . ROS: Intubated and sedated Past Medical History: -IDDM -HTN -s/p AAA repair 1 year ago -CAD s/p MIx2 -"Arrhthymia" (? AF) -on coumadin Social History: No EtOH. 25 pack year smoking history, but stopped 30 years ago. Pt has 2 children. Family History: non contributory Physical Exam: Exam:99.9, 237/92-->137/48, 78, 20, 98% on vent Gen:Intubated and sedated HEENT:MMM.Sclera injected. Intubated. OG tube in place. CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally . Neurologic examination(pt on propofol, but earlier exam off medication with same.): Mental status: Intubated and sedated. . Cranial Nerves: I: not tested II: Pupils fixed at 6 mm bilaterally. No corneals. No cough. +gag reflex . Motor: Withdraws slightly to nox stim in [Name Prefix (Prefixes) ] [Last Name (Prefixes) 6816] vs reflex. No withdraw of UEs to nox stim. Does have occ spontaneous movement to light touch or no touch with arm extension and knee/ankle movement. . Sensation: Withdraws legs to stim vs reflex reaction. . Reflexes: Unable to elicit in arms/legs. Pertinent Results: [2166-1-19] 11:05PM PT-20.0* PTT-26.0 INR(PT)-1.9* [2166-1-19] 11:05PM PLT COUNT-205 [2166-1-19] 11:05PM NEUTS-83.8* LYMPHS-13.1* MONOS-2.8 EOS-0.2 BASOS-0.1 [2166-1-19] 11:05PM WBC-17.7* RBC-5.03 HGB-15.5 HCT-44.4 MCV-88 MCH-30.8 MCHC-34.9 RDW-13.3 [2166-1-19] 11:05PM CALCIUM-8.7 PHOSPHATE-2.9 MAGNESIUM-1.4* [2166-1-19] 11:05PM GLUCOSE-263* UREA N-15 CREAT-1.2 SODIUM-143 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-19 [2166-1-20] 04:00AM PT-16.2* PTT-26.3 INR(PT)-1.5* [2166-1-20] 04:00AM PLT COUNT-200 [2166-1-20] 04:00AM WBC-13.5* RBC-4.41* HGB-14.1 HCT-38.6* MCV-88 MCH-31.9 MCHC-36.5* RDW-13.4 [2166-1-20] 04:00AM OSMOLAL-314* [2166-1-20] 04:00AM CALCIUM-8.7 PHOSPHATE-1.6* MAGNESIUM-1.4* CT C-spine: IMPRESSION: No evidence of cervical spine fracture. . CT head: IMPRESSION: Large right intraparenchymal hemorrhage, likely centered at the basal ganglia, with subfalcian and transtentorial herniation. . CXR: IMPRESSION: Satisfactory position of ETT. Nasogastric tube tip in the mid esophagus. Mild pulmonary edema. . XR wrist: IMPRESSION: No evidence of fracture or dislocation. Images limited by oximeter and poor technique. Brief Hospital Course: The patient is a 83 year old male with complex PMH sig for IDDM, HTN, s/p several MIs,and ? atrial fibrillation who is transferred from [Hospital3 ] with a spontaneous ICH. His bleed probably started in the basal ganglia. It was likely a result of HTN given its location. The fact that his INR was in the high 2 range probably caused the bleed to worsen significantly. By the time his scan was repeated here, it had grown to 7 times it original size. It is unclear if it is still growing or has stopped. His pupils were already fixed and dilated by the time we saw him here. He is was cardiovascularly stable on labetalol gtt, mannitol, and propofol with ventilation. However, his INR was still 1.9 when he arrived to [Hospital1 18] for which he received additional FFP. Given the size of his bleed, the swelling, and the fact that his pupils are already fixed, the likelihood of survival is very poor. Neurosurgery was consulted, but there is no neurosurgical option given the size of the bleed. He did have blood in all ventricles, with entrapment of the left lateral ventricle. The possibility that he will get global hydrocephalus is very high. There is no role for a ventricular drain at this point. His chances of survival are very slim at this point, but we will admit him to observe in the ICU overnight before deciding on the next step in his care. His family is very aware of the situation and agrees with the plan. In the ICU, Labetalol gtt was continued with goal SBP<140. Mannitol was given 50 g q6h. The patient was maintained on propofol for sedation. After discussion with the family (wife, daughter and son in law), the patient was made CMO and he expired soon thereafter. Medications on Admission: (remainder of medications not currently known) Coumadin Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: massive intracranial hemorrhage Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2166-1-20]	[ "250.00", "V58.61", "401.9", "431", "412", "427.31", "V45.81", "272.0" ]	icd9cm	[ [ [] ] ]	[ "96.71", "99.07", "96.04" ]	icd9pcs	[ [ [] ] ]	5920, 5929	4067, 5784	274, 280	6004, 6021	2835, 3671	6085, 6246	1982, 2000		5891, 5897		5950, 5983		5810, 5868			6045, 6062								2015, 2318																						190, 236											308, 1754	2374, 2816		3680, 4044								2333, 2358						1776, 1864	1880, 1966
65,627	108,149	38721	Discharge summary	report	Admission Date: [2113-3-27] Discharge Date: [2113-3-30] Date of Birth: [2042-9-10] Sex: F Service: MEDICINE Allergies: Alprazolam / Acetaminophen Attending:[First Name3 (LF) 1257] Chief Complaint: Lethargy, confusion Major Surgical or Invasive Procedure: Arterial line Right IJ central line History of Present Illness: 70F with history of thyroid cancer, COPD, [Hospital 66942] nursing home resident, found by [Hospital1 1501] staff to be lethargic this AM. O2 sat 84% on RA. EMS was called. No further details available at time of this note. . In the ED, initial vs were: T98.2 75 65/34 16 99% on NRB. Awake but confused. Foley placed and looked like pus. Labs notable for leukocytosis to 15K, creatinine 3.9, K 6.3, lactate 1.7, troponin 0.09. UA positive for WBCs. ECG with ST depressions in precordium. Patient was given vancomycin, levofloxacin, ceftriaxone, and getting 3rd liter NS. CVL placed and repositioned to 3 cm outside neck. . In the [Hospital Unit Name 153], patient lethargic but easily arousable, seems to be a poor historian but denied headache, abdominal pain, chest pain, shortness of breath. Past Medical History: - COPD - details unknown - Chronic kidney disease, stage 3 - baseline creatinine unknown - Thyroid cancer s/p thyroidectomy, now hypothyroid - Bipolar disorder/schizoaffective disorder - Coginitive impairment, likely secondary to mental illness ([Name8 (MD) ] NP, patient A&O at baseline, able to dress and feed herself, though non-ambulatory) - Hyperlipidemia - Esophageal stricture - Osteoarthritis - Hypertension - Peripheral vascular disease - Peptic ulcer disease - s/p Subdural hematoma - s/p cholecystectomy Social History: Resident at [Hospital3 ] facility. Does not make own medical decisions at baseline (son [Name (NI) 2259] [Name (NI) ] is HCP). Has four children - two sons and two daughters. [Name (NI) ] [Name (NI) 2259] (HCP) is youngest. Is not ambulatory (?volitional), but can feed and clothe herself. Family History: Non-contributory Physical Exam: (On admission) General: lethargic and easily arousable, and speech mostly confused but at times appropriate, answers simple questions. HEENT: Sclera anicteric, PERRL (resists eye opening), MM dry and resists further opening mouth. Neck: obese, CVL in place, JVD unable to appreciate given body habitus. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi appreciated, overall somewhat distant sounds. CV: Regular rate and rhythm, S1 + S2, [3-11] SM at R and LUSB, some radiation to carotids. Abdomen: soft, obese, bowel sounds present, denies TTP though appears uncomfortable to palpation. Ext: slightly cool on pressors, palpable DP pulses, no clubbing, cyanosis or edema Neuro: Moving all extremities though some difficulty getting her to follow strength commands. Unable to assess orientation, can say full name. Skin: no posterior decubs, though some skin breakdown with fissuring under bilateral breasts. Pertinent Results: Admission labs [2113-3-27] 10:12AM BLOOD WBC-15.0* RBC-3.55* Hgb-11.5* Hct-34.9* MCV-98 MCH-32.4* MCHC-33.0 RDW-14.6 Plt Ct-383 [2113-3-27] 10:12AM BLOOD Neuts-82.4* Lymphs-11.2* Monos-4.4 Eos-1.7 Baso-0.3 [2113-3-27] 10:12AM BLOOD PT-13.6* PTT-27.0 INR(PT)-1.2* [2113-3-27] 10:12AM BLOOD Glucose-126* UreaN-67* Creat-3.9* Na-140 K-6.3* Cl-107 HCO3-21* AnGap-18 [2113-3-27] 10:12AM BLOOD ALT-17 AST-23 CK(CPK)-100 AlkPhos-75 TotBili-0.3 [2113-3-27] 10:12AM BLOOD Lipase-39 [2113-3-27] 04:34PM BLOOD CK-MB-3 cTropnT-0.06* [2113-3-28] 04:02AM BLOOD CK-MB-4 cTropnT-0.05* [2113-3-27] 10:12AM BLOOD Albumin-3.2* Calcium-8.8 Phos-5.3* Mg-2.4 [2113-3-27] 10:17AM BLOOD Glucose-122* Lactate-1.7 Na-142 K-6.0* Imaging and studies [2113-3-27] - AP CXR - IMPRESSION: Markedly limited study without gross signs of pneumonia or CHF. [2113-3-27] ECG - Normal sinus rhythm. Leftward axis at minus 14 degrees. Increased R wave in the right precordial leads. ST-T wave changes in leads I, II, aVL and V2-V6. No previous tracing available for comparison. While non-specific these ST segment depressions are suggestive of myocardial ischemia. Intervals Axes Rate PR QRS QT/QTc P QRS T 81 138 106 392/428 53 -14 141 [2113-3-28] - Transthoracic ECHO - The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The 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. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: A 70 year old woman with COPD and hypothyroidism s/p thyroidectomy for thyroid cancer who presented from her [Hospital1 1501] with lethargy and was found to be hypoxic, hypotensive, and have a UTI. . # Septic shock/Urinary tract infection. The urinary source was suspected. She had clearly positive UA in [Hospital1 1501] patient; urine culture grew out Strep viridans, an unusual urinary pathogen. She had no evidence of pneumonia. She had no recent antibiotic exposure or diarrhea to suggest C.diff. Blood cultures remained negative. ECHO was negative without evidence of vegetation (Strep viridans is more associated with endocarditits than UTI). Pressors were quickly weaned off and patient's mental status improved. She was initially treated with vancomycin, ceftriaxone, and ciprofloxacin ([3-27]) but continued only on ceftriaxone when urine culture grew out Strep viridans. She will continue to receive Ceftriaxone at her nursening home for 3 days and then oral antibiotics (Amoxicillin) for full course. Her home blood pressure medications were initially held, she received several IVF boluses, and metoprolol was restarted on [3-29]. We did not restart nifedpine, HCTZ, or [Last Name (un) ] on discharge. These medications can be restarted when her kidney function normalizes. She SHOULD NOT RECEIVE HCTZ AT SUCH HIGH DOSE (50 mg) as this will results in numerous side effects without significant reduction in blood pressure. If her GFR decreases, she should not receive HCTZ at all, and Lasix can be used instead for hypervolemia. If she develops bacteremia from Strep viridans, TEE and colonoscopy ( colon cancer) should be considered. . # Acute on chronic renal failure. Patient has a history of stage 3 ARF on CKD. She was prerenal on admission from volume depletion and creatine improved with IVFs. She may have also had some component of ATN from ischemia/hypotension. No reason for postobstructive process. . # Atrial fibrillation. No documented history of Afib. She had Afib on morning of [3-28] after receiving norepinephrine and 500 ml of LR for hypotension. Afib resolved spontaneously after about half hour and likely caused by atrial distention from fluid bolus. Given her lack of history of a fib and quick conversion, anticoagulation was felt to not be indicated. She laready receives ASA and Plavix for unclear reasons (other than ? H/O CAD/PVD from NH notes) . # AMS. She was lethargic at nursing home, in [Hospital1 18] ED, and upon admission to MICU. There was nothing focal on exam to suggest focal CNS process. She is an elderly woman with polypharmacy on a number of sedating meds which may be affected by renal failure. Her mental status rapidly improved over the 2 day ICU stay and was back to normal on discharge. ICU team held sedating medications during ICU stay (depakote, risperidone, wellbutrin, trazadone). Upon leaving ICU, wellbutrin and depakote were restarted. . # Anemia. Hct drop likely dilutional in the setting of receiving IVFs for septic shock. No signs of bleeding on exam, guiac negative. . # Hyperkalemia. In ED patient had K of 6.3. Likely combination of ARF, K supplementation at [Hospital1 1501] in this setting, and [Last Name (un) ] use. K improved rapidly with with improvement in urine output and was down to 3.1 by morning of [3-29]. . # Polypharmacy: This elderly woman with polypharmacy on a number of sedating medications and CKD. Her medications should be reconsidered by her PCP and some should be discontinued. No clear indication for DAPT (dual antipatelet therapy) in this woman, and this combination should be reconsidered. Her BP medications and diuretics should also be reconsidered (see above). . # total discharge time 45 minutes. Medications on Admission: KCl 20 meq [Hospital1 ] Metoprolol 50 mg [Hospital1 ] ASA 325 mg daily plavix 75 mg daily simvastatin 40 mg daily Benicar 40 mg daily nifedipine XL 30 mg daily HCTZ 50 mg daily Levothyroxine 50 mcg daily Combivent inhaler 2 puffs QID spiriva 18 mcg daily guiafenesin 10 ml HS famotidine 40 mg HS fluticasone nasal HS wellbutrin 150 mg [Hospital1 ] / 75 mg [Hospital1 ] per oupt records Risperidone 1 mg HS / 0.5 mg QHS per outpt records depakote 250 mg [Hospital1 ] trazodone 75 mg HS Actonel 35 mg once weekly. colace 100 mg daily oxycodone 5 mg at HS and Q4H prn pain (last dose yesterday HS) // 5 mg [Hospital1 ] per outpt records lidoderm patch to low back daily MVI Caco3 500 mg [Hospital1 ] Vitamin D 800 units daily Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for under breast excoriation/yeast. 12. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [2-4] Puffs Inhalation Q6H (every 6 hours) as needed for wheeze or dyspnea. 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 19. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 20. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 3 days. 22. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO twice a day for 7 days: Please start once she finishs Ceftriaxone. . Discharge Disposition: Extended Care Facility: [Hospital6 4657] - [Location 1268] Discharge Diagnosis: VIRIDANS STREPTOCOCCI urinary tract infection Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You had VIRIDANS STREPTOCOCCI isolated in your urine which is uncommon bacteria to cause urinary tract infection. However, you had a quick recovery with IV antibiotics. If you develop blood infection with this bacteria, you will need more tests such as an echocardiogram through the esophagus and colonoscopy. Followup Instructions: follow up with your PCP at the rehab facility	[ "599.0", "293.0", "295.62", "443.9", "272.4", "785.52", "584.9", "403.90", "285.21", "041.09", "427.31", "276.7", "496", "V10.87", "995.92", "296.89", "585.3", "276.2" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	11551, 11620	4979, 8730	307, 344	11709, 11709	3054, 4956	12215, 12263	2070, 2088		9532, 11528		11641, 11688		8756, 9509			11881, 12192								2103, 3035																						248, 269											372, 1181											11724, 11857						1203, 1724	1740, 2054
73,973	120,478	2735	Discharge summary	report	Admission Date: [2187-11-30] Discharge Date: [2187-12-17] Date of Birth: [2121-6-10] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 4659] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [2187-12-6] - Lysis of adhesions and ileocecectomy. History of Present Illness: 66M with history of colon CA s/p LAR, chemotherapy, and radiation in [2174], has had intermittent abdominal pain with concern for obstruction and multiple ED visits with a few admissions for partial small bowel obstructions that seem to be getting more frequent. He was last admitted [11-19] and was seen by Dr. [Last Name (STitle) ] in clinic [11-26] at which time they scheduled surgery for later in [Month (only) 404]. He started developing his typical abdominal pain and absence of flatus at 7pm [11-29]. Stated he only had a small amount of soft foods for [Holiday ] meal but also that he has eaten a lot less recently. He is only mildly nauseated, no vomitting. He states his pain is diffuse in his abdomen, crampy and occasionally burning. However, feels fairly well and is not as bad as his last attack. Past Medical History: arrythmia/palpitations colorectal cancer s/p chemotherapy and radiation in [2174] s/p LAR in 3/96 s/p removal of port-a-cath in 9/96 Social History: The patient is single. He does not smoke and drinks rarely. He has a step-child. He repairs cars in a garage. Family History: The patient's mother died of some sort of cancer. A first cousin had rectal cancer at the age of 68 and his father died at the age of 40 of unknown cause. Physical Exam: At discharge: V.S: 98.1, 80, 103/64, 20, 98% RA PE: afebrile, nontachycardic, normal vitals Gen: no distress, alert and oriented x 3 HEENT: PERLA, EOMI, anicteric, dry mucus membranes Neck: supple, no LAD Chest: RRR, no murmurs, lungs clear bilaterally Abd: soft, +BS, incision with staples, distal aspect with staples removed and w-d dsg. Ext: palplable pulses, no edema Pertinent Results: [2187-11-30] 01:20AM BLOOD WBC-9.5# RBC-4.46* Hgb-15.3 Hct-42.1 MCV-95 MCH-34.4* MCHC-36.3* RDW-12.9 Plt Ct-259 [2187-12-13] 08:46AM BLOOD WBC-7.7 RBC-3.11* Hgb-10.5* Hct-29.9* MCV-96 MCH-33.8* MCHC-35.1* RDW-13.4 Plt Ct-287 [2187-11-30] 01:20AM BLOOD Glucose-105 UreaN-15 Creat-1.2 Na-140 K-3.7 Cl-102 HCO3-29 AnGap-13 [2187-12-14] 05:16AM BLOOD Glucose-103 UreaN-17 Creat-0.7 Na-139 K-3.9 Cl-108 HCO3-26 AnGap-9 [2187-12-9] 03:56AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [2187-12-9] 03:56AM BLOOD HCV Ab-NEGATIVE . ABDOMEN (SUPINE & ERECT) Study Date of [2187-11-30]: IMPRESSION: Slightly more extensive appearance of dilated small bowel loops and air-fluid levels compared to 11 days prior, and again concerning for small-bowel obstruction, either early or partial. . Pathology Examination: intestinal foreign body, ileo cecectomy. DIAGNOSIS: I. Intestinal foreign body; confirmed by gross examination. II. Ileocecectomy: 1. Marked peritoneal fibrosis adhesions, attached to ileum. 2. Hemorrhagic infarction of the ileum, ranging from mural to mucosal (at margin). 3. Colonic segment, within normal limits. 4. Vermiform appendix, with partial obliteration. 5. No tumor. Brief Hospital Course: Mr. [Known lastname 174] is a 66yo M admitted for management of abdominal pain. He had a x-ray of his abdomen and was initially NPO with IV fluid hydration, IV antibiotics, and PRN Morphine IV. His abdominal pain improved slightly, and he was able to tolerate clear liquids. A Picc line was inserted on HD5 ([12-4]), and TPN was started as supplemental nutrition. He had surgery on [2187-12-6] for Ex-lap, LOA and ileocecectomy. . * Atrial Fibrillaiton with RVR: while on the floor in the AM of [2186-12-7], he developed atrial fibrillation with RVR to 140's, likely secondary to holding of home atenolol in setting of bowel surgery. He was transferred to the MICU and started on diltiazem gtt at 5mg/hr with little effect on heart rate and systolic blood pressures in the 70-80's though patient was asymptomatic. Bolused a total of 2L NS without significant effect. Of note, patient unable to take po medication as he was post-operative from bowel surgery. Given lack of response to diltiazem drip, it was stopped and patient was loaded with digoxin 0.5mg iv followed up 0.25mg q6h for 2 doses. He was transferred to [Hospital Ward Name 1950] 5 and his was controlled with Metoprolol Succinate XL . * S/P Bowel surgery: Pt's pain was controlled by a PCA and his diet continued to be NPO. With the return of bowel function the patient was started on sips advanced to low residue diet as tolerated and oral medications were restarted. TPN was also d/c'd when pt was able to meet caloric needs orally. Pt c/o loose stool, C.diff cultures were sent x2- negative. Distal aspect of pt's incision was opened at bedside on POD9 [1-7] serous drainage, pt d/c'd with VNA for w-d dsging changes. . Prior to discharge wound care and medications were reviewed with pt and his PICC line was removed. Pt will follow up with Dr. [Last Name (STitle) ] in [12-7] weeks to have his staples removed. Medications on Admission: Atenolol 50, Vicodin, Prilosec 20, Viagra 100 PRN, GLUCOSAMINE, MVI, Fibercon Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. Viagra 100 mg Tablet Sig: 1/2-1 Tablet PO PRN. 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks: Do not exceed acteaminophen 4000 mg per day. . Disp:45 Tablet(s) Refills:0 6. Cholestyramine Light 4 gram Packet Sig: .[4-4] packet PO BID (2 times a day). Disp:60 240 grams Refills:2 7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 1 weeks. Disp:28 Capsule(s) Refills:0 8. Erythromycin 5 mg/g Ointment Sig: One (1) both eyes Ophthalmic [Hospital1 ] (2 times a day) for 5 days. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: Small bowel obstruction, Post-op atrial fibrillation, Post-op wound infection, post-op dehydration r/t loose stools, negative c-dif x 2 . Secondary: 1. Colon cancer in [2174], status post sigmoid colectomy and adjuvant chemotherapy and radiation therapy. Per the patient's record his staging was T2, N1, M0. 2. Barrett's esophagus and GERD. 3. History of recurrent small-bowel obstruction. 4. History of cardiac arrhythmia/PAF. The patient reports that he takes atenolol for this as it appears to be stable. Has never been anticoagulated Discharge Condition: Stable. Tolerating low residue diet. Pain well controlled with oral medication. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * 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 your follow up appointment and 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. Followup Instructions: 1. Please call Dr.[Name (NI) 6218] office to make an appointment in [12-7] weeks, [Telephone/Fax (1) 8792] for removal of staples. 2. Please call you PCP, [Known lastname 13532],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 250], to make an appointment in 1 week or as needed. . Scheduled Appointments : 3. Provider: [Name10 (NameIs) ] [Known lastname 13532], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2188-2-5] 1:30 4. Provider: [First Name8 (NamePattern2) 2671] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2188-3-19] 1:15 5. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2038], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2188-8-29] 10:00 [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Name8 (MD) ] MD, [MD Number(3) 4661] Completed by:[2187-12-18]	[ "997.4", "557.0", "V10.05", "E878.6", "997.1", "530.85", "427.31", "682.2", "E915", "560.1", "530.81", "998.59", "276.51", "936", "751.0", "560.81" ]	icd9cm	[ [ [] ] ]	[ "54.59", "99.15", "45.73", "38.93" ]	icd9pcs	[ [ [] ] ]	6289, 6346	3383, 5303	340, 398	6941, 7023	2137, 3360	8539, 9499	1572, 1729		5431, 6266		6367, 6920		5329, 5408			7047, 8084					8099, 8516			1744, 1744														1758, 2118								285, 302											426, 1268																	1290, 1428	1444, 1556
79,931	169,901	5239	Discharge summary	report	Admission Date: [2141-5-15] Discharge Date: [2141-5-21] Date of Birth: [2082-8-25] Sex: M Service: MEDICINE Allergies: Nafcillin Attending:[First Name3 (LF) 3624] Chief Complaint: Septic left knee Major Surgical or Invasive Procedure: [2141-5-16] - Left knee washout History of Present Illness: Mr. [Known lastname 284] is a 58 year-old male with a history notable for kidney-pancreas transplant 15 years ago (on immunosuppressive therapy), Diabetes (on insulin), HTN, HLD, CKD, PVD (status-post L BKA, R TMA) who presented to [Company 191] today for left knee pain and swelling. Of note, he does have a chronic ulcer over his left stump for years that usually does not drain. On Friday, he noted the onset of left knee swelling. Denied trauma to the area or any open wounds around the site. Over the weekend, his symptoms progressed, with intensified pain, and he developed chills and a temperature to 100.7 on the day of presentation. He did continue to wear his prosthesis over the weekend. From [Company 191], he was referred to [Hospital 2225] clinic. In [Hospital ] clinic, he had his knee aspirated which returned 50cc of cloudy fluid concerning for septic arthritis. From there, he was referred to the ED for concern of septic arthritis. In the ED, initial VS were: 101.3 133 106/65 18 99% RA. Labs showed WBC of 9.7, Hct 34.3, Cr of 2.7 (baseline 1.6-2.0), K 5.8. Joint fluid analysis showed WBC of [Numeric Identifier 21397] with 93% polys as well as "FEW RHOMBOID EXTRACELLULAR POSITIVELY BIREFRINGENT C/W CALCIUM PYROPHOSPHATE" as well as crystals C/W Monosodium Urate Crystals. Gram stain was positive for 2+ Gram positive cocci as well as 4+ leukocytes. Blood and urine cultures were sent. Lactate was 3.0. Orthopedics was consulted who recommended ICU admission and NPO for OR tomorrow. He was given vancomycin 1gm IV and meropenem 1gm IV as well as morphine 5mg IV x1. On transfer, vitals were: Temperature 99.5 ??????F (37.5 ??????C). Pulse 129. Respiratory Rate 18. Blood Pressure 117/89. O2 Saturation 99. O2 Flow ra. Pain Level [9-1]. On arrival to the MICU, patient was tachycardic but otherwise VSS without acute distress. Past Medical History: Type 1 diabetes, status post kidney and pancreas transplant [2125] with subsequent 'burnout' of the pancreatic graft, now on insulin (Patient states his DM is now treated more like a type II s/p pancreatic transplant) Congestive heart failure, EF 60-65% on echo [7-3], calcified aortic and mitral valves. Hypertension Hyperlipidemia PVD s/p L BKA, R TMA, and multiple digit amputations both hands DVT in [2133] Chronic Kidney Disease baseline Cr 1.6 Tertiary Hyperparathyroidism s/p parathyroidectomy (three lobes). Sleep apnea (patient does not use CPAP) Multiple admissions for osteomyelitis. Social History: Previously smoked 2 ppd for 10 years, but quit 20 years ago. Drinks alcohol rarely on social occasions. Denies use of illicit drugs. Volunteers in the hospital as a patient liaison. Lives with daughter and wife at home. Family History: Diabetes runs on both sides of his family, many generations. Physical Exam: ADMISSION PHYISCAL EXAM Vitals: T: 101.3. HR 124. BP 131/71. RR 20 95% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal S1 + S2, [1-27] pansystolic murmurs in the aortopulmonic region without radiation to the carotids or the axilla, no rubs or gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Left BKA. Left knee edematous and warm with TTP lateral to the patella. Stump with chronic keratosed wound. Right lower extremity with missing phalanges. Chronic ulceration on right MCP-PCP joint and well as lateral aspect of right foot. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred. Discharge exam - unchanged from above, except as below: CV: RRR, 1/6 systolic murmur heard throughout the precordium Extr: Left knee still mildly tender to palpation, minimal pain with ROM. No erythema or drainage from the incision site. Pertinent Results: Admission labs: [2141-5-15] 08:20PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.007 [2141-5-15] 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-LG [2141-5-15] 08:20PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-<1 [2141-5-15] 08:20PM URINE MUCOUS-RARE [2141-5-15] 07:24PM LACTATE-3.0* [2141-5-15] 07:10PM GLUCOSE-250* UREA N-71* CREAT-2.7# SODIUM-135 POTASSIUM-5.8 CHLORIDE-97 TOTAL CO2-16* ANION GAP-28* [2141-5-15] 07:10PM estGFR-Using this [2141-5-15] 07:10PM CRP-GREATER TH [2141-5-15] 07:10PM WBC-9.7# RBC-4.05* HGB-10.8* HCT-34.3* MCV-85 MCH-26.6* MCHC-31.4 RDW-14.7 [2141-5-15] 07:10PM NEUTS-90.4* LYMPHS-5.8* MONOS-3.2 EOS-0.5 BASOS-0 [2141-5-15] 07:10PM PLT COUNT-255 [2141-5-15] 07:10PM PT-13.1* PTT-25.0 INR(PT)-1.2* [2141-5-15] 07:10PM SED RATE-121* [2141-5-15] 05:15PM JOINT FLUID WBC-[Numeric Identifier 21397]* RBC-750* POLYS-93* LYMPHS-2 MONOS-0 MACROPHAG-5 [2141-5-15] 05:15PM JOINT FLUID NUMBER-FEW SHAPE-NEEDLE LOCATION-I/E BIREFRI-NEG COMMENT-c/w monoso Discharge labs: [2141-5-21] 05:09AM BLOOD WBC-3.7* RBC-3.28* Hgb-8.5* Hct-28.1* MCV-86 MCH-26.0* MCHC-30.3* RDW-15.3 Plt Ct-328 [2141-5-21] 05:09AM BLOOD Glucose-68* UreaN-54* Creat-1.5* Na-143 K-4.4 Cl-104 HCO3-27 AnGap-16 [2141-5-21] 05:09AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.8 MICRO DATA: -Left knee joint fluid: FINAL REPORT [2141-5-21] GRAM STAIN (Final [2141-5-15]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. Reported to and read back by DR. [First Name (STitle) ] [Name (STitle) ] AND [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 21398] (ED) @ [2034], [2141-5-15]. FLUID CULTURE (Final [2141-5-21]): STAPH AUREUS COAG +. SPARSE GROWTH. Daptomycin AND DOXYCYCLINE REQUESTED BY DR.[Last Name (STitle) ] #[Numeric Identifier 21399] [2141-5-19]. Daptomycin MIC = 0.19 MCG/ML Sensitivity testing performed by Etest. SENSITIVE TO DOXYCYCLINE sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S DAPTOMYCIN------------ S ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S -All BCx were no growth at the time of discharge Imaging: -L knee plain film ([2141-5-15]) IMPRESSION: 1. Status post below left knee amputation. 2. Small-to-moderate suprapatellar joint effusion. 3. No evidence of acute fracture or dislocation. 4. Osteoarthritic changes, as above. 5. Extensive vascular calcifications. -TTE ([2141-5-16]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are moderately thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No vegetations seen. Mild symmetric hypertrophy with vigorous global and regional biventricular systolic function. Aortic sclerosis withotu frank stenosis. Mild mitral regurgitation. Mild pulmonary hypertension. -CXR ([2141-5-19]): A new right-sided PICC line tip ends just in the right upper atrium. Consider pulling the PICC line by 2 cm to position the PICC line at low SVC or cavoatrial junction. There is no pneumothorax or pleural effusion. Small bibasilar atelectasis is present. Heart size, mediastinal and hilar contours are normal. Brief Hospital Course: 58 year-old male with history of Type I DM s/p failed pancreatic transplant and working renal transplant/Stage III CKD, dCHF, and PVD s/p left BKA here with septic arthritis of his left knee # Left knee septic arthritis: Initial presentation was concerning for septic arthritis and patient was sent from his [Company 191] appointment to the ED. He was seen by orthopedics and had a washout of the left knee on [2141-5-16]. He has multiple skin ulcers in the area of his amputation sites, which may have been the original source of his infection (although blood cultures this admission were negative and no evidence of bacteremia). He was initially started on vancomycin which was changed to cefazolin when the culture results from the joint fluid showed MSSA. Infectious disease was consulted. Of note, he is allergic to nafcillin (caused leukopenia and [Last Name (un) ] according to records). His pain improved and he was afebrile at the time of discharge. He will continue a 5 week course of cefazoloin at home after discharge. He had a PICC line placed and will have home IV infusion services to assist him with the antibiotics. He will be followed by the [Hospital 4898] clinic after discharge with weekl labs drawn by his VNA. Blood cultures remained negative at the time of discharge. # ESRD s/p renal transplant with [Last Name (un) ] on Stage III CKD: Creatinine was initially elevated to 2.7 at admission and improved back to baseline after he was fluid resuscitated. Likely etiology was pre-renal azotemia in the setting of sepsis. His lisinopril was held because of the [Last Name (un) ]. BP remained well controlled and he will hold lisinopril at discharge, will disucss with outpatient providers when to restart this. His cyclosporine was discontinued in the setting of a severe infection. Sirolimus dose was decreased to 0.5mg daily. He will have rapamycin level checked after discharge and faxed to Dr. [Last Name (STitle) 21400] office. # Anemia: His Hct remained close to his baseline of high 20s to low 30s, baseline very variable in our records. Etiology likely related to his renal disease. He did not receive any blood transfusions and did not have any evidence of active bleeding. # Metabolic acidosis, non-anion gap: Bicarbonate reached a nadir of 13 this admission. He was initially not receiving his home dose of PO bicarbonate. Given that he is s/p pancreatic transplant, he is likely wastnig significant amounts of bicarbonate into his bowel. After he was restarted on his PO doses of bicarbonate, his acidosis improved. # T1DM s/p failed pancreatic transplant: he was continued on his home doses of Glargine and a Humalog sliding scale with fair control of his blood sugar. As described above, he was restarted on his home doses of PO bicarbonate. --Chronic issues-- # Hypertension: Held lisinopril as above, can be restarted as an outpatient if Cr stable and BP elevated. # Hyperlipidemia: Continued on home dose of atorvastatin. # Peripheral vascular disease: Continued on home aspirin dose. # BPH: Continue the patient's home tamsulosin and finasteride. #Code status this admission: Full #Transitional issues: -Will have rapamycin level checked as an outpatient, dose decreased this admission and may need to be titrated -Cyclosporine discontinued this admission in the setting of infection, consider restarting as an outpatient after he has completed his course of antibiotics -Will receive a total of 5 weeks of cefazolin after discharge via PICC line. Followed by [Hospital 4898] clinic -Has follow-up arranged with his transplant nephrologist and orthopedics after discharge -Consider restarting lisinopril as an outpatient, held at discharge because of [Last Name (un) ] Medications on Admission: ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth qpm CYCLOSPORINE MODIFIED - (Dose adjustment - no new Rx) - 100 mg Capsule - 1 Capsule(s) by mouth twice daily Please do not change among generics. CYCLOSPORINE MODIFIED - 25 mg Capsule - 1 Capsule(s) by mouth twice a day V42.0 FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day INSULIN ASPART [NOVOLOG] - 100 unit/mL Solution - 5 units at lunch and 10 units at suppertime as directed INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin Pen - 34 units daily at night please dispense 90 day supply= 3 boxes of 5 pens. LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth daily OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day PREDNISONE - 5 mg Tablet - one Tablet(s) by mouth once daily SIROLIMUS [RAPAMUNE] - 1 mg Tablet - 1 Tablet(s) by mouth daily TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth at bedtime ZOLPIDEM - 5 mg Tablet - One Tablet(s) by mouth at bedtime as needed for sleep . Medications - OTC ASPIRIN - (Prescribed by Other Provider; OTC) - 325 mg Tablet - one Tablet(s) by mouth once daily CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - (OTC) - 315 mg-200 unit Tablet - 1 Tablet(s) by mouth daily INSULIN NEEDLES (DISPOSABLE) [BD INSULIN PEN NEEDLE UF ORIG] - 29 gauge X [1-23]" Needle - Use one daily as directed with lantus solostar INSULIN SYRINGE-NEEDLE U-100 [INSULIN SYRINGE MICROFINE] - 28 gauge X [1-23]" Syringe - use as directed three times a day; [4-1] ML insulin syringes w/28 gauge [1-23]"needles; please dispense 90 day supply MV,CA,MIN-IRON-FA-LYCOPENE [CENTRUM ULTRA MEN'S] - (OTC) - 8 mg (iron)-200 mcg-600 mcg Tablet - 1 Tablet(s) by mouth daily SODIUM BICARBONATE - (Dose adjustment - no new Rx) - 650 mg Tablet - 3 Tablet(s) by mouth three times a day Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. insulin glargine 100 unit/mL Solution Sig: Thirty Four (34) units Subcutaneous at bedtime. 4. insulin aspart 100 unit/mL Solution Sig: Sliding scale units Subcutaneous three times a day: 5 units as lunchand 10 units at dinner. Sliding scale: 151-200: 4 units, 201-250: 6 units, 251-300: 8 units, 301-350: 10 units, 351-400: 12 units, Over 400: [Name8 (MD) ] MD. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. sirolimus 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 9. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for fever or pain: [Name8 (MD) ] MD if giving for fever. 13. cefazolin 1 gram Recon Soln Sig: Two (2) grams Intravenous every eight (8) hours for 32 days: Last dose on [2141-6-19]. Disp:32 days Refills:0 14. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush: For PICC flush. Disp:QS 32 days Refills:0 15. sodium bicarbonate 650 mg Tablet Sig: Three (3) Tablet PO three times a day. 16. morphine 15 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain for 7 days. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: Primary diagnoses: Septic arthritis Secondary diagnoses: Type 1 diabetes s/p pancreas transplant End stage renal disease s/p kidney transplant Peripheral vascular disease 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 284], It was a pleasure taking care of you during your admission to [Hospital1 18] for joint pain and fevers. You were found to have septic arthritis, which is an infection inside your left knee. This was treated with IV antibiotics and the orthopedic surgeons washed out the joint in the operating room. Your fevers and pain improved and you will be discharged to rehab to continue your course of IV antibiotics. Please do not bear weight on your left knee until you are seen by the orthopedic surgeons in follow-up next week. The following changes were made to your medications: START cefazolin 2grams every 8 hours for a total of 5 weeks (last dose [2141-6-19]) START morphine sulfate 15mg every 4-6 hours as needed for pain CHANGE sirolimus to 0.5mg daily STOP lisinopril, Dr. [Last Name (STitle) 21401] will discuss with you when to restart this STOP cyclosporine, Dr. [Last Name (STitle) 21401] will discuss with you when to restart this Followup Instructions: You will be contact[Name (NI) ] regarding an appointment with the Transplant Infectious Disease Clinic after discharge. If you do not hear from them in the next week, please call [Telephone/Fax (1) 457]. Department: TRANSPLANT CENTER With: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage *The office is working on a follow up appt for you in the next 1-2 weeks and will call you at the rehab with the appt. If you dont hear from them by Tuesday, please call the office directly to book. Department: ORTHOPEDICS When: TUESDAY [2141-5-30] at 11:40 AM With: [First Name11 (Name Pattern1) 2191] [Last Name (NamePattern4) 2192], NP [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: PODIATRY When: WEDNESDAY [2141-5-24] at 9:40 AM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 542], DPM [Telephone/Fax (1) 543] Building: Ba [Hospital Unit Name 723] ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970] MD [MD Number(1) 3629**]	[ "711.06", "428.0", "276.7", "403.90", "274.01", "V49.73", "584.9", "E878.0", "V49.75", "600.00", "707.8", "250.00", "276.2", "V42.83", "585.3", "285.21", "356.9", "V58.67", "428.32", "458.9", "V49.62", "041.11", "V70.7", "996.81" ]	icd9cm	[ [ [] ] ]	[ "80.86", "81.91", "80.76" ]	icd9pcs	[ [ [] ] ]	16544, 16612	9066, 12249	288, 326	16828, 16828	4405, 4405	18023, 19507	3135, 3197		14750, 16521		16633, 16670		12872, 14727			17004, 18000		5568, 9043						3212, 4386	16691, 16807															12270, 12846						231, 250											354, 2249						4421, 5552					16843, 16980						2271, 2881	2897, 3119
68,355	114,452	48489+59099	Discharge summary	report+addendum	Admission Date: [2182-5-24] Discharge Date: [2182-6-3] Date of Birth: [2115-12-3] Sex: F Service: MEDICINE Allergies: Motrin Attending:[First Name3 (LF) 4891] Chief Complaint: Hand pain Major Surgical or Invasive Procedure: I+D of the left hand History of Present Illness: 66 y/o with ESRD on HD M/W/F, CAD, PVD, DM, HTN presents with worsening pain and swelling left 3rd digit for 2-3 weeks. Pt had L UE AV fistula banded for vascular steal symptoms on [2182-5-9] by Dr. [First Name (STitle) ]. Prior the operation the pt describes her had as black. Pt says the pain and swelling the the digits started within a few days of the operation. No F/C/S. The syptoms were progressively worsening of the last week. She went to see Dr. [Last Name (STitle) ] (? transplant) today in clinic. There she had diminished L radial pulse with strong doppler signal. Ulnar pulse also has a strong doppler signal. There is good cap refill and was sent in to the ED for eval of possible infection. . In the ED, initial VS: T97.7, 61, 179/49, 18, 100%RA. Initial exam felt consistent with paronychia. I+D attempted without pus by ED resident. Hand was consulted and did a 2nd attempt of I+D was performed. Pt received ampicillin-Sulbactam and Vanco 1gm in the ED. No pus produced. Packed by hand team who argeed with treatment of vanco and unasyn (per ED). X ray performed and read as Soft tissue defect at the nail bad and osteomyelitis of the distal phalanx of the left 4th digit. Per ED report hand is less impressed with the idea of osteomyletis. Hand will continue to follow. Pt remained HD stable in ED. PIV in place. VS prior to transfer 98.5, 65, 180/64, 16, 100% RA. . ON arrival the pt complaints of severe left finger pain and her dressing has quickly soaked through. BP 201/60, but denies CP, HA, change in vision. . 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: PER [Last Name (STitle) ]: PVD - s/p left SFA stent placement [6-15] CAD - 3VD per cath [2179], s/p stent to RCA in [2177] DM - on insulin, last A1C 8.9% in [3-/2181] ESRD - HD-M/W/F @ [Location (un) ] (Dr. [First Name (STitle) ] HTN hyperlipidemia hyperparathyroidism s/p hysterectomy h/o colonic polyps s/p phacoemulsification with posterior chamber lens implant left eye [2181-6-14]. Anemia Paroxysmal atrial fibrillation. Social History: Lives in [Location 2268] with daughter on [Location (un) 448] of her house, no history of tobacco, alcohol, drugs. Family History: Diabetes, hypertension in several family members Physical Exam: VS: T96.9, BP 201/60, 65, 22, 98% GENERAL: elderly appears AA female in moderate painful distress. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: no JVD, HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e. Left 3rd digit with 1cm incision along radial aspect with wick exposed, ongoing bleeding. good cap refill in BL hands. Swelling of finger largely confined to distal to DIP. very TTP on the finger pad. Given pain flexsion PIP, DIP limited. No swelling appreicated proximal to PIP. no erythema. Radial and ulnar only appreciated by doppler. LUE fistula with good thrill. SKIN: dark nail changes in BL U and L ext which pt says is new since operation. No obvious splinter hemrhorages. muliple dark macules on palms / soles which appear chronic and nonblanching (therefore unlikely to be [Last Name (un) ] lesions. NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength and senstion grossly intact throughout. Pertinent Results: [2182-5-24] 04:33PM LACTATE-1.7 K+-5.3 [2182-5-24] 04:25PM GLUCOSE-237* UREA N-33* CREAT-5.2# SODIUM-133 POTASSIUM-7.8 CHLORIDE-95* TOTAL CO2-31 ANION GAP-15 [2182-5-24] 04:25PM CALCIUM-9.3 PHOSPHATE-3.8 MAGNESIUM-2.1 [2182-5-24] 04:25PM WBC-3.6* RBC-3.58* HGB-11.4* HCT-35.1* MCV-98 MCH-31.9 MCHC-32.5 RDW-16.1* [2182-5-24] 04:25PM NEUTS-57.0 LYMPHS-29.5 MONOS-9.8 EOS-3.0 BASOS-0.8 [2182-5-24] 04:25PM [Name (NI) 8255] TO PTT-UNABLE TO INR(PT)-UNABLE TO [2182-5-24] 04:25PM PLT COUNT-107* MICROBIOLOGY: blood cult pending . STUDIES: X-ray left finger: Soft tissue defect at the nail bad and osteomyelitis of the distal phalanx of the left 4th digit. . ECG: [2182-5-24] 2251: NSR at 65, NANI. old TWF in lateral [Location (un) 18187]. No st changes. poor R wave progression. . MRI BRAIN: Multiple areas of high signal in subcortical and periventricular distribution are redemonstrated on FLAIR imaging, compatible with small vessel ischemic disease. Mild prominence of sulci and ventricles is again noted, suggestive of global atrophy. There is no evidence of acute infarction. On T2-weighted images, there is high signal intensity involving the left pons, compatible with remote infarction. MRA BRAIN: There is severe stenosis involving bilateral posterior cerebral arteries. Severe stenosis of the right distal M1 and M2 segments of the right middle cerebral artery are demonstrated. The left MCA is minimally narrowed. A supraclinoid segment of the left internal carotid artery appears markedly narrowed. These multiple foci of stenosis were not visualized on most recent CTA of [2182-5-27]. IMPRESSION: 1. Multiple severe stenoses involving posterior and anterior circulation, as detailed above. These findings appear new from [2182-5-27] CTA exam and are concerning for vasculitis or vasospasm due to meningitis. 2. Small vessel ischemic disease. 3. Old left pontine infarction. CTA HEAD [2182-5-30]: Preliminary Report !! WET READ !! 1. C-Head:1. no large acute major territorial infarction, intracranial hemorrhage or mass. Stable hyperdensity likely calcification in left frontal lobe (2,24) unchanged in size and appearance since [2182-5-27]. 4 2. CTA of the head: Reformats are pending . Within this limitation: a) Stable appearance of bilateral proximal cavernous ICA with e/o stenoses due to calcified atheromatous plaque with normal caliber and contrast enhancement distal to these segments. b) Calcified atheromatous plaque involving the intracranial vertebral arteries is noted with small area of focal stenosis of the right vertebral artery. c) Remaining vessels show no definite flow limiting stenosis, or aneurysm > 3mm. Brief Hospital Course: # Finger infection: Concerned initially for deep tissue infection, however I+D without pus x 2 in the ED. On admission the x-ray wet read osteomyelitis was a possiblility. Hand surgery was consulting on the patient and the patient was placed on vancomycin and ceftazidime with HD. The antibiotitcs were started on [2182-5-24] and will finish on [2182-7-5]. Blood cultures eventually grew multiple strains of bacteria including CONS and GNRs with high levels of resistence. ID was consulted and recommended vanc/meropenem for at least a 6 week course but they will tailor the antibiotics to her clinical status. She will need weekly safety labs while on the antibiotics. These will include cbc, chem 7 and lfts. These will be faxed to the [Hospital 4898] clinic at [Hospital1 18]. A PICC line was placed on [2182-6-2] for meropenem dosing. Hand surgery recommended [Hospital1 ] dressing changes and [Hospital1 ] soaks in betadyne/saline solution (a 1:1 ratio). They will follow up with the patient on the Tuesday after her discharge in hand clinic. If her appointment needs to be rescheduled the number is: [Telephone/Fax (1) 3009]. It is very important that she follow up with them as she may need an amputation of the finger if the infection does not clear up with antibiotics. Her pain was controlled with tylenol RTC. She was unable to tolerate oxycodone or morphine as they made her sleepy. # HTN: BP 201/60 in the setting of pain on admission. Chronic hypertensive on multiple agents. EKG without ischemic changes. Pt without chest pain, HA, vision changes, or abd pain suggestive of hypertensive emergency. Blood pressures were well-controlled after pain controlled on her home regimen. . # Toxic metabolic encephalopathy: Pt had acute altered mental status while on the medicine floors. Pt was aphasic with right sided weakness. CODE stroke was called, and pt had urgent CT head that demonstrated no ICH. She was transferred to the MICU for closer monitoring. Pt was evaluated by neuro, who thought most likely toxic metabolic given fevers. Given fevers, meningitis was considered; however, unable to perform LP given body habitus. MRI head was done which showed was concerning for possible MCA territory infarction but could also have been artifact that was not seen on the prior CTA Head. She underwent a repeat head CT which revealed no changes from the prior one. She was started on ASA 325mg daily per neuro recs. Her EEG revealed epileptiform waves on the right side consistent with seizures. Neurology recommended starting keppra. She remained stable and was transferred to the medical floor. On discharge she was alert and oriented X 3. # DM: continued home doses of NPH and HISS # CAD/PVD: continued statin, BB, imdur, ASA 81mg # ESRD on HD MWF: continued her regular dialysis sessions here and continued renal caps and calcium accetate. # Anemia: Patient's hematocrit down-trended while hospitalized. Her hematocrit at discharge was 26.5. # thrombocytopenia: at baseline. Defer to outpatient providers for followup. # CODE: confirmed full with pt. # CONTACT: [First Name8 (NamePattern2) 1258] [Last Name (NamePattern1) 3234], daughter, HCP, [Telephone/Fax (1) 102079], [Telephone/Fax (1) 102080] # Transitions of care: - Patient will need weekly labs drawn in HD and faxed to the [Hospital 4898] clinic to ensure she does not have toxicity from the vancomycin - Patient will need to follow up with hand clinic to ascertain whether she needs an amputation 7-10days after discharge - Patient has a PICC line in place (placed [2182-6-2]) which will need to be taken out when antibiotic course is completed Medications on Admission: MEDICATIONS per [Name (NI) ], pt unable to confirm except for insulin: amlodipine 10mg PO daily Renal caps 1 PO daily calcium acetate 667 mg PO evenings w/ meals clonidine 0.1mg PO BID furosemide 20mg PO BID gabapentin 300mg PO qhs hydrocodone-acetaminophen 5/500mg [2-10] tab q4-6 hr prn pain imdur 30mg PO daily lidocaine 5% patch to lower back lisinopril 40mg PO daily metoprolol tartrate 200mg PO BID simvastatin 80mg PO daily acetaminophen 1000mg PO q6h prn ASA 81mg Po daily Carbamide peroxide 6.5% drops 2 drops daily prn earwax colace 100mg Po daily regular insulin 4 U qam and 2 units evening NPH 20 units qam, 10 u qpm senna PO daily Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. 9. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. metoprolol tartrate 50 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 11. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) 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. insulin lispro 100 unit/mL Solution Sig: Four (4) units Subcutaneous QAM. 15. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous QAM. 16. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous QPM. 17. insulin lispro 100 unit/mL Solution Sig: Two (2) units Subcutaneous at bedtime. 18. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). Disp:30 Tablet(s) Refills:2 19. Vancomycin 1000 mg IV HD PROTOCOL 20. Carbamoxide Ear Drops 6.5 % Drops Sig: 1-2 drops Otic once a day as needed for ear wax. 21. Outpatient Lab Work Please check weekly CBC, LFTs, Chem 7 and fax to [Hospital 4898] [Hospital ] clinic. 22. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 24. Meropenem 500 mg IV Q24H please give AFTER HD on HD days 25. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Osteomyelitis of left finger DM2 ESRD on HD Seizure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. You were admitted to the hospital with an infection of your hand. You had IV antibiotics (vancomycin, ceftazadine) to treat this. You were seen by the plastic surgeons who cleaned out your hand infection and recommend dressing changes and soaks (in a solution of betadyne and saline) twice a day. They want to see you within one week of discharge to see whether the infection is healing or whether you might need the tip of your finger removed. You should continue the antibiotics for 6 weeks with last dose on [2182-7-5]. You also had an event during which your brain did not seem to be functioning as well as it usually does. You had a ct scan and MRI of your head which did not reveal a stroke or mass or infection. You had an EEG which showed a seizure. The neurologists recommended starting an anti seizure medication called Keppra. You should continue this and follow up with the neurologists as an outpatient. You should also continue to take a full dose aspirin to prevent strokes. It was also thought that your pain medications may have contributed to this episode and these were discontinued. You should continue to take tylenol for your pain. Medication Changes: START: Vancomycin with HD for at least 6 weeks START: Meropenem IV for at least 6 weeks START: Acetominophen 1gm by mouth TID START: Keppra It was a pleasure taking part in your care. Followup Instructions: Department: [Hospital3 249] When: THURSDAY [2182-6-27] at 9:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: TRANSPLANT CENTER When: THURSDAY [2182-6-27] at 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: ORTHOPEDICS When: TUESDAY [2182-6-4] at 8:00 AM With: HAND CLINIC [Telephone/Fax (1) 3009] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: TUESDAY [2182-6-4] at 9:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please follow-up with Hand Surgery Clinic, the office number is [Telephone/Fax (1) 3009] 7-10 days following discharge. Name: [Known lastname 447],[Known firstname ] Unit No: [Numeric Identifier 16479] Admission Date: [2182-5-24] Discharge Date: [2182-6-3] Date of Birth: [2115-12-3] Sex: F Service: MEDICINE Allergies: Motrin Attending:[First Name3 (LF) 1085] Addendum: Discontinuation of Seizure Medications: Following discussion with Neurology on the day of discharge, recommendation was made to discontinue Keppra over the span of two days. There was no EEG evidence that the pt actually suffered a seizure. The following regimen should be provided to the patient so that she does not suffer a seizure. - Keppra 250mg on the morning of Tuesday [6-4] - Keppra 250mg on the morning of Wednesday [6-5] - Please discontinue Keppra on the afternon of Wednesday [6-5]. Discharge Disposition: Extended Care Facility: [Hospital6 609] for the Aged - [Location (un) 1409] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1086] MD [MD Number(2) 1087] Completed by:[2182-6-3]	[ "287.5", "414.00", "110.1", "285.21", "272.4", "349.82", "V58.67", "285.29", "730.24", "780.39", "443.9", "E930.5", "787.02", "427.31", "588.81", "041.85", "041.4", "041.19", "403.91", "V45.11", "585.6", "276.0", "E930.8", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.97", "03.31", "86.04" ]	icd9pcs	[ [ [] ] ]	17184, 17426	6682, 9954	276, 299	13402, 13402	3934, 6659	15031, 17161	2768, 2819		11071, 13198		13327, 13381		10394, 11048			13553, 14802								2834, 3915																					14822, 15008	227, 238											327, 2129											13417, 13529	9975, 10368					2151, 2611	2627, 2752
50,885	106,559	19451	Discharge summary	report	Admission Date: [2102-3-14] Discharge Date: [2102-3-21] Date of Birth: [2049-1-6] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 7333] Chief Complaint: Problems with speech Right sided clumsiness Major Surgical or Invasive Procedure: IR guided PICC History of Present Illness: The pt is a 53 year-old right-handed man with a PMH of afib off coumadin, HTN, HLD, DM and EtOH use who presented to the ED with difficulty with his speech and clumsiness. He states that he stopped coumadin several months ago as he ran out. He did not pursue a refill. This morning he woke in his USOH. He watched TV in the morning and noticed intermittent episodes of problems with his vision on the R side. It was not complete visual loss and he is unable to describe if it was a portion of vision missing vs blurriness. This resolved, however around 3 pm he had abrupt onset difficulty with his speech. He states the he was barely able to speak but was clear about what he wanted to say. He also noticed that his R hand was very clumsy. He denied numbness or focal weakness however. He waited for several hours and went to the grocery store. He then called his recently separated wife around 7 pm. She noticed that he speech was non-fluent with very limited phrases and was concerned. She thought he had either consumed EtOH or "was sick". She picked him up and brought him to the ED. Past Medical History: - DM - HTN - HLD - CAD - afib off coumadin Social History: -currently disabilty, former [Company 2318] driver -EtOh: 6-8 beers per night and "hard Alcohol" (unspecified amount, no hx of DT's, sz or withdrawal) -tobacco: -drugs: denies Family History: Non-contributory Physical Exam: Physical Exam: Vitals: T: 99.2 P: 82 R: 16 BP: 132/80 SaO2: 99% on RA BS 258 NIH SS: 3 1a. Level of Consciousness: 0 1b. LOC questions: 0 1c. LOC commands: 0 2. Best gaze: 0 3. Visual: 0 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 1 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb ataxia: 0 8. Sensory: 0 9. Best language: 1 10. Dysarthria: 0 11. Extinction and inattention: 0 General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: Pansystolic murmur in the mitral area Abdomen: Hepatosplenomegaly with ascites. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Pulses: all peripheral pulses present Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Attentive. Language is non- fluent with frequent pauses. [3-19] words sentences. Repetition is almost intact "No ifs ands and buts". Intact comprehension. Normal prosody. There intermittent paraphasic errors ("captus"). Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was minimally dysarthric. Able to follow both midline and appendicular commands. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. CN I: not tested II,III: VFF to confrontation, pupils 4mm->2mm bilaterally, fundi normal III,IV,V: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: R NLF flattening VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [Doctor First Name 81]: SCM/trapezeii [4-18] bilaterally XII: tongue protrudes midline, no dysarthria Motor: Normal bulk and tone; no asterixis or myoclonus. + R pronator drift. Delt [Hospital1 ] Tri WE FE Grip IO C5 C6 C7 C6 C7 C8/T1 T1 L 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 IP Quad Hamst DF [Last Name (un) 938] PF L2 L3 L4-S1 L4 L5 S1/S2 L 5 5 5 5 5 5 R 5 5 5 5 5 5 Reflex: No clonus [Hospital1 ] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 0-------------- Flexor R 0-------------- Flexor -Sensory: No deficits to light touch. No extinction to DSS. -Coordination: No intention tremor, dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: deferred Pertinent Results: TTE from [12-18] The left atrium is normal in size. The right atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = [9-28] %). A left ventricular mass/thrombus cannot be excluded. Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. The right ventricular cavity is mildly dilated with depressed free wall contractility. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. 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 to moderate ([12-16]+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severely depressed left ventricular systolic and diastolic dysfunction. Depressed right ventricular function. Mild to moderate mitral regurgitation. Moderate to severe tricuspid regurgitation. Cannot exclude left ventricular apical thrombus. [2102-3-14] CThead/CTA - prelim read Stroke in the left MCA superior division territory.Left fronto-temporal hypodensity with increased MTT, decreased blood flow. No cut off seen on vessels. Brief Hospital Course: 2D-ECHOCARDIOGRAM performed on [2102-3-15] demonstrated: The left atrium is normal in size. The right atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = [9-28] %). A left ventricular mass/thrombus cannot be excluded. Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. The right ventricular cavity is mildly dilated with depressed free wall contractility. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. 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 to moderate ([12-16]+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severely depressed left ventricular systolic and diastolic dysfunction. Depressed right ventricular function. Mild to moderate mitral regurgitation. Moderate to severe tricuspid regurgitation. Cannot exclude left ventricular apical thrombus. [2102-3-14] CTA head: No acute intracranial process with no abnormal enhancement, infarction or hemorrhage. #. CAD: Pt has h/o CAD per records. He had a cath sometime in the past at [Hospital1 2177] which showed 90% LAD lesion but not stented. Started coreg for BP control as well as captopril. Continued ASA 81. Held statin in setting of transaminitis but may consider starting as o/p if liver function tests wnl. #. Pump: Pt has severe systolic and diastolic CHF and cardiomyopathy with LVEF of 10. The cardiomyopathy is likely from CAD and alcohol use. Initially, pt seemed volume overloaded and at that point on his starling curve where is not able to mainten enough cardiac output. On lasixc gtt patient was diuresed. He then was put on a PO dose of lasix for maintenance once he was euvolemic. He was started on an ace inhibitor and coreg. He was continued on asa. Statin was held as below. He will discuss with his cardiologist whether he may benefit from an AICD if on follow up TTE's he continues to have low EF. Coreg, lisinopril, and spironolactone were initiated as well. #LV thrombus: Pt has sever global hypokinesis. He ran out of coumadin a few months back and has not been taking it. Likely source of embolic stroke. Was placed on heparin gtt and then bridged onto coumadin. INR was not therapeutic prior to discharge so he was discharged on lovenox with coumadin. He will follow up with Dr. [Last Name (STitle) 5456] for INR checks in 2 days. #Elevated liver enzymes: Pt had acute elevation of AST, ALT (to 1000s range), AP, LDH and Tbili. Liver US didnt show e/o cirrhosis or portal vein thrombosis. Denied any h/o recent ETOH binge, mushroom consumption, herbal supplements. No past h/o viral hepatitis. No h/o acetaminophen overdose. The enzyme pattern was concerning for shock liver in the setting of poor forward flow from his cardiomyopathy. There was also concern for viral hepatitis. Viral serologies were negative. Transaminitis trended down over course of his stay with diuresis/treatment of CHF. # DM2: Uncontrolled with A1C 8.2%. Monitored with FSBS. Given 20units lantus per his home regimen (per patient) plus ISS. [Last Name (un) ] was consulted and titrated his diabetic regimen further. Will likely need further titration of diabetic regimen as outpatient as was uncontrolled pre A1C. # Elevated Cr: 1.3 on admission from 0.8 baseline. Thought likely from poor perfusion. Doesnt seem dehydrated. Improved to baseline with diuresis. # Alcohol abuse: Initially had CIWA scale. Never had signs of withdrawal and this was eventually d/c'd. Social work was consulted and worked with the patient. He understands the dangers of continuing to drink and has said he will not drink in the future. # Code: full Medications on Admission: None - the medications provided in the HPI were not what he was taking Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Outpatient Lab Work Please check INR/Coumadin level on Thursday [3-23] at Dr. [Name (NI) 52848] office. Results to Dr. [Last Name (STitle) 5456] at [Telephone/Fax (1) 5457] 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous twice a day for 2 days. Disp:4 doses Refills:2 7. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day: Check coumadin level on [2102-3-23]. . Disp:90 Tablet(s) Refills:2 8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous at bedtime. Disp:1 bottle Refills:2 11. Insulin Lispro 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous four times a day: Please check Blood sugar 4 times a day and take Lispro right before each meal. . Disp:1 bottle Refills:2 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: left superior MCA stroke Left Ventricular thrombus severe acute on chronic systolic and diastolic congestive Heart Failure with Ejection Fraction 10% atrial fibrillation Secondary diagnoses: uncontrolled type 2 diabetes Hypertension Discharge Condition: The patient was afebrile and hemodynamically stable prior to discharge. Discharge Instructions: You were admitted with a stroke which affected your speech and gave some mild weakness in your right arm. Your symptoms have improved. . The stroke was likely caused from a clot in your heart. You will need to remain on anticoagulation with warfarin (coumadin) and have your lab test called INR monitored for how thin your blood is. Do not stop taking your coumadin or you risk having another stroke. Your primary care doctor, Dr. [Last Name (STitle) 5456], [First Name3 (LF) ] check your INR test 2-3 days after you leave the hospital and help you change your coumadin dose appropriately. You should also take aspirin daily. You have congestive heart failure. This can make you become fluid overloaded. You must maintain a low salt diet (less than 2 grams per day) and restrict your fluid intake to 1.2 liters per day. You have been started on a medication called spironolactone and your furosemide (lasix) was continued to help keep the fluid off. You were also started on Lisinopril to keep your blood pressure low and carvedilol to help your heart pump better. Your new cardiologist, Dr. [Last Name (STitle) ], [First Name3 (LF) ] follow your heart function and possibly put in a defibrillator to make sure you do not have a cardiac arrest in the future. You can discuss this with him at your follow up appointment. You will also be seen in the heart failure clinic here at [Hospital1 18] to help adjust your medicines. . You were seen by the [Hospital ] clinic to help with improving your blood sugars. This will help prevent another stroke and possible kidney failure. Take your long acting insulin at night and take the short acting insulin before each meal according to your blood sugar level. A sliding scale for the short acting insulin was given to you on discharge. Medication Changes: START: Warfarin START: Lisinopril START: Carvedilol START: Aspirin START: Spironolactone CONTINUE: Vitamin B6 and B12 as prescribed by Dr. [Last Name (STitle) 5456] CONTINUE: Lantus insulin at bedtime 20 units CONTINUE: Humalog insulin before meals as per sliding scale. Please check your blood sugar before each meal and at bedtime. You should measure your weight daily. If you gain more than 3 pounds in a week or less, please call Dr. [Last Name (STitle) 5456]. Please follow a low sodium diet to prevent the accumulation of fluid. Information was given to you regarding a low sodium diet, daily wieghts and symptoms to watch for on discharge. . Please call Dr. [Last Name (STitle) 5456] if you notice any trouble breathing, cough, lying flat at night, swelling in your ankles, chest pain, nausea or any other concerning symptoms. Followup Instructions: Neurology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone: ([Telephone/Fax (1) 2532] Date/Time: Friday [4-21] at 2:00pm. [Hospital Ward Name 23] Clinical Center, [Location (un) ]. [Location (un) ], [Location (un) 86]. . Cardiology: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Phone: ([Telephone/Fax (1) 52849] Date/Time: Monday [4-24] at 3:15pm. [Location (un) 10877], [Street Address(1) ]. . Primary Care: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5456] Phone: ([Telephone/Fax (1) 32099] Thursday [3-23] at 2:30pm. Please have your INR level checked and coumadin dosed appropriately. . Diabetes: Dr. [Last Name (STitle) ] Phone: [Telephone/Fax (1) 12068] Date/time: Office will call you with an appt in the next 2-3 weeks. If you do not hear from Dr. [Name (NI) 52850] office in the next week, please call [0-0-] to schedule an appointment with any of the providers. . Congestive Heart Failure Clinic: Dr. [First Name8 (NamePattern2) 401] [Last Name (NamePattern1) 437] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [MD Number(3) 1240]: [Telephone/Fax (1) 62] Date/Time: [4-10] at 2:30pm. [Hospital Ward Name 23] clinical Center, [Location (un) ]. [Hospital Ward Name 516], [Location (un) ]. Completed by:[2102-3-22]	[ "250.02", "414.01", "305.01", "401.9", "570", "429.89", "789.59", "272.4", "428.43", "434.11", "428.0", "584.9", "414.8", "427.31" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	11545, 11551	5795, 9937	315, 332	11829, 11903	4236, 5772	14622, 16053	1735, 1753		10058, 11522		11572, 11743		9963, 10035			11927, 13731								1783, 2641	11764, 11808																				13751, 14599	232, 277											360, 1452											2656, 4217						1474, 1519	1535, 1719
15,690	132,813	9412	Discharge summary	report	Admission Date: [2133-5-3] Discharge Date: [2133-5-6] Date of Birth: [2061-11-13] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[First Name3 (LF) 425] Chief Complaint: Chest pain. Major Surgical or Invasive Procedure: Cardiac catheterization with stent placement to L cirucmflex artery and rescue of jailed OM. History of Present Illness: 71 year old gentleman with coronary artery disease, neg Exercise MIBI in [2130] with LVEF of 63%, who presented with 5 hours chest pain which began last night. Pain was on both sides of chest and pt believes it may have been associated with some shorntess of breath. No loss of consciousness that he can recall. Taken to ED where EKG with ischemic ST changes; he received ASA, plavix, IIB/IIIA gtt, and Hept gtt and was transferred urgently to the catheterization laboratory. There he was found to have 99% LCx lesion and 70% OM lesion. LCx was stented but this resulted in OM jailing. The OM was subsequently rescued. Wedge 25, pt became hypoxic eventually oxygenating only 87-89 on NRB; initial ABG 7.36/56/40. Pt given lasix and transferred to CCU. Past Medical History: 1. CAD: + P-MIBI in [Month (only) 359] or [2130-9-23] at outside hospital (?[Hospital3 5097])in setting of exertional CP. with inf and ant ischemic changes. Deferred catheterization at that time. -Stress [12-27]: 11 minutes on [Initials (NamePattern4) ] [Last Name (NamePattern4) 4001] protocol. The heart rate rose from 51 to 85. The blood pressure rose from 176/80 to 190/80. He stopped because of fatigue. There was no chest or other discomfort. There were no significant ST segment changes. Nuclear images showed no perfusion abnormality. LVEF was 63%. Normal wall motion. -hypertension -hyperlipidemia . 2. GERD (burping after heavy meal) with h/o PUD. 3. Bilateral venous varicosities. s/p venous stripping 4 Pulmonary fibrosis, baseline sat 92 on RA. Social History: Married Quit smoking over 30 years ago. Rare alcohol use. Family History: Non-contributory. Physical Exam: on arrival. P 80 BP 145/56 RR 27 O2 89 on NRB after lasix and metoprolol T 98.6 P 63 BP 126/56 R 24 O2 94 on 3.5 NC. Gen: Currently appears in NAD. An obese Russian gentleman, pleasant, Russian speaking, tired but able to speak in full sentences. HEENT: NC in place. MMM. Neck: Obese, JVP to apprx 10 cm. No bruits. Chest: Lungs, scattered rales, decreased breath sounds anteriorly. Heart: RR occasional extra beat. S1S2 with 3/6 systolic murmur at apex and base. Abd: Obese, minimal bowel sounds. R groin: dressing blood stained. No hematoma, no bruit. Ext: Cool extremities, but not cyanotic. DP Pulses not palpable. Pertinent Results: pH 7.36 pCO2 40 pO2 56 HCO3 24 BaseXS-2 CK: 88 MB: Notdone Trop-T: <0.01 Na 143 Cl 106 BUN 31 Glu 155 AGap=16 K 3.6 HCO3 25 Cr 0.9 WBC 10.0 Hct 43.9 Plt:217 N:37 Band:0 L:35 M:10 E:0 Bas:0 Atyps: 18 Cardiac enzyme trend [2133-5-3] 06:00AM BLOOD CK(CPK)-88 [2133-5-3] 06:00AM BLOOD cTropnT-<0.01 --Catheterization-- [2133-5-3] 02:41PM BLOOD CK(CPK)-1399* [2133-5-3] 02:41PM BLOOD CK-MB-192* MB Indx-13.7* cTropnT-2.87* [2133-5-4] 12:02AM BLOOD CK(CPK)-1083* [2133-5-4] 12:02AM BLOOD CK-MB-101* MB Indx-9.3* cTropnT-2.10* [2133-5-4] 06:12AM BLOOD CK(CPK)-748* [2133-5-4] 06:12AM BLOOD CK-MB-61* MB Indx-8.2* cTropnT-1.55* [2133-5-5] 04:53AM BLOOD CK(CPK)-259* [2133-5-5] 04:53AM BLOOD CK-MB-12* MB Indx-4.6 cTropnT-1.00* STUDIES: EKG: NSR rate 86, ST elevation in AVR, deep ST depression throughout precordial leads. . CXR: Mild congestive heart failure. Small left pleural effusion. Opacity in the left lower lobe could represent atelectasis, although early pneumonia is also possible. . CATH: 1. Selective coronary angiography in this right dominant patient revealed two vessel CAD. The RCA had moderate diffused disease up to 60% in the proximal and mid portions. The LMCA was angiographically normal and the LAD system had mild luminal irregularities. The LCX was the culprit vessel with proximal 99% occlusion involving the first OM which had a 70% occlusion. 2. Resting hemodynamics revealed elevation of right and left sided filling pressures with RA mean of 13mmHG and PCWP of 25mmHG. There was moderate pulmonary hypertension at mean PA 35mmHG. The cardiac index was preserved. The systemic blood pressure was normal. ABG revealed severe hypoxia at the end of the case which responded to lasix and IV nitro without necessitating intubation. 3. Successful PTCA/stenting of the proximal LCX with a 3.0x13mm Cypher DES with great results (see PTCA comments). 4. Right femoral arteriotomy was successully closed with a 8F angioseal closure device. Echocardiography: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is mild 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. Brief Hospital Course: This 71 year old gentleman with hypertension, hyperlipidemia, and obesity presented with 5 hours of chest pain and was found to have an ST elevated MI for with he underwent emergent cardiac catheterization with stent placment to LCx with rescue of jailed OM1. His wedge pressure elevated during the procedure and the post cath course complicated by hypoxia (blood gas 7.36/40/56) requiring non-rebreather therapy. He was given lasix treatment and transferred to the coronary intensive care unit. He had subsequent improvement in oxygenation as he diuresed and was weaned off oxygen support successfully. Likely hypoxia was secondary to fluid overload from necessary fluids periprocedurally. Post cath EKG revealed resolution of the ischemic changes, his cardiac enzymes peaked later that afternoon (CK 1399 MB 13.7 Trop T 2.87). Post cath revealed preserved LV systolic function and preserved RV function with no wall motion abnormalities in either ventricle. No evidence of pulmonary hypertension. The patient remained chest pain free and hemodynamically stable after his catheterization and his cardiac enzymes trended downward. He had no further episodes of respiratory distress. He was discharged with instructions to continue all antiplatelet, antihyperlipidemic, and antihypertensive medications as prescribed in hospital and to follow up with his primary care physician and with [Hospital1 18] Cardiology. In summary, this is a 71 year old gentleman admitted to the CCU for inferior STEMI status post catheterization with DES to L circumflex artery. Post cath course complicated by respiratory distress secondary to volume overload successfully treated with diuretic therapy. Post cath echo reveals preserved LV and RV function. Pt remained chest pain free and hemodynamically stable throughout his post cath course to discharge. Issues and plan from this hospitalization: 1) Cardiovascular, STEMI s/p cath, elevated wedge pressure a) Perfusion--STEMI (deep ST depressions in precordial leads STE in aVR) s/p cath to LCx (99% lesion) c OM1 rescue (70% residual stenosis) -ASA, plavix, -Pt started metoprolol which was changed to Toprol XL on discharge, also restarted felopidine in hospital. -Pt to continue lisinopril, discontinued hydrocholorothiazide b) Pump, last EF 63%, repeat echo revealed preserved RV and LV funcion with no wall motion abnormalities. -continue Toprol, lisinopril c) Rhythm, pt remained in NSR, no episodes of ventricular tachycardia on telemetry post MI d) Follow up: with PCP and arranging to be followed by cardiologist at [Hospital1 18] (Either Dr. [Last Name (STitle) ] or Dr. [Last Name (STitle) 171] . 2) Resp status, after cath was 89-90 on NRB, with pO2 of 63 on ABG. After diuresis sat to 93-95 range on 2 L NC. 92 on RA appears to be baseline. Pt carries diagnosis of pulm fibrosis. . 3) History of stomach ulcers with ASA. Pt needs to continue ASA, he was given protonix in hospital for stomach protection. He will continue ASA and protonxi and follow up with his PCP and cardiologist should this become an issue. . 4) BPH -continued proscar . 5) FEN -heart healthy . 6) Prophylaxis included colace and PPI. Pt to continue colace. . Disp: Home with services (home physical therapy) . Code status remains full. Medications on Admission: Lisinopril 40 mg one daily Felodipine 5 mg qd Lipitor 40 mg qd Plavix 75 mg qd Protonix 40 mg qd. Proscar Allergies/ADR's: Intolerant to ASA (stomach ulcers). Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 2. Trospium 20 mg Tablet Sig: One (1) Tablet PO every morning (). 3. Felodipine 5 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: ST elevated myocardial infarction. Discharge Condition: Good. Free of chest pain. Hemodynamically stable and breathing at baseline on room air. Discharge Instructions: Please seek emergent medical attention if you start to develop chest pain or shortness of breath. Please seek emergent medical attention if you pass out, have sudden weakness, or loss of vision. Please make sure to take aspirin and plavix every day. It is also important to take your protonix to help protect your stomach. Please take your blood pressure medications as prescribed. Note we have added toprol XL to your regimen. You will also continue lisinopril and felodipine. You will no longer need If you find you are coughing up blood or passing blood in your stool or urine please seek medical attention. Followup Instructions: Please follow up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ], within one week. You should also have your blood count and chemistries monitored 2 days after your discharge. We have contact[Name (NI) ] the office of Dr. [Last Name (STitle) ] of [Hospital1 18] Cardiology to arrange for follow up with him. His office number is ([Telephone/Fax (1) 5909].	[ "414.01", "515", "454.9", "278.00", "530.81", "272.4", "410.31", "443.9", "401.9", "250.00", "715.90" ]	icd9cm	[ [ [] ] ]	[ "99.20", "00.66", "37.23", "00.40", "36.07", "88.56", "00.45" ]	icd9pcs	[ [ [] ] ]	10143, 10229	5368, 7879	278, 373	10308, 10400	2732, 5345	11066, 11470	2057, 2076		8871, 10120		10250, 10287		8687, 8848			10424, 11043								2091, 2713								7890, 8661														227, 240											402, 1159																	1181, 1965	1981, 2041
53,086	143,522	43971	Discharge summary	report	Admission Date: [2113-2-12] Discharge Date: [2113-2-17] Date of Birth: [2030-6-27] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 668] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 82 F was in her usual state of health until [Month (only) 359] when she began having vague abdominal pain as well as a 20 lb weight loss over the course of 3 months. She underwent a CT scan of her abdomen at [Hospital6 1597] in [Month (only) 359] that showed a dilated CBD. This prompted an [Month (only) ]. Initial brushings were negative, however an FNA of a small lesion adjacent to her CBD stricture was positive for adenocarcinoma 2 weeks ago. Ms. [Known lastname ] was admitted [2113-2-12] with overall weakness, decreased po intake, and persistent abdominal pain. She reports some improvement with hydration over the last 24 hours, but still feels weak. She denies any fevers, chills, nausea, vomiting, jaundice, pruritis, or changes in her urine or stool. Past Medical History: CKD Stage III (although this is purely by age/weight/height) Benign Hypertension Anxiety Insomnia Social History: History of smoking (Stopped 25 y ago), 1-2 drinks/week, no drugs, lives with her husband who is disabled and on HD and her 2 children Family History: No pancreatic cancer. Physical Exam: VS: Tmax=97.6 Tcurr=97.4 BP=163/89 HR=80 RR=18 O2Sat 95%RA GA: Well-appearing elderly woman in no apparent distress. Alert. Engaged in the conversation. HEENT: Pupils equal, round and reactive to light. Extraocular motion intact. Anicteric sclerae. dry mucous membranes. No lesions in the oropharynx. Clear tympanic membranes bilaterally. NECK: Supple. No cervical or supraclavicular lymphadenopathy. No appreciable thyromegaly or thyroid nodules. CARDIAC: S1 S2 without murmurs. PULMONARY: Clear to auscultation bilaterally. No wheezes, rales or rhonchi. ABDOMEN: Soft. tender in the epigastric area. Nondistended. Positive bowel sounds. EXTREMITIES: Warm. No clubbing, cyanosis or edema. Feet were examined and there were no breaks in the skin or other lesions. Toenails were well-clipped. NEUROLOGIC: Cranial nerves II through XII intact. 5/5 strength in the upper extremities bilaterally. 5+/5 strength in the bilateral lower extremities. Pertinent Results: [2113-2-12] 11:20AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2113-2-12] 11:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-0.2 PH-6.0 LEUK-NEG [2113-2-12] 11:20AM URINE RBC-0 WBC-[4-21] BACTERIA-FEW YEAST-NONE EPI-[4-21] [2113-2-12] 11:20AM URINE AMORPH-FEW [2113-2-12] 11:20AM URINE MUCOUS-MOD [2113-2-12] 10:26AM GLUCOSE-112* UREA N-10 CREAT-0.7 SODIUM-144 POTASSIUM-3.0* CHLORIDE-105 TOTAL CO2-26 ANION GAP-16 [2113-2-12] 10:26AM ALT(SGPT)-37 AST(SGOT)-30 LD(LDH)-203 ALK PHOS-294* AMYLASE-117* TOT BILI-0.5 [2113-2-12] 10:26AM LIPASE-206* [2113-2-12] 10:26AM WBC-7.7 RBC-4.30# HGB-11.7* HCT-34.8# MCV-81 MCH-27.3 MCHC-33.7 RDW-12.8 [2113-2-12] 10:26AM NEUTS-73.4* LYMPHS-18.9 MONOS-5.4 EOS-1.6 BASOS-0.7 [2113-2-12] 10:26AM PLT COUNT-313# [2113-2-12] 10:26AM PT-14.5* PTT-23.7 INR(PT)-1.3* [2113-2-17] 06:40AM BLOOD WBC-5.5 RBC-3.67* Hgb-9.8* Hct-29.8* MCV-81* MCH-26.7* MCHC-32.8 RDW-12.9 Plt Ct-196 [2113-2-17] 06:40AM BLOOD Plt Ct-196 [2113-2-17] 06:40AM BLOOD Glucose-103 UreaN-7 Creat-0.4 Na-142 K-3.2* Cl-106 HCO3-25 AnGap-14 [2113-2-17] 06:40AM BLOOD ALT-32 AST-73* AlkPhos-300* TotBili-0.8 [2113-2-17] 06:40AM BLOOD Albumin-3.3* [2113-2-15] 07:22AM BLOOD Phenyto-17.1 [2113-2-12] 10:26AM BLOOD LtGrnHD-HOLD Brief Hospital Course: This is an 82 year old woman who had a recent endoscopic ultrasound (EUS) with FNA of a pancreatic mass with cytology that was positive for adenocarcinoma. She presented [2113-2-12] with continued abdominal pain, nausea, lightheartedness, and weakness. She had evidence of dehydration. The patient recieved IV hydration, adequate pain control with long/short acting medications, Zofran, and GI/hepatobiliary surgery consultation to discuss treatment options. She has microcytic anemia but no records regarding the etiology or previous colonoscopy. She has hypokalemia related to Lasix which can contribute to her weakness. For unknown reasons, she stopped Benicar but was continued Lasix. Her elevated Lipase and Amylase levels are related to the pancreatic mass without evidence of pancreatitis. Ms. [Known lastname ] was admitted to [Hospital Unit Name 153] on [2113-2-14] after fall on 11 [Hospital Ward Name 1827] resulting in intraparenchymal and subdural hemorrhages. Patient requireed frequent neurologic assessment and close mental status evaluation. She denied any LOC before or after incident or dizziness/lightheadedness on standing. Patient was also on multiple psychiatric medications and narcotics, which surely altered her mental status. Ms. [Known lastname ] is usure of exactly what precipitated fall, but believes that she simply slipped in front of her roommate's bed as they were talking. She was transferred to the ICU for Q1hr neuro checks, and her neuro exam remained stable. A repeat Head CT in the AM did not show significant progression of bleed. Heparin was held, and she was loaded with fosphenytoin then maintained with phenytoin tid. Dilantin levels were checked. She was evaluated frequently for change in mental status. Sedating or altering drugs were minimized. She was evaluated by neurosurgery, who felt that her head CT and neuro exam remained stable; they recommended maintenance on dilantin until f/u with them in one month. She will need repeat head CT at that time. She was transferred to transplant surgery on [2113-2-16] for further work-up of her pancreatic adenocarcinoma. On further study of her CT scan it was decided that Ms. [Known lastname ] was not an operative candidate. Patient was seen by hematology/oncology and advised to follow-up with them in clinic for further treatment. She will also follow-up with [Known lastname ] as an outpatient for change of her stent to a metal stent. She was discharged home on [2113-2-17] into the care of her daughter. 24 hour care was suggested as a precaution as Ms. [Known lastname ] still has some residual unsteadiness following her fall. Medications on Admission: 1. Senna 8.6 mg Tablet [Known lastname ]: 1-2 Tablets PO at bedtime as needed for Constipation. 2. Docusate Sodium 100 mg Capsule [Known lastname ]: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Tylenol with Codeine 4. Alprazolam (Xanax), 5. Prevacid or nexium 6. Olanzapine 7. Paxil 8. Olmesartan and HCTZ (stoped it recently) 9. Lasix 20 MG Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule [Known lastname ]: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 2. Outpatient Lab Work Phenytoin level in 1 week Results to PCP, 3. Oxycodone 5 mg Tablet [Known lastname ]: One (1) Tablet PO every 4-6 hours as needed for pain for 7 days. Disp:30 Tablet(s) Refills:0 4. Colace 100 mg Capsule [Known lastname ]: One (1) Capsule PO twice a day for 7 days. Disp:14 Capsule(s) Refills:0 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). Disp:30 Tablet,Rapid Dissolve, DR(s) Refills:2 6. Sertraline 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 7. Paroxetine HCl 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 8. Olanzapine 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO at bedtime. 9. Furosemide 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 10. Alprazolam 0.25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: subdural hematoma CBD stricture Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires 24 hr assistance or aid (walker or cane) Discharge Instructions: You will need 24 hour supervision to assist you at home. Physical therapy and visiting nurse has been requested Please schedule a follow up appointment with Neurosurgeon, oncologist and your primary care physician. [Name10 (NameIs) ] [Name11 (NameIs) 766] [2-20] to schedule these appointments listed below: fever, jaundice, confusion, seizure activity, falls, nausea, vomiting, or abdominal pain, or any other symptom of concern. Followup Instructions: Please call Dr.[Name (NI) 4674] office ([Telephone/Fax (1) 88] -Neurosurgeon to schedule a follow up appointment in 1 month. Located at [Last Name (NamePattern1) 439] [Location (un) ] ([Hospital 2577] Medical Office Building) His office will need to schedule a repeat head CT scan to reassess the subdural hematoma in 1 month just prior to office visit with Dr. [Last Name (STitle) 739] Please schedule a follow up appointment with Oncologist [Telephone/Fax (1) 6568] in [2-18] weeks. You will see either Dr. [Last Name (STitle) ], Dr. [Last Name (STitle) ] or Dr. [First Name (STitle) ] Please call your primary care doctor to have a follow up appointment in 1 week with blood work to check phenytoin level (antiseizure medication) [First Name4 (NamePattern1) 698] [Last Name (NamePattern1) 699] RN coordinator for Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (surgeon) [Telephone/Fax (1) 17195] Provider: [Name Initial (NameIs) ] 2 (ST-4) GI ROOMS Date/Time:[2113-3-3] 1:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2839], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2113-3-3] 1:00	[ "576.2", "E888.9", "276.8", "276.51", "852.21", "E849.7", "155.1", "403.90", "E944.4", "585.3", "280.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8134, 8192	3881, 6576	328, 334	8268, 8268	2465, 3858	8918, 10140	1442, 1465		7003, 8111		8213, 8247		6602, 6980			8451, 8895								1480, 2446																						274, 290											362, 1153											8282, 8427						1175, 1274	1290, 1426
66,079	107,768	828	Discharge summary	report	Admission Date: [2177-7-1] Discharge Date: [2177-7-3] Date of Birth: [2146-7-21] Sex: F Service: MEDICINE Allergies: Dilaudid / Iodine-Iodine Containing Attending:[First Name3 (LF) 5810] Chief Complaint: tachypnea, hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 30 YO F w ESRD [12-31] DM1 on HD M/W/F s/p recent admission for contrast allergy who presented with SOB after missing her HD session yest. Went to HD today but was found to be tachypneic to the 30s w bibasilar rales. EMS gave 15L NRB 97%. Upon arrival, the patient was 88% on RA. Exam was notable for bibasilar crackles. She was started on BiPap and given 80IV lasix and nitro paste, Ca gluconate for peaked T-waves, 20u regular insulin. Renal was contact[Name (NI) ] and plan to do HD when she arrives to the MICU. . Upon arrival to the MICU, the patient reports improved SOB with the Bipap mask. She was noted by nursing to have an episode of rigors without fever. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. 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: - ESRD since [2174-8-29] HD through L IJ Tunnelled line - Peritonitis [8-7] - Type I DM complicated by neuropathy and nephropathy - Bilateral cataract surgeries - Ventral Hernia, repaired [4-/2177] Social History: The patient lives with her mother. Lives with her mother, + tobacco history, social ETOH, marijuana use noted in history. Family History: DM type II. Physical Exam: While transfer to floor from MICU [7-3] : Vitals: T: 97.1 BP: 120/70 P:47 R:16 18 O2:97% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, 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 SKIN: no pus currently seen around HD line. With no fluctuance, draining fluid, or erythema . Pertinent Results: Admission Labs: [2177-7-1] 01:36PM BLOOD WBC-10.1# RBC-4.20 Hgb-12.8 Hct-38.5 MCV-92 MCH-30.4 MCHC-33.1 RDW-15.8* Plt Ct-203 [2177-7-1] 01:36PM BLOOD Neuts-77.9* Lymphs-14.4* Monos-3.3 Eos-3.5 Baso-1.0 [2177-7-1] 01:36PM BLOOD Glucose-568* UreaN-78* Creat-11.6# Na-129 K-5.6* Cl-90* HCO3-17* AnGap-28* [2177-7-1] 04:43PM BLOOD Calcium-9.2 Phos-4.1 Mg-3.0* [2177-7-2] 09:05AM BLOOD Vanco-32.2* [2177-7-1] 01:43PM BLOOD Glucose-490* Lactate-2.1* Na-132* K-5.4* Cl-92* calHCO3-24 . . Imaging: CXR [2177-7-1]: 1. Increase in interstitial prominence and new development of small bilateral pleural effusions consistent with moderate pulmonary edema. Patchy opacities are most likely related to confluent edema, though infection is not excluded. Repeat radiography after diuresis is recommended. 2. Stable appearance of hemodialysis catheter. . Micro: No growth to date at wound culture preliminary -no growth to date Blood and urine cultures- No growth to date . Reports: EKG [7-1] Sinus rhythm. Possible left atrial abnormality. Poor R wave progression. Consider prior anteroseptal myocardial infarction. Hyperacute T waves in the anterior leads raise concern for hyperkalemia or acute myocardial ischemia. Clinical correlation is suggested. Compared to the previous tracing of [2177-5-15] the rate has decreased. Poor R wave progression and hyperacute T waves are seen on the current tracing. TRACING #1 Read by: [Last Name (LF) ],[First Name3 (LF) ] D. Intervals Axes Rate PR QRS QT/QTc P QRS T 87 170 78 [Telephone/Fax (2) 5811] 73 . CXR [7-1] [Hospital 93] MEDICAL CONDITION: 30 year old woman missed dialysis yesterday with crackles and hypoxia/ REASON FOR THIS EXAMINATION: assess for pulmonary edema Final Report PATIENT HISTORY: 30-year-old female who missed dialysis yesterday. TECHNIQUE AND FINDINGS: Portable AP chest radiograph demonstrates a left subclavian hemodialysis catheter with its tip at cavoatrial junction. Compared with [2177-6-20], there is increase in perihilar and bibasilar interstitial markings and small bilateral pleural effusions consistent with moderate pulmonary edema. The cardiomediastinal silhouette is unchanged in appearance. Patchy opacities are superimposed on parasagittal interstitial pattern bilaterally. IMPRESSION: 1. Increase in interstitial prominence and new development of small bilateral pleural effusions consistent with moderate pulmonary edema. Patchy opacities are most likely related to confluent edema, though infection is not excluded. Repeat radiography after diuresis is recommended. 2. Stable appearance of hemodialysis catheter. The study and the report were reviewed by the staff radiologist. . EKG [7-3] Sinus rhythm. Consider left ventricular hypertrophy although may be non-diagnostic given patient's age. Delayed R wave progression may be due to left ventricular hypertrophy, normal variant or possible prior anterior wall myocardial infarction although is non-diagnostic. Inferolateral lead ST-T wave changes are non-specific but clinical correlation is suggested. Since the previous tracing of [2177-7-2] lateral limb lead ST-T wave changes appear slightly more prominent. . Discharge Labs . [2177-7-3] 06:55AM BLOOD WBC-6.1 RBC-3.88* Hgb-11.6* Hct-34.7* MCV-89 MCH-29.9 MCHC-33.5 RDW-15.8* Plt Ct-149* [2177-7-2] 05:29AM BLOOD WBC-6.9 RBC-4.15* Hgb-12.2 Hct-36.9 MCV-89 MCH-29.5 MCHC-33.2 RDW-15.9* Plt Ct-165 [2177-7-2] 05:29AM BLOOD Neuts-67.3 Lymphs-23.8 Monos-4.0 Eos-4.2* Baso-0.7 [2177-7-1] 04:43PM BLOOD Neuts-80.3* Lymphs-13.4* Monos-2.7 Eos-3.0 Baso-0.6 [2177-7-3] 06:55AM BLOOD Plt Ct-149* [2177-7-2] 05:29AM BLOOD Plt Ct-165 [2177-7-2] 05:29AM BLOOD PT-13.3 PTT-27.9 INR(PT)-1.1 [2177-7-1] 04:43PM BLOOD Plt Ct-195 [2177-7-3] 06:55AM BLOOD Glucose-415* UreaN-33* Creat-6.5* Na-135 K-4.1 Cl-92* HCO3-32 AnGap-15 [2177-7-2] 05:29AM BLOOD Glucose-212* UreaN-33* Creat-7.4* Na-135 K-3.9 Cl-91* HCO3-32 AnGap-16 [2177-7-1] 09:29PM BLOOD Glucose-46* UreaN-32* Creat-6.7# Na-136 K-3.6 Cl-90 HCO3-35* AnGap-15 [2177-7-1] 04:43PM BLOOD Glucose-343* UreaN-78* Creat-12.0* Na-133 K-4.5 Cl-93* HCO3-25 AnGap-20 [2177-7-3] 06:55AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.5 [2177-7-2] 05:29AM BLOOD Calcium-8.8 Phos-4.4# Mg-2.3 [2177-7-1] 09:29PM BLOOD Calcium-9.2 Phos-2.8 Mg-2.4 [2177-7-2] 09:05AM BLOOD Vanco-32.2* [2177-7-1] 04:43PM BLOOD ASA-NEG Ethanol-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2177-7-1] 11:52PM BLOOD HoldBLu-HOLD [2177-7-1] 01:43PM BLOOD Type-[Last Name (un) ] pH-7.33* Comment-GREEN TOP [2177-7-2] 05:56AM BLOOD Lactate-1.1 [2177-7-1] 05:06PM BLOOD Lactate-2.2* [2177-7-1] 01:43PM BLOOD Glucose-490* Lactate-2.1* Na-132* K-5.4* Cl-92* calHCO3-24 [2177-7-1] 01:43PM BLOOD Hgb-13.4 calcHCT-40 O2 Sat-95 COHgb-2 MetHgb-0 [2177-7-1] 01:43PM BLOOD freeCa-1.03* Brief Hospital Course: BRIEF MICU COURSE: MICU Ms. [Known lastname ] was admitted to the ICU with pulmonary edema after missing HD. She underwent HD and UF the day of admission and had another session of UF on [2177-7-2]. She was hypertensive overnight and received both IV and PO Labetolol. After her UF session on [2177-7-2] her blood pressure was 110s-130s systolic. She was put on her Lisinopril 10mg daily, Lasix 60mg daily and Carvediolol 25mg [Hospital1 ] per renal recommendations. She was noted to have pus coming from her HD line and was given Vancomycin per HD protocol. She was cultured from her HD line. Her hyperkalemia resolved after UF. . FLOOR : 30 YO F w ESRD [12-31] DM1 now with tachypnea, hypoxia and hyperkalemia in the setting of missing HD. Was admitted to the MICU intially where she was dialyzed and her fluid status/tachypnea improved and was transferred to the floor. . #Tachypnea, hypoxia. Likely related to missing HD although initially a underlying respiratory infection cannot be excluded. On transfer to the floor she complained of no tachypnea and seemed comfortable with no complaints. Patient tolerated room air well and complains of no shortness of breath. UF recieved yesterday ([7-1]) with improvement in tachypnea. Repeat CXR post-UF to eval for clearance on patchy infiltrates on CXR- showed bilateral parenchymal opacities have decreased in extent and severity with only a ground-glass like pattern of opacities seen diffusely throughout the middle and lower lung zones. Urine/blood /HD entry site cultures-no growth to date. . # Hyperkalemia. Likely related to lack of HD. HD with UF as above . Repeat post-HD-potassium levels were normal Repeat EKG- no curent EKG peaked T waves which were present on [7-1] EKG's. F/u [7-3] EKG - no more peak T waves seen, offical results are pending. . # Hyperglyemia. No gap. - insulin sliding scale with home regimen- Blood sugars were initially above 350 however were then controlled under 200-250. . # Pus around HD line.-no pus was seen around HD line on the floors. With no fluctuance, draining fluid, or erythema. Vancomycin 1.5g with hD per renal fellow- discontinued per renal. F/u cultures- no growth to date. Bacitracin admin. only with dialysis to HD entry site recommended. . # ESRD. - continued home meds.Ordered Folic acid home dose. Contnued Sevelemer 800mg TID per renal. . # HTN. Continued home meds including home dose lisinopril daily in addition to already ordered home dose carvedilol, and lasix (60mg daily) Medications on Admission: . Aspirin 81 mg Tablet, PO DAILY 2. Carvedilol 12.5 mg Two (2) Tablets PO BID 3. Cinacalcet 30 mg PO DAILY 4. Docusate Sodium 100 mg Capsule PO BID 5. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) INJ qweek 6. Insulin Aspart Subcutaneous 7. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) Units qday 8. Latanoprost 0.005 % Drops Ophthalmic HS (at bedtime). 9. Sevelamer HCl 400 mg 2 tabs TID W/MEALS 10. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY 11. Lisinopril 10 mg Tablet PO once a day. Discharge Medications: 1. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous once a day: Please admin AM. 2. Novolog 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day: Please follow prior home sliding scale attatched. . 3. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 7. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed for drainage: Please admin. to hemodialysis entry site only with dialysis . Disp:0 Refills:0 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 13. Travatan 0.004 % Drops Sig: One (1) drop Ophthalmic at bedtime. 14. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection Injection once a week. Discharge Disposition: Home Discharge Diagnosis: Acute Pulmonary Edema Hyperkalemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to care for you as your doctor. . You were brought to the hospital because of diffuculty breathing,a high potassium level and having excess fluid in your system. We felt like this was caused by being fluid overloaded due to missing a dialysis appointment. You were admitted to the intensive care unit where you had fluid taken off with dialysis and were given support for your breathing. After these measures your breathing and potassium levels improved and you were transferred to the general floors. We observed you and you were medically stable to be discharged. . We made the following changes to your home medication list: We added Bacitracin which is a topical antibiotic which should be administered to your hemodialysis entry site before dialysis. We added Lasix 60mg daily. This will help keep your body fluid level appropiate. . Please take your other home medications as prescribed before coming to the hospital. . Please follow your dialysis schedule as you were before coming to the hospital. . Please weigh yourself daily and if you gain more than 3 pounds in one day contact your primary care physician. . Please follow up with the following outpatient appointments below: Followup Instructions: Name: [Last Name (LF) ], [First Name7 (NamePattern1) 1022] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Date: [8-4] 10:40AM Location: [Hospital3 249] [Hospital1 ] Address: [Location (un) ], [Hospital Ward Name ] 1, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 250] Fax: [Telephone/Fax (1) 4004] . Provider:[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1557] RN Date:Teusday [7-8], 3PM Location :[Last Name (NamePattern1) 5812] Service: [Hospital 982] Clinic Phone Number:: [Telephone/Fax (1) 2378] . Department: HEMODIALYSIS When: FRIDAY [2177-7-4] at 7:30 AM . Department: [Hospital ] HEALTH CENTER When: FRIDAY [2177-7-4] at 10:40 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 5808] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: PODIATRY When: TUESDAY [2177-7-8] at 9:20 AM With: [First Name11 (Name Pattern1) 3210] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], DPM [Telephone/Fax (1) 543] Building: Ba [Hospital Unit Name 723] ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "518.4", "V45.11", "250.43", "357.2", "585.6", "276.7", "583.81", "285.9", "250.63", "403.91" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	11879, 11885	7451, 9986	313, 319	11965, 11965	2494, 2494	13346, 14734	1789, 1802		10537, 11856	4140, 4211	11907, 11944		10012, 10514			12116, 13323								1818, 2475																						255, 275	4243, 7428					1042, 1401					347, 1024						2510, 4100					11980, 12092						1423, 1634	1650, 1773
14,060	116,655	23573	Discharge summary	report	Admission Date: [2177-3-15] Discharge Date: [2177-3-20] Date of Birth: [2122-5-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 465] Chief Complaint: back pain Major Surgical or Invasive Procedure: Transesophageal echocardiogram History of Present Illness: M with Crohn's disease recently admitted from [Hospital1 18] from [2177-2-20] to [2177-3-2] with a Crohn's flare c/b cdiff discharged on prednisone, po vanc and po flagyl with good effect who presents with acute bilateral [9-24] lower back pain on the morning of presentation. His back pain radiated to his stomach anteriorly. No radiation to lower extremities or focal weakness. He has had back pain since his last admission which has gradually worsened. He has had difficulty controlling his bowel movements but felt that this was improving. No change in urinary habits. Did not report nausea or emesis. His Crohn's flare had improved such that he was sleeping through the night with 5-6 bowel movements per day. He presented to [Hospital ] Hospital where he was found to be febrile to 106.2. He then became hypotensive to 83/53- his BP on presentation was 180/70 and tachy to 122. He had one episode of non-bloody, non-bilious emesis. He He was given vanc/tylenol/hydrocortisone 100 mg IV/imipenum/fentanyl 75 and NS. Of note he had a root canal performed on [1-31] for which he was given abx. He also has a dental abcess. Upon arrival to the [Name (NI) ] pt was hypotensive to 77/59. Central line placed and started on dopamine in addition to levophed. Had one large BM in ED. Given po vancomycin, and decadron 10 mg IV. . **** In the MICU, patient was maintained initially on pressors, volume resuscitated, given stress dose steroids, treated with flagyl/zosyn/vanc, as well as oral vanc. He was found to have MSSA bacteremia. CT abdomen showed possible stranding around pancreatic head. An MRI of the spine without gadolinium was inconclusive and so on day of call-out to floor an MRI with gad was still pending to evaluate for T10 osteomyelitis. Past Medical History: 1. Ileocolonic colitis 2. Hypertension 3. Hemachromatosis 4. Hypercholesterolemia 5. S/p arthroscopic knee surgery 6. Recent history of clostridium difficile infection Social History: The patient is married and has three adult children, one of whom has juvenile onset diabetes. Tobacco - former use, 1.5pk/day, stopped 9 years ago ETOH - Denies alcohol or illicit drug use Family History: His mother is deceased. She had hypertension and myocardial infarction. His father died at the age of 61 due to colon cancer. The patient has two male siblings, one of whom has hepatitis C requiring a transplant and the other is alive and well. Physical Exam: VS T 98.8 P 81 BP 146/95 RR 17 O2Sat 95% on RA GENERAL: Pleasant obese male HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, decreased bowel sounds, peri-umbilical tenderness with moderate palpation. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -cerebellar: No nystagmus, dysarthria, intention or action tremor, dysdiadochokinesia noted. -DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: [2177-3-15] 05:20PM PT-13.1 PTT-22.0 INR(PT)-1.1 [2177-3-15] 05:20PM PLT SMR-NORMAL PLT COUNT-169 [2177-3-15*] 05:20PM WBC-13.7 RBC-3.99* HGB-11.7* HCT-34.7* MCV-87 MCH-29.4 MCHC-33.7 RDW-15.7* [2177-3-15] 05:20PM NEUTS-93.2* BANDS-0 LYMPHS-3.9* MONOS-2.5 EOS-0.2 BASOS-0.3 [2177-3-15] 05:20PM ALBUMIN-2.9* CALCIUM-7.7* PHOSPHATE-1.3* MAGNESIUM-1.2* [2177-3-15] 05:20PM CK-MB-2 [2177-3-15] 05:20PM cTropnT-0.05* [2177-3-15] 05:20PM ALT(SGPT)-40 AST(SGOT)-25 LD(LDH)-279* CK(CPK)-152 ALK PHOS-87 AMYLASE-192* TOT BILI-0.6 [2177-3-15] 05:20PM LIPASE-234* [2177-3-15] 05:20PM GLUCOSE-113* UREA N-25* CREAT-1.9* SODIUM-137 POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-19* ANION GAP-15 [2177-3-15] 05:28PM TYPE-ART PO2-94 PCO2-38 PH-7.38 TOTAL CO2-23 BASE XS--1 . CT Chest, Abdomen, Pelvis: IMPRESSION: 1. No evidence of pulmonary embolism. 2. No evidence of aortic dissection or injury. 3. Fluid filled colon likely related to colitis. No other bowel pathology identified. 4. Non-specific stranding in the porta hepatis region; this may relate to pancreatitis. 5. Loss of height in the T10 vertebral body, chronicity indeterminate. If clinical concern exists in this area, a dedicated CT or MR of the thoracic spine may be of value. . MR WITHOUT CONTRAST T AND L SPINE: IMPRESSION: 1. Increased signal intensity in the T9-10 disc with increased signal intensity of the adjacent superior endplate of T10 vertebral body, which could be due to infection, given the clinical history of fever and bacteremia. This needs clinical correlation as well as repeat MRI of the thoracic spine with IV contrast. If the patient's EGFR is about 30, IV gadolinium contrast can be administered, provided the risks of possible nephrogenic systemic fibrosis are understood by the patient as well as the treating clinical team. There is also a horseshoe-shaped soft tissue mass under anterior longitudinal ligament at this level, raising the possibility of paraspinal extension of infection anteriorly. No evidence of epidural space or cord involvement on the present study. 2. Multilevel degenerative changes in the cervical spine, most prominent at C4-5 and C5-6 with right neural foraminal narrowing. 3. Moderate left central disc protrusion at L5-S1, impinging left S1 nerve root. . MR W/ AND W/O CONTRAST T-SPINE: INDICATION: Evaluate T9-10 level for a possibility of discitis and paraspinal abscess. TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through the thoracic spine. FINDINGS: As noted on the prior examination of [2177-3-16], there is increased T2 signal within the T9-10 disc as well as increased T2 signal within the superior endplate of T10. As before, there is slight reduction in the height of the T10 vertebral body. Unlike on the prior study, today's exam demonstrates that the increased T2 signal within T9-10 disc level is not any different than the T2 signal within the T10-11, T11-12 and T12-L1 disc spaces. There is no evidence of enhancement or a paraspinal soft tissue mass. These findings could be due to a subacute compression fracture of the T10 vertebral body with marrow edema. There is no retropulsion of bone fragments. There is no spinal canal stenosis or abnormal spinal cord signal. There are no areas of abnormal enhancement. However, mild osteomyelitis and discitis could give a similar appearance, even with the lack of enhancement. Since the T10-11 disc spaces do not appear brighter than any of the discs inferior to that level, the findings are slightly more consistent with degenerative change with a compression fracture of the T10 vertebral body. IMPRESSION: No evidence of enhancement or a paraspinal soft tissue mass. On today's exam, the T9-10 disc T2 hyperintensity is the same as the disc spaces inferior to it. This constellation of findings suggests that the signal abnormalities relate to a subacute T10 compression fracture rather than osteomyelitis and discitis. A followup exam could be obtained if clinically warranted as the possibility of a discitis and osteomyelitis remains. . TRANSTHORACIC ECHO: Left Atrium - Long Axis Dimension: 4.2 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.8 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 5.4 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.4 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.7 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 4.0 cm Left Ventricle - Fractional Shortening: 0.30 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 60% (nl >=55%) Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm) Aorta - Ascending: 3.4 cm (nl <= 3.4 cm) Aorta - Arch: 3.0 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 0.86 Mitral Valve - E Wave Deceleration Time: 227 msec TR Gradient (+ RA = PASP): 18 to 27 mm Hg (nl <= 25 mm Hg) Pericardium - Effusion Size: 1.2 cm INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous hypertrophy of the interatrial septum. LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity size. Overall normal LVEF (>55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. No vegetation seen (cannot definitively exclude). . TRANSESOPHAGEAL ECHOCARDIOGRAM: INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast in the body of the LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF (>55%). AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or vegetations on aortic valve. MITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral valve. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or vegetation on tricuspid valve. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No vegetation/mass on pulmonic valve. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). The posterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related complications. 0.2 mg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion. The patient appears to be in sinus rhythm. Conclusions: No spontaneous echo contrast is seen in the body of the left atrium. 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%). The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. IMPRESSION: No valvular vegetation seen. . ULTRASOUND OF THE RIGHT UPPER EXTREMITY: INDICATION: Right arm swelling. IMPRESSION: Occlusive thrombus within the cephalic vein extending from several centimeters proximal to the antecubital fossa to the distal forearm. No thrombus identified in the other major veins of the right arm. Findings were discussed with Dr. [Last Name (STitle) 29932] at the time of dictation CULTURE DATA: [2177-3-15] 5:25 pm BLOOD CULTURE FINAL REPORT [2177-3-19]* AEROBIC BOTTLE (Final [2177-3-18]): REPORTED BY PHONE TO [Doctor Last Name ] [Doctor Last Name ] [2177-3-16] 10:30AM. STAPH AUREUS COAG +. FINAL SENSITIVITIES. Please contact the Microbiology Laboratory ([6-/2476]) immediately if sensitivity to clindamycin is required on this patient's isolate days after initiation of therapy. Testing of repeat isolates may be warranted Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R ANAEROBIC BOTTLE (Final [2177-3-18]): STAPH AUREUS COAG +. SENSITIVITIES PERFORMED FROM ANAEROBIC BOTTLE. . BLOOD CULTURE X 2 ([2177-3-16]): NO GROWTH TO DATE . BLOOD CULTURE X 2 ([2177-3-17]): NO GROWTH TO DATE DISCHARGE LABS: Na 141 K 3.1 (before repletion) Cl 106 Bicarb 27 BUN 18 Cr 1.1 Mg 1.8 . WBC 8.6 HGB 12.7 HCT 37 Plt 131 . Brief Hospital Course: 1. Hypotension: The patient was found to be hypotensive on presentation and required aggressive fluid infusion and pressors while monitored in the ICU. Blood cultures were positive for Staph aureus, which was found to be sensitive to oxacillin. On initial presentation the patient was noted to have a warm, tender erythematous area of skin just below his right antecubital fossa. This was investigated with ultrasound and found to be an occlusive thrombus of the cephalic vein. The patient reported to have had a peripheral IV at this location during his previous hospitalization in [2177-2-13]. The thrombophlebitis was thought to be the most likely nidus of infection leading to the staph bacteremia. However, other sources were sought: a panarex of the jaw revealed no areas suspicious for infection and TTE and TEE revealed no vegetations either as a cause or a result of the bacteremia. An MR was done of the spine (workup detailed below). The patient quickly stabalized his blood pressure and was transferred to the floor. After his initial presentation, he remained afebrile, his repeat blood cultures were negative, and his WBC trended downward. He was discharged on a 4 week course of nafcillin to be followed by a home-infusion team. The visiting nurse was given instructions on weekly lab reports to be faxed to the patient's infectious disease doctor, [First Name8 (NamePattern2) ] [Name8 (MD) 3394], MD at the [Hospital1 ] infectious disease group, and the patient was scheduled for an [Hospital ] clinic visit in 4 weeks time. . 2. Back pain: The patient described his back pain as [9-24] on the day leading up to admission and he continued to experience pain after his transfer out of the ICU. At no time during his stay did he have a change in his neurologic exam, and he had no bowel/bladder incontinence or saddle parasthesias. An MR without contrast was scheduled initially, which found increased signal intensity in the T9-10 disc and T10 vertebral superior endplate which were somewhat suspicious for infection, given the patient's presentation. This was followed up with an MRI with gadolinium contrast, which again found T9-10 disc enhancement, but found an equal amount of enhancement in the T11-12 an T12-L1 disc spaces. In addition to the finding of T10 vertebral endplate enhancement, the imaging was most consistent with at subacute compression fracture of the T10 vertebra, likely secondary to degenerative changes. However, the study could not entirely rule out the possibility of infection. The orthospine team was consulted and they offered the patient the option of doing a needle biopsy to rule out the chance of infection completely. However the patient declined, and the ID, ortho-spine, and primary teams were in agreement that the patient could be followed clinically and if he showed worsening signs of infection or back pain, the issue could be readdressed. In addition, he was scheduled for a repeat MRI in 4 weeks time, to be done before his 4 week ID appointment. Given the subacute fracture, the ortho-spine team strongly recommended that the patient wear a TLSO brace for support. This was repeatedly reinforced to the patient, but the patient declined the brace. If he continues to have back pain, the recommendation for a brace should be readdressed and an [Hospital ] clinic visit scheduled by his primary care physician. [Name10 (NameIs) 227] the strong indication of the imaging findings that the patient has had a compression fracture, the patient is likely at risk for repeated compression fractures. Chronic high dose steroid use is likely a contributing factor. The patient was started on vitamin D 800 u per day and calcium 500 mg TID on discharge. The patient continued to have intermittent back pain which was particularly exacerbated by certain positions, such as lying flat. He was discharged on percocet and a limited amount of oral dilaudid for control of the back pain, with instructions to call his physician if his pain was escalating. 3. Renal failure: While in the ICU the patient had an increase in his creatinine to a peak of 2.4. This was thought secondary to sepsis and resolved with fluids. On discharge his creatinine was at his baseline range of 1.1. . 4. Hypertension: The patient's outpatient hypertensive medications were held on admission due to hypotension. On the general [Hospital1 ], it was difficult to control his blood pressure. He was discharged on atenolol 50 mg once a day (equal to his previous dose) and lisinopril 40 mg (up from previous dose of 20 mg). He was instructed to follow his blood pressure closely over the next week with his primary care physician. . 4. Diarrhea: The patient tested negative for clostridium difficile on this admission and had no diarrhea. He was continued on a 4 week course after discharge of oral vancomycin with input from infectious disease service. The decision to continue oral vancomycin was made in part because he is scheduled for long course of nafcillin, potentially reexposing him to c.diff infection. . 5. IBD: Ulcerative colitis: The patient was maintained on 60 mg prednisone daily as he had taken prior to admission. On the day before discharge, he was tapered to 50 mg daily as he had previously discussed with his gastroenterologist. Further tapering decisions to made with gastroenterologist. 6. Thrombocytopenia: The patient had steadily decreasing platelets during his stay, reaching a low of 89 (admission 169). Prior to his platelets dropping below 100, his subcutaneous heparin and his central line heparin flushes were discontinued. Heparin antibodies were negative. On the day after the central line was replaced and the labs were drawn off the PICC, his platelets rebounded to 131. The thrombocytopenia was thus thought either secondary to sepsis, with appropriate rebound, or secondary to blood collection technique. The patient did NOT meet diagnostic criteria for HIT on this admission. . 7. Pre-diabetes: The patient had elevated blood sugars during his stay, and steroid use is likely a contributing factor. He was discharged with a glucometer and instructions on use and this will hopefully facilitate further management with his primary care physician. . 8. Prophylaxis: Given his chronic steroid use, the patient was dosed with protonix. 9. Follow-up: Followup with Infectious Disease as described above, with infusion therapy team and weekly labs, with MRI in 4 weeks, and with primary care physician. Medications on Admission: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) 3. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bismuth Subsalicylate Thirty (30) ML PO Q1H (every hour) as needed 7. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO as directed: Take 1 qid for 17 more days. After that, take 1 tid X 1 week, then 1 [Hospital1 ] X 1 week, then 1 daily x 1 week, then 1 qod X 1 week, then 1 q3d X 1 week, then stop. Allergies: Discharge Medications: 1. Nafcillin 2 g Recon Soln Sig: Two (2) g Intravenous every four (4) hours for 4 weeks. Disp:qs grams Refills:0 2. IV care PICC line care per protocol 3. IV Pump Pump for nafcillin home therapy 4. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 4 weeks. Disp:112 Capsule(s) Refills:0 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:90 Tablet, Chewable(s) Refills:2 8. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day: Daily dose 50 mg per day. Further adjustments to dose to be determined by gastroenterologist. Disp:150 Tablet(s) Refills:2 9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for 7 days: Take 1-3 tablets as needed if pain not controlled by percocet and call your doctor if you are requiring this medication. . Disp:30 Tablet(s) Refills:0 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: Do not take more than 4 grams of acetaminophen in one day. . Disp:30 Tablet(s) Refills:2 12. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) ] home therapies Discharge Diagnosis: Primary: MSSA septicemia HTN Hyperglycemia secondary prednisone Thrombocytopenia likely secondary to sepsis (HIT negative) Acute Renal Failure, now at baseline creatinine 1.1 Anemia . Secondary: Hypertension previous Clostridium difficile Ulcerative colitis Hemochromatosis Discharge Condition: Good Discharge Instructions: You were admitted with bacteremia and there was concern that you might have a spine infection. We do not believe that you have an infection of your spine, but it is important that you be vigilant for symptoms. If you develop fevers, increasing severe back pain, incontinence of urine or stool, or numbness/tingling in your legs or groin, you should call your physician [Name Initial (PRE) 2227]. You should also call the [Hospital ] clinic at ([Telephone/Fax (1) 10]. Your infectious disease doctor is Dr. [First Name8 (NamePattern2) ] [Name (STitle) 3394]. . The infusion company will give you instructions on how to deliver the nafcillin through your infusion pump. In addition, they will monitor some laboratory levels for you, including your CBC with differential, BUN, Creatinine and Liver function tests. These results should then be faxed to Dr. [Last Name (STitle) 3394] at [Telephone/Fax (1) 1419]. The visiting nurse drawing the labs will have this information, but if you have your labs drawn at another location, such as your primary care doctor's office, please make sure the results are faxed to this number. . You have been given a prescription for a glucometer. This is for better measurement of your blood sugar on a daily basis. We recommend checking your blood sugars before meals and if you are feeling sick for any reason. If you notice blood sugars greater than 200, please call your primary care doctor. . You have been instructed to follow a diabetic diet in order to keep your blood sugar well controlled. . You are planning to have your blood pressure closely monitored by your primary care physician after discharge. You are being discharged on two blood pressure medications: Atenolol 50 mg once a day Lisinopril 40 mg once a day. . Take your other medications as prescribed in the medications section. . You have been prescribed oral vancomycin for prevention of clostridium difficile infection, which causes diarrhea. Your infectious disease physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 3394], [First Name3 (LF) ] determine how long you need to take this medication at your appointment with her. . You have an appointment scheduled with Dr. [Last Name (STitle) 3394] in the [Hospital ] clinic in the [Hospital1 ] [Hospital Unit Name ] on [2177-4-15] at 9:30 AM. . You have an appointment to get an MRI scan on [2177-4-10] at 3:15 PM. You should get this MRI prior to your ID appointment. . Your prednisone for your ulcerative colitis has been reduced to 50 mg per day. You should discuss further changes with Dr. [First Name (STitle) 2643]. . It was strongly recommended to you that you use a back brace to stabalize your thoracic spine for the next few weeks. At this time, you declined this intervention. Please discuss this decision with your primary care physician, [Name10 (NameIs) ] if you reconsider this decision, please obtain a TLSO back brace as soon as possible. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2837], MD Phone:[Telephone/Fax (1) 1983] Date/Time:[2177-3-26] 1:30 Provider: [Name10 (NameIs) 706] MRI Phone:[Telephone/Fax (1) 327] Date/Time:[2177-4-10] 3:15 [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472] Completed by:[2177-3-21]	[ "785.52", "287.5", "401.9", "556.9", "733.13", "453.8", "038.11", "584.9", "999.2" ]	icd9cm	[ [ [] ] ]	[ "38.93", "88.72" ]	icd9pcs	[ [ [] ] ]	23649, 23715	14721, 21221	324, 357	24033, 24040	3764, 14574	27080, 27489	2585, 2832		22044, 23626		23736, 24012		21248, 22021			24064, 27057		14590, 14698		3431, 3745				2847, 3335																						275, 286											385, 2171											3350, 3414						2193, 2362	2378, 2569
15,128	173,545	26410	Discharge summary	report	Admission Date: [2162-1-10] Discharge Date: [2162-1-15] Date of Birth: [2106-12-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 465] Chief Complaint: hemetemesis and melena Major Surgical or Invasive Procedure: Upper endoscopy History of Present Illness: Pt is a 55y/o M w/ a PMH significant for EtOH abuse resulting in cirrhosis (s/p variceal bleed in [5-14]) who presented to an OSH w/ hemetematsis and melena. He was transfused 5u PRBC, 2u FFP, and 5u Plts at the OSH and intubated for airway protection. EGD there demonstrated non-bleeding varices and a bleeding gastric ulcer (unable to successfully cauterize/epi inject). He was transfered here for further care. . On transfer, the patient was hemodynamically stable in the ER and was started on octreotide, nadolol, protonix, and levaquin. He received a repeat EGD which showed grade III non-bleeding varices in the lower 3rd of the esophagus along with extensive esophageal ulceration. In the stomach, they noted severe gastropathy along with a non-bleeding proximal stomach lesion. He was maintained on a CIWA scale throughout his stay. He has not received blood products since admission. The patient was extubated on [1-11], tolerated this well, and was weaned off supplemental O2 by the time he was called out to the floor. Today, the patient complains of intermittant diffuse abdominal pain that is relieved with passing gas/bowel movements. He also notes intermittant L sided CP that has happened on and off for the past several months only while he is active. He denies radiation or associated symptoms and states that it is happening ~ 1x/d and abates after approximately 1min. He denies any CP currently and also denies current abdominal pain, SOB, HA, weakness, palpatations, paresthesias. Past Medical History: 1. Alcoholism: pt still actively drinking 6 pack per day, never been treated for w/d, never seized 2. EtOH Cirrhosis s/p variceal bleed [5-14] 3. inguinal hernia repair [2159] 4. HTN 5. Pancytopenia (?secondary to EtOHism) 6. s/p finger amputation Social History: EtOh: 12 beers/day No tobacco Lives with wife in [Name (NI) ], worked as a meat cutter 32yrs. states sober for 6 wks after his last variceal bleed but started drinking after this because of the stress of his job and caring for his mother and father-in-law Family History: n/c Physical Exam: 98.7, 108/66, 77, 19, 95% RA Gen: well appearing male lying in bed in NAD HEENT: Eyes - nl visual fields, EOMI, PERRLA Ears - TMs clear, CNVIII intact, [Doctor Last Name 11586] midline Mouth - MMM, red/purple ecchymoses on posterior palate, uvula Neck: small 2mm L cervical LN, non-tender CV: nl PMI, RRR, -M/R/G Lungs: good air entry, clear to percussion, CTA bilaterally Abd: S/NT, mildly distended, +BS, -HSM,liver span 4cm in midclavicular line, - caput medusa/spider angiomata/palmar erythema Ext: -C/C/E, no rashes Neuro: CN 2-12 grossly intact, Strength 5/5 in UE and LE bilat, 2+ patellar reflexes, AAO x3 Pertinent Results: [2162-1-10] 07:23PM PT-13.9* PTT-26.7 INR(PT)-1.3 [2162-1-10] 07:23PM PLT SMR-VERY LOW PLT COUNT-78* [2162-1-10] 07:23PM WBC-6.9 RBC-3.54* HGB-11.8* HCT-32.3* MCV-91 MCH-33.3* MCHC-36.4* RDW-16.3* [2162-1-10] 07:23PM ALBUMIN-3.0* CALCIUM-6.6* PHOSPHATE-2.2* MAGNESIUM-1.6 [2162-1-10] 07:23PM CK-MB-8 cTropnT-<0.01 [2162-1-10] 07:23PM GLUCOSE-229* UREA N-10 CREAT-0.8 SODIUM-143 POTASSIUM-3.2* CHLORIDE-112* TOTAL CO2-21* ANION GAP-13 [2162-1-10] 07:23PM GLUCOSE-229* UREA N-10 CREAT-0.8 SODIUM-143 POTASSIUM-3.2* CHLORIDE-112* TOTAL CO2-21* ANION GAP-13 [2162-1-10] 09:06PM TYPE-ART RATES-/15 TIDAL VOL-600 O2-40 PO2-87 PCO2-41 PH-7.37 TOTAL CO2-25 BASE XS--1 -ASSIST/CON INTUBATED-INTUBATED . Abd U/S [2161-1-11]: 1. Nodular cirrhotic liver. 2. Small amount of ascites in the right upper quadrant. Too small to mark a spot for paracentesis. 3. Normal hepatic Dopplers. 4. Gallbladder wall edema, likely secondary to underlying liver disease . EGD [2161-1-10]: Lesion in proximal stomach body as previously noted, but not actively bleeding. Varices at the lower third of the esophagus Small amounts of older clotted blood was seen in the body and fundus, but no active bleeding was seen. Extensive ulceration of the mid-distal esophagus. Severe erythema, congestion and nodularity in the stomach body and fundus compatible with severe portal gastrophathy. Otherwise normal egd to second part of the duodenum Brief Hospital Course: Pt presented to OSH, with hemetemesis and melena. There, his BP was 147/87 and HR was 100. An NGT was placed. Aspirate revealed 1400cc of red blood. An EGD revealed an actively bleeding gastric ulcer and nonbleeding esophageal varices. Initial Hct was found to be 28.8 and platelets were found to be 37,000. Pt was transfused 5u PRBC, 2u FFP, 5u Plts. Pt was intubated for airway protection and started on octreotide, protonix, levofloxacin, flagyl and ativan. Pt was transferred to [Hospital1 18] for further treatment. On transfer to [Hospital1 18], pt's vital signs were stable. A repeat EGD was performed, which showed non-bleeding grade III esophageal varices in the lower [1-12] of the esophagus. In addition, there were extensive ulcerations in both esophagus and stomach. The stomach was found to be diffusely erythematous, congested and nodular with evidence of severe gastropathy. There were a few dark clots with no active bleeding. In the greater curvature, there was heaped up mucosa, likely the area of recent hemorrhage. The nature of the lesion, (a gastric varix versus focal bleed of gastropathy versus bleeding ulcer) was unable to be determined. No intervention was performed. In the MICU, pt was stable. He has not required any further blood products. Hct has been stable, fluctuating within a range of 30.5-33.8. He passed 2 more melenic stools in the MICU. Pt was extubated on [1-11] and tolerated a wean of supplemental O2. A RUQ U/S was obtained, which showed a small amount of ascites. The liver was nodular and superior mesenteric, portal and splenic veins and hepatic arteries and veins were patent. Pt was transferred to the floor on [1-13]. His vital signs remained stable. His Hct remained stable at 30-34 with no further episodes of hemetemesis or melena. Pt will obtain a repeat EGD as well as a colonoscopy as an outpatient. He will follow up the Liver clinic (Dr. [Last Name (STitle) 25890] on Tuesday [1-19], to have a repeat EGD. Given the pt's history of chronic EtoH abuse, DT prophylaxis with diazepam was continued, following a CIWA scale. On [1-12] and [1-13] the patient had 2 episodes of asymptomatic NSVT. Mg and K were repleted as they were low normal. An Echo was performed which revealed preserved biventricular function. He continued to have low normal potassium and magnesium which was aggressively repleted. His electrolyte loss was attributed to his alcoholic liver disease. The pt was also found to be pancytopenic which platelet counts in the 40s to 60s and mild leukopenia ranging aroun 3700. Platelet counts and leukocytes remained stable. Pt met with social worker to discuss outpatient addiction services. After contacting several programs, the patient decided to attend a daily group program with his son. His family is supportive of this decision. Medications on Admission: Octreotide gtt Levofloxacin 500mg IV X 1 Flagyl 500 mg IV X 1 Protonix 80 mg IV X 1 Ativan gtt Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:5 Tablet(s) Refills:0 3. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Mag-Caps 140 mg Capsule Sig: Three (3) Capsule PO three times a day: Do not take together with Levofloxacin. Disp:180 Capsule(s) Refills:2 6. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day. Disp:120 Tab Sust.Rel. Particle/Crystal(s) Refills:2 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Gastrointestinal bleed, originating most likely from gastric lesion. No evidence of bleeding from esophageal varices. ............... Liver cirrhosis Esophageal varices Mild mitral regurgitation Small ascites Discharge Condition: Stable hematocrit, good condition Discharge Instructions: Please come back to the hospital or see your primary care doctor if you have any, nausea, vomiting, bloody or dark stools, lightheadedness, dizziness or any other concerns. . Please take all the medications as instructed. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 497] on the [1-19]. Please be at the [Hospital Ward Name 121] building at 8am to have your endoscopy at 9am. Afterwards you will see Dr. [Last Name (STitle) 497]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472]	[ "427.1", "456.21", "424.0", "303.91", "571.2", "401.9", "572.3", "789.5", "578.9", "284.8", "530.20", "537.89" ]	icd9cm	[ [ [] ] ]	[ "96.04", "45.13", "96.71" ]	icd9pcs	[ [ [] ] ]	8637, 8643	4613, 7460	338, 356	8896, 8932	3125, 4590	9202, 9551	2467, 2472		7606, 8614		8664, 8875		7486, 7583			8956, 9179								2487, 3106																						276, 300											384, 1895																	1917, 2174	2190, 2451
8,043	197,265	22325	Discharge summary	report	Admission Date: [2162-7-19] Discharge Date: [2162-7-22] Date of Birth: [2099-12-12] Sex: M Service: [Hospital Unit Name 196] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2704] Chief Complaint: Vfib arrest. Major Surgical or Invasive Procedure: Telemetry. Maintained on endotracheal intubation. Arterial line. Subclavian central line. History of Present Illness: 62y/o M found down in field with v fib-->arrest after completing a 2 mile bike ride. Down for approx. 5 min before CPR and 10 min before EMS arrival, shocked for VFib x 4, intubated, given epi, lidocaine, atropine and -> to OSH. In OSH, was in/out of VT, shocked x 6, and started on amiodarone, stabilising in probable junctional rhythm. CT showed occipital hematoma from fall with likely contracoup left frontal subdural hematoma and contusion, also small subarachnoid. Past Medical History: - CAD s/p CABG - stents and s/p balloon angioplasty revision - DM2 - HTN Social History: SocHx: Married, bank worker/chamber of commerce/sedentary. Remote tobacco history, occ. EtOH, -IVDA. Family History: FamHx: MI mother & father, 55 y/o and ~70y/o respectively. Physical Exam: Deceased. Time of death: 3.33pm, [2162-7-22]. Pertinent Results: [Known lastname 58154],[Known firstname ]: [Hospital1 18] Neurophysiology Detail - CCC Record #[Numeric Identifier 58155] 04-1819D - CCC REPORT APPROVED DATE:[2162-7-21] TEST DATE: [2162-7-20] INTERPRETED BY: [Last Name (LF) ],[First Name3 (LF) ] L. FINDINGS: ABNORMALITY#1: The background rhythm is low voltage. At 2 microvolt amplification [Hospital1 ]-frontal beta activity is visible and there is intermittent theta frequency activity with a 1 Hz delta frequency background rhythm. This delta frequency slowing appears synchronous with the cardiac monitor and may reflect a pulse artifact. BACKGROUND: As above. HYPERVENTILATION: Was not performed due to the patient's clinical condition. INTERMITTENT PHOTIC STIMULATION: Was not performed since this was a portable study. SLEEP: Normal sleep architecture was not seen. CARDIAC MONITOR: Sinus tachycardia with a rate of 108 beats per minute. IMPRESSION: This is an abnormal portable EEG due to the low voltage background activity. [Hospital1 ]-frontal beta activity is present as is intermittent theta frequency slowing of the background rhythm. A delta frequency background rhythm is also present and may reflect a pulsation artifact. Painful stimulation during the recording did not alter the background rhythm. These findings suggest a severe encephalopathy and could be consistent with hypoxic injury from cardiac arrest but medication effects are also possible. No epileptiform activity was seen. A narrow complex tachycardia was noted on the cardiac monitor. OBJECT: 62 year old man with a history of recent cardiac arrest. Evaluate for seizures. Brief Hospital Course: The patient was transferred to [Hospital1 18] from an OSH. He was cardiovascularly supported in the CCU, with the hope that the neurological sequelae of his vfib arrest might resolve. However, CT imaging determined that extensive severe anoxic brain injury had occurred. In conjunction with the patient's poor clinical presentation on neurological exam, this indicated a very poor prognosis. The patient was placed on comfort measures on [2162-7-22] and extubated. The patient's cardiovascular status began to deteriorate. Pt. died at 3.33pm. Medications on Admission: Amiodarone HCl 0.5 mg/min IV INFUSION Duration: 18 Hours Acetaminophen 325-650 mg PO Q4-6H:PRN Insulin SC (per Insulin Flowsheet) Sliding Scale Levofloxacin 500 mg IV ONCE Duration: 1 Doses Metronidazole 500 mg IV Q8H Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Pantoprazole 40 mg PO Q24H Aspirin 325 mg PO QD Amiodarone HCl 400 mg PO TID Discharge Medications: None. Discharge Disposition: Extended Care Facility: Patient's family has selected a funeral home in [State 1727]. Discharge Diagnosis: Ventricular fibrillation leading to severe anoxic brain injury. Discharge Condition: Deceased. Discharge Instructions: None. Followup Instructions: None. Completed by:[2162-7-22]	[ "E826.1", "851.85", "250.00", "401.9", "427.41", "348.1", "V45.81", "V45.82" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04", "38.93", "38.91" ]	icd9pcs	[ [ [] ] ]	3974, 4066	2993, 3545	349, 441	4173, 4184	1318, 2970	4238, 4274	1172, 1233		3944, 3951		4087, 4152		3571, 3921			4208, 4215								1248, 1299																						297, 311											469, 941																	963, 1037	1053, 1156
26,617	163,181	30402	Discharge summary	report	Admission Date: [2200-4-9] Discharge Date: [2200-4-20] Date of Birth: [2142-8-14] Sex: F Service: CARDIOTHORACIC Allergies: Celexa / Celebrex / Neurontin Attending:[First Name3 (LF) 5790] Chief Complaint: right Upper Lobe lung cancer Major Surgical or Invasive Procedure: - placement of right side chest tube - radio frequency ablation of right lung mass - intubation - talc pleurodesis of R pleural space History of Present Illness: 57 F with a previously diagnosed R upper lobe Lung Cancer who presenterd to [Hospital1 18] for radio frequency ablation as part of planned definitive nonoperative treatment. During the process of the CT-guided procedure she developed a moderate R pneumothorax for which a pigtail catheter was placed posteriorly in the interventional radiology suite. The pneumothorax was seen to be increasing on follow-up imaging and a R tube thoracostomy was required. Past Medical History: PMH: Spinal stenosis, HTN, COPD, Asthma PSH: Mediastinoscopy, bilateral cataract surgery, Urethral sling in [2191], TAH in [2176] (benign disease) Social History: tobacco - ~60 pack years and quit ~15 years ago Family History: non-contrib Physical Exam: on discharge AVSS WD, WN, NAD RRR, no m/r/g bilateral slightly coarse breath sounds, slight decreased at right base soft, nt, nd, nabs bilateral lower extrem warm Pertinent Results: [2200-4-16] 11:43PM BLOOD WBC-12.9* RBC-3.57* Hgb-12.3 Hct-36.5 MCV-102* MCH-34.4* MCHC-33.6 RDW-15.3 Plt Ct-676# [2200-4-16] 11:43PM BLOOD Plt Ct-676# [2200-4-16] 11:43PM BLOOD PT-12.2 PTT-28.0 INR(PT)-1.0 [2200-4-16] 11:43PM BLOOD Glucose-92 UreaN-7 Creat-0.7 Na-137 K-4.2 Cl-98 HCO3-23 AnGap-20 [2200-4-16] 11:43PM BLOOD Calcium-8.5 Phos-4.4 Mg-2.0 CXR on day of discharge: Showed a stable R pleural effusion of moderate size and no pneumothorax Brief Hospital Course: The patient was admitted to the thoracic surgery service after undergoing radio frequency ablation of a right side lung mass. This procedure was complicated by the development of a right side pneumothorax that required placement of a chest tube by the thoracic surgery service. This was done on HD 1 - upon completion of CT placement a brisk air leak was noted in the pleuravac. On HD 2 / PPD 1 the pt. was still noted to have an airleak with the CT to suction. As the air leak dissapated the pt. was given a trial of water seal later in the day - this resulted in the pt. developing a large amout of subcutaneous air. The pt. did not experience any respiratory distress, however, she was immediately placed back to suction on the CT. Later that evening the subcutaneous air had continued to expand - reaching across the patient's chest, into her neck and face. Throughout this time the CT was continued on 40cm H2O of dry suction, checked regularly to make sure it was working properly, and the pt. did not experience respiratory compromise. The pt. was maintained on the elevated level of suction until PPD 6. At this time the intermittent air leak had disappeared and the pt. was dropped to 20cm H2O in the morning and transitioned to water seal that evening. In the evening of PPD 7 the pt. underwent chemical pleurodesis. The pt. initially did well, however, about 30 min post procedure the pt. was in quite a bit of pain, was splinting, and desaturating. The pt. was intubated for airway protection and transferred to the ICU. She was extubated overnight and transferred out of the ICU on PPD 8. The pt. was kept with her chest tubes to suction until PPD 9. That morning she was placed to water seal and a CXR 4 hours later was stable. She was then clamped for one hour and a follow-up CXR was again stable. The CT was then pulled and her post-pull CXR was stable. A follow-up CXR was done in the morning of PPD 10, was stable, and the pt. was ready for discharge to home. Over the course of her stay the pt. was weaned from supplemental oxygen, encouraged to ambulated in the halls, and advanced to tolerate a regular diet. She was doing well on the day of discharge. Her pain was well controlled with PO dilaudid, she was tolerating a regular diet, and was ambulating without difficulty or needing supplemental oxygen. She was given instructions regarding post-procedure follow-up appointments, recovery, medications, and tolerated activity levels. She understood this information well and was ready for discharge to home. Medications on Admission: Zestril Atenolol Calcium with vitamin D Flovent Spiriva Advair Theophylline 200'' Albuterol Nicorette Wellbutrin Ambien Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (). 5. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): - take every day you take pain medication. Disp:60 Capsule(s) Refills:0 7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed: - do not drive while taking this medication. Disp:45 Tablet(s) Refills:1 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:30 Tablet(s) Refills:0 13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:20 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: - right pneumothorax after RFA of right lung mass - s/p talc pleurodesis of R pleural space - h/o Spinal stenosis, HTN, COPD, Asthma, s/p Mediastinoscopy, bilateral cataract surgery, Urethral sling in [2191], TAH in [2176] (benign disease) Discharge Condition: - good Discharge Instructions: - you may shower; do not soak in a bath tub, swimming pool, or hot tub for three weeks - you should eat a regular diet - you should take pain medication as needed - do not drive while taking pain medication - every day you take pain medication you should also take stool softener: colace, senna, and dulcolax are all good options - you should continue to do your deep breathing and coughing - your chest tube site dressing may come off on Tuesday morning; please cover the area with a band-aid afterwards - call the Thoracic Surgery clinic at [Telephone/Fax (1) 170] if T>101.5, chills, nausea, vomiting, severe chest pain, shortness of breath, swelling in your legs or arms, redness or smelly drainage from the chest tube site, or any other concern Followup Instructions: you will need to call to confirm the following appointments - You will need to follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Please call his office at [Telephone/Fax (1) 170] to schedule this appointment. Furthermore, you will need a chest X-ray prior to your appointment -> the scheduler can arrange this when they make your appointment. - you should also schedule a follow-up appointment with your primary care physician in the next 7-10 days as a post-hospitalization visit.	[ "162.3", "493.20", "401.9", "E878.8", "512.1" ]	icd9cm	[ [ [] ] ]	[ "32.24", "96.71", "34.92", "33.26", "96.04", "34.04" ]	icd9pcs	[ [ [] ] ]	6010, 6016	1917, 4469	324, 460	6308, 6317	1421, 1894	7119, 7620	1210, 1223		4639, 5987		6037, 6287		4495, 4616			6341, 7096								1238, 1402																						256, 286											488, 950																	972, 1129	1145, 1194
22,331	124,408	17680	Discharge summary	report	Admission Date: [2150-5-4] Discharge Date: [2150-5-5] Date of Birth: [2077-10-16] Sex: F Service: [Doctor Last Name ] HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old female with a history of depression, breast cancer, and hypertension, who was in her usual state of health until the evening of [5-2], when she presented to the Emergency Department after two episodes of presyncope with complaints of fatigue and lightheadedness. In the Emergency Room she was found to have a hematocrit of 25 from a baseline of 38. Nasogastric lavage showed a large amount of bright red blood and clots. She was given 1 unit of blood and 1 liter of normal saline in the Emergency Room, and admitted to the MICU. EGD the day after admission showed a small hiatal hernia, erosions in the antrum, and erythema in the bulb consistent with duodenitis, however, no evidence of recent bleed. There was no fresh blood noted. There were no lesions adequate to explain her bleed. At this point, it was recommended that she be monitored and arranged for outpatient colonoscopy. She received a total of 3 units packed red cells in the Intensive Care Unit, and was stable from there on out. She denies any use of NSAIDs, and reports that she has been taking aspirin, however, has not taken it in the last month. She has no history of GI bleeding and no family history of GI bleeds. She denies any significant coffee or alcohol intake. She denies any fevers, chills, nausea, vomiting, weight loss, or weight gain. She denies any history of bright red stools, melena, or hematemesis. PAST MEDICAL HISTORY: 1. Depression. 2. Hypertension. 3. Constipation. 4. Breast cancer status post lumpectomy and XRT in [2126]. 5. Status post vaginal hysterectomy. SOCIAL HISTORY: She lives with her husband in [Hospital3 12272]. She smokes [1-27] cigarettes a day and denies any alcohol or other drug use. FAMILY HISTORY: There is no family history of colon cancer or GI bleeding. ALLERGIES: She has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Seroquel. 2. Atenolol. 3. Paxil. 4. Remeron. 5. MiraLax. 6. Aspirin 81 mg q.d. PHYSICAL EXAM: Vitals revealed a temperature of 97, heart rate of 93, and blood pressure 115/42, respirations 24, and oxygen saturation of 98% on room air. In general, she is alert and oriented times three in no acute distress. She is not chronically ill appearing. HEENT exam revealed pupils are equal, round, and reactive to light and extraocular muscles were intact. Her conjunctivae were not pale. Her heart was regular with no murmurs, rubs, or gallops. She had normal S1, S2. Her lungs were clear bilaterally. Her abdomen was soft, nontender, and nondistended, and she had normal bowel sounds. Her extremities were without clubbing, cyanosis, or edema. She had 1+ pulses. LABORATORIES ON ADMISSION: The day she is transferred out of the Intensive Care Unit she had a hematocrit of 29.9 after 3 units of red cells. She had a PT of 13.1, PTT of 24.2, and INR of 1.1. Serum chemistries revealed a sodium of 141, potassium 4, chloride of 112, bicarb 22, BUN of 32 down from 71 on admission, and creatinine of 0.7. HOSPITAL COURSE: 1. GI: She was transferred from the Intensive Care Unit to the floor on [2150-5-4]. As mentioned above, she had an upper GI bleed based on nasogastric lavage in the Emergency Department, however, endoscopy on [2150-5-3] did not reveal any obvious source of bleeding. She was monitored with b.i.d. hematocrits and her hematocrit was stable, and she was hemodynamically stable throughout admission. She received Protonix 40 mg q.d. She was advised never to take aspirin or NSAIDs again. She was scheduled for colonoscopy as an outpatient, and will follow up with the Division of Gastroenterology. 2. Cardiovascular: She has a history of hypertension, and was initially taken off her atenolol due to concern of GI bleed, however, it was restarted prior to discharge. 3. Psychiatry: She was continued on all of her outpatient psychiatric medications. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed. 2. Depression. 3. Hypertension. DISCHARGE MEDICATIONS: 1. Seroquel 50 mg b.i.d. 2. Remeron 45 mg q.h.s. 3. Protonix 40 mg q.d. 4. Atenolol 50 mg q.d. 5. Paxil 10 mg q.i.d. CONDITION ON DISCHARGE: She was without complaints. Her hematocrit was stable and she was hemodynamically stable. DISCHARGE STATUS: She will be discharged to home with followup with her primary care physician in two weeks to have her hematocrit checked. She will also have followup on [5-18] for colonoscopy at [Hospital1 69]. [First Name8 (NamePattern2) ] [Name8 (MD) 4174], M.D. [MD Number(1) ] Dictated By:[Last Name (NamePattern1) 14268] MEDQUIST36 D: [2150-5-5] 14:42 T: [2150-5-6] 06:27 JOB#: [Job Number 49200]	[ "401.9", "780.2", "786.59", "V10.3", "305.1", "578.9" ]	icd9cm	[ [ [] ] ]	[ "38.93", "45.13", "96.33", "99.04" ]	icd9pcs	[ [ [] ] ]							1948, 2054	4099, 4165	4188, 4306				2080, 2163	3212, 4078										2179, 2866																																	180, 1606									2881, 3195								1628, 1778	1795, 1931	4331, 4902
22,739	160,710	19116	Discharge summary	report	Admission Date: [2181-10-9] Discharge Date: [2181-10-12] Date of Birth: [2150-12-8] Sex: M Service: ACOVE HISTORY OF PRESENT ILLNESS: This is a 30-year-old Haitian male, who presents with a 3.5 week history of increasing thirst and urination. He noticed he was drinking up to 3 gallons per day in the last several days and also urinating multiple times up to 5-6x/hour at night. He has lost 37 pounds in the past month and is now at a weight of 187 from 224. On the night prior to admission, at approximately 2 a.m., he began vomiting and had some associated abdominal discomfort. He was able to tolerate these symptoms and went to work that morning, but then decided to seek medical attention for his symptoms which then included dizziness as well. Patient's primary care physician noted the patient to be tachycardic, hypertensive, who found his fingerstick blood sugar to be critically high and urinalysis showed the presence of ketones. He was referred to the Emergency Department for evaluation and treatment of new onset diabetes. PAST MEDICAL HISTORY: Genital herpes in [2181-8-7]. MEDICATIONS: Ibuprofen prn. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No tobacco or alcohol use, no IV drug use, no illicit drug use. Patient immigrated from [Country 2045] six years ago, currently works in the banking industry. FAMILY HISTORY: Notable for a father who has hypertension, but there is no family history of coronary artery disease, diabetes mellitus, or cancer. PHYSICAL EXAM ON ADMISSION: Vital signs: Temperature 98.4, heart rate 108, blood pressure 152/82, respiratory rate 20, and oxygen saturation 97%. General: Pleasant, conversational, well built African American male. HEENT: Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Oropharynx clear, moist mucosal membranes. Neck: No jugular venous distention, no lymphadenopathy, supple. Cardiovascular: Regular, rate, and rhythm, normal S1, S2, 1/6 systolic murmur at the left sternal border. Lungs are clear to auscultation bilaterally. No wheezes, no rales. Abdomen is soft, nontender, nondistended, no masses, active bowel sounds. Extremities: No clubbing, cyanosis, or edema. Dorsalis pedis pulse is 1+ bilaterally. Neurologically: The patient is awake, alert, and oriented times three. Cranial nerves II through XII intact. EKG: Normal sinus rhythm at 100 beats per minute, normal intervals, normal axis, peak T waves V2 through V6. LABORATORY DATA ON ADMISSION: White count 11.4, hematocrit 55.4, platelet count 337. White count differential: Neutrophils 88%, lymphocytes 8.6%, monocytes 3.0%. Electrolytes on admission: Sodium 134, potassium 5.8, chloride 92, bicarb 21, BUN 27, creatinine 2.1, glucose 1,292. Calcium 12.6, phosphate 6.9, magnesium 3.2. ASSESSMENT AND PLAN: This is a 30-year-old male with no significant past medical history, who presents with new onset diabetes in diabetic ketoacidosis. HOSPITAL COURSE: Patient was admitted to the Intensive Care Unit and treated with an insulin drip at 7 units/hour for nine hours until his fingersticks blood sugar level had reached 121 and the anion gap noted on presentation had closed to 6. On [10-10], he was changed to a regimen including NPH 18 units q.a.m., 9 units q.p.m. per the recommendations of the [Last Name (un) ] Diabetes Team, Humalog sliding scale was also started. This regimen was adjusted throughout the remainder of his hospital stay. On [10-12], he was on a regimen of NPH 22 units q.a.m. and 12 units q.p.m. with an adjusted Humalog sliding scale as per the recommendations of the [Last Name (un) ] Diabetes Team. The patient was referred to the [Last Name (un) ] Diabetes for multiple follow-up appointments including nutrition, dietary consultation, education programs about diabetes, and glucose monitoring, and a follow-up appointment with Dr. [First Name4 (NamePattern1) 2398] [Last Name (NamePattern1) ] at [Last Name (un) ] Diabetes Center. 2. Fluids, electrolytes, and nutrition: Careful monitoring of the patient's electrolytes was done throughout the administration of insulin to correct his sugars with particular attention to potassium and phosphate. The patient was begun on a diabetic appropriate diet, and appropriate nutrition consultation and teaching occurred during his hospital stay. DISCHARGE CONDITION: Good. Blood sugars under adequate control. Patient has no symptoms and is hemodynamically stable. DISCHARGE DIAGNOSES: 1. Diabetic ketoacidosis. 2. Type 1 diabetes mellitus, new onset. 3. Hypovolemia. DISCHARGE MEDICATIONS: Insulin NPH 22 units q.a.m. with breakfast, insulin NPH 12 units subcutaneous q.h.s. Humalog insulin-sliding scale as prescribed by Dr. [Last Name (STitle) ]. Blood glucose test strips, lancets, controlled solution, insulin syringes. FOLLOW-UP PLANS: The patient was recommended to attend the following classes available at [Last Name (un) ] Diabetes: On [10-15], First Steps at 8:30 a.m., [10-18], Nutrition Class "doc, what can I eat" at 10:30 a.m. and Weights and Balances at 1 p.m. [10-19], Nutrition consultation with [First Name5 (NamePattern1) 19415] [Last Name (NamePattern1) 52168] at 5 p.m. Follow-up appointment with Dr. [First Name4 (NamePattern1) 2398] [Last Name (NamePattern1) ] on [10-26] at 12:30 p.m. Patient was advised to schedule a follow-up appointment with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 7790] within one week of his hospital stay. MARK [Doctor Last Name ], M. D. [MD Number(1) 910] Dictated By:[Last Name (NamePattern1) 1615] MEDQUIST36 D: [2181-10-21] 21:24 T: [2181-10-23] 10:16 JOB#: [Job Number 52169] cc:[Last Name (NamePattern1) 52170]	[ "276.5", "250.12", "275.2", "275.42", "593.9", "276.8" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]				4435, 4536			1398, 1545	4557, 4640	4664, 4905					3013, 4413																											4923, 5904																164, 1073									2704, 2995								1096, 1199	1216, 1381
32,727	138,163	31436	Discharge summary	report	Admission Date: [2172-10-4] Discharge Date: [2172-10-10] Date of Birth: [2120-11-25] Sex: M Service: NEUROSURGERY Allergies: Mold/Yeast/Dust / Cefazolin Attending:[First Name3 (LF) 1854] Chief Complaint: seizure, mass on CT Major Surgical or Invasive Procedure: Neurosurgery [2172-10-8] History of Present Illness: Mr. [Known lastname 74031] is a 51 year old right handed male who presents following a seizure, found to have a left parietal mass on CT at and OSH. He was driving home from [Hospital3 635] with his 12yo son when he started to feel "dizzy," no vertigo, just a strange feeling. He pulled the car over to the side of the road and at that time was only producing garbled speech, but he could still understand his son. [Name (NI) ] got up and walked around the car, but his speech deficit did not resolve. EMS arrived within ~10minutes where he then reportedly had a GTC seizure in the ambulance. He recollects being at the [Hospital3 ]. Head CT revealed Left parietal mass. He was loaded on dilantin and given 2mg ativan IV. Transferred to [Hospital1 18] for further evaluation. He notes that in the last few weeks the vision in his right eye seems poor, but he denies bumping into objects. No scotoma. He also noted that on long car trips in the last few weeks he has noted a feeling of "dizziness" no vertigo, just a strange feeling while in the car only. No odd smells, sounds, flashing lights or other phenomena. No rising abdominal sensation. He denies any headaches. At present he denies any numbness, weakness, paresthesia. No bowel or bladder incontinence. He bit his tongue with the GTC earlier today. No diplopia, dysphagia. No facial droop. No difficulty with his gait. ROS: No recent fever or chills. No night sweats or recent weight loss or gain. 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. Denied rash. Past Medical History: Sinus surgery for chronic sinusitis [4-18] Tonsillectomy Osteoarthritis of knees Social History: Lives with his girlfriend and sister, he has shared custody of his two children, he works in logistics for proctor and gamble. He was planning to fly to [Country 4194] tonight for a four day business trip. He smoked ~[2-12] ppd x 20 years, quit four years ago, he drinks 1-3 drinks on rare occasion. No history of illicit or IV drug use. Family History: Mother- breast cancer, alive and well. Grandfather- had lung cancer. Brother- alive and well. Physical Exam: Vitals: T: 98 P: 68 R: 16 BP: 148/70 SaO2: 100%RA General: asleep on the gurney, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no JVD or carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. He is somewhat inattentive and skips months in [Doctor Last Name 1841] backwards without noticing. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [2-13] at 5 minutes, [4-13] with cues. The pt. had good knowledge of current events. There was no apraxia or neglect. He constricts the right side of the clock in clock drawing task, but is able to complete the task without difficulty. -Cranial Nerves: Olfaction not tested. PERRL 3 to 2mm and brisk. VFF to confrontation with a red object. There is no ptosis bilaterally. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. EOMI prominent nystagmus in all fields of gaze, most prominent in left gaze. Normal saccades. Facial sensation intact to pinprick. No facial droop, facial musculature symmetric. Hearing intact to finger-rub bilaterally. Palate elevates symmetrically. 5/5 strength in trapezii and SCM bilaterally. Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No adventitious movements noted. No asterixis noted. No pronator drift bilaterally. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -Coordination: No intention tremor, dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach R 2+ 2+ 2+ 2+ 1 L 1 1 1 2 1 Plantar response was flexor bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. He is unable to tandem. Romberg absent. Pertinent Results: [2172-10-4] 02:30PM WBC-11.7# RBC-4.92 HGB-14.8 HCT-41.0 MCV-83 MCH-30.2 MCHC-36.1 RDW-13.5 [2172-10-4] 02:30PM NEUTS-83.3* LYMPHS-12.2* MONOS-3.7 EOS-0.5 BASOS-0.4 [2172-10-4] 02:30PM PLT COUNT-221 [2172-10-4] 02:30PM GLUCOSE-111* UREA N-15 CREAT-1.1 SODIUM-139 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-30 ANION GAP-13 IMAGING: CT head: ~1.7 cm diameter hypodensity in left parietal subcortical region extending through several cuts on axial series. No mass effect. Chest Xray: no cardiopulmonary process. Brief Hospital Course: Hospital course on neurology service [10-4] - [10-8]: Neurology - Initially on dilantin then changed to keppra for seizure control. No seizures during [Hospital ] hospital stay. Neurologic exam unchanged from admission. Neurosurgical team consulted, recommended surgical resection for likely primary brain tumor vs metastasis. FEN/GI - Normal po intake. Electrolytes within normal limits. CV/Resp - Stable throughout. ID - Infectious team consulted, though low likelihood of infectious process. Sent serum toxoplasma antibodies, cystercircosis antibodies, and cryptococcal antigen. ENDO: On CT torso, while looking for potential primary tumors (of which none identified) a thyroid nodule was serendipitously identified. He is scheduled for an outpt Bx/FNA on [2172-10-14]. Transferred to the neurosurgical service on [10-8] after surgical resection. Pt underwent successful resection of the tumor [10-8]. He was subsequently started on Decadron 4 mg IV Q8hrs and this was decreased to 2 mg PO Q8hrs on DC. Post-op course was complicated only by a one-time fever to 101.2F, likely secondary to atelectasis, and blood and urine cultures from [10-9] remain negative to date. CXR showed only some bibasilar atelectasis. He remained afebrile subsequently. Medications on Admission: Flonase PRN Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:14 Tablet(s) Refills:1 3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:80 Tablet(s) Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Brain tumor Discharge Condition: Stable Discharge Instructions: Provide adequate periods of rest for the next few weeks. No heavy lifting greater than 10 pounds, no straining. This includes heavy house or yardwork. Please monitor any headaches you may develop and the frequency. Headaches should be relieved with the narcotic analgesics you have been prescribed. You may wean yourself from them as you no longer need. Do not stop taking any other medications without first consulting with your healthcare team. You should not drive until after your appointment with the surgeon or oncologist as you are on an anti seizure medication that prohibits the use of a motorvehicle. Followup Instructions: Radiation CT Simulation with Dr. [Last Name (STitle) 3929] on [2172-10-19]. The office will call with the time. Dr. [Last Name (STitle) 3929] also [2172-10-23] @ 12noon. Please call to confirm the second appointment. The appointments will be on the [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1675] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] [Hospital Ward Name 22747] [Location 23] Building [Location (un) ]. Keep your stitches/staples dry until they are removed, 10 days post-surgery. Call your primary care physician's office or Dr. [Name (NI) 28838] office ([Telephone/Fax (1) 88] for an appt for staple removal, whichever is more convenient for you. Call Dr.[Name (NI) 12757] office for follow-up appt following the tumor board meeting: ([Telephone/Fax (1) 88] Provider: [Name10 (NameIs) 703] ULTRASOUND Phone:[Telephone/Fax (1) 327] Date/Time:[2172-10-14] 11:00 Completed by:[2172-10-10]	[ "191.4", "780.39", "241.0", "715.36", "518.0", "348.5" ]	icd9cm	[ [ [] ] ]	[ "01.59" ]	icd9pcs	[ [ [] ] ]	8323, 8329	5967, 7256	314, 344	8384, 8392	5411, 5763	9055, 10077	2599, 2695		7318, 8300		8350, 8363		7282, 7295			8416, 9032				4023, 5392				2710, 3241																						255, 276											372, 2110			5772, 5944								3256, 4006						2132, 2219	2235, 2583
17,614	119,156	3160	Discharge summary	report	Admission Date: [2191-11-8] Discharge Date: [2191-11-15] Date of Birth: [2130-6-27] Sex: M Service: MEDICINE Allergies: Doxycycline Hyclate / Flomax / Crixivan Attending:[First Name3 (LF) 106] Chief Complaint: syncope Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 61 yo male with PMH HIV on HAART (CD4 224, [8-20]), HCV, rectal adenocarcinoma stage 2 (s/p LAR [5-19]) transferred to CCU after acute syncopal episode with elevated cardiac enzymes and severe cardiomyopathy. Pt states that he has had several episodes of lightheadedness and falling without LOC over the past week. First episodes occurred several days ago while gardening. Pt states that episodes are triggered by bending his head. Pt denies CP, SOB, diaphoresis prior to episode. Pt had episodes of likely LOC 3 days prior to admission and night before admission. Pt states that the night before admission, he was standing in his kitchen when his wife found him on the ground. He does not recall any prodromal symptoms. When he came to, he did not feel nauseous but felt briefly confused. On day of admission, pt states he experienced [6-25] substernal chest tightness without radiation, with mild SOB and no nausea, vomiting, diaphoresis. Pain lasted continously from 8am to 1pm, when he went to see his PCP. [Name10 (NameIs) ] he was walking to his PCP's office, he syncopized and fell on his face. Denies prodromal symptoms or witnessed seizure activity. . In [Name (NI) ], pt was afebrile, hemodynamically stable, without complaints of chest pain. Found to have EKG changes with SR, LVH, with new ST depressions in V5-6. Pt was given Aspirin, heparin, Metoprolol. Pt's BP dropped from systolic 130s to 80-90s after Metoprolol. Pt was seen by cardiology fellow who performed an echo which found a severely depressed EF of [9-30]%, 4+MR, 4+TR, [1-18]+ AI, with all 4 [Doctor Last Name 1754] dilated. Pt also had a negative head CT, no fractures on cervical CT. Pt presented with right periorbital echymosis and edema; orbital CT showed multiple fractures. Pt was evaluated by oromaxilofacial surgery. Past Medical History: HIV disease rectal adenocarcinoma hepatitis C Depression cervical spondylosis dermatitis testicular hypofunction HTN lipdystrophy prostate hyperplasia melanoma lumbar radiculopathy carotid stenosis, bilateral hx diverticulitis hx prostatitis 4.5 cm ascending aortic aneurysm colon polyps Social History: lives with wife smokes [12-17] ppd x 35 years Denies current ETOH use, used to drink moderately in past Denies current or past drug use Physical Exam: VS:98.5, p73, 90/56, rr19, 99%RA General: emaciated, NAD HEENT: Right periorbital echymosis and edema, right subconjuctival hematoma, PERRL, EOMI, MMM, elevated JVP to ear CVS: RRR, nl s1 s2, ?s3, no m/g/r Lungs: decreased BS throughout, no c/w/r Abd: soft, NT, ND, +BS Ext: no edema, 1+ DP Neuro: A&Ox3, CN 2-12 intact, [4-20] upper and lower extremity strength, sensation intact to light touch Pertinent Results: [2191-11-8] 02:34PM WBC-4.1 RBC-3.32* HGB-11.6* HCT-32.5* MCV-98# MCH-34.8* MCHC-35.6* RDW-13.6 [2191-11-8] 02:34PM NEUTS-71.2* LYMPHS-21.6 MONOS-6.2 EOS-0.5 BASOS-0.5 [2191-11-8] 02:34PM PLT COUNT-108* . [2191-11-8] 04:05PM PT-13.1 PTT-31.7 INR(PT)-1.1 [2191-11-8] 02:34PM GLUCOSE-90 UREA N-23* CREAT-1.5* SODIUM-136 POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-26 ANION GAP-13 . [2191-11-8] 02:34PM CK(CPK)-297* [2191-11-8] 02:34PM CK-MB-24* MB INDX-8.1* [2191-11-8] 02:34PM cTropnT-1.4* [2191-11-8] 09:18PM CK(CPK)-286* [2191-11-8] 09:18PM CK-MB-19* MB INDX-6.6* cTropnT-1.86* Brief Hospital Course: 1. CAD: Pt is s/p NSTEMI with peak CK of 620, peak Tn of 2.18. Pt was continued on aspirin. Initially, heparin was started, but was discontinued since pt has Hep C cirrhosis with coagulopathy. Baseline LFTs were sent off and pt was started on Lipitor. Lipitor was also discontinued in the setting of pt's liver disease. Beta-blocker and ACEI were initially held in the setting of hypotension in the ED. On HD4, small doses of ACEi and beta-blocker were started. Catheterization was defered in setting of initial fever and elevated creatinine. Cardiac catheterization performed on [11-14] showed three vessel coronary artery disease w/ chronic RCA occlusion and mild to moderate diastolic dysfunction. Patient beta-blocker and ACEi were increased in dosage and follow up appointments were made with Dr. [Last Name (STitle) 9625] within in a week post discharge and cardiology. . 2. Pump: Pt has severe dilated cardiomyopathy with severely depressed EF of 20%. Etiologies of cardiomyopathy include HIV, multivessel CAD, infectious. Initially, pt was felt to be volume overloaded since he had elevated JVP. Pt was given Lasix 10mg without any significant urine output. Foley was placed with adequate urine output noted. On HD 3, pt became hypotensive to 50-60s. Given several IVF boluses without improvement in BP. Dopa started and levo was added. Swan was placed and initial numbers were suggestive by not completely consistent with sepsis, since the pt has a low SVR and normal CI on 2 pressors. It was thought that pt may be septic and Neo was started; Dopamine and Levophed were subsequently discontinued. Pt was also started on empiric vancomycin and zosyn. Repeat swan numbers showed decreased CI and significantly elevated SVR. Neo was discontinued on HD4, with maintenance of normal blood pressures. Transient hypotension was most likely secondary to volume depletion. On HD4, pt was restarted on ACEi and BB. Incidentally, it was noted that pt's fluctuations in mental status seems to correlate with blood pressures. Pt appeared more alert with BP >120s and appeared more lethargic and confused with BP in 100-110s. Goal BP was set at >120. On HD5, pt was started on longer active ACEi, lisinopril 2.5mg and continued on coreg 3.125. Catheterization showed diastolic dysfunction. This was attributed to cardiomyopathy secondary to the patinet's HIV infection. His systloiuc blood pressure became persistenty elevated to the 160's between [Date range (1) 14898]. As a result his Lisionpril was increased to 10 mg daily and his Carvedilol was increased to 6.25 mg [Hospital1 ]. . 3. Rhythm: Pt is at high risk of arrythmia given his severe cardiomyopathy. Found to be hyperkalemic and given kayexalate with normalization of potassium. Pt heart rhythm remained stable without any acute issues on telemetry throughout rest of hospitalization. . 4. Valvular disease: Pt had 3+ MR, 3+ TR, [12-17]+ AI. Possible etiology of valvular disease is secondary to dilated cardiomyopathy. Pt was restarted on ACEI for afterload reduction. . 5. Syncope: Unclear etiology. Differential diagnosis includes ischemia, arrythmia, valvular disease, cardiomyopathy, neurological causes, vasovagal. Most likely cardiovascular cuases include valvular disease and severe cardiomyopathy. Pt was not found to be orthostatic, but orthostasis is a good possibility. From a neurological standpoint: History is not consistent with seizure. Head CT was negative for stroke. On HD1, during the evening, pt had several episodes of brief unresponsiveness. During these episodes, pt appeared purple, eyes deviated upwards, at one point looked like he was choking. Pt responded to stimulation. Afterwards, pt had mild, transient confusion. Neuro was consulted about the etiology of syncope and felt that it was most likely cardiac or orthostasis. EEG was negative. MRI of the brain showed signs of HIV encephalopathy, but no acute changes. Patient was instructed to follow up with PCP in one week to arrange tilt table test. . 6. s/p fall/Orbital fractures: Cervical CT showed no spinal fractures. Orbital CT showed multiple right-sided orbital facial fractures. Orofacialmaxillary surgery was consulted. Pt was managed conservatively per the recommendation of OFM surgery. . 7. ID: Pt initially presented with fevers. These are most likely secondary to local periorbital blood/fluid collection and possible sinusitis. Antibiotics were not started initially. On HD3, pt became hypotensive and sepsis was considered given swan numbers suggestive of sepsis. Pt was started on empiric vanco and zosyn. Blood cultures and urine cultures have been no growth to date. Pt's blood and urine cultures remained and all antibiotics were discharged on [11-14]. He remained afebrile and ID signed off on patinet. He continued on his HAART therapy. . 8. HIV: Pt was continued on his home medications. According to PCP, [Name10 (NameIs) ] has been stable on two drug regimen for many years. CD4 count was reportedly >200. CD4 count here found to be 167, which is low. However, CD4% is normal at 26%. Therefore, pt does not need PCP [Name Initial (PRE) 1102]. . 9. HCV: No active issues. Baseline LFTs were found to be slightly elevated. Per PCP, [Name10 (NameIs) ] has cirrhosis and coagulopathy. Therefore, pt was not continued on statin or heparin. An ammonia level was found to be 32. . 10. Renal insufficiency: Creatinine was 1.1 one year prior. Creatinine on admission was 1.9. Urine lytes showed FeNa of 0.5%. No other abnormalities seen on UA. Creatinine stabilized at 1.5-1.7. Mucomyst and IV hydration were given for cardiac cath and patient's creatinine remained at his baseline. . 11. Mental status: Pt experienced fluctuating mental status. On night of admission, pt appeared very sedated, most likely secondary to valium. Pt took usual 10mg dose of valium prior to going to sleep. Valium was then decreased to 5mg qhs. On HD4, pt was noted to have fluctuating mental status during the day. Incidentally, it was noted that pt's fluctuations in mental status seems to correlate with blood pressures. Pt appeared more alert with BP >120s and appeared more lethargic and confused with BP in 100-110s. 12. FEN: Pt was given low sodium, cardiac diet. . 13. Code status: Full code Medications on Admission: Viread 300mg qd Epivir 300mg qd Acyclovir 400mg [Hospital1 ] Doxepin 50mg qhs Univasc 15mg qd Valium 5mg x 2 qhg Neurontin 500mg qhs Androgel 50mg/5gm powder packet qd Celexa 40mg qd Dexadrine 10mg [Hospital1 ] Discharge Medications: 1. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 6. Diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Testosterone 5 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 11. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO Q2PM (). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 16. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QD (). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: VNA of Greater [Location (un) 5871]/[Location (un) 6159] Discharge Diagnosis: coronary artery disease diastolic heart dysfunction presyncope Discharge Condition: stable Discharge Instructions: Please call your physician if you experience chest pain, tingling in jaw or arms, shortness of breath, heart palpiations, marked leg swelling. Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2192-1-9] 11:00 Provider: [First Name8 (NamePattern2) 2064] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 3512] Date/Time:[2191-12-13] 9:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 285] Date/Time:[2191-12-20] 2:00 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 14899], [Name Initial (NameIs) ].D. Date/Time:[2191-11-17] 3:30 pm	[ "425.4", "416.8", "414.01", "070.54", "458.9", "E888.9", "780.2", "802.6", "410.71", "584.9", "428.30", "802.4", "042", "461.0", "571.5", "286.7" ]	icd9cm	[ [ [] ] ]	[ "00.17", "37.22", "38.93", "89.64", "88.56" ]	icd9pcs	[ [ [] ] ]	11686, 11781	3760, 9454	308, 334	11888, 11896	3104, 3737	12088, 12824			10316, 11663		11802, 11867		10073, 10293			11920, 12065								2683, 3085																						261, 270											362, 2199											9469, 10047						2221, 2510	2526, 2668
13,978	183,805	5519	Discharge summary	report	Admission Date: [2186-1-4] Discharge Date: [2186-1-10] Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: The patient is an 82 year-old male with coronary artery disease. He is status post catheterization at which time the results showed a severe greater then 95% mid left anterior descending coronary artery stenosis, left circumflex, diffuse mild disease with obtuse marginal probably the graft target, showed a total mid right coronary artery occlusion with bridging collaterals. Due to the extensive coronary artery disease the decision was made to proceed with coronary artery bypass graft. The patient was admitted to the Coronary Care Unit at time intraaortic balloon pump was placed in the patient as a bridge to the coronary artery bypass graft. The patient was also placed on nitro and heparin drips. On [2186-1-5] a coronary artery bypass graft times three vessels was completed with saphenous vein graft to distal left anterior descending coronary artery, left internal mammary coronary artery to obtuse marginal, saphenous vein graft to the right coronary artery. The patient tolerated the procedure well and was taken to the Cardiac Surgical Intensive Care Unit at which time the IABP was discontinued as well as the Swan-Ganz catheter on postoperative day one. The patient did quite well and was transferred to the Surgical floor where he continued to do well and engage in physical therapy. His epicardial wires and chest tubes were removed without incident and the patient's course was complicated by some early morning confusion, which was unlike anything encountered at baseline. Urinalysis, electrocardiogram and neurological examinations were without significant findings. Geratology consult was asked for by the family and they were kind enough to see the patient and give their recommendations, but their diagnosis as well as ours was acute delirium. On postoperative day five the patient was discharged to rehab in good condition. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To rehab. DISCHARGE DIAGNOSIS: Unstable angina secondary to coronary artery disease status post coronary artery bypass graft times three. DISCHARGE MEDICATIONS: Sorbitol 15 cc po q day, Lopressor 25 mg po b.i.d., Finasteride 5 mg po q day, Atorvastatin 10 mg po q day, aspirin 325 mg po q day, Lasix 20 mg po b.i.d. times seven, potassium chloride 20 milliequivalents po b.i.d. times seven. DR.[Last Name (STitle) ],[First Name3 (LF) 1112] 02-229 Dictated By:[Last Name (NamePattern1) 8455] MEDQUIST36 D: [2186-1-10] 12:47 T: [2186-1-10] 13:18 JOB#: [Job Number 22291]	[ "401.9", "600.0", "414.01", "411.1", "429.9" ]	icd9cm	[ [ [] ] ]	[ "37.64", "88.56", "39.61", "36.15", "37.61", "88.53", "36.12", "37.22" ]	icd9pcs	[ [ [] ] ]									2207, 2671		2075, 2183																																														128, 1992																			2017, 2054
3,024	139,229	30421	Discharge summary	report	Admission Date: [2158-2-25] Discharge Date: [2158-4-10] Date of Birth: [2083-9-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2641] Chief Complaint: hypoxia, SOB Major Surgical or Invasive Procedure: chest tube placement x3 and removal central line placement and removal arterial line placement and removal intubation and mechanical ventilation bronchoscopy PICC placement percutaneous gastrostomy-jejunostomy tube placement History of Present Illness: Pt is a 74 yo M with history of COPD(on home O2 4L NC) who presented to [Hospital3 7569] with SOB and productive cough for several weeks. History was obtained from the records as the patient was intubated. At [Location (un) ] he was noted to have sats in the low 80's. There CXR showed right sided pleural effusion(concerning for an empyema). He was started on azithromycin, ceftriaxone, 125mg solumedrol and transferred to [Hospital1 18] for further care. . Per his wife he had been having pain in his right groin for about a week. Pain improved with ibuprofen (800mg [Hospital1 ] for 3 days) and heating pad. Pain migrated up to his right side of the chest wall. Has lost about 15 pounds over the last 2 weeks. No fevers, chills. Has been having cough with a small amount of sputum and occasionally blood. He developed worsening SOB over last 24 hrs. At baseline is SOB/DOE and on 4L NC. Decrease PO's over this time. Past Medical History: COPD/Emphysema- on home O2 4L NC Exposed to [Doctor Last Name 360] [Location (un) 2452] in the military Social History: Lives with wife. Retired from the special forces. Traveled abroad while in the service ([Country 3992], [Country ], [Country 10181]). Started smoking at age 10. Quit 4 years ago. Normally smoked 3 ppd. Drinks about [1-29] cans per morning and glass of wine at night but drank more at other times of his life. Family History: Unknown per wife Physical Exam: T 100.4 BP 88/48 HR 130 RR 16 O2sats 100% Vent settings AC 700/16/5/100% Gen: Agitated, thrashing around. Able to nod yes/no to questions HEENT: PERRL, mmm, anicteric, OG tube in place with coffee ground like substance Neck: No JVD, LAD Lungs: Clear on the left. Right side coarse breath sounds, with diminished breath sounds at base Heart: Tachy, no m/r/g Abd: Soft, NT, ND + BS Liver edge 2 cm below costal angle Ext: No edema, 1+ DP/PT bilaterally Neuro: Sedated but moving all 4 extremities Pertinent Results: [2158-2-25] 04:10AM PLT COUNT-930* [2158-2-25] 04:10AM WBC-37.7* RBC-3.83* HGB-14.0 HCT-41.6 MCV-109* MCH-36.6* MCHC-33.7 RDW-15.3 [2158-2-25] 04:10AM NEUTS-92* BANDS-5 LYMPHS-1* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2158-2-25] 04:10AM CK-MB-NotDone cTropnT-<0.01 [2158-2-25] 04:10AM CK(CPK)-47 [2158-2-25] 04:10AM GLUCOSE-83 UREA N-28* CREAT-1.3* SODIUM-137 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-20* ANION GAP-25* [2158-2-25] 04:24AM TYPE-ART PO2-31* PCO2-44 PH-7.36 TOTAL CO2-26 BASE XS--1 [2158-2-25] 05:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-<1 RENAL EPI-[1-30] [2158-2-25] 05:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2158-2-25] 05:00AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.016 [2158-2-25] 08:12AM LACTATE-1.2 [2158-2-25] 08:12AM TYPE-ART TEMP-38.3 TIDAL VOL-700 PO2-248* PCO2-41 PH-7.33* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED [2158-2-25] 10:30AM PLEURAL WBC-[Numeric Identifier 36592]* RBC-1375* POLYS-95* LYMPHS-3* MONOS-2* [2158-2-25] 10:30AM PLEURAL TOT PROT-3.3 GLUCOSE-54 LD(LDH)-1302 AMYLASE-27 ALBUMIN-1.5 [2158-2-25] 11:56AM PT-15.6* PTT-34.2 INR(PT)-1.4* [2158-2-25] 11:56AM CALCIUM-7.0* PHOSPHATE-4.1 MAGNESIUM-1.7 [2158-2-25] 11:56AM LD(LDH)-234 [2158-2-25] 06:15PM HCT-32.4* . [3-14] CXR: FINDINGS: Compared with 04/16, allowing for differences in position, the left pleural effusion is probably not significantly changed. . The multifocal infiltrates in the right mid and lower lung fields appear to have become more confluent superiorly. Persistent retrocardiac collapse/consolidation. . The visualized portions of the left lung are grossly clear. No CHF . [2-25] CT Chest: IMPRESSION: 1. Complex-appearing right pleural effusion, with loculated components. The pleura does not clearly enhance, thus this loculated effusion is not necessarily an empyema. 2. There is dense consolidative change with cystic spaces within the right lower lobe. The finding is concerning for a cavitating pneumonia. However, this lung parenchyma is not evaluated for an underlying mass lesion, and one cannot be excluded. 3. Severe emphysematous changes of the lungs. 4. Scattered nodular opacities within the left lung. Three-month CT followup is recommended. 5. Small pericardial effusion. 6. 5 cm arterially enhancing mass of the liver at the confluence of hepatic veins, not characterized. When the patient's condition improves, if he is able to breath hold, a contrast enhanced MRI is recommended. If he cannot breath hold, multiphase CT is recommended. . [3-4] RUQ U/S: ABDOMINAL ULTRASOUND: The liver is normal in echotexture. Multiple hepatic cysts are seen, the largest of which is in the right lobe measuring 4.3 x 3.8 x 4.3 cm. Additionally, there is a hypoechoic solid lesion in the lateral aspect of the right lobe measuring 5.2 x 5.6 x 4.7 cm. This lesion has a central feeding artery. Multiple small stones are seen within the gallbladder and the wall is thickened measuring 3 mm, however this is likely related to hypoalbuminemia as there is a small amount of ascites and large left pleural effusion. The gallbladder is not distended. Common hepatic duct measures 1.3 cm and the pancreatic duct is also mildly dilated measuring 0.3 cm. No discrete pancreatic head mass is identified. The portal vein is patent with anterograde flow. Limited views of the kidneys demonstrate no hydronephrosis. An additional solid hypoechoic vascular mass is seen above the left kidney measuring 3.3 x 2.6 x 3.4 cm. IMPRESSION: 1. Solid hypoechoic masses are seen in the right lobe of the liver and above the left kidney, concerning for metastases. Recommend CT of the abdomen for metastatic work-up, or hepatic MRI if there is clinical concern for a primary hepatocellular carcinoma. 2. Multiple hepatic cysts. 3. Dilatation of the common hepatic duct and pancreatic duct with no discrete mass seen in the pancreatic head. Again, this could be evaluated with abdominal CT. 4. Cholelithiasis and gallbladder wall edema, likely related to hypoalbuminemia. 5. A small amount of ascites and large left pleural effusion. . [3-1] ECHO: EF 75-80% Conclusions: No atrial septal defect is seen by 2D or color Doppler. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . [2-25] Pleural fluid negative for malignancy . [3-19] CT Abd/Pelvis IMPRESSION: 1. Poorly defined predominantly hyperehancing mass within the medial right hepatic dome just to the right of the IVC surrounding and narrowing the right hepatic vein. CT imaging characteristics are not specific but differential includes hepatocellular carcinoma, hepatic adenoma or even a solitary metastasis. Further charactherization of this mass is recommended with MRI. 2. Complex right lower lobe empyema/parapneumonic effusion. There is an adjacent right lower lobe consolidation. 3. Decrease in the more simple-appearing left pleural effusion and left lower lobe atelectasis. 4. Gallstones. 5. Several left upper quadrant splenules. 6. Multiple hepatic and renal cysts. 7. Descending and sigmoid colonic diverticula. 8. 2-3 mm lingula nodule. Interval follow up is recommended. Length of follow up (3-6 months vs 1 year) should be determined based on whether the patients has a primary malignancy . [3-21] Liver Biopsy: Liver needle biopsy: Adenocarcinoma. Immunostains of the tumor are strongly positive for cytokeratin CK7, weakly positive for CK20, and negative for TTF-1, with satisfactory controls. Iron stain: Moderate iron deposition in hepatocytes. Trichrome stain is reviewed. Note: The tumor histology and immunostains are most consistent with a biliary/pancreatic origin, including both primary cholangiocarcinoma and metastatic disease. Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ] was provided a preliminary diagnosis on [2158-3-22]. . [2158-3-24] Colonoscopy Findings: Protruding Lesions A single sessile 4 mm polyp of benign appearance was found in the ascending colon. A piece-meal polypectomy was performed using a hot snare. The polyp was completely removed. Impression: Polyp in the ascending colon (polypectomy) Otherwise normal colonoscopy to cecum . [2158-3-30] EGD: Findings: normal esophagus, stomach, and duodenum. No signs of bleeding. . [2158-4-6] CT Torso: 1. Persistent right empyema with adjacent opacities consistent with pneumonia, aspiration or atelectasis. 2. Increased intra- and extrahepatic biliary ductal dilatation, as well as somewhat increased prominence of the pancreatic duct. This could suggest an obstructive process near the ampulla, and although no stone or clot is directly observed there, the presence of a stone or blood clot would often not be observable on CT. 4. Cholelithiasis. 5. Satisfactory position of gastrojejunostomy tube. 6. Stable L2 compression fracture. . Labs on discharge: Na 140 Cl 104 BUN 16 Glc 99 K 3.7 CO2 30 Cr 0.5 Phos: 2.0 WBC 12.1 Hgb 8.6/Hct 26.1 Plts 711 Brief Hospital Course: Pt is a 74 yo male with a history of COPD admitted with Strep milleri empyema, now s/p CT tube removal and full course abx, with intercurrent diagnosis of adenocarcinoma of likely biliary primary, course complicated by recurrent aspiration pna and blood loss anemia . # Blood loss anemia- Patient has chronic, macrocytic anemia likely due to alcohol use; B12 and folate were within normal limits. However, Hct acutely dropped from 25.5 on [3-27] to 19.1 on [3-29]; EGD, [Last Name (un) ], CT torso all negative for source of bleeding and Hct responded appropriately to 2units PRBCs and remained stable at 26-27. Then, after PEG placement, patient had maroon, guaiac positive stool x1, remained hemodynamically stable. Lavage from PEG was clear/yellow, no blood seen. Patient has not had further melena although loose brown bowel movement yesterday was guaiac positive. CT abd/pelvis did not reveal any bleeding around PEG site. Discussed with GI briefly possible additional work-up for unexplained Hct drops; ERCP or push enteroscopy with side view scope could identify hematobilia if present, although this is unlikely as explanation of bleeding requiring transfusion since hematobilia would be more chronic; they could perform procedure diagnostically but there would not be endoscopic therapeutic options. Therefore, monitor Hct and transfusing supportively may be best option for this patient. Continue [Hospital1 ] ppi, iron. . # Recurrent/aspiration pna: after completing full course (5 weeks) antibiotics for Strep milleri pneumonia with empyema drained with chest tubes, patient had increasing rhonchi, leukocytosis, low grade fevers. Given his known aspiration risk and prolonged hospital stay, treating empirically with zosyn/vanc for total 3 weeks, which will be through [4-24]. Continue pulmonary toilet, supplemental O2 . # persistent leukocytosis: WBC remains [11-11] thousand despite long course of antibiotics directed at empyema; afebrile. Continue antibiotics. . # COPD- Long time smoker, 4L O2 at home. Received pulse dose steroids in ICU in early [Month (only) 547]. Atrovent/Alb inhalers. Continue oxygen by nasal cannula. . # L2 vertebral body fracture: seen incidentally on CT torso, patient complained only of same chronic/intermittent LBP. Neurosurg/spine saw patient and reviewed films, recommended TLSO brace only if patient having pain that limits ambulation. . # ETOH use- Pt drinks 3-4 beers daily in morning and glass of wine at night. No signs/sx of withdrawal this admission and out of time window. Continue MVI, thiamine, folate, B12 . # Adenocarcinoma: Per pathology prelim read, biopsy specimen c/w adenocarcinoma (not hepatocellular), unlikely lung or colon based on immunohistochemical staining so most likely cholangiocarcinoma. CEA <1; AFP 8.8 (0-8.7, ref range); CA19-9 26 (0-37, ref range). Hep serologies neg. No h/o prostate CA and PSA wnl. + strong smoking history so possibility of Lung ca w/ met but no obvious lesion on CT chest. ? could be a lesion hiding in his RLL PNA/empyema. Colonoscopy w/ one small polyp but no other concerning lesions. EGD normal. Remainder of staging will be completed as outpatient (arranged with Dr [Last Name (STitle) ] by heme-onc consult team). . # Thrombocytosis- Multifactorial, from alcohol, iron deficiency, and inflammation. . # s/p percutaneous gastrostomy-jejunal feeding tube: Patient required feeding tube for aspiration risk; speech and swallow therapists optimistic that patient will be able to regain swallow function with exercise. Pain meds for tenderness at insertion site. Per IR, sutures used to tack stomach to abd wall should be removed on [4-12]; sutures can be cut externally and internal/gastric portion will resorb/pass. . # FEN- Placed PEG-J in IR. TF recs from nutrition: Nutren Pulm. goal 95ml/hr; will cycle over 14 hours at night when tolerating goal rate. . # PPx- Heparin SC, bowel regimen, PPI . # Access- PICC (placed [3-7]) . # Code- FULL . # Communication- [First Name8 (NamePattern2) ] [Known lastname 72326] ([Telephone/Fax (1) 72327] . # Dispo- needs rehab bed Medications on Admission: 1. Advair [Hospital1 ]--patient unsure of dose 2. Aspirin 81mg po daily 3. Ipratropium Bromide Neb [11-29] NEB IH Q6H 4. Multivitamin 5. Niaspan 750mg po daily 6. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. Acetaminophen 325 mg Tablet [Month/Day (2) ]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 2. Heparin (Porcine) 5,000 unit/mL Solution [Month/Day (2) ]: One (1) mL Injection TID (3 times a day): until ambulatory. mL 3. Docusate Sodium 100 mg Capsule [Month/Day (2) ]: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Bisacodyl 10 mg Suppository [Month/Day (2) ]: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 5. Senna 8.6 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Ferrous Sulfate 325 (65) mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [Month/Day (2) ]: One (1) Cap Inhalation DAILY (Daily). 8. Thiamine HCl 100 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 10. Albuterol Sulfate 0.083 % Solution [Month/Day (2) ]: One (1) NEB Inhalation Q4-6H (every 4 to 6 hours) as needed for wheezing. 11. Ipratropium Bromide 0.02 % Solution [Month/Day (2) ]: One (1) NEB Inhalation Q6H (every 6 hours). 12. Sertraline 50 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [Month/Day (2) ]: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 15. Piperacillin-Tazobactam 4.5 g Recon Soln [Last Name (STitle) ]: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 2 weeks. 16. Vancomycin 1,000 mg Recon Soln [Last Name (STitle) ]: One (1) gm Intravenous twice a day for 2 weeks. 17. Morphine 2 mg/mL Syringe [Last Name (STitle) ]: Two (2) mg Injection Q4H (every 4 hours) as needed for pain. 18. PICC Line care PICC line care per protocol Discharge Disposition: Extended Care Facility: [Hospital 169] Center Discharge Diagnosis: Pneumonia Empyema COPD Delirium Macrocytic anemia Adenocarcinoma in the Liver Discharge Condition: Hemodynamically stable. Ambulatory. Discharge Instructions: You were admitted for pneumonia with an empyema (abscess next to the lung) and had chest tubes to drain your lung. You will need to be on antibiotics for a total of 30 days. . Seek medical attention immediately if you develop fever, chills, increased shortness of breath or chest pain. . Several of your medications were changed. Followup Instructions: An appointment has already been made for you with your new PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for [2158-5-2] at 12:45 pm. Tel ([Telephone/Fax (1) 72328]. . Please call either Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 6568]) or Dr. [First Name (STitle) ] [Name (STitle) ] ([Telephone/Fax (1) 13006]) to make a follow-up appointment to pursue further work-up and treatment of your liver cancer. They are both based at [Hospital1 69] and will have access to all of the results from your hospitalization.	[ "496", "238.71", "155.2", "291.81", "293.0", "995.92", "482.39", "303.90", "785.52", "280.0", "518.81", "038.0", "510.9", "211.3" ]	icd9cm	[ [ [] ] ]	[ "96.6", "50.11", "99.04", "45.42", "33.24", "46.32", "34.09", "00.17", "38.93", "96.04", "34.04", "34.91", "45.13", "96.72", "38.91" ]	icd9pcs	[ [ [] ] ]	16534, 16586	10121, 14253	327, 554	16708, 16746	2578, 9976	17125, 17776	2028, 2046		14509, 16511		16607, 16687		14279, 14486			16770, 17102								2061, 2559																						275, 289					9995, 10098						582, 1530																	1552, 1665	1681, 2012
32,526	156,527	19383	Discharge summary	report	Admission Date: [2184-7-28] Discharge Date: [2184-9-1] Date of Birth: [2161-2-19] Sex: M Service: MEDICINE Allergies: Azithromycin / Bactrim Attending:[First Name3 (LF) 358] Chief Complaint: Altered mental status, Fevers Major Surgical or Invasive Procedure: Central line Placement Intubation, mechanical ventilation History of Present Illness: 23 yo male with HIV/AIDS (last CD4 count of 2 on [7-7]) who presented initially [7-28] with altered mental status from his residential treatment program. He was noted to have acute changes in mental status 2 days prior to admission from being fully oriented to lethargic, not oriented and not opening eyes to command. He also reportedly had worsening of his chronically poor po intake, thought to be secondary to dysphagia related to severe oral thrush. . Of note, he was recently admitted [7-2] to [7-13] for confusion at which time he underwent an extensive workup and it was thought by neuro that he most likely was suffering from HIV encephalopathy (workup at that time included MRI brain showed diffuse atrophy but otherwise unremarkable; total spine read as normal. LP negative, CSF HSV PCR neg, HSV viral load neg. CSF JCV PCR neg. Crypto Ag neg. CMV IgG pos but IgM and viral load neg. Toxo IgG/M neg. CSF VDRL and serum RPR neg. [Month/Year (2) ] cultures neg for bacteria neg while fungal and AFB are neg to date. Stool neg for O+P, salmonella, shigella, campylobacter, crypto, giardia; mycobacterium neg to date. Stool was positive for c. diff on [2184-7-6] at which time a 2 week course of flagyl was initiated. . On initial presentation to the ED this admission, his vitals were: T 100.1 HR 133 BP 118/77 RR 14 Sat 96% on RA. He had an LP done which showed 2 wbc, 1 rbc, protein 122, gluc 42. Gram stain with no PML, no microorganisms. Fluid, fungal, mycobacterial, viral cx pending. Crypto Ag neg. He received ceftriaxone 2 g IV, ampicillin 2 g IV, acyclovir 500 gm IV, and flagyl 500 mg IV and admitted to general medicine service, where he was also started on Vanco 1000 mg IV. On the medical floor, the patient was noted to be febrile to 101.7 although his mental status improved improved. Pt was nonverbal when he first came to the floor but was subsequently able to give short answers although he remained extremely lethargic with poor attention. . On [8-1], his mental status was waxing and [Doctor Last Name 688]. He became tachypneic to the 40s and his O2 sat dropped to the 80s; BP remained stable but HR increased to 110. Pt was placed on NRB with improvement in O2 sat to 94% and given 2 L NS bolus with improvement in his BP before being tx to the ICU given concern for sepsis and respiratory distress. . In the ICU, he was intubated upon arrival out of concern for hypoxia and airway protection due to his depressed mental status. He underwent bronchoscopy on [8-1] with 3+ PMNs, but negative cultures, AFB smear, and fungal cx NGTD, PCP [Name Initial (PRE) 5963]. Additional cx data including [Name Initial (PRE) ], urine and stool (including c. diff x3) have been negative this admission. In the ICU he was started on cefepime and continued on vanco/ampicillin/flagyl/acyclovir. He was briefly on voriconazole for fungal coverage which was discontinued at recommendation of ID team; ampicillin and voriconazole both were d/c'd on [7-30]. Additionally, acyclovir was discontinued on [8-4]. As per ID team recommendations, he was started on HAART in the ICU. Past Medical History: 1. HIV/AIDS - CD4 2, VL [Numeric Identifier 52710] on [2184-7-7]; dx in [2178] with PCP, [Name Initial (NameIs) 1095] [1-31] unprotected sex with woman, not on HAART x 1 year [1-31] depression. 2. Depression with paranoia and psychotic features 3. Recent h/o C.Diff colitis 4. Oral thrush 5. PCP [Name Initial (PRE) 1064] [2178], ? in [6-6] treated with bactrim but switched to atovaquone [1-31] granulocytopenia 6. Giardia 7. Primary syphilis per pt, treated with IM PCN 8. Necrotizing granulomatous hepatitis, stage II fibrosis and grade 3 inflammation by MRI and path - neg viral hepatitis 9. Hemorrhoids Social History: Patient has completed high school. He currently is living at a residential treatment facility. Per previous notes (unable to get from pt) he has denied any previous history of illicit drug use or [Month/Day (2) ] transfusions.He admitted to rare alcohol intake, approximately one to two timesper year, and notes tobacco use consistent with two to three cigarettes per day. Family History: Patient admits to a family history of diabetes and hypertension. He denies any liver disease in his family. Physical Exam: V/S: T 97.6 BP 118/62 P 82 RR 20 Sat 92% NC General: young, thin male lying in bed with his eyes closed, barely opening his eyes when spoken to, nonverbal HEENT: patient resisted eye opening and moved his eyes away from the light - unable to assess his pupils, patient did not open his mouth to command. Mouth slightly open with green material present between his teeth. Neck: no LAD, supple, JVP not seen Heart: RRR, no MRG Lungs: coarse breath sounds b/l Abd: +BS, soft ND Ext: no edema Neuro: Patient stuporous, will slightly open his eyes to voice, can squeeze his hands b/l to command, cannot move his toes to command or open his mouth. Down-going toes b/l on Babinski. When either arm is raised off the bed, he will slowly let them drift down when let go. When either leg is lifted off the bed, it will fall down immediately when let go. 2+ biceps and radialis on the Rt side, 1+ Biceps and radialis on the Lt, unable to elicit patellar reflexes b/l Skin: no rashes Brief Hospital Course: #HIV-Previous to this admission, the patient was not treated with HAART therapy [1-31] depression and poor compliance; given severity of infection he was started on HAART therapy with darunavir, raltegravir, tenofovir, ritonavir and lamivudine per ID recs. He tolerated these medications well. . #[Name (NI) 22118] Pt was tachypneic on floor and given MS changes unclear if could protect airway and adequately ventilate; thus pt intubated on arrival to MICU. Etiology of tachypnea unclear but possibly related to infectious process/PCP vs CAP vs aspiration pna. Pt was intubated for a period of time and underwent bronchoscopy during this admission, with 3+ PMNs but otherwise unrevealing bronchial washings. PCP was negative from the BAL, and fungal/viral cultures were negative. On [8-3] the patient was successfully extubated with improvement in his respiratory status after several days of broad spectrum antibiotic coverage for possible bacterial, viral, and fungal infection. A code blue was called on the evening of [8-7] when Mr. [Known lastname ] went into respiratory distress. He was intubated and transferred to the MICU under the MICU-green service. A CXR revealed collapse of his RLL from a mucous plug, with moderate mediastinal shift. The patient underwent urgent bronchoscopy with removal of several right sided mucous plugs. His right lung was better aerated after the procedure with near complete recovery of his mediastinal shift. Vancomycin and cefepime were added back to his regimen that evening given his tenuous repsiratory state, and the BAL washings were sent for culture. After the mucus plug was taken out, the patient's respiratory status improved rapidly and he was able to be extubated the next morning without difficulty. Given this rapid respiratory improvement, his vancomycin and cefepime were d/c and during the remainder of his hospital course he did not have any further respiratory issues. He remained afebrile breathing room air. . #ID/[Name (NI) 15305] Pt has a poorly controlled HIV infection with low CD4 count (count of 1) and thus susceptibility to many opportunistic infections; he may have encephalitis with opportunistic infection; LP most c/w viral infection but need to r/o other sources. Initially transferred to ICU with fever, tachypnea (meets criteria for SIRS) with presumed infection (and thus sepsis) although nothing has cultured and the source was unclear. LP with only 2 WBCs, 1 RBC, elevated protein but normal glucose which is not inconsistent with cryptococcus but PCR negative. CSF for VDRL, HSV, CMV, EBV, [Male First Name (un) 2326], VZV, cryptococcus all negative by PCR. Given negative EBV PCR, CNS lymphoma unlikely. Negative [Male First Name (un) 2326] PCR still does not exclude PML as etiology. CT abdomen without source of infection. CXR with ? patchy infiltrates and pt does have elevated LSH. Differential included PCP pneumonia, CMV, EBV, HSV, VZV, JCV, Histo, Cryptococcus, however PCP ruled out via negative bronch washings. Central line was inserted and pt was aggressively fluid rescitated given his hypotension and fevers. Pt intermittently required pressors for BP support, but at very low doses. LP cultures were negative for HSV, CMV, VZV, EBV, JCV, and Cryptococcus. Urine legionella antigen was negative. [Male First Name (un) ] cultures to date with no growth. ID followed closely and recommended continuing empiric treatment with Vancomycin, Cefepime (for pseumonas coverage), acyclovir, and PCP prophylaxis with Atovaquone. Ampicillin, voriconazole, and Bactrim were discontinued. HAART therapy was intiated during this hospitalization and were tolerated well. All of his cultures remained negative and a full infectious work-up for his altered mental status was negative, including multiple CSF studies. He continued on his HAART for the AIDS, Atovaquone for PCP prophylaxis, Rifabutin for MAC prophylaxis, and completed a course of flagyl for possible C.diff infection, despite continual negative C.diff studies. . #Mental Status change - Patient with HIV/AIDS (CD4 count of 1 on admission) thought to have HIV encephalopathy, but at baseline more alert and oriented than on admit. It is, however, not entirely clear as to whether his mental status is due to CNS infective process (negative CSF studies as above although elevated protein) vs. PML (despite negative [Male First Name (un) 2326] PCR) vs. HIV encephalopathy vs. d/t underlying metabolic insult from different source of infection. Bacterial meningitis ruled out via LP, however, persistently poor MS could be a progression of HIV encephalopathy, or could represent encephalitis (HSV). CSF also negative for ACE on [8-24] therefore rule out neurosarcoid. Head CT on admission showed no bleed. Neurology was consulted and the patient underwent an EEG on [7-30] which showed evidence of benzodiazepine or barbiturate effect (during which was the patient was intubated and sedated). EEG showed no ongoing epileptiform activity, and no focal abnormalities. The pattern was most consistent with a moderate to severe encephalopathy of toxic, metabolic, or anoxic etiology. Of note however repeat MRI again reveals atrophy suggestive of some chronicity to this CNS process and abnormal signal in the basal ganglia (neuro reports nonspeicific), but no masses or focal lesions. Continued work-up by neurology, including additional LP exams continued to not identify any other source for the patients altered mental status. He was continued on the above described medications and did show some overall improvement during his hospitalization while on HAART treatment, although he remained profoundly weak from his shoulders down, essentially remaining non-verbal. On [8-24] CD4 28, viral load 3200. Speech and swallow assessment were done three times with the final assessment showing some progress to allow patient to have light PO intake of fluids via straws. . #Acute Anemia - During his stay in the ICU, the patient was noted to have a decline in his Hct with a nadir of 24. One unit of PRBCs was transfused. The patient was guiac negative and there was no evidence of GI bleeding. Drug-related myelosupression/anemia was considered but given the timing of his recent initiation of HAART therapy, this was considered unlikely. After [Month/Year (2) ] transfusion, the patient's Hct remained stable and his acute anemia was attributed to a combination of dilution and frequent phlebotomy while in the ICU. . # Pancytopenia: Pancytopenic on presentation whereas prior to that was leukopenic and anemic (with nml platelets). Unclear whether due to BM involvement and suppression from underlying HIV or whether bactrim as etiology. Also ? due to other infectious process including viral, fungal, or bacterial despite no positive culture data to date. Appears he had been off bactrim since last admission and was admitted on atovaquone so perhaps less likely due to this. Was neutropenic on last admission, but has not been during this stay and WBC count has improved and is stable with broad spectrum abx and initiation of HAART. Baseline hct fluctuates but appears previously low-mid 30s, most recently in the high 20s and stable. Had BRBPR during last admission without further GI w/u at that time given concurrent c. diff infection. DIC labs revealed normal INR, elevated fibrinogen and normal FDP. Today with 1% bands and suspect less reflection of infectious process and more reflection of productive BM in setting of HAART initiation. . # Systolic dysfunction: LVEF on this admission 25% and ? due to HIV or from other toxic metabolic insult particularly in the setting of sepsis upon presentation to the ICU. Was diuresed with prn IV lasix prior to extubation and currently does not appear markedly overloaded on exam. - will repeat TTE this admission to eval for improvement now that sepsis has resolved . # Transaminitis: Has h/o granulomatous hepatitis with stage 2 fibrosis. Transaminase elevation noted during last admission and upon this presentation, since having normalized as of most recent [8-1] LFTs. Normal alk phos and t.bili. HCV viral load negative here, hep B and hep A neg. Monitored intermittently and continued to show normal levels. . # Recent C.diff infection: C. diff neg x3 on this admission, however given recent infection and on broad spectrum antibiotics otherwise, he was continued on a course of flagyl which he completed and was then taken off of. . # FEN: Patient nutrition was maintained through feeding tube, intially by NGT and then on [8-19] patient had IR guided PEG tube placed without complications. PEG tube started to be used on [8-20] without complications. Nutrition continued to follow patient. Received Probalance feeds at 65 cc/hr with no complications. Patient reported some throat pain and was placed on 5 days of fluconazole (during which time the rifabutin was stopped due to possible drug interactions); throat pain has since resolved. . # PPx: SC heparin; decrease tid dosing if PTT remains significantly elevated. . # Access: RIJ placed ([7-29]), 2 PIV. Will d/c IJ pending continued HD stability on floor. # GU: Patient initially placed on foley catheter. This was converted to condom catheter on [8-14] and patient has been able to void. . # Code: FULL (discussed with the patient's family); will need to have another family meeting in order to further address prognosis and course from here. . # Dispo: pending further w/u and treatment as above. . # Contact: mother, [Name (NI) 52711] [Name (NI) ] [Telephone/Fax (1) 52712]; father, [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 52713]. A code blue was called on the evening of [8-7] when Mr. [Known lastname ] went into respiratory distress. He was intubated and transferred to the MICU under the MICU-green service. A CXR revealed collapse of his RLL from a mucous plug, with moderate mediastinal shift. The patient underwent urgent bronchoscopy with removal of several right sided mucous plugs. His right lung was better aerated after the procedure with near complete recovery of his mediastinal shift. Vancomycin and cefepime were added back to his regimen that evening given his tenuous repsiratory state, and the BAL washings were sent for culture. Medications on Admission: 1. Atovaquone 750 mg po bid 2. Vancomycin 125 mg po q6h 3. Dronabinol 5 mg [Hospital1 ] 4. Citalopram 30 mg daily 5. Nystatin Swich and swallow tid 6. Clotirimazole qid 7. MVI Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: 1. HIV encephalopathy 2. Respiratory distress 3. Systolic dysfunction 5. HIV 6. Oral thrush 7. s/p PEG tube placement Discharge Condition: Hemodynamically stable, tolerating PEG tubefeeds at goal, unable to ambulate, non-verbal Discharge Instructions: You have been diagnosed with HIV encephalopathy, and possibly PML. You should continue to take your HAART Medication until your follow up appointment with infectious disease clinic. Your mouth can continue to be swabbed with Nystatin solution. Please take all medications as prescribed. You will continue to get nutrition via you PEG tube. If you have any questions regarding your HIV treatment, please call Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at ([Telephone/Fax (1) 4170] Followup Instructions: 1. Provider: [Name10 (NameIs) 2341] [Last Name (NamePattern4) 2342], M.D. Phone:[Telephone/Fax (1) 2343] Date/Time:[2184-9-22] 2:00 2. [Doctor First Name ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], [MD Number(3) 13795]:[Telephone/Fax (1) 1047] Date/Time:[2184-9-28] 1:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13447], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2184-9-21] 9:30 Please follow up with Dr. [Name (NI) 52714] [9-13] at 2:00 PM. You can call [Telephone/Fax (1) 10216] if you have problems with your appointment. Completed by:[2184-9-1]	[ "335.23", "934.8", "571.5", "038.9", "263.9", "995.92", "348.30", "112.0", "008.45", "428.0", "428.21", "518.81", "518.0", "322.9", "042" ]	icd9cm	[ [ [] ] ]	[ "33.22", "96.71", "96.04", "33.24", "96.6", "38.93", "45.16", "96.72", "03.31" ]	icd9pcs	[ [ [] ] ]	16362, 16444	5754, 16131	311, 370	16608, 16699		17262, 17930	4632, 4742				16465, 16587		16157, 16339			16723, 17239								4757, 5731																						242, 273											398, 3547																	3569, 4219	4235, 4616
24,477	107,872	17709	Discharge summary	report	Admission Date: [2195-10-28] Discharge Date: [2195-11-14] Date of Birth: [2141-6-26] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (un) 2888] Chief Complaint: Elevated creatinine Major Surgical or Invasive Procedure: [2195-11-2]: Right heart catheterization Dual chamber ICD placement History of Present Illness: Mr. [Known lastname 49249] is a 54 year old gentleman with HTN, DM2, CKD (baseline Cr 2.0-2.2), CAD s/p CABG [2186], as well as systolic and diastolic heart failure (EF had been as low as 20% but last known to be 40%), who was recently admitted to the [Hospital1 18] Cardiology service from clinic on [2195-10-16] for worsening dyspnea over 2 weeks. CHF exacerbation was in the setting of new inferior HK and he was diuresed with hopes of pursuing RHC/LHC. Hospital course was complicated by [Last Name (un) ] (Cr>3.0), PIV-associated MSSA bacteremia (did not want [Last Name (LF) ], [First Name3 (LF) ] dc'ed on IV nafcillin x4 weeks). RHC was done and showed elevated filling pressures, so he was transferred to the CCU for Milrinone to assist with Lasix gtt. Due to infection, he was only on milrinone for a few hours. He was transferred back to the floor and was diuresed well prior to discharge. He followed up in clinic on [2195-10-27] and was found to have creatinine elevated to 5.4 despite holding torsemide on [10-22] (took it [10-27]). He was admitted to [Hospital1 1516] for management of his [Last Name (un) ]. On interview this afternoon, he denies SOB at rest. He hasn't been walking much, but doesn't feel "crushing fatigue" now like he did before. He has been sitting to sleep, which he does think is worse than when he was admitted. His itchiness continues, but isn't worse than when in the hospital. He does endorse nausea, diarrhea (8 loose stools a day) which he reports started with the nafcillin. Denies fever, chills, abd pain. He reports "I don't do well with IVs. They always increase my creatinine regardless of what it is." He has been following the same diet and eating light. He reports poor intake of fluid as he's trying to avoid drinking a lot, "much less than 1L a day." His right eye seems like it has a swollen eyelid today, but he hasn't noticed. His wife reports that it always looks like this. No headache. Reports we weighed 219 today (recorded as 219.2), 215 yesterday, 211 on discharge. On review of systems, he denies any prior history of stroke, TIA, 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, palpitations, syncope or presyncope. +Orthopnea, +PND Past Medical History: Hypertension Dyslipidemia Diabetes mellitus -retinopathy s/p laser surgery -peripheral neuropathy with ulcers Chronic kidney disease (baseline Cr 2.0-2.2) Coronary artery disease -s/p CABG in [2186] (LIMA-LAD, SVG-PDA, and radial-OM1-OM2) Congestive heart failure -[4-/2195]: B&WH admission with EF of 20% in CHF, improved to 40% on discharge Deep vein thrombosis x1 (s/p Warfarin in the past) s/p Right knee arthroscopy Iron deficiency anemia Gout Social History: -Home: Lives in [Location ] with his wife. Married 20 years. -Occupation: Works as a financial planner, lawyer, runs a property company. -Tobacco: used to smoke one cigar daily since high school until stopping after CABG. No cigaretters. -EtOH: None -Illicits: None Family History: Mom had CABG in 60s. 3 brothers all without heart disease or diabetes. Father with ?lymph cancer. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 97.6 - 144/77 - 74 - 20 - 95RA - BS304 weight: 219.2 (on discharge [2195-10-25], 96kg (211 lbs) GENERAL: Alert, oriented x3. Sitting in bed with wife at bedside. No respiratory direstress. HEENT: MMM, R eye seems ptotic NECK: Supple with JVP 8-9 cm CARDIAC: PMI closer to midline w/ RV lift. RR, S1, S2 w/ paradoxical splitting, S3. No murmur or rub. LUNGS: Mild crackled bilateral bases, no wheeze ABDOMEN: Softly distended. Abd aorta not enlarged by palpation. No abdominal bruits. BS present. +hepatojugular reflex EXTREMITIES/SKIN: severe stasis dermatitis with anterior weeping ulcers on lower extremities. also continues to have scab on lateral R thigh. Not grossly edematous (trace) NEURO: CN 2-12 intact, bilateral ue's and le's [6-13], finger extensors [6-13], no sensation to light touch from mid calf downwards (stable from last exam), no decreased sensation to touch in UEs. . DISCHARGE Afebrile, normotensive (SBP 130s-140s), non-tachycardic, non-tachypneic, saturating well on RA Exam same as above except: Chest: L upper chest- well-appearing, no mass palpated, appropriately tender Pulm: mild bibasilar crackles Ext: LE edema much improved, ulcers healing well Pertinent Results: ADMISSION LABS [2195-10-28] 05:35PM BLOOD WBC-6.8 RBC-3.80* Hgb-9.1* Hct-29.4* MCV-77* MCH-23.9* MCHC-30.9* RDW-18.8* Plt Ct-296 [2195-10-27] 02:54PM BLOOD UreaN-105* Creat-5.4# Na-128 K-4.7 Cl-85* HCO3-27 AnGap-21 [2195-10-28] 05:35PM BLOOD Glucose-261* UreaN-91* Creat-4.9* Na-132* K-3.7 Cl-88* HCO3-29 AnGap-19 [2195-10-28] 05:35PM BLOOD Calcium-8.8 Phos-7.0# Mg-3.0 . Imaging: [11-11] Echo Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 30 %). Right ventricular chamber size is normal. with borderline normal free wall function. No 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. Compared with the prior study (images reviewed) of [2195-11-9], left ventricular cavity size is smaller and overall ejection fraction has increased. [2195-11-9] Echo The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 20 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with depressed free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2195-10-29], biventricular systolic function has decreased. [2195-11-2] Cath COMMENTS: 1. Right heart catheterization revealed severely elevated right and left sided filling pressures. The mean RA pressure was severely elevated at 18 mmHg, and the RVEDP was severely elevated at 22 mmHg. There was severe pulmonary arterial hypertension with a PA pressure of 80/33 mmHg and a mean PA pressure of 49 mmHg. The mean wedge pressure was severely elevated at 32 mmHg. The cardiac output and index were reduced at 4.3 L/min and 2.0 L/min/m2. The pulmonary vascular resistance was moderately elevated at 316 dyne-sec/cm5. 2. Ultrasound of the right internal juggular vein suggested thrombus which is possibly related to the patient's right sided PICC line, however subsequent imaging indicated no thrombus but RIJ very medially displaced. FINAL DIAGNOSIS: 1. Severely elevated right and left sided filling pressures. 2. Severe pulmonary arterial hypertension. 3. Reduced cardiac output/index. 4. Moderately elevated PVR. 5. Possible thrombus in the right internal jugular vein which was not confirmed by subsequent studies which showed RIJ very medially displaced. [2195-11-13] CXR Transvenous right atrial pacer and right ventricular pacer defibrillator leads are in standard positions. Yesterday's mild pulmonary edema has resolved. There is no pneumothorax, pleural effusion or mediastinal widening. Heart is top normal size, unchanged over the long term. Also unchanged since at least [10-19] are fractures of the two uppermost sternal wires, which developed sometime after [2186-4-26] when non-fusion of the manubrium was already evident radiographically. [11-12] CXR FINDINGS: In comparison with study of [11-5], there has been placement of an ICD device with the leads in the region of the right atrium and apex of the right ventricle. Specifically, there is no evidence of pneumothorax. Little change in the appearance of the heart and lungs. Persistent separation of the upper sternal fragments therefore does not suggest infection, but it is an explanation for fracture of the wires [10-28] CXR REASON FOR EXAMINATION: Evaluation of the patient with systolic and diastolic heart failure. PA and lateral upright chest radiographs were reviewed in comparison to [2195-10-23]. Heart size is enlarged in a globular manner, unchanged. Mediastinum is stable. Multiple broken sternal wires are redemonstrated. As compared to the prior study, there is interval improvement in interstitial pulmonary edema, currently mild. There is also improvement in more focal right upper lobe opacity. Prominence of pulmonary arteries is demonstrated, most likely consistent with pulmonary hypertension. No appreciable pleural effusion is seen. [2195-10-28] RENAL U/S IMPRESSION: No hydronephrosis seen in either kidney. Small right renal nonobstructing stone. . Discharge [2195-11-13] 04:00AM BLOOD WBC-7.1 RBC-3.28* Hgb-8.4* Hct-28.1* MCV-86 MCH-25.7* MCHC-30.0* RDW-23.2* Plt Ct-234 [2195-11-13] 04:00AM BLOOD PT-15.2* PTT-37.4* INR(PT)-1.4* [2195-11-14] 05:00AM BLOOD Glucose-220* UreaN-74* Creat-3.3* Na-133 K-3.5 Cl-91* HCO3-31 AnGap-15 [2195-11-14] 05:00AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1 Brief Hospital Course: BRIEF HOSPITAL COURSE Mr. [Known lastname 49249] is a 54y/o gentleman with HTN, HLD, DM2, CKD (baseline Cr 2.0-2.2), CAD s/p CABG [2186] (LIMA-LAD, SVG-PDA, and radial-OM1-OM2) with systolic and diastolic heart failure, who was re-admitted from clinic for management of [Last Name (un) ]. #. Acute on chronic renal failure: Baseline Cr 2.1, presented last admission at 2.5, and presented at this admission with creatinine 5.4 in clinic. His renal function fluctuated, and he was initially managed with 40mg [Hospital1 ] torsemide. However, he did not respond well and had worsening renal function. Accordingly, he underwent R heart cath, which showed severely elevated right and left sided filling pressures, severe pulmonary hypertension and depressed CO/CI. He was admitted to the CCU for milrinone drip and more aggressive diuresis. On admission, urine studies suggested pre-renal cause of [Last Name (un) ] (FEurea 44% is indeterminate, FENa 0.86%). Torsemide had been held between hospital admissions. Nephrology was consulted and recommended cefazolin to substitute for Nafcillin (though due to the short time period, they did not believe [Last Name (un) ] was consistent with nafcillin-associated acute interstitial nephritis and urine eosinophils were positive. Sarna lotion and hydroxyzine were given for symptomatic relief of uremia-related pruritus. Pt's Cr trended down to mid 3s, plateaued and then steadily rised. After pt was switched from milrinone drip to dobutamine drip as well as optimized afterload reduction with hydralazine and Isordil, Cr consistently trended down. Upon discharge, Cr was 3.3. . #. Acute on chronic CHF: Due to continued weight gain and poor response, he underwent a R heart cath [see above]. Pt's beta blocker was restarted at a low dose and then later on discontinued as pt was in decompensated HF and later on put on dobutamine drip. Afterload reduction was successful while up titrating hydralazine and Isordil. Upon discharge, pt's BP was ranging 130-140. Heart failure team believed CHF is both related to significant dyssynchrony and contractility issues, both most likely related to ischemia. Pt was diuresed aggressively throughout course initially with Lasix drip and then transitioned to IV Lasix boluses with goal of [3-12].5L negative in 24h using 120mg boluses. Pt was transitioned to 100mg Torsemide at discharge. Dyssynchrony component of HF was addressed with attempting to place CRT-D. Unfortunately, coronary sinus could not be accessed successfully and thus LV lead was not placed. Contractility was addressed with dobutamine drip which pt was discharged with. After starting dobutamine infusion, EF improved from 20 to 30% on TTE. Pt will need to followup with EP in order to access LV for appropriate resynchronization and will probably have a cardiac catheterization to assess coronaries. . #. Peripheral IV-associated MSSA bacteremia: - Changed nafcillin to cefazolin per ID recs; he underwent a [Date Range ] this admission, which did not show any valvular vegetations. As a result, he underwent a shortened course of IV antibiotics (2 weeks), which ended on [2195-11-2]. Pt remained afebrile and stable thereafter. . #. Loose stools - Recent hospital stay could raise concern for C. diff (pt nauseous, but no f/c). Per patient, he feels that loose stools began w/ nafcillin. Either way, may contribute to pre-renal cause of [Last Name (un) ] (along with recent poor intake). Loose stools resolved after stopping nafcillin. In addition, he was c. diff negative. . . #. CAD s/p CABG Last cath in [2191] noted severe native 3VD with patent LIMA-LAD, SVG-PDA, and Radial-OM1-OM2. TTE on prior showed new inferior HK. He was continued on ASA, Pravastatin, and beta blocker (Metoprolol changed to Carvedilol). In the future he needs L heart catheterization in order to assess grafts/native vessels. Pt was continued on ASA and statin. Carvedilol was ultimately held given decompensated heart failure and pt put on dobutamine infusion. . #. Neuropathic & venous stasis ulcers: Pt was seen by wound care specialist during hospitalization. Ulcers appeared to heal more optimally when LE edema decreased with aggressive diuresis. Pt is to followup with PCP to continue DM management and may need referral to vascular surgery if ulcers persist or worsen. . #. Diabetes mellitus: Stable on ISS, and discharged with Lantus 44u at bedtime with ISS. . # Iron deficiency anemia: Hct stable during last admission 30-33. Iron studies showed low level of iron and pt was given 5 days of ferric gluconate IV 125mg to replete iron deficit. Pt's anemia was stable thereafter and discharged with hct of 28.1. #Elevated INR: Pt's INR was elevated over 2 during hospital course without anticoagulation. This was attributed to Vitamin K deficiency secondary to antibiotic use, malnutrition and malabsorption from congested bowels related to decompensated CHF. DIC labs were not remarkable. Pt's elevated INR was refractory to PO Vit K which supported hypothesis of congestion in GI tract causing malabsorption issues. As pt's nutrition improved and preload reduction, INR trended down to 1.4 at time of discharge. Pt was followed by nutrition during stay and would benefit from outpt nutrition management. . >> TRANSITIONAL ISSUES - follow up with EP regarding CRT lead placement into LV - could benefit from ACEI once kidney function improves - readdress restarting carvedilol when HF better controlled off of dobutamine - f/u with PCP regarding lower extremity wounds, medication reconciliation and diabetes management - would benefit from outpt nutritional support (fluid restriction, diabetes) - would benefit from cardiac cath once kidney function stable and adequate to assess coronaries/ischemic disease related to heart failure - f/u with cardiology Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Nafcillin 2 g IV Q4H Four week course [Date range (1) 49250] 2. Aspirin 81 mg PO DAILY 3. Glargine 44 Units Bedtime aspart 22 Units Breakfast aspart 22 Units Lunch aspart 22 Units Dinner 4. Pravastatin 80 mg PO DAILY 5. Carvedilol 12.5 mg PO BID 6. HydrALAzine 50 mg PO Q8H 7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 8. Torsemide 60 mg PO BID held Torsemide on last discharge, from [10-25] onwards Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY 3. Pravastatin 80 mg PO DAILY 4. HydrALAzine 75 mg PO Q8H please hold for SBP <100 RX hydralazine 50 mg 1.5 tablet(s) by mouth three times per day Disp #45 Tablet Refills:0 5. Outpatient Lab Work For VNA to draw: On Tuesday [2195-11-17], please draw Na, K, BUN/Cre, Bicarb, Cl, glucose, Mg. Please fax results to: Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 9825]. Diagnosis: chronic systolic heart failure. 6. DOBUTamine 5 mcg/kg/min IV DRIP INFUSION Please double concentrate if possible RX dobutamine 500 mg/40 mL (12.5 mg/mL) IV DOBUTamine 5 mcg/kg/min continous infusion Disp #30 Bag Refills:0 7. Torsemide 100 mg PO DAILY Hold for SBP <90 RX torsemide 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 8. HydrOXYzine 25 mg PO Q6H pruritus pt may refuse RX hydroxyzine HCl 25 mg 1 tablet by mouth Every 6 hours Disp #120 Tablet Refills:0 9. Potassium Chloride 40 mEq PO DAILY RX potassium chloride 20 mEq 2 tablets by mouth Daily Disp #60 Tablet Refills:0 10. Glargine 44 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 11. Heparin Flush (10 units/ml) 2 mL IV PRN Flush daily and as needed RX heparin lock flush (porcine) [heparin lock flush] 10 unit/mL 2mL to PICC line Flush daily and as needed Disp #100 Milliliter Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (un) 6438] Discharge Diagnosis: PRIMARY Acute on chronic kidney injury Acute on chronic systolic heart failure SECONDARY MSSA bacteremia Type 2 diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 49249], You were first readmitted to [Hospital1 1170] for worsened kidney function as well as worsening symptoms of heart failure. You were then tranferred to the CCU because you required medications to help your heart pump. You were first started on milrinone with minimal improvement and were then started on dobutamine. You will go home on a continuous infusion of dobutamine. It is very important for you to follow up closely with your doctors and to take your medications as prescribed. While you were here we tried to place a CRT device, however there was difficulty placing one of the leads. You now have an ICD. You will need a different procedure in the future to place an additional lead on your heart for cardiac resynchronization. You will also need a cardiac catheterization as an outpatient. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. It was a pleasure caring for you, Your [Hospital1 18] doctors Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [2195-11-18] at 10:40 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please call and schedule the following appointments: 1) With Dr. [Last Name (STitle) ] in the next week: [Telephone/Fax (1) 62] 2) With your primary care doctor in the next week: JAKHRO,[Telephone/Fax (1) ] A at [Telephone/Fax (1) 49260]	[ "584.9", "305.00", "280.9", "V58.67", "428.43", "579.9", "250.80", "V45.81", "E879.8", "285.21", "E930.0", "250.60", "274.9", "426.3", "V12.51", "459.81", "999.31", "263.9", "707.19", "787.91", "585.3", "269.0", "416.8", "V15.82", "357.2", "276.1", "790.92", "403.90", "428.0", "041.11" ]	icd9cm	[ [ [] ] ]	[ "38.93", "88.72", "00.51", "37.22" ]	icd9pcs	[ [ [] ] ]	18200, 18256	10379, 16227	324, 398	18423, 18423	5091, 7936	19598, 20151	3731, 3830		16801, 18177		18277, 18402		16253, 16778		7953, 10356	18574, 19575								3845, 3855											3877, 5072											265, 286											426, 2948											18438, 18550						2970, 3428	3444, 3715
25,635	175,927	50889	Discharge summary	report	Admission Date: [2162-9-20] Discharge Date: [2162-10-8] Date of Birth: [2101-1-28] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 301] Chief Complaint: Patient admitted with Abdominal distension and pain for 1 day. Major Surgical or Invasive Procedure: Status Post Exploratory Laparotomy History of Present Illness: 61 yo male with Hepatitis C and no previous abdominal surgery comes in with complaints of abdominal distension, pain since last night. Had a couple of bowel movements before 6PM which were normal. Not passed flatus since. No nausea , no vomiting. No fever. No previous similar episode. Not had anything to eat since last night because of the distension and pain. Past Medical History: PMH: Hepatitis C, HTN, Seizures, opiod addiction, homeless. Past Surgical History:Tonsillectomy; Eye surgery as a child for strabismus, 3rd degree burns on feet Social History: Patient is a 61 year old homeless male who admits to 40 year history of opioid addiction. Was in jail until 3 weeks ago. His father lives in [Name (NI) 620]. Stated that he has been buying suboxone to manage his addiction but has not seen a primary care provider in [Name Initial (PRE) ] long time. Family History: Non-contributory. Physical Exam: Physical Exam: Vitals: Time Temp HR BP RR Pox + 16:43 98.1 107 177/129mmHg 18 98 Looks uncomfortable. in pain. Lungs: clear bilateral Heart: Regular rate and rhythm; no murmurs. No carotid bruit Abdomen: Distended, tympanitic. generalized tenderness more in lower abdomen. Guarding and rebound in R lower abdomen and suprapubic region. No groin or umbilical hernias Rectal: No masses. Rectum ballooned out with no stool. Prostate moderately enlarged. Occult blood negative Brief Hospital Course: Patient admitted with abdominal pain. Patient taken to the operating room for exploratory laparotomy a bezoar was found in the small bowel. Postoperative course was complicated by delirium, decreased respiratory status and wound infection. Patient placed on antibiotics, chest x-rays monitored. Readmitted to ICU on [9-30] for abdominal distention, vomiting black tarry fluid, tachycardia, pain and dropping HCT. NGT placed for 700 cc of black fluid. [2162-10-1] EGD done showing ulcers in lower third of esophagus. Patient started on PPI intravenously as well as methadone tid. Bleeding resolved. Pt was transferred to the floor on [2162-10-1]. Pt was doing well and tolerating regular diet on the floor but continued to spike low grade fevers, though he did not have a WBC. Infectious disease was consulted and recommending rescanning his abdomen and pelvis. CT done on [2162-10-6] demonstrated multiple fluid pockets in the right lower quadrant and left paracolic gutter and pelvis, which were smaller in size compared to prior imaging. There was discussion between the surgery team, infectious disease and interventional radiology regarding drainage of those fluid collections, and it was determined that the patient would be discharged on four weeks of oral antibiotics with a follow-up CT scan in four weeks. Problems: 1. Opioid Withdrawal - Patient monitored and treated with CIWA scale. Methadone 10mg po tid now being given with adequate control. 2. Respiratory status now much improved to 97% on room air. Chest x-rays confirmed atelectasis and pleural effusion but no pneumonia. Last chest x-ray was [10-4]. 3. Abdominal wound - open inferior aspect of incision. Swab culture confirms enterococcus. Course of ampicillin given for that. Continue wet-dry dressings looks clean. 4. UGI bleed - Patient recieved one unit of PRBC's, hematocrit monitored until stable. PPI given. 5. Intraabdominal abscesses - Patient will be discharged on four weeks of Augmentin and will have a repeat CT scan in four weeks. Will discharge him to rehab facility that can manage abdominal wound care and addiction issues. He will follow up with Dr. [Last Name (STitle) ] in 3 weeks. Medications on Admission: HCTZ 25', Phenytoin 1 "' (not taking it for at least 3 weeks), Suboxone 8-2mg SL once daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Methadone 10 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO three times a day. 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 8. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times a day for 4 weeks. Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: Small Bowel Obstruction Discharge Condition: Stable Discharge Instructions: You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [9-30] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower 48 hours after surgery, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please follow up with your primary care provider [Last Name (NamePattern4) ] [12-18] weeks. Please follow up with Dr. [Last Name (STitle) ] in 3 weeks, his office is located on the [Hospital Ward Name 516], [Hospital Ward Name 23] Building [Location (un) 470]. Please call the following number [Telephone/Fax (1) 2723] to make an appointment. Provider: [Name10 (NameIs) ] SCAN; Phone:[Telephone/Fax (1) 327]; Date/Time:[2162-11-8] 11:45AM Location is on the [Location (un) ] of the [Hospital Ward Name 23] Clinical Center on the [Hospital1 ] [Last Name (Titles) 516].	[ "041.04", "560.89", "292.0", "346.90", "998.59", "304.01", "V17.3", "530.20", "531.90", "291.81", "567.22", "936", "427.31", "303.91", "511.9", "070.70", "518.5", "535.50", "305.1", "V60.0", "401.9", "E915" ]	icd9cm	[ [ [] ] ]	[ "45.02", "45.16", "96.6" ]	icd9pcs	[ [ [] ] ]	4902, 4957	1894, 4101	377, 414	5025, 5034		6649, 7278	1335, 1354		4244, 4879		4978, 5004		4127, 4221			5058, 6256						912, 994		1384, 1871																						274, 339									6268, 6626		442, 807																	829, 890	1010, 1319
6,704	147,759	9582	Discharge summary	report	Admission Date: [2130-9-20] Discharge Date: [2130-9-28] Date of Birth: [2055-12-18] Sex: M Service: Neurosurge HISTORY OF PRESENT ILLNESS: The patient is a 72 year old gentleman with a history of left nephrectomy in [2124] for renal cell carcinoma, reportedly diagnosed during workup for polycythemia. He now presents with a three day history of nausea, vomiting, dizziness, a mild frontal headache and mild lightheadedness, progressing with increased vomiting times three days, three times today. He denies sense of spinning or vertigo. He notes progressive unsteadiness of gait and mild photophobia. He denies chest pain, shortness of breath, cough, dysuria, abdominal pain or diarrhea. The patient reports a positive history of lung metastases, diagnosed in [2130-1-2], treated with two treatments of interleukin-2 with no change in pulmonary metastases on follow-up. MEDICATIONS ON ADMISSION: Multivitamins, ibuprofen, cyclobenzaprine. ALLERGIES: Benadryl. PAST MEDICAL HISTORY: 1. Renal cell carcinoma with lung metastases. 2. Polycythemia. 3. Glaucoma. 4. Rash. PAST SURGICAL HISTORY: Left nephrectomy in [2124]. PHYSICAL EXAMINATION: On physical examination, the patient had a temperature of 95.5, heart rate 77, blood pressure 195/97, respiratory rate 19 and oxygen saturation 93% in room air. The patient was a gentleman in no acute distress, awake, alert and oriented times three, conversant but with towel over eyes secondary to mild photophobia and headache. Pupils equal, round, and reactive to light and accommodation, extraocular movements intact, no nystagmus, tongue midline, palate rises in midline, facial sensation intact bilaterally, V1 through V3, smile symmetric, neck supple. Lungs: Clear to auscultation. Cardiovascular: Regular rate and rhythm, no murmur, rub or gallop. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Sensation intact to light touch, strength 5/5 in all groups, increased tone throughout, no clonus, gait deferred, deep tendon reflexes inconsistent due to increased tone. LABORATORY DATA: CT, low density, round 2.5 to 3 cm midline cerebellar lesion with question of early compression of the fourth ventricle but no obvious hydrocephalus on lateral ventricles. White blood cell count was 12.8, hematocrit 56.7, platelet count 362,000, sodium 137, potassium 4.4, chloride 101, bicarbonate 25, BUN 26, creatinine 1.5, glucose 118, prothrombin time 13.6, INR 1.2 and partial thromboplastin time 28.6. Chest x-ray showed no infiltrates or congestive heart failure. HOSPITAL COURSE: On [2130-9-22], the patient underwent a suboccipital craniotomy for resection of tumor. There were no intraoperative complications. Postoperatively, the patient was monitored in the Surgical Intensive Care Unit. He was afebrile with stable vital signs. His blood pressure was under control with Nipride. He was started on oral Lopressor and Nipride was weaned off. The patient was transferred to the regular floor on postoperative day number two. The patient was seen by physical therapy and occupational therapy and found to require rehabilitation prior to discharge to home. His vital signs have remained stable. He has been afebrile, and neurologically, he is awake, alert and oriented times three, moving all extremities with no drift. DISCHARGE MEDICATIONS: Colace 100 mg p.o.b.i.d. Lopressor 200 mg p.o.b.i.d., hold for systolic blood pressure less than 110, heart rate less than 60. Vasotec 15 mg p.o.b.i.d., hold for systolic blood pressure less than 110. Zantac 150 mg p.o.b.i.d. Decadron 4 mg p.o.q.8h., to wean to 2 mg b.i.d. CONDITION AT DISCHARGE: Stable. FOLLOW-UP: The patient will follow up in the brain tumor clinic to see Dr. [First Name (STitle) ] and is also to see Dr. [Last Name (STitle) 1327] in a week to ten days for staple removal. [Name6 (MD) 1339] [Last Name (NamePattern4) 1340], M.D. [MD Number(1) 1341] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2130-9-27] 10:53 T: [2130-9-27] 10:52 JOB#: [Job Number 32499]	[ "401.9", "198.3", "197.0", "238.4", "V10.52", "365.9" ]	icd9cm	[ [ [] ] ]	[ "01.59" ]	icd9pcs	[ [ [] ] ]									3395, 3680				946, 1013	2619, 3372								1153, 1186													1209, 2601			3695, 4167																			173, 919																	1036, 1129
82,221	180,512	46121	Discharge summary	report	Admission Date: [2112-5-23] Discharge Date: [2112-5-25] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: transferred from OSH with respiratory failure Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ]yo male w/ h/o COPD, CHF, CKD, BPH here from rehab facility with hypoxia following a suspected aspiration event. Since a recent hospitalization for Group B strep bacteremia he has been having some difficulty swallowing, especially with fluids. At dinnertime, had a coughing episode, followed by increased difficulty breathing. He was put on oxygen by the rehab staff. When his son came to visit him, he decided to call an ambulance because the patient looked quite uncomfortable. En route to ED, BPs were low, so EMTs decided to stop at [Hospital1 ]. On arrival to the [Hospital1 ] [Location (un) 620] ED, vitals were 97.9 111 75/40 40 80%. Sats down to the the 70s, so he was intubated. Had been DNR/DNI, but the son felt that this was an acute event that would not require long-term intubation, so he asked his father if he would be okay with intubation and the patient consented. IVF were running and levophed started. He had venous and arterial femoral lines placed. He was given Flagyl, Zosyn and 5L IV fluid. Transferred to [Hospital1 18] by family request. On the floor, patient was intubated and sedated and unable to provide further history. Past Medical History: - Group B strep bacteremia, admitted to [Hospital1 18] from [3-21] to [4-7]. - malnutrition - sacral decubitus ulcer - IDDM w/ assoc. retinopathy - BPH - hyperlipidemia - GERD - L3-4 spinal stenosis with L foot drop and numbness - HTN - COPD - CKD - CHF - cholecystitis Social History: Before admission was at a rehab facility. Has 1 son who is very involved in his care. - Tobacco: has not smoked for 50 yrs; previouly heavy smoker - etOH: none - Illicits: none Family History: father died of mi at 52 mother died of diabetes related illness Physical Exam: VS: 95.4 P 89 114/46 General: Intubated, sedated, unresponsive HEENT: Sclera anicteric, pupils pinpoint but reactive, ET tube in place. Lungs: Diffusely rhoncorus, fair air movement CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present GU: foley in place. Sacral decubitus ulcers Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on Admission ================== WBC-29.4* RBC-3.05* Hgb-9.6* Hct-31.0* Plt Ct-412 -------- Neuts-67 Bands-24* Lymphs-3* Monos-4 Eos-0 Baso-0 [2112-5-23] PT-14.9* PTT-36.7* INR(PT)-1.3* pO2-271* pCO2-37 pH-7.19* calTCO2-15* Intubat-INTUBATED Vent-CONTROLLED Glucose-146* Lactate-1.3 Na-146 K-3.9 Cl-121* CHEST X-RAY IMPRESSION: Possible small right pleural effusion. No overt abnormalities including no definite pneumonia. CT Head IMPRESSION: No acute intracranial process. Brief Hospital Course: [Age over 90 ]yo male w/ COPD and CHF, DM1 admitted to the ICU with hypoxic respiratory failure. # Hypoxic respiratory failure: Related to severe sepsis with severe bandemia and elevated lactate. Posibly due to an aspiration pneumonia.CXR was consistent with a pneumonia. Antibiotic coverage for HCAP/aspiration with Vancomycin and Zosyn was continued from OSH. . # Hypotension: Patient remained on norephinephrine for pressure support until family decided to withdraw support. . # Acute kidney injury/oliguria: Most likely pre-renal etiology. Elevated Creatine suggests he had been ill for longer than the recent aspiration event. # Decubitus ulcers: from immobilization and poor nutritional status Discussed poor prognosis given current infection and comorbidities with the patient's son and daughter. They expressed their father would not want prolonged life support. [Doctor Last Name 1060], the daughter, wanted to come and see her father prior to withdraw life sustaining support. Antibiotics, pressors, and mechanical ventilation were continued until daughter arrived. When both son and daughter were at bedside, the decision was confirm to withdraw life support. He was extubated and the norepinephrine drip stopped. He was declared dead at 1:25am on [2112-5-25]. Medications on Admission: Started at OSH: - Norepinephrine - Flagyl - Zosyn At home: - Advair 250/50 one puff [Hospital1 ] - finasteride 5mg daily - lansoprazole 30mg daily - lovenox 30mg daily - multivitamin one tab daily - insulin aspart sliding scale starting >200 with 2 units - remeron 7.5mg QHS - senna 17.2mg [Hospital1 ] - tylenol 650mg TID - vicodin one tab PRN dressing change - vicodin one tab Q4hrs PRN - vitamin D 1000 units daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Respiratory Failure Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "250.50", "482.9", "585.9", "707.03", "362.01", "041.6", "599.0", "507.0", "707.25", "584.9", "041.12", "038.9", "600.00", "496", "428.0", "518.81", "995.92" ]	icd9cm	[ [ [] ] ]	[ "96.71" ]	icd9pcs	[ [ [] ] ]	4883, 4892	3089, 4377	304, 310	4955, 4964	2578, 3066	5016, 5158	2046, 2111		4855, 4860		4913, 4934		4403, 4832			4988, 4993								2126, 2559																						219, 266											338, 1525																	1547, 1832	1848, 2030
28,270	153,773	34305	Discharge summary	report	Admission Date: [2189-11-17] Discharge Date: [2189-11-23] Date of Birth: [2135-7-8] Sex: F Service: MEDICINE Allergies: Dilaudid (PF) / Epogen / Sudafed / Doxycycline Attending:[First Name3 (LF) 443] Chief Complaint: chest pain, shortness of breath Major Surgical or Invasive Procedure: cardiac catheterization hemodialysis History of Present Illness: This is a 54 yo female with h/o ESRD on HD, DM2, CAD s/p stents x 8 at [Hospital1 112], severe AS, now healed ulcer of RLE [1-6] calciphylaxis recently admitted [9-/2189] with altered mental status now admitted with substernal CP. Pt developed R sided chest pain today radiating to R neck toward end of HD session a/w nausea diaphoresis, SOB and was similar to prior MI. Pain felt like a pressure, like "someone was sitting on my chest." Also complains of neck pain since saturday. Has never had neck pain before, and since Saturday has had neck pain radiating to both shoulders. Not tender to palpation at neck, shoudlers, or chest. Pain improved to [4-13] with nitro x 2. In ambulance, had STE 1mm, now resolved, on arrival to ED. . In the ED, she received ASA 325. CXR neg. On exam, pt obese, abd benign. ECG showed NSR with TWI. She was started on heparin drip. Developed hypotension with nitro gtt, dropped to 90s systolic. Vs prior to transfer: 80 18 98%1LNC 148/46. . On arrival to floor, she is chest pain free, no shortness of breath. Only complains of shoulder and [Last Name (un) 78953] pain that has been consistent since Friday. No chest pain, sob, nausea or other complaints. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . In the ED, initial vitals were 86 96/42 . He was started on nitroglycerin and heparin drips. Past Medical History: - ESRD on HD, on HD since [2188-8-5] (intiated during admission to MICU at [Hospital1 756]) - CAD - reports 8 stents in place in [2188-9-4] plus MI >20 yrs ago -Severe AS- [Location (un) 109] 0.8-1.0 cm2 - DM x >20 years w/ neuropathy - Pyoderma gangrenosum - HTN - CVA (by imaging, not recognized and no residual deficits) - GERD not currently active. - Morbid obesity - Bacteremia in [April 2189], treated with ampicillin/gentamycin then clindamycin - chronic ulcer of RLE with biopsy at [Hospital1 756] c/w calciphylaxis now healed s/p sodium thiosulfate - depression Social History: Patient was a secretary at [Hospital1 112] but has been disabled since [2182]. Lives with her son who is 35 yo. Walked with a cane and walked for 30minutes recently with 1 stop to rest. Does not smoke or drink significant EtOH. Family History: Parents with DM2. Physical Exam: On admission: VS: 97.9 197/86 81 18 100% 2L GENERAL: WDWN F 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 5 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. III/VI systolic murmur best heard at RUSB. 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. decreased breath sounds at bases. 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+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ On dishcharge: VS: 98.2 124/96 (94-124/40-96) 85 18 94% RA GENERAL: Morbidly Obese in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: JVP could not be appreciated due to obese neck. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. III/VI systolic murmur best heard at RUSB. No thrills, lifts. No S3 or S4. LUNGS: CTAB, no crackles, wheezes or rhonchi. Decreased breath sounds at bases. ABDOMEN: Soft, NTND. +BS EXTREMITIES: No c/c/e, L ankle-ttp at punctate lesion, no erythema, no fluctuance SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 2+ DP bil Pertinent Results: [2189-11-17] 11:25PM CK(CPK)-129 [2189-11-17] 11:25PM CK-MB-4 cTropnT-0.04* [2189-11-17] 11:25PM PT-14.3* PTT-116.3* INR(PT)-1.2* [2189-11-17] 03:10PM GLUCOSE-124* UREA N-35* CREAT-4.9* SODIUM-140 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-29 ANION GAP-17 [2189-11-17] 03:10PM CK(CPK)-154 [2189-11-17] 03:10PM cTropnT-0.03* [2189-11-17] 03:10PM CK-MB-4 [2189-11-17] 03:10PM WBC-9.2 RBC-4.04* HGB-12.4 HCT-38.2 MCV-94 MCH-30.6 MCHC-32.4 RDW-14.2 [2189-11-17] 03:10PM PLT COUNT-256 TTE [2189-11-19] The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets are severely thickened/deformed. There is moderate-to-severe aortic valve stenosis (valve area 0.9 cm2). Mild to moderate ([12-6]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Cardiac cath [2189-11-20]: 1. No angiographicall-apparent high grade flow-limiting CAD, with mild-diffuse in-stent restenosis of the LAD and RCA. 2. Mildly elevated PCW consistent with mild left ventricular diastolic dysfunction. 3. Mild pulmonary arterial hypertension. 4. Peripheral arterial disease. Brief Hospital Course: 54 yo female with h/o ESRD on HD, DM2, CAD s/p stents x 8 at [Hospital1 112], severe AS, now healed ulcer of RLE [1-6] calciphylaxis presented initially with substernal CP, elevated trop, CK/MB wnl, likely from worsening AS . # Chest pain/Aortic stenosis: Chest pain initially was concerning for ACS vs demand ischemia in the setting of dialysis and severe AS. She was noted to have EKG changes prior to arrival to hospital, but had no elevation in enzymes. Considering her cardiac history, she was treated with heparin gtt for concern for unstable angina and home plavix, aspirin, bb, and statin were continued. Outpatient cardiologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital1 112], was contact[Name (NI) ] who recommended not repeating cardiac cath considering she had had [7-15] stents already in place and caths prior. She had a second episode of chest pain the day after admission, which worsened during dialysis, with no EKG change and no elevation of enzymes, medical management was continued. Echo was done that day which showed severe AS with valve area 0.9 cm2. . She was taken back to dialysis the following day for ultrafiltration, since she was above her dry weight. During that dialysis session, she complained of chest pain and became unresponsive and code blue was called. Throughout the episode, she remained normotensive with a strong pulse and in NSR on telemetry. EKG showed noted to have STE in V2-V4. She was treated with a 500cc bolus of IVNS with improvment in mental status. She was taken to the cath lab where she was noted to have patent stents and no occlusive coronary disease. She was then transferred to CCU for further management, see below for details. Unresponsiveness and chest pain during this incident were thought to be due to reduced preload in the setting of AS. . After transfer back to the cardiology floor, amlodipine and imdur were discontinued in the setting of systolic BPs in the 90s-100s to maintain preload and agressive ultrafiltration during dialysis was avoided. Imdur and amlodipine were held on discharge. She is discharged with a referral to Csurg here, or may follow up with a cardiac surgeon at [Hospital1 112] for eventual AVR. . # CCU Course: Patient was admitted to the CCU for one day of observation following a period of unresponsiveness at dialysis. On review of the events prior to the episode of unresponsiveness, it was noted that 3L had been dialyzed prior to the event. This reduction in preload in a patient with moderate to severe AS is believed to have resulted in cerebral underperfusion angina and reversible changes on EKG. After a one day admission to the CCU, the patient was returned to the general medical floor. . # PUMP: Appeared euvolemic on exam, EF 70% with normal systolic function. Severe AS as described above, which was likely contributing to chest pain in the setting of demand ischemia, worsening with volume changes. . # RHYTHM: Was monitored on tele, remained in sinus. . # ESRD on HD: Patient on HD TTS. Cinacalcet was discontinued for chronically low calcium; continued nephrocaps, sevelamer. Agressive ultrafiltration was avoided in order to maintain adequate preload with her aortic stenosis. . # DM: FS QID and home insulin regimen continued . # HTN: continued labetalol, lisinopril; amlodipine was discontinued to maintain adequate preload as above. . # Depression: Continue citalopram and was seen by social work for help with coping with frequent admissions. . #. Anemia: Secondary to CKD. Epo was continued with HD. Medications on Admission: 1. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 5. citalopram 20 mg Tablet Sig: One (1) Tablet PO BID 6. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID with meals 9. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS 12. insulin glargine 100 unit/mL Solution Sig: Eight (8) units daily 13. Novolog 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous three times a day. 14. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS prn 15. lisinopril 2.5 mg daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. citalopram 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. insulin glargine 100 unit/mL Solution Sig: Eight (8) units Subcutaneous once a day. 10. Novolog 100 unit/mL Solution Sig: As directed Subcutaneous three times a day: Take as directed according to sliding scale. 11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 12. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:180 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary diagnosis: Unstable angina Secondary diagnosis: Diabetes Mellitus End stage renal disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were seen in the hospital for chest pain, which was most likely due to your aortic stenosis (disease of the aortic valve in your heart). Bloodwork and EKG did not show evidence of a heart attack and your chest pain resolved with morphine and nitroglycerin. If these symptoms occur again, please call your doctor or come to the emergency room. Your aortic valve will most likely need to be replaced and we have referred you to Dr. [First Name (STitle) ], a cardiac surgeon at [Hospital1 ] for an appointment as below. Changes to your medications: STOP taking amlodipine STOP taking imdur STOP taking cinacalcet INCREASE sevelamer to 800 mg three times a day with meals Followup Instructions: Cardiac surgery: You may schedule an appointment with Dr. [First Name (STitle) ], at [Hospital1 ], for aortic valve surgery by calling [Telephone/Fax (1) 170] this week, or with another cardiac surgeon as recommended by Dr. [First Name (STitle) ]. Name: [Last Name (LF) ], [Name8 (MD) ] MD Specialty: INTERNAL MEDICINE Address: [Doctor First Name ], [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 9251] Appointment: Wednesday [11-25] at 10:00AM This appointment is with a member of Dr [Last Name (STitle) 78954] team as part of your transition from the hospital back to your primary care provider. [Name10 (NameIs) 616] this visit, you will see your regular primary care provider. Name: [Last Name (LF) ],[First Name7 (NamePattern1) 2295] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Specialty: Cardiology Address: [Doctor First Name ], [Location (un) ],[Numeric Identifier 6425] Phone: [Telephone/Fax (1) 78955] We are working on a follow up appointment with Dr. [First Name (STitle) ] within a few weeks. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above. Department: ADVANCED VASC. CARE CNT When: WEDNESDAY [2189-12-16] at 9:00 AM 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 Completed by:[2189-11-23]	[ "424.1", "414.01", "V45.82", "403.91", "585.6", "428.0", "357.2", "285.21", "411.1", "278.01", "250.60", "428.33", "V58.67" ]	icd9cm	[ [ [] ] ]	[ "88.56", "39.95", "37.23" ]	icd9pcs	[ [ [] ] ]	12335, 12392	6678, 10278	339, 377	12534, 12534	4788, 6654	13426, 15054	3144, 3163		11326, 12312		12413, 12413		10304, 11303			12717, 13250								3178, 3178																		13279, 13403				268, 301											405, 2254				12469, 12513			12432, 12448		3192, 4769		12549, 12693						2276, 2874	2890, 3128
30,868	196,214	32255	Discharge summary	report	Admission Date: [2164-2-17] Discharge Date: [2164-2-25] Date of Birth: [2100-1-19] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5341] Chief Complaint: DVT found at OSH Major Surgical or Invasive Procedure: none History of Present Illness: This is a 64 year old male with h/o GBM (s/p craniotomy [2163-12-20], [2-19] way through treatment) transferred to [Hospital1 18] for DVT, found to have PE in [Hospital ] transferred to MICU for monitoring. He had complained of progressive SOB and LLE swelling x 2 weeks. He has also had a non-productive cough; denies pleuritic chest pain but does have substernal pain when he coughs. No hemoptysis; no fever or chills. This morning Rad Onc from [Hospital3 3765] was concerned that the patient had a DVT. His SpO2 was low, 84%RA. Dopplers confirmed LLE DVT. Head CT was negative for bleeding. Dr. [Last Name (STitle) 4253] was called and accepted transfer to [Hospital1 18] ED. Per report, she recommended 1000U IV heparin gtt without a bolus. In our ED, vitals were T 99.1 P 82 BP 104/68 RR 20 SpO2 90% on 4L NC. Neurosurgery was called. He was admitted to the MICU for his hypoxia. Past Medical History: GBM s/p craniotomy for tumor resection on [2163-12-23] - initially with sx of depression in [11-23], then gait unsteadiness lead to dx. residual mild left-sided weakness. multifocal right frontal lesions, larger lesion removed. seen by Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 4253]. Started on temodar and XRT. Hypercholesterolemia Elevated PSA noted [2163-6-17]--elected watchful waiting, unclear if had [Name (NI) ] All: NKDA Social History: He was a financial consultant (took a leave of absence in the end of [11-18] trouble driving). Lives with wife and 16 y/o daughter after course in rehab. One daughter in college, 2 grown children live in the area. No tobacco, occ wine with dinner. Family History: Brother with DVT and PE (has elevated PSA), no FH of stroke, seizure, CAD, or cancer Physical Exam: T: 98.3 BP: 111/68 HR:79 R:25 O2Sats: 95% on 5L NC Gen: Comfortable, pleasant, short of breath with talking but able to speak in complete sentences. HEENT: PERRL, EOMI, OP clear, MMM Neck: Supple. Cardiac: S1, S2, RRR, no murmur Lungs: Not using accessory muscles, crackles at bases b/l; takes short, truncated breaths Abd: +BS, soft, NT, ND Ext: no edema on right LE; 2+ LLE pitting edema to knee; no palpable cord in left calf; DP +2 b/l Neuro: Alert and oriented x 3; delayed but appropriate responses with conversation; no dysarthria or inappropriate word choice . CN: I: Not tested II: PERRL III, IV, VI: EOMI, no nystagmus V: sensation intact b/l VII: facial movements symmetric VIII: hearing grossly intact IX, X, XII: tongue midline, palate symmetrically elevated [Doctor First Name 81]: SCM and trapezius [5-21] b/l . Motor: Normal bulk b/l; +tremor of LLE Strength 5/5 in proximal muscles of UE and LE b/l. Hand grip on left slightly decreased (4+), otherwise distal UE strength intact. No pronator drift, no orbiting. Strength in distal LLE 5-/5 and RLE [5-21]. . Sensation: Grossly intact to light touch throughout . Reflexes: +2 at biceps brachii and brachioradialis b/l +2 at right knee; difficult to elicit in left knee. Toes downgoing bilaterally. + clonus in LLE. . Coordination: normal finger-nose-finger b/l. No difficulty with rapid alternating movements in hands. Normal heel to shin b/l. Pertinent Results: [2164-2-16] 09:21PM BLOOD WBC-5.5 RBC-4.43* Hgb-13.5* Hct-38.8* MCV-88 MCH-30.4 MCHC-34.7 RDW-15.7* Plt Ct-204 [2164-2-17] 09:32AM BLOOD WBC-5.7 RBC-3.93* Hgb-11.8* Hct-35.2* MCV-90 MCH-30.1 MCHC-33.6 RDW-15.5 Plt Ct-250 [2164-2-16] 09:21PM BLOOD PT-13.2 PTT-59.1* INR(PT)-1.1 [2164-2-16] 09:21PM BLOOD Glucose-126* UreaN-15 Creat-0.9 Na-140 K-3.3 Cl-103 HCO3-29 AnGap-11 [2164-2-16] 09:21PM BLOOD CK(CPK)-28* [2164-2-16] 09:21PM BLOOD cTropnT-0.04* CTA Chest: 1. Acute pulmonary embolism involving both distal main pulmonary arteries with extension into segmental branches of all pulmonary lobes. Prominence of the right ventricle suggests right heart strain for which further evaluation with echocardiography is suggested. 2. Fatty liver. These findings were immediately discussed with Dr. [First Name8 (NamePattern2) 4320] [Last Name (NamePattern1) 75406] of the emergency room at 10:20 p.m. [2164-2-16] at which time an ER dashboard wet read was placed. EKG [2-16]: NSR @ 77, nl axis/intervals. grossly unchanged from [12-23]. . MR BRAIN: MPRESSION: Since [2163-12-24], increase in size of the enhancing mass involving the right centrum semiovale and possible minimal increase in size of a 0.4-cm lesion more inferiorly involving the right frontal/insular region. Marginal enhancement around the high right frontal resection cavity with improvement in surrounding edema. T2 hyperintensities involving the corpus callosum and the frontal lobe white matter bilaterally which likely represents combination of edema and tumor. Brief Hospital Course: 64 y/o male with GBM and new large DVT/PE, started on heparin drip and transferred from MICU to floor on supplemental oxygen, discharged on room air on lovenox. . HOSPITAL COURSE BY PROBLEM: . # DVT/PE and hypoxia -- clots likely [2-18] cancer. Brother w/ h/o of PE in setting of marathon and long flight, no other h/o hematologic disorders. CEs and EKG within normal limits. Improved oxygenation on heparin gtt with PTT goal 60-80 given brain met, 98% on RA on discharge. Lovenox started [2-23] and patient received teaching. He will have a VNA on discharge to ensure correct injection administartion and adequate oxygen saturation. His LE edema improved and he was ambulating well on room air at discharge. . # Glioblastoma multiforme: s/p neurosurgical resection of one tumor and started radiation for other lesion at outpt rad onc, now on hold since hospitalized. Chemotherapy per Dr. [Last Name (STitle) 4253] and he was restarted on Temodar, to finish with completion of radiation. He had some proximal lower extremity weakness on neurologic exam but otherwise no focal findings. He was continued on dexamethasone which may be tapered after completion of radiation. He was started on a PPI. He will receive cyberknife therapy as outpatient. Repeat MRI w/o significant e/o tumor recurrence. . # H/A: ?[2-18] edema versus hypoxia. Pt agreed to restarting dexamethasone. H/A also potentially related to increased hypoxia overnight but improved on discharge. . # Fatigue: likely [2-18] chemotherapy and worsened by hypoxia. Pt was started on provigil. Rital deferred [2-18] PE and potential right hear strain. . # Dyslipidemia - continued crestor . # Code: Full (confirmed with patient) Medications on Admission: Keppra 500 mg two tablets twice a day. Famotidine 20 mg twice a day. Dolasetron 100 mg QHS. Temodar 140 mg once a day. Crestor 5 mg once a day. Multivitamin one tablet a day. Senna Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [1-18] Tablet, Rapid Dissolves PO Q8H (every 8 hours) as needed for nausea. Disp:10 Tablet, Rapid Dissolve(s) Refills:0 6. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): ween as instructed by Dr. [Last Name (STitle) 4253]. Disp:90 Tablet(s) Refills:2 7. Modafinil 100 mg Tablet Sig: One (1) Tablet PO daily (). Disp:30 Tablet(s) Refills:2 8. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous twice a day. Disp:60 syringes Refills:12 9. Temodar 140 mg Capsule Sig: One (1) Capsule PO once a day for 3 days. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: PRIMARY: pulmonary embolus deep venous thrombosis SECONDARY: Glioblastoma multiforme Hyperlipidemia Discharge Condition: O2 sat: 96% on RA Discharge Instructions: You were admitted with shortness of breath and left leg pain and were found to have a DVT (deep venous thrombosis) and PE (pulmonary embolus) that likely arouse from the clot in your leg. You received blood thinners to treat this. You may have a propensity towards forming clots because of your cancer. You will need to be on life-long anticoagulation (blood thinners). You were started on Lovenox injections twice a day . You were maintained on supplemental oxygen and then were oxygenating well on room air. . Regarding your cancer, you were restarted on your chemotherapy and radiation regimen and will finish your chemotherapy medication on Tuesday and will have they cyberknife radiation tuesday as well. You had an MRI of the brain to stage your cancer that showed normal changes consistent with your tumor and treatments. . Please take all medications as prescribed. You were also started on provigil, a medication which will help your energy while you are receiving therapy. You are receiving steroids (dexamethasone) for now and this will be tapered through the radiation oncologist and Dr. [Last Name (STitle) 4253]. Please do not stop this abruptly. . If you develop any concerning [Last Name (STitle) ] such as persistent fevers, headache, dizzyness, weakness, balance difficulties, shortness of breath or chest pain, please call your physician or proceed to the emergency department. Followup Instructions: Please call your primary care physician to schedule [Name9 (PRE) 702] within 1-2 weeks [Telephone/Fax (1) ] . Provider: [Name10 (NameIs) 5005] [Last Name (NamePattern4) 5342], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2164-3-19] 1:00	[ "453.42", "415.19", "272.0", "342.90", "191.1" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8139, 8188	5239, 5402	333, 340	8332, 8352	3637, 5216	9811, 10073	2082, 2168		7191, 8116		8209, 8311		6986, 7168			8376, 9788								2183, 3618																						277, 295								5430, 6960			368, 1299																	1321, 1794	1810, 2066
45,176	186,422	9212	Discharge summary	report	Admission Date: [2117-10-1] Discharge Date: [2117-10-4] Date of Birth: [2055-5-23] Sex: M Service: MEDICINE Allergies: Egg Attending:[First Name3 (LF) 13256] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: - History of Present Illness: This is a 62 year old male with h/o NASH cirrhosis and esophogeal varices s/p banding, CAD s/p stenting on ASA and plavix, and IDDM who presented for the 3rd time in one week to primary care clinic reporting one episode of blood tinged sputum and 3 episodes of confusion. On Friday evening he had difficutly finding words, and with fine motor activity like putting on his watch. His FS was 150 during the episode (although the symptoms improved after eating cereal). He denies focal weakness or loss of sensation. On Tuesday he again had an episode of confusion. This time he could speak clearly, and again his BS has not low. The wife notes that he has intermittently been "slightly off" this week, with difficulty remembering things and finding items. Labs revealed a stable HCT at 38, and no focal findings. . Last evening he again had confusion, described as difficulty using his glucometer. He then developed nausea and vomitted what he described as 2 cups of red blood. He denies abd pain, change in abd girth, melena, or BRBPR. He has continued to have his baseline [12-30] BMs daily (including today) and reports normal brown stool. . In the ED, inital VS: T=98.2, HR=61, BP=136/68, RR=18, POx=98% RA. He was noted to have guaiac positive brown stool and 2 PIVs (18g and 20g). NG lavage was clear. On transfer, his vitals were BP=137/59, HR=77, RR=17, POx=100% RA. . In the MICU, he further described his episodes of confusion as lasting a few minutes before coming back to baseline. He had similar episodes of this in [Month (only) 956] which was attributed to a neuro etiology. He is currently back to his baseline mental status and has been HD stable since arrival. He does describe intense hand shaking during his episodes of confusion. Past Medical History: CAD: CABG [2103], stenting in [2106], [2109]? Cards Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7389] NEBH. Per him needs plavix for life NASH cirrhosis: followed by Dr [Last Name (STitle) ], c/w esophogeal varices (no prior bleeding), s/p banding (persumed given his anticoagulation). Distant h/o ascites. No encephalopathy. DM II on insulin with frequent episodes of hypoglycemia in the past. TIA [1-6] followed by Dr [Last Name (STitle) ] Squamous cell carcinoma HTN HL Social History: Social History: He works as a plumber for [Company 31653]. He was a heavy smoker, but quit many years ago. He has not drunk in many years. He says he was a heavy drinker as a teenager, but not since that time. No illicit drug use. He is married and his wife is present with him today. . Family History: Family History: He has got a brother with asthma. Mom with diabetes and breast cancer, sister who had a heart attack in stroke in her 50s and father who died of stomach cancer at age 63. Physical Exam: GEN: NAD HEENT: red conjuctiva, non icteric Neck: no JVD Lungs: CTA BL CV: RRR, no m/r/g Abd: ND/NT, + BS, no ascites Ext: no edema Rectal: thin brown liquid, guaiac positive Neuro: no [Company 31654], CN intact, 5/5 strength, nl sensaiton, 2+ DTRS, normal F to N. Difficulty with spelling WORLD backwards and serial 7s. However, oriented x3. Pertinent Results: [2117-10-1] 04:45PM BLOOD WBC-7.6 RBC-4.23* Hgb-14.0 Hct-41.8 MCV-99* MCH-33.1* MCHC-33.5 RDW-12.9 Plt Ct-136* [2117-10-2] 06:08AM BLOOD WBC-5.7 RBC-3.83* Hgb-12.8* Hct-37.9* MCV-99* MCH-33.5* MCHC-33.9 RDW-12.9 Plt Ct-104* [2117-10-3] 05:35AM BLOOD WBC-7.0 RBC-4.09* Hgb-13.8* Hct-39.0* MCV-95 MCH-33.7* MCHC-35.4* RDW-12.9 Plt Ct-89* [2117-10-4] 06:10AM BLOOD WBC-6.3 RBC-3.81* Hgb-12.5* Hct-37.1* MCV-97 MCH-32.7* MCHC-33.6 RDW-12.6 Plt Ct-88* . [2117-10-1] 04:45PM BLOOD Neuts-57.2 Lymphs-21.6 Monos-8.1 Eos-11.5* Baso-1.6 [2117-10-3] 05:35AM BLOOD Neuts-73.9* Lymphs-14.1* Monos-6.1 Eos-5.3* Baso-0.7 . [2117-10-1] 04:45PM BLOOD PT-13.6* PTT-24.9 INR(PT)-1.2* [2117-10-2] 06:08AM BLOOD PT-14.5* PTT-26.7 INR(PT)-1.3* [2117-10-3] 05:35AM BLOOD PT-14.0* PTT-26.8 INR(PT)-1.2* [2117-10-4] 06:10AM BLOOD PT-13.6* INR(PT)-1.2* . [2117-10-1] 04:45PM BLOOD Glucose-132* UreaN-21* Creat-1.3* Na-133 K-4.6 Cl-103 HCO3-20* AnGap-15 [2117-10-2] 06:08AM BLOOD Glucose-128* UreaN-19 Creat-1.0 Na-137 K-4.5 Cl-107 HCO3-19* AnGap-16 [2117-10-3] 05:35AM BLOOD Glucose-91 UreaN-20 Creat-1.0 Na-134 K-4.3 Cl-105 HCO3-18* AnGap-15 [2117-10-4] 06:10AM BLOOD Glucose-110* UreaN-23* Creat-1.1 Na-134 K-4.4 Cl-102 HCO3-23 AnGap-13 . [2117-10-1] 04:45PM BLOOD ALT-41* AST-41* AlkPhos-87 TotBili-0.9 [2117-10-2] 06:08AM BLOOD ALT-34 AST-37 LD(LDH)-205 AlkPhos-74 TotBili-1.2 [2117-10-3] 05:35AM BLOOD ALT-34 AST-41* AlkPhos-79 TotBili-1.0 [2117-10-4] 06:10AM BLOOD ALT-37 AST-39 AlkPhos-75 TotBili-0.6 . [2117-10-2] 06:08AM BLOOD Albumin-3.6 Calcium-8.9 Phos-4.1 Mg-2.0 [2117-10-3] 05:35AM BLOOD Albumin-3.7 Calcium-8.8 Phos-4.3 Mg-1.9 [2117-10-4] 06:10AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.0 . [2117-10-1] 04:45PM BLOOD Ammonia-109* . [2117-10-1] 05:09PM BLOOD Glucose-129* Lactate-1.1 K-4.6 [2117-10-1] 05:09PM BLOOD Hgb-14.1 calcHCT-42 . [2117-10-1] 04:45PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.009 [2117-10-1] 04:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.0 Leuks-NEG . Cardiology Report ECG Study Date of [2117-10-1] 7:13:44 PM Sinus rhythm. Normal tracing. Compared to the previous tracing of [2117-1-12] no significant change. Read by: [Last Name (LF) ],[First Name3 (LF) ] P. Intervals Axes Rate PR QRS QT/QTc P QRS T 66 150 92 [Telephone/Fax (2) 31655] 52 . EGD [2117-10-4] Findings: Esophagus: Other Scarring from prior variceal banding in lower third of esophagus. Stomach Mucosa: Patchy granularity, friability, erythema and congestion of the mucosa with contact bleeding were noted in the antrum. These findings are compatible with portal hypertensive gastropathy. Duodenum: Other Benign-appearing nodule in the duodenal bulb. Impression: Scarring from prior variceal banding in lower third of esophagus. Granularity, friability, erythema and congestion in the antrum compatible with portal hypertensive gastropathy Benign-appearing nodule in the duodenal bulb. Otherwise normal EGD to third part of the duodenum Brief Hospital Course: This is a 62 year old male with h/o NASH cirrhosis and esophogeal varices s/p banding, CAD s/p stenting on ASA and plavix, and IDDM who presented for the 3rd time in one week to primary care clinic reporting one episode of hematemesis and 3 episodes of confusion, admitted with concern for acute GIB w hx of known varices. . #. Hematemesis: Pt reports 1 episode of nausea and vomiting on Thursday prior to admission. He reports bright red contents in vomitus and was concerned about blood however admits that it could have been food particles (pt eats 1 tomato daily) and was encephalopathic at the time. The episode was unwitnessed by his wife who reports that on later inspection of some contents of the vomit, was positive for tomato skins. Pt was seen by his PCP who found him to be guaiac positive, reconfirmed in ED on presentation. NGT lavage negative. He was admitted to MICU for observation and r/o GIB. Pt did not have any additional vomiting, nausea. His Hct was stable and at baseline. Variceal bleed was always on the differential, but much less likely given unchanged vital signs, negative lavage, and no melena. Serial Hct were stable. Aspirin and Plavix were held for EGD on [2117-10-4]. EGD findings positive for portal gastropathy and friable mucosa. Scarring from variceal banding present - no other abnormalities present to suggest active UGIB. Pt was uptitrated on home PPI and restarted on home asa and plavix therapy given cardiac/TID history. . #. Hepatic Encephalopathy. The patient has never been diagnosed with hepatic encephalopathy in the past. He described typical symptoms of HE with confusion and [Date Range 31654] in the setting of known cirrhosis. He has had an extensive work-up by neurology which has been unrevealing. His ammonia level on admission was 109. Lactulose was started and titrated to [1-28] BMs/day. Pt's confusion improved and on transfer to hepatology was at baseline MS [First Name (Titles) ] [Last Name (Titles) 31654]. Pt was discharged on lactulose. He was instructed to stop driving. Liver follow up with Dr. [Last Name (STitle) 10924]. . #. NASH cirrhosis: LFTs normal. Nadolol, lasix, spironolactone were continued. . #. HTN. Continued home regimen given low likelihood for bleed. . #. HLD. Continued home Lipitor. . #. CAD: Home asa and plavix held for dx of possible acute UGIB however pt Hct stable and EGD findings negative. He was restarted on home regimen and uptitrated ppi. Medications on Admission: -atorvastatin 20 mg daily -clopidogrel 75 mg daily -ezetimibe 10 mg daily -folic acid 1 mg daily -furosemide 20 mg daily -Novolog Mix 70-30; 32u am, 28 u pm once a day -lisinopril 2.5 mg dailiy -nadolol 20 mg daily -nitroglycerin 0.1 mg/hour Patch Daily -pantoprazole [Protonix] 40 mg daily -spironolactone 50 mg daily -aspirin 325 mg once a day -coenzyme Q10 50 mg once a day -cyanocobalamin 500 mcg by mouth daily -ferrous sulfate 325mg daily Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 10. nitroglycerin 0.1 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours). 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 12. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q 8H (Every 8 Hours) as needed for constipation: please take this medication until you have 3 bowel movements per day. Disp:qs ML(s) Refills:0 13. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Thirty Two (32) units Subcutaneous qAM. 14. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: 28 units Subcutaneous qPM. 15. coenzyme Q10 50 mg Capsule Sig: One (1) Capsule PO once a day. 16. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. 17. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Hepatic encephalopathy portal gastropathy 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 complaints of 1 week of intermittent confusion and 1 episode of vomiting concerning for blood and possible internal GI bleed. You were admitted to the medical ICU for monitoring. You did not have any additional vomiting while in hospital. Your blood levels were stable and you did not require any acute interventions. Your aspirin and plavix were held prior to the endoscopy study. You were transferred to the liver service and taken for endoscopy on Monday [2117-10-4] which showed irritation of your stomach lining related to your liver disease, called portal gastropathy. This is the likely cause of the small blood detected in your stool and on rectal exam. You will need to continue your antiacid medication to avoid further irritation of your stomach lining. You cannot drive or operate heavy machinery until your Dr. [Last Name (STitle) ] clears you. . The following changes were made to your medications: INCREASED Pantoprazole to decrease ulcers and potential bleeding in your stomach. This dose may be decreased by your PCP/Liver doctor based on your exam findings. STARTED Lactulose 30mg, three times daily or until you have 3 bowel movements per day RESTART your aspirin and plavix. . Please follow up with your physicians as stated below. Followup Instructions: Department: NEUROLOGY When: TUESDAY [2117-10-12] at 4:30 PM With: [Name6 (MD) 4267] [Last Name (NamePattern4) 4268], MD, PHD [Telephone/Fax (1) 657] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: FRIDAY [2117-10-15] at 2:10 PM With: [First Name8 (NamePattern2) 640] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ENDO SUITES When: WEDNESDAY [2117-10-27] at 10:00 AM Department: DIGESTIVE DISEASE CENTER When: WEDNESDAY [2117-10-27] at 10:00 AM With: [Name6 (MD) ] [Last Name (NamePattern4) 2424], MD [Telephone/Fax (1) 463] Building: [First Name8 (NamePattern2) ] [Hospital Ward Name 1950] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 3202] Campus: EAST Best Parking: Main Garage	[ "787.01", "571.5", "414.01", "537.89", "V45.82", "250.00", "571.8", "401.9", "V58.67", "572.2", "272.4" ]	icd9cm	[ [ [] ] ]	[ "45.13" ]	icd9pcs	[ [ [] ] ]	11107, 11113	6644, 9117	276, 279	11199, 11199	3508, 6621	12673, 13773	2952, 3125		9613, 11084		11134, 11178		9143, 9590			11350, 12650								3140, 3489																						226, 238											307, 2066											11214, 11326						2088, 2610	2642, 2920
59,200	175,653	55139	Discharge summary	report	Admission Date: [2107-9-15] Discharge Date: [2107-10-19] Date of Birth: [2080-10-27] Sex: M Service: MEDICINE Allergies: Zosyn Attending:[First Name3 (LF) 3958] Chief Complaint: Pancytopenia Major Surgical or Invasive Procedure: Intrathecal chemotherapy Bone marrow biopsy PICC line History of Present Illness: 26M w/ no PMHx presents with fatigue. Started a month ago, progressively worsened. Occasionally has had fever at night of up to 100.4. Reports that he has profound exertional dyspnea and fatigue, with very decreased exercise tolerance. Scraped left leg two weeks ago, developed cellulitis, has been on Bactrim and Augmentin x 8 days. Yesterday developed lines in his left eye vision, PCP found retinal hemorrhages and pancytopenia. Sent to [Hospital1 ], received 2U pRBCs, transferred here for platelets. No nausea/vomiting, CP, abd pain, epistaxis, hematuria, blood in stool, rashes. Initial VS in the ED: 99.2 92 126/76 16 100%. Exam notable for bilateral retinal hemorrhages. Labs notable for leukopenia to 2.2 with only 7% PMNs, Hct 15, and platelets 6. Patient was given 2 units pRBCs and 1 unit of platelets. HCT went down, Cr went up. Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. 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: None Social History: Social History: Lives with his girlfriend in the basement of his parents' house. Works as a fry cook. No sick contacts. [Name (NI) ] kids or pets. Clean living situation. No travelling although went camping x 1 in [Month (only) 547]/[Month (only) 116] and did remove one tick but it was not engorged and never developed rash. Never smoker, drinks 3 beers a couple times a week, denies illicits. Sexually active with girlfriend only. Family History: No history of autoimmune disorders. Grandfather has leukemia. Physical Exam: ADMISSION EXAM: Vitals: T: 98.0, BP: 123/70, P: 84, R: 16, O2: 100% 2L NC General: Alert, oriented, anxious, pale HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear without ulcers, scattered petechiae on bilateral periorbital skin 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 Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN 2-12 intact, gait normal, strength 5/5 bilateral upper and lower extremities DISCHARGE EXAM: VS: 98.1 118/76 16 100 RA Admission wt 192.79 lbs GEN: NAD HEENT: Ulcers much improved. CV: RRR, S1 S2, no m/r/g CHEST: LCTAB ABD: Soft, NT, ND, no HSM, bowel sounds present EXT: No c/c/e. PICC site non-tender with mild erythema around insertion and around tape. SKIN: Fine, erythematous, maculopapular rash on scalp is improving but with worsening confluent rash on trunk and now on distal arms and legs. R knee lesion, L anterior leg lesion - both stably erythematous. Warts on toes. NEURO: A+O x 3 Pertinent Results: =================================== ADMISSION LABS =================================== [2107-9-15] 09:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2107-9-15] 09:35PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.010 [2107-9-15] 09:35PM FIBRINOGE-155* [2107-9-15] 09:35PM PT-13.4* PTT-30.8 INR(PT)-1.2* [2107-9-15] 09:35PM WBC-2.2* RBC-1.73* HGB-5.4* HCT-15.5* MCV-90 MCH-31.1 MCHC-34.7 RDW-13.3 Plt 6 [2107-9-15] 09:35PM ALBUMIN-4.1 [2107-9-15] 09:35PM LIPASE-22 [2107-9-15] 09:35PM ALT(SGPT)-24 AST(SGOT)-20 LD(LDH)-184 ALK PHOS-44 TOT BILI-1.5 [2107-9-15] 09:35PM GLUCOSE-90 UREA N-14 CREAT-1.1 SODIUM-136 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-22 ANION GAP-14 [2107-9-15] 10:40PM HIV Ab-NEGATIVE =================================== PATHOLOGY =================================== [2107-9-16] Bone Marrow Cytogenetics: Cell culture of this specimen did not yield dividing cells for metaphase chromosome analysis. Interphase FISH assays were most consistent with the presence of a tetraploid or near-tetraploid clone. Interphase FISH did not detect a BCR-ABL1 rearrangement or an MLL rearrangement. [2107-9-16] Bone Marrow Aspirate and Core Biopsy: BONE MARROW EXTENSIVELY INVOLVED BY PRECURSOR B CELL ACUTE LYMPHOBLASTIC LEUKEMIA/LYMPHOMA (PRE-B ALL). [2107-10-4] CSF Cytology NEGATIVE FOR MALIGNANT CELLS. [2107-10-18] Cytogenetics KARYOTYPE: nuc ish(BCR,ABL1)x2[100]. Interphase FISH with the BCR-ABL1 probe set did NOT detect evidence of the presumed TETRPLOID clone seen by FISH in the diagnostic specimen. FISH DETAILS: FISH evaluation for a BCR-ABL (BCR-ABL1) rearrangement was performed on nuclei with the LSI BCR/ABL Dual Color, Dual Fusion Translocation Probe ([Doctor Last Name 7594] Molecular) for BCR at 22q.11.2 and ABL at 9q34, and is interpreted as normal. No nuclei with the prior abnormal pattern were observed in 100 nuclei studied. =================================== MICROBIOLOGY =================================== [2107-10-17] BLOOD CULTURE- Negative [2107-10-17] URINE URINE- Negative [2107-10-17] BLOOD CULTURE- Negative [2107-10-4] BLOOD CULTURE- Negative [2107-10-4] BLOOD CULTURE- {CAPNOCYTOPHAGA SPECIES}; Aerobic Bottle [2107-10-4] URINE CULTURE- Negative [2107-10-1] THROAT CULTURE VIRAL CULTURE: R/O HSV- Negative [2107-9-28] TISSUE GRAM STAIN-FINAL; TISSUE-FINAL; ANAEROBIC CULTURE-FINAL; FUNGAL CULTURE- Negative [2107-9-27] STOOL C. difficile- Negative; FECAL CULTURE- Negative; CAMPYLOBACTER CULTURE- Negative; OVA + PARASITES- Negative [2107-9-20] CSF;SPINAL FLUID GRAM STAIN- Negative [2107-9-16] SEROLOGY/BLOOD LYME SEROLOGY- Negative [2107-9-16] MRSA SCREEN MRSA SCREEN-Negtive [2107-9-16] Blood (EBV) [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgG AB-FINAL; [Doctor Last Name ]-[Doctor Last Name ] VIRUS EBNA IgG AB-FINAL; [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgM AB-FINAL INPATIENT [2107-9-15] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV IgM ANTIBODY-FINAL ================================== PERTINENT IMAGING ================================== [2107-9-16] CT Chest/Abd/Pel w Contrast 1. The spleen is markedly enlarged, measuring 20 cm in craniocaudal dimension, without focal lesion. 2. Scattered subcentimeter axillary, mediastinal, retroperitoneal, and superficial inguinal lymph nodes with normal morphology. 3. Three tiny ground glass nodules in the lungs of indeterminate ignifiance. 4. Right iliac lucent lesion with non-aggressive appearance. [2107-9-17] ECHO IMPRESSION: Normal regional and global biventricular systolic function. Normal diastolic function. No pathologic valvular abnormalities. ================================== DISCHARGE LABS ================================== [2107-10-19] 12:00AM BLOOD WBC-3.7* RBC-3.14* Hgb-9.4* Hct-27.4* MCV-87 MCH-30.0 MCHC-34.4 RDW-15.9* Plt Ct-354 [2107-10-19] 12:00AM BLOOD Neuts-65 Bands-2 Lymphs-18 Monos-3 Eos-0 Baso-0 Atyps-1* Metas-3* Myelos-8* NRBC-6* [2107-10-19] 12:00AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-OCCASIONAL Stipple-OCCASIONAL [2107-10-19] 12:00AM BLOOD Plt Smr-NORMAL Plt Ct-354 [2107-10-19] 12:00AM BLOOD Fibrino-169* [2107-9-28] 05:09AM BLOOD Gran Ct-44* [2107-9-15] 09:35PM BLOOD Ret Aut-0.5* [2107-10-13] 02:31PM BLOOD AT-122 [2107-10-19] 12:00AM BLOOD Glucose-226* UreaN-13 Creat-0.8 Na-138 K-4.3 Cl-101 HCO3-30 AnGap-11 [2107-10-19] 12:00AM BLOOD ALT-132* AST-22 LD(LDH)-371* AlkPhos-73 TotBili-0.6 DirBili-0.2 IndBili-0.4 [2107-10-19] 12:00AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.3 Brief Hospital Course: Mr. [Known lastname 65523] is a 26-year-old gentleman with no significant PMH who preseted to an [Hospital ] hospital with fatigue and retinal heomorrhage. Hew as found to be pancytopenic and ultimately diagnosed with [Location (un) 5622]-chromosome-negative ALL. He was admitted to the BMT service for induction chemotherapy with [Company 2860] #06-254 protocol. ------------------- ACTIVE ISSUES ------------------- 1. [Location (un) 5622]-chromosome-negative ALL: Patient presented with pancytopenia. Prior to the bone marrow biopsy, a broad differential diagnosis was considered including bone marrow suppression secondary to viral infection vs. malignancy (given the 90% lymphocytes). Patient's anemia and pancytopenia were profound, and while in the ICU, he received pRBC to maintain a HCT > 21 and platelets to maintain platelets >50 given recent retinal hemorrhages. Sperm banking was discussed and completed. An echocardiogram was normal. He was transferred to the BMT service, where he was enrolled in the adult ALL consortium trial (protocol #06-254) and started on induction chemotherapy. His induction regimen included Vincristine on days 1,8,15, and 22; Doxorubicin on days 1, and 2; MTX on day 3; e. coli Asparaginase on day 4; IT cytarabine on day 1; IT cytarabine, MTX and hydrocortisone on day 15; and prednisone daily. Patient was anticoagulated with Lovenox given risk of clotting with asparaginase. Platelets were maintained > 30,000, fibrinogen > 100,000, and HCT > 21 with transfusions. ATIII levels were checked weekly to ensure activity > 30%. Patient's course was complicated by neurtopenic fever, hyponatremia, and mucousitis (please see below) but otherwise chemo was tolerated well. At the end of the induction cycle, patient had a repeat bone marrow biopsy to determine whether he is in complete remission. 2. Visual changes/retinal hemorrhage: Ophthalmology was consulted early in patient's admission and determined that his retinal hemorrhages were secondary to thrombocytopenia/newly diagnosed ALL. There was no evidence of leukemic infiltrates. Patient had no pain and visual changes resolved without further intervention. 3. Neutropenic Fever: Patient developed a fever and was initially started on cefepime and clindamycin (clindamycin for oral anaerobe coverage given mouth sores and possible dental cavity). A blood culture from his PICC line (one bottle) grew GNR's at 83 hours. The GNR's speciated as CAPNOCYTOPHAGA SPECIES, which has been described in neutropenic patients with mouth ulcers. Given capnocytophaga's sensitivities (and desire to decrease risk for c. dif), cefepime and clindamycin were discontinued and Zosyn was started. On [10-15], patient developed a drug rash that was most likely secondary to PCN component of Zosyn, and he was switched to Meropenem. Prior to discharge, patient was transitioned to Ertapenem for QD dosing as an outpatient. 4. Mucousitis: Patient developed several very painful oral ulcers. He also reported pain at the site of a dental cavity. His ulcers were swabbed and were negative for HSV. He received mouth care, acyclovir, fluconazole, and ultimately required a dilaudid PCA for pain control. By the end of admission, ulcers had markedly improved and patient no longer required pain control. 5. Hyponatremia: Patient's labs were consistent with SIADH, which was most likely secondary to vincristine or MTX. He received salt tabs and furosemide and sodium improved. 6. Skin findings: Patient had a violaceous patch on R knee after falling in a softball game prior to diagnosis but was very slow to resolve. He was seen by dermatology who biopsied the lesion and determined there were signs of retained foreign body but no signs of fungal infection. 7. Constipation: Most likely secondary to vincristine and narcotics. Patient received bowel regimen. TRANSITIONAL ISSUES - Complete Ertapenem (through [10-21]) - Follow-up final bone marrow results to assess for complete remission - New PCN allergy (rash while on Zosyn) Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. Ibuprofen 400 mg PO Q8H:PRN pain 2. Sulfameth/Trimethoprim DS 1 TAB PO BID had one day left in 10 day cycle 3. Amoxicillin-Clavulanic Acid 500 mg PO Q8H had one day left in 10 day course Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (TU,WE,TH) This week, take Bactrim on [11-21], and [10-20]. After that, take Bactrim Monday, Wednesday, and Friday. RX sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth Three times a week Disp #30 Tablet Refills:0 2. Acyclovir 400 mg PO Q8H RX acyclovir 400 mg 1 tablet(s) by mouth every 8 hours Disp #30 Tablet Refills:3 3. Docusate Sodium 100 mg PO BID RX docusate sodium [Stool Softener] 100 mg 1 capsule(s) by mouth Twice a day Disp #30 Capsule Refills:3 4. Enoxaparin Sodium 40 mg SC DAILY Start: In am RX enoxaparin 40 mg/0.4 mL Inject 40 mg under the skin daily Disp #2 Syringe Refills:0 5. ertapenem NF 1 gram Injection daily Reason for Ordering: Discharging on ertapenem. Want to give today's dose prior to discharge. 6. Fluconazole 400 mg PO Q24H RX fluconazole 200 mg 2 tablet(s) by mouth daily Disp #30 Tablet Refills:0 7. Lorazepam 1 mg PO Q8H:PRN nausea, anxiety Do not drive or operate machinery while taking lorazepam. Do not take with alcohol. RX lorazepam 1 mg 1 tablet by mouth as needed (no more often than every 8 hours) Disp #10 Tablet Refills:0 8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN mouth pain RX oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours Disp #15 Tablet Refills:0 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth daily Disp #60 Unit Refills:5 10. Ranitidine 150 mg PO BID RX ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (un) 6438] Discharge Diagnosis: [Location (un) 5622] chromosome negative ALL Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 65523], It was a pleasure being a part of your care during your admission to [Hospital1 69]. As you know, you were admitted for treatment of your ALL. You received chemotherapy and a medication called Lovenox to prevent clotting. You experienced mouth ulcers and a bacterial infection in your blood, both of which have improved. Your blood counts have also gotten better. On [2107-10-18], you had a bone marrow biopsy which will help us know if you are in a complete remission. We are discharing you with 2 days of IV antibiotics, which you will use through your PICC line. We are also discharging you with a prescription for Lovenox. If you have any fevers (even low fevers), worsening rash, worsening redness or pain at your PICC insertion site, chills, nausea, vomiting, diarrhea, or any other new symptosm that concern you, please call our office immediately. Followup Instructions: Readmission to BMT unit on Friday, [2107-10-21] [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 3962*]	[ "078.10", "693.0", "564.09", "204.00", "285.3", "362.81", "528.01", "E930.0", "V70.7", "682.6", "111.0", "284.19", "275.3", "253.6", "E933.1", "288.03", "041.85", "787.91", "790.7" ]	icd9cm	[ [ [] ] ]	[ "38.97", "03.31", "99.25", "03.92", "41.31", "86.11" ]	icd9pcs	[ [ [] ] ]	14185, 14241	8181, 12226	281, 337	14334, 14334	3380, 8158	15414, 15577	2070, 2133		12580, 14162		14262, 14313		12252, 12557			14485, 15391								2148, 2840						2857, 3361													1234, 1564			229, 243											365, 1215											14349, 14461						1586, 1592	1624, 2054
60,131	190,090	35146	Discharge summary	report	Admission Date: [2194-10-22] Discharge Date: [2194-10-25] Date of Birth: [2140-2-12] Sex: M Service: MEDICINE Allergies: Morphine / Tylenol 8 Hr Attending:[First Name3 (LF) 358] Chief Complaint: submassive pulmonary embolism Major Surgical or Invasive Procedure: thrombolysis for submassive pulmonary embolism History of Present Illness: Patient is 54 yo M with h/o HTN, nephrolithiasis and gout with FH of thrombosis who is MICU callout for saddle emboli treated with TPA and on heparin drip on coumadin bridge. Patient transferred from OSH for same condition after self diagnosis. No previous history of DVT or PE. States he noted R calf pain after a work-out approximately 2 weeks prior. He took Diclofenac for one week with resolution of the pain. Two days prior he noted left foot and calf swelling. He denies recent travel, illness or surgery. The night prior to admission, he felt 'stuffy' and with wheezing concerning for pneumonitis. He also noted SOB with exertion which is unusal for him. The AM of admission, he went to work and was able to work >1H, then noted worsening SOB. Took O2 sat, which was 70%/RA. Applied oxygen and proceeded to nearest radiologist with help of wife who works for him. CTA positive for saddle emboli. Proceeded to [Hospital3 ], initial VS (no noted T), 153/90, 102, 18, 90s on 5L. He had an Echo showing RV dilation without obvious strain or dysfunction. He was then given a heparin bolus of 8800u, Demerol 25mg, Ativan 1mg, Zofran 8mg and started on Tpa @ 150mg/hr. Given concern of instability with saddle emboli, he was transferred to the [Hospital1 18] MICU for furhter management. . ROS negative for recent F/Ch, abdominal pain, N/V, weightloss, nightsweats, BRBPR, melena or heartburn. He currently endorses SOB and retrosternal CP. He has not had a screening colonoscopy. Past Medical History: HTN Obese - BMI 37 Gout s/p Appendectomy [2156] Nephrolithiasis with microscopic hematuria s/p rib & sternal fracture after biking accident Social History: Patient is a Internal medicine physician. [Name10 (NameIs) ] denies tobacco or illegal drug use. He does drink EtOH occasionally. Exercises regularly. Family History: Brother with thrombus s/p ACL repair. Suspects mother died of PE after SOB for several days, then found dead of unclear causes. Physical Exam: VS 96.6, 83, 129/85, 19, 98 on NRB Gen: NAD, breathing comfortably with NRB HEENT: Symmetric, PERRL, oropharynx clear with MMM CV: RRR without m/g/r, clear S1, S2 PULM: Shallow breathing, states painful with deep inspiration, CTAB ABD: Active bowel tones. Soft, NT, no masses Ext: LE asymmetry, L>R slightly without erythema or pain on palpation Neuro: A&O x 3, moving all extremities, CNII-XII grossly intact Pertinent Results: [10-23] TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with mild right ventricular pressure overload. 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. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mildly dilated right ventricle with mild hypokinesis and mildly increased right sided pressures. Normal left ventricular global and regional function. CXR: Of note, the lateral CP angles were not included on the film. Cardiac size is top normal. There is no evident pneumothorax. Faint ill- defined opacity in the right mid lung zone corresponds to a consolidation in the right middle lobe, that is better seen in CTA from the same day earlier. Followup until resolution is recommended. There is no evidence of CHF. LENIS: LOWER EXTREMITY VENOUS ULTRASOUND: [Doctor Last Name ]-scale, color, and pulse wave Doppler ultrasound of the lower extremities was performed to evaluate for deep venous thrombosis. The left popliteal vein demonstrates expansive, occlusive thrombus with no identifiable flow, and non-compressibility of the vein. The thrombus extends into the left posterior tibial veins, where no flow is identified on color imaging. The left common femoral vein and superficial femoral vein demonstrate normal compressibility, with respiratory phasicity of flow and normal responses to augmentation and Valsalva maneuver. The right lower extremity demonstrates normal respiratory phasicity of flow in the common femoral vein, greater saphenous vein, superficial femoral vein, as well as popliteal vein. There are normal responses to augmentation and Valsalva maneuver. IMPRESSION: 1. Occlusive DVT in the left popliteal and posterior tibial veins. 2. No DVT in the right lower extremity. Brief Hospital Course: Patient is a 54 yo M h/o HTN, nephrolithiasis and gout with FH of thrombosis with submassive PE s/p thrombolyis with TPA and anticoagulation with heparin drip switched to lovenox and with coumadin bridge. Patient was transferred from OSH after getting CTA diagnosis of submassive PE and was admitted to the MICU for thrombolysis with TPA and respiratory status monitoring. Echo was done with showed some evidence of RV strain but the patient was hemodynamically stable. LENIs were done which showed evidence of DVT. IVC filter is not a consideration at this time. Anticoagulation was done with heparin and the patient was switched to lovenox with coumadin bridge. PCP to follow up INR on Monday. Target INR is [2-2]. PCP to follow up OSH hypercoagubility studies. Plerutic chest pain was controlled oxycodone and ibprofen. Renal function was monitored in setting of NSAID administartion and the patient was placed on PPI. # HTN: On Cozaar as outpatient. Given potential for HD instability, will hold for now. - Cozaar to be restarted by PCP if needed - Monitor for HD instability on telemetry # Nephrolithiasis: With h/o occult hematuria. Given anticoagulation, will continue to monitor uop for signs of frank hematuria. # Gout: Continue Allopurinol. Medications on Admission: Cozaar 100mg daily ASA 81mg daily Allopurinol 300mg daily Ativan 1mg QHS PRN Discharge Medications: 1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:39 Tablet(s) Refills:0 3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM for 7 days. Disp:7 Tablet(s) Refills:0 4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a day for 5 days. Disp:10 1 Refills:0 7. Outpatient Lab Work INR and BUN/CR check on Monday, [2194-10-27]. Results to be followed up by PCP. [Name10 (NameIs) ] INR [2-2] for PE. Discharge Disposition: Home Discharge Diagnosis: Primary: Submassive pulmonary embolism, deep vein thrombosis, s/p thrombolysis Secondary: hypertension Discharge Condition: stable Discharge Instructions: You were transferred from an outside hospital for a submassive pulmonary embolism for which you received TPA thrombolysis. You were admitted to the intensive care unit and you were monitored for respiratory distress. You were placed on a heparin drip and this was switched to lovenox and you were bridged with coumadin for long term coagulation. The source of your pulmonary embolism warrants further workup. Some lab tests for coagulation disorders were sent at an outside hospital and will be followed up by your PCP. [Name10 (NameIs) 2172] PCP will use this to determine the course of your anticoagulation treatment which will be a minimum of 6 months and possibly lifelong. The immediate source of your pulmonary embolism was found to be a deep vein thrombosis. For pleuric pain control, you are being given a prescription for oxycodone and to take OTC NSAIDs such as ibprofen. For anticoagulation, you are to take warfarin 5mg by mouth once daily and lovenox 100mg/mL synrige subcutaneously twice daily. You are to have your INR and renal function followed by your PCP on [Name9 (PRE) 766] with a target INR of [2-2]. Please go to all follow up appointments. Please return to the ED or seek medical advice if you have concerning chest pain, significant shortness of breath, or start noticing blood in your stool or have minor injuries that will not stop bleeding. Followup Instructions: Please see your PCP [Name9 (PRE) ],[Name9 (PRE) ] [Name Initial (PRE) ]. [Telephone/Fax (1) 5424] on Monday to or after getting your lab work done. Completed by:[2194-10-27]	[ "401.9", "274.9", "V58.61", "453.41", "415.19", "592.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7346, 7352	5164, 6425	315, 364	7499, 7508	2816, 5141	8938, 9134	2241, 2370		6553, 7323		7373, 7478		6451, 6530			7532, 8915								2385, 2797																						246, 277											392, 1885																	1907, 2053	2069, 2225
32,574	131,887	30793+57722	Discharge summary	report+addendum	Admission Date: [2155-7-27] Discharge Date: [2155-8-7] Date of Birth: [2079-10-11] Sex: M Service: CARDIOTHORACIC Allergies: Pyridium / Quinine Sulfate / Levaquin / Macrobid / Vytorin Attending:[First Name3 (LF) 1283] Chief Complaint: Fatigue/Dyspnea Major Surgical or Invasive Procedure: [2155-7-29] - Right Thoracotomy, MVR (29mm [Company 1543] Mosaic Porcine Valve) History of Present Illness: This is a 75-year-old man with a history of multiple myocardial infarctions with resultant cardiomyopathy and an ejection fraction of approximately 20% who had, in the past undergone 2 prior CABG, the first one being in the [2128] and the second one in the [2138]'s at another institution. He had recently undergone treatment by his cardiologist for decompensating heart failure and his diuretics had been adjusted. Recent echo reveals really dilated LV with 3 to 4+ mitral regurgitation. Based on these findings, the patient was referred for evaluation for mitral valve replacement. He underwent cardiac catheterization prior to this which revealed his previous grafts were open and patent as well as his LIMA to LAD. The patient understood the risks and benefits of the procedure including but not limited to bleeding, infection, myocardial infarction, stroke, death, renal and pulmonary insufficiency as well as the possibility of a blood transfusion and the future revascularization procedures. He then agreed to proceed. Past Medical History: CABG [2128] and [2138] PE CHF [Hospital1 ]-Ventricular pacemaker/ICD BPH s/p TURP Benign thyroid nodule Rosacea Social History: Lives with wife. Retired contractor. Quit smoking 30 years ago. Drinks [1-14] alcoholic beverages per week. Family History: None noted Physical Exam: HR 88 BP 112/57 RR 18 GEN: NAD HEENT: Unremarkable LUNGS: CTA bilaterally HEART: RRR, III/VI holosystolic murmur ABD: Soft, ND, no rebound, no guarding, NABS EXT: Warm, dry [1-14]+ pulses. NEURO: Nonfocal Pertinent Results: [2155-7-28] CTA Chest and Pelvis 1. No evidence of an aortic dissection or an aneurysm. 2. Small bibasal effusion with passive atelectasis of the lower lobes. Small ground-glass opacity in the right lower lobe likely represents infectious or inflammatory change. 3. Atherosclerosis of the thoracic and abdominal aorta with atherosclerosis involving the origin of a single right and a single left renal artery. 4. Small trace of free fluid in the pelvis of uncertain significance. [2155-7-31] Ultrasound 1. Gallbladder contains small amount of sludge. Exam is equivocal for cholecystitis. If suspected, consider HIDA scan. 2. Small right-sided pleural effusion. Small amount of free fluid is also noted within the abdominal cavity consistent with ascites. [2155-8-5] 05:40AM BLOOD WBC-7.7 RBC-3.25* Hgb-10.7* Hct-32.9* MCV-101* MCH-33.0* MCHC-32.6 RDW-16.2* Plt Ct-240 [2155-8-6] 05:50AM BLOOD PT-12.7 PTT-24.2 INR(PT)-1.1 [2155-8-6] 11:10AM BLOOD Glucose-149* UreaN-32* Creat-1.4* Na-134 K-4.6 Cl-98 HCO3-24 AnGap-17 [2155-8-5] 05:40AM BLOOD Glucose-73 UreaN-26* Creat-1.3* Na-137 K-4.3 Cl-99 HCO3-31 AnGap-11 [2155-8-6] 11:10AM BLOOD ALT-70* AST-56* LD(LDH)-336* AlkPhos-117 Amylase-31 TotBili-4.4* [2155-8-5] 05:40AM BLOOD ALT-84* AST-77* AlkPhos-98 TotBili-5.8* DirBili-3.9* IndBili-1.9 [2155-8-4] 03:10AM BLOOD ALT-104* AST-127* LD(LDH)-326* AlkPhos-94 TotBili-9.0* Brief Hospital Course: Mr. [Known lastname 72855] was admitted preoperatively for IV heparin. On [7-29] he was taken to the operating room where he underwent a mitral valve replacement with a porcine valve through a right thoractomy. He was transferred to the ICU in critical but stable condition on epinephrine and phenylephrine and propofol. He was seen by elelctrphysiology for his biv icd as well as post op ventricular ectopy in the setting of hypokalemia and epinephrine and milrinone. He was extubated on POD #2. On POD #2 he was jaundiced, complained of right sided pain, and was found to have elevated LFTs. Ultrasound showed sludge in the gallbladder. He was seen by general surgery and hepatology. He was started on ursodiol. His LFTs improved and he was transferred to the floor on pod#6 and his LFTs continued to improve. He was restarted on coumadin for underlying afib. He was not started on an ace inhibitor and his lasix dose was decreased to 20 mg daily slightly increased creatinine and increased need for beta blockade. He was ready for discharge to rehab with continued creatinine and INR monitoring on POD #9 . Medications on Admission: coumadin lasix digoxin toprol accupril flomax clarinex Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:90 Tablet Sustained Release 24 hr(s) Refills:0 10. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [1-14] Tablets PO Q6H (every 6 hours) as needed. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily) for 1 doses: check INR [8-8]. Discharge Disposition: Extended Care Facility: [Location (un) 582] Discharge Diagnosis: CAD s/p CABGx4 in [2128] and redo CABGx5 in [2138] [Hospital1 ]-V Pacemaker/ICD Benign thyroid nodule BPH Rosacea s/p TURP Discharge Condition: Good. Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 1290] in 1 month. ([Telephone/Fax (1) 1504] Follow-up with Dr. [Last Name (STitle) 5310] in 2 weeks. [Telephone/Fax (1) 5315] Follow-up with pcp [Last Name (NamePattern4) ]. [Last Name (STitle) 72898] in [2-15] weeks. [Telephone/Fax (1) 63184] [Hospital Ward Name 121] 2 wound clinic in 2 weeks. Call all providers for appointments. Completed by:[2155-8-7] Name: [Known lastname 12148],[Known firstname 126] L. Unit No: [Numeric Identifier 12149] Admission Date: [2155-7-27] Discharge Date: [2155-8-7] Date of Birth: [2079-10-11] Sex: M Service: CARDIOTHORACIC Allergies: Pyridium / Quinine Sulfate / Levaquin / Macrobid / Vytorin Attending:[First Name3 (LF) 674] Addendum: Additional lab work. Pertinent Results: [2155-8-7] 05:45AM BLOOD WBC-8.2 RBC-3.26* Hgb-10.8* Hct-33.4* MCV-102* MCH-33.2* MCHC-32.4 RDW-16.0* Plt Ct-290 [2155-8-5] 05:40AM BLOOD WBC-7.7 RBC-3.25* Hgb-10.7* Hct-32.9* MCV-101* MCH-33.0* MCHC-32.6 RDW-16.2* Plt Ct-240 [2155-8-7] 05:45AM BLOOD PT-14.7* INR(PT)-1.3* [2155-8-6] 05:50AM BLOOD PT-12.7 PTT-24.2 INR(PT)-1.1 [2155-8-7] 05:45AM BLOOD UreaN-33* Creat-1.6* K-4.9 [2155-8-6] 11:10AM BLOOD Glucose-149* UreaN-32* Creat-1.4* Na-134 K-4.6 Cl-98 HCO3-24 AnGap-17 [2155-8-5] 05:40AM BLOOD Glucose-73 UreaN-26* Creat-1.3* Na-137 K-4.3 Cl-99 HCO3-31 AnGap-11 Discharge Disposition: Extended Care Facility: [Location (un) 176] [Doctor Last Name ] [Last Name (Prefixes) ] MD [MD Number(1) 681] Completed by:[2155-8-7]	[ "599.7", "V45.81", "424.0", "427.31", "997.1", "425.4", "414.00", "428.0", "V45.02", "412" ]	icd9cm	[ [ [] ] ]	[ "35.23", "39.61" ]	icd9pcs	[ [ [] ] ]	8277, 8462	3477, 4598	341, 431	6060, 6068	7658, 8254	6783, 7639	1787, 1799		4703, 5808		5902, 6039		4624, 4680			6092, 6760								1814, 2026																						286, 303											459, 1495																	1517, 1642	1658, 1771
12,542	161,091	52573+59440	Discharge summary	report+addendum	Admission Date: [2109-8-25] Discharge Date: [2109-9-6] Date of Birth: [2033-11-28] Sex: F Service: VSU CHIEF COMPLAINT: Failed left fem-[Doctor Last Name ] bypass graft with ischemic right foot. HISTORY OF PRESENT ILLNESS: This is a 75-year-old female who was admitted the night prior to elective surgery for a right fem-[Doctor Last Name ] bypass which has failed. The patient does admit to right foot numbness, coolness, and pain of sudden onset without improvement. There is no leg swelling or redness, fever or chills. REVIEW OF SYSTEMS: Negative for chest pain, shortness of breath, abdominal pain. ALLERGIES: Penicillin. MEDICATIONS ON ADMISSION: Lipitor 40; lisinopril 20; hydrochlorothiazide 12.5; aspirin 81; multivitamin tablet. PAST MEDICAL HISTORY: Peripheral vascular disease, status post right fem-popliteal bypass in [2090]. History of coronary artery disease, status post CABG x3 in [2102]. History of aortic valvular disease, status post a porcine AVR. History of hypertension. History of carotid stenosis with TIAs. History of hypercholesterolemia. PHYSICAL EXAMINATION: Blood pressure 172/75, pulse 67, respirations 16, O2 sat 100% on room air. General appearance - alert white female in no acute distress. Neck is supple with positive bruits. Heart has a regular rate and rhythm with a good valvular click. Lungs are clear to auscultation. Abdominal exam is soft, nontender without palpable masses. Right extremity shows right toes and forefoot with gangrenous changes and mottling and cool to touch, moderately insensate, motor is intact. Pulse exam shows palpable femorals bilaterally, popliteals are absent bilaterally. On the right the Pt and DP are absent by Doppler and palpation. On the left the PT is absent, the DP is Dopplerable signal. HOSPITAL COURSE: The patient was admitted to the vascular service. IV heparinization was instituted for a goal PTT of 60-80. Preoperatively the patient underwent a diagnostic arteriogram on [2109-8-26], without complication. Her primary cardiologist saw the patient, did note some lateral, inferolateral ST changes. Repeat EKG was obtained. Serial enzymes were obtained which were negative for ischemia x3. In light of this they felt that she could proceed with anticipated elective surgery. The patient had preoperative carotid ultrasounds done for a history of TIAs. A left high- grade internal carotid artery stenosis was noted. The anticipated elective right leg bypass graft was deferred. The patient underwent a left carotid endarterectomy on [2109-8-28]. She tolerated the procedure well, was transferred to the PACU, extubated, neurologically intact. Postoperatively, she was transferred to the SICU for continued monitoring and care. Postop day one she did well overnight. There were no events. She was de-lined and transferred to the regular nursing floor for continued monitoring and care. The patient was continued on IV heparin drip for ischemic leg. She continued to do well from a cardiac standpoint. She returned to surgery on [2109-9-3], and underwent a right fem-BK [Doctor Last Name ] with PTFE. She was transferred to the PACU in stable condition. She continued to do well and was transferred to the MICU for continued monitoring and care. Postoperative day one there were no overnight events. She was afebrile. Her diet was advanced. Her fluids were Hep-Locked. She was converted to oral analgesics and her preoperative medications were reinstituted. Ambulation to a chair was begun. The patient was transferred to the regular nursing floor for continued care. Antibiotics of vancomycin were discontinued on [2109-9-5]. [Last Name (un) ] saw this patient for hyperglycemia. They felt that her sugars had been undercontrolled. Her glucose sliding scale was adjusted before meals and at bedtime with improvement in her hyperglycemia. The patient was transferred to the regular nursing floor on postoperative day 3. Physical therapy was requested to evaluate the patient for discharge planning. They felt she would require rehab. Case management began screening. Her glycemic control is significantly improved. The remainder of her hospital course was unremarkable. The patient will be discharged to rehab when bed available, medically stable. DISCHARGE DIAGNOSES: 1. Acute arterial insufficiency, ischemic right foot. 2. Carotid stenosis with a history of transient ischemic attacks. 3. History of hypercholesterolemia. 4. History of hypertension. 5. History of coronary artery disease, status post CABG x3 in [2102]. 6. History of aortic valvular stenosis, status post porcine valve replacement. 7. History of cataracts. 8. History of type 2 diabetes with hyperglycemia, improved. MAJOR SURGICAL PROCEDURES: Left carotid endarterectomy on [8-28] and a right fem-BK [Doctor Last Name ] bypass with PTFE on [2109-9-3]. DISCHARGE INSTRUCTIONS: The patient will be discharged to rehab. She will follow up with Dr. [Last Name (STitle) 1391] in 2 weeks' time. She will call for an appointment at [Telephone/Fax (1) 1393]. They should call if she develops fever greater than 101.5, or if the neck wound or leg wounds develop swelling, redness, or drainage. The patient may shower but no tub baths. No driving until seen in followup. All medications should be continued as prescribed. DISCHARGE MEDICATIONS: Atorvastatin 40 mg daily; lisinopril 20 mg daily; hydrochlorothiazide 12.5 mg daily; aspirin 81 mg daily; 12.5 of metoprolol b.i.d.; Colace 100 mg b.i.d.; Dulcolax tabs 2 p.r.n. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2380], [MD Number(1) 2381] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2109-9-6] 12:22:18 T: [2109-9-7] 01:12:29 Job#: [Job Number 108547] Name: [Known lastname 17764],[Known firstname 779] Unit No: [Numeric Identifier 17765] Admission Date: [2109-8-25] Discharge Date: [2109-9-8] Date of Birth: [2033-11-28] Sex: F Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 231] Addendum: [2109-9-8] patient remined in the hospital for continued treatmet with physical theraphy. D/cstable condition. Discharge Disposition: Extended Care Facility: [Hospital ] [First Name11 (Name Pattern1) 77] [Last Name (NamePattern1) 237] MD [MD Number(1) 238] Completed by:[2109-9-10]	[ "305.1", "440.22", "401.9", "414.00", "440.31", "440.1", "V45.81", "530.81", "433.10", "250.00", "V42.2" ]	icd9cm	[ [ [] ] ]	[ "88.48", "88.45", "38.12", "39.29", "88.42", "00.40" ]	icd9pcs	[ [ [] ] ]	6358, 6557							4342, 4927	5421, 6335				703, 790	1848, 4321		4952, 5397																			1151, 1830								588, 676			154, 234											263, 568																	813, 1128
24,327	188,902	17012	Discharge summary	report	Admission Date: [2103-12-28] Discharge Date: [2104-1-1] Date of Birth: [2051-1-23] Sex: F Service: ORTHOPEDIC CHIEF COMPLAINT: Right knee pain. HISTORY OF PRESENT ILLNESS: The patient is a 52 year-old female with a history of osteoarthritis scheduled for an elective right total knee on [2103-12-28]. PAST MEDICAL HISTORY: 1. Osteoarthritis of knees and hands. 2. History of bronchitis in the past [2-20]. 3. History of gastroesophageal reflux disease. 4. History of iron deficiency anemia. 5. Anxiety. 6. Depression. MEDICATIONS: 1. Effexor. 2. Geodon. 3. Topamax. 4. Protonix. 5. Iron supplements. 6. Percocet prn. ALLERGIES: Penicillin reactions are shortness of breath and swelling. PAST SURGICAL HISTORY: 1. Left partial knee replacement in [12-20]. 2. Arthroscopy of the knee [7-22]. PHYSICAL EXAMINATION: Blood pressure 105/70. Heart rate 88. Weight 170. Height 5'3". General, female in no acute distress. Heart regular rate and rhythm. Pulses 1 to 2 out of 6. Abdomen soft, nontender. Lungs clear. Extremities no clubbing, cyanosis or edema. 2+ dorsalis pedis pulses and posterior tibial pulses. Mental alert and oriented, calm. Pupils are equal, round and reactive to light. Neck supple. HOSPITAL COURSE: The patient was taken to the Operating Room on [2103-12-28] for right total knee replacement by Dr. [Last Name (STitle) 9694]. Surgery went without incident. On postoperative check vital signs heart rate 109, blood pressure 109/50, respirations 13, pulse ox 99%, temperature 98.1. The patient is doing well, alert and oriented times three. Good pulses. Warm extremities times four. Normal S1 and S2. Clear lungs. Abdomen soft, nontender. The patient is status post right total knee replacement. Plan CPM 0 to 40 degrees, increase as tolerated 10 to 15 degrees, epidural discontinued as directed by pain team. Discontinue Foley after epidural out. Subcutaneous heparin while epidural in and then change to Coumadin. Weight bearing is tolerating. Physical therapy to see. Postoperative day one [2103-12-29] the patient well no issues. Vital signs temperature 98, blood pressure 98/64, heart rate 108, respirations 16, O2 sats 94% on 2 liters. The patient is alert and oriented times three. Right lower extremity warm. Good capillary refill. Good range of motion. Hematocrit 31.7. Status post total knee replacement right leg. CPM at 40 degrees, continue to increase 10 to 15 degrees as tolerated. Discontinue Epidural when pain service aggress. Wean off O2. Physical therapy to see today. Continue subcutaneous heparin, change dressing tomorrow postoperative day two. Later that evening on [2103-12-29] the patient was seen for acute hypoxemia mid 70s on room air with increased heart rate at 120 to 130s, decreased blood pressures to the 90s. The patient was awake and denies any chest pain or shortness of breath or any pain. She was anxious. Vital signs at the time 99.6, 111, 16, 98/56 and 71 on 2 liters. Physical examination at the time in mild distress. Lungs were clear bilaterally. Heart tachy, regular S1 and S2. Right lower extremity neurovascularly intact and unchanged. Foley is clear. Assessment 52 year-old female status post right total knee with acute hypoxemia and tachycardia postoperative day one. Plan check electrocardiogram, x-ray and arterial blood gas, stabilize on nonrebreather 100%, sats to mid 90s. Differential diagnosis includes PE, check spiral CT to rule out, discontinue Epidural for possible anticoagulation. Plan transfer to CICU after CT scan. Electrocardiogram sinus tachycardia at 142. Normal axis. No ST elevation or changes. CT scan was negative for PE. Arterial blood gas 7.22, 59, 99, 25. Discussed plan with Dr. [Last Name (STitle) 9694] who agreed. Chest x-ray bilateral infiltrates, question atelectasis versus pneumonia. Temperature 101, start Levaquin for possible pneumonia, check laboratories. On observation in Intensive Care Unit. Discussed with Intensive Care Unit Service. Dr. [Last Name (STitle) 9694] had agreed with plan before, plans to continue her routine total knee replacement postoperative protocol and Coumadin for anticoagulation. On postoperative day two [2103-12-30] the patient is doing well. She has some complaints of pain to her right lower extremity, but under control. Afebrile, heart rate 110, pulse ox 99% no room air, blood pressure 127/65, hematocrit 26.7. On examination the patient is in no acute distress. Right lower extremity. Neurovascular intact sensation throughout. No calf tenderness. Dorsalis pedis pulse palpable. Dressing in place and dry. Again CT negative, continue with CPM, continue with current management and okay to transfer back to orthopedics when okay with Intensive Care Unit team. Recheck hematocrit went from 32 to 27 today. Will continue to follow. Will discontinue drain this evening if less then 15 cc an hour. On postoperative day three the patient is doing much better, dressing changed, drain has been discontinued. Incision looks good. The patient is comfortable. Hematocrit 26.7, plan to transfuse. Continue on Coumadin. Range of motion at 90 degrees flexion with physical therapy extension this a.m. Hematocrit 26.7 the patient was transfused with 2 units this afternoon on [2103-12-31]. Postoperative day number four vital signs 97, blood pressure 110/70, 91, respirations 16, 94% on room air. The patient doing well. Physical therapy has seen the patient and is out of bed and has been cleared by physical therapy. Recheck on hematocrit is now today 33.3. Plan is to clear with physical therapy and discharge home today. DISCHARGE INSTRUCTIONS ON [2104-1-1]: Full weight bearing right lower extremity, continue Levaquin antibiotic last dose on [2104-1-5], Coumadin for a total of six weeks goal INR is 1.5 to 2.0. Services, VNA Services please draw PT/INR twice weekly. Have primary care physician adjust dose as needed to meet therapeutic goal INR. FINAL DIAGNOSES: 1. Right total knee replacement. 2. Pneumonia. RECOMMENDED FOLLOW UP: Follow up with Dr. [Last Name (STitle) 9694] in two weeks at [Location (un) 86] Orthopedic Group, phone number is [Telephone/Fax (1) 4301]. SURGICAL PROCEDURE: Right total knee replacement. DISCHARGE CONDITION: Good. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg one tab po q 24 hours last dose on [2104-1-5]. 2. Percocet 5/325 mg one to two tabs po q 4 to 6 hours as needed for pain. 3. Coumadin 5 mg tab one tablet po at bedtime for one day and Coumadin 3 mg tablets one tab po at bedtime for five weeks. 3 mg dose to begin on evening of [2103-1-1]. The patient is aware of diagnosis. The family is also aware of diagnosis. POST DISCHARGE ORDERS: Right knee surgical incision keep dry dressing with Ace wrap to the knee. Diet is regular. Follow up with Dr. [Last Name (STitle) 9694] in two weeks at [Location (un) 86] Orthopedic Group again at [Telephone/Fax (1) 4301]. The patient is to continue physical therapy. [Name6 (MD) ] [Last Name (NamePattern4) 9697], M.D. [MD Number(1) 9698] Dictated By:[Last Name (NamePattern1) 47844] MEDQUIST36 D: [2104-1-1] 11:27 T: [2104-1-1] 11:32 JOB#: [Job Number 47845]	[ "E878.1", "997.3", "300.00", "715.36", "530.81", "280.9", "V58.83", "486", "311" ]	icd9cm	[ [ [] ] ]	[ "99.04", "81.54" ]	icd9pcs	[ [ [] ] ]				6386, 6393					6416, 7387					1300, 6068								771, 862						6085, 6147				6159, 6364			885, 1282											161, 179											208, 342																	364, 748
21,220	199,900	47447	Discharge summary	report	Admission Date: [2173-11-19] Discharge Date: [2173-11-30] Date of Birth: [2112-4-1] Sex: F Service: SURGERY Allergies: Lisinopril Attending:[First Name3 (LF) 695] Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: Exploratory laparotomy, resection of 1.5m of small bowel, adhesiolysis, end-end anastomosis on [2173-11-19] History of Present Illness: Ms. [Known lastname 46] is a 61-year-old African American lady with hep-C, liver fibrosis and a prior history of small bowel obstruction requiring laparotomy, lysis of adhesions and small bowel resection. She now presented with a complete small-bowel obstrucion and abdominal pain. She was well until 1400 on [11-18] when she developed abdominal pain that progressed. She aslo notes that she stopped passing flatus. Her last bowel movement was at 1400 that was loose in character but no melena or hematochezia. She presented to the [Hospital1 18] emergency department for further evaluation. Past Medical History: 1. Chronic kidney disease- baseline creatinine 1.4-1.8 2. Type 2 diabetes mellitus- dx age 30, followed at [Last Name (un) ], on Lantus 9U daily and Humalog SS, + nephropathy, A1C 12.9% 7/16, h/o hypoglycemic seizure [7-30] 3. Hypertension- on atenolol and nifedipine XR 4. Hepatitis C- previously followed by Hepatology, treated [2165] w/ Rebetron with no response, [10-25] liver biopsy with stage 2 fibrosis and grade [1-26] inflammation, last VL 600K in [2170], last AFP [2170] wnl, last RUQ US in [7-30] with no mass, acute hepatic failure as below 5. Chronic pancreatitis- presumed [2-26] EtOH 6. Polysubstance abuse history- EtOH, cocaine 7. History of acute hepatitis- [7-30], [2-26] unintentional Tylenol overdose 8. s/p Total abdominal hysterectomy in [2155] 9. s/p Small bowel resection and lysis of adhesions for SBO on [2172-7-20]. Social History: Patient works as a nurse. Lives with a friend in [Location (un) 686], sister lives next door. History of heavy EtOH use, but last drink 6 months ago. History of cocaine use, last use 6 months ago. She has a 7 pack-year h/o smoking before quitting 30 years ago. Family History: HTN runs in the family. Physical Exam: On Admission: Temp 96.2, HR 74, BP 177/91, RR 20, O2 sat 98% on room air Gen: appears somewhat uncomfortable HEENT: anicteric sclera, dry mucus membranes CV: RRR Pulm: clear bilaterally Abd: distended, tympanitic and tense, tender to palpation, no rebound tenderness, (+) voluntary guarding, well-healed midline scar, hypoactive BS Ext: cool to touch GU: normal tone, guaiac (-) On Discharge: Temp 98.4, HR 67, BP 135/75, RR 18, O2 sat 96% on room air Gen: no acute distress, alert and oriented CV: RRR Pulm: clear bilaterally Abd: soft, nondistended, incisional tenderness, incision clean and without erythema or drainage Ext: warm, no edema, 2+ pulses Pertinent Results: Admission labs: [2173-11-19] 12:53AM BLOOD WBC-5.5 RBC-4.60 Hgb-14.5 Hct-43.4 MCV-94 MCH-31.5 MCHC-33.5 RDW-15.4 Plt Ct-153 [2173-11-19] 12:53AM BLOOD Plt Ct-153 [2173-11-19] 12:20PM BLOOD PT-12.2 PTT-26.4 INR(PT)-1.0 [2173-11-19] 12:53AM BLOOD Glucose-480* UreaN-22* Creat-2.2* Na-137 K-4.6 Cl-103 HCO3-19* AnGap-20 [2173-11-19] 12:53AM BLOOD ALT-36 AST-30 LD(LDH)-309* AlkPhos-268* Amylase-89 TotBili-0.4 [2173-11-19] 12:20PM BLOOD Calcium-8.4 Phos-7.0# Mg-2.0 [2173-11-19] 03:04PM BLOOD Glucose-306 Lactate-6.6* Na-138 K-4.7 Cl-113* Peaked WBC on [11-26]: [2173-11-26] 12:36AM BLOOD WBC-25.3# RBC-3.90 Hgb-11.7* Hct-35.5* MCV-91 MCH-30.0 MCHC-33.0 RDW-15.9* Plt Ct-42* Discharge Labs: [2173-11-30] 05:00AM BLOOD WBC-14.6* RBC-3.43* Hgb-10.4* Hct-31.1* MCV-91 MCH-30.2 MCHC-33.3 RDW-16.3* Plt Ct-192 [2173-11-30] 05:00AM BLOOD Plt Ct-192 [2173-11-30] 05:00AM BLOOD Glucose-140* UreaN-16 Creat-1.5* Na-137 K-3.8 Cl-102 HCO3-28 AnGap-11 [2173-11-30] 05:00AM BLOOD ALT-17 AST-29 AlkPhos-248* TotBili-1.6* [2173-11-26] 12:36AM BLOOD Lipase-5 [2173-11-30] 05:00AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.6 [2173-11-25] 02:03AM BLOOD Lactate-1.3 HCV viral load: 717,000 IU/mL. C.diff toxin: Positive Brief Hospital Course: Patient was evaluated at the [Hospital1 18] emergency department. A contrast CT scan of the abdomen was obtained and revealed moderate-to-severe small-bowel obstruction displaying extensive fecalization with a few loops of distal terminal ileum appearing slightly decompressed. No focal transition point was identified. Air and stool is noted within the large bowel. There was no evidence of pneumatosis or free air. Transplant surgery service was obtained. The patient required large doses of narcotics to control pain. On physical exam she was becoming more confused and less alert. Her abdominal exam was significant for severe diffuse pain and guarding. Initial white count was 5.5. Given her concerning physical findings, she was emergently taken to the operating room. Free air was found upon entering the abdomen. She had a 1.5 meter section of ischemic/necrotic non-viable bowel. This was resected and a primary anastomosis was fashioned. For surgical details please see dictated operative report from [2173-11-19]. She was transferred to the ICU for further care. Central access was obtained intraoperatively. On POD 1 patient required large volume resuscitation. Swan-Ganz catheter was placed for monitoring of cardiac function and for guidance in fluid resuscitation. She was initially placed on insulin and required pressors. She was transfused 2 units of PRBCs for post-op anemia and hypotension. These were subsequently weaned off. Her urine output improved, as did her blood pressure. On POD 2 she developed thrombocytopenia. HIT antibodies were sent and heparin was stopped. Once she became adequately resuscitated and started mobilizing fluid, she was diuresed with furosemide. She tolerated this well. On chest radiography she exhibited a small to moderate right pleural effusion that improved with diureses. This fluid collection was not sampled or drained. Her ventilator requirement improved and she was extubated on POD 5 and tolerated extubation. Post operatively she exhibited low grade temps. She was continued on ciprofloxacin and Flagyl. Her bowel function returned and progressed to large volume diarrhea. This occurred in the setting of fevers and rising white count. C.diff was sent. She was prophylactically started on PO vancomycin. Subsequent stool samples returned positive for C.diff toxin. She was continued on PO vanco and IV Flagyl. Her mental status improved. Narcotic requirement was decreased and she remained hemodynamically stable. She was transferred to a skilled nursing floor from the ICU on POD 7. While on the floor her diet was slowly advanced from clear liquids to a regular house diet, she tolerated this well. Her diarrhea subsided and she is now having regular formed bowel movements. On POD 11 Cipro was discontinued and she is to finish an additional 2 weeks of PO Vanc and Flagyl for C.diff. On POD 10 she was started on 9units of Lantus insulin qpm due to blood sugars in the 200s. A physical therapy consult was obtained and their recommendation is discharge home with home physical therapy. Ms. [Known lastname 46] is declining home physical therapy. She is given a prescription for all of her home medications. She states that she does not need glucometer supplies at this time. She is discharged in good condition with appropriate follow up with Drs. [Last Name (STitle) ] and [Name5 (PTitle) ]. Medications on Admission: Atenolol, Calcium, Colchicine, Doxazosin, Epi-pen, Humalog, Lantus, Nifedipine, Ultram Discharge Medications: 1. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 2 weeks. Disp:56 Capsule(s) Refills:0 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:30 Tablet Sustained Release(s) Refills:2 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks. Disp:42 Tablet(s) Refills:0 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 7. Insulin Glargine 100 unit/mL Solution Sig: Nine (9) units Subcutaneous at bedtime: Inject 9 units subcutaneously every evening. Disp:QS units Refills:2 8. Insulin Lispro 100 unit/mL Solution Sig: Per sliding scale Units Subcutaneous four times a day: Dose based on home sliding scale. Disp:QS units Refills:2 Discharge Disposition: Home Discharge Diagnosis: Ischemic/gangrenous small bowel Post-op anemia Post-op hypotension C.diff colitis Discharge Condition: Good Discharge Instructions: Call your physician if you experience: - fever > 101.5 - persistent abdominal pain not relieved by your medication - persistent nausea or vomiting - severe abdominal distension - inability to eat or drink - increasing redness, warmth, foul smelling drainage from your incision - if you have worsening diarrhea that does not improve Resume your home medications. Follow up with your primary care physician regarding your blood sugar control. You may shower and pat your abdomen dry. Do not take tub baths or swim. Continue to take your antibiotics for 2 more weeks. Followup Instructions: Follow up with your surgeon Dr. [Last Name (STitle) ] on Monday [12-6]. Call his office at ([Telephone/Fax (1) 3618] to schedule your appointment. Follow up with Dr. [Last Name (STitle) ] in [1-26] weeks. He is a liver physician. [Name10 (NameIs) ] his office at ([Telephone/Fax (1) 1582] to schedule your appointment. Follow up with your primary care physician [Last Name (NamePattern4) ] [1-26] weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709]	[ "560.81", "008.45", "403.90", "276.8", "577.1", "998.59", "585.9", "789.59", "997.5", "V17.49", "V15.82", "276.2", "997.3", "511.9", "285.1", "584.9", "557.0", "560.2", "287.5", "250.40", "995.92", "038.9", "518.0", "070.70", "458.29", "348.30", "571.5", "518.5", "V58.67", "305.90" ]	icd9cm	[ [ [] ] ]	[ "89.68", "96.72", "89.64", "45.62", "99.22", "99.07", "96.04", "99.04", "54.59", "38.93" ]	icd9pcs	[ [ [] ] ]	8855, 8861	4271, 7669	303, 417	8987, 8994	2985, 2985	9612, 10186	2270, 2295		7806, 8832		8882, 8966		7695, 7783			9018, 9589		3715, 4248						2310, 2310															2704, 2966							231, 265											445, 1050						3001, 3699			2324, 2690								1072, 1969	1985, 2254
20,947	115,342	16128	Discharge summary	report	Admission Date: [2169-1-9] Discharge Date: [2169-1-31] Date of Birth: [2095-1-26] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 73 year old woman, status post a motor vehicle accident in [2168-1-10], during which she was not injured, but she went to the local Emergency Room. A chest x-ray done at that time looked suspicious and a follow up CAT scan was obtained which showed a thoraco-abdominal aneurysm. She was advised to see a cardiothoracic surgeon, which she did, following which she was scheduled for a thoraco-abdominal aneurysm repair. PAST MEDICAL HISTORY: The patient's past medical history is significant for hypertension, hypercholesterolemia, osteoarthritis, non-insulin dependent diabetes mellitus and low back pain. PAST SURGICAL HISTORY: Past surgical history is significant for a left breast lumpectomy, a cholecystectomy, right hand ganglion resection and a T and A. MEDICATIONS: Meds at home include Avandia, 4 mg q a.m.; aspirin, 81 mg daily; Toprol, 10 mg daily; Lipitor, 10 mg daily; Hydrochlorothiazide, 12.5 mg daily; and Celebrex, which the patient stopped prior to admission. SOCIAL HISTORY: Smokes one half to one pack of cigarettes per day times 33 years. Occasional ETOH use. Denies any other recreational drug use. She has three children and lives with her husband. FAMILY HISTORY: Father died of an MI. Mother died of old age. PHYSICAL EXAMINATION: Weight 214 pounds, height 5 feet 4 inches. Vital signs: Temperature 98.9. Heart rate 81. Blood pressure 137/58. Respiratory rate 18. O2 sat 97 percent on room air. General: No acute distress. Neurologic: Alert and oriented times four. No focal deficits. Respiratory: Respiratory clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. S1 and S2. Abdomen: Soft and nontender, non-distended with normoactive bowel sounds and a well healed cholecystectomy scar. No bruits appreciated. Extremities: Warm and well perfused with no ulcers and bilateral lower extremity edema. LABORATORY DATA: White count 10.6, hematocrit 41, platelets 215. Sodium 145, potassium 4.2, chloride 107, CO2 31, BUN 18, creatinine 0.8, glucose 110. LFT's within normal limits. Albumin 4.6. UA was negative. Chest x-ray showed no cardiopulmonary processes and the patient was consented for a thoracoabdominal aneurysm repair. HOSPITAL COURSE: On the first of [Month (only) 956] the past was brought to the operating room. Please see the OR report for full details. In summary, the patient had a thoracoabdominal aneurysm resection and replacement of the descending aorta with a number 28 Hemashield graft from the distal left subclavian to the suprailiac. She tolerated the operation and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer the patient was in sinus rhythm at 70 beats per minute with a mean arterial pressure of 71 and a CVT of 15. The patient did well in the immediate postoperative period. Her anesthesia was reversed. The sedation was weaned to the point where the patient was following commands and moving all four extremities, and then her sedation was reinstated. She remained ventilated throughout the course of the operative day, requiring nitroglycerin and Propofol to maintain an adequate blood pressure. On postoperative day the patient continued to do well. By chest x-ray it appeared that the patient had a left-sided infiltrate and a bronchoscopy was done at that time which showed both left upper and left lower lobe mucous plugging, following which the patient's oxygenation remained a problem, and therefore she was a slow wean from the ventilator. On postoperative day two the patient remained hemodynamically stable. She continued to slowly wean from the ventilator. However, she did have periods of atrial fibrillation for which she was begun on beta blockade, as well as Amiodarone. Additionally the patient underwent a second bronchoscopy, which showed tenacious secretions in both left upper and lower airways. Finally the patient was cardioverted from atrial fibrillation into sinus rhythm. On postoperative day three the patient continued to do well. She unfortunately went back into atrial fibrillation following a short run of sinus rhythm after cardioversion. She continued to slowly wean from her vaso-active medications. We were unable to make any progress in her ventilatory status, and neurologically the patient's sedation was held to the point where she would follow commands and move all extremities. However, she became increasingly agitated and required re-sedation. Over the next several days, the patient remained hemodynamically stable. Several attempts were made to wean the patient from the ventilator, however they were all unsuccessful. On postoperative day six the patient again underwent a bronchoscopy, during which cultures were obtained and sent to the laboratory. The bronchoscopy again showed left upper lobe secretions that were tenacious and a clear right airway. Over the next several days the patient remained hemodynamically stable. The decision was made to bronch the patient on a daily basis, following which several attempts were again made to wean the patient from the ventilator. Each attempt was unsuccessful. By postoperative day 13 the patient was able to be weaned to pressure support ventilation with 5 of pressure support and 5 of PEEP support. The patient tolerated this well. Throughout the day she was rested on increased pressure support overnight and the following morning returned to [4-13] and extubated. The patient failed extubation after several hours, was reintubated. Bronchoscopy was done at that time that showed patent right upper and lower lobes, and completely obstructed left lower lobe with mucous plugs in the left upper lobe as well. At that time the patient additionally required PEEP 12 in order to oxygenate adequately and a plan was made for the patient to undergo a tracheostomy on the following day. On [2169-1-26] the patient underwent tracheostomy with a number 8 Pore-Tex. The procedure was tolerated well and there were no complications. Following tracheostomy the patient was able to be placed back on pressure support ventilation, and within several days was successfully weaned to trach collar vent, tolerating placement of the tracheostomy. The patient was seen by the speech and swallow service. On the [1-30] she underwent a bedside swallow evaluation, as well as a video assisted swallow evaluation, which she passed without restriction. Her diet was advanced at that time. At that time the decision was made that the patient was stable and ready to be transferred to rehabilitation. Rehabilitation screening process was done. At the time of this dictation, which is the [1-31], the patient's physical exam is as follows: General: No acute distress. Neurological: Alert and oriented and moves all extremities. Follows commands. Respiratory: The patient with a number 8 Pore-Tex trach ventilating with a 40 percent trach mask, coarse breath sounds throughout, somewhat diminished in the left lower lobe. Cardiovascular: Regular rate and rhythm. S1 and S2 with no murmurs. Left thoracoabdominal incision with staples. Small areas of erythema but no drainage. Abdomen: Soft and nontender and non-distended with normoactive bowel sounds. Extremities: Warm and well perfused with 1 plus bilateral edema. The skin additionally a red, yeasty-looking rash in the groin and the buttocks, currently being treated with Miconazole powder. LABORATORY DATA: White count 12.5, hematocrit 32, platelets 325, PT 14, PTT 25, INR 1.3. Sodium 134, potassium 4.6, chloride 96, CO2 30, BUN 41, creatinine 0.8, glucose 127. CONDITION ON DISCHARGE: The patient's condition at the time of discharge is good. DISCHARGE DIAGNOSES: 1. Status post thoracoabdominal aneurysm repair with a number 28 Hemashield graft from the distal left subclavian to the suprailiac done on [1-10]. 2. Status post tracheostomy with a number 8 Pore-Tex done on [1-26]. 3. Hypertension. 4. Hypercholesterolemia. 5. Osteoarthritis. 6. Diabetes mellitus type 2. 7. Low back pain. 8. Cholecystectomy. 9. Breast CA, status post lumpectomy. DISCHARGE MEDICATIONS: The patient's discharge medications include: 1. Aspirin, 81 mg daily. 2. Colace, 100 mg [Hospital1 ]. 3. Atrovent inhaler, [Hospital1 ]. 4. Lansoprazole, 30 mg daily. 5. Albuterol inhaler, 4 puffs q4h. 6. Metoprolol, 50 mg tid. 7. Avandia, 4 mg daily. 8. Amiodarone, 400 mg [Hospital1 ] times 7 days, then 400 mg daily times 7 days, then 200 mg daily. 9. Miconazole Powder, [Hospital1 ] prn. 10. Vancomycin, 1 gram q12h times 3 days, the last dose being on [2169-2-3]. DI[Last Name (STitle) ]ION: The patient is to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] two to three weeks after discharge from rehabilitation, and follow up with Dr. [Last Name (Prefixes) ] four weeks following discharge from [Hospital ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ]. ADDENDUM: The patient tube feed regime is intact with fiber via Dobbhoff tube at 65 cc per hour until the patient is taking adequate oral nutrition, at which time tube feeds and Dobbhoff can be discontinued. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2169-1-31] 11:41:59 T: [2169-1-31] 12:23:31 Job#: [Job Number 46105]	[ "V45.79", "998.12", "997.1", "427.31", "041.19", "112.1", "496", "715.90", "441.7", "305.1", "997.3", "996.62", "518.5", "486", "V10.3", "518.0", "112.3", "E878.2", "250.00", "401.9", "724.2", "272.0" ]	icd9cm	[ [ [] ] ]	[ "38.44", "38.45", "39.61", "99.04", "00.13", "96.05", "38.93", "33.22", "96.6", "96.56", "96.04", "96.72", "31.1" ]	icd9pcs	[ [ [] ] ]							1386, 1434	7931, 8333	8357, 9691					2418, 7826								819, 1170													1457, 2400																						164, 606																	629, 795	1187, 1369	7851, 7910
19,437	163,223	8307	Discharge summary	report	Admission Date: [2153-3-26] Discharge Date: [2153-3-31] Date of Birth: [2073-12-2] Sex: M Service: CARDIOTHORACIC Allergies: Aspirin Attending:[First Name3 (LF) 1283] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [2153-3-26] Aortic Valve Replacment(25mm [Company 1543] Mosaic Porcine Valve). Replacement of Ascending Aorta(30mm Gelweave Graft). Single Vessel Coronary Artery Bypass Grafting utilizing saphenous vein graft to right coronary artery. History of Present Illness: This is a 79 year old male with known ascending aortic aneurysm since [2151]. Since that time, serial scans have shown progressive enlargement and echocardiograms have shown worsening aortic insufficiency. He remains asymptomatic. In preperation for surgical intervention, he underwent cardiac catheterization Past Medical History: Ascending Aortic Aneurysm, Aortic Insufficiency, Coronary Artery Disease, Hypercholesterolemia, Lung Nodules, Benign Prostatic Hypertrophy, Deviated Nasal Septum, s/p Pilonoidal Cyst Removal, s/p Hernia Repair Social History: retired electronic engineer history of cigar smoking, wuit [2146] - etoh Family History: sister s/p AVR age 67 Physical Exam: HR 74 RR 18 137/64 NAD 2 small cysts on chest level of t2 on lateral aspect of sternum Lungs CTAB CV RRR 2/6 systolic murmur, [3-6] diastolic murmur Abdomen benign No varicosities noted Pertinent Results: [2153-3-31] 07:10AM BLOOD WBC-12.2* RBC-3.69* Hgb-11.0* Hct-31.5* MCV-86 MCH-29.9 MCHC-34.9 RDW-14.2 Plt Ct-242 [2153-3-31] 07:10AM BLOOD Plt Ct-242 [2153-3-30] 06:05AM BLOOD PT-14.1* PTT-29.0 INR(PT)-1.3* [2153-3-31] 07:10AM BLOOD Glucose-79 UreaN-17 Creat-1.2 Na-137 K-4.0 Cl-101 HCO3-28 AnGap-12 CXR [3-30] Comparison is made to [2153-3-29]. The patient is status post median sternotomy and valve replacement. Cardiomediastinal contours are unchanged. Pulmonary vascularity is unremarkable. A small right-sided pleural effusion is noted. Lungs appear grossly clear. Right apical pneumothorax appears smaller today with tiny component likely remaining. Brief Hospital Course: He was taken to the operating room on [3-26] where he underwent an ascending aortic aneurysm, CABG x 1 (SVG->RCA), AVR (#25 [Company ] mosaic porcine). He was transferred to the ICU in critical but stable condition. He was extubated and weaned from his vasoactive drips later that same day. He was trasnferred to the floor on POD #1. He was seen by opthamology for blurry and painful right eye and was found to have a corneal abrasian, he was started on artificial tears and erythromicin ointment. Late on POD #2 he went into rapid afib, he was given lopressor and amiodarone with little results. His blood pressure remained in the 90s systolic and he was seen by electrophysiology. He spontaneously converted to NSR on POD #3. He was started on cipro for a UTI. He was ready for discharge on POD #5. Medications on Admission: lipitor, atenolol 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 1 weeks. Disp:7 Tablet(s) Refills:0 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily) for 7 days. Disp:14 Capsule, Sustained Release(s) Refills:0 10. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA of Greater [Location (un) 5871]/[Location (un) 6159] Discharge Diagnosis: Ascending Aortic Aneurysm, Aortic Insufficiency, Coronary Artery Disease - s/p Ascending Aortic Replacement, Aortic Valve Replacement and Coronary Artery Bypass Grafting, Postop Atrial Fibrillation, Hypercholesterolemia, Lung Nodules, Benign Prostatic Hypertrophy Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [Last Name (STitle) 1290] in [4-5] weeks. Local PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 141] in [2-3] weeks. Local cardiologist, Dr. [Last Name (STitle) ] in [2-3] weeks. Completed by:[2153-4-2]	[ "272.0", "599.0", "424.1", "V15.82", "441.4", "414.01", "997.1", "E878.2", "V17.4", "518.89", "918.1", "427.31", "512.1", "600.00", "E849.7", "366.9" ]	icd9cm	[ [ [] ] ]	[ "35.22", "39.61", "36.11", "36.15", "38.44", "88.72" ]	icd9pcs	[ [ [] ] ]	4355, 4450	2172, 2983	287, 532	4758, 4765	1468, 2149	5083, 5346	1219, 1242		3051, 4332		4471, 4737		3009, 3028			4789, 5060								1257, 1449																						235, 249											560, 875																	897, 1109	1125, 1203
57,952	117,200	19910	Discharge summary	report	Admission Date: [2114-6-20] Discharge Date: [2114-6-21] Date of Birth: [2065-9-10] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: DOE Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: 48 y/o male with HTN, HCV, and ESRD (on HD MWF) presenting to ED c/o facial puffiness and dyspnea on exertion in the context of missing his previous two dialysis sessions (Monday and today). Patient states that he couldn't get a ride to dialysis center ([Hospital1 ]). Denies CP/F/ABP/N/V/D, denies any pain. HD catheter c/d/i. . In ED, initial vs were: 96.8 80 169/105 20 100%. Potassium found to be 8.3 (hemolyzed). Repeat 7.0. EKG showed slightly peaked T waves in V3-v4, but not diffusely. He was felt to be somewhat somnolent, but responsive to stimuli. He reportedly has a history of chewing on saboxone patches. He was AO x 3 with a normal physical exma. . He received calcium gluconate 1 amp, 1.5 amps dextrose, 10 units insulin. He was seen by renal team, and was admitted to MICU for urgent HD, as he makes minimal urine. CXR c/w volume overload. L EJ was placed for access. . On the floor, his BG was noted to be < 50 and he required an amp of D50. . Review of systems: as per HPI. Remainder of 10 point ROS negative. Past Medical History: - HTN for several years - HCV X 10yrs - Asthma X 15yrs - ESRD (unsure of etiology) - HD MWF (for the past 8-9yrs) - denies MI, DM, CAD but endorses having had episodes of CP previously Social History: (+) tobacco [2-24]/day X 34yrs; etoh 3 drinks ([Last Name (un) ], congac) per day X 34yrs; + IVDU (heroin) in past. Live with parents in [Location (un) ]. Family History: Mother - asthma, htn. Father - healthy, brother died of HIV Physical Exam: Vs: 95.7, 72, 142/87, 19, 93% RA Gen: African American male lying in bed in NAD, drowsy, apprearing older than stated age. HEENT: MMM, poor dentition, no JVD Skin: dialysis cath site look clean and intact, old sutures in left inner thigh from previous dialysis grafts, scars in upper arms bilaterally from previous dialysis grafts Cardio: RRR, no murmurs, rubs, gallops Pulm: no use of accessory muscles, rales diffusely and bilaterally Abd: soft, nontender, nondistended, +BS Ext: warm, 2+ pulses in DP b/l, 1+ pitting edema Neuro: drowsy, oriented to place and person, not to day/date. not cooperating with exam. Exam upon leaving AMA largely unchanged with the following exceptions: Gen: more awake and alert, standing in doorway in street clothes Pulm: minimal rales at bases b/l Ext: no edema Pertinent Results: Labs on Admission: [2114-6-20] 02:30PM BLOOD WBC-6.1 RBC-4.26* Hgb-11.6* Hct-35.6* MCV-84 MCH-27.1 MCHC-32.5 RDW-18.0* Plt Ct-180 [2114-6-20] 02:30PM BLOOD Neuts-72.8* Lymphs-16.5* Monos-4.7 Eos-5.7* Baso-0.4 [2114-6-20] 02:30PM BLOOD PT-12.5 PTT-31.8 INR(PT)-1.1 [2114-6-20] 02:30PM BLOOD Glucose-87 UreaN-66* Creat-15.1* Na-133 K-8.3* Cl-94* HCO3-17* AnGap-30* [2114-6-20] 03:00PM BLOOD ALT-22 AST-35 AlkPhos-166* TotBili-0.4 [2114-6-20] 11:00PM BLOOD Calcium-8.8 Phos-8.8* Mg-2.5 [2114-6-20] 03:00PM BLOOD Osmolal-308 [2114-6-20] 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2114-6-20] 02:36PM BLOOD Lactate-1.4 K-8.5* . Labs on Discharge: [2114-6-20] 11:00PM BLOOD WBC-4.7 RBC-4.37* Hgb-11.7* Hct-36.4* MCV-83 MCH-26.8* MCHC-32.2 RDW-18.0* Plt Ct-132* [2114-6-20] 11:00PM BLOOD Glucose-123* UreaN-47* Creat-11.9# Na-136 K-4.2 Cl-96 HCO3-23 AnGap-21 Brief Hospital Course: 48 y/o male with HTN, HCV, and ESRD (on HD MWF) presenting to ED c/o facial puffiness and dyspnea on exertion in the context of missing his previous two dialysis sessions. He completed urgent HD overnight due to elevated potassium to 7.0 and minimal ability to make urine at baseline. Repeat potassium was 4.2. . # Hyperkalemia/ESRD on HD: likely in the setting of missing his previous two dialysis sessions. Sessions were missed as he was couldn't get a ride to dialysis center ([Hospital1 ]). He received calcium gluconate, dextrose, and insulin in ED. He was admitted to MICU where he underwent urgent HD session overnight for 2 hours at 1 K solution. His K was 4.2 on discharge. There was consideration for additional UF, but patient declined this. He met with SW to arrange for future assistance and rides to dialysis center. He will continue nephrocaps on discharge. . # HTN: reportedly on clonidine, labetolol, atenolol, and ?lisinopril, and he will continue same medications on discharge. . # HCV: unclear status and unclear if he has received treatment in the past. Has been present for 10 years per patient. Patient elected to leave the MICU AMA, knowing that his [Hospital1 18] physicians felt it was medically most beneficial if he stayed. He was made aware of the risks of leaving (fluid overload and electrolyte imbalances). Patient stated he had an appointment at [Hospital6 ] for a fistula mapping and has chosen to leave against physician [Name Initial (PRE) 7219]. Patient is felt to be competent and able to make this decision. Medications on Admission: Medications: "I take lots of meds" -clonidine -promethazine -labetolol -atenolol -thyroid med -ASA 81 -?lisinopril Discharge Medications: 1. labetalol 100 mg Tablet Sig: One (1) Tablet PO twice a day. 2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 5. promethazine 12.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: 1. Hyperkalemia 2. ESRD on hemodialysis 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 swelling/edema and shortness of breath in the setting of missing two dialysis sessions. You received urgent dialysis in the ICU for severe electrolyte imbalance. Your electrolytes normalized, but the kidney team recommended you have dialysis again on [6-21]. You did not want to stay in the hosptial for this and decided to leave against medical advise. . MEDICATION CHANGES: - none You did not know all the doses of the medications you take. We called Dr.[Name (NI) 53740] office to ask about these but they did not have the information as you have not been seen there in some time. You did tell us you go to [Hospital1 2177] for primary care but do not know your PCP's last name and we could not find this out. Due to all of this we could not find out what medications you take and at what dose, and so were unable to give you prescriptions. . You met with the social workers to discuss ways to prevent missing HD sessions. Please use the resources which were provided for you. Followup Instructions: Please follow-up with your PCP, [Name10 (NameIs) ] [Hospital6 ]. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "276.7", "305.1", "403.91", "493.90", "V45.12", "V45.11", "585.6" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	5784, 5790	3656, 5221	315, 329	5883, 5883	2695, 2700	7091, 7303	1799, 1861		5386, 5761		5811, 5862		5247, 5363			6034, 6433								1876, 2676																			1342, 1391		6453, 7068	272, 277					3412, 3633						357, 1323									2714, 3393		5898, 6010						1413, 1599	1615, 1783
22,896	192,841	50939	Discharge summary	report	Admission Date: [2136-7-25] Discharge Date: [2136-8-1] Date of Birth: [2087-5-17] Sex: F Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: Ms. [Known lastname ] is a 49-year-old female with a history of coronary artery disease, status post percutaneous transluminal coronary angioplasty/stent of a proximal circumflex lesion in [2135-6-25]. The patient was admitted to [Hospital6 256] on [7-25] for cardiac catheterization due to recurrent chest pain. Cardiac catheterization showed a 90% LAD lesion at the origin from the OM, 30% circumflex lesion, chronically occluded PDA with a normal ejection fraction. PAST MEDICAL HISTORY: 1. Coronary artery disease 2. Status post percutaneous transluminal coronary angioplasty/stent [6-/2135] 3. Elevated cholesterol 4. Status post surgical removal of fibroids ALLERGIES: 1. NIFEDIPINE 2. SHELLFISH MEDICATIONS: 1. Aspirin 325 mg po q day 2. Verapamil SR 240 mg po q day 3. Lipitor 10 mg po q hs 4. Vitamins PHYSICAL EXAM: GENERAL: This is a 49-year-old female in no apparent distress. The patient is alert and oriented x3. VITAL SIGNS: Pulse 115, regular rate and rhythm. Blood pressure right arm 167/106, left arm 184/108, room air oxygen saturation 100%. HEART: Regular rate and rhythm without rub or murmur. LUNGS: Clear bilaterally. LABS: Hematocrit 37, platelet count 291. BUN 12, creatinine 0.8, potassium 6.7. White blood cell count 6.8. IMAGING: Electrocardiogram with sinus rhythm, rate of 76, nonspecific ST-T wave changes, no change since previous electrocardiogram. HO[Last Name (STitle) ] COURSE: The patient was admitted to [Hospital1 ] Hospital following her cardiac catheterization. Decision was made with cardiology and cardiac surgery that the high grade stenosis of the proximal LAD was not amenable to an interventional procedure. The patient was taken to the Operating Room by Dr. [Last Name (Prefixes) ] on [7-27] for an off pump coronary artery bypass graft x1, left internal mammary artery to LAD. The patient was transferred to the Intensive Care Unit in stable condition. The patient was weaned and extubated on her first postoperative night. The patient was started on Plavix on postoperative day #1. The patient remained in the unit on postoperative day #1 for control of her blood pressure, requiring intravenous sodium nitroprusside and nitroglycerin infusion which were weaned to off by postoperative day #2. The patient was transferred to the floor. The patient remained hemodynamically stable with an occasionally elevated blood pressure, titrating up on antihypertensives on postoperative days #3 and #4. The patient required extra encouragement to increase her physical therapy level on postoperative day #4. The patient completed physical therapy level 5, ambulating 500 feet and climbing one flight of stairs, remaining stable the entire time. The patient was cleared for discharge on postoperative day #5. DISCHARGE CONDITION: T-max 98.0??????, pulse 90 sinus rhythm, blood pressure 140/95, room air saturation 98%, respiratory rate 15, weight 74.5 kg. Neurologically, the patient is alert and oriented x3. Cardiovascular regular rate and rhythm without rub or murmur. Respiratory: Breath sounds are clear bilaterally. Gastrointestinal: Positive bowel sounds. Abdomen: Soft, nontender, nondistended. The patient is tolerating regular diet. Extremities: Without edema. Incision is clean and dry. Steri-Strips are intact. There is no drainage or erythema. Sternum is stable. Laboratory data from 8.5: White blood cell count 13.5, hematocrit 31.6, platelet count 211. Sodium 139, potassium 4.3, chloride 102, bicarbonate 25, BUN 7, creatinine 0.8, glucose 92. The patient is to be discharged to home on postoperative day #5 in stable condition. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft x1 2. Coronary artery disease 3. Hypertension 4. Elevated cholesterol 5. Status post surgical removal of fibroids DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q day 2. Ibuprofen 600 mg po q6h prn 3. Plavix 75 mg po q day x3 months 4. Lopressor 100 mg po bid 5. Captopril 25 mg po tid 6. Percocet 1 to 2 q4h prn 7. Lipitor 10 mg po q hs [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 35122] MEDQUIST36 D: [2136-8-1] 10:24 T: [2136-8-1] 11:24 JOB#: [Job Number 105867]	[ "V45.82", "401.9", "272.0", "413.9", "V17.3", "414.01" ]	icd9cm	[ [ [] ] ]	[ "88.53", "37.22", "88.56", "36.15" ]	icd9pcs	[ [ [] ] ]				3023, 3857				3878, 4042	4065, 4535															1038, 3001																																	176, 664																	686, 1023
59,516	129,916	54134	Discharge summary	report	Admission Date: [2195-8-19] Discharge Date: [2195-9-12] Date of Birth: [2134-9-18] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2777] Chief Complaint: wound dehiscence & infection Major Surgical or Invasive Procedure: None [2195-8-19] wound debrided at bedside [2195-8-24] wound debrided at bedside History of Present Illness: Mr. [Known lastname 110954] is a 60 year old gentleman with DMII, CAD s/p CABG, and HTN who underwent left superficial femoral artery to dorsalis pedis trunk bypass with reverse greater saphenous vein (harvested from the right leg) on [2195-7-13] by Dr. [Last Name (STitle) ] for left lower extremity ischemia and left heel gangrene. He had been recovering well without complaints until he returned to clinic for follow-up today and it was discovered when his staples were removed that he had a wound infection. His wound was opened in two places, one near the superior aspect of the wound (near his groin) and one around the mid-thigh. The graft does not seem to be involved. He was unable to tolerate deep/thorough debridement in clinic so he is being admitted for pain medication, bedside debridement, and antibiotic therapy. He currently denies pain, recent fevers/chills, difficulty walking, changes in sensation or motor strength of his bilateral lower extremities. Past Medical History: CHF with EF < 20%, global right and left ventricle hypokinesis DM2 on insulin HTN CAD: CABG [2187], on asa, plavix; MIBI in [1-31] w/out rev [First Name (Titles) 110951] [Last Name (Titles) 110952] Social History: - no current etoh - no cigarette smoking, no illegal drug use - blood transfusion once before, at hospitalization at [Hospital1 18] in [1-/2193] Family History: non-contributory Physical Exam: 97.6 76 136/76 18 97% RA irregularly irregular rhythm coarse breath sounds bilaterally soft, NT/ND, obese PEG tube in place PICC in L arm left upper thigh wound, dressing in place right upper thigh wound, dressing in place small areas of mild skin breakdown in b/l lower extremities R 1st and 2nd toe amputations L 4th and 5th toe amputations Pertinent Results: [2195-8-19] 04:20PM PT-13.6* PTT-26.3 INR(PT)-1.2* [2195-8-19] 04:20PM WBC-8.8 RBC-4.02* HGB-10.6* HCT-34.1* MCV-85 MCH-26.4# MCHC-31.1# RDW-14.0 [2195-8-19] 04:20PM NEUTS-67.4 LYMPHS-23.3 MONOS-6.6 EOS-2.2 BASOS-0.5 [2195-8-19] 04:20PM PLT COUNT-216 [2195-8-19] 04:20PM CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-2.7 [2195-8-19] 04:20PM GLUCOSE-158* UREA N-38* CREAT-2.6* SODIUM-137 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-27 ANION GAP-17 Brief Hospital Course: Mr. [Known lastname 110954] was seen in clinic on [2195-8-19] and was found to have a clearly infected groin wound from his prior bypass. He was admitted to the floor and placed on broad spectrum antibiotics with vancomycin, ceftriaxone, and metronidazole. The incision was opened at the bedside with a sterile [Doctor Last Name ] for drainage. On the evening of this admission, the patient arrested, with Pulseless electrical activity. He underwent 20 minutes of resuscitation whereupon a cardiac rhythm was obtained and he was transferred to the Cardiovascular Intensive Care Unit. An ECHO at that time showed an EF of 10%. He was intubated, sedated, and an NG tube was placed. He was aggressively fluid resuscitated as well as required pressor support. After this fluid resuscitation and successfully weaning the pressors, the patient was approximately 15 Liters positive. Naturally, the patient was seen by cardiology, who thought it was likely an NSTEMI but would require further workup once stabilized. During his stay in the CVICU, the wound was further opened and packed with wet-to-dry dressings. On HD 5, a silver wound vac was placed, which was changed every other day during his stay. Tube feeds were started and the patient was weaned off the vent over the next week. The antibiotics were continued, with discontinuation of the flagyl after 2 weeks. The patient was extubated on [2195-8-25]. After extubation, the NG tube was removed and the patient was evaluated by Speech and Swallow. He initially passed this evaluation but was noticed to be gargling and having difficulty swallowing. He failed further Speech and Swallow evaluations and thus was made strict NPO status. He was transferred from the Cardiovascular ICU to the Vascular Intermediate Care Unit on [2195-8-27]. The patient had new onset atrial fibrillation on the floor which was rate controlled with IV lopressor. He had a follow up ECHO after stabilization which showed an EF of 40%. He was started on TPN on [2195-9-3] but eventually need for a PEG tube was determined, which was placed on [2195-9-10]. Tube feeds were started and the patient is now at goal. The patient has residual neurologic findings likely due to anoxic brain injury during his arrest, this was evaluated on [2195-9-8] with a head CT, which was essentially negative. He is being discharged, afebrile, with stable hemodynamics, to a extended care facility. Active Issues: Neuro: follows commands, can move extremities CV: coumadin for afib, INR goal of [1-27]. GI: PEG tube, TF at goal, recommend adding banana flakes prn diarrhea GU: po lasix Heme: ASA, coumadin ID: Abx discontinued upon discharge Wound: wound vac, change every three days Medications on Admission: xanax 1mg TID, Amlodipine 5 mg Tablet QD, Coreg 25 QD, Clonidine 0.2 mg Tablet TID, Plavix 75, Lasix 80mg [Hospital1 ], Hydralazine 25 mg Tablet TID, Vicodin prn, Lantus 55 units in a.m., 22 units at night, Lisinopril 2.5 mg Tablet QD, zocor 40mg QD Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheeze. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day): to skin folds, skin surfaces . 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for secretions. 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for congestion. 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Goal INR [1-27]. 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold HR<55, SBP <100 . 14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): Hold SBP<110, HR<55 . 18. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush: Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. . 19. Regular Insulin SLiding Scale Insulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-60 mg/dL [12-26] amp D50 61-150 mg/dL 0 Units 151-200 mg/dL 7 Units 201-250 mg/dL 9 Units 251-300 mg/dL 11 Units 301-350 mg/dL 13 Units 351-400 mg/dL 15 Units > 400 mg/dL Notify M.D. 20. Outpatient Lab Work Weekly CBC, Cr and Vanco through while on ABX INR 2x per week and prn (Goal INR [1-27]) 21. Lantus 100 unit/mL Solution Sig: 18 units Subcutaneous at bedtime. 22. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): [Hospital1 ] to R groin wound . 23. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: Hold RR <12. Discharge Disposition: Extended Care Facility: [Hospital 5503] Rehab Hospital Discharge Diagnosis: 60M s/p left superficial femoral artery to tibial-peroneal trunk bypass for left heel gangrene with right greater saphenous vein admitted with left lower extremity wound dehiscennce, pulseless electrical activity arrest on floor, likely Myocardial infarction PMH/PSH: Diabetes mellitus Type 2, Hypertension, Coronary artery disease status post Coronary artery bypass graft, and Congestive heart failure. Discharge Condition: stable Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Surgery/Woundcare Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [1-27] 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 ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 2625] Date/Time:[2195-9-24] 10:15 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Cardiology: Please call his office at ([Telephone/Fax (1) 2037] to schedule a follow up appointment.	[ "250.80", "427.31", "707.07", "038.12", "V45.81", "E879.9", "707.23", "518.81", "998.59", "995.92", "403.90", "427.41", "707.22", "707.20", "707.01", "414.00", "427.5", "707.03", "585.9" ]	icd9cm	[ [ [] ] ]	[ "96.72", "96.04", "88.72", "99.60", "96.6", "86.22", "93.90", "99.04", "38.93", "43.11", "96.07", "99.15", "38.91", "31.42" ]	icd9pcs	[ [ [] ] ]	8451, 8512	2763, 5204	344, 435	8962, 8971	2272, 2740	10716, 11043	1873, 1891		5800, 8428		8533, 8941		5521, 5777			8995, 10283	10309, 10693							1906, 2253																						275, 306		5219, 5495									463, 1449																	1471, 1686	1702, 1857
46,038	184,442	38238	Discharge summary	report	Admission Date: [2152-12-16] Discharge Date: [2152-12-29] Date of Birth: [2072-1-21] Sex: M Service: MEDICINE Allergies: blueberries Attending:[First Name3 (LF) 3853] Chief Complaint: "hypoxia." Major Surgical or Invasive Procedure: Colonoscopy EGD History of Present Illness: Father [Name (NI) ] is an 80 year old male with past medical history of atrial fibrillation on coumadin, OSA, hypertension, hyperlipidemia, type 2 diabetes mellitus, anemia, h/o TIA and COPD on 3-4L home O2 who presents with four days of worsening dyspnea on exertion and non-productive cough. . In the past week, the patient has noticed increasing shortness of breath. He was able to increase his oxygen concentrator in order to walk around, initially, but eventually despite maximal settings, he still felt short of breath and could not move. He also endorses a dry cough X 3-4 days and feels as though he now has something in his chest but has been unable to bring anything up. Denies fevers/chills, symptoms of upper respiratory infection (sputum, rhinorrhea, itchy eyes, sore throat). He tried to increase his prednisone to 15mg daily, which did not help. He also felt he gained 10 pounds (normal weight 178 pounds), which he attrbiutes to prednisone usage. He has had multiple recent sick contacts (with URIs). Of note, patient has been on vacation for the past 16 days, traveling on trains to NJ and PA. No driving and flying recently. . He had his assistant call his outpatient pulmonologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], on [12-13] and was instructed to increase his prednisone further to 20mg daily. He was also started on a Z-Pak and saw Dr. [Last Name (STitle) ] in the Pulmonary office on [12-14]. His INR was noted that visit to be elevated to 5.3, possibly due to the Z-Pak and thus, his Coumadin 8mg daily was held for two days. Today his INR is 1.5. Because the patient's urinalysis from [12-14] was also infected, he was switched off Z-Pak to Ciprofloxacin. Patient saw his PCP [Name Initial (PRE) 1262] ([12-15]) who did not change current management. Ultimately, the patient developed a strange sensation in his chest before lunch today that was fleeting and self-resolving. He could not tolerate his shortness of breath anymore and presented to the [Hospital1 18] ED. . Initial VS in the ED: 98.2 81 106/30 24 91% 3L Nasal Cannula. Labs showed WBC 7.9, Hct 30.6, INR 1.5, Cr 1.1, Trop <0.01. CXR showed no acute process, but with severe emphysema. Patient was given 500mg azithromycin and 60mg prednisone and transferred to [Hospital Unit Name 153] for hypoxia and significant O2 requirement. VS prior to transfer: 98.4, 144/65, 82, 22, 91% on venturi mask 8L. . On arrival to the [Hospital Unit Name 153], the patient was breathing comfortably on 40% ventimask satting 94%. Other vitals: T: 98.0 BP: 161/75 P: 81 R: 16. Patient is without complaints. . Review of systems: (+) Per HPI. Notes some abdominal pain and constipation with bowel movements. Notes left hand pain that is improving with time, and managed with tylenol. (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies wheezing. Denies current 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: * Atrial fibrillation on coumadin * COPD (on 3-4L O2 at home) * OSA * TIA * Hypertension * Hyperlipidemia * Type 2 diabetes * History of tuberculosis * anemia * mild depression * glaucoma * legally blind and hard of hearing PSH: s/p cholecystectomy s/p appendectomy Social History: Priest, former [Name2 (NI) 1818] (quit 25 years ago - smokes 3 ppd X 40 years); no alcohol or illicit drugs. Currently lives in retirement facility in [Location (un) 86] area. HCP is Father [Name (NI) ] [Name (NI) ]. Family History: Mom: [Name (NI) 40342] cancer, sister: [Name (NI) 2481] dementia, 3 MIs (late in life) and CHF. 3 sisters with breast, lung, renal cancer. 2 nieces with breat CA. Physical Exam: Admission Exam: Vitals: T: 98.0 BP: 161/75 P: 81 R: 16 O2: 94% on 40% ventimask General: Alert, oriented, no acute distress, speaking full sentences HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: comfortable on ventimask, clear to auscultation bilaterally with minimal rales worse on the right base than the left, no wheezes or ronchi, no use of accessory muscles CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: old 10inch scar along the liver edge, obese, soft, non-tender, non-distended, normoactive bowel sounds, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses in posterior tibialis, no clubbing, cyanosis or edema, no calf tenderness or assymetry Neuro: alert and oriented times 2, CN grossly intact, [4-14] strength in all extremities, sensation intact to light touch and temperature. . Discharge Exam Tm:99.7 Tc: 96.6 BP: 140/58 HR:59 RR:18 O2 Sats 94 on 2.5 L I/O 24: 1340/2400 . pain: denies pain GEN: AAOX3, in NAD HEENT: CN 2-12 grossly intact(patient has anisicoria due to prior eye surgery), MMM, vision grossly abnormal NECK: no obvious thyroid masses, no lad CV: slightly irregualr, no rmg RESP: CTAB no wrr ABD: not TTP, flat, active BS X4 EXTR: UE: 5/5 strength, wwwp, pulses 2+ and equal, sensation grossly intact LE: 5/5 strength, wwp, pulses 2+ and equal, sensation grossly intact DERM: no obvious rashes neuro: vision grossly abnormal PSYCH: mood and affect wnl Pertinent Results: LABS: On admission: [2152-12-15] 12:00PM BLOOD WBC-9.2 RBC-2.82* Hgb-9.9* Hct-32.2* MCV-114* MCH-35.0* MCHC-30.6* RDW-17.7* Plt Ct-317 [2152-12-15] 12:00PM BLOOD Neuts-78* Bands-0 Lymphs-14* Monos-7 Eos-1 Baso-0 [2152-12-15] 12:00PM BLOOD PT-28.4* INR(PT)-2.7* [2152-12-15] 12:00PM BLOOD ESR-30* [2152-12-15] 12:00PM BLOOD Ret Aut-6.0* [2152-12-16] 01:50PM BLOOD Glucose-106* UreaN-23* Creat-1.0 Na-139 K-4.5 Cl-105 HCO3-23 AnGap-16 [2152-12-17] 05:10AM BLOOD CK(CPK)-20* [2152-12-15] 12:00PM BLOOD Iron-268* [2152-12-17] 05:10AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2 [2152-12-15] 12:00PM BLOOD calTIBC-316 Ferritn-24* TRF-243 [2152-12-15] 12:00PM BLOOD 25VitD-17* IMAGING: [12-16] wrist xray: IMPRESSION: Small ossified body adjacent to the scaphoid bone could be related to remote trauma, although an acute fracture cannot be excluded. Recommend correlation with clinical exam, particularly within the "snuff box." If clinical concern for a scaphoid fracture persists, repeat radiographs in 14 days would be advisable. [12-16] CXR: IMPRESSION: No acute cardiac or pulmonary process. Severe emphysema. [12-18] Echo: IMPRESSION: Suboptimal image quality. Normal biventricular systolic function. Mild LVH. Mildly dilated ascending aorta. Moderately thickened aortic valve leaflets without stenosis. Mild aortic and mild mitral regurgitation. Mild pulmonary hypertension. No evidence of intracardiac or intrapulmonary shunting on bubble study. Compared with the findings of the prior study (images reviewed) of [2152-6-13], the pulmonary hypertension is now mild. However, the patient's underlying atrial fibrillation during this study may underestimate true pulmonary pressures. The rest of the findings are similar. [12-18] CXR: IMPRESSION: 1. Bilateral ground-glass opacities likely represent an atypical infection. 2. Stable severe COPD. . [2152-12-27] EGD Normal mucosa in the esophagus Congestion and nodularity in the stomach compatible with gastritis (biopsy) Normal mucosa in the duodenum (biopsy) Small hiatal hernia Angioectasia in the second part of the duodenum Otherwise normal EGD to third part of the duodenum . EGD biopsies [2152-12-27] . [Known lastname ],[Known firstname ] (FATHER) [2072-1-21] 80 Male [Numeric Identifier 85229] [Numeric Identifier 85230] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/DR. [Last Name (STitle) ] [Last Name (NamePattern4) 16576] Gross Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) 7001], [Doctor Last Name 15785],[Doctor First Name ]/cofc SPECIMEN SUBMITTED: GI BX'S (2 JARS) Procedure date Tissue received Report Date Diagnosed by [2152-12-27] [2152-12-27] [2152-12-31] DR. [Last Name (STitle) ] [Last Name (NamePattern4) 7001]/ttl Previous biopsies: [-9/3924] CELL BLOCK (C10-[Numeric Identifier 85231]) DIAGNOSIS: Gastrointestinal mucosal biopsies, two: A. Gastric antrum: Antral/corpus mucosa with mild vascular congestion and surface foveolar zone hyperplasia. B. Duodenum: Duodenal mucosa, within normal limits. . C-scope [2152-12-27] Diverticulosis of the right colon Grade 2 internal hemorrhoids Polyps at 45 cm (polypectomy) Polyps in the sigmoid colon and rectum Otherwise normal colonoscopy to terminal ileum . Brief Hospital Course: 80 year old male with past medical history of atrial fibrillation on Coumadin, OSA, hypertension, hyperlipidemia, type 2 diabetes mellitus, anemia, h/o TIA and COPD on 3-4L home O2 who is admitted to the ICU for hypoxia and presumed COPD exacerbation with four days of worsening dyspnea on exertion and non-productive cough. . # Shortness of breath: Most likely an exacerbation of patient's known severe COPD (on home O2 3.5-4L NC). Differential diagnosis of common causes of shortness of breath includes pulmonary and cardiac etiologies: COPD exacerbation, MI/CHF, PNA, asthma, PE, anemia. Patient has had URI like symptoms with a dry cough. He has been partially treated with a levofloxacin, and oral prednisone of 20mg daily but continues to feel SOB. No evidence of CHF on exam despite 10lb weight gain (no significant rales or pedal edema) or CXR (does not appear fluid overloaded), echo several months ago with EF>55%, troponin neg x2, ECG similar to previous. Patient states he typically gains weight when put on short courses of steroids. No evidence of acute infectious process on CXR and WBC WNL (however Neut 90%). No history of asthma. PE less likely given symmetric nontender calves, subacute evolution of symptoms, and supra therapeutic INR; however patient has been traveling on trains over the past 16 days. Additionally, patient was noted to be more anemic than usual at 30.6 today (baseline appears to be 35-37) which could be contributing to symptoms. Patient was treated for COPD exacerbation with prednisone 60mg, tapering down to 20 per Pulmonology recs and azithromycin 500mg initially and then 250mg for a total of 5 days. Albuterol and ipratropium nebs given PRN for symptoms. After spending the night in the ICU, patient was weaned down off ventimask and satting 93% on 4L NC. On the floor the patient was doing well from a pulmonary perspective. He was at or below his baseline oxygen requirement during his stay. Communication with his outpatient Pulmonary physician [Last Name (NamePattern4) ]. [Last Name (STitle) ] was established and we decided that sending the patient out on no prednisone was appropriate given that he is at his baseline oxygen requirement and has no symptoms. . # Atrial fibrillation: Patient was found to have an INR of 5.3 in clinic several days prior to admission. His warfarin was held for 2 days and patient presented with an INR of 1.5. Warfarin 8mg (home dose) was restarted and INR was monitored with a goal of [1-12]. His CHADS-2 score is at least 4, so when it was determined that he would have an EGD/colonoscopy in house he was started on a heparin gtt. He will be bridged with lovenox on discharge. He was also re-started on 8 mg of Coumadin and given a prescription for a INR which will be followed by his PCP. . # DM2: HgbA1c 5.7 on [2152-10-3]. Held home metformin and glipizide in house, and managed on glargine and HISS. Patient now on prednisone, so insulin regimen was titrated as needed. He was restarted his home DM regimen on discharge. . # Hypertension: Patient is [Age over 90 ]-140/60-80 as an outpatient on home regimen of verapamil SR 180mg [Hospital1 ]. Verapamil was continued in house, but captopril was added for improved SBP control. This was then transitioned to lisinopril (has a history of non-compliance). Given that his BP control was still poor, HCTZ was added. After 1-2 days of monitoring, his BP was well controlled. [Month (only) 116] want to consider backing off on HCTZ if the patient's BP is significantly lower then baseline as outpatient. Strict BP control in this age group is likely not necessary. . # Anemia: Hct on admission was 30.6 (baseline 35-37), with no active signs of bleeding. Patient is chronically anemic, on iron supplementation. Per recent PCP note, patient was noted to have small amount of blood in stool and GI endoscopy is being planned as an outpatient. [2152-12-15] iron level above normal (268), ferritin low (24), TIBC 316. Retic count 6.0% (elevated). MCV 114 with normal B12 (439) and folate level (on supplementation). Ferrous sulfate 325mg [Hospital1 ] and folate supplementation were continued. Thyroid studies were normal. No evidence of bleeding. Stool was guaiac negative, but given anemia and difficulty in obtaining GI studies in the past (due to lung status), GI was consulted. EGD showed gastritis, hiatal hernia and a small angioectasia in the duodenum which was an unlikely source of the anemia. Colonoscopy showed polyps (removed) diverticulosis and hemorrhoids. Patient presented with Hgb 9.9 and was 10.7 on discharge. The patient should follow up with GI regarding a possible evalaution of the patients small bowel. . # Hand Pain: Radiographs do not clearly show a fracture. Clinically, patient is with mild pain to palpation over the 2nd metacarpal bone. Denied any trauma and states the pain has been improving with time and Tylenol. No erythema or warmth on exam, ROM intact. Symptoms monitored and pain was managed with Tylenol. . # Low Vitamin D: Patient's vitamin D level is 17 (<30) on recent labs. He was started on vitamin D supplements, 400mg daily. . # Hematuria: Patient with >182 RBC in UA, possibly related to increased INR, however 179 RBCs on UA several months ago. Consider further evaluation as an outpatient. . # Hyperlipidemia: continued home lipitor. . # Mild depression: Denied symptoms of depression currently, has been maintained on venlafaxine chronically. Continued home venlafaxine 75mg [Hospital1 ]. . # Glaucoma: Continued home Dorzolamide 2%/Timolol 0.5%. Patient will have remaining home medications brought in tomorrow as they are not on formulary. . Transitional Issues: * lovenox bridge and INR follow up with PCP (1-2 weeks) * Further BP regimen titration * hematuria work up * Pulmonary follow up in [12-11] weeks Medications on Admission: * Albuterol sulfate 90 mcg inhaler 2 puffs four times daily PRN shortness of breath * Atorvastatin [Lipitor] 10 mg Tablet daily * Ciprofloxacin 500 mg twice daily * Cyclosporine [Restasis] 0.05 % Dropperette 1 drop in the left eye twice a day * Dorzolamide-timolol [Cosopt] 2 %-0.5 % Drops 1 drop to left eye twice a day * Esomeprazole magnesium [Nexium] 40 mg daily * Folic acid 1mg daily * Glipizide [Glucotrol XL] 5mg daily * Loteprednol etabonate [Lotemax] 0.5 % Drops, Suspension 1 drop to left eye twice a day * Metformin 500 mg twice daily * Prednisone 20mg daily * Tiotropium bromide [Spiriva with HandiHaler] 18 mcg Capsule one capsule daily * Venlafaxine [Effexor XR] 75mg twice daily * Verapamil 180mg twice daily * Warfarin 8mg daily * Ferrous sulfate 325mg twice daily Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation four times a day. 2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 4. cyclosporine 0.05 % Dropperette Sig: One (1) Ophthalmic twice a day. 5. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 8. loteprednol etabonate 0.5 % Drops, Suspension Sig: One (1) Ophthalmic twice a day. 9. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a day). 12. warfarin 4 mg Tablet Sig: Two (2) Tablet PO once a day. 13. Lovenox 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous twice a day: please continue until follow up with PCP and INR is [1-12]. Disp:10 syringes Refills:2 14. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. verapamil 180 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 17. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 18. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: -COPD, severe, acute exacerbation -Anemia, acute on chronic blood loss -colonic polyps Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the ICU initially for a severe COPD ("emphysema") exacerbation. You were treated with steroids and an antibiotic. Your breathing improved. You were noted to have a rapid heart rate, and high blood pressure and your medications were adjusted. Your INR, though it had been high prior to coming to the hospital, fell during this admission and you were transitioned to a heparin (blood thinner) infusion while we waited for your INR to improve. You were noted to be anemic during this hospitalization, and the gastroenterology team was asked to help evaluate your anemia. You had a colonoscopy and upper endoscopy that showed gastritis and angioectasia in the small bowel. It was otherwise normal. Your colonoscopy showed polyps which were biopsied and you need to follow up with GI for a possible evalaution of your small bowel Followup Instructions: Department: [Hospital1 ] When: WEDNESDAY [2152-12-27] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 85232], MD [Telephone/Fax (1) 7477] Building: [State 7478] ([Location (un) 86], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: None Department: PULMONARY FUNCTION LAB When: MONDAY [2153-2-26] at 1:40 PM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: DIV. OF GASTROENTEROLOGY When: MONDAY [2153-1-22] at 10:45 AM With: [Name6 (MD) ] [Last Name (NamePattern4) 2163], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage	[ "365.9", "427.31", "562.10", "455.0", "V58.61", "599.0", "250.00", "268.9", "401.9", "V12.51", "311", "V46.2", "272.4", "790.92", "491.21", "518.81", "792.1", "369.4", "280.0", "729.5", "599.72", "276.0", "327.23", "535.50", "211.3", "V49.86", "285.1" ]	icd9cm	[ [ [] ] ]	[ "45.42", "45.16" ]	icd9pcs	[ [ [] ] ]	17642, 17699	9272, 14949	285, 303	17830, 17830	5827, 5834	18885, 19792	4102, 4274		15953, 17619		17720, 17809		15147, 15930			18013, 18862								4289, 5808																14970, 15121			3008, 3546			235, 247											331, 2989									5848, 9249		17845, 17989						3568, 3836	3852, 4086
32,737	151,135	34611	Discharge summary	report	Admission Date: [2138-8-20] Discharge Date: [2138-8-26] Date of Birth: [2057-2-28] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[Last Name (NamePattern4) 290] Chief Complaint: hypotension, hematemeisis Major Surgical or Invasive Procedure: RIJ Arterial Line Endoscopy History of Present Illness: HPI: Patient is an 81 y/o STR resident with a h/o CAD, CHF who was brought to [Hospital3 ] after complaining of epigastric pain associated with nausea and vomiting of bright red bloody emesis. In addition, the patient was noted to be hypothermic to 93F, as well as minimally responsive when EMS arrived on the scene, cold, clammy, and was witnessed to have vomited approximately a cup of "coffee ground red vomit" per EMS. Per son; he had taken patient out during the day, returning around 4pm at which time he was tired and took a nap. Later on he was more lethargic and fell asleep easily; then vomited watery blood around 7pm. The patient had been seen the week prior in the ED for hyponatremia, where he was placed briefly on a 1L fluid restriction. At that time, he was also given a course of Avelox for a presumed PNA? Per patient's son; 2 weeks ago he had 10 day long admission for pneumonia and UTI; previously living at home with son but following this admission patient went to short term rehab due to deconditioning. Per the OSH, the patient was hypotensive upon initial presentation with SBP's in the 50's and HCT of 20. The patient was then intubated in the setting of his hypovolemic shock, requiring Levophed for blood pressure support and shortly transferred to [Hospital1 18] for further management of his GIB. . Past Medical History: CHF (EF=?) CAD s/p CABG and PCI (PCI 8 years ago) in past DM type II Chronic Back Pain, on percocet and gets epidural injections COPD on 2L O2 at home and [Hospital1 1501] Social History: Social History: Smoker x 60 + years of 1.5-2 PPD; on nicotine patch since recent hospitalization. Prior to recent hospitalization, drank 2-3 beers per night. Widowed, one son in the area (lived with him), other son in [Name (NI) 108]. Family History: noncontributory Physical Exam: Physical Exam on admission: Vitals: T: BP: 115/41 P: 96 RR: O2Sat: 100% on Gen: Obese white male, intubated, lightly sedated, moving extremeties HEENT: PERRL, EOMI, sclerae anicteric. NGT in place draining dark red blood tinged material. No bright red blood, no coffee grounds. NECK: supple CV: Regular, nl s1/s2, no murmurs, L TLC in place with no erythema or pus at entry site. LUNGS: Poor air movement bilaterally L worse than R w/ Expiratory wheezes. No rhonchi ABD: soft, non-distended, hypoactive bowel sounds, + hepatomegaly. Rectal: guaiac positive, black tarry stool per ED @ OSH, no BRBPR here EXT: no lower extremity edema SKIN: blanching, mottled appearing skin over distal extremeties Pertinent Results: [2138-8-20] 01:45AM WBC-21.2* RBC-3.79* HGB-10.7* HCT-33.4* MCV-88 MCH-28.2 MCHC-32.0 RDW-16.5* [2138-8-20] 01:45AM CK-MB-NotDone [2138-8-20] 01:45AM cTropnT-<0.01 [2138-8-20] 01:45AM LIPASE-120* [2138-8-20] 01:45AM ALT(SGPT)-21 AST(SGOT)-30 CK(CPK)-52 ALK PHOS-62 TOT BILI-0.9 [2138-8-20] 01:45AM PLT SMR-NORMAL PLT COUNT-438 [2138-8-20] 01:45AM PT-14.5* PTT-23.3 INR(PT)-1.3* [2138-8-20] 01:45AM GLUCOSE-161* UREA N-38* CREAT-1.6* SODIUM-141 POTASSIUM-4.5 CHLORIDE-110* TOTAL CO2-20* ANION GAP-16 [2138-8-20] 03:00AM WBC-21.9* RBC-3.28* HGB-9.6* HCT-28.9* MCV-88 MCH-29.1 MCHC-33.1 RDW-16.7* [2138-8-20] 03:00AM TSH-2.0 [2138-8-20] 03:00AM ALBUMIN-2.7* CALCIUM-7.6* PHOSPHATE-4.9* MAGNESIUM-1.6 [2138-8-20] 03:00AM CK-MB-NotDone cTropnT-<0.01 [2138-8-20] 08:29AM HCT-27.5* [2138-8-20] 08:29AM CK-MB-NotDone cTropnT-<0.01 [2138-8-20] 08:29AM CK(CPK)-60 [2138-8-20] 09:48AM LACTATE-2.3* [2138-8-20] 02:46PM CK-MB-NotDone cTropnT-0.01 [2138-8-20] 02:46PM CK(CPK)-60 [2138-8-20] 03:21PM HCT-27.5* Brief Hospital Course: 81 yo man w/ h/o CAD, recent PNA, who was transferred with hypotension and hematemesis. # Shock: Patient with reported systolic BP's in the 50's at OSH upon initial presentation requiring Levophed for BP support & transferred to [Hospital1 18] on Levophed. Hypotension likely related to combination of GIB plus sepsis in the setting of fever and leukcytosis. Given cardiac history and PAT, cardiogenic shock was also an option. However a TTE showed hyperdynamic EF with fxnal obstruction, and CE were negative. The Pt remained dependent on pressors to maintain BP through the hospital course. Mr [Known lastname 79418] remained febrile throughout the course of hospitalization and was covered for suspected PNA with cipro, vanc, flagyl. A [8-22] sputum culture prelim was postitive for gram neg rods and yeast. The Pt under went CT torso with contrast, which showed no evidence of ulcer perforation, small B/L pleural effusions and compressive atelectasis, heterogenous airspace opacity in RUL, could be aspiration. Although a PNA was suspected because of imaging, fevers, and WBC up to 21, no definite source of infection was identified by culture prior to his death #Hematemesis/GIB: Per OSH notes, pt presented with bright red emesis, Hct of 20, s/p 3U PRBC transfusion, with Hct on transfer of 33. KUB reportedly unremarkable w/no evidence of free air @ OSH. Hct on admission to [Hospital1 18] 33. On exam, NG lavage: dark maroon colored gastric secretions. Stool guaiac + with dark tarry stools at OSH. No bright red blood per rectum. INR slightly elevated but platelet count high/normal. Recieved a total of 5 U pRBC. An Upper endoscopy by GI showed large ulcer, clot removed, not actively bleeding. Serial Hcts remained stable in 28s. Due to the patients shock surgery felt that he was not a good surgical candidate likely requiring a prolonged cause of mechanical ventilation and a fairly high surgical mortality risk. The family felt that Mr [Known lastname 79418] would not want to go through with a surgical procedure. The team talked at length with family about possibilty of bx ulcer to determine if CA. Since it was very possible that the bx would be inconclusive or falsely negative, the family declined to pursue. Family believes the prolonged trach and PEG necessary with stomach surgury would be against the pts wishes. . #Respiratory Failure: Pt intubated @ OSH presumably for airway protection given hypotension and poor mental status. CXR shows interval dev't of R lung opacities which may represent PNA. The pt remained vent dependent throughout the hosptial stay despite attempts at weaning. #Code Status: After lengthy discussion with hte pt's Son, [Name (NI) ] [Telephone/Fax (1) 79419] (Health Care Proxy) as well as the rest of the family the decision was made to transition Mr [Known lastname 79418] to CMO on [2137-8-24]. They strongly felts that the prolonged recovery, poor quality of life, and likely Trach and PEG associated with any surgery to repair the ulcer would be against his wishes. Therefore on [8-25] the pt was extubated, Levophed was withdrawen and all abx were stoped. Pt discomfort was aggressively treatment with fentanyl and versed gtts. Mr [Known lastname 79418] remained tachycardic and hypotensive after withdraw of aggressive measures. At approxamitely 3am the pt became progressively bradycardic and the RR lessened. At 410am the pt entered cardiac arrest. On exam at 420am the pt was without a pulse or respirations, pupils were fixed and dilated, and there was no corneal reflex. The pt was pernounced dead at 420am. Cause of death was determined to be circulatory failure leading to cardiac arrest with the antecedent cause of acute GIB. Medications on Admission: Lisinopril 5mg po daily ASA 325 mg po daily Lasix 20 mg po daily Lopressor 25mg po daily Tetracycline 250 mg po 4x/day DuoNebs Q6 hrs Combivent 18mcg Q6 hrs Percocet 5/325 Q4-6 hrs PRN Nitroglycerin SL PRN Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: death [2-22] circulatory failure leading to cardiac arrest. These events were percipitated by an acute Gastrointestinal bleed. Discharge Condition: expired Discharge Instructions: expired [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2138-8-28]	[ "427.5", "250.02", "280.0", "507.0", "518.0", "584.9", "286.9", "414.00", "401.9", "531.40", "V46.2", "995.92", "518.81", "785.52", "428.0", "038.9", "496" ]	icd9cm	[ [ [] ] ]	[ "99.04", "96.07", "99.15", "45.13", "96.72", "38.91", "38.93" ]	icd9pcs	[ [ [] ] ]	8102, 8111	4063, 7816	305, 334	8285, 8294	2930, 4040		2178, 2195		8073, 8079		8132, 8264		7842, 8050			8318, 8492								2210, 2224																						240, 267											362, 1706									2238, 2911								1728, 1906	1938, 2162
17,041	112,877	1471	Discharge summary	report	Admission Date: [2171-10-21] Discharge Date: [2171-10-23] Service: MEDICINE Allergies: Codeine / Penicillins Attending:[Male First Name (un) 4578] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization with successful PCI of the SVG to PDA History of Present Illness: HPI: Pt is an 83 yo man s/p CABG in [2151] (SVG-LAD, SVG-D1, SVG-LAD and numerous subsequent caths with stenting admitted to OSH with non-radiating, substernal CP, both exertional and non-exertional, without sweating/ dizziness, nausea. Pt had negative enzymes at that time as well as an EKG unchanghed from baseline. Pt felt pain was similar to past episodes of chest pain requiring hospitalization. Pt was transferred to [Hospital1 18]. Pt was shown to have patent stents in his [Last Name (LF) 8714], [First Name3 (LF) ] occluded SVG-D1, a patent stent to the SVG-LAD, and severe stenosis of his SVG-PDA. Successful PCI was performed on the SVG-PDA. Transient no-flow of the stented vessel was treated successfully with vasodilators. Past Medical History: PMH: CAD CABGX3 with multiple subsequent PCIs HL DM CRI Social History: The patient has a history of 30+ pack years of tobacco use. He quit 12 years ago. He uses alcohol occasionally. He has no history of recreational drug use. He lives with his wife. Family History: Father had a myocardial infarction at age 70. Mother had cancer and myocardial infarction. Brothers have diabetes. Physical Exam: PE: 97.4 BP: 140/89 hr:80 rr:18 99% RA Gen: mildly uncomfortable, nad heent: no jvd, no carotid bruits neck: supple with no thyromegaly cv: s1s2 rrr no mrg lungs: ctab no wheezes/rales/rhonchi abd: soft/nt/nd/+BS ext: no edema, peripheral pulses palapble and symmetric neuro: non-focal Pertinent Results: [2171-10-21] 09:03PM GLUCOSE-172* UREA N-50* CREAT-2.1* SODIUM-140 POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-31 ANION GAP-13 [2171-10-21] 09:03PM CK(CPK)-74 [2171-10-21] 09:03PM CK-MB-NotDone cTropnT-0.10* [2171-10-21] 09:03PM CALCIUM-8.3* PHOSPHATE-4.1 MAGNESIUM-1.8 [2171-10-21] 09:03PM WBC-3.4* RBC-3.85* HGB-11.1* HCT-30.1* MCV-78* MCH-28.8 MCHC-36.9* RDW-15.0 [2171-10-21] 09:03PM PLT COUNT-100* Brief Hospital Course: A/P: 83 yo male with h/o CABGX3 with multiple subsequent PCIs stabilized s/p cath with stenting of SVG-RCA. 1) Ischemia/CAD??????As above, the pt was treated with PCI to his SVG-PDA. However, post-cath the pt had [7-5] elevation in leads III and avF c/w inferior MI. The pt??????s CKs were elevated. This was felt to be [2-27] to debris loosened downstream of stenting. Post-cath there was no PCI indicated. His pain was treated with a nitro drip and morphine. He was weaned off the drip and placed on his home nitro dose. During this period his CKs peaked and began to fall. His CP resolved as did his ST elevations on EKG. Throughout his hospitalization he was continued on his home BB, ASA, and statin dose. Given his h/o DM an ACE-I was also added. 2) rhythm??????The pt remained in NSR throughout his admission. 3) pump??????The pt was given a stat ECHO post-cath as there was concern for PDA perforation/tamponade. However that ECHO showed no sign of perf/tamponade. A more complete Echo was later performed and showed and EF 50%. 4) renal failure??????The pt has a h/o CRI by report. This was felt to be likely [2-27] to contrast nephropathy overlying baseline CRI related to DM. He maintained a CR. At 2-2.3 throughout his hospital stay. For his cath he was pre and post-cath treated with mucormyst and bicarb. His Cr was followed throughout his stay and remained stable. Given his DM he was started and d/c??????d on an an ACE-I. 5) DM2??????Throughout his admission he was kept on an ISS and diabetic/card/renal diet. He was d/c??????d on his home glipizide. 6)ppx??????The pt was placed on sq hep throughout his admission. 7)FEN--DM/card/renal diet. His lytes were repleted as necessary. He was on IV bicarb pre- and post his cath. Medications on Admission: plavix asa atenolol simvastatin folic acid amlodipine isosorbide dinitrate MVI glipizide Discharge Medications: 1. Atenolol 50 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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Isosorbide Dinitrate 20 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:360 Tablet(s) Refills:2 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:30 Tablet(s) Refills:2 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Myocardial infarction Discharge Condition: Stable Discharge Instructions: Pt should contact PCP or go to [Name (NI) ] if: experiences chest pain or shortness of breath Pt should follow-up with PCP and cardiologist as below. Followup Instructions: Pt will be contact[Name (NI) ] by cardiologist to set up follow-up appointment. Pt has appt with PCP [Last Name (NamePattern4) ]. [Doctor Last Name 8715] [2171-11-1] at 11:30 am.	[ "V45.81", "997.1", "414.01", "V70.7", "583.81", "250.40", "996.72", "410.41" ]	icd9cm	[ [ [] ] ]	[ "99.04", "36.07", "36.01", "88.55", "37.22", "99.20", "88.52" ]	icd9pcs	[ [ [] ] ]	5230, 5236	2304, 4071	246, 310	5302, 5311	1848, 2281	5513, 5711	1396, 1527		4210, 5207		5257, 5281		4097, 4187			5335, 5490								1542, 1829																						196, 208											338, 1093																	1115, 1173	1189, 1380
26,901	117,444	24114	Discharge summary	report	Admission Date: [2186-5-10] Discharge Date: [2186-5-18] Date of Birth: [2160-11-6] Sex: M Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 2186] Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Mr. [Known lastname 61289] is a 25M with DM, ESRD on HD, recent PE at [Hospital1 112] [3-8] mo ago, who was sent in after routine labs showed hyperkalemia. In the ED, initial vitals were: 97.8 87 172/111 18 100. Complained of CP similar to prior PE. Exam without neuro deficits per ER. EKG done showed peaked Ts but felt similar to prior. Admit labs notable for hypoglycemia to 30, K 6.5, flat CK, tropn at his baseline. Bedside echo showed no pericardial effusion. Given kayexalate, calcium, insulin/glucose for his hyperK. Also given zofran, benadryl, dilaudid 1.25mg IV, and labetalol 100mg bolus and now on labetalol drip. Started on heparin drip given INR of 1 here. Last HD Monday, was due for HD today. Vitals prior to transfer 89 [Telephone/Fax (2) 61291]%RA. Access PIV x2, HD cath. On evaluation in the MICU, he is most concerned about pruritis. He says he wouldn't have come into the hospital had he not been told to do so because of his labs. He is not willing to give a detailed history but on specific questioning endorses midsternal chest discomfort that began in the cab, currently resolved. He says he felt dizzy with it, no SOB, no leg pains. He endorses a mild headache, no back pains. No vision changes - he is blind. He says he took pills the morning of admission, but can't recall the names of his medications. His mother helps him with his meds. He denies depression or substance use. Review of systems is otherwise negative for fevers, chills, sweats, recent illness. Past Medical History: Diabetes mellitus, type I. Diagnosed in [2162]. Poorly controlled with past DKA. Complicated with retinopathy, nephropathy. Hypertension, poorly controlled ESRD on HD MWF - nephrologist is [Doctor Last Name 4090] Pericarditis and pericardial effusion ?minoxidil related per renal note PE dx at [Hospital1 112] ~1mo ago per patient Chronic constipation Chronic anemia Oppositional defiant disorder Social History: Lives with mother. On disability. Smokes since age 16 - he can't say amount. Denies recent alcohol use. Denies illicit drug use including meth or cocaine. Family History: Father, grandmother with diabetes mellitus. No relatives currently on dialysis. Mother with [Last Name ] problem, details unknown to him. No history of clot. Physical Exam: Vitals 97 80 [Telephone/Fax (2) 61292]% on RA General Young man, scratching at body, no acute distress HEENT Anicteric, conjunctiva pale, MMM. PEARL, EOMI. +Bruxism Neck no JVD appreciated Pulm lungs clear bilaterally, no rales or wheezing CV regular S1 S2 no m/r/g +S4 Abd soft bowel sounds present nontender no bruit Extrem warm no edema palpable distal pulses. legs symmetric, nontender Neuro eyes closed but following commands, CN 2-12 intact aside light-only vision, full strength in bilateral upper and lower extremities, sensation intact to light touch, no pronator drift, able to sit up when asked to do so. Skin Multiple tattoos, nodules at sites of itching R tunneled catheter without tenderness or purulence. Pertinent Results: Admission Labs: [2186-5-10] 02:35PM WBC-7.7 RBC-2.75* HGB-8.2* HCT-25.8* MCV-94 MCH-30.0 MCHC-31.9 RDW-16.5* [2186-5-10] 02:35PM NEUTS-66.1 LYMPHS-22.4 MONOS-7.5 EOS-3.4 BASOS-0.5 [2186-5-10] 02:35PM PLT COUNT-541# [2186-5-10] 02:35PM CK-MB-3 cTropnT-0.35 [2186-5-10] 02:35PM CK(CPK)-117 [2186-5-10] 02:35PM GLUCOSE-32* UREA N-47* CREAT-8.7* SODIUM-133 POTASSIUM-6.5* CHLORIDE-93* TOTAL CO2-28 ANION GAP-19 [2186-5-10] 11:00PM CK-MB-3 cTropnT-0.32* STUDIES: EKG SR @84, borderline L axis, normal intervals, TWI in I and vL. No pathologic q's. Nonspecific STD, likely [3-7] LV strain. T's do appear peaked. +LVH by voltage. In comparison to [2185-10-16] EKG, TWI in I is new and axis is more leftward Repeat EKG 1am: notable for TWI in V5-V6 in setting of HTN 220/110's. [5-10] CT CHEST WITH IV CONTRAST: There is no pulmonary embolus or aortic dissection. Cardiomegaly is noted with a small amount of pericardial fluid. There is no pleural effusion or pneumothorax. There is no lymphadenopathy. A dialysis catheter terminates in the cavoatrial junction. There is no worrisome nodule, mass, or consolidation. Subsegmental atelectasis is noted at the left lung base. A hyperenhancing focus is seen in segment [Doctor First Name 690] of the liver measuring approximately 4 mm, not completely characterized on single phase study (3:61). A second hyperenhancing focus is seen in segment II of similar size (3:74). BONES: Osseous structures appear unremarkable. IMPRESSION: 1. No pulmonary embolus or aortic dissection. 2. Cardiomegaly with trace pericardial effusion. 3. Two tiny hyperenhancing foci in the liver, may represent focal nodular hyperplasia, though incompletely characterized on this exam. [5-10] CXR SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: There is moderate to marked cardiomegaly, with no evidence of congestive heart failure. There is no focal consolidation to suggest pneumonia. There is left lung base atelectasis, slightly less severe than previously seen. A right IJ dialysis catheter terminates near the cavoatrial junction. IMPRESSION: Cardiomegaly and left lung base atelectasis. [2186-5-11] TTE: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. An eccentric, posteriorly directed jet of Mild to moderate ([2-4]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. [2186-5-12] CT Head: No acute intracranial process. [2186-5-14]: ECG: Sinus rhythm. Possible left atrial abnormality. Left ventricular hypertrophy. Lateral ST-T wave changes may be due to left ventricular hypertrophy or ischemia. Compared to the previous tracing of [2186-5-11] there are more T wave inversions in leads V5-V6 which may be due to lead placement. However, clinical correlation is suggested. Discharge Labs: WBC 12.6, Hematocrit 32.1, Plts 467, INR 2.6, Na 141, K 4.2, Cl 92, HCO2 27, BUN 28, Crt 6.0, Gluc 186, AST 49, ALT 58, AlkP 696, T Bili 0.4 Pending Labs: Insulin antibody Brief Hospital Course: Mr. [Known lastname 61289] is a 25 year old man with ESRD on HD, Type 1 DM, recent PE who presented with hyperkalemia, chest pain, and hypertensive urgency. #. Hypertensive urgency: It was unclear what medication regimen he was taking as an outpatient prior to admission. It was felt that his hypertension on admission was most likely related to medication nonadherence, anxiety, and volume overload. He was initially managed on a labetalol drip but subsequently weaned off once his oral/transdermal medications used during his recent [Hospital1 112] hospitalization were initiated. His blood pressure remained difficult to control on an oral regimen as well and his oral labetalol was uptitrated. His blood pressure goal was 160-180/90-100 during this admission. He did have episodes of transient hypertension with SBP>200. He also had one episode of hypotension with SBP's in the 80's during hemodialysis. This was treated by giving back fluid during dialysis and his blood pressure normalized. #. Type 1 Diabetes Mellitus: He had labile blood sugars throughout this admission with both hypoglycemic and hyperglycemic episodes. He was followed closely by the [Hospital ] clinic and his lantus dose and humalog sliding scale were adjusted. #. Anxiety: He was very agitated on admission and did not always show insight and judgement about his medical conditions. He was initially treated with lorazepam and haloperidol as needed for anxiety. In the ICU, he was initially felt to not have capacity to leave against medical advice given his inconsistent ability to communicate his wishes and express understanding of the medical consequences of his decisions to refuse treatment. He became more agreeable during the rest of his hospitalization upon transfer to the floor, although commonly refused blood pressures and blood sugar monitoring. #. Hyperkalemia: He had hyperkalemia on admission with peaked T waves on ECG. He was given kayexalate with good effect. He had one further episode of hyperkalemia during his stay prior to dialysis and was given calcium gluconate and kayexalate for peaked T waves on ECG. On discharge, he was given a handout of foods high in potassium to avoid. #. Chest pain: He had chest pain on presentation to the ED but had no further CP on admission to the MICU. He had no evidence of dissection or PE on CTA chest. His cardiac enzymes were negative. It was felt that his CP symptoms were likely anxiety- related. #. History of PE: He had no evidence of recurrent PE on CTA. He had a subtherapeutic INR on admission and was started on a heparin drip as a bridge to Couamdin therapy. His INR at discharge was 2.6 and his heparin drip was stopped. He will need close monitoring of his INR after discharge. He will have his labs drawn at dialysis and faxed to his primary care provider. #. ESRD on HD: He was continued on HD MWF schedule. He was also continued on sevelemer, neutraphos. He had a few extra sessions of ultrafiltration while he was an inpatient. #. Pruritis: He had generalized pruritis and skin lesions thought to be consistent with prurigo nodularis. This was felt to possibly be related to uremia and he was managed with hydroxyzine. #. Elevated LFTs: He had persistently elevated LFTs (most notably Alk phos to the 600 range with mild elevation in AST/ALT). Upon review of his records from [Hospital1 112], he was extensively worked up there with RUQ ultrasound, hepatitis serologies, ceruloplasmin, automimmune workup, hemochromatosis labs, as well as other viral serologies. At that time, his elevated LFTs were thought to possible be due to right heart failure in the setting of PE. However, his lab abnormalities have persisted. Medication liver injury was considered a possibility and his statin was stopped due to this possibility in addition to some complaints of lower extremity muscle pain. Medications on Admission: patient says he gets refills at [Company 4916] pharmacy [Hospital1 8] St in [Location (un) 577]. many medications on hold as has not picked up for per [10/2185] DC summary he endorses names (with exceptions noted below) but can't recall doses. Lisinopril 40mg daily - on hold, not picked up since [2186-2-22] Clonidine 0.3mg patch qwednesday - on hold, last on [2186-1-23] Labetalol 800mg TID - last filled [2186-2-23] and picked up Hydral 10mg TID - last filled [2186-2-13] ASA 81mg daily - pt denies taking Sevelmer 667mg TID - on hold Famotidine 20mg QHS - last filled [12/2185] Simvastatin 20mg daily - last filled [12/2185] Metaclopramide 5mg q6h - not seen in system Insulin glargine 14 units [Hospital1 ] and humalog sliding scale - picked up [2-/2186] Nephrocaps daily - on hold Colace [Hospital1 ] prn - on hold Zofran prn Coumadin 8mg daily - on hold, not picked up Neurontin 300mg QHS - on hold, not picked up Celexa 20mg daily - on hold, last picked up [2186-1-23] Minoxidil 5g daily - on hold, last picked up [1-/2186] Iron - last picked up [12/2185] s/p Nifedipine 90mg XL . MEDICATIONS ON DISCHARGE [Hospital1 112] [4-18] Labetalol 400mg TID Lisinopril 40mg daily Losartan 50mg daily Coumadin 7.5mg QPM Tylenol 650mg Q6h Aspirin 81mg daily Clonidine 0.3mg/day Qweek patch Benadryl 25-50mg PO Q6hr Colace 100mg PO BID Fluocinonide 0.05% cream topical [Hospital1 ] Folic acid 1mg PO daily Gabapentin 400mg QAM, 400mg PM, 600mg QHS Dilaudid 1-2mg Q4hr Hydroxyzine 25mg QID Ibuprofen 600mg PO TID Lantus 25units QAM Aspart [2188-9-14] Reglan 10mg TID with meals Nephrocaps 1 tab PO daily Nicotine patch Omeprazole 20mg daily Sarna lotion daily prn Senna [Hospital1 *] Sevelamer 1600mg PO TID with meals Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:100 Tablet(s)* Refills:0 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Disp:5 Patch Weekly(s) Refills:2 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. 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 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 capsules Refills:2 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:2 9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. Disp:1 tube Refills:2 10. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for itching. Disp:90 Tablet(s) Refills:2 11. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:180 Tablet(s) Refills:2 12. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for anxiety. Disp:60 Tablet(s) Refills:0 13. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. Disp:60 Tablet(s) Refills:2 14. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:45 Tablet(s) Refills:2 15. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO twice a day. Disp:300 Tablet(s) Refills:2 16. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous at bedtime. Disp:qs Refills:2 17. Humalog 100 unit/mL Solution Sig: Insulin sliding scale as directed Subcutaneous four times a day. Disp:qs Refills:2 18. Outpatient Lab Work You should have your potassium and INR checked at your dialysis center on [2186-5-19] and [2186-5-22]. These results should be faxed to your primary care doctor Dr. [Last Name (STitle) 14166] at [Telephone/Fax (1) 43090]. 19. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 20. Prodigy Lancets Misc Sig: One (1) lancet Miscellaneous four times a day. Disp:120 lancets Refills:2 21. Prodigy Strip Sig: One (1) strip In [Last Name (un) 5153] five times a day. Disp:150 strips Refills:2 22. Alcohol Wipes Pads, Medicated Sig: One (1) pad Topical five times a day. Disp:1 box Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hyperkalemia Hypertensive Urgency Secondary Diagnosis: End Stage Renal Disease on Hemodialysis Type 1 Diabetes Mellitus History of Pulmonary Embolus 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 high potassium levels and high blood pressure. You underwent dialysis while you were here and your potassium levels returned to [Location 213]. Your blood pressure medications were changed as well. You had a low Coumadin level (INR) on admission and were placed on a heparin drip until your INR was in therapeutic range. It is important that you take your Coumadin at home and that you have your INR checked when you are at dialysis. These results should be faxed to Dr. [Last Name (STitle) 14166] who will help manage your dose of Coumadin. Changes to your medications: Increased labetalol to 1000mg by mouth two times daily Stopped hydralazine Started aspirin 325mg by mouth daily Increased Sevelamer to 1600mg by mouth three times daily with meals Stopped famotidine Added omeprazole 20mg by mouth daily Added metoclopramide 5mg by mouth three times daily Added nephrocaps 1 cap by mouth daily Added docusate 100mg by mouth twice daily Changed Coumadin to 5mg by mouth daily Changed insulin dosing: Lantus 22 units at bedtime and humalog sliding scale as directed Stopped simvastatin Followup Instructions: You have the following appointments scheduled: Name: [Last Name (LF) ],[First Name4 (NamePattern1) 1575] [Last Name (NamePattern1) 1105] MD Location: [Hospital3 ] HEALTH CENTER Address: [State ], [Location (un) ],[Numeric Identifier 60377] Phone: [Telephone/Fax (1) 14167] Appointment: [2186-6-1] 10:00am Name: [Last Name (LF) 978], [First Name7 (NamePattern1) 7208] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Last Name (un) ] DIABETES CENTER Address: ONE [Last Name (un) ] PLACE, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 2378] Appointment: [2186-6-8] 2:00pm Name: [Doctor Last Name ] Zrebiec, LICSW Location: [Last Name (un) ] DIABETES CENTER Address: ONE [Last Name (un) ] PLACE, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 61293] Appt: [2186-6-8] at 1:00pm	[ "250.43", "305.1", "V15.81", "790.4", "V02.54", "357.2", "313.81", "250.63", "585.6", "698.3", "250.83", "V45.11", "300.00", "V58.61", "250.53", "276.1", "285.21", "276.6", "276.7", "362.01", "V12.51", "794.31", "786.50", "361.07", "V58.67", "790.92", "369.00", "403.01" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	15404, 15410	6896, 10793	281, 295	15623, 15623	3379, 3379	16938, 17881	2457, 2620		12644, 15381		15431, 15431		10819, 12621			15774, 16369		6699, 6873						2635, 3360																		16398, 16915				229, 243											323, 1835			6288, 6683	15506, 15602		3395, 6279	15450, 15485				15638, 15750						1857, 2269	2285, 2441
74,702	144,987	42824	Discharge summary	report	Admission Date: [2175-1-3] Discharge Date: [2175-2-6] Date of Birth: [2151-8-21] Sex: M Service: NEUROLOGY Allergies: ceftriaxone Attending:[First Name3 (LF) 4583] Chief Complaint: Behavioral changes Major Surgical or Invasive Procedure: Lumbar Puncture Tracheostomy Percutaneous Gastrostomy History of Present Illness: The pt is a 23 y/o man who comes in with one day history of confusion. He was well until about 2 weeks ago when he started to complain of flu like symptoms, staying home and not going out with his friends for about 4-5 days. By Monday of last week he felt [Doctor Last Name ] and was able to go to work without a problem. At the end of the week he went to [Doctor Last Name 9437] to go snowboarding and then came back to [Location (un) 86] on Sunday for the NFL game. He drove back to Woster, MA without a problem but was complaining of some body aches on Monday. By Monday evening he was noted to be napping (although not abnormal for him) and needed help getting to his room (up the stairs) as he was lethargic, and on level ground he was having a shuffling type gait. He was placed in bed and his mother checked on him at night. She noted that he was unsettled/"thrashing" so she opened the door and then he awoke and stared to scream. SHe consoled him but when his dad came in he was startled again and started to scream. He then quieted down and then the next morning he was noted to be in bed, unable to get up, unable to answer questions, and had inappropriate laughter. He was then taken to [Hospital6 ] and subsequently transferred to [Hospital1 ] ED. Here in the ED he is awake but non-verbal and unable to give me any history. His mom notes that he had not complain of any rashes, bug or animal bites. They have a parakeet at home. He has one brother at home who is not sick. There has been no recent travel outside the states, but he did go to [State ] last year. Past Medical History: Cleft palate which was surgically corrected Murmur in childhood Social History: Parents state that he has smoked marijuana, drinks etoh occasionally, and have seen pictures of him with a cigarette. They think he is sexually active but believe he wears condoms. Family History: No history of meningitis, early strokes. Physical Exam: On Admission: Vitals: T: 99 P:61 R: 16 BP: 115/67 SaO2:100% ra General: Awake, looks around, chills. HEENT: NC/AT, MMM. Neck: Supple, no LAD noted. Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2 Abdomen: soft, NT/ND. Extremities: No edema or deformities. Skin: no rashes or lesions noted. Neurologic: -Mental Status:Alert, only verbally offered his name and when I asked where he was at he said hospital. He may have said that he also had the flu as well. Otherwise he did not offer spontaneous speech, had inappropriate laughter when I first started to talk to him, was rarely able to follow simple one step commands but mostly able to mime me. I held a NIHSS and asked him to point at specific pictures and he was unable to do so. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and [State 19912]. + blink to threat bilaterally. Funduscopic difficult to perform. III, IV, VI: lateral movements intact, no nystgmus noted. VII: No facial droop appreciated IX, X: Palate elevates symmetrically. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No tremor, asterixis noted. Stregth appreciated as full in the upper extremities at the deltoids, biceps, tricpes, and finger flexors. At the lower extremities he was not able to hold up his legs, and his heel slid back down when flexed at the knee, His quads were appreciated as 3- on the left and 2+ on the right. He wiggles his toes. -Sensory: he withdrew to pin-prick but not vigorously. -DTRs: [Name2 (NI) ] throughout including the ankles -Plantar response was extensor bilaterally. DISCHARGE EXAM: General: Awake and alert, NAD, follows commands. HEENT: NC/AT, MMM. Neck: Supple. Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2 Abdomen: soft, NT/ND. Extremities: No edema or deformities. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake and alert, trach in place but able to say a few words with Passy-Muir valve. Comprehension intact, follows commands well. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and [Name2 (NI) 19912]. III, IV, VI: EOMI VII: Face symmetric IX, X: Palate elevates symmetrically. XII: Tongue protrudes in midline. -Motor: Able to raise both arms anti-gravity, right somewhat better than left. Strong hand grasps, R>L. Able to provide some resistance in biceps, triceps, [3-16]. Able to lift legs anti-gravity off bed, [2-13] in IP's. Full strength distally, wiggles toes b/l. -Sensory: Responds to touch throughout. -DTRs: [Name2 (NI) ] throughout including the ankles. Plantar response extensor bilaterally. -Gait: deferred Pertinent Results: Admission Labs: [2175-1-3] 05:00PM BLOOD WBC-8.6 RBC-4.94 Hgb-14.9 Hct-40.5 MCV-82 MCH-30.3 MCHC-36.9* RDW-11.8 Plt Ct-207 [2175-1-3] 05:00PM BLOOD Neuts-79.1* Lymphs-14.1* Monos-5.7 Eos-0.2 Baso-0.9 [2175-1-3] 05:00PM BLOOD PT-12.7* PTT-31.9 INR(PT)-1.2* [2175-1-3] 05:00PM BLOOD Glucose-95 UreaN-8 Creat-1.1 Na-142 K-4.1 Cl-111* HCO3-23 AnGap-12 [2175-1-3] 05:00PM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1 [2175-1-5] 01:46AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2175-1-5] 01:46AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.002 [2175-1-5] 01:46AM URINE [2175-1-4] 01:27PM CEREBROSPINAL FLUID (CSF) WBC-10 RBC-1* Polys-1 Lymphs-89 Monos-0 Atyps-1 Macroph-9 [2175-1-4] 01:27PM CEREBROSPINAL FLUID (CSF) WBC-85 RBC-10* Polys-0 Lymphs-85 Monos-0 Macroph-15 [2175-1-4] 01:27PM CEREBROSPINAL FLUID (CSF) TotProt-76* Glucose-63 [2175-1-4] 01:27PM CEREBROSPINAL FLUID (CSF) ENTEROVIRUS PCR-NEGATIVE [2175-1-4] 01:27PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-NEG [2175-1-4] 01:27PM CEREBROSPINAL FLUID (CSF) MULTIPLE SCLEROSIS (MS) PROFILE-NOT CONSISTENT WITH MS [2175-1-4] 08:16AM CEREBROSPINAL FLUID (CSF) EBV-PCR-NEGATIVE [2175-1-4] 08:16AM CEREBROSPINAL FLUID (CSF) VARICELLA DNA (PCR)-NEGATIVE [2175-1-11] 01:35AM BLOOD IgA-117 [2175-1-3] 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Reports: CSF Cytology: NEGATIVE FOR MALIGNANT CELLS. Hypercellular specimen with lymphocytes, some with reactive features, and monocytes. EEG [2175-1-3]: This is an abnormal video EEG monitoring session because of very frequent electrographic seizures from bifrontal and left or right frontal regions. These frequent electrographic seizures are nearly continuous at the beginning of the recording and are consistent with non-convulsive status epilepticus. The background between seizures and after administration of intravenous lorazepam shows predominantly theta activity with excess beta activity indicative of a medication effect and moderate diffuse encephalopathy. EEG [2175-1-4]: This is an abnormal continuous ICU monitoring study which captured three pushbutton activations, one of which was for left arm extensor posturing during which diffuse delta frequency activity was seen without evolution and there was no evidence of electrographic seizure activity with any of the pushbuttons. There were frequent generalized, but left greater than right frontal spike and wave epileptiform discharges, indicative of an epileptogenic focus in the left frontal region with rapid spread. The background showed mixed frequency activity with excess beta activity and frequent bursts of delta activity and generalized suppression. These findings are indicative of a moderate to severe diffuse encephalopathy, and the excess beta activity was likely a reflection of medication effects. There were no electrographic seizures. EEG [2175-1-5]: This is an abnormal continuous ICU monitoring study due to the slow and disorganized background with excess beta activity indicative of an encephalopathy. There were frequent bursts of frontally predominant delta activity, indicative of deep midline or subcortical dysfunction. There were rare blunted generalized or bifrontal sharp wave discharges suggestive of underlying cortical irritability; however, there were no clear electrographic seizures. EEG [2175-1-6]: This is an abnormal continuous ICU monitoring study due to the slow and disorganized background, primarily in the [12-12] Hz delta frequency range, indicative of a severe encephalopathy and deep midline or subcortical dysfunction. There were infrequent broad-based generalized or bifrontal sharp wave discharges, suggestive of underlying cortical irritability; however, there were no clear electrographic seizures. There were three pushbutton activations during which no clinical or electrographic evidence of seizure activity was seen. EKG [2175-1-4]: Sinus rhythm and sinus arrhythmia. Non-specific inferior ST-T wave flattening. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 70 136 106 352/369 75 61 26 MR C/T Spine [2175-1-4]: 1. Extensive cervical spinal cord edema and signal abnormality, apparently segmental (though possibly continuous) from the cervicomedullary junction to the C3-4, and the C4-5 to C6-7 level. 2. No definite abnormal enhancement at these sites or elsewhere along the cord. 3. Equivocal subcentimeter T2-hyperintensity in the left lower lobe, not seen elsewhere and could represent an artifact. If clinical concern remains high, recommend follow-up with a CT chest. MR [Name13 (STitle) 430] w and w/o contrast [2175-1-4]: 1. Symmetric, diffuse, confluent T1-hypo and T2-/FLAIR-hyperintensity in bihemispheric subcortical and periventricular white matter, but also involving the thalami, pons and right middle cerebellar peduncle, concerning for a severe infectious/inflammatory process. 2. No definite enhancement post-contrast administration, hemorrhage or slow diffusion, as might be seen in active demyelination or some viral encephalitides. 3. No other structural lesion. EMG [2-1]: There is no evidence for a generalized demyelinating or axonal polyneuropathy. However, the electrophysiologic findings are consistent with a mild, generalized myopathy with modest denervating features, which could be consistent with critical illness myopathy in this clinical setting. There is also evidence for a mild ulnar neuropathy at the left elbow; the findings are also suggestive of a mild-moderate left peroneal neuropathy that cannot be well-localized. The markedly reduced activation in all muscles studied is consistent with the patient's known central pathology. CT torso [2-1]: IMPRESSION: 1. No evidence of pneumonia or abscess. 2. Resolution of right pleural effusion that was seen on prior examination with only minimal residual dependent atelectasis that is seen on current examination. 3. Left adrenal nodule that is not fully characterized. Comparison to prior examinations if available is recommended. CTA [2-2]: 1. Subsegmental pulmonary embolism in both lung bases. 2. Low-lying tracheostomy tube should be withdrawn by at least a centimeter. Brief Hospital Course: 1. Neurologic: The patient presented with a history of a flu-like illness 2 weeks prior and a day history of AMS and weakness. He was taken to an OSH his CSF was notable for a wbc 69 with 94%lymphs (rbc 10, TP 78, gluc 67). NCHCT was read as unremarkable. He was started on CTX, vanc, and acyclovir, and transferred to [Hospital1 18]. Upon admission, he initally came to our general neurology service in the step down unit. Overnight that first night of admission, he was placed on bedside EEG and found to be in NCSE. He was given ativan 1mg x 1 followed by Keppra load of 1500mg x 1 which resolved seizure activity. Maintanence was continued with Keppra 1000mg [Hospital1 ]. He then was taken down for MRI of brain and spine but could not perform due to agitation. Another dose of ativan was administered but due to concern of excessive sedation, MRI was still not performed. Over the course of the night, his exam also worsened as he was no longer answering questions or following commands. This and the need for the MRI with intubation prompted transfer to the ICU. The MRI was performed under general anesthesia, after which he was admitted to the ICU, still intubated. This imaging showed diffuse subcortical leukoencephalopathy with involvement of the thalamus, pons, and right middle cerebellar peduncle. A lumbar puncture was then performed which showed 10wbc (89%lymph), 1rbc, protein 76, and glucose 63. Given the concern for a demyelinating pattern on MRI, after infectious processes were ruled out, he was started on solumedrol 1g dialy x 5 days with a subsequent prednisone taper. He showed minimal response to this. His exam has remained relatively stable, with intermittent opening of eyes and tracking with no clear following of commands. He continues to have diffuse hypertonia and hyperreflexia with Babinski sign present bilaterally. His brainstem reflexes have remained intact throughout. EEG during his ICU course showed low amplitude 1-2hz frontally predominant delta rhythm. Initially there were frequent gneralized and bifrontal epileptiform discharges- this has improved. There was some concern of continued seizure activity with intermittent rhythmic eye blinking during his solumedrol infusions, however these ultimately showed no electrographic correlation. During this period, the keppra was increased transiently but after confirmation that these were not seizures, he was brought back to 1gm [Hospital1 ] which he currently remains on. The etiology for his presentation remained unclear. Infectious workup, as detailed below, was negative. MS profile was also sent and was negative. After transfer back to the floor (s/p trach and PEG), review of imaging and lack of response to both solumedrol and IVIG (initiated on transfer), raised concern for NMO and plasmapheresis was initiated [1-13]. NMO antibodies were ultimately negative. However EBV IgG and IgM were both positive, indicating a recent infection within the last 6 weeks. Given this, the most likely etiology appears to be ADEM related to a post-infectious encephalomyelitis. He improved significantly on plasmapheresis, of which he completed 10 courses between [1-13] and [2-3]. He will continue on Prednisone 60mg daily for a total of 6 weeks (through [2-15]). He will then be slowly tapered over a period of 6 weeks (10mg per week). 2. Infectious disease: Lumbar puncture as above showing lymphocytic pleocytosis. CSF has been negative for bacteria, AFB smear, HSV, EBV, VZV, enterovirus, cryptococcal antigen, and flu. Numerous blood and urine cultures have been collected during low grade fevers and have been negative. He was initially on ceftriaxone, vancomycin, and acyclovir prior to the return of CSF, these were subsequently discontinued. After tracheostomy on [1-10], he did develop a pneumonia with positive sputum cultures that grew GPCs in clusters/pairs as well as GNRs. Vancomycin and zosyn were initiated. When the specificities returned, he was narrowed down to ceftriaxone, however he developed a rash, presumed as a reaction to the CTX and was switched to cipro. He continued to spike low grade fevers prompting a repeat infectious workup without any identifiable source so ID was consulted. Per their recommendations, a CTA chest was obtained to evaluate concern of pneumonia further as well as rule out pulmonary embolism. It was unremarkable. Part of the infectious workup did show a positive blood culture from the PICC so this was removed and repeat culture was obtained. This was ultimately negative and vancomycin was then discontinued. He did continue to have a rash which showed improvement after discontinuing the zosyn and on standing benadryl, therefore supporting his reaction to beta-lactam antibiotics. He remained afebrile until [1-26], when he again developed low grade fevers. A repeat infectious work-up revealed a UTI with culture positive for pseudomonas and serratia. He was treated with Zoysn for 7 days and became afebrile. Repeat CXR and blood cultures were negative. CT torso showed no evidence of infection or abscess but did raise the question of small b/l subsegmental PE's. CTA confirmed this and he was started on anticoagulation. ID also recommended starting Bactrim SS 1 tab daily for PCP prophylaxis while on steroid therapy. He will also need a repeat EBV panel drawn in 2 weeks. 3. Respiratory: Due to his continued poor mental status, a tracheostomy was performed [1-10]. He has been stable on trach mask since, requiring FiO2 from 40-50%. CTA on [2-2] showed b/l small subsegmental PE's. He was started on Lovenox to bridge to Coumadin. 4. Cardiovascular: Has remained hemodynamically stable. Maintained on telemetry monitoring throughout admission with no significant events. 5. Nutrition: Due to his mental status, a PEG tube was placed [1-10] and he has been tolerating continuous tube feeds at 60ml/h. 6. Heme: Due to the persistent fevers and mildly increased O2 requirement with mild tachycardia, bilateral lower extremity ultrasound was performed on [1-17] to rule out DVTs. This was negative. A CTA chest was also performed on [1-18] and showed no evidence of a pulmonary embolism. He was maintained on subQ heparin prophylaxis. A repeat CTA was performed on [2-1] due to concern for small PE's seen on CT torso. This was positive for small b/l subsegmental PE's. Lower extremity dopplers were again negative. He was started on Lovenox 1mg/kg [Hospital1 ] as a bridge to Coumadin for anticoagulation. TRANSITIONAL CARE ISSUES 1. PT/OT, speech therapy, respiratory therapy, social work. [Known firstname 64702] will need intensive PT and OT to regain his strength. He still has a trach in place and has been tolerating some short trials of a Passy-Muir valve. He will need to be followed closely by speech and respiratory therapy and hopefully can work toward having the trach removed in the near future. His swallowing function also needs to be monitored closely. 2. He will need to remain on Keppra for seizure prophylaxis. 3. Prednisone should be continued at 60mg daily for a total of 6 weeks (through [2175-2-15]) and then should be tapered slowly over another 6 weeks (decrease by 10mg per week). While on prednisone he will need to be on Calcium + Vitamin D supplementation, famotidine, insulin sliding scale, and Bactrim for PCP [Name Initial (PRE) 1102]. 4. He will need to continue Lovenox 1mg/kg [Hospital1 ] until his INR is therapeutic between [1-13]. His coumadin dose is currently 5mg daily. INR will need to be monitored closely particularly as he will be on Bactrim. 5. He will need a repeat EBV panel drawn in 2 weeks. Medications on Admission: None Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Please give ACHS as per insulin sliding scale. 4. levetiracetam 100 mg/mL Solution Sig: One (1) PO BID (2 times a day). 5. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Continue 60mg daily through [2175-2-15]. Will then need to be tapered slowly over 6 weeks (down by 10mg per week). 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): To be given until INR therapeutic [1-13]. 11. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 12. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: ADEM - likely resulting from EBV infection Discharge Condition: Mental Status: Awake and alert Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you during your hospital stay. You were admitted to the Neurology service at [Hospital1 771] on [2175-1-3] due to behavioral changes including increased somnolence, gait changes, and agitation. Through a series of physical examinations, laboratory investigations, and neuroimaging studies, our best understanding of Mr. [Known lastname ]' condition is that he experienced an attack of ADEM (acute disseminated encephalomyelitis), which is an autoimmune nervous system condition that can occur after certain viral or flu-like infections. This may have resulted from a recent infection with [Doctor Last Name 3271]-[Doctor Last Name ] Virus, the cause of mononucleosis. As treatment for this condition, he received high dose intravenous steroid therapy as well as intravenous immuneglobulin therapy (IVIg), followed by an extended course of plasmapheresis. He will continue to be treated with steroids (Prednisone) after discharge. He was also started on a medication called Keppra to prevent seizures. To support his airway and nutrition, he received a tracheostomy and a percutaneous gastrostomy. He will be discharged to [Hospital1 ] to continue rehabilitation after discharge. He will require intensive rehab with physical, occupational, and speech therapy and will likely have a prolonged recovery course, but will hopefully steadily continue to improve. We made the following changes to your medications: Started Keppra 1000mg twice a day Started Prednisone 60mg daily. You will continue this dose until [2175-2-15] (total 6 weeks) and then it will need to be gradually tapered over the next 6 weeks (down by 10mg per week). Started Coumadin 5mg daily Started Lovenox injections 70mg twice a day until your coumadin level (INR) is therapeutic (between [1-13]) If you experience any of the below listed danger signs, please call your doctor or go to the nearest Emergency Department. Followup Instructions: You have the following appointment scheduled with Dr. [Last Name (STitle) 8760]: Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 1575] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 22205] Date/Time:[2175-3-23] 9:30 You also have an appointment scheduled with Dr. [Last Name (STitle) ]: Provider: [First Name8 (NamePattern2) 539] [Last Name (NamePattern1) 540] MD Phone:[Telephone/Fax (1) 541] Date/Time:[2175-4-25] 3:00 You will need to have your blood drawn for a repeat EBV test in 2 weeks. This can be done at your rehab facility.	[ "693.0", "794.8", "V13.64", "345.3", "075", "041.85", "041.7", "415.11", "V58.65", "599.0", "486", "E930.5", "112.0", "348.30", "323.61" ]	icd9cm	[ [ [] ] ]	[ "38.97", "03.31", "43.11", "96.72", "96.6", "31.1", "99.71" ]	icd9pcs	[ [ [] ] ]	20556, 20626	11360, 19051	290, 346	20713, 20713	4987, 4987	22896, 23510	2279, 2322		19106, 20533		20647, 20692		19077, 19083			20885, 22356				4358, 4968				2337, 2337						3951, 4197												22385, 22873				232, 252											374, 1977						5003, 11337			2351, 2653		20728, 20861						1999, 2064	2080, 2263
29,470	163,068	52753	Discharge summary	report	Admission Date: [2109-8-4] Discharge Date: [2109-8-30] Date of Birth: [2035-6-5] Sex: F Service: SURGERY Allergies: Codeine / Demerol Attending:[First Name3 (LF) 371] Chief Complaint: abdominal pain, diarrhea, and weakness that started [2109-8-3] Major Surgical or Invasive Procedure: s/p subtotal colectomy w/ end ileostomy History of Present Illness: Mrs. [Known lastname 20932] is a 74yo female s/p a left rotator cuff repair on [2109-7-26] who presented to an OSH on [2109-8-4] with c/o abdominmal pain, non-bloody diarrhea, and weakness that began on [2109-8-3]. She became unstable with sepsis, possible bowel ischemia vs. small bowel obstruction, hypotension refractory to vasopressors-SBP in 60's, and acute renal failure BUN-53, CR-1.9. She transferred to [Hospital1 18] for surgical evaluation. She became unstable on med flight transfer, and was intubated. She was admitted directly to the MICU upon arrival, then admitted to SICU post/op(s/p subtotal colectomy w/ end ileostomy). Past Medical History: PMH: HTN, diverticulitis, OA, RA, ? of PMR on prednisone x 10y, CRI PSH: s/p rotator cuff repair [2109-7-26], s/p bilateral hip replacements Social History: Married, lives with husband in [Name (NI) ], MA. H/o smoking cigarettes, quit. Denies ETOH or illicit drug use. Family History: Mother-CAD, [Name2 (NI) 499] cancer [Name (NI) 46425] [Name (NI) 108802] cancer, fibromylagia [Name (NI) 108803] myeloma Physical Exam: 95.5 66AF 96/60 AC60%/450x26/PEEP5 Gen: no apparent distress, alert and oriented x 3 HEENT: normocephalic, atraumatic, anicteric, neck supple, no masses Card: AFib, irregular rate Lungs: clear to auscultation bilaterally, no wheezes, rales, or rhonchi Abd: soft, nontender, nondistended, incision clean, dry, and intact; mucous fistula on lower left side of abdomen intact; ostomy pink and viable Ext: warm, several stable ecchymotic raised lesions on anterior lower extremities bilaterally, raised erythematous/ecchymotic lesion on right lower extremity Neuro: CNII-XII grossly intact Pertinent Results: Pathology Examination SPECIMEN SUBMITTED: [Name (NI) ] Tissue received Report Date Diagnosed by [2109-8-4] [2109-8-5] [2109-8-7] DR. [Last Name (STitle) ]. [Doctor Last Name ]/kg DIAGNOSIS: I. Ileocolectomy (A-K): 1. Segment of acute colitis with hemorrhage, involving the distal 16 cm and distal margin. 2. Acute peritonitis. 3. Proximal part of [Doctor Last Name 499] and ileal segment, within normal limits. II. Small intestinal segment (L and M): Within normal limits. Note: Probable causes of the acute colitis include ischemia and C. difficile infection. . Cardiology Report ECHO Study Date of [2109-8-5] IMPRESSION: Normal wall thicknesses and cavity sizes with low normal biventricular systolic function. Mild-moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Mildly dilated ascending aorta. Large left pleural effusion. CLINICAL IMPLICATIONS: Based on [2109] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . RADIOLOGY Final Report BILAT LOWER EXT VEINS PORT [2109-8-8] 9:05 AM [Hospital 93] MEDICAL CONDITION: 74 year old woman s/p subtotal colectomy. intubated REASON FOR THIS EXAMINATION: increasing LE swelling R>L TECHNIQUE: Two-dimensional grayscale, color, and pulse Doppler evaluation using a linear-array transducer. IMPRESSION: 1. Exam somewhat limited by dressings bilaterally. 2. Findings consistent with chronic thrombus within the left superficial femoral vein. . RADIOLOGY Final Report CT ABDOMEN W/O CONTRAST [2109-8-11] 11:57 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST [Hospital 93] MEDICAL CONDITION: 74 year old woman with postop ileus REASON FOR THIS EXAMINATION: ?abscess no IV contrast CONTRAINDICATIONS for IV CONTRAST: Cr 1.7, not indicated HISTORY: Post-operative ileus, evaluate for abscess. IMPRESSION: 1. Limited non-contrast CT of the abdomen and pelvis demonstrates ileus without evidence of transition point. 2. Moderate ascites. 3. Tiny right lower pole renal calculus. Mild right hydronephrosis without hydroureter, raises the possibility of ureteropelvic obstruction. . 4. Bilateral small pleural effusion with adjacent passive atelectasis. 5. 5-mm right middle lobe nodule. F/U CT chest is recommeded in 6 months. 6. Moderate-to-severe scoliosis with severe degenerative disease of the spine, and likely central canal stenosis. 7. Moderate aortic atherosclerotic disease with ectasia. There is also kinking of the mid abdominal aorta as described above. 8. Anasarca. . RADIOLOGY Final Report UNILAT LOWER EXT VEINS RIGHT [2109-8-16] 2:16 PM [Hospital 93] MEDICAL CONDITION: 74 year old woman with right leg pain and decreased sensation-starting below right knee. REASON FOR THIS EXAMINATION: Rule out RLE DVT RIGHT LOWER EXTREMITY VENOUS ULTRASOUND IMPRESSION: No evidence of DVT in the right lower extremity. . RADIOLOGY Final Report ABDOMEN (SUPINE & ERECT) [2109-8-21] 12:34 PM Reason: KUB for ?ileus [Hospital 93] MEDICAL CONDITION: 74F s/p subtotal colectomy w end ileostomy for ischemic colitis now has decreased ostomy output REASON FOR THIS EXAMINATION: KUB for ?ileus HISTORY: Evaluate for residual ileus, subtotal colectomy, and end ileostomy with decreased output of the ostomy site. Comparison is made to prior radiographs dated [2109-8-11] and CT dated [2109-8-12]. SUPINE AND LEFT LATERAL DECUBITUS ABDOMINAL RADIOGRAPHS FINDINGS: There has been slight progression to prominent loops of small bowel, most marked within the right upper quadrant with diffuse scattered air- fluid levels noted on the decubitus view. No evidence of pneumatosis or pneumoperitoneum. Extensive degenerative changes and scoliosis of the spine along with bilateral hip prostheses and radiopaque material projecting over the left inferior ramus are stable. A nasogastric tube is noted terminating within the gastric body. IMPRESSION: Slight progression to probable underlying ileus. Findings were discussed with surgical housestaff shortly after exam acquisition. . RADIOLOGY Final Report CHEST (PA & LAT) [2109-8-27] 4:20 PM [Hospital 93] MEDICAL CONDITION: 74 year old woman with oral temp spike 101.7, s/p subtotal colectomy w/ end ileostomy on [2109-8-4] REASON FOR THIS EXAMINATION: Rule out pneumonia TYPE OF EXAMINATION: Chest PA and lateral. INDICATION: Temperature spike to 101.7, status post subtotal colectomy with end ileostomy on [2109-8-4]. Evaluate for possible pneumonia. IMPRESSION: There is no evidence of pulmonary vascular congestion or new parenchymal infiltrates. The left lower lobe atelectasis or possible infiltrate does not show any significant interval change since the last chest examination of [2109-8-11]. This particular density was already identified on the first chest examination of [2109-8-4]. . RADIOLOGY Preliminary Report FINGER(S),2+VIEWS LEFT [2109-8-27] 10:51 AM SHOULDER [2-16] VIEWS NON TRAUMA ; FINGER(S),2+VIEWS LEFT Reason: LT SHOULDER PAIN, LT THUMB PAIN; R/O FX IMPRESSION: Moderate-to-severe osteoarthritis of the glenohumeral joint. Mild acromioclavicular osteoarthritis. IMPRESSION: 1. Severe osteoarthritis of the first CMC joint as above. Mild osteoarthritis of the first IP joint and triscaphe joint. 2. Suspected SLAC wrist. Further workup with dedicated wrist films suggested. 3. Amorphous calcification of the soft tissues adjacent to the ulnar styloid. . RADIOLOGY Preliminary Report SHOULDER [2-16] VIEWS NON TRAUMA LEFT [2109-8-27] 10:51 AM Reason: LT SHOULDER PAIN, LT THUMB PAIN; R/O FX IMPRESSION: Moderate-to-severe osteoarthritis of the glenohumeral joint. Mild acromioclavicular osteoarthritis. IMPRESSION: 1. Severe osteoarthritis of the first CMC joint as above. Mild osteoarthritis of the first IP joint and triscaphe joint. 2. Suspected SLAC wrist. Further workup with dedicated wrist films suggested. 3. Amorphous calcification of the soft tissues adjacent to the ulnar styloid. . RADIOLOGY Preliminary Report CT ABDOMEN W/O CONTRAST [2109-8-29] 11:31 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: CT abd po/iv contrast to r/o abscess [Hospital 93] MEDICAL CONDITION: 74 year old woman with postop ileus, pod25 s/p subtotal colectomy w end ileostomy, spiking fevers past 2d REASON FOR THIS EXAMINATION: CT abd po/iv contrast to r/o abscess CONTRAINDICATIONS for IV CONTRAST: None. CLINICAL INDICATION: Postoperative ileus postop day #25 status post subtotal colectomy, spiking fevers. TECHNIQUE: 0.625-mm helically-acquired images are obtained from the lung bases to the pubic symphysis without intravenous contrast. Multiplanar reformations are provided for interpretation. FINDINGS: Direct comparison is made to prior examination dated [2109-8-12]. Again, bibasilar atelectasis is noted, left greater than right. There has been an overall decrease in the amount of free intraperitoneal fluid. Small pericholecystic fluid is again noted. The liver, spleen, adrenal glands, and pancreas appear grossly unremarkable, given the limitations of a non-contrast CT. Again, stable dilatation of the right renal collecting system is identified. Also, a small, nonobstructing right renal calculus is seen. This may represent a congenital UPJ obstruction, however, renal cortex is not particularly thin. Left kidney appears unchanged since prior exam. The abdominal aorta appears tortuous and mildly ectatic measuring up to 2.8 cm at the level of the diaphragm. Significant atherosclerotic calcification is identified throughout. When compared to the prior examination, there has been significant decrease in the dilated loops of bowel. There is no evidence of bowel dilatation on the current exam. Evaluation of the pelvis is technically limited secondary to artifact related to the patient's hip arthroplasties. However, the pelvis appears grossly unremarkable. No lytic or blastic bony lesions are identified. Again, there are bilateral total hip arthroplasties. Bilateral L5 spondylolysis is identified. Significant multilevel degenerative changes are identified throughout the lumbar and visualized thoracic spine. IMPRESSION: 1. No evidence of acute intraabdominal abnormality. 2. Decrease in the amount of free intraperitoneal fluid since the prior exam. 3. Decrease in dilated loops of small bowel since prior exam. Brief Hospital Course: Mrs. [Known lastname 20932] is a 74yo woman who was transferred from [Hospital ] Hospital for hypotension and worsening hospital pain. At [Hospital1 18], she underwent a subtotal colectomy w/ end ileostomy, and was admitted to the SICU under the care of the General Surgery service for management. Her condition in the ICU stablized, and she was transferred to CC6. Cardiac-She has been in chronic AF. Her BP's have been stable. She was intially managed with IV antihypertensives, and switched to her oral medications. She will leave on lovenox and coumadin. She will require daily INR checks to titrate her coumadin prn. After becoming therapeutic on coumadin the lovenox may be d/c'ed. . Resp-Her resp status has remained stable, but decreased since her transfer from the ICU. She continues to use the IS appropriately. . Pain-She has complaints of chronic low back pain, and shoulder pain due to rotator cuff issues, and osteoporosis. An Acute Pain service consult was obtained on [2109-8-17]-please refer to attached note. Her narcotic pain regimen was discontinued due to ileus management and prevention of recurrence. She currently denies surgery-related pain. . Nut-After surgery she developed a post-op ileus which was treated with NPO/NGT/IVF. Her nutritional status was supplemented with TPN, and she was followed by Nutrition Services. After a course of bowel rest, her bowels resumed function with good ostomy output. She was slowly advance to a Regular diet with Ensure supplements. Her appetite is small, but she has tolerated solids well. . Elim-Her foley catheter was removed. She has been urinating adequate amounts of urine spontaneously. She recovered from her ileus. Her bowel sounds are present. Her ostomy site is intact and viable. She is producing stool. Teaching [Name6 (MD) ] ostomy RN and [Name8 (MD) ] RN initiated and reinforced with patient and family. Both the ostomy and fistula have been evaluated & treated per the ostomy RN-Please refer to ostomy care note. . Skin-She has frail, thin skin with multiple ecchymotic areas due to prolonged steroid use. She was evaluated by the Wound/Ostomy RN for recommendations (please see attached notes). Her midline abdominal incision is healing with no s/s of infection. Her staples were removed at the bedside, and steri strips applied. She has a left mid-abdomen mucofistula that is C/D/I. . Activity-She has been working with Physical Therapy. An arm sling was applied to the left shoulder due to rotator cuff repair. She has become deconditioned, but has been cooperative and motivated. She was screened for rehab, and offered a bed at [Hospital3 ] on [2109-8-27]. Her transfer was placed on hold due to a fever spike. She c/o Left thumb & shoulder pain on [2109-8-27]. An XRAY of bother sites were obtained-negative for fracture. She again spiked a fever on [2109-8-28]. . ID-Her catheter tip from central line placed in OSH was positive for yeast on [2109-8-9]. She was admitted to the ICU where her sepsis was managed. She was treated with IV antifungals/antimicrobials. Her blood cultures from [2109-8-14] have been negative. She developed an oral temp of 101.7 on [2109-8-27] and again developed an oral temp of 101.5 on [2109-8-28] after being off of antimicrobials since [2109-8-25]. Her WBC was 12 on [2109-8-27], an increase from 9.9 on [2109-8-26]. She was pan-cultured, and a chest xray obtained. The right central line was removed, and the catheter tip sent for culture. Final culture results of the catheter tip revealed no growth. Her Lasix & KDUR were placed on hold. Her CXR was negative. Urine culture demonstrated mixed bacterial flora, consistent with skin and/or genital contamination. Blood cultures from [8-27] and [8-28] have shown no growth to date. Other cultures from her fever workup have not grown any causative microorganisms to date, and she will continue empiric vancomycin treatment for 7days after hospital discharge. . Neuro-She was occasionally confused in the ICU. Soft restraints were utilized. Her mental status returned to baseline. She has remained alert and oriented x 3 since her arrival to the med/[Doctor First Name ] floor (CC6). . She is being discharged from the hospital today in stable condition tolerating her medications and a regular diet. Medications on Admission: [Last Name (un) 1724]: actonel 35 q week, cozaar 50', lisinopril 20", nifedidpine 10"', atenolol 50", prilosec 20', premarin 0.3', lipitor 10', prednisone 6', plaquenil 200", furosemide 20,40, MVI', calcium, vit B6 00', l-lysine 500 Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:12 Adhesive Patch, Medicated(s) Refills:2 2. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous once a day for 7 days. Disp:7 Refills:0 3. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q 12H (Every 12 Hours). Disp:30 Refills:2 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 5. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). Disp:30 Refills:2 6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: please check INR daily and titrate warfarin for INR [2-16]. Disp:20 Tablet(s) Refills:0 7. Nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours): hold for sbp<100, hr<60. Disp:30 Capsule(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary: Ischemic colitis treated surgically. DVT-LLE treated with Lovenox Ileus treated medically. septic shock/hypotension treated with IV resusciation. Secondary: HTN, diverticulitis, s/p Right rotator cuff repair [7-26] Discharge Condition: Good Tolerating regular diet Adequate pain control with dilaudid 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 vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, 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 skin, or the whites of your eyes become yellow. * 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. * 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 amubulate several times per day. Followup Instructions: Please call Dr.[Name (NI) 1863] office at([Telephone/Fax (1) 2300] for a follow-up appointment in [1-15] weeks. Please follow up with Dr. [First Name8 (NamePattern2) 2855] [Last Name (NamePattern1) ] (Orthopedist) [Telephone/Fax (1) 108804].	[ "785.52", "733.00", "038.9", "997.4", "557.0", "995.92", "E878.6", "560.1", "401.9", "453.41", "V58.65", "567.21", "714.0", "725" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "46.23", "99.04", "45.73", "99.15", "00.17", "96.72" ]	icd9pcs	[ [ [] ] ]	16242, 16312	10681, 15033	341, 382	16584, 16651	2147, 3044	17742, 18011	1388, 1526		15320, 16219	8499, 8605	16333, 16563		15059, 15297			16675, 17719								1541, 2128							3067, 3380															235, 303	8634, 10658										410, 1070																	1092, 1239	1255, 1372
56,304	126,111	2892	Discharge summary	report	Admission Date: [2166-12-2] Discharge Date: [2166-12-18] Date of Birth: [2134-2-26] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4679] Chief Complaint: abdominal pain lower back pain fever menorrhagia Major Surgical or Invasive Procedure: [2166-12-13]: Right video-assisted thoracic surgery (VATS) decortication. [2166-12-8]: CT-guided drainage of left tubo-ovarian abscess History of Present Illness: 32 yo G3P1 presenting with acute left-sided abdominal/pelvic and back pain, cramping in nature, that began this morning and has worsened throughout the day. The pain is associated with nausea and chills. Prior to the past day, she was feeling well and in her usual state of health, aside from her baseline menstrual cramps (just finished her menses, which are quite heavy). She denies shortness of breath, chest pain, palpitations. Of note, she does have a history of STUMP tumor of the uterus, incidentally found on pathology after a myomectomy. She has been followed, as she desired preservation of fertility. Past Medical History: GynHx: - LMP last week, just finishing menses - sexually active with male partner only x 5 years - reports mutually monogamous relationship OBHx: G3P1 - C/S x 1 - TAB x 1 - SAB x 1 MedHx: anemia, h/o STUMP tumor of the uterus SurgHx: C/S x 1, myomectomy Social History: - Tobacco: none - Alcohol: last drink 3 months ago, infrequent ETOH - Illicits: none Family History: Pt unaware of family history, not in contact w/ [Name2 (NI) ]. Physical Exam: VS:T:98.6 HR 99 ST BP BP: 115/79 Sats: 99% RA General: 32 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: Sinus tachycardic, normal S1,S2, no murmur/gallop or rub Resp; diminished breath sounds throughout. no wheezes GI: benign Extr: warm no edema Incision: R VATs site clean dry, intact, no erythema, margins well approximated Neuro: non-focal Pertinent Results: [2166-12-18] WBC-12.7* RBC-3.42* Hgb-7.1* Hct-23.6* MCV-69* MCH-20.9* MCHC-30.2* RDW-28.7* Plt Ct-734* [2166-12-17] WBC-12.9* RBC-3.46* Hgb-6.9* Hct-23.5* MCV-68* MCH-19.9* MCHC-29.3* RDW-28.2* Plt Ct-684* [2166-12-2] WBC-28.1* RBC-3.35* Hgb-5.6* Hct-19.4* MCV-58* MCH-16.7* MCHC-28.8* RDW-17.9* Plt Ct-296 [2166-12-1] WBC-28.2* RBC-3.87* Hgb-6.6# Hct-22.9# MCV-59# MCH-17.0# MCHC-28.6# RDW-17.7 Plt Ct-375# [2166-12-17] BLOOD Neuts-83.9* Bands-0 Lymphs-9.6* Monos-5.2 Eos-0.9 Baso-0.3 [2166-12-11] Hypochr-3+ Anisocy-2+ Poiklo-2+ Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-1+ Target-1+ Schisto-OCCASIONAL Tear Dr[Last Name (STitle) 833] [2166-12-10] Glucose-98 UreaN-4* Creat-0.8 Na-137 K-3.8 Cl-102 HCO3-28 AnGap-11 [2166-12-7] ALT-13 AST-20 LD(LDH)-284* AlkPhos-57 TotBili-0.5 [2166-12-5] LD(LDH)-353* TotBili-0.9 [2166-12-17] Calcium-8.1* Mg-1.8 [2166-12-5] Hapto-331* [2166-12-4] VitB12-1442* Folate-11.0 Hapto-241* [2166-12-3] calTIBC-289 Ferritn-45 TRF-222 [2166-12-3] TSH-1.4 [2166-12-6] HIV Ab-NEGATIVE MICRO: BC x 5 no growth Pleural Fluid and tissue [2166-12-13]: no growth to date Urine cx [12-2] pnd [2166-12-2] 2:00 am SWAB NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final [2166-12-2]): Negative for Neisseria Gonorrhoeae by PCR. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final [2166-12-2]): Negative for Chlamydia trachomatis by PCR. [2166-12-17]; PELVIS U.S., TRANSVAGINAL; PELVIS, NON-OBSTETRIC: IMPRESSION: 1. Further slight decrease in size of left adnexal collection, measuring up to 5.4 cm, with further decrease in echogenicity of internal contents, indicating increasing fluid component. [2166-12-17]: RUQ US IMPRESSION: No abnormalities in the right upper quadrant. No collection or abscess within or along the liver. Overall, unremarkable right upper quadrant ultrasound. CXR: [2166-12-17]: There is a small-to-moderate right hydropneumothorax, the air component has increased from the prior examination. Cardiomediastinal silhouette is unchanged. Right lower lobe and right middle lobe opacities are stable, a combination of layering pleural effusion and adjacent atelectasis. CCT: [2166-12-7]: Increasing, now moderate-to-severe right pleural effusion extending into the pleural fissures and associated atelectasis of the right lower lobe. Brief Hospital Course: Brief ICU Course ([Date range (1) 13994]) - Patient was transferred to the [Hospital Unit Name 153] peri-transfusion for Hct drop to 19. It was noted during transfusion that she spiked temperature to 104, desat to 80s on RA, tachypnea and tachycardia with associated pleuritic chest pain. CTA was negative for PE but showed pleural effusion. While in the ICU, patient was managed medically with antibiotics switching Zosyn on [12-4] for broader coverage of the [Last Name (un) ], and she was also giving pain medication as part of the tachypnea and tachycardia was contributed to by her splinting the abdominal pain. Flagyl was discontinued as double coverage was unnecessary. Her symptoms of LLQ and epigastric pain persisted throughout [Hospital Unit Name 153] stay, although exam was thought to be slightly improved. Transvaginal U/S was performed to reassess the [Last Name (un) ] on [12-5] which showed decreasing size of the [Last Name (un) ]. - Heme/Onc was consulted for her anemia who was concerned for long standing iron deficiency anemia and ? thalassemia. Oral iron supplement was started. SPEP and hemoglobin electrophoresis are pending. - Of note, patient spiked a fever on [2166-12-5] and CXR showed possible infiltrate in the RLL, suspicious for pneumonia. She was started on vanco and levo for possible HAP/atypical pneumonia on [12-5]. - No PICC was placed at the time of transfer back to GYN due to the fever. - PICC line placed [2166-12-9], removed [2166-12-18]. Thoracic Surgery: was consulted on [2166-12-9] for complicated right pleural effusion. We recommended interventional pulmonology perform ultrasound guided thoracentesis which was performed and drained 25 mL serous thick fluid with pigtail placement on [2166-12-10] with minimal drainage. On [2166-12-13] she was taken to the operating room for Right video-assisted thoracic surgery (VATS) decortication with removal of fair amount of gelatinous and fibrinous exudate within the right chest. There was no evidence of frank pus. She was extubated in the operating room, monitored in the PACU prior transfer to the floor hemodynamically stable with 2 right chest tubes in place. Respiratory: aggressive pulmonary toilet, incentive spirometer and good pain control she titrated off oxygen with oxygen saturation of 97% on room air. Chest tubes: right apical and basilar to suction initially then to water-seal with minimal drainage. The basilar was removed on [12-16], apical on [12-17]. Serial chest films showed stable right apical pneumothorax, atelectasis and small effusion. Cardiac: sinus tachycardia 112-117 improved to 99-100 and 140-150's with activity in the setting of iron-deficient anemia. Blood pressure stable 110'120. Nutrition: she was followed by nutrition for poor appetite. Supplements TID with meals and encourage PO intake, calorie counts. Slow improving in PO intake. Renal; Foley removed [2166-12-14] with good urine output. Electrolytes replete as needed. GYN: followed by GYN s/p IR-guided drainage of left [Last Name (un) ] [12-8]. Her vaginal bleeding was minimal and [12-5] she received Lupron to further control her menorrhagia. On [2166-12-17] internal vaginal US showed slight decrease in size of left adnexal collection, measuring up to 5.4 cm, with further decrease in echogenicity of internal contents, indicating increasing fluid component. RUQ US was also done and showed No abnormalities in the right upper quadrant. No collection or abscess within or along the liver. Heme: Iron-deficiency anemia, s/p one dose IV ferrous gluconate and 2u PRBC transfusion while stable in [Hospital Unit Name 153]. Serial HCTs with baseline of 19-22. Iron supplements [Hospital1 ]. She will need to follow-up with hematology as an outpatient. Endocrine: Followed by [Last Name (un) ] insulin sliding scale with Blood sugars <200 ID: followed by ID for Suspected [Last Name (un) ] and Continued Leukocytosis. Started on Zosyn and Vancomycin empirically. Cultures Left ovian abscess with GPC in pairs/clusters. On [12-10] the Vancomycin was discontinued since no staph grew. Serial WBCs were followed and trended down after starting IV antibiotics. Low-grade fevers persisted over the next few days and slowly resolved. She was converted to PO antibiotics without fevers for 24 hrs. She was discharged Levoflox 750 mg daily & Flagyl 500 tid for 4 weeks. She will follow-up with infectious disease before stopping antibiotics. Pain: Dilaudid PCA converted to PO pain medication with good control. Disposition: She was discharged to home and will follow-up with GYN, Dr. [First Name (STitle) ] and ID as an outpatient. After discharge the patient's pharmacy called to say her insurance would not cover Levofloxacin. ID was called and recommended Avalox 400 mg daily for 4 weeks Medications on Admission: Medication on ICU Admission: MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Oxycodone-Acetaminophen [2-1] TAB PO/NG Q4H:PRN pain Acetaminophen 650 mg PO/PR Q6H:PRN fever Pantoprazole 40 mg PO Q24H Order date: [12-3] @ 2130 Phytonadione 10 mg PO/NG DAILY Duration: 3 Days Order date: [12-3] @ [2115] Docusate Sodium 100 mg PO BID:PRN constipation Levo HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q4H:PRN pain Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation: while taking iron. Disp:60 Capsule(s) Refills:3 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. ascorbic acid 500 mg Tablet Sig: 0.5 Tablet PO three times a day: take with iron. Disp:45 Tablet(s) Refills:2 4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) scoop PO DAILY (Daily): take with iron. Disp:1 can Refills:2 5. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 weeks. Disp:28 Tablet(s) Refills:0 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 weeks. Disp:84 Tablet(s) Refills:0 7. ferrous sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO TID (3 times a day). Disp:90 Capsule, Sustained Release(s) Refills:5 8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever. Discharge Disposition: Home Discharge Diagnosis: Fibroids Uterine STUMP tumor Iron-deficiency anemia Menorrhagia Endometriosis Thalassemia PSH: C-sxn, myomectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[Name (NI) 5067] office [Telephone/Fax (1) 2348] you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or chest pain -Chest tube site cover with a bandaid until healed. -Shower daily. Wash incision with mild soap, rinse, pat dry. -No lifting greater than 10 pounds -Walk daily increasing slowly to a Goal of 30 minutes daily. Antibiotics: Continue Avalox and Flagly until seen by Dr. [Last Name (STitle) ] in Infectious disease. If you have increase in abdominal/pelvic pain or increased vaginal bleeding or fevers >101 then please call Dr. [Last Name (STitle) 13995] [Last Name (Prefixes) 13996] office [Telephone/Fax (1) 13997] Followup Instructions: Follow-up with Dr. [First Name (STitle) ] [0-0-] Date/Time:[2167-1-1] 9:00 on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center [Location (un) 24]. Chest X-Ray 30 minutes before your appointment on the [Location (un) 861] Radiology Department GYN [Hospital1 8] [Location (un) 2274] Tuesday [12-23] with Dr. [Last Name (STitle) 13998] 10am. Their phone number is [Telephone/Fax (1) 13997]. Provider: [Name10 (NameIs) 1412] [Name Initial (NameIs) ] [Name12 (NameIs) 1413], M.D. Infectious Disease [Telephone/Fax (1) 457] Date/Time:[2167-1-8] 1:30 in the [Last Name (un) 2577] Building Ground Floor [Last Name (NamePattern1) 10357] Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 13999], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2166-12-31] 3:00 Completed by:[2166-12-18]	[ "995.92", "511.89", "280.0", "780.66", "617.0", "584.9", "790.92", "E879.8", "790.29", "038.9", "614.0", "276.50", "218.9", "512.1", "276.4", "614.6", "626.2", "999.89", "518.0", "288.60" ]	icd9cm	[ [ [] ] ]	[ "34.52", "34.91", "65.91", "34.04" ]	icd9pcs	[ [ [] ] ]	11093, 11099	4545, 9470	371, 517	11257, 11257	2087, 4522	12120, 13031	1560, 1629		9931, 11070		11120, 11236		9496, 9908			11408, 12097								1644, 2068																						283, 333											545, 1159											11272, 11384						1181, 1439	1455, 1544
40,546	158,114	32916	Discharge summary	report	Admission Date: [2199-12-10] Discharge Date: [2199-12-21] Date of Birth: [2131-2-4] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Heparin Agents Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: none History of Present Illness: 68 y/o male with dyspnea on exertion beginning [12-8]. On [12-9] when urinating slumped to floor in bedroom, with syncope and urinary incontinence. Went to ED at [Location (un) 620]. CT revealed pulmonary embolism. Argatroban was started and he was transferred to [Hospital1 18] for further care. Past Medical History: Coronary Artery Disease s/p Coronary Artery Bypass Graft on [2199-11-27], Myocardial Infarction (non-ST elevation) [2199-11-22], Hypertension, Heparin Induced Thrombocytopenia [11-29], Hypercholesterolemia, Abdominal Aortic Aneurysm (4.6cm), Gastroesophageal Reflux Disease, Benign Prostatic Hyperplasia Social History: retired auto mechanic tobacco: very remote alcohol: 1-2 beers per month lives with wife Family History: Mother died 81 (h/o AAA s/p repair, CAD s/p CABG in her 70s) Father died 87 ?[Name2 (NI) 499] cancer Physical Exam: Admission: VS 98.8 109SR 92/52 19 96%-2L Gen NAD Neuro A&Ox3, nonfocal exam CV RRR, sternum stable, incision CDI Pulm CTA-bilat. diminished @bases Abdm soft, NT/ND/+BS Ext warm well perfused. Palpable pulses Pertinent Results: [2199-12-10] 10:00PM PT-21.2* PTT-62.5* INR(PT)-2.0* [2199-12-10] 02:24AM GLUCOSE-138* UREA N-15 CREAT-1.2 SODIUM-142 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-27 ANION GAP-12 [2199-12-10] 02:24AM ALT(SGPT)-41* AST(SGOT)-27 ALK PHOS-92 TOT BILI-0.3 [2199-12-10] 02:24AM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-2.4 [2199-12-10] 02:24AM WBC-7.6 RBC-3.51* HGB-10.4* HCT-30.9* MCV-88 MCH-29.6 MCHC-33.6 RDW-14.3 [2199-12-10] 02:24AM PLT SMR-NORMAL PLT COUNT-314# [12-10] Echo: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal(LVEF>55%). The right ventricular cavity is mildly dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. [12-10] LE U/S: Nonocclusive thrombus identified at the junction of the left common femoral vein and the left greater saphenous vein. No DVT seen in the remainder of the veins of both legs. [12-12] LE U/S: Some progression of the non-occlusive thrombus at the junction of the left greater saphenous and common femoral veins. An additional non-occlusive thrombus is identified today at the junction of the right femoral vein and deep femoral vein. No occlusive thrombus identified in the remainder of the deep veins of both legs. OPERATIVE REPORT [Month/Year (2) ]: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3186] PREOPERATIVE DIAGNOSIS: Bilateral femoral vein deep venous thrombosis. POSTOPERATIVE DIAGNOSIS: Bilateral femoral vein deep venous thrombosis. OPERATION PERFORMED: 1. Ultrasound-guided puncture of right common femoral vein. 2. Introduction of catheter into inferior vena cava. 3. Inferior vena cavogram. 4. Placement of Bard G2 IVC filter. ASSISTANTS: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 20425], PA and [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3636], MD. [First Name (Titles) 76605] [Last Name (Titles) ] TIME: 1.3 minutes. CONTRAST USED WAS: 22 mL of Visipaque. TOTAL INTRASERVICE CONSCIOUS SEDATION TIME: 8 minutes. PATIENT IDENTIFICATION: This is a 68-year-old gentleman who had previously undergone a coronary artery bypass grafting who was found to have a common femoral vein thrombosis. He was found to have heparin-induced thrombocytopenia. Subsequently he developed a pulmonary embolus and was found to have a right deep and superficial femoral vein DVT. Based on these findings and the progression of the clots on argatroban, the patient was consented for IVC filter placement. PROCEDURE IN DETAIL: After informed consent was obtained, the patient was brought to the angiography suite and placed supine on the angiography table. Both groins were shaved, prepped and draped in usual sterile fashion. Conscious sedation with fentanyl and Versed in divided doses was given and maintained throughout the case. Continuous hemodynamic monitoring was maintained throughout the case. Ultrasound was used to identify the right common femoral vein. It was patent and easily compressible without evidence of thrombus. Real- time visualization of needle puncture into the right common femoral vein was accomplished with a micropuncture set. Hard copies of the images stored in the patient's chart for documentation purposes. A 4-French sheath was placed over [Initials (NamePattern4) ] [Last Name (NamePattern4) 7648] wire into the right common femoral vein and this is followed with an Omni Flush catheter at the iliac bifurcation. Injection of contrast through the sheath showed no evidence of thrombosis within the right ileal to common femoral venous system. Injection of contrast within the inferior vena cava showed no evidence of caval thrombosis. Caval diameter was 20 mm there by assuring that there was no [Last Name (un) 2432] cava. Bilateral single renal veins were identified at the level of L1 body. Once we were satisfied with the anatomy, a Bard G2 filter was brought into the field, introducer set was placed over wire and exchanged for the 4- French Omni Flush catheter and the 4-French short sheath. The sheath was placed into position over the junction of L2 and L3 and the IVC filter was deployed in this position. Post deployment fluoroscopy confirmed the upright placement of a Bard G2 IVC filter in good positioning without evidence of kinking. Once we were satisfied, the sheath was removed and hemostasis was achieved via direct compression for 10 minutes. Dr. [Last Name (STitle) ] was present throughout the entire case. ANGIOGRAPHIC FINDINGS: 1. Patent right common femoral vein. 2. No evidence of DVT within the right ileal to common femoral venous system. 3. 20 mm diameter inferior vena cava. 4. No evidence of vena caval stenosis or thrombosis with patent bilateral renal veins. 5. Accurate deployment of an inferior vena cava filter, Bard G2 type, femoral approach over the junction of L2 and L3 in the inferior vena cava. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3186] BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [2199-12-21] 09:20AM PND PND [2199-12-20] 03:02PM 25.7* 33.7 2.5* [2199-12-20] 05:22AM 230 [2199-12-20] 05:22AM 45.31 101.02 5.1* [2199-12-19] 09:30PM 85.8* [2199-12-19] 12:40PM 93.4* [2199-12-19] 06:15AM 211 Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname 1968] was transferred to the [Hospital1 18] after diagnosis of a pulmonary embolism. Argatroban had been initiated at outside hospital and was continued. He was also started on Coumadin after 48 hours at a therapeutic PTT on argatroban. Lower extremity U/S revealed nonocclusive thrombus at the junction of the left common femoral vein and the left greater saphenous vein. Vascular and Hematology were consulted on [12-12]. Later on [12-12] he was brought to the operating room where a IVC filter was placed. He was transferred to the step down floor for further anticoagulation. As per Hematology reccommendation, repeat lower leg ultrasound was performed on [2199-12-16] which showed residual thrombus bilaterally. Mr. [Known lastname 1968] continued on argatroban until his INR became therapeutic. He was then discharged home. Coumadin will be managed by Dr. [Last Name (STitle) ] as an outpatient for a target INR of 2.0-3.0. He will follow-up with Dr. [Last Name (STitle) ], his cardiologist and his primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) ] as an outpatient. By HD 12 his INR was therapeutic and he was discharged to home. Medications on Admission: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:0 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): take 400mg (2 tablets) two times for day for 1 week, then decrease to 400mg (2 tablets) daily for one week, then decrease to 200mg (1 tablet) daily. Disp:120 Tablet(s) Refills:0 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 9. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:0 10. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a day for 7 days. Disp:28 Tablet(s) Refills:0 Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:30 Tablet(s) Refills:0 6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:14 Tablet(s) Refills:0 9. 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 10. Warfarin 2 mg Tablet Sig: as directed Tablet PO once a day: Target INR 2.5-3. Take 3 mg on [12-21] and [12-22] Then as directed by Dr [Last Name (STitle) ] . Disp:60 Tablet(s) Refills:0 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Hospice and VNA Discharge Diagnosis: Bilateral Pulmonary Embolism Bilateral DVT Heparin induced thrombocytopenia PMH: Coronary Artery Disease s/p Coronary Artery Bypass Graft on [2199-11-27], Myocardial Infarction (non-ST elevation) [2199-11-22], Hypertension, Heparin Induced Thrombocytopenia [11-29], Hypercholesterolemia, Abdominal Aortic Aneurysm (4.6cm), Gastroesophageal Reflux Disease, Benign Prostatic Hyperplasia Discharge Condition: good Discharge Instructions: Please resume previous discharge instructions, which include: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month from date of surgery or while taking narcotics for pain. 7) Coumadin will be managed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] phone ([Telephone/Fax (1) 76606] Fax ([Telephone/Fax (1) 32849]. Goal INR is 2.0-3.0 for Heparin Induced throbocytopenia/Pulmonary embolism/Deep vein thrombosis. . 8) Call with any questions or concerns. Followup Instructions: [Name6 (MD) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2200-1-9] 1:45 Dr. [Last Name (STitle) ] in [2-3] weeks Dr. [Last Name (STitle) ] in [1-2] weeks and for coumadin management as instructed. Phone-([Telephone/Fax (1) 41427] Fax-([Telephone/Fax (1) 32849] Dr [Last Name (STitle) 2805] (Hematologist) on [2200-1-3] ([Telephone/Fax (1) 52944] Completed by:[2199-12-21]	[ "453.41", "441.4", "788.20", "E878.2", "V45.81", "272.0", "997.2", "530.81", "415.11", "289.84", "410.72", "401.9", "V58.61", "600.00" ]	icd9cm	[ [ [] ] ]	[ "38.7", "88.51" ]	icd9pcs	[ [ [] ] ]	11928, 11990	7602, 8851	316, 322	12431, 12437	1480, 7579	13591, 14041	1125, 1231		10363, 11905		12011, 12410		8877, 10340			12461, 13568								1246, 1461																						257, 278											350, 665																	687, 1004	1020, 1109
68,175	145,252	47825	Discharge summary	report	Admission Date: [2124-12-11] Discharge Date: [2124-12-27] Date of Birth: [2070-1-6] Sex: M Service: CARDIOTHORACIC Allergies: Percocet / Percodan Attending:[First Name3 (LF) 1406] Chief Complaint: Exertional angina Major Surgical or Invasive Procedure: [2124-12-15] Coronary bypass grafting x6, with a left internal mammary artery to left anterior descending artery, and reverse saphenous vein graft to the second diagonal artery, and sequential reverse saphenous vein grafts to the distal posterior left ventricular branch artery and the posterior descending artery, and reverse sequential saphenous vein grafts to the obtuse marginal artery and the ramus intermedius artery [2124-12-11] Cardiac Cath History of Present Illness: 54 year old male with a history of high cholesterol, gout and a fatty liver who has been experiencing exertional angina. He states for the past six months he has been complaining of stomach discomfort while exercising describing as substernal gas, belching and substernal pressure. He has been experiencing pain in his left shoulder and bicep for the past six months (he associated this with his tendonitis). At rest patient will occasionally experience chest discomfort and complains of increased stress in his personal life as well as at his job. He was referred for a cardiac catheterization which revealed severe three-vessel coronary artery disease. Past Medical History: High cholesterol Elevated PSA (benign) Gout Fatty Liver Previous Kidney Stones Steatohepatitis s/p Discetomy x3 s/p Vasectomy Social History: Race:caucasian Last Dental Exam:1 month ago Lives with:alone patient has three grown children Occupation:works in sales Tobacco:denies ETOH:[9-22] drinks a week Family History: Brother with PCI at age 45, Grandfather with CAD. Physical Exam: Pulse:59 Resp:14 O2 sat:97/RA B/P Right:132/92 Left:139/98 Height:6'3" Weight:265 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 Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema 0 Varicosities: None [+1] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: 0 Left: 0 Pertinent Results: [2124-12-11] Cardiaac Cath: 1. Coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had 30% distal stenosis that extended into the proximal LAD and LCx. The LAD had 70% proximal stenosis, 90% stenosis of the first diagonal branch, and was occluded in the mid vessel. The LCx had 80-90% proximal and 80% OMB1 stenoses. The RCA had 80% very distal stenosis prior to the 2nd PLB.2. Resting hemodynamics revealed mildly elevated left ventricular filling pressures with LVEDP 15 mmHg. There was no significant pressure gradient across the aortic valve on catheter pullback. There was systemic arterial normotension. 3. Left ventriculography revealed no mitral regurgitation. The estimated LV ejection fraction was 55% with normal wall motion. [2124-12-12] Vein mapping: Duplex evaluation was performed of both lower extremity venous systems for evaluation of the greater saphenous veins. The right greater saphenous vein is patent with diameters ranging from 0.3 to 0.9, on the left 0.2 to 0.9. The majority of the vein bilaterally ranges from 0.3 to 0.4 [2124-12-15] Echo: Pre CPB: 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. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results. Post CPB: The patient is on a phenylephrine infusion being AV paced. There is trace MR and trace AI. Trace pulmonic insufficiency is now seen. The biventricular systolic function is preserved. The visible contours of the thoracic aorta are intact. There is a persistent LEFT sided pleural effusion/hematoma, which despite many attempts to drain by the surgeon, remains unchanged. [2124-12-26] 05:39AM BLOOD WBC-13.6* RBC-3.44* Hgb-10.5* Hct-31.3* MCV-91 MCH-30.6 MCHC-33.5 RDW-15.6* Plt Ct-497* [2124-12-25] 03:36PM BLOOD WBC-14.3* RBC-3.58* Hgb-11.0* Hct-32.9* MCV-92 MCH-30.7 MCHC-33.5 RDW-15.6* Plt Ct-524* [2124-12-27] 04:50AM BLOOD PT-24.0* INR(PT)-2.3* [2124-12-26] 05:39AM BLOOD PT-21.9* PTT-86.7* INR(PT)-2.1* [2124-12-25] 06:11AM BLOOD PT-18.1* PTT-92.1* INR(PT)-1.6* [2124-12-24] 05:09PM BLOOD PT-16.0* PTT-68.4* INR(PT)-1.4* [2124-12-24] 04:28AM BLOOD PT-15.4* INR(PT)-1.3* [2124-12-23] 08:27AM BLOOD PT-14.3* PTT-36.5* INR(PT)-1.2* [2124-12-20] 04:39AM BLOOD PT-13.2 PTT-29.9 INR(PT)-1.1 [2124-12-26] 05:39AM BLOOD UreaN-18 Creat-1.0 Na-135 K-4.3 Cl-103 Brief Hospital Course: Mr. [Known lastname 6164] [Last Name (Titles) 1834] a cardiac cath on [2124-12-11] which revealed severe coronary artery disease and was therefore admitted following cath for pending surgical revascularization. He [Date Range 1834] usual pre-operative work-up while awaiting Plavix washout. On [12-15] he was brought to the operating room where he [Month/Day (4) 1834] a coronary artery bypass graft x 6. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. He remained intubated on pressors in the initial post-op period. He also developed a fever and leukocytosis. Sputum gram stain was positive initially and the patient was started on vancomycin and cipro. He has a history of alcohol dependence, and he was put on a CIWA scale. The patient was placed on Precedex and was eventually weaned and extubated on POD 5. He developed rapid atrial fibrillation and meds were adjusted. EP was consulted. Coumadin was initiated. The patient was unable to maintain rate control chemically. He [Month/Day (4) 1834] electrical cardioversion following a negative TEE on [2124-12-26]. He successfully converted to SR. Chest tubes and pacing wires were discontinued without complication. Cultures were negative, WBC normalized, fever did not return and antibiotics were discontinued. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 12, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home with VNA in good condition with appropriate follow up instructions. Dr. [Last Name (STitle) ] [Last Name (STitle) ] will follow INR/coumadin dosing for atrial fibrillation. Medications on Admission: ALLOPURINOL - 300 mg Tablet - 1 Tablet(s) by mouth once a day ATORVASTATIN [LIPITOR] - 20 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg Tablet - one Tablet(s) by mouth daily METRONIDAZOLE [METROGEL] - 1 % Gel - apply to affected area once a day as needed for rosacea. SILDENAFIL [VIAGRA] - 100 mg Tablet - [12-10] to 1 Tablet(s) by mouth once a day as needed for prn Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - one Tablet(s) by mouth daily MULTIVITAMIN - (OTC) - Capsule - one Capsule(s) by mouth daily OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider; OTC) - 1,000 mg Capsule - two Capsule(s) by mouth daily VITAMIN E - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [Hospital1 ] x 1 week, then 400mg daily x 1 week, then 200mg daily. Disp:120 Tablet(s) Refills:2 10. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain, fever. Disp:90 Tablet(s) Refills:0 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 12. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:20 Tablet(s) Refills:0 13. atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 15. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication a-fib Goal INR 2-2.5 First draw [2124-12-28] Results to Dr. [Last Name (STitle) ] [Last Name (STitle) ], phone [Telephone/Fax (1) 3070] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [Last Name (STitle) ] [Last Name (STitle) ] 16. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dr. [Last Name (STitle) ] [Last Name (STitle) ] to dose for goal INR 2-2.5 for atrial fibrillation. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) ] vna Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 6 Past medical history: High cholesterol Elevated PSA (benign) Gout Fatty Liver Previous Kidney Stones Steatohepatitis s/p Discetomy x3 s/p Vasectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema- none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] on [1-24] at 1:00pm Cardiologist: Please get referral to Cardiologist from PCP Primary [Name9 (PRE) ] Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Doctor Last Name ] [Telephone/Fax (1) 3070] on [1-22] at 11am 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 a-fib Goal INR 2-2.5 First draw [2124-12-28] Results to Dr. [Last Name (STitle) ] [Last Name (STitle) ], phone [Telephone/Fax (1) 3070] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [Last Name (STitle) ] [Last Name (STitle) ] Completed by:[2124-12-27]	[ "291.81", "285.9", "997.1", "427.31", "427.32", "272.0", "413.9", "780.62", "414.01", "571.8", "303.90", "274.9" ]	icd9cm	[ [ [] ] ]	[ "96.72", "99.62", "36.15", "37.22", "88.53", "88.72", "36.14", "88.56", "39.61" ]	icd9pcs	[ [ [] ] ]	10400, 10455	5585, 7451	305, 763	10707, 10924	2504, 4455	11847, 12735	1796, 1847		8304, 10377		10476, 10537		7477, 8281			10948, 11824								1862, 2485																						248, 267											791, 1449																	10559, 10686	1614, 1780				4465, 5562
11,861	185,487	22413	Discharge summary	report	Admission Date: [2130-11-8] Discharge Date: [2130-11-11] Date of Birth: [2105-5-5] Sex: F Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 1990] Chief Complaint: Abd. pain Major Surgical or Invasive Procedure: None History of Present Illness: 25 yo F w/ Hx of DMI p/w abdominal pain, N/V and DKA. Pt. was recently discharged from floor on [11-5] after resolution of her abdominal pain. She was well for the past few days and then last night she started feeling the constant crampy lower abd pain again and vomiting. She took her glargine 31 units last night at 8pm and noted that her finger stick was elevated to 471. Her abdomen and back continued to hurt so she presented to the ED. She was constipated so took some MOM and had some loose stools in the ambulance. In the ED she was noted to be hyperglycemic w/ an anion gap of 28. She was started on insulin drip and given 2L NS. Her only access comming to the ICU was a 20 gauge PIV in the right thumb. . She denies any vaginal discharge, fevers, chills, dysuria. . In the ED, initial VS: 99.2 130 134/84 16 100 Past Medical History: -Diabetes Type I: diagnosed age 16 in [2120] after her first pregnancy. Most recent Hgb A1C 10.9 % ([8-9]) - Previous admissions for nausea/vomiting with h/o esophagitis and with concern for diabetic gastroparesis - Esophagitis / H. Pylori [6-/2128] and again [8-/2130] - Stage I diabetic nephropathy - Anxiety/panic attacks - Depression - Hyperlipidemia - S/P MVA [5-4] - lower back pain since then. Per patient received oxycodone from her primary provider [Name Initial (PRE) ] [Name Initial (PRE) 58252] - G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section in [2122], not menstruating secondary to being on Depo-Provera - Genital Herpes Social History: She was born and raised in [Location (un) 669] but currently lives in her own apartment near [University/College 5130]. She is currently unemployed and received disability. She has a 6 year old son. [Name (NI) ] cousin recently had fevers, myalgias. Her mother and sisters live nearby. She denies tobacco, alcohol or illicit drug use. One current male sexual partner, uses depot shot for birth control. Family History: Her grandmother had type I diabetes. No Hx of CAD, HTN. Physical Exam: Vitals - T: 98.7 BP: 148/96 HR: 135 RR: 16 02 sat: 100 RA GENERAL: a/O x3, appropriate, constantly in motion, unable to sit still, NAD. [Name (NI) 4459]: MMM, OP clear, no LAD CARDIAC: Tachycardic, No MRG LUNG: CTAB BACK: No tenderness in the midline or paraspinal muscles ABDOMEN: Soft, NT, ND, BS+ EXT: No edema, 2+ DP and PT pulses DERM: No rashes Pertinent Results: Admission labs: [2130-11-8] 04:18AM BLOOD WBC-14.3# RBC-4.65 Hgb-13.4 Hct-39.8 MCV-86 MCH-28.8 MCHC-33.6 RDW-14.4 Plt Ct-248 [2130-11-8] 09:57AM BLOOD WBC-14.8 RBC-4.04* Hgb-11.7* Hct-35.9* MCV-89 MCH-28.9 MCHC-32.6 RDW-14.6 Plt Ct-249 [2130-11-8] 04:18AM BLOOD Neuts-85.4* Lymphs-13.2* Monos-1.0* Eos-0.3 Baso-0.2 [2130-11-8] 04:18AM BLOOD PT-12.5 PTT-19.1* INR(PT)-1.1 [2130-11-8] 04:18AM BLOOD Glucose-435* UreaN-19 Creat-1.3* Na-143 K-4.9 Cl-99 HCO3-16* AnGap-33* [2130-11-8] 04:18AM BLOOD ALT-44* AST-43* AlkPhos-78 TotBili-0.4 [2130-11-10] 06:25AM BLOOD Amylase-68 [2130-11-8] 04:18AM BLOOD Lipase-22 [2130-11-9] 04:36AM BLOOD Calcium-8.4 Phos-2.0* Mg-1.7 [2130-11-8] 09:57AM BLOOD HCG-<5 [2130-11-8] 09:57AM BLOOD Ethanol-NEG [2130-11-8] 04:15AM BLOOD Lactate-2.9* K-5.0 [2130-11-8] 04:35AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.033 [2130-11-8] 04:35AM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2130-11-8] 04:35AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [2130-11-8] 02:57PM URINE bnzodzp-NEG barbitr-NEG cocaine-NEG amphetm-NEG mthdone-NEG [2130-11-8] 02:57PM URINE UCG-NEGATIVE [2130-11-8] 3:09 pm SWAB Source: Cervical. FINAL REPORT [2130-11-9] Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final [2130-11-9]): Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final [2130-11-9]): Negative for Neisseria Gonorrhoeae by PCR. [2130-11-8] 4:35 am URINE Site: CLEAN CATCH FINAL REPORT [2130-11-9] URINE CULTURE (Final [2130-11-9]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. PRESUMPTIVE GARDNERELLA VAGINALIS. >100,000 ORGANISMS/ML.. PREDOMINATING ORGANISM. G Study Date of [2130-11-8] 5:57:56 AM Sinus tachycardia. Compared to the previous tracing of [2130-11-1] there is no change. [2130-11-10] gastric emptying study INTERPRETATION: Following the oral ingestion of a low-fat egg white meal consisting of 4 oz of egg whites, two slices of toast, 30 gm jam or jelly and 120 ml water, the patient was placed supine beneath the gamma camera. Continuous anterior and posterior images of tracer activity in the stomach and bowel were recorded for 45 minutes. Delayed anterior and posterior images were obtained at 2, 3 and 4 hours. Residual tracer activity in the stomach is as follows: At 45 mins 90 % of the ingested activity remains in the stomach At 2 hours 26 % of the ingested activity remains in the stomach At 3 hours 19 % of the ingested activity remains in the stomach At 4 hours 3 % of the ingested activity remains in the stomach Marked shifting and back and forth tracer activity from the fundus to the antrum occurred over the course of the first 45 minutes. IMPRESSION: Normal gastric emptying examination. Brief Hospital Course: 25yoF with DM1, h/o anxiety/panic attacks, multiple admissions to this hospital with n/v/d/abd pain/DKA, admitted with the same to the MICU where here AG was closed, blood sugars stable through rest of stay, also abdominal pain of unknown etiology but with negative workup and persistently benign findings, possibly due to psychosomatic causes. 1. DKA: AG of 28 on admission, likely due to medication non compliance. No clear source of infection or other cause of elevated BS's. Admit to MICU, treated with an insulin gtt which was then transitioned to subQ insulin without complications, blood sugars stable through rest of admission. Pt instructed to take 5U Glargine at night and be compliant with her insulin. However, has history of poor follow up and medication noncompliance. On day of discharge, pt insistent on leaving, and f/u with [Last Name (un) ] was not able to be made but pt instructed clearly and repeatedly on the need for medication compliance and follow up. 2. Abdominal pain: Swabs for GC/Chlamydia sent, which were negative. Lipase negative. PE through last admission and this one completely benign, as well as CT scan from admission several days before presentation, which only showed chronic colonic wall thickening, no acute process. Thought to be due to gastroparesis, but gastric emptying study done this admission completely normal. Also thought to have psychosomatic component and pt seen to be very anxious during last admission. During last admission, psych was consulted and agreed pt had significant anxiety and likely psychiatric disease and recommended scheduled Ativan, which seemed to help. Narcotics were strongly avoided. 3. Acute renal failure on admission: Likely pre-renal, resolved on its own. 4. Tachycardia: Cardiac enzymes negative last admission several days before, EKG without concerning findings, no clear source of infection, not anemic, and not symptomatic. Some improvement with IVF's. Still mildly tachy on discharge but not symptomatic. Medications on Admission: Pantoprazole 40 mg PO once a day. Ezetimibe 10 mg PO DAILY Aspir-81 81 mg PO once a day. Insulin Glargine Eight (31) units Subcutaneous at bedtime. Insulin Lispro 100 unit/mL Cartridge Sig: as directed on sliding scale units Subcutaneous three times a day: Please resume the 1:40 correction and 1:14 for insulin to carb ratio. Ativan 0.5 mg PO three times a day as needed for anxiety. Depot provera Q month 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. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units Subcutaneous at bedtime: Please take 5U Glargine at bedtime EVERY night. Measure your blood sugars frequently and see your doctor [First Name (Titles) ] [Last Name (Titles) 11878] the amount of insulin appropriately, as you will probably need more insulin as your food intake increases. . 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Diabetic ketoacidosis 2. Abdominal pain of unknown etiology Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Tolerating PO food and liquids Discharge Instructions: You were admitted to [Hospital1 18] with diabetic ketoacidosis, a condition of elevated blood sugars. You were also evaluated for gastroparesis, but our study shows that you did NOT have this. Your sugars resolved and you improved. While you were admitted we stopped your Ezetimibe. **** PLEASE CONTINUE TAKING YOUR INSULIN ** If you do not take your insulin, you will go into DKA again. Followup Instructions: Please follow up with your primary care [First Name8 (NamePattern2) ] [Last Name (Titles) 58260],[First Name3 (LF) ] M [Telephone/Fax (1) 58261] or if you want, please call [Telephone/Fax (1) 1247] to schedule an appointment with [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 58263], MD one of the doctors who took [Name5 (PTitle) ] of you while you were admitted. Completed by:[2130-11-23**]	[ "584.9", "300.4", "724.2", "V58.67", "272.4", "789.00", "250.13", "V15.81", "250.43", "054.10", "583.81", "240.9", "530.10" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9060, 9066	5887, 7578	279, 285	9173, 9173	2752, 2752	9773, 10214	2300, 2357		8346, 9037		9087, 9152		7915, 8323			9349, 9750								2372, 2733																						230, 241											313, 1141						2769, 5864			7592, 7889		9187, 9325						1163, 1850	1866, 2284
31,585	158,090	5502	Discharge summary	report	Admission Date: [2100-10-6] Discharge Date: [2100-10-13] Service: MEDICINE Allergies: Norvasc / Cipro I.V. Attending:[Known firstname 1257] Chief Complaint: CC:[CC Contact Info 22233] Major Surgical or Invasive Procedure: none History of Present Illness: This is a 89 yo male with type 2 DM, HTN, hyperlipidemia, CHF, s/p CVA, with chronic indwelling foley for bladder diverticulum c/b recurrent UTIs, as well as suspected fungal overgrowth in the bladder who presents with lethargy x 3 days. [Name (NI) 1094] son notes that patient at baseline is oriented x 3, right facial droop and expressive aphasia since CVA but is able to call family members and recalls birthdays. However, for the past couple of days, he has been more lethargic which is c/w prior presentations of UTIs. He notes that besides the depressed MS, pt has not complained of fever/chills, abdominal pain. He has had some decreased appetite but no recent h/o aspiration. In the [Name (NI) ], pt had T 99.2 BP 140/73 HR 73 O2sat 100%RA. He had a set of cardiac enzymes x 1 which were negative. He received 3LNS, CeftriaXONE 1g IV x 1, Lorazepam 2mg IV x 1 for agitation, and Acetaminophen 650mg x 1. . ROS: Chronic right LE edema since stroke. Otherwise, per report no recent weight change, nausea, vomiting, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, vision changes, headache, rash or skin changes. . Past Medical History: L MCA stroke with right-sided hemiparesis, aphasia [12/2090] CHF EF 35-40% global HK from [2091] echo, mild-mod pulm htn Atrial fibrillation with slow ventricular response Heart block s/p [Company 1543] Sensia single-chamber pacemaker [3-25] HTN Hyperlipidemia DM type 2 RLE cellulitis RLE DVT (on coumadin with therapeutic INR) s/p IVC filter [10/2099] Sleep apnea, intolerant of CPAP Bladder diverticulum w/ ? fungal infection, currently inoperable per most recent urology note . Social History: Lives in a nursing home, and is visited daily by his son, who performs many of the tasks of daily care. He does not drink or smoke. Widower with 3 children Family History: NC Physical Exam: On presentation: Vitals: T: 97.6 BP: 102/40 HR:74 RR:14 O2Sat: 99%2LNC GEN: responds minimally to verbal stimuli, withdraws to pain HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry MM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: irregularly irregular, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: obese, Soft, NT, ND, +BS, no HSM, no masses EXT: 2+ RLE edema, No C/C/E on left, no palpable cords NEURO: Withdraws left arm and leg to pain, no movement on right - contracted position. SKIN: stage I decub; No jaundice, cyanosis, or gross dermatitis. No ecchymoses. . Pertinent Results: [2100-10-6] 03:59PM WBC-20.1# RBC-2.95 HGB-9.3* HCT-28.1* MCV-95 MCH-31.6 MCHC-33.2 RDW-15.1 [2100-10-6] 03:59PM NEUTS-86.0* LYMPHS-9.8* MONOS-3.2 EOS-0.7 BASOS-0.3 [2100-10-6] 03:59PM PLT COUNT-603# . [2100-10-6] 03:59PM GLUCOSE-126 UREA N-19 CREAT-0.9 SODIUM-141 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 [2100-10-6] 03:59PM ALT(SGPT)-15 AST(SGOT)-20 LD(LDH)-251* CK(CPK)-30* ALK PHOS-214* TOT BILI-0.3 . [2100-10-6] 02:20PM URINE BLOOD-LG NITRITE-POS PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [2100-10-6] 02:20PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 . [2100-10-6] 04:00PM LACTATE-2.2* [2100-10-6] 03:59PM CK-MB-NotDone cTropnT-0.05* [2100-10-7] 03:02AM BLOOD CK-MB-4 cTropnT-0.05* . [2100-10-6] CT HEAD: IMPRESSION: Stable appearance of the brain and ventricles since [2100-2-16]. Old large left MCA infarct. . [2100-10-6] CXR: There is a persistent left basal effusion. There is stable cardiomegaly. The right lung is clear. There is a pacemaker with the tip in the right ventricle. There are no focal pulmonary consolidations. Right apical atelectasis / collapse noted. Please correlate clinically. . [2100-10-7] ECHO: The left atrial volume is markedly increased (>32ml/m2). The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed (LVEF= XX %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mildly depressed LV systolic dysfunction. Thickened aortic valve leaflets without stenosis. Moderate pulmonary artery systolic hypertension. Brief Hospital Course: The patient is an 89 year old male with medical history pertinent for prior stroke and chronic indwelling Foley complicated by recurrent UTI in setting of bladder diverticula and possible chronic fungal infection, who now presents from his extended care facility with 3 days of lethargy. (At baseline the patient is reported to have expressive aphasia with right facial droop). The patient has been admitted multiple times previously with similar symptoms of lethargy which has been secondary to recurrent UTI. The patient on admission was not noted to have fevers/chills or abdominal pain. On admission from the ED the patient was with vitals as follows: T 99.2; BP 140/73; HR 73; O2 sat 100%RA. While in the ED the patient dropped his pressure as low as 73/37 with improvement after fluids. [Hospital Unit Name 153] Course: In the ICU the patient was initiated on therapy with broad spectrum coverage with Zosyn and Vanc. Microbiology review reveals the patient has had recurrent infection with E. Coli, Morganella Morganii, Group B Strep, and Enterococcus. The dominant organism has been E. Coli which has been quinolone resistant, Zosyn undeterminate (although most recent report states sensitive), sensitive to Cefepime, Ceftriaxone. Urology was consulted with impression that the patient is not an operative candidate for his bladder diverticulum given his medical co morbidities. A CT Head revealed no acute pathology, the patient was ruled out for MI and impression is that patient's agitation and delirium is from his underlying infection. The patient on admission to the ICU was noted to have somnolence alternating with agitation consistent with delirium for which he received intermittent doses of Haldol. During the ICU course the patient's antihypertensives were held given concern for possible urosepsis as patient had low BP on arrival. The patient's BP is reported to have recovered with fluid, did not require repeated boluses or pressors for pressure maintenance. Additional review of micro data reveals that the patient had [12-21] blood cultures positive for Enterococcus from the ED although ICU note reports 1/4 bottles positive with impression of skin contaminant. He initially received broad spectrum treatment with Vancomycin & Zosyn. This was narrowed down to Ampicillin. The patient will require 14 day course IV antibiotics for complicated UTI, PICC placed, He will finish treatment on [2100-10-23]. Nitrofurantoin for suppressive tx should be resumed later. He had TTE without vegetation in ED (performed for different indication), risk/benefit in this patient does not favor TEE. Dysphagia with signs of aspiration were noted. We recommended PEG tube placement, however they decided not to have it placed. The son understands that his father will not meet his nutritional needs and hydration needs with potential developement of dehydration, hypotension, and hypernatremia. They will reconsider it again if has difficulties at the nursing home. Chem7 should be checked at the nursing home to prevent the developement of hypernatremia. We stopped his lasix and some of his antihypertensive medications because of low BP. Sacral Decubitus Ulcer: stage II on wound care to be continued at the nursing home. Malnutrition, moderate - Patient not taking reliable PO, Albumin 2.2. Code - FULL - confirmed with patient's son who is his healthcare proxy and POA - son [Name (NI) ]: Cell [Telephone/Fax (1) 22234]. . . . Total discharge time 87 minutes. . . . . . Medications on Admission: Aspirin 325 mg PO DAILY Simvastatin 10 mg PO DAILY Paroxetine HCl 10 mg PO DAILY Pantoprazole 40 mg PO DAILY Multivitamin One Tablet PO DAILY Metoprolol Tartrate 12.5 mg PO BID Lisinopril 5 mg PO DAILY Furosemide 40 mg PO DAILY Bacitracin Zinc 500 unit/g Ointment Sig: One Appl Topical QID Nitrofurantoin 25 mg/5 mL Suspension Sig: Ten (10) ml PO once a day: please start after ceftrioxone course is finished. Vitamin C Oral Calcium Oral Allopurinol 100 mg PO DAILY Baclofen 10 mg PO DAILY Zinc Oral Warfarin 3 mg PO once a day Senna 8.6 mg PO DAILY Docusate Sodium 100 mg PO BID Metformin 500 mg PO BID . Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ampicillin Sodium 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q6H (every 6 hours) for until [2100-10-23] days. ( metoprolol and lasix were held) Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 5176] Discharge Diagnosis: Enterococcal bacteremia - likely from a UTI. Dehydration Malnutrition Dysphagia Silent aspiration Decubitus ulcers stage II Discharge Condition: Good Discharge Instructions: You were admitted with lethargy. You were noted to have bacteremia, likely from a UTI given your history. You will need IV antibiotics for 14 days with last dose [2100-10-23]. you were unable to meet your nutritional and hydration needs as you have moderately severe dysphagia and silent aspiration. you and your son decided not to place PEG tube for now and to reconsider it in the near future if you re-develop dehydration/hypernatremia. you need to check chem 7 in 2 days at the nursing home . Followup Instructions: 1. PCP, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], ph: [Telephone/Fax (1) 22235], please call and make appt	[ "416.8", "599.0", "428.0", "V58.61", "038.0", "995.91", "780.57", "438.11", "276.0", "276.51", "996.64", "272.4", "428.33", "293.0", "263.0", "285.9", "E879.6", "707.03", "V12.51", "596.3", "427.31", "401.1", "438.83", "250.00", "438.20", "707.22" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	10213, 10291	5108, 8642	258, 264	10459, 10466	2981, 3807	11015, 11187	2264, 2269		9299, 10190		10312, 10438		8668, 9276			10490, 10992								2284, 2962																						189, 220											292, 1549			3816, 5085														1571, 2075	2091, 2248
25,574	121,925	5171	Discharge summary	report	Admission Date: [2163-9-30] [Month/Day/Year ] Date: [2163-10-18] Date of Birth: [2094-10-7] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Syncope Major Surgical or Invasive Procedure: [2163-10-7] Redo-Sternotomy, Aortic Valve Replacement, Coronary Artery Bypass Graft x 2 (SVG to PDA, SVG to LIMA) History of Present Illness: This is a 68-year-old male patient known to [Hospital1 18] with a history of severe AS; CAD, s/p CABG in [2160] (LIMA-LAD, SVG-LAD, SVG-OM); stent to LMCA and stent to Diag 1 in [2160]; PCI to SCG-LAD; ISR of D1 stent in [2161]; and s/p Cypher stent to LMCA in [2162]. He is also a diabetic, has PVD, HTN, CRI, hypothyroidism, CHF, EF 40-50%, Gout, sleep apnea, and a history of GI bleed from AVMs. He presented OSH today with two episodes of syncope. He reports walking to the door to let out his dog at 5 am and passed out. Woke up on the floor. + LOC. Then, syncopized a second time, witnessed by son, about 2-3 hours later. This occurred when walking to the car. Felt "clammy", also had N/V once at the hospital. No post fall confusion. No jerking movements, no incontinence. He hit head posteriorly ?anteriorly also. He has lacerations on his forehead but required no stitches. CT head at OSH reportedly normal per patient (report not available at this time). His blood sugar was greater than 400 on arrival. He was give Lantus and regular insulin, Zofran and because his lungs were diminished at the bases and he is chronically short of breath he was given a nebulizer treatment. He also underwent an echocardiogram with the results still pending. He was given Morphine for chest pain with relief. He reports chronic "congestive" chest pain; with questioning this did not seem to be any worse than his baseline today. Also dyspneic with exertion chronically. Also reports heaviness in his calves and legs that limit his exercise tolerance. The few days PTA he attended a day program at [Last Name (un) ] for improvement in his glucose control. He felt well until one day PTA when he began to feel lightheaded and fatigues despite normal glucose. Also recently had vitrectomy/eye surgery (1.5 weeks ago). Also thought he was starting a gout flare of R foot; took PO prednisone last night to start a taper. ROS negative other than listed above. Past Medical History: -- CABG '[48] (LIMA-LAD, SVG LAD, SVG OM) -- Cath [10/2162]: Three vessel native coronary artery disease, patent grafts, moderate aortic stenosis, patent previously placed stents, elevated left sided filling pressure. -- Stress test [2162-5-24]: Poor functional status. 3.5 minutes of exercise on [Doctor Last Name 4001] protocol. EF 30% and multiple fixed perfusion defects and minor inferior defect. -- multiple coronary stents in [2160], [2161], and [2162] -- Aortic stenosis: [Location (un) 109] 1.09 cm2 [10-8] cath. -- Ischemic CM/CHF - diastolic, systolic EF 45%, multiple admits for diuresis, last [1-9], [6-8]. -- DM2, last HgA1c in [2162-10-3] of 7.1 -- Anemia: baseline HCT 31-33 -- Hypothyroidism -- OSA on CPAP -- Depression -- CKD- with baseline Cr 1.5-2.0 -- hypercholesterolemia -- OA -- Gout -- IBS-diarrhea predominant -- Obesity -- PVD -- UGI and LGI bleeding secondary to AVMs Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Retired [Doctor Last Name ]. Widowed in [2163-1-3]. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS - T97.5, BP 128/56, P97, R20, 96% on 2L Gen: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva pink, MMM, OP clear. Neck: Supple, no noted JVP elevation. Murmur radiation into carotids. CV: RR, normal S1, S2. Loud AS murmur heard throughout the precordium with radiation to the carotids. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored. + bibasilar crackles. Abd: Soft, NTND. No HSM or tenderness. Ext: Trace edema bilat. Skin: No stasis dermatitis, ulcers, scars, or xanthomas Pertinent Results: [10-4] CNIS: There is less than 40% right ICA stenosis and there is 40-59 left ICA stenosis. There is a greater than 50% left ECA stenosis as well, and both vertebral arteries are unable to be visualized. [10-7] Echo: PRE-CPB: The left atrium is mildly dilated. No spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with severe inferior hypokinesis. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Addendum: Episode of increased PA pressures during exposure of coronary bypass grafts with apical akinesis. No change in bp, CO or mixed venous. Nitroglycerine started and patient put on cardiopulmonary bypass within minutes. POST-CPB: On infusions of epi, levo, milrinone, amiodarone, insulin. Well-seated bioprosthetic valve in the aortic position. No paravalvular leak. MR is 3+ with ventricular dilation, improved with IABP insertion. LVEF now 35%. Inferoseptal, apical and inferior hypokinesis. IABP in good position 3 cm below LSCA. Aortic contour is normal post decannulation. RADIOLOGY Final Report CHEST (PA & LAT) [2163-10-12] 1:33 PM CHEST (PA & LAT) Reason: evaluate for effusion with sternal drainage [Hospital 93] MEDICAL CONDITION: 68 year old man s/p avr cabg x2 REASON FOR THIS EXAMINATION: evaluate for effusion with sternal drainage INDICATION: Evaluate for effusion, with sternal drainage. COMPARISONS: Chest radiograph dated [2163-10-10]. FINDINGS: Frontal and lateral views of the chest were obtained. Sternotomy wires and mediastinal clips remain. A cardiac valve prosthesis is noted. A right internal jugular catheter terminates at the cavoatrial junction. There is mild blunting of both posterior costophrenic angles, with associated decreased retrocardiac opacity. There is no pneumothorax. The cardiac silhouette is stable and enlarged. There is no pulmonary vascular congestion. IMPRESSION: Small bilateral pleural effusions with decreased retrocardiac atelectasis. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 7805] [Name (STitle) ] DR. [First Name8 (NamePattern2) 4075] [Last Name (NamePattern1) 5999] Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2163-10-13] 05:44AM 8.7 3.20* 10.0* 29.0* 91 31.3 34.5 16.4* 207 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2163-10-13] 05:44AM 135* 36* 1.4* 135 3.9 99 29 11 Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname 21147] was transferred to OSH following two syncopal episodes. Upon admission he was appropriately worked up and medically managed until cleared for surgery. Finally on [10-7] he was brought to the operating room where he underwent a redo-sternotomy, aortic valve replacement and coronary artery bypass graft x 2. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring and was on Epi, Levo, Milrinone, and Pitressin and an IABP. His drips were slowly weaned and on POD#2 his IABP was d/c'd and he was extubated. ON POD#3 his chest tubes were d/c'd and he was transferred to the floor in stable condition. His epicardial pacing wires were d/c'd on POD#4. He developed serosanguineous sternal drainage on POD#4. He also had a gout flare up that was treated while sternal drainage was monitored. Cleared for [Month/Day (1) ] to home with VNA services on POD #11. Pt. is to make all followup appts. as per [Month/Day (1) ] instructions. Medications on Admission: CURRENT MEDICATIONS (somewhat unclear; multiple sources with a lot of disagreement - pharmacy, [Last Name (un) ] note, past D/C summaries, OMR): Levothyroxine 200 mcg daily Metoprolol XL 100 mg daily Ezetimibe 10 mg daily Sertraline 100 mg daily Imdur 60 mg daily Sucralfate 1 g QID Ambien 5 mg QHS prn Bumex 1 mg daily Metolazone 2.5 mg daily or prn daily for weight gain? Insulin (NPH or glargine) patient reports 50 QAM, 50 QPM Novolog: patient reports 20 units with each meal Allopurinol 100 TID ASA 325 daily Colchicine 0.6 mg daily eye gtts (Xibrom, Zymar) Simvastatin 80 mg daily (but not recently filled at pharm) Lisinopril 2.5 mg daily (but not recently filled at pharm) Spironolactone 25 mg daily mvi Pantoprazole 40 mg daily Calcitriol 0.25 daily (but not according to pharm) oxycodone prn pain Plavix ([First Name8 (NamePattern2) ] [Last Name (un) ] notes but not listed anywhere else) Prednisone taper prn gout flare [Last Name (un) ] Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 3. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. 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:1 6. Metoprolol Succinate 50 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. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:1 11. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:1 12. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 13. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 14. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 15. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day for 7 days. Disp:7 Packet(s) Refills:0 16. Bumex 1 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: twice a day for 7 days, then 1 mg daily ongoing. Disp:30 Tablet(s) Refills:1 17. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Disp:28 Capsule(s) Refills:0 18. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35) units Subcutaneous twice a day. Disp:2100 units Refills:2 19. Ferrous sulfate 325 mg po daily 20. Humalog insulin per printed copy sliding scale [Last Name (un) ] Disposition: Home With Service Facility: [Hospital3 ] VNA [Hospital3 ] Diagnosis: Aortic Stenosis/Coronary Artery Disease s/p Aortic Valve Replacement, Coronary Artery Bypass Graft x 2 PMH: s/p Coronary Artery Bypass x 3 and multiple PCI, Congestive Heart Failure, Ischemic Cardiomyopathy, Hyperlipidemia, Diabetes Mellitus, Hypothyroid, Gout, h/o Upper GI Bleed, chronic renal insufficiency, Obstructive Sleep Apnea, Anemia ?etiology, Depression, Osteoarthritis, Peripheral Vascular Disease [Hospital3 ] Condition: Good [Hospital3 ] Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 911] in [2-5] weeks Dr. [Last Name (STitle) ] in [1-4] weeks You have two appointments with your eye doctors [First Name8 (NamePattern2) ] [Last Name (Titles) ] on Friday [10-28] starting at 1:00 pm with Drs. [Last Name (STitle) 17233] and [Name5 (PTitle) ]. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2163-10-18]	[ "414.01", "244.9", "585.9", "584.9", "250.00", "274.0", "424.1", "276.7", "428.0", "428.23" ]	icd9cm	[ [ [] ] ]	[ "38.93", "35.21", "88.56", "37.23", "39.61", "36.11", "37.61", "36.15" ]	icd9pcs	[ [ [] ] ]		7817, 8886	341, 460		4304, 6526	13072, 13583	3633, 3715			6563, 6595			8912, 13049											3730, 4285																						294, 303	6624, 7794										488, 2462																	2484, 3432	3448, 3617
20,631	120,338	2469	Discharge summary	report	Admission Date: [2127-11-1] Discharge Date: [2127-11-6] Date of Birth: [2089-4-17] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3513] Chief Complaint: Maliase, Poluria, Polydipsia Major Surgical or Invasive Procedure: None History of Present Illness: 38M h/o HTN, Hyperlipidemia, FHx CAD called out from ICU for DKA with new-onset DM. Pt was well until 2w/a when he had left mandibular tooth pain without F/C. Then had severe tooth pain with subsequent extraction (w/ pre-procedure PCN). About 1.5w/a, had generalized fatigue and weakness (was crawling to bathroom for 2-3 days PTA). Pt also had polydipsia, polyuria, mild dysphagia/odynophagia after eating, and visual blurring. Pt has never had these symptoms before this past week. ROS: He had no F/C, weight change, diarrhea, dysuria, rash, brusing, sore throat, N/V, CP, SOB. [Hospital1 18] ED: T98.3 BP103/70 HR94 RR22 OS100%RA. NO RESP DISTRESS/AMS. BG702. AG25. ABG: 7.38/21/128. ECG WITH NON-SPECIFIC ST-T CHANGES. NO UA WAS SENT. STARTED ON IVF, INSULIN BOLUS, INSULIN GTT, GLARGINE. SENT TO MICU WITH DKA. [Hospital1 18] MICU: AG CLOSED AND FS TO 200S-300S. SEEN BY [Last Name (un) ]. GAD AB SENT. ECG UNCHANGED FROM ORIGINAL AND CE'S FLAT X 4. HAD ASYMPTOMMATIC NSVT (13) WITH HYPOKALEMIA (REPLETED). THEN TOLERATED POS. TRANSF TO GERIMED. Past Medical History: HTN, Hyperlipidemia, HA, H/O Malaria, S/P MVA, Idiopathic Cardiomyopathy (Symm LVH), Mild-Mod MR. Social History: Born in Liberia, [Country 480]. Moved to USA in [2109]. Single, but has two children. Works as case manager for residential home. Current smoker (10 p-y). Drinks up to 12-pack of beer on weekend. Uses marijuana occasionally. No other drugs/IVDU. Family History: Father died in 50s from MI. No DM, Vitilago, Thyroid Disease, Anemia. No known autoimmune disease. Physical Exam: T98.8 HR65-70 BP107-134/60-81 RR11-17 OS97-100%RA GEN - NAD. PLEASANT. SPEAKING IN FULL SENT. SKIN - NO RASH/BRUSING. HEENT - MMM. CLEAR OP. PULM - CTAB. CV - NO JVD. RRR. NML S1/S2. II/VI SEM RUSB. NO R/G. ABD - S/NT/ND. POS BS. NO HSM/MASSES. EXT - NO C/C/E. DP 2+. NEURO - A&OX3. STRENGTH 5/5. [Last Name (un) ] NML TO LT. DTR 2+ (PATELLAR). Pertinent Results: ETT MIBI ([2127-11-5]): No anginal symptoms or objective ECG evidence of myocardial ischemia. Nonspecific ST-T wave normalization. Nuclear report sent separately. A mild to moderate reversible perfusion defect of the mid and apical regions of the inferior and inferolateral myocardial walls. There is normal left ventricular size and mild hypokinesis of the inferior wall with a calculated left ventricular ejection fraction of 68%. ECHO ([2127-11-4]): 1. The left atrium is normal in size. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 5.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 6.The estimated pulmonary artery systolic pressure is normal. 7.There is no pericardial effusion. [2127-11-3] 09:34PM BLOOD GLUTAMIC ACID DECARBOXYLASE-Test [2127-11-1] 06:24PM BLOOD K-4.7 [2127-11-1] 06:24PM BLOOD Type-ART pO2-128* pCO2-21* pH-7.38 calHCO3-13* Base XS--10 [2127-11-1] 09:45PM BLOOD GreenHd-HOLD [2127-11-1] 09:45PM BLOOD RedHold-HOLD [2127-11-1] 09:45PM BLOOD HoldBLu-HOLD [2127-11-1] 05:12PM BLOOD Ethanol-NEG [2127-11-2] 05:54PM BLOOD Free T4-1.4 [2127-11-2] 05:54PM BLOOD TSH-0.78 [2127-11-3] 07:00AM BLOOD %HbA1c-13.2* [2127-11-4] 06:35AM BLOOD calTIBC-233* VitB12-668 Folate-5.6 Hapto-95 Ferritn-406* TRF-179* [2127-11-1] 05:12PM BLOOD Albumin-5.0* Calcium-10.6* Phos-4.5 Mg-3.3* [2127-11-1] 09:45PM BLOOD Calcium-8.6 Phos-1.4# Mg-2.8 [2127-11-2] 12:00AM BLOOD Calcium-8.3* Phos-1.0* Mg-2.7* [2127-11-2] 02:36AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.7* [2127-11-2] 05:54PM BLOOD Calcium-7.7* Phos-1.3* Mg-2.2 [2127-11-3] 07:00AM BLOOD Calcium-8.5 Phos-2.4* Mg-2.1 [2127-11-3] 07:30PM BLOOD Calcium-8.3* Phos-1.6* Mg-2.1 [2127-11-4] 02:25AM BLOOD Calcium-8.3* Phos-1.2* Mg-2.0 [2127-11-4] 06:35AM BLOOD Calcium-8.8 Phos-2.3* Mg-2.0 Iron-113 [2127-11-5] 06:20AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.0 [2127-11-1] 05:12PM BLOOD cTropnT-<0.01 [2127-11-2] 12:00AM BLOOD CK-MB-2 cTropnT-<0.01 [2127-11-2] 02:36AM BLOOD CK-MB-2 cTropnT-<0.01 [2127-11-2] 08:45AM BLOOD CK-MB-2 cTropnT-<0.01 [2127-11-1] 05:12PM BLOOD Lipase-83* [2127-11-1] 05:12PM BLOOD ALT-13 AST-11 CK(CPK)-141 AlkPhos-105 Amylase-60 TotBili-0.7 [2127-11-2] 12:00AM BLOOD CK(CPK)-121 [2127-11-2] 02:36AM BLOOD CK(CPK)-128 [2127-11-2] 08:45AM BLOOD CK(CPK)-160 [2127-11-4] 06:35AM BLOOD LD(LDH)-107 TotBili-0.2 [2127-11-1] 05:12PM BLOOD Glucose-702* UreaN-47* Creat-1.5* Na-125* K-4.8 Cl-78* HCO3-15* AnGap-37* [2127-11-1] 09:45PM BLOOD Glucose-373* UreaN-37* Creat-1.4* Na-133 K-4.4 Cl-95* HCO3-16* AnGap-26* [2127-11-2] 12:00AM BLOOD Glucose-227* UreaN-32* Creat-1.1 Na-134 K-3.6 Cl-99 HCO3-23 AnGap-16 [2127-11-2] 02:36AM BLOOD Glucose-149* UreaN-26* Creat-1.1 Na-140 K-4.0 Cl-104 HCO3-26 AnGap-14 [2127-11-2] 05:54PM BLOOD Glucose-350* UreaN-23* Creat-1.0 Na-134 K-3.8 Cl-102 HCO3-25 AnGap-11 [2127-11-3] 07:00AM BLOOD Glucose-58* UreaN-13 Creat-0.6 Na-138 K-3.1* Cl-103 HCO3-25 AnGap-13 [2127-11-3] 07:30PM BLOOD Glucose-272* UreaN-16 Creat-0.9 Na-137 K-4.3 Cl-105 HCO3-26 AnGap-10 [2127-11-4] 02:25AM BLOOD Glucose-521* UreaN-18 Creat-0.8 Na-132* K-4.2 Cl-102 HCO3-24 AnGap-10 [2127-11-4] 06:35AM BLOOD Glucose-244* UreaN-16 Creat-0.8 Na-138 K-3.7 Cl-106 HCO3-25 AnGap-11 [2127-11-5] 06:20AM BLOOD Glucose-346* UreaN-14 Creat-0.9 Na-135 K-4.2 Cl-101 HCO3-27 AnGap-11 [2127-11-4] 06:35AM BLOOD Ret Aut-0.6* [2127-11-1] 05:12PM BLOOD Plt Ct-280 [2127-11-1] 09:45PM BLOOD Plt Ct-148* [2127-11-3] 07:00AM BLOOD Plt Ct-178 [2127-11-4] 02:25AM BLOOD Plt Ct-140* [2127-11-4] 06:35AM BLOOD Plt Ct-147* [2127-11-5] 06:20AM BLOOD Plt Ct-164 [2127-11-1] 05:12PM BLOOD Neuts-73.1* Lymphs-22.3 Monos-2.8 Eos-1.3 Baso-0.5 [2127-11-1] 09:45PM BLOOD Neuts-61.6 Lymphs-32.9 Monos-4.0 Eos-1.1 Baso-0.4 [2127-11-1] 05:12PM BLOOD WBC-9.7# RBC-5.47 Hgb-17.6 Hct-49.6 MCV-91 MCH-32.2* MCHC-35.6* RDW-11.5 Plt Ct-280 [2127-11-1] 09:45PM BLOOD WBC-8.0 RBC-4.98 Hgb-16.0 Hct-44.5 MCV-89 MCH-32.2* MCHC-36.1* RDW-11.5 Plt Ct-148* [2127-11-3] 07:00AM BLOOD WBC-7.4 RBC-3.81* Hgb-12.1# Hct-34.6 MCV-91 MCH-31.8 MCHC-35.0 RDW-11.5 Plt Ct-178 [2127-11-4] 02:25AM BLOOD WBC-6.1 RBC-3.45* Hgb-11.4* Hct-32.3* MCV-94 MCH-33.1* MCHC-35.4* RDW-11.6 Plt Ct-140* [2127-11-4] 06:35AM BLOOD WBC-5.4 RBC-3.71* Hgb-11.9* Hct-34.4* MCV-93 MCH-32.2* MCHC-34.7 RDW-11.6 Plt Ct-147* [2127-11-5] 06:20AM BLOOD WBC-6.1 RBC-3.73* Hgb-12.1* Hct-35.1* MCV-94 MCH-32.5* MCHC-34.6 RDW-11.6 Plt Ct-164 Brief Hospital Course: Pt was admitted to the MICU and then transferred to the GeriMed service with new-onset Diabetes and resolving DKA. 1. Diabetes: Upon admission, the pt was dehydrated and lethargic. By laboratory studies, the pt was in DKA. He was seen by [Last Name (un) ] in the ED and started on the DKA Protocol with IVF, Insulin, and electrolyte repletion. Given his African origin and adult onset of disease, the patient may have an African subset of DM Type II. An HbA1C was 13.2% and GAD Ab was pending on DC to eval for DM Type I. Despire initial persistance of blood sugars greater than 400, an increasing regimen of glargine and sliding scale humalog brought his levels to the 100s to 200s by discharge. After his inital hydration and metabolic correction, the patient felt well and was stable for the remainder of his course. He received DM education [Last Name (un) ] [Last Name (un) ] and a diabetic diet was encourage. 2. Positive MIBI: Of note, had NSSTT changes on his initial ECG, despite all of his vital signs being stable and a lack of cardiac symptoms. An ETT MIBI showed inferior and lateral rev defects and inferior HK. He was seen by cardiology who recommended repeat imaging in one year at now interventions at present. His cardiac enzymes were flat. 3. NSVT: The patient had an asymptomatic episode of NSVT on admission in the setting of hypokalemia. After metabolic correction, he had no events on tele for >24hrs and remained stable and without symptoms. 4. HTN: He was continued on HCTZ and started on Lisinipril, given his new-onset DM and known HTN. 5. Hyperlipidemia: He was continued on Aspirin EC 325 mg PO QD and Atorvastatin 40 mg PO QD. 6. GERD: He was continued on Pantoprazole 40 mg PO Q24H. Medications on Admission: Aspirin EC 325 mg PO QD, Atorvastatin 40 mg PO QD, Norvasc 5mg PO QD, HCTZ, PCN (Now DCed; used for 5d). Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:0 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Lisinopril-Hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 5. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) Units Subcutaneous at bedtime. Disp:1 vial Refills:0 6. Insulin Lispro (Human) 100 unit/mL Solution Sig: Per Scale Subcutaneous four times a day: Follow Scale. Disp:1 vial Refills:0 7. Syringe with Needle (Disp) 1 mL 26 x [2-14] Syringe Sig: One (1) syringe Miscell. four times a day: as directed. Disp:1 box Refills:0 8. One Touch Ultra Test Strip Sig: One (1) strip Miscell. four times a day. Disp:1 box Refills:0 9. Lancets Misc Sig: One (1) lancet Miscell. four times a day. Disp:1 box Refills:0 10. Glucagon Emergency 1 mg Kit Sig: One (1) kit Injection as needed: if patient unconscious from hypoglycemia, administer. Disp:1 kit Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Dx: Diabetes Mellitus Type I. Secondary Dx: Ischhemic Heart Disease, Hypertension, Hyperlipidemia. Discharge Condition: Good Discharge Instructions: 1) If you have any dizziness, shortness of breath, chest pain, increased urination, increased thirst, increased hunger, blurry vision, sweating, or any other concerning symptoms, please contact your doctor or return to the ER. 2) Please take your new medications and monitor your blood sugar as instructed Followup Instructions: 1) Please see Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 3510] ([Telephone/Fax (1) 3511]) in the next week. He will arrange future cardiology follow-up for you. 2) Please the Diabetes doctors at the [Name5 (PTitle) ] Clinic ([Telephone/Fax (1) 12648]; [Telephone/Fax (1) 2378]) on the following dates and times: Monday [2127-11-10] - 830AM - First Steps. 11AM - Mointoring Matters. Wednesday [2127-11-12] - 1030AM - What Can I Eat. 1200PM - Appt with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. 100PM - Foods that Fit. [2127-11-18] - 215PM - Exercise.	[ "530.81", "276.8", "272.4", "427.1", "250.13", "402.90" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	10511, 10517	7273, 9006	339, 345	10668, 10674	2332, 7250	11028, 11669	1848, 1948		9161, 10488		10538, 10647		9032, 9138			10698, 11005								1963, 2313																						271, 301											373, 1440																	1462, 1561	1577, 1832
27,043	185,347	32556	Discharge summary	report	Admission Date: [2141-6-22] Discharge Date: [2141-7-3] Date of Birth: [2087-11-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Thoracentesis Placement of PICC line History of Present Illness: This is a 53 yo M with PMH of chronic vent/trach, severe COPD, prior L CVA with residual R-sided weakness, depression and schizophrenia who presents from rehab w/hypoxia, tachycardia and hypotension after desatting to 70% in the setting of possible suicidal ideation. Per pt, he is not sure why he was brought to the hospital. He feels well and denies suicidal ideation. He denies fever/chills, no cough/SOB/CP. Denies abdominal pain/N/V/D/C. No HA/dizzyness. . In the ED: T 99.0, HR 110-140s, SBP 70-80s improved with 2+ liters IVF to 90s. Femoral CVL was placed and pt was started on levophed and neo. Pt was asxtic throughout hypotension. EKG NSR w/ PACs. Given [Last Name (un) 2830]/vanc in ED for sepsis and w/ concern for h/o recent pseudomonal PNA resistant to cephalosporins and quinolones. . Of note, patient has been on a ventilator since [Month (only) 359] for respiratory failure secondary to severe COPD. He was found to have a RML and RLL collapse and paratracaheal LAD as well as chronic right pleural effusions at that time. Per old discharge summaries, his workup has been negative for malignancy. . Currently endorses low back pain which is chronic for him, but otherwise denies GU/GI/CV/Resp/MSK sx as in HPI. Past Medical History: Past Medical History: - Chronic vent/trach/PEG for hypercarbic respiratory failure at the beginning of [2140-10-10], ?reportedly due to COPD exacerbation - Severe COPD, home O2 dependent in the past - Per rehab admission note, questionable old granulomatous lung disease with calcified hilar LAD - Remote L CVA with residual right sided weakness - New onset generalized TC seizures on [2140-11-5] per rehab neuro note, thought to be [2-11] post-CVA and metabolic abnormalities (on transfer from rehab on Keppra, Depakote) - Diabetes mellitus, on 16U Lantus at rehab and RISS - Depression - Schizophrenia, on effexor and risperdal - Past h/o EtOH abuse - GERD - Afib/sinus tach - Pseudomonas PNA resistant to cephalosporins and quinolones [1-17] - [2140-12-19] TTE: LVEF 50-60% w/dilated right ventricular cavity and depressed right ventricular systolic function - h/o diverticulitis - h/o questionable old granulomatous lung disease with calcified hilar LAD. Social History: Divorced. Former smoking. h/o etoh abuse. lives at [Hospital1 1099] Hospital. Family History: Family History: non-contributory Physical Exam: VS: Temp: 99.0 BP: 120/52 on neo HR: 94 RR: 13 O2sat 100% on AC FiO2 60%, 500x12, PEEP of 8 GEN: comfortable, NAD but lethargic HEENT: PERRL, R pupil slightly more sluggish, EOMI, anicteric, no tongue bite NECK: large neck, difficult to assess jvd, trach in place RESP: coarse BS over L lung anteriorly, R lung with decreased breath sounds at base CV: tachy but regular, S1 and S2 wnl, no m/r/g ABD: obese, nd, nl b/s, soft, nt, no masses, PEG tube in place w/erythema at site, no drainage, EXT: no c/c/e, warm, 1+ DP pulses SKIN: no rash NEURO: Opening eyes. alert and oriented x 3, Handgrip intact, unable to lift of feet from bed or dorsiflex of palmarflex feet R > L. EOMI. Pertinent Results: [2141-6-22] 03:45PM BLOOD WBC-16.0# RBC-3.29 Hgb-9.3* Hct-28.5* MCV-87 MCH-28.3 MCHC-32.6 RDW-15.8* Plt Ct-497* [2141-6-22] 03:45PM BLOOD Neuts-92.8* Lymphs-4.4* Monos-2.4 Eos-0.2 Baso-0.2 [2141-6-22] 03:45PM BLOOD Glucose-216* UreaN-17 Creat-0.4* Na-140 K-4.0 Cl-103 HCO3-30 AnGap-11 [2141-6-22] 03:45PM BLOOD ALT-6 AST-9 CK(CPK)-8* [2141-6-22] 03:45PM BLOOD Calcium-7.9* Phos-3.6 Mg-1.7 [2141-6-22] 07:24PM BLOOD cTropnT-<0.01 [2141-6-22] 07:01PM BLOOD pO2-94 pCO2-75* pH-7.29* calTCO2-38* Base XS-6 [2141-7-3] 02:54AM BLOOD WBC-6.4 RBC-3.08* Hgb-8.6* Hct-27.0* MCV-88 MCH-27.8 MCHC-31.8 RDW-16.3* Plt Ct-355 [2141-7-3] 02:54AM BLOOD Glucose-131* UreaN-15 Creat-0.3* Na-141 K-4.6 Cl-105 HCO3-30 AnGap-11 [2141-7-3] 02:54AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9 [2141-6-28] 04:36PM BLOOD Cortsol-2.7 [2141-6-28] 05:19PM BLOOD Cortsol-17.7 [2141-6-28] 05:19PM BLOOD Cortsol-20.7* [2141-6-30] 03:02PM BLOOD Tobra-0.2* [2141-6-30] 04:58PM BLOOD Tobra-7.0 [2141-6-22] 05:30PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.026 [2141-6-22] 05:30PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2141-6-22] 05:30PM URINE RBC-[3-15]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0 [2141-6-30] 04:30PM PLEURAL WBC-260* RBC-3300* Polys-18* Lymphs-6* Monos-0 Meso-5* Macro-71* [2141-6-30] 04:30PM PLEURAL TotProt-3.0 Glucose-151 LD(LDH)-61 Albumin-1.3 [6-23] Sputum Culture: SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| CEFEPIME-------------- 2 S 8 S CEFTAZIDIME----------- 4 S 8 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM------------- 1 S 4 S PIPERACILLIN---------- 8 S 16 S PIPERACILLIN/TAZO----- 8 S 16 S TOBRAMYCIN------------ <=1 S <=1 S [6-30] BAL Culture: PSEUDOMONAS AERUGINOSA \| STENOTROPHOMONAS (XANTHOMONAS) MALTOPH \| \| CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM------------- 8 I PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [6-28] femoral TLC tip culture: PROTEUS MIRABILIS \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- 4 R [6-30] Chest CTA: IMPRESSION: 1. No evidence of a pulmonary embolism. 2. Right lung collapse with retained secretions, slightly improved aeration compared to [2141-6-28]. 3. Stable mediastinal adenopathy. 4. Stable bilateral pleural effusions. 5. Over inflated fluid-filled tracheostomy tube cuff, unchanged. [7-1] CXR: Moderate-to-large right pleural effusion has increased in size, now tracking along the apex. Persistent atelectasis involving right lower and middle lobes. Heterogeneous opacities in the left lung have progressed, and a small left pleural effusion is unchanged. Brief Hospital Course: # Pneumonia: Sputum and BAL cultures grew Pseudomonas and Stenotrophomonas. Treated with regimen of cefepime, tobramycin, and high dose Bactrim (details in discharge plan). Last tobra peak and trough acceptable, no need to follow for remainder of course. Had frequent mucous plugging requiring bronchoscopic suctioning, no need over the last 72 hours. Currently on vent settings of AC 500x18/8/40%, satting 98-100% and with no significant dyspnea. Continues to have chronic right sided pleural effusion with associated collapse, significantly improved after IR-guided thoracentesis. Pleural fluid not concerning for empyemia. Further vent weaning to be done at extended care facility. . # Hypotension: Mr. [Known lastname 40503] experienced multiple episodes of relative hypotension to SBP 70s. Originally thought to be attributable to septic physiology in setting of above pneumonia. AM cortisol 2.7, with bump to 17, started IV hydrocortisone for likely adrenal insufficiency. No episodes of hypotension since then. Should complete additional 5 days IV hydrocort as below, then switch to PO hydrocortisone 10mg PO qAM, 5mg PO q3pm for chronic management. Held home diltiazem and lasix, which can be restarted if patient becomes hypertensive or volume overloaded. . # Suicidal ideation: Followed by psychiatry for first several days of admission. Had 1:1 sitter. By [6-30], psychiatry team did not feed patient was at risk of self-harm, agreed with discontinuation of sitter and continuation of home psychiatric meds. Pt denies any suicidal or homocidal ideation currently. . # Hyperglycemia: Likely in setting of steroid use. Maintained on insulin sliding scale, added Glargine, which can likely be weaned after hydrocortisone is decreased to a lower-dose PO regimen, as described above. Would monitor for hypoglycemia at that point. . # Seizure disorder: Continued outpatient dose of levetiracetam 250 mg PO BID, divalproex 875 mg TID . # Schizophrenia: - continued outpatient dose of risperadol, trazodone . # F/E/N: Tube feeds via PEG as above . # PPx: proton pump inhibitor for stress ulcer prophylaxis, SC heparin for DVT prophylaxis . # Access: PICC with heparin flushes . # Communication: Guardian [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 46208], fax [Telephone/Fax (1) 75910]. Medications on Admission: Heparin sc TID Lansoprazole 30 mg PO DAILY Senna 8.6 mg PO BID prn Acetaminophen 325 mg Q6H as needed for pain, fever. Levetiracetam 250 mg PO BID Trazodone 50 mg PO TID Folic Acid 1 mg PO DAILY Venlafaxine 75 mg PO BID Risperidone 2 mg PO HS Divalproex 875 mg TID Ipratropium Bromide Inhalation Q6H as needed for wheezing, SOB Docusate Sodium Ten ml PO BID Chlorhexidine Gluconate 0.12 % Mouthwash Miconazole Nitrate 2 % Powder Topical [Hospital1 ] Albuterol 4-6 Puffs Inhalation Q4H Beclomethasone Dipropionate 2-4 puffs [Hospital1 ] Bisacodyl 5 mg Tablet, Delayed Release DAILY as needed. Diltiazem HCl 30 mg 0.5 Tablet PO TID Furosemide 60 mg PO BID Lactulose Thirty ML PO Q8H as needed. Insulin SS Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) mL Injection TID (3 times a day). 3. Acetaminophen 325 mg Tablet [Hospital1 ]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 4. Risperidone 2 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 5. Venlafaxine 75 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 6. Divalproex 125 mg Capsule, Sprinkle [Hospital1 ]: Seven (7) Capsule, Sprinkle PO TID (3 times a day). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 8. Ipratropium Bromide 0.02 % Solution [Last Name (STitle) ]: One (1) neb Inhalation Q6H (every 6 hours) as needed. 9. Levetiracetam 100 mg/mL Solution [Last Name (STitle) ]: Two [Age over 90 1230]y (250) mg PO bid (). 10. Albuterol 90 mcg/Actuation Aerosol [Age over 90 ]: One (1) Puff Inhalation Q6H (every 6 hours) as needed. 11. Folic Acid 1 mg Tablet [Age over 90 ]: One (1) Tablet PO DAILY (Daily). 12. Hexavitamin Tablet [Age over 90 ]: One (1) Cap PO DAILY (Daily). 13. Docusate Sodium 50 mg/5 mL Liquid [Age over 90 ]: One Hundred (100) mg PO BID (2 times a day). 14. Senna 8.6 mg Tablet [Age over 90 ]: One (1) Tablet PO BID (2 times a day) as needed. 15. Chlorhexidine Gluconate 0.12 % Mouthwash [Age over 90 ]: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day): while on mechanical ventilation. 16. Trazodone 50 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 17. Insulin Glargine 100 unit/mL Solution [Hospital1 ]: Ten (10) units Subcutaneous at bedtime. 18. Insulin Lispro 100 unit/mL Solution [Hospital1 ]: per sliding scale Subcutaneous four times a day: FS 0-150: nothing FS 151-200: 2 units FS 201-250: 4 units FS 251-300: 6 units FS 301-350: 8 units FS 351-400: 10 units, call physician. 19. Ibuprofen 100 mg/5 mL Suspension [Hospital1 ]: 200-400 mg PO Q4H (every 4 hours) as needed for pain. 20. Lactulose 10 gram/15 mL Syrup [Hospital1 ]: Thirty (30) ML PO Q8H (every 8 hours) as needed. 21. Acetylcysteine 20 % (200 mg/mL) Solution [Hospital1 ]: 1-10 MLs Miscellaneous Q6H (every 6 hours) as needed: thick secretions. 22. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [Hospital1 ]: Four (4) Tablet PO BID (2 times a day) for 11 days: last dose [2141-7-14]. 23. Oxycodone 5 mg/5 mL Solution [Year (4 digits) ]: Five (5) mg PO Q8H (every 8 hours) as needed. 24. Tobramycin Sulfate 40 mg/mL Solution [Year (4 digits) ]: Three Hundred (300) mg Injection Q24H (every 24 hours) for 4 days: last dose [2141-7-7]. 25. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 26. Cefepime 2 gram Recon Soln [Month/Day/Year ]: Two (2) Recon Soln Injection Q8H (every 8 hours) for 10 days: 2gm q8h, last dose [2141-7-12]. 27. Hydrocortisone Sod Succinate 100 mg/2 mL Recon Soln [Month/Day/Year ]: Fifty (50) Recon Soln Injection Q8H (every 8 hours) for 5 days: 50mg IV q8h, last day [2141-7-8]. 28. Hydrocortisone 5 mg Tablet [Month/Day/Year ]: One (1) Tablet PO q3pm: Start day after expiration of IV hydrocortisone. First dose [2141-7-9]. 29. Hydrocortisone 10 mg Tablet [Month/Day/Year ]: One (1) Tablet PO qAM: Start day after completion of IV hydrocortisone course. First dose [2141-7-9]. Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: Ventilator-Associated Pneumonia Discharge Condition: Stable, oxygenating well, BP stable, afebrile Discharge Instructions: You were admitted to the hospital with pneumonia. You received antibiotics, and will continue to receive care at your extended care facility. You should return to the emergency room if you experience worsening shortness of breath, fevers, low blood pressure, or other problems that concern you. Followup Instructions: Care will be managed in extended care facility.	[ "250.00", "285.9", "295.90", "V70.7", "255.41", "288.60", "999.9", "518.0", "V55.0", "V46.2", "438.20", "496", "038.43", "780.39", "038.9", "V46.11", "482.1", "427.31", "311", "511.9", "518.84", "276.2", "799.02" ]	icd9cm	[ [ [] ] ]	[ "33.24", "33.21", "38.93", "96.72", "38.91", "34.91" ]	icd9pcs	[ [ [] ] ]	14006, 14061	7289, 9605	321, 360	14137, 14185	3498, 7266	14529, 14580	2766, 2784		10367, 13983		14082, 14116		9631, 10344			14209, 14506								2799, 3479																						274, 283											388, 1632																	1676, 2635	2651, 2734
2,476	130,961	12900	Discharge summary	report	Admission Date: [2147-6-23] Discharge Date: [2147-6-29] Date of Birth: [2078-5-6] Sex: F Service: MED Allergies: Morphine Sulfate / Reglan / Sulfa (Sulfonamides) / Betadine / Tape / Macrodantin / Capoten / Cardizem Cd Attending:[First Name3 (LF) 6578] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: Removal dialysis catheter, placement new subclavian dialysis cathether. History of Present Illness: 69 F h/o ESRD h/o MRSA bacteremia, h/o endometritis, h/o PVD who recently had R femoral tunnelled cath placed [6-13]. On admission to MICU [6-23] pt experienced increased rigors, chills during hemodialysis. Pt noted to have purulent d/c from line site. Pt had emergent IR guided removal and replacement of line at new site. Admission ROS negative for recent cough, dyspnea, abd pain, c/p, h/a, lh. Pt given levo/vanco/flagyl. Labs notable for WBC 18.4, ?retrocardiac infiltrate on CXR. Also, pt recently followed by OB/GYN for endometritis. Past Medical History: 1. ESRD - HD since [41], 2. h/o MRSA bacteremia 3. h/o CVA 4. PAF 5. anxiety 6. cataracts 7. PVD - Right AKA, L metarsal amputations Social History: Lives alone with VNS for 5hrs qd. Family History: DM Physical Exam: Vitals: T96.6 HR86 RR21 BP 110/40 PSO2 99%RA Gen: Pleasant woman in NAD HEENT: PERRLA, Mouth and oropharynx clear, decreased hearing bil, neck supple, R subclavian intact with dried blood surrounding Chest: Slight expiratory wheezes, no crackles or ronchi, + breath sounds throughout CV: Nl S1/S2 Abd: Soft, Not tender, Not distended, no organomegaly, normal bowel sounds Ext: R leg AKA, left calf tense, L 3cm D ulcer with black escharous edge Neuro: A&O X 3, CNII-XII intact Pertinent Results: [2147-6-23] 10:40 am BLOOD CULTURE SET 1. FINAL REPORT [2147-6-26] AEROBIC BOTTLE (Final [2147-6-26]): REPORTED BY PHONE TO M. [Doctor Last Name ], R.N. ON [2147-6-24] AT 0445. SERRATIA MARCESCENS. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ SERRATIA MARCESCENS \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S GENTAMICIN------------ 4 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- <=1 S Grown in [4-30] bottles [2147-6-24] 1:38 pm BLOOD CULTURE FINAL REPORT [2147-6-28] AEROBIC BOTTLE (Final [2147-6-28]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 8 I LEVOFLOXACIN---------- =>8 R OXACILLIN-------------<=0.25 S PENICILLIN------------ =>0.5 R ANAEROBIC BOTTLE (Final [2147-6-28]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. STRAIN 2 FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Grown in [12-26] bottles. [Known lastname ],[Known firstname ] I.: Microbiology Detail - CCC Record #[Numeric Identifier 39661] [2147-6-27] 8:30 am BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Preliminary): REPORTED BY PHONE TO TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] AT 2130 [6-28] SAB. GRAM POSITIVE RODS. BEING ISOLATED FURTHER IDENTIFICATION TO FOLLOW. grown in [11-25] bottles following 2d without bacteremia; grew after 36 hours [2147-6-23] 04:58PM GLUCOSE-126* UREA N-12 CREAT-3.1* SODIUM-139 POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-32* ANION GAP-16 [2147-6-23] 04:58PM ALT(SGPT)-22 AST(SGOT)-25 CK(CPK)-43 ALK PHOS-376* Brief Hospital Course: The patient was admitted to the MICU [2147-6-23] with fever and hypotension. She was started on vanc/levo/flagyl and a subclavian TLC was placed. CXR was taken which demonstrated retrocardiac opacity. She was started on levaphed for pressure of 90/42. She received HD for her ESRD. The fever and hypotension were considered to possibly represent sepsis, although there was also consideration of fever in the context of chronically low BP. Sputum has remained NGTD. The patient was observed one examination to have a foot ulcer. Endometritis was considered. However, the most likely etiology was considered the patient's dialysis catheter which was replaced at the same site on admission. The patient grew out serratia narcessans and coag negative staph and was started on a course of levoquin and gentamycin. On [6-26], the tunnelled catheter was removed. on [6-27] the patient's central line was changed to a dialysis catheter and she was dialyzed through it. On discharge, the patient has received seven days of levoquine and seven days of vancomycin and will receive another seven days of each, levoquine PO and vancomycin at dialysis. The patient has been abectermic for 3 days, excepting gram positive rods believe to represent contimination. She has been afebrile for four days and her white blood cell count has decreased from a maximum of 25.3 to 6.6 today. She has been normotensive for several days. She will next receive dialysis tommorow where she will be dosed with vancomycin. Throughout her admission she received wound care for her old foot ulcer by podiatry; she should continue to receive wet to dry dressings on discharge. She continues to need OBGYN followup on her history of vaginal bleeding; she will be given the number for the [Hospital ] clinic to make an appointment. She was full code throughout her stay here. Medications on Admission: Lopressor XL 25 QD Ranitidine 150 QD Renagal 400 TID Insulin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID PRN as needed for constipation. Disp:60 Capsule(s) Refills:3 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:0 4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 7 days. Disp:2 Tablet(s) Refills:0 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). Disp:1 Refills:2 7. Atropine Sulfate 1 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). Disp:1 Refills:2 8. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for pain. Disp:30 Lozenge(s) Refills:3 9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:1 Refills:0 10. Insulin NPH-Regular Human Rec Subcutaneous Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Sepsis with serratia and coagulase negative staph, now resolved. Discharge Condition: Good. Discharge Instructions: Please report to hemodialysis tomorrow to have dialysis and vancomycin redosed. Please call OBGYN at ([Telephone/Fax (1) 22754] for a followup appointment regarding endometriosis. Followup Instructions: Please report to hemodialysis tomorrow to have dialysis and vancomycin redosed. Please call OBGYN at ([Telephone/Fax (1) 22754] for a followup appointment regarding endometriosis. If you become short of breath, have chest pain, fevers, night sweats or other symptoms of concern to you, please call your doctor or come to the emergency room.	[ "707.19", "038.44", "250.40", "585", "427.31", "996.62", "038.19", "995.91", "300.00" ]	icd9cm	[ [ [] ] ]	[ "39.95", "38.95" ]	icd9pcs	[ [ [] ] ]	7590, 7647	4475, 6351	366, 440	7756, 7763	1767, 3898	7995, 8343	1251, 1255		6462, 7567		7668, 7735		6377, 6439			7787, 7972								1270, 1748																						320, 328							3928, 4452				468, 1024																	1046, 1184	1200, 1235
321	199,004	52998+52999	Discharge summary	report+report	Admission Date: [2189-6-11] Discharge Date: [2189-6-19] Date of Birth: [2113-12-13] Sex: F Service: GENERAL MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old woman with a history described in the past medical history, who was admitted to [Hospital ] Hospital on [2189-6-8] with left-sided chest pain and ruled out for myocardial infarction. She was found to be in new onset atrial fibrillation. Persantine Thallium revealed a reversible defect, prompting transfer to [Hospital1 188] for catheterization. However, prior to catheterization, she had chest pain and fell, a mechanical fall resulting in a left intertrochanteric fracture. She had a negative head CT and cervical spine, and then was transferred to [Hospital1 69]. PAST MEDICAL HISTORY: 1. Hypertension 2. Obesity 3. History of sick sinus syndrome status post pacemaker in [2186] 4. Depression 5. Cerebrovascular accident x 2 in [2182] and [2183] affecting the left side 6. Osteoarthritis 7. Gastroesophageal reflux disease 8. Intestinal bypass, cholecystectomy, appendectomy and hernia repair 9. Fibromyalgia MEDICATIONS ON TRANSFER: Her medications as an outpatient are atenolol, Zoloft, aspirin and Tagamet. ALLERGIES: Sulfa drugs, which cause a rash. SOCIAL HISTORY: She has no tobacco or alcohol use. She lives in [Hospital3 ]. PHYSICAL EXAMINATION: At the time of admission, notable for a blood pressure of 112/72, pulse 78, respirations 24, 91% on room air, 97% on 3 liters. In general, she is sleepy, falling asleep during the examination, complained of pain, but in no acute distress. Heart was irregularly irregular, no murmurs, no jugular venous distention, no carotid bruits. The lungs are clear to auscultation anteriorly and laterally. The abdomen is soft, obese, with active bowel sounds, nontender. The extremities showed no edema, cool, 2+ pedal pulses bilaterally. Neurological examination is alert and oriented x 3. Cranial nerves intact. Upper extremities 4/4 strength bilaterally. LABORATORY DATA: On admission, notable for creatinine of 1.3, normal liver function tests. Troponin less than .02 x 3. Urinalysis was negative. All of this was at the outside hospital. Upon admission to [Hospital1 188], her CK was 1058 with an MB of 19, presumed secondary to the fall, and her BUN and creatinine had increased to 36 and 2.6 respectively. Phos was 7.0. Hip x-ray revealed a left hip intertrochanteric fracture with varus deformity, superior displacement of the distal fragment, no evidence of dislocation. Persantine Thallium revealed an ejection fraction of 48% with an ischemic inferoapical wall and anteroapical fixed abnormality, hypokinesis of the apex and lateral wall and inferoapical wall. Chest x-ray revealed moderate cardiomegaly, no pneumonia or congestive heart failure. HOSPITAL COURSE BY SYSTEM: 1. Neurology: The patient had mental status changes after extubation, was able to only answer a few questions, however, this improved as her sodium decreased back down to a normal range. It may also have been related to benzodiazepines or medications that she had at the time of intubation, which were washed out of her system. At the time of discharge, she is alert and oriented x 3. The patient also had two head CT studies which did not show any evidence of acute focal processes. 2. Heart: She was in atrial fibrillation rhythm. It is unclear when that originally occurred. She remained on telemetry for her hospital course, and she was not taking oral medications. She was taking metoprolol intravenously to keep her pulse and blood pressure stable. She became hypertensive and tachycardic in the 130s to 140s at times. Once she was able to pass her swallowing evaluation, she was restarted on Lopressor and then switched to atenolol at discharge. Possible cardioversion was discussed, possibly as an outpatient. The cardiac catheterization was done and revealed minimal coronary artery disease. Therefore, the chest pain was believed not to be secondary to cardiac ischemia. 3. Pulmonary: The patient was intubated at the time of surgery for the left hip repair, and was weaned in the Surgical Intensive Care Unit after surgery. 4. Gastrointestinal: The patient was kept nothing by mouth until her mental status had cleared. She had failed two swallowing studies because of lack of cooperation, however, she was finally able to pass a swallowing study on the [12-18], and was restarted on oral intake and oral medications. She received Zantac throughout her hospital course intravenously. 5. Endocrine: Her sugars were well controlled for the most part on regular insulin sliding scale. 6. Renal: Creatinine and BUN improved during the hospital course. DISCHARGE PLAN: To transfer the patient on the following medications: Coumadin 5 mg by mouth daily at bedtime to be adjusted for an INR of 2 to 3, vitamin B12 1000 mcg intramuscularly or subcutaneously weekly for three weeks then monthly, heparin intravenously until the Coumadin is therapeutic, Protonix 40 mg by mouth once daily, atenolol 100 mg by mouth once daily. She will have physical therapy and be on a cardiac diet. DISCHARGE DIAGNOSIS: 1. Left hip fracture 2. Hypernatremia 3. Atrial fibrillation 4. Diabetes mellitus [First Name11 (Name Pattern1) 2515] [Last Name (NamePattern4) 4517], M.D. [MD Number(1) 4521] Dictated By:[Name8 (MD) 6069] MEDQUIST36 D: [2189-6-19] 01:36 T: [2189-6-19] 03:28 JOB#: [Job Number 32608] Admission Date: [2189-6-11] Discharge Date: [2189-6-19] Date of Birth: [2113-12-13] Sex: F Service: STAT ADDENDUM: DISCHARGE MEDICATIONS: 1. Coumadin 5 mg po q hs to be adjusted for an INR of 2 to 3 2. Vitamin B12 1000 mcg intramuscular or subcutaneous q week x3 weeks and then q month 3. Heparin intravenous until Coumadin is therapeutic 4. Protonix 40 mg po qd 5. Lopressor 100 mg po tid 6. MSIR 15 mg po q6h prn pain. The MSIR should be adjusted according to her mental status and pain control. [First Name11 (Name Pattern1) 2515] [Last Name (NamePattern4) 4517], M.D. [MD Number(1) 4521] Dictated By:[Name8 (MD) 6069] MEDQUIST36 D: [2189-6-19] 14:08 T: [2189-6-19] 14:30 JOB#: [Job Number 109255] cc:[Hospital 109256]	[ "276.0", "E888.9", "820.22", "786.50", "401.9", "266.2", "276.5", "427.31", "584.5" ]	icd9cm	[ [ [] ] ]	[ "79.35", "37.22", "88.55" ]	icd9pcs	[ [ [] ] ]									5791, 6454		5263, 5768								2919, 4812																1423, 2892																						179, 796															4829, 5242	1189, 1313	818, 1163	1331, 1399
32,247	127,308	15733	Discharge summary	report	Admission Date: [2122-12-24] Discharge Date: [2122-12-31] Date of Birth: [2059-1-8] Sex: F Service: MEDICINE Allergies: Percocet / Motrin / Nsaids / Aspirin / Dilantin / Ativan Attending:[First Name3 (LF) 552] Chief Complaint: Hypertension, Altered Mental Status Major Surgical or Invasive Procedure: no History of Present Illness: This is a 63 year-old woman with a history of HD dependent ESRD, hypertension, seizure disorder who presents with mental status changes. Pt was initially seen in ED this AM after being referred from transplant clinic for AMS. At that time, SBP was 210/110; the patient was given 20mg IV labetalol + 200 PO with improvement to the 150/90. She was A+O x 3 and left AMA. One hour later, the patient was found by [Location (un) ] police wondering through traffic. At that time, she was noted to be oriented x1 and subsequently taken to the ED by EMS. There, BP was 219/113, HR 104, 16 with O2 sat 100% on Room Air. She recieved 40mg IV labetalol with little improvement. She became agitated and recieved 2mg ativan and CT was obtained which was without evidence of acute injury. ECG was notable for non-specific anterior lead T wave changes which were stable since last documented EKG in [Month (only) 359]. Blood sugars were between 187-->229 and urinanalysis was marginally postive. Labs were notable for troponin of 0.07 and calcium of 10.3. . On arrival to the floor, the patient was minimally arousable and nonresponsive to commanded. A review of systems could not be obtained and further history was obtained from available medical records Past Medical History: 1. Multiple admission with altered MS - with recent extensive neurological workup revealing multifocal etiology likely due to HD fluid/electrolyte shifts, ? uremia prior to HD, also component of vascular dementia. Started on [Month (only) 13401] [9-14]. 2. Diabetes mellitus. 3 End-stage renal disease secondary to diabetes mellitus s/p failed dual extended-criteria donor renal transplant (BK virus nephropathy) 4. Hemodialysis (T, Th, Sa) 5. Hypertension. 6. Hyperlipidemia. 7. Thrombosis of bilateral IVJ (catheter placement)-- DVT associated with HD catheter RUE on anticoagulation (Coumadin) --balloon angioplasty performed [1-13]. 8. Osteoarthritis. 9. PER OMR NOTES (?) - Arthritis of the left knee at age nine, treated with ACTH resulting in secondary [Location (un) ]. She was diagnosed with rheumatic fever. 10. h/o Trach and PEG [1-13] (reversed [2-13]). 11. h/o L tension pneumothorax [2-7] intubation 12. H/o DVT/SVC syndrome Past Surgical History: 1. Kidney transplant in [2119] b/l in RLQ 2. Left arm AV fistula for dialysis. 3. Removal of remnant of AV fistula, left arm. 4. Catheter placement for hemodialysis. 5. Low back surgery (unspecified) 6. S/P negative laparotomy for abdominal pain Social History: The patient smokes half a pack of cigarettes a day for the last 20 years. She does not drink alcohol or has ever experienced with recreational drugs, has no tattoos. Family History: non-contributory Physical Exam: General: somnolent, snoring, NAD. HEENT: NC/AT, no scleral icterus noted, MMdry, no lesions noted in oropharynx, PERRL Pulmonary: Lungs CTA bilaterally without R/R/W, Left SC HD line in place, dressing CDI. Cardiac: RRR, nl. S1S2, 3/6 systolic murmur best at LUSB. Abdomen: thin, normoactive bowel sounds, soft, NT/ND, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. NEURO: somnolent, minimally arousable to voice, responds to painful stimuli physically/vocally. Moves all 4 extremities. Toes downgoing. Pertinent Results: ========== Labs ========== Admit labs - [2122-12-24] 01:40PM BLOOD WBC-8.4 RBC-3.79# Hgb-12.3 Hct-35.7 MCV-94 MCH-32.4* MCHC-34.3 RDW-15.7* Plt Ct-312 [2122-12-24] 01:40PM BLOOD Neuts-78.5* Lymphs-13.7* Monos-6.3 Eos-1.3 Baso-0.2 [2122-12-24] 01:40PM BLOOD Glucose-61* UreaN-10 Creat-4.6# Na-143 K-5.0 Cl-103 HCO3-27 AnGap-18 [2122-12-24] 06:20PM BLOOD Albumin-4.8 Calcium-10.3 Phos-4.1# Mg-1.7 [2122-12-24] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2122-12-24] 07:20PM URINE Blood-SM Nitrite-NEG Protein-500 Glucose-250 Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [2122-12-24] 07:24PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG RAPID PLASMA REAGIN TEST (Final [2122-12-25]): NONREACTIVE. Reference Range: Non-Reactive. ======== Radiology ======== CT Head [12-24] IMPRESSION: No acute change. No acute intracranial abnormality. . [2122-12-27] MRI Head: 1. Subtle increase of FLAIR signal intensity in the right parietal lobe, could suggest PRES. 2. Chronic white matter T2-intensity in the pons and periventricular region, likely represents chronic small vessel ischemic disease. 3. Paranasal sinus findings as described above. [2122-12-28] EEG: This is an abnormal routine EEG in the waking state due to persistent left frontotemporal slowing. This is indicative of an area of subcortical dysfunction in this region. There were no epileptiform discharges that were noted. [2122-12-29] MIDLINE: Midline catheter placed in right subclavian due to obstruction more distally. Final internal length is 26 cm. The line is ready to use. [2122-12-24] ECG: Sinus rhythm. Short P-R interval. Consider right atrial abnormality. Probable left ventricular hypertrophy. ST-T wave abnormalities. Since the previous tracing of [2122-10-20] QRS voltage is increased. T wave amplitudes are greater. Brief Hospital Course: Ms. [Known lastname ] is a 63 year-old woman with a history of HD dependant diabetic end-stage renal disease, hypertension, hyperlipidemia, seizure disorder who presents with hypertension and altered mental status. 1)Hypertensive emergency - with altered mental status, unclear cause but most likely [2-7] medication non-compliance and possibly missing dialysis. She was placed on labetalol gtt overnight in the ICU, and then transitioned to her home antihypertensive regimen. Pt with history of hypertension, but per previous records BP has been documented from 120-180's systolic making her current blood pressures unusually high and somewhat of an acute change from baseline on admission. There was concern for altered mental status as possible evidence of malignant hypertension. CT without intracranial abnormalities or evidence of CVA. Patient does not remember what led up to her confusion or if she missed her blood pressure medications. BP now well controlled on current regimen. She was continue amlodipine and metoprolol at home doses. In addition, she was on low dose lisinopril. 2) Altered Mental Status: Multiple admissions with altered MS in the past; felt to have multiple possible eitologys (fluid shifts during dialysis as well as seizure disorder). Likely contribution of hypertensive encephalopathy on this admission. She had an EEG which was abnormal however neurology did not feel there was any evidence of uncontrolled seizure activity and she was contiued on her home regimen of [Month/Day (2) 13401] for seizure prophylaxis. She had an MRI initially with some concern for PRES however neurology did not feel that this was likely. She had no evidence of infection and her mental status improved to baseline with continued dialysis and good blood pressure control. 3)h/o DVT, line-associate thrombosis - She initially had subtheraputic INR and midline was placed for heparin gtt and lab draws. Her INR then quickly went to 2.6 and heparin was not needed. She was discharged on 6mg coumadin with INR checks at dialysis. 4)Diabetes mellitus: Does not appear to be pharmaceutically managed at this time. Did not require coverage with humalog while in house. Not discharged on antidiabetics. 5) End-stage renal disease: Secondary to diabetes mellitus and s/p failed dual extended-criteria donor renal transplant (BK virus nephropathy). Pt was dialysed on M, W, Friday. She was continued on cinacalcet. 6)Hyperlipidemia: on Atorvastatin at home. 7)Seizure disorder: EEG during this admission without evidence of uncontrolled seizure activity. EEG with frontal temporal slowing. She was continued on home dose [Month/Day (2) ]. 8)PAF - currently in sinus rhythm. She was discharged on 6mg coumadin with INR theraputic at 2.9. She was continued on home dose metoprolol. 9)CAD: no acute issues, not on ASA at baseline. She was continue atorvastatin 10)Code: FULL CODE 11)Comm: [Name (NI) ] [Name (NI) 431], Cousin, [First Name8 (NamePattern2) ] [Name (NI) ] [Telephone/Fax (1) 45319] or [Telephone/Fax (1) 45320] Medications on Admission: Warfarin 7.5 Tablets PO Once Daily Metoprolol Tartrate 50 mg [Hospital1 ] Lisinopril 5 mg QD Atorvastatin 20 mg QD Sertraline 100 mg QD Cinacalcet 120 mg QD Folic Acid 1 mg QD Levetiracetam 500 mg [Hospital1 ] Hydrocodone-Acetaminophen 5-500 mg [1-7] Q4H PRN pain Docusate Sodium 100 mg [Hospital1 ] Levetiracetam 250 mg PO QHD after dialysis B Complex-Vitamin C-Folic Acid 1 mg QD Amlodipine 10 mg QD Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Lisinopril 5 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Amlodipine 5 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 4. Levetiracetam 250 mg Tablet [Hospital1 ]: Two (2) Tablet PO BID (2 times a day): please take an additional 250mg after dialysis on dialysis days. 5. Folic Acid 1 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 6. Cinacalcet 30 mg Tablet [Hospital1 ]: Four (4) Tablet PO DAILY (Daily). 7. Levetiracetam 250 mg Tablet [Hospital1 ]: One (1) Tablet PO ON HD DAYS (). 8. Sertraline 50 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 9. Atorvastatin 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 10. Warfarin 2 mg Tablet [Hospital1 ]: Three (3) Tablet PO once a day: please have your INR checked closely at dialysis and your coumadin dose adjusted as needed. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: Malignant hypertension, hypertensive encephalopathy . Secondary Diagnoses: - Multiple admission with altered MS - with recent extensive neurological workup revealing multifocal etiology likely due to HD fluid/electrolyte shifts, ? uremia prior to HD, also component of vascular dementia. Started on [Hospital 13401] [9-14]. - Diabetes mellitus type 2 (diagnosed her in 30s), - End-stage renal disease secondary to diabetes mellitus s/p failed dual extended-criteria donor renal transplant (BK virus nephropathy) - Hemodialysis (T, Th, Sa) at [Location (un) ] in [Location (un) ]. - Hypertension. - Hyperlipidemia. - Thrombosis of bilateral IVJ (catheter placement)-- DVT associated with HD catheter RUE on anticoagulation (Coumadin) - balloon angioplasty performed [1-13]. 0 Osteoarthritis. - PER OMR NOTES (?) - Arthritis of the left knee at age nine, treated with ACTH resulting in secondary [Location (un) ]. She was diagnosed with rheumatic fever. - h/o L tension pneumothorax [2-7] intubation - H/o DVT/SVC syndrome - h/o Angioedema - Intubated for angioedema during a prior hospitalization from [Date range (3) 45321], which seemed to correlate with Ativan administration. Treated 24 hours with steroids with remarkable improvement. There is also a prior report of angioedema in the past, attributed to Dilantin--but she received Ativan at that time as well. - Atrial fibrillation with RVR. - H/o depression - GERD Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating without assistance Discharge Instructions: You were admitted with confusion and found to have elevated blood pressures that were treated with IV medications and you required monitoring in the ICU. It is likely that your confusion on admission was most likely due to your very high blood pressure. There was no evidence of infection. Your blood pressure remained under good control with oral medications and you had HD while in the hospital, which you tolerated well. It is important to take your medications to avoid this in the future. It is imperative that you have your INR followed with Dr. [Last Name (STitle) ]. His [Hospital3 ] will call you after discharge to arrange an appointment. Please have your INR checked on Friday at dialysis. . Medications: 1) You were started on lisinopril 5mg daily for your blood pressure. 2)Please continue to take coumadin 6mg daily, have your INR checked on Friday at dialysis and your coumadin dose adjusted as needed. Please call your doctor or return to the hospital if you experience any concerning symptoms including confusion, headache, difficulty taking your medications, high blood pressure, fevers or other worrisome symptoms. Followup Instructions: Please be sure to go to your usual dialysis on Saturday. Please have your INR level checked at that appointment. Continue to get your dialysis tuesday, thursday, saturday at [Location (un) ], [Location (un) ] Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2123-1-15] 9:00 . Provider: [Name Initial (NameIs) 1220]. [Name5 (PTitle) 540] & [Doctor Last Name ] Phone:[Telephone/Fax (1) 44] Date/Time:[2123-2-2] 4:00 Please call Dr.[Name (NI) 670] clinic at [Telephone/Fax (1) 673] and schedule an appointment to follow up after the repair of your aneurysm.	[ "V45.11", "345.90", "437.2", "V42.0", "272.4", "403.01", "250.00", "585.6", "530.81", "427.31" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	10368, 10426	5716, 6833	353, 357	11942, 12020	3747, 5693	13217, 13883	3101, 3119		9281, 10345		10447, 10447		8838, 9258			12044, 13194						2649, 2901		3134, 3728	10541, 11921																					278, 315											385, 1637							10466, 10520				6848, 8812						1659, 2626	2917, 3085
51,025	167,150	27153+57525	Discharge summary	report+addendum	Admission Date: [2110-11-9] Discharge Date: [2110-12-1] Date of Birth: [2045-12-30] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2110-11-20] - CABGx4 (left internal mammary artery->Left anterior descending artery, Saphenous vein graft(SVG)->Diagonal artery, SVG->Obtsue marginal artery, SVG->Posterior descending arerty). [2110-11-11] - Flexible sigmoidoscopy [2110-11-9] - Cardiac Catheterization History of Present Illness: Mr. [Known lastname ] is a 64yo M w/ a PMHx of CAD s/p PCI X 2, most recently [7-18], PAF not on coumadin, ESRD on HD, hypercholesterolemia, COPD, CVA [2107] and [3-18], who was transferred to [Hospital1 18] from [Hospital3 7569] for emergent cath s/p STEMI. Patient reports that he developed aching chest pain and diaphoresis this morning while laying on the couch. Pain was mid-sternum, non-radiating. Patient reports he has not had this in the past, although reports of prior chest pain and stents. + Associated nausea and SOB. Lasted until arrived at OSH. Came to [Location (un) ] ED where vitals at triage were 96.7, HR 90, BP 141/68, RR22, 98% on unknown O2. ECG showed ST elevations in II, V1-V4. Pt underwent VF which terminated with shock X 1, this episode was repeated 3 times in total. Was given Amio bolus and gtt started. Started heparin gtt and was given Aggatroban gtt. Per report, last dialysis was yesterday; however pt states it was friday. On arrival to [Hospital1 18], pt underwent cardiac cath showing 70% LM lesion, mid-LAD lesion with Vision BMS and 0% residual stenosis, also dominal RCA wiht proximal occlusion and r-r and l-r collaterals. LCx was non-dominant 50% lesion. Heparin and aggrastat were stopped. Currently, pt denies chest pain, SOB, nausea. No orthopnea or PND. Walking limited by SOB but able to walk > 1 block without stopping. Cannot tell me how many stairs he can climb. Denies leg pain with ambulation. Denies edema or palpitations. Per daughter, he has hx of CAD with prior MIs and stents at [Hospital1 ], although pt denied prior CAD or MIs. Daughter reports 100lb weight loss over past 6 months due to anorexia and "not feeling well" in the setting of dialysis. Past Medical History: 1. CARDIAC RISK FACTORS:: Dyslipidemia 2. CARDIAC HISTORY: CAD: [2110-4-9] - BMS (Driver) to OM1 [2110-7-24] - 95% in-stent thrombosis of OM1, tx with 2 DES (Xience) in the proximal OM1 extending to the circumflex with no residual stenosis; distal L Cx occluded - per cath report, left main without significant disease - LAD with 30-40% plaque after large septal branch - known RCA occlusion with collateral flow 3. OTHER PAST MEDICAL HISTORY: ESRD on HD M/W/F COPD s/p CVA L MCA [3-16] s/p CVA R MCA [3-18] secondary hyperparathyroidism Social History: -Tobacco history: + [12-11] ppd -ETOH: none recently, but + history -Illicit drugs: pt denies Family History: No hx of CAD, MI, DM per daughter. Physical Exam: VS: T= 95.9 BP= 133/64 HR= 72 RR= 15 O2 sat= 99% on 4L GENERAL: Somnlent but otherwise well-appering man in NAD. Oriented to person, month and year. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with no appreciable JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Distant heart sounds 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. Pursed-lip breathing on exhalation. ABDOMEN: Soft, NTND. No HSM or tenderness. Lower left-midline scar s/p appendectomy per pt. EXTREMITIES: No femoral bruits. R femoral sheath in place. L arm AV fistula, + palpable thrill and audible bruit. SKIN: Ulceration on L anterior skin with eschar and granulation tissue. Chronic skin changes of bilateral lower extremities c/w statis dermatitis. 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: STUDIES EKG (from OSH): NSR at 80bpm, nl QRS axis, ST elevations in V1-V4 with QRS .120 sec. CARDIAC CATH ([11-9]): 1- Selective coronary angiography of this right dominant system revealed three vessel disease with LMCA involvement. The LMCA had a 70% stenosis. The LAD was occluded in mid segment with proximal septal collaterals to the RCA. There was heavy calcification in the LAD. There was a large D1 and S1. The LCX is a non-dominant vessel with origin clacification and 50% lesion in the proximal portion. The RCA is a dominant vessel with occlusion proximally and r-r collaterals and l-r collaterals. 2- Limited resting hemodynamics revealed a normal systemic arterial blood pressure of 115/55 mmHg. 3- Successful PTCA and stenting of the mid totally occluded LAD with 3.0x23 mm Vision BMS. Final angiography revealed 0% residual stenosis with TIMI III flow. 4- Abdominal aortography with run off to the iliac arteries was performed utilizing a Pegtail 5 French caheter positioned at L1. The abdominal aorta had moderate diffuse calcification with modest occlusive iliac disease and bilateral iliac aneurysms. The renal arteries were patent. TTE ([11-10]): The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the distal half of the anterior septum and anterior walls, and distal inferior wall. The apex is mildly aneurysmal and dyskinetic. The remaining segments contract normally (LVEF = 25-30 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Rt upper extrem US ([11-10]): IMPRESSION: Provided limited imaging shows wide patency of the right radial artery with normally triphasic waveforms as described above. Carotid US ([11-10]): 1. Moderate-to-severe left ICA stenosis with apparent interval progression since prior imaging. No significant ICA stenosis on the right. 2. Antegrade flow in both vertebral arteries. CT torso ([11-12]): 1. Concentric wall thickening at the rectosigmoid junction which in the setting of bright red blood per rectum is concerning for possible malignancy. Recommend endoscopic evaluation. 2. Enlarged subcarinal lymph node and borderline pretracheal node. 3. Diffuse atherosclerotic calcification and aneurysmal dilatation of the right iliac artery. 4. Atrophic kidneys and bladder consistent with end-stage renal disease. 5. Degenerative changes in the thoracic spine and healing pelvic fractures. CTA neck ([11-12]): Significant atherosclerotic disease involving the carotid arteries with 50% stenosis in the proximal cervical internal carotid artery on the right and approximately 80-85%% stenosis over a short segment in the proximal left cervical internal carotid artery. No flow limitation distally. Flex sigmoidoscipy ([11-13]): Erythema in the recto-sigmoid. No mass seen. In the setting of circumferential thickening seen on CT scan, this finding is possibly secondary to ischemia that has partially healed. This was most likely the etiology of the patient's bleeding, however, we cannot rule out lesions elsewhere in the GI tract. Otherwise normal sigmoidoscopy to sigmoid colon at 30 cm Cardiac cath ([11-17]): 1. Access via left femoral artery as the RFA had been used last week. The artery was very calcified but access was without complications. 2. Limited hemodynamics with BP 113/46 with HR 65 in sinus 3. Angiography of the aortic arch with a pigtail catheter in the ascending aorta revealed a moderately calcified aorta with a Type 1 Arch. 4. Angiography of the right carotid with the catheter in the right inominate revealed the right common to be patent. The right internal had mild disease. The right internal carotid fills the ipsilateral ACA and MCA as well as the contralateral ACA. 5. Angiography of the left carotid with the Berenstein catheter in the left carotid showed the left common carotid to be normal. The left internal has moderate diffuse disease without critical lesions. There was heavy calcification at the left carotid bifurcation. The left internal fills the left MCA and a fetal origin PCA but not the ACA (filled by right carotid). FINAL DIAGNOSIS: 1. No significant carotid artery stenosis [2110-11-20] ECHO PRE-BYPASS: 1. The left atrium is moderately dilated. A left-to-right shunt across the interatrial septum is seen at rest. A secundum type atrial septal defect is present. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with severe apical hypokinesis. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. There are complex (mobile) atheroma along [Last Name (un) ] the ascending aorta seen on epiaortic scanning. There are focal calcifications in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are complex (mobile) atheroma in the descending aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Moderate to severe (3+) mitral regurgitation is seen. 7. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results. Post Revascularization: Pt is on an infusion of phenylephrine, Norepinephrine and Epinephrine 1. Biventricular function is unchanged. 2. Other findings are unchanged. Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2110-12-1] 05:19AM 12.1* 3.35* 9.9* 30.2* 90 29.6 32.8 17.2* 235 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2110-12-1] 05:19AM 84 24* 4.4* 143 3.7 105 30 12 [Known lastname ],[Known firstname ] [Medical Record Number 66637] M 64 [2045-12-30] Radiology Report CHEST (PORTABLE AP) Study Date of [2110-11-30] 8:22 AM [Last Name (LF) ],[First Name3 (LF) ] CSURG FA6A [2110-11-30] SCHED CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 66638] Reason: please eval chest and upper belly [Hospital 93] MEDICAL CONDITION: 64 year old man s/p cabg with vomiting and loose stools REASON FOR THIS EXAMINATION: please eval chest and upper belly Final Report CHEST SINGLE VIEW ON [11-30] HISTORY: Vomiting and loose stools, evaluate chest and upper abdomen. FINDINGS: This is a single film over the lower chest and upper abdomen which is non-diagnostic for a chest x-ray. No free air is identified though this is unlikely to have been a completely upright film. No dilated loops of bowel are identified. IMPRESSION: No abnormality detected but this is non-diagnostic for chest x-ray or for a abdomen series. DR. [First Name (STitle) ] [Doctor Last Name ] Approved: SUN [2110-11-30] 11:48 AM Brief Hospital Course: Mr. [Known lastname 7518] was admitted to the [Hospital1 18] on [2110-11-9] for further management of his myocardial infarction. He continued on amiodarone for his episode of ventricular tachycardia. He underwent a cardiac catheterization which revealed severe three vessel disease. Given the severity of his disease, the cardiac surgical service was [Date Range 4221] and Mr. [Known lastname 7518] was worked-up in the usual preoperative manner. The renal service was [Known lastname 4221] as he has end stage renal disease and was on hemodialysis. His dialysis schedule was continued. As he had a history of third degree burns throughout his body, the wound care nurse [First Name (Titles) ] [Last Name (Titles) 4221] for assistance in his care. Mr. [Known lastname 7518] developed dark red blood per rectum and the Gastroenterology service was [Known lastname 4221]. A proton pump inhibitor was started and a CT scan was obtained. The CT showed concentric wall thickening at the rectosigmoid junction which in the setting of bright red blood per rectum is concerning for possible malignancy, enlarged subcarinal lymph node and borderline pretracheal node, diffuse atherosclerotic calcification and aneurysmal dilatation of the right iliac artery, atrophic kidneys and bladder consistent with end-stage renal disease and degenerative changes in the thoracic spine and healing pelvic fractures. A sigmoidoscopy was performed which showed erythema in the recto-sigmoid with no mass seen. In the setting of circumferential thickening seen on CT scan, this finding is likely secondary to ischemia that has partially healed and likely the area responsible for his bleeding. Mr. [Known lastname 7518] was otherwise cleared for cardiac surgery. On [2110-11-20], Mr. [Known lastname 7518] was taken to the operating room where he underwent off pump coronary artery bypass grafting to four vessels. Postoperatively he was taken to the intensive care unit for monitoring. Hemodialysis was resumed. Plavix was started for his off bypass revascularization. On postoperative day two, Mr. [Known lastname 7518] self extubated himself without need for reintubation. His pressors were slowly weaned as tolerated however it okk several days before his blood pressure was acceptable off support. The physical therapy service was [Known lastname 4221] for assistance with his postoperative strength and mobility. On postoperative day seven, he was transferred to the step down unit for further recovery. He developed postoperative atrial fibrillation which was treated with amiodarone. He developed diarrhea and was empirically treated with flagyl. His stool culture returned negative for C. difficile and the flagyl was stopped. Mr. [Known lastname 7518] developed pauses as well a mobitz 2 second degree AV block and the electrophyiology service was [Known lastname 4221]. He was seen by EP and they requested that he be sent with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of hearts monitor. His amiodorone was d/c'd. Mr. [Known lastname 7518] continued to make steady progress and was discharged to Life call rehabilitation in [Location (un) ], [State 350] on [2110-12-1]. He will follow-up with Dr. [First Name (STitle) ], his cardiologist, his nephrologist and his primary care physician as an outpatient. Medications on Admission: Plavix 75mg PO qday Aspirin 325mg PO qday Simvastatin 80mg PO qday Mirtazapine 7.5mg PO qHS Pantoprazole 20mg PO BID Sevelamer 800mg PO TID Metoprolol Tartrate 25mg PO qday Sensipar 60mg PO qday Nephrocap 1mg PO qday Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap 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. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 10. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital3 11496] Discharge Diagnosis: CAD s/p CABGx4 s/p MI s/p PTCA/Stent s/p CVA Obstructive sleep apnea HTN Hyperlipidemia Hyperparathyroidism Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [First Name (STitle) ] in 1 month. ([Telephone/Fax (1) 1504] Please follow-up with Dr. [Last Name (STitle) 65155] in [1-12] weeks. Please follow-up with your cardiologist Dr. [Last Name (STitle) ] or Dr. [Last Name (STitle) 15183] in 2 weeks. Please call all providers for appointments. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2110-12-1] Name: [Known lastname 9609],[Known firstname 657] Unit No: [Numeric Identifier 11589] Admission Date: [2110-11-9] Discharge Date: [2110-12-1] Date of Birth: [2045-12-30] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 265] Addendum: EP came and saw pt. again and wanted to restart amiodorone 200 mg daily. He needs to follow up with Dr, [Name (NI) 11590] in 3 months for an echo and VT follow up. Discharge Disposition: Extended Care Facility: [Hospital3 1620] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 266] Completed by:[2110-12-1]	[ "327.23", "427.31", "588.81", "745.5", "414.01", "410.11", "557.0", "427.5", "427.1", "272.0", "585.6", "707.12", "491.21", "459.81", "787.91", "428.0", "427.41", "426.12", "414.8", "V12.54", "403.91" ]	icd9cm	[ [ [] ] ]	[ "00.66", "37.22", "36.06", "00.40", "00.45", "36.15", "88.42", "39.95", "45.24", "88.55", "88.41", "36.13", "88.52" ]	icd9pcs	[ [ [] ] ]	18671, 18838	11911, 15317	332, 616	16841, 16848	4208, 8931	17625, 18648	3102, 3138		15584, 16618	11193, 11249	16710, 16820		15343, 15561		8948, 11153	16872, 17602								3153, 4189		2473, 2835																				282, 294	11281, 11888										644, 2392													2866, 2969				2414, 2453	2985, 3086
80,121	174,483	43217	Discharge summary	report	Admission Date: [2140-5-3] Discharge Date: [2140-5-10] Date of Birth: [2070-9-26] Sex: F Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 4760] Chief Complaint: UTI Major Surgical or Invasive Procedure: R IJ central line placement/removal History of Present Illness: 69F with DM, HTN, breast cancer on tamoxifen, lumbar spinal stenosis admitted to the ICU for sepsis likely secondary to UTI. Pt reports sore throat, dry cough, shaking chills, and runny nose starting on Monday. Says her legs and arms were shaking violently starting at 4pm. She said she called her daughter to tell her she was at home feeling sick. She does not know if her daughter called the ambulance and does not remember the ambulance showing up. She reports to me that she opened the door for the ambulance and fell but does not remember all of this. In ED, had fever to 104, was tachycardia, had FS of 600. She got tylenol, 2L IVF, 10mg IV insulin bolus, started on insulin gtt 7units/hour later changed to 2units/hr, then 3.5 units/hr, and then 4 units sc insulin. She initially had a gap which closed. Her gap closed and her FS trend was 600-> 255 -> 230. She was also placed on D5 1/2 NS for fluids. Her ABG showed 7.49 pCO2 33 pO2 101 HCO3 26 BaseXS 2. Her lactate was 7.1->5.4-> 3.8-> 3.4. She was given ceftazidine 1gm, azithromycin 500mg IV, and vancomycin. In the ED she was not encephalopathic, belly soft, CXR unremarkable, urine with small leuks/blood/nitrite nge/wbc>50/mod bacteria. RIJ placed was placed. She had chest pain [7-13] and given, ASA, morphine 2mg IV x2, no EKG changes, and first set of enzymes pending. . On arrival to the ICU her vitals were T=99.1 BP=111/62 HR=97 RR=19 O2=97%RA. Her chest pain had resolved and her EKG was unchanged from prior. On further questioning she denied diarrhea, epigastric pain, increased frequency of urination, pain with urination, hematuria, changes in vision, headache, increased SOB on exertion (baseline for last few months SOB after 1 flight of stairs), PND, orthopnea, CP prior to today, jaw pain, arm pain. . Review of systems is otherwise negative. Past Medical History: -breast cancer s/p wide excision, radiation, and current endocrine therapy with tamoxifen -diabetes -hypertension -lumbar spinal stenosis Past oncologic history: Stage I (T1cN0M0) Infiltrating ductal carcinoma of the right breast, diagnosed in [2136], ER +, PR -, HER2Neu -, LVI -, grade III. Wide excision with sentinel lymph node procedure. Radiation. Enrolled in clinical trial MA27 and randomized to exemestane [2136-10-28]. Exemestane held due to musculoskeletal side effects, and the patient subsequently taken off study and placed briefly on Arimidex. Arimidex was later discontinued due to intolerable hot flashes. On [8-/2137], initiated tamoxifen. Social History: She is originally from Barbados, however lives in [Location 686]. She is separated. She is here with her sister and [Name2 (NI) 12496] today. As noted above, she quit smoking several yrs ago (started smoking at 18 yo [2-6] PPD) and drinks alcohol only very occasionally socially. She is retired. Family History: Her family history is notable for both parents having died in advanced years from natural causes. Her mother died in her 80s. She has one sister who died last yr of respiratory illness. She has one brother who is healthy. The only diseases that run in the family are diabetes and hypertension. Physical Exam: T=99.1 BP=111/62 HR=97 RR=19 O2=97% RA . PHYSICAL EXAM GENERAL: Tired appearing, A & O x3 NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: tachycardic, normal rate. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549]. JVP=difficult to access given recent placement of central line and body habitus LUNGS: CTAB, somewhat decreased breath sounds bilaterally diffusely ABDOMEN: NABS. Soft, mild tenderness in lower abd EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength throughout. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Labs on admission: [2140-5-3] 05:35PM BLOOD WBC-12.3# RBC-4.17 Hgb-12.7 Hct-37.2 MCV-89 MCH-30.5 MCHC-34.2 RDW-14.0 Plt Ct-192 [2140-5-3] 05:35PM BLOOD Neuts-92.8* Lymphs-3.8* Monos-3.1 Eos-0.1 Baso-0.1 [2140-5-3] 05:35PM BLOOD PT-14.5* PTT-19.8* INR(PT)-1.3* [2140-5-3] 05:35PM BLOOD Glucose-600* UreaN-18 Creat-1.4* Na-133 K-3.8 Cl-91* HCO3-25 AnGap-21* [2140-5-3] 05:35PM BLOOD ALT-29 AST-32 CK(CPK)-324* AlkPhos-107 Amylase-32 TotBili-0.6 [2140-5-3] 05:35PM BLOOD cTropnT-<0.01 [2140-5-4] 09:01AM BLOOD CK-MB-4 cTropnT-<0.01 [2140-5-4] 09:01AM BLOOD CK(CPK)-347* [2140-5-4] 12:21AM BLOOD Calcium-7.9* Phos-2.1* Mg-1.8 [2140-5-3] 05:35PM BLOOD CRP-GREATER TH [2140-5-3] 06:07PM BLOOD Type-ART pO2-101 pCO2-33* pH-7.49* calTCO2-26 Base XS-2 [2140-5-3] 05:43PM BLOOD Lactate-7.1* . Microbiology: [5-3] urinalysis - positive, no urine culture sent [5-4] urinalysis positive, urine culture > 100K e coli Urine culture [5-4]: URINE CULTURE (Final [2140-5-6]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . [5-3] blood culture - e coli [5-4], [5-5], [5-6], [5-7] blood cultures - no growth to date . Blood culture [5-3]: FINAL REPORT [2140-5-7] Blood Culture, Routine (Final [2140-5-7]): ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . Imaging: [5-3] Chest x-ray: IMPRESSION: No acute cardiopulmonary process . [5-4] Chest x-ray: Mild vascular engorgement is new, though heart size is normal and edema if any is limited to a peribronchial cuffing. Plate-like subsegmental atelectasis at the right lung base is new. No focal consolidation to suggest pneumonia. Pleural effusion is minimal, on the left, if any. . [5-5] Chest x-ray: There are lower lung volumes but no evidence of acute focal pneumonia. Elevation of the right hemidiaphragm is seen with minimal atelectatic change. The pulmonary vascularity is essentially within normal limits on this image. . [5-7] CT torso: STUDY: CT torso with contrast and reconstructions. INDICATION: Diabetes, hypertension, and breast cancer. Currently, on tamoxifen, presenting with urosepsis and continued fevers, shortness of breath. COMPARISON: Pelvic ultrasound [2140-3-2]. TECHNIQUE: MDCT axially acquired images were obtained from the thoracic inlet to the symphysis after the uneventful intravenous administration of 100 ml Optiray 350 contrast material. Multiplanar reformatted images were obtained and reviewed. CT CHEST WITH CONTRAST AND RECONSTRUCTIONS: The thyroid gland is grossly within normal limits. Moderate plaque is present within the thoracic aorta. No filling defects identified within the pulmonary arteries, however, this study was not optimized to evaluate this finding. Bibasilar atelectasis and trace left pleural effusion demonstrated. No axillary, mediastinal or hilar adenopathy per CT size criteria. Ill defined soft tissue within the right breast, not able to be correlated on the left given lack of inclusion in the imaging volume. Please correlate with mammographic findings. CT ABDOMEN WITH CONTRAST AND RECONSTRUCTIONS: Diffuse fatty infiltration of the liver. 1.4 cm hypoattenuating lesion within the left lobe of the liver is most consistent with a cyst. Several sub-centimeter hypoattenuating foci in the left lobe are too small to adequately characterize. Gallbladder is not well demonstrated suggesting removal or collapse. No intra- or extra-hepatic biliary ductal dilatation. The spleen and abdominal large and small bowel appear within normal limits. The kidneys are heterogeneous bilaterally involving the cortices with a large region in the right upper pole and significant region in the left mid pole consistent with significant pyelonephritis. The abdominal aorta and iliac branches demonstrate moderate calcified atherosclerotic plaque without aneurysmal dilatation. No free fluid or free air within the abdomen. CT PELVIS WITH CONTRAST AND RECONSTRUCTIONS: A 4.5 x 3.8 cm presumed exophytic fibroid is demonstrated within the left adnexa as depicted on pelvic ultrasound from [2140-3-2]. A focus of calcification is again demonstrated abutting the endometrium on the sagittal projection, also correlated on prior pelvic ultrasound. A new 2.1 cm fluid collection is noted within the right adnexa, possibly representing an adnexal cyst. The bladder appears within normal limits. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are identified. IMPRESSION: 1. Bilateral severe pyelonephritis. No adjacent perirenal fluid collections identified. No hydronephrosis. 2. Multilevel degenerative changes. 3. Bibasilar atelectasis, mild. 4. Fluid attenuation lesion within the right adnexa measuring 2.1 cm, not seen on prior pelvic ultrasound. Finding may reflect an adnexal cystic lesion and recommend correlation with pelvic ultrasound on a non-urgent basis in this postmenapausal female. . Brief Hospital Course: 69 year old woman with history of DM, HTN, breast cancer (in past, currently on tamoxifen) who presented with sepsis due to E Coli UTI and E Coli bacteremia and DKA. . #. Sepsis due to E Coli UTI/E Coli bacteremia/pyelonephritis: Patient presented with fever, tachycardia, leukocytosis, positive urinalysis, urine culture with e coli, with subsequent blood cultures growing gram negative rods, consistent with urosepsis. She was initially admitted to the ICU, aggressively volume rescusitated, started on vancomycin and levofloxacin. When urine and blood cultures grew out pan sensitive e coli, vancomycin was discontinued and she was maintained on levofloxacin alone. With these measures, her tachycardia, leukocytosis and elevated lactate resolved. Patient continued to have low grade fevers and complained of right lower quadrant abdominal pain. Therefore a CT abdomen was obtained that demonstrated bilateral pyelonephritis, no discreet fluid collection. Surveillance blood cultures were with no growth to date at time of discharge and she was discharged to complete a 14 day course of levofloxacin. Of note, pt did still have low grade temps at night to 100.1 prior to discharge, no localizing symptoms, felt to be due to resolving pyelonephritis. Pt had no further abdominal pain at time of discharge. Pt was asked to monitor her temperature at home. . #. Hyperglycemia/DKA/Diabetes: Patient presented hyperglycemic, with anion gap acidosis, glucose and ketones in urine, consistent with DKA. She was treated initially with IV fluids and insulin drip, with closure of anion gap, resolution of her hyperglycemia. She was restarted on her outpatient insulin regimen with fingersticks still up into the 300s. HgbA1c was elevated at 8.7. The patient's NPH was increased from 62 U in AM to 70 U in AM and from 4 U at night to 5U at night. The pt was asked to check her fingersticks at varying times of day and to bring in these recordings with her to her follow up appointment with her PCP. . # Shortness of breath: Patient noted some episodes of shortness of breath, initially had some wheezing on exam, chest x-ray with some evidence of mild volume overload. Treated with nebulizers and 1 dose of lasix during her hospitalization. Given continued symptoms, obtained a CT torso to rule out pulmonary embolism that was negative for any clot. Her complaints of SOB had resolved at discharge and pt was satting upper 90s on room air. Was discharged on albuterol inhaler, with outpatient follow up. . #. Acute renal failure: Creatinine on admission was up to 1.4 up from baseline of 0.8-1.1 on admission. Resolved to baseline with IV fluids. On [5-5] Creatinine started to trend up again to 1.5 on [5-9]. CT of the abdomen had shown no hydronephrosis, but +pyelonephritis. Pts ARF was felt to be most likely due to pyelonephritis vs mild ATN from CT dye. Ulytes showed FeNa of 1.6%. Pt was given fluid challenge with 2 L NS. Her HCTZ was held. Cr trended down to 1.3 prior to discharge. HCTZ will be held until follow up with PCP. . # R adnexal 2.1 cm lesion: Incidentally noted on CT scan--fluid attenuating lesion which may be a adnexal cyst. Pt needs outpatient pelvic US. Pts PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ], is aware. . #. Hypertension: Outpatient meds Amlodipine 5 mg daily, Hydrochlorothiazide 25mg daily held on admission. Both were resumed once BP normalized, but HCTZ was again held in the setting of worsening renal function. HCTZ will not be restarted until pt follows up with her PCP. . . #. Breast cancer: Continued outpatient tamoxifen. Medications on Admission: Tamoxifen 20mg daily Amlodipine 5 mg daily Hydrochlorothiazide 25mg daily Hydromorphone 2mg [2-5] tab qid PRN (last filled in [Month (only) ]- d/c in [10-11] on this med not in OMR) Trazodone 50mg daily Humalin 62units qam and 4 units qhs Naproxen 500mg [Hospital1 ] PRN Ibuprofen 600mg TID PRN (not in OMR) Tramadol 50mg 4x a day PRN Flexeril 10mg TID PRN (not reflected in OMR) Gabapentin 300mg qhs (inactivated in OMR) . Not from pharmacy from OMR Calcium Vit D Omega 3 fatty acids-Vit E Discharge Medications: 1. Tamoxifen 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: This is a stool softener and can be purchased over the counter. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): This is a stool softener and can be purchased over the counter. 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 2 to 4 hours as needed for shortness of breath or wheezing. Disp:1 cartridge Refills:0 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48 () for 7 days. Disp:4 Tablet(s) Refills:0 11. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation: This is a stool softener and can be purchased over the counter. 12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) unit Subcutaneous as directed: Take 70 units in the morning and 5 units a night (this is your humulin). Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: E coli urosepsis Pyelonephritis Diabetic ketoacidosis Acute renal failure Discharge Condition: Stable. Improved symptoms, low grade temp max of 100.1 over past 24 hrs. Discharge Instructions: You were admitted to the hospital with urinary tract infection/sepsis, and treated with antibiotics with improvement in your symptoms. You will need to complete this course of antibiotics. . You had some kidney failure, likely due to the kidney infection. This seems to be improving. You will need to have you kidney function rechecked (a blood test) next week when you see your doctor. . Please take medications as directed. Your hydrochlorothiazide has been discontinued until you follow up with your doctor next week (this can worsen kidney function). You will need to complete 4 more doses of levofloxacin to treat your kidneys. Your Humulin has been increased to 70 units in the morning and 5 units a night. You will need to check your fingersticks several times a day (twice a day at least---try to record some fasting morning fingersticks, some evening fingersticks, and some in the mid-afternoon when your sugars tend to run high (ie 3 PM). Record these readings and bring them with you next week to your doctor's appointment. . Please follow up with appointments as directed. . Please contact physician if develop fevers/chills, shortness of breath, fingerstick over 400 or less than 60, or any other questions or concerns. Followup Instructions: 1. Please follow up next Monday at 1:10 PM with Dr. [Last Name (STitle) ] and [First Name8 (NamePattern2) 714] [Last Name (NamePattern1) ]. Please call [Telephone/Fax (1) 608] if you need to cancel this appointment.	[ "590.10", "584.9", "995.91", "724.02", "174.8", "250.13", "038.42", "995.90", "401.9" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	16236, 16294	10674, 14279	274, 311	16412, 16488	4337, 4342	17769, 18004	3228, 3526		14837, 16213		16315, 16391		14305, 14814			16512, 17746								3541, 4318																						231, 236											339, 2184									4356, 10651								2206, 2884	2900, 3212
19,710	100,298	23751	Discharge summary	report	Admission Date: [2126-2-7] Discharge Date: [2126-2-20] Date of Birth: [2069-4-1] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 56-year-old male who experienced chest pain while undergoing an exercise tolerance test. He was preoperative for right inguinal herniorrhaphy repair. He was referred for cardiac catheterization, which he had when he came into the hospital on [2-7]. This revealed a 70% distal left main, 85% ostial circumflex, and 70% ostial right coronary artery, and an ejection fraction of 62%. He was referred to Dr. [Last Name (STitle) 70] for coronary artery bypass grafting. PAST MEDICAL HISTORY: Hypertension, former smoker with a 4- pack per day history for which he quit in [2111], polio at age 7, former ETOH abuse, and remote fracture of nose and skull. SOCIAL HISTORY: He lives alone, and he works at [Hospital3 2576] as a cargo transporter. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. once a day, Toprol-XL 50 mg p.o. once a day. ALLERGIES: He had no known drug allergies. PREOPERATIVE LABORATORY DATA: White count 6.0, hematocrit 33.3, platelet count 329,000. PT 13.6, PTT 32.8, INR 1.2. Urinalysis was negative. Glucose 182, sodium 134, K 3.9, chloride 102, bicarbonate 24, BUN 18, creatinine 0.7, anion gap of ALT 30, AST 14, alkaline phosphatase 34, amylase 42, total bilirubin 0.8, albumin 3.8. Preoperative chest x-ray showed no acute cardiopulmonary disease, but some suggestive changes of emphysema. On exam he had a left facial droop, status post his childhood polio. Temperature of 97.5, heart rate 65 in sinus rhythm, respiratory rate 18, he was saturating 93% on room air, with a blood pressure of 121/71. His lungs were clear bilaterally. His heart was regular rate and rhythm with S1 and S2 and no murmur. His abdomen was benign. His extremities were warm with no edema, and 2+ pulses bilaterally. He was also seen by Dr. [Last Name (STitle) ] and consented for coronary artery bypass grafting. On the following day, on [2-8] he did undergo coronary artery bypass grafting x 3 with a LIMA to the LAD, a RIMA to the RCA, and a vein graft to the OM by Dr. [Last Name (STitle) 70]. He was transferred to the cardiothoracic ICU in stable condition on a propofol titrated drip and a Neo-Synephrine drip at 1 mcg per kg per minute. On postoperative day 1, he had a blood pressure of 102/51, was A-paced at 90, was saturating 92% on 2 liters nasal cannula. Postoperatively, his white count rose to 21.2, with a hematocrit of 28.7, platelet count 346,000. K 4.2, BUN 9, creatinine 0.6. His chest tubes remained in place for some drainage overnight. His Neo-Synephrine was at 2.4 mcg per kg per minute. His PA line was discontinued. On postoperative day 2, he received 1 unit of packed red blood cells overnight. His hematocrit rose to 26.8 the following morning. His white count dropped to 12.9. His creatinine was stable at 0.6. His Neo-Synephrine continued to be weaned and was at 0.1 mcg per kg per minute on the morning of rounds. His chest tubes and pacing wires remained in place. His heart rate was 95 and blood pressure 109/57. On postoperative day 3, his Neo was discontinued. He began his metoprolol beta blockade, and Lasix diuresis was started. His hematocrit rose to 25.4. He transferred to the floor. His mediastinal chest tubes were discontinued. His pleural chest tube remained in place. His pacing wires were discontinued. His Foley was discontinued, and he began metoprolol 25 b.i.d. On the floor he was seen and evaluated by physical therapy. He began his ambulation and increasing his activity level. He was alert, awake, and oriented and was working with physical therapy and the nurses to also improve his pulmonary toilet. On postoperative day 4, he was in sinus rhythm and was hemodynamically stable. He had a nonfocal exam. His sternum was stable with no click. His incisions were clean, dry, intact. He had 2 pleural tubes which remained in place. They were removed on postoperative day 4. His Lopressor was increased to 50 b.i.d. to reduce his sinus tachycardia and bring his blood pressure down. He was encouraged to continue to increase his activity level. On postoperative day 5, the patient was in sinus rhythm with a good blood pressure. His exam was unremarkable, but he had slightly decreased urine output which responded to an increase in Lasix, and he was encouraged to continue ambulating. His Lopressor was also increased to 75 mg p.o. b.i.d. He also had 1+ extremity edema. On postoperative day 6, he continued diuresis and then was orthostatic, but he had improved oxygenation, and he continued to have a low-grade temperature of 100.3. His creatinine was stable at 0.7, his hematocrit was stable at 32.0, and his white count was normal. He was below his preoperative weight on postoperative day 6. Lasix was changed from b.i.d. to daily. Cultures were sent off, as it was unclear what the fever origin was. The patient continued to ambulate with a plan for discharge the following day if he remained afebrile and had improved blood pressure. On postoperative day 7, he was febrile the evening prior and he continued to be lightheaded while ambulating. His lab work was unremarkable. His Lasix was discontinued. His Lopressor was decreased from 75 down to 50 b.i.d., and he continued to be monitored. On postoperative day 7 he had some diarrhea, and the following day that resolved. There was a question of a possible thrombophlebitis, but it turned out there was no thrombophlebitis. He continued to be very orthostatic. Follow- up cultures did not have any growth at that point. He was given some IV fluids bolus for hypotension, and all the rest of his nonessential medications were discontinued. On postoperative day 9, he had no fever in the 24 hours prior. He continued to diurese on his own, and attempt was made to keep him positive for his I's and O's. His central venous line had already been discontinued as well as his pacing wires. He was in sinus rhythm at 90 with a good blood pressure. On postoperative day 11, an echocardiogram was performed which showed an ejection fraction of 55%, a dilated aortic root, and good wall function. On [2-20], postoperative day 12, he was discharged to home with VNA services. On the day of discharge he was in sinus rhythm, with a blood pressure of 111/81, a pulse rate of 88, saturating 97% on room air. White count 10.2, hematocrit 36.1, platelet count normal. K 4.8, BUN 11, creatinine 0.7. His neurologic exam was nonfocal. His lungs were clear bilaterally. His heart was regular rate and rhythm. He had no drainage or erythema from any of his incisions, and he was discharged home in stable condition with VNA services. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting x 3. 2. Right inguinal hernia. 3. Status post broken nose and skull 30 years ago. 4. Polio at age 7. 5. Former ethanol and tobacco abuse. DISCHARGE INSTRUCTIONS: He was instructed to make an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4469], his primary care physician, [Name10 (NameIs) ] [Name Initial (NameIs) ] visit 1 to 2 weeks post discharge and to make an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70], his surgeon, 6 weeks post discharge for his postoperative surgical visit. MEDICATIONS ON DISCHARGE: 1. Aspirin enteric coated 81 mg p.o. once a day. 2. Colace 100 mg p.o. twice a day. 3. Percocet 5/325 1 to 2 tablets p.o. q.4 hours p.r.n. pain. 4. Metoprolol 50 mg p.o. twice a day. 5. Lipitor 10 mg p.o. once a day. He was discharged to home with VNA services in good condition on [2126-2-20]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5662], [MD Number(1) 5663] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2126-3-18] 16:08:05 T: [2126-3-19] 10:17:06 Job#: [Job Number 60668]	[ "414.01", "458.0", "138", "401.9", "781.94", "780.6" ]	icd9cm	[ [ [] ] ]	[ "89.68", "88.56", "39.61", "36.12", "88.53", "36.15", "37.22" ]	icd9pcs	[ [ [] ] ]								6789, 6976				7442, 8010	980, 6768			7001, 7416																																									163, 668																	691, 858	875, 953
44,445	141,569	23501	Discharge summary	report	Admission Date: [2145-8-23] Discharge Date: [2145-8-28] Date of Birth: [2105-8-12] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 48638] Chief Complaint: Secondary post-partum hemorrhage Major Surgical or Invasive Procedure: Supracervical hysterectomy History of Present Illness: 40YO G1P1 s/p primary LTCS [2145-7-11] for arrest of dilation who presents with heavy VB. Started at 730am, estimated to be ~300cc by EMS upon arrival to their home. In ED, on exam had ~300cc clot in vault, no active bleeding. At the time of this examiner's arrival, pt had just returned from U/S and had soaked peripad and bed pad in 30min, and was c/o dizziness, vaginal pressure. She was triggered for change in mental status/dizziness, BP was 40s/palp and was resuscitated with aggressive IVF and total of 2 units RBC. HR max in 90s, EKG revealed sinus rhythm. Denies recent intercourse or anything in the vagina. She was admitted [2059-8-16] for heavy vaginal bleeding, requiring 2 unit RBC transfusion and observation overnight. Upon discharge home, she had greatly diminished VB and has minimal bleeding at home. Of note, she was transfused 2 units RBC immediately postpartum for incident Hct 16.5 Past Medical History: OBHx: G1P1 GynHx: regular menses prior to pregnancy, cervical polyp MedHx: denies SurgHx: C/S x 1 Social History: Married, Chinese speaking, denies tobacco, alcohol, drugs. Family History: noncontributory Physical Exam: VS: at bedside, HR 70s, BP 80-90s/40-50s, RR 18 GENERAL: pale, responsive, able to speak in complete sentences CARDIO: RRR PULM: CTAB ABDOMEN: mild TTP mid-surapubic area, no R/G, ND EXTREMITIES: NT/NE SSE: +active welling of bright red blood in vault SVE/BME: fundus firm, os 1cm dilated, blood evacuated as above Brief Hospital Course: Ms. [Known lastname ] was taken to the operating room for control of her bleeding. Please see operative note for full surgical details. Post-operatively she was taken to the ICU for monitoring. She received 9units PRBCs and 2 units of FFP throughout her stay. She recovered well and was soon transferred to the gyn floor. She was discharged on [8-28] in stable condition. Medications on Admission: PNV, iron, percocet prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. 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 3. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:50 Tablet(s) Refills:1 Discharge Disposition: Home Discharge Diagnosis: Secondary post-partum hemorrhage s/p supracervical hysterectomy Blood transfusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or return to the hospital if you have: -Increased pain -Redness or unusual discharge from your incision -Inability to eat or drink because of nausea and/or vomiting -Fevers/chills -Chest pain or shortness of breath -Any other questions or concerns Other instructions: -You should not drive for 2 weeks and while taking narcotic pain medications -No intercourse, tampons, or douching for 6 weeks -No heavy lifting or vigorous activity for 6 weeks -You can shower and clean your wound, but do not use perfumed soaps or lotions. Be sure to pat completely dry after washing. -You may resume your regular diet and home medications. Followup Instructions: Please keep your scheduled appointment with Dr. [Last Name (STitle) ] at [Hospital 26626]. Please call ([Telephone/Fax (1) 26420] with questions. You will need an MRI in 4 weeks to assess your cervical vasculature.	[ "286.6", "285.1", "300.00", "648.44", "666.24", "309.81", "666.34" ]	icd9cm	[ [ [] ] ]	[ "68.39" ]	icd9pcs	[ [ [] ] ]	2778, 2784	1930, 2313	362, 391	2910, 2910		3737, 3969	1557, 1574		2387, 2755		2805, 2889		2339, 2364			3061, 3714								1589, 1907																						290, 324											419, 1341											2925, 3037						1363, 1464	1480, 1541
53,939	131,768	45927+58868	Discharge summary	report+addendum	Admission Date: [2140-6-22] Discharge Date: [2140-6-25] Date of Birth: [2058-2-1] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 99] Chief Complaint: feel weak Major Surgical or Invasive Procedure: none History of Present Illness: 82M with myeloproliferative d/o and PCV, discharged yesterday from hospitalization with same chief complaint, now returns from rehab center with concern for increasing lethargy. . Patient was admitted [2140-6-16] for lethargy after a fall several days prior with large R hip hematoma, a near-syncopal episode en route to the hospital, and abnormal labs including WBC 119.3, Plt 808, H/h 8.7/29.7, K 6.8 Cr 1.7. Imaging included negative head CT, abdominal CT with large R buttock/thigh hematoma, splenomegaly, and L adrenal nodule. Surgery consult felt R hematoma was concerning for possible persistent bleed but no concern for compartment syndrome and no surgical intervention indicated. Patient was admitted to the ICU, fluid hydrated, treated for hyperkalemia, given 2U PRBCs, and rate controlled for intermittent atrial fibrillation with RVR. Hematology consulted, concluded that mental status changes and electrolyte imbalances cannot be attributed to tumor lysis syndrome or leukostasis, as patient's smear showed no signs of leukemic transformation. Hematology did find pt to be iron deficient, and suggested possible noncompliance with outpatient PCV meds given absence of expected macrocytic anemia while on allopurinol. Renal consult found ATN, likely secondary to rhabdomyolysis from R thigh hematoma. Renal ultrasound negative for hydronephrosis. Discharge labs were: WBC of 79.7, plt 547 h/h 8.1/27. Cr 1.7. . Today patient sent back from rehab for persistent/worsening lethargy. In the ED, VS were T 97.7 HR 72 BP 101/68 RR 20 O2 99%/2LxNC Wt 71.6 kg. Pt was lethargic and oriented only to self. Found to have jaundice, RUQ pain, abdominal distension, hematuria, and new RBBB on EKG. Denies f/c/n/v/d/cp/sob. Hypotensive SBP 90-105 and tachypneic RR 25-30. CT head negative. RUQ ultrasound showed normal portal vein flor, a gallbladder full of slude but without e/o cholecystitis, and small ascites. CT abd/pelvis revealed mild ileus (gaseous distention of large bowel without obstruction or [Last Name (un) ]), abdominal ascites, bilateral pleural effusions, diffuse anasarca and stable splenomegaly. Grossly dilated bowel loops also seen on KUB. Volume overload on CXR seen as increased perihilar markings and cardiomegaly, plus increased R retrocardiac opacity, with concern for atelectasis vs developing infection. Surgery consult suggested percutaneous cholecystostomy; poor surgical candidate. Given 2L IVF, 1 dose of vanc/zosyn for presumed obstructive cholangitis and admitted to the ICU for further management. . In the ICU, the patient is fatigued-appearing but oriented to self, [Hospital3 ] Hospital, and [Month (only) 116]. He does feel week. Says he's here because rehab staff and his wife were "all crowding around me" today. Denies chest pain and abdominal pain. Some mild shortness of breath. Endorses belly fullness, and agrees that pants and shoes were feeling tight at home prior to recent hospitalization. Also reports diminished appetite; his clothes had been feeling loose before they started feeling tight, and he weighed 150 lbs at his last doctor's appt, down from baseline 170 lbs, time frame unknown. Feels his mouth is dry and voice raspy. He normally lives at home with his wife; he's a retired electrician who golfs and was working on his car a few weeks before hospital admission. 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: Polycythemia [Doctor First Name ] Hypertension Social History: Retired electrician, retired age 77, lives at home with wife. Active independent lifestyle, golfs. Tobacco: Has not smoked in many years. Alcohol: 1 drink per week. Illicits: denies Family History: No conditions run in the family, according to patient. Physical Exam: ADMITTING PHYSICAL EXAM: Vitals: T: 96.5 BP: 95/56 P: 99 R: 20 O2: 100/2LxNC General: fatigued-appearing and gaunt, converses semi-coherently in muffled raspy voice, no acute distress Neuro: oriented to self & [Hospital3 ] but month [Month (only) 116] & date/year unknown, CN intact, strength 5/5 x4 extremities. HEENT: conjunctival pallor, sclera icteris, sublingual jaundice, dry MM, OP clear Neck: supple, JVP elevated to ear, no LAD, thyromegaly/nodules/tenderness Lungs: CTA anteriorly; unable to sit forward for full lung exam CV: irregularly irregular, nl S1/S2 no murmur Abdomen: distended, tympanic to percussion, distant bowel sounds, no rebound/guarding, mod R-sided tenderness to palpation, no palpable liver edge; bilateral extensive non-tender purpura involving dependent surfaces of thighs buttocks and lower back GU: foley draining clear yellow urine Ext: WWP, 2+ pulses, bilateral 2+ thigh/scrotal/sacral edema, pitting to knee, pre-tibial hyperpigmentation of chronic venous stasis without ulceration . ICU DISCHARGE EXAM: Patient passed away. Pertinent Results: ===================== Admitting labs: ===================== [2140-6-22] 03:30PM PT-13.7* PTT-27.4 INR(PT)-1.2* [2140-6-22] 03:30PM PLT SMR-VERY HIGH PLT COUNT-761* [2140-6-22] 03:30PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-2+ POLYCHROM-1+ OVALOCYT-1+ SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL [2140-6-22] 03:30PM NEUTS-95* BANDS-1 LYMPHS-0 MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* [2140-6-22] 03:30PM WBC-91.6* RBC-3.37* HGB-8.1* HCT-28.5* MCV-85 MCH-24.2* MCHC-28.5* RDW-24.0* [2140-6-22] 03:30PM HGB-8.1* calcHCT-24 [2140-6-22] 03:30PM GLUCOSE-99 LACTATE-1.9 K+-3.4* [2140-6-22] 03:30PM TSH-1.4 [2140-6-22] 03:30PM HAPTOGLOB-<5* [2140-6-22] 03:30PM ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-2.2 [2140-6-22] 03:30PM ALT(SGPT)-31 AST(SGOT)-70* LD(LDH)-961* ALK PHOS-270* TOT BILI-6.8* DIR BILI-4.0* INDIR BIL-2.8 [2140-6-22] 03:30PM GLUCOSE-96 UREA N-70* CREAT-1.6* SODIUM-138 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-18* ANION GAP-20 [2140-6-22] 05:00PM URINE MUCOUS-RARE [2140-6-22] 05:00PM URINE AMORPH-RARE [2140-6-22] 05:00PM URINE HYALINE-3* [2140-6-22] 05:00PM URINE RBC-3* WBC-1 BACTERIA-FEW YEAST-NONE EPI-0 [2140-6-22] 05:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-2* PH-5.0 LEUK-NEG [2140-6-22] 05:00PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.013 . ===================== MICRO: ===================== Blood cultures x2 pending Urine culture pending . [6-24] (febrile to 101.7) Blood cultures Urine culture Stool Cdiff . ===================== Imaging: ===================== RUQ U/S [6-22]: (wet read) - Increased liver echogenicity. Portal vein normal flow; other veins not assessed by doppler. Gallbladder w/layering sludge but o/w nl gallbladder, no evidence of cholecystitis. Splenomegaly up to at least 20.1cm. Small ascites. B/l pleural effusions. . CT abd/pelvis [6-22]: IMPRESSION: 1. Gaseous distention of large bowel without obstruction represent mild ileus. 2. Interval development of small volume abdominal ascites, bilateral pleural effusions, and diffuse anasarca could reflect third spacing in the setting of heart failure. Please correlate clinically. 3. Stable splenomegaly as well as renal hypo- and hyper-dense lesions, likely cysts, though incompletely characterized. 4. Diverticulosis without diverticulitis. . KUB [6-22]: marked gaseous distension, large bowel up to 11-12 cm, gas seen within small bowel, no gas seen in rectum. lower obstruction v ileus. no air/fluid level. degenerative change lumbar spine. . KUB [6-23] (wetread): continued gas-distended dilated loops of small and large bowel, similar to slightly progressed from 6 hrs prior. assessment for free air limited by supine positioning and exclusion of non-dependent portion of abdomen on lateral decub view. CXR [6-22]: increased retrocardiac opacity, atelectasis v developing infection, increased perihilar markings and cardiomegaly. . ECHO [6-23]: 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. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Symmetric LVH with normal global biventricular systolic function. Mild aortic stenosis. Mild pulmonary hypertension. . HIDA Scan [6-23]: INTERPRETATION: Serial images over the abdomen show uptake of tracer into the hepatic parenchyma. At 43 minutes, the exam was terminated due to patient claustrophobia. The gallbladder is not visualized. There is tracer activity noted in the small bowel at 15 minutes. Delayed images at 6 hours reveals tracer activity in the gallbladder. The above findings are consistent with delayed tracer excretion secondary to hepatic dysfunction. IMPRESSION: Delayed biliary excretion secondary to hepatic dysfunction. LENIS legs [6-24]: FINDINGS: Color and [Doctor Last Name 352]-scale son[Name (NI) ] was performed on the bilateral lower extremities. The bilateral common femoral, superficial femoral and popliteal veins are normal in compressibility, augmentation, and Doppler waveforms. The calf veins are patent and compressible bilaterally. There is no deep vein thrombosis. Bilateral lower extremity soft tissue edema is moderate, right worse than left. IMPRESSION: 1. No deep vein thrombosis in either lower extremity. 2. Moderate bilateral lower extremity soft tissue edema. KUB [2140-6-24]: Free air under diaphragm. Brief Hospital Course: 82M w/polycythemia [Doctor First Name ] and myeloproliferative disorder re-presents from rehab facility with persistent lethargy, found to have dilated bowel, obstructive LFTs, and negative head imaging in addition to chronically elevated WBC/Plt/splenomegaly, admitted direct to the ICU for workup and management. . #Weakness/fatigue. Lethargy and weakness/fatigue are acute and persistent since admission earlier this week. Mental status more clear than reported at time of ICU admission but waxed and waned over the subsequent 24h. ICU team's ddx included new CHF, hypothyroidism and occult malignancy, either progression of myeloproliferative disorder to AML, or other MPD-association solid tumors. Pt provided history of gradual 20-lb weight loss with abdominal/lower extremity fluid overload. Hoarseness especially concerning for small cell lung cancer but no concerning nodules on CXR. Possible new congestive heart failure or thrombosis was another possible explanation for his current presentation. Echo showed normal EF (70%) with no significant valve pathology. Doppler ultrasound of the portal vein was negative for thrombus, and CT head showed no signs of bleed or infarction. TSH was normal. For his polycythemia [Doctor First Name ], patient is on anagrelide; since anagrelide has edema and new CHF among its side effects, it was stopped. Despite all of the above, weakness & fatigue were likely secondary to the worsening ileus and free abdominal air ultimately seen on KUB. Patient and the family decided not to pursue surgery. He was transitioned to CMO and palliative care was involved making recommendations for the patient's comfort. . #Sepsis ED admitted the patient directly to the ICU with concern for sepsis but patient was notably not hypotensive or febrile, and had no positive cultures/UA/CXR findings concerning for infection so this was not considered to be a likely explanation for his current presentation. However, he did develop fever to 101.7 on the evening following admission. At that time he was agitated & tachypnic, with increasing abdominal pain. Purulent discharge noted at urethral foley insertion site + small purulence at IV insertion sites. Antibiotic coverage was broadened to vancomycin/zosyn. Additional blood and urine cultures + Cdiff test were sent. Urinalysis showed new leukesterase and WBCs. Lactate increased from 1.9 to 2.3. Serial KUB in context of worsening abdominal distension and fever showed free air under the diaphragm. Cause and source unknown but suspected to be his ileus/profoundly distended bowel. . #Ileus. Bowel grossly distended on imaging without obstruction or transition point. Ileus was suspected. Bowel dilatation increased on serial KUBs, so an NGT was placed for decompression. Lipase not appreciably elevated. Rectal exam showed no impaction, no masses, stool guaiac negative. Serial KUB obtained for worsening abdominal exam showed free air under the diaphragm. Surgical options discussed with patient and family, who deferred surgical intervention and changed pt's code status to CMO. Palliative care was consulted. . #RUQ tenderness to palpation, elevated tbili/dbili. Biliary obstruction suspected but not seen on imaging. HIDA scan showed delayed gallbladder filling but no obstruction. Patient was initially started on unasyn for possible cholecystitis, but this was changed to vancomycin/zosyn when patient became febrile. The pt was followed by surgery, who recommended ERCP and possible percutaneous cholecystostomy. Tbili trended upward. ERCP evaluated but no ERCP procedure was performed due to emergent KUB finding of free subdiaphragmatic air, as above. Surgery evaluated the patient, but the patient and his family elected not to pursue surgery. . #Anasarca. Patient presented with bilateral R>L lower extremity and scrotal edema. Albumin was normal. IVF were initially avoided, but he was given IVF boluses when febrile hypotension developed, with underlying etiology free abdominal air, as above. . #Dependent purpura. History of post-traumatic hematoma diagnosed on previous exam. ICU team had concern for coagulopathy/ongoing slow bleed given extensive dependent purpuric appearance of his hematoma appearance ~10 days after fall against car. Hematology was consulted again during this admission; they felt the hematoma was improving compared to last exam. . #New RBBB. Admission EKG showed a RBBB, new since last EKG 1 day prior. Patient denied CP but endorsed SOB. New RBBB may represent new ischemia, especially given increased risk of coronary vessel thrombosis in this patient with PVC. Serial cardiac enzymes showed negative CKMB, trop 0.02. Echo revealed no wall motion artifact within a limited exam. . #Polycythemia [Doctor First Name ]. Patient has known PVC. Hct stable over past week, but likely down from baseline due to extensive soft tissue bleeding evidenced on exam. No e/o thrombosis on imaging: negative LENIs during prior admission, head CT negative, limited RUS doppler study negative. He was continued on home ASA and allopurinol, anagrelide held (as above), and hydroxyurea continued to be held per heme recommendations during last admission given the current state of relative anemia with blood loss into the hematoma. . #Elevated WBC. Chronic. due to known neutrophil-predominant myelodysplasia. Heme consult did not feel patient's current clinical picture aroused sufficient concern for heme malignancy, so no bone marrow biopsy was performed. . #Acute Renal Failure. ATN on last admission. Likely secondary to dehydration, but also considered multiple myeloma, so SPEP/UPEP sent. Bladder pressure, obtained for question of increased intra-abdominal pressure as a cause for anuria, was normal. Patient was given lasix to promote diuresis and urine output, with minimal response. . #Nutrition. Patient had a speech & swallow evaluation during his last admission, with concern for aspiration given coughing observed while eating/drinking. He was kept NPO while awaiting resolution of abdominal distension/bowel dilation. . #Hypertension. Patient initially normotensive but developed hypotension. Home triamterene-hydrochlorothiazid 37.5-25 mg QD and metoprolol 6.25 mg [Hospital1 ] (started during recent admission) were held. . Medications on Admission: allopurinol 100 mg QOD anagrelide 0.5 mg QD aspirin 81 mg QD metoprolol tartrate 6.25 mg [Hospital1 ] triamterene-hydrochlorothiazid 37.5-25 mg QD Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Name: [Known lastname ],[Known firstname 10014] Unit No: [Numeric Identifier 15603] Admission Date: [2140-6-22] Discharge Date: [2140-6-25] Date of Birth: [2058-2-1] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 10841] Addendum: Clarification to the patient's admiting diagnoses and clinical course: The patient on admission did not have strict criteria for sepsis, but developed it after admission. The patient developed a perforated intestine that was possibly due to ischemic bowel or bowel obstruction. The patient had developed ATN on a prior admission that was improved from the prior discharge at the time of current admission but was still present at the time of current admission. Discharge Disposition: Expired [Name6 (MD) ] [Last Name (NamePattern4) 9776] MD [MD Number(2) 10844] Completed by:[2140-8-3]	[ "426.4", "569.83", "274.9", "995.91", "238.79", "789.59", "E888.1", "576.8", "V49.86", "584.5", "924.00", "799.89", "V66.7", "038.9", "557.9", "287.2", "560.1", "289.9", "428.0", "238.4", "560.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	18232, 18380	10729, 16998	312, 318	17291, 17300	5613, 10706	17356, 18209	4450, 4507		17199, 17208		17261, 17270		17024, 17176			17324, 17333								4547, 5555						5571, 5594													3709, 4157			262, 274											346, 3690																	4179, 4232	4248, 4434
19,720	138,827	14462	Discharge summary	report	Admission Date: [2186-6-19] Discharge Date: [2186-6-26] Date of Birth: [2161-9-20] Sex: M Service: Trauma ADMISSION DIAGNOSIS: Left distal radius fracture and T12-L1 fracture with a retropulsed fragment, status post open reduction/internal fixation of left distal radius on [6-22]. HISTORY OF PRESENT ILLNESS: This is a 24-year-old male who fell about 18 feet on [6-19] while [Doctor Last Name ] climbing. He landed on his back. No loss of consciousness. [Location (un) 2611] Coma Scale was 15 but was complaining of back pain on presentation. At the outside hospital, he was found to have a left distal radius fracture and a question of a T12 burst fracture on CT. He was without focal neurologic deficits and was transferred to the [Hospital1 69]. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. MEDICATIONS ON ADMISSION: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Occasional alcohol use. PHYSICAL EXAMINATION ON PRESENTATION: He was alert and oriented, lying flat on the bed. Pupils were reactive. Chest was clear to auscultation. Heart had a regular rate and rhythm. The abdomen was soft, nontender, and nondistended. Extremities were warm. Sensation was intact bilaterally, moving all four extremities equally. T, L, and S spine were nontender with no stepoff. His right upper extremity was nontender. Radial pulse strength was [5-14]. Left upper extremity was positive to sensation to light touch, full range of motion, wiggled fingers, brisk capillary refill with an obvious deformity over the distal radius. Lower extremities revealed rectal tone was normal. He easily moved left lower extremity with 5/5 hand strength, [5-14] quadriceps, gastrocnemius, anterior tibialis, extensor hallucis longus, flexor hallucis longus. Patella and ankle were 2+, bilateral downward going toes, and 2+ dorsalis pedis pulses. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission were unremarkable. RADIOLOGY/IMAGING: Chest x-ray was negative. Cervical spine was negative. Cervical spine was negative. Pelvis was negative. CT of the abdomen showed no visceral injury but did show a burst fracture T12-L1. A CT of the chest was negative. Left wrist showed a comminuted minimally displaced distal radius fracture. HOSPITAL COURSE: The patient was admitted to the Trauma Surgery Service. Steroids were held considering no neurologic findings. He was kept on bed rest in a completely flat position, and a magnetic resonance imaging of the thoracolumbar junction was performed. We also repeated the left wrist films. Magnetic resonance imaging showed no cord compression or evidence of any cord compromise. He remained neurologically intact, and plans were made for a nonsurgical management including a TLSO brace which the patient would receive on hospital day two. For the left distal radius fracture, plans were made to take the patient to the operating room for an open reduction/internal fixation. This was done on [6-22]. He underwent a open reduction/internal fixation of the left distal radius by Dr. [First Name (STitle) 1022] which he tolerated without complication and was transferred to the Postanesthesia Care Unit and then back to the floor in stable condition. Postoperatively, he was treated with a TLSO brace and was made out of bed weightbearing as tolerated with Physical Therapy in the brace only. He remained neurologically intact throughout the course of his hospital stay. Postoperatively, his left upper extremity revealed he had some signs of a medial nerve irritation exhibited as slightly decreased sensation in the thumb, index, and middle finger. He remained with 5/5 strength in grip, wrist flexion and extension, finger flexion and extension, intraosseous, and grip. He was mobilized with Physical Therapy, and by postoperative day three, his Foley had been discontinued. He was off of his patient-controlled analgesia. X-rays of his right shoulder were normal, so the decision was made to transfer the patient to home versus rehabilitation. The decision to be based on Physical Therapy's evaluation and Case Management. MEDICATIONS ON DISCHARGE: 1. Percocet one to two tablets p.o. q.4h. p.r.n. for pain. 2. Tylenol 650 mg p.o. q.6h. p.r.n. for headache. DISCHARGE FOLLOWUP: He was to follow up with Dr. [First Name (STitle) 1022] in one to two weeks for evaluation of his distal radius and also for follow up of his spine. DISCHARGE INSTRUCTIONS: He was to remain in the TLSO brace at all times when out of bed and ambulating. When in brace, his activities were as tolerated and weightbearing as tolerated. Otherwise, dressing on his left wrist should be kept clean, dry, and intact. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) ] Dictated By:[Last Name (NamePattern1) 16498] MEDQUIST36 D: [2186-6-26] 13:32 T: [2186-6-29] 12:44 JOB#: [Job Number 42760]	[ "813.44", "805.4", "805.2", "E884.1" ]	icd9cm	[ [ [] ] ]	[ "79.32" ]	icd9pcs	[ [ [] ] ]												4229, 4341	897, 942	2361, 4203		4542, 5037						863, 870														157, 317														4363, 4517							346, 807																	831, 838	959, 2343
213	179,315	26536	Discharge summary	report	Admission Date: [2122-2-13] Discharge Date: [2122-3-3] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 301] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy History of Present Illness: Mr [Known lastname 65533] is a [Age over 90 ] year old man s/p right nephrectomy, s/p left ureterostomy ileal conduit who was transferred from [Hospital1 18] [Location (un) 620] for sharp and worsening abdominal pain. The patient denied any bowel movement in the 2-3 days prior to presentation but had some flatus in the previous hour. A CT scan performed at [Location (un) 620] was concerning for large bowel obstruction/cecal volvulus. Past Medical History: PMH: CAD, MI, HTN, DJD, renal CA, a-fib PSH: CCY, R nephrectomy, cystectomy/ileal conduit, AAA, pacemaker, PTCA Social History: No tobacco, occasional wine. Family History: Non-contributory Physical Exam: Temp 97.2 72 170/76 24 Gen: sitting up Chest: CTAB CVS: RRR Abd: firm, mild-severe tenderness, severely distended, no rebound, no guarding, no local masses Rectal: no masses, guiaic neg Ext: warm Pertinent Results: CT Abdomen [Location (un) 620] 2//906 Complete large bowel obstruction, possible cecal volvulus, possibly associated with ileal conduit Brief Hospital Course: Mr [Known lastname 65533] is a [Age over 90 ] year old man s/p right nephrectomy, s/p left ureterostomy ileal conduit who presented with complete large bowel obstruction/cecal volvulus and who underwent ex lap, R colectomy, revision ileal conduit w/ Urology on [2122-2-13]. In the OR, the patient was found to have necrotic gut and underwent R colectomy and ileal conduit revision. Please see operative report for full details of the procedure. In the OR, the patient also underwent TEE that revealed an EF of 45%. . Post-operatively, the patient was transferred to the Trauma SICU. The patient was initially thought to be coagulopathic, but this was eventually found to be secondary to 'propofol syndrome' and with suspension of the propofol on post-operative day #1, his lab values improved. Otherwise, he remained on pressors until POD #4, was extubated on POD #7, completed a 7 day course of IV abx (Levo/flagyl) and transferred to the floor on POD #9. On that same day, the patient was found obtunded with worsening O2 sats to the 80s. This did not improve with lasix or nebs. ABG revealed paO2 of 39. Pt was also found to be hypoglycemic (23) due to poor oral intake and NPH administration. The patient was intubated and readmitted to the Trauma SICU. He was started on Levofloxacin prophylacticailly. On post-operative day #11, the patient was successfully extubated. On that day, a feeding tube was placed under fluoroscopy which was later pulled out by the patient. The patient was evaluated by speech and swallow who recommended that the patient reattempt oral feeds with pureed foods under supervision. Given this, the patient was transferred to the floor. . On the floor, the patient recovered well. He was evaluated by Nutrition who recommended supplementation to improve his nutritional status. He was seen by Cardiology after one episode of asymptomatic Vtach (18 beats) who recommended tight blood pressure control and resumption of anti-coagulation for Afib. He was started on warfarin on [2122-2-27] with Lovenox until INR is therapeutic at 2.0-2.5. At this point, Lovenox should be discontinued. The patient was discharged to extended care facility for rehab on [2122-3-3]. Medications on Admission: [Last Name (un) 1724]: prednisone 7.5, Coumadin 5/2.5, digoxin, Lipitor, lisinopril, Ativan, Lopressor, Tramadol Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:QS Tablet(s) Refills:0 2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. Disp:250 ML(s) Refills:0 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous [Hospital1 ] (2 times a day): please discontinue when INR therapeutic. Disp:QS Refills:0 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (once): please adjust to reach therapeutic INR level of 2.0-2.5. Disp:QS Tablet(s) Refills:0 9. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day: Except wednesday. Disp:30 Tablet(s) Refills:0 10. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: Ventral hernia Discharge Condition: stable Discharge Instructions: Please call doctor [First Name (Titles) ] [Last Name (Titles) ] greater than 101, nausea/vomiting, inability to eat, wound redness/warmth/swelling/foul smelling drainage, abdominal pain not controlled by pain medications or any other concerns. Please resume taking all medications as taken prior to this surgery and pain medications as prescribed. Please follow-up as directed. No heavy lifting for 4-6 weeks or until directed otherwise. Wound Care: [Month (only) 116] shower (no bath or swimming) if no drainage from wound, if clear drainage cover with dry dressing Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 304], MD Phone:[Telephone/Fax (1) 274] Date/Time:[2122-3-13] 1:45, [Hospital Ward Name 23] 3 Clinical Specialities Completed by:[2122-3-3]	[ "995.92", "458.9", "V55.6", "285.1", "560.2", "V58.61", "E938.3", "251.1", "414.01", "518.5", "997.5", "038.9", "557.0", "V53.31", "427.1", "276.6", "427.31", "412", "276.2", "255.4", "V45.82", "286.7" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.91", "93.90", "99.07", "89.45", "38.93", "00.17", "56.52", "45.73", "88.72", "96.71", "45.93", "96.04", "99.15" ]	icd9pcs	[ [ [] ] ]	4978, 5051	1397, 3612	274, 298	5110, 5119	1233, 1374	5750, 5983	984, 1002		3779, 4955		5072, 5089		3638, 3756			5143, 5593								1017, 1214																						220, 236									5605, 5727		326, 786																	808, 922	938, 968
73,472	114,297	52193	Discharge summary	report	Admission Date: [2157-9-15] Discharge Date: [2157-9-21] Date of Birth: [2094-7-24] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1943] Chief Complaint: Pleuritic chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 63 year old man with recent diagnosis of widely metastatic undifferentiated adenocarcinoma, likely of the lung, transferred from [Hospital1 ] [Location (un) 620] for further workup and to consider possible initiation of palliative chemo or radiation. Patient presented to OSH [9-10] after worsening substernal chest pain since [Month (only) 205]. He first noted the pain after moving TV's, and he assumed it was musculoskeletal. The pain was continuous, and exacerbated by breathing and laying flat, and began radiating along the right and left thorax. He also developed right shoulder pain and low back pain during this time. Additionally, he has noted increasing shortness of breath over the last few months and developed an occasionally productive cough. He denies recent fevers or chills and has not noted any weight loss. Denies headache, changes in vision, or focal numbness or weakness. Denies pain in hi calves. No nausea or vomiting, although his appetite has been poor as of late. He denies bowel or bladder incontinence. Review of systems was otherwise unremarkable. At OSH, an abnomral CXR led to CTA of the chest which showed likely malignancy and metastatic disease including extensive mediasitnal hilar LAD, rt chest wall soft tissue mass with bony destruction of the adjacent right anteriorr second and third rib, left posteriror chest wasll soft tissue mass with bony destruction of the left posterior 8th rib, and mutliple pathologic rib fractures. CT of the abdomen and pelvis showed multiple metastatic lesions within the liver, right adrenal gland, left gluteal muscles, right groin, and a pathologic L1 vertebral body fracture with soft tissue impressing upon the thecal sac. Biopsy of the rib lesion was attempted, but failed due to patietn's inability to lie flat. Similarly, MRI of the head could not be obtained due to inability to lie flat. Biopsy of the gluteal lesion was obtained which preliminary report showed undifferentiated adenocarcinoma. Of note, patient was also treated empirically for PNA with levaquin and steroid taper. Past Medical History: - Chronic back pain - Possible COPD, no formal diagnosis - Alcohol abuse. Sober for 4 months - Hx of basal cell ca. - Cellulitis/MRSA - Left hip replacement - Metastatic undifferentiated adenocarcinoma, likely of lung Social History: Smokes 1.5 packs per day for 49 years and has history of abusing alcohol. Family History: No family history of lung cancer. Physical Exam: Admission Exam: Vitals: T:97.6 BP:139/73 P:108 R:23 O2:92% 5LNC General: Pleasant, alert, oriented, sitting up in bed in mild distress [1-12] pain HEENT: Sclera anicteric, MMM, tongue midline, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Speaks in short sentences, scattered wheezes with low frequency expiratory ronchi diffusely CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Chest: Tender to palpation diffusely over precordium. No rashes, erythema, or swelling noted Abdomen: soft, non-tender, non-distended, soft bowel sounds present, no rebound tenderness or guarding, no organomegaly Rectal: Deferred Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. ROM rt should limited by pain. Neuro: Alert and oriented x4. Good attention. CNII-XII intact. Strength 5/5 symmetrically throughout lower extremity. Limited by pain in right upper extremity. Finger-to-nose intact with good proprioception of feet. Gait not assessed. Pertinent Results: [2157-9-16] 03:31AM BLOOD WBC-17.2# RBC-4.54# Hgb-15.1# Hct-42.3# MCV-93# MCH-33.2* MCHC-35.7* RDW-12.9 Plt Ct-330# [2157-9-16] 03:31AM BLOOD Glucose-107* UreaN-25* Creat-0.6 Na-136 K-4.2 Cl-100 HCO3-26 AnGap-14 [2157-9-16] 03:31AM BLOOD ALT-10 AST-15 LD(LDH)-470* AlkPhos-84 TotBili-0.4 [2157-9-16] 03:31AM BLOOD Albumin-3.4* Calcium-10.9* Phos-3.8 Mg-2.1 Brief Hospital Course: # Metastatic adenocarcinoma of lung: The patient was admitted to the ICU and was evaluated by oncology, radiation oncology and palliative care. With his poor performace status and advanced disease, palliative radiation alone was offered to the patient. Palliative care made recommendations for pain management with plan to go home with hospice. The patient was agreeable to the plan. He received one dose of radiation on [9-20] and was discharged home with hospice services. # Hypoxia: thought [1-12] possible pna with underlying copd and splinting from pain of bony lesions. He was treated initially at the osh with steroids and levaquin. The abx completed on [9-18] and the steroid taper was continued on discharge. He will also go home with supplemental O2 and nebulizer treatments. # Hypercalcemia: Initial Ca was 10.9 on admission. He was hydrated and given one dose of pamidronate. Repeat calcium level was 9.0. # Goals of Care: patient will go home with hospice care. He was DNR/DNI. Medications on Admission: NSAIDs prn Discharge Medications: 1. Home Oxygen Home oxygen 5L NC countinuous [Male First Name (un) ] 99 Weeks Diagnosis Lung Cancer 2. Hospital Bed Semi-electric with mattress bed + half rails. Please have head of bed elevated to 30 degrees [Male First Name (un) ] 99 weeks Diagnosis Lung Cancern 3. commode 3 in 1 commode 4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:30 capsules Refills:0 5. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:10 Patch 72 hr(s) Refills:0 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO [1-16] as needed for pain, cough, or difficulty with breathing. Disp:60 Tablet(s) Refills:0 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:60 Tablet(s) Refills:0 8. prednisone 10 mg Tablet Sig: taper per instructions PO once a day: Take 2 tablets daily for 7 days, then reduce to 1 tablet daily for 7 days, then 0.5 tablets daily for 7 days, then stop. Disp:25 Tablet(s) Refills:0 9. ipratropium bromide 0.02 % Solution Sig: One (1) dose Inhalation Q4H (every 4 hours) as needed for wheezing. Disp:50 dose Refills:0 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) unit dose Inhalation Q4H (every 4 hours) as needed for SOB/Wheeze. Disp:50 unit dose Refills:0 11. ranitidine HCl 15 mg/mL Syrup Sig: One [Age over 90 1230]y (150) mg PO BID (2 times a day) as needed for dyspepsia. Disp:600 mL Refills:0 12. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: [4-19] MLs PO Q6H (every 6 hours). Disp:400 ML(s) Refills:2 13. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:0 14. naproxen 500 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours: give with food as this med may irritate stomach. Disp:60 Tablet(s) Refills:0 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 16. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. Disp:50 Tablet(s) Refills:0 17. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Metastatic Lung Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to evaluate for radiation therapy and or chemotherapy for lung cancer. The oncologists (cancer doctors) did not feel that chemotherapy would give you any benefit, but did want to provide radiation therapy to help with your bone pain. The radiation was given on [2157-9-20]. Pain medication and home hospice services will be provided to you on discharge. MEDICATION INSTRUCTIONS: 1. Prednisone taper, take 20 mg daily for 7 days, then 10 mg daily for 7 days, then 5 mg daily for 7 days, then stop. This is to help with breathing. 2. Albuterol and Ipratropium nebulizer treatments are also to help with breathing. 3. Spiriva is an inhaled medication to help with breathing. 4. Naproxen and Fentanyl are pain medications that should be used regularly. 5. Oxycodone can be used as needed to help with extra pain or symptoms of shortness of breath. 6. Lorazepam is for anxiety; take as needed. 7. Docusate and Senna are for constipation as Fentanyl and Oxycodone use can cause constipation. 8. Ranidine is for heartburn or acid reflux. 9. Guaifenesin-Dextromethorphan and Benzonatate are for symptoms of cough. Followup Instructions: You may follow-up with your primary care physician as needed: Name: [Last Name (LF) ],[First Name3 (LF) ] U. Location: [Location (un) 2274]-[University/College ] Address: [Hospital1 3470], WELLESLY,[Numeric Identifier 23943] Phone: [Telephone/Fax (1) 86362]	[ "496", "196.1", "198.89", "V15.82", "V49.86", "338.3", "V58.65", "486", "275.42", "V11.3", "198.7", "V46.2", "564.09", "V66.7", "V10.83", "799.02", "197.7", "162.8", "V43.64", "733.13", "198.5" ]	icd9cm	[ [ [] ] ]	[ "92.29" ]	icd9pcs	[ [ [] ] ]	7630, 7679	4244, 5260	325, 331	7745, 7745	3845, 4221	9084, 9372	2787, 2822		5321, 7607		7700, 7724		5286, 5298			7927, 8307								2837, 3826																						265, 287											359, 2439								8332, 9061			7760, 7903						2461, 2680	2696, 2771
25,341	195,190	26397	Discharge summary	report	Unit No: [Numeric Identifier 65280] Admission Date: [2196-1-14] Discharge Date: [2196-1-14] Date of Birth: [2119-12-28] Sex: F Service: [Last Name (un) ] HISTORY OF PRESENT ILLNESS: This is a 76-year-old female with CAD, status post CABG, and end-stage renal disease on peritoneal dialysis who was admitted to an outside hospital with left lower quadrant abdominal pain. She was found to have peritonitis probably due to her peritoneal catheter, so this was removed and she was started on antibiotics. She did not improve from this and she was taken to the operating room for an exploratory laparotomy and was found to have a perforation of her small bowel. A small bowel resection was performed and the patient was transferred back to the intensive care unit there. She started to improve and was transferred to the floor. She then began having increasing abdominal pain and hypotension. A CT scan was done and she was found to have extravasation of contrast and concern for an anastomotic dehiscence. The patient was transferred to [Hospital1 ] at this time for further management. PAST MEDICAL HISTORY: Significant for CAD, hypertension, AFib, mitral regurgitation, aortic stenosis, COPD, end-stage renal disease on HD, diabetes mellitus and has a history of GI bleeds. PAST SURGICAL HISTORY: Significant for the CABG, the peritoneal dialysis catheter placement, exploratory laparotomy and small bowel resection as noted before. ALLERGIES: None. MEDICATIONS: Her medications on transfer included Tylenol, regular insulin sliding scale, Protonix, folate, aspirin, Epogen, oxycodone and Zosyn. PHYSICAL EXAMINATION: Temperature 99.6 and heart rate 134. Her blood pressure was 97/44, respirations 18, and O2 saturation 98%. CVP was 22. She was extremely tender and had peritoneal signs on her exam. LABORATORY DATA: Her white count was 18. Her hematocrit was 39. Her blood gas was 7.41, 36, 101, 24 and zero. Her lactate was 3.3. CT scan showed, as noted before, a large amount of ascites and free air as well as extravasation of contrast. HOSPITAL COURSE: The patient was transferred to the intensive care unit and resuscitation was begun. She was given broad-spectrum antibiotics, and the patient was taken to the operating room. She underwent an exploratory laparotomy and small bowel resection and reanastomosis. Please see the operative report for further details. However, intraoperatively, the patient had a bradycardiac arrest requiring chest compressions and she was started on pressors for blood pressure control. She was transferred back to the intensive care unit postoperatively. She was on high doses of Levophed and on full vent support. The patient also had an echo immediately postoperatively which showed significant wall motion abnormalities with akinesis of the lateral and anterior walls and hypokinesis of the septum. A family meeting was held at this time. The family decided that they would not pursue any other medical treatments. Therefore, the patient was made comfort measures only. The pressors were stopped and the patient expired shortly thereafter. The family refused autopsy at this time. The patient died on [2196-1-14]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 18475] Dictated By:[Doctor Last Name 11225] MEDQUIST36 D: [2196-1-14] 10:27:21 T: [2196-1-14] 11:09:19 Job#: [Job Number 65281]	[ "567.29", "424.0", "997.1", "V66.7", "997.4", "427.5", "574.20", "250.00", "427.31", "585.6", "496" ]	icd9cm	[ [ [] ] ]	[ "45.61", "96.33", "51.22" ]	icd9pcs	[ [ [] ] ]														2103, 3472								1331, 1635													1658, 2085																						209, 1116																	1139, 1307
67,621	166,873	39803	Discharge summary	report	Admission Date: [2133-7-8] Discharge Date: [2133-7-10] Date of Birth: [2091-11-1] Sex: F Service: MEDICINE Allergies: Penicillins / Morphine Attending:[First Name3 (LF) 348] Chief Complaint: Suicide attempt Overdose Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 41 year old female with history of HTN, HL, Type II DM, and depression who presents with overdose of unknown quantity of multiple medications. Per patient and records, patient took unknown quantity of acetaminophen, pravastatin, atenolol, glucophage, duloxetine, methadone, and lisinopril around 23:00 on [2133-7-7]. Patient states she was upset with husband, concerned that he's been "messing around". She did state that her overdose was an attempt to hurt herself- she "just wanted to fall asleep and not wake up". She has a history of depression, and receives counseling monthly. Contrary to reports, she states that she did not turn on the gas at home after the overdose, but in fact turned the gas off. Police were called to the scene, broke down the doors to her house, and transported the patient to an OSH for further evaluation in the setting of her recent overdose. . Initial reports indicate the patient took about 200 pills of the above medications. She now states she took less than that, "a handful". Acetaminophen represented the majority of the pills. She also consumed alcohol, a few drinks. She has not recently refilled any prescriptions. . At the OSH, the patient was normotensive and alert and oriented x 3. Section 12 was performed. She received 25 grams of charcoal. Her SBP dropped to high 70s mmHg; she then received 3 liters of NS and glucagon 1 mg x 1. She was then transferred to [Hospital1 18] ED given concern for hemodynamic instability. Four hour acetaminophen level at OSH was 58. . In ED, initial vital signs were 97.4, 115/90 HR 58, RR 12, 100% on 4 liters. She received an additional 25 grams of charcoal for a total of 50 grams. Her SBP drifted to the 90s mmHg with HR in 50s, and she received 2 more liters of IVF, for a total of 5 liters. QTc noted to be 510. FSBG trended from 138 -> 84. At time of transfer to ICU, vitals were HR 57 BP 95/53 RR 13 97% RA. sleepy, easily arousable. a and o x 3. . Upon arrival to the ICU, patient was sleepy but easily arousable. She was complaining of a dry mouth after receiving the charcoal. She was also complaining of frequent bowel movements. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Type II DM HTN HL h/o asthma depression, no history of SI in past per patient s/p open CCY and appendectomy Social History: Lives with husband and two sons, [11-22] to 1 pack per day for 20+ years, at least 10 year pack history, does not usually consume EtOH, denies IVDU. Family History: non-contributory Physical Exam: PHYSICAL EXAM ON DISCHARGE: VS: T 98, BP 138/90, HR 68, RR 16, 95% RA GA: AOx3, NAD HEENT: PERRLA. MMM Cards: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB Abd: soft, NT, +BS. no g/rt. neg HSM. Scars in RUQ, lower abdomen Extremities: wwp, no edema. DPs, PTs 2+. Skin: Multiple ecchymoses in the arms from subc heparin Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. Pertinent Results: 1. At OSH: bicarb 20, creatinine 1.4, ethanol level 95, acetaminophen level 58.8, WBC 9.6 urine (+) for amphetamnines, benzodiazepines, methadone, and opiates . 2. On admission at [Hospital1 18]: EtOH 24, acetaminophen 39 (down from 58.8), creatinine 1.5 AST 106, ALT 58, alk phos 338, t. bil 0.2, CK 80, lipase 24 . ASA Ethanol Acetmnp Bnzodzp Barbitr Tricycl NEG 24 39 POS NEG NEG . U/A: Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks MOD POS 75 NEG TR NEG NEG 5.0 TR . RBC WBC Bacteri Yeast Epi 0-2 [1-23] MANY NONE 0-2 . 3. On discharge at [Hospital1 18]: creatinine 1.1 AST 26, ALT 28, alk phos 222, t. bili 0.6 . Microbiology: Urine culture showed E. coli >100,000 organisms/ml. . Imaging: 1. Foot plain film: non displaced oblique fracture at the base of the second metatarsal. . ECG: sinus, rate 54, normal axis, QTc 510, non-significant Q waves inferiorly . Repeat ECG: sinus, rate 63, normal axis, QTc 449, non-significant Q waves inferiorly Brief Hospital Course: 41 year old female with history of HTN, HL, Type II DM, and depression with SI and overdose of unknown quantity of multiple medications, alert and oriented and hemodynamically stable, medically cleared. . # Overdose: Ingestion was a combination of acetaminophen, atenolol, pravastatin, multivitamins, with alcohol. Inital acetaminophen level was elevated and patient was treated empirically with n-acetylcysteine, which brought it down to negligible level. CK was normal despite pravastatin ingestion. LFTs were initially slightly elevated but trended down to normal. She showed bradycardia to the 50s and prolonged QTc, which resolved prior to discharge. Patient never developed respiratory distress, neurologic compromise, or cardiac arrhythmias. Patient was kept on CIWA scale throughout but did not show signs of withdrawal. . # Depression: Psychiatry was consulted. Given the serious nature of the suicide attempt, and the overall decreased coping mechanism, inpatient hospitalization was suggested. Patient was placed on Sectioned XII. At the time of her discharge patient expressed regret at any intervention to harm herself and denied any suicidal or homicidal ideation. . # Renal insufficiency: On admission, Cr elevated at 1.5, which trended down to 1.1 prior to discharge. . # Positive UA: Urine culture was postive for >100,000 E. coli that was pan-sensitive. Given that patient was entirely asymptomatic, was not treated. . # Hypertension: Atenelol was held in the context of bradycardia from overdose. She was started on Amlodipine 10 mg po to control her blood pressure, which remained high systolic 160-180 range. On discharge, she was restarted on her home dose of Atenolol. Blood pressure should be monitored as outpatient. . # Hyperlipidemia: On admission pravastatin was held, but given normal CK, was restarted prior to discharge. . # Type II DM: Blood sugar remained stable throughout on sliding scale. . Medications on Admission: methylphenidate 30 mg TID duloxetine 60 mg daily Oxycontin 20 mg [Hospital1 ] valium 10 mg TID pravastatin 80 mg daily hydrocodone 5/500 one tab Q4H PRN Advair 100/50 2 puffs daily albuterol 108 mcg 2 puffs Q6H PRN dyspnea atenolol 50 mg daily Discharge Medications: 1. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 2. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: Two (2) puffs Inhalation once a day. 3. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 ] 4 Discharge Diagnosis: Suicide attempt Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname 87617], you were admitted to the [Hospital1 827] because you took many pills in an attempt to end your life. When you got here, you were somnolent and we found that the tylenol level in your blood and your liver enzymes were elevated. You were treated with medication to prevent permanent liver damage. You were also treated with charcoal to remove the rest of the pills from your system. We noticed that your heart rate was slow, likely from the pills you took, and watched it closely, which resolved. You complained of a left foot pain and we got an x-ray which showed a fracture in the second metatarsal. The podiatrist suggest you wear the surgical boots (which you have) and for you to followup with your outpatient orthopedic doctor. At the time that you were discharged, your liver enzymes are back to normal, your kidneys were working well, and you no longer have tylenol in your blood. A psychiatrist came to see you and based on the severity of your suicide attempt, you will be admitted to an inpatient psychiatric facility after you are discharged here. . We STOPPED the following medications: 1. Methylphenidate 30 mg three times a day 2. duloxetine 60 mg daily 3. Oxycontin 20 mg twice a day 4. valium 10 mg three times a day 5. hydrocodone 5/500 one tab every 4 hours as needed Followup Instructions: Please follow up with your primary care doctor Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 87618] nurse [First Name8 (NamePattern2) 3525] [Last Name (Titles) ] within the next week. An appointment has been made for you: [2133-7-14] at 3:45 pm. Completed by:[2133-7-10]	[ "E950.0", "599.0", "401.9", "V62.84", "041.4", "584.9", "250.00", "272.4", "965.4", "296.23" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7363, 7408	4745, 6675	307, 313	7468, 7468	3682, 4722	8965, 9276	3231, 3249		6973, 7340		7429, 7447		6701, 6950			7619, 8942								3264, 3264													3292, 3663						2535, 2914			242, 269											341, 2516											7483, 7595						2936, 3045	3061, 3215
2,911	187,297	47596	Discharge summary	report	Admission Date: [2156-1-2] Discharge Date: [2156-1-6] Date of Birth: [2104-5-13] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 759] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: 51 y/o F with PMH significant for ALS, asthma, lupus, and rheumatoid arthritis admitted to [Hospital1 18] on [1-2] with SOB. In recent relevent history, pt was diagnosed with ALS in [5-/2155] and has been followed for this at [Hospital6 13753]. Her PCP there is [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 100578]. Pt has been admitted to [Hospital1 112] over 15 times since her ALS diagnosis. Following these admissions, she most often goes to rehab, finishes her steroids, and then returns to the hospital with SOB. Pt was most recently admitted to [Hospital1 112] on [12-22] through [12-29] with cough and SOB. At that time, her NIF was found to be 20 (baseline 25 to 30). She was treated with aspiration PNA with levo and flagyl in addition to prednisone 60 mg daily. The plan was for a slow steroid taper to 10 mg daily then continuing on this indefinetly. A pallitive care consult was obtained during the [Hospital1 112] stay and the pt was discharged to rehab with the plan to transition to an inpatient hospice unit. The pt was discharged from [Hospital1 112] to the Armonoiom House in JP on [12-29]. Per the pt's neice, she was pushed by a staff member at this facility on [12-30] and left without any medications as there was difficulty in obtaining them. Once home, the pt had increasing SOB and called EMS on [1-1] to be trasported to an ED. As [Hospital1 112] was on divert she was transported to the [Hospital1 18] ED. In the ED, her VS were 122/96 100 87% RA and 100% 4L NC. Pt was initially admitted to a medicine service but following neurology consultation and the finding of a NIF of 20 the pt was transferred to the [Hospital Unit Name 153] for care. There, she received levofloxacin, atrovent, morphine, and percocet. Further issues with the pt include recent low grade fevers. She has not had any sweats or recent weight changes. Pt has a chronic cough with increasing sputum production. No CP, tightness, or palpitations. No n/v, abdominal pain, or constipation. Pt had diarrhea for for two days prior to admission and reports three stools per day. No dysuria. Pt reports that he knees have been swollen over the last few days. She has also been experiencing left hip and back pain radiating to her groin. Speaking with the pt, she reports that she is doing fairly well at this time. She does not feel SOB except with exertion. She is able to cough out her sputum. Pt does have pain in her left hip and back. She reports that he diarrhea is much improved. Past Medical History: 1. [Name (NI) ] Pt was diagnosed in [5-10] at [Hospital1 112]. Her baseline MIF is -25 to -30. Pt is a known aspiration risk but declines trach and PEG. She has significant and progressive bulbar symptoms and R side weakness. 2. Asthma - Pt was intubated once in the past for her asthma. PFTs are consistent with a restrictive physiology. She has had multiple admissions since [2152]. Pulm consult at [Hospital1 112] thought she had some reversible bronchoconstriction due to aspiration, poor pulmonary reserve, obesity, and muscle weakness causing her frequent resp decompensations. 3. [Name (NI) 100579] Pt was diagnosed 10 years ago. 4. Seronegative rheumatoid arthritis - Pt was on MTX. 5. Uterine fibroids 6. PCOS 7. OSA 8. H/O polysubstance abuse- Cocaine 9. HTN 10. Sjogern's syndrome 11. Carpel tunnel syndrome 12. Subclinical hypothyroidism 13. Thrombocytopenia- This was felt to be due to her RA. 14. Diastolic heart failure 15. H/O TB at age 10 Social History: Pt lives at home with her 17 year old daughter and [Name2 (NI) 12496]. Has 2 other daughters ages 27 and 35 (incarcerated for life). Pt also had a 31 year old daugher who died in 12/[2154]. Pt's neice [Name (NI) ] [Name (NI) 3501] manages most of her medical issues and lives with the pt to care for her. Pt used to work as a bartender and secretary. She is relatively [Name2 (NI) 15310] and walks without assistance. She eats thickened fluids and foodsNo current ETOH or substances- has a history of cocaine abuse. Family History: Noncontributory. Physical Exam: 98.5 117/71 86 24 97% RA Gen- Pleasant lady resting in bed. Alert and oriented. NAD. Speaks very quitely. HEENT- NC AT. PERRL. EOMI. Mildly dry mucous membranes. No lesions in the orophaynx. Cardiac- Distant heart sounds. RRR. S1 S2. No m,r,g. Pulm- Very faint air movement. No wheezes, rales, or rhonchi. Abdomen- Obese. Soft. NT. ND. Positive bowel sounds. Extremities- No c/c/e. Neuro- CN II-XII intact but minimal palatal elevation and fasciculations of the tongue. 4/5 strength in upper and lower extremities bilaterally. Pertinent Results: [2156-1-1] 11:00PM BLOOD WBC-10.3 RBC-4.73 Hgb-13.3 Hct-39.8 MCV-84# MCH-28.2 MCHC-33.5 RDW-18.3* Plt Ct-393# [2156-1-1] 11:00PM BLOOD Neuts-62.8 Lymphs-27.0 Monos-4.9 Eos-4.5* Baso-0.7 [2156-1-1] 11:00PM BLOOD Anisocy-2+ Microcy-1+ [2156-1-1] 11:00PM BLOOD Plt Ct-393# [2156-1-1] 11:00PM BLOOD PT-13.3* PTT-24.5 INR(PT)-1.2* [2156-1-1] 11:00PM BLOOD Glucose-90 UreaN-12 Creat-0.8 Na-145 K-3.5 Cl-103 HCO3-32 AnGap-14 . CTA chest ([1-2])- CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: There is no axillary, mediastinal, or hilar lymphadenopathy. The heart, great vessels, and pericardium are unremarkable. There are no pleural or pericardial effusions. There is no evidence of aortic dissection or pulmonary embolism. There are a few scattered bullae, and atelectasis in the lingula and right lower lobes. Otherwise, the lungs are clear. There is a relative large amount of retroperitoneal fat. Otherwise limited views of the upper abdomen are unremarkable. BONE WINDOWS: There are mild degenerative changes in the lower thoracic spine with calcifications in the anterior ligaments. IMPRESSION: 1. No evidence of pulmonary embolism or aortic dissection. 2. Likely bibasilar atelectatis, although early pneumonia cannot be excluded. 3. Mild bullous changes. . [2156-1-6] 07:15AM BLOOD WBC-8.3 RBC-3.89* Hgb-10.8* Hct-33.4* MCV-86 MCH-27.6 MCHC-32.2 RDW-18.6* Plt Ct-236 [2156-1-4] 12:18PM BLOOD Neuts-86.3* Lymphs-11.1* Monos-1.7* Eos-0.5 Baso-0.3 [2156-1-4] 12:18PM BLOOD WBC-9.4 RBC-4.37 Hgb-12.0 Hct-36.5 MCV-83 MCH-27.4 MCHC-32.9 RDW-17.5* Plt Ct-302 [2156-1-4] 12:18PM BLOOD Anisocy-1+ Microcy-1+ [2156-1-6] 07:15AM BLOOD Plt Ct-236 [2156-1-4] 12:18PM BLOOD PT-12.8 PTT-22.7 INR(PT)-1.1 [2156-1-6] 07:15AM BLOOD Glucose-77 UreaN-13 Creat-0.7 Na-141 K-3.3 Cl-104 HCO3-27 AnGap-13 [2156-1-6] 07:15AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.0 . EKG: Normal sinus rhythm. Diffuse non-diagnostic T wave flattening with prolonged Q-T interval. Compared to the previous tracing of [2156-1-1] no definite change. Brief Hospital Course: 51 y/o F with PMH significant for ALS, asthma, lupus, and rheumatoid arthritis admitted to [Hospital1 18] on [1-2] with SOB. . 1. [Name (NI) 1621] Pt had significant dyspnea on admission in addition to cough, sputum production, and low grade fevers. Cause of her symptoms are most likely multifactorial: Not taking medications after leaving the rehab facility; asthma; recurrent aspirations in the setting of ALS; and simply the neuromuscular compromise of her ALS. Following a day of treatment in the [Hospital Unit Name 153], her respiratory status is much more compensated and she is currently comfortable. - Completed course of antibiotics for aspiration PNA that was initiated at [Hospital1 112]. This includes levofloxacin and flagyl through [1-5]. EKG obtained and results noted above. Steroid taper initiated at 60 mg/d with plan for taper by 10 mg/q3-4 d to a final dose of 10mg/day. Treated with nebs/inhalers. Treated with BiPAP at night. . 2. [Name (NI) ] Pt was diagnosed in [5-10] and many of her current symptoms are related to her ALS. Neurology consulted. Confirmed c pt that she is DNR/DNI. She also declines trach and Peg. Pt. received thickened food/liquid . 4. [Name (NI) 1622] Pt's pain is most concentrated in her lower back and left hip. Most probably secondary to her RA and seronegative lupus. Continued pain control with oxycontin/oxycodone and encouraged pt. to ask for Tylenol as needed for hip pain. [Month (only) 116] need to be titrated up. . 5. GERD- Continued PPI. . 6. HTN- Continued home meds. BP under good control here. Medications on Admission: 1. Triamterene-HCTZ 37.5-25 mg daily 2. Citalopram 40 mg daily 3. Protonix 40 mg daily 4. Colace 100 mg [Hospital1 ] 5. ECASA 81 mg daily 6. Bactrim SS one tab daily 7. Loratadine 10 mg daily 8. Hydroxychloroquine 200 mg daily 9. Calcium 600 mg TID 10. Advair 500/50 1 puff [Hospital1 ] 11. Flovent 12. Albuterol Q4H PRN 13. Spirvia 18 mcg inhaled daily 14. [Name (NI) 30723] Pt would have been on 30 mg daily at the time of admission. 15. Oxycodone 10 to 15 mg PRN pain 16. Oxycontin 20 mg Q12H 17. Flagyl 500 mg [Name (NI) 21852] Pt will complete planned course on [1-5]. 18. Lovenox 40 mg SC daily- Planned to continue until paitent ambulatory 19. K-lor 30 meQ [Hospital1 ] 20. Levofloxacin 500 mg daily- Pt will complete planned caourse on [1-5]. 21. Tylenol PRN 22. RISS 23. Ativan 0.5 to 1 mg PO Q12H PRN anxiety 24. Nystatin swish and swallow PRN 25. Sarna PRN 26. Senna 2 tabs [Hospital1 ] 27. Simethicone 80 mg QID 28. Ocean nasal spray QID PRN 29. Tucks pads PR PRN 30. Ambien 5 mg QHS PRN 31. Anusol daily 32. Miconazole powder [Hospital1 ] PRN 33. Albuterol and atrovent nebs PRN 34. Potassium chloride 39 mEq [Hospital1 ] Discharge Medications: 1. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Zolpidem 5 mg Tablet Sig: 0.5 to 1 Tablet PO HS (at bedtime) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation [Hospital1 ] (2 times a day). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): please taper by 10mg q4days. 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 7 days. 16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR Transdermal every seventy-two (72) hours. Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Primary diagnosis: SOB Secondary diagnosis: ALS Asthma Aspiration pneumonia Rheumatoid arthritis OSA Hypertension SLE Discharge Condition: Stable Discharge Instructions: 1. Please keep all follow up appointments. 2. Please take all medications as prescribed. 3. Seek medical care for fevers, chills, chest pain, shortness of breath, abdominal pain, or any other concerning symptoms. Followup Instructions: Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 100580] [2156-1-14] at 1:30pm.	[ "493.20", "507.0", "335.20", "786.09", "710.2", "780.57", "244.9", "428.32", "714.0", "428.0", "710.0", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11637, 11710	7134, 8741	273, 280	11873, 11882	5033, 7111	12145, 12291	4449, 4467		9967, 11614		11731, 11731		8767, 9944			11906, 12122								4482, 5014																						230, 235											308, 2877				11776, 11852			11750, 11755										2899, 3880	3896, 4433
4,424	168,442	13418	Discharge summary	report	Admission Date: [2105-11-2] Discharge Date: [2105-11-13] Service: MEDICINE Allergies: Penicillins / Iodine; Iodine Containing / Erythromycin Base Attending:[First Name3 (LF) 3507] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 83 yo F with DM type I, CHF, asthma, HTN, and CAD transfered from an OSH via [Location (un) ] after an acute episode of SOB and hypoxia (O2 sats in the 50's) at her NH. She was speaking in 1 word sentences. . At the OSH, CXR and exam were c/w CHF and BNP was 2270. Lasix 20 mg IV was given twice with 100cc of urine output each time. Nitropaste 1 inch placed. Pt placed on BiPAP and a nitro gtt was started. In the [Hospital1 18] ED her CXR revealed CHF with ?bilateral infilrates. She had a leukocytosis (WBC 15 with 86% Neutrophils). Low grade temp of 100.0. She was given one dose of Ceftriaxone. Nitro drip was continued at a low dose as her BP was well controlled (goal SBP 120-140). She was continued on BiPAP (ABG 7.38/49/264/30). Lactate 1.5. O2 sats 100%. She received Morphine 2mg x1 for anxiety and HA. Her first trop was elevated at 0.17 (CK and MB negative) which was felt to be secondary to demand ischemia and renal insufficiency per cards fellow. Blood and urine cultures were sent. . Upon arrival to the ICU the pt was on 2L NC with sats of 96% and breathing comfortably. Pt notes over the past few weeks she has had a cough with white sputum and a low grade temp of 99.0 Her doctor at the nursing home thought this was asthma and then worsening CHF. Her lasix was recently changed from 20 PO BID to 20 in the AM and 40 at night. Past Medical History: - Type 1 diabetes mellitus. - CAD s/p silent myocardial infarction in [2086]. Cath at [Hospital1 2025] several years ago. Went into ARF after receiving dye. - Asthma. - Hypertension. - Hypothyroidism secondary to partial thyroidectomy after papillary thyroid cancer in [2066]. - Urinary incontinence secondary to neurogenic bladder. - Osteoporosis. - Osteoarthritis. - Spinal stenosis. - Macular degeneration. - h/o Acute angle glaucoma. - Cataracts. Social History: Denies tobacco or illicit drug use EtOH-2 glasses of wine per year Baseline walks with walker Sister is HCP [Name (NI) 4906] died 7 months ago Family History: NC Physical Exam: Physical Exam: Tc 99.2 BP 152/57 HR 101 RR 25 Sat 96% 2L NC Wt 49.2 kg Gen: Comfortable elderly female speaking in complete sentances on NC )2 HENNT: MMM, anicteric, Neck: no LAD, JVD to chin CV: RRR, nl S1S2, soft systolic murmur at LLSB Lungs: crackles at left base, and wheezes b/l Abd: soft, NT/ND, +BS, No HSM Ext: no edema , strong DP/PT pulses bilaterally Neuro: A&Ox3 Pertinent Results: [2105-11-2] 05:12AM BLOOD Albumin-2.8* [2105-11-2] 05:12AM BLOOD cTropnT-0.17* [2105-11-3] 05:00AM BLOOD proBNP-4789* [2105-11-2] 05:12AM BLOOD CK(CPK)-79 [2105-11-7] 05:27AM BLOOD CK(CPK)-52 [2105-11-2] 05:12AM BLOOD Glucose-292* UreaN-36* Creat-1.2* Na-141 K-4.8 Cl-102 HCO3-30 AnGap-14 [2105-11-8] 05:57AM BLOOD Glucose-94 UreaN-81* Creat-2.0* Na-136 K-5.6* Cl-104 HCO3-24 AnGap-14 [2105-11-12] 10:44AM BLOOD Glucose-172* UreaN-41* Creat-1.0 Na-140 K-4.6 Cl-102 HCO3-31 AnGap-12 [2105-11-12] 10:44AM BLOOD Neuts-82* Bands-0 Lymphs-7* Monos-5 Eos-6* Baso-0 Atyps-0 Metas-0 Myelos-0 [2105-11-2] 05:12AM BLOOD WBC-15.8# RBC-4.30 Hgb-11.7 Hct-34.4* MCV-80# MCH-27.3 MCHC-34.1 RDW-14.9 Plt Ct-299# [2105-11-13] 09:15AM BLOOD WBC-16.2 RBC-3.72* Hgb-10.3* Hct-29.9* MCV-80* MCH-27.7 MCHC-34.4 RDW-17.1* Plt Ct-405 . CXR: PORTABLE AP CHEST RADIOGRAPH: The study is slightly limited secondary to positioning. There are bilateral pleural effusions. The cardiac size is within normal limits. There is extensive calcification of the aortic arch and descending aorta. There is mild prominence of the pulmonary vasculature consistent with interstitial edema. Additionally, there are areas of increased opacity in the left mid and lower lung zones and the right lower lung zone. No pneumothorax is seen. The osseous structures appear osteopenic. . IMPRESSION: 1. Bilateral pleural effusions and increased interstitial markings consistent with interstitial edema. 2. Areas of increased opacity in the left mid and lower lung zones and right lower lung zone may represent areas of asymmetric edema, though atelectasis, consolidation, or aspiration are also considerations. . Echo 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis. No aortic regurgitation is seen. 4. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. Trivial mitral regurgitation is seen. . Renal U/S: 1. Markedly limited exam due to patient's inability to cooperate. No evidence of stones, large mass, or hydronephrosis. 2. 7.7 cm cystic structure anterior and superior to the upper pole of the left kidney, incompletely characterized by this limited study. CT scan may help clarify the origin of the cystic structure anterior to the left kidney. . CT Abdomen CT ABDOMEN: Bilateral pleural effusions and associated atelectasis. Calcification of the mitral annulus. Borderline cardiomegaly. Small nodule in the subcutaneous anterior chest wall likely representing a sebaceous cyst (2:4) measuring 11 mm. . The cystic structure seen on ultrasound measures 7.0 x 6.3 cm and is located in the retroperitoneal region in the left upper quadrant. It contacts the pancreas, tip of the spleen, and kidney, but is not definitely arising from any of them. It appears to have simple characteristics, although appears to have a 1-2 mm wall. Additionally, a 1-cm cyst in the body of the pancreas (2:28) which is incompletely characterized in this study. . In the lower pole of the left kidney, there are two exophytic areas best seen in the coronal images. One of them measures 2.0 cm and has fluid density likely representing a cyst. The other located more laterally measures 1.6 cm but is hyperdense with measuring 45 Hounsfield units (image 313D:37). Although this could represent a hyperdense cyst, was incompletely characterized in this study. With the limitations of this non-contrast study, the adrenal glands, gallbladder, and liver are unremarkable. The aorta and both renal arteries are inferiorly calcified. There is edema of the subcutaneous tissues, but no ascites in the abdomen. No retroperitoneal lymphadenopathy. . CT PELVIS: Patient is status post left hip prosthesis placement (probably bipolar prosthesis) which limits the visualization of the pelvis due to artifact. There is a large amount of fecal material within the cecum, ascending and transverse colons likely related to constipation. . CT Head: FINDINGS: There is no intracranial mass lesion, hydrocephalus, brain edema, or hemorrhage. No minor or major vascular territorial infarct is apparent. The density values of the brain parenchyma are within normal limits. Surrounding osseous structures are unremarkable aside from exostosis of right parietal bone. There is some mucosal thickening in the ethmoid and frontal sinuses. There are calcifications in the distal vertebral arteries. Brief Hospital Course: A/P: 83 yo F with DM type I, CHF, asthma, HTN, and CAD admitted with acute SOB and hypoxia (O2 sats in the 50's) secondary to a CHF exacerbation and PNA. Hospital course, by Problem: . # Respiratory Distress: Multifactorial including component of PNA, CHF, and asthma. . A- Pneumonia: The patient presented with a persistent cough, elevated WBC, O2 requirement ranging from 2L NC to FiO2 0.4 and low grade fevers on admission. A consolidation was seen on x-ray in combination with likely volume overload from CHF. She was initially started on Vancomycin and Levofloxacin. Cefepime was added when the patient's respiratory status worsened for concern of a resistant pneumonia but this was discontinued as the patient began to improve. She completed a 10 day course of Vancomycin and Levaquin. No sputum culture could be obtained as the patient's cough was non-productive. . B- CHF: Upon admission, the patient's chest xray showed evidence of CHF/volume overload. Echo showing hyperdynamic LV with normal EF. Her CHF was thought to be secondary Patient with likely diastolic dysfunction. Cr slowly rising to 2.0. She was started on Lopressor 100 mg TID with good control of HR; in addition, ACE/[Last Name (un) ]/Dig on admission were d/c'd (secondary to Cr bump) and changed to Hydral/Imdur which should be titrated at her NH to goal SBP 120-130. She should increase her home Lasix dose from 20 mg [Hospital1 ] to 40 mg [Hospital1 ] until euvolemic. However, some of her peripheral edema is likely d/t poor nutritional stores given low albumin. Needs monitoring of Chem7 at NH. . C- Asthma: given steroid taper/nebs with excellent results. . # Acute Renal Failure: The patient's acute renal failure was thought to be a combination of diuresis for CHF as well as the initiation of a new blood pressure medication regimen. Cr peaked at 2.0. Renal U/S normal. Resolved with gentle fluids, holding of lasix; [Last Name (un) ]/ACE changed to hydral/imdur. Cr should be followed at rehab. Cr 1.0 on discharge. # CAD s/p MI: Pt with h/o CAD and complaints of chronic chest pain. Tnt bump stable in setting of negative CK-MB. Tnt bump likely from CHF, ARF. Cards saw pt and did not feel pt had ACS. Echo showed evidence of diastolic dysfunction and hyperdynamic LV with normal EF and no areas of hypokinesis or wall motion abnormalities. # Leukocytosis: Thought to be likely secondary to combination of IV steroids and possibly antibiotics. Repeat diff showed mild eosinophilia likely secondary to antibiotics; no rash. Her CBC should be followed at her NH. . # Type I DM: The patient was put on an insulin gtt during her hospitalization for difficult to control blood sugars after IV steroids were initiated for an asthma flare. She was transitioned back to her home insulin regimen (34 units NPH QAM, 14units NPH QPM) as her steroids were tapered and she required less insulin. Because of episodes of am hypoglycemia, NPH was eventually adjusted to 30 qam, 6 qpm. . #Abominal Cystic Stuctures: Renal U/S showed cystic structre abutting the spleen/pancreas; Abd CT showed 7.0 x 6.3 cm lesion located in the retroperitoneal region in the left upper quadrant. It contact[Name (NI) ] the pancreas, tip of the spleen, and kidney, but did not definitely arising from any of them. Additionally, a 1-cm cyst in the body of the pancreas was noted. Per discussion with Sister [Name (NI) 382], the patient would not want any aggressive interventions/procedures (in the event these lesions were cancer) and since the patient was asymptomatic, further imaging and workup were declinded. . #?Mental Status changes: per NH, patient has had longstanding problems with paranoia, and there is concern for underlying dementia. Pt had episode in which she thought cats were in her room; Head CT normal, VSS otherwise stable. No organic cause found. Medications on Admission: Azmacort 10 puff [Hospital1 ] Zestril 10 mg PO BID KCL 20 mEq PO qd Lasxi 20 mg PO BID (extra lasix qod) Flonase 2 puffs qd Chlorphenorimile 4 mg PO q 6 hrs Synthroid 175 mcg po qd Accolate 20 mg PO BID Cozaar 50 mg PO BID Digoxin 125 mcg Po qd Duragesic 25 mcg 1 patch q 72 hours NPH 34 units qAM 14 units qPM SSI Ambien 10 mg PO prn . Discharge Medications: 1. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Isosorbide Dinitrate 30 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): hold for SBP <110. Disp:180 Tablet(s) Refills:2 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): hold for HR <60, SBP <110. Disp:180 Tablet(s) Refills:2 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 inhaler Refills:2 8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:10 Patch 72HR(s) Refills:2 11. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal DAILY (Daily). Disp:1 inhaler Refills:2 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U Injection three times a day: until patient is ambulating. Disp:qs U Refills:2 13. 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 14. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:qs Tablet(s) Refills:0 15. Insulin NPH: 30U qam, 6 U qpm with sliding scale 16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: Continue until euvolemic, then resume outpt dose. Disp:60 Tablet(s) Refills:2 17. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:qs qs Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 40721] Manor Discharge Diagnosis: Primary Diagnoses: - CHF exascerbation - PNA, ?Nursing-home acquired - Asthma exascerbation - Leucocytosis, likely secondary to medication effect - Acute Renal Failure, resolved - Abdominal cystic structure, no further w/u indicated Secondary: - Neuropathic pain - Type I Diabetes - CAD - HTN - Hypothyroidism - Spinal stenosis - Osteoporosis - Osteoarthritis - Macular degeneration - Cataracts - h/o glaucoma Discharge Condition: stable Discharge Instructions: Take all medications as prescribed. Please call your doctor if you experience worsening cough, shortness of breath, chest pain, lower leg swelling, or weight gain. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Followup Instructions: Please followup with your primary care doctor in [1-5] weeks.	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11,920	171,086	48648	Discharge summary	report	Admission Date: [2127-11-21] Discharge Date: [2127-11-26] Service: MEDICINE Allergies: Amiodarone / Codeine / Metoprolol Attending:[Last Name (NamePattern1) 1167] Chief Complaint: nausea Major Surgical or Invasive Procedure: none History of Present Illness: Pt is an 86 year old female with a history of systolic/diastolic congestive heart failure, biV pacer, type 2 daibetes mellitus, Atrial fibrillation who presents with 1 day of nausea, fatigue and chest tightness. The patient was somewhat vague in describing her symptoms. She reports that she was in her USOH until today, for that reason she stayed in bed and did not take any of her medications including her insulin. Additional symptoms include frequent diarrhea, back and shoulder pain (old), dyspnea on exertion (old) and chest tightness (intermittent). She has had no vomiting, dizziness or lightheadedness. She notes that her chest tightness is not typical for having MI, but had previously told ED staff that the chest tightness was consistent with previous MI pain On review of systems, she denied any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery (has had persistent nose bleed), cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. All of the other review of systems were negative. Cardiac review of systems is notable for mild LE edema, absence of chest pain paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope. In the ED, initial vitals were 99.6 70 92/50 19 100% RA. She was given morphine, heparin gtt, and cipro PO. Past Medical History: CAD s/p RCA PCI ([2115]), OM PCI ([2122]), RCA x 3 ([5-19]) iCMP (EF 20% on [7-21] TTE) AFib IDDM CRI b/l Cr 1.3-1.5 Anemia b/l Hct ~29% Breast CA s/p lumpectomy ([2105]) Polymyalgia rheumatica hypothyroidism GERD depression DJD spinal stenosis allergic rhinitis Nosebleeds s/p appy s/p CCY s/p C-section x 2 Social History: Lives alone. Walks with a walker. Retired occupational therapist. Rare ETOH. Daughter (HCP) lives in [Name (NI) 7349]. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: 97.5 95/40 68 18 100% RA Gluc 409 GENERAL: elderly woman in NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 12 cm. CARDIAC: RR, normal S1, S2. Systolic murmur [2-19] at apex, back. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Basilar crackles ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Trace LE edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [2127-11-21] 05:50PM BLOOD Glucose-379* UreaN-43* Creat-2.2* Na-136 K-5.4* Cl-94* HCO3-25 AnGap-22* [2127-11-21] 05:50PM BLOOD WBC-11.1# RBC-2.90 Hgb-9.1* Hct-27.6* MCV-95 MCH-31.3 MCHC-32.8 RDW-13.7 Plt Ct-178 [2127-11-21] 05:50PM BLOOD Neuts-87.0* Lymphs-7.8* Monos-5.0 Eos-0.1 Baso-0.1 CARDIAC ENZYMES: [2127-11-21] 05:50PM BLOOD CK-MB-14* MB Indx-11.8* proBNP-[Numeric Identifier 44604]* [2127-11-21] 05:50PM BLOOD cTropnT-0.28* [2127-11-22] 01:45AM BLOOD CK-MB-20* MB Indx-10.2* cTropnT-0.52* [2127-11-22] 08:00AM BLOOD CK-MB-16* MB Indx-6.7* cTropnT-0.69* [2127-11-22] 05:10PM BLOOD CK-MB-9 cTropnT-0.97* [2127-11-21] 05:50PM BLOOD CK(CPK)-119 [2127-11-22] 01:45AM BLOOD CK(CPK)-196* [2127-11-22] 08:00AM BLOOD CK(CPK)-239* [2127-11-22] 05:10PM BLOOD CK(CPK)-202* MICROBIOLOGY: [Known lastname ],[Known firstname ] V [Medical Record Number 102324] F 86 [2041-7-31] Microbiology Lab Results [2127-11-21] 8:00 pm BLOOD CULTURE #1. Blood Culture, Routine (Preliminary): ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [2127-11-23]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 102325] [2127-11-22] @ 8:07 AM. GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final [2127-11-25]): GRAM NEGATIVE ROD(S). [2127-11-21] 8:35 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 261-6937C [2127-11-21]. Anaerobic Bottle Gram Stain (Final [2127-11-23]): GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final [2127-11-24]): GRAM NEGATIVE ROD(S). [2127-11-24] 4:31 am BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): DISCHARGE LABS: [2127-11-26] 06:40AM BLOOD WBC-6.6 RBC-2.77* Hgb-8.5* Hct-26.2* MCV-94 MCH-30.8 MCHC-32.7 RDW-13.7 Plt Ct-171 [2127-11-26] 06:40AM BLOOD Glucose-379* UreaN-49* Creat-1.2* Na-136 K-4.4 Cl-97 HCO3-27 AnGap-16 CXR [2127-11-21]: CONCLUSION: Stable cardiomegaly with minimal atelectasis at the lung bases. There is no definite focal consolidation. ECG [2127-11-21]: Baseline artifact. Probable etopic atrial rhythm with atrial premature beats and ventricular pacing. Since the previous tracing earlier [2127-11-21] no change. ECHO [2127-11-24]: The left atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis (LVEF = XX %). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. Right ventricular chamber size is normal. with moderate global free wall hypokinesis. 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. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2126-8-13], the left ventricular systolic function is similar and the severities of mitral regurgitation and tricuspid regurgitaiton have worsened. Brief Hospital Course: This is an 86 year old female with who presented w/ acute on chronic systolic congestive heart failure exacerbation and elevated cardiac enzymes in the setting of urosepsis. 1)Gram Negative Rod Bacteremia: Patient had blood and urine cultures positive for pansensitive E.Coli. She initially had borderline low blood pressure in the setting of urosepsis, and was transferred to the CCU given her history of severe systolic and diastolic heart failure. She was started on IV ceftriaxone in the CCU which has since been switched to oral ciprofloxacin. Her vital sings stabilized and she returned to the cardiac [Hospital1 ] service. Patient remains afebrile and leukocytosis has since resolved and patient appears clinically improved. Today is day #6 of antibiotic therapy. She should complete a 14 day course with Ciprofloxacin. Given that patient has had recurrent UTIs with multiple organisms she has an appointment to follow up with urology. 2)Non ST Elevation Myocardial Infarction: Patient had elevated cardiac enzymes in the setting of urosepsis, with peak troponin of 0.97, CK 232, MB 20. CKs have trended down. She was maintained on IV Heparin for 48 hours. We continued her on aggressive medical management with Aspirin, Plavix, and statin. Her metoprolol was held until her blood pressure improved. Patient chest pain free at time of discharge. Patient will be continued on her aspirin, statin and plavix. She should also receive metoprolol as her blood pressure tolerates. 3) Acute on Chroninc Systolic Heart Failure: Patient presented with a BNP of 24,000 and clinical evidence of volume overload. She has history of systolic HF with EF 20%. Her repeat ECHO showed no significant change in left ventricular ejection fraction since previous ECHO, but worsening mitral and tricuspid regurgitation. This acute on chronic episode of heart failure likely related her urosepsis. Patient was diuresed well and is currently back on her outpatient regimen of Lasix 20mg [Hospital1 ]. She should also continue taking metoprolol. A low dose of lisinopril was also added at time of discharge. Both of these medications are important for optimizing her heart failure management. 4)Rhythm: Patient remained in a paced rhythm. She is not anticoagulated for atrial fibrillation due to a remote history of gi bleeding. 5) Acute on Chronic Renal Failure: This was likely secondary to low/poor forward flow in the setting systolic heart failure exacerbation and urosepsis. Patient's creatinine resolved following treatment of her urosepsis and improvement of her heart failure. Cr 1.2 at time of discharge which is within her baseline. 6) Type II Diabetes: Initially poorly controlled in the setting of urosepsis and stress dose steroids, though now improving. NPH has been adjusted to maintain glycemic control. We have restarted patient's standing dose of NPH 18 units Qam and 8 units qPM and Humalog per sliding scale. Further adjustements may be necessary to maintain adequate glycemic control. 7) Polymyalgia Rheumatica: Patient received a short course of stress dose steroids in the setting of hypotension/urosepsis. She has now switched back to home regimen of chronic low dose prednisone. 8) Anemia of chronic disease: Hematocrit remained stable. 9) Neuropathy: Gabapentin dose was decreased to 300 mg [Hospital1 ] from 600 mg [Hospital1 ] when creatinine was increased. Given that creatinine returned to baseline patient was restarted on 600 mg [Hospital1 ] dosing. Patient was DNR/DNI during this admission. Medications on Admission: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. 5. Humulin N 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous QAM. 6. Humulin N 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous QPM. 7. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Prednisone 5 mg Tablet Sig: 0.5-1 Tablet PO as directed: Alternative 1 tablet with 1/2 tablet every other day. . 10. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Humalog 100 unit/mL Solution Sig: One (1) injection Subcutaneous as directed per sliding scale. 15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual three times a day as needed for chest pain: Take up to 3 tablets 5 minutes apart as needed for chest pain and call 911. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days. 14. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 18 units Qam and 8 units qPM Subcutaneous twice a day. 16. Insulin Lispro 100 unit/mL Solution Sig: dose per sliding scale Subcutaneous four times a day. 17. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain. 18. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 19. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 20. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Location ] center at [Location (un) ] Discharge Diagnosis: Primary: Gram negative rod bacteremia, gram negative rod urinary tract infection, chronic systolic heart failure exacerbation, non-ST elevation myocardial infarction, acute on chronic renal failure Secondary: Type II diabetes mellitus, gastroesophageal reflux disease Discharge Condition: good, no chest pain Discharge Instructions: You came to the hospital because you were feeling nauseas and generally fatigued. You were found to have an infection in your blood and in your urine. You were also found to be in heart failure and to have had a heart attack. You were given antibiotics for your infection and we increased your lasix to remove fluid. You improved with these therapies. We have managed your heart attack with medications. You were started on the following New medications: -Ciprofloxacin: this is an antibiotic for your blood and urine infections -Metorprolol- this is a medication for your blood pressure that you have been on in the past. -Lisinopril: this is a medication for your blood pressure If you experience persistent chest pain, shortness of breath, difficulty breathing while lying flat, fevers, chills or night sweats please contact your primary care provider or come to the emergency department for evaluation. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Cardiology: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 62] Date/Time:[2127-12-29] 3:00 Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2127-12-29] 2:30 Primary Care Provider: [First Name11 (Name Pattern1) 2482] [Last Name (NamePattern4) 10466], [MD Number(3) 4974]:[Telephone/Fax (1) 250] Date/Time:[2127-12-19] 1:40 Urology: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4653], MD Phone:[Telephone/Fax (1) 274] Date/Time:[2127-12-1] 4:10 (to discuss your recurrent urinary tract infections) Completed by:[2127-11-26]	[ "530.81", "V45.82", "410.71", "V10.3", "790.7", "V58.67", "414.01", "584.9", "428.43", "250.00", "412", "585.9", "244.9", "599.0", "311", "414.8", "285.9", "724.00", "V45.79", "041.4", "725", "427.31", "403.90" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	13981, 14054	7417, 10963	258, 264	14366, 14388	2977, 2977	15447, 16117	2159, 2241		12325, 13958		14075, 14345		10989, 12302			14412, 15424		5544, 7394						2256, 2958					5132, 5491					5527, 5527										3315, 4020		212, 220											292, 1649						2993, 3297											1671, 2002	2018, 2143
24,580	194,645	49515	Discharge summary	report	Admission Date: [2180-8-29] Discharge Date: [2180-9-5] Date of Birth: [2126-3-6] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5644] Chief Complaint: Biliary Sepsis Major Surgical or Invasive Procedure: ERCP and biliary stent placement X 2 History of Present Illness: Pt is a 54 year old male with a hx of metastatic CRC dx'd [6-1] s/p chemo/XRT/surgery [11-1], presenting s/p recent ERCT and stent placement at [Hospital1 756] [2180-8-22] for obstructive jaundice and sepsis [1-31] ascending cholangitis. Pt initially underwent neo-adjuvant chemo and radiation therapy, had colectomy with Hartmann's pouch, then recieved adjuvant chemotherapy. Presented to [Hospital3 4107] [8-29] with fever, chills, and jaundice, started on unasyn emperically for re-obstruction. BP's down to 80's/60's, transiently requiring dopamine gtt. Transferred to [Hospital1 18] for emergent ERCP. Upon [Hospital1 18] arrival, WBC 25.6, HCO3 16, Cr 2.5 Tb 17.8, alb 1.7, admitted to the [Hospital Unit Name 153] and continued on Zosyn. Pt growing [4-2] E.coli (pan-sensitive) at [Hospital3 4107]. Past Medical History: 1. [Hospital3 ] Cancer: as per HPI 2. Basal Cell Skin Cancer: Benign. Present since pt in his 20's. Over 100 resections. Social History: Married, retired lawyer. Quit [Name2 (NI) ] 15 years ago, with 30 years at 1 PPD prior. Prior heavy alchol use, roughly 10 beers/day. Family History: Father with [Name2 (NI) 499] cancer, died at 64. No CAD/CVA. Physical Exam: PE: 98.7 130/70 86 18 97 % RA 0 pain Gen: NAD, cooperative, friendly [Name2 (NI) 1229] [Name (NI) ]: + scleral icterus, EOMI, PEERL, Dry lips, dentures in place Neck: 5-7 cm JVP, no LAD Heart: RRR, no mrg. PMI non-displaced. Lungs: Distant. CTAB, no wheezes or rales. Abd: Distended. Non-tender. +fluid wave. Liver palpable to 3 fingerbreadths beneath RCM. - [Known lastname 515] or RUQ tenderness. Ext: 2+ bilateral pedal edema to knees. Skin: Prominent jaundice. Numerous basal cell carcinomas over trunk and legs. Neuro: Non-focal. No asterexis. Pertinent Results: [2180-9-5] 08:45AM BLOOD WBC-15.1* RBC-2.96* Hgb-9.5* Hct-28.6* MCV-97 MCH-32.1* MCHC-33.2 RDW-16.4* Plt Ct-298 [2180-9-5] 08:45AM BLOOD Neuts-79* Bands-3 Lymphs-2* Monos-6 Eos-4 Baso-1 Atyps-0 Metas-1* Myelos-4* [2180-9-5] 08:45AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [2180-9-5] 08:45AM BLOOD Plt Ct-298 [2180-9-5] 08:45AM BLOOD Glucose-78 UreaN-35* Creat-1.6* Na-135 K-4.8 Cl-105 HCO3-19* AnGap-16 [2180-9-5] 08:45AM BLOOD ALT-152* AST-173* LD(LDH)-387* AlkPhos-425* TotBili-10.6* [2180-9-5] 08:45AM BLOOD Albumin-2.7* Calcium-8.0* Phos-3.9 Mg-2.0 Brief Hospital Course: While on the floor (after [Hospital Unit Name 153]) 1. Biliary Sepsis: CT belly showed mulitple liver mets, slight obstruction of biliary stent and multiple mets at porta hepatis, peritoneal carcinamatosis and duodenal compression. ERCP done morning of [2180-8-30], which showed re-obstruction [1-31] tumor compression, in addition to previous stent displacement into the right collection system. 2 stents were placed and large amount of pus was drained during the procedure. Pt afebrile while on the floor. His WBC count decreased from 23.1 to 15.1 on discharge. His biliruben continued to decrease to 10.6 on discharge, and with the pneumobilia seen on CT [9-4], strongly suggests the new stents are patent. His surveilence blood cx's from [9-3] were negative as were C.diff X 3. The pt has remained hemodynamically stable, with SBP's in the 120's-130's. Pt was treated with IV levofloxacin, until [8-3], when he was switched to IV Zosyn, for fear of possible ongoing infection (increasing Cr 1.7 and increased LDH to the 400's). However, the pt was switched to PO levofloxacin and flagyll proir to discharge. Pt to follow up in [Hospital ] clinic here at [Hospital1 18] Tuesday, [9-12] at 1:pm with Dr.[Last Name (STitle) 3815] [Telephone/Fax (1) 8892]. 2. ARF: Likely pre-renal [1-31] decreased effective arterial volume in the face of sepsis. Pt now tolerating PO very well, and has been encouraged to drink plenty of fluids as an outpt (no cardiac hx). Cr 1.6 on discharge. 3. [Month/Day (2) ] Cancer: Extensive disease including peritoneal carcinamotosis. Stable and could be the source of his high LDH. Repeat CT of the belly [9-3] revealed pneumobilia, "stable" peritoneal carcinamotosis (unchanged from previous study), no evidence of biliary or bowel obstruction. Pt's cough may be related to pulmonary metastatic disease, and his liver mets are likely contributing to his elevated LFT's. Pt to schedule f/u with his primary oncologist Dr.[Last Name (STitle) 7820] at [Hospital3 328]. 4. FEN: Pt tolerating good PO, no nausea or vomiting. He appears adequately hydrated and was advised to keep himself hydrated by drinking plenty of fluids. Discharge Medications: 1. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Biliary Sepsis Discharge Condition: Good Discharge Instructions: If you feel any abdominal pain, nausea and vomiting, inability to tolerate food or liquid, fever > 100.4, shaking chills, or bloody diarrhea, please call your doctor or come to the ER. Followup Instructions: 1. Dr.[Last Name (STitle) 3815] at [Hospital 18] [Hospital ] clinic, [2180-9-12] at 1pm at [Location (un) 8661] building, [Location (un) 436], [Telephone/Fax (1) 8892]. Please call clinic tomorrow to finalize. 2. Please call Dr[Last Name (STitle) 103586] office to schedule an appointment as soon as possible. Completed by:[2180-9-5]	[ "197.7", "995.92", "584.9", "038.42", "576.1", "576.2", "197.6", "V10.05" ]	icd9cm	[ [ [] ] ]	[ "51.87" ]	icd9pcs	[ [ [] ] ]	5328, 5334	2930, 5175	323, 361	5393, 5399	2278, 2907	5632, 6007	1575, 1642		5198, 5305		5355, 5372					5423, 5609								1657, 2259																						269, 285											389, 1249																	1271, 1402	1418, 1559
12,157	182,611	5433	Discharge summary	report	Admission Date: [2126-4-2] Discharge Date: [2126-4-22] Date of Birth: [2056-3-18] Sex: F Service: CARDIOTHORACIC Allergies: Epinephrine / Captopril / Novocain / Gentamicin / Dilaudid / Flexeril / Ace Inhibitors / Morphine Sulfate / Percocet Attending:[First Name3 (LF) 922] Chief Complaint: increasing shortness of breath Major Surgical or Invasive Procedure: MVR/TVRepair History of Present Illness: Pt. is a 70 y/o F with insulin dependent DM, h/o IMI '[17] s/p PTCA and stent, pernicious anemia, MVR (porcine valve) in [2119], recently disagnosed pulmonary HTN, who presented to the ED today with bilateral LE pain and swelling and DOE. Pt. reports she has diffuse pain in both legs from her feet to her hips, which has been present x 1 year, getting worse recently. Also reports DOE that is worse when she bends over and exerts herself, which has gotten worse in the last month, although son reports some improvement in symptoms with Viagra, which was started several weeks ago after she was diagnosed with pulm. HTN. . Per our records pt had a R tibial plateau fracture 1 year ago, c/b erosion of lateral condyle by hardwear s/p hardware removal by Dr. [Last Name (STitle) 22020] in [1-14], and s/p several episodes of "knee infection" per pt. Pt. denies pain centered around knee at present. Pt. reports she was recently admitted at [Hospital 622] Medical Center for similar complaints. Per conversation with pt's son it seems she had a R heart catheterization there and was diagnosed with pulmonary HTN, and a pleural effusion was tapped. There was some concern for PE per pt's son, he thinks that this was eventually ruled out but is not sure how. . In [Name (NI) ], pt was found to be 88%RA, 94% 4L NC with CXR with bilateral pleural effusions and pulm vasc redistribution consistent with CHF. Was given Lasix 40 mg IV x 1, morphine 2 mg IV x 2, Ativan 1 mg IV x 2, ASA 81 mg PO x 1, and Kayexylate 30 mg PO x 1 at 2 am for K of 6.0. . K on recheck was 5.8, had not stooled -> given 30 mg more Kayexelate, Ca gluconate. Past Medical History: 1) Insulin dependent DM x 39 yrs, last hemoglobin A1C here in [2123] of 8 2) H/o silent IMI [2117] dxed by EKG and echo s/p cath at [Hospital1 18] with subtotal occlusion of distal L cx s/p PTCA and Crown Stent 3) MVR (porcine valve) in [2119] 4) Pernicious anemia on Vitamin B12 replacement 5) h/o R ORIF of right lat tibial plateau fracture in [2-10] with h/o cellulitis of R knee and prox tibia requiring septic separation of incision [7-13] 6) h/o multiple surgeries including amputation of 2 toes on R foot (for complications of bunion surgery) 7) Pulmonary hypertension 8) ?removal of R knee hardware [1-14] -> no d/c summary available 9) Chronic kidney disease with baseline creat 1.3-1.5 10) Last echo [9-/2118] with EF 50%, akinesis of inf post wall and basal inf septum, trace AR, mod to severe MR, tricuspid valve thickening with tricuspid valve prolapse, mod pulm HTN Looking through [Last Name (un) ] notes, pt's family called Dr. [Last Name (STitle) 14116] at [Last Name (un) ] and left message that pt was hospitalized in [State 622] for ?clot in lung but this could not be verified with pt given mental status PCP = [Last Name (NamePattern4) ]. [Last Name (STitle) 22021] in [Name (NI) 22022] [Name (NI) 622] Pt sees Dr. [First Name (STitle) 3636] at [Last Name (un) ] Social History: lives in [Last Name (un) 22022] [State 622], independent at home. Denies tob, EtOH or IVDA Family History: noncontributory Physical Exam: Admission VS: T 95.9 140/66 78 24 93% on 2L 72 kg Gen: still somewhat lethargic, required some redirection but woke up during exam. HEENT: PERRL, EOMI, OP clear with MMM Neck: JVP 10 cm, supple, NT, no LAD Chest: +bibasilar crackles, no wheezes CV: RRR, +[2-11] blowing systolic murmur Abd: s/nt/nd +BS Ext: 3+ pitting edema bilateral lower extremities with venous stasis dermatitis and erythema; +black eschar on R tibial plateau; +skin breakdown medially on bilateral tibia, no frank ulceration or purulence, warm, +peripheral pulses Discharge: VS T97.3 BP 125/48 HR 78SR RR 20 Sat 93%2L Gen: Alert/responsive Neuro: A&Ox3, non focal Resp: CTA CV: RRR, sternum stable, incision CDI Abdm Soft, NT/ND/NABS Ext: warm, bilat LE cellulitis Pertinent Results: Admission Labs: [2126-4-2] 12:48AM PT-17.6* PTT-28.6 INR(PT)-1.6* [2126-4-2] 12:48AM PLT COUNT-420 [2126-4-2] 12:48AM HYPOCHROM-3+ ANISOCYT-2+ MACROCYT-2+ [2126-4-2] 12:48AM NEUTS-79.4* LYMPHS-9.1* MONOS-5.1 EOS-4.9* BASOS-1.6 [2126-4-2] 12:48AM WBC-7.1 RBC-3.71* HGB-11.1* HCT-36.2 MCV-98 MCH-29.9 MCHC-30.6* RDW-18.7* [2126-4-2] 12:48AM CK-MB-NotDone cTropnT-0.07* [2126-4-2] 12:48AM CK(CPK)-58 [2126-4-2] 12:48AM GLUCOSE-146* UREA N-85* CREAT-2.3* SODIUM-142 POTASSIUM-6.1* CHLORIDE-112* TOTAL CO2-17* ANION GAP-19 [2126-4-2] 02:45AM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [2126-4-2] 02:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2126-4-2] 02:45AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.013 [2126-4-2] 02:45AM URINE HOURS-RANDOM CREAT-55 SODIUM-56 [2126-4-2] 10:10AM FREE T4-1.1 [2126-4-2] 10:10AM TSH-24* [2126-4-2] 10:10AM OSMOLAL-321* [2126-4-2] 10:10AM ALBUMIN-3.7 CALCIUM-8.7 PHOSPHATE-4.4 MAGNESIUM-1.7 . TTE: Left Atrium - Long Axis Dimension: 3.8 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.7 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 5.2 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 0.8 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.2 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%) Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm) Aorta - Ascending: 2.7 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec) Mitral Valve - Peak Velocity: 2.6 m/sec Mitral Valve - Mean Gradient: 8 mm Hg Mitral Valve - E Wave: 1.7 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A Ratio: 2.13 Mitral Valve - E Wave Deceleration Time: 206 msec TR Gradient (+ RA = PASP): 76 mm Hg (nl <= 25 mm Hg) . LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild regional LV systolic dysfunction. No resting LVOT gradient. No LV mass/thrombus. RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic function. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. There are complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild to moderate ([12-10]+) AR. MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). Thickened MVR leaflets.. Increased MVR gradient. Moderate to severe (3+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate to severe [3+] TR. Severe PA systolic hypertension. PERICARDIUM: Small pericardial effusion. . Conclusions: The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction. No masses or thrombi are seen in the left ventricle. The right ventricular cavity is mildly dilated. Right ventricular systolic function is borderline normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild to moderate ([12-10]+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The prosthetic mitral valve leaflets are thickened. The gradients are higher than expected for this type of prosthesis. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a small pericardial effusion. . IMPRESSION: Preserved LVEF (effective forward LVEF may be depressed given the severity of valvular regurgitation). Degenerated mitral valve prosthesis with moderate to severe valvular regurgitation (cannot exclude paravalvular component). Moderate to severe tricuspid regurgitation. Severe pulmonary hypertension. . Bilateral LE U/S neg for DVT . CXR: Bilateral pleural effusions, mod on L, small on R; +pulm vasc redistribution with mild perihilar prominence c/w CHF . EKG: NSR at 86 bpm, LAD, nl intervals, poor R wave progression, no ST changes Brief Hospital Course: A/P: 70 y/o F with DM, CAD s/p silent IMI '[17], MR s/p porcine MVR in [2116], recently diagnosed with pulmonary HTN at OHS, anemia who presents with worsening bilateral LE swelling and pain and worsening DOE x 1 yr with CXR and exam concerning for CHF. . # Bilateral LE swelling/dyspnea on exertion: Initial DDx included new cardiac ischemia given hx of MI, worsening pulmonary HTN, worsening valve function and heart failure, and PE. Pt. was initially continued on Viagra 50 mg TID and Coumadin 3 mg QD for treatment of pulmonary HTN, and it was thought that this could be contributing to DOE. However, once records of OSH course were obtained and R heart cath that was performed there was reviewed it seemed that pt. actually had elevated R heart pressures and elevated wedge pressures secondary to MR [First Name (Titles) ] [Last Name (Titles) ] and L heart failure, and was not c/w primary pulmonary a. HTN. A VQ scan performed at OSH was indeterminant for PE. Viagra and Coumadin were therefore d/ced and Cardiology was consulted. A TTE showed severe pulm htn, EF 50-55%, 3+ MR, 3+ TR (see results above). Bilateral LENIs were negative for DVT. Pt. was ruled out for MI with cardiac enzymes x 3, and monitored on tele with no events except for one episode of NSVT. Pt. was diuresed with Lasix 40 mg IV BID from [Date range (1) 22023] with [Telephone/Fax (1) 22024] negative QD. This improved pt's symptoms. Cardiology reviewed TTE and felt that symptoms were [1-10] worsening MR [First Name (Titles) ] [Last Name (Titles) ], and recommended MVR and TVR. A Cardiac Catheterization was performed on [2126-4-8] to eval for new coronary lesions prior to MVR and TVR and showed minimal coronary disease. .Pt had tooth extraction by dental service prior to Cardiac surgery. -On [4-16] pt brought to OR for MVR/TVR please see OR report for details in summary Pt had MVR #29 CE Perimount pericardial valve and TVRepair #34 [Doctor Last Name ] Tricuspid annuloplasty band. She tolerated surgery well and was transferred to CT/ICU on Epinephrine and Propofol gtts.Additionally she had nitric inhalation. She did well in immediate postop period, was quickly weaned from Nictric inhalation and Epi gtt on day of surgery, and on POD1 successfully extubated. On POD2 her chest tubes were removed, then on POD3 here pacing wires were removed and she was transferred to the floor for continued postop care. She had an uneventful postop course once on the floors and on POD 6 it was decided she was ready fro discharge to rehabilitation. . # R knee fracture Ortho consult re: R knee-> R knee and tib/fib films with no new changes -> they recommend OP f/u with Dr. [Last Name (STitle) 22025] re: knee replacement, no acute intervention necessary, no evidence of infection in knee . # Acute on chronic kidney disease: Thought to be [1-10] diuresis here and at OSH, creatinine worsened from 1.5 to 2.3 prior to surgery, now back down to 1.8. Tolerating PO Lasix. . # DM: pt is followed at [Last Name (un) ], Lantus titrated up currently 15 units QD, continued sliding scale insulin. . # Anemia: secondary to vitamin B12 deficiency, Hct at baseline. Pt receives bimonthly vitamin B12 shots at PCP's office. . # Communication: Son, [Name (NI) ] [Telephone/Fax (1) 22026] (cell) Medications on Admission: and are not complete): 1) Coumadin 3 mg PO QHS- for presummed PE("blood clot in lung") 2) Vitamin B12 1000 mcg injections 2 x/wk 3) Vicodin 5/500 mg PO q4-6hr prn 4) Viagra 50 mg TID for pulm HTN (listed on d/c paperwork from OSH) 5) Xanax 0.25 mg prn 6) Lantus -->?6 vs 8 units qpm, HISS 7) ASA 325 mg PO daily 8)Lasix -->pt states that she is on this medication but does not know dose 9) Procrit injections on thursday Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. 8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. 9. Terbinafine 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 10. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 2 weeks. 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 15. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection four times a day. 16. glargine Sig: Fifteen (15) units QPM. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: s/p redo MVR(#29 pericardial)TVRepair(#34 annuloplasty band) PMH: CAD,MVR,IDDM,toe amp,anemia,CRI,PHTN,ORIF rt knee w/staph cellulitis Discharge Condition: good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds Followup Instructions: Dr [Last Name (STitle) 914] in 4 wks. Please call for appt ([Telephone/Fax (1) 22027] Dr [First Name (STitle) 4135] orthopedics in 2 weeks. Please call for appt ([Telephone/Fax (1) 5238]. [Hospital ] Clinic for opthalmic/diabetic care, duaghter to call to change scheduled appts Completed by:[2126-4-22*]	[ "521.00", "V58.67", "250.00", "996.02", "996.72", "110.4", "397.0", "416.8", "584.9", "428.0", "707.12", "V49.72", "585.9", "707.09", "244.9", "459.81", "281.0", "412", "V58.61", "719.46" ]	icd9cm	[ [ [] ] ]	[ "00.12", "39.61", "89.64", "88.56", "23.09", "35.14", "88.72", "35.23", "37.23" ]	icd9pcs	[ [ [] ] ]	13977, 14050	8784, 12128	412, 426	14229, 14236	4427, 4427	14437, 14767	3629, 3646		12600, 13954		14071, 14208		12154, 12577			14260, 14414								3661, 4408																						342, 374											454, 2114						4444, 8761											2136, 3496	3512, 3613
22,492	175,769	14766	Discharge summary	report	Admission Date: [2200-7-8] Discharge Date: [2200-7-17] Date of Birth: [2123-12-15] Sex: M Service: CARDIOTHORACIC SURGERY Date of Operation: [2200-7-10] CHIEF COMPLAINT: Dyspnea on exertion HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 76-year-old man with several months of progressive dyspnea on exertion. He has become short of breath given walking around his house. He has never experienced any chest pain in the past. Stress echocardiogram performed on [2200-6-17] revealed shortness of breath and PVCs. There was an extension of an inferior posterolateral defect with exercise. Ejection fraction was 30%. Mr. [Known lastname ] was subsequently evaluated with cardiac catheterization. Cardiac catheterization revealed a completely occluded RCA, tight LAD and diagonal, and 90% stenosed circumflex. Mr. [Known lastname ] was subsequently evaluated for cardiac surgery. PAST MEDICAL HISTORY: 1. Past IMI 2. Congestive heart failure 3. SFS status post pacemaker [December 2199] 4. Diabetes mellitus with retinopathy 5. PAF 6. CRI 7. Chronic lower extremity edema 8. Previous history of anemia 9. Hypertension 10. Hyperlipidemia PAST SURGICAL HISTORY: 1. Hydrocele surgery in [2159] 2. Remote head injury/broken arm 3. Right foot surgery MEDICATIONS: 1. Aspirin 81 mg qd 2. Atenolol 25 mg qd 3. Prinivil 5 mg qd 4. Furosemide 40 mg [Hospital1 ] 5. Chlor-Con 10 milliequivalents qd 6. Minitran 7. Nitroglycerin patch 0.1 mg per hour during the day 8. Cod liver oil 9. Vitamins 10. Colace 11. 70/30 insulin 35 units q a.m., 36 units at 4 p.m., 25 to 35 units q hs 12. Humalog sliding scale before meals ALLERGIES: UNASYN CAUSES FACIAL SWELLING. SOCIAL HISTORY: The patient lives alone. PHYSICAL EXAM: GENERAL: Mr. [Known lastname ] is a pleasant gentleman in no apparent distress. HEAD, EARS, EYES, NOSE AND THROAT: Head is normocephalic, atraumatic. NECK: Supple with no carotid bruits. CHEST: Lungs are clear to auscultation bilaterally. HEART: Regular rate and rhythm, no murmurs, rubs or gallops. ABDOMEN: Obese, but soft, nontender, nondistended with normoactive bowel sounds. EXTREMITIES: Normal pulses and are remarkable for 1+ edema. HOSPITAL COURSE: Mr. [Known lastname ] was admitted on [2200-7-8] and evaluated for cardiac catheterization. Following the catheterization, Mr. [Known lastname ] was subsequently taken back to the Operating Room on [2200-7-10] for coronary artery bypass graft x4. Grafts included left internal mammary artery to LAD, saphenous vein graft to D1, saphenous vein graft to OM1, saphenous vein graft to PDA. Mr. [Known lastname ] was then transferred to the Cardiac Surgical Intensive Care Unit where he was weaned off drips, extubated and hemodynamically stabilized. He was transfused 2 units of packed red blood cells on postoperative day #3 following a hematocrit of 23.4. Mr. [Known lastname ] [Last Name (Titles) ] improved and was subsequently transferred to the floor on postoperative day #5. Mr. [Known lastname 43437] stay on the floor was remarkable for some dysuria and a positive urinalysis. He is being treated with oral ciprofloxacin. He also developed slight clear drainage from the inferior portion of his incision which has been dressed and changed several times daily. Otherwise, Mr. [Known lastname ] continued to progress well. He was tolerating oral diet and his pain was controlled with oral medications. His ambulation gradually improved with physical therapy assistance. On postoperative day #7, Mr. [Known lastname ] was felt stable for transfer to rehabilitation facility for further improvement of his ambulation. DISCHARGE PHYSICAL EXAM: HEAD, EARS, EYES, NOSE AND THROAT: The patient was normocephalic, atraumatic. NECK: Supple. HEART: Regular in rate and rhythm. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. EXTREMITIES: 1+ edema bilaterally. His incision was draining slightly from inferior [1-2]. DISCHARGE MEDICATIONS: 1. Metoprolol 25 mg [Hospital1 ] 2. Docusate 100 mg [Hospital1 ] 3. Aspirin 325 mg qd 4. Captopril 6.25 mg tid 5. Ciprofloxacin 500 mg [Hospital1 ] x5 days 6. Dilaudid 2 to 4 mg q 4 to 6 mg prn for pain 7. Lasix 40 mg [Hospital1 ] 8. KCL 40 milliequivalents [Hospital1 ] 9. Insulin 70/30 35 units q a.m., 36 units q p.m., 25 to 35 q hs 10. Regular insulin sliding scale for glucoses measured every six hours. For glucoses 0 to 150 give 0 units, 151 to 200 give 3 units, 201 to 250 give 6 units, 251 to 300 give 9 units, 301 to 350 give 12 units, greater than 350 give 15 units. Give juice if glucose is less than 60. FOLLOW UP: Mr. [Known lastname ] should follow up with Dr. [Last Name (STitle) 1537] in four weeks. He should also follow up with Dr. [Last Name (STitle) ] in three to four weeks. DISCHARGE CONDITION: Stable DISCHARGE STATUS: Mr. [Known lastname ] is to be discharged to a rehabilitation facility. DISCHARGE DIAGNOSIS: Status post coronary artery bypass graft x4 [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Doctor First Name 24423] MEDQUIST36 D: [2200-7-16] 22:47 T: [2200-7-17] 06:59 JOB#: [Job Number 43438]	[ "414.01", "362.01", "428.0", "427.31", "V45.01", "411.1", "250.51", "599.0", "429.9" ]	icd9cm	[ [ [] ] ]	[ "38.91", "36.13", "96.04", "88.56", "96.71", "39.61", "37.22", "36.15" ]	icd9pcs	[ [ [] ] ]				5009, 5113					4143, 4792		5135, 5456			2286, 3757								1242, 1757		1815, 2268								4804, 4987														210, 231											260, 948																	970, 1219	1774, 1800			3782, 4120
22,297	142,483	45379	Discharge summary	report	Admission Date: [2123-11-27] Discharge Date: [2123-12-10] Service: MEDICINE Allergies: Penicillins / Levofloxacin Attending:[First Name3 (LF) 783] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: This is a 89 yo female smoker w/ pmhx of COPD with last FEV1 1.1 in [2120], CAD, CHF with EF 55%, PVD, HTN who is being transferred from MICU after becoming hypoxic while on the floor. The patient was originally admitted on [2123-11-27] for COPD flare-like PNA and treated with nebs, prednisone, and azithromycin. She became acutely hypoxic w/ sats down to 80's, resolved with NRB, and complained of chest pain as well. The patient was ruled out for an MI by EKG and cardiac enzymes, pain resolved w/ nitro. The patient did not require intubation, was managed on BIPAP and weaned down to nasal cannula. The patient does not use O2 at home. The patient was also treated w/ IV steroids and ceftriaxone for infiltrate on L base seen on repeat CXR. The patient then developed a-fib with RVR, was rate controlled with diltiazem and started on coumadin for anticoagulation. The patient currently denies any shortness of breath or dyspnea, no chest pain, no cough (per pt). The patient denies lightheadedness or palpitations. She has been feeling nauseous, with only one small bowel movement since admission. The patient denies any weakness, numbness, or vision changes. Denies a history of illness or weight loss prior to admission. Typically uses her nebulizers at home every four hours. Past Medical History: 1. COPD - [11-5] FEV1 1.01 (not on home O2) last exaserbation [7-8]) 2. CAD s/p MI 3. CHF - [11-5] echo LVH, mod AR, mild MR, EF> 55%, pulm htn 4. PVD 5. CVA and carotid disease 6. HTN 7. neuropathy 8. hyperlipidemia 9. osteopenia 10. hyperglycemia with HgA1C 6.9 in [3-8] 11. vit B12 deficiency 12. gait disorder 13. spinal stenosis -s/p surgery [2115] Social History: Lives at home with son. [Name (NI) ] 10 children. Smokes half ppd, in past smoked more (total 40 yrs). Occ EtOH. No other drugs. Family History: Noncontributory Physical Exam: VS: Temp: BP:98.4 142-160/60-72 HR:104-->73 RR:24 0% O2sat general: pleasant, comfortable, elderly, NAD, "I want to leave". Able to speak full sentenses. HEENT: PERLLA, EOMI, anicteric, no sinus tenderness, MMdry, op without lesions, dry/prominently red tongue, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits lungs: CTA b/l with poor air movement throughout heart: RR, S1 and S2 wnl, [1-10] hsm at rusb (documented in prior exams) abdomen: non-distended, soft, +b/s, nt, no masses extremities: no cyanosis, +clubbing, no peripheral edema neuro: AAOx3. Cn II-XII intact. [4-7] in both R/L UE/LE. did not assess gait. no Pronator Drift. Pertinent Results: Pertinent results: PFTs: [11-5] decreased DLCO, increased FEV1/FVC ratio (greater than 1), however decreased from previous studies. Findings consistent with airflow obstruction w/ gas trapping. . ECHO: [10-8]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic stenosis. Mild to moderate ([12-6]+) aortic regurgitation is seen. Mild to moderate ([12-6]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. . Baseline creatinine: 1.0-1.2 . Colonoscopy [6-4] Polyp at 10 cm in the rectum (polypectomy) The colon was coated with green stool and it was difficult to distinguish whether there were other polyps or masses. Biopsy result: adenoma IN ED: 137 102 21 201 4.7 26 1.3 . ....13.8 83 12.5>---<261 ....40.7 N:63 Band:0 L:28 M:5 E:4 Bas:0 Brief Hospital Course: A/P: 89 year old female with longstanding smoking history with multiple medical problems, admitted for dyspnea/COPD exacerbation likely due to pneumonia, transferred to MICU for acute hypoxia possibly secondary to mucous plug, now stable on O2 by nasal cannula but developed new onset atrial fibrillation, which is rate-controlled. . 1. COPD exacerbation, likely secondary to infection, appears to have RUL PNA and LLL PNA with effusion (multifocal). - atrovent nebs to q6 with prn dosing - albuterol nebs q4 prn -> watch HR with albuterol - PNA - finished 14 day course of Ceftriaxone and Azithromycin on [2122-12-10] -> should get f/u CXR in few weeks - wean off nasal cannula as tolerated (patient did not use at home) - currently on prednisone taper: 40mg x 3days (last day [2123-12-11]), then 20 mg x 4 days, then off - consider repeat PFTs as outpatient, last set 2 years ago - encourage continued smoking cessation - f/u pending blood cultures, urine cultures - leukocytosis likely secondary to steroids, continue to monitor -> c.diff sent, should be followed up as well as blood and urine cultures . 2. Cardiovascular: a. Coronary- h/o ischemia/CAD, s/p MI -has been ruled out for MI by enzymes and EKG -continue aspirin, statin, started on beta-blocker. The beta blocker may exacerbate her COPD, however, the BB provides a mortality benefit s/p MI, patient tolerating 25mg [Hospital1 ], and on lisinopril 5 mg qd. (cardiac remodeling benefit with the ACEI, renoprotective) b. Pump- h/o CHF, last echo in [10-8] w/ normal EF but signs of diastolic dysfunction (decreased E:A ration, LVH, LAE) - monitor Is/Os - metoprolol 25 mg po bid, hold parameters - lisinopril 5 mg qd c. Rhythm- new onset atrial fibrillation, but currently in sinus rhythm. - continue rate control with diltiazem and metoprolol - monitor on telemetry - AC with warfarin, monitor INR for goal [1-7] - check [Month/Day (3) ] daily . 4. GI- constipation, patient with one large BM today - patient on standing bowel regimen, use lactulose TID prn for severe constipation. - consider enema/disimpaction if patient has not moved bowels - KUB done X2 without dilated loops or free air, nonimpressive for bowel obstruction. . 5. CRI- creatinine appears to be at/ near baseline (of 1.0-1.2). continue to monitor -start ACEI (as above under Cardiovascular)- Cr stable with ACEI -follow I/O . 6. Anemia: DDX likely includes anemia of chronic disease, anemia of CRI, elderly pt. Could also have component of GI bleed given chronic constipation requiring disimpaction. -guiaic stools - negative -anemia labs ordered, ferritin, TRF, Fe, folate and B12: anemia labs suggestive of ACD -h/o polyp in colon [6-4] on colonoscopy, bx results: adenoma -will likely need f/u colonscopy as outpatient if guiaic positive. . 7. FEN- no IVF for now, monitor and replace lytes, cardiac diet as tolerated . 8. Proph- coumadin, PPI, bowel regimen . 9. Dispo- to rehab . 9. Code status-from notes, FULL CODE. Medications on Admission: amlodipine 5mg, aspirin 325, calcium carbonate, folate, lopressor 25 [Hospital1 ],lipitor 10 Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 10. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours). 11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed. 12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 14. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): HOLD FOR [2122-12-10] AND HAVE INR CHECKED ON [2123-12-11], AND DOSE IF INR IS LESS THAN 3, OTHERWISE HOLD UNTIL INR IS LESS THAN 3. PLEASE CHECK [Name (NI) ] (PT/PTT/INR) DAILY. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 19. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 21. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q2H (every 2 hours) as needed for cough. 22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 23. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 24. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 25. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 26. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO ONCE for 1 days: Take tomorrow AM, then start at 20 mg daily. 27. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 4 days: Start on [2122-12-12] after taking 40 mg on [2122-12-11]...take 20 mg daily for four days and then stop prednisone. 28. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight (8) units Subcutaneous qAM. 29. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight (8) units Subcutaneous at bedtime. 30. Insulin Regular Human 100 unit/mL Solution Sig: ASDIR units Injection ASDIR: Insulin Sliding Scale: Check FS QACHS, and then: FS<60: give juice/crackers vs. 1 amp of D50; FS 151-200: 2 units; FS 201-250: 4 units; FS 251-300: 6 units; FS 301-350: 8 units; FS 351-400: 10 units; FS>400, page M.D. +. 31. Potassium & Sodium Phosphates [Telephone/Fax (3) 4228] mg Packet Sig: One (1) Packet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Primary - COPD exaserbation, Pneumonia Secondary - CRI (baseline Cr 1.1-1.3), Atrial fibrillation, Anemia of chronic disease, CAD, HTN, CHF Discharge Condition: Stable on 2L of oxygen Discharge Instructions: -please continue with all medications as prescribed -please see your PCP within one week after discharge from rehab facility -if you have symptoms of fevers, chills, sweats, shortness of breath, chest pain, abdominal pain, n/v, or any other concerning symptoms, please seek medical attention -please hold coumadin dose tonight as INR is 4.9 -> recheck in AM and dose once INR is less than 3 (check daily) Followup Instructions: Provider: [First Name11 (Name Pattern1) 3210] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2124-1-4] 8:50 [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] Completed by:[2123-12-10]	[ "486", "428.30", "427.31", "599.7", "428.0", "285.9", "276.1", "401.9", "585.9", "491.21", "250.02" ]	icd9cm	[ [ [] ] ]	[ "96.6" ]	icd9pcs	[ [ [] ] ]	10427, 10492	3935, 6928	255, 261	10677, 10702	2894, 3912	11155, 11498	2150, 2167		7075, 10404		10513, 10656		6954, 7052			10726, 11132								2182, 2856																						196, 217											289, 1585																	1607, 1982	1998, 2134
6,262	143,549	2021	Discharge summary	report	Admission Date: [2156-6-25] Discharge Date: [2156-7-12] Date of Birth: [2108-11-3] Sex: M Service: MEDICINE Allergies: Bactrim / Aspirin Attending:[First Name3 (LF) 3624] Chief Complaint: Laryngeal edema, shortness of breath, and upper body swelling. Major Surgical or Invasive Procedure: balloon angioplasty of subclavian stent flexible sigmoidoscopy exam under anesthesia and hemorrhoidectomy History of Present Illness: Mr. [Known lastname 10133] is a 47 yo M with HIV, well-controlled, s/p kidney transplant [2156-5-21], who was admitted on [2156-6-18] for proteinuria and biopsy + FSGS, discharged [6-24] and readmitted on [6-26] for laryngeal edema and upper body swelling. . HPI: Briefly, Mr. [Known lastname 10133] received a deceased donor kidney transplant on [2156-5-23]. His biopsy on [5-28] was positive for acute rejection and he received steroids and ATG and was discharged on [6-4]. Lab work and biopsy on [6-17] + for proteinuria and FSGS. Pt. was admitted on [6-18] and received plasmapheresis on [7-17], and [6-23]. Pt. is being followed by nephrology transplant and ID to work-up cause of FSGS. He was discharged to home and returned to the ED on [6-26] complaining of facial swelling. In the ED Laryngoscope by ENT found laryngeal edema, admitted to MICU for close monitoring in case of need for intubation. Patient improved with steroids and antibiotic therapy with clinda and never required intubation. Given left arm swelling there was concern about SVC syndrome so patient started on heparin gtt prior to CT venogram. Heparin dc'd after CT which did show non-occlusive thrombi. Also no DVT by LENIs. Patient's voice is improving and swelling down. Patient will be followed by ENT on floor. . Pt. denies any constitutional symptoms n/v/d/c/urinary symptoms. Past Medical History: 1.HIV/AIDS diagnosed [2139], VL and CD4 as above. 2.H/o Positive RPR 3.Disseminated TB in [2140] with RUQ, psoas, submandibular abscess, peritonitis, pyelonephritis. 4.Anemia 5.HTN 6.Neuropathy 7.OA of right knee 8.Pneumonia 9.Esophagitis/stomach ulcer s/p ? surgery [57].S/p gunshot wound to abdomen 11.Depression 12.vision problems 13.Bacteremia with MSSA in [12-5], [1-20] 14.Depressed EF 15.ESRD due to hypertension or HIV Social History: Lives in a group home with others who are HIV + in [Location (un) 669]. Married, wife lives in area with 2 sons who are HIV negative. Denies ETOH, IVDU, or illicit drugs. Smoking history. Disabled on SSDI since [2140]. Came to the US in [2124], first having lived in [State 531] and since in [Location (un) 86]. Family History: Wife has HIV. Physical Exam: Vitals: T: 96.7 BP: 150/96 P: 94 RR: 18 O2Sat: 100% RA Gen: no acute distress HEENT: Clear OP, MMM, very mild orbital edema, NECK: soft tissue swelling Left >right. no crepitus CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C CHEST: Bilat upper chest swelling L>R ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL. bruit left AV fistula SKIN: No lesions, NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [12-17]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission Labs: WBC-4.5 Hgb-7.9* Hct-24.3* MCV-110* MCH-35.9* Plt Ct-188 PT-10.7 PTT-27.2 INR(PT)-0.9 Glucose-96 UreaN-31* Creat-3.1* Na-142 K-3.8 Cl-111* HCO3-24 TotProt-3.9* Albumin-3.2* Globuln-0.7* Calcium-9.1 Phos-3.8 Mg-1.7 BLOOD tacroFK-11.8 . Studies: [2156-6-25] ECG: Sinus rhythm. Since the previous tracing of [2156-6-19] no significant change. . [2156-6-25] portable CXR IMPRESSION: No radiographic evidence of failure or pneumonia. . [2156-6-25] CT Neck without contrast IMPRESSION: Diffuse inflammatory stranding in the neck, without evidence of focal abscess, most likely infectious. Suggest further eval with ENT as discussed with Dr [Last Name (STitle) 11084] shortly after the study. Multiple calcified lymph nodes likely due to prior treated tuberculous infection. . [2156-6-25] Right Upper Ext Vein U/S IMPRESSION: Unchanged, non-occlusive thrombus in the right axillary and subclavian veins as on prior study. . [2156-6-26] Left Upper Ext Vein U/S IMPRESSION: 1. No evidence for DVT. . [2156-6-26] CT Chest w/ contrast IMPRESSION: 1. Patent SVC. The left brachiocephalic stent remains patent, though it is narrowed in caliber posterior to the manubrium, and there appear to be two hypodense areas within the mid and SVC portions of the stent consistent with non- occlusive thrombus. Please see the above discussion. 2. Small caliber of the distal left internal jugular vein near its junction with the left subclavian vein. Prominent left external jugular vein and small veins in the subcutaneous tissues of the left neck and upper chest. 3. Non-occlusive thrombus in the right axillary vein and at the junction of the right axillary and right subclavian veins. 4. Subcutaneous edema of the chest, greater on the left, and involving the visualized portion of the left upper arm. 5. 8 mm hypodense nodule of the thyroid isthmus. 6. Evidence of prior granulomatous disease. 7. Atrophic kidneys. . [2156-6-29] Balloon angioplasty of stent: IMPRESSION: Venogram demonstrating area of stenosis within the previously placed stent in the left brachiocephalic vein with collateral veins at this level. Uncomplicated balloon angioplasty of the stenotic area with good angiographic results. . [2156-7-4] Renal Transplant U/S IMPRESSION: 1. Interval decrease in the size of right perinephric hematoma. 2. Unchanged resistive indices and renal flow pattern. 3. Unchanged diffuse increased echogenicity of the renal parenchyma compatible with rejection. . [2156-7-7] Pathology report - DIAGNOSIS: Hemorrhoids: A. Right lateral internal: Squamous and rectal mucosa; underlying veins are ectatic with focal thrombosis. B. Anterior, midline: Anal squamous mucosa, within normal l limits. C. Left anterior: Anal squamous mucosa, within normal limits. D. Left lateral: Squamous mucosa with vascular ectasia. E. Posterior midline: Anal squamous and rectal mucosa with vascular ectasia. . [2156-7-11] CXR AP & Lat IMPRESSION: Cardiomegaly. Scattered parenchymal scarring, including left lower lobe. No acute infiltrate identified. Calcified granulomas. . Brief Hospital Course: 47 yo male with HIV, well-controlled, s/p kidney transplant [2156-5-21], with proteinuria and biopsy + FSGS, now presenting with upper body edema L>R. . 1. Larygeal edema/SVC syndrome: The patient came to the hospital due to dyspnea and a sensation of airway swelling. Upon admission, he was taken to the MICU in case of need for urgent intubation. An ENT consult was obtained and the patient was given dexamethasone & clindamycin. Lisinopril was stopped due to concern for possible drug-induced angioedema. The patient's laryngeal edema improved and he was transferred to the floor for care by the transplant nephrology service. A chest CT with contrast was obtained and showed upper body subcutaneous edema. The patient also appeared visibly swollen and was clinically felt to have SVC syndrome. He was started on a heparin gtt. The heparin gtt was stopped for a planned colonoscopy, however, the patient had rapid recurrance of his laryngeal edema and was given dexamethasone x 3 doses and immediately placed back on the heparin gtt. ENT was again called and they felt that his first dose of decadron had worn off and he was experiencing rebound edema. IR was then consulted and the patient underwent balloon angioplasty of a left brachiocephalic stent placed previously in [2-21] for a similar episode of SVC syndrome. The patient's swelling decreased dramatically after stenting and he had no further episodes of swelling or dyspnea. After two additional interruptions in heparin therapy for procedures, the patient was finally transitioned to coumadin and the gtt was stopped. The patient will need at least 6 weeks of coumadin treatment to dissolve the clots in his right axillary and subclavian veins. A hematology consult was obtained to assist with anticoagulation. They recommended obtaining antithrombin III levels and will follow the patient as an outpatient to determine whether he needs further anticoagulation or anti-platelet therapy beyond 6 weeks. . 2. GI Bleed: The patient has a history of gastritis and internal hemorrhoids. On [6-28] he had a melanic stool and received 2 units of pRBCs thereafter. His PPI was increased to [Hospital1 ] dosing and he was scheduled for colonoscopy. The colonoscopy was initially deferred due to rebound laryngeal edema, but he eventually underwent flexible sigmoidoscopy on [7-1]. The exam was unremarkable, except for grade 1 hemorrhoids. The patient did not wish to use steroid cream, and continued to have bright red blood per rectum while on heparin. Given that the patient requires long-term anticoagulation, a colorectal surgery consult was obtained, and on [7-7] the patient underwent an EUA and hemorrhoidectomy. Heparin and coumadin were stopped pre-procedure and resumed afterward. He continued to have some bleeding post-op, but in general it was less than previously. He understood the importance of keep his stool soft post-op as well. . 3. Renal: The patient's prior admission was for work-up and treatment of FSGS that may have come with the transplanted kidney itself or could be secondary to infection or idiopathic. The work-up for infectious causes of FSGS was negative and the renal and ID teams felt that his FSGS may be a result of HIV. The patient was continued on tacrolimus, with dosing adjusted based on daily levels, cellcept, and a prednisone taper. For prophylaxis he was continued on valcyte (renally dosed) and nystatin. On [7-4] the patient experienced some pain over his renal graft site. His UA was concerning for a UTI so he was presumptively started on ciprofloxacin. A renal ultrasound was negative for hydronephrosis and the urine culture was negative as well. The patient's pain resolved in a day and he had no urinary symptoms. The ciprofloxacin was stopped on [7-6]. . 4. Diarrhea: The patient had diarrhea during the early part of his admission which he believed started after his kidney transplant. Stool tests for C. difficile, campylobacter and E coli were negative. The frequency of the patient's stooling decreased during the last week of his hospitalization. A specimen examined on the day prior to discharge was soft, not formed, but not liquid either. Repeat C. difficile and cryptococcus stool tests were sent. . 5. HIV: The patient was continued on his home regimen of abacavir, efavirenz, and zidovudine. He was maintained on a prophylactic regimen of dapsone and azithromycin. . 6. Hypertension: The patient was hypertensive for much of his hospitalization. His recently started lisinopril was held initially on admission due to concern that it may have caused angioedema. His metoprolol dose was increased and amlodipine was added. Eventually it became clear that the lisinopril had not been responsible for the laryngeal edema and it was restarted several days prior to discharge. . 7. Pain control: The patient had significant pain post-operatively. The surgeon advised that this would be a significant issue. The patient previously took percocet at home for pain control (2 tabs [Hospital1 ]) with good effect. However, he stated that he was advised to stop taking that and to take oxycodone instead. His pain medication was adjusted and titrated up to oxycodone 20-25 mg Q4H to provide adequate pain relief. He preferred taking the shorter-acting medication and being able to refuse medication when he did not need it compared to taking a longer acting form. . 8. Depression: The patient was continued on his home medication consisting of mirtazapine 15 mg PO QHS. He has had a very difficult post-transplant course and during this admission interacted with physicians from many different services and often plans changed quickly. He expressed frustration at these issues and at how ill he was after receiving his new kidney, having spent most of the last two months in the hospital. He seen by a social worker on several occasions. If he continues to experience difficulties, he may benefit from a psychiatric assessment. . 9. FEN: The patient received a low sodium diet with Ensure supplements x2 TID. Electrolytes were repleted prn . Medications on Admission: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day: Please take 2 tablets (40 mg) on [7-23]; then starting on [2156-6-27], please take 1 tablet daily (20 mg). Disp:60 Tablet(s) Refills:2 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,TH). 7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:90 Tablet Sustained Release 24 hr(s) Refills:2 8. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (SA). Disp:60 Tablet(s) Refills:2 9. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 11. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO [Hospital1 ] (2 times a day). Disp:180 Tablet(s) Refills:2 12. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tablet(s) 13. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): Total daily dose=7 mg [Hospital1 ]. Disp:60 Capsule(s) Refills:2 14. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day: Total daily dose is 7mg [Hospital1 ]. Disp:120 Capsule(s) Refills:2 15. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 16. Zidovudine 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Medications: 1. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 5. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Zidovudine 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (SA). 9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 11. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (FR). 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day: Take 15 mg daily through [7-12]; then take 10 mg daily from [7-13] - [7-19]; then take 5 mg daily from [7-20] onward until your physician prescribes [Name Initial (PRE) ] new regimen. 14. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 15. Epoetin Alfa 4,000 unit/mL Solution Sig: 10,000 units Injection once a week. 16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 19. Oxycodone 5 mg Tablet Sig: 2-5 Tablets PO Q4-6H as needed for Pain: You should taper this medication as your pain decreases. Disp:180 Tablet(s) Refills:0 20. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 22. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 23. 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 24. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: subclavian and brachiocephalic deep vein thrombosis SVC syndrome lower GI bleeding, s/p hemorrhoidectomy Vitamin D deficiency focal segmental glomerulosclerosis Secondary: end stage renal disease HIV/AIDS Discharge Condition: stable, breathing comfortably on room air Discharge Instructions: You were admitted with facial swelling due to blood clots in the blood vessels of your arms. You have a metal stent in the blood vessel on the left arm called the brachiocephalic vein. You are on a blood thinner called coumadin (warfarin) which will dissolve the current clots and help prevent new blood clots from forming. You have Vitamin D deficiency, and we recommend that you take a high dose vitamin D once a week to replete your levels. You had hemorrhoids that bled more on the blood thinning medication and had an operation to remove them. You are prescribed oxycodone to reduce your pain after the surgery. Please have your blood level for coumadin (INR) checked after discharge. All your medicines were discussed and explained to you thoroughly and a list was faxed to your nurse [First Name4 (NamePattern1) 717] [Last Name (NamePattern1) 8389], RN NP. Your antiviral medications was slighlty modified and you were started on a phosphate binder. Your prednisone dose is being tappered slowly (now 10mg QD). Your also were started on warfarin. The remaining of your medications is similar of what you were at home (see attached list). Please call your doctor if you have any fevers, chills, nausea, vomiting, facial or arm swelling, skin rashes, abdominal pain or any other concerning symptoms. Followup Instructions: Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2156-7-21] 10:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4861], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2156-8-3] 8:30 [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970] MD [MD Number(1) 3629]	[ "V12.01", "478.6", "786.09", "268.9", "403.91", "276.8", "585.6", "285.1", "285.21", "599.0", "459.2", "042", "996.74", "455.2", "V45.1", "581.1", "996.81", "V58.61", "305.1", "V12.71" ]	icd9cm	[ [ [] ] ]	[ "49.46", "88.63", "00.40", "48.25", "99.23", "99.21", "99.04", "45.24", "39.50" ]	icd9pcs	[ [ [] ] ]	16904, 16910	6579, 12713	341, 449	17169, 17213	3447, 3447	18580, 19013	2740, 2755		14547, 16881		16931, 17148		12739, 14524			17237, 18557								2770, 3428																						239, 303											477, 1901						3463, 6556											1923, 2371	2387, 2724
31,684	102,120	45896	Discharge summary	report	Admission Date: [2135-6-7] Discharge Date: [2135-7-6] Date of Birth: [2050-9-9] Sex: M Service: SURGERY Allergies: Lasix / Bumex Attending:[First Name3 (LF) 5569] Chief Complaint: Absominal pain, nausea, empty retching - 12 days ago. Major Surgical or Invasive Procedure: s/p ex lap/right colectomy [2135-6-11] tunnelled line picc line History of Present Illness: 84 year old male veteran of WWII with a complicated history including CAD s/p CABG, ESRD on HD, bladder CA, and ANCA+ vasculitis who initially presented to OSH for abdomainl pain 12 days ago. He developed acute onset of nausea and dry heaves and abdomainl pain which woke him up from sleep. He was admitted on [5-26] and initially treated for diverticulitis with Unasyn and gentamycin (which were on until [5-31]). An NG tube was placed on [6-4] OSH stay which was on gravity at the time of transfer. He was started on TPN on [6-6] (through a peripheral?). TPN discontinued on arrival. NG connected to LCWS. Had normal colonoscopy with melanosis amd Int hemorrhoids grade III in [2131], ascending /transv colon not visualized suboptimal prep. He is anuric and gets HD-MWF via AVG L arm which was placed by Dr.[Last Name (STitle) 816] on [2133-11-4] ans had multiple IR procedures recurrent dysfunctions and suspected stenoses ; the last Fistulogram, 7-mm balloon angioplasty of intragraft stenoses was done on [2135-4-28]. 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. Denied arthralgias or myalgias. Patient requested transfer to [Hospital1 ]. Past Medical History: -CAD s/p Coronary Artery Bypass Graft x 5 [2132-8-8] (Left internal mammary artery > Left anterior descending, saphenous vein graft > diagonal, saphenous vein graft > obtuse marginal 1, saphenous vein graft > obtuse marginal 2, saphenous vein graft > posterior descending artery) -Diastolic CHF -HTN -Mitral regurg (1+), Aortic regurg (1+), Tricuspid regurg (2+) -Dyslipidemia -Hypothyroidism -Gout -Bladder CA (12 years ago) -Pericarditis (remote) -Stage IV CKD; largely secondary to microvascular disease of the kidney, but possibly with a component of atheroembolic disease in light of persistently elevated eosinophil count and mildly low complement levels. -Atrial fibrillation -Hemoptysis ([4-/2133]) thought to be related to ANCA-associated vasculitis -s/p right knee replacement Social History: Pt is a retired CPA, he recently moved into an [Hospital3 ] facility. He is able to maintain ADLs, cares for himself. Pt smoked but quit 45 years ago; does not drink alcohol currently and used rarely before his CABG, and has never used recreational drugs. He is a veteran of WWII. Family History: NC Physical Exam: Admission PE: Temp 97.6 Pulse 84 BP 95/60 RR 18 SATS 100 2L General cooperative, not in distress NEURO Oriented awake alert, no global or local deficits. HEENT no thyromegaly, no lymphadenopathy, no carotid bruit. CHEST crackles basal bilaterally CARDIAC S1 S2 audible no murmurs appreciated. ABDOMEN firm, non tender, moderately distended, BS+ high pitched , no masses, ? R abdominal wall hernia +, guaic positive, no rebound tenderness or guarding. Ext: Warm, well perfused, 2+ pitting edema distal pulses +1 LUE: AVG Brachiocephalic thrill+ murmer+ radial pulse+ functional LABS: 7.3 >30.5 < 237 140 101 52 AGap=18 -------------< 95 4.5 26 6.8 Ca: 8.4 Mg: 2.0 P: 5.8 ALT: 9 AP: 91 Tbili: 0.4 Alb: 2.4 AST: 13 LDH: 158 [Doctor First Name ]: 51 Lip: 31 PT: 12.5 PTT: 39.4 INR: 1.1 MIcro: Per OSH: Blood Cx, Neg and C. diff neg. IMAGING: [5-26]: CT was done which was read as asymmetric cecal wall thickening, inflammatory stranding of peri-cecal fat. Appendix not visualized. Ascending colon epiploic herniation through right abdomainal wall defect. . [5-30] KUB was done for N/V/Ab distention which showed multiple dilated loops of small bowel suggestive of obstruction. CT: Distal mechanical small bowel obstruction. . [6-2] KUB Persistence of small bowel obstruction. CT on same day: with mild improvement in previously seen SBO. . [6-4]: Ab XR - six views: Partial SBO with passage of contrast material into colon, suggests incomplete SBO. right pleural effusion. Pertinent Results: [2135-7-5] 04:57AM BLOOD WBC-4.9 RBC-2.29* Hgb-7.6* Hct-23.9* MCV-105* MCH-33.2* MCHC-31.7 RDW-19.0* Plt Ct-203 [2135-6-30] 05:52AM BLOOD PT-13.1 PTT-43.4* INR(PT)-1.1 [2135-7-5] 04:57AM BLOOD Glucose-107* UreaN-121* Creat-4.8* Na-139 K-4.4 Cl-104 HCO3-23 AnGap-16 [2135-7-5] 04:57AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.4 [2135-6-30] 05:52AM BLOOD Lipase-122* [2135-6-30] 05:52AM BLOOD ALT-5 AST-5 AlkPhos-91 Amylase-151* TotBili-0.5 Brief Hospital Course: He was admitted to the West 1 service under Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] with ESRD and near-obstructing cecal lesion. Initially plan was to obtain a colonoscopy, but he was unable to tolerate the prep and exam was poor quality. CEA was elevated. CXR was without lesions, non-contrast CT did not demonstrated evidence of metastatic disease. A PICC was placed and TPN started while he was kept NPO. On [2135-9-10], he was taken to the OR by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] who performed exploratory laparotomy with right colectomy for a contained cecel perforation. Postop course was complicated by need for intubated SICU stay for hypotension requiring pressor support. Gradually, BP improved and he was able to tolerated CVVHD as well as extubation. Subsequently, he was switched to hemodialysis 3 time per week. He still experienced hypotension at times. Anti-hypertensives were held. Diet was not started for many days due to distension and lack of flatus. TPN via a picc line was inserted. Gradually diet was reintroduced. He experienced diarrhea requiring a flexiceal. Stool was sent several times and was negative each time. The abdominal incision became erythematous with drainage requiring opening. A wound vac was applied. The wound grew citrobacter freundii and yeast. Flagyl and Cefazolin were started on [6-11] and continued through [6-14]. He remained afebrile. He was transferred out of the SICU after several days only to return to the SICU for mental status changes and respiratory distress for aspiration. He was reintubated. He was started on iv flagyl and vancomycin on [6-19]. Sputum [6-19] isolated citrobacter freundii and yeast. Ceftazidime was added on [6-23]. This was switched to meropenum on [6-24]. On [6-20], a min bronch with lavage yielded a sputum spec that isolated the following: RESPIRATORY CULTURE (Final [2135-6-23]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. CITROBACTER FREUNDII COMPLEX. 10,000-100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. ENTEROBACTER CLOACAE. 10,000-100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. YEAST. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX \| ENTEROBACTER CLOACAE \| \| CEFEPIME-------------- <=1 S 4 S CEFTAZIDIME----------- <=1 S =>64 R CEFTRIAXONE----------- <=1 S =>64 R CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ =>16 R <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ 4 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R POTASSIUM HYDROXIDE PREPARATION (Final [2135-6-21]): BUDDING YEAST WITH PSEUDOHYPHAE. FUNGAL CULTURE (Final [2135-7-5]): YEAST. He was also noted to be VRE positive on rectal swab on [6-20]. IV flagyl and Meropenum continued through [6-30] when these were discontinued. He remained afebrile. He received aggressive respiratory care with improvement. He was transferred out of the SICU to the med-[Doctor First Name ] unit where PT worked with him. He was very weak and required max assist. He appeared too tired to swallow food/medicines and a swallow eval was done with recommendations for a video swallow. This was not done as he requested to stop care. Hemodialysis continued, but the patient repeatedly expressed statements that he wanted to stop dialysis and stop all care. He tended to be hypotensive during dialysis. Last hemodialysis was on [7-4]. A family meeting was held with the patient, his family and hospital care givers. The decision was made establish comfort care orders. Palliative Care was consulted. The patient's family requested transfer to a hospice facility closer to their homes. [Location (un) 5481] was contact[Name (NI) ] and a bed became available on [7-6]. The patient expressed that he was in agreement with transfer to [Location (un) 5481] for hospice care. Picc line, wound vac and flexiceal was removed. Telephone consent was obtained on [7-6] at 1725 from son [Name (NI) ] [Name (NI) 6174] to initiate MA comfort care/DNR form consent prior to discharge as the patient was very lethargic with some delerium. He complained of intermittent abdominal pain with radiation to back. Morphine SL was given for abdominal pain. Sublingual pain medication were written prior to discharge. Medications on Admission: Lexapro 20mg daily Levothyroxine 0.088mg daily Zocor 40mg daily Nephrocaps 1 tab daily Trazadone 200mg daily Metoprolol 12.5mg daily Allopurinol 100mg every other day Prednisone 10mg daily Azatioprine 25mg daily Bactrim SS qMWF Prilosec ?dose daily aspirin 325 daily Colace 200mg [Hospital1 ] Renagel 800mg TID Niaspan 500mg ER Clotrimazole 100mg troche astelin NS [Hospital1 ] preservision eye vitamin [Hospital1 ] sensispar 30mg daily lactulose 10mg prn daily . Allergies: Lasix --> rash Bumex --> rash Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO prn: q 4 hours as needed for anxiety: give sublingually. 2. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-10 mg PO Q2H (every 2 hours) as needed for pain: sublingually. Discharge Disposition: Extended Care Facility: [Location (un) 5481] Discharge Diagnosis: ESRD s/p ex lap/right colectomy [2135-6-11] for perforated cecal diverticulitis CAD HTN Afib pneumonia esrd VRE wound cellulitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: awake,lethargic with brief alertness, delerium Activity Status: Bedbound. Discharge Instructions: You will be transferred to [Hospital 5481] Hospice Care today Followup Instructions: Hospice care Completed by:[2135-7-6]	[ "E879.1", "V09.80", "428.33", "998.2", "V02.59", "276.2", "E870.0", "447.6", "428.0", "V43.65", "427.31", "403.91", "E884.2", "041.85", "998.59", "585.6", "458.21", "682.2", "507.0", "560.81", "569.5", "293.0", "V45.81", "272.4", "562.11", "244.9" ]	icd9cm	[ [ [] ] ]	[ "99.15", "33.24", "45.72", "39.95", "86.04", "45.24", "46.75", "54.59", "96.6" ]	icd9pcs	[ [ [] ] ]	11308, 11359	4984, 10494	325, 395	11536, 11536	4506, 4961	11789, 11832	2945, 2949		11062, 11285		11380, 11515		10520, 11039			11698, 11766								2964, 4487																						231, 287											423, 1808											11551, 11674						1830, 2626	2642, 2929
47,852	113,279	36542+58093	Discharge summary	report+addendum	Admission Date: [2173-7-29] Discharge Date: [2173-8-13] Date of Birth: [2099-12-8] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3016] Chief Complaint: Delirium Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. [Known lastname 82732] is a 73 you woman with squamous cell head and nexk cancer currently undergoing XRT, COPD, HTN, CAD s/p MI and stent implantation in [2171] who presents from [Hospital 100] Rehab with delirium and fever. . She is a vague historian, but denies chest pain, fevers, cough, sputum production, shortness of breath, chest pain, LE swelling, blood in her stool or urine. She denies abdominal pain or vomiting. . In the ED, her initial VSs were 102.4, 116, 145/81, 14, 98%RA. She received IVF, levofloxacin and metronidazole. . PAST ONCOLOGIC HISTORY: ====================== The patient noticed a right neck mass approximately in [3-15]. She brought the mass to the attention of her physician who obtained [Name Initial (PRE) ] CT of the neck, chest, abdomen, and pelvis at the [Hospital1 16549]. Neck, chest, and abdominal CT on [2173-4-7] showed marked thickening of the right lateral oropharyngeal wall up to approximately 2 cm and a 4.5 x 3 cm lobulated, heterogeneous, right neck mass deep to the sternocleidomastoid muscle that displaced the right carotid artery. No other lymphadenopathy was visualized and there were no suspicious lung nodules. A 10 cm right adnexal mass was visualized. This right ovarian mass has been stable and was previously evaluated. Neck ultrasound on [2173-4-22] at the [Hospital6 2910] showed a 5.5 x 4 cm neck mass suspicious for neoplastic process. On [2173-4-26], Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 66245] took the patient to the operating room for direct laryngoscopy and tonsillar biopsy. The right tonsil contained an ulcerative lesion, which was biopsied. The larynx and hypopharynx appeared normal. Pathology was read at the [Hospital1 ] as invasive moderately differentiated squamous cell carcinoma. She is currently undergoing radiotherapy. Past Medical History: PAST MEDICAL HISTORY: ==================== Chronic obstructive pulmonary disease Hypertension Hypercholesterolemia Pernicious anemia CAD s/p MI and stent implantation in [2171] h/o GI bleed Social History: EtOH: Doesn't drink Tobacco: quit in [2171], 60-75 PY history Family History: nc Physical Exam: Vitals - T: 98.4 BP: 130/70 HR: 100 RR: 16 02 sat: 93%RA/ GENERAL: NAD, alert and oriented x 2; "[Hospital6 ]" HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, no LAD, no JVD, Reactive change in pharynx in field of radiation. Dry MM. CARDIAC: RRR regular skipped beats, normal S1/S2, no mrg appreciated LUNG: bronchial breath sounds and crackedin left middle lung field. ABDOMEN: soft, large echymossis on LLQ, G tube with moderate amount of erythema surrounding it. 5 inch midline incision c/d/i M/S: moving all extremities well, no cyanosis, clubbing. s, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact. Pertinent Results: [2173-8-11] 05:50AM BLOOD WBC-10.6 RBC-3.06* Hgb-9.5* Hct-28.1* MCV-92 MCH-31.1 MCHC-33.9 RDW-18.6* Plt Ct-344 [2173-8-10] 03:16AM BLOOD WBC-8.6 RBC-2.65* Hgb-8.2* Hct-24.6* MCV-93 MCH-31.0 MCHC-33.3 RDW-18.8* Plt Ct-249 [2173-8-5] 02:25AM BLOOD WBC-8.9 RBC-3.63# Hgb-11.0# Hct-31.5# MCV-87 MCH-30.3 MCHC-34.9 RDW-17.8 Plt Ct-195 [2173-7-29] 05:00PM BLOOD WBC-8.4 RBC-2.38* Hgb-7.7* Hct-23.4* MCV-98 MCH-32.3* MCHC-32.8 RDW-21.5* Plt Ct-244 [2173-8-9] 05:20AM BLOOD PT-14.8* PTT-26.2 INR(PT)-1.3* [2173-8-11] 05:50AM BLOOD Glucose-97 UreaN-10 Creat-1.2* Na-142 K-3.0* Cl-104 HCO3-29 AnGap-12 [2173-8-10] 10:35AM BLOOD Creat-0.9 Na-141 K-3.7 Cl-104 [2173-8-10] 03:16AM BLOOD Glucose-78 UreaN-8 Creat-0.9 Na-143 K-2.8* Cl-105 HCO3-26 AnGap-15 [2173-7-29] 05:00PM BLOOD cTropnT-0.15* [2173-7-30] 09:00AM BLOOD CK-MB-12* cTropnT-0.13* [2173-7-31] 07:20AM BLOOD CK-MB-8 cTropnT-0.12* [2173-8-5] 02:25AM BLOOD CK-MB-6 cTropnT-0.09* Brief Hospital Course: Patient was admitted from [Hospital ] rehab on [2173-7-29] with delirium. She denied all symptoms. In the ED, she was found febrile and to have consolidation in her LLL. Additionally, she was then discovered to be in ARF and anemic with a troponinemia and EKG with various territories of mild ST depression. Accordingly, she was treated for HAP with Vanc/Zosyn. Admitted on tele and transfused with two units. There was some concern for an aspiration PNA. She passed a video-swallow and was put on a diet of thins and purees in which her pills were crushed. The patient proceeded to improve rapdily and in the AM of [2173-7-30], restarted XRT to the neck with Dr. [Last Name (STitle) 3929]. She stayed in house, receiving IV abx and XRT. While in hospital, the patient was restarted on tube feeds to ensure proper nutrition and avoid the burden that PO was placing on the friable mucosa of the pharynx in the field of the XRT. She will be discharged on 55 ml/hour of fibersource per nutrition consultation. The G tube site remained a persistent concern, however. Accordingly, we asked consultants from both surgery and then GI to evaluate the g tube. There was leaking of a dark and viscous fluid from around the 20 french tubing. Given how new it was and the fact that it was not placed by a [Hospital1 18] practioner, the goals of gtube management shifted to wound care. While the site remained irritated and bled about a tea-spoon per day, it was stable and did not bother the patient. Overnight on [8-3], the patient had three dark red bowel movements with a hct that trended from 26 to 24.4 to 19.5. The morning of [8-4], she had another large black tarry bowel movement and was tachycardic to the 120s from a baseline fo 90-100. Her g-tube was also flushed and demonstrated coffee grounds, and was also noted to have an increase in BUN from 16 to 26 from the prior day. The patient received 1.6L IVF and was ordered for 2 units PRBC prior to transfer to the [Hospital Unit Name 153]. On admission to the [Hospital Unit Name 153], the patient was evaluated for active bleeding and transfused 2 unites PRBCs. Endoscopy was performed to evaluate the bleeding around the G-tube site and clamping was attempted, but not successful. Patient was sent for surgery where the bleeding artery was oversewn and the G-tube was replaced and re-sited with another G-tube. The patient recieved two more units of PRBCs and was then transferred post-op back to the ICU for monitoring. Post-operatively, the pt had episodes of hypertension, which improved with pain control. On post-op day 1, the patient was hemodynamically stable the entire day. She was transferred back to the OMED service on [8-6] hemodynamically stable with Hematocrit 29.3, pain well controlled. On the day of planned discharge, the patient began to experience some tachycardia by tele. She was asymptomatic and clinically better than ever before. Nevertheless, an EKG was ordered that was improved when compared to the admission EKG and a unit of blood was transfused over three hours. On [8-8], the patient was transferred back to the [Hospital Unit Name 153] for acute respiratory distress with increased oxygen requirements. A large mucus plug was suctioned from the patient's oropharynx and her respiratory distress resolved. A CXR showed no worsening infiltrate although there was possibly increased pulmonary edema/ atelectasis. The patient was continued on her antibiotic course for HAP and was gently diuresed with fluid goal of -500 to -1L. During the night, the patient intermittently required increased oxygen for saturations down to 88%- this was thought to be related to inadequate clearing of oropharyngeal mucus plugs with a component of sleep apnea. The patient continued to have guiac positive stools, but this was felt to be residual from her GI bleed and her hct remained stable. Overall, the patient's respiratory status improved and she was transferred back to the OMED service on [8-10]. On post-op day 2, the patient was noted to have a possible expressive aphasia. Final review of a CT Head showed a right parietal hypodensity. Neurology was consulted and suspected a right temporal stroke. The patient's mental status improved, but the patient had possible left sided hypesthesia and mild left upper extremity motor weakness. ASA was restarted but her plavix was held in light of the patient's recent GI bleed. Initially there was concern that the right carotid artery may be compressed by tumor, so neurology recommended permissive hypertension until MRA of neck and CNS assessed patency of vessels. TTE with bubble study showed no PFO or ASD as possible source for emboli. Carotid dopplers and MRI looked good but official reads were pending. On the floor, we shifted focus and treated the patient for a CHF exacerbation. After a negative balance of 1500 cc, she was markedly improved clinically and we prepared her for discharge to rehab. <b> SUMMARY </b> . 1. Delirium - while the patient has some baseline dementia, she is fully oriented and interactive ([Location (un) 1131] the paper) at baseline. She presents with delirium for Pneumonia, CHF, and GI bleed . 2. GI bleed - after the operative repair she is stable. It was related to an exposed vessel. Continue tube feeding. . 3. Arterial Disease - Patient should remain on Aspirin and Clopidogrel. Also, continue lovenox. Most likely, the patient did not have a CVA. . 4. CHF - This patient has an EF of 45-50%. She is sensitive to fluids. We used a short course of lasix to improve the balance . 5 Respiratory Failure - the patient had some trouble clearing secretions, requiring deep suction. We recommend regular nebulizer treatments, oral care and suctioning. . 6. Head and Neck cancer - The patient has completed her treatment at present Medications on Admission: Enoxaparin 40 daily Clopidogrel 75 daily Hydrocodone-Acetaminophen 5 mg-500 mg Nystatin 100,000 unit/mL 5 ml by mouth tid Aspirin 81 mg daily Acetaminophen prn Captopril 25 mg tid Alprazolam 0.25 mg tid prn Simvastatin 40 daily Metoprolol Tartrate 25 tid Bisacodyl 10 mg prn Albuterol prn Lansoprazole 15 daily Discharge Medications: 1. Enoxaparin 40 mg/0.4 mL Syringe [Location (un) ]: One (1) Subcutaneous Q 24H (Every 24 Hours). 2. Clopidogrel 75 mg Tablet [Location (un) ]: One (1) Tablet PO DAILY (Daily). 3. Hydrocodone-Acetaminophen 5-500 mg Tablet [Location (un) ]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. Nystatin 100,000 unit/mL Suspension [Location (un) ]: Five (5) ML PO QID (4 times a day) as needed for thrush. 5. Aspirin 81 mg Tablet, Chewable [Location (un) ]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet [Location (un) ]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 7. Captopril 25 mg Tablet [Location (un) ]: One (1) Tablet PO TID (3 times a day). 8. Alprazolam 0.25 mg Tablet [Location (un) ]: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 9. Simvastatin 40 mg Tablet [Location (un) ]: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet [Location (un) ]: One (1) Tablet PO TID (3 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Location (un) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Location (un) ]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of rbeath, wheeze. 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback [Last Name (STitle) ]: One (1) Intravenous Q 12H (Every 12 Hours) for 4 days. 15. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback [Last Name (STitle) ]: One (1) Intravenous Q8H (every 8 hours) for 4 days. 16. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 17. Trazodone 50 mg Tablet [Last Name (STitle) ]: 0.25 Tablet PO ONCE MR1 (Once and may repeat 1 time) for 1 doses. 18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) ]: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing or SOB. 19. Ipratropium Bromide 0.02 % Solution [Last Name (STitle) ]: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing or SOB. 20. Pantoprazole 40 mg Recon Soln [Last Name (STitle) ]: One (1) Recon Soln Intravenous Q24H (every 24 hours). 21. Outpatient Physical Therapy Patient with deconditioning and requiring help in building strength/stability 22. Outpatient Lab Work Patient should have chemistry (sodium, postassium, chloride, bicarbonate, creatinine, BUN) and CBC checked in PM of [2173-8-11] and AM of [2173-8-12] and as directed by rehab physicians thereafter Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: Squamous cell cancer of the head and neck Secondary: sp GI bleed, s/p Laparotomy and G-Tube replacement COPD, HTN, Hypercholesterolemia, Pernicious anemia, CAD s/p MI and stent implantation in [2171], G-tube placed Discharge Condition: tolerating po and tube feeds, afebrile, hemodynamically stable Discharge Instructions: You were admitted with confusion and fevers. We discovered that you had a pneunomia, considered healthcare associated. We worried about aspiration pneumonia, so we ordered a video swallow test that showed you could tolerate purees and thin liquids. We treated you for this. We also transfused you with blood given your low blood count. Your gastric tube was leaking, so we asked surgery and gastroenterology to help us manage it. Eventually, you started bleeding from a large vessel around the tube and this required an operation. After the operation you went back and forth between the ICU and the floor because we were worried about your breathing. You had a good deal of secretions in your lung but also extra fluid because your heart was overloaded. You were discharged to a rehab facility. appointments [Last Name (LF) ],[First Name3 (LF) ] [Telephone/Fax (1) 35276] [Last Name (un) 27542] Return to the hospital if you develop confusion, fever or any other symptoms that concern you Followup Instructions: PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Telephone/Fax (1) 35276] Oncologist [Last Name (un) 27542] [Name6 (MD) ] [Name8 (MD) 831] MD, [Doctor First Name 3018] Completed by:[2173-8-11] Name: [Known lastname 13224],[Known firstname ] Unit No: [Numeric Identifier 13225] Admission Date: [2173-7-29] Discharge Date: [2173-8-13] Date of Birth: [2099-12-8] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5613] Addendum: The patient was kept from discharge on account her history of MRSA colonization and therefore the rehab institution's requirement that she fill a private room. While awaiting placement, however, she experienced an episode of worsening hypoxia. This was treated with deep suctioning and an escalation of pulmonary toilet towards standing nebulized bronchodilators, incentive spirometry and regular suctioning. The respiratory failure was probably due to multiple factors. First, she has great difficulty clearing secretions. Second, she is easily fluid overload. And third, given the green colour of her sputum and the NEW leukocytosis, she likely has a new pneumonia. Accoringly, she was started on broad spectrum antibiotics to treat for a HAP. Also, two points of correction to the previous discharge summary: 1) after discussing further with the radiologist, it has been confirmed that the patient has suffered a subacute stroke that may be embolic in nature. We have managed this expected finding by restarting the patient's antiplatelet and coagulation regime. Namely, plavix and aspirin. She has been on pneuomoboots in hospital, we believe that she should be restarted on lovenox prophylaxis with monitoring of her hematocrit. 2) It should also be corrected that the patient's echocardiogram with bubble study DID show a PFO as well as pulmonary hypertension. <b> SUMMARY </b> . 1. Delirium - while the patient has some baseline dementia, she is fully oriented and interactive ([Location (un) ] the paper) at baseline. She presents with delirium for Pneumonia, CHF, and GI bleed . 2. GI bleed and GI problem list - after the operative repair she is stable. It was related to an exposed vessel. Continue tube feeding. It was [Country 13226] discovered during the management of this process that she has some radiation esophagitis. Nevertheless, she does NOT aspirate from the esophagus and tolerates thin liquids and purees. We have crushed many pills into purees. . 3. Arterial Disease - Patient should remain on Aspirin and Clopidogrel. Also, continue lovenox. This is the recommended treatment from our neurologists for her cerebrovascular disease. . 4. CHF - This patient has an EF of 45-50%. She is sensitive to fluids. We used a short course of lasix to improve the balance. . 5 Respiratory Failure - the patient had some trouble clearing secretions, requiring deep suction. We recommend regular nebulizer treatments, incentive spirometry oral care and suctioning. . 6. Head and Neck cancer - The patient has completed her treatment at present Chief Complaint: Delirium Major Surgical or Invasive Procedure: Exploratory laparotomy for hemostasis and G-Tube replacement (this was incorrectly left off of the original discharge summary) History of Present Illness: as above Past Medical History: PAST MEDICAL HISTORY: ==================== Chronic obstructive pulmonary disease Hypertension Hypercholesterolemia Pernicious anemia CAD s/p MI and stent implantation in [2171] h/o GI bleed Social History: EtOH: Doesn't drink Tobacco: quit in [2171], 60-75 PY history Family History: nc Physical Exam: as above Pertinent Results: as above [2173-8-13] 04:35AM BLOOD WBC-19.5# RBC-3.09 Hgb-9.6* Hct-29.4* MCV-95 MCH-30.9 MCHC-32.5 RDW-19.2* Plt Ct-421 [2173-8-12] 06:45AM BLOOD Hct-27.6* [2173-8-11] 05:20PM BLOOD WBC-12.7* RBC-2.99* Hgb-9.5* Hct-27.9* MCV-93 MCH-31.6 MCHC-33.9 RDW-18.9* Plt Ct-410 [2173-8-11] 05:50AM BLOOD WBC-10.6 RBC-3.06* Hgb-9.5* Hct-28.1* MCV-92 MCH-31.1 MCHC-33.9 RDW-18.6* Plt Ct-344 [2173-8-10] 03:16AM BLOOD WBC-8.6 RBC-2.65* Hgb-8.2* Hct-24.6* MCV-93 MCH-31.0 MCHC-33.3 RDW-18.8* Plt Ct-249 [2173-8-9] 05:20AM BLOOD WBC-13.5* RBC-2.91* Hgb-9.2* Hct-26.3* MCV-91 MCH-31.5 MCHC-34.8 RDW-18.6* Plt Ct-351 [2173-8-13] 04:35AM BLOOD Neuts-93.8* Lymphs-2.3* Monos-3.6 Eos-0.2 Baso-0.1 [2173-8-13] 09:00AM BLOOD Glucose-140* UreaN-23* Creat-1.3* Na-145 K-3.6 Cl-102 HCO3-28 AnGap-19 [2173-8-13] 04:35AM BLOOD Glucose-123* UreaN-22* Creat-1.3* Na-144 K-3.6 Cl-103 HCO3-28 AnGap-17 [2173-8-12] 06:45AM BLOOD Glucose-129* UreaN-18 Creat-1.2* Na-142 K-4.0 Cl-105 HCO3-28 AnGap-13 [2173-8-11] 05:20PM BLOOD Glucose-104 UreaN-14 Creat-1.2* Na-144 K-4.5 Cl-107 HCO3-28 AnGap-14 [2173-8-11] 05:50AM BLOOD Glucose-97 UreaN-10 Creat-1.2* Na-142 K-3.0* Cl-104 HCO3-29 AnGap-12 [2173-8-10] 10:35AM BLOOD Creat-0.9 Na-141 K-3.7 Cl-104 [2173-8-13] 04:35AM BLOOD CK-MB-2 cTropnT-0.08* [2173-8-5] 02:25AM BLOOD CK-MB-6 cTropnT-0.09* [2173-7-31] 07:20AM BLOOD CK-MB-8 cTropnT-0.12* [2173-7-29] 05:00PM BLOOD cTropnT-0.15* [2173-7-30] 09:00AM BLOOD CK-MB-12* cTropnT-0.13* [2173-8-13] 09:00AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.1 [2173-7-30] 09:00AM BLOOD VitB12-1556* [2173-8-8] 04:57AM BLOOD Type-ART pO2-81* pCO2-32* pH-7.52* calTCO2-27 Base XS-3 Brief Hospital Course: as above with addendum <b> SUMMARY </b> . 1. Delirium - while the patient has some baseline dementia, she is fully oriented and interactive ([Location (un) ] the paper) at baseline. She presents with delirium for Pneumonia, CHF, and GI bleed . 2. GI bleed and GI problem list - after the operative repair she is stable. It was related to an exposed vessel. Continue tube feeding. It was [Country 13226] discovered during the management of this process that she has some radiation esophagitis. Nevertheless, she does NOT aspirate from the esophagus and tolerates thin liquids and purees. We have crushed many pills into purees. . 3. Arterial Disease - Patient should remain on Aspirin and Clopidogrel. Also, continue lovenox. This is the recommended treatment from our neurologists for her cerebrovascular disease. . 4. CHF - This patient has an EF of 45-50%. She is sensitive to fluids. We used a short course of lasix to improve the balance. . 5 Respiratory Failure - the patient had some trouble clearing secretions, requiring deep suction. We recommend regular nebulizer treatments, incentive spirometry oral care and suctioning. . 6. Head and Neck cancer - The patient has completed her treatment at present Medications on Admission: as above Discharge Medications: 1. Enoxaparin 40 mg/0.4 mL Syringe [Country 1649]: One (1) Subcutaneous Q 24H (Every 24 Hours). 2. Clopidogrel 75 mg Tablet [Country 1649]: One (1) Tablet PO DAILY (Daily). 3. Hydrocodone-Acetaminophen 5-500 mg Tablet [Country 1649]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. Nystatin 100,000 unit/mL Suspension [Country 1649]: Five (5) ML PO QID (4 times a day) as needed for thrush. 5. Aspirin 81 mg Tablet, Chewable [Country 1649]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet [Country 1649]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 7. Captopril 25 mg Tablet [Country 1649]: One (1) Tablet PO TID (3 times a day). 8. Alprazolam 0.25 mg Tablet [Country 1649]: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 9. Simvastatin 40 mg Tablet [Country 1649]: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet [Country 1649]: One (1) Tablet PO TID (3 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Country 1649]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Country 1649]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of rbeath, wheeze. 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) 1649]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback [Last Name (STitle) 1649]: One (1) Intravenous Q 12H (Every 12 Hours) for 4 days. 15. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback [Last Name (STitle) 1649]: One (1) Intravenous Q8H (every 8 hours) for 4 days. 16. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) 1649]: One (1) Tablet PO TID (3 times a day). 17. Trazodone 50 mg Tablet [Last Name (STitle) 1649]: 0.25 Tablet PO ONCE MR1 (Once and may repeat 1 time) for 1 doses. 18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) 1649]: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing or SOB. 19. Ipratropium Bromide 0.02 % Solution [Last Name (STitle) 1649]: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing or SOB. 20. Pantoprazole 40 mg Recon Soln [Last Name (STitle) 1649]: One (1) Recon Soln Intravenous Q24H (every 24 hours). 21. Outpatient Physical Therapy Patient with deconditioning and requiring help in building strength/stability 22. Outpatient Lab Work Patient should have chemistry (sodium, postassium, chloride, bicarbonate, creatinine, BUN) and CBC checked in PM of [2173-8-11] and AM of [2173-8-12] and as directed by rehab physicians thereafter 23. Vancomycin in Dextrose 1 gram/200 mL Piggyback [Date Range 1649]: One (1) 1 gm Intravenous Q 24H (Every 24 Hours). 24. Cefepime 2 gram Recon Soln [Date Range 1649]: One (1) 2g Recon Soln Injection Q24H (every 24 hours). 25. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback [Date Range 1649]: One (1) 500 mg Intravenous Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [Hospital6 609] for the Aged - MACU Discharge Diagnosis: Primary: Squamous cell cancer of the head and neck Secondary: sp GI bleed, s/p Laparotomy and G-Tube replacement COPD, HTN, Hypercholesterolemia, Pernicious anemia, CAD s/p MI and stent implantation in [2171], G-tube placed Discharge Condition: tolerating po and tube feeds, afebrile, hemodynamically stable Discharge Instructions: You were admitted with confusion and fevers. We discovered that you had a pneunomia, considered healthcare associated. We worried about aspiration pneumonia, so we ordered a video swallow test that showed you could tolerate purees and thin liquids. We treated you for this. We also transfused you with blood given your low blood count. Your gastric tube was leaking, so we asked surgery and gastroenterology to help us manage it. Eventually, you started bleeding from a large vessel around the tube and this required an operation. After the operation you went back and forth between the ICU and the floor because we were worried about your breathing. You had a good deal of secretions in your lung but also extra fluid because your heart was overloaded. You received an MRI that showed that you had a small stroke. You were discharged to a rehab facility. appointments [Last Name (LF) 13227],[First Name3 (LF) ] [Telephone/Fax (1) 13228] Return to the hospital if you develop confusion, fever or any other symptoms that concern you Followup Instructions: PCP: [Name10 (NameIs) 13227],[Name11 (NameIs) ] [Telephone/Fax (1) 13228] Oncologist [Last Name (un) ] [Name6 (MD) ] [Name8 (MD) ] MD, [Doctor First Name 5614] Completed by:[2173-8-13]	[ "933.1", "276.2", "293.0", "507.0", "578.9", "518.81", "401.9", "434.11", "V45.82", "584.9", "530.19", "412", "416.8", "272.0", "530.3", "146.0", "496", "428.0", "285.1", "536.49", "414.01", "745.5" ]	icd9cm	[ [ [] ] ]	[ "44.43", "43.19", "54.11", "42.92", "44.62", "92.29", "96.6" ]	icd9pcs	[ [ [] ] ]	24736, 24802	20295, 21518	18030, 18159	25075, 25140	18563, 20272	26234, 26482	18515, 18519		21577, 24713		24823, 25054		21544, 21554			25164, 26211								18534, 18544																						17982, 17992											18187, 18197																	18241, 18415	18431, 18499
57,290	173,542	46746	Discharge summary	report	Admission Date: [2177-2-10] Discharge Date: [2177-3-3] Date of Birth: [2113-6-20] Sex: M Service: MEDICINE Allergies: Minoxidil Attending:[First Name3 (LF) 11040] Chief Complaint: fall Major Surgical or Invasive Procedure: intubation/extubation tracheostomy and GTube placement bronchoscopy x2 PICC line placement History of Present Illness: This is a 63 y/o male with CKD stage IV, atrial fibrillation on warfarin, T2DM, HtN, and asthma, admitted to the Trauma SICU [2177-2-10] with flaccid paralysis in all extremities and incontinence of bowel, after falling backward from a standing position. He notes that during that day, he had some diminished strength in his legs, which apparently accompanies gout flares. He was otherwise feeling well. He was climbing the stairs with crutches when he fell backwards. He struck his head but did not lose consciousness. He had paralysis in his four limbs immediately. He was attended to by family immediately and EMS was called and brought to [Hospital1 18]. He was awake and alert in the ED, and was able to recall all events. He denied chest pain or shortness of breath at the time. . Initial imaging of the patient's cervical spine is concerning for C3-4 fracture and resultant spinal cord injury. Labs in the ED were notable for Hct 34.9. His INR was supratherapeutic to 7.6. His Cr was 3.5 at his baseline, other electrolytes were normal. Serum and urine tox screens were negative. ECG showed atrial fibrillation at a rate of 91 bpm, with lateral TWI in V4-V6. . In the ED, he was given one unit of FFP and 10 mg of IV vitamin K to reverse his INR. Ortho spine was consulted and admitted him to the TSICU. The night of admission, he was intubated for airway protection. He has a known difficult airway, and a fiberoptic intubation with 7f tube. Neurosurgery did not think he was an operative candidate because of the extent of the injury. Prior to the fall, he already had an 80% canal stenosis, and his cord was likely permanently damaged. He has been hemodynamically stable since admission to the TICU. He complains of back pain when the propofol is stopped. Past Medical History: atrial fibrillation on warfarin hypertension hyperlipidemia type 2 diabetes obstructive sleep apnea gout hyperparathyroidism asthma congestive heart failure s/p bilateral total hip replacement s/p cholecystectomy stage IV CKD of note, ED trauma critical care note reports stroke in PMHx. CT head in ED also reported old R MCA-PCA watershed infarct Social History: Retired high school math teacher. Smoked 1 ppd x 10 years, quit 20 years ago. Social EtOH. Family History: HTN in father, mother died of uterine cancer Physical Exam: T=97.6 BP=154/73 HR=73 RR=17 O2=99% on AC 14/5 ,40% FiO2, RR 14 GENERAL: Intubated, sedated African American male HEENT: Normocephalic, atraumatic. ETT and OGT in place. No conjunctival pallor. No scleral icterus. PERRL. MMM. OP clear. Wearing cervical collar. CARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs or [Last Name (un) 549] LUNGS: CTAB with accompanying ventilator sounds ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: Sedated. Not moving extremities or responding to nail bed pressure in any extremity Pertinent Results: Labs on admission: [2177-2-10] 07:12PM BLOOD WBC-8.7 RBC-3.83* Hgb-12.1* Hct-34.9* MCV-91 MCH-31.5 MCHC-34.5 RDW-16.0* Plt Ct-288 [2177-2-10] 07:12PM BLOOD PT-65.8* PTT-62.8* INR(PT)-7.6* [2177-2-10] 10:29PM BLOOD Glucose-145* UreaN-60* Creat-3.3* Na-139 K-3.2* Cl-103 HCO3-24 AnGap-15 [2177-2-11] 03:05AM BLOOD ALT-16 AST-22 [2177-2-10] 10:29PM BLOOD Calcium-8.8 Phos-3.3 Mg-2.5 [2177-2-11] 12:53AM BLOOD Type-ART Rates-16/ Tidal V-500 FiO2-50 pO2-210* pCO2-38 pH-7.45 calTCO2-27 Base XS-3 -ASSIST/CON Intubat-INTUBATED IMAGING: [2-10] CT head: IMPRESSION: 1. No acute intracranial hemorrhage. 2. No fracture. 3. Old right parietal lobe infarct. 4. Right frontal scalp lipoma. . [2-10] CT T spine: IMPRESSION: 1. No acute fracture or malalignment. 2. Degenerative changes as described above. . [2-10] CT C spine: IMPRESSION: Large posterior bridging osteophytes extending through most of the cervical spine severely narrowing the central canal and placing the patient at increased risk for cord injury. Additionally, osteophyte vs osteophyte fracture fragment of posterior osteophyte of indeterminate age also noted within the central canal at C3-4 level. Possible C6 osteophyte fracture of indeterminate age. MRI is pending to further evaluate for cord injury. . [2-10] MRI C spine: IMPRESSION: Extensive posterior osteophytic formation, severely narrowing the spinal canal dimension with cord flattening, most marked at C3-4 level with myelomalacia changes in the cord at this level. Findings are compatible with diffuse idiopathic skeletal hyperostosis. Multilevel canal narrowing at the remaining levels is as described above. . [2-11] CXR: An endotracheal tube lies with its tip between the clavicles, approximately 7 cm proximal to the carina, this could be safely advanced 2-3cm. An NG tube lies with its tip below the diaphragm, the tip is not visualized on this study. There has been interval development of a right mid lung airspace opacity, the appearances are concerning for right lower lobe pneumonia. No pleural effusion or pneumothorax seen. . [2-18] CXR: FINDINGS: In comparison with the study of [2-17], there is little overall change. Cardiac silhouette remains at the upper limits of normal or slightly enlarged with some fullness of pulmonary vessels suggesting elevated pulmonary venous pressure. Opacification at the right base is consistent with pleural effusion and atelectasis. The possibility of supervening pneumonia would have to be considered in the appropriate clinical setting. . [3-3] Head CT: 1. no acute intracranial process. MRI can be considered if there is a high suspicion for stroke. 2. Old infarct within the right parietal lobe. . . DISCHARGE LABS: [2177-3-3] 03:16AM BLOOD WBC-5.8 RBC-2.77* Hgb-8.9* Hct-26.2* MCV-95 MCH-32.3* MCHC-34.2 RDW-16.2* Plt Ct-157 [2177-3-3] 03:16AM BLOOD PT-17.8* PTT-90.6* INR(PT)-1.6* [2177-3-3] 03:16AM BLOOD Glucose-129* UreaN-140* Creat-4.1* Na-133 K-4.5 Cl-100 HCO3-20* AnGap-18 [2177-3-3] 03:16AM BLOOD Calcium-10.0 Phos-5.6* Mg-3.1* Brief Hospital Course: 63 y/o male with history of atrial fibrillation, possible old stroke, T2DM, Htn, asthma, presenting with spinal cord injury after a fall, noted to have elevated INR and creatinine in setting of warfarin therapy and Stage IV CKD. . # Hypoxemic respiratory failure: secondary to spinal cord injury. Was intubated the night of admission electively. Had a trach and peg placed without problems. [Name (NI) ] did have some intermittent plugging with secretions and at one time here needed an emergent bronch for plugging. He was dypsneic and his vital volumes were slowing increased. His dyspnea continued, and was switched him to pressure control. He was stable on vent after with much PT and suctioning. Also started abx for HAP given CXR finding of PNA, rising wbc and fevers. He was treated with vanco/cefepime for 8 days. Thoracic surgery and IP were following along. He should continue the inexsufflator while at rehab. He eventually was able to speak and eat with the cuff down. He is on a regular diet with thin liquids. He is on pressure control as stated in the discharge paper work. . # Spinal cord injury: Secondary to traumatic fall with C3-4 fracture. Has quadraparesis now, with very low likelihood of any recovery per surgery team. He will now be vent dependent. Is s/p trach/PEG. He has some spontaneous movements of his L side and mild sensation in his L side as well. Per ortho needs hard collar for 8 weeks since his injury. He should continue PT/OT. For pain control, we used dilaudid and oxycodone. We started a fentanyl patch after he was more stable on a regimen, and eventually just transistioned him to oxycodone and fentanyl patch. A lidocaine pathc was palced on his neck with excellent effect. He continues to have headaches and some work finding difficulties, so we re-CT'ed his head prior to discharge. The CT showed an old parietal infarct, but no new acute changes. He should have neuro cognitive testing at some point for his complaints of memory problems. . # Afib: Currently in afib at rate 50s to 60s with pauses off of metoprolol. Does have pauses up to 3 seconds, but not symptomatic and no changes in his blood pressure. We kept atropine at his bedside but never needed it. He came in supratherapeutic on his INR and was reversed. We restarted his coumadin but his INR remained low. We thought it was due to his tube feeds with increased levels of vitamin K. He was on a heparin bridge, with a rate of 1650 on discharge. He currently is on 7.5 mg daily with an INR of 1.6. He will need his INR checked daily to every other day until stable at rehab. Would aim for a goal of [1-29].5 given recent trauma. . # CKD: Admitted with stage IV kidney disease. Initially had some creatinine improvement but then it worsened again to between 3.8-4.2. Renal was consulted and he was started on calcitriol and calcium acetate. He was initially diuresed with IV lasix as his diuretics were held when he first came in. He was then stabalized on lasix 120 [Hospital1 ]. He was continued on spironolactone. . # DM: stable, sugars under good control. Getting nutrition with tube feeds at this time. On a [Hospital1 ] sliding scale for now. Can be stopped or started on once daily long acting if needed at rehab. # HTN: Improved since starting home meds. Now in 110s-120s systolic. Likely had some component of autonomic dysfunction. As for his home meds, we tapered off his clonidine. We continued his amlodipine, lisinopril and spironolactone. We increased his lasix as above. We stopped his HCTZ. . # Hyperlipidemia: We continued atorvastatin. Medications on Admission: OUTPATIENT MEDICATIONS: Active Medication list as of [2177-2-10]: # ALBUTEROL SULFATE [PROAIR HFA] - (Prescribed by Other Provider) - 90 mcg HFA Aerosol Inhaler - as dir use as dir # CALCITRIOL - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 0.5 mcg Capsule - 1 (One) Capsule(s) by mouth once a day alt with 2 tabs qod # CLONIDINE [CATAPRES-TTS-1] - (Prescribed by Other Provider) - 0.1 mg/24 hour Patch Weekly - once a week # COLCHICINE - (Prescribed by Other Provider) - 0.6 mg Tablet - 1 (One) Tablet(s) by mouth once a day as needed for prn # FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 110 mcg/Actuation Aerosol - 1 (One) prn # FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 2 (Two) Tablet(s) by mouth twice a day # HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg Tablet - 1 (One) Tablet(s) by mouth once a day # METOPROLOL TARTRATE - (Prescribed by Other Provider) - 100 mg Tablet - 1 (One) Tablet(s) by mouth twice a day # PRAZOSIN [MINIPRESS] - (Prescribed by Other Provider) - 2 mg Capsule - 1 (One) Capsule(s) by mouth twice a day # SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day # SPIRONOLACTONE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once a day # WARFARIN - (Prescribed by Other Provider) - 2.5 mg Tablet - [12-30] Tablet(s) by mouth once a day depending on INR Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis: C3-4 Fracture Spinal cord Injury with quadraparesis Ventilator Associated Pneumonia Chronic Kidney Disease Bradycardia Atrial Fibrillation Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: You were admitted to the hospital for a fall. You fractured your spine and injured your spinal cord. Because of this, you need a tracheostomy and feeding tube. You also developed a pneumonia in the hospital. We were able to treat your pneumonia with antibiotics. You also continued to have worsening function of your kidney function while here. The kidney doctors were following along and we are adjusting your lasix dose to try to keep too much fluid from building up. You will stay on lasix 120 mg twice daily for that reason. You also had some slow heart rates which was likely related to the spinal cord injury. The cardiologists did not feel that any particular interventions needed to be done. We did keep you on coumadin (with heparin IV while your coumadin level was not as high as it should be). Attached is a list of your medications that you will receive at rehab. There were many changes. Followup Instructions: Please follow up with your doctors at rehab. You should also follow up with a nephrologist in the next month; the rehab doctors [Name5 (PTitle) ] continue to check your labs and determine if you need to see them sooner. You can either see you prior nephrologist or call the [Hospital1 18] nephrologists at ([Telephone/Fax (1) 10135]. Follow up with cardiology as well for your atrial fibrillation. The cardiology number here is ([Telephone/Fax (1) 2037].	[ "427.31", "250.40", "518.81", "806.01", "V58.67", "790.92", "486", "428.0", "276.8", "E880.9", "721.0", "E912", "519.09", "337.3", "585.4", "E934.2", "403.10", "934.9", "428.33", "427.89", "E879.8" ]	icd9cm	[ [ [] ] ]	[ "31.1", "33.23", "97.23", "43.11", "96.72", "96.6" ]	icd9pcs	[ [ [] ] ]	11650, 11720	6510, 10140	275, 368	11922, 12037	3401, 3406	13034, 13511	2673, 2719				11741, 11741		10166, 10166			12098, 13011		6149, 6487						2734, 3382									10190, 11627													231, 237											396, 2172			3976, 5976		5985, 6133		11760, 11901		3420, 3967		12052, 12074						2194, 2549	2565, 2657
21,912	196,372	3620	Discharge summary	report	Admission Date: [2129-1-14] Discharge Date: [2129-2-24] Date of Birth: [2059-6-24] Sex: F Service: DISCHARGE DIAGNOSIS: Status post partial gastrectomy with Roux-en-Y jejunogastrostomy, exploratory laparotomy, oversewing of gastrojej anastomosis, drainage of pancreatic ascites, reinsertion of J tube, repair of small bowel perforation. LABORATORY DATA: The most recent laboratories from [2129-2-20] revealed a white blood cell count of 10.8, hematocrit 30.7, platelets 448,000. Sodium 138, potassium 4.1, chloride 106, bicarbonate 23, BUN 16, creatinine 0.5, glucose 168. ALT 17, AST 19, alkaline phosphatase 130, T bilirubin 1, calcium 8.7, magnesium 1.6, phosphate 4.1. PHYSICAL EXAMINATION ON ADMISSION: General: The patient was a well-developed, well-nourished female in no apparent distress at the time of discharge. HEENT: The sclerae was anicteric. Cranial nerves II through XII intact. No evidence of cervical lymphadenopathy. Mucous membranes were moist. No evidence of oral ulcers noted. Chest: Clear to auscultation bilaterally, although there is some coarse upper airway sounds noted, no evidence of rash noted on the chest wall. Cardiac: Regular rate and rhythm, no murmurs. Abdomen: Soft, obese, with abdominal binder intact. There was a linear incision site which is currently packed with sterile gauze. Furthermore, there are dressings over the prior JP sites. No tenderness to palpation noted. No evidence of guarding. No evidence of rebound. Extremities: The lower extremities were with no evidence of rash. No evidence of edema. HOSPITAL COURSE: The patient is a 69-year-old female with a history of abdominal pain and distention who underwent an EGD evaluation which revealed an adenocarcinoma of the distal stomach. The patient underwent, on [2129-1-14], a partial gastrectomy with Roux-en-Y jejunogastrostomy, for adenocarcinoma of the stomach. This operation was complicated by abdominal distention with CT finding of free air, although no evidence of leakage of contrast per CT. Because of the septic state of the patient, the patient was re-explored resulting in oversewing of gastrojej anastomosis and drainage of pancreatic ascites. On [2129-1-27], the patient became uncooperative and removed the feeding jejunostomy voluntarily. Secondarily, attempts to reinsert the J tube revealed a small bowel perforation which required reopening laparotomy, repair of small bowel, and reinsertion of the feeding jejunostomy. After stabilization, the patient was transferred to the floor from the ICU. Then, with aggressive physical therapy and nutritional support, the patient became fit enough for discharge to the rehab center on [2129-2-24]. DISCHARGE CONDITION: Stable. DISCHARGE DISPOSITION: Rehabilitation center. DISCHARGE MEDICATIONS: 1. Moexipril 15 mg p.o. q.d. 2. Aspirin 325 mg p.o. q.d. 3. Atenolol 100 mg p.o. q.d. 4. Zinc sulfate 220 mg p.o. q.d. 5. Insulin sliding scale. 6. Dulcolax 10 mg per rectum p.r.n. q.h.s. for constipation. 7. Percocet 5/325 one to two tablets p.o. q. 4-6 hours p.r.n. pain. 8. Albuterol one to two puffs IH q.i.d. 9. Tylenol 325 to 650 mg p.o. q. 4-6 hours. DISCHARGE INSTRUCTIONS: The patient is to undergo aggressive physical therapy at the rehabilitation facility along with aggressive oral nutritional support. The patient is also suppose to get wet-to-dry sterile b.i.d. dressing changes along the open abdominal wound site. The patient requires abdominal binders and monitoring for adequate nutritional intake. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2213], M.D. [MD Number(1) 2214] Dictated By:[Name8 (MD) 11079] MEDQUIST36 D: [2129-2-24] 01:33 T: [2129-2-24] 11:36 JOB#: [Job Number 16467]	[ "151.2", "427.31", "789.5", "196.2", "511.9", "518.81", "998.2", "997.4", "577.0" ]	icd9cm	[ [ [] ] ]	[ "38.93", "34.04", "99.15", "43.7", "46.39", "46.73", "45.62", "44.5", "96.6" ]	icd9pcs	[ [ [] ] ]	2795, 2819			2762, 2771					2842, 3210		149, 731			1624, 2740		3235, 3838																																																		746, 1606
79,061	127,004	1546	Discharge summary	report	Admission Date: [2153-6-16] Discharge Date: [2153-7-28] Date of Birth: [2086-12-14] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3233] Chief Complaint: AML requiring induction chemotherapy Major Surgical or Invasive Procedure: PICC line placement, PICC line removal Lumbar Puncture Hemodialysis Several blood and platelet transfusions History of Present Illness: Mr. [Known lastname 9025] is a 65 year old gentleman with a history of CMML and recurrent AML who presents for induction chemotherapy. Patient underwent induction chemotherapy in [2151-8-20], complicated by renal failure and need for hemodialysis for several weeks. Patient was in remission for over a year and was found to have recurred by labs in clinic. Dr. [Last Name (STitle) ] preferred that he be admitted tonight in case his counts rapidly increase. He continues on Hydrea daily and allopurinol. He feels well now. . On review of systems, patient has persistent dry cough since [Month (only) 956]. He also notes reflux symptoms exacerbated by movement, actively sitting up or lying down. He does note that his fatigue has been worsening over the last couple of weeks, though he is still able to care for himself independently at home. He notes that he has chronic post-nasal drip for years which has not affected his cough in the past. He denies fevers, chills, sweats, congestion, dyspnea, dyspnea on exertion, chest pain, palpitations, nausea, vomiting, diarrhea, rashes, bleeding, easy bruising, weight changes. Past Medical History: - Chronic Monocytic Myelogenous Leukemia - Acute Myelogenous Leukemia s/p induction [10/2151] and re-induction therapy - Chronic renal insufficiency with baseline creatinine 3.0-3.5, required temporary hemodialysis while on induction therapy with 7+3 in [2151] - Non-obstructive nephrolithiasis --> ?Urate Nephropathy - Brief hospitalization in [2151] for [Last Name (un) ] and gross hematuria - Right sided inguinal hernia - per CT, contains predominantly fat, not bowel - Splenomegaly - GERD - duodenitis - Eczema - severe - Asthmatic bronchitis, diagnosed in [2139] - Herpes zoster, [2144]. - Erectile dysfunction beginning in [2139] with hypotestosteronemia. - S/p removal of a "lump" from right arm, at dorsal site where elbow rubs tableside. - Basal cell cancer, removed from his nose in Spring [2148]. . ONCOLOGIC HISTORY: CMML - [7-/2146]-sumer [2151] followed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] - [2151] summer - transformation to AML and rise in baseline Cr --> care transferred to Dr. [Last Name (STitle) ], started on Hydrea - [2151-8-20] - induction chemotherapy w idarubicin and ARA-C (7+3), cut short [2-20] worsening renal dysfunction, requiring HD for several weeks; renal dysfunction [2-20] tumor lysis syndrome vs tumor infiltration vs ATN - Re-induction chemotherapy [2-20] persistent AML upon restaging marrow; re-induction done while still on HD in [2151] - [2152-2-20] - subsequent bone marrow biopsy showed continued CMML and remission of AML ; started on Hydrea, which he has been taking intermittently - persistent renal insufficiency not requiring HD - [2152-4-4] -- hospitalized w abd pain, constipation, CT showed hydronephrosis and stones --> likely Urate Nephropathy, was started on allopurinol ; [2153-4-10] ultrasound showed slight improvement of hydronephrosis ; pt followed by nephrology as outpatient ; [4-11] returned for gross hematuria - new lymphadenopathy per CT scan in [Month (only) ] - [2153-4-6] Bone Marrow consistent with CMML, still in remission for AML - Allogenic transplant and post-remission chemotherapy were deffered in setting of renal failure . With Induction therapy, patient received the following doses of Idarubicin: [2151-7-28]: 9mg/m2=18mg [2151-7-29]: 6mg/m2=12mg . [2151-9-7]: 12mg/m2=23mg [2151-9-8]: 12mg/m2=23mg [2151-9-9]: 12mg/m2=23mg . Total Cumulative dose=51mg/m2 Social History: The patient formerly worked as a transportation coordinator in his 60s, has not been working recently. Prior to that he worked in high-tech sales. He has a bachelors in engineering and an MBA. There isno history of smoking, illicit drug use, or alcohol abuse. He has a 15 year old daughter. [Name (NI) ] lives with his wife, daughter and their dog. Family History: No family history of hematologic disorders. Mother died of colon cancer at 58. Father died from cardiovascular disease at 72. Physical Exam: VITAL SIGNS: 99.0 93/48 77 18 97%RA GENERAL: lying supine, easily able to sit up, in no acute distress. HEENT: Oropharynx clear, no ulcerative lesions noted NECK: Supple, diffuse bilateral cervical lymphadenopathy, particularly posteriorly L>R. CHEST: Lung sounds clear to auscultation bilaterally without rhonchi, rales, or wheezes. HEART: Regular rhythm (irregular rhythm on EKG) normal rate, +systolic murmur loudest at LUSB ABDOMEN: Soft, nontender, nondistended with normoactive bowel sounds, +massive splenomegaly EXTREMITIES: No peripheral edema, good DP pulses SKIN: Warm, dry. Mild brownish bruising on left forearm. Patient was examined on day of discharge. Compared to admission, the pt was weaker, deconditioned, with 3+ edema of the ankles and mild crackles throughout lung fields. Pertinent Results: [2153-6-16] 03:27PM GLUCOSE-110* UREA N-61* CREAT-3.7* SODIUM-139 POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-20* ANION GAP-16 [2153-6-16] 03:27PM estGFR-Using this [2153-6-16] 03:27PM ALT(SGPT)-18 AST(SGOT)-15 LD(LDH)-200 ALK PHOS-37* TOT BILI-0.5 [2153-6-16] 03:27PM ALBUMIN-4.2 CALCIUM-8.2* PHOSPHATE-4.8* MAGNESIUM-2.1 URIC ACID-7.9* [2153-6-16] 03:27PM NEUTS-26* BANDS-19* LYMPHS-5* MONOS-16* EOS-3 BASOS-0 ATYPS-1* METAS-4* MYELOS-11* PROMYELO-1* BLASTS-5* OTHER-9* [2153-6-16] 03:27PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ BURR-OCCASIONAL STIPPLED-1+ TEARDROP-2+ [2153-6-16] 03:27PM PLT SMR-NORMAL PLT COUNT-17* [2153-6-16] 03:27PM PT-16.9* PTT-34.9 INR(PT)-1.5* [2153-6-16] 03:27PM FIBRINOGE-234 [2153-7-9] 06:36PM BLOOD VORICONAZOLE-Test [2153-7-28] 12:00AM BLOOD Glucose-118* UreaN-56* Creat-2.1* Na-137 K-4.6 Cl-108 HCO3-19* AnGap-15 Brief Hospital Course: Mr. [Known lastname 9025] is a 66-year-old man with CMML with recurrent AML, presenting for another round of induction chemotherapy. . Patient has been in remission for one year after induction and re-induction chemotherapy. Bone Marrow biopsy was performed by Dr. [Last Name (STitle) ] on [6-15] to reassess disease. Spleen is massive in size. Patient has lifetime limit of anthracycline dosing which should allow for MEC induction therapy. CBC Diff shows ~14% blasts which is elevated from prior, but counts 4 days ago showed 12% blasts. Concern by outpatient hematologist that patient may develop urgent need for chemotherapy in next couple of days, which is why he was admitted today rather than on Monday night. Pt started induction chemotherapy on Tuesday [2153-6-19] with MEC which was dose reduced and given with HD support with the renal team. He was incidentally found to have asymptomatic coag neg staph bacteremia in multiple BCx bottles and his chemo was stopped so he only received 3/5 doses. This was concerning as his counts dropped but still was noted to have blasts in his peripheral blood, concerning for inadequate chemo dose. His line was pulled and he was treated with vanc. Another line was placed and the pt was doing well until on [6-30] he developed acute neutropenic sepsis with 3/3 bottles of pan-sensitive pseudomonas. Due to hypotension and fevers >103 he was sent to the ICU overnight with broad spectrum abx and pressors. He was sent back to the floor the next day and improved. Per ID he was on vanc, cefepime, vori at this time (d/c'd cipro as no need for double coverage for pansens pseudomonas). he was improving until [7-7] when he was found to have acute mental status changes characterized by difficulty with word finding, perseveration, AOx1. The remainder of his neuro exam was nonfocal. The pt is normally very intelligent so these changes are considered profound. Neuro was consulted. He underwent CT head noncon which was neg for bleed or acute process. An LP was performed which only showed RBCs with minimal WBCs (however given the pt's neutropenia it is unclear that he would mount a response). He was started on treatment dose IV acyclovir for HSV consideration, although leukemic involvement was also concerning given the pt's suboptimal chemo regimen due to premature interruption as noted above. His viral studies, Cxs, and flow were non contributory, acyclovir was switched back to prophylactic dosing. He continued on Vanc, Cefepime, and Vori and slowly improved mental status until he was considered to be at baseline. On [7-13] he spiked a neutropenic fever and was found to be +parainfluenza type 3. Once he had completed more than the full course for F+N and had been afebrile x several days and was no longer neutropenic, the vanc and cefepime were discontinued and the patient remained afebrile for the remainder of his admission. Vori was continued due to history of lung nodules and necrotizing PNA concerning for aspergillus. On discharge the patient was afebrile, non-neutropenic, without signs of infection other than a mild cough. He did have persistence of blasts. He was deconditioned and evaluated by PT who felt he was capable of going home with 24h guardianship and home PT services. On discharge he continued to be platelet and blood transfusion dependent, and will have frequent followups and count checks in outpatient clinic to transfuse as necessary. . # Cough/Reflux Patient had RSV pneumonia in [2153-2-19] and has persistent dry cough with mild sputum production occasionally. Prior to starting chemotherapy, will need to ensure that patient is stable without infection. Cough sounds GERD related by history, as he has significant reflux and may actually be at risk for Barrett's esophagus. Pulm was initially consulted as the pt was noted to have small nodules in his chest CT that were read as concern for 'acute infx' although per pulm consult team and ID it was thought to be low likely. He was started on ppx vori and no bronch/BAL was done due to neutropenia and low yield study. Fungal markers were neg. The pt's cough was stable and he was continued on his home PPI as well as Voriconazole. . # Chronic Renal Failure Cr at 3.7 on admission. Patient's basline creatinine 3.0-3.5 after temporarily requiring dialysis with previous induction therapy for AML in [2151]. He does have known nephrolithiasis with secondary hydropnephrosis, likely also contributing to renal failure. With MEC chemotherapy regimen, there was concern for further nephtoxicity. Non-gap acidosis, likely secondary to renal failure -- pt not taking sodium bicarbonate tablets at home as prescribed because it makes him nauseated. Follows with Dr. [Last Name (STitle) 1187]. As noted above the pt had HD support with his MEC doses which were also renally dosed. After this, his Cr actually stabilized to around 2.5-2.7 improved from his prior baseline. At one point the cr increased from 2.7 to 3.1 and acyclovir was changed to PO dosing after which cr returned to 2.7. Creatinine continued to drop and was at 2.2 on the day of discharge. . Medications on Admission: ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) HYDROXYUREA - 500 mg Capsule - 1 Capsule(s) by mouth once a day Medications - OTC SODIUM BICARBONATE - (Prescribed by Other Provider) - 650 mg Tablet - 1 Tablet(s) by mouth twice a day --> ( Patient does not take this b/c it makes him nauseated ) OMEPRAZOLE - dosage uncertain Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:15 Tablet(s) Refills:2 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:90 Tablet, Chewable(s) Refills:2 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 inhaler Refills:2 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation q4h-prn as needed for sob, wheeze. Disp:1 inhaler Refills:2 8. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 9. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary Diagnosis: Acute Myelogenous Leukemia Secondary Diagnoses: Chronic renal insufficiency, bacteremia, pseudomonal sepsis, parainfluenza infection, altered mental status-resolved Chronic Monocytic Myelogenous Leukemia Splenomegaly Gastroesophageal Reflux Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname 9025], You were admitted to the hospital because you had a recurrence of your AML, you received 3/5 doses of induction chemotherapy which was stopped due to a blood infection. Your admission was further complicated by another blood infection that caused you to be septic, a viral respiratory infection, and an acute alteration of your mental status which has now resolved. You are currently improved clinically but are still deconditioned and require frequent platelet and blood transfusions. After discharge, you will require continued transfusions and physical therapy. You will be seen for follow-up blood counts and likely transfusion Monday [7-30] at 2pm in 7-[Hospital Ward Name 1826], please arrive early. Please call if you become febrile, experience uncontrolled bleeding, Followup Instructions: Provider: [Name Initial (NameIs) 455] 6-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[2153-7-30] 2:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3238], MD Phone:[Telephone/Fax (1) 3241] Date/Time:[2153-8-2] 2:30 Provider: [First Name8 (NamePattern2) 3239] [Last Name (NamePattern1) 3240], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2153-8-2] 2:30	[ "591", "585.4", "530.81", "484.6", "480.2", "205.00", "038.43", "692.9", "513.0", "117.3", "550.90", "276.2", "780.61", "592.1", "493.90", "995.91", "289.4" ]	icd9cm	[ [ [] ] ]	[ "03.31", "38.95", "39.95", "99.25", "38.93" ]	icd9pcs	[ [ [] ] ]	13185, 13234	6491, 11635	353, 463	13547, 13547	5506, 6468	14575, 14989	4537, 4664		12028, 13162		13255, 13255		11661, 12005			13730, 14552								4679, 5487	13323, 13526																					277, 315											491, 1637							13274, 13302				13562, 13706						1659, 4147	4163, 4521
82,160	113,773	40644	Discharge summary	report	Admission Date: [2115-2-1] Discharge Date: [2115-2-20] Date of Birth: [2067-10-31] Sex: F Service: NEUROLOGY Allergies: Penicillins / Heparin Agents Attending:[First Name3 (LF) 2569] Chief Complaint: Headache in the setting of dehydration (significant nausea and vomiting) Major Surgical or Invasive Procedure: Decompressive right hemicraniectomy with partial right temporal lobectomy History of Present Illness: PER ADMITTING RESIDENT: The pt is a 47 y/o RHW with a history of UC (no current flare) presented with HA x days. She states that on Monday night she suffered from diarrhea and vomiting x 24 hours, on Wed morning she awoke with a headache worse on the right side associated with right eye pain. The pain was getting gradually worse, aggravated by activity. Because of the pain she showed up in the ED. Here her only complaints are headache and right eye pain. She notes no other problems, no weakness, no fever, chills, no current nasuea or vomiting, chest pain, SOB, palpitations, pain in her extremities, diplopia, or numbness. No neck pain Past Medical History: Ulcerative colitis (well controlled, not currently medicated) Social History: no drugs, etoh, smoking Family History: father had DM and died of complications from such. Physical Exam: On Admission: Vitals: 98.8 62 116/72 16 100% General: Awake, cooperative, NAD. HEENT: NC/AT, MMM. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2 Abdomen: soft, NT/ND. Extremities: No edema or deformities. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. There were no paraphasic errors. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect or graphesthesia. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: left NL fold flat at rest. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No tremor, asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] L 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, cold sensation, proprioception throughout. No extinction to DSS (touch). -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 1 0 0 0 0 R 1 0 0 0 0 Plantar response was flexor bilaterally. -Coordination: No dysmetria on FNF bilaterally. .... On DISCHARGE: ? Pertinent Results: Admission Labs: [2115-2-1] 09:15PM BLOOD WBC-12.1* RBC-4.49 Hgb-9.6* Hct-32.2* MCV-72* MCH-21.4* MCHC-29.9* RDW-18.5* Plt Ct-392 [2115-2-1] 09:15PM BLOOD PT-12.2 PTT-23.3* INR(PT)-1.1 [2115-2-2] 03:15AM BLOOD ESR-29* [2115-2-2] 03:26PM BLOOD Sickle-NEG [2115-2-2] 03:15AM BLOOD Fibrino-450* [2115-2-2] 09:30AM BLOOD ACA IgG-2.5 ACA IgM-6.0 [2115-2-2] 03:26PM BLOOD Lupus-NEG [2115-2-2] 03:26PM BLOOD AT-93 ProtCFn-100 ProtSFn-58 [2115-2-2] 03:26PM BLOOD ACA IgG-2.7 ACA IgM-6.0 [2115-2-1] 09:15PM BLOOD Glucose-85 UreaN-7 Creat-0.7 Na-139 K-3.7 Cl-102 HCO3-23 AnGap-18 [2115-2-9] 05:00AM BLOOD ALT-52* AST-26 LD(LDH)-198 AlkPhos-35 TotBili-0.2 [2115-2-6] 12:58AM BLOOD CK-MB-1 cTropnT-<0.01 [2115-2-6] 05:20AM BLOOD CK-MB-1 cTropnT-<0.01 [2115-2-9] 03:53PM BLOOD CK-MB-1 cTropnT-<0.01 [2115-2-2] 03:15AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.0 Cholest-165 [2115-2-3] 03:47AM BLOOD calTIBC-335 Ferritn-13 TRF-258 [2115-2-2] 03:26PM BLOOD D-Dimer-1100* [2115-2-2] 03:15AM BLOOD %HbA1c-5.6 eAG-114 [2115-2-2] 03:15AM BLOOD Triglyc-85 HDL-50 CHOL/HD-3.3 LDLcalc-98 [2115-2-2] 09:30AM BLOOD Homocys-6.0 [2115-2-2] 03:15AM BLOOD CRP-78.6* [2115-2-2] 03:15AM BLOOD HCG-<5 [2115-2-5] 05:45AM BLOOD ASA-NEG Acetmnp-13 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2115-2-1] 09:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2115-2-1] 09:15PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.032 MICROBIOLOGY Reports: [2115-2-12] 7:00 pm SWAB RIGHT CRANIAL BONE FLAP. GRAM STAIN (Final [2115-2-12]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2115-2-14]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. REPORTS NCHCT [2115-2-1]: Large right temporal and occipital hypodense region which is slightly expansile with effacement of [Doctor Last Name 352]-white matter differentiation worrisome for infarction with areas of subarachnoid and probable intraparenchymal hemorrhage, overall worrisome for infarction which could be seen with venous thrombosis. Less likely considerations include a primary neoplasm with hemorrhagic features. evaluation with MRI/MRV can is recommended to aid in understanding the etiology. CTA Head/neck [2115-2-1]: Although the major arteries are patent, there appears to be a linear high-density area in the right occipital lobe which could be due to a thrombosed vein or a thrombosed branch of the posterior cerebral artery. In addition, some prominent vascular structures in the right sylvian fissure could be due to prominent cortical veins. The findings in correlation with the MRI examination obtained subsequently are suggestive of either a cortical venous thrombosis or in situ arterial thrombosis secondary to vasospasm. Findings were discussed with Dr. [Last Name (STitle) ] at the time of interpretation of this study. MRI [2115-2-2]: Although no major vascular occlusion is seen around the circle of [Location (un) 431], it appears that the linear hyperintensity intensity area seen in the right occipital lobe on T1 images could be connecting to the calcarine branch of the right posterior cerebral artery. Alternatively this could also be a venous structure as described. Mid basilar artery is not well seen on the maximum intensity projections but is visualized on T2-weighted images as flow void and on the CTA and is likely artifactual. Echo [2115-2-5]: The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Agitated saline contrast study revealed trace borderline evidence of an intracardiac shunt (one bubble seen within 3 beats of right atrial opacification with Valsalva release). LENIs [2115-2-5]: No evidence of DVT in bilateral lower extremity veins. CTA Head/neck: [2115-2-5]: 1. Interval increase in the large region of, primarily, vasogenic edema, with worsening mass effect. Decrease in size of hemorrhagic foci within this process, as well as the subarachnoid blood. The prominent peripherally-enhancing vessel in the right occipital lobe is still present, which likely represents a thrombosed cortical vein. Of note, the appearance and evolution of this infarct, and this finding, suggest a venous rather than an arterial etiology. Technical difficulties limit the assessment of vessel narrowing or vasospasm. However, allowing for these limitation, the major arteries of the anterior and posterior circulation enhance symmetrically and the venous sinuses are unremarkable. EKG [2115-2-3]: Sinus bradycardia. Normal tracing. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 55 142 76 [Telephone/Fax (2) 88913] 39 NCHCT [2115-2-5]: 1. Interval worsening of mass effect caused by large infarct of the right MCA and PCA territories. Right uncal herniation is again noted, although it is unclear whether it has worsened compared to prior exam. NCHCT [2115-2-7]: Decrease in the degree of leftward shift of the normally midline structures compared to previous examination. MRV [2115-2-7]: No pelvic venous clot. Fibroid uterus. Bilateral simple ovarian cysts, likely follicular in a patient of this age. Cholelithiasis. Diagnostic 4 vessel angiogram [2115-2-9]: [Known firstname ] [Known lastname 15352] underwent cerebral angiography which showed a paucity of venous structures in the right temporal area consistent with a right vein of [Last Name (un) 70890] occlusion. NCHCT [2115-2-10]: No significant interval change compared to [2115-2-9]. Severe right hemispheric mass effect and uncal herniation. NCHCT [2115-2-11] AM: Minimal increase in leftward shift in normally midline structures from 10 mm to 12 mm, likely due to minimal increase in surrounding vasogenic edema. Severe right hemispheric mass effect and uncal herniation persist. NCHCT [2115-2-11] PM: Minimal increase in leftward shift in normally midline structures from 10 mm to 12 mm, likely due to minimal increase in surrounding vasogenic edema. Severe right hemispheric mass effect and uncal herniation persist. NCHCT [2115-2-12] PM: Stable appearance of right parietal, temporal and occipital lobe infarction. Significant mass effect on the right lateral ventricle, leftward shift of approximately 11 mm, and right uncal herniation is stable since the earlier study of 9:06 a.m. NCHCT [2115-2-13] AM: Stable large right hemispheric venous infarction with surrounding vasogenic edema involving the midbrain and basal ganglia. Increase in leftward midline shift and the degree of cerebral herniation through the craniectomy defect. Unchanged right uncal herniation. NCHCT [2115-2-16]: IMPRESSION: Persistent but decreased mass effect in the right cerebral hemisphere. NCHCT [2115-2-20]: Prelim read: Decreased mass effect. . Conventional Cerebral Angiography ([2115-2-9]): IMPRESSION: [Known firstname ] [Known lastname 15352] underwent cerebral angiography which showed a paucity of venous structures in the right temporal area consistent with a right vein of [Last Name (un) 70890] occlusion. Brief Hospital Course: Ms. [Known lastname 15352] is a 47 year-old woman with a history of ulcerative colitis (untreated) who presented to the [Hospital1 18] emergency department a few days following 'violent' nausea and vomiting with severe right-sided headache. A non-contrast CT showed hypodensities in the right hemisphere (middle cerebral artery and posterior cerebral artery territories) with a hemorrhagic component and midline shift. The etiology of the syndrome was not immediately clear. She was admitted to the stroke service from [2115-2-1] until [2115-2-20] for further evaluation and care. . Further investigation included vessel imaging, which showed the presence of a fetal posterior cerebral artery on the right (in this anatomical variant the blood supply to the middle cerebral artery and posterior cerebral artery comes from the same source - the internal carotid artery). Accordingly, ischemic right MCA and PCA strokes in the setting of cardioembolic disease (eg from valsalva during recent vomiting) was considered a possible explanation. Given the severity of headache and evidence of hemorrhage in the hypodensities, cerebral vasoconstriction (with secondary arterial occlusion) was also thought to be a viable cause. As ulcerative colitis, dehydration, and the use of an estrogen patch (for birth control) can predispose to hypercoaguability, there was also concern for venous thrombosis. However, there was no clear evidence of venous sinus thrombosis on initial imaging. Although there was a suggestion of a thrombosed vein, the distribution of venous drainage at the area of this clot was not thought to be sufficient to explain the degree of her cerebral edema. . To evaluate for arterial embolic sources, a transthoracic echocardiogram was done. The study identified a patent foramen ovale. Lower extremity dopplers were negative for DVT and an MRV of her pelvis did not show any evidence of proximal thrombi or thrombogenic sources. Telemetry monitoring showed no contributory arrhythmias. Aspirin was started as empiric treatment. A heparin drip was deferred in the context of hemorrhage; however, subcutaneous heparin heparin was started. . To address the potential role of reversible cerebral vasoconstriction, verapamil was started. Unfortunately, the medication did not translate into clear relief. Angiography and transcranial doppler studies showed no obvious evidence of arterial vasospasm. . In the setting of persistent headache and cerebral edema (with midline shift), arterial and venous vessel imaging was repeated with the thought that progressive venous processes might be more evident. The tests were unrevealing. She ultimately underwent conventional cerebral angiography which revealed thrombus in the right vein of [Last Name (un) ]. Accordingly, a heparin drip was started with a goal of transitioning to coumadin (INR goal [2-22]). . The patient's examination worsened slightly, with the development of a right ptosis, partial right third nerve palsy, and subtle left pronator drift. As the headache was also unremitting, she was given a mannitol challenge. The mannitol provided relief. In the setting of radiological shift, examination change, and symptomatic relief, scheduled mannitol was started. Hypertonic saline was subsequently added. Decadron was implemented. . Despite aggressive osmotic management, the patient's examination ultimately worsened. A very mild and subtle left hemiparesis progressed gradually to include a complete left hemiplegia, slight right hemiparesis and a pupil sparing right third nerve palsy. She became more lethargic. Neurosurgery was consulted and she ultimately underwent an emergent right hemicraniectomy and partial temporal lobectomy. Keppra was started for seizure prophylaxis. She received two units of PRBCs in the OR. . Two days following her surgery, her exam was such that she was awake, alert and oriented without speech or language deficits. She had no visual or sensory extiction to stimuli on the left, but did have a dense left homonymous hemianopia. Her pupils were equal and briskly reactive to light with full extraocular movements. She displayed full strength on the right and full sensation throughout her body. She did have quite a dense hemiparesis on the left arm and leg without face involvement. There were perhaps a trace of movements in her left fingers and toes. At this time, she was able to tolerate POs and she passed her bedside swallow evaluation. . Given her stable clinical picture, she was transferred to the neuro-step down unit. She was restarted on a heparin drip as a bridge to coumadin, and per neurosurgery recs, she was quickly tapered off of her decadron and remained on keppra seizure prophylaxis. The dose was decreased to 500 mg po bid prior to discharge. Prior to discharge, the INR became therapeutic. The heparin was stopped. A non-contrast head CT was repeated; there was no evidence of new hemorrhage and the edema had markedly decreased. The initially visualized hypodensities are thought to represent edema rather than infarct. Accordingly, she is expected to regain function in the left limbs. . Patient will need to have prothrombin gene mutation and Factor 5 Leiden drawn as an outpatient to complete hypercoagulability work up. Medications on Admission: - None Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. sodium phosphates 19-7 gram/118 mL Enema Sig: One (1) Rectal DAILY (Daily) as needed for constipation. 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 10. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. Ondansetron 4 mg IV Q8H:PRN nausea Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Venous sinus thrombosis cerebral edema s/p craniectomy Ulcerative colitis Iron deficiency anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neurological examination is notable for inattention (able to do DOY backwards but not [Doctor Last Name 1841]), right ptosis, left visual field deficit, and left hemiparesis. More specifically, on the left there is 0/5 strength in the deltoid, biceps, ECR, and finger extensors. 4/5 strength at the triceps and finger flexors. [3-25] strength in the IP, Quad; [2-24] at the Ham and adductors. 0/5 in the TA and [Last Name (un) 938]; and [4-25] in the [Month/Day (1) 2339] and abductors. There is occasional extinction of left-sided stimuli to double simultaneous stimulation. Discharge Instructions: Dear Ms. [Known lastname 15352], You were admitted to the Neurology wards and the Neuro-Intensive Care unit of the [Hospital1 1170] for an evaluation of symptoms of headaches that you were experiencing at home. Through a series of physical examinations, laboratory studies, neuroimaging modalities and other medical tests, we were able to determine that the cause for your symptoms was an occlusion (or blockage) of one of the veins in the right part of your brain. This blockage unfortunately lead to a large amount of swelling (probably from increased backflow and obstruction) which ultimately caused worsening weakness of your left side of the body, problems with moving your right eye, as well as difficulties staying awake. You received a number of treatments including aspirin therapy, heparin therapy and a "decompressive hemicraniectomy", which is a procedure designed to remove the skull over a part of the brain so that the underlying brain can be allowed to swell. - We were able to organize a rehabilitation facility for you, where skilled therapists will continue to help you regain the strength on your left side. You will be discharged to [Hospital1 ] - [Location (un) 86]. - We have arranged a helmet for you to wear so that your brain can be protected in the absence of the overlying skull (on the right). Please keep this helmet on at all times. - We have started you on a medication to thin your blood called WARFARIN While on this medication, there is a higher risk of bleeding problems such as lower intestinal bleeding or traumatic bleeding in your head. Please be sure to seek medical attention following a fall or after hurting yourself. - As part of your work-up, we sent bloodwork to look for any additional disorders that may make you more likely to develop blood clots. Two tests, the prothrombin gene mutation and factor 5 Leiden will need to be drawn in our outpatient bloodwork lab on the [Hospital Ward Name ]. An order for this has been placed in our computer system. Please have this done when you return for follow up with the neurology or neurosurgery clinics. . MEDICATION CHANGES: - Coumadin (warfarin) was started. Followup Instructions: Please follow up with your primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2115-2-25] @ 1020AM [Location (un) ], [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 2261] Fax: [Telephone/Fax (1) 6808] Please also follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of the Department of Neurology, Vascular Division. The clinic is located on the [Hospital1 18] [Hospital Ward Name ], [Hospital Ward Name 23] Bldg, [Location (un) ]. We have made an appointment for you on [4-3] at 3:30pm. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 2574] Date/Time:[2115-4-3] 3:30 Please follow up with Dr. [Last Name (STitle) ] in the [Hospital 4695] clinic in regard to replacing the bone flap in your skull. You will have a CAT scan done prior to your appointment as scheduled below. Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2115-4-9] 10:00 Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 9151], MD Phone:[Telephone/Fax (1) 1669] Date/Time:[2115-4-9] 10:45 [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575**]	[ "556.9", "351.8", "745.5", "430", "342.90", "790.92", "728.87", "348.5", "280.9", "378.51", "325", "787.91" ]	icd9cm	[ [ [] ] ]	[ "38.93", "01.59", "38.97", "38.91", "88.41" ]	icd9pcs	[ [ [] ] ]	17206, 17276	10907, 16215	363, 439	17417, 17417	3063, 3063	20398, 21811	1255, 1308		16272, 17183		17297, 17396		16241, 16249			18193, 20318				1990, 3027				1323, 1323															3041, 3044						20338, 20375	251, 325											467, 1112						3079, 4860			1337, 1649	4896, 10884	17432, 18169						1134, 1197	1213, 1239
82,313	116,027	35901	Discharge summary	report	Admission Date: [2126-5-8] Discharge Date: [2126-7-1] Date of Birth: [2060-8-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: Weakness, rash Major Surgical or Invasive Procedure: catheter exchange [5-10] and [2126-5-17] ultrasound-guided percutaneous cholecystostomy History of Present Illness: Mr. [Known lastname 13275] is a 65 yo M who presented on day +27 status post non-myeloblative matched unrelated donor stem cell transplant for myelofibrosis with weakness and a rash. He reports that he had been feeling well at the time of discharge on [2126-4-29] but had become progressively weaker in the interval. Three days prior to presentation the patient first noted a decrease in his energy, and over the previous two days he was so weak he could not even stand for a few minutes. This was associated with some dizziness with standing, which was without sensation of movement or vertiginous features. He also reported that his rash had worsened despite an increase in prednisone with mild pruritus. Cough had also developed on the day of presentation, which was productive of clear phlegm. He denied dysuria, fevers, chills, diarrhea, nausea or abdominal pain. At presentation he did endorse a mild [1-12] headache that was dull and not associated with photophobia, nausea or neck stiffness. He denied palpitations or dyspnea. His chronic low back pain is at baseline, dull, [3-12], and not associated with leg weakness, saddle anesthesia or bowel/bladder incontinence. He did report constipation x 4 days. He had noted some decrease in appetite but was unsure regarding weight loss. On the day of presentation the patient was seen in clinic and found to be orthostatic from 141/93 to 119/80 with symptoms. He received 2 L NS, and had labs drawn including cultures. He was admitted to the BMT sertvice to further work up his weakness and rash. His dizziness improved after IVF. ROS: Positive per HPI and otherwise essentially negative. The pt denied recent fevers, night sweats, chills, changes in hearing or vision, including amaurosis fugax, neck stiffness, lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia, odynophagia, heartburn, nausea, vomiting, diarrhea, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, shortness of breath, chest pain, palpitations, dyspnea on exertion, increasing lower extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. Past Medical History: ONCOLOGIC HISTORY ==================== Diagnosed with primary myelofibrosis (w/ JAK2 mutation) in [8-/2125] with progressively declining platelet count. -Matched unrelated donor non-myeloablative allogeneic stem cell transplant with Fludarabine/Busulphan/ATG conditioning - day 0 was [2126-4-11] complicated by grade 2 acute cutaneous GVHD for which he was started on steroids and hadn his cyclosporine dose increased OTHER PAST MEDICAL HISTORY ============================= - Epistaxis - TIAs (3 episodes in past 5 years) - Coronary Artery Disease (asymptomatic, diagnosied by positive stress test 8 yrs ago; stress test with imaging in [2123] showed a small area of mild distal inferior apical ischemia. He had a radionucleotide stress test recently, however, that stratified him to low risk.) - Hypertension - Chronic Low Back Pain, found by MRI to have spinal stenosis and disc disease - History of leg edema of unclear etiology - heterozygote for the C282Y gene mutation (hemochromotosis gene; His baseline ferritin in [1-11] was 970) Social History: He is married with four children and 10 grandchildren. He works as a cement finisher and also ploughs snow in the winter. He has an 80 pkyr smoking history, having quit 11 years prior to admission. He drinks 2-3 alcoholic beverages per week. Family History: No history of cancer, marrow disorders. Physical Exam: Vitals: T:96.7 BP: 138/81 P: 81 R: 20 SaO2: 99 RA General: Awake, alert, NAD, pleasant, appropriate, cooperative. HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in OP Neck: supple, no significant JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted Extremities: No edema, 2+ radial, DP pulses b/l Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted Skin: Blanching erythema noted on face, chest and abdomen. No open sores or lesions. Some flaking noted on face. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. Finger to nose normal on RIGHT but some difficult with passing finger on LEFT. Patient unable to spell WORLD backwards. Patient forgets [2-5] words at 2 minutes but rememebers [2-5] with prompting. No deficits to light touch throughout. No nystagmus, dysarthria, intention or action tremor. 2+ biceps, triceps, brachioradialis, 2+ ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: LABORATORY RESULTS ================== On Admission: WBC-4.1 RBC-3.46* Hgb-9.6* Hct-26.4* MCV-76* RDW-19.1* Plt Ct-20* --Neuts-42* Bands-3 Lymphs-22 Monos-22* Eos-5* Baso-1 Atyps-2* Metas-1* Myelos-1* Promyel-1* NRBC-11* Glucose-151* UreaN-28* Creat-0.8 Na-128* K-4.1 Cl-95* HCO3-24 AnGap-13 ALT-44* AST-30 LD(LDH)-597* AlkPhos-186* TotBili-1.1 On Discharge: WBC 20.9 RBC 3.62 Hgb 11.1 Hc2 33.0 Na 119 K 5.0 Cl 91 HC03 16 Creat 1.8 BUN 59 ALT 3458 AST 7528 AP 636 Tot Bili 5.4 Ca 7.4 Mg 2.2 Phos 6.9 ABG: 7.05/50/80 MICROBIOLOGY ============== Blood Cultures on [5-10], [5-17], [5-23]: No Growth Urine Cultures: All negative CMV Viral Load [5-13], [5-20], [5-25], [6-3]: Not detected Stool Toxin Assay for C Diff [5-12], [5-13], [5-14], [5-23], [5-30], [5-31]: Negative Parainfluenza postive respiratory culture PCR of Adenovirus with [Numeric Identifier 81563] copies Sputum [6-20] GNR Mini BAL [6-21] GNR PATHOLOGY ========= Skin Biopsy [2126-5-10]: DIAGNOSIS: 1. Skin, right lateral eyebrow (A,B): Squamous cell carcinoma, well to moderately differentiated and invasive; extends to the peripheral and to the deep specimen margins. 2. Skin, left medial canthus (C,D): Basal cell carcinoma, superficial and nodular types with superficial excoriation and squamous differentiation; extends to the peripheral and to the deep specimen margins. Skin Biopsy [2126-5-13]: DIAGNOSIS: Skin, left abdomen, punch biopsy (A): Vacuolar interface dermatitis with satellite cell necrosis and scattered eosinophils (see note). Note: The findings raise a histologic differential diagnosis that includes acute graft versus host disease and a drug eruption. Clinical correlation is required. GI Biopsies [2126-5-15]: DIAGNOSIS: Colonic mucosal biopsies: A. Descending: 1. Features consistent with involvement by acute graft vs. host disease; see note. 2. No viral inclusions identified on immunostain for CMV. B. Sigmoid: 1. Features consistent with involvement by acute graft vs. host disease; see note. 2. No viral inclusions identified on immunostain for CMV. C. Rectum: 1. Features consistent with involvement by acute graft vs. host disease; see note. 2. No viral inclusions identified on immunostain for CMV. Note: The biopsies demonstrate focally prominent crypt apoptoses, rare crypt abscess, and focal cryptitis with only a mild associated mixed inflammatory infiltrate, consistent with involvement by acute GVHD. Foci of crypt drop-out are identified. While CMV immunostains are negative for viral inclusions, a concomitant infectious process cannot be entirely excluded. Radiology ========== Chest Radiograph [2126-5-8]: IMPRESSION: PA and lateral chest. Lungs are fully expanded and clear. Cardiac silhouette exaggerated by a mild pectus deformity is top normal size. There is no pulmonary edema, pleural effusion, or evidence of central adenopathy. Dual-channel central venous catheter has backed out to the junction of the brachiocephalic veins. This may have no clinical significance but is sometimes seen when thrombus develops at the tip of the catheter. Unilateral Upper Extremity U/S [2126-5-8]: Within this limitation, the right internal jugular vein, axillary vein, brachial veins x 2 and basilic veins were all patent. Limited views of the right subclavian vein were obtained due to patient's bandage. The vein appears to be patent but the useful assessment for clot cannot be made. Chest radiograph from [2126-5-8] showed the tip to lie over the region of the brachiocephalic confluence or proximal SVC. The report at that time is noted. It would be not be possible on ultrasound to interrogate the tip of the catheter, as this is essentially a retrosternal location. A contrast-enhanced study is recommended to further evaluate for clot. RIGHT Venogram 1. Venogram demonstrating no clot in the inferior portion of the right brachiocephalic vein and in the SVC. 2. Existing catheter exchanged with a longer triple-lumen tunneled Hickman catheter with tip in the SVC. CT Torso W/Contrast [2126-5-11]: 1. Wall thickening and inflammatory fat stranding of the terminal ileum, ascending colon and transverse colon. Differential diagnosis includes inflammatory, infectious and ischemic etiology. SMA/SMV are patent. No evidence of free fluid, free air or pneumatosis. Colonoscopy after treatment/resolution is recommended. 2. Splenomegaly. 3. Bilateral renal hypodensities. 4. 1.5-cm pericardial effusion. MRI Head W and W/O Contrast [2126-5-11]: FINDINGS: There are scattered areas of white matter hyperintensity on the FLAIR images in both the deep and subcortical white matter. These suggest chronic small vessel ischemia. The remainder of the brain appears normal with no evidence of hemorrhage, edema, masses, mass effect, or infarction. The ventricles and sulci are within the range of normal for a patient of this age. There are no diffusion abnormalities. There is no abnormal enhancement after contrast administration. CONCLUSION: Findings suggesting chronic small vessel ischemia. No evidence of hemorrhage, infarction, or infection. Chest Radiograph [2126-5-13]: IMPRESSION: No change or evidence of acute pneumonia. Chest Radiograph [2126-5-17]: INDICATION: Line change. Right internal jugular vascular catheter terminates in the mid superior vena cava, with no evidence of pneumothorax. New widespread interstitial opacities are likely due to acute interstitial edema. CT Head W/O Contrast [2126-5-17]: IMPRESSION: No acute intracranial process. Liver/GB Ultrasound [2126-5-18]: IMPRESSION: No evidence of biliary obstruction. Transthoracic Echocardiogram [2126-6-3]: Conclusions The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2126-3-26], the pericardial effusion is slightly larger (still small). CXR [2126-6-14]: The Hickman catheter tip is at the level of mid SVC. The cardiomediastinal silhouette is stable. There is interval development of left lower lobe opacity that is concerning for infectious process. Evaluation with PA and lateral radiographs is recommended for precise characterization of this worrisome for infectious process abnormalities. Cardiomegaly is unchanged, moderate compared to the prior study RUQ US [2126-6-19]: 1. New extra-hepatic biliary ductal dictation. No evidence of choledocholithiasis in the visualized portions, however the head of the pancreas and distal common bile duct are not well visualized. MRCP is recommended. 2. Normal gallbladder. MRCP [2126-6-16]: 1. Limited exam. The extrahepatic common duct is dilated, new from [2126-5-3]. It is seen to the level of the ampulla, with no definite stone. Some internal signal in the distal CBD could represent sludge. However, artifacts significantly limit the images obtained. 2. Hemosiderosis. 3. Abnormal appearance of small bowel loops in the right lower quadrant and distention of the splenic flexure of the colon. These findings may be related to graft versus host disease. CTA [2126-6-17]: 1. No central pulmonary embolus. Severe respiratory motion limits evaluation of the segmental and subsegmental pulmonary arteries, especially in the lower lobes. 2. Multifocal pulmonary opacities, predominently ground glass, with areas of consolidation in the bases. While these findings are consistent with given history of pneumonia, drug toxicity or cryptogenic organizing pneumonia could have a similar appearance CXR [2126-6-18]: FINDINGS: In comparison with the study of [6-14], there is increasing opacification at the left base in the retrocardiac area, as well as some increasing opacification at the right base. This is consistent with the clinical diagnosis of a developing pneumonia [6-23] RENAL U.S. PORT; DUPLEX DOP ABD/PEL LIMITED IMPRESSION: No evidence of hydronephrosis. Markedly limited Doppler examination, probable gross venous patency although if renal vein thrombus were of significant clinical concern then CT or MR would better evaluate. Echo [2126-6-24]: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The number of aortic valve leaflets cannot be determined. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is brief right atrial diastolic collapse. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Compared with the prior study (images reviewed) of [2126-6-3], the pericardial effusion is slightly larger, especially posterior to the heart. There is now evidence of impaired ventricular filling. The left ventricle is smaller and the right ventricle (although not well seen) is probably milldy dilated and hypokinetic. However, the patient is now ventilated with a high PEEP which may explain these findings. Gallbladder US IMPRESSION: 1. Increasing intrahepatic and extrahepatic biliary ductal dilatation. No cholelithiasis or stone seen within the proximal or mid CBD, but visualization of distal CBD is limited. 2. Distended gallbladder with interval appearance of sludge and questionable gallbladder wall edema. The findings are nonspecific given hypoproteinemia and biliary distention but acute cholecystitis cannot be excluded; HIDA scan could be performed for further evaluation of biliary tract function. [6-29] Echo Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. There is a small circumferential pericardial effusion. There is very brief right atrial invagination, but no echocardiographic signs of tamponade. IMPRESSION: Limited study. Small pericardial effusion without signs of tamponade. Right ventricular dilation and systolic dysfunction. [6-30] CXR FINDINGS: Comparison is made to the prior studies from [2126-6-29]. Right-sided central venous catheter, nasogastric tube, left IJ central venous catheter, and nasogastric tube are unchanged in position. There are again seen diffuse airspace opacities throughout both lung fields which are unchanged. Brief Hospital Course: 65 year old male who presented on D+27 of matched unrelated donor non-myeloblative allogeneic stem cell transplant with worsening GVHD and weakness found to have worsening acute GVHD. . # Acute Graft Versus Host Disease: The patient presented with worsening rash but no diarrhea and normal bilirubin and transaminases. As his rash had not improved on prednisone and he was having primarily weakness and some mental status changes at presentation concern for severe, acute GVHD was low and concern for infection was much higher. Therefore prednisone was stopped on [2126-5-12]. Unfortunately, within the first five days of presentation the patient developed severe diarrhea with >1500 ml of stool per day. This led to strong suspicion of acute GVHD being the primary cause of his presentation and symptoms and the patient was put on 1 mg/kg methyprednisolone on [2126-5-13] and made NPO. GI biopsies were performed on [2126-5-15] with flexible sigmoidoscopy, which were consistent with GVHD and negative for CMV while skin biopsies of his rash from [5-13] were non-dignostic. On [2126-5-19] there was an attempt made to wean this steroids back in the context of potential improvement but his diarrhea once again worsened and bilirubin started to climb so that by [2126-5-22] he was back on 1mg/kg methylprednisolone per day. On [2126-5-23] the patient was advanced to 2mg/kg IV methylprednisolone per day divided into two doses and on [2126-5-24] he was started on mycophenolate motefil for what was now considered steroid refractory acute GVHD. Methylprednisolone dosing was was dropped back to 1mg/kg on [5-26] as there was minimal improvement and considerable concern about the risk of this high of a steroid dose. Bilirubin peaked at 7.3 on [5-25] but then began to fall along with the patient having decreased volume of diarrhea and improving rash. The patient was allowed rice once again on [2126-6-2] as his stool output had dropped below 500 cc per day and bilirubin was back to less than 4. However, his stool output continued then increased the first week of [Month (only) ]. PO diet was stopped and he was continued on TPN for nutrition. His symptoms continued to worsen, along with increasing of his LFTs. RUQ US was done which showed sludge in the common bile duct. ERCP was held off secondary to respiratory issues. Stools stopped once intubated (started on sedation and narcotics). On [6-26], in the ICU, IR placed percutaneous cholecystostomy with pigtail. . # Weakness/Cough: At presentation the outpatient oncologist was quite concerned these symptoms could indicate occult infection given the patient was less than 1 month post transplant. Culture data remained unrevealing and UA and chest radiograph were benign and and respiratory viral screen was unremarkable. When CT torso revealed colitis the patient was empirically started on ciprofloxacin/metronidazole on [2126-5-12] though C diff assay was negative. On [2126-5-17] the patient was briefly febrile and had rigors so cipro/metronidazole was discontinued and vancomycin/ pipercillin-tazobactam were started for empiric coverage of a possible enteric infection. His hickman was also changed over a wire as the cuff was noted to be protruding from the skin though culture of the tip remained negative. All cultures remained negative and vancomycin stopped on [5-21], pipercillin-tazobactam stopped [5-22]. These were briefly restarted after another fever on [5-23] but weaned off by [5-26] as once again cultures remained negative and no source of fevers were found. The patient remained afebrile thereafter, until [2126-6-15] when he spiked a temp and was started on cefepime and vancomycin for suspected pulmonary source. The patient's respiratory symptoms quickly progressed. A CT of the chest was performed on [2126-6-17] which showed bilateral infiltrates. Pulmonary was consulted for possible bronchoscopy, however the patient became more hypoxic on [2126-6-18] and required transfer to the [Hospital Unit Name 153] for monitoring. Was intubated due to hypoxia and SOB. Found to have parainfluenza on viral culture. Started on Tamiflu. Also found to have highly positive PCR in blood for adenovirus, and was started on cidofovir on [6-21] with pretreatement of renal protection with probenicid. Also had sputum and mini-BAL from [6-20] and [6-21] showing GNRs identified as STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA sensitive to SMX TMP. ID followed pt and also had changed micafungin to voirconazole on transfer to [Hospital Unit Name 153], continued cefepime and discontinued Vancomycin. BMT decreased steriods, cellcept and cyclosporine due to infection. . # Respiratory Distress: On the evening of [2126-5-17] while having his hickman changed the patient developed acute shortness of breath during the procedure associated with an anxiety attack. The patient is quite claustrophobic and reacted poorly to being placed for the procedure but also developed brief hypoxia that resolved with supplementary O2. Chest radiograph from the time of the procedure showed interstitial edema and it seems likely the patient had flash pulmonary edema in the context of volume overload and being placed flat. He was gently diuresed over the ensuing two days and did well thereafter. The patient had another episode of respiratory distress on [2126-6-17] after being diagnosed with bilateral multifocal pneumonia. He became acutely hypoxic and was transferred to the medical ICU ([Hospital Ward Name 332]) as above on [2126-6-18]. Due to TPN and required medications patient was 21 L positive in the [Hospital Unit Name 153] and difficult to diuresis. Eventually required Lasix drip with pressor support. While he was able to be weaned from pressors during his ICU stay, on [6-29] his requirements increased and phenylepherine and vasopressin were added. On [6-30], his respiratory status declined and he had worsening acidosis and hypoxia. Pt gradually became bradycardic. Family was called to come to bedside. Family arrived to be with the patient in his last moments. Pt was noted to be asystolic on telemetry. Mechanical ventilation was discontinued. On exam, pt had no pupillary reflexes, breath sounds, or heart tones. Pt was pronouced dead at 4:28 AM. . # Hypotension: During ICU stay patient developed hypotension. All outpatient HTN medications were stopped. Patient was started on Levophed for support, which was transitioned over to Phenylephrine due to tachycardia. Later in his stay vasopression was added. Etiology of hypotension most likely sepsis from infections as described above. Patient was weaned off pressors but then became hypotensive and pressors were restarted. . # Acute Renal Failure: Patient developed renal failure following cidovir dose which is a known nephrotoxin. Renal ultrasound was preformed which demonstrated no obstruction. CVVHD started on [6-25]. Renal failure did not improve significantly throughout his ICU stay, . # Confusion: On presentation the patient's wife was concerned about mild deficites in memory and concern about his mental status. These were never particularly obvious to the treating team. Imaging of the head (CT and MRI) were benign and these deficits resolved over his first 3-4 days in the hospital so no further work up was pursued. Most likely this represented delirium in the setting of acute illness. . # Cardiac status: The patient intermittently complained of dyspnea, particularly when standing up though he had no problems with laying flat. ECG remained stable, CXR remained benign, and he was never hypoxic except as described above. Echocardiogram was also completely stable. His BB was weaned down over concern his dyspnea could have been due to difficulty augmenting his cardiac output in the context of standing with beta blockade but this wasn't particularly helpful. Ultimately, there was suspciion his shortness of breath was primarily due to deconditioning/anxiety once other pernicious etiologies were excluded. In the ICU, pt had afib with RVR, tx with amiodarone. . # Myelofibrosis s/p BMT: The patient's counts remained relatively stable throughout his hospitalization with low platelets and relatively stable anemia but no leukopenia or neutropenia. There continued to be abnormal forms in his peripheral smear presumed due to his myelophthisic process (despite this GVHD and resolution of his previous splenomegaly both suggest significant graft versus tumor effect). He was supported with transfusions and cyclosporine was continued with addition of mycophenolate and prednisone as described. . # Hematochezia: After his flexible sigmoidoscopy with biopsies the patient had hematochezia for the following two days. He remained hemodynamically stable and anemia did not worsen during his hematochezia. This stopped without further intervention. During [Hospital Unit Name 153] course GI continued to follow, however patient was felt unstable for flex sigmoidoscopy. . # Hypertension: The patient initially required increased nifedipine dosing in the context of his increased steroid dosing and secondary worsening of hypertension. Eventually, beta blocker was decreased due to concern of worsening his dyspnea. During [Hospital Unit Name 153] stay patient became hypotensive and all outpatient HTN medications were held. . # Pain: The patient has chronic low back pain secondary to degenerative joint disease. This was well controlled with PO oxycodone in the hospital. . # Prophylaxis: On presentation the patient was on voriconazole for fungal prophylaxis as there was concern fluconazole had worsened his rash. This was changed to micafungin out of concern the vori was contributing to his mental status changes. Later in [Hospital Unit Name 153] changed back to vori due to unclear cause of PNA. Acyclovir was briefly stopped out of concern it contributed to rash but he remained on this throughout most of his hospitalization for viral prophylaxis. He never demonstrated signs or symptoms of herpes reactivation. He remained on ursodiol for VOD prophylaxis. . # Hypernatremia: had Na up to 155 in [Name (NI) 153], unclear cause. Given D5W and sodium improved. . # FEN: The patient was NPO from [Date range (1) 81564] and supplemented with TPN. Lytes were repleted per standing scales. Medications on Admission: ACYCLOVIR 400 mg po TID CYCLOSPORINE MODIFIED 200 mg po BID FOLIC ACID 1 mg po LORAZEPAM - 0.5 - 1 mg po QHS METOPROLOL SUCCINATE 200 mg po daily NIFEDIPINE CR 60 mg po daily OXYCODONE 5 -10 mg po Q4H prn OXYCONTIN 10 mg po BID PENTAMIDINE [NEBUPENT] - (given in clinic on [5-1]) - 300 mg Recon Soln - 1 inh po monthly given in clinic [5-1] PREDNISONE 40 mg po BID RANITIDINE HCL - 150 mg po BID SULFACETAMIDE SODIUM - 10 % Drops - 2 gtts ou four times a day for 7 days for eye infection ([2126-5-7] - [2126-5-14]) URSODIOL 300 mg po BID VORICONAZOLE 200 mg po BID ZOLPIDEM - 10 mg Tablet po QHS Medications - OTC DOCUSATE SODIUM 100 mg prn MVI SENNA WHITE PETROLATUM-MINERAL OIL [DERMACERIN] - (discharge med) - Cream - apply to face as needed for for dry, flaky, or itchy skin Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Graft vs host disease, cardiorespiratory failure Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "173.1", "279.51", "518.81", "692.9", "783.7", "401.9", "038.9", "276.0", "V64.1", "079.89", "338.3", "414.01", "E879.8", "996.73", "041.89", "E849.8", "427.31", "569.49", "480.2", "E879.1", "238.76", "284.1", "584.9", "799.02", "782.4", "E849.7", "410.21", "575.10", "996.85", "558.9", "995.92" ]	icd9cm	[ [ [] ] ]	[ "48.24", "96.04", "45.25", "08.11", "38.95", "33.24", "51.01", "99.15", "96.72", "86.11", "39.95", "41.31" ]	icd9pcs	[ [ [] ] ]	28369, 28378	17040, 27496	328, 425	28470, 28480	5298, 5336	28532, 28664	3965, 4006		28341, 28346		28399, 28449		27522, 28318			28504, 28509								4021, 5279															5658, 17017							274, 290											453, 2609									5350, 5643								2631, 3690	3706, 3949
8,619	167,915	50226	Discharge summary	report	Admission Date: [2154-8-8] Discharge Date: [2154-8-19] Date of Birth: [2073-6-26] Sex: F Service: MEDICINE Allergies: Zithromax Attending:[Doctor First Name 1402] Chief Complaint: Cough, Shortness of breath Major Surgical or Invasive Procedure: Intubation History of Present Illness: 81 year-old female with history of CAD (s/p 2V CABG [2145]), Mobitz II Block (s/p PPM), HTN who presented to the ED on [2154-8-8] with complaints of cough and shortness of breath that emerged 1 day prior. Per the pt.'s daughter, she began feeling progressively orthopneic with difficulty lying flat and having to sleep sitting up the night before admission. She also complained of not getting enough air 2-3 days prior to admission. She'd also had a chronic, non-productive cough treated with Advair but of unknown etiology. She did not report fevers, chills, dizziness/lightheadedness, leg swelling, chest pain or palpitations. In the ED, VS were T 99.6; BP 88/49, RR 30. She received IV fluids and developed respiratory distress with hypotension, was intubated and transferred to the MICU. . Since transfer to the floor, antibiotics were stopped, for it was felt that her symptoms were more consistent with CHF flare. She was diuresed well with IV lasix. TTE was checked on [2154-8-9] what showed EF=35-30% (decrement from prior studies) with multiple wmas, 3+ MR, 2+ TR. This was repeated on [8-14] (?was decrement in setting of myocardial suppression, ?sepsis, stress). This TTE showed EF=20% with significant dyssynchrony (with tissue doppler), multiple wma's (including a dyskinetic apex with akinesis of parts of the anterior wall), 2+ MR. She also had her PM interrogated on [8-13] (found to be functioning adequately). She was transferred to F6 for closer cardiac monitoring. . On presentation, she reported some SOB and general deconditioning. She denies a history of LE edema, PND, or orthopnea. She denies CP/F/c and is still c/o a cough. Past Medical History: CAD s/p 2V CABG [4-/2145] to OM/CX and to RCA. Recath [8-/2145] - occluded RCA [Last Name (LF) ], [First Name3 (LF) ] OM [First Name3 (LF) ] disease, previously diseased LCx and LAD free of disease s/p DDD pacer for 2:1 AV block HTN Hyperlipidemia PUD Glaucoma Hypercalcemia [2-7] hyperparathyroidism, s/p parathyroid resection in 80s now with recurrence s/p TAH/BSO Osteoporosis Neurogenic bladder, urethral stricture Hyperplastic colonic polyps Mod MR, mild PAH, LAE Social History: Lives with husband and is very active at baseline. Reported to be a retired physician from [Country 532]. She does not smoke or drink alcohol. Family History: NC Physical Exam: Admission to MICU VS: Tc 95.7, Tm 99.8, BP 109/50, HR 70s, RR 17, SaO2 100%AC 450 x 16, FiO2 70%, PEEP 10 General: Sedated and intubated, ETT in place, OG tube in place HEENT: NC/AT, pupils minimally reactive R>L; MMM Neck: Supple, neck veins flat Chest: Few basilar rales, otherwise CTA anteriorly CV: RRR, s1, s2 nl, [1-11] SM at apex Abd: soft, ND with slight TTP in [Name (NI) ] (pt. withdraws to palpation), no peritoneal signs Ext: no c/c/e, pulses 2+ b/l, warm and well-perfused Neuro: sedated, intubated, not following commands, withdraws to pain Pertinent Results: [2154-8-8] 07:30PM PT-11.6 PTT-21.6* INR(PT)-1.0 [2154-8-8] 07:30PM PLT COUNT-193 [2154-8-8] 07:30PM ANISOCYT-1+ [2154-8-8] 07:30PM NEUTS-63.8 LYMPHS-28.6 MONOS-4.7 EOS-2.0 BASOS-0.9 [2154-8-8] 07:30PM WBC-11.7* RBC-4.17* HGB-12.3 HCT-36.7 MCV-88 MCH-29.4 MCHC-33.4 RDW-16.0* [2154-8-8] 07:30PM ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-5.4# MAGNESIUM-2.7 [2154-8-8] 07:30PM CK-MB-NotDone [2154-8-8] 07:30PM cTropnT-<0.01 [2154-8-8] 07:30PM ALT(SGPT)-54* AST(SGOT)-67* CK(CPK)-37 ALK PHOS-122* AMYLASE-84 TOT BILI-0.6 [2154-8-8] 07:30PM GLUCOSE-184* UREA N-26* CREAT-1.8* SODIUM-136 POTASSIUM-6.0* CHLORIDE-102 TOTAL CO2-21* ANION GAP-19 [2154-8-8] 08:09PM TYPE-ART PO2-66* PCO2-32* PH-7.28* TOTAL CO2-16* BASE XS--10 [2154-8-8] 08:55PM LACTATE-4.0* K+-6.1* [2154-8-8] 08:55PM COMMENTS-GREEN TOP [2154-8-8] 08:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2154-8-8] 08:56PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.008 CXR [8-13]: moderate cardiomegely, small right pleural effusion, improved edema . CTA [2154-8-9]: pulmonary edema, no PE . ECG: Atrial sensed and ventricular paced rhythm at a rate of 60. . TTE: [2154-8-9]: EF=25-30%, e/a =0.91, 3+ MR, 2+ TR, some regional wmas . [2154-8-14]: EF= 20%. dyssynchrony involving delayed contraction of septum, 2+ MR, multiple LV wmas including dyskinesis of apex with akinesis of rest of apex; worsened HK of anterior wall . [11-8]: P-MIBI: EF=54%, no evidence of ischemia . [8-/2145]: Cath: EF=53%, 60% prox RCA with diffusely diseased LAD (20%, mild). TO of SVG-RCA, 40% tubular lesion of SVG-)M2, HK of anterior wall Brief Hospital Course: 81F CAD, HTN, PPM admitted to MICU for hypoxic respiratory failure and shock of unknown etiology, now thought to be cardiogenic in nature since an infectious work up was unrevealing. Pt. transferred to the floor on [8-11] and now being diuresed and further assessed for CHF. The following issues were investigated during her hospitalization: Cardiogenic vs. Septic Shock In the MICU, patient was quickly weaned off pressors and extubated on [2154-8-10]. She was being ruled out for an infectious etiology of her shock and was empirically started on Vancomycin/Levofloxacin/Flagyl. CXR, Chest CT and abdominal CT showed no source of infection and pt. remained afebrile. She had leukocytosis of 12.6 upon admission to the MICU and blood cultures were significant for 1/4 bottles of gram positive cocci in clusters, Coagulase (-). Upon her transfer to the floor, both Levofloxacin and Flagyl had been discontinued and Vancomycin was discontinued on the floor since the pt. had no source of infection and was not thought to be colonized by MRSA since coagulase was negative. She remained afebrile on the floor and had no need to be restart antibiotics. A cardiogenic cause of shock was also pursued and an [Date Range 113] done in the MICU revealed an EF of 30% and focal hypo/akinesis of the apical free wall of the apical free wall of the right ventricle. Pt. was r/o x 3 for an MI. Repeat TTE showed EF to be 20% with apical akinesis. Given this new cardiomyopathy, she was taken for cardiac catheterization which revealed no new critical disease. SPEP/UPEP/TSH/Fe studies were all within normal limits. The most likely etiology for new cardiomyopathy is tachycardia induced (or secondary to pacing). She was started on Coreg, aldactone, losartan. Amiodarone was substitued for norpace (for atrial fibrillation). She was diuresed as possible and will need repeat TTE in 1 month. She may need Biventricular pacer in the future and will follow up with Dr. [Last Name (STitle) ]. She was maintained on her cardiac regimen of ASA, coreg, statin, [Last Name (un) ]. Hypoxia/Respiratory Failure Per MICU notes and admission radiographs, exact source of decompensation remains unclear. There was no documented temperature above 99.8 while in the MICU and only a mild leukocytosis on admission without bands. In the absence of an infection and with the low EF and edema on CXR, the likely cause of the hypoxia was thought to be pulmonary edema. Pt was transferred to the floor on 4 liters of oxygen with o2 saturation ranging from 94-97% and was agressively diuresed with Lasix 20 mg IV BID. A repeat [Last Name (un) 113] was done on [8-14] and results are as above. The patient was followed by cardiology and for cardiac optimization afterload reduction was started with Losartan 25 mg po qd. Aldactone, Coreg, losartan were continued with diuresis as possible. # TRANSAMINITIS On admission, the patient's LFTs were elevated (AST as high as 140, ALT as high as 170). Once she was transferred to the floor, they were followed with serial labs and gradually decreased to AST 47 and ALT 97. Cause of transaminitis was likely passive congestion/shock and had improved at time of discharge. She will require LFT monitoring given Amiodarone therapy. # HCT DROP: after initial drop, hematocrit remained stable. #Constipation Pt. was started on an aggressive bowel regimen to include a fleet enema which was successful at evacuating her bowels on [8-14]. Continue bowel regimen. # HTN: regimen was changed to Coreg, losartan, aldactone with good control # HYPERLIPIDEMIA Pt. was maintained on her outpatient dose of Atorvastatin # ACUTE RENAL FAILURE Resolved, suspect pre-renal azotemia from ? CHF/poor forward flow. Creatinine remained stable throughout the remainder of the hospitalization Disposition: Home with VNA services. Medications on Admission: HOME MEDICATIONS 1. Aspirin 325 mg qd 2. Ativan 0.5 mg [Hospital1 ] 3. Cozaar 50 mg qd 4. Imdur 60 mg qd 5. Lasix 20 mg qd 6. Lipitor 20 mg qd 7. Norpace 300 mg [Hospital1 ] 8. Norvasc 10 mg qd 9. Tenormin 50 mg qd 10. Zantac 150 mg [Hospital1 ] . MEDICATIONS ON TRANSFER: Albuterol nebs Amlodipine 5 mg ASA 325 Lipitor 20 mg Protonix 40 mg Losartan 25 mg Senna/colace/dulcolax Lopressor 25 mg [Hospital1 ] Latanoprost eye drops Lasix 20 mg IV qd Timolol eye drops Norpace 300 mg [Hospital1 ] . ALLERGIES: Zithromax (tongue swelling) Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Amiodarone 200 mg Tablet Sig: as directed Tablet PO TID (3 times a day): Take 200 mg TID for 1 week (until [2154-8-23]), then 200 mg [Hospital1 ] for 1 week (until [2154-8-30]), then 200 mg daily. Disp:50 Tablet(s) Refills:2 11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: Do not take this medication today [2154-8-19], or tomorrow [2154-8-20]. New dose for wednesday will be adjusted pending on INR result. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Suburban VNA Discharge Diagnosis: Primary Diagnoses: 1. Cardiomyopathy 2. Coronary Artery Disease, s/p bypass surgery 3. Atrial Fibrillation 4. Congestive Heart Failure Secondary Diagnoses: 1. Hypertension 2. Hypercalcemia/ Hyperparathyroidism Discharge Condition: Good Discharge Instructions: 1. Please follow up with your PCP and cardiologist as described below. 2. Please take all your medications exactly as prescribed and described in this discharge paperwork. We made the following changes: - We stopped your norvasc and started Coreg, 6.25 mg twice daily - We started losartan 25 mg daily - We stopped your Norpace and started Amiodarone for your atrial fibrillation. Take 200 mg three times daily for 1 week (until [8-23]), then take 200 mg twice daily for 1 week (until [8-30]), then take 200 mg daily. You will need periodic f/u of your liver function, thyroid, and pulmonary function. - We added coumadin. You will need your INR monitored - We added Aldactone 25 mg daily 3. Please call your doctor if you are experiencing chest pain, shortness of breath, fever, chills, or with any other concerning symptoms. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 1300]) within 1 week of discharge. You are schedule for an Echocardiogram on [2154-9-6] in the am prior to see Dr [Last Name (STitle) ]. You will need monitoring of your liver function, thyroid function, and pulmonary function while on amiodarone. Discuss this with Dr. [Last Name (STitle) ]. Attend these scheduled appointments: 1. Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 677], M.D. Phone:[Telephone/Fax (1) 2934] Date/Time:[2154-9-6] 1:00 2. Provider: [First Name11 (Name Pattern1) 312] [Last Name (NamePattern4) 3015], M.D. Phone:[Telephone/Fax (1) 1803] Date/Time:[2154-9-11] 1:00 3. Provider: [Name10 (NameIs) ] LAB TESTING Phone:[Telephone/Fax (1) 128] Date/Time:[2154-9-6] 9:00 Completed by:[2154-8-19]	[ "440.1", "564.00", "785.51", "V45.01", "285.9", "428.0", "252.00", "584.9", "414.01", "518.81", "428.20", "424.0", "427.31", "V45.81", "996.1", "401.9" ]	icd9cm	[ [ [] ] ]	[ "89.45", "37.22", "96.71", "88.57", "96.04", "38.91", "38.93", "99.04", "88.56" ]	icd9pcs	[ [ [] ] ]	10920, 10963	5110, 8979	297, 309	11223, 11230	3317, 5087	12122, 12997	2714, 2718		9585, 10897		10984, 11123		9005, 9265			11254, 12099								2733, 3298	11144, 11202																					231, 259											337, 2017																9290, 9562	2039, 2534	2550, 2698
59,496	189,825	54354	Discharge summary	report	Admission Date: [2107-2-3] Discharge Date: [2107-2-13] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Bronchoscopy Intubation/extubatoin Central venous line Midline placement (IV access for antibiotics) History of Present Illness: 84yo F h/o traumatic SAH, CVA, CAD, AF, BIBS from NH with 2 days h/o prod cough and fever, labored breathing. Pt with no baseline oxygen requirement but at the NH was given 2L NC and found to have O2 sat 95%. Imaging at outside facility revealed bibasilar PNA. Pt had apparent witnessed aspiration event [12-8] and was treated with 10 days of Zosyn. . In the ED, initial vitals were: T 98.2 P 107 BP 143/77 R 40 100% O2 sat on 4L. Desat to low 90s, put on 6L NC back to high 90s, still breathing 30 times a minute. Most recent vitals T 97.8 P 103-113 BP 130/76 RR 37 O2 sat 98% on 4L NC. Patient was given Vancomycin 1g IV and Levaquin 750mg and 2L NS. Pt with 1 PIV and R IJ. Past Medical History: Atrial fibrillation CVA [3-/2097] CAD DM Breast cancer s/p lumpectomy and chemotherapy Cholecystectomy [7-/2098] Social History: lives with daughter, husband passed away 1 month ago, no tobacco, occasional EtOH, no drugs. Family History: Non-contributory Physical Exam: Vitals: T: 98.5 BP: 127/72 P: 114 R: 20-35 O2: 98% 15L NRB General: Alert, working hard to breathe HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: bibasilar crackles, diffusely rhonchorous CV: irreg irreg, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+ pedal edema Pertinent Results: [2107-2-3] 11:21PM URINE HOURS-RANDOM [2107-2-3] 11:21PM URINE UHOLD-HOLD [2107-2-3] 11:21PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.024 [2107-2-3] 11:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2107-2-3] 11:21PM URINE RBC-[3-3]* WBC-[11-18]* BACTERIA-MOD YEAST-NONE EPI-0-2 [2107-2-3] 08:10PM GLUCOSE-231* UREA N-28* CREAT-0.8 SODIUM-140 POTASSIUM-5.3* CHLORIDE-101 TOTAL CO2-27 ANION GAP-17 [2107-2-3] 08:10PM estGFR-Using this [2107-2-3] 08:10PM CK(CPK)-22* [2107-2-3] 08:10PM cTropnT-<0.01 [2107-2-3] 08:10PM CK-MB-NotDone [2107-2-3] 08:10PM WBC-10.9 RBC-3.24* HGB-9.0* HCT-28.9* MCV-89 MCH-27.7 MCHC-31.1# RDW-15.3 [2107-2-3] 08:10PM NEUTS-88.2* LYMPHS-7.6* MONOS-3.2 EOS-0.9 BASOS-0.1 [2107-2-3] 08:10PM PLT COUNT-254 [2107-2-3] 08:10PM PT-13.8* PTT-27.7 INR(PT)-1.2* [2107-2-10] 3:20 pm URINE Source: Catheter. FINAL REPORT [2107-2-12] URINE CULTURE (Final [2107-2-12]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| AMIKACIN-------------- 4 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 1 S PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R [2-3] CXR IMPRESSION: Elevated central venous pressure as noted on multiple prior examinations. However there is suggestion of a hazy opacity in the lateral left lung and air bronchograms in the retrocardiac left lung which may indicate an underlying pneumonia. Close interval followup radiographs during therapy recommended to assess for resolution. [2-5] CXR FINDINGS: The left hemithorax is now quite opaque with small residual of partially aerated lung in the left upper field. Numerous branching calcifications in the left hemithorax are consistent with calcified bronchi. The density of the left hemithorax can also have a contribution from either atelectasis or pneumonia. Correlation with a CT scan is recommended. [2-5] CT CHEST IMPRESSION: 1. Moderate left pleural effusion with collapse of the left lung with only minimal aeration of the left apex. Debris within the left main stem bronchus, extending primarily into the left lower lobe segmental bronchi is identified and could be consistent with mucus plugging. 2. Small to moderate right pleural effusion. 3. Ground-glass opacities with interlobular septal thickening and mild cardiomegaly, likely represents fluid overload with possible superimposed infection, most prominent in the right middle lobe. 4. Calcification in right breast tissue, stable. 5. Small hiatal hernia. [2-6] CXR IMPRESSION: AP chest compared to [2-6], 4:17 a.m. and 1:40 p.m.: Left upper lobe is re-expanded, lower lobe remains collapsed and there is at least a moderate left pleural effusion. Borderline interstitial edema present on the right and along with persistent mild-to-moderate pleural effusion. Heart is moderately enlarged. No pneumothorax. ET tube in standard placement. Brief Hospital Course: This is an 84yo F with a history of traumatic SAH ([12-6]), AF, CVA (99'), CAD who presents with cough, fever and hypoxia. # Hypoxia: Given history of fever, cough, recent hospital course/rehab course, ? of infiltrate on CXR, initial etiologies included HAP, CAP and viral etiologies. The patient initially received vancomycin and levaquin in the ED. On arrival to the MICU the patient was tachypneic to the 40s with O2sats in the 90s on a NRB. She was in AF with RVR to 130s. She was switched to two days of vancomycin and zosyn given h/o aspiration in the past as well as NH/rehab stay. Pt was ruled out for ACS with negative CEs and non-ischemic EKGs. Her respiratory status improved on diltiazem 60mg QID PO and was weaned down on her O2 requirements. Her digoxin was also increased to 125 mcg every other day alternating with 250 mcg every other day. Her outpatient metoprolol was stopped as she was well controlled with diltiazem. Pt was ready to be called-out to the floor on [2-5] and then had an acute desaturation. CXR showed complete atelectasis of the L lung. CT scan showed bilateral effusions as well as left-sided atelectasis. On [2-6] pt was intubated for bronchoscopy and had copious secretions cleared from the L main stem bronchus. Repeat CXR showed marked improvement in atelectasis. Cultures did not reveal any infectious organisms. Pt was extubated on [2-7]. It is believed that her hypoxia is due to an acute congestive heart failure exacerbation. She was gently diuresed and her oxygen requirement slowly decreased. Her outpatient cardiologist, Dr. [Last Name (STitle) ], evaluated her and recommended starting lisinopril 5 mg daily and acetazolamide 250 mg [Hospital1 ]. She was also discharged on 40 mg of lasix daily for continued diuresis. She will need to have daily weights, oxygen saturations, and her creatintine checked every 3 days while at rehab. # UTI: She had an initial U/A concerning for UTI but urine culture was negative. Pt would have been covered by the initial treatment with vancomycin and zosyn. Later in her hospital course she had a U/A with > 50 WBC so she was empirically treated with ciprofloxacin, however her urine culture grew out Psuedomonas resistant to ciprofloxacin. She was started on ceftazidime and had a midline placed and will need to complete a 7 day course for treatment of her UTI (day 1 [2-13]). # CAD: Chest pain free on presentation, but pt is an elderly, diabetic female. Pt was ruled out with negative CEs and non-ischemic EKG. Pt remained on an aspirin, statin and digoxin. # DM: Metformin and glyburide were held as an inpatient. FSBS were monitored and pt was placed on SSI. Her metformin and glyburide were restarted prior to discharge. # AF: Pt initially required multiple boluses of IV diltiazem for better rate control. When pt was protecting airway enough for PO medications pt was transitioned to diltiazem 60mg PO QID. Pt required an increase to 90mg QID for one day and then was titrated down to her normal dose. Pt was also continued on digoxin. Warfarin was not given [1-31] recent traumatic SAH in [Month (only) 1096]. # Depression/Dementia: Stable. She was continued on her outpatient medication regimen of fluoxetine 20 mg daily and mirtazapine 15 mg qhs. # FEN: Maintained on a regular diet. Speech and swallow evaluated her and recommended: nectar thick liquids and ground consistency solids. Pills whole with nectar thick liquids as tolerated. Continue supervision during meals to encourage slow rate of intake. # Code: Changed to DNR/DNI after discussion with son who is HCP. Medications on Admission: Clindamycin 300 mg qid ([2107-2-2] until admission) Albuterol neb qid ([2107-2-2] until admission) Metoprolol 25 mg [Hospital1 ] Rosuvastatin 10 mg daily Fluoxetine 20 mg daily Mirtazapine 15 mg qhs Digoxin 125 mcg every other day Multivitamin 1 tab daily Acetaminophen 650 mg q4h prn Omeprazole 20 mg daily Metformin 1000 mg [Hospital1 ] Glyburide 5 mg daily Bisacodyl 10 mg supp daily prn Docusate Sodium 100 mg [Hospital1 ] Milk of magnesia 30 mL po daily prn Senna 8.6 x 2 mg Tablet qhs prn Aspirin 81 mg daily Regular Insulin Sliding Scale Magnesium Oxide 400 mg [Hospital1 ] Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous ASDIR (AS DIRECTED). 12. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): Alternating with with the other dose. 13. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): Alternating with with the other dose. 14. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 16. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 19. Outpatient Lab Work Potassium, BUN, Creatinine every 3 days, fax to Dr. [Last Name (STitle) ] 20. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 21. Ceftazidime 1 gram Recon Soln Sig: One (1) gram Intravenous Q12H (every 12 hours) for 7 days: Day 1 is [2-13]. 22. Outpatient Lab Work Check daily weights and check creatinine every 3 days. Please call Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] with the results: ([Telephone/Fax (1) 5455]. 23. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. 24. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 9475] Care Center - [Location (un) 3146] Discharge Diagnosis: Primary - Aspiration pneumonitis Acute diastolic/systolic heart failure Severe MR, TR, PR Pseudomonas UTI Oropharyngeal dysphagia Stage II/III sacral pressure ulcer Right heel ulcer Secondary: Advanced dementia Traumatic SDH [12-6] Atrial fibrillation Diabetes mellitus Stroke Breast cancer s/p lumpectomy and chemotherapy Cholecystectomy [7-/2098] Discharge Condition: Stable, satting well on 3L NC Discharge Instructions: You were admitted to the hospital due to difficulty breathing. You were very sick and required many days of support in the Intensive Care Unit where you underwent a bronchoscopy (camera to look in the lungs) and were intubated (tube to help you breathe). You were extubated and the oxygen your requirement to maintain your sats was slowly weaned down. It is thought that acute heart failure caused your shortness of breath and low oxygen levels. You oxygenation has been improving. During your hospitalization you also had atrial fibrillation (irregular rhythm) with rapid heart rate and your medications were changed. You were also found to have a urinary tract infection and will need to complete a 7 day course of ceftazidime. You are being discharged back to acute rehab. Medication changes: Several of your medications were changed. See that attached list for your current medications. Go to the emergency room or call your primary doctor if you experience fevers, chills, confusion, shortness of breath, chest pain, blood in your stool, or dark black stool. Followup Instructions: You will need to make an appointment to follow up with your primary docotor, Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 5455] as an outpatient. You should follow up with him in [12-31] weeks. Completed by:[2107-2-14]	[ "428.43", "250.00", "518.81", "427.31", "041.7", "518.0", "787.22", "707.03", "294.8", "707.23", "428.0", "V10.3", "414.01", "707.14", "V87.41", "507.0", "599.0", "V12.54" ]	icd9cm	[ [ [] ] ]	[ "96.71", "38.93", "96.04", "33.24" ]	icd9pcs	[ [ [] ] ]	11906, 11992	5344, 8985	279, 382	12394, 12426	1908, 5321	13546, 13785	1370, 1388		9659, 11883		12013, 12373		9012, 9636			12450, 13233								1403, 1889																					13253, 13523	220, 241											410, 1098																	1120, 1243	1259, 1354
19,350	108,411	29068	Discharge summary	report	Admission Date: [2198-11-11] Discharge Date: [2198-11-16] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Heparin Agents Attending:[First Name3 (LF) 3705] Chief Complaint: GIB Major Surgical or Invasive Procedure: colonoscopy Central line placement by VIR History of Present Illness: Ms. [Known lastname 70011] is a [Age over 90 ] yo female with severe RA who presented to OSH with LGIB on [11-11]. [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-gastric lavage was negative. Initally the patient was hypotensive with SBP in the 80s. The patient was given fluids and was transfused 2U of FFP and 2U of PRBC. Only poor peripheral access was obtained (20G in foot) and therefore a CVL was attempted. An attempt for a R femoral line was unsuccessful. A RIJ attempt was unsuccessful as the wire was traveling in the head. When trying to place a L subclavian line, the physician in the OSH was unable to withdraw the wire. A CXR revealed the CVL wire coiled in the IVC filter. The patient is transfered for IR intervention to withdraw the wire. . On arrival to the [Hospital1 18], the patient denied any CP, SOB, abdominal pain, back pain. She denied any BRBPR prior to this episode. She states that the BRBPR started last two days. The patient denies ever having had any colonoscopy before. She denies any LH or dizziness. The patient is s/p recent THR that was complicated by a DVT. The pt had an IVC filter placed and was on Heparin sc TID for DVT prophylaxis. Past Medical History: PMH: Rheumatoid Arthritis - c/b chronic right pleural effusion, s/p recent thoracentesis, felt to be due to RA HTN Atrial fibrillation h/o of CVA with residual L sided weakness Frequent UTIs . PSH: S/p b/l TKR in [2193] s/p R total hip replacement in [9-/2198] complicated by a DVT for which an IVC filter was placed Addendum/clarification based on discussion with the PCP ([First Name5 (NamePattern1) 4468] [Last Name (NamePattern1) 70012]): She underwent R THR at [Hospital3 934] in [5-15] without complications, discharged on coumadin for DVT prophylaxis. Readmitted in [6-14] with thigh pain and a DVT was seen. On lovenox, plavix and aspirin, she developed a thigh hematoma complicated by hypotension, so anticoagulation was stopped and they placed an IVC filter. She was D/C'd to [Location (un) 931] House. She was readmitted [8-15] for chest pain and hypotension and found to have RA pericarditis, pericardial effusion, and pleuritis. Placed on steroids. Readmitted [10-15] for the same and also developed A fib which spontaneously recovered. Readmitted [11-11] from rehab because she was placed on heparin SQ despite the IVCF and developed BRBPR and hypotension. Social History: She has been living in a Rehab since her THR in [9-14]. Prior to this, she lived alone with help from her son. She denies ETOH and tobacco use. Family History: Non-contributory Physical Exam: Gen: NAD, AAOx3 HEENT: PERRLA, mmm, no dentures in place NECK: no LAD, no JVD visible COR: S1S2, regular rhythm, non-radiating systolic murmur [12-15] over precordium, distant heart sounds. PULM: CTA b/l, no wheezing or rhonchi ABD: + bowel sounds, soft, nd, nt Skin: cool extremities, no rash, limited range of motion in UE joints, ecchymosis in R groin, wire taped to her left shoulder EXT: 1+ DP, no edema/c/c, dermatosclerotic changes in feet b/l Pertinent Results: [11-11]: EKG: rate 72, Nsr, no ST changes or TWIs, normal intervals . [11-11] CXR: Bilateral pleural effusions. Subsegmental atelectasis right base. Increased density in the retrocardiac area, which may represent atelectasis or consolidation. . CT Abdomen/Pelvis: 1. CT colonography unable to be performed due to lack of rectal tone. 2. Extensive sigmoid diverticulosis. Assessment of the nondistended colon is limited, but there is an area of asymmetric wall thickening with mucosal enhancement in a loop of redundant sigmoid colon low in the left lower quadrant. While this could be related to recent colonoscopy or represent inflammatory changes from diverticulosis, given the history of GI bleeding, a neoplastic process cannot be excluded. Targeted colonoscopy of this area or single-contrast barium enema could be performed for further assessment. Given lack rectal tone, single contrast enema may not be successful. 3. Findings consistent with proctitis. 4. Air in the bladder. Correlate with recent history of Foley catheter placement. Given extensive diverticular disease, in the absence of prior Foley catheterization, this would raise suspicion for enterovesicular fistula. No areas of asymmetric bladder wall thickening are identified adjacent to sigmoid colon to indicate an enterovesicular fistula. 5. Moderate bilateral pleural effusions with associated bilateral lower lobe atelectasis. Brief Hospital Course: A/P: [Age over 90 ] F with PMH of RA, THR c/b DVT, s/p IVC filter placement, admitted to MICU with LGIB. . 1) LGIB: Patient presented to outside hospital with lower GI bleed and hypotension. She received 2 units of FFP and 2 units of PRBC's at outside hospital and was subsequently transferred to [Hospital1 18] for further management. She was admitted to the MICU at [Hospital1 18] and GoLytely was administered in preparation for a colonoscopy. On admission to this institution, she had a large drop in her hct from 33.8 to 26.6 and was transfused an additional 2 units of PRBC's and started on IV PPI. She was subsequently hemodynamically stable for the duration of her hospital course. EGD/colonoscopy revealed ischemic-appearing mucosa in the sigmoid colon and severe sigmoid narrowing, which they were unable to pass with the colonoscope. She underwent a diagnostic colonography under fluroscopy for further evaluation of stricture vs. obstructing mass. This study revealed severe sigmoid diverticulosis and findings consistent with proctitis. If indeed these findings are consistent ischemic colitis, it may be related to hypotensive event (reported per PCP) which occurred at outside hospital. At time of discharge, she was hemodynamically stable, and no further intervention was advised. This was discussed with both patient's son and her PCP who stated their agreement with plan for conservative management. . 2) Access: At the outside hospital, Ms. [Known lastname 70011] had several unsuccessful attempts at line placement and was transferred with a guidewire which was felt to be hooked into her IVC filter. IR found that in fact this was not the case, and they were able to remove the wire without difficulty. A left SVC triple lumen catheter was placed by IR for access in the setting of active GI bleeding, as patient had a tenuous situation with peripheral IV's. . 3) Rheumatoid Arthritis - Patient has a long history of RA for 30 years and is on a slow prednisone taper for recent RA pericarditis & pleuritis. Current dose of 20 mg was continued to prevent adrenal insufficiency. Her PCP will continue to manage the slow taper after discharge. . 4) Leukocytosis: Most likely due to chronic prednisone. No clinical, radiographic, or other laboratory evidence of infection. . 5) Afib: Sotalol was briefly held secondary to concern over brisk bleeding. Once GI bleeding had subsided, it was restarted. Heart rate was well-controlled. She is not currently a candidate for anticoagulation given GI bleed. . 6) FEN: Received gentle IVFs initially following admission. Following colonoscopy, diet was slowly advanced from clear liquids to regular cardiac diet, which patient tolerated well. Electrolytes were repleted as needed to maintain K>4, Mg>2. . 7) Prophylaxis: Pneumoboots for DVT prophylaxis. Patient has IVC filter in place given h/o DVT. PPI for GI prophylaxis. . 8) Access: L SCV line placed by IR; removed prior to discharge. . 9) Code status: DNR/DNI Medications on Admission: Medications on admission to outside hospital: Lipitor 10mg QD Enteric coated Aspirin 81 mg Nexium 40mg QD Sotalol 40mg QD Prednisone 20mg QD . Home Meds: included sq heparin . Medications on transfer to outside hospital: Pantoprazole 40 mg PO Q12H Prednisone 20 mg PO DAILY Acetaminophen 325-650 mg PO Q4-6H:PRN Sotalol HCl 40 mg PO DAILY Atorvastatin 10 mg PO DAILY Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [3-15] hours as needed for pain. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital 941] - [Location 942] Discharge Diagnosis: PRIMARY: GI bleed Diverticulosis Ischemic colitis Gastritis CVL wire coiled in IVC filter . SECONDARY: Atrial fibrillation Hypertension Rheumatoid arthritis Pericarditis Pleuritis Discharge Condition: Stable Discharge Instructions: You were admitted from [Hospital ] Hospital with a catheter coiled in the filter in your inferior vena cava. You were evaluated by Interventional Radiology, and the catheter was disentangled. . You have also been evaluated for the source of your GI bleeding. Initially you received a blood transfusion to stabilize your hematocrit. Your colonoscopy showed evidence of diverticulosis and of ischemia in your sigmoid colon (which means that your bowel may not be getting adequate blood supply to it). Ischemic colitis is likely the source of your lower GI bleed. There is no further intervention necessary for these conditions. Your bleeding has subsided, and you have been hemodynamically stable for several days. . You should return to the hospital if you experience gross blood in your stool, shortness of breath, or chest pain. Followup Instructions: You will follow-up with your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 70012].	[ "438.89", "714.0", "275.41", "996.59", "401.9", "562.10", "V43.64", "729.89", "535.50", "458.9", "288.60", "578.1", "285.1", "427.31", "557.9", "E932.0" ]	icd9cm	[ [ [] ] ]	[ "99.04", "45.23", "97.49", "45.16", "96.33", "38.93" ]	icd9pcs	[ [ [] ] ]	8784, 8850	4913, 7930	251, 294	9074, 9083	3465, 4890	9971, 10092	2956, 2974		8348, 8761		8871, 9053		7956, 8325			9107, 9948								2989, 3446																						208, 213											322, 1530																	1552, 2775	2791, 2940
8,025	169,642	10934	Discharge summary	report	Admission Date: [2151-7-29] Discharge Date: [2151-8-15] Date of Birth: [2101-4-25] Sex: F Service: General Surgery - Blue Team HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old female with a history of Crohn's colitis who complains of three days of abdominal pain, mostly in the left lower quadrant. Chest x-ray revealed free air. The patient also had a white blood cell count of 16. The patient was admitted to the hospital. HOSPITAL COURSE: Considering the free air, there was a likely perforated viscus so the patient was immediately taken to the operating room on [7-29]. The patient underwent exploratory laparotomy, lysis of adhesions, sigmoid colectomy and colostomy and Hartmann's for a perforated sigmoid colon. Surgeon of record was Dr. [Last Name (STitle) ]. Assistant, Dr. [Last Name (STitle) 9779]. Findings included multiple intraperitoneal abscesses, perforated sigmoid colon. Post-operatively the patient was taken to the ICU with a Propofol drip for sedation, was intubated especially considering the patient's history of idiopathic pulmonary fibrosis. The patient also required Neo and a Swan as the case intraoperatively was complicated by hypotension. The patient was put on Vancomycin, Levofloxacin and Clindamycin and Protonix, subcu Heparin and a regular insulin sliding scale. Over the next few days the patient was able to be weaned off of pressors and the SICU team continued to attempt to wean the patient from the ventilator. On [7-31] the patient was extubated. Incidentally cultures came back that day from the intraabdominal fluid, gram positive cocci 3+, gram negative rods 4+, gram positive rods 3+. Status post extubation the patient had several episodes of respiratory distress, likely the patient's history of pulmonary fibrosis and pulmonary hypertension contributed to this. The patient did receive some Lasix with a good effect as she had received a large amount of fluid perioperatively. As of [8-1] the patient required 100% non rebreather with O2 sats greater than 90%. The patient remained on Hydrocortisone as treatment for the patient's pulmonary fibrosis and pulmonary hypertension and was also receiving Lasix 20 mg [Hospital1 ]. The patient continued to get aggressive chest physical therapy. Cultures on the patient's endotracheal tube grew out E. coli and Ceftriaxone was added to the Vanco, Levofloxacin, Clindamycin antibiotic regimen. The patient's respiratory status continued to improve and thus the patient was sent to the floor. On [8-5] the patient was satting 94% on 40% plus 6 liters nasal cannula. The patient had an episode of desaturation on 6 liters to 88% on [8-7]. More aggressive pulmonary toilet was required. The patient was put on 100% non rebreather and sats came up to 95%. Levofloxacin was discontinued. TPN was started. The patient was advanced to clear diet on [8-9]. The patient had an episode of desaturation on the night of [8-9], desaturated to 82% on mask, up to 99% on non rebreather. Also complained of feeling of dyspnea. At 1 a.m. on [8-10] the patient complained of chest pain. EKG showed no change. Chest x-ray showed no change from [8-7]. ABG was 7.47/43/64/32/6 on 15 liters non rebreather. The patient was given Lasix and then was transferred back to the SICU. The patient was found on CT scan to have a small fluid collection in the pelvis which had had a pigtail catheter in. This drainage tube was clogged [8-10], interventional aspirated and flushed the tube and unclogged it and orders were written to flush his catheter tid. Respiratory service was consulted on [8-11]. The pulmonologist recommended continuing antibiotics, tapering Hydrocortisone, continuing general diuresis. On [8-13] the patient was requiring C-pap to maintain oxygen saturation and at noon on [8-13] the patient was reintubated. Patient's blood pressure dropped to 80/40 so the patient was put on Neo-Synephrine. On [8-14] the patient underwent a bronchoscopy that showed thick secretions. During the procedure the patient had episodes of hypotension and tachycardia. The patient required FIO2 in the 90% range to maintain O2 saturation. ICU team was unable to wean down the FIO2. Every time they attempted to wean down the FIO2 the patient would desaturate. On [8-15] the patient required an FIO2 of 100% to maintain O2 sats in the low 90's. At this point in time it appeared that secondary to patient's history of idiopathic pulmonary fibrosis, the patient's prognosis was very poor and this poor prognosis was discussed with the family. At noon the family decided that in light of the patient's poor prognosis, she should be made comfort measures only. The patient was thus taken off all pressors and was pronounced dead at 12:50 p.m. on [8-15] and the death certificate was filed. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3799], M.D. [MD Number(1) 3800] Dictated By:[Last Name (NamePattern1) 4039] MEDQUIST36 D: [2151-9-22] 11:20 T: [2151-9-22] 13:12 JOB#: [Job Number ]	[ "997.4", "997.3", "518.5", "555.9", "482.82", "568.0", "567.2", "562.10", "569.83" ]	icd9cm	[ [ [] ] ]	[ "96.71", "99.15", "33.23", "54.59", "46.11", "45.76", "45.95" ]	icd9pcs	[ [ [] ] ]														485, 5185																																											185, 467
59,344	164,247	54853	Discharge summary	report	Admission Date: [2157-7-25] Discharge Date: [2157-8-17] Date of Birth: [2101-6-14] Sex: F Service: SURGERY Allergies: Vicodin Attending:[First Name3 (LF) 3376] Chief Complaint: fatigue, increased bloody ostomy output, inreased BRBPR Major Surgical or Invasive Procedure: [2157-8-13]: Exlap, small bowel resection [2157-8-14]: Exlap, Washout, jejunostomy, small bowel resection [2157-8-16]: Abdominal washout and closure History of Present Illness: 56 F s/p open total proctocolectomy with ileal J-pouch and anal anastomosis and diverting loop ileostomy [2157-7-1] due to UC now p/w n/v, BRBPR, increased ostomy output, and lethargy. Patient was discharged from the hospital [2157-7-14] and sent home with VNA services and TPN. Patient had a visit with the colorectal surgery team on [2157-7-22], where her TPN was increased from 750 to 1800cc/day. She was feeling well at that time. The following day, she noticed increased ostomy output (baseline 2L) to 2.6L. The VNA nurse [First Name (Titles) ] [Last Name (Titles) ] draining from the ostomy while changing the device. She also started to have increased BRBPR, and nausea/vomiting x1 day. This morning she had one episode of vomiting the VNA nurse reported as coffee ground in character. She has been progressively lethargic and has no appetite. She denies abdominal pain. She went to [Hospital3 ], where she was found to be tachycardic to 108-112 with BP 110s/50s. They transferred her to [Hospital1 18] for further management. Past Medical History: 1. Ulcerative colitis. 2. Total hysterectomy. 3. Ankle surgery. 4. Tonsillectomy. 5. Seasonal asthma/58 . Social History: She works for a nonprofit. Spends her summers on [Location (un) ] and otherwise lived in [State 2690]. She is a former smoker, quitting many years ago. She cannot drink any more due to her symptoms. Family History: Unremarkable. No history of inflammatory bowel disease or colon cancer. Physical Exam: patient is deceased Pertinent Results: CT Abd/Pelvis [2157-8-13]: IMPRESSION: 1. Findings concerning for ischemic bowel, most notably involving the distal loop of the ileum in the right lower quadrant which courses into the proximal limb of the ileostomy. No free intraperiotneal air or portal venous gas is noted. No evidence of contrast extravasation into the free fluid in the abdomen and pelvis to suggest perforation. Moderate-to-large amount of simple-appearing free fluid within the right abdomen and pelvis. 2. Multiple areas of low density intraluminal filling defect throughout the distal small bowel, which likely represents intraluminal clot. Small focus of hyperdensity within an intraluminal clot may represent a focus of pseudoaneurysm or retained focal oral contrast. 4. No CT evidence of internal hernia or volvulus. The mesenteric pedicle the pedicle is maintained. Post-surgical changes of the diverting loop ileostomy, ileal J-pouch and anal anastomosis and total colectomy are as described. Question of narrowing at the ostomy site. Recommend physical exam with digitation of this region. 3. Diffusely dilated proximal and distal small bowel, likely paralytic ileus due to above process. 4. Splenomegaly. 5. Moderate basilar pleural effusions and basilar atelectasis. Pathology [2157-8-13]: 1. Small bowel resection: Extensive areas of ulceration with acute and chronic inflammation and reactive changes. Ulcers focally extend into the muscularis propria. Focally, the mucosa has an ischemic pattern of injury. Fibrin thrombi are noted in small vessels focally in areas of ulceration, but these may be secondary to the ulceration. Scattered glands in the mucosa show atrophic changes and contain necrotic cellular debris. The pathologic changes extend to both resection margins. Focal foreign body type giant cells are present with foreign material consistent with previous surgery. There is no evidence of malignancy. Immunostains for CMV are negative with appropriate positive controls. No granulomas or pyloric metaplasia are seen. The differential diagnosis of these findings include infection (such as C. Difficile, etc), drug effect, immune type injury, vascular pathology,etc. Clinical correlation is needed. 2. Small bowel resection including ileostomy site: The pathologic changes are the same as described in the small bowel resection above and extend to one resection margin. Pathology [2157-8-14]: Small bowel resection, received in 5 segments: Changes are similar to the changes seen in the previous resection (S12-36618m). Severe enteritis with extensive ulceration and transmural acute and chronic inflammation is present in all segments and extends to resection margins. Ulcers extend into the muscularis propria focally. Focally, the mucosa has an ischemic pattern of injury. Scattered gland are dilated with atrophic changes and contain necrotic cellular debris. There is no evidence of malignancy. No viral inclusions are seen. No granulomas or pyloric metaplasia are seen. The differential diagnosis includes infection, immune type injury, drug effect, vascular pathology, etc. Clinical correlation is needed. Brief Hospital Course: The patient was readmitted to the inpatient colorectal surgery service after open total proctocolectomy with ileal J-pouch and anal anastomosis and diverting loop ileostomy [2157-7-1] with increased ileostomy ouput, bloody appearing ileostomy output, nausea and vomiting coffee ground appearing emesis, [Month/Day/Year ] tinged mucus per rectum and lethargy. The patient was given intravenous hydration and continued on her home dose of TPN. On [2157-7-26] she required a 500cc bolus of intravenous fluod. The patient has coffee ground emesis x2. The gastroenterology team was consulted and the patient was started on a protonix drip. The patient's hematocrit was noted to drift from 28.8 to 24.3 and she was given transfused 2 units of packed red [Date Range ] cells. her hematocrit increased to 31.0. She complained of urinary retention and a foley catheter was placed. Efforts were made to arrange an EGD however, because of continued nausea and vomiting, the patient required anesthesia presence suring the scope to be available as a precausion for impaired airway related to emesis and the study was postponed to the following morning. On [2157-7-27], the EGD was preformed and which showed severe friability in the whole examined duodenum. The GI team also examined the pouch which has a similar appearance. It was decided that this was most likely CMV and ganciclovir was initiated. The patient continued to have nausea and vomiting of moderate amounts of brown emesis. On [2157-7-28] she continued to take small amounts of a clear liquid diet with nutritional supplements. The GI team recommended checking a cortisol level and is stable continuing to taper down the steroids. The Ciprofloxacin was discontinued and the patient's hematocrit remained stable. Throughout this time the patient was monitored closely, she was very weak/lethargic and her appearance was concerning however she was hemodynamically stable. [2157-7-29], the surgical team was notified by GI that the biopsies from the EGD and slides prepared in pathology were negative for CMV. This was a concerning result. However, CMV remained very high on the differential and ganciclovir was continued as you can have a negative result and continue to have CMV. On [2157-7-30], ID was consulted who also had a very strong suspicion that this was due to CMV. On [2157-7-31], an NGT was placed and her nausea improved. Her steroids were again tapered to methylprednisolone 5mg. On [2157-8-3], she had another EGD and ileoscopy, which continued to show severe ulcerations with only slight improvement from previous exam. Her NGT was also pulled. On [2157-8-4], she had an episode of hypotension to 80/40s and improved with a fluid bolus. She was weaned completely off of steroids. Her ostomy output started to improve and looked much less bloody, and she was transfused 2U PRBC for low Hct. Her foley was pulled and she failed to void on [2157-8-5] and the foley was replaced. On [2157-8-6], she was started on ciprofloxacin for a UTI. On [2157-8-8], vanc was added to cover a urine culture growing enterococcus and staphylococcus. Rheumatology was consulted and felt her condition may be caused by autoimmune enteritis, likely not a vasculitis. Appropriate labs were sent as part of the work-up and came back normal/negative. [Doctor First Name ] neg, C3 129, C4 24, IgG 1360, CRP 173.6, ANCA neg. On [2157-8-9], dronabinol was started which improved her nausea. She also had some right UE swelling, and an UE doppler was obtained which was negative. Another ileoscopy was performed, and biopsy showed active enteritis and ulceration. High dose steroids was started, solumedrol 20mg q8h. On [2157-8-10], antibiotics for her UTI were discontinued. She developed a sacral ulcer that was given appropriate wound care, and was felt to be likely from constant moisture in the perianal region. On [2157-8-11], her octreotide was decreased due to decreased ostomy output, and she was transfused for a Hct 14.7. She also had a recurrence of dark bloody emesis x 3. On [2157-8-12], she had increased abdominal distention and continued decreased ostomy output. Octreotide was discontinued at that time. Due to increased bloody emesis x6, her heparin was discontinued and hematocrit was closely monitored. Her sacral wound was fully healed. She also was found to have MRSA in her small bowel biopsy, but was rare growth. She has had a history of MRSA infection in the past and was likely chronically colonized. On [2157-8-13], she continued to have bloody emesis, and NGT was placed, a CT scan was obtained showing signs of ischemic bowel, most notably involving distal loop of the ileum in the right lower quadrant which courses into the proximal limb of the ileostomy. The decision was made to take her to the OR for an ex-lap. Intraoperatively, she became very hypotensive and coagulopathic, and was started on pressors and transfused PRBCs, platelets, and FFP. The mesentery did not appear to be twisted and pulses could be felt all the way to the edge of the bowel. The entire bowel was thickened with patchy areas of full-thickness necrosis. Due to the bleeding and hypotension, she was packed and left open with plans to return to the OR the following day pending her stability. In the ICU, she remained hemodynamically stable and was transfused [Date Range ], platelets, and FFP. On [2157-8-14], she was taken back to the OR and underwent another ex-lap and small bowel resection of some necrotic small bowel. She was given a jejunostomy. Upon exploration of the pelvis, she again started to bleed profusely and was then packed with towels. JP drains were put in place to drain the abdomen. A functional wound vac was placed over the open abdomen, fashioned with an NGT and ioban. She was transfused more [Date Range ] products as needed. On [2157-8-15], a family meeting was held and she was made comfort measures only. On [2157-8-16], she was taken back to the OR where her abdomen was closed. She was made hospice and sedation was weaned. She passed away on [2157-8-17]. Medications on Admission: immodium 2mg qid, prednisone 15mg qd, opium 10 drops qid prn, benefiber tid, citalopram 20mg qd Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: bowel necrosis, death Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none Completed by:[2157-8-22]	[ "E878.8", "041.10", "553.3", "556.6", "729.81", "276.52", "788.20", "275.41", "707.22", "289.81", "041.04", "707.03", "276.8", "599.0", "518.51", "285.1", "557.0", "V85.0", "512.1", "V58.65", "V44.2", "789.59", "V02.54", "530.81", "275.2", "E879.8", "V49.86", "286.6" ]	icd9cm	[ [ [] ] ]	[ "45.14", "99.15", "45.61", "54.61", "45.62", "96.71", "45.16", "46.51", "45.24" ]	icd9pcs	[ [ [] ] ]	11571, 11580	5250, 11396	323, 485	11645, 11655	2075, 5227	11708, 11743	1947, 2020		11542, 11548		11601, 11624		11422, 11519			11679, 11685								2035, 2056																						228, 285											513, 1576																	1598, 1706	1722, 1931
49,860	169,383	12806	Discharge summary	report	Admission Date: [2118-6-27] Discharge Date: [2118-6-30] Date of Birth: [2058-7-21] Sex: M Service: MEDICINE Allergies: Ibuprofen Attending:[First Name3 (LF) 7299] Chief Complaint: Fevers, Elevated LFT's Major Surgical or Invasive Procedure: ERCP with stent placement History of Present Illness: 59 y/o M with PMHx significant for DM, who was transferred from the BIDN ED with fevers and elevated LFTs. Per report, the patient has had 3 days of fevers, myalgias, and worsening jaundice. Fevers were as high as 104 at home. He ultimately presented to [Hospital ] Hospital on [6-26] and was referred to BIDN. In the ED at BIDN, labs were significant for WBC 2.2, H/H 14.9/42.0, PLT 43, ALT/AST 59/70, TBili 5.23, AlkPhos 201, Lipase 478. Creatinine was also elevated at 1.5 (baseline 0.9-1.0). Per report, RUQ U/S performed at BIDN showed dilated CBD at 12mm, proximal CBD not visualized, no stones no GB wall thickening. Given leukopenia/thrombocytopenia, elevated LFTs, there was some concern for potential erlichiosis. He was given doxycycline, erlichia serologies pending at BIDN. He was transferred to [Hospital1 18] for ERCP evaluation. . On arrival to the [Hospital1 18] ED, the patient's VS were 102.1 96 106/73 16 98%. ERCP was contact[Name (NI) ] with plans to perform ERCP in the morning. He was given a dose of unasyn. Per ERCP recs, he will need 2 units of platelets in the morning prior to procedure. He was initialy going to be admitted to the general medicine floor. However, he was noted to have some borderline blood pressures (systolics in the 80s) while sleeping in the ED. He was asymptomatic during this time. He is now being admitted to the ICU for closer monitoring. VS prior to transfer were 80 97/45 18 98% on 2L NC. . On arrival to the ICU, the patient's VS were 98.4 115/71 73 21 100%RA. He denied any current complaints. He endorsed generalized body aches several days ago that have resolved. He did endorse some right sided abdominal TTP earlier today. He also endorsed mild nausea. No sick contacts. [Name (NI) ] does spend a lot of time outdoors near his home in [Location (un) ]. He endorses exposure to ticks but does not recall any tick bites. He recently traveled to [Country 6607] for [Hospital1 107] Day Weekend. . 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 vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: - Diabetes mellitus Social History: He is married. Son 20 years old, in college. He denies smoking. He drinks beer or wine sometimes, in small quantity. Used to works in immunology research, now unemployed. Family History: Diabetes involves multiple family members including his mother. One of his brothers passed away from diabetic complications. There is no colon or rectal cancer in the family Physical Exam: Physical Exam on Arrival to the [Hospital Unit Name 153] Vitals: 98.4 115/71 73 21 100%RA General: Alert, oriented, no acute distress HEENT: Sclera icteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Derm: small circular lesion on left lower back with central punture, somewhat resembling insect or tick bite Neuro: CN 2-12 grossly intact, 5/5 strength throughout Pertinent Results: [2118-6-27] 03:51AM BLOOD WBC-1.7# RBC-3.64# Hgb-12.0# Hct-33.7# MCV-92 MCH-32.9* MCHC-35.6* RDW-13.0 Plt Ct-40# [2118-6-28] 06:45AM BLOOD WBC-2.8 RBC-3.65* Hgb-11.7* Hct-34.3* MCV-94 MCH-32.1* MCHC-34.2 RDW-13.4 Plt Ct-57* [2118-6-30] 07:40AM BLOOD WBC-4.9 RBC-4.07* Hgb-12.9* Hct-38.0* MCV-93 MCH-31.8 MCHC-34.1 RDW-13.4 Plt Ct-164# [2118-6-28] 06:45AM BLOOD Parst S-NEGATIVE [2118-6-30] 07:40AM BLOOD Glucose-137* UreaN-9 Creat-1.0 Na-138 K-3.8 Cl-106 HCO3-22 AnGap-14 [2118-6-27] 02:15AM BLOOD LD(LDH)-236 TotBili-3.7* DirBili-3.0* IndBili-0.7 [2118-6-28] 06:45AM BLOOD ALT-52* AST-90* LD(LDH)-223 AlkPhos-211* TotBili-1.9* [2118-6-30] 07:40AM BLOOD ALT-86* AST-79* AlkPhos-208* TotBili-1.3 [2118-6-28] 06:45AM BLOOD Lipase-[2050]* [2118-6-30] 07:40AM BLOOD Lipase-484* [2118-6-29] 06:45AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.1 [2118-6-27] 03:51AM BLOOD Calcium-7.3* Phos-2.0* Mg-2.0 Iron-17* [2118-6-27] 03:51AM BLOOD calTIBC-226* Ferritn-[2073]* TRF-174* [2118-6-27] 03:51AM BLOOD HBsAb-POSITIVE HBcAb-NEGATIVE IgM HAV-NEGATIVE [2118-6-27] 03:51AM BLOOD HCV Ab-NEGATIVE [2118-6-27] 02:15AM BLOOD LYME BY WESTERN BLOT-PENDING [2118-6-29] 09:08AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA [Doctor Last Name ]) IGG/IGM-PENDING . Serologies for babesia negative . RUQ U/S (per ED report, report not available in CareWeb): US shows dilated CBD 12mm proximal part not visualized; no stones; no GB wall thickening. . ERCP Report: Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Mucosa: Moderate patchy erythema and edema was noted in the duodenum Major Papilla: Normal major papilla Cannulation: Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. A straight tip guidewire was placed. Biliary Tree: A moderate diffuse dilation was seen at the biliary tree with the CBD measuring 12 mm. No filling defects were noted. However, given high clinical suspicion of cholangitis, a 10Fr x 5cm plastic biliary stent was placed. Excellent drainage of clear, yellow bile and contrast was noted. A sphincterotomy was not performed today due to pt's thrombocytopenia and high risk of bleeding. Pancreas: The very distal PD was partially opacified with contrast and appeared unremarkable. Impression: Moderate patchy erythema and edema was noted in the duodenum Normal major papilla The very distal PD was partially opacified with contrast and appeared unremarkable Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique A moderate diffuse dilation was seen at the biliary tree with the CBD measuring 12 mm. No filling defects were noted. However, given high clinical suspicion of cholangitis, a 10Fr x 5cm plastic biliary stent was placed. Excellent drainage of clear, yellow bile and contrast was noted. A sphincterotomy was not performed today due to pt's thrombocytopenia and high risk of bleeding Brief Hospital Course: 59 y/o M with PMHx of DM who presented to BIDN with 4 days of high fevers, myalgias and was found to have abnormal LFTs, leukopenia and thrombocytopenia. RUQ u/s showed dilated CBD at 12mm with a Tbili of 5 and pt was transferred to [Hospital1 18] for ERCP evaluation due to concern for possible cholangitis. There was concern for tickborne illness and pt was started on Unasyn with Doxycycline. On [6-27], pt was taken for ERCP which confirmed biliary dilation without any clear obstruction process and a stent was placed due to "high clinical suspician" for cholangitis. There was no purulent drainage seen after stent placement. Pt was transferred back to the floor and initially denying any abd pain or nausea. However, the day following ERCP he developped epigastric pain that was attributed to post ERCP pancreatitis with lipase >[2107]. He was treated with aggressive IVF, morphine and zofran with some improvement in symptoms. Pt noted resolution of fevers within 24hrs of starting Unasyn/Doxycycline. His Leukopenia and thrombocytopenia resolved rapidly while on these antibiotics. Given that there was no evidence of purulent drainage or biliary obstruction it was felt unlikely that cholangitis was the underlying explanation for his presentation. His clinical picture appeared most consistent with severe ehrlichiosis with the 4 days of high fevers and myalgias without further localizing symptoms. Pt was incidentally found to have abnormal LFTs and there is a case report series published of pts with ehrlichiosis developping cholestasis and liver injury. His additional hepatitis work up included a negative CMV and acute viral hepatitis panel. Pt was continued on Doxycycline for a 10 day course with both Ehrlichia and Lyme serologies pending at the time of discharge. He was given a 7 day course of Cipro for post stent prophylaxis. There was consideration of stent removal while in house but the ERCP team felt it would be safer to allow for complete resolution of his pancreatitis prior to repeat ERCP. Pt was discharged with a short course of oxycodone to manage epigastric pain attributed to pancreatitis and he was scheduled to follow up with Dr. [Last Name (STitle) 9006] on [7-4] to monitor for resolution of symptoms. Pt was restarted on Metformin prior to discharge and encouraged to return if he developped recurrent fevers or any other general worsening of condition. Medications on Admission: - Metformin 500mg qAM / 1000mg qnoon / 1000mg qPM - Tylenol prn - Motrin prn Discharge Medications: 1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:9 Tablet(s) Refills:0 2. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 7 days. Disp:14 Capsule(s) Refills:0 3. metformin 500 mg Tablet Sig: 1-2 Tablets PO three times a day: resume home regimen of 1 tab in the am and 2 tabs at lunch & dinner. 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 5 days. Disp:15 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Fevers Abnormal LFTs Leukopenia Thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with fevers, myalgias, abnormal liver function tests and concern for biliary obstruction. You were taken for ERCP and had a stent placed in the biliary tree due to concern for cholangitis. You developped post procedure pancreatitis which is slowly improving with bowel rest and fluids. It is most likely that the fevers were due to a tick borne infection called ehrlichiosis but the serologies for this diagnosis will not be available for another few weeks. . Please note the following changes to your medications: 1. Continue taking Cipro 500mg twice daily for another 4 days to complete 7 days of post stent prophylaxis. 2. Continue taking Doxycycline 100mg twice daily for another 6 days to complete the course for treatment of ehrlichiosis & potential co-infection with lyme disease. 3. Oxycodone 5-10mg every 6hrs as needed for pain (do not drive while taking this medication ) . Please speak with Dr. [Last Name (STitle) 9006] at your appointment [7-4] to ensure that your abdominal pain/pancreatitis is resolving. You should get follow up liver function tests at this appointment to monitor for resolution. Followup Instructions: Department: [Hospital3 249] When: MONDAY [2118-7-4] at 11:20 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ENDO SUITES When: WEDNESDAY [2118-8-3] at 1:15 PM Department: DIGESTIVE DISEASE CENTER When: WEDNESDAY [2118-8-3] at 1:15 PM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 463] Building: [First Name8 (NamePattern2) ] [Hospital Ward Name 1950] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 1951] Campus: EAST Best Parking: Main Garage	[ "577.0", "250.00", "082.40", "E879.8", "784.0" ]	icd9cm	[ [ [] ] ]	[ "51.87" ]	icd9pcs	[ [ [] ] ]	10042, 10048	6945, 9383	294, 321	10150, 10150	3883, 6922	11469, 12194	2949, 3124		9510, 10019		10069, 10129		9409, 9487			10301, 10808								3139, 3864																		10837, 11446				231, 256						2358, 2698					349, 2340											10165, 10277						2720, 2741	2757, 2933
41,899	186,389	53833	Discharge summary	report	Admission Date: [2167-3-16] Discharge Date: [2167-4-10] Date of Birth: [2141-5-23] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3376] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: Sigmoidoscopy total abdominal colectomy with end ileostomy History of Present Illness: Mr. [Known lastname 7635] is a 25 year-old man presenting with abdominal pain. In [2167-1-22] patient presented to PCP with three weeks of loose stools (up to 5 per day) with blood. He was referred to GI who performed a flex-sig showing "ulceration, granularity, friability, erythema, exudates and congestion in the rectum - 40cm compatible with colitis". Biopsy showed "chronic active proctitis". He was then started on asacol. In the interim weeks his symptoms improved but did not return completely to normal (normal formed stools but persistent low amounts of blood). Approximately 5 days prior to admission the number of bowel movements increased to 10-15 per day with blood. He also experienced pain, at times severe, "crampy", "like a balloon". Also nausea without vomiting. Two days prior to admission he took a double dose of asacol. Today, given continued symptoms, he presented for evaluation. No recent antibiotics. ROS: (-) fever (+) <5 lbs of weight loss since diagnosis (+) headache (+) cough (-) CP/SOB (+) back pain (+) decreased urine output (-) rash, arthralgias All other ROS negative Past Medical History: 1. Ulcerative colitis, as per HPI 2. History of tonsilectomy Social History: Has never smoked. Drinks up to 5 alcoholic beverages per week. Over last 6 weeks has not had more htan 2 in a week. No other drug use. Family History: No known history of bowel diseases, including IBD. Physical Exam: Vitals: T 99.5, BP 120/60, HR 76, 97% on room air General: Comfortabel, well-appearing Eyes: No icterus; no pallor ENT: No cervical adenopathy; OP is without exudates; dry MM CV: Regular Pulm: Clear; comfortable Abd: Soft; mildly tender in lower quadrants; no rebound/guarding; bowel sounds present Skin: No rashes; warm Neuro: Alert and oriented x3 Psych: Calm; appropriate Pertinent Results: ADMISSION LABSS: [2167-3-16] NEUTS-53 BANDS-23* LYMPHS-7* MONOS-13* EOS-3 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 WBC-14.5# RBC-4.72 HGB-14.1 HCT-41.7 MCV-88# MCH-29.9 MCHC-33.8 RDW-12.5 GLUCOSE-86 UREA N-7 CREAT-1.1 SODIUM-137 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-22 ANION GAP-22 KUB: A nonspecific bowel gas pattern is present. There is relative paucity of bowel gas within the small bowel. An air-fluid level is seen within the proximal colon, which is not distended. There is no free air. Included views of the lung bases are clear. . Colon biopsy: severe chronic active colitis . CT Scan: 1. Diffuse dilation of the stomach and small bowel loops with gradual tapering toward the ileostomy. No discrete transition zone is seen. These might represent some degree of partial obstruction or reactive ileus given the amount of ascites which is seen with mild enhancement of the peritoneum. This may be reactive to the recent leak, but superimposed infection cannot be ruled out. 2. Surgical staple site at the rectal stump is unremarkable though the assessment is limited due to lack of rectal contrast. 3. Post operative peritoneal free air within expected limits and extra/retroperitoneal air that track into the left thigh and up into the right retroperitoneal space. This is likely related to the presenting subcutaneous crepitus and right colonic perforation. Brief Hospital Course: 25M with a history of ulcerative colitis on mesalamine who is admitted with fever, leukocytosis, lower abdominal pain, and bloody diarrhea. Presentation consistent with acute colitis. . #ULCERATIVE COLITIS: He was started on iv steroids, with only minimal improvement in symptoms. Sigmoidoscopy and colon biopsy revealed severe chronic active colitis. PPD was placed on [3-23] and read on [3-25] (negative, no induration). Infectious work-up including Cdiff and CMV was negative. He was given a first dose of Remicade on [3-25] and a second dose on [3-27], and again on [3-31]. His UC was steroid refractory during the 1st 16 days of admission. On [4-1], he was taken for total colectomy by colorectal Surgery, given his lack of improvement, and persistent e/o subcutaneous air in the R shoulder seen on KUB/CXR's. He was stable during his o/n monitoring in the [Hospital Unit Name 153]. . # Hyponatremia: Pt likely had hypovolemic hyponatremia [12-25] loss of volume secondary to diarrhea. There was likely also component of ADH secretion secondary. Improvements in his sodium have been seen with fluid repletion. In the [Hospital Unit Name 153], he received 100cc/hr LR continuous and frequent Na checks, and his Na remained stable. . # Acute Interstitial Nephritis, probable: Cr rose slightly. He was evaluated by Nephrology and felt to have AIN from mesalamine, which was stopped. Renal function returned to baseline. He should follow-up with Nephrology as an outpatient. . # THRUSH/OROPHARYNGEAL CANDIDIASIS: he developed throat pain while on steroids and exam showed thrush. He was started on po fluconazole and Nystatin swish/swallow on [3-25] to complete a 7 day course. His symptoms improved. He did not have symptoms of esophagitis. The patient underwent laparoscopic converted to open total abdominal colectomy with end ileostomy for UC unresponsive to medical therapy. An NG tube and rectal drain were placed intraoperatively. He remained in the [Hospital Unit Name 153] overnight for intensive monitoring. He was stable overnight. On POD #1 his sodium was stable in the mid-120's and he was transferred to the floor. His NG tube put out very little and was subsequently removed. His electrolytes were rechecked and were stable, and he was switched to normal saline IV fluid at 75/hr. The nephrology service continued to follow him. He was on solumedrol 12.5mg q12 hours which was subsequently tapered since he had been on steroids previously during this hospitalization. He remained NPO with his rectal tube in place w/ minimal output. On POD #2 he was advanced to sips which he tolerated well. His rectal tube was removed. Surveillance blood cultures were obtained. His steroids were decreased by half to 6.25mg solumedrol q12. His sodium was stable and he was given a fluid challenge to see if his sodium would increase. Infectious disease evaluated the patient and recommended a 2 week course of IV antibiotics to treat the group B strep blood infection. On POD #3 he received 2u blood for Hct of 21.7 with an increase to 24.9 following transfusion. He was started on po pain medications and was tolerating a regular diet. His serum sodium was 129. His steroids were discontinued. On POD#4 he had increased abdominal pain and was restarted on a dilaudid PCA. He had nausea with emesis and was made NPO. He was started on protonix. On POD #5 his WBC remained elevated and CT scan was obtained that did not show an abscess, but did show significant stomach and small bowel distention consistent with ileus. A vancomycin trough was therapeutic. His ostomy output was decreased and he was started on reglan. He was put on standing ativan for anxiety and pain and the PCA dose was decreased. On POD #5 the WBC was stable. He remained NPO with IVF. He was drowsy and the ativan was made prn. His pain control remained good. His ostomy output increased to > 1000cc and his reglan was discontinued. On POD #6 the WBC decreased to 17 and he was afebrile. He was started on a clear liquid diet which he tolerated. Per ID recs his IV antibiotics were switched to Ceftriaxone to treat his previous bacteremia for a total course of 2 weeks starting [4-1]. On POD #7 his pain medicines were changed to po and a midline was placed for IV antibiotics. On POD #8 he was tolerating a regular diet, ambulating, and his ostomy had appropriate output. He had a small amount of drainage from his wound without significant induration or erythema, and the decision was made to monitor it as an outpatient. He was passing less serous/bloody fluid per rectum as well. He was stable and was discharged home and will follow-up in colorectal surgery clinic. Medications on Admission: 1. Asacol 2.4 grams daily 2. Vitamin D 3. Multivitamin Discharge Medications: 1. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: Two (2) grams Intravenous Q24H (every 24 hours) for 5 doses. Disp:10 grams Refills:0 2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:60 Tablet(s) Refills:0 4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 5. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Ulcerative colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a Total Abdominal Colectomy for surgical management of your Ulcerative Colitis which resulted in a perforation of your colon. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you regarding these results they will contact you before this time. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or constipation. You have a long vertical incision on your abdomen that is closed with staples. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. The staples will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. You have a new ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. You must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If you find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if you notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If you notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. You may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to you by the ostomy nurses. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. The stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as you have been instructed by the wound/ostomy nurses. You will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. You will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until you are comfortable caring for it on your own. Currently your ileostomy is allowing the surgery in your large intestine to heal, which does take some time. You will need to come back to have further procedures to build a Jpouch and takedown the ileostomy and the timeing for this will be decided by Dr. [Last Name (STitle) 1120]. Until this time there is healthy intestine that is still functioning as it normally would and it will produce mucus and some may leak or you may feel as though you need to have a bowel movement and you may sit on the toilet and empty this mucus, it is normal. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. [Last Name (STitle) 1120] or Dr. [Last Name (STitle) ]. You may gradually increase your activity as tolerated but clear heavy exercise . You will be prescribed a small amount of the pain medication. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. You will complete a course of IV ceftriaxone as an outpatient. Your last dose should be on [4-14]. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: Please call the colorectal surgery office to make an appointment for your first post-operative check wiht [First Name8 (NamePattern2) 1123] [Last Name (NamePattern1) 1124], [Telephone/Fax (1) 110468]. At this vist an appoinment will be made for you with Dr. [Last Name (STitle) 1120] for your first post-operative visit. Please call the clinic with any questions or concerns related to your surgery. Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2167-7-29] at 8:30 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6925] [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Completed by:[2167-4-10]	[ "560.1", "569.83", "276.1", "262", "V85.0", "V64.41", "112.0", "580.89", "556.6", "038.0", "995.91", "285.1" ]	icd9cm	[ [ [] ] ]	[ "45.82", "45.25", "96.6", "46.20" ]	icd9pcs	[ [ [] ] ]	9061, 9119	3632, 8347	312, 373	9182, 9182	2233, 3609	14598, 15407	1771, 1823		8452, 9038		9140, 9161		8373, 8429			9333, 14575								1838, 2214																						264, 274											401, 1519											9197, 9309						1541, 1603	1619, 1755

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