ChanBeDu/relevant_section_length · Datasets at Hugging Face

8,049

109,870

22160

Discharge summary

report

Admission Date: [**2161-7-4**] Discharge Date: [**2161-7-25**] Date of Birth: [**2091-8-28**] Sex: F Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 57860**] is a 69-year-old female, who has developed sudden onset of abdominal pain, which was band like and sharp on the day of admission. She complains of flank and back pain. She states she has had vomiting, which is nonbilious. She was brought to the [**Hospital1 1444**], and an ultrasound was performed in the emergency department, which was consistent with gallstone pancreatitis. The patient denies fevers, chills, or loose stools. PAST MEDICAL HISTORY: Significant for hypertension. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Toprol XL 50 mg q.d. 2. Norvasc 10 mg q.d. SOCIAL HISTORY: The patient lives alone at home. She denies any drug history. FAMILY HISTORY: The patient is adopted. PHYSICAL EXAMINATION: Vital Signs: Temperature 98.1 degrees Fahrenheit, heart rate 60, blood pressure 117/66, respiratory rate 18, and oxygen saturation 97 percent on room air. In general, the patient is alert and oriented, and in no apparent distress. HEENT is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. Sclerae are anicteric. Cardiovascular: Regular rate and rhythm, with no murmurs, rubs, or gallops. No jugular venous distention. Respiratory: Clear to auscultation bilaterally. No crackles. Abdomen: Soft, nondistended, with mild bilateral subcostal tenderness, and epigastric tenderness. There is no rebound, rigidity, or guarding. No [**Doctor Last Name 515**] sign. Rectal exam: Negative. Extremities: Warm. LABORATORY DATA: EKG: Slight ST segment changes in the precordial leads less than 1 mm, but enzymes are negative (outside hospital). EKG here unremarkable with sinus rhythm at 75. Labs obtained in the emergency department: Sodium 144, potassium 3.9, chloride 107, bicarbonate 25, BUN 17, creatinine 0.7, and glucose 160. White blood cell count 10.2, hematocrit 40.2, and platelets 202,000. AST 320, ALT 268, alkaline phosphatase 319, total bilirubin 2.7, amylase 4514, and albumin 4.8. HOSPITAL COURSE: Ms. [**Known lastname 57860**] was admitted to the Platinum Surgery Service on [**2161-7-4**] and underwent an ERCP. The ERCP demonstrated periampullary edema. There was also dilation of the distal pancreatic duct. There was minor common bile duct dilation to 9 mm, and a single 5 mm stone was seen within the common bile duct that was causing partial obstruction. A sphincterotomy was performed, and the stone was extracted successfully using a balloon. The patient was kept n.p.o. and started on imipenem. On [**2161-7-6**], the patient spiked a fever to 102.7 degrees Fahrenheit, and was complaining of shortness of breath with diffuse upper quadrant abdominal pain. She denied chest pain or nausea and vomiting. An ABG was drawn, which was essentially normal. The patient's oxygen was increased to 4 liters, and she was placed on a facemask. A chest x-ray was obtained, which showed a pleural effusion, most likely from her pancreatitis. On the morning of [**2161-7-7**], the patient's oxygen requirements had increased to 6 liters by facemask and she was still short of breath. She had decreased breath sounds bilaterally in her lung bases. Another EKG was done, which showed no change from her previous EKG. Another ABG was drawn, which was again within normal limits. Due to increased oxygen demand and shortness of breath, she was transferred to the ICU for closer observation. On [**2161-7-9**], a central line was placed and total parenteral nutrition was started. She was diuresed with Lasix, and her right chest was tapped. Her blood sugars were consistently elevated in the 200 range. She was therefore on an insulin drip for a short time, and then insulin was added to her TPN, which kept her blood sugars within the normal range. At one point, she required 180 units of insulin in her TPN per day. She also required BiPAP for a short while, while in the ICU. On [**2161-7-15**], her pain had improved to the point where she was able to start sips of clears. On [**2161-7-15**], she was only requiring 2 liters of oxygen per nasal cannula, her pain had improved, and she no longer had shortness of breath. She was therefore transferred to the floor. On [**2161-7-18**], her imipenem was discontinued, as she had completed a 14-day course. She remained on TPN while on the floor. On [**2161-7-20**], the patient underwent a laparoscopic cholecystectomy for gallstone pancreatitis. There were no complications. Also, see the operative note. The patient was kept on TPN postoperatively, but her diet was advanced as tolerated. Throughout her hospital course, her liver enzymes had continued to decrease. However, on [**2161-7-22**], her amylase, alkaline phosphatase, and total bilirubin all slightly increased. She was therefore made n.p.o. and restarted on her TPN. When rechecked the following morning, however, the enzymes had all again fallen. She was therefore restarted on a low-fat diet. On [**2161-7-23**], it was noted that there was slight erythema and purulence of her umbilical port incision. The wound was therefore opened, and wet-to-dry dressing changes were started 3 times a day. She was also started on a 7-day course of Keflex. On [**2161-7-25**], the patient's pain was very well controlled with oral pain medications, her liver enzymes were still falling, and she was tolerating a regular diet and p.o. medications. She was therefore discharged to home with visiting nurses to assist her with her dressing changes. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: Gallstone pancreatitis. Hypertension. Status post laparoscopic cholecystectomy. Status post endoscopic retrograde cholangiopancreatography. DISCHARGE MEDICATIONS: 1. Percocet 5-325 mg tablets, 1 to 2 tablets p.o. q.4-6h. p.r.n. for pain. 2. Cephalexin 500 mg capsule, 1 capsule p.o. q.6h. for 5 days. 3. Atenolol 50 mg tablet, 1 tablet p.o. q.d. 4. Multivitamin with minerals, 1 caplet p.o. q.d. FOLLOWUP PLANS: The patient is to follow up with Dr. [**Last Name (STitle) **] in 1 to 2 weeks. She is to call his office for an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13137**] Dictated By:[**Last Name (NamePattern1) 11988**] MEDQUIST36 D: [**2161-7-25**] 14:21:21 T: [**2161-7-26**] 06:27:59 Job#: [**Job Number 57861**]

[ "401.9", "577.0", "272.0", "511.9", "574.71" ]

icd9cm

[ [ [] ] ]

[ "34.91", "38.93", "51.23", "51.85", "38.91", "99.15", "51.88" ]

icd9pcs

[ [ [] ] ]

907, 932

5831, 5975

5998, 6653

2264, 5748

761, 809

955, 2246

182, 648

671, 740

826, 890

5773, 5809

27,931

179,848

31427

Discharge summary

report

Admission Date: [**2106-10-6**] Discharge Date: [**2106-10-27**] Service: CARDIOTHORACIC Allergies: Morphine Sulfate Attending:[**First Name3 (LF) 165**] Chief Complaint: Fevers, tachycardia, non-healing sternal wound Major Surgical or Invasive Procedure: Debridement of sternum [**10-8**] Debridement of sternum [**10-20**] History of Present Illness: Mr [**Known lastname **] is s/p CABG in [**8-10**] discharged to rehab and subsequently readmitted in [**9-10**] for superficial sternal wound infection which was locally debrided and a VAC dsg applied. Pt now returns with sternal dehisence Past Medical History: s/p CABGx5 [**8-13**], s/p trach & PEG [**8-31**] MI [**2071**], CHF, Afib (currently NSR), lipids, HTN, BLE vein surgery [**2041**], bilat knee surgery. Social History: retired lives with wife at [**Name (NI) 74005**] Place quit tobacco 15 years ago, 30 pack year history occasional etoh Family History: NC Physical Exam: Neuro: Awake- not following commands Pulm: course rhonchi CV: irreg-irreg, sternum with open wound wires exposed. Abdm: soft, NT/ND Ext: warm palpable pulses Pertinent Results: [**2106-10-26**] 02:50AM BLOOD WBC-7.9 RBC-2.62* Hgb-8.2* Hct-25.2* MCV-96 MCH-31.3 MCHC-32.6 RDW-18.8* Plt Ct-103* [**2106-10-26**] 02:50AM BLOOD Plt Ct-103* [**2106-10-26**] 02:50AM BLOOD PT-14.5* PTT-43.5* INR(PT)-1.3* [**2106-10-26**] 02:50AM BLOOD Glucose-124* UreaN-82* Creat-1.9* Na-136 K-4.4 Cl-104 HCO3-23 AnGap-13 [**2106-10-6**] 10:21PM GLUCOSE-100 UREA N-109* CREAT-2.4* SODIUM-154* POTASSIUM-5.5* CHLORIDE-117* TOTAL CO2-23 ANION GAP-20 [**2106-10-6**] 04:21PM PLT COUNT-163# [**2106-10-6**] 04:21PM PT-15.8* PTT-31.5 INR(PT)-1.4* [**2106-10-6**] 04:21PM WBC-7.8 RBC-3.35* HGB-10.4* HCT-31.8* MCV-95 MCH-31.0 MCHC-32.7 RDW-17.3* ECHOCARDIOGRAPHY REPORT [**Known lastname 41110**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 74008**]Portable TEE (Complete) Done [**2106-10-21**] at 3:29:28 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] [**Street Address(2) 15115**] [**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2022-8-21**] Age (years): 84 M Hgt (in): 70 BP (mm Hg): 106/72 Wgt (lb): 180 HR (bpm): 84 BSA (m2): 2.00 m2 Indication: Endocarditis. ICD-9 Codes: 424.90 Test Information Date/Time: [**2106-10-21**] at 15:29 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]: Cardiology Fellow Doppler: Full Doppler and color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2007W000-0:00 Machine: Vivid i-4 Sedation: Patient was monitored by a nurse throughout the procedure Echocardiographic Measurements Results Measurements Normal Range Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Depressed LVEF. RIGHT VENTRICLE: RV function depressed. AORTA: Simple atheroma in ascending aorta. Simple atheroma in aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets. No masses or vegetations on aortic valve. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on mitral valve. Mild to moderate ([**1-5**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on tricuspid valve. Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was monitored by a nurse in [**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 patient was under general anesthesia throughout the procedure. No TEE related complications. Echocardiographic results were reviewed with the houseofficer caring for the patient. Conclusions No atrial septal defect is seen by 2D or color Doppler. LV systolic function appears depressed. Right ventricular systolic function appears depressed. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**1-5**]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. IMPRESSION: No evidence of endocarditis. Complex plaque in the descending thoracic aorta. Mild aortic regurgitation. Mild-moderate mitral regurgitation. Moderate tricuspid regurgitation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting physician Brief Hospital Course: Pt admitted and brought to the operating room for sternal debridement. He was transferred to the cardiac ICU paralyzed and sedated with an open chest, requiring pressors for BP control. Over the next several days the plastic surgery and ID services were consulted. He was weaned from some of his pressor support and on POD5 a wound vac was placed, following which he was able to be weaned from his paralytics and pressor support. He returned to the OR for further debridement on [**10-20**], and again a VAC was placed. On POD 19 the family asked that the patient be supported with comfrt measures only. At 16:46 the pt expired Medications on Admission: Lantus 15 units daily, insulin SS, Sertraline 50 mg daily, lisinopril 2.5 mg daily, trazodone 50 mg QHS, zantac 150 mg daily, nafcillin 2g 4 times daily, metolazone 5 mg daily, lipitor 10 mg daily, metoprolol 25 mg TID, levaquin 500 mg daily, lasix 40 mg IV BID, QVar 80 mcg [**Hospital1 **], MVI, Coumadin (held), ativan 1 mg prn, albuterol & atrovent nebs Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Sternal dehiscence Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: none [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

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icd9cm

[ [ [] ] ]

[ "34.04", "38.91", "88.72", "99.15", "77.61", "96.6", "86.11" ]

icd9pcs

[ [ [] ] ]

6554, 6563

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277, 348

6626, 6637

1146, 5464

6690, 6789

948, 952

6525, 6531

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6143, 6502

6661, 6667

967, 1127

191, 239

376, 618

640, 795

811, 932

10,331

172,911

571

Discharge summary

report

Admission Date: [**2140-1-8**] Discharge Date: [**2140-1-14**] Date of Birth: [**2060-1-20**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Motrin / Erythromycin Base Attending:[**First Name3 (LF) 898**] Chief Complaint: dyspnea, fatigue Major Surgical or Invasive Procedure: central line placement History of Present Illness: 78 F with h/o asthma seen at [**Hospital1 18**] ED on [**1-7**] and found to have LLL pneumonia. Pt was sent home on antibiotics and asked to return on [**1-8**] were she was found to be increasingly dyspneic, tachycardic 120's , and hypoxic 50% (RA). Pt was immediately intubated in the ED and found to have ABG of 71.5/69/556 after intubation. Pt was transfered to the ICU for hypercarbic respitory failure on [**1-8**]. Past Medical History: 1. asthma 2. cataracts 3. severe bilateral hearing loss 4. allergic rhinitis Social History: Lives alone in [**Location (un) **] MA. She is a widow. She has one daughter that lives in [**Location 652**], CA. Her phone # [**Telephone/Fax (1) 4577**]. She does not smoke or drink EtOH. Family History: no cancer or diabetes Physical Exam: T 98.9 BP 121/60 HR 120 RR 16 A/C 400x18 PEEP 8 FI02 50% Gen: intubated, sedated HEENT: PERRL Neck: supple, no LAD Lungs: diffuse b/l wheezing; R>L CV: S1, S2, tachycardia, no murmurs Abd: BS present, soft, ND Ext: no edema, warm, Neuro: responsive to pain Pertinent Results: [**2140-1-8**] 04:10AM WBC-7.2 RBC-4.74 HGB-15.4 HCT-46.2 MCV-98 MCH-32.6* MCHC-33.4 RDW-12.3 [**2140-1-8**] 04:10AM PLT COUNT-282 [**2140-1-8**] 04:10AM NEUTS-40.4* LYMPHS-43.2* MONOS-4.7 EOS-11.0* BASOS-0.9 [**2140-1-8**] 04:10AM GLUCOSE-159* UREA N-17 CREAT-0.7 SODIUM-140 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-31* ANION GAP-11 [**2140-1-8**] 07:29PM LACTATE-2.1* [**2140-1-8**] 08:48PM TYPE-ART PO2-556* PCO2-69* PH-7.15* TOTAL CO2-25 BASE XS--6 Brief Hospital Course: Her medical ICU course is summarized by briefly by problems: 1. resp failure - pt was treated with levofloxacin initially (later changed to ceftriaxone/azithromycin [**2-3**] rash) for community acquired pneumonia and high dose intravenous steroids for asthma exacerbation. Direct florescent antibody testing showed infection with influenza A. Pt's pulmonary status improved and she was extubated on [**2140-1-12**]. 2. GI bleeding - after transfer to ICU she was noted to have bright red blood from NGT. It did not clear with several hundred mL of lavage and pt eventually became hypotensive requiring pressors and several liters of fluids. Emergent EGD was performed on [**1-9**] showing [**Doctor First Name **]-[**Doctor Last Name **] tear with evidence of blood in fundus. Hemostasis was achieved after epinephrine injection. Serial hematocrit were stable during the remainder of the ICU course. Pt required 3 units of pRBC. 3. Hyperglycemia - shortly after initiation of high dose steroids pt's blood sugars were elevated requiring insulin gtt. Levels were well controlled following insulin drip and eventually euglycemia was maintained after transition to sliding scale insulin. Pt was transferred to the medical floor on [**2140-1-13**] for continued care. Her medical issues as mentioned above were resolved. At the time of dictation she has good oxygen saturation (95% 2L), Hct is stable (42), and her blood sugars are in the 130's. However, post extubation she exhibited confusion and agitation consistent with delirium. She has not been communicative dispite Japanese interpreter. Pt has required tube feeds via dohoff secondary to delirium. In addition she has required soft restraints and anti-psychotics for agitation. Medications on Admission: albuterol flonase calcium multivitamins vit E Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q1-2H () as needed for wheezing. 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 5. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection TID (3 times a day) as needed. 7. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 8. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): may discontinue when steroid taper complete. 9. Prednisone 10 mg Tablets, Dose Pack Sig: One (1) Tablets, Dose Pack PO once a day: start at 50 mg on [**2139-1-14**] then 40 mg on [**1-16**] and [**1-17**], then 30 mg [**1-18**] and [**1-19**], then 20 mg on [**1-20**] and [**1-21**], then 10 on [**1-22**] and [**1-23**]. 10. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 11. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours): until [**2140-1-23**]. 12. Metoclopramide HCl 5 mg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 13. Azithromycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours): until [**2139-1-22**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 1. asthma flare 2. influenza A 3. pneumonia 4. GI bleeding [**2-3**] [**Doctor First Name **]-[**Doctor Last Name **] tear 5. delirium 6. steroid induced hyperglycemia Discharge Condition: fair Discharge Instructions: 1. continue steroid taper 2. discontinue antibiotics for two week course on [**2140-1-23**] 3. check blood sugars and give insulin appropriately Followup Instructions: see PCP in the next 2 weeks for follow up.

[ "487.0", "251.8", "E932.0", "293.0", "285.9", "518.81", "E931.3", "458.9", "530.7", "493.92", "693.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.34", "96.6", "42.33", "00.17", "99.04", "96.04", "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

5287, 5366

1934, 3685

317, 342

5578, 5584

1449, 1911

5777, 5823

1126, 1150

3781, 5264

5387, 5557

3711, 3758

5608, 5754

1165, 1430

261, 279

370, 798

820, 898

914, 1110

15,352

132,661

46257+46258

Discharge summary

report+report

Admission Date: [**2187-4-10**] Discharge Date: [**2187-4-16**] Date of Birth: [**2129-11-13**] Sex: F Service: HISTORY OF PRESENT ILLNESS CHIEF COMPLAINT: Hypoxia, hypercarbia and acute renal failure. HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 4011**] is a 57-year-old female patient of Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 98346**]. Well known to the [**Hospital1 69**]. She was recently discharged from the [**Hospital1 188**] after admission for respiratory distress and sent to [**Hospital3 4419**] Center. She represents today, [**2187-4-10**] with short of breath, lethargy. At the rehabilitation she was found to have O2 saturations in the 70's and Arterial blood gases was 7.24/71/58. The patient denied any fever, chills, chest pain, lower extremity edema or orthopnea but noticed increase in migraine headaches at rehabilitation requiring increased Demerol. In the emergency department the patient had an arterial blood gases here of 7.17/70/135 on 12 liters face mask. The patient was initially somnolent but arouseable and she became alert with stimulation. The patient was tried on BYPAP but did not tolerate it. She required intubation. Of note the patient as previously mentioned had been hospitalized twice at [**Hospital1 1444**] within the last several months once from [**3-11**] to [**3-16**] due to worsening short of breath. Over several months the patient had progressive worsening ILD and possibly atypical pneumonia. She was started on Azothioprim and Azithromycin. She is also managed for severe right sided heart failure with increasing Verapamil dose and was started on Lasix, Enalapril and Digoxin. She was re-hospitalized as previously mentioned from [**2187-3-16**] to 3/226/03 with similar symptoms. She was treated with bronchodilators without effect. The Verapamil was discontinued secondary to lower extremity edema. The patient was diuresed secondary to progressive interstitial lung disease and pressure volume overload to her left ventricle. PAST MEDICAL HISTORY: Including but not limited to: 1. Systemic lupus erythematosus. 2. Sarcoid bronchiectasis. 3. Interstitial pulmonary disease. 4. Cerebrovascular accident. 5. Migraines. 6. Asthma. 7. Hypertension. 8. Diverticulosis. 9. Central nervous system aneurysm. 10. Cor Pulmonale. 11. Tricuspid regurg severe. 12. Aseptic meningitis. 13. TAH/BSO. 14. Total hip replacement. ALLERGIES: Penicillin, Dilantin, Percocet. MEDICATIONS: 1. Protonix 40 mg p.o. q day. 2. Azothiopram 150 mg p.o. q day. 3. Folate. 4. Bactrim DS one tab three times a day. 5. Amitiptyline 50 mg p.o. q h.s. 6. Lasix 80 mg p.o. twice a day. 7. Aldactone 75 mg p.o. q day. 8. Enalapril 7.5 mg p.o. q day. 9. Digoxin .125 mg p.o. q day. 10. Klonopin .5 mg p.o. three times a day. 11. Albuterol and Atrovent nebs. 12. Demerol p.r.n. headache. 13. Hydroxyzine p.r.n. headache. 14. Toradol p.r.n. headache. 15. Nystatin. 16. Prednisone 30 mg p.o. q day. MEDICATIONS ON TRANSFER: 1. Advair. 2. Combivent. 3. Azathioprine 150 mg p.o. twice a day. 4. Prednisone 30 mg p.o. q day. 5. Protonix 40 mg p.o. q day. 6. Folate 7. Elavil. 8. Digoxin. 9. Oscal D. 10. Klonopin. 11. Demerol 25 mg intramuscular q 4 hours p.r.n. PHYSICAL EXAMINATION: On presentation the patient's vital signs are as follows: Temperature 98.4, blood pressure 110/68, heart rate 103, respiratory rate 20. O2 sat of 80% on 12 liters. General: The patient is sitting upright in bed, lethargic but arouseable to questions. Head, eyes, ears, nose and throat: Pupils are equal, round, and reactive to light and accommodation but sluggish, anicteric. Oropharynx dry. JVP at 8 cm. Cardiovascular: normal S1 and S2, slightly tachy. Lungs: Diffuse dry inspiratory crackles in all lung fields. Abdomen: Soft, mildly distended. Nontender. Extremities: No edema. Neurologic: Alert and oriented times three. Patient not cooperative with remainder of exam. LABORATORY DATA: On admission the patient had the following. White count 20.3, hematocrit 31.2, platelets 376. Her differential is 72% neutrophils, 24% bands, 3% lymphs, 1% monos. Chem 7 was notable for sodium 131, K 5.8, chloride 88, total CO2 27, BUN 93 up from 35 and creatinine 3.6 up from 1.1. Her free calcium is 1.19, Arterial blood gases was 27, 71, 35, 34. Arterial blood gases last on discharge was 7.39, 63, 74. Her Dig level was .1. Chest x-ray showed extensive diffuse interstitial disease. Electrocardiogram showed sinus tachycardia at 107, normal axis, normal intervals, shortened QT interval. No ST or T-wave changes suggestive of ischemia. Please see previous report from echo and pulmonary function test which showed restrictive pattern. The day prior to discharge the patient had the following laboratory values. Her white count was 17.3, crit 30.1, platelets 267, sodium 141, potassium 3.2, chloride 100, KCL 232, BUN 16, creatinine 0.6, glucose 85. She had an arterial blood gases two days prior to discharge that was 7.4, 51, 89 on four liters nasal cannula. The patient had a chest x-ray on [**4-13**] that showed satisfactory placement of right IJ catheter placed on the 18th and slight increase in interval and increase in bibasilar atelectasis and edema. She had a CT of the head for delirium which showed no intracranial hemorrhage, no explanation for delirium. She had a renal ultrasound which showed a right kidney measurin 10.6 cm, left 11.8. Both kidneys are normal. HOSPITAL COURSE: 1. Pulmonary. As previously mentioned the patient was intubated shortly after admission for hypoxemia and hypercarbic respiratory failure deemed secondary to progression of her interstitial lung disease and an underlying pneumonia which was seen on x-ray as a left sided retrocardiac opacity and pleural effusion on the 15th. She was treated with Ceftriaxone and Levofloxacin for nosocomial pneumonia and pseudomonas coverage. She was extubated within two days and then maintained on four liters nasal cannula which should be titrated to an O2 sat of 91 and 95% She remained afebrile and her respiratory status was stable with the exception of one episode on the floor two days prior to admission of desaturation and pAO2 in the 50's that resolved post diuresis with 40 mg intravenous of Lasix. The patient continued to have a progressive course of interstitial lung disease requiring high oxygen and is susceptible to superimposed infection and other respiratory insults including congestive heart failure. She is to be continued on her Ceftriaxone and Levaquin for a full 14 day course and also to have her fluid status monitored waiting for signs of congestive heart failure which tend to tip her into respiratory failure. The patient had her Azathioprine discontinued. It was felt that this was not helping her interstitial lung disease however, she is continued on 30 mg of Prednisone. The patient was given nebs q 8 hours although likely these only help the patient subjectively. Of note, the patient has dry inspiratory crackles on exam at baseline. 2. Renal. The patient was admitted with acute renal failure, creatinine up to 3.2 that was thought secondary to aggressive diuresis and possibly to Ace inhibitor. Ace inhibitor is discontinued. The patient was gently rehydrated and creatinine returned to baseline 0.6. 3. Neurologic. The patient had experienced delirium during the first three to four days of her hospital stay. This is presumed likely a combination of hypercapnia, infectious etiology from her pneumonia and accumulation of narcotics given for her chronic migraines. Her neurologic status is clear by hospital day four, she required no additional Haldol and she was at her baseline thereafter. 4. Gastrointestinal: During the patient's delirium she is unable to safely consume p.o. diet. Once she regained her normal neurologic function on hospital day four she had a speech and swallow study which was normal and the patient was resumed on regular p.o. diet and a nasogastric tube was discontinued. 5. Cardiovascular. The patient has severe cardiac failure secondary to pulmonary hypertension. She required diuresis to keep her I's equal to her O's. The Lasix was restarted 40 mg p.o. q day. Ace inhibitor was held and Aldactone should be considered to be restarted after she remained stable for several days in rehabilitation, 50 mg q. day. CONDITION ON DISCHARGE: Fair. The patient has a poor prognosis secondary to chronic interstitial lung disease. DISCHARGE STATUS: To rehabilitation. Likely [**Location **]. DISCHARGE DIAGNOSIS: 1. Interstitial lung disease, chronic, likely end-stage. 2. Nosocomial pneumonia. 3. Congestive heart failure secondary to pulmonary hypertension. 4. Delirium secondary to narcotics and infection. 5. Acute renal failure secondary to hypovolemia and Ace inhibitor. DISCHARGE MEDICATIONS: 1. Atrovent nebs q 6 hours p.r.n. 2. Prednisone 30 mg p.o. q day. 3. Bactrim one DS twice daily. 4. Calcium carbonate 500 mg p.o. three times a day. 5. Folic Acid 1 mg p.o. q day. 6. Regular insulin sliding scale four times a day. 7. Subcutaneously Heparin 500 mg p.o. twice a day. 8. Ceftriaxone 1 gram q 24 hours, last dose to be given on [**2187-4-24**]. 9. Levofloxacin 250 mg p.o. q day, last dose [**2187-4-24**]. 10. Prevacid 30 mg p.o. q day. 11. Tylenol 325 mg to 650 mg q 4 to 6 hours p.r.n. pain. 12. Colace 100 mg p.o. twice a day. 13. Albuterol nebs q 6 hours p.r.n. 14. [**Doctor Last Name **] one tab twice a day. 15. Lasix 40 mg p.o. twice a day to keep I equal to O. 16. Cholecofero 400 units one tab p.o. q day. 17. Potassium chloride 20 mEq q day. 18. Demerol 25 mg p.o.q 6 hours p.r.n. headache. FOLLOW-UP: The patient is to follow-up with Dr. [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **] of Pulmonary on Wednesday [**4-25**] at 11;30 AM on the [**Location (un) 25799**] of the [**Hospital Ward Name 23**] Building. She is to call her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 665**] for an appointment within two weeks from discharge from rehabilitation. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**MD Number(1) 5046**] Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2187-4-16**] 17:21 T: [**2187-4-16**] 20:19 JOB#: [**Job Number 98347**] Admission Date: [**2187-4-10**] Discharge Date: [**2187-4-17**] Date of Birth: [**2129-11-13**] Sex: F Service: ADDENDUM: Please note the changes to the medical regimen. Lasix will be changed from 40 mg p.o. b.i.d. to 20 mg p.o. b.i.d. She will also be restarted on amitriptyline 50 mg p.o. q.h.s. The patient should have chest physical therapy daily, ambulate t.i.d. with incentive spirometry. DR.[**Last Name (STitle) **],[**First Name3 (LF) 251**] 11-476 Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2187-4-17**] 12:35 T: [**2187-4-17**] 12:35 JOB#: [**Job Number 98348**]

[ "428.0", "710.0", "584.9", "486", "515", "415.0", "518.81", "276.5", "397.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8928, 11136

8627, 8905

5529, 8428

3300, 5512

177, 224

252, 2051

3031, 3277

2074, 3006

8453, 8606

9,920

117,182

27317

Discharge summary

report

Admission Date: [**2181-6-5**] Discharge Date: [**2181-6-23**] Date of Birth: [**2103-3-28**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: 78 y/o female fell down the stairs now with right sided subdural, intraparenchymal and subarachnoid hemorrhages Major Surgical or Invasive Procedure: Right sided craniotomy History of Present Illness: 78 F s/p fall in the stairs; ? LOC; EMS: GCS 7; admitted to [**Hospital1 18**]; seen moving L arm (?); intubated, sedated stat head CT showed: Extensive bilateral intracranial hemorrhage including right subdural hematoma, bilateral subarachnoid hemorrhage and multiple intraparenchymal hemorrhagic contusions, the largest one in the left frontal lobe with 1-cm shift of the normally midline structure. As said, neurosurgery consultation is recommended. 2. Hemorrhage in left maxillary sinus, raises the possibility of blowout fracture on the left. Opacified right maxillary and bilateral ethmoid sinuses, as well as nasopharynx. 3. Right occipital subcutaneous hematoma. 4. Opacified right mastoid air cells, middle ear cavity and external auditory canal, which is only partially imaged. Past Medical History: s/p quadruple bypass 94; pulmonary fibrosis; diabetes; currently respiratory infection (?); Social History: Widowed of Italian decent, speaks Italian with some English. Children involved in care, recent long illness with patients husband Family History: Unknown Physical Exam: P/E: seen when curarized, sedated, intubated: 68 [**Telephone/Fax (2) 66962**]0% Non responsive to voice or pain; Pupils 3mm, non reactivbe, symetric; no corneal; No response to pain in any extremity Seen later on, on Propofol only: SBP 139/80 Near localization to pain (nipple) w/ RUE; minimal withdrawal w/ RLE; no response on L; DTR's: biceps, triceps, pron, quads, achill: reactive bilat (2+); [**Last Name (un) **]: neutral; Pertinent Results: [**2181-6-5**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2181-6-5**] 07:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2181-6-5**] 07:50PM FIBRINOGE-260 [**2181-6-5**] 07:50PM PT-12.1 PTT-25.2 INR(PT)-1.0 [**2181-6-5**] 07:50PM WBC-14.8* RBC-3.73* HGB-10.9* HCT-31.5* MCV-84 MCH-29.1 MCHC-34.5 RDW-14.1 [**2181-6-5**] 07:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2181-6-5**] 07:50PM URINE GR HOLD-HOLD [**2181-6-5**] 07:50PM URINE HOURS-RANDOM [**Known lastname 66963**],[**Known firstname 66964**]: Laboratory Detail - CCC Record #[**Numeric Identifier 66965**] COMPLETE BLOOD COUNT (BLOOD) DATE WBC 4.0-11.0 K/uL RBC 4.2-5.4 m/uL Hgb 12.0-16.0 g/dL Hct 36-48 % MCV 82-98 fL MCH 27-32 pg MCHC 31-35 % RDW 10.5-15.5 % WBC RBC HGB HCT MCV MCH MCHC RDW [**2181-6-15**] 3:14A 10.1 3.52* 10.3*# 30.5* 87 29.3 33.9 14.4 [**2181-6-14**] 2:00A 7.7 2.87* 8.2* 24.9* 87 28.6 33.0 14.5 [**2181-6-13**] 3:30A 7.4 2.95* 8.4* 25.3* 86 28.6 33.4 14.5 [**2181-6-12**] 5:27A 8.4 2.88* 8.5* 24.8* 86 29.4 34.1 14.2 [**2181-6-11**] 2:29A 7.7 2.88* 8.4* 24.8* 86 29.3 34.0 14.3 [**2181-6-10**] 2:01A 8.3 2.79* 8.2* 23.9* 86 29.5 34.5 14.5 Brief Hospital Course: Pt was brought to [**Hospital1 18**] found to have extensive right sided subdural, IPH and subarachnoid blood. The family agreed to have surgery for right sided craniotomy despite poor prognosis. During the surgery they were found to have large blood collection and brain parenchyma was mottled and brain was pulsatile. Post operatively she was found to localize her right upper extremity to pain and no movement of left upper extremity. She withdrew her lower extremities. Post operative CT showed: 1. Status post right frontal craniotomy and evacuation of mixed density subdural hematoma. Mild interval improvement in subfalcine herniation. Large quantity of subarachnoid hemorrhage seen bilaterally within the frontal and temporal region, right greater than left, grossly unchanged. 2. Bifrontal lobe hemorrhagic contusions, left greater than right, and right anterior temporal lobe hemorrhagic contusions, small to moderate in size, all of which are unchanged. She had a questionable mild L2 compression fracture which was cleared by the spine service. On post operative day 1 her exam she withdrew her lower extremities to pain and had no movement of her upper extremities. On post op day 2 she began to have spontaneous movement of her right upper extremity. She was loaded with Dilantin and level was kept above 10 during her time in the ICU She began spiking fevers on post op day 4 eventual cultures found staph coag negative in her blood and enterococcus in her urine she was started on a 10 day course of Vancomycin. A head CT on [**6-7**] was notable for Evolving small posterior cerebral artery - anterior cerebral artery border zone infarct seen superiorly along the medial aspect of the right cerebral convexity. Slight decrease in size of hemorrhagic contusions, bilateral subdural hematomas and quantity of subarachnoid hemorrhage. The patient was noted to begin to open eyes and questionably follow commands with RUE in Italian on POD [**5-20**], family reports after [**6-12**] she did not follow any further commands in Italian. There were discussion with family regarding extubation and placing of PEG tubes. General family consenus was to extubate and not reintubate which occured on [**6-14**]. CXRs showed possible R lower lobe pneumonia and CHF. On [**6-16**] she was transferred to the floor she continued to have fevers. Her staples from her head wound were DC'd with no sign of infection. Her foley catheter was d/c'd she continued on Vancomycin and tube feeds while the family decided on type of placement and agressiveness of care. At this point they want active medical problems treated and do not want a PEG tube. A pallative care consult was placed. The family expressed a desire for minimally invasive procedures, if necessary, however they did not want any aggressive measures performed. A medicine consult was called to address patient's intermittent fevers as well as elevated blood sugars. Her fixed dose insulin and slifding scale adjusted accordingly. She is on Vancomaycin last dose will be on [**2181-6-24**]. Her chest radiographs showed some left lower lobe consalidation medicine team recommended to add Levo and flagyl which is started on [**2181-6-21**], should be continued total of 10 days rom strat date. She was continued on antibiotics and at the time of discharge, remained afebrile. She was maintained on tube feeds via a dobhoff tube which did need to be replaced multiple times secondary to the patient self-dc'ing the tube. She remained stable and was discharged on POD 16 in stable condition. Medications on Admission: Lipator, Prednisone, Levaquin, Metropolol, Quinipril, Fosamax and Aspirin Discharge Disposition: Extended Care Discharge Diagnosis: R Subdural/Subarachnoid and subarachnoid hemorrhages Discharge Condition: Neurologically stable Discharge Instructions: Please continue your medications as directed. Please continue tube feeds as directed. Do not hesistate to call our office with any questions or concerns. Followup Instructions: Please follow up with Dr.[**Name (NI) 4674**] office in 4 weeks with head CT without contrast. Call his office at [**Telephone/Fax (1) 1272**] to make an appointment and to book Head CT same day or with any questions or concerns. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2181-6-22**]

[ "733.90", "790.7", "486", "428.0", "515", "E880.9", "851.82", "041.19", "V58.65", "599.0", "996.62", "434.91", "518.5", "807.01", "573.3", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "99.05", "96.04", "99.04", "01.31", "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

7053, 7068

3361, 6929

430, 455

7165, 7189

2030, 3338

7391, 7748

1553, 1562

7089, 7144

6955, 7030

7213, 7368

1577, 2011

279, 392

483, 1273

1296, 1390

1406, 1537

20,747

172,101

4079

Discharge summary

report

Admission Date: [**2139-3-3**] Discharge Date: [**2139-3-21**] Date of Birth: [**2086-3-6**] Sex: M Service: MEDICINE Allergies: Erythromycin Base / Protamine / Minoxidil Attending:[**First Name3 (LF) 826**] Chief Complaint: increased edema and shortness of breath Major Surgical or Invasive Procedure: - placement of tunneled HD catheter - initiation of hemodialysis History of Present Illness: 52 y/o M s/p renal transplant with extensive medical history notable for CHF EF 20-30%, CAD s/p CABG, DM, and vasculopathy s/p amputations. Was recently hospitalized in [**Month (only) 958**] with extended stay for volume overload and possible infection. Patient was diuresed with subsequent improvement in his symptoms. Now represents with increasing SOB, weight gain, and scrotal swelling since discharge from rehab 1 month ago. Referred to ED for diuresis. . In the ED, initial vital signs were 150/80, HR 70, RR 18, O2 97% RA. Exam was notable for coarse breath sounds, swollen scrotum, +stump edema of LE. Labs notable for renal failure with Cr 4.2, hyperkalemia, and anemia. Patient was given 40mg IV lasix x1, SL NTG x3 and morphine 2mg IV x1, kayexelate 30mg PO x1. Was admitted to the medicine service for management. Renal aware. ECG in ED unconcerning. . On arrival to the floor patient complained of [**7-6**] pain in stumps bilaterally, lower back and scrotum. Otherwise, without complaints. Patient denies recent change to his diet or medications. . Review of systems is otherwise unremarkable. Past Medical History: - DM I with diabetic retinopathy, nephropathy, neuropathy CAD: --CABG: [**2125**] LIMA-LAD, SVG-PDA, SVG-RI, SVG-OM (occluded) --PCI: [**2135-1-21**] LMCA with no flow limiting stenoses; LAD contained a 90% proximal lesion before becoming totally occluded just after a large septal; LCX contained diffuse disease, up to a 95% mid vessel; OM1 was totally occluded; ramus branch had a 70% proximal lesion; RCA was totally occluded proximally. Congestive heart failure: LVEF 25-30% ([**7-3**]) with 2+ MR CVA [**2135**] R BKA L AKA Right fem-tibial bypass surgery in [**2125**]. RLE bursitis Cellulitis in [**2131**]. Chronic renal failure due to acute tubular nephropathy in [**2131**] s/p renal transplant (second living related renal transplant in [**2122**]) Listeria infection in [**2132**]. Shingles in [**2132**]. Squamous cell carcinoma was diagnosed and removed in [**2133**]. Anemia of chronic disease Glaucoma Gastroparesis Gastritis Diveriticulosis Social History: Pt with several transfers [**Hospital 17946**] hospital and rehab recently, prior to that lived with his wife. Fifteen pack year history of tobacco use per OMR. No history of alcohol, IVDU. Family History: Noncontributory Physical Exam: ADMISSION: VITAL SIGNS: T97.1, Bp 100/d, RR 16, HR 76, O2 99%2L GENERAL: Pleasant, chronically ill appearing man in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck CARDIAC: Regular rhythm, normal rate. Normal S1, S2. Systolic murmur at LLSB, no rubs or [**Last Name (un) 549**] noted with careful auscultation. JVP= difficult to appreciate, ?jaw at 30 degrees. LUNGS: clear anteriorly, but diminished at bases ABDOMEN: NABS. Soft, mild RUQ tenderness, ND. No HSM EXTREMITIES: L-AKA, 3+ edema, R-BKA with wound and 2+ edema, both extremities cool to touch, not mottled. Stage 3-4 pressure ulcer on the inferior aspect of the right stump. SKIN: mild erythema of left leg NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength in upper extremities. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Back: STAGE II sacral pressure ulcer ===================================== Physical Exam at discharge: Edema sisignificantly improved over abdomen, sacrum and stumps bilaterally, but Left stump continues to be more edematous than right. Scrotal edema also significantly improved since admission and less tender. Bibasilar crackles. Exam otherwise not significnatly changed. Pertinent Results: ADMISSION: [**2139-3-3**] 02:00PM BLOOD WBC-5.9 RBC-3.11* Hgb-8.9* Hct-28.2* MCV-91 MCH-28.8 MCHC-31.7 RDW-18.6* Plt Ct-302 [**2139-3-3**] 02:00PM BLOOD Neuts-71.8* Lymphs-17.9* Monos-7.7 Eos-1.7 Baso-0.7 [**2139-3-3**] 02:00PM BLOOD Plt Ct-302 [**2139-3-3**] 02:00PM BLOOD Glucose-120* UreaN-112* Creat-4.2*# Na-131* K-6.5* Cl-103 HCO3-16* AnGap-19 [**2139-3-3**] 02:00PM BLOOD ALT-6 AST-17 CK(CPK)-58 AlkPhos-89 TotBili-0.2 [**2139-3-3**] 02:00PM BLOOD Lipase-19 [**2139-3-3**] 02:00PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 17947**]* [**2139-3-3**] 02:00PM BLOOD TotProt-5.6* Albumin-3.1* Globuln-2.5 Calcium-8.9 Phos-5.4* Mg-2.2 [**2139-3-4**] 08:10AM BLOOD rapmycn-5.2 . INR: [**2139-3-3**] 05:30PM BLOOD PT-24.6* PTT-40.2* INR(PT)-2.4* [**2139-3-4**] 08:10AM BLOOD PT-20.1* PTT-34.2 INR(PT)-1.9* [**2139-3-5**] 08:00AM BLOOD PT-21.7* PTT-35.5* INR(PT)-2.1* [**2139-3-6**] 08:10AM BLOOD PT-23.2* PTT-36.3* INR(PT)-2.2* [**2139-3-7**] 07:15AM BLOOD PT-24.8* PTT-38.8* INR(PT)-2.4* [**2139-3-8**] 08:10AM BLOOD PT-28.3* PTT-39.8* INR(PT)-2.9* [**2139-3-9**] 12:21AM BLOOD PT-23.6* PTT-38.5* INR(PT)-2.3* [**2139-3-9**] 12:25AM BLOOD PT-34.1* PTT-41.2* INR(PT)-3.6* [**2139-3-10**] 02:56AM BLOOD PT-27.3* PTT-40.9* INR(PT)-2.7* [**2139-3-11**] 03:18AM BLOOD PT-40.5* PTT-43.8* INR(PT)-4.4* [**2139-3-11**] 09:48PM BLOOD PT-55.7* PTT-54.1* INR(PT)-6.5* [**2139-3-12**] 06:32AM BLOOD PT-39.1* PTT-50.7* INR(PT)-4.2* [**2139-3-13**] 04:43AM BLOOD PT-22.6* PTT-46.3* INR(PT)-2.2* [**2139-3-13**] 12:54PM BLOOD PT-18.2* PTT-38.5* INR(PT)-1.7* [**2139-3-14**] 03:05AM BLOOD PT-17.1* PTT-36.2* INR(PT)-1.5* [**2139-3-14**] 04:40PM BLOOD PT-17.3* PTT-34.1 INR(PT)-1.6* [**2139-3-15**] 01:20AM BLOOD PT-20.3* PTT-46.6* INR(PT)-1.9* [**2139-3-15**] 08:00AM BLOOD PT-22.2* PTT-68.9* INR(PT)-2.1* [**2139-3-15**] 09:00AM BLOOD PT-21.9* PTT-70.9* INR(PT)-2.1* [**2139-3-15**] 04:50PM BLOOD PT-22.2* PTT-99.5* INR(PT)-2.1* [**2139-3-16**] 06:50AM BLOOD PT-28.0* PTT-64.9* INR(PT)-2.8* [**2139-3-17**] 10:56AM BLOOD PT-36.7* PTT-37.4* INR(PT)-3.9* [**2139-3-18**] 07:35PM BLOOD PT-54.6* PTT-41.3* INR(PT)-6.4* [**2139-3-19**] 08:30AM BLOOD PT-45.9* INR(PT)-5.1* [**2139-3-19**] 03:41PM BLOOD PT-33.6* PTT-39.6* INR(PT)-3.5* . ADMISSION ECG: Sinus rhythm. Right inferior axis. Low limb lead voltage. Late R wave progression. ST-T wave abnormalities. Since the previous tracing of [**2139-1-21**] limb lead voltage has decreased. ST-T wave abnormalities may be more marked . ECHO: The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. There is severe global left ventricular hypokinesis (LVEF = 20-25 %). The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be Significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2138-11-13**], diastolic function cannot be clearly assessed on the current study. The other findings are similar. . RENAL TRANSPLANT DOPPLERS: Diminished diastolic flow within the transplant kidney, although not significantly changed is again concerning for rejection. . LENIs: Normal flow in the lower extremity veins, which excludes occlusive thrombus. However multiple veins were non- compressible, markedly limiting assessment for non- occlusive thrombus. . CXR: Comparison is made with prior study performed a day earlier. Large right and moderate left pleural effusions have increased on the right. Bibasilar atelectasis and mild pulmonary edema are stable. Right supraclavicular catheter is in standard position. There is no evident pneumothorax. Sternal wires are aligned. . URINE CULTURE (Final [**2139-3-10**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 52 y/o M, ESRD s/p renal transplant with extensive medical history notable for CHF EF 20-30%, CAD s/p CABG, DM, and vasculopathy s/p multiple amputations. Was recently hospitalized in [**Month (only) 958**] with extended stay for volume overload and possible infection. Patient was diuresed with subsequent improvement in his symptoms. Presented with increasing SOB, weight gain, and scrotal swelling since 1 month ago. Urine studies on admission demonstrated that his transplanted kidney was functioning and extremely sodium avid. This was attributed to lack of forward flow in the context of a CHF exacerbation and our initial strategy was aggressive diuresis. . Diuresis with lasix by bolus failed; lasix drip (up to 30mg/hr) with bolus thiazides initially increased urine output, but ultimately failed in removing significant volume. Pt was transferred to MICU for coffee ground emesis in the setting of a supratherapeutic INR and worsening uremia. Despite significant reductions in his coumadin dose, INR was very labile likely secondary to poor po intake; he received FFP and 2 packs of PRBCs. He was transiently on a heparin drip when he became sub-therapeutic. Further attempts at diuresis with metolazone and milrinone failed. CVVH done once through a newly placed tunneled HD line and pt was initiated on dialysis. Pt's mental status declined over his course prior to the initiation of dialysis likely secondary to worsening uremia. He had daily dialysis for one week with removal of at least 2L per session. His mental status improved significantly and had returned to baseline by the time of discharge. His edema and stump pain also improved. His INR continued to be labile and his tunneled line insertion site oozed intermittently without significant drop in Hct. ACTIVE PROBLEMS: #. Renal Failure and s/p renal transplant: Attempts to diurese with lasix, thiazides, milrinone and metolazone unsuccessful as detalied above. s/p CVVH, now on dialysis with significant removal of fluid. - HD Tu/Th/Sa, PPD negative and HepB Ag negative on this admission - Continue Rapamycin, prednisone. Continue Bactrim prophylaxis given immunosuppressant meds. Prednisone previously 10mg daily, now 5mg daily. - cont EPO (at dilaysis), sevelamer, nephrocaps . # UGIB. History of gastritis and esophagitis on past endoscopies. No known liver disease to suggest portal HTN/varices. Also consider [**Doctor First Name 329**] [**Doctor Last Name **] with history of retching. No EtOH or NSAID use, though does take coumadin and prednisone. On PPI at baseline. Given 2u PRBC, FFP, and DDAVP. Only episode of bleeding occured in the setting of a supratherapeutic INR and uremia. - cont pantoprazole 40mg [**Hospital1 **] (previously 40mg daily at admission) - Consider EGD if bleeding recurs, not done during this hospitalization b/c on multiple other ongoing medical issues - careful dosing of coumadin to maintain INR in [**12-30**] range. . # LABILE INR: INR trended down to 2.9 at the time of d/c. 2mg of VitK given two days ago with no coumadin for three days. Has been excessively sensitive to coumadin likely due to poor nutrition. Indication is previous stroke and upper extremity vein thrombosis, recommended duration previously determined to be life-long. - Coumadin restarted at 0.5mg daily on the day of discharge; he will likely require very low doses until nutritional status improves. - If supratherapeutic, please dose VitK conservatively (2mg) to avoid overshooting and needing heparin bridge. - Only when supratherapeutic, oozing has been noted at the insertion site of the tunnel cath, this oozing did not cause any Hct drop and was evaluated by Interventional Radiology, they felt the line could be used while oozing and that pressure should be applied if this occurs. - Please check INR daily . # Acute on Chronic Systolic Heart Failure: Ischemic CM. Initial assessment of ARF was poor forward flow in the setting of CHF exacerbation. Poor response to milrinone. Echo on admission showed no significant change from previous study in [**October 2138**]. Pt's Outpt cardiologist is Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] ([**Hospital1 18**]). - Lisinopril 5mg daily has been held during the initiation of dialysis in order to provide more BP room, please resume if blood pressure tolerates. - He was admitted without a beta-[**Hospital1 7005**] which was not initiated also to provide BP room for dialysis, please start Coreg or Toprol after resuming lisinopril as BP tolerates. - After significant volume reduction in consecutive dialysis sessions, pt is now approaching euvolemia. - Pt with severe 3+ mitral regurgitation, previously on hydralazine 50mg TID, held currently b/c pressures have not tolerated. Would resume as pressure tolerates. . # CAD: S/p CABG and PCI. On ASA 81mg. On statin. - We have been giving him his long-acting nitrate after dilaysis to provide BP room for volume removal. Ruled out MI on admission. . # Back pain: Patient has chronic back pain managed with percocet and lidocaine patches as an outpatient. Morphine may have contributed to his delirium as an [**Last Name (LF) 98**], [**First Name3 (LF) **] we swtiched back to his outpatient regimen prior to d/c. Would avoid morphine and may consider dilauid 1mg po q4-6h for additonal pain control if necessary as this is preferred in ESRD pts on HD. . # Diabetes: Prior to initiation of HD, lantus dose was drasctically decreased because of repeated episodes of hypoglycemia, prior to d/c Lantus restored to 20mg qAM with conservative QID SSI. . #. RLE Wound: Stage 3-4. Wound care consulted. Daily dressing changes and respositioning. According to wound care, may benefit from a vac dressing if healing prolonged. . # Metabolic acidosis [**12-29**] renal failure. . # Possible depression: Patient consistently denies depressive symptoms and, however his affect is markedly blunted and this should be addressed again. . # Postitive urine culture. No signs or symptoms of UTI. Two urine cultures grew ESBL Kleb and given clinical picture (no local sxs or systemic signs of infection), this was treated as a colonizer. Sensitivities attached in results section. Would not treat unless pt demonstrates signs of infection. Please avoid foley in this patient. If becomes febrile or develops leukocytosis, would target this resistant organism. . # Gout: controlled. Allopurinol 100mg QOD. Medications on Admission: 1.Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2.Allopurinol 300 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3.Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for PRN for back pain. 4.Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5.Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6.Sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7.Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8.Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9.Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10.Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as needed for wheezing. 11.Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 12.Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13.Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14.Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO Daily PRN as needed for constipation. 15.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 16.Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 17.Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 18.Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19.Aranesp SureClick -Polysorbate 200 mcg/0.4 mL Pen Injector Sig: One (1) Subcutaneous Every 10 days. 20.Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 21.Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 22.Insulin Glargine 100 unit/mL Cartridge Sig: One (1) injection Subcutaneous QHS: See attached insulin sliding scal sheet. 23.Insulin Lispro 100 unit/mL Cartridge Sig: One (1) injection Subcutaneous PRN: Per sliding scale paperwork. 24.Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25.Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 26.Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for back pain: 12hrs on/ 12hrs off. 4. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 5. Nystatin 100,000 unit/g Powder Sig: One (1) application Topical twice a day. 6. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): dosing as per renal. 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day: hold for loose stools. 12. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily) as needed. 13. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 15. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. 16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 18. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection given at dialysis: given at dialysis. 19. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed: no more then 4g APAP per day. 20. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous qam. 21. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: as per sliding scale. 22. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO at bedtime: goal INR = [**12-30**]. 23. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 24. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 25. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 26. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-28**] Sprays Nasal QID (4 times a day) as needed for dry nose/ nose bleed. 27. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 28. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 29. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 30. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 31. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO Once Daily at 4 PM. 32. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO MWF. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: - Acute on Chronic exacerbation of systolic congestive heart failure - End Stage Renal Disease s/p transplant, now on hemodialysis - Upper gastro-intestinal bleed, gastritis - Coronary Artery Disease s/p CABG - Peripheral Vascular Disease - Non-healing stage 3-4 pressure ulcer on right stump, and stage 2 sacral pressure ulcer. - Delirium (resolved) Discharge Condition: Medically stable for transfer to rehab. Discharge Instructions: Dear Mr. [**Known lastname 17839**], You were admitted with signs and symptoms of volume overload. We attempted to remove fluid with very high doses of lasix, but his was not effective and you had to be started on dialysis. While you were here, you had one episode of upper gastro-intestinal bleeding in the context of a high INR and uremia. You were given blood and clotting factors to correct this. We had difficulty controlling your INR because you have been eating so little, so your doses of coumadin will be much lower than prevoiusly. We have also been holding some of your blood pressure medications as your BP has lower while we have been removing fluid. Please let your doctors know if [**Name5 (PTitle) **] vomit and blood or dark fluids or is you have any black & tarry stool. Please let them know if you have chest pain, shortness of breath, fainting, or any other symptoms which seriously concern you. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: After you have been discharged from rehabilitation, please make appointments with the following physicians within 1-2 weeks: - Your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 250**] - Dr. [**First Name (STitle) 437**], Cardiology, [**Telephone/Fax (1) 62**] - Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**], Nephrology Please discuss with your PCP whether referral to gastroenterology for an upper endoscopy would be in line with your goals of care. Completed by:[**2139-3-22**]

[ "E878.0", "585.6", "E849.8", "403.91", "250.61", "428.23", "562.10", "357.2", "414.8", "414.00", "250.41", "276.2", "428.0", "724.5", "E878.8", "041.3", "536.3", "583.81", "997.69", "362.01", "V45.81", "578.9", "285.21", "996.81", "V10.83", "599.0", "338.29", "250.51" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

21293, 21348

9228, 15645

339, 405

21743, 21785

4116, 9205

22857, 23396

2752, 2770

18131, 21270

21369, 21722

15671, 18108

21809, 22834

2785, 3810

3824, 4097

260, 301

433, 1544

1566, 2529

2545, 2736

68,127

196,220

41547

Discharge summary

report

Admission Date: [**2157-5-1**] Discharge Date: [**2157-5-9**] Date of Birth: [**2099-9-15**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2157-5-2**] Cardiac cath [**2157-5-3**] Redo sternotomy and coronary artery bypass graft x3, saphenous vein graft to obtuse marginal 1, 2 and 3. History of Present Illness: 56 year old male ESRD s/p CABG [**5-/2155**] (3vd, 5-CABG with LIMA to LAD double touchdown with endarterectomy from D1 to apex; SVG1 to OM1 and jump to OM2; and SVG2 to PDA) with a complicated post CABG cardiac history who presents with chest pain to OSH. He reports that he developed two episodes of chest pain prior to admission that were relieved by SL NTG. First was while driving to dialysis 4 days ago and relieved with SL nitro and second was [**Year (4 digits) 2974**] morning at rest. He has not had chest pain since his admission with PCI in [**Month (only) 404**] of this year. At outside hospital a TTE was performed and revealed a markedly positive study for symptoms at low work level associated with 2mm downsloping ST depressions diffusely. The nuclear study demonstrated a large severe reversible defect in the entire lateral wall compatible with myocardial ischemia, in addition to global hypokinesis, lateral akinesis, and a markedly decreased LVEF. He developed chest pain on HD 3 (same day of above mentioned tests) and was started on a heparin gtt and transferred to [**Hospital1 18**] for further work-up, consideration for cardiac catheterization. Upon cardiac catheterization he was found to have in stent restenosis of the left main and is now being referred to cardiac surgery for redo bypass surgery. Past Medical History: Coronary artery disease s/p Coronary artery bypass graft x 5 [**2155**] ESRD on hemodialysis (at South Suburban, MWF) Diabetes mellitus with renal complications Neuropathy Retinopathy Obstructive Sleep Apnea (previously on CPAP, now resolved after weight loss) Cataract Charcot foot due to diabetes mellitus Hypothyroidism Hyperlipidemia Obesity s/p Lap Band ([**2154**]) Hyperparathyroidism [**3-17**] renal Renal osteodystrophy Pulmonary Nodule (Solitary) History of Colonic Adenoma Left arm fistula s/p Lap Band ([**2154**]) Social History: Tobacco history: 30 pack year history, quit at time of CABG ~1 year ago ETOH: never Illicit drugs: denies Family History: Father with kidney disease. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle with cancer, NOS. Physical Exam: Pulse:75 Resp:16 O2 sat:100/RA B/P Right:99/60 Left: no BP d/t fistula Height:5'6.5" Weight:235 lbs General:AAOx3 Skin: Dry [x] intact [] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [] Murmur [x] grade I/VI Abdomen: Soft [x] non-distended [x] non-tender [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: IABP Left: palp DP Right: dop Left: dop PT [**Name (NI) 167**]: dop Left: dop Carotid Bruit Right: none Left: none Pertinent Results: CARDIAC CATH [**2157-5-2**]: 1. Selective coronary angiography of this right dominant system revealed three vessel native coronary artery disease. The LMCA had 80% instent restenosis distally. The LAD had 70%ostial disease, 100% occlusion after S1 and 100% occlusion after distal touchdown of LIMA. The LCx was a large caliber vessel with large territory. There was 95% ostial in stent restenosis, 60% mid lesion; there was 100% occlusion of OM1. The SVG-OM1 is flush occluded and the jump segment from OM1-Om2 is patent and fills retrograde. The RCA is 100% proximally occluded. 2. Limited resting hemodynamics revealed borderline normal blood pressure (after sublingual nitroglycerin given at start of case for chest pain) of 99/65 mmHg. 3. Arterial conduit angiography showed a widely patent LIMA-LAD. 4. Saphenous vein graft angiography showed SVG-RPDA widely patent. SVG-OM1-OM2 is known flush occluded. 5. Successful placement of 40cc IABP in RCFA under fluoroscopic guidance. . Echo [**2157-5-3**]: Transgastric views deferred due to increased resistance upon gentle advancement of the probe into the stomach (history of lap band surgery). Mild spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There is an intraaortic balloon pump in good position with the tip 2-3 cm distal to the takeoff of the left subclavian artery. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time of surgery. POST-BYPASS: The patient is in sinus rhythm. The patient is on no inotropes. Biventricular function is unchanged. Mitral regurgitation is unchanged. The intraaortic balloon pump remains in good position. The aorta is intact post-decannulation. Valvular funciton is unchanged. No other changes from prebypass examination. Brief Hospital Course: 57 M with ESRD on Hemodialysis, HTN, insulin dependent diabetes, hyperlipidemia, coronary artery disease s/p CABG [**5-/2155**] complicated by stent restenosis s/p DES, now with recurrent LMCA and ostial LCX restenosis. Admitted on [**2157-5-1**] and underwent CABG X3 (SVG to OM1, OM2 and PDA) on [**2157-5-4**] after completing pre-operative work up- see operative note for details. Off bypass on vasopressin for hemodynamic support. Admitted to the ICU immediately post-operatively for hemodyanamic monitoring and management. Weaned off pressors readily. Weaned from sedation and awoke neurologically intact and was weaned from the ventilator and extubated. He was started on ASA, statin therapy, and betablocker. Amiodarone was added for post-operative atrial fibrillation. Plavix was resumed. His dialysis therapy was resumed post-operatively. Chest tubes and temporary epicardial wires were removed per protocol. He was evaluated by physical therapy for strength and conditioning and was cleared for discharge to home on POD#6. Ace-I was not resumed due to borderline blood pressure. All follow up instructions and appointments were advised. Medications on Admission: Aspirin 325mg daily Lipitor 80mg daily Plavix 75mg daily NPH 10 units qAM, 30 units qPM Regular insulin Sliding Scale Synthroid 300mcg daily Toprol XL 12.5mg [**Hospital1 **] Sevelamer 2400mg TID - 2 packets with dinner one with BR and lunch Discharge Medications: 1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. sevelamer carbonate 2.4 gram Powder in Packet Sig: One (1) PO 1 w/brkfst & lunch, 2 w/ dinner). 11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): twice daily for two weeks, then daily until directed to discontinue. Disp:*60 Tablet(s)* Refills:*2* 13. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 mls PO every four (4) hours as needed for pain. Disp:*720 mls* Refills:*0* 14. NPH insulin 10 units qam and 30 units qpm via pre-filled pen 15. regular insulin regular insulin per sliding scale Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Coronary artery disease s/p Redo-sternotomy, Coronary artery bypass x 3 Past medical history: s/p Coronary artery bypass graft x 5 [**2155**] ESRD on hemodialysis (at South Suburban, MWF) Diabetes mellitus with renal complications Neuropathy Retinopathy Obstructive Sleep Apnea (previously on CPAP, now resolved after weight loss) Cataract Charcot foot due to diabetes mellitus Hypothyroidism Hyperlipidemia Obesity s/p Lap Band ([**2154**]) Hyperparathyroidism [**3-17**] renal Renal osteodystrophy Pulmonary Nodule (Solitary) History of Colonic Adenoma Left arm fistula s/p Lap Band ([**2154**]) Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema-trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Wound check: [**Hospital Ward Name **] 2A on [**2157-5-17**] at 11am [**Telephone/Fax (1) 170**] Surgeon: Dr. [**First Name (STitle) **]([**Telephone/Fax (1) 170**]) ON [**2157-6-7**] AT 1:15PM [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **] Cardiologist: Dr.[**Name (NI) 90367**] OFFICE WILL CALL WITH APPOINTMENT Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 46799**]([**Telephone/Fax (1) 17465**]) in [**5-19**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2157-5-9**]

[ "276.7", "250.40", "287.5", "V45.11", "793.11", "585.6", "997.1", "403.11", "428.0", "357.2", "414.01", "458.29", "250.50", "272.4", "411.1", "362.01", "588.81", "E878.2", "428.22", "285.9", "427.31", "414.2", "V45.86", "588.0", "V12.53", "996.72", "250.60", "V58.67", "E878.1", "244.9", "414.02" ]

icd9cm

[ [ [] ] ]

[ "37.61", "39.61", "36.13", "39.95", "88.56", "37.22", "97.44", "96.71" ]

icd9pcs

[ [ [] ] ]

8723, 8774

5884, 7034

318, 467

9415, 9643

3316, 5861

10566, 11406

2516, 2655

7326, 8700

8795, 8867

7060, 7303

9667, 10543

2670, 3297

268, 280

495, 1826

8889, 9394

2393, 2500

75,468

122,458

50079

Discharge summary

report

Admission Date: [**2134-1-2**] Discharge Date: [**2134-1-6**] Date of Birth: [**2054-4-20**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 10593**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: upper endoscopy colonoscopy History of Present Illness: 79 yo female with h/o DM, rheumatoid arthritis, HTN, [**Last Name (un) **] body dementia and GI bleed in [**2130**] presents with bright red blood per rectum. Patient states her symptoms began 3 days ago when she had painless bleeding following a bowel movement. Says this happened a few times, only with BMs and only small amounts of blood. No pain with defecation, denies straining, stools soft and otherwise brown (not tarry). Does say blood dripped into the toilet after the BM. Along the same time course, has had occasional LLQ pains that are relieved with BMs. Only had small amounts of bleeding until the night of admission, which she had a large amount of blood with the stool. During this episode she felt dizzy/lightheaded and sweaty, but had not had these symptoms previously. She was alarmed, so she called her son upstairs and told him to bring her to the hospital. . The patient does have a history of a GI bleed in [**2130**], and flex sig revealed both diverticulosis and internal hemorrhoids as possible sources. Says she has had no episodes of bleeding since then. Uses aleve for her headaches probably every other day (1-2 tabs). Does not drink alcohol. . In the ED inital vitals were T 96.8, HR 111, BP 104/64, RR 18, O2 sat 99% RA. Exam notable for mild abdominal tenderness and frank blood on rectal exam. Labs showed hct 29.7 (35 in [**1-/2133**]), Cr 1.5 (baseline), otherwise unremarkable. Attempted NG lavage, but could pass NGT. Placed 2 large bore IVs, sent type and screen, and started on protonix gtt. HR in 60s, BP in 120s systolic on transfer. . On arrival to the ICU, the patient is lying in bed comfortably in no acute distress. She has not had any bowel movements in [**5-28**] hours (since the one she had at home prior to presenting to ED). Generally feels well. . Review of systems: (+) Per HPI, also some orthopnea, cough productive of green sputum (longstanding), chronic headaches (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pressure 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: - past GI bleed in [**2130**] - attributed to diverticular bleed vs internal hemorrhoids - Diabetes Type II - Rheumatoid Arthritis - h/o signficant NSAID use in past - Hypertension - Hyperlipidemia - [**Last Name (un) 309**] Body Dementia - Internal hemorrhoids - Hysterectomy - Right knee arthroscopy - Right breast lumpectomy Social History: Lives at home alone, son lives in an apartment upstairs. Has a nurse that comes for a few hours each day to help with washing, etc but she still is independent in some ADLs. Ambulates with a [**Known lastname **]. She has 6 children (5 sons and 1 daughter). No tobacco or ETOH use. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, oropharynx clear, slightly dry MM Neck: supple, JVP flat, 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, mildly tender in epigastrium, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Rectal: not repeated, had just shown frank blood in the ED Ext: feet cool but 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS: On admission: [**2134-1-2**] 11:20PM BLOOD WBC-10.4# RBC-3.17* Hgb-9.7* Hct-29.7* MCV-94 MCH-30.7 MCHC-32.7 RDW-13.3 Plt Ct-235 [**2134-1-2**] 11:20PM BLOOD Neuts-64.3 Lymphs-27.7 Monos-3.9 Eos-3.3 Baso-0.8 [**2134-1-2**] 11:20PM BLOOD PT-11.4 PTT-26.3 INR(PT)-1.1 [**2134-1-2**] 11:20PM BLOOD Glucose-204* UreaN-27* Creat-1.5* Na-142 K-4.0 Cl-107 HCO3-25 AnGap-14 [**2134-1-5**] 08:45PM BLOOD Hct-33.0* [**2134-1-5**] 06:50AM BLOOD UreaN-11 Creat-1.3* EGD [**2134-1-5**]: Small hiatal hernia, Erythema in the duodenal bulb compatible with mild duodenitis Colonoscopy [**2134-1-5**]: Impression: Diverticulosis of the sigmoid colon, Grade 1 internal hemorrhoids Brief Hospital Course: 79 yo female with h/o DM, rheumatoid arthritis, HTN, [**Last Name (un) **] body dementia and GI bleed in [**2130**] presents with bright red blood per rectum, likely due to lower GI bleed. . # Acute blood loss anemia # Gastrointestinal bleeding Admission for similar episode in [**2130**], attributed to either internal hemorrhoids or diverticulosis. Per HPI, sounds consistent with lower GI bleed explained by either of these etiologies. Admitted to ICU for close monitoring. Started on PPI drip in case of upper GI component to bleed. Hematocrit trended q8h, showed small drop initially (29->26), likely reflective of blood lost in BM just prior to arrival. Transfused 1 unit of PRBCs in ICU, repeat hematocrits stable in 27-28 range. Did have occasional small melanotic stools while in the ICU, however remained hemodynamically stable. Last stools were dark brown, guaiac positive. Transferred to the floor. Had EGD and colonoscopy on [**1-5**], revealing: small hiatal hernia, mild duodenitis, grade 1 internal hemorrhoids, diverticulosis, no active bleeding site. Thus, no active site of bleeding was found, though it is possible that she had a diverticular bleed which subsequently stopped. She received another 1 unit PRBC transfusion, and Hct improved to 33. Per GI recommendation, she underwent video capsule endoscopy on [**1-6**], in case of a slow bleeding site that could not be visulaized on EGD or colonoscopy. Report is pending at the time of discharge. . # Acute renal failure: Cr 1.5 on admission, up a bit from her baseline. Trended down to 1.3. . # Hypertension, benign: Takes HCTZ and losartan as an outpatient. Normotensive on admission, held antihypertensives. These were restarted prior to discharge. . # Diabetes Mellitus type 2, controlled, without complications: had previously taken metformin, however not on any meds currently. QID fingerstick checks and gentle insulin sliding scale started. . # Dementia, [**Last Name (un) 309**] body: still living in her own apartment, independent with some ADLs. Continued donepezil. . TRANISITIONAL ISSUES 1. f/u video capsule endoscopy results 2. f/u Hct (33 on last check check, after second PRBC transfusion) 3. f/u Creatinine (1.3 on last check here) 4. f/u blood pressure Discharge Medications: 1. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 7. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: preferred healthcare services Discharge Diagnosis: -Acute blood loss anemia: -Gastrointestinal bleeding -Acute renal failure -Diabetes mellitus type 2, controlled, without complications -Hypertension, benign -Rheumatoid arthritis -[**Last Name (un) 309**] body dementia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid ([**Known lastname **] or cane). Discharge Instructions: You were admitted for gastrointestinal bleeding and anemia. You received 2 red blood transfusions during your hospital stay, and your blood count improved. Upper endoscopy and colonoscopy showed mild inflammation in your duodenum (small intestine), mild internal hemorrhoids, and diverticula (outpouchings in your colon, which can sometimes bleed). No active bleeding was found. You are undergoing a video capsule endoscopy on [**1-6**] (to look for any possible sites of bleeding that could not be seen on upper endoscopy or colonoscopy). The equipment should be returned on [**1-6**] evening or [**1-7**]. If you develop lightheadedness, palpitations, abdominal pain, blood in your stool, or any other concerning symptoms, please contact your primary care doctor or consider returning to the hospital. Followup Instructions: Department: [**Hospital3 249**] When: THURSDAY [**2134-1-14**] at 10:00 AM With: [**Doctor First Name **] FERN, RNC [**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: [**Hospital3 1935**] CENTER When: TUESDAY [**2134-2-23**] at 9:00 AM With: [**Location (un) 394**]/[**Name8 (MD) **] MD [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: MONDAY [**2134-3-29**] at 10:50 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "535.60", "553.3", "294.10", "V88.01", "272.0", "285.1", "403.10", "562.12", "458.9", "585.9", "584.9", "V58.67", "250.00", "455.0", "331.82", "714.0" ]

icd9cm

[ [ [] ] ]

[ "45.23", "45.13" ]

icd9pcs

[ [ [] ] ]

7617, 7677

4676, 6932

332, 362

7940, 7940

3979, 3986

8968, 9864

3356, 3375

6955, 7594

7698, 7919

8138, 8945

3415, 3960

2223, 2685

264, 294

390, 2204

4000, 4653

7955, 8114

2707, 3037

3053, 3340

52,323

122,961

37457

Discharge summary

report

Admission Date: [**2195-12-1**] Discharge Date: [**2195-12-30**] Date of Birth: [**2124-8-4**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4679**] Chief Complaint: lung cancer Major Surgical or Invasive Procedure: [**2195-12-1**] 1. Right thoracotomy. 2. Right lower lobe sleeve lobectomy. 3. Anastomosis of right middle lobe bronchus to bronchus intermedius. 4. Intercostal muscle flap. 5. Therapeutic bronchoscopy. 6. Mediastinal lymph node dissection. [**2195-12-7**] flex bronch [**2195-12-11**] 1. Redo right thoracotomy, completion right middle lobectomy. 2. Buttressing of bronchial suture line with intercostal muscle. [**2195-12-18**] flex bronch [**2195-12-24**] Re-do thoracotomy, lysis of adhesions, closure of bronchopleural fistula and reinforcement of closure with pericardium, thymic fat pad and intercostal muscle. History of Present Illness: The patient is a 71-year-old male with a biopsy-proven non-small cell lung cancer arising from the right lower lobe. Past Medical History: 1. Chronic angina, per report with normal cardiac catheterization 5 years ago, normal echocardiogram in 08/[**2193**]. 2. Elevated PSA. 3. Chronic cough. 4. Mild COPD Social History: Married, 60 pkyr hx smoking, quit in [**2192**], drinks 1-2drinks/night. hx of demolition of homes, and possible exposure. worked as a carpenter. Family History: Mother - died following stomach cancer Father - CAD, diet of MI Siblings - 4 brothers have died (lung, throat, stomach, prostate cancer) Physical Exam: VS:T 97.8, HR76 reg, BP 112/56, RR 18, O2 sats 95% RA, 94-96% on RA ambulating Physical Exam: Gen: pleasant in NAD Lungs: clear t/o Right thoractomy without redness, purulence or drainage. CV: RRR S1, S2, no MRG or JVD Abd: soft, NT, ND Ext: warm, no edema Pertinent Results: [**2195-12-28**] 06:55AM BLOOD WBC-7.4 RBC-2.80* Hgb-8.8* Hct-26.8* MCV-96 MCH-31.4 MCHC-32.8 RDW-17.1* Plt Ct-298 [**2195-12-27**] 06:30AM BLOOD Glucose-118* UreaN-20 Creat-0.8 Na-140 K-5.0 Cl-107 HCO3-28 AnGap-10 [**2195-12-28**] 06:55AM BLOOD K-4.4 [**2195-12-28**] 06:55AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.9 CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2195-12-18**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 84168**] AT 15:24PM ON [**2195-12-18**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). [**2195-12-24**] 8:45 pm TISSUE TISSUE ADJACENT BRONCHUS. **FINAL REPORT [**2195-12-30**]** GRAM STAIN (Final [**2195-12-25**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2195-12-27**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2195-12-30**]): NO GROWTH. [**2195-12-29**] CXR There has been no change in the multiloculated right hydropneumothorax, the largest component at the base, next smaller anteriorly, smallest at the right apex. Subcutaneous emphysema in the right chest wall is improving. Left lung is clear. Heart size is normal. There is persistent edema and atelectasis at the base of the residual right lung. Brief Hospital Course: Mr. [**Known lastname 80151**] was taken to the operating room by Dr. [**First Name (STitle) **] on [**2195-12-1**] for Right thoracotomy, right lower lobe sleeve lobectomy, anastomosis of right middle lobe bronchus to bronchus intermedius, intercostal muscle flap, therapeutic bronchoscopy, and mediastinal lymph node dissection. He recovered in the ICU, extubated POD 0, and had two remaining chest tubes, which were placed on water seal. He was transfered to the floor on POD 1. On [**2195-12-3**] he developed large amounts of subcutaneous emphysema. He underwent bronch [**2195-12-7**] revealing sealed anastomosis site. Right middle lobe secretions were aspirated. The patient developed fevers, rigors, and tachycardia, but maintained blood pressure. He was pancultured and vanco,zosyn were started. He resolved this in one day. His chest tube was discontinued on [**2195-12-9**], but he continued to have persistent airleak out of the posterior chest tube. He developed afib with RVR on [**2195-12-10**], treated with IV lopressor and eventually diltiazem gtt. Cardiology was consulted. On [**2195-12-11**] he had bronchoscopy for worsened airleak and subcutaneous emphysema, revealing an anastomotic leak at 2oclock position. He then went down to the OR for completion right middle lobectomy. He was brought to the ICU where he recovered. To note he had CT revealing air in mediastinum most likely causing the atrial fibrillation. His atrial fibrillation stopped after amiodarone drip and oral dosing. He stabilized in the ICU and was transfered to the floor, where he then on [**2195-12-18**] was found to have persistent air leak secondary to a pinhole opening in the stoma. This was sealed with fibrin glue. On [**2195-12-20**] he went to the OR for Flexible bronchoscopy, instillation of surgical plug (Surgisis collagen matrix), instillation of fibrin glue, and stent placement (Ultraflex covered 30 x 14 mm) from the right mainstem bronchus to the right upper lobe bronchus. He recovered on the floor, then on [**2195-12-24**] required another trip to the OR for re-do thoracotomy, lysis of adhesions, closure of bronchopleural fistula and reinforcement of closure withpericardium, thymic fat pad and intercostal muscle. The patient did well after this last surgery, with two right sided chest tubes remaining, last pulled on [**2195-12-29**], with PA and Lateral CXR revealing normal fluid filling of the right lower pleural space on [**2195-12-30**]. The patient had ID consultation and completed vancomycin, zosyn, and fluconazole. Latest cultures were all negative and antibiotics stopped [**2195-12-24**]. He developed cdif which flagyl was started [**2195-12-25**] and clinically he improved. He did have another 12 hour incident of atrial fibrillation on [**2195-12-27**] which resolved after amiodarone IV loading. After discussion with cardiology, it was determined his [**Country **] score was low enough that he would be fine with just aspirin 325mg, amiodarone taper and outpatient follow up with cardiology. The patient had complaints of dysphagia early on which revealed air near the posterior wall of the pharynx, however this resolved and was most likely related to his anastomotic leak. He was cleared for regular diet and thin liquids by speech and swallow, but with crushed pills. His complaints of tongue pain were evaluated mid hospital course by ENT, however nothing was found. The patient was ambulating the halls, with controlled pain, and good urine output without constipation. He was hemodynamically stable without fever and stable xray. Dr. [**First Name (STitle) **] deemed the patient stable for discharge home with home PT as recommended by PT. The patient was instructed to follow up cdif after the flagyl is complete with his PCP, [**Name10 (NameIs) **] follow up with his cardiologist regarding his hx of atrial fibrillation. His right thoractomy site was intact and sutures removed [**2195-12-29**] with steristrips placed for reinforcement on day of discharge. Medications on Admission: Amlodipine 10', doxazosin 4', combivent 18/103PRN, Ativan 1', protonix 20', spiriva 19mcg' Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. [**Month/Day/Year **]:*30 Tablet(s)* Refills:*2* 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Month/Day/Year **]:*30 Tablet(s)* Refills:*2* 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). [**Month/Day/Year **]:*30 capsules* Refills:*2* 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): once you are done with bottle, you should follow up cdif testing with your primary care physician. [**Name Initial (NameIs) **]:*6 Tablet(s)* Refills:*0* 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO as directed for as written days: take two tabs twice a day for 2 weeks then 1 day twice a day x 2 weeks, then one tab daily thereafter and followup with cardiologist regarding dosing. [**Name Initial (NameIs) **]:*90 Tablet(s)* Refills:*0* 9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: [**4-11**] ml PO every 4-6 hours as needed for pain. [**Month/Year (2) **]:*500 mL* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: non-small cell 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: - do not drive while taking narcotics. - you may shower but keep chest tube sites covered with a bandaid until healed. leave steristrips on thoractomy site until they fall off. - walk for exercise Call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 2348**] if you have fevers greater than 101.5, chills, shakes, shortness of breath, chest pains, nausea, vomiting, constipation or any fast irregular heart beats, dizziness or if your right thoractomy site has drainage, opens, becomes angry red or has pus. - crush pills before swallowing. Followup Instructions: You have appointments arranged to see the following Doctors together on [**Name5 (PTitle) 18**] [**Hospital Ward Name **] [**Location (un) 448**] CDC next week. You should get a chest xray 30minutes before your appointment on [**Location (un) **] radiology of [**Hospital Ward Name **] clincal center: Dr. [**First Name8 (NamePattern2) 828**] [**Name (STitle) 829**], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2196-1-4**] 12:30 and Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2196-1-4**] 1:00 - Follow up with your primary care physician in the next two weeks. Call them for an appointment. If you need a new one please call [**Telephone/Fax (1) 250**]. - Follow up with your cardiologist in the next two weeks. Call them for an appointment. Completed by:[**2195-12-30**]

[ "162.8", "008.45", "401.9", "427.31", "510.0", "496", "414.01", "998.6", "E878.2", "998.81", "512.1", "996.59", "041.11", "E878.8", "196.1", "E849.7", "413.9" ]

icd9cm

[ [ [] ] ]

[ "33.78", "34.73", "34.79", "33.22", "33.48", "83.82", "96.05", "40.3", "33.24", "32.49" ]

icd9pcs

[ [ [] ] ]

8936, 8994

3475, 7491

333, 966

9065, 9065

1916, 3452

9813, 10681

1486, 1624

7633, 8913

9015, 9044

7517, 7610

9242, 9790

1733, 1897

282, 295

994, 1112

9079, 9218

1134, 1307

1323, 1470

28,062

104,984

51202

Discharge summary

report

Admission Date: [**2129-1-5**] Discharge Date: [**2129-1-23**] Date of Birth: [**2081-6-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Intraventricular hemorrhage Altered Mental Status Major Surgical or Invasive Procedure: Intubation NG tube placement A-line placement Central Line Placement History of Present Illness: Pt is a 47 F h/o stroke, vp shunt in place, mental retardation who is a nursing home patient and ([**Hospital1 **] of state) Pt was in her usual state of health when she was noted to become acutely unresponsive with a concomitant rise in her respiratory rate. Pt was noted to vomit at that time and was brought urgently to OSH. As part of the OSH's workup, pt received head CT revealing a large intraventricular bleed. She was transferred by ALS and arrived at [**Hospital1 18**] hyperthermic to 105, seizing during transfer, and tachycardic to 170's. She was emergently intubated and central access placed. As pt was noted to have hr in the 170s she was given adenosine for ? a.flutter then noted to be sinus tach. To control her seizures, pt was given propofol but continued to seize. She was subsequently loaded on dilantin. Seizures were ultimately controlled with versed. In [**Name (NI) **], pt was hypotensive to 80's. She was transferred to the MICU initially on neo with pressures in the 90s. Initial lactate measured in the ED was 10.4. Pt received 4 liters of IV fluid and follow up lactate improved to 5. Pt covered empirically with ceftriaxone/vanco and tx to the MICU for further evaluation and treatment. Past Medical History: Mental retardation Hydrocephalus Ventricular drain Asthma DM - non insulin dependent CVA(unknown residuals) Social History: Resides at [**Hospital 2251**] Nursing and Rehab center Family History: unknown: Pt is [**Hospital1 **] of the state. Physical Exam: expired Pertinent Results: [**2129-1-5**] 10:14PM LACTATE-5.3* [**2129-1-5**] 10:10PM GLUCOSE-130* UREA N-15 CREAT-1.0 SODIUM-144 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-22 ANION GAP-18 [**2129-1-5**] 10:10PM WBC-16.0* RBC-3.94* HGB-11.4* HCT-33.4* MCV-85 MCH-29.0 MCHC-34.2 RDW-14.8 [**2129-1-5**] 10:10PM NEUTS-67.9 LYMPHS-20.9 MONOS-10.6 EOS-0.1 BASOS-0.5 [**2129-1-5**] 10:10PM PLT COUNT-268 [**2129-1-5**] 07:39PM LACTATE-7.2* [**2129-1-5**] 05:00PM GLUCOSE-171* UREA N-18 CREAT-1.2* SODIUM-145 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-19* ANION GAP-27* [**2129-1-5**] 05:00PM estGFR-Using this [**2129-1-5**] 05:00PM CALCIUM-9.3 PHOSPHATE-1.2* MAGNESIUM-1.7 [**2129-1-5**] 05:00PM WBC-15.6* RBC-4.19* HGB-11.9* HCT-35.7* MCV-85 MCH-28.3 MCHC-33.2 RDW-13.8 [**2129-1-5**] 05:00PM NEUTS-82.4* LYMPHS-13.0* MONOS-4.2 EOS-0.2 BASOS-0.3 [**2129-1-5**] 05:00PM PLT COUNT-336 [**2129-1-5**] 05:00PM PT-13.0 PTT-42.4* INR(PT)-1.1 [**2129-1-5**] 05:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2129-1-5**] 05:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2129-1-5**] 05:00PM URINE RBC-[**5-10**]* WBC->50 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2129-1-5**] 05:00PM URINE HYALINE-0-2 [**2129-1-5**] 04:58PM LACTATE-10.4* Brief Hospital Course: Pt was admitted from the ED to ICU. She was hypertensive, hyperthermic, and tachycardic with rates in the 170 range. Pt exhibited roving eye movements and right sided clonus. She was not responsive. Over the course of her hospitalization, pt experienced intermittent fevers, hypotension, rhabdomyolysis. She was evaluated by neurology and neurosurgery, both services concluding that there was not any meaningful recovery expected. As the patient is a [**Hospital1 **] of the state, affidavits were generated and the patient's case was presented before the courts. The patient was subsequently made CMO and expired shortly thereafter. Medications on Admission: Valproic acid, geodon, prozac, metformin, albuterol, enolase, senna, bisacodyl, MOM (all doses unknown) Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "331.4", "518.81", "319", "250.00", "493.90", "728.88", "682.3", "431", "348.4", "780.39" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.91", "96.04", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

4153, 4162

3326, 3966

364, 434

4213, 4222

1996, 3303

4278, 4288

1906, 1953

4121, 4130

4183, 4192

3992, 4098

4246, 4255

1968, 1977

275, 326

462, 1685

1707, 1817

1833, 1890

54,639

134,882

38640

Discharge summary

report

Admission Date: [**2154-7-8**] Discharge Date: [**2154-7-12**] Date of Birth: [**2084-12-4**] Sex: F Service: MEDICINE Allergies: erythromycin Attending:[**First Name3 (LF) 4393**] Chief Complaint: Fever, hypotension, abdominal drainage Major Surgical or Invasive Procedure: Needle aspiration of abdominal fluid collection History of Present Illness: 69yo female with cryptogenic cirrhosis complicated by HCC, ascites and varices, COPD on home O2, dCHF and s/p umbilical hernia repair [**6-6**], comes in with two days of fevers and drainage from her umbilical surgery site. She had a fever two days ago to 102, since then has had more low-grade temps. No N/V, no dysuria. Does have diffuse abdominal pain that has been stable since her umbilical hernia repair. She started having serosanguinous drainage from the surgical site two days ago. She actually feels that her abdomen is less swollen than previously. She called her hepatologist and was instructed to come to the ED. . In the ED, initial VS were: 98.6 68 105/54 16 98% RA. SBPs dropped to the 70s, responded to fluids. Gave one dose of Zosyn. No ascites clear to tap. Hyponatremia to 120. Transplant surgery aspirated 300ccs from the fluid collection and sent for gram stain and culture. Family refused central line, though the patient is full code, given a fear of CVL placement not from personal experience, but from things she has heard about them. The ED did touch base with hepatology. . After fluid resuscitation and normalization of blood pressure, the patient again became hypotensive to the 80s, asymptomatic, but the decision was made at that time to admit the patient to the intensive care unit for closer monitoring. . The transplant surgery team came to the ED to drain the fluid collection, approximately 300cc serous fluid was drained. . Has 18G and 20G, s/p 2L IVF and 25gm albumin. Vitals prior to admission 83/48 62 14 98% RA. . On arrival to the MICU, the patient is comfortable, reporting [**5-21**] pain at her surgical site, [**11-20**] with palpation. Past Medical History: -Cryptogenic cirrhosis complicated by esophageal variceal bleeding s/p banding, encephalopathy, ascites, caput medusae, and hepatic hydrothorax. -HCC (3cm liver lesion with AFP=16,322) s/p TACE with follow-up AFP=2.1 -Iron deficiency anemia, presumed secondary to GI loss from multiple AVMs and internal hemorrhoids (Baseline Hct 24-30) -CAD status post possible MI. -Diastolic, right sided CHF with EF greater than 55% ([**3-/2153**]) -Hypertension -AAA s/p endovascular repair -Pulmonary hypertension (per ECHO) -CKI (Baseline Cr 1.0-1.4) -COPD on home O2 and bronchodilators in the past. Currently not requiring bronchodilators. -GERD -Right ankle surgery following injury in [**2128**], which prevents her from being get MRIs. -Prolapsed uterus. -H/o Lower extremity cellulitis. -s/p Tonsillectomy. -[**2154-6-6**] umbilical hernia repair with mesh Social History: The patient lives with her husband in [**Name (NI) 1562**], MA. She has two grown children. She used to smoke 10 cigarettes/day but quit [**2-19**]. She does not drink EtOH nor use illicit drugs Family History: Father died of liver disease at age 40. Mother had HTN Physical Exam: Admission Physical: Vitals: T: 36.8 BP: 88/49 P: 60 R: 16 O2: 100%RA General: Alert, oriented, no acute distress, slightly yellowish skin HEENT: Sclera icteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Distant, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, bibasilar crackles. Abdomen: Healing surgical scar, small amount of serosanguinous drainage in the left, lower corner. Tender above the drainage site. Redness around surgical site, not warm or indurated. Otherwise soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . No asterixis. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Discharge exam - unchanged from above, except as below: Abdomen: recent umbilical hernia repair site with opened wound below the umbilicus, approx 4cmx3cmx3cm. At discharge, wet-to-dry dressing in place. Pertinent Results: Admission Labs: [**2154-7-8**] 09:15AM BLOOD WBC-13.6*# RBC-2.65* Hgb-6.9* Hct-23.5* MCV-89 MCH-26.0* MCHC-29.2* RDW-20.8* Plt Ct-190 [**2154-7-8**] 09:15AM BLOOD Neuts-83.2* Lymphs-9.7* Monos-3.8 Eos-2.9 Baso-0.3 [**2154-7-8**] 09:15AM BLOOD PT-12.9* PTT-28.2 INR(PT)-1.2* [**2154-7-8**] 09:15AM BLOOD Plt Ct-190 [**2154-7-8**] 09:15AM BLOOD Glucose-139* UreaN-39* Creat-2.0* Na-120* K-4.4 Cl-85* HCO3-27 AnGap-12 [**2154-7-8**] 09:15AM BLOOD ALT-19 AST-40 AlkPhos-150* TotBili-2.3* DirBili-1.2* IndBili-1.1 [**2154-7-8**] 09:15AM BLOOD Lipase-16 [**2154-7-8**] 09:15AM BLOOD Albumin-2.7* Calcium-7.9* Phos-3.6# Mg-2.0 [**2154-7-8**] 09:27AM BLOOD Lactate-1.5 Discharge labs: [**2154-7-12**] 06:30AM BLOOD WBC-6.3 RBC-2.96* Hgb-7.7* Hct-26.9* MCV-91 MCH-26.0* MCHC-28.7* RDW-19.7* Plt Ct-163 [**2154-7-12**] 06:30AM BLOOD PT-11.7 PTT-30.3 INR(PT)-1.1 [**2154-7-12**] 06:30AM BLOOD Glucose-118* UreaN-13 Creat-0.9 Na-131* K-4.2 Cl-99 HCO3-26 AnGap-10 [**2154-7-12**] 06:30AM BLOOD ALT-22 AST-52* LD(LDH)-200 AlkPhos-158* TotBili-1.6* [**2154-7-12**] 06:30AM BLOOD Calcium-7.7* Phos-2.1* Mg-1.9 Micro: -Wound cx ([**2154-7-8**]): FLUID,OTHER SUBCU FLUID.FLUID RECEIVED FROM CYTOLOGY.SPECIMEN REFRIGERATED. Interpret results with caution. GRAM STAIN (Final [**2154-7-9**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. Reported to and read back by AKUTHORA [**Doctor First Name **] [**2154-7-9**] @ 350PM. FLUID CULTURE (Final [**2154-7-12**]): STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. -BCx x2 - NGTD at discharge -UCx - No growth final Imaging: CT Abd/Pelvis: ([**2154-7-8**]): IMPRESSION: 1. Large non-hemorrhagic fluid collection in the anterior subcutaneous tissues at the site of prior hernia repair. Further evaluation is limited without IV contrast. Superinfection cannot be excluded on this study. 2. Unchanged abdominal aortic aneurysm status post endovascular repair. 3. Diverticulosis without diverticulitis. 4. Cirrhosis, splenomegaly, and abdominal varices are similar to prior. LENI ([**2154-7-8**]): IMPRESSION: No left lower extremity deep venous thrombosis. TTE ([**2154-7-10**]): The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is dilated with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Low normal left ventricular systolic function. Dilated and hyokinetic right ventricle. Mild mitral regurgitation. At least mild pulmonary hypertension. Mildly dilated thoracic aorta. Brief Hospital Course: 69yo female with a history of cryptogenic cirrhosis complicated by HCC who is s/p mesh ventral hernia repair on [**2154-6-6**] presenting with increasing peri-incisional abdominal pain, drainage from her surgical site, and fever up to 102 two days ago presenting to the emergency department with hypotension refractory to fluid boluses # Hypotension: Thought to be from volume depletion (she was fluid responsive at admission). Baseline blood pressure appears to be in the 80-90s which is likely a result of her cirrhosis. Sepsis was also considered in setting of fever and surgical site infection. She was initially admitted to the MICU for her hypotension with SBPs as low as the 70s in the ED. The patient received additional volume in the MICU, her BP was stable in the mid 80s, she was also transfused 2 units PRBCs with good response. Repeat urinalysis was negative for infection. Blood culture results are pending at discharge. Patient also experienced a short run of ventricular bigeminy on [**2154-7-9**], but was asymptomatic and hemodynamically stable. Cardiac enzymes were within normal limits. Her BP improved to the 100s systolic upon arrival to the medicine floor and were stable at discharge. # Infected surgical site fluid collection: She was initially started on Zosyn in the MICU while culture data was pending. 300cc was drained from the fluid collection. Fluid from the aspiration grew MSSA and she was switched to cephalexin. She will continue a 10 day course of cephalexin after discharge. A wound vac was placed by transplant surgery, which she will continue to use at home. A wet-to-dry dressing was applied at discharge until she receives her home Wound Vac. She has follow-up arranged with the transplant surgery clinic after discharge. # Hyponatremia: Likely hypovoluemic hyponatremia as her sodium improved with folume resuscitation. Her diuretics (Lasix and spironolactone) were held at admission and at discharge she will be restarted on Lasix 20mg and spironolactone 50mg. She will have lytes and BUN/Cr checked Monday [**2154-7-15**]. Her baseline Na appears to be in the high 120s to low 130s, she was 131 at discharge. # Acute on CKI: As above, likely due to volume depletion. Cr was 2.0 at admission from baseline of 1.1-1.5. After fluid resuscitation, Cr improved to 0.9 at discharge. # Crypotgenic cirrhosis: LFTs remained at baseline and her MELD was 7 at discharge. She was continued on lactulose this admission with no evidence of encephalopathy. As mentioned above, she will be restarted on her nadolol and lower doses of Lasix/spironolactone at discharge. # Anemia: Likely due to chronic disease, no evidence of acute blood loss. She received 2 units PRBCs this admission and her Hct was 26 at discharge, baseline is in the mid 20s. # Ventricular ectopy: She had a significant amount of ectopy on telemetry while in the MICU. A TTE was obtained which showed only depressed free wall contracility in the right ventricle and pulmonary hypertension. She was asymptomatic during these episodes of ectopy. # Code status this admission: FULL # Transitional issues: -F/u blood cultures which were pending at discharge -Has VNA arranged to re-apply Wound Vac on the day after discharge, wet-to-dry dressing in place at discharge -Chem-7 and CBC to be checked on Monday [**2154-7-15**], results faxed to Dr. [**Last Name (STitle) 497**] [**Name (STitle) 85863**] on lower doses of Lasix and spironolactone (20mg and 50mg, respectively). Can be uptitrated as an outpatient. Medications on Admission: - furosemide 60mg daily - lactulose 15ml [**Hospital1 **] - nadolol 20mg daily - oxycodone 2.5mg Q3hrs PRN - spironolactone 100mg daily Discharge Medications: 1. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2 times a day). 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q3H (every 3 hours) as needed for pain. 5. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days: Continue until all pills are gone. Disp:*24 Capsule(s)* Refills:*0* 6. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Outpatient Lab Work Please check Chem-10 and CBC on Monday [**2154-7-15**]. Dx: 571.5 Cirrhosis without alcohol. Fax results to Dr. [**Last Name (STitle) 497**] ([**Telephone/Fax (1) 4400**]) Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary diagnoses: Wound infection Hypotension Secondary diagnoses: Cryptogenic cirrhosis with hepatocellular carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 68042**], It was a pleasure taking care of you during your admission to [**Hospital1 18**] for fever and low blood pressure. You were found to have an infection in the area around your umbilical hernia repair which was treated with antibiotics. You will continue to receive oral antibiotics after discharge. You will also continue to use the wound vac at home and the VNA will help set this up for you. You will go home with a gauze dressing and the wound vac will be reapplied tomorrow. Your blood pressure improved with fluids and was stable at the time of discharge. Please have your labs checked on Monday [**2154-7-15**], the results will be faxed to Dr. [**Last Name (STitle) 497**]. The following changes were made to your medications: START cephalexin 500mg by mouth every 6 hours for 6 days (last day [**2154-7-18**]) CHANGE Lasix to 20mg daily CHANGE Spironolactone to 50mg daily Followup Instructions: Department: TRANSPLANT CENTER When: THURSDAY [**2154-7-18**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: THURSDAY [**2154-7-18**] at 2:50 PM With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**] Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. Department: LIVER CENTER When: FRIDAY [**2154-8-2**] at 10:00 AM With: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13146**] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage *This is a follow up appointment for your hospitalization. You will be reconnected with gastroenterologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] after this visit. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]

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icd9cm

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Discharge summary

report+report

Admission Date: [**2188-6-21**] Discharge Date: [**2188-6-27**] Date of Birth: [**2110-4-29**] Sex: M Service: Neurology HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old man who presented with two transient 15-minute episodes of left- face, arm and leg weakness lasting greater than 15 minutes usually resolving completely and separated by two or three hours. The patient had no sensory symptoms; only motor weakness and arm and leg and perhaps face. PAST MEDICAL HISTORY: (The patient has a past medical history significant for) 1. Coronary artery disease (status post coronary artery bypass graft). 2. Gastrointestinal bleed with [**Doctor First Name **]-[**Doctor Last Name **] tear. 3. Chronic obstructive pulmonary disease. 4. Chronic renal insufficiency. 5. Transurethral resection of prostate. 6. Alcohol abuse. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, the patient had a blood pressure of 112/70, afebrile, heart rate was 80, and respiratory rate was 16. General examination revealed no physical findings. On neurologic examination, the patient's mental status was alert and oriented times three. Cranial nerves II through XII were intact. The face was symmetric. Extraocular movements were intact. Visual fields were full to confrontation. The tongue was midline. Shoulder shrug was [**4-7**]. The patient also had pronator drift on motor examination. The patient did have 4+/5 isolated weakness of the left deltoid on admission; however, that resolved to [**4-7**] with all upper and lower extremities being [**4-7**] prior to discharge. The patient had no sensory deficits. Examiantion of the cerebellar functions revealed truncal ataxia and mild dysmetria on finger- to- nose and heel to shin bilaterally. Gait was wide- based and unsteady. HOSPITAL COURSE: The patient was admitted for a stroke workup, but on his first night of admission had an episode of hematemesis with 900 cc of coffee-grounds emesis. The patient was kept nothing by mouth with intravenous fluids. The patient also had a nasogastric tube with low suction to decompress the gastrointestinal tract. Nasogastric lavage was performed which produced no frank blood. Hemodynamically, the patient was stable throughout the first night, and the patient reported hematemesis every week since episode of gastrointestinal bleed in [**2186**] at [**Hospital1 346**] for coronary artery bypass graft. The patient's complete blood count and Chemistry-8 were normal on admission at 10/32. The patient had complete blood count monitored q.8h. after episode of gastrointestinal bleed for four days with a stable hematocrit and hemoglobin of around [**10-2**]; sometimes even increasing to 12/32. The patient also had a Gastroenterology consultation, and they performed an esophagogastroduodenoscopy which revealed grade III esophagitis in the middle bulb of the esophagus with granularity, erythema, and congestion of the distal bulb, anterior bulb, and posterior bulb compatible with duodenitis. Gastroenterology consultation recommended a proton pump inhibitor twice per day and to avoid anticoagulants as much as possible. Therefore, prior to discharge, the decision was made to have the patient on Protonix 40 mg p.o. twice per day for four to six weeks until a repeat esophagogastroduodenoscopy. Thereafter, the patient would see Dr. [**Last Name (STitle) 14506**] (primary medical doctor), in community who would refer the patient to Gastroenterology for his repeat esophagogastroduodenoscopy and would resume Aggrenox for transient ischemic attack prophylaxis at that time. Until repeat esophagogastroduodenoscopy, the patient will be maintained on aspirin 325 mg p.o. once per day on discharge. The patient also had episodes of a heart rate in the low 40s to high 30s on atenolol. An ACE inhibitor was considered if heart rate dipped below 40. Heart rate was monitored for three to four days prior to discharge and remained in the middle 40s. The patient presented with a heart rate in the high 40s; therefore, the decision was made to keep atenolol and perhaps switch to an ACE inhibitor as an outpatient. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: DISCHARGE DIAGNOSIS: Transient ischemic attack most likely secondary to small vessels or branch disease. MEDICATIONS ON DISCHARGE: (Discharge medications were as follows) 1. Pantoprazole 40 mg p.o. q.12h. 2. Atorvastatin 10 mg p.o. once per day. 3. Enteric-coated aspirin 325 mg p.o. once per day. 4. Multivitamin one tablet p.o. once per day. 5. Atenolol 25 mg p.o. once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [**Last Name (STitle) 14506**] who was notified of esophagogastroduodenoscopy results and will refer outpatient esophagogastroduodenoscopy after four to six weeks on pantoprazole by mouth. 2. The decision to switch to ACE inhibitor due to bradycardia as an outpatient will be left in the hands of his primary care provider (Dr. [**Last Name (STitle) 14506**]. DR.[**Last Name (STitle) 726**],[**First Name3 (LF) 725**] 13-268 Dictated By:[**Name8 (MD) 15274**] MEDQUIST36 D: [**2188-6-24**] 14:36 T: [**2188-6-24**] 16:11 JOB#: [**Job Number 44018**] Admission Date: [**2188-6-21**] Discharge Date: [**2188-6-26**] Date of Birth: [**2110-4-29**] Sex: M Service: NEUROLOGY HISTORY OF THE PRESENT ILLNESS: The patient is a 78-year-old male with a history of MI times two, CABG in [**2186**], peripheral vascular disease, now presenting from an outside hospital for investigation of two transient episodes of left-side hemiparesis. According to the patient, he awoke on Saturday, [**2188-6-21**] at 5:30 a.m. and could not move his entire left side of body including leg and foot for a half an hour. The patient reports that approximately two to three hours later, while sitting on an armchair, felt the sudden onset of the same left-sided weakness for 15-30 minutes. The patient called his wife who called EMS. By the time they had arrived, the patient's strength had returned. The patient arrived to the ER at [**Hospital 882**] Hospital where a head CT was negative. The hospital gave him Aggrenox post aspirin and he was transferred to [**Hospital1 18**] for further evaluation. At [**Hospital1 18**], the patient was admitted to the Neurology Service for workup of TIA and stroke. On initial imaging, the MRI showed no abnormalities on DWI. However, the study did show periventricular white matter signal changes most likely secondary to small vessel disease. On MRA there was evidence of decreased flow of left vertebral artery. HOSPITAL COURSE: The patient was admitted to the General Medical Floor for further workup including carotid ultrasound and transthoracic echocardiogram, both within normal limits; however, on the day of admission at 9:00, the patient had an episode of coffee ground emesis. The patient was kept n.p.o., given IV fluids with NG tube to low suction. The patient continued to have 900 cc of coffee ground emesis. The GI service was consulted and upper esophageal gastric duodenoscopy that showed grade III esophagitis and gastritis. The patient's CBC was monitored throughout the admission. The patient's hematocrit decreased from 28 to 33 after two days of admission. He was therefore was transfused 1 unit of packed red blood cells. The patient's hematocrit stabilized at 36 prior to discharge. Because of his risk factors for stroke it was discussed what would be his best anti-platetel regimen, in the setting of GI bleed. Both GI and Neurology Services agreed that the patient will tolerate aspirin 325 mg enteric coated and Protonix p.o. for four to six weeks. At that time, he will have a repeat esophageal duodenoscopy as an outpatient. After this study, a decision will be made by Dr. [**Last Name (STitle) 14506**], the patient's primary care physician, [**Name10 (NameIs) **] add on Aggrenox for stroke prophylaxis. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSIS: Transient ischemic attack. DISCHARGE MEDICATIONS: 1. Atenolol 25 mg p.o. q.d. 2. Protonix 40 mg p.o. q.d. 3. Lipitor 10 mg p.o. q.d. 4. Aspirin, enteric coated 325 mg p.o. q.d. 5. Multivitamin one capsule p.o. q.d. FOLLOW-UP PLANS: The patient will follow-up with Dr. [**Last Name (STitle) 14506**], primary care physician, [**Name10 (NameIs) **] four to six weeks. [**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**] Dictated By:[**Name8 (MD) 15274**] MEDQUIST36 D: [**2188-6-26**] 03:27 T: [**2188-7-5**] 10:42 JOB#: [**Job Number 44019**]

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2199-8-14**] Discharge Date: [**2199-8-21**] Date of Birth: [**2132-3-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Hypoxia and chest pain at dialysis. Major Surgical or Invasive Procedure: Ligation of LUE AV fistula. History of Present Illness: Ms. [**Known lastname 1728**] is a 67-year-old woman with multiple medical problems, including ESRD on HD, CAD s/p stent, CHF EF 45%, COPD, and DM, who was initially admitted to the transplant surgery service on [**2199-8-14**] for ligation of LUE AV fistula due to steal symptoms. Per notes, operative course was unremarkable, and patient was sent for dialysis per routine on [**2199-8-15**]. While at the terminal end of her routine dialysis session today, patient reportedly became hypoxic to 80s. She was placed on a NC with initial sats 83% 4L NC. She became tachypneic and reportedly complained of chest pressure. EKG was unchanged, and patient was placed on NRB with gradual improvement in symptoms. O2 sat improved to 100% on NRB within minutes. She was unable to tolerate nebulizer treatments. Patient denied any diaphoresis. Chest pressure lasted approximately ~1-2 minutes, self-resolved. ABG done while at MICU showed 7.44/48/105. 1.8 L had been removed at dialysis. . On arrival to the MICU, patient reported that she was feeling much better. Denied any chest pain. Reported breathing was improved but not back to baseline. No diaphoresis. No headache, fevers, chills, abdominal pain, nausea, vomiting. She was stabilized in the MICU and was transferred to the Medicine floor. . On arrival to the medicine floor, the patient mentioned that she has only had a small BM in the past five days; otherwise, no complaints. Past Medical History: -Diabetes Mellitus -Coronary Artery Disease: Cypher x 2 to left circumflex in [**2196**] and Cypher to LAD after NSTEMI in [**2198-11-21**] -Congestive Heart Failure: most recent EF of 45% pre Cypher to LAD in [**2198**] in setting of NSTEMI, pulmonary edema -Chronic kidney disease, initiated on HD as above -COPD -Lung CA, status post resection [**2182**] -Neuropathy secondary to DM -Gout: [**1-22**] gouty flares every 2-3 months. Patient takes colchicine during flares, and if necessary receives steroid injection at PCP office [**Name9 (PRE) 26283**] Apnea -Obesity -GERD: status post endoscopy in [**2198-11-21**] which revealed nonerosive gastritis, reflux disease -Depression Social History: Lives with husband who is involved in care. History of smoking for many years (50-pack years), occasional alcohol, no drug use. Family History: Mother died of heart disease at 61. Father died of heart disease at 67. Also significant for hypertension and diabetes. Physical Exam: VS: T 98.9 HR 80 BP 100/52 RR 22 O2 96% 2L NC FS: 120 GEN: obese woman in NAD, sitting up, [**Location (un) 1131**] HEENT: EOMI grossly. MMM. CV: RRR, distant heart sounds, nl S1, S2. PULM: faint scattered crackles, limited by cooperation. ABD: + BS, soft, NTND EXT: no c/c/e NEURO: alert and oriented x 4, CN II-XII grossly intact. Pertinent Results: ADMISSION LABS: ================ 9.6 6.8 >------< 291 MCV 92 29.3 141 98 37 -----|-----|-----< 64 Ca 9.6 Mg 2.0 P 5.3 4.2 32 4.6 . ABG 7.44/48/105 . [**2199-8-15**] 12:30PM BLOOD CK(CPK)-31 Trop 0.04 [**2199-8-15**] 09:40PM BLOOD CK(CPK)-27 Trop 0.05 [**2199-8-16**] 05:34AM BLOOD CK(CPK)-27 Trop 0.05 . PERTINENT LABS DURING HOSPITALIZATION: ====================================== INR trend: 1.2 - 1.3 - 1.4 - 1.3 - 1.4 - 1.9 - 2.6 - 3.5 - 4.6 - 5.7 . STUDIES: ========= LUNG SCAN [**2199-8-15**] IMPRESSION: 1. No evidence of pulmonary embolism. 2. Patchy ventilation slightly worse than on prior study from [**2197-5-8**]. . CHEST (PORTABLE AP) [**2199-8-15**] IMPRESSION: No evidence of pneumothorax, pulmonary congestion or acute infiltrate. . EKG [**2199-8-15**] Sinus rhythm. Left atrial abnormality. Compared to the previous tracing of [**2199-4-18**] no diagnostic interim change. . UNILAT UP EXT VEINS US LEFT [**2199-8-16**] IMPRESSION: 1. Deep vein thrombosis in the left subclavian vein surrounding the subclavian central venous catheter. . CHEST (PORTABLE AP) [**2199-8-16**] Portable AP chest radiograph compared to [**2199-8-15**] obtained at 1:40 p.m. The heart size is mildly enlarged but stable. Mediastinal contours are unremarkable. The lungs are clear. No sizeable pleural effusion is identified. Double lumen catheter is inserted through the left subclavian vein is demonstrated terminating at the level of cavoatrial junction. . CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2199-8-19**] IMPRESSION: 1. No evidence of pulmonary embolism. 2. Limited evaluation of the subclavian, brachiocephalic, and SVC. 3. Subcentimeter pulmonary nodules as described above, measuring up to 9 mm in left lower lobe. Followup in three months is recommended. 4. Dilated ascending aorta with atherosclerosis. 5. Atrophic right kidney with exophytic cyst, which cannot be further characterized on this CT scan. If clinically indicated, ultrasound can be performed on non-urgent basis. . PERSANTINE MIBI [**2199-8-19**] INTERPRETATION: Left ventricular cavity size is normal. Rest and [**Month/Day/Year **] perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 54%. IMPRESSION: Normal study; LVEF 54%. . [**Month/Day/Year 10081**] ECHO 07/30/07INTERPRETATION: IMPRESSION: No ischemic ST-T wave changes or anginal-type symptoms. Nuclear report sent separately. . LABS UPON DISCHARGE: ===================== 11.0 9.0 >-------< 348 MCV 92 34.0 142 100 25 ------|------|-----< 130 Ca 9.7 Mg 2.0 P 4.0 4.6 28 4.6 PT-48.7* PTT-33.2 INR(PT)-5.7* Brief Hospital Course: Ms. [**Known lastname 1728**] is a 67-year-old woman with multiple medical problems, including ESRD on HD, CAD s/p stent, CHF EF 45%, COPD, and DM, who was initially admitted to the transplant surgery service on [**2199-8-14**] for ligation of LUE AV fistula due to steal symptoms. She became hypoxic to the 80's and complained of chest pressure at the end of her routine dialysis session with initial sats of 83% 4L NC. She was transferred to the MICU for respiratory distress, which resolved, and then to the medical team for further management. . # Respiratory Distress: Cause of hypoxia and chest discomfort were not clearly found. While in the ICU she was ruled out for cardiac ischemia with serial enzymes. Additionally, she was given neb treatments for dyspnea. Etiology continued to be unknown, but respiratory distress resolved. Pt with known DVT in LUE. Continued nebs for COPD. . # Subclavian thrombosis near HD catheter: Her left arm was noted to have increased swelling and discoloration, and ultrasound was done to evaluate the graft area. A subclavian thrombosis was found near the left subclavian dialysis catheter and heparin was started. A CTA was also done to assess for PE in order to gauge duration of anticoagulation. This showed no PE; thus, anticoagulation is only needed for 1 month. Began coumadin for anticoagulation and continued heparin drip until therapeutic. Did not pull port because of theoretical risk of dislodging clot as well as disrupting access throughout arm and possible emboli. Towards end of hospitalization, pt became uncooperative with medical team, refused medications and labs, and demanded discharge. Her heparin drip was discontinued, and she continued on coumadin; however, her INR was too high towards the end of admission, so it was held. She was discharged with instructions to hold her coumadin dose until labs were drawn at her home and her PCP could advise her on how to achieve the correct thereupeutic level. . # CAD s/p stent: No further c/o chest pain while in MICU and on medicine floor. She was ruled out for MI after transfer to the MICU with no EKG changes observed with acute episode. Continued outpatient ASA, BB, ACE, Statin, Plavix. Per PCP, [**Name10 (NameIs) **] test ordered and resulted in a normal study with LVEF of 54%. . # ESRD: HD on T, TH, Sat. The patient tolerated HD without incident. Renal team continued to follow patient and advise on management during her hospitalization. . # COPD, stable: Continued on outpatient Fluticasone, Montelukast, Pentoxyphylline. Nebulizers prn. . # DM: Continued outpatient Glargine 35U with humalog sliding scale. FS QID. . # Pruritus in lower extremities: She was given topical creams with good results. . # CODE: Full, discussed with patient. Medications on Admission: MEDICATIONS ON TRANSFER: 1. Aspirin 81 mg daily 2. Clopidogrel 75 mg daily 3. Metoprolol Tartrate 50 mg PO twice daily 4. Atorvastatin 80 mg daily 5. Lisinopril 10 mg daily 6. Montelukast 10 mg daily 7. Pantoprazole 40 mg Tablet twice daily 8. Pentoxifylline 400 mg PO 3x daily 9. Paroxetine HCl 20mg daily 10. Isosorbide Dinitrate 10 mg 3x daily 11. Sevelamer 12. Insulin SS and fixed dose 13. Aranesp 14. Fluticasone 2 Spray Nasal DAILY Discharge Medications: 1. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal DAILY (Daily). 2. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Daily (). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Ipratropium Bromide 0.02 % Solution Sig: Two (2) puffs Inhalation Q6H (every 6 hours). 10. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). 17. Salsalate 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Insulin Glargine Subcutaneous Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: 1. Respiratory distress 2. Thrombus at HD catheter Secondary Diagnosis: 1. Coronary Artery Disease 2. Diabetes Mellitus 3. COPD 4. Depression 5. GERD Discharge Condition: Stable. Discharge Instructions: You were admitted to the intensive care unit due to respiratory distress that occurred while at hemodialysis. After being stabilized, you were transferred to the medicine floor. You were found to have a clot around your hemodialysis catheter. PLEASE DO NOT REMOVE YOUR CATHETER. . We stopped your coumadin because your level was too high. DO NOT TAKE YOUR COUMADIN. You will get a lab draw at home tomorrow to check your INR. Dr. [**Last Name (STitle) 3649**] will tell you when to restart the coumadin. You must go to the nearest emergency room if you have any signs of bleeding (including in your urine, stool, mouth or from your skin). . You are to go to hemodialysis tomorrow ([**2199-8-22**]) at your normally scheduled time. . Continue to take all medications EXCEPT your coumadin. DO NOT TAKE COUMADIN until we check your lab and Dr. [**Last Name (STitle) 3649**] tells you to restart. . Please call your PCP or go to the ER if you have a nosebleed, bright red blood out of your rectum, lightheadedness, dizziness, headache, protracted nausea and vomiting or abdominal pain. Followup Instructions: Hemodialysis on Thursday, [**8-22**] at normally scheduled time. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD, RENAL TRANSPLANT Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-9-2**] 2:20 . Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], APG [**Location (un) **] INTERNAL MEDICINE (NHB) Date/Time:[**2199-9-9**] 11:30 . Provider: [**Name10 (NameIs) **] [**First Name (STitle) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2199-9-16**] 2:00 Completed by:[**2199-8-31**]

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icd9cm

[ [ [] ] ]

[ "39.42", "39.95" ]

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3833

Discharge summary

report

Admission Date: [**2192-8-25**] Discharge Date: [**2192-9-7**] Date of Birth: [**2115-3-31**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: witnessed sz, fall at home Major Surgical or Invasive Procedure: Serial stereotactic biopsy. History of Present Illness: 77M h/o Alzheimer's dementia became confused, weak, and had 1 episode of urinary incontinence 8pm yest. Around midnight he had seizure activity in bed at home witnessed by his wife and he fell out of bed with no LOC when she called 911. He was taken to [**Hospital 4199**] hospital where a head CT revealed a mass ?tumor and he was given ativan for agitation. He was transferred from OSH to [**Hospital1 18**] for further evaluation, and now presents with post-ictal confusion and excitement. Past Medical History: Alzheimer's dementia 5+yrs HTN ^chol Social History: married, retired, lives at home in [**Location (un) 3146**], MA h/o EtOH abuse, now only allowed 2 drinks/day per PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17225**] last drink evening prior to hospitalization denies tob/IVDU Physical Exam: On Admission 96.3 77 143/68 20 97%RA Gen: unkempt, agitated. HEENT: normocephalic, atraumatic, PERRLA, pupils 2->1mm bilat, EOMI, no nystagmus detected. Neck: Supple. C-collar on, no C-spine tenderness elicited. Lungs: CTAB. Cardiac: RRR. nl S1/S2. Abd: +BS, S, NT/ND. Extrem: Warm and well-perfused. Neuro: Mental status: AA+Ox1. "[**2115-4-7**]", agitated. wants to see wife. Language: Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: CNII-XII grossly intact bilaterally. Limited exam as patient uncooperative. Patient follows simple command, uncooperative with motor exam. Moves all 4 extremities. No clonus. Nonfocal neuro exam. Toes downgoing bilaterally. Pertinent Results: CT HEAD W/O CONTRAST [**2192-8-25**] 5:58 AM IMPRESSION: 2.8-mm right temporoparietal mass without shift of normally midline structures. Differential includes both primary and metastatic malignancy as well as focal infection and clinical correlation is recommended. Overall, there is limited evaluation without contrast and MRI is recommended for further characterization. MR HEAD W & W/O CONTRAST [**2192-8-26**] 7:32 PM IMPRESSION: Right parietal lobe mass with vasogenic edema. In absence of slow diffusion within the central portion of the lesion, this most likely represents a neoplastic lesion and locations are suggestive of metastatic disease. MRA OF THE HEAD: The head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. A fetal right posterior cerebral artery is incidentally noted. There is no vascular occlusion or high-grade stenosis seen. IMPRESSION: Normal MRA of the head. RADIOLOGY Final Report [**2192-8-27**] 12:17 AM CT CHEST W/CONTRAST; CT NECK W/ & W/O CONTRAST IMPRESSION: 3 cm lobulated right upper lobe mass with indentation and spiculation, with continuous extensive mediastinal and hilar and subcarinal lymphadenopathy representing primary lung cancer with lymph node metastasis. The mediastinal mass invades into the lower SVC, and compresses right main pulmonary artery. 2. Centrilobular emphysema. Small bilateral pleural effusion with atelectasis. 3. Diverticulosis without evidence of active inflammation. 4. Left renal cyst. 5. Degenerative changes of thoracolumbar spine. No suspicious lytic or blastic lesion is noted, however, bone scan can be performed for staging. Cardiology Report ECG Study Date of [**2192-8-30**] 8:57:20 AM Sinus rhythm Left axis deviation RBBB with left anterior fascicular block Since previous tracing of [**2182-8-13**], right bundle branch block and left anterior fascicular block present Intervals Axes Rate PR QRS QT/QTc P QRS T 77 146 134 420/449 68 -64 70 Cardiology Report ECHO Study Date of [**2192-8-28**] GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - patient unable to cooperate. Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small (0.5 cm) circumferential pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. No right ventricular diastolic collapse is seen. Suboptimal image quality - patient unable to cooperate. IMPRESSION: Small, echo dense pericardial effusion without echocardiographic signs of tamponade. Mild left ventricular hypertrophy with preserved biventricular systolic function. Mild diastolic dysfunction. Mild pulmonary hypertension. CT HEAD W/O CONTRAST [**2192-9-5**] 3:36 PM IMPRESSION: Since [**2192-8-31**], resolution of intracranial air. No significant change in the 2.7-cm right parietal mass with large area of surrounding edema. Brief Hospital Course: Mr. [**Known lastname 17226**] was admitted [**2192-8-25**] after a witnessed sz and fall at home. A head CT showed a 2.8cm R parietotemporal mass with edema, no midline shift. This patient presented with a single seizure and CAT scan and MRI scan revealed an irregularly contrasting enhancing mass in the right parietal lobe. The patient was also demented since several years and the torso CT showed multiple lung lesions. The situation was discussed in detail with the family and once due to the dementia of the patient, a first line resection was denied. After extensive discussions of the pros and cons, the family wished a serial stereotactic biopsy to be done so that a definitive histological diagnosis could be obtained and any further measures could be decided upon on the basis of a definitive diagnosis of the lesion and the pertinent prognostic outlook. During his pre-operative course the pt was intubated and sedated during imaging. The pt was extubated on the morning of [**2192-8-27**]. The stereotactic brain biopsy was conducted on [**2192-8-31**]. Preoperatively, Dilantin was started for seizure prophylaxis as well as decadron. Post-operatively PO intake was decreased and a 3 day calorie count was done and PO intake was encouraged. At time of discharge, pt was taking adequate PO intake. Medications on Admission: ASA 81 zestril atenolol Vit B12 [**2184**] Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day: hold for SBP<120 HR<60. 2. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Vitamin B-12 1,000 mcg Tablet Sig: Two (2) Tablet PO once a day. 4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 5. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for agitation. 7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezes. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 11. Phenytoin 100 mg/4 mL Suspension Sig: Two (2) PO BID (2 times a day): 200mg [**Hospital1 **]. Discharge Disposition: Extended Care Facility: [**Hospital 169**] Center-Elmhurst Discharge Diagnosis: Right parietal metastatic brain tumor, most likely small cell lung cancer. Discharge Condition: Good Discharge Instructions: ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Please call the office of Dr.[**Last Name (STitle) **] at [**Telephone/Fax (1) **]. If you have any post-operative questions or concerns. Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB) Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2192-9-17**] 9:10

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icd9cm

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Discharge summary

report

Admission Date: [**2109-7-12**] Discharge Date: [**2109-7-16**] Date of Birth: [**2075-10-22**] Sex: M Service: SURGERY Allergies: Amoxicillin / Penicillins Attending:[**First Name3 (LF) 1**] Chief Complaint: iliostomy closure [**2109-7-12**] Major Surgical or Invasive Procedure: iliostomy closure which was successfully done [**2109-7-12**] History of Present Illness: 33 year old male with recent diagnosis of severe ulcerative colitis recently more suspicious of Crohn's, s/p TAC w/ ileoanal pouch, loop ileostomy [**2109-3-6**] which was complicated by intrabdominal abscess, SMV/splenic vein thrombus (on coumadin that was discontinued by pt in [**5-/2109**] though to be completed on [**7-7**]), was admitted to surgical service for iliostomy closure which was successfully done [**2109-7-12**]. Patient was already having bowel movement after the surgery and passing gases (on clear diet) and the plan was to transition to PO narcotics from IV narcotics on the day of transfer to [**Hospital Unit Name 153**]. He received 4mg IV dilaudid q 2 hr at 7.30am, 9.30am, 11.30am. Code blue was called for respiratory arrest (unwitnessed). 0.4 mg of narcan IV was administered followed by 1 mg of IV narcan. This resulted in improvement of his respiratory status and regain of his consciousness. He had pulse during the code. Per surgeons, the patient had respiratory arrest in the PACU in the past secondary to opioids. On arrival to the MICU, patient's VS were T 97.4, HR 94, BP 143/74, RR 13-15, Sat 99% on 2-3L NC. Started narcan drip at 0.2 mg / hr. received 4mg iv zofran x1 for nausea. Review of systems: (+) Per HPI. He was shivering and complaining of cold. Denies SOB, CP. Reported abdominal pain [**8-5**]. Past Medical History: -Inflammatory bowel disease (initially diagnosed as ulcerative colitis, however, most recent path suspicious for Crohn's) s/p TAC/ileoanal pouch/loop ileostomy w/ course c/b intraabdominal abscess s/p drainage and SMV/splenic vein thromboses (started on Coumadin but self discontinud by patient [**5-/2109**]); -iliostomy closure [**2109-7-12**] -Depression PAST SURGICAL HISTORY: -Skin graft LLE -Total abdominal colectomy w/ ileoanal pouch, loop ileostomy ([**2109-3-6**]) -iliostomy closure [**2109-7-12**] Social History: Lives at home with significant other. Currently on disability. Denies tobacco use. Social EtOH [**11-26**] drink per month. Denies illicits. Family History: Denies history of IBD, his grandmother and grandfather had colitis Physical Exam: VS:98.2,66, 148/70,18,97% RA General:Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Cardiac Regular rate and rhythm, normal S1 + S2, no murmurs,rubs,gallops Pulmonary: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen:soft, non-distended, bowel sounds present,no organomegaly, tenderness to palpation at surgical site, no rebound,mild guarding Incision:staples c/d/i,mild erythema receding,no ecchymosis,no drainage GU:no foley Ext:Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro:CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: [**2109-7-13**] 08:07AM BLOOD WBC-11.5* RBC-3.99* Hgb-12.4* Hct-37.5* MCV-94 MCH-31.1 MCHC-33.0 RDW-15.9* Plt Ct-289# [**2109-7-14**] 04:20AM BLOOD Glucose-103* UreaN-11 Creat-0.8 Na-138 K-4.0 Cl-104 HCO3-27 AnGap-11 [**2109-7-13**] 10:44AM BLOOD Glucose-133* UreaN-15 Creat-1.0 Na-136 K-3.3 Cl-99 HCO3-28 AnGap-12 [**2109-7-14**] 04:20AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.9 Brief Hospital Course: MICU COURSE: # Respiratory arrest: Likely secondary to opioid overdose with receiving 4 mg IV dilaudid q2hr in the morning prior to transfer to MICU. Consideration also paid to potential PE, but was ambulating and with SQH on board. Patient received a total 1.4 mg iv narcan during the respiratory arrest. Continued on narcan drip and then titrated off with close monitoring. Patient did well without any further episodes of respiratory distress. # Pain control: Patient was kept on iv tylenol and iv toradol for pain control with effort to avoid high dose narcotics. After respiratory depression resolved, oxycodone was restarted. # IBD: s/p TAC w/ ileoanal pouch, loop ileostomy [**2109-3-6**] s/p ileostomy closure. Was not active issue in MICU. Transitional Issues from MICU:None Patient was transferred back to the floor on [**2109-7-14**] and was hemodynamically stable. Patient had mild abdominal distention however continued to pass gas and had several bowel movements. Patient was able to tolerate brat diet which was advanced to soft regular which was tolerated well.POD 3, his abdomen was mildly distended however he was able to pass gas later in the day and had several bowel movements.Of note,the erythema at his incision site continued to recede, and we were unable to express any drainage from surgical site. POD 4, his abdominal distention improved. Patient reported having several bowel movements per day, greater than 5 in 24 hour period. Therefore he was started on Loperamide and instructed to titrate his bowel movements to 3 per day. In regards to his surgical incision the erythema was receding and we were unable to express any drainage. However, he reported mild tenderness on palpation at surgical site. Antibiotics were deferred at this time due to receding erythema and no fevers. Patient was instructed to continued to monitor his incision site for worsening erythema and purulent drainage. His pain was well controlled on oral pain medication. He was discharged home in good condition with follow-up instructions. Medications on Admission: melatonin 10 mg daily OTC trazodone 25 mg daily oxycodone 20 mg daily as needed (mainly for low back pain, [**11-26**] per week, stopped 2 weeks prior to his [**7-12**] surgery per surgeon's recommendation) Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 3. traZODONE 25 mg PO HS:PRN sleep 4. Loperamide 2 mg PO QID:PRN diarrhea titrate to 3 bm per day RX *loperamide 2 mg 1 tablet by mouth four times a day Disp #*90 Capsule Refills:*3 Discharge Disposition: Home Discharge Diagnosis: Chronic ulcerative colitis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 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. * 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 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. * Please titrate Loperamide(Imodium), take 2 mg four times a day as needed for diarrhea; titrate to 3 bowel movements per day. * Continue to ambulate several times per day. Incision Care: -If you have staples they will be removed at your follow-up appointment with Dr. [**Last Name (STitle) **]. If you have steri-strips they 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: Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks [**Telephone/Fax (1) 9**]. Completed by:[**2109-7-17**]

[ "V15.1", "V55.2", "799.1", "997.49", "V45.72", "997.39", "E935.2", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "96.23", "46.51" ]

icd9pcs

[ [ [] ] ]

6361, 6367

3661, 5711

318, 381

6441, 6441

3264, 3638

7953, 8067

2471, 2540

5969, 6338

6388, 6420

5737, 5946

6616, 7473

7488, 7930

2166, 2297

2555, 3245

1654, 1762

244, 280

409, 1635

6456, 6568

1784, 2143

2313, 2455

21,479

147,336

26163

Discharge summary

report

Admission Date: [**2101-2-22**] Discharge Date: [**2101-2-28**] Date of Birth: [**2033-8-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8487**] Chief Complaint: resp distress Major Surgical or Invasive Procedure: CVL placement and arterial line placement History of Present Illness: 67F with recently diagnosed metastatic renal cell cancer, mets to lungs, recurrent malignant R pleural effusion, s/p R VATS and pleurex cath placement [**2-9**], p/w increasing dyspnea and lethargy. Since her dischrage from the last hospitalization here at the [**Hospital1 **] 2 weeks ago, she's been staying with her daughter and was noted to have progressing DOE, anorexia, dizziness. She was noted to have an increased resp distress and was started on home O2 Friday (3 days prior to presentation). Her newly replaced pleurex catheter has not been putting out much (40 cc/day ; previously 200-400 cc/day prior to replacement on [**2101-2-9**]). She had some cough productive of clear [**Last Name (un) 1993**] but no cough for the past few days. Also has been noted to be hoarse for the past few days. Her DOE has progressed to the point that she was unable to be supine and had to sit upright in bed and had significant DOE with minimal activity (walking few steps, eating, talking). Pt was too weak to ambulate for the past day. No fevers, chills, diarrhea, CP, H/A. + weakness The morning of presentation, her daughter fed her, bathed her and took her in the car to her outpt chest CT recommended by thoracics. She was lethargic and dyspnic in the car and the family was unable to get her out of the car upon arrival to [**Hospital1 18**], therefore she was taken to the ED. In our ED, she was afebrile, tachycardic to 120s (sinus); initially w/ stable BP. She was given lasix 80 IV x 1; put on BIPAP, became hypotensive to the 80s systolic; taken off. Her code status was confirmed by her family and she was intubated. She subsequently got a CTA of her chest which showed dramatic progression of her metastases vs superimposed infection, B pleural effusions (R>L). The CT revealed a R mainstem bronchus intubation and the ETT was readjusted. She was given Vanco and CTX and was sent to the [**Hospital Unit Name 153**] with one PIV. In the [**Hospital Unit Name 153**], she was initially responsive to commands, but within 30 min became unresponsive, hypotensive to the mid70s to 80s. She got a 1 L NS bolus, levophed was started, a RIJ was placed without complications, L radial a-line was placed. Past Medical History: 1. Metastatic renal cell ca: DOE in [**Month (only) 1096**]--> local ER--> new R pleural effusion; CT with L renal mass (5 x 6 cm, enhancing left renal mass) and B pulm nodules. Had recurrent R pleural effusions since then She had a biopsy of her left kidney on [**2101-1-3**], which showed renal cell carcinoma vs transitional cell ca with some granular and some clear cells features and a bone scan showed some skull involvement. Performance status one. Pleurodesis an pleurex cath placement at OSH, then repreat R VATS and Pleurex Catheter re-placement [**2-9**] at [**Hospital1 18**] CT scan from [**2101-1-5**]: an enhancing left mid-to-lower pole renal mass. This mass is somewhat centrally located; therefore, it is somewhat concerning for a transitional cell carcinoma. multiple pulmonary nodules and also what appears to be a malignant right pleural effusion. Also R pleural based tumor. Bone scan was also done which had demonstrated increased uptake in the skull consistent with metastatic disease in the skull 2. DOE 3. Recurrent R pleural effusion 4. LLE swelling: neg LENIs in [**Month (only) **]; started on lasix as outpt 5. Restr lung dz (FEV1 0.67 (32%); FVC 0.9 (30%); FEV1/FVC 104%; MMF 0.41 (20%). Flow-Volume Loop: Restrictive pattern with abrupt termination of exhalation. 6. CAD: s/p CABG in [**2095**]; not seen by a cardiologist in 3 yrs; unknown EF 7. LGIB 8. Diverticulosis 9. bursitis in her arm 10. ? TB exposure 40 years ago. Social History: Retired daycare worker, nonsmoker with heavy secondary smoke exposure from her husband's. Family History: Mother with bladder cancer and cervical cancer, father had diverticulosis and angina. Physical Exam: PE 98.5 HR 130 85/55 16 100% on A/C 500/16/5/100 Gen'l: elderly F; responds to voice; follows commands HEENT: constricted pupils B (1-2 mm; reactive); dry mm; ETT in place Neck: no JVD Pulm: coarse BS; decreased at B bases (R>L); no whezzing CVS: tachy; RR; S1/2; no m/r/g Abd: +BS; soft; obese; NT/ND Ext: no c/c; B pitting edema (3+) Pertinent Results: CXR [**2101-2-22**] pre intub: Redemonstration of multiple bilateral pulmonary masses and nodules. Interval development of right lower lobe and retrocardiac consolidations as well as a small left and likely right pleural effusion. . CXR 2/7/06post intub: Compared to the exam of one hour earlier, there has been interval placement of an endotracheal tube with the tip approximately 2 cm above the carina. A nasogastric tube has also been placed with the tip near the GE junction. Appearance of the chest is otherwise stable . CTA [**2101-2-22**]: no pe. progression of pleural and intraparenchymal mets. ETT in right mainstem bronchus and ngt at GE junction . [**2101-2-22**] 11:25PM CORTISOL-23.3* [**2101-2-22**] 10:27PM TYPE-ART TEMP-38.2 RATES-16/0 TIDAL VOL-500 O2-50 PO2-91 PCO2-50* PH-7.40 TOTAL CO2-32* BASE XS-4 INTUBATED-INTUBATED VENT-CONTROLLED [**2101-2-22**] 10:27PM LACTATE-2.7* [**2101-2-22**] 10:24PM URINE COLOR-LtAmb APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2101-2-22**] 10:24PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2101-2-22**] 10:24PM URINE RBC-8* WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2101-2-22**] 10:00PM GLUCOSE-137* UREA N-19 CREAT-0.6 SODIUM-142 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-31 ANION GAP-15 [**2101-2-22**] 10:00PM ALT(SGPT)-12 AST(SGOT)-12 CK(CPK)-41 ALK PHOS-88 AMYLASE-19 TOT BILI-0.3 [**2101-2-22**] 10:00PM LIPASE-18 [**2101-2-22**] 10:00PM CK-MB-4 cTropnT-0.04* [**2101-2-22**] 10:00PM ALBUMIN-3.4 CALCIUM-8.3* PHOSPHATE-3.2 MAGNESIUM-1.9 [**2101-2-22**] 10:00PM CORTISOL-23.6* [**2101-2-22**] 10:00PM CRP-49.8* [**2101-2-22**] 10:00PM WBC-10.9 RBC-3.54* HGB-9.8* HCT-30.0* MCV-85 MCH-27.6 MCHC-32.5 RDW-14.8 [**2101-2-22**] 10:00PM NEUTS-88.1* LYMPHS-8.9* MONOS-2.5 EOS-0.2 BASOS-0.2 [**2101-2-22**] 10:00PM HYPOCHROM-1+ POIKILOCY-1+ [**2101-2-22**] 10:00PM PLT COUNT-455* [**2101-2-22**] 10:00PM PT-14.4* PTT-24.2 INR(PT)-1.3* [**2101-2-22**] 09:10PM O2 SAT-58 [**2101-2-22**] 05:31PM GLUCOSE-227* UREA N-19 CREAT-0.7 SODIUM-142 POTASSIUM-5.3* CHLORIDE-97 TOTAL CO2-33* ANION GAP-17 [**2101-2-22**] 05:31PM CALCIUM-8.7 PHOSPHATE-4.4 MAGNESIUM-2.1 [**2101-2-22**] 05:31PM WBC-11.8*# RBC-3.95* HGB-10.8* HCT-33.4* MCV-85 MCH-27.4 MCHC-32.5 RDW-14.9 [**2101-2-22**] 05:31PM NEUTS-94.7* LYMPHS-3.3* MONOS-1.7* EOS-0.1 BASOS-0.2 [**2101-2-22**] 05:31PM HYPOCHROM-1+ POIKILOCY-1+ [**2101-2-22**] 05:31PM PLT COUNT-507* [**2101-2-22**] 05:31PM PT-14.5* PTT-24.1 INR(PT)-1.3* [**2101-2-22**] 03:46PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2101-2-22**] 03:42PM LACTATE-3.1* [**2101-2-22**] 03:25PM GLUCOSE-230* UREA N-19 CREAT-0.6 SODIUM-141 POTASSIUM-5.6* CHLORIDE-97 TOTAL CO2-31 ANION GAP-19 Brief Hospital Course: Briefly, this is a 67 yo female with metastatic renal cancer, met to lung parenchyma, pleural mets w recurrent R pleural effusion, who p/w respiratory distress and hypotension. In the [**Hospital Unit Name 153**], she was initially responsive to commands, but within 30 min became unresponsive, hypotensive to the mid70s to 80s. She got a 1 L NS bolus, levophed was started, a RIJ was placed without complications, L radial a-line was placed. The pt was intubated upon arrival to the [**Hospital Unit Name 153**]. She was treated for presumed sepsis. The next day, thoracic surgery was contact[**Name (NI) **] regarding drainage of R pleural effusion, and oncology was contact[**Name (NI) **] regarding her metastatic renal cancer. It was concluded that there was a small amount of effusion in the lungs and the cause of the pts respiratory distress is due to the large tumor load in the lungs. The pt was never stable enough to be a candidate for chemo treatment since the initial diagnosis of renal cancer in [**2100-12-16**]. Pt stayed on ventilator until all family members arrived. Ultimately the pt was weaned from the vent and passed away on a morphine gtt on hd #7. . 1. Hypotension: The pt developed hypotension on arrival to the [**Hospital Unit Name 153**], felt possibly secondary to hypovolemia and sepsis, although afebrile on admission. Presumed pulmonary source. The pt was given IVF boluses and started on levophed gtt. For the most part, pt's CVP was kept above 12, MAP above 65. SVO2 was monitored to maximize oxygen delivery. Levophed was weaned off after about 24 hours. ISS was ordered for FSBS > 250. UOP was monitored. Toward the end of her stay, urine catheter was clogged causing decrease in UOP, and it was changed. Pt's hct was stable at 30 most of the time. Pt was started on CTX/Vanco in the ED and was changed to Zosyn/Levo (double coverage for gram neg) and Vanc (given recent hospitalization). Pt was given steroid stress dose for 7 days b/c she failed the [**Last Name (un) 104**] stim test. Urine culture was negative. Blood culture was negative. Sputum culture showed gram postive cocci in pairs and oralpharyngeal flora. Levo was d/c'd. Vanco was d/c'd after 3 days [**2-17**] no evidence of MRSA from screen test. Zosyn was continued. . 2. Resp failure was likely secondary to large tumor burden from malingancy and superimposed infection. CTA was neg for PE. Pt was put on ventilation setting A/C 500/16/5/.5 and later 500/16/8/.5. Pt was never able to withstand weaning of ventilator to pressure support mode. . 3. R pleural effusion: thoracic surgery was consulted. It was determined that there was a small amount of pleural effusion and that removal of the effusion would do more harm than good to the patient. The main cause of the patient's respiratory distress was the large tumor burden. . 4. Metastatic renal cell ca was rapidly progressing. Oncology was consulted. It was concluded that there was no treatment that could reverse the spread of tumor. Patient was never a candidate for chemo therapy because of her unstable condition. Family members were informed at all times about [**Hospital **] medical condition, and code status was changed from full code to dnr/dni. Pt was eventually put on morphine drip, weaned from ventilator and passed away. . 5. Cardiac: patient did not have any evidence of ischemia. Cardiac enzymes and ekg were negative. Beta blocker was held. CVP was monitored. . 6. H/o GIB: hct was stable for the most part at around 30 during the course of her stay. . 7. PPx: pt was put on prophylaxis with Lansoprazole, SQ heparin, and bowel regimen. Medications on Admission: Zetia 10 po qday Atenolol 25 po qday Iron 325 po qday Albuterol Lasix 40 po qday Potassium 20 po qday Colace Ambien : stopped Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Renal Cell CA; expired Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

[ "189.0", "518.81", "785.52", "995.94", "038.9", "197.0", "V45.81", "197.2", "198.5", "276.52", "996.31" ]

icd9cm

[ [ [] ] ]

[ "34.91", "38.93", "96.04", "38.91", "96.72" ]

icd9pcs

[ [ [] ] ]

11397, 11406

7555, 11190

329, 372

11472, 11481

4695, 7532

11534, 11541

4233, 4321

11368, 11374

11427, 11451

11216, 11345

11505, 11511

4336, 4676

276, 291

400, 2616

2638, 4109

4125, 4217

65,399

110,778

36657

Discharge summary

report

Admission Date: [**2110-7-11**] Discharge Date: [**2110-7-22**] Date of Birth: [**2039-10-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**7-18**] Coronary artery bypass grafting x3 with left internal mammary artery to the left anterior descending artery; reverse saphenous vein single graft from the aorta to the posterior descending artery; as well as reverse saphenous vein graft from the aorta to obtuse marginal 1, Repair of aortovenous fistula in the right groin by vascular (this will be dictated by vascular surgery History of Present Illness: 70 year old male with no PMH who presented to OSH with confusion in setting of NSTEMI. All head imaging negative. Transferred for cardiac cath. Past Medical History: none Social History: Occupation: Former professional baseball player. Works in sporting goods store. Last Dental Exam:>1 yr ago Lives with:sister and nephew [**Name (NI) **]:Caucasian Tobacco:Denies ETOH:4 drinks/week Family History: 1 brother and 1 sister/14 siblings with CAD s/p stenting Physical Exam: Pulse:79 Resp:13 O2 sat: 98% RA B/P Right:144/75 Left:140/68 Height:5'[**11**]" Weight:188 LBS General:ALert & oriented x 3 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 [] No Murmur or gallops. Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema Varicosities: None [X] Neuro: Grossly intact Pulses: Femoral Right:+2 Left:+2 DP Right:+2 Left:+2 PT [**Name (NI) 167**]:+2 Left:+2 Radial Right:+2 Left:+2 Carotid Bruit Right: None Left: None Pertinent Results: [**7-14**] Cardiac cath: 1. Coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had a distal 60% stenosis. The LAD was diffusely disease with a 20% stenosis proximally and 80% stenosis in the mid vessel. The diagonals were small and diffusely diseased. The Cx had a 90% stenosis at the origin with a thrombotic subtotal occlusion at the mid Cx where the OM1 came off. The RCA was diffusely diseased with a 90% stenosis in the proximal vessel. The mid RCA had a 60% stenosis. The distal vessels of the RCA fill via left to right collaterals. 2. Central aortic pressure was 130/70 mmHg. [**7-18**] Echo: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is sclerosis of the aortic valve with decreased mobility of the non-coronary cusp. ([**Location (un) 109**]~ 2.1 cm2) No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. POSTBYPASS: There is preserved biventricular systolic function. The exam is unchanged from prebypass [**7-16**] Femoral U/S: Grayscale and color Doppler son[**Name (NI) 1417**] were performed in the right groin at the puncture site. Color flow is identified within both the common femoral artery and vein. Proximal to the puncture site in the common femoral vein, there are elevated velocities of approximately 260 cm/sec. This waveform demonstrated pulsatility and turbulence. There is a normal arterial waveform in the adjacent femoral artery. Distal to the puncture site in the common femoral vein, there were appropriate waveforms with a velocity of approximately 20 cm/sec. Surrounding small hematoma was identified. A fistulous connection between the common femoral artery and common femoral vein is possibly seen. [**2110-7-11**] 09:15PM BLOOD WBC-8.6 RBC-4.97 Hgb-15.3 Hct-44.6 MCV-90 MCH-30.9 MCHC-34.3 RDW-13.9 Plt Ct-283 [**2110-7-21**] 05:10AM BLOOD WBC-14.7* RBC-2.88* Hgb-9.1* Hct-26.3* MCV-91 MCH-31.5 MCHC-34.6 RDW-13.9 Plt Ct-248 [**2110-7-11**] 09:15PM BLOOD PT-12.7 PTT-25.2 INR(PT)-1.1 [**2110-7-19**] 03:50PM BLOOD PT-15.1* PTT-30.2 INR(PT)-1.3* [**2110-7-11**] 09:15PM BLOOD Glucose-102 UreaN-24* Creat-0.9 Na-140 K-4.0 Cl-105 HCO3-26 AnGap-13 [**2110-7-21**] 05:10AM BLOOD Glucose-128* UreaN-29* Creat-0.9 Na-135 K-4.7 Cl-100 HCO3-29 AnGap-11 [**2110-7-18**] 06:10AM BLOOD ALT-33 AST-26 AlkPhos-70 TotBili-1.1 Brief Hospital Course: Mr. [**Known lastname 82924**] was transferred from OSH with a myocardial infarction. Upon admission he underwent a cardiac cath which revealed severe three vessel and 60% left main disease. After cath he was admitted for cardiac surgery work-up and Plavix washout. On [**7-18**] he was brought to the operating room where he underwent a coronary artery bypass graft x 3(Left internal Mammary Artery grafted to Left Anterior Descending/Saphenous Vein Grafted to Obtuse Marginal/Posterior Descending Artery) and repair of Right Groin aortovenous fistula.Cross Clamp Time= 90 minutes. Cardiopulmonary Bypass Time=111 minutes. Please see Dr[**Last Name (STitle) 5305**] operative report for further details. He tolerated the procedure well and was transferred in critical but stable condition to the CVICU. He weaned from sedation, awoke neurologically intact and extubated on POD#1. All lines and drains were discontinued when criteria was met.Chest tubes remained in to POD#3 due to drainage/Plavix preop. Beta-Blocker, Plavix, and diuresis was initiated when tolerated. He continued to progress and was transferred to the step down Floor for further monitoring. Physical Therapy was consulted for evaluation/mobility. POD#3 on exam, bloody sternal drainage was noted and antibiotics were initiated. CXR was reviewed by DR.[**Last Name (STitle) 914**] and DR.[**Last Name (STitle) **] from radiology. The remainder of his postoperative course was essentially uneventful. He continued to progress and was cleared by Dr.[**Last Name (STitle) 914**] for discharge to home with VNA on POD#4. All follow up appointments were advised. Medications on Admission: ASA 81 mg daily Discharge Medications: 1. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: Please take 400mg (two 200mg pills)daily for one week, then decrease to 200mg daily for one week. Disp:*60 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*60 Tablet, Chewable(s)* Refills:*2* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for poor targets. Disp:*60 Tablet(s)* Refills:*2* 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:*28 Tablet(s)* Refills:*0* 10. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 10 days. Disp:*40 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Myocardial Infarction 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) 4044**]. 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 or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: [**Hospital Ward Name 121**] 6 for wound check in 1 week, call for appointment [**Telephone/Fax (1) 3071**] Dr. [**Last Name (STitle) 914**] in 4 weeks, [**Telephone/Fax (1) **], please call for appointment Dr. [**Last Name (STitle) 12167**] in [**1-28**] weeks PCP [**Last Name (NamePattern4) **] [**12-27**] weeks Completed by:[**2110-7-22**]

[ "401.9", "997.2", "414.01", "E879.0", "293.0", "437.7", "410.71" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.56", "39.53", "36.15", "37.22", "36.12" ]

icd9pcs

[ [ [] ] ]

7631, 7689

4632, 6263

332, 721

7815, 7821

1916, 4609

8613, 8959

1154, 1212

6329, 7608

7710, 7794

6289, 6306

7845, 8590

1227, 1897

282, 294

749, 895

917, 923

939, 1138

109

158,995

14807

Discharge summary

report

Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-26**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 338**] Chief Complaint: altered mental status, solmolence, and relative hypotension Major Surgical or Invasive Procedure: none, HD per schedule on the day of discharge, transfused 1u PRBC History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, hx of malignant HTN admitted with change in mental status. Patient missed HD on [**2142-2-24**] and was found unresponsive and diaphoretic by mother this morning after she took some dilaudid. EMS was called, 1 mg of narcan was administered with slight improvement in mental status. On arrival to the ED her vitals were 112/64 62 16 99RA she was noted to be hyperkalemic in the absence of EKG changes and was given calcium, D5, 10U regular insulin, 30 mg po kayxalate and repeat K was 5.4. ABG: 7.29/38/199. Repeat glucose was 41 and 1amp D50 was given. She was sent to the ICU for monitoring. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including [**Month/Year (2) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: HR: 80 (79 - 80) bpm BP: 127/59(76) {127/59(76) - 139/64(82)} mmHg RR: 34 (21 - 34) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Physical Examination Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact Pertinent Results: [**2142-2-25**] 01:50PM PT-14.9* PTT-36.8* INR(PT)-1.3* [**2142-2-25**] 01:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2142-2-25**] 01:50PM WBC-5.0 RBC-2.21* HGB-6.4* HCT-20.7* MCV-94 MCH-29.1 MCHC-31.1 RDW-19.6* [**2142-2-25**] 10:30PM GLUCOSE-87 UREA N-66* CREAT-8.4* SODIUM-142 POTASSIUM-5.9* CHLORIDE-110* TOTAL CO2-16* ANION GAP-22* HISTORY: Altered mental status. Evaluate underlying for pneumonia. UPRIGHT PORTABLE CHEST: Comparison is made to [**2-14**] and [**2142-2-19**], exams. Study is slightly limited by patient motion. In the interval, the degree of pulmonary edema appears improved with slightly decreased prominence of the pulmonary vascularity. There is unchanged extensive retrocardiac consolidation obscuring the majority of the left hemidiaphragm with persistent blunting of the left CP angle, likely related to small effusion. Exam is otherwise unchanged from prior with persistent cardiomegaly. A catheter is seen projecting over the abdomen, partially imaged. IMPRESSION: Slight improvement in pulmonary edema with persistent retrocardiac opacity, which again may represent atelectasis versus underlying pneumonia. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted hypotension and decreased mental status. Hypotension and altered mental status were in the setting of excessive narcotic use. Patient's narcotics were held, pressors returned to [**Location 213**] and patient was mentating fine. Hct was below baseline and patient was transfused 1u PRBC and was given HD before discharge. Patient is to continue anti-hypertensive medications as previously scheduled. Patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # Change in mental status: Resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. Patient received 1 dose of narcan with slight improvement in BP and mental status. patient without fevers or leuckocytosis which argue against infection. # Hypertension ?????? resumed outpatient regimen. Patient did not have any hypertensive episodes requiring hydralizine 10mg IV. # Hypotension: resolved, Patient normotensive on arrival to ICU. Relative hypotension likely due to dilaudid. Other considerations include sepsis, although patient without objective signs of infection. Held pain medications and hypotension resolved. Resumed hypertensive medications. # Abdominal pain ?????? from previous peritoneal [**Location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # Hyperkalemia: Likely due to missed HD session. She received calcium, D5, insulin and kayexalate in ED. HD in am ESRD: Renal following, had HD the day of discharge, transfused while there. Will continue normal schedule as an outpatient with HD T/Th/F this week. # Metabolic Acidosis: likely due to renal failure and missed HD. # SLE: continued prednisone at 4 mg PO daily. # OSA: CPAP for sleep with 7 pressure, however patient refuses. Continued to offer as inpatient. Should try to follow up with sleep medicine. Medications on Admission: Prednisone 4mg qd Citalopram 20 mg daily Gabapentin 300 mg [**Hospital1 **] Warfarin 4mg daily Pantoprazole 40 mg qd Clonidine 0.1 mg/24 QWED Clonidine 0.3 mg/24 hr QWED Labetalol 900 mg tid Nifedipine 90 mg qd Aliskiren 150 mg [**Hospital1 **] Hydralazine 100 mg q8h Morphine 7.5 mg q8h prn pain Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home Discharge Diagnosis: Primary: narcotic overdose relative hypotension anemia Secondary: ESRD on HD [**2-12**] SLE malignant hypertension Discharge Condition: stable - received HD prior to discharge Discharge Instructions: You were admitted for altered mental status after missing hemodialysis. It was likely from the dilaudid you took as well as missing your scheduled [**Month/Day (2) 2286**]. You were also relatively hypotensive in the setting of excessive narcotic medicaiton usage. Narcotic medications were held and hypotension and altered mental status resolved. Please use narcotic medications with caution. You are recommended to use morphine for pain control rather than dilaudid. No medication changes were made. Please return to the ED if you have any altered mental status or miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] or have symptoms such as vision changes or headache from your history of malignant hypertension. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-3-20**] 3:00 HD as previously scheduled Completed by:[**2142-2-26**]

[ "582.81", "287.5", "285.21", "780.97", "403.01", "327.23", "300.4", "V45.12", "585.6", "965.09", "276.7", "729.92", "458.29", "710.0", "446.6", "E850.2", "V12.51", "V58.61", "425.4", "276.2" ]

icd9cm

[ [ [] ] ]

[ "39.95", "99.04" ]

icd9pcs

[ [ [] ] ]

8422, 8428

5311, 5918

352, 419

8588, 8630

4013, 5288

9407, 9621

3258, 3383

7634, 8399

8449, 8567

7312, 7611

8654, 9384

3398, 3994

253, 314

447, 1124

5934, 7286

1146, 3030

3046, 3242

8,832

179,467

51676+59371

Discharge summary

report+addendum

Admission Date: [**2133-10-3**] Discharge Date: [**2133-12-2**] Date of Birth: [**2068-1-29**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old male admitted to [**Hospital6 256**] on [**10-3**] from [**Hospital3 4419**] with shortness of breath. The patient apparently had vomited while eating at the rehabilitation center and was felt to have an aspiration Levofloxacin and Clindamycin with a white blood cell count of 16.9 on admission. The patient was also noted to have ST depressions laterally and subsequently ruled in for a non-Q-wave myocardial infarction. The patient was initially managed medically and given concern for infection (aspiration pneumonia). On [**10-12**], the have sustained another non-Q-wave myocardial infarction. The patient was intubated. An intra-aortic balloon pump was placed, and the patient was transferred to the CCU. The patient has known coronary artery disease (three-vessel disease) and underwent a two-vessel coronary artery bypass grafting on [**2133-10-13**]. The patient was extubated on [**2133-10-15**]. The patient was treated with Levofloxacin and Vancomycin for ten days given the history of aspiration pneumonia and MRSA positive sputum. The patient had bilateral pleural effusions postoperative and had chest tubes placed bilaterally. The pleural fluid was not evaluated. CT Surgery course was notable for postoperative atrial fibrillation on postoperative day #10 and treated with Amiodarone. PEG was placed by IR on [**10-23**]. The patient was felt to be volume overloaded postoperatively and was treated with Lasix 80 mg IV b.i.d. and Diuril 250 mg IV b.i.d. The patient responded well to this regimen. The patient later suffered right lung collapse when the chest tube was placed water seal. The lung did not reexpand when chest tube was placed to suction. The patient had the right chest tube, and a second was placed with reexpansion of right lung. The patient then underwent bronchoscopy on [**11-3**] which revealed copious secretions. No mass or mucous plug was visualized. On [**11-4**], the patient was transferred to the SICU Service. The patient was noted to have elevation in BUN and creatinine (95/2.5). FENA was less than 1, and urine osmosis was elevated. The patient was felt to have prerenal azotemia. The patient received intravenous fluids, and diuretics were held until [**11-12**]. The patient gradually became more tachypneic with increasing oxygen requirement initially on approximately 70% FIO2 shovel mask with respiration rate in the 30s. Over the next few days, the patient had been placed on BIPAP with improvement on oxygenation and has also been on 100% non-rebreather. On [**11-7**], the patient had underwent a right Doxycycline pleurodesis with no repeated lung collapse. On [**11-8**], the sputum grew Staphylococcus aureus, and the patient was restarted on Vancomycin. On [**2133-11-12**], the patient was transferred to the MICU Service from the SICU Service for further management of his respiratory distress. PAST MEDICAL HISTORY: 1. Hypertension. 2. Coronary artery disease with OM stent in [**2127**] and a two-vessel coronary artery bypass grafting on [**10-13**]. 3. Insulin-dependent diabetes mellitus. 4. Prostate cancer. 5. Chronic renal insufficiency. 6. Multiple lacunar infarcts. 7. Hypercholesterolemia. 8. Gait disorder. 9. Right-sided weakness. MEDICATIONS ON TRANSFER: Vancomycin, NPH Insulin 12 U subcue b.i.d., regular Insulin sliding scale, Epogen 10,000 U subcue q.Wednesday, ASA 81 mg q.d., Zoloft 25 mg q.d., Lipitor 20 mg q.h.s., Lopressor 50 mg t.i.d., Amiodarone 400 mg q.d., Hydralazine 25 mg q.6, Clonidine patch 0.2 mg, free water bolus at 250 cc b.i.d., Zantac 150 mg q.d., Iron Sulfate 325 mg t.i.d., Zinc 220 mg q.d., Vitamin C 500 mg q.d., ........... 10 drops b.i.d., Nepro 35 cc/hr, ProMod 35 cc/hr. SOCIAL HISTORY: The patient is married. He smoked one pack per day times 30 years and quit ten years ago. His primary care physician is [**Last Name (NamePattern4) **]. [**First Name (STitle) 3510**]. PHYSICAL EXAMINATION: Vital signs: On admission to the MICU temperature was 97.5?????? with a T-max of 98.6??????, blood pressure 118/43 to 140/53, heart rate 60-70, respirations 30, 100% oxygen non-rebreather, oxygen saturation 95%, 24-hour I&Os at 4380 in, 1300 out. HEENT: Pupils 2 mm constricted to light. Sclera anicteric. Neck: Supple. No lymphadenopathy. JVP 9-10 cm (5 cm above the sternal notch). Chest: Diffuse rhonchi. No crackles or wheezing. Sternum healing well. Cardiovascular: Regular, rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops. Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. Extremities: Warm. Pedal edema 1+. Skin breakdown over the right shin. Sacral ulcer, healing. Neurological: Opens eyes to verbal stimuli. Not communicative. LABORATORY DATA: Electrocardiogram showed normal sinus rhythm at 70 beats per minute with normal axis, normal intervals, and T-wave inversions in V5 and V6 with a Q-wave in leads III. Chest x-ray showed congestive heart failure with left lower lobe collapse and pleural effusions bilaterally. Echocardiogram on [**10-23**] showed a left atrium of 4.1 cm and an ejection fraction of 45-55%. WBC was 16.5, hemoglobin 8.1, hematocrit 24.8, platelet count 240; sodium 141, potassium 5.9, chloride 112, bicarb 22, BUN 103, creatinine 2.7, glucose 113, phosphate 24, magnesium 2.4; arterial blood gases on 100% non-rebreather showed a 7.35/37/70; sputum on [**11-7**] and 25 showed MRSA positive. HOSPITAL COURSE: The patient is a 65-year-old man with a complicated hospital course. The patient was admitted with likely aspiration pneumonia, non-Q-wave myocardial infarction and underwent coronary artery bypass grafting and initially did well. The patient was diuresed regular, but over the last few days before admission to the MICU, had an elevation in BUN and creatinine. The patient was felt to be volume depleted and was treated with intravenous fluids and withholding diuretics. The patient then gradually had a worsened respiratory status with increasing oxygen requirement and decreased responsiveness. Chest x-ray had revealed the vascular congestion which supported fluid overload. The patient also had copious secretions on bronchoscopy on [**11-7**] with a history of recurrent aspiration, left lower lobe collapse and consolidation, as well as elevated WBC which supported possible incompletely treated aspiration pneumonia. Physical exam at the time of MICU admission was not impressive for overload. JVP was not elevated. There was no peripheral edema, and chest exam was not impressive for wet crackles. The patient's respiratory decline was gradually progressive and not acute. While in the MICU, the patient was placed on BIPAP. The patient had poor tidal volumes and increased respiration rate and had continued copious secretions. The patient was eventually intubated on [**11-13**]. The patient then had a bronchoscopy which removed a significant amount of secretions, as well as revealed white plaques in the trachea which was deemed to be likely candidal infection. The patient was then started on Fluconazole and completed a 7-day course. He also completed an 8-day course of Flagyl, as well as Ceftriaxone for presumed aspiration pneumonia. In addition, he completed a 14-day course of Vancomycin for MRSA positive sputum. From a cardiovascular standpoint, the patient has coronary artery disease status post two-vessel coronary artery bypass grafting during this admission. The patient while in the hospital was continued on Aspirin, Lopressor, and loaded on Amiodarone given postoperative atrial fibrillation. On [**11-16**] a chest CT was obtained which revealed bilateral loculations, left greater than right, with collapse of left lung and bilateral pleural effusions, as well as a left upper lobe consolidation and fluid in the anterior pericardium with some air extending up into the mediastinum. A left thoracentesis was performed, and pleural fluid labs were only significant for transudative fluid. Cultures from the pleural fluid were negative. A right thoracentesis was deferred due to difficulty to access the loculated area in the right apex of the lung. CT Surgery decided to hold off on any surgical intervention of the pleural fluid, effusions and loculations. On [**11-23**], a Swan was placed to help determine fluid status and cardiac output. The patient was found to have normal cardiac output, cardiac index, stroke volume, as well as SVR. It was determined that the patient was not intravascular dry, and the etiology of his elevated BUN, and creatinine was unclear until an MRA of his kidneys were obtained which revealed bilateral renal artery stenosis. The MRA which was done on [**11-28**] showed high-grade stenosis of the right renal artery and moderate stenosis of the left renal artery, as well as sclerosis of the aorta and iliacs. The Renal Team was consulted, and the best option was for intervention by stenting across the ostial lesions of both the right and left renal artery. The stenting procedure will be deferred until infection is completely ruled out. On [**11-27**], a tracheostomy was placed. During the hospital stay, the patient has been oxygenating and ventilating well on pressure support; however, the patient has continued to have thick tan secretions requiring suctioning approximately every three hours. This suggested a continuing pulmonary infection, most likely due to a bronchitis; however, the patient has been afebrile, and the white count has been stable from [**10-16**] to 15. All antibiotics were discontinued on [**11-24**]. The patient's long vent dependence has been attributed to deconditioning, as well as respiratory muscle weakness, as well as likely temporary diaphragmatic dysfunction due to status post coronary artery bypass grafting and phrenic nerve involvement. The patient was screened for pulmonary rehabilitation facilities and was accepted to [**Hospital3 33538**]. From a gastrointestinal standpoint, the patient's hematocrit has slowly declined during the hospital stay and has required approximately 1 U every three days. The work-up had been deferred until the patient was deemed more stable. The patient has a history of colon polyps, and likely the decrease in hematocrit is due to a lower GI bleed not likely to be acute. GI was consulted, and EGD will be performed prior to the patient's discharge. The remainder of his GI work-up will be done after transfer. The patient's hematocrit has been maintained equal to or greater than 30 given his history of coronary artery disease. While in the hospital, the patient was maintained on tube feeds which eventually reached goal at 25 cc/hr with Impact with Fiber. One other electrolyte issue with the patient was that he has been hypernatremic which has since then resolved after D5W intravenous fluids, as well as free water boluses p.r.n. The patient has had a sacral ulcer which has been followed by Skin Care, as well as Plastic Surgery. The ulcer has been treated with wet-to-dry bandages and has been healing well. As per Plastic Surgery, debridement was not deemed necessary at this time. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post two-vessel coronary artery bypass grafting. 2. Pneumonia/bronchitis. 3. Bilateral renal artery stenosis. 4. Likely lower gastrointestinal bleed. 5. Hypertension. 6. Insulin-dependent diabetes mellitus. 7. Chronic renal insufficiency. 8. Hypercholesterolemia. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Last Name (NamePattern1) 1183**] MEDQUIST36 D: [**2133-12-1**] 15:49 T: [**2133-12-1**] 15:47 JOB#: [**Job Number **] Name: [**Known lastname 32**], [**Known firstname 389**] E. Unit No: [**Numeric Identifier 17484**] Admission Date: [**2133-10-3**] Discharge Date: [**2133-12-4**] Date of Birth: [**2068-1-29**] Sex: M Service: MICU ADDENDUM: 1. Gastrointestinal: Esophagogastroduodenoscopy performed on [**2133-12-2**] showed normal esophagogastroduodenoscopy to third part of duodenum. The patient should have follow-up colonoscopy once clinical situation improves. Decrease in hematocrit requiring approximately one unit of packed red blood cells every two to four days most likely due to a slow lower gastrointestinal bleed. The patient has a history of colon polyps. Further work up to be done. 2. Renal: Angiogram performed on [**2133-12-3**] revealed no renal artery stenosis. Renal artery stenosis found on MRA most likely due to artifact. No stenting procedure was done. The patient's renal issues must be reevaluated. DISCHARGE MEDICATIONS: 1. Hydralazine 100 mg per G-tube q six hours (hold if systolic blood pressure less than 100) 2. Lopressor 75 mg per G-tube tid (hold if systolic blood pressure less than 100, heart rate less than 55). 3. Isordil 20 mg per G-tube tid. 4. Erythromycin ointment applied to O.U. (0.5% ointment) tid. 5. NPH 10 units subcutaneous [**Hospital1 **]. 6. Iron sulfate (FeSO4) 325 mg per G-tube tid. 7. Zinc 220 mg per G-tube q day. 8. Vitamin C 500 mg per G-tube q day. 9. Dressing changes to the sacral wound (normal saline wet-to-dry dressings) [**Hospital1 **]. 10. Right lower extremity wound (apply normal saline wet-to-dry dressings) [**Hospital1 **]. 11. Prevacid suspension 30 mg per G-tube q day. 12. Calcium carbonate liquid 1,250 mg per G-tube tid. 13. Free water boluses 250 cc per G-tube [**Hospital1 **]. 14. Zoloft 25 mg per G-tube q day. 15. A.S.A. 81 mg per G-tube q day. 16. Heparin subcutaneous 5,000 units [**Hospital1 **]. 17. Lipitor 20 mg per G-tube q HS. 18. Amiodarone 200 mg per G-tube q day. 19. Regular insulin sliding scale. 20. Epogen 10,000 units subcutaneous q Wednesday. 21. Tube feeds - Impact with 5 reps in 5.0 cc per hour. 22. Albuterol inhaler six puffs q four hours prn. 23. Atrovent inhaler six puffs q four hours prn. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3662**] Dictated By:[**Last Name (NamePattern1) 2736**] MEDQUIST36 D: [**2133-12-3**] 14:43 T: [**2133-12-10**] 07:39 JOB#: [**Job Number 17485**]

[ "410.71", "414.01", "427.31", "511.9", "428.0", "707.0", "578.9", "518.0", "507.0" ]

icd9cm

[ [ [] ] ]

[ "37.61", "31.1", "96.04", "36.12", "96.71", "39.61", "37.23", "88.56", "88.53" ]

icd9pcs

[ [ [] ] ]

12965, 14497

11400, 12942

5658, 11345

4154, 5640

165, 3083

3476, 3926

3106, 3450

3943, 4131

11370, 11379

27,128

196,884

616

Discharge summary

report

Admission Date: [**2125-8-31**] Discharge Date: [**2125-9-2**] Date of Birth: [**2059-7-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 552**] Chief Complaint: BRBPR after colonoscopy with polypectomy Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: 66 y/o M with PMHx of Atrial Fib who went for colonoscopy on [**8-29**] after holding coumadin for 3 days prior to procedure and underwent three polypectomies-proximal transverse, distal transverse, and cecum. On [**2125-8-30**], pt noted some crampy lower abdominal pain when he awoke and noticed a small amount of blood in BMs. Pt went to work but was concerned with the continued BRBPR approx 4 episodes. Pt reportes feeling dizzy when he saw the blood in the toilet, but denied any syncope or presyncope. Pt initially presented to [**Hospital Ward Name **], thinking it was the ED and medical emergency was called. Pt was found with blood on seat of pants & e/o incontinence. . Pt was transferred directly to the ED where initial VS 96.7 HR 90 BP 117/70 RR 16 and Sats 97% on RA. Hct was down from 54 in [**3-17**] to 39.1. Pt received 2L of NS but did not receive any blood products overnight and am HCT was down at 29.7. Pt had an episode of BRBPR on the floor and became tachy to 140s. Decision was made for transfer to ICU and per GI recs, pt had already begun taking Golytely prep. . On arrival to ICU, pt was anxious but denying any CP/SOB/Abd pain or nausea. He had already taken approx half of the golytely prep and was complaining of chills. . ROS: The patient denies any fevers, chills, nausea, vomiting, diarrhea, constipation, hematemesis, shortness of breath, cough, urinary frequency, urgency, dysuria. Past Medical History: Atrial fibrillation anticoagulated but pt has been holding coumadin for approx 3 days prior to colonoscopy, not restarted Gout Hyperlipidemia Hypertension Social History: patient lives in [**Location 745**]. He is married with 2 children. He is an active smoker and has prior 50-pack-year cigarette history, and has never used IV drugs. He drinks alcohol rarely, only on social occasions. Family History: non-contributory Physical Exam: Vitals: T- 96.7 BP 111/67 HR 90 RR 18 Sats 100% on RA GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2 PULM: Lungs CTAB, no apprec W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, good distal pulses NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2125-8-30**] 11:15PM BLOOD WBC-21.4*# RBC-4.12* Hgb-13.2*# Hct-39.1*# MCV-95 MCH-32.0 MCHC-33.7 RDW-13.7 Plt Ct-310 [**2125-8-31**] 06:35AM BLOOD WBC-11.4* RBC-3.02*# Hgb-9.9*# Hct-29.7* MCV-98 MCH-32.8* MCHC-33.3 RDW-13.2 Plt Ct-189 [**2125-8-31**] 12:39PM BLOOD WBC-11.6* RBC-3.72* Hgb-12.0* Hct-34.8* MCV-94 MCH-32.2* MCHC-34.3 RDW-15.0 Plt Ct-183 [**2125-8-31**] 12:39PM BLOOD Hct-33.8* [**2125-8-31**] 08:28PM BLOOD Hct-32.5* [**2125-9-1**] 02:22AM BLOOD WBC-8.1 RBC-3.57* Hgb-11.8* Hct-32.7* MCV-92 MCH-33.2* MCHC-36.2* RDW-15.4 Plt Ct-168 [**2125-8-30**] 11:15PM BLOOD PT-13.8* PTT-51.8* INR(PT)-1.2* [**2125-9-1**] 02:22AM BLOOD PT-13.2 PTT-47.0* INR(PT)-1.1 [**2125-8-30**] 11:15PM BLOOD Glucose-156* UreaN-28* Creat-1.7* Na-141 K-4.9 Cl-106 HCO3-23 AnGap-17 [**2125-8-31**] 06:35AM BLOOD Glucose-95 UreaN-27* Creat-1.1 Na-142 K-4.3 Cl-114* HCO3-21* AnGap-11 [**2125-8-31**] 12:39PM BLOOD Glucose-93 UreaN-19 Creat-0.8 Na-145 K-4.3 Cl-114* HCO3-22 AnGap-13 [**2125-9-1**] 02:22AM BLOOD Glucose-84 UreaN-13 Creat-0.8 Na-142 K-3.9 Cl-112* HCO3-23 AnGap-11 [**2125-8-31**] 12:39PM BLOOD Calcium-7.4* Phos-2.5* Mg-1.8 [**2125-9-1**] 02:22AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.7 . Portable abdomen ([**2125-8-31**]): No evidence of free air or obstruction. . CXR ([**2125-8-31**]): 1. No evidence of free air under the hemidiaphragms. 2. Probable mild interstitial lung disease - if clinically indicated, a high-resolution CT (HRCT) of the chest could be obtained to further characterize this process. Brief Hospital Course: 66 yo [**First Name11 (Name Pattern1) 4746**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4747**], Hyperlipidemia was hospitalized after he noticed hematochezia s/p outpt colonoscopy w polypectomy 1. Acute blood loss anemia/Hematochezia - -Likely [**2-10**] polypectomy (of note, pt had been off of coumadin prior to colonoscopy) -H/H, vitals stabilized s/p 5 units PRBC -Repeat colonoscopy w/o signs of active bleed -D/C home as h/H stable and pt noted brown stools -Hold coumadin,ASA, atenolol until FU w/ PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] this thursday 2. Atrial fibrillation -rate controlled on its own -low risk per CHADS score -Hold atenolol and coumadin [**2-10**] recent bleed -Pt will discuss anticoag w/ PCP next week 3. Hyperlipidemia -cont Simvastatin 4. Hx of Gout -Continue Allopurinol Medications on Admission: 1. Simvastatin 20mg QD 2. Allopurinol 300mg QD 3. Atenolol 25mg QD 4. Coumadin (held) Discharge Medications: 1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Bright red blood per rectum, post-polypectomy bleeding . Atrial fibrillation Hypertension Hyperlipidemia Gout Discharge Condition: Stable Discharge Instructions: You were admitted due to blood in your stool after a recent colonscopy. You received several units of blood transfusion. You underwent a repeat colonoscopy that did not show any sign of active bleeding. This was likely a complication of your recent colonoscopy with polypectomy. Do not restart your coumadin or atenolol until you have discussed these medications further with your primary care doctor. . You have told us that you already have an appointment w/ your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**], this thursday. Please keep that appointment . Call your doctor or return to the hospital for any new or worsening dizziness, lightheadedness, nausea, vomiting, blood in the stool or any other concerning symptoms. Followup Instructions: Follow-up with your primary care next thursday, w Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**], ph [**Telephone/Fax (1) 133**]

[ "285.1", "998.11", "272.4", "427.31", "515", "E878.8", "584.9", "785.59", "V58.61", "274.9" ]

icd9cm

[ [ [] ] ]

[ "45.43" ]

icd9pcs

[ [ [] ] ]

5664, 5670

4482, 5375

354, 368

5824, 5833

2949, 4459

6668, 6826

2252, 2270

5511, 5641

5691, 5803

5401, 5488

5857, 6645

2285, 2930

274, 316

396, 1820

1842, 1999

2015, 2236

21,356

166,102

19340+19341

Discharge summary

report+report

Admission Date: [**2146-12-28**] Discharge Date: [**2119-1-16**] Date of Birth: [**2126-12-7**] Sex: M Service: CHIEF COMPLAINT: Status post motor vehicle crash. HISTORY OF PRESENT ILLNESS: The patient is a 20 year old male involved in a single vehicle car crash. The patient was the driver who struck a pole at unknown speed. His initial [**Location (un) 2611**] coma scale was 3 and he was intubated at the scene. The patient was hemodynamically stable during transport to [**Hospital6 256**]. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. SOCIAL HISTORY: History of both drug abuse and alcohol abuse. MEDICATIONS ON ADMISSION: None. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION/LABORATORY DATA: Initial physical examination revealed temperature 96.2, blood pressure 116/palpable, heart rate 51, respiratory rate 22, oxygen saturation 100% intubated. White blood cell count 13, hematocrit 43, platelets 194. Chem-7 142, 3.6, 108, 25, 9, 0.7, calcium 1.19. Coags revealed PT 13.5, PTT 32.8, INR 1.2, lactate 2.4, fibrinogen 171, amylase 33. Head, eyes, ears, nose and throat: Pupils fixed at 3. Oropharynx clear. Abrasions over his right and left face. Cardiovascular: Regular rate and rhythm. Respiratory: Clear to auscultation bilaterally. Chest: No deformities or tenderness. Abdomen: Soft, nondistended. Pelvis stable. Flank: No deformities, no tenderness. Back: No deformities. Cervical spine, no deformities or stepoffs. Thoracic, lumbar spine, no deformities or stepoffs. Rectal: Guaiac negative. No rectal tone. Right upper quadrant, right clavicular deformity and an abrasion over his right neck. Left upper extremity, no deformity. Right lower extremity, left lower extremity no deformity. Pulses: Radial, femoral, dorsalis pedis and posterior tibial palpable. [**Location (un) 2611**] coma scale 3. Imaging - Chest x-ray, right clavicular fracture, fast within normal limits. Head computerized tomography scan, right frontal contusion, left temporal hemorrhage. Computerized tomography scan of the abdomen, negative. Head computerized tomography scan, facial computerized tomography scan fluid, bilateral sphenoids, maxillary sinus fractures, right orbital floor fractures, right lateral orbital wall fracture, left zygomatic arch fracture, posterior maxillary wall fracture. HOSPITAL COURSE: The patient was admitted to the Trauma Intensive Care Unit with a diagnosis of poly-trauma. The patient's injuries included - 1. A right frontal contusion with left temporal interparenchymal hemorrhage; 2. Facial fractures; 3. Right clavicular fracture. Orthopedic Surgery and Plastic Surgery were consulted. Orthopedic Surgery recommended a sling for the right upper extremity. Plastic Surgery reviewed the images and decided on a conservative management of the fractures. Ophthalmology was also consulted for questionable entrapment of the rectus muscles. Their feeling there was no entrapment of rectus muscles and that no further intervention was needed. After the patient's tertiary physical, his injuries included - 1. Right frontal contusion; 2. Left temporal [**Doctor Last Name 534**] hemorrhage with diffuse axonal injury; 3. Multiple facial fractures with no impingement of the rectus muscles; 4. Displaced right clavicular fracture; 5. Right hemothorax/pneumothorax; 6. Right pulmonary contusion; 7. Right C7, T1 transverse process fractures; 8. Right rib fractures; 9. Decreased mental status. The patient's initial hospital stay included an ICP monitor and Mannitol prn for controlling osmoles. The patient was continued on a ventilator for upper respiratory support. The patient's neurologic status did not improve over his hospital course and he remained semi-alert but did not respond to commands. The patient initially was treated with total parenteral nutrition and then switched to tube feeds. The chest tube which was placed for his hemo/pneumothorax was removed during the hospital stay without incident. The transverse process fractures were treated conservatively with a cervical collar for a minimum of 12 weeks. The displaced right follicular fracture was also treated conservatively by Orthopedics. The multiple face fractures were evaluated by Plastic Surgery and deemed nonoperative. After the first week of Intensive Care Unit care, the patient remained stable from a cardiac and respiratory standpoint. Due to the patient's depressed mental status and ventilator requirement it was decided the patient would require a tracheostomy and gastrostomy tube placement, and on [**1-5**], the patient had a percutaneous tracheostomy, and also a percutaneous endoscopic gastrostomy tube placement by Dr. [**Last Name (STitle) 111**] and Dr. [**Last Name (STitle) **]. The patient tolerated the procedure well. Following the patient's tracheostomy and percutaneous endoscopic gastrostomy placement, the tube feeds were advanced as tolerated with very little residuals. The patient did develop a pneumonia which grew gram negative rods and also Staphylococcus aureus. This was treated originally with Ceftriaxone and Vancomycin and then switched to appropriate antibiotics with respect to the BAL and sputum cultures. During that time, the patient's platelets had increased to the 900 to 1000 range and his white count also increased. A Hematology/Oncology consult was obtained, and it was thought that his platelet count was due to his stress response, also known as reactive membranocytosis. Hematology/Oncology did recommend starting Agrylin to assist with the reactive membranocytosis. The patient was continued for several days as a result of decrease in his platelet and white cell count. The patient was eventually transferred out of the Trauma Intensive Care Unit to a Stepdown Unit. The patient continued with a high amount of secretions from his tracheostomy and continued with antibiotics for the presumed pneumonia. During the hospital course the patient's mental status did not improve. The patient remained with high secretions and the patient also had intermittent spiking temperatures. The patient developed a hypertensive state which was treated with Lopressor, Enalapril and a Clonidine patch. The patient does intermittently become tachycardiac in the range of 120s to 150 on a routine basis. This normally responds to Lopressor and/or just conservative management. Neurorehabilitation was consulted and it was decided that the patient would need wrist restraints and passive range of motion with physical therapy. They also recommended transfer to rehabilitation services when appropriate. On [**2-2**], it was decided the patient was well enough to be discharged to an acute rehabilitation center. DISCHARGE PHYSICAL EXAMINATION: Temperature maximum 103.6 which the patient has been cultured for. The chest x-ray for the temperature spike showed a resolving pneumonia, this is most likely the result of a mixture of atelectasis and also a result of pneumonia. The patient is continued on antibiotics per the culture and sensitivity. 183, 117/64, 92% on tracheostomy mask. No acute distress. Minimal diaphoresis. Regular rate and rhythm. Bilaterally soft, nondistended, gastrostomy tube intact. DISCHARGE DIAGNOSIS: 1. Status post motor vehicle crash. 2. Right frontal contusion. 3. Left temporal [**Doctor Last Name 534**] hemorrhage. 4. Multiple facial fractures with impingement. 5. Displaced midclavicular fracture. 6. Right hemothorax with pulmonary contusion. 7. Right C7, T1 transverse process fracture. 8. Right rib fracture. 9. Pneumonia. RECOMMENDED FOLLOW UP: Please follow up in four weeks with Dr. [**Last Name (STitle) 1327**], at that time the patient will need x-rays of his cervical spine (AP and lateral). The patient should stay in a cervical collar until then. The patient is to follow up in Trauma Clinic in two to three weeks. The rehabilitation center should call the office for an appointment. Major surgical procedures, status post tracheostomy and percutaneous endoscopic gastrostomy tube placement on [**1-5**], left chest tube placement on [**12-28**], status post interventricular drain placement on [**12-28**]. DISCHARGE MEDICATIONS: 1. Artificial tear ointment. 2. Heparin 5000 units b.i.d. 3. Tylenol elixir 650 mg p.o. q. 4-6 hours prn. 4. Regular insulin sliding scale, please see the attached sheet. 5. Lopressor 25 mg p.o. t.i.d. 6. Biaxin 10 mg p.o. q. 8 hours 7. Levofloxacin 500 mg p.o. q. 24 hours times an additional seven days. 8. Dilaudid 0.5 to 1 mg q. 3-4 hours prn. 9. Vancomycin 1 gm intravenously b.i.d. for an additional seven days. CONDITION ON DISCHARGE: Fair to an acute rehabilitation service. ADDITIONAL CARE: 1. The patient will require aggressive pulmonary suctioning and toilet to help clear secretions. During the [**Hospital 228**] hospital stay this has been a major clinical issue. With aggressive suctioning, pulmonary toilet and out of bed, his secretions do decrease. 2. Tracheostomy care. 3. Ventilator if needed. 4. Keep cervical collar on until follow up visit with Dr. [**Last Name (STitle) 1327**]. 5. Gastrostomy tube care. 6. Aggressive suctioning as stated above. 7. Diet - Promote 95 cc per hour. 8. Aggressive physical therapy. 9. Passive range of motion. 10. Splints to the upper extremities per occupational therapy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Last Name (NamePattern4) 959**] MEDQUIST36 D: [**2147-2-3**] 08:06 T: [**2147-2-3**] 08:24 JOB#: [**Job Number 52642**] Admission Date: [**2146-12-28**] Discharge Date: [**2147-2-7**] Date of Birth: [**2126-12-7**] Sex: M Service: TRA ADDENDUM: This is an addendum to the previously dictated discharge summary for this patient covering his period of admission from [**2146-12-28**] to [**2147-2-3**]. The patient actually was discharged on [**2147-2-7**] because of a delay in obtaining a rehabilitation hospital bed for the patient. There was absolutely no change in his medical status during this period of delay. All of the particulars of his earlier discharge summary remain relevant for the additional four days of hospitalization. [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**] Dictated By:[**Last Name (NamePattern4) 17555**] MEDQUIST36 D: [**2147-6-20**] 13:06:10 T: [**2147-6-20**] 13:39:35 Job#: [**Job Number **]

[ "860.4", "507.0", "805.07", "428.0", "482.41", "851.46", "805.2", "518.0", "305.01" ]

icd9cm

[ [ [] ] ]

[ "33.24", "34.04", "31.1", "38.93", "96.6", "43.11", "02.2", "89.14", "96.72", "99.15" ]

icd9pcs

[ [ [] ] ]

8269, 8698

7304, 7658

674, 2377

2395, 6789

576, 583

7670, 8246

6812, 7283

150, 184

213, 522

545, 552

600, 647

8723, 10606

55,731

150,992

55087

Discharge summary

report

Admission Date: [**2127-8-27**] Discharge Date: [**2127-9-3**] Date of Birth: [**2060-5-18**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2248**] Chief Complaint: Palpitations and SOB (transfer from OSH) Major Surgical or Invasive Procedure: Implantable cardiac defibrillator placed on [**2127-8-29**] ([**Company **] single chamber ICD) History of Present Illness: 67 y/o M with PMH of CHF (EF 25% from OSH Echo [**2127-8-26**]), CAD s/p [**2111**] MI with cath showing right dominant 100% prox LAD and 100% proxLCx s/p stentx2 to prox LAD @ [**Hospital1 112**] in [**2111**], Cardiomyopathy, HTN, long standing tobacco use and alcohol abuse, who presented to an OSH ([**Hospital **] Hospital) on [**8-25**] with c/o waking up with Palpitations and SOB. At OSH, his EKG showed a wide complex tachycardia (VT vs SVT?) with heart rate of 200. He was given 6 mg adenosine and then 12 mg adenosine without response, and subsequently a blous of amiodarone 150 mg with HR slowing to 160s and Sinus with wide complex and LBBB pattern (unclear if LBBB new or old). He was then sedated with 6 mg of Versed and and cardioverted with 100 joules to sinus rythm with heart rate of 80's and persistent LBBB pattern. Transfered to [**Hospital1 18**] for eval of LBBB and ICD placement for 2ndary prevention. . On arrival to the floor, patient vitals were HR:68 BP:116/69 RR:21 SpO2 sats: 92 with 2L O2 down, labile affect/confused, AAOx2 Past Medical History: CAD (MI with LAD stent [**2111**] at [**Hospital1 112**]) Dyslipidemia, Hypertension Cervical Spine laminectomy for stenosis 6 years ago Social History: - long time and active smoker - drinks 2 bottles wine / night - no other drug use - accountant Family History: Mom: HTN, CAD/PVD, MI Physical Exam: ADMISSION: VS: T=98.1 BP=116/68 HR=66 RR=18 O2sat=96 GENERAL: NAD. Difficult historian, Confused speech is slurry. Unclear orientation with difficult communication. AAOx2 HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No ascites, No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXT: Asterixis +, 2+ DP/PT, [**Name (NI) **] LE Edema, SKIN: cherry angiomas, rosacea of nose DISCHARGE: VS: T= 98.4 BP= 110s-120s/60s-70s HR= 60s-70s, O2sat=98 RA, RR=16 GENERAL: NAD. Orientation improved from yesterday, knows self, knows month, knows date, not sure about day of week, knows president. Answers questions quickly and appropriately. [**Location (un) **] a book with glasses this morning. HEENT: Left eye downbeating nystagmus on upward gaze. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 5 cm. CARDIAC: Normal s1,s2, sinus, normal rate, no m/r/g. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No ascites, No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXT: Asterixis negative, 2+ DP/PT, [**Name (NI) **] LE Edema, SKIN: cherry angiomas, rosacea of nose Pertinent Results: ADMISSION: [**2127-8-27**] 04:34PM BLOOD WBC-7.4 RBC-4.11* Hgb-13.3* Hct-39.2* MCV-95 MCH-32.2* MCHC-33.8 RDW-13.4 Plt Ct-200 [**2127-8-27**] 04:34PM BLOOD PT-11.1 PTT-36.3 INR(PT)-1.0 [**2127-8-27**] 04:34PM BLOOD Glucose-89 UreaN-17 Creat-0.8 Na-139 K-3.7 Cl-101 HCO3-28 AnGap-14 [**2127-8-27**] 04:34PM BLOOD ALT-30 AST-29 CK(CPK)-63 AlkPhos-97 TotBili-0.9 [**2127-8-27**] 04:34PM BLOOD CK-MB-2 cTropnT-0.04* [**2127-8-27**] 04:34PM BLOOD Albumin-3.7 Calcium-8.4 Phos-3.7 Mg-1.9 Cholest-138 [**2127-8-27**] 04:34PM BLOOD %HbA1c-5.7 eAG-117 [**2127-8-27**] 04:34PM BLOOD HDL-53 CHOL/HD-2.6 STUDIES: CT/CTA Non contrast: There is no hemorrhage, major vascular territory infarction, edema, mass, or shift of the midline structures. Periventricular and subcortical white matter hyperintensities are consistent with mild small vessel ischemic changes and old lacunar infarctions. CTA: The basilar artery terminates at the level of the superior cerebellar arteries and gives off two small caliber arteries that head towards the posterior communicating arteries. The bilateral posterior communicating arteries are large caliber and feed normal, patent posterior cerebral arteries. There is anatomical variation is likely congenital. The remainder of the intracranial vasculature is patent without evidence of thrombosis stenosis or vasospasm. The cervical vasculature is patent. . DISCHARGE: [**2127-9-1**] 06:55AM BLOOD WBC-6.7 RBC-4.42* Hgb-14.3 Hct-44.2 MCV-100* MCH-32.4* MCHC-32.4 RDW-13.0 Plt Ct-226 [**2127-9-1**] 06:55AM BLOOD Neuts-68.3 Lymphs-20.0 Monos-7.9 Eos-2.0 Baso-1.8 [**2127-9-1**] 06:55AM BLOOD Plt Ct-226 [**2127-9-1**] 06:55AM BLOOD Glucose-92 UreaN-14 Creat-0.9 Na-139 K-4.2 Cl-103 HCO3-25 AnGap-15 [**2127-9-1**] 06:55AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.2 Brief Hospital Course: A 67 year old male with history of cardiomyopathy with an EF of 25%, MI in [**2113**] s/p LAD stent, and HTN presented to OSH with complaints of shortness of breath, palpitations and tachycardia found to be in VT/SVT s/p cardioversion into sinus rhythm then transferred to [**Hospital1 18**] for ICD implantation and LBBB workup. . ## Wide Complex Tachycardia: Consistent with Polymorphic VT. He was found to be in a wide complex tach, LBBB, right inferior axis with Q waves in V1-V3. This was consistent with VT from the mid to basal anterior LV. Seen on OSH EKG, and there was refractory to Adenosine 6mg, 12mg, Amio, responded to Synchronized Cardioversion into sinus rhythm. Etiology likely multifactorial including past anterior MI, dilated cardiomyopathy possibly d/t alcohol toxicity with ongoing remodeling as patient was not on ACEI. He was in sinus rhythm upon transfer and was continued on Amiodarone 400mg daily. In addition, an ICD([**Company **] single chamber icd) was placed on [**8-29**] via axillary vein for secondary prevention. He decided to defer VT ablation until he has recurrence. In addition, he did not receive BiV given low likelihood of benefit with large ant MI. He was discharged to Rehab given his ongoing delirium, and will follow-up in device clinic as an outpatient. . ## Left Eye Nystagmus - on upward gaze with downbeat nystagmus. Unclear duration of symptoms. CTA of Head and Neck, RPR and B12 analysis. CT head was negative, RPR negative, and B12 normal. Given sxs of ataxia, nystagmus and encephalopathy a dx of Wernicke's encephalopathy was made. IV Thiamine was started and continued for 10 days until [**2127-9-9**]. . ## Delirium - pt was AAO to self only on arrival and improved. On day of discharge could say the year is [**2126**], month is [**Month (only) **], and date is the 10th. Not clear about day of week. Etiology likely multifactorial. Long history of EtOH abuse, combined with new hospital admission. Also pt has chronic gait abnormality, which would be consistent with Wernickes. We monitored his neurological exam and observed left eye downbeating nystagmus on vertical gaze, neurology was consulted, see recs and workup above. Unlikely infarct given imaging. No electrolyte abdnormalities. Pt has no history of dementia and at baseline is AAOx3 but with poor recall at times of hospital course or illness. Pt will be discharged to Rehab with 24 hour care and IV thiamine until [**2127-9-9**]. . ## Alcohol withdrawal: Pt did not have s/s of withdraw at [**Hospital1 18**], however, OSH records note + s/s of withdraw requiring Ativan drip. Pt drinks ~2 bottles of wine/night, and he has been drinking for many years with a + hx of DT's in the past per his wife. [**Name (NI) **] had elevated LFTs at OSH, but were normal on arrival to [**Hospital1 18**]. At OSH placed on Ativan gtt (unlcear total ativan given) and upon transfer was on Ativan PO. He was delirious, but no real agitation, did not score on CIWA and Ativan CIWA was d/c on hospital day #2. He was given thiamine and folic acid daily. Social work was consulted who spoke with the patient and found that Pt somewhat vague and slow in answering questions, he denies current ETOH abuse, but does have HX of overuse. Pt denies any other current needs but SW gave pt and family information about alcohol treatment. . ## LBBB: Currently seen on EKG, unclear if new or resolved ischemic event. Troponin 0.04, MB wnl. HD Stable, no ongoing angina, no sustained arrhythmia. We continued medical management with statin, ASA, BB, [**Last Name (un) **]. Further evaluation with stress test versus cath was deferred during this hospitalization given his acute delirium. . ## Cardiomyopathy: Echo on [**2127-8-26**] shows 25% EF with global hypokinesis and apical akinesis. Likely etiologies include ischemia, alcohol, current volume status is euvolemic. He was managed medically and with ICD for seconday prevention. He was started on ASA, Metoprolol and continued on home Losartan and Rosuvastatin. . ## Transitional Issues: - Follow up in [**Location (un) 2274**] Device Clinic - Follow up with Cardiologist Dr. [**First Name (STitle) **] for stress test as outpatient, once delirium resolves - Continue IV Thiamine x 10 days Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Atrius. 1. Rosuvastatin Calcium 40 mg PO DAILY 2. Losartan Potassium 25 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Thiamine 100 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Losartan Potassium 25 mg PO DAILY 4. Rosuvastatin Calcium 40 mg PO DAILY 5. Amiodarone 400 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Nystatin Oral Suspension 5 mL PO QID 9. Thiamine 100 mg IV DAILY Duration: 10 Days last dose [**2127-9-9**] Discharge Disposition: Extended Care Facility: [**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**] Discharge Diagnosis: Primary Diagnosis: Ventricular tachycardia Secondary Diagnoses: Wernicke's Encephalopathy Systolic Heart Failure (EF 20%) Coronary artery disease Cardiomyopathy Alcohol Abuse Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. [**Known lastname **], You were transferred from [**Hospital **] hospital for your fast and abnormal heart rate called Ventricular tachycardia(VT). You received an implantable cardiac defibrillator (ICD) that will deliver a shock to your heart should you develop ventricular tachycardia in the future. You were started on two new medicines, amiodarone and metoprolol to prevent the rhythm from reoccurring. Please seek help to stop smoking and drinking. Both alcohol and tobacco increase the chance that you will return to the hospital for additional heart problems. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**], LICSW gave you information to help you with this process. Followup Instructions: Name: [**First Name8 (NamePattern2) 2259**] [**Last Name (NamePattern1) **], MD When: Friday [**9-12**] at 1:30pm Location: [**Location (un) 2274**] [**Location (un) **] Address: 133 [**Location (un) **], [**Location (un) 86**],MA Phone: [**Telephone/Fax (1) 2258**] . Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]-[**Name6 (MD) **] [**Name8 (MD) **], MD When: Monday [**9-8**] at 3:45pm Location: [**Hospital **] MEDICAL ASSOCIATES Address: ONE [**Location (un) 542**] ST, [**Location (un) **],[**Numeric Identifier 9310**] Phone: [**Telephone/Fax (1) 8506**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2264**]

[ "425.4", "401.9", "428.22", "V45.82", "427.1", "112.0", "303.90", "426.3", "412", "379.56", "265.1", "428.0", "305.1" ]

icd9cm

[ [ [] ] ]

[ "37.94" ]

icd9pcs

[ [ [] ] ]

10314, 10428

5385, 9413

344, 442

10648, 10648

3583, 5362

11552, 12234

1819, 1842

9944, 10291

10449, 10449

9665, 9921

10826, 11529

1857, 3564

10514, 10627

264, 306

470, 1530

10468, 10493

10663, 10802

9436, 9639

1552, 1690

1706, 1803

3,362

146,178

1652

Discharge summary

report

Admission Date: [**2177-2-5**] Discharge Date: [**2177-2-5**] Date of Birth: [**2111-11-23**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3561**] Chief Complaint: Cardiac Arrest Major Surgical or Invasive Procedure: Endotracheal intubation. History of Present Illness: This is a 65 yo female with a history of CAD s/p CABG, CHF (EF of 55% with basal inferior hypokinesis), pulmonary HTN, Stage IV CKD, DM and hypothyroidism who had a syncopal episode c/w asystolic cardiac arrest. Apparently earlier today the patient began to c/o dizziness and midscapular pain. She the fell to the ground. The patient was found down after 8-10 minutes in asystole and was administered epi/atropine x4 by EMS with return of pulse and blood pressure. Initially the patient was transferred to [**Hospital **] [**Hospital 1459**] Hospital and did not require pressors until arrival there. She was started on dopamine there at 4 and was intubated. The pt was then transferred to our ED. . At [**Hospital1 18**] ED, her vitals were HR 50s-80s, BP 90s-160/50s-60she was found to have pupils 5mm NR, unresponsive without sedation, and EKG with lateral deep ST depressions. CT of the head revealed no ICH or mass effect. The patient was found to have a K of 6.2 and was treated with 1 amp of Na HCO3, 1 amp Ca gluconate, 10 U of insulin with D50, kayexalate 30 gm x1. Past Medical History: 1. Hypertension. 2. Diabetes mellitus with last hemoglobin A1C of 8.7 in 12/[**2172**]. 3. Chronic renal insufficiency baseline creat 1.7-2.0 . 4. Coronary artery disease status post coronary artery bypass graft in [**2163**] (LIMA to LAD, SVG to D1 and PDCA), last cath [**3-/2164**] with elev R and L filling pressures, PTCA of RCA and 2 VD; last ETT-MIBI [**6-21**] 6 min on [**Doctor Last Name 4001**] protocol, no reversible defects. 5. Hypothyroidism. 6. Depression. 7. Osteoarthritis. 8. Hyperlipidemia. 9. CHF with EF 45-50% on last echo [**10-20**], mild LV systolic dysfunction, mildly depressed LV function, inf and mid inf HK, mild 1+MR. 10. Anemia - unclear etiology; baseline Hct 29-31, last iron studies nl [**7-21**]; per pt, has never had EGD or colonoscopy Social History: SH: lives with her boyfriend at home, retired; previous tob user 2ppdx20 yrs, quit [**2155**]; no ETOH Family History: FH: sig for father who deceased in his 50s from cirrhosis secondary to alcoholism; 1 brother deceased from MI in his 40s; other brother who died of lymphoma in his 50s Physical Exam: Vitals: T 98.2 P 86 BP 122-163/55-65 R [**10-9**] Sat 99% on AC 500x22, PEEP 5, FiO2 60%, PIP 36 UO: minimal ABG: 7.21/50/21 on current settings Gen: obese caucasian female laying in bed at 30 degrees, unresponsive HEENT: pupils fixed and dilated at 5-6 mm, conjunctivae injected, OG and ET tube in place Neck: obese CV: RRR, no m/r/g Lungs: coarse breath sounds diffusely Ab: soft, protuberant Extrem: trace pitting pretibial edema BL LE, full dp/pt and radial pulses Skin: no rashes or ulcers Neuro: comatose, GCS score of 3, no pupillary/oculcephalic reflex, negative doll's eye, no knee or biceps reflexes, toes mute Pertinent Results: Echocardiogram on [**2177-2-5**]: Conclusions: The left atrium is normal in size. The estimated right atrial pressure is [**3-27**] mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. The right ventricular cavity is mildly dilated with focal hypokinesis of the apical free wall. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be quantified. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2175-6-30**], right ventricular cavity enlargement and regional dysfunction is now identified and left ventricular systolic function now appears normal. Is there a history to suggest right ventricular ischemia or ARVC? If clinically indicated, a cardiac MRI ([**Telephone/Fax (1) 9559**]) may be able to clarify RV pathology. Head CT on [**2177-2-5**]: HEAD CT WITHOUT CONTRAST: There is no comparison. There is no acute intracranial hemorrhage. There is no shift of normally midline structures or ventricular dilatation. There is poor differentiation of [**Doctor Last Name 352**]-white matter which could be due to technique or due to mild diffuse brain edema. There is small amount of fluid in the nasopharynx. Mucosal thickening is seen in the ethmoid sinus. Cerumen is noted in the left external auditory canal. The surrounding skeletal structure is unremarkable. The evaluation of the skull base is limited. IMPRESSION: No acute intracranial hemorrhage. ? diffuse brain edema. Dr. [**Last Name (STitle) **] was informed. Brief Hospital Course: This is a 65 yo F with a history of CAD s/p CABG, CHF (EF of 55% with basal inferior hypokinesis), pulmonary HTN, Stage IV CKD, DM and hypothyroidism who had a syncopal episode c/w cardiac arrest. . #Asystolic Cardiac Arrest: The precipitant of the cardiac arrest is unclear, but likely related to an MI. Etiologies include hyperkalemia, MI, drug O/D, PE, tamponade. Serum tox was negative, and BP is stable off pressors so a massive PE or tamponade is unlikely as well. Intubated for unresponsiveness . # Neuro: Pt had lost meaningful neurologic function at this time. She has no pupillary/oculocephalic/corneal reflexes, indicating very poor prognosis. GCS is 3 at this time. She has evidence of anoxic brain injury on imaging. She also appears to have an ?epidural hematoma vs. artifact on CT of the C spine, for which its contribution to her presentation is unclear. Started dexamethasone 4. EEG ordered to eval for brain activity. Neurology consulted: "Recent AAN guidelines suggest that the most specific indicators of prognosis are absent pupillary light response, absent corneal reflexes, extensor or worse motor response to pain, myoclonus status epilepticus, elevated serum neuron-specific enolase, and absent somatosensory evoked potential studies (Wijdicks, et [**Doctor Last Name **], Neurology [**2175**];67:203-210). Of the above, the pt demonstrates absent pupillary light response, absent corneal reflexes absent motor response to pain. NSE assay takes roughly 14 days to return, and is not practical. Neuroimaging findings are also useful adjuncts, however, and CT yesterday already demonstrated loss of grey-white differentiation throughout. The neurologic examination three days after the event has been demonstrated to be a reliable indicator of prognosis, however the literature supports the notion that patients with absent brainstem reflexes at any time after the event have relatively poor prognosis with low likelihood of returning to a high functional status. " Organ bank notified. Care was withdrawn and patient expired at 4:30PM. . #Hypercarbic Respiratory Failure/Acidemia: Likely related to altered mental status. PCO2 was 72 with pH of 7.11 and bicarb of 22 indicating a primary respiratory acidosis. Hyperventilated pt given brain anoxic injury . #Elevated cardiac enzymes: The patient likey has elevated enzymes secondary to defibrillation as well as possible ACS. Her troponin is also elevated in the setting of renal failure. EKG on admission revealed lateral ST depressions. She likely has at least an element of demand in the setting of known CAD and hypotension. . # Acute on Chronic Renal Failure: The patient's Cr is 3.1, with BL of 2.2-2.8. The patient's renal insufficiency is unlikely to account for the hyperkalemia as her creatinine is not far from baseline. . #Hyperkalemia: Likely secondary to respiratory acidosis as well as renal failure. Treated with bicarb, kayexalate, calcium gluconate, insulin in ED, as well as one more amp of bicarb in ICU. . # DM: The patient has known DM with glucose levels in the 300s-400s. #Hypothyroidism: . #Contact: [**Name (NI) 4906**], [**Telephone/Fax (1) 9560**] . #Code: Patient was made comfort measures only after prognosis ascertained and subsequently expired. Medications on Admission: aspirin Bumex two tablets twice a day calcitriol 0.5 mcg daily Celexa Epogen 4000 units once a week iron sulfate insulin hydralazine 100 mg three times a day hydrochlorothiazide 25 mg every day Isordil levothyroxine 150 daily metoprolol 25 sustained release daily Lipitor 80 mg a day . Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Patient expired. Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2177-2-11**]

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icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

8689, 8698

5064, 7361

329, 355

8758, 8763

3222, 5041

8815, 8849

2396, 2565

8661, 8666

8719, 8737

8350, 8638

8787, 8792

2580, 3203

7378, 8324

275, 291

383, 1460

1482, 2259

2275, 2380

25,493

180,226

5245

Discharge summary

report

Admission Date: [**2123-10-5**] Discharge Date: [**2123-10-9**] Date of Birth: [**2062-1-31**] Sex: M Service: UROLOGY HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old man with a history of prostate cancer was here for a prostatectomy on [**2123-10-5**]. PAST MEDICAL HISTORY: Coronary artery disease status post myocardial infarction, arthritis. PAST SURGICAL HISTORY: Coronary artery bypass graft. ALLERGIES: Codeine. OUTPATIENT MEDICATIONS: Lopressor, Medrol, Accupril, Lipitor, aspirin. HOSPITAL COURSE: The patient underwent a radical prostatectomy on [**2123-10-5**]. The patient received 500 cc of CellSavers in the Operating Room. Estimated blood loss was 600 cc. On postop day zero the patient's blood pressure was around 90s to 100s/50s to 60s despite multiple fluid boluses. The patient was admitted to the Intensive Care Unit overnight for observation. Cardiac enzymes were also ordered for rule out myocardial infarction. On postop day number one the patient's blood pressure stabilized. The patient was transferred out of the Intensive Care Unit. Cardiac enzymes were negative times three. On postop day number two, the patient continued to be NPO. On postop day number three the patient passed flatus. The patient was started on a house diet. On postop day number four a JP drain was discontinued. The patient was discharged to home. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Prostate cancer. DISCHARGE MEDICATIONS: 1. Ciprofloxacin 500 mg po b.i.d. starting [**2123-10-12**] for seven days. 2. Percocet one to two tabs po q 4 to 6 hours prn pain. 3. Colace 100 mg po b.i.d. FOLLOW UP: The patient was to go home with Foley catheter. The patient has a follow up appointment with Dr. [**Last Name (STitle) **] on [**2123-10-13**]. A Foley catheter and staples are to be removed at that time. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**] Dictated By:[**Last Name (NamePattern1) 1909**] MEDQUIST36 D: [**2123-10-11**] 09:17 T: [**2123-10-11**] 11:34 JOB#: [**Job Number 21447**]

[ "185", "285.1", "530.81", "725", "412", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "60.5", "40.3" ]

icd9pcs

[ [ [] ] ]

1523, 1688

1481, 1499

544, 1397

400, 453

1700, 2192

478, 526

165, 282

305, 376

1422, 1460

58,878

168,820

39653

Discharge summary

report

Admission Date: [**2101-12-1**] Discharge Date: [**2101-12-8**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: PEA arrest Major Surgical or Invasive Procedure: intubation History of Present Illness: [**Age over 90 **] yo female with DM, HLD, CKD who presents s/p witnessed PEA arrest in the setting of a possible aspiration event at her [**Hospital3 **] facility. She collapsed at dinner table, found in PEA, underwent CPR with epinephrine x1, atropine x1, CPR lasted for about 5-6 minutes. She was intubated in the field (cottage cheese noted in mouth during intubation). Later went into v tach and was shocked into sinus rhythm, she received amiodarone 150mg x1, had return of spontaneous circulation. Brought to [**Hospital 21242**] hospital. There, EKG showed inferior ST elevations and she was transferred to [**Hospital1 18**] for cooling protocol. Per the grandson, pt was in her usual state of health earlier today, she did complain of mild abdominal discomfort which the grandson attributed to anxiety about commuting independently to a doctor's appointment. Pt had been living at home independently with good functional status and independent in ADLs until her husband passed away at end of [**2101-9-23**], she moved to an [**Hospital3 **] facility 1 week ago. Grandson reports that pt has possibly had difficulty swallowing over the past 6-8 weeks. Past Medical History: DM Hyperlipidemia CKD Anemia Gout Social History: Pt moved into an [**Hospital3 **] facility 1 week prior to admission, her husband passed away 1 month ago and she has been depressed. Previous to admission, she was indepedent in ADLs and had good functional status per son. - Tobacco: never smoked, husband smoked 3PPD for many years but quit 30 yrs ago - Alcohol: no EtOH use - Illicits: none Family History: cardiac history, DM, HTN Physical Exam: PE on Admission: Vitals: T: BP: 140/62 P: 91 R: 16 on vent, O2 sat 97% General: Intubated and sedated HEENT: Sclera anicteric, pupils 3mm sluggishly reactive Neck: supple, JVP not elevated, no LAD Lungs: Coarse breath sounds b/l anteriorly, limited exam CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, reducible ventral hernia, non-distended, bowel sounds present, no organomegaly GU: foley in place, draining clear urine Skin: petecchiae on anterior chest, venous stasis changes in LE b/l, good capillary refill, cool feet b/l R>L, faint distal pulses, 3+ edema b/l to mid-calf Neuro: intubated and sedated, localizes to painful stimuli, does not respond to verbal stimuli or follow commands, pupils 3mm and sluggish, no posturing Pertinent Results: Labs on Admission: [**2101-12-1**] 07:19PM BLOOD WBC-19.9* RBC-2.96* Hgb-8.6* Hct-25.9* MCV-88 MCH-29.1 MCHC-33.1 RDW-15.3 Plt Ct-303 [**2101-12-1**] 07:19PM BLOOD PT-14.9* PTT-27.1 INR(PT)-1.3* [**2101-12-1**] 07:19PM BLOOD Fibrino-404* [**2101-12-2**] 12:11AM BLOOD Glucose-269* UreaN-41* Creat-1.5* Na-138 K-4.9 Cl-108 HCO3-20* AnGap-15 [**2101-12-2**] 12:11AM BLOOD ALT-46* AST-72* CK(CPK)-103 AlkPhos-96 TotBili-0.3 [**2101-12-1**] 07:19PM BLOOD cTropnT-0.04* [**2101-12-2**] 12:11AM BLOOD Albumin-2.7* Calcium-7.7* Phos-3.4 Mg-1.6 [**2101-12-1**] 07:19PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2101-12-1**] 07:26PM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-5 FiO2-100 pO2-252* pCO2-38 pH-7.33* calTCO2-21 Base XS--5 AADO2-448 REQ O2-74 -ASSIST/CON Intubat-INTUBATED [**2101-12-1**] 07:26PM BLOOD Glucose-228* Lactate-2.6* Na-139 K-4.8 Cl-108 [**2101-12-1**] 07:26PM BLOOD freeCa-1.03* Brief Hospital Course: [**Age over 90 **] yo female who presented s/p PEA arrest. . Differential diagnosis of the patient's PEA arrest at presentation included PE, stroke, cardiac causes, aspiration PNA. Patient underwent cooling protocol upon presentation. She was cooled using the Artic sun with goal of 32.5 degrees and subsequently rewarmed. The patient was treated with levofloxacin and flagyl for presumed aspiration pneumonia. ECHO demonstrated RV dilatation suggestive of PE and the patient was started on heparin drip. She underwent a 48 hour EEG done that demonstrated activity consistent poor neurologic prognosis. They evaluated the patient and stated that her inability to breath on her own and absent corneal reflex were a poor prognostic sign. Spoke extensively with grandson who agreed on DNR, and subsequently made the patient comfort measures only. . The patient's date/time of death was [**2101-12-8**] at 2:35 PM. The chief cause of death was cardiac arrest. Other antecedent cause included aspiration pneumonia. Medications on Admission: Lasix 40mg daily Metoprolol 25mg daily Lisinopril 10mg daily Levothyroxine 0.75mcg daily ASA 81mg daily Ferrous sulfate 325mg - 2 tabs daily NPH 11U in AM Senna [**Hospital1 **] prn Multivitamin Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

[ "38.91", "96.72", "38.93", "99.81" ]

icd9pcs

[ [ [] ] ]

4978, 4987

3693, 4705

269, 281

5039, 5049

2740, 2745

5105, 5252

1908, 1934

4950, 4955

5008, 5018

4731, 4927

5073, 5082

1949, 1952

219, 231

309, 1473

2759, 3670

1495, 1530

1546, 1892

58,308

136,856

35679

Discharge summary

report

Admission Date: [**2188-2-12**] Discharge Date: [**2188-2-19**] Date of Birth: [**2149-11-29**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1990**] Chief Complaint: Patient struck by car/alcohol detox Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 38F with h/o alcohol abuse, h/o withdrawl seizures. She presents by EMS as a pedistrian struck by vehicle in [**Location (un) 81173**]. She was obviously intoxicated upon arrival in the ED. She was Of note she was admitted to [**Hospital1 18**] in [**1-/2188**] for EtOH withdrawl. . She does not remember the incident, so history was gathered from OMR (social work note). She was struck by vehicle, per report with no loss of consciousness. She reports that she has been drinking a couple of fifths of vodka daily for the last 2 weeks. She reports that her last seizure was in the last couple weeks. She also reports that her last sobriety was during her last hospitalization. She is interested in getting sober. . In the ED, initial vs were: 99.0T 107P 124/74BP 15R 94%O2sat. Labs were significant for EtOH level of 400s. Patient had scans which showed possible coccyx fracture, some abnormality around her appendix, but nothing else. Pt received 60mg valium, motrin, banana bag, toradol, zofran. She was seen by social work and trauma. Past Medical History: - Alcohol abuse: Patient started drinking in [**2186-5-12**] when her husband died. She has had 14-16 hospital admission in the past year related to alcohol abuse. She has tried rehabilitation programs and had stopped drinking since [**Month (only) 1096**], but started drinking again 5 days PTA. She says that her father has recently passed away and she appears to have had a conflict with her sister related to her inheritance. She says that once she starts drinking, she feels like she has to keep drinking because she gets shaky and anxious after a few hours without alchohol. She says that she sometimes wakes up just to drink and then goes back to sleep. . - History of withdrawal seizures. She notes a history of withdrawal seizures for which she had been prescribed valproate. The patient denies a history of seizure not in the setting of withdrawal. The seizures she experiences are often preceded by tremulousness and whole body shaking. She reports urinary and fecal incontinence. Per her significant other ([**Name (NI) 81085**]) he has observed these seizures and confirms them as "her whole body shakes back and forth." . Social History: Boyfriend: [**Name (NI) 81085**] [**Telephone/Fax (1) 81172**]. Pt drinks daily, "a couple" fifths of vodka (one "fifth"= 750 mL). Denies smoking or other drug use. She says that she lives "nowhere" and that she "steals stuff" to manage her finances. She says that she receives foodstamps but she will often buy something and return it for credit, in turn to use the store credit to purchase alcohol. She also takes advantage of other sources of alcohol, including vanilla extract and cooking wine. Family History: Noncontributory. Physical Exam: Tc: 97.6 HR: 97 BP: 125/84 SpO2: 97%RA General: Alert, oriented, shaking, nauseous HEENT: Sclera anicteric, MMM Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic normal S1 + S2, 2/6 SEM (likely flow) no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no clubbing. significant edema in hands, excoriations, and bruising more on right side than left. right lateral popliteal region with ecchymosis. Air cast boot on R leg. Pertinent Results: [**2188-2-12**] 07:00PM WBC-5.7 RBC-3.96* HGB-12.2 HCT-34.3* MCV-87 MCH-30.7 MCHC-35.5* RDW-15.1 [**2188-2-12**] 07:00PM PT-12.1 PTT-29.4 INR(PT)-1.0 [**2188-2-12**] 07:00PM PLT COUNT-318 [**2188-2-12**] 07:00PM GLUCOSE-90 UREA N-7 CREAT-0.8 SODIUM-144 POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-23 ANION GAP-19 [**2188-2-12**] 07:00PM ALT(SGPT)-39 AST(SGOT)-83* LD(LDH)-333* ALK PHOS-74 TOT BILI-0.2 [**2188-2-12**] 07:00PM LIPASE-82* [**2188-2-12**] 07:00PM ASA-NEG ETHANOL-446* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG Brief Hospital Course: 1. Alcohol withdrawl: Pt was admitted to the MICU for withdrawl given her history of withdrawl seizures. She was treated with valium and ativan per CIWA scale. She received a banana bag in the ED. She was transfered to the floor and was continued on valium, thiamine, folate, and MVI. She had no seizures. 2. R fibular fracture: Imaging showed a R fibular fracture. Ortho placed R leg in an aircast boot. She was given percocet for pain. She will f/u with ortho in [**1-16**] weeks. 3. Elevated CK: CK peaked at 682, most likely secondary to MVA. It trended downward with hydration. 4. Abd CT abnormality: Abd CT showed a dilated distal appendix read as either early appendicitis, mucocele, or variant of normal. No abd pain or clinical signs of appendicitis. There was no indication for surgery during this hospitalization. Pt may f/u with PCP if she has abd symptoms. 5. Social issues: Pt is currently homeless. She wanted to go to [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] house for detox/rehab. However, day of discharge her nares swab was positive for MRSA and she was no longer eligible for [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] house. She was d/c to a shelter. Medications on Admission: Depakote (Valproate) 500 mg TID Trazodone 50 mg QHS Prilosec prn Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain for 1 weeks. Disp:*15 Tablet(s)* Refills:*0* 2. Hydroxyzine HCl 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for Anxiety for 1 weeks. Disp:*30 Tablet(s)* Refills:*0* 3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: primary: Alcohol withdrawl alcohol abuse secondary: gastritis anxiety depression Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating without assistance. Discharge Instructions: You came to the hospital after being struck by a car while intoxicated. Your right fibula is broken so ee put an aircast boot on your right leg. We treated your withdrawl with valium and ativan. We managed your pain with Toradol and Dilaudid. We made no changes to your medications. Please seek immediate medical attention if you have seizures, nausea and vomiting, fevers and chills, worsening R leg pain, chest pain, or night sweats. Followup Instructions: You have the following appointment with your primary care physician: [**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2188-2-25**] 2:00

[ "823.01", "787.01", "790.5", "V60.0", "303.01", "920", "291.0", "923.00", "543.9", "E814.7", "535.50", "338.11", "V02.54", "724.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6281, 6287

4263, 5497

309, 316

6413, 6492

3696, 4240

6978, 7187

3090, 3108

5613, 6258

6308, 6392

5523, 5590

6516, 6955

3123, 3677

234, 271

344, 1398

1420, 2558

2574, 3074

14,465

199,525

5642

Discharge summary

report

Admission Date: [**2161-5-20**] Discharge Date: [**2161-6-10**] Date of Birth: [**2117-2-24**] Sex: F Service: PLASTIC SURGERY HISTORY OF PRESENT ILLNESS: Patient is a 44-year-old morbidly obese female status post Roux-en-Y gastric bypass procedure performed by Dr. [**Last Name (STitle) **] on [**2161-4-3**], admitted to the [**Hospital3 **] Emergency Department for increasing crampy abdominal pain, fevers to 102 degrees for a duration of four days prior to admission. [**Name (NI) **] husband also noted skin color changes to greenish hue with blisters and fluctuance. The patient also reported nausea and vomiting, and decreased oral intake. PAST MEDICAL HISTORY: 1. Gastric bypass on [**2161-4-3**]. 2. Insulin dependent-diabetes mellitus. 3. Hypertension. MEDICATIONS ON ADMISSION: 1. Insulin. 2. Zestril. PHYSICAL EXAMINATION: Vital signs as follows: Temperature of 101.6, heart rate of 130, blood pressure of 90/60, respiratory rate of 16, and O2 saturation of 94% on room air. Upon initial assessment, the patient was alert and oriented times three. Patient had anicteric sclerae. Cardiovascular examination revealed regular, rate, and rhythm, normal S1, S2, no S3, S4, but with tachycardia. Respiratory examination was clear to auscultation bilaterally. Abdominal examination demonstrated positive bowel sounds, soft abdomen, and a 10-15 cm area of induration with small bullae and greenish color changes. There is also abdominal tenderness and erythema. There was no edema noted in the extremities. LABORATORIES: Initial laboratories showed a white count of 20. CT SCAN: Of the abdomen demonstrated large lower abdominal fluid collection with subcutaneous air fluid consistent with necrotizing fasciitis. HOSPITAL COURSE: On [**5-20**], the patient was admitted to the Intensive Care Unit with a presumptive diagnosis of necrotizing fasciitis. The patient was intubated and sedated. A right side internal jugular triple lumen central venous line was inserted. The patient was started on broad-spectrum antibiotics IV, which included penicillin, gentamicin, and Flagyl. Patient went to the OR for wound debridement of the necrotizing fasciitis of the abdomen and drainage of intraabdominal abscess. Patient suffered no postoperative complications, and was returned to the Intensive Care Unit. Wound cultures were taken from the abdomen which eventually demonstrated gram-positive cocci in pairs and clusters, gram-negative rods, and gram-positive rods. On postoperative day one, the patient's IV antibiotics was changed to Zosyn and clindamycin. On [**5-22**], the patient was returned to the operating room for further debridement and additional cultures of the abdominal wall. Patient was again returned to the Intensive Care Unit without further complications. Patient received 1 unit of packed red blood cells for hematocrit of 25. Patient was self extubated overnight without complications. On [**5-23**], postoperative day three, the patient was started on TPN. On [**5-24**], the patient was sent again to the operating room for a third washout and debridement of the abdominal wound. Plastics Service was also consulted, and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] decided to place a vacuum dressing on the abdomen. On [**5-25**], Physical Therapy was consulted to help patient out of bed. CT scan of the abdomen and pelvis was performed to evaluate for leaks, abscesses, or fistulas, all of which were negative. On [**5-26**], postoperative day six, clindamycin was discontinued for the reason of no evidence of group beta Strep. Patient was started on a Stage II diet with TPN. Patient's Foley catheter was also discontinued. Psychiatry consult was also requested to see the patient for question of depression. Their initial diagnosis was adjustment disorder, rule out major depressive disorder. Patient was not started on any further medication, however, the patient was given Ativan 0.5 mg IV prn for agitation and anxiety. On [**5-27**], the VAC dressing was changed and the patient's diet was advanced to Stage III. On [**5-28**], PICC line was placed for intravenous antibiotics, and the patient's diet was advanced to Stage IV. Patient was taken down to the operating room on [**6-1**] for an abdominal split thickness skin graft from her left thigh to abdomen with a VAC dressing placed on top. [**6-2**] the patient's diet was again started on Stage IV, and her IV was HEP locked. On [**6-3**], the patient's left thigh dressings were taken down, and opened to air, and blow dried 20 minutes 3x a day. On [**6-6**], the patient's VAC dressing was taken down from the abdomen. The abdominal skin graft looked healthy. On [**6-8**], Zosyn was discontinued, and on [**6-9**], Physical Therapy visited with successful, out of bed, and ambulation. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Abdominal necrotizing fasciitis. 2. Status post split thickness skin graft from left thigh to left abdomen. DISCHARGE MEDICATIONS: 1. Reglan 10 mg one tablet po qid as needed for nausea for 14 days. 2. Keflex 500 mg one capsule po qid for two weeks. 3. Ativan 0.5 mg one tablet po q8h as needed for anxiety or agitation for 14 days. FOLLOW-UP INSTRUCTIONS: The patient is to followup at the [**Hospital 3595**] Clinic on [**Hospital Ward Name 23**] 7. The patient is to call [**Telephone/Fax (1) 22587**] to make an appointment within two weeks. Patient is also to followup with Infectious Disease with Dr. [**Last Name (STitle) **] on [**2161-6-26**] at 11 am at the Riseman Building, 11th floor. Their office number is [**Telephone/Fax (1) 457**]. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2647**], M.D. [**MD Number(1) 2648**] Dictated By:[**Name8 (MD) 3430**] MEDQUIST36 D: [**2161-6-10**] 11:57 T: [**2161-6-18**] 08:58 JOB#: [**Job Number 22588**]

[ "998.59", "401.9", "309.89", "250.01", "041.04", "728.86", "458.9", "278.01", "567.2" ]

icd9cm

[ [ [] ] ]

[ "86.22", "54.3", "54.19", "86.69", "93.56", "38.93", "54.62", "83.21" ]

icd9pcs

[ [ [] ] ]

4920, 5032

5055, 5258

811, 836

1770, 4867

859, 1752

173, 668

5283, 5974

690, 785

4892, 4899

7,695

189,563

401

Discharge summary

report

Admission Date: [**2180-5-23**] Discharge Date: [**2180-5-27**] Date of Birth: [**2115-9-8**] Sex: M Service: MEDICINE Allergies: Unasyn / Oxycodone Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: hypotension, diarrhea, poor PO intake Major Surgical or Invasive Procedure: EJ placement Swan placement ICU stay History of Present Illness: Pt is a 64 yo male PMHx significant for non-ischemic cardiomyopathy with EF 25%, s/p ICD placement [**2175**] (v paced), mild-mod MR/TR, DM, ICD, Afib on coumadin, gout, hypothyroidism, CKD p/w vtach and ICD firing, recently admitted for ICD firing, CHF w/ EF 20-25%% who presents from heart failure clinic w/hypotension. Pt has presumed Cdiff w/ continued diarrhea, vomitting and decreased PO intake w/ associated dehydration and lethargy at [**Hospital 100**] rehab facility, d/c'ed from [**Hospital1 18**] ~1.5 wk ago. Has been taking PO vanco. At heart failure clinic pt was found to have BP of 60/40 (baseline SBP of 90s) and sent to ED. . In ED, VS were 97.1 99 106/70 16 100% 15L NRB then switch to BiPAP. Lactate:2.4, Trop of 0.05, Na 130, BUN 68, Cr 3.6, lipase was 277, [**Hospital1 3539**] 2.4 and INR of 3.1. Blood cultures pending. CXR showed increased alveolar opacities most consistent w/pulmonary edema but atypical PNA can't be ruled out. Very dehydrated on exam; has L arm PICC in place, L 16 ga EJ placed in ED. Pt recieved cefepime and vanco. RUQ US performed which showed dilated hepatic veins and right atrium c/w right heart failure, gallbladder sludge and mild wall thickening w/trace fluid in porta hepatis but no gallbladder distension, wall edema or tenderness on exam. For hypotension pt rec'd 500cc over 2 hrs, then approx 100 cc/hr, givne low EF and worsening renal fxn. . On arrival to the floor and when seen in ED, patient is lethargic. VS improved VS on transfer 80, 87/55, 22, 100% on 4L. Pt wife and pt, he denies belly pain but does have nausea and vomitting in addition to diarrhea. Pt reports SOB as well. Less LE edema per wife. Possible fever. Blood cultures were drawn at rehab but pt's wife was not told what they were treating w/abx. . REVIEW OF SYSTEMS On review of systems, has some sputum but minimal cough, possible fevers but chills or rigors. . Cardiac review of systems is notable for absence of chest pain, but does have SOB, some orthopnea, and ankle edema. . Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: ICD v paced placed [**2175**] 3. OTHER PAST MEDICAL HISTORY: Nonischemic cardiomyopathy, LVEF 15-20% ICD placement for primary prevention of sudden cardiac death Diabetes mellitus type 2 insulin dependent Gout Peripheral neuropathy Chronic atrial fibrillation Chronic kidney disease Elevated transaminases, unknown etiology Umbilical hernia repair, [**8-/2175**] Gallstone pancreatitis s/p ERCP ([**2176-6-28**]) Internal hemorrhoids Hemoglobin C carrier Social History: Pt originally from [**Country 3515**], spends much of year there but recently had to return to US b/c of severe gout flare. Married, lives w/ his wife. [**Name (NI) **] had difficult maintaining low salt diet. Also, his diet is generally difficult because he feels like any food he eats causes gout flare. -Tobacco history: No smoking. -ETOH: He quit alcohol use -Illicit drugs: No IV drug ues Family History: No first-degree relatives with coronary artery disease. Mother had breast cancer. Physical Exam: Exam on Admission: VS on transfer 80, 87/55, 22, 100% on 4L VS after fluids: T=97.6 BP= 100/61 HR= 81 RR= 28 O2 sat= 99% on 4L NC GENERAL: lethargic very ill appearing. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. very dry mucus membranes. NECK: Supple, JVD difficult to appreciate b/c of beard. dehydrated appearing CARDIAC: heart sounds very distant, RR. No m/r/g. LUNGS: No chest wall deformities, ICD in place, scoliosis. Coarse lung sounds especially at bases but no accessory muscle use. on sup O2 ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits appreciated. neg murphies EXTREMITIES: LE +2 edema, but per report this is better than previously SKIN: dry skin, signs of chronic edema. NEURO: lethargic but able to follow commands and answer questions. weak but able to squeeze hands and wiggle toes. sensation intact. Pertinent Results: Labs: WBC: [**2180-5-23**] 01:50PM BLOOD WBC-10.2 RBC-3.85* Hgb-11.4* Hct-32.3* MCV-84 MCH-29.5 MCHC-35.1* RDW-19.3* Plt Ct-214 [**2180-5-23**] 09:22PM BLOOD WBC-9.2 RBC-3.51* Hgb-10.4* Hct-29.4* MCV-84 MCH-29.6 MCHC-35.4* RDW-19.3* Plt Ct-204 [**2180-5-24**] 06:50AM BLOOD WBC-10.1 RBC-3.54* Hgb-10.9* Hct-29.7* MCV-84 MCH-30.7 MCHC-36.6* RDW-19.4* Plt Ct-212 [**2180-5-25**] 03:57AM BLOOD WBC-12.3* RBC-3.60* Hgb-10.6* Hct-30.2* MCV-84 MCH-29.4 MCHC-35.0 RDW-19.6* Plt Ct-187 [**2180-5-26**] 03:53AM BLOOD WBC-11.7* RBC-3.28* Hgb-9.9* Hct-27.7* MCV-85 MCH-30.1 MCHC-35.6* RDW-19.5* Plt Ct-169 Coags: [**2180-5-23**] 01:50PM BLOOD PT-31.1* PTT-51.8* INR(PT)-3.1* [**2180-5-24**] 06:50AM BLOOD PT-33.6* PTT-52.3* INR(PT)-3.3* [**2180-5-25**] 03:57AM BLOOD PT-35.9* PTT-59.7* INR(PT)-3.6* [**2180-5-26**] 03:53AM BLOOD PT-41.9* PTT-67.5* INR(PT)-4.3* Chemistry: [**2180-5-23**] 01:50PM BLOOD Glucose-108* UreaN-68* Creat-3.6* Na-130* K-4.1 Cl-94* HCO3-23 AnGap-17 [**2180-5-23**] 09:22PM BLOOD Glucose-114* UreaN-66* Creat-3.1* Na-132* K-4.1 Cl-99 HCO3-21* AnGap-16 [**2180-5-24**] 06:50AM BLOOD Glucose-86 UreaN-64* Creat-2.8* Na-131* K-4.2 Cl-98 HCO3-23 AnGap-14 [**2180-5-25**] 03:57AM BLOOD Glucose-117* UreaN-62* Creat-2.5* Na-136 K-3.8 Cl-101 HCO3-19* AnGap-20 [**2180-5-25**] 03:45PM BLOOD Glucose-182* UreaN-62* Creat-2.5* Na-136 K-3.7 Cl-103 HCO3-20* AnGap-17 [**2180-5-26**] 03:53AM BLOOD Glucose-156* UreaN-58* Creat-2.7* Na-135 K-3.7 Cl-102 HCO3-21* AnGap-16 [**2180-5-26**] 04:13PM BLOOD UreaN-64* Creat-2.8* Na-127* K-8.6* Cl-99 HCO3-22 AnGap-15 LFTs: [**2180-5-23**] 01:50PM BLOOD ALT-8 AST-88* AlkPhos-212* TotBili-2.4* [**2180-5-24**] 06:50AM BLOOD ALT-8 AST-86* LD(LDH)-229 CK(CPK)-26* AlkPhos-198* TotBili-2.1* DirBili-1.2* IndBili-0.9 [**2180-5-25**] 03:57AM BLOOD ALT-9 AST-81* AlkPhos-183* TotBili-2.2* [**2180-5-26**] 03:53AM BLOOD ALT-10 AST-87* AlkPhos-166* TotBili-2.1* [**2180-5-23**] 01:50PM BLOOD Lipase-227* [**2180-5-24**] 06:50AM BLOOD Lipase-184* [**2180-5-25**] 03:57AM BLOOD Lipase-160* [**2180-5-26**] 03:53AM BLOOD Lipase-119* Enzymes: [**2180-5-23**] 01:50PM BLOOD cTropnT-0.05* [**2180-5-23**] 09:22PM BLOOD CK-MB-2 cTropnT-0.03* proBNP-[**Numeric Identifier 3542**]* [**2180-5-24**] 06:50AM BLOOD CK-MB-2 cTropnT-0.03* Elements: [**2180-5-24**] 06:50AM BLOOD Albumin-2.7* Calcium-8.2* Phos-4.1 Mg-2.4 UricAcd-9.7* [**2180-5-25**] 03:57AM BLOOD Albumin-2.9* Calcium-8.1* Phos-3.4 Mg-2.2 [**2180-5-25**] 03:45PM BLOOD Calcium-7.8* Phos-3.5 Mg-2.0 [**2180-5-26**] 03:53AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.9 TFTs: [**2180-5-23**] 09:22PM BLOOD TSH-20* [**2180-5-24**] 06:50AM BLOOD TSH-21* [**2180-5-24**] 06:50AM BLOOD Free T4-1.0 Microbiology: [**2180-5-23**] BC x 2 PENDING [**2180-5-23**] Urine Cx No growth FINAL [**5-23**] / [**5-24**] Blood cultures PENDING [**2180-5-24**] **FINAL REPORT [**2180-5-27**]** FECAL CULTURE (Final [**2180-5-27**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2180-5-26**]): NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O VIBRIO (Final [**2180-5-26**]): NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [**2180-5-26**]): NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2180-5-26**]): NO E.COLI 0157:H7 FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2180-5-25**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2180-5-24**] MRSA No MRSA isolated [**2180-5-24**] NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN Imaging: - ECG Study Date of [**2180-5-23**] 1:48:00 PM Ventricular paced rhythm. Atrial mechanism is uncertain. Since the previous tracing of [**2180-5-7**] no significant change. - CHEST (PORTABLE AP) Study Date of [**2180-5-23**] 1:48 PM IMPRESSION: 1. Increasing alveolar opacities, most consistent with severe pulmonary edema. Persistent small bilateral effusions. 2. Intact and standard position of ICD and pacemaker wires. 3. New left PICC at the level of the mid SVC. No pneumothorax. 4. Stable moderate-to-severe cardiomegaly 5. Increasing left lower lobe atelectasis. - LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2180-5-23**] 3:59 PM IMPRESSION: 1. Mild gallbladder edema and sludge. No signs of acute cholecystitis. 2. Dilated hepatic veins and right atrium consistent with right-sided heart failure. - ABDOMEN (SUPINE ONLY) PORT Study Date of [**2180-5-23**] 10:05 PM IMPRESSION: 1. Normal bowel gas pattern. No evidence of obstruction, ileus, or megacolon. - Cardiac Cath Study Date of [**2180-5-24**] HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.03 m2 HEMOGLOBIN: 10.9 gms % FICK **PRESSURES RIGHT ATRIUM {a/v/m} 18/14/16 7/10/8 RIGHT VENTRICLE {s/ed} 60/12 44/21 PULMONARY ARTERY {s/d/m} 60/22/34 53/17/30 PULMONARY WEDGE {a/v/m} 26/29/26 24/28/23 AORTA {s/d/m} 96/54 97/64/75 **CARDIAC OUTPUT HEART RATE {beats/min} 80 80 RHYTHM N N O2 CONS. IND {ml/min/m2} 125 125 CARD. OP/IND FICK {l/mn/m2} 3.63/1.79 4.38/2.16 **RESISTANCES SYSTEMIC VASC. RESISTANCE 1300 1224 PULMONARY VASC. RESISTANCE 176 128 **% SATURATION DATA (NL) SVC LOW 52 55 PA MAIN 49 55 AO 96 94 TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 0 hour46 minutes. Arterial time = 0 hour minutes. Fluoro time = 3 minutes. IRP dose = 136 mGy. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol ml Anesthesia: 1% Lidocaine subq. Anticoagulation: Other medication: Milrinone ggt iv Lidocaine 8ml sq Cardiac Cath Supplies Used: - ALLEGIANCE, CUSTOM STERILE PACK - MERIT, RIGHT HEART KIT - ARROW, BALLOON WEDGE PRESSURE CATHETER 110CM - [**Doctor Last Name **], SWAN-GANZ VIP COMMENTS: 1. Limited resting hemodynamics revealed moderately elevated left and right sided filling pressures with an LVEDP of 26mmHg and RVEDP of 12mmHg. There was moderately elevated pulmonary artery systolic pressures with a PASP of 60mmHg. There was a moderately reduced cardiac index at baseline of 1.79L/min/m2 with significant response to milrinone to 2.16mmHg. FINAL DIAGNOSIS: 1. Dilated cardiomyopathy. 2. Good hemodynamic response to milrinone. 3. To CCU with milrinone infusion. - CHEST (PORTABLE AP) Study Date of [**2180-5-25**] 1:58 PM FINDINGS: AP single view of the chest has been obtained with patient in sitting semi-erect position. Analysis is performed in direct comparison with the next preceding similar study obtained six hours earlier during the same day. The findings are unchanged and characterized by severe pulmonary congestion with perivascular haze and central edema densities. The Swan-Ganz catheter approached via right internal jugular sheath was advanced far into the left pulmonary circulation and the tip in location indicating a posterolateral branch of the left lower lobe. The catheter is still in an unusual peripheral position and withdrawal was not effective. New effort to withdraw the Swan into more central position in the pulmonary circulation is recommended. Position of previously described ICD device is unchanged. No pneumothorax has developed. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was paged. Brief Hospital Course: Pt is a 64 yo male PMHx significant for non-ischemic cardiomyopathy with EF 25%, s/p ICD placement [**2175**] (v paced), mild-mod MR/TR, DM, ICD, Afib on coumadin, gout, hypothyroidism, CKD p/w vtach and ICD firing, recently admitted for ICD firing, CHF w/ EF 20-25%% who presents from heart failure clinic w/hypotension. Pt has ?Cdiff w/ continued diarrhea, vomitting and decreased PO intake w/associated dehydration and lethargy after recently being d/c'ed to [**Hospital 100**] rehab facility ~1wk ago. . # Goals of care: Upon admission to the ICU, the patient was started on a milrinone gtt, with some improvement in fluid balance and blood pressures. A discussion was held with both the wife and the patient spelling out the patient's very poor prognosis; cardiac transplant was off the table secondary both to the patient's wishes in addition to his poor compliance in the past. The patient did not wish for any further escalation of care. Palliative care was consulted, and the ptaient's nausea was treated with haldol/ativan/zofran PRN; he was given morphine boluses for pain. All non-comfort medications were discontinued, and the patient was made DNR/DNI. The patient expired on [**2180-5-27**] at 945 PM # Hypotension/diarrhea/vomiting/?C diff: Pt reportedly had ?c diff associated diarrhea, nausea/vomiting and decreased PO intake over the last week. Pt presented to Heart Failure clinic and found to be very hypotensive (60/40; wife reported SBP in 70s) and was sent to ED. Cr was elevated to 3.6 and pt appeared very dehydrated on exam. There he had a lactate of 2.5. Started on vanco and cefepime. Also received gentle fluid rehydration. CXR showed significant pulmonary edema but atypical PNA could not be ruled out. KUB was negative. All BP lowering meds (holding metoprolol, amioderone) were held as was torsemide. The patient was subsequently transferred to the ICU for a milrinone gtt in order to maintain pressures, particularly after the small bolus of NS he received caused him to go into pulmonary edema. A Swan-Ganz was floated, which showed moderately elevated left and right sided filling pressures with an LVEDP of 26mmHg and RVEDP of 12mmHg. There was moderately elevated pulmonary artery systolic pressures with a PASP of 60mmHg. There was a moderately reduced cardiac index at baseline of 1.79L/min/m2 with significant response to milrinone to 2.16mmHg. [**Hospital 100**] Rehab was contact[**Name (NI) **] and indicated that they had emperically started C. Diff treatment with PO vancomycin without cultures; C. Diff assay here was negative, and so antibiotics were discotninued on the patient. The patient was noted to have nausea controlled with Zofran and Prochlorperazine; nausea was attributed to hepatic congestion secondary to heart failure. The diarrhea similarly was thought to be attributable to the patient's congestive heart failure. # Pancreatitis: Pt found to have elevated lipase in ED, nause, vomitting. Pt does not drink. RUQ US did not show stones or dilation. Evidence of sludge. Concern for possiblely being drug related. Recently started on amiodarone so held but per pharm, unlikely to cause pancreatitis. Non-acute belly on exam, negative [**Doctor Last Name 515**]. Was made NPO given ?pancreatitis, N/V and given gentle fluids given low EF. Repeat lipase trending down (277-->184), making pancreatitis less likely. Ultimately the patient was transitioned from NPO to thin liquids. # CHF: Pt has hx of non-ischemic cardiomyopathy with EF 25%, s/p ICD placement [**2175**] (v paced), mild-mod MR/TR. Was recently admitted for CHF exacerbation and ICD firing in setting of running out of meds and non-adherence to low salt diet. Had ICD leads changed so no [**Hospital1 **]-v paced in setting of having ?inappropriate discharges. Pt initially d/c'ed to [**Hospital 100**] rehab on [**5-13**] after diuresis. Per wife pt got worse at rehab. In ED, CXR now showed ?pulm edema vs atypical PNA (started on vanco, flagyl and cefipime on day of admission [**2180-5-23**]). Pt also has been vomiting so possible aspiration was also complicating the picture. Pt was given very gentle fluids which improved renal function but pt reported worsening respiratory status and O2 sats began to decline, required sup O2. Decision was made by attending that pt should be transferred to the ICU for closer monitoring given tenuous fluid state, in addition to be monitored with a Swan for closer fluid management. Milrinone gtt during Swan improved cardiac output, and so the patient was continued on milrionne gtt while in the ICU; after goals of care discussion, ths gtt was discontinued. # Pulmonary Edema vs ?PNA: pt found to have signs of pulmonary edema but per read can't r/o atypical PNA. Also, given vomitting, aspiration is also possible. Chest xray was significant for cardiomegaly, pulmonary edema vs ?atypical PNA or both. Started on vanco, flagyl and cefipime on day of admission [**2180-5-23**]. These medications were subsequently DC'ed after the patient was found to be C. Diff negative and was not displaying any other signs of infection such as fever or WBC count. # Hyponatremia: tends to run low, baseline around low 130s. [**Month (only) 116**] be worse in setting of dehydration. Remained stable during admission. Labs were subsequently discontinued once the patient was made CMO. # [**Last Name (un) **] on chronic renal failure: Pt has significant bump in Cr 3.6 baseline Cr of 2.6-2.8. Likely bump related to dehydration due diarhea, N/V, decreased PO intake and getting home diuretics. Received gentle fluids and improved, and subsequently the patient but fluid and diuresis were both discontinued after goals of care discussion. # Afib: The patient was on coumadin on admission, and was continued on such until his goals of care discussion, at which point it was discontinued. # DMII: Initially on ISS, subsequently DC'ed after goals of care discussion . # Gout: Has a history of severe gout; did not require colchine on this admission. # Hypothyroid: Continued home dose levothyroxine. Medications on Admission: -allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). -colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). -digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). -levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). -docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). -multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). -senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. -polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. -aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). ****Pt wife states should be on 200mg now but per OMR should still be 400mg-amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Until [**2180-6-1**] and then decrease to 200mg PO Daily. -warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please hold warfarin and Check INR on Sunday [**2180-5-14**]. If below 3 start warfarin at 2mg. ****[**Name (NI) 1094**] wife says [**Name2 (NI) 3543**] him so will hold-trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. -torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). -metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. -insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime as needed for As needed for high sugar. -insulin lispro 100 unit/mL Solution Sig: As per sliding scale Subcutaneous QACHS. Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "274.9", "V58.67", "276.2", "425.4", "428.0", "584.9", "V45.02", "427.1", "428.23", "250.00", "V49.86", "276.1", "585.9", "427.31", "244.9", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "89.64", "38.93" ]

icd9pcs

[ [ [] ] ]

19344, 19353

11644, 17707

324, 362

19404, 19413

4428, 9557

19469, 19479

3458, 3542

19374, 19383

17733, 19321

10528, 11621

19437, 19446

3557, 3562

2512, 2601

9576, 10511

247, 286

390, 2405

3576, 4409

2632, 3027

2427, 2492

3043, 3442

3,929

103,671

4975+55623+55624+55625

Discharge summary

report+addendum+addendum+addendum

Admission Date: [**2142-3-1**] Discharge Date: [**2142-3-7**] Date of Birth: [**2083-10-25**] Sex: M Service: [**Hospital1 139**] HISTORY OF PRESENT ILLNESS: Patient is a 58-year-old white male with complicated past medical history including diabetes mellitus type 1, complicated by retinopathy, nephropathy, neuropathy, end-stage renal disease status post living related kidney transplant in [**2130**] now with evidence of chronic rejection, now on hemodialysis, status post peritoneal dialysis catheter placement in [**2141-12-9**], status post recent hospitalizations in [**2142-1-8**] for choledocholithiasis, and cholecystitis status post ERCP and cholecystectomy, presented on [**2142-3-1**] with complaints of abdominal pain, nausea, vomiting, diarrhea, and elevated systolic blood pressure. Patient reported that earlier on the day of admission, he had undergone a session of hemodialysis. While at hemodialysis, his blood pressures elevated to a systolic blood pressure to the 220s. Per the patient, his baseline systolic blood pressure is closer to 150. After hemodialysis, later that evening, he had the onset of nonbloody, nonbilious emesis, and diffuse, generalized abdominal pain. At that time, he had also noted a fever of 102.9 associated with shaking chills. REVIEW OF SYSTEMS: Upon admission was negative for chest pain, shortness of breath, cough, sputum, sick contacts, rash, medication changes, dysuria, or increased urinary frequency. Of note, the patient has a history of chronic loose stools secondary to autonomic insufficiency caused by his diabetes. He also reports intermittent fevers of unclear etiology dating back to his open cholecystectomy on [**2142-2-7**]. While in the Emergency Department, he was noted to have a temperature of 102.0, blood pressure of 227/101, heart rate of 95, respiratory rate of 22, oxygen saturation of 98% on room air. While in the Emergency Department, he received total hydralazine of 10 mg IV x2, Phenergan 25 mg IV x2, and levofloxacin 500 mg IV x1. He also received Tylenol 650 mg en route to the Emergency Department. CT scan of the abdomen and pelvis was performed on [**2142-3-1**], which noted two postoperative fluid collections with internal air bubbles, one in the gallbladder fossa, and the other in the subcutaneous tissue incision line. Per the [**Location (un) 1131**], could not exclude abscess formation. There is stable appearance of a transhepatic kidney with one large cyst. Per Transplant Surgery, the CT findings were consistent with postoperative changes. However, in light of these findings, the patient was admitted to the Transplant Surgery service, and was started on linezolid and levofloxacin for antibiotic coverage. During the admission, Surgical staff also noted trauma to the right great toe. He was seen by Podiatry. Foot x-rays demonstrated evidence of heavy calcification, but there was no evidence of acute fracture in the region of the right great toe. There was noted an old healed fracture of the fourth metatarsal bone. While on the Surgical service, he continued to spike temperatures to 101.3 and 101.5 while on linezolid and levofloxacin. He also had irregularities in his blood sugar, for which he is followed by the [**Last Name (un) **] Diabetes consult service for better blood sugar control. In light of his complicated medical history and hospital course, he was transferred from the Transplant Surgical service to the Medicine service on [**2142-3-5**]. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 1, diagnosed at age 28, complicated by nephropathy, autonomic insufficiency causing orthostatic hypotension and gastroparesis, sensomotor neuropathy and retinopathy resulting in blindness. Last hemoglobin A1C was on [**2141-12-5**] 7.3. 2. End-stage renal disease on hemodialysis since [**2140-1-9**] via right tunneled Permacath. 3. Status post living related kidney transplant in [**2130**], with [**Year (4 digits) **] in [**2140**] showing chronic inflammation consistent with rejection. 4. Status post peritoneal dialysis catheter placement in [**2141-12-26**]. 5. Status post recent hospitalization on [**1-/2142**] for choledocholithiasis complicated by cholecystitis status post ERCP and sphincterotomy, status post cholecystectomy in [**2142-2-7**] complicated by postoperative fevers, treated with Vancomycin and Zosyn. He was transferred to the Surgical ICU after a period of unresponsiveness. Workup failed to reveal etiology of fevers. He was discharged to rehabilitation facility with one week of Augmentin therapy. 6. Recurrent presumed aspiration pneumonia with history of hypoxic respiratory failure requiring intubation in [**2141-12-9**], bronchoalveolar lavage negative for organism. Transbronchial [**Year (4 digits) **] in [**12/2141**] with patchy interstitial fibrosis, status post VATS with right lower lobe wedge [**Year (4 digits) **] with patchy acute and organizing pneumonia. 7. Multiple pulmonary nodules. 8. MGUS with SPEP significant for monoclonal IgG spikes, status post bone marrow [**Year (4 digits) **] in [**2140-2-9**]. In [**2140-9-8**] with increased plasma cells. 9. Obstructive-sleep apnea. 10. Anemia of chronic disease secondary to renal disease. 11. History of left lower extremity DVT. 12. Coronary artery disease status post non-ST-elevation myocardial infarction in [**2140-3-11**], status post PTCA and stent to distal LAD [**7-10**]. Catheterization at that time also with mild diffuse disease of the right coronary artery and left circumflex artery. Persantine MIBI in [**2142-1-11**] showed fixed severe apical perfusion defects with moderate size partially reversible defects in the inferior wall and septum. Unchanged from prior study of [**2141-2-8**]. 13. CHF with echocardiogram in [**2141-8-8**] with an ejection fraction of 40%. 14. History of right pontine lacunar infarction. 15. Gastroesophageal reflux disease with history of Barrett's esophagitis. 16. Diverticulosis. 17. History of Clostridium difficile infection. 18. History of methicillin-resistant Staphylococcus aureus bacteremia complicated by septic pulmonary emboli and empyema. 19. History of hypoglycemic coma in [**2141-5-9**] and [**2141-12-9**]. 20. Hypertension. 21. History of nasopharyngeal swab positive for MRSA in [**2141-12-9**]. 22. Hypothyroidism. MEDICATIONS PRIOR TO ADMISSION: 1. Midodrine 5 mg p.o. t.i.d. 2. Prednisone 5 mg p.o. q.d. 3. Levoxyl 25 mcg p.o. q.d. 4. Nephrocaps. 5. Calcium carbonate 500 mg p.o. b.i.d. 6. Calcitriol 0.25 mcg p.o. q.d. 7. Protonix 40 mg p.o. q.d. 8. Nifedipine SR 60 mg p.o. q.d. 9. Calcium acetate 1334 mg p.o. t.i.d. 10. Isosorbide sustained release 90 mg p.o. q.d. 11. Colace 100 mg p.o. b.i.d. 12. Neurontin 300 mg p.o. b.i.d. 13. Pravastatin 40 mg p.o. q.d. 14. Atenolol 200 mg p.o. q.d. 15. Lantus 30 units subcutaneous q.h.s. 16. Epogen 20,000 units subcutaneous twice a week. 17. Insulin Lispro q.i.d. with meals. 18. Sublingual nitroglycerin 0.3 nanograms sublingual prn chest pain. ALLERGIES: Patient reports allergies to Compazine and dicloxacillin resulting in nausea and vomiting. SOCIAL HISTORY: The patient lives with his wife and daughter. [**Name (NI) **] is a former military officer. He reports a 20 pack year tobacco history, but quit approximately 20 years ago. He denies any alcohol or IV drug use. He has a distant history of [**Doctor Last Name 360**] [**Location (un) 2452**] exposure. FAMILY HISTORY: Noncontributory. PHYSICAL EXAM UPON ADMISSION: T max 100.7, blood pressure 160/84, heart rate 82, respiratory rate 18-20, and oxygen saturation 100% on room air. Fingerstick blood glucose 189. General appearance: Well-developed and well-nourished white male, comfortable in no acute distress. HEENT: Normocephalic, atraumatic. Right eye with cataract and ptosis. Left pupil with post surgical changes. Sclerae are anicteric. Mucous membranes moist. Oropharynx clear. Neck: Supple, no masses, or lymphadenopathy. No jugular venous distention. No carotid bruits. Lungs: Fair inspiratory effort. Clear to auscultation bilaterally, no rhonchi, rales, wheezes. Cardiac: Regular rate and rhythm, normal S1, S2 heart sounds auscultated. Grade [**3-16**] holosystolic murmur heard best at apex with radiation to axilla. No rubs or gallops. Abdomen: Soft, nontender, nondistended, positive normoactive bowel sounds, peritoneal catheter in place with no erythema, edema, or exudates. Positive post surgical/post cholecystectomy wound in the right upper quadrant with overlying bandage clean, dry, and intact. Extremities: No clubbing or cyanosis, trace pretibial edema. Multiple healed lesions on shins and toes. Left ankle indicative of Charcot joint. Extremities warm with good capillary refill. Two plus dorsalis pedis pulses. Right great toe bandage clean, dry, and intact. Neurologic: Alert and oriented times three. No evidence of asterixis. PERTINENT LABORATORIES, X-RAYS, AND OTHER STUDIES: Complete blood count on transfer showed a WBC of 7.9, hematocrit 25.4, platelets 215. Serum chemistry demonstrated a sodium of 136, potassium 3.7, chloride 98, bicarbonate 25, BUN 48, creatinine 6.6, glucose 211. Liver function tests showed ALT 11, AST 19, alkaline phosphatase 108, total bilirubin 0.4. [**Month/Day (4) **] studies were pending at the time of this dictation. Microbiological data demonstrated serial blood cultures from [**2142-3-1**], [**2142-3-2**], [**2142-3-3**], and [**2142-3-5**] demonstrating no growth to date. Urine culture from [**2142-3-2**] was negative. A wound swab of his right hallux ulcer demonstrated no polymorphonuclear cells, no microorganisms. Culture had evidence of rare coagulase positive Staphylococcus aureus. Peritoneal dialysis fluid sample from [**2142-2-21**] demonstrated one sample with 2+ polymorphonuclear, 2+ gram-positive cocci in pairs, chains, clusters with culture demonstrating coag-positive Staphylococcus aureus, oxacillin sensitive. Second culture from [**2142-2-21**] demonstrated 3+ polymorphonuclear cells with sparse Enterococcus species faecium, sensitive to Synercid, minocycline, and linezolid. Followup peritoneal dialysis fluid culture on [**2142-3-3**] demonstrated no polymorphonuclear cells, no microorganisms, and fluid culture with no growth. PA and lateral chest x-ray from [**2142-3-1**] demonstrated the heart size and mediastinal contours were normal. Central venous line terminated within the mid right atrium. The pulmonary vascularity was normal with no evidence of failure. There was scarring at the right lung base with old rib fractures in the right that appeared unchanged compared with prior radiographs. There was atelectasis noted at the left lung base. There was no evidence of pneumothorax or pleural effusion. The osseous structures were unremarkable aside from the old right healed rib fractures. There was a pulmonary parenchymal opacity at both lung bases that was likely consistent with atelectasis. CT scan of the abdomen and pelvis from [**2142-3-1**] noted two postoperative fluid collections with internal air bubbles, one in the gallbladder fossa, and the other in the subcutaneous incision line. [**Location (un) **] could not exclude abscess formation. There is stable appearance of a transplanted kidney with one large cyst. EKG demonstrated sinus rhythm at 90 beats per minute with normal intervals. The axis leftward deviated. There was evidence of left atrial enlargement and borderline left ventricular hypertrophy with T-wave inversions in I, aVL, V5 through V6 with [**Street Address(2) 4793**] depressions in V6. There was [**Street Address(2) 4793**] elevations in leads V1 through V3, however, these were not significantly changed from an [**2141-12-30**] study. BRIEF SUMMARY OF HOSPITAL COURSE: 1. Fevers: Patient had multiple sources for infection including tunneled hemodialysis catheter, peritoneal catheter, his wound infection status post cholecystectomy, possibility of intraabdominal abscess status post cholecystectomy, and the traumatic wound to his right great toe. However, it also felt that fever could be noninfectious secondary to progression of his MGUS or due to another malignancy or could be due to worsening rejection of his transplanted kidney. However, in light of the clinical history of abdominal pain, nausea, and vomiting and associated fevers, it was felt initially the most likely source appeared to be the peritoneal dialysis catheter. This was also reinforced by the fact that his peritoneal dialysis catheter was not functioning well and was not flushing easily. Although prior to this admission, the peritoneal dialysis catheter had not been accessed for peritoneal exchange. Decision was made to attempt to use a catheter in order to attempt to obtain further culture data as well as to assess its overall function. Another confusing factor was that the patient's temperature spikes seemed to occur after his hemodialysis sessions. This led to the speculation that perhaps his hemodialysis catheter was infected, and this could be the culprit of his recurrent fevers. However, culture data from both his peritoneal dialysis catheter and his hemodialysis catheter had failed to reveal any significant causative organism. While he was on the Surgical service from [**2142-3-1**] to [**2142-3-5**], the patient was receiving linezolid and Levaquin. However, as it was not clear what organisms were being covered with these antibiotics nor was it clear via our culture data what his source of infection was, decision was made to discontinue these antibiotics. Infectious Disease consultation was obtained on [**2142-3-6**]. The Infectious Disease consultants agreed withholding antibiotics until further culture data can be obtained. As the patient was followed by the Renal team, there were discussions in terms of whether discontinuation of his peritoneal and hemodialysis catheters would be necessary in order to remove the multiple lines that could be nidus sites for infection. At the time of this dictation, that discussion was still ongoing. Of note, in addition to the linezolid and Levaquin, the patient did receive one dose of cefazolin through the peritoneal dialysis catheter as ordered by the Renal team. He also had a chest x-ray which ruled out any evidence of infiltrative process or pneumonia. At the time of dictation, multiple culture data sets were will pending. His culture data will be followed while he is the patient in the MICU and antibiotic coverage adjusted appropriately. 2. Diabetes mellitus type 1: The patient was continued on diabetic diet with Humalog insulin-sliding scale and glargine insulin q.h.s. He was followed closely by the [**Last Name (un) **] Diabetes Center consultation service, and their recommendations were taken in consideration and implemented. 3. End-stage renal disease on hemodialysis: Patient was continued on his outpatient prednisone dose for immunosuppression status post his renal transplant. He was dialyzed via hemodialysis on a scheduled by the Renal team. He was continued on Nephrocaps, calcium acetate, and a renal diet. His peritoneal dialysis catheter was accessed as per Renal's recommendations with multiple culture samples sent for evaluation of the peritoneal dialysis catheter as his source of infection. 4. Coronary artery disease: On initial presentation, there was no clinical history suggest active coronary artery disease. Patient was initially continued on nifedipine, Imdur, atenolol, Pravastatin, and aspirin. His amlodipine was discontinued in order to streamline his medication regimen somewhat. However, on the evening of [**2142-3-6**], the patient experienced an episode of hypoxia in which he dropped his oxygen saturation level to the mid 80s on room air. He was therefore transferred to the Medical Intensive Care Unit for evaluation of his hypoxemia with a differential that was related to volume overload versus transfusion reaction versus possible coronary ischemic event. At the time of this dictation, the determination of that is still being evaluated. 5. Neuropathy: Patient was continued on Neurontin. The Podiatry service followed him for his right great toe injury and felt that there was no evidence of any underlying infection or fracture. They made recommendations as to wound changes which were appreciated. 6. Hypertension: Patient is continued on atenolol, Imdur, nifedipine. These medications were to be titrated up for better blood pressure control. As he also has a history of severe orthostasis, he was continued on midodrine in light of history of autonomic insufficiency. As stated above, amlodipine was discontinued from his medication regimen during this hospitalization. 7. Hypothyroidism: Patient was continued on his outpatient dose of Levoxyl. 8. Anemia: Patient continues to receive Epogen twice weekly at hemodialysis. As there was a slow downward trend of his hematocrit on [**2142-3-6**], he underwent transfusion of 1 unit of packed red blood cells. Chest x-ray prior to this did not demonstrate any evidence of fluid overload. However, during the transfusion, the patient had an episode of hypoxemia as well as elevated systolic hypertension. Transfusion was discontinued at that time. He was transferred to the Medical Intensive Care Unit for further evaluation and treatment. The results of that portion of his hospital course will be dictated as a separate addendum to this report. 9. Fluids, electrolytes, and nutrition: Patient was maintained on a diabetic and renal diet. Electrolytes were followed and repleted as needed. 10. Prophylaxis: Patient was maintained on a bowel regimen, Tylenol, subQ Heparin for DVT prophylaxis, and Ambien for sleep. 11. Code status: Patient is full code. 12. Disposition: As outlined above, the patient had an episode of hypoxemia and elevated systolic blood pressure on [**2142-3-6**]. As they was concern for possible transfusion related reaction versus fluid overload resulting in congestive heart failure, the patient was transferred to the Medical Intensive Care Unit. The results of that portion of his hospitalization will be dictated as a separate addendum to this report. In addition, a separate addendum will be dictated denoting the remainder of his hospital course, post discharge medications, and follow-up plans. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 11865**], M.D. [**MD Number(1) 11866**] Dictated By:[**Last Name (NamePattern1) 257**] MEDQUIST36 D: [**2142-3-7**] 16:43 T: [**2142-3-8**] 06:53 JOB#: [**Job Number 20636**] Name: [**Known lastname 3425**], [**Known firstname 499**] Unit No: [**Numeric Identifier 3426**] Admission Date: [**2142-3-1**] Discharge Date: [**2142-3-11**] Date of Birth: [**2083-10-25**] Sex: M Service: [**Hospital1 248**] ADDENDUM TO SUMMARY HOSPITAL COURSE: On the evening of [**2142-3-6**], the patient was receiving a blood transfusion. During the transfusion, he had onset of severe dyspnea and dropped his oxygen saturations to 80 percent on 2 litres of nasal cannula. At that time he also had an elevated blood pressure, fever to 101.7 and rigors. Blood transfusion was stopped and transfusion reaction investigation was undertaken. Chest x-ray at that time was performed with evidence of mild congestive heart failure and questionable right lower lobe infiltrate. He was treated with nitropaste, morphine, and Levaquin. Electrocardiogram was performed and was unchanged. He was transferred to the Medical Intensive Care Unit for higher lever of care. While in the Medical Intensive Care Unit, his hypoxia and dyspnea improved with noninvasive ventilation, namely BiPAP therapy. He was also started on broad spectrum antibiotics including Linezolid, meropenem, Kefzol, Phenergan. He will continue to be pan cultured. From the evening of [**3-6**] to [**3-3**] he was stable and was able to have his oxygen requirement decreased and was afebrile, therefore antibiotics were discontinued. After transfer back to the medical floor, he had a transthoracic echo which was negative for any vegetations or valvular abnormalities. His blood pressure medication was also briefly changed in that he had been converting to short acting [**Doctor Last Name 932**] in light of his hypotension while he was in the Intensive Care Unit. His insulin regimen was adjusted several times for episodes of hyper and hypoglycemia. 1. Fevers: The patient continued to have multiple sources of infection including his tunnel dialysis catheter, peritoneal catheter, possible intraabdominal abscess or wound infection status post cholecystectomy. This also could be secondary to rejection of his transplanted kidney. He was followed by the Infectious Disease Service. He continued to have cultures taken of his blood both peripherally and through his hemodialysis catheter as well as peritoneal fluid cultures. At the time of this dictation, culture data failed to reveal any significant organismal growth. Therefore he was maintained off antibiotics. Because of his fever, his white blood counts were monitored. CMV viral load was also evaluated and at the time of this dictation was pending. At the time of this dictation on [**2142-3-11**], the patient had been afebrile for about 2 days. He subjectively felt that his fever was broken. We will continue to follow again his temperature curve as well as culture data. We will hold off on antibiotics. 2. Diabetes mellitus. The patient was continued on diabetic diet with Humalog sliding scale and Glargine at night. He is followed by the [**Last Name (un) 616**] Diabetic Consultation Service and their recommendations were implemented regarding his insulin regimen. 3. End stage renal disease, on hemodialysis. The patient was continued on prednisone for immunosuppression status post kidney transplant. He was continued on hemodialysis as per Renal. He was also continued on peritoneal dialysis with multiple different formulations and cycline regimens investigated. His dialysis will continue to be managed by the Renal Service. He will continue on Nephrocaps and calcium carbonate for phosphate binding. 4. Coronary artery disease/ congestive heart failure. The continues to have no clinic history to suggest active coronary artery disease during this hospitalization. He was continued on pravastatin and aspirin. After transfer out from the Intensive Care Unit he was restarted on his outpatient dosages of atenolol and Imdur as he was more comfortable on that regimen than on shorter acting agents. In light of his history of congestive heart failure, his peritoneal dialysis solution was adjusted in order to help correct for volume overload. He is continued on BiPAP at night. 5. Neuropathy. He was restarted on Neurontin and tolerated this well. 6. Hypertension. He was continued on his outpatient atenolol and Imdur. 7. Hypothyroidism. He was continued on his outpatient dose of Levoxyl. 8. Anemia. He is continued on Epogen twice weekly. 9. Fluids, electrolytes, and nutrition. He tolerated diabetic diet well. Electrolytes were followed serially and repleted as needed. Please note that a separate addendum will be done to this report dictating the remainder of the [**Hospital 1325**] hospital course as well a discharge medications and disposition plan. [**Name6 (MD) 116**] [**Last Name (NamePattern4) 1531**], M.D. [**MD Number(1) 1532**] Dictated By:[**Last Name (NamePattern1) 3083**] MEDQUIST36 D: [**2142-3-11**] 14:28 T: [**2142-3-12**] 02:58 JOB#: [**Job Number 3432**] Name: [**Known lastname 3425**], [**Known firstname 499**] Unit No: [**Numeric Identifier 3426**] Admission Date: [**2142-3-1**] Discharge Date: [**2142-3-11**] Date of Birth: [**2083-10-25**] Sex: M Service: [**Hospital1 248**] ADDENDUM TO SUMMARY HOSPITAL COURSE: On the evening of [**2142-3-6**], the patient was receiving a blood transfusion. During the transfusion, he had onset of severe dyspnea and dropped his oxygen saturations to 80 percent on 2 litres of nasal cannula. At that time he also had an elevated blood pressure, fever to 101.7 and rigors. Blood transfusion was stopped and transfusion reaction investigation was undertaken. Chest x-ray at that time was performed with evidence of mild congestive heart failure and questionable right lower lobe infiltrate. He was treated with nitropaste, morphine, and Levaquin. Electrocardiogram was performed and was unchanged. He was transferred to the Medical Intensive Care Unit for higher lever of care. While in the Medical Intensive Care Unit, his hypoxia and dyspnea improved with noninvasive ventilation, namely BiPAP therapy. He was also started on broad spectrum antibiotics including Linezolid, meropenem, Kefzol, Phenergan. He will continue to be pan cultured. From the evening of [**3-6**] to [**3-3**] he was stable and was able to have his oxygen requirement decreased and was afebrile, therefore antibiotics were discontinued. After transfer back to the medical floor, he had a transthoracic echo which was negative for any vegetations or valvular abnormalities. His blood pressure medication was also briefly changed in that he had been converting to short acting [**Doctor Last Name 932**] in light of his hypotension while he was in the Intensive Care Unit. His insulin regimen was adjusted several times for episodes of hyper and hypoglycemia. 1. Fevers: The patient continued to have multiple sources of infection including his tunnel dialysis catheter, peritoneal catheter, possible intraabdominal abscess or wound infection status post cholecystectomy. This also could be secondary to rejection of his transplanted kidney. He was followed by the Infectious Disease Service. He continued to have cultures taken of his blood both peripherally and through his hemodialysis catheter as well as peritoneal fluid cultures. At the time of this dictation, culture data failed to reveal any significant organismal growth. Therefore he was maintained off antibiotics. Because of his fever, his white blood counts were monitored. CMV viral load was also evaluated and at the time of this dictation was pending. At the time of this dictation on [**2142-3-11**], the patient had been afebrile for about 2 days. He subjectively felt that his fever was broken. We will continue to follow again his temperature curve as well as culture data. We will hold off on antibiotics. 2. Diabetes mellitus. The patient was continued on diabetic diet with Humalog sliding scale and Glargine at night. He is followed by the [**Last Name (un) 616**] Diabetic Consultation Service and their recommendations were implemented regarding his insulin regimen. 3. End stage renal disease, on hemodialysis. The patient was continued on prednisone for immunosuppression status post kidney transplant. He was continued on hemodialysis as per renal. He was also continued on peritoneal dialysis with multiple different formulations and cycline regimens investigated. His dialysis will continue to be managed by the Renal Service. He will continue on Nephrocaps and calcium carbonate for phosphate binding. 4. Coronary artery disease/ congestive heart failure. The continues to have no clinic history to suggest active coronary artery disease during this hospitalization. He was continued on pravastatin and aspirin. After transfer out from the Intensive Care Unit he was restarted on his outpatient dosages of atenolol and Imdur as he was more comfortable on that regimen than on shorter acting agents. In light of his history of congestive heart failure, his peritoneal dialysis solution was adjusted in order to help correct for volume overload. He is continued on BiPAP at night. 5. Neuropathy. He was restarted on Neurontin and tolerated this well. 6. Hypertension. He was continued on his outpatient atenolol and Imdur. 7. Hypothyroidism. He was continued on his outpatient dose of Levoxyl. 8. Anemia. He is continued on Epogen twice weekly. 9. Fluids, electrolytes, and nutrition. He tolerated diabetic diet well. Electrolytes were followed serially and repleted as needed. Please note that a separate addendum will be done to this report dictating the remainder of the [**Hospital 1325**] hospital course as well a discharge medications and disposition plan. [**Name6 (MD) 116**] [**Last Name (NamePattern4) 1531**], M.D. [**MD Number(1) 1532**] Dictated By:[**Last Name (NamePattern1) 3083**] MEDQUIST36 D: [**2142-3-11**] 14:28 T: [**2142-3-12**] 02:58 JOB#: [**Job Number 3432**] Name: [**Known lastname 3425**], [**Known firstname 499**] Unit No: [**Numeric Identifier 3426**] Admission Date: [**2142-3-12**] Discharge Date: [**2142-3-15**] Date of Birth: [**2083-10-25**] Sex: Service: During the last few days of hospitalization, [**Hospital 1325**] hospital course was relatively uneventful. Remainder of hospital course will be dictated by systems. Fevers: The patient remained afebrile for the remainder of hospitalization. His white blood count was declining. Microdata remained negative to date. There still remains no clear etiology of patient's fevers to date. Is currently off antibiotics. Per previous ID consult thought was to obtain a gadolinium scan as the patient spiked, however, this was not necessary as patient did not develop any further fevers. At the time of discharge, the patient was afebrile and again microdata was negative to date. Diabetes: The patient was continued on diabetic diet with Humalog sliding scale and Glargine at night. He is followed by [**Last Name (un) 616**] and will be continued to follow with [**Last Name (un) 616**] as an outpatient. End-stage renal disease: The patient is on hemodialysis. Continued on low-dose prednisone for his renal transplant. Patient received dialysis per renal schedule. Daily electrolytes were followed. Patient was continued on Nephrocaps and calcium carbonate for phosphate binding. Cardiovascular: The patient was continued on Imdur and atenolol for blood pressure control. He was continued on pravastatin for lipid control. Patient's blood pressure remained stable during the remainder of hospitalization. Anemia: The patient was continued on Epogen on hemodialysis twice weekly. FEN: The patient was given a diabetic diet, calcium carbonate for phosphate binding, daily electrolytes were followed. Prophylaxis: Was with Heparin and proton-pump inhibitor. Code: The patient remained full code during this hospitalization. DISCHARGE CONDITION: Stable. DISCHARGED TO: Home with services. DISCHARGE DIAGNOSES: Fever of unknown origin. Type 1 diabetes with neuropathy, nephropathy, and retinopathy. End-stage renal disease on dialysis. Status post renal transplant. Peritoneal dialysis catheter placement. Cholecystectomy. History of pneumonia. History of multiple pulmonary nodules. Obstructive-sleep apnea. Anemia. Coronary artery disease status post non-ST elevation myocardial infarction status post left anterior descending artery stent. Congestive heart failure with ejection fraction of 40 percent. Gastroesophageal reflux disease. Diverticulosis. History of methicillin-resistant Staphylococcus aureus bacteremia. Hypertension. Hypothyroidism. MEDICATIONS ON DISCHARGE: 1. Midodrine 5 mg p.o. t.i.d. 2. Prednisone 5 mg p.o. q.d. 3. Synthroid 25 mcg p.o. q.d. 4. B complex. 5. Vitamin C. 6. Folic acid 1 mg capsule one tablet p.o. q.d. 7. Calcium carbonate 500 mg p.o. b.i.d. 8. Calcitriol 2.5 mcg p.o. q.d. 9. Protonix 40 mg p.o. q.d. 10. Nifedipine 60 mg p.o. q.d. 11. Calcium acetate 667 mg two capsules p.o. t.i.d. 12. Isosorbide mononitrate 90 mg p.o. q.d. 13. Colace 100 mg p.o. b.i.d. 14. Gabapentin 300 mg p.o. q.d. 15. Pravastatin 40 mg p.o. q.d. 16. Atenolol 200 mg p.o. q.d. 17. Epogen 20,000 units biweekly. 18. Aspirin 325 mg p.o. q.d. FOLLOW UP: Dr. [**First Name (STitle) **] of Nephrology within 7-10 days. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1614**] on [**2142-3-20**]. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 980**] on [**2142-7-24**]. [**Name6 (MD) 116**] [**Last Name (NamePattern4) 1531**], M.D. [**MD Number(1) 1532**] Dictated By:[**Name8 (MD) 3433**] MEDQUIST36 D: [**2142-7-16**] 09:36:20 T: [**2142-7-16**] 10:10:18 Job#: [**Job Number 3434**]

[ "285.21", "403.91", "E878.0", "707.15", "250.51", "250.41", "780.6", "428.0", "996.81" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.91", "00.14", "93.90", "39.95", "54.98" ]

icd9pcs

[ [ [] ] ]

30763, 30809

7478, 7512

30831, 31489

31515, 32140

24014, 30741

32152, 32651

11834, 18959

6385, 7138

1320, 3509

175, 1300

7527, 11806

3531, 6353

7155, 7461

8,039

152,040

23207

Discharge summary

report

Admission Date: [**2196-2-23**] Discharge Date: [**2196-3-4**] Date of Birth: [**2132-8-1**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: Headache Pain LLE Major Surgical or Invasive Procedure: ORIF left tib-fib fx [**2196-2-24**] History of Present Illness: 63 yo female pedestrian struck by motor vehicle. Ijuries sustained include: bilateral frontal lobe contusions; left occipital contusion, Left comminuted tib-fib fx Social History: Lives with her daughter Family History: Non-Contributory Pertinent Results: [**2196-2-22**] 02:39PM FIBRINOGE-251 [**2196-2-22**] 02:39PM PT-13.5 PTT-25.3 INR(PT)-1.1 [**2196-2-22**] 02:39PM PLT COUNT-207 [**2196-2-22**] 02:39PM WBC-15.3* RBC-5.18 HGB-14.8 HCT-45.6 MCV-88 MCH-28.6 MCHC-32.5 RDW-12.2 [**2196-2-22**] 02:39PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2196-2-22**] 02:39PM AMYLASE-183* [**2196-2-22**] 02:39PM UREA N-28* CREAT-0.9 [**2196-2-22**] 02:46PM GLUCOSE-132* LACTATE-3.6* NA+-143 K+-3.6 CL--104 Brief Hospital Course: Patient arrived to trauma bay via ambuance after being struck by motor vehicle while crossing the street. She was taken to the OR on [**2196-2-24**] for an ORIF of her left tib-fib fx. Neuro - Patient with bilateral frontal lobe contusions,left occipital contusion, and small multiple SDH's. She was initially treated with Keppra, this was discontinued on [**2196-2-24**]. She became agitated during her ICU stay; Behavioral Neurology consulted who recommended adequate pain control with f/u in Behavioral Neurology in [**7-20**] weeks following her discharge. Patient has been less agitated throughout her hospital course. She has complained of intermittent headaches; trial with around the clock Tylenol and Fioricet were helpful. Over the last [**2-14**] days patient has not required Fioricet; continues on her [**Last Name (un) **] RTC. Cardiac - Patient started on beta-blocker for blood pressure control to maintain SBP less than 140. She had a temporary IVC filter placed which will be removed as an outpatient. Respiratory - No active issues at this time. Gastrointestinal - Patient seen and evaluated by Speech & Swallow, no signs of aspiration on her bedside swallowing evaluation. She is tolerating a regular diet. Genitourinary - Voids on own, continent of urine. Musculoskeletal - Moves all extremities x4. Must remain NWB LLE until follow-up with Orthopedics. She will remain on [**Hospital1 **] Lovenox injections at lease 6 weeks post-discharge. Medications on Admission: none reported. Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 3. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for itching. Disp:*60 Tablet(s)* Refills:*0* 4. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous every twelve (12) hours. Disp:*60 * Refills:*1* 5. 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* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. Left comminuted tib-fib fracture 2. Bilat frontal lobe contusions 3. Left occipital contusion 4. Small multiple subdural hematoma Discharge Condition: Stable Discharge Instructions: Pleae keep the left leg non-weight bearing at all times until follow up with Orthopedics. Please contact Neurosurgery for worsening headaches. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 1005**] from orthopedics within 2 weeks. Call for an appointment. His number is ([**Telephone/Fax (1) 8746**]. You must discuss your continued use of Lovenox with him at that time Please call Dr. [**Last Name (STitle) **] to arrange to have your IVC filter removed (the wire filter in your vein to catch blood clots). His number is ([**Telephone/Fax (1) 9393**]. Follow up with Dr. [**Last Name (STitle) 59664**] from neurosurgery in 5 weeks. You will need a repeat head CT before this appointment. Call [**Telephone/Fax (1) 59665**] to arrange both your head CT and your appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2196-3-4**]

[ "801.11", "401.9", "823.22", "E814.7", "958.8", "801.21", "823.02" ]

icd9cm

[ [ [] ] ]

[ "38.7", "79.36", "93.59" ]

icd9pcs

[ [ [] ] ]

3348, 3406

1175, 2645

330, 369

3583, 3591

656, 1152

3783, 4574

619, 637

2710, 3325

3427, 3562

2671, 2687

3615, 3760

273, 292

397, 562

578, 603

32,548

113,240

33607

Discharge summary

report

Admission Date: [**2164-12-22**] Discharge Date: [**2164-12-26**] Date of Birth: [**2107-7-11**] Sex: M Service: SURGERY Allergies: Codeine / Percocet / Dilaudid / Penicillins / Morphine Attending:[**First Name3 (LF) 695**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2164-12-28**]: EGD History of Present Illness: 57yM with EtoH cirrhosis, MELD 18 on the liver [**Month/Day/Year **] list. He is presenting with a few days of abdominal pain and retching, was sent home from the ED yesterday but called back in because of a SMV thrombosis that was noted. He currently has minimal abd pain, is not nauseated, and is actually hungry. He has a remote history of segemental occlusion of his SMV which led to small bowel ischemia, perforation, and Exlap with resection. Has been doing well until the past few days. Denies fevers, chills, dysuria, melena. . Past Medical History: 1. ETOH cirrhosis: complicated by variceal hemorrhage in [**2158**]. *Last endoscopy was done in of [**2164**]--1 cord of grade 1 varices. He is on propranolol 10 mg TID. *Alpha-fetoprotein of 4 on [**2164-6-13**]. *Imaging [**7-3**]: no lesions, coarse echogenic liver. 2. Gastric ulcer 3. Restless leg syndrome 4. History of acute mesenteric ischemia from a venous thrombosis ([**2-2**]). Found to have protein C and antithrombin III deficiencies. 5. S/p bowel resection for small bowel perforation ([**2-2**]). 6. Ventral hernia - no repair planned until after liver [**Month/Year (2) **]. 7. S/p repair of a perirectal abscess. 8. S/p multiple He has arthroscopic and orthopedic procedures involving his right rotator cuff. 9. Osteoarthritis: needs bilateral total knee replacements. . Echo [**6-2**]: LVEF:55%, a pulmonary pressure of 22. There was a slight increase of left ventricular cavity size and systolic function was a little bit less vigorous. Social History: Married to his wife [**Name (NI) **] who he lives with in [**Name (NI) 8242**]. Has three children and 6 grandchildren. On liver [**Name (NI) **] list at [**Hospital1 18**]. Family History: Noncontributory. Physical Exam: VS: 98 HR 58 BP 110/60 RR 18 98% RA PE: gen-Well appearing, AAOx3, NAD heent-anicteric CV-RRR pulm-CTA b/l abd-soft, mild umbilical discomfort, no rebound or guarding. Large ventral hernia with previous well healed scar Rectal: trace guaiac positive Ext-no edema. . LABS 139 105 16 94 AGap=13 4.7 26 1.0 Ca: 8.5 Mg: 2.1 P: 3.6 ALT: 35 AP: 91 Tbili: 2.7 Alb: 3.1 AST: 36 Lip: 23 12.7 5.7 78 39.6 N:73.4 L:16.0 M:7.6 E:2.7 Bas:0.3 PT: 16.4 PTT: 37.1 INR: 1.5 . IMAGING: CT Abdomen-new SMV thrombosis, partial portal vein thrombosis. Isolated loop of small bowel with edema and thickening concerning for venous congestion and early ischemia. No pneumatosis or free air. . Pertinent Results: [**2164-12-21**] 07:20PM BLOOD WBC-6.8# RBC-4.19* Hgb-12.7* Hct-39.5* MCV-94 MCH-30.3 MCHC-32.2 RDW-16.1* Plt Ct-84* [**2164-12-24**] 05:30AM BLOOD WBC-2.8* RBC-3.88* Hgb-11.8* Hct-36.0* MCV-93 MCH-30.5 MCHC-32.8 RDW-16.5* Plt Ct-66* [**2164-12-26**] 05:50AM BLOOD WBC-2.7* RBC-3.78* Hgb-11.6* Hct-34.7* MCV-92 MCH-30.7 MCHC-33.5 RDW-16.8* Plt Ct-72* [**2164-12-21**] 07:20PM BLOOD PT-16.6* PTT-35.2* INR(PT)-1.5* [**2164-12-26**] 05:50AM BLOOD PT-17.1* PTT-38.8* INR(PT)-1.5* [**2164-12-21**] 07:00PM BLOOD Glucose-82 Creat-0.7 Na-140 K-3.7 Cl-108 HCO3-24 AnGap-12 [**2164-12-26**] 05:50AM BLOOD Glucose-87 UreaN-14 Creat-0.7 Na-141 K-4.0 Cl-109* HCO3-25 AnGap-11 [**2164-12-22**] 11:00AM BLOOD ALT-35 AST-36 AlkPhos-91 TotBili-2.7* [**2164-12-25**] 05:40AM BLOOD ALT-31 AST-42* AlkPhos-87 TotBili-1.5 [**2164-12-26**] 05:50AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.8 Brief Hospital Course: 57yM with cirrhosis on liver [**Month/Day/Year **] list found on abd CT to have new SMV thrombosis with associated small bowel changes concerning for venous congestion. He was initially admitted to ICU and started on a Heparin Gtt. He kept NPO and given IV fluid. He remained hemodynamically stable while on the heparin. He was transferred to the med-[**Doctor First Name **] unit. An EGD was done as he was scheduled to get this as an outpatient with Dr. [**Last Name (STitle) 696**]. EGD revealed Grade I varices in the esophagus. No stigmata or red sign was noted. Stomach was notable for protruding Lesions. Many localized nodules with overlying erythema ranging in size from 2 mm to 3 mm seen in the antrum. Duodenum appeared normal. Esophageal varices were markedly diminished since previous banding. Schatzki's ring. Otherwise normal EGD to third part of the duodenum Diet was resumed. It was decided that he would be discharged to home on coumadin with a lovenox bridge. INR was 1.5 at time of discharge. Of note, he had initially presented to the ED and was noted to have episode of bradycardia to high 30s, EKG w/ brady and bigeminy (baseline per pt). This was noted again on [**12-25**]. EKG revealed a rate in the 60s with bigeminy. He was asymptomatic and stated that this is not a new finding. He denied dizziness, cp, or sob. Blood pressure was on the low side. Propranolol had been stopped for the EGD and was resumed at time of discharge. He was discharged home in stable condition. Medications on Admission: lasix 40', glyburide 2.5', lactulose 15', omeprazole 20', propanolol 10''', viagara 50', aldactone 100', colace, MVI, Mag oxide Discharge Medications: 1. Lovenox 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous twice a day: Give 0.9 ml for 90 mg dose. Disp:*14 0.9 ml* Refills:*1* 2. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Propranolol 10 mg Tablet Sig: One (1) Tablet PO three times a day. 7. Viagra 50 mg Tablet Sig: One (1) Tablet PO as indicated as needed for ED. 8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for constipation. 10. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. 11. MagOx 400 mg Tablet Sig: One (1) Tablet PO once a day. 12. Outpatient [**Name (NI) **] Work PT/INR Friday [**12-28**] with results faxed to Dr [**Last Name (STitle) 77863**] at [**Telephone/Fax (1) 77865**] attn coumadin clinic 13. Coumadin 1 mg Tablet Sig: Five (5) Tablet PO once a day: Dose adjustment per PCP Dr [**Last Name (STitle) 77863**]. Take 5 mg on [**12-26**] and [**12-27**]. Disp:*150 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: new SMV thrombosis grade 1 varices, no need for banding at this time Discharge Condition: Stable/good A+O x3 Ambulates ad lib, no assistive devices Discharge Instructions: Please call the [**Month/Day (4) **] clinic for fever, chills, increased abdominal pain, yellowing of skin or eyes, lack of appetite, inability to take or keep down food fluids or medications or any other concerning symptoms. Lovenox bridge to coumadin therapy for new SMV thrombus. Dr [**Last Name (STitle) 77863**] will be following your coumadin dosing at his coumadin clinic Continue all follow up appointments as previously scheduled Followup Instructions: PT/INR faxed to Dr [**Last Name (STitle) 77863**]. First level to be drawn Friday [**12-28**] Fax: [**Telephone/Fax (1) 77865**] Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2165-1-9**] 8:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2164-12-28**]

[ "572.3", "571.2", "557.0", "289.81", "456.21", "333.94", "750.3" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

6739, 6745

3777, 5283

330, 354

6858, 6918

2890, 3754

7405, 7817

2139, 2157

5461, 6716

6766, 6837

5309, 5438

6942, 7382

2172, 2871

276, 292

382, 923

945, 1931

1947, 2123

59,458

172,887

38831

Discharge summary

report

Admission Date: [**2177-3-2**] Discharge Date: [**2177-3-5**] Date of Birth: [**2117-9-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2279**] Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy ([**2177-3-2**]) History of Present Illness: 59 yo M with minimal past medical history presents from OSH initially with nausea, vomitting and near syncope. He denies Chest pain or dyspnea. Patient was out to dinner with his wife eating [**Name2 (NI) **] and [**Last Name (un) 86188**] salad. He drove home feeling fatigued but otherwise fine. At home, he experienced acute onset nausea, vomitting and diahporesis and presented to [**Hospital6 **]. At the OSH ED he was found to have 1mm ST elevations in V1 and V2 with no old EKGs for comparison. Given concern for STEMI, he was given aspirin and started on heparin and integrellin drips. Apparently no guaiac was done prior to this. During this time he had a witnessed syncopal episode with SBP of 60 which improved with fluids. At this time he again experience nausea and lightheadedness, but not chest pain. Pressures improved with fluids and he was transferrred to [**Hospital1 18**]. At [**Hospital1 18**], he was initially hypotensive to the 70s with melena and later maroon colored stool. Heparin and integrellin were stopped. EKG releaved persistent ST elevations in V1 and V3 and new TWIs laterally since last EKG at OSH. Cardiac enzymes were flat at [**Hospital1 18**] and [**Hospital1 **]. Cardiology felt that underlying prodcess was not cardiac and that patient should be evaluated in the MICU. NG lavage was negative. FAST exam at the bedside was negative. CT torso was negative. Hct was stable at 33.9 from the OSH hct at 36.7, and he received no blood transfusions. Patient received 5 L NS and lactate rose from 2.8 to 3.5. There is some distention on exam, but nontender. Patient was noted to have a transaminitis with elevated LDH and lipase. In the ED he received Cipro 400 mg IV, Flagyl 500 mg IV, thiamine 100 mg IV, Zofran 4mg IV and tylenol 1 g po. Patient was initially on a PPI drip but was discontinued after NG lavage was negative. He remained CP free throughout his course. On transfer, VS were 97.3, 84, 96/59, 20, 93 RA (98 2L). Patient has 4 peripheral IVs. Per the patient, he was seen by his PCP last week and EKG and LFTs at that time were normal. In the ICU, patient feels the urge to defeacate but othewise feels well. He denies Chest pain, nausea, and dizziness. Past Medical History: (1) Dyslipidemia (2) Anxiety (3) NASH confimred on biopsy 10 years ago, with reportedly normal LFTs at baseline (4) Patient reports normal screening colonoscopy 7 years ago (5) Right inguinal hernia repair [**2161**] Social History: Denies alcohol, tobacco, and illicit drug use. Former teacher now works as SAT tutor. Lives with his wife in [**Name (NI) 1110**]. Family History: Family History: One first degree relative with DM. No CAD or CVA. Daughter with Celiac. Physical Exam: Vitals: T: 97 BP: 145/95 P: 110 R: 25 O2: 95 % 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM at apex, but no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2177-3-2**] 05:18PM HCT-30.1* [**2177-3-2**] 01:01PM CK(CPK)-113 [**2177-3-2**] 01:01PM CK-MB-3 cTropnT-<0.01 [**2177-3-2**] 08:50AM HCT-28.0* [**2177-3-2**] 07:22AM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP [**2177-3-2**] 07:22AM LACTATE-2.3* [**2177-3-2**] 07:00AM ALT(SGPT)-33 AST(SGOT)-27 LD(LDH)-165 CK(CPK)-105 ALK PHOS-34* TOT BILI-0.4 [**2177-3-2**] 07:00AM CK-MB-3 cTropnT-<0.01 [**2177-3-2**] 07:00AM HCT-27.6* [**2177-3-2**] 05:15AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.023 [**2177-3-2**] 05:15AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2177-3-2**] 05:15AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-1 [**2177-3-2**] 04:37AM COMMENTS-GREEN TOP [**2177-3-2**] 04:37AM LACTATE-3.5* [**2177-3-2**] 04:37AM HGB-11.5* calcHCT-35 [**2177-3-2**] 02:33AM COMMENTS-GREEN TOP [**2177-3-2**] 02:33AM LACTATE-2.8* K+-4.5 [**2177-3-2**] 02:33AM HGB-12.4* calcHCT-37 [**2177-3-2**] 02:22AM GLUCOSE-146* UREA N-35* CREAT-1.2 SODIUM-139 POTASSIUM-7.7* CHLORIDE-106 TOTAL CO2-23 ANION GAP-18 [**2177-3-2**] 02:22AM estGFR-Using this [**2177-3-2**] 02:22AM ALT(SGPT)-44* AST(SGOT)-95* LD(LDH)-831* CK(CPK)-196 ALK PHOS-26* TOT BILI-0.9 [**2177-3-2**] 02:22AM ALT(SGPT)-44* AST(SGOT)-95* LD(LDH)-831* CK(CPK)-196 ALK PHOS-26* TOT BILI-0.9 [**2177-3-2**] 02:22AM LIPASE-86* [**2177-3-2**] 02:22AM cTropnT-<0.01 [**2177-3-2**] 02:22AM CK-MB-3 [**2177-3-2**] 02:22AM CALCIUM-8.6 PHOSPHATE-3.9 MAGNESIUM-1.9 URIC ACID-6.0 [**2177-3-2**] 02:22AM WBC-16.6* RBC-3.90* HGB-11.2* HCT-33.9* MCV-87 MCH-28.9 MCHC-33.1 RDW-13.9 [**2177-3-2**] 02:22AM NEUTS-81.7* LYMPHS-13.3* MONOS-4.2 EOS-0.5 BASOS-0.3 [**2177-3-2**] 02:22AM PT-14.8* PTT-39.2* INR(PT)-1.3* [**2177-3-2**] 02:22AM PLT COUNT-245 Studies: ECG [**2177-3-2**]: Sinus rhythm. Anteroseptal ST segment elevations raise consideration of myocardial ischemia. Lateral ST-T wave changes may be due to left ventricular hypertrophy or ischemia. Clinical correlation is suggested. No previous tracing available for comparison. Chest Xray [**2177-3-2**]: The cardiomediastinal contour is normal, and the heart is not enlarged. The lungs are clear, with no focal consolidation, evidence of congestive heart failure or pneumothorax. There is no evidence of free air. Mild left hemidiaphragm elevation is due to a large gastric bubble. Osseous structures appear unremarkable. Chest/Abd/Pelvis CT [**2177-3-2**]: 1. No evidence of acute abdominal process. 2. Cholelithiasis without cholecystitis. 3. Fatty infiltration of the liver. 4. Multiple large bilateral renal cysts. TTE [**2177-3-4**]: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Dilated thoracic aorta. Mild mitral and tricuspid regurgitation. EGD [**2177-3-2**]: Mucosa suggestive of Barrett's esophagus Food in the stomach body Ulcer in the first part of the duodenum (endoclip) No blood was seen in the stomach or in the duodenum. Medium hiatal hernia Brief Hospital Course: 59 yo M with past medical history of dyslipidemia who initially presented to an OSH with nausea and found to have ST elevations on ECG, initially started on heparin and integrellin, and then found to have a GI bleed. #. GI bleed: He presented to the [**Hospital1 18**] ED with hypotension and melena that transitioned to maroon-colored stool. There was concern for a brisk upper GI bleed. He underwent urgent EGD that showed a small duodenal ulcer with evidence of recent bleeding. This was clipped and he had no further bleeding. He remained hemodynamically stable and his hematocrit remained stable after the EGD. He was advised to stop taking Excedrin and aspirin and to avoid all NSAIDs. He took large amounts of NSAIDs prior to presentation and it was felt this may have contributed to his ulcer formation. His diet was advanced to regular without difficulty. #. ST elevations: He had ST elevations in leads V1-V3 on ECG on admission. At the OSH there had been concern for STEMI. It was initially felt that he was having demand ischemia due to his GI bleed. He remained chest pain and symptom free. A baseline ECG was obtained which showed some ST elevations in the same leads at baseline. It was felt that his changes did not represent cardiac injury as his cardiac biomarkers remained negative. He may have had some demand ischemia, and his CT chest did show calcifications in his LAD. He had a TTE which showed mild LVH. He was continued on atorvastatin during his hospitalization but this was stopped at discharge. He should have lipids checked after discharge and consideration of statin use, as his NASH does not represent a contraindication to statin use. #. Transaminitis: He had elevated LFTs on admission but this rapidly corrected with a recheck of his labs. #. Renal cysts: He was incidentally noted to have numerous bilateral renal cysts on abdominal CT, some of which are exophytic. The largest on the right measured up to 6.5 cm laterally (2:65). Further workup/evaluation was deferred to the outpatient setting. Medications on Admission: [**Doctor Last Name 1819**] Aspirin 325 mg Tab Oral Excedrin Extra Strength -- Unknown Strength Klonopin 0.5 mg daily OTC Cholestin powder Discharge Medications: 1. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety: Take as you were prior to this hospitalization. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Upper GI Bleed Secondary Diagnosis: NASH 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 bleeding from your gastrointestinal tract. You had a study where a camera was put down your throat which showed an ulcer in your small intestine which likely caused your bleeding. You also had changes on your EKG which you had prior to admission and are likely a normal variation for you. You should carry your ECG with you when you go to hospitals for them to refer to. You may have also had decreased blood flow to your heart during the bleed from your GI tract. You should avoid all NSAIDs such as aspirin, ibuprofen, and naproxen. You should discuss with your PCP when to restart aspirin. You should also have your hematocrit (red blood cell count) checked on [**Last Name (LF) 766**], [**3-10**]. You should also discuss with your PCP if you should take a statin to lower your cholesterol and prevent heart disease. Changes to your medications: Added pantoprazole 40mg by mouth twice daily STOP taking aspirin and excedrin Followup Instructions: You have the following appointments scheduled: Name: [**Last Name (LF) **],[**First Name3 (LF) **] I Location: [**Hospital3 **] INTERNISTS Address: [**2177**], [**Apartment Address(1) 86189**], [**Location (un) 8925**],[**Numeric Identifier 8926**] Phone: [**Telephone/Fax (1) 8927**] Appointment: [**2177-3-10**] 1:45pm Department: GASTROENTEROLOGY When: TUESDAY [**2177-3-18**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]

[ "794.31", "532.00", "300.00", "574.20", "593.2", "530.85", "285.1", "272.4", "790.4", "288.60", "553.3", "571.8" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

9373, 9379

6792, 8849

329, 374

9484, 9484

3671, 3671

10632, 11384

3032, 3105

9038, 9350

9400, 9400

8875, 9015

9632, 10501

3120, 3652

10530, 10609

274, 291

402, 2612

9456, 9463

3687, 6769

9419, 9435

9499, 9608

2634, 2852

2868, 3000

25,694

190,852

19541

Discharge summary

report

Admission Date: [**2138-3-26**] Discharge Date: [**2138-3-28**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 83 year old man who lives in [**Male First Name (un) 1056**], who arrived in the United States four days prior to admission to visit his daughter who lives in the [**Name (NI) 86**] area. On the day of admission, the patient developed subscapular chest pain radiating to the left arm but denied other symptoms. The patient reports that he had similar pain in the past for which he has not sought medical attention. He had unclear medical follow-up in [**Male First Name (un) 1056**]. In the Emergency Room, the patient's EKG was concerning for anterolateral myocardial infarction with ST elevations in V1 to V3 and ST depressions inferolaterally. The patient was given aspirin, Nitroglycerin as well as Lopressor in the Emergency Room and sent to the Cardiac Catheterization Laboratory. At the Catheterization laboratory the patient was found to have severe three vessel disease with moderately elevated filling pressures. The patient received cypher stents to the left anterior descending coronary artery as well as the left circumflex artery. The patient was stable throughout the procedure and was transferred to the Coronary Care Unit for close monitoring due to the high risk of lesions that were stented. PAST MEDICAL HISTORY: 1. Asthma. 2. Extensive tobacco history with presumably chronic obstructive pulmonary disease. 3. The patient denies any history of diabetes mellitus, hypertension or previous myocardial infarction. PAST SURGICAL HISTORY: The patient denies any past surgical history. MEDICATIONS: He denies taking any medications at home. ALLERGIES: The patient denies any allergies. SOCIAL HISTORY: The patient lives alone in [**Male First Name (un) 1056**] with six children living in the United States. The patient smoked tobacco approximately [**2-14**] to one pack per day for most of his life, but quit approximately 20 years ago. The patient denies alcohol use. PHYSICAL EXAMINATION: The patient's temperature was 98.0 F.; heart rate 58; blood pressure 104/30; respiratory rate 16. Pulmonary artery pressure 29/11. Oxygen saturation 98% on room air. Generally, the patient was alert, pleasant, Spanish speaking elderly man with regular rate and rhythm on heart examination with distant heart sounds. The patient with good carotid pulses without bruits. The patient with diffuse high pitched wheezes throughout his lung examination as well as bibasilar crackles. Physical examination is also notable for right groin site that was clean and without hematoma or bruit. Good distal pulses in all extremities without edema. Neurological examination intact. LABORATORY: On admission, white blood cell count 7.0, hematocrit 36, platelets 392. Chemistry is 142/4.3. Also notable for a BUN and creatinine of 15/1.1. Magnesium 2.3. The patient's creatinine kinase was 52 with CK MB of 2 and troponin T of less than 0.01. ECG showed sinus rhythm at 72 beats per minute with normal axis and intervals. [**Street Address(2) 2914**] elevations V1 to V3. Q waves in V1 and V2. Please refer to formal coronary catheterization report for details on that procedure. Chest x-ray hyperinflated without opacities or evidence of heart failure. CONCISE SUMMARY OF HOSPITAL COURSE: This is an 83 year old Spanish speaking gentleman who lives in [**Male First Name (un) 1056**] and was visiting his daughter in [**Name (NI) 86**], who presented with substernal chest pain with ECG finding concerning for anterolateral ischemia, status post catheterization with stents to the left anterior descending and left circumflex coronary arteries. 1. CORONARY ARTERY DISEASE STATUS POST STENTS TO THE LEFT ANTERIOR DESCENDING AND LEFT CIRCUMFLEX: The patient was started on aspirin, Plavix and also was given Integrilin times 18 hours which was renally dosed due to his decreased creatinine clearance. The patient was also started on Metoprolol as well as Captopril. The patient tolerated the catheterization very well without incident and had no complaints or anginal symptoms throughout his hospital stay. The patient was also started on Lipitor 20 once a day. PUMP: The patient with moderately elevated filling pressure on coronary catheterization, but clinically without any signs or symptoms of congestive heart failure. The patient underwent transthoracic echocardiogram on [**3-28**], which showed mildly dilated left atrium, mildly dilated left ventricular cavity as well as severe global left ventricular hypokinesis and overall severely depressed left ventricular systolic function without significant valvular issues. Estimated ejection fraction of 25 to 30%. As the patient did not have any signs or symptoms of congestive heart failure, he was just started on an ACE inhibitor from which he was discharged on. RHYTHM: The patient is in sinus rhythm on Telemetry without any major events of Telemetry. 2. PULMONARY: Extensive tobacco history with wheezes on examination and chest x-ray consistent with chronic obstructive pulmonary disease. The patient remained comfortable and saturated well on room air. The patient was given Albuterol and Atrovent nebulizers p.r.n. The patient had no pulmonary complaints throughout his hospital stay. 3. RENAL: The patient denies any history of renal disease but given his likely low muscle mass, his creatinine is abnormally high. The patient's medications, such as Integrilin, were renally dosed. The patient also received gentle intravenous fluids as well as Mucomyst peri-catheterization. The patient self diuresed overnight in the Coronary Care Unit and did not required any diuretic use. The patient's creatinine remained stable and was in the low 1.0 range at discharge. 4. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was maintained on a cardiac diet which he tolerated well. 5. ACCESS: The patient actually with femoral sheath from catheterization which was discontinued without hematoma or major blood loss. 6. PROPHYLAXIS: The patient was continued on pneumoboots as well as proton pump inhibitor throughout his hospital stay. Communication was with the family who was with the patient and the family daily. CONDITION ON DISCHARGE: Stable, tolerating p.o., ambulating and without anginal symptoms. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post stent placement. 2. Congestive heart failure. 3. Chronic renal insufficiency. DISCHARGE MEDICATIONS: 1. Aspirin 325 once a day. 2. Plavix 75 once a day for 90 days. 3. Lipitor 20 once a day. 4. Albuterol metered dose inhaler as needed. 5. Lisinopril 10 mg once a day. 6. Metoprolol sustained release, 75 mg once a day. DISCHARGE INSTRUCTIONS: 1. The patient is to follow-up with me in Clinic and has an appointment in [**4-15**]. The patient also has an appointment with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] of Cardiology in [**Month (only) 958**]. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Name8 (MD) 6906**] MEDQUIST36 D: [**2138-3-29**] 15:25 T: [**2138-3-30**] 15:08 JOB#: [**Job Number 53009**]

[ "493.20", "593.9", "428.0", "414.01", "410.11" ]

icd9cm

[ [ [] ] ]

[ "37.23", "36.05", "36.07", "88.56", "99.20" ]

icd9pcs

[ [ [] ] ]

6424, 6545

6568, 6793

6817, 7341

1605, 1757

3365, 6280

2071, 3336

117, 1355

1377, 1580

1775, 2047

6306, 6403

83,496

150,879

35608+58021

Discharge summary

report+addendum

Admission Date: [**2187-10-9**] Discharge Date: [**2187-10-17**] Date of Birth: [**2122-8-11**] Sex: M Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Levaquin Attending:[**First Name3 (LF) 1271**] Chief Complaint: nausea and headaches Major Surgical or Invasive Procedure: Right Crnaiotomy for tumor History of Present Illness: This is a very pleasant 65 year old male who has been extensively worked up for nausea, vomiting, and headaches. This has been going on for about six months. He is also reporting problems with blurry vision, which is occasional, as well as double vision sometimes. He had neuro-ophthalmology workup, which did not show anything abnormal. Also, no cataract. This started happening about six months ago as well. Had a head CT done when his gastroenterologist did not find anything abnormal from the GI tract and revealed what seems to be primarily fatty tumor over the right frontal base. An MRI was also done and further characterized this lesion. A CTA was done for surgical planning. He opted to proceed for surgery. Past Medical History: 1. Diabetes. 2. Hypertension. 3. Hypercholesterolemia. 4. Acid reflux. 5. Sleep apnea, officially diagnosed in [**2186-3-24**], treated with CPAP. 6. Status post appendectomy. 7. Status post cholecystectomy. 8. Status post tonsillectomy. Social History: The patient is married with grown children. He worked at the VA for 28 years in food services and is also retired from [**Name (NI) **] Brothers. [**Name (NI) **] continues to smoke 6 cigarettes a day, and his wife is a smoker as well, as are a few of his children. He does not drink and denies asbestos exposure. Family History: NC Physical Exam: On Admssion: neurologically intact On Discharge: neurologically intact Pertinent Results: MRI BRAIN [**2187-10-9**]: Right frontal lobe mass, which appears to be extra-axial and on the CT scan contains fat and calcium. Differential would include a dermoid or a fatty meningioma. CT HEAD W/O CONTRAST [**2187-10-9**] (4PM): Status post right frontal extra-axial mass resection with slightly decreased mass effect. Blood products and gas in the surgical bed. It is not clear whether linear hyperdensities along the margins of the surgical bed represents calcifications in the residual shell of the resected mass, or iatrogenic material. The operative report is not available for correlation at the time of this dictation. CT HEAD W/O CONTRAST [**2187-10-9**] (8PM): No significant change compared to [**2187-10-9**], at 4:25 p.m. Chest X-ray [**2187-10-9**] ET tube tip is 2.7 cm above the carina, the tip lies against the right tracheal wall. There are low lung volumes. Cardiac size is top normal. Bilateral pleural effusions are small. There is mild vascular congestion. EEG [**2187-10-10**] This is an abnormal video EEG telemetry due to the presence of 4 Hz background rhythm which represents a moderate to severe encephalopathy such as can be seen in diffuse ischemia, toxic/metabolic, infectious, or other etiologies. It is also abnormal due to the presence of right frontal slowing in the delta frequency range such as can be seen with subcortical dysfunction such as from ischemia, trauma, or mass, among other etiologies. Of note, there is significant electrical artifact from 17:00 onward in the right hemisphere leads. There were no clear epileptiform discharges or electrographic seizures noted. Chest X-ray [**10-14**] Mild interstitial edema has progressed accompanied by some increase in pulmonary vascular congestion. Mild cardiomegaly is unchanged. New opacification at the right lung base could be pneumonia or pleural effusion, statistically it is most likely atelectasis. No pneumothorax. Dr. [**Last Name (STitle) 17597**] was paged. Brief Hospital Course: Mr. [**Known lastname 73193**] was taken to the OR on [**10-9**]. He had a right craniotomy for tumor resction. Frozen section was dermoid or epidermoid tumor. While in the PACU he demonstrated generalized tonic-clonic seizure activity and was given Dilantin (300 mg boluses) along with Ativan PRN. He was extubated following his case, but required re-intubation when seizure to protect his airwya. He required nicardipine for a SBP goal < 140. He was getting Dilantin, decadron and his home medications. Post-op CT head showed post-surgical changes reflective of removal of his dermoid tumor. The patient had a repeat CT head 4 hours later on [**10-9**] given his seizure activity, which noted no significant changes. The patient was transfered to the TSICU while still intubated for further monitoring. Frequent neuro exams were attempted off propofol infusion, although seizure activity resumed. It should be noted that the patient's left upper extremity IV access site showed signs of infiltration and his left extremity turned mottle and blue in appearance, concerning for compartment syndrome in the PACU post-operatively. The plastic surgery team felt the pressures were not consistent with compartment syndrome and recommended arm elevations and warm compresses which seemed to improve the swelling. On [**10-11**] the patient had an EEG which demonstrated no seizure activity. The patient was weaned from sedation in order to optimize the neurologic exam. The patient was started on a Nicardipine gtt for blood pressure control. Dermatology was consulted about the patient's left extremity, they had few additional recommendations to what plastic surgery recommended. The patient had a much improved neurologic exam on [**10-12**] and the patient's sedation was weaned. The patient was successfully extubated on [**10-13**], and the patient was doing well neurologically with no focal deficits. He was doing well on the floor with daily dressing changes for his arm with nursing. He had no further seizures. He required a lot of insulin and was followed by [**Last Name (un) **]. He was cleared by PT for home on [**10-16**]. He was receiving insulin teaching overnight. The patient's central venous catheter was discontinued and his scalp staples were removed on [**10-17**]. He was discharged to home on [**2187-10-17**] with physical therapy home serivces, VNA wound care for his left arm and insulin/diabetes teaching. The patient is neurologically intact. Medications on Admission: Advair", Norvasc 10mg', ASA 325' held, Atenolol 100mg', Furosemide 80mg", Lisinopril 40mg', Metformin 1000mg", Xopenex, Protonix 40mg', Zocor 40mg' Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. phenytoin sodium extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 6. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). Disp:*90 tabs* Refills:*2* 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/temp/ha: max 4g/24 hrs. 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 12. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Glucose test strips new insulin requirments 15. Glucometer new insulin requirments 16. lancets new insulin requirments 17. insulin syringes (disposable) 1 mL Syringe Sig: One (1) syringe Miscellaneous prn hyperglycemia. Disp:*25 syringes* Refills:*0* 18. oxycodone 5 mg Capsule Sig: [**11-25**] Capsules PO Q4H (every 4 hours) as needed for pain: Do not take with alcohol or if you anticipate driving. Disp:*30 Capsule(s)* Refills:*0* 19. insulin NPH & regular human 100 unit/mL (50-50) Suspension Sig: One (1) 40 units Subcutaneous twice a day. Disp:*QS * Refills:*2* 20. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO once a day for 1 days: Take on [**2187-10-18**]. Disp:*1 Tablet(s)* Refills:*0* 21. dexamethasone 1 mg Tablet Sig: One (1) Tablet PO once a day for 1 days: Take on [**2187-10-19**] and then taper is complete. Disp:*1 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Right brain tumor Generalized Convulsion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. 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. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Do not take Aspirin ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. ** Please continue taking Insulin NPH and Regular as prescribed and check your blood sugars at least three times daily to maintain adequate glycemic control. ** Followup Instructions: Follow-Up Appointment Instructions ?????? Please return to the office in [**6-2**] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ?????? You will need a CT scan of the brain without contrast. You will need follow-up with your primary care physician [**Last Name (NamePattern4) **] 1 week for new diabetes/insulin medications. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Name: [**Known lastname 13008**],[**Known firstname **] D Unit No: [**Numeric Identifier 13009**] Admission Date: [**2187-10-9**] Discharge Date: [**2187-10-17**] Date of Birth: [**2122-8-11**] Sex: M Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Levaquin Attending:[**First Name3 (LF) 1698**] Addendum: On the date of discharge [**2187-10-17**], your LFTs showed slight elevation. Given your lack of concerning symptoms, please follow-up with your primary care physician regarding these abnormal values. Discharge Disposition: Home With Service Facility: [**Hospital1 328**] VNA [**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**] Completed by:[**2187-10-17**]

[ "787.01", "E878.6", "518.81", "997.09", "349.31", "428.0", "349.82", "225.0", "272.0", "368.2", "530.81", "482.0", "305.1", "E936.1", "709.8", "E937.8", "327.23", "V58.67", "250.00", "E928.3", "428.32", "E870.0", "345.10", "873.64", "999.9", "401.9", "493.90" ]

icd9cm

[ [ [] ] ]

[ "89.19", "38.93", "33.29", "02.12", "96.6", "01.59", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

12336, 12516

3826, 6299

329, 357

8729, 8729

1828, 3803

10896, 12313

1717, 1721

6497, 8566

8665, 8708

6325, 6474

8880, 10873

1736, 1772

1786, 1809

269, 291

385, 1104

8744, 8856

1126, 1366

1382, 1701

21,951

181,441

19567

Discharge summary

report

Admission Date: [**2126-4-11**] Discharge Date: [**2126-4-15**] Date of Birth: [**2056-3-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 134**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: This is a 70 gentleman with history of CABG with LIMA-LAD in [**2125**], AVR([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]), severe mitral stenosis who was admitted to CCU for acute anterior MI and cardiogenic shock. He has been complaining of shortness of breath for the poast few weeks. This was thought to be related to mitral stenosis. On the night prior to admission, he had severe SOB in bed with no chest pain. He went to an OSH in congestive heart failure and hypoxic. He was also tachycardic to 200 and given adenosine with HR in 150s. He was then given ASA, heparin, IV NTG. Subsequently, he became hypotensive to 90/60 and dopamine was started. He was intubated for airway protection. On arrival to [**Hospital1 18**] ED, he remains intubated. Echocardiogram that was done at bedside demonstrated new anterior wall hypokinesis. However, his INR was found to be 6.5. He was transiently brought to the unit for reversal and then emergently to the cath lab. Past Medical History: 1. LIMA-LAD in [**2125**] 2. AVR(St. [**Male First Name (un) 923**]) 3. MS 4. post-op AF 5. hypercholesterolemia 6. hypertension Pertinent Results: echo [**2126-4-11**]: The left atrium is normal in size. Overall left ventricular ejection fraction is severely depressed (20-30 percent); the anterior septum, anterior free wall, and apex are severely hypokinetic/akinetic. Right ventricular chamber size and free wall motion are normal. A bileaflet aortic valve prosthesis is present. The aortic prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The mitral valve leaflets are severely thickened/deformed. There is no mitral valve prolapse. There is moderate thickening of the mitral valve chordae. There is moderate mitral stenosis, with markedly elevated mean pressure gradient across the mitral valve (heart rate is 132 beats per minute). Mitral regurgitation is present but cannot be quantified. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. cath result [**4-12**]: 1. Selective angigraphy of the LIMA showed it to be widely patent with no angiographically apparent disease. Left subclavian angiography showed it to be widely patent without apparent disease. CXR [**2126-4-11**]: Single AP view of the chest dated [**2126-4-11**] at 10:12 a.m. is compared with a single AP view of the chest dated [**2126-4-11**] at 8:46 a.m. An endotracheal tube has been placed and terminates 3 cm above the carina. Previously identified congestive heart failure has slightly worsened in the last 1.5 hours. No discrete infiltrates are identified. There is no pneumothorax. [**2126-4-11**] 06:04PM TYPE-ART TEMP-37.8 PEEP-10 PO2-215* PCO2-43 PH-7.39 TOTAL CO2-27 BASE XS-1 INTUBATED-INTUBATED [**2126-4-11**] 03:45PM TYPE-ART TIDAL VOL-600 PEEP-10 O2-100 PO2-89 PCO2-46* PH-7.32* TOTAL CO2-25 BASE XS--2 AADO2-579 REQ O2-95 -ASSIST/CON INTUBATED-INTUBATED [**2126-4-11**] 03:45PM HGB-12.2* calcHCT-37 O2 SAT-96 [**2126-4-11**] 01:21PM TYPE-ART RATES-12/ TIDAL VOL-600 PEEP-10 O2-100 PO2-140* PCO2-40 PH-7.34* TOTAL CO2-23 BASE XS--3 AADO2-534 REQ O2-89 -ASSIST/CON INTUBATED-INTUBATED COMMENTS-VENTED [**2126-4-11**] 01:21PM GLUCOSE-134* LACTATE-1.2 K+-4.7 [**2126-4-11**] 01:21PM HGB-15.6 calcHCT-47 O2 SAT-98 [**2126-4-11**] 08:50AM GLUCOSE-210* UREA N-21* CREAT-1.4* SODIUM-143 POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-16* ANION GAP-29* [**2126-4-11**] 08:50AM CK(CPK)-218* [**2126-4-11**] 08:50AM cTropnT-0.09* [**2126-4-11**] 08:50AM CK-MB-21* MB INDX-9.6* [**2126-4-11**] 08:50AM CALCIUM-9.7 PHOSPHATE-6.9*# MAGNESIUM-2.0 [**2126-4-11**] 08:50AM WBC-18.2*# RBC-5.71# HGB-17.1# HCT-49.2# MCV-86 MCH-29.9 MCHC-34.8 RDW-15.1 [**2126-4-11**] 08:50AM NEUTS-89.8* BANDS-0 LYMPHS-6.1* MONOS-3.1 EOS-0.9 BASOS-0.2 [**2126-4-11**] 08:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2126-4-11**] 08:50AM PLT SMR-NORMAL PLT COUNT-305 [**2126-4-11**] 08:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2126-4-11**] 08:50AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2126-4-11**] 08:50AM URINE RBC-[**4-13**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**4-13**] [**2126-4-11**] 08:50AM URINE AMORPH-FEW Brief Hospital Course: 70 gentleman with history of CABG with LIMA-LAD in [**2125**], AVR([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]), severe mitral stenosis who was admitted to CCU for acute anterolateral MI and cardiogenic shock.Patient presented with pulmonary edema and hypotensive requiring intubation and dopamine drip. This is compatible with cardiogenic shock, differential being ischemia vs sudden decompensation of mitral stenosis. However, echocardiogram showed acute anterior wall HK, new decreased EF and unchanged MS, suggesting ischemia.Sepsis workup was negative. Cardiac catheterization [**2126-4-11**]: cypher to LMCA and prox LAD, kissing ballon to LAD and LCx. IABP not placed since iliac angiography showed diffusely small iliac and femoral vessels. He remained on pressors after the procedure and hemodynamics were monitored by swan. He was extubated and off pressors on the second day. He continued on integrillin for 18 h and plavix for 9 months. He was discharged on aspirin, lipitor, ACE and metoprolol. Coumadin was also continued for history of atrial fibrillation and mechanical valve. Medications on Admission: aspirin lopressor 75 TID lasix 40 lescol coumadin Discharge Medications: 1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 300 days. Disp:*30 Tablet(s)* Refills:*2* 3. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: acute coronary syndrome hypercholesterolemia hypertension atrial valve replacement Discharge Condition: stable Discharge Instructions: Please return to the hospital or call your doctor if you experience chest pain/shortness of breath or if there are any concerns at all. Please take all your prescribed medication. Please do not resume your job until you have been evaluated by the Electrophysiology clinic. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] within one month after your discharge. Preferably, please keep your appointment this coming Friday. Please follow up with your PCP for INR check in the next week becuase you are on coumadin ([**Doctor Last Name **]-[**Last Name (LF) **],[**First Name3 (LF) **] Z. [**Telephone/Fax (1) 3183**]). Please follow up with the electrophysiology clinic. Dr. [**Last Name (STitle) 73**] [**4-22**] at 11:30 AM. [**Hospital1 1170**], Cardiac Services, [**Location (un) 830**], [**Hospital Ward Name 23**] 7, [**Location (un) 86**], [**Numeric Identifier 718**], Phone: [**Telephone/Fax (1) 902**]. Completed by:[**2126-4-17**]

[ "410.01", "584.9", "414.01", "V43.3", "401.9", "428.0", "272.0", "427.31", "424.0", "785.51", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "37.23", "36.07", "88.56", "96.71", "00.17", "36.05", "96.04", "88.52", "99.20" ]

icd9pcs

[ [ [] ] ]

6735, 6790

4757, 5875

321, 346

6917, 6925

1531, 4734

7248, 7922

5975, 6712

6811, 6896

5901, 5952

6949, 7225

274, 283

374, 1360

1382, 1512

8,812

157,700

7308

Discharge summary

report

Admission Date: [**2147-5-27**] Discharge Date: [**2147-7-7**] Date of Birth: [**2100-11-10**] Sex: F Service: MEDICINE [**Doctor Last Name 1181**] CHIEF COMPLAINT: Abnormal liver enzymes. HISTORY OF PRESENT ILLNESS: The patient is a 46 year old female with advanced AIDS with CD4 count of 10 and viral load of greater than 100,000, admitted initially on [**2147-5-27**], for unresponsiveness. The events leading up to her admission were: [**2147-2-17**], the patient had aseptic meningitis with empiric treatment with Ampicillin for listeria. In [**2147-5-17**], the patient developed frontal headache with seizure and loss of consciousness less than 30 seconds. On the [**5-20**], the patient had a fever of 101.0 F., with intermittent lightheadedness. On [**5-21**], the patient had an abnormal sensation in the left hand and weakness, noted to be dropping objects. On [**2147-5-22**], the patient was in the outpatient transition unit for IVIG for myositis. On arrival, the patient had a temperature of 101.5 F., and a heart rate of 120, and admitted. The patient had an extensive Infectious Disease work-up which was all negative including Cryptococcal antigen, CMV antigen, blood cultures and fungal cultures. The patient refused a lumbar puncture at the time and head CT scan showed no acute process. The patient was then discharged on [**5-23**]. On [**2147-5-26**], the patient presented for intravenous IG and was then found to be somewhat somnolent thereafter and had labored breathing, incontinent of stool and urine, and gurgling. The patient was then sent to the Emergency Department where she got Vancomycin, Acyclovir and Ceftriaxone. A lumbar puncture with normal opening pressure. The patient, at the time, had minimally responded to pain. Neurology was consulted and observed left arm flexion, decorticate, and an episode of rhythmic jaw clenching as well as right arm flexion. The head CT scan was negative and the patient was admitted to the Intensive Care Unit. On [**5-26**], the patient was treated with Ampicillin, Ceftriaxone, Acyclovir. On [**5-27**], the patient had a MRI of the head with multiple signal abnormalities in the basal ganglion, left medial frontal lobe, bilateral frontal areas. The MRA showed subtle middle cerebral artery flow abnormalities. The patient was intubated for airway protection. On [**5-28**], the patient had an EEG without any focal seizure activity. On [**5-29**], Ceftriaxone and Ampicillin were discontinued. On [**5-30**], the patient had a repeat MRI which showed increasing abnormalities including multiple foci of increased signals. Findings from [**5-27**] all persist. On [**5-31**], the Dilantin level was 8.6, and the patient's Dilantin was increased. The patient was then extubated and had received some Decadron and epinephrine for laryngeal edema. On [**6-1**], the patient had an HSV PCR negative. On [**6-2**], the patient was called out of the Intensive Care Unit to the Neurology Service. On [**6-7**], the patient was noted to have elevated liver transaminases. On [**6-8**], TB was considered and Infectious Disease felt this to be unlikely given cerebrospinal fluid and MRI findings. On [**6-10**], varicella-zoster virus associated vasculitis was considered as a diagnosis and the lumbar puncture was repeated. On [**6-14**], a brain biopsy was performed without complications. On [**6-15**], transaminases continued to increase and work-up was deferred as the family was considering Hospice. Nevertheless, HAART was initiated as family wanted to remain aggressive until biopsy results of the brain returned. On [**6-16**], bilirubin was increased and after one day of HAART this regimen was stopped. The patient had a temperature maximum of 102.5 F., and Vancomycin and Ceftriaxone were started by Infectious Disease in the setting of persistent fevers. Abdominal CT scan was ordered. PAST MEDICAL HISTORY: 1. End-stage Acquired immunodeficiency syndrome; CD4 count of 10; viral load of greater than 100,000, complicated by HIV idiopathic thrombocytopenic purpura in [**2145-10-17**]; perianal herpes simplex virus; cervical dysplasia; HIV related myositis; HPV co-infection. 2. G6 PD deficiency. MEDICATIONS AS OUTPATIENT: 1. No HAART. 2. Bactrim Double Strength. 3. Azithromycin. 4. IVIG for myositis. MEDICATIONS ON TRANSFER: 1. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**]. 2. Normal saline intravenous. 3. Dilantin. 4. Lansoprazole. 5. Vitamin C. 6. Zinc. 7. Epogen. 8. Bactrim. 9. Azithromycin. 10. Acyclovir. 11. Ceftriaxone. 12. Vancomycin. 13. Heparin subcutaneously. 14. Fluconazole. ALLERGIES: Dapsone (causing hemolysis secondary to G6 PD deficiency). SOCIAL HISTORY: The patient is widowed with two children, seniors in high school, living with sisters. [**Name (NI) **] history of smoking or alcohol use. No recent travel. No pet exposures. No sick contacts. [**Name (NI) **] new sexual contacts. Health Care Proxy: Sister [**Name (NI) **], [**Telephone/Fax (1) 26993**]. PHYSICAL EXAMINATION: (upon transfer to Medicine Service) vital signs 98.7 F., temperature maximum of 102.7 F.; blood pressure 106 to 132/72 to 74; respiratory rate 15; O2 saturation 97 to 100% on room air. General appearance: Opens left eye to stimulation; right eye swollen shut. right frontal skull with staples, clean, dry and intact. HEENT: Conjunctivae pink; pupils equally round and reactive to light. No icterus. Moist mucous membranes. No lymphadenopathy. Supple neck. Lungs clear to auscultation anteriorly and laterally. Cardiovascular: Tachycardia, regular rhythm, no murmurs, normal S1, S2. Abdomen: Normoactive bowel sounds, soft, nondistended, no splenomegaly. Slight hepatomegaly. Extremities warm, good distal pulses. No cyanosis, clubbing or edema. Neurologic: Flaccid left upper and lower extremities. Reflexes with increased tone in the right upper and lower extremity. LABORATORY: White blood cell count 5.0, hematocrit 29.4, platelets 271, differential of neutrophils 77, lymphocytes 13, monocytes 8, eosinophils 1. Urinalysis negative. INR 1.1. Cerebrospinal fluid on [**6-10**], white blood cell count 5, protein 50, glucose 57, red blood cells 80. On [**6-2**], white blood cell count zero, red blood cells [**Pager number **], protein 67, glucose 57. Gram stain negative, culture negative, fungal negative, Crypto antigen negative. On [**5-26**], white blood cell count 2, red blood cells [**Pager number **]. Viral culture negative, Gram stain negative, glucose 45, protein 114, Crypto antigen negative, fungal negative, culture negative. Sodium 139, potassium 3.4, chloride 102, bicarbonate 27, BUN 8, creatinine 0.2, glucose 108. ALT 205, AST 113, alkaline phosphatase 639, total bilirubin 2.0, GTT 460. HDH stim test 14.3 with 25.0 to 38.6 on [**6-6**]. On [**6-13**], Dilantin level 7.9, free Dilantin 1.2. On [**6-14**], arterial blood gas 7.38/45/215. MICROBIOLOGY: Blood cultures on [**5-20**], 13th, 19th, 20th, 28th and 30th all, two sets each, negative. Urine cultures on [**5-29**], 19th, 28th, and 30th, all negative. Brain biopsy on [**6-14**], Gram stain negative, no PNM, tissue culture negative, anaerobic culture negative, fungal culture negative, ASB culture negative. Special stains all negative. Serologies: VZV, [**6-10**] blood IgG positive. RPR [**6-4**] negative. Toxoplasmosis [**6-2**], IgG positive, IgM negative. Crypto [**5-20**] negative. Catheter tip [**6-4**] negative. Stool for Clostridium difficile [**6-4**] negative. Sputum [**5-27**], greater than 25 PMNs, less than 10 epi, sparse oropharyngeal flora, fungal isolates [**5-23**], negative times two sets. CMV antigen [**5-23**], negative. Cerebrospinal fluid Toxo PCR [**6-10**] negative. Cerebrospinal fluid HCV PCR negative times two [**5-23**], [**5-26**], and [**6-2**]. Cerebrospinal fluid EBV PCR [**5-26**] negative, [**6-2**] negative. Cerebrospinal fluid [**Male First Name (un) 2326**] PCR [**5-26**] negative. Cerebrospinal fluid CMV PCR [**5-26**] negative. Cerebrospinal fluid EVZ PCR [**6-10**] negative. Cerebrospinal fluid TB PCR [**6-10**] negative. IMAGING: MRI of the head on [**6-13**] revealed multiple hyperintense lesions visible on post-contrast study. There distribution suggest ischemic lesions with associated enhancement, perhaps with petechial hemorrhage compared to the study of two weeks previously. New lesions are visible to the posterior circulation with involvement of the right thalamus and left cerebellum. Vasculitis or embolic disease are considerations. MRI of the head on [**5-27**], showed subtle flow signal irregularities in both the middle cerebral arteries, which could be secondary to basal meningeal inflammatory process; clinical correlations of these findings is recommended. In addition, bilateral basal ganglia and right temporal frontal signal abnormalities with leptomeningeal and subtle parenchymal enhancement. Leptomeningeal enhancement favors effective pathologies such a Toxo or Cryptococcus infection. MRI of the head on [**5-30**], found compatible results with those of the MRI from [**5-27**]. There are signs of cortical and deep [**Doctor Last Name 352**] matter edema, probably infarction which could be related to vasculitis from Leptomeningeal infection or inflammation. Correlation with cerebrospinal fluid findings is again recommended. Chest x-ray on [**6-15**] within normal limits. CT scan of the head on [**6-16**], showed multiple small regions of enhancement in the basal ganglia with no mass effect. Abdominal and pelvic CT scan with contrast on [**6-16**], showed no hepatic pathology detected by CT scan. There was trace effusion on the right. Short segment of narrowed and possibly thickened sigmoid, although this may simple represent segmental peristalsis and not true thickening. Non-specific perirectal stranding. Brain biopsy on [**6-14**] revealed gliosis and numerous macrophages. Small recent infarctions of up to 0.2 cm in length, in the cortex and [**Doctor Last Name 352**]-white junction. Arteriosclerosis including arterial wall thickening, perivascular clearing and perivascular hemisphere and later macrophages. No diagnostic vasculitis, no diagnostic neoplasia, no organs or bowel inclusions identified on H&E stains. No bacteria, yeast, fungi, protozoa identified in ASB tissue gram, PAS, GM, Asci stains. Liver biopsy on [**2147-6-26**], revealed no diagnostic abnormalities. There is no steatosis necrosis or abscesses; no significant nodal inflammation and no granulomas. No diagnostic abnormalities recognized in the pleural areas and trigone stain revealed no fibrosis. Iron stain was negative with positive control slide. Findings are consistent with chronic Hepatitis B with Grade 01 inflammation, Stage 0 fibrosis. EEG on [**5-27**] showed no focal epileptiform abnormalities and an EEG repeated on [**6-12**] was again without significant change. SUMMARY OF HOSPITAL COURSE: (Upon transfer to Medicine Service) The patient is a 46 year old female with [**Hospital 26994**] [**Hospital 26995**] transferred from the Neurologic Service status post extensive medical work-up for multiple issues, most acute being an increase in her ALT and AST and alkaline phosphatase, and bilirubin, along with persistent fevers concerning initially for AIDS cholangeopathy. After extensive liver work-up including ultrasound and biopsy, no abnormalities were found. Her transamonitis was most likely secondary to drug effect. Her AST and ALT began to decrease following discontinuation of Dilantin. However, the AST and ALT again began to increase following the start of Fluconazole which was eventually then discontinued. With the remainder of her hospital stay, her AST and ALT trended back down after all eventual antibiotics were discontinued. The patient's neurological status has remained at her baseline of a comatose like state. It was thought most likely secondary to multi-infarct disease of her brain, possibly caused by IVIG that the patient was receiving for her myositis. Exact etiology of her microinfarct disease of her brain, however, is not entirely clear. Bromine compounds have been started per Neurology for possible stimulation of frontal areas in an effort to allow her to initiate more behavior. Her neurologic condition throughout the remainder of her hospital stay remained stable. The patient, at baseline, responds to verbal stimuli and squeezes with her right hand on command. The patient has been followed by the Infectious Disease Service throughout her hospital stay and their extensive work-up has been negative. Her persistent fevers eventually developed and all antibiotics were discontinued. Throughout her hospital stay, the patient mostly remained on tube feeds via nasogastric tube. On [**2147-7-4**], a PEG was placed without complication. The patient was then restarted on tube feeds via her PEG. The PEG was placed by the Surgical Team. The patient was screened for rehabilitation/skilled nursing facility. Throughout her hospital stay, the patient's code status remained a Full Code. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: To extended care facility. DISCHARGE DIAGNOSES: 1. Advanced acquired immunodeficiency syndrome. 2. Microinfarction disease status post brain biopsy, of unclear etiology. 3. PEG tube placed [**2147-7-4**]. DISCHARGE MEDICATIONS: 1. Bromocriptine via PEG q. day. 2. Bactrim Double strength one tablet via PEG q. day. 3. Lansoprazole 30 mg via PEG q. day. 4. Ascorbic Acid 500 mg via PEG twice a day. 5. Zinc sulfate 220 mg via PEG q. day. 6. Epogen 40,000 units subcutaneously q. two. 7. Heparin 5000 units subcutaneously q. 12 hours. 8. Azithromycin 1000 mg via PEG q. Sunday. [**Doctor First Name 4623**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4624**], MD [**MD Number(2) 4625**] Dictated By:[**Last Name (NamePattern1) 1183**] MEDQUIST36 D: [**2147-7-6**] 11:15 T: [**2147-7-6**] 11:29 JOB#: [**Job Number 26996**]

[ "070.32", "112.0", "518.81", "728.0", "042", "263.9", "780.01", "434.91", "276.8" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "38.91", "96.72", "01.14", "03.31", "50.11", "01.59", "43.19" ]

icd9pcs

[ [ [] ] ]

13311, 13472

13495, 14149

11054, 13218

5104, 11025

13234, 13290

184, 209

238, 3923

4375, 4751

3945, 4350

4768, 5081

13,667

110,007

29560

Discharge summary

report

Admission Date: [**2135-12-31**] Discharge Date: [**2136-1-1**] Service: MEDICINE Allergies: Fosamax / Zinacef / Penicillins / Iodine / Miacalcin / Amiodarone / Sotalol Attending:[**Doctor First Name 1402**] Chief Complaint: syncope Major Surgical or Invasive Procedure: none History of Present Illness: This is a [**Age over 90 **]yo woman with h/o CAD, CHF LVEF 30%, HTN, VT s/p dual chamber ICD [**2135-11-30**] who presented to the ED this AM after syncopal epsode. She was in her USOH until this morning when she woke with poor appetite. She ate a few bites of cereal and tea and immediately became nauseated with epigastric/B lower rib pain, had a large bowel movement, vomited and then syncopized. her granddaughter was there and attempted to catch her fall. She did not hit her head. She denied any palpitations, chest pain, shortness of breath, arm or jaw pain. She awoke when the paramedics came and she was taken the the [**Hospital1 18**] ED. . In ED her SBP was in the 170's, her HR in the 70's. In the Emergency department she evidently reported chest pain "that felt like my heart attack" asoociated with nausea, relieved by SL NTG and morphine. She also received aspirin and plavix. On interview in the CCU she adamantly denies any chest pain. EKG with NSR, RBBB + [**Last Name (LF) 16990**], [**First Name3 (LF) **] deprssion in Vs-6. Bedside ecchocardiogram showed LVEF 45%, 1+ AR, [**12-27**]+ MR, no MS, [**12-27**]+ TR, no effusion. Pacer interrogation showed no events tachy or brady. DDDR 50-120 ppm . In addition in the ED she had an abdominal CT which was negative, CT head and neck negative, CXR showed only cardiomegaly. . On the floor she feels well with the only complaint being mild abdominal pain. she denies chest pain, SOB, nausea, vomiting. On ROS she endorses decreased appetite x 1 week with ? 5lbs wt loss. Denies previous abd pain; hematochezia, melena. She denies palpitations, CP, SOB, light headedness, sensation of pacer firing, weakness, numbness, etc. No known sick contacts or dietary changes. . She had a recent hospital admit in [**11-29**] for abnormal stress test with new lateral ischemia; cardiac cath [**2135-11-28**] showed new occlusion of diag (comp to [**2133**]), anterolateral, apical, posterobasilar hypokinesis. Lmain with mild dz; LAD w/ mod diffuse dz; EF 30%; mod to severe MR; s/p ptca of occluded first diag (unsuccessful) Past Medical History: CAD; "modest dz" in [**2133**]; [**2134**] cath with new diag occlusion s/p MI in [**2118**]'s VT since [**12-30**]; s/p amio Rx and sotalol Rx (d/c'd for side effects); most recently on flecainide; recently d/c'd; s/p pacer [**11-29**] CHF with recent hospitalization [**2135-11-28**]; EF 30-40% s/p pacer in [**11/2135**] for VT Carotid stenosis: 40-50% L CAS; 40% R CAS HTN iron deficiency anemia ?osteopenia GERD h/o esophageal ulceration and anemia remote h/o PE Social History: widowed, lives in [**Location **] alone; has help with cleaning/housework. No smoking, no EtOH, no illicit drugs. Family History: + MI in mother and sister. [**Name (NI) **] h/o stroke Physical Exam: T 98 BP 123/30, HR 58, RR 18, 88-92% on RA Gen: Well-appearing elderly woman in NAD; appears younger than stated age Neck: + R-sided carotid bruit; no LAD; approx 7cm JVD CV: RRR grade II/VI systolic murmur heard best at RLSB; approx 7cm JVD Pulm: CTAB Abdomen: + BS, soft, non-distended, mild RUQ and epigastric TTP Extremities: warm, well-perfused, no edema 2+ DP pulses B guiaic neg in ED. neuro: CN II-XII grossly intact; 5/5 strength all 4 extremities, no sensory deficits. Pertinent Results: ruled out by cardiac enzymes x 3 . Na 140, K 4.1, Cl 104, bicarb 28, BUN 20, Cr 0.7, gluc 112 CK 39, Trop T <0.01 LFTs all WNL; [**Doctor First Name **], lip wnl albumin 4.0 WBC 9.6 with nl diff, hct 30.2 MCV 88, plt 216 . CT head: No evidence of acute intracranial hemorrhage. No fracture identified. . CT neck: 1. No evidence of traumatic injury. 2. Multilevel degenerative changes in the cervical spine. 3. Extensive carotid artery calcifications. . Abd CT: 1. No acute abdominal pathology. 2. Extensive aortic and vascular calcifications without aneurysmal dilatation. 3. No free air in the abdomen. 4. Sigmoid diverticulosis without evidence of acute diverticulitis. . CXR: cardiomegaly, no effusion, no pulm edema, no infiltrate . Eccho LVEF 45%, 1+ AR, [**12-27**]+ MR, no MS, [**12-27**]+ TR, no effusion. Inferolat hypokinesis . Pacer interrogation showed no events tachy or brady. . EKG: sinus brady (a-paced); axis -50, ?Q in II, III, aVF. RBBB. PR 160, QRS 150, ST depression and TWI in V4-6; similar appearance to [**11-29**] stress test EKG . [**11-27**] cardiac cath: cardiac cath [**2135-11-28**] showed new occlusion of diag (comp to [**2133**]). Lmain with mild dz; LAD w/ mod diffuse dz; s/p ptca of occluded first diag (unsuccessful); 50% RCA lesion at ostium; 20% L main; anterolateral, apical, posterobasilar hypokinesis EF 30%; mod to severe MR; Brief Hospital Course: [**Age over 90 **] yo woman with CHF, CAD s/p MI (?IMI) and s/p recent pacemaker for VT now presenting with syncopal episode and EKG concerning for TWI in V4-V6. . # Syncope: story appears c/w situational vasovagal episode from nausea/vomiting/defecation. She was ruled out for MI x 3 and was chest-pain free during her admission. Arrhythmia was ruled out by negative pacer interrogation and no telemetry events. Her carotid stenosis is a [**Last Name 19390**] problem however there is no h/o focal neuro symptoms. She was not hypotense. She tolerated a regular diet and walked up the stairs w/o further syncope. . # Chest pain: Pt denied any chest pain, other than lower-rib/epigastric pain to myself; however reported it to others. This could be be [**1-27**] angina vs abdominal etiology. In the Ddx of abdominal source is GERD, passed gall-stone, gastritis, PUD although LFTs and abd CT were negative. She was kept on her home-dose PPI; her stools were guiac negative. She ruled out for MI by 3x cardiac enzymes. She may have had ischaemia from the stress of vagally-induced hypotension. She remained chest pain free on admission even walking up the stairs. . # Cardiac: 1. Ischaemia: known CAD with 12/06 admit for new lat TWI on stress; recent cath showing new D1 occlusion and eccho with similar findings as today (inferolat hypokinesis/post-lat hypokinesis). Findings on EKG likely stable from prior month. She denies chest pain; her epigastric/rib pain and syncope could have represented an ischaemic event vs abdominal pathology and syncopy from vagal episode. She ruled out for MI x 3. Repeat EKG was similar (slightly decreased STdepression/TWI). Kept on ASA, plavix, BB, ACEI, statin. Her outpt cardiologist should decide on the need for repeat stress test as an outpatient. . 2. Pump: EF 45% with moderate MR [**First Name (Titles) **] [**Last Name (Titles) **]; no current evidence of CHF exacerbation; appeared euvolemic on exam. kept on outpt Carvedilol 12.5 [**Hospital1 **] and quinupril/hct 10/12.5 daily. . 3. Rhythm: h/o VT s/p dual-chamber pacer; Set to pace 50-120. Appears to be intermittently atrially paced. No arrhythmia on pacer interrogation. . # Abdominal pain/nausea/vomiting: Resolved after admission, could have been [**1-27**] passed gallstone although LFTs wnl, PUD, gastritis, esophagitis. She was kept on nexium and tolerated a regular diet. She should be considered for outpt endoscopy/ other GI work-up given her iron-deficiency anemia and abdominal pain. . # Anemia: labs c/w iron-deficiency. Should be f/u by PCP/gastroenterologist. . # HTN: normotense on her home regimen . # FEN/GI: Tolerated regular diet; continued nexium . # PPX: was kept on SQ heparin, PPI . # Code: DNR/I confirmed with pt, family, and attd. Medications on Admission: nexium 40 coreg 6.25 QHS; 6.25 QAM Quinapril/hct 10/12.5 ASA 81 zocor 20mg QHS quinapril 10mg daily ambien qhs nifirex 150mg po bid fosamax q week Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO daily (). 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Quinapril-Hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1) Tablet PO q tuesday, thursday, sat. Discharge Disposition: Home Discharge Diagnosis: primary: syncope, likely vasovagal secondary: CHF, iron deficiency anemia, s/p IMI Discharge Condition: good: AFVSS, chest-pain free. able to walk up flight of steps without chest pain or dyspnea Discharge Instructions: Please continue to take the same medications you were on before coming to the hospital. You were admitted after fainting which we think was a "vagal" reaction to your nausea/vomiting. You did not have a heart attack, you did not have a serious arrhythmia when we interrogated your pacemaker, your ecchocardiogram was improved from last month, CT of your abdomen, head and neck were normal. . There were some changes on your EKG that were similar to the changes found on stress test in [**Month (only) **]. You should follow up with your PCP and or cardiologist about this; they may suggest a repeat stress test, but not necessarily. . You also have low iron levels causing anemia. You should discuss this with your PCP and possibly [**Name Initial (PRE) **] gastroenterologist to evalute GI causes of bleeding. . If you have any chest pain or pressure, shortness of breath, light headedness, or fainting you should seek immediate medical attention. . Please follow up with your PCP and cardiologist within the next week. Followup Instructions: with your PCP and cardiologist in the next week

[ "787.02", "428.0", "412", "530.81", "280.9", "414.01", "V45.02", "780.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8642, 8648

5019, 7794

292, 299

8775, 8870

3624, 3847

9943, 9994

3052, 3108

7992, 8619

8669, 8754

7820, 7969

8894, 9920

3123, 3605

245, 254

327, 2413

3856, 4996

2435, 2905

2921, 3036

60,518

119,153

28702

Discharge summary

report

Admission Date: [**2107-9-15**] Discharge Date: [**2107-9-17**] Date of Birth: [**2067-11-1**] Sex: F Service: MEDICINE Allergies: Morphine Sulfate / Oxycodone Attending:[**First Name3 (LF) 8104**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 39 yo woman with tuberous sclerosis, b/l nephrectomy on HD, frequent ED visits/admissions for abdomen/stoma pain who presented to the ED with same. She has had some nausea and decreased PO and potentially loose ostomy output over the past day but at present describes no alterations in her ostomy bag. She has chronic pain around her ostomy site, where there is a medium sized hernia, and recently escalated her home pain medication taking PO dilaudid with some relief. She describes the pain as sharp without referred pain. She denies any change in character from her chronic pain. She was planning on undergoing take-down of her ostomy tomorrow (Dr. [**Last Name (STitle) **], [**Hospital6 33**]) but called to reschedule because she is moving. In the ED, it was noted that she was hypotensive, and this is consistent with recent history over the past few days. Usual BPs in her are 100s-110s and usual heart rates are in the 90s-100s per patient. The patient had HD/UF today per patient no fluid remoced and 1.4L of fluid was given back given that she was initially under her dry weight. In the ED, initial vs were: T P 116 BP 93/58->87/56 R O2 sat. Patient was given dilaudid 1mg iv x2. She got 1L total of NS. She was evaluated by surgery who felt there was no incarceration of her hernia or any acute abdominal process. KUB was obtained which showed no e/o perforation. At present, she is comfortable and hungry, wanting to trial POs Past Medical History: 1) Tuberous sclerosis s/p bilateral nephrectomy ([**2101**]) at [**Hospital1 2177**], complicated by bowel perforation, now hemodialysis dependent 2) Ostomy s/p bowel perforation during nephrectomy 3) Tertiary hyperparathyroidism s/p parathyroidectomy 4) Hypertension 5) GERD Social History: Lives with 16 year-old son Currently disabled No alcohol use, no current cigarette use (1 ppw for several years) No history of IVDU/illegal drugs Family History: Father: Tuberous sclerosis Mother: HTN, breast cancer Pt. has had 3 children w/ tuberous sclerosis, one of her children passed from seizures. Her grandchildren also have tuberous sclerosis. Physical Exam: General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: No(t) Normocephalic, multiple facial tumors Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ), kyphotic Abdominal: Soft, Tender: peri-ostomy Extremities: Right: Absent, Left: Absent Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed Pertinent Results: Imaging: ======= ABDOMEN (SUPINE & ERECT) Study Date of [**2107-9-15**] 10:09 PM IMPRESSION: 1. No obstruction or ileus. 2. Osseous changes of renal osteodystrophy. Micro: ===== None Labs: ==== [**2107-9-15**] 06:40PM BLOOD WBC-6.2 RBC-4.51 Hgb-12.8 Hct-38.8 MCV-86 MCH-28.4# MCHC-33.0# RDW-19.8* Plt Ct-256 [**2107-9-17**] 05:30AM BLOOD WBC-3.7* RBC-3.56* Hgb-10.4* Hct-30.3* MCV-85 MCH-29.2 MCHC-34.3 RDW-19.8* Plt Ct-217 [**2107-9-15**] 09:50PM BLOOD PT-14.7* PTT-26.7 INR(PT)-1.3* [**2107-9-15**] 06:40PM BLOOD Glucose-101 UreaN-10 Creat-4.2* Na-141 K-3.8 Cl-94* HCO3-27 AnGap-24* [**2107-9-17**] 05:30AM BLOOD Glucose-90 UreaN-18 Creat-7.2*# Na-137 K-4.2 Cl-96 HCO3-26 AnGap-19 [**2107-9-15**] 06:40PM BLOOD ALT-13 AST-22 AlkPhos-378* TotBili-0.3 [**2107-9-15**] 06:40PM BLOOD Albumin-4.7 Calcium-9.2 Phos-1.7*# Mg-1.7 [**2107-9-17**] 02:22PM BLOOD PTH-59 Brief Hospital Course: 39 y/oF with TS on HD s/p b/l nephrectomy with recent hypotension likely attributable to poor PO intake presenting for abdominal pain and admitted to ICU for relative hypotension with lactate of 3.0. There was no evidence of infection and the patient clinically responded to fluids. She was transferred to the floor in stable condition and her BPs remained adequate. Her abdominal pain was consistent with her chronic pain and she was seen by Surgery given her reducible hernia, although this was thought not to be strangulated, thus not likely to be the cause of her pain. She was dialyzed without event and remained on her renal medications. After discussion with the patient and the medical team, all were in agreement that Ms. [**Known firstname 69408**] [**Known lastname **] was a suitable candidate for discharge. Medications on Admission: dialavite 1 daily calcium/tums 5 daily lopressor 100mg [**Hospital1 **] twice in last week prilosec Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 5. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day: Hold for blood pressure <100/60. 6. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO q8h prn as needed for pain. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Dehydration. Hypotension. Gastroenteritis. End-stage renal disease . Secondary diagnosis: Tuberous sclerosis Discharge Condition: Good. Discharge Instructions: You were admitted with low blood pressure and diarrhea. Your diarrhea improved while you were in the hospital, and your blood pressure was low because you were dehydrated. You received intravenous fluids and a regular diet and your blood pressure improved. . You will continue all the medications that you take at home except for sevelamer and losartan. Please do not take sevelamer and losartan. Please take your medications as they are prescribed. . Please call ([**Telephone/Fax (1) 1300**] to arrange an appointment with your primary care doctor Dr. [**Last Name (STitle) **]. . If you develop sudden chest pain, shortness of breath, loss of consciousness or lightheadedness, please call your primary care doctor or go to the nearest emergency room. Followup Instructions: Please call ([**Telephone/Fax (1) 1300**] to arrange an appointment with your primary care doctor Dr. [**Last Name (STitle) **]. Completed by:[**2107-10-28**]

[ "285.21", "403.91", "276.51", "759.5", "252.1", "585.6" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

5724, 5730

4098, 4925

304, 310

5902, 5910

3211, 4075

6712, 6873

2278, 2469

5076, 5701

5751, 5751

4951, 5053

5934, 6689

2484, 3192

250, 266

338, 1799

5860, 5881

5770, 5839

1821, 2098

2114, 2262

14,316

102,903

19514

Discharge summary

report

Admission Date: [**2147-9-16**] Discharge Date: [**2147-9-19**] Date of Birth: [**2103-7-8**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 943**] Chief Complaint: emesis/melena Major Surgical or Invasive Procedure: EGD History of Present Illness: Pt is a 44 yo male with h/o Hep C/etOH cirrhosis and hepatoma s/p ablation and known esophageal varices who p/w emesis and melena since yesterday. He was given 7 day course of amoxicillin and naprosyn for toothache and was scheduled to have his extraction today. However, he started to have black stool(X6) and threw up black material(X2). No BRBPR. Called his liver doctor and referred to ED for evaluation of GIB. Despite known varices, he has no known history of GIB requiring transfusion in the past. Pt denied any CP/SOB/F/C/NS. In ED, afebrile and hemodynamically stable. He was transfused 1U plt in ED for plt count of 47. Past Medical History: 1. Cirrhosis (Hep C/etOH) 2. hepatoma -s/p ablation now on transplant list/evaluation 3. Esophageal varices 4. s/p femur/tibia/fib fx 5. h/o polysubstance abuse Social History: 44 yo man, currently unemployed who lives with girlfriend. h/o alcohol use remission for 5 years tobacco-1ppd X22 yrs h/o cocaine, heroine, amphetamine abuse - none since [**2138**] Family History: mother died of MI at 65 yo Physical Exam: On admission: T: 98 HR: 72 BP: 102/55 RR: 20 O2 sat: 99% RA General: mildly juandiced middle aged male, A&OX3, NAD HEENT: PERRL, EOMI, OP-clear, neck supple, no LAD, JVP flat lungs: CTA bilat with good air movt, nml work of breathing cardiac: distant heart sounds, rrr, no m/g/r abd:mod distention, non tender +ascites, stool black and guaiac positive no flank/CVA tenderness ext: no c/c/e, warm with good capillary refill Pertinent Results: [**2147-9-16**] 09:05PM HCT-26.8* [**2147-9-16**] 03:47PM GLUCOSE-88 UREA N-22* CREAT-0.6 SODIUM-137 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-24 ANION GAP-9 [**2147-9-16**] 03:47PM ALT(SGPT)-51* AST(SGOT)-64* LD(LDH)-210 ALK PHOS-84 TOT BILI-1.6* [**2147-9-16**] 03:47PM ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-1.7 IRON-319* [**2147-9-16**] 03:47PM calTIBC-332 FERRITIN-237 TRF-255 [**2147-9-16**] 03:47PM ETHANOL-NEG [**2147-9-16**] 03:47PM WBC-5.5# RBC-3.00*# HGB-11.0*# HCT-30.1*# MCV-101* MCH-36.6* MCHC-36.4* RDW-15.3 [**2147-9-16**] 03:47PM NEUTS-60.8 LYMPHS-31.7 MONOS-5.2 EOS-1.9 BASOS-0.4 [**2147-9-16**] 03:47PM MACROCYT-2+ [**2147-9-16**] 03:47PM PLT COUNT-47* [**2147-9-16**] 03:47PM PT-14.5* PTT-29.7 INR(PT)-1.3 [**2147-9-16**] 03:47PM RET AUT-4.2* Brief Hospital Course: A/P: pt is 44 yo male with hep c cirrhosis, HCC and UGI bleed in setting of known varices s/p 7 days of nsaid use. 1. GI bleed: Pt was admitted to the MICU for evaluation and urgent EGD. He was hemodynamically stable throughout admission. GI bleed thought more likely due to NSAID use than esophageal varices as varices noted to be mild in past. On admission, he was started on octreotide transiently. He was transfused 2 units of PRBC's to keep hct >25 prior to transfer to floor. Endoscopy revealed: 3 cords of grade 1 varices in lower [**1-14**] of esoph but no active bleeding. Stomach: melena seen in body but no sign of active bleeding;antrum with erythema but no bleeding; multiple acute superficial ulcers 2-5mm in antrum with pigmented material suggestive of recent bleeding. He was started on carafate, protonix, and H pylori serology sentand were negative for H.Pylori. Emesis resolved s/p EGD and advanced to PO diet which he tolerated well. Transferred to floor on [**9-17**]. That evening hct dropped from 31 to 25.1(24.6 on repeat) and he was transfused 1 unit of blood(3rd during admission). He responded appropriately with hct inc to 27.9. His hct remained stable throughout rest of admission and had increased to 30.5 by time of discharge. On discharge, reinforced importance of avoiding NSAIDS to prevent further GI bleeds. 2. HEME: Thrombocytopenic on admission with platelets of 47. He has received 1 Units of platelets on admission. On the floor, pt was transfused another 3 units of platelets to keep plt>75, per hepatology recommendations. Plt on discharge were 89. 3. [**Name (NI) 52965**] Pt is currently undergoing transplant evaluation. He was continued on oupt dose of nadalol during admission. He received one week of ciprofloxacin for SBP prophylaxis in setting of UGIB. Pt will be in touch with Dr. [**Last Name (STitle) 497**] for recommendations of oral surgeons to perform his tooth extraction. He will need this procedure to be done in hospital setting where hct and platelets can be monitored. He is also to f/u in liver center on [**9-21**] as previously scheduled. 4. Smoking cessation - discussed with patient impact of smoking on health and benefits of cessation. He expressed interest in quiting and was successful on nicotine patch during admission. He was discharged on the patch Medications on Admission: nadolol 60 mg po daily lactulose mvi Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day). 4. Nadolol 20 mg Tablet Sig: Three (3) Tablet PO QD (once a day). 5. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal QHS (once a day (at bedtime)). 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 7. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain uncontrolled by Tylenol. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. GI bleed 2. PUD - EGD on [**2147-9-16**] 3. cirhhosis 4. HCC 5. esophageal varices Discharge Condition: stable Discharge Instructions: Please call the liver clinic or return to the ER if you experience nausea, vomiting, dizziness, or continued black stools. Please take all medications as prescribed. Complete the remaining 3 days of Ciprofloxacin. Please call Dr.[**Name (NI) 948**] office tomorrow regarding appointment with the oral surgeon who will be performing your tooth extraction. This should be done in a supervised setting where your blood levels and platelets can be monitored. Followup Instructions: Provider: [**Name10 (NameIs) **] TRANSPLANT,ORIENTATION TRANSPLANT CENTER-MEDICINE Where: TRANSPLANT CENTER-MEDICINE Date/Time:[**2147-9-21**] 3:00 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Where: LM [**Hospital Unit Name 7129**] CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2147-10-12**] 9:15 Where: PSYCH TRANSPLANT Date/Time:[**2148-2-27**] 1:30

[ "456.21", "285.1", "070.54", "533.40", "571.5", "E935.9", "305.03" ]

icd9cm

[ [ [] ] ]

[ "99.05", "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

5918, 5924

2689, 5017

321, 326

6054, 6062

1873, 2666

6565, 6958

1386, 1414

5104, 5895

5945, 6033

5043, 5081

6086, 6542

1429, 1429

268, 283

354, 986

1443, 1854

1008, 1170

1186, 1370

25,365

125,176

43072

Discharge summary

report

Admission Date: [**2116-12-19**] Discharge Date: [**2116-12-19**] Date of Birth: [**2057-4-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5438**] Chief Complaint: hypoxemic respiratory failure Major Surgical or Invasive Procedure: esophageal balloon placement History of Present Illness: 59 M transferred from [**Hospital6 17032**] with persistent hypoxemia for further ICU management. Past Medical History: Depression CHF Chronic Atrial Fibrillation COPD, on home O2 and steroid dependent Diabetes Mellitus Social History: Pt lives with his wife in [**Name (NI) **], MA. Quit tobacco ? time ago. Family History: Noncontributary Physical Exam: intubated, cyanotic. Pertinent Results: [**2116-12-19**] 03:01PM O2 SAT-56 [**2116-12-19**] 02:46PM TYPE-ART TEMP-38.7 PEEP-25 PO2-51* PCO2-93* PH-7.20* TOTAL CO2-38* BASE XS-4 INTUBATED-INTUBATED [**2116-12-19**] 02:46PM LACTATE-3.9* [**2116-12-19**] 02:46PM freeCa-1.26 [**2116-12-19**] 01:14PM TYPE-ART TEMP-37.8 TIDAL VOL-700 PEEP-20 O2-100 PO2-55* PCO2-82* PH-7.29* TOTAL CO2-41* BASE XS-9 AADO2-585 REQ O2-95 INTUBATED-INTUBATED [**2116-12-19**] 12:55PM GLUCOSE-226* UREA N-36* CREAT-0.9 SODIUM-140 POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-34* ANION GAP-14 [**2116-12-19**] 12:55PM CALCIUM-8.9 PHOSPHATE-3.1 MAGNESIUM-2.0 [**2116-12-19**] 12:55PM WBC-17.7* RBC-5.47 HGB-16.6 HCT-52.2* MCV-95 MCH-30.3 MCHC-31.8 RDW-15.8* [**2116-12-19**] 12:55PM NEUTS-86.3* BANDS-0 LYMPHS-9.2* MONOS-4.4 EOS-0 BASOS-0.2 [**2116-12-19**] 12:49PM TYPE-ART TEMP-37.8 TIDAL VOL-700 PEEP-18 O2-100 PO2-33* PCO2-58* PH-7.37 TOTAL CO2-35* BASE XS-5 AADO2-631 REQ O2-100 -ASSIST/CON INTUBATED-INTUBATED [**2116-12-19**] 12:49PM O2 SAT-57 Brief Hospital Course: 59 year old Male with past history of COPD and CHF who presented to [**Location (un) **] for hypersomnolence after gradual decline per wife since [**Holiday 1451**]. Apparently, pt treated with several courses antibiotics with no improvement prior pt presentation. At [**Name (NI) **], pt hypoxemic on ventilator for days. Decision made to transfer patient to [**Hospital1 18**] for further ICU care [**12-19**]. Patient arrived and was placed on ventilator. He was grossly cyanotic and had low pO2's in the 50s. An esophageal balloon was placed to titrate PEEP to adequate oxygenation. The patient was paralyzed to try to improve oxygenation. Patient seemed to improve somewhat, yet shortly thereafter, the patient became bradycardic and had an asystolic cardiac arrest. A code was called. CPR was administered. The patient was given epinephrine and atropine without effect x 2. Fluids were administered wide open. He was shocked for what looked like ventricular rhythm of 50s without effect. Pt pulseless. The patient was declared dead after approximately 15 minutes of aggressive resuscitation without pulse. The attending Dr. [**Last Name (STitle) **] and fellow Dr. [**Last Name (STitle) **] were present throughout the arrest. The patient's wife was [**Name (NI) 653**] and personally informed of the patient's passing. Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary Arrest Pneumonia Discharge Condition: Deceased Discharge Instructions: none Followup Instructions: none

[ "482.41", "250.00", "427.31", "496", "428.0", "518.81", "311", "276.2" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "99.60" ]

icd9pcs

[ [ [] ] ]

3182, 3191

1826, 3159

346, 376

3267, 3277

805, 1803

3330, 3337

732, 749

3212, 3246

3301, 3307

764, 786

277, 308

404, 503

525, 626

642, 716

23,316

126,257

13194

Discharge summary

report

Admission Date: #11 Discharge Date: [**2104-5-23**] Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female who was an unrestrained passenger involved in a high speed motor vehicle crash with positive loss of consciousness, was found to be neurologically intact at the scene. She was hemodynamically stable during transfer to the Emergency Room. The motor vehicle sustained large amount of damage with significant intrusion. The patient had prolonged extrication time. She complained of left lower extremity as well as right hip pain. She was transferred to the [**Hospital1 1444**] Emergency Room in the C spine collar and on the board. It should also be noted that the driver of the motor vehicle suffered a traumatic arrest at the scene. ALLERGIES: The patient has no known allergies. PHYSICAL EXAMINATION: In the Emergency Room vitals signs included temperature of 99.9, blood pressure 105/60, heart rate 92. She had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] come scale of 15. Her pupils were equal, round and reactive. Her extraocular muscles were intact. She had a 7 cm laceration of her forehead which involved her right eyelid and she had cervical tenderness as well but no step-off. Her lungs were clear. There was no crepitus. Her heart was regular. Her abdomen was soft, distended but not tender. She had a midline incision. She did not have any tenderness of her pelvis but did have right hip tenderness and the gross deformity of her left tib/fib area. Her rectal exam, she had a mass in the rectum. She was guaiac negative. Back exam, there was some tenderness at the T1 to T3 area but no step-off. LABORATORY DATA: On admission her white count was 12.1, hematocrit was 32.6, platelet count 220,000, sodium 142, potassium 3.6, chloride 111, CO2 20, BUN 17, creatinine 0.7, glucose 167, INR 1.0, amylase 40. Her tox screen was negative. Her C spine revealed a C6 fracture. Her chest x-ray revealed no effusions but she did have a questionable widened mediastinum. Her pelvis film showed the right intertrochanteric fracture of her femur. Her head CT was negative. Her C spine, CT showed a fractured C6 vertebral body. Her CT scan of chest was questionable for an aortic tear but there was no extravasation. Her CT of abdomen and pelvis was negative. Facial bone CT was negative. X-ray of left tib/fib area showed a left tibial plateau fracture. X-ray of her right hip showed an intertrochanteric fracture of the femur. Her x-ray of her left ankle was negative. On review of her CT scan of her head, there was a question of a small subarachnoid hemorrhage. HOSPITAL COURSE: The patient was admitted on to the Trauma Intensive Care Unit. The pulmonary artery catheter was placed to optimize her managing of her hemodynamic status. Orthopedic surgery was consulted as well as cardiothoracic surgery was consulted. The patient was evaluated by the cardiothoracic surgery service because of a questionable contained aortic wall hematoma. Neurosurgery service was consulted for management of her C6 vertebral body fracture and the decision was made to treat this with a hard collar and no surgical intervention. She had no evidence of cord injury. Orthopedic service was consulted for her fractures and the decision was made to take the patient to the operating room and repair her left tibial plateau fracture as well as her right intertrochanteric fracture once she is stable. Her ICU course was further complicated by two brief episodes of atrial fibrillation which responded to Lopressor. The patient was hemodynamically stable throughout those two episodes. In order to further delineate her questionable injury to her aorta, she underwent a thoracic angiogram which was read by the cardiothoracic service and it was decided that patient did not have any aortic injury. Subsequently the patient was intubated in the Intensive Care Unit using fiberoptic intubation because of the planned procedures as well as the need to undergo an MRI of her C spine as well as having low oxygen saturation requiring an intubation. She subsequently underwent a transesophageal echocardiogram in order to confirm that there was no aortic injury and that was negative. Because of two episodes of atrial fibrillation, the patient was ruled out for MI. Cardiology was consulted and she was started on Lovenox for the episodes of atrial fibrillation as well as DVT prophylaxis. She was also seen by the gastroenterology service because of the rectal mass and the recommendation was made to undergo colonoscopy once she is more stable and in order to evaluate the rest of her colon and possible excision of this mass during colonoscopy vs operative excision of the mass. On [**2104-5-6**] the patient was taken to the operating room and underwent an open reduction internal fixation of left tibial plateau and right femoral fracture. The patient tolerated the procedure well and had no complications. She was subsequently seen by the physical therapy service. It was subsequently noted that patient had hemiparesis of her left upper extremity. CVA as well as aortic dissection was suspected. The patient underwent an MRI of her head which revealed multiple embolic CVAs. She then underwent an angiogram of her carotid arteries which was negative for dissection. The neurology service was consulted as well and her left sided weakness was attributed to be due to embolic CVAs as dissection was ruled out by an arteriogram. The source was suspected to be cardiac or fat emboli due to the two episodes of atrial fibrillation which were short-term as well as her orthopedic surgeries. The patient was then anticoagulated. An attempt was made to extubate the patient. She failed extubation and was reintubated due to respiratory distress. Subsequently there was a second attempt of extubation made which patient did not tolerate as well and her sputum cultures were positive for MRSA. She was started on Vancomycin and reintubated. She received a full course of Vancomycin and subsequently was afebrile with normal white blood cell count. Her sputum contained pseudomonas as well and she was treated with a full course of Ceftazidime for pseudomonas infection. Her central lines were subsequently discontinued and the PICC line was placed for future IV access. On [**2104-5-16**] a percutaneous tracheostomy as well as gastrostomy tubes were placed. The patient was subsequently weaned from ventilator support and now remains on a trach collar and she is tolerating full tube feeds of Impact. The patient was therapeutic on Coumadin but due to change in Coumadin dosing, her INR was low in the 1.3 range and she was started on Lovenox to maintain anticoagulation. Patient was subsequently screened and accepted to rehab. She was seen by the speech and language service and a PMV valve was placed which she tolerated and was able to speak. On [**5-23**] the patient was started on Kefzol due to some drainage at her right thigh incision area. The patient will be transferred to rehab in stable condition. DISCHARGE MEDICATIONS: Impact with fiber tube feeds at 60 cc per hour, Roxicet when needed, Haldol when needed, Lasix 20 mg [**Hospital1 **], Coumadin dose pending PT and INR, regular insulin sliding scale, Albuterol and Atrovent nebs, Lopressor 75 mg per G tube [**Hospital1 **] and Colace 100 mg per G tube [**Hospital1 **] as well as Lovenox. She will also be on a 10 day course of Keflex 500 mg qid, first day [**5-23**]. Final recommendations from the orthopedic service will be non weight bearing left lower extremity with a knee immobilizer, pivot right lower extremity, discontinue the sutures on [**5-28**] and follow-up with orthopedics, Dr. [**First Name (STitle) 13469**], on [**6-9**]. The patient will also need to follow-up with gastroenterology or general surgery to further evaluate her rectal mass as well as with Dr. [**Last Name (STitle) 1327**] from the neurosurgery service regarding the fracture of her C6 vertebral body. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-239 Dictated By:[**Last Name (NamePattern1) 27423**] MEDQUIST36 D: [**2104-5-23**] 11:24 T: [**2104-5-23**] 11:44 JOB#: [**Job Number 10098**]

[ "823.00", "805.06", "434.11", "518.5", "820.22", "482.1", "482.41", "E812.1", "427.31" ]

icd9cm

[ [ [] ] ]

[ "88.72", "33.21", "96.04", "79.36", "31.1", "88.41", "96.72", "43.11", "79.35" ]

icd9pcs

[ [ [] ] ]

7162, 8324

2700, 7138

870, 2682

122, 847

67,691

160,957

13235

Discharge summary

report

Admission Date: [**2140-8-17**] Discharge Date: [**2140-8-22**] Date of Birth: [**2083-10-16**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 598**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 56 yo fisherman who fell 15 feet off a dock with brief loss of consciousness but quickly returned to a GCS of 15. He was found to have multiple facial fractures and a L scapula fracture. Past Medical History: PMH: DM II, hyperlipidemia PSH: denies Social History: commercial fisherman, 2 drinks of hard EtOH/day x 30yrs. no tobacco, no illicits Family History: n/c Physical Exam: In trauma bay: afebrile HR 83 BP 158/94 RR 28 SpO2 98%RA GCS 15 L periorbital ecchymosis EOMI, PERRL, but left pupil difficult to evaluate [**1-5**] swelling blood in nares and in L external auditory canal, no chipped teeth trachea midline RRR, no crepitus midthoracic spine tenderness CTA, symmetric abrasions on left shoulder and left knee pain with movement of LUE, which is in sling + ankle pain, no obvious deformity Pertinent Results: [**2140-8-17**] 04:51PM WBC-16.1* RBC-4.37* HGB-13.5* HCT-37.7* MCV-86 MCH-30.9 MCHC-35.8* RDW-13.3 [**2140-8-17**] 04:51PM PT-13.7* PTT-23.5 INR(PT)-1.2* [**2140-8-17**] 04:51PM PLT COUNT-199 [**2140-8-17**] 04:51PM FIBRINOGE-249 [**2140-8-17**] 04:51PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2140-8-17**] 05:04PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2140-8-17**] 05:04PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.047* [**2140-8-17**] 05:04PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2140-8-17**] 04:53PM GLUCOSE-164* LACTATE-1.3 NA+-140 K+-4.1 CL--109 TCO2-19* CT torso [**2140-8-17**]: Left scapular fracture. Otherwise, no traumatic injuries in the chest, abdomen, or pelvis. CT head [**2140-8-17**]: 1. Left cerebral subdural hematoma measuring up to 7 mm in thickness, with scattered foci of subarachnoid hemorrhage in the left frontal lobe as well as a small amount of parenchymal contusion adjacent to the fracture of the left frontal bone/orbital roof. 2. Left temporal bone longitudinal fracture with apparent disruption of the middle ear ossicles. Given fracture line extension to the left carotid canal, correlation with CTA to exclude carotid injury is strongly advised. 3. Small amount of pneumocephalus, likely from fracture mastoid air cells. 4. Left frontal bone fracture extending to the left orbital roof with left maxillary sinus fractures. Please refer to dedicated facial bone CT scan report for further details. CT sinus/mandible/maxilla [**2140-8-17**]: 1. Left frontal bone fracture extends inferiorly to involve the sphenoid (lesser [**Doctor First Name 362**]) and left maxillary sinus. 2. Extraconal hematoma along the left orbital roof, mild left globe proptosis. 3. Left temporal bone fracture, possible ossicular disuption. Recommend CTA to exclude carotid injury as fracture line abuts the left carotid canal. 4. Blood within left maxillary and bilateral sp[henoid sinuses. CT C-spine [**2140-8-17**]: 1. No acute fractures or malalignment. 2. Thickening of ligaments posterior to C2. Recommend attention to this region on followup (CTA) imaging. [**Month (only) 116**] consider an MRI for further evaluation if clinically warranted. 3. Chronic appearing defect in the C1 lamina and C7 spinous process. L femur, knee, and ankle xrays [**2140-8-17**]: Acute fracture of the left lateral malleolus with lateral soft tissue swelling at the ankle. Otherwise, no acute fractures seen. L shoulder and elbow xrays [**2140-8-17**]: Acute fracture of the left scapula with more detailed assessment on CT torso performed earlier today. Otherwise, unremarkable. CTA neck [**2140-8-17**]: 1. No evidence of vascular injury or soft tissue injury in the neck. No signs of dissection. 2. A small filling defect in the left sigmoid sinus adjecent to the fracture site probably due to a small subdural collection or focal injury to the sinus wall. 3. Transverse fracture in the left temporal bone. Please refer to CT temporal study performed. CT orbits, sella, and IAC: Transverse fracture through the temporal bone involving the anterior portion of the jugular foramen and the roof of the attic. The facial nerve does not appear to have any bony fragments within its canal; however, laceration or injury to the nerve during trauma would not be well assessed by CT and MR would be the recommended modality if clinical suspicion exists. There is a notable amount of blood and soft tissue swelling that may be exerting some mass effect on the nerve. Brief Hospital Course: Mr. [**Known lastname 40341**] was admitted to the Trauma SICU after being evaluated in the Trauma Bay due to history of confusion and LOC. He was transferred out of the unit after being deemed stable for transfer to the floor. His diet was advanced and he was able to tolerate PO diet and pain meds. His hospital course is summarized below by system: Neuro: He remained alert and oriented throughout his stay. He was monitored closely in the unit for signs of deterioration. On HD 2, it was noted that he had developed a L facial nerve paresis and so urgent ENT evaluation was obtained who recommended a CT scan of the temporal bone. This showed no bony fragments in the canal but possible swelling which could be impinging on the nerve. For this, he was started on a prednisone taper, which he will continue for a total of 10 days. He was also started on floxin otic 4 gtt AS tid for 10 days as well as decadron drops 2 gtt AS tid x 10 days. He will follow up with Dr. [**Last Name (STitle) **] in clinic and should have an outpatient audiogram prior to this visit. Facial fractures: Pt was seen by plastics who recommended no intervention at this time and that the patient should follow up in clinic on [**8-26**] with Dr. [**First Name (STitle) **] to discuss surgical options. L eye swelling improved with time. Ophtho: seen by ophthalmology who did not find need for intervention, he will follow up in clinic with them as outpatient. Ortho: His left ankle fracture was placed in a [**Doctor Last Name **] splint and is NWB and was placed in an Aircast before D/C. His left arm was put in a sling for his L scapular fracture. He will follow up with ortho as an outpatient. CV: pt. remained hemodynamically stable Pulmonary: Pt remained stable from a pulmonary perspective. GI/Abdomen/Nutrition: Diet was advanced as tolerated. At discharge, the patient was tolerating a regular diet. Renal: He continued to have sufficient urine output. His foley was dc'd and he was able to void without issue. PT: [**Name (NI) **] was seen by PT and was recommended for acute rehab given the patient's size and NWB status of his LLE and LUE. Medications on Admission: crestor, actos, prilosec, baby ASA, niacin, Discharge Medications: 1. wheelchair: wheelchair elevated leg rests diagnosis: tib-fib fracture 2. Ciprofloxacin 0.3 % Drops Sig: Four (4) Drop Ophthalmic TID (3 times a day) for 10 days. Disp:*qs * Refills:*0* 3. Dexamethasone 0.1 % Drops, Suspension Sig: Two (2) Drop Ophthalmic TID (3 times a day) for 10 days. Disp:*qs * Refills:*0* 4. Prednisone 10 mg Tablet Sig: see below Tablet PO see below for see below days: Please take 6 tabs(60mg) for 3 more days, then 5 (50mg) for 2 days, then 4 (40mg) for 2 days, then 3 (30mg) for 2 days, then 2 (20mg) for 2 days, then 1 (10mg) for 2 days, then stop. Disp:*qs Tablet(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain for 10 days. Disp:*20 Tablet(s)* Refills:*0* 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation for 5 days. Disp:*10 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 5 days: stop if having diarrhea. Disp:*10 Capsule(s)* Refills:*0* 8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 6 days. Disp:*18 Capsule(s)* Refills:*0* 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q12H (every 12 hours) as needed for constipation. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constaipation. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: s/p ~15ft Fall Subdural hematoma Subarachnoid hematoma Left temporal bone longitudinal fracture Left scapular fracture Left lateral malleollus fracture Basilar skull fracture Facial & orbital fractures Left facial nerve dysfunction Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after a fall from great height. You sustained multiple injuries none of which requiring any operations. Your ankle fracture was managed with an air ankle stirrup. You are going to require extensive follow up with various specialists for ongoing evaluation of your injuries - the appointment information has provided in the recommended follow up section of this discharge. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 3878**] in the [**Hospital **] clinic in [**12-5**] weeks by calling [**Telephone/Fax (1) 41**]. Please also call this number to schedule an audiogram. Follow up in Ophthamology (Eye) clinic in [**12-5**] weeks for ongoing evaluation of your optic disc; call [**Telephone/Fax (1) 253**] for an appointment. Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Hospital **] clinic in 2 weeks by calling [**Telephone/Fax (1) 1228**] for an appointment. Please call the Plastic surgery clinic, [**Telephone/Fax (1) 4652**], upon discharge for a follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-6**] weeks for your facial fractures. Please call the [**Hospital 16364**] clinic, [**Telephone/Fax (1) 4296**], upon discharge for a follow up appointment with Dr. [**First Name (STitle) **] in approximately 4 weeks. You will need a repeat non-contrast head CT scan for this appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]

[ "530.81", "801.22", "811.09", "802.6", "872.00", "824.2", "951.4", "250.00", "272.4", "388.60", "E884.9" ]

icd9cm

[ [ [] ] ]

[ "18.4" ]

icd9pcs

[ [ [] ] ]

8654, 8728

4827, 6969

280, 286

9003, 9003

1141, 4804

9568, 10708

679, 684

7064, 8631

8749, 8982

6995, 7041

9138, 9545

699, 1122

232, 242

314, 502

9018, 9114

524, 564

580, 663

3,862

149,703

27244

Discharge summary

report

Admission Date: [**2165-7-2**] Discharge Date: [**2165-7-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: hypoxic respiratory failure Major Surgical or Invasive Procedure: intubation arterial line History of Present Illness: Mr [**Known lastname **] is a 83 y/o M with MMP including CAD s/p CABG, afib, HTN, Parkinson's and chronic aspiration recently admitted for GIB and PNA who represents with hypoxic respiratory distress requiring intubation in the ED. . During his last admission ([**Date range (1) 66812**]); Pt presented from his NH intubated after being found in respiratory distress, febrile, hypotensive and anemic/melena. Pt was admitted to the MICU and started on pressors and broad spectrum ABx. Transfused aggressively requring 7 units PRBC and FFP to reverse a therapeutic INR. HCT stabilized and EGD was not pursued based on family wishes. Abx course for MRSA PNA: Vanc/Zosyn -> Vanc/Flagyl -> Vanc/Levo which he was d/c home on to complete 10 more days of therapy. Of note; during this hospitalization he had occasional desaturations, but these resolved with aggressive chest PT and expectoration of large mucus plugs. Pt subsequentlt d/c'd to rehab on [**6-29**] to complete his ABx course. . Rehab: Apparently Pt with worsening lung examination and hypoxia with SaO2 66% on unclear O2. . ED Course: Intubated for hypoxic respiratory failure [7.38/68/48] Became hypotensive -> transiently started on Levophed ABx: Levo/Flagyl Past Medical History: 1. Parkinson's 2. chronic aspiration with g-tube 3. AFib on coumadin (had been evaluated by cardiologist in [**12-22**], and it was decided not to place him on coumadin given history of multiple falls, but to rate control him with metoprolol. Had been on sotalol in the past) 4. CAD s/p CABG [**2157**], 4 coronary vein grafts 5. frequent falls 6. GERD 7. Hyperlipidemia 8. Myelodysplastic syndrome 9. Urinary obstruction (?BPH) 10. HTN 11. Antral gastritis 12. malignant melanoma right ear excised 13. multiple polyps (from ascending, transverse and sigmoid colons - hyperplastic tubulovillous adenomas) seen on colonoscopy [**3-/2164**] 14. Restrictive lung disease [**3-21**] to asbestos exposure 15. chronic vit B12 deficiency 16. BPH Social History: Patient lives in a nursing home. Quit smoking in [**2128**] after 20 years. Quit alcohol in [**2154**]. Family History: diabetes in brother Physical Exam: ED -> 98.1, 149/90, 134, 41 90% NRB ICU -> 99.1, 143/73, 162, 100 % (AC 500x20/5/50%) . Gen: intubated and sedated HEENT: PERRL, anicteric, ETT Neck: visible carotid pulsations, no obvious JVD Lungs: course BS thru/o with scattered rhonchi ant. CV: tachycardic, no appreciated m/r/g Abd: soft, nd. g-tube site intact. +BS Ext: No edema, 1+ DP bilaterally, PT not felt SKIN: dry and cool Neuro: sedated Pertinent Results: CXR AP [**7-2**]: 1. Findings consistent with multifocal pneumonia. 2. There is mild pulmonary edema. ECG [**7-2**]: Atrial fibrillation with rapid ventricular response Probable left ventricular hypertrophy Poor R wave progression - could be in part left ventricular hypertrophy but clinical correlation is suggested Nonspecific ST-T wave changes Since previous tracing of [**2165-6-25**], no significant change Moderate pulmonary edema, worse in the right lung, unchanged over the past three days. Small right pleural effusion persists. Heart size normal. Tip of the ET tube at the level of the sternal notch. No pneumothorax. ECHO [**7-4**]: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**2-18**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. No vegetation seen (but cannot exclude). Time Taken Not Noted Log-In Date/Time: [**2165-7-2**] 10:12 pm BLOOD CULTURE AEROBIC BOTTLE (Preliminary): ENTEROCOCCUS SP.. FURTHER IDENTIFICATION TO FOLLOW. PRELIMINARY SENSITIVITY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ R CHLORAMPHENICOL------- S LEVOFLOXACIN---------- R VANCOMYCIN------------ R ANAEROBIC BOTTLE (Preliminary): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 1605 ON [**7-3**].. ENTEROCOCCUS SP.. IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. [**2165-7-3**] 3:04 pm SPUTUM Site: ENDOTRACHEAL GRAM STAIN (Final [**2165-7-3**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | STAPH AUREUS COAG + | | CEFEPIME-------------- 16 I CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- =>16 R MEROPENEM------------- =>16 R PIPERACILLIN---------- 32 S PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ =>16 R ECHO: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**2-18**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. No vegetation seen (but cannot exclude). [**2165-7-2**] 10:10PM GLUCOSE-86 UREA N-10 CREAT-0.5 SODIUM-140 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-35* ANION GAP-11 [**2165-7-2**] 10:10PM CK(CPK)-31* [**2165-7-2**] 10:10PM CK-MB-NotDone cTropnT-<0.0 [**2165-7-2**] 10:10PM WBC-10.0 RBC-3.49* HGB-11.4* HCT-33.8* MCV-97 MCH-32.7* MCHC-33.8 RDW-19.5* [**2165-7-2**] 10:10PM NEUTS-84.7* LYMPHS-10.2* MONOS-4.2 EOS-0.6 BASOS-0.2 [**2165-7-2**] 10:10PM PLT COUNT-381 [**2165-7-2**] 10:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR [**2165-7-2**] 10:10PM URINE RBC->50 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [**2165-7-2**] 08:00PM PO2-48* PCO2-68* PH-7.38 TOTAL CO2-42* BASE XS-11 [**2165-7-2**] 08:00PM LACTATE-1.7 Brief Hospital Course: 83 y/o M with CAD s/p CABG, AF, HTN, Parkinson's and chronic aspiration recently admitted for GIB and PNA who represented from rehab with hypoxic respiratory failure. . [**Hospital Unit Name 153**] Course: started on Vanco and Zosyn Extubated on [**7-4**] with no further resp distress Pressors weaned off on day of [**Hospital Unit Name 153**] admission Grew VRE in [**5-21**] blood cultures, Pseudomonas and MRSA in sputum -> changed to Linezolid and Zosyn PICC pulled TTE showed no vegetations Episodes RVR -> Metoprolol titrate up to 75 [**Hospital1 **] . # Hypoxic respiratory failure: Likely multifactorial, aspiration event vs mucus plug / secretions. Lung function compromised by recent MRSA PNA + Pseudomonal superinfection contributing. - O2 as needed, weaned to room air on the floor - Continued Zosyn for Pseudomonas for 14 day course, [**Date range (1) 66813**] - frequent suctioning, pulmonary toilet, CPT - Midline placed [**7-8**] for the rest of Zosyn course . # Bacteremia: grew VRE in [**5-21**] blood cultures from [**7-3**], repeat surveillance cultures negative, no vegetation on TTE. - d/ced PICC and sent tip for Cx [**7-4**] -> cx NTD - line holiday over the weekend -> placed midline [**7-8**] for the rest of Zosyn course (see above) - continued Linezolid for 2 weeks, [**Date range (1) 34961**] . # A Fib: Continued to titrate up Metoprolol on the floor for episodes of RVR to 120-140s (BP stable, asymptomatic) to 100 mg QID. Has tried Amio in past but recently d/c'd [**3-21**] concerns for side effects given hx of restrictive lung disease. No anti-coagulation given GIB on last admission . # CAD: stable without active ischemia. Continued BB, ASA, statin. . # H/O GIB: In setting of supratherapeutic INR. Currently off Coumadin and Hct stable over admission. Family refused EGD on last admission. - PPI [**Hospital1 **] . # Parkinson Dz: c/b chronic aspiration. Continued Sinemet at outpatient doses. . # FEN: continued TFs . # PPx: Hep SC / PPI / HOB>30' / MRSA precautions . # Full Code . # PCP [**First Name8 (NamePattern2) 2127**] [**Last Name (NamePattern1) 9780**], NP [**Telephone/Fax (3) 66809**] . # Communication: [**Name (NI) **] [**Name (NI) **] (nephew and HCP) [**Telephone/Fax (1) 66810**]; [**Telephone/Fax (1) 66814**] Medications on Admission: 1. Acetaminophen 325 mg Tablet PRN 2. Carbidopa-Levodopa 25-100, 2 Tabs PO TID 3. Ropinirole 1 mg Tablet 1 Tab PO TID 4. Aspirin 81 mg Tablet QD 5. Simvastatin 20 mg Tablet PO HS 6. Lansoprazole 30 mg Susp, [**Hospital1 **] 7. Metoprolol Tartrate 50 mg PO BID 8. Vancomycin 1 gram Intravenous Q 12H for 10 days ([**6-29**]) 9. Levofloxacin 500 mg PO QD for 10 days. ([**6-29**]) 10. Heparin (Porcine) 5,000 Injection TID 11. Vitamin B-12 100 mcg Tablet Sig: One (1) Tablet PO once a day. 12. Neurontin 300 mg Capsule TID 13. Terazosin 2 mg Tablet QHS. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO BID (2 times a day). 5. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 6. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days: through [**2165-7-17**]. 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 10. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 7 days. 11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 12. Cyanocobalamin 1,000 mcg/mL Solution Sig: One Hundred (100) mcg Injection DAILY (Daily). 13. Terazosin 2 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 14. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 38**] Landing Discharge Diagnosis: Primary: 1) Hypoxic Respiratory Failure with intubation, secondary to aspiration, MRSA and Pseudomonal pneumonia 2) VRE Bacteremia presumed from PICC Line infection Secondary: 3) Parkinson's disease with chronic aspiration, s/p G-tube placement 4) dementia 5) delirium 6) Atrial Fibrillation with rapid ventricular response 7) CAD s/p CABG in [**2157**] 8) Restrictive lung disease [**3-21**] to asbestos exposure 9) Hypertension 10) Hyperlipidemia 11) myelodysplasia 12) B12 deficiency 13) BPH Discharge Condition: Improved- breathing comfortably on room air, afebrile for several days Still with waxing and [**Doctor Last Name 688**] mental status, confused with hypophonia attributed to recent intubation. If voice does not improve with time, would consider ENT evaluation. Discharge Instructions: Please call your doctor or go to the ER if you have any fevers, chills, shortness of breath, chest pain, confusion, pain with urination, or any other symptoms that concern you. Followup Instructions: 1) Weekly CBC and LFTs while on linezolid 2) repeat LFTs in one month (mild transaminitis here) 3) Check Thyroid function tests in 1 month 4) condsider head CT if delirium fails to resolve over the next week as the pneumonia and bacteremia/septicema are treated 5) titrate up beta blocker as needed for HR control, to achieve HR less than 100 beats per minute at the minimum. Consider re-initiation of other nodal [**Doctor Last Name 360**] (i.e., sotolol). Avoid amiodarone given history of chronic lung disease. Completed by:[**2165-7-9**]

[ "332.0", "238.7", "V58.61", "518.81", "482.1", "V44.1", "482.41", "266.2", "530.81", "401.9", "427.31", "600.01", "790.7", "V45.81", "996.62", "507.0", "396.3", "272.4", "707.07", "V09.80", "V10.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11846, 11903

7664, 9942

287, 313

12443, 12707

2927, 5358

12932, 13478

2468, 2489

10545, 11823

11924, 12422

9968, 10522

12731, 12909

2504, 2908

5399, 7641

220, 249

341, 1563

1585, 2328

2344, 2452

2,309

125,182

4470

Discharge summary

report

Admission Date: [**2141-2-25**] Discharge Date: [**2141-2-27**] Date of Birth: Sex: F Service: CHIEF COMPLAINT: Fever, mental status changes, and hypertension. HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old female with metastatic breast cancer and malignant pleural effusions, insulin dependent diabetes, and coronary artery disease, status post four vessel CABG presenting with mental status changes, fevers, and hypoxia, and hypotension. She was recently discharged from [**Hospital3 **] status post right sided pleurodesis by Dr. [**Last Name (STitle) **]. The procedure went well. The patient had several episodes of shortness of breath following the procedure attributed the procedure itself, then a question of a parapneumonic effusion. She was given a two week course of levofloxacin which had recently ended. The patient has now had worsening mental status changes x3 days characterized by agitation, confusion. At rehab, she had a positive urinalysis and was started on Vancomycin and gentamicin without worsening dyspnea and sats down to 84% on 3 liters nasal cannula consistent with an arterial blood gas of 7.21/43/162 on FIO2 of 100%. She was brought to the Emergency Department with a temperature of 102.9. Had a negative head CT scan. Put on 100% nonrebreather. Electrocardiogram paced rhythm unchanged, 60. PAST MEDICAL HISTORY: 1. Breast cancer diagnosed in 07/00 with metastases to the spine, femur, lungs, colon, and more. Status post bilateral lung and pleural effusions with pleurodesis. 2. Coronary artery disease status post CABG x4, status post pacer for bradycardia. 3. Insulin dependent-diabetes mellitus with triopathy. 4. Hypercholesterolemia. 5. Carotid disease. ALLERGIES: 1. Ativan. 2. Penicillin. 3. Erythromycin. MEDICATIONS ON ADMISSION: 1. Imdur. 2. Lipitor. 3. Metoprolol. 4. Paxil. 5. Ambien. 6. Epogen. 7. Aspirin. 8. Albuterol. 9. Atrovent. 10. Protonix. 11. Dulcolax. 12. Ativan. 13. Lactulose. 14. Flexeril. 15. NPH. 16. Motrin. 17. Xeloda. PHYSICAL EXAM ON ADMISSION: Temperature of 102.7, heart rate 60 paced, blood pressure 102/60. She is [**Age over 90 **]% on 100% nonrebreather mask. General: Agitated, lethargic when disturbed. HEENT: NCAT. Pinpoint pupils, sluggishly reactive equal, anicteric. OP dry. Neck supple. Lungs: Decreased breath sounds in bases. Cardiovascular: Paced rhythm, distant heart sounds, no murmurs. Abdomen is soft, nondistended, questionable tenderness. Extremities: Bilateral lymphedema with peu d'orange in the skin and lower extremities. Skin: Multiple ecchymoses on shins and ankles bilaterally. Neurologic: Agitated, noncommunicative, moves all extremities, localizes to pain. LABORATORY VALUES ON ADMISSION: White blood cell count 16.6, hematocrit 36.7, platelets 219. Chem-7: 143, 5.8, 110, 18, 29, 2.0, and 469, anion gap of 21. CK of 379, MB of 7, troponin of 4.5. HEAD CT SCAN: Negative. CHEST X-RAY: Obscuration of left heart border, small left pleural effusion, right sided moderate pleural effusion. HOSPITAL COURSE BY SYSTEMS: Patient came in severely ill toxic appearing, not responsive, responsive only to pain needing 100% nonrebreathers to keep sats up. She was DNR/DNI, and in light of her multiple recent hospitalizations and overall downtrending course in the light of metastatic breast cancer and multiple infections, the family had a lengthy discussion about her prognosis, decided to withdraw care, and make the patient comfort measures only. Patient expired shortly after making that decision. All family was present. Patient expired on [**4-29**]. CAUSE OF DEATH: Respiratory arrest secondary to infection and metastatic breast cancer. DISCHARGE DIAGNOSES: 1. Mental status change. 2. Metastatic breast cancer. 3. Pneumonia. 4. Urinary tract infection. 5. Insulin dependent diabetes. Dictated By:[**Last Name (NamePattern1) 1737**] MEDQUIST36 D: [**2141-5-1**] 12:17 T: [**2141-5-5**] 09:23 JOB#: [**Job Number 19153**]

[ "272.0", "276.2", "998.32", "197.2", "198.5", "584.9", "038.9", "486", "410.91" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3744, 4020

1823, 2048

3094, 3723

140, 189

218, 1371

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1393, 1797

23,039

114,032

5589

Discharge summary

report

Admission Date: [**2202-3-15**] Discharge Date: [**2202-3-22**] Date of Birth: [**2143-8-20**] Sex: M Service: MEDICINE Allergies: Vancomycin / Nsaids / Iodine / Versed / Ativan / Haldol Attending:[**First Name3 (LF) 287**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: lumbar puncture History of Present Illness: Mr. [**Known lastname 10653**] is a 58 year-old with history of brittle DM 1, ESRD on HD, h/o tunelled catheter infections, h/o UGIB, h/o VSE septic shoulder initially presented from [**Hospital **] Hospital with Fever, mental status change, and question of stroke/TIA on [**3-15**] admitted to MICU. At [**Location (un) **] patient had elevated blood sugars and fever to 101, hypertensive to 240's. Head CT showed severe atrophy without bleed. He received ceftriaxone, refused LP and was sent to [**Hospital1 **]. On arrival patient agitated, somnolent, arousable to pain; t 100.8, HTN, LP negative. MICU work-up included negative head CT, unchanged MRI, negative TEE for endocarditis. Patient weaned from insulin drip to sliding scale, hypertension controlled initially with IV drips and then switched to po meds, now well-controlled, mental status improved from admission, although still somewhat disoriented, ID work-up revealed no infection and patient is now afebrile off antibiotics. He is transferred to floor on [**2202-3-20**]. Denies specific complaints at this time. Is still confused and unsure if he is in hospital but does know person and date. Family members reports his mental status is signficantly improved. Past Medical History: Recent VSE septic shoulder (right) with HD line infection DM1 for 42 yrs with retinopathy, nephropathy, vasculopathy ESRD on HD (Tues,Thurs,Sat) PVD s/p RF, DP graft. H/o osteomyelitis and L BKA HTN h/o MRSA h/o VRE (from wound cx prior to L BKA) Gastroparesis Depression Hip fx Penile implant Social History: 30 pack year Tob historyLives with wife; wife _very_ supportive of patient and very involved. Wife worked for PCP as medical assistant.No EtOH history. Family History: noncontrib Physical Exam: Physical Exam: (On transfer to the floor) VS: temp: 98 bp 140/80 hr: 86 rr: 20 98% rm air general: pleasant but confused as to where he is, NAD, comfortable, not in any pain HEENT: PERLLA, EOMI, [**Date Range 5674**], op without lesions, no jvd, no carotid bruits lung: minimal crackles at bases heart: RR, S1 and S2 wnl, no m/r/g abd: +b/s, soft, nt, nd extr: multiple distal joint amputations, left bka, right foot with missing toenail, dressed and bottom right foot with approx 4x2 inch area of exposed muscle, well-appearing wihtout evidence of infection, no edema neuro: alert, orineted to person and date, but not place, CNII-XII intact. Good strength in upper extremities, diminished in lower extremities, no sensation below knees. Pertinent Results: Admit labs: [**2202-3-14**] 11:40PM WBC-10.4 RBC-4.44*# HGB-13.3* HCT-40.9 MCV-92 MCH-29.8 MCHC-32.4 RDW-19.2* [**2202-3-14**] 11:40PM NEUTS-82.8* LYMPHS-12.9* MONOS-3.2 EOS-0.3 BASOS-0.8 [**2202-3-14**] 11:40PM PLT COUNT-215 [**2202-3-14**] 11:40PM PT-13.2 PTT-34.9 INR(PT)-1.1 [**2202-3-14**] 11:40PM ALT(SGPT)-10 AST(SGOT)-17 ALK PHOS-80 AMYLASE-46 TOT BILI-0.4 [**2202-3-14**] 11:40PM GLUCOSE-340* UREA N-37* CREAT-5.8* SODIUM-142 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-25 ANION GAP-23* LP: [**2202-3-15**] 02:10AM CEREBROSPINAL FLUID (CSF) PROTEIN-66* GLUCOSE-186 [**2202-3-15**] 02:10AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-3* POLYS-0 LYMPHS-67 MONOS-0 MACROPHAG-33 Cardiac Enzymes: [**2202-3-14**] 11:40PM cTropnT-0.24* [**2202-3-15**] 05:00AM CK(CPK)-461* [**2202-3-15**] 05:00AM CK-MB-8 cTropnT-0.27* [**2202-3-15**] 10:45AM CK(CPK)-1086* [**2202-3-15**] 10:45AM cTropnT-0.26* [**2202-3-15**] 10:45AM CK-MB-11* MB INDX-1.0 [**2202-3-15**] 04:45PM CK(CPK)-990* [**2202-3-15**] 04:45PM CK-MB-10 MB INDX-1.0 cTropnT-0.20* [**2202-3-15**] 11:50PM CK(CPK)-1254* [**2202-3-15**] 11:50PM CK-MB-13* MB INDX-1.0 cTropnT-0.32* Micro 2/27,2/28 [**3-16**] blood negative [**3-15**] CSF negative [**3-15**] echo: 1.The left atrium is normal in size. The left atrium is elongated. 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 root is mildly dilated. The ascending aorta is mildly dilated. 5.The aortic valve leaflets are mildly thickened. A mass is present on the non-coronary cusp of the aortic valve. Can not rule out endocarditis. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7.There is no pericardial effusion. [**3-17**] TEE: The left atrium is normal in size. There is symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta, aortic arch, and the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened (focally thickened non-coronary cusp) but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. [**3-15**] chest x-ray: SUPINE AP VIEW OF THE CHEST: Left subclavian central venous catheter remains in stable and satisfactory position. Heart is normal in size. The mediastinal and hilar contours are unremarkable. The lungs are clear. The pulmonary vascularity is within normal limits. No effusions or pneumothorax demonstrated. Soft tissues and osseous structures are unchanged. IMPRESSION: No acute cardiopulmonary process [**3-16**]-negative head CT [**3-18**]-negative head mr/mra Brief Hospital Course: This is a 58 year-old man with a history of diabetes [**Month/Day (4) **], end stage renal disease on hemodialysis, peripheral [**Month/Day (4) 1106**] disease s/p amputation, bacteremia, who presented to [**Hospital1 18**] with hypertensive emergency, non-ketotic hyperosmolar state, mental status change and fevers and was admitted to MICU. The following issues were addressed on this admission: Concerning his altered mental status: Extensive work up in MICU was largely negative. Patient had negative LP, head CT, unchanged MRI of head, negative infectious work-up including negative cultures and negative TEE for endocarditis as well as largely unrevealing toxic-metabolic work-up. The patient's altered mental status was attributed to his hypertensive emergency and his non-ketotic hyperosmolar state. With sugar control and control of his hypertension, the patient's mental status improved and by discharge was at previous baseline. Concerning his hypertensive emergency: Patient non-compliant with anti-hypertensive regimen before admission. He was noted to have blood pressure to 220's on admission. He was initially placed on IV medications to control blood pressure in the MICU and was transitioned to oral regimen. Oral regimen of lisinopril 20 QID, clonidine 0.2 qid, metroprolol 100 [**Hospital1 **], nifedipine 90 resulted in stable blood pressures generally in the 130's to 150's. He is discharged on this regimen. Concerning his fever: Ultimately unclear etiology. After initial fever, patient defervesced and remained afebrile for the rest of his hospital stay off of antibiotics (last 5 days.) Extensive work-up including LP, TTE, cultures, CXR were negative for infectious source. Discharged off antibiotics with no source of infection. Concerning his hyperosmolar non-ketotic hyperglycemia/DM: The patient never demonstrated evidence of diabetic ketoacidosis. Sugars were controlled initially with aggressive fluids and insulin drip. He was then transitioned to NPH dosing of 10 qAM and 6qPM along with ISS with good glycemic control. Sugars generally in mid 100's to low 200's. Concerning his end-stage renal disease: No acute issues, continued to receive hemodialysis on schedule. Concerning his elevated troponin on admission: Attributed to demand ischemia as well as baseline elevation secondary to his end-stage renal disease. Clean coronaries by cath in [**2200**]. Aspirin was held secondary to patient's history of gastric ulcers. Beta-blockade maintained. EKG's revealed no concerning ischemic changes. Concerning episodes of hematemesis before admission: Patient has history of gastric ulcers, is to have colonoscopy/endoscopy as outpatient. Guiaic positive. Protonix maintained throughout. Patient was full code throughout admission. Heparin subcu and protonix were maintained as prophylaxis. Discharged in stable condition. Patient and family did not desire rehab as patient has upcoming wedding of his daughter and wished to be discharged home and forego consideration of rehabilitation at this time. Medications on Admission: clonidine 0.2, nexium, sertraline 150, nifedipine 90 sr, sucralfate, lisinopril 20 qid, sevalemer 800 [**Hospital1 **], cal acetate, metoprolol 100 [**Hospital1 **], ceftriaxone Discharge Medications: 1. Lisinopril 40 mg Tablet Sig: Two (2) Tablet PO once a day. [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 2. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 3. Clonidine HCl 0.2 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*60 Tablet Sustained Release(s)* Refills:*2* 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: Ten (10) units Subcutaneous every morning. 7. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: Six (6) units Subcutaneous at bedtime. 8. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) Injection as directed: as per sliding scale. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Hyperglycemia, hypertensive emergency, end stage renal disease Discharge Condition: stable Discharge Instructions: Take all medications as prescribed. Contact MD if you have any change in your mental status or experience any chest pain, shortness of breath, fevers or new concerning symptoms. Take all medications as prescribed. Follow-up as below. You should go to dialysis on your usual schedule tomorrow [**3-23**]. Followup Instructions: You must call Dr. [**First Name (STitle) **] and set up an appoinment with him this week. His number is [**Telephone/Fax (1) 22468**]. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] Where: [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] Date/Time:[**2202-9-6**] 11:00 Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **] SURGERY Date/Time:[**2202-9-6**] 11:45 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**] MD, [**MD Number(3) 289**]

[ "411.89", "V15.81", "780.6", "518.82", "531.90", "V49.75", "403.91", "250.21", "250.41" ]

icd9cm

[ [ [] ] ]

[ "88.72", "03.31", "96.6", "38.93", "96.71", "38.91", "39.95", "96.04" ]

icd9pcs

[ [ [] ] ]

10367, 10430

6050, 6473

337, 354

10537, 10545

2905, 3591

10898, 11613

2117, 2129

9345, 10344

10451, 10516

9141, 9322

10569, 10875

2159, 2886

3609, 6027

276, 299

382, 1614

8320, 9115

6489, 8306

1636, 1932

1948, 2101

77,842

170,389

45339

Discharge summary

report

Admission Date: [**2110-8-14**] Discharge Date: [**2110-9-16**] Date of Birth: [**2059-8-5**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 338**] Chief Complaint: severe acute pancreatitis, hypotension, fever to 107 Major Surgical or Invasive Procedure: Arterial line placement x2 LIJ CVL Right IJ HD catheter Left EJ HD catheter History of Present Illness: The patient is a 51 year old female with history significant for diabetes mellitus type 2, hypertension and alcohol abuse, and chronic abdominal pain who was transferred from [**Hospital3 417**] Hospital for further management of severe acute pancreatitis and acute kidney injury. She initially presented to OSH on [**2110-8-13**] with several days of abdominal pain radiating to the back. On arrival to the OSH ED, her vitals were T 98.4, BP 133/100, HR 134, and SpO2 97% on RA. Initial labs showed elevated amylase 183 and lipase 157. Her creatinine was 0.3, WBC 10.5, and Hct 36.6. CT abdomen in the OSH ED showed moderate acute pancreatitis with contiguous inflammation of the duodenem and fatty infiltration of the liver. RUQ US showed no evidence of gallstones. She had several prior ED visits for abdominal pain, with negative workup including colonoscopy, EGD, and abdominal imaging. Prior CTA on [**2110-7-25**] showed no evidence of pancreatitis. She was admitted to the floor and started on IV fluids with NS at 150 ml/hr. . She decompensated overnight, with continued pain despite narcotics, multisystem failure, and multiple lab abnormalities. In the morning, she was found to have a rise in creatinine from 0.3 to 2.0, lipase increasing from 157 to >[**2099**], and hyperglycemia with glucose 400s. She developed respiratory distress around noon. She was transferred to the ICU and intubated. She had a severe metabolic acidosis with pH 6.9 and was started on a bicarb drip. Her creatinine continued to increase to 2.8 in the ICU. Her glucose increased to the 600s with evidence of DKA, and she was started on an Insulin drip. Her lactate rose to 9 and she spiked a fever to 106.2. Her BP dropped to the 60s systolic, and she was started on Norepinephrine. She reportedly received a total of about 6 L of fluids during her OSH stay. She was also treated empirically with Imipenem for possible necrotizing pancreatitis. . Prior to transfer, she was paralyzed for continued ventilation due to being dyssynchronous on the vent and overbreathing. She was on AC with RR 26, PEEP 5, and FiO2 70%. Her most recent ABG was pH 7.09, PCO2 47, and PO2 98. She continued on a bicarb drip, Insulin drip, and Norepinephrine. For access, she had a right subclavian central line. She was transferred to [**Hospital1 18**] by [**Location (un) **]. On arrival to the [**Hospital Ward Name 332**] ICU, she was intubated, sedated, and paralyzed. She was unable to provide any additional history. . Review of systems: Unable to obtain due to patient intubation and sedation. Past Medical History: # Diabetes Mellitus Type 2 # Hypertension # Rheumatoid Arthritis # Alcohol abuse Social History: # Tobacco: Smokes 1 PPD # Alcohol: Unclear alcohol consumption, possibly several drinks daily, but could be significantly more # Illicits: Denies Family History: non contributory Physical Exam: Physical Exam on Admission: Vitals: T 41.6, BP 107/63, HR 151, RR 22, SpO2 93% on 100% FiO2 General: African American female, obese, intubated and sedated HEENT: Sclera anicteric, dry MM, ET tube in place Neck: JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally on anterior exam CV: Regular tachycardia, normal S1 + S2, no murmurs, rubs, gallops Abdomen: midline surgical scar, obese, moderately distended, firm but not tense, bowel sounds present GU: foley in place draining cloudy urine Ext: cool extremities, 1+ pulses, no clubbing, cyanosis, or edema . ==================================================== . Physical Exam on Discharge: VS 96.5 103 117/72 23 100%RA Gen: Off trach mask now, appears comfortable, moving around, slightly agitated. CV: Tachycardic, [**2-16**] holosystolic murmur (not easy to appreciate previously [**2-12**] tachycardia, ventilator noise) Pulm: Lungs clear Abd: Distension improved, improving, mildly tender, + BS Neuro: answers questions, follows simple commands (moves toes, squeezes fingers). Moves all 4 extremities to prompting. Pertinent Results: Labs on Admission: [**2110-8-14**] 09:09PM NEUTS-63 BANDS-6* LYMPHS-26 MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-2* [**2110-8-14**] 09:09PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-NORMAL [**2110-8-14**] 09:09PM PLT SMR-NORMAL PLT COUNT-153 [**2110-8-14**] 09:09PM PT-16.1* PTT-36.4* INR(PT)-1.4* [**2110-8-14**] 09:09PM FIBRINOGE-557* [**2110-8-14**] 09:09PM TRIGLYCER-3950* [**2110-8-14**] 09:09PM ALBUMIN-2.8* CALCIUM-5.6* PHOSPHATE-1.8* MAGNESIUM-1.3* [**2110-8-14**] 09:09PM CK-MB-7 cTropnT-0.01 [**2110-8-14**] 09:09PM LIPASE-2863* [**2110-8-14**] 09:09PM ALT(SGPT)-202* AST(SGOT)-871* LD(LDH)-1630* CK(CPK)-5889* ALK PHOS-80 AMYLASE-589* TOT BILI-0.6 DIR BILI-0.5* INDIR BIL-0.1 [**2110-8-14**] 09:09PM GLUCOSE-235* UREA N-24* CREAT-4.6* SODIUM-145 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-22 ANION GAP-17 [**2110-8-14**] 11:39PM TYPE-ART TEMP-40.2 RATES-24/ TIDAL VOL-400 O2-100 PO2-121* PCO2-90* PH-7.06* TOTAL CO2-27 BASE XS--7 AADO2-514 REQ O2-85INTUBATED-INTUBATED VENT-CONTROLLED [**2110-8-14**] 11:52PM CALCIUM-4.6* PHOSPHATE-1.9* MAGNESIUM-1.1* [**2110-8-14**] 11:52PM GLUCOSE-448* UREA N-23* CREAT-4.8* SODIUM-139 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-25 ANION GAP-17 . Imaging: . CXR portable [**8-14**]: 1. Central line at the cavoatrial junction. 2. Mild pulmonary edema. 3. Left-sided pleural effusion with mild-to-moderate atelectasis. . TTE [**8-15**]: The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast (resting injection only). 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 75%). Left ventricular contractile function appears dyssynchronous. There is a moderate resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality. No gross evidence of intracardiac shunt . CXR [**8-15**]: The lungs are low in volume and show bilateral lower lobe opacities. The cardiomediastinal silhouette is not well evaluated. The hilar contours and pleural surfaces are normal. An ET tube pushes into the right tracheal side wall. An NG tube terminates with its tip in the stomach. A right IJ catheter terminates with its tip in the distal SVC. No pneumothorax is present. A left pleural effusion is small. IMPRESSION: Mild bibasilar opacities could represent pneumonia. Endotracheal tube terminates with its tip against the right tracheal side wall and may be withdrawn. . KUB [**8-19**]: Portions of the right and left abdomen are not included in the field of view provided. Within this limitation, the nasointestinal tube is in postpyloric position. The distal-most portion of the nasointestinal tube noted to be turned on itself within the jejunum with the tip projecting over the expected region of the duodenojejunal junction. A kink is noted. The tube should be pulled back slightly to reposition. . CXR [**8-17**]: Lines and catheters are in appropriate position. Cardiac silhouette, vascularity are normal. There are low lung volumes. There is improving aeration at the left lung base with some residual consolidation or atelectasis. Left costophrenic angle is not included so evaluation for pleural fluid suboptimal. Right lung remains generally clear. IMPRESSION: Improving aeration at the left lung base. . CT head [**8-20**]: There is no acute intracranial hemorrhage, extra-axial collection, or mass effect. The ventricles and sulci are normal in size and configuration. There is periventricular white matter hypodensity, compatible with chronic small vessel ischemia, most prominent adjacent to the frontal [**Doctor Last Name 534**] of the right lateral ventricle. The evaluation of [**Doctor Last Name 352**]-white matter differentiation is somewhat limited by patient motion; however, it appears grossly intact without evidence of large territorial infarct. The orbits are unremarkable bilaterally. The soft tissues are normal in appearance. There are air-fluid levels in the bilateral maxillary sinuses with associated mucosal thickening, consistent with an intubated state. There is opacification of multiple ethmoid air cells as well as the sphenoid sinuses. There is no osseous abnormality. IMPRESSION: 1. Motion limited, without acute intracranial process. 2. Air-fluid levels within the paranasal sinuses consistent with intubated state. ATTENDING NOTE: Due to motion, it is difficult to exclude loss of [**Doctor Last Name 352**]-white matter differentiation. If there is focal neurological deficit and concern for an acute infarct, a repeat CT or MRI can help. No hemorrhage. . CT abdomen/pelvis [**8-20**]: The lung bases have bilateral atelectasis. The liver is homogeneously fatty. The gallbladder appears to have mild gallbladder wall thickening; however, there are no gallstones identified. The wall thickening is likely secondary to fatty liver and pancreatitis rather than acute cholecystitis. Without IV contrast, the evaluation of the kidneys, ureters, spleen, and adrenals is limited; however, with this limitation in mind, these organs are normal. The visualized loops of bowel and colon within the abdomen are unremarkable. There is an NG tube seen extending into the ligament of Treitz. There is extensive pancreatitis visualized in the mesentery and the lesser sac. There is free fluid seen within the pelvis. There are multiple diverticula within the colon with no evidence of diverticulitis. IMPRESSION: 1. Extensive pancreatitis whose characterization is limited without the aid of IV contrast. 2. Bibasilar atelectasis. 3. Fatty liver. 4. Free fluid within the pelvis. . RUQ US [**8-20**]: The liver appears echogenic consistent with fatty infiltration. The main portal vein is patent. Pericholecystic fluid and ascites as well as mild gallbladder wall thickening likely reflecting secondary inflammatory changes due to the acute pancreatitis. There is no evidence of acute cholecystitis. No cholelithiasis is noted. The bile duct measures 0.6 cm. The spleen measures 10 cm and is within normal limits. The visualized pancreas appears slightly swollen with peripancreatic inflammatory changes consistent with known diagnosis of pancreatitis. IMPRESSION: 1. Peripancreatic inflammatory changes consistent with known diagnosis of acute pancreatitis. 2. Echogenic liver consistent with fatty infiltration. Other forms of more advanced liver disease such as hepatic cirrhosis or fibrosis cannot be excluded in this study. 3. Pericholecystic fluid and ascites as well as mild gallbladder wall thickening likely reflecting secondary inflammatory changes due to the acute pancreatitis. . CXR [**8-25**]: FINDINGS: In comparison with the study of [**8-24**], the monitoring and support devices remain in place. Minimal opacification persists at the left base consistent with mild atelectasis and probable small effusion . CXR [**8-29**]: FINDINGS: Tip of the endotracheal tube is 2 cm above the carina with neck in the flexed position. Though the tip of the left internal jugular line appears to be now more medially placed, it may be an apparent finding due to the rotation of the patient. Assessment of the left lower lung is limited because of the multiple external lines and devices obscuring the left lower lung field. Overall the findings are unchanged since [**2110-8-27**]. Both lung volumes remain low. The right lung base atelectasis is stable. There are no newly appearing lung opacities concerning for pneumonic consolidation. . CT sinus/max [**8-30**]: FINDINGS: The patient is intubated and an NG tube is in place. Again noted is opacification of the bilateral sphenoid sinuses. Two mucus retention polyps are seen within the left maxillary sinus. Opacification is noted in multiple ethmoid air cells. The frontal sinuses are clear. There is no osseous destructive change. The mastoid air cells are opacified bilaterally. The visualized portions of the orbits are unremarkable. There is no soft tissue abnormality. The visualized intracranial structures are unremarkable. IMPRESSION: Opacification of the paranasal sinuses, unchanged when compared with [**2110-8-20**], consistent with intubated state. There is no osseous destructive change to suggest an aggressive sinusitis. . CT abdomen/pelvis/chest [**8-30**]: 1. Evolving acute pancreatitis with widespread early organization of fluid collections with rim enhancement, primarily retroperitoneal. These may be areas of early organizing extrapancreatic fat necrosis or pseudocysts. However, there is no evidence for parenchymal pancreatic necrosis. 2. Delayed contrast excretion by the kidneys bilaterally represents underlying renal dysfunction, consistent with history of hemodialysis. 3. Right basilar opacification is most likely related to atelectasis, though superimposed infection is not excluded. 4. Sigmoid diverticula, without evidence of diverticulitis . US left sided neck veins [**9-3**]: IMPRESSION: Occlusive deep venous thrombosis involving the left internal jugular vein. The proximal aspect of the left internal jugular vein was not visualized secondary to overlying bandages. . CXR [**9-6**]: FINDINGS: As compared to the previous radiograph, the lungs have improved ventilation. Pre-existing opacities in the perihilar and the basal lung zoneshave almost completely resolved. Unchanged position of the monitoring andsupport devices. No evidence of pleural effusions. . TTE [**9-8**]: Focused study. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. 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 borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . MRI head [**2110-9-11**]: 1. Multiple FLAIR/T2 hyperintense lesions seen throughout the periventricular and deep subcortical white matter. Nonspecific though can represent small vessel ischemic disease or inflammatory/demyelinating disease. 2. Opacification of the mastoid air cells bilaterally, could represent fluid within mastoid air cells. . CXR: [**2110-9-11**] Minimal interval worsening of the right lung base atelectasis, whereas on the left side is unchanged. Pleural effusions if any are minimal bilaterally. . CXR: [**2110-9-12**] The NG tube is in the stomach, in good position. There is obscuration of the left CP angle, some of which could be due to overlying soft tissues but there is probably also small effusion in that region. The right PICC line, tracheostomy, dialysis catheter are unchanged. There are some other areas of streaky atelectasis in the left lower lobe. Other than the left lower lobe the lungs are clear. . CT Abd/Pelvis [**2110-9-12**]: 1. Persistently extensive peripancreatic stranding with increased amount of ascites pooling in the mesocolon and bilateral paracolic gutters. Identification of discrete organized collection is difficult without intravenous contrast. 2. Decreased right basilar atelectasis. 3. Sigmoid diverticulosis. . . Labs on Discharge: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2110-9-16**] 03:24 12.3* 3.16* 8.6* 25.6* 81* 27.2 33.6 16.1* 296 BASIC COAGULATION (PT, PTT, INR) 15.9* 93.4* 1.4* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2110-9-16**] 03:24 1001 103* 7.1* 129*2 4.4 83* 20* 30* ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2110-9-16**] 03:24 60* 73* 401* 188* 0.9 Calcium Phos Mg 9.9 10.9* 2.8* Brief Hospital Course: Primary Reason for Hospitalization: 51 year old female with history of diabetes mellitus type 2, hypertension, rheumatoid arthritis, and chronic abdominal pain who was transferred from [**Hospital3 417**] Hospital for further management of severe acute pancreatitis, respiratory failure, transaminitis and acute kidney injury. . Active Diagnoses: # Acute Pancreatitis: She initially presented to OSH with evidence of pancreatitis on labs and imaging and was initially stable. She decompensated overnight with rapid worsening of her pancreatitis and multisystem failure requiring intubation. Differential for cause of pancreatitis included EtOH abuse and hyperTGs (TGs ~4000 on admission, trended down to 1700) although PCP records revealed she does not have a history of hypertriglyceridemia. Patient was treated with aggressive fluid resuscitation. Antibiotics were deferred given recent studies have demonstrated that this would not be beneficial. Several days into the the hospital course, patient developed bladder pressures to the high 20s. General surgery was consulted to discuss the possibility of decompression. Surgery stated that decompression would be a futile procedure since bladder pressures would go back up shortly after decompression. Another option would be to leave the abdomen open, but this would have a high risk of infection. After discussion with family, decompression was deferred and bladder pressures trended down on their own. Since patient remained intubated for a prolonged period of time, she was started on TPN for nutrition. She was then transitioned gradually to tube feeds and TPN was stopped. Currently, patient is able to tolerate PO and has been eating well the past couple of days. . # Hypoxic, hypercarbic respiratory failure: She developed respiratory distress at OSH was was intubated in the setting of her multisystem failure. She was dyssynchronous on the vent and neuromuscular blockade was initiated for transport. On arrival here, she was ventilated off paralytics, but had continued difficulty with dyssynchronous respiration and ABG showing pH 7.08, PCO2 95, and pO2 106. Neuromuscular blockade was resumed with improvement in her ventilation. Patient was sedated with Fentanyl and Versed. Hypercarbia most likely due to hypoventilation and increased CO2 production. Aa gradient of >500, with PaO2:FiO2 100-130 suggested ARDS, which was supported by her CXR. Given ARDS, ventilated by ARDSnet protocol with low Vt and high PEEPs. An esophageal balloon was placed to help adjust level of PEEP. She remained intubated for approximately 2 weeks of her course and ventilatory settings were weaned gradually. With suctioning, patient often became vasovagal with HR decreasing drastically, down to low 60s. Given hemodynamic instability with manipulation of airway, patient was taken to the OR for tracheostomy placement rather than having this procedure done at bedside. Patient tolerated tracheostomy well and within days was weaned off the vent with sats in the high 90s on tracheostomy mask. Since then, patient had improved and is satting at 100%RA. Her trach tube was downsized to a 6.0 and patient is able to speak and also eat solid foods. She will need to follow up with Interventional Pulmonology and have the tube removed once she's more healed and stable. . L IJ thrombosis: Patient's L IJ hemodialysis line was thrombosed and she was started on anticoagulation. Patient was started on heparin drip and coumadin PO as well. She is subtherapeutic on Coumadin at this point and will need heparin bridging as well as frequent INR checks to make sure that patient remains therapeutic. She will need anticoagulation for at least 3 more months and will need to be reassessed at that time by her PCP for whether or not she will need to continue more anticoagulation. . # Hypotension: Was likely due to volume depletion due to third spacing initially, with component of septic shock. Volume resuscitated patient aggressively on admission, and she transiently required blood pressure support with norepinephrine. Pressors were weaned and discontinued early in the hospital stay. She remained normotensive with heart rates ranging from 90s to 120 sinus rhythm. . # Acute Kidney Injury: Her creatinine was 0.3 on OSH presentation, but acutely rose to 2.0 and then 2.8 prior to transfer. On arrival, her creatinine was 4.6 and rose to 5.5 by the morning. Patinet had pre-renal [**Last Name (un) **] which quickly progressed to ATN. She was anuric during the first 2 weeks of admission. Patient was initially started on CVVH and then transitioned to HD. All medications were renally dosed. She gradually began to have some urine output, though minimal, approx 10cc/hr. Plans for long term HD were discussed with family who agreed. Plan for M/W/F hemodialysis. . #Transaminitis: Patient p/w transaminitis and elevation of LFTs to the 1000s. This was thought to be secondary to volume depletion/septic shock and hypoperfusion. With hydration and resolution of septic shock, LFTs trended down gradually but did not fully normalize. CK halfway through the hospital course returned at [**Numeric Identifier 96825**], raising concern for rhabdo contributing to the elevated LFT picture. This was treated with continued CVVH and then HD. CK's trended down and on last check was 285. On discharge, LFTs were stable an notatble for mild transaminitis (AST/ALT 60-70s) and elevated alk phos (188). Would recommend continuing to following this several times weekly at discharge. . #Hyperglycemia: Patient was hyperglycemic on admission with FSBG up to high 400s. This was secondary to underlying DM II as well as severe pancreatitis and inability of pancreas to produce insulin. Initially, patient was on insulin gtt but eventually the gtt was stopped and she was on an insulin sliding scale for glucose control. She should be continued on sliding scale per protocol, which is attached. . #Ventilator associated pneumonia: Patient had 2 bouts of ventilator associated pneumonia. During the first episode, sputum culture grew out pan sensitive Klebsiella and was treated with first Cefepime/Vancomycin and then just Ceftriaxone once sensitivities of sputum cultures were known. Second time, VPA based on chest x ray and was treated with Vancomycin/Cefepime/Ciprofloxacin for 8 days, which she has completed. . #Anemia: Patient had periodically low Hct likely in the setting of sepsis as well as exacerbated by renal failure and necessity of frequent blood draws. Patient was transfused with PRBCs periodically throughout admission, less frequently towards end of admission. Her Hematocrit remains in the mid 20's at this point and today was 25. . #Positive line tip cultures: Patient had coagulase negative streptococcus grow out from A line tip and LIJ CVL tip. However, she never had positive blood cultures and thus was not bacteremic. Based on these cultures, Vancomycin started for VAP was continued to complete a 14 day course of treatment. . # Hyperthermia: She had extreme fever to 106.9 on arrival and was treated with Tylenol IV and cooling blankets. Fever thought to be [**2-12**] inflammation from pancreatitis and trended down with initiation of CVVH (see above). Patient did have several infections throughout hospital course including 2 bouts of ventilator associated pneumonia, and coag negative staph on blood cultures from A-line on [**8-29**] and IJ tip catheter on [**9-3**]. Toward the end of the patient's hospitalization, fever curve was improving and the patient was afebrile at the time of discharge. . #Hyponatremia: Her sodium was trending down at discharge from 132 to 129. Would recommend following this closely and checking urine lytes. . #Agitation: She was started on started on Olanzapine 5mg [**Hospital1 **] with improvement in agitated delirium. Medications on Admission: Home Medications: Hydrochlorothiazide 25 mg PO daily Cyclobenzaprine 10 mg PO QHS Nabumetone 750 mg PO BID Metoprolol succinate 100 mg PO daily Amlodipine 5 mg PO daily Fluticasone 50 mcg nasal spray Transfer Medications: Imipenem 250 mg IV Q6H (last dose 8/4 1846) Amlodipine 5 mg PO daily ([**8-14**] 0817) Metoprolol 50mg PO BID ([**8-14**] 1000 not given) Acetaminophen 1000 mg once ([**8-14**] 1743) Insulin gtt 4 units/hr Midazolam gtt Fentanyl gtt Morphine 2 mg ([**8-14**] 0136) Dilaudid 0.5-2 mg ([**8-14**] 1149) Zofran 4 mg IV Q6H PRN nausea Heparin 5000 units SC Q8H ([**8-14**] 1850 not given) Pantoprazole 40 mg IV Q12H ([**8-14**] 0814) Calcium gluconate ([**8-14**] 1619 and [**8-14**] 1754) . Allergies: NKDA Discharge Medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-12**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for firm stools: please hold for loose stools. 3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheeze. 5. aluminum hydroxide gel 600 mg/5 mL Suspension Sig: Ten (10) ML PO Q6H (every 6 hours). 6. B-complex with vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. insulin lispro 100 unit/mL Solution Sig: per ss units Subcutaneous four times a day: please administer via Insulin Sliding Scale; please see attached; may not need as patient improves clinically. 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. heparin (porcine) in NS 10,000 unit/1,000 mL Parenteral Solution Sig: as directed, per protocol, to titrate of PTT 60-80 Intravenous per protocol, please see attached.: please see attached protocol; until therapeutic INR reached. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Pancreatitis Respiratory Failure Acute Renal Failure Rhabdomyolysis Ventilator Associated Pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted for pancreatitis, a severe infection of your pancreas, likely a result from alcohol abuse. Should you continue to abuse alcohol, this infection is likely to recur. The pancreatitis was so severe that it led to many other complications such as acute renal failure, muscle breakdown, respiratory failure leading to having a machine help you breathe, and pneumonia. You had made remarkable improvement with all of these complications and are now doing quite well. You continue to have a tracheostomy tube down your throat and will need to have that removed in the near future. In the mean time, you will be going to [**Hospital1 **] Rehabilitation Center to regain your strength. You will also continue to have outpatient dialysis three times a week until your kidney functions returns to baseline. . During your stay, we found that you developed a blood clot in your neck, for which you are to use a blood thinner, coumadin. This medication requires frequent monitoring (blood tests) to make sure that the dose you are taking are rendering the desired effects. It is very important that you have this monitored by your PCP. . We wish you a speedy recovery and hope that you are able to return home soon. Followup Instructions: Please follow up with your PCP (Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 10216**]) in 1 week following your rehab stay. The rehab should help you coordinate an appointment. Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE Location: [**Hospital **] [**Hospital **] HEALTH CENTER Address: [**Location (un) 10215**], [**Hospital1 **],[**Numeric Identifier 9647**] Phone: [**Telephone/Fax (1) 10216**] **Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge** Name: [**Last Name (LF) **], [**Name8 (MD) **] MD Location: [**Hospital1 18**] - DIVISION OF PULMONARY MEDICINE Address: [**Location (un) **], [**Hospital1 **] 116, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3020**] **We are working on a follow up appointment with Dr. [**Last Name (STitle) **] within 1 week. If you have not heard from the office within 2 days or have any questions, please call the number above.**

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39667

Discharge summary

report

Admission Date: [**2104-8-1**] Discharge Date: [**2104-8-10**] Date of Birth: [**2029-5-17**] Sex: M Service: CARDIOTHORACIC Allergies: Morphine Attending:[**First Name3 (LF) 165**] Chief Complaint: Shortness of breath with exertion Major Surgical or Invasive Procedure: [**8-5**] Coronary Artery Bypass Graft x 4 History of Present Illness: Patient is a 75-year-old male with history of PE on Coumadin, HL, polycythmia that presents with new onset solitary dyspnea on exertion in the past few weeks with no associated chest pain, orthopnea, PND, or lightheadedness. He has had lower extremity edema for the past ten years for which he takes Lasix. He usually is able to do activities without any issues. A stress ECHO was performed by his outpatient cardiology with inferior depressions with dyspnea on exertion. In addition, distal septum and apex hypokinesis were noted. He was transferred to [**Hospital1 18**] for cath and found to have three vessel disease (see report for full details). . Cardiac surgery was consulted for evaluation of patient for CABG. He received 600 mg of Plavix today at cath in addition to ASA. Past Medical History: Polycythemia s/p phlebotomy q 3 months- last phlebotomy 2 weeks ago per patient Glucose Intolerance Hypothyroidism Lymphedema Pulmonary Embolus [**2092**] after DVT of Right popliteal vein Arthritis left shoulder Bladder CA [**09**] years ago Right knee torn ligaments Dyslipidemia Past Surgical History: s/p laminectomy in setting of Cauda Equina syndrome [**2084**] s/p Right carpal tunnel release 10 years ago s/p bladder surgery for malignancy Social History: Patient lives with wife and is retired [**Doctor Last Name 9808**] operator. He quit smoking 20 years ago with 1.5 ppd x 30 years. Occ EtOH, no recreational drugs. Family History: Son died age 22 SCD(autopsy showed enlarged heart) Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: VS - T 96.0 BP 117/66 P 55 SpO2 98 RA Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with no apparent JVD CV: PMI not palpable. RR, normal S1, S2. Heart sounds distant. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c. No femoral bruits. 1+ pretibial edema bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Rectal: Hemoccult negative, stool in vault Pertinent Results: [**2104-8-10**] 04:56AM BLOOD WBC-7.3 RBC-3.35* Hgb-9.9* Hct-29.3* MCV-88 MCH-29.6 MCHC-33.8 RDW-16.7* Plt Ct-156 [**2104-8-10**] 04:56AM BLOOD PT-13.9* PTT-26.4 INR(PT)-1.2* [**2104-8-5**] 01:56PM BLOOD PT-14.5* PTT-42.3* INR(PT)-1.3* [**2104-8-10**] 04:56AM BLOOD Glucose-102* UreaN-17 Creat-1.1 Na-140 K-3.9 Cl-105 HCO3-28 AnGap-11 [**2104-8-9**] 03:40AM BLOOD Glucose-114* UreaN-18 Creat-1.1 Na-137 K-3.9 Cl-102 HCO3-28 AnGap-11 [**2104-8-2**] 04:11AM BLOOD ALT-17 AST-17 LD(LDH)-157 AlkPhos-106 TotBili-0.6 Intra-op TEE [**2104-8-5**] PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. There are complex (mobile) atheroma in the descending aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post_Bypass: Normal RV systolic function. LVEF 55%. Intact thoracic aorta. Minimal MR. [**First Name (Titles) 5544**] [**Last Name (Titles) **]. Brief Hospital Course: BRIEF HOSPITAL COURSE (PRE-CABG): Patient is a 75-year-old male with history of PE on Coumadin, HL, polycythmia that presented new onset dyspnea on exertion over the past two weeks. The patient underwent cardiac catheterization after an abnormal stress test at an outside facility. Cardiac cath showed three vessel coronary artery disease, and the patient was evaluated by the cardiac surgery service for CABG. The patient received vein mapping and ECHO during the pre-operative evaluation process. ECHO showed findings consistent with longstanding hypertension. The patient was deemed a candidate for CABG, and underwent the procedure on [**2104-8-5**]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis, given the pre-operative stay of greater than 24 hours. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He developed atrial fibrillation for which he received amiodarone, and lopressor was titrated. Coumadin was resumed for a history of PE and DVT. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. Foley was re-inserted for urinary retention. The patient does have a history of bladder cancer and frequently catheterizes himself at home. The foley is discontinued prior to discharge with instructions to self-cath prn. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home with VNA and PT home services as well as a rolling walker. He is in good condition and is given appropriate follow up instructions. Medications on Admission: Coumadin 5mg/2.5mg alternating depending on INR Lipitor 20mg PO daily Levothyroxine 150mcg PO daily Gabapentin 100mg po daily Furosemide 20mg po daily ASA 81mg po daily Percocet PRN leg pain Plavix - last dose:600mg [**2104-8-1**] Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication a-fib Goal INR [**2-6**] First draw day after discharge Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [**Last Name (STitle) 10543**] Results to phone [**Telephone/Fax (1) 4475**] 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day: 40mg daily x 1 week, then 20mg daily until further instructed. Disp:*60 Tablet(s)* Refills:*2* 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day: 40mEq daily x 1 week, then 20mEq daily until further instructed. Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. 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 until further instructed. Disp:*120 Tablet(s)* Refills:*2* 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: dose to change daily for goal INR [**2-6**], Dr. [**Last Name (STitle) 10543**] to resume management. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 86**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Past medical history: Hyperlipidemia Polycythemia s/p phlebotomy q 3 months- last phlebotomy 2 weeks ago per patient Glucose Intolerance Hypothyroidism Lymphedema Pulmonary Embolus [**2092**] after DVT of Right popliteal vein Arthritis left shoulder Bladder CA [**09**] years ago Right knee torn ligaments Past Surgical History: s/p laminectomy in setting of Cauda Equina syndrome [**2084**] s/p Right carpal tunnel release 10 years ago s/p bladder surgery for malignancy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait (using rolling walker) Incisional pain managed with dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 2+ bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) Septemeber 13, [**2104**] at 1:15PM Please call to schedule appointments with your Cardiologist/Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] in [**1-5**] 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** Labs: PT/INR for Coumadin ?????? indication a-fib Goal INR [**2-6**] First draw day after discharge Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [**Last Name (STitle) 10543**] Results to phone [**Telephone/Fax (1) 4475**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2104-8-10**]

[ "V10.51", "V12.51", "272.4", "790.29", "E878.2", "459.81", "788.20", "414.01", "427.31", "244.9", "289.0", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "38.93", "88.56", "39.61", "36.13", "37.22", "36.15" ]

icd9pcs

[ [ [] ] ]

8372, 8432

4254, 6386

307, 351

9008, 9267

2673, 4231

10104, 10992

1831, 1883

6667, 8349

8453, 8514

6412, 6644

9291, 10081

8843, 8987

1898, 1919

234, 269

379, 1163

1933, 2654

8536, 8820

1650, 1815

13,837

163,839

10873

Discharge summary

report

Admission Date: [**2163-2-12**] Discharge Date: [**2163-2-16**] Date of Birth: [**2086-7-12**] Sex: F Service: MEDICINE Allergies: Colchicine / Atorvastatin / Cinacalcet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: 76 year old woman with type 2 DM complicated by ESRD on HD, hypertension/hyperlipidemia, CHF (EF 30-40% in [**3-/2162**]), severe AS, sarcoidosis who presented to ED with respiratory distress. Patient describes feeling "weak" and acutely short of breath around 2 am which lasted approximately 2 hours. She describes associated nausea, no vomiting. Denies chest pain, jaw or arm pain. Denies cough, fever, chills. Denies recent increase in fluid intake or decrease in fluid removal at [**Year (4 digits) 2286**]. Denies increase in lower extremity edema. Reports baseline orthopnea and PND - no change recently. . Documentation from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] reports patient not feeling well with shortness of breath at 3am - VS T 97.2, BP 80/53, HR 103, RR 24, O2 Sat 94% 2 L - reported appearing diaphoritic with FS 257. EMS documented BP 172/88, O2 Sat high 70s, speaking in short sentances and working to breath. On arrival to the ED patient required NRB with T 97.8, HR 97, BP 160/125, RR 28. Patient hypertensive during ED stay ranging 159-198/95-115. She had peaked T waves on EKG consequently received calcium, dextrose and insulin. Femoral line was needed to be placed for labs and notable for K 4.5, Creatinine 4.5, BNP [**Numeric Identifier 35408**], HCT 27.1 (baseline 27) and lactate 1.5. CXR revealed hazy opacity right lung base suggestive of atelactasis and prominent mediastinum suggesting volume overload. Patient was treated with albuterol. Due to continued respiratory distress required BiPap. On transfer vitals HR 85 RR 16 BP 173/78 100% BiPap (settings FiO2 30%, [**1-16**]). . On arrival to ICU patient reports feeling well andn denies any shortness of breath, weakness or chest pain. She is on 3 L NC on arrival. . Of note, patient has had several admissions to the hospital, most recently discharged [**2163-1-31**] for syncope felt to be secondary to severe AS. For concern of bactermia patient was discharged on Vancomycin for 14 days which was completed [**2163-2-10**] however no blood cultures were ever positive. Patient also had a recent ICU stay [**2163-1-18**] for LGIB felt to be secondary to a diverticular bleed. . ROS (+) Per HPI (-) Denies fever, chills. Denies headache, cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea. Past Medical History: * Dyslipidemia/hypertension - coronary artery disease on aspirin * Hypertension * Complicated proximal humerus fracture ([**6-/2161**]) * Cerebral hypoperfusion: Evidence of multifocal previous strokes despite aspirin - clopidogrel added [**3-/2162**] * Post polypectomy bleed admitted on [**4-24**] for BRBPR and LGI bleed [**1-/2163**] with further non-bleeding polyps [**1-14**] * ESRD on HD: Tues, Thurs, Sat at [**Location (un) **]. * CHF: ECHO [**2162-3-25**]: EF 30-40%. LVH ([**Month/Day/Year 1192**], and diastolic dysfunction) * Type 2 DM: diagnosed >40 years ago, complicated by ESRD, controlled on insulin * Sarcoidosis with ocular involvement: seen every 3 months for eye exam - not biopsy proven * Gout: last flair [**10-18**]; usually occurs in R toes * Knee surgery s/p fall * Obstructive sleep apnea: [**2161-8-12**] sleep study shows [**Year (4 digits) 1192**] obstructive sleep apnea consisting mainly of hypopneas that produced substantial drops in oxygen saturation. She refuses CPAP. . Previous operations . Op left knee with ligamentous injury R hand op Previous R fistula but not working so R tunnelled line was placed No problems with GA Social History: Currently resides at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] ([**Hospital3 **]) after L arm fracture, previously lived with her daughter. Retired [**Hospital3 1810**] billing clerk Ambulatory with waljer and at tines uses wheelchair No smoking history, No alcohol intake. Denies illicit drugs. No pets. No recent foreign travel. Family History: Mother - HTN and "blocked neck artery" Father - died young Sibs - Type 2 Diabetes mellitus, hypertension. Maternal uncle/aunt CVA and IHD. No FH ca. Physical Exam: VS: Temp: 98.4 BP:186/84 HR:95 RR:22 O2sat99% on 1 L GEN: Pleasant, comfortable, NAD HEENT: MMM, oro/nasopharynx clear, JVD at mandible. RESP: Shallow breath sounds throughout with mild wheezes. CV: RRR, S1 and S2 wnl, no r/g, RUSB --> apex holosystolic blowing murmur, right sided HD catheter c/d/i w/o TTP or erythema ABD: nd, +b/s, soft, nt, no palpable masses EXT: no c/c/e, RUE AV fistula c/d/i SKIN: No rashes/lesions NEURO: AAOx3. CN II-XII intact. Strength and sensation grossly intact Pertinent Results: Admission labs: [**2163-2-12**] 05:15AM BLOOD WBC-8.7 RBC-2.82* Hgb-8.5* Hct-27.1* MCV-96 MCH-30.2 MCHC-31.4 RDW-17.3* Plt Ct-229 [**2163-2-12**] 05:15AM BLOOD Neuts-65.6 Lymphs-12.4* Monos-3.7 Eos-18.2* Baso-0.1 [**2163-2-12**] 05:15AM BLOOD Glucose-300* UreaN-40* Creat-5.2* Na-140 K-4.5 Cl-97 HCO3-32 AnGap-16 [**2163-2-12**] 02:04PM BLOOD CK(CPK)-37 [**2163-2-12**] 05:15AM BLOOD Calcium-9.9 Phos-3.9 Mg-2.3 . Other labs: [**2163-2-12**] 02:04PM BLOOD CK(CPK)-37 [**2163-2-12**] 11:59PM BLOOD CK(CPK)-32 [**2163-2-12**] 05:15AM BLOOD proBNP-[**Numeric Identifier 35408**]* [**2163-2-12**] 05:15AM BLOOD cTropnT-0.08* [**2163-2-12**] 02:04PM BLOOD CK-MB-3 cTropnT-0.11* [**2163-2-12**] 11:59PM BLOOD CK-MB-3 cTropnT-0.13*\ . . Microbiology: BC [**2-12**] pending . . Radiology: . XR CHEST (PORTABLE AP) Study Date of [**2163-2-12**] 4:23 AM FINDINGS: Single portable upright chest radiograph was obtained. The study is extremely limited due to patient motion. A right internal jugular central [**Date Range 2286**] catheter ends at the right atrium. Cardiomediastinal contours are stable. There is a hazy opacity overlying the right lung base, which may represent atelectasis. No left pleural effusions or pneumothorax is identified. A small rigth pleural effusion may be present. Prominence of the vascular interstitium suggests a mild degree of volume overload. IMPRESSION: Extremely limited study. Possible right basal atelectasis and mild volume overload. . XR CHEST (PORTABLE AP) Study Date of [**2163-2-13**] 5:31 AM FINDINGS: Comparison is made to previous study from [**2163-2-12**]. There is cardiomegaly, which is stable. There is a right-sided central venous catheter with distal lead tip in the right atrium. There is mild prominence of pulmonary interstitial markings, consistent with pulmonary edema. There is a left retrocardiac opacity and small bilateral pleural effusions. No pneumothoraces are identified. Overall, the findings are likely unchanged allowing for patient motion. Discharge Labs: [**2163-2-16**] 05:15AM BLOOD WBC-8.4 RBC-3.09* Hgb-9.4* Hct-30.1* MCV-97 MCH-30.5 MCHC-31.3 RDW-17.6* Plt Ct-247 [**2163-2-16**] 05:15AM BLOOD Glucose-109* UreaN-20 Creat-4.0*# Na-144 K-4.4 Cl-97 HCO3-39* AnGap-12 [**2163-2-15**] 02:12AM BLOOD Calcium-9.5 Phos-4.5 Mg-2.7* Brief Hospital Course: 76 year old woman w/ CAD on ASA/Plavix, ESRD on HD, type 2 DM, severe AS who presents with acute episode of shortness of breath requiring BiPap in the emergency department. . # Respiratory distress: Patient was treated initially with BiPAP in the emergency department. She spent one night in the ICU with BiPAP which was able to be weaned off without difficulty and she was weaned down to to 1-2L nasal cannula by time of discharge with O2 Saturation in the mid 90s range. Patient tolerated room air without difficulty, but was kept on nasal cannula for comfort. Respiratory distress was felt to be secondary to combination of poor physiological compensation with severe aortic stenosis in the setting of flash pulmonary edema due to rising hypertension and elevated heart rates. Heart rate controlled with carvedilol and BiPAP intervention. Also had better blood pressure control after continued [**Year/Month/Day 2286**] fluid removal and losartan therapy. She will continue on losartan and carvedilol at discharge. . # Aortic Stenosis: Progression from mild to severe aortic stenosis in recent months with clinical decline and sensitivity to drops in pre-load volume with her [**Year/Month/Day 2286**] sessions has made management especially challenging. Patient was seen and evaluated by cardiologist Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] who helped communicate to patient and family that future surgical interventions for aortic stenosis would not be feasible. Additional cardiac medications with [**Last Name (un) **], beta blocker continued as above. . # Goals of care - Discussions were held between HCP, Dr. [**Last Name (STitle) **] (nephrologist) and Palliative Care. Patient and HCP both feel that they want to continue with HD and feel that quality of life is good enough to continue with it. She remains FULL CODE and wishes to continue on until "god feels her time is up". . # ESRD on HD: Continued with hemodialysis per home schedule. . # Hypertension: Remained normotensive for majority of stay after initial hypertension on hospital day one. Controlled with medications and HD . # Type 2 Diabetes Mellitus: Was continued on sliding scale plus AM NPH. Because of 2 episodes of asymptomatic hypoglycemia (to 40s), the sliding scale was decreased. The patient responded well to supplemental glucose. Medications on Admission: carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). - senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). - simvastatin 40 mg qhs - allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). - aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). - clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). - sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). - insulin NPH & regular human 100 unit/mL (70-30) Cartridge Sig: as per regimen Subcutaneous once a day: Insulin sliding scale in addition to NPH 14 unit sin am. - acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. - Lumigan 0.03 % Drops Sig: One (1) drop Ophthalmic at bedtime: Both eyes. - Avapro 150 mg Tablet Sig: One (1) Tablet PO at bedtime. - polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO BID (2 times a day). - docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for contipation. 11. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for pruritus. 12. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 14. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO BID (2 times a day). 17. insulin NPH & regular human 100 unit/mL (70-30) Cartridge Sig: One (1) Subcutaneous once a day: as per regimen Subcutaneous once a day: Insulin sliding scale in addition to NPH 14 unit sin am. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Primary diagnoses: - Flash pulmonary edema - End stage renal failure Secondary diagnoses: - Aortic stenosis - Diabetes mellitus - Carotid stenosis - 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. Discharge Instructions: It was a pleasure taking care of you. You were seen in the hospital for shortness of breath secondary to flash pulmonary edema from fluid retention related to renal failure and worsening aortic stenosis. You were treated with BiPap face oxygen in the ED, hemodialysis to remove excess fluid, and your home blood pressure medications for congestive heart failure. You tolerated hemodialysis without difficulty, and your breathing improved considerably. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2163-2-17**] 7:30 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2163-2-18**] 10:30 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 16956**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2163-2-25**] 11:00 Completed by:[**2163-2-17**]

[ "274.9", "585.6", "428.23", "272.4", "425.4", "424.1", "403.91", "V66.7", "294.8", "135", "428.0", "564.00", "327.23", "V58.67", "250.40", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

12478, 12600

7299, 9658

320, 326

12801, 12801

4979, 4979

13453, 13815

4299, 4449

10864, 12455

12621, 12691

9685, 10841

12977, 13430

7001, 7276

4464, 4960

12712, 12780

260, 282

354, 2720

4995, 5393

12816, 12953

2742, 3906

3922, 4283

5406, 6985

9,821

151,942

17664

Discharge summary

report

Admission Date: [**2193-6-18**] Discharge Date: [**2193-7-2**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea, mitral regurgitation, atrial fibrillation Major Surgical or Invasive Procedure: [**2193-6-21**] MVR (27mm [**Last Name (un) **] [**Doctor Last Name **] [**Doctor Last Name 49168**] prosthesis) and MAZE. [**2193-6-18**] Cardiac Catheterization and IABP placement. History of Present Illness: 82 year old man with a 1 year history of mitral regurgitation/ partial flail mitral leaflet. He states that he has had chronic dyspnea on exertion, although over the past month or so it has become significantly pronounced associated with PND/orthopnea. He recently went to see his primary physician who found him to be in atrial fibrillation and started coumadin. On [**2193-6-11**] he was admitted to [**Hospital 18**] [**Hospital 620**] Campus for CHF exacerbation. He ruled out for an MI. [**2193-6-12**] echo: Mild LA enlargement, moderately dilated RA, mild symmetric LVH with an EF 35-40%. Moderately dilated RV cavity. Trace AI, 4+ MR with a torn mitral chordae, mild MVP, 2+ TR. Severe pulmonary hypertension noted. [**2193-6-13**] Persantine ETT: ventricular couplets noted at peak heart rate. The preliminary [**Location (un) 1131**] was reported as a fixed mild lateral defect as well as a fixed mild inferior defect- EF 48%. The patient states that he has felt somewhat better over the past two days. Yesterday he was able to do light chores around the house. Earlier in the week he was finding it enormously difficult to sleep due to severe orthopnea/PND. He denies any significant history of chest discomfort or palpitations. In cath lab [**2193-6-18**], RHC revealed RA 17, RV 80/17, PA 80/43 (55), PCWP 26, CI 1.4. LHC -->, LV 92/21. LMCA mild disease, LAD 40% distal lesion, LCx 40% after OM1, LCA mild luminal irregularities. Summary: Severe biventricular diastolic dysfxn with severe pulm HTN. IABP placed and pt sent to CCU for diuresis and surgery evaluation. Patient has no complaints. Denies SOB or CP. Past Medical History: Mitral regurgitation/CHF Atrial fibrillation - diagnosed within the past month Left cataract surgery [**2188**] Prostate cancer s/p XRT [**2192**] Colon cancer, s/p exploratory laparotomy, lysis of adhesions, right colectomy, s/p ileocolo-anastomosis. Hx of C. Diff colitis Non-Hodgkin's Lymphoma (B-cell), s/p chemo in ? [**2190**], currently in remission Appendectomy Cholecystectomy [**2163**], [**2169**]- hernia repairs Recovered alcoholic , [**2159**] [**2129**]-Duodenal ulcer Iron deficiency anemia CRI (creatinine 1.3-1.7) Social History: denies tobacco (quit 28 years ago). Patient lives alone. He is divorced and has 7 children. Recovered alcoholic. Family History: Non-contributory Physical Exam: PE: T 96.7, 97/68, 73 irreg irreg, 16, 97% on 4L GEN - NAD, A&Ox3 HEENT - MMM NECK - supple HEART - irreg irreg II/VI HSM LUNGS - clear anterolaterally ABD - soft, NT/ND, NABS EXT - IAPB in place R groin, 2+ edema to just below knees, 1+ DP on R, 2+ DP on L, 2+ PT b/l Pertinent Results: [**2193-6-18**] 01:30PM WBC-9.0 RBC-4.53* HGB-14.4 HCT-42.4 MCV-94 MCH-31.8 MCHC-34.0 RDW-14.1 [**2193-6-18**] 01:30PM PT-16.6* PTT-38.0* INR(PT)-1.8 [**2193-6-18**] 01:30PM ALT(SGPT)-12 AST(SGOT)-18 ALK PHOS-58 AMYLASE-74 TOT BILI-2.2* DIR BILI-0.6* INDIR BIL-1.6 [**2193-6-18**] 01:30PM GLUCOSE-147* UREA N-28* CREAT-1.1 SODIUM-138 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13 [**2193-6-30**] 05:10AM BLOOD WBC-12.1* RBC-3.50* Hgb-11.0* Hct-32.8* MCV-94 MCH-31.3 MCHC-33.4 RDW-14.4 Plt Ct-145* [**2193-7-2**] 05:35AM BLOOD PT-14.8* INR(PT)-1.5 [**2193-7-1**] 06:00AM BLOOD Glucose-80 UreaN-16 Creat-1.0 Na-139 K-4.5 Cl-102 HCO3-29 AnGap-13 [**2193-6-21**] 03:21PM BLOOD ALT-10 AST-42* LD(LDH)-415* AlkPhos-44 Amylase-80 TotBili-2.3* [**2193-6-18**] CXR The tip of the balloon pump lies opposite the 7th vertebral body in the mid thoracic aorta. The tip of the Swan-Ganz catheter lies in the right main pulmonary artery. No gross failure is seen allowing for the supine position. No infiltrates are present. [**2193-6-24**] CXR Cardiac, mediastinal, and hilar contours are stable, status post median sternotomy and mitral valve replacement. Right IJ Swan-Ganz catheter tip is in the main right pulmonary artery. There continues to be a small left pleural effusion as well as basilar atelectasis versus possible consolidation. Compared to prior exam of [**2193-6-21**], bilateral chest tubes and mediastinal tubes have been removed. There is no evidence of pneumothorax. Osseous and soft tissue structures are stable. [**2193-6-21**] EKG Atrial fibrillation with a moderate ventricular response. Occasional ventricular premature contractions. Intraventricular conduction defect of right bundle-branch block type. QTc interval prolongation. Anterolateral ST-T wave changes - cannot rule out myocardial ischemia. Compared to the previous tracing of [**2193-6-18**] ventricular response is slower. Anterolateral ST-T wave changes persist. [**2193-6-20**] Abdominal Ultrasound 1. Status post cholecystectomy, with normal appearing bile ducts. 2. Small right pleural effusion. Bilateral simple renal cysts. [**2193-6-18**] Cardiac Catheterization 1. Selective coronary angiography demonstrated mild, nonobstructive coronary artery disease. LMCA had mild disease. LAD had a 40% stenosis in the distal vessel. LCx had a 40% lesion after OM1. RCA had mild luminal irregularities. 2. Left ventriculography was not performed. 3. Resting hemodynamics demonstrated severe pulmonary arterial hypertension (80/43 mmHg). Filling pressures were markedly elevated (RA 17 mmHg, RVEDP 17 mmHg, PCWP 26 mmHg with "v" waves to 40 mmHg). Forward cardiac output was markedly diminished at 2.8 L/min (index 1.4 L/min/m2). There was no gradient across the aortic valve. 4. Administration of nitroglycerin 200 mg IV resulted in a mild decrease in PA systolic pressure to 70 mmHg, with a concomitant decrease in the systemic systolic pressure to 85 mmHg. 5. In order to improve forward flow and allow tailored preoperative medical therapy, intraaortic balloon counterpulsation was initiated with an 8 French 40 cc IAB pump inserted via the right femoral artery. With IABP at 1:1, PA systolic pressure decreased to 55-60 mmHg, and PCWP decreased to ~22 mmHg. Brief Hospital Course: Mr. [**Known lastname 8389**] was admitted to then [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical Center on [**2193-6-17**] for further management of his congestive heart failure. He underwent a cardiac catheterization which revealed mild coronary artery disease, severe biventricular dysfunction, severe pulmonary hypertension and severe mitral regurgitation. An intra-aortic balloon pump was placed for severe pulmonary hypertension. Due to the severity of his disease, the cardiac surgical service was consulted and Mr. [**Known lastname 8389**] was worked-up in the usual preoperative manner. A carotid duplex ultrasound was performed which showed no significant stenosis of the bilateral internal carotid arteries. Vitamin K was given to reverse his INR from his coumadin. The hematology service was consulted for thrombocytopenia and found evidence of myelodysplasia likely secondary to chemotherapy. No contraindication to surgery was noted after discussion with his oncologist. On [**2193-6-21**], Mr. [**Known lastname 8389**] was taken to the operating room where he underwent a mitral valve replacement utilizing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3843**] [**First Name5 (NamePattern1) 7624**] [**Last Name (NamePattern1) 49168**] bioprosthesis and a MAZE procedure. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On Postoperative day one, his intra-aortic balloon pump was weaned off and removed with complication. Platelets were transfused for thrombocytopenia. On postoperative day two, Mr. [**Known lastname 8389**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Gentle diuresis was initiated. He continued in atrial fibrillation. Heparin was started with transition to coumadin for anticoagulation. His drains and epicardial pacing wires were removed per protocol. On postoperative day 8, Mr. [**Known lastname 8389**] was transferred to the cardiac surgical step down unit for further recovery. The physical therapy service was consulted for assistance with his postoperative strength and mobility. His heparin was discontinued as his INR became therapeutic. Mr. [**Known lastname 8389**] continued to make steady progress and was discharged to [**Hospital 745**] Health Care Center on postoperative day eleven. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Coumadin 3 mg po qW, 2 mg po MTRFSS, last dose [**2193-6-13**] Furosemide 80 mg po qd Aspirin 81 mg po qd Metoprolol 12.5 mg po qd Discharge Medications: 1. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 10. Warfarin Sodium 1 mg Tablet Sig: Two (2) Tablet PO ONCE (once): Dose for INR between 2.0-2.5. Monitor daily PT/INR. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: Mitral Regurgitation Atrial Fibrillation Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These included redness, drainage or increased pain. 2) Monitor vital signs. Report any fever greater then 100.5. 3) Report any weight gain of more then 2 pounds in 24 hours. 4) No lifting more then 10 pounds for 1 month. No driving for 1 month. 5) Do not apply lotions, creams or powders to wounds. When wound is healed, use sunscreen while in the sun. 6) Coumadin for Atrial fibrillation and a tissue mitral valve prosthesis. Goal INR 2.0-2.5. Dr.[**Last Name (STitle) 5292**] ([**Telephone/Fax (1) 26278**] will manage coumadin as an outpatient. Please contact office to arrange appointment upon discharge from rehab. Discharge dose will be 2mg daily. Please monitor daily PT/INR and adjust coumadin dose accordingly. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 6 weeks. ([**Telephone/Fax (1) 1504**] Follow-up with your cardiologist Dr. [**Last Name (STitle) 3321**] in 2 weeks. Follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5292**] in [**2-14**] weeks for routine postoperative follow-up and immediately after discharge from rehab for coumadin management. Please call providers for appointment. Completed by:[**2193-7-2**]

[ "785.51", "427.31", "416.8", "V10.46", "202.80", "424.0", "V45.3", "287.3", "V10.00", "V15.3", "428.33" ]

icd9cm

[ [ [] ] ]

[ "35.23", "88.72", "99.05", "37.33", "37.23", "39.61", "37.61", "88.56", "00.13" ]

icd9pcs

[ [ [] ] ]

10133, 10210

6484, 8987

318, 503

10295, 10301

3195, 6461

11111, 11576

2873, 2891

9168, 10110

10231, 10274

9013, 9145

10325, 11088

2906, 3176

228, 280

531, 2170

2192, 2725

2741, 2857

13,715

156,530

50174

Discharge summary

report

Admission Date: [**2116-5-9**] Discharge Date: [**2116-5-25**] Service: CCU HISTORY OF PRESENT ILLNESS: Patient is a 79-year-old male with history of hypertension transferred to the Coronary Care Unit following respiratory failure and hypercapnia on the floor requiring intubation. History from spouse since the patient is intubated and sedated reports approximately 1-1.5 weeks ago the patient started to complain of a cold (with productive cough, increased shortness of breath, and dyspnea on exertion). Called the PCP who started Zithromax for presumed community acquired pneumonia, no chest x-ray, no culture, or data. The patient's symptoms increased to the point where he is not able to sleep secondary to shortness of breath. No chest pain, no palpitations, no weight changes, or lower extremity edema. Wife reports increased dyspnea on exertion. He could not walk in the room without becoming extremely short of breath, fatigue, and decided the morning of admission to go to the Emergency Department. In the Emergency Department, the patient was found to be nonresponsive. Arterial blood gas showed 7.14, 72, 109 on CPAP. Laboratories showed a BMP of 690, normal less than 150 with a chest x-ray showing bilateral pulmonary edema. The patient was started on CPAP and diuresed with Lasix. His symptoms improved and the patient was transferred to [**Hospital3 **] for further care. Upon arrival to the floor, he was found to be lethargic with decreased responsiveness. Arterial blood gas showed 7.10, 96, and 41. The patient was intubated and transferred to the CCU. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Osteomyelitis at age 14. ALLERGIES: He has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Timolol 10 mg [**Hospital1 **]. 2. Norvasc 5 mg po q day. 3. Lipitor 10 mg q day. 4. Zithromax for two days. SOCIAL HISTORY: Rectal cancer and coronary artery disease. Smoker quit 30 years ago, approximately 60 pack years. Patient no alcohol use. Lives at home with wife, two children in area. PHYSICAL EXAM ON ADMISSION: He was sedated and intubated, no jugular venous distention, no lymphadenopathy. Oropharynx is clear. Mucous membranes moist. Cardiovascular: Tachycardic, III/VI systolic murmur radiating to both carotids. PMI increased, but not to place, soft S2. Pulmonary: Unable to properly assess. Abdomen is soft, nontender, nondistended, bowel sounds positive. Extremities: No clubbing, cyanosis, or edema. LABORATORIES: White blood cell count 13.3, hematocrit 39.1, platelets 267, INR of 1.2. Urine is positive for blood. Chem-7: Sodium 141, potassium 3.8, chloride 104, CO2 25, BUN 18, creatinine of 1, platelets of 292, magnesium of 1.6, PO4 is 6.2, calcium 8.7. AST 88, ALT of 44, LDH 231, alkaline phosphatase 109. T bilirubin of 0.7, lactate of 1.6. CK 86 increased to 102, troponin 3.3, MB index of 9.8. Electrocardiogram showed a sinus rhythm, normal axis, left ventricular hypertrophy, left atrial abnormality, ST changes in precordial leads, ST depressions in V5 and V6, ST elevations, normal intervals. More pronounced when tachycardic. A transthoracic echocardiogram for this patient showed severe aortic stenosis with approximate valve area of 0.7. This was followed by a cardiac catheterization on [**2116-5-11**] and found to have a pulmonary capillary wedge of 14 with severe aortic stenosis, mean gradient of 65 mm and a valve area of 0.54. He also had diffuse coronary artery disease with 20% left main, a 60% left anterior descending artery, a mid and proximal circumflex lesion of approximately 30%, right coronary artery of mid 40% and 100% distal right coronary artery. The patient did rule in for myocardial infarction. CT Surgery was consulted to assess for aortic valve replacement and CABG. CT Surgery agreed that aortic valve replacement/CABG was indicated in this patient. Preoperative evaluation revealed a 90-100% stenosis of the right coronary artery. In view of the heavily calcified aorta and therefore the need for circulatory arrest during surgery it was felt that the risk of stroke was high and would require carotid intervention prior to that. After careful review of the options carotid stenting was recommended. This was successfully performed on [**5-14**]. He was then put on aspirin and Plavix with plans to wait two weeks for the surgery while controlling the patient's heart failure on the floor. Patient was extubated and did well in the CCU. He was transferred to the PCU subsequently. While in the PCU the patient had a recurrent episode of pulmonary edema requiring transfer back to the CCU as well as reintubation He also developed hemoptysis which was evaluated and felt to be predominantly related to his CHF.An IABP was place on [**5-19**] to optimize his hemodynamics and surgery was scheduled for [**5-21**]. Prior to the scheduled surgery the patient developed a leukocytosis with gm + cocci in his sputum. The surgery was cancelled by the cardiac surgical team and the patient evaluated by ID. Antibiotic treatment was advised and their recommendations followed. Although there was a concern about a positive blood culture as well that was ultimately concluded to probably be a contaminant. The patient was successfully extubated on [**5-22**]. While in the CCU the patient had some recurrent hemoptysis (evaluated by pulmonary) and he began to develop renal insufficiency.On [**5-24**] he was noted to have an ischemic left lower extremity despite being on systemic heparin . He was evaluated by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]- the IABP was removed. The renal service was also consulted due to a rising creatinine and they felt that the acute renal failure was possibly related to emboli from the IABP/aorta.CT surgery did not feel there was any role for urgent cardiac surgery at this time. On the night of [**5-24**], patient developed high grade transaminitis with AST and ALTs in the thousands, mild scleral icterus with bilirubin approximately 1.5. Lactate was initially stable throughout the night in the range of [**2-24**], but then rose dramatically to 9. In addition, the patient began to decompensate with hypotension requiring Neo-Synephrine and dopamine drips as well as fluid boluses to maintain MAPS above 90. He was also having seizure-like activity and required increased doses of Fentanyl, diazepam, and Haldol for sedation. As the patient's condition deteriorated, CCU fellow and attending were contact[**Name (NI) **] as well as Surgery to evaluate for a possible mesenteric ischemia and acute abdomen. The team was united in feeling that any intervention at this time would be a high risk of mortality and more likely that would not only prolong an inevitable decline. The family was contact[**Name (NI) **] and told of the patient's grave prognosis and instructed to come in as soon as possible. Family arrived, and the seriousness of the condition and prognosis were explained to them. After discussion, the family decided that it would not be consistent with the wishes of Mr. [**Known lastname 22917**] to become dialysis dependent or prolonged existence on a ventilator. Spiritual counseling was brought in the early morning of [**5-25**]. The family decided to withdraw care. Given the underlying medical conditions, the Medical and Surgical teams involved fully agreed with this decision. Mr. [**Known lastname 22917**] passed away at 7:45 am on [**5-25**]. CAUSE OF DEATH: Respiratory arrest secondary to congestive heart failure and renal failure. HOSPITALIZATION DIAGNOSES: 1. Critical aortic stenosis. 2. Congestive heart failure. 3. Coronary artery disease. 4. Pneumonia. 5. Hemoptysis. 6. Acute renal failure. 7. Acute hepatitis. 8. Lower extremity vascular arterial thromboembolism. 9. Probable mesenteric ischemia. 10. Hypertension. 11. Atrial fibrillation. [**Last Name (LF) **], [**Name8 (MD) 870**] M.D. [**MD Number(1) 5219**] Dictated By:[**Last Name (NamePattern1) 1737**] MEDQUIST36 D: [**2116-5-25**] 10:49 T: [**2116-5-29**] 08:08 JOB#: [**Job Number 104689**] F1 ESC

[ "428.0", "584.9", "482.41", "518.81", "424.1", "410.71", "570", "786.3", "433.10" ]

icd9cm

[ [ [] ] ]

[ "96.04", "37.61", "37.23", "37.21", "97.44", "96.71", "39.90", "39.50", "88.56", "88.45", "88.41" ]

icd9pcs

[ [ [] ] ]

1757, 1870

115, 1599

2087, 8173

1621, 1731

1887, 2072

75,159

109,611

39676

Discharge summary

report

Admission Date: [**2102-9-4**] Discharge Date: [**2102-9-13**] Date of Birth: [**2027-6-27**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6075**] Chief Complaint: Called by Emergency Department to evaluate IPH Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a 75 year-old right-handed woman with a history of HTN and depression who presents with a headache and left sided weakness, found to have a large (5x5x7cm) right temporal lobe hemorrhage. According to her husband, ~1 week ago the patient was complaining of a headache, as well as the sensation that she had 'funny lines' in her left eye. She went to see her ophthalmologist, who found no abnormalities, but thought this may be secondary to a migraine headache (though according to her husband she has no history of migraines). The vision changes and headache improved, and later that week she had a routine physical, which reportedly showed a 'normal' blood pressure, and no other abnormalities. Today her husband reports that around noon she began complaining of a severe headache. Shortly after that he noticed that she was having trouble keeping her balance, and fell down in the living room. Around this time she vomited, and also was incontinent of stool. Her husband initially just left her on the floor, as he thought she had 'a stomach bug' and was going to let her rest. After ~30 minutes, when she didn't get up, he tried to help her up. He reports he struggled with her for ~1 1/2 hours, and notes that he kept telling her to try to help him, and noting that she didn't seem to be using her left arm and leg the way she should. Eventually he became concerned about the lack of movement on that side, so decided to call the ambulance. She was initially taken to an OSH, where she had a NCHCT which showed a large (5x5x7cm) right temporal lobe hemorrhage, at which time she was transferred to [**Hospital1 18**] for further evaluation. Past Medical History: - HTN (?) - husband is not aware of this diagnosis, but does confirm that she has taken verapamil for several years. - Depression/anxiety Social History: Lives with her husband in [**Name (NI) **] Family History: Family Hx: NC Physical Exam: Pt passed away. No heart sounds, no breath sounds auscultated. No palpable pulse Pupils fixed an dilated, no corneal reflex Pertinent Results: [**2102-9-4**] 03:36AM GLUCOSE-164* UREA N-18 CREAT-0.6 SODIUM-139 POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13 [**2102-9-4**] 03:36AM CK-MB-4 cTropnT-<0.01 [**2102-9-4**] 03:36AM WBC-11.8* RBC-4.04* HGB-13.1 HCT-37.2 MCV-92 MCH-32.4* MCHC-35.1* RDW-13.3 [**2102-9-4**] 03:36AM PLT COUNT-196 NCHCT FINDINGS: Again noted is a large intraparenchymal hemorrhage involving the right parietal, frontal and temporal lobes. It measures 6.4 x 5.0 cm , previously 6.6 x 4.7 cm and is overall unchanged in size or appearance. There is persistent peri-hemorrhagic edema with stable effacement of sulci and ventricles. There is a 4-mm leftward shift from normally midline structures which is minimally decreased from prior. Stable intraventricular hemorrhage bilaterally and persistent hemorrhage into the supravermian cistern is again noted. The subarachnoid hemorrhage in the left occipital lobe is unchanged from prior study. The basal cisterns remain patent. No hydrocephalus is noted. An unchanged large CSF hypodensity in the anterior left middle cranial fossa is compatible with large arachnoid cyst. Prominent anterior falcine calcifications are present. There is no evidence of acute fracture. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: Overall, no significant change in intraparenchymal hemorrhage and associated edema. Stable intraventricular hemorrhage bilaterally with persistent hemorrhage into supravermian cistern, unchanged from prior study. Brief Hospital Course: ICU Course: Patient was admitted on [**2102-9-4**] for left-sided weakness and headache and was found to have a large R temporal hemorrhage. Exam findings on presentations were: the patient was arousable to voice, oriented to self and [**Location (un) 86**], but thought it was [**Location (un) 8599**]Hospital and was unsure of the date/year. She had gross neglect of the left side, to self, visual stimuli and to sensory stimuli. Eyes did not move past midline to the left, and sensory input from left side of face was different as well as decreased hearing on left v. neglect. L arm was extensor to pain and left lower extremity had triple flexion to pain with downgoing toes. Exam remained stable for 2 days in the ICU. MRI imaging revealed no evidence of mass leading to likely etiology of amyloid angiopathy. MRI showed early to late subacute blood indicating that bleed may have started days prior to presentation. Repeat CT on [**9-5**] showed no new blood and no increase in midline shift. Blood pressure was stable and between 120-150 systolic on home dose of Verapamil. On the neuro-floor the patietns blood pressure was not controlled and verapamil was increased. The use of a second theraputic [**Doctor Last Name 360**] was then used; norvasc 5mg qday. The patient did have leukucytosis a CT chest with contrast was ordered which did not demonstrate pulmonary embolism. A urinalysis was also checked and was within normal range. The chest x-ray itself did not show any infiltrate. A transthoracic echo was completed and non concering for endocarditis or any overt pathology. The patietns alertness was observed and found to wax and wane significantly throughout the day. there was a repeat head CT scan which did not show any diffrence in comparison to older studies. Over the weekend the patient decomensated and was found to be more unresponsive. The patient was then made CMO-comfort measures only. The patient passed away from repiratory depression secondary to stroke on [**2102-10-14**] at 9:35 am. No autopsy was completed or wanted by family. Medications on Admission: - Celexa 20mg - Verapamil 240mg daily - Omeprazole 20mg - Klonapin 0.5mg - Naproxen 500mg [**Hospital1 **] Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Death: Primary stroke Secondary respiratory failure Discharge Condition: Death. Discharge Instructions: Death: n/a Followup Instructions: Death: N/A Completed by:[**2102-9-14**]

[ "348.4", "276.6", "277.39", "348.89", "780.61", "348.5", "438.22", "431", "401.9", "311", "276.8", "788.5" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

6258, 6267

4006, 6072

363, 369

6362, 6370

2481, 3983

6429, 6470

2305, 2321

6230, 6235

6288, 6341

6098, 6207

6394, 6406

2336, 2462

276, 325

397, 2065

2087, 2228

2244, 2289

31,904

116,137

33820

Discharge summary

report

Admission Date: [**2188-7-1**] Discharge Date: [**2188-8-2**] Date of Birth: [**2121-12-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1377**] Chief Complaint: Small Bowel Obstruction Incarcerated Umbilical Hernia Major Surgical or Invasive Procedure: Exploratory Laparotomy Adhesiolysis Repair of Umbilical Hernia Re-exploration of recent laparotomy History of Present Illness: 66 yoF with multiple medical problems [**Name (NI) 78191**] CHF, HCV Cirrhosis, CKD comes with altered mental status from a nursing home. On exam noted to have two large hernias, one in the R inguina and the other umbilical. KUB in ED showed multiple small bowel loops the largest of which are 4 cm. Past Medical History: 1. HCV cirrhosis currently undergoing transplant work-up, had SBP in [**5-6**] 2. Diabetes mellitus type 2: Per old records, pt had diagnosis of diet controlled type 2 diabetes. 3. Umbilical hernia 4. [**Date Range **] in [**5-6**]: EKG c/w anteroseptal MI with new ST elevations in V2-3. Elevated troponins but not cath candidate. Echo confirmed anteroseptal WMA and pt was medicallly managed. 5. diastolic CHF 6. CKD Social History: From [**Location (un) 5354**], lived alone there and now moved in with her brother here in [**Name (NI) 86**]. Presented to the ED directly from the airport upon arrival in [**Location (un) 86**] several weeks ago for possible liver txplnt. Former smoker, 20 pack-years, quit 10 years ago. Former moderate EtOH consumption. Denies current EtOH use. Denies illicit drug use/IVDU. Family History: Father died of MI at age 62, brother had MI at age 60, brother also has DM. Physical Exam: N: grossly non verbal, responds in all four extremites to deep pain stimulation. Icteric, PERLA. CV: RRR, tachy at times, no MRG R: CTA B/L short quick inspiratory effort, non compliant with deep breath ABD: soft, protuberant with ascites, large umbilical hernia with early erythematous skin changes, tender to palpation, non-reducible. Large R inguinal hernia, soft, minimal erythema, fluid filled, partially reducible with immediate return, mildly tender to palpation. No obvious scars from previous surgery. EXT: minimal edema, pulses palpable throughout. Pertinent Results: [**2188-7-1**] 10:05AM AMMONIA-198* LACTATE-5.3* [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-12* PH-6.5 LEUK-NEG WBC-6.6 RBC-2.67*# HGB-9.0* HCT-26.9* MCV-101*# MCH-33.8* MCHC-33.6 RDW-18.6* 10:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG cTropnT-0.16* LIPASE-29 ALT(SGPT)-47* AST(SGOT)-62* CK(CPK)-88 ALK PHOS-159* TOT BILI-5.2* [**2188-7-1**] 08:12PM TYPE-ART PO2-191* PCO2-37 PH-7.38 TOTAL CO2-23 BASE XS--2 LACTATE-3.7* freeCa-1.09* GLUCOSE-104 UREA N-26* CREAT-1.4* SODIUM-144 POTASSIUM-4.3 CHLORIDE-113* TOTAL CO2-21* ANION GAP-14 CALCIUM-8.7 PHOSPHATE-3.9 MAGNESIUM-1.4* WBC-6.1 RBC-2.04* HGB-6.8* HCT-20.5* MCV-101* MCH-33.4* MCHC-33.2 RDW-18.3* PLT COUNT-72* PT-21.2* PTT-45.3* INR(PT)-2.0* ECG Study Date of [**2188-7-1**] 10:16:44 AM Sinus tachycardia. Baseline artifact. Poor R wave progression. Compared to the previous tracing of [**2188-5-18**] sinus tachycardia and artifact are new. CHEST (PORTABLE AP) Study Date of [**2188-7-1**] 10:13 AM IMPRESSION: No evidence of pneumonia. CT HEAD W/O CONTRAST Study Date of [**2188-7-1**] 10:15 AM IMPRESSION: No acute intracranial process. PORTABLE ABDOMEN Study Date of [**2188-7-1**] 10:27 AM IMPRESSION: Findings suggestive of small bowel obstruction. CT may be performed to further evaluate. ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2188-7-28**] 2:32 PM IMPRESSION: 1. Heterogeneous liver with no focal masses seen. 2. No biliary dilatation. 3. Splenomegaly. 4. Right pleural effusion and a small amount of perihepatic ascites. Brief Hospital Course: This is a 66 yo F with HCV cirrhosis and minimal reserve initially admitted with hepatic encephalopathy, and small bowel obstruction. # Small Bowel Obstruction: On [**2188-7-1**] the patient went to the OR for repair of umbilical hernia and reduction of small bowel obstruction. On [**2188-7-7**], she had Re-exploration of above laparotomy for Bacterial peritonitis, extremely high peritoneal ascites white count of 19,000. In that her liver failure continued to progress, and she was vasopressor-dependent and had poor urine output, there was concern for an intra-abdominal pathology source fueling this peritonitis. Upon repeat laparotomy, there was no evidence of any compromise or bowel death or obstruction; bowel was inflamed and edematous, as would be expected from peritonitis, but there was no evidence of any compromise nor incarcerated hernia. She was treated with a course of zosyn/vanco, was weaned off pressors and was transferred out of the SICU onto the liver medical service. # Altered Mental Status: She was confused and at times inappropriate and agitated. Pt attempted to remove Foley and PICC on several occasions. This was thought not entirely due to hepatic encphalopathy as she was stooling well on standing lactulose and rifaximin with decrease in asterixis. She had soft restraints and a 1:1 sitter. Her mental status was improving. She was evaluated by Psych on [**2188-7-14**]. They recommended Haldol as needed initially, and then standing doses of Haldol after PRN was not sufficient. Psych also recommended using lactulose for her hepatic encephalopathy. On [**7-28**] the patient appeared somnolent and her standing Haldol dose was [**Month/Year (2) 8910**] with an improvement in her mental status. She remained intermittantly confused, but was minimally agitated for the remainder of her hospital course. # Liver Failure/ HCV Cirrohsis: Pt was followed by the Transplant team but determined not to be a transplant candidate. She received lactulose enemas daily. She was having high ascitic output, at times as much as 8 liters/day. With the high JP output, her urine output was low (Hypovolemia). JP output was replaced with saline. She was also ordered for Albumin to help with the ascites. She was unable to tolerate NGT feedings and she had a high residual. Tubefeedings were stopped and she was started on TPN while on the surgical service. She was seen by Speech and Swallow and cleared for nectar thick liquids and ground consistency solids, however, due to her poor PO she was continued on TPN. Her bilirubin continued to climb and this was thought due to TPN. # Hyperbilirubinemia: Total bilirubin was 5.2 on admission, and with minor fluctuations, rose to 18.0 on [**7-24**]. Bilirubin continued to rise daily to 28 on [**7-29**]. No further labs were obtained after that time. # Renal Failure: Upon callout from the surgical ICU, her creatinine began to rise. She had large volume output of ascites from lap site that continued so it was intially postulated that she was likely intravascularly dry due to inadequate intake and high volume output from abdomen and stool. Her renal function, did not, however improve with fluid and albumin challenge and thus renal was consulted for probable HRS. Given the trajectory of her renal failure and development of oliguria/anuria, hemodialysis was considered. In discussion with her health care proxy, however, it was decided that rather than to initiate HD, team would focus on comfort care. # Anemia/GIB: She had post-op Anemia and received PRBCs as needed for [**Month/Day (4) **] loss anemia. Her HCT on POD 1 was 20 and rose to 26. Her HCT remained stable and low in the 23-24 range. Thrombocytopenia was also noted. INR remained elevated. On [**7-26**] the patient was found to have guiac positive emesis and a drop in her hematocrit from 25-->19. She was transferred to the ICU and transfused 3 U pRBCs. Endoscopy showed evidence of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear with stimata of recent bleeding. She was sabilized and returned to the hepatorenal service on [**7-27**]. Her hematocrit was stable for 24 hours until she had a large heme positive stool and her hct dropped again from 25-->20. She again was transfused 2u with an approptiate response with stable hematocrit thereafter. # DNR/DNI/CMO: On [**2188-7-30**], the issue of resusitation orders were discussed with the patient's brother [**Name (NI) **] [**Name (NI) 78192**]. During this discussion, it was determined that in light of her ineligability for transplant, DNR/DNI orders should be made. The issue of her imminent renal failure was also approached and this lead to the decision by her brother that dialysis should not be initiated. On [**2188-7-31**], the patient was made CMO and all unnecessary medical therapy was stopped. Pt remained on lactulose to maintain mental status. The patient died peacefully on the morning of [**8-2**]. Medications on Admission: -Acetaminophen 500 mg 1 tab PO Q6 hrs PRN pain -Albuterol Sulfate 2.5 mg/3 mL [**Male First Name (un) **] for neb. inhalation Q4 hrs PRN -Aspirin 325 mg tab PO daily -Ciprofloxacin 250 mg tab PO q24 hrs -Folic Acid 1 mg tab PO daily -Furosemide 40 mg 1 tab PO daily -Hexavitamin 1 Cap by mouth DAILY -Lactulose 10 gram/15 mL syrup 30 ML PO TID (titrate to 3 BM daily) -Metoprolol 25 mg 0.5 tab PO BID -Pantoprazole Delayed Release (E.C.) 40 mg 1 tab PO daily -Spironolactone 100 mg 1 Tab PO daily -Insulin Regular Human 100 unit/mL solution 0-10 Solution(s) sliding scale. Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 3. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 5. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO QID (4 times a day). 6. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 7. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). Discharge Disposition: Expired Discharge Diagnosis: Incarcerated Right Inguinal Hernia Umbilical Hernia Small bowel Obstruction Hepatic Encephalopathy Cirrhosis Renal Failure Cardiopulmonary arrest Discharge Condition: Deceased Followup Instructions: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] Completed by:[**2188-8-20**]

[ "041.84", "250.40", "535.61", "550.10", "285.1", "V09.0", "V17.49", "698.9", "428.33", "584.9", "552.1", "572.3", "560.81", "572.8", "412", "571.5", "782.4", "414.01", "585.6", "567.29", "570", "V58.67", "070.71", "V15.82", "041.11", "458.9", "V18.0", "789.59", "428.0", "456.21", "V66.7", "530.7", "286.7" ]

icd9cm

[ [ [] ] ]

[ "54.12", "99.07", "45.13", "99.05", "96.6", "54.59", "99.04", "53.49", "54.25", "38.93", "53.59", "99.15" ]

icd9pcs

[ [ [] ] ]

10349, 10358

4047, 5055

367, 467

10548, 10558

2344, 4024

10611, 10733

1655, 1732

9664, 10326

10379, 10527

9067, 9641

1747, 2325

274, 329

495, 799

5070, 9041

821, 1242

1258, 1639

19,518

160,317

46302+46303

Discharge summary

report+report

Admission Date: [**2114-3-19**] Discharge Date: [**2114-3-28**] Date of Birth: [**2045-11-30**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old female with a history of primary biliary cirrhosis and end-stage liver disease awaiting transplant with a history of hypertension, atrial fibrillation, and depression who presents with increased confusion and worsening mental status over the past two days. Of note, the patient's diuretics were increased on [**3-14**] (Lasix from 40 mg to 80 mg and Aldactone from 50 mg to 100 mg once per day). The patient has had increased diarrhea/loose stools four to five times per day, and notes that in the past week she has had bright red blood on her tissue with wiping and a question of blood with her stools. The patient denies nausea, vomiting, fevers, abdominal pain, or increased abdominal distention. She noted a cough in the supine position. No dysuria. No headache. Per her family, the patient has lost 30 pounds in the past two weeks. Records show a 12-pound loss in the past week. PAST MEDICAL HISTORY: 1. Primary biliary cirrhosis with end-stage liver disease; having rapid progression over the past year. The patient is awaiting a liver transplant. 2. Hypertension. 3. History of atrial fibrillation. 4. Anxiety and depression. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Diovan 160 mg by mouth once per day. 2. Protonix 40 mg by mouth once per day. 3. Folate 1 mg by mouth once per day. 4. Atenolol 50 mg by mouth once per day. 5. Ursodiol 30 mg by mouth once per day. 6. Lasix 40 mg by mouth once per day. 7. Spironolactone 50 mg by mouth once per day. 8. Zoloft. SOCIAL HISTORY: No tobacco. No alcohol. She is single. She lives with her brother. PHYSICAL EXAMINATION ON PRESENTATION: The patient was a markedly jaundiced and obese female, confused, in no acute distress. Vital signs revealed her temperature was 96.1, her blood pressure was 89/41, her heart rate was 69, her respiratory rate was 20, and her pulse oximetry was 97% on room air. Head, eyes, ears, nose, and throat examination revealed anicteric sclerae. The mucous membranes were dry. The oropharynx was clear. The pupils were equal, round, and reactive to light. The neck was supple. There was no lymphadenopathy. No jugular venous distention. The lungs were clear to auscultation bilaterally. Heart was regular in rate and rhythm. Normal first heart sounds and second heart sounds. The abdomen was distended, obese, soft, and nontender. There was upper quadrant fullness bilaterally. There were positive bowel sounds. Extremities revealed 2+ dorsalis pedis pulses bilaterally. No clubbing, cyanosis, or edema. Neurologic examination with asterixis present. Alert and oriented times two. Cranial nerves were intact. Strength was [**5-23**] in the upper and lower extremities. Skin revealed blanching patchy rash on the medial aspect of her right leg, markedly jaundiced throughout. Rectal examination was guaiac-positive (per Emergency Department report). PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 9 (71.4% neutrophils and 16.2% lymphocytes), her hematocrit was 31.2, and her platelet count was 163. Electrolytes revealed sodium was 133, potassium was 5, chloride was 103, bicarbonate was 19, blood urea nitrogen was 47, and creatinine was 1.8. Lactate was 2.5. INR was 1.7. Aspartate aminotransferase was 208, alanine-aminotransferase was 92, alkaline phosphatase was 161, amylase was 47, total bilirubin was 17.7, and her lipase was 69. Albumin was 2.5. Ammonia was 49. Urinalysis revealed moderate bilirubin and 1+ urobilinogen; otherwise negative. PERTINENT RADIOLOGY/IMAGING: An abdominal ultrasound revealed portal vein was patent, small ascites (not enough for paracentesis), and nodule seen in the left lobe of the liver (which corresponds to an enhancing mass seen on recent computed tomography). No new masses present. Cholelithiasis was present without evidence of cholecystitis. A chest x-ray revealed a left pleural effusion, questionable left lower lobe infiltrate versus consolidation, and mild pulmonary edema. BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. HEPATIC ENCEPHALOPATHY ISSUES: The patient had confusion and a change in mental status attributed to hepatic encephalopathy likely related to her dehydration, gastrointestinal bleed, anemia, and the possibility of infection. Given her recent increase in diuretic doses, dehydration was the most probable cause of this decompensation. The patient was treated with lactulose 30 cc by mouth three times per day, and her mental status steadily improved throughout the first several days of her hospital stay. Her ammonia level trended down during this time. As she was markedly volume depleted, she was given intravenous fluids aggressively to improve her volume status. The Hepatology Service was consulted, and their recommendations were followed. Throughout her hospital stay, close monitoring of her liver function tests and INR continued. The patient was eventually weaned off of lactulose and then developed some mild confusion. Therefore, she was restarted on a standing lactulose dose. On the day of discharge, she was continuing to require lactulose. She was to follow up with her hepatologist with regard to further management of her hepatic encephalopathy. 2. GASTROINTESTINAL ISSUES: The patient had evidence of a gastrointestinal bleed with guaiac-positive stools and a history of bright red blood per rectum. She was transfused one unit or packed red blood cells on [**3-22**] for a hematocrit of less than 28. During her hospital stay, she had a colonoscopy that showed nonbleeding grade 1 internal hemorrhoids and an esophagogastroduodenoscopy which showed a small hiatal hernia, grade 1 varix at the gastroesophageal junction, and portal gastropathy. Her hematocrit remained stable for the remainder of her hospital course. She was to follow up with her gastroenterology specialist with regard to further management as no active bleeding was suspected. 3. END-STAGE LIVER DISEASE ISSUES: The patient had continued workup for her transplant including a stress test which showed no myocardial perfusion defects and had [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus testing. With regard to her coagulopathy from liver disease, the patient was given vitamin K by mouth and subcutaneously during her hospital stay. 4. RENAL ISSUES: The patient had evidence of acute renal failure on presentation that was due to prerenal causes given her history of gastrointestinal bleed and marked volume depletion on presentation with a history of diuretic dose increase. The patient's creatinine did improve with rehydration; however, she did not reach her baseline creatinine during her hospital stay. Her creatinine did improve to 1.3 but then did worsen to 1.6 when intravenous fluids were discontinued. Initiation of diuretics were held until [**3-27**] when the patient did appear more volume overloaded despite her renal function. She will be restarted on low-dose diuretics for discharge and should have close followup from her hepatologist with regard to her volume status and renal function. 5. CARDIOVASCULAR ISSUES: The patient was hypotensive on admission. She had no hypertension during her hospital stay. Due to concerns about her blood pressure stability, her outpatient regimen, including atenolol and Diovan, were held throughout her hospital stay. Following her colonoscopy, the patient's blood pressure did increase to a systolic blood pressure in the 80s. She required intravenous fluid boluses to improve her volume status and did respond appropriately. Her blood pressure medications will be restarted as an outpatient when her blood pressure returns to baseline. 6. INFECTIOUS DISEASE ISSUES: The patient had evidence of consolidation/infiltrate on her admission chest x-ray. Although, she was afebrile and did not have a white blood cell count elevation, there was concern that an infectious process could be leading to her decompensation. She was given a course of Levaquin for seven days and remained afebrile and stable without a white blood cell count elevation. Blood cultures and urine cultures were not revealing. 7. PSYCHIATRIC ISSUES: The patient was continued on her outpatient Zoloft dose to address her baseline depression and anxiety. 8. RESPIRATORY ISSUES: On [**3-27**] the patient was noted to have intermittent wheezing throughout the day. Her pulse oximetry did drop to 92% on room air during the evening that day. She responded well to albuterol nebulizer and a dose of intravenous Lasix. A chest x-ray done following this event showed a small left pleural effusion, but no evidence of infiltrate or congestive heart failure. 9. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was initially given intravenous fluids to replete her volume deficits. She was advanced to clears and then to a low-protein diet and was tolerating a full diet at the time of discharge. 10. PROPHYLAXIS ISSUES: The patient was continued on Protonix and had baseline auto anticoagulation. CONDITION AT DISCHARGE: Hemodynamically stable, afebrile, tolerating a full diet, with improved mental status. DISCHARGE STATUS: To rehabilitation. DISCHARGE DIAGNOSES: 1. Hepatic encephalopathy. 2. Primary biliary cirrhosis with end-stage liver disease. 3. Hypotension. 4. Anemia. 5. Gastrointestinal bleed. 6. Acute renal failure. 7. Ammonia. 8. Depression and anxiety. MEDICATIONS ON DISCHARGE: 1. Folic acid 1 mg by mouth once per day. 2. Sertraline 50 mg by mouth once per day. 3. Pantoprazole 40 mg by mouth once per day. 4. Spironolactone 25 mg by mouth once per day. 5. Furosemide 20 mg by mouth once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with her liver doctor (Dr. [**First Name (STitle) **] [**Name (STitle) **]) within the next week to follow up on management of her hepatic encephalopathy and her volume status. At that time restarting her outpatient blood pressure medications including atenolol and Diovan should be considered. She will need followup regarding her renal failure issues. The patient had an appointment scheduled with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2114-4-17**] at 1:50 p.m. 2. The patient was instructed to follow up with her primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**] (telephone number [**Telephone/Fax (1) 904**]) within the next week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 1615**] MEDQUIST36 D: [**2114-3-28**] 09:30 T: [**2114-3-28**] 09:32 JOB#: [**Job Number 98462**] Admission Date: [**2114-3-20**] Discharge Date: [**2114-5-22**] Date of Birth: [**2045-11-30**] Sex: F Service: Tranplant Surgery HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old female with a history of primary biliary cirrhosis and end-stage liver disease with a past medical history of hypertension, history of atrial fibrillation, anxiety, and depression. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Diovan 160 mg by mouth once per day. 2. Protonix 40 mg by mouth once per day. 3. Folate 1 mg by mouth once per day. 4. Atenolol 50 mg by mouth once per day. 5. Ursodiol 30 mg by mouth once per day. 6. Lasix 40 mg by mouth once per day. 7. Spironolactone 50 mg by mouth once per day. 8. Zoloft. SOCIAL HISTORY: No tobacco. No alcohol. She is single and lives with her brother. PHYSICAL EXAMINATION ON PRESENTATION: The patient was markedly jaundiced and obese. The patient was afebrile with slight hypotension. She was saturating 97% on room air. The lungs were clear to auscultation bilaterally. The heart was regular in rate and rhythm. The abdomen was soft, nontender, and nondistended. Extremities revealed 2+ dorsalis pedis pulses bilaterally. There was no clubbing, cyanosis, or edema. The patient did have asterixis on presentation. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 9, her hematocrit was 31.2, and her platelets were 153. Aspartate aminotransferase was 208, alanine-aminotransferase was 92, alkaline phosphatase was 161, albumin was 2.5, and her total bilirubin was 17.7. She had chemistries which revealed sodium of 133, potassium was 5, chloride was 103, bicarbonate was 19, blood urea nitrogen was 47, creatinine was 1.8, and her blood glucose was 82. Urinalysis was negative. SUMMARY OF HOSPITAL COURSE: The patient has end-stage liver disease secondary to primary biliary cirrhosis with chronic renal failure and a high MELD score and presented for orthotopic liver transplantation on [**2114-3-20**] where she was managed perioperatively with continuous venovenous hemofiltration. The patient's postoperative course was remarkable for development of a delayed bleed on postoperative day 16, for which she was taken back to the operating room and washed out. At that time, a bile duct anastomosis was revised. The patient developed a second stricture which was treated with endoscopic retrograde cholangiopancreatography and stenting. She had a hepatic artery stenosis for which she was treated with a metal stent and then treated with aspirin and then aspirin and Plavix. She also developed acute cellular rejection treated with a steroid taper. Lastly, she developed contrast nephropathy with intravenous dye which was worsened by development of hemolytic uremic syndrome secondary to cyclosporine. Her cyclosporine and Plavix were discontinued, and she required one week of dialysis before her renal function returned. The patient currently requires tube feedings to meet her caloric goal. Once she reaches 2500 kilocalories per day, tube feedings may be discontinued. The patient will require intense Physical Therapy and Occupational Therapy at rehabilitation. She is a diabetic and on a diabetic diet. The patient has type 2 diabetes mellitus worsened by a steroid taper. She is on 30 units of NPH in the evening with q.6h. fingerstick checks as well as a Humalog sliding-scale. Lastly, the patient is on a steroid taper for rejection at 0.4 mg/kg of prednisone equalling 25 once per day; for which she will be on for seven days and then 0.3 mg/kg equalling 20 mg of prednisone once per day for 30 days, at which point the steroid taper will be adjusted at clinic. She will require Monday and Thursday laboratories; including a Chem-10, liver function tests, complete blood count, and rapamycin level. Every Wednesday, the patient should return to the clinic for an appointment. Postoperatively, the patient developed agitation and anxiety which resolved after anxiolytic medications were given. DISCHARGE DISPOSITION: The patient was discharged to rehabilitation on [**2114-5-22**]. CONDITION AT DISCHARGE: On postoperative days 47 and 30 the patient was discharged to rehabilitation without event; in good condition, on tube feeds, and requiring intensive physical therapy. MEDICATIONS ON DISCHARGE: 1. Prednisone 25 mg by mouth once per day. 2. Levofloxacin 250 mg by mouth once per day. 3. ?Prednisone 25 mg by mouth twice per day. 4. Lasix 80 mg by mouth twice per day. 5. Rapamycin 1 mg by mouth once per day. 6. Humalog sliding-scale. 7. NPH fixed dose of 30 units in the evening. 8. Lopressor 100 mg by mouth twice per day. 9. Norvasc 5 mg by mouth once per day. 10. Hydralazine 50 mg by mouth q.4h. 11. Imdur 10 mg by mouth three times per day 12. Sertraline 50 mg by mouth once per day. 13. Erythromycin 0.5% ophthalmic ointment left eye four times per day. 14. Albuterol nebulizer solution 1 nebulizer inhaled q.6h. as needed. 15. Aspirin 325 mg by mouth once per day. 16. CellCept [**Pager number **] mg by mouth q.6h. 17. Lansoprazole 30 mg by mouth once per day. 18. Fluconazole 200 mg by mouth once per day. 19. Alprazolam 2.25 mg by mouth at hour of sleep. 20. Valcyte 450 mg by mouth every other day. 21. Bactrim single strength one tablet by mouth every day. 22. Miconazole powder 2% one application topically three times per day. DISCHARGE DIAGNOSES: 1. End-stage liver disease secondary to primary biliary cirrhosis. 2. Status post orthotopic liver transplantation. 3. Status post biliary duct revision and washout. 4. Status post hepatic artery thrombosis with stenting. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to follow up in the clinic on Wednesday and have routine laboratory draws of complete blood count, Chemistry-10, liver function tests, and rapamycin level twice weekly (on Monday and Thursday). [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**] Dictated By:[**Last Name (NamePattern4) 7013**] MEDQUIST36 D: [**2114-5-21**] 18:26 T: [**2114-5-21**] 18:50 JOB#: [**Job Number 98463**]

[ "998.11", "584.5", "789.5", "283.11", "578.9", "572.2", "572.4", "996.82", "571.6" ]

icd9cm

[ [ [] ] ]

[ "54.12", "45.23", "96.6", "39.90", "50.12", "50.59", "38.95", "96.04", "39.50", "88.47", "51.98", "39.95", "96.72", "51.94" ]

icd9pcs

[ [ [] ] ]

15067, 15143

16453, 16680

15354, 16432

11443, 11749

16715, 17212

12828, 15042

4256, 9251

15158, 15327

11152, 11417

1105, 1376

11766, 12799

47,286

155,315

39799

Discharge summary

report

Admission Date: [**2182-7-29**] Discharge Date: [**2182-8-19**] Date of Birth: [**2113-6-9**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Heparin Agents / Arixtra Attending:[**Attending Info 65513**] Chief Complaint: Ovarian Cancer Major Surgical or Invasive Procedure: bilateral salphingo-oopherectomy, tumor debulking, rectosigmoid colectomy with reanastamosis, diaphragmatic ablation, ureterolysis History of Present Illness: Ms. [**Known lastname 32400**] is a 69 yo G0 transferred from [**Hospital6 16464**] where she was admitted [**2182-7-19**] with progressive abdominal distension and discomfort, and was found to have ascites, omental caking and evidence of carcinomatosis with a markedly elevated CA-125. Primary surgical management with radical cytoreductive surgery and debulking with a goal of optimal debulking were planned. She was admitted to the surgical floor the evening before for a bowel prep. Past Medical History: POBHx: G0 PGynHx: Menarche at age 13. Surgical menopause at age 39 at time of hysterectomy. She then had menopausal symptoms 10-12 years later. She did not have hormone replacement therapy. No history of pelvic infections. She never had any abnormal Pap tests. She is not currently sexually active and has not been for about a decade. PMH: 1. Arthritis 2. Hypothyroidism 3. Anxiety disorder 4. Osteoporosis 5. Hypertension PSH: 1. TAH for fibroid uterus ([**2151**]) (ovarian sparing) 2. Bilateral knee replacement ([**2167**]) Social History: She lives alone. Widowed 7 years ago. She denies tobacco, alcohol, or durgs. Uses a cane for ambulation over long distances. Family History: No family history of ovarian, uterine, breast, or colon cancer. Physical Exam: VS: 95.9 132/74 109 20 99%RA Gen: NAD Card: Not tachycardiac on exam. Normal S1, S2 without murmur Resp: Clear bilaterally, no wheezes or crackles. Abd: Soft, +BS, distended and dull to percussion, diffuse mild tenderness without rebound or guarding. No HSM or other masses appreciated. Well healed infra-umbilical vertical midline scar. Pelvic: Deferred Ext: NT, NE. Scars bilaterally over knees. Pertinent Results: Labs on admission: [**2182-7-29**] 12:55PM CA125-2292* [**2182-7-29**] 12:55PM WBC-10.8 RBC-4.38 HGB-12.0 HCT-37.2 MCV-85 MCH-27.4 MCHC-32.2 RDW-13.5 [**2182-7-29**] 03:45PM PT-16.0* PTT-38.7* INR(PT)-1.4* [**2182-7-29**] 12:55PM GLUCOSE-146* UREA N-12 CREAT-0.5 SODIUM-137 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-28 ANION GAP-15 Imaging: [**8-5**] CTA Chest: 1. Eccentrically located focal right upper lobe pulmonary embolism, age indeterminate, but which does not have the typical appearance of an acute embolus. 2. Large bilateral pleural effusions with significant collapse of the lower lobes bilaterally. Micro/Cytology: [**2182-7-30**] Peritoneal fluid(ascites) negative for malignant cells [**2182-8-5**] Blood Culture: [**1-9**] sets w/ ABIOTROPHIA/GRANULICATELLA SPECIES. Brief Hospital Course: Ms. [**Known lastname 32400**] was admitted pre-operative for a bowel prep prior to her planned debulking procedure for metastatic ovarian cancer. She tolerated the procedure well; please see operative note for full surgical details. She was taken to the [**Hospital Unit Name 153**] for further monitoring post-operatively. She did well overall but her course was complicated by pulmonary embolism, bacteremia, atrial fibrillation and UTI. . #. Pulmonary Embolism: seen on CTA [**2182-8-5**] in the right middle lobe. Lower extremity ultrasounds were negative for DVT. Patient has history of Heparin allergy (severe rash with desquamation) and thus received Arixtra postoperatively. She developed a PE while on Aritxta, therefore she was started on Argatroban drip per recommendations from the allergy team. She was simultaneously started on Coumadin. She reached INR goal on [**2182-8-12**] and Argatroban was discontinued on [**2182-8-14**]. She was discharged on Coumadin 2.5mg PO with INR of 2.9. She should not receive Aritxta in the future as per hematology. . #. Bacteremia: She had blood cultures from [**8-5**] showing ABIOTROPHIA/GRANULICATELLA. She was started on IV Vancomycin 1g [**Hospital1 **] on [**2182-8-9**] and ID was consulted. Knee plain films were normal. TEE revealed no vegetations. She was sent home after her last Vancomycin dose on [**2182-8-19**]. . #. Paroxysmal Atrial Fibrillation with rapid ventricular response: In the ICU her rhythm was converted with metoprolol, which was continued on the floor. The afib was likely secondarily to her bacteremia and she had no further Arrythmias noted during the rest of her hospitalization. She was continued on metoprolol at discharge. . #. UTI: Urine culture on [**2182-8-15**] noted to grow Proteus Mirabilis and was started on Bactrim on [**2182-8-18**] for 3 days. The Bactrim was switched to Amoxicillin on [**2182-8-19**] for the remainder of the course given the fact that Bactrim interacts with Warfarin. She was asymptomatic. . She was discharged on [**2182-8-19**]. She will follow up for chemotherapy with Dr [**Last Name (STitle) **] for chemotherapy as an outpatient. Medications on Admission: 1. Levothyroxine 25 mcg po daily 2. Alprazolam 0.25 mg po tid prn anxiety 3. Methotrexate 15 mg qweek (qTuesday) 4. Amlodipine 10mg po qhs 5. Vitamin D 1000 units 1 tab po daily 6. Folic acid 1 mg po daily 7. Tums 1200 mg po daily 8. Percocet 1-2 tabs every 4-6 hours prn pain Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: please have your INR checked 1-2 times a week while taking this medication as your primary care provider [**Name Initial (PRE) 41154**]. Disp:*30 Tablet(s)* Refills:*2* 3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 2 days. Disp:*8 Capsule(s)* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: not to exceed 4000mg tylenol in 24 hours. Do not drive while taking this medication. Disp:*30 Tablet(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Ovarian cancer Pulmonary Embolism urinary tract infection 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: 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 -Nothing in vagina 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 [**Name Initial (PRE) **] completely dry after washing. -You may resume your regular diet and home medications. Followup Instructions: Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**]. You should see Dr [**Last Name (STitle) 5797**] in [**1-9**] weeks. Please call his office for a follow up appointment. Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2182-8-22**] 11:00 Your primary care doctor, Dr [**First Name (STitle) **] [**Name (STitle) 20260**], [**First Name3 (LF) **] be following your INR lab test while you are on Coumadin. you should call his office at [**Telephone/Fax (1) 20261**] to coordinate having this lab drawn 1-2 times a week. His office will call you with any concerning results. [**Name6 (MD) 35354**] [**Name8 (MD) **] MD [**MD Number(2) 65515**] Completed by:[**2182-8-19**]

[ "244.9", "300.00", "415.11", "197.5", "599.0", "197.6", "198.89", "197.4", "427.89", "584.9", "427.31", "733.00", "790.7", "789.59", "997.5", "041.09", "293.0", "288.60", "041.6", "276.0", "518.5", "183.0", "714.0", "V88.01", "V43.65", "998.59", "427.32", "997.1", "401.9", "E878.8", "240.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "48.23", "65.61", "45.33", "88.72", "59.02", "48.69", "96.71", "34.81", "54.4" ]

icd9pcs

[ [ [] ] ]

6464, 6470

2999, 5160

311, 444

6572, 6572

2185, 2190

7434, 8261

1682, 1748

5487, 6441

6491, 6551

5186, 5464

6755, 7411

1763, 2166

257, 273

472, 960

2205, 2976

6587, 6731

982, 1520

1536, 1666

54,110

146,300

52273

Discharge summary

report

Admission Date: [**2195-5-4**] Discharge Date: [**2195-5-11**] Date of Birth: [**2114-8-25**] Sex: M Service: SURGERY Allergies: Tetanus / Vicodin / Ambien Attending:[**First Name3 (LF) 4691**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2195-5-5**] Exploration of left inguinal hernia with small- bowel resection of approximately 60 cm with primary stapled side-to-side anastomosis, omentum resection and primary closure of the inguinal defect. [**2195-5-7**] Right basilic PICC line History of Present Illness: Patient is an 80M with PMH significant for MI x 2 s/p stents placement ([**2179**]), COPD/emphysema and sleep apnea, presenting with incarcerated likely left femoral hernia. Patient is uncertain as to when the herniation happen, but denies any pain until early last night/ this morning. Pain described as constant and is localized to left lower quadrant. Incidentally he also fell out of bed in the morning on day of presentation, does not recall how, did not sustain any injury. Patient reports last bowel movement 2 days ago. Normally has a bowel movement every day. He denies constipation or diarrhea, vomiting or nausea. Denies fevers, chills or night sweats. Patient was seen by his PCP last week for evaluation of the rash that he developed in the left groin area. The PCP did not notice the hernia. Patient had no abdominal pain at that time. Past Medical History: PMH: - chronic dyspnea - Severe osteoarthritis - Right parotid cyst - Asthmatic bronchitis/ emphasyma - COPD - sleep apnea - Right cataract extraction - CAD - MI x 2 s/p cardiac stents placement (? [**2179**]) - hypertension - cardiomyopathy - LVEF 40% PSH: - Bilateral total knee replacements - left inguinal hernia repair approximately 25 years ago Social History: lives with a wife, increasing dementia over the past 6 months, walks with a cane, was a real eastate lawyer Family History: non contributory Physical Exam: Upon presentation to [**Hospital1 18**]: Temp 98.0 HR 74 BP 187/88 RR 20 O2 sat 97% RA gen: NAD, pleasant CV: RRR pulm: CTA b/l abdomen: obese, + BS, ND, tender in the LLQ where there is a large hernia contanining bowel, it is not reducible extremities: no edema bilaterally Pertinent Results: [**2195-5-4**] 04:50AM WBC-8.4 RBC-4.35* HGB-13.8* HCT-41.3 MCV-95 MCH-31.7 MCHC-33.3 RDW-14.4 [**2195-5-4**] 04:50AM NEUTS-79.2* LYMPHS-17.0* MONOS-2.1 EOS-0.9 BASOS-0.8 [**2195-5-4**] 04:50AM PLT COUNT-141* [**2195-5-4**] 04:50AM ALT(SGPT)-22 AST(SGOT)-26 ALK PHOS-63 TOT BILI-0.9 [**2195-5-4**] 04:50AM GLUCOSE-127* UREA N-29* CREAT-1.4* SODIUM-145 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-23 ANION GAP-18 [**2195-5-4**] CT Abd/pelvis : 1. Incarcerated left inguinal hernia with multiple dilated bowel loops within the hernia sac. 2. Bilateral adrenal nodules, incompletely assessed. Recommend further evaluation with non-emergent MRI. 3. Multiple bilateral probable renal cysts, some of which too small to fully characterize [**2195-5-5**] Head CT : No acute intracranial process. Brief Hospital Course: Mr. [**Known lastname 23**] was evaluated by the Acute Care service in the Emergency Room and based on his physical exam and Abdominal CT urgent surgery was recommended. Due to his other co morbidities he underwent medical clearance from Pulmonology and Geriatric Medicine prior to going to the Operating Room. On [**2195-5-5**] he was taken to the Operating Room and underwent an exploration of the left inguinal hernia with a small bowel resection and closure of the hernia defect. He tolerated the procedure well and returned to the SICU in stable condition. He maintained stable hemodynamics and was eventually extubated. Postoperatively he had problems with profound delirium which reportedly happened with previous hospitalizations. A Head CT was done to assure there was no acute pathology and it was essentially normal. Following transfer to the Surgical floor his mental status remained about the same. He knew his name but otherwise perseverated and had periods of agitation. The Geriatric team had consulted early on during his hospital stay and were re-consulted again with this acute delirium. They felt that he may have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 309**] Body dementia and recommended treatment with Ativan as opposed to Haldol. His narcotics were minimized and eventually he improved. Currently he is awake, oriented to self, cooperative and without any episodes of agitation. Due to difficult venous access a PICC line was placed in the Right basilic vein on [**2195-5-7**]. This was strictly for IV access and can be removed once it is no longer needed. His diet was advanced on post op day #3 and he remained free of nausea or vomiting. His abdominal incision was noted with erythema and mild induration, Keflex was started and ordered for a total of 7 days. Physical Therapy was consulted and have recommended a stay in a short term rehab prior to returning home to increase his mobility and endurance. Medications on Admission: - amlodipine 5 mg daily - lasix 20 mg daily - atorvastatin 20 mg daily - carvedilol 12.5 mg qam - carvedilol 25 mg qpm - fexofenadine - ipratropium - nitroglycerin - acteaminophen - aspirin 325 mg daily - ibuprofen 200 mg dialy - benadryl 50 mg daily Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing . 3. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 4. quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO three times a day. 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 6 PM. 11. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 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. 14. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 15. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days. 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) Grams PO DAILY (Daily). 19. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. Incarcerated left inguinal hernia with gangrenous small bowel and gangrenous omentum 2. Wound cellulits 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 hospitalized with a hernia in your groin that was incarcerated with a portion of your intestines that was badly damaged requrirng an operation to repair this. Your operation was successful, you did however develop an infection along your incision called cellulitis and now being treated with an antibiotic called Keflex for 7 days total. *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. Followup Instructions: Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment next week. Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2195-5-19**] 1:30 Completed by:[**2195-7-17**]

[ "428.22", "V45.82", "998.59", "294.10", "278.00", "682.2", "327.23", "272.0", "557.0", "E878.2", "550.01", "401.9", "428.0", "493.20", "412", "331.82", "425.4", "V43.65", "293.0" ]

icd9cm

[ [ [] ] ]

[ "45.62", "45.91", "53.00", "54.4" ]

icd9pcs

[ [ [] ] ]

7127, 7193

3108, 5074

300, 553

7344, 7344

2291, 3085

8139, 8435

1952, 1970

5376, 7104

7214, 7323

5100, 5353

7527, 8116

1985, 2272

246, 262

581, 1434

7359, 7503

1456, 1810

1826, 1936

7,524

183,007

27049

Discharge summary

report

Admission Date: [**2194-1-10**] Discharge Date: [**2194-1-25**] Date of Birth: [**2153-11-28**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: MVA: pedestrian v car or s/p assault Major Surgical or Invasive Procedure: Right frontal bolt placement Right hemicraniotomy with temporal lobectomy. History of Present Illness: Patient is a 40y/o female presumed to have been struck by a car or s/p assault at around 11pm and taken to an OSH where she was noted to have been combative and was intubated. She was then transferred to [**Hospital1 18**] for ongoing care of a basilar skull fracture. Past Medical History: unavailable Social History: Unavailable Family History: Unavailable Physical Exam: Vitals: T 101.8 rectal, HR 58, BP 127/69, RR 15, SaO2 100% on FiO2 100% Gen intubated in NAD Neuro: Pt withdrawls to pain, but does not follow commands. Pupils are 2mm and equal bilaterally, Right reactive, Left fixed. Pt does move all extremities in response to pain. HEENT: there is hemotympanum in the pt's R ear, but the Left is obscured by impacted cerumen. Blood is noted in the pt's hair posteriorly, but no battle sign, no racoon eyes. Pulm: LCTAB/L CV: RRR Pertinent Results: Labs:+cocaine, +methadone. Na 139, K 4.0, Cl 100, glu 177, BUN 13, Cr 0.7 Wbc 21.3, Hgb 11.8, Hct 33.4, plt 242 CT Head: Basilar skull frx across the clivus, bitemporal and bifrontal intraparenchymal bleeds, R>L. There is diffuse effacement of the sulci superiorly, and compression of the R ventricle. 4th ventricle intact. No subdural or epidural hematomas seen. Some opacification noted of the ethmoid air cells, with air/fluid level noted in sphenoid sinus. No pneumocephalus. Brief Hospital Course: 40 year old female admitted via ED after pressumed struck by a car vs s/p assault, intubated at OSH. A CT scan revealed bilateral frontoparietal hemorrhages, skull base fracture, and diffuse cerebral edema. The patient was administered Dilantin, Decadron and mannitol. A bolt was placed on the right side on [**2194-1-10**] to monitor ICP. Started kefzol while bolt in place. Intial ICP is ~50, despite mannitol administration ICP's remained high therefore patient placed on pentabarb coma on [**1-10**] and discontinued on [**2194-1-12**]. The patient was taken to the OR on [**2194-1-11**] for a right hemicraniotomy and temporal lobectomy for increased vasogenic edema surrounding the bilateral frontal and temporal lobe hemorrhagic contusions and ICP's continued to be high . A post-op CT scan showed no new hemorrhages or mass effect. The right side bolt was removed on the same day of surgery. Patient started on tube feeds however patient unable to tolarete, therefore placed on a total parenteral nutrition. Patient has been febrile since admission. Initial blood cultures and urine culture was negative fo growth but sputum cultures from [**2194-1-10**] grew H. influenzae and yeast, Ampicillin is (sensetive to H. flu)started, she received a 10 day course per ID and did not need any further antibiotics. On [**1-11**] there was questionable seizure activity which was left sided shakiness and twitching on the face. EEG revealed [**1-11**] encephlopathy repeat on [**1-18**] no seizure activity. After discontinuing the pentabarb, the patient opened her eyes and moved all four extremities in response to pain. A CTA of the head and neck obtained on [**2194-1-13**] was negative for dissection. A repeat CT head [**1-13**] showed a slight increase of edema in the left temporal lobe. Restarted her methadone as she was dose to half her home dosage. Urine culture [**1-14**] grew enterococcus sensetive to ampicillin as well. On [**2194-1-17**] and [**1-20**] LP preformed to rule meningitis for ongoing fever. Gram stain of CSF was negative for any infectious process. Patient neurologically improwed slowly and gradually, able to extubate approximately on [**1-19**] and was transferred to the neurostep down on [**1-21**] While in stepdown unit her antibiotic course was completed and no further antibiotics were needed per ID. Her tube feedings were at goal. She was fitted for a helmet in order to begin ambulation. She had survelliance LENIs on [**1-20**] which were negative for an DVT. Neurologically she was awake, alert, followed simple commmands, attempted to speak with a weak voice. Her head incision was noted to have some breakdown near where the helmet ended, a wound care consult was obtained and patient was started on Keflex. On the afternoon of [**2194-1-25**] she was noted to be tachypnic, tachycardic, and hypotensive. The house officer was called and responded (see HO note). Pt deteriorated quickly and a code was called several minutes after the HO had begun assessing the pt. The code ran for over 40 min but the pt was never in a stable perfusing rythym. Pt was declared dead and the medical examiner has elected to perform the post-mortem. Medications on Admission: methadone Discharge Medications: none Discharge Disposition: Extended Care Discharge Diagnosis: s/p head trauma - bilateral frontal lobe contusions, right temporal lobectomy, right sided hemicraniectomy, complicated by acute cardiopulmonary decompensation, possible PE Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2194-2-3**]

[ "518.0", "E988.8", "378.54", "E849.5", "801.26", "780.39", "304.01", "599.0", "E878.6", "304.21", "E849.7", "292.0", "415.11", "041.04", "801.16", "276.3" ]

icd9cm

[ [ [] ] ]

[ "38.91", "99.15", "96.72", "03.31", "02.12", "99.60", "89.14", "94.65", "01.18", "99.04", "38.93", "01.59" ]

icd9pcs

[ [ [] ] ]

5125, 5140

1839, 5036

358, 434

5357, 5366

1329, 1442

5419, 5453

814, 827

5096, 5102

5161, 5336

5062, 5073

5390, 5396

842, 1310

281, 320

462, 734

1451, 1816

756, 769

785, 798

19,402

134,254

25894

Discharge summary

report

Admission Date: [**2188-8-4**] Discharge Date: [**2188-8-14**] Date of Birth: [**2154-3-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: Chest pain, empyema Major Surgical or Invasive Procedure: [**2188-8-4**]: Transfer to MICU and Intubation [**2188-8-6**]: VATS procedure with placement of three chest tubes 07-[**Numeric Identifier 64404**]: Placement of right IJ line [**2188-8-11**]: Extubation and removal of three chest tubes [**2188-8-14**]: Removal of Right IJ line History of Present Illness: 34yr old female with hx of substance abuse, hepatitis C who developed back pain 5 days prior to admission. Over the next 2 days, the pain became pleuritic and she developed increasing shortness of breath and a productive cough. She noted fevers to 102. Pt used cocaine to numb her pain but any movement made the pain worse. She denied chest pain, orthopnea, PND, edema, weight loss and night sweats. Pt called EMS and was brought to [**Hospital6 **]. There, pt was found to have an effusion and PNA on CXR. Given that the effusion was loculated, it was tapped using CT guidance. The thoracentesis revealed 20 cc of turbid fluid with gelatinous appearance. Based on lab results (see below), effusion consistent with a parapneumonic effusion vs empyema. Pt was then started on clinda/flagyl/ceftriaxone transferred to [**Hospital1 18**] for VATS procedure. . On arrival to [**Hospital1 18**], pt was evaluated by surgery and scheduled for VATS on [**8-6**]. On the day following admission, pt was doing well, satting in the low 90s on RA. However, during the evening, pt's pain increased, she began splinting, breathing at 30-40 and her room air sats dropped to 70%. She was placed on a NRB and her sats improved to 90s. She was then transferred to the MICU for elective intubation and pain control prior to VATS. . Allergies: NKDA Past Medical History: 1. Polysubstance abuse - currently on methadone, recent cocaine use 2. Hepatitis C 3. Spontaneous Abortion ([**Month (only) 116**]) with persistent spotting, inc b-HCG 4. Asthma 5. Nephrolithiasis 6. s/p appendectomy Social History: Pt lives with a friend. She has a three year old daughter who is currently in the custody of the DSS. Pt has a mother but did not want her involved regarding the details of her care. Pt used heroin in the past but reported only IV cocaine use prior to admission. Denies ETOH. Current tobacco use. - Current PSA: on needle exchange, current cocaine use, prior heroin use, on methadone - has been in jail multiple times - denied TB exposure Family History: father with lung cancer Physical Exam: Exam: temp 100.3, BP 114/79, HR 90, RR 36, O2 71% RA --> 94% on NRB Gen: sleepy but arousable to voice, answers questions appropriately; tachypneic HEENT: PERRL, EOMI, MM dry, scabbed ulcer on upper left lip CV: RRR, no murmurs Chest: short insp breaths [**3-5**] pain, crackles heard throughout, decreased on right side [**2-3**] way up chest Abd: +BS, soft, NTND, obese Back: tender over right lower back Ext: no edema, 2+ DP Skin: multiple track marks on both hands; no splinter hemorrhages or [**Doctor Last Name **] spots Pertinent Results: OSH labs: ** Pleural fluid: yellow cloudy fluid WBC 560, 95% neuts, 4% lymphs RBC 1110 TP 5.3 LDH 942 Glucose 2 Culture: no growth . . [**Hospital1 18**] Labs: Admission Labs: [**2188-8-5**] 02:30AM BLOOD WBC-15.6* RBC-3.76* Hgb-10.3* Hct-30.4* MCV-81* MCH-27.2 MCHC-33.8 RDW-11.9 Plt Ct-289 [**2188-8-5**] 02:30AM BLOOD Neuts-84.9* Lymphs-10.0* Monos-3.9 Eos-0.8 Baso-0.3 [**2188-8-5**] 02:30AM BLOOD PT-12.9 PTT-26.1 INR(PT)-1.1 [**2188-8-5**] 02:30AM BLOOD Glucose-122* UreaN-10 Creat-0.5 Na-141 K-3.7 Cl-107 HCO3-25 AnGap-13 [**2188-8-5**] 02:30AM BLOOD Calcium-8.3* Phos-3.8 Mg-1.8 [**2188-8-5**] 02:30AM BLOOD HCG-22 [**2188-8-5**] 08:40AM BLOOD HIV Ab-NEGATIVE Microbiology: Blood cultures: [**8-11**]- No growth [**8-10**]- No growth [**8-9**]- No growth [**8-8**]- No growth [**8-5**]- No growth . HIV ([**8-5**])- Negative . Pleural tissue: [**8-6**]- Gram stain with 2+ PMNs and no organisms- Cultures pending. [**8-6**]- Sparse oxacillin resistant coag + staph aureus. . . Radiology: [**2188-8-5**]: CXR: similar to prior though with worse inspiration: Findings most likely consistent with pneumonia. Loculated pleural effusion to suggest empyema. [**2188-8-11**]: The heart size and mediastinal contours are unchanged. There has been interval removal of the right-sided chest tubes. Interval increase in size of a right pneumothorax. Stable right pleural effusion layering within the fissure and stable bibasilar atelectasis. The osseous structures appear unchanged. [**2188-8-13**]: Since the previous examination of [**8-13**], the right subclavian venous access catheter appears in unchanged position. There is stable enlargement of the cardiac silhouette. No pulmonary edema. Bilateral pleural effusions, more prominent on the right and bibasilar atelectasis appear similar. No pneumothorax. . Chest CT: [**2188-8-5**] 1. Multifocal pulmonary and parenchymal consolidation, most prominent within the right lower lobe, consistent with pneumonia. 2. Bilateral pleural effusions. The right pleural effusion is loculated with suggestion of peripheral enhancement, indicating the possibility of infected effusion/empyema. 3. Mild cardiomegaly and possible mild congestive heart failure. . . Discharge Labs: [**2188-8-13**] 05:26AM BLOOD WBC-9.7 RBC-3.93* Hgb-10.4* Hct-31.1* MCV-79* MCH-26.5* MCHC-33.4 RDW-12.3 Plt Ct-625* [**2188-8-13**] 05:26AM BLOOD Neuts-61.9 Lymphs-25.6 Monos-5.9 Eos-6.0* Baso-0.6 [**2188-8-13**] 05:26AM BLOOD Plt Ct-625* [**2188-8-12**] 06:33AM BLOOD Glucose-88 UreaN-6 Creat-0.5 Na-140 K-4.1 Cl-102 HCO3-30 AnGap-12 [**2188-8-13**] 04:12PM BLOOD ALT-13 AST-15 LD(LDH)-173 AlkPhos-63 Amylase-40 TotBili-0.3 Brief Hospital Course: 1. Empyema: Patient was admitted to [**Hospital1 18**] on [**2188-8-4**] with known diagnosis of empyema from OSH. She was admitted for planned VATS and drainage of infected fluid.On the day of admission. Upon admission she was receiving ceftriaxone, flagyl, and clindamycin which was continued upon admission. The patient was evaluated by thoracic surgery with planned Right thoracotomy and vats procedure for loculated right pleural effusion. However, the patient became increasingly tachypnic on the floor with decreasing O2 saturation requiring intubation and transfer to the MICU and Flagyl was discontinued. ON [**2188-8-6**] the patient underwent VATS with decortication and placement of three chest tubes. Patient failed original weaining trials secondary to sedation. Additionally, as the patient continued to spike despite abx coverage, the patient was changed from ceftiaxone and clindamycin to zosyn and vancomycin for broadened coverage. The patient was successfully extubated on [**2188-8-11**] and the patient's chest tubes were removed without complication. The patient was transferred back to the medical service after successful extubation, afebrile with a resolving leukocytosis and all blood cultures with no growth. However, pathology from pleural tissue removed from the VATS demonstrated oxacillin resistant staph aureus. The patient was continued on Zosyn and Vancomycin and remained afebrile while on the floor. The patient was found additionally to have a small pneumothorax s/p removal of chest tubes which remained stable with some resolution while patient was on medicine service. The patient remained afebrile and clinically stable with good Os sats without O2 support. The patient was discharged to home with Linezolid 600mg [**Hospital1 **] for 1 week for coverage of her known MRSA infection. The patient was discharged with plans to follow up with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for blood work and follow up. . 2. Back/Chest Pain: The patient was in significant pain upon admission and was thought to be splinting which contributed to her respiratory distress. The patient was electively intubated as described above and given adequate pain control while intubated. After extubation, the patient was given her usual methadone dose of 60mg po daily as well os percocet 1-2 tabs every 4 to 6 hours with adequate control. . 3. Substance Abuse: Prior to admission the patient was planned to undergo a methadone taper. She was continued on a maintenance dose of 60mg po qd while in house, but contact was made with her methadone clinic to make them aware of her dosing as well as her recent cocaine use. . 4. Pneumothorax: S/p extubation and chest tube withdrawal on [**2188-8-11**] the patient was noted to have a small pneumothorax. This was followed daily and assessed to be stable with some resolution. The patient was instructed to follow up with her PCP and ensure full resolution. . 5. Gyn: Patient was known to have recent miscarriage and ongoing spotty bleeding. The patient' B-HCG was 25, down from 970 in [**Month (only) 116**]. Gyn was consulted and advised that the B-HCG was consistent with resolving from previous miscarriag rather than an ongoing ectopic and signed off with advise that a follow up HCG be performed in a week. The patient upon discharge was advised to have a repeat b-HCG performed when she went to see her PCP. Medications on Admission: 1. Docusate 100 mg [**Hospital1 **] 2. Methadone 60 mg daily 3. Metoclopramide 10 mg IV Q6H 4. Pantoprazole 40 mg daily 5. Zosyn 4.5 mg IV Q8H 6. Vancomycin 1000 mg Q12H 7. SC heparin TID Discharge Medications: 1. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks: Please complete entrie course of antibiotics,even if feeling better. Thank you. Disp:*14 Tablet(s)* Refills:*0* 2. Methadone 10 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily): You will need to obtain this through your methadone treatment center. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for 1 weeks. Disp:*25 Tablet(s)* Refills:*0* 5. Outpatient Lab Work Please check a CBC on [**8-21**]. Thanks. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Right sided empyema and paraneumonic effusion Secondary diagnosis: Drug abuse- IV cocaine Hepatitis C Asthma Discharge Condition: Stable. Patient's oxygen saturation mid to high 90's on room air. Patient afebrile. Patient with small stable right pneumothorax s/p removal of three chest tubes on [**2188-8-11**]. Discharge Instructions: 1. Please keep all follow up appointments. 2. Please take all medications as prescribed. 3. Seek medical attention for fevers, chills, chest pain, shortness of breath, bleeding from the chest tube sites, or any other concerning symptoms. 4. You must follow up at [**Hospital **] Community Health Center on [**8-21**]. It is very important that you have lab tests while on the linezolid. You will have a lab draw and a physician's appointment on [**8-21**]. 5. It is extremely important that you avoid all drugs and alcohol. You have been very sick and these could slow your recovery. Followup Instructions: 1. Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Last Name (NamePattern1) **] Community Health Center on Thurs [**8-21**] at 9:45. If you have any questions or need to change this appointment time, please call [**Telephone/Fax (1) 64405**]. 2. It is very important that you follow up in cardiothoracic surgery clinic. I have called and they will be contacting you with an appointment within the next two weeks. If you do not hear from them with an appointment time within two days, please call [**Telephone/Fax (1) 170**].

[ "510.9", "512.1", "V64.41", "285.9", "518.81", "304.23", "041.11", "070.54" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "34.51", "96.04" ]

icd9pcs

[ [ [] ] ]

10282, 10288

5972, 9384

334, 615

10461, 10644

3289, 3449

11280, 11859

2701, 2726

9622, 10259

10309, 10309

9410, 9599

10668, 11257

5522, 5949

2741, 3270

275, 296

643, 1988

10396, 10440

3465, 5506

10328, 10375

2010, 2229

2245, 2685

44,557

151,254

37525

Discharge summary

report

Admission Date: [**2179-11-25**] Discharge Date: [**2179-11-29**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1136**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: Bronchoscopy Lung Mass Biopsy History of Present Illness: [**Age over 90 **]F with h/o AF on ASA, CAD, HTN with a known left lung mass and collapsed lung with chronic cough now with hemoptysis, like "red jelly." She notes that her "dry cough" began in [**Month (only) **] and was initially worked up at [**Hospital 1562**] Hospital. Patient has a left lung mass identified on CT scan in [**6-1**] at [**Hospital 1562**] Hospital. The scan showed left upper lobe consolidation with occlusion of the bronchus. Following that hospitalization, the patient underwent a bronchoscopy with tissue biopsy of the mass in [**7-1**] which was non-diagnostic. The tissue pathology showed acute and chronic inflammation with necrosis but no evidence of neoplasm. Per patient's son, there was some concern about re-attempting biopsy due to recent MI in [**Month (only) **]. Given the size of the mass and the surrounding consolidation, the patient was referred to see Dr. [**Last Name (STitle) **] at [**Hospital1 18**] on [**2179-11-30**]. Although the patient has experienced intermittent hemoptysis in the past, she notes that 2 days prior to admission she experienced more severe hemoptysis. She notes that she intermittently coughs up a significnat amount of blood, difficult to quantify but more than a spoonfool ("more like a shovel"); after a while, the coughing settles down and less and less blood comes out, and she may not cough again for a couple more days. She feels a "tickle" in her throat which makes her cough; she feels a "rumbling" from deep in her lungs. Patient also notes that her voice is different from normal. Patient denies chest pain, shortness of breath, fever, nausea, vomiting, diarrhea. She notes that she does sleep on two pillows at home for comfort, but denies shortness of breath. In the ED, VS: 98.4 92 145/70 19 98% RA. CT Chest showed LUL collapse with hilar lesion. She was transferred to the floor for further management. On the floor, she felt comfortable and was hemodynamically stable. She had a mild cough without active hemoptysis. Past Medical History: -Multiple myeloma diagnosed in [**3-1**] s/p 4 cycles of Velcade -MI in [**May 2179**] -HTN -HLD -AF on ASA -Hypothyroidism -Diverticulosis -Colon polyp s/p removal and radiation -Spinal stenosis -Gout diagnosed last week -Incontinence PAST SURGICAL HISTORY: -C-section x2 -HRT -Colon poly removal w/ radiation -Cataract surgery Social History: The patient is retired and lives with her daughter in [**Hospital3 **]. Previously she lived in [**Location 2251**], but moved to [**Hospital3 **] 4 years ago. The patient walks with a cane and is capable of performing ADLS (washing dishes/preparing meals), however, her daughter usually performs them for her. She has a remote tobacco history, and denies EtOH and ilicit drug use history. Family History: -Non-contributory. No history of cancer. -Mother and father died of "natural causes" -4 brothers are all healthy Physical Exam: VS: 98.3 81 122/74 20 97%RA GEN: Pleasant elderly woman, sitting up in bed in no apparent distress, occasionally coughing HEENT: Normocephalic, atraumatic, MMM, OP clear NECK: Supple. No thyromegaly. No cervical/supraclavicular [**Doctor First Name **]. CHEST: Expiratory wheezes throughout and coarse rhonchi at apices. No rales. CV: Irregularly irregularly rhythm, no M/R/G ABD:Vertical midline scar through umbilicus, +BS, soft, non-tender, non-distended EXT:WWP, 2+ DP and 1+PT pulses b/l, no swelling/erythema of the ankles/toes. No clubbing, cyanosis, or edema. SKIN: No ecchymoses or lesions NEURO:Alert and oriented. CNII-XII grossly intact. Pertinent Results: ADMISSION LABS: [**2179-11-25**] WBC 11.8 / Hct 30 / Plt 399 INR 1.1 / PTT 24.8 Na 139 / K 3.9 / Cl 104 / CO2 24 / BUN 28 / Cr 1.2 / BG 93 Iron 21 / Ferritin 40 / TIBC 378 / TRF 291 Ca 9.1 / Mg 2.1 / Phos 3.2 [**2179-11-27**] TSH .6 / Free T 8.5 DISCHARGE LABS: [**2179-11-29**] WBC 8.7 / Hct 27.2 / Plt 339 INR 1.1 / PTT 28.3 Na 139 / K 3.5 / Cl 107 / CO2 24 / BUN 19 / Cr .9 / BG 95 MICROBIOLOGY [**2179-11-26**] Urine Cx - mixed bacterial flora STUDIES: CT Chest with contrast [**2179-11-25**] 1. Extensive soft tissue density occluding the left mainstem and upper lobe bronchus with subsequent left upper lobe collapse. No definite hilar or lung parenchymal mass seen. Bronchoscopy is recommended for further evaluation. 2. 1.5-cm right upper lobe ground-glass nodule, which is nonspecific and may be neoplastic, infectious or inflammatory in etiology. 3. Pulmonary arterial hypertension. 4. Cardiomegaly and coronary artery calcifications as well as aortic calcifications. 5. 6- mm arterially enhancing liver lesion. Differential diagnosis includes flash-filling hemangioma or FNH. If clinicallly indicated, an MRI of the liver can be performed for further evaluation. 6. 8-mm sclerotic focus within the T2 vertebral body, for which correlation with bone scan is recommended. CXR [**2179-11-27**]:REASON FOR EXAMINATION: Followup of the patient with bronchoscopy due to suspected lung cancer and multiple myeloma. Portable AP chest radiograph was compared to several prior studies obtained on [**11-25**] and [**2179-11-26**] The patient was extubated in the meantime interval. There is no change in the left perihilar opacity accompanied by atelectasis of the left upper lobe consistent with the known mass. There is no evidence of pneumothorax. There is no appreciable pleural effusion or pulmonary edema demonstrated. [**2179-11-26**] Pathology of lung mass: Pending at time of discharge Final report on [**2179-12-3**] 1. Lung, left main stem mass and blood clot (A-B): - Adenocarcinoma, well differentiated, small fragments. - Blood clot. 2. Lung, left upper lobe, endobronchial mass (C-D): Adenocarcinoma, well differentiated, see note. Note: The morphological features are consistent with colonic origin. However, immunoperoxidase studies show the tumor to be CK7, CDX2 (very focally) positive; ER and PR stains are positive as well; TTF-1 and CK20 are negative. This immunophenotype is not typical of colonic carcinoma; ovarian origin is a consideration. Brief Hospital Course: 1. Hemoptysis and Left Lung Mass: The patient has a known lung mass found on CT scan at [**Hospital 1562**] Hospital and chronic cough with acute onset of worsening hemoptysis. The patient was referred to a cardiothoracic surgeon at [**Hospital1 18**] to evaluate the lung mass and had an appointment scheduled for next week. However, her recent onset of hemoptysis is concerning for bronchial arterial invasion with the potential of causing massive hemoptysis. The differential diagnosis for her lung mass include: malignancy vs. extramedullary plasmacytoma vs. amyloidosis. On admission, the patient was hemodynamically stable with a HCT of 30, stable vital signs, and satting in the high 90's on room air. To further evaluate her lung mass, a bronchoscopy with tumor excision was performed and the specimen was sent to pathology. During the procedure, a large blood clot was removed which extended halfway up the L mainstem bronchus. Following the evacuation of the blood clot there was active bleeding and the patient was intubated to secure her airway. She was transferred to the ICU overnight for observation. She was subsequently extubated the following day ([**2179-11-27**]). During her hospitalization, the patient's aspirin was held in light of her active bleeding. We continued to hold it until [**12-7**] when she will be seen by interventional pulmonary and thoracic oncology in case a procedure is planned. Also of note, the patient's WBC increased from 11 to 12.6 and there was concern for post obstructive pneumonia based on bronchoscopy. She was started on empiric treatment with Flagyl and ceftriaxone for suspected post-obstructive pneumonia with community-acquired pneumonia and anaerobe coverage. A sputum gram stain and culture were sent and were contaminated with oropharygeal flora. The results of her tissue pathology are still pending and she will follow-up with [**Hospital1 18**] cardiothoracics and interventional pulmonology one week following discharge. She was treated empirically with a total 8 day course of antibiotics and ceftriaxone was changed to cefpodoxime at discharge. 2. Anemia: The patient had a normocytic anemia with HCT of 30 on admission. Her OSH records indicate that she was anemic during her last hospitalization in [**6-1**] and was discharged with a HCT in the 30s. Iron studies indicated an iron deficiency anemia. Recommend starting on iron supplementation as outpatient. Hematocrit remained relatively stable and was 28.5 at d/c. 3. Acute on Chronic Renal Failure The patient's creatinine was 1.2 on admission, however, decreased to 1.1. This appeared to be consistent with prerenal etiology, however, the patient's FeUrea was 0.45, which is more consistent with intrinsic renal injury. She may have some chronic renal insufficiency secondary to her multiple myeloma. on discharge her creatinine was 0.9. 4. Atrial fibrillation: The patient's EKG on admission indicated that the patient was in atrial fibrillation with left axis deviation. Patient has a CHADS2 score of 2 (HTN and age). Her aspirin was held due to her active bleed. She was monitored on telemetry without any events. She should address restarting coumadin with her primary care physician 5. Benign Hypertension: Her blood pressure was well-controlled during this hospitalization. Her home medications were continued. 6. Coronary artery disease Patient was continued on her home medication of Atenolol and simvastatin. Her aspirin was held in the setting of bleed. 7. Multiple Myeloma: The patient was diagnosed in [**3-1**] with multiple myeloma. She reports that she is s/p 4 treatments of Velcade with excellent response (last M protien level was 0.5g [**2179-11-2**]). Patient is followed closely by her oncologist. 8. Hypothyroidism: Stable. Continued on home dosage of levothyroxine. Medications on Admission: -Atenolol 50 [**Hospital1 **] -Tricor (fenofibrate) 48mg DAILY -Zocor (simvastatin) 20 mg DAILY -Lisinopril 20mg DAILY -KCl 2.5mg 4 TABS TID -Hydrochlorothiazide 25mg DAILY -Levoxyl (levothyroxine) 100mcg DAILY -Furosemide 20mg DAILY -Allopurinol 100mg DAILY -Ecotrin (ASA) 325mg DAILY -Robutussin (OTC) Discharge Medications: 1. Slow Fe 47.5 mg (Iron) Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Disp:*30 Tablet Sustained Release(s)* Refills:*2* 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO three times a day. 10. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day. 11. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*11 Tablet(s)* Refills:*0* 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 5 days. Disp:*16 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Bayada Discharge Diagnosis: Primary Diagnosis: Hemoptysis Lung Mass Secondary Diagnoses: Hypertension Atrial Fibrillation Multiple Myeloma Hypothyroidism Discharge Condition: Stable, alert and oriented completely. Saturating well on room air. Stable hematocrit. Discharge Instructions: Dear Mrs. [**Known lastname 1356**], You were admitted to the hospital because you were coughing up large amounts of blood. As you know, you have a large lung mass on the left side, so the Interventional Pulmonologists placed a scope into your lungs and removed part of the obstructing mass. This tissue was sent to pathology for testing. While the Pulmonologists were looking into your lungs they decided to keep a breathing tube in overnight to ensure that you would not have any problems with breathing in case it were to start bleeding again. You spent one night in the Intensive Care Unit just to make sure that you did not continue to bleed from the tumor site in your lungs. The results from the lung mass biopsy have not returned yet, however, your thoracic surgeon will go over these results with you when they return. You were also started on antibiotics for a possible pneumonia that may have been developing in the part of the lung beyond the lung mass. The following changes were made to your medications. - Please START taking Cefpodoxime 200mg by mouth twice a day for 5 more days (last day [**2179-12-4**]). Your first dose will be tonight - Please START taking Metronidazole 500mg by mouth three times a day for 5 more days (last day [**2179-12-4**]). Your first dose will be tonight. - Please STOP taking your aspirin daily until you follow up with your primary care physician and interventional pulmonary because it could making your bleeding worse Please be sure to keep all of your followup appointments. Please be sure to seek medical attention if you begin to cough up very large amounts of blood, if you begin to have difficulty breathing, or if you experience any other symptoms concerning to you. Followup Instructions: Please remember to keep the following appointments with the thoracic surgeon and interventional pulmonologist: Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2179-12-7**] 9:00am Provider: [**Name10 (NameIs) 12554**] CLINIC INTERVENTIONAL PULMONARY (SB) Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2179-12-7**] 9:30am Please also follow up with your primary care doctor, Dr. [**Last Name (STitle) 4467**]. You have an appointment on [**2179-12-9**] at 4pm. Call ([**Telephone/Fax (1) 84263**] if you have any questions or concerns about this appointment.

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13181

Discharge summary

report

Admission Date: [**2124-12-11**] Discharge Date: [**2124-12-20**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: Cough, shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 84 year old male with past medical history of Parkinson's disease, CHF, CAD, and DM, who presents with 1 week history of productive cough, 4 days of nausea and vomiting, and 1 day of diarrhea. He states that he has been feeling 'sick' for the past week, with the above constellation of symtpoms. He has not had a fever or chills. He started with some loose stools, then developed a cough productive of white sputum. The cough has persisted. He then developed some nasusea and vomiting. . He has also felt a bit more SOB this past week. He relates that he does not do much walking at baseline, but gets SOB with going up 5 stairs. He has felt some SOB at rest this past week. He has not had any chest pain. His LE swelling has been much better recently. . He has continued to take all of his medications this week, including his oral hypoglycemics, warfarin, and lasix. . ED Course: Patient's vitals were noted to be: 97.3 75 86/56 16 96%ra. He was given 750 mg of levofloxacin, potassium, Vancomycin 1 gram, and 10 mg of Vitamin K. He had a CXR which was not read as a pneumonia. . ROS: Denies sick contacts or recent hospitalizations. He denies dysuria, abdominal pain, HA, ST, chest pain, hematochezia, melena, myaligias. He endorses knee pain bilaterally, rhinorrhea. . Past Medical History: 1. CAD, cath 5 years ago at NEBH (cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) 2. CHF, TTE [**3-5**] w/depressed EF 3. Hypertension, per daughter pt's bp usually 90s-100s on meds 4. Severe Lumbar Spinal stenosis, mild cervical stenosis 5. Sleep apnea, on 2L home O2 at night 6. Afib, s/p DCCV which failed, now rate controlled 7. Arthritis 8. Gout 9. COPD? No PFTs 10. NIDDM 11. E-coli-Sepsis (admission [**2122-12-23**] - [**2123-1-1**]) 12. BPH? (Flomax) 13. Parkinson's disease ? ?sinemet Social History: Patient uses a cane for assistance at baseline. He lives with his daughter [**Name (NI) 13118**]. Formerly worked at Sears. Widowed. No tobacco or EtOH use. Family History: Notable for CAD, HTN, and stroke. Physical Exam: PE on admission: Physical Exam: 98.0 90/50 75 18 95% 2L General: Elderly male with masked facies, speaking full sentences, NAD HEENT: MMdry, anicteric, EOMI, no sinus tenderness Neck: Supple, JVP 6cm, no LAD Cardiac: Irreg irreg, no m/r/g Chest: Bilateral diffuse wheeze, no rales, no consolidation Abdomen: obese, soft, nt, nd, pos bs on left, quiet on right Extr: no c/c/e Skin: multiple excoriations, scar from prior BCC removal on back Neuro: AAO x 3, masked facies, cn intact, pill rolling tremor, minor cogwheel rigidity on right Psych: Flat affect, appropriate Msk: FROM at both knees, right slightly warmer than left . On transfer from MICU to medicine floor: Baseline Physical Exam (on transfer to medicine floor from MICU): t 98.8 bp 96/56 hr 80 rr 20 by vitals sheet; 28 by my exam slightly later o2 sat: 98% RA . General: Elderly man with visibly faster-than-usual respiratory rate but without evident discomfort HEENT: PERRL, EOMI; anicteric Neck: JVD not appreciated on my exam (8 cm by prior MICU attg note) Cardiac: Mostly regular rate with occasional "extra beats"/irregular beats; no murmurs or rubs appreciated Chest: Expiratory wheezing heard throughout, good air movement throughout, no rales appreciated Abdomen: BS+, NT, ND Extr: 1+ edema Skin: ecchymoses on arms, IV sites, hands; several scabs on face Neuro: strength 4+ and symmetrical at: grip, pedal dorsi/plantarflexion, biceps/triceps, shoulder shrug. CN: as above EOMI and PERRL, tongue to midline, palate elevates, no facial asymmetry, no slurring of speech, shoulder shrug intact. Alert and oriented to place, town, date, day, year, self. Psych: appropriate range of affect Msk: slightly swollen R knee with bandaid and betadyne stains c/w recent tap; tender inferior and medial to patella. . Pertinent Results: [**2124-12-11**] 08:57PM WBC-13.8* RBC-4.30* HGB-13.8*# HCT-40.4 MCV-94 MCH-32.2* MCHC-34.2 RDW-14.4 [**2124-12-11**] 08:57PM NEUTS-83.9* LYMPHS-8.3* MONOS-7.0 EOS-0.6 BASOS-0.1 [**2124-12-11**] 08:57PM PLT COUNT-232 [**2124-12-11**] 08:57PM PT-64.5* PTT-55.3* INR(PT)-8.1* . [**2124-12-11**] 08:53PM LACTATE-2.0 . [**2124-12-11**] 08:57PM GLUCOSE-87 UREA N-94* CREAT-3.9*# SODIUM-133 POTASSIUM-3.1* CHLORIDE-87* TOTAL CO2-25 ANION GAP-24* . [**2124-12-11**] 08:57PM CK(CPK)-173 [**2124-12-11**] 08:57PM CK-MB-4 cTropnT-0.05* . [**2124-12-11**] 11:42PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2124-12-11**] 11:42PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2124-12-11**] 11:42PM URINE RBC-[**7-9**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 Brief Hospital Course: Patient is an 84 year old male with past medical history significant for CAD, CHF, DM, and atrial fibrillation who presents from home with one week of productive cough, decreased PO intake, diarrhea, and N/V. . # Cough/N/V: As the hospital course continued, we felt it most likely that he had a viral syndrome that led to nausea, vomiting, decreased PO intake, and cough. His productive cough with a leukocytosis was initially concerning for pneumonia; however, his chest x-rays were unrevealing. His vomiting by his history was actually ambiguous and may have represented violently coughing up large quantities of white sputum, according to his daughter's history. . Given the possibility of pneumonia, he was started on levofloxacin for community acquired pneumonia, which was discontinued on the equivalent of day [**7-6**] of the course (uncertainty based on changing renal function at the time of discontinuation). Vancomycin was started as well for this, but was discontinued given that patient lives at home and has not had a lot of exposure to the healthcare system. Vancomycin was re-introduced for concern for septic joint (see below). Cultures were unrevealing, influenza DFA was negative, legionella ag was negative, and follow-up chest x-rays were unrevealing. . When on the medicine floor he continued to be afebrile. His white count rose while on the medicine floor; given that his respiratory status remained stable, this was judged unlikely to be secondary to the respiratory infection, and ultimately, more likely to be the result of a florid gout flare. . # Atrial fibrillation: In the MICU he was continued on sotalol, dosed 40 mg [**Hospital1 **] in light of ARF; he is on 80 mg [**Hospital1 **] at baseline. As his renal function improved he had an episode of afib with RVR to the 150s, with hypotension (70s over palp), for which he was triggered, given IV metoprolol and IV fluids; this eventually resolved, and he was then continued on 80 mg sotalol [**Hospital1 **] thereafter, and had no further episodes of RVR. . His anticoagulation was held, first because of supratherapeutic INR, and then because of concern for hemorrhagic joint. He was started on enoxaparin (Lovenox) on [**2124-12-17**]. He was then started on warfarin on [**2124-12-18**]. . # Hypotension: Appears to be at baseline at this time, mainly in 90s-100s, and his baseline SBP is 80's to 90's per OMR records. He responded well to the fluids given during first day of admission. His lactate was 2.0 at admission, and he remains not tachycardic. Ultimately we felt that it was more likely that his hypotension was due to low baseline BP and severe dehydration in setting of poor PO intake and diarrhea/vomiting. He had one other episode of hypotension, which was clearly secondary to afib with RVR, described above. . # Knee swelling, likely gout: Patient has right knee that appeared bruised on admission, with possible joint effusion appreciated. Rheumatology was consulted, given history of gout as well as history of septic joint in setting of gout infection. Joint aspiration of the R knee revealed hemarthrosis with joint fluid Hct of 42, which was confirmed by MRI. Joint aspiration of the L knee revealed a high white count ([**Numeric Identifier 24869**]). Both taps showed gout crystals. Because of our initial concern for septic joint we treated first with Ancef, and then when his white cell count continued to rise and his joints appeared to be more inflamed, we switched to vancomycin with concern for MRSA. However, he remained afebrile and joint cultures were negative, as were joint fluid gram stains; we thus discontinued antibiotics for the joint. We consulted the [**Numeric Identifier 1083**] diseases service which recommended this discontinuation of antibiotics followed by close observation. . We treated pain with colchicine, celebrex, lidocaine patches, tylenol, ultram, and ultimately steroids to reduce inflammation. We avoided opioids because his family had given us the history of delirium with mild opiates (likely codeine), and we judged him to be at significant risk for delirium as well as for falls should he become delirious. . At this point we believe that the hemarthrosis in the R joint would be best dealt with by physical therapy that kept the joint flexible, and would expect that this hemarthrosis will gradually dissolve and be reabsorbed, particularly in the context of anticoagulation therapy; we see no indication of rebleeding. We had been holding colchicine in the setting of ARF but restarted it. He also got celebrex as an anti-inflammatory. . # Diarrhea: He has had several days of diarrhea, with no recent exposure ot antibiotics or health care institutions. This could be part of a viral syndrome. With a climbing white count we were concerned for C. diff and had him on flagyl for several days; however, C. diff toxin assays were negative twice and he was taken off precautions and we did not continue flagyl. He had formed stool starting several days before discharge. His cultures were all negative. . # Acute renal failure: His creatinine was 3.9 at admission. With hydration and holding his lasix, his creatinine declined to 1.5 before rising slightly again before discharge once a small dose of lasix (40 mg daily compared to his 160 mg daily home dose) was restarted. This was held once more. His urine lytes and clinical picture was consistent with a mainly pre-renal picture, worse on admission secondary to poor PO and diarrhea. Urine output improved substantially. He will need to have his lasix dose titrated back up as his gout flare and renal function improve again, as he has consistently had lower extremity edema that has responded well to lasix in the past. . # Coronary artery disease: Per records, he had a cath at NEBH with Dr. [**Last Name (STitle) **] that showed non-obstructive coronary disease. We restarted ASA 81 daily, as he does take this as an outpatient. We continued his statin. . # Chronic diastolic congestive heart failure: He appears to be well compensated at this point, with no clinical evidence of failure. We monitored i/o, had him on a low Na diet, and checked several chest x-rays during the course of his admission to look for signs of worsening failure. We held lasix as above but he did not have clinical indications of heart failure with us. . # Diabetes: Patient is on glipizide at home. Given poor PO intake and his renal failure, his PO [**Doctor Last Name 360**] was held in the MICU, replaced by insulin sliding scale; and given changing circumstances of high white blood count, changing intake, and changing renal function, we continued his insulin scale while on the medicine floor. . # Parkinson's disease: We continued home medications of carbidopa. He did not have significant manifestations of parkinsonism while on the medicine floor, though as above he apparently did have manifestations on arrival to the hospital. . # Coagulopathy: He received some vitamin K in the ED. Coumadin was held. His INR drifted down over the admission; as above, enoxaparin (Lovenox) was started on [**12-17**] and warfarin was restarted on [**12-18**]. . # AG acidosis: Resolved. Was felt to be likely due to acute renal failure. Also, he was hypochloremic from vomiting. He had no ketones in his urine. His lactate remained within normal limits. . # COPD: He had wheezes on exam fairly frequently which improved with nebulizers and beta-agonist inhalers (levalbuterol to minimize cardiac effect). Per Dr. [**Last Name (STitle) **], he has had no clear diagnosis of COPD or history of wheezing. He had PFT's at NEBH in [**2120**] which showed a restrictive pattern with a mildly decreased TLC and diffusion capacity. He is not on an inhaler at home, but his daughters report this is partly because when he has been prescribed them he has been unable or unwilling to learn how to use them properly. His overall wheezing improved over the admission. Given that he did not have signs of progression of heart failure the wheezing was more likely secondary to bronchitic infection, likely viral. The wheezing seemed to benefit from steroids, which were started for gout. . # BPH: He had been on Flomax at home. We held this for concern for labile blood pressure as described above. This could be restarted. . # FEN: Cardiac [**Doctor First Name **] diet. . # PPx: Anticoagulated (high INR), PPI . # Code status: Full, discussed with patient . # Communication: Daughter [**Name (NI) 13118**] [**Telephone/Fax (1) 40195**] . # Dispo: To rehabilitation to build ability to walk independently. . Medications on Admission: Wellbutrin 100mg ER by mouth every morning Celebrex 200 mg qd Coumadin 2.5 mg alternating with 5 mg Protonix 40 mg, Lasix 160 mg, potassium 20 mEq, Crestor 5 mg, carbidopa 25 mg/100 mg one three times a day, Flomax 0.4 mg, glipizide 5 mg two a day, colchicine 0.6 mg every other day, Niaspan 500 mg, trazodone 100 mg at bedtime, [**Doctor First Name **] 180 mg, sotalol 80 mg two times a day, doxepin 100 mg at bedtime for skin itch, lidocaine patches on the knees. metolazone MWF . MEDICATIONS ON TRANSFER Acetaminophen 650 mg PO q6h Aspirin 81 mg PO Bupropion 100 mg PO qAM Carbidopa-levodopa 25-100 1 tab po TID Docusate 100 mg PO BID:PRN Fexofenadine 60 mg PO BID Insulin scale Ipratropium bromide Neb, 1 neb IH q6h Levofloxacin 750 mg PO q48h Lidocaine 5% patch 1 ptch TD daily Niaspan 500 mg oral daily Ondansetron 4-8 mg IV q8H: nausea Pantoprazole 40 mg PO q24h Potassium prn per lytes Rosuvastatin calcium 5 mg PO daily Senna 1 tab PO BID:PRN Sotalol 40 mg PO BID Tamsulosin 0.4 mg PO HS Xopenex 0.63 mg/3 mL inhalation q6-8h prn wheezing/SOB Trazodone 100 mg PO HS:PRN Discharge Medications: 1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 2 doses: start [**12-22**], after 25 mg dose on [**12-21**]. 2. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO daily () for 2 doses: after 20 mg doses. 3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 2 doses: after 15 mg doses. 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 2 doses: after 10 mg doses. 5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for knee pain. 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours) as needed for knee pain. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 11. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 15. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO daily (). 17. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 18. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) inhalation Inhalation q6-8h prn () as needed for wheezing/SOB. 19. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO daily (). 21. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): do not give more than 4 grams per day. 22. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 23. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Guaifenesin 100 mg/5 mL Syrup Sig: [**2-1**] 5 mL doses PO four times a day as needed for cough. 25. Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day: 1 tablet (2.5 mg) MWF; 2 tablets (5 mg) SaSuTuTh. 26. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED): SCALE: Breakfast, lunch and dinner scale: Glucose 0-75 mg/dL: 4 oz. juice. 76-149: none. 150-199: 3 units. 200-249: 5 units. 250-299: 7 units. 300-349: 9 units. 350-400: 11 units. >400: notify MD. . BEDTIME SCALE: Glucose 0-75 mg/dL: 4 oz. juice. 76-149: none. 150-199: 2 units. 200-249: 4 units. 250-299: 6 units. 300-349: 8 units. 350-399: 10 units. >400: notify MD. PLEASE NOTE: THIS SCALE WILL LIKELY REQUIRE ADJUSTMENT OVER THE NEXT FEW DAYS BECAUSE PATIENT IS ON RAPID PREDNISONE TAPER. . 27. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 28. Prednisone 10 mg Tablet Sig: 2.5 Tablets PO 1x on [**2124-12-21**] for 1 days: starting on [**12-22**], use doses listed elsewhere on this list, continue taper accordingly. (each dose for 2 days, decreasing 5 mg, 2 more days at lower, decreasing 5 mg again, and so on.). Discharge Disposition: Extended Care Facility: [**Hospital3 2732**] & Retirement Home - [**Location (un) 55**] Discharge Diagnosis: Primary Diagnosis: Diarrhea Gout Atrial Fibrillation with Rapid Ventricular Rate Leukocytosis . Secondary Diagnosis: Coronary Artery Disease Chronic Diastolic Heart Failure Diabetes Mellitus Discharge Condition: Good Patient stable, with no fevers Discharge Instructions: You were admitted to the hospital with diarrhea and a cough. This was most likely due to a viral infection, although we gave you antibiotics to treat a possible bacterial infection in your lungs, which you have finished. You also developed swelling of your knees, which is likely due to gout. We started steroid therapy for gout, which will be "tapered"--that is, its dose will be reduced every two days. Your rehabilitation facility will have instructions about how to continue this therapy. . Please take all of your medications as prescribed. We held your lasix and reduced its dose on discharge because of concern about your kidneys. As your health improves, it's likely that you'll need to go back to your home dose of 160 mg daily. . Your allopurinol was stopped because of concern about your kidneys. This will also likely need to be restarted later as your health improves. Finally, your 81 mg of aspirin was held because of the prednisone you are taking; it should be restarted once you are finished with the prednisone. . Work with the rehabilitation facility staff, particularly the physical therapists, to try to improve your mobility and your overall health. Once you are discharged, please call your doctor or return to the ER if you have chest pain, feelings that your heart is racing fast, diarrhea, abdominal pain, fevers, chills, shortness of breath, increasing pain in your knees, or other concerning symptoms. . Go to a follow-up appointment with Dr [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] at the [**Hospital1 **] Wednesday [**1-10**], 3 pm. . Go to the rheumatology follow-up appointment with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Tuesday [**1-9**], 2 pm. [**Last Name (NamePattern1) 439**], [**Hospital1 18**]. Followup Instructions: Go to a follow-up appointment with Dr [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] at the [**Hospital1 **] Wednesday [**1-10**], 3 pm. [**Telephone/Fax (1) 7960**]. . Go to the rheumatology follow-up appointment with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Tuesday [**1-9**], 2 pm. [**Last Name (NamePattern1) 439**], [**Hospital1 18**]. [**Telephone/Fax (1) 2226**]. . Lasix dose is 160 mg at home; we have held it until today because of concern re renal function; his renal function has improved and we are dosing it at 40 mg daily to start. This will likely need to be increased but renal function should be followed. . His blood sugar levels have been in flux due to prednisone. His scale was recently increased slightly, and the scale for discharge represents a slight further increase. Because the prednisone is on a fairly rapid taper downward, the appropriate approach to blood sugar control is likely to change over the next 2 weeks, and this will need to be followed. . We have thus far avoided opiates for pain control because of concern about hospital delirium, which his family reports he has had in the past. . Please feel free to contact [**Name (NI) **] [**Last Name (NamePattern1) 4427**], MD, via the [**Hospital1 18**] operator at [**Telephone/Fax (1) 2756**] if you have further questions about the inpatient course for this complicated and treasured patient; Dr. [**Last Name (STitle) 4427**] is the medical intern who followed Mr [**Known lastname **] for this admission.

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icd9cm

[ [ [] ] ]

[ "81.91" ]

icd9pcs

[ [ [] ] ]

18160, 18250

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291, 298

18485, 18523

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132,914

4222+55556

Discharge summary

report+addendum

Admission Date: [**2185-10-12**] Discharge Date: [**2185-10-16**] Date of Birth: [**2135-1-27**] Sex: F Service: MEDICINE Allergies: Heparin Agents / Augmentin / Lisinopril / Metoprolol Attending:[**First Name3 (LF) 3561**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 50 yo f with PNA, hx of scarcoid, on HD for ESRD who presented with SOB. She states she started having a cough several months ago, with productive sptutum that recently changed from yellow to greenish. She states 3 days ago she started having SOB. She went to HD yesterday, but it needed to be cut short due to muscle cramps, which has occurs with her recent HD sessions. She was having more SOB today and called EMS. She also reports being on a course of azithro for 4 days starting [**2185-9-27**] for her cough. Did not check her temp at home, but did have chills. . In the ED, initial VS: VS 102.2 126 179/106 35 100% on NRB. She was [**Last Name (un) 4662**] in by EMS. She was hypoxic to 80s per EMS. She was transitioned to 6 liters NC. She was had a CXR concerning for RLL PNA and was given levo 750mg and vanco 1g. She was febrile and given tylenol and motrin. Renal was not notified. EKG showed sinus rhythm with RBBB which was unchanged. She had an elevated trop (but at baseline) and was give ASA 325mg. Her MS [**First Name (Titles) **] [**Last Name (Titles) 18350**]t. At transfer VS were 100.3 113 154/109 24 96% on 6 liters NC. She was amitted to the ICU due to tachypnea to 30s while on 6 liters oxygen. . Currently, she states her breathing is improved, but feels tired now. No pain or SOB. . ROS: negative except for HPI Past Medical History: -SVC thrombis -Heparin-induced thrombocytopenia, on coumadin for HD -Hypertension -End-stage renal disease on dialysis [**2-28**] sarcoid -sarcoidosis -epilepsy, last sz [**2182**] -chronic pancreatitis -secondary hyperparathyroidism -hyperlipidemia -anemia -angioectasias of the stomach and colon Social History: Originally from [**State 622**]. Lives at home with husband. 4 children, 3 grandchildren. She does not smoke, use alcohol or drugs. She is a previous substance abuse counselor. She is currently on medical disability due to her multiple medical illnesses. Family History: father-kidney failure 70 mother-HTN, breast ca, dx 68 uncle-kidney resection Physical Exam: Vitals - T: BP: 155/106 HR: 103 RR: 28 02 sat: 91% on 6L NC GENERAL: NAD, awake and alert, polite HEENT: clear OP, MMM, no SI CARDIAC: RRR, no m, 2+pulses LUNG: crackles at bases R>L, dullness at right base to percussion ABDOMEN: soft, NT ND, +BS, no HSM EXT: no c/c/e, warm NEURO: A&O x 3, strength 5/5, CN 2-12 intact DERM: no rashes visible Pertinent Results: labs- [**2185-10-12**] 06:45PM BLOOD WBC-9.0 RBC-4.54# Hgb-13.1# Hct-45.3# MCV-100*# MCH-28.9 MCHC-28.9* RDW-21.8* Plt Ct-156 [**2185-10-12**] 06:45PM BLOOD Neuts-91.2* Lymphs-5.9* Monos-2.5 Eos-0.2 Baso-0.2 [**2185-10-12**] 06:45PM BLOOD PT-14.5* PTT-31.2 INR(PT)-1.3* [**2185-10-12**] 06:45PM BLOOD Glucose-70 UreaN-36* Creat-7.8*# Na-144 K-5.2* Cl-101 HCO3-28 AnGap-20 [**2185-10-12**] 06:45PM BLOOD CK(CPK)-76 [**2185-10-14**] 02:13AM BLOOD ALT-8 AST-23 AlkPhos-268* TotBili-2.5* [**2185-10-12**] 06:45PM BLOOD cTropnT-0.11* [**2185-10-13**] 04:37AM BLOOD CK-MB-NotDone cTropnT-0.10* [**2185-10-12**] 06:45PM BLOOD Albumin-4.0 Calcium-9.5 Phos-4.0 Mg-2.4 [**2185-10-14**] 02:13AM BLOOD PTH-565* [**2185-10-14**] 07:08AM BLOOD Vanco-31.8* [**2185-10-13**] 12:58AM BLOOD Type-ART O2 Flow-6 pO2-57* pCO2-36 pH-7.44 calTCO2-25 Base XS-0 Intubat-NOT INTUBA [**2185-10-13**] 11:42AM URINE Color-RED Appear-Cloudy Sp [**Last Name (un) **]-1.015 [**2185-10-13**] 11:42AM URINE Blood-LG Nitrite-NEG Protein-300 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-MOD [**2185-10-13**] 11:42AM URINE RBC->1000* WBC-43* Bacteri-FEW Yeast-NONE Epi-0 [**2185-10-13**] 11:42 am URINE Source: Catheter. **FINAL REPORT [**2185-10-14**]** URINE CULTURE (Final [**2185-10-14**]): NO GROWTH. [**2185-10-13**] 7:52 pm BLOOD CULTURE Source: Line-femoral. Blood Culture, Routine (Pending): Reports- CXR FINDINGS: Portable upright AP chest radiograph is obtained. A left IJ dialysis catheter is seen with the tip in the expected location of the cavoatrial junction. Elevation of the right hemidiaphragm is again noted. Increased opacity at the right lung base is concerning for pneumonia. Scarring in the upper lungs is again noted and has been previously assessed on multiple prior CT scans. The heart is enlarged. Central pulmonary vessels appear slightly prominent, which may be secondary to mild fluid overload. No pleural effusions or pneumothorax is seen. Osseous structures appear grossly intact. IMPRESSION: Cardiomegaly, suggestion of mild congestion. Opacity at the right lung base concerning for pneumonia. Echo The left atrium is elongated. A right-to-left shunt across the interatrial septum is seen at rest (by bubble study); cannot distinguish between a patent foramen ovale vs an atrial septal defect on the basis of this study. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is markedly dilated with depressed free wall contractility. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are moderately thickened. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2185-9-5**], right-to-left shunting is now identified at the atrial level. MRV- IMPRESSION: 1. Occlusion of the righ internal jugular vein. 2. Moderate stenosis of the right subclavian vein. 3. Moderate stenosis of the right brachiocephalic vein near the confluence with SVC. 4. Small amount of adherent fibrin around the portion of the left IJ venous catheter within the SVC. Otherwise the SVC grossly patent. 5. Small-to-moderate right pleural effusion. 6. Known interstitial disease not well evaluated by MR. Brief Hospital Course: 50 y.o. F with hx of sarcoid, ESRD, HTN, admitted with SOB with hypoxia in setting of fever concerning for PNA. 1. Hypoxia: Likely secondary to decresed RV function and worsening lung disease at baseline as well as contribution of volume overload given history of not being able to complete full HD sessions in the last few weeks. Pt was intially on BiPAP which was rapidly converted to her baseline 3 L NC. Albuterol and ipratropium nebs RTC. Treated patient with vancomycin and levofloxacin for pnemonia. Pt received HD while in the hospital. She was discharged to complete 8 day course of vancomycin and levofloxacin. 2. Sepsis: On admission, the patient had high fever and elevated lactate of 2.9 with likely pneumonia on CXR in the RLL. Cultures sent and NGTD. Pt will continue vancomycin and levofloxacin to complete 8 day course. Vancomycin via HD protocol. 3. Melena: During HD session in ICU, pt became tachypnic, tachycardic and hypertensive. She was initially treated with nebs and CXR did not show a change from prior. She then had a large bowel movement; this was melena. Femoral line was placed at bedside. GI was consulted. IV PPI gtt was initiated and later changed to po PPI [**Hospital1 **]. GI did not decide to pursue endoscopy as this was likely due to known AVMs. Instead, hct was monitored. 1 pRBC was transfused during hospitalization with some resolution of her tachycardia. She remained hemodynamically stable with stable Hcts for 24 hours prior to discharge. No melena for 24 hours prior to discharge. 4. ESRD on HD: Renal followed patient while in ICU. HD was continued. Ultrafiltration occurred once. She continued on her phos binder and nephrocaps. Per request of her nephrologist, MRV of SVC was performed, which showed no SVC syndrome but known occlusions in IJ. She is to have outpatient angioplasty. 5. Hypertension: BPs elevated to 170s in ER. Held anti-hypertensives during GI bleeding. These were reinitiated prior to discharge. 6. Epilepsy: Continued keppra. 7. Sarcoid: Reduced prednisone to 15 mg po daily. Converted BiPAP to 3 L NC (baseline). Pt to follow up with Dr. [**Last Name (STitle) 2168**] as outpatient. Echo completed while in house to follow pulmonary hypertension. # FEN: replete lytes prn / renal diet, Nephrocaps, MV # PPX: PPI- home med, bowel regimen, Bactrim # CODE: Full confirmed # CONTACT: [**Name (NI) 4906**] [**Telephone/Fax (3) 18310**] Medications on Admission: Azithromycin 5 day course- started [**9-27**] Epo Hydroxyzine 25mg [**Hospital1 **] Lamotrigine 150mg [**Hospital1 **] Lorazepam 0.5 Qday PRN cramps Losartan 150mg [**Hospital1 **] Nifedipine 90mg [**Hospital1 **] Protonix 40mg Qday Sevelamer 2400mg TID Bactrim DS MWF Ursodiol 300mg TID Colace 100mg [**Hospital1 **] Predinsone 20mg Qday Discharge Disposition: Home Discharge Diagnosis: Primary: [**Hospital 7502**] Hospital Acquired Gasterointestinal Bleed Secondary: End Stage Renal Disease on Dialysis Sarcoidosis Discharge Condition: Stable, afebrile, able to ambulate Discharge Instructions: You were admitted to [**Hospital1 18**] due to shortness of breath. You were found to have a pneumonia and too much fluid on your body. You were treated with dialysis and antibiotics. You also had bleeding in your intestines that was likely from your AV malformations. You were given one unit of blood. Please keep your follow up appointments. Please talk to Dr. [**Last Name (STitle) 4883**] about a possible outpatient angioplasty for your known clots in your blood vessels. Please take your medications as instructed. The following changes were made to your medications: - You were started on vancomycin for your infection. This should be dosed at your dialysis center, last day on [**2185-10-19**] - You were started on levaquin for your pneumonia, please complete your antibiotic course, your last day should be on [**2185-10-19**] - Your prednisone dose was decreased to 15mg to reduce your risk of stomach bleeding - You were given an albuterol inhaler to use if you are short of breath while you have pneumonia. Please take [**1-28**] puff inhaled every 4 hours if short of breath. - Continue 3 L NC continuously Please stay on a renal diet. If you have blood in your stool or black tarry stools, chest pain, shortness of breath, fevers, worsening cough, or other concerning symptoms please seek medical attention or go to the ER. Followup Instructions: Please make an appointment to see your PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 250**] Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2185-10-18**] 8:00 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2185-10-18**] 8:00 Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2185-10-18**] 8:30 Completed by:[**2185-10-16**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 2938**] Admission Date: [**2185-10-12**] Discharge Date: [**2185-10-16**] Date of Birth: [**2135-1-27**] Sex: F Service: MEDICINE Allergies: Heparin Agents / Augmentin / Lisinopril / Metoprolol Attending:[**First Name3 (LF) 2969**] Addendum: Of note, patient was maintained on Lamotrigine (Lamictal) for epilepsy while in the ICU and NOT on Keppra. Discharge Medications: 1. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 3. Losartan 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for for cramps: for dialysis cramps. 5. Sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 4 days: take through [**2185-10-19**]. Disp:*2 Tablet(s)* Refills:*0* 9. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*0* 10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 1 months: take twice a day for a month, before decreasing back to your regular daily dose. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Vancomycin 750 mg Recon Soln Sig: One (1) Intravenous Q HD by level for 4 days: please give on HD days, based on level, with goal trough 15-20. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): take this dosing for 1 month, then reduce to 1 pill daily. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 unit* Refills:*2* 16. Oxygen Home oxygen 3 L / NC continuously Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2970**] MD [**MD Number(2) 2971**] Completed by:[**2185-10-17**]

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icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "39.95" ]

icd9pcs

[ [ [] ] ]

14233, 14397

6777, 9211

323, 338

9782, 9819

2777, 4176

11211, 12297

2318, 2397

12320, 14210

9628, 9761

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9843, 11188

2412, 2758

4211, 6754

276, 285

366, 1708

1730, 2030

2046, 2302

1,610

145,005

960

Discharge summary

report

Admission Date: [**2164-2-7**] Discharge Date: [**2164-2-24**] Date of Birth: [**2092-1-11**] Sex: M Service: MEDICINE Allergies: Sinemet-10/100 Attending:[**First Name3 (LF) 2297**] Chief Complaint: SOB, tremor Major Surgical or Invasive Procedure: Intubation Central line placement History of Present Illness: 72 yo male with severe COPD, on home oxygen and chronic prednisone who presented with increasing SOB and oxygen sat per VNA of 68%. He states he has been more SOB over past week, (at baseline he is SOB but this has been worse). He has a cough but no sputum. His wife also reports his speech was slurred this AM. his wife notes that his tremors have been worse. This started [**1-28**] mos ago, worse in R leg and that causes him to be unsteady on his feet. He did fall on Sat and hurt his R foot. He denies syncope with this event. He was admitted to [**Hospital1 2025**] in [**2163-12-28**] for tremor and they thought it was from theophylline so that was discontinued, however the tremors did not improve. Wife thinks he had brain MRI and spine MRI that were normal. He also notes hallucinations in the AM that they were told might be from melatonin that he takes to help him sleep. . In summary, this is 72 yo M with severe COPD admitted with SOB and tremors. 1. SOB: Likely COPD flare, will tx with prednisone, nebs, azithormycin. Monitor on tele o/n. Calcium and vit D given steroids. Sputum cx, gs, cont bactrim ppx for PCP 2. Tremors: DDX includes zoloft (but spoke to outpt psych who said has been on this dose for 10yrs), Parkinsons, essential tremor, hyperthyroidism, myclonus. CT head normal, [**Hospital1 2025**] MRI showed micorangiopathic ischemic changes. TSH nl. Trying klonopin per mvmt d/o team. 3. CV: Had TWI in one lead on EKG initially then infer STE, but [**Last Name (un) **] neg, cont tele. COnt ASA, pravastatin, CE negative 4. Depression: cont zoloft 5. Hallucinations: ? if from melatonin, will follow, neuro consult. 6. HTN: BP high in [**Last Name (LF) **], [**First Name3 (LF) **] increase norvasc 7. Foot fracture: comminuted fx in 5th metatarsal of R foot, will wrap toes. 8. Urinary urgency - U/A negative. place foley 8. FEN: reg diet 9. PPX - PPI, Sq heparin 10. Full code Past Medical History: COPD - on home oxygen 2-6 liters at all times, PFTS [**2161**] FEV1 1.09 (38% pred), FEV1/FVC 32 (48% pred). Followed at [**Hospital1 2025**], pulmonologist is Dr. [**Last Name (STitle) 6376**] Chronic constipation, sees [**Doctor Last Name 1940**] Elev PSA s/p needle bx that were neg for malig in [**8-/2163**] Hallucinations in AM Tremors x [**1-28**] mos S/P ulnar nerve redistribution in L arm. bronchiectasis hyperlipidemia hypertension depression spinal stenosis bladder cancer kidney stones childhood pyloric stenosis status post surgical repair. Social History: married, 50 pack year smkr quit 4 yrs ago, no ETOH, no drugs Family History: CAD in brother and father, [**Name (NI) 5895**] in father Physical Exam: 97.1 80 116-140/61-70 100% venti mask, 15 L, 91-94% GENL: somnolent, sleepy, in restaints, unable to assess mental status, confused during code HEENT: OP clear, PERL, EOMI, no elev JVP, no LAD CV: RRR no MRG Lung: profoundly decreased BS diffusely Abd: soft, nt, nd, +bs Ext: +ecchymises on R 4th and 5th metatarsal, tender to palpation, +clubbing Neuro: A&Ox3, +tremors, strength 5/5 diffusely GU: with light pink urine slowly clearing, foley Pertinent Results: Studies Foot xray - fx 5ht metatarsal CXR: Aorta is tortuous. Heart size stable, allowing for technical differences. There is lucency of both upper lung zones consistent with patient's known emphysematous disease. Pulmonary vasculature is unchanged. Lung parenchyma is unchanged compared to the previous studies. Left costophrenic angle is not imaged. Right costophrenic angle is sharp. No evidence of pneumothorax. The right apex is obscured by overlying breathing apparatus. . Head CT: No evidence of acute intracranial hemorrhage . EKG: SR, rate 76, nl axis, nl int, TWI in V1 . MRI ([**Hospital1 2025**] [**2163-12-31**]) mult small scattered foci of T2/FLAIR hyperintesity in subcort white matter, periventr regions and pons. Nonspecific, likely from microangiopathic ischemic change. Mineralziation in basal ganglia. . Brief Hospital Course: Floor course: Pt was treated for COPD flare with 60 mg prednisone, azithro, frequent nebs, and bactrim ppx. While on the floor, pt's oxygen reuqirement appeared to be at baseline of [**12-31**] L oxygen. Other VS stable, afebrile. Pt was seen by neurology for evaluation of his tremor which was thought to be myoclonus rel to COPD. Started on klonopin on [**2-9**] for help of this tremor. . MICU was called for question of intubation. Pt was acutely agitated. VS otherwise stable, sats 80% on 8 L oxygen. ABG 7.43/71/63/49 during event. Prior ABG in am. was 7.40/71/64/46. Pt received a total of 4 mg haldol and 4 mg ativan during event. Security called and pt placed in 4 pt leather restraints. A PIV was placed. Pt was on 20% venti mask with sats in high 80's to 90's, increased to 40 % venti mask. Intubation was witheld as earlier observed accessory muscle use and paradoxical breathing improved, sats stable. Of note, when suctioned light pink material noted. . # Septic shock/aspiration pneumonia/COPD exacerbation/respiratory failure: Transferred to the MICU for hypoxia and closer monitoring. The patient was continued on steroids and MDIs for COPD exacerbation. Once the patient arrived to the MICU, he was noted to be hypoxic, hypotensive and subsequently was intubated. L IJ and a-line was placed. The patient was on a pressor briefly and was weaned off. On CXR for line placement showed a white out of the left lung. Bronch was done and ruled out complete collapse of the left lung and the patient was started on vanco and cefepime for nosocomial pneumonia on [**2-11**]. Cefepime was switched to Zosyn on [**2-13**] given likelihood of aspiration pneumonia in the setting of mental status changes. The patient was difficult to wean off ventilator, and to facilitate his weaning and decrease sedation, standing haldol was started on [**2-15**]. Although goal was to decrease sedation and wean off vent, because of his movement disorder causing bruises on his legs and for pt safety, propofol was restarted on [**2-18**] in addition to fentanyl and versed with good result. Patient remained aggitated once drips were weaned despite increasing haldol. Family thus decided not to escalate further care. Patient was subsequently started on morphine gtt on [**2-24**] AM and extubated and expired soon afterwards. . # Atrial fibrillation: The patient developed a-fib with RVR to 130-160s on [**2-12**]. This was thought to be secondary to COPD and new PNA. The patient received diltiazem IV boluses and was placed on drip for rate control but did not respond and dropped his pressures. Thus, amiodarone bolus and drip were started, and pt converted to sinus and rate was controlled. Pt also was started on IV heparin but discontinued after 4 days as pt remained in sinus on amiodarone, underlying PNA that likely triggered afib was being treated and his high risk for fall as an outpatient. Patient subsequently was controlled with PO amiodarone and he remained in SR up until he expired. . # For neuro/myoclonus, neuro and psych both followed the patients. Neither neuro or psych had clear explaination for his neuro abnormalities. CT of head was negative. EEG or MRI were considered but neuro thought they will not be revealing given his metabolic disturbances and sepsis. For depression, pt was off Zoloft initially in the MICU then was restarted and continued on Zoloft 250mg qday on [**2-15**]. . # Initially full code. After discussing with wife who is HCP, pt was made DNR/DNI on [**2164-2-18**]. Patient did not tolerated the lightening of sedation as he became acutely aggitated and restless. Family decided not to escalate any further care on [**2-21**] while they contemplated further plan of care. Patient was started on morphine drip for comfort and was subsequently extubation. Patient was apnic and expired soon. Medications on Admission: Advair discus 500/50 [**Hospital1 **] Albuterol nebs Q4 hr Atrovent nebs Q4 hr Combivent IH Atrvent IH Flonase 50 mcg [**Hospital1 **] Flovent IH Lasix 40 mg PO KCL slow rel 20 mg [**Hospital1 **] Norvasc 5 mg QD Pravachol 10 mg QD Prednisone 20 mg QD Protonix 40 mg QD Bactrim DS 3 x / wk Dyazide 37.5/25mg QD Zoloft 250 mg QD Mucinex 600 mg [**Hospital1 **] Colace Melatonin PRN Fiber con Iron 27 mg QD There tears Ipratoprium nasal spray 15 ml PRN Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2164-2-25**]

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icd9cm

[ [ [] ] ]

[ "96.6", "38.91", "38.93", "03.31", "96.04", "96.72", "33.22" ]

icd9pcs

[ [ [] ] ]

8717, 8726

4325, 8184

286, 321

8777, 8786

3475, 3954

8842, 8880

2936, 2995

8685, 8694

8747, 8756

8210, 8662

8810, 8819

3010, 3456

235, 248

349, 2262

3963, 4302

2284, 2840

2856, 2920

23,366

154,818

420+421

Discharge summary

report+report

Admission Date: [**2168-12-13**] Discharge Date: [**2168-12-26**] Date of Birth: [**2141-2-21**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is as 27-year-old male with history of schizophrenia and non compliance with medications who was transferred from [**Hospital **] Hospital as a trauma. The patient reportedly ran in front of a car on route 128. The patient was walking in the accessory [**Male First Name (un) **] of the highway, was struck by a car that was taking the exit ramp. This occurred at a slow velocity. The patient was found face down with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 3 and in the prehospital stage was hemodynamically stable with strong pulses and intact gag reflex but dilated and fixed pupils. The patient was subsequently transferred to [**Hospital **] Hospital and intubated. He was then transferred to [**Hospital1 188**] for definitive care. On arrival the patient was found to have a superficial open head laceration, a left open tibia and fibula fracture and a laceration to the right upper extremity. The patient had received 1 gm of Ancef prior to arrival in the Emergency Room. PAST MEDICAL HISTORY: Schizophrenia. He has not been compliant with medications and has been increasingly paranoid per the patient's father. There is question of a history of rhythm disorder. MEDICATIONS: Neurontin, Risperdal. ALLERGIES: No known drug allergies. PAST SURGICAL HISTORY: Adenoidectomy, tonsillectomy and left upper extremity fracture. SOCIAL HISTORY: The patient lives at the [**Company 3596**] in [**Hospital1 **]. Father lives in [**Hospital1 3597**]. The patient smokes and drinks alcohol but denies recreational drug use. PHYSICAL EXAMINATION: The patient initially had a heart rate of 100, blood pressure 160/94, respiratory rate was determined by respiratory therapist as he was intubated. He was satting 100%. The patient had a large equalizing posterior scalp avulsion and forehead laceration. These were closed immediately with staples. His left tympanic membrane was clear, his right tympanic membrane had a question of hemotympanum. His C spine was collared. There were no step-offs. Chest is clear to auscultation bilaterally. Abdomen was soft, nontender, non distended. Pelvis is stable. There was decreased rectal tone and no gross blood. He had palpable dorsalis pedis pulses bilaterally and an open fracture at the left shin. LABORATORY DATA: White blood cell count 25.7, hematocrit 43.3, platelet count 310,000, fibrinogen 142. Urine, specific gravity 1.032, PH 5.0, [**7-10**] red blood cells, rare bacteria. Sodium 137, potassium 4.5, chloride 101, CO2 28, BUN 10, creatinine 1.0, glucose 137, amylase 63. Serum toxicology screen was negative. Urine toxicology was also negative. Initial blood gas had PH 7.46, PCO2 40, PO2 287, bicarb 29. A trauma series including AP view of the chest, lateral C spine and AP view of the pelvis were read as negative. CT of the C spine showed a linear non displaced fracture of the pars intraarticularis at C7. A CT of the head showed a very small amount of subarachnoid blood seen on the right tentorium. CT of the chest, abdomen and pelvis showed only a small area of consolidation in the left upper lobe and bibasilar dependent atelectasis. There was no evidence of other injuries. The left tib fib film showed a mid shaft comminuted left tibial and fibular fracture. A left elbow x-ray was normal. T spine and LS spine x-rays were also normal. HOSPITAL COURSE: The patient was brought to the operating room by orthopedic surgery for repair of the left tibia and fibular fractures and open reduction and internal fixation was performed with placement of an intramedullary rod. The patient tolerated the procedure well and was subsequently admitted to the Surgical Intensive Care Unit for close monitoring. In the unit neurosurgery was consulted who commented on the questionable area of subarachnoid hemorrhage. Their recommendation was to load with Dilantin which was promptly done. On hospital day #2 the patient was completely stable. Spine surgery was consulted for the C7 to T1 facet fracture who recommended that the patient continue the C collar for approximately 6 weeks. The patient was placed on antibiotic prophylaxis with Ancef throughout his Intensive Care stay. The patient was transferred to the floor on [**2168-12-16**]. He was seen by psychiatry and followed up throughout the next several days. He remained markedly confused with disorganized speech. This was initially felt to be consistent with the schizophrenia although after several days of evaluation it was determined that this is likely a component of traumatic brain injury as well. Neurology was consulted and recommended MRI of the patient's head. This study showed multiple areas of low signal insusceptibility images at the [**Doctor Last Name 352**] white matter junction indicative of diffuse axonal injury and bilateral frontal subdural effusion. There was also a large hematoma seen which was followed while the patient was on the hospital floor. It was determined that the patient would benefit from a neuro rehab facility. Case management screened the patient and placement is currently pending. The patient was kept on a 1:1 sitter throughout his entire hospital course. Physical therapy followed him for exercises. His range of motion instructions at discharge are weight bearing as tolerated on the left lower extremity. Dilantin was slowly weaned to off on [**2168-12-25**]. DISCHARGE MEDICATIONS: Heparin 5000 units subcu [**Hospital1 **] while the patient is confined to bed. Risperdal 3 mg po bid, Percocet [**2-2**] q 4 hours prn severe pain, Tylenol 1 gm po q 4 hours prn pain. DISCHARGE DIAGNOSIS: 1. Status post struck by car. 2. Head trauma with diffuse axonal injury. 3. Schizophrenia. 4. Left tibia and fibula fracture status post open reduction and internal fixation. 5. C7 facet fracture. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**] Dictated By:[**Last Name (NamePattern1) 3600**] MEDQUIST36 D: [**2168-12-26**] 11:50 T: [**2168-12-26**] 13:14 JOB#: [**Job Number 3601**] Admission Date: Discharge Date: [**2169-1-9**] Date of Birth: Sex: M Service: ADDENDUM: The patient has been on a one to one sitter for quite some time. He, however, was placed in a Veil bed last week and the patient has been without a one to one sitter and doing well for approximately four days now. Since the screening process has been reinstituted and the patient is just awaiting a rehab placement. DR.[**Last Name (STitle) 3598**],[**First Name3 (LF) **] 02-352 Dictated By:[**Name8 (MD) 3181**] MEDQUIST36 D: [**2169-1-9**] 09:55 T: [**2169-1-9**] 10:18 JOB#: [**Job Number 3602**]

[ "295.32", "823.92", "805.8", "884.0", "851.80", "E814.7", "293.0" ]

icd9cm

[ [ [] ] ]

[ "78.57", "79.66", "96.71" ]

icd9pcs

[ [ [] ] ]

5618, 5805

5826, 6975

3570, 5594

1491, 1556

1773, 3552

162, 1196

1219, 1467

1573, 1750

44,145

144,314

41027

Discharge summary

report

Admission Date: [**2110-1-17**] Discharge Date: [**2110-1-27**] Date of Birth: [**2041-7-3**] Sex: M Service: CARDIOTHORACIC Allergies: Atenolol / Piroxicam / Niacin Attending:[**First Name3 (LF) 5790**] Chief Complaint: left upper lobe mass Major Surgical or Invasive Procedure: [**2110-1-17**] Right video-assisted thoracoscopy lung wedge, pleural biopsy, and lymph node dissection. [**2110-1-24**] Tunnelled right subclavian hemodialysis catheter History of Present Illness: The patient is a 68-year-old gentleman who was found to have a left upper lobe mass, which on needle biopsy was unremarkable, but hypermetabolic on PET. Subsequent to this heunderwent a bronchoscopic biopsy of some lymph nodes which also were indeterminate. Given concern for malignancy we brought the patient in for R VATS wedge of lung nodules and lymph node biopsy. Past Medical History: Gout Hypertension Renal insufficiency Social History: Married and lives with his wife. [**Name (NI) **] has 3 sons. Quit [**Name2 (NI) 1139**] 20 years ago. Smoked for about 10 years 1- 1 [**12-15**] ppd. Retired, worked for the city repairing and constructing sidewalks. + Asbestos exposure. Occasional ETOH. Family History: Hypertension Diabetes Physical Exam: Discharge vital signs: T 98.4, BP 116/74, HR 74, RR 18, O2 sats 96% RA Blood sugar 116 Discharge physical exam: Gen/Neuro: Pleasant in NAD. MAE equally to command. PERRLA. Lungs: rhonchi t/o. R VATS incisions healing without redness, purulence or swelling. CV: RRR S1, S2, 2/6 systolic ejection murmer, R sternal border Abd: soft, NT, ND Ext: warm without edema R IJ HD tunneled cath intact without redness, drg or swelling. Pertinent Results: [**2110-1-27**] 08:00AM BLOOD PT-16.9* PTT-29.8 INR(PT)-1.5* [**2110-1-26**] 07:20AM BLOOD Plt Ct-260 [**2110-1-26**] 07:20AM BLOOD PT-15.3* PTT-28.8 INR(PT)-1.3* [**2110-1-25**] 09:20AM BLOOD PT-13.8* PTT-26.4 INR(PT)-1.2* [**2110-1-24**] 07:00AM BLOOD PT-11.8 PTT-25.7 INR(PT)-1.0 [**2110-1-26**] 07:20AM BLOOD WBC-9.6 RBC-3.10* Hgb-8.1* Hct-24.6* MCV-79* MCH-26.1* MCHC-32.9 RDW-17.4* Plt Ct-260 [**2110-1-25**] 07:25AM BLOOD WBC-9.7 RBC-3.30* Hgb-8.5* Hct-26.4* MCV-80* MCH-25.7* MCHC-32.1 RDW-16.8* Plt Ct-219 [**2110-1-27**] 07:20AM BLOOD Glucose-124* UreaN-69* Creat-5.3* Na-138 K-4.0 Cl-102 HCO3-23 AnGap-17 [**2110-1-26**] 07:20AM BLOOD Glucose-111* UreaN-52* Creat-4.7* Na-138 K-3.9 Cl-100 HCO3-24 AnGap-18 [**2110-1-21**] 02:23AM BLOOD ALT-11 AST-17 AlkPhos-155* TotBili-0.3 [**2110-1-19**] 01:48PM BLOOD CK-MB-4 cTropnT-0.02* [**2110-1-19**] 06:33AM BLOOD cTropnT-0.03* [**2110-1-18**] 10:55PM BLOOD cTropnT-0.05* [**2110-1-27**] 07:20AM BLOOD Calcium-8.9 Phos-5.2* Mg-2.1 [**2110-1-26**] 07:20AM BLOOD Calcium-8.9 Phos-5.0* Mg-2.2 [**2110-1-21**] 02:23AM BLOOD TSH-2.9 [**2110-1-22**] 02:14AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2110-1-18**] 11:06AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2110-1-22**] 02:14AM BLOOD HCV Ab-NEGATIVE SPECIMEN SUBMITTED: Pleural implant, right lower lobe nodule, right lower lobe superior segment wedge, 4R lymph node, level 7 lymph node. Procedure date Tissue received Report Date Diagnosed by [**2110-1-17**] [**2110-1-17**] [**2110-1-21**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dwc?????? DIAGNOSIS: Right pleural implant, biopsy (A-B): Chronic pleuritis with reactive mesothelial hyperplasia and focal granulation tissue. Right lower lobe nodule, wedge resection (C-D): Pleural tissue with fibrous adhesions. Right lower lobe superior segment, wedge resection (E-I): - Organizing pneumonia (bronchiolitis obliterans organizing pneumonia). - Intra-parenchymal lymph node, negative for malignancy. - Respiratory bronchiolitis. - No evidence of malignancy. 4R lymph node, excision (J-L): Negative for malignancy. Level 7 lymph node, excision (M): Negative for malignancy. Echo [**2110-1-20**] Conclusions The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). The severity of aortic regurgitation may be underestimated. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. [**2110-1-23**] Bilateral upper arterial and venous duplex: IMPRESSION: Patent bilateral brachial and radial arteries with diameters described above. [**2110-1-22**] CXR: FINDINGS: In comparison with the study of [**1-21**], there has been some decrease in the opacifications at the right base. Some of this may reflect change in patient position with decreased layering of pleural fluid. Indistinctness of pulmonary vessels, most prominent on the right, is consistent with asymmetric pulmonary edema. In the appropriate clinical setting, supervening pneumonia would have to be considered. Brief Hospital Course: Mr. [**Known lastname 89482**] was taken to the operating room on [**2110-1-17**] for a Right video-assisted thoracoscopy lung wedge, pleural biopsy, and lymph node dissection by Dr. [**Last Name (STitle) **] for suspicious looking lung nodules and a PET avid left upper lobe mass. He was transfered initally from PACU to ICU for hemodialysis needs postoperatively along with monitoring. He remained for pulmonary edema, CRRT, and atrial fibrillation until stabilized and transfered to the floor on [**2109-1-22**]. He was discharged home on [**2110-1-27**] with VNA services. Below is a systems review of his hospital course: Neuro: The patient was initially given PCA dilaudid for pain, which then converted to IV q 4hour prn, then to tylenol for pain control. He did not complain of pain once awake post extubation, and was sent home on prn tylenol. He remained neurologically intact throughout his stay. While intubated propofol and fentanyl were used. Pulmonary: The patient required CPAP postoperatively, then at onset of HD became acutely hypoxic and required intubation [**2110-1-18**] with mechanical ventilation. He was kept intubated until [**2110-1-20**]. Pulmonary toilet was continued. A right chest tube was discontinued [**2110-1-19**] after surgery and postpull chest xray did not reveal any pneumothorax. Pathology from RVATS wedge revealed organizing pneumonia. Dr. [**Last Name (STitle) 575**] with Pulmonary was consulted and felt that he should have repeat CT in [**1-16**] weeks which was ordered for followup with us on [**2110-2-6**]. He will have followup with pulmonologist Dr. [**Last Name (STitle) 89483**] at [**Location (un) **] after CT chest. This is being scheduled. The patient is aware. The patient room air oxygen saturation on day of discharge were 95%. CV: On POD 1, after HD initiated the patient went into atrial fibrillation with RVR 150 with hemodynamic instability requiring cardioversion with shock x 2. He was bolused with amiodarone and continued with drip load. [**2110-1-19**] a run of VTach noted, with IV lopressor given. The patient was transitioned to oral amiodarone 400mg po BID which he received 7 days of and sent home on 200mg po daily. He was placed on lopressor [**2110-1-19**] which was uptitrated to 100mg XL [**Hospital1 **] on [**2110-1-24**]. Diltiazem was added on [**1-22**] and stopped [**2110-1-24**] for some short term burst afib on, which resolved after 10mg IV dilt on [**2110-1-22**]. His other lisinopril and amlodipine was discontinued given these new medications. Cardiology was consulted early on ([**1-20**]) in management of his arrhythmias, and assisted in management of his afib. Echo done revealed mod to severe Aortic stenosis. On [**2110-1-22**] he was placed on a short term heparin gtt for recurrent afib, but this was stopped on [**2110-1-23**] for HD tunneled line and it was felt he was safe for coumadin without heparin. EKG's were watched and QTc remained 0.47 last on [**1-26**]. The patient remained in NSR since [**2110-1-22**]. Coumadin 2.5mg po nightly was started on [**2110-1-23**] and continued each night. INR's were as follows: [**1-24**] 1.0 [**1-25**] 1.2 [**1-26**] 1.3 [**1-27**] 1.5 Dr. [**Last Name (STitle) **] (PCP) coumadin clinic in queue to manage- thank you. GI/Nutrition: The patient was given tubefeedings via dobhoff while intubated but advanced renal diet and tolerated thereafter. Last BM [**2110-1-26**]. Dietician followed and pt kept on renal diet. Renal: The patient had metabolic acidosis postoperatively, therefore a right HD catheter was placed and POD 1, HD started. The patient did not tolerate HD with AF with RVR 150's, hemodynamic instablity and acute respiratory failure requiring intubation for hypoxia. CRRT was then initiated with renal following closely. It was determined the patient would require permanent HD, therefore bilateral upper extremity mapping was done and a right tunneled HD line placed in right subclavian on [**2110-1-24**]. The patient was dialyzed [**2110-1-27**] (UF 1.5L) and set up for outpt HD tomorrow. The patient did have UOP daily (500-800cc/day). Foley was removed [**2110-1-23**] and he voided thereafter. Lines: [**2110-1-19**] left IJ triple lumen CVL, dc'd [**2110-1-22**], R SC tunnelled HD line [**2110-1-24**] Temp HD Right IJ- [**1-17**] to [**2110-1-24**] [**2110-1-18**]: Flu shot given. Physical Therapy evaluated the patient and felt he was safe for home with PT, but on date of discharge PT was discontinued as he was stable on his feet. The patient and his wife were given verbal and written discharge instructions as well as days of coumadin education. Hospital course communicated with pt's primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Medications on Admission: Calcium Acetate Cochicine .6mg daily Lisinopril-HCTZ 20mg -12.5mg daily amlodipine 10mg daily Na Bicarbonate 650mg Epo-alpha 20,000units Simvastatin 80mg qHS Discharge Medications: 1. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: this dose will change depending on your INR. Goal INR [**1-16**]. Dr. [**Last Name (STitle) **] will manage. Disp:*60 Tablet(s)* Refills:*0* 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheeze. Disp:*1 inhaler* Refills:*0* 3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: discuss continuation of this with your cardiologist. Disp:*45 Tablet(s)* Refills:*0* 4. Crestor 10 mg Tablet Sig: One (1) Tablet PO at bedtime: this is new. do not take simvastatin with this. this replaces simvastatin. Disp:*30 Tablet(s)* Refills:*1* 5. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO twice a day. Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*1* 6. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain. Discharge Disposition: Home With Service Facility: [**Location (un) 1468**] VNA Discharge Diagnosis: Organizing pneumonia Atrial fibrillation Aortic Stenosis Ventricular tachycardia End stage renal failure Hypertension OSA --> on CPAP at home Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 2347**] office at [**Telephone/Fax (1) 2348**] if you have: -Fevers greater than 101.5 -Chills -Shakes -worsening cough or shortness of breath -right incisions develop redness, swelling or drainage If you have a fast irregular heartrate and feel dizzy go to the ED. Your lung pathology reveals an organizing pneumonia which will need to be following closely by a pulmonologist. While in the hospital you developed a heart arrythmia called atrial fibrillation. You are on a new medications to control your heart rate. Please continue the medications given to you and followup with your cardiologist about continuation or adjustment of dosing. One of these new medications is coumadin, a blood thinner. Depending on how thin your blood is your doctor may adjust. VNA will draw your blood three time a week and send this to the coumadin clinic associated with Dr. [**Last Name (STitle) **]. They will call you to tell you how much coumadin to take. This will help prevent a stroke. You also have tightness in your aortic valve called "aortic stenosis". Your cardiologist will need to watch this and fine tune your medication to keep you feeling well. While in the hospital it was determined you need dialysis. You will be set up with a dialysis clinic who will clean your blood and take off extra fluid if needed, that your kidneys do not filter. Followup Instructions: Please get a CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2110-2-6**] 1:15p Location [**Hospital Ward Name 23**] [**Location (un) **]- Clinical Center radiology. Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2110-2-6**] 3:30 Followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], your primary care doctoer [**Telephone/Fax (1) 31019**] on [**2110-2-19**] at 11am. Followup with Dr. [**Last Name (STitle) **] (cardiology) as in [**1-16**] weeks. His office number is [**Telephone/Fax (1) 2258**]. We are in the process of obtaining an appointment. They will call you. If you do not hear back by the end of this week. Call his assistant Fidora. Followup with Dr. [**Last Name (STitle) 89483**] at [**Location (un) 2274**] [**Location (un) **] office. This is a pulmonologist who will follow your organizing pneumonia. They are in the process of making the appointment. You need to see them in [**1-16**] weeks. ([**Telephone/Fax (1) 89288**] First HD appointment: Tuesday, [**2110-1-28**] at 1:00pm The address & phone number of the hemodialysis facility is: [**Doctor Last Name 15284**] Circle Dialysis Center [**Doctor Last Name 89484**] [**Location (un) 1468**], [**Numeric Identifier 11562**] Tel: [**Telephone/Fax (3) 89485**] Nephrologist: Dr. [**First Name8 (NamePattern2) 7656**] [**Name (STitle) **] His outpt hd schedule will be every Tues, Thurs & Sat at 1:00pm Completed by:[**2110-1-27**]

[ "428.30", "584.9", "275.3", "516.8", "785.6", "799.02", "428.0", "276.2", "511.0", "V15.82", "424.1", "427.31", "276.7", "518.81", "V45.11", "585.6", "403.91", "427.1" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "40.3", "96.71", "38.93", "34.20", "96.6", "99.62", "96.04" ]

icd9pcs

[ [ [] ] ]

11482, 11541

5522, 6132

316, 490

11732, 11732

1727, 5499

13278, 14782

1241, 1265

10498, 11459

11562, 11711

10315, 10475

6150, 10289

11883, 13255

1280, 1368

256, 278

518, 889

11747, 11859

911, 951

967, 1225

1393, 1708

9,691

127,138

54358

Discharge summary

report

Admission Date: [**2177-10-15**] Discharge Date: [**2177-10-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 134**] Chief Complaint: CC: dyspnea, weakness Major Surgical or Invasive Procedure: [**10-15**]--cardiac cath with successful stenting of the LMCA, LAD, and LCX, as well as IABP placement and removal. [**10-21**]--re-look cardiac cath showing patent stents [**10-24**]--PICC placement History of Present Illness: . HPI: 87yo woman with a h/o HTN, dyslipidemia, mild dementia/short term memory deficit, who was transferred from [**Hospital3 **] for urgent cath after presenting there with SOB, found to have NSTEMI. Pt was in her USOH until several days PTA when she started "not feeling well." Denied CP, reported progressively increasing SOB and lightheadedness. Was seen at [**Hospital3 **] on DOA where she was noted to have an initial SBP of 89, and had an initial EKG that was reported to show sinus bradycardia to 51bpm, ST elev in aVR and V1, ST dep in II, III, aVF. She was transferred to [**Hospital1 18**] for urgent cath, which she received immediately upon arrival. Of note, she was without symptoms of shortness of breath, CP, or any other complaints upon arrival. The cath revealed significant CAD: LMCA clear; LAD 99% ostial with thrombus; LCx mild ostial, 100% occlusion of bifurcating OM1 filling via L-to-L collaterals; RCA mod calcified with 60% diffuse mid and 100% PDA disease, with PDA filling via R-to-L collaterals. Dr. [**Last Name (STitle) **] of CT [**Doctor First Name **] was consulted for possible CABG but felt pt was not a candidate given her age, renal failure, dementia. After discussion with the son/HCP, Dr. [**Last Name (STitle) **] successfully placed one DES in the prox LAD and one DES in the LCx, such that the stents each extended to the LMCA ostium. An IABP was also placed prophylactically prior to the stenting. The final result was LAD ostium 10%, LCx ostium 0% stenosis. Pt was transferred to the CCU for management of her IABP and remained asymptomatic. Past Medical History: . PMH: -HTN -Dyslipidemia -Mild AI -Mild dementia -Osteopenia -Syncope, h/o falls -s/p hysterectomy -s/p colonic polyp removal -s/p appy Social History: SH: lives alone in a senior housing facility, walks with walker; no etoh, tob, or other drugs; widowed, with son as HCP actively involved in her care . Family History: FH: noncontributory . Physical Exam: PE Vitals: HR 85 BP 100/50 RR 14 Sat 99% on RA Gen: lying in bed, initially asleep but arousable to voice, pleasant and in no distress HEENT: surgical L pupil, reactive R pupil, MMM, OP clear Neck: JVP 10cm, no LAD CV: RRR, IABP obscuring cardiac noises, no rub Lungs: rales at bases bilaterally, difficult to hear with IABP Abd: soft, nt, nd, nl BS Groin: L groin with IABP in place, R groin with introducer sheath from cath in place; no hematoma or ecchymosis on either side Ext: no LE edema, leg braces in place post cath, DP pulses intact bilaterally Neuro: A+Ox3, moving all extremities, no gross deficit Pertinent Results: [**2177-10-15**] 11:40PM O2 SAT-63 [**2177-10-15**] 11:22PM URINE HOURS-RANDOM UREA N-593 CREAT-48 SODIUM-87 [**2177-10-15**] 11:22PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2177-10-15**] 11:22PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2177-10-15**] 11:22PM URINE RBC-28* WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2177-10-15**] 06:55PM GLUCOSE-188* UREA N-62* CREAT-2.4*# SODIUM-140 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-18* ANION GAP-20 [**2177-10-15**] 06:55PM CK-MB-14* cTropnT-5.95* [**2177-10-15**] 06:55PM CALCIUM-8.0* PHOSPHATE-3.6 MAGNESIUM-2.1 [**2177-10-15**] 06:55PM WBC-8.1 RBC-2.85* HGB-9.3* HCT-26.7*# MCV-94 MCH-32.7* MCHC-35.0 RDW-13.5 [**2177-10-15**] 06:55PM PT-13.3 PTT-25.8 INR(PT)-1.2 [**2177-10-15**] 02:29PM HGB-10.5* calcHCT-32 O2 SAT-95 ECHO: [**10-15**]: 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 severely depressed (20-25%) with akinesis of the infero-lateral wall, mid to distal septum and apex. The remaing segmetns are hypokinetic (basal septum and anterolateral wall move best). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) 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. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior report (tape unavailable for review) of [**2176-4-11**], there are new regional wall motion abnormalities involving the septum and apex. Severe pulmonary hypertension is now detected. IMPRESSION: Severe regional LV systolic dysfunction c/w multivessel CAD. Severe pulmonary hypertension. ECHO [**10-21**]: No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (ejection fraction 20 percent) secondary to severe hypokinesis of the midventricular segments and akinesis of the apex. Right ventricular chamber size and free wall motion are normal. Mild to moderate ([**1-5**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (tape reviewed) of [**2177-10-15**], the left ventricular ejection fraction is somewhat further reduced (20%). . CXR: [**10-21**]: Comparison is made to prior study performed one day earlier. There has been no significant interval change in cardiomegaly, interstitial edema, small bilateral pleural effusions, and left lower lobe atelectasis. Osseous structures are unremarkable. IMPRESSION: No significant interval change. . Cath report: [**10-15**]: COMMENTS: 1. Selective coronary angiography revealed a right dominant system with severe three vessel coronary artery disease. The LMCA had no angiographically apparent flow limiting lesions. The LAD had a 99% ostial lesion with thrombus. The LCX had mild ostial disease with a 100% occlusion of a bifurcating OM1 that filled via left to left collaterals. The moderately calcified RCA had 60% diffuse mid vessel disease with a 100% PDA lesion that filled distally via collaterals. 2. Resting hemodynamics demonstrated severely elevated right sided (mean RA 18 mmHg), pulmonary ([**Location (un) **] PA 36 mmHg), and left sided pressures (mean PCWP 30 mmHg) with a mildly depressed cardiac index (2.1 l/min/m2). 3. Left ventriculography was deferred. 4. A 30 cc 7 French intraaortic balloon pump was placed via the left femoral artery. 5. Successful stenting of the LMCA into the LAD and LCX with two kissing Cypher DES (3.5 x 13 mm in LAD, 3.0 x 13 mm in LCX). FINAL DIAGNOSIS: 1. Severe three vessel coronary artery disease. 2. Severe ventricular systolic and diastolic dysfunction. 3. Successful placement of an intraaortic balloon pump. 4. Successful stenting of the LMCA, LAD, and LCX. Cath [**10-21**] COMMENTS: 1. Coronary angiography of this right dominant circulation demonstrated two vessel coronary artery disease. The kissing stents in LMCA and proximal LAD and LCX were widely patent. The LAD had mild luminal irregularities. Spasm was relieved from previous case. The ostial diagonal disease was unchanged. The OM2 was totally occluded and filled retrogradely via LAD collaterals, which was unchanged from prior. The RCA was severely diseased with mid vessel 60% lesion. Small (1.5 mm) PDA and PL had severe but unchanged disease. 2. Left ventriculography was not performed. 3. Limited resting hemodynamics demonstrated normal systemic pressure. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Widely patent kissing stents from LMCA to LAD and LCX. Brief Hospital Course: A/P: 87yo woman with mult cardiac risk factors who p/t [**Hospital1 **] with dyspnea, found to have NSTEMI, transferred for urgent cath. Hospitalization further complicated by multiple episodes of polymorphic VT/VF. . CV a) CAD: The pt was initially admitted for NSTEMI with CEs peaking the night of admission at CK 156, CK-MB 14, TpnT 5.95. The pt was cath'ed on admission and found to have an LAD with a 99% ostial lesion with thrombus. The LCX had mild ostial disease with a 100% occlusion of a bifurcating OM1 that filled via left to left collaterals. The moderately calcified RCA had 60% diffuse mid vessel disease with a 100% PDA lesion that filled distally via collaterals. An IABP was placed during cath. Peri-cath the pt was treated with 18 hours of integrillin as well as ASA, plavix, lopressor, and lipitor, which were continued through the remainder of her admission. The IABP was removed on [**2177-10-17**] and the pt was transferred to the floor. b) Rhythm: The pt has remained relatively stable on the floor with the exception of two episodes of dyspnea associated with failure (discussed below). However, on [**10-21**], the pt had two episodes of polymorphic VT/VF. In each case, the pt was shocked at 200 J and given chest compressions, after which she came back into NSR. She was bolused with amiodarone after her first drip and started on an amio infusion. After her second episode, because of the rhythm morphology, the etiology was suspected ischemic. The pt was taken back to the cath lab on [**10-21**] to r/o restenosis of her stents. However, her stents were patent. Her electrolytes during her episodes of Vt/VF were wnl. Per EP, an ICD was not optimal in this 87 year old with dementia. The pt had two more episodes of VT/VF in the pm on [**2177-10-21**], despite receiving more boluses of amio. The episodes had a similar response to chest compressions plus a 200J shock. During her last episode, the pt was given a lidocaine 100mg bolus and placed on a 1mg/min drip. She responded well to lidocaine except that she became very uncomfortable, including multiple vagal episodes associated with vomiting, diaphoresis, bradycardia. However, these symptoms resolved and she has since done well, without any further episodes of bradycardia <40s or vagal episodes. Her amiodarone was changed to PO and the Lidocaine gtt was d/c'ed w/o further episodes of arrhythmia on tele. Patient on scheduled dose of amiodarone with eventual taper to 200mg daily. c). Pump function: The pt has a h/o CHF. Her echo on [**10-21**] demonstrated an EF of 20%. During her admission her CXRs have shown gradual improvement of edema. Prior to her episodes of VF/VT the pt has two episodes of nocturnal dyspnea. Both episodes were treated with IV lasix and nebs, after which the pt's symptoms improved. Afterload reduction has been held in general because of the pt's relatively low BP. An ACE-I in particular has been held due to the pt's poor renal fxn, although if her creatinine continues to trend down, would recommend starting one as an outpatient. However, spironolactone was added for diuresis/RALES trial. The pt has remained asymptomatic from a pulmonary standpoint since her episodes of VT/VF. Her daily wts, I/Os have been followed and her fluid status has been kept negative with a daily dose of PO lasix. ARF: Prior to her transport to [**Hospital1 18**], the pt's initially presented with a Cr of 3.0 (baseline 1.1-1.2). During her first few days of admission her creatine came down. The differential included poor perfusion due to low cardiac output vs. ATN. A measurement of Ulytes indicated that the likely cause of the pt's ARF was pre-renal pushing low CO to the forefront of her diff. The pt's Cr was stable at around 1.8-1.9 for a few days after admit, but then came back up to 2.9 (calculated FeUrea 27.8%) with decreased urine output. This rise was temporally related to the pt's VT/VF. Her elevated Cr was most likely secondary to ATN (cath dye vs poor forward flow). The pt's Cr began to improve in the days following her episodes of arrythmia. Tender, erythematous arms: ? thrombophlebitis due to infiltrated IV sites vs. cellulitis. The pt was started on keflex [**10-25**] cont x 7 days. She was given warm compresses and arm elevation. NSAIDS were held for renal fxn. Dementia: Throughout her admission the pt was continued on Aricept. During her admit she appeared to be reasonably well-oriented to time, person, and place though did have some difficulty with day-to-day memory. FEN: With the exception of periods before procedures the pt was kept on a low salt cardiac diet. PPx: The pt was maintained on a heparin gtt or sc hep, fall precautions, colace, dulcolax. . Code: FULL Dispo: screened for [**Hospital 100**] rehab Comm: son/HCP: [**Name (NI) 23461**] [**Name (NI) 1617**] [**Telephone/Fax (1) 111296**] (cell), [**Telephone/Fax (1) 111297**] (office). Medications on Admission: . Meds: Aricept Lescol 20mg qd Lisinopril 20mg qd ASA 81mg qd Colace qd . All: NKDA Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 7 days. 9. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for skin irritation. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please take 400mg [**Hospital1 **] for one week, then 400 mg daily for one week, then 200mg daily. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please monitor daily weights, Is/Os, can decrease to 20mg daily if patient becomes too dehydrated. 14. Atropine 0.1 mg/mL Syringe Sig: .5 mg Injection X1 (ONE TIME) as needed for symptomatic bradycardia & hypotension. 15. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5-25 mg Intravenous Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: Acute Coronary Syndrome with NSTEMI, s/p stent placement Discharge Condition: Good- patient chest pain free with no oxygen requirements, afebrile. Discharge Instructions: You have been started on a new medication, Amiodarone, to help control your heart rate and rhythm. Please continue to take this and all of your medications as instructed. Please maintain your follow-up appointments which are listed below. Please return to the hospital if you experience any chest pain, shortness of breath, fevers or chills.

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icd9cm

[ [ [] ] ]

[ "99.62", "37.22", "36.07", "37.61", "00.41", "97.44", "00.66", "00.46", "88.56", "99.04", "37.23", "99.10", "38.93" ]

icd9pcs

[ [ [] ] ]

15116, 15189

8613, 13523

286, 489

15290, 15361

3131, 7567

2455, 2479

13658, 15093

15210, 15269

13549, 13635

8491, 8590

15385, 15732

2494, 3112

224, 248

517, 2108

2130, 2269

2285, 2439

10,236

114,574

51361

Discharge summary

report

Admission Date: [**2199-11-10**] Discharge Date: [**2199-11-16**] Date of Birth: [**2123-4-14**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: increased ostomy output Major Surgical or Invasive Procedure: bilateral percutaneous nephrostomy tube placement History of Present Illness: 76 y/o F with a PMHx of anal CA/colon CA s/p colectomy [**8-/2199**] and recent anal resection for residual disease on [**9-25**] who had ureteral compression and hydro s/p bilat nephrostomy tube placement [**8-/2199**] and recent removal on [**11-5**] who presents with decreased UOP and increased anal leakage. Since having her tubes pulled, she has had decreased UOP. She denies any pain/burning with urination. Denies any fevers, +chills. No cough, odynophagia. +nonbloody watery diarrhea since having tubes pulled on [**11-5**]. No antecedent Abx course. . In the ED, VS were: T97.7, HR110, BP 115/58, RR22, 100%RA. In the ED, her K was noted to be elevated, and EKG showed peaked T waves. An emergent renal U/S showed worsening bilat hyrdonephrosis. She received Levaquin 500mg IV x1, Calcium gluconate 1g x1, amp D50 + 10u SC insulin, Kayexylate 30mL x1 and was taken to the IR suite for placement of (bilateral vs unilateral) percutaneous nephrostomy tube placement. . Past Medical History: OncHx: Paget's disease of anal canal dx by path [**12-2**]. Subsequent repeat biopsy [**8-3**] found residual/recurrent CIS. She was admitted [**7-4**] for descending colectomy after an anal stricture. Colon pathology demonstrated adenocarcinoma involving lymphatics, submucosa, and superficial part of muscularis propria. Omental specimens confirmed metastatic adenocarcinoma, predominantly signet ring cell type. This was same histology as previous anal Paget's disease from [**12-2**] biopsy. She was seen on [**7-23**] by Dr. [**Last Name (STitle) **], and will be undergoing palliative surgery in upcoming weeks . Other PMHx: - Colon cancer s/p lap resection in [**2193**] at [**Hospital3 **]. Believed to be node-negative, no chemo or radiation at time. - HTN - Extra-mammary Paget's disease s/p resection [**12-2**] - s/p partial hysterectomy - s/p breast reduction surgery - h/o ophthalmologic zoster [**2192**] . Social History: No EtOH or tobacco Family History: Noncontributory Physical Exam: VS: Temp:99.2 BP: 110-150/55-60 HR:110s RR:22 O2sat: 97-99%RA GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric RESP: CTA b/l with good air movement throughout CV: Tachycardic, regular. S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly BACK: L nephrostomy tube placed on left. EXT: no c/c/e SKIN: no rashes NEURO: AAOx3. Cn II-XII intact. Pertinent Results: [**2199-11-10**] 01:05PM WBC-21.2*# RBC-4.00* HGB-11.7* HCT-35.1* MCV-88 MCH-29.3 MCHC-33.3 RDW-15.8* PLT COUNT-437 [**2199-11-10**] 01:05PM NEUTS-92* BANDS-0 LYMPHS-6* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2199-11-10**] 01:05PM GLUCOSE-100 UREA N-89* CREAT-7.7*# SODIUM-126* POTASSIUM-8.1* CHLORIDE-91* TOTAL CO2-19* ANION GAP-24* . [**2199-11-10**]: Urine Culture: PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML. pan-sensitive. . [**2199-11-10**]: Bilateral hydronephrosis, probably worse than the [**2199-10-25**] study, but mildly improved since [**2199-9-13**] study. Layering material in the right upper pole may represent sediment or old blood. . [**2199-11-10**]: L nephrostomy placement - Nephrostogram demonstrating moderate left-sided hydronephrosis and proximal hydroureter. Only a minimal amount of contrast was seen to pass beyond the proximal ureter, although a guidewire was able to be threaded through the course of the ureter into the bladder. Successful placement of an 8 French percutaneous nephrostomy tube on the left by way of a posterior mid pole renal calix. Approximately 10 cc of turbid urine drained to gravity during the procedure. . [**2199-11-11**]: R nephrostomy placement - Successful placement of an 8 French nephrostomy tube in the right kidney attached to a bag for external drainage. Severe hydronephrosis and hydroureter on the right side. Brief Hospital Course: In brief, the patient is a 76 y/o F with anal CA/colon CA s/p resection, hx of hydro with bilateral nephrostomy tubes s/p removal [**11-5**] here with decreased UOP, anal leakage found to have new ARF and bilateral hydro. . 1.) Bilateral hydronephrosis: The patient presented with bilateral hydronephrosis following a recent removal of ureteral stents that had been placed for her known cancer mass that had been compressing her ureters. She had successful placement of bilateral percutaneous nephrostomy tubes with gradual resolution of the hydronephrosis. She will need f/u with IR in 3 months to change tubes or earlier if decision made to eschange for ureteral stents. . 2.) Acute renal failure: Her baseline Cr is 1.8. On presentation the Cr had increased to 7.7 secondary to the bilateral hydronephrosis. It showed gradual improvement over the course of the hospital stay. Her medications were dosed for her impaired renal clearance. She will need a chem7 panel checked approximately one week after discharge. . 3.) Hypotension/Sepsis: Patient developed sepsis following placement of R PCN tube UCx was positive for pan-sensitive pseudomonas. There was no evidence of acute end-organ hypoperfusion. She was briefly monitored in the ICU. She recovered her hemodynamics. By time of discharge her WBC continued to trend down. She will complete a 14 day total course of antibiotics. . 4.) Increased Ostomy output: subacute increase in ostomy output. no blood. could be secondary to co-incident illness (hydro/pyelo). A c dif toxin was negative. The increased ostomy output began to slow prior to discharge. She will need to follow-up with gen [**Doctor First Name **] as outpatient. . 5.) Metabolic Acidosis: This was a mixed anion-gap, non-anion gap acidosis due to a combination of renal failure (incr AG), hyperphosphotemia (incr AG), increased ostomy output (low AG), and dilutional acidosis from IVF (low AG). She did not have a lactic acidosis. By time of discharge her anion gap was improving. It was anticipated that the acidosis would continue to resolve as her renal function improved. . 6.) Anal CA s/p resection: no acute inpatient events other than the hydronephrosis above. She will follow-up with her general surgeon and meet with the radiation oncologist to discuss further treatment options. . 7.) Hypertension - blood pressure now resolving to baseline after her brief period of hypotension following the nephrostomy tube placement. Her home ACE inhibitor was discontinued in the setting of renal failure. . 8.) FEN: low potassium diet for now, replete as needed . 9.) Access: PIV . 10.) PPx: Hep SQ, ppi . 11.) DISPO: she was discharged to home with close PCP [**Last Name (NamePattern4) 702**] Medications on Admission: Lisinopril 5mg po Qday Centrum Silver 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Outpatient Lab Work Please have your blood drawn in 4 days while you are taking the ciprofloxacin so that the dose can be changed as necessary. Please draw: Na, K, Cl, bicarbonate, BUN, Cr, CBC and send results to Dr. [**First Name (STitle) **] [**Name (STitle) 2405**] (phone [**Telephone/Fax (1) 56399**]) 4. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO once a day for 9 days: please take as directed. Disp:*18 Tablet(s)* Refills:*0* 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 6. Ostomy Care ostomy care per protocol 7. Nephrostomy Tube Bilateral Nephrostomy Tube care per protocol Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Bilateral Hydronephrosis Pyelonephritis Acute Renal Failure . Secondary: Rectal Cancer Discharge Condition: good. ambulating with cane. afebrile. stable vital signs. tolerating oral medications and nutrition. Discharge Instructions: You have been evaluated and treated for an infection in your kidney and for an obstruction to the flow of urine. Tubes were placed into your kidneys to drain the urine bypassing the obstruction. A urine infection was found for which you will complete the rest of the antibiotics at home. Your kidney function was improving by time of discharge. . Please take the medications prescribed to you. Your lisinopril was stopped during this admission. You and your primary doctor can discuss starting a new blood pressure medicine as an outpatient. . Please make and attend the recommended appointments. . If you develop any new or concerning symptom, particularly fever to greater than 100.5F, decreasing urine output into the tubes, persistent nausea, please seek medical attention. . You, Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) 13734**] should discuss which would be the better option either changing the nephrostomy tubes periodically or having them exchanged for ureteral stents. Followup Instructions: Please call Dr. [**First Name (STitle) **] [**Name (STitle) **] office at [**Telephone/Fax (1) 56399**] to schedule an appointment within 7-10 days. You will need to get your blood drawn by the visiting nurse prior to that appointment to confirm that you blood counts and kidney function are improving appropriately. . You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2199-11-22**] at 3:15pm. Please call ([**Telephone/Fax (1) 6449**] with questions. .

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icd9cm

[ [ [] ] ]

[ "38.91", "55.93" ]

icd9pcs

[ [ [] ] ]

7949, 8007

4254, 6985

341, 392

8147, 8251

2833, 4231

9304, 9817

2398, 2415

7074, 7926

8028, 8126

7011, 7051

8275, 9281

2430, 2814

278, 303

420, 1399

1421, 2345

2361, 2382

816

116,423

50993

Discharge summary

report

Admission Date: [**2124-3-1**] Discharge Date: [**2124-3-9**] Date of Birth: [**2054-3-31**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfonamides / Atenolol Attending:[**First Name3 (LF) 1711**] Chief Complaint: Chest pain, shortness of breath. Major Surgical or Invasive Procedure: cardiac catheterization PICC line placed and removed History of Present Illness: 69 year old female with CAD s/p MI and CABG '[**09**] presents with intermittent chest pain x 1 week, worse in last 3 days with shortness of breath, lower extremity swelling. Patient was recently seen by PCP and aldactazide was d/c'ed on [**12-19**] and lasix was d/c'ed on [**2124-1-19**] (in setting of worsening renal function -lasix d/c'ed). In past couple weeks she notes increasing SOB, 10-lb wt gain and increasing dyspnea on exertion. She also noted intermittent chest pain during this period but worse in past 3 days. She has slept sitting up for the past 8 months. She came to ED after becoming very short of breath on morning of admission. EKG q wave anterior ?ST elevation in III. She was started on heparin gtt and nitro gtt. She went to cath lab and found to have 90%lesion in OM which was ballooned opened (couldn't stent). In the recovery area, patient SOB lying flat (likely h/o OSA although none diagnosed). She was on a non-rebreather satting 97%. . She was transferred to the CCU for further management. ABG in the holding area on NRB was 7.29/57/148. On arrival to the CCU she was placed on BiPAP, PS 10 PEEP 5, FiO2 50%. Her ABG on noninvasive ventilation was 7.36/53/146. After approximately [**12-14**] hours, she was feeling sufficiently less short of breath to be weaned to nasal cannula, at which point her ABG was 7.39/49/67. . Initial vitals in the ED: 97.8, 98, 152/72, 20, 88% on RA. She was given ASA, heparin gtt, lasix and sent to the cath lab. . On review of systems, + for non-productive cough X 3 weeks, and post-nasal drip. She has gained 10 pounds over the past 2 weeks. She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. All of the other review of systems were negative. Past Medical History: 1. Coronary artery disease status post MI in [**2101**] and CABG in [**2109**] 2. Diabetes mellitus type II, requiring large amounts of insulin (last HgA1c 7.9) 3. CHF, last EF per echocardiogram 55% Hypertension 4. Hypercholesterolemia 5. History of metastatic left-sided infiltrating ductal breast cancer s/p chemo/XRT (post-CABG) dx'ed [**2111**] 6. Hypothyroidism 7. UTIs (h/o recurrent Ecoli UTI in past) 8. COPD 9. Anxiety 10. Postmenopausal bleeding status post D&C procedure on [**2120-5-28**] 11. Obesity Social History: +70 pack-year history but quit in [**2101**], no EtOH or other drug use. Widowed 5 years ago. Three grown children. Lives in her own apt in her son's townhouse. Her daughter has helped her with her ADLs over the past couple of days and does help her with her shopping. Family History: No family history of premature coronary artery disease or sudden death. Brother with both multiple myeloma and "thyroid problems." [**Name2 (NI) **] mother had ?oral cancer. Physical Exam: VS - 120/64, 86, 19, 100% on CPAP 50% FiO2 Gen: Obese, elderly female in NAD. Oriented x3. Mood, affect appropriate. On CPAP HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple, unable to appreciate JVD [**1-14**] obesity CV: Unable to palpate PMI. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: Midline surgical scar. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi anteriorly. Radiation skin changes to L breast. Abd: Obese, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: 2+ Bilateral LE edema to mid-shins. No femoral bruits. R femoral sheath with minimal ooze. Skin: no ulcers, rash Pulses: Dopplerable dp/pt pulses Pertinent Results: Labwork on admission: [**2124-3-1**] 09:40AM WBC-14.3* RBC-4.00* HGB-10.6* HCT-33.3* MCV-83 MCH-26.4* MCHC-31.8 RDW-16.7* [**2124-3-1**] 09:40AM PLT COUNT-273 [**2124-3-1**] 09:40AM PT-13.2* PTT-23.9 INR(PT)-1.2* [**2124-3-1**] 09:40AM NEUTS-83.7* LYMPHS-12.2* MONOS-3.1 EOS-0.3 BASOS-0.7 [**2124-3-1**] 09:40AM GLUCOSE-277* UREA N-41* CREAT-1.2* SODIUM-141 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-18 [**2124-3-1**] 09:40AM CK(CPK)-159* [**2124-3-1**] 09:40AM cTropnT-.48* [**2124-3-1**] 09:40AM CK-MB-33* MB INDX-20.8* proBNP-6666* . Pertininent labs: Creatinine: baseline 1.1, peak 6.1, on discharge 2.0 Hct: Baseline 26-27, Hct on discharge 24 (prior to receiving 1UPRBCs) . IMAGING . CHEST (PORTABLE AP) [**2124-3-1**] This AP bedside radiograph is limited by patient's large size. The heart is probably enlarged with previous CABG. No vascular congestion. I doubt the presence of consolidations. I cannot exclude effusions particularly on the right. Other than the equivocal pleural changes on current examination there is a little change from more satisfactory bedside exam [**2123-10-11**]. IMPRESSION: Suboptimal exam. No pneumonia and I doubt the presence of CHF. . [**2124-3-1**] CARDIAC CATH: report pending . [**2124-3-2**] ECHO The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is moderately-to-severely depressed (30 percent) secondary to global hypokinesis with regional variation (the inferior and posterior walls appear more hypokinetic). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-14**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2122-2-24**], the left ventricular ejection fraction now appears reduced, but the technically suboptimal nature of both studies precludes certainty. Brief Hospital Course: 69 year old female with CAD s/p MI and CABG, DMII, obesity, CHF p/w NSTEMI in setting of CHF exacerbation. . #. Congestive heart failure. Ejection fraction on this admission 30% from 45% on last stress test [**2121**]. The patient was volume overload on admission and soon became oliguric as below despite escalating doses of lasix. The patient's oxygen saturations remained stable. The patient was followed by Renal and may need dialysis if urine output does not improve. The patient's ACE-inhibitor was held for renal failure. The patient has not tolerated a beta-blocker in the past and had one episode of junctional bradycardia during admission. The patient should have a repeat echocardiogram in two months for consideration of ICD placement. . #. Acute renal failure. The patient remained oliguric/anuric and volume overloaded but oxygen saturations remained stable. The renal failure is likely contrast nephropathy. Her Diovan and HCTZ were stopped given renal failure. The patient was followed by Renal during admission, and creatinine gradually improved from 6.1 to 2.0 on day of discharge. She will need to follow-up with PCP one week after discharge to have kidney function evaluated and further address resuming [**Last Name (un) **] and/or diuretics. . #. Coronary artery disease. The patient is status post CABG in [**2109**] and admitted with NSTEMI on this admission now status post cardiac catheterization on [**2124-3-1**] with no obvious source for STEMI. The patient received PCTA to 90% stenosis of OM2. The NSTEMI was likely demand ischemia from CHF exacerbation in setting of discontinuation of diuretics. The patient was continued on ASA, plavix, statin. The patient received integrilin and heparin gtt on admission. The patient's ACE-inhibitor was held for renal failure. The patient has not tolerated a beta-blocker in the past and had one episode of junctional bradycardia during admission. . #. Rhythm. Sinus rhythm. The patient hd one episode of junctional bradycardia of unclear etiology but no subesequent episodes. Electrophysiology followed the patient during admission. . #. Hypoxemia, hypercarbic respiratory failure. Now resolved. The patient has a 70 pack year smoking history with COPD and likely restrictive defect secondary to obesity. The patient had an additional element of pulmonary edema in the setting of anxiety post-cath/lying flat/copious fluids peri-cath. The patient was continued on albuterol/atrovent nebs. . #. Anemia. Stable. Iron studies consistent with iron-deficiency. The patient also has a history of ACD and mild B12 deficiency. The patient was started on iron supplementation, and prior to discharge, she was transfused 1U PRBC for Hct 24 given her extensive cardiac history. After discharge, she was monitored for several hours for SOB, worsening DOE. She was able to ambulate and dress herself with baseline shortness of breath, oxygenation remained 97%. . #. Diabetes mellitus, type 2. Not well-controlled based on last HgA1c. The patient was continued on lantus and HISS. . # Urinary tract infection. The patient was given a dose of levaquin in the ED, but this was changed to ceftriaxone and then cefpodoxime as the patient had a history of quinonlone-resistant UTI in the past. Urine culture on this admission showed sensitivity to quinolones and cephalosporins. . # Hypothyroidism. TSH 3.1 during this admission. The patient was continued on her outpatient levothyroxine. . #. FEN : cardiac/[**Last Name (un) **] diet . #. Access: R PICC was placed for blood draws and d/c'd on discharge . #. PPx: - heparin sc . #. Code: FULL (confirmed with patient but would not want prolonged intubation) . Post Discharge Follow-up by PCP [**Name Initial (PRE) 105948**]: 1) Repeat creatinine, hct one week post discharge 2) Address whether to restart Diovan 160, HCTZ 25, and/or other diuretics 3) Repeat echo in 2 months to reassess EF and need for ICD placement Medications on Admission: diovan 160mg po qday aspirin 325 simvastatin 80 mg qday LANTUS 100 U/ML--155 units sq every morning LEVOTHYROXINE 150 MCG--One every day HCTZ 25mg qday levothyroxine 150mcg qday metformin 1000mg po bid lantus 155u sc qam HISS sliding scale FLONASE 50 mcg/Actuation--2 sprays each nostril once a day lasix 40mg qod (on hold on [**2124-1-19**]) spironolactone 25mg po qday (D/c'ed on [**2123-12-19**]) cranberry tablets (UTI prevention) Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal DAILY (Daily). 4. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Cyanocobalamin 100 mcg Tablet Sig: 0.25 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Insulin Please continue your outpatient insulin (Lantus) regimen as before Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: coronary artery disease Non ST segment elevation myocardial infarction congestive heart failure acute renal insufficiency urinary tract infection . Secondary: diabetes mellitus obesity hypothyroidism iron deficiency anemia Discharge Condition: stable, saturating at baseline on room air Discharge Instructions: You had a heart attack as well as congestive heart failure. During cardiac catheterization, you had an occlusion in one of your coronary arteries which was subsequently opened. After this, you also had renal failure, which is now improving significantly. You will need to have your kidney function checked regularly until it returns to baseline. Please continue to take all of your medications as prescribed. Please weight yourself every day, maintain a low salt diet and call your doctor if you have a greater than 3 pound weight gain in [**12-14**] days, worsening swelling in your feet, or shortness of breath. Please call 911 or go to the emergency room if you have chest pain, chest pressure, shortness of breath, fever, chills, nausea/vomiting, or any other concerning symptoms. Followup Instructions: Please call [**Hospital3 **], [**Telephone/Fax (1) 250**], and schedule an appointment with your primary care physician or [**Name Initial (PRE) **] nurse practioner, to have your kidney function (creatinine) rechecked early next week. You already have to following appointments scheduled: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2124-3-28**] 2:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2124-5-16**] 10:00

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icd9cm

[ [ [] ] ]

[ "38.93", "88.56", "00.40", "00.66", "99.20", "37.22" ]

icd9pcs

[ [ [] ] ]

11778, 11836

6565, 10488

329, 384

12112, 12157

4153, 4161

12994, 13583

3142, 3317

10975, 11755

11857, 12091

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3332, 4134

257, 291

412, 2303

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173,283

25872+25873+57469+57446

Discharge summary

report+report+addendum+addendum

Admission Date: [**2164-7-24**] Discharge Date: [**2165-1-11**] Date of Birth: [**2099-9-23**] Sex: F Service: SURGERY Allergies: Dilantin Attending:[**First Name3 (LF) 1556**] Chief Complaint: Endometrial CA Major Surgical or Invasive Procedure: [**7-24**] TAH and BSO complicated by large ventral hernia repair History of Present Illness: 64 G5P5 with endometrial CA admitted for TAH/BSO. Pt initially presented with postmenopausal bleeding in [**2164-3-13**]. Endometrial biopsy perfomed on [**2164-6-27**] revealed endometrial adenocarcinoma, endometrioid type, grade 1. D&C performed one year prior was benign. She was otherwise asymptomatic. Past Medical History: 1. Atrial fibrillation 2. CVA [**2156**] - embolic, when off coumadin for colectomy 3. Crohn's Disease 4. Hypothyroid 5. Hypercholesterolemia Past Surgical History: 1. Total colectomy s/p perforation during Barium enema 2. Ileostomy [**2156**] and repair [**2157**] Past OB/GYN History: Pap smear [**2164**] wnl, Mammogram [**2163**] wnl. S/p 5 NVD Social History: Lives with family. Nonsmoker (quit [**2156**]). Rare ETOH. Family History: Grandaughter: Hodgkins Disease Grandaughter (different than above): Liver cancer (treated) Father: MI Mother: CVA Physical Exam: (Admission Physical Exam) Normal general exam, WDWN female in NAD Baseline confusion but AOx3 irregular rhythm, normal rate CTAB Obese, nontender, no palpable masses No lymphadenopathy No nodularity, masses, or tenderness on pelvic exam No rectum Pertinent Results: CBC [**2164-7-24**] 07:15PM BLOOD WBC-29.2*# RBC-3.91* Hgb-12.1 Hct-35.7* MCV-91 MCH-30.9 MCHC-33.9 RDW-13.0 Plt Ct-280 Differential: Neuts-93* Bands-1 Lymphs-3* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2164-7-26**] 12:36PM BLOOD WBC-17.5* RBC-2.79* Hgb-8.5* Hct-25.4* MCV-91 MCH-30.3 MCHC-33.4 RDW-13.1 Plt Ct-202 [**2164-7-27**] 04:00AM BLOOD WBC-20.3* RBC-4.56 Hgb-13.8 Hct-40.5 MCV-89 MCH-30.4 MCHC-34.2 RDW-13.7 Plt Ct-252 Differential: Neuts-87.8* Lymphs-6.9* Monos-3.6 Eos-1.1 Baso-0.6 [**2164-7-29**] 12:09PM BLOOD WBC-10.8 RBC-3.09* Hgb-9.5* Hct-27.6* MCV-90 MCH-30.8 MCHC-34.4 RDW-14.0 Plt Ct-251 [**2164-7-31**] 05:25AM BLOOD WBC-13.6* RBC-3.04* Hgb-9.3* Hct-27.0* MCV-89 MCH-30.5 MCHC-34.3 RDW-15.0 Plt Ct-270 Coags [**2164-7-24**] 07:15PM BLOOD PT-14.4* PTT-21.6* INR(PT)-1.4 Lytes [**2164-7-24**] 07:15PM BLOOD Glucose-164* UreaN-13 Creat-0.8 Na-139 K-4.7 Cl-110* HCO3-21* AnGap-13 [**2164-7-27**] 04:00AM BLOOD Glucose-105 UreaN-14 Creat-0.9 Na-139 K-4.3 Cl-102 HCO3-27 AnGap-14 LFTs [**2164-7-24**] 07:15PM BLOOD ALT-26 AST-26 LD(LDH)-204 AlkPhos-128* TotBili-0.6 [**2164-7-26**] 04:27AM BLOOD ALT-17 AST-23 LD(LDH)-182 AlkPhos-102 TotBili-0.3 Cardiac Enymes [**2164-7-24**] 07:15PM BLOOD CK-MB-4 cTropnT-<0.01 [**2164-7-25**] 03:02AM BLOOD CK-MB-8 cTropnT-<0.01 [**2164-7-25**] 11:54AM BLOOD CK-MB-14* MB Indx-2.2 cTropnT-<0.01 Thyroid [**2164-7-30**] 12:44AM BLOOD TSH-4.9* [**2164-7-30**] 04:44AM BLOOD T4-6.9 Pathology Endometrial CA, endometrioid adenocarcinoma, Stage 1B, grade 1, 10% invasion Brief Hospital Course: Pt was admitted postoperatively following a TAH/BSO complicated by large ventral hernia repair. She received 1U PRBC intraoperatively. EBL ~750cc. Please see Operative note for details. ICU admission: Patient was admitted postoperative to the ICU for evaluation of shock. Initially, differential diagnosis included septic vs. hypovolemic. Her ICU course by systems was as follows: 1) ID: Pt had a fever to 39C intraoperatively but was afebrile for the remainder of her admission. WBC on POD#0 peaked at 29.2 (93%N, 1 band) and declined on subsequent days. All cultures including blood, line, sputum, and urine had no growth. Empiric Zosyn was initiated on POD#0 and discontinued on POD#3. Post op day 7 WBC elevated to 16, pt remained afebrile. CT done revealed SBO, no abscess. WBC declined with management of SBO. 2) Resp: Pt was intubated to control her airway given shock. She was successfully extubated on [**2164-7-26**]. 3) CV: Shock postoperatively initially thought to be septic, but on reevaluation of vitals, hypovolemia was more likely. Pt was resuscitated with IVF with good response and UOP. She required pressors until POD#1 then maintained BP without medications. Cardiogenic shock was ruled out by three sets of enzymes and unchanged EKG. Septic shock ruled out by negative cultures and afebrile as above. Patient continued to be in atrial fibrillation throughout her stay. Metoprolol and Digoxin were restarted in ICU for maintenance of rate control. Although pt was tachycardic on POD#0, this resolved after resuscitation. Anticoagulation was initiated in ICU with heparin gtt and coumadin. After this, patient had evidence of bleeding into JP drains, from IVs, and hematuria. HCT declined to 25. She was subsequently transfused 2U PRBC with posttransfusion HCT 40. Heparin gtt was held given concerns for bleeding but coumadin was continued. 4) Miscellaneous: Outpatient medications were restarted including lipitor, levoxyl, pentasa (for Chrohn's disease). An insulin gtt was initiated in the acute period in the ICU and transitioned to regular ISS. This was discontinued when transferred to the regular floor. Remainder of Postoperative Course after Transfer from ICU (POD#0-3) until time of transfer to surgery service POD 9 [**8-2**]: 1) CV: Pt remained hemodynamically stable throughout the remainder of postoperative course. Heparin gtt restarted POD#4 and again discontinued POD#5 after clinical bleeding per vagina and JP drains. Hct nadired at 27 and patient received 1U PRBC. Coumadin was continued without loading doses. She was maintained on asa and coumadin for anticoagulation with plan to d/c asa when INR [**2-16**]. Her INR plateaued at 1.5 but Coumadin was not increased due to concern for high risk of bleed. She will likely need coumadin dose increased to achieve therapeutic INR. 2) Neurology: On POD#5, pt was disoriented with slurred speech. Neurology consult was obtained. The leading diagnosis was delirium associated with postoperative course. An MRI and CT scan showed no evidence of intracranial bleeding or acute CVA. Evidence of known old infarct was seen. Mental status stable for remainder of course of gyn. Pain was managed effectively with SC Dilaudid. 3) Respiratory: Pt required O2 via NC to maintain O2 sats until POD 6. She required several doses of IV lasix for fluid overload. She was trabsferred to surgery with O2 sats stable on RA. 4) GI: patient developed evidence of ileus between POD#5 and POD#7. She had nausea/vomiting; CT abdomen revealed dilated loops of bowel c/w partial SBO vs. ileus. She was made NPO/IVF pending output from her ileostomy. Subjectively she improved and was allowed sips of fluids which she tolerated well. On POD 9 she underwent CT scan of abdomen due to elevated WBC count - CT revealed complete SBO at level of ostomy. She was transferred to gen [**Doctor First Name **] for further management. 5) GU: UoP was borderline up until POD#7. She responded well to lasix and IVF boluses. Fractional excretion of urea was c/w prerenal disease. There were no urinary eosinophils to suggest intrinsic disease. UP improved following tx for SBO. 6) Endo: TSH was evaluated during evaluation of mental status changes. TSH was elevated but T4 was within normal limits. She was maintained on levoxyl. Gen [**Doctor First Name **] (from POD 9): CT showed SBO - patient was made NPO, NGT & foley placed for decompression, IVFs and TPN started, patient monitored with serial exams. Initial subjective and clinical improvement was seen as patient was afebrile and WBC decreased. However, POD 12 patient spiked fever and WBC increased. Had UTI, started on levaquin. High output still from NGT, increasing drainage and erythema. repeat CT scan showed perwistent SBO, no abcess collection. Because of persistent obsturction and no improvement, patient was taken to the OR on POD 15 for exploratory laparotomy, resitting of ileosotmy, lysis of adhesions, resection of small intestine, closure of enterotomys x2 and closure of abdomen with vicryl mesh and VAC. Patient remained on levo/flagyl. POD 1 - IN PACU, then TSICu patient remained intubated .had initial pressor requirement. swan catherter placed. POD 2 - TPN restarted. Vancomycin added to levo/flagyl for GPC in wound. POD [**3-16**] - pt still intubated, but awake and alert; Vac had draingage sent for labs b/c of possible fistula formation. POD 5 - enterocutaneous fistulas from open ab wound diagnosed; VAC changed; bowel function returned with good osteomy output. VRE grew from abd mesh - Linazolid started. Patient was extubated successfully. POD 6 transferred to floor, but POD 7 transferred back to ICU - had increasing SOB/tachy; controlled with meds/nebs, had thoracentesis. POD 11 patient was transferred back to the floor. Patient continued to have low grade fevers without a source. POD19 - CT scan obtained; did not show abcess. POD21 - vac change showed large amount of sucus trapped behind inferior portion of the mesh. POD22 - mesh was removed and new suction drainage system was employed to drain the wound. After this time, patient's low grade fever disappeared. POD25 - all antibiotics were dc'd; latest urince culture was contamination, no growth. For the next two weeks patient was stable without any issues. POD 40 - patient had some bleeding from the left superior portion of the wound, asymptomatic. Remainder of discharge summary dictated and to be appended to this portion of the hospital course. Medications on Admission: Metoprolol 50 [**Hospital1 **] Meclizine 25 qd Pentasa 1000 mg QID Levoxyl 50 qd Digoxin 0.[**Age over 90 **] M/W/F, 0.25 T/Th/S/S Lipitor 20 QD Warfarin 5 qd held ? since [**7-19**] Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Crohn's disease, enterocutaneous fistulae, endometrial cancer status post total abdominal hysterectomy and bilateral salpingo-oophorectomy, prior cerebrovascular accident, atrial fibrillation, hypothyroidism, hypercholesterolemia, history of total colectomy, ileostomy, asthma Discharge Condition: stable Discharge Instructions: Patient to be discharged to a rehabilitation facility and to have daily wound care with dressing changes once a day to keep fevers, chills, nausea, vomiting, shortness of breath, chest pain, redness or drainage about the wounds, or if there are any questions or concerns. Followup Instructions: Patient to follow up with Dr. [**Last Name (STitle) **] in two weeks and to call to schedule an appointment at [**Telephone/Fax (1) 64379**]. Unit No: [**Numeric Identifier 64380**] Admission Date: [**2164-7-24**] Discharge Date: [**2165-1-3**] Date of Birth: [**2099-9-23**] Sex: F Service: [**Last Name (un) **] HOSPITAL COURSE: This is a continuation of the discharge summary that was started by Dr. [**Last Name (STitle) **] that was truncated on [**2164-9-17**]. This will dictate the additional 3-1/2 months of her hospital course. Both will be included in the final paper work to describe this hospital stay. On [**2164-9-17**] the patient was continued on total parenteral nutrition and continued to have laboratories checked. On [**2164-9-19**] the patient was continued on total parenteral nutrition and was on the floor at this time receiving wound care to her stoma site with Nugauze. She continued on total parenteral nutrition throughout this period and was then prepared for eventual abdominal closure and likely fistula take-down. The important aspects of her care at this point were improving her nutritional status through the use of total parenteral nutrition. She was having weekly nutrition laboratories checked as well. Albumin, transferrin, ferritin and iron every Monday. Of note, the patient was also on Lovenox for anticoagulation at this time for atrial fibrillation. She was eventually converted to warfarin and her INR was checked 3 times a week during the period leading up to surgery as she was prepared. She was also on Digoxin at this time with levels being checked routinely and had been placed on Levofloxacin on [**2164-10-20**] for a urinary tract infection. She underwent a 5 day course and the infection was noted to have resolved and the antibiotics were able to be stopped. In the period leading up to her operation she did of note have other infectious events with 2 central line infections, one in the middle of [**Month (only) 359**] and one at the end of [**Month (only) **] which required transfer into the Intensive Care Unit when she became septic and hypotensive. For both of these events she was treated with Vancomycin and fluconazole in addition to Flagyl and Levofloxacin. She continued to be prepared for surgery which was supposed to take place at the end of [**Month (only) **]. However, this was unable to occur due to the septic event that occurred on Sunday, [**2164-12-9**]. The patient was brought to the Intensive Care Unit. She was assessed with blood cultures, chest x-ray, urine cultures and lime cultures. The peripheral inserted central catheter from 2 months before ended up growing back staph enterococcus that was presumed to be possibly Vancomycin resistant. The patient was started on linezolid during this time and completed a 2 week course. The bulk of the management for the interval from [**9-17**] into early [**Month (only) 1096**] was for this complex wound management and optimization of her nutrition prior to the embarkment upon repair of such complicated fistulae and hernias. It was determined that the patient was adequately preoperatively prepared and having been treated for her line complication. She was brought to the operating room on [**2164-12-25**] and underwent an enterectomy with anastomosis with enteroenterostomy, excision of enterotomies, jejunostomy tube placement, adhesiolysis of abdominal adhesions of extensive nature, repair of incisional hernia and implantation of mesh for repair of incisional hernia and myocutaneous fascial flap for repair of incisional hernia. The case was performed by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 3826**] as assistants. The case went as planned and the patient was able to tolerate the procedure well with blood loss of approximately 150 ml. The patient received 5200 ml of Crystalloid fluid in the operating room and her urine output was 620 ml during the case. Significant findings during the case were 4 separate enterocutaneous fistulae with resulting 8 separate small bowel openings, a large area of incisional hernia secondary to dehiscence and removal of prosthetic mesh following her previous repair and a total of 24 inches of small intestine that were removed. The remaining small intestine length was estimated to be greater than 8 feet. The patient left the operating room intubated and was brought to the Intensive Care Unit at this time. She was able to be extubated on postoperative day 2 without any difficulties and was weaned and her nasal cannula oxygen was weaned during this time. Her tube feeds were then restarted at a trophic rate of 10 ml per hour and gradually increased to 60 ml per hour at a rate of increase of approximately 10 ml per increment every 1 to 2 days. The patient gradually advanced to a regular diet which she was noted to be tolerating well at the time of discharge and was receiving Boost 3 times a day as the patient tolerated. Also of note the patient was started with physical therapy again after her operation to increase her activity and to improve her likelihood of success in terms of her rehabilitation. She was an eager participant despite feeling fatigued at times and made significant progress with them. From a system space perspective to round out this summary I view her issues as such: Neurologically the patient was stable in the postoperative period. She had some occasional issues with pain that was treated with Percocet elixir as well as occasional issues with anxiety for which she received lorazepam 0.5 mg IV q 8 hours as needed. She had no neurologic events during this time. From a cardiovascular standpoint she was stable throughout receiving p.o. metoprolol and Digoxin with levels checked 2 or 3 times weekly. In the days before discharge it was determined that patient could benefit from an extra dose of metoprolol and was increased from b.i.d. to t.i.d. dose of 50 mg due to the patient's occasional morning episodes of tachycardia where her blood pressure was maintained. From a respiratory standpoint she was stable on room air breathing in saturation ranges of the high 90%. She was fairly diligent in terms of her use of incentive spirometry and breathing exercises and getting herself out of bed and practicing pulmonary toilet. From a gastrointestinal standpoint she was on lansoprazole oral suspension given once daily for acid suppression. She was on tube feeds, Impact with Fiber at half strength that is 60 ml per hour with feedings held for residuals for 100 ml checked very 4 hours. She was on Boost breakfast, lunch and dinner supplements as tolerated. She was on a regular diet. She was on calorie counts in the days leading up to her discharge and was found to be averaging around 700 to 800 kilocalories per day with a goal of course eventually being to eliminate the tube feeds and for her to be able to support herself on a regular diet per os. Genitourinary: Patient was without Foley catheter at the time of discharge and was urinating without issue at the time of discharge and making between 1-1/2 and 2 liters a day. From a hematologic standpoint the patient was also doing well with stable blood counts. However, the goal was to bring her international normalized ratio up to 2.5 or thereabouts on warfarin and on the day of discharge she still had not achieved that goal and was receiving 2 and 5 mg of warfarin dosage daily with the goal INR as stated before. [**Doctor Last Name **] were no other hematologic abnormalities noted during her hospital stay. Endocrine: Patient was on a regular insulin sliding scale postoperatively. However, blood sugars were noted to be very well controlled and she was noted to not require this. Hence fingersticks were discontinued. She was also on levothyroxine which was continued throughout the postoperative period with plans for her to be discharged on 100 mcg once daily. Infectious disease issues were resolved at the time of discharge. The patient had had several infections during her hospital stay that were treated with various and sundry antibiotics such as linezolid, levofloxacin, fluconazole, Vancomycin, metronidazole, etc. She was afebrile at the time of discharge and her white counts were within normal limits. For prophylactic regimen the patient at this time was on lansoprazole oral suspension 30 m daily as mentioned before. The patient was on heparin 5,000 units subcutaneously 3x a day. The patient was on Pneumoboots when in bed. The patient was to continue wearing an abdominal binder when out of bed. Patient was encouraged to walk around and practice incentive spirometry. Fluids, electrolytes and nutrition: The patient was off all intravenous fluids at this time and was on tube feeds and a regular diet. It will be suggested that she receive occasional laboratory draws in the period of time that she spends at rehabilitation, perhaps drawing electrolytes twice a week would be wise in addition to her daily INR checks to reach a therapeutic goal through means of warfarin. Psychiatric: There were no issues in the postoperative period of significant note. However, the patient obviously had had a long and difficult hospital course and gone through numerous events and various transfers throughout the hospital that surely were taxing on her as well has having to go through a fairly major operation and recovery lasting from mid summer through the first days of winter. She was not requiring any medications at this time to address any of these issues. However, several teams and staff throughout the hospital eagerly participated in her care to help her progress through this hospital stay. DISCHARGE INSTRUCTIONS: The patient will be discharged to the rehabilitation facility and to have daily wound care with dressing changes once a day to keep wound clean and dry as needed. M.D. to be made aware if patient having fevers, chills, nausea, vomiting, shortness of breath, chest pain, redness or drainage about the wound or if there are any questions or concerns. FINAL DIAGNOSES: Crohn's disease. Enterocutaneous fistulae. Endometrial cancer, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. Prior cerebrovascular accident. Atrial fibrillation. Hypothyroidism. Hypercholesterolemia. History of total colectomy and ileostomy. Asthma. RECOMMENDED FOLLOW UP: Patient to follow up with Dr. [**Last Name (STitle) **] in 2 weeks and to have appointment set up through [**Telephone/Fax (1) 3201**]. MAJOR SURGICAL OR INVASIVE PROCEDURES: Total abdominal hysterectomy and bilateral salpingo-oophorectomy. Ventral hernia repair. Jejunostomy feeding tube placement. Partial small bowel resection, take down of enterocutaneous fistulae, closure of abdominal wall and [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain placement. Central venous line placements (multiple), peripheral inserted central catheter placements (multiple). Foley catheter placements (multiple). Endotracheal intubations (multiple). Peripheral intravenous line placements (multiple). Arterial line placements (multiple). DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: Albuterol 0.083% solution, 1 inhalation q 4 - 6 hours as needed for wheezing and shortness of breath. Ipratropium bromide 0.02% solutions, 1 inhalation q 6 hours as needed for wheezing and shortness of breath. Miconazole nitrite 2% powder, 1 application topical t.i.d. as needed. Heparin 5,000 subcutaneous t.i.d. Levothyroxine 100 mcg p.o. q.d. Lansoprazole 30 mg p.o. q.d. Digoxin 250 mcg p.o. q.d. Metoprolol 50 mg p.o. t.i.d., hold for a systolic blood pressure less than 100, heart rate less than 60. Percocet elixir 525/5 5 to 10 ml p.o. q 4 to 6 hours as needed for pain. Bismuth 262 mg per 15 ml, 15 ml p.o. t.i.d. Loperamide 2 ml p.o. t.i.d. Tylenol as needed for pain. TREATMENTS AND FREQUENCY: Patient must have regular physical therapy and be encouraged to get out of bed as frequently as possible. Patient to have wound care with daily examination and changes of dressing to keep wounds clean and dry as needed. DIET: Patient to be discharged on Impact with Fiber half strength with a rate of 60 ml per hour and not to advance and to check the residuals every 4 hours with holds for residuals greater than 100. Patient to receive Boost supplements in addition to her regular diet. DISPOSITION: Patient to be discharged to rehabilitation and to follow up with Dr. [**Last Name (STitle) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 15912**] MEDQUIST36 D: [**2165-1-3**] 13:25:19 T: [**2165-1-3**] 14:55:06 Job#: [**Job Number 64381**] Name: [**Known lastname 11310**],[**Known firstname 1647**] Unit No: [**Numeric Identifier 11311**] Admission Date: [**2164-7-24**] Discharge Date: [**2165-1-11**] Date of Birth: [**2099-9-23**] Sex: F Service: SURGERY Allergies: Dilantin Attending:[**First Name3 (LF) 3524**] Addendum: There was an error in the previous transcription of my dictation from [**2165-1-3**]. In the final copy it read that Mrs. [**Known lastname **] was achieving oxygen saturations of 90% on room air. What I meant to say is that the patient was actually achieving saturations in the 95-97% range on room air at the time of discharge. Thanks. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Discharge Disposition: Extended Care Facility: [**Hospital1 49**] - [**Location (un) 50**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**] Completed by:[**2165-1-4**] Name: [**Known lastname 11310**],[**Known firstname 1647**] Unit No: [**Numeric Identifier 11311**] Admission Date: [**2164-7-24**] Discharge Date: [**2165-1-11**] Date of Birth: [**2099-9-23**] Sex: F Service: SURGERY Allergies: Dilantin Attending:[**First Name3 (LF) 3524**] Addendum: This is an addendum to a discharge summary that encompassed Ms. [**Known lastname 11312**] hospital stay until [**2165-1-4**]. From [**Date range (1) 11313**], the patient continued to make good progress in her recovery. She received daily physical therapy. She continued to receive cycled tube feeds via her jejunostomy tube. She tolerated these well. She would have mild intermittant abdominal pain from time to time that resolved with oral pain medication. Calorie counts performed from [**Date range (1) 11314**] revealed that the patient was eating everything on her food tray. Tube feeds will be continued for the time being, but may soon be rendered unnecessary. She is being discharged on [**2165-1-11**] to The [**Doctor Last Name 321**] Skilled Nursing Facility in [**Location (un) 322**], MA (contrary to what was reported on the original discharge summary. She is in good condition, but is in need of physical therapy rehabilitation. She is to see Dr. [**First Name4 (NamePattern1) 84**] [**Last Name (NamePattern1) 2206**] in clinic in 2 weeks, at which time her abdominal sutures can be removed. Discharge Disposition: Extended Care Facility: [**Doctor Last Name 321**] Nursing & Rehabilitation Center - [**Location (un) 322**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**] Completed by:[**2165-1-11**]

[ "038.9", "998.11", "569.69", "427.31", "182.0", "785.59", "552.21", "614.6", "996.62", "280.0", "518.5", "555.9", "293.0", "998.31", "996.69", "569.81", "560.9", "568.0", "599.0", "244.9", "995.92", "998.2" ]

icd9cm

[ [ [] ] ]

[ "96.6", "54.59", "68.4", "45.62", "99.15", "38.93", "53.61", "00.14", "46.41", "96.72", "38.86", "86.74", "46.73", "93.59", "65.61", "46.39" ]

icd9pcs

[ [ [] ] ]

25903, 26171

3108, 9636

283, 350

21781, 21790

1553, 3085

10590, 10914

1156, 1271

21814, 24175

9962, 10240

9662, 9846

10932, 20299

20324, 20674

877, 1063

1286, 1534

20692, 20987

20999, 21759

229, 245

378, 689

711, 854

1079, 1140

5,924

182,867

19376

Discharge summary

report

Admission Date: [**2197-3-10**] Discharge Date: [**2197-3-17**] Date of Birth: [**2143-2-22**] Sex: M Service: [**Location (un) 259**] HISTORY OF PRESENT ILLNESS: This is a 54 year-old male patient with Down Syndrome, bilateral deafness, status post two hemorrhagic strokes ([**2195-11-3**] and [**2196-12-3**]) who was noted at home to have altered mental status progressing to unresponsiveness. The patient was initially brought to the [**Hospital 40262**] Hospital where he was intubated and transferred to [**Hospital1 69**] for further evaluation. A head CT was significant for a left frontal lobe bleed with smaller bleeds in the parietal area, a right lateral ventricle and basal ganglia. An MRI was significant for a left frontal bleed and old right parietal/fontal bleeds. The patient's INR was noted to be 1.6 and he was given fresh frozen platelets infusions and vitamin K. Neurosurgery evaluated the patient and felt that he was not a surgical candidate and the patient was eventually transferred to the Neurology Service. The patient was given Mannitol 1 gram per kilogram and loaded with Dilantin 1 gram. Five weeks prior to admission the patient had left hand clumsiness, which improved. He was evaluated with an MRI/MRA on [**2197-2-3**], which showed subacute right parietal aneurysm. He had a normal TTE with an anticardiolipin IGG weekly positive at 26.4. PAST MEDICAL HISTORY: 1. Down syndrome. 2. Status post two hemorrhagic strokes, [**2195-11-3**] with left sided weakness that resolved, [**2196-12-3**] with right sided weakness that has persisted. 3. Deaf. 4. Hypothyroidism. 5. Chronic lower back pain. MEDICATIONS: 1. Levothyroxine 150 micrograms po q day. 2. Naprosyn. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives at home with his parents and gets assistance with his activities of daily living. He walks with a cane. There is no tobacco or alcohol use. PHYSICAL EXAMINATION: Vital signs temperature 97.8. Blood pressure 107/52. Heart rate 66. Respirations 12. 100% on room air. General the patient is intubated and sedated with an initial examination performed under anesthesia, the patient exhibited no spontaneous movements. Pupils were pinpoint bilaterally and minimally reactive. The patient was unable to follow commands or localize to pain in any extremities. His only response to painful stimuli is biting of the ET tube. Right lower extremity toes upgoing. Left lower extremity toes equivocal. Cardiovascular regular rate and rhythm. No murmurs, rubs or gallops. Lungs clear to auscultation bilaterally. LABORATORY: White blood cell count 7.8, hematocrit 32.3, platelets 139, PT 14.7, PTT 26.8, INR 1.6, sodium 141, potassium 3.7, chloride 108, bicarb 29, BUN 14, creatinine 0.8, glucose 100. Calcium 8.5, phosphate 2.8, magnesium 1.6. Tox screen is negative. Urinalysis was negative. Amylase 86. HOSPITAL COURSE: 1. Neurological: The patient initially presented to an outside hospital with increasing altered mental status, which progressed to unresponsiveness. Head CT and MRI significant for a left frontal bleed. The patient was admitted to the Neurosurgery Intensive Care Unit. He was loaded with Dilantin given Decadron for concern for cerebral edema. He remained clinically stable. The neurosurgery team decided that he was not a surgical candidate. The patient was therefore transferred to the Neurology Service where his Dilantin was continued and levels checked. The patient had serial head CTs, which showed no evidence of new bleeding or progression of his previous hemorrhage. Once extubated the patient became gradually more alert, responsive and interactive. His neurological examination was stable. The etiology of the patient's recurrent intracranial hemorrhages was thought likely secondary to amyloid angiopathy as a previous outpatient workup with protein C, protein S, anticardiolipin and factor 5 liden was normal. 2. Hematology: The patient was admitted with a history of two hemorrhagic strokes and noted to have a new intracranial hemorrhage. The patient had been evaluated as an outpatient by a hematologist who considered the etiology of the patient's recurrent bleeds to be likely amyloid angiopathy, which can be seen with Down syndrome. The Hematology/Oncology consult service was contact[**Name (NI) **] and felt that amyloid angiography was the most likely cause for the ICH, so there was no further workup of coagulopathy rate indicated. The patient was noted to have a edematous right arm and an ultrasound was significant for a deep venous thrombosis. In light of the patient's intracranial hemorrhage and deep venous thrombosis the hematology team recommended treating the patient's elevated INR with 6 units of fresh frozen platelets. The patient was also started on vitamin K injections 10 mg subq q day for five days. A DIC profile was checked and noted to be consistent with the patient's deep venous thrombosis. An SPEP was also recommended for the patient's high IGG and IGA noted in [**Month (only) 404**] to rule out monoclonal gammopathy. The patient's right arm thrombosis was treated locally and symptomatically with elevation and heat as there was little concern for a life threatening pulmonary embolus. With 6 units of fresh frozen platelets the patient's INR decreased to 1.3. Anticardiolipin antibody IGG was noted to be elevated at 44.7. The lupus anticoagulants was negative and beta two lipoprotein is pending at the time of dictation. 3. Infectious disease: On the day following admission the patient was noted to have a low grade fever with an increase in white blood cell count. A chest x-ray was obtained, which was thought to be consistent with aspiration pneumonia and he was started on Levofloxacin and Flagyl. A repeat chest x-ray showed interval improvement in the patient's left lower lobe infiltrate. A urine culture was positive for E-coli. The patient's Foley catheter was discontinued and he received a seven day course of Levofloxacin for a urinary tract infection. The patient was afebrile for several days, but again began having low grade fevers that were attributed to his right upper extremity thrombosis as well as fresh frozen platelets infusions. The patient was clinically stable, a decreasing white blood cell count with blood cultures that were consistently negative. 4. Endocrine: The patient was admitted with a history of hypothyroidism and was continued on his Synthroid throughout this admission. 5. FEN: The patient was noted to have consistently low potassium and phosphate levels and was continued on Neutra-Phos two packets t.i.d. He was evaluated by speech and swallow, which was negative for aspiration. He was continued on thin liquids and pureed solids and encouraged to take frequent meals for poor nutritional status. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is discharged to an extended care facility where he should continue all medications as prescribed. DISCHARGE DIAGNOSES: 1. Left frontal lobe ICH. 2. Down syndrome. 3. Deafness. 4. Status post hemorrhagic strokes. 5. Hypothyroidism. DISCHARGE MEDICATIONS: 1. Ranitidine 150 mg po b.i.d. 2. Levothyroxine 150 micrograms po q day. 3. Neutra-Phos two packets po t.i.d. 4. Dilantin 300 mg po q day to be continued for one month and then titrated down if the patient is asymptomatic. 5. Vitamin K 2 mg po q day times two days. FOLLOW UP: The patient will be followed by the physicians at the extended care facility. The patient's family is instructed to call their primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **] to schedule a follow up appointment within one to two weeks after discharge. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern1) 4950**] MEDQUIST36 D: [**2197-3-17**] 09:46 T: [**2197-3-17**] 10:00 JOB#: [**Job Number 52695**]

[ "431", "599.0", "459.9", "244.9", "996.62", "707.0", "758.0", "507.0", "451.84" ]

icd9cm

[ [ [] ] ]

[ "99.07", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

7072, 7190

7213, 7485

2943, 6886

7497, 8074

1976, 2925

185, 1406

1428, 1775

1792, 1953

6911, 7051

23,770

138,681

20591

Discharge summary

report

Admission Date: [**2142-12-31**] Discharge Date: [**2143-1-3**] Date of Birth: [**2109-5-4**] Sex: F Service: MEDICINE Allergies: Platelet Concentrate Infusion / Blood-Group Specific Substance / Ambisome Attending:[**First Name3 (LF) 6169**] Chief Complaint: Dyspnea and progressive AML Major Surgical or Invasive Procedure: none History of Present Illness: 33yoF with leukemia AML s/p allo [**First Name3 (LF) 3242**] and recurrence, last chemo [**12-3**], presents with 8hrs of increasing SOB, orthopnea, and right sided chest pain, pleuritic in nature. Acutely worsening one hr pta. PMH sig for known large pleural effusion on left and chronic pericardial effusion. She experiences intermittent SOB but never severe over past 6 months. This week she has been in good state of health, she noted feeling well. Had platelet transfusion yesterday without event. Was at home last night and had acute onset CP and SOB. Progressively more severe overnight. Called EMS this am, sats 80s on room air in field by EMS. Noted to be hypoxic, tachycardic. Diffuse abdominal guarding and reproducible right low CP and back tenderness. In ED was given 1L NS IVF. Dilaudid for cp. Notes increased dyspnea over past few hours. . H/o recurrent AML after allo-[**Month/Day (4) 3242**]. chronic large left pleural effusions. She recently finished a 5 day course of Clofarabine (1st cycle) on [**2142-12-3**]. Today, she is day + 185 from her allo transplant. . ROS: no recent f/c/n/v/sweats. No change in bowel or bladder function. Past Medical History: Past Oncology History: Patient is a 33 year old female who was diagnosed with AML in [**4-/2141**] when a left pleural effusion was found to contain myeloblasts, with an inititally negative bone marrow biopsy. At that time she presented with SOB and CP and was intubated at [**Hospital3 **]. She required multiple thoracenteses for symptomatic control and eventually underwent induction chemotherapy (7+3), requiring a D+C as the patient was pregnant at the time, with complete remission and consolidation therapy with HIDAC. She had recurrence of disease in [**12/2141**] with a left pleural effusion and circulating blasts. Repeat bone marrow biopsy was positive for AML. Patient again underwent induction with 7+3, resulting in complete remission. However, in [**2-/2142**] bone marrow bx demonstrated recurrent AML. She underwent reinduction therapy with mitoxantrone, etoposide, and cytarabine(MEC). Hospitalizations have been complicated by admissions for neutropenic fever, VRE bacteremia, and C. difficile infection. Repeat BM Bx in [**5-/2142**] showed a hypocellular marrow with blasts. She finally underwent MRD-allo-SCT on [**2142-6-29**] for recurrent disease. Patient did well until [**8-31**], when she presented with fevers and was treated for a S. Viridans and Bacillus cereus bacteremia. During that admission, patient seroconverted with a positive CMV viral load of 747 copies/ml. Given these results, the patient was started on Valganciclovir. For her relapse, she completed a 5 day course of Clofarabine (1st cycle) on [**2142-12-3**]. Currently maintained on hydrea 500mg [**Hospital1 **] and prednisone 40mg daily. . Other Past Medical History: 1. Asthma 2. History of right popliteal DVT in [**2141-4-27**] 4. History of malignant pleural effusions L sided persistent since [**8-31**] 5. History of chemotherapy induced cardiomyopathy with EF 25%, improved w/ EF 50% on echo [**8-/2142**]; cardiomegaly on CXR since [**8-31**] 6. b/l knee pain due to erythropeoitic conversion versus leukemic infiltrate on MRI 7. Anemia due to AML and chemo baseline 26% 8. Persistent thrombocytopenia with splenomegaly baseline 10 9. Hepatomegaly and transaminitis, elevated alkaline phosphatase 10. Neutropenia since [**2142-12-1**] due to chemo, w/persistent blasts; admitted 11/10-13/05 for neutropenic fever. 11. h/o intermittent pericardial effusions. Social History: The patient lives at home with her husband, son and (intermittently) her mother. She has an extensive travel history (has visited 28 countries) and is an executive assistant for EF Travel although she has not worked since [**Month (only) 1096**]. No ETOH, tobacco or illicit history. Family History: There is no known history of leukemia, lymphoma, or other cancers. Her mother has nephrolithiasis and HTN. Her father, son and three siblings are healthy. Grandmother passed away of stroke. Physical Exam: Vitals: Temperature: 97 Pulse: 135 (125-145 in ED) Blood Pressure: 99/50 (92-165/70s) Respiratory Rate: 35 (26-44 in ED) Oxygen Saturation: 90% RA, 99% on NRB, 80% RA documented by EMS Pulsus paradoxus 12 at 15:10 General: ill appearing female sitting in bed, upright at 90 degrees, grimacing, conversational dyspnea noting increased dyspnea with each breath HEENT: Pupils equal and reactive, extraoccular movements intact, anicteric, dry mucous membranes. Neck: JVP at mandible, distended EJ rises with inspiration Cardiac: tachy rate, regular, no rub, murmurs, or gallops appreciated, extrem cool, pulses 2+ b/l equal, cap refill <2 s Pulmonary: shallow breathing, mild accessory mm use, poor air movement, decreased bs [**3-30**] way up on R>L Abdomen: quiet bowel sounds, mildly tender RUQ and LUQ, nondistended, +HSM. Extremities: cool, [**3-1**]+ pedal edema. Pertinent Results: Pertinent labs:141 | 103 | 15 / 97 AG=17 3.9 | 21 | 0.5\ Ca: 8.2 Mg: 2.0 P: 3.9 MCV 80 WBC 1.8 HGB 11.2 PLT 15 HCT 30.4 Gran-Ct: 70 PT: 13.1 PTT: 22.7 INR: 1.1 . IMAGING: ECG: sinus tach, reg, left axis, nl intervals, + alternans, nl voltage, no ischemic ST/TW changes seen in wavy baseline Chest x-ray: Persistent left pleural effusion with atelectasis/consolidation at the left lung base. Cardiomegaly, unchanged. CTA: PE study inadequate due to patient resp motion. No saddle embolus but no further comment can be made. Bilat pleural effusions with associated atelectasis/consolidation, unchanged. Interstitial opacities bilaterally as well. Moderate to large pericardial effusion. No bowel obstruction or acute pathology in abdomen. Left ov. dermoids. TTE: 1. The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No color doppler studies were performed to evaluate either mitral or aortic regurgitation. 5.The mitral valve leaflets are structurally normal. (see above) 6.There is mild pulmonary artery systolic hypertension. 7. There is a large pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior report (tape unavailable for review) of [**2142-10-12**], the effusion is circumferential but somewhat loculated given that there is a larger collection of pericardial fluid laterally to the left ventricular and posterior to the right ventricle. The effusion laterally is up to 2.4 cm thick. By description the effusion is much larger than previously reported. There is a large pleural effusion present. Brief Hospital Course: Impression/Plan: 1. Hypoxic respiratory failure: A large pericardial effusion was noted on echo and CT. The SOB however improved on steroids and may have been related to a post platelet tranfusion reation. Pleural effusion was stable. TTE showed large retrocardiac pericardial effusion, but no tamponade physiology. Patient with pulsus of 12 in MICU, the 6 on arrival to 7 [**Hospital Ward Name 1826**]. The Left pleural effusion was also not drained because the risk of a pneumothorax. A CTA was done to evaluate for PE and showed no saddle embolus, but was inadequate due to respiratory motion. Patient was stabilized on 4-6L NC with O2 sats of 100%. On the [**Hospital Ward Name 3242**] floor, her O2 was weaned off and she had O2 sats of 96-97% on RA. She continued to have orthopnea, but her shortness of breath has markedly improved since admission. She received a total of 3 units of platelets in anticipation of a thoracentesis. She was evaluated for thoracentesis on the day of discharge, but her Left pleural effusion was thought to be too small to be tapped. She was discharged breathing easily on room air. . 2. AML: She had recurrent disease after 7+3 induction and consolidation. She then underwent reinduction with MEC followed by an allo-MRD [**Hospital Ward Name 3242**]. She has subsequently relapsed. She is day +188 from allo-[**Hospital Ward Name 3242**] with relapse. She was continued on prophylaxis with Bactrim, levofloxacin, acyclovir and voriconazole. Her prednisone and allopurinol were also continued. She will receive chemo from Dr. [**First Name (STitle) 1557**] as an outpatient. . 3. Tachycardia: Sinus tachycardia. The MICU team felt that this might be due to low CO, therefore they held nodal blockers as she may have had compromised SV and need for adequate HR for optimal CO. Given her HTN and tachycardia on the floor, however, we restarted her metoprolol to increase filling time for a larger SV and CO. . 4. Hypertension: Metoprolol and lisinopril were held initially [**2-28**] hypotension, but that is resolved, so these were continued. Medications on Admission: 1. Hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 5. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day. 9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day. 10. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours. Disp:*30 Tablet(s)* Refills:*0* 11. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for menstrual cramps. 13. Ambien 10 mg Tablet Sig: One (1) Tablet PO HS as needed for insomnia. 14. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Discharge Medications: 1. Hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 5. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day. 9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day. 10. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours. Disp:*30 Tablet(s)* Refills:*0* 11. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for menstrual cramps. 13. Ambien 10 mg Tablet Sig: One (1) Tablet PO HS as needed for insomnia. 14. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Discharge Disposition: Home With Service Facility: [**Company **]/Hospice Discharge Diagnosis: pericardial effusion pleural effusion leukemia anemia neutropenia thrombocytopenia Discharge Condition: good Discharge Instructions: 1. Take all of your medications as directed. 2. Please follow-up with Dr. [**First Name (STitle) 1557**] tomorrow in clinic. 3. Please seek medical attention if you develop worsened shortness of breath, chest pain, fevers, chills, nausea, vomiting or any other concerning symptoms. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11755**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3237**] Date/Time:[**2143-1-4**] 1:30 Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], RN Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2143-1-4**] 2:00 Provider: [**Name10 (NameIs) 3242**] [**Apartment Address(1) 1641**] Date/Time:[**2143-1-4**] 2:00 Completed by:[**2143-1-4**]

[ "401.9", "423.9", "996.85", "288.0", "284.8", "518.81", "511.9", "E878.0", "205.00" ]

icd9cm

[ [ [] ] ]

[ "99.05", "99.04" ]

icd9pcs

[ [ [] ] ]

12059, 12112

7300, 9394

362, 369

12239, 12246

5358, 5358

12576, 13023

4263, 4454

10739, 12036

12133, 12218

9420, 10716

12270, 12553

4469, 5339

294, 324

397, 1554

5373, 7277

3246, 3946

3962, 4247

24,386

124,911

24711+24712

Discharge summary

report+report

Admission Date: [**2132-8-7**] Discharge Date: [**2132-9-10**] Date of Birth: [**2068-7-24**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 64 year-old white male has a history of hypertension, hyperlipidemia and noninsulin dependent diabetes mellitus. He has a past medical history significant for coronary artery disease and was catheterized several years ago. He recently had a stress test which was positive and denies any chest discomfort, shortness of breath or increased fatigue but has limited exercise tolerance due to bilateral calf claudication. He is now admitted for elective cardiac catheterization. PAST MEDICAL HISTORY: Significant for history of hyperlipidemia, hypertension, noninsulin dependent diabetes mellitus, gastroesophageal reflux disease, claudication, status post reconstructive facial surgery after a motor vehicle accident in [**2102**], heavy alcohol use, drinks 6 to 10 beers per day. He has no known allergies. MEDICATIONS ON ADMISSION: Diovan 160 mg p.o. daily, Niaspan 500 mg daily, omeprazole 20 mg p.o. daily, Lipitor 40 mg p.o. daily, Actos 30 mg p.o. daily, nifedipine 90 mg p.o. daily, hydrochlorothiazide 12.5 mg p.o. daily, aspirin 325 mg p.o. b.i.d., Zetia 10 mg daily. SOCIAL HISTORY: He lives with his wife and works as a mechanic. He has a 45 pack year smoking history but quit 8 years prior to admission and drinks 6 to 10 beers per day. FAMILY HISTORY: Is unremarkable. REVIEW OF SYSTEMS: Is unremarkable. PHYSICAL EXAMINATION: He is a well developed white male in no apparent distress. Vital signs stable, afebrile. Head, eyes, ears, nose and throat examination normocephalic, atraumatic, extraocular movements intact. Oropharynx was benign. Neck was supple, full range of motion, no lymphadenopathy or thyromegaly. Carotids 2+ and equal bilaterally with bruits. Lungs were clear to auscultation and percussion. Cardiovascular examination: Regular rate and rhythm, normal S1 and S2 with no murmurs, rubs or gallops. Abdomen was soft, nontender with positive bowel sounds. No masses or hepatosplenomegaly. He had bilateral varicosities and palpable pulses bilaterally on his lower extremities. HOSPITAL COURSE: He underwent cardiac catheterization on [**8-7**] which revealed a 90% left main stenosis and 100% right coronary artery stenosis. The left circumflex had an 80% stenosis. The left anterior descending coronary artery had an 80% stenosis. He had a 55% ejection fraction. Dr. [**Last Name (STitle) **] was consulted and on [**8-8**] the underwent a coronary artery bypass graft x3 with left internal mammary artery to the left anterior descending coronary artery, reverse saphenous vein graft to the diagonal and obtuse marginal. Crossclamp time was 67 minutes. Total bypass time was 92 minutes. He was transferred to the CSRU on propofol in stable condition. He was extubated on his postoperative night, was on nitroglycerine postoperative day, a nitroglycerine drip and was diuresed and started on Lopressor. Postoperative day 2 he was in stable condition then became very confused and agitated and was felt to be having withdrawal from alcohol. His breathing then became labored and he was intubated. He then had complaint of abdominal pain and his creatinine increased to 1.5. He had a lactate of 10 and he had elevated liver function tests. General surgery was consulted and they were concerned about abdominal ischemia and he was taken to the operating room for exploratory laparotomy at which time they found a necrotic gallbladder which was perforated and he underwent a cholecystectomy by Dr. [**Last Name (STitle) 816**] and he had bile peritonitis and his liver also was dusky. He was transferred back to the CSRU and was then also seen by neurology as he had unequal pupils. His head CT was negative and he appeared to have a left facial droop and neurology suggested keeping his blood pressure above 120 and getting an MRI and MRA of the head when the patient was stable. He remained intubated. His lactate continued to climb up to 23.4 that same day. He was closely followed by surgery and he had a bedside fascial opening of the abdomen and the bowel looked dusky and there was felt to be thrombus in his mesenteric artery. He had a celiac artery occlusion. So interventional cardiology was called as well as vascular surgery. He went to the operating room for that. He also had a bronchial thrombus that same day and vascular removed that. He then went to the angio suite to have a stent of the superior mesenteric artery placed. He was transferred back to the CSRU, started on CVH as he had become acidotic with a gas of 7.26, 33, 141, 15 and negative 11. He was on Dopamine at 6 at that point and on propofol. He remained on these drips. He received multiple blood products and he was on a fresh frozen plasma drip to keep his INR under 2. He also received factor 7, a total of 7 units of blood that day, 9 of fresh frozen plasma, 3 bags of platelets and 1 of cryo. He continued to remain critically ill. He was also followed by hematology to rule out thrombotic event. A HIT screen was sent. His lactate did start to come down. The next day it was around 13.5. He remained on the fresh frozen plasma drip. He continued to be oliguric and remained on CVVHD. He was taken off the propofol and started on Fentanyl and Versed. On postoperative day #4, 2 and 1 he began to have atrial fibrillation and was seen by ET who did cardioversion and this was not successful. On [**8-13**] he had an exploratory laparotomy and a wash out. The bowel appeared viable and his belly was left open. He did have Doppler flow to the liver. He was continued to be followed by multiple services. He remained on Dopamine, Fentanyl, Versed and Levophed. His screen was negative and he got another HIT screen which also eventually was negative as well. He finally had the other type of HI screen sent to [**State 3706**] and that came back positive. He continued to be in atrial fibrillation, remained critically ill, was on amiodarone. He remained on a fresh frozen plasma drip and CVVH. He was started on total parenteral nutrition on postoperative day 7. On postoperative day 8 he had the fascia of his belly closed. He had slight debridement of necrotic skin an subcutaneous tissue. His liver, duodenum and small bowel and large bowel looked viable. He remained on amiodarone, midazolam and was now on Neo-Synephrine at this point and he continued to remain somewhat stable. He had an infectious disease consult on [**8-18**] as his white count was 35.7 but he was not particularly febrile. He had his lines changed and his dose and dosage was increased and his fluconazole was increased. He began to become more responsive and his sedation was weaned off. He underwent a bronchoscopy which was normal. He had several transesophageal echocardiographies which never revealed any vegetations or infectious cardiac issues. He was started on tube feeds on [**8-20**], postoperative day 12. However, his liver function tests, his total bilirubin was still elevated at 28.5. He continued to slightly improve but did remain on amiodarone and Levophed. He had required intermittent large doses of Levophed. Then began spiking to 102. He had increasing liver function tests and continued to require the fresh frozen plasma drip. He had a full body scan on [**8-22**] that was negative which was postoperative day 14. He remained unchanged. His total bilirubin continued to rise. He was in florid liver failure. He did grow out some [**Female First Name (un) 564**] in his sputum for which he was treated. He continued to be intermittently febrile and again he began to become more neurologically responsive. He continued throughout this time to have an elevated bilirubin which did not come down. He required fresh frozen plasma to keep his INR from rising. He continue to have a high Levophed requirement and he remained on total parenteral nutrition. He remained on CVVH. His bilirubin climbed to 44 and there were intermittent attempts at tube feed which he did not tolerate. He had CVVH discontinued intermittently but remained oliguric. He was improving neurologically and was up in the chair, was more alert and then on postoperative day #20 he was extubated and had a large improvement. He remained slightly confused and was still on his Levophed but was successfully extubated. He then had a Dobhoff placed again. He started on tube feeds. His bilirubin did continue to remain elevated. He was on hemodialysis during this time tolerating that well and then he had some diarrhea but he was doing well and then he did develop gastrointestinal bleeding on postoperative day #25. He had an upper gastrointestinal bleed. Gastroenterology was consulted and scoped him and found blood in the descending duodenum. They could not find the source of the bleeding and in order to coagulate it he was given 6 units of fresh frozen plasma, 8 units of blood, 1 bag of platelets. He was taken to interventional radiology to try to have them intervene but they were unsuccessful. He continued to bleed into the next day. He [**Last Name (un) **] diffuse esophagogastritis. He was scoped frequently and remained on a fresh frozen plasma drip. He was reintubated as well also during this and was again put on CVVH and total parenteral nutrition. He continued to remain critical and required large amounts of blood products and he then had increased oxygen requirement to 100% and 18 of PEEP. He had bilateral chest tubes placed without helping this. He was seen by pulmonary who felt this was due to volume overload and he was then paralyzed in order to be properly oxygenated and on postoperative #32 he was requiring increasing pressors and it was very hard to keep his blood pressure up and he was taken back to the operating room by surgery and was found to have a perforated duodenum. His abdomen remained open and a drain was placed and he returned to the CSRU and he was unable to maintain a blood pressure. So he gradually deteriorated and expired at 3:05 A.M. on [**2132-9-10**]. The family was notified. Dr. [**Last Name (STitle) **] was available and the family did not want a postmortem. The medical examiner waived a postmortem. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Hypertension. 3. Hyperlipidemia. 4. Noninsulin dependent diabetes mellitus. 5. Alcohol abuse. 6. Gastroesophageal reflux disease. 7. Multisystem organ failure. 8. Hepatic failure including hepatic, renal and pulmonary failure. 9. Upper gastrointestinal bleed with duodenal perforation. 10. Necrotic gallbladder. 11. Bile peritonitis. 12. HIT. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2132-10-24**] 14:48:07 T: [**2132-10-24**] 20:36:32 Job#: [**Job Number 62334**] Admission Date: [**2132-8-7**] Discharge Date: [**2132-9-10**] Date of Birth: [**2068-7-24**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 64 year old white male had a positive stress test and was referred for an elective cardiac catheterization. He DICTATION ENDED [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2132-10-24**] 13:58:32 T: [**2132-10-24**] 21:41:07 Job#: [**Job Number 62335**]

[ "995.92", "440.21", "518.5", "571.2", "532.20", "997.79", "427.5", "570", "287.5", "427.31", "E934.2", "038.49", "303.90", "584.5", "414.01", "250.00", "444.21", "575.0", "112.5", "567.81", "557.0", "996.74", "272.0", "453.9", "575.4", "285.1", "038.43", "557.1", "287.4", "286.7", "401.9", "433.10" ]

icd9cm

[ [ [] ] ]

[ "44.43", "54.99", "38.03", "00.13", "99.15", "39.61", "00.45", "54.11", "45.13", "96.72", "99.62", "39.50", "33.24", "54.12", "88.53", "39.95", "37.22", "36.15", "36.12", "44.42", "96.6", "51.22", "96.04", "00.40", "50.11", "88.47", "88.56", "39.90" ]

icd9pcs

[ [ [] ] ]

1438, 1456

10246, 11008

1003, 1247

2202, 10225

1517, 2184

1476, 1494

11037, 11409

667, 976

1264, 1421

26,212

159,674

22772

Discharge summary

report

Admission Date: [**2190-1-14**] Discharge Date: [**2190-1-22**] Date of Birth: [**2133-11-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Left hip pain Major Surgical or Invasive Procedure: Left open reduction internal fixation with dynamic hip screw 3 blood transfusions History of Present Illness: Mr. [**Known lastname 724**] is a 56 year old gentleman with a history of ESRD on HD [**3-7**] IgA nephropathy, labile HTN, DM, CAD who was initially admitted to the medicine service on [**2190-1-14**] with left wrist and hip pain following fall at hemodialysis after his legs "gave out on him". Of note, he was admitted most recently in [**11-11**] with sepsis from Morganella Morganii bacteremia at which time he also had c. diff infection since which he reports he has been doing well at home. . In the ED, initial VS were T: 98.6 BP: 164/95 HR: 74 RR: 20 O2sat 100%RA. He underwent multiple radiologic studies including CT head which was negative for bleed, but did show "destructive progressive process involving the left eye with differential, neoplasm, hemorrage, and infection." Plain films of the left hip, knee, and femur were reportedly negative for fracture/dislocation. X-ray of left wrist and hand showed probable distal radius fracture per radiology read. Ortho was consulted and felt that wrist and hand films actually did not show evidence of radial fracture. He was splinted anyhow due to his pain. He received 2mg IV morphine and 500mg acetaminophen PO. He is now being admitted for r/o occult fracture and PT evaluation d/t persistent hip pain and inability to walk d/t pain despite negative plain films of the hip. Past Medical History: 1. HTN - difficult to control 2. DM - retinopathy, nephropathy 3. ESRD - due to IgA nephropathy/DM 4. diabetic retinopathy - blindness 5. R subclavian Thrombus [**2187**] - stopped anticoagulation in [**2187**] 6. Anemia of chronic disease 7. Hyperlipidemia 8. CAD - Cardiac catheterization from [**2188-2-4**] showed 3VD with a 30% left main, a diffusely diseased LAD with 80% mid stenosis, 90% diagonal, 60% second diagonal, and 90% OM1. None suitable for PCI or CABG. EF 60-70% TTE [**2188-10-14**] Social History: Cantonese speaking, limited English, immigrated to the US 10 yrs ago, currently lives with wife and 3 children, has been blind for approx 3 years, has not worked recently; No history of tobacco use, alcohol, or illicit drug use. Wife injects insulin. Family History: No family history of DM, CAD, Stroke, HTN, or Renal Disease Physical Exam: VS: Chronically ill appearing man. pale appearing. Lethargic. Pale conjunctiva. Right pupil round and minimally reactive to light, left eye clouded. OP clear, MMM. JVP low RRR, II/VI sytolic murmur loudest at LUSB. CTAB soft +BS, NT/ND, No HSM appeciated. No edema. Full popliteal, PT, and DP pulses B. Left radius TTP. Left hip with large ecchymoses and palpable hematoma with increased warmth and pain with palpation. Neuro: A&Ox3. Lethargic but easily arousable. Follows commands. Moving all extremities spontaneously. Pertinent Results: [**2190-1-13**] 08:15PM PLT COUNT-270 [**2190-1-13**] 08:15PM NEUTS-76.3* LYMPHS-12.9* MONOS-6.8 EOS-3.0 BASOS-0.9 [**2190-1-13**] 08:15PM WBC-6.1 RBC-4.81# HGB-15.5# HCT-44.4# MCV-92 MCH-32.2* MCHC-34.9 RDW-14.3 [**2190-1-13**] 08:15PM CALCIUM-9.5 PHOSPHATE-4.2 MAGNESIUM-1.9 [**2190-1-13**] 08:15PM estGFR-Using this [**2190-1-13**] 08:15PM GLUCOSE-181* UREA N-24* CREAT-4.9*# SODIUM-142 POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-28 ANION GAP-19 [**2190-1-14**] 06:15AM PT-13.5* PTT-26.1 INR(PT)-1.2* [**2190-1-14**] 06:15AM PLT COUNT-305 [**2190-1-14**] 06:15AM WBC-5.9 RBC-4.42* HGB-14.3 HCT-40.4 MCV-91 MCH-32.4* MCHC-35.5* RDW-14.3 [**2190-1-14**] 06:15AM CALCIUM-9.1 PHOSPHATE-5.7* MAGNESIUM-1.9 [**2190-1-14**] 06:15AM GLUCOSE-202* UREA N-31* CREAT-5.9* SODIUM-137 POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-29 ANION GAP-16 [**2190-1-22**] 05:17AM BLOOD WBC-8.7 RBC-2.91* Hgb-9.4* Hct-27.1* MCV-93 MCH-32.4* MCHC-34.8 RDW-15.4 Plt Ct-258 [**2190-1-21**] 09:40AM BLOOD PT-12.3 PTT-26.5 INR(PT)-1.0 [**2190-1-21**] 09:40AM BLOOD Glucose-220* UreaN-20 Creat-3.7*# Na-136 K-4.1 Cl-98 HCO3-27 AnGap-15 [**2190-1-19**] 05:55AM BLOOD CK(CPK)-1119* [**2190-1-18**] 07:22PM BLOOD CK(CPK)-1216* [**2190-1-18**] 07:22PM BLOOD CK-MB-9 cTropnT-0.37* [**2190-1-19**] 05:55AM BLOOD CK-MB-11* MB Indx-1.0 cTropnT-0.45* [**2190-1-21**] 09:40AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.6 . . STUDY: CT head without contrast. INDICATION: Left leg weakness. COMPARISON: CT head without contrast [**2188-10-17**], [**5-11**], [**2189**]. FINDINGS: There is no evidence of acute intracranial hemorrhage, mass lesion, shift of normally midline structures, hydrocephalus, or evidence of major territorial infarct. The [**Doctor Last Name 352**]-white matter differentiation is preserved. The major intracranial cisterns are preserved. Bilateral basal ganglia calcification is again noted. Calcified atherosclerotic plaque is present within bilateral cavernous carotid arteries. The extracalvarial soft tissues appear unremarkable. There is mucosal thickening within the posterior sphenoid sinuses. The left globe is abnormal with a shrunken appearance and hyperdense material within the vitreous space (?blood). Lens calcification also noted. The right orbit appears unremarkable. IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. MRI with diffusion is more sensitive for acute ischemia. 2. Shrunken left globe with hyperdense material in the vitreous space (?hemorrhage) and lens calcification. Findings have progressed appreciably since prior studies. Recommend ophthalmologic consult for further evaluation. . . Left hand, three views of the left wrist, six radiographs total. FINDINGS: There is overall diffuse osteopenia to the osseous structures with coarsened trabeculae likely reflecting patient's chronic renal failure. Within the distal radius are regions of cortical irregularity both laterally and medially, concerning for acute impacted fracture. Clinical correlation is advised. No other evidence of acute fracture is detected. Normal joint alignment appears preserved. IMPRESSION: 1. Findings concerning for left distal radius fracture. 2. Osteopenia, likely reflecting chronic renal failure. .. . HIP (UNILAT 2 VIEW) W/PELVIS (; FEMUR (AP & LAT) LEFT; KNEE (2 VIEWS) LEFT FINDINGS: There is diffuse osteopenia, possibly related to patient's known chronic renal failure. No cortical irregularities are identified to suggest acute fracture; however, diffuse osteopenia limits optimal evaluation of subtle non-displaced fractures. The hip and sacroiliac joints appear intact. The bowel gas pattern appears unremarkable. A small focus of calcification is noted within the lateral articular compartment about the knee. . . CT PELVIS ORTHO W/O C Study Date of [**2190-1-14**] 1:10 PM FINDINGS: There is subtle cortical buckling of the left femoral neck (401B:63). There is a left hip joint effusion. These findings raise concern for nondisplaced left femoral fracture. A discrete fracture line is not identified. A 5 mm sclerotic focus within the left femoral head and a 4 mm sclerotic focus within the right lesser trochanter are of uncertain clinical significance. There is likely diffuse demineralization, which limits evaluation for a nondisplaced fracture. Sclerosis of S3 is noted (400B:83). Evaluation of surrounding soft tissues demonstrate equivocal circumferential wall thickening of the rectum. The distal sigmoid and rectum are underdistended, as oral contrast was not administered for this study. Bladder wall thickening is incompletely evaluated on this non-contrast CT. IMPRESSION: 1. Subtle buckling of the cortex of the left femoral neck, with large left hip joint effusion concerning for a nondisplaced hip fracture. MRI is recommended to evaluate for edema and/or fracture line. 2. Equivocal circumferential rectal thickening on this CT, for which oral contrast was not administered. Recommend correlation with annual colonoscopy. Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 6:05 p.m. on [**2190-1-14**]. . . MR HIP W/O CONRAST LEFT Study Date of [**2190-1-16**] 4:27 PM Final Report IMPRESSION: Left femoral neck edema and subtle contour abnormality of the lateral subcapital left femoral neck in the setting of motion artifact. Taken together, these findings are suspicious for acute nondisplaced fracture, though no discrete fracture line is identified. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12919**] reviewed the findings with musculoskeletal pathologist, Dr. [**First Name (STitle) **], and discussed the findings with Dr. [**Last Name (STitle) 7376**] at 8:30 a.m. on [**2190-1-17**], stating "edema in the left femoral neck with regions of low signal on T1- weighted images but no discrete fracture line plus joint effusion. In conjunction with CT, the findings are still most consistent with a nondisplaced femoral neck fracture." . . ECG Study Date of [**2190-1-18**] 10:50:38 AM Sinus rhythm with borderline 1st degree A-V block Prolonged QT interval Poor R wave progression - probable normal variant Lateral ST-T changes may be due to myocardial ischemia Since previous tracing of [**2189-11-24**], heart rate slower, and ST-T wave abnormalities present Brief Hospital Course: Mr. [**Known lastname 724**] is a 56 year old man with history of end-stage renal disease on dialysis, CAD, hypertension, diabetes, and hyperlipidemia who presented with musculoskeletal pain and inability to walk due to pain in left hip following mechanical fall. . During this hospitalization the following issues were addressed: . # Left Arm Pain: The pt's initial evaluation did not reveal any hip fracture but did suggest a distal radius fracture. Ortho was consulted and felt that wrist and hand films actually did not show evidence of radial fracture and he was splinted for pain. . # Left Hip Pain: On physical therapy evaluation the pt was unable to walk due to left hip pain and had a CT of the hip performed which was equivocal but showed a possible non-displaced femoral neck fracture. He then had an MRI of the hip performed which showed edema and per the orthopedic service suggested a non-displaced femoral neck fracture. On 12/14the pt had an open reduction internal fixation with dynamic hip screw placed in the OR. The pt's post operative course was relatively unremarkable, but on the day following surgical repair of the hip the pt was noted to have a large hematoma over the site of surgical repair and his blood pressure, which at baseline is elevated and difficult to control was trending in the 100's systolic. During physcial therapy on the day following surgery the pt's systolic blood pressure was noted to be in the 60's systolic and patient was somnolent. At that time the patient was noted to have lost his only peripheral IV. The pt's HD line was accessed and he was given 1 L of normal saline with improvement in SBPs to 80s and improved mental status. A stat hematocrit was sent and trend showed hematocrit drop of 40 ([**1-17**] am)to 35 ([**1-17**] pm post-op) to 26 on [**1-18**]. The pt's hip looked large and warm with significant pain and ecchymoses. The orthopedic service determined that if the pt had preserved neurovascular signs, then there was no need for additional intervention. The pt was transferred to the medical intensive care unit where he received 3 units RBC's through a left external jugular IV and his blood pressures and mental status improved. On discharge the pt's hematocrit was stable at 27 and the pt was able to participate in ongoing physical therapy. The pt will follow up with orthopedic surgery as an outpatient. The pt will also meet with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to discuss whether a bisphosphonate would be warranted for further management of the pt's osteopenia. . # Hyperkalemia: During this admission the pt had elevated potassium that improved with dialysis. The pt was continued on a [**Last Name (STitle) 766**], Wednesday, Friday dialysis [**Last Name (STitle) **]. . # Left eye findings on CT: On CT head there was noted to be a "shrunken left globe with hyperdense material in the vitreous space (?hemorrhage) and lens calcification. Findings have progressed appreciably since prior studies. Recommend ophthalmologic consult for further evaluation." These findings were discussed with the ophthalmology service which recommended outpatient follow up. . # History of right subclavian thrombus: This was first noted [**2187-7-13**]. Right upper extremity swelling was more prominent after line change during last admission in [**11-11**] and he was restarted on coumadin at that time. At that time the plan was for coumadin therapy for 3 months and then to reassess/reimage however it is not clear that the pt's INR has been followed at his outpatient dialysis center as planned. The pt should follow up with his primary care physician to address whether to restart coumadin, but at this time of discharge it is being held. . # CAD: On cardiac catheterization in [**2188-2-20**] the pt had 3 vessel disease that was not amenable to PCI or CABG. The pt was started on Plavix and Aspirin and a statin. During this admission the pt had elevated troponins to 0.45 that occurred in the setting of the pt becoming hypotensive and developing a large drop in hematocrit due to bleeding into his left hip. Due to bleeding aspirin, plavix and subcutaneous heparin were held. On discharge the pt was restarted on his aspirin, plavix and subcutaneous heparin. . # Rectal thickening on CT: The pt had circumferential thickening of the rectum on CT during this admission that should be correlated with the pt's annual colonoscopy. . . Rehab To Do: [ ] Arrange appointment with the pt's outpatient ophthalmologist. [ ] Have pt see Orthopedic Surgery and Primary care (Dr. [**Last Name (STitle) **]) as directed in the discharge plans [ ] Dialysis [**Last Name (STitle) 766**], Wednesday, Friday [ ] Titrate up blood pressure medications (including Isosorbide Mononitrate and Minoxidil which were not added on prior to discharge) as tolerated. [ ] Continue physical therapy, occupational therapy. Medications on Admission: Amlodipine 10 mg PO DAILY Clonidine 0.2 mg PO BID Atorvastatin 40 mg PO DAILY Labetalol 800 mg PO TID Minoxidil 2.5 mg PO DAILY Losartan 100 mg PO DAILY Nephrocap 1 PO daily Fluticasone 110 mcg One (1) Puff Inhalation [**Hospital1 **] nasal Clopidogrel 75 PO DAILY Metoclopramide 5 mg PO QIDACHS Isosorbide Mononitrate 30 mg PO DAILY Pantoprazole 40 mg PO Q24H Warfarin 1 mg PO Once Daily--> HD paperwork reports 2mg daily dose since [**12-16**]. Aspirin 81 mg PO DAILY Insulin 70/30 10 units qAM, 6 units qPM Docusate Sodium 100 mg PO BID Senna 8.6 mg PO BID . Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 4. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO QIDACHS. 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): hold for sbp<100, hr<60 . 6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day): hold for sbp<100, hr<60 . 7. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): hold for sbp<100, hr<60 . 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: hold for sbp<100, hr<60 . 9. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO once a day: hold for sbp<100, hr<60 . 10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Insulin Sliding Scale Please see attached sliding scale. 16. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 17. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] - [**Location (un) **] Discharge Diagnosis: 1. Left femoral neck fracture, left radial fracture 2. End-stage renal disease, diabetes, hypertension Discharge Condition: Stable, breathing comfortably on room air, able to participate in physical therapy Discharge Instructions: You were admitted after a fall. You were found to have a left fracture of the radius (arm) and a left femoral neck fracture (hip). You underwent surgery for your hip, and following surgery you had some bleeding into your hip. You were transferred to the ICU and there you received 3 blood transfusions. You also continued to receive dialysis on Mon, Wed and Fri. Your blood pressure stabilized after the transfusions and the bruise over the site of your hip surgery was stable. . During this admission some of your medications were changed. Your coumadin was discontinued and your aspirin and plavix and subcutaneous heparin were held. Your blood pressure medications are currently being added on sequentially, and minoxidil and isosorbide mononitrate are still being held. . Below are your follow up [**Location (un) 4314**], it is very important that you attend your follow up [**Location (un) 4314**]. . Call your doctor or return to the ED if you have fevers or chills, chest pain, shortness of breath, dizzyness or lightheadedness, nausea, vomitting, abdominal pain, increasing diarrhea, worsening hip pain, or any other concerns. Followup Instructions: Please call [**Telephone/Fax (1) 8236**] to make an appointment to see your primary care doctor, Dr. [**Last Name (STitle) **] within the next two weeks. . Orthopedic Follow Up: [**2190-2-9**], 9:00 am. [**Hospital Ward Name 23**] building, [**Location (un) **].

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icd9cm

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icd9pcs

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53741

Discharge summary

report

Admission Date: [**2165-5-7**] Discharge Date: [**2165-5-20**] Date of Birth: [**2097-3-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 18794**] Chief Complaint: Somnolence and hyponatremia. Major Surgical or Invasive Procedure: PICC placement on [**5-12**]. T9-T12 spinal fusion and L1 Laminectomy History of Present Illness: Ms [**Known firstname 1743**] [**Initial (NamePattern1) **] [**Known lastname **] is a 68 year-old female with hypertension on HCTZ, hyothyroidism, s/p left BKA with back pain who was admitted for elective s/p T9-l2 fusion and L1 laminectomy on [**5-7**] who was found to have altered mental status and sodium of 115. She was in her prior state of health with chronic back pain, s/p Kyphoplasty L1 a year ago without any significant improvement in her symptoms, so she was brought 5 days ago for elective s/p T9-l2 fusion and L1 laminectomy on [**5-7**]. During her postoperative course she has been either NPO of with very poor PO. Her net fluid balance has been -5.5 L aproximately. She has not received any IVF and has been having good UOP. Furthrmore, she has had severe post-operative pain that required dilaudid PCA, oxycodone, morphine SR and IV dilaudid. Her mental status was noted by her sister to be altered, specially in the terms of memory and not recognizing friends. Initially it was thought that her symptoms were secondarily to narcotics, which were progressively decreased without improvement in her symptoms. Yesterday the primary team checked a sodium of 116 (on repeat was 115) with osm 244, K 2.1, urine 21 and urine osm 457 and urine specific gravity of 1.016. She was started on 1000 mL NS Continuous at 150 ml/hr for 1000 ml. Medicine and nephrology consults were called who recommended transfer for ICU for administration of 3% saline. She has been on HCTZ for at least 3 years (per patient's report) and it has been continued in house. . Of note, she has developped new thrombocytopenia up to 56 with baseline of 161. There is no record of any form of heparin administration. Pt has been on CefazoLIN 1 g (3 doses), but no vancomycin. She has been continued in her home-dose HCTZ as well. . She was transfused 3 units of PRBC on [**5-7**] and 1 units of RBC on [**5-8**]. She has not received any PLTs. . She has been very constipated as well. Past Medical History: 1. Status post left BKA in [**2150**] due to osteomyelitis (performed at [**Hospital1 2025**]) 2. Hypertension 3. Hypothyroidism 4. Hyperlipidemia 5. Lung nodules 6. Osteoporosis 7. Hx of Squamous and basal cell carcinomas 8. Chronic low back pain secondary to L5-S1 disc bulge 9. Status post left thumb CMC arthroplasty as well as left MP joint volar plate advancement. 10. s/p hysterectomy 11. s/p L5-S1 ant/post fusion laminectomy 12. s/p kyphoplasty 13. s/p right ORIF patella Social History: The patient worked as a nurse practitioner until [**2159**] when she developed back pain. She is single and lives with her sister. She has never been pregnant. She smokes half a pack of cigarettes a day. She has tried to quit. Has smoked for "many" years and was unable to quantify. She does not drink alcohol. She exercises regularly with a personal trainer. Family History: Sister with osteoarthritis of the back and hips. Physical Exam: VITAL SIGNS - Temp F, BP 123/59 mmHg, HR 72 BPM, RR 11 X', O2-sat 94% RA GENERAL - well-appearing woman in NAD, comfortable, appropriate, not jaundiced (skin, mouth, conjuntiva), complaining of back pain and headache HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs). Pt had a L AKA. SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEUROLOGIC: Mental status: Awake and alert, cooperative with exam, normal affect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. Non papilledema on fundoscopic exam. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1- V3. Facial movement symmetric. Hearing decreased to finger rub bilaterally, L=R. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact. . [**Last Name (un) **]-Hallpike: Defered. . Cerebellum: Normal hands up & down; normal finger-nose. Did not walk patient. . Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor. No pronator drift. D [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 . Sensation: Intact to light touch, throughout. No extinction to DSS . Reflexes: Trace and symmetric throughout. Toes downgoing bilaterally. Reflexes: B T Br Pa Pl Right 3 3 3 3 3 Left 3 3 3 3 3 Pertinent Results: LABORATORY RESULTS ON DISCHARGE: [**2165-5-20**] 05:31AM BLOOD WBC-13.6* RBC-3.13* Hgb-9.4* Hct-28.2* MCV-90 MCH-30.2 MCHC-33.5 RDW-13.6 Plt Ct-238 [**2165-5-20**] 05:31AM BLOOD PT-12.3 PTT-45.0* INR(PT)-1.0 [**2165-5-20**] 05:31AM BLOOD Glucose-102* UreaN-10 Creat-0.4 Na-129* K-3.9 Cl-97 HCO3-26 AnGap-10 [**2165-5-20**] 05:31AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.9 . IMAGING/STUDIES: CXR [**2165-5-12**]: No focal masses are appreciated. There is no evidence of consolidation or effusion. A skin fold is prominently visualized over the lateral aspect of the right lung field. [**Location (un) 931**] rods project over the thoracolumbar spine. Cardiac silhouette and mediastinal contours are normal. IMPRESSION: No acute cardiopulmonary disease and no lung masses detected. . KUB [**2165-5-15**]: The patient is status post fixation of the lower thoracic and lower lumbar spines. No acute fracture or dislocation is detected. Mildly dilated loops of small bowel are seen. The cecum is moderately dilated. Findings may be compatible with ileus in the setting of recent surgery. No free air is seen. IMPRESSION: Moderately dilated cecum, with mildly dilated loops of small bowel, compatible with postoperative ileus. Brief Hospital Course: Ms [**Known firstname 1743**] [**Initial (NamePattern1) **] [**Known lastname **] is a 68 year-old female with hypertension on HCTZ, hyothyroidism, s/p left BKA with back pain who was admitted for elective s/p T9-l2 fusion and L1 laminectomy on [**5-7**] who was found to have altered mental status and sodium of 115. . #. Hyponatremia - Pt was transfered to the ICU with altered mental status per the family members that know her well and nurses in the floor. Her sodium was found to be 115 with serum osm of 244 and calculated osm of 240, urine osm of 457 and sodium of 21. Her TTKG was 2.8. She looked euvolemic on physical exam, but her I/O balance has been very negative secondarily to poor PO, no IVF and high UOP. She had severe back after her back surgery. Initially it was not clear how much it was dehydration, poor PO intake only taking free water and HCTZ in the post-op setting vs. SIADH, most likely secondarily to pain. Nephrology was consulted who recommended 3% saline. Initially we tried free water restriction and follow up Na, but pt did now improve within 6-8 hours. PICC was placed and 3% NaCl was started. Her sodium was 120 upon the next lab check, and 3% was stopped. Her pain was controlled (see below). She was then placed on 1500cc free water restriction with minimal improvement. Salt tablets, 2 gm three times daily were started on [**5-15**] and her Na improved with this measure and fluid restriction. She should continue on 1500cc fluid restriction daily, and 2 gram salt tabs TID on discharge. Please check electrolytes every other day to ensure that sodium continues to normalize. On discharge, sodium was 129, and should continue to be monitored until it stabilizes above 130 for several days. # Ileus - Patient with constipation noted post-operatively. Had minimal improvement to soap suds enemas. On [**5-15**] her abdomen was noted to be markedly distended. Abdominal x-ray revealed very distended colonic loops upwards of 10 cm. She was made NPO, a rectal tube was placed, her narcotics were decreased and she was started on oral narcan for opiod contributions. With further enemas, her abdominal distension improved markedly by [**5-16**]. She was started on a clear diet and the rectal tube was removed. After resolution of her ileus, the patient was changed back to her home dose of oxycodone, but pain was not well-controlled. Consequently, her pain medications were increased. She should continue bowel regimen with colace, senna and bisacodyl while on narcotics, and bowel movements monitored closely to avoid recurrence of her ileus. . #. Thrombocytopenia - Pt with new thrombocytopenia; her initial WBC were in the 150s and dropped up to 105 on day 5. She also had a high PTT of 44. This strongly suggested heparin side effect, however there was no documentation in the chart of administration of either heparin or LMWH. Heparin was briefly held while discussing the possibility of HIT. She was restarted on heparin [**5-15**]. The exact cause of her thrombocytopenia was unclear but she did have Cefazolin perioperatively. Thrombocytopenia resolved over the course of her hospitalization, and platelets were 238 on the day of discharge. . #. Hypochloremic metabolic alkalosis - with urine chloride of 69. Pt has been with very poor PO, constipated, no vomit. Most likely is contraction alkalosis in the setting of poor PO and HCTZ. Her sodium was corrected and she was encouraged to have better PO (free water restriction only). . #. Isolated PTT elevation - Unclear etiology, no evidence of heparin or coumadin or lovenox, but matches well, specially given thrombocytopenia on day 5. Pt received 5 mg of PO vitamin K and her PTT remained unchanged. Patient did recall a prior extensive workup for this abnormality in the past, but could not recall her diagnosis. She should follow-up with her PCP [**Name Initial (PRE) **]/or hematologist as an outpatient to follow this lab abnormality. . #. T9-l2 fusion and L1 laminectomy - pt was admitted for elective back surgery. She had good post-op evolution. DVT prophylaxis was initially not started given increase risk of bleeding and recommendation of our orthopaedic colleagues. However, during her stay in the MICU, DVT prophylaxis was started and should be continued until patient is appropriately ambulatory. Patient had significant post-operative pain requiring significant narcotics, as noted above. At the time of discharge, the patient's narcotics regimen was oxycontin 10 mg [**Hospital1 **], with oxycodone 5 mg PO q3h prn. . #. Hypokalemia - Pt with poor PO, no diarrhea or vomit on HCTZ. Pt good blood pressure, but also low sodium. TTKG was 2.8. Cortisol was 27. She was corrected and her K remained normal. . #. Hypertension - Pt was having sinus bradycardia to 40s. normal renal function. Atenolol was initially held, and restarted with good blood pressure effect. As HCTZ was discontinued, patient was slightly hypertensive on atenolol alone, and was started on amlodipine with improved BP control. . #. Hypothyroidism - Continued on home levothyroxane. Her TSH was 6.3. . #. Hyperlipidemia - Continued home-dose statin. Medications on Admission: ASA atenolol HCTZ neurontin 900mg TID Oxycontin Fluoxetine Simvastatin Synthroid Trazadone Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Fever / pain. 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 4. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. Calcium Citrate-Vitamin D3 315-200 mg-unit Tablet Sig: Two (2) Tablet PO twice a day. 6. Ocuvite Tablet Sig: Two (2) Tablet PO once a day. 7. Fish Oil 1,200-144-216 mg Capsule Sig: Two (2) Capsule PO once a day. 8. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day). 19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Please discontinue when patient appropriately ambulatory. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Primary Diagnoses: Hyponatremia Delerium Post-operative Ileus . Secondary Diagnoses: Hypothyroidism Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital for an elective spinal surgery. Your post-operative course was complicated by severe pain, electrolyte abnormalities and an ileus. We decreased your pain medication and treated your ileus with a rectal tube and enemas, with good effect. You were also in the ICU for treatment of your electrolyte abnormalities, which are slowly resolving with restriction of your fluid intake and salt tabs. . We made the following changes to your medications: -Stop HCTZ - we think this may have contributed to your electrolyte abnormalities -Start Amlodipine - this is a new blood pressure medication to replace HCTZ -Start Sodium chloride tabs, 2 grams three times daily -Start bowel regimen, including colace, senna and bisacodyl -Start Oxycontin 10 mg twice daily, and with oxycodone decreased to 5 mg every three hours as needed for breakthrough pain Followup Instructions: Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital3 **] [**Hospital **] MEDICAL CENTER Address: [**Location (un) **], [**Hospital Ward Name 23**] Building [**Location (un) 551**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3573**] Appointment: Thursday [**2165-5-23**] 11:00am Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital3 **] [**Hospital **] MEDICAL CENTER Address: [**Location (un) **], [**Hospital Ward Name 23**] Building [**Location (un) 551**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3573**] Appointment: Friday [**2165-6-21**] 9:30am Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital3 **] [**Hospital **] MEDICAL CENTER Address: [**Location (un) **], [**Hospital Ward Name 23**] Building [**Location (un) 551**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3573**] Appointment: Thursday [**2165-8-1**] 9:30am

[ "V10.83", "560.1", "276.3", "276.8", "733.00", "338.18", "287.5", "253.6", "518.0", "V49.75", "272.4", "244.9", "305.1", "780.09", "733.13", "276.9", "401.9", "737.10", "285.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "81.05", "77.79", "81.63", "96.09" ]

icd9pcs

[ [ [] ] ]

13388, 13533

6407, 11566

344, 416

13690, 13690

5167, 5186

14768, 16001

3314, 3364

11708, 13365

13554, 13618

11592, 11685

13866, 14318

3379, 4092

13639, 13669

5200, 6384

14347, 14745

276, 306

444, 2417

4178, 5148

13705, 13842

2439, 2921

2937, 3298

21,468

197,551

6830

Discharge summary

report

Admission Date: [**2176-3-7**] Discharge Date: [**2176-3-13**] Date of Birth: [**2104-2-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion, chest pain Major Surgical or Invasive Procedure: [**3-7**] CABG x 3 (LIMA->LAD, SVG->OM1, OM2), AVR (25mm pericardial valve) History of Present Illness: Delightful 72 year old gentlema with h/o aortic insufficiency and dilated ascending aorta who was being evaluated for a total knee replacement. He has noted worsening dyspnea and angina with activity. In work-up for his knee surgery, a stress test was performed which noted early onset angina and inferolateral ischemia. A cardiac catheterization was performed which revealed moderate coronary artery disease, severe aortic insufficiency and a dilated ascending aorta. He now presents for surgical management. Past Medical History: Hyperlipidemia HTN Hypothyroid Arthritis BPH Social History: Retired [**Company 2318**] Employee. Never smoked and does not drink alcohol. Lives with his wife in [**Name (NI) 38**]. Family History: Noncontributory Physical Exam: 74 SR 12 122/68 126/68 GEN: WDWN in NAD SKIN: Warm, no c/c/e, well healed ventral hernia incision. HEENT: NCAT, PERRL, EOMI, anicteric sclera, OP benign NECK: Supple, FROM, 2+ carotids without bruits. LUNGS: Clear HEART: RRR, II/VI late systolic and I/VI diastolic murmur. ABD: Benign EXT: Warm, well perfused, no edema NEURO: Nonfocal Pertinent Results: [**2176-3-7**] ECHO Prebypass: 1. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending aorta is moderately dilated. There are simple atheroma in the ascending aorta. The aortic arch is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to aortic regurgitation. Moderate to severe (3+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Postbypass: On phenylephrine infusion. Well-seated bioprosthetic valve in the aortic position with trivial central AI and washing jets. Preserved biventricular systolic funbction. Normal aortic contour post decannulation. [**2176-3-13**] 06:10AM BLOOD WBC-9.6 RBC-3.40* Hgb-10.8* Hct-30.4* MCV-89 MCH-31.9 MCHC-35.6* RDW-15.1 Plt Ct-164 [**2176-3-13**] 06:10AM BLOOD Plt Ct-164 [**2176-3-8**] 03:09AM BLOOD PT-13.8* PTT-33.1 INR(PT)-1.2* [**2176-3-13**] 06:10AM BLOOD Glucose-139* UreaN-13 Creat-0.6 Na-138 K-3.6 Cl-99 HCO3-29 AnGap-14 [**2176-3-13**] 06:10AM BLOOD ALT-27 AST-27 AlkPhos-43 Amylase-78 TotBili-0.9 [**2176-3-13**] 06:10AM BLOOD Lipase-49 Brief Hospital Course: Mr. [**Known lastname 25839**] was admitted to the [**Hospital1 18**] on [**2176-3-7**] for surgical management of his heart disease. He was taken to the operating room where he underwent coronary artery bypass grafting to three vessels and an aortic valve replacement with a 25mm pericardial valve. Please see operative note for details. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. He was noted to have a high output from his drains and was thus returned to the operating room where he was re-explored for bleeding. Hemostasis was acheived and he was taken back to the intensive care unit for monitoring. By postoperative day one, Mr. [**Known lastname 25839**] had awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. He was then transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. On [**3-12**] he was found to have a distended abdomen, KUB showed colonic ileus. He was seen by general surgery who felt that he had a resolved ileus. He tolerated an advancing diet, and continued to pass gas and have bowel movements. He was ready for discharge on POD #6. Medications on Admission: Synthroid 125mcg daily Aspirin 81mg daily Diovan 160mg daily Dyazide 37.5/25mg daily Zocor 40mg daily Flomax 0.4mg daily Finasteride 5mg daily Nabumetone 750mg daily Discharge Disposition: Home With Service Facility: [**Hospital **] home health Discharge Diagnosis: CAD, AI lipids HTN hypothyroid OA BPH s/p IHR s/p appy s/p R knee arthroscopy s/p cataract surgery Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) 25840**] 2 weeks Already scheduled appointments: Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2176-10-15**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2177-1-30**] 4:00 Completed by:[**2176-3-18**]

[ "998.11", "600.00", "272.4", "E878.2", "997.4", "414.01", "441.9", "512.8", "560.1", "244.9", "715.96", "424.1", "401.9", "E849.7" ]

icd9cm

[ [ [] ] ]

[ "39.61", "99.05", "36.12", "35.21", "34.03", "99.07", "99.04", "36.15" ]

icd9pcs

[ [ [] ] ]

4568, 4626

3040, 4352

352, 430

4769, 4777

1582, 3017

5076, 5506

1191, 1208

4647, 4748

4378, 4545

4801, 5053

1223, 1563

281, 314

458, 969

991, 1037

1053, 1175

20,038

126,882

1814

Discharge summary

report

Admission Date: [**2165-2-27**] Discharge Date: [**2165-3-4**] Date of Birth: [**2124-11-3**] Sex: F Service: CSU HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This 40 year old female, who has no symptoms at this time, presented with right sided weakness. A neurologic workup revealed the presence of 2 strokes. Cardiology workup revealed a patent foramen ovale and the patient was referred to Dr. [**Last Name (Prefixes) **] for patent foramen ovale closure. The patient did not have cardiac catheterization. A transesophageal echocardiography showed a patent foramen ovale with left to right flow. PAST MEDICAL HISTORY: Patent foramen ovale. Depression. Cerebrovascular accident. PAST SURGICAL HISTORY: Cesarean section x2. MEDICATIONS ON ADMISSION: Medications at preoperative workup were as follows: 1. Celexa 20 mg p.o. once daily. 2. Coumadin 5 mg p.o. 4 times a week and 7.5 mg p.o. 3 times a week. ALLERGIES: She is allergic to Penicillin which caused hives. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She lived with her husband and had no smoking or alcohol history and no use of recreational drugs. LABORATORY DATA: Preoperative laboratory work as follows: White count 7.2, hematocrit 39.0, platelet count 284,000. PT 16.8, PTT 37.2 with an INR of 1.8. This was all approximately a week and one half preoperatively when the patient was still on Coumadin. Her urinalysis showed some hematuria with a small amount of bacteria. Sodium 138, potassium 3.6, chloride 101, bicarbonate 30, BUN 9, creatinine 0.6, with a blood sugar of 76, ALT 41, AST 43, alkaline phosphatase 75, total bilirubin 0.4, total protein 7.8, albumin 4.4, globulin 3.4. HBA1C 5.4%. Chest x-ray showed no acute cardiopulmonary process. EKG showed sinus rhythm at 67 with nonspecific ST-T wave flattening. PHYSICAL EXAMINATION: On examination, she had a heart rate of 66 and sinus rhythm with a blood pressure of 120/61, height 5 feet five inches tall, weight 105 pounds. She was in no apparent distress. She had no obvious skin lesions. Her extraocular movements were intact. The pupils are equal, round and reactive to light and accommodation. Her neck was supple. Her lungs were clear bilaterally without any rhonchi or rales. The heart was regular rate and rhythm, with S1 and S2 tones and no murmurs, rubs or gallops. Her abdomen was soft, nontender, nondistended with positive bowel sounds. Her extremities are warm and dry with no cyanosis, clubbing or edema. She had no obvious varicosities. She was alert and oriented and grossly neurologically intact cranial nerves II through XII. She had 2+ bilateral femoral, DP, PT and radial pulses and no carotid bruits. HO[**Last Name (STitle) **] COURSE: The patient was admitted to the hospital on [**2165-2-27**], after stopping her Coumadin at home. On [**2165-2-27**], she underwent minimally invasive atrial septal defect repair through a mini right thoracotomy by Dr. [**Last Name (Prefixes) 411**] and was transferred to the Cardiothoracic ICU in stable condition on a Propofol drip. She had a small right [**Doctor Last Name 406**] drain for thoracotomy drainage. She was given Morphine and Toradol for good pain control. She was extubated overnight and remained on a Neo-Synephrine drip at 1 mcg/kg/minute. She had a good blood pressure of 88/53 and sinus rhythm at 75 and temperature maximum of 99.9 postoperatively. White count rose to 13.0, hematocrit 25.2, and platelet count 303,000. Potassium 4.0, BUN 10, creatinine 0.6. She had coarse breath sounds which were decreased on the right. Her Foley and her chest tubes remained in place. Diet was advanced. She had been extubated and her [**Doctor Last Name 406**] drain was placed to water seal and she remained on Neo-Synephrine drip overnight. This was weaned the following morning down to 0.25. Her hematocrit dropped slightly to 20.2, white count remained at 9.6. She finished her perioperative Vancomycin. Her creatinine was stable at 0.5. Her chest tube was discontinued. Repeat chest x-ray was done. She was hemodynamically stable in sinus rhythm with a pressure of 110/58 and was transferred out to the floor. Lasix diuresis was begun. On the floor, the patient was evaluated by physical therapy to begin ambulation and activity tolerance and was seen by case management also for evaluation. Her Foley was removed that afternoon. On postoperative day #3, she did complain of some sharp right inner thigh pain with some activity. She was alert and oriented, began her aspirin, vitamins, iron and was restarted on her Celexa as well as Zantac. She was given Vitamin B6 for neurologic pain. Her aspirin was increased to 325 mg p.o. once daily. She was hemodynamically stable. Her weight was 88.2 kilograms. She was saturating 96% in room air. Her white count dropped to 8.0, her hematocrit rose to 25.4 and her creatinine remained stable at 0.7. She continued to work with physical therapy. She did have some incisional pain under her right breast, the site of her mini thoracotomy. This was treated with p.o. Percocet. She had decreased breath sounds at the bases. She was tolerating her p.o. well and was medicated for pain control. On postoperative day #4, her right inner thigh tingling decreased. She put out almost 6 liters of urine. Her heart was regular rate and rhythm. Her lungs were clear bilaterally. Her abdomen was soft, nontender. She was doing very well. The patient complained of a visual field deficit from the right eye since surgery without prior history. On examination, appeared to be nontoxic. Her visual fields were intact. Her extraocular movements were intact. Cranial nerves II through XII were intact, and she had no neurologic deficit. Question was whether the patient had an embolic stroke at that time. A CT of the head was ordered. Neurology consultation was ordered and plans were for discharge were placed on hold, given the patient's complaint of right eye blurriness. An ophthalmology consultation was obtained. The diagnosis was a small right macular area hemorrhage. Per initial consultation ophthalmology, it was recommended that the patient have a follow-up at her ophthalmologist in [**Location (un) 3307**] or at the [**Hospital3 **] Eye Clinic in [**Hospital Ward Name 23**], fifth floor. Telephone number was given to the patient, [**Telephone/Fax (1) 10153**], to make an appointment on Monday after discharge. On postoperative day #5, neurology saw the patient on [**2165-3-3**], after ophthalmology consultation. At the time, this was also noted about the sensory changes of her right thigh in the distribution of the femoral nerve and lateral femoral cutaneous nerve. Neurology recommended a state CT of the pelvis with stat coagulation studies to assess for retroperitoneal bleed as well as MRA of the brain with a stroke protocol to evaluate for any infarctions, either water shed or embolic, given her various neurologic complaints. This was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], neurology attendings. Ophthalmology consultation was performed as previously noted. On postoperative day #5, the patient was then in sinus rhythm at 72, was stable hemodynamically, had trace peripheral edema. Her thoracotomy incision was clean, dry and intact. Her pacing wires had been removed. Her central venous line was out. MRI was performed, awaiting final result. The MR scan was negative per Dr. [**Last Name (STitle) **], and the patient was neurologically cleared. The patient was also evaluated to go home with VNA services by case management. The patient was instructed to follow-up with ophthalmologist and was discharged home with VNA services on [**2165-3-4**]. DISCHARGE DIAGNOSES: Status post minimally invasive atrial septal defect repair. Status post cerebrovascular accident. Right macular hemorrhage. Depression. Status post cesarean section x2. DISCHARGE INSTRUCTIONS: 1. To follow-up with Dr. [**First Name (STitle) **], her primary care physician in approximately 2-3 weeks postdischarge with specific instructions to follow-up with Dr. [**First Name (STitle) **] on the right kidney mass and left pelvic cyst that were both found on CT scan in the hospital. 2. The patient was also instructed to follow-up at the ophthalmology clinic here at [**Hospital1 10154**], [**Telephone/Fax (1) 10153**], or to see her own ophthalmologist in [**Location (un) 3307**] as discussed for follow-up of her right retinal hemorrhage. 3. The patient was also instructed to follow-up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in approximately 4 weeks for her postoperative surgical visit in the office. MEDICATIONS ON DISCHARGE: 1. Celexa 20 mg p.o. once daily. 2. Ferrous Sulfate 325 mg p.o. once daily. 3. Vitamin C 500 mg p.o. twice daily. 4. Pyridoxine Hydrochloride 50 mg p.o. once daily. 5. Enteric-coated aspirin 325 mg p.o. once daily. 6. Percocet 5/325 one tablet p.o. p.r.n. q.4hours for pain. 7. Ibuprofen 400 mg p.o. q.6hours p.r.n. for pain. DISCHARGE STATUS: The patient was discharged to home in stable condition with VNA services on [**2165-3-4**]. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2165-4-16**] 16:12:56 T: [**2165-4-16**] 19:43:38 Job#: [**Job Number 10155**]

[ "362.81", "V58.61", "745.5", "458.29", "793.5", "285.9", "782.0", "V12.59", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.61", "99.04", "35.71", "88.72" ]

icd9pcs

[ [ [] ] ]

1026, 1044

7807, 7981

8801, 9493

787, 1009

8005, 8775

738, 760

1860, 7785

651, 714

1061, 1837

31,639

145,624

34534

Discharge summary

report

Admission Date: [**2111-7-10**] Discharge Date: [**2111-7-14**] Date of Birth: [**2061-1-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10293**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Diagnostic Parasentesis EGD Therapeutic Parasentesis (6.2 L) History of Present Illness: Mr. [**Known lastname 15670**] is a very nice 50 YO M with history of cirrhosis, Wernicke/Korsakoff's encephalopathy with poor short term memory with complaints of increasing abdominal girth and lower extremity swelling x several months who recently was noted to have an episode of hematemesis on the night prior to admission. The patient arrived to [**Hospital1 18**] ED from a NH where it was noted that the pt vomited approx 2 mouth fulls of bright red blood mixed with clotted material. The pt reports having a larger episode of hematemesis while at home several months ago, but is unclear about the timing of this. Per the patient, he has never been hospitalized for variceal bleeding, or had a history of SBPand recently saw Dr. [**Last Name (STitle) 696**] in the hepatology clinic on [**2111-7-8**] . The patient reports seeing a physician in [**Name9 (PRE) **] for his cirrhosis, and has been on a home regimen including: Nadolol, ciprofloxacin, lasix, spironolactone and lactulose. He does not know what most of these medications are for, but does report improvement in his lower extremity edema, but not his abdominal ascites since beginning this medication medications. He does not have a history of blood transfusions, tattoos, but was a chef in the Merchant marines for the past several years. Per the patient, he has not been exposed sexually to anyone who is high risk for Hepatitis, and is currently living in a nursing home. . On ROS the patient denied any fevers or chills, but does admit to having some abdominal discomfort which has been on-going. He also admits to having epigastric burning/GERD. Currently he denies any nausea, SOB, CP, or HA, but does admit to sometimes feeling confused. . In the ED the patient was found to have stable vital signs and a Hct of 35.6, relatively unchanged from a Hct of 34.9 on [**2111-7-8**]. Given his abdominal discomfort and ascites a paracentesis was performed and the patient was given a dose of Ceftriaxone. Past Medical History: Alcoholic cirrhosis w/portal hypertension Esophageal varices w/history of variceal bleeding. None seen during this hospitalization EGD Chronic alcoholism Wernicke's Encephalopathy with Korsakoff's syndrome Post-Concussive syndrome - poor short and long term memory No history of MI, CAD, CVA Social History: Pt previously worked installing indoor sprinkler heads, then worked as a cook on ships in the merchant marines. Has not worked in over a year since he began getting ill. Reports ~30 year history of smoking 1 pack of cigarettes every 3 days. + ETOH use, reportely [**2-10**] drinks of wine or beer per night, no hard liquor, though he "doesn't count". Remote history of illicit drug use including marijuana, and snorting cocaine, though none in several years. 3 grown adult sons. Currently [**Name2 (NI) 546**] at [**Location (un) 23741**]. Family History: Father with a history of alcholism, and some type of unknown cancer. Physical Exam: Vitals Signs: T: 98.1 BP: 113/74 P:61 RR:14 O2Sat: 97% RA Gen: Somewhat disheveled appearing white male with central obesity and wasted extremeties. Alert and oriented x 3. Walking throughout all the [**Hospital1 **]. HEENT: PERRL, EOMI, no scleral icterus. NECK: Supple, no LAD, thyroid not palpable, no bruits. CV: RRR, nl s1/s2, no m/g/r LUNGS: Dry bibasilar crackles, no exp wheezes ABD: large ascites, soft, mild tendernes in RUQ. no rebound, no guarding. + BS, + captut. EXT: no lower extremity edema, no asterixis SKIN: No spiders, no palmar erythema. Pertinent Results: [**2111-7-10**] 06:00PM COMMENTS-GREEN TOP [**2111-7-10**] 06:00PM HGB-12.6* calcHCT-38 [**2111-7-10**] 04:03PM COMMENTS-GREEN TOP [**2111-7-10**] 04:03PM LACTATE-1.2 [**2111-7-10**] 02:40PM ASCITES WBC-235* RBC-170* POLYS-14* LYMPHS-18* MONOS-25* EOS-1* MESOTHELI-23* MACROPHAG-19* [**2111-7-10**] 10:45AM GLUCOSE-81 UREA N-7 CREAT-0.7 SODIUM-137 POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14 [**2111-7-10**] 10:45AM ALT(SGPT)-12 AST(SGOT)-32 ALK PHOS-85 TOT BILI-1.5 [**2111-7-10**] 10:45AM WBC-7.6 RBC-3.90* HGB-11.9* HCT-35.6* MCV-91 MCH-30.5 MCHC-33.4 RDW-14.2 [**2111-7-10**] 10:45AM NEUTS-66.1 LYMPHS-22.1 MONOS-5.7 EOS-5.5* BASOS-0.6 [**2111-7-10**] 10:45AM PLT COUNT-250 [**2111-7-10**] 10:45AM PT-17.1* PTT-30.5 INR(PT)-1.5* [**2111-7-10**] 10:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2111-7-10**] 10:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Brief Hospital Course: Patient was seen in the ER of the [**Hospital1 18**] with a Temp of 98.9 F PO, HR 68, BP 108/64 (orthostasis not reported), RR 16, SaO2 98% on RA on [**2111-7-10**]. He was complaining of severe abdominal pain in the right flank. Patient's BP was stable during the ER stay and patient did not vomit blood. 2 large-bore IVs were put in place (R forearm and L AC), patient received a total of 12 mg of morphine IV. SBP prophylaxis was started with 1g of ceftriaxone IV x1. Patient was admitted to the [**Location (un) 2452**] MICU. In the MICU patient had an EGD done the same day of admission, which showed no esophageal varices, food in the stomach as well as thick veins with classic changes associated with protal hypertension. Patient was started on ocreotide gtt, IV PPIs and nadolol. A diagnostic parasentesis was done in the right side, which showed less than 250 WBC and no organisms seen on gram stain. An abdominal CT showed no evidence of choelltihiasis, but no colecystitis. LFTs were normal, except for TB 1.5. Patient had bowel movements. Patient was contninued most of his home medications. Patient has a guardian, who is his brother. The contact information we received were [**Name (NI) **] [**Known lastname 15670**] [**Telephone/Fax (1) 79322**] and [**First Name8 (NamePattern2) 1258**] [**Known lastname 15670**] [**Telephone/Fax (1) 79323**]. The following day patient was transferred to the kidney-liver floor in [**Hospital Ward Name 121**] 10. He was switched from CTX to ciprofloxacin PO. Patient HCT was stable, did not have hematemesis for 24 hours and was able to tolerat [**Last Name (LF) **], [**First Name3 (LF) **] ocreaotide drip was stopped. Patient kept improving in the floor. Was tolerating PO, denied nausea and vomit. Patient only complained of pain and requested stronger pain medications. However, on physical exam patient only had mild pain on deep palpation in the upper R quadrant. Pain changed with every exam. Patient received only morphine PO 2-3 times per day. The abdomen became tense on HD4, so a therapeutic parasentesis was done, which drained 6.2 L. Fluid was sent for analysis and had 220 WBC, 1.4g/L of albumin and 2.5 g/L of protein. Patient was given 50g of albumin afterwards and his VS were monitored. He was stable overnight. His only complain was mild right lower quadrant pain. His creatinine on discharge was 0.6, with a stable hematocrit of 28.5, WBC 6.7 and plt of 175. His vital signs are stable, he has no orthostasis and is able to deambulate. He is tolerating PO. Time was spent explaining the importance of quitting alcohol ASAP and how it will benefit him. Time was spent discussing how lactulose will help him get back to normal his day-night cycle and how the diuretics with a low salt diet can prevent the fluid from re-accumulating. Patient was given warning signs and symptoms to come back to the hopsital. Medications on Admission: Albuterol MDI prn Spiriva 18mcg po daily Cipro 750mg po qweek Folic acid 1mg po daily Thiamine 100 mg po daily Lasix 20 mg po daily Lactulose 15cc po bid Nadolol 40 mg po daily Prilosec 20 mg po daiy Spironolactone 25mg po daily Discharge Medications: 1. Lactulose 10 gram Packet Sig: [**12-10**] PO twice a day: Titrate as needed for [**2-10**] bowel movements per day. 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain: Do not give more than 2 grams per day due to his poor liver funciton. Thank you. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Location (un) 23741**] - [**Hospital1 **] Discharge Diagnosis: Upper GI bleed Alcoholic cirrhosis (with no esophageal varices seen) Chronic alcoholism Wernicke's Encephalopathy Discharge Condition: Stable, breathing comfortably on room air. Discharge Instructions: You were seen at the [**Hospital1 1388**] ER on [**2111-7-10**] for vomiting bright blood on [**7-9**] and increased abdominal pain. At your arrival to the ER your vital signs were stable and your physical exam showed some fluid in your abdomen. 2 large IVs were placed, you were given fluids and morphine for the pain. You also were started on an antibiotic (cefrtiaxone), because some patients with liver disease and bleeding can have infections, specially if they have abdominal pain. You had blood cultures, urine cultures and a diagnosit parasentesis done, which none showed infection. You were admitted to the ICU, despite being stable, to monitor your vital signs and in case you re-bleed. You had your esophagus and stomach scoped; there were no varices and there was a lot of food in your stomach, which decreased visibility. Despite these factore, the GI doctors were [**Name5 (PTitle) 460**] to see thick veins characteristic of cihrrotic patients, which may have bleed. You were started in an ocreotide drip to prevent you from bleeding and decrease your portal pressures (veins in your stomach, esophagus and small intestines). The following day you were transfered to the kidney-liver floor, where you continued to be stable. Your were given morphine in multiple occasions for the pain. The following day your ocreotide drip was stopped. You were observed and your pain was controlled. You were stable and your blood level was stable too. There was no blood in your stool. On [**7-13**] you had a therapeutic parasentesis done, where XXX liters were obtained. You were given albumin afterwards. Your vitals were stable. You are being discharged to the nursing house, where you were before in stable condition. Please avoid alcohol. You already have liver problems due to chronic alcohol use. The best treatment for you liver problems is to quit drinking. Otherwise, the mortality and the probability of complications are very high. The best treamtent we currently have is liver transplant, but if you continue drinking you cannot get to the liver transplant list. We are discharging you with medicines to protect your stomach and to decrease the pressure in your portal veins to try to prevent this from happening again. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2111-8-5**] 2:30

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icd9cm

[ [ [] ] ]

[ "54.91", "45.13" ]

icd9pcs

[ [ [] ] ]

9198, 9269

4957, 7848

328, 391

9427, 9472

3947, 4934

11762, 11934

3281, 3351

8127, 9175

9290, 9406

7874, 8104

9496, 11739

3366, 3928

277, 290

419, 2393

2415, 2708

2724, 3265

10,446

146,958

2712

Discharge summary

report

Admission Date: [**2164-3-28**] Discharge Date: [**2164-4-19**] Date of Birth: [**2086-10-17**] Sex: M Service: MEDICINE Allergies: Quinidine / Hydralazine Attending:[**First Name3 (LF) 2485**] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: endotracheal intubation central line placement percutaneous liver biospsy History of Present Illness: 77 year old male with multiple medical problems, pertinently including coronary artery disease status post CABG with CHF and EF 30-35% as of [**2157**], hypertension, and chronic renal insufficiency, who is transferred from [**Hospital 1474**] Hospital after an admission for pancreatitis complicated by pseudomonal UTI, asystolic cardiac arrest, and respiratory failure. The patient actually had a prior hospitalization in [**Month (only) 958**] of [**2163**] when he presented with epigastric pain and was found to have "abnormal liver function tests." Ultrasound demonstrated a hepatic mass, confirmed by CT scan. MRI, demonstrated a 5.5 x 5.6 cm lesion in the posterior segment of the right lobe of the liver, however it did not enhance and seemed more consistent with focal fatty infiltration. His AFP level was normal, but CA [**75**]-9 was elevated at 260. His hepatitis serologies were negative. It is unclear what happened subsequently, however he represented to [**Hospital 1474**] Hospital on [**3-13**], again complaining of abdominal pain radiating to the back, with nausea and vomiting. He was found to have elevated amylase and lipase (1324, and 3500 respectively), consistent with pancreatitis. Total bili was 2.6, with a direct fraction of 1.9. ALP 466, GGT 810, AST 210, ALT 170. A repeat CT scan again demonstrated a heterogeneous 5 cm mass in the liver, as well as multiple gallstones. He was seen by GI who felt that the picture was most consistent with gallstone pancreatitis, however given the extent of alkaline phosphatase elevation, with only minimal bilirubin elevation, and the intrahepatic mass, they suggested ERCP, with possible liver biopsy as well, for further workup. While there, however, he developed respiratory distress on the floor and was transferrred to the ICU where he desaturated and had an asystolic arrest. He was intubated, and received 2 rounds of epinephrine and atropine with 2 minutes of CPR. He regained a rhythm, which reportedly was an SVT. He required pressors for a period of time, and had a hematocrit drop requiring multiple units of PRBCs. He was felt to have mucous plugged, and had a bronchoscopy on [**3-20**] which demonstrated rective bronchial cells, histiocytes, and neutrophils, but had no growth on cultures. He was weaned off of pressors and extubated on [**3-21**], however failed, thought secondary to pulmonary edema secondary to CHF, and ended up getting reintubated on [**3-25**]. After diuresis they were in the process of performing an SBT, however he self-extubated on [**3-27**]. He was placed on 100% nonrebreather, and ultimately required non-invasive positive pressure ventilation on the day of transfer, though we have no ABGs. His chest x-ray on [**3-27**] demonstrated enlarged heart with worsening pulmonary edema, as well as left lower lobe consolidation and pleural effusion. He failed a speech and swallow test, raising concern for aspiration pneumonia. His hospital course was otherwise complicated by rising BUN and creatinine, for which a renal consult was called. His BUN seemed to be rising out of proportion to creatinine (BUN 102, creatining 1.9, up from 36 and 1.4, respectively, on [**3-18**]), raising the question of GI bleeding, versus a pre-renal azotemia from aggressive diuresis. The decline in renal function also seems to have been after his cardiac arrest, therefore hypotension could have contributed as well. Past Medical History: 1) Coronary artery disease status post CABG in [**1-/2158**], post-operative course complicated by sternal wound infections (Oxacillin sensitive staph aureus) requiring drains, plastic surgery, and debridement. 2) Atrial fibrillation 3) Congestive heart failure: Ejection fraction of 30% to 35% with 1+ mitral regurgitation. 4) Diabetes 5) Chronic renal insufficiency 6) Hypertension 7) Hypercholesterolemia 8) Peripheral vascular disease, status post iliac stenting 9) Transient ischemic attacks, status post carotid endarterectomy. 10) Hypothyroidism 11) Chronic renal insufficiency (baseline 1.1 in [**2157**]) 12) Alzheimer's Disease 13) Vancomycin resistant enterococcus UTI in [**3-/2158**] 14) Gastroesophageal reflux disease 15) Status post abdominal aortic aneurysm repair Social History: Per report, he is married and lives with his wife. [**Name (NI) **] history of alcohol abuse or tobacco. his eldest son is his HCP Family History: NC Physical Exam: On arrival to MICU: 94.4, 157/52, 66, 30, 92% on Bipap 10/5, 40% FiO2. CVP 13. GENERAL: Obese caucasian male, not responsive, appearing somewhat dyssynchronous with positive pressure ventilation. HEENT: Marked chemosis. Pupils equal. NECK: Obese, difficult to evaluate JVP. COR: Irregularly irregular rhythm with distant heart sounds. LUNGS: Decreased breath sounds bilaterally, but relatively clear, without rhonchi or rales. ABDOMEN: Obese, non-tender. No organomegaly. BACK: Sacral decubitus ulcer with areas of probable necrosis. Sacral edema present. EXTR: No edema. Early pressure ulcer on left heel. Pertinent Results: Labs: [**2164-3-28**] 03:58PM WBC-11.1* RBC-3.51* HGB-9.5* HCT-31.3* MCV-89 MCH-27.0 MCHC-30.3* RDW-17.1* [**2164-3-28**] 03:58PM PLT COUNT-443* [**2164-3-28**] 03:58PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL TARGET-OCCASIONAL [**2164-3-28**] 03:58PM PT-14.5* PTT-49.7* INR(PT)-1.3* [**2164-3-28**] 03:58PM GLUCOSE-190* UREA N-92* CREAT-2.0* SODIUM-154* POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-32 ANION GAP-14 [**2164-3-28**] 03:58PM ALT(SGPT)-13 AST(SGOT)-35 LD(LDH)-423* ALK PHOS-130* AMYLASE-94 TOT BILI-2.2* [**2164-3-28**] 03:58PM LIPASE-138* [**2164-3-28**] 03:58PM ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-5.3* MAGNESIUM-3.4* IRON-40* . Micro: Sputum - multiple negative Blood - multiple negative C. dif - mulitple negative . Imaging: [**2164-3-28**] - CXR: There is complete opacification of the right hemithorax increased compared to the previous film with leftward deviation of the mediastinum thus suggesting atelectasis of the left lung, most likely due to mucous plaque. The increase in the diameter of the right pulmonary vessels suggesting fluid overload. . 5/4/07l: CT abd/pelvis: 1. 5.2 x 5.3 cm heterogeneous mass in the posterior aspect of the right lobe of the liver. Differential diagnosis includes metastatic disease or pseudocyst with internal debris. MRI could be performed for further characterization. 2. Questionable mass in the left lobe of the liver with focal dilatation of the left intrahepatic biliary ducts. Differential diagnosis includes metastatic disease or cholangiocarcinoma. This questionable mass can also be evaluated with MRI. 3. Peripancreatic soft tissue stranding suggestive of pancreatitis. 4. Anasarca. 5. Bilateral dilated ureters. 6. Bilateral iliac stents, cannot assess for patency. 7. Sigmoid diverticulosis without evidence of diverticulitis. . Pathology: [**2164-4-5**]: Liver Core - pending at time of discharge. Brief Hospital Course: ASSESSMENT AND PLAN: 77 year old male with significant cardiac history, including CAD status post CABG in [**2157**], CHF with EF 30%, chronic renal insufficiency, and AF with slow response, admitted to [**Hospital1 1474**] with probable gallstone pancreatitis, but also with recently discovered hepatic mass, course complicated by respiratory failure, acute renal failure, and a pseudomonal UTI. 1) Respiratory failure: This was felt to be multifactorial secondary to his underlying poor pulmonary mechanics (paradoxical chest wall movement) leading to mucous plugging, CHF, and hospital acquired pneumonia. He completed a course of antibiotics of linezolid and zosyn. He was initially on NIPPV but subsequently developed mucous plugging and LLL collapse. He had a bronchoscopy for mucous clean-out. He was diuresed. He failed one extubation as he had subsequent mucous plugging resulting in left lung collapse and was re-intubated and underwent a second bronchoscopy. As he had persistent ventilator requirements, he was evaluated for trach and G-tube. Following extensive discussions with the patient's family including the health care proxy, it was concluded that living with mechanical ventilation was not compatible with his prior stated wishes. He was ultimately extubated, received comfort measures only, and expired. The family was notified and declined autopsy. . 2) Pancreatitis: The patient's prior presentation was consistent gallstone pancreatitis. There was no evidence of recurrent inflammation. . 3) Hepatic mass: This was an incidental finding. Liver biopsy was performed which was negative for hepatocellular carcinoma but was still pending at the time of the patient's death. . 4) Anemia: The patient had an asymptomatic drop in his hematocrit which was thought secondary to gastritis (as OG aspirate was pink and heme positive) and a left chest hematoma. He periodically received blood transfusions for Hct support. He received a PPI. . 5) Diabetes, type 2: His blood sugars were managed with glargine and sliding scale. . 6) Hypertension: Low dose metoprolol was continued. . 7.) CHF: Last echo with EF 30%, however at the outside hospital one of the notes says repeat echo with normal EF. Diuresis was attempted as above. . 8) Atrial fibrillation: He was rate controlled. . 9) Hypothyroidism: Continue levothyroxine. . 10) FEN: cont TF . 11) PPx: subc hep, Colace. Protonix. . 12) Disp: As above, in keeping with the patient's prior expressed wishes not to be supported on mechanical ventilation for an extended period of time, he was extubated and received comfort care only. He expired on [**2164-4-19**] at 12:05am. The family was contact[**Name (NI) **] and declined autopsy. Medications on Admission: 1. Coumadin 5 mg daily 2. Furosemide 40 mg daily 3. Isosorbide mononitrate 30 mg daily 4. Pantoprazole 40 mg daily 5. Simvastatin 40 mg daily 6. Zolpidem 10 mg daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary: Respiratory Failure Hospital acquired pneumonia Partial lung collapse Liver Mass Gallstone pancreatitis Congestive Heart Failure . Secondary: Atrial fibrillation Hypothyroidism Hypertension Discharge Condition: expired Discharge Instructions: NA Followup Instructions: NA

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icd9cm

[ [ [] ] ]

[ "50.11", "96.72", "33.22", "00.14", "96.04", "96.6", "38.91", "33.24", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

10353, 10362

7398, 10107

306, 381

10604, 10613

5448, 7375

10664, 10669

4801, 4805

10324, 10330

10383, 10583

10133, 10301

10637, 10641

4820, 5429

246, 268

409, 3831

3853, 4637

4653, 4785

13,985

178,267

19693

Discharge summary

report

Admission Date: [**2172-2-16**] Discharge Date: [**2172-2-26**] Date of Birth: [**2121-4-23**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 50 year old male with a history of diabetes mellitus status post laparoscopic cholecystectomy on [**2-14**], who was transferred from [**Hospital1 **] with hypotension, oliguria, increased BUN and creatinine. He underwent cardiac catheterization on [**2-11**], which was negative and then underwent laparoscopic cholecystectomy on [**2-14**]. On postoperative day #1, the patient was noted to have decreased urine output and tachycardia with hypotension. On [**2172-2-15**], the patient underwent a computerized tomography scan which showed no ductal dilatation and was negative for free air. HIDA scan showed no excretion from the liver to small bowel. There was a questionable common bile duct obstruction. The patient was started on Levofloxacin and Flagyl and transferred to [**Hospital6 2018**] for further workup. PAST MEDICAL HISTORY: Diabetes mellitus, hypertension, asthma, status post cardiac catheterization [**2-11**]. PAST SURGICAL HISTORY: Laparoscopic cholecystectomy [**2-14**], tonsillectomy. MEDICATIONS ON ADMISSION: Insulin, Metformin, Klonopin, Lisinopril, Ursodiol. ALLERGIES: Prednisone. SOCIAL HISTORY: No tobacco, no alcohol. FAMILY HISTORY: Non-contributory. No pancreatitis. PHYSICAL EXAMINATION: Vital signs 99.5, 108, 142/72, 18, 92% on 4 liters of nasal cannula. The patient was alert and oriented times three. Oropharynx was clear. Sclera was anicteric. Regular rate and rhythm. No murmurs, rubs or gallops. Clear to auscultation bilaterally. Abdomen was distended, tender, in the epigastric. Wounds were clean, dry and intact. Lower extremities were warm without edema. SUMMARY: In summary the patient is a 50 year old male with a history of diabetes mellitus who was transferred to [**Hospital6 1760**] for workup of questionable common bile duct obstruction, status post laparoscopic cholecystectomy. HOSPITAL COURSE: The patient was directly admitted to the Intensive Care Unit where he had monitored hemodynamics, via PA catheter to maximize optimal perfusion and was continued on Ampicillin, Levofloxacin, and Flagyl antibiotics. On hospital day #2, the patient had a creatinine of 8.6 and had an endoscopic retrograde cholangiopancreatography done and was given on Lasix 100 mg times one and the Renal Team was consulted at that time and recommended decreasing all antibiotics to renal dosing. At this time, the patient's creatinine was 9.5. Lopressor was increased on hospital day #3 for an increased blood pressure and the patient had continued to have minimal urine output and a creatinine of 10.8. The patient's urinary output picked up increased urine output at 500 cc and hemodialysis was delayed. Endoscopic retrograde cholangiopancreatography showed normal biliary anatomy but, due to the severity of his condition at that time, a 10 French by 7 cm cotton [**Doctor Last Name **] biliary stent was placed successfully in the common bile duct. At this point the patient's creatinine began to rise to 12.2. On hospital day #5, the patient remained in the Intensive Care Unit with increase in creatinine, however, was having good urine output. The patient's creatinine began coming down to 11.7 and with nonoliguric renal failure, the patient was stable and was off of oxygen at this point. He was transferred to the floor, and taken off of fluid restriction. He was given free access to water and Lasix was held. Physical therapy began seeing the patient at this time no acute distress continued to see the patient throughout his hospital course. On hospital day #7, the patient was encouraged to ambulate and made 2 liters of urine output with creatinine of 10.2. The patient continued to do well on hospital day #8 and antibiotics were discontinued. The patient was placed on p.o. medications and dialysis was delivered for decrease in creatinine. Other than hyponatremia the patient had a benign examination and Foley catheter was discontinued on hospital day #9. Creatinine continued to decrease to now 7, and was 6.1 on [**2-24**], and on hospital day #10, the patient continued to be encouraged to drink to thirst and physical therapy evaluated the patient and had follow up with [**Hospital6 407**] for home physical therapy. The patient was discharged on hospital day #11 with a creatinine of 3, was placed on diabetic diet and was instructed to only take half of NPH and no regular insulin until follow up with primary care physician for decreased sugars in the daytime and was encouraged to drink as much as he desired p.o. to keep himself well hydrated. He was encouraged to follow up with Dr. [**Last Name (STitle) **] at next available visit and encouraged to follow up with primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] also as soon as possible. DISCHARGE MEDICATIONS: Percocet 5/325 mg tablet, one to two tablets p.o. q. 4-6 hours prn pain. Lopressor 50 mg tablet, p.o., .5 tablet p.o. b.i.d. Protonix 40 mg tablet, one tablet p.o. q. day TUMS 500 mg tablet, one tablet p.o. q.i.d. Colace 100 mg tablet, one tablet p.o. b.i.d. DISCHARGE DIAGNOSIS: 1. Status post laparoscopic cholecystectomy. 2. Acute nonoliguric renal failure. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8275**] Dictated By:[**Last Name (NamePattern4) 7013**] MEDQUIST36 D: [**2172-2-26**] 21:28 T: [**2172-2-26**] 22:27 JOB#: [**Job Number 53275**]

[ "250.00", "576.1", "997.5", "E849.7", "584.9", "493.90", "E878.6", "276.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "51.87", "38.91", "89.64" ]

icd9pcs

[ [ [] ] ]

1362, 1399

4992, 5252

5274, 5635

1225, 1303

2063, 4969

1141, 1198

1422, 2045

160, 1004

1027, 1117

1320, 1345

3,787

116,024

11892

Discharge summary

report

Admission Date: [**2135-12-19**] Discharge Date: [**2135-12-31**] Date of Birth: [**2078-1-25**] Sex: F HISTORY OF PRESENT ILLNESS: This is a 51-year-old woman with a history of a recent stroke, asthma, insulin-dependent diabetes, and renal disease who was at Stone Hinge Convalescent Center and noted to have changes in her behavior On the day of admission at 2:25 p.m. she had an episode of unresponsiveness and then she developed status epilepticus at [**Hospital 882**] Hospital. She received 6 mg of Ativan and Versed as well loaded on Dilantin intravenously. At that time she was intubated and then transferred to the Neurology Intensive Care Unit. Congestive heart failure, stroke, lupus, asthma, insulin-dependent diabetes, renal disease. MEDICATIONS ON ADMISSION: Synthroid 0.1, Catapres transdermal patch 2 every week, Novolin NPH 24 units, Serevent 2 puffs b.i.d., Zantac 150 mg p.o. b.i.d., [**Doctor First Name 233**] Ciel, hydralazine, furosemide, Flovent, calcium, Milk of Magnesia. PHYSICAL EXAMINATION ON PRESENTATION: Blood pressure 217/97, heart rate 119, 100% on room air. Rectal temperature of 100. Cardiovascular revealed tachycardia with a 2/6 systolic murmur. Chest revealed bilateral crackles, low breath sounds (left compared to right). The abdomen was soft, nontender, and nondistended. Extremities revealed no clubbing, cyanosis or edema. Neurologically, intubated and sedated, positive tongue abrasion. Held her right hand in fist with eyes contracted. Right leg flexed spontaneously. Did not follow commands. Pupils revealed left 4 mm to 5 mm, right 3.5 mm, reactive to light bilaterally. No blink to visual threat. Extraocular movements appeared conjugate. Left side had decreased abduction with dolls. Positive occasional right nystagmus with dolls. No obvious facial asymmetry which was difficult to tell with a tube in place. Positive gag. Positive cough. Motor revealed spontaneously moved the right side more than the left. Spontaneous movement in the right upper and lower extremities. Positive withdrawal to pain on the left lower extremity. Positive extension to pain in the left upper extremity. Her reflexes were symmetric bilaterally with upgoing toes bilaterally, 4+ on the right ankle, 1+ on the left ankle. PERTINENT LABORATORY DATA ON PRESENTATION: The patient had basic laboratories with a white blood cell count of 15.8, a hematocrit of 32.2. Normal electrolytes except for her blood glucose which was 336. PT, PTT, and INR were normal. Her urinalysis showed 0 to 2 white blood cells, and rare bacteria. RADIOLOGY/IMAGING: Head CT done at the time showed only chronic microvascular changes. No infarct. No axillar hemorrhage. Chest x-ray showed left lower lobe opacity, a question of atelectasis. HOSPITAL COURSE: The patient was admitted to the Neurolgy Intensive Care Unit and followed. Blood pressure was controlled. She was moving all extremities to pain, left greater than right. Slight increased tone on the right side. She was started on a maintenance dose of Dilantin. Acute coronary artery syndrome was r/o with serial EKGs, creatine kinases and troponin. Magnetic resonance imaging showed extensive encephalomalacia change in atrophy from multiple old infarct. No acute infarct. MRA at the same time was read as motion artifact, severely aluminated the Circle of [**Location (un) 431**], visualized internal carotid arteries were likely vertebrobasilar system patent; however, the patient after extubation had new left arm weakness which was not at her baseline. When the stroke team reviewed her MRA they felt that she could possibly have basilar artery stenosis; and, therefore, she was started on a heparin drip. Prior to that a workup for the seizure included a lumbar puncture which was unrevealing with 1 white blood cell, no red blood cells, and a differential of 65% lymphocytes, 30% monocytes, and 5% polys. Glucose was 126. No protein was sent. She was continued on Synthroid. Her serum glucose was controlled. She did require an insulin drip at one point until she started eating again. In addition, she had an electroencephalogram on [**12-20**] which showed very low voltage background with beta in most areas, not epileptiform. She was transferred out from the NICU to the Neurologyfloor on [**2135-12-22**] and remained stable on a heparin drip. Her PTT was kept between 60 and 80. Her blood pressure was watched carefully. At the time she was transferred she was alert and oriented times hospital. She felt well, and she was consistently following commands. She moved her right arm and had some difficulty moving her left arm. Her Dilantin levels were followed and on [**12-22**] it was 9.3. She was bolused with Dilantin with subsequent repeat being 10.9, and her chronic dose was increased. During her stay, her hematocrit fell to 28. Because of her diabetes and risk factors for coronary artery disease, she was transfused 2 units with a repeat hematocrit of 34 on [**2135-12-25**]. We continued to follow her hematocrit, and again it dipped down to 28, and she needed to receive another transfusion. Her Dilantin was continued, and her mental status improved. She was started on Levaquin for a possible aspiration pneumonia and then found to have urinary tract infection, and thus the Levaquin was continued. Her urine grew out Staphylococcus aureus and group B strep. She was started on vancomycin and continued on the levofloxacin. The sensitivities studies showed methicillin-resistant Staphylococcus aureus, and a peripherally inserted central catheter line was placed for a prolonged course of vancomycin. Vancomycin peak and trough was checked on [**2135-12-29**] which showed a peak of 22 and a trough of 10.9, which seemed adequate and continued on the vancomycin dose 500 mg q.24h. The patient's neurologic examination improved with her able to have antigravity movement with her left hand. Her heparin was discontinued after the second hematocrit drop, and Gastrointestinal was consulted. They had originally planned to take her for upper and lower endoscopy; however, her daughter did not want any intervention unless the patient had life threatening problems, and after the discontinuation of the heparin, her hematocrit remained stable. The patient was then started on Plavix for stroke prophylaxis since she had an aspirin allergy. Her stools were consistent guaiac-positive through the hematocrit drops, and thus we thought that the source was gastrointestinal. MEDICATIONS ON DISCHARGE: 1. Dilantin 100 mg p.o. t.i.d. 2. Nitroglycerin patch 0.4 mg q.d. 3. Catapres 0.2 mg transdermal patch every week. 4. Serevent meter-dosed inhaler 2 puffs b.i.d. 5. Flovent meter-dosed inhaler 2 puffs b.i.d. 6. Vancomycin 500 mg intravenously q.24h. 7. Protonix 40 mg p.o. q.d. 8. Plavix 75 mg p.o. q.d. 9. Zantac 150 mg p.o. q.d. 10. Regular insulin sliding-scale. 11. NPH 12 units q.a.m. and 4 units q.p.m. 12. Labetalol 100 mg p.o. b.i.d. (hold for a blood pressure of less than 160 and heart rate less than 40). 13. Synthroid 100 mcg p.o. q.d. 14. Colace 100 mg p.o. b.i.d. DISCHARGE DIAGNOSES: 1. Seizure and question stroke. 2. Diabetes. 3. Gastrointestinal bleed. DISCHARGE FOLLOWUP: Follow up with stroke team. [**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**] Dictated By:[**Last Name (NamePattern1) 8853**] MEDQUIST36 D: [**2135-12-29**] 16:41 T: [**2135-12-29**] 18:06 JOB#: [**Job Number 37481**]

[ "401.9", "780.39", "435.3", "434.91", "428.0", "599.0", "276.0", "250.00" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.6", "03.31", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

7204, 7280

6581, 7183

800, 2805

2824, 6554

7302, 7580

153, 772

67,040

124,551

36340

Discharge summary

report

Admission Date: [**2119-3-21**] Discharge Date: [**2119-3-31**] Date of Birth: [**2046-1-25**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: Nausea, dry heaves. Major Surgical or Invasive Procedure: [**2119-3-24**] - sigmoid colectomy with Hartmann's, end colostomy History of Present Illness: Pt is a 73 y/o F who was recently discharged after being treated for complicated diverticulitis as well as being evaluated for a distal pancreatic mass (likely IPMN). She now returns to the hospital with 2 days of intractable nausea with dry heaves. Her vomiting has never been productive. She is passing flatus and having normal bowel movements. Since discharge she has been pain free but generally has a sense of pelvic fullness. She has no pain now, just nausea. She has been eating "ok" until yesterday - small frequent meals - but reports that she has had a 20lb wieght loss in the past month, 6lbs in past week. She denies fever, chills, rhinorrhea, cough, sore throat, chest pain, shortness of breath, abdominal/back/shoulder pain, dysuria, hematuria, BRBPR, change in bowel movements. She completed her cipro and clinda three days ago. Past Medical History: Diverticulitis, Cerebral aneurysm with SAH s/p clipping, Back surgery, Right femoral angioplasty, HTN, Hysterectomy Social History: No tobacco, drugs, 1ppd cigs for 60 yrs, lives at home Family History: Her mother died of a stroke at 89; her father died of Alzheimer. No one in the family has colon cancer. Physical Exam: On admission: 98.9 103 127/76 18 96RA Alert Oriented x 3 NAD NCAT MMM No icterus or jaundice RRR No murmurs CTAB No crackles wheezes or rhonchi Abd soft nondistended nontender, no hernias, trace guaiac pos No edema Pertinent Results: [**2119-3-21**] 10:25PM WBC-15.5*# RBC-4.10* HGB-12.1 HCT-35.5* MCV-87 MCH-29.4 MCHC-33.9 RDW-13.0 [**2119-3-21**] 10:25PM NEUTS-84.2* LYMPHS-11.0* MONOS-3.9 EOS-0.7 BASOS-0.3 [**2119-3-21**] 10:25PM PLT COUNT-396 [**2119-3-21**] 10:25PM GLUCOSE-113* UREA N-12 CREAT-1.0 SODIUM-140 POTASSIUM-2.9* CHLORIDE-100 TOTAL CO2-30 ANION GAP-13 [**2119-3-21**] 10:25PM ALT(SGPT)-16 AST(SGOT)-14 ALK PHOS-83 AMYLASE-144* TOT BILI-0.7 [**2119-3-21**] 10:25PM LIPASE-132* [**2119-3-21**] 10:44PM LACTATE-1.5 . [**3-22**] CT ABDOMEN/PELVIS: 1. Severe sigmoid diverticulitis, with a perisigmoid abscess, which directly abuts the left posterolateral wall of the bladder. While by size criteria, this is potentially drainable, its location and approach is unfavorable for percutaneous drainage. 2. Changes of chronic pancreatitis, with pancreatic calcifications. 4-mm rounded calcific focus in the pancreatic duct within the tail of pancreas, with dilated pancreatic duct distally. 3. Several cystic lesions in the pancreas, the largest in the pancreatic tail, which may represent dilated side branches from chronic pancreatitis, side branch IPMN, or small pseudocysts. These can be evaluated with MRCP in six months on a non-emergent basis . [**3-23**] EGD: Erythema in the antrum compatible with mild gastritis (biopsy) Inflammatory polyp in the cardia Otherwise normal EGD to third part of the duodenum . [**2119-3-24**] OPERATIVE REPORT: PREOPERATIVE DIAGNOSES: Sigmoid phlegmon with pelvic abscess. POSTOPERATIVE DIAGNOSES: Sigmoid phlegmon with pelvic abscess. PROCEDURE PERFORMED: 1. Low anterior resection. 2. Hartmann turn-in. 3. Sigmoid colostomy. 4. Drainage of pelvic abscess. ANESTHESIA: General. INDICATIONS FOR OPERATION: This was a 73-year-old woman who entered the hospital in transfer from an outside facility approximately 3 weeks earlier with lower abdominal discomfort and an apparent sigmoid colon phlegmon on CT scan. She appeared to have a contained abscess there. She had extensive diverticulosis in the other areas of her colon on the CT scan, and a presumptive diagnosis of complicated diverticulitis was made. She was also found to have cystic dilatation of the pancreas, potentially suggestive of intraductal papillary mucinous neoplasia. I initially treated the patient with antibiotics as an inpatient. Her white blood cell count, which had been approximately 14,000, fell to normal. Her pain resolved. Her diet was successfully advanced. She was able to be discharged to home. There, she completed a full course of outpatient antibiotics. I had seen her as an outpatient a few days after cessation of the antibiotics, at which time she reported having no abdominal pain. However, she did complain of mild nausea and her family reported a 20-pound weight loss over the previous few months, with reportedly 6 pounds of weight loss only in the past 10 days since she had gone home. I had planned to obtain an outpatient upper endoscopy with endoscopic ultrasound for the purposes of a potential transgastric biopsy of the pancreas. While the patient had been hospitalized, a CEA had been sent which was 14, three times normal. A CA19-9, however, was normal. Two days after I had seen the patient as an outpatient, I was called to be told that she was extremely nauseated and unable to leave her bed. Her family was quite alarmed. I readmitted her to the hospital. Her white blood cell count was again 15. A CT scan showed persistent inflammation of the sigmoid with enlargement of her abscess, now measuring 4.5 cm. She was placed on antibiotics again. I obtained an upper endoscopy to rule out any type of intrinsic gastric mass. It showed mild gastritis only, there was no obstruction. I had already decided to forego the transgastric biopsy. She was started on intravenous nutrition. I was concerned that nonoperative management had only led to a progressive decline. It remained possible that she either had an unusual form of perforated colon cancer as opposed to severe diverticulitis. I decided to not perform a preoperative sigmoidoscopy due to my concern of inducing an acute perforation. Accordingly, approximately 48 hours after her readmission and following a mechanical bowel prep, she was brought to surgery. DESCRIPTION OF PROCEDURE: The procedure was performed in the operating room of the [**Hospital1 69**], [**Hospital Ward Name 516**]. The patient was brought into the room and laid supine on the table. She was successfully induced and intubated for general endotracheal anesthesia. Pneumatic compression boots were applied. A Foley catheter was inserted. She was placed into lithotomy with appropriate padded supports. Her preoperative ciprofloxacin had been continued. She was also continued with her preoperative Flagyl. In addition, for additional perioperative coverage, she was given 2 grams of intravenous Kefzol and 100 mg of intravenous gentamicin. We prepped the abdomen with Betadine and sterilely draped. I made a midline incision extending from the pubis to slightly above the umbilicus. The patient had a prior hysterectomy, and at the time of her exploration, I also concluded that she had undergone bilateral salpingo- oophorectomy and appendectomy. Regardless, after opening the abdomen, she had no evidence of ascites. There was no carcinomatosis. There were no adhesions. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 24412**] retractor was placed. She had, as expected, an intense inflammatory process in the left lower quadrant and pelvis. Her sigmoid colon was extensively adherent to multiple surrounding structures. She appeared to have a very redundant cecum and right colon and the cecum and ileocecal junction were extensively involved with the inflammatory process. I engaged in a laborious dissection to separate the cecum and ileum from the area of the sigmoid colon. We entered at least two areas of abscess formation close to the sigmoid mesentery. The patient also had a much larger abscess which essentially was centered on the dome of the bladder. However, after entering the inflammatory peel in the perivesical abscess, I concluded that there was no actual violation of the bladder itself. I could feel the patient's Foley balloon with what appeared to be intact tissue, deep within the abscess cavity. In the course of mobilizing the right colon and freeing it from the inflammatory process, we induced a linear tear in what appeared to be a combination of intense inflammatory peel and some of the serosa of the terminal ileum. The patient also had one focus of inflammatory peel that had been adherent to the cecum. Throughout the case, I could not be certain if some of the areas of intense desmoplastic reaction, in fact, represented a perforating colon cancer with extensive transmission throughout the pelvis. As it was late in the evening, and I felt that it would not change my operative plan at all, I did not request the pathologist to come to perform any type of frozen section. At the end of our entire procedure we ultimately repaired the linear serosal tear of the ileum with Lemberted sutures of 3-0 silk. Everything looked quite nice after that. After mobilizing the cecum, I packed it away along with the small bowel, giving us much better visualization of the pelvis. I mobilized the left ureter proximal to the area of inflammation and controlled it with a vessel loop. After mobilizing the cecum, the right ureter had also been displayed and remained intact throughout the case. I then engaged in an extremely arduous dissection to separate the sigmoid colon from the left ureter. I stayed close to the colon and left quite a bit of inflammatory peel behind. I entered the presacral space and took the superior sigmoid artery, controlling the proximal portion with a 2-0 silk suture ligature. The sigmoid colon was extensively thickened along its course. I was somewhat suspicious, however, because there did seem to be a more bulbous area in the midpoint of the process, potentially consistent with tumor. Regardless, after entering the prepelvic space and taking down the peritoneal reflection, I found some soft rectum to work with beyond the area of inflammation. I went proximally just beyond the area of inflammation and divided the sigmoid colon with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] stapler using the blue 3.5-mm staple closure. I then completed the resection by dividing the rectum with a TA-60 stapler with the blue cartridge. We completed our mesenteric dissection and delivered the specimen to the pathologist. Our hemostasis was good. The left ureter clearly had remained intact throughout our dissection. The urine also had remained clear. There was absolute no evidence of any leakage from the defect overlying the bladder. I then liberated the proximal sigmoid almost all the way up to the splenic flexure. We had good mobility. I formed a stoma as marked by the enterostomal therapist just to the left of the midline in the mid rectus. We took a divot of skin and then formed a cruciate incision in the rectus sheath. We brought the stoma without any difficulty at all. We then proceeded to close the midline rectus fascia with a running looped #2 PDS suture. I placed a #10 [**Location (un) 1661**]-[**Location (un) 1662**] drain in the pelvis, putting the end into the perivesical soft tissue defect where the majority of the abscess cavity resided. We liberally irrigated the subcutaneous space and then closed the skin with staples. Dry sterile dressings were applied. We then matured our colostomy with full-thickness interrupted sutures of 4-0 Vicryl to the dermis and bowel. We had good eversion. The stoma was clearly viable. An appliance was placed. I would also note that upon manual exploration and inspection, the liver was completely normal. There was no evidence of carcinomatosis. There was no obvious retroperitoneal adenopathy. She had no other palpable colon lesions. The patient was then awakened and extubated without incident. ESTIMATED BLOOD LOSS: Approximately 200 mL. DISPOSITION: She was transferred to the surgical intensive care unit in stable condition. Brief Hospital Course: Mrs. [**Known lastname 82346**] underwent a CT scan in the ED which revealed severe diverticulitis with a pericolonic abscess. She was admitted to the surgical service. A PICC line was placed on [**3-22**] and TPN was initiated. Gastroenterology consult was obtained to r/o an upper GI source for her nausea/wretching, and an EGD performed [**3-23**] revealed little more than a gastric polyp. As her disease was complicated by an abscess and was unresponsive to antibiotics, the decision was made to take her to the operating room for a sigmoid colectomy. See operative report for further details of the operation. . She was transferred to the ICU postoperatively for close hemodynamic monitoring. Antibiotics were continued. She did well overnight and was transferred to the floor the next day. Her pain was initially controlled with a Dilaudid PCA, but this was tapered and changed to Extra Strength tylenol because of confusion with the narcotic. She was advanced to sips the next day. Her white blood cell count was elevated to 20K on POD #1 but this spontaneously returned to [**Location 213**] over the next few days. She was out of bed on POD #1 and ambulated on POD #2. She was continued on TPN since her preoperative nutrition had been poor. On POD #4 she had some tachycardia and hypertension so was started on IV lopressor, which was transitioned to PO lopressor. Her ostomy began to function on POD #5 and her diet was advanced to regular diet. The TPN was discontinued on POD #6. Her foley was left in place, and a cystogram was performed on [**2119-3-31**], which revealed no bladder injury. Foley catheter was DC'd and the patient voided on her own. She was discharged to home with services on [**2119-3-31**] Medications on Admission: Lisinopril 20', Simvastatin 40', Colace, MVI Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain. Disp:*40 Tablet(s)* Refills:*1* 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Complicated diverticulitis Discharge Condition: Tolerating POs Ambulating Ostomy functioning Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. . No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. . Activity: No heavy lifting of items [**9-7**] pounds until the follow up appointment with your doctor. . Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You should continue taking extra strength tylenol as needed for your pain. . Diet: You may resume a regular diet. Followup Instructions: 1. Call Dr.[**Name (NI) 1745**] office ([**Telephone/Fax (1) 6554**]) to schedule a followup appointment for [**2119-4-10**]. 2. Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10132**], Ostomy Rn on [**4-10**] 3. Please follow up with PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 9674**], [**4-12**] at 1:15. Please call if you can not make this appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2119-3-31**]

[ "577.1", "496", "276.51", "562.11", "569.5", "577.2", "276.8", "567.22", "535.50", "401.9" ]

icd9cm

[ [ [] ] ]

[ "46.11", "45.76", "99.15", "45.16", "38.93" ]

icd9pcs

[ [ [] ] ]

14307, 14378

12074, 13817

334, 402

14449, 14496

1869, 12051

15424, 16038

1511, 1618

13912, 14284

14399, 14428

13843, 13889

14520, 15401

1633, 1633

275, 296

430, 1283

1647, 1850

1305, 1423

1439, 1495

7,708

193,067

30052

Discharge summary

report

Admission Date: [**2151-1-16**] Discharge Date: [**2151-2-2**] Date of Birth: [**2104-3-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1973**] Chief Complaint: acute headache Major Surgical or Invasive Procedure: Angiograms x2 ventriculoperitoneal shunt placement ([**2151-1-29**]) History of Present Illness: HPI: Pt is a 46 yo male w/ PMhx sig for sleep apnea, hypertension, hypercholesterolemia, borderline DM who was in his USOH state of health this AM when he was driving and experiences an acute onset headache. Pt states that the headache was [**9-8**] and radiated to the back of the neck. This had never happened to him before. Pt was brought to an OSH where CT scan showed a SAH. He was then medflighted to [**Hospital1 **] for further evaluation. There is no history of head trauma. Pt denies visual changes, nausea, vomiting, fevers, chills, night sweats, bowel/bladder incontinence. Past Medical History: Past Medical History: HTN, DM, hypercholesterolemia, GERD, sleep apnea. Social History: Social History: non-smoker. 12 pack of beer/week Family History: Family History: father - MI, mother DM Physical Exam: Vitals: T 97.5; BP 208/106; P 91; RR 28; General: lying in bed, appears in pain HEENT: NCAT, moist mucous membranes Neck: + meningismus, no carotid bruit Pulmonary: CTA b/l Cardiac: regular rate and rhythm, with no m/r/g Carotids: no blood flow murmur Abdomen: soft, nontender, non distended, normal bowel sounds Extremities: no c/c/e. Neurological Exam: Mental status: A & O x3, tells coherent stor, Fluent speech with no paraphasic or phonemic errors. Adequate comprehension. Follows simple and multi-step commands. Cranial Nerves: I: Not tested II: PERRL, 4-->2mm with light. VFF. III, IV, VI: EOMI. no nystagmus. V, VII: facial sensation intact, facial strength VIII: hearing intact b/l to finger rubbing. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: SCM [**4-3**] XII: Tongue midline without fasciculations. Motor: Normal bulk. Normal tone. No pronator drift. Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB RT: 5 5 5 5 5 5 5 5 5 5 5 5 5 5 LEFT: 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: intact to pinprick, light touch. Reflexes: Bic T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally. Coordination: FNF intact. Pertinent Results: Labs: 139 109 11 - - - - - - gluc 150 3.4 24 0.9 ) CK: 36 Ca: 7.2 Mg: 1.8 P: 2.2 ALT: 100 AP: 54 Tbili: 0.4 Alb: AST: 77 LDH: Dbili: TProt: 5.8 [**Doctor First Name **]: 37 Lip: WBC 11.3 HCT 35.2 PLT 227 N:71 Band:2 L:17 M:6 E:2 Bas:1 Metas: 1 PT: 12.7 PTT: 26.3 INR: 1.1 Radiology: CTA head - Diffuse subarachnoid hemorrhage in the supra cellar cistern along the tentorium and extending to 3rd and 4th ventricles; as well as pons, midbrain medulla and superior spinal canal. There is some mass effect on the right lateral aspect of the pons. There is mucosal thickening of the right maxillary sinuses and ethmoid sinuses. CTA performed demonstrates normal arteries of circle of [**Location (un) 431**]. no discrete aneurysm or focal stenosis identified. Conventional angiogram may provide additional information. Brief Hospital Course: Pt was admitted to the hospital and was monitored in PACU for close neurologic observation. He remained intact. Repeat head CT showed hydrocephalus and ventriculostomy was placed [**1-17**]. Pt was then transferred to neuro stepdown for close monitoring. He had angiogram [**1-16**] that was negative for aneurysm. His vent drain was slowly raised. He had fevers and and was found to have pneumonia on CXR and was treated with levaquin. He also had hyponatremia and was treated with salt tabs. Repeat angiogram done [**1-25**] is again negative for aneurysm. Nimodipine will be continued for full 21 day course to finsih on [**2151-2-6**]. He had Lower extremity dopplers to r/o DVT on [**1-26**] which were negative. CT brain on this same day with drain at 20 is stable. His ventriculostomy drian was clamped at 12 noon [**1-26**]. It is thought that his fevers are central in origin. Dilantin was discontinued and keppra was started to make sure that the fevers are not dilantin related. Foley catheter is now out. His LFT's are pending. Staples at the site of the insertion of EVD are out - the wound in clean and dry. Gram stain of CSF on [**1-22**] and [**1-26**] are negative - cultures of the later are pending. He continues on a 1000cc fluid restriction and serum Na's are monitored daily. . At this point, on [**2151-1-26**], he was transferred to the medicine service for further management of his hypertension, hyponatremia, and fevers. . For his hypertension, his regimen was simplified to his outpatient valsartan and a beta blocker (in addition to the centrally-acting calcium channel blocker, nimodipine, which he was taking as part of the subarachnoid hemorrhage regimen). These medications were titrated to a goal SBP of <160 per neurosurgery. . For his hyponatremia, a renal consultation was obtained. His urine osms and urine sodium were markedly elevated, consistent with SIADH. They agreed that the likely etiology of his SIADH was his subarachnoid hemorrhage and they agreed with fluid restricting him and continuing PO NaCl tablets. They also recommended a high protein diet and to give him a several day trial of standing Lasix. With these interventions, his sodium remained stable and ws beginning to trend back to normal by discharge. He will follow up with his new PCP regarding continuation/discontinuation of the fluid restriction and NaCl tabs. . Regarding his subarachnoid hemorrhage, the neurosurgery team continued to follow him. Since his intracranial pressure (as measured through his EVD) remained elevated when the EVD was clamped, he was taken back to the OR on [**2151-1-29**] and had a ventriculoperitoneal shunt placed. The post-op head imaging confirmed no worsening of his hydrocephalus post-operatively and he will follow up at Dr.[**Name (NI) 9034**] office for staple removal and further management. . Regarding his fevers, an extensive workup had been done by the neurosurgical team prior to transfer, with multipl negative blood, urine, and CSF cultures. They had treated a possible community-acquired pneumonia with levofloxacin for seven days prior to transfer. There was some suspicion that his fevers could have been drug fevers from his phenytoin so this was switched to levetiracetam. There was also a suspicion that these may have been central fevers due to his subarachnoid hemorrhage. Supporting this theory was the fact that he never developed a leukocytosis or hypotension, so no further antibiotics were given. The frequency of his fevers gradually decreased and, by discharge, he had been afebrile for approx 4 days. . His course was somewhat complicated by an acute worsening of his chronic low back pain (he reported a history of disc herniation). It was thought that his long stay with bedrest had exacerbated his chronic back pain. His pain was treated with prn Tylenol and low-dose narcotics. NSAIDs were avoided due to his recent bleeding. A chronic pain consult was obtained and they recommended against epidural steroid injection due to his fevers and recent CNS instrumentation. His pain improved somewhat once he was able to get out of bed, stretch, and work with PT. . Prior to discharge, he was cleared by PT for both ambulation and walking on stairs. . The patient requested a new PCP which was arranged through [**Company 191**]. His new PCP should recheck his sodium to ensure continued resolution of his hyponatremia (and possible discontinuation of his fluid restriction and NaCl tabs). He should also have his blood pressure checked and his regimen adjusted accordingly for a goal SBP<140 due to his recent hemorrhage. Lastly, he would likely benefit from referral to a dietician given his diagnosis of insulin resistance/"borderline diabetes". . He will follow up in Dr.[**Name (NI) 9034**] office for staple removal and repeat imaging of his head. Medications on Admission: Medications: Ranitidine, Claritin, valsartan (dose unknown) Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day: Please start this medication on the morning of [**2151-2-7**]. Disp:*30 Tablet(s)* Refills:*2* 2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 7. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) for 5 days: last dose on the evening of [**2151-2-6**]. Disp:*54 Capsule(s)* Refills:*0* 8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for back pain: Please note that this medication can make you confused and drowsy. Disp:*30 Tablet(s)* Refills:*0* 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain, fever: please limit daily intake to less than 2000mg per 24 hrs. Disp:*60 Tablet(s)* Refills:*0* 11. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Subarachnoid Hemorrhage Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR HEAD INJURY ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Fever greater than or equal to 101?????? F Followup Instructions: Please go to Dr.[**Name (NI) 9034**] office on [**2151-2-12**] at 11 am to have your staples removed. His office is in the [**Hospital **] Medical Office Building at [**Last Name (NamePattern1) **]. (phone [**Telephone/Fax (1) 2731**]). At this appointment, they will schedule you for an additional followup with Dr. [**Last Name (STitle) **] and for a followup head CT. . You have expressed a desire to establish a new Primary Care Physician here at [**Hospital1 18**]. We have arranged for you to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2151-2-11**] at 2:00 pm. His office is in the Atrium Suite on the [**Location (un) 448**] of the [**Hospital Ward Name 23**] Clinical Center (at the corner [**Location (un) 71679**] [**Hospital1 39240**]). The office phone number is [**Telephone/Fax (1) 250**]; please call this number prior to your appointment to update you information in the office's records.

[ "331.4", "780.6", "253.6", "507.0", "E935.2", "285.9", "250.00", "272.0", "564.09", "724.5", "458.9", "430", "401.0", "327.23" ]

icd9cm

[ [ [] ] ]

[ "02.39", "88.41", "02.34", "93.90", "02.43" ]

icd9pcs

[ [ [] ] ]

9871, 9877

3350, 8209

286, 357

9944, 9968

2494, 3327

11016, 11966

1175, 1200

8320, 9848

9898, 9923

8235, 8297

9992, 10993

1215, 1553

1572, 1572

232, 248

385, 979

1753, 2475

1587, 1737

1023, 1075

1107, 1143

67,843

151,004

37435

Discharge summary

report

Admission Date: [**2197-12-4**] Discharge Date: [**2197-12-7**] Date of Birth: [**2160-4-3**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Acute Right Lower Extremity Weakness Major Surgical or Invasive Procedure: * Cerebral Angiography History of Present Illness: PER ADMITTING RESIDENT: 37 year-old RHM w/ remote history of migraines who presents from OSH w/ a left frontal [**Hospital 18505**] transferred to [**Hospital1 18**] for further care. At 1pm today, while walking, pt. hit his knee on a door while walking, felt a bit of numbness and tingling, but thought nothing of it at the time. At 2pm on [**12-3**], after having a bowel movement (no straining) patient noted acutely that he could not move his RIGHT leg. Felt that it fell asleep or perhaps was from a prior injury to the knee. He took a nap, when he awoke at 5pm, he still could not move the leg. His wife called EMS. He was taked to [**Last Name (un) 1724**] with SBP of 188/110 on arrival, underwent a HCT showing the 1.2x1.8x2.6 cm L superior frontal gyrus hemorrhage. CTA brain (per report from outside hospital) did not show an aneurysm. Given the new ICH and negative CTA, he was transferred to [**Hospital1 18**] for further care. Of note, he started taking a body building supplement (Jacked3D) containing dimethylamylamine (adrenergic stimulant) this Monday. He noted two episodes of dull HA on Tue/Wed, at vertex but [**2-24**] in intensity and lasting hours, relieved w/ Ibuprofen. There were no other associated symptoms at the time. Today, in addition to the weakness, he noted a few seconds of RIGHT hand tingling, but no other concerns. By time of transfer to [**Hospital1 18**], his strength at hip and knee improved, however remained weak distally. He denies any additional drug use, but does report drinking [**8-28**] drinks the night before. . On neuro ROS: ( - ) loss of vision, blurred vision ( - ) diplopia, dysarthria, dysphagia ( - ) lightheadedness, vertigo, tinnitus or hearing difficulty ( - ) difficulties producing or comprehending speech. ( - ) focal weakness, numbness, parasthesiae other than per HPI. ( - ) bowel or bladder incontinence or retention. On general ROS: ( + ) wife noted a small rash behind the ear and on forehead. ( - ) fever or chills, night sweats or recent weight loss. ( - ) cough, shortness of breath, chest pain, palpitations. ( - ) nausea, vomiting, diarrhea, constipation or abdominal pain. ( - ) arthralgias or myalgias. Past Medical History: - Migraines in childhood. Social History: - Lives w/ wife in [**Name (NI) **], MA. - Works as a sales clerk in Nordstroms. HABITS - Tobacco - 1/2ppd x10 years - EtOH - [**5-1**]/week - Drug use - denies. - Herbal/Non-prescription Drug Use: supplement including caffeine ("Jacked -3") Family History: CVA - Fa and paternal GFa in 70s. Ca - [**Name (NI) 84132**], mother Sz - none Connective tissue d/o - none Autoimmune or inflammator d/os - none. Physical Exam: ON ADMISSION: Physical Exam: . Vitals: T:98.3F P:67 BP:149/91 RR: 12 SaO2: 99% RA General: Awake, cooperative, NAD. Gynecomastia. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: mild erythematous, blanching, macular rash behind R ear, on forehead and on anterior chest crossing midline. No bullae. MSK: TTP at Right dorsiflextion tendon. . Neurologic: . -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. 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 [**1-17**] at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. . -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus, but somewhat irregular saccades, occasional overshoot. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. 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. Mild intention tremor, L >> R. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 4+ 4 0 0 0 0 Hip adduction - full b/l Hip abduction - [**2-19**] on R. -Sensory: Light touch - intact Pinprick - intact Cold sensation - intact Vibratory sense - intact Proprioception - intact No sensory level. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2+ 1 R 2 2 2 2+ 1 Plantar response was flexor bilaterally. -Coordination: No dysmetria on FNF b/l, or HKS on L. -Gait: unable to assess. Pertinent Results: WBC-7.9 RBC-5.13 HGB-16.2 HCT-47.9 MCV-93 PLT-232 GLUCOSE-113* UREA N-9 CREAT-1.0 SODIUM-139 POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-21* ANION GAP-16 ALBUMIN-4.9 CALCIUM-9.5 PHOSPHATE-2.6* MAGNESIUM-2.0 LIPASE-35 ALT(SGPT)-109* AST(SGOT)-85* LD(LDH)-201 CK(CPK)-2282* ALK PHOS-83 TOT BILI-0.6 CK-MB-4 cTropnT-<0.01 PT-11.5 PTT-25.1 INR(PT)-1.0 . [**Doctor First Name **]-NEGATIVE ANCA-NEGATIVE B SED RATE-0 CRP-0.4 RHEU FACT-9 . URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . IMAGING . CT Head without Contrast ([**2197-12-4**]): IMPRESSION: Left frontal parenchymal hemorrhage with surrounding edema. . MRI Head with and without Contrast (): IMPRESSION: Unchanged left frontal parenchymal hemorrhage with no enhancing masses or vascular malformation identified. Several small vessels clustered superficially over the region of hemorrhage are most likely reactive and a small vascular malformation is unlikely. The location suggests cortical vein throbosis, though no imaging findings of thrombosis are present. . Cerebral Angiogram ([**2197-12-5**]): FINDINGS: Evaluation of the above branches demonstrates no evidence of aneurysms or vascular malformations. Good opacification of the intracranial portions of these arteries is noted. IMPRESSION: Evaluation of the right internal carotid artery, right external carotid artery, left internal carotid artery, left external carotid artery, and left vertebral artery demonstrates no aneurysms or vascular malformations. Brief Hospital Course: Mr. [**Known lastname 84133**] is a 37 year-old right-handed man with a remote history of headache who presented to [**Hospital6 2561**] with the acute onset of right lower extremity weakness in the setting of a supplement use. After a non-contrast CT of the head revealed a left frontal intraparenchymal hemorrhage, he was transferred to the [**Hospital1 18**] on [**2197-12-3**] for further evaluation and care. He was admitted to the stroke service from [**2197-12-4**] to [**2197-12-7**]. . NEURO Following admission, an MRI of the head and neck was performed to better define the nature of the intraparenchymal lesion. The study showed a stable left frontal parenchymal hemorrhage with no enhancing masses or identifiable vascular malformation. Although several small vessels clustered superficially over the region of hemorrhage were thought to most likely represent a reactive process, it was considered important to evaluate for an underlying arteriovenous malformation. Accordingly, a conventional cerebal angiogram was performed. The imaging demonstrated no identifiable cause for the patient's hemorrhage (no aneurysm or arteriovenous malformation). The hemorrhage may have been due to a sudden elevation of his blood pressure. Although no neoplasm was seen underlying this hemorrhage, he will require follow up MRI brain in six weeks to rule out underlying neoplasm. . To evaluate for contributory autoimmune processes, several investigatory studies were performed. The sedimentation rate, CRP, RF, [**Doctor First Name **], and ANCA were normal or negative. . The patient's blood pressure continued to be quite elevated during the hospital course (170s-190s systolic). At the time of discharge his blood pressure had been in the 130s systolic on norvasc, lisinopril, and hydrochlorothiazide. He will be discharged home on this regimen and have a repeat MRI/A brain in six weeks and follow up with Dr. [**Last Name (STitle) **] as an outpatient. . Medications on Admission: Medications: - none . Allergies: PCN - anaphylaxis Discharge Medications: 1. Outpatient Physical Therapy 2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Left frontal intraparenchymal hematoma Discharge Condition: 5-/5 strength in R IP, 0/5 DF, PF, [**Last Name (un) 938**] on R, otherwise full strength throughout. Discharge Instructions: You were admitted for evaluation of right leg weakness and were found to have a bleed in your brain. It was thought this may have been due to hypertension. An angiogram did not show a vascular cause for your bleed. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] (neurology) in 6 weeks. His office can be reached at ([**Telephone/Fax (1) 7394**] to schedule an appointment (Ideally after your MRI is performed as below). Also, you will need a repeat MRI of your head and MRA head/neck in six weeks as follow up. Please call ([**Telephone/Fax (1) 6713**] to schedule an appointment.

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53943

Discharge summary

report

Admission Date: [**2113-3-10**] Discharge Date: [**2113-4-10**] Date of Birth: [**2077-9-28**] Sex: F Service: SURGERY Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 473**] Chief Complaint: Cholelithiasis, duodenal perforation Major Surgical or Invasive Procedure: [**2113-3-10**]: ERCP . [**2113-3-16**]: Successful CT-guided percutaneous drainage catheter placement into the right perinephric space . [**2113-3-21**]: 1. Wide incision and drainage of retroperitoneal abscess/infection/hematoma. 2. [**Location (un) **] patch of potential duodenal perforation region with drainage. 3. Antecolic isoperistaltic side-to-side gastrojejunostomy. History of Present Illness: 35F with a h/o active IV drug abuse who presented to an OSH ED c/o jaundice and abdominal pain on [**2113-3-6**], found to have and ultimately transferred to the [**Hospital1 18**] [**2113-3-10**] for ERCP. Ms. [**Last Name (un) 110632**] reports noticing RUQ pain intermittently for the past three months, but it had not become bad enough for her to seek medical attention. When she also developed jaundice associated with generalized malaise and myalgias, she presented to the [**Hospital3 **] ED, where she was found to have elevated LFTS (TB 9.6, DB 6.6, alb 3.6, AST 638, ALT 640, AP 615, and WBC 13.6), and cholelithiasis without ductal dilation on ultrasound. Hepatitis C titer was positive. She was admitted for further work-up. When MRCP on [**1-/2030**] revealed cholelithiasis, possible cholecystitis, and cystic duct stones without CBD or IHD dilation, she was transferred to [**Hospital1 18**] on [**2113-3-10**] for ERCP. ERCP revealed a laceration of the major papilla suggestive of recent stone passage, and stones were noted in the lower CBD with an impacted stone at the ampulla. Sphincterotomy and stone extraction were performed, but subsequent cholangiography revealed constrast extravasation suggesting perforation. Two biliary stents and an NGT were placed, and arrangement for direct admission to the West 2A Surgery service was made. Past Medical History: PMH: Cholelithiasis, hepatitis C, IV drug abuse, anxiety, depression, chronic low back pain, migraines PSH: Tubal ligation Social History: Unemployed and currently homeless, though she stays frequently with her ex-husband. Two children: ages 3 and 5. +tobacco use, 1PPD currently. Denies ETOH. Using heroin, marijuana regularly, most recently Saturday prior to her admission to the OSH on Monday. Family History: Mother and sister with symptomatic cholelithiasis requiring CCY. Father died in [**2107**] from MI, mother, alive, with alcoholic cirrhoisis. Physical Exam: On Admission: Vitals: 98.9 79 127/55 22 99% RA GEN: A&O, markedly jaundiced, uncomfortable HEENT: + scleral icterus, mucus membranes dry, NGT in place, very poor dentition. CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: +diffuse TTP, no guard or rebound, soft, nondistended, no palpable masses SKIN: Marked jaundice, multiple tattoos Ext: No LE edema, LE warm and well perfused On Discharge: VS; 98.6, 92, 126/76, 14, 98% RA GEN: NAD, AAO x 3 CV: RRR RESP: Diminished breath sounds on right base, left cta ABD: Midline abdominal incision open to air with steri strips and c/d/i. RLQ JP drain to bulb suction with stopcock for flushing/aspirating. EXTR: Warm, no c/c/e Pertinent Results: [**2113-4-10**] 06:35AM BLOOD WBC-12.3* RBC-4.10* Hgb-11.6* Hct-38.3 MCV-93 MCH-28.2 MCHC-30.2* RDW-13.6 Plt Ct-433 [**2113-4-8**] 08:10AM BLOOD Neuts-78.7* Lymphs-14.7* Monos-3.9 Eos-2.1 Baso-0.6 [**2113-4-10**] 06:35AM BLOOD Glucose-90 UreaN-10 Creat-1.5* Na-137 K-4.0 Cl-94* HCO3-28 AnGap-19 [**2113-4-7**] 06:10AM BLOOD Calcium-8.2* Phos-4.4 Mg-1.8 [**2113-4-6**] 8:31 am PERITONEAL FLUID GRAM STAIN (Final [**2113-4-6**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): Reported to and read back by DR. [**Last Name (STitle) **] [**Name (STitle) **] #[**Numeric Identifier 11536**] [**2113-4-7**] 10:46AM. YEAST. SPARSE GROWTH. Fluconazole Susceptibility testing requested by DR. [**Last Name (STitle) **] [**Name (STitle) **] #[**Numeric Identifier 11536**] [**2113-4-7**]. SENSITIVE TO Fluconazole. sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. This test has not been FDA approved but has been verified following Clinical and Laboratory Standards Institute guidelines by [**Hospital1 69**] Clinical Microbiology Laboratory.. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. ID PERFORMED ON CORRESPONDING ROUTINE CULTURE. [**2113-3-15**] 8:19 am BLOOD CULTURE Source: Line-left picc 1 OF 2. **FINAL REPORT [**2113-3-21**]** Blood Culture, Routine (Final [**2113-3-21**]): STAPHYLOCOCCUS EPIDERMIDIS. FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS EPIDERMIDIS | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN-------------<=0.25 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ 2 S Anaerobic Bottle Gram Stain (Final [**2113-3-16**]): GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by DR [**First Name (STitle) **] [**Doctor Last Name **] 2PM [**2113-3-16**]. [**2113-3-12**] CT ABD: IMPRESSION: 1. Large amount of intraperitoneal and retroperitoneal free air. A large amount of fluid in the right anterior and posterior pararenal spaces tracking down to the lower quadrant of the abdomen. No obvious leak of contrast to identify the site of perforation. If needed a delayed non-contrast CT abdomen can be obtained to assess for a delayed leak. 2. Small amount of pneumomediastinum. 3. A small simple right pleural effusion with right basilar atelectasis. [**2113-3-16**] CT ABD: IMPRESSION: 1. Decreased but persistent large intraperitoneal and retroperitoneal free air. A large amount of fluid in the right retroperitoneum is seen with anterior displacement of the right kidney. No rim-enhancing fluid collection is seen. 2. Decreased pneumomediastinum. 3. Bilateral pleural effusions with adjacent atelectasis as described above. [**2113-3-20**] CT ABD: IMPRESSION: 1. Improvement in right lower lobe consolidation and decrease in right pleural effusion. 2. Slight decrease in fluid component of right perinephric collection at site of Drain. Extensive multiloculated phlegmonous change with no significant large fluid component to target for drainage. 3. No new collections are identified. 4. Persistent extensive free intra-abdominal air with multiple pockets of air surrounding the second part of duodenum, likely at site of duodenal perforation. [**2113-3-29**] CT ABD: IMPRESSION: 1. Decrease in size of loculated gas-fluid collections with four drains in place. There are small pockets of loculated collections that may not be adequately drained. Significant resolution of intra-abdominal free air. 2. Right hydronephrosis likely from obstruction of ureter due to surrounding inflammation. 3. Slight improvement in right lower lobe consolidation; however, slight increase in right pleural effusion. [**2113-3-31**] RENAL US: FINDINGS: 1. There is stable mild hydronephrosis in the right kidney. Adjacent to the lower pole, is a partially imaged complex fluid collection containing a drain. The right kidney measures approximately 14 cm. 2. The left kidney measures approximately 14.2 cm. There is no hydronephrosis, renal lesion or nephrolithiasis. 3. The bladder is minimally distended limiting evaluation and grossly unremarkable. [**2113-4-6**] CT ABD: IMPRESSION: 1. Limited study due to lack of intravenous and oral contrast demonstrates an interval decrease in the phlegmonous collection in the right perinephric space now measuring 8.0 x 3.0 cm with a drain in place. Multiple adjacent collections with air and fluid are again noted and appear relatively stable to minimally decreased in size. Three of the previously visualized drains have since been removed. 2. Continued mild right hydronephrosis. 3. Resolution of right pleural effusion. Right lower lobe opactiy has decreased in size. 4. Two common bile duct stents are in place with pneumobilia. 5. 2-mm non-obstructive left renal stone. Brief Hospital Course: The patient was admitted to the General Surgical Service with duodenal perforation status post ERCP. The patient was made NPO with NGT, started on IV fluids and IV Zosyn, and Dilaudid PCA for pain control. CT scan on HD # 2 demonstrated large amount of fluid in the right anterior and posterior pararenal spaces tracking down to the lower quadrant of the abdomen and large amount of free air. Nutritional consult was called for TPN recommendations and PICC line was placed. The patient continued to spike low grade fever and her blood cultures were positive for STAPHYLOCOCCUS EPIDERMIDIS, Vancomycin Iv was added on HD # 6. Repeat abdominal CT demonstrated decreased but persistent large intraperitoneal and retroperitoneal free air with a large amount of fluid in the right retroperitoneum is seen with anterior displacement of the right kidney. The patient continued to spike fever and IR drainage of the right retroperitoneal fluid collection was ordered. The patient underwent CT-guided percutaneous drainage catheter placement into the right perinephric space on HD # 6 and fluid was sent for cultures. The patient's diet was advanced as tolerated on POD # 8, and was well tolerated. The cultures were positive for [**Female First Name (un) 564**] Albicans and IV Fluconazole was added. Despite antibiotics treatment patient continued to spike fever and her abdominal pain was continued to be significantly high requiring large amount of IV Dilaudid, Ativan and Ketorolac to manage it, patient's WBC also continued to increased (16->38).Repeat abdominal CT scan on HD # 10 revealed slight decrease in fluid component of right perinephric collection, extensive multi loculated phlegmonous change with no significant large fluid component to target for drainage and persistent extensive free intra-abdominal air with multiple pockets of air surrounding the second part of duodenum. The decision was made to take the patient in OR for washout. On [**2112-3-20**], the patient underwent wide incision and drainage of retroperitoneal abscess/infection/hematoma, [**Location (un) **] patch of potential duodenal perforation region with drainage and antecolic isoperistaltic side-to-side gastrojejunostomy and JP drains placement x 4, which went well without complication (reader referred to the Operative Note for details). Intraoperatively patient received 2 units of pRBC, she was extubated post op and was transferred in ICU for observation. On POD # 2, patient received 2 units of pRBC for HCT 23.4, her post transfusion Hct was 28.3. The patient was transferred to the floor on POD # 3, NPO on TPN and IV fluids, and Dilaudid PCA for pain control. The patient was continued to have low grade fever and she was continued on IV Vancomycin, Zosyn and Fluconazole. The patient was hydrodynamically stable. Neuro: The patient is an active Heroin user. Her pain was controlled with Dilaudid PCA and she had high requirements for pain medication. When tolerating oral intake, the patient was transitioned to oral Dilaudid and Chronic Pain Service was consulted. The patient's pain medications was weaned to [**1-14**] gm of Dilaudid PO Q4H and patient instructed to continue wean off her pain medications in home. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI: The patient was started on TPN on admission. Her diet was advanced to clears on HD # 6 and to regular on HD # 8. The patient was made NPO prior surgery and TPN was continued. Diet was advanced to clears on POD # 5 and to regular on POD # 9, TPN was weaned off and d/c/d on POD # 8. The patient was able to tolerate regular diet prior discharge. Electrolytes were routinely followed, and repleted when necessary. Renal/GU: The patient's Cre/BUN were monitored routinely, on HD # 21 (POD # 10) her Cre increased to 1.9. During hospitalization patient underwent several abdominal CT scans with contrast, she received IV Vancomycin x 14 days, and she received IV Toradol for pain control. The combination of these factors and inflammatory respond from fluid collection, which lead to mild right kidney hydronephrosis contributed to patient's acute renal injury. Urology and Renal were called for consult and their recommendations were followed. The kidney function started to improve on POD # 16, and returned to 1.5 prior discharge. The patient continued to urinate without any difficulties and her electrolyte balance was generally within normal limits. The patient will required to have a follow up Renal US to re-evaluate her hydronephrosis in 6 months as outpatient. ID: The patient had a positive blood cultures on admission with STAPHYLOCOCCUS EPIDERMIDIS, she was treated with IV Vancomycin for 14 days. Surveillance blood cultures were negative. Intra abdominal fluid was positive for [**Female First Name (un) 564**] and patient was started on IV Fluconazole for 14 days also. After discontinue of IV antibiotics, the patient continued to spike low grade fever and her increased on POD # 15. Blood and urine cultures were negative, intra abdominal cultures were positive with [**Female First Name (un) 564**]. The patient was restarted on PO Fluconazole and Augmentin. WBC and fevers subsided after abx was started. She will continue on PO Abx for 10 days after discharge. She was discharged with one JP left within biggest fluid collection, she will follow up with Dr. [**Last Name (STitle) 468**] in 2 weeks with Ct scan to evaluate her fluid collection and possible d/c JP drain. Hematology: The patient's complete blood count was examined routinely; she received total 6 units of pRBC during hospitalization. Her Hct was stable prior discharge and no further transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Xanax 1''', Fioricet PRN, oxycodone 10 mg qid Discharge Medications: 1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 2 weeks. Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0* 2. acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR (AS DIRECTED). Disp:*1 tube* Refills:*0* 3. alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 7. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 8. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day for 10 days. Disp:*20 Tablet(s)* Refills:*0* 9. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0* 10. Xanax 1 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: 1. Choledocholithiasis 2. Doudenal perforation s/p ERCP 3. Infected right perinephric fluid collection 4. Right hydronephrosis 5. Acute kidney injury 6. Chronic pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service at [**Hospital1 18**] for treatment of duodenal perforation s/p ERCP. Your condition continuing to improve and are now safe to return home to complete your recovery with the following instructions: *You will need to repeat Renal Ultrasound six months after discharge. Please follow up with Dr. [**Last Name (STitle) **] (PCP) to schedule this test. *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 [**4-20**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. *Avoid driving or operating heavy machinery while taking pain medications. *Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. JP Drain Care: *Flush and aspirate drain with 10 cc of NS daily. *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in 1 week after discharge to check you kidney function test. Follow up with Dr. [**Last Name (STitle) **] (PCP) in 6 month with Renal Ultrasound to follow up on your right kidney hydronephrosis and left kidney 2-mm non-obstructive left renal stone. . Department: RADIOLOGY When: MONDAY [**2113-4-24**] at 9:15 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage . Department: SURGICAL SPECIALTIES When: MONDAY [**2113-4-24**] at 10:45 AM With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2113-4-10**]

[ "338.29", "305.1", "E947.8", "724.2", "112.89", "591", "998.59", "998.2", "E879.8", "E935.7", "305.21", "790.7", "584.5", "346.90", "V60.0", "311", "305.51", "574.90", "070.70", "041.19", "300.00", "567.38", "593.4" ]

icd9cm

[ [ [] ] ]

[ "46.71", "38.97", "99.15", "51.88", "54.91", "54.0", "51.85", "51.87", "44.39" ]

icd9pcs

[ [ [] ] ]

16663, 16718

8893, 15332

326, 706

16928, 16928

3416, 3949

19292, 20207

2547, 2692

15429, 16640

16739, 16907

15358, 15406

17079, 18055

18070, 19269

2707, 2707

4779, 8870

3119, 3397

250, 288

734, 2100

2721, 3105

4716, 4743

16943, 17055

2122, 2250

2266, 2531

3984, 4680

1,597

125,822

11482

Discharge summary

report

Admission Date: [**2159-9-13**] Discharge Date: [**2159-9-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Debridement of stage 4 sacral ulcer Muscle biopsy of right arm Bronchoscopy History of Present Illness: 83 yo male with PMH CAD, HOCM, dysphagia, and recent hypercarbic respiratory failure (s/p trach/PEG) initially admitted to MICU from [**Hospital 100**] Rehab for "altered mental status". . The pt originally underwent an elective EGD to evaluate persistent dysphagia (negative for stricture or malignancy). He became hypoxic with oxygen sat in the 80's following procedure. Pt was subsequently intubated for hypercarbic respiratory failure of unclear etiology, unable to wean from vent and trach/ PEG placed. He also had evidence of respiratory muscle weakness with NIFs around -6. . Pt has undergone extensive w/u for neuromuscular dysfunction which included: -Negative head CT, c-cpine CT -EEG: diffuse slowing in delta range and intermediate frontal sharp complexes -EMG 1: Moderately severe sensorimotor axonal polyneuropathy with concomitant median neuropathy at left wrist. -EMG 2: suggestive of mild to moderate myopathy process affecting proximal muscles in the upper/lower extremities. not suggestive of generalized disorder of motor neurons (as seen in ALS). . Labwork included: -RPR negative. CSF: wbc 0, rbc 1600 negative for crypto, VDRL, HSV Enterovirus negative. -Acetylcholine receptor Ab nl -SPEP: polyclonal c/w inflammation -Neuron specific enolase 21.2 (nl 0-30) (released in neuroblastoma and small cell lung cancer) -fat pad bx - negative for amyloid -TSH: 2.2; ACE 11; iron studies nl -Heavy metal screen negative . While in the MICU, patient was weaned off to trach mask and had a stable respiratory course. He was found to have chronic osteomyelitis of his sacrum secondary to stage 4 sacral ulcer which probed to bone, confirmed by bone scan [**9-18**]. He was started on zosyn and vanco for broad antibiotic coverage. Platics took patient to the OR for debridement on [**9-14**]. . From a neurologic standpoint, he was intially able to squeeze right hand, close eyes, and open mouth. His mental status was thought possibly due to overall picture of rapid neurologic decline. He was continued on a fentanyl patch but his neurontin, morphine, and ativan were held. Without improvement, morphine was once again added for comfort. Neurology consulted, and repetitive stimulation negative for myasthenia [**Last Name (un) 2902**] or [**Location (un) **] [**Location (un) **] syndrome. A trial of dantrolene was given for possible NMS but no response, EMG showed polyneuropathy and polymyopathy. Sinemet started for possiblity of Parkinson's. The pt was then transferred to a general medicine floor and ID was consulted for fevers- rec fungal work-up and anti-fungal therapy started. Pt also found to have B/L UE DVTs, started on Lovenox for anti-coagulation. Pt also had runst of NSVTs, evaluated by cardiology. . Surgery was consulted for diagnostic muscle biopsy given persistent rigidity. He was taken to the OR for bx of L biceps brachi. He had an episode of hemoptysis during the procedure, about 300 cc of blood. Thoracics was consulted, underwent intra-operative bronch and washings. They did not localize a source of bleed. The patient was then transferred to MICU for further eval and observation. . Currently, patient is unresponsive to verbal stimuli, does not follow commands. He does respond to movement of his extremities with grimaces and fights against manual opening of his eyes. Past Medical History: Hypercarbic respiratory failure (s/p trach/PEG) GERD HOCM DDI pacer CAD prostate cancer (s/p brachytherapy -[**2154**]) Dysphasia/Achalasia/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 36646**] HTN Gout Glaucoma Anemia AFib Hx SVT Depression Social History: Used to live alone with frequent aid of son. In [**Name2 (NI) 116**]/[**Month (only) **] was able to ambulate, pay own bills, attend church, talk about current events. Family History: 3 brothers with prostate cancer Physical Exam: PE: 96.8/ 66/ 101/46/ 99% saturation/ rr 15 GEN: not responsive to questions or commands. Trached. + spontaneous movement in all extremities w/ occasional grimacing HEENT: atraumatic, constricted pupils, anicteric, CV: + 3/6 systolic ejection murmur LUNGS: coarse BS B/L ABD: distended, soft, hypoactive BS EXT: + muscle rigidity in UE, R/L, with +cogwheeling. + tremor in RUE. No [**Location (un) **] NEURO: not responsive to voices/ commands Pertinent Results: [**2159-9-13**] 04:15PM BLOOD WBC-13.0*# RBC-3.60* Hgb-10.3*# Hct-30.7* MCV-85 MCH-28.5 MCHC-33.5 RDW-17.8* Plt Ct-469*# [**2159-9-13**] 04:15PM BLOOD Neuts-83.0* Lymphs-10.3* Monos-4.0 Eos-2.5 Baso-0.2 [**2159-9-13**] 04:15PM BLOOD PT-15.0* PTT-28.1 INR(PT)-1.3* [**2159-9-13**] 04:15PM BLOOD Glucose-120* UreaN-26* Creat-0.8 Na-139 K-4.4 Cl-102 HCO3-29 AnGap-12 [**2159-9-14**] 04:30AM BLOOD Calcium-8.2* Phos-4.8* Mg-2.5 [**2159-9-16**] 03:45AM BLOOD ALT-40 AST-44* LD(LDH)-254* AlkPhos-147* TotBili-0.6 [**2159-9-14**] 04:30AM BLOOD CK(CPK)-103 [**2159-9-16**] 03:45AM BLOOD ESR-115* [**2159-9-13**] 04:15PM BLOOD Iron-32* [**2159-9-13**] 04:15PM BLOOD calTIBC-185* Ferritn-574* TRF-142* [**2159-9-21**] 06:15AM BLOOD CRP-104.4* [**2159-9-13**] 11:38PM BLOOD Type-[**Last Name (un) **] pO2-31* pCO2-38 pH-7.47* calTCO2-28 Base XS-2 . . CXR [**2159-9-14**]: Cardiac silhouette is moderately to severely enlarged. Relatively mild perihilar opacification in both lungs is consistent with edema but there are two regions of more dense focal consolidation, the suprahilar right lung and the lateral left lung base, suggestive of multifocal pneumonia. Small bilateral pleural effusion is present and there may well be pericardial fluid. Transvenous pacer leads follow their expected courses to the right atrium and floor of the right ventricle. A second ventricular lead has a large loop in the region of the tricuspid valve, but its tip projects along the anticipated location of the floor of the right ventricle. There is no pneumothorax. The tracheostomy tube is slightly canted. Clinical evaluation is recommended to confirm appropriate placement. . HEAD CT [**2159-9-16**]: 1. Atrophy. 2. Prominence of the ventricles probably not out of proportion to the degree of overall atrophy, but the possibility of communicating hydrocephalus cannot be entirely excluded. 3. Areas of white matter hypodensity, most suggestive of chronic small vessel ischemic disease. 4. Vascular calcifications. 5. Fluid throughout the right mastoid air cells, which could be seen in mastoiditis. . EMG [**2159-9-16**]: Abnormal study. There is electrophysiologic evidence for a generalized myopathic process with minimal denervating features. In addition, the findings are suggestive of a mild-to-moderate, generalized sensorimotor polyneuropathy with predominantly axonal features. There is no evidence for a pre- or post- synaptic disorder of neuromuscular transmission based on the repetitive stimulation studies performed. The reduced activation on needle electromyography also suggests a central component to the patient's weakness; however, this cannot be adequately assessed given the patient's reduced level of consciousness throughout the study. . US DOPPLER [**2159-9-20**]: Bilateral upper extremity DVTs as described. . ECHO [**2159-9-21**]: These findings are consistent with hypertrophic non-obstructive cardiomyopathy (HCM). Cardiac amyloidosis should also be considered. . MUSCLE BX [**2159-9-24**]: PRELIMINARY RESULTS: PRELIMINARY DIAGNOSIS: LEFT BICEPS MUSCLE BIOPSY (formalin-fixed tissue only): Scattered nuclear knots and scattered small, angulated myofibers, suggestive of denervation atrophy. Moderate variation in myofiber size. Increased internalized nuclei. No significant myofiber degeneration, regeneration, or myophagocytosis. No demonstrable endomysial infiltrating process. No significant lymphocytic inflammation. . CHEST CT [**2069-9-25**]: 1. Airspace consolidation in right upper and right lower lobes, concerning for pneumonia. Differential diagnosis includes multifocal aspiration and pulmonary hemorrhage. 2. Large left and small right pleural effusions. 3. Over-distention of fluid filled tracheostomy tube cuff; opacification of airway proximal to tube level, presumably due to retained secretions proximal to this level. Correlation with results of recent bronchoscopy suggested. 4. Cardiomegaly and moderate pericardial effusion. 5. Slight narrowing of left lower lobe bronchus, difficult to assess in the setting of left lower lobe atelectasis adjacent to a large effusion. Correlation with recent bronchoscopy results recommended. 6. Left renal hilar fluid density structure, which may be due to parapelvic cyst or hydronephrosis. Renal ultrasound is recommended for further characterization. Brief Hospital Course: # Altered mental status/rigidity: Unknown etiology currently. Has had extensive neurologic and infectious workup. Ddx now includes amyloidosis, sarcoidosis, tentanus, parkinson's. Neurology was following. Please follow up on final results on muscle biopsy. Limit sedating medications . # Polyneuropathy/myopathy/rigidity: Unclear cause currently but EMG showed diffuse sensorimotor polyneuropathy as well as myopathy. Many etiologies ruled out on prior work ups. CJD or other prion diseases possible given rapidly progressive course. [**Location (un) **] [**Location (un) **] syndrome possible, but repetitive stim test negative. Neurology considered tetanus but ID did not feel course was consistent with Tetanus infection. ECHO findings suggestive of infiltrative cardiomyopathy without vegetations. Please follow up on results of muscle biopsy, particulary to look for evidence of sarcoid and/or amyloidosis. *** Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) 557**] from Neurology as an outpatient (Phone: [**Telephone/Fax (1) 558**]). . # Respiratory Failure: Most likely secondary to respiratory muscle weakness related to pt's neuromuscular disorder. Possibly secondary to amyloidosis or sarcoidosis. Pending work up as above. Pt is oxygenating well on trach mask. Continue albuterol/atrovent nebs. Continue suctioning prn. . # Hemoptysis: episode occurred during muscle biopsy, bronchoscopy done inter-op non-revealing of source. Diff dx includes trauma associated with trach or mass, although intra-operative bronchoscopy was unrevealing. He did not have any subsequent episodes of hemoptysis. His hematocrit remained stable. PE was on the differential but he could not get a CTA due to poor access. He is put on heparin gtt for b/l upper-extremity DVTs. . # UE DVT: UE ultrasound showed bilateral DVTs. Currently therapeutic on heparin gtt at PTT goal of 50-80. He will need to be transitioned to Coumadin as an outpatient with target INR [**1-12**]. . # ID: Pt has history of chronic osteolmyelitis, currently being treated with Vanc and Zosyn. Started on Fluconazole for fungal positive PICC cath tip. Surveillance blood cx have been negative to date. Sputum cultures from [**9-21**] +MRSA. Continue treating pneumonia and chronic osteomyelitis for three weeks total, start date [**2159-9-18**], end date [**2159-10-9**]. After three weeks, switch patient to chronic oral antibiotics: dicloxicillin 500 qid and Cipro 500 [**Hospital1 **]. Continue fluconazole for possible fungemia for 2 weeks, start date [**2159-9-20**], end date [**2159-10-4**]. Follow up blood cultures for beta-glucan, Galactomannan. *** Please follow up with Dr. [**Last Name (STitle) 3394**] at [**Hospital **] clinic on [**2159-10-23**] at 9AM ([**Telephone/Fax (1) 457**]). . # Ventricular tachycardia - patient has had multiple episodes of NSVT on telemetry, hemodynamically stable, asymptomatic. ECHO obtained [**9-21**] suggested HOCM. DDI pacer was placed for history of SVT; he is not an ICD candidate. EP interrogated pacemaker but could not determine whether VT or SVT as atrial lead was shut off. Pacer settings now changed to overdrive suppress SVT. Continue metoprolol 100 mg TID and aggressive lyte repletion . # Sacral decubitus ulcer: Debrided by plastics and was followed by wound care. . # Htn: cont metoprolol for now . # Anemia: Baseline hct 30-33 during this admission. Iron studies [**Location (un) 381**] iron and elevated ferritin, consistent with anemia of chronic disease. . # Glaucoma: No active issues. Cont timolol, latanoprost drops. ID also notes that patient should have an outpatient eye exam to rule out [**Female First Name (un) **] seeding in the eyes since his PICC culture grew out [**Female First Name (un) **]. . # FEN: Tube feeds. Cont aggressive electrolyte repletion, IVF as necessary for pressure support . # PPX- pneumoboots, PPI, pain control, bowel regimen. . # CODE- FULL, per primary team, confirmed by family meeting [**9-20**]. . # Dispo- pending stability, possibly call out to medicine floor in am. . # Comm: HCP: Dr. [**First Name8 (NamePattern2) 2174**] [**Known lastname 1968**] [**Telephone/Fax (3) 36647**] Medications on Admission: Diamox 250mg qod Ascorbic acid 250mg qd Aspirin 325mg qd Buproprion 75mg [**Hospital1 **] Ceftazidime 1gm [**Hospital1 **] Peridex tid Coenzyme q10 100mg qd Docusate Esomeprazole 40mg qd Fentanyl 100 mcg q72h Ferrous sulfate 220mg qd Lasix 100mg [**Hospital1 **] Gabapentin 200mg [**Hospital1 **] Latanoprost 0.005 opth solution Lorazepam 1mg q8h Lopressor 75mg tid morphine 5mg q4h sl Miralax Flagyl 500mg tid Lovenox 40mg qd Timolol ou [**Hospital1 **] Vancomycin 1000mg qd Zinc 200mg qd Albuterol prn bisacodyl epinephrine prn atrovent prn morphine prn ativan prn tylenol zofran prn Discharge Medications: 1. Vancomycin HCl 750 mg IV Q 12H 2. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 3. Fluconazole 200 mg IV Q24H 4. Piperacillin-Tazobactam Na 4.5 gm IV Q8H 5. Morphine Sulfate 1-2 mg IV Q4H:PRN hold for sedation or RR<8 6. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day). 11. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. 12. Docusate Sodium 150 mg/15 mL Liquid Sig: One [**Age over 90 1230**]y (150) mg PO BID (2 times a day). mg 13. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 14. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic [**Hospital1 **] (2 times a day). 15. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 16. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 17. Insulin Lispro (Human) 100 unit/mL Solution Sig: AS PER SLIDING SCALE AS PER SLIDING SCALE Subcutaneous ASDIR (AS DIRECTED). 18. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: AS PER SLIDING SCALE AS PER SLIDING SCALE Intravenous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Altered mental status of unknown etiology Myopathy Polyneuropathy Fungemia Pneumonia Sacral ulcer Sacral osteomyelitis Hypercarbic respiratory failure (s/p trach/PEG) Hemoptysis GERD HOCM DDI pacer CAD Prostate cancer (s/p brachytherapy -[**2154**]) Dysphasia/Achalasia/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 36646**] HTN Gout Glaucoma Anemia AFib Hx SVT Depression Discharge Condition: Hemodynamically stable, afebrile. Discharge Instructions: Please take all medication as prescribed. Keep all appointments listed below. If you have any chest pain or shortness of breath, please seek medical attention immediately. If you have fever please call your doctor. In general, call your doctor if you have any medical questions or concerns. Followup Instructions: PRIMARY CARE DOCTOR: PCP: [**Name10 (NameIs) 26849**], [**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 26850**] Please follow up with your primary care doctor. Appointment is set [**2159-10-5**] at 11:45am. NEUROLOGY: Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) 557**] from Neurology ([**Telephone/Fax (1) 36648**]. Appointment is set for [**2159-10-2**] at 9AM. Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2159-10-2**] 9:00 --------------- INFECTIOUS DISEASE: Please follow up with Dr. [**Last Name (STitle) 3394**] at [**Hospital **] clinic on [**2159-10-23**] at 9AM ([**Telephone/Fax (1) 457**]). Completed by:[**2159-9-28**]

[ "276.0", "787.2", "453.8", "428.0", "414.01", "518.83", "V10.46", "285.29", "365.9", "482.41", "276.4", "427.31", "401.9", "425.1", "117.9", "786.3", "730.18", "707.03", "427.1", "310.9", "358.8" ]

icd9cm

[ [ [] ] ]

[ "83.21", "96.6", "86.28", "96.72", "33.21", "38.93" ]

icd9pcs

[ [ [] ] ]

15568, 15634

9049, 13248

282, 359

16059, 16095

4708, 9026

16438, 17218

4192, 4225

13884, 15545

15655, 16038

13274, 13861

16119, 16415

4240, 4689

221, 244

387, 3717

3739, 3991

4007, 4176

83,343

185,237

34945

Discharge summary

report

Admission Date: [**2151-5-31**] Discharge Date: [**2151-6-8**] Date of Birth: [**2068-6-13**] Sex: F Service: SURGERY Allergies: Tetracycline Analogues / Scopolamine / Iodine; Iodine Containing / Terramycin Attending:[**First Name3 (LF) 3376**] Chief Complaint: Presence of colostomy after anal stenosis which has been repaired. Major Surgical or Invasive Procedure: Laparotomy and Colostomy Takedown History of Present Illness: s/p advancement flap reconstruction of anal stenosis after WLE for perineal Paget's. Colostomy still in place. has had knee surgery and is having significant pain in right knee. This pain is really limiting her activity and ambulation. Preop'ed and consented as an outpatient for colostomy reversal Past Medical History: PMH: elevated lipids, depression, GERD, melanoma, sjogren's, asthma, diverting sigmoid colostomy for anal stricture s/p vulvectomy for pagets with adv flaps PSH: hysterectomy, cervical fusion, laminectomy, fusion od 5 fingers, melanoma excised right thigh, right pretibial SCC excises, right forearm SCC that needs to be excised, hemorrhoidectomy, arthritis, Sjogren's disease. Social History: Works at home as a writer. She writes copy for Democratic politicians as well as writes short stories, poetry, music and historical videos. Family History: Non Contributory Physical Exam: General: Behavior Appropriate, cooperative with care, no apparent distress Neuro: A&OX3 Cardiac: RRR, NSR on telementry, HR=91 Pulmonary: No increased work of breathing, no respiratory distress, no cough Abd: appears slightly round, c/o nauseaX1, BMX1 Lower Extremity: Pt. abulating in hallway with physical therapy, tolerates 40 ft of ambulation, +2 lower extremity edema. Pertinent Results: ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF 80%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The right ventricular cavity is dilated with depressed free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: hyperdynamic left ventricle with mild resting left ventricular outflow tract obstruction; dilated hypocontractile right ventricle with moderate-to-severe tricuspid regurgitation [**2151-6-6**] 06:20AM BLOOD WBC-10.3 RBC-3.50* Hgb-10.4* Hct-31.8* MCV-91 MCH-29.7 MCHC-32.7 RDW-13.1 Plt Ct-419 [**2151-6-5**] 05:24AM BLOOD WBC-9.0 RBC-2.91* Hgb-8.9* Hct-26.6* MCV-92 MCH-30.7 MCHC-33.6 RDW-12.9 Plt Ct-355 [**2151-6-4**] 03:11PM BLOOD Hct-27.8* [**2151-6-4**] 04:34AM BLOOD WBC-8.8 RBC-2.86* Hgb-9.1* Hct-26.1* MCV-91 MCH-31.8 MCHC-34.9 RDW-12.6 Plt Ct-281 [**2151-6-1**] 06:55AM BLOOD WBC-7.8 RBC-3.27* Hgb-10.3* Hct-31.2* MCV-95 MCH-31.6 MCHC-33.2 RDW-12.5 Plt Ct-222 [**2151-5-31**] 03:14PM BLOOD Hct-32.3* [**2151-6-4**] 04:34AM BLOOD Neuts-75.4* Lymphs-15.2* Monos-6.2 Eos-2.9 Baso-0.2 [**2151-6-6**] 06:20AM BLOOD Plt Ct-419 [**2151-6-5**] 05:24AM BLOOD Plt Ct-355 [**2151-6-5**] 05:24AM BLOOD PT-13.0 PTT-24.6 INR(PT)-1.1 [**2151-6-4**] 04:34AM BLOOD Plt Ct-281 [**2151-6-4**] 04:34AM BLOOD PT-12.7 PTT-25.2 INR(PT)-1.1 [**2151-6-6**] 06:20AM BLOOD Glucose-107* UreaN-21* Creat-1.1 Na-140 K-4.5 Cl-104 HCO3-23 AnGap-18 [**2151-6-5**] 05:24AM BLOOD Glucose-134* UreaN-19 Creat-1.1 Na-140 K-4.3 Cl-109* HCO3-23 AnGap-12 [**2151-6-4**] 03:11PM BLOOD Glucose-121* UreaN-17 Creat-1.0 Na-142 K-3.6 Cl-107 HCO3-24 AnGap-15 [**2151-6-4**] 02:02AM BLOOD Glucose-120* UreaN-15 Creat-1.1 Na-141 K-3.6 Cl-106 HCO3-24 AnGap-15 [**2151-6-4**] 03:11PM BLOOD CK(CPK)-452* [**2151-6-4**] 04:34AM BLOOD CK(CPK)-623* [**2151-6-4**] 03:11PM BLOOD CK-MB-18* MB Indx-4.0 cTropnT-0.18* [**2151-6-4**] 04:34AM BLOOD CK-MB-24* MB Indx-3.9 cTropnT-0.22* [**2151-6-6**] 06:20AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0 [**2151-6-5**] 05:24AM BLOOD Calcium-8.2* Phos-2.1* Mg-2.1 [**2151-6-4**] 03:11PM BLOOD Calcium-9.0 Phos-2.4* Mg-2.3 [**2151-6-4**] 02:02AM BLOOD Calcium-8.8 Phos-1.5*# Mg-1.8 Brief Hospital Course: The patient was admitted to the inpatient [**Hospital1 **] after a colostomy takedown to reverse the patient's colostomy originally placed after repair of rectal stricture. The patient tolerated this procedure well, however pain management for this patient was a challenge and the acute pain service was consulted. The patient's pain was managed with PCA narcotics as well as an epidural. The patient ambulated the [**Hospital1 **] postoperatively and pain was controlled on PO medications after discontinuing the epidural and PCA however return of bowel function was prolonged. The patient had intermittent nausea and a small amount of emesis prior to passing gas. On POD 4 after her colostomy takedown, the patient was noted to be tachycardic to the 160's on a VS check. At that time, her SBP was in the 140's and she was sating well. EKG was performed and showed Afib with RVR. She was mildly symptomatic with some slight dyspnea and some palpitations. She received multiple doses of IV metoprolol with transient improvement in HR to 80s and drop in BP to 108. She then received IV diltiazem with HR improvement to the 80s and SBP to the 120s. During her ICU course, her regimen of PO diltiazem was adjusted. She was also started on PO metoprolol. Initially, when given PO metoprolol and PO diltiazem, ECG showed atrial flutter with 4:1 conduction. Doses were adjusted, and she eventually converted to sinus rhythm. While in the ICU, the patient was also diuresed with IV Lasix, given signs of fluid overload on exam. There was some concern for possible DVT, as well, given her unilateral LE swelling. However, she had recently had a negative LENI performed at [**Hospital1 2025**]. She was started on aspirin while she was in the ICU. Anticoagulation with Coumadin was also discussed and should be further addressed by the patient's PCP. After this ICU stay, the patient was transferred back to the inpatient [**Hospital1 **] for further monitoring. The patient did not have any recurrence of rapid atrial fibrillation and remained rate controled on the regimen of Dilitiazem and Lopressor. The patient was started on an aggressive bowel regimen and was able to have a bowel movement prior to discharge. The patient should continue therapy with anal dilation device after discharge. Physical therapy evaluated the patient during her inpatient stay and recommended a rehabilitation facility to increase the patient's strength and maintain safety. However, the patient had done so well with physical therapy she was able to return home with the assistance of physical therapy. Medications on Admission: Pravastatin 40 daily Asa 81 Fluoxetine 20 Ativan 0.5 daily Prilosec 20 daily Tylenol Lisinopril 10 daily HCTZ 12.5 daily Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Saliva Substitution Combo No.2 Solution Sig: Thirty (30) ML Mucous membrane TID (3 times a day) as needed for dry mouth. 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-23**] Drops Ophthalmic PRN (as needed) as needed for dry eye. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed for wheeze, sob. 5. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 units Injection TID (3 times a day). 7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO twice a day as needed for constipation. 15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Presence of colostomy after anal stenosis which has been repaired. 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 your colostomy takedown. During this procedure your rectum was examined becaise of your anal stenosis whic has been repaired. You tolerated this procedure well and have tolerated a regular diet. You were able to have a bowel movement prior to leaving the hospital. It is important that you continue to take Miralax daily as well as use the anal dilation kit to ensure that your anal stenosis continues to resolve. You will be admitted to a rehabilitation facility as your family will not be able to provide care for the next few days and you have required increased help with walking which will be provided by physical therapy at this facility. It is important that you monitor your bowel function closely. Please monitor the number and consistancy of your stool. If you go for more than 2 days without having a bowel movement please call the office, if you develop nausea, abdominal distension, increased abdominal pain, vomiting, or inability to tolerate food and liquids please call the office or seek medical attention. Continue to take adequate amounts of food through small frequent meals and keep yourself adequately hydrated. Your hospital stay was complicated by an occurance of atrial fibrillation which caused you to be admitted to the intensive care unit for one day. You have been started on a new medication fo rthis condiiton call diltiazem. Please take this medication exactly a prescribed. It is important that you make a follow-up appointment with your outpatient cardiologist to discuss further managment of this condition including the possiblity of the need to thin your blood to prevent blood clots from this arrythmia. Youhave an abdominal incision which may be left open to air. You may cover this area with a dry dterile dressing if there is a [**Last Name (un) **] amount of clear/pink drainage from the site. Please watch for any signs or symptoms of infection and call the office if they are noticed including: pink/reddness at the incision line, green/white drainage at the incision line, fever, or foul odor from wound. Call or go to the emergency if severe. Followup Instructions: You will need to follow up with your cardiologist after discharge. Please call to make an appointment. You should also discuss starting coumadin for anticoagulation for your atrial fibrillation with your Cardiologist.

[ "401.9", "710.2", "427.31", "V55.3", "V10.82", "493.90" ]

icd9cm

[ [ [] ] ]

[ "46.52" ]

icd9pcs

[ [ [] ] ]

8628, 8677

4483, 7067

403, 439

8792, 8792

1774, 4460

11102, 11325

1346, 1364

7240, 8605

8698, 8771

7093, 7217

8943, 11079

1379, 1755

297, 365

467, 770

8807, 8919

792, 1172

1188, 1330

3,078

117,694

21246

Discharge summary

report

Admission Date: [**2176-1-5**] Discharge Date: [**2176-1-16**] Date of Birth: [**2128-2-22**] Sex: M Service: MEDICINE Allergies: Vitamin K Attending:[**First Name3 (LF) 943**] Chief Complaint: septic shock Major Surgical or Invasive Procedure: paracentesis [**1-14**] History of Present Illness: HPI: 47 y.o. man with ESRD on HD, Hep C/ETOH cirrhosis, Asthma, recently discharged [**2175-12-19**] after being treated for enterobacter pneumonia with hypoxic resp distress, which was complicated by allergic rxn to certain HD filters, who was found on the floor by his wife on the evening of [**1-2**]. He was arousable and responsive, so she did not move him. On the AM of [**1-3**], the patient's wife again tried to arouse him from the floor, but this time, he could not be aroused. She called 911 and he was admitted to [**Hospital3 2568**] ICU. . At [**Hospital3 2568**], He was hypotensive (60/30) and started on levophed, dopamine, and vasopressin to maintain his BP. He also was hypoglycemic and received D50. Blood cultures (1/2 bottles on [**1-3**], then 2/4 bottles on [**1-4**]) grew GPC in pairs and chains. He also had a paracentesis which was consistent with SBP based on WBC but did not grow any bacteria. He was started on Vanco/Zosyn, which was changed to Dapto/zosyn out of concern for VRE, but then . He has a tunnelled HD line which was a potential source but it was felt that SBP was the more likely source. His INR was initially 11, which came down to 5 after FFP. B/c of the coagulopathy, it was felt unsafe to take out the HD catheter. He had a left IJ line placed. Past Medical History: - Cirrhosis [**2-17**] untreated HCV, alcohol abuse, not on transplant list - Esophageal varices s/p [**12-20**] banding - h/o SBP - ESRD on HD T/Th/Sat (from ATN, HRS) - Anemia of chronic disease - Asthma - Depression - Schizotypal personality disorder - Left LE abscess in [**9-/2175**] at [**Hospital3 2568**], growing enterobacter Social History: - Personal: Lives with wife. - Substance abuse: Denies current tobacco, ETOH, or drug use. Per [**Hospital3 2568**], he may not be reliable and his wife is not certain since he is alone much of the day. - Heavy ETOH use in past, prior IV drug use in [**2148**], but last reportedly [**4-21**]. Former smoker. Family History: - No history of liver disease. - Maternal aunt with DM Physical Exam: VS: T 96.1 BP 75/61, HR 87, R 25, 100% 2L Gen: no apparent distress HEENT: icteric sclerae, dry MMM, Neck: no JVD Lungs: bibasilar crackles Heart: RRR nl S1S2, no m/r/g Abd: +BS, mod distention, soft, mild TTP diffusely. No rebound or guarding. Ext: 2+ dependent edema up to thighs and sacrum Neuro: AAO x 3, conversant. strength 5/5, + asterixis Pertinent Results: [**2176-1-5**] 07:33PM BLOOD WBC-19.6*# RBC-2.65* Hgb-9.6* Hct-28.9* MCV-109* MCH-36.1* MCHC-33.1 RDW-25.7* Plt Ct-31*# [**2176-1-9**] 03:35AM BLOOD WBC-11.1* RBC-2.64* Hgb-9.7* Hct-29.5* MCV-112* MCH-36.7* MCHC-32.9 RDW-24.5* Plt Ct-82* [**2176-1-14**] 05:00AM BLOOD WBC-19.49* Hct-33.0* Plt Ct-125* [**2176-1-5**] 07:33PM BLOOD Neuts-94* Bands-0 Lymphs-4* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-3* [**2176-1-14**] 05:00AM BLOOD Neuts-84.2* Bands-0 Lymphs-7.0* Monos-8.4 Eos-0.3 Baso-0.1 [**2176-1-5**] 07:33PM BLOOD PT-46.1* PTT-62.1* INR(PT)-5.2* [**2176-1-8**] 03:23AM BLOOD PT-24.8* PTT-49.9* INR(PT)-2.4* [**2176-1-10**] 03:33AM BLOOD PT-30.8* PTT-55.8* INR(PT)-3.2* [**2176-1-14**] 05:00AM BLOOD PT-36.2* PTT-65.1* INR(PT)-3.8* [**2176-1-5**] 07:33PM BLOOD FDP-80-160* [**2176-1-7**] 03:15AM BLOOD Fibrino-89* [**2176-1-5**] 07:33PM BLOOD Glucose-69* UreaN-45* Creat-5.8*# Na-135 K-4.4 Cl-100 HCO3-22 AnGap-17 [**2176-1-6**] 05:11AM BLOOD Glucose-128* UreaN-49* Creat-5.4* Na-133 K-4.4 Cl-99 HCO3-22 AnGap-16 [**2176-1-11**] 06:15AM BLOOD Glucose-98 UreaN-40* Creat-4.2*# Na-133 K-4.4 Cl-99 HCO3-24 AnGap-14 [**2176-1-14**] 05:00AM BLOOD Glucose-56* UreaN-41* Creat-4.5* Na-136 K-5.0 Cl-98 HCO3-20* AnGap-23* [**2176-1-5**] 07:33PM BLOOD ALT-303* AST-1155* LD(LDH)-609* CK(CPK)-59 AlkPhos-132* TotBili-12.4* [**2176-1-11**] 06:15AM BLOOD ALT-57* AST-67* LD(LDH)-421* AlkPhos-158* TotBili-21.9* [**2176-1-14**] 05:00AM BLOOD ALT-38 AST-50* LD(LDH)-398* AlkPhos-145* TotBili-26.3* [**2176-1-5**] 07:33PM BLOOD Albumin-2.2* Calcium-7.9* Phos-6.5* Mg-2.0 [**2176-1-15**] 07:24AM BLOOD Calcium-9.4 Phos-9.2* Mg-2.4 [**2176-1-10**] 03:33AM BLOOD calTIBC-105* Ferritn-511* TRF-81* . OSH u/s abdomen: portal vein thrombosis . [**1-3**]: 4/4 bottles with GPC in pairs/chains -> VRE [**1-4**]: 2/4 bottles with CPC in pairs/chains -> VRE [**1-5**]: [**2-17**] - NGTD . Paracentesis at [**Hospital3 2568**]: RBC 14,000 WBC 500 Poly's 97% (#447 after correction for RBCs) Albumin < 1 Gram stain: no polys, no organnisms. Culture VRE 1. ENTEROCOCCUS Target Route Dose RX AB Cost M.I.C. IQ ------ ----- ------------------ ------ -- ------ --------- ------ AMPICILLIN R >8 LEVOFLOXACIN SERUM X R >4 LINEZOLID SERUM X S 1 VANCOMYCIN SERUM X R >16 . US [**2176-1-6**]: IMPRESSION: 1. Shrunken and nodular liver consistent with cirrhosis as seen previously. Large amount of ascites. Gallbladder wall thickening likely secondary hepatic disease. 2. Splenomegaly. 3. Patent main portal vein with hepatopetal flow. Patent hepatic vasculature with appropriate waveforms and directional flow. . Echo [**2176-1-6**]: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets appear structurally normal with good leaflet excursion. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is no pericardial effusion. Normal estimated pulmonary artery pressures. IMPRESSION: Suboptimal image quality. Focused views. Preserved global left ventricular systolic function. Compared with the prior study (images reviewed) of [**2175-12-4**], left ventricular systolic function remains preserved. . Echo [**1-11**]-The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The mitral valve leaflets are structurally normal. A catheter tip appears to be present in the right atrium near the caval junction. No Doppler images were obtained. No vegetation seen but cannot exclude. Compared with the prior study (images reviewed) of [**2176-1-6**], there is no definite change. . Brief Hospital Course: 47 y.o. man with Hep C/ETOH cirrhosis, ESRD/HD p/w septic shock, subsequently foudn to have VRE bacteremia due to presumed SBP. . # Septic shock: BP was 60/30 upon admission to OSH. He initially required 3 pressors to keep his MAP > 65. WBC of 19. Patient was subsequently weaned off Levophed/Vasopresin/Dopamin. HIs lactate initially was 5.6 and trended down. The ascites fluid and the blood cultures confirmed VRE as a source. Patient had his right subclavian tunelled line removed by transplant surgery on [**1-7**]. He had a L IJ placed at OSH on [**1-5**]. He had a L IJ/SCL tunelled line placed by IR on [**1-10**]. His blood cultures remained negative at [**Hospital1 18**]. ([**2092-1-4**]). He was continued on Daptomycin - started on [**1-5**] @ OSH - with instructions to continue for 6 weeks and followed up by ID. Patient was also continued on 5 days of Ceftriaxone but there was no evidence of other gram negatives. Patient was c/o to the floor on [**1-10**]. His SBP remained in the 90-110 range, he was not tachycardic and was afebrile x 3 days at that point. From [**Date range (1) 56230**] the patient remained normotensive and afebrile while continuing daptomycin. On [**1-14**] the patient was found to be hypotensive 74/40, with increased O2 requirement, dyspnea, Leukocytosis, decreased blood glucose, and increased somnolence. CXR showed decreased lung volumes and increased atelectasis. The patient expressed his desire to not undergo aggressive measures, including, transfer to MICU, or use of pressors, and wished to be made DNR/DNI, without any escalation of care. The patient requested home hospice, however, given his acuity of illness it was believed his wife would be unable to care for him. Given his dyspnea, the patient underwent a therapeutic paracentesis with removal of 3.5L. He reported increased comfort after the paracentesis. On [**1-15**] the patient's systolic blood pressure dropped to high 60's to 70's. He was hypothermic with axillary temp 93.7, and was increasingly somnolent. The patient passed away at 4am on [**2176-1-16**] . # ESLD - Patient was not a transplant candidate due to nonadherence to his follow ups and social situation. His bilirubin was considerably increased during this admission, reaching a high of . He was followed by liver service. His INR also continued to rise after transfer from MICU to the floor. The patient was continued on lactulose and rifaxamin. . # ESRD - on HD, Tues, Thurs, Sat. Patient HD dependent. He had his R SCL tunelled catheter removed on [**1-7**], and it was replaced by a left subclavian temporary dialysis catheter. Plans for reinserting a permanent dialysis catheter were postponed by continued increasing INR, refractory to oral vitamin K administration. . # Portal vein thrombosis: New since last u/s done here in 9/[**2175**]. However, US done at [**Hospital1 18**] did not confirm it. . # DIC - patient with elevated INR, with acute on chronic component, also low platelets at baseline and transiently low fibrinogen suspicious for DIC. He received 1 unit of cryoprecipitate in the MICU. Medications on Admission: 1. Rifaximin 400 mg PO TID 2. Nadolol 20 mg PO Daily 3. Lactulose 60 ML PO qid 4. B Complex-Vitamin C-Folic Acid - 1 cap daily 5. Thiamine 100 mg po daily 6. Folic Acid 1 mg po daily 7. Sevelamer 1600 mg PO TID W/MEALS 8. Protonix 40mg daily 9. Fluticasone-Salmeterol 250-50 1 puff [**Hospital1 **] 10. Albuterol 1 puff Q6H 11. Atrovent 1 puff Q4H 12. Dilaudid 1mg PO q6H prn 13. Sucralfate 1gm po QID . Meds on transfer: 1. Zosyn 2.25gm Q8H 2. Lactulose QID 3. Insulin sliding scale 4. Levophed gtt 5. Vasopressin gtt Discharge Disposition: Expired Discharge Diagnosis: Septic Shock End Stage Liver Disease Discharge Condition: expired

[ "286.6", "070.44", "785.52", "567.23", "995.92", "571.2", "285.21", "585.6", "038.8", "301.22", "493.90", "V09.80" ]

icd9cm

[ [ [] ] ]

[ "99.05", "39.95", "54.91", "99.07", "38.95" ]

icd9pcs

[ [ [] ] ]

10350, 10359

6669, 9780

281, 306

10439, 10449

2771, 6646

2331, 2388

10380, 10418

9806, 10210

2403, 2752

229, 243

334, 1629

1651, 1988

2004, 2315

10228, 10327

13,161

121,249

46953

Discharge summary

report

Admission Date: [**2173-11-23**] Discharge Date: [**2173-12-8**] Date of Birth: [**2095-6-24**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: confusion for several days. Major Surgical or Invasive Procedure: right craniotomy for resection of fronto-temporal tumor right epidural hematoma evacuation History of Present Illness: The patient is a 78 year old R-handed woman with hypercholsterolemia who was brought to the ED by her daughter for confusion. The patient's daugther noticed that she had been acting differently for the past 4 days. She forgot where she put things, did not pay attention to her mail, did not finish household tasks, etc. Prior to this she had been behaving normally, without any changes noted over the last weeks/months. The daughter has not noticed any changes in walking or and did not see clumsiness. The patient is able to tell that she has had difficulties concentrating and cannot think clearly. She is not alarmed by this at all and would like to go home. She denies any headache, nausea, vomiting, weakness, clumsiness, problems speaking, dizziness, double vision or blurry vision, numbness or tingling. During the interview she has a hard time remembering recent events, and is thinking slowly. ROS: Denies fevers or colds, but finished Z-pack today for URI; no change in weight, no night sweats; no palpitations, no ankle swelling; no BRBPR, abd pain, or hematemesis; no constipation; no dysuria or hematuria. Past Medical History: - hypercholesterolemia - recent URI - labile blood pressure - s/p cataract surgery - glaucoma - thyroid nodule, s/p resection 8 years ago - on schedule with mammograms Social History: -no tobacco; no alc -widowed; lives alone; daughter checks on her twice a day -walks without assistance -finished [**Male First Name (un) 1573**] college; worked for investment company Family History: N/C Physical Exam: PHYSICAL EXAM: VS: T 98.7 P70 BP 149/54 RR 16 sO2 96% RA GEN: NAD HEENT: MMM, anicteric sclerae; neck supple; no bruits PULM: CTA bilaterally COR: S1 S2 regular no murmur ABD: nl bs, soft, nt, nd EXT: No edema, pulses +/+ Neuro: MS: awake, alert, cooperative, oriented to place, time and person; attention intact (DOWbw), could not do MOYbw ([**Month (only) **]), language fluent, no dysarthria, registration [**4-8**]; recall [**3-11**]; naming intact; comprehension ok, able to follow 2 step commands; repetition intact; [**Location (un) 1131**] intact; writing intact. No apraxia. Able to generate list of 11 animals/minute, lost interest after 20 seconds. No neglect. CN: II: Pupils 3-->2 bilaterally; visual fields full to confrontation, no extinction to DSS. III, IV, VI: EOMI. No nystagmus. No ptosis. V: facial sensation intact to LT, pinprick and cold VII: facial musculature symmetrical when moving; mild flattening nasolabial folds on the L VIII: hearing intact to finger rubs IX, X: palate midline [**Doctor First Name 81**]: scm's and trap's intact XII: tongue midline, no fasciculations Motor: Normal bulk and tone. No tremor. Strength full throughout on formal testing except for deltoids 4+ [**Hospital1 **]; triceps 4+ [**Hospital1 **]; Hamstr 4L, 4+R. Very mild drift L-arm. Sensation: Intact to pinprick, cold, light touch, vibration and position; no extinction to DSS. Reflexes: [**Hospital1 **]/tri/[**Last Name (un) **]/patellar 2+ bilaterally; achilles 1+ bilaterally. Toes mute bilaterally. Coord: FNF intact bilaterally; heel to shin intact, symmetrical. [**Doctor First Name **] slightly better on R (patient L-handed) Gait: Romberg negative; gait normal, with good initiation. Unable to do tandem gait. Pertinent Results: [**2173-11-23**] GLUCOSE-143* UREA N-11 CREAT-0.7 SODIUM-139 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15 [**2173-11-23**] ALT(SGPT)-27 AST(SGOT)-34 [**2173-11-23**] CALCIUM-9.4 PHOSPHATE-2.5* MAGNESIUM-2.0 [**2173-11-23**] TSH-3.4 [**2173-11-23**] PHENYTOIN-24.0* [**2173-11-23**] WBC-7.4 RBC-4.31 HGB-12.5 HCT-36.7 MCV-85 MCH-29.1 MCHC-34.1 RDW-13.4 [**2173-11-23**] PT-13.6* PTT-28.8 INR(PT)-1.2 Brief Hospital Course: The patient is a 78-year-old female who was recently admitted to [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] from the ER with several days of confusion noted by a daughter. She presented with progressive confusion and left-sided hemiparesis. The patient was worked-up in the ER and was found to have a left-sided intracranial lesion consistent with a skull base meningioma. Patient electively taken to the OR after informed consent. Postoperatively she found to be awake, alert following commands and moving all extremeties. She had received some blood products and became fluid overloaded and was moved to the MICU. On Postop day 3 postoperative MRI was performed and showed persistent edema. Full resection with no intracranial complications. There was small subgaleal hematoma at that time. The patient was clinically doing well and was in the MICU. The patient developed overnight suddenly a change in mentation and was barely arousable with slightly dilated pupil on the right side, and progressive weakness on the left side. Repeat CT scan was performed that showed persistent right sided edema with temporal lobe compression, midline cyst, right sided subgaleal as well as epidural hematoma, as well as some intraparenchymal blood. There is an evolving right sided PCA and MCA stroke. The patient has incipient herniation and was taken emergently to the operating room for decompression. A post op CT showed There are new foci of parenchymal hemorrhage in the right frontal lobe and right temporal lobe. There is continued edema, marked leftward subfalcine herniation, and an evolving right posterior cerebral artery distribution infarct. The overall degree of mass effect is unchanged. The extraaxial hemorrhage along the resection margin had been evacuated. Her exam postoperatively showed a slightly dilated right pupil and withdrawal to pain in all extremeties but nothing to command. A follow up head CT the next day showed a reaccumulation of blood in the right sided subgaleal and epidural hematoma. After discussion with the family they decided to make the patient comfort measures only. She passed away a few hours later. Medications on Admission: -levoxyl 75mcg daily -alphagan 1 gtt [**Hospital1 **] on both eyes -lipitor 10mg daily -fosamax 70mg weekly (Fridays) -calcium daily -MVI Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Meningioma Epidural Hematoma Cerebral edema Discharge Condition: Death Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2173-12-8**]

[ "348.5", "E878.8", "272.0", "401.9", "518.5", "997.02", "225.2", "432.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.04", "01.53", "01.24", "99.04", "96.6", "01.51", "38.91" ]

icd9pcs

[ [ [] ] ]

6621, 6630

4216, 6404

348, 440

6717, 6724

3783, 4192

6776, 6810

2003, 2009

6593, 6598

6651, 6696

6430, 6570

6748, 6753

2039, 3764

281, 310

468, 1592

1614, 1784

1800, 1987

8,799

164,646

18748

Discharge summary

report

Admission Date: [**2139-8-14**] Discharge Date: [**2139-8-17**] Date of Birth: [**2104-9-10**] Sex: F Service: MEDICINE Allergies: Tape [**1-25**]"X10YD / Augmentin / Hydrocodone Attending:[**First Name3 (LF) 983**] Chief Complaint: nausea/vomiting in setting of DKA Major Surgical or Invasive Procedure: None History of Present Illness: 34-year-old female with history of DM type I who is transferred from OSH with DKA and possible osteomyelitis. . She was in her usual state of health until Wed AM when she developed nausea and vomiting. She has sores on her right foot from a recent cast that was in place. She notes some drainage from the ulcers and some erythema that was present since her cast was removed. She denies fevers, chills, medication non-compliance, cough, shortness of breath, dysuria, diarrhea, change in diet or other symptoms. She is unsure of what caused the worsened control of her glucose. . She presented to [**Hospital 1562**] Hospital Wed PM and was found to have DKA. Labs revealed AG 21, HCO3 22, WBC 12,000 with 92% neutrophils, FSBS 400. ABG was 7.34/22.7/126. UA showed ketones, glucose. Her foot wound was cultured. She was started on an insulin gtt, IVF, K, vancomycin and unazyn. She had an x-ray which showed right heel avulsion fracture with concern about osteomyelitis. She was admitted to the ICU and eventually transferred to [**Hospital1 18**] for further evaluation and management. Past Medical History: 1. Type 1 diabetes complicated by retinopathy and likely nephropathy, diagnosed at age 11. Poorly controlled per recent records, with the exception of during her pregnancy when she required TPN (with insulin it) for hyperemesis. She has had multiple episodes of diabetic ketoacidosis. Aic was 15.1 [**10-30**] appt with her [**Last Name (un) **] attending Dr. [**Last Name (STitle) 9978**]. No visits since then. Last eye exam [**5-1**] - "quiescent" PROLIFERATIVE diabetic retinopathy. 2. Depression 3. Severe hyperemesis requiring TPN. 4. Status post C section at 33 weeks because of hyperemesis. 5. Migraines 6. Accquired hemophilia (FVIII inhibitor in [**2132**]) treated with steroids and rituximab 7. Anti-E and warm autoantibody 8. GERD, antral ulcer 9. Hypertension 10. Hydronephrosis 11. - Osteoporosis ([**2138-11-12**] T-score lumbar spine -2.2, femoral neck -3.1) . PSH: - Cesarean section ([**2132**]) - Laparoscopic appendectomy ([**2132**]) - TAB [**3-31**] - Proximal gastroduodenal artery embolization - Excision of a skin mole - Achilles avulsion repair Social History: The patient does not smoke or drink alcohol, had piercing of ears, a transfusion in [**2132**]. Married, living with her husband and one son. A homemaker currently. On disability since [**2132**]. Exercises regularly at a gym. Family History: Has 1 sister, no hx of cancer or bleeding/ blood disorders in family but positive IBD history in grandfather and [**Name2 (NI) 12232**]. Physical Exam: Admission PE: Vitals: T: 98.6 BP: 139/88 P: 106 R: 15 SaO2: 99% RA General: Sleeping, lethargic, easily arousable, AOx3, no apparent distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes or crackles CV: Regular rhythm, normal rate, no rubs, gallops or murmurs, normal S1 + S2 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. R foot with ulceration anterior base of right great toe, anterior foot over tarsus, well healed scar over achilles, no drainage, erythema present, ?warmth Skin: slight <.2mm petechial rash on right hand ICU Discharge PE: Vitals: T: 99.6 BP: 151/91 P: 120 R: 18 SaO2: 100% RA General: Lethargic, easily arousable, AOx3, no apparent distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes or crackles CV: Regular rhythm, normal rate, no rubs, gallops or murmurs, normal S1 + S2 Abdomen: soft, tender to deep palpation in epigastric area, 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. R foot with ulceration anterior base of right great toe, anterior foot over tarsus, well healed scar over achilles, no drainage, erythema present Skin: slight <.2mm petechial rash on right hand Day of discharge VSS Gen: patient feeling well NAD CV: RRR no m/r/g Pulm: ctab Abd soft nt nd bs+ Extremities: healing ulcer on the right foot no oozing. 2+ pulses bilaterally Pertinent Results: [**2139-8-15**] 03:40AM BLOOD WBC-10.2 RBC-3.00* Hgb-8.6* Hct-27.0* MCV-90 MCH-28.6 MCHC-31.9 RDW-13.8 Plt Ct-505* [**2139-8-14**] 05:48PM BLOOD WBC-10.6 RBC-2.81* Hgb-8.0* Hct-25.6* MCV-91 MCH-28.5 MCHC-31.3 RDW-13.9 Plt Ct-515* [**2139-8-14**] 05:48PM BLOOD Neuts-75.8* Lymphs-19.3 Monos-4.2 Eos-0.5 Baso-0.2 [**2139-8-14**] 05:48PM BLOOD PT-12.2 PTT-23.2 INR(PT)-1.0 [**2139-8-15**] 03:40AM BLOOD Glucose-301* UreaN-9 Creat-0.8 Na-143 K-4.2 Cl-111* HCO3-22 AnGap-14 [**2139-8-14**] 05:48PM BLOOD Glucose-96 UreaN-15 Creat-0.9 Na-146* K-3.6 Cl-113* HCO3-23 AnGap-14 [**2139-8-14**] 05:48PM BLOOD CK-MB-2 cTropnT-<0.01 [**2139-8-15**] 03:40AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.2 [**2139-8-14**] 05:48PM BLOOD Calcium-8.6 Phos-3.2 Mg-2.5 [**2139-8-15**] 12:09AM BLOOD HCG-<5 Micro: [**2139-8-14**]: Blood culture and MRSA screen pending Imaging: CXR [**2139-8-14**]: No acute cardiopulmonary. No PNA. Left PICC tip in the lower SVC. No PTX. (Preliminary read) PA/Lateral X-ray (Foot) OSH read: pathologic avulsion fracture of the calcaneus involving the Achilles attachement. Likely based upon osteomyelitis. No additional regions of OM suspected. Brief Hospital Course: 34-year-old female with history of DMI, achilles avulsion s/p repair who is transferred from outside hospital with DKA s/b possible osteomyelitis; Also with nausea and some vomiting likely due to chronic gastroparesis. Improving now with reintroduction of home ativan for nausea. . # DKA: Most likely secondary to systemic stress from possibly right foot ulcer, as the patient is compliant with her medications. She presented to the ICU on an insulin drip, with a closed anion gap and low glucose. She was given D5 1/2NS and started on subcutaneous insulin glargine at her home dose. She was further resuscitated with IVF and her potassium was aggressively repleted. As further work-up, CXR was unremarkable, cardiac enzymes were negative, and pregnancy test was negative. [**Last Name (un) **] consult felt that chronic poor glucose control and noncompliance likely played a role. Pt discharged with lantus 9 U qhs and insulin sliding scale after having some asymptommatic hypoglycemic episodes on day of discharge(improved with meal) She will call to have f/u with [**Last Name (un) **] center . # Cellulitis: Initial concern for cellulitis vs. osteomyelitis of the right foot, which was unclear based on her history and information from OSH. Broad-spectrum antibiotics (vancomycin and Unasyn) were used initially. OSH wound cultures grew Staph aureus and Serratia Marcesans sensitive to levofloxacin so she was swiched to IV levofloxacin on [**8-15**]. Podiatry consult at this point did not clinically feel that she had OM and recommended f/u with OSH ortho for achilles surgery. MRI showed no evidence of osteomyelitis. Pt discharged on levaquin to complete a 7 day course(through [**8-24**]) # Anemia: Chronic but appears to be worse than baseline, but no apparent active bleeding. [**Month (only) 116**] be related to resuscitation. Trending of hematocrit levels showed no changes; should be monitored to establish future baseline. # Hypertension: The patient was continued on her home medications. Medications on Admission: Medications Home: - amlodipine 10 mg PO daily - citalopram 40 mg PO daily - colchicine 0.6 mg 1 Tablet(s) by mouth twice a day start 2 tabs in am and then 1 tab 1 hour later - epinephrine 0.3 mg/0.3 mL (1:1,000) Pen Injector - ergocalciferol 50,000 unit PO qweek - gabapentin 600 mg PO qHS - insulin glargine 15 U SC HS - insulin lispro 100 unit/mL Solution per sliding scale - lorazepam 0.5 mg PO q6-8 hours prn nausea or vomiting - metoprolol succinate 25 mg PO daily - omeprazole 40 mg PO daily - simvastatin 40 mg PO qHS - valsartan 160 mg PO daily - CALCIUM CITRATE 315MG-200 PO QID - capsaicin [Zostrix-HP] 0.075 % Cream Apply once a day . . Medications on transfer: - potassium chloride 40mEq x1 - Reglan 5mg PO q6H - Labetalol 10mg IV x2 - Unasyn 1.5g IV q6H - Vancomycin 1000mg IV q12H - Zofran 8mg IV q4H prn Discharge Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 2. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. gabapentin 600 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. Lantus 100 unit/mL Solution Sig: One (1) 9 Units Subcutaneous at bedtime. 9. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 10. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain. 11. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 12. insulin lispro 100 unit/mL Solution Sig: One (1) Per sliding scale Subcutaneous three times a day. Discharge Disposition: Home Discharge Diagnosis: DKA right foot ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were treated for diabetic ketoacidosis(high blood sugar and dehydration) and a foot infection Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2139-9-1**] 2:10

[ "041.11", "707.15", "530.81", "V15.81", "782.1", "362.02", "285.9", "250.83", "250.63", "V58.67", "250.43", "041.85", "682.7", "427.89", "357.2", "250.13", "250.53", "401.9", "536.3", "583.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9772, 9778

5907, 7927

341, 347

9842, 9842

4732, 5884

10114, 10260

2822, 2960

8796, 9749

9799, 9821

7953, 8601

9992, 10091

2975, 3750

3764, 4713

268, 303

375, 1462

9857, 9968

8626, 8773

1484, 2558

2574, 2806

59,726

181,414

22050

Discharge summary

report

Admission Date: [**2142-9-15**] Discharge Date: [**2142-11-10**] Date of Birth: [**2090-9-21**] Sex: F Service: [**Last Name (un) **] SERVICE: Transplant Surgery. ADMISSION DIAGNOSIS: 1. End-stage liver disease secondary to alcoholic cirrhosis complicated by encephalopathy, ascites and splenomegaly. 2. Primary sclerosing cholangitis. 3. Insulin-dependent diabetes mellitus. 4. History of multiple cerebrovascular accidents. 5. Chronic hemolytic anemia. 6. Ulcerative colitis. 7. History of Clostridium difficile colitis. 8. Chronic pancreatitis with endocrine and exocrine failure. 9. History of esophageal strictures. 10.Hypothyroidism. 11.Peripheral neuropathy. 12.Rheumatoid arthritis. 13.Anxiety disorder. 14.Depression. 15.Migraine headaches. 16.History of C2 fracture. DISCHARGE DIAGNOSES: 1. End-stage liver disease - status post orthotopic liver transplantation [**2142-9-20**]. 2. Swallowing dysfunction. 3. Bilateral pneumothoraces. 4. Recurrent bilateral pleural effusions - status post thoracentesis, tube thoracostomy, pleurocentesis. 5. Bilateral hemithoraces. 6. Respiratory failure, status post percutaneous tracheostomy. 7. Atrial fibrillation/atrial flutter. 8. Malnutrition. 9. High-volume ascites. 10.Chronic malabsorptive diarrhea, status post flexible sigmoidoscopy. 11.Renal failure (secondary to acute tubular necrosis and renal tubular acidosis). 12.Blood loss anemia. 13.Gram-negative sepsis with multisystem organ failure resulting in death. 14.Remainder of discharge diagnoses as above in admission diagnoses. ADMISSION HISTORY AND PHYSICAL: [**Known firstname **] [**Known lastname 2470**] was a 52-year- old woman who was admitted on [**2142-9-15**], with problems with a clogged nasojejunal feeding tube which had been in place to provide nutritional support for her severe malnutrition. She has had recurrent problems with the tube and was brought in from her rehab facility for placement of a new feeding tube. While hospitalized for this, a liver became available for her for transplantation. At the time of her transplant, her MELD score was 30. Notably preoperatively she was quite malnourished and with an albumin of 2.7. There was significant consideration given to whether it might be beneficial to hold off upon transplantation until her nutritional status could be improved, but given the suitability of the liver and her present condition, it was elected to proceed with the transplant and she underwent orthotopic liver transplantation on [**2142-9-20**]. Her hospital course subsequent to that time is quite extensive and will be discussed in moderate detail below. Briefly, as noted, she underwent orthotopic liver transplantation on [**2142-9-20**], secondary to end-stage liver disease from a combination of alcoholic cirrhosis and primary sclerosing cholangitis. She was quite malnourished preoperatively. Her early postoperative course was significant for a prolonged respiratory failure and some delay in improvement of her liver function after transplantation, as well as significant coagulopathy secondary to liver dysfunction. This all tended to improve over the course of the first four to eight days with significant improvement in terms of her liver function. She underwent multiple duplex imaging studies which indicated that the vasculature was patent. There was otherwise no evidence of rejection, slight improvement in her liver function. She continued to have persistent respiratory failure. This was secondary to the presence of pleural effusions and secondary to intrinsic weakness of her respiratory musculature secondary to her malnourished state. This required prolonged ventilatory support, eventually requiring tracheostomy and weaning from the ventilator. Over the course of the next four weeks, her respiratory status improved and there was some improvement seen in her nutritional status, but her primary problem centered around continued high volume ascites output from her abdominal [**Location (un) 1661**]-[**Location (un) 1662**] drains and some transudation of this fluid into the chest, resulting in bilateral pleural effusions which were drained with tube thoracostomies. No final etiology was ever really found for this and managing her fluid status became quite and issue given the fact that she was quite volume overloaded and malnourished and essentially in renal failure. Despite thorough investigation, no etiology of the high volume ascites was found but as noted, her liver function had normalized and she was able to wean off the ventilator with the aid of the tracheostomy and her hemodynamics had normalized. Her renal function remained poor with a creatinine clearance of about 22 but otherwise she seemed to be improving with continued nutritional support and physical therapy. In fact by postoperative week five to six, she was out of bed into chair and talking with the use of Passy-Muir valve and considerations were being made to transfer her to the floor. One to two days prior to her planned transfer to the floor, she developed an increase in her temperature from a baseline of 96 degrees to 98 degrees with this slowly worsening tachycardia. Her mental status was somewhat changed and there was concern for the onset of sepsis. She developed some slight erythema of right lower extremity concerning for an early cellulitis but otherwise on exam there was really nothing notable for the source of the sepsis. She was pancultured and broad-spectrum antibiotic coverage was started. At the time of this onset, she became acutely neutropenic as well with a white blood cell count of 0.4 thousand and a bandemia of 20% consistent with onset of the sepsis. This progressed to significant hypotension requiring multiple vasopressors and high volume of fluid resuscitation requirements. Her sepsis progressed rapidly and severely over the course of the next 38 hours with gram-negative rods growing on blood culture. Despite intensive efforts at full support with mechanical ventilation, triple vasopressors and broad-spectrum antibiotic coverage, her multisystem organ failure worsened and we were unable to maintain adequate an perfusion pressure despite maximal therapy. She became progressively more acidotic with a lactate reaching a level of 20 and manifested evidence of a shock liver in addition to her cardiovascular collapse, respiratory failure and renal failure. Given the lack of improvement in her status at this time, after extensive discussion with the family, the family requested that the patient be made comfort measures only as there was no real hope for significant improvement. The patient was made CMO on [**2142-11-10**], and expired shortly thereafter. The details of her extended hospitalization are below and grouped by systems. In terms of her neurologic status, as noted Ms. [**Known lastname 2470**] was admitted. She was somewhat deconditioned secondary to her severe malnutrition. She had multiple episodes of altered sensorium during her postoperative course after liver transplantation which were likely secondary to what was described as toxic metabolic causes. Overall she essentially cleared about three weeks into her hospitalization after liver transplant and then there were no more secondary signs of encephalopathy. Her primary neurologic issue was severe weakness from prolonged bedrest and malnutrition. This was managed with nutritional support as described below and continued physical and occupational therapy. She did have some degree of swallowing dysfunction secondary to muscle weakness but there was otherwise no evidence of any other neurologic deficits. In terms of her respiratory status, initially after her transplant, she developed bilateral pleural effusions. These were complicated by some bleeding secondary to her coagulopathy which resulted in bilateral hemithoraces. These were all managed with initially tube thoracostomy bilaterally. She developed what seemed to be spontaneous bilateral pneumothoraces given that they developed in the absence of any intervention. She occasionally had an air leak but the air leak seemed to close spontaneously without intervention. Etiology again of the pneumothoraces remained unclear at the time of her death. Her respiratory failure was thought to be secondary to a combination of intrinsic weakness of her respiratory muscles secondary to malnutrition as well as the ongoing presence of recurring bilateral pleural effusions thought to be coming from her high-volume intra-abdominal ascites. She ended up requiring again bilateral tube thoracostomies as noted with interval combinations of pigtail drain placement. A percutaneous tracheostomy was placed on [**2142-10-9**], by the thoracic surgical service. This aided greatly in her ventilatory wean. She was off the ventilator by the first week of [**2142-10-17**] and did not require any further ventilatory support after that time until her septicemia right before her expiration. Regarding the pleural effusions as noted, these were thought to be secondary to the high volume ascites from her abdomen with drainage into the chest through lymphatics. Attempts to treat her hepatic hydrothoraces with drainage were unsuccessful and she actually underwent several attempts at chemical pleurodesis which were unsuccessful secondary to the high volume of her chest output. Cardiovascular: In terms of her cardiovascular status, her postoperative course was complicated by atrial fibrillation with rapid ventricular response. This required attempts at chemical cardioversion with amiodarone and digoxin, both of which were unsuccessful with converting her to sinus rhythm but which were successful in maintaining her with a heart rate averaging below 110 beats per minute. She remained in atrial fibrillation throughout the course of her hospitalization. She did have multiple echocardiograms performed on [**9-21**], [**10-9**], and [**11-1**] which were all essentially notable for moderate left ventricular hypokinesis with an ejection fraction of 40. There were no acute changes indicating myocardial infarction and there was no evidence of any sort of pericardial effusion on any of these studies. As noted above, she did go into septic shock with collapse of her cardiovascular system refractory to multiple vasopressors just prior to her expiration. GI: For nutritional support, initially a postpyloric Dobbhoff catheter was placed endoscopically. She was maintained on a proton pump inhibitor for ulcer prophylaxis. As noted, her liver function began to improve by about postoperative day four which was marked by stabilization in her blood glucose and improvement in her lactate metabolism and slow resolution of her coagulopathy with a continued decrease in her bilirubin. Her liver function continued to improve daily. After that she had occasional episodes during her hospitalization with slight rises in her alkaline phosphatase which was thought to be possible signs of acute rejection but these seemed to be self-limited and they were managed with adjustment of her immunosuppression regimen and her early postoperative course was also notable for persistent diarrhea which was thought likely to be secondary to exocrine failure in the setting of her chronic pancreatitis for which she was maintained on enzymatic supplements but a flexible sigmoidoscopy was performed in order to rule out any sort of infectious etiology. The flexible sigmoidoscopy took place on [**2142-9-24**], and demonstrated no abnormality in mucosa and just some evidence of sigmoid diverticulosis. Her primary GI issue was high volume ascites after her liver transplantation. Her ascites ranged between 1 to 2 liters a day of drain output from her abdominal drain with an additional 1 to 2 liters a day from her thoracic drains. The fluid never evidenced any infection. Initially this was thought to be secondary to slow resolution of her prior ascites but given the persistence of the output, multiple strategies were followed in attempt to reduce the output. Initially duplex ultrasounds evidenced no evidence of vascular [**Last Name 7528**] problem. We performed a CT venogram on [**2142-10-24**], to look for hepatic venous inclusion nor caval stenosis. There was no evidence of this. Given the fact that this remained refractory, we performed a vena cavogram in interventional radiology on [**10-30**] and again there were no significant pressure gradients or evidence of any sort of inclusion in her hepatic veins or vena cava. Given the fact that there did not seem to be any evidence of outflow occlusion, attempts were made to improve her intravascular oncotic pressure with combination of albumin and Hespan. This seemed to temporarily improve this situation, but did not provide any long-term benefit in terms of reducing her high volume of ascites. In terms of her overall fluid balance, she was significantly volume overloaded with soft tissue edema secondary to her hypoalbuminemia preoperatively. She was supplemented with albumin for albumin levels less than 2 mg/dL. Initially volume resuscitation was essential but over the course of the next four to six weeks, the goal was slow diuresis secondary to her significant anasarca and edema. Her renal function had deteriorated to a creatinine of 1.6 as detailed below, and while this was not significantly high, her creatinine clearance was only 22 indicating she had severe renal dysfunction. Essentially, we did not see a rise in her BUN and her creatinine as she was autoperitoneally dialyzing via her high-volume ascites. Her malnutrition was addressed with full caloric support via postpyloric tube feedings. Her albumin slowly improved over the course of her hospitalization and by postoperative week five, her nitrogen balance indicated that she was synthesizing protein. In terms of her renal function, she developed renal failure likely initially secondary to acute tubular necrosis as noted with rise in her creatinine to 1.6 but this with a creatinine clearance of 22. This was followed by a secondary rise in her creatinine and a persistent metabolic acidosis secondary to renal tubular acidosis. Both of these were managed in conjunction with the nephrology service with essentially maintenance of euvolemia and bicarbonate support as needed and the avoidance of any nephrotoxic drugs. As noted, she was likely autoperitoneally dialyzing herself through the high-volume ascites in her abdomen and did not require hemodialysis. Heme: In terms of her hematologic issues, it was noted she had a chronic hemolytic anemia and her baseline hematocrit ran in the mid to high 20s. She required multiple transfusions of packed red blood cells, platelets and fresh frozen plasma throughout the course of her hospitalization. Notably she did develop severe coagulopathy during her septicemia prior to her death. Immunosuppression: She was maintained on a standard immunosuppression regimen postoperatively with a combination of CellCept, tacrolimus and the standard steroid taper. Infectious disease: In terms of her infectious disease issues, she was initially treated for what was thought to be an infected pleural effusion in mid [**2142-9-17**]. At that time, she was growing VRE from the effusion. This was treated with linezolid and broad-spectrum gram-negative coverage simultaneously initially followed by therapy tailored to linezolid. There was never any evidence of loculated effusion or empyema, otherwise, there were no other significant infectious complications aside from that detailed below. She was presumptively treated at multiple points through her hospitalization for bacterial pneumonia but these episodes seemed to be self-limited and no micro-organisms were grown on culture. She otherwise never manifested any evidence of any viral, fungal or parasitic infection. The immediate cause of her death was gram-negative sepsis which was rapid in onset and which led to her death within 36 to 40 hours of onset. The speciation of the gram-negative rods which were found on blood cultures is pending at the time of this dictation and the source also remains unclear. Possible sources include pulmonary, GI and also possibly her central line which had been in place for approximately 35 days although it never evidenced any secondary signs of infection. As noted, the sepsis was rapid in onset and managed initially with aggressive fluid resuscitation, broad-spectrum antibiotic coverage and vasopressor and mechanical ventilatory support. Despite maximal efforts, the multisystem organ failure progressed and we were unable to maintain an adequate perfusion blood pressure and her metabolic acidosis became increasingly worse. The high volume of vasopressor support led to ischemia in all four of her extremities secondary to intense vasoconstriction. Given the extremely poor prognosis and chance of recovery, it was noted the family wished the patient be made comfort measures only and this was initiated on [**11-10**], and she expired shortly thereafter. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**] Dictated By:[**Doctor Last Name 3763**] MEDQUIST36 D: [**2142-11-12**] 09:51:45 T: [**2142-11-12**] 11:48:34 Job#: [**Job Number 57686**]

[ "V55.4", "427.31", "427.32", "997.1", "570", "038.40", "576.1", "571.2", "261", "996.82", "584.5", "512.1", "785.52", "789.59", "572.2", "283.9", "995.92", "280.0", "997.5", "250.01", "998.59", "518.5", "577.1", "511.9" ]

icd9cm

[ [ [] ] ]

[ "34.09", "38.93", "31.1", "96.6", "50.4", "45.13", "50.59", "34.04", "88.51", "33.23", "45.24" ]

icd9pcs

[ [ [] ] ]

830, 17375

207, 809

31,415

132,530

30776

Discharge summary

report

Admission Date: [**2137-6-23**] Discharge Date: [**2137-6-27**] Date of Birth: [**2076-5-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: pancreatitis Major Surgical or Invasive Procedure: ERCP x2 History of Present Illness: 61 yo female with pmh significant for cholecystectomy [**12-29**] and ercp in [**4-29**] for pancreatitis and elevated bilirubin which revealed moderately dilated duct of 18mm with no filling defect. small amount of sludge is removed. pt now represents with epigastric and LUQ pain to outside hospital. Symptoms began saturday and pt concurrently complaints of nbnb vomiting, loose diarrhoea and dark yellow urine. no fever/chill/rigor. lab test revealed elevated lipase/amylase/gi panel. uss of ruq revealed dilated cbd. she was cultured and started on iv levofloxacin. she's subsequently transferred for ercp tomorrow for possible gallstone pancreatitis. Past Medical History: as above Situs inversus Social History: denies any tobacco/alcohol/drug use. Family History: noncontributory Physical Exam: bp 129/66, hr 85/min, rr 16/min, sats 98% on ra, temp 97. comfortable at rest, no apparent distress neck supple, no jvd. CV rrr, nl s1+s2, normal otherwise RS normal. [**Last Name (un) **] mild discomfort in epigastrium, no rebound/guarding/regidity. Normal otherwise Pertinent Results: [**2137-6-27**] 06:10AM BLOOD WBC-6.1 RBC-4.04* Hgb-11.6* Hct-36.7 MCV-91 MCH-28.8 MCHC-31.8 RDW-14.5 Plt Ct-262 [**2137-6-24**] 07:20AM BLOOD WBC-5.5 RBC-4.11* Hgb-12.0 Hct-36.7 MCV-90 MCH-29.2 MCHC-32.7 RDW-14.4 Plt Ct-246 [**2137-6-26**] 04:32AM BLOOD PT-12.7 PTT-23.6 INR(PT)-1.1 [**2137-6-24**] 07:20AM BLOOD PT-13.9* PTT-27.7 INR(PT)-1.2* [**2137-6-27**] 06:10AM BLOOD Glucose-114* UreaN-8 Creat-0.7 Na-142 K-3.8 Cl-106 HCO3-30 AnGap-10 [**2137-6-24**] 07:20AM BLOOD Glucose-116* UreaN-9 Creat-0.9 Na-141 K-3.9 Cl-108 HCO3-27 AnGap-10 [**2137-6-27**] 06:10AM BLOOD ALT-256* AST-69* AlkPhos-312* Amylase-31 TotBili-0.7 [**2137-6-24**] 07:20AM BLOOD ALT-629* AST-356* AlkPhos-411* Amylase-50 TotBili-3.1* [**2137-6-27**] 06:10AM BLOOD Lipase-125* [**2137-6-24**] 07:20AM BLOOD Lipase-170* [**2137-6-27**] 06:10AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2 [**2137-6-26**] 04:32AM BLOOD Triglyc-79 ERCP - Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Previously performed sphincterotomy was seen in the major papilla Cannulation: Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. Biliary Tree: Cholangiogram showed CBD of 15mm. No strictures or filling defects was seen. Procedures: A 12mm balloon was introduced for dilation and the diameter was progressively increased to 15 mm successfully in the sphincterotomy due to current presentation. There was bleeding from the sphincterotomy site post dilation with 15 mm balloon. A 5 cm by 10F double pigtail biliary stent was placed successfully. Impression: 1. Previously performed sphincterotomy was seen in the major papilla 2. Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. 3. Cholangiogram showed CBD of 15mm. No strictures or filling defects was seen. 4. A 12mm balloon was introduced for dilation and the diameter was progressively increased to 15 mm successfully in the sphincterotomy due to current presentation. 5. There was bleeding from the sphincterotomy site post dilation with 15 mm balloon. 6. A 5 cm by 10F double pigtail biliary stent was placed successfully. Recommendations: 1. Observe in ICU post procedure. 2. Check serial hematocrits and hemodynamics. 3. No ASA or NSAIDS for 10 days. 4. Repeat ERCP in [**8-2**] weeks for stent pull cholangiogram. Additional notes: The procedure was performed by Dr. [**Last Name (STitle) **] and the GI fellow. Brief Hospital Course: Gallstone pancreatitis - ERCP was done the first time that failed and hence she was taken again for ERCP under anesthesia. This time baloon dilation was done of the sphincter at ampulla and complicated by bleeding. She was monitored overnight in ICU, hematocrit remained stable and was sent to floor. At discharge the hematocrit was at baseline. THE liver function tests improved after the procedure and bilirubinw as down to normal. The patient was stable at discharge. Prophylactic levofloxacin and metronidazole were given for a total of 7 days. The patient will be called by Dr [**Last Name (STitle) 70485**]/[**Doctor Last Name **] (ERCP team) for a repeat ERCP in 8 weeks. Medications on Admission: pepcid Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. Disp:*6 Tablet(s)* Refills:*0* 3. Pepcid Oral Discharge Disposition: Home Discharge Diagnosis: Biliary obstruction Gallstone pancreatitis Anemia, blood loss Discharge Condition: stable Discharge Instructions: Return to the emergency room or call your doctor if you notice bleeding, black stool, worsening jaundice, abdominal pain, nausea, vomiting or any other symptoms of concern to you. keep your appointments. Do not take any aspirin or ibuprofen, advil or any such drugs without consulting your doctor for the next 7 days. This may increase your risk of bleeding. Followup Instructions: Dr [**Last Name (STitle) 5361**] on [**2137-7-4**] at 1500 hours. Please follow with him for a blood test ( CBC, liver tests) (your doctor is on a leave - hence this follow up is with Dr [**Last Name (STitle) 5361**]. Dr [**Last Name (STitle) **] [**Name (STitle) 70485**] with call you at home for scheduling another ERCP procedure (to be done in 8 weeks). If you don't hear from him, call the gastroenterology clinic ([**Telephone/Fax (1) 2233**] and ask for Dr [**Last Name (STitle) 70485**] or Dr [**Last Name (STitle) **].

[ "574.51", "998.11", "577.1", "285.1", "576.8" ]

icd9cm

[ [ [] ] ]

[ "51.87" ]

icd9pcs

[ [ [] ] ]

5041, 5047

4028, 4708

328, 338

5153, 5162

1461, 4005

5572, 6104

1141, 1158

4765, 5018

5068, 5132

4734, 4742

5186, 5549

1173, 1442

276, 290

366, 1024

1046, 1071

1087, 1125

66,152

109,703

21280

Discharge summary

report

Admission Date: [**2142-11-19**] Discharge Date: [**2142-12-1**] Service: NEUROLOGY Allergies: Levofloxacin Attending:[**First Name3 (LF) 1032**] Chief Complaint: OSH Transfer for AMS and ? seizures Major Surgical or Invasive Procedure: none History of Present Illness: 86 RHM with PMH of afib currently not on coumadin due to IPH in [**2142-8-9**], was transfered from OSH. His neurological problems began in [**2142-8-9**]. Before that, he was independent in ADLs and was high functioning. He had acute HA and left arm numbness/weakness for which he was taken to [**Hospital1 2025**] where he was found to have right temporal bleed. He was managed conservatively and was dced in late [**Month (only) 205**] to rehab. The Coumadin was stopped and keppra was added 750 [**Hospital1 **]. The hospital course was complicated by MSSA bacteremia with negative TEE, for which he was treated with abx for 2 weeks with recovery. At rehab he did make good progress and was sent home on [**9-23**]. From that time, he is with his son. per son, he did bot have any significant neurological deficits other than generalised fatigue. He was doing well till 3 days ago. On friday early am, aroud 3, he came back from the restroom and as he was coming, he suddenly fell down. He was yelling for help and was having pain in left ankle. He sat down and could not get up. 911 was called , he was taken to OSH where he was evaluated for UTi,PNa which were negative. CT head showed no acute bleed. CBC Chem 7 were normal. EKG and card enzymes didnt show anything acute. He was however noted to be increasingly confused, drowsy and having repeated jerking movements of left UE and LE lasting few seconds. Per son, during few of these movements he was talking and was responding to voice. The concern was for seizure and small doses of ativan were used. He underwent MRI this am which showed 2cm AVM in right ant temp lobe with minimal edema and enhancement. He was loaded with dilantin 1 gram IV and trasfered to [**Hospital1 18**] for eval. In the ED, later, he was noted to have fever 101, was increasingly tachypneic and was on the verge of intubation. Next, neurology was called. While examining him, I saw an episode where he had transient jerking of left UE and LE lasting few secs also some shaking of RLE, though much less than Left side. Past Medical History: - HTN - Lipids - Chronic afib on coumadin till [**2142-8-9**] - Right Temporal IPH [**2142-8-9**] - Bovine aortic valve replaced [**2137**] [**Hospital1 2025**] - Remote h/o seizure ds, not on AEDs for last 6yrs, details not known at this point Social History: Lives with son, was very high functioning before [**2142-8-9**]. Denies smoking or alcohol use. antique design expert Family History: ? h/o brain AVM in nephew Physical Exam: HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: Irre Irre, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neuro: Drowsy and Inattentive. No sponataneus verbal output. Responds minimal to verbal commands. opens eye to painful sternal rub but closed again. Inconsistently follows few commands to combination of verbal and tactile stimuli. Couldnt answer any questions. unable to assess for any apraxia or hemineglect. Cranial Nerves: Pupils equally round and reactive to light, 2-1 mm bilaterally. fundus difficult to evaluate Extraocular movements intact bilaterally without nystagmus.face appears symmetric Motor: Normal bulk and tone bilaterally. was moving all limbs spontaneously and to painful stimuli. withdraws to noxious stimuli. DTRs: 1 plus and symmetric Toes downgoing on right and up on left Coordination/Gait- Defd No neck stiffness Pertinent Results: [**2142-11-19**] 11:15PM CEREBROSPINAL FLUID (CSF) PROTEIN-64* GLUCOSE-60 [**2142-11-19**] 11:15PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-13* POLYS-6 LYMPHS-85 MONOS-9 [**2142-11-19**] 11:15PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-198* POLYS-13 LYMPHS-75 MONOS-12 [**2142-11-19**] 08:02PM LACTATE-2.2* [**2142-11-19**] 07:35PM cTropnT-<0.01 [**2142-11-19**] 07:35PM ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-3.5 MAGNESIUM-1.7 [**2142-11-19**] 07:35PM PHENYTOIN-9.7* [**2142-11-19**] 07:35PM PLT COUNT-125* [**2142-11-19**] 07:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2142-11-19**] 07:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: Mr [**Known firstname **] was admitted as an outside hospital transfer on dilantin. He was admitted into the ICU on dilantin and was placed on Keppra as well on [**2142-11-20**]. On [**2142-11-21**] he was tried off of propfol and was noted to be comatose with shaking of his left side of his body. He was then placed on Keppra 1500mg [**Hospital1 **] which was originally placed at 1000mg [**Hospital1 **]. On [**2142-11-22**] He was tried off of propofol again. He was noted to have frequent shaking of his left side off of propofol within a 2-3 hour period. Propofol was again restarted and because he was still comatose without eeg data we clinically believed he was in status epilepticus and a loading dose of phenobarbital was given. His post load dose was 25. Afterward we had some analyzed EEG data that did not show generalized seizures so phenobarbital was not continued and propofol was taken off. He continued off of propofol for the next couple of days and kepra was reduced to 1g [**Hospital1 **]. His Dilantin was titrated to a dose of 300mg Twice daily and this was titrated to an adequate free dilantin level. on [**2142-11-25**] Mr [**Known firstname **] was still not able to awaken from his comatose and further imaging and repeat lumbar puncture were unrevealing. He respiratory status stablized in the ICU and he was extubate and remained stable but with poor mental status. He was transferred to the neurology floor on [**11-30**] and then began having worsening respiratory distress and breakthrough seizures. His family decided to make him comfort measures only and the palliative care team was consulted. He was treated with morphine for comfort and he expired on [**12-1**]. Medications on Admission: - ASA 81 - Keppra 1000 [**Hospital1 **] - Proscar 5 - toprol 50 - zocor 80 - lisinopril 30 - trazodone 50 Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Not applicable Followup Instructions: Not applicable. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 1041**]

[ "345.71", "V49.86", "482.41", "401.9", "E947.9", "518.81", "349.82", "788.20", "V42.2", "438.89", "430", "272.4", "427.31", "041.11" ]

icd9cm

[ [ [] ] ]

[ "33.24", "88.72", "96.72", "03.31", "96.6" ]

icd9pcs

[ [ [] ] ]

6516, 6525

4625, 6332

259, 265

6576, 6585

3872, 4602

6648, 6789

2774, 2802

6489, 6493

6546, 6555

6358, 6466

6609, 6625

2817, 3416

183, 221

293, 2353

3432, 3853

2375, 2622

2638, 2758

7,699

181,158

50805+50806+50807

Discharge summary

report+report+report

Admission Date: [**2152-5-24**] Discharge Date: [**2152-6-30**] Date of Birth: Sex: Service: Continuation ... Her past medical history is significant for numerous disc surgeries in the 80's. She also had a motor vehicle accident in 1/95 with residual pain syndrome. MEDICATIONS ON ADMISSION: 1. Feldene 20 mg b.i.d. 2. Flexeril 10 mg t.i.d. 3. Tylenol #3 1 t.i.d. p.r.n. 4. Doxepin 125 mg at bedtime. ALLERGIES: PENICILLIN. MENTAL STATUS ON ADMISSION: She appeared to be well-groomed, well-dressed, pleasant lady with normal rate, rhythm and tone of speech. Her behavior showed no psychomotor retardation or agitation. Thought content revealed positive suicidal ideation with possible plan to overdose on medications. No homicidal ideation, no delusions. Her thought processes were organized with no tangentiality. Her perception showed no auditory or visual hallucinations. Her mood was "numb." Affect was restricted but mood congruent. Her insight was good, but her judgement was poor. Cognition: She was alert and oriented times three. Her memory was [**12-26**] after five minutes. She had a good ability to do serial 7's and digit spans. She could remember the presidents to Nixon. She appeared to be, in sum, a 41-year-old woman with increased hopelessness and despair due to unresolved chronic pain after a motor vehicle accident, now with increased suicidality with a plan, and she was admitted to Six-North for psychopharm evaluation and diagnostic clarification of her depression and treatment recommendations. PHYSICAL EXAMINATION: On admission was significant for total body pain with no bowel or urinary incontinence associated with her back pain. No straight leg sign and no treatment deemed necessary by the medical doctor who cleared her in the emergency room at the time of admission. LABORATORY: On admission revealed a tox screen that was positive for opiates consistent with Tylenol #3. Her other laboratories revealed a T4 of 10.2, B12 within normal limits, and other labs were unremarkable. HOSPITAL COURSE: The patient was extremely tearful, hopeless and focused on somatic complaints during her admission. She was seen frequently by her outpatient psychologist, Dr. [**First Name8 (NamePattern2) 2033**] [**Last Name (NamePattern1) 46**], who suggested psychological testing for the patient. A psychopharm evaluation suggested increasing her Doxepin from 125 mg. It was increased to 175 mg which the patient tolerated and Zoloft was added to augment the Doxepin, and that was also gradually increased with a good response from the patient. The patient was seen several times at the [**Hospital3 **] Pain Management Center by Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 105655**], and they recommended trigger point injections to relieve some of acute pain, and the patient received two of these occipital nerve blocks which reduced the pain somewhat. Several meetings were held with numerous members of the patient's outpatient treatment team including her outpatient psychologist, psychopharmacologist, her pain physicians and her inpatient treaters, as well as the patient and her husband, and a unified plan was constructed to help the patient cope with her pain. This would include continued followup at the Pain Management Center at the [**Hospital3 **], also continued weekly psychotherapy with Dr. [**First Name (STitle) 46**], and psychopharmacology overseen by Dr. [**Last Name (STitle) 105656**] with continued Zoloft and Doxepin. The plan for discharge also included group therapy and possibly biofeedback and relaxation techniques. The patient gradually became more comfortable with this plan and felt more like "myself." By [**2145-9-10**], she felt significantly less overwhelmed and began to accept responsibility for her treatment. She had a family meeting at 1 p.m. on [**2145-9-11**] and was able to tolerate a pass off the unit. She was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20598**], a psychologist, who does biofeedback at the [**Hospital3 **], and plans were arranged for her to continue biofeedback. The patient was discharged on [**2145-9-12**]. Her plans were for individual psychotherapy with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 46**], psychopharm with Dr. [**Last Name (STitle) 105656**], group therapy to be arranged with Dr. [**First Name (STitle) 46**], biofeedback with Dr. [**Last Name (STitle) 20598**] at the [**Hospital3 **] and Pain Clinic followup at the [**Hospital3 **] with Dr. [**Name (NI) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) 105655**]. She returned home with her husband. CONDITION ON DISCHARGE: Stable. She had no suicidal or homicidal ideation. She was not psychotic and she felt safe. DISCHARGE DIAGNOSIS: Axis I: Major depressive disorder. Axis II: Deferred. Axis III: Chronic pain secondary to motor vehicle accident. Axis IV: Moderate chronic pain and hopelessness. Axis IV: 60. ATTENDING PHYSICIAN Dictated by:[**2146-4-15**] Admission Date: [**2152-5-24**] Discharge Date: [**2152-6-30**] Date of Birth: [**2103-10-9**] Sex: F Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 48-year-old female with history of hypertension, history of transient ischemic attack and status post lumbar laminectomy. The patient presented to an outside hospital with what appeared to be a left groin infection. The patient noticed some tenderness in her left groin, which then became erythematous. She noticed that the area of erythema and tenderness was spreading. She presented to [**Hospital3 3834**] [**Hospital3 **] for evaluation. The patient was admitted to the hospital. She denied any trauma to the area, any shaving, no insect or animal bites. After admission to the hospital, the patient began to manifest decreased blood pressures, which required Neo-Synephrine for support. At this time, the patient was referred to the [**Hospital1 69**] for further management with the question of necrotizing fasciitis. Of note, at the outside hospital, CT scan was obtained, which showed evidence of air in the left groin, worrisome for a Fournier gangrene picture. Once again, the patient was transferred to the [**Hospital1 188**] on [**2152-5-24**]. PAST MEDICAL HISTORY: 1. History is significant for hypertension. 2. The patient gives a history of transient ischemic attacks. 3. The patient did not give a history of diabetes mellitus, chronic obstructive pulmonary disease, or coronary artery disease. PAST SURGICAL HISTORY: 1. Lumbar laminectomy. 2. Pilonidal cyst excision. MEDICATIONS ON ADMISSION: 1. Atenolol. 2. Baclofen. 3. Effexor. 4. Tylenol #3. 5. Trazodone. ALLERGIES: The patient is allergic to PENICILLIN. SOCIAL HISTORY: The patient has one pack per day smoking history and rare alcohol use. PHYSICAL EXAMINATION: On examination on presentation to this hospital, the patient's temperature was 98.7, pulse 100, blood pressure 95/56, respiratory rate in the 30s and 95% saturation on two liters nasal cannula. GENERAL: The patient was a white female, alert and oriented and in no acute distress. CARDIAC: Examination revealed regular, mildly tachycardia. LUNGS: Lungs were clear bilaterally. ABDOMEN: Soft, nondistended. There was some tenderness in the left lower quadrant and flank, which was also erythematous. Perineum was notable for erythema around the left labia and groin. There was induration. The erythema tracked along the left medial anterior thigh. There was no crepitus. Pelvic examination was notable for some cervical motion tenderness, however, there was no purulent discharge. RECTAL: Examination was unremarkable and guaiac negative. HOSPITAL COURSE: The patient was admitted to the ICU and taken to the operating room fairly urgently for debridement of necrotic tissue. The patient underwent an extensive debridement of the left labial area, left groin, left thigh, and left abdominal wall. Necrotic subcutaneous fat and tissue was identified and resected. This tissue was sent for culture and pathological analysis. The patient was taken to the ICU postoperatively, where she remained intubated. She was started on Vancomycin, Clindamycin, and Ceftriaxone. Infectious Disease consultation was obtained to manage the antibiotic treatment. The patient remained hypotensive and required a pulmonary artery catheter placement for hemodynamic management and monitoring. She also required blood-pressure support with Levophed during the first several postoperative days. The patient was returned to the operating room on hospital day #1, #2, #3, and #4, for serial debridements, which included the left labia, groin, left thigh, and abdominal wall. The patient was pancultured, initially. Wound cultures were significant for Staphylococcus epidermidis and group A Beta-hemolytic streptococcus. Antibiotics were changed to include just Vancomycin and Clindamycin. Ceftriaxone was discontinued. The patient, for the first five or six hospital days, required a large amount of volume resuscitation to maintain her blood pressure. She was actually weaned off the Levophed on postoperative day #3, again, just receiving volume resuscitation to support the blood pressure. She remained intubated with a question of ARDS on chest x-ray. The patient remained essentially hemodynamically stable by postoperative day #6 with blood pressure being adequately supported with volume resuscitation. At this time, the PA catheter was discontinued, changed to a triple-lumen catheter for CVP monitoring. She continued on antibiotics. It was attempted to wean her off ventilatory support. TPN was started for nutritional support at this time. Over the next two weeks, the patient was essentially stable receiving nutritional support and general supportive care. She continued to require a large amount of volume resuscitation. She remained on Vancomycin and Clindamycin for antibiotic therapy. Attempts to wean the patient from the ventilator were unsuccessful. On [**2152-6-14**], the patient underwent percutaneous tracheostomy placement by Dr. [**Last Name (STitle) **]. The patient was transitioned from TPN to tube feedings with a post-pyloric Dobbhoff to be placed. She advanced to goal tube feeds without difficulty. The patient's wounds remained clean and there was no evidence of any further extension of the infection. She did not require any further surgical debridement. The patient eventually was weaned off ventilatory support on her tracheostomy, maintaining saturations in the high 90s with a low respiratory rate on 40% tracheostomy collar. The tracheostomy was downsized from a #6 to a #4 and she was given [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-Muir valve allowing her to speak. Of note: The [**Hospital 228**] hospital course was complicated by an Enterobacter line sepsis, treated initially with Gentamicin and then later this was changed to Levaquin. Follow blood cultures after several days of treatment with antibiotics were negative for any further bacteremia. The patient was planned to be continued on two weeks of Levaquin after the most recent set of negative blood cultures. The patient completed a long course of Vancomycin to treat her group A strep necrotizing fasciitis. The patient remained hemodynamically stable and afebrile. She required less volume resuscitation and eventually was maintained only on tube feeds goal without any additional volume resuscitation. The Department of Physical Therapy was consulted. They began working with the patient to begin to increase her mobility. She was weaned off sedatives in terms of Ativan drip and was maintained only on p.r.n. sedation. At this point, VAC dressing was applied to the larger of her groin and abdominal wounds and the wounds continued to look excellent with good granulation tissue and contraction of the wounds. She remained afebrile. There were no further positive blood cultures or sputum or urine cultures. At this point, the patient was felt to be ready for discharge to a rehabilitation facility. The patient had undergone swallow evaluation to determine if she was safe to begin oral feedings. It was felt, at this time, that she was a significant aspiration risk, therefore, tube feeds were continued. Prior to discharge, the Plastic Surgery Service was consulted for management of the wounds. They recommended at this time to continue treatment with VAC dressing until the wounds had contracted somewhat more and they plan to see her in followup in the office for surgical closure of the wounds at that time. The patient was discharged in stable condition with the diagnosis group A strep, necrotizing fasciitis, with Fournier's gangrene, status post multiple debridements in the operating room. She is also status post percutaneous tracheostomy placement with the postoperative course complicated by respiratory failure and Enterobacter line sepsis. MEDICATIONS ON DISCHARGE: 1. Levaquin 500 mg PO NG tube once a day to be discontinued on [**2152-6-25**]. 2. The patient was also on Clonidine 0.1 mg PO b.i.d. 3. Oxycodone p.r.n. 4. Effexor 150 mg PO b.i.d. 5. Vitamin C. 6. Regular insulin sliding scale. 7. Subcutaneous heparin 5000 units t.i.d. 8. Zantac 150 mg PO b.i.d. Upon discharge, the patient has a PIC line for venous access and IV antibiotic therapy on Foley catheter, as well as tracheostomy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Last Name (NamePattern1) 33441**] MEDQUIST36 D: [**2152-6-30**] 10:45 T: [**2152-6-30**] 11:08 JOB#: [**Job Number 105657**] Admission Date: [**2152-5-24**] Discharge Date: [**2152-7-5**] Date of Birth: [**2103-10-9**] Sex: F Service: ADDENDUM: This is an addendum to the Discharge Summary on Ms. [**Known firstname **] [**Known lastname 105658**]. Her date of admission was [**2152-5-24**]. Her date of tentative discharge is now scheduled as [**2152-7-5**]. In the intermittent time between her last Discharge Summary and this addendum, the patient stayed in house secondary to placement issues. The patient has now been accepted at a rehabilitation facility and is being discharged accordingly to that facility. In this time, the patient has a Doppler confirmed, has a postpyloric tube, and she has had a Speech and Swallow evaluation which has allowed us to progress her diet from liquids to puree with supervision to make sure the patient does not have any evidence of aspiration. MEDICATIONS ON DISCHARGE: Her discharge medications were unchanged and will be per page 1 which will accompany the patient to her rehabilitation facility. CONDITION AT DISCHARGE: She remained in good condition with a vac dressing times two on two of her debridement wounds and wet-to-dry on the rest with good granulation tissue, and no evidence of any infection. She was afebrile, and she was tolerating a trach collar well. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2152-7-4**] 18:01 T: [**2152-7-4**] 18:08 JOB#: [**Job Number 105659**]

[ "038.9", "996.62", "E879.8", "401.9", "518.5", "728.86" ]

icd9cm

[ [ [] ] ]

[ "86.22", "99.15", "38.93", "31.1" ]

icd9pcs

[ [ [] ] ]

4842, 6347

14731, 14871

6709, 6834

7816, 13072

6629, 6683

6946, 7798

14886, 15398

494, 1564

6369, 6606

6851, 6923

4728, 4821

26,027

107,384

7489

Discharge summary

report

Admission Date: [**2205-11-13**] Discharge Date: [**2205-11-14**] Date of Birth: [**2166-7-13**] Sex: M Service: MEDICINE Allergies: Gabapentin / Trazodone / Codeine Attending:[**First Name3 (LF) 2712**] Chief Complaint: AMS, concern for toxic alcohol ingestion Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 27389**] is a 39 year old man with h/o EtOH and polysubstance abuse, seizure disorder, who was found to be unresponsive while visiting his partner in the ICU earlier today. . The patient was visiting his partner in the ICU earlier today. He was awake and conversant in the morning with no acute complaints. He was noted to be sleeping on the floor, but walked to the chair by himself when he was awakened. Later in the afternoon, the patient was noted to still be asleep in the chair. He was unarousable with verbal stimuli or sternal rub, so he was taken down to the ED. . In the ED, the patient was initially altered, but was otherwise hemodynamically stable. No urine incontinence or e/o toxidromes. Labs notable for EtOH 86, Osms 366, anion gap 16, lactate 3.8. Utox positive for barbs, but Stox and Utox otherwise negative. Given high serum osmolar gap (60), toxicology was consulted for concern of toxic alcohol ingestion. Most likely isopropyl alcohol given osmolar gap with small anion gap (likely due to lactate) and access to CalStat in the hospital today. However, given a dose of Fomepizole 15mg/kg IVx1 in the ED for possible ethylene glycol vs methanol ingestion. Also given Diazepam 10mg x1 for EtOH withdrawal. EEG following, as the patient is enrolled in a study for AMS. Vitals prior to transfer: 97.5 103 120/60 22 RA 100% . On the floor, the patient is currently hungry and feels like he is going to withdraw. He is anxious and has some palpitations. No shortness of breath, chest pain. He denies ingesting anything today. He has had no PO intake x4 days. Past Medical History: * Subdural hematoma ([**2204-4-12**]) from fall * Alcohol and polysubstance abuse * Hepatitis C virus infection * Mood disorder with multiple suicide attempts * ?PTSD, bipolar/anti-social personality/impulse/rage disorders * Migraines * Chronic lower back pain * MVA s/p chest tube placement in [**2200**] * Seizure disorder since [**08**] yo, alcohol withdrawal seizures Social History: Stays with his girlfriend in [**Name (NI) **]. - Tobacco: +intermittent tobacco use - Alcohol: 1/5th daily of hard liquour, has been drinking since 9 yo, has h/o DTs and alcohol withdrawal seizures - Illicits: Past use of cocaine, heroin, opiates, benzodiazepines documented in [**Name (NI) **], but patient currently denying any of this. Family History: Father was an alcoholic. Physical Exam: On admission: Vitals: T: 95.9 BP: 123/84 P: 99 R: 18 O2: 94%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: diminished breath sounds throughout R>L, no wheezes, rales, rhonchi CV: tachycardic, 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 Neuro: aaox3, CNs [**2-23**] intact, strength and sensation grossly nl. . On discharge: [**Name (NI) 4650**] Pt allert and oriented, walking without difficulty, R knee with large effussion, exam otherwise unchanged Pertinent Results: [**2205-11-14**] 06:14AM BLOOD WBC-6.4 RBC-3.68* Hgb-12.2* Hct-36.1* MCV-98 MCH-33.2* MCHC-34.0 RDW-14.3 Plt Ct-267 [**2205-11-13**] 05:21PM BLOOD WBC-4.4 RBC-4.15* Hgb-13.4* Hct-40.0 MCV-96 MCH-32.2* MCHC-33.5 RDW-14.2 Plt Ct-307 [**2205-11-13**] 05:21PM BLOOD Neuts-53.9 Lymphs-43.4* Monos-0.9* Eos-1.2 Baso-0.6 [**2205-11-14**] 06:14AM BLOOD Glucose-96 UreaN-5* Creat-0.7 Na-141 K-3.5 Cl-107 HCO3-27 AnGap-11 [**2205-11-13**] 05:21PM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-140 K-4.2 Cl-103 HCO3-21* AnGap-20 [**2205-11-14**] 06:14AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7 [**2205-11-13**] 09:07PM BLOOD Albumin-4.5 Calcium-9.3 Phos-4.6* Mg-1.7 [**2205-11-14**] 06:14AM BLOOD Osmolal-325* [**2205-11-13**] 05:21PM BLOOD Osmolal-366* [**2205-11-13**] 05:21PM BLOOD ASA-NEG Ethanol-86* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2205-11-13**] 09:12PM BLOOD Type-ART O2 Flow-3 pO2-92 pCO2-38 pH-7.42 calTCO2-25 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2205-11-13**] 05:31PM BLOOD freeCa-1.10* [**2205-11-13**] 05:28PM BLOOD ALCOHOL PROFILE-Test pending on discharge Head CT: IMPRESSION: No acute intracranial process. Atrophy advanced for age. Chest xray: No acute intrathoracic process. COPD with stable right basilar scarring/chronic atelectasis. Brief Hospital Course: Mr. [**Known lastname 27389**] is a 39 year old man with h/o EtOH and polysubstance abuse, seizure disorder, who was found unresponsive while visiting his partner in the ICU, admitted with concern for toxic alcohol ingestion. . #. AMS: Patient was unresponsive to verbal stimuli and sternal rub while in the ICU, but was alert and oriented just several hours prior. Concern in the ED for toxic ingestion (?isopropyl alcohol given easy and serum osmolar gap with explained anion gap), however patient denies ingesting anything today. Phenobarbital OD also considered (mentioned earlier on day of admission that he can tolerate 12 pills at a time), however phenobarb level was not elevated. Patient given Fomepizole x1 in the ED. No urinary incontinence or tongue biting to suggest seizure. Infectious etiology unlikely (afebrile, no leukocytosis, CXR unremarkable). CT head negative for acute process. Given h/o EtOH withdrawal, pt was monitored closely in the ED. He was seen by toxicology and treated with CIWA scale and supportive care. Once MS improved, pt left AMA, alcohol profile pending on discharge. . #. Hypoxia: Patient desat to high 80s on RA while asleep. E/o atelectasis and COPD on CXR. No e/o acute infection or COPD exacerbation. Sats improved with improving MS. . #. Elevated lactate: Likely [**2-13**] to alcohol use. Improved with treatment of intoxication. . #. EtOH abuse: History of withdrawal and seizures in the past. Concern for toxic alcohol ingestion in addition to usual EtOH use. Last drank brandy evening of [**2205-11-12**], unclear if there were co-ingestions. Pt was treated with CIWA, MV, thiamine, folate. . #. Chronic Pain: Not currently c/o pain, sedating meds held. . #. Seizure disorder: Less likely to have been seizing this afternoon, but is at high risk for EtOH withdrawal. Home phenobarbital was continued. . #. R knee effusion: pt c/o pain but refusing US and pt left AMA before receiving further diagnosis or treatment. Medications on Admission: Phenobarbital ?34.2mg PO TID Klonopin 2mg PO TID Folate 1mg PO daily MVI 1tab PO daily Thiamine 100mg PO daily Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. phenobarbital 30 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*3 Tablet(s)* Refills:*0* 5. Klonopin 2 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: primary: isopropyl and alcohol withdrawal Secondary: knee effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ICU for withdrawal. You were treated with medications to help with your withdrawal symptoms. You left against medical advice. . No changes have been made to your medications. Because you left against medical advice, we were unable to schedule a follow up appointment for you. Please follow up with your doctor in [**1-13**] wks. Followup Instructions: Follow up with your doctor in [**1-13**] wks

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Discharge summary

report

Admission Date: [**2147-4-20**] Discharge Date: [**2147-4-26**] Date of Birth: [**2111-12-11**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 618**] Chief Complaint: Left sided weakness Major Surgical or Invasive Procedure: Transesophageal echocardiogram History of Present Illness: HPI; 35 yo M with history of HTN presenting with acute onset of left face and arm weakness at 9:50 PM while eating dinner. He was noted to have water spill out the side of his mouth and have slurred speech. He was sitting and was unsure if his leg was involved. The episode lasted five minutes and resolved spontaneously. Shortly after he had another episode and continued to have intermittent episodes lasting 5-10 minutes at a time with last one lasting up to an hour. He was taken to an OSH and upon presentation BP 168/116, CT head was reported to be unremarkable, INR 1.04, plts 115, and FS was normal. His symptoms continued to wax and wane. At midnight records indicate he had no deficits and then again developed left face and arm weakness at 00:05. He was noted to have a NIHSS of 12 and given IV TPA prior to transfer to [**Hospital1 18**] for further care. Of note at 0118 he was noted to "grip equally, moving all extremities" prior to transfer. He was noted by EMS to have recurrence of his symptoms five minutes after his TPA infusion ended and minutes prior to arrival at [**Hospital1 18**]. He currently denies headache, nausea, or vomiting. ROS otherwise negative. Past Medical History: HTN Social History: Lives with his girlfriend in [**Name (NI) 47**]. Works as a construction worker. No history of smoking or illicits. Family History: Grandmother with a history of stroke. Physical Exam: VS; T 178/98 RR 13 P 80 98% RA 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 Cardiac: RRR, nl. S1S2 Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally 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. Normal prosody. There were no paraphasic errors. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Decreased sensation to light touch V1-V3 on left VII: Left facial droop 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 adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 0 0 0 0 0 0 0 0 0 0 0 0 0 0 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: Decreased to light touch and pinprick on left. Extinguishes to DSS but inconsistently. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No dysmetria on right. Unable to assess on left -Gait: deferred Pertinent Results: Admission Labs: 140 | 103 | 21 ---------------< 106 3.5 | 26 | 1.0 Ca: 8.9 Mg: 2.3 PO4: 4.2 14.9 10.8 >-----< 254 42.6 CK: 87 Trop: <0.01 Multiple hypercoagulatibility and secondary hypertension studies were performed to assess the underlying etiology: -Normal complement levels -[**Doctor First Name **] negative -ANCA negative -Tox screen negative -Lupus anticoagulant - neg -Aldosterone < 1 Pending results requiring follow up: -Anticardiolipin antibodies -Protein C/S -AT III -Factor V Leiden -Metanephrines, plasma -Prothrombin mutation -Renin Imaging: NON-CONTRAST CT HEAD: There has been no significant interval evolution over approximately a 3/2 hour time interval of the ill-defined hypodensities within the right centrum semiovale, right lentiform nucleus, and right subinsular cortex. The remaining [**Doctor Last Name 352**]-white matter differentiation is otherwise preserved. There is mild hypoattenuation of the periventricular and deep subcortical white matter. The ventricles and cortical sulci are normal in size and configuration without evidence of mass effect or shift of the normally midline structures. There is no evidence of intra- or extra-axial hemorrhage. There are mucus retention cysts or polyps within both maxillary sinuses. There is opacification involving multiple bilateral ethmoid air cells, the sphenoid sinuses, and the frontal sinuses. The mastoid air cells and middle ear cavities are well aerated. CTA HEAD: The right vertebral artery is dominant. The right posterior communicating artery is hypoplastic. The left posterior communicating artery is visualized. There is mild narrowing involving the mid-to-distal M1 segment of the right MCA. The remaining intracranial arterial vasculature is within normal limits. There is no evidence of aneurysm or arteriovenous malformation. CT PERFUSION: The perfusion images are nondiagnostic secondary to technical failure. CTA NECK: The great vessel origins at the level of the aortic arch are within normal limits. The vertebral artery origins are patent. The paired vertebral arteries are normal in course and caliber without evidence of occlusion, flow-limiting stenosis, or dissection. The common, internal, and external carotid arteries are normal in course and caliber without evidence of occlusion, flow-limiting stenosis, or dissection. Cross-sectional analysis of the internal carotid arteries is as follows: On the right: Proximal DMIN 7.0 mm; distal DMIN 4.2 mm. On the left: Proximal DMIN 5.8 mm; distal DMIN 4.0 mm. The lung apices are clear. The airway is patent. The thyroid gland demonstrates homogeneous attenuation. There are no osseous lytic or blastic lesions identified. IMPRESSION: 1. Hypodensities of indeterminate age in the right centrum semiovale, right subinsular cortex, and right lentiform nucleus with mild narrowing of the mid to distal right M1 segment, which may be secondary to intrinsic disease or thrombus. Recommend MRI for further evaluation of acute infarction. 2. Pansinus disease as described above, the activity of which is to be determined clinically. 3. No CT evidence of aneurysm, dissection, or arteriovenous malformation. MRI: FINDINGS: Increased FLAIR signal of the posterior limb of the right internal capsule extending to involve the posterior caudate nucleus and putamen with corresponding diffusion restriction is consistent with acute to early subacute infarct. There is no intracranial hemorrhage, edema, or shift of midline structures. The ventricles and cerebral sulci are normal in size and configuration. Basal cisterns are preserved. There is a mucous retention cyst of the right anterior maxillary sinus, and mucosal thickening of the ethmoid air cells, frontal sinuses and fluid levels in the sphenoid sinuses. The mastoid air cells are clear. IMPRESSION: 1. Acute to early subacute infarct of the posterior limb of the right internal capsule, extending into the posterior caudate nucleus and putamen. Discussed by Dr. [**Last Name (STitle) 20059**] with Dr. [**Last Name (STitle) 7594**] on [**2147-4-20**] at 3 p.m. 2. Pansinus disease. Carotid Dopplars: Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right and the left there is no plaque seen. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 69/30, 51/23, 51/23 cm/sec. CCA peak systolic velocity is 86 cm/sec. ECA peak systolic velocity is 74 cm/sec. The ICA/CCA ratio is .8. These findings are consistent with no stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 83/28, 58/27, 57/28 cm/sec. CCA peak systolic velocity is 109 cm/sec. ECA peak systolic velocity is 100 cm/sec. The ICA/CCA ratio is .76. These findings are consistent with no stenosis. Right vertebral antegrade artery flow. Left vertebral antegrade artery flow. Impression: Right ICA no stenosis. Left ICA no stenosis. Multiple hypercoagulatibility and secondary hypertension studies were performed to assess the underlying etiology: -Normal complement levels -[**Doctor First Name **] negative -ANCA negative -Tox screen negative -Lupus anticoagulant - neg -Aldosterone < 1 Pending results requiring follow up: -Anticardiolipin antibodies -Protein C/S -AT III -Factor V Leiden -Metanephrines, plasma -Prothrombin mutation -Renin Carotid series [**4-21**]: Impression: Right ICA no stenosis. Left ICA no stenosis. Renal ultrasound [**4-21**]: IMPRESSION: 1. No evidence of hydronephrosis, or renal stone. 2. No evidence of renal artery stenosis bilaterally. TTE [**4-21**]: Conclusions The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve 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 TEE [**4-24**]: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers (though prominent inflow from the inferior vena cava directed towards the interatrial septum by the Eustachian valve seems to blunt the amount of superior vena caval inflow that comes in contact with the interatrial septum). There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. IMPRESSION: No cardiac source of embolism. No evidence of atrial septal defect or patent foramen ovale with saline contrast and maneuvers. No significant valvular abnormality. Normal thoracic aorta to 40 cm from the incisors. If exclusion of a PFO is a clinical necessity, injection of saline via a femoral vein might help to completely exclude a PFO. Brief Hospital Course: 35 yo M with history of HTN presenting with acute onset of left face and arm weakness at 9:50 PM while eating dinner. Symptoms have had a stuttering course and he was given IV TPA for NIHSS 12 prior to transfer. He was called as a CODE STROKE for recurrence of his deficits shortly after infusion of tPA and minutes prior to arrival to [**Hospital1 18**]. His examination is notable for a dense left hemiplegia as well as decreased sensation on the left. #Neuro: He received IV tPA prior to transfer, so was initially admitted to the Neuro ICU. He underwent an MRI which confirmed the presence of a posterior limb of the right internal capsule infarct, extending into the posterior caudate nucleus and putamen. He had a carotid dopplers, as well as a CTA of the head and neck which showed no signs of vascular occlusion. TTE and TEE were peformed (see above) which failed to show a PFO, ASD, right to left shunt or a source of an embolism. Echocardiograms were notable for mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%) suggestive of prior hypertension. The ascending, transverse and descending thoracic aorta were normal in diameter and free of atherosclerotic plaque. Fasting lipids showed LDL of 121 and an A1C was 5.1. Patient was started on Simvastatin. It was thought that his infarct was secondary to hypertension, however possibility of an embolic infarction (though no clear source was identified) which can occur in up to many patients with this presentation could not be ruled out. Given his risk of stroke recurrence (3-5% per year) and age, he was started on coumadin daily (goal INR [**1-25**]) with ASA bridge until therapeutic. He will require further monitoring of INR, at time of discharge was 1.1 (coumadin initiated on [**4-24**] at 5mg daily and may need adjustment). He will require follow up with Dr. [**Last Name (STitle) **] of neurology at [**Hospital1 18**] which was arranged. #CV: The patient was hypertensive on admission, and reported that this was a problem his PCP had been following for several years, recommended dietary changes at this time. Given his relatively young age, he underwent an evaluation for secondary causes of hypertension, including a renal ultrasound which showed no signs of renal artery stenosis, and plasma renin, aldosterone and metanephrines which are pending at time of discharge. Given persistently elevated SBPs (150-170s) mmHg even 4 days after the CVA, he was started on Lisinopril 10mg daily. No significant response was noted after 2 days of therapy, thus dose was increased to 20mg daily on [**4-26**]. No change in Cr was observed after tx initiation. This will require follow up. His eventual goal of BP is 130/80 and should be achieved within 1-2 months after his CVA. Due to LDL of 127 and CVA, he was started on Simvastatin to control the RFs. The following studies will require follow up (pending at [**Hospital1 18**]): -Anticardiolipin antibodies -Protein C/S -AT III -Factor V Leiden -Metanephrines, plasma -Prothrombin mutation -Renin level Neurological exam notable for: Alert, oriented to time, place person. Language intact. CNs: L facial droop, mild Leftward tongue deviation (due to facial) Motor: RUE and RLE full in strength. LUE flaccid. LLE: [**2-24**] IP, [**1-27**] Hamstring, [**1-27**] quadriceps, Remainder is 0/5. Tone: Flacid in LUE, LLE mildly increased relative to LUE. DTRs 3+ at L biceps, triceps, patella. Toes: extensor bilaterally. Sensory: intact LT, proprioception. Extinction on the LEFT with DSS. Medications on Admission: None Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash in armpit. 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 11. HydrALAzine 10 mg IV Q6H:PRN SBP>180 Discharge Disposition: Extended Care Facility: [**Hospital 38**] Rehab in [**Location (un) 1110**] Discharge Diagnosis: Primary: Right Anterior Choroidal Artery Secondary: Hypertension, Hyperlipidemia Discharge Condition: Neurological exam notable for: Alert, oriented to time, place person. Language intact. CNs: L facial droop, mild Leftward tongue deviation (due to facial) Motor: RUE and RLE full in strength. LUE flaccid. LLE: [**2-24**] IP, [**1-27**] Hamstring, [**1-27**] quadriceps, Remainder is 0/5. Tone: Flacid in LUE, LLE mildly increased relative to LUE. DTRs 3+ at L biceps, triceps, patella. Toes: extensor bilaterally. Discharge Instructions: You were admitted to the hospital after sudden onset left sided weakness. You were found to have a significant stroke in the right side of your brain. You underwent a thorough evaluation for the source of this stroke (detailed in discharge summary). After a thorough evaluation, we were unable to identify a definite source of the stroke, however, it was felt that it was due to hypertension and a possible embolic source. Because of this, you were started on the following medications: - Coumadin 5mg daily - ASA 325mg until coumadin is therapeutic range (INR [**1-25**]) - Simvastatin 20mg - Lisinopril 20mg - Bowel regimen, pain regimen as per your rehabilitation physician Because of the aftermath from your stroke, you will require extensive rehabilitation. You were discharged to such a facility There are still tests pending that will require follow up: Followup Instructions: Please follow up with the following providers: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2147-6-27**] 1:00 Please call the PCP's office to arrange for a follow up appointment in 1month from your discharge: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Address: [**Location (un) **] [**Apartment Address(1) 5524**], [**Location (un) **],[**Numeric Identifier 7331**] Phone: [**Telephone/Fax (1) 7401**] Fax: [**Telephone/Fax (1) 7400**] [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2147-4-26**]

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Discharge summary

report

Admission Date: [**2121-4-30**] Discharge Date: [**2121-5-2**] Date of Birth: [**2099-10-6**] Sex: F Service: MEDICINE Allergies: Tylenol Attending:[**First Name3 (LF) 4219**] Chief Complaint: passed out Major Surgical or Invasive Procedure: None History of Present Illness: This is a 21 year old woman with PMH of seizures who presents following loss of consciousness in class. She reports being in class and developing pleuritic chest pain for 10 minutes. She says it was a sharp pain. The next thing she remembers is waking up in the ED, naked. Per records, she was brought to the ED by EMS and observed to have a episode of her eyes rolling back, and her pupils were pinpoint. She received 2 mg iv narcan and appeared to wake up. She had a positive D-dimer and was getting her CTA and also became unresponsive. Head CT was unremarkable. She got 2 mg more of Narcan and woke up somewhat again. Due to concern for her becoming unresponsive repetitively and needing more narcan, she was admitted to the MICU for observation. Over the last few months, she remembers passing out over the last few months. For example, she was evaluated at the [**Hospital1 112**] ED on [**3-14**] with seizures. She reports some dizziness over the last few days and a decreased appetitite over the last few weeks. She's lost 15 pounds over the last 2 weeks. Denies night sweats, diarrhea, fevers, chills, incontinence, tongue biting. . On ROS, she reports having a miscarriage 4 days ago with passing of spongy material. Her last menstrual period was around [**3-17**] and she tested postive on a urine pregnancy test. She has had some bleeding since that time, decreasing each day. She is okay with the pregnancy terminating. Past Medical History: palpitations dysfunctional uterine bleeding(likely cyst rupture; seen at ob/gyn clinic) migraine Social History: college student, originally from [**Name (NI) 21380**], uncle who lives in area, lives in [**Location **], denied smoking or drinking or IVDU. Family History: father and mother alive and well, 5 sisters without medical problems. [**Name (NI) **] history of childhood seizure/ epilepsy Physical Exam: : T98.3 BP 94/58 P70 R20 99% RA Gen: slowed speech but appropriate responses. no apparent distress HEENT: pupils 4 mm and reactive bilaterally. OP clear. MMM Resp: CTA bilaterally CV: RRR nl s1s2 no MRG Abd: soft NTND +BS Gyn: deferred Ext: no cyanosis, clubbing, or edema Neuro: CN 2-12 intact, strength 5/5/ UE and LE. no pronator drift. Pertinent Results: EKG: NSR, no ST/T wave changes. . CXR: IMPRESSION: Possible widening of the superior mediastinum. Please correlate with mechanism of injury. No pneumothorax or fracture identified. . CT head: IMPRESSION: No evidence of intracranial hemorrhage. . CT chest with contrast: IMPRESSION: No evidence of pulmonary embolism or other acute cardiopulmonary process. . TTE: Conclusions: 1.The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. 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. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. 6.There is no pericardial effusion. Brief Hospital Course: The patient was admitted to the MICU out of concern for repeated unconsciousness. There was no history to suggest tongue biting, bowel/bladder incontinence, shaking or other seizure activity. She had a urine and serum tox screen in ED that was negative. She was rehydrated with 1 liter of NS, was not found to be orthostatic. Neurology had evaluated her in the ED, initial evaluation recommended outpatient follow-up with her neurologist, however the next morning the neuro service recommended an echo and an EEG. The patient did not have any further episodes of unresponsiveness while in the unit, remained afebrile and hemodynamically stable. . She was restarted on her home dose of Topamax, and her outside neurologist was trying to be reached. She was transferred to a medicine floor on the morning after admission. The following course by problem is summarized from the time the pt was transferred to the medicine service: . #) Loss of consciousness: The etiology of the pts syncopal episode still remains unclear. The differential diagnosis included seizure vs. basilar migraine vs. opiate overdose per neuro. The pts story was somewhat inconsistent, given that she had pinpoint pupils and responded to narcan, however her tox screen was negative. There is also a possibity of psychiatric disturbance in the differential. Apparently witnesses from the original episode were not reachable, and the pt was unable to recall the name of the woman who had helped her out of the classroom. The pt was monitored on telemetry throughout her stay, but there were no reported events on tele to suggest cardiac etiology. TTE revealed no valvular abnormalities, EF 55%. The pt was slightly orthostatic on the day of discharge, but this resolved after she was given 1 L NS. The pt was seen by psychiatry and was diagnosed with adjustment disorder and anxiety disorder. Psychiatry recommended the pt undergo neuropsychological testing and follow up with a psychiatrist, possibly under the referral of her primary neurologist, Dr. [**Name (NI) **]. The pt was also given the phone number for [**Location (un) 44009**]Counseling Services by the psychiatric consultants. EEG was also perfromed prior to the pts discharge, revealing diffuse slowing. Neurology recommended discontinuation of the pts Topamax as it was felt this medication could be the culprit of the diffuse slowing. . #) History of recent preganacy with likely miscarriage: The pt complained of mild vaginal bleeding throughout her stay. Interestingly, the pts urine HCG was negative, although she claimed she had a miscarriage 4 days prior to admission (however serum bHCG levels were not checked). Of note, the pt also has a history of dysfunctional uterine bleeding noted in prior discharge summaries. Medications on Admission: Topomax- dose recently increased from 100 to 125. Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: syncopal episode Discharge Condition: stable, no further episodes of syncope, no seizure activity documented Discharge Instructions: 1) Stop taking your Topamax 2) Follow up with your neurologist as scheduled below, you will need an oupt eeg 3) Return to the ER or call your doctor [**First Name (Titles) **] [**Last Name (Titles) 16169**] episodes of fainting, chest pain, worsening pelvic pain or vaginal bleeding, loss of consciousness, or any other concerning symptoms Followup Instructions: 1) Please follow up with your neurologist Dr. [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 21076**] on Tuesday at 2 PM [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]

[ "E850.2", "780.2", "E855.0", "780.39", "966.3", "309.4", "346.90", "965.09" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6391, 6397

3484, 6262

279, 285

6458, 6531

2552, 2738

6919, 7182

2048, 2176

6362, 6368

6418, 6437

6288, 6339

6555, 6896

2192, 2533

228, 241

313, 1750

2747, 3461

1772, 1871

1887, 2032

10,926

101,590

46506

Discharge summary

report

Admission Date: [**2185-10-31**] Discharge Date: [**2185-11-8**] Date of Birth: [**2125-11-6**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 59 year old female patient who was struck by a motor vehicle. She presented to the Emergency Department as a trauma patient. Trauma workup revealed the presence of intracranial bleeding which was followed by the neurosurgical service. In addition to this injury, she had an anterior plateau fracture in the lower extremity which was addressed by my service. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Bilateral total hips. MEDICATIONS ON ADMISSION: 1. Norvasc. 2. Lopressor. 3. Plavix. 4. Zocor. 5. ______. HOSPITAL COURSE: After appropriate clearing was provided by neurosurgical service, the patient was taken to the operating room mainly for management of her anterior plateau fracture. The patient was cleared for surgery and went to the operating room on [**2185-11-3**]. She underwent an uncomplicated open reduction, internal fixation of a Schatzker 6 left anterior plateau fracture. She remained nonweight-bearing on the operated extremity with a hinge brace. She was anticoagulated with Lovenox for deep venous thrombosis prophylaxis and she was managed with 24 hours preoperative antibiotics. She was followed by the physical therapy service and was discharged to rehabilitation on [**2185-11-8**]. The patient had an uneventful hospital course and was to be followed two week postoperative for wound checks. MEDICATIONS ON DISCHARGE: 1. Percocet one to two q4hours p.r.n. 2. Preoperative regimen. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16347**] Dictated By:[**Last Name (NamePattern1) 16348**] MEDQUIST36 D: [**2186-2-16**] 08:27:53 T: [**2186-2-18**] 09:47:35 Job#: [**Job Number 98782**]

[ "V45.81", "912.0", "823.00", "851.81", "873.42", "401.9", "276.8", "924.01", "458.9", "E814.7" ]

icd9cm

[ [ [] ] ]

[ "79.36", "86.59" ]

icd9pcs

[ [ [] ] ]

1547, 1884

642, 702

720, 1521

161, 539

561, 616

8,835

198,325

8893

Discharge summary

report

Admission Date: [**2192-3-26**] Discharge Date: [**2192-4-25**] Service: GEN SURGER HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 30928**] is an 83-year-old male with a past medical history significant for coronary artery disease, diabetes mellitus type 2, and peripheral vascular disease, who had undergone prior peripheral vascular operations, and presented to the hospital on [**2192-3-26**] with an infection of a thigh wound status post a left femoral to perineal bypass graft. The patient had noticed a lump on his medial thigh and it had begun to turn erythematous with some drainage. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2 with neuropathy and retinopathy. 2. Hypertension. 3. Peripheral vascular disease. 4. Osteoarthritis. 5. Chronic renal insufficiency with a baseline creatinine of 1.7 to 2.1. 6. Coronary artery disease. PAST SURGICAL HISTORY: 1. A left femoral to perineal bypass with insitu saphenous vein graft. 2. Cataract repair. 3. Laser eye surgery. 4. Status post a left fifth metacarpal phalangeal joint resection. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Lasix 20 mg po q.d. 2. Lopressor 50 mg po q.d. 3. Zestril. 4. Aspirin 325 mg po q.d. 5. Iron sulfate 325 mg q.d. 6. Epogen 10,000 units q. week. 7. NPH insulin 20 units q.a.m. and 15 units q.h.s. 8. A regular insulin sliding scale. SOCIAL HISTORY: The patient has no significant tobacco or alcohol history. PHYSICAL EXAMINATION ON ADMISSION: Mr. [**Known lastname 30928**] was found to be an alert white male in no acute distress. His heart rate was 62 beats per minute in sinus rhythm. His blood pressure was 120/50, with a respiratory rate of 12 breaths per minute. He was found to be normocephalic with a supple neck and no lymphadenopathy. His trachea was in the midline. His lungs were clear to auscultation bilaterally. His heart showed a regular rate and rhythm with normal S1, S2, as well as no murmurs, rubs or gallops. His abdomen was soft, nontender, and nondistended with no hepatosplenomegaly or other palpable masses. His left thigh showed an area of induration on the medial aspect with a slightly open area which was draining fluid. It was able to be probed medially. In terms of neurological status, he was alert and oriented to person, place and time, and his gross motor and sensory functions were intact. HOSPITAL COURSE: Mr. [**Known lastname 30928**] was initially admitted to the Vascular Surgical Service on [**2192-3-26**] in order to deal with his postoperative wound infection. He was started on antibiotics at that time. The Renal and Cardiology Services were consulted to help follow this patient due to standing cardiac and renal issues. He was also followed by the [**Hospital **] Clinic in regards to his diabetes. On hospital day number five, the patient was noted to vomit 750 mL of blood while on the regular patient floor. The patient was noted to have no prior history of peptic ulcer disease, and at that time was on aspirin and prophylactic doses of subcutaneous heparin to prevent deep vein thrombosis. At the time, the patient denied having any chest pain, shortness of breath or abdominal discomfort. At this time, large bore intravenous access was obtained and a nasogastric tube was placed with return of dark fluid with blood clots. He was continuously lavaged without clearing. Due to changes at this time in his hemodynamic stability, he was transferred to the Intensive Care Unit and seen by the Gastroenterology Service in consult for potential therapeutic endoscopy. Once in the Intensive Care Unit, he was actively repleted with packed red blood cells, crystalloid, as well as blood products to maximize his coagulation factors. An esophagogastroduodenoscopy was carried out that night, Friday, [**2192-3-30**], and showed a normal esophagus, as well as localized erythema and erosions of the mucosa of the stomach with stigmata of recent bleeding. One of the sites that was observed was treated with BICAP cautery. The duodenum was found to be normal in appearance. At this time, the patient also developed atrial fibrillation. His blood pressure did remain stable, and he was continually transfused with red blood cells and fresh frozen plasma. His rhythm was corrected using beta-blockade, and the patient remained hemodynamically stable at that time. On hospital day number six, [**3-31**], blood was again noted to be coming from the nasogastric tube. At this time, the patient went into respiratory arrest and was emergently intubated. It was noted that there was a good deal of blood aspirated through the endotracheal tube. The patient was resuscitated and again scoped by the Gastroenterology Service, where a large amount of blood was found in the esophagus and stomach. He at that time was evaluated by the General Surgery Service in consult, and the decision was made to take the patient to the Operating Room. The patient was taken to the Operating Room on [**2192-3-31**] where he was underwent an exploratory laparotomy, a subtotal gastrectomy, an incidental splenectomy, a Roux-en-y gastrojejunostomy, as well as a placement of a feeding jejunostomy tube. Please refer to the dictated operative note for full details of this procedure. It was found intraoperatively, that the patient's stomach was distended with multiple punctate ulcers throughout, as well as a good deal of clotted blood. The patient tolerated the procedure and was transferred postoperatively back to the Surgical Intensive Care Unit. At this time, the patient was also quite acidotic with a lactate of 5.7, he had a potassium of 6.1, as well as a creatinine elevated well above his baseline. He continued to be followed by the Renal Service in consult for these issues. Due to the acute blood loss and hemodynamic instability form the patient's upper gastrointestinal bleed and surgical procedure, he was found to have had a perioperative myocardial infarction. His troponin rose as high at 33.8, as well as having an elevated CK-MB fraction and index. His creatinine at this time was 2.4. His hematocrit was 25.7. He was continued to be followed by the Cardiology Service for these issues. He slowly began to recover remaining intubated in the Surgical Intensive Care Unit. Tube feeds at a rate of 10 cc per hour were started a few days later. On postoperative day number three, the patient was found to be awake and following commands. He was also found to have recurrent atrial fibrillation. His oxygenation and hemodynamic remained stable however. On postoperative day number five, the tube feeds were at goal, and continued ventilator weaning was being undertaken. At this time, also, the patient was found to have yeast growing in [**12-24**] blood culture bottles. The patient was extubated successfully on postoperative day number seven, which he tolerated fairly well. He continued to have brief periods of atrial fibrillation, but did convert back into normal sinus rhythm. The patient was started on antifungal medication to treat the yeast which had grown from his blood culture. He was seen by the Infectious Disease Service in consult at that time. A surface echocardiogram was done to look for valvular vegetations which were not seen. During this echocardiogram, it was noted that his left ventricular ejection fraction was 20-30%. Per the Infectious Disease Service, the patient was started on Caspofungin as therapy for his fungemia. He also was experiencing diarrhea, and for that reason was started on oral vancomycin. His subsequent blood cultures on the 22nd and [**4-13**] were negative. An attempt was made to start the patient on anticoagulation for his atrial fibrillation, but he prompted developed bright red blood per rectum, so this was immediately stopped. His creatinine slowly began to normalize, as did his white blood cell count. His hematocrit remained stable. The patient underwent a speech and swallowing evaluation at this time, and it was found that he was in danger of aspiration for thin liquids, but he was clear to drink nectar thick liquids, as well as pureed foods and very soft solids. On postoperative day number 19, the patient was deemed stable and ready for transfer to the regular patient floor. Since that time, he has done quite well. He is tolerating his tube feeds which are Nepro full strength at 45 cc an hour without any difficulty. He is tolerating oral intake consisting of nectar thick liquids and very soft solids without any difficulty. He remains afebrile and his creatinine has normalized back to its baseline level. His white blood cell count has also been fine. The patient is afebrile and following commands, communicating easily. On postoperative day number 25, it was deemed that the patient was medically and surgically stable and ready for discharge from the hospital. It is, however, necessary that he be discharged to an extended care facility as his hospitalization has caused him to become quite physically debilitated and he will require much help in this area. It is also necessary that he continue to be on the antifungal medication for another five weeks. DISPOSITION: To an extended care hospital facility. PATIENT ACTIVITY: Patient requires a great deal of assistance in order to be able to get out of bed and perform his activities of daily living at this time. PATIENT'S DIET: The patient must not be allowed to have thin liquids of any kind pending further speech and swallow evaluated, but because at this time, he is at risk for silent aspiration of thin liquids. He is permitted to have nectar thick liquids, as well as purees and very soft solids. His diet should consist of a diabetic and cardiac formulation due to those two disease processes in this gentlemen. PATIENT'S MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg per J tube q.d. 2. Caspofungin acetate 35 mg intravenous q.d. The patient has a left-sided PICC line. 3. Heparin 5,000 units subcutaneously q. 12 hours. 4. Lopressor 25 mg po t.i.d. 5. NPH insulin 25 units q. 12 hours. 6. A regular insulin sliding scale. 7. Benadryl 25 mg po q.h.s. prn. 8. Amiodarone 400 mg po q.d. 9. Lansoprazole oral solution 30 mg po q.d. 10. Atrovent nebulizer solution q. 6 hours prn. 11. Albuterol nebulizer solution q. 6 hours prn. 12. Epogen 10,000 subcutaneously q. week on Wednesday's. It should be noted at this time, that the patient should not be given any other type of anticoagulation other than the subcutaneous heparin, which he is on for deep vein thrombosis and pulmonary embolus prophylaxis, and which he has thus far tolerated. The patient will be leaving with one [**Location (un) 1661**]-[**Location (un) 1662**] drain in his abdomen which should be emptied and recorded on an as needed basis. He has a jejunostomy tube through which he is being fed and should continue to be fed with this Nepro at 45 cc an hour. The patient also has a venostasis ulcer on the medial aspect of his left leg which will need to be cared for. As the patient has been restarted on his Lasix, his peripheral edema should decrease somewhat, but the patient should continue to receive bilateral ACE wraps of both legs, which should include the feet and go to the knee, bilateral leg elevation at all times, as well as Venodynes, and multipodis splint for protection or in alternative sheep skin to the foot of his bed to protect his heels from further breakdown. FOLLOW-UP: Follow-up should be with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30929**] of the General Surgery Department at the [**Hospital6 649**]. The patient may call for a specific appointment and time. There should also be follow-up with Dr. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3640**], of the Infectious Disease Department, on [**5-7**] at 9:30 a.m. She has requested that the patient undergo a CAT scan of his abdomen on [**5-3**] and to have his results with him when he arrives. She has also requested that liver function enzymes be checked once per week so that Caspofungin toxicity if evident, may be monitored. These results should be faxed to [**Telephone/Fax (1) 1419**]. Dr.[**Name (NI) 30930**] clinic number is [**Telephone/Fax (1) 457**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**First Name3 (LF) 30931**] MEDQUIST36 D: [**2192-4-25**] 01:38 T: [**2192-4-25**] 13:40 JOB#: [**Job Number 30932**]

[ "518.5", "410.41", "785.59", "584.5", "427.5", "998.51", "998.2", "117.9", "532.00" ]

icd9cm

[ [ [] ] ]

[ "43.7", "34.91", "41.5", "38.93", "46.39", "96.04", "88.48", "99.15", "96.34", "45.13", "44.43", "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

9879, 12582

1158, 1402

2426, 9853

893, 1132

125, 611

1515, 2408

633, 870

1419, 1500

7,815

169,106

9710

Discharge summary

report

Admission Date: [**2191-11-13**] Discharge Date: [**2191-11-23**] Date of Birth: [**2148-6-7**] Sex: M Service: Vascular Discharge date is pending. CHIEF COMPLAINT: "Black toe." HISTORY OF PRESENT ILLNESS: This is a 43-year-old white male with end-stage renal disease status post living related renal transplant who had a loose nail two days ago. He pulled the nail off and applied bacitracin ointment, unwrapped it to check it, and found a black toe. He has had several toe amputations in the past. He denies any pain. "Has neuropathy." Has had a fever over the last several days. Denies chest pain, shortness of breath, nausea, or vomiting. He has a history of claudication half a mile bilateral calves relieved with rest. Patient is now admitted for further evaluation and treatment. PAST MEDICAL HISTORY: Type 1 diabetes, coronary artery disease, hypertension, end-stage renal disease, neuroretrogastropanii. Past surgical history includes living related renal transplant [**Month (only) 404**] of this year, coronary artery bypasses in [**Month (only) **] of 01, toe amputations secondary to trauma, vitrectomy one month ago. ALLERGIES: No known drug allergies. Medications include Prograf 0.5 mg [**Hospital1 **], prednisone 5 mg po q day, CellCept [**Pager number **] mg tid, Bactrim-SS q day, Protonix 40 mg q day, Reglan 10 mg q day, Lipitor 10 mg q day, Florinef 0.1 tid, lantus insulin 25 units q day. SOCIAL HISTORY: Is a smoker four cigarettes per day, maybe 1-2 drinks per month. He is unemployed. PHYSICAL EXAMINATION: Vital signs are 98.1, 93, 110/68, 18. General appearance is alert and oriented male in no acute distress. HEENT examination was unremarkable. There was no lymphadenopathy. Chest examination shows lungs are clear to auscultation bilaterally. Heart is a regular, rate, and rhythm. Abdomen is benign. Left lower quadrant transplant can be palpated. Pulse examination shows palpable carotids without bruits. Radials are palpable. Femorals are palpable bilaterally. Popliteals are triphasic bilaterally. Dorsalis pedis is palpable on the left and monophasic Doppler signal on the right. Posterior tibial pulses are absent bilaterally. Abdominal aorta is nonprominent. There are no abdominal bruits. The left foot shows the second and fifth toe amputations, right foot toes one, three, and five are dusky in color, two is with dry gangrene. LABORATORIES: Preoperative complete blood count: White count 8.6, hematocrit of 47.9, BUN 18, creatinine 1.2, 1.6 repeated. Coags are normal. Electrocardiogram is normal sinus rhythm, left axis deviation. Q's in II, III, and aVF, ST changes in I and aVL, V5 and V6. Chest x-ray was unremarkable. HOSPITAL COURSE: The patient was admitted to the Vascular Service. He was placed on bed rest. Patient was begun on levofloxacin and Flagyl. He was prehydrated and Mucomyst protocol was instituted in anticipation for arteriogram. The patient underwent an abdominal aortogram with a right leg run-off. The aorta was patent with diffuse disease. Iliacs were patent with patent hypogastrics bilaterally. The common femoral profunda were patent. The SFA was occluded. There was a reconstituted AK [**Doctor Last Name **] with single vessel run-off via the AT. The PT, peroneal, and tibioperoneal trunk were occluded. AT was with less than 50% stenosis via 2 cm beyond its origin. The AT perfused the DP and arch. Renal service followed the patient for his immunosuppressive needs. Carotid duplexes were obtained which were negative for significant hemodynamic disease. Cardiology was requested to see the patient prior to any surgical intervention. They felt from a primary cardiac standpoint, patient was stable for any vascular procedure. Patient's midodrine was discontinued secondary to normotensive blood pressures at rest. [**Last Name (un) **] was consulted regarding diabetic management. He required aggressive management with IV insulin for his hyperglycemia. Patient underwent on [**11-17**] a right fem AK [**Doctor Last Name **] with [**Doctor Last Name 4726**]-Tex with the intraoperative arteriogram, tolerated the procedure well, and was transferred to the PACU in stable condition. Postoperative hematocrit was 38.9, BUN 19, creatinine 2.9. Electrocardiogram without acute changes. Chest x-ray was without pneumothorax. The patient remained hemodynamically stable. Had a palpable dorsalis pedis and dopplerable posterior tibial pulse. He was transferred to the VICU for continued monitoring and care. On postoperative day one, his Neo was weaned off. He remained hemodynamically stable. IV Reglan was begun for his history of gastroparesis. There were no events. The patient was de-lined. Diet was advanced to tolerate. Fluids were HEP locked. Was transferred to the regular nursing floor. His hematocrit remained stable. BUN and creatinine improved 15 and 0.8. Postoperatively the patient required IV insulin drip for aggressive management of his hyperglycemia with a significant improvement on his glucose ranges. Patient underwent on [**2191-11-21**], a right second toe amputation without complication. Initial dressing was removed on postoperative day one. The wound was clean, dry, and intact. There was no ischemic changes. On postoperative day one from his toe amputation, physical therapy was requested to evaluate the patient, but nonweightbearing, ambulation essential distances only. Remaining hospital course was unremarkable. Glucoses were adequately controlled with aggressive insulin adjustments. At the time of his discharge, his wounds were clean, dry, and intact. He had a palpable dorsalis pedis and dopplerable posterior tibial pulses. The amputation site wound was stable. Patient should follow up with Dr. [**Last Name (STitle) **] in two weeks' time. The patient is to followup with [**Last Name (un) **] as instructed. Should continue to monitor his glucoses qid. DISCHARGE MEDICATIONS: Percocet tablets [**2-9**] q4 hours prn for pain, metoprolol 12.5 mg [**Hospital1 **], hold for systolic blood pressure less than 110, heart rate less than 55, Protonix 40 mg q day, aspirin 325 mg q day, Artificial Tears drops [**2-9**] OU prn, averstatin 10 mg q day, Reglan 10 mg q day, Bactrim-SS one q day, prednisone 5 mg q day, Mycophenolate mofetil 500 mg tid, tacrolimus 0.5 mg [**Hospital1 **], Humalog sliding scale, please see flow sheet, insulin six doses please see flow sheet. DISCHARGE DIAGNOSES: 1. Ischemic foot changes status post right femoral AK popliteal with [**Doctor Last Name 4726**]-Tex. 2. Gangrenous right second toe changes status post right second toe amputation. 3. Type 1 diabetes with episodes of hyperglycemia treated improved. 4. Status post renal transplant. 5. Immune suppressed stable. 6. Recent vitrectomy with stable vision. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2191-11-23**] 07:25 T: [**2191-11-23**] 07:53 JOB#: [**Job Number 32792**]

[ "440.24", "707.15", "401.9", "V42.0", "250.61", "337.1", "536.3", "V45.81", "250.71" ]

icd9cm

[ [ [] ] ]

[ "39.29", "88.48", "84.11" ]

icd9pcs

[ [ [] ] ]

6513, 7121

6000, 6492

2747, 5976

1575, 2729

187, 201

230, 818

841, 1450

1467, 1552

10,589

164,518

2862

Discharge summary

report

Admission Date: [**2186-8-14**] Discharge Date: [**2186-8-22**] Date of Birth: [**2114-1-10**] Sex: M Service: CHIEF COMPLAINT: Patient is a 76-year-old gentleman with known autoimmune hepatitis, who presented to the [**Hospital1 346**] with acute onset abdominal pain ultimately leading to a colonic resection for ischemic gut. PRIOR MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypercholesterol. 3. COPD. 4. Hypertension. 5. Left carotid occlusion. 6. Gastritis. 7. Non-insulin dependent-diabetes mellitus. 8. Raynaud's. 9. Autoimmune hepatitis. 10. Cholelithiasis. 11. Idiopathic pleural effusions. MEDICATIONS ON ADMISSION: 1. Aspirin. 2. Atenolol 50 mg q.d. 3. Lipitor 20 mg q.d. 4. Atrovent two q.d. 5. Coumadin two q.d. 6. Citrucel q.d. 7. Multivitamin. 8. Protonix 40 q.d. 9. Actigall 250 b.i.d. 10. Prednisone 40 mg q.d. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: In the [**Hospital1 **] Emergency Department, patient's vital signs were a temperature of 97.4, pulse 78, blood pressure 181/98, respirations 20, and sating 97% on room air. White blood cell count was 11.2, hematocrit 48.8, platelets 181. PT 12.0, INR 1.0, PTT 20.7. Sodium 141, potassium 3.3, chloride 98, CO2 32, BUN 31, creatinine 1.6, and a glucose of 283. AL7 176, AST 21, amylase 71, alkaline phosphatase 165, total bilirubin 1.2. KUB on admission showed colonic distention and stool and air in the rectum distal colon. CLINICAL COURSE: This patient originally presented on [**2186-6-8**] with an approximately six week history of pruritus, 12 pound unintentional weight loss, dark urine, and light stools. At that time, he was noted to have increased LFTs, so ERCP was performed on [**2186-6-23**]. No obstruction or lesion was found, although a stent was placed ultimately leading to no relief. Subsequent workup by GI Hepatology showed that the patient had autoimmune hepatitis, and liver biopsy was found to be consistent with this. Patient was then started on prednisone with relief of symptoms. On the Friday prior to admission, the patient had his stent removed. The following morning at approximately 3 a.m., the patient awoke constipated with diffuse [**9-15**] abdominal pain radiating to the back, steady, but not crampy. There is no change in the pain, intensity, or quality based on position, eating, or activity. There was associated nausea and vomiting during the entire morning and following day. CT scan performed that morning showed uniformly dilated colon with air in the colon wall (pneumatosis). Air was also seen in the portal system and small amount of air tracking along the colon wall. Based on the these results, the patient was started immediately on IV antibiotics, and transferred to the Surgical Intensive Care Unit. From the Intensive Care Unit, the patient underwent a right hemicolectomy, with creation of a diverting ileostomy and mucus fistula. Following the surgery on the [**2186-8-15**], patient returned to the Intensive Care Unit and was paced on the ventilator for respiratory support. On postoperative day three, on [**2186-8-17**], the patient was successfully extubated and his supportive requirements were gradually decreased. On [**2186-8-18**], the patient was transferred from the Intensive Care Unit to a normal patient care floor. On the floor, he continued to progress well with bowel function gradually returning over the next several days. On [**2186-8-19**], his diet was advanced from sips to clear liquids to full liquids and ultimately soft foods. He tolerated all of this without problem or episode. Following a Physical Therapy consult and evaluate on [**2186-8-21**] and conferring with the attending surgeon, it was felt that the patient was a suitable candidate for discharge. Prior to his departure, he completed full training with both the wound care nurse and the ostomy nurse at the [**Hospital1 **]. CONDITION ON DISCHARGE: On discharge, patient is stable, tolerating full p.o. DISCHARGE STATUS: Patient is discharged to home with visiting nursing. DISCHARGE DIAGNOSES: 1. Status post hemicolectomy for ischemic bowel. 2. Autoimmune hepatitis. 3. Coronary artery disease. 4. Hypercholesterol. 5. COPD. 6. Hypertension. 7. Left carotid occlusion. 8. Gastritis. 9. Non-insulin dependent-diabetes mellitus. 10. Raynaud's. 11. Autoimmune hepatitis. 12. Cholelithiasis. 13. Idiopathic pleural effusions. MEDICATIONS ON DISCHARGE: 1. Aspirin. 2. Atenolol 50 mg q.d. 3. Lipitor 20 mg q.d. 4. Atrovent two q.d. 5. Coumadin two q.d. 6. Citrucel q.d. 7. Multivitamin. 8. Protonix 40 q.d. 9. Actigall 250 b.i.d. 10. Prednisone 40 mg q.d. 11. Levofloxacin 500 mg q.d. x6 days. 12. Flagyl 500 mg t.i.d. also for six days. FOLLOWUP: The patient is scheduled to see Dr. [**Last Name (STitle) **] in clinic on Thursday, [**8-31**]. He has an occlusion clamp in place over his mucus fistula. This will most likely fall off on its own by the time of discharge and his clinic appointment, and he is instructed to bring this with him to the clinic when he sees Dr. [**Last Name (STitle) **]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Last Name (NamePattern1) 6825**] MEDQUIST36 D: [**2186-8-22**] 10:21 T: [**2186-8-24**] 07:13 JOB#: [**Job Number 13912**]

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icd9cm

[ [ [] ] ]

[ "46.13", "46.20", "45.73" ]

icd9pcs

[ [ [] ] ]

4122, 4452

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650, 3948

145, 624

3973, 4101

48,414

192,814

36743

Discharge summary

report

Admission Date: [**2132-9-15**] Discharge Date: [**2132-9-18**] Date of Birth: [**2088-9-11**] Sex: F Service: PLASTIC Allergies: Amoxicillin / Bactrim Attending:[**First Name3 (LF) 16920**] Chief Complaint: Inflammatory carcinoma of the left breast diagnosed [**2131-8-6**] s/p neoadjuvant chemo and s/p left modified radical mastectomy on [**2132-1-18**] now with left breast defect. Major Surgical or Invasive Procedure: Left delayed [**Last Name (un) 5884**] flap breast reconstruction History of Present Illness: Mrs. [**First Name (STitle) **] is a 44-year-old Caucasian female with history of inflammatory carcinoma of the left breast diagnosed [**2131-8-6**]. She underwent neoadjuvant chemotherapy and then subsequently underwent a left modified radical mastectomy on [**2132-1-18**]. At the time of her mastectomy, she was found to have residual invasive ductal carcinoma, 6.5 cm, grade 2, five of six nodes positive for metastatic disease, the largest metastasis 0.9 cm with extranodal extension. Patient was then placed on Zoladex and monthly and tamoxifen for estrogen blockade as well as Zometa to prevent bone loss. She was encouraged to wait 6 months post mastectomy before considering reconstructive options. She now presents for a desired delayed left breast reconstruction. Past Medical History: Depression Left breast cancer Social History: Ms. [**Known lastname 83070**] lives with her mother, brother, and sister. She is a substitute teacher in the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] system. Family History: negative for breast and ovarian cancer. Physical Exam: Pre-procedure PE as per Anesthesia Record [**2132-9-15**]: General: overweight woman in NAD Mental/psych: cooperative, pleasant Airway: as documented in detail on anesthesia record Dental: good Head/neck Range of motion: free range of motion Heart: RRR Lungs: clear to auscultation Abdomen: soft, nontender, no bruits Extremities: no edema, skin warm and dry Other: R chest portacath, anicteric, neck supple Pertinent Results: [**2132-9-16**] 04:44AM BLOOD WBC-8.8# RBC-3.46* Hgb-10.5* Hct-32.1* MCV-93 MCH-30.3 MCHC-32.7 RDW-14.0 Plt Ct-306 Brief Hospital Course: The patient was admitted to the plastic surgery service on [**2132-9-15**] and had a left breast [**Last Name (un) 5884**] flap reconstruction. The patient tolerated the procedure well. . Neuro: Post-operatively, the patient received Morphine PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to Oxycodone with good pain control reported. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#2. Intake and output were closely monitored. . ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO cefadroxil for discharge home. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD#4, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: effexor 75 mg po daily Ativan 0.5mg PRN zolidex implanted tamoxifen 20 mg daily xometa yearly viatamin C, B12 and calcium +D Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily) for 30 days. Disp:*45 Tablet, Chewable(s)* Refills:*0* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, HA, T>100 degrees: Do not exceed 4gms/4000mg of Tylenol per day. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 5. Cefadroxil 500 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours for 7 days. Disp:*14 Capsule(s)* Refills:*0* 6. Tamoxifen 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Personal Care: 1. Remove dressings and discard. Dressings may be replaced as needed. Use tape sparingly. 2. Clean around the drain site(s), where the tubing exits the skin, with hydrogen peroxide. 3. Strip drain tubing, empty bulb(s), and record output(s) [**3-5**] times per day. 4. A written record of the daily output from each drain should be brought to every follow-up appointment. your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. DO NOT wear a bra for 3 weeks. You may wear a camisole for comfort as desired. 6. You may shower daily with assistance as needed. 7. The Dermabond skin glue will begin to flake off in about [**8-9**] days. 8. No pressure on your chest or abdomen 9. Okay to shower, but no baths until after directed by your surgeon . Activity: 1. You may resume your regular diet. Avoid caffeine and chocolate. 2. DO NOT drive for 3 weeks. 3. Keep hips flexed at all times for 1 week, and then gradually stand upright as tolerated. 4. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity for 6 weeks following surgery. 5. Please perform the occupational therapy exercises as instructed. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 2. Take Aspirin, 120 mg by mouth once daily, for 30 days after surgery. 3. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 4. Take prescription pain medications for pain not relieved by tylenol. 5. Take your antibiotic as prescribed. 6. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softerner if you wish. 7. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, welling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness,swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. . DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16921**], MD Phone:[**Telephone/Fax (1) 4649**] Date/Time: [**2132-9-23**] 8:45 . Provider: [**Name11 (NameIs) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 17898**] Date/Time: [**2132-12-11**] 10:30

[ "V51.0", "V87.41", "196.3", "V15.3", "V45.71", "V10.3" ]

icd9cm

[ [ [] ] ]

[ "85.74" ]

icd9pcs

[ [ [] ] ]

4513, 4519

2232, 3649

461, 529

4577, 4577

2093, 2209

8231, 8520

1608, 1650

3824, 4490

4540, 4556

3675, 3801

4728, 8208

1665, 2074

243, 423

557, 1336

4592, 4704

1358, 1389

1405, 1592

14,109

148,414

51901

Discharge summary

report

Admission Date: [**2194-10-4**] Discharge Date: [**2194-10-16**] Date of Birth: [**2122-8-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor Last Name 10493**] Chief Complaint: Hyperkalemia, Bleeding Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 72 year old male with ESRD on HD and Mantle cell lymphoma noncompliant with HD or chemotherapy for the last 4-6 weeks presenting from home for evaluation of bleeding facial wound. The patient has been refusing all therapy for his known chronic medical conditions, which is well documented in OMR notes. Per his sister, he had been functioning well until the last week when he stopped taking his medications. He has been intermittently taking kayexelate at home. He reports stopping his medications because "there are so many pills." He otherwise reports feeling "great" with a normal appetite (diminished per his sister), good energy level, denied chest pain, shortness of breath, fever, chills, abdominal pain, constipation, diarrhea, nausea or vomiting. The day prior to admission he developed epistaxis and bleeding from a right facial wound. The bleeding was difficult to control and the patient came to the ED tonight for evaluation of his epistaxis. . In the ED, vitals were 96.1, 157/61, 83, 16, 99% RA. His epistaxis was controlled as was the bleeding from his facial wound. Because he looked cachectic and ill the ED team put him on a monitor and found peaked T waves. EKG done demonstrated peak T waves and wide QRS as well as diffuse T wave and ST changes. Potassium 8.8. He was treated with 4 grams calcium gluconate, 1 amp bicarb and insulin/D50 and potassium returned at 7.9. He was given another amp of bicarbonate and insulin/D50 and was transferred to the MICU for emergent HD. Past Medical History: 1. ESRD on HD: after long history of CRI without medical follow up. Started HD via tunnelled line [**6-26**] but has been noncompliant over the last 4-6 weeks. 2. Mantle cell lymphoma: presented with weakness in [**6-26**] and found to be pancytopenic. Bone marrow biopsy consistent with Mantle cell lymphoma, FISH positive for 11;14 translocation. Treated with 2 cycles Rituxan then loss to follow up. 3. Diastolic murmur: echo with 1-2+ AI 4. Seborrheic dermatitis 5. Right inguinal hernia repair Social History: SH - Retired messenger. Lives at home with his sister. [**Name (NI) **] tobacco/EtOH. Family History: NC Physical Exam: PE: 97.2, 178/54, 73, 20, 98% RA Gen: elderly, cachectic male, dry blood around nose and lesion on right cheek covered. alert and oriented X 3, answered questions appropriately. Asking for coffee and eggs HEENT: PERRL, OP clear without petechiae, dry blood around nostrils bilaterally, covered right facial lesion, dry blood and small excoriations on face and neck. Neck: JVP at 7 cm, bleeding skin excoriations Car: RRR II/VI DM across precordium Resp: CTAB-poor effort Abd: nephrostomy tube intact, site clean, soft, nontender, nondistended +BS Ext: no edema, petechia of shins bilaterally Skin: diffuse 1-2 mm pustules, petechiae and excoriations of skin Neuro: + asterixis Pertinent Results: [**2194-10-4**] 11:21PM GLUCOSE-125* UREA N-101* CREAT-13.6*# SODIUM-145 POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-17* ANION GAP-27* [**2194-10-4**] 11:21PM CALCIUM-8.0* PHOSPHATE-5.7* MAGNESIUM-2.3 [**2194-10-4**] 11:21PM WBC-3.1* RBC-2.74* HGB-8.2* HCT-23.2* MCV-85 MCH-30.0 MCHC-35.5* RDW-17.2* [**2194-10-4**] 11:21PM PLT COUNT-38* [**2194-10-4**] 06:03PM TYPE-ART TEMP-37.3 PO2-102 PCO2-25* PH-7.37 TOTAL CO2-15* BASE XS--8 [**2194-10-4**] 03:25PM GLUCOSE-103 UREA N-98* CREAT-12.5*# SODIUM-142 POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-15* ANION GAP-23* [**2194-10-4**] 03:25PM WBC-3.1* RBC-2.94*# HGB-8.7*# HCT-25.0*# MCV-85 MCH-29.5 MCHC-34.7 RDW-17.1* [**2194-10-4**] 03:25PM PLT COUNT-39* [**2194-10-4**] 03:25PM PT-13.9* PTT-27.0 INR(PT)-1.2* [**2194-10-4**] 11:05AM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010 [**2194-10-4**] 11:05AM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010 [**2194-10-4**] 11:05AM URINE RBC-18* WBC-5 BACTERIA-FEW YEAST-NONE EPI-0 [**2194-10-4**] 11:02AM TYPE-ART PO2-69* PCO2-23* PH-7.50* TOTAL CO2-19* BASE XS--2 [**2194-10-4**] 11:02AM LACTATE-2.0 [**2194-10-4**] 11:02AM freeCa-1.12 [**2194-10-4**] 08:20AM GLUCOSE-79 UREA N-195* CREAT-21.4* SODIUM-143 POTASSIUM-8.3* CHLORIDE-110* TOTAL CO2-10* ANION GAP-31* [**2194-10-4**] 08:20AM CALCIUM-8.7 PHOSPHATE-6.3*# MAGNESIUM-3.4* [**2194-10-4**] 08:20AM CALCIUM-8.7 PHOSPHATE-6.3*# MAGNESIUM-3.4* [**2194-10-4**] 08:20AM PLT COUNT-50* [**2194-10-4**] 08:20AM PT-14.2* PTT-150* INR(PT)-1.3* [**2194-10-4**] 04:35AM COMMENTS-GREEN TOP [**2194-10-4**] 04:35AM K+-7.9* [**2194-10-4**] 03:48AM K+-8.6* [**2194-10-4**] 03:00AM GLUCOSE-141* UREA N-192* CREAT-22.0*# SODIUM-140 POTASSIUM-8.8* CHLORIDE-109* TOTAL CO2-6* ANION GAP-34* [**2194-10-4**] 03:00AM estGFR-Using this [**2194-10-4**] 03:00AM CK(CPK)-66 [**2194-10-4**] 03:00AM NEUTS-32* BANDS-2 LYMPHS-59* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2194-10-4**] 03:00AM PLT SMR-VERY LOW PLT COUNT-38* [**2194-10-4**] 03:00AM PT-14.0* PTT-27.9 INR(PT)-1.2* CHEST (PORTABLE AP) Reason: Assess for infiltrates [**Hospital 93**] MEDICAL CONDITION: 72 year old man with hyperkalemia, mantle cell lymphoma REASON FOR THIS EXAMINATION: Assess for infiltrates EXAMINATION: AP chest. INDICATION: Lymphoma. A single AP view of the chest is obtained on [**2194-10-4**] at 10:24 hours and is compared with the most recent study performed on [**2194-6-25**]. Patient has a right- sided dual-lumen catheter with its tip in the expected location of the cavoatrial junction. Linear densities again seen in the left and right midlung zones likely represent fibrosis since they were present on the prior examination. Linear atelectasis of the left base. No evidence of acute infiltrate or pleural effusion. Brief Hospital Course: The patient is a 72 yo M with ESRD and mantle cell lymphoma, presenting to ED with epistaxis and found to be hyperkalemic to 8.8 with classic ECG findings after being off HD and chemotherapy x4-6weeks and off medications x1-2weeks. He was admitted for emergent HD. . # Hyperkalemia: On arrival to [**Name (NI) **] pt. found to have peaked T waves on telemetry. EKG done demonstrated peak T waves and wide QRS as well as diffuse T wave and ST changes. His K was found to be 8.8. Pt. reported non-compliance with HD for approx [**4-25**] weeks. He was given kayexelate, 4 grams calcium gluconate, 1 amp bicarb and insulin/D50 with decrease in K to 7.9. Pt. was given additional 1 amp of bicarbonate and insulin/D50 and was transferred to MICU for emergent HD. Pt. clinically improved and transferred to floor the day after admission. Pt. K improved with HD and he was continued on MWF schedule throughout admission. Plan to change HD schedule to TTHSat based on his prior outpatient schedule. . # ESRD - Pt. with ESRD related to hydronephrosis from anatomic displacement of the left kidney by an enlarged spleen. Pt. was maintained on MWF HD schedule during admission as above. He was dialyzed for 2 hours on day of discharge with plan to continue his previous Tues., Thurs., Sat. schedule. During admission pt. has been fully compliant with treatment plan. The patient was also rescheduled to follow up with urology for further care of his nephrostomy tube for [**2194-11-6**] as he had cancelled his prior appointments before admission. Pt. has chronic anemia related to ESRD. He was transfused 2units PRBC on [**10-13**], 1unit on [**10-5**] Units [**10-4**]. His HCT was 22.0 on admission and on discharge HCT 26.7. Pt. receiving EPO w/ HD. . #. Epistaxis/petechiae/pancytopenia: Pt. bleeding and pancytopenia most likely secondary to progression of underlying mantle cell lypmhoma, ongoing without therapy. Pt. did not receive heparin with HD. Plan for platelet transfusion as needed for bleeding (with ddAVP) or otherwise >10K however pt. had no further bleeding during admission and required no plt transfusions. . # Mantle Cell Lymphoma - Pt. was initially diagnosed in [**6-/2194**] after presenting to [**Hospital1 18**] with weakness and pancytopenia. On bone marrow biopsy, he was found to have hypercellurlar marrow with involvement by a B-cell lymphoproliferative disorder; staining was positive for CD5, CD19, CD20, and negative for CD10. FISH analysis for 11;14 chromosomal rearrangement was positive, consistent with mantle cell lymphoma. He was seen by Dr [**Last Name (STitle) 2148**] as an outpatient and received 2 cycles of rituximab (last dose [**2194-8-4**]) before he decided that he did want any further medical therapy. Pt. reports willingness to pursue treatment. He will follow up with Dr. [**Last Name (STitle) 2148**] as outpatient for plan for rituximab therapy. Appointment scheduled for [**2194-10-21**]. . # Dementia - likely mixed DAT/vascular. Patient shows impairment of new learning, is unable to report anything about what he has been told about his cancer or kidney disease. He denies that he wants to die and is compliant with treatment here, and he states clearly that he would want his sister to make decisions for him if he is unable to do so. However, by history, it appears that when he is outside of the hospital his sister has been unable to persuade him to come to dialysis or for other medical treatment. Request for appointment of guardianship has been discussed with family and the medical certificate has been completed. Pt's. neice has agreed to be guardian. Pt. sister has also completed medicaid paperwork. His code status has been verified as DNR/DNI with patient and family. During admission the pt. has been compliant with our treatment plan and guardianship has been advised to address future plans. . # HTN - Pt. noncomplaint with medications prior to admission. Pt. had been on metoprolol 25mg daily. He was persistently hypertensive during admission and was started on diltiazem which was titrated to diltiazem ER 360mg daily. Pt. continued to have systolic BP 150-160s and was started on metoprolol 25mg [**Hospital1 **] and titrated up to 37.5 [**Hospital1 **] prior to discharge. . # Hypercholesterolemia - pt. continued on Zocor . On day of discharge the patient was clinically stable and improved after the reinitiation of HD and medical management. He has a history of medical non-compliance and has a baseline dementia. Legal guardianship is being pursued. He will follow up in [**Hospital **] clinic for further management of mantle cell lymphoma and will continue HD on TTHSat schedule. The patient will be followed by the [**Hospital3 4262**] group during rehab stay. He should follow up with Dr. [**Last Name (STitle) 1007**] upon discharge from rehab. Medications on Admission: Colace 100 mg [**Hospital1 **] Senna Nephrocaps Paxil Cipro after HD Toprol tid Zocor daily Renagel tid . Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 7. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 583**] House Nursing and Rehab Center Discharge Diagnosis: Primary: 1. Hyperkalemia 2. End Stage Renal Disease - hemodialysis dependent 3. Mantle Cell Lymphoma Secondary: 1. Hypertension 2. Hypercholesterolemia Discharge Condition: Stable, Improved Discharge Instructions: You were admitted with bleeding and found to have high potassium levels in your blood. You were continued on hemodialysis with improvement of your potassium level. You should continue to receive hemodialysis as scheduled on Monday, Wednesdays and Fridays. Please continue to take your medications as directed. . You also are known to have mantle cell lymphoma and are planned to follow up with Dr. [**Last Name (STitle) 2148**] in clinic for further treatment. Please maintain your scheduled follow up appointment. . Please return or call Dr. [**Last Name (STitle) 1007**] at [**Telephone/Fax (1) 10492**] if you experience chest pain, shortness of breath, weakness or increased fatigue at home. Followup Instructions: Your next hemodialysis session should be Saturday, [**2194-10-18**] at 3:30pm at [**Doctor First Name 12074**]/[**Location (un) **] [**Telephone/Fax (1) 5972**]. Please maintain your scheduled follow up appointment with Dr. [**Last Name (STitle) 2148**] scheduled on [**2194-10-21**] at 2:00pm. Please maintain your scheduled follow up appointment with Dr. [**Last Name (STitle) 3748**] in Urology on [**2194-11-6**] at 7:30am for further care of your nephrostomy tube. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

[ "585.6", "782.7", "202.80", "784.7", "276.2", "284.1", "272.0", "293.0", "285.21", "403.91", "276.7" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

11775, 11856

6088, 10918

339, 353

12052, 12071

3239, 5379

12815, 13419

2522, 2526

11075, 11752

5416, 5472

11877, 12031

10944, 11052

12095, 12792

2541, 3220

277, 301

5501, 6065

382, 1879

1901, 2402

2418, 2506