Split (1)

train · 26.9k rows

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58,773	112,076	45302	Discharge summary	report	Admission Date: [2133-2-20] Discharge Date: [2133-2-25] Date of Birth: [2054-5-20] Sex: F Service: MEDICINE Allergies: Penicillins / Vancomycin Attending:[First Name3 (LF) 2901] Chief Complaint: Chest pain, dark stools Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: 78 yo female with significant history of coronary artery disease s/p CABG, ischemic cardiomyopathy s/p BiV-ICD placement and ventricular tachycardia who presents with acute onset of likely GI bleed and left-sided chest pain. The pain was located under her left breast radiating to her back that awoke her from sleep around 3 AM on the day of admission, [8-7] in severity. She reports taking a few nitroglycerin tablets with some relief in her pain. The pain was reported as being constant in nature as achey in character. She also reports that she had significant dyspnea on exertion this morning, upon walking to the bathroom, which is not typical for her, no shortness of breath at rest. At baseline, she can walk less than a city block without stopping for rest. She received nitroglycerin and aspirin prehospital. She reports no fever or chills, no cough. On further questioning the patient does report having some dark stool intermittently for the last month or so. . In the ED, initial VS were pain [4-7], T 97.2, P 64, BP 163/64, R 16, Sat 97%. On physical exam, patient had guaiac positive black stool. ECG reportedly showed paced rhythm, with LAD, RBBB, new ST depressions in V3 and V5, as well as new TWF in V3. Labs were significant for hematocrit of 25 from baseline 34. Troponin was noted to 0.04, which is below her baseline. In addition, potassium was elevated at 5.5, creatinine elevated at 1.8 from baseline of 1.5, and INR was 1.3. Patient was administered full-dose aspirin and started on a nitroglycerin gtt. GI was consulted for GI bleed, and recommended protonix bolus and gtt, transfusion of 2 units PRBCs and possible EGD on [2-20]. Transfusion has not started at the time of transfer. Chest X-ray was performed and showed no acute cardiopulmonary process. Patient was chest pain free at the time of transfer. Peripheral line and EJ line was placed in ED. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: - CAD status post inferoposterior wall MI, CABG in [2106] (LIMA-LAD, SVG-OM, SVG-PDA, known SVG to PDA stenosis)--> Taxus stent to SVG - PDA in [2125-2-26]--> stenting of anterograde limb of PDA in [2127-9-28]. Demonstration of SVGSVG-rPDA demonstrated 40%ostial lesion consistent with in-stent restenosis. - Permanent atrial fibrillation - Ischemic CM, EF 22% on PMIBI [2130-7-29]. NYHA Class III. - [2131-5-2] Biventricular ICD implant ([Company 2267] Cognis). - [2131-5-4] LV lead revision - Ventricular tachycardia status post ICD placement; generator change 6.05 3. OTHER PAST MEDICAL HISTORY: - Hypertension/LVH. - Type 2 diabetes (HbA1c 7.5 in 6.10), followed at the [Last Name (un) ] by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10083]. - Mild AS/AR. - Hypothyroidism - Irritable bowel syndrome/diverticulosis - Chronic kidney disease - Anemia - Arthritis - Breast CA, s/p R mastectomy and XRT [2108] - Gastritis on EGD, w/ hiatal hernia - diverticulosis Social History: - Widowed. Previously owned toy stores with husband. Lives independently at home in [Location (un) ]. Independent for all ADLs. - Tobacco history: none - ETOH: none - Illicit drugs: none Family History: Mother died at 53 of an MI, also had a stroke. Brother died of MI at 40; sister died of MI in her 60s, another brother died of congenital heart defect at 32(valve). Father died at 86. Children both have diabetes. Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: 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 JVD at level of the jaw. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps, wrist, knee/hip flexors/extensors, 2+ reflexes biceps, brachioradialis, patellar, ankle. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM: Vitals - Tm/Tc 97.8 HR 59-66 BP 110-125/55-64 RR 18-20 02 sat 100% RA In/Out: Last 24H: -300, Last 8H: 0/1100 Weight: 67.9 (up 0.2 kg from yesterday) Tele: paced FS: 129 GENERAL: 78 yo female in NAD. Oriented x3. Mood, affect appropriate. HEENT: Conjunctiva pink with injection on right side only that extends to lower eyelid, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVD at 3cm above clavicle CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. Systolic mumur [2-2] in RUSB. Murmur radiating to bilateral carotids. No thrills, lifts. LUNGS: CTAB no w/r/r ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 2+ DP/PT, no pedal edema GAIT: in bed, awaiting PT to see. ambulated with PT using walker, steady on feet Pertinent Results: ADMISSION LABS: WBC-5.0 RBC-2.76# Hgb-8.2# Hct-0# MCV-90 MCH-29.9 MCHC-33.1 RDW-13.4 Plt Ct-164 Neuts-63.9 Lymphs-24.6 Monos-7.3 Eos-3.4 Baso-0.8 PT-14.1 PTT-57.0* INR(PT)-1.3* Glucose-161* UreaN-65* Creat-1.8* Na-135 K-6.7* Cl-103 HCO3-22 AnGap-17 CK-MB-4 . CHEST X-RAY ([2133-2-20]): Compared with prior, there has been no significant interval change. The lungs remain clear. There is no pleural effusion. There is no pulmonary vascular engorgement. Cardiac silhouette is enlarged, but stable in configuration. Biventricular pacing device again seen with multiple leads in stable positions. Atherosclerotic calcifications seen throughout the aorta. Median sternotomy wires and mediastinal clips again noted. IMPRESSION: No acute cardiopulmonary process. . DC LABS: [2133-2-25] 06:30AM BLOOD WBC-6.5 RBC-3.38* Hgb-10.3* Hct-30.1* MCV-89 MCH-30.4 MCHC-34.2 RDW-13.7 Plt Ct-145* [2133-2-25] 06:30AM BLOOD Glucose-104* UreaN-47* Creat-2.2* Na-137 K-4.6 Cl-101 HCO3-30 AnGap-11 [2133-2-25] 06:30AM BLOOD Calcium-10.4* Phos-3.5 Mg-2.6 . ENDOSCOPY [2133-2-23]: Impression: Irregular z-line. Abnormal mucosa in the esophagus (biopsy) Slightly thickened gastric folds. Polyp in the first part of the duodenum (biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: Follow-up biopsy results. If duodenal polyp is adenomatous, may need repeat endoscopy. The findings do not account for the symptoms Brief Hospital Course: Ms. [Known lastname ] is a 78 year old woman with significant history of coronary artery disease s/p CABG, ischemic cardiomyopathy s/p BiV-ICD placement and ventricular tachycardia who presented with acute onset of likely GI bleed with resultant exertionalleft-sided chest pain. She underwent an endoscopy which didnt show any active signs of bleeding and was dc/ed to [Hospital 100] Rehab d/t orthostatic hypotension. . # Gastrointestinal bleed: Ms. [Known lastname ] experienced a hematocrit drop from baseline of 34 to 24 in setting of guaiac positive dark stool. Differential diagnosis for upper GI bleed included bleeding ulcer, gastritis, or variceal bleed. She has history of gastritis on previous EGD and diverticulosis on prior colonoscopy. On admission, Ms. [Known lastname ] was started on a protonix drip, and GI was consulted who performed EGD on [2-23] which demonstrated no acitve site of bleeding and no lesion that may have been responsible for the GIB. Ms. [Known lastname ] [Last Name (Titles) 35325] 3 units of blood on the first day of admission which resulted in resolution of her chest pain. . # Chest pain: Ms. [Known lastname ] experienced left-sided chest pain which is similar to her prior anginal symptoms. There were no discernible EKG changes but these are difficult to interpret in the setting of BiV pacing. Her MB was flat and troponins were less than baseline (normally elevated secondary to CKD). Patient received full-dose aspirin and was initiated on a nitroglycerin gtt in the ED with resolution of her pain. Pain did not recur after weaning the nitroglycerin drip and receiving 3 units of PRBCs until 2 days later on [2-22]. Beta blockade and lisinopril were initially held but were restarted at lower dose on [2-21]. Lisinopril however was held at the time of dc due to a Cr bump. . # Ischemic cardiomyopathy: Ms. [Known lastname 96778] furosemide and spironolactone were initially held given concern for GI bleed. Before d/c her Cr was high so lasix and lisinopril were held. . # Atrial fibrillation: CHADS2 score of 4. Ms. [Known lastname ] states that her physicians told her to stop dabigatran several months ago and according to GI note from [Month (only) 404] her dabigatran had already been stopped. Her outpatient cardiologist, Dr. [Last Name (STitle) ], was contact[Name (NI) ] and an appt was set up. On discharge, she was prescribed dabigatran 75 [Hospital1 ] and set up with outpt f/up. . # Type 2 diabetes mellitus: Home lantus and a sliding scale were continued in lieu of her januvia and sulfonyluea. . # Hypothyroidism: Continued home levothyroxine . TRANSITIONAL ISSUES: The pt developed some orthostatic hypotension just before the time of discharge and her Cr spiked, likely in the setting of being NPO for a long period and getting lisinopril and lasix. These meds were held at the time of dc and she will need a CHEM 7 before these meds can be restarted. Medications on Admission: Metoprolol succinate 200 mg PO daily Lisinopril 10 mg PO daily Furosemide 40 mg PO daily Aspirin 81 mg PO daily Isosorbide mononitrate 30 mg PO daily Rosuvastatin 20 mg PO daily Levothyroxine 0.1 mcg PO daily Omeprazole 20 mg PO daily Insulin glargine 16 units PO QAM Insulin Humalog per sliding scale patient only takes when BS>400 Januvia 50 mg PO PO daily Glipizide 2mg [Hospital1 ] Ferrous sulfate 325 mg PO daily Vitamin B6 100 mg PO daily Vitamin B12 100 mcg PO daily Doxercalciferol Multivitamin 1 tab PO daily Loperamide PO PRN Discharge Medications: 1. Outpatient Lab Work Please have your labs drawn at rehab [2-27] and have those results faxed to your PCP: [Last Name (NamePattern4) ]. [First Name (STitle) ] [Name (STitle) 1728] [Telephone/Fax (1) 7922] 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 4. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 7. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day. 9. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 10. Vitamin B-6 100 mg Tablet Sig: One (1) Tablet PO once a day. 11. multivitamin Tablet Sig: One (1) Tablet PO once a day. 12. insulin glargine 100 unit/mL Cartridge Sig: Sixteen (16) units Subcutaneous qAM. 13. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 14. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a day. 15. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab Sublingual Q 5 minutes x3 as needed for chest pain: take as directed. 16. Pradaxa 75 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Hectorol 0.5 mcg Capsule Sig: Two (2) Capsule PO twice a day. 18. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary diagnosis: Blood loss from unknown source (likely GI) Chest pain from blood loss Secondary diagnosis: Coronary artery disease Cardiomyopathy (weak heart muscle) Hypertension Diabetes Chronic kidney disease Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you at [Hospital1 18]. You were admitted to the hospital for chest pain and dark stools. You met with the GI doctors, and an EGD scope procedure was performed. You also had a biopsy done, the results of which are pending on discharge. Your bleeding stopped after 3 units of blood, and your blood counts remained stable. Your chest pain was felt to be related to the bleeding, and this improved. . You had mild worsening of your kidney function, which was likely related to dehydration. This improved with IV fluids. You will require a repeat blood test to ensure that your blood counts and kidney function are stable. You should have this test done on friday, if the kidneys look better, we will restart you on your lasix and lisinopril. . MEDICATION CHANGES: - INCREASE omeprazole to 20 mg twice a day - HOLD your Lasix (Furosemide) - HOLD your Lisinopril if your kidney function is improving on Friday [2-27], please resume both Lasix 40mg daily and Lisinopril 10mg daily For your heart failure diagnosis: Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs in 2 days or 5 lbs in 3 days, follow a low salt diet and restrict your fluids to 1500 ml/ day. Please have your hematocrit and BMP drawn on Friday [2-27] Followup Instructions: Please draw Hct and BMP on Friday [2-27] and fax to Dr. [First Name (STitle) ] [Name (STitle) 1728] [Telephone/Fax (1) 7922] Department: GASTROENTEROLOGY When: THURSDAY [2133-3-5] at 10:30 AM With: [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern4) 2301], M.D. [Telephone/Fax (1) 463] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [State ]When: MONDAY [2133-3-9] at 9:45 AM With: [Name6 (MD) ] [Name8 (MD) 9862], MD [Telephone/Fax (1) 2205] Building: [State ] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking Department: CARDIAC SERVICES When: FRIDAY [2133-7-10] at 10:00 AM With: [Name6 (MD) ] [Last Name (NamePattern4) ], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Dr. [Last Name (STitle) ] is working on a [Month (only) 958] appointment for you. She will contact you directly if she can fit you in. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "403.90", "211.2", "578.9", "564.1", "428.22", "272.4", "585.9", "458.0", "427.31", "V10.3", "V45.81", "V58.67", "244.9", "V45.02", "716.90", "V45.71", "562.10", "250.00", "411.89", "414.00", "440.0", "285.1" ]	icd9cm	[ [ [] ] ]	[ "45.16", "38.93" ]	icd9pcs	[ [ [] ] ]	12831, 12897	7585, 10256	309, 321	13176, 13176	6124, 6124	14713, 15989	4086, 4300		11157, 12808		12918, 12918		10592, 11134			13359, 14168									4340, 5300		2837, 3435											10277, 10566				14188, 14690		246, 271									349, 2727			13029, 13155		6140, 7562	12937, 13008				13191, 13335	3466, 3861					2749, 2817	3877, 4070				5325, 6105
42,231	171,878	35639	Discharge summary	report	Admission Date: [2102-8-29] Discharge Date: [2102-9-6] Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11304] Chief Complaint: Gross hematuria Major Surgical or Invasive Procedure: Radical laparascopic nephrectomy - Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3748]- [2102-8-29] History of Present Illness: 85F with gross hematuria, cytology +, CT: 3-cm right renal pelvis transitional cell collecting system tumor Past Medical History: HTN, Hyperlipidemia, Kidney stones, Hx Breast CA, benign cystic pancreatic mass, herpes zoster Social History: No tobacco/EtOH Pertinent Results: [2102-9-4] 11:10AM BLOOD WBC-7.2 RBC-4.07* Hgb-11.3* Hct-35.8* MCV-88 MCH-27.8 MCHC-31.6 RDW-15.1 Plt Ct-401 [2102-9-4] 11:10AM BLOOD Glucose-168* UreaN-18 Creat-1.1 Na-144 K-4.0 Cl-108 HCO3-24 AnGap-16 Brief Hospital Course: Patient was admitted to Urology on [2102-8-29] after undergoing laparoscopic right nephroureterectomy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, provided with pneumoboots and incentive spirometry for prophylaxis, and was out of bed to theh chair. On POD 1, the patient was disoriented with PCA, so narcotics were discontinued and toradol was implemented for pain control. On POD 2, the patient ambulated with assistance and was restarted on home medications (verapamil, lisinopril, meclizine), basic metabolic panel and complete blood count were checked. In the afternoon of POD 2, the patient became bradycardic and hypotensive x 2 episodes. The first episode, the patient's HR and BP returned to [Location 213] with only 1 L fluid bolus. During the second episode, the patient's HR was brady/atrial fibrillation, and she required atropine administration by Cardiology. The patient was transferred to the ICU for hemodynamic monitoring. The patient's ICU course was significant only for delirium. The etiology of the bradycardia was unclear, and thought to be a profound vagal response or due to home verapamil dosing. Echo showed EF of 60% to 65%, Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Mild pulmonary hypertension. Small circumferential pericardial effusion. On the evening of POD 3, the patient's diet was advanced as tolerated, and the patient was transferred back to the floor in stable condition. On POD 4, urethral catheter (foley) were removed without difficulty. PT evaluation deemed patient appropriate to go home with home PT. The patient's blood pressure was elevated, and due to the bradycardic/hypotensive episode, cardiology did not recommend restarting calcium channel blockers or starting beta blockers. The patient's lisinopril was titrated to 20mg daily over POD [5-31], and the patient's blood pressure responded appropriately (and her creatinine was stable at 1.1). Geriatric consult was requested on POD 7 due to delerium during hospital course, and they deemed the patient appropriate for discharge from their standpoint. On POD 8, the patient was discharged to home with VNA/PT in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incisions were clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic with Dr. [Last Name (STitle) 3748] in 3 weeks. Medications on Admission: Verapamil 240, Lisinopril 5, Rosuvastatin 10, Meclizine 25 TID PRN, imipramine 25 QHS, colace, loratidine 10 Discharge Medications: 1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. Imipramine HCl 25 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Renal cell carcinoma status post right nephroureterectomy Discharge Condition: Stable Discharge Instructions: -You may shower but do not bathe, swim or immerse your incision. -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -Tylenol should be your first line pain medication, Max daily Tylenol dose is 4gm. -Do not drive or drink alcohol while taking narcotics -Resume all of your home medications-Call your Urologist's office today to schedule/confirm your follow-up appointment in 3 weeks AND if you have any questions. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER -Call Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3748] upon discharge to arrange/confirm follow-up appointment and if you have any urological questions. [Telephone/Fax (1) 3752] -Please follow up with your PCP related to management of hypertension and discontinuance of one of your medication (Verapamil), and an increase of your daily dosage of Lisinopril to 20 mgs daily. Followup Instructions: -Call Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3748] to set up follow-up appointment and if you have any urological questions. [Telephone/Fax (1) 3752] -Please contact PCP upon discharge related to continued management of HTN medications and recent changes made to medications during hospital stay. Completed by:[2102-9-6]	[ "998.2", "511.9", "285.9", "458.29", "293.0", "E870.0", "401.9", "427.89", "196.6", "V10.3", "272.4", "427.31", "189.0" ]	icd9cm	[ [ [] ] ]	[ "55.51", "39.32", "40.3" ]	icd9pcs	[ [ [] ] ]	4256, 4311	947, 3755	277, 405	4413, 4422	712, 924	5583, 5944			3914, 4233		4332, 4392		3781, 3891			4446, 5560																												222, 239									433, 542																564, 660	676, 693
18,949	106,839	48160	Discharge summary	report	Admission Date: [2136-10-23] Discharge Date: [2136-10-24] Date of Birth: [2076-4-5] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7934] Chief Complaint: CC: Transfer from OSH for ? Sepsis/ARF and Hemachromatosis with liver failure. Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 60 year old female with a PMH of DM, Met Breast CA admitted to Sturdy [Hospital ] Hospital with cc of [3-30] wks of fatigue and constipation. Workup revealed elev. WBCs and abdominal CT ordered showed small amount of ascites and cirrhotic liver. Initial labs were Bicarb 19, BUN 47, Creat 1.8, Alb 3, T. bili 0.3, Alk phos 178 ALT 155, AST 55, WBC 17 (80N, 3B) plt 42, INR 2.1, Ferritin 4751 with iron 168. Over her 6 day stay, pt deteriorated and became increasingly somnolent. Lactulose was started and greatly improved MS. Genetic screen revealed heterozygous for hemachromatosis. Remained afebrile with WBC [10-23] of 17 with 13 bands. Cx data revealed urine cx of mixed flora and Blood cx negative to date. Levoquin and Ceftaz since [10-18]. Pt also developed increased O2 requirements thought to be from CHF/Vol overload despite a normal echo. Renally, Cr. increased from 1.7 to 3.2. Pt was given albumin/lasix with effect. Currently oliguric at transfer. Decreased HCT 36 --> 26.5. EGD was neg. Given 1U PRBC. Also developed Decreased SBP on [10-21] and wet to MICU. Swan numbers consistent with sepsis. On [10-23] (day of admission) she was hypertensive with decreased UOP and started on levophed. Soon after arrival at [Hospital1 18], she had agonal respirations with no gag and was intubated. Past Medical History: PMH: DM type 2; Metastatic Breast CA rx'd with [Doctor First Name ], chemo and rad; Elevated cholesterol; s/p CCY. Social History: SH/FH: Unobtainable. Family History: SH/FH: Unobtainable. Physical Exam: VS: Pertinent Results: [2136-10-23] 04:47PM PT-20.3* PTT-44.4* INR(PT)-2.9 [2136-10-23] 04:47PM PLT SMR-RARE PLT COUNT-17* [2136-10-23] 04:47PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-1+ TEARDROP-OCCASIONAL BITE-OCCASIONAL ACANTHOCY-OCCASIONAL [2136-10-23] 04:47PM NEUTS-79* BANDS-7* LYMPHS-5* MONOS-6 EOS-2 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-13* [2136-10-23] 04:47PM WBC-16.5* RBC-3.15* HGB-9.8* HCT-28.5* MCV-91 MCH-31.1 MCHC-34.2 RDW-23.3* [2136-10-23] 04:47PM CALCIUM-10.5* PHOSPHATE-10.1* MAGNESIUM-2.2 [2136-10-23] 11:30PM HAPTOGLOB-<20* [2136-10-23] 11:30PM CORTISOL-21.1* [2136-10-23] 11:30PM FDP->1280* [2136-10-23] 11:30PM D-DIMER-4431* [2136-10-23] 09:30PM URINE HOURS-RANDOM UREA N-42 CREAT-33 SODIUM-LESS THAN [2136-10-23] 07:47PM TYPE-MIX TEMP-36.7 RATES-16/4 TIDAL VOL-360 PEEP-5 O2-60 PO2-64* PCO2-48* PH-7.19* TOTAL CO2-19* BASE XS--9 -ASSIST/CON INTUBATED-INTUBATED [2136-10-23] 07:47PM HGB-9.9* calcHCT-30 O2 SAT-88 [2136-10-23] 05:03PM TYPE-ART PO2-198* PCO2-46* PH-7.21* TOTAL CO2-19* BASE XS--9 [2136-10-23] 05:03PM GLUCOSE-137* LACTATE-2.4* NA+-134* K+-5.4* CL--106 [2136-10-23] 05:03PM HGB-10.0* calcHCT-30 O2 SAT-97 [2136-10-23] 05:03PM freeCa-1.41* [2136-10-23] 04:47PM GLUCOSE-138* UREA N-99* CREAT-4.0* SODIUM-137 POTASSIUM-5.5* CHLORIDE-106 TOTAL CO2-18* ANION GAP-19 [2136-10-23] 04:47PM ALT(SGPT)-25 AST(SGOT)-160* LD(LDH)-8250* ALK PHOS-201* AMYLASE-41 TOT BILI-4.4* Brief Hospital Course: Assessment: 60 year old female with a PMH significant for type 2 DM, h/o met. breast ca, increased chol now presents with 3-4 weeks of fatigue and constipation found to have cirrhotic liver and heterozygous for hemachromatosis. Also developed presumed sepsis (unclear etiology), ARF and worsening hypotension. . PLAN: 1) Liver failure: Heterozygous for C282Y allele. With increased ferritin and incr. LFTs --> ReportedlyOSH CT demonstrating cirrhosis. Hep panel and AMA neg. Planned to repeat RUQ U/S with flow for ascites. Avoided all hepatotoxic agents. 10mg SQ Vit K for INR elevation. Liver was consulted. Pt decompensated overnight and family decided to make her CMO. She expired at 5am less than 10 hours after MICU admission. . 2) ARF: DDx ATN, HRS, AIN Renally dosed all meds . 3) Sepsis: Pt's initial WBC @ [Hospital1 ] 18.3 with 7 bands. Cirrhosis on CT. DDx includes Line, Ascites/SBP. CXR no clear etiology. Awaiting cx data at time of death. Broad spectrum Abx were administered including Vanc/Ceftaz/Flagyl. We repeated Blood, Urine and Sputum Cx. Checked [Last Name (un) 104] stim. Scheduled abd u/s to check for ascites but pt expired before this testing was done. . 4) Heme: Pt with increased LDH, Decr. Platelets, Decr. HCT, Incr. INR - Plt decr. likely [2-29] splenomegaly, decreased transpoeitin and ? DIC - Checked haptoglobin, fibrinogen (DIC screen) FDP >1280, D Dimer 4431 - Guiaic all stools - Transfused 2 units for HCT <24 and HD unstable . 5) Started Insulin gtt- titrated to FS 80-110 and hold glucophage . 6) FEN- Started D5W with 2 amps of bicarb per renal recs @75cc/hr - renagel - tube feeds - checked K frequently. No EKG signs of High K. . 7) PPx [Hospital1 ] PPI and Pneumoboots . 9) Comm with daughters. Pt expired on [10-24] at 5pm of complications associated with presumed sepsis in the setting of liver failure. Her vital signs continued to be unstable and she required pressors until the time of death. The family was present at the time of death. Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "V10.3", "572.4", "518.81", "272.0", "570", "276.2", "995.92", "250.00", "275.0", "038.9", "584.9", "789.5" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	5701, 5710	3642, 5678	395, 401	5761, 5770	2023, 3619	5826, 5836	1962, 1984				5731, 5740					5794, 5803									1999, 2004																			277, 357									429, 1766																1788, 1908	1924, 1946
3,807	154,285	29250	Discharge summary	report	Admission Date: [2141-11-10] Discharge Date: [2141-11-16] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 783] Chief Complaint: bright red blood per rectum and fall Major Surgical or Invasive Procedure: Upper GI endoscopy Colonoscopy History of Present Illness: [Age over 90 ] yo man with a past medical history significant for 4V CABG in [2117] stated he felt like he had diarrhea this morning and as he went to the bathroom, he slipped and hit his head. Daughter did not hear from him throughout the day and went to his home where he was found, pale, shaky and noted toilet bowl was full of blood. . He was then taken to OSH where he had an NGL positive for coffee-ground emesis and a head CT noted intracranial bleeds. He was transferred to [Hospital1 18] for further evaluation. . Upon arrival to the MICU, Mr. [Known lastname ] states he feels fine, with no headache, nausea, vomiting, diarrhea, abdominal pain, or weakness. He has no back pain, or pain in other extremities. He denies loss of consciousness after fall. He remembers hitting his forehead, but nothing else. Of note, the patient fell about 3 weeks ago while at home rising from his chair. Noted R calf pain/R leg weakness. Was taken to [Hospital3 ] where "he was scanned up and down" without any significant abnormality. . Mr. [Known lastname ] was transferred to the general medical floor on the third day of admission. He was currently without any complaints, denied, HA, diplopia, meningismus, dysethesias or focal weakness. He is scheduled for endosopy by gastroenterology tomorrow morning. Past Medical History: Past Medical History: CABG [2117] (4 vessel), no angiography or stents since then hypercholesterolemia history of prostate cancer, off lupron for > 3 years skin cancers hard of hearing no history of colonoscopy Social History: widower x 2 years, wife died at home with hospice from MI lives alone, performs all ADLs, 2 daughters, no tobacco (quit in his 20s), occ. Etoh, WW2 veteran, worked as manager at post office, lifetime Bostonian, walks daily. . Family History: significant for CAD, many died from MIs Physical Exam: T99.5, BP 122/50, HR 70, R 16, 94%RA Gen: pale, non-diaphoretic, no apparent distress HEENT: forehead with small abrasion, 4x5cm R occipetal ecchymosis. dry MM, no lesions or exudates Neck: supple, non-tender, no LAD, no thyromegaly CV: nl s1 and s2, no MRG Lungs: good volumes, CTAB Abd: BS+, soft, nt, nd, no organomegaly Back: non-tender Ext: no lesions, non-tender, no edema Neuro: alert, oriented to person, place, date somewhat impersistent at times. Strength 5/5 globally. EOM's Full, Smooth. No nystagmus, low amplitude action tremor, normal finger to nose. CN's II-XII. Gait- wide based, shortened stride, decreased armswing. Pertinent Results: [2141-11-10] 4:00p na 139 cl 106 bun 56 gluc 126 k 4.8 bicarb 23 cr 1.1 estGFR: 63 / >75 (click for details) CK: 228 Trop-T: <0.01 ALT: 21 AP: 74 Tbili: 0.4 Alb: AST: 29 Lip: 18 wbc 15.3 hgb 10.8 plt 223 hct 30.3 N:89.0 Band:0 L:8.9 M:1.9 E:0 Bas:0.3 Plt-Est: Normal PT: 13.4 PTT: 22.2 INR: 1.2 . [2141-11-12] 3:20am Na 138 Cl 107 BUN 23 Gl 134 K 3.5 Bic 22 Cr 0.9 . Ca: 8.4 Mg: 2.0 P: 2.5 . MCV 90 WBC13.0, Hb 10.8, Hct 30.4, Plates 146 . PT: 13.8 PTT: 27.1 INR: 1.2 . CT HEAD W/O CONTRAST [2141-11-10] 4:59 PM FINDINGS: There are numerous foci of subarachnoid hemorrhage including in the left superior frontal lobe, bilateral medial frontal and parietal lobes, left and right frontal lobes in the sylvian fissures, and left parietal lobe. There is subdural hematoma overlying the left frontal, parietal, and temporal lobes that tracks into the left middle cranial fossa with maximal thickness of 6 mm overlying the left temporal lobe anteriorly. There is a parafalcine subdural hematoma with maximal thickness of approximately 4 mm. There is no significant left to right midline shift. There is encephalomalacia in the right anterior frontal lobe, right parietal lobe, and right occipital lobe consistent with previous infarction. Additionally, a linear focus of hyperdensity consistent with hemorrhage is also seen projecting at the right temporal lobe (series 2, image 10), the location of which is not entirely certain. There is no definite intraventricular hemorrhage. There is no hydrocephalus. There is diffuse prominence of the ventricles and sulci consistent with volume loss. There is periventricular white matter hypodensity consistent with chronic small vessel infarction. There are atherosclerotic calcifications of both vertebral arteries and internal carotid arteries. No fractures are identified. There is relative under [Name2 (NI) 70320] of the left mastoid air cells with associated sclerosis that could suggest previous-chronic mastoiditis. The visualized portions of the paranasal sinuses are clear. IMPRESSION: 1. Numerous foci of subarachnoid hemorrhage as described above. 2. Left subdural hematoma with a maximal thickness of approximately 6 mm, without significant mass effect. 3. Parafalcine subdural hematoma. . CT HEAD W/O CONTRAST [2141-11-11] 8:20 AM Again seen are multiple areas of subarachnoid hemorrhage interdigitating within the sulci of the frontal, parietal, and temporal lobes. Bifrontal and parafalcine subdural hemorrhages are again noted. There is no mass effect or shift of normally midline structures. Chronic infarcts in the right frontoparietal and occipital lobes are again noted. Osseous and soft tissue structures are stable. IMPRESSION: Stable subdural and subarachnoid hemorrhages as described above. . CHEST (PORTABLE AP) [2141-11-16] 9:13 AM CHEST (PORTABLE AP) Reason: Please assess for infiltrate [Hospital 93] MEDICAL CONDITION: [Age over 90 ] year old man with GI bleed with fever, RLL crackles. please assess for infiltrate. REASON FOR THIS EXAMINATION: Please assess for infiltrate INDICATION: Fever, right lower lobe crackles. . PORTABLE AP CHEST Patient is status post sternotomy with normal alignment of the sternal sutures. The heart size is normal. The mediastinal and hilar contours are normal. The right hemidiaphragm remains elevated. The lung fields are clear without any consolidations, pleural effusions, or pneumothorax. IMPRESSION: No significant change from prior radiograph of [2141-11-10]. No pneumonia. . Brief Hospital Course: [Age over 90 ] yo man with a history of CAD/CABG on aspirin/plavix pw GIB likely secondary to NSAID use, s/p mechanical fall with head [Last Name (un) ] resulting in both subdural and subarachnoid hemorrhage. . 1. Gastrointestinal Bleeding- patient was trasfused 2 units with stable hematocrits following. No further episodes of BRBPR during bowel prep. UGI revealed antral gastritis that could be consistent with NSAID induced gastritis. H. pylori serology was pending at time of discharge. He should continue on twice daily Protonix. He was restarted on low dose aspirin alone as therapy for cardioprotection. . 2. Subdural hematoma/subarachnoid hemorrhage- No neurological impairment noted by exam. Stable interval CT scans (listed above) The should continue dilantin until seen by Dr. [Last Name (STitle) ] in neurosurgery at follow up. His office will contact the pt's daughter for an appointment and interval CT scan in 6 weeks. . 3. Coronary Artery Disease- Patient was ruled out by enzymes. He has had no intervention since CABG [2118]. Patient's clopidogrel was stopped in the setting of GIB and intracranial hemorrhage as there was no clear indication for dual antiplatelet therapy. He was re-started on low dose aspirin daily after approval by neurosurgery and gastroenterology. We re-started Simvastatin. . 6. Contact- The patient's daughter [Name (NI) ] (pt also calls her [Doctor First Name 70321] her middle name) is actively involved in the patient's care. home-[Telephone/Fax (1) 70322]//cell-[Telephone/Fax (1) 70323] 7. Code Status- FULL, daughter states he has a living will and would not want "extraordinary measures", but at this time the patient states he wants to live and would want things done, but if his quality of life was determined to be not acceptable, he should be made comfortable. Medications on Admission: plavix aspirin zocor motrin x 3-4 weeks (for back pain, s/p mechanical fall- evaluated at [Hospital3 4107]) Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] Discharge Diagnosis: NSAID induced gastritis Upper gastrointestinal bleeding Subdural and subarachnoid hemorrhage Discharge Condition: Stable Discharge Instructions: You were admitted after a fall at home relating to bleeding for upper intestinal gastritis. You were transfused 2 units of blood and stabilized. You were found to have some bleeding around your brain after hitting your head. This was found to be stable on repeated scans and by neurosurgery. Upper GI endoscopy found likely relating to relating use of ibuprofen. Lower GI scope found three small polyps that were excised and sent to pathology (likely benign). Please take all of your medications as prescribed. Avoid any further use of ibuprofen also known as NSAIDS. Call your doctor or 911 if you experience any chest pain, shortness or breath, blood in your stools, dizziness, blurred vision, difficulty speaking, weakness, numbness or tingling, fevers, chills, or any other concerning symptoms. Followup Instructions: Please see your doctor next week See Dr. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] in Neurosurgery for follow-up in 6 weeks. Obtain a repeat Head CT scan prior to your visit. He should address whether to continue taking phenytoin (dilantin) at that time. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799]	[ "535.41", "E888.9", "285.1", "211.3", "852.01", "V45.81", "852.21", "414.00", "E935.9" ]	icd9cm	[ [ [] ] ]	[ "45.25", "45.41", "45.13" ]	icd9pcs	[ [ [] ] ]	9018, 9110	6457, 8307	300, 333	9247, 9256	2902, 5790	10105, 10542	2190, 2231		8470, 8995	5827, 5929	9131, 9226		8333, 8447			9280, 10082									2246, 2883																			224, 262	5958, 6434								361, 1690																1734, 1929	1945, 2174
20,207	133,837	5711	Discharge summary	report	Admission Date: [2110-2-20] Discharge Date: [2110-2-28] Date of Birth: [2036-12-26] Sex: M Service: MEDICINE Allergies: Adhesive Tape / Keflex / Percocet Attending:[First Name3 (LF) 134] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: cardiac cathetirization History of Present Illness: 73 yo M with estensive past hx of CAD with multiple interventions as outlined below, renal insufficiency who presented to [Hospital 1474] Hospital on [2-16] c/o 4 days of progressive angina with exertion, characterized as crushing chest pain, worse than his usual angina sx's, associated with increased DOE. At [Hospital1 1474], troponin peak was 0.5, rise in BUN and Cr to 101 and 2.9 respectively. Persantine MIBI on [2-19] was performed showing no reversible ischemia. Also on [2-19] he developed new onset A. Fib with relative hypotension, was cardioverted, developed subsequent bradycardia with junctional rhythm in the 30's, required temporary transcutaneous pacing and was hypotensive to 60s systolic, started on dopamine, and converted to sinus rhythm in the 80s and improved of BP to 130s/80s. While in recovery from the propofol anesthesia he reportedly developed SVT in the 120s, controlled with cardizem and started on amiodarone drip. On [2-20] in the afternoon, pt went into junctional rhythm in the 50's, given atropine x1. He subsequently developed chest pain, given SL NTG x 3, no MSO4 given. New ST depressions and T wave inversions noted. Started on heparin drip with some groin bleeding and hematuria. Transferred to [Hospital1 18] cath lab. Here, CO 2.84, CI 1.36, PCwp 48, RA 34, AO 92/48/58, PA 80/32/48, RV 80/23/36. Angio showed occluded LMCA, LIMA to LAD patent, RCA occluded, SCG-OM2 patent with 40% restenosis, SCG-OM1 and SVG-PDA occluded, no angio intervetion performed, started on dobutamine drip, nitro drip, given 100mg lasix IV. Past Medical History: Cardiac PMH: - [2093]: CABG - LIMA to LAD, SVG to rPDA, SVG to OM2, SVG to OM3 - [1-/2103]: 4.0 x 16 mm [Doctor First Name 10788] stent to the proximal portion of the SVG to OM3 and a second 4.0 x 16 mm [Doctor First Name 10788] stent to the distal anastamosis of the SVG to OM3. - [9-/2103]: SVG to rPDA was totally occluded, a 3.5 x 25 mm [Doctor First Name 10788] stent was placed in the distal SVG to OM2 and postdilated to 4.0 mm. - [8-24]: 4.0 x 18 mm BX velocity upsized to 4.5 mm was placed in the mid SVG to OM2, 4.5 X 23 mm BX velocity was placed in the ostium of the SVG to OM3. - [12-28]: Two 3.5 x 33 mm Cypher DES and one 3.5 x 18 mm Cypher DES were placed in the proximal SVG to OM2 and upsized to 4.0 mm in the ostium. - [1-25]: 2.25 x 18 mm Hepacoat was placed in the native OM3 after the touchdown of the SVG and postdilated to 2.5 mm, 3.5 x 12 mm Taxus DES was placed in the distal SVG to OM3, and a second 3.5 x 12 mm Taxus DES was placed in the proximal portion of the SVG to OM3. - [3-27]: Thrombotic occlusion of the SVG to OM3. Successful rheolytic thrombectomy, PTCA, and stenting of the SVG to OM3. . Other PMH: CRI (baseline Cr 1.5), DM, peptic ulcer, CHF, HTN, on home o2, dyslipedimia, pulmonary HTN, neuropathy, prostate ca s/p xrt, s/p total hip, s/p L CEA, s/p 2nd R toe amputation, lower extremity stent placements. Social History: The patient has a desk job in accounts. He quit smoking 27 years ago, was a 90-pack-year smoker. No alcohol use, no IV drug use. Family History: Positive for coronary artery disease and hypertension. No hypercholesterolemia or diabetes. Mother died at age 52 of hepatitis. Father died at age 64 of hypertension and myocardial infarction. Physical Exam: Temp 96.0, BP 129/51, HR 72, RR 16, O2sat 97% on 4L NC Gen: obese male, asleep, snoring, appears comfortable, in NAD, during placement of A-line, conversant, although somnolent. HEENT: OP clear, large obese neck, unable to appreciate JVP CV: RRR nl s1, s2, II/VI syst. M at LLSB Resp: diffuse crackles, snoring, fair air movement Abd: obese, soft, ND, NT Extr: ischemic ulcers on toes incl 2nd toe L, amputated R 2nd toe, palpable pulses, no edema Neuro: moves all extremities, responsive to voice commands Pertinent Results: Echo [2110-2-19]: Dilated CM, EF 20%, [12-27]+ MR [First Name (Titles) ] [Last Name (Titles) ], dilated RV . Echo [4-28]: EF 35-40%, 2+ MR . Persantine MIBI [2-19]: LV dilatation, EF 23%, global hypokinesis, and accentuated hypokinesis of the inferobasal region, dyskinesis of septum. [2110-2-20] 08:25PM BLOOD WBC-10.1 RBC-3.59* Hgb-11.7* Hct-34.2* MCV-95 MCH-32.5* MCHC-34.2 RDW-16.0* Plt Ct-134* [2110-2-28] 07:10AM BLOOD WBC-9.9 RBC-3.56* Hgb-11.0* Hct-33.4* MCV-94 MCH-30.9 MCHC-32.9 RDW-16.2* Plt Ct-177 [2110-2-20] 08:25PM BLOOD PT-16.9* PTT-59.0* INR(PT)-1.6* [2110-2-28] 07:10AM BLOOD PT-14.8* PTT-27.8 INR(PT)-1.3* [2110-2-20] 08:25PM BLOOD Glucose-218* UreaN-104* Creat-3.0# Na-130 K-4.9 Cl-97 HCO3-17* AnGap-21* [2110-2-28] 07:10AM BLOOD Glucose-92 UreaN-80* Creat-2.2* Na-133 K-4.0 Cl-98 HCO3-22 AnGap-17 [2110-2-20] 08:25PM BLOOD ALT-25 AST-22 LD(LDH)-200 CK(CPK)-56 AlkPhos-117 TotBili-2.6* DirBili-1.0* IndBili-1.6 [2110-2-20] 08:25PM BLOOD CK-MB-NotDone cTropnT-0.22* [2110-2-20] 08:25PM BLOOD Albumin-3.5 Calcium-8.5 Phos-5.7# Mg-2.4 [2110-2-27] 06:25AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3 [2110-2-20] 08:25PM BLOOD Hapto-58 [2110-2-21] 05:54AM BLOOD TSH-1.1 [2110-2-22] 05:22AM BLOOD Type-ART pO2-139 pCO2-40 pH-7.40 calHCO3-26 Base XS-0 . CXR [2-20]: IMPRESSION: 1. Pulmonary edema. Enlarged heart suggested possibility of the congestive heart failure. 2. Status post Swan-Ganz insertion through low approach with its tip projecting distally and within the pulmonary artery to the right lower lobe. Unchanged status post CABG and carotid stenting. . C. Cath [2-20]: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed severe native three vessel disease. The left main coronary artery was proximally occluded. The right coronary artery was the dominant vessel and was proximally occluded. 2. Graft angiography revealed patent SVG --> OM2, with 40% stenosis. Graft angiography revealed occluded SVG --> OM1, and occluded SVG --> PDA. 3. Arterial conduit angiography revealed patent LIMA --> LAD. 4. Right heart catheterization revealed severely elevated filling pressures. Mean RA pressure 34 mmhg, PA pressures 80/32, PCWP mean 48 mmhg. Cardiac output was severely depressed. Calculated cardiac index was 1.3 L/min/m2. 4. Peripheral imaging revealed mild to moderate right sided iliac disease. There was severe sub-common femoral disease on the right. . FINAL DIAGNOSIS: 1. Severe native three vessel coronary artery disease. 2. Patent LIMA --> LAD. 3. Patent SVG --> OM2. 4. Occluded SVG --> OM1. 5. Occluded SVG --> PDA. 6. Severely elevated right and left sided filling pressures. (RA = 34 mmhg, PCWP mean 48 mmhg). 7. Systemic hypotension. 8. Cardiogenic shock - calculated cardiac index 1.3 L/min/m2. 9. Mild to moderate right sided iliac disease, severe sub-common femoral artery disease. . Echo [2-21]: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate to severe global left ventricular hypokinesis (ejection fraction 30 percent). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 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. Moderate to severe [3+] tricuspid regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2108-1-17], the left ventricular ejection fraction is reduced. . [2-22] R LE u/s: IMPRESSION: No evidence of DVT in the right upper extremity. . [2-24] Echo: Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction witn inferior septal and inferior akinesis. The remaining segments are hypokinetic. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([11-25]+) mitral regurgitation is seen. [Due to suboptimal apical image quality, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2110-2-21], the severity of mitral regurgitation is slightly increased (previously mild). Left ventricular systolic function (global and regional) is similar. Brief Hospital Course: A/P: 73 y.o. M with hx of extensive CAD presented with worsened CHF, found to have worsened systolic function, no reversible changes on stress testing, no new intervenable coronary vessel obstruction. . # Cardiogenic shock/decompensated CHF - initially pt was maintained on dobutamine, nitro drip and diuresed agressively with IV lasix boluses. He responded well with improvement in his symptoms over the next two days. He was placed back on home dose of lasix (80mg PO daily) and beta blocker, and fluid status appeared stable prior to discharge. He was started in long acting nitrates and hydralazine for afterload reduction as he had interval worsening of renal function after cath, and ACE-I was avoided as a result, would consider ACE-I as outpatient. . # CAD - pt with extensive disease, s/p multiple interventions. Cardiac enzymes remained flat, no new obstructions on cath, no reversible defects on outside stress test. Continued aspirin, plavix,statin. Consider revascularization on an outpatient basis. Pt has EP f/u [Year (4 digits) 1988] as he is a candidate for ICD placement for primary SCD prevention, which he is agreeable to. Echo did not show any significant dyssynchrony. . # Rhythm - pt with recent atrial fibrillation at outside hospital, tx with amiodarone drip at [Hospital1 1474], then complicated by junctional rhythm bradycardia. During his stay here, his rate remained well controlled off amiodarone. EP reviewed rhythm strips and concluded that this was more consistent with NSR with multiple PACs. Pt had a large amount of hematuria, and anticoagulation was discontinued. Given his reduced EF he may also be a candidate for ICD of primary prevention of SCD. He is [Hospital1 1988] to follow-up with Dr. [Last Name (STitle) ] to evaluate this. There was some concern regarding the status of his feet and some possible cellulitis in setting of peripheral vascular disease. Podiatry who had seen the patient in the past did not think this was changed from his baseline, but it was felt to be safer to reassess this after some time prior to ICD implantation. . # Hematuria - pt developed gross hematuria with clots while on heparin, requiring continuous bladder irrigation. He is [Last Name (STitle) 1988] to follow-up with urology for an outpatient work-up. . # Chronic renal insufficiency - pt with Cr elevated from baseline (1.5), worsened with decompensated CHF, and after cath, improved somewhat although not back to baseline. Received mucomyst for prophylaxis, held off on using ACE-I. . # Diabetes type II - patient was maintained on lower dose of [Hospital1 ] NPH than at home (40U [Hospital1 ] as opposed to 60U at home). Will likely need to increase once back on home diet. . # Code - full Medications on Admission: plavix 75 QD protonix 40 lasix 80 mg ASA 325 Gabapentin 300 tid Lispro 60 U SC BID 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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Primary: CHF exacerbation, systolic Coronary Artery Disease Atrial Fibrillation Chronic Renal Insufficiency Diabetes type II Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 Liters Please take your medications as prescribed. Follow-up with your doctors [First Name (Titles) 3] [Last Name (Titles) 1988]. Be sure to follow-up with the urologist to investigate the source of urinary bleeding, follow-up with Dr. [Last Name (STitle) ], as well as with Dr. [Last Name (STitle) 2357] regarding defibrillator placement. You should seek medical care if you develop any chest pain, worsened shortness of breath, fever > 101, or any other concerning symptoms. Followup Instructions: 1) ICD placement: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], Monday [4-14], 9:00 am, ([Telephone/Fax (1) 22784]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 5518]) will contact you prior to the procedure date with further instructions. 2) Vascular Surgery: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [2110-3-24] at 3:00pm, ([Telephone/Fax (1) 22785]. 3) Urology: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 770], [2110-3-25] at 10:10am, ([Telephone/Fax (1) 22786]. 4) Please call your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Name (STitle) 1057] ([Telephone/Fax (1) 22787], to schedule a follow up appointment within the next 1-2 weeks. Completed by:[2110-3-19]	[ "414.01", "414.02", "427.31", "785.51", "585.9", "428.0", "428.20", "V58.67", "250.00" ]	icd9cm	[ [ [] ] ]	[ "37.23", "88.56" ]	icd9pcs	[ [ [] ] ]	13331, 13386	9344, 12111	314, 339	13555, 13564	4275, 6771	14231, 15093	3537, 3732		12245, 13308		13407, 13534		12137, 12222		6788, 9321	13588, 14208									3747, 4256																			255, 276									367, 1960																1982, 3374	3390, 3521
51,802	184,299	45541	Discharge summary	report	Admission Date: [2143-3-19] Discharge Date: [2143-3-25] Service: NEUROSURGERY Allergies: Penicillins / Tetracycline Attending:[First Name3 (LF) 78] Chief Complaint: Left sided weakness, gait instability Major Surgical or Invasive Procedure: [2143-3-20]: Right sided craniotomy for evacuation of subdural hemorrhage History of Present Illness: [Age over 90 ] year old female presented to her PCP [Last Name (NamePattern4) ] [3-19] with left sided weakeness and gait instability. She is s/p mechanical fall in [Month (only) 958] of this year. At that time she was seen in the local ER and did not have any imaging. She has has increasing difficulty walking and she has noticed that her left arm is "clumsy." She reports dropping things frequently. Her son reports that she leans towards the left when walking. Her PCP sent her to the OSH ER for a CT scan [3-19]. Past Medical History: pacemaker placement 14 years ago tonsillectomy age 21 appendectomy age 14 carotid endarterectomy left side 10 years ago Meniere's Disease - had a procedure in the right ear Right ear complete hearing loss Left ear partial hearing loss Bilateral cataracts removed several years ago Social History: Has son who accompanied her on admission, and a fiancee. Patient lives alone, finacee lives in same complex. Son lives nearby. Her husband died about 14 years ago. Family History: Non-contributory Physical Exam: On Admission: T:96.7 BP:148/60 HR:74 RR:16 O2Sats:94% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs-intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing loss in left ear. Total hearing loss right ear. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Overall strength is diminished. Her right side is 5-throughout. Left upper extremity is 4 throughout and 3 in the deltoid. Left IP, Gastrocs, AT, 5. Left Quad, Ham 4. Left pronator drift. Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally On Discharge: awake alert oriented / pupils 4-2.5 [Doctor Last Name ], eomi, no drift, strength in general 4+/5, MAE, ambs with assist. Pertinent Results: Labs on Admission: [2143-3-19] 07:30PM BLOOD WBC-6.3 RBC-3.93* Hgb-12.8 Hct-36.0 MCV-92 MCH-32.5* MCHC-35.4* RDW-13.6 Plt Ct-248 [2143-3-19] 07:30PM BLOOD PT-13.0 PTT-25.7 INR(PT)-1.1 [2143-3-19] 07:30PM BLOOD Glucose-101 UreaN-17 Creat-0.7 Na-143 K-2.6* Cl-103 HCO3-30 AnGap-13 [2143-3-19] 09:28PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.011 [2143-3-19] 09:28PM URINE Blood-NEG Nitrite-POS Protein-NEG Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [2143-3-19] 09:28PM URINE RBC-0-2 WBC-[1-17] Bacteri-MANY Yeast-NONE Epi-0-2 Imaging: Head CT [3-20]: FINDINGS: Again seen is a heterogeneous concave extra-axial collection over the right frontoparietal curvature similar in size to the prior study. There is a 7-mm leftward shift, unchanged from prior. The density within the fluid collection increases dependently suggesting a hematocrit effect. Apparently increased hypodensity (series 2, image 13) is probably due to technical factors and intreval development of septations. There is a prominent extra-axial space adjacent to the right cerebellar hemisphere. No definite new intracranial hemorrhage. The mastoid air cells and visualized paranasal sinuses are clear. IMPRESSION: 1. Subdural hematoma layering over the right frontoparietal curvature producing 7 mm of leftward shift. 2. More conspicuous hyperdensity within this collection is likely technical in etiology and hematoma septations. CXR [3-19]: PA AND LATERAL VIEWS OF THE CHEST: Right-sided dual-chamber pacemaker with leads overlying the right atrium and right ventricle is present. The cardiac silhouette is mildly enlarged with a left ventricular predominance. The aorta is slightly tortuous. The mediastinal and hilar contours are otherwise unremarkable. Pulmonary vascularity is normal. Lungs are clear. No pleural effusion or pneumothorax is identified. An old left posterolateral third rib fracture is present. Additionally, a 3-mm nodule is seen within the right mid lung field, likely a granuloma. Degenerative changes are noted within the thoracic spine. IMPRESSION: No acute cardiopulmonary abnormality. [Known lastname ],[Known firstname 3996] [Medical Record Number 97143] F 91 [2051-8-1] Radiology Report CT HEAD W/O CONTRAST Study Date of [2143-3-21] 10:59 AM [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 12630] TSICU [2143-3-21] 10:59 AM CT HEAD W/O CONTRAST Clip # [Clip Number (Radiology) 97144] Reason: s/p craniotomy eval for acute changes [Hospital 93] MEDICAL CONDITION: [Age over 90 ] year old woman with new lethargy s/p craniotoy for acute on chronic SDH REASON FOR THIS EXAMINATION: s/p craniotomy eval for acute changes CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: IPf [Doctor First Name ] [2143-3-21] 4:33 PM [Year (4 digits) ]: No significant interval change. Final Report HISTORY: [Age over 90 ]-year-old woman with new lethargy, status post craniotomy for acute on chronic subdural hematoma. Evaluate for acute changes. TECHNIQUE: CT head without contrast. COMPARISON: Compared to CT head [2143-3-20] at 5:10 p.m. FINDINGS: Again seen is a small right-convexity pneumocephalus within the spectrum of frontotemporal craniotomy change. The right subdural hemorrhage in the right frontal convexity has a similar appearance compared to prior scan, with a small dense collection measuring up to 8 mm from the inner table. The shift of the normally placed midline structure is stable, measuring 6 mm. There is no evidence of herniation. There is no evidence of parenchymal hemorrhage or acute infarct. The ventricles and sulci are normal in caliber and configuration. IMPRESSION: Stable size of right-convexity subdural hematoma and mass effect with a small high-density component remaining in the extra-axial space post- subdural evacuation. Differential includes retained high-density material within a septation, epidural hematoma, or residual subdural hematoma. Continuous followup as clinically indicated. The study and the report were reviewed by the staff radiologist. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 7415] Approved: FRI [2143-3-22] 11:42 AM [Known lastname ],[Known firstname 3996] [Medical Record Number 97143] F 91 [2051-8-1] [Known lastname ],[Known firstname 3996] [Medical Record Number 97143] F 91 [2051-8-1] Radiology Report CT HEAD W/O CONTRAST Study Date of [2143-3-25] 9:15 AM [Last Name (LF) ],[First Name3 (LF) ] J. [First Name3 (LF) 12630] FA11 [2143-3-25] 9:15 AM CT HEAD W/O CONTRAST Clip # [Clip Number (Radiology) 97145] Reason: please evaluate for interval change [Hospital 93] MEDICAL CONDITION: [Age over 90 ] year old woman with s/p crani for SDH REASON FOR THIS EXAMINATION: please evaluate for interval change CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: GWp MON [2143-3-25] 11:52 AM No significant interval change. Preliminary Report !! [Year (4 digits) ] !! No significant interval change. DR. [First Name8 (NamePattern2) 5206] [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] entered: MON [2143-3-25] 11:52 AM Imaging Lab Brief Hospital Course: Patient is a [Age over 90 ]F s/p mechanical fall earlier this year, who presented to PCP after experiencing left sided weakness and increased clumsiness. Her PCP sent her to an OSH for imaging, where a sizable right subdural hematoma was noted. She was then transferred to [Hospital1 18] for definitive neurosurgical care. On [3-20], she went to the operating room for a right sided craniotomy for decompression of hematoma. Her pre-operative labs revealed a urinary tract infection, and she was started on a course of Cipro. Additionally, due to her chronic ASA use, she was administered platelets prior to surical intervention. Post-operatively she was transferred to the ICU for monitoring overnight. She continued to do well and was transfered to floor status. She was evalutated by PT OT and found appropriate for rehab. She was discharged to rehab and agrees with the plan. Medications on Admission: Evista NF 60 mg Oral daily Senna 3 TAB PO HS Alprazolam 0.25 mg PO QHS:PRN sleep / anxiety Potassium Chloride 40 mEq PO DAILY Amlodipine 5 mg PO DAILY Propafenone HCl 150 mg PO TID Metoprolol Succinate XL 50 mg PO HS Metoprolol Succinate XL 100 mg PO DAILY Aspirin 325 daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime). 4. Propafenone 150 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for sleep / anxiety . 7. Senna 8.6 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime): pts home regime. 8. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily (). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache, fever. 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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). 14. Ondansetron 4 mg IV Q8H:PRN nausea 15. HydrALAzine 10 mg IV Q4-6H:PRN SBP>140 16. Metoprolol Tartrate 5 mg IV Q4-6H:PRN hypertension > 160 while NPO 17. DiphenhydrAMINE 25 mg IV Q6H:PRN anxiety 18. HYDROmorphone (Dilaudid) 0.25 mg IV Q3H:PRN pain Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Right Sided subdural hemorrhage Urinary tract infection Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? 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]. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please have your staples removed in rehab on [2143-3-30] ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 2 weeks. ??????You will need a CT scan of the brain without contrast on the same day as this appointment / please notify the office when you call for an appointment. Completed by:[2143-3-25]	[ "E888.9", "781.2", "599.0", "389.9", "386.00", "285.9", "V45.01", "729.89", "852.21", "780.79" ]	icd9cm	[ [ [] ] ]	[ "01.31" ]	icd9pcs	[ [ [] ] ]	11302, 11399	8487, 9383	274, 354	11499, 11523	2952, 2957	13186, 13610	1424, 1442		9710, 11279	7947, 8004	11420, 11478		9409, 9687			11547, 13163									1457, 1457												2805, 2933							197, 236	8036, 8464								382, 921	1968, 2791							2971, 5559		1731, 1952						943, 1226	1242, 1408
70,592	124,140	38873	Discharge summary	report	Admission Date: [2113-4-2] Discharge Date: [2113-4-11] Date of Birth: [2051-1-29] Sex: M Service: NEUROLOGY Allergies: Lisinopril Attending:[First Name3 (LF) 2569] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: intubation, lumbar puncture, extubation History of Present Illness: 62 yo M with hx of HTN, DM, [Hospital 85819] transferred from [Hospital6 86268] Center after found to have SAH. The patient was found down in Stop and Shop, unresponsive this afternoon. As per notes, it appears no specific seizure activity was witnessed, but it was thought by EMS that the patient was post-ictal. He was taken to [Hospital6 28728] Center. At time of arrival his bp was 170/100, P 110, GCS 10 (eyes - 4, verbal - 2, motor - 4). He was noted to become very agitated, combative, and harmful. He was subsequently intubated, received etomidate, rocuronium, versed 20 mg total, ativan 2 mg, labetalol 10 mg, and fosphenytoin 1g. Laboratory data notable for WBC 11.9, trop < 0.01, CK 109, CO2 18, Cr 1.3. U tox and serum tox were negative. Patient was transferred to [Hospital1 18] for further care. Of note, the patient was recently started on ativan 0.5 mg tid after his wife had passed away in [2113-1-3]. It is unclear if he has been taking this daily or PRN. ROS unobtainable. Past Medical History: -HTN -diabetes -HLD -CAD -Anxiety Social History: Lives alone, works at Lowes. Wife died [12-12], patient has [Last Name (un) 6550] saddened and extremely anxious. Tobacco - remote EtOH - unknown Drug use - denied by family Family History: CAD, HTN, DM Physical Exam: On admission: VS; BP 111/63 P 78 RR 16 100% on vent, afebrile General: intubated, sedated. Obese, mildly disheveled middle-aged male. HEENT: NC/AT, no scleral icterus noted, atraumatic. Neck: c-collar in place Pulmonary: Lungs CTA anteriorly Cardiac: RRR, distant S1,S2, no murmurs Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurological Examination; Mental Status; patient becomes agitated, trashing all limbs when taken off sedation. Does not follow commands. Cranial Nervies; Pupils 2mm and minimally reactive. Eyes in midposition. No corneals. Face symmetric. Motor; normal bulk and tone. Appears to move all extremities equally and symmetrically when off sedation. Sensory; withdraws to light touch Reflexes; 1+ and symmetric throughout in upper extremities, 0 at patellars and achilles bilaterally. Toes mute. Coordination; unable to assess Gait; unable to assess Exam at time of discharge: Pertinent Results: [2113-4-2] 06:45PM BLOOD WBC-12.7* RBC-4.87 Hgb-14.5 Hct-42.2 MCV-87 MCH-29.8 MCHC-34.5 RDW-14.1 Plt Ct-251 [2113-4-3] 03:05AM BLOOD WBC-8.4 RBC-4.39* Hgb-13.6* Hct-38.4* MCV-88 MCH-31.1 MCHC-35.5* RDW-14.2 Plt Ct-267 [2113-4-6] 01:50AM BLOOD WBC-7.3 RBC-3.59* Hgb-11.3* Hct-31.6* MCV-88 MCH-31.5 MCHC-35.8* RDW-14.0 Plt Ct-229 [2113-4-2] 06:45PM BLOOD Neuts-88.5* Lymphs-7.5* Monos-3.6 Eos-0.4 Baso-0.1 [2113-4-2] 06:45PM BLOOD PT-11.9 PTT-19.5* INR(PT)-1.0 [2113-4-2] 06:45PM BLOOD Glucose-173* UreaN-17 Creat-1.2 Na-138 K-3.8 Cl-99 HCO3-27 AnGap-16 [2113-4-2] 06:45PM BLOOD ALT-28 AST-26 CK(CPK)-198 AlkPhos-64 TotBili-0.8 [2113-4-5] 01:49AM BLOOD CK(CPK)-1213* [2113-4-5] 09:02AM BLOOD ALT-30 AST-78* CK(CPK)-1150* AlkPhos-63 TotBili-0.5 DirBili-0.2 IndBili-0.3 [2113-4-5] 05:58PM BLOOD LD(LDH)-337* CK(CPK)-993* [2113-4-6] 01:50AM BLOOD CK(CPK)-686* [2113-4-2] 06:45PM BLOOD cTropnT-<0.01 [2113-4-3] 03:05AM BLOOD CK-MB-4 cTropnT-<0.01 [2113-4-5] 01:49AM BLOOD CK-MB-46* MB Indx-3.8 cTropnT-0.92* [2113-4-5] 09:02AM BLOOD CK-MB-33* MB Indx-2.9 cTropnT-1.20* [2113-4-5] 05:58PM BLOOD CK-MB-18* MB Indx-1.8 cTropnT-1.24* [2113-4-6] 01:50AM BLOOD CK-MB-9 cTropnT-0.88* [2113-4-3] 03:05AM BLOOD Albumin-3.7 Calcium-8.4 Phos-3.7 Mg-1.9 Cholest-121 [2113-4-6] 01:50AM BLOOD Albumin-3.0* Calcium-8.1* Phos-2.6* Mg-2.1 [2113-4-3] 09:23AM BLOOD %HbA1c-6.1* eAG-128* [2113-4-5] 05:58PM BLOOD Triglyc-212* HDL-37 CHOL/HD-3.4 LDLcalc-45 [2113-4-5] 09:02AM BLOOD TSH-0.53 [2113-4-3] 12:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2113-4-3] 12:10AM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.015 [2113-4-3] 12:10AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 [2113-4-5] 05:58PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-75* Polys-24 Lymphs-13 Monos-37 Macroph-26 [2113-4-5] 05:58PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1383* Polys-27 Lymphs-18 Monos-36 Macroph-20 [2113-4-5] 05:58PM CEREBROSPINAL FLUID (CSF) TotProt-81* Glucose-102 LD(LDH)-29 [2113-4-5] 05:58PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-PND Micribiology: BCx - 2/28 1/4 bottles positive for MSSA. BCx [4-3] - [4-4] negative. [4-5] CSF - Bacterial cultures negative. [4-5] CSF HSV PCR - pending [2113-4-5] CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN-negative. [4-4] UCx - negative Imaging: CT head [4-2]: IMPRESSION: 1. Stable right parietal subarachnoid hemorrhage. 2. Rounded lesion in the superior right orbit, inseparable from the ophthalmic vasculature on the right, likely representing an aneurysm MRI/A/V brain [4-3]: IMPRESSION: 1. Small right superior parietal subarachnoid hemorrhage, which could be post-traumatic in the setting of the associated right parietal subgaleal hematoma. 2. Mild chronic small vessel ischemic disease. 3. No evidence of central intracranial aneurysms. Please note that the location of the patient's subarachnoid hemorrhage is not included on the MRA of the head. 4. No evidence of deep venous thrombosis. 5. Nondiagnostic, technically unsuccessful neck MRA. 6. Bulbous lesion in the right orbit, intimately associated with the superior ophthalmic vein, which most likely represents a venous aneurysm. Given the presence of a gadolinium level on post-contrast images, a lymphangioma could also be considered. A cystic schwannoma or a hemangioma would be much less likely. Further evaluation could be obtained by either a CT venogram or a dedicated MRI of the orbits. EEG [4-5] - pending ECHO [4-5]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). No definite regional wall motion abnormality seen. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal with borderline normal free wall function. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. MR [Last Name (Titles) 12784] [4-4]: IMPRESSION: 1. No evidence of vertebral body bone marrow edema, ligamentous edema, paraspinal soft tissue edema, or other acute traumatic injuries. 2. Ossification of the posterior longitudinal ligament from C3 through C6, indenting the spinal cord and causing moderate spinal canal stenosis, worst at C5 and C6. No evidence of associated cord signal abnormality. 3. Moderate-to-severe neural foraminal narrowing at C3-4. Moderate neural foraminal narrowing at C6-7. CTA chest [4-5]: IMPRESSIONS: 1. No evidence of pulmonary embolism, noting the limitation of superimposed opacities obscuring lower lobe subsegmental vessels somewhat. 2. Multifocal opacities in the lungs with pleural effusions. The appearance is suspected to represent a combination or pneumonic consolidations (particularly in the right upper lobe) and extensive atelectasis. Follow-up chest CT is recommended to show resolution in several months if clinically appropriate given the mass-like apppearance of a consolidative opacity in the right upper lobe. A lung mass cannot be excluded at that site. Brief Hospital Course: 62-year-old male with history of HTN, DM, HLD, found down in Stop and Shop this afternoon after unwitnessed event, presumed to be post-ictal upon arrival by EMS. He presented to outside hospital with GCS 10 and found to have a right parietal subarachnoid hemorrhage. #NEURO. Patient was admitted to NEURO ICU and managed per SAH protocol. MRI/A/V of head was obtained and showed no VST, AVM as causes of SAH, but did reveal a R subgaleal hematoma. No infarction or vessel abnormalities in vessels of COW and neck. ASA was held x 2 days and restarted on HD2. Heparin SC was started 48 hrs after admission. BP was maintained to goal of < 160, however, due to significant patient agitation at times would reach nearly 180 systolic. He was on Dilantin for Sz ppx while in ICU. Dilantin discontinued prior to transfer to the floor. CT head was repeated and showed improved SAH. Patient was extubated on HD2, however remained extremely agitated and required use of Haldol, ativan, zyprexa and Precedex to prevent self harm. Due to agitation, he underwent periodic episodes of hypertension and tachycardia. LP was performed to assess for etiology of agitation and was negative. Etiology of agitation was felt to be due to ICU delerium. His agitation improved after transfer to the floor. He did not require seroquel on the floor. He was assessed by PT/OT and he does not require outpatient therapy. His neurologic exam on day of discharge was significant for normal mental status, normal cranial nerve exam, muscle strength full throughout, and slight pronator drift on the right. #CV/PULM. On HD2, patient was noted to have worsening hypoxemia and require NRB in setting of elevated BPs during agitation (SBPs to 190s). He developed flash pulmonary edema clincially and was noted to have troponin/CK but not MB elevations (see above). EKG showed RV strain and ECHO showed no WMA w/ EF 60% and RV borderline function. Lasix was used for diuresis, however, due to persistent agitation and hypoxemia, he required reintubation on [4-5], sedated w/ propofol requiring general anesthesia levels. CTA was performed to r/o PE and was negative, revealing however pulmonary edema and b/l effusions. There was no evidence of PNA and patient remained afebrile. Patient was extubated prior to transfer to the floor. He was cardiovascularly stable on the floor. #ID. Patient had one positive BCx ([2-6]) on [4-2] from the ED felt to be contaminant. No fevers developed. Blood culture on [2113-4-7] grew gram positive rods. Repeat blood culture on [2113-4-9] and central line tip culture on [4-9] were negative after 48 hours. He remained afebrile without leukocytosis throughout. Medications on Admission: -aspirin 325 mg daily -atenolol 25 mg daily -ativan 0.5 mg tid -olmesartan 10 mg daily -diltiazm ER 180 mg -fish oil 100 mg tid -folate 1 mg daily -glimepiride 2 mg daily -HCTZ 25 mg daily -isosorbide mononitrate 20 mg [Hospital1 ] -lipitor 40 mg qhs -lisinopril 5 mg daily -metformin 1000 mg [Hospital1 ] -Nitroglycerin prn Discharge Medications: 1. Diltzac ER 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 2. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 4. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO three times a day. 5. Fish Oil Oral 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 7. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day. 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. Isosorbide Mononitrate 20 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Lipitor 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Outpatient Cardiac Rehab Program 13. Olmesartan 5 mg Tablet Sig: Three (3) Tablet PO once a day: 15 mg/day. Usually takes 10 mg tabs. 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Admission Diagnosis: Subarachnoid hemorrhage Secondary Diagoses: -HTN -diabetes -HLD -CAD -Anxiety Discharge Condition: His neurologic exam on day of discharge was significant for normal mental status, normal cranial nerve exam, muscle strength full throughout, and slight pronator drift on the right. Discharge Instructions: You were admitted to [Hospital1 18] with a fall and a traumatic subarachnoid hemorrhage. It was unclear why you had fallen, however you were ruled out for infection, seizures and other etiologies. While hospitalized you had remarkable episodes of agitation leading to elevated blood pressures and cardiac stress leading to enzyme leakage but no heart attack. You were treated for the blood pressure and required high amounts of multiple medications to remain sedated. Your agitation resolved prior to discharge. You were evaluated by physical therapy who recommended that you would benefit from an outpatient cardiac rehab program to improve your endurance and cardiac function. A prescription has been provided for this. Please keep all follow-up appointments and take all medications as directed. . Should you develop any symptoms as listed below or concerning to you, please call your doctor or go to the emergncy room. Followup Instructions: Please call Dr. [First Name8 (NamePattern2) 2530] [Name (STitle) ], neurologist at [Hospital1 18]. Phone [Telephone/Fax (1) 2574]. Please follow-up within 2 months. [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2113-4-12]	[ "428.0", "300.00", "293.0", "518.81", "V15.82", "272.4", "348.30", "852.01", "410.71", "428.21", "250.00", "414.01", "E888.9", "416.8", "401.9" ]	icd9cm	[ [ [] ] ]	[ "03.31", "38.93", "96.04", "96.71" ]	icd9pcs	[ [ [] ] ]	12465, 12471	8387, 11095	280, 321	12622, 12806	2709, 8364	13785, 14108	1646, 1660		11478, 12442		12492, 12500		11121, 11455			12830, 13762									1675, 1675									12521, 12601										232, 242									349, 1373								1690, 2690								1395, 1430	1446, 1630
78,705	141,816	4184+55552	Discharge summary	report+addendum	Admission Date: [2182-9-25] Discharge Date: [2182-10-3] Date of Birth: [2108-8-15] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: flexible bronchoscopy with suction of secretions bronchoscopy with stent removal History of Present Illness: 74 y/o F with history of TBM, s/p Silicone Y-stent placement on [2182-8-22] and therapeutic bronch with clearance of secretions [9-5] who presented on [9-25] with cough and shortness of breath for 5 days. She states that she feels similar to her prior occlusion [9-5]. She has trouble bringing secretions up, but when she does expectorate it is mostly yellow/white mucus. She saw her PCP last week who started a "penicillin-based antibiotic" without much improvement. She has been on steroids in the past for COPD flares and notes that they make her feel very agitated and requires sedation with them. She initially presented to [Hospital 1562] Hospital ED and was afebrile, sating 94% on RA before transfer to [Hospital1 18]. . In the ED, initial vitals were T 98, P 60, RR 20, BP 133/60, 95% on 4L. The patient underwent CXR which showed no evidence of pneumonia on prelim read. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. Last BM today, she reports decrease po over last week due to worsening respiratory symptoms. Denied arthralgias or myalgias. Past Medical History: TBM s/p Y stenting in [8-25] COPD Obesity hypoventilation syndrome H/o C. diff colitis Anxiety Depression Hypothyroidism CAD, diastolic heart failure Seizure disorder R colon cancer s/p hemicolectomy in [2178] s/p tonsillectomy s/p thyroid lobectomy [2151] s/p cholecystectomy [2151] s/p appendectomy [2179] Social History: Tobacco: >25 pack years, denies any active smoking Alcohol: denies Widow, lives by her self Family History: Mother and father with CAD No lung cancer or congenital lung diseases Physical Exam: General: NAD, mildly tachypneic, using accessory muscles and pursed lips for exhalation HEENT: Sclera anicteric, dry MM, oropharynx clear Lungs: diffuse inspiratory and expiratory rhonchi, no crackles, occaisional scattered wheezes, audible airway secretions CV: RRR, diff to appreciate over lung sounds Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: Warm, well perfused, 2+ pulses, no edema Pertinent Results: CXR ([2182-9-25]): FINDINGS: PA and lateral views of the chest are obtained. A Y-shaped stent is noted in the lower trachea and entering the mainstem bronchi. The lungs are hyperexpanded with upper lobe lucency and splaying of bronchovasculature as well as widened AP diameter compatible with underlying emphysema. There is no evidence of superimposed pneumonia or CHF. No pneumothorax is seen. Cardiomediastinal silhouette is grossly unremarkable. Mild atherosclerotic calcification is noted along the thoracic aorta. The osseous structures are diffusely demineralized but appear intact. IMPRESSION: Emphysema, no evidence of acute superimposed process. Tracheal stent in place. Labs: [2182-9-26] 11:44AM BLOOD WBC-12.9# RBC-4.54 Hgb-12.7 Hct-39.8 MCV-88 MCH-28.0 MCHC-31.9 RDW-13.8 Plt Ct-278 [2182-9-26] 11:44AM BLOOD Plt Ct-278 [2182-9-26] 11:44AM BLOOD PT-12.5 PTT-29.0 INR(PT)-1.1 [2182-9-26] 11:44AM BLOOD Glucose-113 UreaN-10 Creat-1.1 Na-141 K-4.5 Cl-113* HCO3-19* AnGap-14 [2182-9-26] 11:44AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 [2182-9-26] 08:15AM BLOOD Type-ART pO2-59* pCO2-30* pH-7.42 calTCO2-20* Base XS--3 Intubat-NOT INTUBA Brief Hospital Course: 74 y/o F with PMHx of COPD, and TBM s/p silicone Y-stent on [2182-8-22], followed by therapeutic bronch on [9-5], preseted on [9-25] with cough and shortness of breath for five days. . On arrival to the floor, pt was c/o shortness of breath and having difficultly clearing secretions. Despite additional nebs, and humidified O2, she triggered for increased RR. She was also desatting to high 80s and complaining of tiring out. ABG was 7.42/30/59. She was tranferred to the ICU. . On [2182-9-26], she received theapeutic bronchoscopy. On [2182-9-27], IP removed the Y stent, given lack of improvement. Patient reported subjective improvement in breathing and ability to cough up secretions. She was maintained on albuterol/atrovent nebs, advair, and morphine for anxiety component. She was started on azithromycin for presumed COPD exacerbation. Patient was not started on steroids in the ICU given previous history of psychosis with prednisone. Upon transfer out of the MICU, she was saturating at 95% on 5L of oxygen. . On the floor, pt had increased dyspnea, although she was on four liters O2 and on q4h standing nebulizers. She was started on prednisone 40mg. After two days and no improvement, prednisone was increased to 60mg daily. The pulmonary team was also consultued and had no further recommendations. She was also given several empiric doses of lasix. Within two days she had significant improvement. She was tachypneic, though did not desaturate when she would walk and climb stairs with physical therapy. She was discharged when stable on 2L, with home O2, and outpatient pulmonary rehab. She was instructed to call her pulmonologist immediately upon reaching home and set an appointment within one week. . Chronic diastolic heart failure: Pt is not maintained on any CHF ppx meds at baseline and appeared euvolemic to dry on exam. She had no crackles on lung exam or lower extremity edema, CXR without signs of edema. I/Os were net even throughout her hospitalization. She was given several doses of lasix, empirically given no improvement in pulmonary symptoms and her respiratory status improved to some degree, and it was thought that she might have had some of fluid retention affecting her respiratory status. . Smoking cessation: Smoking cessation was highly encouraged on a daily basis by multiple teams. She stated that boredome was the most significant component to not quitting. After this experience, she stated she was encouraged and make every effort to quit. Medications on Admission: Effexor extended release 150mg PO daily Atrovent MDI 2 puffs qid Lamictal 150mg PO daily Seroquel 25mg PO qHS Synthroid 150 mcg PO daily Tylenol 650mg PO q6h PRN pain/fever Mucinex 1200 mg PO BID Mucomyst nebs Q8Hrs Advair 250/50 Discharge Medications: 1. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:90 Capsule(s) Refills:0 2. Lamotrigine 150 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [Hospital1 ] (2 times a day). Disp:2 disks Refills:2 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): please take with daily prednisone to prevent stomach pain. Disp:30 Tablet(s) Refills:2 8. Outpatient Physical Therapy PT: Evaluate and Treat, Pulmonary Rehab Dx: tracheobronchomalacia 9. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day: Prednisone, take 60mg X1 day, then 40mg for 5 days, then 20mg X 5 days, then 10mg X 5 days, then 5mg X 5 days. Please take 40mg if symptoms increase and call your PCP to evaluate symptoms. Please discuss your prednisone dosing at your pulmonology visit. . Disp:200 Tablet(s) Refills:0 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety. Disp:30 Tablet(s) Refills:0 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q4H (every 4 hours). Disp:180 nebulizer Refills:2 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4 hours). Disp:180 nebulizer Refills:2 Discharge Disposition: Home Discharge Diagnosis: primary: tracheobronchomalaica and COPD Discharge Condition: stable, RR, 22, O2sat 91% 2L Discharge Instructions: You were admitted for treatment of shortness of breath caused by tracheobonchomalacia and COPD exacerbation. During your hospitalization you were transferred to the ICU given increasing effort required to breath. You underwent bronchoscopy twice, once for suction of secretions, and once for stent removal. You were transferred to the floor, where you were treated for a COPD exacerbation with steroids and nebulizers. Your respiratory status improved and you were discharged. . Medications changed on this admission: --> Prednisone, take 60mg X1 day, then 40mg for 5 days, then 20mg X 5 days, then 10mg X 5 days, then 5mg X 5 days. Please go back to 40mg if symptoms increase and call your PCP. [Name10 (NameIs) 357] discuss your prednisone dosing at your pulmonology visit. --> Nicotine patch - apply daily for 7 days then quit. --> Tesselon Pearls for cough --> Famotidine - to protect the stomach while on prednisone . Please call your doctor or return to the ED if you experience worsening shortness of breath, chest pain, or any other concerning symptom. Please take 40 mg of prednisone if you feel you are about to experience a COPD exacerbation. Followup Instructions: Please follow up with your pulmonologist Dr [Last Name (STitle) 18220] - ([Telephone/Fax (1) 18221] within one week of when you get home. No appointments are available at this time, but they should be able to schedule you when you call them. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2182-10-3] Name: [Known lastname 2942],[Known firstname 2943] Unit No: [Numeric Identifier 2944] Admission Date: [2182-9-25] Discharge Date: [2182-10-3] Date of Birth: [2108-8-15] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1472] Addendum: Ms. [Known lastname 2945] hospital course was also complicated by diastolic heart failure for which she was treated empirically with several doses of lasix during her hospitalization. While there were no signs of pulmonary edema or heart failure on physical exam or radiographic evidence, clinical response to diuretic supported this diagnosis. Secondary diagnosis: acute on chronic diastolic heart failure Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: bronchoscopy X 2 History of Present Illness: Ms. [Known lastname ] is a 74 year old woman with history of TBM, s/p Silicone Y-stent placement on [2182-8-22] and therapeutic bronch w/ clearance of secretions [9-5] who presents with cough and shortness of breath for 5 days. She states that she feels similar to her prior occlusion [9-5]. She has trouble bringing secretions up, but when she does expectorate it is mostly yellow/white mucus. She saw her PCP last week who started a "penicillin-based antibiotic" without much improvement. She has been on steroids in the past for COPD flares and notes that they make her feel very agitated and requires sedation with them. She initially presented to [Hospital 2946] Hospital ED and was afebrile, satting 94% on RA. She had had decreased appetite and eating mostly soup. . In the ED, initial vitals were T 98, P 60, RR 20, BP 133/60, 95% on 4L. The patient underwent CXR which showed no evidence of pneumonia on prelim read. . ROS: Negative for fevers, chills, chest pain, abdominal pain, nausea, vomiting, diarrhea. . Past Medical History: TBM s/p Y stenting in [8-25] COPD Obesity hypoventilation syndrome H/o C. diff colitis Anxiety Depression Hypothyroidism CAD, diastolic heart failure Seizure disorder R colon cancer s/p hemicolectomy in [2178] s/p tonsillectomy s/p thyroid lobectomy [2151] s/p cholecystectomy [2151] s/p appendectomy [2179] Social History: Tobacco: >25 pack years, denies any active smoking Alcohol: denies Widow, lives by her self Family History: Mother and father with CAD No lung cancer or congenital lung diseases Physical Exam: On Admission: Vitals: T 98.0 P 84 RR 28 BP 117/68 O2 97% on 2L Gen: Uncomfortable elderly female with moderate respiratory distress and audible upper airway rhonchi HEENT: EOMI. MMM. OP clear. Conjunctiva well pigmented. Neck: Supple, without adenopathy or JVD. Chest: Lungs - coarse rhonchi in all lung fields, no wheezes appreciated. Cor: Normal S1, S2. RRR. No murmurs appreciated. Abdomen: Soft, non-tender and non-distended. +BS, no HSM. Extremity: Warm, without edema. 2+ DP pulses bilaterally. Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all extremities. Sensation intact grossly. Pertinent Results: [2182-9-26] WBC-12.9# RBC-4.54 Hgb-12.7 Hct-39.8 Plt Ct-278 Glucose-113 UreaN-10 Creat-1.1 Na-141 K-4.5 Cl-113* HCO3-19* AnGap-14 Calcium-8.7 Phos-3.4 Mg-1.9 CK-MB-NotDone cTropnT-<0.01 [2182-9-26] 08:15AM BLOOD Type-ART pO2-59* pCO2-30* pH-7.42 calTCO2-20* Base XS--3 [2182-9-29] 07:39AM BLOOD Type-[Last Name (un) ] pO2-189* pCO2-36 pH-7.43 calTCO2-25 CXR [9-25]: Emphysema, no evidence of acute superimposed process. Tracheal stent in place. [9-29]: The heart size is normal. Mediastinal position, contour and width are unremarkable. Bibasal linear opacities have slightly improved and might represent interval improvement in bronchiectasis or bronchial wall inflammation/infection Brief Hospital Course: 74 y/o F with PMHx of COPD, and TBM s/p silicone Y-stent on [2182-8-22], followed by therapeutic bronch on [9-5], preseted on [9-25] with cough and shortness of breath for five days. . On arrival to the floor, pt was c/o shortness of breath and having difficultly clearing secretions. Despite additional nebs, and humidified O2, she triggered for increased RR. She was also desatting to high 80s and complaining of tiring out. ABG was 7.42/30/59. She was tranferred to the ICU. . On [2182-9-26], she received theapeutic bronchoscopy. On [2182-9-27], IP removed the Y stent, given lack of improvement. Patient reported subjective improvement in breathing and ability to cough up secretions. She was maintained on albuterol/atrovent nebs, advair, and morphine for anxiety component. She was started on azithromycin for presumed COPD exacerbation. Patient was not started on steroids in the ICU given previous history of psychosis with prednisone. Upon transfer out of the MICU, she was saturating at 95% on 5L of oxygen. . On the floor, pt had increased dyspnea, although she was on four liters O2 and on q4h standing nebulizers. She was started on prednisone 40mg. After two days and no improvement, prednisone was increased to 60mg daily. The pulmonary team was also consultued and had no further recommendations. She was also given several empiric doses of lasix. Within two days she had significant improvement. She was tachypneic, though did not desaturate when she would walk and climb stairs with physical therapy. She was discharged when stable on 2L, with home O2, and outpatient pulmonary rehab. She was instructed to call her pulmonologist immediately upon reaching home and set an appointment within one week. . Chronic diastolic heart failure: Pt is not maintained on any CHF ppx meds at baseline and appeared euvolemic to dry on exam. She had no crackles on lung exam or lower extremity edema, CXR without signs of edema. I/Os were net even throughout her hospitalization. She was given several doses of lasix, empirically given no improvement in pulmonary symptoms and her respiratory status improved to some degree, and it was thought that she might have had some of fluid retention affecting her respiratory status. . Smoking cessation: Smoking cessation was highly encouraged on a daily basis by multiple teams. She stated that boredome was the most significant component to not quitting. After this experience, she stated she was encouraged and make every effort to quit. Medications on Admission: Effexor extended release 150mg PO daily Atrovent MDI 2 puffs qid Lamictal 150mg PO daily Seroquel 25mg PO qHS Synthroid 150 mcg PO daily Tylenol 650mg PO q6h PRN pain/fever Mucinex 1200 mg PO BID Mucomyst nebs Q8Hrs Advair 250/50 Discharge Medications: 1. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:90 Capsule(s) Refills:0 2. Lamotrigine 150 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [Hospital1 ] (2 times a day). Disp:2 disks Refills:2 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): please take with daily prednisone to prevent stomach pain. Disp:30 Tablet(s) Refills:2 8. Outpatient Physical Therapy PT: Evaluate and Treat, Pulmonary Rehab Dx: tracheobronchomalacia 9. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day: Prednisone, take 60mg X1 day, then 40mg for 5 days, then 20mg X 5 days, then 10mg X 5 days, then 5mg X 5 days. Please take 40mg if symptoms increase and call your PCP to evaluate symptoms. Please discuss your prednisone dosing at your pulmonology visit. . Disp:200 Tablet(s) Refills:0 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety. Disp:30 Tablet(s) Refills:0 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q4H (every 4 hours). Disp:180 nebulizer Refills:2 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4 hours). Disp:180 nebulizer Refills:2 Discharge Disposition: Home Discharge Diagnosis: primary: tracheobronchomalaica and COPD secondary: diastolic heart failure, tobacco abuse Discharge Condition: stable, RR, 22, O2sat 91% 2L Discharge Instructions: You were admitted for treatment of shortness of breath caused by tracheobonchomalacia and COPD exacerbation. During your hospitalization you were transferred to the ICU given increasing effort required to breath. You underwent bronchoscopy twice, once for suction of secretions, and once for stent removal. You were transferred to the floor, where you were treated for a COPD exacerbation with steroids and nebulizers. Your respiratory status improved and you were discharged. . Medications changed on this admission: --> Prednisone, take 60mg X1 day, then 40mg for 5 days, then 20mg X 5 days, then 10mg X 5 days, then 5mg X 5 days. Please go back to 40mg if symptoms increase and call your PCP. [Name10 (NameIs) 2947] discuss your prednisone dosing at your pulmonology visit. --> Nicotine patch - apply daily for 7 days then quit. --> Tesselon Pearls for cough --> Famotidine - to protect the stomach while on prednisone . Please call your doctor or return to the ED if you experience worsening shortness of breath, chest pain, or any other concerning symptom. Please take 40 mg of prednisone if you feel you are about to experience a COPD exacerbation. Followup Instructions: Please follow up with your pulmonologist Dr [Last Name (STitle) 2948] - ([Telephone/Fax (1) 2949] within one week of when you get home. No appointments are available at this time, but they should be able to schedule you when you call them. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 1473] Completed by:[2182-10-21]	[ "519.19", "V45.89", "428.33", "518.83", "428.0", "300.4", "933.1", "244.9", "996.59", "787.20", "305.1", "E915", "E879.8", "585.3", "V10.05", "414.01", "345.90", "491.21", "V15.81", "278.00" ]	icd9cm	[ [ [] ] ]	[ "98.15", "33.24" ]	icd9pcs	[ [ [] ] ]	18502, 18508	14031, 16564	11002, 11021	18642, 18673	13288, 14008	19888, 20291	12568, 12640		16844, 18479		18529, 18621		16590, 16821			18697, 19865									12655, 12655															1370, 1723				10943, 10964									11049, 12090			10884, 10926					12669, 13269								12112, 12442	12458, 12552
62,606	117,075	45241	Discharge summary	report	Admission Date: [2185-8-31] Discharge Date: [2185-9-10] Date of Birth: [2108-5-8] Sex: F Service: SURGERY Allergies: Bactrim / Actonel / Codeine / Synthroid Attending:[First Name3 (LF) 598] Chief Complaint: fatigue, BRBPR Major Surgical or Invasive Procedure: exlap, tumor and small bowel resection History of Present Illness: 77F with PMH significant for previous endometriosis and benign tumor removed from uterus, who presented to [Location (un) 620] ED with GI bleeding and BRBPR. On the day of presentation, she felt fatigued and lightheaded like she was going to syncopize. She also felt increased abdominal pain and bloating. Upon going to the bathroom, she noticed a large amount of bright red blood in the toilet bowel. She called her PCP and was told to go to the [Location (un) 620] ED. There, her initial Hct was 22.8. She received 3 units of packed red blood cells and her Hct came up to 31.2, but then dropped to 26.1. Overnight she was prepped for colonoscopy with a GoLYTELY, but threw most of it up, so spent another day prepping. She still had continuous bleeding through her [Location (un) 1662]. She underwent a colonoscopy on the day of transfer showing continuous bleeding potentially above the ileocecal valve, but was not well-visualized. She had a CTA of the abdomen that showed a uterine mass that could be eroding into the intestinal wall. Patient was transferred here for potential hysterectomy and surgical repair of her small intestine. Of note, patient states she has been feeling more fatigued for the past 3-4 months, and has been worked up by both her PCP here and in [State 108] for anemia. Her [Hospital1 18] notes on anemia do not mention guaiac or GI bleeding. Of the past few weeks, she has also experienced more abdominal distention and pain, which she attributed to weight gain. The patient's last pelvic exam was by a gynecologist in [State 108] in [2185-1-29] and was normal per the patient. . In the ICU, her initial vitals on transfer were T 98.6 HR86 BP133/97 HR17 O2sat 100(RA). She denied shortness of breath, chest pain, or abdominal pain. No dizziness, confusion, does not feel like she's about to faint again. She is on a bed pan and still bleeding a little. Past Medical History: (per OMR) ECTOPIC PREGNANCY - [2138] - REMOVED 1 TUBE ENDOMETRIOSIS ENDOMETRIAL TUMOR - BENIGN - REMOVED ATROPHIC VAGINITIS D&C X 1 FOR EVAL POST MEN BLEEDING - HAD UTERINE POLYPS in [2178] SBO DUE TO ADHESIONS [2175] - RX CONSERVATIVELY CHOLECYSTECTOMY SQUAMOUS CELL CA X2 BASAL CELL CA X2 MACULAR DEGENERATION HYPOTHYROIDISM OSTEOPOROSIS HERPES ZOSTER [2179] HIATAL HERNIA ALLERGIC RHINITIS ROTATOR CUFF TEAR NEGATIVE STRESS TREADMILL TEST [2177] THROMBOCYTOPENIA WRIST INJURY Social History: Married lives with husband - lives in [Name (NI) 108] from [Month (only) 359] to [Month (only) 116] each year. retired from own business - had Kiosk in Fanueil [Doctor Last Name ] - Tobacco: 30 pack yr hx, stopped in 40s - Alcohol: none - Illicits: none Family History: Breast cancer - mother and sister Father had emphysema, asthma Sister and cousin had [Name (NI) 4522] Physical Exam: Admission Physical Exam: Vitals: T:98.6 BP:133/97 P:86 RR:17 SpO2:100(RA) General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, soft, non-distended, tenderness right of umbillicus, no rebound tenderness or guarding Ext: warm, well perfused, 2+ pulses, trace edema Pertinent Results: Admission Labs: [2185-8-31] 06:17PM WBC-9.0 RBC-3.62* HGB-10.9* HCT-31.1* MCV-86 MCH-30.0 MCHC-35.0 RDW-16.4* [2185-8-31] 06:17PM NEUTS-69.5 LYMPHS-23.4 MONOS-6.1 EOS-0.7 BASOS-0.3 [2185-8-31] 06:17PM PT-13.0 PTT-24.0 INR(PT)-1.1 [2185-8-31] 06:17PM CALCIUM-8.2* PHOSPHATE-2.0* MAGNESIUM-2.3 [2185-8-31] 06:17PM GLUCOSE-90 UREA N-9 CREAT-0.4 SODIUM-144 POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-22 ANION GAP-16 . [Hospital3 ]: Hct trend: . Microbiology: . Imaging: [2185-8-31] CT ABDOMEN AND PELVIS: ABDOMEN: There are several subcentimeter hypodense lesions in both lobes of the liver. These are too small to accurately characterize by CT. The left hepatic duct and common hepatic and common bile duct are moderately dilated down to the level of the sphincter of Oddi. No obstructing lesion is identified. The patient is status post cholecystectomy. The pancreas, spleen, and adrenal glands are unremarkable. There are bilateral circumscribed hypodense lesions in the kidneys consistent with cysts. Almost all of these are too small to accurately characterize by CT. No lymphadenopathy is apparent. PELVIS: The uterus is markedly enlarged and has an irregular lobulated contour. Its density is very inhomogeneous. Overall, it measures 17.2 cm longitudinal x 10.4 cm transverse x 9.5 cm AP. Endometrium is not delineated. There is a short segment of small bowel abutting the uterine fundus that demonstrates some ill-defined hyperemia or active bleeding. A cluster of numerous surgical clips in the right pelvic adnexa. The bladder is distended. No lymphadenopathy is apparent. The ureters are mildly prominent. Abdominal and pelvic wall structures are intact. No osteolytic or osteoblastic lesion is noted. IMPRESSION: ABNORMAL ENLARGED UTERUS AS DESCRIBED. FINDINGS ARE SUSPICIOUS FOR MALIGNANT NEOPLASM SUCH AS LEIOMYOSARCOMA OR ENDOMETRIAL CARCINOMA. THERE IS AN ADJACENT SHORT LOOP OF ABNORMAL SMALL BOWEL. ITS ENHANCEMENT SUGGESTS POSSIBLE INVASION BY TUMOR AND THERE [Month (only) ] BE ACTIVE BLEEDING AT THIS SITE. . MRI Pelvis w/ and w/o contrast: Large, heterogeneously enhancing, multilobulated mass within the pelvis, with central areas of necrosis and focal hemorrhage. Given its large size, its relationship to adjacent structures is difficult to discern. However, it appears to displace, rather than arise from, the uterus. It is intimately associated with and inseparable from a distal loop of small bowel. Given this relationship to the small bowel and its appearance, this is thought most likely to represent a small bowel GIST. While neither ovary is seen, this is thought less likely to be ovarian in origin given only the trace amount of free fluid and no evidence of metastatic disease within the pelvis. Discharge Labs: [2185-9-9] 11:00AM BLOOD Hct-29.1* [2185-9-6] 06:10AM BLOOD WBC-4.1 RBC-2.61* Hgb-8.4* Hct-24.2* MCV-93 MCH-32.1* MCHC-34.7 RDW-17.7* Plt Ct-210 Pathology: Small bowel, segmental resection: Atypical spindle and focally epithelioid neoplasm (13.5 cm in greatest dimension), consistent with gastrointestinal stromal tumor of high malignant potential; see note. Nine mesenteric lymph nodes with no tumor seen (0/9). Note: The tumor demonstrates a predominantly spindle cell pattern arranged in irregular fascicles, with focally epithelioid areas and foci of prominent necrosis. Tumor nuclei demonstrate areas of marked pleomorphism with coarse chromatin and irregular nuclear contours. Immunohistochemical stains of the tumor are diffusely, strongly positive for C-kit, focally, weakly positive for actin, and negative for desmin and S-100, consistent with a gastrointestinal stromal tumor (GIST) immunophenotype. Mitoses number greater than 15 per 50 high power fields and frequent tumor cell apoptosis is identified. The tumor size of greater than 10 cm and mitotic activity of greater than 15 per 50 high power fields confer a high risk of malignant potential The tumor appears to arise within the muscularis propria, but extensively involves the submucosa and subserosa, with focally marked attenuation of the overlying mucosa, and the exact layer of origin is difficult to discern; definitive mucosal invasion by tumor cells is not identified. The tumor is received partially disrupted, precluding definitive evaluation of the serosal surface for invasion in these areas. Where evaluable in non-disrupted areas, however, a thin (from <1 mm to 3 mm) rim of serosal tissue is present along the external surface. Brief Hospital Course: 77F with PMH significant for previous endometriosis and s/p benign uterine tumor removal, who presented to [Location (un) 620] ED with GI bleeding and BRBPR, found on colonoscopy to have bleeding from above the ileocecal valve, and on CTA to have a uterine tumor impinging on small bowel at OSH and she was transferred to [Hospital1 18] [Hospital Unit Name 153] . MRI pelvis here demonstrated that the primary mass was actually in the small bowel abutting the uterus. . #. Lower GI bleeding. Source of bleed appeared by [Location (un) 620] colonoscopy to be from above the ileocecal valve. Based on CTA at [Location (un) 620], there was suspicion for uterine tumor eroding into small bowel leading to GI bleeding. On arrival to [Hospital Unit Name 153], Hct was stable (at 31.1, up from 26 which was the last [Location (un) 1131] prior to transfer from [Location (un) 620]). Hemactocrits were checked every 6 hours. She was transfused 1 more unit of PRBCs on [8-31] for Hct 26. Gynecology and general surgery were consulted for managment of the tumor. Tumor markers were sent, CEA, CA [93]-9 and CA125 all came back normal. An MRI of the pelvis demonstrated that the primary tumor was in the small bowel and was abutting but not invading the uterus. Throughout the [Hospital Unit Name 153] course, patient was not lightheaded and did not have melena. Patient was then transferred to surgery service. . # Hypertension. The patient has hx of hypertension. Antihpertensive medications were held in the setting of active GI bleed. . #Hypothyroidism. Continued levothyroxine. . #Hx of [Doctor First Name ]. Patient has chronic cough from [Doctor First Name ] and followed by [Hospital1 ] pulmonology. Continued home guaifenasin and [Hospital1 ]. . The patient had a stable course on the floor. Her foley was d/c'd on POD #6 mostly due to patient anxiety about having to void on her own. Her pain was well controlled on PO Diluadid. She received HSQ for prophylaxis and encouraged to ambulate on her own. At the time of discharge on POD#8, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, passing gas and pain was well controlled. Medications on Admission: CLONAZEPAM - 1 mg PO daily ESTRADIOL [ESTRACE] 0.01 % Cream twice weekly LEVOTHYROXINE - 50 mcg PO daily MOM[Name (NI) ] [Name2 (NI) 4010] 100/50 Tessalon pearls NORTRIPTYLINE 10 mg PO qhs OMEPRAZOLE 40 mg po daily VAGIFEM weekly ZOLPIDEM 10 mg PO qhs PRN MVI CALCIUM 600 2X DAILY WITH 400 IU VIT D PER PILL VIT C OCCUVITE B12 VIT D [2174] IU QD Fish oil 1000mg Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:80 Tablet(s) Refills:0 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for before bed. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: GIST tumor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the acute care surgery service for exploratory laparotomy for removal of a GIST tumor and a portion of small bowel. Since you have had an abdominal operation, this sheet goes over some questions and concerns you or your family may have. If you have additional questions, or [Male First Name (un) ]??????t understand something about your operation, please call your [Male First Name (un) 5059]. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside. But avoid traveling long distances until you see your [Male First Name (un) 5059] at your next visit. [Male First Name (un) ]??????t lift more than 20-25 pounds for 6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. You may resume sexual activity unless your doctor has told you otherwise. HOW YOU [Month (only) ] FEEL: You may feel weak or ??????washed out?????? for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. All these feelings and reactions are normal and should go away in a short time. If they do not, tell your [Month (only) 5059]. YOUR INCISION: Your incision may be slightly red around the area where staples were. This is normal. You may gently wash away dried material around your incision. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that, it??????s OK. It is normal to feel a firm ridge along the incision. This will go away. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your [Month (only) 5059]. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. Over the next 6-12 months, your incision will fade and become less prominent. YOUR BOWELS: Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as Milk of Magnesia, 1 tablespoon) twice a day. You can get both of these medicines without a prescription. Do not worry if you see blood with your first bowel movement. This is normal. After some operations, diarrhea can occur. If you get diarrhea, [Male First Name (un) ]??????t take anti-diarrhea medicines. Drink plenty of fluids and see if it goes away. If it does not go away, or is severe and you feel ill, please call your [Male First Name (un) 5059]. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as ??????soreness.?????? Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your [Name2 (NI) 5059]. You will receive a prescription from your [Name2 (NI) 5059] for pain medicine to take by mouth. It is important you take this medicine as directed. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your [Name2 (NI) 5059] about how long you will need to take prescription pain medicine. Please [Male First Name (un) ]??????t take any other pain medicine, including non-prescription pain medicine, unless your [Male First Name (un) 5059] has said it is OK. If you are experiencing no pain, it is OK to skip a dose of pain medicine. To reduce pain, remember to exhale with any exertion or when you change positions. Remember to use your ??????cough pillow?????? for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your [Name2 (NI) 5059]: sharp pain or any severe pain that lasts several hours pain that is getting worse over time pain accompanied by fever of more than 101 a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. In some cases, you will have a prescription for antibiotics or other medication. If you have any questions about what medicine to take or not to take, please call your [Name2 (NI) 5059]. DANGER SIGNS: Please call your [Name2 (NI) 5059] or go to the emergency room if you develop: Worsening abdominal pain Sharp or severe pain that lasts several hours Temperature of 101 degrees or higher Severe diarrhea Vomiting Redness around the incision that is spreading Increased swelling around the incision Excessive bruising around the incision Cloudy fluid coming from the wound Bright red blood or foul smelling discharge coming from the wound An increase in drainage from the wound Followup Instructions: Call the Acute Care Clinic at [Telephone/Fax (1) 600] upon discharge to arrange a follow up appointment in [3-3] weeks. Office is located at [Hospital1 18], [Hospital 2577] Medical Office Building, [Location (un) ]. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2185-9-10]	[ "733.00", "530.81", "790.01", "152.9", "578.1", "238.75", "493.90", "300.00", "244.9", "627.3", "287.5", "031.0", "401.9" ]	icd9cm	[ [ [] ] ]	[ "54.4", "45.91", "45.62" ]	icd9pcs	[ [ [] ] ]	11713, 11771	8335, 10611	313, 354	11826, 11826	3781, 3781	17607, 17981	3142, 3250		11036, 11690		11792, 11805		10637, 11013			12009, 17584			6584, 8312						3290, 3762																			258, 275									382, 2311					3797, 6567					11841, 11985						2333, 2835	2851, 3126
41,937	197,042	53305	Discharge summary	report	Admission Date: [2146-8-16] Discharge Date: [2146-8-23] Date of Birth: [2098-4-18] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 13159] Chief Complaint: ETOH intoxication and diarrhea with h/o C. difficile Major Surgical or Invasive Procedure: none History of Present Illness: 48 y.o male with pmhx of alcohol dependence and previous episodes of withdrawal presents with EtOH intoxication and SI. Patient states he had [3-27] drinks today and drinks on a daily basis. He reports "I feel that life is not worth living," but will not answer when asked if he currently wants to hurt himself. Patient is A&O to self only and only intermittently answers questions. Patient has signs of trauma on exam including black eye and dried blood under right nare, but is unable to explain history of trauma. Additionally reports some current abdominal pain.Patient endorsed diarrhea in the ED and c.diff diagnosis in the past few months. . Initial Vitals in the ED was 98.9 94 139/71 16 100%. He was given Lorazepam 2mg/mL X1,Magnesium Sulfate 2 g IV X 1,Thiamine 100mg Tablet X 1,Multivitamins 1 Tablet 1,FoLIC Acid 1 mg Tab 1,Potassium Chloride 10mEq ER Tablet X 4, Vancomycin Oral Liquid 125mg, Lorazepam 1mg TabletX 1, Ciprofloxacin IV 400mg Premix Bag.He recieved a surgical consult for abodminal pain and elevated lactate. . On arrival to the MICU, the patient endorses abdominal pain and diarrhea for 2 days. He has been having approx 7 BM per day, intermittently dark brown/black, and diffuse abdominal pain. He denies vomiting, nausea. He is alert but only oriented X 3. He denies cough, chest pain, vision changes, headache. He denies current SI but says he was feeling down earlier tonight. He denies IV drug use, or any other substance abuse except alcohol.He denies hx. of alcohol withdrawl seizures. Review of systems: Obtained from patient (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness,rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: HCV diagnosed in [2130], genotype 1A Idiopathic osteoporosis Tinea versicolor anxiety/depression hep c w/ cirrhosis s/p TIPS at [Hospital1 3278] for ascites unknown time Past hepatic encephalopthy in [2145-10-23],and Variceal bleed s/p banding per patient in [2145-12-23]. osteoporosis depression and anxiety alcohol abuse c.diff-Per patient, though records are unavailable, he has a history of recurrent clostridium difficile infections X 3, starting [5-/2146], for which he has been on outpatient antibiotics, however he claims to have run out of these last week. Social History: Lives with second wife and two cats. Has a son from first marriage. Works as an electrician for a sign company. Born and raised in [Location (un) ], MA, with five siblings. Mother died in [2130], patient remains close with his father. Several siblings are estranged from the family. rare tobacco use, ETOH 4-5 drinks per day, no illicit drugs, currently homeless, unemployed. Family History: Father with alcoholism. Brother, [Name (NI) ], died of heroin OD. Mother with depression. No other family history of psychiatric illness or suicide. Physical Exam: ADMISSION EXAM: Vitals: T: 99.1 BP: 140/66 P: 87 R:12 18 O2:96% RA General: Alert, oriented X 3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, tender to palp in the LLQ no rebound tenderness/guarding , non-distended, bowel sounds present, no organomegaly. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact No asterixis, baseline hand tremor Rectal- external hemmhorids at 9 oclock and brown stool in rectal vault, Guaiac pos. . DISCHARGE EXAM: VITALS: Afebrile, VSS GEN Alert, oriented, no acute distress HEENT NCAT bruise below left eye, MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, rhonchi CV RRR normal S1/S2, no mrg ABD soft, non-tender, non-distended, normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNII-XII intact, motor function grossly normal SKIN no ulcers or lesions Pertinent Results: ADMISSION LABS: [2146-8-16] 03:50PM BLOOD WBC-4.9 RBC-3.43* Hgb-11.5# Hct-33.0 MCV-96 MCH-33.5* MCHC-34.9 RDW-16.6* Plt Ct-102# [2146-8-16] 03:50PM BLOOD Neuts-57.3 Lymphs-36.8 Monos-3.9 Eos-1.5 Baso-0.5 [2146-8-16] 03:50PM BLOOD PT-13.9 PTT-42.3* INR(PT)-1.3* [2146-8-16] 03:50PM BLOOD Glucose-81 UreaN-2* Creat-0.6 Na-151* K-3.1* Cl-115* HCO3-27 AnGap-12 [2146-8-16] 03:50PM BLOOD ALT-64* AST-170* AlkPhos-119 TotBili-1.8* [2146-8-16] 03:50PM BLOOD Lipase-25 [2146-8-16] 03:50PM BLOOD Albumin-3.8 Calcium-8.1* Phos-3.2 Mg-1.9 [2146-8-16] 03:50PM BLOOD ASA-NEG Ethanol-461* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2146-8-16] 04:01PM BLOOD Lactate-2.4* . DISCHARGE LABS: [2146-8-21] 08:00AM BLOOD WBC-4.4 RBC-3.64* Hgb-12.1* Hct-35.5* MCV-98 MCH-33.2* MCHC-34.0 RDW-16.9* Plt Ct-81* [2146-8-21] 08:00AM BLOOD PT-15.0* PTT-41.9* INR(PT)-1.4* [2146-8-21] 08:00AM BLOOD Glucose-126* UreaN-6 Creat-0.6 Na-137 K-3.4 Cl-103 HCO3-27 AnGap-10 . CT HEAD w/o CONTRAST: [2146-8-16] There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. The ventricles and sulci are prominent, which is out of proportion for the patient's age. The basal cisterns are patent. There is preservation of [Doctor Last Name 352]-white matter differentiation. Again noted is encephalomalacia in the bilateral inferior frontal and temporal lobes, as well as the anterior left frontal lobe. These are stable from the prior exams and likely the sequelae of prior injury. No acute fracture is identified. Changes from a prior right temporoparietal craniotomy are noted. Post-surgical changes are noted in the frontal bone as well as the frontal sinuses. These are unchanged from the prior exam. An old left mandibular neck and left orbital floor fractures also unchanged in appearance. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The soft tissues are unremarkable. IMPRESSION: 1. No acute intracranial abnormality or acute fracture. 2. No change in the age-inappropriate volume loss, bilateral encephalomalacia and multiple healed fractures. . CT C-SPINE: 7/24/12Final Report There is no abnormality of the prevertebral soft tissues. No fracture is identified. Alignment is maintained through C6. The C6-7 and C7-T1 joint spaces are not fully included in the field of view. Mild degenerative changes are present with disc space narrowing, posterior osteophytes, and uncovertebral hypertrophy, most severe at C6-7. There is a small disc bulge at this level, but no significant spinal canal narrowing. There is no lymphadenopathy. The thyroid is unremarkable. The visualized portions of the brain are normal. IMPRESSION: No fracture or malalignment through C6. If high clinical suspicion for injury at C6 through T1 exists, the patient can return for further imaging. . CT PA/LATERAL: [2146-8-16] Low lung volumes are present. The heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vascularity is not engorged. There is minimal atelectasis in the lung bases. No pleural effusion or pneumothorax is present. Multiple embolization coils are noted within the left upper quadrant abdomen. There are no acute osseous abnormalities. IMPRESSION: Low lung volumes with mild bibasilar atelectasis. No acute traumatic injury identified. . CT abd/pelvis with contrast: [2146-8-16] 1. Colonic wall thickening extending from the rectum to the splenic flexure with mild adjacent fat stranding, compatible with colitis. Etiology includes infection versus inflammation. 2. Cirrhotic liver status post TIPS. . RUQ U/S with Doppler: [2146-8-18] 1. Although a baseline comparison study is not available post-TIPS placement, the current exam demonstrates a patent TIPS with normal waveforms and velocity without evidence of neointimal hyperplasia/stenosis. Portal vein and branches demonstrate normal flow towards the TIPS. 2. Coarse and heterogeneous echogenicity of the liver may be due to known history of cirrhosis. No hepatic lesions are identified. The study and the report were reviewed by the staff radiologist. . Abd upright and supine: [2146-8-18] Normal bowel gas pattern with no evidence of bowel obstruction. Brief Hospital Course: 48 year old male with pmhx of alcohol dependence and recurrent C. diff colitis, who presented with abdominal pain and diarrhea, found to have colitis on CT abdomen and treated for presumptive C. diff colitis. . # Colitis- CT abdomen demonstrated colitis from the rectum to splenic flecture. The patient has a history of recurrent C. diff colitis, though may have been undertreated rather than recurrent. We were unable to obtain a stool specimen for the first several days so the patient was empirically treated for C. diff infection with Vancomycin and flagyl. We did eventually obtain a stool specimen which was negative for C. diff, but at this point he had been on several days of antibiotics. Gastroenterology was consulted and considering his history of C. diff, they recommended continuing empiric treatment for C. diff. The Flagyl was stopped and we continued the Vancomycin for a planned 6-week course with taper. . # Emesis- During hospitalization the patient had terrible bouts of emesis, non-bloody and non-bilious. Imaging was negative for obstruction. Pt was always able to pass gas from below and pass bowel movements. It was felt that the flagyl was contributing to the nausea/emesis, and it was discontinued. . # Hepatitis C/ETOH Cirrhosis- Status post TIPS with no current ascites, signs of bleeding, or jaundice. Ultrasound revealed patent TIPS. His INR and albumin were near normal. Mild thrombocytopenc from cirrhosis and continued alcohol abuse. Patient's LFTs were elevated and TBili were also rising, concerning for alcoholic hepatitis, however his discriminate function was low. Hepatology was consulted, and felt that the C. diff colitis was the primary problem. The patient does not require hepatitis A or B vaccinations since he has been exposed to hepatitis A in the past and has already been immunized for hepatitis B. He was encourged to restart the nadolol. . # Alcohol intoxication/SI- The patient endorsed SI with no known active attempt while intoxicated. After sober he denied any further SI. He was monitored via CIWA scale and exhibited no signs of alcohol withdrawal. He was counciled to abstain from alcohol. He was started on thiamine, folate, and a multivitamin. . # Lactic acidosis- The patient had an elevated lactate on admission which prompted admission to the ICU. There was no evidence for hypoperfusion of organs and lactate improved with hydration. ETOH also likely contributing. Medications on Admission: *Per recent discharge summary these are the medications the patient was prescribed but he has not been taking them regularly. 1. Citalopram 20 mg PO DAILY 2. Rifaximin 550 mg PO BID 3. Quetiapine Fumarate 100 mg PO QHS 4. Quetiapine Fumarate 25 mg PO QAM 5. Omeprazole 20 mg PO BID 6. Simethicone 100 mg PO TID 7. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Citalopram 20 mg PO DAILY 3. Quetiapine Fumarate 100 mg PO QHS 4. Quetiapine Fumarate 25 mg PO QAM 5. Rifaximin 550 mg PO BID 6. Simethicone 100 mg PO TID 7. Omeprazole 20 mg PO BID 8. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 9. Thiamine 100 mg PO DAILY RX thiamine HCl 100 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 10. Nadolol 40 mg PO DAILY hold for SBP<90 and HR<55 RX Corgard 40 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 11. Vancomycin Oral Liquid 125 mg PO SEE INSTRUCTIONS BELOW Duration: 42 Days Please take 125 mg orally four times daily for 7 days THEN 125 mg orally twice daily for 7 days THEN 125 mg orally once daily for 7 days THEN 125 mg orally every other day for 7 days THEN 125 mg orally every 3 days for 14 days RX vancomycin 125 mg See instructions by mouth see below Disp #58 Capsule Refills:0 Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) 11015] house Discharge Diagnosis: Primary diagnosis: presumed C. diff colitis, alcohol intoxication Secondary diagnosis: hepatitis C cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 931], It was a pleasure taking care of you at [Hospital1 18]. You were admitted because of your alcohol intoxication and your diarrhea. We obtained a cat scan of your abdomen which showed colitis. We treated you with antibiotics, for presumed C. diff infection. . The following medications were added to your regimen: - START vancomycin for six weeks 125 mg orally four times daily for 7 days 125 mg orally twice daily for 7 days 125 mg orally once daily for 7 days 125 mg orally every other day for 7 days 125 mg orally every 3 days for 14 days - START nadolol - START thiamine - START folic acid You should continue to take your other medications as prescribed. Followup Instructions: Please call your primary care doctor Dr. [Last Name (STitle) ] [Telephone/Fax (1) 5139] to schedule a follow up appointment within the next week. Please call your liver doctor [First Name (Titles) ] [Last Name (Titles) 3278*] Medical Center to schedule a follow up appointment within the next week.	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77,614	140,792	1706	Discharge summary	report	Admission Date: [2153-9-15] Discharge Date: [2153-11-15] Date of Birth: [2070-9-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP x 2 Tracheostomy PEG tube placement Hemodialysis Catheter Placement Central Venous Access History of Present Illness: Mr. [Known lastname ] is an 82M with DM, CRI, and COPD who presents with abdominal pain x 4 days. The pain began after he returned home from a golf outing. He ate a roast beef [Location (un) 6002] and some pizza and later developed pain that he describes it as sudden in onset, "like someone was punching him in the stomach," unrelenting but worsening over time. He had nausea and one episode of non-bloody emesis. Appetite has been poor. He has not moved his bowels since the pain began, no rectal bleeding. He also reports no fevers, chills, or sweats. He took ibuprofen and acetaminophen with incomplete relief. He also tried a couple of oxycontin pills he had from an expired prescription, again with incomplete relief. He denies having similar pain before, though one month prior did have several hours of right chest/RUQ discomfort that resolved spontaneously. . In the ED, initial vs were 97.5 59 146/129 23 97% on RA. Admission labs were notable for WBC 19k, lipase of 4k, transaminitis in 100's with total bilirubin of 4.7 and acute on chronic renal failure with Cr of 3.4. Abdomen distended on exam but no peritoneal signs; reported epigastric tenderness to palpation, no [Doctor Last Name 515] sign. He was given a total of 10mg of IV morphine, 1g calcium, and 500mg of levofloxacin and 500mg flagyl. Got 2.5L of saline. EKG showed a LBBB, new from [2150]. RUQ ultrasound was notable for CBD dilatation to 7-9mm, without a CBD stone seen. His abdominal CT showed inflammatory stranding around the pancreas. He was seen by the surgical and GI consult services who recommended ERCP. Last vitals 61 140/63 96% on 2L. . On evaluation in the ICU, he reports continued abdominal discomfort at 5/10. He reports a mild chronic cough and postnasal drip and feels that his breathing is at his baseline. He does endorse rare episodes of chest pressure or increased dyspnea when climbing a [Doctor Last Name ] on the golf course, last one week ago but denies prior MI. Denies any chest discomfort currently. No known liver or pancreatic disease. His urine looked a little darker at home but he did not notice any jaundice. Review of systems is otherwise negative. Past Medical History: * DM * COPD --[11-28] FVC 1.78 (45% pred), FEV1 0.75 (30% pred), ratio 0.42 (66% pred) * CRI thought [2-26] HTN * AAA 5.8cm s/p endovascular repair [2149] * M. avium isolated in sputum [9-28] * HTN * Hyperlipidemia * BPH * Diverticulosis on [2150] colonoscopy * Colon polyps adenomas [2141] colonoscopy * Stress test last [1-29] 7.5 mins on modified [Doctor First Name ], MIBI negative. Social History: Former smoker, rare EtoH. Married. Former police officer. Family History: no family history of liver or pancreatic disease, no colon CA Physical Exam: Physical Exam on admission [2153-9-15]: Vitals 97 70 144/86 24 97% on 5L General Pleasant elderly man mildly tachypneic with pursed lip breathing HEENT Sclera with mild icterus, conjunctiva pink, MMM with palatal jaundice Neck No JVD Pulm Lungs with diminished breath sounds bilaterally, few rales R base no wheezing CV Heart sounds distant, no murmurs appreciated Abd Soft distended tender RUQ and epigastrium, no rigidity or guarding, +bowel sounds GU heme+ stool on ER exam Extrem Warm no edema palpable distal pulses Neuro Alert awake and answering appropriately, moving all extremities Derm Mildly jaundiced, no rash Lines/tubes/drains Foley draining amber urine Pertinent Results: Labs on admission [2153-9-15]: WBC-19.1# RBC-5.30 Hgb-15.3 Hct-47.5 MCV-90 MCH-28.8 MCHC-32.2 RDW-13.8 Plt Ct-144 Neuts-62 Bands-30* Lymphs-2* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 PT-13.4 PTT-23.4 INR(PT)-1.1 Glucose-167* UreaN-45* Creat-3.4# Na-135 K-4.8 Cl-100 HCO3-17 AnGap-23* ALT-135* AST-127* LD(LDH)-616* AlkPhos-54 TotBili-4.7* DirBili-3.4* IndBili-1.3 Lipase-4550* Albumin-4.0 Calcium-7.2* Phos-4.7# Mg-1.8 ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Lactate-1.5 freeCa-0.84 . CE negative x3 Labs on Discharge: [2153-11-15] WBC-10.5 RBC-2.64* Hgb-7.8 Hct-25.5 MCV-97 MCH-29.5 MCHC-30.6 RDW-15.1 Plts-220 Glucose- 127* UreaN-70* Creat-2.3* Na-137 K-4.1 Cl-97 HCO3-33* AnGap-11 Ca-8.3* Phos-3.0 Mg-2.3 Imaging: [2153-9-15] EKG: Sinus brady @57, nl axis, 1st degree HB and LBBB, the latter of which are new compared to [2150-11-17] EKG . [2153-9-15] RUQ U/S: 1. Diffusely echogenic liver consistent with fatty infiltration. 2. Common bile duct at the upper limits of normal. No intrahepatic ductal dilation. 3. No gallstones. A small amount of pericholecystic fluid is likely reactive due to the acute pancreatitis described on CT. 4. Right renal cyst. . [2153-9-15] CT Abdomen/Pelvis w/o contrast: 1. Findings compatible with acute pancreatitis. 2. Diverticulosis without evidence for diverticulitis. 3. Endovascular aortic stent, stable in position with reduction in size of infrarenal AAA. 4. Fatty infiltration of the liver. . [2153-9-21] LENI's: negative for DVT . [2153-9-21] CT Chest/Abdomen/Pelvis: Final read pending . [2153-9-16] ERCP: Erythema and congestion in the area of the papilla, c/w acute pancreatitis. Stones and sludge in bile duct. A partial sphincterotomy was performed. Stone retained Copious amount of sludge and pus was noted. A biliary stent was placed. Otherwise normal ercp to third part of the duodenum . [2153-9-20] ERCP: Multiple erosions in stomach probably due to NG trauma Severe edema of the duodenum Old plastic stent removed Sludge extraction using balloon catheter New biliary stent placed Repeat ERCP in 8 weeks for stent pull . Chest X-Ray: AP view: [2153-11-14] The tracheostomy is in place, the tip of the tracheostomy is approximately 7 cm above the carina. The extensive bilateral consolidations involve the entire lung, and accompanied by bilateral pleural effusions are unchanged with the left pleural effusion being larger than the right. Note is made that the lung bases were only partially included in the field of view. . Micro: Blood cultures 8/22, [9-19], [9-20], [9-21] - NGTD Urine cultures - all negative Sputum cx [2153-9-20]- no growth C. diff [2153-9-21] - negative MRSA negative . . . [2153-10-25] 4:23 pm SPUTUM Source: Endotracheal. FINAL REPORT [2153-10-29] GRAM STAIN (Final [2153-10-25]): [11-18] PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2153-10-29]): Commensal Respiratory Flora Absent. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. GRAM NEGATIVE ROD #3. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| KLEBSIELLA PNEUMONIAE \| \| AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- 8 S <=1 S CEFTAZIDIME----------- 4 S <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ 4 S <=1 S MEROPENEM------------- =>16 R <=0.25 S PIPERACILLIN---------- 32 S PIPERACILLIN/TAZO----- 64 S 8 S TOBRAMYCIN------------ <=1 S <=1 S . . . [2153-10-20] 4:30 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. FINAL REPORT [2153-11-5] GRAM STAIN (Final [2153-10-20]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2153-10-24]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| KLEBSIELLA PNEUMONIAE \| \| AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- 16 I <=1 S CEFTAZIDIME----------- 4 S <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ 4 S <=1 S MEROPENEM------------- =>16 R <=0.25 S PIPERACILLIN---------- 32 S PIPERACILLIN/TAZO----- 64 S 8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S LEGIONELLA CULTURE (Final [2153-10-27]): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Final [2153-11-5]): YEAST. . . . [2153-10-13] 7:16 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. FINAL REPORT [2153-10-16] GRAM STAIN (Final [2153-10-14]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [2153-10-16]): SPARSE GROWTH Commensal Respiratory Flora. KLEBSIELLA OXYTOCA. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA \| AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . . . [2153-10-13] 7:54 pm BLOOD CULTURE Source: Line-dialysis cath. FINAL REPORT [2153-10-16] Blood Culture, Routine (Final [2153-10-16]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S Aerobic Bottle Gram Stain (Final [2153-10-14]): REPORTED BY PHONE TO [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] @ 7PM [10-14]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [2153-10-14]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Brief Hospital Course: Hospital Course by Problem: Mr. [Known lastname ] is an 83M who initially presented with severe gallstone pancreatitis who had an ERCP that was complicated by sepsis, hypercapnic respiratory failure requiring a tracheostomy and acute renal failure secondary to hypotension. . #) Hypercapnic repiratory failure ?????? Pt was intubated for ERCP and had continued ventilator requirement post procedure due to inability to compensate for his metabolic acidosis. After his initial intubation he was unable to be weaned from the ventilator and had a tracheostomy placed on [2153-9-28]. He was also volume overloaded with resultant pulmonary edema from his aggressive IV fluid resuscitation from his original sepsis, so he was diuresed to help improve his pulmonary function. Additionally, as his metabolic acidosis improved, he was able to be furhter weaned from the ventilator. However, after brief period of improvement, he again became septic (see below) with CXR findings concerning for a ventilator associated pneumonia (VAP) and positive blood cultures-likely from a line infection. Sputum cultures from [10-13] grew Klebsiella oxytoca for which he was started on cefepime, blood cultures and HD catheter cultures from the same date grew coagulase negative Staph which was oxacillin resistant, he was started on vancomycin for treatment. Repeat sputum culture on [10-20] grew out Klebsiella and Pseudomonas, for which he was continued on the cefepime. With antibiotic treatment he began to improve again, with improvement in his vent settings, however in the first week of [Month (only) 359] he started having increased secretions. Sputum culture from [10-25] again showed klebsiella and pseudomonas, but with a change in the sensitivities, so he was started on inhaled tobramycin to complete a 21 day total course of antibiotics. . As his infections began to clear, he continued to have difficulty making progress with ventilator weaning due to large pleural effusions with associated bibasilar atelectasis and significant respiratory muscle weakness. He was continually trialed on decreased pressure support settings, and would complain of shortness of breath with stable vital signs and oxygen saturation. In addition to his weakness, the prolonged ICU stay and feelings of grief over his loss of function also often led to anxiety and decreased effort. He continued with intermittent SBT's/decreases in pressure support with periods of rest to try and build up respiratory muscle strength while taking fluid off. He began to make larger improvements prior to discharge with large volumes of fluid being taken off during HD. Leading to increased tidal volumes and decreases in his PCO2. Prior to discharge to [Hospital 100] Rehab, patient had improved tidal volumes on Pressure Support, due to increased fluid removal on HD, and was able to tolerate the Passy Muir Valve for two hours. He tolerated pressure support for nearly 15 hours before his tidal volumes decreased to the 200's and his respiratory rate increased. He was changed to AC and his parameters improved. It was felt that PS trials should occur during the day and a "rest" on AC at night may be beneficial for Mr. [Known lastname ], as he is so de-conditioned. . #) Sepsis ?????? Pt developed biliary sepsis in setting of pancreatitis. He was initially treated with 5 day course of unasyn and fluids. After period of improvement,he again worsened with concern for VAP on [2153-9-20], he was started on vancomycin, zosyn, cipro. He had an extensive work up for the source of infection, a repeat ERCP was negative for cholangitis, CT abd/pelvis and sinuses were all negative, C.diff was negative x 3, blood/urine/sputum cultures were all negative, and all lines were changed. No source was found but he continued to spike daily high fevers for a period of time and his antibiotics were discontinued on [10-1]. . After resolution of the initial presentation his course was further complicated by Coagulase Negative Staph bacteremia and Klebsiella pneumonia, for which he was started on Vancomycin and cefepime. Sputum culture from [10-20] grew out Klebsiella and Pseudomonas, for which he was continued on the cefepime. On [10-25] a repeat sputum culture showed klebsiella and pseudomonas, but with a change in the sensitivities, so he was started on inhaled tobramycin to complete a 21 day total course of antibiotics. . Throughout his course Mr. [Known lastname ] [Last Name (Titles) 3781] required blood pressure support with pressors. For most of the first month of his ICU his blood pressure was supported with phenylephrine, at which point he was transitioned to vasopressin with intermittent levophed. He was weaned off of pressors during the second week of [Month (only) 359], but still had some hypotension with dialysis, so he was started on midodrine 10mg three times daily on days of dialysis. It should be noted that his arterial line read systolic blood pressures 30 points higher than his cuff pressures. . #) Gallstone Pancreatitis - On admission, pt had severe disease by Ransons's (score=3 for age, WBC, and LDH), no evidence of pancreatitic necrosis on imaging - though limited by lack of contrast. Pt underwent ERCP [9-16] which suggested gallstone pancreatitis, he had a partial sphincterotomy with retained stone. Repeat ERCP on [9-20] with old stent removal/new stent placement. He completed a 5 day course of unasyn but still developed sepsis. LFTs, amylase and lipase trended down to normal range despite persistent clinical picture. A post-pyloric feeding tube was placed on [9-27] and trophic tube feeds were started on [2150-9-29]. Tube feeds were increased to goal, and after he had been tolerating feeds well a PEG tube was placed on [10-25]. He will have a repeat ERCP with stent removal scheduled for [2153-12-27]. . #) Acute on chronic renal failure ?????? Pt's baseline Cr was 1.1. He developed acute renal failure likely from ATN due to periods of hypotension. His renal function continued to worsen, and an HD line was placed on [9-28]. He had difficulty tolerating HD initially due to drops in blood pressure so CVVH was also tried. He had problems with hypotension on CVVH as well, along with clotting and increased ectopy seen on telemetry. After CVVH he was trialed on a lasix drip, which initially resulted in good urine output. However, his urine output tapered off with the drip over the next week, due to difficulty mobilizing his extra-vascular volume. Additionally, his BUN continued to climb as his urine output decreased. On [11-9], he was re-started on HD for uremia, though his Cr had been stable at 2.3, likely his new baseline. Mr. [Known lastname ] was able to tolerate dialysis of increasing amounts of fluids with the addition of midodrine, which significantly improved his edema, decreased the extent of his pleural effusions, and improved his breathing. He is currently scheduled for Monday/Wednesday/Friday for the foreseeble future. On the day of discharge he was 31 liters length of stay positive. . #) Anemia ??????Hematocrit was normal on admission but likely elevated due to hemoconcentration. Initially his HCT remained stable in the mid-thirties, however over the course of his stay in the ICU his hematocrit continued to decrease. He was found to have guaiac positive stool on different occasions, with his history of GI bleed he was maintained on a PPI. Also, with his new renal failure, he was started on epogen, and he was continually phlebotomized. All these factors in conjunction with the ongoing inflammation during his stay causing bone marrow suppression were likely contributing to his anemia. . #) Depression/Anxiety - After over one month in the ICU, s/p tracheostomy, PEG tube and unable to speak, Mr. [Known lastname ] had become very frustrated and had a sad affect. He was not able to sleep comfortably most nights, which likely contributed to his daytime agitation. In late [Month (only) ], Mr. [Known lastname ] was started on low dose Citalopram to help with his depression, which was titrated up to 40mg daily. He had been given trazodone to help him sleep, which was not effective, so he was instead started on zolpidem at bedtime to help him rest. Psychiatry was consulted as the patient's mood appeared to significantly worsen over the weeks of his prolonged ICU stay. Psychiatry felt that the patient may have been experiencing hypoactive delirium, so the zolpidem were stopped, and the patient was not to be given any form of benzodiazepines for anxiety. Instead, he was started on low dose Haldol for agitation or insomnia as needed only before bed. Every effort was made to keep his room dark at night and let him rest and regain a proper sleep-wake cycle. It was felt that changing to an AC vent setting at night for "rest" may help his sleep until his respiratory muscles regain strength. It was also felt that he had built up significant anxiety around the ventilator weaning and was experiencing intermittent panic attacks. When he was aware of ventilator changes he would become more and more anxious since he had had difficulty in the past. He tended to do significantly better on lower ventilator settings when unaware that the settings were being changed. . #) HTN ?????? Patient with a history of hypertension prior to admission, all medications initially held due to pressor requirement and hypotension with sepsis. As patient improved, prior to discharge on his arterial line he was found to be hypertensive with systolic blood pressures ranging from the 110's to the 170's, which would decrease significantly while sleeping. No anti-hypertensives were restarted due to labile blood pressures. Additionally, it was noted that his cuff BP's on the right arm were significantly lower than his arterial line readings, about 30-40 points lower systolic on the cuff compared to the A-line on the day prior to discharge. . #) COPD ?????? He retains CO2 at baseline initially making it more difficult for him to compensate for his metabolic acidosis. With correction of his acidosis his PCO2's remained in the 50's. He was maintained on albuterol and atrovent MDI's during his course. . #) LBBB ?????? First noted on EKG in the abscence of chest pain, cardiac enzymes were cycled at the time and were negative x 3. A repeat EKG over a week later showed resolution of the left bundle branch block. Later in his course he complained of chest pain and an EKG at the time again showed a LBBB. Cardiac enzymes were again sent, which were suggestive of demand ischemia, with mildly elevated troponins and negative CK's and CK-MB's. On further EKG's it was shown that he has intermittent LBBB. . #) DM ?????? Home oral agents were held, he initially was covered by insulin in his TPN, once he was started on tube feeds an insulin regimen was started. At the time of discharge he was on glargine 38units QHS and insulin sliding scale. . #) Atrial Fibrillation: patient had an episode of A.Fib with RVR during his ICU course, he was treated with metoprolol for rate control, and converted back to sinus rhythm with no further episodes. . #) Thrombocytopenia: initially thought to be due to sepsis or possibly DIC, also medications likely contributing. DIC labs were negative and during his ICU his platelet count normalized. . #) Right renal upper pole cyst: 2 cm hypoechoic structure with posterior acoustic enhancement noted on ultrasound and CT scan. Should be followed up as appropriate as an outpatient. . #) Nutrition: Patient is currently on continuous tube feeds with Novasource Renal Full strength at 40 ml/hr. 45 mg of Beneprotein was added [11-14] to the tube feeds as the patient's albumin was 2.2 on [2153-11-14]. It was felt an increase in his protein and ultimately albumin will help mobilize extravascular fluid into his intravascular space. . #) Access: Patient has a dialysis catheter in his right internal jugular vein. This was placed [2153-10-31]. . #) Code Status: Full Code . #) Outstanding Issues: --Patient currently completing an inhaled tobramycin course which should be completed on [11-16], his current dose is 300mg inhaled [Hospital1 ]. He has three more doses left. . --Patient should not be given any benzodiazepines or ambien for sleep due to hypoactive delirium, can be given haldol 0.5 mg HS for agitation, insomnia. He would do well to have good sleep hygeine as well. . --Blood pressure readings on his arterial line were [Location (un) 1131] about 30-40 points higher systolic than the blood pressure cuff readings in the 24 hours prior to discharge. . --Progressive decrease in ventilator settings including time on PMV especially when family is present as fluid is decreased with HD with a goal to transition to trach mask. Patient would do well to rest on Assist Control - Volume control ventilation overnight, then be placed on Pressure Support in the daytime. . Medications on Admission: Atenolol 50mg daily Atorvastatin 10mg daily Glipizide 5mg daily Metformin 850mg [Hospital1 ] ASA 325mg daily Ipratropium 2 puffs [Hospital1 ] Terazosin 2mg QHS Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash [Hospital1 ]: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). 2. Ipratropium Bromide 17 mcg/Actuation Aerosol [Hospital1 ]: Six (6) Puff Inhalation Q4H (every 4 hours). 3. Acetaminophen 160 mg/5 mL Solution [Hospital1 ]: [11-13] ML PO Q6H (every 6 hours) as needed for fever: Not to exceed more than 2 grams per day. 4. Epoetin Alfa 4,000 unit/mL Solution [Month/Year (2) ]: One (1) ml Injection QMOWEFR (Monday -Wednesday-Friday). 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Month/Year (2) ]: 5-10 MLs PO Q4H (every 4 hours) as needed for pain: Hold for sedation NOt to exceed more tahn 2 grams of tylenol in 24 hours. 6. Fluticasone 50 mcg/Actuation Spray, Suspension [Month/Year (2) ]: Two (2) Spray Nasal DAILY (Daily). 7. Tobramycin 300 mg/5 mL Solution for Nebulization [Month/Year (2) ]: Five (5) ml Inhalation [Hospital1 ] (2 times a day) for 3 doses: 21 day course finishes [2153-11-16]. 8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Month/Day/Year ]: Six (6) Puff Inhalation Q4H (every 4 hours). 9. Docusate Sodium 50 mg/5 mL Liquid [Month/Day/Year ]: Ten (10) ml PO BID (2 times a day) as needed for constipation. 10. Heparin (Porcine) 5,000 unit/mL Solution [Month/Day/Year ]: One (1) ml Injection TID (3 times a day): DVT prophylaxis. 11. Citalopram 20 mg Tablet [Month/Day/Year ]: Two (2) Tablet PO DAILY (Daily). 12. Heparin (Porcine) 5,000 unit/mL Solution [Month/Day/Year ]: 4000-[Numeric Identifier 2249] units Injection PRN (as needed) as needed for line flush: DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. . 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 14. Midodrine 5 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO TID ON HEMODIALYSIS DAYS (). 15. Haloperidol 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO HS (at bedtime) as needed for insomnia/agitation. 16. Insulin Glargine 100 unit/mL Solution [Last Name (STitle) ]: Thirty Eight (38) units Subcutaneous at bedtime. 17. Insulin Regular Human 100 unit/mL Solution [Last Name (STitle) ]: 1-10 units Injection TIDHS: per sliding scale that is attached. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: 1. Gallstone Pancreatitis 2. Sepsis 3. Pneumonia 4. COPD 5. Acute Renal Failure 6. Anemia 7. Sacral Decubitus Ulcer 8. Hypoactive Delirium Discharge Condition: Stable on ventilator and receiving Hemodialysis Discharge Instructions: You were admitted to [Hospital1 18] with pancreatitis, you had an ERCP done to try and find the cause of the pancreatitis which was thought to be due to gallstones. After your procedure you were unable to be extubated and eventually a tracheostomy was placed because you were unable to be taken off the ventilator. Your prolonged stay in the ICU was complicated by infection and sepsis, you had two different courses of pneumonia and an infection in your bloodstream from your dialysis catheter. . During your infections your blood pressures were low, during that time your kidneys did not get enough blood flow and as a result your kidney function worsened. In the hospital you were on dialysis at first, then your kidneys started to work with a diuretic, but with time, your kidneys did not respond to the medication to urinate and dialysis was restarted to help take extra fluid off. We starte midodrine during your hemodialysis days as your blood pressure would drop some. Of note, the arterial line blood pressure measurements were approximately 30 points higher in systolic blood pressure than your cuff pressure. Please see below for your new medications. You should see your doctor or go to the emergency room if you have severe chest pain, or having problems with your trach/ventilator or your dialysis, or anything else that is concerning to you. Followup Instructions: You have follow up appointments scheduled with your primary care provider: [Name10 (NameIs) 7158] [Last Name (NamePattern4) 7159], M.D. Phone:[Telephone/Fax (1) 250] Date/Time:[2153-12-25] 10:10; You should keep this appointment unless you are still in your rehab facility. You have a repeat ERCP scheduled for [2153-12-27] 10:00 at ERCP 2 (ST-4) GI ROOMS with Dr. [First Name (STitle) ] [Last Name (NamePattern4) ], MD Phone:[Telephone/Fax (1) 463] You should also discuss an endoscopy to [Telephone/Fax (1) 4656] for gastritis and PUD You should also set up an outpatient stress test with your primary care doctor [First Name (Titles) ] [Last Name (Titles) 4656] for a new left bundle branch block	[ "V45.11", "707.20", "427.31", "486", "574.50", "275.41", "997.39", "577.0", "482.0", "995.91", "038.9", "707.03", "518.5", "403.91", "287.5", "584.9", "996.73", "276.2", "998.59", "285.9", "585.6" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.72", "96.04", "51.87", "51.85", "38.95", "96.6", "99.15", "44.13", "31.1", "43.11", "39.95" ]	icd9pcs	[ [ [] ] ]	27920, 27986	12242, 12242	331, 428	28178, 28228	3945, 4490	29644, 30393	3173, 3237		25507, 27897		28007, 28157		25315, 25484			28252, 29621									3252, 3926																			277, 293				4509, 12219		12270, 25289			456, 2640																2662, 3082	3098, 3157
27,795	173,161	52476	Discharge summary	report	Admission Date: [2194-9-11] Discharge Date: [2194-9-13] Date of Birth: [2117-9-23] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2181] Chief Complaint: Restlessness, agitation, and tachypnea Major Surgical or Invasive Procedure: RIJ Sepsis Line placement History of Present Illness: 76 M with history of Afib, CVA, resident of [Hospital3 2558], sent to ED with restlessness, hypotension, increased respiratory rate. While at the [Name (NI) 1501], pt's BP was noted to be 88/60, RR 22, O2 sat 93%. 45 minutes later, patient noted to be sweaty with O2 sat reportedly 45%, and BP 65/45. The patient also had a reported vomiting a small amount of emesis. . With EMS, the patient was noted to be hypoxic with sats in 80s as well as hypotensive to the 90's, and at the time was in AFib with RVR with HR's in the 140-160's, but upon arrival to the ED was in improved condition. The patient's BP improved to 96/70, HR 120, R20, 98% on 8L on triage. Shortly following his arrival, the patient's O2 sats improved to the mid 90s on 2L NC. Given the patient's hypotension, tachycardia and leukocytosis to 15.6 on admission, a CVL placed (CVPs 5-7) and the patient recieved 6 liters IVFs. In addition, his lactate was noted to be elevated and ranged [5-17]. He was given vanco and zosyn in the ED. SvO2 from sepsis line with sats of 48-50%. . In discussion with patient's wife and daughter, he was confused yesterday (has dementia though unusual for him to not know where he was). In last 2 weeks he has complained of increased thirst (not able to take much PO, had Gtube). Also with recent diagnosis of diabetes, on glyburide. Unknown if polyuria or diarrhea, no bleeding known. Has denied pain at [Hospital3 ], currently denies to wife/daughter. Past Medical History: Atrial fibrillation on coumadin h/o CVA with L sided hemiparesis h/o dysphagia requiring Gtube placement Infected sebaceous cysts x 2 last in [2194-7-13], s/p I&D and keflex in past Hypertension Depression Paranoid psychosis (?) Dementia Diabetes, recently diagnosed on glyburide. Social History: SOCIAL HISTORY: Resident of [Hospital3 ] since his stroke. Significant smoking history (quit age 65; prior smoked [2-13] PPD). Family History: FAMILY HISTORY: unknown Physical Exam: PHYSICAL EXAM: Vitals: T 98.6, HR 136, R 23, BP 149/80, 95% 3L NC General: Elderly male, NAD. HEENT: NC/AT. Resists eye opening, but pupils appear equal and reactive (to 2 mm). MM slightly dry. Neck: Supple, no LAD Lungs: CTA bilat Heart: irreg irreg, tachy, no murmur appreciated Abdomen: soft, appears NT, ND +BS Extrem: Warm extremities, 2+ distal pulses, no edema or rashes. Neuro: Lethargic but arousable and spontaneously moving all extremities. Turns towards wife when spoken to, not verbal, shakes head "no" to question of pain. Skin: Warm, well perfused, back exam pending. Pertinent Results: [2194-9-11] 02:55AM PT-19.6* PTT-43.1* INR(PT)-1.8* [2194-9-11] 02:55AM WBC-15.6* RBC-4.83 HGB-15.9 HCT-43.9 MCV-91 MCH-32.8* MCHC-36.1* RDW-12.9 [2194-9-11] 02:55AM NEUTS-70.3* LYMPHS-25.2 MONOS-3.4 EOS-0.9 BASOS-0.4 [2194-9-11] 02:55AM CK-MB-4 cTropnT-<0.01 [2194-9-11] 02:55AM ALT(SGPT)-85* AST(SGOT)-70* LD(LDH)-350* CK(CPK)-142 ALK PHOS-71 AMYLASE-68 TOT BILI-0.5 [2194-9-11] 02:55AM GLUCOSE-234* UREA N-25* CREAT-1.5* SODIUM-139 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-23 ANION GAP-21* [2194-9-11] 03:11AM LACTATE-5.1* [2194-9-11] 07:16AM WBC-10.5 RBC-3.65* HGB-11.4# HCT-33.1# MCV-91 MCH-31.3 MCHC-34.5 RDW-13.0 [2194-9-11] 07:16AM DIGOXIN-0.6* [2194-9-11] 07:16AM CORTISOL-15.0 [2194-9-11] 07:16AM TSH-0.98 [2194-9-11] 07:16AM CK-MB-6 cTropnT-0.01 [2194-9-11] 07:16AM GLUCOSE-205* UREA N-19 CREAT-1.1 SODIUM-140 POTASSIUM-4.2 CHLORIDE-111* TOTAL CO2-19* ANION GAP-14 [2194-9-11] 04:09PM LACTATE-1.8 [2194-9-11] 03:48PM CK(CPK)-243* [2194-9-11] 03:48PM CK-MB-6 cTropnT-<0.01 Brief Hospital Course: #Hypotension/question sepsis. Upon admission, initially concerned for sepsis given hypotension, leukocytosis and elevated lactate. However patient was afebrile on admission and has remained afebrile throughout the course of his hospitalization. Hypotension seems most consistent with hypovolemia at the time of admission given low CVPs initially. Pt was adequately fluid resuscitated with no pressor requirement at all during his stay in the MICU. Unclear why the pt would be so volume depleted, but daughter does report ongoing patient complaint of thirst. ?osmotic diuresis vs. diarrhea. No evidence of bleeding, diarrhea, or other losses. Also unclear why doesn't have more metabolic derangements if so significantly volume down. Tor concern of infection, pt was continued on ABx with Vanc and Zosyn and should complete an empiric course given that cultures have so far been negative. Lactate improved to 1.8 from peak of 5.4; since in ED no further episodes of hypotension. There has been no obvious source of infection; no lines/known hardware, UA clean, CXR without obvious infiltrate, but pt does have a G-tube in place, copious secretions and could be at high risk for aspiration. Pt was C.diff negative x 1, CT abd read showed no acute intra-abdominal process, and given warm extremeties and low BP there was also an initial concern for cardiogenic shock, but CE not elevated x 3 and LVEF>55% on TTE. TSH, & cortisol checked and unremarkable. # Hypoxia. Noted to be hypoxic at [Hospital3 ], though not significantly hypoxic here and only required O2 via nasal cannula. No definite evidence of pneumonia or volume overload on CXR. [Month (only) 116] have been related to acute episode of hypotension/distress at the NH. On the floor he had a short oxygen requirement but was weened off quickly and was saturating in the high 90s without oxygen. . # Rectal bleeding: Had small amount of BRBPR with bowel movement overnight. Subsequent bowel movement this morning nonbloody and normal. INR 2.7 ([9-12]) up from 2.2 ([9-13]). Likely hemorrhoidal bleed in setting of therapeutic INR. Plan to monitor Hct closely, and hold Coumadin given trajectory of INR. Coumadin was held on the medical floor and INR on d/c was 2.4. . # Leukocytosis. With hypotension, concerning for infection (though unclear source); also consider stress response. Leukocytosis has since improved and was 8 on d/c. Plan to transition from vanco/unasyn to augmentin x 5 days. . # Diabetes. Recent diagnosis, on sulfonylurea at home. Concern that having an osmotic diuresis as above, though not spilling glucose currently. Patient maintained on ISS, recent A1C 7.6%. Will continue to hold glypizide with close followup at extended care facility of blood sugar. . # Transaminitis. Likely related to hypotension. Pattern of LFT elevation not cholestatic appearing. No evidence of bile duct dilatation on recent abdmoninal CT. . # Renal failure. Likely prerenal with volume depletion above. Creatinine has since improved and is down to 1.1 with several liters of IVFs. No evidence of hydro in abdominal CT. . # Atrial fibrillation. On admission was in RVR. Now in sinus. Initally, home diltiazem/metoprolol held given hypotension. Digoxin was continued throughout this hospitalization. Given improvement in BP, home meds re-started with good control of HR and BP. Metoprolol titrated up slowly and now back to 50 [Hospital1 ] (home dose). Patient getting extended release dilt via Gtube at [Location (un) ], not okay to crush per pharmacy, will switch to regular formula. Coumadin was held when transferred to the medical floor. . # Oral thrush noted on exam on [9-12]: Start nystatin swish and swallow today and continued on the medical floor. . # FEN. Tube feeds at rate given at [Location (un) ]. # PPx: therapeutic coumadin, PPI (on at home) # Access: RIJ sepsis line placed [9-11] - d/c once pt arrives to floor. # Communication. With daughter (phone # on board). # Code: Full (discussed with daughter on admission). # Dispo: Transfer to floor today. Medications on Admission: Digoxin 0.125 daily Metoprolol 50 mg [Hospital1 ] Celexa 10 mg daily Aricept 10 mg daily Simvastatin 20 mg daily lisinopril 30 mg daily remeron 15 mg daily glyburide 7.5 mg daily dulcolax supp prn MOM prn [Name2 (NI) 108392] (omeprazole/Nabicarb) 20-1680 packet daily tums 500 mg daily colace 100 [Hospital1 ] warfarin 3-5 mg daily lidoderm patch MVI B12 500 mcg Gtube daily diltiazem 240 daily herbal medication given by wife daily recent med changes: increase lisinopril, decrease digoxin from 0.25, d/c ritalin, increase celexa, increase remeron, increase glyburide Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 11. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:10 Tablet(s) Refills:0 12. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Dehydration Atrial fibrillation on coumadin h/o CVA with L sided hemiparesis h/o dysphagia requiring Gtube placement Infected sebaceous cysts x 2 last in [2194-7-13], s/p I&D and keflex in past Hypertension Depression Paranoid psychosis (?) Dementia Diabetes, recently diagnosed on glyburide. Discharge Condition: afebrile, normal vital signs Discharge Instructions: You presented to the hospital from the Cooldige House with restlessness, hypotension and increased repiratory rate. You received 6 L of IVF on admission and were empirically started on antibiotics for suspected infection. However, you did not have a fever during your stay and it appeared that your presentation was likely related to dehydration rather than infection. You were initially started on antibiotics, but these were stopped when the concern for infection lessned. Although you were noted to be hypoxic on admission, you had only a minimal oxygen requirement in the hospital. You were observed to have some bleeding from the rectum, but this was felt to be secondary to hemorrhoids. Your heart rate was fast when you came to the hospital, but this improved and you were back in a normal rhythm at the time of discharge. Finally, you had some acute renal failure when you came to the hospital, but this improved with IV hydration. Please hold coumadin in setting of supratherapeutic INR. Please monitor INR daily and restart coumadin when INR is 2. Also please hold glypizide in setting of possible osmotic diuresis [3-15] glipizide use. Montior finger sticks at extended care facility and restart glipizide if necessary. Followup Instructions: CT Abdomen/Pelvis [9-11] showed 3 cm aorta that should be followed up when acute issues have resolved. Please follow up with Dr. [Last Name (STitle) ] next week regarding this hospitilization. Completed by:[2194-9-13]	[ "401.9", "438.20", "294.8", "455.2", "427.31", "276.51", "458.9", "584.9", "112.0", "V58.61", "V44.1", "288.60", "250.00" ]	icd9cm	[ [ [] ] ]	[ "96.6", "38.93" ]	icd9pcs	[ [ [] ] ]	9829, 9899	4116, 8207	354, 382	10240, 10271	3015, 4093	11558, 11790	2386, 2395		8840, 9806		9920, 10219		8233, 8817			10295, 11535									2425, 2996																			276, 316									410, 1892																1914, 2201	2233, 2354
29,810	197,536	54536	Discharge summary	report	Admission Date: [2106-4-9] Discharge Date: [2106-4-19] Date of Birth: [2041-8-24] Sex: M Service: MEDICINE Allergies: Sulfonamides / Wellbutrin / Tape / Latex Attending:[First Name3 (LF) 800] Chief Complaint: Syncope, nausea, vomiting Major Surgical or Invasive Procedure: EP study History of Present Illness: This is a 64-year-old gentleman with a history of metastatic RCC on Bevacizumab/Temsirolimus, sick sinus syndrome s/p PPM in [2091], HTN, and hypothyroidism who is transferred here from [Hospital 7912] after syncopal event. Patient reports that he had just finished showering and entered his walk-in closet when everything went blank. His wife heard a "thud" and went upstairs to find her husband unconscious. Wife called 911 and began administering rescue breaths. According to wife, patient was making gurgling noises and was cyanotic. EMS arrived and transported patient to [Hospital1 34] (no note of CPR or shock, but per report, patient was bagged). Wife denies seizure-like activity or bladder/bowel incontinence. At [Hospital1 34], CT head, CT spine, and CXR were negative. Patient was transported to [Hospital1 18] without incident. . In [Hospital1 18] ED VS 98, BP 140/98, HR 70, RR 19, Sat 98%2L. (P 36 to 72 in ED). Repeat CT head without new pathology. Seen by EP fellow in ED, interrogation showed normally functioning duel chamber PM with occasional ventricular bigeminy with normal PM inhibition. There is also a question of ventricular tachycardia at the onset of the syncopal episode. . Admitted to medicine [2-14] to [2-15] and again [2-16] to [2106-2-17] for lightheadness. Attribued to dehydration [2-16] poor PO intake and diarrhea in setting of chemo. Of note at that time, "His pacer was interrogated without any brady or tachyarrhythmias. He was noted to have a HR of 30 but this was false, it was related to PVCs in a bigemy pattern which would lead to a peripheral pulse or pulse oximeter recording a pulse of 30, but an EKG revealed a rate of 60." . PT has had > 5 bouts of non-bloody diarrhea for last 3 days. Did note small blood on TP x 1. Poor PO intake as well last few days. He Reports that 3 nights ago he has multiple episodes of seconds long dull chestpain radiating from right to left chest occuring in bed without SOB, diaphoresis or N/V. No palpatations. ROS: + chronic frontal HA. No change in vision or hearing. No focal weakness or loss of sensation. + N/V at [Hospital ]. + diarrhea x 3 days. No dysuria or hematuria. Past Medical History: Hypertension Metastatic papillary renal cell cancer on chemo (initially diagnosed [2103]) syncope, SSS s/p pacer (DDD) in [2091], generator change in [2092] PAF A flutter s/p ablation VEA, ??????Triggered ventricular tachycardia?????? Remote ??????seizure??????- treated at [Hospital6 ], attributed to Wellbutrin [2103-6-1]: Removal of colon polyps Tobacco abuse (1ppd x approximately 40 years) Hypothyroid s/p Tonsillectomy Social History: Patient has a 40-pack-year history, quit in [2103]. Occasional ETOH, none in months. Lives with wife and works in IT at [Name (NI) 82882] power plant. Family History: Father had stroke in 70s. Mother had colitis. Sister has [Name2 (NI) ]-valvular disease. Physical Exam: VS - 98.1, 125/82, 78, 18, 96% RA Orthostatics lying 99/70, 83 sitting 120/83, 84 standing 112/78, 46 Gen: NAD. HEENT: non icteric. EOMI, PERRL, OP clear. No trauma Neck: no jvd CV: RRR, no m/r/g Chest: CTA Abd: mild TTP in llq, pt says chronic since operation Ext: no edema Skin: no rash neuro: A+Ox3, CN intact, [5-19] strenght, NL sensation, NL F to N. 2+ DTRs throughout. NL babinski. Pulses: Right: DP 2+ Left: DP 2+ Rectal: guaiac negative Pertinent Results: [2106-4-9] 11:34PM CK(CPK)-143 [2106-4-9] 11:34PM CK-MB-3 cTropnT-0.01 [2106-4-9] 03:18PM K+-4.9 [2106-4-9] 03:10PM GLUCOSE-116* UREA N-22* CREAT-1.3* SODIUM-140 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-22 ANION GAP-15 [2106-4-9] 03:10PM CK(CPK)-139 [2106-4-9] 03:10PM cTropnT-0.03* [2106-4-9] 03:10PM CK-MB-3 [2106-4-9] 03:10PM WBC-6.6# RBC-4.47* HGB-12.1* HCT-37.2* MCV-83 MCH-27.0 MCHC-32.5 RDW-14.6 [2106-4-9] 03:10PM NEUTS-90.1* LYMPHS-6.7* MONOS-2.6 EOS-0.6 BASOS-0.2 [2106-4-9] 03:10PM PLT COUNT-141* [2106-4-9] 03:10PM PT-22.7* PTT-24.8 INR(PT)-2.1* . CT HEAD [4-9]: IMPRESSION: 1. No acute intracranial process. Stable findings of chronic small vessel ischemic changes and old prior right cerebellar infarct. 2. Slight progression of pansinus mucosal thickening. The study and the report were reviewed by the staff radiologist. . CXR [4-9]: One portable view. The right chest is not entirely included. Comparison is made with the previous study of [2106-2-14]. There is minimal streaky density at the lung bases consistent with subsegmental atelectasis or scarring, as before. The heart and mediastinal structures are unchanged. Spinal fusion hardware remains in place. A bipolar transvenous pacemaker is present as demonstrated earlier. There is no acute change. IMPRESSION: No acute change. . TTE [2106-4-12]: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is severe regional left ventricular systolic dysfunction with near akinesis of the inferior and inferolateral wall and hypokinesis of the mid to distal anterior septum and anterior wall. There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study ([Month/Day/Year ] echo - limited images reviewed) of [2106-2-18], the above mentioned wall motion abnormalities were present in a milder form on the prior echo. The ejection fraction has decreased. . TEE [2106-4-14]: No atrial septal defect is seen by 2D or color Doppler. There is mild regional left ventricular systolic dysfunction with basal to mid inferior hypokinesis. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 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 valve abscess is seen. 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. No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: Good quality study. No valvular vegetations or perivavlar abcesses seen. No vegetations seen on RA/RV pacer leads. Mild mitral regurgitation. Mild focal left ventricular dysfunction with basal to mid wall hypokinesis. Compared to the transthoracic echo of [4-12]/9, the anterior wall motion looks normal and the inferior wall is less hypokinetic. Brief Hospital Course: This is a 64-year-old gentleman with metastatic RCC, SSS s/p pacemaker, history of seizure x 1, who is transferred here from [Hospital6 33] for an episode of syncope, agonal breathing, and cyanosis. Upon interrogation of PPM, appears as though patient had an episode of V-Tach at symptom onset. . #) Syncope/Ventricular Tachycardia: Initially his symptoms appeared consistent with cardiac etiology (history of sick sinus syndrome, no prodrome, "drop attack," cyanosis). According to EP, his pacermaker was functioning normally, but there was concern that he may have an an ectopic focus possibly near left coronary, causing dysrhythmia. The initial plan was for him to undergo an EP study, however over the weekend prior to his EP study, he developed fevers, rigors, and a new rash. He was febrile to 104, tachycardic to 120s, and became hypotensive. The rash on his arms appeared at the sites of venipuncture. That afternoon he was transferred to the ICU for further management. In the ICU he initially required pressors, and his blood cultures became positive for [Last Name (LF) 8974], [First Name3 (LF) ] his antibiotic coverage was changed to nafcillin. However, during his stay in the ICU when he became febrile, he would go into ventricular tachycardia, become hypertensive and required esmolol drips. After the patient defervesced in the ICU, he had no further episodes of ventricular tachycardia. In the ICU he was also started on amiodarone and metoprolol for the ventricular tachycardia. After he was well enough to leave the ICU, EP did not feel that he needed an EP, because they believed that his ventricular tachycardia was all in the setting of his sepsis. At the time of discharge he was sent home on an oral amiodarone regimen to complete his loading, and then on maintenance amiodarone, continued on metoprolol and would see his outpatient cardiologist about an ICD placement six weeks after discharge. . # Sepsis/Cellulitis: when he became febrile and hypotensive, he also developed areas of erythema and induration around the sites of prior venipuncture, and he was transferred to the ICU for further management. Blood cultures then became positive in [2-18] bottles for [Date Range 8974]. He was started on nafcillin after the sensitivities returned. Infectious disease was consulted and recommended a 4 week course of IV antibiotics due to his bacteremia complicated by septic thrombophlebitis. Hand surgery was consulted for evaluation of the septic thrombophlebitis of his hand, an ultrasound was done that showed only superficial involvement, and they recommended conservative management. # RCC: The patient's primary oncologist was contact[Name (NI) ] who suggested that the patient's normal chemotherapy be held until he was well enough to restart as an outpatient. # AFIB: Patient was initially maintained on a BB (at a decreased dose) and coumadin while on the cardiology service. His coumadin was stopped and his INR reversed in anticipation of his EP study, then his coumadin continued to be held through his ICU course, his coumadin was restarted prior to discharge. . # HTN: Patient was continued on lisinopril and metoprolol, though this was discontinued upon admission to the MICU. Metoprolol was restarted as his blood pressure tolerated. . # Thrombocytopenia: During his course in the MICU, the patient's platelets gradually trended down to a nadir of 66 from an admission level of 141. A HIT antibody was sent that was negative, and he clinically improved his platelet count increased and had returned to the normal range by the time of discharge. . # Hypothyroid: Home synthroid was continued. . Medications on Admission: Bevacizumab (Avastin) 10mg/kg q2wks. Citalopram 20mg PO daily Fluticasone 50mcg [Hospital1 ] Gemfibrozil 600mg PO daily Levothyroxine 88mcg Po daily lisinopril 20mg PO dailiy Metorpolol succinate 100mg PO daily Mirtazapine 15mg PO qpm Temsirolimus (Torisel) 25mg IV weekly (resumed [2106-2-23]) Warfarin 3mg daily except for 4mg Monday, Thrusday. zolpidem 10mg PO qpm colace glucosamine chondriotin hexetidine ibuprofen 200mg PO q6h prn Lecithin 1200mg PO daily omega 3 fatty acid 360mg-1200mg PO daily Prasterone (DHEA) 50mg PO daily Selenium 200mcg PO daily Vitamin E 400 unit PO daily Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary: 1. [Hospital3 8974] Bacteremia complicated by superficial thrombophlebitis 2. Sustained ventricular tachycardia . Secondary: 1. Hypertension 2. Metastatic papillary renal cell cancer on chemo (initially diagnosed [2103]) 3. syncope, SSS s/p pacer (DDD) in [2091], generator change in [2092] 4. PAF 5. A flutter s/p ablation Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Dear Mr. [Known lastname 71430], It was a pleasure taking care of you on this admission. You were transferred to [Hospital1 18] from an outside hospital because of syncope and nausea. You most likely had a heart arrythmia, which caused you to lose consciousness. Shortly after your admission you were found to have a fever, areas of redness on your right hand/left arm and then had blood cultures that showed bacteria growing in your blood stream. You were than transferred to the ICU for closer monitoring, and you also needed medications to help keep your blood pressure in the normal range. While in the ICU when you had a fever it was found that your heart went into an abnormal rhythm called ventricular tachycardia. To help treat this rhythm you were started on two new medications, amiodarone and metoprolol. The electrophysiologists (heart rhythm doctors) saw you and felt that the abnormal heart rhythm was likely related to the infection. After you finish your course of antibiotics for the bacteria in your bloodstream, you will follow up with Dr. [Last Name (STitle) 120] to discuss putting in a defibrillator. . The following changes were made to your medications: 1. START taking metoprolol 12.5mg three times per day instead of Toprol XL 100mg 2. START amiodarone 400mg a day for one week, then change to 200mg a day from then on 3. DECREASED warfarin dose to 3mg daily as you are on new medications that can interact with warfarin 4. STARTED Loperamide 2mg every 4 hours as needed for diarrhea . Please take all of your medications as prescribed. Please keep all of your follow-up appointments. . Return to the hospital if you develop chest pain, shortness of breath, syncope or near syncope, headache, nausea, vomiting, diarrhea, bright red blood in urine or stool, fevers, chills, or any other concerning signs or symptoms. Followup Instructions: Department: INFECTIOUS DISEASE When: FRIDAY [2106-5-7] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 288], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: CARDIAC SERVICES When: TUESDAY [2106-5-18] at 2:30 PM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: TUESDAY [2106-5-18] at 3:00 PM With: [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 126], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 810] MD, [MD Number(3) 811]	[ "041.11", "999.2", "426.4", "427.31", "E933.1", "E849.7", "785.50", "585.9", "999.39", "682.4", "427.1", "V10.52", "428.22", "V45.01", "682.3", "197.6", "790.7", "E879.8", "790.92", "787.91", "451.82", "244.9", "V58.61", "403.90", "287.5", "300.4", "198.0", "428.0" ]	icd9cm	[ [ [] ] ]	[ "38.91", "88.72", "89.45", "38.93" ]	icd9pcs	[ [ [] ] ]	11818, 11869	7492, 11171	325, 335	12267, 12267	3827, 7469	14302, 15359	3247, 3342				11890, 12246		11197, 11795			12415, 14279									3357, 3808																			260, 287									363, 2584										12282, 12391						2606, 3053	3069, 3231
17,041	198,974	1472	Discharge summary	report	Admission Date: [2174-1-21] Discharge Date: [2174-1-25] Service: MEDICINE Allergies: Codeine / Penicillins Attending:[First Name3 (LF) 2901] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 86 yo M w pmh of CAD s/p cabg (SVG to LAD, SVG to diag, SVG to RPDA) and multiple PCI's, renal stenosis s/p stent, HTN, hyperchol, DMII. Presented to an OSH with SSCP. He had 2 episodes of CP (similar to his usual angina) on [2174-1-18] while walking (short distance), relieved by SL NTG. He again had an episode of CP on [2174-1-20] while walking, relieved by SL NTG. The CP was substernal ([11-4]) without radiation, diaphoresis, SOB or N/V. The pt. has not had CP since his prior presentation at [Hospital1 18] in [9-1]. Due to these recurrent episodes of CP the pt. called EMS and was given 4 ASA and SL NTG x 2 prior to presenting to the OSH. At the OSH he was pain free. He was given 1 inch of nitro paste for unclear reasons. CE were neg at the OSH (CK 32, MB 0.7 trop I 0.02). Here CE are neg. ECG without any change from prior. in the ED: initial vitals: T 97.1BP 157/68 HR 80 RR 18 02 sat 96 on 2L. He was pain free. cxr is wnl, given 325mg ASA, 25 mg lopressor po. . ALLERGIES: codeine, pcn Past Medical History: CABG in [2153] DES to SVG-LAD graft in [4-29], DES x2 to SVG-RPDA in [9-30], BMS to SVG-RCA in [10-1]; SVG-Diag 100% occluded . Other Past History: Renal artery stenting in [3-31] Chronic kidney disease, GFR 25 Type 2 Diabetes Mellitus HTN Hyperlipidemia PTSD zoster in L groin 5 years ago, no active lesions Social History: 30+ pack years of tobacco use. He quit 12 years ago. He uses alcohol occasionally. He has no history of recreational drug use. He lives with his wife. Family History: Father had a myocardial infarction at age 70. Mother had cancer and myocardial infarction. Brothers have diabetes. Physical Exam: VS - BP 148/74, 80, 20 193 lbs. Gen: 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 without elevation of JVD. Right carotid bruit CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 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. Well healed sternal scar s/p cabg Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c. no edematous. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . Pertinent Results: EKG demonstrated old q waves in III and aVF, NSR, rate 78, normal axis, no STTW changes as compared to prior ECG dated [2173-9-17]. . Echo:The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. 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. Overall left ventricular systolic function is mildly depressed (LVEF= 45-55 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. 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. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2173-9-18], the left ventricular systolic function may have slightly worsened, but regional wall motion abnormalities cannot be adequately assessed due to suboptimal image quality. . CXR [1-23]: No acute intrathoracic pathology, including no pneumonia. Findings suggestive of bronchiectasis in the right lower lobe; is there history of aspiration or other pneumonia? . Cardiac catheterization: 1. Initial angiography in this right-dominant circulation revealed LM with minimal disease. The [Month/Year (2) ] had minimal disease. The LAD ahd a 100% known stenosis in the mid vessel. The rca was not injected as it was known to be occluded. The SVG-->OM graft was not injected as it was known to be occluded. The SVG--> LAD was patent with a discrete 40% stenosis. The SVG--> RCA was patent proximally but had a 90% ISR of the distal vessel,close to the anastamosis site distally in an area which already had 2 cypher and 1 BMS previously. There was disease present in the diagonals,one of which was subtotally occluded chronically. 2. Limited hemodynamics revealed a central aortic pressure of 120/53. 3. Successful PTCA and stenting of the distal svg-->rca vein graft with a 2.5x12mm taxus stent. Disatl dissection treated with a 2.25x12mm driver stent and 2.5x15mm quantum maverick balloon inflation. Type A linear PDA dissection. (See ptca comments). The patient left the lab free of angina and in stable condition. . Cardiac Enzymes: [2174-1-21] 01:35AM CK-MB-NotDone cTropnT-<0.01 [2174-1-21] 08:40AM CK-MB-NotDone cTropnT-<0.01 [2174-1-21] 08:40AM CK(CPK)-28* . Misc: [2174-1-21] 01:35AM LIPASE-52 [2174-1-21] 01:35AM ALT(SGPT)-15 AST(SGOT)-16 CK(CPK)-29* ALK PHOS-71 TOT BILI-0.4 [Month/Day/Year ] Cx: negative Urine Cx: <10,000 Influenza DFA: negative UA: negative . Chem 7 [2174-1-21] 01:35AM GLUCOSE-167* UREA N-40* CREAT-2.0* SODIUM-140 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14 [2174-1-21] 01:35AM CALCIUM-9.5 PHOSPHATE-2.9 MAGNESIUM-2.0 [2174-1-22] 07:35PM [Month/Day/Year 3143] Glucose-159* UreaN-41* Creat-2.6* Na-136 K-4.1 Cl-99 HCO3-26 AnGap-15 [2174-1-23] 06:40AM [Month/Day/Year 3143] Glucose-82 UreaN-43* Creat-2.7* Na-142 K-4.4 Cl-102 HCO3-28 AnGap-16 [2174-1-24] 05:00AM [Month/Day/Year 3143] Glucose-79 UreaN-49* Creat-2.7* Na-139 K-3.5 Cl-102 HCO3-26 AnGap-15 [2174-1-25] 05:30AM [Year/Month/Day 3143] Glucose-134* UreaN-45* Creat-2.5* Na-139 K-4.1 Cl-102 HCO3-26 AnGap-15 . CBC [2174-1-21] 01:35AM WBC-3.3* RBC-4.02* HGB-11.3* HCT-32.2* MCV-80* MCH-28.1 MCHC-35.1* RDW-14.9 [2174-1-21] 01:35AM NEUTS-61.8 LYMPHS-21.3 MONOS-10.4 EOS-6.1* BASOS-0.4 [2174-1-23] 08:40AM [Month/Day/Year 3143] WBC-4.0 RBC-3.51* Hgb-9.6* Hct-28.2* MCV-80* MCH-27.4 MCHC-34.2 RDW-14.8 Plt Ct-93* [2174-1-24] 05:00AM [Month/Day/Year 3143] WBC-3.9* RBC-3.22* Hgb-9.1* Hct-25.8* MCV-80* MCH-28.3 MCHC-35.4* RDW-14.8 Plt Ct-88* [2174-1-25] 05:30AM [Year/Month/Day 3143] WBC-3.3* RBC-3.25* Hgb-9.3* Hct-26.5* MCV-81* MCH-28.5 MCHC-35.0 RDW-15.8* Plt Ct-103* . Brief Hospital Course: The patient was transferred to [Hospital1 18] for cardiac catheterization. On presentation, he had no EKG changes and cardiac enzymes were subsequently neagative. His chest pain was releived by sublingual nitro by the time of admission to [Hospital1 18]. He was continued on his cardiac medications: ASA, Plavix, Simvastatin, HCTZ, Imdur, Lisinopril; Toprol XL 100mg daily was switched to Metoprolol 50mg [Hospital1 ] while in house. He had no more episodes of chest pain prior to to cardiac catheterization. He underwent cardiac catheterization and stent placement in the distal SVG to RCA. During the cardiac catheterization, he developed a distal RCA dissection, chest pain and ST segmement elevations. He received a nitro drip, integrillin and placement of a microdriver stent. He was admitted to CCU for further observation. He remained stable overnight, was weaned off the nitro drip and had no further episodes of chest pain. Cardiac enzymes remained negative. . Despite receiving pre-cath hydration with bicarb as well as mucomyst, the patient's creatinine climbed from baseline 2.0 to 2.7 2 days after catheterization presumably due to contrast nephropathy. Lisinopril was held. His creatinine was trending down at 2.5 on discharge. In addition, a day after being transfered from the CCU to the floor, the patient developed a temperature of 102.3. [Hospital1 ] cx, UA, CXR found no source of infection. DFA for influenza was also negative. The patient developed mild myalgias and sore throat the follow day c/w a viral syndrome. His fever curve trended down and he was discharged home afebrile and chest pain free. . He was continued on the majority of his home medications during his hospital stay - Glypizide held while NPO, Lisinopril held for ARF, Toprol->Metoprolol. He was switched from Simvastatin 40mg to Atorvastatin 80mg daily. Medications on Admission: isosorbide mononitrate 60mg [Hospital1 ] Aspirin 325 mg PO DAILY Gabapentin 300 mg PO HS Hydrochlorothiazide 25 mg PO DAILY Toprol XL 100 mg PO daily Simvastatin 40 mg PO DAILY Glipizide 5 mg 1 tablet before breakfast and lunch, 1 and a half tablets before dinner [1-26] tablet at night. Clopidogrel 75 mg po daily Lisinopril 10 mg po daily . Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BREAKFAST (Breakfast). 9. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). 10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO LUNCH (Lunch). 11. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO DINNER (Dinner). 12. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain: do not take more than 4000mg in 1 day. Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease with instent restenosis Distal RCA dissection Discharge Condition: improved, breathing comfortable, low-grade temperature Discharge Instructions: You were admitted for chest pain and received a cardiac catheterization with re-stenting of a blocked heart vessel. If you have chest pain, you should take sublingual nitro three times 5 minutes apart. If your chest pain does not resolve, please call 911 and go to the emergency room. You had a fever while here which we think is likely due to a respiratory virus. A test for influenza, a more virulent virus, was negative. If you have recurrence of high fevers, please call your primary care physician. [Name10 (NameIs) ] cultures showed that you did not have an infection in your [Name10 (NameIs) ] stream . Continue taking all your home medications as you have previously. You should stop taking Simvastatin 40mg and take Atorvastatin 80mg instead. For your stent you should continue to take aspirin and plavix for 1 year. Do not stop these medications without speaking to your cardiologist. Followup Instructions: Please call Dr [Last Name (STitle) ] to make a follow up appointment in the next 1-2 weeks. [Telephone/Fax (1) 3183]. . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. Phone:[Telephone/Fax (1) 920] Date/Time:[2174-10-25] 1:40 [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "250.00", "997.1", "272.4", "414.01", "585.9", "413.9", "V17.3", "583.9", "V18.0", "E947.8", "079.99", "E879.0", "414.05", "E849.7", "403.90", "272.0", "V15.82", "V58.66", "414.12", "309.81", "365.9" ]	icd9cm	[ [ [] ] ]	[ "00.66", "88.56", "88.72", "36.07", "37.22", "36.06", "00.47", "00.41" ]	icd9pcs	[ [ [] ] ]	10512, 10518	7188, 9053	240, 265	10632, 10689	2907, 5502	11647, 12061	1855, 1971		9454, 10489		10539, 10611		9079, 9431			10713, 11624									1986, 2888																5519, 7165			190, 202									293, 1317																1339, 1669	1685, 1838
30,183	132,536	32878	Discharge summary	report	Admission Date: [2154-10-4] Discharge Date: [2154-10-18] Date of Birth: [2120-11-19] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 13541] Chief Complaint: Headache, right-sided neck pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 4702] is a 33 yo M with PMH of ESRD secondary to HTN, on HD MWF, and medication non-compliance who presents with headache and right-sided upper body pain (head, neck, arm, chest, & back) intermittantly for the past week, but acutely worse since yesterday. Prior to the onset of this pain a little over a week ago, he lifted a 75 pound sack at home. He also states that he has not taken his medications for the past two days and that he missed his dialysis appointments on monday and wednesday of this week, but did have dialysis today. His headache worsened toward the end of his dialysis session today and he was encouraged to seek medical attention. He has had bad headaches in the past, but denies any previous upper body pain similar to what he is currently experiencing. He denies any visual changes, shortness of breath, nausea/vomiting, abdominal pain, or diarrhea. He endorses subjective fevers today only and a mild cough. In the ED initial vitals were Temp 99.5, HR 89, BP 197/142, R 29, 99% 2L NC; BP went as high as 230/152. EKG showed sinus rhythm at 85 with inferior and lateral ST depressions and T wave inversions with trop 0.16 (bl 0.12) and creatinine of 15.9. He received morphine 4 mg IV x 3, nitro gtt titrated up to 200 mcg/min, and labetalol 20 mg IV x 2. Initial concern was for hypertensive urgency vs ACS. Past Medical History: - ESRD [12-29] HTN - started on dialysis in [12/2152] - HTN - h/o medication non-compliance - h/o intubation in the setting of hypertensive urgency/flash pulmonary edema - h/o right internal jugular vein thrombus - h/o pulmonary edema in the setting of hypertensive urgency Social History: He used to work as a plasterer, but is now on disability and lives with his mother. [Name (NI) 1139]: 1PPD x 20 years, currently 5 cigarettes a day. No recent alcohol use, + cocaine- denies recent use, does endorse recent marijuana use, denies any intravenous drugs; spent time in jail. Family History: Father - dead at age 36 from unknown cancer Mother - alive, 56, + HTN Maternal grandmother - on hemodialysis for end-stage renal disease. - The patient has a younger sister and an older brother, both alive and well. - son - 8, alive and well Physical Exam: VS: 99.5, HR 87, BP 174/116, R 18, 95% on RA Gen: WDWN African American male in NAD HEENT: NTTP of the scalp, Clear OP, MMM NECK: Supple, No LAD, No JVD. Tenderness to palpation over the right anterio-lateral base of the neck with associated fullness. CV: RRR, normal S1, S2. [1-2] flow murmur. No rubs or [Last Name (un) 549] LUNGS: CTAB, without W/R/C CHEST: Right upper chest with dialysis access site c/d/i. BACK: No TTP over the spinous processes, shoulders, or CVA tenderness ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moves all extremities. Pertinent Results: Blood work on admission: [2154-10-4] 07:25PM BLOOD WBC-6.0 RBC-4.65# Hgb-13.5# Hct-40.8 MCV-88 MCH-29.0 MCHC-33.0 RDW-14.9 Plt Ct-274 [2154-10-4] 08:21PM BLOOD PT-14.8 PTT-36.0* INR(PT)-1.3* [2154-10-4] 07:25PM BLOOD Glucose-103 UreaN-60* Creat-15.9# Na-143 K-4.8 Cl-90 HCO3-36* AnGap-22* [2154-10-4] 07:25PM BLOOD ALT-6 AST-6 CK(CPK)-489* AlkPhos-61 [2154-10-4] 07:25PM BLOOD cTropnT-0.16* [2154-10-5] 05:35AM BLOOD CK-MB-4 cTropnT-0.16* [2154-10-5] 05:35AM BLOOD Calcium-7.4* Phos-9.6# Mg-1.8 [2154-10-4] 07:25PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2154-10-4] CXR: There is a right-sided central venous line with the tip projected over the right atrium. Cardiomediastinal silhouette is unremarkable. The lungs are clear. There is stable appearance to a large calcified lesion in the right upper quadrant consistent with a calcified right renal mass and better documented on the CT of [2154-5-21]. Head CT [2154-10-4]: No evidence of acute intracranial hemorrhage or major territorial infarct. Small focus of rounded hypoattenuation within the posterior left frontal lobe which likely represents volume averaging of a prominent sulcus. This finding is unchanged and may be confirmed with MRI as indicated. Chest CTA [2154-10-4]: 1. No evidence of acute pulmonary embolism, dissection or pneumonia. 2. Findings suggestive of right subclavian vein stenosis which may be related to long-term catheter placement. 3. Partially calcified right upper pole renal lesion, incompletely evaluated, without appreciable gross change. A dedicted abdominal CT is recomended for further assesment. 4. Dense calcification of the left anterior descending coronary artery. Upper Ext U/S [2154-10-5]: Occlusive clot visualized in right subclavian vein, with decreased flow in the right axillary and brachial veins which are otherwise without evidence of thrombus. Right IJ appears patent. ECHO [10-6]: IMPRESSION: Marked symmetric left ventricular hypertrophy with regional systolic dysfunction suggestive of CAD. Mild aortic regurgitation. Mild-moderate mitral regurgitation. Small secundum type atrial septal defect. Compared with the prior study (images reviewed) of [2154-5-6], the left ventricular hypertrophy is slightly more prominent with similar regional and global systolic function. Valvular dysfunction is similar. A very small secundum atrial setpal defect is now identified. In the absence of a history of marked systemic hypertension, an infiltrative process (e.g., Fabry's or amyloid) is suggested. Brief Hospital Course: 33M with poorly-controlled hypertension, ESRD, and medication non-compliance, admitted with hypertensive urgency and right-sided upper body pain. # Hypertensive urgency: The patient was given IV labetalol and started on a nitro gtt in the ED. He was then admitted to the MICU and the nitro gtt was weaned off with resumption of his home blood pressure regimen. His hypertensive urgency was evidently attributed to his medication non-compliance and missed hemodialysis sessions for 2 days, with resultant volume retention. After his BP was stabilized, he was transferred to the floor. However, he continued to have SBP>190 and DBP>120 periodically. His hypertension ultimately resolved with revision of his hemodialysis catheter and effective hemodialysis. His calcium channel blocker was stopped, and beta blockade titrated. Lisinopril was continued. # Right subclavian DVT: The patient complained of right arm pain and a RUE U/S demonstrated a clot in the R subclavian vein. He was started on heparin gtt and warfarin. His INR was therapeutic at the time of discharge and will be followed by Dr. [First Name (STitle) 76545] [Name (STitle) 14558], a physician at [Name9 (PRE) ] who adjusts his warfarin. Her beeper contact information is: [Telephone/Fax (1) ], beeper [Pager number ]. # Unstable angina: On [10-16], the patient awoke with left-sided chest pain, with resolution after administration of morphine and nitro SL. His symptoms were concerning for ACS, further supported by deeper ST depressions in the inferior leads on ECG. These were difficult to interpret, however, given the patient's LVH and abnl EKG at baseline. A CTA chest was neg for aortic dissection or PE. An ECHO was performed and demonstrated stable EF (35%) and stable inferior and inferoseptal hypokinesis. Cardiology was consulted, and his presentation was ultimately felt to be consistent with unstable angina. The patient was considered for stress test for risk stratification and cardiac catheterization, but expressed a lack of confidence in his ability to remain adherent to antiplatelet therapy, should an intervention be needed. As such, conservative management was advised. He was started on ASA, statin, and long-acting nitrate. He had no recurrence of chest pain after the initial episodes. Cardiology follow-up as an outpatient was also arranged. # ESRD on HD: At the time of presentation, the patient last had dialysis on [2154-10-4] after missing 2 sessions on the monday and wednesday prior. During his admission, he was continued on a MWF schedule. He also had an elevated phosphate level at the time of admission and was started on aluminum hydroxide, and his sevelamer was continued. Aluminum hydroxide was continued only during the inpatient stay, as recommended by the renal service, and the patient was instructed to not continue this medication as an outpatient. His phosphate declined modestly to a value of approximately 9 at the time of discharge. He will continue dialysis at his normal facility, the [Location (un) ] dialysis clinic ([Telephone/Fax (1) ]). His INR will be checked at dialysis and the results will be shared with Dr. [First Name (STitle) 76545] [Name (STitle) 14558], a phsyician at [Location (un) ] who adjusts his warfarin. Her beeper contact information is: [Telephone/Fax (1) ], beeper [Pager number ]. # HD line revision: Patient has a right tunneled HD line that required revision after dialysis became difficult due to thrombosis within the line's lumen. Revision was completed successfully and the patient's revised line was used without difficulty during HD. He developed a hematoma at the insertion site after the revision but this gradually resolved. # Medication non-compliance: Patient has a long history of non-compliance with medications. SW was consulted and the patient ultimately stated that he would attempt to be more compliant with medications after discharge. Medications on Admission: Calcium Acetate 1334 mg PO TID Sevelamer HCl 2400 mg PO TID Lisinopril 40 mg PO BID Labetalol 300 mg PO BID Pantoprazole 40 mg PO daily Nifedipine 180 mg Sustained Release Daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s)* Refills:2 2. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:30 Tablet(s) Refills:2 3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:45 Tablet Sustained Release 24 hr(s) Refills:2 4. Cinacalcet 60 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Isosorbide Mononitrate 30 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 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual as directed: If you experience chest pain, take one tablet. If no relief in 5 minutes, take another and call 911. Disp:30 tablets Refills:2 9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 10. Warfarin 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QFRI,MON (). Disp:30 Tablet(s) Refills:2 12. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 13. Outpatient Lab Work Please check INR at [Location (un) ] dialysis clinic ([Telephone/Fax (1) ]) on [10-20] at dialysis (and every dialysis session afterward until INR is stable) and share results with Dr. [First Name (STitle) 76545] [Name (STitle) 14558], a phsyician at [Location (un) ] who adjusts his INR. To reach her, call [Telephone/Fax (1) ], beeper [Pager number ]. Discharge Disposition: Home Discharge Diagnosis: 1. Hemodialysis-catheter associated right subclavian vein thrombosis 2. Hypertensive urgency 3. End-stage renal disease on hemodialysis 4. Unstable angina. Discharge Condition: Hemodynamically stable and chest pain free. Discharge Instructions: **[Hospital ] clinic is open on Sunday, [10-20], because of the [Holiday 1451] schedule. You should go on Sunday at 10am, Tuesday, and Thursday this week. You were admitted because your blood pressure was elevated. We treated you with medications to reduce your blood pressure. We also revised your hemodialysis line because it was not functioning properly. While you were here, we also diagnosed you with a blood clot in your right arm. To treat you for this, we gave you warfarin (coumadin) and heparin, medications that are blood thinners. You should continue to take your warfarin at home. While you were here, you also had a small heart attack. You were seen by cardiologists and your medications were adjusted to help protect your heart from further damage. It will be important to control your blood pressure and to stop smoking, as both of these put you at high risk for heart attacks. Please take all of your medications as prescribed. Please keep all of your follow-up appointments. Please call your doctor or return to the hospital if you experience fevers, chills, sweats, chest pain, shortness of breath or anything else of concern. Followup Instructions: Scheduled Appointments : Fistula for dialysis: Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2154-11-7] 1:40 Cardiology: Provider [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2154-11-7] 3:40 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 13546] Completed by:[2154-10-19**]	[ "V45.11", "276.7", "996.73", "410.71", "585.6", "E879.1", "444.89", "425.4", "V15.81", "403.01", "459.2", "V58.61", "V12.51", "424.0" ]	icd9cm	[ [ [] ] ]	[ "99.10", "38.95", "39.95" ]	icd9pcs	[ [ [] ] ]	12101, 12107	5911, 9891	350, 356	12307, 12353	3291, 3302	13576, 14118	2382, 2625		10119, 12078		12128, 12286		9917, 10096			12377, 13553									2640, 3272																			279, 312									384, 1751								3317, 5888								1773, 2056	2072, 2366
68,989	135,692	54946	Discharge summary	report	Admission Date: [2179-5-3] Discharge Date: [2179-5-10] Date of Birth: [2127-1-24] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 983] Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: Intensive Care Addmission EEG monitoring PICC line placement Lumbar Puncture History of Present Illness: This is a 52 year old lady with unknown PMHx who presents from OSH after an unwitnessed fall with hyponatremia. Per documented report, her son reports hearing his mother fall on the back porch. He found her unconscious with blood comiung from her mouth. EMS found the patient confused and combative which improved on transfer to the OSH. The patient reports a 6 day history of flu like symptoms including nausea and emesis. She reports drinking up to 12 bottles of water per day to impove her flu symptoms and then subsequently developing diarrhea. She has not eaten in over six days. The patient reports significant etoh history w/ recent cessation 2 days ago in setting of diarrhea and emesis. She reports drinking approximately 2 drinks per day, last drink about a week ago. Never had withdrawal symptoms and states alcohol has never been a problem. She is otherwise a difficult historian. Her family reports she drinks 6 glasses of wine per day, does not have a history of w/drawal but has not ever not had wine. They report that she replaced a lot of the wine with water during the last several days. At the OSH, initial labs demonstrated a Na of 117, K+ of 3.2, Cl- 78 and hco3 30 and transaminitis. A CBC demonstrated WBC 5.4, hct 45.2, plts 54. Her exam was significant for a posteror lump on her head andevidence of tongue biting. She was confused and not following commands initially. She was given 10meq of potassium for repletion of her potassium. A CT c-spine at the OSH revelaed no evidence of gross fracture and a CT head revealed a high density focus noted alont the septum pellucidum concerning for intraventricular hemorrahge given the history of trauma. She was given 1 IV NS with 1meq of KCL. Of note, she has been admitted to the OSH in the past for hyponatremia and felt to be secondary to beer potomania per records. In the ED, initial VS were: 97.4 108 160/99 22 92%. The patient was noted to be confused and unable to give a history. She was intermittantly combative and exam was significant for upper extremity tremors, nystagmus. An initial cxr demonstrated concern for significant hilar adenopathy concerning for an early infectious process. She spiked a recetal temperature to 100.8. She was started on vancomycin and cefepime for broad spectrum coverage of a possible pneumonia. For her etoh history she was given lorazepam 2mg IV, folic acid 1mg IV x1, and thiamine 100mg IV x 1. Review of CT c-spine was normal and her c-spine was cleared. Review of her CT head report from the OSH was concerning for high density focus intraventricular hemorrhage. A NSG c/s was placed who evaluated the patient in the ED and initially felt the findings were not c/w acute hemorrhage. Final recommendations pending on transfer. Vitals on tranfer were: 93 21 143/86 96% on 2L NC. On arrival to the MICU, initial vitals were: 98.8 101 134/78 92% on 2L NC. She is easily distracted, with slurred speech Past Medical History: 1. Hypnatremia 2. Abnormal Liver Function Tests (? etoh induced hepatitis, AST/ALT ratio 2:1 in past) 3. Thrombocytopenia 4. Macrocytosis (MCV 112) 5. Hypertension (not treated) Social History: - Tobacco: 1ppd - Alcohol: >6 drinks of wine per day - Employment: works at family shop - Housing: lives with husband and 2 sons Family History: non contributory Physical Exam: ADMISSION EXAM: Vitals: 98.8 101 134/78 92% on 2L NC. General: Disoriented, oriented only to self and hosptial, confused and easily distracted HEENT: Sclera anicteric with secretions, MMM, oropharynx clear, EOMI, PERRL, + horizontal nystagmus, there is also a 1in Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly SKIN: Yellowing of the index fingers 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, finger-to-nose intact DISCHARGE EXAM: 98.2, 97/59, 66, 18, 100RA General: AOx3, at baseline HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm,S1S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 4/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact no asterixis. Pertinent Results: INITIAL LABS: [2179-5-3] 06:40AM BLOOD WBC-5.8 RBC-3.86* Hgb-13.6 Hct-39.5 MCV-102* MCH-35.1* MCHC-34.3 RDW-13.7 Plt Ct-53* [2179-5-3] 06:40AM BLOOD PT-10.5 PTT-26.1 INR(PT)-1.0 [2179-5-3] 06:40AM BLOOD Glucose-122* UreaN-3* Creat-0.3* Na-122* K-2.7* Cl-83* HCO3-28 AnGap-14 [2179-5-3] 06:40AM BLOOD ALT-77* AST-224* AlkPhos-118* TotBili-1.2 [2179-5-3] 12:05PM BLOOD Calcium-7.8* Phos-2.4* Mg-1.4* [2179-5-4] 08:48AM BLOOD Osmolal-257* [2179-5-3] 09:05AM BLOOD TSH-2.0 [2179-5-3] 09:05AM BLOOD Cortsol-32.2* [2179-5-3] 06:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2179-5-3] 08:47PM BLOOD O2 Sat-88 . PERTINENT INTERVAL LABS: [2179-5-5] 02:22AM BLOOD WBC-4.9 RBC-4.10* Hgb-14.7 Hct-42.8 MCV-105* MCH-35.9* MCHC-34.3 RDW-13.7 Plt Ct-103* [2179-5-5] 02:22AM BLOOD PT-10.0 PTT-35.3 INR(PT)-0.9 [2179-5-3] 09:05AM BLOOD Na-119* K-3.3 Cl-84* [2179-5-3] 12:05PM BLOOD Na-125* K-3.3 Cl-86* [2179-5-3] 04:07PM BLOOD Glucose-106* UreaN-3* Creat-0.3* Na-132* K-3.0* Cl-93* HCO3-30 AnGap-12 [2179-5-3] 06:19PM BLOOD Glucose-133* UreaN-2* Creat-0.3* Na-136 K-2.8* Cl-99 HCO3-26 AnGap-14 [2179-5-4] 08:48AM BLOOD Glucose-116* UreaN-2* Creat-0.3* Na-128* K-2.9* Cl-90* HCO3-28 AnGap-13 [2179-5-4] 03:51PM BLOOD Glucose-109* UreaN-2* Creat-0.2* Na-125* K-3.3 Cl-88* HCO3-28 AnGap-12 [2179-5-5] 02:22AM BLOOD Glucose-102* UreaN-2* Creat-0.2* Na-131* K-3.6 Cl-97 HCO3-29 AnGap-9 [2179-5-5] 07:57AM BLOOD Glucose-101* UreaN-3* Creat-0.3* Na-133 K-4.5 Cl-99 HCO3-25 AnGap-14 [2179-5-6] 05:50AM BLOOD Glucose-98 UreaN-5* Creat-0.3* Na-135 K-3.7 Cl-99 HCO3-27 AnGap-13 [2179-5-8] 05:18AM BLOOD Glucose-92 UreaN-7 Creat-0.3* Na-136 K-3.3 Cl-100 HCO3-27 AnGap-12 [2179-5-4] 02:23AM BLOOD ALT-61* AST-135* AlkPhos-97 TotBili-0.7 [2179-5-4] 05:29AM BLOOD ALT-69* AST-136* LD(LDH)-442* AlkPhos-108* TotBili-0.8 [2179-5-5] 02:22AM BLOOD ALT-68* AST-125* LD(LDH)-389* AlkPhos-107* TotBili-0.8 [2179-5-5] 02:22AM BLOOD Osmolal-269* [2179-5-5] 07:57AM BLOOD Osmolal-272* [2179-5-4] 03:51PM BLOOD Triglyc-72 [2179-5-6] 05:50AM BLOOD VitB12-534 Folate-12.0 [2179-5-3] 06:40AM URINE Osmolal-219 [2179-5-3] 09:34AM URINE Osmolal-376 [2179-5-3] 05:30PM URINE Osmolal-297 [2179-5-8] 02:06AM URINE Osmolal-149 [2179-5-3] 06:40AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . DISCHARGE LABS: [2179-5-10] 05:25AM BLOOD WBC-4.9 RBC-3.24* Hgb-11.6* Hct-34.7* MCV-107* MCH-35.8* MCHC-33.4 RDW-14.1 Plt Ct-196 [2179-5-10] 05:25AM BLOOD Glucose-92 UreaN-5* Creat-0.3* Na-135 K-3.3 Cl-99 HCO3-30 AnGap-9 [2179-5-9] 04:54AM BLOOD ALT-75* AST-86* CK(CPK)-441* AlkPhos-87 TotBili-0.4 [2179-5-9] 04:54AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.5* [2179-5-6] 05:50AM BLOOD VitB12-534 Folate-12.0 [2179-5-4] 03:51PM BLOOD Triglyc-72 . SEROLOGIES: [2179-5-4] 03:51PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2179-5-4] 03:51PM BLOOD HCV Ab-NEGATIVE . Pertinent Imaging: -------------------- CT Chest [5-5]: 1. There is no central lymph node enlargement. Diffuse bronchial wall thickening is nonspecific and can be seen in aspiration or bronchitis, acute or chronic. 2. Fatty infiltration of the liver. 3. Right upper lobe nodules and ground glass opacity is likely inflammatory, [1-26] month followup chest CT is recommended to document resolution. -------------------- CT HEAD [5-5]: 1. Increasing attenuation of the previously-identified intraventricular hyperdense lesion suggests it is most likely an organizing intraventricular hematoma with adherent clot. No new hemorrhage is identified. 2. Encephalomalacia in the right frontal lobe consistent with old infarct. 3. Subcutaneous sebaceous cyst. -------------------- MRI HEAD [5-5]: 1. A focal lesion in the right lateral ventricle adjacent to the septum pellucidum - likely hematoma; however, consider close followup to confirm based on evolution and exclude underlying lesion. No new areas of hemorrhage are seen. There is no abnormal enhancement seen in the brain parenchyma.A follow-up MRI is recommended once hemorrhage resolves to assess for underlying lesion. 2. Mild dural thickening and enhancement along the right frontoparietal region- etiology uncertain-correlate with CSF analysis (LP not performed) for etiology- infectious/inflammatory. 3. Prominent white matter hyperinternse area in the right frontal lobe- consider f/u in a few months to exclude slow growing lesion. 4. Enhancing right parietal scalp mass. Further evaluation with ultrasound study is recommended to exclude vascular etiology/ mass. -------------------- ECHO: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF 55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. No clinically significant valvular regurgitation or stenosis. Normal pulmonary artery systolic pressure. ------------------- LIVER ULTRASOUND: Increased liver echogenicity, compatible with fatty deposition. However, more advanced forms of liver disease such as fibrosis or cirrhosis cannot be excluded. No focal hepatic lesion is seen. ------------------- HEAD ULTRASOUND: Solid oval subcutaneous scalp mass with internal vascularity. This cannot be further characterized by ultrasonography. The appearance is not consistent with a cyst or hematoma, given the internal vascularity identified on Doppler. ------------------- MRI C SPINE: No cord compression; assessment for cord signal changes limited due to motion. ------------------- EEG: ABNORMALITY #1: Intermittent left mid-temporal theta and delta slowing is seen. BACKGROUND: Waking background is characterized by an 8-8.5 Hz alpha rhythm which attenuates symmetrically with eye opening. Symmetric [4-1] mcV beta activity is present, maximal over bilateral frontal regions. HYPERVENTILATION: Could not be performed due to patient's underlying medical condition. INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation from [12-21] flashes per second (fps) produces no activation of the record. SLEEP: The patient progresses to drowsiness and stage II sleep with centrally maximal theta and delta activity and symmetric sleep spindles and K complexes appear. CARDIAC MONITOR: A single EKG channel shows a generally regular rhythm with an average rate of 75-80 bpm. IMPRESSION: This is an abnormal routine EEG in the awake and asleep states due to the presence of intermittent left temporal slowing indicative of subcortical dysfunction in this region. No epileptiform discharges are present. Brief Hospital Course: HOSPITAL COURSE: This is a 52 year old lady with unknown PMHx who presents from OSH after an unwitnessed fall with hyponatremia. . HYPONATREMIA: Etiology felt to be multifactorial including hypovolemic hyponatremia in setting of emesis/diarrhea, excess of free water to solute intake exacerbated by recent illness and SIADH. Her initial sodium was 117 which improved to 122 w/ 2L NS likely improved by her correction of her hypovolemia. With further volume rescussitation in our ED, her subsequent sodium fell to 119 likely to inappropriate ADH secretion that became evident when her volume status was corrected. After volume restriction her sodium improved to 125 quickly. Further correction of her sodium was made difficult by aggressive k+ repletion in normal saline and lab draws off her PICC line. Ultimately with 1.5L free water restriction her sodium slowly corrected. She was briefly on d5 to slow correction. A TSH and cortisol were normal. . LOSS OF CONSICOUSNESS: Severe hyponatremia and physical exam findings of lacerated tongue concerning for seizure. She was actively withdrawing from etoh on arrival to the floor which could have further reduced her seizure threshold. However, no seizure was witessed and mechanical fall cannot be excluded. Per neurology recomendaitons a 20 minute EEG was performed and while some frontotemporal slowing was noted no epileptiform changes were observed. . HIGH DENSITY FOCUS: Noted along the septum pellucidum concerning for intraventricular hemorrhage on CT head from OSH. This was reviewed by neurosugery who felt this finding was tiny and likely represented a cyst. In the setting of persistent altered mental status, a repeat CT head was performed whhich again demonstrated this high denisty focus that appeared more dense and was concerning for a hematoma. Neurosurgery evaluated the imaging and recommended MRI w/ and w/out contrast which showed a right frontal white matter abnormality of unclear etiology, dural enhancement of unclear significance and a focal lesion in the right lateral ventricle adjacent to the septum pellucidum - likely hematoma. Neurology attending did not feel repeat MRI prior to discharge would be of value, and neurosurgery did not see role for surgical intervention. Patient was discharged with outpatient neurology follow up. LP was performed and cytology pending at the time of discharge. . ETOH USE: Per family history, she was drinking more than 6 glasses of wine per day. Serum etoh level prior to transfer negative. Last drink ~ days prior to admission. She was tremulous, anxious, disoriented, tachycardic and hypertensive on admission to the ICU. She was maintained on a CIWA scale w/ IV lorazepam. Her mental status improved by HD 4. She was treated empirically for Wernickes with IV thiamine given her profound delirium on admission. Social work was consulted and provided counseling though patient felt to be precontemplative. . ABNORMAL LIVER ENZYMES: Abnormal liver function enzymes in setting of chronic etoh use. AST/ALT ratio 2:1 c/w possible etoh hepatitis. A hepatitis panel was negative. Liver US showing increased liver echogenicity, compatible with fatty deposition. However, more advanced forms of liver disease such as fibrosis or cirrhosis cannot be excluded. Patient discharged with hepatology follow up. . MACROCYTOSIS: Chronic. Likely [12-24] chronic etoh abuse. She was repleted with IV thiamine and folate. B12 and Folate levels were normal. . THROMBOCYTPOENIA: Chornic. Likely [12-24] chronic etoh abuse. . TRANSITIONAL ISSUES: - Patient set up with [Company 191] PCP due to her preferance - Right upper lobe nodules and ground glass opacity is likely inflammatory, [1-26] month followup chest CT is recommended to document resolution - Follow-up brain MRI given intraventricular hematoma in right lateral ventricle. A follow-up MRI is recommended once hemorrhage resolves to assess for underlying lesion. - Liver and Neurology follow up scheduled prior to discharge - CSF cytology pending at the time of discharge. Medications on Admission: none Discharge Medications: 1. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg daily Disp #30 Tablet Refills:6 2. Multivitamins 1 TAB PO DAILY RX Daily Multi-Vitamin daily Disp #30 Tablet Refills:6 3. Nicotine Patch 14 mg TD DAILY RX nicotine 21 mg/24 hour (28)-14 mg/24 hour (14)-7 mg/24 hour (14) 1 patch daily Disp #1 Kit Refills:0 4. Thiamine 100 mg PO DAILY RX thiamine HCl 100 mg daily Disp #30 Tablet Refills:6 Discharge Disposition: Home Discharge Diagnosis: PRIMARY -SIADH -hyponatremia -encephalopathy -alcoholic hepatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted for evaluation of your altered mental status and required an admission to the intensive care unit. Your mental status was felt to be secondary to low sodium as a result of a process called SIADH. Your intake of water was limited to 1.5 L, your sodium corrected an your mental status improved. You also had an MRI of your brain which showed some changes of unclear significance. You had a study to measure your brain waves as well which was normal and showed no evidence of seizure. You will need to follow up with our neurologists and may need a repeat MRI in about a months time. You were also seen by our liver experts because of your alcohol use at home, an ultrasound showed that you might have developed chirrosis of the liver. You will need to follow up with our liver experts as well. It is extremely important that you quit drinking to prevent a recurrance of your altered mental status and prevent further damage to your liver. Given the complex nature of your medical care an appointment with a primary care doctor [First Name (Titles) ] [Last Name (Titles) 19379]d for you. The following changes were made to your medications: -START Folic acid 1 gm daily -START Thiamine 100 mg daily -START Multivitamin daily -START Nicotine patch 14 mg daily Followup Instructions: Department: [Hospital3 249] When: TUESDAY [2179-5-18] at 1:45 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 86580], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] North [Hospital ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] is your new physician in [Name9 (PRE) 191] and Dr. [Last Name (STitle) ] works closely with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [First Name3 (LF) ] both will be involved in your care. For insurance purposes please indicate Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] as your Primary Care Physician. Department: LIVER CENTER When: MONDAY [2179-6-14] at 9:30 AM With: [Name6 (MD) 1382] [Name8 (MD) 1383], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Please check with your [Company 25186] insurance to see if you are required to get a referral for this appointment. We are working on a follow up appointment for your hospitalization in Neurology with Dr. [First Name8 (NamePattern2) 9485] [Last Name (NamePattern1) ]. It is recommended you follow up within 1 month of discharge. The office will contact you with the appointment information. If you have not heard within a few business days please contact the office at [Telephone/Fax (1) 541*].	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71,534	170,940	53987	Discharge summary	report	Admission Date: [2136-5-1] Discharge Date: [2136-5-4] Date of Birth: [2077-5-31] Sex: F Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2265] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 58yo F with HTN presenting with 2 weeks of exertional chest pain and shortness of breath that recently began occuring at rest. She reported that the pain radiated to the jam and both shoulders. The episodes lasted approximatedly 5 mins. She was referred to the ED by her PCP for further evaluation. . She was observed overnight and underwent an ETT the following day during which she reported experiencing chest pains and was noted to have a 15 point drop in SBP, inferolateral STD and STE in avR/avL. She was given aspirin 325 mg and admitted for cardiac catheterization during which 2 nonoverlapping DES were placed in the proximal and mid LAD. She reportedly had mild chest pains following PCI, but was noted to have good flow without ECG changes. She was given Plavix and Integrilin was started for a plan of 12 hours. . On arrival to the floor, patient reported to her nurse that she felt the need to move her bowels and urinate. She then was noted to become bradycardic (30s) and hypotensive (SBP 60s). She was given atropine 0.5 mg. She then was noted to have no pulse and chest compression were initiated. She regained a pulse in ~1 minute and was noted to be HD stable (SBP > 100s, HRs 100s). . Early in the code, her groin was examined and felt to be wnl, however later she was noted to have fullness appreciated in the RLQ. Stat labs were sent and manual pressure was initiated on her right groin. She was transferred to the CCU and taken to CT, which was significant for evidence of an RP bleed. . While in the CCU, the patient has remained in NSR and hemodynamically stable. She remains chest pain free and is currently receiving pRBCs. Manual pressure continues to be held on her right groin. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: -CABG: Non -PERCUTANEOUS CORONARY INTERVENTIONS: 2 DES to LAD on [2136-5-2] -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -Hypertension) -Osteoarthritis, knee, bilat. -Spondylosis, cervical -GERD Social History: No t/a/d, originally from [Country 3992] Family History: +CAD, sister had PCI around age 55y. Physical Exam: VS: T 98.2 BP 104/62 HR 99 RR 13 O2 sat 99% on NRB, later 98% on RA. GENERAL: Tired appearing woman in mild distress from pain. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple. CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3/S4. LUNGS: No chest wall deformities, respirations unlabored. CTAB anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: Soft/ND, firmness in RLQ, very tender to palpation. No rebound or guarding. EXTREMITIES: No edema, right leg appears more red given active manual pressure on right femoral artery. PULSES: Right: Femoral 2+ DP/PT non dopplerable (manual pressure actively being held). Left: DP 2+ PT 2+ Pertinent Results: [2136-5-4] 07:10AM BLOOD WBC-5.7 RBC-4.39 Hgb-12.8 Hct-39.6 MCV-90 MCH-29.1 MCHC-32.3 RDW-12.7 Plt Ct-166 [2136-5-4] 07:10AM BLOOD Glucose-103* UreaN-9 Creat-0.4 Na-140 K-3.9 Cl-108 HCO3-27 AnGap-9 [5-3] ECHO The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The 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. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. [5-2] CT ABDOMEN CT OF THE ABDOMEN AND PELVIS WITH AND WITHOUT IV CONTRAST TECHNIQUE: Multidetector scanning is performed from the diaphragm through the symphysis prior to and during dynamic injection of 130 cc of Omnipaque. No prior studies are available for comparison. CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: The lung bases are clear. Only part of the liver is depicted; however, no focal liver lesions are noted. The gallbladder is unremarkable. The spleen is normal in size. The pancreas is unremarkable. The adrenal glands are normal. The kidneys are normal. There is no hydronephrosis. There is no retroperitoneal lymphadenopathy. Starting at the inferior pole of the right kidney, there is a retroperitoneal hematoma anterior to the iliopsoas muscle and extending down into the pelvis. On the arterial phase, there is no evidence for arterial extravasation of contrast. The small and large bowel are normal. CT OF THE PELVIS WITH AND WITHOUT IV CONTRAST: A Foley catheter is identified within the bladder. The bladder is compressed and displaced to the left side of the pelvis. There is a large retroperitoneal hematoma on the right side of the pelvis which pushes the uterus to the right. There is no free fluid in the pelvis. There is no evidence for active extravasation. On bone windows, there is a small sclerotic focus in the right femoral head. Degenerative changes of the lumbar spine are noted. CT ANGIOGRAPHY: The aorta is normal in caliber. There is mild narrowing of the SMA at its origin. The mesenteric vessels are patent. No active extravasation is identified. IMPRESSION: Large retroperitoneal hematoma extending from the inferior pole of the right kidney into the right hemipelvis. This displaces the uterus and bladder to the left. There is no evidence for active extravasation at this point. [5-2] CARDIAC CATH 1. Selective coronary angiography of this right dominant system demonstrated single vessel coronary disease. There was intiially vasospasm in the LMCA relieved by IC nitroglycerin. There was no significant LMCA disease. The LAD had a 30% ostial stenosis and tandem 60% stenoses in the mid LAD immediately distal to the origin of D1. There is a 60% long stenosis in D1. The LCX and RCA were patent. 2. Limited resting hemodynamics revealed normotension. 3. Positive pressure wire interrogation of the LAD with FFR 0.78 (see PTCA comments). 4. Successful PCI of the LAD with non-overlapping 3.0x12mm (distal) and 3.0x16mm (proximal) [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]-dilated to 3.25mm (see PTCA comments). 5. Successful right groin closure with 6F AngioSeal device. [5-2] EXERCISE STRESS This 58 year old woman with a history of HTN was referred to the lab from the ER following negative serial cardiac markers for evaluation of exertional chest discomfort with a similar episode at rest. The patient exercised for 6.5 and was stopped for a progressive drop in systolic BP with exercise. The peak estimated MET capacity was 7.5 which represents an average functional capacity for her age. At low level exercise, the patient noted right shoulder discomfort as well as epigastric discomfort that radiated up to her throat and a peak intensity of [5-8]. This was associated with 1.5 mm of horizontal/downsloping ST segment depression in the inferolateral leads with 1-1.[Street Address(2) 1755] elevation in aVR and aVL. The symptoms and ST changes resolved with rest by minutes 9 and 5 of recovery, respectively. The rhythm was sinus with no ectopy. Abnormal drop in systolic BP with increasing workloads. IMPRESSION: LV dysfunction with anginal type symptoms and ischemic EKG changes at a low cardiac demand and average functional capacity. The Duke score is -5 which has a moderate CV risk. The patient was given 1 325 mg ASA po and is being transferred to the cardiac cath lab for further evaluation. Brief Hospital Course: 58 yo F presenting with exertional chest pain, brought to cath lab for two nonoverlapping DES to LAD, postprocedure course complicated by bradycardia and asystole, found to have RP bleed on CT. . # STEMI She had initially presented to the ED with chest pains and was observed overnight. In the morning, she underwent exercise stress test and was noted to have chest pain with inferolateral ST depressions and ST elevations in avR/avL. She was brought to the cath lab and found to have single vessel disease. Stenting of the LAD was performed with non-overlapping 3.0x12mm (distal) and 3.0x16mm (proximal) [Name Prefix (Prefixes) ] [Last Name (Prefixes) ]-dilated to 3.25mm. Her groin was closed with Angioseal. She was then transferred to [Hospital Ward Name 121] 3 from the PACU. # Cardiac Arrest Shortly after her arrival to the floor, she reported to her nurse that she felt the need to move her bowels and urinate. She then was noted to become bradycardic (30s) and hypotensive (SBP 60s). She was given atropine 0.5 mg. She then was noted to have no pulse and chest compression were initiated. A Code Blue was called. She regained a pulse in ~1 minute and was noted to be HD stable (SBP > 100s, HRs 100s). # Retroperitoneal Bleed After she was stabilized hemodynmically, she was noted to have increased fullness in her RLQ. Manual pressure was applied to her cath site and she was brought immediately to CT scan. She was found to have a large retroperitoneal hematoma, without evidence of active extravasation. She was transferred the CCU and manual pressure was held for at least 90 minutes. She was transfused 3 units of PRBCs and her hematocrit remained stable. Her bleed was managed conservatively. She remained stable and was called out of the ICU then discharged home. # Chest pain She was noted to have significant chest pain, likely in the setting of her chest compressions. No further evidence of ischemia was found on repeat ECGs. Medications on Admission: Losartan 25 mg po daily Omeprazole 20 mg po daily Calcium Carbonate-Vitamin D3 600 mg(1,500mg) -400 unit po qday. Mom[Name (NI) 6474] (NASONEX) 50 mcg 2 sprays each nostril daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating. Disp:qs Tablet, Chewable(s) Refills:0 3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain for 1 weeks. Disp:qs Tablet(s) Refills:0 4. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 9. hydrocodone-acetaminophen 5-500 mg Capsule Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain for 1 weeks: Do not drive or operate heavy machinery while taking this medication. Disp:qs Tablet(s) Refills:0 10. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Coronary artery disease Retroperitoneal bleed causing bradycardia, hypotension, and brief cardiac arrest Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for blockages in your arteries putting you at high risk of a heart attack. You had a procedure to open up the blocked arteries, called a cardiac catheterization, and the placement of a stent which helps keep the arteries open. You will need to take multiple new medications and follow-up closely with your PCP and cardiologist to prevent complications. . You also had a low blood pressure and heart rate after the procedure, which was caused by bleeding into your belly. During this time we had to perform chest compressions to keep your heart pumping until we were able to give you medicines and fluids and help your heart start pumping sufficiently on its own. Because of this, you will have some chest discomfort for at least a week or so, and you should take the prescribed medications. Please return to the hospital immediately if you develop any bleeding, and light-headedness, pass out, or if you stop being able to urinate. . Please note the following medication changes: -Please START Asprin daily to help keep your stent open -Please START Plavix 75mg daily to help keep your stent open -Please START Simvastatin to lower your cholesterol -Please START metoprolol to help with your heart rate -Please START Pantoprazole to help with your reflux -Please START Simethicone as needed for bloating/gas pain -Please START Tramadol as needed for pain -Please START Vicodin as needed for pain . -Please STOP Omeprazole (replaced by pantoprazole) . -Please continue your other medications as previously prescribed Followup Instructions: *We are working to schedule you a follow-up appointment with a Cardiologist. If you do not hear about this appointment within 1-2 days of discharge, please call [Telephone/Fax (1) 2258] to confirm the time. . Name: [First Name4 (NamePattern1) 636] [Last Name (NamePattern1) 110694], NP (works with Dr [Last Name (STitle) 61187] Location: [Location (un) 2274]-[Hospital1 ], Primary Care Address: [Location (un) 17467], [Hospital1 ],[Numeric Identifier 20089] Phone: [Telephone/Fax (1) 68410] Appt: [5-8] at 3:20pm [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2273**]	[ "V17.3", "E879.0", "721.0", "427.5", "998.11", "410.21", "715.36", "458.9", "530.81", "786.59", "998.12", "414.01", "780.52", "401.9", "477.9", "997.1", "733.90" ]	icd9cm	[ [ [] ] ]	[ "88.56", "00.46", "36.07", "00.40", "37.22", "99.60", "99.20", "00.66" ]	icd9pcs	[ [ [] ] ]	11610, 11616	8058, 10019	300, 326	11765, 11765	3307, 8035	13477, 14151	2457, 2495		10253, 11587		11637, 11744		10045, 10230			11916, 12897									2510, 3288		2175, 2273															12917, 13454		250, 262									354, 2062										11780, 11892	2304, 2379					2084, 2155	2395, 2441
11,342	169,487	49014	Discharge summary	report	Admission Date: [2176-8-25] Discharge Date: [2176-9-6] Date of Birth: [2130-4-3] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Rifaximin Attending:[First Name3 (LF) 1148] Chief Complaint: Melena and coffee ground emesis. Major Surgical or Invasive Procedure: Revision of TIPS Embolization of duodenal varix EGD Intubated Bronchoscopy History of Present Illness: 46 year old female with a history of alcohol and HCV cirrhosis, esophageal and duodenal varices, multiple GI bleeds, status post TIPS. Recently admitted on [8-9] with hematemesis and melena. Per report, on day of admission [8-25], the patient had originally experienced episodes of vomiting "coffee ground" material, which was preceded by abdominal pain. When found by EMS, she was in bed dry heaving, having dark color diarrhea, and only oriented to name. In ED, she was intubated for airway protection and transferred to the ICU. She underwent EGD, which revealed a large duodenal varix as culprit, that was unable to be banded or injected. She then underwent embolization, followed by TIPS revision. Her Hct was stable afterwards. She was also noted to be difficult to wean off the ventilator, and was noted on bronchoscopy to have a pneumonia that was likely secondary to aspiration. She was treated for 7 days with vancomycin and aztreonam. When she was transfered to CC-7 from the MICU on [9-3] she was being actively diuresed. Past Medical History: Cirrhosis -Heavy ETOH abuse, +HCV (viral load undetectable), c/b coagulopathy/thrombocytopenia, elevated portal pressures with varices and portal gastropathy s/p TIPS [6-13] Early Celiac sprue dx on Bx EGD [4-13] however not on diet since has no symptoms according to patient Chronic LE neuropathy Diastolic CHF a. last echo in [1-15], PASP 28, EF >55% b. ETT/MIBI: [12-13], no ischemic regions Anemia: Baseline Hct ~30, chronic blood loss, ?sprue Asthma Depression Osteopenia Hypothyroidism s/p CCY for cholelithiasis TAH for endometrial hyperplasia Mild COPD GERD Social History: Lives with husband and 29 year old son. Heavy etoh abuse in the past, but last drink occurred on [2176-3-9], per patient. History of positive screens in past. Stopped tobacco on "day of admission ([2176-8-25])", per patient. 1 ppd x 30 years. No IVDU. Family History: Father died of MI in 80's. Many alcoholics in family. One cousin with celiac sprue. Physical Exam: Physical Exam (on admission to medical floor [9-3]). . Vitals: T:98.6, BP:102/60, HR:73, RR:20, RR:93% Room air General: No acute distress. Patient examined and laying comfortably in bed. Denies fever, chest pain, abdominal pain, nausea, and vomiting. HEENT: Mild scleral icterus. No phrenular icterus. Poor dentition. Moist mucous membranes. Neck: Supple. No cervical adenopathy. Lungs: Clear to auscultation, bilaterally. Slightly decreased breath sounds in lower lung fields. Cardiac: Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops. Abd: Surgical scar. Soft. Active bowel sounds throughout. Nontender and nondistended. Ext: Minimal dorsal feet edema. Nonpitting. 2+ bilateral DP and radial pulses, bilaterally. Skin: Multiple telangiectasias on chest. No palmar erythema. Ecchymosis on left wrist. Neuro: Alert and oriented to person, place, and date. Mildly confused during questioning, but could relate current president. Asterixis. Pertinent Results: [2176-9-5] 04:48PM BLOOD WBC-7.6 RBC-2.89 Hgb-9.2* Hct-26.6* MCV-92 MCH-31.9 MCHC-34.7 RDW-17.7* Plt Ct-95* [2176-8-30] 03:52AM BLOOD WBC-4.7 RBC-3.10* Hgb-9.8* Hct-28.7* MCV-93 MCH-31.7 MCHC-34.2 RDW-17.3* Plt Ct-54* [2176-8-27] 04:27AM BLOOD WBC-8.7 RBC-3.29* Hgb-10.3* Hct-29.2* MCV-89 MCH-31.2 MCHC-35.2* RDW-16.2* Plt Ct-56* [2176-8-26] 02:54AM BLOOD WBC-10.5 RBC-2.72* Hgb-8.7* Hct-24.5* MCV-90 MCH-32.1* MCHC-35.6* RDW-15.7* Plt Ct-89# [2176-8-25] 09:22PM BLOOD WBC-17.5# RBC-2.70* Hgb-8.5* Hct-24.1* MCV-89 MCH-31.3 MCHC-35.1* RDW-16.5* Plt Ct-216# [2176-8-25] 09:00PM BLOOD WBC-15.8# RBC-2.45# Hgb-7.7* Hct-21.8# MCV-89 MCH-31.2 MCHC-35.1 RDW-16.4* Plt Ct-196# [2176-9-5] 04:48PM BLOOD Plt Ct-95* [2176-9-5] 04:48PM BLOOD PT-17.6* PTT-32.9 INR(PT)-1.6* [2176-8-25] 09:00PM BLOOD PT-22.9* PTT-44.5* INR(PT)-2.3* [2176-8-27] 11:48AM BLOOD Fibrino-277 [2176-8-26] 02:54AM BLOOD Fibrino-188 [2176-9-5] 04:48PM BLOOD Glucose-88 UreaN-11 Creat-0.7 Na-142 K-4.2 Cl-109* HCO3-24 AnGap-13 [2176-8-25] 09:00PM BLOOD Glucose-261* UreaN-77* Creat-1.2* Na-138 K-4.1 Cl-92* HCO3-24 AnGap-26* [2176-9-3] 04:52AM BLOOD ALT-23 AST-37 LD(LDH)-179 AlkPhos-56 Amylase-9 TotBili-3.4* [2176-8-25] 09:00PM BLOOD ALT-24 AST-69* CK(CPK)-52 AlkPhos-78 Amylase-20 TotBili-3.9* [2176-9-3] 04:52AM BLOOD Lipase-15 [2176-9-5] 04:48PM BLOOD Calcium-8.4 Phos-2.2* Mg-1.9 [2176-8-25] 09:00PM BLOOD Albumin-3.6 Calcium-8.9 Phos-5.5# Mg-1.5 [2176-9-4] 05:49AM BLOOD Cortsol-5.3 [2176-8-26] 11:39AM BLOOD Cortsol-0.9* [2176-9-2] 01:09PM BLOOD Type-ART pO2-93 pCO2-40 pH-7.50* calTCO2-32* Base XS-6 [2176-8-26] 09:43AM BLOOD Type-ART Temp-37.3 Rates-/16 Tidal V-890 FiO2-50 pO2-81* pCO2-45 pH-7.43 calTCO2-31* Base XS-4 Intubat-INTUBATED Vent-SPONTANEOU [2176-8-25] 09:44PM BLOOD Glucose-267* Lactate-8.3* [2176-8-26] 03:18AM BLOOD Lactate-2.5* . Urine culture: No growth. Negative for legionella. Blood Cultures: No growth. Sputum: Pending. . [2176-9-1] 08:40PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.022 [2176-9-1] 08:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR . STUDIES: ENDOSCOPY [8-26]: Varices at the lower third of the esophagus. Congestion and erythema in the antrum; stomach body and fundus compatible with gastroapathy. Erythema and friability in the first part of the duodenum compatible with duodenitis. Varices at the second part of the duodenum. . HEAD CT [8-26]: No evidence of acute intracranial process. Widespread sinus opacification. However, this could be seen in intubation. Subcutaneous left parietal nodule, unchanged. It measures 13 mm in diameter and may represent a sebaceous cyst. . BRONCHOSCOPY [8-28]: INDICATION: Respiratory failure with left-sided atelectasis,hypoxemia, lack of chest rise on the left. NOTED: The airways were examined to the subsegmental level bilaterally and there were no endobronchial lesions seen. The right side was within normal limits, however, the left side was completely obstructed by tenacious and copious thick secretions which were therapeutically aspirated. Subsequent to the bronchoscopy, the airways on the left side were patent and the patient had good chest rise on the left. Brief Hospital Course: A/P: 46 year old female with alcohol and questionable HCV cirrhosis and portal hypertension, admitted for variceal bleed and status post TIPS revision and varix embolization. Stable hematocrit over the past several days. . 1) GI Bleed: -Emergent EGD on [8-26] revealed grade 1 varices in distal [12-12] of esophagus that were not bleeding; portal gastropathy was noted. The protruding second part of the duodenum showed stigmata of recent bleed. The varix was smaller than on prior EGD, consistent with recent embolization. No bleeding was visualized so no intervention was performed. Despite no evidence of bleed, hematocrit fell from 31 on [8-23] to 21 on [8-25]. Patient was continued on octreotide gtt and protonix gtt; she also received 6 units packed RBCs and 6 units FFP. - On [6-18] the patient's pre-TIPS gradient was 13mmHg and post-TIPS gradient was 9mmHg. On [8-28] patient underwent TIPS revision and repeat embolization. If patient rebleeds, then injection of glue (experimental) will be considered. Once transferred from the MICU, she continued proton pump inhibitor, [Hospital1 ]. Her hematocrit stayed stable in high 20's (nadir was 20-21 during acute GI bleed). . 2) End stage liver disease: -Etiology likely from alcoholic or HCV cirrhosis. Patient was followed by GI and liver teams throughout her hospital stay. She received lactulose, rifamixin and spironolactone during hospital stay; she was discharged on these medications. The patient has no history of SBP, so prophylaxis was not restarted. She was maintained on low dose nadolol 10mg. She will follow up with Dr. [Last Name (STitle) 497] on [2176-9-13]. . 3) Hypokalemia: [Hospital ] transferred from ICU and noted to have hypokalemia, probably secondary to diuresis. Lasix and sliding scale insulin were discontinued, but she remained on spironolactone. By the time of discharge, her potassium was in the range of 3.5-4.0. She was not discharged with any potassium supplementation due to concern for hyperkalemia on spironolactone. Patient was instructed to return to [Hospital Ward Name 23] [Location (un) ] for follow up electrolyte blood work on [9-9] at Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] office. . 4) Hypoxemia: -Bronchoscopy revealed and therapeutically aspirated left mainstem mucous plugs, presumed to be the result of pneumonia secondary to aspiration. Patient was treated with 7 day course of vancomycin and aztreonam. Patient was slowly weaned off the ventilator on [9-2]. A series of CXRs showed mild interstitial edema, moderate right and small left pleural effusion which worsened minimally and a left lower lobe atelectasis that improved. Patient had persistent pleural effusions but was aggressively diuresed. On discharge, she did not require supplemental oxygenation to maintain an oxygen saturation in the mid 90's. . 5) Hypotension: -While in the ICU the patient's SBP fell to 80-90's on [8-26], so she received 3L IVF. There was initial concern for sepsis, so patient was started on a seven day-course vancomycin, aztreonam and flagyl for presumed aspiration pneumonia (stopped on [9-2]). There was also concern about adrenal insufficiency (see below). Patient initially required levophed for pressure support, but was weaned off pressors, as she was stable following blood product and IVF bolus infusions. On [9-5] she was started on nadolol 10mg for her portal hypertension, had some SPB's in high 80's/low 90's. Orthostatics were normal. Was discharged with week's worth of nadolol with instructions to follow up with Dr. [Last Name (STitle) 497] on [2176-9-13]. . 6) Adrenal insufficiency: -Patient had a cortisol 0.9 on admission to the ICU, but increased to 6 with ACTH. This prompted a questioned underlying adrenal insufficiency given her low level on admission and patient received a week's course of hydrocortisone 50mg (finished [9-3]). Repeat cortisol level on [9-6] was 10.3. Patient should have a repeat cortisol stimulation test at PCP visit on [2176-9-13] to assess adrenal function in non-stress situation and after a period since finishing steroid course. . 7) Neuropathy: -Gabapentin was initially held due to concern for renal clearance but was restarted once the patient left the ICU. . 8) Hypothyroidism: -Patient continued with her levothyroxine treatment throughout her hospital course. . 9) FEN: -Due to concern for her volume overload and early celiac disease, patient was discharged with instructions to follow low-salt and gluten free diet. Medications on Admission: Medications at last discharge ([8-3]): 1. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 2. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. 2. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Month/Year (2) ]:30 Tablet(s) Refills:2 3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). [Month/Year (2) ]:180 Tablet(s) Refills:2 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Month/Year (2) ]:30 Tablet(s) Refills:2 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [Month/Year (2) ]:60 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. [Month/Year (2) ]:30 Tablet(s) Refills:0 7. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). [Month/Year (2) ]:30 Patch 24HR(s) Refills:2 8. Gabapentin 300 mg Tablet Sig: Three (3) Capsule PO TID (3 times a day). [Month/Year (2) ]:270 Capsule(s) Refills:2 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): Hold if having three regular bowel movements each day. [Month/Year (2) ]:2700 ML(s) Refills:2 10. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). [Month/Year (2) ]:14 Tablet(s) Refills:0 11. Outpatient Lab Work Please have blood work drawn on Monday, [9-9]. Have basic metabolic panel drawn. Please fax results to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] office. Thank you. Discharge Disposition: Home Discharge Diagnosis: Primary: Duodenal Varix Bleed Alcohol induced Cirrhosis Delirium Aspiration Pneumonia . Secondary: Adrenal Insufficiency? Hypothyroidism Neuropathy Diastolic CHF Asthma Depression Osteopenia Early celiac disease Discharge Condition: Stable Discharge Instructions: You have been admitted for a GI bleed. You were treated and the bleed was stabilized. While in the ICU, you developed an aspiration pneumonia, so you received antibiotics. Your cirrhosis also was treated. When you go home, you need to take all medications that are prescribed. You should remain on a gluten-free and sodium free diet, as recommended by GI. You have an outpatient appointment with Dr. [Last Name (STitle) 497] and Dr. [Name (NI) 102885] resident, [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], on Friday, [9-13] at 1pm and 2:30pm. If you develop any light headedness, dizziness, difficulty concentrating, vomiting, bleeding from your rectum, or any other concerning symptoms, please call your doctor immediately or go to the nearest ED. You have been provided a "prescription" to have your blood drawn on Monday [2176-9-9] at the [Hospital Ward Name 23] Building. The results will be sent to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] office. In addition, you will need to contact the patient assistance program ([Telephone/Fax (1) ]) in the next to weeks to try and have the rifaximin prescription subsidized. Followup Instructions: You are scheduled for an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 497] at 1:00 pm on Friday, [9-13]. [Last Name (NamePattern1) 439], [Location (un) 858]. You have an appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] office at 2:30pm on Friday [2176-9-13]. You will have blood work drawn on Monday, [2176-9-9**].	[ "572.3", "934.1", "303.93", "070.71", "285.1", "456.8", "570", "785.59", "578.0", "E912", "995.92", "518.81", "286.7", "507.0", "356.9", "579.0", "038.9", "496", "571.2", "244.9", "428.30", "578.1", "276.8", "255.4" ]	icd9cm	[ [ [] ] ]	[ "96.72", "45.13", "00.40", "88.64", "33.24", "44.44", "39.50", "99.04", "96.6", "00.17", "00.45", "99.07", "38.93", "96.04", "39.90", "96.34" ]	icd9pcs	[ [ [] ] ]	13624, 13630	6867, 11486	325, 401	13886, 13895	3509, 6844	15159, 15577	2403, 2489		12054, 13601		13651, 13865		11512, 12031			13919, 15136									2504, 3490																			253, 287									429, 1480																1502, 2110	2126, 2387
14,535	162,571	22993	Discharge summary	report	Admission Date: [2148-3-7] Discharge Date: [2148-3-13] Date of Birth: [2072-7-22] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: Asymptomatic w/ Mitral Valve Prolapse Major Surgical or Invasive Procedure: Mitral valve replacement with a 25 mm CE pericardial valve History of Present Illness: 75 y/o female w/ h/o MVP. Recent Echo ([12-8]) showed decreased EF and severe MR [First Name (Titles) 6643] [Last Name (Titles) 59337] cardiac surgery consult. Past Medical History: MVP/MR HTN ^Chol Osteoporosis OA Diverticulosis Cataracts s/p removal s/p bilat ovary removal Social History: Pt. is retired and lives with husband. Quit smoking in [2103] after <10 pk yr hx. Rare ETOH use. Family History: Sister w/ "heart problems" requiring multiple surgeries starting at age 20. Physical Exam: VS: Ht: 4'[53]" Wt: 114 HR: 74 BP: 138/80 General: Walked into office in NAD HEENT: PERRLA, EOMI Neck: supple, +carotid bruits Chest: Fine rales at bilat. bases Heart: RRR, 4/6 SEM loudest at base with radiation to carotids & axilla Abd: soft, NT/ND, +BS Ext: Warm, well-perfused, - edema, RLE varicosities Neuro: A&O x 3 Pertinent Results: Pre-op CXR: Cardiomegaly without vascular congestion. Pre-op EKG: Sinus rhythm (62). Modest diffuse non-specific ST-T wave changes. Pre-op UA: Negative [2148-3-7] 05:08PM BLOOD Hct-32.9* [2148-3-8] 03:16AM BLOOD WBC-17.7# RBC-3.66 Hgb-10.6* Hct-31.5* MCV-86 MCH-29.0 MCHC-33.7 RDW-14.4 Plt Ct-209# [2148-3-12] 05:40AM BLOOD WBC-4.8 RBC-3.17* Hgb-9.2* Hct-27.7* MCV-87 MCH-29.0 MCHC-33.2 RDW-14.3 Plt Ct-193 [2148-3-7] 04:57PM BLOOD PT-19.2* PTT-38.6* INR(PT)-2.3 [2148-3-12] 05:40AM BLOOD Plt Ct-193 [2148-3-13] 07:01AM BLOOD PT-18.9* INR(PT)-2.3 [2148-3-7] 05:08PM BLOOD UreaN-9 Creat-0.4 Cl-111* HCO3-24 [2148-3-12] 05:40AM BLOOD Glucose-100 UreaN-8 Creat-0.5 Na-138 K-4.2 Cl-104 HCO3-30* AnGap-8 Brief Hospital Course: Pt. was a same day admit to the operating room. She was brought to the OR and after general anesthesia pt. underwent a mitral valve replcement for severe MR/MVP. Please see operative note for full surgical details. Pt. tolerated the procedure well with a total CPB time of 115 minutes and XCT of 94 minutes. Pt. was transferred to CSRU in stable condition with a MAP of 76, CVP 13, PAD 16, [Doctor First Name 1052] 23, HR 77 A-paced and being titrated on neosynephrine and propofol drips. That night pt. suddenly went into V. Fib. arrest and was quickly converted with electric cardioversion. A lidocaine bolus and Iv drip were also started. Pt. remained sedated and intubated overnight. POD #1 - Pt. was in NSR and Propofol was weaned early morning and pt. became awake and alert. She was then extubated, breathing well and neurologically intact. Lidocaine was d/c'd and lopressor and lasix was started. POD #2 - Remained in the ICU secondary to Neo support. HR sinus in 50-60s (paced in 80s). Chest Tubes & Foley removed. Coumadin Started. POD #3 - Pt. had run of A.Fib/A. Flutter in AM. Back in SR after lopressor. POD #4 - Pt. had another brief run of A. flutter and self converted. She is stable and was trnaferred to [Hospital Ward Name 121] 2 today. POD #5 - Pacing wires removed. Pt. hemodynam. stable. Encouraged pt to continue PT and increase activity. POD #6 - Pt. at level 5. Doing well with some complications post-op. D'C'd home today with VNA. D/C PE: VS: T 97.7 P 83 SR BP 125/53 RR 18 Neuro: alert, oriented, non-focal Pulm: CTAB Cardiac: RRR Sternum: stable, incision c&d, -drainage/erythema Abd: soft, NT/ND +BS Ext: Warm, 1+ edema Medications on Admission: 1. Lipitor 10mg qd 2. Atenolol 50 mg qd 3. Diovan 80 mg qd 4. Fosamax 70 mg qweekly 5. ASA 81 mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Warfarin Sodium 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): target INR 2-2.5 Pt to take 3mg [3-13] and [3-14] then as directed by Dr [Last Name (STitle) 40797]. Coumadin x 3 month. Disp:75 Tablet(s) Refills:0 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week. 8. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO four times a day. Discharge Disposition: Home With Service Facility: All Care VNA Discharge Diagnosis: Severe Mitral Regurgitation & Mitral valve prolapse, s/p mitral valve replacement with a 25 mm CE pericardial valve. HTN ^Chol Osteoporosis OA Diverticulosis Cataracts s/p removal s/p bilat ovary removal Discharge Condition: Stable. Discharge Instructions: Shower daily and wash incisions with soap and water; rinse well. Do not apply ANY creams, lotions, powders, or ointments. No swimming or bathing in a tub. No driving for 6 weeks. No heavy lifting, greater tahn 10 pounds. Followup Instructions: Schedule appointment with Dr. [Last Name (STitle) ] in 4 weeks. Schedule appointment with Dr. [Last Name (STitle) 59338] in 4 weeks. Schedule appointment with Dr [Last Name (STitle) 40797] in [2-9] weeks. VNA to call Dr [Last Name (STitle) 40797] with INR results [3-15] and [3-18] Completed by:[2148-3-13]	[ "427.5", "V45.77", "997.1", "272.0", "401.9", "V58.61", "424.0", "733.00", "715.90", "V45.61", "E878.4", "V15.82", "427.32", "427.31" ]	icd9cm	[ [ [] ] ]	[ "35.23", "89.68", "99.62", "39.64", "39.61", "99.04" ]	icd9pcs	[ [ [] ] ]	4846, 4889	2023, 3683	315, 375	5137, 5146	1265, 2000	5415, 5756	827, 904		3833, 4823		4910, 5116		3709, 3810			5170, 5392									919, 1246																			238, 277									403, 576																598, 693	709, 811
822	101,322	48293	Discharge summary	report	Admission Date: [2182-2-14] Discharge Date: [2182-2-19] Date of Birth: [2145-10-30] Sex: M Service: MEDICINE Allergies: Bactrim DS / Levaquin / Vancomycin Hcl / Dilantin Kapseal / Keflex / Ciprofloxacin / Baclofen Attending:[First Name3 (LF) 1990] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: intubation History of Present Illness: 36 yo M with h/o T12 paraplegia, CKD, and polysubstance abuse who presents with altered mental status and overdose. Per history from his mother, blood pressures had been running 150s-160s at home on his new dose of amlodipine 7.5 mg PO daily prescribed by his PCP [Last Name (NamePattern4) ] 12/[2181]. She also reported that he was slightly more depressed than usual and had not been going out as frequently. Patient was in his usual state of health today until after he ate dinner. His mother heard gurgling and went to his room and subsequently found him with acutely altered mental status, gurgling and moaning, very angry, but able to name the president. Mother reports that his previous declines from UTIs have been similar in their acuity. She called EMS to take him to the ED. Pt received Narcan 2 mg IM x1 prior to arrival at ED with little change in mental status. Pinpoint pupils noted. Per previous discharge summaries, patient has been positive on toxicology screens for benzos, opiates, and cocaine in the past. Per mother, metoprolol is available at home, but she keeps it locked up. . In the ED, VS were 96.4 48 177/104 100% on NRB Labs sig for initial FS of 130, lactate of 2.0, trop-T of < 0.01, WBC of 11.5, and normal LFTs. Toxicology screen positive for benzos, opiates, and cocaine. Patient triggered for altered mental status and was intubated for altered mental status (described as yelling garbled, unintepretable sounds) with Rocuronium and Etomidate (succinylcholine not used as can prolong effects of cocaine if used for intubation). Patient also received Atropine 1 mg IV x1, and Cefepime/Linezolid for broad UTI/meningitis coverage. LP could not be performed b/c patient has rods in his back and would require an IR guided LP. CXR negative for aspiration event, Head CT negative for acute intracranial bleed. Cardiology and toxicology were consulted. EKG with junctional bradycardia. Cardiology thought no need for pacer given lack of hypotension. Toxicology thought this could appear to be a mixed ingestion, but did not think it was a beta-blocker or CCB overdose, recommended serial FS, supportive care, and did not recommend glucagon at this time. VS on transfer were: [Telephone/Fax (2) 101746] 100% on AC FiO2 40% 500 x 15 PEEP 5. . On the floor, patient is intubated and sedated. IV hydralazine 10 mg x1 was given with good effect on his blood pressure and heart rate (HR up to 55, SBP down to 150/80). Past Medical History: - T12 paraplegia secondary to MVA in [2165] - chronic kidney disease, with baseline creatinine of [2-28] - history of MRSA decubitus ulcers - chronic indwelling foley - recurrent urinary tract infections growing pseudomonas, e. coli, and enterococcus - seizure disorder (last episode in [2176]) - history of c. diff colitis - osteomyelitis in the right hip - chronic back pain - anxiety Social History: As per prior discharge summary, patient lives with his mother, who is primary caretaker. [Name (NI) ] a girlfriend, with whom he always stays. Unemployed. Former heavy alcohol use, quit over 1.5 years prior. Occasional prior marijuana. No tobacco use. No other illicits. Cocaine positive on toxicology screens in the past admissions. Family History: Maternal great aunt: DM. Maternal uncle: colon cancer. HTN. Physical Exam: Initial exam: VS: [Telephone/Fax (2) 101747] 100% on AC 500 x 16 FiO2 40% PEEP 5 GA: intubated; biting at tube and fighting restraints; intermittently following commands (squeezing hand) HEENT: pinpoint pupils minimally reactive to light CARDIAC: bradycardic. no m/g/r PULM: CTAB no wheezes GI: soft +BS no g/rt GU: foley Neuro: intermittenly following commands; 2+ reflexes bilaterally (biceps, achilles,plantar); babinski's downgoing BL. EXTREMITIES: wwp, +dry skin and warm, pulses 2+, bounding; moving all extremities with excellent grip strength bilaterally Discharge: VS: 99.5 126/100 80 18 100% RA GA: NAD HEENT: NCAT, PERRLA CARDIAC: RRR, nl s1s2 no m/g/r PULM: CTAB no wheezes GI: soft +BS no g/rt GU: foley in place EXTREMITIES: wwp, pulses 2+ Pertinent Results: Admission labs: [2182-2-14] 09:46PM LACTATE-2.0 [2182-2-14] 08:34PM GLUCOSE-117* UREA N-22* CREAT-2.9* SODIUM-140 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-22 ANION GAP-18 [2182-2-14] 08:34PM ALT(SGPT)-14 AST(SGOT)-24 CK(CPK)-88 ALK PHOS-107 TOT BILI-0.3 [2182-2-14] 08:34PM LIPASE-54 [2182-2-14] 08:34PM cTropnT-<0.01 [2182-2-14] 08:34PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [2182-2-14] 08:34PM WBC-11.5* RBC-5.27# HGB-15.7 HCT-45.4 MCV-86 MCH-29.8 MCHC-34.6 RDW-13.6 [2182-2-14] 08:34PM NEUTS-67.1 LYMPHS-26.5 MONOS-3.3 EOS-2.3 BASOS-0.7 [2182-2-14] 08:34PM PLT COUNT-259 [2182-2-14] 08:34PM PT-13.5* PTT-31.5 INR(PT)-1.2* [2182-2-14] 08:16PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG [2182-2-14] 08:16PM URINE BLOOD-TR NITRITE-POS PROTEIN-75 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD Discharge labs: [2182-2-19] 06:10AM BLOOD WBC-7.0 RBC-4.55* Hgb-13.5* Hct-40.5 MCV-89 MCH-29.6 MCHC-33.2 RDW-13.6 Plt Ct-212 [2182-2-19] 06:10AM BLOOD Plt Ct-212 [2182-2-19] 06:10AM BLOOD Glucose-94 UreaN-30* Creat-2.3* Na-139 K-4.9 Cl-106 HCO3-25 AnGap-13 [2182-2-15] 05:31AM BLOOD CK(CPK)-50 [2182-2-16] 08:53PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG Micro: [2182-2-16] 8:53 pm URINE Source: Catheter. FINAL REPORT [2182-2-18] URINE CULTURE (Final [2182-2-18]): NO GROWTH. [2182-2-14] 8:27 pm URINE Site: NOT SPECIFIED FINAL REPORT [2182-2-16] URINE CULTURE (Final [2182-2-16]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. Imaging: Head CT ([2182-2-14]) - no acute intracranial process Renal u/s: 1. No renal obstruction or son[Name (NI) 493] findings of pyelonephritis/renal abscess. 2. Unchanged thickened bladder likely related to underlying neurogenic bladder. Brief Hospital Course: 36 yo M with T12 paraplegia, CKD, and polysubstance abuse who presents with altered mental status and overdose. . # Altered mental status: Patient admitted to the MICU with altered mental status, likely in the setting of toxic/metabolic etiology such as medication/drug overdose. Ct head showed no acute process. Patient with positive toxicology screens for opiates, benzos, and cocaine (and has been in past admission as well), and is only medically prescribed oxycodone, percocet, and klonopin. Of note, Oxycodone should only show up in GC/MS toxicology send-out, not in the first pass urine toxicology screen peformed in the ED, indicating patient may have been taking other narcotics other than his prescribed oxycodone. Per toxicology, symptoms are not consistent with a pure toxidrome, therefore there are likely multiple substances on board. Psychiatry was consulted, and they felt that patient was not actively suicidal, that this overdose was a mistake. He was given an outpatient psychiatry referral and was also provided with substance abuse resources by social work. . # Respiratory Failure: Intubated for airway protection in the setting of altered mental status. CXR appears clear and shows no evidence of PNA or aspiration. Excellent oxygenation noted on admission ABG. Pt was successfully extubated on HD #2. . # Bradycardia: EKG demonstrates sinus bradycardia and with a junctional rhythm. No evidence of hypotension. [Month (only) 116] be combined ingestion of benzos/opiates resulting in bradycardia. Definite concern for [Location (un) ] Reflex in the setting of hypertension, as pt's HR improved with lowering of blood pressure with hydralazine. Discussed with cardiology unofficially, no pacer currently required for bradycardia given no evidence of hypotension. Bradycardia improved over the course of his MICU stay, no events of bradycardia on the floor. Was monitored on tele. # Hypertension: Likely in setting of cocaine overdose versus medication non-compliance. Has hypertension with baseline SBPs in 150s as outpatient, so well above his current baseline. Likely non-compliant with home medications as well. Treated as hypertensive emergency given altered mental status with IV hydralazine 5 mg IV q6H goal SBP > 150. B-blockers were held in the MICU given concern for cocaine use. Was restarted on amlodipine (home medication) while on medical floor with improvement in BP, did not require any PRN. . # Possible Overdose: Patient with positive toxicology screen, history of polysubstance abuse and positive tox screens for opiates, benzos, and cocaine in the past. Per mother, patient has been more depressed recently. Seen by psychiatry as soon as he was extubated; they felt that there was no acute danger of suicide. Pt was also seen by social work in the MICU. . #. Chronic Kidney Disease: baseline Cre at 2.9. Medications were renally dosed. . # ?UTI: pt with UA suggestive UTI on admission, also with altered mental status c/w prior UTIs so was initially started on cefepime. Urine culture came back no growth, a repeat UA was checked which also was c/w UTI (however pt with chronic foley), no growth on cx. Pt with flank pain (not tenderness; pt without sensation below T12) and possible UTI, so renal u/s was done to r/o abscess, pyelo, which was negative. Cefepime was dc'ed after 5 days, was given a 2 day course of nitrofurantoin (allergies to keflex, bactrim, cipro) to complete total 7 day course. He will f/u with PCP. . #. Seizure disorder: continued Keppra (dosed IV while NPO). Medications on Admission: 1. Docusate sodium 100 mg po BID 2. Senna 8.6 mg po BID 3. Bisacodyl 10 mg PR qhs prn constipation 4. Levetiracetam 500 mg po BID 5. Tolterodine 2 mg po prn bladder spasms 6. Pantoprazole 40 mg po BID 7. Oxycodone 60 mg SR po q8 8. Clonazepam 1 mg po qhs 9. Ferrous sulfate 300 mg po BID 10. Sevelamer HCl 800 mg po TID with meals 11. Ambien 5 mg 1-2 tablets po qhs prn insomnia 12. fluticasone 50 mcg/Actuation Spray one inhalations [Hospital1 ] 13. Oxycodone-acetaminophen 5-325 mg po q4 prn pain 15. Amlodipine 7.5 mg PO daily (started [12/2181] by PCP) 16. Renagel Discharge Medications: 1. amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. tolterodine 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for bladder spasm. 5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed for constipation. 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 9. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 10. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 11. sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three times a day. 12. Ambien 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. 13. fluticasone 50 mcg/Actuation Disk with Device Sig: One (1) Inhalation twice a day. 14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. 15. alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 16. nitrofurantoin macrocrystal 100 mg Capsule Sig: One (1) Capsule PO twice a day for 2 days. Disp:4 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Substance abuse/Overdose Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were seen in the hospital for an overdose, for which you were medically managed and found to be stable after leaving the intensive care unit. One of the social workers saw you here and provided you with information for follow up treatment. You were also seen by the psychiatrists here who believe you would benefit from seeing a psychiatrist as well, and gave you information to set up an appointment with one of the doctors [First Name (Titles) ] [Hospital3 ]. You also had symptoms suggestive of a urinary tract infection for which you were treated with a course of intravenous antibiotics. Please take oral antibiotics for two more days at home. Changes to your medications: START taking nitrofurantoin 100 mg twice a day for two days (start tomorrow morning) Followup Instructions: Department: [Hospital1 18] [Location (un) 2352] - ADULT MED When: WEDNESDAY [2182-2-27] at 10:45 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1143], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site Please also make an appointment to see a psychiatrist, either one recommended by Dr. [Last Name (STitle) 81147], the psychiatrist who saw you here, or one closer to home. Please also follow up with a substance abuse treatment program, as this will be very important for helping you with your drug use. Completed by:[2182-2-20]	[ "403.90", "518.81", "V58.69", "907.2", "304.71", "V15.81", "599.0", "969.4", "344.61", "300.4", "585.3", "965.00", "970.81", "E854.3", "E850.2", "780.97", "349.82", "730.25", "724.2", "305.03", "E853.2", "427.89", "E929.0", "344.1" ]	icd9cm	[ [ [] ] ]	[ "96.04", "94.65", "00.14", "96.71" ]	icd9pcs	[ [ [] ] ]	12294, 12300	6621, 6745	378, 390	12393, 12393	4525, 4525	13332, 14038	3669, 3730		10795, 12271		12321, 12372		10193, 10772			12528, 13194			5495, 6598						3745, 4506														13223, 13309					316, 340									418, 2874					4541, 5479					12408, 12504						2896, 3297	3313, 3653
54,147	182,215	10498	Discharge summary	report	Admission Date: [2105-4-6] Discharge Date: [2105-4-10] Date of Birth: [2050-2-12] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 78] Chief Complaint: found down Major Surgical or Invasive Procedure: Right Craniotomy for evacuation History of Present Illness: 55M with a extensive history of polysubstance abuse who was found down on the sidewalk after drinking a bottle of brandy. There was no evidence of trauma, and EMS noted him to be cold. He was brought to the ER where he was alert and conversant. He was hypothermic and was kept in the ER for observation. Later in the evening his mental status declined- he was more lethargic and confused, a head CT was done which showed a large right subdural hematoma with midline shift. Neurosurgery was called. Upon neurosurgical assessment, he was lethargic but conversant. Patient was unable to provide information on next of [Doctor First Name ]. He then became unresponsive and was intubated. Mannitol and Dexamethasone were given. A repeat head CT was ordered and the OR was on call Past Medical History: Polysubstance abuse - ETOH/cocaine Hep C Afib Schizophrenia Social History: Legally blind, substance abuse, on disability. Unknown support system. Family History: unknown Physical Exam: Gen: Lethargic, conversant, speech slurred, no external signs of trauma. Neuro: Lethargic, conversant, oriented to self, place, and month. Speech slurred, face symmetric. Pupils are surgical bilaterally/ legally blind. Follows simple commands. MAE- BUE full, BLE antigravity (would not fully cooperate with exam). Discharge exam: A&Ox3 bilateral surgical pupils Legally blind MAE full Incision c/d/i Pertinent Results: Labs on admission: [2105-4-6] 06:10PM PLT COUNT-106* [2105-4-6] 06:10PM NEUTS-57.0 LYMPHS-34.1 MONOS-4.5 EOS-3.8 BASOS-0.6 [2105-4-6] 06:10PM WBC-8.8# RBC-4.92 HGB-15.8 HCT-46.4 MCV-94 MCH-32.0 MCHC-34.0 RDW-12.1 [2105-4-6] 06:10PM VoidSpec-UNABLE TO [2105-4-6] 07:50PM ASA-NEG ETHANOL-81* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2105-4-6] 07:50PM OSMOLAL-312* [2105-4-6] 07:50PM ALBUMIN-3.8 [2105-4-6] 07:50PM LIPASE-51 [2105-4-6] 07:50PM ALT(SGPT)-40 AST(SGOT)-44* CK(CPK)-108 ALK PHOS-52 TOT BILI-0.2 [2105-4-6] 07:50PM estGFR-Using this [2105-4-6] 07:50PM GLUCOSE-123* UREA N-10 CREAT-0.7 SODIUM-142 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-33* ANION GAP-7* [2105-4-6] 11:59PM PT-12.0 INR(PT)-1.1 Imaging studies: CT-HEAD w/o contrast: IMPRESSION: Preliminary Report1. Large right subdural hematoma involving the frontal, parietal and temporal Preliminary Reportextra-axial spaces causing local mass effect. Preliminary Report2. Subfalcine herniation with evidence of impending uncal herniation. POST-OP CT HEAD w/o contrast: 1. Status post right craniotomy and replacement and evacuation of subdural hematoma with normal postoperative changes. 2. The fluid collection over the right convexity is decreased in size compared to study done eight hours ago. There is persistent but decreased mass effect upon the right lateral ventricle. Midline shift to the left has decreased. No uncal or transtentorial herniation. PORTABLE HEAD CT: 1. Decrease in size of post-operative right subdural fluid collection and pneumocephalus. 2. Decrease in mass effect on the right lateral and the third ventricle, with decreased leftward shift of normally midline structures. 3. No new hemorrhage and no acute infarction; however, there is a vague triangular hypodense focus in the right external capsule that was not seen on prior studies. Attention to this site on follow-up studies is recommended Brief Hospital Course: 55M with a history of schizophrenia, polysubstance abuse and bilateral blindness who was found on a sidewalk by EMS on [2105-4-6]. Per report he was drinking a bottle of brandy but was without evidence of trauma. He was then transferred to the [Hospital1 18] ED where he was awake, conversant and oriented. He was observed in the ED before becoming lethargic and confused prompting a head CT which showed large right subdural hematoma with 10 mm midline shift. Worsening clinical exam prompted a repeat head CT which showed worsening midline shift to 12 mm. 25 mg of mannitol and 10 dexamethasone administered and he was taken emergently to the operating room for right craniotomy and evacuation of SDH. Intraoperatively some SAH was also appreciated. EBL was approximately 160 cc and a subgaleal drain left in place. He did have a small pressor requirement during the case. The patient's EKG on presentation showed afib but upon presentation to the SICU he is in sinus rhythm. Unfortunately there is no known next of [Doctor First Name ]. [4-7]: OR for R crani, admitted to ICU. His post op head CT was stable with post operative changes and pneumocephalus. Patient was following commands and MAE on post operative examination. He was extubated and SW from his facility identified patient. On [3-/2022], he was transferred to the floor after a stable head CT. JP drain remained in, but was removed on [4-9]. He was seen to be orthostatic and he was transfused 2 units of PRBCs. Post transfusion hct was stable at 34. His exam remained stable and patient was being screened for rehab. On [4-10], patient was discharged to rehab in stable condition. Medications on Admission: unknown Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain/ fever. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 4. risperidone 2 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing SOB. 6. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 7. fluphenazine decanoate 25 mg/mL Solution Sig: One (1) Injection Q2WEEKS (). 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 12. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. benztropine 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [Hospital1 ] Care & Rehabilitation for Wood Mill Discharge Diagnosis: right subdural hematoma traumatic brain injury Cerebral edema 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: ?????? 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. ?????? Dressing may be removed on Day 2 after surgery. ?????? If you have dissolvable sutures you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? If your wound was closed with staples or non-dissolvable sutures then you must wait until after they are removed to wash your hair. 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. ?????? If 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]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [8-18] 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. [First Name (STitle) ], to be seen in 4 weeks. ?????? You will a CT scan of the brain without contrast. Completed by:[2105-4-10]	[ "E008.9", "348.5", "427.31", "780.65", "369.4", "852.20", "295.60", "070.70", "E928.8", "348.4", "E849.8", "303.01" ]	icd9cm	[ [ [] ] ]	[ "01.31", "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]	6668, 6747	3797, 5480	316, 350	6853, 6853	1793, 1798	9133, 9763	1347, 1356		5538, 6645		6768, 6832		5506, 5515			7029, 9110									1371, 1687					1703, 1774														266, 278									378, 1158				3321, 3774				1813, 2579		6868, 7005						1180, 1242	1258, 1331					2596, 3312
2,747	160,561	12979	Discharge summary	report	Admission Date: [2142-8-11] Discharge Date: [2142-9-3] Date of Birth: [2080-6-29] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2569] Chief Complaint: "I have been running a fever and I was not feeling well, then my left face started drooping." Major Surgical or Invasive Procedure: Cerebral angiogram and MCA mycotic aneurysm embolization with Onyx History of Present Illness: Patient is a 62 yo L handed man with a history of SAH in [Month (only) 404], aortic valve stenosis s/p mechanical AVR (complicated by subsequent new Afib) who presented to our hospital on [2142-8-11] complaining of fever and generalized malaise. Patient was in his usual state of health until [2142-8-10] when he noticed that he was not feeling well. Specifically, the patient noticed that he had a decreased appetite, fever, and felt fatigued with a generalized malaise. His symptoms continued through the night, and on the morning of admission ([8-11]) he woke with severe frontal headache with chills and fever of 101.6F (measured at home); he was not experiencing nausea, vomiting, abdominal pain, or chest pain. Throughout the day, his symptoms progressed and he eventually realized that he was having difficulty using swipe text (w/ his Left hand) on his smart phone. Specifically, he was leaving his finger on letters for a prolonged period of time without fluid swiping and he was also missing and incorrectly dialing many letters. His visual field, vision and comprehension were all intact; however he felt that his L hand was slow and responsible for the newfound deficit. Furthermore, patient reports that he and his wife noticed that while he was drinking from a soda can, he would set the can on its side rather than upright. Lastly, the patient noticed that he was having difficulty putting his pants on because his left leg felt clumsy and weak. In the ED he had a CT which showed a small intraparenchymal bleed in the right frontal opercular cortex. He got ceftriaxone, acyclovir and vancomycin for empiric meningitis treatment. Patient denies photophobia or new/worsening neck stiffness. He was admitted to Neurology for further care. With regard to the left superior frontal SAH in [Month (only) 404], the patient had been on coumadin and aspirin. He was managed conservatively on the neurosurgery service. His angiogram did no show any source of his bleeding. His aspirin was stopped but coumadin was continued with a lowered goal of INR 2-2.5 (previous goal was 2.5-3.5). On neuro ROS, the pt denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. Denies difficulty with gait. On general review of systems, the pt denies recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. Denies rash. +Recently endorses palpitations Past Medical History: - Aortic Stenosis: Congenital aortic stenosis s/p Open valvulplasty [2091] and Bentall [2132] - Aortic pseudoaneurysm s/p Redo Sternotomy/Bentall/Prox.Arch repl. (homograft to Gelweave)) [2132] (Dr. [Last Name (STitle) 1290] - Ascending aortic aneurysm - Benign prostatic hypertrophy - Erectile dysfunction - Hypertension - Vasectomy Social History: Lives with: Wife Occupation: [Name2 (NI) ] works for a federal agency that performs audits and financial analyses of federal contractors. Cigarettes: Smoked no [] yes [X] Hx: Quit [2132] ETOH: < 1 drink/week [X] Illicit drug use: None Family History: Sister with valvular disease Physical Exam: PHYSICAL EXAM (on admission to Neurology): Vitals: T100.3 BP 83-164/47-80 HR 67-109, RR 18-20 98% on RA General: Awake, cooperative, NAD, constricted and flattened affect HEENT: NC/AT, No [Doctor Last Name ] spots on exam Neck: Supple, No nuchal rigidity, mildly painful Pulmonary: CTABL Cardiac: Irregular rate and rhythm, systolic murmur; No [Last Name (un) ] lesions or osler's nodes Extremities: no edema Skin: no rashes or lesions noted Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty, though slow and sparse responses. Language is fluent with intact repetition and comprehension. Monotone 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. There was no evidence of neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: left lower facial droop, activated symmetrically. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No 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] L 5 5 5 5 4 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 APB [4-14] bilaterally -Sensory: No deficits to light touch or joint position -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was slightly upgoing on the left, down on the right. -Coordination: No intention tremor, No dysmetria on FNF or HKS bilaterally, some clumsiness on left side -Gait: Romberg absent. Nl narrow based gait w/ appropriate arm swing. = = = = = = = = = = = = ================================================================ DISCHARGE EXAM: VSS General: Awake, coopeartive, but severely abulic with flat affect. Slow to respond. Right gaze preference but can cross midline. Some left visual neglect still present. Left facial droop. Dense left hemiplegia. Right arm & leg full strength. Some extinction to DSS still present on left. Pertinent Results: ADMISSION LABS: [2142-8-11] 12:10PM GLUCOSE-106* UREA N-14 CREAT-1.1 SODIUM-131* POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-27 ANION GAP-15 [2142-8-11] 12:10PM WBC-10.8 RBC-4.13* HGB-12.0* HCT-35.1* MCV-85 MCH-29.1 MCHC-34.2 RDW-14.7 [2142-8-11] 12:10PM BLOOD Neuts-78.8* Lymphs-15.1* Monos-5.8 Eos-0.1 Baso-0.2 [2142-8-11] 10:35AM PT-22.3* PTT-36.5 INR(PT)-2.1* [2142-8-11] 10:35AM BLOOD ALT-21 AST-80* TotBili-1.0 [2142-8-11] 10:35AM BLOOD Lipase-28 [2142-8-11] 12:10PM BLOOD CRP-73.3* [2142-8-11] 12:28PM BLOOD Lactate-1.3 RELEVANT LABS, WARFARIN AND HEPARIN: [2142-8-13] 06:15AM BLOOD PT-31.3* PTT-35.1 INR(PT)-3.0* [2142-8-14] 11:23PM BLOOD PT-26.7* PTT-28.4 INR(PT)-2.6* [2142-8-22] 02:02AM BLOOD PT-12.7* PTT-33.1 INR(PT)-1.2* [2142-8-25] 04:46AM BLOOD PT-12.5 INR(PT)-1.2* [2142-8-27] 04:49AM BLOOD PT-13.4* INR(PT)-1.2* [2142-8-28] 04:33AM BLOOD PT-14.1* PTT-48.4* INR(PT)-1.3* [2142-8-29] 12:30AM BLOOD PT-15.1* PTT-54.0* INR(PT)-1.4* [2142-8-29] 06:51AM BLOOD PT-16.3* PTT-46.7* INR(PT)-1.5* RELEVANT LABS, SIADH: [2142-8-29] 06:51AM BLOOD Glucose-120* UreaN-19 Creat-0.7 Na-132* K-3.5 Cl-95* HCO3-29 AnGap-12 [2142-8-28] 04:33AM BLOOD Glucose-111* UreaN-19 Creat-0.7 Na-133 K-3.1* Cl-95* HCO3-29 AnGap-12 [2142-8-25] 02:57PM BLOOD Na-135 K-3.9 Cl-101 HCO3-26 AnGap-12 [2142-8-25] 04:46AM BLOOD Glucose-101* UreaN-13 Creat-0.5 Na-132* K-3.2* Cl-97 HCO3-27 AnGap-11 [2142-8-23] 11:10AM BLOOD Glucose-132* UreaN-14 Creat-0.6 Na-129* K-3.6 Cl-94* HCO3-27 AnGap-12 [2142-8-22] 05:29PM URINE Hours-RANDOM UreaN-588 Creat-42 Na-96 K-88 Cl-160 [2142-8-22] 05:29PM URINE Osmolal-598 RELEVANT LABS, MICROBIOLOGY: [2142-8-17] 08:18PM BLOOD Q-FEVER (COXIELLA BURNETTI) ANTIBODY-Test - Negative [2142-8-17] 08:18PM BLOOD BARTONELLA (ROCHALIMEA) HENSELAE ANTIBODIES, IGG AND IGM-Test - Negative STUDIES: -CT Head [8-11] - IMPRESSION: New white matter abnormality without mass effect in the right frontal lobe, with a possible small focus of hemorrhage in the right frontal opercular cortex. The left parietal white matter abnormality seen on [2142-2-8] has resolved, and the right frontal white matter abnormality seen on [2142-1-8] is not evident today or on [2142-2-8]. The fleeting and changing nature of the white matter findings suggests the possibility of vasculitis, though no evidence of vasculitis was seen on the [2142-1-11] conventional angiogram. An inflammatory condition may also be considered. MRI of the brain with and without contrast may be helpful for further assessment -CXR [8-11] - IMPRESSION: No acute cardiopulmonary process. -MRI Head [8-12] - IMPRESSION: 1. Early-subacute infarct involving the right corona radiata, subinsular region and overlying portion of the insula, corresponding to the findings on the recent NECT. 2. Corresponding to the small hyperattenuating structure at the margin of the infarct on that study, is an abnormal flow-void structure in the right frontal operculum that demonstrates both flow-related and contrast enhancement; in this context, this finding is suspicious for mycotic aneurysm, perhaps in the setting of endocarditis. 3. Similar, but smaller abnormality at the [Doctor Last Name 352]-white matter junction of the right frontal centrum semiovale, likely a second mycotic aneurysm. 4. Multiple punctate foci of susceptibility artifact in both the supra- and infratentorial compartment, which, in this context, likely represents "embolic shower" from the mechanical prosthetic valve. There is no finding on this study or the preceding CT to specifically implicate cerebral air emboli. 5. Previous abnormalities in right frontal and left paramedian parietal vertex subcortical white matter are no longer seen, and may have related to prior transient ischemia related to embolic infarction. Such transient findings may also be seen with seizure activity, which should be correlated clinically. 6. Superficial siderosis involving the parietovertex, left significantly more than right, with volume loss, related to known previous episode of subarachnoid hemorrhage. 7. Relatively mild global atrophy, unchanged. 8. Otherwise unremarkable cranial and cervical MRA, with no flow-limiting stenosis or evidence of dissection. 9. Normal enhancement of the principal dural venous sinuses, with no evidence of cerebral venous thrombosis. - CT head w/out Contrast [8-14] IMPRESSION: 1. Extensive parenchymal hemorrhage involving the right frontal cerebral hemisphere. Subarachnoid hemorrhage involving bilateral hemispheric sulci, sylvian fissures (right greater than left) and cisterns. 2. Intraventricular extension of hemorrhage involving right lateral ventricle extending into third and possibly fourth ventricle. 3. 7 mm leftward shift of normally midline structures. Given that the location of the hemorrhages appear to correspond to the sites of presumed mycotic aneurysms seen on prior MRI, the cause of hemorrhage may be secondary to rupture of these aneurysms. -TTE [8-14]- Impression: No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers (however cannot definitively exclude particularly since views were technically suboptimal). The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There is an ascending aorta tube graft. A mechanical aortic valve prosthesis is present. The prosthetic aortic valve leaflets are thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. No cardiac source of embolus identified other than the mechanical prosthetic aortic valve and presence of atrial fibrillation. Compared with the prior study (images reviewed) of [2142-1-1],findings are similar -CT Head w/out Contrast [8-15] IMPRESSION: 1. Evolution of blood products in large right frontal parenchymal hemorrhage. No new hemorrhage. 2. 4-mm leftward shift of midline structures, not significantly changed from NECT performed 9 hours earlier. - TTE [8-15] IMPRESSION: Well seated bileaflet mechanical aortic valve with thickened leaflets (? Pannus) but normal transvalvular gradients and no significant aortic regurgitation. No evidence of valvular vegetations (although exclusion of small vegetations involving the aortic valve prosthesis is limited by mild diffuse thickening). No intracardiac thrombus. Normal ascending aorta tube graft. - Cerebral Angiography [8-15]: IMPRESSION: [Known firstname ] [Known lastname 3646] underwent cerebral angiography demonstrating findings consistent with mycotic aneurysm of a branch of the right middle cerebral artery. This was successfully embolized with Onyx 34 liquid embolic [Doctor Last Name 360]. No additional aneurysms were identified. - CT head w/out Contrast [8-15]: IMPRESSION: 1. Interval emobolization of mycotic aneurysms arising from branches of the right middle cerebral artery. New coils/clips result in streak artifact obscuring complete evaluation. 2. Stable large right frontal intraparenchymal hemorrhage with intraventricular extension. Unchanged 4 mm leftward shift of the usually midline structures, not significantly changed from prior. No evidence of transtentorial herniation. 3. No new hemorrhage. 4. Stable diffuse subarachnoid hemorrhage. NOTE ADDED AT ATTENDING REVIEW: I agree with the above, but note increased edema surrounding the hematoma, and extension of this into the overlying cortex. The latter finding suggests a component of infarction in addition to edema due to the hematoma. - CXR [8-16]: FINDINGS: The patient has received a nasogastric tube. The course of the tube is unremarkable, the tip of the tube projects over the middle parts of the stomach, the sidehole is at the gastroesophageal junction. The tube could be advanced by several centimeters. Status post CABG and valvular replacement. Postsurgical material is seen projecting over the sternum and the heart. Normal lung volumes. Borderline size of the cardiac silhouette without overt pulmonary edema. No pneumothorax. No pleural effusions. - CT head w/out contrast [8-16]: CONCLUSION: 1. Extent and distribution of hemorrhage appears to be unchanged from the prior exam. 2. Hypodensities surrounding the site of the hemorrhage with extension to the overlying cortex, concerning for a new or evolving infarction, in addition to edema due to the hematoma. 3. Stable, diffuse subarachnoid hemorrhage without evidence of a new hemorrhage. - CT Chest, Abd, Pelvis w/out contrast [8-16]: IMPRESSION: 1. No evidence of pneumonia or intra-abdominal abscess on this limited non-contrast CT scan. 2. Status post aortic valve replacement with prosthetic patching of ascending aortic homograft, with interval decrease in size of ascending aorta. Complex ascending aortic morphology difficult assess without IV contrast. 3. Increased bilateral perinephric fat stranding, trace intraperitoneal ascites, and fat stranding, nonspecific and may be secondary to third spacing of fluid. 4. Minimally prominent mediastinal and retroperitoneal lymph nodes, may be reactive and is nonspecific. - CT Head w/o contrast [8-19]: IMPRESSION: No change in the extent and distribution of a large right frontal parenchymal hemorrhage. Decreasing volume of intraventricular hemorrhage. Hypodensity surrounding the hemorrhage is similar. This may represent vasogenic edema versus infarction. - CXR [8-24]: CONCLUSION: 1. Moderate-to-severe pulmonary edema has increased. 2. Right lower lung increased opacity could be compatible with dependent edema. Aspiration or pneumonia cannot be excluded in appropriate clinical settings. - CT Head w/o contrast [8-27]: CONCLUSION: 1. Interval improvement of the large right frontal intraparenchymal hemorrhage with persistent mass effect on the ipsilateral lateral ventricle and leftward shift of the normally midline structures. 2. Persistent, extensive surrounding edema around the hemorrhage extending to the overlying cortex, is concerning for superimpose infection. 3. No new evidence of new hemorrhage or new infarction. - Video oropharyngeal swallow [8-27]: IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy study. [2142-9-3] 05:23AM BLOOD Plt Ct-244 [2142-9-3] 05:23AM BLOOD PT-13.1* INR(PT)-1.2* Brief Hospital Course: Mr. [Known lastname 3646] is a 62 yo L handed man with a history of SAH in [Month (only) 404], aortic valve stenosis s/p mechanical AVR (complicated by subsequent new Afib) who presented to our hospital on [2142-8-11] with fever, generalized malaise, fatigue, left UMN pattern facial droop, and left hand weakness and poor coordination and brain MR revealing possible "embolic shower" from a mechanical prosthetic aortic valve. He recieved ceftriaxone, vancomycin, and acyclovir for empiric treatment of community-acquired meningitis/encephalitis. Patient initially denied headache, photophobia or new/worsening neck stiffness. Given Mr. [Known lastname ] presentation with 3 minor Duke's criteria (prior AVR, vascular phenomenon, and persistent fever), the initial management course was to proceed with workup and treatment for infective endocarditis. However, on [2142-8-14], he started to have a severe headache and became unable to move his left side limbs, with imaging revealing a very large ICH in the right frontoparietal area. He was subsequently transferred to the ICU for further management. 1. Left sided Hemiplegia: The patient's intitial presentation was positive for 3 minor Duke's criteria and MRI suggesting "embolic shower" pattern of stroke. This was suggestive of a septic embolic stroke precipitated by infective endocarditis. The differential diagnosis for the left sided hemiplegia included mycotic aneurysm vs embolic clot secondary to afib vs meningitis. On [2142-8-14], he began to experience a severe headache and left sided paralysis and imaging revealed a large IPH in the right frontoparietal area, suggestive of mycotic aneurysm rupture. Coumadin was discontinued with an INR of 1.3. He had a cerebral angiogram that confirmed a ruptured myocotic aneurysm in the distal right MCA that was embolized with Onyx. He now has left sided hemiplegia, left facial droop, abulia, and mild neglect. He was given nimodipine 60 mg Q4H for 2 weeks as vasospasm prophylaxis. Transcranial doppler showed mildly increased velocities in right proximal MCA but never at levels high enough to signify vasospasm. CT head on [2142-8-27]: no progression in ICH, decreased IVH. Neurologically stable. - PRN Percocet for pain or fever - In light of significant abulia, giving trial of mirtazapine for its antidepressant (serotonergic) and activating (noradrenergic) effects; the appetite-stimulating effect may also be beneficial 2. Suspected valve endocarditis: The patient has a history of aortic valve stenosis status post multiple surgeries with aortic valve replacement within the last year. Transthoracic and transesophageal echo did not show any changes compared to a previous study in [Month (only) 404] with no evidence of valvular vegetation. Blood cultures x 6 were negative, as were Coxiella and Bartonella antibodies. Nevertheless, given the high suspicion for infective endocarditis, treatment with vancomycin and ceftriaxone should be continued per ID recs for 6 weeks from [8-15]. - Restarted warfarin for AVR with goal INR 2.5-3.5, bridging with enoxaparin 70 mg [Hospital1 ]. 3. Paroxysmal atrial Fibrillation. He was treated with metoprolol succinate 100 mg [Hospital1 ] and PRN metoprolol IV for rate control in setting of atrial fibrillation. 4. Renal: Creatinine was initially elevated. However with administration of fluids, creatinine trended down, suggesting his elevated Cr was due to pre-renal azotemia. Patient developed hyponatremia with normal creatinine values and urine electrolytes demonstrating increased osmolality (588) and elevated urine Na+ in the context of hyponatremia (96). These findings were consistent with SIADH. His hyponatremia was gently corrected with 1000 ml 3%NS at 35 ml/hr, 0.2mg [Hospital1 ] fludrocortisone and salt tablets 3gm TID. The patient's sodium stabilized at 132-133. 3%NS was stopped first, then fludrocortisone. - Continue to check daily Na. Treat SIADH with 1L/day fluid restriction. Can d/c salt tablets when stable. 5. Infection and fevers: Patient presented with positive parameters for 3 minor Duke's criteria (Fever, synthetic valve placement + replacement, and stroke). Blood cultures x6 have returned negative, as have Bartonella and Coxiella serologies, and TEE and TTE show no valvular vegetation. Nevertheless, clinical suspicion for infective endocarditis was high and Infectious Disease recommened empiric treatment with vancomycin 1250 mg IV BID and ceftriaxone 2gm IV QD for 6 weeks from [8-15] 6. Respiratory: Patient's oxygen saturation dropped to the mid 80s on the night of [2142-8-23]. A CXR showed pulmonary edema, but could not rule out aspiration pneumonia. He did not have an elevated WBC or a fever that was concerning for pneumonia. His oxygen requirement quickly returned to [Location 213] and he maintained oxygen saturations of 95-97% on RA. 7. Gastrointestinal / Abdomen: Patient presented with nausea with one episode of vomiting. He was treated with ondansetron, abdominal CT was negative for intraabdominal inflammation. Patient was maintained on tube feeds and started on PO after passing swallow study on [8-21]. PO was stopped on [8-24] after concern for aspiration based on CXR. Video swallow on [8-27] showed normal oropharyngeal swallowing and PO was resumed in addition to tube feeds at night. Mirtazapine was started in an attempt to treat abulia, and as an appetite stimulant. 8. Dermatology: Red vesicular rash noted at sacral level bilaterally. Patient did not complain of pain or itching. Direct antigen test confirmed herpes simplex virus type 2, and the patient was started on a [6-19] day course (starting [2142-8-24]) of valacyclovir 1000mg PO BID. Medications on Admission: Metoprolol ER 200mg daily Coumadin 5mg 5 days a week and 2.5mg two days a week Enoxaparin 70 mg every 12 hours Discharge Medications: 1. Bisacodyl 10 mg PR HS:PRN constipation 2. CeftriaXONE 2 gm IV Q24H 3. Docusate Sodium (Liquid) 100 mg PO BID 4. Enoxaparin Sodium 70 mg SC BID Please continue to give enoxaparin until INR therapeutic 5. Gabapentin 600 mg PO Q8H 6. Metoprolol Succinate XL 100 mg PO BID 7. Mirtazapine 15 mg PO HS 8. Oxycodone-Acetaminophen (5mg-325mg) [12-11] TAB PO Q6H:PRN pain 9. Senna 1 TAB PO BID 10. Sodium Chloride 3 gm PO TID 11. ValACYclovir 1000 mg PO Q12H crush and place in ng 12. Vancomycin 1250 mg IV Q 12H 13. Warfarin 10 mg PO DAILY Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Culture negative infective endocarditis Intracranial hemorrhage secondary to mycotic aneurysm rupture status post embolization Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Abulic, hence slow to respond to questions. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname 3646], You were evaluated at [Hospital1 69] for fever, malaise, fatigue, left facial droop and left hand weakness. During this admission, we discovered that you had suffered a series of small strokes, likely due to clots thrown off from your artificial heart valve. It is possible that these clots were from an infection of your heart valves but we were never able to establish this conclusively. During this admission, you also suffered a bleed in your brain, likely from an aneurysm. You had a procedure to treat this aneurysm. Because of the deficits that you have from your bleed, we will discharge you to a rehab facility. At this point, we have also restarted the warfarin that you need for your artificial heart valve. You will remain on Lovenox until your INR is greater than 2.5 (range 2.5-3.5). You will also need to continue to take the antibiotics that we are giving you for the suspected infection of your heart valve, for a total of 6 weeks of therapy. Please follow up with Dr. [First Name (STitle) ] from neurology after this admission (see below for appointment). Please also call your cardiologist, Dr. [Last Name (STitle) ] for an earlier follow-up appointment. Followup Instructions: Provider: [First Name11 (Name Pattern1) 2053] [Last Name (NamePattern4) 2761], MD Phone:[Telephone/Fax (1) 7773] Date/Time:[2142-12-25] 1:40 Provider: [Name10 (NameIs) 2788] [Hospital ] CLINIC Phone:[Telephone/Fax (1) 7773] Date/Time:[2142-12-25] 12:45 Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) 162], MD Phone:[Telephone/Fax (1) 2574] Date/Time:[2142-10-15] 1:30 [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575] Completed by:[2142-9-3]	[ "401.9", "996.61", "784.51", "E878.1", "584.9", "276.7", "430", "434.11", "421.0", "799.89", "054.9", "427.31", "781.94", "600.00", "V15.82", "342.91", "253.6", "514", "V43.3", "449" ]	icd9cm	[ [ [] ] ]	[ "38.93", "88.41", "88.72", "39.72" ]	icd9pcs	[ [ [] ] ]	23638, 23708	17141, 22913	398, 466	23879, 23879	6362, 6362	25349, 25916	3842, 3873		23074, 23615		23729, 23858		22939, 23051			24099, 25326						4802, 6033			3888, 4352					6049, 6343														265, 360									494, 3192					6378, 17118					23894, 24075						3214, 3565	3581, 3826
10,705	126,507	28552	Discharge summary	report	Admission Date: [2152-10-9] Discharge Date: [2152-10-16] Date of Birth: [2079-10-21] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2152-10-9] Mitral Valve Replacement with 29 mm [Company 1543] Mosaic porcine valve History of Present Illness: 72 yo Caucasian male with increasing DOE for the past 6 months.Also has paplitations. Echo in [7-20] showed a dilated LV, MAC, severe MR, EF 69%,and a dilated aortic root at 4cm. Subsequent cath revealed moderate MR with normal coronaries and EF 68%. CTA showed a tortuous aorta, atheromatous calcifications of the thoracic and abdominal aorta, 4.0 cm asc. aorta, 1.8 cm innominate artery, no dissection, 3.7 cm AAA, and bilateral upper and lower lobe emphysema. Referred to Dr. [Last Name (STitle) 1290] for MVR. Past Medical History: HTN elev. chol. migraines COPD AAA GERD herniated lumbar disc remote eye injury childhood tonsillectomy left vocal cord Ca in situ ( s/p removal x 4) removal of lipoma of back Social History: retired, lives with wife quit smoking 36 years ago rare ETOH Family History: No premature CAD Physical Exam: 5'[56]" 218# HR 68 RR 18 right 128/70 left 130/70 well-appearing in NAD skin/HEENT unremarkable neck supple with no carotid bruits CTAB RRR 4/6 SEM at apex abd soft, NT, ND with + BS extrems warm, well-perfused, 1+ bil. edema no varicosities neuro grossly intact 2+ bil. fem.radials 1+ bil. DP/PTs Pertinent Results: [2152-10-14] 05:35AM BLOOD WBC-7.9 RBC-2.92* Hgb-9.0* Hct-25.9* MCV-89 MCH-30.8 MCHC-34.7 RDW-14.0 Plt Ct-248 [2152-10-15] 04:55AM BLOOD PT-14.3* PTT-32.4 INR(PT)-1.3* [2152-10-14] 05:35AM BLOOD Glucose-97 UreaN-17 Creat-1.0 Na-137 K-4.5 Cl-104 HCO3-27 AnGap-11 [2152-10-13] Chest x-ray(PA and Lat): No evidence of CHF. Improvement in left lower lobe atelectasis without complete resolution. Small bilateral pleural effusions. Brief Hospital Course: Admitted on [2152-10-9] and underwent MVR with Dr. [Last Name (STitle) 1290]. Transferred to the CSRU in stable condition on Phenylephrine and Propofol drips. He has some postop bleeding and went into AFib. Experienced mild hypotension with Afib. Amiodarone and Levophed were started. Also transfused with PRBC. He was extubated that afternoon. Hemodynamics gradually improved. Levophed weaned off on POD #2 and chest tubes were removed without complication. Gentle diuresis and beta blockade were begun. Transferred to the floor to begin increasing his activity level. Continued to experience postop atrial fibrillation and started on Warfarin. Transiently required intravenous Heparin for subtherapeutic INR. Warfarin was dosed for a goal INR between 2.0 - 3.0. Over several days, continued to make clinical improvements with diuresis and made excellent progress with physical therapy. Medically cleared for discharge on postoperative day seven. Arrangements were made with Dr. [Last Name (STitle) ] to monitor Warfarin as an outpatient. At discharge, his BP was 110/54 with a HR 51. Chest x-ray showed improved atelectasis and only small bilateral effusions. EKG at discharge showed normal sinus rhythm with first degree AV block. All surgical wounds were clean, dry and intact. Medications on Admission: Lipitor 10 mg daily, Protonix 40 mg [Hospital1 ], ASA 81 mg daily, Cardura 8 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:1 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 5. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:2 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 10 days: Take with Lasix for ten days then stop. Disp:20 Capsule, Sustained Release(s) Refills:0 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days: Take with KCL for ten days then stop. Disp:10 Tablet(s) Refills:0 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 7 days: Take 2 tabs(400mg) twice daily for one week. Then take 1 tab(200mg) twice daily for one week. Then take 1 tab(200mg) daily until follow up with cardiologist. Disp:60 Tablet(s) Refills:1 12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QPM: Take daily Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital ] Hospice and VNA Discharge Diagnosis: Mitral Rergurgitation - s/p Mitral Valve Replacement Postop Atrial Fibrillation First Degree AV Block(new) History of Paroxysmal Atrial Fibrillation, Preop Hyperlipidemia HTN COPD AAA GERD History of right spont. pneumothorax in [2138] History of migraines History of herniated lumbar disc Left vocal cord Ca in situ - s/p removal Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Take Warfarin as directed. Dr. [Last Name (STitle) ] will monitor Warfarin as an outpatient. Please have INR checked within 48 hours of discharge. Warfarin should be dosed for goal INR between 2.0 - 3.0. Followup Instructions: Dr. [Last Name (STitle) ] in [1-17] weeks, call for appt Dr. [Last Name (STitle) 5874] in [2-18] weeks, call for appt Dr. [Last Name (STitle) 1290] in [4-19] weeks, call for appt [Telephone/Fax (1) 170] Completed by:[2152-10-16]	[ "346.90", "998.11", "426.11", "441.4", "997.1", "V10.21", "530.81", "427.31", "272.4", "458.29", "424.0", "401.9", "496" ]	icd9cm	[ [ [] ] ]	[ "39.61", "99.04", "88.72", "35.23" ]	icd9pcs	[ [ [] ] ]	5327, 5389	2109, 3404	343, 437	5768, 5775	1641, 2086	6302, 6565	1281, 1299		3544, 5304		5410, 5747		3430, 3521			5799, 6279									1314, 1622																			284, 305									465, 988																1010, 1187	1203, 1265
23,761	161,216	10571	Discharge summary	report	Admission Date: [2189-2-27] Discharge Date: [2189-3-7] Date of Birth: [2130-3-24] Sex: F Service: MEDICINE CHIEF COMPLAINT: Left leg pain. HISTORY OF THE PRESENT ILLNESS: The patient is a 58-year-old female with multiple medical problems including CHF, COPD, peripheral vascular disease, obstructive sleep apnea who presents with left lower extremity pain, swelling, and erythema. She injured the leg approximately one week prior to admission when she bumped it against the wall. There was no initial skin breakdown but there was occasional bleeding at the site. The area slowly became erythematous and it started hurting about two days after the injury. She noticed some discharge from the site which was bloody but she denied any pus or yellow or greenish discharge. She denied any fevers, chills, nausea, or vomiting. In general, she was feeling quite well, in her usual state of health besides her left lower extremity pain. She visited the Dialysis Center for this prior to admission where she received p.o. antibiotic, most likely Keflex. She noticed no improvement in her symptoms at all after four days of therapy. Her pain has remained the same for the last several days and has excalated. The erythema and swelling are getting much worse. She denied any shortness of breath, chest pain, or orthopnea. REVIEW OF SYSTEMS: No change in appetite. No constipation. No diarrhea. PAST MEDICAL HISTORY: 1. CHF. An echocardiogram in [2187] revealed an EF of 55%, 4+ TR, severe pulmonary hypertension. 2. COPD. 3. Obstructive sleep apnea. The patient refuses to use a BIPAP machine. 4. Hypertension. 5. Atrial flutter. 6. End-stage renal disease, on hemodialysis. 7. Peripheral vascular disease. 8. Multiple UTIs in the past. ALLERGIES: The patient is allergic to nuts which cause anaphylaxis. The patient also has an allergy to Demerol. ADMISSION MEDICATIONS: 1. Amiodarone 200 q.d. 2. Hydroxychloroquine 200 b.i.d. 3. Nephrocaps one tablet q.d. 4. Prozac 20 q.d. 5. Albuterol and Atrovent p.r.n. 6. Neurontin 300 q.o.d. 7. Amphojel 30 cc t.i.d. SOCIAL HISTORY: She lives alone at home with her husband. She apparently is not ambulatory and uses a wheelchair. She has a 70 pack tobacco history but not currently smoking. She uses alcohol rarely. She denied IV drug use. FAMILY HISTORY: Mother and father both died of an MI, mother in her 60s, father in his 70s. Her sister had breast cancer. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.7, blood pressure 100/80, pulse 70, respiratory rate 18, saturating 95% on 2 liters. General: The patient was a comfortable obese female in no acute distress. Moist mucous membranes. Neck: No JVD. No lymphadenopathy. Supple. Lungs: Poor air movement. No crackles. No wheezes. Heart: Very distant sounds, suggestion of systolic murmur at the base. Abdomen: Obese but soft. No real distention. Normoactive bowel sounds, nontender. Extremities: The right lower extremity revealed no edema, was nontender, and had no chronic venostasis changes, no palpable pulse. The left lower extremity has a large area of what appears to be a hematoma with associated erythema and tenderness. There was no discharge from the site. LABORATORY DATA ON ADMISSION: White count 19.2, differential 88 polys, 0 bands, 5 lymphs, hematocrit 33, platelets 220,000. The initial ultrasound revealed no DVT and large hematoma. HOSPITAL COURSE: 1. INFECTIOUS DISEASE: The patient initially was started on levofloxacin and clindamycin for what appeared to be significant cellulitis. A consultation with the Surgical Service was obtained and their feeling was that this was a large hematoma requiring debridement. The patient received several debridements in the room and was subsequently transferred to the OR on day number three for extensive surgical debridement. Their feeling was that this was most likely extravasation of blood that is probably not associated with a significant amount of infection. While being taken to the Operating Room, the patient apparently decompensated with hypotension requiring intubation and was transferred to the Medical Intensive Care Unit. She stayed about three days in the Medical Intensive Care Unit requiring occasional pressors for hypotension. Her blood pressure eventually resolved and there is no evidence that she was septic. During her MICU stay, she received some vancomycin. She hemodynamically significantly improved. Her blood cultures were negative. She was transferred to the regular floor where Surgery continued to debride the wound. A consultation with Plastics was obtained and they felt that the patient required an eventual skin graft to this area. She is going to be discharged home on a VAC dressing which she will need for the next four weeks. She will follow-up with Outpatient Plastics in about two weeks and may require a skin graft in about four weeks. Even though we cannot exclude the possibility of cellulitis, she was continued on her p.o. levofloxacin and p.o. clindamycin. She also had arterial studies of her lower extremity in anticipation of future surgery. 2. RENAL: The patient continued on hemodialysis. She was also started on Renagel 1,600 t.i.d. p.o. She was reluctant to take her Amphojel most of the time. 3. CARDIOVASCULAR: The patient remained relatively stable except from a hypotension standpoint. The hypotension originally resolved with 250 cc of normal saline boluses and there was no evidence at any point that the hypotension was due to sepsis. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSIS: 1. Left lower extremity hematoma requiring multiple surgical debridements with possible associated cellulitis. 2. Chronic obstructive pulmonary disease. 3. Congestive heart failure. 4. Morbid obesity. DISCHARGE MEDICATIONS: 1. Amiodarone 200 q.d. 2. Hydroxychloroquine 200 b.i.d. 3. Nephrocaps one tablet q.d. 4. Prozac 20 q.d. 5. Levofloxacin 250 q. 48 hours for the next five days. 6. Renagel 1,600 t.i.d. 7. Albuterol p.r.n. 8. Atrovent p.r.n. 9. Neurontin 300 p.o. q.o.d. 10. Amphojel 30 cc t.i.d., although the patient is reluctant to take this medication. 11. Clindamycin 450 p.o. q.i.d. for five days. The patient will have VNA at home to assist with VAC dressing changes for the next four weeks. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2506] Dictated By:[Name8 (MD) 5094] MEDQUIST36 D: [2189-3-7] 10:31 T: [2189-3-8] 15:00 JOB#: [Job Number 34785]	[ "518.5", "924.10", "038.9", "E917.4", "458.2", "278.01", "682.6", "585", "285.9" ]	icd9cm	[ [ [] ] ]	[ "86.22", "86.28", "39.95", "00.11", "93.57" ]	icd9pcs	[ [ [] ] ]				5616, 5625			2366, 2495		5875, 6622		5646, 5852			3476, 5594			1926, 2120																							1375, 1430				154, 1355																	3303, 3458								1452, 1903	2137, 2349
51,231	173,012	38580	Discharge summary	report	Admission Date: [2184-4-4] Discharge Date: [2184-4-16] Date of Birth: [2147-12-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 12] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: Mr. [Known firstname ] [Known lastname 85785] is a very nice 36 year-old gentleman with history of smoking and hemoptysis who was recently diagnosed with a mediastinal mass who presented with hemoptysis. He had been well in his prior state of health until ~3 months ago when he started with cough and feeling upper back and left shoulder pain that occasionally went down his left arm and to his fingers. It was dull. He also reported feeling dizzy on occasion but did not relate that to any position or certain movement. He had been having dry cough since then but over the past 2 weeks started noting occasional blood streaked sputum once or twice in the am and later would not have any more hemoptysis. He presented to [Hospital3 934] Hospital where he was admitted on [3-22] and discharged on [3-25] and during that period he had a CT guided biopsy of the mass with the results inconclusive but showing malignant cells suggestive of carcinoma vs germ cell tumor. . The afternoon prior to admission, he started noting more blood in his phlegm which he quantified as a quarter of a dime when he cough blood. He estimates a total of around 15 ml from all episodes of hemoptysis over the previous day, with the amount each time and frequency stable. He denied having had any further episodes of hemoptysis since presenting to the ED. He also had noted 2 days prior a transient sharp pain in his left mid chest that he can point to with 3 fingers. . In our ER his initial VS were T 99.3 F, HR 123 BPM, BP 132/83 mmHg, RR 20 X', SpO2 98% on RA. He had slightly decreased breath sounds in the lower left of his chest. There was no wheezing. His ECG showed sinus tachycardia at 120 BPM without any signs of ischemia. His labs were significant for a microcytic normochromic anemia with HCT of 36. Coags were normal. He underwent a CT-PE, which showed a small PE in left upper lobe segmental artery. The mass in the upper mediastinum was visualized measuring 14x5 cm aprox and was compressing the pulmonary artery. His CT scan of his head showed no acute intracranial process. IP was consulted in regards to management of PE in a patient with a mediastinal mass and they recommended gentle anticoagulation with heparin gtt and possible rigid bronchoscopy with biopsy after admission. Past Medical History: - Smoking - Superior mediastinal mass s/p CT-guided biopsy with - undetermined path GERD - History of having a cut wound and bacteremia afterwards when he was a kid Social History: He lives in [Location 1439], MA. He has been smoking 1 PPD for 22 years and quit 4 weeks ago (22 pack-years). He smokes Marijuana on daily basis and has been cutting down recently. He drinks alcohol occasionally. He works at [Company ]. He lives with his uncle and aunt. Family History: His maternal uncle had lung cancer and was a smoker, his paternal grandmother had lung cancer and was not a smoker, his paternal aunt had breast cancer. Physical Exam: VITAL SIGNS - Temp 99 F, BP 127/76 mmHg, HR 108 BPM, RR 13 X', O2-sat 94% RA <br> GENERAL - well-appearing man in NAD, comfortable, appropriate, not jaundiced (skin, mouth, conjuntiva) HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits, left lymphadenopathy of ~3 cm, movile LUNGS - Bibasilary crackles, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), clubbing present 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. Pertinent Results: Pertinent Results: [2184-4-4] 04:20PM LACTATE-1.4 K+-4.2 [2184-4-4] 04:20PM HGB-13.4* calcHCT-40 [2184-4-4] 04:10PM GLUCOSE-99 UREA N-14 CREAT-0.8 SODIUM-135 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-26 ANION GAP-17 [2184-4-4] 04:10PM CALCIUM-9.9 PHOSPHATE-4.1 MAGNESIUM-1.7 [2184-4-4] 04:10PM WBC-11.0 RBC-4.82 HGB-12.5* HCT-36.9* MCV-77* MCH-25.8* MCHC-33.8 RDW-13.5 [2184-4-4] 04:10PM PT-13.3 PTT-29.7 INR(PT)-1.1 [2184-4-4] 04:10PM NEUTS-85.3* LYMPHS-7.9* MONOS-5.3 EOS-1.0 BASOS-0.5 Imaging: Chest CTA IMPRESSION: 1. Small filling defect within the left upper lobe segmental pulmonary artery, concerning for pulmonary embolus. 2. Extensive large left paramediastinal mass lesion which markedly attenuates and encases the left main pulmonary artery. Moderate left pleural effusion with paraseptal emphysematous changes. Left lower lobe atelectasis. 3. Focal patchy opacity in the left lingula may represent a superimposed infectious process vs. tumor involvement. 4. Prominent left retrocrural lymph node. 5. Lucency within the sternum with a sclerotic border. Given the patient's history of lung cancer, bone scan may be performed for further evaluation or correlation with PET-CT. CT Head w/o contrast: IMPRESSION: No acute intracranial process. Mild sinus disease. MRI Head: IMPRESSION: No evidence of metastatic disease to the head. CT Abdomen/Pelvis: IMPRESSION: 1. Retrocrural and celiac lymphadenopathy, no other evidence of disease in the abdomen and pelvis. 2. Partially imaged large left pleural effusion FNA, Left Mediastinal: Left mediastinal: Poorly differentiated carcinoma, see note. Note: Tumor cells are positive for cytokeratin cocktail, cytokeratin 7, TTF-1, and p63. Tumor cells are negative for cytokeratin 20, AFP, PLAP, and CD30. Overall, the morphologic and immunohistochemical findings are suggestive of a poorly differentiated primary lung carcinoma, possibly with squamous differentiation. Mediastinal Mass Biopsy: (from [Location (un) ], sent for review) Malignant poorly differentiated epithelioid neoplasm; see note. Note: The biopsy is comprised of tiny fragments of fibrous tissue being infiltrated by malignant epithelioid cells. Submitted immunostains show that the neoplastic cells are positive for cytokeratin AE1/AE3, focally cytokeratin 7, EMA, and focally TTF-1. In addition, by report, immunostains performed at [Hospital6 1708] showed that the neoplastic cells are also positive for p63 and SALL4. The neoplastic cells are negative for cytokeratin 20, LCA, monoclonal CEA, HCG, PLAP, and S-100. A mucicarmine stain does not demonstrate mucin. Overall, the morphologic and immunohistochemical findings are most suggestive of a poorly differentiated carcinoma, possibly of lung origin, given the TTF-1 expression. However, the significance of the reported p63 and SALL4 positivity is unclear, and a thymic carcinoma or germ cell neoplasm cannot be entirely excluded. Therefore, in this very limited sample, definitive classification is not possible. C Spine/Left Shoulder X-ray: In the cervical spine, two views demonstrate cervical spine through the cervicothoracic junction. Cervical vertebral body height and alignment are maintained. There is loss of disc height at C3-4 with endplate sclerosis and anterior and posterior osteophytes. There are mild degenerative changes at the remainder of the levels. There is prevertebral soft tissue swelling. Facet joints are aligned. There is mild uncovertebral narrowing at all levels. In the left shoulder, three views demonstrate normal acromioclavicular and glenohumeral joint. There is normal mineralization. Left upper lung zone is clear. Brief Hospital Course: MICU COURSE: Following bronchoscopy on [Hospital Ward Name ], patient was admitted to the MICU for observation. He was initially restarted on heparin gtt post-bronchoscopy per IP recs, but this was stopped the following morning given the setting of recent hemoptysis and concern that pulmonary clot occurred secondary to structural process related to mediastinal mass rather than systemic coagulopathy. He was seen by the oncology consult team who recommended MRI brain, and CT abd/pelvis for staging as well as radiation oncology consult. During his MICU stay, he was alert and oriented with throat pain post-bronch as his major complaint. O2 sat were stable in the mid-90s on [4-13] L O2 by NC. SQUAMOUS CELL LUNG CANCER: Upon transfer to the OMED service, patient was noted to be in sinus tachycardia to the 110s to 140s and normotensive requiring 4L NC for sats in the 90s. Imaging obtained as above showed large lung/mediastinal mass measuring 17.8 x 5.7 x 14.3 cm causing mass effect with shift of mediastinal structures to the right. The mass encased the left main pulmonary artery and markedly narrowed it causing a central filling defect within the left upper lobe segmental pulmonary artery. Given this large mass and no evidence of clot burden systemically, it was felt this was a pulmonary thrombus, not an embolus. Given his continued hemoptysis, it was again felt the risk of bleeding from systemic anticoagulation was higher than the benefit. He received no further anticoagulation during his hospital stay. MRI of head was negative for mets. CT Abd/Pelvis showed LAD in the celiac and retrocrural axis. Given these findings along with biopsy results consistent with squamous cell carcinoma, it was felt patient was at least Stage 3A SCCA Lung CA, however given the patient's pleural effusion and possible LAD below the diaphragm, patient's staging may be higher. Further staging will be performed in the outpatient once he receives a PET/CT. Patient was started on cisplatin/etoposide with concurrent XRT on HD9. During his treatment course, patient's hemoptysis improved from several teaspoons per hour to [2-11] teaspoons per day. He no longer needed supplemental oxygen and his tachycardia improved ranging from 80s to low 100s. After his final dose of etoposide he was discharged home with close follow up with Dr. [Last Name (STitle) 3274] for continued chemo/radiation. PAIN CONTROL: Patient initially complained of pleuritic chest pain which was controlled on po dilaudid. During his chemo/radiation he began to complain of posterior neck/left shoulder/scapular pain. He had a normal neurological exam without weakness in his upper extremities. Plain films of cervical area and shoulder did not show any obvious cause of his pain. Pain was felt to be due to large tumor burden along with XRT. His pain regimen was increased with good effect. Patient was discharged on 15 mg MS Contin [Hospital1 ] with 2-4 mg po dilaudid prn. GERD: Developed symptoms of this during hospitalization. Started omeprazole with good effect. Code: Full Medications on Admission: Tums Robitussin Oxycodone (has had only 1 pill) Aleve Mucinex Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for reflux. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 4. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane Q6H (every 6 hours) as needed for sore throat. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever / pain. 6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for anxiety: Do not drive, operate machinery, or do anything that requires significant concentration while taking this medication. . Disp:30 Tablet(s) Refills:0 7. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for reflux. 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours): Do not drive, operate machinery, or do anything that requires significant concentration while taking this medication. . Disp:60 Tablet Sustained Release(s) Refills:0 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [4-13] hours as needed for breakthrough pain: Do not drive, operate machinery, or do anything that requires significant concentration while taking this medication. . Disp:30 Tablet(s) Refills:0 11. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:30 Tablet(s) Refills:2 12. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for nausea. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: Squamous Cell Carcinoma of Lung Pulmonary Thrombus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because you were coughing up blood and having chest pain. We found a large mass in your lungs that was consistent with lung cancer. We started chemotherapy and radiation while you were in the hospital. Your symptoms improved. You also had a blood clot in your lungs that was felt secondary to your lung cancer. Since you were coughing blood, we watched you closely and you remained stable throughout your hospitalization. You are strongly advised to stop smoking. You new medications include: MS contin 15 mg every 12 hours Dilaudid 2-4 mg to be taken every 4-6 hours as needed for pain. Zofran 4-8 mg as needed for nausea Ativan 0.5-1 mg every 4-6 hours as needed for anxiety Compazine (Prochlorperazine) 10 mg to be taken every 6 hours as needed for nausea Prilosec 40 mg daily (this will help your indigestion) Followup Instructions: You have the following appointments scheduled: 1. DR. [First Name (STitle) 251] [Last Name (NamePattern4) 15108], MD/[First Name4 (NamePattern1) 488] [Last Name (NamePattern1) 6401], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2184-4-19] 9:00 2. MS. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4053], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2184-4-19] 10:00 3. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]/[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD. [Last Name (Titles) 23] [Location (un) 436]. Wednesday, [5-5] at 9:00 AM. You will need to contact your insurance and change your PCP. [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 1356] [Last Name (NamePattern1) ] is no longer accepting new patients.	[ "530.81", "198.89", "197.1", "305.1", "415.19", "786.3", "162.8", "511.9", "196.2" ]	icd9cm	[ [ [] ] ]	[ "99.25", "34.25", "92.29", "33.22" ]	icd9pcs	[ [ [] ] ]	13378, 13384	8311, 11395	324, 339	13488, 13488	4614, 8288	14497, 15359	3168, 3322		11508, 13355		13405, 13467		11421, 11485			13639, 14474									3337, 4066																			274, 286									367, 2668	4152, 4575									13503, 13615						2690, 2856	2872, 3152
81,775	177,734	9136	Discharge summary	report	Admission Date: [2123-4-2] Discharge Date: [2123-4-6] Date of Birth: [2063-10-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1377] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: Diagnostic Paracentesis Endoscopy History of Present Illness: 59 y/o M with hx of hepatitis C cirrohsis who presents to the emergency room today with hematemesis. He had been feeling well except for mild fluid overload and back pain until yesterday when he spit up about a cupful of blood. He denies abdominal pain, nausea, vomiting, cough, fevers, chills. Has mild abominal pain and increased bloating. Has chronic back pain as well. Of note, he had recently been hospitalized at [Hospital ] hospital and discharged a little over a week ago. He had problems with encephalopathy, increased fluid overload. He had a 3L paracentesis, but per him, no SBP. He was having fevers and chills at that time. Also, while hospitalized, he was having difficulty breathing, but that improved with the paracentesis. In the ED, initial vs were T 97.2, p 79, bp 105/66, r 20, 97% on RA. Patient was started on an octreotide gtt and given protonix 40 mg IV and zofran in the ED. He did not receive any blood products in the ED. On the floor, patient is in bed, comfortable except for his chronic back pain. Does not complain of dizziness, light-headedness, stomach ache, nausea, vomiting. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: # Hepatitis C Cirrhosis -completed four years in the COPILOT trial in [2117-9-8]. He was treated with interferon and ribavirin prior to that but did not have a sustained virologic response # Esophageal Varices -s/p banding multiple times, most recently [2122-3-8] # Ascites Social History: - Tobacco: yes, few cigarettes daily - Alcohol: used to drink when younger; no drinking in 9+ years - Illicits: none Family History: dad with DM, mom with COPD; otherwise non-contributory Physical Exam: Vitals: T 97.6, P 88, BP 123/62, R 15, 97% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: mildly distended, firm, tympanic, epigastric point tenderness, no rebound or guarding, positive BS GU: no foley Ext: warm, well perfused, 2+ pulses, 1+ B edema Pertinent Results: LABS ON ADMISSION: [2123-4-2] 02:20PM PT-19.6* PTT-43.8* INR(PT)-1.8* [2123-4-2] 02:16PM AMMONIA-43 [2123-4-2] 02:00PM GLUCOSE-104* UREA N-8 CREAT-0.8 SODIUM-133 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-11 [2123-4-2] 02:00PM ALT(SGPT)-22 AST(SGOT)-53* ALK PHOS-88 TOT BILI-4.1* [2123-4-2] 02:00PM LIPASE-32 [2123-4-2] 02:00PM ALBUMIN-2.2* [2123-4-2] 02:00PM WBC-7.3 RBC-3.21* HGB-11.6* HCT-34.4* MCV-107* MCH-36.0* MCHC-33.6 RDW-15.2 [2123-4-2] 02:00PM NEUTS-67.4 LYMPHS-18.0 MONOS-11.3* EOS-2.2 BASOS-1.1 [2123-4-2] 02:00PM PLT COUNT-112* [2123-4-1] 10:40AM UREA N-9 CREAT-0.9 SODIUM-132* POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-29 ANION GAP-12 [2123-4-1] 10:40AM estGFR-Using this [2123-4-1] 10:40AM ALT(SGPT)-23 AST(SGOT)-57* ALK PHOS-90 TOT BILI-4.8* DIR BILI-1.6* INDIR BIL-3.2 [2123-4-1] 10:40AM ALBUMIN-2.4* [2123-4-1] 10:40AM AFP-4.3 [2123-4-1] 10:40AM WBC-8.0 RBC-3.30* HGB-11.7* HCT-36.5* MCV-111* MCH-35.6* MCHC-32.2 RDW-14.4 [2123-4-1] 10:40AM NEUTS-68 BANDS-0 LYMPHS-16* MONOS-13* EOS-1 BASOS-1 ATYPS-1* METAS-0 MYELOS-0 [2123-4-1] 10:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL TARGET-OCCASIONAL [2123-4-1] 10:40AM PLT SMR-LOW PLT COUNT-102* [2123-4-1] 10:40AM PT-20.0* INR(PT)-1.8* [2123-4-1] 10:40AM PT-20.0* INR(PT)-1.8* . Micro: [2123-4-2] 7:28 pm PERITONEAL FLUID PERITONEAL. GRAM STAIN (Final [2123-4-3]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2123-4-6]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. . Images: CXR [2123-4-3] IMPRESSION: Blunting of the posterior costophrenic sulci likely due to small pleural effusions. . [2123-4-3] Abdominal Ultrasound IMPRESSIONS: 1. Cirrhotic liver, without focal liver lesion seen. 2. Splenomegaly as before. New moderate ascites since [2122-8-5]. 3. Patent hepatic vasculature, with normal hepatopetal flow within portal veins. . Discharge labs: [2123-4-6] 06:00AM BLOOD WBC-4.6 RBC-2.89* Hgb-10.5* Hct-31.4* MCV-109* MCH-36.3* MCHC-33.5 RDW-16.4* Plt Ct-95* [2123-4-6] 06:00AM BLOOD PT-20.1* PTT-43.4* INR(PT)-1.9* [2123-4-6] 06:00AM BLOOD Glucose-79 UreaN-12 Creat-0.7 Na-134 K-3.9 Cl-103 HCO3-26 AnGap-9 [2123-4-6] 06:00AM BLOOD ALT-17 AST-44* LD(LDH)-277* AlkPhos-70 TotBili-2.9* [2123-4-6] 06:00AM BLOOD Albumin-1.8* Calcium-7.6* Phos-3.6 Mg-2.1 . Iron studies: [2123-4-5] 06:36AM BLOOD calTIBC-127* VitB12-1301* Folate-10.2 Ferritn-522* TRF-98\ . EGD [4-5]: Unable to intubate the esophagus secondary to patient agitation and discomfort. Unable to increase sedatives secondary to hypotension to 70's. Responded to 1.5 L fluid bolus. Patient currently stable. NPO after midnight. EGD tomorrow under MAC anesthesia. . EGD [4-6]: Small AVM at GE junction Varices at the lower third of the esophagus and gastroesophageal junction Erythema, congestion, abnormal vascularity and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy Otherwise normal EGD to third part of the duodenum Recommendations: grade I esophageal varices. Not large enough to band. Portal hypertensive gastropathy. Please continue current management. Brief Hospital Course: Mr. [Known lastname 31469] is a 59 year old man with ESLD secondary to hepatitis C cirrhosis who presented with an episode of hemoptysis/hematemesis. He was initially admitted to the ICU out of concern for ongoing bleeding. His hematocrit remained stable. . # Hematemesis/Hemoptysis: Unclear initially if episodes of hemoptysis or hematemesis. Then, patient clarified episode as hemoptysis (no vomiting, just coughed up blood gob). He has a history of varices requiring banding. Hct drifted down slightly but then stable throughout hospitalization. [Hospital1 ] PPI. Attempted EGD on [4-5], but patient hypotensive with increased sedation needed to prevent gagging. As such, procedure did not occur. On [4-6] patient sedated with general anesthesia and underwent EGD. No evidence of active bleed, and no varices requiring banding. Patient tolerated EGD well, was feeling well after procedure ended. Discharged later that day. Given GI was not believed to be source of hemoptysis, set-up patient with pulmonologist appointment and CT scan of the chest; this was explained to patient. There is obviously concern for malignancy in smoker, 59 y/o male, and we feel this needs a pulmonary work-up with imaging and specialist investigation. Patient and pulmonologist aware of need for imaging and appointment. . # Abdominal Pain: Resolved. No evidence of SBP. . # Fatigue: Likely due to anemia, hypotension, cirrhosis. Monitored, keen to go home. # Ascites: Restarted furosemide and spironolactone. . # Hepatitis C Cirrhosis: Continue current treatment of furosemide, nadolol, and spironolactone. . # Back Pain: Chronic and stable. Oxycodone - home regimen. . # ?COPD: Patient without reported history of COPD but on inhalers at home. Continue home medications . Code: Mr. [Known lastname 31469] was a full code during this admission. Medications on Admission: # Fluticasone 50 mcg nasally 2 sprays daily # Adviar 100-50 mcg [Hospital1 ] # Lasix 40 mg daily # Ketoconazole cream [Hospital1 ] # Lactulose 30 mg TID PRN # Nadolol 10 mg daily # Oxycodone 5 mg q6hrs PRN # Protonix 40 mg daily # Potassium Chloride 20 mg daily # Spironolactone 100 mg daily # Sonata 10 mg qHS PRN # Tylenol 1000 mg [Hospital1 ] PRN # Tums PRN Discharge Medications: 1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Zaleplon 10 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)) as needed for insomnia. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for dyspepsia. 8. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for severe pain. 10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 12. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO three times a day as needed for confusion or constipation. 13. CT scan at [Hospital1 18] [Hospital Ward Name 516] Radiology, before [2123-5-7]. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hepatitis C Cirrhosis Hemoptysis Esophageal varices Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Thank you for allowing us to take part in your care. You were admitted to the hospital with bleeding. There was a concern that you may have been bleeding from varices in your esophagus. You underwent an EGD or endoscopy with anesthesia which used a camera to look at your esophagus and stomach. This did not show bleeding; it only showed very small varices that need to be monitored every 6 months. Your blood counts remained stable while you were in the hospital. You will need to follow up with a pulmonary (lung) doctor to make sure that the blood you coughed up was not coming from your lungs. Before going to the appointment with the pulmonologist on [5-7], please have a CT scan done at [Hospital1 18], at your convenience. It is important that they have the results of the CT scan when you go to the appointment with the lung doctor, so that they can take care of you. We made no changes to your medications. Please continue your home medications as prescribed. Followup Instructions: Because you coughed up blood, we would like you to have your lungs examined. Please go to [Hospital1 18] [Hospital Ward Name 516] Radiology to have a CT scan (please call the attached phone # first, to schedule an appointment for the scan). Also, please go to the following important appointment at the Pulmonary (Lung) clinic: [Last Name (LF) 2974], [5-7] at 8:30AM; [Hospital Ward Name 23] Building, [Location (un) 436], Medical specialties. Dr. [First Name (STitle) 437]. [Telephone/Fax (1) 612]. Please have the CT scan done before the appointment so that its results can be used to guide your care. . Previously-scheduled appointment: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 2422] Date/Time:[2123-4-14] at 11:10 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379] Completed by:[2123-4-7*]	[ "571.5", "537.82", "572.3", "537.89", "496", "789.59", "305.1", "338.29", "070.54", "289.51", "458.29", "456.21", "V64.1", "724.5", "280.0", "786.3" ]	icd9cm	[ [ [] ] ]	[ "54.91", "45.13" ]	icd9pcs	[ [ [] ] ]	9980, 9986	6407, 8259	325, 361	10101, 10101	3009, 3014	11252, 12212	2430, 2486		8683, 9957		10007, 10007		8285, 8660			10249, 11229			5139, 6384						2501, 2990															1526, 1973				275, 287									389, 1507						10026, 10080		3029, 4694	4730, 5123	10116, 10225						1995, 2279	2295, 2414
11,280	143,558	7954+55841	Discharge summary	report+addendum	Admission Date: [2131-3-26] Discharge Date: [2131-4-11] Date of Birth: [2087-5-28] Sex: M Service: MEDICAL ICU This is a discharge summary from admission on [2131-3-26] to [2131-4-11]. The remainder of the hospital course will be completed by the team assuming the patient's care. CHIEF COMPLAINT: Fever, cough, nausea and vomiting. HISTORY OF PRESENT ILLNESS: The patient is a 44 year-old male with a past medical history significant for diabetes mellitus type 1, status post cadaveric renal transplant ([2126]) with chronic rejection and pancreatic transplant ([2129]) on chronic immunosuppressives, coronary artery disease, and history of gastrointestinal bleed who presents with complaint of general malaise, nausea, vomiting, sore throat and cough productive of white sputum. The patient was reportedly and his usual state of health until five days prior to admission when he developed general fatigue. Three days prior to admission, the patient reports increasing malaise and productive cough. The patient's symptoms reportedly waxed and waned over several days, however, the morning of admission, the patient woke with acute onset nausea, vomiting, fever with chills, and decreased urine output. The patient presented to the [Hospital1 190] Emergency Department for further evaluation. In the Emergency Department, the patient was found with a temperature of 102.2, heart rate 118, blood pressure 207/88, respiratory rate 19, oxygen saturation 95% on room air. Given the patient's complaint of decreased urine output a Foley catheter was placed with 120 cc of clear urine drained. An abdominal CT was obtained for complaint of abdominal pain with nausea and vomiting without evidence of acute pathology. While in the Emergency Department the patient's temperature spiked to 104.3. Intravenous fluids (less then 1 liter normal saline), cooling blanket and ice packs were applied. the patient's oxygen requirement subsequently increased with decreased oxygen saturation on room air from 95 to 90%. The patient was placed on nasal cannula with increasing oxygen requirements and eventually intubated secondary to impending hypoxic respiratory failure. An initial chest x-ray in the Emergency Department demonstrated a right upper lobe and left lower lobe opacity, however, on repeat chest x-ray post intravenous fluids, the patient's pulmonary infiltrates increased consistent with pulmonary edema. The patient was started on broad spectrum empiric antibiotics including Ampicillin, Levofloxacin, and Flagyl for multilobar pneumonia. The patient also received Nitropaste and Hydralazine 20 mg intravenous times one for hypertension with systolic blood pressures greater then 200. The patient was placed on Versed post intubation for sedation. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus complicated by end stage renal disease requiring hemodialysis. 2. History of cadaveric renal transplant [2126] complicated by biopsy proven chronic rejection in [2130-1-10]. 3. Status post pancrease transplant in [2129-10-10]. 4. Coronary artery disease status post myocardial infarction in [2124]. 5. Hypertension. 6. History of large gastrointestinal bleed (source unknown), felt to be secondary to CMV colitis. 7. History of C-difficile colitis. 8. Status post appendectomy. 9. Status post retinal detachment in [2124]. 10. Status post cataract surgery in [2125]. 11. History of pancytopenia secondary to Imuran [2130-11-10]. 12. History of left arteriovenous graft thrombus. ALLERGIES: Lidocaine with a reaction of rash. C-mycin with a reaction of anaphylaxis. MEDICATIONS ON ADMISSION: 1. Diltiazem 60 mg po q.i.d. 2. Clonidine 0.1 mg po b.i.d. 3. Sevelamer 800 mg po t.i.d. 4. Azathioprine 100 mg po q.d. 5. Prednisone 5 mg po q day. 6. Protonix 40 mg po q day. 7. Iron sulfate 250 mg po b.i.d. 8. Lopressor 50 mg po t.i.d. 9. Lasix 80 mg po q.o.d. 10. Folate 1 mg po q day. 11. Isordil 10 mg po t.i.d. 12. Sodium bicarbonate 1300 mg po t.i.d. 13. Mycelex. 14. Sirolimus 1 mg po q day. 15. Bactrim single strength one tablet po q day. PHYSICAL EXAMINATION ON ADMISSION: Temperature 103.4. Blood pressure 236/104. Heart rate 130. Respiratory rate 28. Oxygen saturation 88% on 4 liters nasal cannula. In general, the patient is found agitated and rigoring in moderate to severe distress. HEENT examination normocephalic, atraumatic. Pupils are equal, round and reactive to light and accommodation. Extraocular movements intact bilaterally. Anicteric. Dry mucous membranes. Neck examination supple, no lymphadenopathy. Cardiovascular examination regular rate and rhythm with normal S1 and S2 and 3 out of 6 systolic murmur at the left upper sternal border. Pulmonary examination diffuse rhonchi throughout bilaterally with egophony in the right lower lobe as well as left lower lobe. No wheezing or rales noted. Abdominal examination soft, nontender, nondistended, normoactive bowel sounds, no masses appreciated. Guaiac negative. Extremities warm and well perfuse with 2+ dorsalis pedis pulses and posterior tibial pulses and 1+ lower extremity edema to the mid shin bilaterally. LABORATORIES AND STUDIES ON ADMISSION: CBC with a white blood cell count of 18.9 with a white blood cell differential of 87% neutrophils, 6% lymphocytes, 5% monocytes and 2% eosinophils. H&H is 8.9 and hematocrit of 26.3 and platelets of 132 (hematocrit on [2131-1-30] of 28.1). Chem 7 with a sodium of 146, potassium 4.2, chloride 116, bicarb 14, BUN 54, creatinine 4.8 (baseline 3.5 to 3.7) and glucose 121 with an anion gap of 16, calcium 8.5, phosphorus 3.5, and magnesium 1.3. Liver function tests ALT of 38, AST 24, alkaline phosphatase 180, amylase 66, total bilirubin 0.3. Chest x-ray on admission demonstrated cardiomegaly with bilateral interstitial edema consistent with congestive heart failure, question possible pericardial effusion, right upper lobe vague opacity likely representing pneumonia and right sided subpulmonic effusion with a left lower lobe infiltrate. Electrocardiogram on admission sinus at 120 with left atrial deviation, normal intervals, left ventricular hypertrophy, with delayed R wave progression and T wave inversions in V4, V6 and AVL. Echocardiogram in [2130-5-10] demonstrating ejection fraction of 60%, mild symmetric left ventricular hypertrophy. HOSPITAL COURSE: 1. Pulmonary: The patient presented with complaint of shortness of breath and productive cough and was found to have multilobar (right upper lobe and left lower lobe) infiltrates on chest x-ray in the setting of fever. While in the Emergency Department the patient's oxygen requirements progressively increased and the patient was intubated for impending hypoxic respiratory failure. The patient was maintained on the ventilator from [3-26] through [4-10] with adequate oxygenation and ventilation. The patient was initially started on assist control and eventually changed to pressure support for weaning mode. The patient underwent bronchoscopy on [3-27] and later on [4-4] to better sample the secretions in the lungs for microscopic data as well as visually evaluate the large airways. On [3-31] a chest CT was obtained with evidence of a round cavitary lesion in the right upper lobe (upper apices). The patient was evaluated for CT guided biopsy, however, this was deemed too risky given its location and depth. The etiology of the patient's cavitary lesion remained unclear with negative sputum and bronchoscopy results. However, the patient had, per wife's report, a prior gram negative rod right upper lobe pneumonia. It was felt that the right upper lobe cavitary lesion may be secondary to pneumonia resolving with necrosis. The patient was noted with increased secretions requiring frequent suctioning as well as intermittent agitation requiring frequent sedation making ventilator weaning difficult. With improved mental status, off sedation the patient was successfully extubated on [4-10] without complications. The patient is currently on face tent with adequate oxygenation at the time of dictation. 2. Infectious disease: The patient presented febrile with a temperature of 104 with recent history of productive cough and malaise. The patient was found with multilobar infiltrates and initially started on Ampicillin, Levofloxacin and Flagyl for empiric therapy for multilobar pneumonia. The patient was later switched to Ceftriaxone and Levofloxacin for double gram negative rod coverage. While in the Emergency Department (as previously reported) the patient underwent an abdominal/pelvic CAT scan without evidence of pathology including fluid collection, mass, or signs of inflammation. Despite broad spectrum antibiotics, the patient remained persistently febrile throughout the hospitalization to date with temperatures ranging from 100 to 102 without obvious source, extensive microbiology studies have been obtained to date including multiple blood cultures, myolytic blood cultures, bronchiolar lavage times two, acid fast bacteria smears and cultures times three, urinary Legionella antigen, sputum culture, as well as CMV antigen without growth with the exception of several urine cultures, which were notable for candiduria. On [3-31], the patient underwent a chest CT, which demonstrated evidence of right upper lobe cavitary lesions (with bilateral basilar consolidation and right pleural effusion). The patient was subsequently started on Flagyl for anaerobic coverage. The infectious disease service was consulted for further recommendations. Given the funguria, the patient was treated with a five day course of Fluconazole without significant response. The patient was subsequently started on Amphotericin B bladder washes (continue at the current time) for a total of five days. Given the persistent fevers despite broad spectrum antibiotics the patient underwent a repeat chest and abdominal CT with the addition of head and sinus CT on [4-9]. The CAT scans were notable for acute sinusitis with diffuse fluid collection throughout the sinuses right greater then left, overall smaller diameter of the right upper lobe cavitary lesion with increasing cavitary size, resolving bilateral lower lobe consolidation, as well as minimal omental swelling, moderately dilated calyces with decreased opacification of the transplanted kidney. Post CAT scan studies the patient's Ceftriaxone (on day 15) was stopped secondary to potential drug reaction. At the time of dictation the patient continues on Levofloxacin day 17, Flagyl day 9, Bactrim prophylaxis and Amphotericin bladder washes. All cultures to date with the exception of yeast, urinary tract infection are negative to date. 3. Renal: The patient is status post renal transplant with biopsy proven chronic transplant nephropathy with proteinuria and anemia on chronic immunosuppression. On admission the patient was found with acute on chronic renal insufficiency with a creatinine of 4.8. The patient's acute renal failure was felt secondary to acute tubular necrosis based on urinary sediment secondary to sepsis (and myocardial infarction). The patient was taken off Imuran secondary to a history of bone marrow failure and was continued on Sirolimus, Tacrolimus, and Prednisone. The patient's immunosuppressive drug levels were checked frequently with decreased doses by low normal levels in order to maximize the patient's immune response to infection. The patient continued with persistent metabolic acidosis throughout the early portion of the admission felt secondary to renal failure. The patient was started on sodium bicarbonate repletion, however, the patient's acidosis was refractory to medical therapy and the patient's urine output subsequently decreased in the setting of worsening renal failure. On [3-30], the patient was started on hemodialysis and ultrafiltration for volume management. The patient required multiple dialysis treatments and frequent ultrafiltration in order to maximize volume removal throughout the early portion of the admission. The patient's creatinine continues to slowly increase despite and at the time of dictation there is concern for significant compromise of the renal transplant. The patient will continue on hemodialysis for an undetermined duration. 4. Cardiovascular: The patient has a history of coronary artery disease status post myocardial infarction. On admission the patient was found with severe hypertension and tachycardia. A transthoracic echocardiogram on hospital day number one demonstrated a depressed left ventricular systolic function with an ejection fraction of 30 to 35% with global hypokinesis of the left ventricular. There was no focal wall motion abnormality noted, however, a moderate (2 cm) pericardial effusion was demonstrated with 2+ tricuspid regurgitation and 0 mitral regurgitation. No tamponade physiology was noted on echocardiogram and the patient was followed with serial echocardiograms without evidence of increased pericardial effusion with the tamponade physiology. After receiving intravenous fluids in the Emergency Department the patient developed pulmonary edema consistent with congestive heart failure. While in the Medical Intensive Care Unit a PA catheter was placed to assess the patient's hemodynamics. The patient's initial cardiac output was 4.7 with an SVR of 596 and pulmonary capillary wedge of 21. However, the patient became progressively hypotensive on hospital day number one requiring a brief period of blood pressure support. The patient was evaluated with three sets of cardiac enzymes with a peak CK of 755 with a negative MB and peak troponin of 15.[Street Address(2) 28538] elevations anteriorly and T wave inversions laterally on electrocardiogram. The Cardiology Service was consulted and the patient was started on aspirin and followed (as previously mentioned) with serial echocardiograms (last echocardiogram [4-2]) without evidence of increasing pericardial effusion, however, progressive improvement in the left ventricular systolic function with a current ejection fraction approximately 55%. After the patient's hypotension resolved the patient developed subsequent hypertension requiring multiple antihypertensive medications. The patient's blood pressure was titrated to a systolic blood pressure in the range of 140 to 160 in order to maintain renal perfusion. At the time of dictation the patient is currently on Hydralazine 5 mg po q 6 hours, Metoprolol 50 mg po t.i.d. and Clonidine 0.1 mg po t.i.d. 5. Hematology: The patient has a known history of anemia with a prior history of a large gastrointestinal bleed. The patient's admission hematocrit was 26.3 (previously 28.1 in [Month (only) 404] of 03). The patient was transfused a total of 5 units of packed red blood cells to date for intermittent hematocrit drops less then 28 given the patient's coronary artery disease. The patient's hematocrit drop is of unclear etiology, however, possibilities include end stage renal disease, bone marrow suppression with immunosuppression agents, as well as slow gastrointestinal bleed (despite consistently negative guaiac studies). Hemolysis studies were negative on multiple occasions. The patient also was noted to develop thrombocytopenia during the early portion of the admission with a nadir of 47. The patient's heparin was stopped, however, the HITT antibody was negative. The platelets stabilized at 60 without episodes of spontaneously bleeding or need for transfusion. The thrombocytopenia was felt secondary to immunosuppressive medications, acute illness, as well as potential antibiotics (Ceftriaxone) drug effect. 6. Endocrine: The patient is status post a pancreatic transplant for type 1 diabetes mellitus in [2129]. The patient is maintained on chronic low dose steroids for immunosuppression and received a course of stress dosed steroids early in the admission. Per the Transplant Service the patient was started on an insulin drip (followed by sliding scale insulin) in order to avoid excessive taxation of the transplanted pancrease. The patient's blood glucose remained well controlled throughout the admission. 7. FEN: The patient was started on tube feeds on [3-27] and was advanced to goal without complications. The preceding dictation completes the [Hospital 228] hospital course from [3-26] to [2131-4-11]. The remainder of the [Hospital 228] hospital course will be completed by the medical service assuming the patient's care. [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD [MD Number(1) 1335] Dictated By:[Doctor Last Name 28539] MEDQUIST36 D: [2131-4-11] 09:30 T: [2131-4-12] 07:12 JOB#: [Job Number 28540] Name: [Known lastname 4731], [Known firstname 126] A Unit No: [Numeric Identifier 4732] Admission Date: [2131-3-26] Discharge Date: [2131-4-17] Date of Birth: [2087-5-28] Sex: M Service: ADDENDUM: This is an Addendum to a previously dictated Discharge Summary covering the course of hospitalization from [2131-4-12] through [2131-4-17]. On [4-12], the patient was again febrile to 101 degrees Fahrenheit. At this time, a central venous catheter was pulled and the tip was sent for culture. The catheter tip culture ultimately returned negative. Following the removal of the central venous catheter, however, the patient's white blood cell count gradually trended down into the normal range. In addition, his temperature curve started to trend down; and at the time of discharge, his temperature was 99.4 degrees Fahrenheit. Blood cultures obtained on [4-12] were also negative at the time of discharge. Given the herpes simplex virus cytopathic effect seen on the bronchoalveolar lavage, the patient's oral mucosal lesions were swabbed on [4-12]. These swabs grew out oropharyngeal flora. There was no growth of herpes simplex virus. Because the patient did not have active oral herpes simplex virus lesions, no treatment for herpes virus was initiated. In addition, the patient's cytomegalovirus immunoglobulin M and immunoglobulin G were found to be negative. A cytomegalovirus viral load was pending at the time of discharge. On [4-13], the patient's amphotericin bladder washes were stopped. Subsequent urinalysis and urine culture did not demonstrate any infectious process. Also, on [4-14], the patient had an episode of orthostatic hypotension that responded to intravenous fluid administration. On the day prior to discharge, the patient had an episode of nausea. By the day of discharge, however, he was tolerating a full diet and had no further nausea. On the day of discharge, his white blood cell count was 5.1. His hematocrit was stable in the high 20s and low 30s. His platelet count had gradually started to trend upward and was 127,000 on the day of discharge. In addition, his renal function had continued to improve, and his serum creatinine was 7.1 on the day of discharge. The patient had an adequate hourly urine output at the time of discharge. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge status was to home. DISCHARGE DIAGNOSES: 1. Respiratory failure necessitating intubation. 2. Pneumonia. 3. Acute renal failure. 4. Candiduria. 5. Hypertension. 6. Pericardial effusion. MEDICATIONS ON DISCHARGE: 1. Prednisone 5 mg p.o. q.d. 2. Sirolimus 1 mg p.o. q.o.d. 3. Bactrim single-strength one tablet p.o. three times per week. 4. Metoprolol 50 mg p.o. t.i.d. 5. Clonidine 0.1 mg p.o. t.i.d. 6. Tacrolimus 1 mg p.o. q.o.d. 7. Levofloxacin 250 mg p.o. q.48h. (through [2131-4-23]). 8. Metronidazole 500 mg p.o. q.12h. (through [2131-4-23]). 9. Sodium bicarbonate 1300 mg p.o. b.i.d. 10. Hydralazine 25 mg p.o. q.6h. 11. Prochlorperazine 10 mg p.o. q.8h. as needed (for nausea). 12. Pantoprazole 40 mg p.o. q.d. 13. Folic acid 1 mg p.o. q.d. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to follow up with me in clinic in 1 week. [First Name4 (NamePattern1) 460] [Last Name (NamePattern1) 461], MD [MD Number(1) 4733] Dictated By:[Name8 (MD) 4735] MEDQUIST36 D: [2131-4-17] 10:51 T: [2131-4-17] 10:58 JOB#: [Job Number 4736]	[ "250.01", "486", "428.0", "585", "287.5", "V42.83", "996.81", "518.81", "584.9" ]	icd9cm	[ [ [] ] ]	[ "33.23", "96.72", "96.6", "96.04", "39.95", "38.95" ]	icd9pcs	[ [ [] ] ]								19453, 19604				19631, 20198	3701, 4188	6447, 19331				20233, 20567																		19346, 19432								342, 378									407, 2816								5266, 6429								2838, 3675
31,799	160,844	44652+58729	Discharge summary	report+addendum	Admission Date: [2105-12-2] Discharge Date: [2105-12-6] Date of Birth: [2028-5-11] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor / Lisinopril Attending:[First Name3 (LF) 922] Chief Complaint: chest pain and DOE Major Surgical or Invasive Procedure: Aortic valve replacement (pericardial valve) on [2105-12-2] History of Present Illness: 77 yo M with h/o heart murmur now with recent exertional chest pain and dyspnea referred for catheterization to evaluate moderate to severe AS on echo. Past Medical History: HTN, HLIPID, AS, CRI, L knee repl '[04], Sleep apnea (CPAP), Basal cell/Sq cell CA, Nasal polyps, Depression, Obesity, BPH, Memory loss, Appy, Partial uvulectomy, Probable lacunar infarct, Glaucoma Social History: quit tobacco [2088] 1 etoh/day works as lutheran minister. Family History: NC Physical Exam: Admission exam unremarkable. x distant heart sounds and right groin cath site C/D/I. Pertinent Results: [2105-12-6] 07:40AM BLOOD WBC-14.5* RBC-3.31* Hgb-10.2* Hct-29.4* MCV-89 MCH-30.8 MCHC-34.7 RDW-13.2 Plt Ct-326# [2105-12-5] 06:55AM BLOOD WBC-15.8* RBC-3.33* Hgb-10.2* Hct-29.1* MCV-87 MCH-30.6 MCHC-35.0 RDW-13.5 Plt Ct-186 [2105-12-4] 03:59AM BLOOD WBC-16.2* RBC-3.47* Hgb-10.5* Hct-30.1* MCV-87 MCH-30.2 MCHC-34.8 RDW-13.4 Plt Ct-170 [2105-12-6] 07:40AM BLOOD Plt Ct-326# [2105-12-6] 07:40AM BLOOD PT-15.1* INR(PT)-1.4* [2105-12-2] 02:00PM BLOOD PT-14.0* PTT-30.9 INR(PT)-1.2* [2105-12-6] 07:40AM BLOOD UreaN-29* Creat-1.4* K-4.4 [2105-12-5] 06:55AM BLOOD Glucose-130* UreaN-29* Creat-1.5* Na-134 K-4.4 Cl-97 HCO3-25 AnGap-16 CHEST (PORTABLE AP) [2105-12-3] 7:16 AM CHEST (PORTABLE AP) Reason: assess left ptx [Hospital 93] MEDICAL CONDITION: 77 year old man s/p AVR on water seal REASON FOR THIS EXAMINATION: assess left ptx HISTORY: 77-year-old male, aortic valve replacement, now with chest tube on waterseal. COMPARISON: Chest radiographs from [2105-11-19] through [2105-12-2]. SEMI-UPRIGHT PORTABLE CHEST X-RAY: The patient is now extubated and NG tube removed. There has been interval resolution of left apical pneumothorax and left paramediastinal atelectasis. A left retrocardiac opacity persists, likely representing atelectasis, although consolidation cannot be excluded. Otherwise, the lungs are grossly clear. Mild cardiomegaly is unchanged. A right IJ Swan-Ganz sheath with indwelling central venous catheter terminates in the right atrium. Two mediastinal drains remain. IMPRESSION: Resolved left apical pneumothorax and left paramediastinal atelectasis. Left retrocardiac opacity persists, likely representing atelectasis. Right IJ central venous catheter terminates in the right atrium. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 95572] (Complete) Done [2105-12-2] at 8:00:00 AM PRELIMINARY Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 177] [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2028-5-11] Age (years): 77 M Hgt (in): 69 BP (mm Hg): 146/84 Wgt (lb): 238 HR (bpm): 64 BSA (m2): 2.23 m2 Indication: Intraoperative TEE for AVR on [12-2] ICD-9 Codes: 745.5, 440.0, 424.1, 424.2 Test Information Date/Time: [2105-12-2] at 08:00 Interpret MD: [First Name8 (NamePattern2) 6506] [Name8 (MD) 6507], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5740], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW2-: Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 60% >= 55% Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 2.8 cm <= 3.6 cm Aorta - Descending Thoracic: 2.7 cm <= 2.5 cm Aortic Valve - Peak Velocity: 3.5 m/sec <= 2.0 m/sec Aortic Valve - Mean Gradient: 40 mm Hg Aortic Valve - Valve Area: 0.7 cm2 >= 3.0 cm2 Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Left-to-right shunt across the interatrial septum at rest. Secundum ASD. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS (AoVA <0.8cm2). No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE-BYPASS: 1.. A left-to-right shunt across the interatrial septum is seen at rest. A secundum type atrial septal defect is present. 2. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). No aortic regurgitation is seen. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. POST-BYPASS: Pt removed from cardiopulmonary bypass AV paced. 1. There is a bioprosthetic valve in the aortic postion. The valve is well seated with good leaflet excursion. There is no aortic regurgitation or paravalvular leak. The mean gradient across the valve is 17mmHg, with a peak gradient of 22mmHg. 2. Biventricular function is preserved. 3. Aortic contours are intatc post-decannulation. Brief Hospital Course: On [12-2] he was taken to the operating room where he underwent an AVR (tissue). He was transferred to the ICU in critical but stable condition. He was extuabted later that same day. He had some atrial fibrillation for which he was given amio and lopressor and eventually started on coumadin. He was transferred to the floor on POD #2. He did well postoperatively and was ready for POD #4. Medications on Admission: ASA 81', Caltrate 600' + D, Lisinopril 5', Folic acid 2', Felodipine 10', MVI', Coreg CR 10', Glucosamine/chondroitin, Flomax 0.4', Gemfibrozil 600" (only taking one every evening) Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:28 Tablet(s)* Refills:0 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). Disp:60 Tab Sust.Rel. Particle/Crystal(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:50 Tablet(s) Refills:2 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:50 Tablet, Delayed Release (E.C.)(s) Refills:2 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:50 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:40 Tablet(s) Refills:0 8. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:50 Tablet(s) Refills:2 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:50 Capsule, Sust. Release 24 hr(s) Refills:2 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:50 Tablet(s) Refills:2 12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: vna of [Location (un) ] Discharge Diagnosis: Aortic valve stenosis now s/p AVR HTN, HLIPID, CRI, L knee repl '[04], Sleep apnea (CPAP), Basal cell/Sq cell CA, Nasal polyps, Depression, Obesity, BPH, Memory loss, Appy, Partial uvulectomy, Probable lacunar infarct, Glaucoma Discharge Condition: Satisfactory Discharge Instructions: Sternal precautions Followup Instructions: F/U with cardiologist in [1-6] weeks F/U with primary care physician [Last Name (NamePattern4) ] 1 weeks F/U with Dr. [Last Name (STitle) 914] in [2-8] weeks Have INR checked on Tuesday, [12-8] Completed by:[2105-12-7] Name: [Known lastname 1799],[Known firstname ] Unit No: [Numeric Identifier 15114] Admission Date: [2105-12-2] Discharge Date: [2105-12-6] Date of Birth: [2028-5-11] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor / Lisinopril Attending:[First Name3 (LF) 1543] Addendum: Spoke with [Doctor First Name ] at Dr. [Last Name (STitle) ] office. They have already assumed management of Mr. [Known lastname 15115] [Last Name (Titles) ], VNA drew INR today, and patient has already been called with adjustments. Discharge Disposition: Home With Service Facility: vna of [Location (un) ] [First Name11 (Name Pattern1) 33] [Last Name (NamePattern4) 1544] MD [MD Number(2) 1545] Completed by:[2105-12-7]	[ "427.31", "600.00", "512.1", "585.9", "278.00", "518.0", "311", "E849.7", "424.1", "V43.65", "E878.4", "V15.82", "403.90", "438.0", "272.4" ]	icd9cm	[ [ [] ] ]	[ "88.72", "39.61", "35.21" ]	icd9pcs	[ [ [] ] ]	10231, 10448	6698, 7093	305, 371	9271, 9286	997, 1751	9354, 10208	873, 877		7324, 8915	1788, 1826	9017, 9250		7119, 7301			9310, 9331									892, 978																			247, 267	1855, 6675								399, 552																574, 777	793, 857
21,413	182,227	45362	Discharge summary	report	Admission Date: [2168-1-8] Discharge Date: [2168-1-18] Service: Vascular CHIEF COMPLAINT: Bilateral lower extremity discomfort; left greater than right over the past several months with pain at rest and pain with ambulation. HISTORY OF PRESENT ILLNESS: The patient is wheelchair bound and has had a myocardial infarction in [Month (only) 205] of this year with an ejection fraction is 20% to 25%. An echocardiogram in [Month (only) 205] demonstrated global hypokinesis with 1+ aortic insufficiency and 2+ mitral regurgitation. He did undergo an angioplasty at that time of his right coronary artery with stenting. The native vessel disease showed irregularities in the left main trunk. There was no left anterior descending artery disease. The first diagonal was 60% stenosed. There was a large branching ramus intermedius which was normal. The circumflex was very short and immediately gave rise to the atrial circumflex artery and branching obtuse marginal. The lower pole of the first obtuse marginal was occluded and filled via left-to-left collaterals. The dominant artery was the right coronary artery which was severely diseased. It had a long proximal 90% tubular stenosis and a 60% ablation and an 85% lesion involving the medial right coronary artery with a distal right coronary artery lesion of 40%. The patient is now admitted for further vascular evaluation and treatment. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Hypertension. 3. Chronic anemia. 4. Gout. 5. Peripheral vascular disease. 6. Coronary artery disease; status post myocardial infarction; status post congestive heart failure. PAST SURGICAL HISTORY: 1. Aortobifemoral bypass 15 years ago. 2. Bilateral femoral-popliteal bypass in the past. 3. Left carotid endarterectomy. ALLERGIES: ASPIRIN. MEDICATIONS ON ADMISSION: (Medications on admission included) 1. Metoprolol 25 mg p.o. b.i.d. 2. Protonix 40 mg p.o. q.d. 3. Atorvastatin 10 mg p.o. q.d. 4. Moexipril 30 mg p.o. q.d. 5. Colchicine 0.6 mg p.o. q.d. 6. Prednisone 60 mg p.o. q.d. 7. Allopurinol 200 mg p.o. q.d. SOCIAL HISTORY: The patient has a 50-pack-year smoking history. He denies alcohol use since last hospitalized in [2167-7-27]. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed vital signs were stable. General appearance revealed alert and oriented times three. In no acute distress. Chest examination was clear to auscultation bilaterally. Heart had a regular rate and rhythm. No murmurs, gallops, or rubs. Abdominal examination revealed soft, nontender, and nondistended. Extremity examination revealed left foot was cool and tender to palpation. Pulse examination on the left showed the femoral and popliteal pulses were palpable. The dorsalis pedis and posterior tibialis pulses were nonpalpable. On the right, the femoral pulse was palpable. The popliteal was palpable. There was dopplerable signal of the dorsalis pedis and posterior tibialis pulses on the right. The patient refused a rectal examination. PERTINENT LABORATORY VALUES ON PRESENTATION: Admission laboratories revealed white blood cell count was 5.1, hematocrit was 33.7, and platelet count was normal. Prothrombin time and INR were normal. Blood urea nitrogen was 39 and creatinine was 2.1. RADIOLOGY/IMAGING: Electrocardiogram showed a sinus rhythm with an atrioventricular conduction delay. Prior anteroseptal myocardial infarction. When compared with previous tracings of [2168-1-8] there were no changes. A chest x-ray was unremarkable for congestive heart failure. HOSPITAL COURSE: The patient was admitted to the Vascular Service. He was begun on an intravenous heparin drip. His coagulation parameters were monitored, and his goal INR was between 60 and 80. Intravenous hydration and Mucomyst preparation was begun because of his chronic renal insufficiency. The patient underwent an arteriogram. This demonstrated bilateral femoral-popliteal bypass grafts were intact. The abdominal aorta showed mildly diseased suprarenal aorta. The left renal artery which had previously received endarterectomy was widely patent; although, there was a fibrinous probable hyperplastic intima at the renal artery midportion prior to its bifurcation. There was a visible nephrogram on that side. The renal artery on the right was substantially higher, and there were two lesions with approximately 50% to 60% stenosis in the artery of post stenotic dilatation. The nephrogram was visualized on that side. The celiac axis and superior mesenteric arteries were both patent. There was a previously placed aortobifemoral graft which was widely patent without evidence of thrombosis or stenosis of either arteries. There was no left common femoral artery, and the left limb of the aortobifemoral was anastomosed to the profunda femoris. Along the branch of the profunda femoris, there were multiple stenoses of 99%. The bypass graft was visualized coming off the profunda, and there was no evidence of stenosis proximally. It traveled through the upper and lower thigh at the level of the knee. The bypass was anastomosed to the below-knee popliteal artery. Approximately 60% narrowing was noted at this point. Distally, there was a patent reconstructed anterior tibial. Anterior tibial constitutes runoff to the ankle which perfused the dorsalis pedis which promptly occludes 4 cm. However, there was a small tarsal branch visualized prior to determination. There was reconstitution of a very small peroneal artery which filled all collaterals which go to the heel. The arch was incomplete. The patient's creatinine remained stable status post angioplasty. Cardiology was requested for risk assessment. They felt there was no need for any interventional or diagnostic cardiac studies since the patient had been recently revascularized, and that he should be treated for any susceptible congestive heart failure and maintained with a systolic blood pressure in the 120s to 130s. Other recommendations were to add and aspirin after there was no surgical contraindication. The patient proceeded to surgery on [2168-1-13]. He underwent a left femoral to distal anterior tibial bypass jump graft from the lower end of the previous saphenous vein femoral-popliteal bypass to the distal anterior tibial artery using right arm vein, cephalic and basilic loop partially valve optimized. He tolerated the procedure well and was transferred to the Postanesthesia Care Unit in stable condition. Postoperatively, he was hemodynamically stable. His x-ray was without pneumothorax. Electrocardiogram was without acute changes. His hematocrit was 29.1. Blood urea nitrogen was 42. Creatinine was 1.9. Otherwise, he received hydrocortisone stress perioperatively. On postoperative day one, there were no overnight events. His hematocrit was 42.7 on postoperative day one. His wounds were clean, dry, and intact. His pulse examination was unchanged. A hydrocortisone taper was begun. His preoperative medications were instituted. His diet was advanced as tolerated. He remained in the Vascular Intensive Care Unit. Cardiology followed the patient perioperatively. On postoperative day two, there were no overnight events. His hematocrit was 30. His pulmonary artery line was converted to central venous line. His arterial line was discontinued, and he was transferred to the regular nursing floor. On postoperative day three, there were no overnight events. His Foley catheter was discontinued, and he had no difficulty voiding. He continued to do well. He was seen by Physical Therapy who felt that the patient would be able to be discharged to home. The patient was ambulating by postoperative day four and was de-lined. DISCHARGE STATUS: The patient was discharged to home on [2168-1-18]. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up with Dr. [Last Name (STitle) 1476] in two weeks' time. MEDICATIONS ON DISCHARGE: He was discharged with adjustments in his antihypertensive medications. 1. Metoprolol 50 mg p.o. b.i.d. 2. Moexipril 30 mg p.o. q.d. 3. Prednisone 60 mg p.o. q.d. 4. Aspirin 325 mg p.o. q.d. 5. Colchicine 0.6 mg p.o. q.d. 6. Allopurinol 200 mg p.o. q.d. 7. Atorvastatin 10 mg p.o. q.d. DISCHARGE DIAGNOSES: 1. Left graft stenosis; status post jump graft from popliteal to anterior tibial. 2. Blood loss anemia; corrected. 3. Hypertension; controlled. 4. Coronary artery disease; stable. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1477], M.D. [MD Number(1) 1478] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2168-2-29] 12:53 T: [2168-3-1] 13:19 JOB#: [Job Number ]	[ "414.01", "428.0", "440.22", "427.31", "401.9", "425.4", "440.31", "593.9", "285.9" ]	icd9cm	[ [ [] ] ]	[ "88.47", "88.42", "39.29" ]	icd9pcs	[ [ [] ] ]								8381, 8839				8066, 8360	1856, 2114	3624, 7865				7950, 8039						1681, 1829												7880, 7916								109, 245									274, 1426																1448, 1658	2131, 3606
22,327	129,535	44033	Discharge summary	report	Admission Date: [2138-7-4] Discharge Date: [2138-7-16] Service: MEDICINE Allergies: Iodine Containing Agents Classifier Attending:[First Name3 (LF) 898] Chief Complaint: Lower extremity swelling Major Surgical or Invasive Procedure: None History of Present Illness: The patient is an 85 year old female with a history of craniophayngioma s/p resection with resultant panhypopituitarism presenting with a one day history of pain and swelling of the left lower extremity. The patient did not notice these symptoms prior and has no history of trauma and there is no pain on ambulation. She does report shin redness and warmth. She denies recent travel or immobility. She recalls having one mammogram approximately 30 years ago and she has never had a colonoscopy. She called her PCP who sent her to the ED for evaluation. . Initial ED vitals 97.8, BP 193/83, HR 72, RR 16, O2 96% RA. She had a ultrasound which demonstrated a large common femoral vein DVT on the left and she was started on a heparin drip and admitted. Past Medical History: 1. Craniopharyngioma s/p resection at [Hospital1 2025] in [2127]. XRT. 2. Panhypopituitarism 3. Hypothyroidism 4. Addison's disease secondary to resection 5. s/p Cervical fusion 6. s/p total hip replacement on left 7. Rotator cuff tear repair [1-10] 8. Carpal tunnel surgery 9. Hypercholesterolemia Social History: The patient lives alone in [Hospital3 ] and has a son and daughter in the area. Denies tobacco or alcohol. She is widowed. Family History: No history of endocrinopathy. Sister died of throat cancer. Physical Exam: VS: 98.6, BP 176/90, 62, 18, 100% RA Gen: well appearing elderly female, no distress, short answers, unhappy about having to repeat history HEENT: OP clear, EOMI Car: RRR II/VI SM LLSB Resp: CTAB, no pleuritic pain Abd: s/nt/nd/nabs Ext: 1+ edema right, 2+ left. mild discoloration of left shin, 1+ DP bilaterally Neuro: [6-14] upper and lower extremities Pertinent Results: Admission Labs: [2138-7-4] 12:20PM BLOOD WBC-8.9 RBC-3.65* Hgb-12.8 Hct-36.9 MCV-101# MCH-35.1# MCHC-34.7 RDW-14.6 Plt Ct-110* [2138-7-4] 12:20PM BLOOD Neuts-81.6* Bands-0 Lymphs-14.4* Monos-2.9 Eos-0.9 Baso-0.3 [2138-7-4] 12:20PM BLOOD PT-11.4 PTT-23.0 INR(PT)-1.0 [2138-7-4] 12:20PM BLOOD Glucose-94 UreaN-26* Creat-1.4* Na-139 K-4.8 Cl-106 HCO3-26 AnGap-12 [2138-7-4] 12:20PM BLOOD Calcium-9.5 Phos-3.2 Mg-2.6 Iron-60 [2138-7-4] 12:20PM BLOOD calTIBC-237* VitB12-466 Folate-16.9 Ferritn-44 TRF-182* . Bilateral lower extremity ultrasound: There is occlusive thrombosis of the left common femoral vein and femoral vein. The popliteal vein is patent. The proximal extent of the thrombus cannot be well assessed in this ultrasound examination due to body habitus, but the thrombus certainly extends at least into the distal external iliac vein. On the right side, there is normal compressibility of the common femoral vein, superficial femoral vein, and popliteal veins. . There is no evidence of DVT in the right lower extremity. . Head CT [7-6]: No acute intracranial hemorrhage. Limited study due to motion. Status post transsphenoidal surgery, with soft tissue in the region of the sella and sphenoid sinus, not grossly changed since the most recent enhanced MRI; if warranted, targeted MRI could provide further information. . CXR [7-7]: Lungs are very much lower today than on [7-2] with discrete consolidation at the left lung base that could represent atelectasis due to aspiration or early pneumonia. Mild interstitial edema is also new. Cardiac silhouette is partially obscured by the elevated diaphragm, probably top normal size. Thoracic aorta is tortuous and mildly enlarged throughout but unchanged in appearance since [2135-7-12]. No pneumothorax. . CT Head [7-7]: No acute intracranial hemorrhage or mass effect . TTE [7-8]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . C diff negative x2 . Labs on discharge: [2138-7-16] 05:40AM BLOOD WBC-6.7 RBC-3.16* Hgb-10.6* Hct-32.2* MCV-102* MCH-33.5* MCHC-32.9 RDW-14.5 Plt Ct-237 [2138-7-16] 05:40AM BLOOD PT-38.1* PTT-37.3* INR(PT)-4.2* [2138-7-16] 05:40AM BLOOD Glucose-84 UreaN-11 * Na-140 K-3.7 Cl-108 HCO3-25 AnGap-11, Cr 1.4 [2138-7-10] 05:15AM BLOOD TSH-<0.02* [2138-7-10] 05:15AM BLOOD Free T4-1.1 [2138-7-10] 05:15AM BLOOD Cortsol-12.2 [2138-7-10] 05:15AM BLOOD ALT-15 AST-15 LD(LDH)-226 AlkPhos-77 TotBili-0.6 Brief Hospital Course: A/P: 85 year old female with history of craniopharyngioma s/p XRT with resultant hypopituitarism presenting with left lower extremity swelling found to have large DVT. . 1. DVT: Patient was started on heparin gtt and coumadin. Given her renal insufficiency she was not felt to be a good Lovenox candidate. Patient does not have history of falls, but does use walker for ambulation. Unclear precipitant for DVT--no recent travel or immobility, however, patient not up to date on mammogram or colonoscopy. Also known malignancy/craniopharyngioma resection in [2127], ? recurrence, not evident on head CT. Can continue malignancy workup as outpatient. During the hospitalization her PTT was very hard to control on heparin. It was decided to switch her to lovenox for bridging which was renally dosed. She was continued on coumadin and lovenox was discontinued when her INR was therapeutic (>2). Her INR then became supratherapeutic to 7.6 and her coumadin was held. There was no sign of bleeding with stable hct so she was not reversed. It was felt that her elevated INR was in setting of concurrent antibiotics and poor nutritional status. Her INR will need to be checked regularly and coumadin can be restarted when her INR is <3. . 2. Panhypopituitarism: Patient was continued levothyroxine for hypothyroidism and prednisone for adrenal insufficiency. She was briefly on stress-dose steroids in the ICU due to transient [Year (4 digits) ]. This was changed back to her outpatient dose of PO prednisone and she remained stable. . 3. [Year (4 digits) ]: Patient developed altered MS [First Name (Titles) ] [Last Name (Titles) ] on the floor with SBP 70s-90s. She was transferred to the MICU for closer monitoring. While in the MICU her blood pressure rapidly improved with IVF resusitation. She did not require pressors and an infectious work-up was pursued. Blood and urine cultures were negative. C. diff was negative x2. CXR revealed ? LLL consolidation on chest x-ray and mild pulmoary edema. She was given zosyn and vancomycin for presumed aspiration PNA and completed a 10 day course of these. Her BP normalized and remained stable. She was given stress-dose steroids while in the ICU which were changed back to PO prednisone on the floor. Her BP remained stable thereafter. . 4. Altered mental status: The day following admission the patient became agitated, refusing her heparin gtt. The following day she c/o frontal headache, chills, and had an episode of nausea and vomiting. She was afebrile at that time, but BP was 180/100. She was delirious and only oriented x1 which was a change from earlier that morning. Her heparin was held (PTT had been supratherapeutic numerous times the day prior) and she was ordered for a stat head CT to r/o subdural which was negative. She was agitated prior to the CT, and so received haldol 1 mg IV and zyprexa 5 mg po. Her CT did not show an acute bleed so her heparin was restarted. Overnight she was "arousable to sternal rub for short periods of time", but at some point woke up and tried to get out of bed. The following morning her BP dropped to 90/70 and then to 70/40. Remainder of vitals were T 99.7, P 80, RR 48, and O2 sat 95% on RA. She continued to be arousable to sternal rub only, was not speaking, and would open her eyes intermittently but not attend to voice. Her PTT was again supratherapeutic and so her heparin gtt was shut off again. WBC increased from 8 to 28, and creatinine increased from 1.3 to 2.1. She received a 500 cc NS bolus but her BP remained in the 70s-80s. Her ABG was 7.44/32/79 with lactate of 1.7. She was transferred to the MICU for further monitoring. Etiology of her altered MS was thought to be multifactorial with infection, medications and ARF contributing. Her MS slowly improved with treatment of her PNA and resolution of her ARF. She did not appear to have any focal deficits and head CT was neg x2. She was transferred to the floor where she continued to be confused at times, however she was alert, more appropriate, able to answer questions and comply with exam. She was oriented to person and city but not to hospital or time. . 5. Thrombocytopenia: Platelets were initially between 88-125 throughout the admission (was low prior to beginning heparin), and has been as low as 80s-90s 2 years ago. They remained stable and slowly trended up to normal levels prior to discharge. Unclear etiology. . 6. Macrocytosis: B12 and folate were checked and were wnl. Iron studies were unremarkable. Her hct remained stable and she did not require blood transfusion. . 7. Hypercholesterolemia: continued lipitor and zetia per home regimen. . 8. Osteoporosis: continued on calcium and vitamin D. Held Fosamax, which can be restarted as outpatient. . 9. ARF: Patient's Cr bumped to 2.1 from 1.3 2 days into the admission. The etiology of her renal failure was thought to be prerenal due to poor PO intake and worsened by episode of [Last Name (Titles) ]. Improved back to baseline following IVF. Prior to discharge her Cr rose again to 1.6. She was given an IV fluid bolus and her Cr improved to 1.4. Her medications were renally dosed. Her ACEI was held given ARF and episode of [Last Name (Titles) ]. This can be restarted as an outpatient if her Cr remains stable. . 10. FEN: Patient was transiently kept NPO while her mental status was altered. When she became more alert her diet was advance to soft solids which she tolerated well. Electrolytes were followed and repleted as necessary. Due to persistantly low potassium she was started on daily potassium. . 11. PPX: coumadin, bowel regimen . 12. Disposition: discharged to rehab. Medications on Admission: Prednisone 5 mg daily Zetia 10 mg daily Levothyroxine 88 mcg daily Lipitor 40 mg daily Univasc 15/25 mg daily Enablex (unknown dose) Caltrate Fosamax 70 mg weekly Aspirin 81 mg daily Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcium 500 mg Tablet Sig: One (1) Tablet PO three times a day. 8. Coumadin 5 mg Tablet Sig: as directed Tablet PO at bedtime: please start when INR <3. 9. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO DAILY (Daily). 10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary: LLE DVT Pneumonia ARF Altered mental status Thrombocytopenia, resolved Panhypopituitarism [Location (un) ], resolved . Secondary: Anemia Hyperlipidemia Craniopharyngioma s/p resection Urinary/bowel incontinence Discharge Condition: Afebrile. Hemodynamically stable. Ambulating with walker. Tolerating POs. Discharge Instructions: You were admitted to the hospital with a blood clot in your left leg. We have started you on a medication called coumadin which is a blood thinner. You will need to take this for 6 months. You will have to have your blood checked at least twice a week initially to monitor your coumadin levels. your INR should be [3-15]. . While in the hospital you developed a pneumonia which was treated with IV antibiotics for 10 days. . Please continue to take your medications as directed. . If you experience chest pain, difficulty breathing, bleeding, fainting or other concerning symptoms please call your doctor or come to the emergency room. Followup Instructions: Please follow up with your PCP [Last Name (NamePattern4) ] [2-11] weeks. Provider: [Name10 (NameIs) 7726],[Name11 (NameIs) 177] [Name Initial (NameIs) ]. [Telephone/Fax (1) 7728]	[ "453.41", "733.00", "272.0", "253.7", "276.2", "584.9", "281.9", "486", "458.9", "787.6", "427.31", "272.4", "995.91", "287.5", "788.30", "038.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11858, 11930	5172, 7497	266, 272	12198, 12275	2012, 2012	12966, 13174	1554, 1617		11084, 11835		11951, 12177		10877, 11061			12299, 12943									1632, 1993																			202, 228				4667, 5149					300, 1057					2028, 4648					7512, 10851						1079, 1392	1408, 1538
71,603	127,430	39525	Discharge summary	report	Admission Date: [2104-4-17] Discharge Date: [2104-4-23] Date of Birth: [2048-4-13] Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending:[First Name3 (LF) 2042] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: [2104-4-18] IVC Filter Placement History of Present Illness: 56F h/o metastatic melanoma s/p resection of parietal masses, whole brain radiation, currently on decadron taper found to be hypotensive to 80s with increased lethagry and weakness at [First Name4 (NamePattern1) 2299] [Last Name (NamePattern1) ]. Sent over by ambulabnce, SBP 70s per EMS. + cough x 3 days. No fevers, chills, n/v, abd pain, diarrhea. s/p radiation [2104-4-4]. Decreased appetite. Recent Admission from [Date range (3) 87289] for bilateral lower extremity weakness (inability to ambulate) and LUE clumsiness due to hemorrhage into known brain mets. Treated with whole brain XRT after prior stereotactic treatment. Discharged to rehabilitation. . In the ED initial VS significant for BP 84/53, T 101.3. Exam significant for guiac positive brown stool. Labs significant for left shift, Hct 26 (down from 42 on [4-14]) lactate 3.5. CXR showed persistent LLL opacity, ? atelectasis. CT abdomen pelvis showed no acute process. Consulted GI, who thought GI source unlikely for such a large hct drop without sx. Given vanc/zosyn empirically for sepsis, CVL (RIJ triple lumen) placed and started on levophed. Hydrocortisone 100mg IV given. . On arrival to the ICU, patient's only complaint was cough. . . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Metastatic Melanoma diagnosed in [2102] status post... --[8-/2102] Resection of initial back lesion --Axillary lymph node dissection --Adjuvant radiotherapy to the axilla --[1-/2103] wide local excision of second lesion at ankle --[2103-3-13] Started adjuvant interferon --[2103-7-4] restarted interferon after interruption for cholecystectomy --[2103-10-26] Right side weakness led to diagnosis of metastatic disease to brain. Had surgical resection of left parietal metastases followed by stereotactic radiosurgery to multiple lesions. --Admission from [Date range (3) 87289] for bilateral lower extremity weakness (inability to ambulate) and LUE clumsiness due to hemorrhage into known brain mets. Treated with whole brain XRT after prior stereotactic treatment. Discharged to rehabilitation. Obesity Hyperlipidemia Depression s/p appendectomy s/p uterine myectomy s/p cholecystectomy Social History: Lives alone, sister is close by and assists patient. Previously worked in insurance. No tobacco, etoh or illicits. Family History: Her father died at age 58 from complications of colon cancer and her mother died at age 88 from complications of an intracranial hemorrhage. She has a 50-year-old sister who suffers from epilepsy and multiple sclerosis. There is no family history of melanoma. Physical Exam: Physical Exam on Admission: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Lab Results on Admission: [2104-4-17] 11:45AM BLOOD WBC-6.2 RBC-3.02# Hgb-9.1# Hct-26.2# MCV-87 MCH-30.3 MCHC-34.9 RDW-19.3 Plt Ct-57* [2104-4-17] 11:45AM BLOOD Neuts-90.8* Lymphs-5.6* Monos-2.2 Eos-0.5 Baso-1.0 [2104-4-17] 07:58PM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL [2104-4-17] 11:45AM BLOOD PT-11.6 PTT-20.0* INR(PT)-1.1 [2104-4-17] 07:58PM BLOOD Fibrino-357 [2104-4-17] 07:58PM BLOOD Ret Aut-2.7 [2104-4-17] 11:45AM BLOOD Glucose-181* UreaN-21* Creat-0.4 Na-137 K-3.6 Cl-102 HCO3-27 AnGap-12 [2104-4-17] 07:58PM BLOOD ALT-98* AST-50* LD(LDH)-648* AlkPhos-102 TotBili-1.1 DirBili-0.4* IndBili-0.7 [2104-4-17] 11:45AM BLOOD cTropnT-<0.01 proBNP-99 [2104-4-17] 11:45AM BLOOD Calcium-6.9* Phos-2.1# Mg-2.1 [2104-4-17] 07:58PM BLOOD Albumin-2.8 Calcium-7.3* Phos-2.0* Mg-2.2 [2104-4-17] 07:58PM BLOOD Hapto-110 [2104-4-17] 11:20AM BLOOD Lactate-3.5* [2104-4-17] 02:04PM BLOOD Lactate-1.5 . Brain MRI [2104-3-24]: IMPRESSION: 1. Interval hemorrhage in left frontal metastatic lesion, with worsening surrounding edema. 2. Worsening dural nodularity and enhancement along the left frontal convexity, concerning for progressive dural metastasis. 3. Interval development of leptomeningeal enhancement in the left frontal and parietal lobes at the vertex, likely leptomeningeal metastatic disease. 4. Right frontal and parietal lobe enhancing lesions, are stable-to-slightly decreased in size, with mildly decreased surrounding edema. . [2104-4-20] pCXR FINDINGS: As compared to the previous radiograph, a pre-existing right pleural effusion has minimally increased in extent. No left pleural effusion. No evidence of pneumonia. No pneumothorax. . [2104-4-19] LUE ultrasound: IMPRESSION: No evidence of deep venous thrombosis in the left upper extremity. . [2104-4-18] LENI's: IMPRESSION: 1. Occlusive thrombus within the entire left superficial femoral, popliteal, peroneal, and posterior tibial veins with nonocclusive thrombus in the left common femoral vein. 2. Nonocclusive thrombus within the right superficial femoral vein in its mid and distal portions which has a subacute or chronic appearance, but is new since [2103-11-2]. . [2104-4-18] CXR: FINDINGS: In comparison with the study of [4-17], the vascular congestion seen on the prior study appears to have decreased. The hemidiaphragms are not wellseen. This could be a technical artifact or reflect small pleural effusions with associated atelectatic change. Enlargement of the cardiac silhouette persists. . [2104-4-18] Echo: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened 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. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. . [2104-4-17] Abd/Pelvic CTA: 1. No explanation for patient's drop in hematocrit. There is no intraperitoneal or retroperitoneal hematoma, and no evidence of active extravasation into the gastrointestinal tract. 2. Innumerable hypodense liver lesions, progressed in size and number compared to [2104-2-25], compatible with metastases from known melanoma. 3. Asymmetric opacification of the left common femoral and distal external iliac vein relative to the right is concerning for DVT. Ultrasound is recommended for further evaluation. 4. Bilateral renal cysts. 5. Small nonhemorrhagic right pleural effusion with associated atelectasis. . [2104-4-17] 11:45 am BLOOD CULTURE 2 OF 2 (felt to be skin contamination). Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. GRAM POSITIVE RODS. CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. . [2104-4-17] 11:45 am URINE URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h.Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . Most recent labs (not drawn since [4-21] due to palliative goals of care: [2104-4-21] 06:30AM BLOOD WBC-7.7 RBC-3.30* Hgb-10.0* Hct-29.2* MCV-89 MCH-30.2 MCHC-34.0 RDW-19.9* Plt Ct-61* [2104-4-21] 06:30AM BLOOD Neuts-92* Bands-4 Lymphs-3* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* [2104-4-21] 10:50AM BLOOD Fibrino-244 [2104-4-21] 06:30AM BLOOD Glucose-292* UreaN-12 Creat-0.4 Na-140 K-3.2* Cl-105 HCO3-23 AnGap-15 [2104-4-21] 06:30AM BLOOD ALT-61* AST-25 LD(LDH)-582* AlkPhos-92 TotBili-0.6 [2104-4-21] 06:30AM BLOOD Albumin-2.7* Calcium-8.5 Phos-3.0 Mg-1.8 [2104-4-18] 02:30AM BLOOD Hapto-89 [2104-4-17] 02:04PM BLOOD Lactate-1.5 Brief Hospital Course: Prognosis less than 6 months. . The patient is a 56 yo F with melanoma metastatic to brain s/p parietal tumor resection and whole brain radiation, who presented from rehab with hypotension, lethargy, fever, cough and acute anemia. She was treated briefly in the intensive care unit for sepsis and transferred to the floor on [2104-4-18]. Progressive left upper extremity weakness developed [2104-4-20] indicating progression of her melanoma. After discussion with patient and her sister, who is her health care proxy, the patient was made DNR/DNI. She is transferred now for hospice care to focus on alleviating her symptoms of cough, left arm pain, and anxiety. She has become progressively more confused and is no longer competent to make complex medical decisions. Her health care proxy is her sister, [Name (NI) ]. . # LUE weakness due to progressive metastatic disease: The patient's sister elected not to do further imaging but to focus care on her symptoms. She is now DNR/DNI. Antibiotics DC'd on [2104-4-21] and not drawing labs. Appreciate palliative care consult. - DNR/DNI - antibiotics DC'd - lab draws stopped - no further diagnostic tests - care will focus on symptoms - no ICU transfer - IV medications and finger sticks have been DC'd . # Worsening Mental status changes: Likely due to her progressive disease and possible worsening of brain mets. Maybe exacerbated by her infection. She does NOT appear competent to make complex decisions but can do review of systems. She does not want to be resuscitated and her sister (and health care proxy) is in agreement. . # Hypokalemia: repleted po and IV. No longer following labs . # New LUE swelling: ultrasound negative. Suspect this is from hypoalbumenemia and progressive disease. . # Bilateral LE DVT: CNS mets preclude anticoagulation. IVC filter placed [2104-4-18]. . # Diabetes and poorly controlled hyperglycemia on high dose steroids: treated initially with insulin sliding scale. Steroid dose was decreased to Decadron 4 mg [Hospital1 ] and glu came down into the 200 range. Sliding scale has been discontinued based on palliative goals of care. . # Bacteremia- occurred in setting of clinical pneumonia and hypotension. Cultures suggest skin contamination. Had reviewed informally with ID and had planned 8 full days to treat as pneumonia acquired at her rehab placement. Given progressive melanoma, we have stopped antibiotics. . # Hypotension - Resolved. Likely dehydration and possibly sepsis in setting of pneumonia. Responsive to IVF resuscitation. Blood cultures are likley contaminant. Currently stable. Stopped vanc/cefepime/levoflox on [4-21]. . # Anemia - Acute drop in the setting of her infection and sepsis. No melena, hematochezia, hematemesis. CT showed no evidence of RP bleed. Hemolyis work up is negative, but haptoglobin drawn after her transfusion. Doubt DIC. Smear reviewed by heme but no schistocytes. Possible contribution of H2 blocker so changed to pantoprazole. No longer following CBC given goals of care. Tranfused [2104-4-17]. . # Thrombocytopenia - Stable at 50k. Occurred in setting of bacteremia and sepsis. no evidence of bleeding, had been on heparin (now DC'd). No evidence of DIC. Peripheral smear without schistocytes to support TTP or intravascular hemolysis. Discontinued famotidine, started pantoprazole. Will not follow labs given goals of care. . # UTI - pansensitive e. coli growing in cx. Has foley in place. Treated with Cefepime. . # Pneumonia with sepsis & bacteremia: Had improved. Have DC'd antibiotics given the goals of her care. Continue nebulizers for comfort. Using morphine and ativan for air hunger and anxiety. Using codeine to suppress cough. . # Metastatic melanoma: ECOG PS4 with progression of liver mets and recent hemorrhage in CNS mets (from which she has not regained her former functional status). Now DNR/DNI. . # Depression: contined buspar . # Severe malnutrition: albumin 2.3 with poor po intake and ECOG PS4. . # Hypocalcemia: will not follow further labs. # UTI - pan sensitive e. coli infection was treated with Cefepime. . # Hyperlipidemia - statin was discontinued given the goals of care. . DNR/DNI Medications on Admission: Prilosec 40 mg once daily vitamin D [2092] international units daily buspirone 10 mg twice a day, dexamethasone 2 mg daily tapering weekly LEVETIRACETAM 750MG po tid simvastatin 20mg PO QHS Atrovent 1 unit via nebulizer every 8 hours as needed for shortness of breath or wheeze Bisacodyl 10mg PR daily prn constipation fleet enema once daily as needed for constipation lorazepam 1mg PO Q8H prn anxiety milk of magnesia 30mL daily as needed for constipation Lantus 8 units SC QHS nystatin swish and swallow Lasix 20mg PO daily potassium chloride 240meq by mouth daily tylenol 650mg by mouth every 6 hours as needed for pain/fever VHC 60mL by mouth TID between meals metoprolol 50mg by mouth twice daily Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing/sob. 5. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H:PRN as needed for wheezing/sob. 6. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 7. docusate sodium 100 mg Capsule Sig: [2-4] Capsules PO BID (2 times a day). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for groin and perineal rash. 10. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H:prn as needed for pain. Disp:60 Tablet(s) Refills:0 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever. Tablet(s) 13. ondansetron HCl 4 mg Tablet Sig: 1-2 Tablets PO Q8H:PRN as needed for nausea. 14. lorazepam 0.5 mg Tablet Sig: 1 to 4 Tablet PO Q4H (every 4 hours) as needed for anxiety, insomnia, nausea. Disp:60 Tablet(s) Refills:0 15. codeine sulfate 30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for cough. Disp:60 Tablet(s) Refills:0 16. morphine 15 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for shortness of breath, air hunger. Disp:60 Tablet(s) Refills:0 17. haloperidol 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for agitation. Discharge Disposition: Extended Care Facility: [Hospital 3137] Care Center - [Location (un) 1468] Discharge Diagnosis: Metastatic melanoma Liver metastases Brain metastases with hemorrhage Leptomeningeal metastases Bilateral lower extremity DVT's Paralysis of bilateral lower extremities and left upper extremities Hypotension Pneumonia Encephalopathy & Confusion due to brain mets Urinary Tract Infection Anxiety Diabetes Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted with low blood pressure and a pneumonia requiring intensive care, IV antibiotics and pressor support. Your blood pressure improved and you were transferred to the regular hospital floor. You developed blood clots in both of your legs that were treated with an IVC filter because you cannot have blood thinners with tumor in your brain. Your Left arm became weaker due to tumor growth. Because your tumor is worsening, you and your sister decided that you are now DNR/DNI and we should focus on keeping you comfortable. We have stopped antibiotics, stopped checking your blood sugar, stopped IV medications, stopped blood draws and stopped following vital signs except to focus on your comfort. you were seen by the palliative care service and they have helped us to find hospice care close to your sister's home. Followup Instructions: You may cancel these appointments since you are moving to hospice care. . Department: [Hospital1 ] MRI (MOBILE) When: MONDAY [2104-5-5] at 2:05 PM With: MRI [Telephone/Fax (1) 327] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2104-5-5] at 2:30 PM With: DRS. [Name5 (PTitle) ]/[Doctor Last Name ] [Telephone/Fax (1) 13016] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2104-5-5] at 2:30 PM With: [Doctor First Name 10838] [Name8 (MD) ], NP [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "785.52", "486", "995.92", "348.30", "275.41", "276.8", "V58.65", "V49.86", "453.41", "599.0", "250.00", "198.3", "261", "278.00", "V10.82", "311", "345.90", "038.9", "285.9", "287.5", "272.4" ]	icd9cm	[ [ [] ] ]	[ "88.51", "38.7" ]	icd9pcs	[ [ [] ] ]	16878, 16963	10042, 14229	291, 330	17311, 17311	3976, 3988	18301, 19239	3154, 3417		14986, 16855		16984, 17290		14255, 14963			17445, 18278									3432, 3446				8326, 8568											1614, 2062				239, 253					8597, 10019				358, 1595								4003, 8288		17326, 17421						2084, 3003	3019, 3138
25,282	173,566	46281	Discharge summary	report	Admission Date: [2110-6-5] Discharge Date: [2110-6-23] Date of Birth: [2051-10-26] Sex: F Service: SURGERY Allergies: [Doctor First Name ] Attending:[First Name3 (LF) 4111] Chief Complaint: Colon cancer found on routine screening Major Surgical or Invasive Procedure: Sigmoid Colectomy History of Present Illness: This patient is a 58-year-old single lady, working at [Company ], who underwent a routine screening colonoscopy on [2110-5-12] and was found to have a sigmoid colon lesion, which was biopsied and came back as carcinoma. It was inked and is at 25 cm. She has not lost any weight, and denies any changes in appetite or taste. The patient denies nausea or vomiting, change in bowel activity, or change in energy level. She is referred for resection. Past Medical History: Past medical history includes sarcoidosis, which is apparently inactive; glaucoma, which has been treated on the left side with some loss of vision; arthritis as a child; and a history of fibroids. Past surgical history includes bilateral eye surgery for glaucoma with some loss of acuity on the left side. She also had some laparoscopy for symptomatic fibroids. Social History: The patient is single but has a boyfriend. Drinks alcohol socially, but does not smoke, does not take drugs. Family History: Her mother is still alive. Her father died of a perforated ulcer. Physical Exam: The patient is a thin looking woman. Blood pressure 178/74, temperature 97.6, heart rate 81, and respirations 16. She appears well and does not appear to be cachectic. Her eyes show signs of previous operation for glaucoma. Her ears, she has wax in the right ear, but the drum is clearly visible on the left ear, which is normal. Her squamous mucous membranes are normal. She has no carotid bruit. Her thyroid is not enlarged. Her chest, the diaphragms move 4-6 cm and there are no rales or adventitious sounds and no dullness. The heart is not enlarged. There is a regular sinus rhythm, A2 is greater than P2, and there are no murmurs except for a very short, mid systolic whiff at the apex. The abdomen is benign and without masses. There are no groin adenopathy. Brief Hospital Course: Ms. [Known lastname 634] was taken to the OR for a sigmoid colectomy. See Dr.[Name (NI) 6275] Operative Note for detail. On POD#1, she did well. She had good pain control with her epidural and was out of bed to a chair. On POD#2, Ms. [Known lastname 634] was noted to be hypotensive over night with a systolic blood pressure in the 80s. Her pressure responded to fluid boluses. She was also noted to have some bleeding around her epidural site. Her SC heparin was discontinued and the epidural was capped. Her hematocrit was 24 and a repeat hematocrit was 25, and became as low as 18. Ms. [Known lastname ] PTT was >150 and her INR 1.8. She was transferred to the ICU for closer monitoring and neuro checks. On exam, Ms. [Known lastname 634] had a soft abdomen, mild staining of her dressing, but no overt signs of a hematoma. She remained clinically stable and neurologically intact. She received a total of 7units of FFP and 3 units of pRBCs. Her coagulopathy was corrected and her hematocrit rose to 27. Some oozing continued from her epidural site and she was placed on Vancomycin for empiric coverage. Later that evening, on exam, a more noticeable and tender hematoma was evident at the left inferior aspect of her incision. On POD#3, the patient received 2 additional units of pRBCs to a hematocrit of 30. She was closely monitored and was found to have a stable hematocrit. The remainder of the patient's course in the ICU was unremarkable. She was transferred to the floor on POD#6 in stable condition. The remainder of the patient's course was complicated by prolonged post-operative ileus. She was seen by the physical therapy service and routinely ambulated. She was advanced to a clear liquid diet. On POD#10, the patient was started on levofloxacin for presumed pneumonia. On POD#11, the patient experienced an episode of nausea with ongoing nausea. A KUB was obtained, and showed multiple loops of dilated bowel with air-fluid levels, consistent with ileus. She also experienced an episode of diarrhea and was started on PO vancomycin for emperic threatment for Clostridium difficile infection. The remainder of the patient's course was unremarkable. Her ileus slowly resolved, and her diet was advanced to soft solids. She was able to ambulate well. At the time of discharge to home, the patient was noted to be stable, tolerating PO intake and experiencing formed stools. She was discharged with instructions for follow-up with Dr. [Last Name (STitle) ] and with Dr. [Last Name (STitle) 98416] of the oncology service. Medications on Admission: Multivitamin Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 3. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). Disp:60 Tablet(s) Refills:2 4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:2 Tablet(s) Refills:0 5. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 5 days. Disp:20 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Colon cancer s/p sigmoid colectomy and myomectomy Post-operative bleeding Discharge Condition: Good Discharge Instructions: Please call Dr.[Name (NI) 6275] office or return to the hospital if you experience chills or fever greater than 101.5 degrees F. Please return if you notice excessive swelling, redness or tenderness of your wounds. Please take all medications as prescribed. Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2110-7-9] 1:00 Provider: [Name10 (NameIs) ],[Name11 (NameIs) 3628] SURGICAL ASSOC [Name11 (NameIs) 3628]-3A (NHB) Where: LM [Hospital Unit Name 3665] ASSOCIATES Phone:[Telephone/Fax (1) 3666] Date/Time:[2110-7-9] 11:00 Please follow up with Dr. [Last Name (STitle) ] in one month. Call ([Telephone/Fax (1) 96633] for an appointment.	[ "997.4", "560.1", "211.8", "E878.6", "153.3", "486", "998.11" ]	icd9cm	[ [ [] ] ]	[ "45.75", "99.04", "99.07", "83.32" ]	icd9pcs	[ [ [] ] ]	5566, 5572	2229, 4809	324, 344	5689, 5695		6005, 6548	1357, 1424		4872, 5543		5593, 5668		4835, 4849			5719, 5982									1439, 2206																			245, 286									372, 828																850, 1215	1231, 1341
1,104	175,915	44053	Discharge summary	report	Admission Date: [2187-5-15] Discharge Date: [2187-5-22] Date of Birth: [2148-11-12] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2234] Chief Complaint: right lower extremity pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 38 year-old man with a history of recent possible pulmonary embolism, cellulitis, type I diabetes, renal insufficiency who presents with 2-3 days of right lower extremity pain and edema. Says it feels similar to when he last had cellulitis in [Month (only) 547]. Has also noticed increased swelling. Minimal change in color. Has felt feverish over past few days. . No water, insect or animal exposures or bites. No recent travel. No trauma to the area. Hospital admission in [Month (only) 547] of this year for lower extremity cellulitis. During this admission, hypoxic respiratory failure thought to be due to possible PE vs. aspiration pneumonia vs. hosp acquired pneumonia. Plan is for six months anti-coagulation. . In ER given vancomycin, unasyn for cellultiis, morphine for pain control, aspirin, NPH 62 units at 4:30 AM. Blood cultures sent. . On ROS, reports intermittent shortness of breath associated with pleuritic chest pain occurring every few days and lasting for a few minutes. Not associated with wheezing. Past Medical History: 1. Presumed PE diagnosed in [2187-2-18] based on V/Q scan in setting of infiltrates on CXR, currently on coumadin with plan for 6 months of treatment--etiology attributed to immobility secondary to lle swelling/cellulitis 2. Cellulitis 3. Type 1 diabetes, 4. hypercholesterolemia 5. hypertension 6. obesity 7. asthma 8. renal insufficiency 9. chronic tobacco use. Social History: He lives in [Location 686] with his wife, their 11 year-old son and two step sons. Currently not smoking, former long history of smoking. Occasional alcohol, no ivdu. Family History: Diabetes Physical Exam: VS: Temp:100.1 BP: 136/81 HR:105 RR:16 96%rm airO2sat . general: pleasant, discomfort secondary to leg pain, no distress HEENT: PERLLA, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd lungs: CTA b/l with good air movement throughout heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: obese, nd, +b/s, soft, nt, no masses extremities: right lower extremity with 2+edema, tender over tibia, increased area of pigmentation over front of tibia-->area marked, left lower extremity with 1+edema, symmetric calor neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. vasc: 2+ dp pulses bilaterally Pertinent Results: Admit labs; [2187-5-14] 08:40PM WBC-14.8* RBC-4.33* HGB-12.3* HCT-34.1* MCV-79* MCH-28.3 MCHC-36.1* RDW-14.8 [2187-5-14] 08:40PM NEUTS-80.7* LYMPHS-14.7* MONOS-3.4 EOS-1.1 BASOS-0.2 [2187-5-14] 08:40PM PLT COUNT-295 . . [2187-5-14] 08:40PM GLUCOSE-216* UREA N-39* CREAT-2.2* SODIUM-136 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-27 ANION GAP-13 . [2187-5-14] 08:40PM PT-30.0* PTT-34.3 INR(PT)-3.2* . Discharge labs: [2187-5-22] 06:50AM BLOOD WBC-10.9 RBC-3.66* Hgb-10.2* Hct-29.4* MCV-80* MCH-28.0 MCHC-34.8 RDW-14.3 Plt Ct-407 [2187-5-18] 07:55PM BLOOD Neuts-71.8* Lymphs-19.1 Monos-7.3 Eos-1.5 Baso-0.3 [2187-5-22] 06:50AM BLOOD PT-26.6* PTT-33.3 INR(PT)-2.7* [2187-5-22] 06:50AM BLOOD Glucose-146* UreaN-43* Creat-2.4* Na-138 K-4.7 Cl-100 HCO3-31 AnGap-12 [2187-5-20] 04:19AM BLOOD ALT-47* AST-35 AlkPhos-361* TotBili-0.5 .. .. Echo:[2187-5-21] Conclusions: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [2187-2-20], the findings are consistent with normal diastolic function and normal left ventricular filling pressures (not fully evaluated on prior study). .. v/Q scan: IMPRESSION: Normal lung perfusion scan. Compared with the prior study, there is no significant interval change. .. Tib/fib films: IMPRESSION: No gas is noted within the soft tissue. Prominent soft tissue swelling of the calf region is unchanged compared to the prior study. .. [5-20] CXR: FINDINGS: Comparison is made to the chest CT from [2187-2-21], and plain film radiograph from [2187-5-19]. Cardiac silhouette demonstrates left ventricular prominence, which is stable. The right lung is clear. The left lung demonstrate some vague opacity in the left retrocardiac region, however, this may be secondary to atelectasis or due to vessel crowding from poor inspiratory effort. No definite consolidation is identified. There are no signs of overt pulmonary edema. Brief Hospital Course: Assessment and Plan: This is a 38 year old man with a history of recent possible pulmonary embolism, cellulitis, type I diabetes, renal insufficiency who presentsed with right lower extremity pain/edema. The following issues were addressed on this admission: . 1)Right lower extremity pain/edema: Cellulitis: Patient maintained on vancomycin/unasyn over the course of his admission for first 6 days. (Got zosyn instead of unasyn for a few doses after he spiked and had respiratory decompensation, please see below). Switched to augmentin and remained afebrile with improvement of cellulitis over the last two days of admission. No evidence compartment syndrome other than pain. LENI negative for dvt (already on coumadin) Anti-fungals maintained throughout. No evidence of osteo on plain film. To complete 14 day total course of antibiotics, six more days of augmentin. Patient has appointment in two days with Dr. [Last Name (STitle) ] for re-evaluation. . 2)Fever: on antibiotics, vanc and unasyn on [5-18]. Multiple blood cultures and urine cultures negative. Initially unasyn broadened to zosyn and then antibiotics switched to augmentin on HD#6. Afebrile on augmentin x2 days prior to discharge. Likely from cellulitis. Blood cultures and urine cultures pending at time of discharge. . 2)Respiratory: History of OSA and asthma as well as recent diagnosis of possible PE. Intermittent shortness of breath reported on admission. Initially stable but patient with decompensation/desaturation [5-16] and again [5-18] both in early AM while sleeping. [5-18] event required ICU admission. Also febrile at this time. Felt to be secondary to not being on his usual home CPAP. Because of history of prior possible PE, V/Q scan repeated and demonstrated no PE. Cardiac enzymes cycled and negative, ECG without concerning changes, cxr unremarkable. Echo checked and no evidence of heart failure. . 3)Acute renal failure/CKD stage 3: Patient developed renal failure in setting of fevere, hypoxia on [5-18]. Patient hypovolemic, likely pre-renal. Ace, hctz held, patietn hydrated and bp allowed to auto-regulate. patient's creatinine returned to baseline of low 2's. Continuing to hold ace, hctz through discharge, to be re-started at discretion of Dr. [Last Name (STitle) ] and [Doctor Last Name 4920]. Should have repeat chem-10 on [5-24] Consider MRA to look for renal artery stenosis as outpatient. SPEP/UPEP without concerning abnormalities. . 4)Alkaline phosphatase elevation: should have repeat testing as outpatient, no acute pathology noted. . 5)Possible recent PE: On last admission, decision made to maintain coumadin x 6 months. Maintained on coumadin throughout, inr therapeutic. Discharged on 6mg to be taken [5-22] and [5-23] and will need repeat INR on [5-24]. followed in [Hospital 2786] clinic. . 6)OSA: Initially not on home CPAP. Placed on home CPAP after desats and hypoxia resolved. Has machine at home, agrees to compliance. Will need pulmonary follow-up. . 7)DM: continued outpatient insulin regimen. Low on AM of [5-22] because patient did not eat full dinner. Knows to decrease insulin if does not eat. Will take lower dose on [5-22] PM to avoid low in Am. Has follow-up at [Last Name (un) ] Diabetes. . 8)Asthma: continued albuterol/atrovent/advair . 9)Hypertension: continued lisinopril, diltiazem, hctz initially. With renal failure lisinopril and hctz held and then hydralazine initiated. Patient discharge [Male First Name (un) ] diltiazem and hydralazine with plan to re-initiate ace and hctz at discretion of Dr. [Last Name (STitle) ] and Heonig once creatinine re-checked. Off ace and hctz and on hydralazine BP's generally 150's to 160's. . 10)Hyperlipidemia: off statin given lft rise during last hospital admission. Mild lft elevation again here. Needs repeat lft's as outpatient. . 11)Smoking cessation: maintained on wellbutrin. . GI prophylaxis: protonix . DVT prophylaxis:therapeutic on coumadin . Code:full throughout . Medications on Admission: 1. buproprion 100mg [Hospital1 ] 2. diltiazem xr 180mg daily 3. advair 4. atrovent 5. albuterol 6. coumadin--varying dose, but currently 10qhs 7. hctz 50 8. lisinopril 40 9. Insulin--nph 62 qam, 52 q pm, sliding scale Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation [Hospital1 ] (2 times a day). 2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO QHS (once a day (at bedtime)). 3. Warfarin 6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): take this dose until you are seen by Dr. [Last Name (STitle) ]. 4. Terbinafine 1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:1 tube Refills:2 5. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:60 Capsule(s) Refills:0 7. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 6 days. Disp:18 Tablet(s) Refills:0 8. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) unit Subcutaneous once a day: as directed continue your current insulin dose, 62UNPH in AM and 52U NPH in PM. 9. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO four times a day: continue this medication until you are re-started on your other blood pressure medications. Disp:40 Tablet(s) Refills:0 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 12. Outpatient [Name (NI) ] Work PT/PTT, Chem-10 to be done on [2187-5-24] when you see Dr. [Last Name (STitle) ]. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Cellulitis 2. Respiratory Failure 3. Acute Renal Failure . Secondary: 1. Obstructive Sleep Apnea 2. Type II DM with renal complications, controlled 3. CKD stage 3 4. Anemia 5. Hypertension 6. Hyperlipidemia 7. Transaminitis 8. Alkaline phosphatase elevation 9. Asthma Discharge Condition: Stable. Tolerating PO, ambulating, using CPAP, breathing well. Discharge Instructions: Take all your medications as prescribed. I have changed a number of your medications. You should not take the hydrochlorothiazide or lisinopril until you are seen by a doctor. Instead, you will be taking the hydralazine. . For the next two days take 6mg of coumadin each night until you have your INR checked on Thursday. Make sure to have your INR checked on Thursday, I have provided you a prescription. [Hospital ] clinic will adjust your coumadin appropriately based on that value. You should also have your creatinine checked on thursday when you see Dr. [Last Name (STitle) ]. . Make sure to use your CPAP as scheduled. Continue to take your antibiotic as prescribed, Dr. [Last Name (STitle) ] will evaluate your cellulitis and may change your antibiotics. The doctors here noted some swollen lymph glands, make sure Dr. [Last Name (STitle) ] follows this up to make sure it resolves. You also were noted to have blood in your urine, make sure your kidney doctor knows about this. Take your insulin as we discussed. Followup Instructions: You should schedule an appointment this week with your kidney doctor, Dr. [Last Name (STitle) 4920] at [Last Name (un) ]. You have the number, call him Thursday to make an appointment. . You must follow up with Dr. [Last Name (STitle) ] on thursday as below. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5377], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2187-5-24] 4:40 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5377], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2187-6-21] 4:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5377], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2187-5-24] 4:40	[ "585.2", "403.91", "493.90", "799.02", "682.6", "285.9", "518.82", "584.9", "790.4", "790.5", "272.4", "250.40", "278.00", "V58.67", "V58.61", "305.1", "327.23" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	11350, 11356	5443, 9502	343, 350	11680, 11746	2756, 3182	12838, 13569	2030, 2040		9775, 11327		11377, 11659		9528, 9752			11770, 12815			3199, 5420						2055, 2737																			277, 305									378, 1431																1453, 1823	1839, 2014
11,825	127,918	6915	Discharge summary	report	Admission Date: [2179-4-28] Discharge Date: [2179-5-14] Date of Birth: [2136-2-6] Sex: M Service: [Last Name (un) ] CHIEF COMPLAINT: Enterococcal bacteremia. HISTORY OF PRESENT ILLNESS: This patient is a 43-year old male status post orthotopic liver transplant on [2178-12-1] with hepatitis C, status post multiple stent placement, presented to the [Hospital 1326] Clinic on [2179-4-28] with acutely elevated liver function tests. The patient reported increasing fatigue times approximately 1 month with intermittent abdominal cramping. The patient was found to have positive blood cultures [3-1] revealing pansensitive enterococcus. PAST MEDICAL HISTORY: Hepatitis C, cirrhosis status post orthotopic liver transplant in [11-29], common bile duct stenting, and diabetes mellitus. PAST SURGICAL HISTORY: As above. MEDICATIONS: 1. Prograf 7 mg p.o. b.i.d. 2. CellCept [Pager number ] mg p.o. b.i.d. 3. Bactrim SS q.day. 4. Lopressor 50 mg p.o. b.i.d. 5. Prednisone 30 mg p.o. b.i.d. 6. Protonix 40 mg p.o. b.i.d. 7. Procrit q.Friday. 8. Paxil. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He denies ETOH or tobacco. PHYSICAL EXAMINATION: On presentation, the patient was afebrile with stable vital signs. The exam is remarkable for a midline abdominal wound that is healing well and soft, nontender, and nondistended abdomen. HOSPITAL COURSE: The patient was admitted to the Transplant Surgery Service and put on vancomycin. The patient continued his home immunosuppressant and was put on fluconazole, and was taking Bactrim as well. The patient had an ERCP on [2179-4-29], which demonstrated a stone in the common hepatic duct proximal to the biliary anastomosis and biliary stricture compatible with anastomotic stricture following transplant. A common hepatic duct stone was extracted and the anastomotic stricture was dilated to 10 mm. Triple stents were placed in the common bile duct and the patient had a previous sphincterotomy from previous ERCPs. An Infectious Disease consult was called and it was recommended that the patient start penicillin G and a couple of doses of gentamicin for synergy. The patient was also being followed by [Last Name (un) ] for management of his diabetes. A PICC was placed for IV antibiotics during the hospital stay and a percutaneous liver biopsy was attempted on [2179-5-4] by Hepatology. This was aborted secondary to complaint of right- sided chest pain radiating to the shoulder. A chest x-ray was ordered and it showed free air and right pleural effusion. A CAT scan was obtained at this time and a right chest tube was placed. Cardiothoracic Surgery was consulted and the patient was taken to the OR on [2179-5-4] for a thoracotomy and evacuation of hemothorax. The patient tolerated this procedure well and was transferred to the floor and hemodynamically stable. The patient's chest tube was discontinued on [2179-5-6] without any complications. Throughout the events, the patient required multiple blood transfusions and tolerated these well. On [2179-5-10], given that the patient's LFTs continued to elevate, a transjugular liver biopsy was attempted by IR. This biopsy was consistent with hepatitis C and it was decided upon discharge that the patient would start another course of interferon and ribavirin treatment. On [2179-5-14], the patient was afebrile with stable vital signs with good p.o. intake and urine output. On exam, the patient's right thoracotomy incision was clean, dry, and intact and the patient's midline incision was healing well with PTC tubes in place. The patient was to start PEG-interferon and ribavirin treatment as per Hepatology and Transplant Surgery. The patient finished his course of 14 days of penicillin and followup blood cultures were negative. DISCHARGE DISPOSITION: To home with services for lab draws. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: Recurrent hepatitis C. Common bile duct stenosis and stone status post endoscopic retrograde cholangiopancreatography and stone retrieval, stent placement times 3. Right hemothorax status post chest tube placement and thoracotomy for evacuation. Diabetes mellitus. FOLLOW UP: The patient was to follow up with [Hospital 1326] Clinic on Wednesday, [2179-5-19], as arranged by the transplant coordinator. INVASIVE PROCEDURES: The patient is status post endoscopic retrograde cholangiopancreatography with stent placement times 3 on [2179-4-29]. The patient is status post attempted liver biopsy on [2179-5-4]. The patient is status post right chest tube placement on [2179-5-4]. The patient is status post right thoracotomy/evacuation of hemothorax on [2179-5-4]. The patient is status post transjugular liver biopsy on [2179-5-10]. DISCHARGE MEDICATIONS: 1. Bactrim 1 tablet p.o. q.day. 2. Protonix 40 mg p.o. q.day. 3. Lopressor 50 mg p.o. b.i.d. 4. Paxil 10 mg p.o. q.day. 5. Fluconazole 400 mg p.o. q.day. 6. Valganciclovir 450 mg p.o. q.day. 7. Ursodiol 300 mg p.o. t.i.d. 8. Epogen 20,000 units q.Friday. 9. Nystatin swish and swallow. 10. CellCept [Pager number ] mg p.o. b.i.d. 11. Prednisone 20 mg p.o. q.day. 12. Sucralfate 1 g p.o. q.i.d. 13. Insulin sliding scale. 14. Dilaudid 10 mg p.o. q.6h. until follow up where further pain medications will be prescribed and narcotics will be tapered. 15. PEG-interferon 180 mcg subcutaneously q.Friday. 16. Ribavirin 1000 mg p.o. q.day. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 3432] Dictated By:[Last Name (NamePattern1) 4881] MEDQUIST36 D: [2179-5-14] 14:03:47 T: [2179-5-15] 02:26:01 Job#: [Job Number 26047]	[ "998.11", "996.82", "276.7", "574.51", "E878.0", "284.8", "070.51", "790.7", "511.8" ]	icd9cm	[ [ [] ] ]	[ "34.04", "51.87", "50.11", "51.88", "34.09", "99.04", "38.93", "51.84" ]	icd9pcs	[ [ [] ] ]	3895, 3933			3955, 3964				3986, 4255	4880, 5826					1430, 3871										870, 1154							4267, 4857		1222, 1412											171, 197									226, 693																716, 846	1171, 1199
9,216	168,948	23779	Discharge summary	report	Admission Date: [2199-10-2] Discharge Date: [2199-10-6] Date of Birth: [2170-4-19] Sex: M Service: MEDICINE Allergies: Erythromycin Base Attending:[First Name3 (LF) 2234] Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: none History of Present Illness: 29M with uncontrolled DM-I, erosive gastritis, and esophagitis with multiple prior admissions for severe gastroparesis (s/p [First Name3 (LF) ] and gastric pacer without relief) and UGIB who was admitted with a two day h/o nausea, vomiting, and inability to tolerate POs. He also c/o mild abdominal discomfort. He denied coffee-ground emesis, melena, hematochezia, or hematemesis. He also reported diaphoresis and a syncopal episode 2 days prior to admission; he struck his head and was down for an unknown period of time. Pt denies antecedent palpitations or chest pain. He reported that his blood sugar was low, but he does not remember the exact value. . In ED T 100.1, HR 116, BP 139/95, 98%RA. FS 261. Coffee-ground emesis was noted. He was given morphine 4 mg IV x1, Zofran 4 mg IV x3, Protonix IV x1, Reglan 10 mg IV. Pt refused NG lavage or rectal exam. KUB and CXR were unremarkable. CT abdomen showed a markedly distended bladder; this had been seen previously and has been attributed to autonomic dysfunction. A Foley catheter was placed. He was initially admitted to the [Hospital Unit Name 153] in the setting of relentless nausea and vomiting. He stabilized within 48 hours and was transferred to the floor. Past Medical History: 1. Diabetes Mellitus Type I 2. Gastroparesis, failed [Hospital Unit Name ] and gastric pacer 3. Erosive gastritis, esophagitis 4. Fe deficiency anemia 5. hypercholesterolemia 6. Hypertension 7. Chronic renal failure Social History: Patient lives with his wife who is very dedicated to his care. Denies tobacco, alcohol, and illicit drug use. He is currently unemployed and on disability. Family History: Paternal grandfather with [Name (NI) 59282] Mother and sister with thyroid disease Physical Exam: VS: 99.5, 106, 170/103, 15, 98% RA Gen: nauseous appearing male sitting in bed HEENT: MMD, Op clear, Non elevated JVP when sitting up. Left EJ line CV: Tachycardic. Regular rhythm. No M/R/G. Non displaced PMI Lungs: CTAB, no wheezes, rales or rhonchi Abd: soft, no focal right upper quadrant pain. Mild midepigastric tenderness. Diffuse discomfort during exam given nausea Ext: No LE edema, cyanosis or clubbing Pertinent Results: [2199-10-2] WBC-7.8 RBC-4.47* Hgb-10.9* Hct-32.7* MCV-73* MCH-24.4* MCHC-33.3 RDW-14.7 Plt Ct-413 [2199-10-2] 11:53PM Hgb-10.8* Hct-33.1* [2199-10-3] WBC-10.2 RBC-3.83* Hgb-9.4* Hct-28.7* MCV-75* MCH-24.4* MCHC-32.6 RDW-14.8 Plt Ct-382 [2199-10-3] 02:48PM Hct-26.6* [2199-10-2] 07:00PM BLOOD PT-13.0 PTT-25.5 INR(PT)-1.1 [2199-10-2] Glucose-237* UreaN-15 Creat-2.2* Na-140 K-4.5 Cl-101 HCO3-26 [2199-10-3] 07Glucose-212* UreaN-17 Creat-1.7* Na-138 K-4.5 Cl-104 HCO3-24 Albumin-3.8 Calcium-8.8 Phos-3.2 Mg-2.1 [2199-10-2] 07:00PM BLOOD ALT-58* AST-106* CK(CPK)-4027* AlkPhos-106 Amylase-131* TotBili-0.4 Lipase-17 [2199-10-3] 07:21AM BLOOD ALT-43* AST-59* LD(LDH)-175 CK(CPK)-[2215]* AlkPhos-87 Amylase-84 TotBili-0.3 Lipase-15 [2199-10-2] 07:00PM BLOOD CK 4027 CK-MB-4 cTropnT-<0.01 [2199-10-3] 07:21AM BLOOD CK [2215] CK-MB-3 cTropnT-<0.01 [10-2] CXR: No evidence of acute intrathoracic process. [2199-10-2] KUB: No evidence of obstruction or ileus. [2199-10-3] CT Abd/Pelvis: CT OF THE ABDOMEN: The lung bases are clear. Visualized heart and pericardium appear unremarkable. Distal esophageal thickening is unchanged and may relate to the patient's gastroparesis or gastritis. Given the limitations of a non-contrast study, the liver, gallbladder, adrenal glands, spleen, pancreas, and kidneys appear normal. Hydronephrosis seen on the previous exam has resolved. There is minimal perinephric stranding. Loops of small and large bowel are normal in caliber and contour. Note is made of a gastric stimulator device with a subcutaneous component and leads extending to the anterior surface of the stomach. Several small retroperitoneal lymph nodes are noted, which do not meet criteria for pathological enlargement, and there are also several small mesenteric lymphnodes. There is no free air or free fluid. CT OF THE PELVIS: The bladder is massively distended, but less so than the previous exam. The prostate is not enlarged. The seminal vesicles and rectum appear unremarkable. The pelvic loops of bowel appear normal. The appendix is normal. There is no free fluid in the pelvis. OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic lesions. IMPRESSION: 1. No evidence of bowel abnormality. 2. Distended bladder, as seen previously. . [2199-10-3] CT Head: No evidence of acute intracranial hemorrhage. Unchanged appearance of the brain compared to [2197-3-7]. . EKG: Sinus tachycardia rate 110. Brief Hospital Course: 29 yo male with DM-I, severe gastroparesis refractory to treatment (including [Year (4 digits) ] and gastric pacer), chronic kidney disease, and anemia, admitted with nausea, vomiting, and coffee ground emesis likely secondary to diabetic gastroparesis and gastritis/esophagitis. Patient admitted to [Hospital Unit Name 153] on [10-2], transferred to floor night of [10-4]. 1. Nausea and Coffee-Ground Emesis: Secondary to patient's longstanding gastroparesis and gastritis. Although the pt refused rectal exam and NG lavage on admission, his hematocrit stabilized to its baseline following administration of IV fluids. The patient was initially kept NPO with antiemetics including zofran, phernergan, ativan. Morphine was given as needed for pain. Gastroenterology recommended stopping his anticholinergics and increasing his Zofran to 8 mg IV QID. This was done. The patient was also given suppositories to facilitate bowel movements. He was transitioned to PO zofran and reglan on the floor and his symptoms resolved. hematocrit stable throughout and no further bloody emesis. Patient will follow up with Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) 679] on [10-15] for consideration of domperidone or ativan to help with gastroparesis. Protonix maintained throughout, omeprazole as outpatient. 2. DM-I: FSBG was 300 on admission to ICU. Although his baseline Lantus and HISS were initially continued, [Last Name (un) ] was consulted; the patient's Lantus was thereafter given at night, and his HISS was changed to a RISS (because he has diabetic gastroparesis). After the regimen change, he was hypoglycemic overnight. D5-containing IV fluids were started; there was no anion gap, but ketones were found in the urine. His Lantus was decreased to 20 units QHS, and his sliding scale continued. On [10-5] patient maintained on D5 drip and began taking clears. [10-5] lost IV access and not given Lantus (incident report filed). Patient able to take good PO by [10-6] AM and no need for access. Given NPH 10 units AM of [10-6] for basal insulin and then planned re-start of home lantus dosing on [10-6] evening, night of discharge. Has [Last Name (un) ] follow up. Of note, did have low blood sugar on [10-6] but after juice, up to 140. Patient instructed to monitor blood sugars closely overnight, he did not want to stay for monitoring and felt he was going to have good PO intake at home and would monitor closely. 3. HTN: The patient takes valsartan and metoprolol at home; initially held in [Hospital Unit Name 153]. Re-started with PO intake on [10-5]. 4. Sinus tachycardia: Likely due to hypovolemia and discomfort. Improved with ivf's and control of gastroparesis. 5. Acute Renal Failure/Chronic Kidney Disease: Most likely prerenal due to vomiting, improved with fluids. Creatinine 1.8 on discharge, which is recent baseline. . 6. Fall/Rhabdomyolysis: The patient's CK was over 4000 on admission. This is likely due to his recent syncopal episode, fall, and unknown period of time being down. His CK continues to trend down rapidly; it was 900 this morning. His liver enzymes were also abnormal on admission but normalized. A head CT (s/p fall) showed no evidence of an acute intracranial process. CK down to 400 by [10-5]. MB's and troponins negative. 7. GERD: PPI continued 8. Transaminitis: resolved with treatment of gastroparesis. 9. anemia: chronic disease, stable throughout. Medications on Admission: Folic Acid 1 mg daily Thiamine HCl 100 mg daily Senna 8.6 mg po bid Docusate Sodium 100 mg po bid Valsartan 80 mg po bid Metoclopramide 10 mg PO QIDACHS Ondansetron 8 mg Tablet, Rapid Dissolve po q8h* Omeprazole 20 mg po daily Toprol XL 25 mg po daily Insulin Glargine - 25 units at bedtime- as per pt Insulin [Name (NI) ] per insulin sliding scale Discharge Medications: Discharge Disposition: Home Discharge Diagnosis: gastroparesis upper GI bleed secondary diagnosis: diabetes mellitus type I gastritis chronic renal insufficiency hypertension Discharge Condition: stable, tolerating food, ambulating Discharge Instructions: You admitted with gastroparesis and blood in your vomit. We gave you medications for your nausea and intravenous fluids. Gastroeneterology saw you while you were in the hospital. Please call 911 or return to the hospital if you experience fevers, abdominal pain, nausea, vomiting, unable to take food/drink, vomiting blood, blood in stools or other concerning symptoms. Followup Instructions: Please schedule a follow-up appointment with Dr. [Last Name (STitle) ] within 1 week after leaving the hospital. You have the following scheduled appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7212], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2199-11-12] 4:00	[ "250.63", "401.9", "728.88", "280.9", "357.2", "536.3", "584.9", "535.41", "272.0" ]	icd9cm	[ [ [] ] ]	[ "99.04" ]	icd9pcs	[ [ [] ] ]	9007, 9013	5060, 8580	295, 302	9184, 9222	2543, 4884	9642, 9962	2006, 2095		8984, 8984		9034, 9064		8606, 8960			9246, 9619									2110, 2524																			239, 257									330, 1573		4893, 5037	9085, 9163													1595, 1816	1832, 1990
6,749	190,849	44565	Discharge summary	report	Admission Date: [2112-3-17] Discharge Date: [2112-3-22] Date of Birth: [2033-2-26] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 79 year-old female with a past medical history significant for breast cancer status post left mastectomy with known metastases to lung and pericardium status post multiple drainages who presents with acute shortness of breath. The patient had recently been admitted to [Hospital1 188] [2-25] through the 8th for shortness of breath, congestive heart failure and acute renal failure. She was thought to be in acute congestive heart failure, diuresed and then discharged to [Hospital1 ]. Following her discharge from [Hospital1 ] the patient noted gradually progression of her shortness of breath "my heart building up water." She noted dyspnea on exertion after approximately 10 feet of walking on room air. Her symptoms were improved on oxygen nasal cannula. This is much changed from her baseline of walking several 100 feet before fatigue. Her review of systems was also positive for decreased appetite, mild weight gain with increased lower extremity edema and increased abdominal girth. The patient was admitted for management of her shortness of breath. PAST MEDICAL HISTORY: 1. Breast cancer status post left mastectomy. No radiation therapy. Known metastases to lung and pericardium. Status post multiple drainages. 2. Hypertension. 3. Chronic Klebsiella urinary tract infections. 4. Left knee replacement. 5. Glaucoma. 6. Pernicious anemia. 7. Peripheral vascular disease. 8. History of gastrointestinal bleed. 9. Gastritis. 10. Left nephrectomy. 11. Chronic renal insufficiency. 12. Gout. 13. Hypercholesterolemia. 14. Hypothyroidism. 15. Diabetes mellitus type 2. 16. Status post right knee arthroscopy 17. Paroxysmal atrial fibrillation. 18. History of endocarditis. 19. Congestive heart failure with diastolic dysfunction. 20. Depression. HOME MEDICATIONS: 1. Lasix. 2. Atrovent. 3. Albuterol. 4. Senna. 5. Levoxyl. 6. Insulin. 7. Glimepiride. 8. Lactulose. 9. Dulcolax. 10. Multivitamin. 11. Paxil. 12. Calcium acetate. 13. Metoprolol. 14. Amlodipine. 15. Vitamin B-12. 16. Subcutaneous heparin. 17. Prevacid. 18. Lipitor. 19. Folate. 20. Iron. 21. Arimidex. 22. Allopurinol. ALLERGIES: No known drug allergies. FAMILY HISTORY: Father with diabetes. SOCIAL HISTORY: The patient admitted from [Hospital1 ]. No current alcohol or tobacco use. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.3. Blood pressure 130/62. Pulse 84. Respirations 22. O2 sat 93% on 4 liters of oxygen nasal cannula. Physical examination general elderly female sitting up in bed in no acute distress. HEENT pupils are equal, round and reactive to light and accommodation. Extraocular movements intact. JVD to 7 cm. Neck without lymphadenopathy. Cardiovascular regular rate and rhythm. 3 out of 6 crescendo murmur heard best at the left upper sternal border. Lungs decreased breath sounds at bilateral bases. Diffuse expiratory wheezes. Abdomen obese, soft, nontender, nondistended with positive bowel sounds. Extremities trace lower extremity edema. LABORATORIES ON ADMISSION: White blood cell count of 6.7, hematocrit 32.3, platelets 284, sodium 140, potassium 4.7, chloride 91, bicarb 41, BUN 32, creatinine 1.1, glucose 166. CT angio negative for PE, increased pleural effusion left greater then right, persistent pericardial effusion. HOSPITAL COURSE: 1. Dyspnea: The patient admitted with acute and progressive shortness of breath. She had baseline bilateral pleural effusions. CT of the chest showed an interval increase in these effusions. The patient underwent thoracentesis on her left side on [3-18] with approximately 300 cc of fluid removed. Initial pleural studies were consistent with an exudate with cytology pending at the time of discharge. The patient did have symptomatic improvement following thoracentesis. She then developed mild respiratory distress with hypercarbia. She was briefly placed on BiPAP with improvement of symptoms. She was then weaned off of BiPAP and maintained on oxygen via nasal cannula. The patient was initially considered for pleurodesis, however, following discussion with the family the patient decided she did not desire any further treatment for her recurrent pleural effusions. 2. Congestive heart failure with diastolic dysfunction: The patient initially admitted with mild congestive heart failure. She was maintained on Hydralazine and Imdur for after load reduction. She also was gently diuresed with intravenous Lasix. She also was maintained on a beta-blocker, statin and aspirin. She had an echocardiogram showing no significant change from previous studies with significant tricuspid regurgitation and mitral regurgitation. The patient was initially maintained on her cardiac medications, however, with decision to progress to CMO status these were discontinued. 3. Glaucoma: The patient was maintained on her eye drops for glaucoma as per her outpatient regimen. 4. Diabetes: Patient maintained on sliding scale insulin initially with her blood sugars essentially normoglycemic. As the patient progressed to CMO status she did not desire further finger stick monitoring and this was discontinued. 5. Chronic renal insufficiency: Patient admitted with elevated creatinine thought to be due to over diuresis. Po intake with intravenous fluids was encouraged. Creatinine then trended down back to her baseline. She maintained excellent urine output. 6. Oncology: Patient with metastatic breast cancer with known mets to lung and pericardium. She has had multiple admissions for this and with persistent reaccumulation of pleural effusions. The patient decided she did not desire further treatment for her breast cancer and that she instead wished palliative care. She was discharged to hospice. The patient was given morphine as needed for her pain and respiratory distress. DISPOSITION: Following lengthy discussion with the patient, patient's family and multiple physicians involved in her care the patient decided that she wished to be made CMO. She did not desire any aggressive interventions for management of her cancer, dyspnea, cardiovascular disease or other issues. She wished to be managed in a way as to maintain her comfort. Per her wishes laboratory draws were discontinued. In addition, her maintenance medications were discontinued. She was maintained on morphine for pain and respiratory distress. She also was maintained on oxygen as needed for comfort. The patient was evaluated by Health Care [Hospital 94111] Hospice Service with plans to be discharged into their care. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Ativan .5 to 2 mg q 4 hours prn sublingual dispense 2 cc of 5 mg per cc elixir. 2. Levsin .125 to .25 mg q 4 to 6 hours prn sublingual dispense 2 cc of .25 mg per cc elixir. 3. Morphine concentrate 5 to 20 mg q one to two hours prn sublingual dispense 2 cc of 50 mg per cc elixir. DISCHARGE FOLLOW UP: The patient is discharged into care of hospice and the remainder of her medical management will be managed by hospice. [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 1197] Dictated By:[Last Name (NamePattern1) 5212] MEDQUIST36 D: [2112-3-22] 10:00 T: [2112-3-22] 10:01 JOB#: [Job Number 95449]	[ "V10.3", "428.0", "198.89", "281.0", "197.0", "428.30" ]	icd9cm	[ [ [] ] ]	[ "34.91", "93.90" ]	icd9pcs	[ [ [] ] ]				6799, 6808			2402, 2425		6831, 7129					3533, 6777														2004, 2385			7141, 7509																						170, 1270								3252, 3515								1292, 1986	2442, 2544
441	188,256	13837+56488	Discharge summary	report+addendum	Admission Date: [2123-5-16] Discharge Date: [2123-8-5] Date of Birth: [2082-2-7] Sex: F Service: SURGERY Allergies: Azithromycin / Zosyn Attending:[First Name3 (LF) 695] Chief Complaint: fulminant hepatic failure secondary to HSVII Major Surgical or Invasive Procedure: emergent ABO incompatible OLT w/splenectomy for HSV/fulminant hepatic failure [5-23] sp [Last Name (un) ] ICP monitor placement [5-22] sp liver biopsy X 2 sp Bronchoscopy [6-5] sp tracheostomy CT guided drainage of intra abd fluid collection [6-8] sp brain biopsy [7-8] History of Present Illness: 41 y/o F w/past med hx of recently diagnosed HTN, who went to the [Hospital3 3765] ED last night with nausea, vomiting, and diarrhea. Her illness began 6 weeks ago with only watery, non-bloody diarrhea (7-8x/day). She attributed this to stress as she's been going through a divorce. However, 9 days ago (on [5-8]), she began to feel worse, with generalized body aches, chills, sweats and a cough. She saw her PCP who felt she had bronchitis and gave her Zithromax. This was on [2123-5-10]. She took the Zithromax that night and the next morning, and subsequently developed nausea and vomiting 4-5x/day (and diarrhea continued). She went to the [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [5-11], and she was tachycardic at 120, febrile to 100.5. They felt she had gastroenteritis. At that time, her WBC count was 10, AST 163, ALT 116, and K 2.6. Her BUN was 7, creatinine 1.0, bicarb 19. She was given IV fluid, Reglan, and was discharged home on Levaquin 250 mg daily and Potassium 20 meq daily. All of last week, she continued to feel poorly with continued nausea, vomiting, fevers, chills, and vague abdominal pain. She also had some low back pain and for this took 12 tablets of Ibuprofen/day for 4-5 days. She also c/o left knee pain and a lower extremity rash. On Friday she went to [Location (un) 6408]for work, and came back last night. Upon returning home, she went immediately back to the Emergency Room as she still felt terrible. At [Hospital3 3765], she was noted to have acute renal failure with a BUN 36, creatinine 7.6, AST 1500, ALT 800, (nl bili), pH 7.22, bicarb 18, ESR 55, WBC 1.9 with 81% polys, hgb 10.4. Urine sediment examined by physician at [Name9 (PRE) ] (who is also a renal fellow) demonstrated many WBCs, many RBCs, many squamous epithelial cells, many renal tubular epithelial cells, many coarse granular casts, and no red cell casts. She had a stool culture from [5-11] which grew abundant Staph and did not grow normal gram negative enteric flora. O&P neg, stool cx neg for salmonella, campylobacter, shigella, or EColi O157:H7. They felt she had ATN due to NSAIDs as well as a necroinflammatory hepatitis, and transferred her to [Hospital1 18] for further care. On further review of systems, she denies recent travel to anywhere other than the recent trip to [Location (un) ]. She denies any sick contacts, IVDU, tattoos, or eating anything out of the ordinary. She does report unprotected sexual intercourse approximately 2 weeks ago. She had a D&C on [2123-4-23] for abnormal uterine bleeding, but denies any abnl vaginal discharge. Past Medical History: 1. HTN, diagnosed 2 months prior to admission 2. Hypothyroidism 3. Depression 4. D&C [2123-4-23] for abnl uterine bleeding 5. h/o Syncope one month prior to admission Social History: Lives in [Location 1514], in the middle of a very stressful divorce. Has 3 children, ages 6, 7, and 9 years old (6 and 9 year old girls adopted from [Country 651], 7 year old boy biological). Works as a writer and speaker. Drinks 2-3 alcoholic drinks one night per week. Denies tobacco or IVDU. No tattoos or piercings. No recent travel. One pet at home (rabbit). Family History: HTN DM Physical Exam: T: 98.9 BP: 113/53 P: 108 RR: 43 O2 sat 100% RA Gen: awake/alert pleasant female, appears anxious, uncomfortable, and in mild distress HEENT: face flushed, sclerae anicteric, conjunctivae noninjected, mucous membranes dry Neck: + tender anterior cervical lymphadenopathy on L, approx 1 cm Lungs: decreased breath sounds at left base, mild inspiratory crackles at R base, o/w clear to auscultation bilaterally CV: tachycardic, regular, no murmurs, rubs, or gallops Abd: + TTP RUQ without rebound or guarding, nondistended, soft, with normoactive bowel sounds. Liver edge palpable approx [2-4] cm below costal margin. Mild left CVA tenderness. No vertebral tenderness. Ext: toes are cold, 2+ dorsalis pedis pulses bilaterally Skin: vague livedo reticularis rash on lower extremities, good skin turgor Pertinent Results: Admission: PT-14.5* PTT-31.5 INR(PT)-1.4 PLT COUNT-274 WBC-2.0* RBC-3.65* HGB-10.7* HCT-31.2* MCV-86 MCH-29.4 MCHC-34.3 RDW-14.0 ALBUMIN-3.0* CALCIUM-6.1* PHOSPHATE-4.0 MAGNESIUM-1.4* ALT(SGPT)-882* AST(SGOT)-1865* ALK PHOS-313* TOT BILI-0.2 GLUCOSE-120* UREA N-38* CREAT-7.3* SODIUM-136 POTASSIUM-3.1* CHLORIDE-105 TOTAL CO2-9* ANION GAP-25* TYPE-ART PO2-95 PCO2-19* PH-7.19* TOTAL CO2-8* BASE XS--18 Hospital Course: CBC: [2123-5-18] 07:45PM BLOOD WBC-1.9* RBC-3.51* Hgb-10.7* Hct-29.8* MCV-85 MCH-30.6 MCHC-36.0* RDW-14.2 Plt Ct-144* [2123-5-20] 03:12PM BLOOD WBC-5.1 RBC-3.33* Hgb-10.1* Hct-28.9* MCV-87 MCH-30.5 MCHC-35.1* RDW-14.5 Plt Ct-43* [2123-5-21] 08:25PM BLOOD Hct-23.8* Plt Ct-65* [2123-5-22] 08:15PM BLOOD WBC-7.1 RBC-3.53* Hgb-10.3* Hct-29.0* MCV-82 MCH-29.2 MCHC-35.6* RDW-16.4* Plt Ct-84* [2123-5-24] 09:13PM BLOOD WBC-11.7* RBC-3.63* Hgb-10.9* Hct-29.9* MCV-82 MCH-30.2 MCHC-36.6* RDW-14.6 Plt Ct-180 [2123-5-28] 03:00PM BLOOD WBC-9.0 RBC-3.70* Hgb-11.1* Hct-32.4* MCV-88 MCH-29.9 MCHC-34.1 RDW-16.8* Plt Ct-123* [2123-6-5] 02:30AM BLOOD WBC-25.0* RBC-2.79* Hgb-8.6* Hct-25.9* MCV-93 MCH-30.7 MCHC-33.1 RDW-23.6* Plt Ct-109* [2123-6-6] 08:23PM BLOOD WBC-30.5* RBC-3.28* Hgb-9.9* Hct-30.0* MCV-91 MCH-30.2 MCHC-33.0 RDW-22.0* Plt Ct-79* [2123-6-21] 05:17PM BLOOD Hct-25.1* [2123-6-23] 03:12AM BLOOD WBC-18.5* RBC-3.37* Hgb-10.2* Hct-30.7* MCV-91 MCH-30.3 MCHC-33.3 RDW-19.6* Plt Ct-204 [2123-8-1] 03:50AM BLOOD WBC-17.6* RBC-3.70* Hgb-11.1* Hct-34.1* MCV-92 MCH-30.0 MCHC-32.6 RDW-16.4* Plt Ct-565* Coags: [2123-5-31] 01:12PM BLOOD PT-14.9* PTT-27.7 INR(PT)-1.5 [2123-6-3] 10:00AM BLOOD PT-13.2 PTT-22.2 INR(PT)-1.2 [2123-6-7] 02:00AM BLOOD PT-14.4* PTT-21.5* INR(PT)-1.4 [2123-6-15] 02:05AM BLOOD PT-13.6* PTT-19.9* INR(PT)-1.2 [2123-7-1] 02:07AM BLOOD PT-12.7 PTT-23.7 INR(PT)-1.1 [2123-7-11] 01:41AM BLOOD PT-12.5 PTT-22.3 INR(PT)-1.0 Chemistries: [2123-5-23] 08:00AM BLOOD UreaN-44* Creat-2.6* [2123-5-25] 10:00AM BLOOD Glucose-87 UreaN-59* Creat-3.3* Na-143 K-5.4* Cl-100 HCO3-31* AnGap-17 [2123-5-28] 08:45AM BLOOD Glucose-95 UreaN-92* Creat-3.2* Na-149* K-2.9* Cl-108 HCO3-28 AnGap-16 [2123-5-31] 10:00AM BLOOD Glucose-117* UreaN-115* Creat-2.1* Na-145 K-4.4 Cl-117* HCO3-16* AnGap-16 [2123-6-2] 05:22AM BLOOD Glucose-175* UreaN-94* Creat-1.5* Na-143 K-5.6* Cl-112* HCO3-20* AnGap-17 [2123-6-3] 06:11PM BLOOD Glucose-131* UreaN-94* Creat-1.3* Na-143 K-3.4 Cl-107 HCO3-23 AnGap-16 [2123-6-4] 03:14AM BLOOD Glucose-128* UreaN-88* Creat-1.2* Na-142 K-3.9 Cl-109* HCO3-21* AnGap-16 [2123-6-4] 10:45AM BLOOD Glucose-90 UreaN-83* Creat-1.1 Na-142 K-3.6 Cl-111* HCO3-21* AnGap-14 [2123-6-6] 02:08AM BLOOD Glucose-111* UreaN-63* Creat-0.7 Na-144 K-4.0 Cl-111* HCO3-22 AnGap-15 [2123-7-1] 02:07AM BLOOD Glucose-179* UreaN-27* Creat-0.3* Na-142 K-3.7 Cl-108 HCO3-22 AnGap-16 [2123-5-16] 02:08PM BLOOD ALT-882* AST-1865* CK(CPK)-91 AlkPhos-313* Amylase-881* TotBili-0.2 [2123-5-17] 06:12AM BLOOD ALT-1240* AST-3103* AlkPhos-416* TotBili-0.4 [2123-5-18] 04:14AM BLOOD ALT-1549* AST-4278* LD(LDH)-3935* AlkPhos-628* Amylase-795* TotBili-0.7 [2123-5-18] 07:45PM BLOOD ALT-1804* AST-5595* LD(LDH)-4960* AlkPhos-783* Amylase-437* TotBili-1.4 [2123-5-20] 04:05AM BLOOD ALT-1608* AST-5716* LD(LDH)-5590* AlkPhos-950* TotBili-3.1* DirBili-2.4* IndBili-0.7 [2123-5-21] 01:41PM BLOOD ALT-805* AST-3214* LD(LDH)-2638* AlkPhos-599* TotBili-4.0* [2123-5-22] 04:00PM BLOOD ALT-427* AST-1469* LD(LDH)-1730* AlkPhos-464* Amylase-470* TotBili-5.0* [2123-5-23] 03:48PM BLOOD ALT-282* AST-800* AlkPhos-357* TotBili-5.6* [2123-5-23] 06:10PM BLOOD ALT-109* AST-304* LD(LDH)-516* AlkPhos-161* Amylase-248* TotBili-4.0* [2123-5-24] 08:00AM BLOOD ALT-1022* AST-2252* AlkPhos-95 Amylase-219* TotBili-2.3* [2123-5-31] 04:43AM BLOOD ALT-112* AST-185* AlkPhos-134* Amylase-163* TotBili-3.3* [2123-6-1] 12:00AM BLOOD ALT-83* AST-133* AlkPhos-88 TotBili-2.4* [2123-7-2] 02:38AM BLOOD ALT-61* AST-33 AlkPhos-181* TotBili-0.4 [2123-7-26] 07:00AM BLOOD ALT-56* AST-44* AlkPhos-155* TotBili-0.3 [2123-8-3] 03:54AM BLOOD ALT-111* AST-48* AlkPhos-140* TotBili-0.3 [2123-5-16] 02:08PM BLOOD calTIBC-187* VitB12->[2118] Folate-GREATER TH Hapto-457* Ferritn->[2118] TRF-144* [2123-7-2] 02:38AM BLOOD calTIBC-159* TRF-122* [2123-6-6] 08:23PM BLOOD TSH-5.9* [2123-6-28] 11:30AM BLOOD TSH-7.4* [2123-7-8] 03:25PM BLOOD TSH-3.1 [2123-7-27] 12:25PM BLOOD TSH-6.2* [2123-5-16] 05:25PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2123-5-16] 05:25PM BLOOD HIV Ab-NEGATIVE MICRO: [8-1]- pan ctx'd [7-31] sputum- GPC, GNR [7-30] CMV Pending. [7-17] ALine neg. [7-12] CMV neg. [7-8] Brain abscess neg. [7-8] Abd-wound - staph, enterococcus, diphtheroids. [7-8] R SCL cath tip NG. [7-7] R SCL cath tip NG. [7-6] Sputum: Aspergillus, BCx: coag neg staph, UCx: yeast < 10^5. [7-3] Sputum: enterobacter, aspergillus. [6-30] Cath tip neg. [6-28] SpCx Aspergillus, UCx <10^5, BCx diphteroids [1-5] Brief Hospital Course: Ms. [Known lastname ] was sent to the [Hospital1 18] for further evaluation. She was on the tranplant surgery service awaiting transplantation with fulminant hepatic failure secondary to herpes virus. A bolt was placed on [2123-5-22] for encephalopathy and she was intubated. Broad spectrum antibiotics were started. A liver biopsy performed on [5-23] revealed 40-50% necrosis with viral changes consistent with herpes virus. Patient was taken to the operating room on [5-23] to have an ABO incompatible piggyback liver transplant. 19 units of PRBC, 17 units FFP, 6 units platelets, and 3 units FFP were given. Initially she received OKT3, methylprednisolone, and MMF for immunosupression. The regimen that she is currently on is MMF, tacrolimus, and prednisone. An ultrasound of the liver on [5-25] showed hepatic vessels with good flow. Her bolt was removed on [5-27]. Ms. [Known lastname ] had a prolonged postoperative course with multiple issues. Some of her most important issues are described below. It was discovered that she had an aspergillus pneumonia for which she was started on caspofungin [5-24]. She had the development of ascites and had CT guided drainage on [6-8]. She had further a further LUQ collection which was drained [6-15]. It was decided at this point to perform a tracheostomy on [6-16]. A brancheoalveolar lavage was performed on [6-27] which revealed enterobacter sensitive to aztreonam. A repeat head CT performed on [7-8] revealed an abscess from her prior burr hole site. She was taken to the operating room by the neurosurgery service for abscess drainage. A repeat head CT scan show improvement of the abscess on [7-13]. Patient also had a positive CMV viral load for which she was started on ganciclovir. Tube feeding was started and was tolerated well through a Dobhoff tube. A gradual vent wean was performed throughout the month of [Month (only) 205]. By the time of discharge, she was on trach mask. The weekend of [7-31], the was a temperature spike with a rising WBC count. After her central line was change, her clinical status improved.The patient was on mulitple antibiotic regimens throughout her hospital course which we tailored in consultation with the Infectious disease service. Her final regimen in listed below in the discharge medications. Pt should get FK levels checked daily and called into the transplant center. Medications on Admission: Atenolol lisinopril Levothyroxine Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 3. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 4. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution Sig: Two [Age over 90 1230]y (250) PO BID (2 times a day). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Lansoprazole Oral 13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 14. Caspofungin 50 mg IV Q24H Start: In am 15. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 17. Vancomycin HCl 750 mg IV Q 12H check trough BEFORE 4th dose please 18. Haloperidol 2 mg IV BID:PRN 19. Lorazepam 1 mg IV Q12H PRN PLEASE DO NOT GIVE UNLESS DIRECTED BY THE TRANSPLANT TEAM. Thanks 20. Ganciclovir 350 mg IV Q12H Handle as for chemotherapy. 21. insulin fixed/sliding scale Sig: see attached Subcutaneous once a day. 22. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO 2 DOSES (): dosed per level daily. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: fulminant hepatic failure secondary to HSVII s/p ABO incompatible OLT w/splenectomy Discharge Condition: stable Discharge Instructions: Please call the transplant center if experiencing fevers/chills, nausea/vomiting, redness/drainage from your wound, chest pain, shortness of breath, lightheadness/dizziness, or any questions or concerns. Followup Instructions: Please follow up at the transplant clinic as instructed by the transplant coordinator. Follow up with Dr. [Last Name (STitle) ] (Neurosurgery) after repeat head CT in [2-5] weeks. Follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6173] in [Hospital ] clinic on [2123-8-10] at 2pm. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2123-8-5] Name: [Known lastname 7501],[Known firstname ] Unit No: [Numeric Identifier 7502] Admission Date: [2123-5-16] Discharge Date: [2123-8-5] Date of Birth: [2082-2-7] Sex: F Service: SURGERY Allergies: Azithromycin / Zosyn Attending:[First Name3 (LF) 48] Addendum: Tacrolimus level [8-5] 10.6-please give 3mg in the pm [8-5], 3 mg in the am [8-6] and obtain a trough daily. Discharge Disposition: Extended Care Facility: [Hospital6 41] - [Location (un) 42] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 51] MD, [MD Number(3) 52] Completed by:[2123-8-5]	[ "324.0", "038.8", "054.71", "996.82", "117.3", "244.9", "286.6", "518.84", "401.9", "078.5", "572.2", "995.92", "284.8", "998.59", "285.1", "484.6", "707.09", "570", "584.5", "286.7" ]	icd9cm	[ [ [] ] ]	[ "33.24", "00.93", "54.91", "50.59", "01.18", "31.1", "50.11", "96.04", "93.59", "01.39", "51.22", "88.72", "96.6", "41.5", "99.15", "96.72", "99.71" ]	icd9pcs	[ [ [] ] ]	15769, 15992	9973, 12440	322, 618	14530, 14538	4769, 5172	14791, 15746	3914, 3922		12524, 14310		14424, 14509		12466, 12501	5189, 9950		14562, 14768									3937, 4750																			238, 284									646, 3309																3331, 3503	3519, 3898
68,075	169,386	40788+58398+58399	Discharge summary	report+addendum+addendum	Admission Date: [2143-6-3] Discharge Date: [2143-6-10] Date of Birth: [2078-4-29] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 922] Chief Complaint: Chief Complaint: Increasing peripheral edema, shortness of breath Major Surgical or Invasive Procedure: PROCEDURES: 1. Coronary bypass grafting times 2: Left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from the aorta to the distal right coronary artery. 2. Mitral valve repair with a 26-mm [Doctor Last Name ] Physio II ring annuloplasty. 3. Full left and right-sided Maze procedure with resection of left atrial appendage using the AtriCure in bipolar RF device as well as the CryoCath. 4. Endoscopic right greater saphenous vein harvest History of Present Illness: History of Present Illness: 65 yo male with new onset Afib in the past few months admitted to OSH with increasing peripheral edema and shortness of breath 5 days ago. In the past few days, weight had increased from 230-239# and he noticed worsening leg edema to knees with associated orthopnea. He also experienced left axillary discomfort at the time of presentation, which he had never experienced before. Troponins were negative x 2, BNP 600. He had a TEE which showed EF ~30%(unchanged from 2 months ago), regional wall motion abnormalities and a ? left atrial appendage thrombus. He had been on Pradaxa for a month and a half for AF but had not been taking it for the past 4 days in preparation for an upcoming colonoscopy. He had a left heart cath on [5-31] which significant LAD, RCA disease. He was hemodynamically stable over the weeked and currently denies chest pain/pressure. He is transferred to [Hospital1 18] for CABG/MAZE evaluation. Past Medical History: Past Medical History: DM-type II, HTN, CAD, severe MR, New onset A fib (onset 1-2 months ago - treated with CV [3-22] -> converted to SR for 2 days --> rate controlled Afib), hx colon polyps with "precancerous cells" 1 yr ago - follow up colonoscopy scheduled for [2143-6-3] Past Surgical History: Tonsillectomy as child, Colon polypectomy 1 yr ago for "precancerous cells" Social History: Lives with: Wife Occupation:Repairing industrial laser printers Tobacco: Former 3 ppd smoker - quit 28 years ago ETOH: 2 drinks a "few times a week" Family History: Father died in MVA 50's. Mother died at 84 had angina and lung CA. Sister with Lupus and DM Race:Caucasian Last Dental Exam: 1 year ago Physical Exam: Pulse: Resp:18 O2 sat: 98-100% RA B/P Right: 135/85 Left: Height:6'4" Weight:226# General: AAOx 3 in NAD, pleasant Skin: Dry [] intact [] Scaling on forehead, 5 cm well circumscribed raised erthematous areas on right forearm (~5 cm) and lateral left calf (~2cm) HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: Bilateral 1+ LE 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 Discharge Medications VS: General: 65 year-old male who is in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: irregular Resp: decreased breath sounds with bibasilar crackles GI: obese, bowel sounds positive, abdomen soft non-tender Extr; warm 1+ bilateral edema Incision: sternal & RLE incision clean dry intact, no erythems Neuro: awake, alert oriented Pertinent Results: [6-5] intra-op TEE: The left atrium is markedly dilated. Overall left ventricular systolic function is moderately depressed (LVEF=40%).The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 35 cm from the incisors. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. There is ischemic mitral regurgitation with (2+) mitral regurgitation.There is no pericardial effusion. Right ventricular systolic function is normal,with 2 + TR Post The patient is on a Norepinephrine drip @.15mcg/kg/min The cardiac index is 3.1 The patient is now s/p a physio 2, 26 mitral ring annuloplasty with CABGX2 The ring is well seated with no regurgitation and a mean gradient of 4mmhg across the ring The Ejection fraction is 50% with no RWMA There are no dissection flaps visible in the proximal ascending aorta [2143-6-7] 02:06AM BLOOD WBC-11.6* RBC-2.99* Hgb-8.5* Hct-25.2* MCV-84 MCH-28.4 MCHC-33.7 RDW-15.6* Plt Ct-267 Brief Hospital Course: The patient was brought to the operating room on [2143-6-5] where the patient underwent Coronary bypass grafting times 2: Left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from the aorta to the distal right coronary artery. Mitral valve repair with a 26-mm [Doctor Last Name ] Physio II ring Annuloplasty. Full left and right-sided Maze procedure with resection of left atrial appendage using the AtriCure in bipolar RF device as well as the CryoCath. Endoscopic right greater saphenous vein harvesting. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. The patient was transferred to the telemetry floor for further recovery. Low-dose Beta blocker was initiated but subsequently held for rate controlled atrial fibrillation in the 60's. EP was consulted recommended holding nodal agents and plan for cardioversion in 1 month if remains in atrial fibrillation. Dabigatan 150 mg [Hospital1 ] was restarted [2143-6-8]. Statins and low-dose aspirin were restarted. The patient was gently diuresed toward his preoperative weight. Chest tubes and pacing wires were discontinued without complication. Insulin was titrated to maintain blood sugars < 150. Once tolerating PO's his home diabetic medications were restarted. The patient was evaluated by the physical therapy service for assistance with strength and mobility. 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 family on POD#5in good condition with appropriate follow up instructions. Of note thoracic surgery was consulted for an incidental 1 cm Right lower lobe nodule suspicious for primary lung CA. They recommended follow-up with Dr. [First Name (STitle) ] as an outpatient. Medications on Admission: Medications at home: Amaryl daily (uncertain dose) Ecotrin 81 daily Hyzaar 12.5 mg daily Metformin 1000 [Hospital1 ] Lopressor 50 mg [Hospital1 ] Pradaxa 150 daily Zocor 40 mg daily Discharge Medications: 1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:75 Tablet(s) Refills:0 6. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days. Disp:14 Tablet(s) Refills:0 7. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 7 days. Disp:14 Tablet Extended Release(s) Refills:0 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. glimepiride 1 mg Tablet Sig: One (1) Tablet PO daily (). 11. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Hospital1 ] of [Location (un) 5087] Discharge Diagnosis: 1. Severe coronary artery disease. 2. Mitral regurgitation 3. Atrial fibrillation. 4. Diminished left ventricular function. Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: The cardiac surgey office will contact you regarding the following appointments: Wound Check at Cardiac Surgery Office [Telephone/Fax (1) 170] Surgeon Dr. [Last Name (STitle) 914] [Telephone/Fax (1) 170] Cardiologist Dr.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3321] Please call to schedule the following: Primary Care Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1617] - [Location (un) 39908] in [4-16] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2143-6-10] Name: [Known lastname 2581],[Known firstname ] Unit No: [Numeric Identifier 14136] Admission Date: [2143-6-3] Discharge Date: [2143-6-10] Date of Birth: [2078-4-29] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1543] Addendum: Mr. [Name13 (STitle) ] had transient hyponatremia post -op due to fluid shifts. Placed on a fluid restriction and hyponatremia resolved. He also had acute on chronic heart failure and was treated with diuretics, dabigatroban, losartan and statin. Discharge Disposition: Home With Service Facility: [Hospital1 ] of [Location (un) 5670] [First Name11 (Name Pattern1) 33] [Last Name (NamePattern4) 1544] MD [MD Number(2) 1545] Completed by:[2143-6-28] Name: [Known lastname 2581],[Known firstname ] Unit No: [Numeric Identifier 14136] Admission Date: [2143-6-3] Discharge Date: [2143-6-10] Date of Birth: [2078-4-29] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1543] Addendum: see previous addendum: clarification- acute on chronic systolic heart failure w/ EF of 40%. Discharge Disposition: Home With Service Facility: [Hospital1 ] of [Location (un) 5670] [First Name11 (Name Pattern1) 33] [Last Name (NamePattern4) 1544] MD [MD Number(2) 1545] Completed by:[2143-7-22]	[ "285.9", "427.31", "458.29", "V15.82", "428.0", "401.9", "414.01", "428.23", "429.89", "276.1", "518.89", "250.00", "424.0" ]	icd9cm	[ [ [] ] ]	[ "39.61", "37.36", "36.11", "37.33", "35.33", "36.15" ]	icd9pcs	[ [ [] ] ]	11878, 12112	4988, 7146	375, 895	8825, 8981	3834, 4965	9769, 11124	2474, 2614		7387, 8559		8678, 8804		7172, 7172			9005, 9746					7193, 7364			2212, 2290	2629, 3815																			286, 337									951, 1883																1927, 2189	2306, 2457
2,304	185,356	29948	Discharge summary	report	Admission Date: [2154-1-7] Discharge Date: [2154-1-11] Date of Birth: [2089-5-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3507] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Central Line Placement Abdominal Angiogram with embolization History of Present Illness: 64 yo M with h/o HTN, hypercholesterolemia, and known internal hemorrhoids and diverticulosis seen on colonoscopy [2153-12-27] p/w BRBPR. Pt. reports increased urge to defecate at approximately 5am and had an episode of loose watery bloody stool. He is currently not on any anti-coagulation. He presented to the emergency department following his original episode and has had a total of 8 episodes since, all moderate large amounts of blood and clots per patient's report. He reports having felt weak today, but denied lightheadedness, dizziness, chest pain, palpitations. He denies abdominal pain, nausea/vomiting. Screening colonoscopy was performed in [Location (un) 5770] on [2153-12-27] at which time he was found to have diverticulosis and internal hemorrhoids. A hyperplastic polyp was removed from the hepatic flexure at that time as well. . In ED initial vitals were T 96 HR 70 BP 126/67 RR 14 O2 sat 97% RA. He received 3L IVFs. GI was consulted and they recommended tagged red cell scan to identify bleeding source. Hct was 33.3 on arrival to the ED and was 27.5 upon transfer to the ICU. He did not receive PRBCs in the ED. . Upon transfer to the ICU, pt. got OOB w/ assistance to use the commode at which time he passed clots and bright red blood. He became diaphoretic, lightheaded and presyncopal. His blood pressure decreased to the 70s systolic. IVFs were hung wide open and he 2U prbcs were delivered. During the acute episode he remained verbally responsive and was transferred back to bed. SBPs returned to 120s. HR remained in the 60s despite his blood loss and hypotension; he is not beta blocked. . Past Medical History: 1. HTN 2. Hypercholesterolemia 3. OSA on bipap 4. Diverticulosis 5. Internal hemorrhoids 6. s/p polypectomy (7mm polyp) at hepatic flexure 10 days ago 7. BPH 8. s/p appendectomy Social History: Lives in [Location (un) 5770], works as attorney. Very rare EtOH socially. Smoked cigarettes [1-8] ppd for 18 years, but quit 30 years ago. Family History: Father with "borderline DM," Mother with COPD. Siblings are "healthy." Denies CAD, [Doctor Last Name 6056]. Physical Exam: Temp 97.0 BP 119/73 Pulse 64 RR 20 O2 sat 99% 2L Gen - Alert, no acute distress, pale HEENT - PERRL, extraocular movements intact, anicteric, mucous membranes moist, pale pink conjunctivae Neck - no JVD, no cervical lymphadenopathy, no carotid bruits Chest - Clear to auscultation bilaterally, no wheezes/rales/rhonchi CV - Normal S1/S2, RRR (occ. sinus bradycardia), no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds, obese, no organomegaly appreciated Extr - No clubbing, cyanosis, or edema. Neuro - Alert and oriented x 3, cranial nerves [2-18] grossly intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Skin - No rash, pale Pertinent Results: [2154-1-8] 02:32AM BLOOD Albumin-2.8* Calcium-6.3* Phos-2.7 Mg-2.0 [2154-1-10] 06:30AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.0 [2154-1-8] 02:32AM BLOOD ALT-10 AST-15 LD(LDH)-220 AlkPhos-37* TotBili-1.6* [2154-1-10] 06:30AM BLOOD Glucose-112* UreaN-11 Creat-0.6 Na-141 K-3.9 Cl-108 HCO3-28 AnGap-9 [2154-1-7] 12:30PM BLOOD PT-12.2 PTT-28.4 INR(PT)-1.0 [2154-1-7] 10:45AM BLOOD WBC-9.4 RBC-3.84* Hgb-11.8* Hct-33.3* MCV-87 MCH-30.6 MCHC-35.3* RDW-14.3 Plt Ct-185 [2154-1-7] 02:38PM BLOOD Hct-27.5* [2154-1-8] 09:45AM BLOOD Hct-30.4* [2154-1-9] 04:43AM BLOOD WBC-10.7 RBC-3.18* Hgb-9.8* Hct-26.9* MCV-85 MCH-30.6 MCHC-36.3* RDW-15.4 Plt Ct-115* [2154-1-10] 01:00PM BLOOD Hct-26.2* [2154-1-11] 01:51PM BLOOD Hct-31.3* . RUQ U/S: FINDINGS: The liver has normal size but has increased echogenicity. The liver has normal hepatopetal flow. The gallbladder contains sludge with no evidence of cholecystitis. The common bile duct is not dilated and measures 5 mm. The pancreas is normal in appearance. The kidneys are normal in size and appearance. The spleen has normal appearance and size measuring 12.9 cm. The aorta has normal caliber throughout its course. The kidneys are normal in size and appearance with no evidence for stones or hydronephrosis. . IMPRESSION: 1. Liver has increased echogenicity. This might be due to fatty infiltration; however, diffuse parenchymal infiltration and fibrosis of the liver cannot be ruled out. 2. Gallbladder contains sludge with no evidence of cholecystitis. Brief Hospital Course: 64 yo M with h/o HTN, hypercholesterolemia, diverticulosis and internal hemorrhoids, with recent colonoscopy and polypectomy at hepatic flexure who presents with several episodes of BRBPR since 5am day of admission. Etiology of bleed felt to be post-polypectomy. . # GIB: Patient's admission hct was 33.3 and dropped to 27.5 4 hours later upon transfer to the ICU prior to receiving blood products. GI was consulted in the ED and surgery was consulted in the [Hospital Unit Name 153], both requested imaging to define a site of the bleed. He was sent for tagged red blood cell scan, but was unable to tolerate the study [2-8] to hypotension with systolics in the 70s. He was transiently on dopamine to maintain his blood pressure while central venous access was obtained to transfuse prbcs wide open. He received a total of 6U prbcs and 1 bag platelets (had been on ASA prior to admission). Angiography was called in emergently and bleeding site was found to be at the hepatic flexure at his polypectomy site. It was embolized with gel foam. He required 1 post-embolization transfusion the day before discharge. He remained hemodynamically stable and had no further episodes of bright red blood per rectum, only small amounts of maroon stool felt to reprezent old blood. He had no abdominal pain or other signs/symptoms to suggest bowel ischemia post embolization. . # Hypoalbuminemia: His albumin was found to be 2.8 and there is no reason to suspect nutritionally deficient. ?Stress response? INR nl, other LFTs normal, UA without protein. However, given mild thrombocytopenia, a RUQ U/S was obtained which showed fatty infiltration vs fibrosis. Per discussion with his Gastroenterologist, he will be referred to a hepatologist as an outpatient. # HTN: Given GIB and hemodynamics and normotensive currentley, [Last Name (un) ] held on discharge (along with ASA). . # Hypercholesterolemia: Continued on home dose zocor. . # OSA: Continued on bipap on home settings. . # Leukocytosis: WBC count was maximum 21.3 and was likely elevated in setting of stress response. This resolved prior to discharge. . # BPH: Continued on finasteride. Medications on Admission: Zocor 40mg Benicar Proscar 5mg ASA 81mg MVI Fish oil Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 4. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Post-polypectomy Lower GI bleed 2. Fatty Liver, ?NASH 3. Hypoalbuminemia Secondary Diagnoses: 1. h/o HTN 2. Hypercholesterolemia 3. OSA on bipap 4. Diverticulosis 5. Internal hemorrhoids 6. BPH 7. s/p appendectomy Discharge Condition: HCT stable Discharge Instructions: Please come back to the emergency room should you develop any lightheadedness, dizziness, fresh blood in your stools, or any other complaints. Do not take your Aspirin or Benicar until you follow up with your primary care doctor. Followup Instructions: You should see a hepatologist (liver specialist) when you return home to further evaluate your liver. You may have fatty liver and may need a biopsy to make sure you do not have cirrhosis.	[ "562.10", "600.00", "401.9", "272.0", "785.59", "V12.72", "327.23", "273.8", "455.0", "998.11", "571.8", "458.9" ]	icd9cm	[ [ [] ] ]	[ "93.90", "49.21", "88.47", "38.91", "99.05", "39.79", "99.04" ]	icd9pcs	[ [ [] ] ]	7437, 7443	4863, 7031	319, 382	7727, 7740	3307, 4840	8019, 8211	2444, 2559		7135, 7414		7464, 7563		7057, 7112			7764, 7996									2574, 3288	7584, 7706																		274, 281									410, 2058																2080, 2260	2276, 2428
25,794	105,270	27715	Discharge summary	report	Admission Date: [2149-10-23] Discharge Date: [2149-11-7] Date of Birth: [2084-7-17] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2969] Chief Complaint: Esophageal Ca Major Surgical or Invasive Procedure: 1. Bronchoscopy. 2. Left thoracoscopy with pleural drainage and talc poudrage 3. Flexible bronchoscopy ([10-29]) History of Present Illness: 66-year-old gentleman with metastatic esophageal cancer who recently returned to the hospital with shortness of breath and was found to have a left pleural effusion. This was tapped and unfortunately found to be cytologically malignant. He was seen yesterday in the outpatient department with worsening dyspnea and an x-ray showed reaccumulation of the fluid. Past Medical History: Esophageal Ca s/p bronchoscopy, right exploratory thoracotomy and mediastinal LN sampling on [2149-10-1] HTN DM II GERD Crohn's colitis Dysphagia Social History: The patient did not smoke cigarettes, however, he did smoke pipes since age 18 but he has not smoked pipes lately. He drinks wine occasionally. He is self employed and runs his own business. He has not had any toxic chemical exposures. Family History: Mother had breast cancer at age 65, father with multiple myeloma, sister also had breast cancer at age 58, brother with acid reflux who receives yearly EGD but has had no evidence of cancer. No other cancers in the family. The patient is here at his appointment with his wife and two children, a son and a daughter. His daughter lives nearby. His son lives in [State 2748]. The patient lives in [Hospital1 1474] with his wife. Pertinent Results: . PATH: [2149-10-27] [-5/4334] PLEURAL FLUID SUSPICIOUS. Scattered highly epitheloid cells, present singly and in small groups, suspicious for adenocarcinoma, in a background of blood and mesothelial cells. CXR [2149-11-5]: IMPRESSION: Mild improvement in the previously identified pulmonary vascular redistribution. Focal hazy opacities at the lung bases appear stable with improvement in the left perihilar opacity. Pleural thickening versus loculated effusion again noted on the right. RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2149-11-6] 06:15AM 50* 33* 1.2 140 4.3 100 35* 9 CHEMISTRY TotProt Albumin 3.0* COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2149-11-6] 06:15AM 8.1 3.00* 9.6* 29.1* 97 32.0 33.0 15.0 392 Brief Hospital Course: pt was admitted for increased dyspnea at home and was taken to the OR for Bronchoscopy, Left thoracoscopy with pleural drainage and talc poudrage. [Doctor Last Name 406] and chest tube to sxn. On the post op noc pt developed increased shortness of breath and desaturation to 75% w/increased oxygen requirement. Pt was emergently transferred to the CRSU for acute pulmonary managemnt. CXR showed left lung collapse. Pt was bronched for copious purulent secretions. Post bronch sats improved but still w/ high O2 requirement. Started on emperic zosyn, vanco. Pt w/ resp decompensation on NIV. Pt w/ oliguria on IV levo w/ map ~mid 60's w/ worsening resp acidosis requiring intubation. Pt underwent serial bronchoscopies and aggressive diuresis once his hemodynamics stabilized. Intermittant rapid afib requiring iv amiodarone w/re-bolus in addition to IV lopressor and diltiazem drip after cardiology consult. [Doctor Last Name 406] and chest tube remained to sxn w/ minimal drainage and CT was d/c'd on POD# 5. [Doctor Last Name 406] was d/c'd on POD#10. Multiple family discussions were had w/ family and decision regarding code status made -DNR. Once cardiolpulmonary status was optimized, pt was extubated on POD#7 and remained in the ICU for continued pul tiolet. Pt transferred out of ICU on POD#10. Pt noted to be in an asyptomatic brady escape rhythm w/ rate in the 30's on amiodarone, lopressor and dilt po. Cardiology was reconsulted and dilt was d/c'd and amiodarone and lopressor were decreased w/ approp increased rate response. PT was maintained on supplemental tube feed via j-tube and po's as tolerated. able to ambulate w/ walker, supervision and supplemental oxygen. Pt's oral hypoglycemic agents were resumed but pt was consistently hypoglycemic therefore his metformin was d/c'd and his glyburide dose was cut in [12-23] and avandia was unchanged. Pt was d/c'd to home w/ [Month/Day (2) 269], home PT, O2. He will follow up with his PCP [Last Name (NamePattern4) ]: glucose control. Medications on Admission: ASA 81 Qday Zyban 150 [Hospital1 ] Amlodipine 5 Qday Asacol 400 TID HCTZ 25 Qday Metformin 850 [Hospital1 ] Celebrex 100 Qday Metoprolol 50 [Hospital1 ] Avandia 8 Qday Glyburide 10 [Hospital1 ] Lipitor 80 Qday Senna Ativan Pantopraozole 40', Amiodarone 200' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. fingersticks check finger sticks before meals and at bedtime. 9. tube feeds nutren 1.5 w/ fiber 6 cans per day via pump 10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:300 ML(s) Refills:0 11. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 12. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 Discharge Disposition: Home With Service Facility: [First Name9 (NamePattern2) 269] [Hospital1 1474] Discharge Diagnosis: Recurrent malignant left pleural effusion Esophageal Ca HTN DM 2 GERD Crohns Discharge Condition: deconditioned. requires [Name (NI) 269], PT, home oxygen and supplemental tube feeding. Discharge Instructions: Call Dr.[Name (NI) ] office [Telephone/Fax (1) 170] if you have any chest pain, shortness of breath, fever, chills, nausea, vomiting, inability to take food or tolerate tube feed. check you finger sticks before meals and at bedtime and call your PCP if they are >200- your blood sugar was too low to restart your metformin in the hospital. Followup Instructions: Follow up with Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] and Dr. [Last Name (STitle) ]. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 1989] Date/Time:[2150-1-28] 11:00 Please follow up with Dr. [Last Name (STitle) 696] in one month. Call his office, ([Telephone/Fax (1) 32070], to arrange an appointment. Completed by:[2149-11-10]	[ "197.2", "997.1", "555.9", "401.9", "427.31", "997.3", "486", "518.81", "250.00", "530.81", "150.8" ]	icd9cm	[ [ [] ] ]	[ "96.05", "33.24", "96.72", "96.04", "34.21", "38.93", "96.6", "34.92", "33.23" ]	icd9pcs	[ [ [] ] ]	6060, 6148	2578, 4604	336, 461	6269, 6363	1749, 2555	6759, 7219	1293, 1730		4929, 6037		6169, 6248		4630, 4906			6387, 6736																												283, 298									489, 850																872, 1023	1039, 1277
60,929	109,316	47601	Discharge summary	report	Admission Date: [2142-6-29] Discharge Date: [2142-7-4] Date of Birth: [2084-6-29] Sex: F Service: MEDICINE Allergies: Penicillins / Pollen/Hayfever Attending:[First Name3 (LF) 4095] Chief Complaint: Seizures Reason for MICU transfer: Intubation for airway protection Major Surgical or Invasive Procedure: none History of Present Illness: 57F known history of alcohol abuse and withdrawal seizures presenting with several suspected seizures and a prolonged generalized seizure this [Last Name (un) 44550]. From neurology note: Per husband, he noted her to have urinary incontinence followed by brief twitching of both her hands with eye deviation upwards around 4:30 AM while in bed. He changed the sheets and then went back to sleep. There was a second short episode around 8AM of similar semiology with urinary incontience. Later in the morning, she was noted to have a similar but more prolonged episode that also involved urination and rhythmic movements of all extremities. EMS was called and arrived to the house with her continued seizing, for which she received 4 mg IV ativan. Total duration of last episode was at least 15 minutes. Initial ED vitals were temp of 97.4, 98, 148/99, 100% RA. Patient was noted to be somnolent and unarousable but was protecting her airway, but then began seizing again with clonic movements of all extremities. She received 6 mg Ativan which did not stop the event; she was then intubated for airway protection with 120 succinate and 20mg etomodate and given another 4 mg Ativan which did stop the clinical seizures. She was also given narcan 0.04mg x1.She was started on propofol for sedation. Per husband, patient has been drinking more heavily in past 3 weeks, but progressed to double or more of her usual for the past 3 days where she has essentially been drinking and sleeping only. The last known drink was at 11PM last night ([6-28]) just before she went to bed. Labs remarkable for an etoh level of 20 and serum benzos positive. K on ABG was 3.1. On arrival to the MICU, patient is intubated and sedated. Past Medical History: EtOH abuse with withdrawal seizures in past Hypertension Depression Sickle cell Social History: Works at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Lives with husband, son and daughter. Another son murdered about one year ago, anniversary is coming up. EtOH abuse for at least 10 years, but is sensitive and usually affected with 1-2 beers. No tobacco or illicit drug use per report. Family History: Alcoholism in patient's mother and sister. Daughter with schizophrenia, father was institutionalized as well. Physical Exam: Vitals: T:98.6 BP:166/109 P:93 R:21 O2:100 Admission: General: Intubated HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, able to hear sounds in tube, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: PERRL, no dolls eyes, no withdrawl to pain, reflexs 2+ patellar, down going toes bilaterally. Discharge: VS: 98.0 90 130/80 15 97 RA GENERAL: AOx3, NAD HEENT: MMM. no LAD. no JVD. neck supple. HEART: RRR S1/S2 heard. no murmurs/gallops/rubs. LUNGS: B/l crackles, improved with coughing. No wheezing appreciated. ABDOMEN: soft, nontender, nondistended. no guarding or rebound, neg HSM. neg [Doctor Last Name 515] sign. EXT: No tremors noted, no edema. DPs, PTs 2+. LYMPH: no cervical, axillary, or inguinal LAD SKIN: dry, no rash NEURO/PSYCH: CNs II-XII intact. gait not assessed. Pertinent Results: Admission Labs: [2142-6-29] 09:40AM WBC-4.7 RBC-4.32 HGB-14.2 HCT-40.7 MCV-94 MCH-32.9* MCHC-35.0 RDW-15.3 [2142-6-29] 09:40AM ASA-NEG ETHANOL-20* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [2142-6-29] 09:40AM GLUCOSE-115* UREA N-7 CREAT-0.6 SODIUM-146* POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-22 ANION GAP-17 Discharge Labs: [2142-7-2] 05:00AM BLOOD WBC-7.9 RBC-3.88* Hgb-12.8 Hct-37.3 MCV-96 MCH-33.1* MCHC-34.4 RDW-15.3 Plt Ct-265 [2142-7-4] 07:50AM BLOOD Glucose-103* UreaN-6 Creat-0.6 Na-138 K-3.3 Cl-102 HCO3-26 AnGap-13 Radiology: Head CT: IMPRESSION: No intracranial hemorrhage or calvarial fracture. Pan-sinus disease. CXR:IMPRESSION: No significant interval changes or evidence of pneumonia EEG: IMPRESSION: This is an abnormal continuous ICU monitoring study because of diffuse background slowing during wakefulness and brief runs of frontal intermittent rhythmic delta activity along with triphasic waves. These findings are indicative of mild diffuse cerebral dysfunction, which is etiologically nonspecific. There are rare multifocal sharp waves indicative of multifocal cortical irritation and propensity towards multifocal seizures. There are no electrographic seizures. Compared to the prior day's recording, there is no significant change Brief Hospital Course: 57F known history of alcohol abuse and withdrawal seizures presenting with several suspected seizures and a prolonged generalized seizure. Active Diagnoses # Alcohol withdrawl seizures: History of alcohol abuse and previous withdrawal seizures. Non contrast Head CT was negative. Pt was monitored with continuous bedside EEG monitoring and followed by Neurology for seizure management. Pt initially required propofol sedation and intubation for airway protection. The first attempt at extubation on [6-30] resulted in apnea and agitation. However, a second attempt on [7-1] was successful. Thiamine, folate, MVI on board now. Of note, Dilantin should be avoided in EtOH withdrawal seizures. Once extubated, the patient was placed on a CIWA protocol with diazepam. EEG monitoring was discontinued. On the morning of [7-2], she had no asterixis or tremors, but had been given diazepam as part of CIWA protocol 3 times in prevous 24 hours. She spoke of grief over the death of her son as a cause of her drinking, and a social work consult was requested. The patient was considered stable enough for transfer to the floor from the MICU. On arrival to the floor, the patient remained stable. She did not score on the CIWA and required no diazepam. Her vital signs remained stable, no AMS, and no tremors. # Hypokalemia: Pt presented with hypokalemia, likely nutritional. Repleted throughout admission. #Throat pain: Following transfer from the MICU, the patient developed a cough, sore throat, and right sided pleurtic chest pain. These symtoms were most likely secondary to intubation. A CXR showed no signs of infiltrate or consolidation and the patient remained afebrile with no white count. The patient was never SOB or tachypneic. Pain was improving at discharge. Chronic Diagnoses # Hypertension: Patient initially hypertensive on admission, but this resolved with sedation. On extubation, her home dose of amlodipine was re-initiated. # Sinusitus: Unclear if active. Home meds held initially, but fluticasone was restarted when patient was extubated. # Reactive airway disease. Stable, restarted albuterol MDI after extubation for her cough. Transitional Issues #Patient to follow up with social work recommendations for alcohol recovery programs. # Communication: Patient, husband [Name (NI) ]: [Telephone/Fax (1) 100588] # [Name2 (NI) 7092]: Full code Medications on Admission: Information was obtained from OMR 1. Fluticasone Propionate NASAL [12-25] SPRY NU DAILY 2. Amlodipine 5 mg PO DAILY 3. Multiple Vitamin, Womens NF (multivitamin-Ca-iron-minerals) 1 Oral daily 4. Fluticasone Propionate 110mcg 1 PUFF IH [Hospital1 ] Rinse mouth after use 5. Naproxen 375 mg PO BID:PRN pain 6. Fexofenadine 60 mg PO BID 7. albuterol sulfate NF 90 mcg/actuation Inhalation 4-6 hr cough/ wheezing 8. FoLIC Acid 1 mg PO DAILY 9. Thiamine 100 mg PO DAILY Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Fluticasone Propionate 110mcg 1 PUFF IH [Hospital1 ] Rinse mouth after use 3. FoLIC Acid 1 mg PO DAILY 4. albuterol sulfate NF 90 mcg/actuation Inhalation 4-6 hr cough/ wheezing 5. Fexofenadine 60 mg PO BID 6. Thiamine 100 mg PO DAILY RX thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 7. Multiple Vitamin, Womens NF* (multivitamin-Ca-iron-minerals) 1 Oral daily 8. Fluticasone Propionate NASAL [12-25] SPRY NU DAILY 9. Naproxen 375 mg PO BID:PRN pain Discharge Disposition: Home Discharge Diagnosis: Alcohol Withdrawal Seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 4249], It was a pleasure taking care of you during your time at [Hospital1 18]. You came in due to alcohol withdrawal seizures. We stopped the seizures and sedated you to prevent additional seizures. It has now been a week since your last drink and we believe you are stable. The social workers saw you to discuss resources to stop drinking. Please continue all of your home meds following discharge Followup Instructions: Department: [Hospital3 249] When: TUESDAY [2142-7-10] at 12:00 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7869], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "473.9", "786.03", "303.01", "276.8", "307.9", "401.9", "786.52", "345.3", "311", "291.81", "493.90" ]	icd9cm	[ [ [] ] ]	[ "96.71", "89.19", "96.04", "94.62" ]	icd9pcs	[ [ [] ] ]	8626, 8632	5137, 7544	360, 366	8704, 8704	3813, 3813	9314, 9644	2575, 2687		8073, 8603		8653, 8683		7570, 8050			8855, 9291			4168, 4389						2702, 3794																			250, 322									394, 2126				4398, 5114	3830, 4152					8719, 8831						2148, 2229	2245, 2559
49,457	117,328	37149	Discharge summary	report	Admission Date: [2115-3-1] Discharge Date: [2115-3-6] Date of Birth: [2052-5-17] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Coronary Artery Bypass Surgery Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x 3 with Left Internal Mammory Artery to the Left Anterior Descending, Reverse saphenous vein graft --> Obtuse marginal, PLV History of Present Illness: The patient is a 62 yo caucasian male with a family history of CAD as well as a personal history of hypercholesterolemia. He developed dyspnea on exertion as well as chest tightness while climbing stairs over the preceeding months. Stress test was abnormal. Cardiac catheterization revealed three vessel coronary artery disease. He was referred for surgical revascularization. Past Medical History: Past Medical History: hypercholesterolemia migraines Past Surgical History right knee x2 bilateral shoulders right elbow appendectomy Social History: Race: Caucasian Last Dental Exam: 2 weeks ago Lives with: wife, 2 kids Occupation: retired athletic director Tobacco: denies ETOH: 2-3 beers/year Family History: Dad- CABG in his 60s, mom- CABG in her 80s Physical Exam: Pulse: 65SR Resp: 16 O2 sat: 99%RA B/P Right: 122/69 Left: Height: 5'[15]" Weight: 102.5kg General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact x Pulses: Femoral Right:2+ Left: 2+ DP Right:2+ Left: 2+ PT [Name (NI) 167]:2+ Left: 2+ Radial Right:2+ Left: 2+ Carotid Bruit no carotid bruits Pertinent Results: [2115-3-1] 07:49AM HGB-14.0 calcHCT-42 [2115-3-1] 07:49AM GLUCOSE-97 LACTATE-2.4* NA+-136 K+-4.6 CL--102 [2115-3-1] 01:51PM PT-13.7* PTT-35.9* INR(PT)-1.2* [2115-3-1] 01:51PM PLT COUNT-151 [2115-3-1] 01:51PM WBC-12.9# RBC-3.55 HGB-10.0* HCT-27.9# MCV-79 MCH-28.2 MCHC-35.9* RDW-13.7 [2115-3-1] 01:51PM HCV Ab-NEGATIVE [2115-3-1] 01:51PM UREA N-11 CREAT-0.8 CHLORIDE-109* TOTAL CO2-26 [2115-3-5] 05:55AM BLOOD WBC-9.5 RBC-3.22* Hgb-9.3* Hct-26.0* MCV-81* MCH-28.8 MCHC-35.7* RDW-14.5 Plt Ct-207 [2115-3-5] 05:55AM BLOOD Plt Ct-207 [2115-3-1] 01:51PM BLOOD PT-13.7* PTT-35.9* INR(PT)-1.2* [2115-3-4] 08:10AM BLOOD Glucose-122* UreaN-20 Creat-1.0 Na-134 K-4.7 Cl-95* HCO3-32 AnGap-12 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [2115-3-1] RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PRE BYPASS No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POST BYPASS Biventricular systolic function remains preserved. The study is otherwise unchanged from prebypass. CHEST (PA & LAT) Clip # [Clip Number (Radiology) 83696] Final Report HISTORY: Status post CABG. Follow-up evaluation. PA AND LATERAL CHEST RADIOGRAPHS: Comparison is made to prior films of [2115-3-1] and [2115-3-2]. There is improved aeration of the lower lobes with small bilateral pleural effusions noted on the lateral view, but no new airspace opacities identified. No overt pulmonary edema, or pneumothorax is seen. Cardiomediastinal silhouette remains enlarged in this patient status post CABG. IMPRESSION: Small bilateral pleural effusions, stable to minimally increased in size from prior exams. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5785] Brief Hospital Course: Mr. [Known lastname 83697] presented as a same day admission for Coronary Artery Bypass Graft on [3-1]. Please see operative report for details. In summary he had coronary bypass grafting x3 with Left Internal Mammory Artery to the Left Anterior Descending, Reverse saphenous vein graft to Obtuse marginal and Reverse saphenous vein graft to PLV. He tolerated the operation well and was transferred to the intensive care unit for hemodynamic monitoring in stable condition. During the first twenty four hours he was weaned off all vasoactive medications and extubated without incidence. He remained hemodynamically stable and was transferred to the step down unit in stable on post operative day 2. Chest tubes and pacing wires were removed per cardiac surgery protocol. Over the next several days he continued to recover from surgery. He worked with physical therapy for improved strength and endurance. The patient was found to have nocturnal desaturations to 81% while sleeping. He will be discharged on home oxygen with arrangements to follow up with the sleep clinic. The remainder of his hospital course was uneverntful and on POD 5 he was discharged home with visiting nurses. He is to followup with Dr [Last Name (STitle) ] in 4 weeks. Medications on Admission: nadolol 20' amerge 2.5 prn (migraines) zocor 40' asa 325 QOD MVI omega 3 fish oils Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:60 Tablet(s) Refills:0 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 9. Amerge 2.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for migraine. 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 2 weeks. Disp:28 Tab Sust.Rel. Particle/Crystal(s) Refills:0 12. Home oxygen portable home oxygen for nocturnal desaturation to 81% pulse dose system for portability 2Lpm contiuous via nasal cannula Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Coronary Artery Disease s/p CABG x3 PMH: hypercholesterolemia, migraines, right knee x2, bilateral shoulders right elbow, appendectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal wound is healing well, without drainage or erythema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Surgeon Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] [4-4] at 1:15 PM Please call to schedule appointments Primary Care Dr. [Last Name (STitle) 21448] in [2-9] weeks [Telephone/Fax (1) 69547] Cardiologist Dr. [Last Name (STitle) ] in [2-9] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule prior to discharge Sleep Clinic, [Hospital Ward Name 23] [Location (un) ], Dr. [Last Name (STitle) ]/Dr. [Last Name (STitle) ] [2115-3-13], 11:20am [Telephone/Fax (1) 6856] Completed by:[2115-3-6]	[ "787.02", "411.1", "346.90", "780.57", "V17.3", "272.0", "E935.8", "414.01" ]	icd9cm	[ [ [] ] ]	[ "36.12", "39.61", "36.15" ]	icd9pcs	[ [ [] ] ]	7653, 7728	4929, 6193	350, 506	7907, 8024	1959, 4906	8649, 9285	1253, 1298		6327, 7630		7749, 7886		6219, 6304			8048, 8626									1313, 1940																			280, 312									534, 915																959, 1073	1089, 1237
28,026	188,217	47535	Discharge summary	report	Admission Date: [2169-2-23] Discharge Date: [2169-3-8] Date of Birth: [2107-12-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 330] Chief Complaint: confusion Major Surgical or Invasive Procedure: Paracentesis L IJ Cordis Intubation EGD History of Present Illness: Ms. [Known lastname ] is a 61 year old female with a h/o Hep C cirrhosis c/b varices, ascites and liver lesion concerning for HCC who was admitted on [2-21] with worsening encephalopathy. Per nursing notes, the pt was noted to be 'sluggish and irritable', as well as nonverbal at times and had seemed more encephalopathic for the past 24 hrs. Her VS were BP 90/60-112/50, HR 80-100, RR 16 and 100% on RA. Rectal temp was noted to be 94.0. She was incontinent of stool X 5 and per her son, was noted to be picking her own feces up with her hands an putting it to her mouth. She received 2 U FFP at her facility in anticipation of paracentesis, but she was transferred to [Hospital3 ] as mental status declined before being tapped. She was directly admitted to the floor. Past Medical History: . Past Medical History: # HCV cirrhosis: s/p multiple treatment regimens, estimated has had hep C for ~30 years, acquired during IV drug use. last vL >580k ([2168-6-13], genotype 1) - Grade 2 esophageal varicies + portal hypertensive gastropathy ([6-19]) - Ascites - Hepatic encephalopathy - AFP 140, hepatic lesions concerning for hepatoma # Psoriasis # s/p TAH for uterine CA # Diverticulosis Social History: Quit smoking 8 years ago (40 pack year history). Former IVDU at age 27. No ETOH. Used occasional amphetamines from [2163]-[2165] while she was in a graduate program for literature at the MFA. Lives alone. She lives in assisted housing currently in [Location (un) 22361], MA. divorced in 3 yrs ago, separated 4 years. 10 years married. had one son from a prior relationship. Family History: Mother and sister died of uterine CA. Father with TB and lung disease died in 60s of ETOHism and lung disease. Physical Exam: VS: T: 96.6 BP: 102/43 HR: 82 RR 11 O2 98% RA I/O: 1710/1150 24 hrs 1650/810 in last 17 hours Gen: chronically ill appearing, jaundiced with fetor hepaticus HEENT: Icteric sclera, MMM CV: RRR,nl S1 S2, no m/r/g Pulm: CTAB Abd: distended but soft, hypoactive BS, NT Ext: no LE edema (pt wearing pneumoboots) Neuro: awake, alert, eating with no asterixis Pertinent Results: [2169-3-8] 02:53PM BLOOD WBC-9.3 RBC-2.29* Hgb-7.5* Hct-21.2* MCV-93 MCH-32.6* MCHC-35.2* RDW-16.9* Plt Ct-38* [2169-3-8] 11:16AM BLOOD WBC-14.4* RBC-3.37# Hgb-10.5# Hct-30.0# MCV-89 MCH-31.2 MCHC-35.2 RDW-16.6* Plt Ct-44* Brief Hospital Course: On arrival to the floor, she was somnolent and and minimally responsive to sternal rub. She received one lactulose enema PR X 1. While receiving FFP, she was found to be hypothermic to 90 rectally & orally & 91 axillary. Her other vitals at that time were stable (BP 90s/50s, HR 80s, satting > 95% on room air). She was alert but not oriented (same as earlier in the day). She was transferred to the MICU with concern for early sepsis. She received vancomycin, zosyn and one dose of albumin. . In the ICU she was initially continued on vancomycin and zosyn. She had a diagnostic paracentesis that was negative for SBP and CXR negative for PNA. Two c.diff toxin assays have been negative. Urine culture grew out e.coli today and her vancomycin was dc'd today. She has been continued on lactulose and rifaximin and MS has improved. She was also found to have ARF with Cr of 1.5 at admission, up from 1 on [2-17] (had been 1.8 on [2-16]). She has been treated with albumin for this. She also had a a transient episode of afib with rate to the 140s this morning. She was given diltiazem, with brief drop in her pressures to the 60s systolic. She is currently hemodynamically stable with a NSR. She was also found to have acute renal failure and has been treated with albumin. . She was transferred back to the floor where she completed a 14 day course of antibiotics for her UTI. She was continued on lactulose and rifaximin for her HCV cirrosis and continued to mentate well with minimal to no evidence encephalopathy. She underwent bedside therapeutic paracentesis on [3-6] for tense ascites, -2.5L. No evidence of SBP. She was seen by psychiatry for her depression and was started on citalopram and methlylphenidate per their recommendations. Pt's diuretics were held on the floor due to progressively worsening hyponatremia with a nadir of 113, she was asymptomatic. Her hyponatremia was believed to be a mixed picture of pre-renal and cirrhotic physiology. Her renal failure continued to worsen with a peak creatinine of 2.8, minimally responsive to fluids, treated with albumin, midodrine and octreotide. She also continued to have low temperatures, with a nadir of 92 on the floor, at which point she was pan cultured, with no growth, treated with bair hugger. Temps averaged 95F. On evening of [3-7] she became hypotensive to SBP 70s, she was having guaiac positive brown stool with some visible clots and an acute HCT from from 23 to 17 in the setting of receiving 1 unit PRBCs. Her INR went up acutely from 3 to >5 and her BP continued to drop into 50s-60s. She was transfered to the MICU with hypotension, melena and hematemesis. She was intubated for increasing somnolence, hematemesis, and airway protection. She underwent a cordis placement, immediate transfusion with several units of PRBC, FFP and saline due to hypotension. EGD showed bleeding varices which was cauterized. Unfortunately, she rebleed within several hours. She was more acidotic, on pressors, hypothermic and continued hematemesis and melena. Per family meeting she was made CMO and expired shortly thereafter. . # Hepatitis C cirrhosis: Has been complicated by encephalopathy, varices, ascites HCC. Patient is currently on the [Date Range ] list. continued lactulose & rifaximin, held diuretics d/t hyponatremia wich worsened today and ARF. As noted above progressive decline with GIB. . # ARF: Pt's creatinine has been fluctuating in the recent past. had responded to albumin and transfusion in the past. baseline mostly between 1- 1.3. Did have one value of 1.8 at previous admission, but was 1 at discharge. worsening decline with GIB as noted above, severe metabolic acidosis in MICU, ? ATN from hypotension. No hemofiltration initiated. . # psych: pt with depressive presentation. appreciate psych recs. now on ritalin low dose, tolerated first dose well. Increased somnolence with worsening clinical picture, encephalopathic and obtundation with GIB in MICU. . # Atrial Fibrillation: Had episode of atrial fibrillation in MICU and has no previous history of afib, but h/o atrial tachycardia for which she is on BB as outpt. Could be d/t recent infection, dehydration. BB was held in the setting of infection, which could also be contributing. Pt did get hypotensive after administration of 10 mg IV diltiazem. All nodal agents held due to GIB. no episodes of AF in MICU. . # Anemia and thrombocytopenia: Has h/o gastropathy seen on EGD in [6-19] and occasionally transfused. Her hct is at baseline, plt count slightly lower than baseline. Exsanguination as above due to coagulopathy and liver failure. OTHER MEDICAL ISSUES WHICH ARE NOT ACTIVE ANY MORE: . # Hypothermia: Improved. Thought to be early sepsis, d/t e.coli UTI now on cefriaxone. Diagnostic para negative for SBP, two c.diff toxin assays negative, CXR negative for infiltrate and blood culture with NGTD. Pt currently hemodynamically stable and no longer hypothermic. completed total of 7 days for complicated uti. Hypothermic in MICU. . # Encephalopathy: This has improved and patient is alert and awake today. No asterixis on exam. Could have been precipitated by infection and possibly d/t missing a dose of lactulose at rehab. Treated infection as possible source, worsening liver disease and active GIB. . # Hyponatremia: Pt's hyponatremia improved since last admission but worsened again last night. At that time diuretics were stopped due to ongoing hyponatremia. Currently sodium back at baseline . . # Communication: With patient & her family. HCP is ex-husband, [Name (NI) ] [Name (NI) 100489]. Home [Telephone/Fax (1) 100493], cell [Telephone/Fax (1) 100494]. Okay to communicate any updates to patient's son as well per HCP. [Name (NI) ] [Name (NI) ] [Name (NI) 1120] ([Telephone/Fax (1) 100495]. If unable to reach son, can contact his girlfriend [Name (NI) ] [Name (NI) ] ([Telephone/Fax (1) 100496]. . DISPO: Death as noted above from GIB Medications on Admission: lactulose 300 ml pr prn daily bisacodyl suppository pr daily fleet enema prn simethicone 80 mg four times daily atrovent MDI q puffs q6h albuterol 1-2 puffs q6h omeprazole 20 mg daily rifaximin 800 mg po TID ciprofloxacin 250 mg po daily lopressor 12.5 mg [Hospital1 ] ursodiol 300 mg [Hospital1 ] sarna lotion [Hospital1 ] lactulose 30 ml po q4h daily calcium carbonate 500 mg four times daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Death Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a Completed by:[2169-6-30]	[ "251.2", "286.9", "427.89", "300.4", "155.0", "789.59", "995.92", "572.4", "599.0", "572.8", "427.31", "780.99", "571.5", "584.9", "276.1", "287.5", "041.4", "038.9", "537.89", "285.22", "070.20", "276.2", "276.3", "785.59", "296.90", "263.9", "456.20" ]	icd9cm	[ [ [] ] ]	[ "54.91", "99.04", "96.04", "99.07", "42.33", "38.93", "96.71" ]	icd9pcs	[ [ [] ] ]	9263, 9272	2784, 8776	324, 365	9321, 9330	2525, 2761	9382, 9416	2023, 2136		9234, 9240		9293, 9300		8802, 9211			9354, 9359									2151, 2506																			275, 286									393, 1176																1222, 1603	1619, 2007
72,280	187,202	38451	Discharge summary	report	Admission Date: [2199-10-25] Discharge Date: [2199-10-31] Date of Birth: [2140-8-17] Sex: M Service: CARDIOTHORACIC Allergies: Sotalol Attending:[First Name3 (LF) 165] Chief Complaint: paroxysmal atrial fibrillation Major Surgical or Invasive Procedure: transcatheter pulmonary vein isolation [2199-10-25] emergency repair of left atrial laceration [2199-10-25] History of Present Illness: This 58 year old male has a 15 year history of atrial fibrillation. he has undergone cardioversions, been treated with Propafenone, Sotalol, Dronedarone and Atenolol but was rcently found to be in fib again. He was admitted for pulmonary vein isolation. Past Medical History: Bladder tumor resection (benign) with intermittent hematuria [2199] mitral prolapse resection basal cell carcinoma s/p transurethral resection of prostate [2190] Social History: non smoker 1 beer night married, three sons Family History: noncontributory Physical Exam: Admission: None in chart Pertinent Results: [2199-10-28] 04:30AM BLOOD WBC-3.3# RBC-4.38 Hgb-10.9* Hct-32.3* MCV-74* MCH-24.8* MCHC-33.7 RDW-16.8* Plt Ct-132* [2199-10-25] 07:10AM BLOOD WBC-6.5 RBC-6.48* Hgb-15.0 Hct-46.1 MCV-71* MCH-23.1* MCHC-32.5 RDW-15.2 Plt Ct-214 [2199-10-27] 02:46AM BLOOD PT-18.0* PTT-26.1 [Month/Day/Year 263](PT)-1.6* [2199-10-26] 02:06AM BLOOD PT-19.4* PTT-29.1 [Month/Day/Year 263](PT)-1.8* [2199-10-25] 09:41PM BLOOD PT-19.2* [Month/Day/Year 263](PT)-1.8* [2199-10-25] 04:22PM BLOOD PT-17.1* PTT-28.2 [Month/Day/Year 263](PT)-1.5* [2199-10-25] 02:45PM BLOOD PT-20.2* PTT-27.9 [Month/Day/Year 263](PT)-1.9* [2199-10-25] 12:30PM BLOOD PT-19.1* PTT-86.3* [Month/Day/Year 263](PT)-1.7* [2199-10-28] 04:30AM BLOOD Glucose-120* UreaN-20 Creat-0.9 Na-138 K-3.6 Cl-101 HCO3-30 AnGap-11 [2199-10-25] 07:10AM BLOOD Glucose-106* UreaN-16 Creat-1.0 Na-142 K-4.1 Cl-107 HCO3-27 AnGap-12 Brief Hospital Course: Mr. [Known lastname 9765] [Last Name (Titles) 1834] a transcatheter pulmonary vein isolation on [2199-10-25]. He was cardioverted, he became acutely hypotensive to the 70s systolic and an echocardiogram revealed a new pericardial effusion. A pericardiocentesis was done with 500cc of frank blood removed with improvement of the blood pressure. Blood continued to drain and he was taken emergently to the operating room. A laceration of the left atrium was found, repaired and he was stable. He was transfered to the ICU where he was weaned and extubated. He transferred to the floor where chest tubes and pacing wires were removed in the usual manner. Physical Therapy worked with him for mobility and strength. His pain was well controlled, wounds were clean and healing well. Heparin was begun on POD 4 as his [Date Range 263] was subtherapeutic. Coumadin was continued and he remained in sinus rhythm. He became supertherapeutic on doses of 10mg coumadin. His coumadin was held for three days until the [Date Range 263] began to decrease. On post-operative day six his [Date Range 263] was 4.3 and Dr. [First Name (STitle) ] cleared him for discharge to home. The [University/College ] [Hospital 38299] [Hospital 197] Clinic will manage his Coumadin as previously. Arrangements were made for follow up. Medications on Admission: Atenolol 25 mg daily Enalapril 10mg daily Finasteride 5 mg daily ISMN 30mg daily Coumadin 2.5-5mg daily Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Flecainide 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Disp:50 Tablet(s) Refills:0 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/temp. 8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 10. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day: take daily as directed by MD. [First Name (Titles) 263] [Last Name (Titles) ] 2-2.5. Disp:100 Tablet(s) Refills:2 11. Outpatient Lab Work [Last Name (Titles) 263]/PT for Coumadin ?????? indication atrial fibrillation [Last Name (Titles) 18303] [Last Name (Titles) 263] 2-2.5 First draw [11-1] Results to [University/College ] Vangard - [University/College ] please phone results to ([Telephone/Fax (1) 85589] Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: paroxysmal atrial fibrillation s/p emergent repair of left atrial perforation s/p transcatheter pulmonary vein isolation hypertension mitral regurgitation benign prostatic hypertrophy s/p resection basal cell carcinoma s/p bladder tumor resection Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Edema none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] 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]) on [11-18] at 1:45pm Cardiologist:Dr. [First Name (STitle) 2920] on [11-26] at 9:10 am Please call to schedule appointments with: Primary Care Dr.[First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] ([Telephone/Fax (1) 17794]) in [4-29] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/[Telephone/Fax (1) 263] for Coumadin ?????? indication atrial fibrillation [Telephone/Fax (1) 18303] [Telephone/Fax (1) 263] 2-2.5 First draw [11-1] Results to [University/College ] Vangard - [University/College ] ([Telephone/Fax (1) 85589], plan confirmed with [Doctor First Name ] on [2199-10-31] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2199-10-31]	[ "423.3", "E870.8", "V10.83", "424.0", "285.1", "458.29", "427.31", "V58.61", "401.9", "998.2", "998.11", "V17.3" ]	icd9cm	[ [ [] ] ]	[ "37.0", "37.49", "37.34", "37.28", "37.27", "39.61", "99.69" ]	icd9pcs	[ [ [] ] ]	4977, 5026	2004, 3363	306, 424	5317, 5486	1054, 1981	6327, 7386	977, 994		3517, 4954		5047, 5296		3389, 3494			5510, 6304									1009, 1035																			236, 268									452, 707																729, 900	916, 961
3,449	102,772	14233	Discharge summary	report	Admission Date: [2162-3-12] Discharge Date: [2162-3-17] Date of Birth: [2084-8-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Dyspnea, Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: This is 77 yo M with a PMH of IPF on 6L O2 at home, severe pulmonary artery hypertension, CAD s/p 4 vessel CABG [2140] with PCI [2159], DM who was initially admitted [2162-3-12] from [Hospital1 3325] for chest pain and worsening SOB. On arrival to the outside hospital, his O2 sats were in the low-80's on his 4L, and he was thought to be in CHF. Troponin I at [Hospital1 46] was mildly positive at 0.13, his hematocrit was 24, and his EKG showed a RBBB. His chest pressure resolved with ASA and nitro SL. He was started on 100%[Hospital1 597] and transferred to the [Hospital1 18] ED. . In our ED, he was given IV Lasix 80 mg IV x1 with 1.6 L UO. He was subsequently transferred to the [Hospital1 1516] service for elevated troponin T of 0.05 and CHF. On [3-12], the patient was noted to become tachycardic with HR in 120s-140s and sats of 60% on 6L NC-->100% on [Name (NI) 597] (pt was though to be mouth breathing). As there was concern for PE given he acute nature of the event, the patient was started on heparin and transferred to the MICU for further care. . The patient at this time feels SOB but does not feels any more SOB than he has over the past several days. He denies any current chest pain. He does complain of some RLE cramping that he relates to diuresis. He denies any abdominal pain. He admits to coughing up blood-tinged sputum over the past several months. His Plavix was stopped 2 weeks prior to admission in the setting of this hemoptysis. He admits also to orthopnea, PND, and DOE. In addition, the patient notes he has become more SOB than usual starting this past [Month (only) ]. He was diagnosed with IPF one month ago, and prior had carried a diagnosis only of COPD. Past Medical History: Pulmonary fibrosis (recently diagnosed) Emphysemia Hypertension Diabetes (followed at [Last Name (un) ]) CAD: - MI in [2138] - 4-vessel CABG in [2140] - PTCA in [2143] - Multiple stents placed in [2159] ([Hospital3 ]) Dyslipidemia Severe pulmonary artery hypertension Social History: He worked as a machinist doing fine parts. He does not know about any toxic exposure.100 pack year history of smoking, no current tobacco use, no ETOH use, lives with wife. Family History: noncontributory Physical Exam: Admission to Hospital: PHYSICAL EXAMINATION: Blood pressure was 136/66 mm Hg while seated. Pulse was 105 beats/min and regular, respiratory rate was 28 breaths/min. Oxygen saturation was 89-99% on 100% [Hospital3 597]. . Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVD to the angle of the jaw. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were labored and there was occasional use of accessory muscles. There were coarse crackles at the bases and [12-23] the way up bilaterally. . Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart rate was tachycardic. The heart sounds revealed a normal S1 and S2. There were no appreciable rubs, murmurs, clicks or gallops. . The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor or cyanosis. Clubbing of the upper extremities was present. There was 1+ pitting edema to the knees bilaterally. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Admission to ICU: . Physical Exam: Vitals: T101.1 BP 144/67 P 119 R 22 Sat 94% on 100%[Month/Day (4) 597]-->ABG: 7.49/41/65 Gen: Elderly male, sitting up in bed, tachypneic, unable to complete full sentences HEENT: PERRL, conjunctivae anicteric/noninjected, MMM Neck: JVP at the level of the mandible, +use of accessory muscles CV: tachycardia, no m/r/g, no RV heave Lungs: dry crackles 2/3 up both lungs bilaterally Ab: soft, NTND, NABS, no HSM Extrem: trace pitting up to the knees bilaterally, +clubbing of the fingernails, no cyanosis Neuro: MAFE, A and Ox3, CN II-XII grossly intact Guaiac negative in ED . Pertinent Results: ECG [2162-3-12]: ECG Study Date of [2162-3-12] 12:10:24 PM Sinus rhythm. Left atrial abnormality. Incomplete right bundle-branch block pattern. Probable prior inferior wall myocardial infarction. Compared to the previous tracing of [2162-2-20] right precordial ST-T wave changes are less apparent and the rate is faster. CT Chest [2162-3-13] 2:55 PM IMPRESSION: 1. Severe, diffuse fibrosis and emphysema throughout the lungs, with marked interval worsening of the fibrosis compared to prior study of [2162-2-17]. Findings compatible with known idiopathic pulmonary fibrosis and emphysema. 2. Mediastinal and hilar lymphadenopathy. 3. Extensive coronary artery calcifications in a patient with prior CABG surgery. 4. No evidence of pulmonary embolism. Findings suggestive of pulmonary arterial hypertension. Brief Hospital Course: Assessment/Plan: 77 yo M with a PMH of IPF on 6L O2 at home, severe pulmonary artery hypertension, CAD s/p 4 vessel CABG [2140] with PCI [2159], DM, admitted for dyspnea and transferred to the MICU for hypoxia. . # Hypoxic Respiratory Distress: Initial ddx includes CHF, PNA, MI, PE and worsening pulmonary fibrosis. CTA of chest was obtained - negative for PE but showed rapid progression of pulmonary fibrosis. Not felt likely to be due to cardiac ischemia, as CKMBI was negative and Tn were stable, though mildly elevated at 0.03-0.05. Initially was treated empirically with azithromycin and ceftriaxone for possible CAP complicating underlying lung disease. Additionally started on high dose steroids for IPF. Despite antibiotic treatment and steroids, dyspnea persisted without improvement. Mr. [Known lastname 42307] also was diuresed in the ED without improvement in respiratory status. . Respiratory distress is likely secondary to acute and rapid worsening of IPF that is not steroid responsive. After discussions with the Mr. [Known lastname 42307] and his family, he [Known lastname 28092] to discontinue aggressive treatment and [Known lastname 28092] for hospice care at home. Supportive care includes supplemental oxygen, anti-tussives and morphine/codeine prn. . Chest Pressure: had chest pressure with coughing spasm which resolved spontaneously. Likely musculoskeletal, though could also be secondary to demand ischemia, as patient desturated to 75% during coughing spasm. EKG was unchanged from prior and cardiac enzymes were unchanged x 2. . # ID: Pt was initially febrile and was treated empirically for possible pneumonia. CTA was negative for PE. There was no improvement in respiratory status with antibiotic treatment; antibiotics were discontinued on [3-16] after Mr. [Known lastname 42307] [Last Name (Titles) 28092] to transition to hospice care. . Mr. [Known lastname 42307] was discharged to home on [2162-3-17] with home hospice services. Medications on Admission: Metformin 1000mg Daily Glimepiride 4mg [Hospital1 ] Toprol XL 75mg Daily Avandia 4mg [Hospital1 ] Zetia 10mg Daily Omeprazole 40mg Daily Atacand 16mg Daily Lipitor 40mg Daily Isosorbide 120mg QAM/60mg QPM Levothyroxine 88mcg Daily Diltiazem 120mg QAM Aspirin 325mg Daily Iron 65mg Daily Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO Q1hr. Disp:90 cc Refills:0 2. Oxygen therapy Please provide continuous oxygen at 15L/minute via 100% non-rebreather. Also will need 6L continuous oxygen via nasal canula. 3. Guaifenesin AC 10-100 mg/5 mL Liquid Sig: [4-29] mL PO every 4-6 hours as needed for cough. Disp:120 mL Refills:0 4. Senna-S 50-8.6 mg Tablet Sig: 1-2 Tablets PO twice a day. Disp:120 Tablet(s) Refills:2 5. Acetaminophen 650 mg Suppository Sig: One (1) suppository Rectal every six (6) hours as needed for fever or pain. Disp:100 suppositories Refills:2 6. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). Disp:50 Lozenge(s) Refills:2 7. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for fever or pain. Disp:100 Tablet(s) Refills:2 8. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:0 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebs Inhalation Q6H (every 6 hours) as needed for cough. Disp:30 nebs Refills:0 11. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for anxiety. Disp:60 Tablet(s) Refills:0 12. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours as needed for secretions. Disp:10 patches Refills:0 13. Levsin/SL 0.125 mg Tablet, Sublingual Sig: 0.125-0.25 mg Sublingual every four (4) hours as needed for secretions. Disp:10 mL Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) ] Discharge Diagnosis: Primary Diagnoses: -Endstage, rapidly progressive Interstitial Pulmonary Fibrosis -Pulmonary Artery Hypertension Secondary Diagnoses: -Coronary Artery Disease -Diabetes -Hypertension Discharge Condition: Stable, requiring supplement oxygen via [Location (un) 597] at 15L. Discharge Instructions: You were hospitalized at [Hospital1 18] for problems with your breathing and chest pain. Your symptoms are believed to be related to rapid worsening of your pulmonary (lung) fibrosis. You were initially treated with antibiotics and steroids, but these did not help with your breathing. As you have decided with your family, you are being discharged to home with hospice services. You will receive oxygen at home. You will also receive other treatments, including medications to treat your cough and pain medications. Take as prescribed. Followup Instructions: With hospice care providers as planned at home. Completed by:[2162-3-17]	[ "515", "428.0", "285.29", "250.00", "518.81", "416.8", "V45.81", "401.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9846, 9897	5830, 7857	335, 341	10123, 10196	4977, 5807	10790, 10869	2642, 2659		8203, 9823		9918, 10031		7883, 8180			10220, 10767									4376, 4958	10052, 10102							2719, 4361											276, 297									369, 2121																2143, 2436	2452, 2626
17,664	123,887	4730	Discharge summary	report	Admission Date: [2168-12-13] Discharge Date: [2168-12-20] Date of Birth: [2093-3-27] Sex: F Service: MEDICINE Allergies: Codeine / Hydrochlorothiazide / Biaxin / Ciprofloxacin / Thiazides / Darvocet-N 100 / Demerol Attending:[First Name3 (LF) 5552] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: PCP: [Last Name (NamePattern4) ]. [Last Name (STitle) ], Pulmonologist: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], Heme-onc: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]/[Doctor Last Name ] . HPI: Patient is a 75 yo female with pmhx non-small cell lung cancer who presents with sob after coughing/choking incident yesterday afternoon after eating a nut. She also reports a similar incident last week on thursday but did not have any sob, cough after this episode unlike today. Her initial vs in the ED were T 99.4 and O2 sat 97% on 3 liters. CXR showed RLL infiltrate and she was diagnosed with aspiration pneumonia and was given 1 g ceftriaxone and 500 mg flagyl yesterday and a dose of 600 mg clindamycin and part of dose of levaquin this am. During her time in the ED, she became progressively more sob and hypoxic with sats in the 80s on room air. She was tried on 4 liters nc and sats remained in the 80s. She eventually required the nrb and sats came up to low 90s. Given her h/o lung cancer and worsening hypoxia, pt underwent CTA chest which was preliminarily negative for PE when she arrived in the ICU. During her stay in the ED, patient continued to have episodes of nausea and vomiting and required zofran for symptomatic relief. She also received 2.5 IV NS. P On admission to the ICU, vs were: T 96.2 BP 77/56 P 89 R 25 O2 sat 93% on 100% NRB. Initial abg showed pH 7.24 pCO2 54 pO2 107 HCO3 24. She appeared very sob, but denied dizziness, cp, nausea, abd pain, melena, hematochezia. No bm in the last couple days. Past Medical History: . Past Medical History: non-small cell lung cancer ---This 75-year-old female initially presented [11-28] with sob and swelling in her left arm. On workup, she was found to have a left upper lobe and left superior-anterior mediastinal nonsmall cell lung cancer. She had a biopsy of this, which was consistent with a well-differentiated adenocarcinoma of the mucinous type. Of note, she has a history of prior thyroid radiation back in [2112]. The case was discussed with Dr. [Last Name (STitle) ] and was determined that she was not an operative candidate. During [Month (only) 404] and [2167-12-24] she had two cycles of [Doctor Last Name ] and Taxol, which were complicated by acute shortness of breath, nausea, myalgias, and neuropathy. In [1-/2168] she had a cycle of carboplatin and gemcitabine, which was complicated by epistaxis, thrombocytopenia, and fatigue. She actually required an admission for febrile neutropenia during which she developed acute respiratory distress requiring admission to the ICU and BIPAP. Since that time, she has been gradually feeling better and has undergone no further therapy at this point. . other pmhx: 1. CAD status post CABG x2 in [2164]. 2. Aortic valve replacement in [2164]. 3. Chronic back pain with sciatica 4. Diastolic CHF. 5. Hypertension. 6. Status post cholecystectomy. 7. Status post TAH-BSO. 8. Status post cataract surgery. 9. Status post thyroid cancer treated with surgery and radiation in [2112]. 10. Status post knee arthroscopy Social History: She lives with her husband. She has three children. She smoked one cigarette a day for about 35 years. She rarely drinks. She used to work as a freelance writer. Family History: Her mother died at age 83 of senile dementia and CHF. Her father died at age 86 of emphysema. He was a smoker and had prostate cancer. She has a brother age 73 in good health with the exception of diabetes and sister age 77 and a sister age 69. She has two maternal aunts with breast cancer in her early 60s but, otherwise, there is no family history of cancer. Physical Exam: Physical Exam on MICU admission: VS: Temp: 96.2 BP:77 /56 HR: 89 RR: 25 O2sat 93% on 100% NRB GEN: tacchypneic, winded with speaking, using belly and neck accessory muscles to breath, pleasant HEENT: NCAT, PERRL, EOMI, anicteric, MM dry, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, jvp to mandible, no thyromegaly or thyroid nodules RESP: diffuse rhonchi and wheezing, poor air movement at LL base CV: RR, S1 and S2 wnl, difficult to appreciate murmur over loud lung sounds ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. RECTAL: deferred Pertinent Results: CXR: Right lower lobe airspace consolidation compatible with pneumonia/aspiration. Left lung base atelectasis and probable small left pleural effusion. CTA: No evidence of central or segmental pulmonary embolus. Limited evaluation of subsegmental branches due to bolus timing and airspace consolidation. Significant perihilar peribronchial infiltrates, right greater than left, likely secondary to aspiration or pneumonia. Left upper lobe mass invading the mediastinum is again identified. Brief Hospital Course: # Hypoxia/aspiration pneumonia- Patient had known event of choking after eating with resultant sob. CXR shows RLL consolidation suggestive of aspiration pna. Patient has nl white count 13 with 24 bands, no fever at this time. CTA negative for PE. EKG negative for ischemic changes. BNP was mildly elevated compared to previous. Patient could also have some component of fluid overload at this point after IVF in the ED but is hypotensive. ABG suggesting patient is getting hypercarbic and may be tiring out. She does not want to be intubated. Persistently with increased O2 requirements, new desat o/n [12-14] with ?mucous plugging. Improved with suctioning and increased O2. She was given azithromycin until urine legionella was negative. She was treated with Unasyn. She stabilized and was sent to the floor. She continued to have an oxygen requirement for several days following transfer to the floor. Her unasyn was transitioned to PO augmentin for home discharge. . # Hypotension- Patient has RLL consolidation, white count, bandemia suggesting she may be getting septic. Patient responded well to 500 liter IV NS bolus on presentation to the ICU. Patient could also be hypovolemic from vomiting in the ED several times. Lactate is reassuring at 1.7. Resolved the day of admission with mild fluid resuscitation. Cortisol 62.7. On the floor, she became hypertensive and her blood pressure medication was transitioned to her home regimen. . # Diarrhea: pt c/o diarrhea at the end of her discharge which she attributed to the antibiotics. C diff cultures were sent and were negative x 2. She was instructed to return if her diarrhea worsened or persisted. . # CAD status post CABG x2 in [2164]- Per ED, no EKG changes, but no EKG sent up with patient. Patient denies cp and has other reasons for symptoms. TTE without new focal WMA. ASA was continued and her home beta blocker was started as above. . # Aortic valve replacement in [2164]- tissue valve, not anticoagulated. . # Chronic back pain with sciatica- Upon admission, patient not complaining of any pain. Narcotics initially held for concern of sedation, hypotension, poor respiratory status. As improved restarted home dose pain medications. . # Diastolic CHF- Patient has normal EF 55%, but history of diastolic dysfunction. BNP 1427 (had been 1200 in [12-29]), not clearly an acute change. TTE unchanged with hyperdynamic LVEF = 75%, 1+MR/TR, moderate PA systolic hypertension. Hyperdynamic state may indicate slightly hypovolemic despite dynamic JVD. . # hypothyroidism- continued on levothyroxine at home dose . # Hyperlipidemia: continued on statin. . # Code Status: DNR/DNI- confirmed with patient . # Communication: [Doctor First Name ] [Known lastname ] [Telephone/Fax (1) 19893] Medications on Admission: 1. Synthroid 0.125 mg qd. 2. Pepcid-AC 20 mg qd. 3. Atenolol 25 twice a day. 4. Premarin 0.3 daily. 5. Lipitor 10 daily. 6. Ativan 0.5 q4-6 prn anxiety 7. Ambien 5 at night. 8. Hydrocodone-acetominophen [11-23] teasponns q4-6 hrs prn pain daily. 9. Neurontin 250 mg /5 ml- 2 tsp by mouth nightly 10. zofran 4 mg / 5 ml q8 hrs prn nausea 11. ASA 325 mg QD 12. Provigil 100 mg qd 13. albuterol inhaler 2 pufffs qid prn sob . Allergies: Codeine / Hydrochlorothiazide / Biaxin / Ciprofloxacin / Thiazides / Darvocet-N 100 / Demerol Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Gabapentin 250 mg/5 mL Solution Sig: One (1) PO QHS (once a day (at bedtime)). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times a day for 3 days. Disp:9 Tablet(s) Refills:0 8. Home Oxygen Please dispense home oxygen to maintain saturations >92% Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: Primary Diagnosis: Penumonia Secondary Diagnosis: non-small cell lung CA chronic diastolic CHF Discharge Condition: Requiring 3L O2 with ambulation Discharge Instructions: You came to the hospital with a pneumonia. You were treated in the ICU initially and you improved with antibiotics. Please take Augmentin for 3 more days to complete a 10 day course of antibiotics. Please otherwise continue your medications as you were taking them previously Please call your doctor or return to the emergency room if you have fevers, chills, shortness of breath, or any other concerning symptoms. Followup Instructions: Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD Phone:[0-0-] Date/Time:[2168-12-29] 9:00 . Provider [Last Name (NamePattern4) ]. [Last Name (STitle) 3150] Phone:[Telephone/Fax (1) 22] Date/Time:[2168-12-29] 9:00 . Provider ECHOCARDIOGRAM Phone:[Telephone/Fax (1) 128] Date/Time:[2169-1-10] 10:00	[ "272.4", "244.0", "V15.3", "428.32", "414.00", "V42.2", "458.9", "787.01", "787.91", "V10.87", "401.9", "162.3", "428.0", "507.0", "V15.82", "724.3", "164.2", "338.29", "V45.81" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	9414, 9500	5413, 8208	364, 370	9640, 9674	4896, 5390	10139, 10506	3755, 4118		8800, 9391		9521, 9521		8234, 8777			9698, 10116									4133, 4877																			317, 326									398, 1989			9572, 9619			9540, 9551										2035, 3557	3573, 3739
56,184	146,416	29109	Discharge summary	report	Admission Date: [2151-11-23] Discharge Date: [2151-11-26] Date of Birth: [2103-3-15] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1711] Chief Complaint: hypoxia, respiratory failure Major Surgical or Invasive Procedure: ASD repair Impella placement History of Present Illness: 48YOM incarcerated, with hx of recently diagnosed hemochromatosis associated to with long standing DM2 and liver cirrhosis complicated by hepatic encephalopathy, portal hypertension and esophageal varices who presented to [Hospital1 18] [Location (un) 620] ED with presyncope and dyspnea; was found to be hypoxic hypotensive with SBP 60s and started on levophed. He was transferred to the [Hospital1 18] ED, given IVF and transferred to the ICU. On admission, he endorsed stiff neck, sore throat, headache, dyspnea, lower extremity edema, and pleuritic chest pain. A CT was notable for a filling defect consistent with chronic pulmonary embolism versus lymph node as well as signs of colitis or pancreatitis. He was started on broad spectrum antibiotics. His initial ECG was read as loss of R-wave progression. He was maintained on levophed overnight but switched to dobutamine this AM as concern for cardiogenic shock increased. His hypoxia also progressed, necessitating intubation this AM. . Cardiac review of symptoms are unobtainable as the patient is intubated. . The current work up has revealed cardiogenic shock of unkown ethiology, noted to have newly reduced LVEF ejection fraction(down to 10-20% from 40%) with no evidence of vegetations or severe valvulopathy, noted to have an ASD on bubble study. There is no evidece of aotic disection on CTA, and cardiac enzimes are in the indeterminate range. Infectious work up has been negative so far and there is not a clear cause for the hypoxia althought he Ct showed subsegmental chronic PE. S/P ASD repair and Impala placement. Past Medical History: Hemochromatosis Diabetes Mellitus Type 2 with neuropathy End Stage Liver Disease s/p CCY Social History: Per report: Currently incarcirated for the last 2 month. Married to wife [Name (NI) ] (HCP). Quit smoking & alcohol 2.5 years prior. Used to be a carpenter. No known hx of IVDU of recreational drug use. Last travel to bahamas about 6 years ago. no hx tick exposure. no outdorrs activities. no pets. no [Location (un) ] exposure. Per Jail nurse no other sick contacts. Wife [Name (NI) ] (HCP). recent vacc'd for flu prior to incarceration. Family History: Father with MI in 60s Physical Exam: GENERAL: WDWN, sedated and intubated. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. unable to assess pupils. NECK: Supple. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No femoral bruits, [2-16]+ edema throughout SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Labs: 04:47a 7.30/43/66/22 on FiO2%:100; Glu:113 01:56a Lactate:1.4 . 01:35a 132 105 14 -------------<129 4.8 21 1.0 estGFR: >75 Ca: 7.6 Mg: 2.1 P: 3.6 ALT: 34 AP: 92 Tbili: 1.0 Alb: 2.8 AST: 73 Lip: 6 UricA:4.1 . 10.7 14.1>----<190 33.2 N:76.0 L:18.2 M:5.6 E:0.1 Bas:0.2 . PT: 18.6 PTT: 29.2 INR: 1.7 . Micro: Blood Culture Pending . Images: CTA, CT Torso Wet Read: 1. LLL seg branch peripheral filling defect ? chronic PE. 2. Cirrhosis, Varices, ascites 3. ascending colon wll thickening and colonic diverticulosis... Infectious etiology such as colitis/diverticulitis not excluded due to intrabdominal ascites obscuring the picture. 4. small areas decreased renal enhancement likely scaring... Pylonephritis not excluded. 5: Peripancreatic fluid likely [2-15] liver dz.. pancreatitis not excluded 6. UA and lipase not available at time of this dictation . EKG: NSR @ 99; TWI in 1 & AVL. EKG from [11-22] w/ TWI in V3-V6. ECHO [2151-11-23] The left atrium is mildly dilated. The estimated right atrial pressure is 10-20mmHg. There is severe regional left ventricular systolic dysfunction with hypokinesis of the basal LV segments and akinesis of the distal [2-16] of the LV. Overall left ventricular systolic function is severely depressed (LVEF= 15-20%). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Moderate [2+] tricuspid regurgitation is seen, but is probably underestimated. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Severe global biventricular systolic dysfunction with some regionality. Moderate tricuspid regurgitation. Elevated filling pressures. Among other etiologies, these findings could be consistent with a global process (septic, toxic, metabolic) or a variant of acute stress (Takotsubo) cardiomyopathy. Multivessel coronary artery disease as the sole etiology of these abnormalities is less likely. Compared with the report of the prior study (images unavailable for review) of [2149-3-11], biventricular systolic dysfunction and tricuspid regurgitation are new. . ECHO with bubble study [2151-11-24]: A right-to-left shunt across the interatrial septum is seen at rest with prompt appearance of contrast in the left heart after intravenous injection c/w an atrial septal defect. . CTA 11/10/09IMPRESSION: 1. Peripheral filling defect in the posterior segment branch of the lower lobe pulmonary artery may represent a chronic pulmonary embolism versus lymph node.No other filling defects are seen. 2. Severe liver cirrhosis with recanalization of the umbilical vein and varices adjacent to the gastroesophageal junction and moderate intra-abdominal ascites. 3. Apparent wall thickening of the ascending colon may be related to liver disease and intra-abdominal ascites; however colitis cannot be excluded. Clinical correlation is recommended. 4. Peripancreatic fluid may be related to liver disease; however pancreatitis is not entirely excluded and correlation with amylase, lipase is recommended. 5. Bilateral small pleural effusions and lower lobe atelectasis - consolidation. Brief Hospital Course: 48 yo male at baseline immunosupressed given DM and hemochromatosis, presented with sudden onset of severe cardiogenic shock of unknown etiology. The likelihood of multivessel disease is low given the acute change in his EF and lack of signficant changes on ECG. He had significant decreased EF within the past couple of month is of unknown etiology. This could be due to an infectious vs. progression of hemachromatosis with new diagnosed ASD vs metabolic vs toxic related cardiomyopathy. In regard to ASD, this created a R->L shunt in the setting of chronic PE, hemachromatosis, and pulmonary hypertension. Due to the shunting he had respiratory failure that was initially unresponsive to oxygen. Respiratory status was improved after ASD closure, however, his hemodynamics were still poor. He had been spiking fevers without an obvious source (Head/Neck CT has been negative and CSF has been negative). He was placed on cipro/zosyn/vanc for generalized bacterial infection, clindamycin for coverage of toxic shock and doxycycline for atypical source. Multiple serologies were sent. After ASD repair, he also had a Impella device placed. This has helped his cardiac output, but did not help overall his cardiogenic/septic shock. He continued to have poor perfusion, spike fevers, and had increased presser requirement. After discussion with family, he was made DNR/DNI and family withdrawn care. Medications on Admission: (Per Med list in chart, patient unaware of meds): Ambien 5mg PO QHS PRN Insomnia Omeprazole 20mg PO BID Gabapentin 100mg PO QAM; 300mg QPM Lacutolose 30mL TID PRN Nadolol 20mg PO Daily Sertraline 25mg PO daily Novolog SS [Hospital1 ] Levemir 18 units [Hospital1 ] Spironolactone 50mg PO daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Cardiogenic shock Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A	[ "745.5", "275.0", "357.2", "416.8", "572.3", "571.5", "276.2", "276.1", "250.60", "785.51", "427.31", "518.81", "348.30", "416.2", "789.59", "584.9" ]	icd9cm	[ [ [] ] ]	[ "37.23", "03.31", "88.56", "96.71", "96.04", "89.64", "35.52", "37.68" ]	icd9pcs	[ [ [] ] ]	8746, 8755	6957, 8367	346, 376	8816, 8826	3316, 6934	8878, 8884	2600, 2623		8718, 8723		8776, 8795		8393, 8695			8850, 8855									2638, 3297																			278, 308									404, 2004																2026, 2116	2132, 2584
13,864	129,255	49304	Discharge summary	report	Admission Date: [2179-4-1] Discharge Date: [2179-4-5] Service: CCU CHIEF COMPLAINT: Chest pain and shortness of breath. HISTORY OF PRESENT ILLNESS: This is a 86-year-old female with a history of CABG and CABG re-do in [2166]. Initial CABG in [2156] was RCA bypass, SVG to PDA aneurectomy; SVG to PDA, SVG to OM2. The patient's history is also significant for hypertension, hyperlipidemia, EF 15 percent, and was admitted with a chief complaint of shortness of breath and chest pain. The patient was recently admitted from [2179-3-22] to [2179-3-23] and ruled out for myocardial infarction. She had biventricular pacer placed on [2178-9-24]. It is a [Company 1543] InSync type III. On admission the patient had atrial fibrillation, as well as old left bundle-branch block. The patient was found to be in rapid ventricular response at 150 to 170 beats per minute. EP was called to evaluate the patient. The patient had an increased shortness of breath and secondary to respiratory distress was intubated. Her systolic blood pressure at that time was 120, diastolic 70. Pacemaker interrogation by EP demonstrated atrial fibrillation and the patient was admitted to the CCU. ALLERGIES: THE PATIENT'S ALLERGIES ARE QUESTION PROCAINAMIDE AND QUESTION BACTRIM. MEDICATIONS ON ADMISSION: 1. Coumadin, dose unknown. 2. Aspirin 81 mg once a day. 3. Fentanyl patch dose unknown. 4. Spironolactone 25 mg once a day. 5. Venlafaxine 75 mg once a day. 6. Olanzapine 1.25 mg twice a day. 7. Iron dose unknown. 8. Lisinopril 40 mg once a day. 9. Imdur 30 mg once a day. 10. Digoxin 0.125 mg once a day. 11. Furosemide 20 mg once a day. 12. Pantoprazole 40 mg once a day. 13. Carvedilol 12.5 mg twice a day. 14. Amlodipine 5 mg once a day. 15. BuSpar 50 mg 3 times a day. SOCIAL HISTORY: She lives alone, no tobacco, no current ETOH use. FAMILY HISTORY: Noncontributory. LABORATORY DATA: The patient's data on admission: EKG, atrial fibrillation with left bundle-branch block at 150. Echocardiogram on [2178-7-17], left atrial enlargement, left ventricular dilation; LV EF of 15 percent; TR gradient 43; 3 plus MR, 1 plus TR. Cardiac catheterization on [2167-8-5] LJA/RJA, LV EF 32 percent; pRCA 100 percent, origin PDA 90 percent, SVG to DRCA okay, LMCA 20 percent, PLCx 80 percent. Chest x-ray consistent with CHF. First troponin 0.01, sodium is 136, potassium 4.4, chloride 98, bicarbonate 26, BUN 20, creatinine 0.8, glucose is 216, white count 23.9, hematocrit 45.6, platelet count 418, INR 2.7. PHYSICAL EXAMINATION: The patient's temperature on admission was 98.9 degrees, heart rate 95, respiratory rate 12, blood pressure 140/85. Generally, the patient is intubated and in no distress. HEENT is normocephalic, atraumatic, PERRL. Oropharynx again intubated. Neck is supple. JVD is elevated to 12 cm. Respiratory rate, coarse breath sounds at the bases bilaterally, as well as decreased breath sounds bilaterally. Heart is irregular, no murmurs. Abdomen is nontender, nondistended. Extremities are free of any clubbing or cyanosis; there is 2 plus pitting edema and a right internal jugular line is placed. No hematoma, no pulsatile masses, or bruits. The femoral pulses are 2 plus; no bruits or pallor auscultated; 2 plus dorsalis pedis pulses are palpated. HOSPITAL COURSE BY SYSTEM: Respiratory distress, which is felt likely secondary to CHF. The patient was maintained on her intubated state for approximately 24 hours. She was maintained on aggressive diuresis with goal negative 1 to 2 liters a day and was subsequently extubated without difficulty. CHF: Felt due to AF with rapid ventricular response and lose of ventricular resynchronization due to LBBB conducction in AF. There was also a question of pneumonia versus atypical infection. Given that repeat chest x-ray had question of left upper lobe infiltrate in the setting of an increased white count. The patient was aggressively diuresed, initially was maintained on nitroglycerin, which was weaned off. She was maintained on Lasix with good effect and was continued on her outpatient Digoxin. The patient had good diuretic effect. Cardiac arrhythmia: The patient is with atrial fibrillation with RVR. The patient was initially rate controlled with beta blocker and amiodarone was subsequently added with good effect. ID: Question of left upper lobe infiltrate with the setting of increased white count. The patient was maintained on levofloxacin for a total of 7 days. Code: The patient is a full code. Atrial fibrillation: The patient also underwent TEE cardioversion and subsequently was maintained on amiodarone. DISPOSITION: The patient was discharged on [2179-4-5]. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg one by mouth q.d. 2. Lisinopril 40 mg once a day. 3. Spironolactone 25 mg once a day. 4. Amiodarone 200 mg take 1 tablet 3 times a day for 28 days. 5. Amlodipine 5 mg 1 tablet once a day. 6. Carvedilol 1 tablet twice a day. 7. Venlafaxine 75 mg 1 by mouth q.d. and this is the sustained release form. 8. Olanzapine 2.5 mg tablet, take [11-27]-a-tablet by mouth twice a day. 9. BuSpar 15 mg by mouth 3 times a day. 10. Lasix 40 mg one tablet once a day. 11. Levofloxacin 215 mg tablets, 1 by mouth every day times 2 days. 12. Coumadin 3 mg tablets, 1 by mouth in the evening with dose probably needing to be adjusted by primary care physician based on coagulation studies. 13. Amiodarone 200 mg tablets 1 p.o. once a day start after done with the 28 days of amiodarone 200 mg 3 times a day. DISCHARGE DIAGNOSES: 1. Ischemic congestive heart failure with an EF of 15 percent. 2. Atrial fibrillation status post cardioversion. 3. Status post coronary artery bypass graft with re-do. 4. Coronary artery disease. DISCHARGE PLAN: The patient was discharged to home with VNA for management of congestive heart failure. FOLLOW UP: 1. The patient's followup included followup with [First Name8 (NamePattern2) 11320] [Last Name (NamePattern1) ], RN at the [Hospital Ward Name 23] Cardiac Services Center on [2179-4-8] at 2 p.m. 2. Dr. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) ] at the [Hospital Ward Name 23] Cardiac Services Center on [2179-4-8] at 2:30 p.m. 3. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at the [Hospital 23] [Hospital6 733] on [2179-4-15] at 2:20 p.m. 4. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at the [Hospital6 733] Medical Center Clinic on [2179-5-13] at 9:20 a.m. [First Name8 (NamePattern2) ] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], MD [MD Number(2) 15194] Dictated By:[Last Name (NamePattern1) 18827] MEDQUIST36 D: [2179-10-4] 08:10:33 T: [2179-10-4] 15:55:06 Job#: [Job Number 103315]	[ "428.0", "518.81", "V45.01", "486", "V45.81", "427.31", "427.32", "412" ]	icd9cm	[ [ [] ] ]	[ "96.04", "96.71", "99.61" ]	icd9pcs	[ [ [] ] ]							1930, 1985	5671, 5873	4795, 5650				1339, 1845							3397, 4772											5990, 6988		2614, 3369											105, 142									171, 1313								2000, 2591						5890, 5979			1862, 1913
12,088	117,337	15965	Discharge summary	report	Admission Date: [2123-2-22] Discharge Date: [2123-3-2] Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is an 82-year-old male patient of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4469] who was referred for outpatient cardiac catheterization which was performed on [2123-2-8]. The patient reported recent increase in exertional chest pain over the past year. Positive exercise tolerance test was obtained in [Month (only) 404] of this year, and he was referred for cardiac catheterization. Cardiac catheterization on [2123-2-9], revealed left ventricular ejection fraction of 45%, 50% left main, occlusion and three-vessel coronary artery disease. The patient was subsequently discharged home and was admitted on [2123-2-22], for coronary artery bypass graft. PAST MEDICAL HISTORY: Hypertension. Non-insulin-dependent diabetes mellitus. Chronic obstructive pulmonary disease. Right lower extremity claudication. History of bladder cancer which was treated with radical cystectomy and radiation therapy in [2097]. The patient is also a former smoker. PREOPERATIVE LAB VALUES: White blood cell count 8.8, hematocrit 34.8, platelet count 205; CHEM7 preoperatively was with a sodium of 138, potassium 4.2, chloride 105, CO2 21, BUN 27, creatinine 1.2; INR 0.91. On [2123-2-22], the patient was admitted to the Preoperative Holding Area and was subsequently taken to the operating room where he underwent coronary artery bypass graft times four with a LIMA to the left anterior descending, a vein to the LPL, vein to the OM3, and jump graft to the OM1 by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537]. Postoperatively the patient was transported from the Operating Room to the Cardiac Surgery Recovery Unit on Propofol and Neo-Synephrine drip. On postoperative day #1, the patient remained hemodynamically stable. He was in sinus rhythm with a first degree AV block, and his vitals signs were unremarkable, and he remained on Neo-Synephrine drip, low dose, for hypotension. He was also transfused 1 U packed red blood cells. On postoperative day #2, the patient was noted to have an elevation in his creatinine from a baseline of 1.1 to 1.5, and his diuretics were held. He had previously received one postoperative dose of Lasix. The patient began with progressive pulmonary toilet. His chest tubes were removed. His Swan-Ganz catheter had been removed. On [2-25], the patient was noted to be in rapid atrial fibrillation with a ventricular response rate to the 130s. He was treated with intravenous Amiodarone and p.o. Lopressor. He subsequently converted to normal sinus rhythm after that episode and has not had further subsequent episodes of atrial fibrillation. On the same night, [2-25], the patient was noted to be confused and agitated. He had been transferred out of the Intensive Care Unit and was on the Telemetry Floor. He was treated with low-doses of Haldol, and the confusion resolved after approximately 24-48 hours of treatment with Haldol. The patient remained hemodynamically stable. On [2-26], he was noted to have a small left apical pneumothorax; however, was oxygenating well on room air with an oxygen saturation of 96%. The patient began to ambulate and work with Physical Therapy for cardiac rehabilitation. Although the patient has not had subsequent episodes of atrial fibrillation, it was felt prudent to leave him on Amiodarone for probably 4-6 weeks depending upon the patient's primary cardiologist postdischarge. The patient has continued to progress with physical therapy, although not completely independent yet. It was then recommended that the patient go to a rehabilitation facility for short-term cardiac rehabilitation. The patient's condition today, [2123-3-2], is stable. He is in normal sinus rhythm with a rate of 57. His blood pressure is 144/60. Neurologically the patient is completely intact. His Haldol had been discontinued, and he is alert and oriented. His lungs are clear to auscultation. His coronary exam is regular, rate and rhythm. Abdomen is benign. His incisions are clean, dry, and intact. His sternum is stable. He has 2+ pitting edema bilaterally. Right lower extremity is with some ecchymosis noted. Postoperatively the patient did have a rising creatinine which peaked on [2-28] at 1.9. On [3-1], it came down to 1.7 with some intravenous hydration, and today [3-2], it is down to 1.6. It is our recommendation that he have his creatinine followed very closely over the next couple of days. The patient was not started on his Captopril, which he was on preoperatively, and he was also not continued on any diuretics because of his increasing creatinine. DISCHARGE MEDICATIONS: Metformin SR 500 mg p.o. q.d., Aspirin 300 mg p.o. q.d., Glyburide 5 mg p.o. q.d., Amiodarone 400 mg p.o. q.d., this is to be continued for 4 weeks and then discontinued at the discretion of his primary cardiologist, Colace 100 mg p.o. b.i.d., Tylenol 650 mg p.o. q.4 hours p.r.n. pain, Lopressor 75 mg p.o. b.i.d., Hydralazine 25 mg p.o. q.6 hours. CONDITION ON DISCHARGE: Good. FOLLOW-UP: He is to follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537] at approximately four weeks postoperatively upon discharge from the rehabilitation facility at [Telephone/Fax (1) 170]. He is also to follow-up with his primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) ], upon discharge from the rehabilitation facility, and he is to follow-up with his primary cardiologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4469], approximately four weeks postoperatively. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Name8 (MD) 964] MEDQUIST36 D: [2123-3-2] 09:57 T: [2123-3-2] 10:01 JOB#: [Job Number 45742]	[ "293.9", "496", "427.31", "426.11", "458.9", "414.01", "411.1", "997.1", "440.21" ]	icd9cm	[ [ [] ] ]	[ "36.13", "36.15", "39.61" ]	icd9pcs	[ [ [] ] ]									4830, 5181																																												136, 845																868, 4806		5206, 6054
55,507	189,435	37240+58129+58133	Discharge summary	report+addendum+addendum	Admission Date: [2200-9-23] Discharge Date: [2200-10-5] Date of Birth: [2117-1-3] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Coronary artery bypass grafting times three (Left interior mammary artery to left anterior descending, saphenous vein graft to posterior descending, and saphenous vein grafting to obtuse marginal) [2200-9-26] History of Present Illness: Ms. [Known lastname 83836] is a 83 year old Arabic speaking woman with two days of chest pain, brought to [Hospital3 ] by her son. [Name (NI) ] initial troponin was elevated at 4.85 and she had minimal ST depressions in lead I and AVL. She was found to have multi-vessel CAD and referred for CABG. Past Medical History: Coronary Artery Disease Hypertension Diabetes Hyperlipidemia DVT after knee surgery-on Coumadin Chronic kidney disease-on Hemodialysis (x5weeks) Congestive Heart Failure Anemia Enlarged appendix-?appendicitis Social History: She lives with her son, [Name (NI) ] [Name (NI) 83837]. She has never been a smoker. Family History: No premature coronary artery disease Physical Exam: T 97.6 Pulse: 66 Resp: 16 O2 sat: 96%-RA B/P Right: 140/64Left: Height: Weight: 187lbs General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] tunneled permacath-HD catheter right SC/IJ Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema: None Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: cath site Left: 2+ Carotid Bruit Right:no Left: no Pertinent Results: [2200-9-26] Intra-op TEE Conclusions PRE-BYPASS: -No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. -No atrial septal defect is seen by 2D or color Doppler. -There is symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). -Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. with normal free wall contractility. -There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. -There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. -The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Pseudonormal diastolic dysfunction. Dr. [Last Name (STitle) ] was notified of the results at the time of the study. POSTBYPASS: Preserved LV systolic funciont LVEF > 55%, no swma, no dissection seen after cannula removed. NO SWMA after chest closed. Decreased SVR requiring phenylephrine indicated by normal [Female First Name (un) ] with reduced ESA in the setting of mildly decreased BP. No other changes from prebypass. \ [2200-10-1] 07:47AM BLOOD WBC-8.7 RBC-2.53* Hgb-7.9* Hct-23.5* MCV-93 MCH-31.4 MCHC-33.8 RDW-15.4 Plt Ct-244 [2200-10-1] 07:47AM BLOOD PT-18.3* INR(PT)-1.6* [2200-10-1] 07:47AM BLOOD Glucose-88 UreaN-42* Creat-4.9# Na-133 K-4.1 Cl-95 HCO3-25 AnGap-17 [2200-10-2] 04:11AM BLOOD WBC-8.8 RBC-2.99* Hgb-9.2* Hct-27.3* MCV-91 MCH-30.8 MCHC-33.7 RDW-15.4 Plt Ct-258 [2200-10-1] 07:47AM BLOOD WBC-8.7 RBC-2.53* Hgb-7.9* Hct-23.5* MCV-93 MCH-31.4 MCHC-33.8 RDW-15.4 Plt Ct-244 [2200-9-30] 06:25AM BLOOD WBC-9.1 RBC-2.64* Hgb-8.1* Hct-24.0* MCV-91 MCH-30.6 MCHC-33.7 RDW-15.4 Plt Ct-235 [2200-10-2] 04:11AM BLOOD PT-21.8* INR(PT)-2.0* [2200-10-1] 07:47AM BLOOD PT-18.3* INR(PT)-1.6* [2200-9-30] 06:25AM BLOOD PT-14.9* INR(PT)-1.3* [2200-9-29] 02:13AM BLOOD PT-12.2 INR(PT)-1.0 [2200-10-2] 04:11AM BLOOD Glucose-71 UreaN-28* Creat-4.0* Na-135 K-4.2 Cl-97 HCO3-26 AnGap-16 [2200-10-1] 07:47AM BLOOD Glucose-88 UreaN-42* Creat-4.9# Na-133 K-4.1 Cl-95 HCO3-25 AnGap-17 [2200-9-30] 06:25AM BLOOD Glucose-56* UreaN-27* Creat-3.5* Na-137 K-4.0 Cl-99 HCO3-29 AnGap-13 Brief Hospital Course: Ms. [Known lastname 83836] was admitted for pre-operative work-up. Renal was consulted for hemodialysis recommendations. She was found to have a positive urinalysis and was started on Cipro. The patient was brought to the Operating Room on [2200-9-26] where the he underwent coronary artery bypass grafting with Dr. [Last Name (STitle) ]. Vancomycin was used for peri-operative antibiotics given her pre-operative inpatient stay of greater than 24 hours. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Post-operative day one found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward her preoperative weight. [Last Name (un) ] was consulted for assistance with post-operative glucose management. Coumadin was resumed for pre-operative deep vein thrombosis. The patient was transferred to the telemetry floor for further recovery on post-operative day three. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on post-operative day four the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home on post-operative day six. All appropriate follow-up appointments were advised. Medications on Admission: Medications at home: Renegal 1600mg TID Coumadin 5mg daily -last dose 9/19 Vit D2 1.25mg weekly Clonidine 0.1mg [Hospital1 ] Doxazosin 2mg daily Lisinopril 5mg daily Fluoxetine 20mg daily Furosemide 40mg daily Pravastatin 40mg daily Amlopidine 10mg daily NPH 40AM/30PM RISS Meds on Transfer: Heparin Infusion- off Metoprolol 50mg [Hospital1 ] ASA 325 daily Fluoxetine 20mg daily Furosemide 40mg daily Lisinopril 20mg daily Pravastatin 40mg daily Nephrocaps 1cap daily Amlopidine 10mg daily Insulin SS Tylenol prn MOM prn NTG sl/prn Discharge Medications: 1. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 12. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1) 35 Units at Breakfast and 22 Units HS Subcutaneous as above. Disp:qs Refills:2 13. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous four times a day. Disp:qs Refills:2 14. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 15. Outpatient Lab Work Serial PT/INR Dx: DVT, goal INR [2-6] Management per Dr. [First Name (STitle) ] [Telephone/Fax (1) 25736] Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary Artery Disease Hypertension Diabetes Hyperlipidemia DVT after knee surgery-on Coumadin Chronic kidney disease-on Hemodialysis (x5weeks) Congestive Heart Failure Anemia Enlarged appendix-?appendicitis s/p CABGx3 Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. No edema 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: Recommended Follow-up: You are scheduled for the following appointments Surgeon: [Name6 (MD) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2200-10-29] 1:45 Cardiologist: Dr. [Last Name (STitle) 83838] [2200-10-27] at 1PM Please call to schedule appointments with your Primary Care: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7988] [Telephone/Fax (1) 18099] in [4-8] 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 Goal INR [2-6] Dx: DVT First draw [2200-10-3] INR/Coumadin to be managed by Dr. [First Name (STitle) ] [Telephone/Fax (1) 25736] Completed by:[2200-10-2] Name: [Known lastname 13310],[Known firstname 13311] Unit No: [Numeric Identifier 13312] Admission Date: [2200-9-23] Discharge Date: [2200-10-5] Date of Birth: [2117-1-3] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 741] Addendum: Insulin was changed. See below. Discharge Medications: 1. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 12. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1) Subcutaneous twice a day: 25 Units at breakfast, 18 Units HS. Disp:qs Refills:2 13. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous four times a day. Disp:qs Refills:2 14. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 15. Outpatient Lab Work Serial PT/INR Dx: DVT, goal INR [2-6] Management per Dr. [First Name (STitle) ] [Telephone/Fax (1) 13313] Discharge Disposition: Home With Service Facility: [Company 720] [Name6 (MD) ] [Name8 (MD) 747] MD [MD Number(2) 748] Completed by:[2200-10-2] Name: [Known lastname 13310],[Known firstname 13311] Unit No: [Numeric Identifier 13312] Admission Date: [2200-9-23] Discharge Date: [2200-10-5] Date of Birth: [2117-1-3] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 741] Addendum: Pt was not discharged until POD#9. She was unable to receive rehab placement and did not qualify for home care services. Therefore she remained in the hospital for continued medical management. She continued with HD three times a week. [Last Name (un) 616] continued to adjust her insulin due to persistent hypo and hyperglycemia. Needed extensive physical therapy in order to prepare her for home enviornment. Physical therapy worked with family to help transition to home and on POD#9 she was discharged to home in stable condition. She will need to continue to monitor her blood sugars closely and f/u with her endocrinologists. She will continue with her regularly scheduled outpatient dialysis. Discharge Medications: 1. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 12. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1) Subcutaneous twice a day: 25 Units at breakfast, 18 Units HS. Disp:qs Refills:2 13. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous four times a day. Disp:qs Refills:2 14. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 15. Outpatient Lab Work Serial PT/INR Dx: DVT, goal INR [2-6] Management per Dr. [First Name (STitle) ] [Telephone/Fax (1) 13313] Discharge Disposition: Home With Service Facility: [Company 720] [Name6 (MD) ] [Name8 (MD) 747] MD [MD Number(2) 748] Completed by:[2200-10-7]	[ "298.9", "V45.11", "428.0", "250.82", "285.9", "599.0", "V43.65", "V12.51", "585.6", "272.4", "V58.61", "425.4", "458.29", "414.01", "250.42", "411.1", "403.91" ]	icd9cm	[ [ [] ] ]	[ "36.15", "39.95", "38.93", "39.61", "36.12" ]	icd9pcs	[ [ [] ] ]	15051, 15222	4347, 5985	321, 536	8392, 8606	2004, 4324	9530, 10738	1236, 1275		13549, 15028		8150, 8371		6011, 6011			8630, 9507					6032, 6292				1290, 1985																			270, 283									564, 876																898, 1109	1125, 1220		6310, 6556
23,657	102,662	13522	Discharge summary	report	Admission Date: [2145-11-19] Discharge Date: [2145-11-22] Date of Birth: [2112-11-14] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil / Hydralazine Attending:[First Name3 (LF) 30] Chief Complaint: nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 21822] is a 33 yo M with DM Type I, ESRD on HD (T/Th/S), HTN with multiple past admissions for DKA, who self-presented to the ED on [2145-11-19] with recurrent nausea and vomiting. He had been in his usual state of health until Thursday evening, [2145-11-18], when he suddenly developed nausea and multiple episodes of vomiting of a non-bloody, non-bilious emesis that lasted throughout the night. He also experienced progressively worsening abdominal pain, describing it as a "fire" diffusely located within his abdomen that was accompanied by new onset back pain. Mr. [Known lastname 21822] reported that his presenting nausea and vomiting feels distinct from those associated with his past admissions for DKA in severity and acuity. He denied any fever or chills at home, but did experience diffuse sweating. He denied recent cough or dyspnea; denied any constipation, diarrhea and change in bowel habits; denied dysuria and change in his urination. . Mr. [Known lastname 21822] initially denied any significant changes in his oral intake prior to the onset of his symptoms, but upon further discussion mentioned that his refrigerator had stopped working in the middle of the week and he and his girlfriend had been eating out for most of their meals. Additionally, on Thursday evening he drank some juice that had been in the refrigerator and stated that he believes his symptoms are likely due to ingestion of juice "that had something growing in it," particularly as he had his first episode of vomiting soon after he drank the juice. . Over the course of the night, Mr. [Known lastname 21822] felt too ill to check his blood glucose level and administer his insulin. His symptoms became progressively worse, without any relief the next morning. He did not take his morning dosage of glargline or anti-hypertensives, and instead self-presented to the ED. . Mr. [Last Name (Titles) 40896] insulin regimen consists of glargine 15 units in the morning with breakfast and lispro sliding scale injections. He reported that his blood sugars have been under reasonable control (~140s) over the past few days. His last HD prior to presentation (on Thursday [2145-11-18]) had been uneventful. After dialysis is blood glucose levels were in the 70s and he received some [Location (un) 2452] juice. He denies experiencing any recent dizziness, lightheadedness, or sensation that the room is spinning. . <I>Per MICU signout</I>: In the ED, initial VS T 100.8, BP 203/110, HR 112, RR 18, O2 100% RA. He was later febrile to 101.9 and was given 1 g vancomycin. His AST/ALT/AP were elevated at 73/42/165 respectively. Finger stick blood glucose (FSBG) was initially 712, with an AG of 25. He was given 10 units of regular insulin IV after which FSBG decreased to 583. He was then given another 10 units IV regular insulin followed by 10 units SC insulin. A R external jugular line was placed for access. He received a total 2L IVF. . While in the MICU, Mr. [Known lastname 21822] was initially placed on insulin gtt and later transitioned to glargine and lispro sliding scale as his diet was advanced. His AG (25 at presentation) decreased to 15. He was given oxycodone prn for pain and compazine for nausea. His ALT and AP have decreased from their values at presentation, yet were still elevated on [11-20] at 55 and 135 respectively. His AST normalized at 31. His LDH was elevated at 266. . Currently, on the floor the patient has no acute complaints. He denies any nausea, vomiting or abdominal pain and reports feeling ready to go home. . ROS: (+) Per HPI as above. (-) Per HPI as above, and denies recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. He denies any sick contacts or recent travel. Past Medical History: # DM I since age 19, seen at [Last Name (un) ]. -- Complicated by nephropathy, gastroparesis (patient denies), and retinopathy. -- Followed at [Last Name (un) ] HgbA1C of 10.2% on [2145-8-19]. # ESRD/CKD: secondary to HTN and DM1 -- Hemodialysis T/Th/Sat at [Location (un) ] [Location (un) ]. -- On kidney/pancreas transplant wait list since 4/[2144]. # Hypertension # Anemia on Epo with dialysis # Depression # s/p appendectomy in [7-/2144] . Social History: Lives in [Location 686] with girlfriend of 4 years; no children. Recently lost his job and concerned about current financial situation. Currently smokes 1-1.5 packs/week. Denies recent EtOH use and illicit drug use. Family History: Grandfather with DM and CAD. Physical Exam: VS: 98.8 142/98 82 16 95RA General: Sitting upright in bed, eating. Appears to be in no acute distress. Poor eye-contact throughout history and physical. HEENT: Sclerae anicteric, EOMI, MMM, oropharynx clear without erythema or exudate. Neck supple. No cervical lymphadenopathy. No thyromegaly. Lungs: No use of accessory muscles. Able to complete full sentences. CTAB, no wheezes, rales, rhonchi. No dullness to percussion. No CVAT. CV: RRR. nl S1 and S2. No murmurs/rubs/gallops. No elevated JVP. Abdomen: +BS, soft, nontender. Appeared slightly distended. No rebound tenderness or guarding. No HSM. Ext: Warm, well perfused, 2+ DP and radial. No clubbing, cyanosis, edema. R LUE AV fistula with palpable thrill, not tender or erythematous . Neuro: AOx3. Answers questions appropriately with good fund of knowledge of recent events. CNIII-XII intact. No abnormal movements noted. Pertinent Results: [2145-11-19] 12:15PM BLOOD WBC-10.3# RBC-4.33# Hgb-12.9# Hct-39.7# MCV-92 MCH-29.8 MCHC-32.5 RDW-14.2 Plt Ct-201 [2145-11-19] 12:15PM BLOOD Neuts-89.2 Lymphs-6.7* Monos-3.5 Eos-0.4 Baso-0.2 [2145-11-19] 12:15PM BLOOD Glucose-712* UreaN-45* Creat-8.5# Na-129 K-6.6* Cl-82* HCO3-22 AnGap-32* [2145-11-19] 12:15PM BLOOD ALT-73* AST-42* AlkPhos-165* [2145-11-20] 06:01AM BLOOD ALT-55* AST-31 LD(LDH)-266* AlkPhos-135* TotBili-0.4 [2145-11-19] 01:30PM BLOOD Lipase-122* [2145-11-20] 12:58PM BLOOD Lipase-51 [2145-11-19] 12:15PM BLOOD cTropnT-0.15* [2145-11-19] 02:50PM BLOOD cTropnT-0.14* [2145-11-19] 05:47PM BLOOD Calcium-8.6 Phos-5.6* Mg-1.7 [2145-11-19] 02:50PM BLOOD Osmolal-324* [2145-11-19] 01:30PM BLOOD Acetone-SMALL [2145-11-19] 05:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2145-11-19] 01:37PM BLOOD Type-[Last Name (un) ] pO2-105 pCO2-40 pH-7.43 calTCO2-27 Base XS-1 [2145-11-19] 05:48PM BLOOD Type-ART pO2-67* pCO2-42 pH-7.44 calTCO2-29 Base XS-3 [2145-11-19] 12:55PM BLOOD Glucose-GREATER TH Lactate-2.9* K-7.4* [2145-11-19] 05:48PM BLOOD Glucose-459* Lactate-1.7 Na-130* K-4.2 Cl-86* . DISCHARGE LABS: [2145-11-22] 05:50AM BLOOD WBC-5.3 RBC-4.31* Hgb-12.9* Hct-38.0* MCV-88 MCH-30.0 MCHC-34.1 RDW-13.7 Plt Ct-214 [2145-11-22] 01:10PM BLOOD Glucose-108* Na-134 K-4.2 Cl-88* HCO3-29 AnGap-21* . Imaging: # KUB [11-19]: Nonspecific bowel gas pattern and no evidence of acute abnormality. . # TRANSTHORACIC ECHO [11-22]: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is moderately depressed (LVEF= 30-35 %) with global hypokinesis and regional inferior akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. RV with mild global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course: Mr. [Known lastname 21822] is a 33 yo M with DM Type I, ESRD on HD (T/Th/S), HTN with multiple past admissions for DKA, who self-presented to the ED on [2145-11-19] with recurrent nausea and vomiting and FSBG of 712. . # DKA: It is likely that Mr. [Known lastname 21822] had a viral gastroenteritis or episode of food poisoning, leading to his nausea and vomiting, which in the absence of his regular insulin administration, triggered DKA. Though he denied any diarrhea or change in bowel habits, or subjective fever, Mr. [Known lastname 21822] experienced diffuse sweats prior to his presentation and later became febrile following admission suggesting that infection is a likely precipant of DKA. He received vancomycin in the ED, after which he was afebrile. His CXR did not demonstrate any acute pulmonary process, and on physical exam, his AVF was neither tender or erythematous making PNA and fistula infection a less likely cause of his symptoms. KUB demonstrated no evidence of an acute abdominal process. Urine culture demonstrated <10,000 organisms/ml. Blood cultures were sent with no growth to date. . At presentation, patient's AG was 25 in the setting of FSBG >600. He was started initially on an insulin gtt at 7 U/h. FS were checked q1h and fell from 700s into the 100s over several hours. D5 1/2 NS was started, and insulin drip down-titrated to [1-9] U/h. Electrolytes were checked every four hours, and gap went from 25 on admission to 15, his baseline, during the first hospital night. His diet was advanced. Upon transfer to the floor from the MICU, his AG was 15. However at discharge, his AG was elevated to 17 with a BG of 108. His fs's had improved with increase of his lantus to 20 units. The patient insisted on discharge. Prior to his discharge, [Initials (NamePattern4) ] [Last Name (NamePattern4) ] diabetes consult was called and recommended he keep his outpatient insulin dosing after discharge. He was instructed to make a follow-up appointment with Dr. [Last Name (STitle) 20502], his [Last Name (un) ] diabetologist. . # Systolic Heart Failure: During this admission, patient obtained an ECHO notable for mild LVH with moderate dilation and LVEF = 30-35 % with global hypokinesis and regional inferior akinesis. Of note, his LVEF from prior ECHO in [3-/2145] was 52%. He was switched from labetalol to carvedilol for known improvement in morbidity and mortality. He was informed of this new change in his cardiac function. He was set-up with outpatient cardiology follow-up for both his systolic heart failure and hypertension. . # Hypertension: Patient was initially hypertensive in the setting of not having taken any of his meds since yesterday morning. Home doses of lisinopril amlodipine, and labetalol were restarted. His blood pressure has historically been difficult to control and should be monitored closely as his labetalol was changed to carvedilol in consideration of his heart failure. . # ESRD on HD: Patient was continued on dialysis schedule (T/Th/S) via LUE fistula and maintained on his home dosage of sevelamer during the course of his hospitalization. There was no acute indication for HD on admission (although his potassium was elevated, it improved with insulin administration). . # Transaminitis: Patient had elevated AST/ALT upon presentation that is likely due to elevated glucose and triglycerides secondary to DKA. With treatment of DKA, transaminases have trended downwards and approached their baseline levels. No acute intervention was required. . # Anemia: Patient's anemia is Likely secondary to ESRD. Has been stable throughout his admission and required no acute interventions. . # Code Status: FULL CODE. Medications on Admission: 1. Amlodipine 10 mg daily 2. Insulin glargine 15 units daily 3. Insulin lispro sliding scale 4. Labetalol 200 mg tid 5. Lisinopril 40 mg daily 6. Omeprazole 20 mg [Hospital1 ] 7. Ondansetron 4 mg q8h prn nausea 8. Sevelamer 800 mg TID ac for control of serum phosphorus 9. Sumatriptan prn Discharge Medications: 1. amlodipine 5 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). Tablet(s) 2. lisinopril 20 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. sevelamer carbonate 800 mg Tablet [Hospital1 ]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. oxycodone 5 mg Tablet [Hospital1 ]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. carvedilol 25 mg Tablet [Hospital1 ]: Two (2) Tablet PO twice a day. Disp:120 Tablet(s) Refills:2 7. insulin glargine 100 unit/mL Solution [Hospital1 ]: Twenty (20) Units Subcutaneous once a day. 8. Humalog 100 unit/mL Solution [Hospital1 ]: One (1) injection Subcutaneous four times a day: please check finger sticks at breakfast, lunch, and dinner. please take humalog as directed by sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Diabetic Ketoacidosis, Systolic Heart Failure Secondary Diagnoses: End Stage Renal Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for very high blood sugars (diabetic ketoacidosis). You initially went to the intensive care unit for IV fluids and an insulin drip. When your lab tests were improving, you were switched to subcutaneous insulin and transferred to the general medicine floor. You also had an ultrasound of your heart which showed that it is not squeezing as well as it should. You will need to follow-up with cardiologist regarding your heart function. You were dialyzed by the renal team. . The following changes were made to your medications: Your labetalol was STOPPED. You were STARTED on Carvedilol. Your insulin regimen was CHANGED. Followup Instructions: Department: HEMODIALYSIS When: TUESDAY [2145-11-23] at 7:30 AM Department: [Hospital3 249] When: WEDNESDAY [2145-12-1] at 9:30 AM With: [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: MONDAY [2145-12-13] at 3:20 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "250.43", "790.4", "250.53", "362.01", "285.21", "311", "V58.67", "428.0", "428.22", "276.51", "585.6", "583.81", "250.13", "403.91", "V45.11", "536.3", "V49.83", "250.63" ]	icd9cm	[ [ [] ] ]	[ "39.95" ]	icd9pcs	[ [ [] ] ]	13406, 13412	8384, 12110	346, 353	13566, 13566	5903, 7114	14402, 15096	4952, 4983		12454, 13383		13433, 13498		12136, 12431			13717, 14379			7130, 8361						4998, 5882	13519, 13545																		274, 308									381, 4202										13581, 13693						4224, 4698	4714, 4936
19,632	188,512	8741	Discharge summary	report	Admission Date: [2145-8-24] Discharge Date: [2145-9-2] Date of Birth: [2073-12-28] Sex: M Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Nsaids Attending:[First Name3 (LF) 689] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: Right Internal Jugular Central Line Placement Right Internal Jugular temporary dialysis catheter placement Right Groin Tunneled Dialysis Catheter Placement History of Present Illness: Pt is a 71 y/o male with htn, dm2, cad s/p cabg, chf, pvd, esrd on hd with a recent admission for mrsa hd-line sepsis who presents from hd with fever, chills, and altered mental status. He'd been in his usual state of health the night prior to admission, but at dialysis was noted to have chills; he was subsequently noted to be febrile though not hypotensive. The HD team reported purulent drainage from the HD cath site (right subclavian placed at the last admission - [8-1] to [8-11], during which his MRSA infected left subclavian was removed). He has been on vancomycin since this admission, with plans for a 4 week total course due to end in 1 week. He was also notably started on coumadin at the nursing home for a L IJ clot, however it is unclear how they obtained this information. . In the ED, he was febrile to 102.3, bp 135/49, hr 122, rr 16, and O2 sat 97% on ra. He was fluid resuscitated with 2 liters of NS, a right IJ was placed, and he was given vancomycin, cefepime, and gentamicin. He complained of some developing sore throat. Past Medical History: 1)Hypertension 2)DM2 3)Coronary artery disease s/p CABG [2133]; stress in [2142] with severe, fixed perfusion defect in the inferior wall; moderate sized, partially reversible perfusion defect in the lateral wall; and fixed left ventricular enlargement with decreased ejection fraction of 18%. 4)CHF with EF 30% on [2144] TTE, E/A 0.6 5)PVD s/p multiple amputations 6)H/O SVT 7)ESRD on HD 8)CVA: Right paramedian pontine hemorrhage [2142] 9)Chronic anemia, labs consistent with ACD . PSH: 1)R AKA [2140] 2)L BKA [2142] 3)CABG [2133] Social History: Resident of [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Has two sons. > 100 pk yr history; quit 2 years ago. H/o heavy EtOH use but has quit (unable to state when he quit and how much he used to drink). Pt is unable to state when he quit and how much he used to drink. Family History: Father and mother had DM. Cannot recall what they died of. Physical Exam: t 102.3, bp 135/50, hr 122, rr 16, spo2 98%ra gen- chronically ill appearing male, lying flat in bed, nad heent- perrl, oropharynx with dentures, clear, mmm neck- r ij in place, oozing at site, no lad chest- r subclv hd line in place with mod erythema at site cv- rrr, s1s2, [1-10] murmur ulsb pul- soft breath sounds throughout, though moves air fairly well, no w/r/r abd- soft, nt, nd, nabs, no organomegaly extrm- rue without cyanosis/edema, lue with 2+ pitting edema and rubor from wrist to above elbow; right aka, left bka both sites without edema/erythema nails- no clubbing, no pitting/color changes/indentations neuro- awake, alert oriented to person/situation, place with prompting, and season. cn show mild left facial droop but otherwise intact. motor/sensory show no focal deficits. Pertinent Results: ECG: NSR, lateral mild ST-depr, no significant change from prior CXR: No infiltr, effusion, or chf [2145-8-24] - L UE US: Left internal jugular and subclavian vein deep vein thrombosis. [2145-8-27] - Near occlusive thrombus in the right internal jugular vein, which has increased since the previous exam. These findings were relayed to the clinical service on [2145-8-27]. The remainder of the examination is unremarkable. CXR [8-28]: The lateral aspect of the left lung and left costophrenic angle are not included on this radiograph. The patient is status post median sternotomy, and there is fragmentation of the superior-most wire. The right IJ catheter terminates within the lower SVC. There is no evidence for pneumothorax. There is patchy opacity overlying the right lower lung zone, which may relate to developing atelectasis/consolidation. [8-30] TEE: No atrial septal defect is seen by 2D or color Doppler. There is moderate regional left ventricular systolic dysfunction included inferior akinesis, anterior hypokinesis, and anteroseptal and inferoseptal hypokinesis. Overall left ventricular systolic function is moderate to severely depressed. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch and complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild to moderate ([12-6]+) mitral regurgitation is seen. There is no pericardial effusion. Admit Labs: [2145-8-24] 09:55AM LACTATE-5.1* [2145-8-24] 09:55AM GLUCOSE-122* UREA N-20 CREAT-3.3* SODIUM-139 POTASSIUM-5.2* CHLORIDE-106 TOTAL CO2-19* ANION GAP-19 [2145-8-24] 11:08AM FIBRINOGE-113* [2145-8-24] 11:08AM PT-27.2* PTT-45.6* INR(PT)-5.5 [2145-8-24] 11:08AM PLT SMR-LOW PLT COUNT-93* [2145-8-24] 11:08AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [2145-8-24] 11:08AM NEUTS-85.4* BANDS-0 LYMPHS-9.8* MONOS-3.8 EOS-0.6 BASOS-0.3 [2145-8-24] 11:08AM WBC-4.5 RBC-2.95* HGB-9.2* HCT-30.0* MCV-102* MCH-31.4 MCHC-30.8* RDW-14.9 [2145-8-24] 11:08AM CK-MB-NotDone [2145-8-24] 11:08AM cTropnT-0.04* [2145-8-24] 11:08AM LIPASE-6 [2145-8-24] 11:08AM ALT(SGPT)-16 AST(SGOT)-19 CK(CPK)-22* ALK PHOS-128* AMYLASE-6 TOT BILI-0.4 [2145-8-24] 11:44AM LACTATE-3.4* [2145-8-24] 12:20PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 TRANS EPI-0-2 [2145-8-24] 12:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [2145-8-24] 12:43PM LACTATE-2.3* [2145-8-24] 02:21PM LACTATE-1.3 Discharge labs: [2145-9-2] 07:45AM BLOOD WBC-3.6* RBC-3.05* Hgb-9.8* Hct-30.5* MCV-100* MCH-32.1* MCHC-32.1 RDW-15.2 Plt Ct-92* [2145-9-2] 07:45AM BLOOD Plt Ct-92* [2145-9-2] 07:45AM BLOOD Glucose-103 UreaN-15 Creat-3.5* Na-135 K-4.2 Cl-101 HCO3-26 AnGap-12 [2145-9-2] 07:45AM BLOOD Albumin-2.5* Calcium-7.8* Phos-3.4 Mg-1.6 anti- Factor 10A level on [9-2] was 0.22 (low) INR on [9-1] was 1.4 Brief Hospital Course: # Sepsis -- Patient was started on broad spectrum abx with vancomycin and ceftazidime. BP remained stable. He did not require pressors. His Lactic acid trended down from 5. Source of infection thought to be right subclavian HD catheter vs b/l internal jugular and subclavian thrombosis (septic thrombophlebitis). He had been treated with vanco at HD since his last admission for MRSA bacteremia. He had a TEE which was negative for vegetations during his last admission. He received Linezolid and Ceftaz initially for concern for Pseudomonas and VRE. ID was consulted and felt the cause of his sepsis was likely a persistent MRSA infection and not VRE. He was continued on Vanco at HD. He will complete a 6 week course to end on [10-5]. He will have follow-up b/l UE U/S. He will be seen in the [Hospital ] Clinic to determine the need for further treatment at that time. His Urine and blood cultures were w/o growth at the time of discharge. A right groin tunneled dialysis catheter was placed on [8-31] and his temporary Right IJ line was removed. A repeat TEE on [8-30] was negative for vegetations. # NSVT: He had two 20 beat runs of VT while off his B-B. They did not recur once his B-B was restarted and his Mg was aggressively repleted. Also, his BB was increased. Consider EP consult for AICD placement as an outpatient once his infection and thromboses have resolved. # Right and left IJ venous thrombus and left subcalvian venous thrombus. Right U/S revealed >80% stenosis of IJ. He was maintained on a heparin gtt (HIT ab negative) until his tunneled dialysis cath was placed. He was started on Lovenox 30mg qd as a bridge to a theraputic INR. His initial coumadin dose was 10, then 7.5, then he was discharged on 2. The Lovenox will be stopped once his INR is above 2. # Coagulopathy. Elevated INR (5.5) on admission thought to be secondary to coumadin and malnutrition. He was given Vit K. # DIC. His labs were concerning for DIC given his thrombocytopenia, low fibrinogen, occasional schistocytes on smear, low haptoglobin, elevated FDP's and D-dimer level. However his LDH was normal. His DIC labs remained stable throughout his hosptial stay. HIT ab was negative. His sepsis was treated aggressively. He initially received FFP and Vit K prior to dialysis catheter removal. He needs to have his plts monitored as an outpatient. If they do not return to baseline he should f/u with a hematologist. # CAD -- ECG with slight lateral ST-depressions, not significantly changed from baseline. His Trop was stable (baseline elevated secondary to renal failure). His ASA and plavix were restarted prior to discharge. His Plavix was held [1-6] to low platlets and it can be restarted after checking a CBC in a week. # CHF -- He was euvolemic without evidence of CHF on CXR. His was continued on lisinopril 5 mg daily and metoprolol 50 mg tid (B-B was titrated up as tolerated). These were held when he was septic. He was euvolemic at discharge. # ESRD on HD TRSatMon. Vanco was dosed at dialysis. Epo was given at dialysis. # Anemia [1-6] to ESRD. He was transfused to keep his hct > 28 given h/o cad and pvd. He was given Epo at dialysis. # Swallowing: Pt received a Speech and Swallow evaluation for aspiration risk and a video swall eval. It was determined that he does not aspirate during these studies ane can have normal fluids. # Comm -- With NH; HCP is [Name (NI) ] [Name (NI) ] H [Telephone/Fax (1) 30592], W [Telephone/Fax (1) 30593] and/or [First Name8 (NamePattern2) ] [Doctor Last Name 10544] H [Telephone/Fax (1) 30594], Cell [Telephone/Fax (1) 30595]. # Code -- DNR/DNI, this was confirmed with the patient. Medications on Admission: Coumadin 2 mg PO daily Albuterol INH Q6 hours PRN Percocet 5/325 mg PO Q6 hours PRN Reglan 10 mg PO QACHS Zestril 2.5 mg po MWF Prevacid 30 mg PO BID Folic Acid T mg po daily Plavix 75 mg po daily Iron sulfate 325 qd Reglan 10 mg po before meals and at bedtime - hold on dialysis days Vitamin C 500 mg po daily Lomotil T tab po T, thurs, Sat Lopressor 12.5 mg po 3x/day Nephrocap 100 mg po qd Atarax 25 mg po 3x daily prn Novasource, renal 120 cc po tid Lipitor 20 mg po daily Tylenol prn Bisacodyl 10 m supp Senna Nystatin 2% powder TP 4 times daily to groin Insulin SSI, Lantus 6U SQ qhs MOM Questran 4G 1 packet mixed with H2O daily Artificial tears to both eyes PRN Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Nystatin 150,000,000 unit Powder Sig: One (1) Miscell. every six (6) hours as needed: to groin. 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day): HOLD ON DIALYSIS DAYS . 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-6] Drops Ophthalmic PRN (as needed). 16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours) for 2 days: MD [First Name (Titles) 4801] [Last Name (Titles) 11197] Lovenox dose daily based on anti-factor 10A levels. 18. Humalog 100 unit/mL Solution Sig: ASDIR Subcutaneous ASDIR per sliding scale. 19. Insulin Glargine 100 unit/mL Solution Sig: Four (4) units Subcutaneous at bedtime. 20. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Patient should have qweek INR drawn. 21. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 Units/ml heparin (100 units heparin) each lumen Daily and PRN. Inspect site every shift 22. Vancomycin HCl 1000 mg IV QHD Dialysis nurses will give. No longer need to check level. 23. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: ON HOLD UNTIL HIS PLATLETS ARE ABOVE 100. 24. Iron 325 (65) mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day: to be given with Vit C. 25. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO once a day as needed for diarrhea. 26. Questran 4 g Powder Sig: One (1) PO once a day: Mixed with water. Discharge Disposition: Extended Care Facility: [Doctor Last Name ] Nursing & Rehabilitation Center - [Location (un) ] Discharge Diagnosis: Sepsis Bilateral Upper Extremity Thrombi End Stage Renal Disease Discharge Condition: Fair Discharge Instructions: Please call your primary care physician or return to the hospital if you experience fever, chills, worsening UE edema, shortness of breath, chest pain, or have any other concerns. You are scheduled to have an ultrasound of your arms on [2145-9-29] at 10 AM. Please do not miss [First Name (Titles) ] [Last Name (Titles) 648]. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] (PCP) at the NH in one week. [Telephone/Fax (1) 17753] You have the following appointments scheduled: 1. Provider: [Name10 (NameIs) ] STUDY Where: CC CLINICAL CENTER RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2145-9-29] 10:00 2. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 4340], MD Where: LM [Hospital Unit Name 4341] DISEASE Phone:[Telephone/Fax (1) 457] Date/Time:[2145-10-5] 10:30	[ "286.9", "V18.0", "453.8", "250.00", "427.1", "V49.76", "996.62", "285.21", "443.9", "V45.81", "995.92", "V09.0", "263.9", "V49.75", "428.0", "038.11", "403.91" ]	icd9cm	[ [ [] ] ]	[ "99.04", "39.95", "99.07", "88.72", "38.95", "38.93", "00.14" ]	icd9pcs	[ [ [] ] ]	13785, 13890	6706, 10437	307, 465	13999, 14006	3361, 6264	14394, 14905	2464, 2524		11157, 13762		13911, 13978		10463, 11134			14030, 14371			6281, 6683						2539, 3342																			261, 269									493, 1555																1577, 2139	2155, 2448
41,070	132,140	33787	Discharge summary	report	Admission Date: [2102-3-27] Discharge Date: [2102-4-5] Date of Birth: [2039-12-17] Sex: F Service: NEUROSURGERY Allergies: Codeine / Morphine Attending:[First Name3 (LF) 2724] Chief Complaint: right lower extremity pain down the right leg and into the lateral aspect of her foot. She also has severe pain in her right buttocks Major Surgical or Invasive Procedure: Angiogram with embolectomy Sacrectomy with lumbar-ilial fusion History of Present Illness: She is a very pleasant 62-year-old woman who presents with a right sacral metastasis of a renal cell carcinoma. She was diagnosed in [2093] and underwent a right kidney nephrectomy. She has metastatic disease in her lungs as well. She is dependent on Sutent. During her off cycle, she develops exacerbating right lower extremity radicular symptoms that radiate down the right leg and into the lateral aspect of her foot. She also has severe pain in her right buttocks that seems to have a positional component. She has no difficulty with bowel or bladder function. Past Medical History: angina, which has been corrected with coronary artery stenting. She has had surgery in [2058] for a herniated disc. Social History: nonsmoker,retired Family History: nc Physical Exam: a and o x 3 perrla lungs cta ht rrr neuro: motor strength is [5-24] in hip flexion,extension, quadriceps, hamstrings, dorsiflexion and plantar flexion bilaterally. sensory examination is intact light touch. reflexes are normal and symmetric in the patellar and Achilles bilaterally. back had no point tenderness in the midline, but was tender at the SI joint on the right side. SLR was negative as was [Doctor Last Name ] maneuver. no clonus. Perianal sensation was preserved as well. exam upon discharge: neurologically intact, wound cdi Pertinent Results: CT scan of the pelvis: metastatic lesion in the right sacral ala, intimate with the sacroiliac joint over more than two-thirds. It does not appear to traverse the joint. The mass does erode into the bony canal and is clearly intimate with the S1 nerve root. It extends ventral to the sacrum as well.The alignment is normal. Brief Hospital Course: Patient was admitted to the hospital electively [2102-3-27] and went to angiogram where she underwent lumbar/sacral embolization. She tolerated this procedure well and was intact neurologically post op. She was readied for the OR including pre-op PRBC transfusion on [2102-3-28] and on [2102-3-29] she was taken to the OR where under general anesthesia she underwent sacrectomy and fusion. She tolerated this procedure well and was transferred to ICU post op intubated as planned. She required multiple transfusions post op for blood loss anemia. She was intact on post op check, she was able to be extubated without difficulty. She had some confusion post op but this ultimately cleared, She was transferred to step down and then floor. Her diet and activity were advanced. Her foley was removed. Her wound was clean and dry. She was evaluated by PT and felt appropriate for dc to home with Home PT. Medications on Admission: atenolol, lisinopril, atorvastatin, ezetimibe, pregabalin Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for diarrhea. 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pregabalin 200 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:1 8. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) as needed for pain . Disp:10 Patch 72 hr(s) Refills:0 10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q4H (every 4 hours) as needed for nausea. 12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Home Health of [Location (un) 24402] Discharge Diagnosis: Renal cell carcinoma metastatic to spine post op blood loss anemia post op confusion 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: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up but please begin daily showers ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months. ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE RETURN TO DR[Doctor Last Name ] OFFICE [4-11] FOR REMOVAL OF YOUR STAPLES OR YOU [Month (only) ] HAVE THEM REMOVED AT PCP OR BY VISITING NURSE AT HOME around [4-12] PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) ] TO BE SEEN IN 6 WEEKS. YOU WILL NEED 1) MRI with and without gadolinium and 2) XRAYS PRIOR TO YOUR APPOINTMENT Please follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] NP for Dr. [Last Name (STitle) 1005] in 2 weeks ([4-11]), call [Telephone/Fax (1) 1228] FOR APPT TIME. Please follow up with Dr. [Last Name (STitle) ] in 2 weeks, call his office for appt. [Telephone/Fax (1) 13016] Please follow up with Dr. [Last Name (STitle) 35885] in Radiation therapy [5-2] at 1:30pm [Telephone/Fax (1) 9710] These appt were already scheduled and are included here for your information: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 9402], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2102-4-12] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 11058], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2102-4-12] 3:00 Completed by:[2102-4-5]	[ "198.89", "401.9", "731.3", "197.0", "V10.52", "V45.82", "293.9", "424.0", "198.5", "V45.73", "733.99", "285.1", "724.6", "198.3", "338.3" ]	icd9cm	[ [ [] ] ]	[ "77.89", "81.08", "81.62", "39.79", "77.79" ]	icd9pcs	[ [ [] ] ]	4418, 4505	2223, 3143	418, 483	4634, 4634	1871, 2200	6092, 7357	1281, 1285		3251, 4395		4526, 4613		3169, 3228			4814, 6069									1300, 1796																			244, 380									511, 1087										4649, 4790						1109, 1230	1246, 1265			1817, 1852
57,436	197,664	38389	Discharge summary	report	Admission Date: [2153-5-13] Discharge Date: [2153-5-18] Date of Birth: [2077-12-6] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1936] Chief Complaint: GIB Major Surgical or Invasive Procedure: Colonoscopy [5-17] History of Present Illness: Pt is a 75 yo F with morbid obesity, AF on coumadin, and porphyria who presents with an acute onset of GI bleed. She noticed BRBPR in her bed pan this morning at her nursing home. Her VS were stable at the time (BP 148/78) She reports 3 bloody BMs at her nursing home after being given lactulose 2 am, another 2 at [Hospital3 4107], and 1 in the [Hospital1 18] ED. Pt was unable to report the consistency and color of the blood [1-23] her body habitus, but states she was told it was 'red and bloody' and clotted. She reports she may have been on antibiotics ('some penicillin') recently but does not know the results. Her INR was recently supratherapeutic to 4.7 on [4-28] -> 3.6 on [4-30].8 on [5-2], and 2.0 on [5-9]. Her coumadin was held from [4-28] - [5-2] for her supratherapeutic INR. She also reports a history of diverticulitis 30 years ago, but no bleeding. She denies any recent ibuprofen or alcohol use. No uncooked hamburgers or fresh water ingestion. She was transferred to [Hospital3 ], where she recieved 1 U PRBCs. Labs significant for a Cre of 1.3, INR of 2.5, and Hct was noted to be 29.3 She had 2 PIVs placed and was transferred to [Hospital1 18] for further management. . In the ED, initial vs were: 97.8 128/62 67 16 97% on RA. Labs notable for Hct stable at 28.6 and Cre of 1.2. She refused NG lavage. Maroon colored blood clots admixed with stool were noted in the ED. Patient was crossmatched for 4 [Location 16678] and PRBCs, and was given 10 mg IV vitamin K in the ED. GI was consulted in the ED, who recommended INR reversal and NPO for possible colonoscopy tomorrow vs. tagged RBC scan. She was transferred to the MICU for treatment of active GI bleed. On transfer, VS were afebrile 66 161/62 14 94% on room air. . On the floor, she denies any fevers, chills, cough, abdominal pain, nausea, vomiting, LH, dizziness, or syncope. She has chronic SOB from her asthma. She reports she is bedbound but can be transferred to a wheelchair. She reports a LLE laceration on transfer from bed to wheelchair a few day ago that is s/p repair. Past Medical History: Asthma Lower extremity cellulitis Morbid Obesity, home bound at nursing home HTN Hypercholesterolemia atrial fibrillation on coumadin DMII Gout Chronic Constipation Social History: lives in [Hospital ] nursing home, recently moved there 1 month ago [1-23] multiple medical problems and multiple hospital admissions for viral illness/asthma exacerbations. Used to be an elementary school teacher in [Location (un) 86]. - Tobacco: denies - Alcohol: denies - Illicits: denies Family History: no family hx of IBD. Physical Exam: General: obese F lying in bed, Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: increased expiratory phase, wheezes in upper lung bases CV: irregularly irregular rate, no murmurs, rubs, gallops Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pitting edema BL, chronic venous stasis changes BL, bandages over LLE wound c/d/i; 1+ pulses, no clubbing, cyanosis or edema . On discharge PE: Vitals: 96.2 172/100 (agitated) 83-90s 18 93%RA I/Os: neg 5L so far Pain: denies Access: LUE PICC Gen: nad, obese female HEENT: mmm CV: irreg irreg, no m Resp: CTAB, no crackles, +exp wheezing Abd; soft, very obese, nontender, +BS Ext; 2+ b/l LE and UE edema Neuro: A&OX3, grossly nonfocal-at baseline Skin: chronic venous stasis changes BLE with bandages over LLE wounds c/d/i; psych: easily frustrated GU +foley-->will remove . Pertinent Results: wbc [6-28] hgb 9->10s stable HCT 28->31 2U->29->32s stable BUN/Creat 31/1.2-->10/0.8 INR 2.2->1.3 LFTs wnl Trop 0.03->0.01 . . Imaging/results: CXR [5-15]: IMPRESSION: Technically limited study. Lateral view demonstrates moderate bilateral pleural effusions. Otherwise, no new gross focal abnormality concerning for pneumonia . C-scope [5-17]: Impression: Polyp in the colon Diverticulosis of the sigmoid colon, descending colon and ascending colon Two prominent folds at approximately 25cm. Erythema of the mucosa was also noted in this area likely due to scope trauma. Ulceration in the anus-->biopsy Otherwise normal colonoscopy to terminal ileum Recommendations: Follow-up biopsies. Pt will need repeat colonoscopy in near future for removal of polyps. Brief Hospital Course: 75 year old female with h/o Afib on coumadin, morbid obesity, DM, Gout, remote diverticulitis who was admitted from [Hospital1 1501] with hematochezia in setting of therapuetic INR. Initially presented to OSH. Recieved 1U at OSH and transfered to [Hospital1 18]. Admitted to MICU. Recieved 2U more prbc for active hematochezia and 2U FFP and Vitamin K for INR 2.5 at OSH. Refused NGT but low suspicion for UGIB as she remained stable. Strong suspicion for diverticular bleed given acute history and spontaneous resolved. Her HCT stabilized around 30s and she was transfered out of MICU [5-14]. Plan was for EGD/[Last Name (un) ], but this was delayed by a few days because of both poor prep and difficulty arranging for OR time (couldnt do in GI suite due to weight). Finally underwent colonoscopy on [5-17], EGD not done due to high risk procedure and low suspicion for UGIB. C-scope showed diverticulosis, rectal ulcer (would not have expected such a brisk bleed), and polyps (nonbleeding)-->likely diverticular bleed. She needs f/u C-scope for removal of polyps in future (not done due to recent bleed). GI will contact with biopsy of rectal ulcer to r/o malignancy. Will reccommend it should be safe to resume prior dose of coumadin after 1week (so less risk for bleeding from rectal ulcer biopsy site). Also ASA 81 was resumed. Her HCT was above 30 for 4days before discharge. She was tolerating diet. Placed on PO PPI daily (on asa/coumadin). Other issues during this hospitalization: Her creat was 1.3 on admission. She got blood and gentle fluids. Creat improved to 0.8 and was stable thereafter. She was total body volume overloaded [1-23] acute dCHF (hypoxia, UE/LE edema, wheezing) and got IV lasix X2 with neg 5L and creat remained stable. She will be discharged on lasix 40mg daily and her creat should be followed. Kept on lisinopril at higher dose. Presumed not on BB due to bad asthma. Her Afib was not rate controlled and she was started on dilt which was titrated to 240mg (HR 80s). Also her BP was not controlled and her lisinopril was increased to 10, dilt added as above, and lasix added as above. Her BP was 120/80s but would go to 180SBP when she was anxious/upset. Her O2 sats were okay 92% during day but she would desat at night, likely OSA, she has refused CPAP in past. Can consider giving nocturnal O2 so can avoid stress on heart/hypoxia. Asthma was stable on claritin and inhalers. Some fluid component to wheezing, improved with diuresis. Rest of meds are kept the same. . Below is progress note from day of discharge 75 year old female with h/o Afib on coumadin, morbid obesity, DM, Gout, remote diverticulitis who is admitted with hematochezia in setting of therapuetic INR. Stable. Transfered out of MICU [5-14]. Awaiting EGD/[Last Name (un) ] on [5-17], delayed due to poor prep and issue related to body habitus. Has issues with Afib/RVR and dCHF. . Acute GI bleed: Patient likely with lower GI bleed given history of diverticulosis and HDS while active hematochezia. Lower suspicion for UGIB. Hct 29-30 stable after total 3U prbc. INR reversed with ffp and vit K. -C-scope [5-17] with diverticulosis, rectal ulcer (would not have expected such a brisk bleed), and polyps (nonbleeding)-->still suspect was a diverticular bleed -needs f/u C-scope for removal of polyps in future -GI will contact with biopsy of rectal ulcer to r/o bleed -EGD not done because high risk, again, very low suspicion for UGIG, d/c IV PPI, place on oral -resume coumadin in 1 week -can resume ASA now . ARF:unclear baseline. Creat 1.3 on admission, down to 0.9 after gentle fluids. Pt is total body volume overloaded and has effusions on CXR -no more fluids -s/p lasix 40mg IV [5-15] and 20mg IV on [5-16], creat 0.8--> so far pt about negative 5L -start on lasix 40mg QD-can titrate to [Hospital1 ] as BP and creat tolerates -lisinopril-titrate dose . Acute diastolic CHF: effusions on CXR. got fluids. needs better rate control (afib and gets albuterol) and BP control. previously on lasix. no recent echo. clinically overloaded with edema, hypoxia -s/p lasix IV [5-15] and [5-16]. -start lasix 40mg daily--titrate as BP, creat tolerates -O2 sats good during day but needs O2 at night -dilt started and titrated to 240mg-->HR is now in 80s -unclear why not on BB, but possible due to recurrent asthma exacerbations. -d/c foley . Asthma: recurrent admissions for this. currently requiring 2L O2 which is new. no clear asthma flare, more likely fluid component as above -continue duonebs prn, advair, claritin 10mg daily . Atrial fibrillation/RVR: Rates were not well controlled while here. Was not on any nodal blocking agents. Patient with CHADS-2 score of 3, warranting anticoagulation (HTN, Age, Diabetes). Coumadin was held in setting of acute GI bleed. -will resume coumadin in 1 week given they biopsied rectal ulcer yesterday--notify [Hospital1 1501] -dilt started and titrated to 240mg-->HR is now in 80s . HTN: was difficult to control: titrated lisinopril to 10mg and added dilt as above. Also started lasix 40mg daily . DM: -SSI while here. doesnt appear to be on anything at [Hospital1 1501] -ACE-i as above . dyslipidemia: cont simva 40mg daily. Okay to resume ASA 81 . Chronic Pain: - continue home pain meds, including neurontin 900mg [Hospital1 ] and vicodin/tylenol prn . Atypical CP: Pt endorsed atypical CP on admission. EKG with non-specific ST-T wave changes. She has CAD risk factors including age, HTN, HLD, obesity. Trop negative X2.. continue statin, ACEi. started CCB. ASA resumed. . LE wounds: continue wound care. . OP: Ca+Vit D and vitamins . FEN/Proph: HLIV, monitor and replete electrolytes, hold bowel regimen, diabetic diet, hold AC, SCDs, PO PPI, continue vitamins . Dispo/Code: full code (confirmed). Plan to d/c back to [Hospital1 1501] today. Communication: Patient/Son [Name (NI) ] [0-0-] Medications on Admission: Simvastatin 40 mg PO QHS Lisinopril 5 mg PO daily Neurontin 900 mg PO BID Colchicine 0.6 mg PO BID Propoxyphene-N w/ Apap 1 tablet PO BID ASA 81 mg PO daily B complex/Folic Acied 1 tablet PO daily Vitamin D [2142] IU PO daily Claritin 10 mg PO daily Coumadin 5.5 mg PO daily Vicodin 1 tablet PO PRN: pain Colace 100 mg PO BID CAlcium + Vitamin D 1 mg PO BID Advair 500/50 1 puff INH [Hospital1 ] Bisacodyl 10 mg PO:PRN constipation Tylenol 650 mg PO:PRN MoM Discharge Medications: 1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain,fever. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for asthma. 5. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Propoxyphene N-Acetaminophen 100-325 mg Tablet Sig: One (1) Tablet PO twice a day. 13. B Complex-Folic Acid 0.4 mg Tablet Sig: One (1) Tablet PO once a day. 14. Biscolax 10 mg Suppository Sig: One (1) Rectal once a day. 15. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 18. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 19. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: Start on [5-25]. titrate dose for INR [1-24]. 20. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every [5-29] hours as needed for pain. 21. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 22. Milk Of Magnesia Concentrated 2,400 mg/10 mL Suspension Sig: One (1) PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital ] Health Care - [Hospital1 ] Discharge Diagnosis: hematochezia-likely diverticular bleed acute blood loss anemia Afib, RVR Acute diastolic heart failure HTN uncontrolled Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted for rectal bleeding. this is likely from diverticulosis. you got total 3U blood and some ffp to reverse your coumadin. your bleeding spontaneously stopped and you remained stable. After some delays, you underwent colonoscopy which showed diverticulosis. this also showed a rectal ulcer and a biopsy was taken which is pending at the time of discharge (GI will contact you with results). You also had colon polyps. You need these removed at some point as they could be cancer. Please arrange a colonoscopy with your gastroenterologist to arrange this. You can resume your coumadin in one week. Resume your aspirin now. A few new meds were started: lasix 40mg daily (for your swelling) and diltiazem 240mg daily (for fast heart rate). your lisinopril was increased for high blood pressure. Protonix was started to protect you from ulcers Followup Instructions: Please arrange a follow up with a gastroenterologist of your choice to perform colonoscopy to remove polyps . The nursing home will make a follow up with your primary care doctor when you are ready to leave	[ "250.00", "274.9", "211.4", "V85.4", "277.1", "V58.61", "562.12", "428.31", "584.9", "493.90", "285.1", "272.4", "427.31", "569.41", "401.9", "428.0", "564.09", "278.01" ]	icd9cm	[ [ [] ] ]	[ "49.23", "45.25", "38.93" ]	icd9pcs	[ [ [] ] ]	13279, 13352	4864, 10798	319, 343	13516, 13516	4069, 4841	14529, 14738	3010, 3032		11314, 13256		13373, 13495		10824, 11291			13650, 14506									3047, 4050																			276, 281									371, 2485										13531, 13626						2507, 2673	2689, 2994
70,989	156,500	40653	Discharge summary	report	Admission Date: [2108-7-16] Discharge Date: [2108-7-25] Date of Birth: [2056-12-24] Sex: F Service: SURGERY Allergies: Benadryl Attending:[Doctor Last Name 88932] Chief Complaint: Right chest wall abscess. Major Surgical or Invasive Procedure: PROCEDURE PERFORMED: 1. Incision and drainage of right chest wall abscess. 2. Debridement of mastectomy cavity History of Present Illness: The patient is a 51-year-old female who underwent a right total mastectomy with right axillary sentinel lymph node biopsy on [2108-7-2] for multicentric right breast carcinoma. She presented approximately 2 weeks postoperatively to the emergency room with concern for septic shock and hypovolemia. Her surgical incision site was imaged with ultrasound and showed a 5-cm x 5-cm simple fluid collection which was aspirated to resolution. The cultures grew out methicillin-sensitive Staph aureus. She was placed on broad-spectrum IV antibiotics at this time. She underwent fluid resuscitation and supportive care in the intensive care unit. On exam, her surgical site remained clean, dry and intact without evidence of cellulitis or induration. There was no appreciable fluid collection at the surgical site. Over the course of the following days, her laboratory values returned towards normal limits and she appeared clinically well. However,continued to have elevated fevers to the 38.3 with as a persistently elevated white count of 15,000 to 16,000. The decision was made to proceed with re-imaging of the right chest wall. On repeat ultrasound, was found to have 7- cm x 2-cm fluid collection at the site, not appearing loculated or rim-enhancing. She then underwent an ultrasound- guided aspiration at this time which revealed cloudy serosanguineous fluid. Due to her low-grade fever, the persistently slightly elevated white count,and the finding of cloudy fluid within the mastectomy cavity, the decision was made to proceed with operative incision and drainage, and debridement. Social History: The patient is from [Country 16465] originally. She has lived in [Location 86] for the past two years. She denies tobacco use. She denies ethanol use. She is unemployed currently. She has one male partner. Family History: Mom with an intra-abdominal cancer, unknown type. The patient does not have any further details. Physical Exam: AFVSS Gen: awake. pleasant. very pleasant. CV: RRR s1d2 nl, no MRG Resp: CTAB, no w/r/r Abd: soft, NT, ND, bs+ x4 Extremities: 2+ non-pitting edema bilaterally in hands and lower extremities up to mid tibia, continuing to improve, PPPx4 Neuro: AOx3, affect appropriate, globally hyporeflexic but able to move all four extremities, proximal weakness R>L, 3+ to 4- on R, 4 on L upper and lower extremities, also continuing to improve. Breast: R breast incision open with packing. With packing removed, beefy red granulation tissue within cavity, no evidence of infection or purulence Pertinent Results: EMG [2108-7-19]: -esentially normal nerve conduction studies. -although F waves were impersistent in the ulnar nerve and absent in the peroneal and tibial nerves, as may be seen in early [First Name9 (NamePattern2) 7816] [Location (un) ] Syndrome (<1 week), normal recruitment argues against GBS -no evidence for a presynaptic or postsynaptic disorder of neuromuscular junction transmission (as in Botulism and myasthenia [Last Name (un) 2902] respectively) -no evidence for a generalized myopathy Radiologic Data: MRI Brain w/Contrast: Few scattered non-specific foci of T2/FLAIR hyperintensities. Otherwise, no significant abnormalities on MRI without Gadolinium. MRI C-Spine w/o Contrast: mild degenerative changes of C-spine in the form of mild discrete disc bulging (C5-C6, C6-C7), no significant spinal stenosis or evidence of cord compression CT Chest: Foci of subcutaneous air and fluid collection measuring up to 7.5 cm within the right mastectomy site, likely post-surgical. Ultrasound R. Chest: An initial limited ultrasound of the right mastectomy scar confirmed the presence of a 5.2 x 1.5 x 5 cm fluid collection in the 9 o'clock position. Approximately 45 mL of clear serosanguineous fluid were aspirated without difficulty. Following completion of the procedure, there was near complete resolution of the fluid collections. Repeat Ultrasound R Chest [2108-7-18]: Successful ultrasound-guided aspiration of right breast fluid collection with approximately 55 mL of cloudy serosanguinous fluid removed. The sample was sent to laboratory for analysis. [2108-7-25] 06:30PM BLOOD WBC-10.5 RBC-3.42* Hgb-10.1* Hct-29.8* MCV-87 MCH-29.6 MCHC-34.0 RDW-15.1 Plt Ct-469* [2108-7-23] 09:58AM BLOOD Neuts-86* Bands-0 Lymphs-6* Monos-3 Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-1* [2108-7-22] 06:18AM BLOOD PT-13.8* PTT-26.8 INR(PT)-1.2* [2108-7-25] 05:15AM BLOOD Glucose-120* UreaN-11 Creat-1.1 Na-138 K-4.3 Cl-106 HCO3-20* AnGap-16 [2108-7-23] 09:58AM BLOOD ALT-27 AST-19 AlkPhos-95 TotBili-0.8 [2108-7-25] 05:15AM BLOOD Calcium-7.9* Phos-3.6 Mg-2.0 [2108-7-17] 10:12AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [2108-7-16] 05:00PM BLOOD WBC-13.9# RBC-4.43 Hgb-13.2 Hct-37.0 MCV-84 MCH-29.8 MCHC-35.7 RDW-14.2 Plt Ct-250 [2108-7-16] 05:00PM BLOOD Neuts-81* Bands-3 Lymphs-7* Monos-5 Eos-1 Baso-0 Atyps-0 Metas-3* Myelos-0 [2108-7-16] 05:00PM BLOOD PT-18.5* PTT-37.8* INR(PT)-1.7* [2108-7-16] 05:00PM BLOOD Glucose-69* UreaN-68* Creat-5.9# Na-128 K-4.7 Cl-88* HCO3-15* AnGap-30* [2108-7-16] 05:00PM BLOOD ALT-281* AST-723* LD(LDH)-899* AlkPhos-89 Amylase-12 TotBili-2.0* [2108-7-17] 01:55AM BLOOD Albumin-2.6* Calcium-6.8* Phos-4.4 Mg-1.8 [2108-7-16] 05:11PM BLOOD Lactate-6.7* [2108-7-18] 03:05PM BLOOD Lactate-1.5 Brief Hospital Course: This is a 51 year old woman with a recent mastectomy who presented to the ED with sepsis syndrome and proximal weakness and was found to have a Staph aureus infection of a collection at the mastectomy site. Due to her presentation, she was admitted to the surgical intensive care unit where she underwent agressive fluid recuitation and was treated with broad spectrum antibiotics. Her symptoms progressively improved over several days, however she continued to have low grade fevera and leukocytosis. Thus the decision was made to take patient to the operating room where she underwent an incision and drainage of right chest wall abscess and debridement of mastectomy cavity.The patient was transferred to the inpatient general surgery unit in good condition. Please refer to the following review of systems to summarize the patient hospital course. Neuro: The patient presented with new onset bilateral lower extremity weakness. Neurolgy was consulted and she underwent various neurological studies none of which showed any clear cut diagnosis. The patient's weakness progressively improved. Postoperatively PT/OT were consulted and patient continues to progress well. She is alert and oriented x3 and has adequate pain control on oral pain medication. Cardiovascular: The patient's hypotension resolved and BP normalized. Vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet,and incentive spirometer was encouraged. The patient denied cough or respiratory symptoms. Pulse oximetry was monitored closely and the patient maintained adequate oxygenations. GI/GU/FEN: Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. Her renal status improved after agressive fluid resucitation. The foley catheter was discontinued postoperatively and voided without difficulty. The IJ was also discontinued. ID: Infectious Disease were consulted. The patient's white blood count and fever curves were closely watched for signs of infection. The patient continued on IV antibiotic Nafacillin and was switched to PO levofloxacin. After the washout the patient was receiving [Hospital1 ] dressing changes,wet-to-right breast. The wound bed appeared clean with beefy red granulaetion tissue. Endocrine: The patient's blood sugar was monitored throughout hospital stay. Hematology: The patient's complete blood count was examined routinely. Prophylaxis: Venodyne boots were used during this stay. Pt was encouraged to and ambulate, though felt deconditioned.The patient was maintained on Heparin SC during hospitalization. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Wound care teaching was done with patient and niece who will assist with dressing changes. The patient was discharged home in good condition and will follow-up with Dr. [First Name (STitle) 3459] and infectious disease as an outpatient. Medications on Admission: percocet 5-325 [12-11] tab q 4-6h prn pain Discharge Medications: 1. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 2. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 3. dextromethorphan HBr 5 mg Lozenge Sig: One (1) lozenge PO every 4-6 hours as needed for cough. percocet 5-325 [12-11] tab q 4-6h prn pain Discharge Disposition: Home Discharge Diagnosis: Infected seroma, Right breast, sepsis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for sepsis from an abscess in your right breast. You received IV antibiotics for this infection. You also had the previous incision from your right breast surgery opened and the abscess was drained. The incision was left open and was packed with damp sterile gauze and covered with a dressing. These dressings need to be changed twice a day until your follow-up. If there is any increased redness, pain, or discharge from the wound or the dressings are becoming soaked, Followup Instructions: Provider: [First Name11 (Name Pattern1) 20] [Last Name (NamePattern1) 21], M.D. Phone:[Telephone/Fax (1) 22] Date/Time:[2108-8-3] 9:00 Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 2801] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 22] Date/Time:[2108-8-3] 9:00 Provider: [Name10 (NameIs) ] [Name11 (NameIs) 3459], MD, phone [Telephone/Fax (1) 2756], [2108-7-31] at 4pm Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724], [2108-8-3], 9AM, [Telephone/Fax (1) 2756] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 88933] Completed by:[2108-7-26]	[ "570", "V10.3", "V45.71", "E878.8", "276.2", "276.1", "995.92", "584.9", "729.89", "785.52", "038.11", "611.0", "276.52", "998.51" ]	icd9cm	[ [ [] ] ]	[ "85.21", "03.31", "85.91", "38.97" ]	icd9pcs	[ [ [] ] ]	9695, 9701	5872, 9231	297, 409	9782, 9782	3013, 5849	10450, 11188	2291, 2391		9328, 9672		9722, 9761		9257, 9305			9933, 10427									2406, 2994																			231, 259									437, 2040										9797, 9909							2056, 2275
50,807	149,724	2596	Discharge summary	report	Admission Date: [2173-2-8] Discharge Date: [2173-2-10] Date of Birth: [2124-8-13] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine Attending:[First Name3 (LF) 1936] Chief Complaint: Viral prodrome Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 13100] is a 48M with a PMH s/f HIV (last CD4 count [11/2172] 1200, viral load undetectable), chronic pain on narcotics, who presents to the ED with progressive dyspnea and systemic viral prodrome. The patient was in his USOH until friday [2-4], when he began to experience sudden onset of dyspnea on exertion, cough productive of yellow sputum, rhinorrhea, pharyngitis, myalgias, diarrhea, fevers to 102, fatigue, anorexia, and chills. He denies any pleuritic chest pain or hemoptysis, nausea or vomiting. He was seen by his PCP [Last Name (NamePattern4) ] [2-4], where he was started on moxifloxacin 400mg daily for presumed community acquired PNA. Throughout the weekend, he slept, with decreased po. Today his symptoms progressed, and he was directed to the ED for further evaluation. . In the ED his presenting vital signs were T=98.6, BP=135/75, HR=71, RR=18, O2sat=97% on room air. Initial exam was notable for clear lungs and mild somnolence. A CXR showed "platelike atelectasis in the lingula". ABG showed a mild respiratory acidosis and mild hypoxia: 7.29/63/58. The patient transiently desaturated on ambulation to 86%, and was started on CPAP. He was having apneic episodes on CPAP, for which he was given 0.4mg narcan with good effect. It was thought that this may be due to his outpatient narcotic regimen. He was given 750mg of IV levofloxacin and 1LNS. A rapid influenza test was sent. His labs were notable for new ARF with a BUN of 22 and a Cr 1.6 His current vital signs are T=98.6, BP=120-130, HR=70-80, RR=12, O2sat 96-99% on 4L. Past Medical History: 1. HIV: Last CD4 count [11/2172] 1200, viral load undetectable 2. Depression/anxiety 3. Chronic myofascial pain syndrome: Managed at [Doctor Last Name 1193] pain center 4. Seizure disorder Social History: Remote smoking history, 8 years from age 22-30. Non-drinker, no IVDU. Acquired HIV through sexual intercourse. Homosexual. Lives with a roomate, does not work, is on disability. Family History: NC Physical Exam: on discharge: Vitals: 95.4 59 18 115/77 96%RA Pain: denies Access: PIV Gen: nad HEENT: o/p clear, mmm CV: RRR, no m Resp: CTAB, no crackles or wheezing Abd; soft, nontender, +BS Ext; no edema Neuro: A&OX3, grossly nonfocal Skin: no changes psych: flat, strange affect at times Pertinent Results: no leukocytosis, wbc 4 with 46%N chem panel: BUN 22-->17, creat 1.6-->1.0 lactate 1.2 Serum tox negative LDH 164 . UA negative Resp viral screen [2-9] (including flu) Antigen neg, Cx pending blood cx [2-8] X2 NTD . . Imaging/results: CXR [2-8]: linguilar platelike atelectasis vs early PNA . CXR [2-9]: improved Abx in linguila. no PNA. . Brief Hospital Course: 48year old male with HIV CD4 1200, chronic myofascial pain syndrome, depression/anxiety, seizure disorder in his USOH until [2-3], had acute onset of flu-like symptoms with fevers 102, myalgias, sore throat, n/v, and cough with yellow sputum a/w DOE. Outpt PCP started [Name9 (PRE) 13101], no improvement in flu symptoms, slept for next 2days, then decided to come to ER [2-8]. In ER, depressed MS (on many narcotics at home) and transient hypoxia to 85%RA, started on CPAP. Recieved, narcan with improvement in MS. [Name13 (STitle) 227] concern for PNA and sepsis, got levaquin IV, IVFs, and was admitted to MICU. Flu screen (done 5days after onset of symptoms) was negative. CXR unremarkable. Got IVFs for [Last Name (un) ], resolved. In MICU remained afebrile, weaned off Oxygen, stable OFF any Abx. Transfered to floor [2-9]. Repeat CXR showed NO infiltrates and cough better so kept OFF Abx. Continued to feel back to baseline, had no more viral symptoms, remained afebrile and on RA. He continued to demonstrate some strange affect and slow mentation. Given his somnolence on arrival to ER and his multiple sedative meds at home, some of his outpt meds are being held (percocet, xanaflex, trazadone) and klonipine started at lower dose 2mg tid. His celexa/lyrica/piroxicam will be continued and he will be given ultram for breakthrough pain since he has issues with chronic myofascial pain for which he is followed by pain clinic. Strongly advice PCP or pain physicians to review his regimen as I was unable to reach PCP by phone. He states he has an appt in 2days. Rest of his meds were the same. . See below for rest of plan per problem: . 48M with male with h/o HIV (CD4 1200, VL undetectable), chronic myofascial pain on multiple meds, seizure d/o admitted with 5days of acute onset viral syndrome a/w DOE and hypoxia. . . Viral Syndrome/Cough/hypoxia: Very typical viral syndrome concerning for flu, though swab checked 5days later is negative. CXR repeated w/o any evidence of secondary PNA. Had some hypoxia PO2 58 in ER, but resolved and stable off Abx. Afebrile since admission -continue to monitor off Abx -robitussion for cough . . Respiratory acidosis: ABG is consistent with a chronic respiratory acidosis. No history of COPD or asthma, no clear signs of chest wall myopathy, not obese. Per the ED resident, pt appeared somnolent on initial presentation, and responded to narcan. He is on chronic percocet, as well as clonazapam, tizanidine, and trazodone, all of which can be sedating. Leads very sedentary lifestyle, this is possibly a medication induced hypoventiliation. -will ask to continue to hold percocet, tizanidine, and trazodone -resume klonipin at 2mg tid, cymbalta, lyrica okay-->dont want to withdraw all meds as pt has chronic myofascial pain -reccommend to PCP to [Name9 (PRE) 13102] all these meds-could not reach while here . . [Last Name (un) ]: Creat up to 1.6 on admission in setting fevers/[Month (only) ] PO. -s/p IVFs, creat 1.0 today, monitor . . HIV on ART: last CD4 1200, VL undetectable -continue home HAART regimen . . Depression/anxiety: holding home trazodone and tizanidine. Continue celexa 20mg tid, lyrica 25mg qd, klonipin 2mg tid (lower dose) . . Seizure disorder: continue home depakote XR 750mg [Hospital1 ] . . Chronic pain: continue piroxicam 20mg qd and pregabalin 25mg qd, will hold tizanidine and percocet given MS. . . Medications on Admission: Abacavir-Lamivudine [Epzicom] 600 mg-300 mg Tab daily Atazanavir [Reyataz] 400mg daily Citalopram 20mg TID Clonazepam 4/2/4mg TID Divalproex [Depakote ER] 750mg [Hospital1 ] Percocet 5/325mg q8-6Hprn Piroxicam 20mg daily Pregabalin [Lyrica] Tizanidine 4 mg daily Trazodone 100 mg qhs Loratadine 10 mg daily as needed Moxifloxacin 400mg daily Discharge Medications: 1. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO three times a day. 3. Piroxicam 10 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): for constipation. 6. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Lamivudine 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 8. Divalproex 250 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO BID (2 times a day). 9. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): decreased dose. 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed. Disp:45 Tablet(s) Refills:0 12. Robitussin-DM 10-100 mg/5 mL Syrup Sig: One (1) PO every 6-8 hours as needed for cough. Disp:qs bottle Refills:0 Discharge Disposition: Home Discharge Diagnosis: Viral syndrome, possibly influenza [Last Name (un) ]-resolved hypercapneia [1-18] excess sedation Discharge Condition: STABLE Discharge Instructions: You were admitted with a flu like illness. You do not have a pneumonia. You are on TOO MANY medications that cause you to be very sleepy. Please DO NOT restart the tizanidine, trazadone, percocet, loratadine. You can continue the celexa, depakots, piroxicam, lyrica, and klonipine at lower dose (2mg three times a day). If you have pain that is not controlled by this, take ultram as prescribed. Please bring ALL of your medications to your doctors [Name5 (PTitle) 648] [Name5 (PTitle) 13103] that he can review all your meds and stop the unneccessary ones that are causing excess sedation. Followup Instructions: Follow up with your PCP as scheduled in 2days Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD Phone:[Telephone/Fax (1) 1652] Date/Time:[2173-3-9] 2:10	[ "300.4", "E935.4", "E945.2", "729.1", "345.90", "079.99", "276.2", "E939.0", "584.9", "V08", "E933.0", "780.09" ]	icd9cm	[ [ [] ] ]	[ "93.90" ]	icd9pcs	[ [ [] ] ]	7956, 7962	3074, 6504	296, 302	8112, 8120	2693, 3051	8767, 8963	2372, 2376		6901, 7933		7983, 8091		6530, 6878			8144, 8744									2391, 2391												2405, 2674							242, 258									330, 1937																1959, 2157	2173, 2356
42,685	162,142	14070	Discharge summary	report	Admission Date: [2127-11-17] Discharge Date: [2127-11-20] Date of Birth: [2057-5-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2387] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac cath intra-aortic balloon pump History of Present Illness: This is a 70 yr old male with h/o HTN and OA now tranferred from [Hospital6 ] for a cath tomorrow. Pt states about 2 weeks ago, he who an episode of dizziness, lightheadedness, shortness of breath with exertion. Did not have chest pain or pressure at that time. Since then, pt had a couple of similar episodes. All of them resolved with rest. Last Saturday night, pt got up from sleep to go to the bathroom and noticed that he had chest discomfort that did radiate to left arm. Describes it as a heaviness, not pain. Pt went back to sleep and when he got up the next morning, still had the discomfort. It persisted all morning, so he finally presented to New [Hospital ] [Hospital ] hospital in the afternoon. There, he was sent for a stress test Monday morning. Per report, he developed chest pain and 2mm ST elevation in inferior leads on the treadmill, which resolved with rest. Also, per report had an ECHo that showed normal LV fxn w/o regional wall motion abnlormalities. He was given ASA, loaded with Plavix and placed on heparin gtt. Pt awas also started on statin, beta-blocker. Pt was then transferred to [Hospital1 18] for plan for cath with Dr. [Last Name (STitle) ] tomorrow. . Upon arrival to the floor, pt is comfortable, has no complaints. Denies any chest pain, shortness of breath. . Review of systems: as per HPI. endorses some mild rhinorrhea. endorses occ pain in knees and hip. denies fever, chills, night sweats, recent weight loss or gain, headache, sinus tenderness. denies cough, palpitations. denies nausea, vomiting, diarrhea, constipation or abdominal pain. denies dysuria. . Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Osteoarthritis - left hip and left knee treated with motrin in past Social History: lives with wife and a son at home in [Name (NI) 86]. works at an office, sometimes delivers luggage to homes. No smoking, occasional ETOH socially. No other drugs. Family History: father with CAD in late 50s, mother with "cardiomyopathy" in 70s, GM with DMII Physical Exam: Admission Exam: Vitals: T: 97.7 BP: 147/92 P: 57 R: 18 O2: 98% on RA General: alert, oriented, no acute distress HEENT: EOMI, MMM, oropharynx clear Neck: supple, no JVD Lungs: CTAB, no wheezes, rales, ronchi CV: RRR, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Cardiac Cath: 1. Selective coronary angiography in this right dominant system demonstrated 1 vessel coronary artery disease. The LMCA had minimal diffuse atherosclerotic disease. The LAD and LCx had diffuse non-critical disease. The RCA had 90% proximal stenosis as well as 80% mid-segment stenosis. The R-PDA had diffuse disease. 2. Resting hemodynamics revealed normal left and right sided filling pressures with an RVEDP of 9 mmHg and a PCWP of 13 mmHg. The pulmonary arterial pressure was normal at 23/12 mmHg. Systemic arteral pressures were initially elevated at 173/89 mmHg, however post-intervention normalized to 117/64 mmHg. Cardiac output and index were within normal limits. FINAL DIAGNOSIS: 1. 1 vessel coronary artery disease. 2. Normal left and right sided filling pressures. 3. Normal pulmonary and systemic arterial blood pressures. Echo: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global systolic function. Mild mitral and aortic regurgitation. Mild aortic dilation. Borderline pulmonary hypertension. Brief Hospital Course: This is a 70 yr old gentleman with h/o HTN tranferred from OSH for chest pain and a positive stress test found to RCA occlusion s/p 2 [Name Prefix (Prefixes) ] [Last Name (Prefixes) 10157]. . # CORONARIES: RCA had 90% proximal stenosis as well as 80% mid-segment stenosis, s/p 2 DES to RCA. Pt also with diffuse minimal/non-critical disease of LAD, LMCA and Left Circ. Cardiac cath procedure complicated with vagal episode of hypotension and bradycardia and brief ST elevations. He was given atropine and dopamine and had IABP placed. IABP was removed few hours after procedure. Trop peaked at 0.09. Echo showed no regional or global systolic dysfunction wtih EF 55% and mild symmetric LV hypertrophy. Pt was started on plavix 75mg daily, asa 325mg daily, simvastatin 40mg daily, metoprolol succ 25mg daily and lisinopril 5mg daily. He will follow up with cardiologist outpatient. . # PUMP: EF 55% with no regional or global systolic dysfunction and mild LV hypertrophy. . # Vaso-Vagal episodes: Likely secondary to manipulation during cardiac cath and post-procedure resulting in increased vagal tone. Pt had 1 episode during the cath procedure and 1 episode while in the CCU. During cath procedure, pt was given atropine and dopamine and had IABP placed. Shortly after cardiac cath, IABP was removed. After all hardwear was removed, pt had no further vagal episodes. . # HTN: Pt takes felodipine at home which was stopped. Started on metoprolol and lisinopril. Medications on Admission: Ibuprofen (stopped 2 weeks ago) Felodipine 7.5 mg daily Discharge Medications: 1. metoprolol succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:11 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 4. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO three times a day as needed for pain. 5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Coronary artery disease status post drug eluting stent to the right coronary artery. Vaso-vagal episodes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for a positive stress test. Your heart had a blockage in one of the arteries of your heart. A stent was placed to improve blood flow. Other vessels of your heart have some smaller plaques. We started you on new medications to manage your coronary artery disease. Please make sure to take these medications every day to protect your heart. During your cardiac catheterization procedure, you had some "vagal episodes" which caused a low blood pressure and improved after the procedure and after all the tubes were removed from your body. The vagal episodes of nausea and low blood pressure were likely due to your body's reaction to the procedure. Please avoid any strenuous exersize over the next 1 week. We do not recommend you go back to work for one week and should increase your activity slowly. We recommend you change your diet to a low cholesterol and heart healthy diet. We also recommend you eat foods low in salt. It is important to exercise regularly. The following changes were made to your medications: STOP: Felodipine and Ibuprofen START: Lisinopril to lower your blood pressure START: Metoprolol ot lower your heart rate and prevent a heart attack START: Clopidogrel or Plavix and a full dose (325mg) aspirin to prevent the stent from clotting off. You will need to take these medicines every day without fail for the next 1 year and possibly longer. Stopping or missing these medicines may cause a heart attack. Do not stop these medicines unless Dr. [Last Name (STitle) ] tells you it is OK. START: Simvastatin to lower your cholesterol and prevent blockages in your heart arteries. START: Tylenol at 1000mg Three times a day as needed to treat your arthritis. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) ] R. Address: [Street Address(2) ], 4W, [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 41966] Appointment: Monday, [12-1] at 3:00PM Name: [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Doctor Last Name ] BLDG, [Apartment Address(1) 17383] Address: [Last Name (NamePattern1) 8541], [Location (un) ],[Numeric Identifier 8542] Phone: [Telephone/Fax (1) 7960] Appointment: Wednesday, [12-3] at 2:20PM	[ "401.9", "780.2", "411.1", "414.01", "715.09" ]	icd9cm	[ [ [] ] ]	[ "00.46", "00.40", "37.21", "36.07", "00.66", "37.61" ]	icd9pcs	[ [ [] ] ]	7001, 7007	4723, 6197	328, 368	7156, 7156	3015, 3713	9047, 9650	2473, 2553		6304, 6978		7028, 7135		6223, 6281		3730, 4700	7307, 9024									2568, 2996		2103, 2171													1737, 2023				278, 290									396, 1718										7171, 7283	2202, 2272					2045, 2083	2288, 2457
28,138	155,056	12906	Discharge summary	report	Admission Date: [2176-7-8] Discharge Date: [2176-7-11] Date of Birth: [2100-5-7] Sex: M Service: MEDICINE Allergies: Percodan Attending:[First Name3 (LF) 106] Chief Complaint: eval for TIA Major Surgical or Invasive Procedure: carotid/cerebral angiography History of Present Illness: 76 y/o man with PMH sig for DM2, HTN, hyperlipidemia, CAD (s/p 2vCABG, s/p PTCA w/ RCA [Name Prefix (Prefixes) ] [Last Name (Prefixes) 5175]), carotid stenosis (severe 80-99% on R, moderate 60-70% on left), thought to be [2-10] rad therapy for oropharyngeal cancer, now referred for evaluation and R carotid stent placement by Dr. [Last Name (STitle) ]. . Pt has been experiencing episodes of blurry vision (L>R, sometimes b/l), confusion (no orientation to time, place) [2-11] times a week for the last several months, last episode on [2176-6-27]. Pt also admits to a syncopal fall in the bathroom in the morning 5 days PTA([2176-7-3]). The fall was unwitnessed, but patient denies head trauma, LOC, chest pain, palpitations, language impairement, focal deficits. As per wife, who pt was awake and oriented by the time she arrived to the BR (20-30 secs). They went to the [Hospital 487] [Hospital ] Hosp ED, where he head a normal workup. On follow-up, his cardiologist (Dr [Last Name (STitle) ] suggested evaluation for TIA and stenting of the R carotid artery. . ROS: no HA, no dizziness, no CP/SOB, no abd pain. Past Medical History: Hypertension Hyperlipidemia Diabetes CAD: - [2161]: LAD and RCA PTCA - [2163]: 2 vessel CABG (LIMA-->LAD, SVG-->OM) (Dr. [Last Name (STitle) 39668] [Hospital1 2025]) Significant carotid artery disease per wife's report (records requested from [Hospital1 2025]) [2156] malignant tumor involving the tonsil, s/p radical neck surgery and radiation ([Hospital1 2025]) [2167] Hematuria related to kidney stone GERD Lap Cholecystectomy Social History: Patient is married with two children. His wife [Name (NI) ] is a nurse. Lives with: Wife Occupation: Retired. Previously worked for [Company 2676] Smoking 30pack-year (quit 25 yrs ago) ETOH: occasional No drugs Pt not very active anymore, but independent in daily activities. Contact person upon discharge: [Name (NI) ] (wife): [Telephone/Fax (1) 39669] Family History: Mother with heart disease, passing away in her late 70??????s. Father with similar throat cancer. No family history of premature CAD, DM. Physical Exam: VS: afebrile, 178/68, 51, 18, 99% on RA Gen: pleasant gentleman sitting in bed in NAD HEENT: NC/AT, EOMI, OP clear, slightly dry MM Neck: supple, neck muscles on R side s/p radical dissection, 2+ carotid pulse, palpable stenotic carotids, strong bruit b/l CV: bradycardia, nl s1s2, no m/r/g Resp: CTAB, no w/r/r Abd: soft, NT/NE, NABS Extr: 1+ edema in legs, no TTP, wwp, 2+ rad/dp/femoral pulse, no femoral bruis Neuro: AOx3, CN II-XII intact, [5-13] motor strength, 1+ DTR b/l, sensation intact to light touch Pertinent Results: [2176-7-8] 03:10PM BLOOD WBC-4.4 RBC-3.58* Hgb-10.9* Hct-31.8* MCV-89 MCH-30.3 MCHC-34.2 RDW-13.8 Plt Ct-164 [2176-7-8] 03:10PM BLOOD PT-12.5 PTT-25.8 INR(PT)-1.1 [2176-7-8] 03:10PM BLOOD Glucose-85 UreaN-45* Creat-1.6* Na-140 K-5.2* Cl-105 HCO3-27 AnGap-13 [2176-7-8] 03:10PM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1 Brief Hospital Course: 76 y/o man with PMH sig for DM2, HTN, hyperlipidemia, CAD (s/p 2vCABG and PTCA), severe carotid stenosis [2-10] rad therapy for OP cancer, now referred for evaluation and R carotid stent placement, transferred to the CCU after right carotid stenting, transferred back to cadiology, [Hospital1 1516], service. . #. Carotid stenosis: pt has severe symptomatic carotid stenosis (80-99% on R on Doppler U/S). Evaluated for stenting by cerebral angiography and treated w carotid stent placement x3. Pt was hypertensive in the cath lab prior to transfer, sBP on arrival was 161 and pt was symptomatic when BP dropped quickly to 100. Pt was on nitro gtt for tight BP control in the 110-160 range and HA has resolved. Bp stabilized and remained stable on home regimen. . # Hct drop: Pt with hct 26.5 in the morning prior to procedure & hct dropped to 23. Pt had a prolonged time with cath lab with ?blood loss. Pt hemodynamically stable, groin site without ecchymoses, no obvious hematoma and pt received precath IVF the next day. It is unclear if this is a true hct drop vs dilution/lab error. . #. CAD: Pt has significant CAD s/p 2V CABG in 95 and RCA stenting in [4-16]. Pt denies any current chest pain & EKG shows no acute changes. Home regimen continued. . #. Pump/Rhythm: pt reports intermittent lower extremity edema but no other symptoms of acute CHF and recent ETT MIBI with preserved EF of 51%. Pt is clinically euvolemic to dry currently. Home regimen was continued. . #. DM2: well-controlled on home meds; diabetes medications were held before procedure, insulin RISS to cover. . #. Hyperlipidemia: continue home regimen, Pravastatin 40mg daily Medications on Admission: Pharmacy: CVS in [Location (un) ]: [Telephone/Fax (1) 39670] . Metformin (Glucophage) 500mg twice a day Glimeperide (Amaryl) 4mg twice a day Pioglitazone (Actos) 15mg every morning Metoprolol (Toprol XL) 50mg one tablet daily at bedtime Valsartan(Diovan)/HCT 160/25mg one tablet daily every morning Aspirin (Ecotrin) 325mg one tablet daily every morning Pravastatin (Pravachol) 40mg one tablet daily at supper Mononitrate (Imdur) 60mg one tablet daily at supper Omeprazole (Prilosec) 20mg one tablet daily every morning Clopidogrel (Plavix) 75mg daily at 12pm (started on [5-3]) Omega 3 fish oil 1000mg three times a day Nitroglycerin SL 0.4mg as needed for chest pain Furosemide (Lasix) 40mg one tablet prn for LE edema Discharge Medications: Pharmacy: CVS in [Location (un) ]: [Telephone/Fax (1) 39670] . Metformin (Glucophage) 500mg twice a day Glimeperide (Amaryl) 4mg twice a day Pioglitazone (Actos) 15mg every morning Metoprolol (Toprol XL) 50mg one tablet daily at bedtime Valsartan(Diovan)/HCT 160/25mg one tablet daily every morning Aspirin (Ecotrin) 325mg one tablet daily every morning Pravastatin (Pravachol) 40mg one tablet daily at supper Mononitrate (Imdur) 60mg one tablet daily at supper Omeprazole (Prilosec) 20mg one tablet daily every morning Clopidogrel (Plavix) 75mg daily at 12pm (started on [5-3]) Omega 3 fish oil 1000mg three times a day Nitroglycerin SL 0.4mg as needed for chest pain Furosemide (Lasix) 40mg one tablet prn for LE edema Discharge Disposition: Home Discharge Diagnosis: Peripheral Vascular Disease Discharge Condition: stable Discharge Instructions: You were admitted for carotid artery stenting which was performed sucessfully. . Per Dr. [Last Name (STitle) ], you can stop taking Trental. . If you have severe headache, neurologic deficits or chest pain, you should go to the emergency room. Followup Instructions: Dr.[Name (NI) 8664] office will contact you for re-admission in [2-11] weeks to perform carotid srtery stenting on the other side. . Follow up with Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 2037] [2176-8-30] 2:20pm. . Follow up with your PCP:[Name10 (NameIs) ],[Name11 (NameIs) ] in the next month. [Telephone/Fax (1) 12551] Completed by:[2176-7-12]	[ "433.10", "V10.02", "433.30", "285.9", "V45.82", "414.00", "V45.81", "272.4", "250.00", "V15.82", "401.9", "V15.3" ]	icd9cm	[ [ [] ] ]	[ "00.40", "00.63", "00.47", "88.41", "00.61", "99.04" ]	icd9pcs	[ [ [] ] ]	6633, 6639	3427, 5091	279, 309	6711, 6720	3076, 3404	7016, 7408	2385, 2524		5875, 6610		6660, 6690		5117, 5852			6744, 6993									2539, 3057																			227, 241								2312, 2369	337, 1494																1516, 1979	1995, 2296
24,612	177,216	10385	Discharge summary	report	Admission Date: [2193-2-19] Discharge Date: [2193-2-26] Date of Birth: [2118-1-11] Sex: M Service: BLUMEGART INTERNAL MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old man with a history of hypertension, type 2 diabetes mellitus, and invasive adenocarcinoma of the gallbladder who is status post recent admission for hemobilia and stent placement who presented to the Emergency Department after one episode of hematemesis. The patient noted on the evening prior to admission he ate dinner and then later developed nausea with emesis times one consisting of partially digested food. He took Compazine. One hour later the patient was talking on the phone and had another episode of nausea followed by vomiting of brownish material with blood clots. He then came to the Emergency Department where he was found to have a hematocrit of 32 and INR of 1.3. Intravenous access was difficult, and therefore, a right femoral central venous catheter was placed, and the patient was line resuscitated. Nasogastric tube was placed, and lavage was performed which did not clear after 2 L of saline. The GI Service was [Name (NI) 653], and the patient was subsequently admitted to Blumegart for upper GI bleed in the setting of invasive adenocarcinoma of the gallbladder. The patient received approximately 2 L normal saline in the Emergency Department, as well as intravenous Zantac. PAST MEDICAL HISTORY: 1. Locally invasive gallbladder adenocarcinoma diagnosed in [2192-12-4], on salvage chemotherapy with 5FU and Leucovorin. 2. Hypertension. 3. Type 2 diabetes mellitus. 4. Atrial and ventricular ectopy on Amiodarone. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS ON ADMISSION: ASA 81 mg p.o. q.d., Glyburide 5 mg p.o. q.d., Amiodarone 400 mg p.o. q.d., Lopressor 50 mg p.o. b.i.d., Lasix 40 mg p.o. q.d., Compazine p.r.n., Imodium. SOCIAL HISTORY: The patient lives with his wife and four children. He denied alcohol, smoking, or intravenous drug abuse. He is a retired librarian. The patient was born in Barbados. PHYSICAL EXAMINATION: Vital signs: The patient was afebrile, with a heart rate of 68, blood pressure 130/76, respirations 18, oxygen saturation 100% on room air. General: The patient was an elderly man in no acute distress. HEENT: Pupils equal, round and reactive to light. Extraocular movements intact. The patient had a left-sided ptosis. Oral mucosa moist and pale. Neck: Supple. No jugular venous distention. No bruits. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rhythm with ectopy. Normal S1 and split S2. There was a 2 out of 6 systolic ejection murmur heard best at the left lower sternal border. Abdomen: The belly was soft, mildly distended, nontender, with normal bowel sounds. The liver span was 8 cm. There was no splenomegaly. The patient was guaiac positive. Extremities: The patient had peripheral pulses that were 2+ with mild pedal edema. The patient had a right femoral line in place in his groin. Neurological: The patient was grossly intact. LABORATORY DATA: Initial studies indicated a white blood cell count of 11.6, hematocrit 32.1, platelet count 270, with a differential significant for 90% polys, 8% lymphocytes; CHEM7 was remarkable only for a glucose of 286; INR 1.3; ALT 126, AST 162, alkaline phosphatase 331, total bilirubin 1.9. Chest x-ray indicated no pneumonia or effusions. Electrocardiogram indicated normal sinus rhythm at 64 with right bundle branch block, a prolonged QTC at 493 msec. HOSPITAL COURSE: The patient was admitted to Blumegart Internal Medicine Firm for work-up of upper GI bleed. His Aspirin was discontinued, and he was placed on intravenous Protonix. On hospital day #2, the patient's hematocrit was stable, and his liver function tests were trending down. He received an upper endoscopy which indicated a normal esophagus, clotted blood in the stomach, and erythema and congestion of the duodenal mucosa with contact bleeding. There was no active bleeding noted on exam. The patient was therefore switched to p.o. Protonix. The patient was transfused 2 U of packed red blood cells with a pretransfusion hematocrit of 29.6 and a posttransfusion hematocrit of 30.0; although this was thought to be an inappropriate response to a transfusion, his hematocrit remained stable, and no further transfusions were attempted at that time. On hospital day #3, the patient started to complain of moderately severe epigastric tenderness with associated nausea. He was then witnessed to have one episode of hematemesis with approximately 50 cc of dark blood. He was then noted to have melena with a substantial amount of maroon colored stool. A repeat upper endoscopy was performed which indicated red blood in the area of the papilla consistent with hemobilia. The patient was also noted to develop atrial fibrillation with a rapid ventricular response and rate in the 150s. He was restarted on Lopressor with improved rate control but remained in atrial fibrillation during the remainder of his hospital stay. The patient was then taken to the Interventional Radiology Suite for emergent angiography of the celiac access which revealed a right hepatic artery pseudoaneurysm. Multiple coils were deployed proximally to the pseudoaneurysm, as well as infusion of Gelfoam pledgets. The patient also received coil and Gelfoam embolization distally to his right hepatic artery pseudoaneurysm. The patient was then transferred to the Medical Intensive Care Unit for monitoring overnight. He remained hemodynamically stable, and his hematocrit remained stable. Blood cultures returned positive for gram-negative rods in 2 out of 2 bottles. This organism was later identified as Klebsiella pneumonia which was pansensitive. The patient was started on a two-week course of Ciprofloxacin and Metronidazole. On hospital day #4, the patient was returned to the floor in stable condition; however, his hematocrit was noted to trend down from 30 to 25 over the course of hospital day #5, and the patient again received a transfusion of 2 U packed red blood cells. The patient's posttransfusion hematocrit remained stable at 30 for the remainder of his hospital stay. On hospital day #7, the patient was evaluated by Physical Therapy and was thought to benefit from an acute stay at an inpatient rehabilitation hospital. At the time of this dictation, it was planned that the patient will be discharged to an acute rehabilitation setting for several days prior to anticipated discharge to home. While the patient was in-house, the Oncology Service was aware of his status, and the patient is to follow-up with his oncologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] following discharge. The patient remained afebrile with a normal white count and resolving liver function tests during his hospital stay. Following several conversations with the patient and his family, it was clear that although the patient was aware of his grim diagnosis, that he wished to remain FULL CODE for the time being. At the time of discharge, the patient remained in atrial fibrillation with a ventricular rate of approximately 100. Although he was maintained on Lopressor, it was felt that the patient's rate control should not be increased given his risk of continued bleeding. DISCHARGE DIAGNOSIS: 1. Adenocarcinoma of the gallbladder with local invasion of the liver. 2. Hemobilia with right hepatic artery pseudoaneurysm, status post embolization. 3. Atrial fibrillation with rapid ventricular response. 4. Hypertension. 5. Type 2 diabetes mellitus. DISCHARGE MEDICATIONS: Ciprofloxacin 500 mg p.o. b.i.d. x 7 days, Flagyl 500 mg p.o. t.i.d. x 7 days, Lopressor 50 mg p.o. b.i.d., Glyburide 5 mg p.o. q.d., Amiodarone 400 mg p.o. q.d., Protonix 40 mg p.o. b.i.d. DISPOSITION: It was planned that the patient will be discharged to an acute rehabilitation facility. FOLLOW-UP: He is to follow-up with Dr. [Last Name (STitle) 1683] within two weeks and with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of Oncology within one week. CONDITION ON DISCHARGE: Improved. [Initials (NamePattern4) ] [Last Name (NamePattern4) 8873] [Name8 (MD) ], M.D. [MD Number(1) 8874] Dictated By:[Last Name (NamePattern1) 194] MEDQUIST36 D: [2193-2-26] 11:26 T: [2193-2-26] 11:41 JOB#: [Job Number ]	[ "156.1", "401.9", "427.69", "578.0", "427.31", "038.49", "250.00", "442.84", "197.7" ]	icd9cm	[ [ [] ] ]	[ "39.79", "38.93", "45.13" ]	icd9pcs	[ [ [] ] ]									7696, 8186		7412, 7672		1747, 1903	3588, 7391																			2114, 3570																				189, 1432																1455, 1720	1920, 2091	8211, 8510
20,291	123,354	2285+55367	Discharge summary	report+addendum	Admission Date: [2104-8-14] Discharge Date: [2104-8-22] Service: NMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6075] Chief Complaint: right hand weakness Major Surgical or Invasive Procedure: none History of Present Illness: This is an RH 87 yo woman with afib off coumadin secondary to SDH, HTN, osteoarthritis, dementia, gerd, hypercholesterolemia who presents with right hand weakness. The patient is unable to provide the history given her dementia. The history is provided by the daughter, she witnessed the entire event. The patient awoke from a nap on the couch yesterday AM and had sudden onset right hand weakness, "it litterally dropped." Also with a mild headache. No language disturbances, no facial or leg weakness. SHe was unable to extend her fingers or make a fist. She was taken to an OSH. Per the daughter, upon arrival her hand weakness was slightly improved. A CT scan of the head was reportedly negative for hemorrhage (no scan or reports here to verify). This morning she has no complaints - no headache, fevers, chills, abd pain, cp, SOB. Does c/o arthritis pain on strength exam. Her daughter reports that the strength in her right hand is slightly improved. Past Medical History: 1. afib not on coumadin 2o2 SDH 2 yrs ago, one sz s/p SDH, currently on dilantin 2. s/p PM placement 3. HTN 4. severe osteoarthritis 5. dementia 6. gerd 7. hypercholesterolemia Social History: lives in Arena [Hospital3 ], no tob, social etoh in the past, no drugs Family History: not able to obtain Physical Exam: VITALS: T 97.6, Tc 97, BP 140-150/70-76, HR 72-86, RR 18, 95% on RA, I/O: 0/400 GEN: NAD, pleasantly demented HEENT: NC/AT, clear OP NECK: supple, nontender, no carotid bruits CV: irreg irreg rhythm, no mur CHEST: CTA bilat ABD: soft, NT/ND, + BS EXTREM: no edema NEURO: MS: awake, alert, pleasant affect, oriented to self but not time or place. Poor attention, unable to name days of week or months of the year backwards. Speech is fluent without dysarthria. Repeats "dogs [Male First Name (un) ] but rarely catch clever cats." Speaks in full sentences (>4 words). Follows 3 step command. Able to name 10 clothing objects you'd find in a store. Memory 0/3 in 1 minute. No neglect. Brushes teeth appropriately but uses her hand as a brush when asked to demonstrate how to brush her hair. CN: I: deferred II, III: Visual fields full to confrontation. Pupils are 2mm-> 1mm bilaterally and consensual reaction to light. III, IV, VI: EOMI intact, no nystagmus, no ptosis. V, VII: normal facial sensation and strength. (?mild right lower face droop??) VIII: hearing intact to finger rubs bilaterally IX, X: palate elevates symmetrically. [Doctor First Name 81]: SCM [5-21] bilaterally XII: tongue is midline without fasiculations. Motor: + right pronator drift unable to perform fast finger movements on the right. Delt Tri [Hospital1 ] Br WE FE FF IP Ham DF Toe RIGHT: 5 5 4+ 4+ 4+ 3 4+ 5 5 5 5 LEFT: 5 5 5 5 5 5 5 5 5 5 5 DTRs: [Name2 (NI) ]: 2. LE 1. Toe up on the right, down on the left. Sensory: position sense intact throughout. localizes to touch with eyes closed. recognizes numbers drawn on the palm of the hand. intact to light touch, vibration, pain throughout. [Last Name (un) ]: intact FTN bilat, although slower on the right. Gait: not tested this am, but was narrow based with tandem intact last night. Pertinent Results: WBC 7.9, Hct 39.2, plt 173 coags nl [8-14] Na 144, K 3.9, Cl 107, bicarb 26, BUN 29, Cr 0.7, gluc 98 CK: 57, 58. MB ND x2. TropT < 0.01 x 2. Chol 189, Tg 137, HDl 61, LDL 101 HBA1c pending. Phenytoin 5.2 CT scan hemorrhage: no bleed, no acute stroke seen Carotid duplex: < 40% stenosis bilaterally Brief Hospital Course: This is an 87 woman with multiple vascular risk factors including PAF not on coumadin, HTN, hypercholesterolemia, who p/w right hand (distal) weakness and possibly a mild right lower face droop. Her findings are most likely consistent with a small embolic stroke, likely from her afib, to the left cortex. Per the daughter, it sounds as though the right hand weakness has improved over the past 24 hours. Initially she was unable to make a fist or elevate her fingers. On the day after admission she was weak in the distal right arm (brachioradialis, biceps. wrist extensors, finger flexors), not plegic. Workup included: < 40% stenosis ICA bilaterally. Ruled out for MI. CT head unrevealing. Tele unrevealing. She came in on aspirin 81 mg. I have discussed with the family re: treatment options: 1. increasing ASA to 325 mg. 2. starting aggrenox or plavix. or 3. coumadin given her afib. The family is not interested in coumadin given her past fall and SDH. THey are most interested in increasing the dose of aspirin to 325 mg po [Last Name (LF) ], [First Name3 (LF) ] that was done. We continued all of her current meds. PT/OT were consulted. PPX: ranitidine, OOB to chair, work with PT FEN: cardiac healthy diet Dispo: d/c to rehab on [2104-8-17] Medications on Admission: 1. vasotec 5mg [Hospital1 ] 2. atenolol 50 qd 3. lipitor 10 qPM 4. aricept 10mg qAM 5. dilantin 100 [Hospital1 ] 6. diazide qAM (dose?) 7. zantac 150 [Hospital1 ] 8. multivitamin qam 9. asa 81 10. glucosamine qam and pm 11. calcium q am 12. iron qpm (dose?) 13. zoloft 200 mg qAM Discharge Medications: 1. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Sertraline HCl 100 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 8. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day). 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 10. Calcium + Vitamin D 600-200 mg-unit Tablet Sig: Two (2) Tablet PO once a day. 11. MEDS Patient may be taking dyazide and iron, but doses are currently unknown. Please have her daughter phone her PCP to verify meds and doses. Thank you. Discharge Disposition: Extended Care Facility: [Doctor First Name 391] Bay Skilled Nursing & Rehab. Center Discharge Diagnosis: 1. stroke, likely cortical and left sided, resulting in right distal hand weakness and very mild right lower face droop. 2. atrial fibrillation 3. hypertension 4. osteoarthritis 5. dementia 6. gerd 7. hypercholesterolemia Discharge Condition: good - ambulating with PT, eating on her own Discharge Instructions: Please take all medications. Please return to the ED or call your PCP if you experience any worsening weakness/numbness, visual changes, fever/chills. Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 59] Date/Time:[2105-2-10] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 127] Date/Time:[2105-2-10] 3:30 Provider: [First Name11 (Name Pattern1) 8122] [Last Name (NamePattern4) 8123], M.D. Where: [Hospital6 29] DERMATOLOGY Phone:[Telephone/Fax (1) 2977] Date/Time:[2105-4-14] 3:00 Name: [Known lastname 1723],[Known firstname ] Unit No: [Numeric Identifier 1724] Admission Date: [2104-8-14] Discharge Date: [2104-8-22] Date of Birth: [2017-3-4] Sex: F Service: NMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1725] Chief Complaint: see d/c summ Major Surgical or Invasive Procedure: see d/c summ Brief Hospital Course: On the day of planned discharge, [2104-8-17], patient was found having a partial complex seizure. The duration of the seizure is unclear. Ativan and 1 gram of IV dilantin was administered until the seizure ceased, taking approximately 15 minutes until the event ended. She was then transferred to the ICU for monitoring as she was quite sedated. During her ICU stay she developed a fever and was found to have a right infrahilar infiltrate on CXR as well as a UTI with e coli and enterococcus both sensitive to levofloxacin. She completed a 5 day course of levofloxacin and indwelling foley was discontinued. After her solmnolence wore off, she was transferred to the floor. She passed a bedside swallow eval, although should be on soft solids as she is missing some teeth. She worked with PT/OT. Upon discharge, her distal right hand weakness persists, she is maintained on a full aspirin and statin. Her phenytoin level has been theraputic since [2104-8-17] and no further seizures occured. She also developed LUE swelling; LUE US revealed no clot and the swelling resolved with elevation. Her afib was rate controlled with metoprolol, dose was titrated up to keep HR<100. Medications on Admission: see d/c summ Discharge Medications: Metoprolol 50mg PO TID, hold for sbp<110, HR<55 Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Phenytoin 100 mg PO TID Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Sertraline HCl 100 mg Tablet Sig: Two (2) Tablet PO QD (once a day). Multivitamin Capsule Sig: One (1) Cap PO QD (once a day). Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). Bisacodyl prn Colace 100mg PO TID Acetaminophen prn Heparin 5000 units SC TID for dvt prophylaxis albuterol inh prn Discharge Disposition: Extended Care Facility: [Doctor First Name 1726] Bay Skilled Nursing & Rehab. Center Discharge Diagnosis: 1. stroke, likely cortical and left sided, resulting in right distal hand weakness and very mild right lower face droop. 2. status epilepticus, resolved 3. atrial fibrillation 4. HTN 5. osteoarthritis 6. dementia 7. gerd 8. hypercholesterolemia Discharge Condition: good - ambulating with PT, eating on her own, still with distal right hand weakness Discharge Instructions: Please take all medications. Please return to the ED or call your PCP if you experience any worsening weakness/numbness, visual changes, fever/chills. Followup Instructions: Provider: [Name10 (NameIs) 1727] CLINIC Where: [Hospital6 189] CARDIAC SERVICES Phone:[Telephone/Fax (1) 1728] Date/Time:[2105-2-10] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1729], M.D. Where: [Hospital6 189] CARDIAC SERVICES Phone:[Telephone/Fax (1) 1730] Date/Time:[2105-2-10] 3:30 Provider: [First Name11 (Name Pattern1) 1731] [Last Name (NamePattern4) 1732], M.D. Where: [Hospital6 189] DERMATOLOGY Phone:[Telephone/Fax (1) 1733] Date/Time:[2105-4-14] 3:00 Please call the neurology stroke clinic for a followup appointment after you finish rehabillitation. [Telephone/Fax (1) 1734] [First Name11 (Name Pattern1) 657] [Last Name (NamePattern4) 1735] MD [MD Number(1) 1736] Completed by:[2104-8-22]	[ "272.0", "599.0", "729.89", "345.3", "427.31", "486", "781.94", "294.8", "434.11" ]	icd9cm	[ [ [] ] ]	[ "96.6" ]	icd9pcs	[ [ [] ] ]	9978, 10069	8094, 9290	8057, 8071	10365, 10450	3559, 3869	10649, 11493	1597, 1618		9353, 9955		10090, 10344		9316, 9330			10474, 10626									1633, 3540																			8005, 8019									313, 1281																1303, 1488	1504, 1581
14,612	158,239	18785+56987	Discharge summary	report+addendum	Admission Date: [2151-7-26] Discharge Date: [2151-8-2] Service: C-MED CHIEF COMPLAINT: Transfer from [Hospital3 3583] for pacemaker placement. HISTORY OF PRESENT ILLNESS: An 87-year-old female, with a history of myocardial infarction one week ago, refusing PTCA at that time, with a history of paroxysmal atrial fibrillation and sick sinus syndrome, who has had recent pauses of up to 12 seconds at an outside hospital. She has refused a pacemaker in the past and was discharged to rehab. At rehab on the day prior to admission to [Hospital3 3583], she had some shortness of breath, and was again admitted to [Hospital3 3583] with an elevated troponin of 0.17. As she was agreeable for pacemaker placement, she was transferred to [Hospital1 ]. She has had an attempt at a previous pacemaker placement that was complicated by an anomalous superior vena cava. PAST MEDICAL HISTORY: 1. Systolic CHF with an ejection fraction of 30%. 2. Paroxysmal atrial fibrillation. 3. Sick sinus syndrome. 4. Anomalous vena cava. 5. Coronary artery disease. 6. Myocardial infarction. 7. Ischemic cardiomyopathy. 8. Hypertension. 9. History of coagulopathy. 10.Chronic bilateral pleural effusions. ALLERGIES: Penicillin. MEDICATIONS ON ADMISSION: 1. Lipitor 10 mg qd. 2. Amiodarone 200 mg qd. 3. Imdur 30 mg in the am. 4. Aspirin 81 mg qd. 5. Metoprolol 25 mg [Hospital1 ]. 6. Lasix 20 mg [Hospital1 ]. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient was transferred from [First Name5 (NamePattern1) 46] [Last Name (NamePattern1) ]. She does not smoke and does not drink alcohol. EXAMINATION: The patient was afebrile, heart rate 110, blood pressure 128/70, respiratory rate 20, oxygen saturation 92% on 2 liters. GENERAL: Alert, oriented, no acute distress. HEENT: Supple neck. Pupils equal, round and reactive to light. CARDIOVASCULAR EXAM: Irregularly irregular, tachycardic. RESPIRATORY EXAM: Decreased breath sounds at the bases to half way up bilaterally. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Weak distal pulses bilaterally. Extremities warm. No edema. NEUROLOGICAL EXAM: Alert and oriented. Strength slightly weak but symmetric and equal throughout. Cranial nerves II through XII grossly intact bilaterally. EKG: Atrial fibrillation, rate 137, right bundle branch block, borderline right axis deviation. Some ST-T wave changes in leads V1 and V2 that are nonspecific. LABS ON ADMISSION: White blood cell count 13.5, hematocrit 36.8, platelets 448, sodium 138, potassium 4.3, chloride 100, bicarb 29, BUN 37, creatinine 0.8, glucose 135, CK 20, CK-MB 1.4, calcium 9.0, AST 21, ALT 36. ECHOCARDIOGRAM: Ejection fraction less than 20%. Left atrium dilated. Left ventricle - severe global LV hypokinesis. Severely depressed LV systolic function. 2+ mitral regurgitation. No pericardial effusion. HOSPITAL COURSE - 1) ATRIAL FIBRILLATION, SICK SINUS SYNDROME: The patient was taken to the EP Lab for pacemaker placement which was again complicated by her anomalous superior vena cava. A ventricular lead was placed. However, an atrial lead was not obtained. The patient was continued on telemetry and was found to have episodes of rapid atrial fibrillation followed by compensatory pauses, at which time ventricular pacing would begin. The patient was continued on a beta blocker; however, she was changed over to carvedilol 6.25 mg [Hospital1 ]. She was started on Coumadin for anticoagulation at a loading dose of 5 mg once, followed by 3 mg q hs. Her amiodarone was increased from 200 to 400 mg which should be continued for the first four weeks, at which time she should be changed over to 200 mg qd. 2) RESPIRATORY FAILURE, HYPOXIA: Upon return from the Electrophysiology Lab, the patient was found to be hypoxic with an oxygen saturation in the 60% range. In addition, her respiratory rate was found to be two breaths per minute at that time. She was placed on high flow nonrebreather mask with 100% FIO2, and responded to verbal stimulation, began taking more breaths. At that time, she was transferred to the Intensive Care Unit for her respiratory failure where she was started on a nesiritide drip, in addition to lasix for effective diuresis of her congestive heart failure. Her decreased respiratory rate and hypoxia were felt to be secondary to oversedation after her pacemaker placement, as well as some component of congestive heart failure. She diuresed quickly in the CCU on the nesiritide drip and was transferred back to the cardiology floor where the nesiritide drip was continued for three days. After discontinuing the nesiritide, the patient was started on lasix po. 3) PLEURAL EFFUSIONS: The patient has had chronic bilateral pleural effusions that were felt to be secondary to her congestive heart failure. The effusions appeared stable on multiple chest x-rays on this admission, and it is felt that over time, with diuresis, the effusions will slowly resolve. 4) CONGESTIVE HEART FAILURE: The patient's ejection fraction was found to be 15%, with severe systolic left ventricular dysfunction. The patient was diuresed with nesiritide drip, as well as IV lasix, and was restarted on scheduled [Hospital1 ] po lasix. She was also placed on 1 liter of fluid restriction and a 2 gm sodium diet. The patient was started on a low-dose ACE inhibitor for her congestive heart failure. 5) CORONARY ARTERY DISEASE: The patient was continued on her daily aspirin, beta blocker and Lipitor, and an ACE inhibitor was started. 6) DEPRESSION: During her admission, the patient at one point refused all blood draws, and refused to take all PO medication. This was discussed with medical staff, as well as with the patient and her grandniece. The patient continued to insist on refusing PO medications and blood draws, and psychiatry was consulted to evaluate the patient's mental status and depressed mood. 7) CODE STATUS: The patient clearly expressed her wishes to be DO NOT RESUSCITATE and DO NOT INTUBATE. Her grandniece was present at that time who agreed that that was the patient's wishes. CONDITION AT DISCHARGE: Stable. DISCHARGE INSTRUCTIONS: The patient's I's and O's and daily weights should be measured. The patient's lasix may need to be increased if she is not slowly diuresing, or if she gains a significant amount of weight. The patient's INR should be checked 2-3 days after discharge, as her Coumadin dose may need to be adjusted; her goal INR is between 2.0 and 3.0. The patient should follow-up with her primary care doctor within 1 week, and should follow-up with her cardiologist within 1-2 weeks. DISCHARGE DIAGNOSES: 1. Paroxysmal atrial fibrillation. 2. Sick sinus syndrome. 3. Systolic congestive heart failure. 4. Respiratory failure. 5. Coronary artery disease. 6. Ischemic cardiomyopathy. 7. Hypertension. 8. Bilateral pleural effusion. 9. Depression. [Doctor First Name 900] [Name8 (MD) 901], M.D. [MD Number(1) 2144] Dictated By:[Last Name (NamePattern1) 51445] MEDQUIST36 D: [2151-8-2] 10:12 T: [2151-8-2] 09:13 JOB#: [Job Number 51446] Name: [Known lastname 9573], [Known firstname 1683] Unit No: [Numeric Identifier 9574] Admission Date: [2151-7-26] Discharge Date: [2151-8-6] Date of Birth: [2063-11-5] Sex: F Service: [Hospital Unit Name 319] HOSPITAL COURSE: 1. Congestive heart failure: The patient was continued on nesiritide drip until the day of discharge. In addition, she was treated with daily IV Lasix and started on five days of Diamox therapy. She continued to have negative fluid balance daily and was comfortable on low flow oxygen on the day of discharge with oxygen saturations in the mid 90s. She should continue to have her daily Lasix, and she should complete four more days of Diamox therapy. Please check her weights daily and follow her potassium as Lasix may cause hypokalemia. Please continue her daily digoxin at 0.125 and check her digoxin level in one week. 2. Fall: The patient fell on [8-4], while trying to wipe herself on the commode. She hit her head on the floor and had a 3 cm in diameter superficial hematoma on her left parietal scalp. She had a nonfocal neurological examination. Head CT scan, C spine films, and hips and pelvis x-rays showed no acute trauma. The patient is weak after her extended hospital stay, and will need Physical Therapy in rehab. She continues to have a nonfocal examination and is cleared for discharge. 3. Bilateral pleural effusions: The patient has had chronic bilateral pleural effusions that were being treated with aggressive diuresis. The right effusion has improved during her hospital, however, the left side has had an interval increase in size. The patient refused an inpatient thoracentesis despite having all of the benefits explained to her. She should be asked again as an outpatient and should call the Interventional Pulmonary Department at [Hospital1 960] to schedule an outpatient thoracentesis if she changes her mind. 4. Swallowing: The patient passed her swallowing study, but should have her medications crushed in apple sauce as she refuses to take them if they are not prepared in that way. 5. Depression: The patient was seen by Psychiatry during this admission as she was refusing po medications. She was seen and it was determined that she was not clinically depressed at this time. She responds well to attention and should be engaged in conversation and group activities, and rehab as much as possible. 6. Atrial fibrillation: She should continue to take her daily Coumadin and have her INR checked every 2-3 days initially. Her goal INR is 2.0-3.0. She should continue to take 400 mg po of amiodarone daily for the next four weeks. At that time, her dose should be adjusted to 200 mg daily. Please check LFTs every 2-3 months. 7. Code status: The patient has clearly expressed her wishes to be DNR/DNI. The family members were present, were in agreement. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg po daily. 2. Carvedilol 6.25 mg [Hospital1 ]. 3. Captopril 6.25 mg tid. 4. Lasix 20 mg IV once daily. 5. Acetazolamide 250 mg one tablet po q day. 6. Digoxin 125 mcg po daily. 7. Amiodarone 400 mg po daily for 28 days, and then decrease the dose to 200 mg po daily. 8. Aspirin 81 mg po daily. 9. Warfarin 3 mg daily, please check the patient's INR three days after discharge and adjust the Coumadin dose to have a goal INR of 2.0-3.0. [Doctor First Name 1332] [Name8 (MD) 1333], M.D. [MD Number(1) 1334] Dictated By:[Last Name (NamePattern1) 5373] MEDQUIST36 D: [2151-8-6] 18:35 T: [2151-8-9] 10:52 JOB#: [Job Number 9575]	[ "428.23", "511.9", "747.40", "E935.2", "518.5", "427.31", "410.91", "428.0", "427.81" ]	icd9cm	[ [ [] ] ]	[ "37.81", "37.71", "00.13" ]	icd9pcs	[ [ [] ] ]							1457, 1475	6706, 7469	10136, 10846				1275, 1440	7486, 10113		6214, 6685																				6180, 6189							2167, 2475	108, 169									198, 901								2490, 6165								923, 1249	1492, 2147
28,863	140,125	6163	Discharge summary	report	Admission Date: [2131-11-3] Discharge Date: [2131-11-4] Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 7223] Chief Complaint: transfer from OSH for NTSEMI, respiratory failure, CHF exacerbation Major Surgical or Invasive Procedure: arterial line History of Present Illness: History taken mainly from OSH reports ast pt is intubated. Briefly, this is a [Age over 90 ] yo female with history of CAD, s/p MI in [2125], htn, type II diabetes, PE and CHF who was transferred from [Hospital3 7362] for CHF exacerbation. The pt initially presented to [Hospital3 7362] complaining of intermittent chest pain x 2 days and SOB. EKG showed ST depressions in I and avL, V2-V6. Troponin I elevated, CK peaked at 752. Cardiology was consulted and medical management was pursued. In addition the patient was thought to be in acute diastolic heart failure, and started on a lasix and nitro drip, along with C-PAP to help with respiratory distress. The pt's respiratory status worsened, and she was subsequently intubated. Following intubation she became hypotensive and started on peripheral neo. At the family's request, she was transferred to [Hospital1 18] for further management. . After talking with her grandson, he states her chest pain and SOB have been chronic for the past 10 months, typically relieved with nitropaste. He denies any recent change in quality, frequency, or quantity of her chest pain, no recent SOB or increased DOE. He states she was brought to the hospital by her daughter as she was unable to walk and found crawling from the bedroom to the bathroom. . Review of systems was unobtainable other than as stated above due to the fact that the patient was intubated. Past Medical History: CAD s/p MI in [2125] HTN TYPE II DIABETES PE IN [2129] CHF w/ diastolic dysfunction (EF unknown) CHRONIC RENAL INSUFFICIENCY OA PVD DEPRESSION Social History: Per grandson, very functional at baseline. Lives with her daughter. 65+ year smoking history. Retired surgical nurse Family History: non-contributory Physical Exam: VS: T 100.4 BP 113/55 HR 75 RR 14 O2 92% on AC/1.00/450/14/10 Gen: elderly female, intubated, not sedated. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. CV: RRR, 2/6 systolic murmur, ULSB Chest: mild crackles at bases, L>R Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Extremities warm, no pallor Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Pertinent Results: [2131-11-4] 05:00AM BLOOD WBC-8.3 RBC-4.17* Hgb-11.8* Hct-35.9* MCV-86 MCH-28.2 MCHC-32.7 RDW-16.7* Plt Ct-392 [2131-11-3] 08:00PM BLOOD WBC-13.4# RBC-3.76 Hgb-10.8# Hct-32.4# MCV-86 MCH-28.7 MCHC-33.3 RDW-16.7* Plt Ct-489# [2131-11-3] 08:00PM BLOOD Neuts-87.0 Bands-0 Lymphs-9.0* Monos-3.2 Eos-0.4 Baso-0.3 [2131-11-4] 05:00AM BLOOD Glucose-179* UreaN-75* Creat-3.2* Na-145 K-3.7 Cl-102 HCO3-25 AnGap-22* [2131-11-3] 11:45PM BLOOD Glucose-187* UreaN-72* Creat-3.0# Na-145 K-4.0 Cl-103 HCO3-26 AnGap-20 [2131-11-4] 05:00AM BLOOD CK(CPK)-834 [2131-11-3] 11:45PM BLOOD ALT-42* AST-61* LD(LDH)-450* CK(CPK)-567* AlkPhos-76 Amylase-109* TotBili-1.3 [2131-11-4] 05:00AM BLOOD CK-MB-12* MB Indx-1.4 cTropnT-13.27* [2131-11-3] 11:45PM BLOOD CK-MB-11* MB Indx-1.9 cTropnT-9.75* [2131-11-4] 05:00AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.1 [2131-11-3] 11:45PM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.5 Mg-2.2 Brief Hospital Course: The patient was transferred from an OSH after a non-ST elevation MI. She presented intubated and sedated and showing signs of cardiogenic shock and acute systolic and diastolic heart failure. She was supported by vassopressors and started on wide spectrum antibiotics. She also had signs of acute renal failure. Despite aggressive measures, including escalation of pressor support, and administration of multiple pressors, the patient expired. The patient's family was contact[Name (NI) ] throughout her hospital course and were frequently updated about her grave prognosis and eventual death. Medications on Admission: lopressor 25 mg [Hospital1 ] albuterol atrovent protonix venlafaxine insulin mirtazapine morhpine aspirin Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[2132-1-21]	[ "486", "585.9", "250.00", "428.0", "785.51", "443.9", "311", "584.9", "412", "403.90", "414.01", "V12.51", "715.90", "427.31" ]	icd9cm	[ [ [] ] ]	[ "38.91", "96.72" ]	icd9pcs	[ [ [] ] ]	4532, 4541	3730, 4331	312, 327	4592, 4601	2764, 3707	4657, 4695	2104, 2122		4492, 4509		4562, 4571		4357, 4469			4625, 4634									2137, 2745																			205, 274									355, 1779																1801, 1954	1970, 2088
42,782	121,514	55086	Discharge summary	report	Admission Date: [2138-7-29] Discharge Date: [2138-8-9] Date of Birth: [2090-11-19] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2291] Chief Complaint: Lithium Toxicity Major Surgical or Invasive Procedure: Left femoral temporary hemodialysis catheter placed on [2138-7-29] Hemodialysis on [2138-7-29] History of Present Illness: 47 yo female w/ h/o bipolar d/o, schizophrenia and DM2, who presents to the ED from [Hospital1 1680]-HRI with progressively worsening mental status and tremulousness, found to have a lithium level of 3.5. History was obtained by patient's nurse [First Name (Titles) ] [Last Name (Titles) 1680]-HRI. At some point in [Name (NI) 205], pt's clozapine was discontinued due to agranulocytosis. This resulted in an acute psychotic episode, requiring hospitalization at [Hospital1 1680]-HRI on [6-22]. She has been hospitalized at this facility for the past 5 weeks. Her nurse notes that over the first 2-3 weeks of her hospitalization, she steadily became more psychotic and paranoid, believing that she was being poisoned. For the past 3 weeks, pt. has had very poor PO intake. Per her nurse, she did not have any nausea, vomiting, diarrhea, abdominal pain, SOB, cough, chest pain, fevers, or dysuria. Of note, a full set of basic labs were obtained on [7-18]. These were all wnl, including a BUN/Cr of 24/0.8. She was started on lithium 300mg TID on [7-23]. Over the past week, staff have noted that she has been increasingly tremulous and unsteady on her feet, requiring a walker to ambulate. Over the past two days, pt. became increaisngly confused and incoherent. She was refusing to get out of bed and being more agitated. A lithium level was checked and was 3.5. This prompted transfer to [Hospital1 18] ED. In the ED, initial VS were: 100.2 120 115/92 18 97% Labs were notable for Lithium level of 3.0. Na 133 K 5.5 Cl 101 HCO3- 23 BUN 47 Cr 3.3 Glucose 84. AST 32 ALT 24 AP 103 T Bili 0.4. WBC 11.9 (74.2% PMN) HCT 43.8 Plt 288. PTT 30.5 INR 1.0 Pt. was noted to be very tremulous and agitated. A temporary HD line was placed in the ED. For her agitation, she was given a total of 4mg of Ativan, and was transfered to the MICU for HD and further management. On arrival to the MICU, VS:T 97.8 HR 95 BP 111/68 RR 19 97% on RA Review of systems: As per HPI. unable to obtain further ROS due to mental status Past Medical History: 1. Schizophrenia 2. Bipolar d/o 3. DM2 4. hypothyroidism Social History: unable to obtain Family History: unable to obtain Physical Exam: Physical Exam ON ADMISSION VS:T 97.8 HR 95 BP 111/68 RR 19 97% on RA General: oriented to self. stated the date was [2139-8-25]. mumbling incoherently HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, diffusely tender to palpation, no rebound tenderness or guarding, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Minimal tremor at rest, but all four extremities exhibit significant tremor with active and passive motion. No rigidity noted. Unable to assess strength as pt. uncooperative with exam. Patellar DTRs were 3+ bilaterally. 4 beats of clonus elicited with ankle dorsiflexion bilaterally. Physical Exam on Discharge: VS - 97.6, 129/68, 73, 20, 96% RA GENERAL - Ms. [Known lastname 77651] is an overweight female found lying in bed resting in NAD. Patient blinking frequently and is tremulous. HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no lymphadenopathy LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - normal 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) LUE with edema (mostly in hand and forearm), very minimal erythema of dorasal aspect of hand, no warmth. RUE with midline access in place and without surround erythema. Pertinent Results: [2138-7-29] 01:47PM BLOOD WBC-11.9* RBC-4.57 Hgb-14.5 Hct-43.8 MCV-96 MCH-31.8 MCHC-33.2 RDW-13.7 Plt Ct-288 [2138-7-31] 03:54AM BLOOD WBC-6.3 RBC-3.43* Hgb-10.5* Hct-32.9* MCV-96 MCH-30.6 MCHC-31.9 RDW-13.5 Plt Ct-160 [2138-7-29] 01:47PM BLOOD Glucose-84 UreaN-47* Creat-3.3* Na-133 K-5.5* Cl-101 HCO3-23 AnGap-15 [2138-7-31] 03:54AM BLOOD Glucose-66* UreaN-9 Creat-0.8 Na-138 K-3.6 Cl-108 HCO3-27 AnGap-7* [2138-7-31] 03:54AM BLOOD Calcium-7.8* Phos-3.2 Mg-1.6 [2138-7-29] 06:12PM BLOOD TSH-0.99 [2138-7-29] 01:47PM BLOOD Lithium-3.0* [2138-7-30] 04:34AM BLOOD Lithium-1.0 [2138-7-30] 01:05PM BLOOD Lithium-1.2 [2138-7-30] 06:20PM BLOOD Lithium-1.1 [2138-7-31] 03:54AM BLOOD Lithium-1.0 [2138-7-31] 12:03PM BLOOD Lithium-0.9 UA [2138-7-29]: clean [2138-7-29] 2:50 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STREPTOCOCCUS SPECIES. PROBABLE MULTIPLE MORPHOLOGIES. Anaerobic Bottle Gram Stain (Final [2138-7-30]): Reported to and read back by [First Name8 (NamePattern2) ] [Doctor Last Name ],9/05/12,12:05PM. GRAM POSITIVE COCCI IN PAIRS AND CHAINS. EKG [7-29]: NSR, no abnormalities CXR [7-29]: IMPRESSION: No acute cardiopulmonary process. TTE [7-30]: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No evidence of vegetations. Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded. LUE US [2138-8-2]: FINDINGS: Grayscale and color Doppler son[Name (NI) 493] evaluation was performed of the left upper extremity. Normal compressibility and flow was seen in the left subclavian, internal jugular, brachial, basilic and cephalic veins without evidence of left upper extremity DVT. Labs on Discharge: [2138-8-6] 07:00AM BLOOD WBC-7.0 RBC-3.49* Hgb-10.9* Hct-32.4* MCV-93 MCH-31.1 MCHC-33.6 RDW-14.2 Plt Ct-281 [2138-8-6] 07:00AM BLOOD Glucose-122* UreaN-9 Creat-0.9 Na-138 K-3.9 Cl-104 HCO3-25 AnGap-13 [2138-8-6] 07:00AM BLOOD Lithium-<0.2 Brief Hospital Course: Ms. [Known lastname 77651] is a 47 y/o female with a h/o schizophrenia, bipolar, DM, and hypothyroidism who presented to [Hospital1 18] with altered mental status and tremulous and was found to have lithium toxicity, [Last Name (un) ], and streptococcus viridans in bacteremia. Acute Issues: # Lithium Toxicity: The patient was found to ahve a Lithium level of 3.0 on arrival. It is unlikely that this represents an overdose as patient has been an inpatient at a psychiatric hospital. She has only been on lithium for approximately 1 week. It is likely that patient sustained an acute kidney injury over the course of the past few weeks, causing decreased renal lithium clearance, resulting in toxicicty. Toxicology and renal were consulted. Temporary femoral HD line was placed, and she was dialyzed x 1 session. Lithium level was checked 6 hours after dialysis and was 1.0, re-check was 1.2, then came down to 0.9 as UOP picked up. Her lithium level decreased again to 0.7 and then to < 0.2. # Acute Renal Failure: The patient was found to have a Cr of 3.3 on presentation (baseline was 0.8 on [2138-7-18]). This was likely pre-renal [12-26] poor po intake over past few weeks. She received 2L boluses of NS and had maintenance fluids of NS at 200-250cc. Her UOP increased significantly with aggressive hydration and her creatinine returned to her baseline of 0.8. # Streptococcus Viridans bacteremia: The patient was found to have strep viridans present in [11-25] bottles. The patient was initially started on Vancomycin and it was thought that the gram positive cocci represented a contamination. Upon speciation of strep viridans, Infectious Disease was consulted. They considered this a low risk bacteremia and recommended 14 days of ceftriaxone 2 g IV daily from negative cultures. Repeat cultures on [2138-7-30] were with no growth. The temporary hemodialysis catheter tip was sent for culture on [7-31] and was with no growth. A midline was placed on [2138-8-2] for antibiotic administration and antibiotics will be completed on [2138-8-14]. # AMS/Psychosis: Improved somewhat after dialysis and normalization of lithium level. Agitation was generally well controlled with PRN Ativan. Continued to be agitated and responding to internal stimuli. Her antipsychotics were initially held in setting of acute lithium toxicity due to increased risk of NMS. Psych was consulted and followed patient. They recommended re-starting her aripiprazole and it was slowly titrated back to home dose of 30 mg daily. She was discharged to inpatient psych bed on [Hospital1 ] 4. Chronic: # Schizophrenia/Bioplar: Psych was consulted and followed patient. Initially all psych meds were held in the setting of acute lithium toxicity. Her aripriprazole was started back and slowly titrated back to home dose. The remainder of psych meds were held. She was discharged to inpatient psych bed on [Hospital1 ] 4. #DM2: The patient's home metformin was held during hospitalization and she was maintained on insulin sliding scale. #Hypothyroidism: The patient's TSH was within normal limits. Her home synthroid was continued during hospitalization and cytomel will be restarted upon discharge. Transitional Issues: -Will need to complete 14 day course of ceftriaxone with 9/6 conuted as day 1 (to be completed on [8-14]). -Psychiatry to continue titrating and adjust psychiatric medicaitons. -Patient will need to restart metformin when not refusing to eat. - patient will need Panorex and/or Dental eval for multiple caries when acute psychosis improves as possible source for her bacteremia Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from [Hospital1 1680]-HRI. 1. Aripiprazole 30 mg PO DAILY 2. BuPROPion (Sustained Release) 200 mg PO BID 3. Benztropine Mesylate 1 mg PO BID 4. Bisacodyl 5 mg PO DAILY 5. Cytomel 10 mcg PO DAILY 6. Chloral Hydrate 500 mg PO QHS 7. Clonazepam 1 mg PO Q4H:PRN anxiety 8. Clonazepam 0.5 mg PO BID 9. Haloperidol 10 mg PO BID 10. Lithium Carbonate 300 mg PO QHS 11. MetFORMIN (Glucophage) 500 mg PO DAILY 12. Ibuprofen 400 mg PO Q6H:PRN pain 13. Omeprazole 20 mg PO Q 12H 14. Prazosin 1 mg PO HS 15. Levothyroxine Sodium 50 mcg PO DAILY 16. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Aripiprazole 30 mg PO DAILY 2. Ibuprofen 400 mg PO Q6H:PRN pain 3. Levothyroxine Sodium 50 mcg PO DAILY 4. CeftriaXONE 2 gm IV Q24H 5. Bisacodyl 5 mg PO DAILY 6. Cytomel 10 mcg PO DAILY 7. Omeprazole 20 mg PO Q 12H 8. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [Hospital1 ] 4 Discharge Diagnosis: Primary Diagnosis: Lithium Toxicity Streptococcs Viridans bacteremia Secondary Diagnosis: Schizophrenia Bipolar Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Currently refusing to get out of bed, previously ambulatory. Discharge Instructions: Ms. [Known lastname 77651], You were admitted to the hospital for lithium toxicity and you were also found to show that your kidneys were not functioning well. You were treated with one session of hemodialysis and you lithium level came down in to the normal range. We gave you IV (through your vein) fluids and you kidney function returned to [Location 213]. While you were here we also found that you had a bacteria in your blood. To treat this we are giving you IV (through your vein) antibiotics. While you were here psychiatry followed you and adjusted your medications. It was a pleasure caring for you, Your [Hospital1 ] doctors Followup Instructions: PCP and psychiatry follow up to be scheduled by inpatient psychiatry. Completed by:[2138-8-10]	[ "333.1", "276.7", "584.9", "790.7", "295.90", "250.00", "796.1", "307.9", "E849.7", "E939.8", "244.9", "292.81", "296.80", "781.0", "276.51", "041.09" ]	icd9cm	[ [ [] ] ]	[ "38.95", "39.95" ]	icd9pcs	[ [ [] ] ]	11591, 11636	6973, 10207	321, 426	11793, 11793	4359, 5206	12654, 12755	2635, 2653		11316, 11568		11657, 11657		10637, 11293			11978, 12631									2668, 3582				5250, 6678						3610, 4340			10228, 10611		2440, 2504				265, 283				6697, 6950					454, 2421			11748, 11772			11676, 11727				11808, 11954						2526, 2585	2601, 2619
44,508	130,279	37216+58132	Discharge summary	report+addendum	Admission Date: [2176-1-27] Discharge Date: [2176-2-2] Date of Birth: [2105-12-31] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 1990] Chief Complaint: AMS Major Surgical or Invasive Procedure: none History of Present Illness: 70 y/o F with h/o stage IV L thoracic rhabdomyosarcoma s/p R frontal mass resection of hemorrhagic brain mass on [2176-1-12] with Dr. [Last Name (STitle) ] presents with 1 day history of AMS, increasing agitation and refusal of all POs at rehab facility. Her Risperdal was recently discontinued due to concerning EKG changes (no documentation). She was also found to have UTI but was not treated as she was refusing po medications. She was transferred to [Hospital1 18] for further evaluation. . In the ED, initial vs were: 96.8 HR 64 BP 104/70 RR 16 SaO2 97 RA. On physical exam she was oriented X 1 with well healing scalp. In order to sedate for scan 10 mg IM haldol, ativan 1 mg was given and BP dropped to 80. Levophed was started through her port. Patient was given ampicillin, ceftriaxone, 4 L NS for concern of urosepsis. Mildly elevated lactate. Neurosurgery saw patient and felt no active neurosurgery issues and recommended admission to MICU. Vitals on transfer were BP 106/50 (0.6 levophed), HR 106, RR 24, 100% 2L. . On admission patient is unable to give further history and majority of history is through the chart. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Stage IV L thoracic rhabdomyosarcoma - Currently receiving chemotherapy, L breast cancer - DCIS s/p lumpectomy - Right frontal brain lesion s/p resection [2176-1-12] (possible met, hemorrhagic) Social History: - Lives with husband. - Worked as a bookeeper in husband's law practice. - Never smoked. - Occasionally drinks champagne. Family History: - Parents deceased from heart disease. - Brother - colon cancer Physical Exam: General: Somnolent. Withdraws to pain. Neuro: Pupils 2 mm -> 1 mm with light, respond equal b/l. Withdraws to pain and moves all limbs spontaneously. HEENT: dry MM Neck: supple, JVP not elevated, no LAD Lungs: lungs clear throughout, poor effort CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on Admission: [2176-1-26] 10:45PM BLOOD WBC-5.3# RBC-3.78* Hgb-11.4* Hct-35.0* MCV-93 MCH-30.3 MCHC-32.7 RDW-16.3* Plt Ct-205 [2176-1-26] 10:45PM BLOOD PT-13.2 PTT-26.9 INR(PT)-1.1 [2176-1-26] 10:45PM BLOOD Glucose-113* UreaN-36* Creat-0.8 Na-141 K-4.1 Cl-107 HCO3-20* AnGap-18 [2176-1-26] 10:45PM BLOOD ALT-22 AST-25 AlkPhos-53 TotBili-0.5 [2176-1-26] 10:45PM BLOOD Albumin-3.8 Calcium-9.5 Phos-3.2# Mg-2.0 Labs on Discharge: [2176-2-2] 05:18AM BLOOD WBC-3.6* RBC-3.32* Hgb-10.0* Hct-31.1* MCV-94 MCH-30.2 MCHC-32.2 RDW-16.6* Plt Ct-175 [2176-2-2] 05:18AM BLOOD Glucose-118* UreaN-12 Creat-0.6 Na-141 K-4.1 Cl-108 HCO3-24 AnGap-13 [2176-2-2] 05:18AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND [2176-2-2] 05:18AM BLOOD B-GLUCAN-PND Micro: [2176-1-27] URINE CULTURE-FINAL {PROBABLE ENTEROCOCCUS} [2176-1-27] MRSA SCREEN NEG [2176-1-27] BLOOD CULTURE -NEG [2176-1-31]: Blood Cultures- PENDING Studies: [2176-1-30] Radiology CTA CHEST: 1. No evidence of pulmonary embolism. 2. Massive mediastinal and left hilar tumor with obvious mass effect and compression or infiltration of the left and the right main pulmonary artery, the pulmonary veins, the esophagus, and the left main bronchus. Subsequent perihilar partly cavitated parenchymal consolidation. 3. Multiple bilateral mainly subpleural nodular opacities, the biggest one of which is located in the left upper lobe and this cavitated, containing a soft tissue structure. This lesion could be representing Aspergillus colonization. 4. Bilateral paramediastinal areas of subtle fibrosis could be the sequela of mediastinal radiation. 5. Small left pleural effusion. 6. 7-mm liver hypodensity, status post rib fractures, sclerotic rib and T-spine lesion, potentially representing metastasis. ECG [2176-1-31]: Sinus tachycardia. Left atrial abnormality. Right ventricular conduction delay. Compared to the previous tracing of [2176-1-30] the anterolateral ST-T wave abnormalities persist without diagnostic interim change. Brief Hospital Course: 70 y/o F s/p R frontal mass resection on [2176-1-12] for metastatic rhabdomyosarcoma presents with UTI and AMS. # Altered Mental Status: Mrs [Known lastname 69844] had a Head CT that showed stable changes s/p resection. The location of the resection may account for some of her neurological symptoms, her acute agitation was likely from UTI/delirium. She had no cough or infiltrate on CXR to suggest pneumonia. Sodium and calcium within normal limits. Mental status improved although pleasantly confused. She respond well to zyprexa when agitated and is easily redirectable. Resperiadone was stopped due to concern for EKG changes (namely QT prolongation). She required continous fluid support, continous IVF of NS at 125cc/hr with periodic bolus of 1L over 2 hours PRN. Because she runs negative usually with her ins and out. Please avoid unnecessary tethers, lines and reorient frequently. # UTI: Enterococcus in urine sensitive to Ampicillin, Nitrofurantoin, Vancomycin. We reconfirmed the infection with UA positive and UCx + for Enterococcus. She is to be continued on ampicillin IV for 14 days (Day 1 of antibiotic was [2176-1-27]). # Tachycardia: Tachycardia is persistent. Patient report baseline low BP 90-100's. The source of her tachycardia may be due to dehydration, infection, underlying malignancy, steroid side effects. Patient runs negative I/O, unknown cause. Notable for serum OSM is 283, Urine Osm is 496. Imaging study suggest pulmonary vasculature and airway compromise by the tumor. This is like the reason for her underlying tachycardia. On CT scan, we noted the extend of the tumor and findings suggest a fungal ball in her LUL. Interventional pulmonology recommended no intervention at this time. We sent fungal markers which are pending at the time of discharge. Patient's VSS, hemodynamically stable, no sign of infection, no + blood cultures. Barium swallow was done to eval for extrinsic compression of the chest mass on the esophagus. Results pending at the time of discharge. I discussed this with her primary care MD at the time of discharge, as well as the ? of aspirgillus colonization of the lt. apex of the lung. # s/p right frontal mass resection: CT head changes consistent with post-op peroid, no acute changes. Neurosurgery evaluated in ED and felt no acute neurosurg issues. She was place on heparin SQ ppx, dexamethasone, and keppra. Xenaderm ointment to scar on scalp. Insulin sliding scale and bactrium for PCP prophylaxis while on dexamethasone. # Malignancy: Patient with history of stage IV thoracic rhabdomyosarcoma currently on chemotherapy. Path from right frontal lesion confirms metastatic rhabdomyosarcoma. Also history of L breast cancer - DCIS s/p lumpectomy. Patient's oncological care is deferred to family and oncologist. She is to follow up with her outpatient oncologist after discharge. # Concern for aspiration: The nursing staff became concerned that Ms. [Known lastname 69844] might not be swallowing her pills safely. She therefore had a speech and swallow evaluation in coordination with a study of her esophagus. Contrast was able to get through her esophagus, although it was noted to have some external compression from her tumor. Per speech and swallow recommendations, she should be on a PO diet of ground solids and thin liquids; no mixed consistencies including solid cereal in milk or whole pills with water. Her medications should be given crushed in puree and she should have 1:1 supervision with all POs. Encourage small bites and sips and maintain aspiration precautions. # Access: double-lumen port # Communication: husband ([Doctor Last Name ]: [Numeric Identifier 83791]/[Numeric Identifier 83792]) # Code: DNR/DNI Medications on Admission: Dalteparin 5000 units qd Dexamethasone 2 mg TID Docusate Insulin Aspart sq before meals Levetiracetam 1000 mg [Hospital1 ] Multivitamins Nystatin Pantoprazole 40 mg qd Senna Bactrim DS M,W, F Xenaderm ointment [Hospital1 ] Tylenol every 4 hours prn Albuterol NEB every 4 hours prn Bisacodyl 10 mg qd prn Hydromorphone 2mg q6 hours prn Lactulose prn Milk of Mag prn Zofran 4mg every 8 hours prn Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO M, W, F (). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 7. port line care Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 8. port line care Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. Tablet, Rapid Dissolve(s) 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. insulin Insulin SC (per Insulin Flowsheet) Sliding Scale 15. Ampicillin Sodium 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q6H (every 6 hours) for 7 days. Discharge Disposition: Extended Care Facility: [Hospital1 ] [Hospital1 8] Discharge Diagnosis: Urosepsis Altered Mental Status Tachycardia s/p right frontal mass resection Malignancy Discharge Condition: Mental Status:Confused - always Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You came to the hospital with altered mental status and findings of urinary tract infection. We treated your infection and provided you with fluid support. You recovered and was in stable condition. We did find on imaging studies that you have an extensive tumor in your lung, which compress the great vessels from the heart to the lungs and obstructed the left main wind pipe. We think this is the reason for you to be continously tachycardic. You responded to intravenous fluid. We believe you need to get continous fluid support as you pee out alot more than you taking in. You were discharged in stable conditions. Please follow up with you oncologist for further oncologic care. You need to figure out additional treatment. Please note we made the following changes to your medications. Followup Instructions: Please follow your oncologist Carolin Block, ([Telephone/Fax (1) 83793], regarding your oncologic care. Name: [Known lastname 13317],[Known firstname ] Unit No: [Numeric Identifier 13318] Admission Date: [2176-1-27] Discharge Date: [2176-2-2] Date of Birth: [2105-12-31] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 429] Addendum: Pt.s discharge diagnosis of 'urosepsis' is actually: sepsis due to urinary tract infection, enterococcal. Pt. was admitted with altered mental status, enterococcal urinary tract infection, and developed hyotension requiring pressors, IVF, and treatment of urinary tract infection with parenteral antibiotics, all consistent with sepsis due to bacterial urinary tract infection. Discharge Disposition: Extended Care Facility: [Hospital1 ] [Hospital1 15] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 430] MD [MD Number(2) 431] Completed by:[2176-2-23]	[ "171.4", "038.0", "995.91", "530.3", "293.0", "599.0", "518.89", "198.3", "284.1", "447.1" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	12942, 13159	4984, 5111	272, 279	11090, 11090	2909, 2914	12084, 12919	2298, 2363		9202, 10874		10979, 11069		8776, 9179			11259, 12061									2378, 2890															1472, 1920				229, 234				3362, 4961					307, 1453								2928, 3343		11104, 11235						1942, 2143	2159, 2282
25,188	199,132	4053	Discharge summary	report	Admission Date: [2153-1-18] Discharge Date: [2153-1-23] Date of Birth: [2083-10-19] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 633] Chief Complaint: Cough, SOB Major Surgical or Invasive Procedure: None History of Present Illness: This is a 69 year-old female with a history of COPD, CAD, HTN, HLD, DM type 2, PVD who presents with 2 weeks of worsening SOB and a productive cough. She also report orthopnea X 4 pillows and PND new over the past two weeks. The night prior to her admission she had to sit up in bed all night, could not sleep and had trouble catching her breath. She denies weight gain, peripheral swelling or woresening nocturia. She reports exertional dyspnea from baseline of 2 blocks and 20 steps two weeks ago to dyspnea at rest. Pt denies fever or chills. No URT symptoms. No recent febrile illness. No recent travels, no contact with animals no other exposures. She denies recent imobility. She had Flu vaccine 11/[2151]. She is a heavy active smoker with known COPD and has history of admission with pneumonia, intubation and MV one year ago. She does not use chronic steroids or inhalers and is not on home oxygen. She saw her PCP for above complaints on [1-5] who prescribed Atrovent inhaler. She had a CXR which was reportedly unremarkable and did not recieve antibiotics recently. . In the ER VS were 96.9 86 165/62 24 91% RA. On exam triage with insp/exp wheezes throughout. ABG was 7.38, 42, 63, 26. She had no leukocytosis. CXR with segmental collapse and atelectasis unchanged from baseline. Pt was given Neb x 3, solumedol 125mg, IV ceftriaxone and IV azithro given. Lung sounded better, but pt was still 93% on 5 liters with increased RR. PIV x [Street Address(2) 8582]. EKG not concerning.On transfer VS: 98.3 79 125/53 36 93%5 liters. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain except when coughing, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. . Past Medical History: coronary artery disease with an angioplasty in the [2121]'s echocardiography [12/2151]: mild LVH, Mild focal left ventricular systolic dysfunction, LVEF = 55% c/w prior inferior infarction. type 2 diabetes on oral agents, hypertension hypercholesterolemia. PNA with intubation [1-25] LUL hilar lung mass seen on CTA [1-25], flexible bronchoscopy showed 0.5-0.7 cm endobronchial mass on the medial wall of the left lower lobe, biopsy and brushings were negative for malignancy. . Past Surgical History: Multiple bypass vascular procedures: s/p left retroperitoneal to left femoral with left vein graft on [2147-2-24]. s/p thrombectomy of right axillo-femoral-femoral graft on [11-18] s/p Aorto-bifem [3-/2141] excision of infected aorto-[Hospital1 ]-femoral graft in [9-18] s/p right axillofemoral to left profunda bypass 10/[2145]. . Social History: She lives in a senior living complex alone. She is ADL independent.She has 3 children in the [Location (un) ] area. She is seperated from her Husband. She Smokes 1.5ppd x 50 years. No EtoH Family History: Father: MI at 62, Twin Sister - MI at 49, Another sister - MI (age ?) Physical Exam: Physical Exam on ICU admission: Vitals: T:98.2 BP:137/47 HR: 99 RR: 25 O2Sat: 87 RA 96% 4L GEN: looks tired, tachypnic, speech dyspnea HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear, false teeth NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: HS distant RRR, no M/G/R, normal S1 S2, radial pulse +2 on left 0 on right PULM: reduced air movement above right base, diffused exp wheezing and prolonged expiration in all lung fields, no crackles. Fremitus and precussion are symetrical. Surgical scar over upper anterior right chest. ABD: vertical and RLQ surgical scars, Soft, NT, ND, +BS, no HSM, no masses EXT: surgical scars LE, No C/C/E, no signs of DVT NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. . Pertinent Results: Laboratories: Notable for ABG 7.38/42/63/HCO3 = 23. No leukocytosis. Normocytic anemia Hct 34.8 unchanged from baseline. Cr/BUN 0.8/33. trop = 0.02. Lactate = 1.0. . ECG: Sinus rhythm at 80 bpm, axis wnl, normal intervals, no evidence of ischemia, LVH or myocardial strain. . Imaging: CXR [1-19]- FINDINGS: Perihilar left upper lobe opacity is still present on the current study suggestive of persistent consolidation and/or mass. Atelectasis versus consolidation at the left base is new since the prior study. There is persistent evidence of right middle lobe collapse. The heart and mediastinal contours are normal. No effusion or pneumothorax is present. IMPRESSION: Persistent left upper lobe opacity. Patient should have a chest CT after possible sources of infection have been treated to rule out underlying mass. . [1-18] FINDINGS: Compared to the prior radiograph from [2152-1-27], the right middle lobe collapse has slightly increased. There is unchanged opacity in the left upper lobe in perihilar region, persistent since the CT from [2152-1-16]. Cardiomediastinal silhouette and hila are normal. There is no pleural effusion, and no pneumothorax. On the lateral view, an linear opacity is seen, consistent with atelectasis/collapse along a major fissure. IMPRESSION: 1. No definite pneumonia, atelectasis/collapse in portions of the lung seen on lateral view. 2. Ill-defined opacity in the left upper lobe (persistent since the CT and radiographs from [2151-12-17]); recommend further workup with dedicated chest CT to rule out underlying mass. . Historical studies: CT scan [2152-1-16]: 1. No evidence of pulmonary embolism. 2. Left hilar fullness with vague suggestion of hilar adenopathy or mass. Associated left upper lobe consolidation may reflect post-obstructive pneumonia. 3. Small bilateral pleural effusions, with associated atelectasis of the adjacent lung. 4. Scattered peribronchiolar nodular opacities in the right upper and right lower lobes, may be infectious or inflammatory. 5. Bilateral pulmonary nodules as detailed, comparison to prior studies suggested. Echocardiography [12/2151] The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with focal basal inferior hypokinesis, where the myocardium is also slightly thinned. The remaining segments contract normally (LVEF = 50-55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild focal left ventricular systolic dysfunction, c/w prior inferior infarction. . [2153-1-18] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2153-1-18] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2153-1-18] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] . Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2153-1-23] 06:25 8.7 3.74* 10.0* 31.6* 84 26.7* 31.7 13.4 276 [2153-1-22] 06:10 7.1 3.77* 10.1* 31.9* 85 26.7* 31.6 13.2 280 [2153-1-21] 04:40 9.7 3.85* 10.5* 33.1* 86 27.3 31.8 13.5 308 [2153-1-20] 03:04 13.4* 3.74* 10.1* 32.9* 88 27.1 30.9* 13.8 331 [2153-1-19] 15:34 12.1* 3.59* 9.8* 30.6* 85 27.4 32.1 13.5 320 [2153-1-19] 03:43 10.2 3.76* 10.0* 31.2* 83 26.6* 32.0 13.3 326 [2153-1-18] 07:30 9.2 4.16* 11.2* 34.8* 84 26.8* 32.1 13.1 335 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [2153-1-20] 03:04 80.3* 14.3* 4.3 0.7 0.3 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2153-1-23] 06:25 276 [2153-1-22] 06:10 280 [2153-1-21] 04:40 308 [2153-1-21] 04:40 11.9 21.3* 1.0 [2153-1-20] 03:04 331 [2153-1-19] 15:34 320 [2153-1-19] 15:34 13.0 29.5 1.1 [2153-1-19] 03:43 326 [2153-1-19] 03:43 12.4 20.9* 1.0 [2153-1-18] 07:30 335 [2153-1-18] 07:30 11.61 21.7* 0.9 HEMOLYZED LAB USE ONLY [2153-1-23] 06:25 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2153-1-23] 06:25 961 41* 1.0 142 3.8 105 31 10 [2153-1-22] 06:10 991 42* 1.1 140 3.8 104 31 9 [2153-1-21] 04:40 911 48* 1.0 142 4.4 107 28 11 [2153-1-20] 03:04 961 59* 1.2* 143 4.1 108 26 13 [2153-1-19] 15:34 2801 54 1.2* 141 4.5 105 26 15 [2153-1-19] 03:43 2081 49 1.3* 139 4.8 105 25 14 [2153-1-18] 07:30 1411 33 0.8 138 4.5 103 23 17 ADDED BNP 1:25PM IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES ESTIMATED GFR (MDRD CALCULATION) estGFR [2153-1-18] 07:30 Using this1 ADDED BNP 1:25PM Using this patient's age, gender, and serum creatinine value of 0.8, Estimated GFR = 71 if non African-American (mL/min/1.73 m2) Estimated GFR = >75 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 60-69 is 85 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2153-1-20] 03:04 571 [2153-1-19] 03:43 14 15 127 42 0.1 NEW REFERENCE INTERVAL AS OF [2151-12-20];UPPER LIMIT (97.5TH %ILE) VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201 BLACKS 801/414 ASIANS 641/313 CPK ISOENZYMES CK-MB cTropnT proBNP [2153-1-20] 03:04 4 0.031 [2153-1-19] 20:53 3 0.021 [2153-1-19] 15:34 4 0.021 [2153-1-18] 15:54 4 0.011 [2153-1-18] 07:30 0.021 ADDED TNT @ 09:32 AM ON [2153-1-18]. [2153-1-18] 07:30 5 3362 ADDED BNP 1:25PM CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI REFERENCE VALUES VARY WITH AGE, SEX, AND RENAL FUNCTION;AT 35% PREVALENCE, NTPROBNP VALUES; < 450 HAVE 99% NEG PRED VALUE; >1000 HAVE 78% POS PRED VALUE;SEE ONLINE LAB MANUAL FOR MORE DETAILED INFORMATION CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2153-1-23] 06:25 10.1 4.4 2.1 [2153-1-22] 06:10 2.1 [2153-1-21] 04:40 9.7 3.5 2.4 [2153-1-20] 03:04 9.5 4.6* 2.4 [2153-1-19] 15:34 9.6 4.2 2.2 [2153-1-19] 03:43 3.9 9.6 4.9* 2.1 LAB USE ONLY LtGrnHD [2153-1-18] 07:30 HOLD ADDED TNT @ 09:32 AM ON [2153-1-18]. Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS Intubat [2153-1-18] 10:13 ART 63* 42 7.38 26 0 NOT INTUBA1 NOT INTUBATED WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate K [2153-1-18] 07:54 1.0 4.21 Brief Hospital Course: This is a 69 year-old female with a history of CAD, HTN, DN type II, PVD, Pneumonia w/ mechanical ventilation, heavy smoking and COPD who presented with cough and SOB and clinical picture consistent with COPD exacerbation. # COPD execrbation: Cough, Hypoxia, Sputum production. CXR showed chronic changes w/o new pneumonia, no leukocytosis or fever to suggest bacterial infection. No clinical, radiological or electrocardiographic signs to suggest cardiac event or acute heart failure, BNP was not elevated, and CE were neg X 2. She had no risk factors for PE and no signs of DVT. Patient was treated for COPD exacerbation: She received one dose of IV azithro+ceftriaxone in the ED and was subsequently started on PO Levofloxacin 500mg daily in the ICU. She completed a 5 day course while inpatient. Prednisone 60mg daily was started and was reduced to 40mg daily on day 4 with plan for 14 day course due to the severity of her presentation. Pt discharged on 40mg daily to continued until outpatient PCP f/u 1 week after discharge. Taper can be begun at that time if indicated. Patient was further managed with Nebs, O2 was weaned as tolerated from to 2L through NC on ICU discharge. Patient was also treated symptomatically with tensilon pearls and acetaminophen as well as oxycodone for chest pain during cough. Blood Cx were still pending at discharge. Pt still with 2L 02 requirement at time of dicharge. She was discharged on home oxygen. She was instructed on smoking cessation and discharged with a nicotine patch. . #Chest pain episode: at 1230PM on [1-19] day complained of sudden onset pressure-like anterior chest pain radiating to left arm and accompanied by SOB. No diaphoresis, Nausea or dizziness. BP was stable. HR was 106. Patient appeared to be in significant distress with otherwise unchanged examination, no new murmurs. Her ECG showed sinus tachycardia with minimal ~ 0.5mm ?upsloaping ST depression in V3-V5 which later resolved. Pain did not respond to NG SL but improve with IV morphine 5mg and resolved completely 30 minutes following onset. Patient had received her daily aspirin 325mg and Simvastatin 80mg. She was givem IV metoprolol 5mg once and SQ Lovenox 80mg once. MI was ruled out by CE negative X2. Anti-coagulation and Beta-Blockade were not continued. ACE-I continued to be held in the setting of renal failure. Patient's PCP who is also her cardiologist was emailed regarding indication at this time for myocardial stress testing as well as regarding restarting beta-blocker therapy in this woman with multiple coronary risk factors and history of ACS. She had apparently been on carvedilol which was d/c'ed in [2152-4-15] for reasons we have not been able to clarify. Pt will follow up with her cardiologist after discharge to consider resuming beta blocker therapy as well as be scheduled for dobutamine stress echo. PT continued on statin, asa 325mg daily, and ACEi. . # benign hypertension: continued home meds including Amlodipine 10 mg QD, Hydrochlorothiazide 12.5 mg QD, Hydralazine 75 mg Tablet QID. Lisonopril held initially pending improvment in renal function and this was resumed prior to dicharge. Clonipine was also held on admission and not restarted as BP's seemed to be well controlled on the above. Pt can discuss with her PCP/cardiologist need to resume this medication. . #DM2-HISS for inpatient, DM diet, FS QID. Pt instructed to restart glyburide and metformin after discharge. . #Hyperlipidemia-continued simvastatin, pt may resume zetia/fenofibrate as an outpatient. She was advised to discuss the need for all of these medications with her cardiologist. . # Renal Failure: Cr/BUN from 0.8/33 to 1.3/49, FeNa < 1% was compatible with pre-renal etiology. Patient was given IVF and oral hydration with gradual improvement in her renal functions. Home lisinopril, Glyburide and Metformin held at ICU discharge. Renal function continued to improve and was 1.0 at time of discharge. Pt advised to resume her lisinopril, metformin as outpatient. . # hypertension: continued home meds including Amlodipine 10 mg QD, Hydrochlorothiazide 12.5 mg QD, Hydralazine 75 mg Tablet QID. Lisonopril held pending improvment in renal functions. Clonipine was also held on admission and not restarted as BP's seemed to be well controlled on the above. . # Code status: full during this admission (discussed with patient). . #radiographic findings-?LUL opacity seen on CXR. Radiology recommended CT after tx for infection. This finding was discussed with the patient. Pt advised to follow up for repeat imaging. She has an appointment with Interventional pulmonology as an outpatient in the next coming weeks. . FEN: cardiac, DM . DVT PPx: heparin SC . Precautions for: vre . Lines: PIV . CODE: FULL Medications on Admission: Medications (reconciled with PCP covered by Dr. [Last Name (STitle) 17854]: 1. Amlodipine 10 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. Clonidine 0.2 mg PO BID 5. Hydralazine 75 mg Tablet PO Q6H 6. Multivitamin PO DAILY 7. Ipratropium-Albuterol 18-103 mcg 1-2 Puffs Q6H prn SOB. 8. Ezetimibe 10 mg PO DAILY 9. Simvastatin 80 mg PO DAILY 11. Fenofibrate Micronized 145 mg PO daily 12. Metformin 1000 mg PO twice a day. 13. Aspirin 325mg . Discharge Medications: 1. home oxygen Home oxygen 2L continuous for portability pulse dose system. Dx: COPD 2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Combivent 18-103 mcg/Actuation Aerosol Sig: [12-17] Inhalation every six (6) hours as needed for shortness of breath or wheezing. 7. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 8. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. hydralazine 50 mg Tablet Sig: 1.5 Tablets PO every six (6) hours. 10. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): take until seen by your PCP [Last Name (NamePattern4) ] [2153-1-31]. Then discuss a taper. Disp:40 Tablet(s) Refills:0 11. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:0 12. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 13. fenofibrate micronized 134 mg Capsule Sig: One (1) Capsule PO once a day: outpt regimen. Discharge Disposition: Home Discharge Diagnosis: COPD exacerbation HTN, benign type 2 diabetes hyperlipidemia CAD . anemia, nos Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with cough and shortness of breath. This was due to a COPD flare. For this, you were treated with steroids, nebulizers and an antibiotic with good effect. You finished your antibiotic course prior to discharge. You were found to require home oxygen and this was set up for you. You should stop smoking. Please continue to discuss this with your primary care doctor. DO NOT SMOKE WHILE USING OXYGEN OR NEAR THE OXYGEN EQUIPMENT. You were also evaluated by your cardiologist who would like you to have a stress echo after discharge. He will arrange this test for you. . You have an "opacity" (hazy area) seen on your chest x-ray. This could be due to your known infection. However, you will need to have a CT Scan or repeat CXR for further evaluation after treatment for your infection to rule out other causes. You have an appointment with a pulmonologist for further care. See below. . You have a very mild anemia. Please discuss whether you may need further work up, including routine colonoscopy, with your primary care doctor. . Medication changes: 1.your clonidine was not given this admission. Your blood pressure was not elevated. Please STOP this medication unless instructed to resume by your cardiologist/PCP. 2.prednisone 40mg daily for now, until instructed to decrease. 3.nicotine patch -please also discuss with your cardiologist whether you need fenofibrate, zetia and simvastatin for your cholesterol. . Please take all of your medications as prescribed and follow up with the appointments below Followup Instructions: PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Name: [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: CARDIOLOGY ASSOCIATES OF GREATER [Location (un) ] Address: [Street Address(2) ], [Location (un) ],[Numeric Identifier 822] Phone: [0-0-] We have rescheduled your appointment that was scheduled for tomorrow to next week. You appointment is now scheduled for Wednesday [2153-1-31] 1:00pm. . Department: WEST [Hospital 2002] CLINIC When: TUESDAY [2153-2-6] at 10:00 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 3020] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage . Department: WEST PROCEDURAL CENTER When: WEDNESDAY [2153-2-7] at 1 PM [Telephone/Fax (1) 5072] Building: [Hospital Ward Name 121] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: WEST PROCEDURAL CENTER When: WEDNESDAY [2153-2-7] at 1:30 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 5072] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "V45.82", "250.00", "491.21", "285.9", "412", "799.02", "305.1", "401.1", "793.1", "786.50", "584.9", "414.01", "272.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	18029, 18035	11559, 16311	279, 285	18158, 18158	4446, 11536	19862, 21371	3337, 3409		16844, 18006		18056, 18137		16337, 16821			18309, 19359								2750, 3110	3424, 4427																	19379, 19839		229, 241									313, 2210										18173, 18285						2232, 2727	3127, 3321
24,251	124,789	23147	Discharge summary	report	Admission Date: [2110-6-10] Discharge Date: [2110-6-12] Date of Birth: [2033-6-29] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2597] Chief Complaint: lowr extremity claudication left greater then right Major Surgical or Invasive Procedure: Abdominal aortogram with left lower extremity run off, angioplasty of left external iliac artery, left superficial femoral artery and left above knee popliteal artery, venting of left superficial femoral artery. History of Present Illness: 76 y.o female with b/l lowr extremity claudication left greater then right / Pt had preevious left sfa sngioplasty. Past Medical History: PMH: left sfa sngioplasty, B/L kissing iliac stents, ight femoral endarectomy, cataract, d/c, increase chloesterol, CRI (1.5) Social History: pos smoker pos drinker Family History: non contributary Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [Doctor Last Name ], pt, dp lle - palp fem, [Doctor Last Name ], pt, dp Pertinent Results: [2110-6-12] 04:55AM BLOOD Hct-27.1* [2110-6-11] 12:49AM BLOOD Plt Ct-273 [2110-6-12] 04:55AM BLOOD UreaN-10 Creat-1.3* K-4.2 [2110-6-10] 03:34PM BLOOD Glucose-131* UreaN-12 Creat-1.3* Na-126* K-4.1 Cl-95* HCO3-20* AnGap-15 [2110-6-10] 2:55 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST CT OF THE ABDOMEN: There are emphysematous changes of the lung bases with superimposed atelectasis and scarring. The visualized pericardium appears unremarkable. Extensive coronary artery calcifications are identified. Non- contrast examination limits assessment of the abdominal organs. The liver, adrenal glands, spleen, and pancreas appear unremarkable. Gallstones are seen within the gallbladder lumen without evidence of gallbladder wall edema or pericholecystic fluid. The kidneys appear symmetric without hydronephrosis. Contrast is seen within the collecting systems bilaterally, consistent with recent angiography. A 1.3-cm hypodensity in the left kidney is incompletely characterized. The loops of small and large bowel appear normal in caliber. There is extensive atherosclerosis of the abdominal aorta and its major branches. No free air or free fluid is seen within the abdomen. There is some nonspecific perinephric stranding. No obvious mesenteric or retroperitoneal lymphadenopathy is identified. CT OF THE PELVIS: There is a large right-sided retroperitoneal hematoma measuring at least 9.2 x 6.4 cm, causing mass effect on the bladder. A Foley catheter is seen within the bladder lumen. The uterus and rectum appear unremarkable. Bilateral common iliac stents are identified. The lack of intravenous contrast prevents the assessment of possible active extravasation into the hematoma. The osseous structures demonstrate healed fractures of the inferior pubic rami bilaterally. Degenerative change of the spine is identified. IMPRESSION: 1. Large right-sided retroperitoneal hematoma. 2. Cholelithiasis. 3. Emphysematous change of the lung bases. Brief Hospital Course: Pt admitted for angiogram he underwent a Abdominal aortogram with left lower extremity run off, angioplasty of left external iliac artery, left superficial femoral artery and left above knee popliteal artery, venting of left superficial femoral artery. She tolerated the procedure well,. There were no complications. Sheath was pulled in the usual fashion. Approximately 1 hr after sheath pull / Pt dripped her SBP to the 80 / c/o abdominal pain. Pt resuscitated with fluids / STAT CT Scan revealed a large retroperitoneal hematoma. Pt sent to the SICu serial hct obtained / pt did recieve 1 unit of PRBC On DC pt stable has had 3 serial stable hct On DC is taking PO / ambulating / pos urination / pos bm Medications on Admission: lipitor 40, fosomax, acipltex, ranitidine, actonoel Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Alendronate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Outpatient Lab Work Chem 7 / CBC - please get on [6-13] - have the results faex to [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 17352]. Discharge Disposition: Home Discharge Diagnosis: PAD Retroperitoneal bleed Discharge Condition: Stable Discharge Instructions: Please take it easy for the next three days If you feel dizzy / faint / or if you have increasing pain in your abdomen. Loss off appetite pleaes call Dr [Last Name (STitle) ] office. You also have a presciption to have your blood checked. When you have your blood checked / have the lab fax the results to [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 59560]. Followup Instructions: Call Dr [Last Name (STitle) ] office at [Telephone/Fax (1) 3121] / schedule an appointment for two weeks. You will also need an arterial duplex study at the time of your follow-up / please mention this to the secretary / she will schedule this for you Completed by:[2110-6-12]	[ "440.21", "585.9", "E878.8", "492.8", "998.12" ]	icd9cm	[ [ [] ] ]	[ "88.48", "88.42", "00.42", "39.90", "39.50", "00.46" ]	icd9pcs	[ [ [] ] ]	4860, 4866	3457, 4174	366, 580	4936, 4945	1444, 3434	5408, 5700	930, 948		4276, 4837		4887, 4915		4200, 4253			4969, 5385									963, 1425																			275, 328									608, 725																747, 874	890, 914
11,861	142,227	22408	Discharge summary	report	Admission Date: [2128-8-22] Discharge Date: [2128-8-24] Date of Birth: [2105-5-5] Sex: F Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 330] Chief Complaint: Back pain, DKA Major Surgical or Invasive Procedure: None History of Present Illness: 23 F with history of DM1 with multiple admissions for DKA, last in [6-5], unclear precipitating factor. Came to ED for back pain, states that she usually comes into [Hospital1 18] ED for dilaudid for chronic back pain. Her BG was found to be > 500, she states she took Lantus 31 units last night (her normal home regimen), and that she has been carb counting and taking her short acting insulin as prescribed. Per her PCP, [Name10 (NameIs) ] has insulin compliance issues, and she has been admitted here and [Hospital1 2177] multiple times for DKA. . In the ED, her EKG showed sinus tach, K 5.4 was on hemolyzed specimen as repeat K 4.6. She was afebrile, WBC 21, UA negative, CXR negative, she was given levofloxacin 500 x1 for nonspecific source. She was given dilaudid 0.5 x 2 with resolution of back pain. She was given 4 L NS in ED. She was vomiting in the ED, question of whether her vomiting and retching was self-induced by putting her fingers down her throat. She was transferred to MICU on insulin gtt 4 units/hr with most recent BG 395. . REVIEW OF SYSTEMS: Sore throat, vomiting, vaginal itching/yeast infection, anxious/panic attacks. Past Medical History: - Diabetes Type I diagnosed in [2120] after her first pregnancy. Most recent Hgb A1C 13.4 % ([1-/2128]) - Hyperlipidemia -S/P MVA [5-3] - lower back pain since then. + back muscle spasm treated with tylenol. - Goiter - Depression - Multiple DKA admissions - G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section in [2122], not menstruating secondary to being on Depo-Provera shots - Genital Herpes - Anxiety/panic attacks Social History: The patient was born and raised in [Location (un) 669], where she lived in house with siblings, mother, grandmother, and [Name2 (NI) 12232] when growing up. Currently lives in her own apartment. Attended job corp training following h.s., but presently unemployed feeling too overwhelmed between diabetes care and caring for three year old her son. She has a boyfriend. She is close to mother, sister, and [Name2 (NI) 12232] who live nearby. Denies abuse in childhood or adulthood. She denies tobacco, alcohol or illicit drug use. Family History: GM with Type I diabetes. Otherwise non-contributory. Relatives with "acid in blood" not related to diabetes. Physical Exam: VS: 98.3 / 124 / 16 / 100% RA / 121/81 GENERAL: Tired, lethargic, thin HEENT: PERRL, green contacts, anicteric sclerae, no JVD, no LAD, OP clear LUNGS: CTA B HEART: RRR, no m/r/g ABDOMEN: Soft, ND, NT, +BS EXTR: No c/c/e SKIN: No rash or lesions NEURO: [4-3] motor, normal sensation Pertinent Results: [2128-8-22] 08:43PM URINE HOURS-RANDOM [2128-8-22] 08:43PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2128-8-22] 07:52PM GLUCOSE-104 UREA N-24* CREAT-1.0 SODIUM-145 POTASSIUM-3.9 CHLORIDE-115* TOTAL CO2-17* ANION GAP-17 [2128-8-22] 07:52PM GLUCOSE-104 UREA N-24* CREAT-1.0 SODIUM-145 POTASSIUM-3.9 CHLORIDE-115* TOTAL CO2-17* ANION GAP-17 [2128-8-22] 07:52PM HCG-<5 [2128-8-22] 07:52PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2128-8-22] 03:30PM %HbA1c-12.7* [2128-8-22] 02:56PM GLUCOSE-203* UREA N-29* CREAT-1.2* SODIUM-146* POTASSIUM-4.6 CHLORIDE-115* TOTAL CO2-12* ANION GAP-24* [2128-8-22] 02:56PM ALT(SGPT)-18 AST(SGOT)-23 LD(LDH)-140 ALK PHOS-67 AMYLASE-150* TOT BILI-0.3 [2128-8-22] 02:56PM LIPASE-26 [2128-8-22] 02:56PM ALBUMIN-4.1 CALCIUM-9.1 PHOSPHATE-3.3# MAGNESIUM-2.4 IRON-34 [2128-8-22] 02:56PM calTIBC-302 VIT B12-826 FOLATE-16.6 FERRITIN-103 TRF-232 [2128-8-22] 02:56PM WBC-21.2* RBC-4.10* HGB-12.1 HCT-37.3 MCV-91 MCH-29.6 MCHC-32.5 RDW-13.3 [2128-8-22] 02:56PM NEUTS-78.3* BANDS-0 LYMPHS-18.5 MONOS-2.2 EOS-0.3 BASOS-0.7 [2128-8-22] 02:56PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2128-8-22] 02:56PM PLT SMR-NORMAL PLT COUNT-227 [2128-8-22] 02:56PM PT-13.2* PTT-19.6* INR(PT)-1.2* [2128-8-22] 12:15PM GLUCOSE-395* UREA N-34* CREAT-1.4* SODIUM-143 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-9* ANION GAP-32* [2128-8-22] 12:15PM LIPASE-17 [2128-8-22] 12:15PM CALCIUM-9.6 PHOSPHATE-5.0# MAGNESIUM-2.6 [2128-8-22] 09:27AM K+-5.4 [2128-8-22] 08:30AM GLUCOSE-703* UREA N-37* CREAT-1.7* SODIUM-139 POTASSIUM-5.4* CHLORIDE-95* TOTAL CO2-6* ANION GAP-43* [2128-8-22] 08:30AM estGFR-Using this [2128-8-22] 08:30AM ALT(SGPT)-25 AST(SGOT)-29 ALK PHOS-85 AMYLASE-135* TOT BILI-0.4 [2128-8-22] 08:30AM LIPASE-15 [2128-8-22] 08:30AM ALBUMIN-4.9* CALCIUM-11.0* PHOSPHATE-8.7# MAGNESIUM-2.8 [2128-8-22] 08:30AM WBC-21.3# RBC-4.77# HGB-14.1 HCT-44.7# MCV-94# MCH-29.6 MCHC-31.6# RDW-13.3 [2128-8-22] 08:30AM NEUTS-83.1 LYMPHS-15.0* MONOS-1.7* EOS-0.1 BASOS-0.1 [2128-8-22] 08:30AM PLT COUNT-265 [2128-8-22] 08:30AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.025 [2128-8-22] 08:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: 23 F with DM1, multiple DKA admissions, here in DKA. . # Diabetic ketoacidosis: No known precipitating factor for DKA, but had throat swabbed for strep and was treated for vaginal yeast infection with fluconazole. LFTs, amylase, lipase, and urine/serum illicit drug screens were negative. WBC 21 which resolved to normal after DKA resolved. She was afebrile, UA negative, CXR negative. She vomited once in the ED, once in the ICU, witnessed by ED nurse as possibly self-induced by putting fingers down her throat. PCP feels repeated DKA episodes may be a compliance issue with taking insulin that is instigating these DKA episodes. Patient states that she takes her glargine every night, carb counts, and takes novolog per sliding scale. She was admitted to MICU where insulin gtt was continued until her gap closed and she could tolerate POs to defend her BG, and she was restarted on her home insulin regimen. . # Yeast infection: She was treated with fluconazole PO for 2 days. . # Vomiting: Resolved after two episodes, liver and pancreatic enzymes were negative. . # Anxiety/panic attacks: She is to follow up with psychiatry as an outpatient, and social work consult was called for her. No anxiety or panic attack was witnessed during her admission. . # Hyperlipidemia: Zetia was continued per her home regimen. Medications on Admission: - Zetia dose unknown - Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). - Insulin Glargine 100 unit/mL Solution Sig: as directed units Subcutaneous four times a day: Take 31 units of Lantus at bed time and follow Carbohydrate counting regimen. Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 4. Insulin Glargine 100 unit/mL Solution Sig: Thirty One (31) untis Subcutaneous at bedtime. 5. Humalog 100 unit/mL Solution Sig: [12-20] untis Subcutaneous four times a day: Please follow your sliding scale. 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical DAILY (Daily) for 7 days: please apply to your lower back once a day. Disp:7 patches Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Diabetes Mellitus Secondary Diagnosis: Hyperlipidema Back Pain Discharge Condition: Stable; blood sugars consistently <150 Discharge Instructions: You were admitted to the hospital for elevated blood sugars. We had you on an insulin drip and then transitioned you back to your home medications. It is very important that you continue you home insulin as you are prescribed by your [Last Name (un) ] doctors. We did not change your home medications. Please take your insulin everyday as you were prior to being admitted to the hospital. It is very important that you take you insulin everyday. Please return to the hospital for fevers, chills, abdominal pain, nausea, vomiting, or if you blood sugar is elevated. Followup Instructions: We have made a follow-up appointment for you with Dr. [First Name (STitle) ] at [Last Name (un) 22652] Corner Health Center on Monday [8-30] at 5:45pm. If you need to reschedule, please call her office at ([Telephone/Fax (1) 58249]. . Please follow up with Dr.[Name (NI) 58250] nurse [First Name8 (NamePattern2) 3639] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 58251] on [8-26] at 9am.	[ "311", "300.01", "241.0", "250.13", "300.00", "112.1", "272.4" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7753, 7759	5508, 6827	282, 288	7886, 7927	2961, 5485	8550, 8988	2528, 2639		7151, 7730		7780, 7780		6853, 7128			7951, 8527									2654, 2942															1401, 1481				228, 244									316, 1382			7839, 7865			7799, 7818										1503, 1951	1967, 2512
8,368	175,153	19151	Discharge summary	report	Admission Date: [2177-7-17] Discharge Date: [2177-8-12] Service: HISTORY OF PRESENT ILLNESS: This 85-year-old white male has a history of hypertension, hypercholesterolemia, and had a positive stress test. He has had six months of increased dyspnea on exertion, shortness of breath, and nausea. His exercise tolerance test on [7-4] revealed moderate-severe inferior apical ischemia and inferior apical hypokinesis. He underwent cardiac catheterization on [2177-7-17] at [Hospital1 346] which revealed the left main coronary artery had 80% distal concentric stenosis, LAD had 70 and 80% tandem mid vessel lesions and diffuse disease with left to right collaterals. Diagonal 1 had a 60% lesion. Left circumflex had a 70% OM-1 lesion, and the RCA had a 50% mid lesion. The left ventricle had an apical aneurysm with an ejection fraction of 55%, apical dyskinesis. Dr. [Last Name (STitle) 70] was consulted for CABG. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Status post gastrointestinal bleed secondary to nonsteroidal use. 4. History of prostate cancer status post radiation therapy. 5. Status post orchiectomy. 6. Status post inguinal hernia repair. 7. History of gout. MEDICATIONS ON ADMISSION: 1. Lopressor 50 mg po q am, 25 mg po q pm. 2. Imdur 60 mg po q am, 30 mg po q pm. 3. Lipitor 10 mg po q day. 4. Allopurinol 100 mg po q day. 5. Aspirin 81 mg po q day. 6. Iron 325 mg po q day. ALLERGIES: Ether. FAMILY HISTORY: Positive for coronary artery disease. SOCIAL HISTORY: He lives alone. He has a 120 pack year smoking history, quit 25 years prior to admission. Does not drink alcohol. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: On physical exam, he is a well-developed elderly white male in no apparent distress. Vital signs stable, afebrile. HEENT exam: Normocephalic, atraumatic. Extraocular movements are intact. Oropharynx is benign. He had upper and lower dentures. Neck was supple, full range of motion, no lymphadenopathy or thyromegaly. Carotids are 2+ and equal bilaterally with a positive radiating murmur. Lungs were clear to auscultation and percussion. Cardiovascular examination regular, rate, and rhythm, normal S1, S2, with no murmurs, rubs, or gallops. Abdomen was soft and nontender with positive bowel sounds. No masses or hepatosplenomegaly. Extremities are without clubbing, cyanosis, or edema. Pulses were 2+ and equal bilaterally throughout. He had an intra-aortic balloon in place in the right groin. Neurologic examination was nonfocal. The patient was admitted to the CCU following cardiac catheterization, and Dr. [Last Name (STitle) 70] was consulted, and on [7-18], the patient underwent a CABG x3 with LIMA to the LAD, reverse saphenous Y graft to the diagonal and OM. Cross-clamp time was 87 minutes, total bypass time 112 minutes. He was transferred to the CSRU on nitroglycerin and propofol in stable condition. He did have increased chest tube output immediately postoperatively, and was re-explored for bleeding. There was no specific source found. Hematoma was evacuated, and the patient was transferred back to the CSRU in stable condition. He remained intubated overnight. He did have his intra-aortic balloon pump removed on postoperative day #1. He did remain intubated as he was quite fluid overloaded. He continued to be diuresed, was off all drips. He did complain of right lower quadrant abdominal tenderness and General Surgery was consulted, that was on postoperative day #3. He got an abdominal CT scan which revealed question of thickened cecum with stranding, but was negative for free air. He was followed and continued to have abdominal distention and pain which waxed and waned. He was extubated on postoperative day #5. His chest tubes were also discontinued. He was then started on a regular diet. He did then continue to complain of right lower quadrant abdominal pain, so he had an abdominal CT scan on [7-24] and was taken to the operating room for small bowel resection, and a necrotic ileal segment was found. The patient was transferred back to the CSRU and was stable. He was intubated and on TPN. He slowly improved. He is on Flagyl and Zosyn, and he was followed by ID. He was extubated on postoperative day of abdominal surgery. Continued to require pulmonary therapy and diuresis. He remained on TPN. He had some temperature spikes. All the cultures were negative, and he was continued empirically on Zosyn. Patient remained NPO and on postoperative day #7 he had his nasogastric tube inserted and started on clear liquids. He continued to advance his diet. Continued to progress and on postoperative day 17 and 10, he started to have melena. He was seen by GI. He had a negative upper scope, EGD, and then he continued to bleed required 10 units of packed cells. He also had a colonoscopy on [8-6] in which the anastomotic site of the ileum was not shown, but there was no evidence of active bleeding throughout the entire colon and distal terminal ileum. So he was treated conservatively and continued to eat, and eventually this bleeding resolved. The patient was transferred to the floor postoperative day #22. He continued to progress, and was discharged to rehabilitation on postoperative day 25. LABORATORIES ON DISCHARGE: Hematocrit is 33.3, white count 9,700, platelets 420. Sodium 133, potassium 4.1, chloride 102, CO2 22, BUN 26, creatinine 1.1, blood sugar 89. DISCHARGE MEDICATIONS: 1. Ecotrin 325 mg po q day. 2. Percocet 1-2 tablets po q4-6h prn pain. 3. Amiodarone 200 mg po q day x6 weeks. 4. Combivent 1-2 puffs q6h. 5. Miconazole powder tid. 6. Protonix 40 mg po q day. 7. Lipitor 10 mg po q day. 8. Allopurinol 100 mg po q day. FOLLOW-UP INSTRUCTIONS: He will be followed by Dr. [Last Name (STitle) ] in two weeks, by Dr. [Last Name (STitle) ] in [1-23] weeks, by Dr. [Last Name (STitle) ] in [2-24] weeks, and Dr. [Last Name (STitle) 70] in six weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 32413] MEDQUIST36 D: [2177-8-11] 16:43 T: [2177-8-11] 16:50 JOB#: [Job Number 52254]	[ "414.01", "401.9", "998.11", "427.31", "578.9", "557.0", "272.0", "E878.2", "V10.46" ]	icd9cm	[ [ [] ] ]	[ "37.23", "88.56", "39.61", "99.15", "37.61", "88.53", "45.23", "36.15", "45.13", "34.03", "45.62", "36.12" ]	icd9pcs	[ [ [] ] ]							1495, 1534		5524, 5777				1264, 1478																				1726, 5341				5356, 5501			1688, 1703													113, 956												5802, 6333				978, 1238	1551, 1668
8,416	113,916	14956+56593	Discharge summary	report+addendum	Admission Date: [2195-7-8] Discharge Date: [2195-7-30] Service: SURGERY HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a [Age over 90 ]-year-old man with a history of coronary artery disease, congestive heart failure, hypertension, chronic obstructive pulmonary disease, who was transferred from [Hospital3 4527] Hospital. He was admitted to the outside hospital on [2195-7-7] with complaints of right upper quadrant pain and fevers to 102. He also had complaints of nausea and vomiting. A CT scan at the outside hospital showed the presence of gallstones with a moderately dilated gallbladder and evidence of pericholecystic fluid. The patient was subsequently transferred to [Hospital1 346] for evaluation and possible surgical intervention. At the outside hospital, the patient was started on intravenous antibiotics for broad spectrum coverage for cholecystitis. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction 2. Congestive heart failure 3. Hypertension 4. Gout 5. Chronic obstructive pulmonary disease 6. Benign prostatic hypertrophy 7. Cholelithiasis PAST SURGICAL HISTORY: 1. Bilateral total hip arthroplasties 2. Right elbow surgery 3. Transurethral resection of prostate 4. Right carotid endarterectomy ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Peri-Colace, Serax 10 mg by mouth daily at bedtime, protein powder, potassium chloride 10 mEq by mouth twice a day, Isordil 10 mg by mouth twice a day, Tums, aspirin, multivitamin, Thiazide 37.5 mg by mouth once daily, Prevacid, allopurinol 300 mg by mouth once daily, lasix 40 mg by mouth once daily. SOCIAL HISTORY: The patient lives in a nursing home. He has a 50 pack her smoking history. He denies any alcohol use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On presentation, temperature 98.4, heart rate 83, blood pressure 94/51, respiratory rate 16, oxygen saturation 96% on 12 liters. General: Elderly male, able to follow commands. Head, eyes, ears, nose and throat: Notable for icteric sclerae. Neck: No jugular venous distention. Respiratory: Crackles at bilateral bases. Cardiovascular: Regular rate and rhythm, II/VI systolic murmur. Abdomen: Positive bowel sounds, no evidence of surgical scars, nontender, nondistended, no rebound or guarding. Extremities: 2+ pitting edema. Rectal: Guaiac negative. LABORATORY DATA: White blood cells 21.0, hematocrit 32.1, platelets 118. Sodium 142, potassium 3.8, chloride 105, bicarbonate 29, BUN 35, creatinine 1.0, glucose 80. PT 14.3, PTT 35.1, INR 1.4. Calcium 8.8, magnesium 2.1, phosphate 3.9, albumin 2.7. ALT 148, AST 208, alkaline phosphatase 222, total bilirubin 4.9, amylase 59, lipase 21. HOSPITAL COURSE: The patient was initially admitted to the Surgical Intensive Care Unit for further evaluation and management of his cholecystitis. He was made nothing by mouth and continued on intravenous Unasyn. A nasogastric tube was also placed. While in the Surgical Intensive Care Unit, a central venous line was placed to monitor the patient's fluid status, given his history of congestive heart failure. The patient was also evaluated by the endoscopic retrograde cholangiopancreatography team given his symptoms and elevated bilirubin and white blood cell count. The decision was made to proceed with an endoscopic retrograde cholangiopancreatography rather than surgical intervention with a cholecystectomy, given the patient's multiple medical problems. On [2195-7-9], the patient underwent an endoscopic retrograde cholangiopancreatography with general anesthesia. Moderate diffuse dilation was seen at the biliary tree, with the common bile duct measuring 10 mm. The gallbladder was noted to be edematous and very abnormal appearing. Multiple stones were also seen in the gallbladder. The intrahepatic ducts were normal. A sphincterotomy was also performed with drainage of purulent bile. Recommendations were made to perform a percutaneous cholecystostomy tube placement under CT guidance. On that same day, an 8 French pigtail catheter was inserted into the gallbladder under CT guidance. Approximately 100 cc of dark bile was retrieved and sent for culture. The culture eventually grew out Klebsiella organisms which were sensitive to both Unasyn and levofloxacin. Following the placement of the cholecystostomy tube, the patient symptomatically improved. He complained of less abdominal pain and nausea and vomiting. On hospital day number three, the patient was noted to convert his cardiac rhythm from normal sinus rhythm to a rapid atrial fibrillation. His blood pressures were initially stable, and an esmolol infusion was started. Thirty minutes following the initiation of the esmolol infusion, the patient was found profoundly hypotensive, with systolic blood pressures in the 60s, and also decreasing oxygen saturation to 88%. He was started on Neo-Synephrine infusion to maintain his blood pressures. His cardiac rhythm did convert back to normal sinus rhythm. He also received fluid boluses and his requirement for pressors was eventually obviated. The patient was ruled out for myocardial infarction with serial cardiac enzymes. On hospital day number five, the patient was also noted to have a low hematocrit. He was transfused with two units of packed red blood cells, with an appropriate rise in his hematocrit. Given his nothing by mouth status, the patient was also started on total parenteral nutrition for nutrition. The likely etiology of the patient's decreased hematocrit was a post-sphincterotomy bleed. His hematocrit eventually stabilized, and the patient required no additional blood transfusions. On hospital day number seven, the patient was transferred from the Surgical Intensive Care Unit to the floor. The patient was also found to have elevated amylase and lipase levels. His lipase eventually reached a level in the 500s. He was thought to have post-endoscopic retrograde cholangiopancreatography pancreatitis. The patient was therefore kept nothing by mouth, and administered total parenteral nutrition, since he had biochemical evidence of pancreatitis. On hospital day number nine, the patient was switched from intravenous Unasyn to levofloxacin for antibiotic coverage. His diet was also advanced to a full liquid diet, given his clinical improvement. The patient, however, continued to complain of abdominal pain in his epigastric area. He was also noted to have increasing alkaline phosphatase and total bilirubin levels. This was concerning for possible obstruction of his bile ducts. On [2195-7-20], the patient underwent a cholangiogram through his existing cholecystostomy tube. He was found to have a single large and multiple small stones, as well as a patent cystic and common bile duct. These findings were consistent with a nonobstructing distal common bile duct stone. These new cholangiogram findings prompted further discussion of a possible cholecystectomy vs. a repeat endoscopic retrograde cholangiopancreatography for stone removal. Given the patient's multiple medical problems, a risk factor assessment was initiated. He underwent a surface echocardiogram on [2195-7-21] to assess his ejection fraction. He was noted to have mildly dilated left atrium and mild symmetric left ventricular hypertrophy. The overall left ventricular systolic function was mildly depressed. The aortic valve leaflets were moderately thickened. Moderate tricuspid regurgitation was seen. His estimated ejection fraction was 50 to 55% on echocardiogram. On [2195-7-22], the patient also underwent a stress MIBI. During this examination, he had no anginal symptoms. His electrocardiogram was uninterpretable since he had an existing left bundle branch block on electrocardiogram. He was found to have a mild reversible defect of the basilar portion of the lateral wall and normal wall motion with an ejection fraction of 46%. With the patient's worsening alkaline phosphatase and bilirubin levels, he was switched back to Unasyn for antibiotic therapy. A Cardiology consult was also obtained for risk assessment for non-cardiac surgery. The patient was deemed to get only limited benefit from revascularization and, in addition, in light of his other medical illnesses, only medical management was recommended. An endoscopic retrograde cholangiopancreatography was repeated on [2195-7-23]. A filling defect consistent with a calculus in the distal common bile duct was noted. This stone was extracted and successful placement of a double-pigtail biliary stent was performed. After discussion with the patient and his family, the decision was made to proceed with a laparoscopic cholecystectomy with the possibility of an open cholecystectomy. On [2195-7-28], the patient was taken to the operating room for a laparoscopic cholecystectomy. The patient tolerated the procedure well, and there were no perioperative complications. Postoperatively, the patient has not had any more symptoms of abdominal pain. He is slowly being advanced to a regular diet. He did require some diuresis with lasix following his operation. On postoperative day number two, the patient's total parenteral nutrition was decreased to half volume in attempts to stimulate the patient's appetite. He has been making progress with physical therapy, and was able to get out of bed to a chair. Case Management has been involved, and planning for possible discharge to an acute level rehabilitation facility. At the time of this dictation, the patient is currently being screened and will likely be discharged on [2195-7-30] or [2195-7-31]. DISCHARGE DIAGNOSIS: 1. Cholelithiasis and choledocholithiasis status post endoscopic retrograde cholangiopancreatography x 2 and laparoscopic cholecystectomy 2. Status post cholecystostomy placement and removal 3. Cholangitis treated with intravenous antibiotics 4. Coronary artery disease 5. Chronic obstructive pulmonary disease 6. Congestive heart failure 7. Hypertension DISCHARGE MEDICATIONS: The patient's discharge medications will be included on his page one summary and on his discharge addendum. DISCHARGE CONDITION: Good. DISCHARGE STATUS: The patient will be discharged to an acute level rehabilitation facility. FOLLOW-UP INSTRUCTIONS: The patient will follow up with his primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. [Name6 (MD) 843] [Name8 (MD) 844], M.D. [MD Number(1) 845] Dictated By:[Doctor Last Name 43796] MEDQUIST36 D: [2195-7-29] 22:15 T: [2195-7-30] 00:19 JOB#: [Job Number 43797] Name: [Known lastname ], [Known firstname 63] P Unit No: [Numeric Identifier 7987] Admission Date: [2195-7-8] Discharge Date: [2195-7-31] Date of Birth: [2101-12-13] Sex: M Service: Addendum: DISCHARGE MEDICATIONS: 1. Albuterol 1 to 2 puffs q6h prn 2. Peri-Colace 1 capsule po bid 3. Allopurinol 300 mg po q day 4. Triamterene hydrochlorothiazide 1 cap po q day 5. Protonix 40 mg po q day 6. Aspirin 81 mg po q day 7. Multivitamin 1 tablet po q day 8. Isordil 10 mg po bid (hold for systolic blood pressure less than 110) 9. Tylenol 325 to 650 mg po q 4 to 6 hours prn pain DISCHARGE CONDITION: Good DISCHARGE STATUS: The patient will be discharged to [Hospital3 7988] [Hospital6 ] on [2195-7-31]. FOLLOW UP INSTRUCTIONS: The patient is to follow up with his primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. He is also instructed to make an appointment with Dr. [Last Name (STitle) 3200] in two months for a repeat ERCP for stent removal. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 3676] Dictated By:[Doctor Last Name ] MEDQUIST36 D: [2195-7-31] 12:24 T: [2195-8-4] 10:04 JOB#: [Job Number 7989]	[ "496", "574.90", "577.0", "427.31", "414.01", "998.11", "428.0", "997.4", "576.1" ]	icd9cm	[ [ [] ] ]	[ "51.85", "38.93", "51.23", "51.88", "51.02", "99.15" ]	icd9pcs	[ [ [] ] ]				11468, 12137			1820, 1838		11077, 11446		9752, 10115		1378, 1681	2789, 9731										1176, 1351									1861, 2771																				121, 919												10396, 11054				941, 1153	1698, 1803
65,824	175,284	47347	Discharge summary	report	Admission Date: [2132-12-15] Discharge Date: [2132-12-23] Date of Birth: [2049-11-29] Sex: M Service: MEDICINE Allergies: Vicodin / Percocet / Darvocet A500 / Oxycodone / Vancomycin / Adhesive Tape Attending:[First Name3 (LF) 1257] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: EGD X2 PICC and arterial line placement Hemodialysis History of Present Illness: This is an 83 year old male with a history of CAD (S/P CABG), ESRD on HD, AAA, who was transferred from [Hospital3 ] hospital for GI bleed. Per records, melanotic stool started at noon today. The patient mentions that he has had black stools for 1-2 days, and his aide was the one that pointed it out to him. He denies having felt lightheaded or dizzy. But felt "queasy" this morning. HCT at OSH was 21.4, WBC 21.6. He received 1 unit of PRBCs and was transferred to [Hospital1 18]. . Of note, patient has had prior rectal bleeds in the past. Colonoscopy in [2132-2-27] showed sigmoid diverticula and an ulceration consistent with ischemic colitis. He also has a history of hemorrhoids. Last EGD was performed in [2129] and was within normal limits. He believes that his GI bleeds have been in the setting of prednisone which he intermittently takes for Bullous pemphigoid. He is currently being tapered off of prednisone. . In the ED, initial vs were: T 97.9 HR 75 BP 109/35 RR16 100% on RA. While in the ED, he had a large amount of melanotic, liquid stool. Patient was given IV fluids, IV pantoprazole, Zofran. He got Calcium gluconate for a K of 5.9. NG lavage was negative. GI was consulted, and will evaluate her in the ICU. R IJ was attempted twice, however they were unable to thread the wire. As a result, they placed a L femoral triple lumen. Vitals prior to transfer were HR 80 BP 112/44 RR 20 99% on RA. . On the floor, patient is eager to go to sleep. But not in any pain or discomfort. Past Medical History: 1)CAD -s/p 3-vessel CABG in [2122] (LIMA-LAD, SVG-RCA-occluded, SVG-OM1/OM3 occluded) -s/p NSTEMI in [2-2] (DES in L main) 2)ESRD -LUE AVF, HD MWF -Per patient, has congenital left kidney hypoplasia 3)AAA -s/p repair ([2123]) 4)PVD -s/p aortobililiac graft in [2123] -s/p left CEA in [2123] ([2132-5-22] US showed right ICA 70-79% stenosis, left ICA 1-39% stenosis) 5)Ischemic colitis -Admitted [2132-3-9] for bloody diarrhea, uneventful hospital course 6)Spinal stenosis -s/p discectomy and arthrodesis at C5-C6 and C6-C7 [2130-12-4] -Baseline impairment in walking (uses motoroized wheelchair or walker) 7)Right renal tumor, suspicious for RCC, undergoing watchful waiting, followed by Dr. [Last Name (STitle) 3748] 8)Prostate cancer -s/p brachytherapy in [2122] 9)Abdominal wall abscess in [5-5], s/p I&D, cultures grew Actinomyces 10)Cholangitis -s/p CCK in [2130-3-21] 11)Bullous pemphigoid (diagnosed in [7-/2132]) -Dermatologist is Dr. [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ] 12)s/p Cataract surgery on left eye Social History: Lives alone at [Location (un) 33866] [Hospital3 400] Residency. He previously worked as a district manager for Metropolitan Life. 60 pack-year smoking history, quit 10 years ago. Occasional social alcohol use. Family History: One daughter (53) and son (57), both in good health. One sister with diverticulitis. Physical Exam: Vitals: T: BP:135/42 P:77 R: 15 O2: 100% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Incisonal scar present. Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 1+ pulses, 1+ pitting edema bilaterally. Pertinent Results: Labs on Admission: WBC-19.3# RBC-3.53 HGB-10.8* HCT-34.6* MCV-98 MCH-30.6 MCHC-31.2 RDW-19.2* NEUTS-94.1* LYMPHS-3.2* MONOS-2.2 EOS-0.2 BASOS-0.2 PLT COUNT-215# PT-13.2 PTT-44.7* INR(PT)-1.1 CK(CPK)-30, CK-MB-NotDone, cTropnT-0.19 GLUCOSE-103* UREA N-167* CREAT-7.0# SODIUM-138 POTASSIUM-6.0 CHLORIDE-98 TOTAL CO2-19* ANION GAP-27* . Studies: EGD [12-16] - Blood in the esophagus, no active bleeding site noted Blood in the stomach with blood clots, no active bleeding site noted Blood clot in the duodenum, no active bleeding site noted Otherwise normal EGD to second part of the duodenum . EGD [12-18] - Abnormal mucosa in the stomach (biopsy) Otherwise normal EGD to second part of the duodenum . Stomach fundus biopsy - Corpus mucosa with superficial [Month/Year (2) 1106] congestion and mild edema; no diagnostic abnormalities otherwise recognized. Hpylori negative (per pathologist). . Microbiology: Cdiff negative X2 Blood cultures ([2132-12-16]) No growth to date Brief Hospital Course: 82 year old male with a history of CAD (S/P CABG), ESRD on HD, AAA, who was transferred from OSH with lower GI bleed. . 1. Lower GI bleed: Nasogastric lavage negative. No bright red blood per rectum throughout this hospital stay. Only large amounts of melanotic stool initially that resolved as hospital course progressed. Patient has a history of diverticulosis, and prior rectal bleeding. He remained hemodynamically stable and hematocrit stabilized at 31-33 by [12-16] after 7 units pRBC and 2 units FFP (goal >30). [Month (only) ] Surgery was consulted and recommended CT abdomen with contrast which ruled out Aortoenteric Fistula (in setting of patient's AAA s/p repair). Patient was intubated from [Date range (1) 34518] but extubated and weaned successfully. Patient's initial EGD on [12-16] showed blood in esophagus, stomach and duodenum but was otherwise unelucidating -- the second EGD on [12-18] showed a fundus ulcer that had been previously bleeding but stabilzied. Biopsies taken from the ulcer were not concerning for malignancy or H.pylori infection. Patient was continued with active type and screen and telemetry until two days prior to discharge; no events were noted on telemetry. His blood pressures slowly improved and he was resumed on his home metoprolol. He was initially on a proton pump inhibitor gtt and transitioned to home Pantoprazole with good effect; he was also on stress dose steroids initially but transitioned to home Prednisone for management of his Bullous Pemphigoid. Of note, there was some concern that his upper GI bleed was in part due to the long-term steroids. - Continue Pantoprazole 40mg twice daily for one month * Please have patient discuss need for long term Pantoprazole twice daily with his gastroenterologist at his appoinment - Follow-up in [Hospital ] clinic with Dr. [First Name (STitle) ] [Name (STitle) ] on [2-5] at 1:30pm . 2. Delirium: Patient was mildly delirious starting [12-16] (per daughter) with waxing and [Doctor Last Name 688] throughout the days. Patient had been briefly intubated for his EGDs, on sedating/hypnotic medications, underwent significant GI bleed with multiple transfusions, in the ICU - all of which could have contributed to his delirium. By two days after discharge, his confusion had improved significantly. He was discharged with baseline mental status. . 3. Leukocytosis: White blood cells intiially 27.3, likely secondary to demargination and stress dose intravenous steroids. Infectious work-up was intiated although patient remained afebrile with no localizing symptoms. Urinalysis, urine culture, blood cultres, Cdiff toxin and chest xray were all negative. Patient's leukocytosis gradually trended down to ~13 by day of discharge, which is within normal limits considering patient's ongoing steroid use. . # ESRD on HD: Missed hemodialysis on day of admission and was found to be hyperkalemic to 6.0. Patient underwent hemodialysis and ultrafiltration with good effect on his significant anasarca. Patient was likely significantly volume overloaded due to the many transfusions he received and general immobility; left upper extremity remained significantly edematous >> right upper extremity but was negative for DVT on ultrasound. Patient did become hypotensive on hemodialysis so he was started on Midodrine 5mg to be given before hemodialysis on hemodialysis days. Medications were renally dosed while in-house, with avoidance of nephrotoxins as well. - Continue Midodrine 5mg PRIOR to hemodialysis on hemodialysis days, until Renal physicians at Hemodialysis decide otherwise - Continue to hold morning Metoprolol 25mg dose on hemodialysis days until after hemodialysis - Increased Sevelamer from 800mg three times daily to 1600mg three times daily . # Coronary Artery Disease: Three vessel CABG in [2122] and NSTEMI in [2123-1-27]. Patient was continued on Simvastatin inhouse but aspirin 325mg and beta blocker (Metoprolol 25mg twice daily) were held in-house in the setting of his GI bleed - DECREASE Aspirin to 81mg daily for now, given his GI bleed - Continue home Metoprolol 25mg twice daily and Simvastatin daily . # Back and hip pain: Managed with Tylenol in-house - Resume tramadol, oxazepam as outpatient, as blood pressure tolerates . # Bullous pemphigoid: Stable. Patient on prednisone taper (10mg daily for one month, starting [12-19] --> 5mg daily afterwards). There was concern that patient's long-term Prednisone use exacerbated, played a role in his presenting GI bleed - Continue 10mg daily until [1-19]; start 5mg daily on [1-19] for another month - Patient has an appointment to follow-up with his primary dermatologist, Dr. [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ]. Date/ Time: Tuesday, [1-13], 1pm Location: [Location (un) ], [Location (un) 55], MA Phone number: [Telephone/Fax (1) 3965] . # Code: Confirmed full with patient. Medications on Admission: 1. Acetaminophen 325 mg po q6h PRN pain 2. Oxazepam 10 mg po qhs PRN insomnia 3. Calcium Carbonate 500 mg po tid 4. Citalopram 20 mg po daily 5. Docusate Sodium 100 mg po bid 6. Calcium Acetate 667 mg po tid 7. Simethicone 80 mg po qid PRN gas pain 8. Ezetimibe 10 mg po daily 9. Minocycline 100 mg po bid 10. Simvastatin 80 mg po daily 11. B Complex-Vitamin C-Folic Acid 1 mg po daily 12. Senna 8.6 mg po bid PRN constipation 13. Sevelamer HCl 800 mg po tid 14. Metoprolol Tartrate 12.5 mg po qid 15. Tramadol 50 mg po q6h PRN pain 16. Clobetasol 0.05 % Cream Topical [Hospital1 ] 17. Pantoprazole 40 mg po bid 18. Aspirin 325 mg po daily 19. Prednisone 10mg daily x1 month until [2133-1-2]. Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 30 days: Please discuss with GI at your appointment the need to continue this medication dose. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 8. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO three times a day. 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 26 days: Decrease to Prednisone 5mg daily on [1-19]. 13. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO four times a day as needed for gas pains. 14. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO at bedtime as needed for insomnia. 16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 17. Midodrine 5 mg Tablet Sig: One (1) Tablet PO QTUTHSA (TU,TH,SA): On hemodialysis days, PRIOR to hemodialysis. 18. Clobetasol 0.05 % Cream Sig: One (1) application to affected areas Topical twice a day. 19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Baypointe - [Hospital1 1474] Discharge Diagnosis: Primary: Upper GI bleed (stomach fundus ulcer) Secondary: Coronary artery disease, end-stage renal disease on hemodialysis, bullous pemphigoid 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 with blood loss from your gastrointestinal tract. You underwent an EGD that showed a bleeding ulcer in your stomach. You were transfused with 7 units of blood and 2 units of clotting factors with good effect; the bleeding from the ulcer has stopped. You were started on a medication that heals/protects ulcers. You also required extra hemodialysis because the transfusions caused you to swell with excess fluid. . -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> DECREASE Aspirin 325mg to 81mg daily (after your stomach bleed) --> DECREASE Prednisone 20mg to 10mg daily (until [1-19], start 5mg daily that day) --> INCREASE Sevelamer from 800mg --> 1600mg three times daily --> STOP Minocycline 100mg twice daily --> On hemodialysis days, take Metoprolol 25mg twice daily AFTER hemodialysis --> On hemodialysis days, START Midodrine 5mg BEFORE hemodialysis --> CONTINUE all other home medications . -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: You have a radiation oncology appointment on [Last Name (LF) 2974], [12-26]. Please take the CD we have provided you to this appointment. It contains imaging of your neck and chest that will help guide your radiation treatments for your oropharyngeal cancer. . Please follow-up with your dermatologist, Dr. [First Name8 (NamePattern2) 402] [Last Name (NamePattern1) ]. You have an appointment with her on Tuesday, [1-13] at 1pm. Location: [Location (un) ], [Location (un) 55], MA Phone number: [Telephone/Fax (1) 3965] . You also have an appointment with your cardiologist, Dr. [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911] on [1-22] at 3:40pm. You can reach his office at: [Telephone/Fax (1) 62]. . You have an appointment with your neurosurgeon, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 548] on [2-3] at 3:30pm. You can reach his office at: [Telephone/Fax (1) 3736] . You also have an appointment with Gastroenterology, to follow-up on your current stomach ulcer bleed. Please follow-up with Dr. [First Name (STitle) ] [Name (STitle) ] on [2-5] at 1:30pm. You can reach his office at: [Telephone/Fax (1) 463] .	[ "V45.81", "719.45", "458.21", "E879.8", "E932.0", "285.1", "694.5", "414.00", "443.9", "E879.1", "V45.89", "288.60", "999.89", "V10.46", "787.02", "276.7", "556.9", "724.5", "V45.11", "562.10", "455.6", "149.0", "531.00", "293.0", "276.6", "585.6" ]	icd9cm	[ [ [] ] ]	[ "38.93", "45.16", "45.13", "39.95", "99.04" ]	icd9pcs	[ [ [] ] ]	12533, 12592	5005, 9967	354, 409	12779, 12779	3986, 3991	14209, 15442	3335, 3421		10718, 12510		12613, 12758		9993, 10695			12949, 14186									3436, 3967																			300, 316									437, 1959								4005, 4982		12793, 12925						1981, 3083	3099, 3319
2,394	152,213	1731	Discharge summary	report	Admission Date: [2140-4-3] Discharge Date: [2140-4-6] Date of Birth: [2098-4-4] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[First Name3 (LF) 5755] Chief Complaint: fever, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname ] is a 41 y/o M with history of recently diagnosed HIV infection (VL > 100,000, CD4 pending), depression/anxiety, and gonococcal infections of pharynx and anus who presents 2 days after discharge from recent admission with recurrent fever up to 103.8. The patient was admitted from [3-29] to [4-1] with fevers to 102 and acute renal failure. During that admission, his renal failure resolved with IVF, and his fever workup was remarkable for positive ASO titer without symptoms of pharyngitis for which he was discharged on augmentin. He was discharged on [4-1] at which time he felt fairly well. He continues to have joint pains diffusely for which he is taking oxycodone and tylenol. The patient has been taking his medications, including augmentin, as prescribed. . The morning prior to this admission pt felt somewhat unwell with "red eyes" and missed his augmentin dose. At that time his temperature was 101.2. He thinks that he took one bactrim pill by mistake as well as 6 ibuprofen but continued to feel poorly. His temperature increased to 103.8 at which time he came to the emergency room. Patient was reported to have a rash, but on interview in the [Hospital Unit Name 153], patient denied having any rash but thought his skin was somewhat red from his fever. He admitted to a frontal headache located just supraorbitally which has been ongoing since last week; he also had sinus congestion. He denied cough, ear pain or fullness, visual difficulty, sore throat, difficulty swallowing, difficulty breathing, nausea or vomiting, abdominal pain, diarrhea, dysuria, and penile lesions or discharge. He denied neck stiffness as well as numbness/tingling/weakness of the extremities. . In the ED, VS T 102.5 HR 131 BP 110/50 O2 97% RA. His blood pressure did fluctuate from a low of ~ 90 systolic up to 110. He received a total of 7 L of IVF. Lactate was 2.8. Blood cultures were drawn and an LP was performed which showed 3 WBCs (69% polys, 22% lymphs), 0 RBCs, protein 45, glucose 53. He was treated with ceftriaxone 2 g IV X 1, vancomycin 1 g IV X 1, and acyclovir 800 mg IV X 1; for his rash, he was treated with solumedrol 125 mg X 1 and benadryl. Imaging studies revealed normal CXR and CT was negative for incranial hemorrhage or mass effect. . Pt was subsequently admitted to the [Hospital Unit Name 153] for borderline hypotension. In the [Name (NI) 153], pt was started on azithyromycin for sinusitis. He was continued on ceftriaxone for presumed pneumonia based on RML infiltrate on poor CXR. He had extensive work up for fever during the recent admission and not source has been found at present. His hypotension responded to fluid and [Last Name (un) 104] stim was adequate. Pt was subsequently transferred to the floor. Past Medical History: 1. Anal fissure 2. Adjustment disorder 3. Urethritis NOS [2133] 4. Depression/Anxiety 5. Pharyngeal gonococcal infection 6. Anal gonococcal infection 7. New diagnosis of HIV, VL > 100K, CD 4 pending; per his report had negative HIV test in [2139-12-18] Social History: Pt is involved with a monogamous partner, with whom he lives ([Name (NI) 449]). He works as a social worker for the [Location (un) ] of Mass. He reports no recent sexual contact (>6 weeks [2-19] decreased libido). His partner is monogamous per his report. He drinks [3-21] glasses of wine on weekends. He denies tobacco use. He does not use heroin or cocaine, but does admit to rare marijuana use. Family History: Glaucoma (father, [Name (NI) 9876]. Sister and GM with DM. Physical Exam: PE: T 100.3 BP 106/75 HR 90 RR 18 O2 100% on RA Gen: comfortable at rest, no apparent distress. HEENT: bilateral scleral injection, no discharge, PERRL, EOMI, no tonsillar exudate. blister-like lesion on right lateral tongue which is not painful per his report. Neck: supple, no JVD, no carotid bruit CV: rrr, nl s1+s2, no m/r/g Resp: ctab, nl effort Abd: mild distention, nl bs, non tender. Ext: no peripheral edema/cyanosis/clubbing, DP pulses 2+ bilaterally. Neuro: A&O X 3. CN II-XII intact. Strength 5/5 in all four limbs. Sensation intact throughout. Pertinent Results: [2140-4-3] 07:20PM WBC-8.4# RBC-3.48* HGB-11.4* HCT-31.8* MCV-91 MCH-32.9* MCHC-36.0* RDW-13.5 [2140-4-3] 07:20PM NEUTS-92.3* BANDS-0 LYMPHS-6.2* MONOS-1.3* EOS-0.2 BASOS-0 [2140-4-3] 07:20PM PLT SMR-NORMAL PLT COUNT-321 [2140-4-3] 07:20PM PT-12.5 PTT-31.7 INR(PT)-1.1 . [2140-4-3] 07:20PM GLUCOSE-122* UREA N-12 CREAT-1.2 SODIUM-139 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16 ALT 33, AST 37, ALK PHOS 63, T BILI 0.2, LIPASE 32, AMYLASE 47, ALBUMIN 3.1 . [2140-4-3] 07:30PM LACTATE-2.8* . [2140-4-3] 07:20PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-0 POLYS-69 LYMPHS-22 MONOS-0 EOS-1 MACROPHAG-8 [2140-4-3] 07:20PM CEREBROSPINAL FLUID (CSF) PROTEIN-45 GLUCOSE-53 . CSF GRAM STAIN (Final [2140-4-3]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2140-4-6]): NO GROWTH. VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary): No Virus isolated so far. FUNGAL CULTURE (Pending): CRYPTOCOCCAL ANTIGEN (Final [2140-4-6]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. Performed by latex agglutination. (Reference Range-Negative). Results should be evaluated in light of culture results and clinical presentation. . [2140-4-4] 12:00AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.000* [2140-4-4] 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG . BLOOD PARASITE SMEAR: NEGATIVE G6PD: PENDING RETIC COUNT 1.3% CORTISOL 30.8 LEGIONELLA URINE ANTIGEN: NEGATIVE CMV VIRAL LOAD: PENDING INFLUENZA A/B DFA: NEGATIVE URINE CX: NEGATIVE URINE GONORRHEA/CHLAMYDIA: NEGATIVE THROAT VIRAL CX: NO GROWTH TO DATE (STREP, GONORRHEA CX NEGATIVE) BLOOD CX: NO GROWTH TO DATE . [2140-4-3] CT HEAD: Unchanged exam from previous [2140-3-29]. No acute abnormality identified. . [2140-4-3] CXR: 1. Limited PA view probably due to technical reason. No acute cardiopulmonary process identified on this study. If clinical concern persists, please repeat the frontal view. 2. Opacity overlying the hilum, which can represent hilar adenopathy. Further evaluation is recommended. Dr. [First Name (STitle) ] was informed in the monrning of [2140-4-4]. . [2140-4-4] CXR: Rapid onset interstitial pattern, most likely due to fluid overload, but viral pneumonia cannot be excluded. . [2140-4-6] CXR: Resolution of interstitial edema with persistent small bilateral pleural effusions. Brief Hospital Course: # Fever: Patient had no focal signs or symptoms of infection. DFA negative for influenza. I suspect his fever is due to acute HIV versus possible Lyme disease. Known HIV with viral load > 100,000. CD4 count came back during this admission at 180. Patient was initially covered with empiric ceftriaxone and azithromycin in the ICU without clear source. LP was negative. Throat cultures were negative. CXR was most consistent with volume overload (received 7 liters NS in ED alone). Urinalysis without evidence for infection and blood cultures remain no growth to date. CMV viral load pending but normal LFTs and no diarrhea. Recent extensive work-up during his prior admission was unrevealing, however his Lyme antibody came back positive. ID was consulted and agreed with empiric treatment with doxycycline x 30 day. They also suggested ruling out PCP, [Name10 (NameIs) ] low suspicion given his low CD4 count. However, patient denied any cough and was unable to provide sputum, including with induction. Bronchoscopy was not pursued given very low suspicion. Patient will follow-up with Dr. [Last Name (STitle) 2392] and this can be reconsidered if CXR or O2 sat worsens. . # Newly diagnosed HIV: CD4 < 200. Given bactrim allergy, patient was started on atovaquone for PCP [Name Initial (PRE) 1102]. G6PD was sent. If normal, could start dapsone for prophylaxis instead given this is pill form and only once daily. He will follow-up with Dr. [Last Name (STitle) 2392] to discuss starting HAART. . # Hypotension: Again, patient hypotensive in the setting of his fever. His blood pressure improved with aggressive hydration. AM cortisol was normal. Patient has been hemodynamically stable on the floor. . # Joint pain: Resolved prior to discharge. In conjunction with conjunctivitis, could be reactive due to inflammatory process such as acute HIV or other viral syndrome. Also concerning for possible Lyme - getting treated with 30 days of doxycycline. [Doctor First Name ] and RF negative on last admission. . # Conjunctival injection: Patient noted to have similar symptoms on his last admission, likely viral conjunctivitis. However, given he is a contact lens wearer, he was started on cipro eye gtt and this symptom significantly improved. He will continue these drops for 5 days total. . # Rash: Patient was noted to have a diffuse erythroderma which is not concerning to him or causing any symptoms at present. Likely secondary to HIV seroconversion rash versus allergy to bactrim which he took prior to admission. Could also be related to Lyme. It resolved prior to discharge. . # Anemia: High ferritin on last admission suggests more likely anemia of chronic disease. Iron supplement discontinued. . # Depression/Anxiety: Patient was contined on his home dose celexa, klonopin and temazepam prn. . # Dispo: Patient discharged to home Medications on Admission: Meds: D/C'd on [3-31] with 1 week or augmentin for + aso titer. 1. Citalopram 30 mg daily 2. Temazepam 30 mg QHS prn insomnia 3. Clonazepam 0.5-1 mg [Hospital1 ] prn for anxiety. 4. Oxycodone 5 mg Q4-6H prn joint pain 5. Ferrous Sulfate 325 mg daily 6. Amoxicillin-Pot Clavulanate 500-125 mg PO TID X 7 days Discharge Medications: 1. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO twice a day for 27 days. Disp:54 Capsule(s) Refills:0 2. Atovaquone 750 mg/5 mL Suspension Sig: Five (5) mL PO BID (2 times a day). Disp:300 mL Refills:2 3. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. Clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for anxiety. 5. Temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime) as needed for insomnia. 6. Ciprofloxacin 0.3 % Drops Sig: Two (2) Drop Ophthalmic every six (6) hours for 3 days. Disp:1 bottle Refills:0 Discharge Disposition: Home Discharge Diagnosis: primary: acute HIV lyme disease conjunctivitis secondary: depression and anxiety Discharge Condition: good: afebrile x 24 hours, clinically looks well Discharge Instructions: Please call your doctor or go to the emergency room if you experience temperature > 101, shortness of breath, headache, or other concerning symptoms. Please take all medications, as prescribed. Please follow-up as instructed below Followup Instructions: Please follow-up with Dr. [Last Name (STitle) 2392] on Monday 26, [2140] at 3:20 PM to have a repeat chest xray and to follow-up the lab test that is still pending to determine if you can take a once a day medication, instead of the atovaquone. Location: [Last Name (un) 9878]Phone: [Telephone/Fax (1) 2393]	[ "V08", "088.81", "280.9", "372.30", "276.0" ]	icd9cm	[ [ [] ] ]	[ "03.31" ]	icd9pcs	[ [ [] ] ]	10929, 10935	7064, 9951	284, 291	11061, 11112	4508, 6333	11393, 11721	3851, 3915		10318, 10906		10956, 11040		9977, 10295			11136, 11370									3930, 4489																			226, 246									319, 3114		6342, 7041														3136, 3399	3415, 3835
43,121	128,585	52979	Discharge summary	report	Admission Date: [2107-9-27] Discharge Date: [2107-10-5] Date of Birth: [2037-12-10] Sex: F Service: SURGERY Allergies: Levofloxacin / Iodine / Premarin / Mustard / ondansetron Attending:[First Name3 (LF) 30894] Chief Complaint: Nausea and Vomiting, weight loss, abdominal pain Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: Ms. [Known lastname 32277] is a 69 y/o F s/p Subtotal gastrectomy, Roeux-en-Y gastrojejunostomy, J-tube ([2107-8-9]) now with nausea and vomitting. Pt has had decreased appetite and nausea over the last week and a half. Pt noted the nausea got worse since [9-21]. She started vomitting after meals and by [9-25] couldn't keep anything down. Pt states emesis is non-bilious. Pt only has nausea and vomitting after meals. Pt has been having regular bowel movements, last one was on Saturday. Patient had flatus this am. Pt notes that she has had pain near the J tube since surgery and this has been unchanged. Pt denies fever, chills, CP, SOB, diarrhea, or constipation. Past Medical History: Subtotal gastrectomy, Roeux-en-Y gastrojejunostomy, J-tube([2107-8-9]) Cervical Laminoplasty C2-C6 on [11-12] Left calcaneal fracture s/p ORIF [2103] Hypothyroidism Macular Degeneration- left eye is legally blind GERD hx of pyloric channel ulcer Essential Tremor COPD hx of left salpingo-oopherectomy-remote past appendectomy in childhood Social History: Pt has 50 pack year history of tobacco, currently at 1/2 ppd, patient denies EtoH, denies recreational drug use. Pt is a former nurse. Is a retired professor [First Name (Titles) ] [Last Name (Titles) 9929]. She lives alone in a house and is divorced. Has 1 child who lives out of state. Family History: Father-died of CAD at 84 Mother-died of 54 shy-[Last Name (un) ] disease Maternal grandmother-renal Ca Maternal grandfather- lung cancer Physical Exam: Vitals: Gen: Thin, frail F lying awake in bed, NAD Card: RRR, no RMG Pulm: CTAB Abd: Soft, minimally tender around J tube side, no erythema or signs of infection, non distended, + bs Neuro: AAOx3 Ext: WWP, + pulses Pertinent Results: Admission Labs: [2107-9-26] 07:30PM BLOOD WBC-4.1 RBC-3.96* Hgb-11.3* Hct-34.8* MCV-88 MCH-28.6 MCHC-32.5 RDW-14.6 Plt Ct-256 [2107-9-26] 07:30PM BLOOD Neuts-67.5 Lymphs-25.8 Monos-4.4 Eos-1.5 Baso-0.7 [2107-9-26] 07:30PM BLOOD PT-13.2 PTT-27.5 INR(PT)-1.1 [2107-9-26] 07:30PM BLOOD Plt Ct-256 [2107-9-26] 07:30PM BLOOD Glucose-342* UreaN-8 Creat-0.6 Na-142 K-2.7* Cl-105 HCO3-29 AnGap-11 [2107-9-26] 07:30PM BLOOD ALT-9 AST-11 AlkPhos-81 TotBili-0.3 [2107-9-26] 07:30PM BLOOD Lipase-24 [2107-9-26] 07:30PM BLOOD Calcium-8.0* Phos-2.1* Mg-1.8 [2107-9-26] 07:41PM BLOOD Lactate-2.2* Reports: [2107-8-27] EKG: Sinus rhythm. Possible left atrial abnormality. Compared to the previous tracing of [2107-8-6] no interim diagnostic change. [2107-8-27] KUB: IMPRESSION: 1. Nonobstructive bowel gas pattern. 2. No free air. [2107-8-27] Ct Abd/Pelvis w/PO contrast IMPRESSION: 1. New areas of mucoid impaction/aspiration in the right lower lobe with resolution of several other previously noted areas. 2. Area of hypodensity within the left lobe of the liver is not as well evident. Limited evaluation of liver on this non-contrast enhanced CT. 3. Status post partial gastrectomy with gastrojejunostomy. Significant retention of oral contrast within a dilated esophagus and the gastric remnant which may relate to holdup at the anastomotic site/slow transit. No evidence of obstruction with oral contrast demonstrated within distal loops of small bowel past the jejunostomy site. 4. Colonic diverticulosis. 5. Apparent mild interval increase in size of the common bile duct now measuring up to 11mm. Recommend clinical correlation with LFTs and ultrasound can be considered. 6. New subcutaneous nodule in the mid uper abdomen may relate to small postoperative seroma. 7. Multiple non-obstructing sub 4mm renal calculi. [2107-9-30] EKG Moderate baseline artifact. Sinus tachycardia. Slight non-specific ST segment changes. Short P-R interval. Compared to the previous tracing of [2107-9-26], except for increase in rate, no diagnostic interval change. [2107-9-30] CXR: IMPRESSION: Findings concerning for acute aspiration or evolving aspiration pneumonia. [2107-10-1] CXR: Impression: Bibasilar opacities are again visualized. The right lower lobe has a plate-like appearance, and it may be secondary to either volume loss or small infiltrate on the left. It has more linear appearance and most likely represents volume loss. Overall, no substantial change compared to the film from the prior day. [2107-10-4] Barium Swallow/Small Bowel Follow Through: IMPRESSION: No emptying of barium from stomach after 85 minutes likely represents obstruction at the gastrojejunal anastamosis. Brief Hospital Course: BRIEF HOSPITAL COURSE: The patient was admitted to the West 3 surgery service on [2107-9-26] for nausea and vomiting. The patient was about 6 weeks s/p subtotal gastrectomy with [Last Name (un) ] gastrojejunostomy and J Tube. Neuro: Patient reported severe pain that has been constant ever since surgery at her J-tube site. The patient received Dilaudid IV and oxycodone through the J tube with some relief. Higher doses of narcotic pain medication did not seem to help her pain dramatically. Regarding her nausea she was treated with IV zofran and PR compazine which somewhat improved her symptoms, though she continued to vomit persistently despite aggressive antiemetic therapy. Later in her admission she was placed on Ativan for retching which subjectively helped to some degree. CV: The patient had one episode of SBP in the 80's the day that her sats dropped, presumptively due to aspiration. The ICU team gave her several small fluid boluses which promptly increased her SBP nicely. Otherwise the patient was stable from a cardiovascular standpoint during this admission. Pulmonary: On [2107-9-30] the patient had a saturation of 70 on her late morning vitals as well as a temp of 101. She was not complaining of dyspnea or SOB. She was placed on 6 L nasal canula with resolution of her saturation to the low 90's. Cxr was consistent with aspiration or evolving aspiration PNA. ABG showed she was not acidotic or hypercarbic but her PO2 was 54. She was started on Vanc/Zosyn and transferred to the ICU. During her ICU stay she initially had some SBP in the 80's which responded nicely to fluid boluses. The AB's were stopped in the ICU as this was thought to be caused by an aspiration pneumonitis rather than an aspiration pneumonia and she was improving nicely. She was called out on [2107-10-1] and was stable from a pulmonary standpoint from there forward. GI/GU: Initially it was thought that perhaps her nausea was in some way related to her J-tube. CT scan showed possible holdup at the anastomotic site/slow transit without any evidence of obstruction. On HD 1 the J-tube cuff was partially deflated, with relatively little effect. GI was consulted who took the patient for EGD which showed some edema around the tube site but no obvious cause for her N/V. She was started on tube feedings via J-Tube on HD 1. She tolerated the tube feeds well, though she persistently vomited clear, foamy fluid (not tube feed-like in appearance). Because of her persistent vomiting GI was reconsulted. They recommended Barium swallow with small bowel follow through. This showed lack of gastric emptying as outlined in the reports section. The etiology of this lack of emptying is likely due to edema of the gastrojejunal anastamosis, and it is thought that this will resolve with time. ID: The patient's temperature was closely watched for signs of infection. Other than the aforementioned aspiration pneumonitis event the patient was afebrile without elevated white count. Cancer: The patient was seen by the inpatient oncology service during her admission for her previously diagnosed gastric adenocarcinoma. They recommended obtaining a CEA during this admission which was done. They did not have any other inpatient recommendations and would like the patient to follow up as an outpatient with Drs. [Last Name (STitle) ] and [Name5 (PTitle) ] for further chemo/radiation options. 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 HD 9, the patient was doing well, afebrile with stable vital signs, tolerating tube feeds, ambulating, voiding without assistance, and pain was adequately controlled. Medications on Admission: #Os-Cal 1000', #PreserVision 452' #Prilosec 40' #Prochlorperazine maleate 5 (dosage uncertain) #Dilaudid 2q4 pain #Levothyroxine 100' #Bentyl 20' Proventil 180prn #Carafate 1"" #Flovent HFA 220" #Nardil 5' #nicotine patch' Discharge Medications: 1. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Oral 2. PreserVision 226-200-5 mg-unit-mg Capsule Sig: Two (2) Capsule PO once a day. 3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day. 4. Bentyl 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Proventil HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 6. Carafate 1 gram Tablet Sig: One (1) Tablet PO four times a day. 7. Flovent HFA 220 mcg/actuation Aerosol Sig: One (1) INH Inhalation twice a day. 8. Nardil 15 mg Tablet Sig: Two (2) Tablet PO once a day. 9. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day. 10. oxycodone 5 mg/5 mL Solution Sig: [4-12] mL PO Q4H (every 4 hours) as needed for pain. Disp:300 mL Refills:0 11. ondansetron 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 12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for retching. Disp:30 Tablet(s) Refills:0 13. prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours) as needed for nausea. Disp:30 Suppository(s) Refills:0 14. acetaminophen 650 mg/20.3 mL Solution Sig: 20.3 mL PO Q6H (every 6 hours). Disp:500 mL Refills:0 15. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Nausea and Vomiting Stage IIIc (T4aN3) gastric adenocarcinoma Aspiration Pneumonitis Chronic Obstructive Pulmonary Disease Hypothyroidism Gastroesophageal Reflux Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 32277], You were admitted to the West 3 General surgery service for nausea and vomiting. While you were here you were seen by the gastroenterologists who performed an upper GI endoscopic exam. This did not show any definitive cause for your nausea and vomiting. Additionally they recommended some further imaging which showed that your nausea and vomiting are likely due to inappropriate emptying of the stomach. Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. [Known lastname 17779] Care: Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the [Known lastname ] site. Avoid swimming and baths until cleared by your surgeon. You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Thank you for letting us participate in your care. We wish you a speedy recovery. Followup Instructions: Please call ([Telephone/Fax (1) 1483] upon discharge to schedule an appointment in the office of Dr. [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) ] in [1-7] weeks, or with any questions/concerns. Clinic is located in the [Hospital 2577] Medical Office Building, [Location (un) ], [Hospital1 18]. Please call [Telephone/Fax (1) 22] to make an appointment with Dr. [Last Name (STitle) *] in Oncology to discuss chemotherapeutic options.	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23,477	137,517	7814	Discharge summary	report	Admission Date: [2123-5-5] Discharge Date: [2123-5-8] Date of Birth: [2074-6-10] Sex: F CHIEF COMPLAINT: Hematemesis. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old-female with a history of alcohol abuse with gastrointestinal bleed on [2123-5-5]. The patient has a history of grade III varices and portal hypertensive gastropathy status post banding on [2123-3-5]. Two week prior to admission the patient resumed alcohol use. On [5-4], the patient presented with emesis that was bright red and later became coffee-grounds. On the day of and lightheadedness. In the Emergency Room heart rate was 105, blood pressure of 108/61 (which decreased to 67/39 with continued hematemesis). The patient received Octreotide 50-mcg per hour drip, ciprofloxacin 400 mg intravenously, Protonix 40 mg intravenously, 4 units of packed red blood cells, and 2 units of fresh frozen plasma. On [2123-5-5], a repeat esophagogastroduodenoscopy showed grade III varices with active bleeding. The patient was then referred for transjugular intrahepatic portosystemic shunt. The patient received 3 more units of packed red blood cells and 2 more units of fresh frozen plasma. Transjugular intrahepatic portosystemic shunt was inserted on [2123-5-5]. The patient remained hemodynamically stable and was transferred to the floor for further monitoring. The patient was in the Medical Intensive Care Unit from [2123-5-5] to [2123-5-6]. PAST MEDICAL HISTORY: 1. Alcoholic cirrhosis, presumed complicated by variceal bleeds. A [2119] admission for variceal bleeding, treated with band ligation. In [2122-3-22] new onset ascites thought secondary to portal hypertension, but no paracentesis for confirmation. The patient was treated with diuretics. In [2122-10-16], esophagogastroduodenoscopy grade II (nonbleeding) varices with 5-mm ulcer, status post injection and sclera therapy. On [2122-11-19] esophagogastroduodenoscopy revealed grade III (nonbleeding) varices and portal hypertensive gastropathy, status post sclera therapy. On [2123-3-5], grade III varices, portal hypertension, gastropathy, 8-mm ulcer status post banding. 2. Hypertension. 3. Hypothyroidism. 4. Vitiligo. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Propanolol 40 mg p.o. b.i.d., Levoxyl 100 mcg p.o. q.d., spironolactone 50 mg p.o. q.d., hydrochlorothiazide 50 mg p.o. q.d., omeprazole 20 mg p.o. b.i.d. MEDICATIONS IN MEDICAL INTENSIVE CARE UNIT: Regular insulin sliding-scale, Levoxyl, spironolactone, hydrochlorothiazide, Octreotide 50-mcg per hour drip, ciprofloxacin 500 mg p.o. q.d., lactulose 30 mg p.o. t.i.d., Serax 50 mg p.o. t.i.d., and CIWA scale, Sucralfate 1 g q.i.d., Protonix 40 mg p.o. q.d., folic acid, thiamine, and multivitamin. FAMILY HISTORY: Family history negative for liver disease. Positive for alcohol abuse. SOCIAL HISTORY: She lives alone and works as a travel [Doctor Last Name 360]. PHYSICAL EXAMINATION ON PRESENTATION: Heart rate of 94 and systolic blood pressure of 120. In general, the patient was edematous, lying in bed, in no apparent distress. Head, eyes, ears, nose, and throat revealed positive icterus. Extraocular movements were intact. Positive periorbital edema. Heart was normal, tachycardic, normal first heart sound and second heart sound. Lungs revealed decreased breath sounds at the bases; otherwise, clear to auscultation. Right subclavian nontender, some blood under dressing. The abdomen was soft and nontender, positive bowel sounds. Positive ascites. Extremities revealed right groin with no hematoma, 1 to 2+ pitting edema. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data revealed hematocrit trended from 33 to 25 to 27.4. Platelets trended from 176 to 40. INR of 2, fibrinogen of 117, FDP of 40 to 80, D-dimer of greater than [2120]. Chem-7 was unremarkable. ALT of 58, AST of 193, total bilirubin of 7, LDH of 463, alkaline phosphatase of 69, lipase of 36, albumin of 2.6. Thyroid-stimulating hormone of 0.75, INS calcium of 1.04. Urine culture was no growth. RADIOLOGY/IMAGING: [5-5] liver ultrasound revealed cirrhotic liver with a large amount of ascites. Hepatic and portal veins were patent. Electrocardiogram from [5-5] showed sinus tachycardia at 112. HOSPITAL COURSE: In summary, this is a 48-year-old-female status post acute variceal bleed due to presumed alcoholic cirrhosis, status post transjugular intrahepatic portosystemic shunt, transferred from the Medical Intensive Care Unit for further monitoring. 1. ALCOHOLIC CIRRHOSIS: (Complicated by variceal bleed, status post transjugular intrahepatic portosystemic shunt). The patient's hematocrit was monitored status post transjugular intrahepatic portosystemic shunt, and ultrasound confirmed patency of the transjugular intrahepatic portosystemic shunt. Octreotide drip was discontinued. Protonix was changed to p.o., and propanolol was discontinued. Hydrochlorothiazide was also discontinued, and spironolactone was continued. The patient was continued on ciprofloxacin as well. Lactulose 30 cc t.i.d. was also continued, and the patient continued her Serax 15 mg p.o. t.i.d. with CIWA scale for ethanol withdrawal. The patient's hematocrit remained stable, and she did not require any further transfusions. 2. HYPOXIA: It was noted that on hospital day three the patient was hypoxic, especially with exertion, with oxygen saturation decreasing to 82%. A chest x-ray was done which showed bilateral effusions, but no overt congestive heart failure. However, the patient was diuresed with 20 mg of p.o. Lasix. The patient responded to diuresis, and oxygen saturations increased. 3. GLUCOSE INTOLERANCE: It was noted that the patient was glucose intolerant during this admission. An insulin sliding-scale was started, and fingersticks q.i.d. 4. CODE STATUS: The patient wished to be full code, but if she is permanently debilitated with irreversible condition, she did not want continued aggressive care. DISCHARGE DISPOSITION: Physical Therapy was consulted and recommended rehabilitation; however, the patient preferred to discharged to home and this was done. DISCHARGE DIAGNOSES: 1. Alcoholic cirrhosis complicated by acute variceal bleed causing hemodynamic instability, status post transjugular intrahepatic portosystemic shunt. 2. Coagulopathy most likely secondary to liver disease. 3. Alcohol withdrawal. 4. Hypoxia most likely secondary to fluid overload, secondary to liver failure. MEDICATIONS ON DISCHARGE: 1. Levoxyl 100 mcg p.o. q.d. 2. Spironolactone 50 mg p.o. q.d. 3. Ciprofloxacin 500 mg p.o. q.d. 4. Lactulose 30 mg p.o. t.i.d. 5. Protonix 40 mg p.o. q.d. 6. Multivitamin. 7. Thiamine. 8. Folate. 9. Sucralfate 1 g q.i.d. DISCHARGE STATUS: To home. DISCHARGE FOLLOWUP: Follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 28247] on [5-14]. [Doctor Last Name ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD [MD Number(1) 5708] Dictated By:[Last Name (NamePattern1) 218] MEDQUIST36 D: [2123-5-23] 18:26 T: [2123-5-25] 07:56 JOB#: [Job Number 28248]	[ "572.3", "401.9", "571.2", "244.9", "789.5", "456.20", "291.81" ]	icd9cm	[ [ [] ] ]	[ "39.1", "42.33" ]	icd9pcs	[ [ [] ] ]	6108, 6244						2846, 2918	6265, 6580				6606, 6867	2326, 2829	4368, 6084																														134, 148			6888, 7285						177, 1488																1510, 2299	2935, 4350
3,506	170,410	84+93+55183	Discharge summary	report+report+addendum	Admission Date: [2195-6-29] [Year (4 digits) ] Date: [2195-7-2] Date of Birth: [2120-5-13] Sex: F Service: ADMISSION DIAGNOSES: 1) Anoxic brain injury. 2) End-stage renal disease on hemodialysis. 3) Sternal wound. 4) Diabetes. 5) Respiratory distress. HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old female, status post a long hospitalization at [Hospital1 18] culminating in CABG x 4, porcine AVR, aspiration, infection, sternal wound infection, saphenous vein site infection, status post a G-tube with abdominal wall necrosis, status post J-tube, ARF requiring hemodialysis. The patient eventually discharged on [2195-5-28]. Then readmitted on [2195-6-6] for fever to 103. In VICU for sternal wound infection and transferred to [Hospital ] Rehab. At [Hospital1 ], two days prior to admission per report, the patient had a PEA arrest, status post epinephrine. The patient went into V-fib arrest, status post 100 mg joule shock which converted into A-fib. The patient was transferred to [Hospital 8] Hospital late PM on [2195-6-28]. The patient there was continued on vent. Chest x-ray and CT showed a bilateral lower lobe consolidation and left upper lobe consolidation. The [Year (4 digits) ] report from [Hospital 8] Hospital attributed mucous plugging and vent associated pneumonia leading to PEA arrest. Also contributing were elements of hyperkalemia, hypoxia and hypovolemia. The patient had initially had episodes of SVT in the 70s-90s which responded to 250 of normal saline. The patient remained in atrial fibrillation and spontaneously converted to sinus. She was transferred to [Hospital1 18] for continuity of care. PAST MEDICAL HISTORY: 1) Coronary artery disease, status post CABG x 4 - LIMA to LAD, SVG to diagonal, SVG to OM sequential, 2) AVR, porcine, 3) End-stage renal disease on hemodialysis, 4) Diabetes, 5) OSA, 6) OA, 7) Vertigo, 8) Skin cancer, 9) History of abdominal hernia repair, 10) Uterine cancer, status post TAH, 11) Obesity, 12) Hypertension, 13) Status post esophageal dilatation, 14) Status post gastric bypass with ventral hernia, 15) High cholesterol. MEDS ON TRANSFER: 1) prevacid, 2) Reglan, 3) Zofran, 4) iron, 5) zinc sulfate, 6) amiodarone, 7) Vitamin C, 8) tobramycin, 9) vancomycin, 10) heparin, 11) ..................., 12) epogen. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a rehab patient at [Hospital1 ]. She has three sons. FAMILY HISTORY: Mother and grandmother died of diabetes. EXAM: Temperature 101, heart rate 85, blood pressure 103/42, respiratory rate 44, 98% on vent, IFMV 600x14, FIO2 0.5, pressure support 10, PEEP 5. General - an elderly woman, chronically ill, in no acute distress. HEENT - pupils equally round and reactive to light minimally. OP - mucous membranes moist, evidence of some EOMI. In general, patient not responsive. Neck - trach, no JVD. Lungs - crackles at the left lower zone. Cardiovascular - regular rate and rhythm, systolic murmur, I/VI ejection murmur. Abdomen - positive bowel sounds, nontender, nondistended. Evidence of sternal wound draining, suctioned with VAC. Evidence of a J-tube entrance of a ventral hernia wound and evidence of a wound under the left breast. Extremities - left heel eschar. Right leg saphenous vein site erythematous. Neuro - patient grimaces to sternal rub, does not follow commands. She has positive Snell, positive grasp. No decreased deep tendon reflexes in lower extremities. Babinski equivocal. LABS FROM [6-29] FROM [Hospital1 ]: White blood cell count 12, hematocrit 35.9, platelets 209, N 87, L 8, M 3, E 1. Electrolytes - 128/5.7, 102/20, 47/3.5, 243. CT of the head showed no bleed. CT of the chest showed left upper lobe infiltrate, bilateral pleural effusions and bilateral consolidation. ABG - 7.26, 45, 91, INR 1, T4 5.4, ALT 11, AST 21, alk phos 165, total bili 0.7. LABS AT [Hospital1 18] [6-29]: White blood cell count 8.5, hematocrit 31.9, platelets 193, N 86, L 8, M 5. Electrolytes - sodium 144, K 3.3, chloride 107, bicarb 27, BUN 27, creatinine 2.5, platelets 150, lactate 1.4, ..................... ABG - 7.42, 45, 109 on FIO2 of 50%. Tobra level and vanc level pending. HOSPITAL COURSE: Please see previous [Hospital1 18] hospitalization summaries. Outside hospital [Hospital1 8] report head CT - chronic degenerative changes. On [6-29] chest CT report - no PE, bilateral lower lobe consolidation, effusions, left upper lobe consolidation. Echo from [6-8] - LVEF of greater than 55%, RV function reduced, mild MR. ASSESSMENT AND PLAN: The patient was a 75-year-old woman with coronary artery disease, CABG, end-stage renal disease, diabetes, status post a PEA arrest, V-fib, A-fib, now in sinus, likely secondary to hypoxia, hyperkalemia. 1) CARDIAC - Status post arrest. Patient with history of arrest. The patient was ruled out by enzymes. The arrest was likely a combination of hypoxia and mucous plugging, as well as metabolic with possible hyperkalemia and hypercalcemia. The patient has a history of a normal echo. The patient's rhythm was in sinus. The patient was continued on 200 mg po qd. The patient placed on telemetry and monitored in the MICU. Monitored electrolytes and in's and out's. The patient remained stable throughout her hospitalization. The patient's sternal wound placed to VAC. 2) PULMONARY: Patient with a history of being vent and trach dependent. Patient treated with vanc, tobra, ceftaz and Flagyl, given history of vent-associated, given history of antibiotic resistant organisms. Sputum showed gram-negative rods. We will await final sensitivities from sputum. The patient's O2 sats remained stable throughout her hospitalization. 3) RENAL: Patient with end-stage renal disease on hemodialysis. The patient obtained hemodialysis in-house. 4) ENDOCRINE: Patient with diabetes on sliding scale. The patient was maintained on sliding scale. Thyroid level was checked and normal. 5) ID: Patient had one episode of being febrile on [6-30]. The patient since then afebrile. The patient's blood, urine, sputum cultures pending. Patient with several wounds, nonhealing in nature. The patient had no evidence of active pus or drainage from any of the sites. The patient's sternal wound is set to the VAC. 6) NEURO: Patient evaluated by neuro in-house given change in mental status, status post PEA arrest. The patient's initial diagnosis was most likely hypoxic damage resulting from hypoxic event. The patient's head CT showed no changes. MRI was obtained. EEG was obtained. 7) HEME: Patient on Epogen and hemodialysis. 8) FEN: The patient's electrolytes were monitored in-house. Peripheral - Patient maintained on subcu heparin, Protonix. Lines - patient with left Quinton, right subclavian peripherals. 9) CODE: Patient remained full. PLAN: [Month/Year (2) ] was discussed with family and PCP. [Name10 (NameIs) ] to rehab. Patient was also seen by a social worker in-house. Patient discharged to rehab. [Name10 (NameIs) 894] CONDITION: Poor. [Name10 (NameIs) 894] DIAGNOSES: 1) Anoxic brain injury. 2) End-stage renal disease on hemodialysis. 3) Diabetes. 4) Status post pulseless electrical activity. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Last Name (NamePattern1) 201] MEDQUIST36 D: [2195-7-1] 12:17 T: [2195-7-1] 11:52 JOB#: [Job Number 969] Admission Date: [2195-6-29] Discharge Date: [2195-7-6] Date of Birth: [2120-5-13] Sex: F Service: ADDENDUM: 1. Neurological: The patient had an MRI and EEG to evaluate neurologic status, status post anoxic brain injury. The EEG showed diffuse encephalopathy and the MRI showed no severe edema. The patient's neurologic status improved during her hospital course. The patient spontaneously opened her eyes, was able to slightly move her extremities and interact with the family. 2. Renal: The patient continued on hemodialysis throughout her hospitalization course. 3. Fever/infectious disease: The patient has a history of recurrent line and wound infections. The patient's sputum grew Serratia and Pseudomonas sensitive to meropenem and tobramycin respectively. 4. GI: The patient has a J-tube and she was continued on tube feeds throughout her hospitalization. 5. Hematology: The patient's hematocrit remained stable. 6. Access: A PICC line was placed. Her arterial line and central line were removed. The retains her Quinton. 7. Wound: The patient was monitored by plastic surgery. Her wound dressing was changed in house on [2195-7-4]. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Last Name (NamePattern1) 201] MEDQUIST36 D: [2195-7-6] 08:46 T: [2195-7-6] 09:07 JOB#: [Job Number 1086] Name: [Known lastname 68], [Known firstname 69] C. Unit No: [Numeric Identifier 70] Admission Date: [2195-6-29] Discharge Date: [2195-7-7] Date of Birth: [2120-5-13] Sex: F Service: The following is a list of discharge medications: 1. Amiodarone 200 mg po q day. 2. Zinc sulfate 220 mg po q day. 3. Ascorbic acid 500 mg po q day. 4. NPH insulin 4 units subQ q am and 4 units subQ q pm. 5. Regular insulin-sliding scale. 6. Epoetin 5,000 units IV q hemodialysis. 7. Acetaminophen 325-650 mg po q4-6h prn fever or pain. 8. Aspirin 325 mg po q day. 9. Heparin 5,000 units subQ q8h. 10. Lansoprazole 30 mg po q day. 11. Calcium carbonate 1500 mg po tid. 12. Meropenem 500 mg IV q24h x17 days to end on [2195-7-24]. 13. Tobramycin 80 mg IV qod after dialysis continuously. 14. Docusate sodium 100 mg po bid. 15. Bisacodyl 10 mg po q day prn constipation. 16. Vancomycin 1 gram IV whenever a trough level is below 16. FOLLOWUP: The patient is to followup with her primary care physician within one month. She is also to followup with her Cardiothoracic Surgery, Dr. [Last Name (STitle) 71] for followup of her sternal wound. DR [Last Name (STitle) 72] [Doctor First Name 73] 12.761 Dictated By:[Name8 (MD) 74] MEDQUIST36 D: [2195-7-7] 11:43 T: [2195-7-7] 12:02 JOB#: [Job Number 75]	[ "599.7", "998.31", "348.1", "518.84", "707.0", "482.1", "482.83", "998.59", "403.91" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.6", "96.05", "96.72", "39.95" ]	icd9pcs	[ [ [] ] ]							2534, 4297		9317, 10428					4315, 9294																		165, 294																					323, 1735																1758, 2199	2444, 2517		2218, 2427
44,787	138,964	9266	Discharge summary	report	Admission Date: [2122-4-12] Discharge Date: [2122-5-6] Date of Birth: [2044-4-18] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2569] Chief Complaint: MS change Major Surgical or Invasive Procedure: none History of Present Illness: 77 yo Cantonese-only speaking PMHx HTN, DM2, stroke in [2101] with residual deficits and another recent stroke early [2122-4-4], treated at [Hospital 3278] Medical Center started on ASA/Plavix was discharged from [Hospital1 3278] to rehab [2122-4-9] where nursing noted that he's had a fluctuating mental status. Per medical records, he had a fall the day before yesterday and another fall out of bed last night at 1:30 am. In this context, RN notes that this morning pt was "sluggish" but was able to get OOB with assist and eat breakfast. After this, he appeared fatigued and pt was brought back to bed for a nap. RN concerned that pt was becoming less responsive and so called EMS. On EMS arrival, pt was felt to be unresponsive to verbal or tactile stim. . In the ED, initial VS:T-100.6 F BP- 128/56 HR- 77 RR- 21 O2Sat 100%RA. Code stroke called upon arrival to ED. Had recent d/c from [Hospital1 3278] with stroke recently (last week). Became unresposive at 1300 today. Awakens to pain, little else. When neuro evaluated pt was actually opening eyes to voice and moving all 4 ext against gravity. FS WNL. On Plvix. ?hemorrahgic transformation. Could not clinically clear spine. 2L IVF. Cspine film wnl. T 128/53 95 24 96% on RA. . On floor, history could not be obtained but nurse spoke with son who said his mental status was improving. . ROS: could not be obtained. Past Medical History: multiple strokes: 1)old remote left frontal stroke in [2101] that per NH notes purportedly left him with R-hemi and dysarthria (per son, able to think of words he wants to say and makes grammatically intact sentences, but is often unintelligible) 2)[4-13](MRI [2122-4-6] showing acute infarcts in the R medial temporal lobe, R basal ganglia, and high signal in the petrous portion of the R-ICA thought to be 2/2stenosis/occlusion started on asa/plavix, thought to be too sig a fall risk for anticoagulation DM2 (last HgbA1C [2-11] was 6.6) CRI (baseline Cre ~1.6) HTN gout GERD Social History: Prior to recent stroke, lived at home with wife now at rehab. Remote history of alcohol and smoking cigarettes (quit 1 year ago.) Family History: NC Physical Exam: Vitals - T:98.5 BP:168/80 HR:100 RR:20 02 sat: 98% on RA GENERAL: Chronically ill appearing man responsive to name and pain although difficult to arouse. Breathing non labored, protecting airway. HEENT: Normocephalic, atraumatic. Some purulence in right eye. No scleral icterus. PERRLA/EOMI. dryMM. OP clear. Neck not assess bc of C-collar. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or gallops. JVP= unable to assess LUNGS: CTAB, no wheezes, rales, rhonchi, poor effort ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: Unable to assess orientation. CN 2-12 grossly intact. Withdraws to pain and moves all 4 extremites against gravity. Gait assessment deferred PSYCH: unable to assess Pertinent Results: Admission labs: [2122-4-12] 03:05PM BLOOD WBC-15.1* RBC-4.98 Hgb-15.7 Hct-47.6 MCV-96 MCH-31.4 MCHC-32.9 RDW-13.4 Plt Ct-191 (Highest WBC 18.4 on [4-13]) [2122-4-13] 06:30AM BLOOD Neuts-92.0* Lymphs-3.2* Monos-4.1 Eos-0.2 Baso-0.4 [2122-4-12] 03:05PM BLOOD PT-13.8* PTT-31.4 INR(PT)-1.2* [2122-4-12] 03:05PM BLOOD Fibrino-621* [2122-4-12] 03:05PM BLOOD Glucose-191* UreaN-25* Creat-1.7* Na-137 K-6.1* Cl-101 HCO3-19* AnGap-23* [2122-4-12] 03:05PM BLOOD ALT-14 AST-41* AlkPhos-92 TotBili-1.1 [2122-4-12] 09:05PM BLOOD CK-MB-1 cTropnT-<0.01 [2122-4-13] 06:30AM BLOOD CK-MB-<1 cTropnT-<0.01 [2122-4-13] 04:15PM BLOOD CK-MB-1 cTropnT-<0.01 [2122-4-12] 03:05PM BLOOD Calcium-8.8 Phos-4.3 Mg-2.2 [2122-4-12] 09:05PM BLOOD VitB12-254 [2122-4-12] 09:05PM BLOOD Triglyc-116 HDL-27 CHOL/HD-4.7 LDLcalc-78 [2122-4-12] 03:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-15.2 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2122-4-12] 09:11PM BLOOD Type-[Last Name (un) ] pO2-63* pCO2-36 pH-7.43 calTCO2-25 Base XS-0 Intubat-NOT INTUBA [2122-4-12] 03:09PM BLOOD Lactate-2.1* Albumin: 3.0 [2122-4-13] 10:03 pm STOOL CONSISTENCY: FORMED FINAL REPORT [2122-4-14] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2122-4-14]): REPORTED BY PHONE TO [Initials (NamePattern4) ] [Last Name (NamePattern4) 31774], R.N. ON [2122-4-14] AT 0510. 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). RPR [4-12] negative [2122-4-12] 4:00 pm URINE Site: CATHETER FINAL REPORT [2122-4-14] URINE CULTURE (Final [2122-4-14]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Blood culture [4-13] NGTD [4-12] NON-CONTRAST HEAD CT: There is no intracranial hemorrhage. A large area of encephalomalacia in the left frontal lobe is noted and appears chronic. There is no CT evidence for acute transcortical infarction. Additional scattered white matter hypodensities are noted, likely the sequelae of chronic small vessel ischemia. There are more focal lacunar infarcts in the left and right basal ganglia. Ventricles and sulci are prominent, compatible with age-related parenchymal atrophy. There is no shift of midline structures. There is no hemorrhage or parenchymal edema. There are no abnormal extra-axial fluid collections. The basal cisterns are preserved. There are no fractures. Visualized paranasal sinuses and mastoid air cells are normally pneumatized and clear with the exception of minimal mucosal thickening in the ethemoid air cells. The extracranial soft tissues, including the globes and orbits, are unremarkable. IMPRESSION: No acute intracranial pathology, including no evidence for hemorrhage. Large area of left frontal encephalomalacia likely reflects a prior infarct. Additional white matter hypodensity, which likely reflects sequelae of chronic small vessel infarcts, with more focal lacunes identified in the bilateral basal ganglia. [4-12] FINDINGS: There is no fracture or traumatic malalignment involving the cervical spine. The atlanto-axial, atlanto-occipital articulations are maintained. There is no significant prevertebral soft tissue swelling. Vertebral bodies are normal in height. There are moderate degenerative changes identified in the lower cervical spine, worse from C4 through C7, where there is loss of intervertebral disc height, and marginal osteophyte formation, resulting in moderate canal stenosis. There is also moderate neural foraminal narrowing secondary to uncovertebral osteophyte formation and facet hypertrophy. Nuchal ligament calcification is noted. A nasal trumpet is noted in the left naris, terminating above the epiglottis. There are carotid calcifications. There is no lymphadenopathy or soft tissue mass in the neck. The right thyroid lobe demonstrates small hypodense nodules, which could be further evaluated with ultrasound as clinically indicated. Visualized lung apices demonstrate no acute pathology. There is a small bleb medially at the left apex. IMPRESSION: 1. No definite fracture or traumatic malalignment involving the cervical spine. Degenerative changes from C4 through C7 are noted, with associated moderate canal stenosis. If there is concern for cord injury, MRI could be considered for further evaluation, if not contraindication. 2. Tiny hypodense nodule in the right lobe of the thyroid may be further evaluated with ultrasound on a non-emergent basis if indicated. 3. Carotid calcifications. [4-13] ekg Compared to the previous tracing normal sinus rhythm has given way to sinus tachycardia, rate 111. Otherwise, there is no significant change. Q waves present from prior [4-13] eeg: prelim no epileptiform wave [4-12] CXR FINDINGS: Single semi-upright portable AP view of the chest was obtained. The lungs are clear without focal consolidation. No large pleural effusion or pneumothorax is seen. The aorta is calcified and tortuous. The cardiac silhouette is top normal in size. Right lower paratracheal opacity most likely corresponds to vasculature. IMPRESSION: No acute intrathoracic abnormality. Endoscopy [2122-4-19]: There is blood clot attached at the GE junction with no activate bleeding. Erosions in the stomach body Erosion in the second part of the duodenum There was no coffee-ground liquid or fresh blood in the stomach. Otherwise normal EGD to third part of the duodenum CTA [2122-4-29]: There is satisfactory contrast opacification of the pulmonary artery to subsegmental level with no pulmonary embolism or acute aortic pathology. The caliber of the aorta, pulmonary artery, and heart size is normal with trace pericardial effusion most likely physiological. The central airways are widely patent to subsegmental level. No pathologically enlarged mediastinal or axillary lymph nodes by CT size criteria. Marked mediastinal lipomatosis could be due to concurrent steroid therapy. Mixed atherosclerotic plaque is in the aortic arch and extends to the origin of the left subclavian artery. Calcification is mild in the coronary arteries and aortic valve. Allowing for the expiratory phase of imaging, the lungs are clear. Pleural surfaces are smooth, no pleural effusion. This examination was not designed for subdiaphragmatic evaluation except to note an NG tube, which passes into the duodenum. A PICC line tip is in the SVC. IMPRESSION: No pulmonary embolism or acute aortic pathology. MR [2122-5-3]: There is extensive left frontal post-ischemic encephalomalacia with moderate global volume loss. There are linear regions of abnormal decreased diffusion within the centrum semiovale and corona radiata. There is no evidence for recent or prior intracranial hemorrhage. Abnormal flow void is present within the intracranial right internal carotid artery, compatible with its known occlusion. Extensive small vessel changes are present within the pons. IMPRESSION: 1. Acute/subacute right hemispheric infarct in a pattern suggestive of watershed infarct likely related to the occlusion of the right ICA. 2. Chronic extensive left frontal post-ischemic encephalomalacia. Brief Hospital Course: 77 yo Cantonese-only speaking PMHx HTN, DM2, CVA in [2101] with residual deficits and CVA early [2122-4-4], treated at [Hospital 3278] Medical Center admitted with fluctuating mental status. . Patient was initially admitted to the medicine service, course below: # AMS: Patient improved somewhat during admission however not back to recent baseline where he was eating and walking independently with walker at rehab. Given recent fluctuating mental status concerning for delirium. Neuro felt exam nonfocal and presentation c/w delirum given UTI and metabolic derangements which seems reasonable especially insetting of UTI and fever. He had a negative head CT for CVA. Patient was r/o for an MI and had unchanged Qwaves in his EKG in right heart distribution. TSH, RPR, B12 within nl and CXR without pna. Most likely MS changes from below infections. Patient was treated for cdiff and UTI as below. . # inability to eat: Patient continued to keep food in his cheeks, swallowing at his own pace, and was unable to follow directions of speech and swallow eval. He had many oral secretions, concerning that he was at high risk of aspiration. Intially family wanted to try food despite this risk, however he failed swallow study multiple times. NGT was placed for TFs and meds on [4-16] with hope that with nutrition delerium might also improve. . # Klebsiella UTI: pansensitive. Patient had foley on morning after admission which was d/c'd. Finised 7 day course of treatment for UTI with Ceftriaxone on [4-18]. . # cdiff: most likely contributor (over UTI) of leukocytosis and MS change -Now on Vancomycin PO. Consider treating for 10 day course after treatment for UTI finishes ([4-28]). . # hypernatremia: improved with free water. . # HTN: uncontrolled on oral meds during admission. Metoprolol was increased and amlodipine was added. . # s/p recent stroke: Per records occured at Tuffs [2122-4-6]. Now on secondary prevention and in rehab. Continued asa/plavix and added statin. . # DM2: appears diet control. Was on ISS. . # CKD: Cr improved at baseline(1.3) after IVF, likely prerenal. . # Gout: on colchicine with CKD, was held. . *COURSE IN NEURO ICU* #NEURO: On [4-21], the medical team examined him at 7am and did not observe a decrease in his baseline speech (does not speak more than a word or phrase at baseline). They did not observe new left arm weakness although they had difficult testing him as he was not following commands at the time. At 10:15am, team observed that patient was not speaking. He was not following any commands. Patient was not moving his left arm. The neurology stroke consult was recalled and evaluated the patient. It was noted that he was moving his left side but his eyes were deviated to the right and he had profound neglect of the left side of his body. He had a CTA and a CTP of the head and neck and there was determined to be ischemia of the right hemisphere, although not frank infarction. He was noted also to have an occulsion of the R ICA in the petrous portion. CT perfusion showed that there was increased mean transit time (indicating decreased flow) in the right ACA and MCA indicating ischemia. Cerebral blood volume was not decreased suggesting that there was not completed infarct in this region. CTA neck and brain showed that the right ICA was occluded from the proximal right ICA to the supraclinoid area. It was not clear when this occlusion had occurred - if it was that day or in prior days. It was discussed with Dr. [Last Name (STitle) ] of Neurointerventional Radiology regarding whether to attempt opening the right ICA with MERCI device and stenting. However, it was felt that the risks outweighed the benefits. Attempting to open the right ICA could result in emboli to the right ACA and MCA which could worsen his situation because his right ACA and MCA vessels were open. The family was informed that the procedure was not offered due to the high risk. The patient was started on an heparin drip, and his antihypertensive medications were held. He was started on fluids and transferred to the ICU for monitoring. He was noted to have guaic positive stools at the time but it was felt that this risks of stroke from stump emboli outweighed the risk of the possible GI bleed. In the unit the patient's exam improved, and he was attending to both sides, and intermittently following commands. On [2122-4-22] he was noted to have dark tarry stools and some suction from his NGT was frankly bloody. This was accompanied by a drop in HCT. His vitals remained stable througout this course. The heparin drip was stopped, and he was evaluated by GI consult. He was scoped on [4-23] and was noted to have an ulcer in the GE junction and a duodenal ulcer. The GE junction ulcer was noted to have a blood clot indicating a recent bleed. He was also noted to have multiple erosions that GI thought were due to NSAID use. They recommended sulcrafate and not to give anti-coagulation. They also recommended not resuming aspirin but plavix would be acceptable in 48-72 hours. The patient Hct remained stable and he was transferred out of the unit on [2122-4-24]. *NEUROLOGY FLOOR* ##NEURO: Given the need for the ACA and MCA territories to maintain flow from collateral vessels, the patient's blood pressure was allowed to autoregulate up to 180 systolic. The patient was started on plavix on [4-27] for stroke prevention, and aspirin and coumadin were held per the GI consult team recommendations. The patient's exam remained notable for inattention to the left, minimal volitional use of his left upper extremity, and minimal response to commands, following commands intermittently but only ever simple commands such as open your mouth or wiggle your fingers. He also remained mute and unable to manipulate his tongue for swallowing. Given the lack of improvement in these areas despite no clear infarction on his CT perfusion studies, on [4-29] he underwent a brain MRI to ascertain if there had been any further infarcts. Indeed, there were areas of subacute/acute watershed infarction in the right hemisphere. The likely explanation for worsened speech and oral manipulation was thought to be due to a combination of remapping of language after his first left hemispheric stroke and bilateral loss of deeper hemispheric tissue which controls swallowing. Given his multiple infarcts, it was discussed with the family that the patient was unlikely to be able to improve greatly due to progressive infarctions. After multiple family meetings discussing goals of care with the palliative care team facilitating, the family felt that it was appropriate to place a PEG tube. They understood that he might never be able to walk, talk, or live outside of a nursing facility, and they will continue to revisit the goals of care as they assess his improvement. ##GI Bleed: The patient's hematocrit was followed closely while he was on the floor and remained stable in the 28-30 range. Given this stability, frequency was decreased to daily checks on [5-1]. The patient's sucralfate was noted to be clogging his NG tube, thus the medication was discontinued after discussion with GI consult on [4-27]. GI felt that despite his ulcer it was safe to proceed with PEG placement, and they have been consulted regarding this placement. The PEG was placed on [2122-5-5] and tube feeds were started the next day. His H/H has remained stable with Hct of 30 the last few days. ##UTI: The patient completed his antibiotic course for UTI that had been started on the medicine service on [4-28]. A repeat UA was sent on [5-1] just to assess off of antibiotics given that the patient seemed slightly less interactive and was normal. ##C dif: The patient was briefly NPO after the NG tube became clogged, and during that time he was given flagyl IV as there was no evidence seen that he had initially failed flagyl, however once the NG was replaced he was started back on oral vancomycin to be completed on [5-9] (10 days after completing UTI therapy). ##DEPRESSION: The patient's affect seemed to become flatter and he appeared less interactive from [Date range (1) 31775]. This was may have related to his new strokes, however, he was started on a trial of celexa on [5-1] given that the decision had been made to continue aggressive therapy. ##GU: the patient had a foley removed. His input and output should be watched and if urine output drops a bladder scan should be performed and consider a straight catheterization # PPX: d/c'd H2 blocker given delerium, heparin SQ, bowel regimen # CODE: full code # CONTACT: [Name (NI) ]: [Name (NI) ] ([Name (NI) 12239], HCP) [Name (NI) ]: [Telephone/Fax (1) 31776] (cell: [Telephone/Fax (1) 31777]), PMD: [First Name8 (NamePattern2) 429] [Known lastname ]: [Telephone/Fax (1) 16171] Wife: [Name (NI) ]: [Telephone/Fax (1) 31778] [Location (un) ] Health direct line 1051 2581 [Location (un) 453] Medications on Admission: (from rehab list): ASA 81 mg Qday Plavix 75 mg Qday Metoprolol 50 mg [Hospital1 ] Lisinopril 20 mg Qday Iron 325 mg [Hospital1 ] Lasix 40 mg Qday Colchicine 0.06 mg Qday Ranitidine 150 mg Qday Flomax 0.4 mg Qday Senna PRN Fleet prn constipation Dulcolax 10mg suppository PRN MOM PRN Tylenol PRN . ALLERGIES: PCN, beta-lactams, CCB's Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 4. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 5. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: Five (5) mL Injection TID (3 times a day). 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 10. insulin sliding scale QAC and HS, start 2U Humalog at FS of 150, increase by 2U every 50 of glucose until 400. 11. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): stop on [2122-5-9]. 12. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day) as needed for dry eyes. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 15. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Location (un) ] Discharge Diagnosis: Primary: - stroke new right watershed infarcts - GI bleed (GE junction ulcer and duodenal ulcer) Discharge Condition: Alert, aphasic (though said son's name once during admission), occasionally follows midline and appendicular commands, with a translator but not consistently. CN: EOMI, pupils equal and reactive, NL flattening on R, does not activate face much on either sides. Motor: moves right UE and RLE full, left occasional antigravity but does not consistently move, very often allows arm to drop, will withdraw slightly to noxious stimulation, neglects limb, both legs antigraity but not consistently, withdraws to pain [Last Name (un) ]: withdraws at all 4 ext Not ambulating Discharge Instructions: You were initially admitted to [Hospital1 1170] because of change in mental status and less interaction. While you were here we found that you had a urine and stool infection which were likely causing these symptoms. However while you were hospitalized you had an acute worsening of your previous stroke symptoms. The imaging was concerning for a decreased perfusion of your right brain. You were noted to have an occluded right carotid but it was deemed that the risks outweighed the benefits for any intervention. You were started on a heparin drip however you had a gastrointenstinal bleed. You had an endoscopy which noted 2 ulcers and multiple erosions. Given your multiple medical problems and multiple strokes your prognosis was not good. On [2122-5-5] you had a PEG placed and you were discharged to a skilled nursing facility the following day. Please take all medications as prescribed. Please make all follow up appointments. If you have any worsening of your symptoms please contact your doctor or return to the nearest ED. Followup Instructions: You should make an appointment to see your PCP [Name9 (PRE) ],[Name9 (PRE) ] [Telephone/Fax (1) 8236] on discharge from rehab. Neuro: [First Name8 (NamePattern2) 2530] [Doctor Last Name ] Friday [6-12] at 10:30am in the [Hospital Ward Name 23] building [Location (un) ] in the [Hospital Ward Name ] of [Hospital1 1170] [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2575]	[ "532.40", "008.45", "438.21", "787.20", "274.9", "V15.82", "276.0", "041.3", "599.0", "403.90", "250.92", "263.0", "348.31", "276.2", "434.91", "585.9", "E935.9", "531.90", "790.01", "311", "530.81" ]	icd9cm	[ [ [] ] ]	[ "96.6", "43.11", "45.13", "38.93" ]	icd9pcs	[ [ [] ] ]	22405, 22488	11433, 20504	325, 332	22629, 23203	3406, 3406	24305, 24779	2543, 2547		20895, 22382		22509, 22608		20530, 20872			23227, 24282									2562, 3387																			276, 287									360, 1762				6014, 11410	3423, 6004											1784, 2380	2396, 2527
10,569	103,954	2737	Discharge summary	report	Admission Date: [2140-11-11] Discharge Date: [2140-11-16] Date of Birth: [2082-7-4] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 297] Chief Complaint: vomitting Major Surgical or Invasive Procedure: right and left heart catheterization blood transfusion History of Present Illness: Ms. [Known lastname 13537] is a 58 year old Female with DM, CAD, pulm. HTN (minimally responsive to inhaled NO on cath [9-/2136]), presents with a 3 day history of Nausea Vomitting and chest pain, subjective fevers and sore throat. Unable to tolerate liquids. ED course notable for initial BP 88/54, improved with fluids. ECG concerning for changes, started on NTG and heparin gtt, with resultant hypotension. Remained hypotensive, and eventually started on pressors. Mildly elevated TnT of .12. CTA negative for PE. Areas of mild patchy opacity in RML, which may represent atypical inf vs inf changes. ECG: TWI v1-v6 (old), III (new). TWF in I, II, III, F. Past Medical History: pulm HTN (primary vs. rheum condition vs undiagnosed cardiac dz). Seen in [Hospital ] clinic in [2135] ([Doctor Last Name ]). PFTs 11, [2135]: Reduced FVC suggests a restrictive ventilatory defect, however the TLC was within normal limits when measured on [2136-6-13]. FVC 1.78 2.48 72 FEV1 1.38 1.85 75 MMF 0.90 2.61 34 FEV1/FVC 78 75 104 DMII CAD. Cath [9-/2136] severe LM with 50% ostial stension. other Cs without sig lesion. No intervention. PA syst 80, with elevated R-sided pressures (RV 80/15), though nl L-sided, minimal response to inhaled NO. EF 65%. hypothyroid. MIBI in [2136] with no perfusion defects, but dilated RV. ?pan-hypo pit: partially empty sella on MR [2131], though has not required hormone replacement. ?small ASD. TEE in [2135] with no ASD or anomalous venous return. bedside ECHO: nl LV function, TR grad 66, dilated RV, no flow across mobile intraatrial septum. anticardiolipin IgM anemia Social History: lives with husband, has children Family History: noncontributory Physical Exam: Vitals: T 97.3, HR 66 RR BP 118/60, HR 66 PAP 82/25 PCWP 45 (40's to 50's), CO 6.3, CI 3.33 (fick and thermodilution), CVP 13, SVR 863 Gen: pleasant and cooperative HEENT:MMM PERRLA Pulm: CTAB no crackles Cor: RRR no murmurs Abd: soft NT ND Ext: WWP DP 2+ bilaterally Neuro/Psych: A+O x 3 moving all 4 extremities Pertinent Results: [2140-11-11] 11:56PM CK(CPK)-98 [2140-11-11] 11:56PM CK-MB-NotDone cTropnT-0.18* [2140-11-11] 11:56PM PT-15.6* PTT->150* INR(PT)-1.5 [2140-11-11] 07:19PM cTropnT-0.12* [2140-11-11] 07:19PM CK(CPK)-82 [2140-11-11] 01:00PM ALT(SGPT)-13 AST(SGOT)-26 CK(CPK)-85 ALK PHOS-37* AMYLASE-23 [2140-11-11] 01:00PM GLUCOSE-160* UREA N-26* CREAT-1.3* SODIUM-136 POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-25 ANION GAP-18 [2140-11-11] 01:00PM LIPASE-18 [2140-11-11] 01:00PM ACETONE-SMALL [2140-11-11] 01:00PM TSH-0.18* [2140-11-11] 01:00PM WBC-10.4# RBC-4.09* HGB-11.2* HCT-33.4* MCV-82 MCH-27.5 MCHC-33.7 RDW-13.7 ECG: Sinus rhythm, Ventricular premature complex, Right axis deviation, Probable right ventricular hypertrophy, Inferior and precordial ST-T wave abnormalities - may be due to right, ventricular hypertrophy but cannot exclude in part ischemia, Clinical correlation is suggested, Since previous tracing of [2140-11-12], precordial lead ST-T wave abnormalities decreased Intervals Axes Rate PR QRS QT/QTc P QRS T 75 188 100 422/450.57 80 110 -18 Cardiac Cath: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed no flow limiting coronary disease. The LMCA contained a 40% ostial lesion but was otherwise widely patent. The LAD contained a proximal 40% lesion just before the takeoff of a large first diagonal branch. The apical LAD was small in caliber. The LCX contained diffuse plaquing with a 40% lesion after OM2. THe RCA had diffuse mild plaquing with slow washout of contast consistent with the patient's RV pressure elevation. 2. Resting hemodynamics revealed evidence of severe pulmonary hypertension at baseline with mean PA pressure of 41 mm Hg, a PVR of 605, and a cardiac index of 2.2 l/min/m2 (Fick). With 100% oxygen therapy, the mean PA remained approximately the same at 40mmHg, but the PVR dropped to 385 and the cardiac index rose to 2.98 l/min/m2. Little further improvement was seen with Nitric Oxide: the mean PA dropped slightly to 39mmHg, the PVR rose slightly to 415, and the cardiac index fell slightly to 2.8 l/min/m2. In summary, neither oxygen nor nitric oxide significantly dropped the mean PA pressure, but both therapies resulted in a modest increase in CO which drove a fall in PVR compared to baseline. 3. Left ventriculography was not performed. FINAL DIAGNOSIS: 1. No flow limitng coronary artery disease. 2. Mild LV diastolic dysfunction. 3. Severe primary pulmonary hypertension. 4. No change in mean PA pressures with 100% oxygen or Nitric Oxide. Brief Hospital Course: Ms. [Known lastname 13537] is a 58 year old woman with pulmonary hypertension who presented with a likely viral gastroenteritis which quickly resolved. She responded to NO in past on cath [2135]. A swan was attempted on [2140-11-12] and was unsuccessful but one was placed at cardiac cath. She had a right and left heart cath on [2140-11-14] which showed no change from previous. She started sildafenil after catheterization and was observed. It appeared to have an effect of 30% or more improvement on her cardiac output but her pulmonary artery pressures only seemed to decrease transiently. It was decided that she would benefit from the sildafenil and was discharged with a prescription and follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. In the emergency department the patient had been transiently hypotensive in ED secondary to nitroglycerin as the patient is preload dependent. It quickly resolved. In terms of her CAD, Ms. [Known lastname 13537] had 50% LMCA stenosis, otherwise clean Cs. Her aspirin and statin were continued and she was restarted on bblocker. TNT elevation was thought likely secondary to RH strain but not to ACS. Regarding her acute renal failure, the patient's Cr is 0.8 at baseline, and 1.3 on admit. This was thought to be prerenal and resolved with rehydration. Ms. [Known lastname 13537] was anemic with a hct drop 32 to 26 after line placement. There was no evidence of bleed. She received a unit of prbcs and following that her hct remained stable. She was guaiac negative. The patient has a history of hypothyroidism for which levothyroxine was continued. She was discharged in her usual state of health. Medications on Admission: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Levothyroxine Sodium 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 8. Bosentan 62.5 mg Tablet Sig: One (1) Tablet PO twice a day for 4 weeks. Disp:56 Tablet(s) Refills:0 9. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Levothyroxine Sodium 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 8. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 10. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:2 11. Sildenafil Citrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Pulmonary Hypertension CAD Discharge Condition: good Discharge Instructions: Please return to the hospital if you experience worsening chest pain and shortness of breath, fevers, dizzyness, or any other severe symptoms. Please call your doctor if you have any questions about your symptoms. Please start 2 new medications: metoprolol which is good for your heart and sildafenil which is good for your lungs. Followup Instructions: Please follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in one week for your pulmonary hypertension. [Hospital1 18] - Division of Pulmonary and Critical Care, [Location (un) 830], KSB-23 [Location (un) 86], [Numeric Identifier 718], Phone: [Telephone/Fax (1) 612] Provider: [Name10 (NameIs) ],[First Name8 (NamePattern2) ] [Hospital1 7975] INTERNAL MEDICINE Where: OFF CAMPUS [Hospital1 7975] INTERNAL MEDICINE Phone:[Telephone/Fax (1) 3666] Date/Time:[2140-12-7] 2:00	[ "458.29", "414.01", "584.9", "285.9", "008.8", "416.8", "250.00", "276.5", "244.9" ]	icd9cm	[ [ [] ] ]	[ "89.64", "00.12", "37.23", "99.04", "89.68", "88.56", "00.17" ]	icd9pcs	[ [ [] ] ]	9347, 9353	5227, 6941	325, 381	9423, 9429	2607, 4998	9809, 10361	2241, 2258		8073, 9324		9374, 9402		6967, 8050		5015, 5204	9453, 9786									2273, 2588																			276, 287									409, 1083																1105, 2175	2191, 2225
8,501	180,616	10386	Discharge summary	report	Admission Date: [2145-5-18] Discharge Date: [2145-6-1] Date of Birth: [2120-12-21] Sex: F Service: NEUROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 2090] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Plasmapheresis Central line placement PICC line placement History of Present Illness: 24 yo female with PMH asthma, GERD presents with asthma exacerbation. Pt states that she had a URI 3 weeks ago with sx of congestion, sore throat, dry cough, with residual symptoms over the past few weeks. Over the past 3 days, pt has developed increasing SOB and increasing usage of albuterol nebs ~q1.5 hours. Her usually triggers are URIs, environmental triggers such as pollen in the spring, and the winter season. She denies any significant symptoms with exercise or exertion. She believes her current trigger may have been the URI; she also went outdoors 3 days ago. Denies recent sx of productive cough. States a fever of 101 a few weeks ago. Her baseline peak flow is 350. . ROS: CP with coughing. Vomited x 1 yesterday. No abd pain, dysuria. . In the ED her initial vitals were 98, p72, 135/81, rr30, rr99%RA. Initial peak flow was 280. She was given frequent nebs, prednisone 60mg x 1, magnesium 2gm over the course of 9am to midnight. Peak flow improved to 330. In the evening around 10pm, pt c/o feeling tired out and continued to have SOB and was placed on continuous nebs and tx to the unit. CXR with peribronchial cuffing, but no infiltrate. VBG was 7.45/35/38. . On admission to the [Hospital Unit Name 153], vitals were stable with O2 sat 100% on RA and RR 15-20. During the first part of our conversation, pt appearing to be breathing comfortably and able to complete full sentences. Continuous nebs were removed briefly, after which pt began to make erratic bilateral eye movements and c/o double vision. then began to look increasingly SOB with use of accessory muscles. ABG was 7.56/23/98 on RA. Pt was placed back on continuous nebs and RR decreased to 14 and pt appeared more comfortable. A repeat ABG on neb showed 7.47/32/286/24 Past Medical History: Asthma -2 ED visits/hospitalizations in [2144], last [11/2144] -never been intubated GERD Social History: Single mom of 3.5yo son. [Name (NI) ] BF. Smokes 2pk/wk for past 10 years; quit 5 months ago. Works as medical assistant. Drinks 2-3 times a month. Denies drugs. Family History: First cousins with asthma. Physical Exam: VS: t95.3, p74, 144/88, rr20, 100%RA Gen: see HPI above HEENT: PERRL, clear OP CVS: RRR, nl s1 s2, no m/g/r Lungs: diffuse expiratory wheezing Abd: soft, NT, ND, +BS Ext: no edema Neuro: difficulty with eye movements. [5-29] bilateral upper extremity strength. Repeat exam revealed improved ability to follow finger with eyes, CN o/w intact, 4+ bilateral LE strength. Pertinent Results: [2145-5-18] 09:40AM WBC-5.6 RBC-4.86 HGB-14.7 HCT-42.5 MCV-88 MCH-30.3 MCHC-34.6 RDW-13.5 [2145-5-18] 09:40AM NEUTS-56.4 LYMPHS-31.8 MONOS-4.0 EOS-5.5* BASOS-2.4* [2145-5-18] 11:01PM freeCa-1.16 [2145-5-18] 11:01PM TYPE-ART PO2-38* PCO2-35 PH-7.45 TOTAL CO2-25 BASE XS-0 COMMENTS-IONIZED CA . CXR: No focal infiltrates are identified. There is mild peribronchial cuffing noted bilaterally (left greater than right). No evidence of pneumothorax, pulmonary edema, or pleural effusions. Cardiomediastinal silhouette and hilar contours are unremarkable. IMPRESSION: Mild bilateral peribronchial cuffing may suggest underlying bronchitis with no focal infiltrates or pneumothorax identified. . EMG ([2145-5-20]): Motor nerve conduction studies (NCSs) of the right median and left tibial nerves were normal, including F responses. Sensory NCSs of the right median and left sural nerves were normal. Slow (3-Hz) repetitive nerve stimulation of the right facial nerve produced an abnormal decrement of 11.5% which was not reproduced on further testing of the right facial nerve. Exercise testing was not possible due to the patient's mental status. Concentric needle electromyography (EMG) of right deltoid, biceps, and tibialis posterior was normal. EMG of right vastus lateralis showed normal insertional activity and no motor unit activity due to the patient's sedation. Single-fiber EMG was not possible secondary to the patient's mental status. IMPRESSION: Nondiagnostic study. Based on the studies performed, a disorder of neuromuscular transmission (as in myasthenia [Last Name (un) 2902] or botulism) or a demyelinating polyneuropathy cannot be definitively excluded. . CT chest/abd/pelvis ([2145-5-24]): 1. Multifocal pulmonary opacities concerning for right upper lobe and left lower lobe pneumonia or aspiration. The more mass-like 2.1 cm airspace opacity in the left lower lobe has an atypical appearance for infection and dedicated imaging following treatment to exclude underlying mass is recommended. 2. No acute intra-abdominal process to explain the patient's pain. The appendix is not visualized, however there are no inflammatory changes in the right lower quadrant. 3. Incidentally noted malrotation of the small bowel. 4. Residual thymic tissue with no evidence of a thymoma. . Brief Hospital Course: The patient was admitted with apparent complaints of an asthma exacerbation, incluidng shortness of breath and decreased peak flow. The patient was started on nebulizers and oral steroids with some improvement in peak flow. The patient had persistent shortness of breath with complaints of fatigue including clinical signs of respiratory distress, including use of accessory muscles. On ABG she was found to have hypoxemia. The patient had no signs of an acute infiltrate on chest x-ray. The ICU team noted that the patient had diplopia, extraocular muscle paresis in addition to the respiratory weakness and called a neurology consult. She was clinically diagnosed with myasthenia [Last Name (un) 2902] on the day after admission. Two days after admission, the patient developed myasthenic crisis with respiratory failure requiring intubation and plasmapheresis. The patient had a nondiagnositc EMG revealing a disorder of neuromuscular transmission (differential of myasthenia vs. botulinum) or a demyelinating polyneuropathy. AchR Ab and modulating Ab were negative. Botulinum toxin was negative. The patient underwent plasmapheresis every other day x10 days (5 total treatments) with good response. The patient was successfully extubated on [2145-5-28]. She was started on pyridostigmine 60mg q8h and called out to the general neurology service. . The patient's ICU course was complicated by a ventilator associated pneumonia with growth of MSSA and H. Flu beta lactamase positive in the sputum. The patient will complete a 14 day total course of MSSA coverage. She was started on vanco (day 1: [2145-5-26]) though she was then switched to a 14 day course with bactrim once sensitivities returned, given her history of allergy to penicillin. The patient's MSSA coverage will complete on [2145-6-8]. The patient will complete a 10 day total course of azithromycin for the H. Flu (day 1: [2145-5-26], to be completed on [2145-6-4]). The patient will complete a longer than usual course of both antibiotics given recent plasmapheresis and possible complication of underdosing due to drug removal with pheresis. . She was also found to have an lung nodule discovered incidentally on CT scan. Patient needs to have f/u CT scan in 6 months to follow R lung nodule. . The patient remained stable on the floor, although her neurological exam still showed evidence of mild residual fatiguability. Thymectomy was discussed with the patient at length, as was the seriousness of her medical condition. She was started of Prednisone 20 mg PO QOD and Mycophenolate Mofetil 500 mg PO BID, in addition to the pyridostigmine 60mg q8h. She was discharged in stable condition, on these medications,along with her usual home meds (advair, ranitidine, albuterol) and her remaining antibiotics (bactrim and azithromycin) with scheduled appointments with neurology and pulmonary. Medications on Admission: Advair diskus Albuterol in prn Atrovent qid Claritin Discharge Medications: 1. Mycophenolate Mofetil 250 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:120 Capsule(s) Refills:0 2. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). Disp:2 Capsule(s) Refills:0 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:14 Tablet(s) Refills:0 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:1 Disk with Device(s) Refills:0 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:90 Tablet(s) Refills:0 7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:15 Tablet(s) Refills:0 8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inhaler Inhalation four times a day as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:0 Discharge Disposition: Home Discharge Diagnosis: myasthenia [Last Name (un) 2902] pneumonia asthma Discharge Condition: stable Discharge Instructions: You have myasthenia [Last Name (un) 2902]. You need to follow up with your primary care doctor and your neurologist. In addition, you have a nodule on your chest CT. This may represent an infection or a cancer. You need to have a follow up CT scan in 6 months. Please work with your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] this study. Take all medications EXACTLY as prescribed. You must finish all of your antibiotics even if you are feeling better. Not taking all of your antibiotics can lead to a relapse. You are on three medications for your myasthenia [Last Name (un) 2902]: prednisone, mycophenolate mofetil. and pyridostigmine. You must take these medications as they are prescribed. If you stop taking these medications or miss too many doses, you are at high risk of having a relapse which could lead to needing to be brought back to the hospital. If you have any fevers, chills, worsening weakness, or any other concerning symptoms, either call your doctor or come to the emergency room. Followup Instructions: 1. PULMONARY: Provider: [Name10 (NameIs) 1571] BREATHING TESTS Phone:[Telephone/Fax (1) 612] Date/Time:[2145-7-1] 7:40 on the [Location (un) 436] of the [Hospital Ward Name 23] building followed immediately by... Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ]/DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2145-7-1] 8:00 2. PRIMARY CARE: please call to make a follow appointment with your primary care doctor in [3-28] weeks. At that visit you should discuss this hospitalization. Please take these papers with you to the visit. - CT chest in 6 months to evaluate progression of right lung nodule. 3. Neurology Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2145-6-15] 8:00 [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 43] MD [MD Number(1) 2107]	[ "V09.0", "286.7", "518.81", "482.41", "482.2", "530.81", "493.92", "358.01", "276.8" ]	icd9cm	[ [ [] ] ]	[ "99.71", "96.72", "38.93", "96.04" ]	icd9pcs	[ [ [] ] ]	9310, 9316	5254, 8148	293, 352	9414, 9423	2895, 5231	10518, 11483	2460, 2488		8251, 9287		9337, 9393		8174, 8228			9447, 10495									2503, 2876																			234, 255									380, 2140																2162, 2261	2277, 2444
2,580	129,237	7542	Discharge summary	report	Admission Date: [2175-5-28] Discharge Date: [2175-6-6] Date of Birth: [2129-3-5] Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Tetracyclines Attending:[First Name3 (LF) 562] Chief Complaint: AMS Major Surgical or Invasive Procedure: Lumbar puncture performed on [2175-6-1] without complication. History of Present Illness: Mr [Known lastname 12067] is a 46 yo man w/ HIV, HCV, polysubstance abuse found with changes in MS, with fecal incontinence/explosive diarrhea. All HPI at that time obtained from EMS report, as patient intubated quickly after arrival for airway protection. Per EMS report, pt w/ BP 62/P, admitted to using IV heroin, initially reticent to come to ED for evaluation. After arrival in ED, agitated with increasing secretions and intubated for airway protection. Now Mr. [Name13 (STitle) 429] is alert and orientated x 3, conversant. He cannot recall much of the circumstance surrounding last evening, reports developing moderate and then explosive diarrhea yesterday afternoon. Again endorses using heroin yesterday. Denies any other systemic symtems including fever, chills, SOB, urinary changes. States he had a recent viral load and CD4 check though nothing is recorded in this system. Past Medical History: - HIV, last CD4 292, VL >100K in [5-7], OI: PCP, [Name Initial (NameIs) 11395]. Followed br Dr. [Last Name (STitle) ]. - Hepatitis C. grade [12-4] liver fibrosis. - Alcohol abuse. h/o withdrawl seizures, shakes - ETOH pancreatitis - HIV nephropathy - Polysubstance abuse. - History of Tylenol overdose. - Peripheral neuropathy and neurogenic bladder. - CAD s/p stent LCx - UGI bleed, no EGD done Social History: Patient has a history of heavy alcohol and heroin abuse. Denies drinking now, used heroin yesterday. Is current smoker. Lives independently in affiliation with an HIV case management group, on disability. Formerly in methadone clinic, "walked off" shortly prior to admission. Family History: N/C Physical Exam: Exam on transfer to the medicine floor, [2175-5-31] . PE T 98.9 BP 111/67 HR 95 NSR R 14, 99% RA Gen: pleasant, talkative, NAD HEENT: MMM, PERRLA, EOMI, sclerae anicter, conjuntiva normal apprearing. Neck: Without LAD or noted JVD, R IJ triple lumen in place Lungs: Diffuse coarse crackle B, no wheeze. Coughing up grey sputum. CV: RRR s m/r/g, nl s1/s2 Abd: S/NT/ND. + BS. liver edge 1 cm below costal margin. RLQ scar from prior app'y noted. extrm: no edema, pulses 2+ BLE. skin: no rashes, no erythema neuro: AOx3, CN 2-12 intact, MAE, neurologic function grossly intact, MS now appropriate Pertinent Results: [2175-5-28] 07:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-POS [2175-5-28] 07:40PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.019 [2175-5-28] 07:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG [2175-5-28] 07:40PM URINE RBC-[2-4]* WBC-[2-4] BACTERIA-MOD YEAST-NONE EPI-[2-4] TRANS EPI-[5-12] [2175-5-28] 07:40PM URINE GRANULAR-0-2 [2175-5-28] 07:05PM ALT(SGPT)-27 AST(SGOT)-29 CK(CPK)-298* ALK PHOS-130* AMYLASE-71 TOT BILI-0.6 [2175-5-28] 07:05PM CK-MB-7 cTropnT-0.06* [2175-5-28] 07:05PM CALCIUM-9.3 PHOSPHATE-7.5# MAGNESIUM-1.9 [2175-5-28] 07:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-POS Brief Hospital Course: Patient was admitted intially to the MICU and then transferred to the floor the next day. . 1. Hypotension: Though not thought to be sepsic shock, pt was pan-cultured and also checked for adrenal insufficiency by CoSyntropin stim test (which was negative). Ingestion of ativan, heroin, TCA and extreme GI loss postulated to contribute to hypotension, which was responsive to fluids. Lactate was WNL. R internal jugular triple lumen and foley were placed, and patient was intubated for airway protection. Once transferred out of the MICU, BPs were appropriate. Eventually pt was restarted on anti-hypertensives, and was discharged on lisinopril 20 mg daily. . 2. Fevers: Mr [Name13 (STitle) 429] was afebrile on admission to the MICU as well as on transfer to the medicine floor. He developed intermittent spiking fevers. CXR was initally read as unchanged from the prior studies, and all Bcx and UCx demonstrated NG on day of discharge. LP was also negative for infectious process. Fevers had resolved prior to discharge, and were attributed to questionable post-intubation pulmonary process. . 3. Altered Mental Status: Pt brought to emergency department with severely AMS, presumed at that time to partially secondary to drug use and hypotension. Mr. [Name13 (STitle) 429] was promptly intubated and sent to MICU for mangament of hypotension. After extubation, patient was A and O x 3 on transfer to the medicine floor. While on the floor, patient became quite confused and engaged in bizzare behaviors such as putting sputum on cereal thinking it was milk. He also was intermittently lethargic and very difficult to arouse. In the setting of intermittent fevers, an LP was performed which was negative. To r/o any IC pathology or mass, an MRI of the head was obtained and also negative. Eventually, in conjuction with attending and pt's case manager, team determined that AMS was most likely secondary to in-house methadone dose, 120 mg daily. Patient's methadone dose with reduced to 60 mg daily, with a dramatic improvement in patient's functional capacity and MS. Methadone was titrated up to avoid withdrawal and preserve MS. [First Name8 (NamePattern2) ] [Last Name (Titles) 429] was discharged on 100 mg methdone daily, and kept in house for several days longer than medically necessary until the next intake appointment at a methadone clinic could be arranged. He was scheduled to resume methadone dosing and counseling at Bay Cove on [2175-6-7]. . 4. Acute Renal Failure: On admission to the MICU, pt also had marked ARF with Cr to 7 from 1. He received aggressive hydration and creatinine fell to 4.3 after 24 hours. FENa (calculated) = 1.3%, c/w renal etiology presumed to be ATN [1-4] hypovolemia. Patient continued to receive agressive IVF and on discharge, creatinine was back at baseline level of 1.1. Lisinopril reintiated as stated. . 5. Diarrhea: Stool was sent for cultures to r/o infectious etiolgy of diarrhea, especially in the setting of intermittent fevers. Stool cultures for O & P, campylobacter, vibrio, yersinia, e. coli, cyclospora, cryptosporidium, giarida and c. difficle were all negative. Diarrhea resolved spontaneously while in house. . 6. HIV: Patient's HIV was under poor control and pt demonstrated questionable reliability in regards to medication compliance. For this reason, HAART was held during this hospitalization. . 7. Hep C stable during hospitalization. Medications on Admission: As stated by patient on transfer: 1. Kaletra [Hospital1 ] 2. Truvada qAM 3. Klonopin 1 mg TID 4. Lipitor 20 mg qday 5. ASA 325 mg q day 6. Atenolol 100 mg qday 7. Lisinopril 5 mg qday 9. Neurontin 1800 mg qday As taken from past records from [2173], not included above: 1. Indinavir Sulfate 400 mg [Hospital1 ] 2. Tenofovir Disoproxil Fumarate 300 mg qd 3. Ritonavir 100 mg [Hospital1 ] 4. Lamivudine 150 mg [Hospital1 ] Discharge Medications: 1. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:2 4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 6. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:10 Patch 72HR(s) Refills:2 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:20 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnones: 1. Hypotension 2. Altered Mental Status 3. Diarrhea 4. ARF 5. Fever . Secondary Diagnoses: 1. HTN 2. Hepatitis C 3. HIV 4. h/o substance abuse Discharge Condition: Good, patient feeling well with clear mental status. Discharge Instructions: To patient: You have been accepted at the Bay Cove [Hospital 27559] clinic for an appointment tomorrow, [2175-6-7]. You will need to follow up with them thereafter according to their explicit instructions. Follow up with Dr [Last Name (STitle) ] with the next two weeks. You should return to the clinic or to the emergency department with acute changes in your health, including fever (>101F), chills, shortness of breath, confusion, or excess sleepiness. Followup Instructions: With Dr. [Last Name (STitle) ] in [6-15] days ([Telephone/Fax (1) 2393]), as well as with [Doctor Last Name 8214] at Bay Cove ([Telephone/Fax (1) 27560]).	[ "995.93", "785.59", "305.00", "070.70", "584.5", "787.91", "304.00", "042", "276.5", "780.09", "V63.2", "305.1" ]	icd9cm	[ [ [] ] ]	[ "38.93", "96.04", "03.31", "96.71" ]	icd9pcs	[ [ [] ] ]	8105, 8111	3509, 4621	304, 372	8317, 8371	2681, 3486	8888, 9066	2042, 2047		7438, 8082		8132, 8221		6972, 7415			8395, 8865									2062, 2662	8242, 8296																		261, 266									400, 1296										4636, 6946						1318, 1732	1748, 2026
47,906	140,006	47432	Discharge summary	report	Admission Date: [2187-12-19] Discharge Date: [2187-12-31] Date of Birth: [2110-3-27] Sex: F Service: MEDICINE Allergies: Penicillins / Hydrochlorothiazide / Ibuprofen / Zosyn Attending:[First Name3 (LF) 4365] Chief Complaint: DVT, Coagulopathy, Acute Blood Loss Anemia, Bradycardia, Dysphagia and Diarhea Major Surgical or Invasive Procedure: Colonoscopy EGD History of Present Illness: 77 year old Female who was initially scheduled for a workup of dysphagia and diarhea, and was brought by her family from home with severe leg pain. On arrival in the ED, there was concern for a DVT, which diagnosed with a LENI as bilateral common femoral vein DVT's. She was recently started on coumadin due to a new diagnosis of atrial fibrillation in [11-13]. Initially plans were to start LMWH, as her access has been extremely problem[Name (NI) 115] in the past including inability to draw labs. Eventually labs were drawn, when it was noted that her INR was 8.1 and her hematocrit had dropped to 22. She was also noted to be bradycardic. Past Medical History: Stroke L MCA infarct [10-19] s/p IV tPA, IA tPA+penumbra CAD and Infranodal Heart Block: Cath [12-12]: LMCA: 30-40%, LAD: 50-60%, LCx: 50%, with OM1 T.O, 99% OM2; RCA: diffuse disease. No percutaneous intervention done. [12-12] TTE: EF 70%, moderate symmetric LVH [10-13] TTE: LVEF>55% No PFO; complex atheroma. His/Purkinje block PEG placement Bladder lesion under investigation: soft tissue density seen on CT pelvis in bladder [2186-10-25] (found to be organizing clot) DM type II, peripheral [Month/Day/Year 1106] disease DVT in [2157] Hyperlipidemia HTN idiopathic Pancreatitis Hemorrhoids cdiff colitis PVD s/p [2187-4-2] L CFA endarterectomy ..1. Exploration of left common femoral artery. ..2. Left common femoral artery endarterectomy. ..3. Thrombectomy of left iliac artery. ..4. Stenting of left common iliac artery. ..5. Stenting of left profunda femoris artery. ..6. Left iliofemoral arteriogram. Social History: Currently living on [Location (un) 470] with her daughter living on floor below. She is a widow, was working full time in accounting and finance. Former smoker, 40 year pack history, denies illicits. Family History: Mother with CAD. Parents with HTN. Physical Exam: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding, + Dysphagia CARDIAC: - Chest Pain, + Palpitations, - Edema GI: - Nausea, - Vomitting, + Diarhea, - Abdominal Pain, - Constipation, - Hematochezia PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache On admission, PHYSICAL EXAM: VSS: 97.9, 109/70, 52, 20, 96% GEN: barely arousable, non-communicative HEENT: Dry MM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: NT/ND, +BS, - CVAT EXT: 2+ edema, 1+ dorsalis pedis pulses. Mild R calf erythema NEURO: Aphasic, non-cooperative with exam, Right Facial Droop Pertinent Results: On admission: [2187-12-19] 04:35PM BLOOD WBC-5.7 RBC-2.66* Hgb-6.1* Hct-22.0* MCV-82 MCH-22.8* MCHC-27.6* RDW-16.7* Plt Ct-390 [2187-12-19] 04:35PM BLOOD Neuts-63.5 Lymphs-28.6 Monos-5.7 Eos-1.9 Baso-0.3 [2187-12-19] 04:35PM BLOOD PT-69.3* PTT-55.1* INR(PT)-8.1* [2187-12-19] 04:35PM BLOOD Glucose-223* UreaN-47* Creat-1.3* Na-142 K-4.4 Cl-115* HCO3-18* AnGap-13 [2187-12-19] 04:59PM BLOOD K-5.6* On discharge: [2187-12-31] 05:11AM BLOOD WBC-8.6 RBC-3.20* Hgb-7.5* Hct-26.0* MCV-81* MCH-23.5* MCHC-28.9* RDW-16.9* Plt Ct-278 [2187-12-31] 05:11AM BLOOD PT-21.7* PTT-56.9* INR(PT)-2.0* [2187-12-31] 05:11AM BLOOD Glucose-77 UreaN-13 Creat-0.8 Na-141 K-3.5 Cl-111* HCO3-24 AnGap-10 [2187-12-19] 04:35PM BLOOD calTIBC-339 Hapto-149 Ferritn-29 TRF-261 [2187-12-20] 03:45AM BLOOD PEP-POLYCLONAL IgG-2237* IgA-139 IgM-227 IFE-NO MONOCLO [2187-12-24] 04:05PM BLOOD tTG-IgA-6 [2187-12-24] 04:05PM BLOOD AT-88 [2187-12-23] 08:55AM BLOOD AT-78 [2187-12-21] 07:45AM BLOOD ACA IgG-<10 ACA IgM-<10 [2187-12-21] 07:45AM BLOOD Inh Scr-NEG Imaging: LENI:1. Non-occlusive thrombus involving the right common femoral, right mid-to-distal superficial femoral, left common femoral, and left superficial femoral veins. 2. Right popliteal cyst. CT head w/o contrast: 1. No acute intracranial abnormality. 2. Mucosal thickening of the right maxillary and sphenoid air cells. 3. Stable appearance of prior left MCA infarct. Video Swallow: Barium passed freely through the oropharynx and esophagus without evidence of obstruction. There was a small amount of penetration and aspiration with thin consistency. LUE U/S: No left upper extremity deep venous thrombosis. Micro: [2187-12-24] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative [2187-12-23] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative [2187-12-20] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative [2187-12-20] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2187-12-20] URINE Legionella Urinary Antigen -FINAL INPATIENT [2187-12-20] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI} INPATIENT ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: 1. Acute DVT, Coagulopathy: INR on admission was 8.1. Unclear what her INR had been over the past several days, but she certainly was not subtherapeutic as the pharmacokinetics would be inconsistent with this. Her differential diagnosis for her hypercoagulability includes chiefly widespread malignant processes. Hereditary causes are also possible given h/o DVT in [2157], however, less likely given the lateness of these presentations. Also, it seems patient is not very active at home and with this recent acute illness may have been more bedbound than usual. During hospitalization, received 2 units FFP for partial reversal and INR slowly drifted down until not therapeutic. Received 1 unit PRBCs and hematocrit stable during hospitalization. When INR was 1.7, patient had colonoscopy for malignancy workup and for chronic diarrhea (as below). After this, she was bridged with heparin x 24 hours, then switched to lovenox bridge. She will need 24 hour lovenox bridge (until AM of [2188-1-1] as long as INR remains therapeutic at 2-3) with every other day INR checks starting tomorrow ([2188-1-1]). Heme-onc was consulted while inhouse, heme workup was started (results as above) and patient will f/u in thrombosis clinic as outpatient. In addition, she had colonoscopy for malignancy workup, biopsies pending. SPEP with elevated IgG, unclear implications, will f/u as outpatient. Restarted on ASA 81mg given cardiac history. 2. Delerium - Given coagulopathy and fairly severe delerium at time of examination, was concerned about intracranial bleed on admission, but CT head normal. Mental status improved to baseline over course of hospitalization. 3. Acute Blood Loss Anemia - Unclear etiology, however with INR of 8, bleeding occultly is the primary concern. Colonoscopy unimpressive, will f/u with GI as outpatient. Received 1 unit PRBCs during hospitalization and Hct stable, hemodynamically stable. Discharged on iron supplementation as well. 4. Bradycardia, Atrial Fibrillation - Spoke with outpatient cardiologist, Dr. [Last Name (STitle) ]. Asymptomatic of her bradycardia, remained euvolemic without worsened heart failure during hospitalization. EP not consulted because she was asymptomatic and unclear if pacer placement in line with goals of care of patient/family, and no acute need to do so given her coagulopathy as above. 5. Chronic Diarrhea: Three negative C diff's, TTG wnl. Had colonoscopy with biopsies pending, to be followed up as outpatient. 6. Acute Renal Failure: Creatinine on admission 1.3, resolved to baseline of 0.8 on discharge after given IVF. 7. UTI: Patient grew E. coli from urine (asymptomatic on admission, chronic foley). Treated with 10 day course of nitrofurantoin completed on [2187-12-30]. 8. Diastolic CHF: Euvolemic during hospitalization. Held beta blocker b/c bradycardic. Continued ACEi on discharge. On statin and EC ASA. FULL code Medications on Admission: ATORVASTATIN [LIPITOR] - 80 mg Tablet - one Tablet(s) by mouth once a day FUROSEMIDE - 40mg Tablet - 1 Tablet(s) by mouth once a day GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth every twelve (12) hours LISINOPRIL - 2.5 mg Tablet - one Tablet(s) by mouth once a day METFORMIN - 500 mg Tablet Sustained Release 24 hr - one Tablet(s) by mouth qd with largest meal of day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - one Tablet(s) sublingually q 5 [Last Name (LF) ], [First Name3 (LF) ] x3 as needed for prn chest pain ONE TOUCH SURE STEP GLUCOSE TEST STRIPS - - FOR USE IN TWICE A DAY GLUCOSE TESTING WARFARIN - (Prescribed by Other Provider: [Name10 (NameIs) ],[Name11 (NameIs) ]) - Dosage uncertain WARFARIN [COUMADIN] - 2 mg Tablet - take up to 3 Tablet(s) by mouth Once Daily at 4 PM or as directed by coumadin clinic WARFARIN [COUMADIN] - 5 mg Tablet - take up to 2 Tablet(s) by mouth once a day or as directed by coumadin clinic Medications - OTC ALCOHOL SWABS - Pads, Medicated - apply to skin prior to using lancet twice a day ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth DAILY (Daily) BLOOD-GLUCOSE METER [ONE TOUCH ULTRA 2] - Kit - use as directed for blood sugar monitoring up to four times a day DOCUSATE SODIUM - 100 mg Capsule - 1 cap Capsule(s) by mouth twice a day as needed for constipation INSULIN REGULAR HUMAN [HUMULIN R] - 100 unit/mL Solution - As per sliding scale twice a day ; Maximum of 16 units per day MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Atorvastatin 80 mg Tablet [Name11 (NameIs) ]: One (1) Tablet PO once a day. 2. Multivitamin Tablet [Name11 (NameIs) ]: One (1) Tablet PO DAILY (Daily). 3. Furosemide 40 mg Tablet [Name11 (NameIs) ]: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 300 mg Capsule [Name11 (NameIs) ]: One (1) Capsule PO Q12H (every 12 hours). 5. Lisinopril 5 mg Tablet [Name11 (NameIs) ]: 0.5 Tablet PO DAILY (Daily). 6. Metformin 500 mg Tablet Sustained Release 24 hr [Name11 (NameIs) ]: One (1) Tablet Sustained Release 24 hr PO once a day. 7. Warfarin 2 mg Tablet [Name11 (NameIs) ]: Two (2) Tablet PO Once Daily at 4 PM. Tablet(s) 8. Enoxaparin 100 mg/mL Syringe [Name11 (NameIs) ]: One Hundred (100) mg Subcutaneous Q12H (every 12 hours): please stop on AM of [2188-1-1] if INR is [1-9] . 9. Enteric Coated Aspirin 81 mg Tablet, Delayed Release (E.C.) [Month/Day (3) ]: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Insulin INSULIN REGULAR HUMAN [HUMULIN R] - 100 unit/mL Solution - As per sliding scale twice a day ; Maximum of 16 units per day. (Please resume as taking prior to hospitalization) 11. Docusate Sodium 100 mg Capsule [Month/Day (3) ]: One (1) Capsule PO BID (2 times a day) as needed for constipation. 12. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment [Month/Day (3) ]: One (1) Appl Rectal PRN (as needed) as needed for hemorrhoids. 13. Ferrous Sulfate 300 mg (60 mg Iron) Tablet [Month/Day (3) ]: One (1) Tablet PO DAILY (Daily). 14. Thiamine HCl 100 mg Tablet [Month/Day (3) ]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Bostonian - [Location (un) 86] Discharge Diagnosis: . Primary diagnoses: Deep vein thromboses Idiopathic diarrhea Secondary diagnoses: Peripheral [Location (un) 1106] disease Anemia Congestive heart failure History of stroke Discharge Condition: . Expressive aphasia but alert and nods appropriately to questions. Hemodynamically stable. Discharge Instructions: . You were admitted to the hospital for pain in both legs that prevented you from walking. We found that the blot clots in your legs were larger than before and that you had poor circulation to your feet. This resolved and we now have you on the appropriate dose of blood thinners. You will need to have your INR checked every other day for now, though. We also found that your blood was very thin, which probably occurred because you have had diarrhea for the past month and this can interfere with coumadin dosing. We investigated whether you have any additional underlying reasons to have developed thin blood but all these tests were normal. We restarted your coumadin; it was in therapeutic range when you were discharged. While you were here, you were also seen by your gastroenterologist, Dr. [First Name8 (NamePattern2) 2530] [Name (STitle) ], who has been investigating the cause of your diarrhea. He performed upper and lower endoscopy and everything looked normal, he will follow up with you regarding the results of the biopsies at your appointment this week. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. The following changes were made to your medications: 1. Take lovenox injections until the AM of [2188-1-1], pending results of your INR level tomorrow morning 2. Start taking coumadin 4mg daily 3. Start taking enteric coated aspirin 81mg 4. Start taking thiamine daily 5. Start taking iron supplements daily Followup Instructions: . You have the following appointments scheduled: [Name6 (MD) 7158] [Name8 (MD) ], MD [Telephone/Fax (1) 250] Date/Time: [2188-1-2] at 9:30am You should follow-up with your gastroenterologist [First Name8 (NamePattern2) ] [Name8 (MD) 10314], MD [Telephone/Fax (1) 463] Date/Time:[2188-1-2] 1:30 PM You will need to follow up with the blood clotting specialist (hematologists) [Telephone/Fax (1) 3062] Dr. [Last Name (STitle) ] on [1-11] 11am, [Hospital Ward Name 23] 9.	[ "599.0", "438.12", "486", "041.4", "V58.61", "787.21", "272.4", "V15.82", "250.70", "584.9", "276.2", "455.6", "293.0", "428.0", "427.31", "453.41", "401.9", "787.91", "438.11", "280.9", "285.1", "428.32", "V12.51", "562.10", "V58.67", "443.81" ]	icd9cm	[ [ [] ] ]	[ "45.25", "38.93", "45.13" ]	icd9pcs	[ [ [] ] ]	11968, 12029	5829, 8744	395, 413	12251, 12345	3196, 3196	13878, 14401	2299, 2335		10347, 11945		12050, 12113		8770, 10324			12369, 13855									2892, 3177	12134, 12230											3629, 5806							277, 357									441, 1094								3210, 3614								1116, 2060	2076, 2283
72,231	191,885	53271	Discharge summary	report	Admission Date: [2120-4-17] Discharge Date: [2120-4-20] Date of Birth: [2063-11-28] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2265] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 56 year old woman with a history of coronary artery disease s/p drug-eluting stent to the LAD and history of cardiomyopathy thought secondary to radiation therapy for Hodgkin's Disease. She has had a day of worsening shortness of breath. She reports no change in her diet or medication regimen. She denies any chest pain or fevers. . She presented to her PCP's office today and appeared to be in respiratory distress. She was given 60 mg of IV furosemide, one sublingual nitroglycerin, and placed on a non-rebreather. Reportedly room air sats were 74%. On arrival to the ED, she was tachypneic and appeared uncomfortable. Her vital signs were HR 105 RR 26 100% cpap. She could only speak in one syllable words. She was placed on Bipap and a nitro gtt. Her chest xray was consistent with pulmonary edema. The nitro was weaned out of concern for BP's in the 100's. She was placed on 15 L. She appeared to become more uncomfortable (after 30-60 minutes), so Bipap was placed back on per patient request. She was also given inhalers which did not change her symptoms. She got an additional 80 mg IV furosemide. She had put out approximately 600 cc of urine in the ED. However, this was partially estimated due to incontinence. Vital signs on transfer were 78 23 97/59. . Past Medical History: CAD s/p DES to LAD in [4-22] LMCA at ostium tubular eccentric 30% lesion, mid LAD with discrete eccentric 30% lesion, no significant LCx lesions, mid RCA with luminal irregularities 20% lesion, [10-22] stress echo- non-occlusive with apical hypokinesis that persists with stress, low functional capacity . CHF- 48% on [Name (NI) ] (unclear date) mild AS moderate MS . Quoted in Atrius Records from [Hospital1 112] on [2120-3-4] note normal LV size, mild concentric LVH, EF 60%, normal RV size and function, mild left atrial enlargement, sclerotic aortic valve with peak mean gradients of 29 and 15 mmHg, aortic valve area of 1.3, thickened mitral valve with circumferential mitral annular calcification, peak and mean gradients of 20 and 8-10 mmHg, trace- mild MR, trace TR with estimated PASP 25 mmHg plus right atrial pressure CHB s/p PPM placement restrictive lung disease (PFT's in [2116] FEV1 46%, FVC 46%, FEV1/FVC 100%, TLC 45%, DLCO 48%) Diabetes mellitus, type 2 Hypertension Hyperlipidemia Hypothyroidism Dysphagia secondary to XRT Hodgkin's Disease- nodular sclerosing variant s/p ABVD + mantle XRT [2098]-[2099] Hysterectomy in [2117] secondary to vaginal bleeding pacemaker placement [5-21] Chronic Renal Insufficiency secondary to diabetes- creatinine in [8-24] was 1.3 Social History: Lives alone. Single, unmarried, no children. Previously worked at registrar's office at [University/College ] Law School. Denies tobacco or illicits. Rare alcohol. Family History: CAD in father at age 49 Diabetes in mother and brother Hypertension in maternal grandmother, mother, father. Denies any other significant medical history. Physical Exam: VS: T 97.9 BP 101/54 HR 82 RR 23 O2 sat 100% on NRB. GENERAL: Mild resp distress, able to speak in short sentances. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP 1-2 cm below the mandible sitting up. 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 are labored, patient speaking in only short sentances. Scattered crackles throughout, but exam limited due to resp distress, No wheezes or rhonchi. ABDOMEN: +Obese, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas noted NEURO: AAOx3, CNII-XII intact, strength 5/5 throughout PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [2120-4-20] 06:06AM BLOOD WBC-8.0 RBC-4.10* Hgb-10.4* Hct-34.1* MCV-83 MCH-25.3* MCHC-30.5* RDW-15.8* Plt Ct-265 [2120-4-20] 06:06AM BLOOD Glucose-84 UreaN-31* Creat-0.8 Na-145 K-3.8 Cl-103 HCO3-30 AnGap-16 [2120-4-18] 05:00AM BLOOD ALT-21 AST-52* LD(LDH)-408* CK(CPK)-213* AlkPhos-90 TotBili-0.4 [2120-4-18] 05:00AM BLOOD CK-MB-8 cTropnT-0.15* [2120-4-18] 12:00AM BLOOD CK-MB-7 cTropnT-0.14* [2120-4-17] 07:00PM BLOOD CK-MB-4 proBNP-1864* [4-19] CARDIAC CATH1. Selective coronary angiography of this co-dominant system demonstrated non-obstructive coronary artery disease. The LMCA had a proximal 20% lesion. The LAD had minimal luminal irregularities. The stent in the mid-LAD was noted to be widely patent. The LCx and RCA were noted to be free of any angiographically-apparent coronary artery disease. 2. Resting hemodynamics revealed normal right- and left-sided filling pressures, with a RVEDP 11 mmHg and LVEDP 10 mmHg. There was mild pulmonary arterial hypertension with pulmonary pressures of 40/20, mean 31 mmHg. The systemic arterial pressures were normal with a central aortic pressure of 128/69, mean 93 mmHg. The PCWP was elevated to 20 mmHg. There was mitral stenosis with a mean transvalvular gradient of 10.75 mmHg with a calculated mitral valve area of 1.5 cm2. 3. Selective renal angiography of the left and right renal arteries demonstrated no angiograhically-apparent stenoses or lesions. FINAL DIAGNOSIS: 1. Mild non-obstructive coronary artery disease. 2. Normal right- and left-sided filling pressures. 3. Mild pulmonary arterial hypertension. 4. Systemic arterial normotension. 5. Moderate mitral valve stenosis. 6. Normal left and right renal arteries. [4-18] ECHO The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with distal and apical LV hypokinesis (LAD territory). The remaining segments contract normally (LVEF = 40%). Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are severely thickened/deformed. There is moderate functional mitral stenosis (mean gradient 13 mmHg) due to mitral annular calcification. There is no pericardial effusion. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Post-radiation valvular disease with mild mitral stenosis and mild aortic stenosis. Mild regional biventricular systolic dysfunction, most c/w CAD, although post-radiation changes cannot be excluded. Brief Hospital Course: 56 year old woman with a history of cardiomyopathy thought secondary to radiation therapy. She presents with a CHF exacerbation. . # Acute on chronic diastolic and systolic CHF: Her most recent echo showed a normal EF with diastolic dysfunction. A repeat echo on this admission showed a depressed LVEF of 40%. Her symptoms were most consistent with a CHF exacerbation. She was initially started on a lasix drip and this was transitioned to boluses of IV lasix as her dyspnea and hypoxia improved. Her antihypertensives were held in the setting of hypotension. When improved, she was discharged home on 20mg of PO torsemide. . # CAD: She has a history of CAD with a known stent in the LAD. Her echo indicated reduced systolic function concerning for recent ischemic disease. She was brought to cardiac catheterization where she was found to have non occlusive coronary disease. Her home regimen of aspirin, plavix and lipitor were all continued. Lisinopril and metoprolol were held due to hypertension but restarted on discharge. # HTN As above, imdur, metoprolol and lisinopril were held due to hypotension. These were restarted on discharge. . # DM Continued home insulin. Held metformin but continued on discharged. Medications on Admission: Metformin 1,000 mg Oral Tablet TAKE 1 TABLET TWICE A DAY Metoprolol Succinate 200 mg Oral Tablet Extended Release Levothyroxine 150 mcg Oral Tablet TAKE ONE TABLET DAILY Insulin Lispro Protam & Lispro (HUMALOG MIX 75-25 KWIKPEN) 100 unit/mL (75-25) Subcutaneous Insulin Pen inject 40-50units with breakfast and 42 units with dinner Albuterol Sulfate (PROAIR HFA) 90 mcg/Actuation Inhalation HFA Aerosol Inhaler 2 puffs every 4-6 hours as needed for wheezing Furosemide 40 mg Oral Tablet take 1 tablet daily Clopidogrel (PLAVIX) 75 mg Oral Tablet TAKE ONE TABLET DAILY Lisinopril 10 mg Oral Tablet take 1 tablet by mouth daily Isosorbide Mononitrate 30 mg Oral Tablet Extended Release 24 hr TAKE TWO TABLET ( = 60 MG ) DAILY Atorvastatin (LIPITOR) 80 mg Oral Tablet take 1 tablet daily CYANOCOBALAMIN 100 MCG TAB 100 mcg Oral Tab One daily NITROGLYCERIN 0.4 MG SUBLINGUAL TAB place 1 tablet under the tongue as needed for chest pain - has not used in over a year OMEGA-3 FATTY ACIDS-VITAMIN E 1,000 MG CAP (OMEGA-3 FATTY ACIDS/VITAMIN E) 1 capsule daily CALCIUM 500 + D (D3) 500 MG-125 UNIT TAB 1 daily FOLIC ACID 1 MG TAB TAKE ONE TABLET DAILY ASPIRIN EC 81 MG TAB, DELAYED RELEASE 1 daily MULTIVITAMIN TAB (MULTIVITAMINS) 1 tab Discharge Medications: 1. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day: Please start [4-21]. 2. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 3. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Insulin Insulin Lispro Protam & Lispro (HUMALOG MIX 75-25 KWIKPEN) 100 unit/mL (75-25) Subcutaneous Insulin Pen inject 40-50units with breakfast and 42 units with dinner 5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 minutes as needed for chest pain: As needed for chest pain. If you still have pain after 3 tabs, STOP and call your doctor or go to the emergency room. 12. omega-3 fatty acids-vitamin E 1,000-5 mg-unit Capsule Sig: One (1) Capsule PO once a day. 13. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1) Tablet PO once a day. 14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute on Chronic systolic and diastolic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for shortness of breath, and this was because of a heart failure exacerbation - meaning you had build-up of fluid around the heart. We also did a cardiac catheterization to look at the arteries that supply the heart, and this did not show any significant change from a previous procedure. We gave you medications to reduce the fluid in your lungs, which improved your breathing. . You should make sure to follow-up with your doctors, and to take your medications exactly as prescribed. . Please note the following medication changes: -Please STOP Lasix -Please STOP Aldactone -Please STOP Potassium . -Please START Torsemide (a water pill to replace lasix) Followup Instructions: *Please call your PCP (primary care doctor) and schedule a follow-up visit within one week of discharge from the hospital . Please note that you have an appointment with [Name6 (MD) ] [Name8 (MD) 109633], NP, in the cardiology office, in 2 weeks. We are working to MOVE THIS APPOINTMENT TO WITHIN ONE WEEK OF DISCHARGE. If you do not hear from their office by Monday [4-22], please call [Telephone/Fax (1) ] to confirm the time of your new appointment. [First Name8 (NamePattern2) ] [Name8 (MD) 162] MD [MD Number(2) 2273*]	[ "V58.67", "414.01", "244.9", "272.4", "424.0", "201.50", "428.43", "250.00", "V45.82", "V45.01", "202.80", "428.0", "416.8", "518.89", "401.9", "425.4" ]	icd9cm	[ [ [] ] ]	[ "88.56", "88.57", "37.23" ]	icd9pcs	[ [ [] ] ]	11363, 11369	7105, 8325	313, 339	11478, 11478	4338, 5784	12330, 12918	3187, 3343		9604, 11340		11390, 11457		8351, 9581		5801, 7082	11629, 12163									3358, 4319																	12183, 12307		266, 275									367, 1635										11493, 11605						1657, 2986	3002, 3171
52,872	195,467	44929	Discharge summary	report	Admission Date: [2137-2-19] Discharge Date: [2137-2-23] Date of Birth: [2058-6-25] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 5893] Chief Complaint: Lethargy Major Surgical or Invasive Procedure: Intubation Central venous line placement Arterial line placement History of Present Illness: This is a 78 year-old female with a history of ILD who presents with altered mental status. Per the daughters report she was suffering from respiratory symptoms for the last 2 weeks with fever, mild cough and laryngitis. She is on 3 liters O2 at the NH. She was tx with 1 week of Levo starting [2137-1-31] for possible PNA. Although her respiratory symptoms were improving on monday she noted her to be significantly fatigued in her nursing home and less conversational. She required more assistance yesterday and was dropping objects. Today she was found slumped in her wheelchair, lethargic but opening her eyes to voice. VS, FS 117, BP 84/54 R, 87/52 L, P 62, R 12, 100% 3L NC. On review of her med list it appears lasix 60mg PO was started [2-15] and lopressor 25mg PO BID was started on [2137-2-14]. It was thought she was having a CHF exacerbation. Her Chem7 yesterday was Na 140, K4.2, bicarb 36, BUN 53, Cr 1.6, Ca 8.4. . In the ED, Inital VS 97.3, HR 70, BP 98/70, R 18, 100%. FOund to be hypoglyemic and given D50 with improvement of BG to 189. CT head negative. Became more arousable and able to answer questions. EKG showed Aflutter with Ventricular rate in the 60s. CXR showed BL lower lob markings felt consistent with CHF or PNA. BNP 2586. In the ED she developed hypotension with SBP to the 70s but responded to 2L IVF bolus. She was given Levo 750mg and Vanco 1gm IV. Blood culture was drawn. She was admitted to the ICU for AMS and recent hypotension. VS prior to transfer were 96.2 71 97/55, 20, 100% on oxygen. The daughter (HCP) was called and confirmed full code status while in the ED. . ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: - Hypertension. - Diabetes. - Arthritis-pain in all joints. - Carpal tunnel syndrome. - Depression and anxiety-apparently since [2086] with h/o auditory hallucinations. - Interestitial lung disease diagnosed 7/[2135]. - SVT in the setting of hypoxia with admission [5-28] - [5-28] PNA treated with Vanc, Cefepime Social History: Transfered from [Hospital3 ]. Per OMR has 10 children including 2 daughters in [Name (NI) 86] (others in [Name (NI) 6482], elsewhere). Also has a granddaughter in [Name (NI) 86] ([Doctor First Name ]). Denies [Male First Name (un) 1554]. Family History: Mother died age 24 from apparent poisoning, father died at 90s of old age Physical Exam: GEN: elderly AA female, ill appearing, somulent, responsive to noxious stimulis, intermittantly following commands. HEENT: PERRL 2 to 1mm BL, sclera anicteric, MMM. NECK: JVD to angle of jaw (has TR), no bruits, trachea midline COR: regularly irregular no M/G/R, normal S1 S2, radial pulses +1 PULM: BL prominent crackles, no rhonchi. ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: 3+ BL LE edema to thigh, no palpable cords NEURO: somulent, responsive to noxious stimulus and intermittantly to voice., CN II ?????? XII grossly intact. Moves all 4 extremities. Patellar DTR difficult to illicit. Plantar reflex downgoing. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: Labs on admission: [2137-2-19] 01:45AM BLOOD WBC-5.6 RBC-5.20 Hgb-11.6* Hct-40.7 MCV-78* MCH-22.4* MCHC-28.5* RDW-17.0* Plt Ct-73* [2137-2-19] 01:45AM BLOOD PT-19.2* PTT-30.3 INR(PT)-1.8* [2137-2-19] 10:00AM BLOOD FDP-10-40* [2137-2-19] 01:45AM BLOOD Glucose-70 UreaN-56* Creat-2.0# Na-138 K-5.3 Cl-97 HCO3-33* AnGap-13 [2137-2-19] 01:45AM BLOOD LD(LDH)-605* TotBili-0.6 [2137-2-19] 01:14PM BLOOD ALT-261* AST-343* LD(LDH)-250 AlkPhos-97 TotBili-0.6 [2137-2-19] 01:45AM BLOOD proBNP-2586* [2137-2-19] 10:00AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.1 [2137-2-19] 10:00AM BLOOD Hapto-60 [2137-2-19] 01:14PM BLOOD TSH-2.0 [2137-2-19] 07:23AM BLOOD Type-ART pO2-89 pCO2-61* pH-7.38 calTCO2-37* Base XS-7 [2137-2-19] 10:28AM BLOOD Type-CENTRAL VE Temp-34.2 FiO2-. pO2-59* pCO2-58* pH-7.38 calTCO2-36* Base XS-6 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2137-2-19] 04:05AM BLOOD Lactate-2.9* WBC [2137-2-22] 04:30 16.2* [2137-2-21] 19:03 11.6* [2137-2-21] 14:01 11.1* [2137-2-19] 01:45 5.6 INR [2137-2-22] 04:30 4.3* [2137-2-21] 19:03 2.9* [2137-2-21] 03:23 1.8* [2137-2-20] 05:25 1.8* Creatinine [2137-2-22] 04:30 1.9* [2137-2-21] 21:00 1.6* [2137-2-21] 14:01 1.3* [2137-2-21] 03:23 0.7 [2137-2-20] 05:25 0.9 [2137-2-19] 10:00 1.4* [2137-2-19] 01:45 2.0* LFTS ALT AST LD(LDH) AlkPhos DirBili [2137-2-22] 04:30 179* 313* 736* 93 2.5* [2137-2-19] 13:14 261* 343* 250 97 0.6 MICRO: Blood cultures - NGTD x 2 MRSA screen - (+) Urine cx - NGTD Legionella ag - (-) C. diff toxin - (-) IMAGING: CT head: IMPRESSION: 1. No evidence of an acute intracranial process. MRI would be more sensitive for an acute infarction, if indicated. 2. Likely retrocerebellar arachnoid cyst in the right posterior fossa. . TTE: The left atrium is normal in size. The right atrium is dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets are moderately thickened. Severe aortic valve stenosis is not suggested. The mitral valve appears structurally normal with trivial mitral regurgitation. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [2136-5-21], right atrial and right ventricular cavity enlargement with now identified, with marked right ventricular free wall hypokinesis and new tricuspid regurgitation. This constellation of findings is suggestive of an acute pulonary process (e.g, pulmonary embolism). LE U/S: IMPRESSION: No evidence of deep venous thrombosis in the right or left lower limb. CXR (admission): IMPRESSION: 1. Diffuse chronic bilateral interstitial lung disease (IPF). 2. Prominent hila from prominent pulmonary vessels suggesting pulmonary hypertension. 3. Progressive cardiomegaly. CXR (intubated): FINDINGS: AP single view of the chest has been obtained with patient in supine position. The patient has been now intubated and ETT is seen to reach the central portion of the right main bronchus. It should be withdrawn by at least 3 cm so to avoid obstruction of the left main bronchus. Previously described left internal jugular approach central venous line remains in unchanged position. An apparently new NG tube reaches only to mid portion of esophagus. No pneumothorax has been generated. Previously described extensive bilateral interstitial congestion and probably edema pattern remains. Brief Hospital Course: 78 year old female with history of progressive interstitial lung disease, presents in respiratory distress, hypotension, and increased lethargy. . #Shock: Patient arrived hypotensive despite extensive IVF resuscitation and required dopamine via PIV. Multiple etiologies were in the differential diagnosis. Septic shock was the most likely etiology, given her respiratory symptoms prior to admission, but her skin was cool on exam and all cultures were negative. With marked peripheral edema and cool extremities, we also considered cardiogenic shock, which was supported by an echocardiogram showing increased right-sided failure, confirmed on repeat echo. She was covered broadly for infection with Cefepime and Vanco, with the addition of Azithromycin and Flagyl later in the hospitalization. Central venous access was obtained and an arterial line was placed for close blood pressure and ABG monitoring. She was persistently tachycardic and started on metoprolol and diltiazem for control of her atrial fibrilliation/atrial flutter, without success. The patient's blood pressure began to drop once again and she was placed on phenylephrine and eventually needed to be started on norepinephrine + vasopression with minimal effect. The family was informed about her poor prognosis and wished for care to be withdrawn. She passed away soon after. . # Hypoxemic respiratory failure, in setting of ILD: At baseline, she is on 3L. On admission, her respiratory status was close to baseline, but her progressive lung disease combined with the fluids she was given to support her blood pressures would intermittently put her into pulmonary edema. Her oxygen requirement slowly climbed and her chest x-rays appeared to worsen, requiring intubation due to increased work of breathing, outstripping non-invasive ventilation. Her arterial blood gases were consistently acidotic with relatively normal [Name (NI) 96100], indicating a metabolic acidosis that was not correcting. As above, a family meeting was held to discuss her poor prognosis. The decision was made to extubate her and she passed away soon after. . # Altered mental status - She arrived quite lethargic, likely [2-20] to hypotension vs delirium. Her CT head was negative and her shock was treated as above. Her sensorium improved briefly for 1 day, but quickly deteriorated during her respiratory failure. . # Thrombocytopenia / coagulopathy: She has a known history of thrombocytopenia, but was apparently not worked up before. She had not had any exposure to heparin since her previous hospitalization. Her last recorded platelet count in [Month (only) ] [2136] was 188. DIC labs were normal and she was continued on heparin SQ. RUQ U/S showed an incidental finding of ?acalculous cholecystitis and IR was consulted. They believed that the gallbladder wall was edematous, but not neccessarily indicative of acalculous cholecystitis and was likely secondary to her hypoalbuminemia and heart failure. No intervention was performed. . # Atrial fibrillation/atrial flutter: As described above in "Shock". She was tried on increasing amounts of AV nodal blockers to control her tachycardia, without effect. Tachycardia likely secondary to septic state. Medications on Admission: Seroquel 25mg PO qam, 50mg PO qpm vitamin D3 800 U daily prilosec 20mg PO BID caclium carbonate 1000mg PO BID tramadol 25mg PO BID acetylcysteine 200mg/1ml, 3ml via neb q3h gabapentin 100mg PO TID glipizide 5mg PO daily cardizem 360mg SR PO daily celebrew 200mg PO daily fluvoxamine 200mg PO daily robitussion 20mls PO daily bisacodyl 10mg Supp daily prn cheratussin AC 10ml PO q4h prn erythromycin opth ointment [1-20] inch to left eyelip [Hospital1 ] as needed MOM 30ml PO daily prn senna 2 tabs daily prn fleet enema supp daily simethicone 80mg PO QID mirtazapine 30mg PO qhs lasix 60mg PO daily (start [2-15]) lopressor 25mg PO BID (start [2-14]) albuterol neb q6h ipratropium neb q6h Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Septic and cardiogenic shock Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A	[ "401.9", "276.2", "287.5", "518.89", "276.0", "428.0", "427.32", "482.9", "416.8", "354.0", "716.99", "785.51", "276.7", "785.52", "518.81", "250.80", "995.92", "038.9", "300.4", "427.31", "584.9", "515", "286.9" ]	icd9cm	[ [ [] ] ]	[ "38.97", "96.71", "38.91", "96.04" ]	icd9pcs	[ [ [] ] ]	11813, 11822	7789, 11028	281, 347	11894, 11904	3805, 3810	11956, 11962	3004, 3079		11785, 11790		11843, 11873		11054, 11762			11928, 11933									3094, 3786																			233, 243									375, 2355		5518, 7766						3825, 5509								2377, 2708	2724, 2988
50,545	193,076	33361	Discharge summary	report	Admission Date: [2125-6-4] Discharge Date: [2125-6-29] Date of Birth: [2048-1-16] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1] Chief Complaint: 77M s/p sigmoid colectomy for recurrent diverticulitis presented 10 days post operatively with shortness of breath, abdominal distention, bloating, diarrhea, and abdominal pain Major Surgical or Invasive Procedure: [2125-6-16] Total abdominal colectomy, end-ileostomy. History of Present Illness: 77 year old male with multiple medical problems admitted with abdominal pain, leukocytosis and fever s/p sigmoid resection [5-25] for recurrent diverticulitis. His postoperative course was complicated by NSTEMI post-operatively, as well as concern regarding possible anastamotic leak. He had a CT scan of the abdomen and pelvis on [5-28] without evidence of leak. He was treated with Zosyn from [Date range (1) 57306] empirically. He was discharged on [6-2] to home off of antibiotics. The patient recently [Month/Year (2) 1834] the above operation, he presented to [Hospital 77429] medical center complaining of fairly acute onset of abdominal pain after having a bowel movement on [6-4]. In the ER, he was noted to be afebrile with abdominal pain and tenderness. At that time, he was complaining of frequent loose liquid stools and progressive abdominal distension. He had a WBC of 18.5, 79 % polys, 12 % bands with minor derangements in his chemistries and liver function testing, normal amylase and lipase. He was sent to radiology to have a CT scan and apparently rigored in the radiology department at [Hospital3 ] so he was given empiric antibiotics with vancomycin, Zosyn and flagyl. Arrangements were made for transfer to [Hospital1 ] and he was transferred here for ongoing care. Past Medical History: Prostate CA, CAD/CABG '[13], Aortic stenosis Social History: married, quit smoking [2088], denies EtOH Family History: Positive for early CAD, father had MI before 55, 2 brothers d from MI Physical Exam: On day of admission: T 98.9 HR 88 BP 110/84 RR 18 97% on 3L Gen - alert and oriented Pulm - clear to auscultation bilaterally CVS - RRR Abd - moderately firm, distended, tympanitic, diffuse pain to palpaption, no guarding Abdominal wound - intact, no erythema, no drainage Penis very swollen . At Discharge: Vitals:T-98.5,HR-68,BP-148/80,RR-18,O2 sat-94% on RA GEN: NAD, A/Ox3 CV: RRR RESP: CTAB ABD- +BS, soft, NT/ND, stoma beefy red & viable with liquid brown stool Incision: midline OTA with steri strips, CDI. No erythema Extrem: RUE with 1-2+ edema r/t PICC, LUE no edema, Lower extremities with 0-1+ edema, CSM's intact Pertinent Results: [2125-6-26] 05:13AM BLOOD WBC-8.1 RBC-3.81* Hgb-11.1* Hct-32.3* MCV-85 MCH-29.1 MCHC-34.3 RDW-14.3 Plt Ct-452* [2125-6-18] 02:40AM BLOOD WBC-17.1* RBC-2.56* Hgb-7.6* Hct-23.0* MCV-86 MCH-29.8 MCHC-34.6 RDW-14.8 Plt Ct-308 [2125-6-16] 04:18PM BLOOD WBC-22.6# RBC-4.06 Hgb-12.0* Hct-35.1* MCV-86 MCH-29.5 MCHC-34.1 RDW-14.7 Plt Ct-514* [2125-6-5] 12:39AM BLOOD WBC-26.7# RBC-4.05 Hgb-11.9* Hct-35.4* MCV-88 MCH-29.4 MCHC-33.6 RDW-14.2 Plt Ct-370 [2125-6-22] 04:25AM BLOOD PT-14.3* PTT-29.9 INR(PT)-1.2* [2125-6-20] 05:50AM BLOOD PT-13.7* PTT-28.8 INR(PT)-1.2* [2125-6-5] 12:39AM BLOOD PT-14.3* PTT-27.7 INR(PT)-1.2* [2125-6-27] 05:16AM BLOOD Glucose-99 UreaN-20 Creat-0.8 Na-136 K-3.3 Cl-99 HCO3-32 AnGap-8 [2125-6-21] 04:20AM BLOOD Glucose-150* UreaN-19 Creat-0.7 Na-135 K-4.1 Cl-99 HCO3-32 AnGap-8 [2125-6-25] 01:10PM BLOOD cTropnT-<0.01 [2125-6-24] 07:49AM BLOOD CK-MB-2 cTropnT-<0.01 [2125-6-18] 08:18PM BLOOD CK-MB-3 cTropnT-<0.01 [2125-6-18] 02:40AM BLOOD CK-MB-3 cTropnT-<0.01 [2125-6-5] 05:20PM BLOOD CK-MB-3 cTropnT-0.05* [2125-6-5] 07:35AM BLOOD CK-MB-3 cTropnT-0.06* [2125-6-5] 12:39AM BLOOD CK-MB-2 [2125-6-27] 05:16AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.7 [2125-6-21] 09:52AM BLOOD Albumin-1.7* [2125-6-20] 11:51AM BLOOD Albumin-1.6* Calcium-7.2* Phos-3.5 Mg-1.9 [2125-6-11] 06:27AM BLOOD Albumin-1.9* Calcium-7.4* Phos-3.9 Mg-1.7 Iron-22* [2125-6-7] 06:50AM BLOOD Calcium-7.4* Phos-2.9 Mg-2.5 [2125-6-6] 06:30AM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.7 Mg-2.4 [2125-6-5] 07:35AM BLOOD Albumin-2.3* Calcium-7.7* Phos-3.9 Mg-2.4 [2125-6-11] 06:27AM BLOOD calTIBC-95* Ferritn-694* TRF-73* [2125-6-19] 03:13PM BLOOD Triglyc-97 [2125-6-11] 06:27AM BLOOD Triglyc-126 [2125-6-17] 03:42AM BLOOD Cortsol-23.1* . [2125-6-5] 2:44 am STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [2125-6-5] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2125-6-5]): REPORTED BY PHONE TO [First Name5 (NamePattern1) 24448] [Last Name (NamePattern1) 24449] ON [2125-6-5] AT NOON. 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 . STUDIES: [6-5]: CT with rectal contrast: no leak, pancolitis [6-14] KUB: distended colon (~9cm), no distension of small bowel [6-15] KUB: No [Month/Year (2) 65] change in gaseous distention of colon. Diffuse distention of small-bowel loops that may reflect adynamic ileus. . Pathology Examination Procedure date [2125-6-16] DIAGNOSIS: Colon and omentum, subtotal colectomy: 1. Severe pseudomembranous colitis with marked colonic dilation; see note. 2. Proximal ileal and distal colonic margins, uninvolved. 3. Appendix with fibrous obliteration. 4. One unremarkable lymph node. 5. Previous colocolonic anastomosis intact. Note: The findings are consistent with C. difficile colitis in the appropriate clinical setting. Clinical: Colitis. Brief Hospital Course: The patient was admitted to the surgical floor for continued monitoring. He was started empirically on cipro/flagyl, started on IVF and a foley catheter was placed. CT scan on admission showed pan colitis associated with an elevated white count. [6-5] - started on sips, continued on PO vancomycin and flagyl, cipro discontinued. GI consult obtained, agreed with antibiotic plan. [6-6] advanced to clears as the patient looked to be improving [6-7] - WCC increasing, but patient clinically improving. KUB showed dilated transverse colon. Diet changed to NPO [6-8] - PICC line placed, TPN started [6-9] TPN, antibiotics continued [6-10] - sips started, cont TPN, antibiotics [6-11] - [6-13] - advanced to clears, gentle diuresis started, cont TPN, antibiotics [6-14] - flagyl discontinued [6-15] - abdominal pain increasing, KUB showed [Last Name (un) ] increase in colonic distention, no flatus/BM x 48 hours [6-16] - increasing pain, no improvement, patient taken to the operating room for subtotal colectomy, end ileostomy. Following the procedure the patient was transferred intubated to the [Hospital Unit Name 153], required minimal pressor support for transient hypotensive, started on zosyn / vanc / flagyl [6-17] - fluid resuscitated for low CVP, pressor support as needed [6-18] - Patient fluid overloaded, in heart failure - cardiology consulted - recommended lasix drip and diuresis of 1 liter per day, pressors as needed, transfused one unit RBC for hct of 23.0, TPN resumed after being held for 2 days for fluid overload [6-19] - continued on minimal pressors, lasix drip, TPN, antibiotics, transfused 2 units RBC [6-20] - [6-21] - continued ventilator support, minimal pressors, lasix drip, TPN, antibiotics, discontinued zosyn, continued on vanc / flagyl [6-22] - patient extubated without difficulty, vancomycin discontinued, continued on antibiotics, TPN, lasix drip [6-23] - continued diuresis, TPN, antibiotics, started on clear liquid diet, discontinued central line, a line [6-24] - started on a regular diet, transferred to the floor, started on PO meds, continued flagyl, started on PO lasix [Hospital1 ], continued TPN [6-25] - evaluated by speech and swallow for difficulty swallowing - no deficit noticed. Discomfort swallowing likely related to endotracheal tube from prolonged intubation in ICU. Managed with Chlorasceptic spray PRN and Oxymetazoline for 3 days. Medications given with applesauce. Tolerating well. No s/s of aspiration. [6-26] - cont ambulation and gentle diuresis, foley traumatically removed during dressing change. Patient reported frequent urination with dribbling due to PO Lasix. Foley reinserted. Urology consulted-recommended starting Flomax, and keeping Foley in place for 5 day. Foley will be removed in REHAB, with post-void bladder scans. Goal residual <200cc. Abdominal staples removed. Steri strips applied. [Date range (1) 77430] -PO lasix discontinued. Foley in place with decrease in urine output. 500cc normal saline bolus given with increase in urine output. Urine output has remained adequate for past 20 hours. PICC line removed. Continue elevation of RUE to decrease swelling. Pain well controlled with oral medication. Abdominal incision OTA with steris, CDI. Stoma beefy red & viable with liquid brown stool. Ostomy appliance changed [Name6 (MD) ] Ostomy RN on [2125-6-29] prior to transfer to REHAB. Continue checking daily weights. Plan to follow-up with Dr. [Last Name (STitle) ] 2 weeks, and with Urology as needed. Medications on Admission: Avapro 150', Lipitor 40', Triamterene, ASA, Omega 3 Discharge Medications: 1. Aspirin 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [Last Name (STitle) ]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Multivitamin,Tx-Minerals Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 4. Lorazepam 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) as needed for Anxiety/insomnia. 5. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day): Crush & give with applesauce. 6. Miconazole Nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical QID (4 times a day) as needed for groin for 2 weeks. 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 8. Hydromorphone 2 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Phenol-Phenolate Sodium Mouthwash [Last Name (STitle) ]: One (1) Spray Mucous membrane Q6H (every 6 hours) as needed for sore throat. 10. Oxymetazoline 0.05 % Aerosol, Spray [Last Name (STitle) ]: One (1) Spray Nasal [Hospital1 ] (2 times a day) as needed for 3 days. Discharge Disposition: Extended Care Facility: [Location (un) 49880] Nursing Facility Discharge Diagnosis: Primary: Toxic megacolon from Clostridium difficile colitis Post-op fluid overload Post-op pulmonary edema requiring prolonged intubation Post-op urinary retention . Secondary: recurrent diverticulitis, Prostate CA, CAD/CABG, moderate AS Discharge Condition: Stable Tolerating a regular diet with supplements Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or becoming progressively worse, or inadequately controlled with the prescribed pain medication. * 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. . Incision Care: You may shower. Pat incision dry. Avoid swimming and baths until further instruction at your followup appointment. Leave the steri-strips on. They will fall off on their own, or be removed during your followup. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Monitoring Ostomy Output / Prevention of Dehydration: Keep well hydrated. Replace fluid loss from ostomy daily. Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. Try to maintain ostomy output between 1000mL to 1500mL per day. If Ostomy output exceeds 1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg in 24 hours. . Foley/Flomax: -Please continue PO Flomax until follow-up appointment with Dr. [Last Name (STitle) ]. -Remove Foley on [2125-7-1]. Scan bladder after voiding to assess for retention. -Please contact Urology Department at [Hospital3 ] with any Urologic concerns ([Telephone/Fax (1) 772], pager: [Numeric Identifier 42293]. Followup Instructions: Please call the office of Dr. [Last Name (STitle) ] for a follow up appointment within 2-3 weeks [Telephone/Fax (1) 9]. . Follow-up with Urology Department at [Hospital1 827] as needed ([Telephone/Fax (1) 772]. . Follow-up with your PCP--[Last Name (NamePattern4) ]. [Last Name (STitle) 14206] K. AGIOMAVRITIS, [Telephone/Fax (1) 71705] in [1-24] weeks and as needed. Completed by:[2125-6-29*]	[ "V15.82", "V15.3", "424.1", "410.72", "V45.81", "008.45", "V10.46", "428.0", "518.5", "V17.3", "997.1", "311", "458.29", "997.5", "788.20", "790.29" ]	icd9cm	[ [ [] ] ]	[ "38.93", "46.23", "45.8", "99.04", "99.15" ]	icd9pcs	[ [ [] ] ]	11004, 11073	5997, 9621	487, 547	11354, 11448	2791, 5974	13420, 13851	2056, 2127		9723, 10981		11094, 11333		9647, 9700			11472, 12303							12318, 13397		2142, 2439											2453, 2772								271, 449									575, 1904																1926, 1976	1992, 2040
61,581	159,918	49197	Discharge summary	report	Admission Date: [2156-6-15] Discharge Date: [2156-6-22] Date of Birth: [2105-7-21] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Speach difficulties Major Surgical or Invasive Procedure: Iv tpa History of Present Illness: 50 RHM w/ hx multiple prior strokes (one [2152] sx of sig language difficulty, requiring long term speech tx, and mem problems, one [3-11] with sx of vertigo, transient diplopia and left arm weakness) DM, HTN, HLD, AF, not on coumadin [1-5] job w/ BPD, and CRF (Cre ~2.0), was at home, talking with his wife, heated some pizza, and got distracted by some nails sticking up on the deck that he felt needed hammering. In the process of hammering, he stopped, put the hammer down, and appeared confused. His wife started calling to him and noticed that his speech was unintelligble. Despite her urges to remain seated on the ground, the pt stood up, ate more pizza (wife suggests he may have been thinking his sugar was low), and walked to the living room without report of ataxia, though his wife suggested he was bumping into things on the L. In the living room, he finally sat down, but continued to have dysarthric speech, difficulty producing coherent language, and a possible R facial droop. EMS was called and he arrived at the [Hospital1 18] ER 45 min after onset of sx. In the ER he received a CT/CTA/CT perf with CT head showing several areas of old hypodensities (one prominently in the R occipital area, one in the L parietal ares, and a small L capsular one) and CT Perf showed an area in the left frontal lobe with proolnged MTT but relatively normal CBV, suggestive of an ischemic penumbra, probably in the territory of the superior div of the L-MCA. Due to his significant deficit and rapid arrival in the ER, risks and benefits of IV tPA were discussed w/ pt and his wife and they opted to accept this tx. Past Medical History: PMH: IDDM c/b diabetic foot ulcers - HgbA1c 9.3% on [2156-1-5] Atrial fibrillation/flutter Cardioembolic CVA - [2152], [3-11] CAD HTN Hyperlipidemia s/p MVA in [2116]'s w/ reported myocardial contusion toe amputation [1-5] DM Social History: Married, two daughters ages 23 and 17, > 20 year veteran of the [Location (un) 86] Police Department, works in [Location (un) 583], is in the narcotics division hence needs to knock down doors and etc. Nonsmoker, no current ETOH, denies illicit or IV drug use. Family History: Father- has [Name2 (NI) 499] cancer Mother- recently dx with DM2 Siblings all in good health Physical Exam: T-97.5 F BP- 147/97 HR- 82 RR- 17 O2Sat 100%RA Gen: Obese AA male, lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit CV: irreg irreg, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: NIHSS: NIH SS: 1a. Level of Consciousness: 0 1b. LOC questions: 2 1c. LOC commands: 0 2. Best gaze: 0 3. Visual: 1 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb ataxia: 0 8. Sensory: 0 9. Best language: 2 10. Dysarthria: 0 11. Extinction and inattention: 1 Total: 7 Mental status: Awake and alert, normal affect. Unable to state name, date,or locale. Follows some commands (open/close eyes, grip hands) but unable to understand many other commands. Speech is largely non-fluent though has periods of fluency for short phrases. No repetition; Unable to name. No dysarthria. Unable to read. (+) R neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields w/o BTT on R. Extraocular movements cross midline bilaterally, no nystagmus. Facial movement w/ slight R droop. Hearing grossly intact Palate elevation symmetrical. Tongue midline. Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor No pronator drift Strength appears full in the UE and LE B/L. Sensation: withdraws to noxious stim or tickle in all 4 ext Reflexes: +2 and symmetric at the [Hospital1 ] and patellae. 1 at the tri and BR, 0 at the Achilles B/L. Toes appear down but withdraws bilaterally Coordination: no gross ataxia Gait: deferred Pertinent Results: CT/ CTA/ CTP: 1. Large acute infarction in the left frontal lobe. Large acute infarction in the left parietal lobe, which is shown to also involve the left posterior temporal and lateral occipital lobes on current MRI. Both of these infarctions are located in the left internal carotid artery territory, given the fetal configuration of the posterior cerebral arteries. 2. Multiple chronic infarctions as described above. 3. No evidence of hemodynamically significant stenoses or occlusions in the intracranial circulation. Mild cervical carotid atherosclerosis without evidence of hemodynamically significant stenosis. 4. Chronic left maxillary sinusitis with atelectasis and wall sclerosis. 5. Enlarged inferior left thyroid lobe with questionable nodularity. Further evaluation may be performed by thyroid ultrasound, if not done previously. MRI: 1. Two large acute infarctions in the left cerebral hemisphere, both in the territory supplied by the left internal carotid artery, given the fetal configuration of the left posterior cerebral artery. 2. Chronic infarctions in the left parietal, right parietal, and right occipital lobes, as well as in the right cerebellar hemisphere ECHO: The left atrium is moderately dilated. There is mild-moderate symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). LPs: Cholesterol:293 Triglyc: 165 HDL: 39 CHOL/HD: 7.5 LDLcalc: 221 HbA1C 8.1 Brief Hospital Course: 50 RHM w/ hx multiple prior strokes (one [2152] sx of significant language difficulty, requiring long term speech tx, and memory problems, one [3-11] with sx of vertigo, transient diplopia and left arm weakness) DM, HTN, HLD, AF, not on coumadin [1-5] job w/ BPD, and CRF (Cre ~2.0), presents now with the acute onset of mixed expressive and receptive aphasia (though expressive seems worse), with evidence of hypoperfusion to an area in the L frontal lobe, likley the product of a cardioembolic event to the superior div of the L-MCA. Due to his significant deficit and rapid arrival in the ER, risks and benefits of IV tPA were discussed w/ pt and his wife and they opted to accept this treatment. He recieved t PA therapy, and he was admitted to neuro ICU for close monitering. he was later shifted to neuro med floors on stroke team. he was started on coumadin and Heparin SQ was conrinued for DVT prophylaxix. Aspirin was continued. we will stop ASA and SQ heaprin once he is therapeutic INR [1-6] is reached. Heparin IV was not considered given recent t PA and small bleed. Blood pressure otimisation and heart rate control was achieved using metoprolol. his blood sugars were monitored and he was started on Insulin basal dose and sliding scale. OT PT speech swallow eval was done and recs followed. He was dicherged to rehab facility for futher care. Medications on Admission: Amlodipine 5mg daily Avapro 300mg daily Aspirin 81mg daily Amiodarone 200mg daily Crestor 40mg daily Docusate 100mg [Hospital1 ] Ferrous Sulfate 325mg daily Humalog insulin 30units QAM, 30units Q dinner Lantus 10-15units QHS depending on PO intake Metoprolol XL 75 mg daily (increased from 50 mg Qday on last admission) Viagra PRN (has not used in several months) Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Two large acute infarctions in the left cerebral hemisphere, both in the territory supplied by the left internal carotid artery, given the fetal configuration of the left posterior cerebral artery. Chronic infarctions in the left parietal, right parietal, and right occipital lobes, as well as in the right cerebellar hemisphere. IDDM c/b diabetic foot ulcers - HgbA1c 9.3% on [2156-1-5] Atrial fibrillation/flutter Cardioembolic CVA - [2152], [3-11] CAD HTN Hyperlipidemia s/p MVA in [2116]'s w/ reported myocardial contusion toe amputation [1-5] DM Discharge Condition: stable Discharge Instructions: Please call 911 or your doctor if you develop any new alarming symptoms. please take the medications as prescribed. Followup Instructions: Please follow up with Dr.[First Name4 (NamePattern1) ] [Last Name (NamePattern1) 722], DPM Phone:[Telephone/Fax (1) 543] Date/Time:[2156-9-6] 9:00 Please follow up with Dr.[First Name8 (NamePattern2) ] [Name (STitle) 162], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2156-7-23] 9:00 [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "V49.72", "434.91", "427.31", "250.00", "427.32", "585.9", "403.90" ]	icd9cm	[ [ [] ] ]	[ "99.10" ]	icd9pcs	[ [ [] ] ]	7712, 7782	5915, 7293	335, 343	8399, 8408	4437, 5892	8572, 8981	2584, 2683				7803, 8378		7319, 7689			8432, 8549									2698, 3021																			276, 297									371, 2010	3748, 4418									3404, 3732			3045, 3389			2032, 2281	2297, 2568
3,201	137,892	51498	Discharge summary	report	Admission Date: [2112-3-21] Discharge Date: [2112-3-24] Date of Birth: [2037-3-4] Sex: M Service: ICU HISTORY OF PRESENT ILLNESS: This is a 75 year old with history of congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, who was originally admitted with pneumonia to the Medical service and transferred to the Intensive Care Unit for respiratory failure. The patient saw Dr. [Last Name (STitle) 575] one week prior to admission complaining of five weeks of progressive dyspnea on exertion without fevers or sputum. Chest x-ray showed no new disease. Given his response to steroids in the past, he was started on 60 mg of Prednisone. Three days prior to admission he had worsening shortness of breath and also had some brown sputum and was started on Levaquin. Despite this, he had a fever of 101 and came into the Emergency Department. He denied any chest pain, nausea, vomiting, diaphoresis, increased wheezing from baseline or episodes of paroxysmal nocturnal dyspnea. He was admitted to the general medical service and started on Ceftazidime and Azithromycin for concern about pseudomonas, but he continued to have dyspnea and progressive desaturation. He had thick increased secretions starting the day prior to Intensive Care Unit transfer but was able to bring them up. The a.m. of transfer, he was noted to be obtunded, cyanotic and tachypneic and he was then intubated. Vital signs were temperature of 97, pulse 112, respiratory rate 30s and oxygen saturation of 98% on 100% nonrebreather. PAST MEDICAL HISTORY: 1. Coronary artery disease with a history of congestive heart failure, ejection fraction of 20%. Mild pulmonary hypertension. Moderate global right ventricular hypokinesis with a myocardial infarction and catheterization showing three vessel disease, status post VF arrest approximately five years ago, status post ICD placement. 2. Severe bullous emphysema with last FEV1 36% of predicted and FVC of 27% predicted on home oxygen four to five up to ten liters. On chronic Prednisone 7.5 mg once daily. Question of some interstitial lung disease from Amiodarone. 3. Mild renal insufficiency. 4. Question of transient ischemic attack. ALLERGIES: Penicillin which caused hives. MEDICATIONS ON TRANSFER: 1. Flovent. 2. Albuterol. 3. Serevent. 4. Insulin sliding scale. 5. Ceftazidime and Azithromycin. 6. Ultram. 7. Tylenol. 8. Singulair. 9. Lipitor. 10. Prednisone. 11. Zantac. 12. Plavix. 13. Aspirin. 14. Subcutaneous Heparin. 15. Quinaglute. 16. Digoxin. PHYSICAL EXAMINATION: Immediately after intubation, this is a well developed, well nourished elderly man in no acute distress. The neck was supple with visible jugular venous distention lying flat. His lungs were coarse bilaterally, decreased at the bases. He was tachycardia with a regular rhythm, I/VI systolic murmur. He had positive bowel sounds, nontender, nondistended. He had some bluish discoloration over his shins and no palpable pulses. Extremities were cool. He withdrew to painful stimuli. LABORATORY DATA: Electrocardiogram showed tachycardia to 119 with some PR prolongation, right bundle branch block and left anterior fascicular block similar to prior electrocardiogram. Complete blood count with a white blood cell count of 10.0, hematocrit 35.0, platelet count 234,000. Coagulation studies were within normal limits. Creatinine increased to 2.0 from baseline of 1.5. Initial cardiac enzymes were negative. INTENSIVE CARE UNIT COURSE: His respiratory failure was hypercarbic with initial pH of 7.2, 83, and 88, thought to be possibly from chronic obstructive pulmonary disease as he had significant obstruction and thickened amount of auto PEEP. Initially his antibiotics were changed to Ceftriaxone given the gram positive cocci in sputum and Vancomycin was also added. Extremity noninvasive studies were negative for deep vein thrombosis and he was unable to tolerate CTA secondary to renal function. Immediately after intubation, he became hypotensive. He was bolused with some fluid and started on pressors. His acute renal failure was suspected from hypotension and respiratory arrest. Over the course of the next 24 hours, he spiked a temperature to 102 and then up to 105 with a progressive hypotension and progressive worsening hypoxia with no clear change in his chest x-ray. Cardiac enzymes returned positive with troponin greater than 50. He became oliguric and then anuric and had hyperkalemic bradycardic event which responded to Atropine and treatment of his hyperkalemia. As he continued to decline the next morning, discussion was held with his family members, his wife, son and two daughters, and decision was made especially in light of his recently declining health and poor quality of life for the resuscitation efforts. Several hours later, the pressors were withdrawn and the patient expired. DISCHARGE DIAGNOSES: 1. Septic shock from community acquired pneumonia. 2. Myocardial infarction. 3. Acute renal failure. 4. Respiratory failure secondary to pneumonia and chronic obstructive pulmonary disease. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4561] Dictated By:[Name8 (MD) 13286] MEDQUIST36 D: [2112-4-13] 14:14 T: [2112-4-13] 20:57 JOB#: [Job Number 106777]	[ "428.0", "515", "038.9", "491.21", "486", "518.81", "414.8", "785.59", "584.9" ]	icd9cm	[ [ [] ] ]	[ "96.71", "96.04" ]	icd9pcs	[ [ [] ] ]								4951, 5406																									2597, 4930																				160, 1577															2309, 2574	1599, 2284
24,077	180,485	44215	Discharge summary	report	Admission Date: [2177-3-26] Discharge Date: [2177-4-21] Date of Birth: [2109-3-3] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 148] Chief Complaint: Pancreatic cystic lesion in neck of pancreas Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Central partial pancreatectomy with Roux-en-Y anastomosis and reconstruction. 3. Repair of strangulated ventral hernia. 4. Extended adhesiolysis History of Present Illness: Mr. [Known lastname ] is a 64-year-old kidney transplant recipient and has multiple other medical health issues including diabetes, COPD, peripheral vascular disease and coronary artery disease. He has been followed for a cystic lesion in his pancreas and recently this showed growth up to a size of 1.5 cm now. This has changed from 2 years ago at which point it was 0.8 cm. An endoscopic ultrasound was performed to evaluate this and an aspirate of the lesion yielded a CEA level of 9100. The amylase content in this was also elevated. There was also concern of other cystic lesions throughout the pancreas and he was thought to perhaps have IPMT. Preoperative MRI, however, distinguished this dominant lesion in the neck of the pancreas to be distinct from the pancreatic duct. There was one other smaller cystic lesion in the uncinate process, but distal glandular cysts were actually felt to be the sequelae of chronic pancreatitis from a pancreas divisum which was obvious on the MR as well. At the request of Dr. [First Name8 (NamePattern2) 1586] [Name (STitle) 2161], Dr. [Last Name (STitle) ] was asked to see Mr. [Known lastname ] about this pancreatic cyst. After long discussions with Dr. [Last Name (STitle) ], the patient decided to have surgery. Past Medical History: Diabetes Mellitus Hypertension Coronary artery disease s/p PCI Hyperlipidemia GERD ESRD s/p kidney transplant [2163] BPV [7-7] BPV, admitted [7-7] at [Last Name (un) 1724], recommended vascular rehab at [Hospital1 2025] but pt did not go Social History: 2 PPD x 60 years no EtOH no IVDU Recently Widowed (wife passed in [2177] of CAD) Family History: + father with DM2, and HTN Pertinent Results: SPECIMEN SUBMITTED: PANCREATIC NECK (CYST WALL) & MORE DISTAL MARGINS. Procedure date Tissue received Report Date Diagnosed by [2177-3-26] [2177-3-27] [2177-3-31] DR. [Last Name (STitle) ]. [Doctor Last Name ]/kg DIAGNOSIS: I. Pancreatic neck cyst, excision (A-F): 1. Inflammatory pseudocyst with fibrotic wall. 2. Tiny foci of ductal low grade dysplasia (PanIN II). 3. No carcinoma. II. Pancreas distal margin (G-K): 1. Tiny focus of intraductal PanIN I. 2. Otherwise within normal limits. Brief Hospital Course: The patient tolerated the surgery [see operative note for further details] and was immediately transferred to the surgical intensive care unit [SICU] where he remained for 10 days. He was intubated for about a week while in the ICU. Post-operatively, he was also followed by Renal transplant as well as Infectious Disease for MRSA, VRE, and Candidal infections. His hospital course was also complicated by poor wound healing and cellulitis around the incision area, in which staples had to be removed. His abdomenal wound was intially packed with wet-to-dries and then wound vac was placed to promote granulation. He was switched back to wet-to-dries, and his wound is currently looking healthy with good granulation tissue. Due to his multiple morbities, extensive surgery, and a fluid collection in the pancreatic bed post-op, a decision was made to have the patient be on bowel rest and be given TPN to support his caloric needs. With antibiotics, TPN, and support of the physical therapists, the patient has done quite well after being transferred to the surgical floor. He has been afebrile for over a week, while ambulating with some assistance, and producing good urine. He will be discharged to a rehabilitation center in stable condition with specific instructions for post-hospital care as well as follow-up. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Pancreatic cyst Discharge Condition: Stable Discharge Instructions: Please follow directions as discussed previously with Dr. [Last Name (STitle) ]. Please take medications as prescribed and read warning labels carefully. If signs of infections such as purulent discharge from wound/drain site, increased pain and redness at wound/drain site, please call or go to the emergency room. Remember to get a CT scan and follow up with Dr. [Last Name (STitle) 94852] in 2 weeks (bellow). Light activities until seen in clinic. [Month (only) 116] take quick showers if able to keep wounds and drains dry. No baths. Absolutely no smoking. Followup Instructions: Please follow up with Dr. [First Name (STitle) 3122] [Initials (NamePattern4) ] [Last Name (NamePattern4) 1860] in 1 week. Please call ([Telephone/Fax (1) 773] for an appointment. Make sure Electrolytes and Cyclosporin trough level (drawn 30 minutes before dose given) are drawn on the day before the appointment. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2832], MD Phone:[Telephone/Fax (1) 2833] Date/Time:[2177-5-2] 11:00 Please call the phone number above to confirm day and time of the CT scan. Completed by:[2177-4-21]	[ "568.0", "V58.67", "V42.0", "041.11", "997.4", "112.89", "496", "V45.82", "401.9", "682.2", "998.59", "305.1", "577.1", "567.29", "577.2", "552.20", "250.40", "278.00" ]	icd9cm	[ [ [] ] ]	[ "99.04", "53.59", "52.59", "38.93", "99.15", "93.59", "54.59" ]	icd9pcs	[ [ [] ] ]	4209, 4288	2857, 4186	358, 542	4348, 4357	2306, 2834	4986, 5578	2258, 2287				4309, 4327					4381, 4963																												273, 320									570, 1858																1880, 2139	2155, 2242
55,966	144,067	36005	Discharge summary	report	Admission Date: [2118-1-24] Discharge Date: [2118-2-14] Date of Birth: [2070-11-1] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6346] Chief Complaint: Abdominal pain, intermittant nausea, emesis, and anorexia x 3 weeks Major Surgical or Invasive Procedure: 1. Exploratory laparotomy washout, ileocolectomy, ileocolostomy [Doctor Last Name 406] drain placement and primary fascial closure with back drain placement. 2. Exploratory laparotomy, incarcerated ventral hernia reduction, hernia sac removal and hernia repair with mesh. History of Present Illness: The patient is a 47-year-old male who dates the beginning of his symptoms to around [Holiday ], at which time he drank some "bad booze" and ate some macadamia nuts. For the past 3 weeks, he has had anorexia, pain, and intermittant diarrhea in addition to nausea and emesis. He denies fever/chills. He was prompted to seek care today because his pain exacerbated. He has had a ventral hernia for some time, but now [Last Name (un) 81717] that it has enlarged in the left inferior portion. He has never had a colonoscopy. He denies history of hematochezia or melena. Past Medical History: PMH: pneumonia PSH: ORIF L wrist and L knee after MVC at age 15 Social History: Works in construction, 15-20 pack-year smoker, now smokes daily cigars. Drinks 3-4 40oz. beers a day, but hasn't had a drink since [2118-1-6]. Family History: Parents both alive and healthy. 2 sibs., one alive and well and the other dead from complications of cocaine use. Has a healthy son. [Name (NI) ] family history of cancers. Physical Exam: PHYSICAL EXAM: Vital Signs: 97.9, 93, 118/76, 18, 96% RA Gen: Obese male, appears younger than stated age, NAD HEENT: NC/AT, EOMI, PERRLA bilat., dry MM, without cervical LAD Cor: RRR without m/g/r, no JVD, no bruits Lungs: CTA bilat. [Last Name (un) ]: +BS, soft, NT. 25cm x 20cm x 5cm with approx. 8-12cm lateral underpining bilateral mid-abdomial surgical wound with granulation tissue and some exudate. Muscle wall with well approximated midline incision with sutures in place. With VAC dressing in place, site remains intact. Ext: warm feet, no edema Pertinent Results: [2118-1-24] 12:40PM BLOOD WBC-11.8* RBC-5.35 Hgb-16.4 Hct-45.3 MCV-85 MCH-30.8 MCHC-36.3* RDW-12.1 Plt Ct-490* [2118-1-24] 12:40PM BLOOD PT-15.7* PTT-21.6* INR(PT)-1.4* [2118-1-24] 12:40PM BLOOD Glucose-135* UreaN-25* Creat-1.1 Na-133 K-4.2 Cl-90* HCO3-24 AnGap-23* [2-8] Stool Culture - C diff toxin A and B - negative [1-24] CT: Large ventral hernia(s) containing loops of both small and large bowel, likely site of transition point for high-grade bowel obstruction. [1-25]: ECHO There is mild regional left ventricular systolic dysfunction with inferior hypokinesis, EF 45% [2-1] CT Head: No acute intracranial process [2-3] Abd CT: No free air or fluid collection is noted within the abdomen. [2-4] Bilateral upper and lower extremity ultrasound - no DVT Brief Hospital Course: The patient underwent repair of his incarcerated ventral hernia. He tolerated the procedure well and was transferred to the PACU in good condition. It was felt that the bowel was viable and nonischemic or injured at the time of that laparotomy, but there was clinical deterioration in the recovery room and then there was succus that came out of the drain placed in the subcutaneous tissue at the time of the completion of the procedure. The patient was given broad-spectrum antibiotics and taken back to the operating room after risks and benefits of procedure were discussed. Following the second procedure, he remained NPO, IVF for hydration, NGT in place, foley catheter in place, JP drain in place in abdomen, on ancef and flagyl, IV pain medication, transferred to the ICU for close monitoring on ventilator support and intermittent pressor requirement. [1-25] pm - d/c ancef, started on zosyn and vancomycin, on ventilator support [1-26] - continued antibiotics, fluconazole added, ventilator support, pressors and sedation as needed, albumin given for volume support, ECHO performed for continued pressor requirement showing mild regional left ventricular systolic dysfunction with inferior hypokinesis, EF 45%. [1-27] - [1-30] - continued antibiotics, ventilator support and vasopressors as needed. [1-31] - TPN started, continued antibiotics, ventilator support, vasopressors as needed, lasix 20IV [Hospital1 ] started [2-1] - started tube feeds via NG tube, continued TPN, antibiotics, ventilator support, changed lasix to ethacrynate, head CT ordered for dilated poorly reactive left pupil which was normal with no acute pathology, fluconazole discontinued [2-2] - continued tube feeds, TPN, antibiotics, ventilator support [2-3] - CT torso ordered for fevers, raised [Name (NI) 81718], unclear source of sepsis, vent dep resp failure showing no fluid collections, no abscess, no free air; continued antibiotics, tube feeds, TPN and ventilator support [2-4] - antibiotics switched to cipro / flagyl; b/l upper and lower extremity non-invasives performed showing no DVT, successfully extubated [2-5] - continued TPN, tube feeds, antibiotics [2-6] - continued TPN, stopped tube feeds, diet advanced to clears, transferred to the floor [2-7] - diet advanced to regular, PICC line placed, continued TPN, foley catheter removed at midnight, vac dressing placed [2-8] - patient voided, continued antibiotics, regular diet [2-9] vac dressing changed, foley replaced for incomplete emptying, flomax started, continued regular diet [2-10] - cipro discontinued, continued on flagyl, continued regular diet, which he tolerated well. Patient experienced episodic tachycardia, particularly when ambulating to 120-150. Lopressor was initially increased to 75mg BIB, then to 100mg [Hospital1 ] on [2-11] with improved heart rate. His blood presure remained stable. [2-13]- Foley catheter was replaced due to urinary retention. He continues on Flomax. Plan is to keep foley indwelling until outpatient follow-up at clinic. Discharge planning has been ongoing during hospitalization. Patient will be discharged home with [Month/Day (4) 269] services to care for his VAC dressing and Physical Therapy for conditioning. The patient was discharged with a wet-to-dry abdominal dressing, which will be converted later today back to the VAC dressing at 125mm Hg. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, and pain was well controlled. Medications on Admission: None Discharge Medications: 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. Disp:30 Tablet(s) Refills:0 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:0 3. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:60 Capsule(s) Refills:0 4. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 5. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] [Hospital3 269] Discharge Diagnosis: Primary: 1. Incarcerated ventral hernia 2. Enterotomy, peritonitis Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Wound Vac is in place. It should be changed every 3 days. It should contain a black sponge set to -125mmHg pressure. Your [Hospital3 269] nurse will care for and change the dressing, and provided relevant teaching. Call your [Hospital3 269] nurse if the VAC dressing loses suction, the equipment malfunctions, the clear cover comes undone, or with any questions. Foley Care: Monitor urine for foul odor, blood, cloudiness, particles; advise [Name8 (MD) 269] RN or call Dr.[Name (NI) 11471] office Maintain adequate fluid intake Prevent kinking or twisting of tube Report any problems or concerns to you [Name (NI) ] Nurse Followup Instructions: You have [Last Name (un) 6550] scheduled to follow-up with Dr. [First Name (STitle) 2819] on [2-16] at 10:30 at [Hospital Unit Name 14956] in [Location (un) 86]. Please call the Dr.[Name (NI) 11471] office this week to provide insurance information; office Tel #: ([Telephone/Fax (1) 8105]. Call to schedule follow-up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 8338] in [2-8] weeks; office Telephone#: ([Telephone/Fax (1) 33013]. Completed by:[2118-2-14]	[ "552.29", "569.83", "788.20", "276.3", "567.29", "995.92", "E878.8", "038.9", "518.5", "785.52", "998.59", "276.2" ]	icd9cm	[ [ [] ] ]	[ "57.94", "96.6", "45.73", "53.69", "96.72", "99.15", "45.93", "38.93" ]	icd9pcs	[ [ [] ] ]	7483, 7550	3134, 6768	383, 661	7661, 7668	2309, 2924	9510, 10038	1534, 1712		6823, 7460		7571, 7640		6794, 6800			7692, 9487									1742, 2290																			275, 345									689, 1265		2933, 3111														1287, 1354	1370, 1518
46,983	175,638	41369	Discharge summary	report	Admission Date: [2104-6-2] Discharge Date: [2104-6-7] Date of Birth: [2048-5-25] Sex: M Service: CARDIOTHORACIC Allergies: pollen Attending:[First Name3 (LF) 1505] Chief Complaint: Increasing exertional dyspnea and fatigue Major Surgical or Invasive Procedure: [2104-6-2] aortic valve replacement ([First Name8 (NamePattern2) 11688] [Male First Name (un) 923] regent mechanical) History of Present Illness: This 55 year old gentleman with a history of a patent ductus arteriosus repair as a child and a known bicuspid aortic valve which has been followed by serial echocardiograms over the past decade. Serial echocardiograms have shown a progressive decrease in his aortic valve area and now a slightly depressed left ventricular function. He is symptomatic with dyspnea and chest heaviness with exertion as well as a generalized fatigue. Given the progression of his disease and early decline in LV function, he has been referred for surgical management. Past Medical History: aortic valve stensosis/insufficiency Hypertension Hyperlipidemia Gout Anemia insulin dependent diabetes mellitus Chronic kidney disease (Creat 1.4) Diabetic neuropathy gastroesophageal reflux s/p Patent Ductus Arteriosus Repair as child 8 y/o([2056]) s/p Cataract surgery s/p Tonsillectomy Social History: Lives with: Wife in [Name2 (NI) 3494] Occupation: Cook at [University/College ] Univ. dining services Tobacco: 40 pack year history quit [2088-2-1] ETOH: [2-4] drinks per day Family History: Mother died of MI at 84. Sister with MI at 58. Physical Exam: Pulse: 84 SR Resp: 18 O2 sat: 100% B/P Right: 177/66 Left: 170/65 Height: 70" Weight:182lb BSA: 2.01m2 General: WDWN in NAD Skin: Warm, Dry, intact. Well healed Left thoracotomy HEENT: PERRLA, EOMI, sclera anicteric. Teeth in poor repair. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X]; well healed left thoracotomy extending very close to the sternum. Heart: RRR, III/VI systolic ejection murmur; Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema Varicosities: none. Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:1 Left:1 PT [Name (NI) 167]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit Bilat: Transmitted soft sound likely from the heart murmur vs bruit Pertinent Results: [2104-6-2] Intraop TEE: PRE-CPB: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF=40-45 %). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve is bicuspid with a horizontal commisure. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Trivial mitral regurgitation is seen. POST-CPB: There is a mechanical valve in the aortic position. The valve is well-seated with normally mobile leaflets. There is no evidence of paravalvular leaks. The peak gradient across the aortic valve is 14mmHg, the mean gradient is 7mmHg with CO of 5L/min. The LV systolic function remains mildly impaired, unchanged from pre-op, estimated EF=40-45%. There is no evidence of aortic dissection. . [2104-6-7] 11:00AM BLOOD Hct-25.4* [2104-6-7] 05:45AM BLOOD WBC-5.9 RBC-2.66* Hgb-8.7* Hct-23.8* MCV-90 MCH-32.9* MCHC-36.8* RDW-13.5 Plt Ct-262 [2104-6-6] 04:45AM BLOOD PT-29.1* PTT-34.1 INR(PT)-2.8* [2104-6-6] 01:15PM BLOOD PT-34.5* INR(PT)-3.4* [2104-6-7] 05:45AM BLOOD PT-32.2* INR(PT)-3.2* [2104-6-6] 04:45AM BLOOD UreaN-34* Creat-1.6* Na-138 K-4.3 Cl-102 [2104-6-6] 04:45AM BLOOD Mg-1.8 Brief Hospital Course: Mr. [Known lastname 90057] was admitted and underwent mechanical aortic valve replacement by Dr. [Last Name (STitle) ](see operative report for further details). He received Cefazolin for perioperative antibiotics. Following the operation, he was brought to the intensive care unit for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without complication. On post operative day one he was started on beta blockers, lasix for gentle diuresis and transferred to the floor. Warfarin was initiated and dosed for a goal INR between 2.5 - 3.0. He remained in a normal sinus rhythm without atrial or ventricular arrhythmias. Beta blockade was advanced as tolerated and his preoperative Labetolol was resumed. Chest tubes and pacing wires removed per protocol.Over several days, he continued to make clinical improvements with diuresis and was cleared for discharge to home on postoperative day # 5. At discharge, his INR was 3.2. Prior to discharge, arrangements were made with the [First Name9 (NamePattern2) 2287] [Hospital 1468] [Hospital3 ] to monitor Warfarin as an outpatient.First INR check tomorrow [6-8]. Medications on Admission: ALLOPURINOL 100 mg daily AMLODIPINE 5 mg daily ATORVASTATIN 80 mg daily COLCHICINE 0.6 mg daily ENALAPRIL MALEATE 5 mg daily FUROSEMIDE 40 mg daily LABETALOL 300 mg qpm and 150 mg qam LORAZEPAM 0.5 mg prn OMEPRAZOLE 20 mg daily ASPIRIN 81 mg daily ERGOCALCIFEROL 1,000 unit Capsule daily NPH INSULIN 100 unit/mL Suspension per sliding (3-7 units before dinner) OMEGA-3 FATTY ACIDS 1,000 mg daily VITAMIN E 400 unit daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s) Refills:0 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 3. warfarin 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily) for 1 days: 4 mg dose today [6-7] only; then all further daily dosing per coumadin clinic provider at [Name9 (PRE) 2274]/[Name9 (PRE) 2287]; target INR 2.5-3.0 for mechanical aortic valve. Disp:100 Tablet(s) Refills:1 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:1 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 11. labetalol 100 mg Tablet Sig: 1.5 Tablets PO QAM (once a day (in the morning)): 150 mg every morning. Disp:100 Tablet(s) Refills:1 12. labetalol 200 mg Tablet Sig: 1.5 Tablets PO QPM (once a day (in the evening)): 300 mg every evening. Disp:100 Tablet(s) Refills:1 13. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks. Disp:7 Tablet(s) Refills:0 15. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily) for 1 weeks. Disp:14 Tablet Extended Release(s) Refills:0 16. NPH insulin /humulin N Sig: 3-7 units sliding scale Injection every evening before dinner. Disp:20 100u/ml solutions Refills:1 17. Outpatient Lab Work please draw BUN/creatinine in one week with results to PCP Discharge Disposition: Extended Care Facility: [Hospital1 599] Senior Living Discharge Diagnosis: aortic valve stenosis/insufficiency s/p aortic valve replacement (MECHANICAL) Hypertension Hyperlipidemia Gout Anemia Insulin dependent diabetes mellitus Chronic kidney disease Diabetic neuropathy Gastroesophageal reflux disease 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 Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [Last Name (STitle) ] ([Telephone/Fax (1) 170]) on [6-26] at 1:15pm Cardiologist: Dr [Last Name (STitle) 25982] on [7-2] at 2:20pm Please call to schedule appointments with: Primary Care Dr [Last Name (STitle) 64786] in [5-6] weeks ([Telephone/Fax (1) 83559]) Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication mechanical aortic valve Goal INR 2.5-3.0 First draw Sunday [6-8] Results to [First Name9 (NamePattern2) 2287] [Location (un) 1468] coumadin clinic phone [Telephone/Fax (1) 31020] Completed by:[2104-6-7]	[ "250.60", "357.2", "746.4", "585.9", "403.90", "746.3", "V15.1", "530.81" ]	icd9cm	[ [ [] ] ]	[ "39.61", "35.22" ]	icd9pcs	[ [ [] ] ]	8102, 8162	4172, 5347	314, 446	8435, 8610	2478, 4149	9451, 10238	1568, 1617		5819, 8079		8183, 8414		5373, 5796			8634, 9428									1632, 2459																			232, 276									474, 1025																1047, 1343	1359, 1552
51,890	148,107	41079	Discharge summary	report	Admission Date: [2133-5-18] Discharge Date: [2133-6-1] Date of Birth: [2107-3-17] Sex: F Service: SURGERY Allergies: Penicillins / Shellfish Attending:[First Name3 (LF) 301] Chief Complaint: 1. Obesity with body mass index of 52. 2. Fatty liver. 3. Gallstones. 4. Sleep apnea. 5. Gastroesophageal reflux. 6. Polycystic ovary syndrome. Major Surgical or Invasive Procedure: 1.Laparoscopic cholecystectomy converted to open; open Roux-en-Y gastric bypass. 2.Exploratory laparotomy for removal of foreign body. History of Present Illness: [Known firstname 4890] has class III morbid obesity with weight of 303.7 pounds as of [2133-4-29] with her initial screen weight on [2133-4-7] as 304.6 pounds, height 64 inches and BMI of 52.1. Her previous weight loss efforts have included 3 months of prescription weight loss medication orlistat (Xenical) in [2131] losing 10 pounds that she gained back in two months, 4 months of Slim-Fast in [2131] without results and she also took over-the-counter herbal preparation green tea for weight loss in [2132] but achieved no results. She has not taken over-the-counter ephedra-containing appetite suppressants. Her weight at age 21 was 260 pounds her lowest adult weight with her highest weight being 307.8 pounds on [2133-4-21]. She weighed 220 pounds one year ago. She states she developed a significant weight problems since her teenage years and cites as factors contributing to her excess weight genetics, late night eating, large portions, too many carbohydrates in saturated fats as well as lack of exercise. She denies history of eating disorders or depression. She has not been seen by a therapist nor has she been hospitalized for mental health issues and she is not on any psychotropic medications. Past Medical History: gastroesophageal reflux, hyperlipidemia with elevated triglycerides, obstructive sleep apnea testing use CPAP, vitamin D deficiency, polycystic ovary syndrome, fatty liver and cholelithiasis Social History: She has been smoking two cigarettes a day for 6 years and quit one month ago and has been using Chantix for smoking cessation. She denied recreational drug usage and has alcoholic beverage on rare occasion, does drink both caffeinated and carbonated beverages. She is a student at [Location (un) 6188] Community College studying hospitality. She is single and has no children. She lives with her sister at age 34 and 3 nieces. Family History: father living age 54 with obesity and sister living age 27 with asthma. Physical Exam: VITALS on discharge: Temp-97.8 BP-120/77 P-104 RR-20 O2 100% room air Constitutional: No acute distress; comfortable appearing Neuro: Alert and oriented to person, place and time Cardiac: Regular, rate and rhythm, nl S1,S2 Lungs: CTA Bilaterally, no respiratory distress Abd: Soft, ND, + peri-incisional tenderness, no rebound tenderness/ guarding Wounds: Abdominal midline incision superior aspect intact. Inferior aspect open: wound bed- 100% red granulation tissue, drainage- serosanguinous, periwound edges- no erythema, no edema. Ext: No edema Pertinent Results: Laboratory results: [2133-5-18] 06:32PM BLOOD Hct-33.6* [2133-5-19] 09:05AM BLOOD WBC-12.4* RBC-4.34 Hgb-11.8* Hct-34.3* MCV-79* MCH-27.2 MCHC-34.5 RDW-15.0 Plt Ct-338 Neuts-88.7* Lymphs-6.9* Monos-4.2 Eos-0.1 Baso-0.1 Glucose-125* UreaN-7 Creat-0.7 Na-139 K-4.1 Cl-105 HCO3-27 AnGap-11 ALT-141* AST-122* AlkPhos-44 Amylase-27 TotBili-0.9 Albumin-3.5 Calcium-8.3* Phos-2.7 Mg-1.5* [2133-5-19] 08:00PM BLOOD Type-ART pO2-74* pCO2-46* pH-7.40 calTCO2-30 Base XS-2 [2133-5-20] 03:30AM BLOOD WBC-13.0* RBC-3.81* Hgb-10.5* Hct-30.2* MCV-79* MCH-27.5 MCHC-34.7 RDW-14.9 Plt Ct-329 Glucose-105* UreaN-6 Creat-0.7 Na-137 K-4.1 Cl-103 HCO3-29 AnGap-9 ALT-119* AST-103* AlkPhos-41 Amylase-23 [2133-5-20] 02:06PM BLOOD Calcium-8.6 Phos-1.8* Mg-1.9 [2133-5-20] 03:09PM BLOOD Type-ART Rates-/20 PEEP-5 pO2-81* pCO2-54* pH-7.38 calTCO2-33* Base XS-4 Intubat-NOT INTUBA [2133-5-21] 01:59AM BLOOD WBC-11.5* RBC-3.50* Hgb-9.7* Hct-28.4* MCV-81* MCH-27.7 MCHC-34.2 RDW-14.8 Plt Ct-298 Glucose-78 UreaN-7 Creat-0.6 Na-139 K-3.8 Cl-100 HCO3-31 AnGap-12 Calcium-7.9* Phos-2.6* Mg-1.9 [2133-5-22] 01:46AM BLOOD WBC-11.4* RBC-3.40* Hgb-9.4* Hct-27.1* MCV-80* MCH-27.8 MCHC-34.8 RDW-15.0 Plt Ct-347 Glucose-81 UreaN-6 Creat-0.5 Na-134 K-3.5 Cl-95* HCO3-28 AnGap-15 Calcium-8.2* Phos-2.5* Mg-1.8 [2133-5-23] 06:40AM BLOOD WBC-13.7* RBC-3.49* Hgb-9.7* Hct-28.2* MCV-81* MCH-27.9 MCHC-34.5 RDW-14.8 Plt Ct-365 [2133-5-19] CHEST (PORTABLE AP): IMPRESSION: Findings concerning for retained sponge within the right upper quadrant of the abdomen [2133-5-19] ABDOMEN (SUPINE & ERECT): IMPRESSION: Apparent interval removal of a retained sponge [2133-5-20] CHEST (PORTABLE AP): The lung volumes are low. The heart size is top normal, probably exaggerated by the presence of low lung volumes and portable character of the study. There is a right perihilar opacity that might represent infectious process or may be a combination of infection and asymmetric pulmonary edema. Left lung demonstrates mild interstitial pulmonary edema. Bilateral pleural effusions cannot be excluded. No appreciable pneumothorax is seen. [2133-5-20] CTA CHEST W&W/O C&RECON: IMPRESSION: 1. No evidence of pulmonary emboli. Bilateral moderate atelectasis. 2. No evidence of intra-abdominal fluid collection with close attention paid to the region of the hepatic fossa of the gallbladder as well as at the jejunostomy and gastrojejunostomy site. [2133-5-21] CHEST (PORTABLE AP): IMPRESSION: 1. Stable bibasilar atelectasis and right upper lung zone linear atelectasis. 2. No focal consolidation, pneumothorax or pulmonary edema. [2133-5-23] CHEST (PA & LAT): IMPRESSION: Findings concerning for developing pneumonia and possibly mild fluid overload. [2133-5-24] ABDOMEN (SUPINE & ERECT): Air in the colon and scattered small bowel segments, nonspecific bowel gas pattern. No frank obstruction.No radiopaque foreign body is identified. Clips are present in the right upper quadrant. [2133-5-24] CHEST (PA & LAT): IMPRESSION: Developing pneumonia. [2133-5-25] [Last Name (un) ] DUP EXTEXT BIL (MAP/DVT): No evidence of deep vein thrombosis either right or left lower extremity Microbilogy results: [2133-5-20] URINE CULTURE (Final [2133-5-22]): ESCHERICHIA COLI.>100,000 org/ml [2133-5-20] Blood Culture, Routine (Final [2133-5-26]): NO GROWTH. [2133-5-20] MRSA SCREEN (Final [2133-5-23]): No MRSA isolated. [2133-5-24] Blood Culture: [2133-5-24] Urine Culture: No growth [2133-5-26] SPUTUM GRAM STAIN (Final [2133-5-26]): [12-1] PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. [2133-5-26] Abdominal wound: No growth Brief Hospital Course: Pt was evaluated by anaesthesia and taken to the operating room for laparoscopoic converted to open cholecystectomy and Roux-en-Y gastric bypass. There were no adverse events in the operating room; please see the operative note for details. Pt was extubated, taken to the PACU until stable, then transferred to the [Hospital1 ] for observation. POD 0 ([2133-5-18]): The patient was tachycardic (HR 120-130's)and was given a bolus of 1 litre of intravenous fluids. POD 1 ([2133-5-19]): The patient continued to be tachycardic during the early morning hours. She was afebrile and had no pain. She was scheduled for an urgent UGI of the abdomen to rule out any leak. An abdominal film done at this time showed evidence of a retained foreign body possibly a sponge in the right upper quadrant of the abdomen. She was then taken to the OR for an emergent exploratory laparotomy to remove the sponge. Please see the operative note for details. She was not extubated and transferred to the PACU where she was extubated after a few hours. She was kept on BIPAP overnight on which she stayed very stable. POD 2 ([2133-5-20]): She was transferred to the Trauma ICU where she had a brief episode of desaturation to 80% on 4 L of O2. She was tachycardic and hemodynamically stable through out this period. A CT angiogram of the chest was performed and ruled out any pulmonary embolism. She required 15 L of O2/min during the day and this was further weaned down to 10 L/min overnight. Her diet was advanced to stage 1 which was tolerated very well. She also recieved intravenous lasix 20 mg twice since she was thought to be fluid overloaded. POD 3 ([2133-5-21]): She continued to do well on the 10L/min of O2 which was further weaned down to 4L/min. She had a fever spike to 102 F when she was pan cultured. Her urine culture grew E.coli and she was then started on ciprofloxacin. She recieved a few hous of CPAP overnight. POD 4 ([2133-5-22]): She was transferred to the floor and her diet was advanced to stage II. This was tolerated well. POD 5 ([2133-5-23]): Diet was advanced to stage III which was tolerated well. There was an increase in the WBC count from 11.4 to 13.7. A chest x-ray was done given her persistent O2 requirement, which was concerning for a possible developing pneumonia. POD 6 ([2133-5-24]): She had a fever spike to 101.9F when she was pan cultured again. A Chest x-ray was done that showed developing pneumonia. Also there was an increase in the WBC count noted. POD 7 ([2133-5-25]): She did well during the day except for being tachycardic to 130's & occasionally 140's with activity. She stayed completely asymptomatic throught this period. In view of her rising white count and recent Chest x-ray, Intavenous vancomycin and cefepime were started empirically. POD 8([2133-5-26]): The lower part of abdominal wound appeared erythematous and was hence opened. Wound swabs were sent for gram stain & culture. The gram stain did not show any organisms. She had a fever spike to 101.7F during the day. Otherwise, she conitnued to do well on stage III. Her tachycardia was better than the day before and her HR stayed in the 120's and occasionally in 130's with activity. POD 9([2133-5-27]): The JP was removed and an infectious disease consult was sought. A repeat Chest x-ray was done and blood and urine cultures were sent following their recommendations. She stayed afebrile through out the day. POD 10 ([2133-5-28]): The abdominal wound was examined and a wound vac dressing was placed. Her white cell count was down from 14.7 to 11.7. POD 11 ([2133-5-29]): She remained afebrile with continued intravenous antibiotics; a wound vac remained in place; her tachycardia had resolved and vital signs remained stable. POD 12 ([2133-5-30]): No new events POD 13 ([2133-5-31]): No new events POD 14 ([2133-6-1]): Antibiotics were discontinued with completion of a 7 day course. The vac was removed and the wound was dressed with dry, sterile gauze. The patient's sister was given instruction and demonstrated efficiency in performing the dressing changes. The patient did not have a CPAP machine at home, therefore, it was arranged to have one delivered to her home. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a stage 3 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. A CPAP machine will be delivered to her home with mask fitting and instruction for machine operation. Medications on Admission: omeprazole 20mg OD, MVI 1 tab OD, VitD 5000U OD Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day) as needed for constipation for 10 days. Disp:200 ml Refills:0 2. oxycodone 5 mg/5 mL Solution Sig: One (1) PO every 4-6 hours as needed for pain for 10 days: Please do not drive or operate heavy machinery while taking this medication. Disp:100 ml Refills:0 3. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO BID (2 times a day): Chewable. 4. Vitamin D 5,000 unit Tablet Sig: One (1) Tablet PO once a day: Please crush. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: Open capsule; do not chew beads. Discharge Disposition: Home With Service Facility: CareGroup VNA Discharge Diagnosis: 1. Obesity with body mass index of 52. 2. Fatty liver. 3. Gallstones. 4. Sleep apnea. 5. Gastroesophageal reflux. 6. Polycystic ovary syndrome. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Stay on Stage III diet until your follow up appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: Resume your home medications, CRUSH ALL PILLS. You will be starting some new medications: 1. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. 2. You should begin taking a chewable complete multivitamin with minerals. No gummy vitamins. 3. You will be taking Zantac liquid 150 mg twice daily for one month. This medicine prevents gastric reflux. 4. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 5. You must not use NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. Activity: No heavy lifting of items [11-21] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Please perform dressing changes with dry, sterile gauze twice daily as instructed or more frequently as needed. Please contact Dr. [Last Name (STitle) 15645] office if you have increased drainage from the wound requiring more frequent changes. Also, please call Dr. [Last Name (STitle) ] if you develop redness surrounding the wound and/ or fevers greater than 101F. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Doctor Last Name ], RD,LDN Phone:[Telephone/Fax (1) 305] Date/Time:[2133-6-3] 11:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 304], MD Phone:[Telephone/Fax (1) 305] Date/Time:[2133-6-3] 12:00 Completed by:[2133-6-8]	[ "998.11", "486", "998.4", "278.01", "518.5", "599.0", "530.81", "327.23", "041.4", "998.59", "V85.43", "276.69", "V64.41", "571.8", "574.20", "256.4", "E871.0" ]	icd9cm	[ [ [] ] ]	[ "44.39", "54.92", "38.91", "93.90", "51.22" ]	icd9pcs	[ [ [] ] ]	12498, 12542	7011, 11716	426, 564	12730, 12730	3178, 6988	15254, 15575	2520, 2593		11814, 12475		12563, 12709		11742, 11791			12881, 13447									2608, 2615												2629, 3159							242, 388							14520, 15231		592, 1839							13472, 14508			12745, 12857						1861, 2053	2069, 2504
52,945	116,274	47293	Discharge summary	report	Admission Date: [2195-11-27] Discharge Date: [2195-12-3] Date of Birth: [2130-10-1] Sex: F Service: MEDICINE Allergies: Statins-Hmg-Coa Reductase Inhibitors / Reglan / Pravastatin Attending:[First Name3 (LF) 38277] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname 10528] is a 65 year old woman with diabetes, hypertension, hyperlipidemia, and prior remote left circumflex MI transferred from OSH to our CCU for evaluation and treatment of CHF exacerbation. Two weeks ago she was admitted to OSH for treatment of DKA associated with significant nausea and vomiting and involving a 5 day ICU stay. On transfer to the floor, her family states she got lots of IV and PO fluids out of concern for dehydration and was discharged, by their thoughts, prematurely. According to her family, she entered the hospital weighing 160lbs and left weighing 180lbs. When at home she felt very short of breath and noticed significant lower extremity swelling. She returned to the hospital 3 days later in what was assessed as an acute CHF exacerbation. . She was initially admitted to the floor and was given IV furosemide. Cardiac biomarkers were cycled. Her troponin reached a high of 0.41. Her CK-MB reached a high of 8. Her renal function gradually climbed from 1.5 -> 2.6. UOP decreased and started on dobutamine with improved UOP. She also had a few episodes bradycardia to the 30's which required atropine. This occured in the setting of using the bedpan. On [11-26] she received two units of pRBC's without any diuretics for a drop in hematocrit from 25 to 21. There were no obvious areas of bleeding. She was on [3-6] L nasal cannula prior to her transfer. . On arrival to the CCU, she was on a non-rebreather. She had been transferred on a dobutamine and furosemide drip. She had 300 cc in her foley. She reported her breathing was slightly better than the past few days. . On review of systems, she reports some constipation. She denies any blood in her stools. She still has episodes of nausea. . Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. Past Medical History: CHF Hypertension Diabetes mellitus Chronic Kidney Disease (recent baseline 1-1.5) Episodes of Nausea and Vomiting Hyperlipidemia 1. Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: [2178] left circumflex angioplasty without stent - PERCUTANEOUS CORONARY INTERVENTIONS: Social History: No tobacco or illicits. Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM GENERAL: appears slightly uncomfortable Oriented x3. HEENT: NCAT. Sclera anicteric. Pupils equal. NECK: Supple with JVP of to earlobes. CARDIAC: RRR, no murmurs, rubs, or gallops although difficult to assess given loud lung findings LUNGS: Respirations were unlabored, no accessory muscle use. Diffuse rales mixed with rhonchi in all lung fields. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 1+ clubbing to mid shin SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ DISCHARGE EXAM: Unchanged, except as below General: Comfortable, A&Ox3 Neck: JVP below the clavicle Lungs: CTAB with no crackles in the lung bases Cardiac: RRR, no m/r/g Extremities: No edema, no clubbing or cyanosis Pertinent Results: ADMISSION LABS: [2195-11-27] 06:45PM BLOOD WBC-19.2* RBC-3.46* Hgb-10.3* Hct-30.2* MCV-87 MCH-29.8 MCHC-34.1 RDW-14.7 Plt Ct-183 [2195-11-27] 06:45PM BLOOD Neuts-91.8* Lymphs-6.0* Monos-1.9* Eos-0.1 Baso-0.1 [2195-11-27] 06:45PM BLOOD PT-14.6* PTT-25.3 INR(PT)-1.3* [2195-11-27] 06:45PM BLOOD Plt Ct-183 [2195-11-27] 06:45PM BLOOD Ret Aut-2.6 [2195-11-27] 06:45PM BLOOD Glucose-223* UreaN-50* Creat-2.2* Na-140 K-4.2 Cl-101 HCO3-25 AnGap-18 [2195-11-27] 06:45PM BLOOD ALT-148* AST-63* LD(LDH)-382* CK(CPK)-144 AlkPhos-81 Amylase-44 TotBili-1.8* DirBili-0.7* IndBili-1.1 [2195-11-27] 06:45PM BLOOD Lipase-6 [2195-11-27] 06:45PM BLOOD Albumin-3.7 Calcium-9.3 Phos-4.4 Mg-1.6 [2195-11-27] 06:45PM BLOOD Hapto-267* [2195-11-27] 06:56PM BLOOD Type-ART pO2-83* pCO2-36 pH-7.48* calTCO2-28 Base XS-3 [2195-11-27] 06:56PM BLOOD Lactate-1.4 [2195-11-27] 06:56PM BLOOD O2 Sat-94 PERTINENT LABS AND STUDIES: [2195-11-27] 06:45PM BLOOD CK-MB-7 cTropnT-0.45* [2195-11-28] 04:49AM BLOOD CK-MB-4 cTropnT-0.56* proBNP-9288* [2195-11-28] 03:10PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2195-11-27] BLOOD CULTURE staph coag neg 1/5 bottles [2195-11-28] BLOOD CULTURE ENTEROCOCCUS FAECALIS AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S PENICILLIN G---------- 4 S VANCOMYCIN------------ 1 S [2195-11-29] BLOOD CULTURE ENTEROCOCCUS FAECALIS AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S PENICILLIN G---------- 2 S VANCOMYCIN------------ 1 S [2195-11-30] URINE CULTURE ENTEROCOCCUS SP. 10,000-100,000 ORGANISMS/ML AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S [2195-11-30] URINARY LEGIONELLA ANTIGEN NEGATIVE [2195-11-30] CATHETER TIP CULTURE NEGATIVE [2195-11-29] BLOOD CULTURE X3 PENDING * [2195-11-27] CXR New right PIC line passes to the mid SVC, where the tip is partially obscured by a nasogastric tube that is looped in the stomach and ends at the level of the carina in the esophagus. Nasogastric tube was removed on subsequent radiograph available at the time of this dictation, so I made no attempt at position verification. Heart is moderately enlarged. Lungs are filled with multiple nodules and moderately severe pulmonary edema and/or consolidation. Right pleural effusion is small. No pneumothorax or appreciable left pleural effusion. [2195-11-27] ABDOMEN XRAY AP view of the chest and left decubitus frontal view of the abdomen show marked fecal impaction of most of the colon and a nasogastric tube is looped in the stomach returning to the level of the carina, subsequently removed on chest radiograph performed on [2195-11-28] at 7:50 p.m. and available at the time of this dictation. The absence of appreciable distention of bowel proximal to the impacted colon corroborates an intact ileocecal valve. There may also be a right femoral or inguinal hernia, without evidence of incarceration or obstruction. [2195-11-28] CXR Nasogastric tube has been removed. Right PIC line ends close to the superior cavoatrial junction. Widespread pulmonary opacification, has worsened appreciably, obscuring the margins were previously well defined lung nodules. Pleural effusions may also have increased and cardiomegaly worsened. No pneumothorax. [2195-11-28] ABDOMEN US GALLBLADDER OR LIVER The liver echotexture is coarse. There is no focal intrahepatic lesion or intrahepatic bile duct dilation. A 5-mm calcified granuloma lies within the right lobe. The main portal vein is patent, demonstrating proper hepatopetal flow. The CBD is not dilated, measuring 2 mm. The gallbladder is normal. No ascites is detected. The spleen is not enlarged, measuring 8.7 cm. Bilateral pleural effusions are present. IMPRESSION: 1. Coarsened liver echotexture, suggestive of underlying liver disease. Clinical correlation is recommended and advanced disease such as cirrhosis or fibrosis cannot be excluded with this technique. 2. No intra- or extra-hepatic bile duct dilation. 3. Bilateral pleural effusions. [2195-12-2] CXR Cardiomegaly is stable. Now mild-to-moderate pulmonary edema has improved. There is no evidence of pneumothorax or increasing pleural effusions. The pleural effusions are small and bilateral. There are no new lung abnormalities, lung nodules are not appreciated, and continued followup is recommended until resolution of acute findings of CHF. Brief Hospital Course: 65F with hx of remote LCx MI in [2178], CAD, IDDM, and [Hospital 2091] transferred from OSH for further evaluation and management of acute diastolic CHF exacerbation. ACTIVE ISSUES: # Acute Diastolic CHF Exacerbation: Her echo shows depressed EF 45-50% with inferior wall hypokinesis which does not appear to new finding for her given records of old ECHO's and likely related to her remote LCx infarct. On exam at time of admission she was grossly volume overloaded in her neck, lungs, and extremities. She also has an elevated BNP of 2900 at OSH. This was likely a result of the volume resuscitation she received during a recent admission to an OSH for DKA. She was initially placed on a Lasix drip and was then transitioned back to her home dose of torsemide 20mg daily. She was diuresed to a dry weight of 161 lbs. Her oxygen requirement was weaned and she was able to ambulate without difficulty. Her CXR showed improved edema at the time of discharge and her exam showed resolution of peirpheral edema, JVD and crackles in the lungs. # Concern for NSTEMI/CAD: Ms. [Known lastname 10528] had a previous LCx MI in [2178]. Her anginal symptoms at that time included nausea and vomiting (similar to what she was having at admission). Her troponins were elevated in the context of renal insufficiency and MB's peaked at 8. This is likely a demand ischemia pattern given her lower grade enzyme leak and lack of ischemic findings on CXR although it is concerning because N/V was her prior anginal equivalent. Her CKMB remained not elevated at 7 and then 4. She was treated with Aspirin 325mg PO daily. Restarted on home metoprolol. Did not receive heparin or plavix due to hematocrit drop with unclear source. #Positive BCx and leukocytosis: WBC of 19 on admission with GPC??????s in blood, these subsequently speciated to pan-sensitive Enterococci. Prior CXR showed nodules vs abscess, which were hard to evaluate in setting of prior volume overload, but repeat CXR after diuresis showed absence of nodules. WBC improved and afebrile. BCx from [11-28] shows Enterococcus which is sensitive to amp. She was initially treated with vanc and cefepime, but narrowed to ampicillin when sensitivities returned. At discharge, she will continue on Augmentin 875/125 q12h for a total course of 2 weeks (finish on [12-12]). # Acute on Chronic Renal Failure. Patient has elevated baseline creatinine. During this recent admission her creatinine had increased to 2.6 while her urine output decreased. Cr here on admission is 2.2 and her urine output so far is robust following 100mg IV lasix @ ~100cc/hr. [Last Name (un) ] likely related to prior diuresis and poor forward flow. Her creatinine improved to 1.0 at time of discharge. # Nausea/Transaminitis: As discussed above, patient's anginal equivalent appears to be nausea. It appears that her presentation last week was reported to be in the setting of hyperglycemia and DKA. Has mild-moderate transaminitis on admission labs but negative lipase and amylase. Ultrasound revealed coarse liver echotexture. The patient's symptoms improved throughout her hospital course. # Anemia. Patient has baseline hematocrit of 28-30. Her hematocrit at the OSH decreased from 25 to 21. She received to units of pRBC today but without any lasix chaser per report. Crit 30 here on admission. No active signs of bleeding and she refuses rectal with guiaic. Her hematocrit was stable around 27-32 prior to admission. INACTIVE ISSUES # HTN: She is on metoprolol as an outpatient. We restarted home metoprolol XL 12.5mg daily, lisinopril 10mg daily. # HLD: Intolerant of statins. Restarted home zetia. . # Diabetes: Mildly hyperglycemic to the 200's. Will place on home glargine and insulin sliding scale in-house. Home dose of insulin is 28units AM and 32 units PM; Glargine was increased to 30 units PM and 24 units AM yesterday. ISSUES OF TRANSITIONS IN CARE: CODE: Full Code (confirmed) COMM: daughter PENDING STUDIES AT TIME OF DISCHARGE: blood cultures Medications on Admission: lisinopril 20 daily metoprolol xl 12.5 daily aspirin 81 mg colace 200 mg [Hospital1 ] Lantus 15 units qAM and 25 units qPM insulin sliding scale novolog omeprazole 20 mg TID vitamin D 1000 units daily colestipol 1 gm daily 94 hours away from all other meds) erythromycin 250 mg TID ferrous sulfate 325 mg daily ? percocet prn pain ? torsemide 20 mg daily trazodone 50 mg QHS senna 2 tablets QHS Discharge Medications: 1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: [1-4] Capsules PO BID (2 times a day). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lantus 100 unit/mL Solution Sig: Twenty Eight (28) units Subcutaneous qam. 9. Lantus 100 unit/mL Solution Sig: Thirty Two (32) units Subcutaneous qpm. 10. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: Two (2) Tablet PO once a day. 11. cod liver oil Capsule Sig: Two (2) Capsule PO once a day. 12. multivitamin Tablet Sig: One (1) Tablet PO once a day. 13. insulin aspart 100 unit/mL Solution Sig: solution units Subcutaneous three times a day: Please resume home sliding scale. 14. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 10 days. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: acute diastolic heart failure, acute on chronic renal failure, anemia secondary diagnosis: hypertension, hyperlipidemia, diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 10528], You were admitted for fluid overload due to your congestive heart failure. You received Lasix and torsemide to help you to remove the fluid. Please weigh yourself every morning, call the CCC hotline if your weight goes up by more than 2 pounds in one day or more than 4 pounds in one week. We have changed some of your medications, as described below. Please discuss these changes with your outpatient providers at your follow-up appointment. There was also some bacteria in your blood and urine, we have started an antibiotic which you will continue for 10 days at home, as outlined below. Please note the following changes to your medications: - START: Augmentin 875/125mg every 12 hours for 10 days (last dose on [12-12]) - STOP: trazodone, erythromycin, colestipol, - INCREASE: aspirin from 81mg to 325mg daily - DECREASE: lisinopril from 20mg to 10mg daily - Continue your other medications as prescribed, as outlined on your medication list Please be sure to follow up with your physicians as outlined below. Followup Instructions: Name: [First Name8 (NamePattern2) ] [Last Name (un) ], PA (works with Dr [Last Name (STitle) ] Location: [Location (un) 2274]-[Location (un) ] -Primary Care Address: 111 [Doctor Last Name ] DR, [Location (un) ],[Numeric Identifier 17464] Phone: [Telephone/Fax (1) 17465] Appt: [12-8] at 11:30am Name: Come, [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Location (un) 2274] [Location (un) ], Cardiology Address: [Location (un) ], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 2258] *THe office is working on an appt for you in the next two weeks and will call you at home with the appt. IF you dont hear from them in the next two business days, please call them dircectly to book. Department: DIGESTIVE DISEASE CENTER When: TUESDAY [2195-12-15] at 10:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 100114], MD [Telephone/Fax (1) 85583] Building: [First Name8 (NamePattern2) ] [Hospital Ward Name 1950] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 3202] Campus: EAST Best Parking: Main Garage Department: ENDO SUITES When: TUESDAY [2195-12-15] at 10:15 AM Name: [First Name8 (NamePattern2) ] [Last Name (un) ], PA (works with Dr [Last Name (STitle) ] Location: [Location (un) 2274]-[Location (un) ] -Primary Care Address: 111 [Doctor Last Name ] DR, [Location (un) ],[Numeric Identifier 17464] Phone: [Telephone/Fax (1) 17465] Appt: [12-8**] at 11:30am	[ "285.9", "250.60", "362.01", "412", "357.2", "428.33", "790.4", "250.50", "584.9", "536.3", "403.91", "428.0", "585.6" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	14002, 14008	8228, 8404	342, 348	14201, 14201	3641, 3641	15437, 17092	2598, 2715		12702, 13979		14029, 14029		12278, 12679			14352, 15010									2730, 3404		2448, 2541			3420, 3622									15039, 15414					283, 304		8420, 12252							376, 2236			14139, 14180		3657, 8205	14048, 14118				14216, 14328						2258, 2427	2557, 2582
23,318	173,828	44211	Discharge summary	report	Admission Date: [2151-11-18] Discharge Date: [2151-11-24] Date of Birth: [2080-11-30] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1990] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Pt. is a 70 yo female with PMH of stage IV sarcoidosis, resulting COPD with obstructive and restrictive components, and diastolic CHF who presents with worsening SOB and tacchypnea with resp rates in the 30s. Patient was on steroid taper starting [10-21] and tapered off last thursday. On monday, she reports feeling more sob with productive cough of clear sputum and non-bloody. Denies fever or chills. Feels very wheezy. No travel or sick contacts. [Name (NI) ] flare before this one was last year in [Month (only) ]. She denies URI symptoms, chest pain, nausea, vomiting. She has had decreased appetite recently. Her initial vs in the ED were: T 99.3 P 110 BP 160/70 R 35 100 %O2 sat. . In the ED, she got 2 hrs continuous albuterol and ipratropium bromide nebs as well as 1g of ceftriaxone, 500mg of azithromycin, 125 mg IV solumedrol, and 2 g Mag. She had increasingly acidotic blood gases with pH to 7.19 with pCO2 to 91. She refused intubation. She was started on bipap 35% FIO2, ps 15 peep 5 in the ED prior to transfer and ABG improved to 7.33/63/97/35. . On admission to the [Hospital Unit Name 153], patient's vs were: T 96.5 P 93 BP 128/49 R 21 O2 sat 93% on bipap. She appeared tacchypneic but was able to speak in complete sentences. Pt reports that she felt much better than when she came to the ED. Past Medical History: - sarcoidosis, stage IV, chronic and fibrotic. No h/o ophthalmic, hepatic, dermatologic or renal manifestations - COPD with combined obstructive/restrictive lung disease - on home O2 - HTN - Pulmonary hypertension - diastolic CHF - Anemia Social History: Lives with husband, has three children, retired medical assitant. Denies etoh, tob, drug. Upon questioning she states that she was exposed to tuberculosis as a child (she thinks around age 12) because her uncle and aunt had it. During her adult life, she states that she was checked yearly with the tuburculin skin test which was negative. At one time it was positive, and she had to leave work for a couple of weeks to get it checked out, but said that "it was wrong. With the other tests they knew I didn't have TB". She had subsequent TB tests that were negative, last one years ago. Family History: Cousin with sarcoidosis, no CV disease in family. Physical Exam: Admission: vitals: T 96.5 BP 128/49 HR 93 RR 21 SpO2 98% on bipap 15/5 general: tacchypneic, able to speak in complete sentences heent: NCAT, anicteric, no injectins, PERRLA, MM dry pulm: prolonged I: E ratio, tight wheezing insp and exp but moving air throughout, no crackles cv: tacchy, reg rhythm, no mgr abd: +bs, soft, nt, nd, no masses or hsm extr: no cce, pedal pulses 2+ b/l neuro: A/O x 3 Pertinent Results: CHEST (PORTABLE AP) Study Date of [2151-11-18] 4:33 PM UPRIGHT CHEST: Compared to [2150-12-18] there has been little change. Extensive fibrotic changes in the upper lobes bilaterally and elevated hilar structures. Multiple calcified lymph nodes are unchanged and consistent with changes related to sarcoid. Increased lucency of the more inferior pulmonary tissues demonstrates no new opacities or infiltrates. Position of diaphragms again may represent underlying COPD. Calcified bilateral breast implants appear unchanged as does a _____ right hemiarthroplasty of the shoulder. IMPRESSION: Chronic changes related to sarcoid and underlying COPD. No acute cardiopulmonary process. Brief Hospital Course: 70 yo with severely obstructive COPD from sarcoidosis presents with SOB and hypercapneic respiratory failure. On admission, she was diagnosed with a COPD exacerbation. Given a relatively normal BNP, EF> 75% and dry status on physical exam, her lasix was held; her lasix QOD was eventually restarted after she became euvolemic. She was started on Solumedrol 125mg IV q6hrs, Azithromycin and Ceftriaxone for COPD with moderate amount of yellow/green sputum production. In addition, she was given Ipratropium and Albuterol nebs - initially on continuous Albuterol. She was also started on BiPap for increased respiratory effort, tachypnea and ABG showing severe respiratory acidosis with pH7.21 and pCO2 91. She tolerated BiPap well and was maintained on it for the next two days with intermittent breaks on nasal canula. Her breathing became less labored and serial ABG's showed decreasing hypercapnia. On HD 3, she was transitioned to nasal cannula and was able to maintain oxygen saturations. In addition, her steroid dose was decreased to Prednisone 60mg daily. Placing the patient on PCP prophylaxis given her chronic steroid use was discussed but deferred in the ICU setting. She was transferred to the medical floor where she continued to be stable on 2 L pm Nasal cannula, combivent nebs prn (approx q 4 hours), and 60 mg of prednisone. Her antibiotics were transitioned to oral cefpodoxime and azithromycin was discontinued. She was discharged home with services and a long steroid taper (down by 10 mg every five days) Medications on Admission: Albuterol nebs Atrovent, 2 puffs, 4 x daily Verapamil, 240 mg daily calcium twice daily Singulair, 10 mg nightly Lasix, 20 mg QOD supplemental oxygen 2 l nc iron 325 qd p.r.n. insulin last flu shot was one day prior to admission Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:60 Tablet, Chewable(s) Refills:0 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:180 neb Refills:0 5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:180 neb Refills:0 6. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 7 days. Disp:28 Tablet(s) Refills:0 7. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:30 Tablet Sustained Release(s) Refills:0 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:15 Tablet(s) Refills:0 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) blister inhalation Inhalation twice a day. Disp:1 disc and device Refills:0 10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 inhaler Refills:0 11. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 12. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO TIW. Disp:12 Tablet(s) Refills:0 13. Insulin Regular Human 100 unit/mL Solution Sig: as directed by sliding scale (included) Units, insulin Injection ASDIR (AS DIRECTED): as directed by sliding scale (included). 14. Prednisone 10 mg Tablet Sig: as directed below Tablet PO once a day for 35 days: Starting on [2151-11-25] 6O mg for five days 50 mg for five days 40 mg for five days 30 mg for five days 20 mg for five days 10 mg for ten days then stop. Disp:110 Tablet(s) Refills:0 15. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:1 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: COPD exacerbation Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Return to the [Hospital1 18] Emergency Department for: Shortness of breath Fevers Followup Instructions: Call your primary doctor for a follow up appointment for within two weeks of leaving the hospital: [Last Name (LF) ],[First Name3 (LF) ] L. [Telephone/Fax (1) 3511] Call Dr. [Last Name (STitle) ] for a follow up appointment for within one month of leaving the hospital: ([Telephone/Fax (1) 513]	[ "491.21", "135", "V46.2", "285.29", "401.9", "518.81", "251.8", "428.32", "428.0", "416.8", "276.2", "E932.0" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	7813, 7871	3803, 5334	338, 345	7933, 7942	3083, 3780	8178, 8497	2594, 2646		5613, 7790		7892, 7912		5360, 5590			7966, 8155									2661, 3064																			279, 300									373, 1711																1733, 1974	1990, 2578
67,404	189,155	299	Discharge summary	report	Admission Date: [2115-12-29] Discharge Date: [2116-1-29] Date of Birth: [2060-12-23] Sex: F Service: SURGERY Allergies: Morphine / Oxycodone / Penicillins / Sulfonamides / Vancomycin And Derivatives / Ibuprofen / Dolobid / Naproxen / Clindamycin Hcl Attending:[First Name3 (LF) 148] Chief Complaint: Necrotizing Pancreatitis Cholelithiasis Major Surgical or Invasive Procedure: OR [12-30]: Exploratory laparotomy, open cholecystectomy, intraoperative cholangiogram, common bile duct exploration with choledochoscopy, Pancreatic necrosectomy with wide external drainage, transgastric feeding jejunostomy. IR [1-16]: CT drainage of panc collection w/pigtail placed History of Present Illness: 55F was admitted to [Hospital3 417] with mental status changes and weakness 5 days ago. Of note she has chronic abdominal pain form IBS and chronic bony pain from multiple hips replacements and rheumatoid arthritis. She got a CT today to complete her workup which demonstrated severe necrotizing pancreatitis with gas filled abscess. Here she complains of [11-19] abdominal pain. Denies any n/v/d/c/CP/SOB. Per OSH notes her LFTs have all normalized, her last INR was 1.6 and her WBC on admission was 20. Past Medical History: RA, IBS, GERD, multiple hip replacments Social History: Pt was married for 22 years. Her husband past away recently. She is unable to work secondary to pain and her rheumatoid arthritis. Family History: Non-contributory Physical Exam: PE: 97.4 113 127/69 95%RA NAD AOX3 no scleral icterus, no rashes CTAB RRR distended soft, diffusely tender mild guarding no rebound no c/c/e guiac neg Pertinent Results: [2115-12-30] 12:10AM BLOOD WBC-31.0# RBC-4.14 Hgb-12.0# Hct-34.6# MCV-84 MCH-29.0 MCHC-34.7 RDW-15.5 Plt Ct-298 [2115-12-30] 12:10AM BLOOD PT-24.1 PTT-35.0 INR(PT)-2.3* [2115-12-30] 12:10AM BLOOD Glucose-59* UreaN-11 Creat-0.6 Na-137 K-2.8* Cl-99 HCO3-27 AnGap-14 [2115-12-30] 12:10AM BLOOD Albumin-2.2* Calcium-7.8* Phos-3.5 Mg-2.4 Iron-19* [2115-12-30] 12:40AM BLOOD Type-ART pO2-96 pCO2-35 pH-7.48* calTCO2-27 Base XS-2 [2115-12-30] 12:40AM BLOOD Lactate-1.2 [2115-12-30] 12:10AM BLOOD ALT-20 AST-34 AlkPhos-121* Amylase-183* TotBili-0.8 [2115-12-30] 12:10AM BLOOD Lipase-73* [2115-12-30] 10:06PM BLOOD ALT-33 AST-101* LD(LDH)-429* AlkPhos-161* Amylase-131* TotBili-4.7* PATH: Gallbladder, choLecystectomy: Chronic cholecystitis and cholelithiasis. Abd Xray [12-30]: IMPRESSION: No foreign object resembling the imaged item is identified in the radiograph field. Please note that the right lateral abdomen and the dome of the liver have been excluded from the field of view. Chest Xray [1-1]: IMPRESSION: AP chest compared to [12-30] through 20: Moderate left pleural effusion is larger. Small right pleural effusion persists, right basal atelectasis is improved. Left lung base is obscured, probably severely atelectatic. Heart size is top normal and unchanged. Mediastinal veins slightly engorged. No pulmonary edema. No pneumothorax. ET tube, left subclavian central venous line, and nasogastric tube in standard placements. Chest Xray [1-2]: No pneumothorax. Decrease in left pleural effusion. Bibasilar retrocardiac atelectasis. No edema. Chest Xray [1-5]: IMPRESSION: PA and lateral chest compared to [1-2]: Left lower lobe consolidation is improving, probably resolving atelectasis. Small bilateral pleural effusions probably unchanged. Right lung grossly clear. Heart size normal. Left subclavian line ends at the junction of the brachiocephalic veins. Skin staples and drains noted in the upper midline abdomen and right upper quadrant. Chest Xray [1-15]: Improvement in left lower lobe retrocardiac atelectasis ERCP [1-13]: Contrast extravasation from the pancreatic duct. Nonvisualization of the pancreatic duct within the body and the tail. CT Abdomen [1-14]: No extraluminal contrast identified on non-contrast images. No active extravasation on arterial or venous phase imaging. Large, multiloculated peripancreatic collection with gas and multiple smaller collections associated with the pancreas. A medial catheter courses through a portion of the dominant peripancreatic collection. The visualized pancreatic parenchyma enhances normally, however, due to the close association with the low-density peripancreatic fluid collection, pancreatic necrosis cannot be excluded. Attenuation of the splenic vein, which remains patent CT Guided Drainage [1-16]: Successful placement of 8 French pigtail drainage catheter into left lateral aspect of peripancreatic collection. Overall decreased size of peripancreatic collection compared to two days earlier with near resolution of the lateral portion following today's drainage. CT Abdomen & Pelvis [1-22]: Slight decrease in peripancreatic collections since [2116-1-16] Brief Hospital Course: Ms. [Known lastname 2818] was transferred from an OSH to [Hospital1 18] for further management of her necrotizing pancreatitis. She was placed in the SICU and was aggressively resuscitated with IVF and placed on broad spectrum Abx. She was also noted to have a markedly elevated INR and was reversed with Vitamin K and FFP. She was closely monitored overnight and taken to the OR with Drs. [First Name (STitle) 2819] and [Name5 (PTitle) ] the next morning. She toleratd the procedure well and taken back to the SICU postoperatively. She remained intubated and sedated and on pressors. She came off her pressors on POD 2, and was extubated on POD 3. She remained in the SICU until POD 4 when she was transferrred to the floor. -CVS: Pt rate and rhythm monitored on telemetry. She has been persistently tachycardic in sinus rhythm, controlled with beta blockade which she will continue on discharge to rehab. -RESP: Incentive spirometry encouraged during hospital stay. -GI: OR for pancreatic debridement as above, nutrition provided via J-tube and PO as described below. Post-op constipation treated with aggressive bowel regimen, which she will continue as an outpatient. CDiff toxin was negative on [1-6] and [1-20] -GU: Foley catheter was removed [1-9] and pt was able to void without difficulty. Urine cultures were negative [12-30] and [1-14]. -NEURO: Pain was controlled on the floor with a dilaudid PCA and, when pt started taking PO, changed to PO dilaudid. -ACTIVITY: Pt worked with Physical Therapy on the floor. She did have pain with activity secondary to her Rheumatoid Arthritis but was able to walk with assistance. -F/E/N: Electrolytes were monitored and repleted regularly. Pt maintained on tube feeds while recovering from surgery. Diet was advanced slowly as tolerated and tube feed were stopped when pt was taking adequate PO. -ID: Pt was treated with empiric antibiotics post-operatively until culture and sensitivity data was available. Her positive cultures were: Pan-sensitive E.Coli from OR culture of pancreatic abscess on [12-30], MRSA from IR culture of pancreatic abscess on [1-16], MRSA on culture from biliary drain on [1-21]. Antibiotic therapy during her hospital stay was as follows: Fluconazole ([Date range (1) 2820]); Meropenem ([Date range (1) 2821]); Cipro([Date range (1) 2822], [1-17]-ongoing at d/c); Vancomycin ([1-17]-ongoing at d/c). She was persistently febrile for a period on the floor and was worked up appropriately. Blood cultures were all negative. Her symptoms improved with vanc/cipro and will maintaining her biliary drain to gravity. -T,L,D: Feeding jejunostomy, biliary drain, 2x #19 [Doctor Last Name 406] drains were placed in the OR: 1x #19 [Doctor Last Name 406] drain was placed in the pancreatic necrosectomy bed cavity in the lesser sac from the right side of the abdomen through the omentum where it was curled up liberally & oversewn w/the omental attachments to the transverse mesocolon again in order to close down the lesser sac and contain any leakage from it. 1x #19 [Doctor Last Name 406] drain was placed in the gallbladder fossa by the biliary drain--both intraop Blakes enter on the right abdomen. On [1-16] an 8F [Last Name (un) 2823] pigtail drain was placed by IR via left lateral into the pancreatic necrosectomy bed to further aid in drainage. The biliary drain was capped on [1-18] but was uncapped on [1-20] due to fevers. The coiled [Doctor Last Name 406] in the necrosectomy bed was pulled back by 3 inches on two occasions and will be slowly withdrawn on future follow-up visits in order to ensure slow and permanent collapse of the space. Right-sided PICC line was placed for antibiotics [1-25] and confirmed to terminate in the RA [1-26]. Medications on Admission: Omeprazole, Clonazepam, Levothyroxine, Citalopram, Dilaudid, Hysocamine, Furosemide Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [Month/Year (2) ]: One (1) Injection TID (3 times a day). 2. Insulin Regular Human 100 unit/mL Solution [Month/Year (2) ]: 1-16 units Injection ASDIR (AS DIRECTED): please see sliding scale. 3. Levothyroxine 100 mcg Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 4. Miconazole Nitrate 2 % Powder [Month/Year (2) ]: One (1) Appl Topical QID (4 times a day) as needed. 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 6. Hydromorphone 2 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 7. Acetaminophen 500 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO Q 8H (Every 8 Hours). 8. Ciprofloxacin 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q12H (every 12 hours). 9. Ondansetron HCl (PF) 4 mg/2 mL Solution [Last Name (STitle) ]: One (1) Injection Q8H (every 8 hours) as needed. 10. 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. 11. Vancomycin 1000 mg IV Q 12H please pre-medicate with benadryl and watch for redman syndrome 12. DiphenhydrAMINE 25 mg IV Q6H:PRN premedicate for vancomycin 13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 14. Fentanyl 75 mcg/hr Patch 72 hr [Last Name (STitle) ]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 15. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [Last Name (STitle) ]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 16. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [Last Name (STitle) ]: 15-30 MLs PO QID (4 times a day) as needed for constipation. 17. Calcium Carbonate 500 mg Tablet, Chewable [Last Name (STitle) ]: One (1) Tablet, Chewable PO BID (2 times a day). 18. Docusate Sodium 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO BID (2 times a day) as needed for constipation. 19. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day): Please hold for HR<60, SBP<90. 20. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 21. Lactulose 10 gram/15 mL Syrup [Last Name (STitle) ]: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 22. Polyethylene Glycol 3350 100 % Powder [Last Name (STitle) ]: Seventeen (17) g PO DAILY (Daily) as needed for constipation. 23. Multivitamin,Tx-Minerals Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 24. Magnesium Hydroxide 400 mg/5 mL Suspension [Last Name (STitle) ]: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary Diagnosis: Infected pancreatic necrosis, cholelithiasis Secondary Diagnoses: GERD, Rheumatoid arthritis, IBS Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * 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. Other: Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: You will need to follow up with Dr. [Last Name (STitle) ] in 2 weeks in clinic. You will also have an appointment for CT scan of your abdomen on the same day. Please call [Telephone/Fax (1) 1231] to arrange this	[ "574.70", "511.9", "428.0", "785.0", "564.1", "041.12", "714.0", "789.59", "564.00", "286.9", "041.4", "997.4", "577.0", "E878.8", "530.81", "V43.64", "518.0" ]	icd9cm	[ [ [] ] ]	[ "51.85", "38.93", "51.22", "87.53", "52.01", "96.71", "51.41", "44.39", "52.22" ]	icd9pcs	[ [ [] ] ]	11821, 11893	4958, 8812	430, 725	12054, 12063	1701, 4935	13594, 13817	1496, 1514		8946, 11798		11914, 11914		8838, 8923			12087, 13234							13249, 13571		1529, 1682	11999, 12033																		351, 392									753, 1268						11933, 11978										1290, 1332	1348, 1480
64,332	159,531	1267	Discharge summary	report	Admission Date: [2191-3-27] Discharge Date: [2191-3-29] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1838] Chief Complaint: seizure and unresponsiveness Major Surgical or Invasive Procedure: intubation neuro-intervention/clot retrieval History of Present Illness: 88RHF Russian-speaking with a past history of HTN, HLD, vertigo treated with meclizine presented with collapse and unresponsiveness and then proceeded to have a seizure and intubated in the ED for airway protection. Prior to presentation, patient had been feeling unwell for the past 2 days with significant vertigo (which is a chronic issues for her) with nausea and vomiting and treated with meclizine. She last vomited [2191-3-26]. Patient was otherwise more tired and fatigued. Patient was last seen well at 10pm on [2191-3-26] and went to bed. She had been staying overnight at her daughter's house. However at 22:30, her daughter heard a bang and found her on the floor completely unresponsive and not moving. EMS were called and in the ambulance had a GTC seizure with eye deviation to the rightand was given 2mg IV lorazepam. On arrival to the ED, she was intubated for airway protection. This was not traumatic. On insertion of an OG tube, there was drainage of dark red blood. She had no episodes of hematemesis prior to this per her daughter. CT showed right temporal and occipito-parietal hypodensities in keeping with a right PCA distribution. She was markedly hypertensive to 220s/120 and was given IV labetalol 20mg which transiently lowered her BP to 120s systolic and on stopping propofol this came back into the 160s range. She was then taken to CTA whch showed a left ICA T occlusion (and a right MCA occlusion in retrospect). Given the presence of an UGI bleed it was felt that thrombolysis would be contraindicated and hence a dscussion was g=held with the family by the stroke fellow Dr [Last Name (STitle) 7886] and latterly by Dr [Last Name (STitle) ], attending physician regarding possible [Name9 (PRE) 7887]. The family agreed and the patent went on to have the left ICA opened up which was patent other than an area in the left ACA as the A2 segment was still occluded. The right MCA had a distal clot and was not intervened upon. The patient was transferred to the ICU. Patient was intubated and sedated and would withdraw right>left legs and have extensor posturing of the arms at times with some withdrawal ainly on the right. Continued to drain dark red blood from her OG tube but remained hemodynamically stable. On neuro ROS, the pt denied the following symptoms to daughter before the time of last seen well - headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt notes recent vertigo with vomiting (a chronic issue) denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: HTN HLD Vertigo (likely BPPV given description) treated with Meclizine. Several episodes each year always associated with nausea/vomiting. The patient is intolerant of car motion. Anxiety Varicose veins. Vitamin D deficiency. Decreased hearing bilaterally. History of "inflamed adnexa". Previous skin ca with excision PSurg HX: Skin ca operation Social History: The patient lives alone but on this occasion was staying at daughter's. Chernobyl in [2165]. She moved to the U.S. in [2168]. Occupation: Mobility: Unaided but somewhat unsteady per family Smoking: Never Alcohol: No Illicits: Denies Lived near Family History: Mother - died 100 of old age Father - nil of note Sibs - 1 Brother has hypertension, s/p nephrectomy for renal cancer, and h/o prostate cancer. Children - well save son with [Name2 (NI) 499] ca There is no history of seizures, developmental disability, learning disorders, migraine headaches, strokes at age less than 50, neuromuscular disorders, or movement disorders. Physical Exam: ADMISSION PHYSICAL EXAM: Physical Exam: Vitals: T 99.2F BP 220/109 HR 69 SR sO2 100% on 100% O2 on vent RR18 General: Intubated and sedated. OG tue draining dark red blood. Some spontaneous movement in right leg and intermittent extensor posturing of upper limbs. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: NIH Stroke Scale score was 18 1a. Level of Consciousness: 2 1b. LOC Question: 2 1c. LOC Commands: 2 2. Best gaze: 0 3. Visual fields: UN 4. Facial palsy: 0 5a. Motor arm, left: 3 5b. Motor arm, right: 2 6a. Motor leg, left: 2 6b. Motor leg, right: 2 7. Limb Ataxia: UN 8. Sensory: 0 9. Language: 3 10. Dysarthria: UN 11. Extinction and Neglect: UN -Mental Status: Patient intubated and sedated. Unable to verablise. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2.5 on left and 2mm on right and reactive bilaterally. Funduscopic exam revealed no papilledema, exudates, or hemorrhages although somewhat challenging fundoscopy. III, IV, VI: Slight Doll's eye. V: Unable to assess - patient winces to painon face. VII: Facial musculature grossly symmetric and intubated. VIII: Unable to assess. IX, X: Present cough and gag. [Doctor First Name 81]: Unable to assess. XII: Unable to assess. -Motor: Normal bulk, tone throughout. No asterixis. Bilateral extension episodes spontaneously and to pain in UEs with more movement on right. In [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] leg withdraws and left leg less well. -Sensory: Wiothdraws to pain all 4 limbs. -DTRs: Reflexes brisk throughout. Plantar response was extensor bilaterally. -Coordination: Unable to assess. -Gait: Unable to assess. EXAM AT THE TIME OF EXPIRATION (5:30pm on [2191-3-29]) Pt's pupils were fixed and dilated There was no spontaneous respirations or hearbeat auscultated or palpated Her extremities were cool to palpation Pt had no corneal, Doll's or gag reflex Pt did not move any of her extremities to noxious stimulus Pertinent Results: ADMISSION LABS: [2191-3-26] 11:30PM BLOOD WBC-15.2* RBC-4.67 Hgb-13.6 Hct-39.4 MCV-84 MCH-29.2 MCHC-34.6 RDW-12.8 Plt Ct-406 [2191-3-26] 11:30PM BLOOD PT-11.5 PTT-25.5 INR(PT)-1.1 [2191-3-26] 11:30PM BLOOD Fibrino-460* [2191-3-27] 08:34AM BLOOD Glucose-109* UreaN-13 Creat-0.7 Na-143 K-3.9 Cl-113* HCO3-22 AnGap-12 [2191-3-27] 08:34AM BLOOD ALT-10 AST-21 LD(LDH)-168 CK(CPK)-215* AlkPhos-108* TotBili-0.2 [2191-3-26] 11:30PM BLOOD Lipase-70* [2191-3-27] 08:34AM BLOOD CK-MB-8 cTropnT-<0.01 [2191-3-27] 08:34AM BLOOD Albumin-3.0* Calcium-7.6* Phos-4.4 Mg-1.7 Cholest-216* [2191-3-27] 08:34AM BLOOD %HbA1c-5.8 eAG-120 [2191-3-27] 08:34AM BLOOD Triglyc-179* HDL-35 CHOL/HD-6.2 LDLcalc-145* [2191-3-28] 02:21AM BLOOD Osmolal-299 [2191-3-26] 11:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2191-3-27] 02:08AM BLOOD Type-ART Temp-36.7 Rates-20/0 Tidal V-400 PEEP-5 FiO2-100 pO2-363* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 AADO2-313 REQ O2-58 -ASSIST/CON Intubat-INTUBATED [2191-3-26] 11:35PM BLOOD Glucose-169* Na-141 K-3.9 Cl-106 calHCO3-21 [2191-3-27] 04:45AM BLOOD Hgb-12.2 calcHCT-37 [2191-3-27] 04:45AM BLOOD freeCa-1.05* LABS ON DAY OF EXPIRATION: [2191-3-29] 05:40AM BLOOD WBC-21.3* RBC-3.86* Hgb-11.6* Hct-34.3* MCV-89 MCH-30.0 MCHC-33.7 RDW-13.3 Plt Ct-301 [2191-3-29] 05:40AM BLOOD Glucose-120* UreaN-17 Creat-1.0 Na-175* K-2.9* Cl-GREATER TH HCO3-22 [2191-3-29] 05:40AM BLOOD Calcium-9.4 Phos-1.3# Mg-3.0 Brief Hospital Course: [Known firstname 440] [Known lastname 7888] is an 88RHF with HTN previously functional presented with collapse and unresponsiveness at 10:30pm on [3-26] and subsequent GTC seizure found on CT to have right occipital and temporal hypodensities, hyperdense right superior division of MCA and left ICA T occlusion on CTA. Patient had significant UGI bleeding on OG lavage (non-tramautic intubation) - as a result, although she was in the window for tPA, this was not given because of the UGI bleeding. After the family's consent, she underwent neuroendovascular intervention for clot retrieval. Patient was taken to intervention where left ICA was opened up. The superior division of the right MCA was occluded by clot and was not intervened upon. These strokes were most probably cardioembolic in origin. She remained unresponsive with a very limited exam, that progressed to loss of brainstem reflexes throughout her stay. . # NEURO: She was initially given mannitol to help with swelling, but she became hyperosmotic and hypernatramic and this was therefore stopped. She was unable to maintain an adequate BP without pressor support. Phenylephrine was thus started. This was continued until she was made [Month/Year (2) 3225] and terminally extubated on [2191-3-29]. Prior to being made [Date Range 3225] she was continued on keppra 750mg [Hospital1 ] to help prevent further seizures. She expired after terminal extubation at 5:30pm on [2191-3-29]. . # Cardiovascular: pt was monitored on telemetry, and was noted to have episodes of likely atrial fibrillation (didn't get a confirmatory EKG). She was put on atorvastatin and ASA of 81mg QD. . # Pulmonary: pt was terminally extubated on [2191-3-29] once pt's son arrived and agreed to [Name (NI) 3225] status. She expired at 5:30pm on [2191-3-29] with her family at the bedside. . # Gastrointestinal / Abdomen: Pt's presentation included an initial concern for a GI bleed, but pt had been hemodynamically stable with no additional episodes of bleeding. She was continued on pantoprazole. . # ENDO: pt was on an insulin sliding scale while here to minimize further neurological injury from hypo or hyperglycemia. . # FEN: pt was NPO given that she was unresponsive. . # PPX: pt was unable to be get SQH given her massive stroke, so she was put on pneumoboots for DVT ppx. . # CODE: Pt was full code on arrival, which was then changed by the family to DNR/DNI and then finally [Date Range 3225] prior to terminal extubation on [2191-3-20]. Medications on Admission: Lisinopril 20 mg daily Sertraline 50 mg p.o. daily. Chlorthalidone 25 mg daily Omeprazole 20 mg p.o. daily Vitamin B12 p.o. daily Xanax 0.5 mg p.o. nightly. Tolterodine 4 mg p.o. daily. Aspirin 81 mg p.o. daily. Meclizine 12.5 mg b.i.d. Tylenol 500 mg p.o. b.i.d. Valerian as needed. Discharge Medications: N/A Pt expired Discharge Disposition: Expired Discharge Diagnosis: Stroke seizure Discharge Condition: Please see discharge summary for physical exam at time of expiration. Discharge Instructions: N/A Pt expired at 5:30pm on [2191-3-29] Followup Instructions: N/A pt expired at 5:30pm on [2191-3-29]	[ "780.39", "V49.86", "300.00", "401.9", "E884.4", "276.0", "780.01", "578.0", "V10.83", "272.4", "427.31", "348.5", "348.4", "386.11", "V66.7", "389.9", "268.9", "434.11" ]	icd9cm	[ [ [] ] ]	[ "96.04", "00.44", "39.74", "88.41", "96.71", "00.41" ]	icd9pcs	[ [ [] ] ]	11304, 11313	8379, 10930	289, 335	11372, 11444	6830, 6830	11536, 11583	4101, 4477		11265, 11281		11334, 11351		10956, 11242			11468, 11513						5615, 6811			4532, 5530																			221, 251									363, 3441					6847, 8356					5545, 5598						3463, 3815	3831, 4085
29,736	136,597	3418	Discharge summary	report	Admission Date: [2179-9-22] Discharge Date: [2179-9-28] Date of Birth: [2113-7-28] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Percocet Attending:[First Name3 (LF) 5790] Chief Complaint: new right upper lobe nodule- FDG avid Major Surgical or Invasive Procedure: right upper lobe wedge History of Present Illness: Ms. [Known lastname 14209] is a 66-year-old woman who had a colectomy for T4 N1 colon cancer in [2173]. She underwent adjuvant chemotherapy and in [2176] developed several pulmonary nodules. A VATS right middle lobe and right lower lobe wedge resection was performed in [2177-6-16] which revealed metastatic foci in those specimens. She suffered an empyema postoperatively. She now has a new right upper lobe nodule which is growing and FDG avid. Past Medical History: Colon CA s/p LAR [12-19], s/p VATS RUL/RML/RLL wedge bx [6-20] c/w colon mets p/w RUL nodule at staple line, hypothyroidism, appendectomy Brief Hospital Course: Pt was admitted and taken tot he OR [2179-9-22] for right upper lobe wedge resection. An epidural was paced for apin control w/ good effect. Post op pt was hypotension requiring neo gtt and ICU admission. R'd/O for MI via enzymes. 2 right chest tubes to sxn w/ air leak and mod amt serosang drainage. CXR showed right upper lobe collection presumably blood. Chest tubes stripped and subsequent CXR w/ resolution of hemothorax. Pt was transfused 2UPRBC for post op anemia. On POD#2 - neo was weaned off neo w/ stable SBP and transferred from ICU. POD#3 chest tubes placed to waters eal w/ stable CXR. anterior chest tube d/c'd. POD#4 epidural d/c'd and pain well controlled on po pain med. POD#5 remaining chest tube - clamping trial w/ stable cxr. POD#6 repeat CXR stable -Chest tube unclamped w/ minimal drainage. chest tube removed - cxr stable. pt d/c'd to home. Medications on Admission: Cyanocobalamin 1000 qmo, levoxyl 100, MVI, Vit D 1000U . Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:75 Tablet(s) Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. Discharge Disposition: Home Discharge Diagnosis: Colon CA s/p LAR [12-19], s/p VATS RUL/RML/RLL wedge bx [6-20] c/w colon mets p/w RUL nodule at staple line, hypothyroidism, appendectomy Discharge Condition: good Discharge Instructions: call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 170] if you develop chest pain, shortness of breath, productive cough, fever, chills, redness or drainage from your incision. You may shower on thursday. after showering, remove your chest tube site dressing and cover the site with a lean bandaid daily until healed. Take a mild laxative while you are taking pain medication to avoid constipation. Followup Instructions: You have a follow up appointment with Dr. [Last Name (STitle) ] on [10-12] at 10:30am in the [Hospital Ward Name ] building [Location (un) 448] chest disease center. Please arrive 45 minutes prior to your appointment and report to the [Location (un) ] clinical center for a CXR. Completed by:[2179-9-30]	[ "V10.05", "197.0", "512.1", "285.1", "458.29", "197.2" ]	icd9cm	[ [ [] ] ]	[ "34.23", "33.23", "32.20" ]	icd9pcs	[ [ [] ] ]	2747, 2753	1039, 1910	327, 352	2943, 2950		3405, 3735			2018, 2724		2774, 2922		1936, 1995			2974, 3382																												250, 289									380, 845																867, 1016
16,680	172,777	5591	Discharge summary	report	Admission Date: [2157-11-18] Discharge Date: [2157-11-23] Date of Birth: [2085-6-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 19193] Chief Complaint: Hypertensive emergency. Major Surgical or Invasive Procedure: None. History of Present Illness: Mrs. [Known lastname 22473] is a 72 yo woman with a h/o poorly controlled HTN, CRI (recent baseline 3.5-4.2), and DM2 who presented with hypertension and chest pain. She was recently admitted to the medicine service from [11-2] - [11-5] for peripheral extremity tingling and shortness of breath. During this admission, she was ruled out for an MI, transfused 2 units PRBC for anemia, and spironolactone was stopped secondary to hyperkalemia. Over the past few days at home, she c/o a sore throat, cough and congestion. She states that her husband has similar sxs. Her cough is productive of whitish sputum. She has not had any fevers or sweats, but c/o chills. She c/o several months of DOE with climbing 10 steps at her home, worse when she is carrying her laundry. At these times, she also c/o left sided CP which is dull in nature, nonradiating, and lasts for up to one minute. Her last episode was last night. She does not c/o PND/orthopnea. She had increased bilateral LE edema over the past few days and came into the ED for evaluation. She states her appetite has been poor recently and she has lost [10-15] lbs over the past few months. She c/o nausea but no emesis. No bleeding from her stools. She c/o dysuria, no hematuria, no decreased frequency or quantity of urine. She also has constipation and complains of gas. She has a right inguinal hernia which has been more bothersome lately. She does not c/o HA, abdominal pain, or focal neurologic sxs. In the ED, her BP was initially 210/120. She was given Lopressor 5 mg IV x 3, 25 mg po x 1, ASA 325 mg po x 1, Clonidine 0.2 mg po x 1 and then started on a Labetolol gtt at 2 mg/min which was subsequently increased to 4 mg/min. She was then given Lisinopril 20 mg po x1, and Lantus 30 units. Her SBP improved to 180/80. She did not have any CP. Her WBC was found to be 15 and she was given a dose of Levofloxacin 500 mg po x 1. Past Medical History: 1) Chronic renal insufficiency: followed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10083] at [Last Name (un) ]. (Baseline over the past 3 months 3.5-4.2). 2) HTN: Prior MRA showed three left renal arteries with superior artery significant for renal artery stenosis. Several recent admissions with HTN urgency in MICU/CCU. 3) Small hiatal hernia with severe GERD sx. 4) DM2: started insulin [2157-8-1]. 5) Osteoporosis. 6) Vertebral fractures. 7) History of depression. 8) Anxiety. 9) Hypercholesterolemia 10) Chronic constipation. 11) Sickle cell trait. 12) Osteoarthritis. 13) Status post left knee replacement. 14) History of mechanical falls. 15) Total hysterectomy - about 20 years ago. Social History: Patient from Barbados, lives with husband, never used tobacco, no EtOH. Family History: Father died of old age, mother had DM, HTN Physical Exam: PE: 96.0 180/80 55 19 100%RA GEN: A+O x 3, NAD, laying in bed, thin AA female HEENT: PERRL, EOMI, OP clear without exudates, no LAD or thyromegaly CV: RRR, no m/r/g, JVD 6 cm LUNGS: CTAB ABD: soft, distended, NTND +BS, +left inguinal hernia that was nontender EXT: 1+ pitting edema bilaterally, decreased peripheral pulses Neuro: 5/5 strength in all extremities, decreased sensation at feet bilaterally, CN II-XII intact Pertinent Results: LABS: Discharge CBC: wbc 5.5, hct 32.4, plt 156 Discharge electrolytes: Na 134, K 4.6, Cl 102, HCO3 19, BUN 129, Cr 4.8, glucose 72, Ca 8.2, Mg 2.1, Ph 7.3 Troponin trend: 0.2 -> 0.18 -> 0.18 -> 0.19 -> 0.19 -> 0.17 U/A: WNL MICROBIOLOGY: [11-18] Blood culture: negative. [11-18] Urine culture: negative. IMAGING: CHEST (PORTABLE AP) [2157-11-18] There is prominence of the pulmonary vasculature indicating mild congestive heart failure with cardiomegaly and small bilateral pleural effusion. No pneumothorax is seen. IMPRESSION: Mild congestive heart failure with cardiomegaly. ECHO [2157-11-21] Conclusions: The left atrium is moderately dilated. The right atrium is markedly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([1-2]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. Compared with the prior study (tape reviewed) of [2157-5-18], systolic function appears slightly more vigorous today and systemic blood pressure at the time of the study is lower today. Brief Hospital Course: Mrs. [Known lastname 22473] is a 72 year old woman with a history of diabetes, chronic kidney disease that has recently been deteriorating (over last few months baseline creatinine has increased from 2 to 4), and poorly controlled hypertension on multiple antihypertensive agents. She was admitted to MICU on [11-18] with hypertensive emergency characterized by SBP in 220's, anginal chest pain, shortness of breath and edema in lower extremities. In MICU, a labetalol drip was required to control blood pressure, but she is now back on her home regimen of antihypertensives with the only change being a slight increase in her dose of isosorbide mononitrate. At this point she was transferred to the medical floor. 1. Hypertension: Her blood pressure stayed stable on her regimen of multiple anti-hypertensives (Labetolol, Valsartan, Lisinopril, Amlodipine, Hydralazine, Imdur, Clonidine, Lasix). Her difficult to control blood pressure is almost certainly due to her extensive renal disease and ultimately her treatment for her blood pressure will require hemodialysis. This was emphasized to her and she is at this point reluctant to start HD. Since there was no acute need for HD during this hospitalization, she was discharged to home and she will let her PCP (Dr. [Last Name (STitle) 16258] and her renal physician (Dr. [First Name (STitle) 10083] know about her plans for hemodialysis in the future. 2. Chest pain: Her chest pain and initial EKG changes (deep T wave inversions) were thought to be due to her initial hypertension in the ED. The cardiology service was notified and involved in her care and thought she had demand ischemia in the setting of hypertension. Her EKG changes resolved with correction of her blood pressure and her cardiac enzymes remained flat (their slight elevation was likely due to her chronic renal failure). An echocardiogram was done which revealed normal systolic function and no wall motion abnormalities. She was continued on her anti-hypertensives as well as aspirin. She will likely have a p-MIBI as an outpatient at the discretion of her PCP. 2. CRI: She was followed by her nephrologist, Dr. [First Name (STitle) 10083], while she was hospitalized. Her renal function and hypertension have reached the level where she will soon likely need hemodialysis. Again, she was resistant to starting this during this hospitalization and will discuss this with her family before contacting Dr. [First Name (STitle) 10083] and Dr. [Last Name (STitle) 16258] regarding the timing of starting hemodialysis. Her renal medications included sevelamer 1600 tid and epo 10,000 units weekly. 3. DM: She was continued on lantus with a sliding scale and was in adequate control during her hospitalization. At discharge she was instructed to take lantus 28 units daily and continue to use a sliding scale. 4. Anemia: Her anemia is thought to be a combination of her sickle cell trait, chronic disease, and her renal disease. At discharge her hct was stable around 32 and she was restarted on epo. 5. GERD: She was maintained on pantoprazole twice daily. Medications on Admission: 1. Labetalol 800 mg PO TID 2. Atorvastatin 10 mg PO DAILY 3. Pantoprazole 40 mg PO once a day. 4. Ferrous Sulfate 325 PO DAILY 5. Lisinopril 20 mg PO BID 6. Valsartan 100 mg PO HS 7. Hydralazine 100 mg PO TID 8. Clonazepam 1 mg PO daily 9. Clonidine 0.9 mg let PO BID 10. Isosorbide Mononitrate 90 mg Sustained Release PO DAILY 11. Folic acid 1 mg daily 12. Procrit 10,000 unit/mL 10,000 units Injection once a week. 13. Insulin Lantus 30 units QAM 14. Lasix 30 mg PO twice a day 15. MVI 1 tablet daily 16. B12 50 mcg po daily 17. Tylenol prn arthritis 18. Sevelemer 800 mg three times daily 19. ASA 81 mg daily 20. Amlodipine 10 mg daily Discharge Medications: 1. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 7. Clonidine 0.3 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:60 Tablet Sustained Release 24HR(s) Refills:2 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Epoetin Alfa 4,000 unit/mL Solution Sig: 10,000 U Injection once a week. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: 1. Hypertensive emergency 2. Demand ischemia 3. ESRD Discharge Condition: Stable on her home BP regimen. TTE unchanged. Needs to have a P-MIBI for a complete evaluation to rule out coronary disease as did have demand ischemia in the setting of severe hypertension Discharge Instructions: Please take all your medications as directed. Please take insulin (lantus): note new dose; 28U qhs. Please come to the emergency room should you experience any CP/dyspnea/fevers/chills or other concerning symptoms Followup Instructions: 1. Please follow up with your PCP within next weeks. 2. Please follow up with your kidney doctors within next [Name5 (PTitle) 15935] weeks 3. Your PCP should refer you for a stress test to make sure you do not have coronary artery disease Completed by:[2157-11-24]	[ "733.00", "553.3", "250.00", "276.7", "285.9", "282.5", "585.6", "300.4", "403.91", "530.81" ]	icd9cm	[ [ [] ] ]	[ "99.04" ]	icd9pcs	[ [ [] ] ]	10434, 10492	5250, 8376	342, 349	10589, 10781	3644, 5227	11045, 11320	3143, 3187		9066, 10411		10513, 10568		8402, 9043			10805, 11022									3202, 3625																			279, 304									377, 2285																2307, 3037	3053, 3127
28,403	134,343	1012	Discharge summary	report	Admission Date: [2108-11-14] Discharge Date: [2108-11-22] Date of Birth: [2041-5-8] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Exploratory laparotomy Lysis of adhesions Incisional hernia repair History of Present Illness: 67yo female with an extensive medical history including Hep C/cirrhosis, T2DM, recurrent colorectal CA s/p resection x2, now with colostomy, h/o melanoma s/p XRT, and h/o recurrent SBOs, transferred here from [Hospital6 5016] with likely SBO. Patient reports sudden onset of diffuse abdominal pain last night around 7pm with decreased output from her ostomy. She presented to [Hospital3 ] at 4am with severe abdominal pain, nausea, and vomiting, non bloody, non bilious. She received pain medications at the OSH and had a KUB which showed no obstruction and no dilated loops of bowel. She did not require an NGT. Her nausea and vomiting resolved early this afternoon. Her pain is improving. She reports normal output in her ostomy bag tonight. Past Medical History: Cirrhosis [2-10] chronic Hepatitis C, Genotype 1, with Grade II varices Diabetes mellitus, Type II Recurrent colorectal cancer s/p resection x2, now with colostomy Hypertension h/o melanoma s/p R inguinal node dissection and XRT Depression Social History: Lives at home with her husband. [Name (NI) 4084] smoked, rarely drinks EtOH. Family History: No significant history of malignancy, DM2, HTN or heart disease. Physical Exam: Vitals: T: 97.5 BP 125/60 HR 51 RR 18 O2sat 98% General: NAD, appropriate Pulm: CTAB, no wheezes, crackles, rales CV: RR, nl S1 S2, II/VI systolic murmur Abd: obese with panus, soft, non distended, mildly tender to palpation - especially periumbilically, hypoactive BS, L sided ostomy with normal output Ext: RLE with pitting edema to knee w/ venous stasis, no increased warmth or tenderness compared with LLE; LLE no edema Pertinent Results: [2108-11-22] 05:16AM BLOOD WBC-2.5* RBC-2.89* Hgb-7.8* Hct-23.1* MCV-80* MCH-27.1 MCHC-33.8 RDW-18.8* Plt Ct-96* [2108-11-14] 08:00PM BLOOD WBC-8.1# RBC-3.56* Hgb-9.6* Hct-28.4* MCV-80* MCH-27.0 MCHC-33.9 RDW-17.7* Plt Ct-119* [2108-11-17] 03:04PM BLOOD Neuts-86.1* Bands-0 Lymphs-8.4* Monos-3.7 Eos-1.6 Baso-0.1 [2108-11-14] 08:00PM BLOOD Neuts-74.9* Lymphs-15.7* Monos-4.7 Eos-4.3* Baso-0.4 [2108-11-22] 05:16AM BLOOD Plt Ct-96* [2108-11-22] 05:16AM BLOOD PT-15.2* PTT-32.5 INR(PT)-1.3* [2108-11-22] 05:16AM BLOOD Glucose-137* UreaN-15 Creat-1.0 Na-138 K-3.9 Cl-110* HCO3-20* AnGap-12 [2108-11-14] 08:00PM BLOOD Glucose-58* UreaN-17 Creat-0.9 Na-139 K-4.2 Cl-106 HCO3-25 AnGap-12 [2108-11-22] 05:16AM BLOOD ALT-20 AST-32 AlkPhos-68 TotBili-1.4 [2108-11-14] 08:00PM BLOOD ALT-46* AST-65* AlkPhos-73 TotBili-1.4 [2108-11-22] 05:16AM BLOOD Calcium-7.5* Phos-3.5 Mg-1.7 [2108-11-14] 08:00PM BLOOD Calcium-8.2* Phos-3.2 Mg-2.1 [2108-11-18] 02:36AM BLOOD Type-ART pO2-81* pCO2-37 pH-7.38 calTCO2-23 Base XS--2 [2108-11-17] 09:56AM BLOOD Type-ART Rates-/8 Tidal V-600 FiO2-55 pO2-151* pCO2-37 pH-7.40 calTCO2-24 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [2108-11-18] 02:36AM BLOOD Glucose-129* K-4.3 [2108-11-17] 05:37PM BLOOD Hgb-8.6* calcHCT-26 [2108-11-18] 02:36AM BLOOD freeCa-1.24 Brief Hospital Course: Patient was transferred here from [Hospital6 5016] was diffuse, severe, abdominal pain, nausea and vomiting. KUB at the outside hospital was consistent with a small bowel obstruction. On arrival to [Hospital1 18], patient's nausea and vomiting had resolved and no NG tube was placed. In light of her history of multiple episodes of small bowel obstruction and abdominal pain (up to 2 times per week), likely secondary to a large incisional hernia, the patient elected for surgical intervention. She understood the risks involved with this surgery due to her significant medical history, including portal hypertension, cirrhosis, previous colon operations, and radiation to her pelvis for melanoma in the past. The patient underwent extensive lysis of adhesions and incisional hernia repair without complication. Central access was placed in the operating room by anesthesia. The patient was transferred to the surgical ICU for close monitoring in light of her multiple medical problems. In the SICU she did well and was transferred to a regular floor bed on POD #3. ABD: Her midline abdominal incision was closed with staples. Her abdomen was obese, non distended, appropriately tender, +BS at discharge. Her staples will be removed at her follow up appointment. NUT: She was NPO initially after surgery. Her diet was advanced to a regular diet as her bowel function returned. She tolerated a regular diet at discharge without nausea or vomiting. ELIM: Patient's foley catheter was removed on POD#3. She had adequate urine output. Patient reported passing flatus and had regular ostomy output at time of discharge. PAIN: Patient's pain was managed with an IV PCA. She was transitioned to PO pain medications once she was tolerating regular food. She was discharged with PO pain medication for 2 weeks. HEPATIC/RENAL: Patient's liver and renal function was monitored closely throughout her hospital stay. The patient's hepatologist saw the patient during her stay. Initially after surgery, she had some mild elevation in total bilirubin, INR, and creatinine. At her time of discharge, all her labs had normalized to her baseline. The patient was discharged on POD 5 in stable condition. Medications on Admission: Zoloft 100mg qday, Bactrim 1 tab [Hospital1 ], Trazadone 100mg qhs, Nadolol 20mg qday, Lisinopril 5mg qday, Lasix 20mg qday, Glyburide 10mg qday, K-dur 20meq qday, Lantus 10units qhs, Bicillin C-R 2cc monthly, PCN G 1.2 million unit inj qmonth, PCN V QID ** per patient she takes the PCN when she "feels an infection coming on". Discharge Medications: 1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:35 Tablet(s) Refills:0 8. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day. 9. Iron-Vitamin C 100-250 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:30 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction secondary to incisional repair Discharge Condition: Stable 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. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or becoming progressively worse, or inadequately controlled with the prescribed pain medication. * 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. Incision Care: You may shower. Pat incision dry. Avoid swimming and baths until further instruction at your followup appointment. Leave the steri-strips on. They will fall off on their own, or be removed during your followup. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: 1. Please call Dr.[Name (NI) 1863] office to arrange for follow up in the next 1-2 weeks. # [Telephone/Fax (1) 1864] . 2. Please follow up with your PCP as needed. Provider: [Name8 (MD) 6664], MD, MPH[MD Number(3) 708]:[Telephone/Fax (1) 4775] Date/Time:[2108-12-3] 1:00 .	[ "568.0", "V44.3", "459.81", "V10.05", "V15.3", "V10.82", "572.3", "571.5", "250.00", "552.21", "401.9", "070.54" ]	icd9cm	[ [ [] ] ]	[ "53.51", "54.59", "99.04" ]	icd9pcs	[ [ [] ] ]	6944, 6950	3474, 5692	329, 398	7049, 7058	2098, 3451	8274, 8575	1571, 1638		6075, 6921		6971, 7028		5718, 6052			7082, 7912							7927, 8251		1653, 2079																			275, 291									426, 1188																1210, 1456	1472, 1555
18,657	193,070	50693	Discharge summary	report	Admission Date: [2121-2-28] Discharge Date: [2121-3-9] Date of Birth: [2036-2-24] Sex: F Service: MEDICINE Allergies: Zestril Attending:[First Name3 (LF) 30062] Chief Complaint: Hypoxia, lethargy, tachycardia Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname ] is an 84 year-old female with a history of HTN, DM, CAD, CHF, COPD, afib, MR, CKD, Alzheimers dementia who presents today with lethargy. Since the beginning of this year, she has had 4 admissions. She was most recently admitted to the [Hospital Unit Name 153] from [Date range (1) 3683]/10 for shortness of breath and AMS in the setting of a CHF exacerbation. She was diuresed with improvement and was discharged on an increased dose of lasix 40mg [Hospital1 ] (from daily) and metoprolol 37.5mg [Hospital1 ] (from 25mg [Hospital1 ]). . Today, she was noted to be more lethargic at her NH with decreased interaction and clarity of speech. She has had a cough for 1 week and congested sounding but nonproductive per daughter. She did complain of feeling cold today. Later in the day, she was noted to be more wheezy by her daughter and found to to be hypoxic to the 83 on RA, tachypneic, and tachycardic, FSBS 232. VS T 97.9 (ax), BP 125/89, P 148, RR 20, O2sat 83%RA. She was transferred here. . In the ED, initial VS were: T 99.6, P 128, BP 123/85, RR 24, O2sat 100 on NRB. Pt awake but lethargic and poorly cooperative with exam. Exam notable for increased WOB and cardiac wheezes. CXR initially concerning for CHF. Patient given nitro 0.4mg SL, ASA 600mg pr, and lasix 40mg IV. However, subsequently found to have rectal temp found to be 103, very concentrated apperaing urine (100cc UOP after lasix), and persistently tachycardic, so then clinical picture thought more consistent with PNA on review of CXR. Labs without leukocytosis; Hct, Cr at baseline. INR subtherapeutic at 1.5. Bcx were drawn. Pt was given 1L IVF, ceftriaxone and levofloxacin in the ED with vancomycin hung en route. HR improved to 120-130s. VS on transfer: P 125, BP 135/87, RR 20, O2sat 100% on bipap ([3-26]). . Patient currently on Bipap, lethargic, and not responsive to questions. . ROS: Unable to obtain due to MS. Past Medical History: 1. Obesity 2. Hypertension 3. Diabetes mellitus, type II 4. Hyperlipidemia 5. Coronary Artery Disease, s/p 2 anterior MI - 3 vessel disease: Refused CABG - s/p stent of left circumflex, LAD, RCA 6. Ischemic and possibly valvular cardiomyopathy: EF 26%, 3+ MR on echo in [7-31] 7. Chronic atrial fibrillation 8. Chronic kidney disease with baseline creatinine of 1.9 9. Anemia. 10. Multiple myeloma: monoclonal IgG kappa, being observed by Heme-Onc. 11. Osteoarthritis. 12. Gastroesophageal reflux disease 13. Seizure disorder, on dilantin 14. Chronic bronchitis/COPD 15. Detrusor instability 16. Frequent UTIs: in [1-28] Klebsiella pneumonia Social History: Currently living at [Hospital3 2558]. Per prior discharge summary, requires wheelchair for mobility. No tobacco or alcohol use. Family History: Per prior d/c summary, sister with coronary artery disease. Physical Exam: General: Lethargic, opens eyes sporadically to voice, speech unintelligible, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, EJ elevated - IJ difficult to assess, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, obese, 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: Labs on admission: [2121-2-28] 09:00PM URINE RBC-21-50* WBC-[1-24] BACTERIA-MOD YEAST-NONE EPI-21-50 [2121-2-28] 09:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2121-2-28] 09:00PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.012 [2121-2-28] 09:00PM PT-16.8* PTT-27.5 INR(PT)-1.5* [2121-2-28] 09:00PM PLT COUNT-354 [2121-2-28] 09:00PM NEUTS-68.6 LYMPHS-21.4 MONOS-5.2 EOS-3.9 BASOS-0.8 [2121-2-28] 09:00PM WBC-4.7 RBC-2.94* HGB-9.3* HCT-28.2* MCV-96 MCH-31.7 MCHC-33.1 RDW-14.7 [2121-2-28] 09:00PM PHENYTOIN-8.7* [2121-2-28] 09:00PM DIGOXIN-0.4* [2121-2-28] 09:00PM ALBUMIN-2.6* CALCIUM-7.9* PHOSPHATE-2.8 MAGNESIUM-1.8 [2121-2-28] 09:00PM proBNP-[Numeric Identifier 105465]* [2121-2-28] 09:00PM cTropnT-0.05* [2121-2-28] 09:00PM GLUCOSE-145* UREA N-43* CREAT-1.8* SODIUM-146* POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-27 ANION GAP-15 [2121-2-28] 09:14PM LACTATE-1.6 [2121-2-28] 09:14PM COMMENTS-GREENTOP [2121-3-6] 05:58AM BLOOD WBC-4.3 RBC-2.76* Hgb-8.8* Hct-26.8* MCV-97 MCH-32.1* MCHC-33.0 RDW-14.8 Plt Ct-309 [2121-3-6] 05:58AM BLOOD Plt Ct-309 [2121-3-6] 05:58AM BLOOD PT-18.9* PTT-38.1* INR(PT)-1.7* [2121-3-6] 05:58AM BLOOD [2121-3-6] 05:58AM BLOOD Glucose-113* UreaN-35* Creat-1.5* Na-139 K-4.4 Cl-106 HCO3-24 AnGap-13 [2121-3-6] 05:58AM BLOOD Calcium-7.3* Phos-3.3 Mg-2.1 . ECG [2121-2-28]: Atrial fibrillation. Right bundle-branch block with left anterior fascicular block. Compared to the previous tracing of [2121-2-24]. Portable CXR [2121-2-28]: IMPRESSION: Nearly nondiagnostic study due to respiratory motion and artifacts projecting over the right hemithorax. Repeat radiography, if clinically feasible in the radiology suite, are recommended for more sensitive evaluation. Overlying pulmonary edema and pneumothorax cannot be excluded on the basis of this exam. ECG [2121-3-1]: Atrial fibrillation. Right bundle-branch block. Left anterior fascicular block. Compared to the previous tracing there is no change. Portable CXR [2121-3-1]: IMPRESSION: 1. Decreased pulmonary edema. 2. Increased left retrocardiac density consistent with consolidation or atelectasis. Portable CXR [2121-3-2]: There is a left retrocardiac opacity with obscuration of the left hemidiaphragm. There is also left-sided pleural effusion which is slightly increased from previous. No overt pulmonary edema or pneumothoraces are seen. The cardiac silhouette is prominent but unchanged. Portable CXR [2121-3-2]: IMPRESSION: Increased cardiogenic edema. CHEST, AP: Lung apices are obscured by overlying soft tissues. No focal consolidation is present. Venous congestion and bilateral layering effusions are increased. Moderate cardiomegaly persists. IMPRESSION: Increased cardiogenic edema. Brief Hospital Course: 84 y/o F with hx of DM, CAD, CHF, COPD, afib, MM, HTN and CKD who presents from NH with increased lethargy and hypoxia. # Hypoxia: The patient has had multiple prior admissions for hypoxia in the setting of CHF exacerbation, although on this admission did not appear significantly volume overloaded clinically or by initial chest film. She reported cough x1 week, fever of 103.4 rectally in the ED, poor clearance of secretions and aspiration risk (although no consolidation on film); she was therefore covered for hospital-acquired PNA with vanco and zosyn. Blood cultures and urine cultures were negative and her MRSA screen was negative. The patient was unable to provide a satisfactory sputum sample. Legionella UA was negative. The patient was low risk by [Doctor Last Name 3012] Criteria for PE so no CTA. She underwent speech and swallow evaluation given concern for possible aspiration, but was cleared for thin liquids and regular-consistency food (this study was done on hospital day 3 when she was more alert than on admission). She received IV furosemide PRN to maintain euvolemic volume status and then returned to her home dose of lasix. She was monitored in the MICU for 3 days, during which time OS was weaned to 3 L by NC (from initial facemask/NRB) and she eventually was weaned to room air. She remained afebrile after the initiation of Abx. A picc line was placed for continued antibiotic therapy as an outpatient. She ultimately expired on [2121-3-9]. # AMS/lethargy: This was felt to be likely multifactorial, with contributions from infection, hypoxia, and electrolyte imabalance in the setting of a severe underlying Alzheimer's dementia. MS followed a waxing and [Doctor Last Name 688] course consistent with delirium. Given h/o seizure disorder, it is possible that she had ictal or postictal events, although there was no clear evidence of seizure. She was at times borderline unresponsive (non-verbal, withdrawing to pain but not orienting to voice) and at other times awake, conversant, and able to communicate needs. After discussion with patient's daughter, it appeared that this was not an acute event but she may have baseline waxing/[Doctor Last Name 688] mental status that has been going on for weeks to months in the setting of frequent exacerbations of illness. Treatment was aimed at underlying infection, hypoxia and electrolyte imbalances with apparent improvement in MS. # Fever: To 103 rectally in ED per report. Patient was started on broad spectrum antibiotics for presumed pulmonary source with resoultion of fevers. Lactate remained WNL, and WBC was not elevated. # Hypernatremia: Na was elevated on admission to 146. This ultimately normalized with control of volume status to 140 by hospital day #3. # CHF: The patient has known CHF with LVEF of 25% and 3+ MR [First Name (Titles) ] [Last Name (Titles) 28753]o. Given her recent admission [Date range (1) 95167] for presumed CHF exacerbation, it is likely that some degree of volume overload contributed to her symptoms of hypoxia. . # COPD: The patient was continued on home medications, although albuterol nebs were held in the setting of tachycardia. # Suprapubic swelling: The patient was noted to have right suprapubic swelling involving the right labia majora which was somewhat mobile but there was no defined mass. This may be due to a hernia or soft tissue mass such as a lipoma or fibroma. Malignancy was also considered. The patient did not experience any discomfort from the swelling and did not have any obstructive physiology. This was discussed with her daughter who was the primary medical decision maker and a plan was made not to pursue this further diagnostically. . # Seizure Disorder: Phenytoin level was initially subtherapeutic. The patient was started on phenytoin 100mg IV q8h with and was then converted to PO home dose when able to tolerate oral medications. # Atrial fibrillation: Initially patient had RVR to 150s, but rate was better controlled s/p IVF. CE baseline. INR was subtherapeutic but Coumadin was held given concern that antibiotics may augment these levels. Metoprolol and digoxin were continued; Coumadin was ultimately restarted and her INR was 1.8 on last check. # Chronic renal failure: At baseline. Creatinine was trended daily. # Coronary artery disease: EKG stable, elevated trop (at baseline) likely related to CRF. She was continued on aspirin, statin, BB. # Anemia: [Month (only) 116] be related to CRF, multiple myeloma. Hct stable at baseline. # Multiple myeloma: Trend creatinine and electrolytes. No treatment at this time. # Diabetes: Patient was maintained on an insulin sliding scale. Code: She was a DNR/DNI during this hospitalization. Palliative care was consulted and in discussion with her daughter [Name (NI) 6359], who has been the primary medical decision maker, a plan was made for the patient to return to [Hospital3 ] under guardianship, with a plan to become hospice care. However the patient ultimately expired on [2121-3-9] in the hospital before this plan could be executed. Her cause of death was pneumonia in the setting of chronic congestive heart failure and alzheimer's dementia. Medications on Admission: 1. Senna 8.6 mg [Hospital1 ] prn constipation 2. Docusate Sodium 100 mg [Hospital1 ] prn constipation 3. Aspirin 81 mg daily 4. Ergocalciferol (Vitamin D2) 50,000 unit 1x/week 5. Montelukast 10 mg daily 6. Ferrous Sulfate 300 mg (60 mg Iron) daily 7. Multivitamin,Tx-Minerals 1 tab daily 8. Warfarin 5mg qPM 9. HISS 10. Phenytoin 250mg [Hospital1 ] 11. Metoprolol Tartrate 37.5mg [Hospital1 ] 12. Digoxin 125 mcg 2x/week (TU, SAT) 13. Ipratropium Bromide 0.02 % Solution q6h 14. Furosemide 40 mg [Hospital1 ] (planned increased to 60mg qAM, 40mg qPM on [2121-3-1]) 15. Atorvastatin 20mg daily 16. Zantac 150mg daily (planned to start [2121-3-1]) 19. Mucinex 600mg [Hospital1 ] x 7 days (planned to start [2121-3-1]) 20. Guaifenesin 10ml q4-6h prn cough 21. MoM 30mL daily prn constipation 22. Fleet enema pr daily prn constipation 23. Bisacodyl 10mg supp prn constipation Discharge Medications: none -patient expired [2121-3-8] Discharge Disposition: Expired Discharge Diagnosis: Primary Health Care Associated Pneumonia . Secondary Acute on Chronic heart failure Discharge Condition: patient expired [2121-3-9] Discharge Instructions: None Followup Instructions: patient expired [2121-3-9]	[ "294.10", "331.0", "203.00", "412", "585.9", "427.31", "486", "428.33", "345.90", "250.00", "530.81", "403.90", "496", "276.0", "275.41", "414.01", "428.0" ]	icd9cm	[ [ [] ] ]	[ "38.93" ]	icd9pcs	[ [ [] ] ]	12949, 12958	6705, 11930	299, 306	13086, 13118	3770, 3775	13171, 13204	3138, 3200		12888, 12926		12979, 13065		11956, 12865			13142, 13148									3215, 3751																			229, 261									334, 2300								3789, 6682								2322, 2973	2989, 3122
5,062	123,244	29106	Discharge summary	report	Admission Date: [2100-11-30] Discharge Date: [2101-1-1] Date of Birth: [2029-2-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: Back Pain Major Surgical or Invasive Procedure: 1. Total vertebrectomy of T7 and T8. Fusion of T6 to T9. Anterior cage placement. Anterior instrumentation placement T6-9. Autograft. 2. Posterior spinal fusion T3 to T11. Segmental instrumentation T3 to T11. 3. External pacemaker placement and removal 4. Central venous catheter placement and removal 5. Thorocentesis 6. Placement of permanent pacemaker History of Present Illness: Mr. [Known lastname 70072] is a 71 yo male who with a PMH of hypertension and MI, who presents with back pain of 2 weeks duration. He states that he first noticed that something was wrong a couple of weeks ago, after eating eating ice cream and drinking ice water at night. Later that night, after going to bed and falling asleep, he was woken with a strange feeling which he describes as a curtain descending down over his abdomen. He states it felt as if his body, in the region of his abdomen, had just shut down. He fell back asleep the night, hoping that the strange feeling would go away on its own. Over the next few days, he began to notice a pain in his upper back. He describes that pain as similar to a muscle spasm, in his back, that does not radiate. When the pain first began, it was intermittent and could be brought on by nearly anything, including getting up to walk and eating. He tried Advil and acetominophen which helped at first to relieve his pain. He noticed that his pain gradually became more intense, and more intolerable. He reports occasional chest pain, shortness of breath, and feeling feverish when his pain would become severe. At the time of presentation to an OSH, his pain was constant, not relieved with Advil or acetominophen, and he reports it as a [9-26]. He also developed a dry, non-productive cough over the past 2-3 days, and a feeling of nausea that developed when he would cough. At times, when the pain would become severe, he began to feel feverish and developed sweats. He reports that his last bowel movement was nearly a week ago. Patient reports that he was in Tripoli, North [Country 480] in the [2044]'s during the Korean war. Recalls one episode of walking pneumonia, nearly 20 years ago, was not hospitalized. Recalls no episodes of hemoptysis. He estimates that he has lost ~10 pounds over the past two months due to decreased appetite and pain with eating. He denies chills, night sweats, changes in vision, headache, shortness of breath, chest pain, vomiting, abdominal pain, diarrhea, numbness, parasthesias. Past Medical History: ## Hypertension- not on medication ## Cataracts- repaired in right eye ## MI- history of MI in '[83] and '[86], with balloon angioplasty in '[86] ## History of coccygeal fracture ~20 years ago Social History: Divorced. Used to work in the stock market, retired for 20 years. Has three sons and one daughter. Former heavy smoker, since teenage years, quit in '[86]. Drinks beer [2-19]/night, quit with onset of back pain. History of cocaine use when he was a stock broker. No history of IV drug use. Family History: non-contributory Physical Exam: PE VS: T 96.3 BP 144/80 P 84 RR 20 O2sat 98% 3l HEENT: PERRL constricting from 3mm to 2mm bilaterally, EOMI, MMM, no LAD Neck: No JVD Pulm: Lungs CTAB, no wheezes or rales CV: Regular rate and rhythm, Normal S1, loud S2, III/VI holosystolic murmur heard best over RUSB Back: bony mass located near spinous processes of T3-T4, no tenderness to palpation Abd: + bowel sounds, soft, non-tender, no organomegaly Ext: warm, well-perfused, distal pulses 2+, no cyanosis, clubbing or edema Neuro: Mental Status: Alert and oriented to time place and person CN II-XII: II- no vision in left eye, decreased visual acuity in left eye, III, IV, VI- EOMI, no lid lag, nystagmus or ptosis, V- sensation intact to light touch, VII- muscles of facial expression intact, IX, X- good palatal elevation, [Doctor First Name 81]- [5-21] SCM, trapezius, XII- tongue protrudes midline Motor: Strength 5/5 in deltoids, biceps, triceps, hip flexors, quadriceps, gastrocnemius, and plantar flexors Sensory: intact to light touch distally, and in T2-T12 dermatomes Reflexes: 2+ biceps and brachioradialis Decreased patellar reflexes Babinksi: Downgoing bilaterally Pertinent Results: MRI C/T/L spine [2100-11-29]: MRI OF THE CERVICAL SPINE WITH GADOLINIUM: There is no evidence of disc infection. There is degenerative disc disease at multiple levels. At C4-C5, there is a small central disc protrusion without evidence of canal or foraminal stenosis. At C5-C6, there is a broad-based disc-osteophyte bar producing moderate canal and moderate bilateral foraminal stenosis. At C6-C7, there is mild retrolisthesis producing moderate canal and moderate bilateral foraminal stenosis. There is no evidence of abnormal cord signal or abnormal cord enhancement. IMPRESSION: Multilevel degenerative disease as described. . MRI OF THE THORACIC SPINE WITH GADOLINIUM: IMPRESSION: Paraspinal mass with vertebral body involvement at T7-T8. There is involvement of the disc, and there is an epidural mass. The features in general suggest that this may be a malignant process rather than an active infection, although granulomatous disease would be an additional consideration. The findings are a bit unusual for bacterial abscess, but this is not entirely excluded. . MRI OF THE LUMBAR SPINE: IMPRESSION: First degree spondylolisthesis at L5-S1. Mild disc bulging. No evidence of focal disc protrusion. No evidence of a destructive mass or abscess in the lumbar region. . CT T-spine w/o contrast [2100-11-30]: Again seen is destruction of the inferior one-half of T7 and superior endplate of T8 with a large associated paraspinal mass. There is a small epidural component as well as retropulsion of bone fragments into the ventral part of the spinal canal. The degree of cord compression is better evaluated on the previous day's MRI. Again noted is kyphotic angulation of the thoracic spine at this locale. No new abnormalities are identified. There are emphysematous changes in the lungs. Aortic calcifications are identified. . CT abdomen/pelvis [2100-12-2]: CT ABDOMEN: The gallbladder is distended likely due to fasting. However, clinical correlation is recommended. The liver, spleen, and pancreas are unremarkable. The small 11-mm left adrenal gland nodule is not well characterized in this study. The right adrenal gland is normal. Small hypodense area at the interpolar region of the right kidney is too small to be characterized. Small and large bowel are grossly unremarkable. There is a moderate amount of stool within the colon. The appendix is within normal limits. Severe calcifications of the aorta. All the major branches are patent. No free fluid or retroperitoneal lymphadenopathy. CT PELVIS: Urinary bladder, distal ureters are unremarkable. No free fluid or free air in the pelvis. Calcifications within the prostate. Small segment of chronic dissection involving both proximal common ilia arteries. . TTE [2100-12-6]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. LVEF=55%. The left ventricular cavity is mildly dilated with focal near akinesis of the basal half of the inferolateral wall. The remaining segments contract well. Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular cavity size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No systolic prolapse is seen. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is top normal. There is no pericardial effusion. . CXR PA/Lateral [2100-12-6]: IMPRESSION: No evidence for pneumonia. Small bilateral pleural effusions but no evidence for CHF. Small well defined nodular density right lung base. Correlate with prior outside films if available . Further evaluation, either by follow up plain radiographs in approx 3 months or by CT is suggested. . Chest CT [2100-12-7]: The multiple mediastinal lymph nodes are subcentimeter ranging up to 9 mm in the right paratracheal, 8 mm in the outer pulmonary, and 1 cm in subcarinal are. There is no hilar or axillary lymphadenopathy. The aorta is calcified with relatively thick mural plaques ranging up to 4 mm, some of them ulcerated, for example in the proximal distending thoracic aorta, series 2, image 26, 27; at the level of the aortic arch, series 2, image 21; in the distending aorta, series 2, image 31. The extensive mural thickening also involve the origin of the left subclavian and left carotid and innominate arteries. The assessment of the lung parenchyma demonstrate mild centrilobular emphysema involving predominantly the upper lobes. A focal thickening of the left fissure is 4.3 mm in length. The bilateral pleural effusion is small with adjacent lung atelectasis. Additional area of focal pleural thickening is in the right upper lobe, series 4, image 45. No other lung nodules or masses are identified. The images of the upper abdomen demonstrate normal liver, spleen, adrenals, pancreas and kidneys. The gallbladder is markedly distended measuring up to 6 cm in diameter with some high-attenuation of the posterior portion suggesting vicarious excretion. . [2100-12-17] U/S: IMPRESSION: Negative bilateral lower extremity DVT study. . [2100-12-27] CXR: IMPRESSION: Increase in size of left pleural effusion and new relatively large area of consolidation in lingula and left lower lobe since prior study of [2100-12-24]. . [2100-12-30] CT CHEST: IMPRESSION: 1. Decrease in size of a moderate left pleural effusion with loculated components. High attenuation within a loculated fluid collection in the left upper hemithorax suggests component of possible hemothorax and is unchanged. No evidence of new or active extravasation. 2. Ground-glass opacity at the left base consistent with reexpansion edema in the setting of recent thoracentesis. Bibasilar hydrostatic interstitial edema. 3. Stable appearance of postoperative change within the mid thoracic spine as above. 4. Tiny left hydropneumothorax, likely secondary to recent thoracentesis . [2101-1-1] CXR: prelim read: no pneumothorax. small bilateral effusions. . [2100-12-3] From surgical specimen: Touch prep of core biopsy, soft tissue mass: NEGATIVE FOR MALIGNANT CELLS. Poorly preserved epithelioid to spindled cells with vacuolated cytoplasm, most consistent with macrophages. Neutrophils and debris are also present. . [2101-1-1] cytology from pleural fluid: pending MICRO: Blood cultures and urine cultures have all been negative. [2100-12-19]: Sputum Culture - ENTEROBACTER CLOACAE. RARE GROWTH. sensitive to 3rd gen cephalosporins, carbapenems, quinolones. . Epidural mass: - gram stain 2+ PMLs, 2+ GPC in pairs - Culture: Coag + staph SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S PENICILLIN------------ =>0.5 R -ACID FAST SMEAR (Final [2100-12-6]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. . Epidural mass biopsy: Fibrovascular and adipose tissue with epithelioid histiocytes, lipid-laden macrophages and chronic inflammation. A stain for acid fast bacilli is negative. . .. [2101-1-9]: . T7-8 disc, frozen (A-B): Fibroconnective tissue and bone with acute and chronic inflammation and necrosis; consistent with acute and chronic osteomyelitis. II. T7-8 disc (C-D): Fibroconnective tissue and bone with acute and chronic inflammation and necrosis; consistent with acute and chronic osteomyelitis. III. Epidural mass, T7-T8 (E): Bone with acute and chronic inflammation consistent with acute and chronic osteomyelitis. PPD: Negative C diff x3 negative C diff B toxin-pending BCXs: all no growth to date UCXs: no growth. . Labs on discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2101-1-1] 06:30AM 9.2 3.31* 10.2* 29.5* 89 30.9 34.7 17.6* 303 INR 1.3 Glucose UreaN Creat Na K Cl HCO3 AnGap [2101-1-1] 06:30AM 80 18 1.1 138 3.5 106 24 12 . Calcium Phos Mg [2101-1-1] 06:30AM 7.0* 2.9 2.0 Brief Hospital Course: In brief, the patient is a 71 yo male with history of coccygeal fracture, and CAD, who presented with back pain of 2 weeks duration, found to have a T7-T8 epidural mass on MRI. He subsequently was found to have a MSSA osteomyelolitis, underwent colpectomy and fusion, however his course was complicated by post-op NSTEMI, bradycardic arrest (complete heart block), upper extremity venous clot, and delerium. . ## Epidural Mass: Patient presented with back pain of increasing severity of 2 weeks duration, that he rated as [9-26] on admission. Patient had decreased patellar reflexes but no other focal neurological deficits, and back was non-tender to palpation. No leg weakness, sensory deficits or bowel/bladder incontinence. MRI on admission showed an epidural mass at T7-T8 level with some moderate cord compression. CT spine confirmed this finding. Found to have elevated ESR to 102 and CRP of 216 concerning for infectious process. Based on imaging the differential of the epidural mass was infection (bacterial abscess vs tuburculoma), vs malignancy vs AV malformation. The patient denied any history or exposure to TB, however he was in North [Country 480] in the [2044]'s during the Korean war. Recalled one episode of walking pneumonia, nearly 20 years ago, was not hospitalized. Recalls no episodes of hemoptysis. The patient denied any history of malignancy, however he has not seen a physician in many years. Given the possibility of infection he was started on broad-spectrum abx including Ceftriaxone, vancomycin and flagyl IV. He was afebrile. Ortho spine followed the patient and he was provided with a TLSO brace given his T7 collapse. Serial neurological exams were performed looking for signs of cord compression and were normal. On [12-3] the patient underwent CT-guided biopsy of the mass and tissue was sent to microbiology and pathology. Gram stain and culture returned positive for GPC. ID was consulted for further recommendations. When organisms were identified as Staph aureus the ceftriaxone and flagyl were discontinued. He was continued on vancomycin with goal troughs 17-20. When sensitivities returned MSSA the vancomycin was switched to Nafcillin 2gm IV q4h. . ID recommended TTE given epidural abscess and murmur on exam (unclear age given no regular medical care). TTE showed no evidence of endocarditis with no vegetations or abscesses. A TEE was not performed given the patient would require a long course of antibiotics and TEE would not change the management. A PPD was also placed given tuburculoma was in the differential and was negative. Additionally, AFB smear and stain were both negative. AFB culture is pending. There was no evidence of granulomas on CXR or chest CT suggestive of old TB infection. . Although the patient appeared to have an MSSA abscess, an underlying process could not be excluded. Given possibility for underlying malignancy an SPEP/UPEP were sent. PSA was 1.0 and chest CT showed no lung nodules. Path of epidural biopsy showed inflammation. Given the location of the abscess and involvement of T7-T8 vertebrae with T7 collapse, the patient was taken to the OR for surgical spine debridement/stabilization by ortho spine. He underwent two surgical procedures to debride and stabilize his spine (please see op notes from [12-10] and [12-13] for details). He should complete a 6 week course of nafcillin to end on [2101-1-20]. He has follow up with [Hospital ] clinic on [2101-1-5] and may need lifelong suppressive therapy. . ## NTEMI - Two days after his second surgery, the patient developed chest pain. An EKG revealed lateral ST depressions. The pain was relieved by nitroglycerine complicated by mild hypotension. His cardiac enzymes were positive with a troponin T peak of 0.27. His CPK-MB was also mildly elevated to 12. He was conservatively managed particularly with regard to his recent spine surgery. His cardiac regimen was adjusted to include aspirin, beta-blocker, ACE inhibitor, and Imdur. . ## Cardiac arrest - The patient's course was further complicated by a bradycardic arrest leading to asystole. This episode was not captured on telemetry. He received CPR as his DNR status had temporarily been changed peri-operative. He was resuscitated successfully without use of epinephrine, atropine, or electricity. He was initially stabilized after transfer to the CCU but had a similar arrest twice the next morning each following repositioning. Telemetry revealed complete heartblock. An externalized pacemaker was placed with a screw-in lead in the RV as putting a permanent pacer in while the osteomyelitis was being treated. The bradycardia appears to have been triggered by excessive vagal tone. The day before discharge a perm. pacemaker was placed and was interrogated by EP and found to be working well. He has follow up on [2101-1-5] with the device clinic to further evaluate the pacer. . ## Anemia: Patient was found to be anemic on admission. No baseline for comparison. Fe studies suggestive of anemia of chronic disease. Patient reports no hemoptysis, hematemesis,melena, or hematochezia. EBL from the surgery was ~500cc. Late into his CCU stay, he developed guaiac positive stool. His Hct stabilized after transfusion. He continued on a PPI. He can follow-up with his PCP for potential referral to GI for colonoscopy as an outpatient. . ## Delirium: The patient developed delirium attributed to medications (narcotics and benzodiazepines), and disruption in sleep-wake cycle and CCU psychosis. He was found not to have capacity to refuse life saving interventions. His daughter [Name (NI) 2127] [Name (NI) 70073] was appointed health care proxy. The patient's agitation was managed with nightly haldol with as needed haldol as well. Other sedating medications such as narcotics and benzodiazepines should be avoided as much as possible. Once he was transferred to the regular medical floor his delirium improved and by discharge he no longer displayed any signs of delirium. . ## Constipation/diarrhea: Patient had not had a bowel movement in over a week when he presented. He was started on an aggressive bowel regimen given constipation and requirement of large amount of narcotics. This bowel regimen was weaned down over the course of his hospital stay. Since being on the antibiotics, he has developed diarrhea and has a rectal tube in place. The diarrhea could be from an infectious source vs. the antibiotics themselves. He was tested for C diff and found to be negative x3. A C diff B toxin has been sent and will be followed up after discharge. . ## Hypertension: Patient has a history of hypertension but had never been treated. BP was initially labile and elevated readings seemed to correlate with pain. When pain was better controlled the patient's BP remained elevated with SBP 140-150 at times. His blood pressure was controlled as above. . ## Iliac artery dissections: Incidental finding on CT. Vascular consult obtained. No evidence of peripheral vascular compromise. Vascular team recommended outpatient follow up in 6 months with ultrasound. . ## Upper Extremitiy DVT - The patient developed a clot in the right cephalic vein in the setting of a RIJ central venous catheter. He was initially anticoagulated but this was held in the setting of the GIB. Warm compresses and arm elevation should be used to limit propagation of the clot. The patient had a CTA of the chest that was negative for PE. . ## Enterobacter in sputum - The patient did have a sputum culture that revealed a pan-sensitive enterobacter cloacae. He did not have any clinical evidence of pneumonia (no fever, normalizing WBC, no definitive consolidation on imaging). Antibiotics, levofloxicin, directed at this bacteria were started when he was noted to have an infiltrate on CXR and some shortness of breath. He also developed a large pleural effusion and underwent a thorocentesis. The fluid was exudative and likely related to the pneumonia although the gram stain was negative (he has been on antibiotics). The cytology is still pending and should be followed up by his PCP. . ## Elevated Creatinine - Creatinine was 1.6 on admission. corrected following IVF. . ## Prophylaxis: PPI, heparin converted to [Male First Name (un) ] stockings and pneumo-boots with slow GIB. . ## FEN -Regular diet with 5x/day nutritional supplements with ensure plus. Did have hypokalemia likely secondary to medications and loose stools. He will receive standing potassium repletion and need potassium level checked shortly after discharge to adjust the dose. . ## CODE - DNR/DNI. patient's daughter [Name (NI) 2127] [Name (NI) 70073] was appointed health care proxy during this admission. . ## Dispo - discharged to rehab . . Follow up: C diff B toxin potassium on [2101-1-4] Weekly LFTs, CBC, Cr on Mondays to be faxed to Dr. [Last Name (STitle) 11382] in ID cytology from pleural fluid B12 levels out-patient colonoscopy Ultrasound of bilateral lower extremities in 6 months for evaluation of iliac artery dissections Medications on Admission: Tylenol prn Advil prn Discharge Medications: 1. Outpatient Lab Work Please draw every Monday until [2101-1-20]: LFTs, CBC, Cr. Fax results to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11382] at [Telephone/Fax (1) 1419] 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 8. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Haloperidol 1 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day) as needed for agitation. 10. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Three (3) Tab Sust.Rel. Particle/Crystal PO once a day. 12. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours) for 20 days: last dose to be given on [2101-1-20]. 13. midline care midline line care per protocol 14. Outpatient Lab Work Please draw Potassium on [2101-1-4]. Adjust potassium replacement accordingly. 15. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 17. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 19. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 20. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Primary: Vertebral osteomyelitis NSTEMI Complete Heart Block s/p external pacemaker placement and then perm. pacemaker placement vitamin B12 deficiency enterobacter pneumonia with pleural effusion s/p thorocentesis Delirium -now resolved Acute blood loss anemia Hypokalemia hypocalcemia right upper extremity DVT iliac artery dissection . secondary diagnosis: gout hypertension Discharge Condition: stable. afebrile. stable pacer settings with appropriate ventricular response. tolerating oral nutrition and medication. Discharge Instructions: You have been evaluated and treated for an infection in your vertebral column. You underwent 2 surgeries to remove as much of the infection as possible and to stabilize the spine. However, after the surgeries you had a small heart attack. Your course was further complicated by a very slow heart rate that required a pacemaker to keep you rate fast enough. . Please take all medications as prescribed. . You will need to continue the nafcillin until [2100-1-20]. You should follow up with [Hospital ] clinic on [2101-1-5] as below to determine if lifelong antibiotics will be needed. . You will need to schedule an appointment with ortho spine Dr. [Last Name (STitle) 1352] (number written below) in mid [Month (only) ]. You must wear your TLSO brace for 3months whenever you want to get out of bed and walk around or sit in a chair. This helps to stablize your back and is very important to keep from damaging you back. . Your new pacemaker is working well. You must keep your appointment on Wed [1-5] at 10am to have it further evaluated. With your new pacemaker, you must not raise your arm above your head for 6 weeks. . You had some blood in your stool. You will need an outpatient colonoscopy in the future. . A CT scan of your abdomen saw some illiac artery dissections. You should follow up with vacular surgery (see below) in 6 months for ultrasound to evaluate these further. Followup Instructions: 1) Orthopedics: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1352]. Please call the clinic to make an appointment for 4 weeks from now (mid [Month (only) ]) in the [Hospital Ward Name 23] Center [Location (un) ]. Please call ([Telephone/Fax (1) 2007]. 2) Cardiology Device Clinic: Wed. [2101-1-5] at 10AM in the [Hospital Ward Name 23] Center [Location (un) 436]. Please call [Telephone/Fax (1) 59] with questions. 3) Infectious Disease: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11382] on [2101-1-5] at 9am in the [Hospital Unit Name ] [Last Name (NamePattern1) ]. Basement Suite G. Please call [Telephone/Fax (1) 457] with questions. 4) Please call your primary care physician to schedule an appointment in [1-18] weeks. You will need to have several things followed up with your PCP: [Name10 (NameIs) 70074] from cytology of the pleural (lung) fluid -vitamin B12 levels -colonoscopy -follow up with vacular surgery ([Telephone/Fax (1) 8343] in 6 months for ultrasound to evaluate iliac artery dissestions Completed by:[2101-1-1]	[ "E935.8", "292.81", "512.1", "414.01", "275.41", "324.1", "285.1", "426.0", "E939.4", "266.2", "453.8", "997.1", "482.83", "V45.82", "733.13", "281.9", "401.9", "737.10", "787.91", "564.09", "410.71", "511.1", "276.8", "730.08", "041.85", "238.71", "427.5", "041.11", "412", "443.22" ]	icd9cm	[ [ [] ] ]	[ "99.60", "37.83", "34.91", "81.05", "77.79", "81.64", "38.93", "37.78", "84.51", "89.45", "99.04", "03.32", "37.72", "81.04", "80.99" ]	icd9pcs	[ [ [] ] ]	24315, 24387	13085, 21899	322, 681	24809, 24933	4589, 12672	26395, 27580	3375, 3393		22274, 24292		24408, 24747		22228, 22251			24957, 26372									3408, 3902						21910, 22202													273, 284				12714, 13062					709, 2811			24768, 24788							3917, 4570						2833, 3039	3055, 3359
81,067	176,698	48359	Discharge summary	report	Admission Date: [2179-5-7] Discharge Date: [2179-5-9] Date of Birth: [2115-5-27] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7744] Chief Complaint: UGIB Major Surgical or Invasive Procedure: [2179-5-8] esophago-gastro-duodenoscopy (EGD) History of Present Illness: 63 yo M physician with history of hypothyroidism, GERD, colonic adenoma and arthritis presenting about 7-10 days of melena, generalized weakness, and presyncope. Patient reports taking 445 mg Aleve [Hospital1 ] daily for the last [2-5] months for his tendonitis as well as ASA 81 mg daily for prophylaxis. He stopped his omeprazole about 9 months ago after his GERD symptoms resolved. Patient noticed about melena with stomach "queasiness" for about 7-10 days. He also has increased weakness and fatigue. He attribute these symptoms to a viral illness. He denies chest pain, shortness of breath. He denies BRBPR. Today, he went to see his PCP and was found to have guiaic postive melenic stool with Hct down to 27 from previous of 42.8 in 9/[2178]. He was referred to the ED for further evaluation. In the ED, initial VS were: T 98.2, HR 67, BP 127/84, RR 18, O2Sat 100%. Repeat HCT was stable at 27.7. Patient was started on a protonix infusion at 8mg/hr. GI was consulted and recommended admission to MICU for possible EGD today. He did not receive blood products. He has 2 peripheral IV 18 Gs. VS upon transfer: 97.1, 67, 130/82, 16, 100% RA On arrival to the MICU, patient reports feeling okay. Past Medical History: - ankle sprian - esophageal reflux - hypothyroidism - colonic adenoma - h/o hematuria - basal cell carcinoma '[65], Left malar - HTN - HDL Social History: Patient is an OB/GYN M.D Never smoked, does not drink. Drinks about [2-5] cups of coffee daily Married. Family History: Father with HTN Mother with glaucoma Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.2, 73, 123/74, RR 16, 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: RRR, normal S1 and S2, occasional S3, no m/r/g Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Rectal: dark guaiac + stool Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, gait deferred. . DICHARGE PHYSICAL EXAM: afebrile, BP 110-120s/60-70s, HR 60s-70s, saturations >98% RA exam unchanged Pertinent Results: ADMISSION LABS: [2179-5-7] 03:51PM BLOOD WBC-6.4 RBC-2.84* Hgb-9.0* Hct-27.8* MCV-98 MCH-31.5 MCHC-32.2 RDW-14.2 Plt Ct-210 [2179-5-7] 03:51PM BLOOD Neuts-60.8 Lymphs-29.6 Monos-5.4 Eos-3.6 Baso-0.6 [2179-5-7] 03:51PM BLOOD PT-10.8 PTT-29.4 INR(PT)-1.0 [2179-5-7] 03:51PM BLOOD Glucose-76 UreaN-23* Creat-1.4* Na-137 K-4.5 Cl-105 HCO3-24 AnGap-13 [2179-5-8] 03:07AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0 . DISCHARGE LABS: [2179-5-8] 08:50PM BLOOD Hct-27.2* [2179-5-9] 07:08AM BLOOD Hct-26.3* [2179-5-9] 07:08AM BLOOD Glucose-97 UreaN-18 Creat-1.5* Na-137 K-3.8 Cl-103 HCO3-25 AnGap-13 [2179-5-9] 07:08AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.3 . [2179-5-8] EGD: Esophagus: Mucosa: Localized erythema of the mucosa with no bleeding was noted in the gastroesophageal junction. These findings are compatible with Mild esophagitis. . Stomach:Mucosa: Localized erythema and erosion of the mucosa with no bleeding were noted in the antrum. These findings are compatible with Moderate gastritis. . Duodenum: Mucosa: Diffuse erythema, congestion and friability of the mucosa with no bleeding were noted in the duodenal bulb compatible with Severe duodenitis. Excavated Lesions A single non-bleeding 1.5 cm ulcer with clean base was found in the duodenal bulb. There were no stigmata of recent bleed. . Impression: Erythema in the gastroesophageal junction compatible with Mild esophagitis Erythema and erosion in the antrum compatible with Moderate gastritis Erythema, congestion and friability in the duodenal bulb compatible with Severe duodenitis Ulcer in the duodenal bulb Otherwise normal EGD to third part of the duodenum . Recommendations: The findings account for the symptoms Antireflux regimen: Avoid chocolate, peppermint, alcohol, caffeine, onions, aspirin. Elevate the head of the bed 3 inches. Go to bed with an empty stomach. Continue Protonix drip. Serial Hct. Avoid NSAIDs. Check H.Pylori Ab in serum and treat if positive. Clear liquids today.Advance diet today/tomorrow if no further bleeding. If stable, patient can be transferred to floor today/tomorrow. Discharge on [Hospital1 ] PPI high dose. Brief Hospital Course: Dr. [Known lastname 9192] is a 63 year old male with hypothyroidism and left ankle sprain who presented with 7-10 days of melanotic stool and hematocrit drop in the setting of NSAID use x 2-3 months for the ankle sprain. Found to have gastritis/duodenitis with duodenal ulcer on EGD. . # Upper gastrointestinal bleed: Because of melena and the hematocrit drop of 14 points (from baseline [2178]), he underwent an EGD which showed large 1.5 cm duodenal ulcer with duodenitis, gastritis, esophagitis consistent with NSAID injury. The GI team felt this definitely explained his symptoms and was most likely from chronic NSAID use for left ankle pain (thought to be a acute on chronic sprain in [1-/2179]) and aspirin use. H. pylori IGG negative from the clinic, biopsy results pending. Patient was started on pantoprazole bolus with drip. Serial hematocrit remained stable and did not have further melena during admission. He did not require blood transfusion. He was transitioned from IV pantoprazole to PO BID and should continue [Hospital1 ] for 2 weeks then daily until follow-up with GI. . # Left ankle sprain: NSAIDs were stopped due to bleeding above. He will use tylenol for joint pains and this ankle sprain. . # Hypothyroidism: He was continued on home levothyroxine 100 mcg daily # Hypertension: Diet controlled. # Hyperlipidemia: Diet controlled. . TRANSITIONAL ISSUES: - Please follow-up final biopsy results from duodenal ulcer - Please encourage adherence to recommended diet Medications on Admission: - Aleve 445 mg [Hospital1 ] - ASA 81 mg - levothyroxine 100 mcg daily - MVI daily - Fish Oil daily Discharge Medications: 1. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 2 weeks. Disp:28 Tablet, Delayed Release (E.C.)(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS duodenal ulcer due to NSAID use anemia of acute blood loss Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Dr. [Known lastname 9192], You were admitted to the hospital because you had melena and a hematocrit drop. You underwent an EGD which showed a duodenal ulcer and gastritis/duodenitis. We think that this is due to excessive NSAID intake. You should avoid NSAIDs completely for at least a month and then only take them sparingly with food. Try to use acetaminophen instead for pain but also do not exceed 4 grams per day. Also, there are some diet modifications for your ulcer: Antireflux regimen: Avoid chocolate, peppermint, alcohol, caffeine, onions, aspirin, tomatoe-based foods. Elevate the head of the bed 3 inches. Go to bed with an empty stomach. The following changes were made to your medications: - INCREASE pantoprazole to 40 mg twice daily for 2 weeks. After this, you can decrease to once daily again - STOP taking NSAIDS, use acetaminophen for pain instead. Do not exceed 4 grams of acetaminophen per 24 hours - STOP aspirin 81 mg daily until you have completed the 14 days of pantoprazole. If you motice melena again, then you should stop the aspirin and see your PCP or GI doctor. It is very important that you make follow-up appointments with your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] specialists. It was a pleasure taking care of you in the hospital! Followup Instructions: Please call to make an appointment with your primary care doctor, Dr. [Last Name (STitle) ] within 2 weeks. The information is Name: [Last Name (LF) 17528],[First Name3 (LF) 17529] Location: [Location (un) 2274]-[University/College ] Address: [Hospital1 3470], [University/College ],[Numeric Identifier 23943] Phone: [Telephone/Fax (1) 17530] Fax: [Telephone/Fax (1) 6808] Also, please call to make an appointment with the GI team. You can pick who would like to start seeing as an outpatient. The attending physician on your EGD here was Dr. [First Name8 (NamePattern2) 1586] [Name (STitle) 2161]. The phone number for [Hospital1 18] GI is: ([Telephone/Fax (1) 2233].	[ "535.60", "530.81", "250.00", "285.1", "272.0", "244.9", "E935.9", "532.40", "535.40", "401.9", "718.97" ]	icd9cm	[ [ [] ] ]	[ "45.13" ]	icd9pcs	[ [ [] ] ]	6995, 7001	4904, 6285	307, 359	7122, 7122	2733, 2733	8623, 9356	1924, 1962		6570, 6972		7022, 7101		6442, 6547			7273, 8600			3172, 4881						2636, 2714													6306, 6416						263, 269									387, 1615					2749, 3156					7137, 7249						1637, 1782	1798, 1908
28,386	186,255	45633	Discharge summary	report	Admission Date: [2184-10-25] Discharge Date: [2184-10-29] Date of Birth: [2103-5-19] Sex: F Service: MEDICINE Allergies: Ranitidine / Esomeprazole Attending:[First Name3 (LF) 1436] Chief Complaint: Hypoxia, Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: 81 F with hypertension, diabetes, afib (on coumarin), CHF, h/o deep vein thrombosis, COPD. Per [Hospital1 5595] documentation, awoke [10-25] AM at 2:15 with SOB, diaphoresis, CP radiating to jaw. Noted to be tachypneic (RR 32), and hypoxic with O2 sat in 70s. Placed on 4L O2 by NC, with improvement in O2 sat to 94-96%. Sent to [Hospital1 18] ED. In [Name (NI) ], pt was hypertensive with SBP 170s, tachycardic with HR 110s. CXR showed mod L pleural effusion & small R pleural effusion, mild CHF. White count measured to be 16.9. Vitals were 96.1, 139/86, 108, 22, 96% on 4L. Received ASA, metoprolol. Also received levoflox, atrovent, and 125mg solumetrol. Pt admitted to CCU. In CCU, pt was afebrile. On [10-26], WBC down to 10.3. No ABX ordered, cultures pending. Pt received metoprolol 12.5 TID, HR down to 70-80, then increased to 25 mg. BP in 1-Teens to 130/70s. Pt had three sets of negative enzymes. Pt had decreased BS bilaterally with large pleural efusion. Was Sat'ing 94-98% on 4L. Folex draining clear urine. Diuresed with Lasix x 3. Pt's condition improved and now admitted to [Hospital Ward Name ] 6. Past Medical History: Atrial fibrillation Hypertension Diabetes CHF h/o DVT COPD Dementia Urinary incontinence h/o skin cancer anxiety bilateral cataracts glaucoma essential tremor Dysphagia (on soft diet) Social History: Lives at [Hospital6 459] for Aged x 9 mo. Previously lived in senior housing, prior to having difficulty with ADLs. Previous 2 PPD tobacco x 30 yr. No EtOH. Walks with a walker. Family History: Non-contributory Physical Exam: VS - T 96.1, BP 139/86, HR 108, RR 29, O2 sat 96% 4L NC, Wt 80kg HEENT - PERRL, EOMI, OP clr, MMM CV - irreg irreg, tachy, no mur Chest - poor inspiratory effort, but bilat crackles 1/4 up Abdomen - soft, NT/ND, no g/r Extremities - trace bilat edema, warm Neuro - A&Ox1 Pertinent Results: Chest AP - Mild-to-moderate perihilar haze in conjunction with a moderate left and small right pleural effusion is noted. There are adjacent areas of probably compression atelectasis but no evidence of focal pneumonia. No evidence of pneumothorax. Please note that examination is slightly limited due to marked patient rotation. . ECG [10-25] @ 3:47 AF @ 126; no old for comparison [10-25] @ 6:07 AF @ 95 . [2184-10-25] 12:07PM GLUCOSE-228* UREA N-15 CREAT-0.6 SODIUM-132* POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-31 ANION GAP-11 [2184-10-25] 12:07PM CK(CPK)-86 [2184-10-25] 12:07PM CK-MB-NotDone cTropnT-0.05* [2184-10-25] 12:07PM CALCIUM-8.7 PHOSPHATE-3.5 MAGNESIUM-2.1 [2184-10-25] 12:07PM OSMOLAL-285 [2184-10-25] 12:07PM WBC-10.3 RBC-4.18* HGB-12.9 HCT-36.5 MCV-88 MCH-30.9 MCHC-35.3* RDW-14.3 [2184-10-25] 12:07PM PLT COUNT-300 [2184-10-25] 05:41AM LACTATE-1.7 [2184-10-25] 05:29AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.020 [2184-10-25] 05:29AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2184-10-25] 05:29AM URINE RBC-0-2 WBC-[3-8] BACTERIA-FEW YEAST-NONE EPI-0-2 [2184-10-25] 05:29AM URINE HYALINE-[11-23]* [2184-10-25] 05:20AM URINE HOURS-RANDOM UREA N-743 CREAT-88 SODIUM-18 CHLORIDE-29 [2184-10-25] 05:20AM URINE OSMOLAL-586 [2184-10-25] 04:37AM TYPE-ART PO2-73* PCO2-54* PH-7.36 TOTAL CO2-32* BASE XS-2 [2184-10-25] 04:00AM GLUCOSE-261* UREA N-15 CREAT-0.7 SODIUM-129* POTASSIUM-4.2 CHLORIDE-92* TOTAL CO2-27 ANION GAP-14 [2184-10-25] 04:00AM CK(CPK)-104 [2184-10-25] 04:00AM cTropnT-<0.01 [2184-10-25] 04:00AM CK-MB-7 [2184-10-25] 04:00AM CALCIUM-8.3* PHOSPHATE-4.3 MAGNESIUM-2.0 [2184-10-25] 04:00AM CALCIUM-8.3* PHOSPHATE-4.3 MAGNESIUM-2.0 [2184-10-25] 04:00AM WBC-16.9* RBC-4.53 HGB-13.8 HCT-40.0 MCV-88 MCH-30.5 MCHC-34.5 RDW-14.2 [2184-10-25] 04:00AM NEUTS-93.4* BANDS-0 LYMPHS-3.8* MONOS-2.4 EOS-0.4 BASOS-0 [2184-10-25] 04:00AM PLT SMR-NORMAL PLT COUNT-318 [2184-10-25] 04:00AM PT-37.1* PTT-28.3 INR(PT)-4.1* . Echo [2184-10-25]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior hypokinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion without tamponade. Brief Hospital Course: 81F EF 45% inf HK, afib/C, DVT, dm2, copd p/w rapid afib and in setting of rapid rate has angina and CHF . 1. Cardiac: a. Rhythm: Pt was in rapid afib on admission. Initially ther was poor rate control in house and the patient went to ICU. She was on atenolol 12.5 daily that uptitrated gradually and rate control improved. Pt's coumadin was held on admission for a supratherapeutic level, though it was restarted. . b. Coronaries: The patient did have anginal symptoms in the setting of rapid heart rate. There was no known h/o CAD, though there is EF 45% with inf HK which suggests CAD. The chest pain was likely related to the rapid afib. The ECG showed only non-specific changes. Enzymes showed trop t 0.03 with negative CK and MB. Pt was rate controlled as described and continued with aspirin, beta blocker, and statin. c. [Name (NI) ] Pt presented in acute CHF with pulmonary edema. LVEF 45%. The patient was diuresed. She was continued on beta blocker and we started an ace inhibitor as well. 2. Confusion: Pt has h/o dementia and was hospitalized with mutliple sedatives and psych meds. Pt's sedating medications were held in house. Confusion resolved and patient oriented again to person, place, and time by hospital day 4. 3. Pleural effusions: There were bilateral, moderate on the left and small on the right. This is unlikely contributing to SOB. The plan was to diurese and treat CHF. . 4. Leukocytosis: Pt had WBC of 16 on admission, but this resolved over hospital course down to 11.1. Likely stress response. Pt is afebrile, UA is negative. CXR is c/w CHF. 5. Diabetes Mellitus Patient c/w metformin and SSI in-house. . Access - PIV . Prophylaxis: anticoagulated for afib, PPI, bowel regimen, per home regimen Medications on Admission: Risperdal 1 qhs ativan 0.25 q6h prn Latanoprost 0.005% 1 drop qhs ASA 81 qd B12 1000 mcg qd Simvastatin 20 qpm Tylenol 650 q4h prn Combivent 2 puffs q6h prn Coumadin Metformin 1000 daily Robitussin 10 cc q4h prn Atenolol 12.5 qd Celexa 40 qhs Calcium 650 [Hospital1 ] Vit D 1000 U ad Senna 2 tabs qhs Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Cyanocobalamin 250 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Atrovent 0.02 % Solution Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 8. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 10. Metformin 500 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection three times a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Rapid Atrial Fibrillation Primary Diagnosis: Congestive heart failure, systolic atrial fibrillation, uncontrolled anginal chest pain, CAD Secondary Diagnosis: diabetes dementia Discharge Condition: Improved Discharge Instructions: You came to the hospital because you were short of breath. You were found to have congestive heart failure because your heart rate was too fast. We changed your medications to better control your heart rate. Please note the following changes in your medication regimen: You should stop taking the combivent inhaler and rather use an atrovent inhaler to avoid albuterol which will make your heart rate faster. You should start taking Prilosec, which is an antacid, to protect your stomach from ulcers. You should start taking lasix to prevent you from returning to the hospital with heart failure. We changed atenolol to metoprolol and started that at a higher dose to help control your heart rate. We also started lisinopril, a medication to control high blood pressure and help your heart. If you have any shortness of breath, fevers, chills, chest pain, dizziness, or any other concerning symptoms, then please call your doctor or go to the emergency room Followup Instructions: Please call your primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 9474] to establish a follow-up appointment in [1-6] weeks. [Telephone/Fax (1) 9251] You should have electrolytes checked in a week since we started lisinopril and INR checked as usual. If your INR is therapeutic, the subcutaneous heparin can be stopped.	[ "428.0", "288.60", "413.9", "V10.83", "333.1", "799.02", "427.31", "294.8", "787.20", "788.30", "276.1", "428.20", "414.01", "300.00", "250.00", "496", "V12.51", "V58.61", "365.9" ]	icd9cm	[ [ [] ] ]	[]	icd9pcs	[ [ [] ] ]	8603, 8668	5255, 6998	308, 314	8890, 8900	2247, 5232	9910, 10273	1923, 1941		7353, 8580		8689, 8715		7024, 7330			8924, 9887									1956, 2228																			249, 270									342, 1501			8849, 8869			8734, 8828										1523, 1708	1724, 1907
27,854	150,745	33416	Discharge summary	report	Admission Date: [2108-1-1] Discharge Date: [2108-1-18] Date of Birth: [2055-7-19] Sex: F Service: MEDICINE Allergies: Keflex / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 30] Chief Complaint: Tx from OSH with pancreatitis Major Surgical or Invasive Procedure: Intubation Central line placement Arterial line placement X 2 History of Present Illness: 52YO female, pw four day history of N/V/D, generalized weakness and decreased PO. Pt denied abdominal pain. On arrival to [Location (un) ] she was noted to have o2 sats of 87% on RA. In addition, she was tachycardic to 118. She was ill appearing and cachectic with "cyanotic" fingers. Pt had an initial ph of 7.08, 20, po2 68. Her bicarb was five. Pt had elevated troponin to 1.16. She received three amps of bicarb with D5, cipro 400 IV, flagyl 500 IV. EKG demonstrated antero inferior q waves. ETOH at presentation was 50. At [Name (NI) ], pt received 5 liters of normal saline. Pt transferred from [Location (un) ] by [Location (un) ] Pt was intubated and sedated on arrival to [Hospital1 18]. She was noted to have a heart rate of 125 and a blood pressure of 97/60. Her exam was notable for coarse but equal breath sounds and a distended abdomen. Pt was noted to be guiac positive, She was evaluated by general surgery out of concern for necrotizing pancreatitis. They concluded that given the patient's down-trending LFT's and CT changes, these were not consistent with nec pancreatitis. In the ED, the patient received another four liters of normal saline for a total-pre-arrival to the MICU of 9 liters of IV fluid. At [Hospital1 18], pt received zosyn, thiamine, Pt was admitted to the MICU for further evaluation and treatment. Past Medical History: pancreatitis anemia COPD Social History: Smokes [11-23] PPD. ETOH abuse, unknown IVDA. Family History: Unknown Physical Exam: VS: Temp: BP: / HR: RR: O2sat GEN: Chronically ill appearing HEENT: scleral icterus. NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps RECTAL: FOBT(+) Pertinent Results: [2107-12-31] 07:03PM BLOOD WBC-8.3 RBC-2.78* Hgb-10.5* Hct-31.9* MCV-115* MCH-37.7* MCHC-32.8 RDW-13.3 Plt Ct-151 [2108-1-18] 06:05AM BLOOD WBC-6.8 RBC-2.95* Hgb-10.0* Hct-31.2* MCV-106* MCH-34.0* MCHC-32.1 RDW-15.9* Plt Ct-784* [2107-12-31] 07:03PM BLOOD Neuts-91.8* Lymphs-5.2* Monos-2.7 Eos-0.2 Baso-0.1 [2108-1-17] 06:05AM BLOOD Neuts-63.0 Lymphs-25.0 Monos-6.4 Eos-4.7* Baso-1.0 [2107-12-31] 07:03PM BLOOD PT-16.4* PTT-34.2 INR(PT)-1.5* [2108-1-17] 06:05AM BLOOD PT-12.3 PTT-22.1 INR(PT)-1.0 [2108-1-18] 06:05AM BLOOD Glucose-85 UreaN-7 Creat-0.5 Na-137 K-4.4 Cl-101 HCO3-23 AnGap-17 [2107-12-31] 07:03PM BLOOD Glucose-147* UreaN-8 Creat-0.7 Na-141 K-3.7 Cl-110* HCO3-11* AnGap-24* [2107-12-31] 07:03PM BLOOD ALT-35 AST-96* CK(CPK)-88 AlkPhos-181* TotBili-4.9* [2108-1-18] 06:05AM BLOOD ALT-70* AST-110* LD(LDH)-256* AlkPhos-496* Amylase-56 TotBili-4.3* [2107-12-31] 07:03PM BLOOD Lipase-1090* [2108-1-1] 01:44AM BLOOD Lipase-663* [2108-1-1] 03:41PM BLOOD Lipase-510* [2108-1-2] 02:38AM BLOOD Lipase-446* [2108-1-4] 03:58AM BLOOD Lipase-51 [2108-1-18] 06:05AM BLOOD Lipase-130* [2107-12-31] 07:03PM BLOOD Albumin-2.7* Calcium-6.0* Phos-3.3 Mg-1.2* [2108-1-4] 03:58AM BLOOD VitB12-971* Folate-9.8 [2108-1-11] 10:20AM BLOOD Hapto-170 [2108-1-1] 06:05AM BLOOD Triglyc-210* [2108-1-7] 06:26PM BLOOD CRP-121.4* [2107-12-31] 07:31PM BLOOD Type-ART Rates-/24 Tidal V-450 FiO2-100 pO2-84* pCO2-30* pH-7.12* calTCO2-10* Base XS--18 AADO2-619 REQ O2-98 -ASSIST/CON Intubat-INTUBATED [2108-1-15] 02:42PM BLOOD Type-ART pO2-69* pCO2-34* pH-7.51* calTCO2-28 Base XS-3 [2107-12-31] 07:31PM BLOOD Glucose-130* Lactate-4.3* Na-140 K-3.3* Cl-115* [2107-12-31] CT ABD: IMPRESSION: 1. Moderate amount of stranding within the anterior pararenal space surrounding the pancreas, which is consistent with the clinical diagnosis of acute pancreatitis. There is no evidence of complication (on this essentially unenhanced scan). 2. Persistent renal parenchymal enhancement, with a somewhat striated appearance, which despite the normal serum creatinine, raises the question of acute renal dysfunction, particularly ATN or other tubular abnormality. This should be correlated with clinical and laboratory information. 3. Low-attenuation liver consistent with generalized fatty infiltration. 4. Large consolidation in the lower lobes bilaterally and posteriorly, raises the possibility of aspiration pneumonia. 5. Mild hypodensity in the wall of the cecum and ascending colon which could represent submucosal edema with mild apparent hyperemia of the mucosa, focally. This finding is nonspecific, and could related to the patient's known hypoalbuminemia; correlation with the clinical status of the patient is recommended. 6. High density within the cystic duct and common bile duct as well as intermediate density within the gallbladder. These findings, in this context, are most suggestive of vicarious excretion of contrast, also suggestive of underlying renal abnormality. [2107-12-31]: ECG: Sinus tachycardia. Diffuse low QRS voltage. Left axis deviation. Poor R wave progression - cannot rule out old anteroseptal myocardial infarction. Diffuse non-specific ST-T wave changes which are non-specific. No previous tracing available for comparison. [2108-1-1]: CXR: There has been interval worsening in bibasilar consolidations and effusions greater on the right side. There is no pneumothorax. ET tube and NG tube remain in place [2108-1-10] ECHO: The left atrium is normal in size. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis (LVEF = 35-40 %). Systolic function of apical segments is relatively preserved. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. Compared with the report of the prior study (images unavailable for review) of [2108-1-2], biventricular systolic function is now improved. [2108-1-12] CT ABD/Pelvis: IMPRESSION: 1. No evidence of pancreatic pseudocyst or hepatobiliary obstruction. 2. Multifocal pneumonia. 3. Featureless sigmoid colon may represent C. diff infection. Recommend correlation with serum C. Diff toxin markers. 4. Fatty liver, unchanged since [2108-1-5]. 5. Anasarca, unchanged since [2108-1-5]. Brief Hospital Course: This is a 52 year old female transferred from OSH with pancreatitis, likely ETOH, intubated with possible ARDS and aspiration pna. # Pancreatitis: Nausea, vomiting, decreased PO, CT scan, and lipase of > 1000 demonstrate pancreatitis on admission. There was no evidence of hemorrhage or pseudocyst on CT scan. She was transferred from [Hospital3 7569] and intubated at in the ED and then transferred to the MICU. She was extubated successfully and transferred out to the medical floor. Patient admits to drinking whiskey daily which is the likely cause of her pancreatitis. Her pancreatitis has now resolved and she has been advanced to a PO diet. She is to follow up with her primary care physician as an outpatient. She was educated on the harms of alcohol abuse and was told to refrain from any EtOH use in the future as it may precipitate another episode of pancreatitis. # Acute on chronic systolic heart failure: TTE on [1-2] with LVEF 25%, with severe global hypokinesis. [1-10] f/u TTE showed improvement in systolic function. Patient denies any history of CHF. CHF is likely [12-24] EtOH cardiomyopathy. She was started on Aspirin, Toprol and Lisinopril. # Pneumonia: Patient was admitted with PNA and ARDS thought to be [12-24] aspiration pneumonia. She was started on Levofloxacin and Flagyl for treatment. During her MICU stay, she continued to spike fevers and her antibiotics were broadened to Vancomycin and Zosyn IV. She was treated for 10 days of antibiotics and was afebrile on discharge. # NSVT: Ms. [Known lastname 1726] had a few 5-10 beat runs of NSVT while in the hospital. She has no history of CAD but may have EtOH cardiomyopathy based on TTE done here. She was started on Toprol for treatment of her CHF and NSVT. This should be followed up by her PCP as an outpatient. # Elevated LFTs. An obstructive pattern. No evidence cholecystitis, biliary tree abnormality on RUQ u/s x2 and CT torso. Given history, likely, [12-24] EtOH hepatitis. Hepatology was consulted and recommended ERCP if LFT's rose again, however they remained stable and the patient was discharged home. She should be follow up by her PCP regarding this matter. # Respiratory Failure- Initially intubated for ARDS, likely [12-24] aspiration PNA. She was extubated successfully and was breathing at baseline on discharge with good oxygen saturations. # ETOH abuse: Social work was consulted for EtOH abuse. Patient was referred to local programs for help. Medications on Admission: folic acid Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Home With Service Facility: [Hospital3 77534] Care Discharge Diagnosis: Primary: - Hypovolemic/Septic shock - Aspiration pneumonia - Acute respiratory distress syndrome - Necrotizing pancreatitis - ETOH hepatitis - Non-thrombotic troponin elevation - Acute Systolic heart failure - SVT with aberrancy - NSVT - Multifactorial anemia - Rash NOS - Malnutrition, moderate degree Secondary: - ETOH abuse - COPD Discharge Condition: good. pancreatitis resolved. Discharge Instructions: you were admitted for pancreatitis to the intensive care unit. Your pancreatitis has now resolved. You were also found to have heart failure which will need to be addressed with your cardiologist. . please refrain from drinking alcohol. . please take your medications as prescribed. . follow up as below. Followup Instructions: please follow up with your primary care physician [Name Initial (PRE) 176] 1 week. [Last Name (LF) ],[First Name3 (LF) 1955] F. [Telephone/Fax (1) 20587] . please follow up with your cardiologist to address your heart failure. . please follow up with your gastroenterologist to address you abnormal liver function and for continuing care of your pancreatitis.	[ "507.0", "571.1", "428.0", "577.0", "428.23", "511.9", "496", "518.81", "693.0", "285.9" ]	icd9cm	[ [ [] ] ]	[ "99.15", "96.72", "34.91", "96.71", "96.6", "96.04", "38.93" ]	icd9pcs	[ [ [] ] ]	10045, 10102	7118, 9628	317, 380	10481, 10512	2547, 7095	10865, 11244	1920, 1929		9690, 10022		10123, 10460		9654, 9667			10536, 10842									1944, 2528																			248, 279									408, 1788																1810, 1836	1852, 1904

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