ChanBeDu/relevant_section_length · Datasets at Hugging Face

48,806

116,558

45593

Discharge summary

report

Admission Date: [**2135-12-1**] Discharge Date: [**2135-12-16**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: AV fistulogram Tunneled dialysis catheterization Hemodialysis History of Present Illness: Mr. [**Known lastname 97237**] is an 88 y/o man with PMH notable for stage IV CKD, afib on coumadin, and CHF who was at his home earlier today when he noted the onset of nausea. He reports no chest pain, diaphoresis or abdominal pain at the time. He did have several episodes of dry heaves. He called EMS and was taken to [**Hospital1 **]. On arrival to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], he was noted to have acute decompensation. O2 sat on arrival was 77-80% on [**Name6 (MD) 597**] [**Name8 (MD) **] MD notes. He received lasix 100 mg and bumex 1 mg but made only 100 cc urine over the course of his stay; he then received 50 more mg of lasix with no response. He was also placed on a nitro gtt but blood pressures declined to 80s-90s systolic so this was intermittently stopped. As his primary nephrologist is at [**Hospital1 18**] and the outside hospital ED was worried about dialysis initiation, he was then transferred to [**Hospital1 18**] for further evaluation. . In the [**Hospital1 18**] ED, initial VS were T 96.8, HR 62, BP 92/61, RR 17, 99% on bipap. BP transiently dropped to 88/28 and he was given a 250 cc NS bolus X 1. Due to ? infiltrate on CXR, he was given 1 g IV vancomycin and 750 mg IV levofloxacin. He was also treated with combivent nebs. Eventually, he was placed on a [**Hospital1 597**] but dropped his O2 sats to 88-92% so was placed back on BiPAP with improvement in sats. Nitro gtt was also discontinued. Potassium was found to be 6.8 and he was given calcium gluconate, insulin/D50 and kayexelate. . On the floor, the patient states his breathing has improved compared to earlier today. He denies any current nausea, chest pain, abdominal pain, headache, dizziness, or diaphoresis. He would like to try to take off the BIPAP again. He states he did have a few canned soups over the past few days but no other dietary changes. After seeing Dr. [**Last Name (STitle) **] on Tuesday, he held his lasix on Tuesday afternoon and Wednesday morning per instructions and then resumed 80 mg Wednesday evening. . ROS: Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Does have dizziness intermittently, especially with lying down. Denies cough, chest pain or tightness, palpitations. Denies PND or orthopnea. Uses CPAP at night chronically. Denies vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. Occasionally has small amounts of bright red blood in stool but none recently. No dysuria but some difficulty initiating urination. Slight decrement in urine output. Denies arthralgias or myalgias. Past Medical History: # CAD s/p CABG [**2123**]. # Diabetes Mellitus, type 2 - HbA1C 6.3 [**12/2131**] # ESRD on HD initiated [**2135-12-9**] - s/p LUE AV fistula in [**3-/2135**] # Atrial fibrillation on coumadin # Chronic systolic CHF, EF 25% [**2135-12-2**] # Hypertension # Hyperlipidemia # chronic venous stasis Social History: Married, lives with wife in [**Hospital3 **] facility. Daughter lives in close proximity. No EtOH or tobacco. Family History: Mother with aortic dissection. Father with MI. Physical Exam: VS: T 97.2, BP 112/46, HR 61, RR 22, O2 96% Gen: no distress, pleasant HEENT: NCAT, EOMI, PERRL. Anicteric, no conjunctival pallor. OP clear, MMM. Neck: JVD difficult to assess, no LAD, no thyromegaly Cor: irregularly irregular, no appreciable murmur Pulm: no wheezing, + bibasilar crackles Abd: soft, normoactive bowel sounds, nontender to palpation Extrem: no peripheral edema, feet cool bilaterally with stigmata of chronic venous stasis, DP pulses dopplerable bilaterally, LUE AV fistula Skin: dry skin bilateral anterior legs with color change compatible with venous stasis bilaterally but L>R Neuro: alert, speaking clearly and in full sentences, face symmetric, moving all extremities without difficulty Pertinent Results: Admission: [**2135-12-11**] 01:50AM BLOOD WBC-9.7 RBC-2.90* Hgb-9.9* Hct-28.0* MCV-97 MCH-34.0* MCHC-35.3* RDW-18.5* Plt Ct-168 [**2135-12-10**] 03:04PM BLOOD Glucose-219* UreaN-88* Creat-3.1* Na-136 K-4.2 Cl-98 HCO3-26 AnGap-16 [**2135-12-11**] 01:50AM BLOOD Glucose-121* UreaN-54* Creat-2.7* Na-143 K-4.5 Cl-104 HCO3-28 AnGap-16 [**2135-12-1**] 06:20PM BLOOD WBC-13.6*# RBC-3.75* Hgb-12.1* Hct-36.9* MCV-98 MCH-32.4* MCHC-32.9 RDW-19.0* Plt Ct-167 [**2135-12-1**] 06:52PM BLOOD PT-30.0* PTT-32.3 INR(PT)-3.1* [**2135-12-1**] 06:20PM BLOOD Glucose-163* UreaN-92* Creat-4.2* Na-137 K-6.5* Cl-103 HCO3-20* AnGap-21* [**2135-12-1**] 06:20PM BLOOD CK(CPK)-92 [**2135-12-2**] 02:04AM BLOOD CK(CPK)-91 [**2135-12-2**] 08:00AM BLOOD CK(CPK)-102 [**2135-12-1**] 06:20PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]* [**2135-12-1**] 06:20PM BLOOD cTropnT-0.20* [**2135-12-2**] 02:04AM BLOOD CK-MB-NotDone cTropnT-0.20* [**2135-12-2**] 08:00AM BLOOD CK-MB-4 cTropnT-0.19* [**2135-12-2**] 02:04AM BLOOD Calcium-9.4 Phos-5.9* Mg-2.4 [**2135-12-1**] 06:35PM BLOOD Glucose-149* Lactate-3.2* Na-138 K-6.8* Cl-101 calHCO3-20* [**2135-12-1**] 06:56PM BLOOD Lactate-3.1* K-6.4* [**2135-12-1**] 10:53PM BLOOD Lactate-3.4* K-6.1* [**2135-12-16**] 08:00AM BLOOD WBC-10.3 RBC-2.63* Hgb-8.7* Hct-25.3* MCV-96 MCH-33.0* MCHC-34.3 RDW-18.7* Plt Ct-181 [**2135-12-15**] 05:35AM BLOOD PT-26.6* PTT-38.9* INR(PT)-2.6* [**2135-12-16**] 08:00AM BLOOD Glucose-192* UreaN-56* Creat-4.0* Na-130* K-4.4 Cl-95* HCO3-26 AnGap-13 [**2135-12-10**] 10:51AM BLOOD CK(CPK)-85 [**2135-12-10**] 03:04PM BLOOD CK(CPK)-78 [**2135-12-10**] 10:30PM BLOOD CK(CPK)-79 [**2135-12-15**] 11:50AM BLOOD CK(CPK)-45 [**2135-12-10**] 10:51AM BLOOD CK-MB-NotDone cTropnT-0.46* [**2135-12-10**] 03:04PM BLOOD CK-MB-NotDone cTropnT-0.50* [**2135-12-10**] 10:30PM BLOOD CK-MB-NotDone cTropnT-0.58* [**2135-12-15**] 11:50AM BLOOD CK-MB-NotDone cTropnT-0.40* [**2135-12-16**] 08:00AM BLOOD Albumin-3.3* Calcium-9.5 Phos-3.9 Mg-1.9 [**2135-12-9**] 05:45AM BLOOD calTIBC-268 Ferritn-246 TRF-206 [**2135-12-10**] 03:04PM BLOOD PTH-691* [**2135-12-10**] 08:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE [**2135-12-9**] 04:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2135-12-9**] 04:15PM BLOOD HCV Ab-NEGATIVE [**2135-12-10**] 10:54AM BLOOD Type-ART pO2-77* pCO2-55* pH-7.20* calTCO2-22 Base XS--6 Intubat-NOT INTUBA [**2135-12-10**] 03:10PM BLOOD Lactate-1.6. [**2135-12-1**] 06:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 [**2135-12-1**] 06:20PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2135-12-1**] 06:20PM URINE RBC-0-2 WBC-0 Bacteri-RARE Yeast-NONE Epi-0 [**2135-12-2**] 02:04AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.018 [**2135-12-2**] 02:04AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-SM [**2135-12-2**] 02:04AM URINE RBC-21-50* WBC-[**3-9**] Bacteri-MOD Yeast-NONE Epi-0 [**2135-12-7**] 08:42AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2135-12-7**] 08:42AM URINE RBC-[**6-14**]* WBC-[**3-9**] Bacteri-RARE Yeast-NONE Epi-0-2 [**2135-12-10**] 01:45PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.026 [**2135-12-10**] 01:45PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-TR Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-SM [**2135-12-10**] 01:45PM URINE RBC-21-50* WBC-[**11-24**]* Bacteri-MANY Yeast-NONE Epi-0-2 [**2135-12-11**] 04:41PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019 [**2135-12-11**] 04:41PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR [**2135-12-11**] 04:41PM URINE RBC-[**6-14**]* WBC-[**3-9**] Bacteri-MOD Yeast-NONE Epi-0 MICRO: Blood CX: [**12-1**], [**12-1**], [**12-10**], [**12-10**], [**12-10**], [**12-10**]: NO GRWOTH [**12-14**], 12,10: NGTD Urine Cx: [**12-2**], [**12-7**], [**12-10**], [**12-11**] NO GROWTH [**12-2**]: TTE The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 25 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal/mild aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2134-6-8**], the LVEF appears slightly lower. [**12-1**] CXR: IMPRESSION: Limited evaluation due to low inspiratory volumes. Retrocardiac opacity may represent atelectasis but developing infection is not excluded. A dedicated PA and lateral views of the chest are recommended when the patient is able to take a better inspiration for further evaluation of the lung bases. [**12-2**] CXR IMPRESSION: Cardiomegaly without evidence of pulmonary edema or focal infiltrate to suggest pneumonia. Bibasilar atelectasis. Unchanged retrocardiac opacity likely reflective of a moderate-to-large hiatal hernia. When clinically feasible, this can be better evaluated with dedicated repeat PA and lateral radiographs. [**12-10**] CXR This film is somewhat obscured by motion. There are patchy alveolar opacities that have increased compared to the prior study and retrocardiac opacity has probably increased as well. The findings are suggestive of increased pulmonary edema although an infectious etiology cannot be totally excluded. There is a right IJ line with tip in the SVC/RA junction. [**12-9**] AV Fistula PFI: Left AV fistulogram demonstrated mild stenosis at the proximal venous portion of the cephalic vein and mild stenosis at the distal portion of the cephalic vein near the anastomosis site. Balloon dilation at both stenosis sites with both stenoses resolved and improved flow. Brief Hospital Course: 88 year old male with a history of CAD s/p CABG, CHF (EF 25%), ESRD newly initiated on [**Hospital **] transferred to the ICU with hypoxia, pulmonary edema, and lactic acidosis. . #Dyspnea/ Hypoxia: Mr. [**Known lastname 97237**] was initially admitted to [**Hospital1 18**] ICU on [**12-1**] after transfer from an OSH with CHF exacerbation and hypoxia. A repeat ECHO on [**12-2**] showed slight worsening of systolic function (EF 25%). He was treated with a lasix gtt (due to borderline low blood pressures), and was weaned to nasal cannula. He was transferred to the Cardiology service on [**12-3**]. While on the Cardiology service he was transitioned to bolus diuretics and was responding well to lasix 60 mg IV BID and metolazone 5 mg po BID with I/Os 1-1.5 L negative per day. . It was eventually decided to initiate HD during this hospital admission. He had a fistulogram performed [**12-9**] and also had a tunnelled R IJ HD catheter placed and he had his first run of HD without ultrafiltration. In the setting of HD initiation it was requested that his diuretics be held so he did not receive lasix or metolazone yesterday. The patient became acutely SOB on [**12-10**] in the morning. O2 sats were in the mid-80s on nasal cannula and improved to 90% on [**Month/Day (4) 597**]. Prior to episode, patient was hypertensive with SBP 160 and was tachycardic on telemetry as high as 140s. CXR c/w pulmonary edema. ABG showed 7.20/55/77 with a lactate of 7.4. The patient's venous lactate was repeated and was 6.2. The patient also had a leukocytosis of 12.8. Blood cultures were sent and the patient got a 1gm of Vancomycin. The patient had a new AG of 21. Cardiac enzymes were eventually negative x3 (elevated Trop, but flat CK in the setting of renal failure). He received albuterol and atrovent nebulizers, 80 mg of IV lasix, and 1 inch of nitropaste with improvement. . The patient had HD again on [**12-10**] w/ 1.5kg removed and weaned to home CPAP overnight and 3L NC in the morning. His AG improved and lactate normalized. The patient's WBC trended down to 9.7. The patient's UA was also postive and he was started on cipro, but urine cx were negative and cipro was discontinued. The patient was transferred back to the floor on [**12-11**] on 3L NC. He continuned dialysis with fluid removal and was able to be weaned to back to room air on [**12-14**]. The patient's repiratory status improved and he was discharged on [**12-16**]. His home lasix was held secondary to low blood pressure and having fluid removed at dialysis and he should be followed up as an outpatient regarding reinitiation. . # ESRD: It was eventually decided to initiate HD during this hospital admission. He had a fistulogram performed [**12-9**] and also had a tunnelled R IJ HD catheter placed and he had his first run of HD on [**12-9**] without ultrafiltration. On [**12-10**] the patient again had HD with 1.5L removed. The patient continued to have HD with fluid removal and his respirtroy status improved. He had hepatitis serologies performed and were negative. Additionally, he had a PPD placed that was also negative. The patient continuned HD and was closely followed by the renal team. He was setup with outpatient HD M/W/F. His last HD session prior to discharge was [**12-16**] and will have outpatient HD on Monday, [**12-9**]. # anion gap metabolic acidosis: The patient was transferrred to the ICU on [**12-10**] with elevated lactate. There was no clear source of the new lactic acidosis. The patient also had a newly elevated WBC count but not left shifted so could have been a stress response from pulmonary edema. The patient did receive vancomycin 1 gram per HD protocol to cover for possible bacteremia from line placement, but blood cultures were negative. However, the patient's lactate rapidly closed and leukocytosis resolved. . # CHF: The patient had an ECHO that showed his EF 25% down from 30-40%. Please see above. The patient was restarted on metoprolol 6.25mg [**Hospital1 **], but was limited by his low blood pressure. Additionally, his ACE-I was attempted to be restarted, but his blood pressures could not tolerate. . # AF: The patient has been on coumadin, but was held for his HD line placement. His coumadin was restarted on his home dose on [**12-11**] (INR 1.2) . The patient's INR continued to trend upward and was therapeutic on discharge. He was continued on his home dose of 4.5mg daily at dischage. The was also continued on metoprolol 6.25mg [**Hospital1 **] for rate control, but the dose was limited by low blood pressures. . # DM2: The patient was continued on his home NPH dose of 15U in the AM and 30U in the PM. His blood sugars were well controlled, however he did have an episode of asymptomatic hypoglycemia with a AM glucose of 44, repeat FS showed 64 on [**12-15**]. He was given juice and crackers. The patient's PM NPH dose was adjusted to 25U and was titrated back to 28U on discharge given mildly elevated AM sugars 194. He was followed with QID FS and ISS during his stay. . # CAD: s/p CABG. On [**12-10**] the patient had cardiac enzymes drawn that were eventually negative x3 (elevated Trop, but flat CK in the setting of renal failure). He also did not have compliants of chest pain or EKG changes. The patient also had an episode of chest pain on [**12-15**] after working with PT. The episode resolved spontaneously and no EKG changes and CE x1 were negative. The patient was continued on ASA and his BB. The patient remained chest pain free at discharge. . # FEN: cardiac, renal diet . # PPx: coumadin, bowel regimen . # ACCESS: R tunnelled HD catheter, PIV x2 . # Code: DNR/DNI, confirmed with patient Medications on Admission: Lipitor 10 mg once a day Zemplar 1 mcg once a day Aranesp 60 mcg/0.3 mL s/c once a week Humulin N 100 unit/mL Susp, Sub-Q Inj 15 u in the AM and 30 u in the PM, humalog 4 U prior to dinner Aspirin [**Hospital1 1926**] 81 mg once a day Allopurinol 200 mg once a day Furosemide 80 mg twice a day Enalapril Maleate 40 mg once a day Cozaar 100 mg once a day Ferrous Gluconate 324 mg once a day Warfarin 4.5 mg once a day Toprol XL 50 mg once a day Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). Disp:*15 Tablet(s)* Refills:*2* 11. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS) as needed for nausea. Disp:*45 Tablet(s)* Refills:*0* 12. Warfarin 1 mg Tablet Sig: 4.5 Tablets PO Once Daily at 4 PM. 13. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as directed Subcutaneous twice a day: 15U in the AM 28U in the PM. 14. Humalog 100 unit/mL Solution Sig: Four (4) U Subcutaneous prior to dinner. 15. Zemplar 1 mcg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary Diagnosis: 1. Acute on chronic renal failure (Stage IV) 2. Chronic systolic congestive heart failure 3. Respiratory distress Secondary Diagnosis: 1. Coronary artery disease status post coronary artery bypass grafting in [**2123**]. 2. Hypertension. 3. Hyperlipidemia. 4. Chronic venous stasis 5. Type 2 Diabetes Discharge Condition: Stable. Breathing comfortably. Discharge Instructions: You were admitted for shortness of breath. This was caused by worsening of your kidney function. You received diuretics during your admission that helped with your breathing. You also were initiated with hemodialysis during your hospitalization. Unless otherwise indicated, you should resume all of your home medications as presribed. It is very important that you take your medications as prescribed. Please Stop: 1) Enalapril Maleate 40mg daily 2) Cozaar 100mg daily 3) Toprol XL 50mg daily New Medications: 1) Metoprolol 6.25mg [**Hospital1 **] 2) Metoclopramide 5mg po TID w/meals 3) Docusate 100mg [**Hospital1 **] 4) Senna 1 tab [**Hospital1 **] Please keep all your medical appointments. If you develop chest pain, shortness of breath, or any other concerning symptoms, please call your PCP or go to your local Emergency Department immediately. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**] [**Telephone/Fax (1) 2205**]. Appointment: [**12-20**]. (Tues) 3:30pm Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2135-12-28**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2136-1-17**] 3:00 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2136-2-24**] 1:40 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2135-12-18**]

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374

Discharge summary

report

Admission Date: [**2198-2-13**] Discharge Date: [**2198-2-20**] Service: SURGERY Allergies: Zestril Attending:[**First Name3 (LF) 1481**] Chief Complaint: Lyphoma, scheduled palliative splenectomy Major Surgical or Invasive Procedure: Open splenectomy History of Present Illness: 80 yo M with known lymphoma, in need of splectomy Past Medical History: 1. Congestive Heart Failure 2. HTN 3. s/p Tracheal reconstruction 4. Spinal stenosis s/p laminectomy 5. Chronic Renal Failure with baseline creatinine in mid 2's. 6. BPH 7. CAD s/p LAD PTCA in '[**91**]. Stress in [**2194**] with normal EF and fixed inferior perfusion defect. 8. Anemia 9 PAF not on anticoagulation 10. Depression 11. OSA Social History: Lives with his wife but son visits daily. Walks with walker at baseline. Remote tobacco history. Drinks approximately 2 glasses of vodka per week. Family History: Non-contributory Physical Exam: (pre-op) 96.4 120/50 82 24 94%RA NAD, age-appropriate HEENT: MMM, minimal periorbital edeam, ATNC CTA-B with decreased BS @ bases B RRR, ?S3 ABD: NT/ND, soft (obese) EXT: +1 LE edema, no UE edema, symmetric motion Skin: dry Pertinent Results: [**2198-2-13**] 08:00AM BLOOD WBC-5.1 RBC-3.85* Hgb-11.5* Hct-36.0* MCV-93 MCH-29.8 MCHC-32.0 RDW-16.5* Plt Ct-172 [**2198-2-19**] 06:50AM BLOOD WBC-10.5 RBC-3.45* Hgb-10.2* Hct-32.3* MCV-94 MCH-29.6 MCHC-31.6 RDW-15.4 Plt Ct-310 [**2198-2-15**] 02:53AM BLOOD Neuts-82.1* Lymphs-12.6* Monos-5.1 Eos-0.1 Baso-0.1 [**2198-2-19**] 06:50AM BLOOD Plt Ct-310 [**2198-2-13**] 08:00AM BLOOD PT-13.7* PTT-28.8 INR(PT)-1.2 [**2198-2-13**] 08:00AM BLOOD Plt Ct-172 [**2198-2-13**] 12:47PM BLOOD Glucose-154* UreaN-31* Creat-2.3* Na-140 K-4.6 Cl-109* HCO3-23 AnGap-13 [**2198-2-15**] 03:11PM BLOOD Glucose-121* UreaN-41* Creat-2.7* Na-141 K-4.4 Cl-109* HCO3-25 AnGap-11 [**2198-2-19**] 06:50AM BLOOD Glucose-93 UreaN-38* Creat-2.0* Na-145 K-4.4 Cl-112* HCO3-25 AnGap-12 [**2198-2-15**] 02:53AM BLOOD CK(CPK)-743* [**2198-2-15**] 02:53AM BLOOD CK-MB-4 cTropnT-0.03* [**2198-2-13**] 12:47PM BLOOD Calcium-7.8* Phos-4.1 Mg-1.6 [**2198-2-19**] 06:50AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0 Brief Hospital Course: Pt was admitted on [**2-13**] for the purpose of undergoing a splenectomy. The procedure itself was without complication or findings necessitating a change in the pre-operative diagnosis. At the time of this summary, the final pathology on the resultant specimen was pending. In the immediate post-op period, pt had low UOP, that responsed sluggishly to repeated bolus of NS, but his lung exam and sats remained stable. On POD#1, pt developed progressive respiratory distress that was refractory to 02 via non-rebreather, and appear globally edematous, including extremtity and facial edema as well as a CXR suggestive of pulm edema. Given his know Hx of CAD and CHF, he was transferred to the MICU on the morning of POD#2 for closer monitoring. He was aggressively diuresed and underwent chest PT with good result, but remained in the unit until the morning of POD#4 when he was transferred back to the floor. Thereafter, his diet and activity were able to be quickly advanced. By POD#6, he was making adequate urine on his home medication regimen and was tolerating POs. He was discharged to home on POD#7 after being cleared by PT. Medications on Admission: 1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Terazosin HCl 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Isosorbide Dinitrate 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) As per sliding scale Injection ASDIR (AS DIRECTED). 5. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 7. Allopurinol 150' 8. Imdur 30' 9. MVI Discharge Medications: 1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Terazosin HCl 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Isosorbide Dinitrate 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) As per sliding scale Injection ASDIR (AS DIRECTED). 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 6. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-2 puffs Miscell. Q4-6H (every 4 to 6 hours) as needed. Disp:*qs puffs* Refills:*0* 7. Ipratropium Bromide 0.02 % Solution Sig: [**12-17**] Inhalation Q6H (every 6 hours) as needed. 8. Levothyroxine Sodium 150 mcg 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. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*40 Tablet(s)* Refills:*0* 11. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: 1) Lyphoma s/p splenectomy 2) CAD 3) Chronic kidney disease Discharge Condition: Fair, improving Discharge Instructions: Discharge to home with instructions for follow up as stipulated below. If you experience persistent fever >101.5, severe abdominal pain/vomiting, acute shortness of breath or other symptoms of concern, please seek medical evaluation at a convenient ER. Otherwise you may resume your regular diet and activities; you should, however, avoid strenous activities (i.e. moderate-heavy lifting) until after your follow-up visit. You may shower with careful drying of the incision sites, but do not take baths or immerse yourself in water. You should also restart your home medication regimen with the additions from this admission. Followup Instructions: Please call Dr.[**Name (NI) 1482**] office to schedule a follow-up appointment ([**Telephone/Fax (1) 1483**] Also, please keep this previously scheduled appointment: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2198-3-15**] 2:00

[ "428.0", "414.01", "403.91", "600.00", "V45.81", "202.80" ]

icd9cm

[ [ [] ] ]

[ "41.5" ]

icd9pcs

[ [ [] ] ]

5100, 5175

2178, 3321

256, 275

5279, 5296

1183, 2155

5974, 6338

897, 915

3906, 5077

5196, 5258

3347, 3883

5320, 5951

930, 1164

175, 218

303, 354

376, 717

733, 881

26,469

181,588

11866

Discharge summary

report

Admission Date: [**2137-6-9**] Discharge Date: [**2137-7-2**] Date of Birth: [**2074-8-6**] Sex: M Service: CARDIOTHORACIC SURGERY CHIEF COMPLAINT: Dyspnea on exertion. HISTORY OF PRESENT ILLNESS: The patient is a 62 year old with a history of pericardial aortic valve replacement and one vessel coronary artery bypass graft admitted for worsening dyspnea on exertion over the last month. The patient was without known heart disease until [**8-18**], when he developed heart failure with an ejection fraction of 15% with severe aortic stenosis. Catheterization was performed [**2136-12-18**], followed by one vessel coronary artery bypass graft and pericardial aortic valve replacement. Follow-up transthoracic echocardiogram at outside hospital reported an ejection fraction of 50%. The patient had no further events until one month ago when he started having dyspnea on exertion and lower extremity edema. He was admitted to [**Hospital1 69**] on [**2137-6-9**], with congestive heart failure. At this time, four out of four blood cultures were positive for alpha Streptococcus and the patient was started on Penicillin G and Gentamicin for bacterial endocarditis. Subsequent cultures have been negative. Transthoracic echocardiogram performed on [**2137-6-9**], revealed an ejection fraction of less than 20% with an AO mean gradient of 42. Transthoracic echocardiogram on [**2137-6-11**], showed vegetation with moderate aortic stenosis, severe global left ventricular hypokinesis, trace aortic regurgitation with multiple vegetations. The test also revealed mild to moderate mitral regurgitation and 3+ tricuspid regurgitation. Despite medical management of Lasix, antibiotics and ace inhibitors, the patient's condition has not improved. By [**2137-6-17**], the patient's systolic blood pressure had fallen to 60s to 70s and his urine output declined to less than 30 cc/hour. He was started on Dopamine and subsequently transferred to the Cardiac Intensive Care Unit. During his stay in the Cardiac Intensive Care Unit, the patient was subsequently taken for catheterization and placement of an intra-aortic balloon pump. After successful placement of this balloon pump, the patient was subsequently evaluated for cardiac surgery. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Anemia of uncertain origin. 3. Status post excision of rectal cancer. 4. Coronary artery bypass graft times one with pericardial aortic valve replacement. SOCIAL HISTORY: The patient quit smoking twenty years ago. He does not consume any alcohol. He lives with his wife and has a very supportive family. FAMILY HISTORY: Father died of myocardial infarction at age 61. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg once daily. 2. Iron Sulfate. 3. Colace. 4. Ambien. 5. Captopril and Amiodarone which were stopped [**2-16**]. REVIEW OF SYSTEMS: Negative unless otherwise stated above. PHYSICAL EXAMINATION: Temperature is 96.6, blood pressure 86/58, heart rate 107, respiratory rate 16, oxygen saturation 98% on two liters. The patient is comfortable in no apparent distress. Head, eyes, ears, nose and throat examination - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The neck is supple with no lymphadenopathy or bruits. Respiratory clear to auscultation bilaterally. Cardiac examination - regular rate and rhythm, II/VI holosystolic murmur. Abdomen was soft, nontender, nondistended with normoactive bowel sounds. Extremities were remarkable for 2+ pitting edema in the bilateral lower extremities. HOSPITAL COURSE: The patient was taken to the operating room on [**2137-6-19**], for redo aortic valve replacement. Valve placed was a #19 millimeter Carbomedics mechanical valve. The operation was performed without complication. The patient was subsequently transferred to the Cardiothoracic Surgical Intensive Care Unit. The patient was given perioperative Vancomycin and continued his intravenous Penicillin G administration. He was gradually weaned off drips and hemodynamically stabilized. He was extubated on postoperative day one. On postoperative day two, the intra-aortic balloon pump was discontinued which the patient tolerated well. The patient's condition progressively improved. Foley catheter and central line were discontinued as well as his pacing wires. His hematocrit was stable and he was progressively diuresed. Anticoagulation was begun with Heparin infusion and oral Coumadin. The patient was then transferred to the floor postoperative day five. He was tolerating an oral diet and ambulating well. His pain was controlled with oral medications. Due to the long course of his illness, the patient was encouraged to increase his p.o. intake and was provided with nutritional supplements. The patient continued to be diuresed with increasing amounts of Lasix. His lower extremity edema continues to slowly improve. Captopril was started from low dose and gradually increased which the patient tolerated well. On [**2137-6-28**], an echocardiogram was performed which revealed a large pericardial effusion over the right ventricle with suggestive tamponade physiology. The patient was subsequently taken for pericardiocentesis where 200 cc of hemorrhagic fluid were removed. The patient tolerated this procedure well and was subsequently observed in the Cardiothoracic Surgical Intensive Care Unit. He remained stable over the next several days. His postprocedure course was complicated by an extended episode of atrial fibrillation. He does remain rate controlled and hemodynamically stable and on [**2137-7-2**], the patient was felt stable for transfer to a rehabilitation facility on long term anticoagulation therapy. PHYSICAL EXAMINATION: Discharge vital signs revealed temperature 96.8, pulse 67, blood pressure 108/62, respiratory rate 20, oxygen saturation 98% in room air. The heart is regular rate and rhythm. The lungs are clear to auscultation bilaterally. The incisions are clean, dry and intact. The abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are remarkable for 2+ pitting edema. MEDICATIONS ON DISCHARGE: 1. Lisinopril 10 mg p.o. once daily. 2. Penicillin G 3 million units intravenously q4hours for a total of six weeks - course ending [**2137-7-24**]. 3. Amiodarone 400 mg p.o. once daily. 4. Calcium Carbonate 500 mg three times a day. 5. Docusate 100 mg p.o. twice a day. 6. Potassium Chloride 40 meq p.o. twice a day. 7. Lasix 40 mg p.o. twice a day. 8. Hydromorphone 2 to 4 mg q4-6hours p.r.n. for pain. FOLLOW-UP: The patient should follow-up with Dr. [**Last Name (STitle) **] in four weeks and follow-up with Dr. [**Last Name (STitle) 29994**] in three to four weeks. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is to be discharged to a rehabilitation facility. DISCHARGE DIAGNOSES: Status post redo mechanical aortic valve replacement following bacterial subacute bacterial endocarditis. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Name8 (MD) 11235**] MEDQUIST36 D: [**2137-7-1**] 19:58 T: [**2137-7-1**] 20:14 JOB#: [**Job Number 37435**]

[ "421.0", "396.2", "570", "785.51", "423.0", "584.9", "427.31", "996.61", "398.91" ]

icd9cm

[ [ [] ] ]

[ "37.0", "88.72", "89.68", "37.21", "37.61", "37.22", "89.64", "35.22", "39.61" ]

icd9pcs

[ [ [] ] ]

2656, 2705

6946, 7317

6225, 6808

2731, 2864

3629, 5779

5802, 6199

2884, 2925

169, 191

220, 2274

2296, 2487

2504, 2639

6833, 6924

62,160

146,566

21874

Discharge summary

report

Admission Date: [**2153-10-2**] Discharge Date: [**2153-10-9**] Date of Birth: [**2077-1-22**] Sex: F Service: ORTHOPAEDICS Allergies: Allopurinol / Protonix Attending:[**First Name3 (LF) 11415**] Chief Complaint: Right anterior column posterior hemitransverse fracture Major Surgical or Invasive Procedure: Open reduction internal fixation anterior column posterior transverse fracture with posterior exposure History of Present Illness: 76 yo f s/p mechanical fall from standing this evening landing on right side. no paresthesia, weakness, UI/[**Hospital1 **]. has not been ambulatory since fall secondary to right hip pain. no lightheadedness, dizziness. Past Medical History: PMH: AVN of bilateral hips COPD renal stenosis GERD Ischemic colitis Hypercholesterol Hypertension renal stenosis asthma Bilateral iliac angioplasty and stenting. Multiple skin cancer removal- including this week Social History: historical tobacco. denies etoh, drugs Family History: NC Physical Exam: On admission: Physical exam: Gen: Nad Msk: Full rom of bilateral shoulders, elbows,wrists, knees, and ankle are non tender to palpitation no shortening or external rotation. 2+dp pulses bilateral with cap refill less than 2 seconds. LE sensation intact. able to flex/extend hip limited by pain, able to flex extend knee limited by pain. On discharge: Gen: NAD Ab: soft, non-distended RLE: dressing c/d/i, no erythema or induration SILT s/s/t/dp/sp [**6-7**] gs/ta/[**Last Name (un) **] 2+ dp/pt Pertinent Results: CT PELVIS W/O CONTRAST IMPRESSION: 1. Extensive right acetabular fracture involving the right anterior and posterior walls and columns and medial wall with extension into the right iliac bone. There is likely a small chip fracture fragment in the right hip joint space. 2. Right superior pubic ramus spiral fracture and right inferior pubic ramus segmental fracture. 3. Asymmetric hyperdensity and enlargement of the right obturator externus and right iliacus muscles consistent with intramuscular hematoma and muscle injury adjacent to fracture sites. Mild enlargement of the right gluteus medius and minimus muscles consistent with muscle injury. 4. Soft tissue stranding and mild hyperdensity in the pre-vesicular space is concerning for either hemorrhage and/or extraperitoneal bladder injury, which may be masked with Foley catheter in place. Consider cystographic study for assessment of bladder integrity. 5. Degenerative changes and chondrocalcinosis involving the left hip joint and pubic symphysis, suggesting CPPD. 6. Sacroiliac joint degenerative disease bilaterally without signs of diastasis. CT PELVIS W/CONTRAST IMPRESSION: 1. No evidence for intra- or extraperitoneal bladder leak. 2. Unchanged appearance to the both column right acetabular fracture. Unchanged superior and inferior pubic ramus fractures. Stable pelvic and intramuscular hematomas Brief Hospital Course: Ms. [**Known lastname **] was admitted to the Orthopedic service on [**2153-10-3**] for right acetabular fracture after being evaluated in the emergency room. She was initially scheduled for surgery on [**2153-11-02**] but was hypotensive and was kept under observation in the ICU until she became hemodynamically stable with transfusion of 2 units of packed red blood cells and one unit of fresh frozen plasme. She underwent open reduction internal fixation of the right acetabulum without complication on [**2153-10-4**] after being evaluated as stable for the operation. She was extubated without difficulty and transferred to the recovery room in stable condition. In the early post-operative course Ms. did well and was transferred to the floor in stable condition. On hospital day [**2153-10-4**], [**2153-10-6**], and [**2153-10-7**] she was transfused one unit of packed red blood cells for post-operative anemia. on [**2153-10-5**] she received a fluid bolus for post-operative hypotension. She had adequate pain management and worked with physical therapy while in the hospital. The remainder of her hospital course was uneventful and Ms. [**Known lastname **] is being discharged to rehab on [**2153-10-9**] in stable condition. Medications on Admission: CELECOXIB [CELEBREX] - (Prescribed by Other Provider) - 200 mg Capsule - 1 Capsule(s) by mouth twice a day COLCHICINE [COLCRYS] - (Prescribed by Other Provider) - 0.6 mg Tablet - 1 Tablet(s) by mouth daily DULOXETINE [CYMBALTA] - (Prescribed by Other Provider) - 30 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other Provider) - 250 mcg-50 mcg/Dose Disk with Device - 1 puff(s) po daily LANSOPRAZOLE [PREVACID] - (Prescribed by Other Provider) - 15 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth once a day LISINOPRIL [ZESTRIL] - (Prescribed by Other Provider) - 20 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day METOPROLOL SUCCINATE [TOPROL XL] - (Prescribed by Other Provider) - 100 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day MONTELUKAST [SINGULAIR] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day OXYCODONE [OXYCONTIN] - (Prescribed by Other Provider) - 40 mg Tablet Extended Release 12 hr - 2 Tablet(s) by mouth twice a day for back pain POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Prescribed by Other Provider) - 17 gram/dose Powder - by mouth daily PRAVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily ZOLPIDEM [AMBIEN] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth as needed CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other Provider) - 2,000 unit Capsule - 1 Capsule(s) by mouth once a day MAGNESIUM - (Prescribed by Other Provider) - 200 mg Tablet - 1 Tablet(s) by mouth once a day MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Prescribed by Other Provider) - 17 gram (100 %) Powder in Packet - 1 pkt by mouth as needed Discharge Medications: 1. montelukast 10 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device [**Date Range **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. cholecalciferol (vitamin D3) 1,000 unit Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. pravastatin 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 6. zolpidem 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime) as needed for sleep. 7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1) PO DAILY (Daily) as needed for constipation. 9. colchicine 0.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. enoxaparin 40 mg/0.4 mL Syringe [**Last Name (STitle) **]: One (1) Subcutaneous QPM (once a day (in the evening)) for 4 weeks. Disp:*28 * Refills:*0* 11. docusate sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 12. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6 hours). 13. oxycodone 5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 14. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 15. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 16. oxycodone 40 mg Tablet Extended Release 12 hr [**Last Name (STitle) **]: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours) as needed for pain. Disp:*90 Tablet Extended Release 12 hr(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Right anterior column posterior hemitransverse fracture post operative blood loss anemia post operative fluid volume deficit 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: Wound Care: -Keep Incision dry. -Do not soak the incision in a bath or pool. -Sutures/staples will be removed at your first post-operative visit in [**11-16**] days. Activity: -Continue to be touch down weight bearing on your right leg. -You should not lift anything greater than 5 pounds. -Elevate right leg to reduce swelling and pain. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox for 4 weeks to prevent blood clots. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. If you have questions, concerns or experience any of the below danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go to your local emergency room. Physical Therapy: Activity: Activity: Out of bed w/ assist tid Right lower extremity: Touchdown weight bearing Treatments Frequency: Wound care: Site: right hip Type: Surgical Change dressing: qd Followup Instructions: Please follow up in trauma clinic in [**11-16**] days. You may make your appointment by calling [**Telephone/Fax (1) 1228**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]

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icd9cm

[ [ [] ] ]

[ "79.39" ]

icd9pcs

[ [ [] ] ]

8124, 8218

2935, 4185

344, 449

8387, 8387

1543, 2912

10300, 10559

1008, 1012

6093, 8101

8239, 8366

4211, 6070

8570, 8570

1056, 1365

10084, 10183

10207, 10207

1379, 1524

249, 306

10220, 10277

477, 698

1041, 1041

8402, 8546

720, 935

951, 992

618

181,546

26769+26770

Discharge summary

report+report

Admission Date: [**2117-3-13**] Discharge Date: [**2117-3-25**] Date of Birth: [**2039-8-22**] Sex: M Service: CSU CHIEF COMPLAINT: Chief complaint at time of admission was hip pain. HISTORY OF PRESENT ILLNESS: 77 year old man with a history of hypertension, TIAs, Parkinson's, and osteoporosis who felt at home and sustained a right hip fracture, fell following getting up from a chair while he was working at the computer. No trauma to the head or neck. PAST MEDICAL HISTORY: Significant for hypertension, TIAs, Parkinson's, and osteoporosis. MEDICATIONS: Meds at home include 1. Sinemet 25/250 q. d. 2. Lotrel [**6-17**] q. d. 3. Triamterene 37.5/25 q. d. 4. Fosamax 70 q. d. 5. Aspirin 81 q. d. 6. Zinc 220 q. d. 7. Multivitamin 1 q. d. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Remote smoking. No ETOH use. Married and lives with wife. REVIEW OF SYSTEMS: Noncontributory. PHYSICAL EXAMINATION: Temperature 97.4, heart rate 89, blood pressure 192/94, respiratory rate 16, O2 100% on room air. Neurologic, alert and oriented x3. HEENT: Normal head and oropharynx. Neck is supple with no JVD and no bruits. Lungs clear to auscultation. Cardiac: Regular rate and rhythm. Abdomen is soft, nontender, with normoactive bowel sounds and no hepatosplenomegaly. Extremities with no edema and 1+ peripheral pulses. LABORATORY DATA: White count 17, hematocrit 38, platelets 267. Sodium 125, potassium 3.8, chloride 90, CO2 25, BUN 19, creatinine 0.8, glucose 126. CK 163 with a troponin of less than .01. Hip film with a right femur fracture, avulsion of the lesser trochanter, fracture of the greater trochanter. Chest x-ray with a question of opacity at the left lung base. EKG: Sinus rhythm with normal axis, T wave inversion in lead III, nonspecific T wave changes in Q and lead III. HOSPITAL COURSE: Patient was admitted to medicine and was scheduled to undergo surgery for hip repair, however, was found to have additional EKG changes prior to his surgical time. At that point, his surgery was delayed and a cardiology consult was obtained. It was felt the patient was having an NSTE MI by enzymes and he was scheduled for cardiac catheterization which he underwent on [**3-17**]. Please see the cath report for full details. In summary, he was found to have left main 70% stenosis, LAD 70% stenosis, left circumflex with an 80% stenosis and an RCA that was a total occlusion proximally with left to right collaterals. A ventriculogram was not obtained at that time. An intra- aortic balloon pump was placed and cardiac surgery was emergently consulted. Following the cath, the patient went emergently to the operating room where he underwent coronary artery bypass grafting. Please see the OR report for full details. In summary, the patient had coronary artery bypass grafting x5 with the LIMA to the LAD, saphenous vein graft to the diagonal and sequentially to OM1 and 2 as well as a saphenous vein graft to the PDA. His bypass time was 110 minutes with a crossclamp time of 86 minutes. He tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. At the time of transfer, the patient had Levofed, propofol and insulin drips infusing. His mean arterial pressure was 68 with a CVP at 20. He additionally had an intra-aortic balloon pump at 1:1. The patient did well in the immediate postoperative period. He remained hemodynamically stable on the day of the surgery. On the morning following surgery, the intra-aortic balloon pump was removed. The patient was weaned from sedation following which he was weaned from the ventilator and successfully extubated. Gentle diuresis was begun at that time. Additionally, the patient was weaned from all vaso active medications on postoperative day 1. On postoperative day 2, the patient continued to progress. He was begun on low dose beta blockade. His diuresis was increased and his chest tubes were removed and he was transferred from the cardiothoracic intensive care unit to 5- 2 for continuing postoperative care. Additionally, the patient was followed by orthopedic surgery service during his postoperative recovery. By postoperative day 3, the patient had transitioned to all oral medications. He remained on complete bedrest given his fractured right hip. His temporary pacing wires were removed on postoperative day 4 and on postoperative day 5, he was scheduled to go to the operating room for ORIF of his right hip. However, on that day, he inadvertently had breakfast and his surgery had to be delayed for 1 day. Therefore, on [**3-23**], the patient was brought to the operating room at which time he underwent a repair of his fractured right hip by Dr. [**Last Name (STitle) **]. Please see OR report for full details. In summary, the patient had an ORIF of his fractured right hip. He remained hemodynamically stable throughout the procedure, was transferred from the operating room to the post- anesthesia recovery unit. Following recovery from anesthesia, the patient was again transferred to [**5-25**] for continuing postoperative care and rehabilitation. Over the next 2 days, the patient had an uneventful postoperative course. His activity level was increased with the assistance of the nursing staff as well as the physical therapy staff and on postoperative days 7 and 1, he was cleared for transfer to rehabilitation for ongoing postoperative care. At the time of this dictation, the patient's physical examination was as follows: Vital signs: Temperature 99, heart rate 67 sinus rhythm, blood pressure 116/62, respiratory rate 18, O2 saturation 98% on 2 liters nasal prongs. Lab data: White count 17, hematocrit 34, platelets 428, potassium 4.4, BUN 27, creatinine 0.7, calcium 8.1. Physical examination: Alert and oriented, moves all extremities, follows commands. Pulmonary clear to auscultation bilaterally. Cardiac: Regular rate and rhythm. Sternum is stable. Incision with Steri-strips, clean and dry, no drainage or erythema. Abdomen is soft, nontender, nondistended with normoactive bowel sounds, however, no flatus or BM at this time. Extremities are warm with no edema. Left leg incision with Steri-strips from his endoscopic harvest site is clean and dry. CONDITION: Patient's condition at time of discharge is good. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass grafting x5 with a LIMA to the LAD, saphenous vein graft to diagonal, OM1 and OM2 sequentially, and saphenous vein to PDA. 2. Status post open reduction/internal fixation. 3. Parkinson disease. 4. Hypertension. 5. Hypercholesterolemia. 6. Osteoarthritis. 7. Bladder CA status post excision x3. DISPOSITION: The patient is to be discharged to rehabilitation. He is to have follow up with Dr. [**Last Name (STitle) 914**] in 4 weeks, follow up with Dr. [**Last Name (STitle) **] in 4 weeks and follow up with his primary care provider [**Last Name (NamePattern4) **] 3 to 4 weeks. Patient is to call to schedule appointments with Dr. [**Last Name (STitle) 914**] and Dr. [**Last Name (STitle) **]. DISCHARGE MEDICATIONS: The patient's medications at the time of discharge include: 1. Lasix 40 mg q. d. x2 weeks. 2. Potassium chloride 20 mEq q. d. x2 weeks. 3. Colace 100 mg b.i.d. 4. Zantac 150 mg q. d. 5. Aspirin 81 mg q. d. 6. Tylenol 325 to 650 q. 4 hours p.r.n. 7. Atorvastatin 10 mg q. d. 8. Carbodopa/levodopa 25/100 1 q. d. 9. Heparin 5,000 units subcutaneously t.i.d. 10. Digoxin .25 q. d. 11. Metoprolol 37.5 mg b.i.d. 12. Percocet 5/325 1 to 2 tabs q. 4 to 6 hours p.r.n. 13. Multivitamin 1 q. d. 14. Fosamax 70 mg q. Friday. 15. Lisinopril 2.5 mg q. d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10585**], M.D. [**MD Number(2) 10586**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2117-3-24**] 16:49:44 T: [**2117-3-24**] 17:49:51 Job#: [**Job Number 65925**] Admission Date: [**2117-3-13**] Discharge Date: [**2117-3-26**] Date of Birth: [**2039-8-22**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: summary dicatated Major Surgical or Invasive Procedure: [**2117-3-17**] - CABG x5 on IABP. (Lima-Lad, SVG->Diag, OM1, OM2, SVG->PDA) [**2117-3-17**] - Cardiac Catheterization [**2117-3-23**] - Right hip open reduction internal fixation Brief Hospital Course: His white count improved on [**3-26**] and he was ready for discharge to rehab. 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO once a day. 6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. 7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every Friday). 11. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): 30 mg [**Hospital1 **]. 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 1 weeks. Tab Sust.Rel. Particle/Crystal(s) Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: s/p CABG x 5 Discharge Condition: Good. Discharge Instructions: 1) Keep wounds clean and dry. OK to shower, no bathing or swimming. 2) No lotions, creams or powders to incision until it has healed. 3) Take all medications as prescribed. 4) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 5) Report any fever greater then 100.5 6) Report any signs of wound infection. These include redness, drainage or increased pain. 7) No driving for 1 month 8) No lifting greater then 10 pounds for 10 weeks. 9) Take lasix with potassium for 2 weeks and then stop. 10) Call with any questions or concerns. Followup Instructions: Dr [**Last Name (STitle) 914**] in 4 weeks, please call CT [**Doctor First Name **] office [**Telephone/Fax (1) 1504**] to schedule appoointment. Follow-up with cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 120**] in [**1-25**] weeks. Call [**Telephone/Fax (1) 127**] for appointment. Follow-up with orthopedist Dr [**Last Name (STitle) **] in 2 weeks, please call orthopedic surgery office [**Telephone/Fax (1) 2007**] to schedule appointment. Follow-up with your primary care physician [**Last Name (NamePattern4) **] 2 weeks. Please call all providers for appointments. Completed by:[**2117-3-26**]

[ "E849.0", "733.00", "E884.2", "401.9", "416.8", "332.0", "276.0", "820.21", "414.01", "410.71", "V10.51" ]

icd9cm

[ [ [] ] ]

[ "37.23", "79.35", "88.56", "39.61", "37.61", "36.15", "36.14" ]

icd9pcs

[ [ [] ] ]

9957, 10027

8617, 8698

8412, 8594

10083, 10091

10689, 11322

832, 850

6429, 7211

8721, 9934

10048, 10062

1903, 5853

10115, 10666

5876, 6408

948, 966

8355, 8374

235, 481

504, 815

867, 928

26,701

189,710

28291

Discharge summary

report

Admission Date: [**2153-10-2**] Discharge Date: [**2153-10-19**] Date of Birth: [**2076-11-14**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 6075**] Chief Complaint: Right thalamic hemorrhage with ventricular spread Major Surgical or Invasive Procedure: Tracheostomy History of Present Illness: This is a 76 yo man with hx HTN, afib on coumadin for past few months, DM, CAD s/p cabg, among other medical problems, who presents as transfer from OSH (S. Shore) with R subcortical and intraventricular ICH. As he is intubated and sedated when neurology consulted, hx obtained from wife. [**Name (NI) **] had been in USOH yesterday, and noticed after he woke up this am that his "legs weren't working properly." He had trouble getting down the stairs; he took his medications and ate breakfast. When he tried to get up the stairs again, he had to crawl on his hands and knees. He called his wife at 10:50AM and she told him to come to hospital. He had also c/o dizziness, but did not specify if this was lightheadedness or vertigo. He had no headache, no visual changes, no problems with the arms, no trouble speaking or swallowing, and no changes in his appearance or voice. He had to lean on a chair to stand up properly. He had no n/v until after he had gotten to OSH. In the ambulance, his BP was 164/90 and HR was 108, BG 290. However, at the OSH, his family members noted that his bp was above 200/100. His GCS was 15, and his INR was 2.4, for which he received 4 units FFP and Vitamin K as well as dilantin. He did not tell anyone whether he had fallen (we have report of "no falls" per [**Hospital **] report to neurosurg team); his wife feels that if he had hit his head or fallen today, he would have mentioned it, but she cannot remember anyone asking him. He had c/o dizziness and had a head CT at the OSH with R thalamic bleed and intraventricular extension, R>L; he was given valium and ativan at the osh ER for complaint of "dizziness" and within about an hour or two after the medication, his family noticed that he became progressively sleepier. Though he could still follow commands and answer simple questions, it took more to keep him awake. He vomited several times. He was transferred to [**Hospital1 18**] for possible intervention/neurosurgery, and en route, he became even drowsier and incoherent, at some point unable to keep awake at all. At [**Hospital1 18**] ER he was promptly intubated and taken to head CT where a large R IVH and R thalamic hemorrhage was identified, with extension into contralateral and 3rd ventricle, no blood in 4th, and large ventricular system but no definitive hydrocephalus. There is some mass effect on the R temporal lobe. Neurosurgery saw the patient and does not plan to put in a drain at this time. Past Medical History: -PAF dx'ed several months ago, has been on coumadin since -DM with "severe neuropathy" and charcot arthropathy -CAD s/p cabg in [**2127**] -HTN -BPH s/p turp 20 yrs ago -s/p cataract surgery in the past -Gout -s/p R knee surgery 5 yrs ago -Spinal stenosis s/p cortisone shots -bilat hand surgery for dupuytren's contractures and for carpal tunnel Social History: Lives with wife, nonsmoker (remote hx), occ etoh, no drugs. Formerly managed Symphony [**Doctor Last Name **]. Family History: Daughter had cerebral aneurysm rupture 6 yrs ago. Mother had cervical ca, father had leukemia. Physical Exam: HR 80s, BP 120s systolic RR 16 on vent (set) 100% on 100%fio2, temp pending. General appearance: intubated/sedated head/neck: ET tube in, hard collar on, mmm Heart: regular rate and rhythm, distant heart sounds Lungs: diminished anteriorly bilaterally Abdomen: soft, nontender +bs Extremities: warm, well-perfused Neuro: exam limited by propofol; grimace to sternal rub+, no resp to voice. pupils equal 2->1mm, +corneals, +gag, +nasal tickle, unable to perform OCR though at least trace pos with collar on. No w/d to nailbed, but + spont mvmt equal in legs, none in arms. Nl tone throughout. DTRs 2 at [**Hospital1 **], [**Last Name (un) **], tri; 0 at knees and ankles, L toe upgoing, R downgoing. Pertinent Results: pH 7.30 pCO2 66 pO2 411 HCO3 34 Type:Art [**2153-10-2**] 4:40p 139 100 17 140 AGap=13 -------------< 3.8 30 1.0 MCV 99 WBC 12.3 H/H 14.2 / 41.2 PLT 135 N:75.8 L:18.0 M:3.9 E:2.2 Bas:0.1 Macrocy: 1+ PT: 19.3 PTT: 28.6 INR: 1.8 Imaging: Head CT reviewed - R thalamic bleed with extensive R>L IVH, blood in 3rd ventricle, some sulcal effacement of the L temporal lobe /mass effect, no shift, no blood in 4th vent "IMPRESSION: Extensive hemorrhage centered within the right thalamus and deep white matter structures with intraventricular extension. Prior study not available to assess for interval change. Findings discussed with neurosurgical team after the study." CXR: IMPRESSION: Endotracheal tube approximately 6 cm above the carina. No pneumothorax. Cardiomegaly. EKG: nsr with first Brief Hospital Course: 76 yo man with hx HTN, afib on coumadin for past few months, DM, CAD s/p cabg, among other medical problems, who presents as transfer from OSH (S. Shore) with R subcortical and intraventricular ICH. The hemorrhage may have started in the thalamus, and may relate to his hypertension, as well as the fact that he is on coumadin and thus more at risk for ICH. At the present time, neurosurgery does not plan to put in an external ventricular drain, and prefers to follow exams for now and repeat imaging in the morning. Received 4U FFP, Vit K, PHT load at OSH, and receiving more FFP x 4U. Rec: -Admit to neurology ICU, attg: [**Doctor Last Name 1693**] -Give FFP now to lower INR to <1.2 (recheck at MN); if high, give vitamin K again -Keep sbp 120-140 -Hold off on giving more dilantin, but check level in AM -Q1h neuro checks (focus on brainstem exam) -Monitor on telemetry -Head CT in AM or if any change in exam -Check lytes, cbc, coags in am -Check UA -ventillator support for now pending repeat imaging -consider drain, as blood in 3rd ventricle is worrisome for impending hydrocephalus -Protonix, pneumoboots [**10-3**]: Likely hypertensive bleed in setting of supratherapeutic INR. No history to suggest trauma. Trial of pressor support overnite and attempt to extubate in am. Repeat INR this pm 1.2 and Hct 34.8. Plan to clear c-collar once extubated and more awake. Dr. [**Last Name (STitle) 1693**] spoke with son. [**10-5**]: Spoke w/immediate fam, code discussion established DNR. Spiked fever ON, repeating cxs, CXR. Tolerating pressure support off propofol, neuro exam unchanged and notified family. Attempt to extubate later today per TICU team. [**10-9**]: Bld cxs back 3/4 bottles pansensitive coag neg staph switched to Cefazolin. Bronch'd [**10-8**] GPCs on BAL gram stain and cxs PND. Repeat head CT stable. Started vitK 10mg PO x3days for uptrending INR (1.3 today). [**10-10**]: Per micro lab, sm colony of S aureus growing from BAL fluid sensitivity pending and sputum from [**10-7**] growing MSSA. However, pt defervescing. ICU team spoke with family and plan is to place trach and peg and IVC filter tomorrow in OR. Head CT radiology read as ?IPH [**Hospital1 **]-parietal likely overead and bleed tracking from ventricles; however, TICU team d/c'd SC heparin and plan to place IVC filter (?). Will discuss with stroke team. [**10-11**]: Getting peg and trach TODAY. ID recs, check abd CT (ordered for Sat concurrent with head CT) to r/o diveritculitis, GB dz. Rads reread head CT as likely ventricular blood biparietally NOT worsening bleed. Restarted SC heparin. Will get TEE today prior to ETT out. Uric acid normal. Awaiting urine legionalla. [**10-12**]: TTE: complex (>4mm) atheroma in the aortic arch and descending thoracic aorta, LVEF 45-50, no endocarditis - Urine legionella negative - Abd CT: 1. Right colonic diverticula with adjacent minimal inflammatory changes. Cannot exclude early diverticulitis. No evidence of abscess. 2. Small bilateral pleural effusions and adjacent atelectasis, with Lower lobe patchy opacities, consistent with atelectasis versus early pneumonitis. 3. Gallstone without evidence of cholecystitis. 4. Intraperitoneal free air secondary to recent gastrostomy tube placement. [**Date range (1) 23681**]: Exam continuing to gradually improve. Following midline and right appendicular commands. Starting to intermittently follow commands with LUE (wiggles fingers some times), and able to purposefully withdraw left foot to noxious stimluli. Main issue over these several days was his strongly insulin resistant Diabetes Mellitus. [**Last Name (un) **] consulted and he was started initially on Lantus 96 units times one day, then switched to 48 units [**Hospital1 **] on [**10-18**]. Titrated up to 52units [**Hospital1 **] and also covered by a sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **]. Can continue to titrate Lantus slowly as needed. Medications on Admission: Insulin (NPH+regular, unknown doses) Triamterene 1 tab qhs Captopril 50 mg [**Hospital1 **] Allopurinol 300 mg qd Coumadin x several months PRN aleve Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID (4 times a day) as needed. Disp:*30 ML(s)* Refills:*0* 2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 4. Docusate Sodium 150 mg/15 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). Disp:*30 1* Refills:*2* 5. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 7. Captopril 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 8. Levofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 9. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection [**Hospital1 **] (2 times a day). Disp:*60 1* Refills:*2* 10. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Hospital1 **]: One (1) Subcutaneous every six (6) hours: start at BS 120, and increase one unit for each 20mg increase of BS. Disp:*5 pen* Refills:*2* 11. Lantus 100 unit/mL Cartridge [**Hospital1 **]: One (1) Subcutaneous twice a day: start with 56 units [**Hospital1 **] and titrate for goal of BS 100-200. Also, if tube feeds stop for any reason, patient will need dextrose IV to prevent hypoglycemia. Disp:*5 1* Refills:*2* 12. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable [**Hospital1 **]: One (1) ML Injection ONCE (Once) for 1 doses. Disp:*1 ML(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Hemorrhagic stroke Discharge Condition: Fair and stable. Making slow progress and has good tone on the left side which is a positive sign that function may return. Has trach and peg. Discharge Instructions: Patient has had large hemorrhagic stroke. Needs rehab, trach care and Peg care. Wean trach per weaning protocol. If new will need to be resumed in the future when patient is able to make a decision regarding the risks and benefits of restarting this medication. Followup Instructions: Follow up with Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] at [**Hospital Ward Name 23**] [**Location (un) **] on [**Hospital 61**] [**Hospital Ward Name 516**]: [**2153-11-21**] at 1:00PM

[ "278.00", "253.6", "V45.81", "724.00", "274.9", "427.31", "507.0", "431", "995.91", "401.9", "038.19", "342.82", "357.2", "263.9", "518.81", "V58.61", "482.41", "250.60", "428.0" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.72", "96.04", "33.24", "88.72", "96.6", "99.07", "43.11" ]

icd9pcs

[ [ [] ] ]

11049, 11146

5038, 8990

325, 339

11209, 11355

4202, 5015

11668, 11874

3363, 3461

9191, 11026

11167, 11188

9016, 9168

11379, 11645

3476, 4183

236, 287

367, 2848

2870, 3218

3234, 3347

31,068

107,370

43010

Discharge summary

report

Admission Date: [**2152-5-19**] Discharge Date: [**2152-5-27**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: slurred speech, confusion, and hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 85 Russian-speaking only woman brought in from NH with confusion and slurred speech, and hypotension. Her niece called her at the nursing home this am and she did not answer; later, in the afternoon ([**5-19**]), she answered the phone but was slurring her speech and was somewhat disoriented. VNA visited and found she was disoriented and sent her to the ED, where she was found to be hypotensive at 65/43 on arrival. She described a night of nausea, vomiting, and diarrhea. Her slurred speech resolved and she was AAOx3 after receiving approximately 4 liters of IVF, at which time SBP 90s with MAP 50s; she also received levofloxacin and metronidazole empirically as well as dexamethasone 10mg. . . The family was not aware of any hematemesis or melena. There was no report of fevers and no localizing signs of infection. Pt was guaiac positive with brown stool in the ED, and so PRBCs hung, but stopped once Hct came back at 37, and protonix IV. EKG showed accelerated junctional rhythm with TWI anteriorly, cardiac enzymes were negative. Past Medical History: "mini stroke" in [**2151-11-18**], for which she spent 2 weeks in rehab and was prescribed coumadin, which she does not take, according to her niece - inferior MI (non-Q wave) in [**2138-10-18**] Rx'd with balloon angioplasty of prox RCA - s/p R lobectomy - mitral regurgitation - dyslipidemia - HTN - s/p TAH Social History: Lives alone, niece calls daily and VNA visits once/week. former smoker. No alcohol. Family History: NC Physical Exam: Tmax: 35.6 ??????C (96 ??????F) Tcurrent: 35.6 ??????C (96 ??????F) HR: 80 (80 - 88) bpm BP: 91/50(61) {80/27(44) - 96/60(65)} mmHg RR: 22 (11 - 26) insp/min SpO2: 99% Height: 61 Inch General Appearance: Thin Eyes / Conjunctiva: PERRL, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal), S3, (Murmur: Systolic), soft early systolic murmur at LUSB c/w aortic sclerosis Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: No(t) Crackles : , Wheezes : ) Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t) Distended Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t) Clubbing Skin: Warm, No(t) Rash: Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: ADMIT labs:[**2152-5-19**] 05:45PM BLOOD WBC-13.4*# RBC-4.45 Hgb-11.9* Hct-37.0 MCV-83 MCH-26.8* MCHC-32.2 RDW-14.3 Plt Ct-328# [**2152-5-19**] 05:45PM BLOOD Neuts-62 Bands-22* Lymphs-2* Monos-7 Eos-1 Baso-0 Atyps-1* Metas-5* Myelos-0 [**2152-5-19**] 05:45PM BLOOD PT-14.6* PTT-27.2 INR(PT)-1.3* [**2152-5-19**] 05:45PM BLOOD Glucose-140* UreaN-39* Creat-1.9*# Na-145 K-4.1 Cl-102 HCO3-23 AnGap-24* [**2152-5-20**] 04:59AM BLOOD Calcium-7.0* Phos-3.3 Mg-1.4* ==================================================== CT abd/pelvis IMPRESSION: 1. No evidence of free fluid, or aortic dilatation. Assessment for aortic dissection is limited on this non-contrast evaluation. 2. [**Doctor First Name **] appearance to the abdominal mesentery, with multiple small nodes. This appearance is nonspecific but can be seen with sclerosing mesenteritis, mesenteric adenitis, but could also be seen in lymphoma. Followup is recommended, consider 6-12 months. 3. Probable liver hemangiomas, though incompletely characterized without contrast. 4. Diverticulosis without evidence of diverticulitis. 5. Multiple vertebral body hemangiomas -------------- CT head IMPRESSION: No intracranial hemorrhage. Moderate atrophy, and microangiopathic change as described above. ----------------- CXR FINDINGS: Lung volumes are diminished. There is a mild engorgement of the vascular pedicle and small interlobular septal lines at the lung bases. These findings suggest overall mild pulmonary edema. No focal consolidation is seen. There is a tortuous atherosclerotic aorta. The cardiac silhouette is enlarged. No effusion or pneumothorax is seen. There is deformity of the mid portion of the right clavicle and the lateral portions of upper right ribs presumably from remote trauma. IMPRESSION: Mild volume overload with no focal consolidation ============================================================== [**2152-5-19**] 05:45PM BLOOD WBC-13.4*# RBC-4.45 Hgb-11.9* Hct-37.0 MCV-83 MCH-26.8* MCHC-32.2 RDW-14.3 Plt Ct-328# [**2152-5-19**] 05:45PM BLOOD Neuts-62 Bands-22* Lymphs-2* Monos-7 Eos-1 Baso-0 Atyps-1* Metas-5* Myelos-0 [**2152-5-19**] 05:45PM BLOOD PT-14.6* PTT-27.2 INR(PT)-1.3* [**2152-5-19**] 05:45PM BLOOD Glucose-140* UreaN-39* Creat-1.9*# Na-145 K-4.1 Cl-102 HCO3-23 AnGap-24* [**2152-5-20**] 04:59AM BLOOD Calcium-7.0* Phos-3.3 Mg-1.4* ================================================ [**Last Name (un) **] stim/TSH: [**2152-5-19**] 05:45PM BLOOD Cortsol-43.9* [**2152-5-20**] 04:11AM BLOOD Cortsol-30.3* [**2152-5-20**] 04:59AM BLOOD Cortsol-33.0* [**2152-5-19**] 05:45PM BLOOD TSH-1.1 Brief Hospital Course: 85 year old Russian speaking woman with 1 day of nausea, vomiting, and diarrhea, with report of slurred speech and confusion on day of admit, found to be hypotensive to 60's by VNA at home 1. Hypotension: 2. Hypovolemia 3. Nausea/Vomiting 4. Diarrhea 5. Dysarthria/Altered mental status: Patient admitted to [**Hospital Unit Name 153**] for SBP at home by VNA in the 60??????s in the setting of vomiting, diarrhea, leukocytosis with bandemia, and guaiac positive stools. Patient underwent aggressive fluid rescucitation in emergency room and in ICU with normalization of BP. Slurred speech and altered mental status resolved with improvement of blood pressure. Head CT negative. Also given cipro/flagyl for GI complaints, ruled out by cardiac enzymes, appropriate adrenal response to stimulation, normal TSH, stable hematocrit. Nausea, vomiting diarrhea have been chronic issue. Patient had these symptoms for months prior to admission, then they remitted for about a month, and recurred in the week prior to admission. Had seen [**Hospital Unit Name **], had negative CT scan and negative for c. diff x 1 with past few months. CT abdomen on admission here read as "[**Doctor First Name 9189**] mesentery", non specific finding. In first two days of admit, no GI symptoms, but then by HD#3 recurrence of nausea, vomiting, diarrhea. Therefore, ultimately underwent EGD/colonoscopy after great difficulty with prep, only could tolerate mag citrate. EGD and [**Last Name (un) **] with gastritis/duodenitis but revealed no clear etiology of patient's nausea, vomiting, diarrhea, early satiety. Biopsies taken at EGD for ? celiac, h. pylori. TTG/IGA sent given possibility of celiac, pending at discharge. After EGD/colonoscopy, patient was able to tolerate full diet. Patient received 6 day course of cipro/flagyl but missed many doses due to her refusal to comply with pills inspite of extensive efforts by nursing and staff to explain necessity of medications. Blood and urine cultures ultimately negative. Possible etiologies include viral illness, possible intolerance to flagyl, H. pylori , celiac. BIopsy and celiac results should be followed up. Patient should have CT abdomen within 6 months to ensure resolution of non specific [**Doctor First Name 9189**] mesentery findings, ?adenitis. Lymphoma is consideration. 6. Acute renal failure: 7. Hypokalemia: Renal failure resolved with aggressive hydration. Aggressive potassium repletion. 8. HTN: 9. CAD: 10. Hyperlipideima 11. TIA's and atrial fibrillation - pt. in atrial fibrillation here, rate controlled. On a home regimen of HCTZ and metoprolol, aspirin. had been started on coumadin at OSH but patient ultimately decided to discontinue given difficulty with compliance and concern it was contributing to GI symptoms. Discussed this with neice (health care proxy) and GI. GI stated OK to restart day after bx. if indicated (bx at colonoscopy was [**5-25**], restarted warfarin [**5-27**]). HCP stated that she wants pt. on warfarin to minimize stroke risk, understands risk of bleeding and ? of N/V/D as side effect of warfarin. Will monitor for bleeding, side effects, and INR at rehab. Restarted metoprolol, aspirin, statin, and warfarin in hospital. 12. Hypophosphatemia: repleted, occured after colonscopy. Medications on Admission: Medications at home--pt states she does not take, b/c medicines are "not good for her" trazodone 50mg qhs HCTZ 12.5mg daily lopressor 12.5mg [**Hospital1 **] simvastatin 80mg daily omeprazole 20mg daily docusate 100mg [**Hospital1 **] acetaminophen Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR will need to be checked daily and dose adjusted accordingly by MD for target INR 2.0 to 3.0 (indication is atrial fibrillation). Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: 1. Hypotension 2. Hypovolemia 3. Nausea with vomiting 4. Diarrhea 5. Hypokalemia 6. Hypophosphatemia 7. Atrial fibrillation Discharge Condition: Stable, afebrile, tolerating PO Discharge Instructions: Follow up as below. All medications as prescribed. If you have recurrent nausea, vomiting, abdominal pain or diarrhea, or bleeding in your bowel movements contact your doctor. Followup Instructions: Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]. Your PCP is [**Name9 (PRE) **] [**Name9 (PRE) 92817**] [**Telephone/Fax (1) 92818**] Your [**Telephone/Fax (1) **] is Dr. [**Last Name (STitle) 41956**] [**Telephone/Fax (1) 92819**] You will need to follow up with these doctors [**Name5 (PTitle) **]: management of your coumadin levels, as well as for the results of the biopsies obtained on colonoscopy/endoscopy.

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icd9cm

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Discharge summary

report+report

Admission Date: [**2178-1-6**] Discharge Date: [**2178-1-14**] Date of Birth: [**2121-12-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: Tracheostomy replacement History of Present Illness: 56M with T2DM, HTN, DL, previously admitted for Fournier's gangrene c/b need for diverting colostomy and failure to wean from vent, s/p tracheostomy now p/w respiratory distress from [**Hospital3 **] hospital. . At rehab, in the PM of [**1-5**], began c/o of SOB/left chest pain. On assessment, was AAOx3, 80% sat on 12 L O2 tracheostomy. His BP ranged from 133/73-151/81, HR 100. Enroute 02 sat decreasd to 70s. Tracheostomy suctioned x4 enroute with improvement in oxygenationation to 70's to 80s. . In the ED initial vitals, 97.8, 85, 160/75, 18, 86% on NRB. Patient was uncomfortable in obvious distress. Unable to ventilate through trach. ED team bronched patient and found an obstructing 'mass'- fibrinous. Was given toradol when feeling feverish and ativan for anxiety. Surgery was consulted and replaced trach - patient desatted. ABG at this time 7.40/51/69. Anesthesia was contact[**Name (NI) **] and patient was intubated (difficult intubation). CXR with ET tube at 6.8 cm, bilateral patchy infiltrates stable from prior, cardiomegaly with left lower lobe opacity conerning for effusion vs infiltrate. Labs with white count of 16.4 with left shift. Creatinine of 1.4. BNP of [**Numeric Identifier 87941**] and Troponin T of 0.18. EKG with sinus tachycardia no evidence of ischemia. Patient started on nitro drip and lasix 40mg IV x one given concern for CHF. Also given Vanc/Zosyn for HAP. Dysynchronous on vent so given propofol and patient became hypotension. Vitals prior to transfer: HR 82, CMV 15/500/Fi02 100%, 136/75. . In the ICU, patient intubated and sedated, hemodynamically stable. Past Medical History: -DM type 2 -gastroparesis -MRSA infections -kidney stones -hypertension -hypercholesterolemia -Fournier's gangrene Social History: Former policeman. Was at rehab recovering from recent hospitalization ([**Hospital3 7665**] in [**Hospital1 3597**], NH). HCP is brother [**Name (NI) **] [**Name (NI) **]. Family History: Noncontributory Physical Exam: VS: Temp: Afebrile BP:133/72 HR:80 RR:14 O2sat 100 GEN: intubated, sedated HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: Diminished left base, good airmovement no wheezing/rales/rhonchi CV: RR, S1 and S2 wnl, no m/r/g ABD: obese, nd, +b/s, soft, nt EXT: 3+ lower extremity SKIN: no rashes/no jaundice/no splinters - deep decubitus ulceration perineum and left gluteus which appears stable. NEURO: Sedated. Pertinent Results: **FINAL REPORT [**2178-1-9**]** GRAM STAIN (Final [**2178-1-6**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2178-1-9**]): RARE GROWTH Commensal Respiratory Flora. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. . 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. YEAST. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.5 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Brief Hospital Course: 56M with T2DM, HTN, DL, previously admitted for Fournier's gangrene c/b need for diverting colostomy and failure to wean from vent, s/p tracheostomy now p/w respiratory distress from [**Hospital3 **] hospital. . # Hypoxic Respiratory Failure: Patient intubated when unable to effectively oxygenate through trach. Reports of "mass" seen with bronchoscope in ED. CXR with similar bilateral patchy infiltrate compared to prior though ? increased left lower lobe opacity. Patient with elevated white count and left shift concerning for infection and certainly raises the question of HAP. BNP elevated to support the diagnosis of CHF though stable compared to one prior measurement, further patient with 3+ lower extremity edema. Initially on Vanc/Zosyn, zosyn changed to ceftriaxone once urine grew Ecoli sensitive to CTX. Vancomycin and CTX should be continued until [**1-15**]. Pt was extubated on day 2 on admission and a new tracheostomy tube was placed by the surgical service. On [**1-11**] trach was removed due to malfunctioning, and pt was able to breathe comfortably on 2l NC oxygen. Diureses during the admission was with 40 lasix IV bid which was decreased to 40 lasix IV daily. He was discharged on oral lasix as below. # Hx of Fourneir's Gangrene: Evaluated by the surgical team in the ED who felt there were no active surgical issues. Evaluated by wound care team and recommmedations were provided and followed. Wound care recommendations include: His wounds are clean and pink with granulation tissue and are draining significant amount of serous drainage. The posterior wound is 10 x 11 with undermining of 2.5 cm in the area of 6 -11 o'clock there is a tunnel of 6 cm in the center of the wound. The other woundis in the groin to the right of the scrotum it measures 6 x 4 cm with a tunnel of 6 cm at 7 o'clock. Both wounds were cleansed with commercial wound cleanser and patted dry. The peri-wound skin was treated with Critic aid anti-fungal to protect the skin and prevent yeast formation. The wounds were packed with Kerlix making sure to wick into the tunnels and the undermined areas. Have asked that Kerlix AMD be used to help decrease the bio burden of the wound. do not pack the wound tight and change when wet [**Hospital1 **] and PRN. . 3. Elevated Troponin: Mild elevation in troponin on admission. EKG without evidence of MI. Ruled out MI with CE at 8 hours. Continued Full Strength ASA . 4. HTN: Home antihypertensives held initially and blood pressure controlled with Labetelol PRN. Home antihypertensives were then started . 5. Diabetes: He was managed with glargine 10 units and humalog sliding scale insulin. . Code: FULL CODE Medications on Admission: Norvasc 10 mg daily Lasix 40 mg daily Neurontin 300 mg [**Hospital1 **] Amaryl 4 mg daily lisinopril 5 mg daily Reglan 10 mg QID Lopressor 50 mg [**Hospital1 **] Zocor 40 mg daily DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Neb Solution INH Q6H PRN Clonidine 0.3 mg/24 hr Transdermal Patch QSunday Heparin (porcine) 5,000 unit SC TID Aspirin 325 mg Tab daily Hydromorphone 2-4 mg Tab Q4H PRN Novolin N 12 units QAM at 0730 and 16 units QPM at 1700 SC Hyoscyamine 0.25 mg Q6H PRN Hexavitamin daily Milk of Magnesia 30 mL QHS Discharge Medications: 1. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) g Intravenous Q24H (every 24 hours) for 1 days. 2. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q 12H (Every 12 Hours) for 1 days. 3. insulin glargine 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous once a day. 4. Humalog 100 unit/mL Cartridge Sig: as directed Subcutaneous qachs: please give according to sliding scale. 5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 9. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day. 13. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. 14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 15. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 16. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: -Hypoxic Respiratory Failure: Felt in setting of suboptimal tracheostomy placement, bilateral patchy infiltrates from volume overload and left lower lobe pneumonia/tracheobronchitis (MRSA) -Pneumonia -Urinary tract infection -Fournier's Gangrene Anemia hypertension hyperlipidemia diabetes depression/anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to [**Hospital1 69**] for respiratory distress. You were admitted to the intensive care unit where your tracheostomy was removed. You were treated with antibiotics for pneumonia and for a urinary tract infection. The following changes were made to your medications: START Vancomycin 1250 mg intravenous every 12 hours for one more day START CeftriaXONE 1 gm intravenous once a day for one more day STOP Amaryl START Glargine 10 units once a day START Humalog as directed by sliding scale insulin STOP Novolin STOP hydromorphone STOP milk of magnesia START Docusate twice a day STOP Hyocyamine Please continue your home medications. Followup Instructions: Please see your primary care doctor within two to four weeks. Admission Date: [**2178-1-17**] Discharge Date: [**2178-2-3**] Date of Birth: [**2121-12-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: 1. thoracentesis 2. chest tube placement 3. central venous line placement History of Present Illness: 56 yo male with h/o Type II DM, HTN, HL, Fournier's gangrene and recent admission for hypoxic respiratory failure thought secondary to both systolic left heart failure and tracheobronchitis presents with sudden onset dyspnea this morning. Patient was just discharged three days ago to rehab. Reports waking this morning with sudden onset dyspnea, denies any other associated symptoms; specifically denies fevers, chills, chest pain, pre-syncope, and syncope. Vitals at that time were 188/103, HR 105, RR 32. Patient reported feeling that he "couldn't catch his breath", with O2 sat of 82%. Patient reports chronic cough, non-productive. On call physician was notified by rehab, and with complaint of shortness of breath at [**Hospital6 **] at [**Hospital3 **], advised patient to be transferred to [**Hospital1 18**] ED for further evaluation. Vitals at OSH ([**Hospital3 **]) were 98.2 156/92 HR 109 96% on CPAP 10 cm/H2O. Received furosemide 40 mg IV x 1, maintain on CPAP prior to arrival at [**Hospital1 18**] ED, with improved symptoms. On CPAP upon arrival, no increased WOB. Nitro gtt and lasix 40 IV x 2. vanc, ceftriaxone and levaquin. power picc. HR 95 140/69 18. . In [**Hospital1 18**] ED, arrived on CPAP, vitals 97.2 84 156/92 18 96% Other. Received furosemide 40 mg IV x 1, kayexelate 30 cc PO x 1. Nitro gtt was started for management of CHF. Patient also received vancomycin 1 gram, levofloxacin 750 mg, and ceftriaxone 1 gram all IV. Power PICC in place. . Upon arrival to the ICU, patient reported improved breathing, reported some chest discomfort that had improved since starting this morning. He had no other complaints. Past Medical History: -recent hypoxic resp failure, [**2-25**] sCHF and MRSA tracheobronchitis -DM type 2 -gastroparesis -MRSA infections -kidney stones -hypertension -hypercholesterolemia -Fournier's gangrene Social History: Former policeman. Was at rehab recovering from recent hospitalization ([**Hospital3 7665**] in [**Hospital1 3597**], NH). HCP is brother [**Name (NI) **] [**Name (NI) **]. Family History: Noncontributory Physical Exam: On Admission: VS: HR 86 135/79 93% 50% face mask GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, jvd to tragus of ear, no carotid bruits, no thyromegaly or thyroid nodules RESP: decreased breath sounds at bases, right > left, otherwise CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g, no S3 noted ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: 2+ LE edema bilaterally SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. 2+DTR's-patellar and biceps . On Discharge: Tm/c:97.7/97.7, BP: 144/76(120-165/50-76), HR: 77 (71-93), RR: 18, O2 95% 2LNC, I/O: 2172/1625 GA: AOx3, no pain from former chest tube site HEENT: MMM. no LAD. no JVD. neck supple. Cards: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: Crackles on right lower and mid-posterior lung fields, chest tube site with dressing in place, no drainage. Abd: soft, NT, +BS. Colostomy bag in place with air in the bag. Posterior: Large perianal wound with purulent drainage and a base with granulation tissue. Extremities: trace lower extremity edema Neuro/Psych: CNs II-XII intact. Pertinent Results: LABS: . CBC [**2178-1-17**] 10:05AM BLOOD WBC-12.0* RBC-2.81* Hgb-8.5* Hct-25.4* MCV-90 MCH-30.3 MCHC-33.5 RDW-16.0* Plt Ct-286 [**2178-1-19**] 04:03AM BLOOD WBC-8.9 RBC-2.84* Hgb-8.6* Hct-25.7* MCV-91 MCH-30.2 MCHC-33.3 RDW-15.5 Plt Ct-303 [**2178-1-21**] 11:38AM BLOOD WBC-10.0 RBC-2.65* Hgb-8.3* Hct-22.9* MCV-86 MCH-31.1 MCHC-36.0* RDW-15.5 Plt Ct-219 [**2178-1-22**] 04:14AM BLOOD WBC-9.4 RBC-3.43* Hgb-10.3* Hct-30.1* MCV-88 MCH-30.0 MCHC-34.2 RDW-15.1 Plt Ct-199 [**2178-1-23**] 02:50AM BLOOD WBC-8.2 RBC-3.31* Hgb-10.1* Hct-29.2* MCV-88 MCH-30.5 MCHC-34.6 RDW-14.9 Plt Ct-203 [**2178-1-28**] 05:04AM BLOOD WBC-10.8 RBC-3.46* Hgb-10.2* Hct-31.3* MCV-91 MCH-29.6 MCHC-32.7 RDW-13.6 Plt Ct-296 [**2178-2-2**] 05:07AM BLOOD WBC-10.5 RBC-3.43* Hgb-10.2* Hct-30.6* MCV-89 MCH-29.6 MCHC-33.2 RDW-13.5 Plt Ct-331 . Coags [**2178-1-17**] 10:25AM BLOOD PT-12.4 PTT-22.7 INR(PT)-1.0 [**2178-1-21**] 11:37PM BLOOD PT-13.5* INR(PT)-1.2* [**2178-2-2**] 05:07AM BLOOD PT-13.1 PTT-23.2 INR(PT)-1.1 . Fibrinogen [**2178-1-21**] 11:37PM BLOOD Fibrino-450*# . BMP: [**2178-1-17**] 10:05AM BLOOD Glucose-386* UreaN-39* Creat-2.4* Na-135 K-6.0* Cl-96 HCO3-32 AnGap-13 [**2178-1-18**] 02:16PM BLOOD Glucose-159* UreaN-39* Creat-2.8* Na-138 K-5.2* Cl-96 HCO3-33* AnGap-14 [**2178-1-20**] 03:51AM BLOOD Glucose-179* UreaN-46* Creat-3.1* Na-139 K-5.0 Cl-98 HCO3-34* AnGap-12 [**2178-1-22**] 04:14AM BLOOD Glucose-166* UreaN-46* Creat-3.2* Na-140 K-4.8 Cl-100 HCO3-33* AnGap-12 [**2178-1-24**] 03:58PM BLOOD Glucose-192* UreaN-39* Creat-2.8* Na-141 K-4.8 Cl-99 HCO3-38* AnGap-9 [**2178-2-2**] 05:07AM BLOOD Glucose-161* UreaN-38* Creat-2.3* Na-137 K-5.0 Cl-102 HCO3-28 AnGap-12 . LFT [**2178-1-23**] 11:12PM BLOOD ALT-6 AST-16 Amylase-19 TotBili-0.4 . Troponin: [**2178-1-17**] 10:05AM BLOOD cTropnT-0.33* [**2178-1-18**] 02:16PM BLOOD CK-MB-5 cTropnT-0.54* [**2178-1-19**] 04:03AM BLOOD CK-MB-5 cTropnT-0.46* [**2178-1-20**] 03:51AM BLOOD CK-MB-4 cTropnT-0.42* [**2178-1-21**] 03:12AM BLOOD CK-MB-4 cTropnT-0.36* . Pro-BNP [**2178-1-17**] 10:05AM BLOOD proBNP-[**Numeric Identifier 87942**]* . electrolytes: [**2178-1-17**] 04:19PM BLOOD Calcium-8.3* Phos-5.7*# Mg-1.9 [**2178-1-21**] 06:47PM BLOOD Calcium-8.2* Phos-6.8* [**2178-1-23**] 04:59PM BLOOD Calcium-8.9 Phos-6.1* Mg-2.0 [**2178-1-25**] 04:49PM BLOOD Calcium-8.5 Phos-5.0* Mg-2.1 [**2178-2-2**] 05:07AM BLOOD Calcium-8.8 Phos-4.8* Mg-2.1 . Lactate: [**2178-1-17**] 10:19AM BLOOD Lactate-1.6 [**2178-1-17**] 01:17PM BLOOD Lactate-2.0 [**2178-1-20**] 05:18PM BLOOD Lactate-1.7 . IMAGING: [**2178-1-17**] CXR FINDINGS: Previously noted malpositioned right approached PICC is now terminating within the right axilla. There are low lung volumes with bilateral lower lobe atelectasis/collapse. Bilateral lower lobe opacification likely atelectasis/collapse. In addition, there is worsening, now moderate to large right and stable moderate left pleural effusions. There are increased pulmonary interstitial markings, compatible with a component of interstitial pulmonary edema. There are no new focal consolidations concerning for pneumonia, though an underlying pneumonia particularly at the bases cannot be excluded. The cardiomediastinal and hilar contours are stable. IMPRESSION: Worsening now moderate to large right and stable moderate left pleural effusion. Bilateral lateral lower lobe collapse/atelectasis, though pneumonia cannot be excluded. Moderate interstitial pulmonary edema . [**2178-1-20**] CXR IMPRESSION: AP chest compared to [**1-9**] through 27: Large right pleural effusion has worsened since [**1-19**]. Left lower lobe is severely consolidated, consistently since [**1-9**], presumably collapsed. Moderate left pleural effusion increased since [**1-17**] is stable since [**1-19**]. Upper lobe vasculature is engorged but there is no good evidence for severe pulmonary edema. Left PIC line ends at the junction of brachiocephalic veins. Moderate-to-severe cardiomegaly is chronic. No pneumothorax. . [**2178-1-23**] CXR FINDINGS: Study is limited due to technique and the lower lung fields are cut off from the study. There is again seen increased density surrounding the periphery of the right lung consistent with known hemothorax. Bilateral pleural effusions and a left retrocardiac opacity are again seen. There is a right IJ central venous catheter with distal lead tip in the cavoatrial junction. . [**2178-1-24**] CXR FINDINGS: Comparison is made to previous study from [**2178-1-23**]. There is again seen increased density along the periphery of the right chest. This has decreased since previous likely representing improvement of the hemothorax. There is unchanged cardiomegaly. There is a left-sided pleural effusion and left retrocardiac opacity, which appears stable. There is some mild pulmonary vascular congestion, stable. The right IJ central venous catheter has the distal lead tip in the cavoatrial junction and is unchanged. . [**2178-1-28**] CXR IMPRESSION: AP chest compared to [**1-20**] through [**1-25**]: The volume of the right pleural abnormality surrounding the right lung has decreased slightly, but now air has appeared in the apical region of the right hemithorax. There is no fluid level to suggest a readily drainable fluid. Previous mild pulmonary edema, as best evaluated in the left lung has improved. Right pleural tube unchanged in position. One reason for unreliable function of the right pleural tube may be that it is fissural, and has been since at least [**1-22**]. . [**2178-1-30**] CXR IMPRESSION: AP chest compared to [**1-23**] through [**1-30**]: Moderate right hemopneumothorax continues to increase both in the volume of air which is largely apical and fluid which is costal and dependent. Small left pleural effusion has been present without much change. Moderate-to-severe cardiac enlargement unchanged. Left PIC line curving medially beyond the level of the carina, is separated by such a distance from the right lateral wall of the cardiac silhouette that it suggests persistence of pericardial effusion. . [**2178-1-31**] CXR IMPRESSION: AP chest compared to [**1-23**] through [**1-30**]: Moderate right hemopneumothorax continues to increase both in the volume of air which is largely apical and fluid which is costal and dependent. Small left pleural effusion has been present without much change. Moderate-to-severe cardiac enlargement unchanged. Left PIC line curving medially beyond the level of the carina, is separated by such a distance from the right lateral wall of the cardiac silhouette that it suggests persistence of pericardial effusion. ......................................................... [**2178-1-18**] Left Upper Extremity Doppler venous U/S A tiny non-obstructive thrombus is seen within the left basilic vein. The proximal portion of the cephalic vein appears diminutive, and an underlying nonocclusive thrombus cannot be excluded. There is patent flow seen more distally. IMPRESSION: 1. No DVT. 2. Small non-occlusive thrombus within the left basilic vein. 3. Diminutive caliber of the proximal portion of the left cephalic vein. A small thrombus in this area cannot be excluded. . [**2178-1-19**] ECHO The left atrium is mildly dilated. The estimated right atrial pressure is 10-15mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with severe hypokinesis of the distal septum and low normal contraction of the remaining segments (LVEF = 45-50 %). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([**1-25**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Normal left ventricular cavity size with mild regional systolic dysfunction suggestive of CAD (distal LAD distribution). Mild-moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Dilated ascending aorta. Compared with the prior study (images reviewed) of [**2177-12-11**], the left ventricular systolic function is less vigorous with suggestion of regionality and the severity of mitral regurgitation is slightly greater. The pericardial effusion is similar. . [**2178-1-19**] renal U/S: FINDINGS: Suboptimal scan due to patient positioning. The right kidney measures 12.7 cm. Left kidney measures 11 cm. There is no evidence of hydronephrosis. The 2-mm non-obstructive stone seen on recent CT in the lower pole of the left kidney is not clearly visualized. The urinary bladder is collapsed, containing a Foley catheter. There is right pleural effusion as seen on recent CXR. IMPRESSION: No hydronephrosis. . [**2178-1-19**]: CT chest w/o contrast: FINDINGS: The superior segment of the left lower lobe is minimally aerated. Otherwise, both lower lobes are still collapsed. Aeration in both upper lobes is intact except for residual atelectasis in the posterior segment of the right upper lobe. There are no findings to suggest pneumonia or persistent edema. Small pericardial effusion has decreased; there is no indication of tamponade. Moderate to large, nonhemorrhagic layering pleural effusions are stable and the pleural surfaces remain smooth. Atherosclerotic calcification is present in left main and its anterior descending and circumflex branches. IMPRESSION: Severe, mildly improved bilateral lower lobe atelectasis. Improved right upper lobe atelectasis. Stable moderate layering bilateral pleural effusion. No edema or pneumonia. . [**2178-1-22**] CT Chest w/o contrast CT CHEST WITHOUT IV CONTRAST: A right internal jugular line terminates in the distal SVC and a left PICC terminates at the cavoatrial junction. The moderate posterior dependent right pleural effusion is smaller and now contains large, hyperdense clots. The circumferential hemothorax in the right upper chest, new since the prior chest CT is comparable in extent to the pleural rind on subsequent chest radiographs. There is new atelectasis of the posterior segment of the right upper lobe (2:13). Although there is minimal reexpansion of the anterior basal segment, the remainder of the right lower lobe is collapsed. On the left, the moderate layering nonhemorrhagic pleural effusion is not appreciably changed and causes persistent left lower lobe collapse. A low density small pericardial effusion is stable, and there are no radiographic findings of tamponade. The right chest tube is unchanged in position, terminating at the superior aspect of the right major fissure. There is no mediastinal, axillary or supraclavicular lymphadenopathy. Dense coronary calcifications appear unchanged. The upper abdomen is partially imaged and appears unremarkable. IMPRESSION: 1. New partially layering and partially loculated right hemothorax. 2. New collapse of the posterior segment of right upper lobe; persistent near-collapse right lower lobe. 3. No change in moderate layering nonhemorrhagic left pleural effusion and left lower lobe collapse. Brief Hospital Course: 56 yo male with history of HTN, Type II DM,, and Fournier's gangrene presented with hypoxemic respiratory failure and [**Last Name (un) **] thought to be secondary to flash pulm edema whose course was complicated by hydrothorax, now improving with stable Hct and decreased O2 requirement. # Hypoxemic respiratory failure/Acute on chronic systolic heart failure: Patient likely awoke with PND, and subsequent sympathetic drive likely led to flash pulm edema given history (not catching breath) and initial vitals of 180s/100s and HR 100s. Recent TTE showed LVH and diastolic dysfunction with some regional systolic dysfunction. Patient denied medication non-compliance, and did not report heavy salt load. Patient was discharged three days prior to admission with furosemide 40 mg daily, and was clearly overloaded on exam on admission. He had improvement in his dyspnea with diuresis, positive airway pressure, and hypertensive control. He was initially diuresed with a lasix drip. He underwent a chest CT which showed pleural effusions so IP was consulted for a therapeutic thoracentesis which removed 1900 cc serous fluid. His thoracentesis was complicated by a hemothorax, requiring chest tube placement. He was ruled out for MI with serial cardiac biomarkers. His metoprolol was increased to 50 mg tid. He had a repeat echo which showed slightly increased distal septum hypokinesis, but no other changes from prior (EF 40%). Pt was transferred to the floor and auto-diuresed remaining negative 800-1800cc/day. On the day prior to discharge he was positive 500cc and so his home lasix dose was restarted. Pt had excellent oxygen saturations on 2L NC. . # Fluid overload - Of note, the patient had over 17L diuresed both with a lasix drip and auto-diuresis. It is important to monitor the patient's fluid status and fluid restrict him to less than 2L/day and make sure his I/O's are even on a daily basis. If there is any weight gain greater than 5lbs, or noticeable swelling of his lower extremities or other signs of dependent edema, his lasix dose should be adjusted to ensure he remains evolemic. . # Hemo/pneumothorax: Initial post-[**Female First Name (un) 576**] film showed no pneumothorax, however shortly afterwards he developed right-sided pleuritic chest pain, became diaphoretic and hypotensive, and syncopized. He was found on repeat CXR to have a right [**Last Name (un) **] lung hemothorax. Thoracics was consulted and placed a posterior right-sided chest tube which drained bloody fluid. His Hct acutely dropped and he was transfused a total of 10 units of PRBC over several days (last transfusion was [**1-22**]). A repeat chest CT showed no change in the moderate right dependent effusion or loculated hemothorax component. His tube was on wall suction at the time he was transferred to the floor. Mr. [**Known lastname **] had severe pain at the chest tube insertion site. The site was non-infected and his pain was controlled with Morphine Q4H:PRN. The patient continued to drain serosanguinous fluid from his chest tube, but his Hct remained stable. He was monitored by thoracics and they pulled his chest tube on [**2178-1-29**]. Follow up CXR initially showed some increase in pleural fluid on the right, but it then stabilized on serial CXR. Pt chest tube site was non-tender at time of discharge and his respiratory status is stable. He will continued to be moniotored at Rehab and we will continue to keep the patient overall fluid negative. Pt has follow up CXR on [**2178-2-8**] and follow up appt with thoracic surgery on [**2178-2-18**] # [**Last Name (un) **]/Chronic kidney disease - Thought to be initially secondary to poor forward flow from acute systolic heart failure, however it worsened with diuresis so renal was consulted. Renal felt it was consistent with ATN. Improved somewhat with diuresis, but not yet back to his recent baseline. His creatinine during this hospitalization never dipped below 2.3, which is still above his recent baseline. After speaking with renal it may be that this is his new baseline as his kidneys may not fully recover from this insult. Also, he may just have prolonged recovery and his creatinine may continue to trend down in the coming 8 weeks. He will need follow up labs to further assess his renal function. His lisinopril was also held in the setting of acute renal failure and will be held for 3-4 weeks and then restarted at a home dose of 5mg PO Daily. # Type II DM- He was initially treated with an insulin drip and transitioned to basal/bolus a regimen. He was continued on ASA. His insulin regiment was adjusted throughout the course of his hospital stay as he had difficult to control finger sticks. . # HTN- He was continued on the metoprolol as above, clonidine, and amlodipine. The patient was hypertensive on arrival to the floor in the setting of holding his lisinopril because of ARF. His amlodipine was increased to 10mg PO Daily and his BP was better controlled. His amlodipine should be continued at 10mg PO daily for now, but may need to be reduced back to 5mg when his lisinopril is restarted on [**2178-2-24**]. . # constipation: The patient had intermittent episodes on left sided abdominal pain, nausea and vomiting that resolved when he had bowel movements. While on the floor he would have one day with large bowel movements and then would not have a bowel movement for 2 days. During these episodes of constipation, he would develop nausea/vomiting and left sided pain. These symptoms were well controlled with zofran and increasing his bowel regiment. At the time of discharge all of his bowel meds were standing and to be held if he had loose stools. He will be followed at rehab where they can further adjust his meds if necessary. # Fourniers gangrene- His dressings are changed daily and according to wound care orders. His wound has remained stable and well granulated. # Staph epi bactermia: Blood cultures from the OHS returned during this hospitalization with 1/4 showing staph epi. It was thought to be a contaminant, however he was treated with 1 week of vancomycin. Pt has been afebrile and cultures have all been negative at [**Hospital1 18**]. # HL- He was continued on his statin. This was not an active issue during the course of his hospital stay. Code: full Medications on Admission: insulin glargine 100 unit/mL Cartridge Sig: Ten (10) units daily Humalog 100 unit/mL Cartridge Sig: as directed QACHS SS amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY aspirin 325 mg Tablet Sig: lisinopril 5 mg Tablet (has not received since discharge) clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. heparin (porcine) 5,000 unit/mL Solution DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Neb Q6H PRN wheezing. multivitamin daily docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID Discharge Medications: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). 4. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours): Hold for loose stools. 12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily): Hold for loose stools. 13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily): Hold for loose stools. 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stools. 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Hold for loose stools. 16. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 17. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 18. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours. 19. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 20. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous QHS. 21. insulin lispro 100 unit/mL Solution Sig: Six (6) Units Subcutaneous before meals (breakfast, lunch, Dinner). 22. insulin lispro 100 unit/mL Solution Sig: As per sliding scale Subcutaneous QAC and hs: 101-150: 2 units 151-200: 4 Units 201-250: 6 Units 251-300: 8 units 301-350: 10 Units 351-400: 12 Units >400: 14 units and notify MD. 23. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Primary Diagnosis: Fluid overload . Secondary diagnosis: -recent hypoxic resp failure, [**2-25**] sCHF and MRSA tracheobronchitis -DM type 2 -gastroparesis -MRSA infections -kidney stones -hypertension -hypercholesterolemia -Fournier's gangrene 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 are being discharged from [**Hospital1 **]. It was a pleasure taking care of you during your hospital stay. You were admitted to the hospital on [**2178-1-17**] for excessive fluid in your body and shortness of breath because a lot of the fluid was in your lungs. You were transferred here from Rehab and you were admitted to the ICU. In the ICU you required oxygen support and we agressively removed fluid from your body. It was hard to get fluid off and you were still very short of breath. The intensive care unit thought it would be best to drain the fluid from the right lung and evaluate it. A thoracentesis was done and it was complicated by blood building up in the space between your lungs and the chest wall. A chest tube was placed to drain the blood. During your ICU stay, over 15L of fluid was removed from your body with diuretics and drainage from the chest tube. Your oxygen requirement decreased and you were transferred to the floor for further management. On the floor you were continued to be monitored and you continued to improve. The chest tube was removed a few days prior to discharge. You did well and follow up CXR showed stable lung fields with minimal to no accumulation of blood or other fluid. During your stay you had episodes of nausea that were well controlled with medications. The nausea and vomiting also coincided with episodes of constipation. Your bowel regiment was maximized and your symptoms always resolved with movement of stool. You will be sent to Rehab on a bowel regiment that will help to keep you regular. It is important that you learn to care for your colostomy bag as you will need to do a lot of self-care after discharge from Rehab. The Rehab facility will be given instructions on how to care for the colostomy bag as well as the debrided gangrene site. . The Following medications were STARTED during this admission: Bisacodyl 10 mg by mouth DAILY Milk of Magnesia 30 mL by mouth every 6 hours Polyethylene Glycol 17 g by mouth DAILY Senna 2 TAB by mouth at bedtime Zinc Sulfate 220 mg by mouth DAILY Ondansetron 8 mg by mouth every 8 hours as needed for nausea Famotidine 20 mg by mouth daily Please take your medications as prescribed. Followup Instructions: Please call your PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 32949**] when you are out of rehab for an appt for follow up. Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2178-2-17**] at 10:30 AM With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: EAST Best Parking: [**Street Address(1) 592**] Garage

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Discharge summary

report

Admission Date: [**2181-10-19**] Discharge Date: [**2181-10-23**] Service: MEDICINE Allergies: Penicillins Attending:[**Doctor Last Name 10493**] Chief Complaint: Bleeding from the left ear Major Surgical or Invasive Procedure: 1. Upper endoscopy [**2181-10-19**] 2. Colonoscopy [**2181-10-22**] History of Present Illness: [**Age over 90 **] year old female with PMH significant for HTN, atrial fib on coumadin, and CHF (EF 20%) admitted to the [**Hospital Unit Name 153**] on [**10-19**] with a Hct of 20. Pt was in her normal state of health until four days prior to admission when her ear began bleeding after she cleaned it with a Qtip. Pt denies pain or decrease in hearing from this ear. She presented to the ED on [**10-19**] for evaluation of the continued bleeding. In the [**Name (NI) **], pt was found to have a Hct of 20--- it was 33.5 on [**2181-8-25**]. Rectal exam showed melena. NG lavage was negative showeing clear fluid and no bile. Pt denied any abdominal pain. Pt's INR was 3.3 and she was given vit K 1 mg, 2U FFP, and 1U PRBC. Her post-transfusion Hct was 22. Pt then had an EGD which showed normal mucosa in the stomach, possible gastric inlet patch 17 cm from incisors, 20 mm in diameter, erythematous and not friable (unlikely to have caused her bleeding), normal mucosa in the duodenum and spots in the stomach. After EGD, pt desatted and became tachycardic to the 170s. She responded well to a NRB and lasix. In further discussion, pt had noted two "purple colored" stools prior to admission and several maroon colored stools. She also noted feeling week and fatigued. She has felt lightheaded for approximately six months. Pt has had a significant weight loss over the past few months from 130 to 90 pounds. She notes a decrease in her appetite and intrest in activities since her husband's death last year. Past Medical History: 1. Hypertension 2. CHF- LVEF 20% 3. Mitral Regurgitation documented on prior echo 4. Recent ([**8-17**]) hospitalization for CP. This was felt to be musculoskeletal. 5. Atrial fib- Diagnosed in [**1-17**] and thought to be secondary to mitral regurgitation. Pt has been anticoagulated on coumadin. 6. Hemicolectomy 10 y ago for diverticular bleed. No malignancy found, per pt. 7. Colonoscopy [**2176**]- Previous side to end ileo-colonic anastomosis of the ascending colon Polyp in the rectum (polypectomy) Diverticulosis of the sigmoid colon and descending colon Grade 2 internal hemorrhoids Otherwise normal Colonoscopy to ascending colon. 8. S/P left hip replacement Social History: Lived with her husband until he passed away in [**Month (only) 359**]. Pt now lives alone. Her sons and daughter-in-law are involved in her care. Non-smoker. Occassional EtOH. Family History: Non-contributory. Physical Exam: Gen- Pleasant lady resting in bed. Alert and oriented. NAD. Heent- PERRL, EOMI, mmm, OP clear Cardiac- Irreguraly irregular. II/VI SEM. Pulm- CTAB. No wheezes, rales, or rhonchi. Abdomen- Soft. NT. ND. Positive bowel sounds. Extremities- No c/c/e. Neuro- AOX3, nonfocal exam. Pertinent Results: [**2181-10-19**] 08:45AM BLOOD WBC-4.1 RBC-2.74*# Hgb-6.1*# Hct-20.0*# MCV-73* MCH-22.2* MCHC-30.4* RDW-15.5 Plt Ct-151 [**2181-10-19**] 08:45AM BLOOD Neuts-78.6* Lymphs-15.6* Monos-5.1 Eos-0.7 Baso-0.1 [**2181-10-19**] 08:45AM BLOOD Hypochr-3+ Poiklo-1+ Microcy-2+ [**2181-10-19**] 08:45AM BLOOD PT-21.6* PTT-33.4 INR(PT)-3.3 [**2181-10-19**] 09:21PM BLOOD Glucose-96 UreaN-17 Creat-0.9 Na-144 K-4.0 Cl-107 HCO3-24 AnGap-17 [**2181-10-19**] 09:21PM BLOOD ALT-19 AST-26 LD(LDH)-206 AlkPhos-76 Amylase-88 TotBili-1.2 [**2181-10-19**] 06:50PM BLOOD CK(CPK)-112 [**2181-10-19**] 09:21PM BLOOD Lipase-41 [**2181-10-19**] 06:50PM BLOOD CK-MB-3 cTropnT-<0.01 [**2181-10-19**] 09:21PM BLOOD Calcium-8.8 Phos-3.1 Mg-1.7 [**2181-10-19**] 09:56AM BLOOD Hgb-6.0* calcHCT-18 . CHEST (PORTABLE AP) [**2181-10-19**] 8:47 PM Reason: Evaluate for pulm edema. IMPRESSION: Mild pulmonary edema and bilateral pleural effusions. . EKG [**2181-10-19**] Atrial fibrillation with a rapid ventricular response. Ventricular premature beats. Left anterior fascicular block. Left ventricular hypertrophy. Poor R wave progression, cannot exclude old anteroseptal myocardial infarction but could be due to left ventricular hypertrophy. Compared to the previous tracing of [**2181-8-24**] the rate is faster. Intervals Axes Rate PR QRS QT/QTc P QRS T 109 0 96 332/396.28 0 -37 128 . CHEST (PORTABLE AP) [**2181-10-21**] 5:58 AM Reason: pulm edema, with GI bleed Improving CHF. Brief Hospital Course: This is a [**Age over 90 **] year old female with past medical history significant for hypertension, atrial fibrillation on coumadin, and congestive heart failure (ejection fraction of 20%) admitted to the [**Hospital Unit Name 153**] on [**10-19**] with a Hct 20 down from 34 and INR 3.3. NG lavage was clear without bile. An upper endoscopy was performed which was negative for source of bleed and patient suffered post procedure flash pulm edema which resolved with IV lasix. Patient received another 2 units of PRBC with an appropriate increase in her Hct. Pt received 40 mg IV lasix between these units of blood and her respiratory status remained stable. Patient's hematocrit remained stable with no further bleeding. Pt was transferred to the floor on [**10-21**] for further care. . 1. GI bleed- Patient presented with melanotic stools. Patient was at high risk for bleed given anticoagulation with coumadin. Negative NG lavage and no evidence of active bleeding on EGD [**10-19**]. Differential diagnosis of lower source of bleeding included diverticular bleed, AVM or internal hemorrhoids. A colonoscopy was performed on [**10-22**] with diverticulosis of the sigmoid and descending colon and grade 2 internal hemorrhoids without active bleed. Per GI, colonscopy findings Were nonbleeding but could have caused bleed per GI. Patient was continued on IV protonix twice daily and her Hct was followed every 6 hours with a transfusion threshold of Hct 30. Patient's hematocrit remained stable after colonoscopy until day of discharge. . 2. [**Name (NI) 4964**] Pt with LVEF of 20%. Her respiratory status is stable at this time but need to monitor closely for any fluid overload. Will give IV lasix with any needed blood transfusions. . 3. Atrial fib- Pt was well rate controlled. Since she was hemodynamically stable and no evidence of further bleeding, she was continued on her beta blocker. Coumadin was held. Patient was not resumed on her coumadin at discharge given her risk of GI bleed in the setting of recent bleed. She will follow-up with her PCP and discuss long term plans for anti-coagulation. . 4. HTN- Continued on beta blocker at this time as vitals stable and no further active bleeding. Held lisinopril, CCB. . 5. CAD- Continued on beta blocker given stable vitals but holding ASA. . 6. Ear bleeding- Traumatic in nature. Was irrigated in the ED with removal of several clots. Scant bleeding since that time. . 7. FEN- Full liquids. Electrolyte replacement as needed. . 8. Proph- Pneumoboots; PPI . 9. Code status- DNR/DNI. Medications on Admission: 1. Metoprolol Tartrate 25 mg [**Hospital1 **] 2. Sertraline 50 mg daily 3. Verapamil 40 mg Q12H 4. Warfarin Sodium 2 mg Sun, Thurs, and Fri 5. Warfarin Sodium 1 mg Mon, Wed, and Sat 6. Lasix 20 mg daily 7. Lisinopril 8. Aspirin 81 mg qd Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed: Not to exceed 4g/day. 2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Verapamil 40 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: 1. Melena 2. Diverticulosis of sigmoid and descending colon 3. Grade 2 internal hemorrhoids Secondary diagnosis: 1. Afib 2. CHF with EF 20% 3. History of diverticular bleed status post partial colectomy 4. Hypertension Discharge Condition: Stable Discharge Instructions: 1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet 2. Please take medications as prescribed. 3. Please call your PCP or return to the ED if you have bright red blood in your stool, black tarry stools, chest pain, shortness of breath or any other worrying symptoms. 4. You have been taken off of your coumadin as it can contribute to bleeding. Please do not take any more of this medication. Followup Instructions: Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**] in [**Telephone/Fax (1) 10492**] in one week. Call his office at [**Telephone/Fax (1) 10492**] to make the appointment. I have spoke with Dr. [**Last Name (STitle) 1007**] and they will be expecting your call. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**] Completed by:[**2181-10-24**]

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icd9cm

[ [ [] ] ]

[ "45.13", "99.04", "45.23" ]

icd9pcs

[ [ [] ] ]

7990, 7996

4573, 7123

249, 319

8279, 8288

3097, 4550

8782, 9268

2767, 2786

7410, 7967

8017, 8017

7149, 7387

8312, 8759

2801, 3078

183, 211

347, 1865

8150, 8258

8036, 8129

1887, 2558

2574, 2751

31,618

108,933

33480

Discharge summary

report

Admission Date: [**2173-4-19**] Discharge Date: [**2173-4-23**] Date of Birth: [**2123-5-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion and worsening chest pain Major Surgical or Invasive Procedure: CABGx4 ([**4-19**]) History of Present Illness: Patient with known CAD s/p MI and stent to LAD [**11-1**] now with worsening dyspnea on exertion and chest pain. Had +ETT then referred for repeat cardiac catheterization which revealed 3VD then referred for CABG. Past Medical History: s/p CABG x4 (LIMA-LAD, SVG-OM, SVG-RCA, SVG-PDA)MVRepair(#28 CE Physio ring)[**4-19**] PMH: CAD,MI, DM2, Kidney stones, HTN, ^chol, Lumbar disc [**Doctor First Name **] x3, Appy Social History: Married, lives with wife and children. Works in sales Denies tobbacco No ETOH since [**2171**] Family History: noncontributory Physical Exam: Admission VS HR 98 BP 100/60 RR 16 Gen NAD Neuro Grossly intact Chest CTA Bilat Heart RRR Abdm soft, NT/+BS Ext warm trace edema bilat, L knee tender with limited ROM/+ swelling-no erythema. no varicosities Discharge VS 99.9 T 100/71 HR 99 RR 18 94% RA sat Pertinent Results: [**2173-4-19**] 04:12PM GLUCOSE-90 NA+-133* K+-3.9 [**2173-4-19**] 03:57PM UREA N-26* CREAT-0.9 CHLORIDE-111* TOTAL CO2-23 [**2173-4-19**] 03:57PM WBC-14.2* RBC-3.41*# HGB-10.7*# HCT-30.5*# MCV-89 MCH-31.3 MCHC-35.0 RDW-12.6 [**2173-4-19**] 03:57PM PLT COUNT-141* [**2173-4-19**] 03:57PM PT-14.1* PTT-61.4* INR(PT)-1.2* [**2173-4-19**] 01:55PM GLUCOSE-142* LACTATE-3.3* NA+-132* K+-4.4 CL--108 [**2173-4-23**] 05:10AM BLOOD WBC-8.1 RBC-3.19* Hgb-10.1* Hct-29.0* MCV-91 MCH-31.6 MCHC-34.7 RDW-13.4 Plt Ct-178 [**2173-4-23**] 05:10AM BLOOD Plt Ct-178 [**2173-4-23**] 05:10AM BLOOD Glucose-128* UreaN-20 Creat-1.0 Na-135 K-4.5 Cl-97 HCO3-29 AnGap-14 RADIOLOGY Final Report CHEST (PA & LAT) [**2173-4-21**] 12:24 PM CHEST (PA & LAT) Reason: r/o ptx [**Hospital 93**] MEDICAL CONDITION: 49 year old man s/p cabg and ct removal REASON FOR THIS EXAMINATION: r/o ptx HISTORY: Status post CABG with chest tube removal. FINDINGS: In comparison with the study of [**4-19**], there has been removal of the various tubes including the left chest tube. No evidence of pneumothorax. Mild residual atelectatic changes are seen at the bases, especially on the left. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: WED [**2173-4-21**] 4:12 PM Conclusions PRE-BYPASS: 1. The left atrium is normal in size. 2. A patent foramen ovale is present. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction of septal wall from the mid-papillary segments to the apex. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). 4. The right ventricular cavity is mildly dilated with normal free wall contractility. 5. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. With provactive maneuvers (Trendelenberg and phenylephrine infusion), a mildly eccentric, posteriorly directed jet of Moderate to severe (3+) mitral regurgitation is seen, with noted posterior leaflet (P1 and P2) restriction. The mitral regurgitation vena contracta is >=0.7cm. 7. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and wasAV paced. 1. A well-seated mitral annuloplasty ring is seen with normal leaflet motion and gradients (mean gradient = 1.5 mmHg, MVA by PHT 3.2 cm2). There is no valvular systolic anterior motion ([**Male First Name (un) **]). Trivial mitral regurgitation is seen. 2. Regional and global left ventricular systolic function are mildly depressed LVEF 45-50%, there is improvement of wall motion of the apical segments. 3. Right ventricular systolic function is normal. 4. Aortic contours are intact post-decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2173-4-19**] 16:41 ?????? [**2168**] CareGroup IS Brief Hospital Course: Patient was a direct admission to the operating room on [**4-19**] where he had a coronary artery bypass, please see OR report for details. In summary he had a CABGx4 with LIMA-LAD, SVG-RCA, SVG-OM, SVG-PDA. He tolerated the operation well and was transferred from the OR to the CVICU in stable condition. He did well in the immediate post-op period, his anesthesia was reversed, he was weaned from the ventilator and extubated. He remained hemodynamically stable and on POD1 was transferred from the ICU to the step down floor for continued care. On POD2 his chest tubes and epicardial wires were removed. He was gently diuresed toward his perop weight. The remainder of his post operative course was uneventful and on POD #4 he was discharged home with visiting nurses. Pt. is to make all postop appts. as per discharge instructions. Medications on Admission: ASA 81' Plavix 75' Lopressor 50" Lisinopril 20' Coreg 12.5" Zocor 40' Percocet prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while taking percocet;may stop when off narcotics. Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. 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* 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: s/p CABG x4(LIMA-LAD,SVG-OM,SVG-RCA,SVG-PDA)[**4-19**] PMH: CAD s/p stent/LAD, HTN, DM2, Back surgery MI, renal calculi,elev. chol. Discharge Condition: stable Discharge Instructions: Shower daily and pat incisions dry.No bathing or swimming. Take all medications as prescribed. Call for any fever greater than 100.5,, redness or drainage from wounds. No driving for one month. No lotions, creams or powders on any incision. Followup Instructions: wound clinic in 2 weeks Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Drs. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14522**] [**Name5 (PTitle) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 77640**] in 2 weeks Completed by:[**2173-4-23**]

[ "997.1", "420.91", "424.0", "427.89", "401.9", "272.4", "414.01", "V45.82", "412", "250.00" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.13", "39.61", "35.33", "89.60" ]

icd9pcs

[ [ [] ] ]

6655, 6711

4581, 5418

366, 388

6887, 6896

1280, 2044

7185, 7488

960, 977

5551, 6632

2081, 2121

6732, 6866

5444, 5528

6920, 7162

992, 1261

282, 328

2150, 4558

416, 631

653, 832

848, 944

68,145

178,575

39741

Discharge summary

report

Admission Date: [**2100-11-3**] Discharge Date: [**2100-11-16**] Date of Birth: [**2035-2-21**] Sex: M Service: MEDICINE Allergies: Imitrex / Biaxin Attending:[**Doctor First Name 2080**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: rigid bronchoscopy, IR embolization of bleeding pulmonary vessels History of Present Illness: 65 y/oM with stage IV lung CA on home 2L [**Hospital **] transferred from OSH with hemoptysis x 1 week and resultant Hct drop from baseline 28 to 17. Patient first started coughing up dark clots of blood on Friday; states last hemoptysis was 1 day prior to transfer to [**Hospital1 18**], and was about a tablespoon of blood. Patient had not required mechanical ventilation and was saturating well on room air in [**Hospital Unit Name 153**]. Per [**Hospital Unit Name 153**], patient also c/o dyspnea on mild exertion. Of note, dyspnea has been a longterm complaint and patient was recently admitted for removal of y-stent in [**Month (only) 359**](first placed 2 mo ago). Per report, OP oncologist who did not want to repeat bronchoscopy. . Patient also with recent chemo of [**Doctor Last Name **]/gemcitabine (last dose on [**2100-10-24**]), and had radiation to lung in [**2100-8-11**]. Patient also c/o rib and right hip pain. In [**Hospital Unit Name 153**], radiographs revealed new lytic lesions in ribs and new right femur lytic lesion. . Finally, per [**Hospital Unit Name 153**], patient also c/o dysphagia x several days and states he can't take liquids+solids. The [**Hospital Unit Name 153**] team was concerned that the large mass in lungs may be compressing the esophagus, so GI consulted for feeding tube. Also with 75 pound weight loss. . Per [**Hospital Unit Name 153**] note, at OSH, transfused 2 UpRBC on [**2100-10-28**]. CT scan of chest no active source of hemorrhage or PE. Given concern for large volume bleed, patient was transferred to [**Hospital1 18**] for further evaluation and treatment. Upon arrival to [**Hospital1 **], initial VS: 97.9 100 113/72 18 100% 4L NC, able to be weaned to 99% on RA. Physical exam notable for scattereed rales and trace guiac positive rectal exam. Repeat Hct had risen appropriate to 25, and Hct has been stable throughout [**Hospital Unit Name 153**] stay. . Because IP wanted to use a rigid bronch to see if they can coagulate and localize source of bleeding, patient was transferred West for OR. During bronchoscopy, found to be tumor invasion into both left and right proximal [**Last Name (LF) 87542**], [**First Name3 (LF) **] invasion into the carina. IP able to obtain hemostasis/coagulate much of it, but areas are still oozing and will need IR angioembolization. Patient intubated in OR and comes to MICU intubated. Past Medical History: - Lung Cancer: poorly differentiated adenocarcinoma occluding R main stem bronchus, s/p rigid bronchoscopy, tumor excision and Y-stent [**2100-7-28**]. Medical oncologist and rad-onc doctors [**First Name (Titles) **] [**Name5 (PTitle) **]. Removed in [**Month (only) 359**]. - Hyperlipidemia - BPH - Migraines - Vertigo Social History: Recently quit smoker, 40 py history. No EtOH, no drugs. lives alone Family History: Mother: pancreatic cancer Maternal uncle: lung cancer Siblings: sister diabetes Physical Exam: GEN: thin, fragile, NAD, occassionally labored breathing HEENT: EOMI, PERRLA, no supraclavicular or cervical lymphadenopathy, RESP: rhonchorus breath sounds throughout CV: RRR, S1 and S2 wnl, systolic murmur ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters EXT limited ROM of right hip, minimal pain on palpatition of right trochanter Neuro: II-XII intact; no sensory deficits Pertinent Results: Admission: [**2100-11-3**] 05:48PM HGB-9.2* calcHCT-28 [**2100-11-3**] 09:03AM HCT-23.8* [**2100-11-3**] 02:58AM WBC-5.4# RBC-2.98* HGB-9.0* HCT-25.8* MCV-87 MCH-30.0 MCHC-34.7 RDW-17.2* [**2100-11-3**] 02:58AM NEUTS-80.1* LYMPHS-10.8* MONOS-8.3 EOS-0.6 BASOS-0.3 [**2100-11-3**] 02:58AM PLT COUNT-235# [**2100-11-3**] 02:58AM RET AUT-3.0 [**2100-11-3**] 02:58AM PT-14.8* PTT-26.0 INR(PT)-1.3* [**2100-11-3**] 02:58AM GLUCOSE-86 UREA N-29* CREAT-0.6 SODIUM-140 POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-27 ANION GAP-20 [**2100-11-3**] 02:58AM ALT(SGPT)-11 AST(SGOT)-29 LD(LDH)-425* ALK PHOS-114 TOT BILI-1.5 . MICRO: RESPIRATORY CULTURE (Final [**2100-11-7**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. HEAVY GROWTH OF TWO COLONIAL MORPHOLOGIES. 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. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . ACINETOBACTER BAUMANNII COMPLEX. RARE GROWTH. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ACINETOBACTER BAUMANNII COMPLEX | | AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- <=0.25 S CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R <=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S VANCOMYCIN------------ 1 S IMAGING: CT Chest [**11-3**] 1. No aortic dissection, pulmonary embolism. 2. Persistent tumor encasing the posterior mediastinum, carina and right hilum. The overall extent of this tumor appears to have decreased from the previous study with resultant improved patency of the airways and resolution of right upper lobe and lower lobe atelectasis. 3. New bilateral lytic rib lesions consistent with metastatic disease. There is also a new pathologic left posterior eighth rib fracture. 4. Tumor involvement in the posterior mediastinum is inseparable from the esophagus and there is a large volume of ingested material seen in the proximal esophagus. This finding raises concern for aspiration. 5. Emphysema. 6. Unchanged thickening of both adrenal glands. . Bone Scan: [**11-5**] IMPRESSION: Multiple osseous metastatic lytic foci involving the thoracic ribsthe right femoral neck with associated pathologic fracture involvingthe left posterior 8th rib as can be correlated on recent CT/radiographs. . CT PELVIS: [**11-5**] IMPRESSION: 1. Innumerable lytic lesions throughout the sacrum, bilateral iliac bones, and proximal femurs. 2. The largest lesion is in the right intertrochanteric region of the femur which is not completely imaged. There is rarefaction of the medial aspect of the right femur medially at the site of the lesion which is at risk for pathologic fracture. 3. Interval development of ascites in the abdomen. . CT CHEST [**11-11**] IMPRESSION: 1. Overall progression of subcarinal and paraesophageal mass with occlusion of the distal unstented portions of the right middle and lower lobe bronchi. 2. Subtotal occlusion of the esophageal stent in its mid portion with associated distention of the proximal esophagus. 3. Marked interval enlargement of bilateral pleural effusions and associated compressive atelectasis at the lower lobes. Brief Hospital Course: # Metastatic Lung Cancer. During this hospitalization the was tumor found to be increasingly aggressive in nature with continued growth, despite active chemotherapy. Continued growth resulted in esophageal compression as well as invasion into the bronchial tree. Furthermore, patients additional presenting complaint of right hip weakness found to result from tumor infiltration of right intertrochanteric space. On admission patient optimistic and eager for treatment. Underwent angioembolization to treat bleed. Underwent tracheal and esophageal stenting in hopes of improving the dysphagia. Unfortunately, the force of the surrounding tumor resulted in near occlusion of esophageal stent 24hours after placement. The severity of the situation was relayed and after several discussions with the family, primary outpatient team as well as inpatient team patient changed code status to DNI/DNR with wish to proceed with hospice care. At time of discharge antibiotics, TPN were stopped, PICC line pulled and comfort measure were applied. Patient with plan to be discharged with home hospice. Provided with prescriptions to minimize pain, decrease nausea, decrease anxiety and improve work of breathing. . # Hemoptysis: Secondary to endobronchial tumor burden. Invasion of tumor into right and left proximal [**Month/Year (2) 87542**] and also into carina. Arrived in MICU intubated for airway protection. Now s/p rigid bronch with IP. Pt with continued slow bleeding initially, embolized by IR. s/p IR procedure no further episodes of active hemopytsis. . # Esophageal obstruction: Tumor was found to be compressing espogeal resulting in near occlusion. After reviewing imaging decision made to first stent tracheal stent to protect airway prior to esophageal stent placement. Unfortunately CT scan on day following stent placement revealed subtotal occlusion of distal esphagus. No further interventions performed. Patient able to tolerate liquid diet at time of discharge. . # Pelvic lesion. Spoke with both Ortho onc as well and Radiation Oncology. Initially discussion of possible operative intervention vs XRT. However after much discussion decision made to treat pain with and forego additional treatment measures. . # Pneumonia. Patient developed worsening post-obstructive pneumonia after esophageal stent placement. Treatment with antibiotics discontinued after code discussion finalized. Medications on Admission: - Atorvastatin 20 mg daily - Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr QHS - Menthol-Cetylpyridinium 3 mg Lozenge prn - Guaifenesin 600 mg Tablet Sustained Release 2 tabs [**Hospital1 **] - Omeprazole 20 mg Capsule, Delayed Release(E.C.) daily - Docusate Sodium 100 mg Capsule [**Hospital1 **] - Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution q 6hrs prn - Acetylcysteine 20 % (200 mg/mL) Solution q 6hrs - Amoxicillin-Pot Clavulanate 875-125 mg Tablet x 4weeks - Benzonatate 100 mg Capsule TID - Cyclobenzaprine 10 mg Tablet TID - Oxycodone 5 mg Tablet q 4-6 hrs prn - Acetaminophen 325 mg q 6hrs prn - Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL 5mL QID - Codeine Sulfate 30 mg Tablet QID prn Discharge Medications: 1. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*1 Patch 72 hr(s)* Refills:*2* 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. Disp:*24 Tablet(s)* Refills:*0* 3. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for cough. 4. morphine 10 mg/5 mL Solution Sig: One (1) PO Q2H (every 2 hours) as needed for pain. Disp:*1 bottle* Refills:*2* 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. Disp:*2 inhalers* Refills:*0* 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath. Disp:*2 cartridges* Refills:*0* 7. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:*24 Tablet, Rapid Dissolve(s)* Refills:*0* 8. acetaminophen 650 mg/20.3 mL Solution Sig: [**12-12**] PO every six (6) hours as needed for fever for 1 doses. Discharge Disposition: Home With Service Facility: Hospice of [**Hospital3 **] Discharge Diagnosis: Primary: Metastatic Lung cancer Discharge Condition: Mental status: clear and coherent Unable to bear weight on left leg. Discharge Instructions: You were transferred to [**Hospital1 18**] for continued treatment of your lung cancer with associated complications of trouble swallowing, coughing up blood, and hip pain. . To address the bleeding, the team of interventional pulmonologists were able to a perform a bronchoscopy, a procedure which allows visualization of your airways. During this procedure they were able identify the source of the bleed and apply thermal energy to stop it. You had not further episodes of coughing up large volumes of blood while hospitalized. . You also noted difficulty swallowing. It was discovered that the tumor was compressing your esophagus making it difficult for you to swallow. The decision was made to place an esophageal stent in hopes of making swallowing easier. A tracheal stent was placed prior to the esophageal stent to ensure airway protection. Unfortunately, the force of the tumor on the esophageal stent caused the area of the stent to lessen only allowing passage of liquids. Prior to discharge you were able to swallow liquids with limited difficulty. . Imaging was taken of your hip. Ultimately it was determined that your increased pain was due to tumor involvement in the bones of the hip. Your pain was controlled with morphine and physical therapy worked with you to optimize your strength and ability to transfer. . During your hospitalization, ongoing discussion took place between your primary care physician, [**Name10 (NameIs) **] primary oncologist as well as your inpatient medical team and consult services. After much discussion you determined that you would rather return home with hospice care rather than proceed with ongoing hospital care. Your ongoing goals of care will be optimizing comfort. . Mr [**Known lastname **] it was an honor taking care of you. . You will be discharged with medications to control pain, decrease nasuea and improve breathing: - MORPHINE 5-10mg PO every 2 hours as needed for the pain - ZOFRAN 4mg tablets. Take one tablet every 8 hours as needed for pain - ALBUTEROL Inhaler 2 PUFFS as needed for shortness of breath - ALBUTEROL Nebulizer treatment. 1 every 6hrs as needed for shortness of breath - LORAZAPAM 0.5 mg SL Q4H as needed for anxiety - Guaifenesin [**4-19**] mL PO/NG every four hours for cough Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 27009**] and Dr. [**Last Name (STitle) 87543**] as needed and contact your hospice program with any questions or difficulties Completed by:[**2100-11-16**]

[ "996.59", "482.42", "511.81", "733.19", "338.3", "285.1", "530.3", "787.20", "V15.82", "E879.2", "E879.8", "262", "197.8", "909.2", "285.22", "238.71", "V49.86", "162.8", "272.4", "600.00", "276.1", "198.5", "197.3", "530.19" ]

icd9cm

[ [ [] ] ]

[ "99.15", "32.01", "33.91", "39.79", "96.05", "42.23", "34.91", "42.81" ]

icd9pcs

[ [ [] ] ]

12252, 12310

7931, 10330

290, 357

12386, 12386

3779, 7908

14770, 14976

3222, 3303

11134, 12229

12331, 12365

10356, 11111

12481, 14747

3318, 3760

240, 252

385, 2776

12401, 12457

2798, 3121

3137, 3206

9,935

157,296

17874

Discharge summary

report

Admission Date: [**2144-7-8**] Discharge Date: [**2144-7-31**] Date of Birth: [**2091-4-23**] Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old gentleman with a history of substance abuse with cervical degenerative joint disease and lumbar surgery for low back pain who now presents to the Emergency Room after developing neck pain for three days prior to admission, more left-sided than right-sided. He states that there has been a stabbing- like pain, an electric shock pain in that region and this radiates down his back to the level of his buttocks. His shoulders and arms to a lesser extent. His forearms have been painful as well. He also states that he has some numbness across the shoulder blades as well. Denies fever or chills. Has had some difficulty walking due to the pain. Has not had bowel or bladder incontinence. Denies recent intravenous drug abuse. Did drink two beers the morning of admission. He had otherwise been sober for the last 11 months. Somewhat inattentive and is unable to tell complete details of his past medical history. PAST MEDICAL HISTORY: Includes EtOH and heroin abuse, cervical degenerative joint disease, lumbar surgery, hypertension, gastric bypass surgery, history of depression and neuropathy of unknown etiology manifesting as feet numbness. MEDICATIONS: Include: Gabapentin 600 p.o. q.i.d., folate 1 mg p.o. q. day, Celexa 20 mg q. day, MVI one cap p.o. q. day, verapamil 60 p.o. t.i.d., amitriptyline 150 p.o. q. hs. ALLERGIES: He has no known allergies. PHYSICAL EXAMINATION: His temperature is 98, blood pressure 118/69, heart rate 96, respiratory rate 18, sats 97 percent on room air. He is a well-appearing gentleman in no acute distress. HEENT: Large firm neck mass in the left posterior cervical trapezius region with erythema spreading down his neck. His lungs are clear to auscultation. Cardiovascular: Regular rate and rhythm. No murmur, rub or gallop and no carotid bruits. His abdomen is soft, non-tender, obese, midline scar. Extremities: No pedal edema and no rashes. Skull and spine: Neck movements are severely limited by pain. He has electric shock-like sensation whenever he moves his neck and cannot lay his head flat. His paraspinal tissues are tender all the way down but less towards the lumbar region. Mental status: The patient is inattentive, oriented to [**2125-1-23**], [**Hospital6 1129**]. Language is intact and naming, repetition and comprehension. Cranial nerves: Visual acuity is intact. His visual fields are full. His optic discs are normal. Eye movements are normal. His pupils are equal, round and reactive to light. His sensation on the face is intact to light touch and pinprick. Facial movements are normal and symmetric. Hearing is intact to finger rub. He has no nystagmus. The palate elevates midline. The tongue protrudes in the midline and is normal in appearance. The sternocleidomastoid and trapezius muscles are strong bilaterally. He is unable to abduct his shoulder. Motor strength: His deltoid are 2 bilaterally, triceps 4 bilaterally, biceps 2 bilaterally, wrist extension 4 plus, finger extension 4 plus, finger flexion [**5-27**], IP [**5-27**], hamstrings [**4-27**], quads [**5-27**], AT 5/5, gastroc [**5-27**]. Wrist extension and finger extension are give- way. The tone is increased in the lower extremities. There are no adventitious movements. There is no ataxia or rapid finger tapping or foot tapping. Reflexes: Deep tendon reflexes are all present, brisk in the triceps and biceps and brachioradialis with spread to the fingers. There is no [**Doctor Last Name 937**] reflex. The patella and Achilles are two plus. There are no crossed adductor reflexes. The toes are upgoing bilaterally. Sensation is intact to light touch but decreased to pin all across the back up to and including the shoulders but preserved on the front starting at the inguinal region. Temperature appears intact throughout the trunk and extremities with the exception of stocking distribution to the knees. Joint position is slightly impaired. Gait and stance: The patient is able to walk but is wide-based and hesitant due to pain. HOSPITAL COURSE: The patient was evaluated in the Emergency Room by the Neurology Service and Neurosurgery Service. Neurosurgery recommended a stat MRI scan and, due the patient's continued problems with pain and some agitation, he was medicated with Ativan and Dilaudid. The patient was taken down to the MRI scan and while in MRI scan the patient had a cardiac arrest and went into PA. The patient was resuscitated and was brought to the Intensive Care Unit after being intubated. On admission to the Medical Intensive Care Unit, the patient was intubated and was not responding to commands. His pupils were equal, round and reactive to light. The patient also began to have progressive neurologic deterioration while in the Emergency Room becoming weaker in all four extremities. The patient was started on a Solu-Medrol protocol as soon as this deterioration was noted and the patient did eventually have an MRI scan. MRI scan which was done showed a C4 to T5 epidural enhancing lesion consistent with epidural abscess with intrinsic spinal stenosis in the upper levels. Abscess maximal at the T1 to T2 level with intrinsic core T2 signal changes at C4. The patient was taken emergently to the Operating Room for decompression of his cervical and thoracic spine. He was started on empiric antibiotic coverage of vancomycin, gentamicin and ceftazidine on admission. He also had a CT of the neck on admission which showed evidence of infection or inflammation within the soft tissue of the neck. The left-sided swelling with muscular striatum as well as edematous fat planes extending to prevertebral soft tissue with no frank fluid collection on CT. Cultures from the Operating Room debridement and decompression showed Gram positive cocci in pairs and clusters on Gram stain. Culture was pending. Blood cultures from the 16th grew out Staphylococcus aureus and the patient spiked to 102. On [**2144-7-10**], the patient was opening his eyes. The patient was not following commands. He had some slight withdrawal in his lower extremities and no movement of his upper extremities. Head CT was also performed which showed no infarct or hemorrhage. The patient had a transesophageal echocardiogram done on [**7-10**] that showed no vegetation with a normal echocardiogram study. Infectious Disease continued to follow the patient. There was concern for a retropharyngeal fluid collection which was not decompressed at the time of the original surgery. However, on subsequent MRI scans the fluid collection did not require drainage. On the 19th he was able to open his eyes spontaneously. Still not following commands. His pupils were 1.5 down to 1 mm. Slight grimace to stimulation. Slight withdrawal of his lower extremities. Right upper with no movement or grimace. He was neurologically unchanged. The patient had repeat MRI scan of the cervical spine on [**2144-7-10**], which showed evidence of T2 signal change in the C4 to C5 area of the spinal cord consistent with possible infarct of the cord and continued probable osteomyelitis at the C5 vertebral body. Continued IC and antibiotics were recommended. The patient also had a chest CT on [**7-10**]. We had multiple cavernous lesions which were suggestive of septic emboli. Head CT again showed no evidence of hemorrhage or infarct. The patient's cultures came back as MSSA Staphylococcus aureus and the patient was switched to oxacillin for antibiotic coverage. The patient's neurologic status continued to remain unchanged and the patient was awake but not following commands and had no movement of his upper or lower extremities. Due to his lack of ability to follow commands, an MRI of his head was obtained to rule out infarct. His head MRI was negative. The MRI of his spine showed continued paraspinal fluid collection on the right side but no further drainage of that was done during his hospitalization. The patient had difficulty with desaturations on the ventilator and was becoming more difficult to ventilate. He had a CTA which was negative for emboli. Chest x-ray showed a left lower lobe pneumonia. A family meeting was held on [**2144-7-16**], and patient was at this point still not following commands. His eyes were open but would not track or follow any commands or recognize faces and still had no movement of any of his extremities. The family was told of his likely poor prognosis and discussion was had about making the patient comfort measures only. The family was considering those options but wanted to wait a couple more days to see if the patient's condition changed. On [**2144-7-17**], his neurologic status did begin to improve. He did begin to track with his eyes and a question of whether he was starting to follow commands. He was still at this time a DNR/DNI. On [**2144-7-20**], there was definite improvement in neurologic status. The patient was able to nod appropriately to questions and follow commands by blinking. A meeting was held with the family again and the family opted to move forward with trach and PEG and rehabilitation placement. The patient continued to have on and off spikes in temperatures, continued on oxacillin. On [**7-20**] he was day six of 18 and levofloxacin was day six of 23. He did have positive blood cultures, one out of four bottles on [**7-17**] that grew out Gram positive cocci. Left lower lobe consolidations consistent with Klebsiella though Infectious Disease feels that this is colonization and not active infection. A repeat MRI of the neck on [**2144-7-23**], showed decreased retropharyngeal edema and no fluid. There was still question of posterior soft tissue infection. The patient had trach placed on [**2144-7-24**], without complication. The patient was unable to have PEG placement due to previous gastric bypass surgery. The patient had a Dobbhoff tube placed. A Speech and Swallow evaluation on [**2144-7-30**], revealed that the patient could tolerate soft solids with thickened liquids and, therefore, a feeding tube would no longer be necessary. The patient's neurologic status remained stable with improvement in right upper extremity movement at the deltoid and withdrawal to stimulation in the lower extremities and definitely awake, alert and following commands at this point. DISCHARGE MEDICATIONS: Include baclofen 5 mg p.o. t.i.d., Haldol 2 mg p.o. b.i.d., metoprolol 12.5 b.i.d., famotidine 20 mg b.i.d., citalopram hydrobromide 20 NG b.i.d., ___________ sodium 40 subcu q. day, vancomycin 1000 mg IV q. 12h., insulin sliding scale, folic acid 1 mg p.o. q. day, thiamine 100 mg p.o. q. day, oxacillin 2 grams IV q. 4h., hydralazine 10 mg IV q. 6h. p.r.n. for systolic blood pressure greater than 150, Lacrilube O.U. p.r.n., Colace 100 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: The patient also had Dopplers of the lower extremities on [**7-24**] that ruled out deep venous thrombosis. His chest x-ray showed good placement of his Dobbhoff tube at the time but that has since been removed and the patient is tolerating soft solids with thickened liquids. Oxacillin 2 grams IV q. 4h. should continue for at least six to eight weeks. The patient should have liver function tests, CBC and electrolytes followed weekly while on oxacillin. The patient should continue on vancomycin for 12 weeks. Prior Klebsiella infection should complete a 14 day course of levofloxacin and remain on MRSA precautions. Psychiatry was also consulted due to the patient's prognosis and quadriplegic diagnosis and they discontinued following recommending standing Haldol and avoiding benzodiazepines and follow patient as he recovers. The patient's neurologic status has remained stable. The patient will continue on oxacillin 2 grams IV q. 4h. for several weeks. Will have a follow-up MRI scan follow-up appointment with Dr. [**First Name (STitle) **] in two to three weeks. Will follow up with the Infectious Disease Service on [**9-7**] at 9:30 a.m. in the Infectious Disease Clinic. Number is [**Telephone/Fax (1) 457**]. As mentioned before, he should have liver function tests, CBC with differential and a Chem-7 checked q. week while on oxacillin. CONDITION ON DISCHARGE: Stable. FOLLOW UP: He will follow up with Dr. [**First Name (STitle) **] in his clinic in two to three weeks' time with a repeat MRI scan. The number is [**Telephone/Fax (1) 1669**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**] Dictated By:[**Last Name (NamePattern1) 6583**] MEDQUIST36 D: [**2144-7-30**] 15:48:42 T: [**2144-7-30**] 17:17:38 Job#: [**Job Number 49554**]

[ "518.81", "790.7", "324.1", "427.5", "V45.3", "355.8", "401.9", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.91", "96.6", "38.93", "99.04", "96.04", "88.72", "31.1", "03.4" ]

icd9pcs

[ [ [] ] ]

10542, 10997

4245, 10518

11022, 12386

12432, 12865

1591, 2351

164, 1115

2524, 4227

2367, 2507

1138, 1568

12411, 12420

75,586

185,363

19234

Discharge summary

report

Admission Date: [**2126-6-1**] Discharge Date: [**2126-6-17**] Date of Birth: [**2062-12-18**] Sex: F Service: NEUROSURGERY Allergies: Levaquin / Quinolones Attending:[**First Name3 (LF) 1835**] Chief Complaint: Unsteady Gait Major Surgical or Invasive Procedure: [**2126-6-5**] BILATERAL SUBOCCIPITAL CRANI FOR MASSES History of Present Illness: [**Known firstname 501**] [**Last Name (NamePattern1) 52403**] is a 63 yo right handed woman with a history of NSCLC who presents with 1 week history of headache and unsteady gait. The patient and her husband report an overall decline in her energy level for the past 2 weeks. She has been fatigued and short of breath when walking. A week ago, she noted the onset of a frontal headache with associated nausea and vomiting (x2 this week). She describes the headache as a general ache which is relieved with alleve or tylenol PM. It is worse when she is standing and does not wake her from sleep. She denies having a history of headaches. She has not visual changes or changes in hearing. She states that she has had difficulty walking for the past week as well. She denies vertigo and states that she just feels unsteady when walking. She went to her PCP who evaluated her with blood work and an EKG which where initially unremarkable, however given the peristence of her symptoms, she was referred for an urgent MRI which was completed this morning. This non-contrast study demonstrated 2 large cerebellar masses. Ms. [**Known lastname **] was referred to [**Hospital1 18**] for further evaluation. Past Medical History: Parkinsons, stage IIIa (T1N2MO) right-sided lung CA s/p chemoradiation, PE on lovenox/coumadin, HLD, HTN Social History: ex-smoker:D/C'd on 20 years ago Pack-years: [**10-16**] Occupation: office worker Marital Status: Married Lives:With family ETOH: Denies Family History: Non-contributory Physical Exam: PHYSICAL EXAM: T: 97.9 BP: 123/89 HR:108 R14 98%O2Sats Gen: WD/WN, comfortable, NAD. HEENT: EOMs 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. Oriented to person, place, and date. Recall: [**2-27**] objects at 5 minutes. 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 bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: slight left facial droop at rest, sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk, increased tone on left. No abnormal movements, slight left dysmetria, no resting tremor appreciated. Strength 5-/5 in left triceps otherwise [**5-1**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Diminished temperature sensation in a stocking glove distribution. Reflexes: B T Br Pa Ac Right brisk 3 3 3 2 2 Left brisk 2---------> Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin. Gait cautious and Romberg positive. EXAM ON DISCHARGE: Neurologically intact, however gait was not assessed Pertinent Results: ADMISSION LABS: [**2126-6-1**] 02:10PM PT-23.5* PTT-25.6 INR(PT)-2.2* [**2126-6-1**] 02:10PM WBC-7.6 RBC-4.44# HGB-13.7# HCT-41.7# MCV-94 MCH-31.0 MCHC-33.0 RDW-13.7 [**2126-6-1**] 02:10PM GLUCOSE-93 UREA N-18 CREAT-0.8 SODIUM-139 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16 LABS ON DISCHARGE: [**2126-6-17**] 07:55AM BLOOD WBC-7.1 RBC-2.92* Hgb-9.2* Hct-28.0* MCV-96 MCH-31.6 MCHC-33.0 RDW-15.1 Plt Ct-192 [**2126-6-1**] 02:10PM BLOOD Neuts-81.2* Lymphs-11.6* Monos-4.9 Eos-1.8 Baso-0.4 [**2126-6-14**] 10:09AM BLOOD Fibrino-260# [**2126-6-17**] 07:55AM BLOOD Glucose-95 UreaN-13 Creat-0.5 Na-135 K-4.6 Cl-101 HCO3-28 AnGap-11 [**2126-6-2**] 05:25PM BLOOD ALT-8 AST-17 LD(LDH)-203 AlkPhos-76 TotBili-0.4 [**2126-6-17**] 07:55AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0 [**2126-6-12**] 04:26PM BLOOD Osmolal-279 IMAGING: MRI +/- [**6-1**]: Two large heterogeneous lesions in the cerebellar hemispheres, with moderate surrounding edema and mass effect on the fourth ventricle with moderate dilation of the lateral and third ventricles related to obstruction. These represent metastatic lesions. Recommend neurosurgical consult. Close followup if no intervention is contemplated. CTA [**6-3**]: There are some prominent veins along the superior margin of the cerebellar lesions, particularly on the left. No large arterial supply is noted. There is no high-grade stenosis or aneurysm within the vasculature.There is no AV shunting. The cerebellar lesions do not appear to be hypervascular with some prominent veins along the superior surface of the lesion, particularly on the left. NCHCT [**6-5**] Post Op Postoperative changes related to cerebellar mass. Minimal hemorrhage in the surgical bed NCHCT [**6-6**]: 1. Status post interval placement of right frontal ventriculostomy catheter terminating in the third ventricle with subsequent decrease in size of the third and lateral ventricles. 2. Post-surgical changes status post bilateral suboccipital craniotomy and mass resection with edema surrounding the surgical bed causing mild interval increase in mass effect on the fourth ventricle. Small amount of hemorrhage and air noted in the surgical bed. 3. Stable tonsillar herniation with patency of the suprasellar cistern, unchanged from the prior study. MRI Head [**6-6**]: 1. Post-surgical changes status post bilateral suboccipital craniotomy and mass resection with hazy nodular enhancement lateral to the left cerebellar surgical resection cavity which may be secondary to postoperative changes; however, recurrent or residual neoplasm cannot be entirely excluded. Recommend continued interval followup for further evaluation. 2. No significant interval change in positioning of the right frontal ventriculostomy catheter terminating in the third ventricle with interval collapse of the right lateral ventricle. 3. Diffusion abnormality surrounding the surgical resection bed which is thicker than the thin peripheral rim of enhancement. This most likely represents simple hemorrhage within the post-operative site or post-operative diffusion slowing secondary to the recent surgery. This less likely represents neolasm considering that the original tumor did not demonstrate decreased diffusion. 4. Stable tonsillar herniation since CT examination performed earlier the same day. Brief Hospital Course: Patient was seen in the Emergency Room by the Neurosurgery team and admitted to Neurosurgery, Attending Dr. [**First Name (STitle) **]. She was initiated on treatment with decadron 4mg q6 hours for edema and monitored with q 4 neuro checks. Sinemet and Mirapex were continued but Coumadin was held (and reversed with 10mg Vitamin K). Hematology oncology was consulted who were in agreement that cerebellar lesions require surgical decompression prior to radiation therapy. Per the patients request, she also contact[**Name (NI) **] her primary oncologist, who also spoke with the patient and agreed with surgical resection. The patient was taken to the operating room on [**2126-6-5**] for a bilateral suboccipital craniotomy for mass resection. Surgical procedure was tolerated well. Post-operatively she was kept intubated because of the potential fluid shifting. A CT of the head was done immediatley post-op, which showed persistent and marginally worse vasogenic edema abutting the brain stem. Because of this an EVD drain was placed at the bedside, and kept open at 10cm. She was also placed on mannitol 25gm q6h, and 3% HTS. On [**6-7**], the mannitol was changed to 25gm q8h, 12.5Q6 on [**6-10**], and off on [**6-11**]. Her dex was weaned every other day. The 3% HTS was d/c'd on [**6-10**]. She has remained on Na tabs since being off the 3% drip. Her ICPs remained in the low teens, and the EVD was open raised to 20 on [**6-10**]. She tolerated this well. In the evening, her EVD was trial clamped. Approximately 3hrs later, her ICPs were recorded in the 30's with symptoms of Headache. In this setting, the drain was opened to resume drainage. Her mental status was also stable, so she was transferred to the neurosurgical stepdown unit. The patient remained in the stepdown unit with trials of weaning from the EVD but these were unsuccessful. On [**6-14**] she was brought to the operating room and underwent VP Shunt placement (Medtronics at 1.5). Surgery was without complication and she was transferred to the 11th floor. Post operative head CT was stable. She was monitored for 48 hours and was tolerating a regular diet and worked with PT and was recommended to go to rehab. Medications on Admission: Metoprolol 25mg daily Mirapex .25mg TID Carbadopa-levadopa 25/100mg TID Warfarin 3mg, 3mg, 2mg (?) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezes. 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 12. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 13. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3 times a day). 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezes. 15. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 16. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO bid () for 99 days. 17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for PAIN. 19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Cerebellar Masses(bilateral) Discharge Condition: Neurologically Stable Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE: ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You may wash your hair with a mild shampoo 24 hours after your sutures are removed. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. Be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation. MEDICATIONS: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: o Narcotic pain medication such as Dilaudid (hydromorphone). o An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? You were on Coumadin (Warfarin), prior to your surgery, you may safely resume taking this on [**2126-6-21**]. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ACTIVITY: The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. . Followup Instructions: FOLLOW UP APPOINTMENT INSTRUCTIONS ??????Please return to the office on or around [**6-25**] to remove your staples. You may that done at rehab if still there. If there is any concern about the wound please call have them call our office for a wound check. By calling [**Telephone/Fax (1) 2731**]. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**6-24**] at 0930. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. This is a multi-disciplinary appointment. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain as this was done during your hospitalization. - Follow up with your primary oncologist for your lung cancer treatment - Have a Na checked in the next week at the rehab facility Completed by:[**2126-6-17**]

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icd9cm

[ [ [] ] ]

[ "01.59", "02.34", "02.06", "02.2" ]

icd9pcs

[ [ [] ] ]

11075, 11172

6880, 9079

300, 357

11245, 11269

3548, 3548

16373, 17370

1897, 1915

9229, 11052

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385, 1597

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3565, 3840

2162, 2401

1619, 1726

1742, 1881

68,691

137,771

36042

Discharge summary

report

Admission Date: [**2163-2-15**] Discharge Date: [**2163-2-20**] Date of Birth: [**2084-11-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: This is a 78 year-old male with a history of afib, PEs while on coumadin, pulmonary hypertension and hypothyroidism who is admitted with shock on pressors. EMS was initially called as the patient was experiencing extreme fatigue over the last 2 days which had become progressively worse. EMS reports that the patient was AAOx2, eyes open, no complaints other than weakness. He denied n/v/d, headache, chest pain, fever, chills, abdominal pain. He was able to follow commands. Initial ECG showed 2nd degree AV block per report. Fluid boluses were given without improvement, so atropine 0.5 mg IV x1 was given which improved his heart rate. As his BP began to fall, dopamine was infused peripherally at 10 mcg/min with improvement in BP on arrival to the ED at [**Hospital1 **] [**Location (un) 620**]. . In the ED at [**Location (un) 620**], the patient was continued on dopamine and was given ctx 1 gm IV, levaquin 750 mg IV, and vancomycin 1 gm IV. He additionally rec'd 1 unit of prbcs and dexamethazone 10 mg IV for possible adrenal insufficiency. He was also given an additional 3L NS with minimal increase in BP. A trial of levophed at 10 mcg/min resulted in decreased BPs to the 60s, so the patient was placed back on dopamine with BPs in the 110s. . As the patient refused an IJ for access, a femoral line was placed to continue pressor support. He was transferred on 10 mcg/kg. . Of note, the patient had a recent admission in [**Month (only) 359**] of this year to [**Hospital3 **] for hypotension. He was admitted to the ICU. He had a TTE at that time showing EF of 65% and RV dysfunction, not significantly changed from prior. A chest CT showed inflammatory/infectious etiology and sputum cultures grew Serratia marcescens and citrobactor amalonaticus. Repeat imaging and bronchoscopy yielded evidence of likely COP. He was started on prednisone for concerns of COP/BOOP and amiodarone was discontinued due to concerns of pulmonary toxicity. He was also fluid overloaded during the admission given his hypotension and ICU stay and was diuresed prior to discharge. 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 oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: Pulmonary hypertension followed by Dr. [**Last Name (STitle) 9779**] at [**Hospital1 2025**], on Viagra Hypothyroidism Gout CAD - denies history of MI Hypercholesterolemia Staph bacteremia Afib/flutter formerly on amiodarone, now on coumadin/digoxin (amio was stopped during [**Month (only) 359**] admission, but patient believes he is still taking it) R TKA [**4-3**] complicated by protracted ICU stays, on chronic suppressive antibiotics (Augmentin/Bactrim) Multiple PEs (2 diagnosed 5 years ago while on coumadin) Social History: Lives with his wife. Uses a wheelchair primarily to mobilize. Denies alcohol, tobacco, drugs. Family History: NC Physical Exam: On Presentation: GEN: NAD, ill appearing VSS HEENT: dry MM, cobblestone appearance of lower oral mucosa with poor dentition but not clear evidence of abscess or infection at RL mandible CV: regaulr rate PULM: rales/rhonchi at bilateral bases ABD: soft, NTND EXT: knee with open wound/crusted serous material surroundign wound, no pus apparent, L knee with well-healed wound, stage 2 decub over coccyx Pertinent Results: ECHOCARDIOGRAM: The left atrium is dilated. The right atrium is markedly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). 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 root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Markedly dilated and hypokinetic right ventricle. The distal apex has relatively normal function. There is moderate to severe tricuspid regurgitation, likely secondary to ventricular dilatation. At least moderate pulmonary hypertension (likely UNDERestimated - given severity of tricuspid regurgitation, the right atrial pressure is likely substantially greater than 10mm Hg.). There is evidence of pressure and volume overload of the right ventricle with a small, normally functioning left ventricle. CT HEAD: 1. Unchanged rounded 9 mm right frontal extra-axial hyperdensity, more likely representing a small meningioma than a subdural hematoma. Further evaluation by head MRI with and without contrast is suggested. 2. Resolution of previously noted gas in the masticator spaces, infratemporal fossae and temporomandibular joints. Brief Hospital Course: 78 year-old male with a history of PEs, pulmonary hypertension, COP, chronic knee infection, afib/flutter and hypothyroidism who is transferred from [**Hospital1 **] [**Location (un) 620**] with shock and acute renal failure. Shock was thought to be his end stage pulmonary hypertension and right ventricular failure which significantly improved by increasing his dose of sildenafil to 100mg tid. Family meeting held to address goals of care given the end stage nature of his disease in spite of his improvement on increased dose of sildenafil. The decision was made to transition him to home hospice. He was discharged home in stable condition with home hospice. # Goals of Care: Family meeting held to discuss goals of care and prognosis. Outcome of discussion was to attempt to wean patient off of pressors in and transition him to home hospice. Discussed medication regimen at length with team and the following decisions were made: 1. Continue sildenafil at 100mg tid to treat his RV failure, keep him off pressors and allow him to go home with hospice 2. Intravenous antibiotics were discontinued as has been no clear infection. Oral Bactrim for prophylaxis continued. 3. Weaned off stress dose steroids and will continue oral prednisone for COP. 4. Coumadin discontinued given patient was guaiac (+) as OSH given risk of bleed. Patient does have hisotry of PE while on anti-coagulation. # Shock NOS: Thought to be secondary to RV failure (chronic) and sub-optimally treated pulmonary hypertension as patient has not desired full treatment in the past. Patient with leukocytosis which is likely [**2-28**] to stress dose steroids as not clinically systemically infected. Initially on pressors which have been able to be weaned off with increased dose of sildenafil at 100mg tid. P Patient with extremely poor forward flow and has little ability to maintain blood pressures with changes in posture. Physical therapy saw him and patient was able to ambulate safely. # Hyperkalemia: Potassium elevated at 6.8 on admission. Resolved with kayexalate and lactulose. # Acute Renal Failure: Secondary to decreased perfusion in setting of shock. Improving. Renally dosed meds. Avoid nephrotoxins. Has low Ca, did not work up given goals of care. # Cryptogenic Organizing Pneumonia: Steroid dependent since [**Month (only) 359**], has been unable to wean below 10 mg daily. Was treated with stress dose steroid initially which are currently being weans down with transition to oral prednisone prior to discharge. Continued Bactrim for prophylaxis. # Leukocytosis: Stable, likely [**2-28**] steroids. # Right Total Knee Replacement: Has known chronic infection. Plain film showing free air within the joint space. Was treated with iv antibiotics on admission given concern for sepsis as cause of shock. These were discontinued given negative cultures and transition to home hospice. He was however continued on oral suppressive therapy with Augmentin and Bactrim. # Diastolie CHF: Echo showed marked RV dysfunction with RV bowing into LV as above. Prior echo in [**Month (only) 359**] showed EF 65% with some old RV dysfunction, likely from prior PEs. Also with end stage pulmonary hypertension. Fluids managed cautiously as in very delicate balance. # Multiple PEs: Had history of developing new PEs while on anticoagulation. Also has pulmonary hypertension [**2-28**] PEs on sildenafil. D/c'ed coumadin as below. Patient will follow up with pulmonary in 2 weeks and will have INR check and revisit coumadin. # Anemia: Thought to be anemia of chronic disease. Had no signs of bleeding though has guaiac pos stool in [**Location (un) 620**] ED. Baseline Hct around 32 per report. Got 1 unit pRBC at OSH, none here. # Afib/flutter: Coumadin was initially continued and then held for supratherapeutic INR. Decision was made to d/c coumadin given goals of care and transition to home hospice. Digoxin was continued as keeping patient rate controlled important for maintenance of BP and quality of life. # ECG changes: He does have S1Q3T3, though not significantly changed from prior, patient has old RBBB. Troponin mildly elevated, and some ST depression in lateral precordial leads. No CP. Not acitvely treated. Medications on Admission: [**Location (un) **] Apothecary in [**Location (un) **] [**Telephone/Fax (1) 81799**] - will need to confirm meds and doses in am Lasix 40 mg daily Viagra 25 mg TID Allopurinol 100 mg daily Bactrim DS MWF Digoxin 0.125 mg QOD Colchicine 0.6 mg prn Folate 1 mg daily Prednisone 10 mg daily Synthroid 50 mcg daily Augmentin once daily Prilosec 20 mg daily MVI Coumadin Discharge Medications: 1. 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:*6* 2. Sildenafil 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*6* 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). Disp:*30 Tablet(s)* Refills:*3* 4. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*6* 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*30 Tablet(s)* Refills:*3* 6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 7. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*6* 8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain: use for gout pain. Disp:*30 Tablet(s)* Refills:*2* 9. Synthroid 50 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*6* Discharge Disposition: Home With Service Facility: season's hospice Discharge Diagnosis: Primary: Pulmonary Hypertension Secondary: Hypothyroidism Gout CAD Hypercholesterolemia Afib/flutter Right Total Knee Replacement complicated by protracted ICU stays, on chronic suppressive antibiotics (Augmentin/Bactrim) History of Pulmonary Embolism while on coumadin Discharge Condition: Vitals stable with stable blood pressures in 80-90's at rest. On oxygen. Discharge Instructions: You were transferred to this hospital after your blood pressure was low and your oxygen requirement increased. It was eventually determined that your symptoms were due to right-sided heart failure from you long standing pulmonary hypertension. Your sildenafil was increased to 100mg three times a day and this has helped control your symptoms. You are being discharged on the following medications, all other medications should be stopped: ***PredniSONE 10 mg once a day ***Digoxin 0.125 mg every other day ***Amoxicillin-Clavulanic Acid (Augmentin) one tablet twice a day ***Sulfameth/Trimethoprim DS (Bactrim) one tab Mon, Wed, Fri ***Sildenafil (Viagra)100 mg three times a day ***Omeprazole (Prilosec) 20 mg once a day ***Levothyroxine (Synthroid) 50mcg once a day ***Allopurinol 300mg once a day ***Colchicine 0.6mg once a day as needed for gout pain You have an appointment with Dr. [**Last Name (STitle) **] who took care of you in the ICU on [**2163-3-16**] at 3pm. He will determine then whether or not to restart your coumadin and may adjust other medications. Be sure to eat a high protein diet (chicken, beef, pork, beans) and drink at least 2 cans of Ensure (or another protein shake) a day. It was a pleasure meeting you and participating in your care. Followup Instructions: PUMONOLOGY: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2163-3-16**] 3:00

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icd9cm

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[ "38.93" ]

icd9pcs

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116,403

49102

Discharge summary

report

Admission Date: [**2155-9-5**] Discharge Date: [**2155-9-11**] Date of Birth: [**2107-2-1**] Sex: M Service: IDENTIFICATION/CHIEF COMPLAINT: This is a 48 year old man with a history of hypertension, Type 1 diabetes and end stage renal disease on hemodialysis (Monday, Wednesday and Friday) who presented to the Emergency Department with hypertensive crisis. PAST MEDICAL HISTORY: 1. Diabetes times 27 years 2. End stage renal disease on hemodialysis, Monday, Wednesday and Friday 3. Diabetic retinopathy 4. Hypertension 5. Nephrolithiasis times two 6. Back surgery 7. Hernia repair MEDICATIONS ON ADMISSION: 1. Cardizem 2. Catapres 3. Insulin 15 units q AM/q PM with sliding scale for meals 4. Phoslo ALLERGIES: Minoxidil causing facial swelling HISTORY OF PRESENT ILLNESS: The patient describes being in his normal state of health until the day of admission when he felt unwell and dizzy while at work. The patient then became confused and disoriented and was given some juice and crackers for presumed hypoglycemia. Glucose was noted to be at 90 when taken by his wife. The patient was also noted to have some slurred speech and then developed some vomiting and a headache which was rated at 9 out of 10. The patient was taken to the Emergency Department by the emergency medical technicians and was found to have a blood pressure of 214/96 with a pulse of 76. In the Emergency Department the patient was treated with enteric coated Aspirin and was started on a Nitroprusside and Labetalol drip. The patient also received 21 units of insulin for his blood sugar over 300. He underwent a computerized tomography scan which demonstrated no intracranial pathology. The patient had a recent echocardiogram on [**2154-5-30**] which demonstrated left atrial enlargement and left ventricular hypertrophy. He had an ejection fraction of over 50% and trace mitral regurgitation. He also had a stress test in [**2152-10-5**] which was an exercise stress test which he was able to perform for 11 minutes achieving 80% of his maximum heart rate and had to stop secondary to fatigue. He at that time was also noted to have an ejection fraction of 54% with no wall motion abnormalities. PHYSICAL EXAMINATION: The patient was in no apparent distress and/or somewhat somnolent. He had a temperature of 101.0 with a heartrate of 86 and a blood pressure of 230/90. His respiratory rate was 16 on 5 liters of nasal cannula resulting in an oxygen saturation of 95%. Head and neck examination was unremarkable as his mucous membranes were moist. Extraocular movements intact and pupils were equal and reactive to light. His neck was supple without any lymphadenopathy and he had no meningismus. His lungs had crackles bilaterally a third of the way up from the bases without any wheezes. He had a jugulovenous pressure of 8 to 9 cm and his carotids demonstrated normal volume and upstroke. He did not have any carotid bruits. He had a regular rate and rhythm with normal S1 and S2 and no history of S4. He had a II/VI systolic ejection murmur. His abdominal examination was unremarkable and he had 1+ edema to his ankle. He had the presence of a right bruit in his forearm fistula. His neurological examination showed that he was moving all four extremities spontaneously and that he was somewhat delirious. LABORATORY DATA: The patient had a normal complete blood count and coags. His chem-7 was notable for a BUN of 59 and a creatinine of 7.9 with glucose of 514. He had normal liver function tests and his arterial blood gases was 7.41, 46 and 70. His chest film showed him to be in mild pulmonary edema. His electrocardiogram showed that he was in normal sinus rhythm at 66 with axis of -30 and T wave inversions in lead 1, AVL, V5 and V6. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit where he was continued on the Nitroprusside and Labetalol infusions. The Neurology Service was consulted after the patient was noted to have some left-sided weakness. In addition to left-sided weakness, the patient was also found to have some left-sided neglect and a left hemianopia. An magnetic resonance imaging scan was recommended at that time which did not demonstrate any distinct lesions. The patient was able to wean off of the Nitroprusside and Labetalol infusion on [**2155-9-6**]. He was then converted to oral hydralazine and Labetalol. The patient also ruled out for myocardial infarction by enzymes. Due to the nature of the patient's hypertensive crisis the patient was sent for an magnetic resonance imaging scan of his kidneys to rule out renal artery stenosis. This was performed on [**9-10**] which showed him to have no abnormality in his renal artery stenosis or with his renal arteries. The patient's blood pressure continued to be managed with Hydralazine and Labetalol. With the negative magnetic resonance imaging scan the patient was then started on Lisinopril on [**2155-9-11**]. The patient's neurologic symptoms resolved two to three days prior to discharge from the hospital. The patient was discharged from the hospital on [**2155-9-11**] in stable condition. He also underwent an echocardiogram prior to discharge. His echocardiogram demonstrated an ejection fraction of over 60% with mild left atrial enlargement, left ventricular hypertrophy and normal valves. DISCHARGE MEDICATIONS: 1. NPH insulin 15 units q. AM and 15 units q. PM followed by a sliding scale insulin t.i.d. with his meals. 2. The patient also was discharged home on Labetalol 400 mg p.o. b.i.d. 3. Hydralazine 75 mg p.o. q.i.d. 4. Lisinopril 10 mg p.o. q.d. 5. Enteric coated Aspirin 325 mg p.o. q.d. 6. Phoslo 3 packets p.o. t.i.d. with meals 7. Colace 100 mg p.o. b.i.d. 8. Dulcolax 5 to 10 mg p.o./p.r. q.h.s. prn [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 26201**] MEDQUIST36 D: [**2155-9-11**] 16:45 T: [**2155-9-11**] 17:17 JOB#: [**Job Number 39021**]

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

5394, 6031

638, 783

3811, 5371

2247, 3793

162, 380

812, 2224

402, 612

60,680

197,939

53329

Discharge summary

report

Admission Date: [**2157-5-13**] Discharge Date: [**2157-5-17**] Date of Birth: [**2073-9-11**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: syncope and exertional shortness of breath Major Surgical or Invasive Procedure: [**2157-5-13**] Aortic Valve Replacement (21mm St. [**Male First Name (un) 923**] Epic tissue) History of Present Illness: 83 year old female who presented to [**Hospital3 1443**] on [**2157-3-20**] with syncope and head trauma with laceration on forehead s/p 18 stiches, eccymosis. She had bent over to pick something up at home and blacked out. Known history of aortic stenosis with prior [**Location (un) 109**] last year of 1.5cm2. Seen by [**Doctor Last Name 5686**] this admission and had an echo- done which demonstarted worsening aortic stenosis with [**Location (un) 109**] of 0.8cm2. She was transferred to [**Hospital1 18**] for a cardiac catheterziation and surgical evaluation for an aortic valve replacement. Past Medical History: Aortic Stenosis PMH: Multiple syncopal episodes Diabetes Dyslipidemia Hypertension Urge incontinence Peptic ulcer disease Colon polyps Umbilical hernia Gout Rheumatoid arthritis Anemia Degenerative joint disease Ovarian cancer [**2124**] Mitral regurgitation Aortic stenosis Past Surgical History: Bilateral knee replacements Appendectomy Hysterectomy s/p resections of skin cancer Social History: Lives with:Alone Contact:[**Name (NI) 11556**] (daughter) Phone #[**Telephone/Fax (1) 109726**] Occupation:retired Cigarettes: Smoked no [] yes [x] Hx:quit in [**2115**] Other Tobacco use:denies ETOH: < 1 drink/week [x] [**3-15**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Father died of throat cancer at age 65, brother died of throat cancer Physical Exam: Pulse:89 Resp:13 O2 sat:97/RA B/P Right:121/62 Left:133/68 Height:5'4" Weight:184 lbs General: awake, alert, 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 [x] grade _III_ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] c/o mild R flank discomfort, tender on deep palpation Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: palp Left: palp DP Right: palp Left: palp PT [**Name (NI) 167**]: palp Left: palp Radial Right: palp Left: palp R groin c/d/i, no bleed/hematoma Carotid Bruit Right: none Left: none Pertinent Results: Intra-op TEE [**2157-5-13**] Conclusions No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate ([**2-7**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. IMPRESSION: Pre-bypass: Normal LV and RV systolic function. Mild-mod MR, severe AS, mild AI, mild-mod TR, mild [**Last Name (un) 6879**], low CO. Post-bypass: Normal LV and RV systolic function with EF>75-80%. Aortic valve peak gradients ranged between 35-40, mean 18-22mm Hg. No AI. Valve well-seated, no leaks. MR improved to mild, TR improved to mild. All finding discussed with surgeon at time of exam. PRELIMINARY REPORT developed by a Fellow. Not reviewed/approved by the Attending Echo Physician. [**2157-5-16**] 04:30AM BLOOD Hct-28.9* [**2157-5-13**] 03:33PM BLOOD WBC-13.1*# RBC-4.08* Hgb-10.2* Hct-33.2* MCV-81* MCH-25.0* MCHC-30.7* RDW-15.1 Plt Ct-250 [**2157-5-13**] 03:33PM BLOOD PT-12.2 PTT-31.6 INR(PT)-1.1 [**2157-5-17**] 04:30AM BLOOD Na-139 K-4.2 Cl-101 [**2157-5-13**] 03:33PM BLOOD UreaN-14 Creat-0.6 Na-146* K-3.3 Cl-114* HCO3-24 AnGap-11 Brief Hospital Course: The patient was brought to the Operating Room on [**2157-5-13**] where she underwent Aortic Valve Replacement with Dr. [**Last Name (STitle) **]. Cardiopulmonary Bypass time=63 minutes. Cross Clamp time= 51 minutes. 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. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. She had a brief episode of atrial fibrillation which converted to NSR with Amiodarone. She will continue on oral Amiodarone on discharge. The patient was evaluated by the physical therapy service for assistance with strength and mobility. The remainder of her hospital course was essentially uneventful. By the time of discharge on POD # 4 she was ambulating freely, the wound was healing and pain was controlled with oral analgesics. Ms.[**Known lastname 109727**] was discharged to Aberjona Nursing and rehabilitation facility. All follow up appointments were advised. Medications on Admission: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: do not exceed 6 tablets per day. Disp:*30 Tablet(s)* Refills:*0* 2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 7. tramadol 50 mg Tablet Sig: One (1) Tablet PO three 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. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 12. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 14. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily). 15. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Aberjona Nursing Center - [**Hospital1 2436**] Discharge Diagnosis: Aortic Stenosis PMH: Multiple syncopal episodes Diabetes Dyslipidemia Hypertension Urge incontinence Peptic ulcer disease Colon polyps Umbilical hernia Gout Rheumatoid arthritis Anemia Degenerative joint disease Ovarian cancer [**2124**] Mitral regurgitation Aortic stenosis Past Surgical History: Bilateral knee replacements Appendectomy Hysterectomy s/p resections of skin cancer Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2157-6-22**] at 1:00 Cardiologist Dr. [**Last Name (STitle) 5686**], [**First Name3 (LF) **] on [**2157-6-6**] at 10:45a Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 109728**],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 109729**] in [**5-12**] 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:[**2157-5-17**]

[ "V15.82", "V12.71", "V43.65", "V12.72", "443.9", "396.2", "401.9", "250.00", "433.30", "V10.83", "997.1", "V10.43", "788.31", "V85.25", "272.4", "427.31", "V15.07", "518.51", "780.2", "458.29", "V14.8", "433.10" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

8183, 8256

4519, 5901

353, 450

8682, 8838

2699, 4496

9709, 10343

1810, 1882

6810, 8160

8277, 8552

5927, 6787

8862, 9686

8575, 8661

1897, 2680

271, 315

478, 1079

1101, 1376

1501, 1794

21,072

112,884

17851+17852

Discharge summary

report+report

Admission Date: [**2105-2-10**] Discharge Date: Date of Birth: Sex: M Service: GU SURGERY The date of discharge is provisionally [**2105-2-15**]. BRIEF CLINICAL HISTORY: The patient is a 59 year old gentleman with multiple medical problems most notably advanced amyotrophic lateral sclerosis. Due to his amyotrophic lateral sclerosis, he is completely dependent on ventilatory support and has been a resident of [**Hospital1 20731**] for several years now. Starting several weeks ago, this patient's clinical course was notable for multiple episodes of urosepsis and septicemia. As part of the work-up for this, it was found that he had an atrial thick right kidney with multiple calculi and it was believed that this was a likely cause of the urosepsis. On [**1-4**], the patient grew Klebsiella in his blood which was sensitive to Amikacin. He also grew out pseudomonas in his urine which was sensitive to Zosyn. These drugs were both initiated on [**1-15**] and were in place up until the time of his surgery. On [**12-23**], the patient was evaluated by Dr. [**Last Name (STitle) 4229**] in the Clinic and it was felt that it was reasonable to remove this kidney given that renal function was estimated at less than 2% within this one kidney. Of note is this patient's current condition. He is paralyzed from the neck down due to his amyotrophic lateral sclerosis. His communication is limited through movements of his eyes and grinding his jaws. He looks upwards to indicate a yes and downward to indicate a no and grinds his jaws for dissatisfaction. He has an ocular tracking device which does allow him some additional communication. Extremely active in his care has been his brother and there have been several discussions in the past regarding code status and aggressiveness of treatment. Throughout these discussions, both the patient and his brother have remained determined that the patient receive the most aggressive of possible care for all conditions as they arise. PAST MEDICAL HISTORY: 1. Amyotrophic lateral sclerosis diagnosed at age 50 with a tracheostomy at 52 and nasogastric tube at age 52. 2. Chronic left lower lobe scarring. 3. Pulmonary embolism with IVC filter placed in [**2103-12-22**]. 4. Status post colon cancer with resection in [**2103-12-22**], with creation of colostomy at [**Hospital1 190**]. 5. Sepsis events requiring hospitalization in [**2098**] and [**2103**], both thought to be secondary to pneumonia. SOCIAL HISTORY: The patient is a former artist and painter. He has no tobacco and no intravenous drug use. He has been a [**Hospital1 700**] resident since [**2096**]. As mentioned, his brother [**Name (NI) **], is very involved. His two children, a son and daughter are minimally involved. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Noncontributory. MEDICATIONS ON PRESENTATION TO [**Hospital1 **]: 1. Amikacin 850 mg intravenously q. day started [**2105-1-15**]. 2. Ferrous sulfate 300 mg twice a day. 3. Magnesium oxide 400 mg q. day. 4. Zosyn 3.375 grams q. six since [**2105-1-16**]. 5. Potassium chloride 20 mEq by G-tube q. day. 6. Tequin 150 mg p;o q. day twice a day. 7. Senokot two tablets p.o. q. day. 8. Vitamin E 400 Units q. day. 9. Tylenol p.r.n. 10. Lactulose 15 ml via G-tube twice a day. 11. Ativan 0.5 mg intravenously q. four hours p.r.n. anxiety. 12. ProMod tube feedings at 80 cc an hour. 13. Free water 350 cc q. eight hours. 14. Ventilatory settings have been constant: SIMV of 10 to 12; tidal volume 700, PEEP 5 and oxygen content 30%. LABORATORY: Values on presentation were CBC which showed a white blood cell count 45.4, however, this was thought to be secondary to intraoperative use of steroids. Hematocrit 35.8. Platelets 376,000. Urinalysis unremarkable for blood, nitrite, protein, glucose, ketone, bilirubin, urobilin, however, greater than 50 red blood cells and greater than 1000 white blood cells. Bacteria is noted as many and yeast is noted as none. Sodium is 142, potassium 3.7, chloride 113, bicarbonate 16, BUN 22, creatinine 0.2, glucose 179. PHYSICAL EXAMINATION: Pertinent examination in the post anesthesia care unit shows a moderately obese man ventilated through a trachea. His motion is limited to his ocular motion and clenching his jaw. He is coherent and oriented and can answer questions, yes, no, indicating through his eyes. Pupils are equal, round and reactive to light. He has no evidence of any anterior or posterior lymph node adenopathy. The lungs are clear to auscultation bilaterally. Cardiac examination is unremarkable. Abdominal examination is notable for a G-tube in left upper quadrant. There is a healthy appearing colostomy with appliance in place in the left lower quadrant. There is a triple lumen subclavian catheter on his left side. Abdominal examination is soft, nontender, good bowel sounds in all four quadrants. Lower extremities are again moderately obese. There is a fair amount of swelling but in general there is no evidence of any breakdown of his skin on his back or thighs. HOSPITAL COURSE: On [**2-9**], the patient underwent his surgery without any complications. The kidney was noted to be atrophic but there was no evidence of any frank pus in the kidney. The patient was transferred to the Post Anesthesia Care Unit in stable condition. The ventilator was then rapidly returned to his home settings without any problems. On the night of postoperative day zero, a femoral arterial line was placed after several failed attempts at radial and ulnar arterial lines. Arterial blood gases on 30% oxygen showed a pH of 7.39, pCO2 of 26, pO2 of 195, bicarbonate 16 and base excess of negative seven. Otherwise, the hospital course through operative day zero was unremarkable. On postoperative day one, the patient was again stable with adequate urine output. Consideration was then turned to assessing his antibiotic coverage in light of removal of his kidney. To this effect, Infectious Disease consultation was requested. IN reviewing the patient's case in its entirety, the Infectious Disease team made note of the fact that the subclavian catheter that the patient had in place had been indeed the same catheter throughout his several septic episodes, having found not record of this having been changed. Therefore, on hospital day three, the patient was taken to Interventional Radiology and a dual lumen PICC catheter was placed in his arm. Cardiac echocardiogram and subclavian vein echocardiograms were performed to assess for any evidence of any vegetations which could have been foci for the infections and none were found. The subclavian line was then removed and several sets of surveillance blood cultures have been sent and will continue to be followed. As a final recommendation, Infectious Disease suggested that the patient's antibiotic coverage be changed from Amikacin and Zosyn to Meropenem 1 gram intravenously q. eight hours. A full course of this meropenem would be two weeks, having started this on [**2105-2-11**] and the Meropenem should be run until [**2105-2-28**]. On postoperative day three, the patient was restarted on his home benzodiazepine regimen p.r.n. On postoperative day four, the patient's tube feeds were started at a rate of 10 cc an hour of ProMod and gradually advanced to a target rate of 80 cc an hour, checking residuals every six hours. On [**2105-2-14**], the patient was evaluated by Dr. [**Last Name (STitle) 4229**] and the Intensive Care Unit Team and was felt to be a good candidate for return to his long term care facility, pending resolution of State Transfer Requirement and the patient will be transferred there. DISCHARGE DIAGNOSES: 1. In addition to prior noted diagnoses, the patient is status post right nephrectomy, urosepsis, septicemia. DISPOSITION: The patient will return to extended care facility where he can have ventilatory support. DISCHARGE MEDICATIONS: The patient will resume all of his preoperative regimen with the addition of Meropenem one gram intravenously q. eight times 14 days which would conclude [**2105-2-28**]. DISCHARGE INSTRUCTIONS: 1. The patient should arrange follow-up with Dr. [**Last Name (STitle) 4229**] within one to two weeks for a check of his wound and final confirmation of his surgical pathology. [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8916**] Dictated By:[**Last Name (NamePattern1) 6825**] MEDQUIST36 D: [**2105-2-13**] 17:37 T: [**2105-2-13**] 19:58 JOB#: [**Job Number 49517**] Unit No: [**Unit Number 49518**] Admission Date: [**2105-2-10**] Discharge Date: [**2105-2-18**] Date of Birth: [**2046-3-16**] Sex: M Service: URO BRIEF CLINICAL HISTORY: The patient is a 59-year-old gentleman with multiple medical problems, most notably advanced amyotrophic lateral sclerosis. Due to his amyotrophic lateral sclerosis, he is completely dependent on ventilatory support and has been a resident of [**Hospital1 20731**] for several years now. Starting several weeks ago, this patient's clinical course was notable for multiple episodes of urosepsis and septicemia. As part of the workup for this, it was found that he had an atrophic thick right kidney with multiple calculi, and it was believed that this was a likely cause of the urosepsis. On [**2105-1-4**], the patient grew Klebsiella in his blood, which was sensitive to amikacin. He also grew out Pseudomonas in his urine, which was sensitive to Zosyn. These drugs were both initiated on [**2105-1-15**] and were in place up until the time of his surgery. On [**2104-12-23**], the patient was evaluated by Dr. [**Last Name (STitle) 4229**] in his clinic and it was felt that it was reasonable to remove this kidney given that renal function was estimated at less than two percent within this one kidney. Of note is this patient's current condition. He is paralyzed from the neck down due to his amyotrophic lateral sclerosis. His communication is limited through movements of his eyes and grinding his jaw. He looks upwards to indicate a yes and downwards to indicate a no and grinds his jaws for dissatisfaction. He has an ocular tracking device, which does allow him some additional communication. Extremely active in his care has been his brother, and there have been several discussions in the past regarding code status and aggressiveness of treatment. Throughout these discussions, both the patient and his brother have remained determined that the patient receives the most aggressive of possible care for all conditions as they arrive. PAST MEDICAL HISTORY: Amyotrophic lateral sclerosis diagnosed at age 50 with a tracheostomy at 52 and nasogastric tube at age 52. Chronic left lower lobe scarring. Pulmonary embolism with IVC filter placed in [**11-22**]. Status post colon cancer with resection in [**11-22**], with creation of colostomy at [**Hospital1 188**]. Sepsis events requiring hospitalization in [**2098**] and [**2103**], both thought to be secondary to pneumonia. SOCIAL HISTORY: The patient is a former artist and painter. He has no tobacco and no intravenous drug use. He has been a [**Hospital1 700**] resident since [**2096**]. As mentioned, his brother, [**Name (NI) **], is very involved. His two children, a son and daughter, are minimally involved. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Noncontributory. MEDICATIONS: On presentation to [**Hospital1 190**], 1. Amikacin 850 mg IV q.d. started [**2105-1-15**]. 2. Ferrous sulfate 300 mg b.i.d. 3. Magnesium oxide 400 mg q.d. 4. Zosyn 3.375 g q.6 h. since [**2105-1-15**]. 5. Potassium chloride 20 mEq by G-tube q.d. 6. Tequin 150 mg p.o. b.i.d. 7. Senokot 2 tablets p.o. q.d. 8. Vitamin E 400 units q.d. 9. Tylenol p.r.n. 10. Lactulose 15 mL via G-tube b.i.d. 11. Ativan 0.5 mg IV q.4 h. p.r.n. anxiety. 12. ProMod tube feedings at 80 cc an hour. 13. Free water 350 cc q.8 h. 14. Ventilatory settings have been constant SIMV of 10 to 12, tidal volume 700, PEEP 5, and oxygen content 30 percent. LABORATORY DATA: Values on presentation were CBC, which showed a white blood cell count 45.4; however, this was thought to be secondary to intraoperative use of steroids. Hematocrit 35.8 and platelets 376,000. Urinalysis unremarkable for blood, nitrate, protein, glucose, ketone, bilirubin, and urobilin, however, greater than 50 RBCs and greater than 1000 WBCs. Bacteria is noted as many and yeast is noted as none. Sodium is 142, potassium 3.7 chloride 113, bicarbonate 16, BUN 12, creatinine 0.2, and glucose 179. PHYSICAL EXAMINATION: Pertinent examination in the Post- Anesthesia Care Unit shows a moderately obese man ventilated through the trachea. His motion is limited to his ocular motion and clenching his jaw. He is coherent and oriented and can answer questions, yes, no, indicated through his eyes. Pupils are equal, round, and reactive to light. He has no evidence of any anterior or posterior lymph node adenopathy. The lungs are clear to auscultation bilaterally. Cardiac examination is unremarkable. Abdominal examination is notable for a G-tube in the left upper quadrant. There is a healthy-appearing colostomy with appliance in place in the left lower quadrant. There is a triple-lumen subclavian catheter on his left side. Abdominal examination is soft, nontender, good bowel sounds in all four quadrants. Lower extremities are again moderately obese. There is a fair amount of swelling, but in general, there is no evidence of any breakdown of his skin on his back or his thighs. HOSPITAL COURSE: On [**2105-2-9**], the patient underwent a surgery without any complications. The kidney was noted to be atrophic, but there was no evidence of any frank pus in the kidney. The patient was transferred to the Post- Anesthesia Care Unit in stable condition. The ventilator was then rapidly returned to his home settings without any problems. On the night of postoperative day zero, a femoral arterial line was placed after several failed attempts at radial and ulnar arterial lines. Arterial blood gas on 30 percent oxygen showed a pH of 7.39, pCO2 of 26, pO2 of 195, bicarbonate 16, and base excess of negative 7. Otherwise, the hospital course through operative day zero was unremarkable. On postoperative day one, the patient was again stable with adequate urine output. Consideration was then turned to assessing his antibiotic coverage in light of removal of his kidney. To this effect, Infectious Disease consultation was requested. In reviewing the patient's case in its entirety, the Infectious Disease team made note of the fact that the subclavian catheter that the patient had in place had been indeed the same catheter throughout the several septic episodes, having found no record of this having been changed. Therefore, on hospital day three, the patient was taken to Interventional Radiology and a dual lumen PICC catheter was placed in his arm. Cardiac echocardiogram and subclavian vein echocardiogram were performed to assess for any evidence of any vegetation, which may have been foci for the infection and none were found. The subclavian line was then removed and several sets of surveillance blood cultures had been sent and will continue to be followed. As a final recommendation, Infectious Disease suggested that the patient's antibiotic coverage be changed from amikacin and Zosyn to meropenem 1 g IV q.8 h. A full course of his meropenem would be two weeks, having started this on [**2105-2-11**], and the meropenem should be run until [**2105-2-28**]. On postoperative day three, the patient was restarted on his home benzodiazepine regimen p.r.n. On postoperative day four, the patient's tube feeds were started at a rate of 10 cc an hour of ProMod and gradually advanced to a target rate of 80 cc an hour, checking residuals every six hours. On [**2105-2-14**], the patient was evaluated by Dr. [**Last Name (STitle) 4229**] and the Intensive Care Unit Team and was felt to be a good candidate to return to his long-term care facility. The patient was then transferred to his long-term care facility on [**2105-2-18**]. [**Name6 (MD) **] [**Last Name (NamePattern4) 8918**], [**MD Number(1) 19072**] Dictated By:[**Last Name (NamePattern1) 15649**] MEDQUIST36 D: [**2105-5-29**] 18:24:33 T: [**2105-5-29**] 22:43:47 Job#: [**Job Number 32695**]

[ "V44.1", "591", "335.20", "V44.3", "344.00", "592.0", "V44.0", "590.00", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "96.6", "55.51", "38.91", "96.72" ]

icd9pcs

[ [ [] ] ]

11536, 12750

7770, 7987

8011, 8183

13767, 16593

8207, 10719

12773, 13749

10742, 11167

11184, 11519

24,533

112,226

30838

Discharge summary

report

Admission Date: [**2175-6-10**] Discharge Date: [**2175-6-20**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Ceftriaxone Attending:[**First Name3 (LF) 3507**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo female with hx of HTN, afib, ? PE, multiinfarct dementia and recurrent UTI who presents with lethargy, hypoxia, and LE erythema. Pt is aphasic at baseline. Per notes from ED and PCP coverage, the patient was being treated for recurrent UTI with a course of levofloxacin started on [**6-7**] but was otherwise doing well. Last night she was noted to be more lethargic than normal with increasing SOB. She was noted to be hypoxic with O2 Sats of 80% so was transferred to the ED. In the ED she had a fever to 101.8 with intermittent hypoxia that improved to 98% with 4LNS oxygen . She was given Clindamycin 600mg IV x1 for LE cellulitis and a dose of Levofloxacin 500mg IV for possible UTI. For her hypoxia, she was given 20mg IV Lasix and a combivent neb with significant improvement with CTA neg for PE and LENI neg for DVT. She continued to have intermittent hypoxia of unclear etiology so was transferred to the [**Hospital Unit Name 153**] for closer monitoring. . In the MICU, the patient was treated with CTX and Vanc for UTI/cellulitis. Also diuresed. Patient improved and sent to floor [**6-11**] on 2L NC. Patient noted to have increased Eos in blood and urine so CTX stopped and placed on levo/macrodantin. . [**6-13**] Patient decompenstated on the floor. Patient desatted to 80's on 6L NC. ABG 7.46/52/63 on 6L NC. Patient initially with HR in 80's. Patient given lasix 20mg IV x 1 and an alb neb. Then went into afib with RVR into the 140's maintaining her pressure. Patient given 5mg IV lopressor x 3 with out response in HR. Transferred back unit for further mgt of HR and hypoxia, where she was started on a diltiazem drip; CTA was without evidence of PE. Course complicated by persistent hypotension requiring multiple fluid boluses; this resolved after the discontinuation of the diltiazem drip. She was started on an amiodarone load with conversion into NSR. Her O2 sat improved with diuresis. A picc line was placed and she was started on aztreonam (instead of macrobid) for UTI. She was transferred back to the general medical floor on [**2175-6-16**]. Currently, she has a new rash over her trunk and arms bilaterally--thought to be from Ceftriaxone. Past Medical History: CVA-with multiinfarct dementia-aphasic at baseline Afib UTI Zoster-L thorax Syncope PE Hypothyroidism DJD Social History: Divorced, lived alone in [**Location (un) 7349**] until fall at home with hip fx then moved to NH here in [**Location (un) 86**] because son lives in [**Name (NI) 392**], had CVA at [**Name (NI) **], never smoker, no ETOH, no illicits. Family History: NC Physical Exam: T 98 HR 93 BP 100/37 RR 24 O2Sat 99 (3LNC) Gen: chronically ill, in bed listing to left side, NAD HEENT: R nasolabial flattening, Edentulous, Dry MM, Neck: JVP to mandible Heart: regular with occasional premature beats, no MRG, no heave, not parvus et tardus Lungs: Marked kyphosis, Bilateral crackles throughout, decreased breath sounds at R base- not dull to percussion. Abd: soft, NT, ND, BS+ Extrem: 2+ LLE with erthema to midshin, 1+ RLE, 1+ DP pulses bilaterally. Neuro: expressive aphasia- unintelligable speech, follows verbal commands "close your eyes" "wiggle your toes" Pupils 2-->1cm bilaterally, arcus senilis, moving all 4 extremities. Skin: Large 3x4cm SK's over thorax, crusted raised lesions in T4 distribution on Left back and chest. Pertinent Results: [**2175-6-10**] CT CHEST: 1. No evidence of acute pulmonary embolism, aortic aneurysm, or dissection. 2. No evidence of pneumonia. 3. Midthoracic vertebral body compression fracture likely chronic. 4. Calcified left lung granuloma and mediastinal lymph node consistent with old granulomatous disease, such as tuberculosis. 5. Moderate-sized hiatal hernia. . [**2175-6-10**] BILAT LOWER EXT VEINS: No evidence of DVT. . [**2175-6-10**] CT HEAD: Slightly limited study by patient motion, but no intracranial hemorrhage is identified. . [**2175-6-10**] CXR: No evidence of pneumonia or CHF. . [**2175-6-10**] ECG: Technically difficult study Sinus tachycardia Left ventricular hypertrophy Early R wave progression Lateral ST-T changes are probably due to ventricular hypertrophy Clinical correlation is suggested No previous tracing available for comparison . [**2175-6-13**] CTA CHEST: 1. No pulmonary embolism. 2. Right lower lobe atelectasis/consolidation with tiny bilateral pleural effusions. 3. Moderate hiatal hernia. 4. Unchanged calcified mediastinal lymph node. . [**2175-6-13**] CXR: Small bilateral pleural effusions without overt CHF/pulmonary edema and no evidence for new pneumonia. Calcified granuloma and node on left. Osteoporosis of spine with compression fractures. . [**2175-6-13**] ECG: Sinus rhythm @ 78 with atrial premature beats. Left ventricular hypertrophy. Since the previous tracing of [**2175-6-10**] probably no significant change, although baseline artifact on both tracings makes comparison difficult. TRACING #1 . [**2175-6-13**] ECG: Atrial fibrillation with a rapid ventricular response. Left ventricular hypertrophy. Non-specific ST-T wave changes. Since the previous tracing of [**2175-6-13**] atrial fibrillation and ST-T wave changes are present. TRACING #2 . [**2175-6-14**] FLUORO: Successful repositioning of the right-sided PICC which now terminates in the distal SVC. Line is ready for use. . [**2175-6-14**] ECHO: The left atrium is mildly dilated. The estimated right atrial pressure is 16-20 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 70-80%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Impression: hypertrophic, hyperdynamic left ventricle . [**2175-6-16**] CXR: Lung volumes have improved, borderline interstitial edema decreased, heart size normal, but left atrium likely enlarged. Stable pulmonary vascular congestion. Small right pleural effusion may also have decreased. Leftward tracheal deviation just above the thoracic inlet is due to tortuous head and neck vessels. . [**2175-6-11**] 8:35 am URINE Source: Catheter. URINE CULTURE (Final [**2175-6-12**]): NO GROWTH. . [**2175-6-10**] 03:15AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2175-6-10**] 03:15AM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2175-6-10**] 03:15AM URINE RBC-[**7-23**]* WBC->50 Bacteri-RARE Yeast-NONE Epi-[**4-17**] [**2175-6-12**] 06:31PM URINE Eos-POSITIVE [**2175-6-11**] 08:35AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 [**2175-6-11**] 08:35AM URINE Blood-LGE Nitrite-NEG Protein-100 Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2175-6-11**] 08:35AM URINE RBC-88* WBC-2 Bacteri-FEW Yeast-NONE Epi-0 [**2175-6-10**] 03:15AM BLOOD WBC-17.6* RBC-3.73* Hgb-11.3* Hct-34.2* MCV-92 MCH-30.4 MCHC-33.1 RDW-13.8 Plt Ct-229 [**2175-6-10**] 03:15AM BLOOD Neuts-84* Bands-9* Lymphs-2* Monos-2 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2175-6-10**] 03:15AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Stipple-OCCASIONAL [**2175-6-10**] 03:15AM BLOOD Plt Ct-229 [**2175-6-10**] 03:15AM BLOOD Glucose-144* UreaN-19 Creat-0.8 Na-138 K-4.5 Cl-99 HCO3-30 AnGap-14 [**2175-6-10**] 03:15AM BLOOD ALT-11 AST-21 AlkPhos-101 Amylase-23 TotBili-0.4 [**2175-6-10**] 03:15AM BLOOD Lipase-17 [**2175-6-10**] 03:15AM BLOOD CK-MB-2 cTropnT-0.03* [**2175-6-10**] 10:30AM BLOOD CK-MB-NotDone proBNP-1148* [**2175-6-10**] 10:30AM BLOOD cTropnT-0.03* [**2175-6-10**] 04:41PM BLOOD CK-MB-2 cTropnT-0.03* proBNP-1259* [**2175-6-10**] 03:15AM BLOOD Albumin-3.6 Phos-3.4 Mg-2.1 [**2175-6-10**] 11:55AM BLOOD Type-ART pO2-101 pCO2-49* pH-7.43 calTCO2-34* Base XS-6 Intubat-NOT INTUBA [**2175-6-10**] 03:34AM BLOOD Lactate-1.9 . [**2175-6-11**] 10:15AM BLOOD WBC-10.2 RBC-3.35* Hgb-10.5* Hct-31.9* MCV-95 MCH-31.2 MCHC-32.8 RDW-13.1 Plt Ct-211 [**2175-6-11**] 10:15AM BLOOD Neuts-73.5* Lymphs-12.2* Monos-1.0* Eos-12.2* Baso-0 Atyps-1.0* [**2175-6-11**] 10:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2175-6-11**] 10:15AM BLOOD PT-14.3* PTT-32.3 INR(PT)-1.3* [**2175-6-11**] 10:15AM BLOOD Plt Smr-NORMAL Plt Ct-211 [**2175-6-11**] 05:54AM BLOOD Glucose-95 UreaN-15 Creat-0.6 Na-140 K-3.6 Cl-101 HCO3-31 AnGap-12 [**2175-6-11**] 05:54AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.2 . CT Head FINDINGS: There is no intracranial hemorrhage, mass effect, hydrocephalus, or shift of normally midline structures. Ventricular prominence is unchanged, consistent with moderate cortical atrophy. Focal hypodensities in the left parietal lobe, coronal radiata, and frontal lobe are unchanged, representing chronic infarction. More diffuse hypodensities in the periventricular white matter are unchanged, and most consistent with chronic small vessel ischemic disease. Surrounding osseous and soft tissue structures are unremarkable. . IMPRESSION: No significant change since [**2175-6-10**]. Unchanged appearance of several left-sided chronic infarcts, and small vessel ischemic disease. No intracranial hemorrhage. . [**2175-6-20**] 06:10AM 98 13 1.3* 141 4.0 100 36* 9 . CXR [**6-19**]: IMPRESSION: Slight interval improvement in pulmonary vascular congestion, otherwise no significant interval change. Brief Hospital Course: A/P: [**Age over 90 **] yo female with hx of HTN, afib, PE, multinfarct dementia admitted with UTI, left leg cellulitis, and diastolic CHF; course c/b AF with RVR. . #Diastolic CHF: initially due to infection, worsened by AF with RVR and fluid resuscitation, was continued on Lasix with good diuresis. Needs serial assesments of volume status/weights at her nursing home with her lasix titrated accordingly. Low dose ACE was added. No evidence of ACS. Lasix held on day of d/c secondary to bump in Cr (.8-->1.3). Needs serial Chem 7 at her nursing home. Currently has minimal oxygen requirements. . #AF: Now in NSR on amiodarone and Lopressor 12.5 TID. Needs one more week of Amio 200 [**Hospital1 **] then 200 mg daily. Poor anticoagulation candidate given fall risk and advanced age. . #UTI: Pt has received 7 days of treatment (CTX, macrodantin, aztreonam) for E. coli UTI; d/c'd aztreonam/ctx given rash. . #LLE Cellulitis: resolved with 10 days of vancomycin. . #Rash: suspect secondary to ceftriaxone or aztreonam. Resolving. . #Dementia: pt noted to be more somnolent on [**6-19**]; CT head/ABG/toxic-metabolic w/u unrevealing. ?secondary to benadryl (from rash) along with neurontin. Would avoid sedating meds until MS completely back to baseline. No evidence of recurrent infection. Medications on Admission: Ciprofloxacin 250mg [**Hospital1 **] Amoxicillin 500mg PO tid ? d/c'ed Lopressor 25mg tid Lasix 40mg alt 20mg qd held Neurontin 100mg [**Hospital1 **] Levofloxacin 250mg qd-started on Tylenol prn Erythromycin eye ointment Levalbuterol Nebs q6h prn Nortryptilline 25mg qhs MVI Digoxin 0.125mg qd KCl 10 meq qd Celexa 10mg qd Colace Levothyroxine 50mcg qd Macrodantin 50mg qid-completed Discharge Medications: 1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 100 mg Tablet Sig: One (1) Tablet PO twice a day: Pleaes hold for somnolence. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours: hold for SBP <110 or HR <55 . 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Please alternate with 20 mg daily to start [**6-21**]. 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: to begin after one week of [**Hospital1 **]. Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay Skilled Nursing Facility Discharge Diagnosis: Left Lower Extremity Cellulitis Urinary Tract Infection Diastolic Dysfunction/Congestive Heart Failure Atrial Fibrillation Drug Rash Secondary Diagnoses: CVA-with multiinfarct dementia-aphasic at baseline h/o Zoster-L thorax Hypothyroidism DJD Discharge Condition: Stable Discharge Instructions: Please come back to the emergency room should you develop any fevers, chills, chest pain, shortness of breath, difficulty thinking, or any other complaints. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] within the next two weeks.

[ "428.33", "E930.8", "E849.7", "401.9", "599.0", "458.9", "553.3", "437.0", "288.3", "682.6", "427.31", "693.0", "715.90", "428.0", "290.40", "244.9", "438.11", "511.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

12816, 12899

9995, 11301

246, 252

13188, 13197

3667, 4102

13402, 13484

2875, 2879

11737, 12793

12920, 13054

11327, 11714

13221, 13379

2894, 3648

13075, 13167

203, 208

280, 2476

4111, 9972

2498, 2606

2622, 2859

15,480

177,622

29214

Discharge summary

report

Admission Date: [**2185-11-29**] Discharge Date: [**2185-12-7**] Date of Birth: [**2123-4-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: transfer from OSH for STEMI Major Surgical or Invasive Procedure: cardiac catheterization with stent to left circumflex artery and ballon angioplasty to OM1 History of Present Illness: 62 year old gentleman was is transferred from an outside hosptial for urgent catheterization. He presented to Caritas [**Hospital3 **] with 7/10 SSCP, STE of inf leads and depression of ant and lat leads. He was given ASA, originally started on NTG gtt and integrillin gtt. In their ED he had VT/VF for which he was DC cardioverted 10 times and placed on Amio and lido gtts. He was intubated and sent via [**Location (un) **] for cardiac cath. Briefly recieved CPR for pulseless VT while being transported via med flight. His PMH is sig for type II DM, HTN, Hypercholestrolemia, ? CVA s/p L CEA. Of note hx of L leg Art thrombosis s/p toe amputations on coumadin. In the cath lab he was found to have a L dom system with total prox occlusion of his Lcx and had successful PCI of the lesion with a stent and subsequnt ballooning of his OM1. He required Dopamine Gtt and IABP Amio and Lido gtt throughout the course of his cath. His HD showed CI 4.75 with PCWP 24. He was sent to the CCU intubated, on integrillin gtt with IABP, dopa, amio gtt. He was given 600 mg plavix through NGT. Past Medical History: HTN DM II (diet controlled) L foot Art thrombosis s/p L 4&5th Toe amputations s/p L CEA Social History: Hx of tobacco use, quit smoking Family History: Father died of MI at age 49 Physical Exam: gen- sedated, intubated lying in bed in NAD vs- 94.9 83 124/60 20 93% on 100 % FIO2 heent- nc/at, eomi, perrl, mmm neck- supple, unable to assess jvp, no lad, no thyromegaly, no bruits cv- normal s1, s2, no m/r/g Abd- mildly obese, soft, nt Ext- trace b/l le edema, no cyanosis, 2+ dp/Pt pulses b/l, s/p l [**4-27**] toe amputations. L groin site minimal oozing, R sheath/ Aline without bleeding or hematoma Rectal- Heme - per OSH ED note Pertinent Results: [**12-5**] Echo- LVEF 40% Conclusions: The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with basal to mid inferior and infero-lateral hypokinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2185-11-30**], no major change. . [**11-30**] Echo- LVEF 40% Conclusions: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with inferior and infero-lateral hypokinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2185-11-29**], overall LVEF appears lower. . [**11-29**] Echo- LVEF 50-55%, Mild inf/inferolat hypokinesis, 1+ MR, no AI. Normal RV function. . [**12-4**] CXR (2-view)- There is no significant interval change. There is again seen small bilateral pleural effusions. There is mild prominence of the pulmonary vascular markings without overt pulmonary edema. Vascular pedicle is not widened and the cardiac silhouette is normal. . [**11-30**] CXR- Bilateral edema/infiltrates, normal size heart . [**11-29**] EKG- Sinus brady, > 50% resolution of Inf ST elevations. V1-V5 ST depressions persistent. Q waves in inf leads . [**11-29**] Cath- COMMENTS: 1. Selective coronary angiography in this left dominant system revealed one vessel coronary artery disease. The LMCA, LAD and RCA had no significant disease. The LCx was totally occluded proximally. THere was a large thrombus burden that extended into OM1. 2. Left ventriculography was deferred. 3. Hemodynamics demonstrated a mean RA pressure of 12 mmHg. Pulmonary artery systolic hypertension was noted. The PA pressure was 59/24 mmHg. Central aortic pressure was 87/60 with a mean of 74 (all mmHg). Pulmonary capillary wedge pressure was 24 mmHg. Cardiac output was elevated at 10.1 L/min (index of 4.75 l/min/m2). 4. An intra aortic balloon pump was placed in the left femoral artery. 5. Successful thrombectomy and PCI of a dominant circumflex system with placement of a 3.0x33mm bare metal stent in the proximal to mid AV groove circumflex coronary artery. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Intra aortic ballon pump placement. 3. Successful PCI of a dominant circumflex coronary artery using a 3.0x33mm bare metal stent. (see ptca comments for further details) . Hematology: [**2185-11-29**] 06:19PM HGB-14.8 calcHCT-44 O2 SAT-93 [**2185-11-29**] 06:19PM GLUCOSE-252* LACTATE-1.5 NA+-133* K+-3.8 [**2185-11-29**] 06:19PM PO2-76* PCO2-50* PH-7.19* TOTAL CO2-20* BASE XS--9 [**2185-11-29**] 08:41PM PLT COUNT-327 [**2185-11-29**] 08:41PM WBC-24.6* RBC-4.97 HGB-14.6 HCT-42.9 MCV-86 MCH-29.5 MCHC-34.1 RDW-13.8 . Chemistry: [**2185-11-29**] 08:41PM CORTISOL-45.4* [**2185-11-29**] 08:41PM CALCIUM-8.2* PHOSPHATE-3.9 MAGNESIUM-2.5 [**2185-11-29**] 08:41PM ALT(SGPT)-170* AST(SGOT)-486* LD(LDH)-1406* ALK PHOS-94 TOT BILI-0.6 [**2185-11-29**] 08:41PM GLUCOSE-304* UREA N-32* CREAT-1.1 SODIUM-138 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-17* ANION GAP-18 [**2185-11-29**] 08:46PM O2 SAT-89 [**2185-11-29**] 08:46PM GLUCOSE-285* [**2185-11-29**] 08:46PM TYPE-ART TEMP-34.4 RATES-12/ TIDAL VOL-600 PEEP-5 O2-100 PO2-53* PCO2-41 PH-7.27* TOTAL CO2-20* BASE XS--7 AADO2-648 REQ O2-100 -ASSIST/CON INTUBATED-INTUBATED [**2185-11-29**] 08:51PM O2 SAT-71 [**2185-11-29**] 08:51PM TYPE-MIX [**2185-11-29**] 09:53PM TYPE-MIX [**2185-11-29**] 11:30PM CK-MB-GREATER TH [**2185-11-29**] 11:30PM CK(CPK)-7871* [**2185-11-29**] 11:30PM POTASSIUM-3.8 Brief Hospital Course: 62M h/o DM II, HTN, Hyperlipidemia, who presented to an OSH with SSCP with inferolateral STEMI who had subsequent episodes of monomorphic and polymorphic VT s/p DCCV x 10 OSH. . # CAD- The patient was taken directly to the cath lab where he received a BMS to LCx (3.0 x 33) with eventual TIMI III flow. He also had a POBA to the OM 1. He presented in cardiogenic shock and an IABP was placed and the patient was on a dopamine drip for two days. By day 2 post intervention, the dopamine had been weaned off, the IABP was removed and the patient was extubated. He was maintained on ASA 325, Plavix 75 and started on a low dose BB. Statin was initially held due to mildly elevated LFTs in setting of MI, but was started on 10mg lipitor prior to discharge. Recommend follow-up LFTs as an outpatient. . # Rhythm- The patient had sustained mono and polymorphic VT/VFib and was DCCV x 10 prior to arrival at [**Hospital1 18**]. He was started on an amio gtt for supression of ventricular ectopy. On day 2 post intervention, the patient had two episodes of stable sustained monomorphic VT at a rate of 120-130 and converted with an amio bolus both times. As these episodes were monomorphic with a slow rate, it was not likely to be attributed to ischemia but rather idioventricular arrythmia secondary to reperfusion. This raised questions about further episodes of VT and therefore the need for possible ICD placement. The amio drip was increased and EP was consulted. His electrolytes were aggressively monitored and repleted. He had one episode of 4 beat NSVT but otherwise no further arrythmias during stay. Outpatient f/u evaluation with EP was arranged prior to discharge. . # Pump- The patient was in cardiogenic shock with BP maintained on a dopamine drip and IABP x 2 days. An echo done the day after his intervention on dopamine showed LVEF 40% with mild inf-inferolat hypokinesis. Dopamine was eventually weaned off and the IABP was pulled on day 2. Repeat echo off dopa revealed LVEF 40%. As his wedge pressure was high coming out of the cath lab, he was diuresed with IV lasix. Once his BP had stabilized off of the balloon pump and dopamine, a low dose BB was started which he tolerated well. . # Pulm- The patient was intubated for cardiogenic shock. A CXR done on the day of admission showed diffuse bilateral infiltrates/edema. He was extubated on day two s/p intervention. He was weaned off supplemental oxygen with subsequent diuresis. However, cont to have productive cough and low-grade fevers. Concern for PNA. Started on ceftriaxone IV with resolution of fevers. Transitioned to cefpodoxime prior to discharge to complete 10 day course for CAP. . # DM II- Blood sugars in 300's at presentation and started on insulin gtt for tight blood sugar control. Had anion Gap of 14 x 2 and was acidotic. DKA was ruled out. FS eventually well-controlled and transitioned to ISS which was discontinued prior to discharge. He is diet-controlled at baseline and will f/u with PCP for further management. . # Transaminitis- Likely [**2-24**] MI. No evidence for shock liver as Cr stable and BP stable. LFTs improved but cont to have AST and ALT in 50's. Started on low-dose atorvastatin. Will need oupatient LFT monitoring. . # AG metabolic acidosis: Pt presented with mild lactic acidosis (lactate 2.4) from low CI/perfusion during cardiogenic shock. AG resolved, glucose WNL. . # h/o arterial thrombosis: coumadin initially held given multiple lines, IABP. restarted on heparin gtt bridge to coumadin prior to discharge. goal INR [**2-25**]. coumadin increased compared to home dose. INR level to be checked Friday [**2185-12-9**] at usual outpatient lab and followed by PCP. Medications on Admission: Tricor 145 qd Vytorin 10/40 Atenolol 25 qd Coumadin 5 qd nifedipine XR 60 qd ASA 81 qd Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day/Year **]:*30 Tablet(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day/Year **]:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day/Year **]:*30 Tablet(s)* Refills:*2* 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. [**Month/Day/Year **]:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day/Year **]:*30 Tablet(s)* Refills:*2* 6. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 4 days. [**Month/Day/Year **]:*16 Tablet(s)* Refills:*0* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day/Year **]:*30 Tablet(s)* Refills:*2* 8. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). [**Month/Day/Year **]:*30 Tablet(s)* Refills:*2* 9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual prn as needed for chest pain: call your doctor. [**Last Name (Titles) **]:*30 tablets* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: ST elevation Myocardial infarction Discharge Condition: Good Discharge Instructions: 2gm sodium diet call your doctor if your weight increases by > 3 pounds please take all medications as prescribed . Please call your PCP or return to the hospital if you experience any shortness of breath, chest pain, nausea, vomiting, or any other symptoms that concern you. . You have had a heart attack with stents placed in you coronary arteries. You must take aspirin and plavix every day to prevent stent thrombosis. Failure to do this could be life threatening. Followup Instructions: Contact the appropriate provider with any questions or if you need to reschedule . Please call to schedule a follow up appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12593**], 1-2 weeks after discharge. You must have your INR level checked on Friday [**2185-12-9**]. . Please schedule an appointment with your cardiologist, Dr. [**First Name (STitle) 3646**], in [**4-28**] weeks. . Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2186-1-20**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "250.00", "414.01", "482.89", "V49.72", "428.0", "276.2", "427.1", "785.51", "401.9", "410.21" ]

icd9cm

[ [ [] ] ]

[ "37.61", "37.23", "96.71", "00.66", "00.41", "88.56", "36.06", "00.45", "97.44" ]

icd9pcs

[ [ [] ] ]

12061, 12144

7043, 10723

344, 436

12223, 12230

2236, 5588

12747, 13440

1727, 1757

10860, 12038

12165, 12202

10749, 10837

5605, 7020

12254, 12724

1772, 2217

277, 306

464, 1549

1571, 1661

1677, 1711

45,949

131,126

42686

Discharge summary

report

Admission Date: [**2106-12-5**] [**Month/Day/Year **] Date: [**2106-12-9**] Date of Birth: [**2039-2-8**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: Chest tube thoracostomy History of Present Illness: 67 year old male transferred from [**Hospital1 **] [**Location (un) 620**] for further care following a mechanical fall while walking down a flight of stairs while using crutches last evening. He slipped down about 5 steps and fell forward and his head broke through the drywall and he landed on his left side. There was no LOC and the fall was witnessed by his family. He endorses alcohol consumption that evening and was using crutches due to the pain and unsteadiness resulting from a recently diagnoses [**Hospital Ward Name **] cyst. He initially denied any chest pain, shortness of breath, headache, neck pain or any other musculoskeletal pains; however, while in the ER he had described some discomfort in the left posterolateral chest. The pain scale has been [**6-20**], worse with movements which also led to mild shortness of breath. He was given IV morphine for pain control and underwent a Chest CT which showed left sided [**1-17**] rib fractures as well as a moderately sized left pneumothorax. Additionally he had a 1cm scalp laceration on the left side of the head that was closed with 3 surgical staples in the ED. Patient was admitted to the ICU for closer monitoring and was noted to have oxygen desaturation. This morning he underwent bronchoscopy with removal of mucus from the airway and placement of a left sided chest tube which successfully evacuated the pneumothorax. His respiratory status improved be he continues to require a non-rebreather face mask at 15L 02. An epidural was attempted to be place at [**Hospital1 **] [**Location (un) 620**] but without good effect. He was kept on a morphine PCA and continues to report discomfort with deep inspiration or coughing. ________________________________________________________________ Past Medical History: GERD, Hypertension, Hyperlipidemia PAST SURGICAL HISTORY: craniotomy for a nail gun injury 25 years ago at [**Hospital1 2025**]. Social History: Lives with wife Family History: Noncontributory Physical Exam: Temp: 96.3 HR: 68 BP: 129/68 RR: 14 O2 Sat: 92% non-rebreather at 15L 02 GENERAL [ ] All findings normal [ ] WN/WD [X] NAD [X] AAO [X] abnormal findings: Somnolent HEENT [ ] All findings normal [ ] NC/AT [X] EOMI [X] PERRL/A [X] Anicteric [ ] OP/NP mucosa normal [ ] Tongue midline [ ] Palate symmetric [ ] Neck supple/NT/without mass [X] Trachea midline [X] Thyroid nl size/contour [X] Abnormal findings: Small laceration on left temple and a roughly 1cm laceration on left scalp closed with 3 surgical staples. RESPIRATORY [ ] All findings normal [ ] CTA/P [ ] Excursion normal [ ] No fremitus [ ] No egophony [ ] No spine/CVAT [X] Abnormal findings: Inspiratory wheezes, short, shallow respirations, unable to produce a strong cough; Subcutaneous emphysema palpable on left chest below the clavicle; chest tube in place to -20mm Hg suction without evidence of air leak. No [**Hospital1 **]. CARDIOVASCULAR [x] All findings normal [ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema [ ] Peripheral pulses nl [ ] No abd/carotid bruit [ ] Abnormal findings: GI [x] All findings normal [ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia [ ] Abnormal findings: GU [x] Deferred [ ] All findings normal [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] All findings normal [ ] Strength intact/symmetric [ ] Sensation intact/ symmetric [ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact [ ] Cranial nerves intact [ ] Abnormal findings: MS [x] All findings normal [ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl [ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl [ ] Nails nl [ ] Abnormal findings: LYMPH NODES [x] All findings normal [ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl [ ] Inguinal nl [ ] Abnormal findings: SKIN [x] All findings normal [ ] No rashes/lesions/ulcers [ ] No induration/nodules/tightening [X] Abnormal findings: Subcutaneous air over left chest as noted above PSYCHIATRIC [x] All findings normal [ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect [ ] Abnormal findings: Pertinent Results: STUDIES: Chest CT scan Date: [X] outside film [**Hospital1 **] [**Location (un) 620**] Impression: 1. ACUTE LEFT LATERAL SECOND THROUGH SIXTH RIB FRACTURES AS DESCRIBED ABOVE WITH RESULTANT LEFT PNEUMOTHORAX, SMALL LEFT LINGULAR PULMONARY CONTUSION, AS WELL AS LEFT ANTERIOR AND LATERAL CHEST WALL SUBCUTANEOUS EMPHYSEMA, AS DESCRIBED ABOVE. 2. SEQUELA OF PRIOR GRANULOMATOUS DISEASE, AS DESCRIBED ABOVE. 3. POSTTRAUMATIC DEFORMITY OF THE LEFT CLAVICLE AND LEFT SCAPULA. CT Head: Date: [**2106-12-4**] [x] [**Hospital1 **] [**Location (un) 620**] IMPRESSION: NO ACUTE HEMORRHAGE. CRANIECTOMY DEFECTS. Other CT C-spine Date: [**2106-12-4**] [X] [**Hospital1 **] [**Location (un) 620**] IMPRESSION: NO FRACTURE SEEN. DEGENERATIVE CHANGES. LEFT APICAL PNEUMOTHORAX. Chest X-ray Date: [**2106-12-5**] [X] [**Hospital1 **] [**Location (un) 620**] IMPRESSION: EVACUATION OF PNEUMOTHORAX POST-CHEST TUBE PLACEMENT Chest X-ray Date: [**2106-12-5**] Preliminary Read: No persistent pneumothorax, CT in place, mild left sided pleural effusion. [**2106-12-5**] 09:11PM TYPE-ART PO2-69* PCO2-40 PH-7.42 TOTAL CO2-27 BASE XS-0 [**2106-12-5**] 09:11PM GLUCOSE-156* LACTATE-2.3* [**2106-12-5**] 08:44PM GLUCOSE-160* UREA N-30* CREAT-1.0 SODIUM-137 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-14 [**2106-12-5**] 08:44PM CK(CPK)-1046* [**2106-12-5**] 08:44PM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-1.9 [**2106-12-5**] 08:44PM WBC-24.8* RBC-3.92* HGB-12.4* HCT-37.1* MCV-95 MCH-31.7 MCHC-33.5 RDW-12.1 [**2106-12-5**] 08:44PM PLT COUNT-202 [**2106-12-5**] 08:44PM PT-12.8* PTT-29.5 INR(PT)-1.2* [**2106-12-9**] 09:00AM BLOOD WBC-9.5 RBC-3.77* Hgb-11.9* Hct-35.7* MCV-95 MCH-31.5 MCHC-33.3 RDW-11.9 Plt Ct-230 [**2106-12-9**] 09:00AM BLOOD Plt Ct-230 [**2106-12-6**] 04:23AM BLOOD Glucose-128* UreaN-35* Creat-1.1 Na-136 K-4.5 Cl-105 HCO3-24 AnGap-12 [**2106-12-8**] 05:27AM BLOOD CK(CPK)-175 Brief Hospital Course: He was admitted to the Acute Care Surgery team for management of his rib fractures and pneumothorax. He was given intravenous narcotics initially for pain control and was later changed to oral pain medications as his pain improved. Serial chest xrays were followed and the chest tube was pulled on HD #3. The post pull chest xray revealed a small apical pneumothorax along with some atelectasis and small effusion. Clinically he required [**1-14**] liters nasal oxygen which was gradually weaned off; he was also given nebulizers and incentive spirometer which improved his overall respiratory status. On day of [**Month/Day (3) **] the xray showed that the previously seen pneumothorax was stable. At time of [**Month/Day (3) **] he is also tolerating a regular diet and ambulating independently. His home medications were restarted and his pain is well controlled with oral narcotics. He is also continuing on a course of Levaquin for 2 weeks for his pneumonia. He will follow up with Acute Care Surgery team in a few weeks and also with his primary care doctor for a general physical. Medications on Admission: Zocor 20 mg qhs, lisinopril 5mg', ASA 81', prilosec 20mg' [**Month/Day (3) **] Medications: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 10. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:*20 Tablet(s)* Refills:*0* 11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. 12. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's PO once a day as needed for constipation. 13. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours. Disp:*1 inhaler* Refills:*1* 14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*1* [**Month/Day (3) **] Disposition: Home [**Month/Day (3) **] Diagnosis: s/p Fall Left [**1-17**] rib fractures Left pneumothorax Community acquired pneumonia [**Month/Day (3) **] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [**Month/Day (3) **] Instructions: * Your fall caused rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer [**7-21**] times every hour while awake along with coughing and deep breathing. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). * You may resume any home medications prescribed for you. Followup Instructions: Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] to schedule an appointment to be seen in the next 1-2 weeks. Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2106-12-30**] at 2:45 PM With: ACUTE CARE CLINIC with Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage You will need a chest x-ray prior to this appointment. Please go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **] Radiology 30 minutes prior to your appointment. Completed by:[**2106-12-9**]

[ "799.02", "727.51", "873.0", "401.9", "860.0", "958.7", "272.4", "511.9", "E880.9", "807.05", "530.81", "486" ]

icd9cm

[ [ [] ] ]

[ "96.05", "34.09", "86.59", "33.22" ]

icd9pcs

[ [ [] ] ]

6633, 7724

323, 349

4671, 5155

11231, 12004

2356, 2373

7751, 9527

2234, 2307

2388, 4652

275, 285

377, 2152

5171, 6610

9542, 11208

2175, 2210

2323, 2340

4,679

160,080

45090

Discharge summary

report

Admission Date: [**2196-8-31**] Discharge Date: [**2196-9-9**] Date of Birth: [**2128-12-29**] Sex: F Service: MEDICINE Allergies: Vancomycin And Derivatives / Tetracyclines / Penicillins / Sulfonamides Attending:[**First Name3 (LF) 7934**] Chief Complaint: septic shock Major Surgical or Invasive Procedure: 1. Lumbar puncture 2. Central line placement 3. Left nephrostomy tube placement. History of Present Illness: This is a 67 y/o female with a h/o HTN, NIDDM, persistent left UPJ stone, s/p left ureteral stent placement and ESWL [**1-29**] with incomplete fragmentation and demonstration of the renal stone in the inferior calyx of the left kidney, who underwent a left ureteroscopy, left retrograde pyelography, laser lithotripsy, left ureteral stent removal and replacement yesterday, and now presents with hypotension, fever, tachycardia, and septic shock. . Per op note, no complications were noted at the time of procedure. Patient was sent home in stable condition yesterday. However, she began developing left flank pain and difficulty breathing last night. Her daughter brought her into the [**Name (NI) **] this morning and the patient was found to be febrile, tachycardic, and hypotensive. . In the ED, her VS were T 101.7, BP 58/36, HR 95, RR 39, SaO2 86%/RA. Lactate was 7.3. She was intubated for hypoxic respiratory distress. She was given 6 L of NS for resuscitation, however she remained hypotensive and was started on levophed, dopamine (added when levo maxed out), and neo (added when levo and dopa maxed). She was also given 500 mg IV levofloxacin, 500 mg IV flagyl, 10 mg IV decadron, and fentanyl/versed for sedation. She was also evaluated by both surgery and urology - no surgical intervention required at this time. CT abd/pelvis demonstrated diffuse perinephric stranding with ?active bleeding. Pt was transferred to the MICU for further management. Past Medical History: HTN, DM, Breast Ca, Thyroid Ca - Thyroidectomy, TAH/SBO, Appendectomy, SBOs Social History: Rare EtOH , no tobacco Family History: NC Physical Exam: VS: T 98.9, BP 139/81, HR 102, RR 18, SaO2 97%/AC 550 x 18, FiO2 100%, PEEP 8, SvO2 81, CVP 25 General: Intubated, partially sedated but withdraws to pain. HEENT: NC/AT, pupils minimally reactive. ETT and NGT in place. Neck: supple, R IJ in place Chest: diffuse rhonchi throughout CV: RRR, s1 s2 normal but distant, no m/g/r Abd: soft, NT/ND, few BS Ext: no c/c/e, warm, pulses 1+ b/l Neuro: Sedated, withdraws to pain, moves all 4 extremities Pertinent Results: [**2196-8-31**] 09:38AM PT-12.9 PTT-26.8 INR(PT)-1.1 [**2196-8-31**] 09:38AM PLT SMR-NORMAL PLT COUNT-265 [**2196-8-31**] 09:38AM NEUTS-67 BANDS-21* LYMPHS-2* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-7* MYELOS-3* [**2196-8-31**] 09:38AM WBC-19.4*# RBC-3.75* HGB-10.8* HCT-31.6* MCV-84 MCH-28.7 MCHC-34.0 RDW-14.4 [**2196-8-31**] 09:38AM CALCIUM-8.2* PHOSPHATE-2.7# MAGNESIUM-1.2* [**2196-8-31**] 09:38AM CK-MB-13* MB INDX-1.5 cTropnT-0.03* [**2196-8-31**] 09:38AM CK(CPK)-864* [**2196-8-31**] 09:38AM CK(CPK)-864* [**2196-8-31**] 09:38AM GLUCOSE-206* UREA N-42* CREAT-3.5*# SODIUM-135 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-17* ANION GAP-24 [**2196-8-31**] 09:46AM LACTATE-7.3* Brief Hospital Course: ASSESSMENT/PLAN - 67 y/o female with HTN, NIDDM, s/p recent urologic procedure, now presenting with shock. . # Shock - On admission, patient was found to have fever, leukocytosis and left shift with a positive U/a. This was consistent with likely urinary source, especially given recent urologic instrumentation and lithotripsy. On further cultures, we found E. Coli in blood and urine. Given her shock, she initially required fluid resussitation and pressors. She was transfused with 2 units PRBC. She demonstrated evidence of end-organ damage with elevated lactate, elevated Cr, troponin leak. Pt with h/o multiple abx allergies and resistant organisms during past septic shock hospitalization. Given likely renal source, left nephrostomy tube was placed under IR for drainage of kidney. . She also had cardiac evaluation with Echo which showed: . Conclusions: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is no pericardial effusion. . CT Evaluation of Chest and pelvis for identification of source of infection/renal imaging showed: . IMPRESSION: 1. Status post placement of left percutaneous nephrostomy tube. Left ureteral stent remains in place. Interval improvement in left perinephric stranding and fascial thickening. No significant hydronephrosis. 2. Persistent small bilateral pleural effusions and generalized edema consistent with anasarca. 3. Small fat-containing paraumbilical hernia. . # Hypoxic respiratory distress - We felt respiratory distress was most likely caused by ARDS in setting of sepsis. Patient was intubated for ~24 hrs during hospitalization. WIth treatment of sepsis, she quickly weaned from mechanical ventilation. On discharge she is currently requiring only nasal cannula. . # Metabolic acidosis - Patient presented with severe metabolic acidosis, [**2-25**] lactic acidosis. Continued high minute ventilation for compensation. Given Bicarb. Resolved after resolution of septic shock. . # ARF on CRI - Patient presented with elevated creatinine to 3.5 [**2-25**] hypoperfusion +/- ATN. Her medications were renally dosed. Creatinine on discharge was back to 1.1. . # Elevated CE's - patient presented with elevated cardiac enzymes likely [**2-25**] hypoperfusion and demand ischemia. Echo results above revealed normal cardiac function. . # NIDDM - Patient was known diabetic and was covered with insulin gtt and ISS while in the hospital. . # PPx - For prophylaxis, patient was on IV PPI, heparin SC, insulin gtt Medications on Admission: 1. Metformin 500 mg [**Hospital1 **] 2. Lasix 40 mg qd 3. Atenolol 50 mg qd 4. Levoxyl 75 mcg qd 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. Tablet, Delayed Release (E.C.)(s) 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 4. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours): Please continue for 3 week course. . 5. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. 6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. E. Coli sepsis Discharge Condition: Good. Discharge Instructions: Please return if you have any fever, chills, increased headache, chest pain, faintness, difficulty swallowing, pain with urination, blood in urine or stool, or any other concerning symptoms. Followup Instructions: Please follow up with your PCP [**Name Initial (PRE) 176**] 3 days of discharge.

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icd9cm

[ [ [] ] ]

[ "55.03", "87.75", "96.04", "03.31", "00.14", "96.71", "38.91", "99.04", "96.6" ]

icd9pcs

[ [ [] ] ]

7166, 7232

3277, 6281

345, 428

7294, 7302

2563, 3254

7541, 7625

2079, 2083

6429, 7143

7253, 7273

6307, 6406

7326, 7518

2098, 2544

293, 307

456, 1923

1945, 2022

2038, 2063

5,370

145,390

49826

Discharge summary

report

Admission Date: [**2103-2-17**] Discharge Date: [**2103-2-28**] Date of Birth: [**2028-10-30**] Sex: M Service: MEDICINE Allergies: Remeron Attending:[**First Name3 (LF) 2698**] Chief Complaint: lethargy, decreased po intake, nausea Major Surgical or Invasive Procedure: intubation History of Present Illness: Pt is a 75 yo man with pmh sig for CAD, s/p CABG [**2086**] with stress imaging [**8-/2102**] with fixed reversible defect only, colon ca (normal scope [**2100**]), melanoma, right middle and lower lobectomy of lung and radiation of lung as treatment of carcinoid tumor, congestive heart failure, and recent onset of atrial fibrillation who has had increased nausea over the past year with marked increase accompanied by poor po intake to only minimal fluids. He was scheduled for an elective cardiac catheterization to evaluate a cardiac etiology of his vague symtoms, as all other work-ups have been unremarkable. He was noted to have increased lethargy to the point of "difficulty to arouse" for the past few days. On day of admission he was Seen by PCP at home who found him to be, oliguric & hypotensive. Increased fluid replacement was not successful in increasing BP and patient was sent to ED. On presentation to the [**Name (NI) **] pt is unable to answer questions other than "yes/no", but history is given by family. He denies chest pain, has had some shortness of breath at rest, no orthopnea or pnd, no dysuria, nausea but no vomitting, and no fever/chills. He has had over 10 pound weight loss over the past year. Past Medical History: Carcinoid tumor of the lung s/p RML/RLL resection Melanoma Congestive Heart Failure Restrictive lung disease by PFTs CAD - see HPI Colon CA History of hepatitis/ascites after antidepressant use(?) Social History: Lives in [**Location 745**] with wife. Was a business man by trade. Has three daughters actively involved in his healthcare. No alcohol or tobacco use. Physical Exam: On Discharge: T 98 BP 110/68 HR 70 RR 14 95%RA Cachectic, very rigid posture with action and when passive, no tremor, masked facies. No JVD, no LAD, no TM Cardiac exam regular in rate and rhythm with normal s1/s1, [**3-11**] SEM at USB w/o radiation. Lungs with decreased breath sounds on right middle to lower areas, otherwise clear. Abdomen soft and scaphoid, nt, nd, nabs Extremities wwp, no cyanosis/clubbing/edema, 1+ dp. Neuro AAOx3, MAE, no tremor Pertinent Results: LABS ON ADMISSION: [**2103-2-17**] 08:25PM TYPE-ART PO2-104 PCO2-91* PH-7.18* TOTAL CO2-36* BASE XS-2 [**2103-2-17**] 08:00PM WBC-8.3 RBC-3.79* HGB-12.4* HCT-37.3* MCV-99* MCH-32.7* MCHC-33.2 RDW-14.1 [**2103-2-17**] 08:00PM ALT(SGPT)-44* AST(SGOT)-62* CK(CPK)-150 ALK PHOS-78 AMYLASE-83 TOT BILI-0.7 [**2103-2-17**] 08:00PM BLOOD Glucose-146* UreaN-36* Creat-2.8*# Na-119* K-5.4* Cl-79* HCO3-31* AnGap-14 [**2103-2-17**] 08:00PM BLOOD CK-MB-26* MB Indx-17.3* cTropnT-0.42* [**2103-2-18**] 03:39AM BLOOD CK-MB-27* MB Indx-13.8* cTropnT-0.45* [**2103-2-18**] 09:14PM BLOOD CK-MB-6 cTropnT-0.46* . CT Head: FINDINGS: There is no intracranial hemorrhage, mass lesion, hydrocephalus, shift of normally midline structures, minor or major vascular territorial infarct. [**Doctor Last Name **]-white matter differentiation is preserved. Osseous and soft- tissue structures are unremarkable. . ECHO: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The right atrial appendage appears to be akinetic. The right ventricular free wall is severely hypokinetic. The left ventricular functon is moderately depressed (LVEF ~30-35%) with global hypokinesis, inferior akinesis and inferobasal akinesis/dyskinesis. The aortic valve leaflets are moderately thickened. Mild-moderate ([**2-4**]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. An eccentric jet of mild to moderate ([**2-4**]+) is seen directed toward the left atrial appendage. The tricuspid valve leaflets are mildly thickened. Moderate tricuspid regurgitation is seen.There is no pericardial effusion. Brief Hospital Course: Respiratory Failure: In the ER pH 7.18, CO2 98, with hypercarbic lethargy. After repeat ABG revealed increasing CO2, the patient was intubated. The suspected etiology of his respiratory failure was a chronic respiratory acidosis with superimposed acute metabolic acidosis from acute renal failure, causing decompensation and marked acidemia. A swan-ganz catheter was placed and numbers were consistent with hypovolemia with a small element of heart failure. Pt underwent fluid resuscitation and was placed on dopamine with good response and improvement in renal function, and Levaquin was started for possible sepsis/pulm infection. Small bump in CK and Troponin postulated secondary to demand ischemia. TEE done while intubated showed no change in cardiac function from previous TTE at OSH. On hopital day 4, it was felt that he may be volume overloaded after fluid resuscitation in setting of CHF with elevated CVP, PAPD, and also was demonstrating low SVR likely due to sepsis. Decreased UOP this day was thought to be due to low perfusion in setting of elevated preload and so he was placed back on renal dose dopamine and given lasix for diuresis until his numbers were consistent with euvolemia. He was soon after weaned off all pressors and extubated. Pulmonary was consulted for episodes of hypercarbia during sleep, bipap was suggested but refused by patient. The plan was to follow up with pulmonary as an outpatient with a formal sleep study. As part of the work up for increased nausea and lethargy a CT scan of the head was completed which was normal. Atrial Fibrillation: The patient had known atrial fibrillation but was NSR on admission, and had recently been started on sotalol. He had an episode of atrial fibrillation with short reponse to 100J cardioversion, was started on amiodorone and then converted spontaneously. He was later placed on Metoprolol as well. Medications on Admission: Warfarin Atorvastatin Aspirin 325 mg Tablet Furosemide 20 mg Tablet Moexipril HCl 7.5 mg Tablet Betapace Gabapentin Discharge Medications: 1. Warfarin Sodium 1 mg Tablet Sig: 2.5 Tablets PO once a day: take as directed until doseage changed by PCP according to lab work. Disp:*75 Tablet(s)* Refills:*0* 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO qhs:prn as needed for insomnia for 10 days. Disp:*10 Tablet(s)* Refills:*0* 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation q6h:prn as needed for shortness of breath or wheezing. Disp:*qs qs* Refills:*0* 5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 10 days: Take two pills twice per day for four days then two pills once per day for 2 weeks, then one pill once per day. Disp:*44 Tablet(s)* Refills:*0* 6. 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* 7. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*0* 8. Moexipril HCl 7.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Acute renal failure Chronic respiratory acidosis Congestive heart failure Discharge Condition: stable Discharge Instructions: Call your PCP or return to emergency room if you develop chest pain, shortness of breath, or markedly increased lethargy. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2103-7-12**] 2:15 . You must make an appointment to see Dr. [**Last Name (STitle) 1407**] within two days to have you blood checked for coumadin adjustment. . Please make an appointment to see Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] at Pulmonary Clinic in 4 weeks. Call [**Telephone/Fax (1) 2756**] for the pulmonary clinic to make an appointment. Completed by:[**2103-3-8**]

[ "V10.82", "584.9", "518.89", "458.9", "276.2", "427.31", "518.84", "428.0", "V15.3", "V45.81", "V10.11", "276.5", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "00.17", "99.62", "88.72", "99.04", "96.04", "89.64", "96.72", "96.6" ]

icd9pcs

[ [ [] ] ]

7569, 7655

4224, 6127

307, 320

7773, 7781

2461, 2466

7951, 8531

6294, 7546

7676, 7752

6153, 6271

7805, 7928

1986, 1986

2000, 2442

230, 269

348, 1580

3072, 4197

2480, 3063

1602, 1800

1816, 1971

2,383

160,878

8726

Discharge summary

report

Admission Date: [**2114-9-2**] Discharge Date: [**2114-9-10**] Date of Birth: [**2043-10-28**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet Attending:[**First Name3 (LF) 1283**] Chief Complaint: recent onset angina and DOE Major Surgical or Invasive Procedure: Redo Coronary Artery Bypass Graft (Saphavenous graft - Posterior descending artery, Saphavenous graft - Obtuse marginal, Saphavenous - Diagonal); Atrial Septal defect closure; biventricular lead placement [**2114-9-3**] History of Present Illness: 70 yo male with history of CAD and prior cabg x4 in [**2098**]. His angina has been relatively stable and resolves with rest. He has had yearly PTCAs with some stents in [**2108**]- [**2113**]. In [**2109**], he had a pacer placed. Presents now after [**6-21**] cath showed occluded LM, diffusely diseased LAD and diagonals, RCA 100%, SVG to Diag 1 60-70% mid-graft, and 80% in-stent restenosis.LIMA to LAD was patent. Echo showed EF 25-30%.Referred to Dr. [**Last Name (STitle) 1290**] for surgery. Past Medical History: CABG [**2098**] CAD with prior PTCAs/ stents prostate CA with XRT cardiomyopathy CRI ( baseline 1.3) elev. chol. HTN obesity Social History: works part-time married with 2 children 30 pack/yrs, quit [**2098**] rare ETOH Family History: mother with CAD died at 62 father died at 72 of leukemia Physical Exam: 68" 96.6 kg 97.0 HR 70 142/73 RR 20 97% RA sat obese, NAD RRR, no m/r/g no JVD, carotid bruits L > R CTAB soft abd, + BS, NT, ND, no palpable, pulsating masses extrems 2+ pulses, no edema, warm feet Pertinent Results: [**2114-9-7**] 06:25AM BLOOD WBC-7.6 RBC-3.41* Hgb-10.6* Hct-30.6* MCV-90 MCH-31.0 MCHC-34.6 RDW-14.8 Plt Ct-119* [**2114-9-7**] 06:25AM BLOOD Plt Ct-119* [**2114-9-6**] 02:59AM BLOOD PT-12.2 PTT-26.4 INR(PT)-1.0 [**2114-9-7**] 06:25AM BLOOD Glucose-98 UreaN-29* Creat-1.6* Na-140 K-4.1 Cl-100 HCO3-32 AnGap-12 [**2114-9-6**] 02:59AM BLOOD ALT-41* AST-48* AlkPhos-88 Amylase-260* TotBili-0.9 [**2114-9-6**] 02:59AM BLOOD Lipase-19 [**2114-9-6**] 02:59AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.9* [**2114-9-2**] 05:35PM BLOOD %HbA1c-5.8 [Hgb]-DONE [A1c]-DONE FINAL REPORT PORTABLE CHEST, 10:12 A.M. ON [**9-5**] INDICATION: Status post redo CABG and chest tube removal. Evaluate for pneumothorax. FINDINGS: Compared with [**2114-9-3**], multiple tubes and catheters have been removed. No pneumothorax identified. No overt CHF. Patchy left lower lobe atelectasis/effusion is grossly unchanged. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: WED [**2114-9-5**] 10:32 PM Procedure Date:[**2114-9-5**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 30536**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 30537**] (Congenital) Done [**2114-9-3**] at 9:58:10 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2043-10-28**] Age (years): 70 M Hgt (in): 72 BP (mm Hg): 126/78 Wgt (lb): 212 HR (bpm): 70 BSA (m2): 2.19 m2 Indication: Left ventricular function. Intra-op TEE for Re-do CABG ICD-9 Codes: 745.5, 440.0, 414.8 Test Information Date/Time: [**2114-9-3**] at 09:58 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Congenital) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2006AW02-: Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Peak Pulm Vein S: 5.0 m/s Left Atrium - Peak Pulm Vein D: 2.1 m/s Left Ventricle - Ejection Fraction: 15% >= 55% Aorta - Valve Level: 2.2 cm <= 3.6 cm Aorta - Ascending: 3.0 cm <= 3.4 cm Aorta - Arch: 2.7 cm <= 3.0 cm Aorta - Descending Thoracic: *3.0 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Aortic Valve - LVOT pk vel: 0.75 m/sec Aortic Valve - LVOT VTI: 18 Aortic Valve - LVOT diam: 2.1 cm Mitral Valve - Peak Velocity: 1.0 m/sec Mitral Valve - Mean Gradient: 2 mm Hg Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.29 Findings LEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Left-to-right shunt across the interatrial septum at rest. Small secundum ASD. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Moderately dilated LV cavity. Severe global LV hypokinesis. Severely depressed LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. Normal aortic arch diameter. There are complex (>4mm) atheroma in the aortic arch. Mildly dilated descending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. Eccentric TR jet. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The rhythm appears to be A-V paced. The patient has runs of a supraventricular for the patient. See Conclusions for post-bypass data Conclusions PRE-BYPASS: 1. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. 2.The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3.There is mild global right ventricular free wall hypokinesis. 4.There are complex (>4mm) atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen (restricted anterior leaflet motion). Vena contracta measures 3mm. 7.The tricuspid regurgitation jet is eccentric and may be underestimated. POST-BYPASS: Pt is being a paced and is on an infusion of Noepinephrine, Epinephrine and Milrinone 1. Overall LV systolic function is slightly improved. 2. Other findings are unchanged. 3. No flow across the Interatrial septum by color. Bubble study with valsalva is negative for flow across the interatrial septum. 4. Aorta is intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician ?????? [**2110**] CareGroup IS. All rights reserved. Brief Hospital Course: Admitted on [**9-2**] for IV heparinization prior to surgery. Patient had been off his coumadin approx. 5 days prior to admission.EP performed pacer interrogation prior to OR. Underwent redo cabg x3/ASD closure/ biventricular lead placement on [**9-3**] with Dr. [**Last Name (STitle) 1290**]. Transferred to the CSRU in stable condition on epinephrine, milrinone, and levophed drips. Extubated on POD #1 and weaned off milrinone.Pacer check completed by EP postop.Epinephrine weaned off. Went into rapid Afib and was treated with amiodarone on POD #2 and chest tubes also removed.Off all drips on POD #3 and pacing wires removed. Re-bolused with amiodarone for Afib again and converted to SR. Seen by EP on POD #3 for a 7 beat run of VTach. Recommended upgrade to Biventricular ICD in 3 months with follow up sooner with Dr. [**Last Name (STitle) **]. Transferred to the floor on POD #3 to begin increasing his activity level. Another episode of Afib again on the morning of POD #4 required additional amiodarone. Developed a small amount of sternal drainage and was started on vancomycin. Made good progress and cleared for discharge to home with VNA on POD #7. Medications on Admission: ASA 325 mg daily plavix 75 mg daily ( held since last week) valsartan 80 mg [**Hospital1 **] lisinopril 10 mg daily atenolol 100 mg [**Hospital1 **] zocor 20 mg daily NTG 0.4 mg patch q 24 hours lasix 20 mg daily coumadin ( held for 5 days) 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 1 months. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 12 days: for 2 weeks, then 200 mg daily for one month. Please check with Dr. [**Last Name (STitle) **] before discontinuing drug. Disp:*110 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0* 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Redo coronary artery bypass graft and atrial septal defect closure and biventricular lead placement Hypertension Heart Failure Prostate Cancer Permanent Pacemaker Elevated Cholesterol cabg x4 [**2098**] Afib obesity Discharge Condition: Stable Discharge Instructions: [**Month (only) 116**] shower, no baths. No creams, lotions, powder, or ointments on incisions. No driving for at least one month. No lifting more than 10 pounds for 10 weeks. Call for fever > 101.5, redness, or drainage from incisions. Please call with any questions or concerns. Followup Instructions: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13534**] in 1 week ([**Telephone/Fax (1) 17207**]) please call for appt Dr [**Last Name (STitle) 30538**] in [**1-19**] weeks ([**Telephone/Fax (1) 17206**]please call for appt Dr [**First Name (STitle) **] [**Last Name (Prefixes) **] in 4 weeks ([**Telephone/Fax (1) 3633**]) please call for appt Dr [**Last Name (STitle) **] & pacer clinic - [**Hospital Ward Name 23**] [**10-23**] at 3pm ([**Telephone/Fax (1) 59**]) Completed by:[**2114-9-11**]

[ "413.9", "428.0", "414.01", "745.5", "425.4", "397.0", "401.9", "V10.46", "427.1", "427.31", "424.0", "997.62", "585.9", "272.0" ]

icd9cm

[ [ [] ] ]

[ "00.52", "39.61", "35.71", "36.13" ]

icd9pcs

[ [ [] ] ]

10361, 10432

7498, 8663

303, 526

10691, 10700

1618, 7475

11033, 11550

1316, 1374

8955, 10338

10453, 10670

8689, 8932

10724, 11010

1389, 1599

236, 265

554, 1055

1077, 1203

1219, 1300

70,775

133,442

37114

Discharge summary

report

Admission Date: [**2150-12-4**] Discharge Date: [**2150-12-8**] Date of Birth: [**2083-4-6**] Sex: M Service: CARDIOTHORACIC Allergies: Iodine / Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: worsening fatigue Major Surgical or Invasive Procedure: [**2150-12-4**] CABG X 3 (LIMA to LAD, SVG to DIAG, SVG to PLV) History of Present Illness: 67 year gentleman with a past medical history of metabolic syndrome, non-insulin dependent diabetes, chronic renal insufficiency and a non-Q-wave myocardial infarction over this past summer. A follow-up nuclear stress test revealed apical lateral and apical septal ischemia. He was subsequently referred for a cardiac catheterization which revealed severe two vessel disease. Given the severity of his disease, he has been referred for surgical revascularization. Currently denies chest pain and shortness of breath. He does admit easy fatiguability and worsening fatigue.Referred for surgery. Past Medical History: Coronary Artery Disease, Prior Myocardial infarction Dysplipidemia Hypertension Obesity Non-Insulin dependent diabetes History of Pneumonia - resolved GERD Hypothyroid Chronic renal insufficiency (Creat 2.2) Reactive Airway Disease Prostatism Social History: Lives: alone in [**Location (un) 12017**], RI Occupation: Retired Tobacco: Quit pipe [**2120**]'s ETOH: Denies Family History: Denies premature CAD Physical Exam: Pulse: 57 Resp: 24 O2 sat: 98 B/P Right: 154/91 Left: 148/88 General: Obese male in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema trace Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 DP Right: 2 Left: 2 PT [**Name (NI) 167**]: 2 Left: 2 Radial Right: 2 Left: 2 Carotid Bruit Right: none Left: none Pertinent Results: Conclusions PRE-CPB:1. The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. The right ventricular cavity is mildly dilated with normal free wall contractility. 4. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are moderately thickened. There is a flail chordal remnant seen in the left atrium. There is a snmall central jet. Mild (1+) mitral regurgitation is seen. The mitral annular size is normal. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: The bisystolic function is preserved post CPB. The aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2150-12-7**] 11:36 Brief Hospital Course: Admitted [**12-4**] and underwent surgery with Dr. [**Last Name (STitle) **]. Please see operative note. Transferred to the CVICU in stable condition on a titrated propofol drip. Extubated and transferred to the floor on POD #1 to begin increasing his activity level. Beta blockade titrated and he was gently diuresed toward his preop weight.Chest tubes and pacing wires removed per protocol.Brief episode of A Fib treated with IV lopressor. Contiunued to make good progress and was cleared for discharge to home on POD #4 Medications on Admission: Exforge (10-320mg) QD Metoprolol ER 50mg [**Hospital1 **] Lipitor 10mg QD Fenofibrate 160mg QD Niaspan 500mg QD Januvia 100mg QD Actos 30mg QD L-Thyroxine 0.025mg QD Prilosec 20mg QD Aspirin 325mg QD Plavix 75mg QD Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Fenofibrate Micronized 145 mg Tablet Sig: resume pre-op dose Tablet PO once a day. 6. 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* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day: 20mg/[**Hospital1 **] x10 days then 20mg QD. Disp:*40 Tablet(s)* Refills:*1* 12. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Actos 15 mg Tablet Sig: Thirty (30) mg PO once a day. 14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 10 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA services of [**Location (un) 16221**] County Discharge Diagnosis: Coronary Artery Disease, Prior Myocardial infarction,s/p cabg Dysplipidemia Hypertension Obesity Non-Insulin dependent diabetes History of Pneumonia - resolved GERD Hypothyroid Chronic renal insufficiency (Creat 2.2) Reactive Airway Disease Prostatism Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn 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**] Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] [**Name (STitle) 83627**] [**2151-1-7**] @ 1:15 PM [**Telephone/Fax (1) 170**] Primary Care Dr.[**Last Name (STitle) 83628**] in [**12-26**] weeks Cardiologist Dr. [**Last Name (STitle) 14522**] in [**1-27**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2150-12-8**]

[ "493.90", "600.90", "244.9", "V43.64", "272.4", "413.9", "412", "997.1", "530.81", "423.9", "459.81", "E878.2", "403.90", "278.00", "585.9", "V45.89", "427.31", "250.00", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.12", "39.61", "39.64" ]

icd9pcs

[ [ [] ] ]

6109, 6188

3542, 4066

304, 370

6484, 6580

2077, 3519

7121, 7557

1406, 1429

4332, 6086

6209, 6463

4092, 4309

6604, 7098

1444, 2058

247, 266

398, 994

1016, 1261

1277, 1390

32,401

187,361

33181

Discharge summary

report

Admission Date: [**2200-12-11**] Discharge Date: [**2200-12-25**] Date of Birth: [**2125-2-16**] Sex: M Service: MEDICINE Allergies: Oxycodone / Heparin Sodium Attending:[**First Name3 (LF) 492**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Lumbar puncture under fluoroscopic guidance PICC placement History of Present Illness: 75 y/o M with PMHx as below who presented to OSH on [**12-5**] with increased weakness/difficulty ambulating x2 weeks. He was prev at [**Hospital **] Rehab for the past 2 weeks where he was noted to be prog declining, requiring more assistance and c/o decreased sensation in hands/feet. His appetite has been poor, and he c/o low energy level as well. . During his hosp course, he was found to have bilat effusions, a VRE UTI and a Proteus UTI and has been treated with Levaquin/Clinda/Flagyl x3d (although no coverage for VRE apparently). He was admitted and had a full neuro w/u as below (head CT, MRI, EEG, MRI c/l spine) that was unremarkable and did not discover an organic etiology to his neuropathic complaints. A psych eval felt he was suffering from delirium/encephalopathy from infxn/meds and he was started on Zyprexa (Reglan/Thorazine/Tylenol # 3 were stopped). . Prior to his admission to the OSH, he had a renal biopsy was performed for worsening renal failure (starting in [**Month (only) 359**]); it showed focal proliferative crescentic glomerulonephritis and prednisone 20mg TID was started. He developed diarrhea and palpable purpura, the biopsy of which showed leukocytoclastic vasculitis. At some point in this time frame, the p-ANCA was presumed positive, although it was not documented. Both rheumatology and neurology were consulted. He was started on high dose steroids. . On arrival here, he is confused and not able to answer any questions, although he does follow commands. Past Medical History: 1) CKD, has required HD in past when admitted for sepsis. 2) Prostate CA s/p XRT 3) Bladder CA s/p XRT 4) s/p cystectomy and ileal loop ostomy 5) s/p L urethral restenosis 6) ? CAD with stenting (details not available) 7) HTN 8) Anemia Kidney biopsy - FGN Social History: Lives with wife. Retired engineer. 2 children. Smoked 1ppd but quit > 30 yrs ago. Also drank a substantial amount of alcohol (Gin) but quit 6 months ago when dx with bladder cancer. Family History: F bladder CA, M pancreatic CA Physical Exam: BP:106/61 HR:76 RR:19 O2 sat:94% 2L NC Gen: sleepy, opens eyes to voice. CV: RRR, nl S1S2, no M/R/G Resp: Decr BS at bases b/l, but otherwise CTA Abd: +BS, ileal loop draining dark urine, soft, ND/NT Ext: no edema, 2+ DP pulses b/l. Neuro: AAO x0, does not follow commands. Non-verbal. Withdraws to pain (ABG). Pertinent Results: [**2200-12-22**] 10:26AM BLOOD Hct-22.8* [**2200-12-22**] 03:56AM BLOOD WBC-21.0* RBC-2.65* Hgb-8.5* Hct-24.5* MCV-93 MCH-32.2* MCHC-34.8 RDW-18.0* Plt Ct-57* [**2200-12-21**] 06:19PM BLOOD WBC-22.2* RBC-2.95* Hgb-9.5* Hct-27.5* MCV-93 MCH-32.3* MCHC-34.6 RDW-18.4* Plt Ct-54* [**2200-12-21**] 10:59AM BLOOD WBC-19.3* RBC-3.00* Hgb-9.6* Hct-27.7* MCV-93 MCH-32.2* MCHC-34.7 RDW-18.4* Plt Ct-49* [**2200-12-21**] 03:50AM BLOOD WBC-21.3* RBC-3.11*# Hgb-10.0*# Hct-28.7* MCV-92# MCH-32.2* MCHC-34.9 RDW-18.2* Plt Ct-43* [**2200-12-20**] 07:25PM BLOOD Hct-23.6* [**2200-12-20**] 03:27AM BLOOD WBC-18.9* RBC-2.19* Hgb-7.4* Hct-22.5* MCV-103* MCH-33.9* MCHC-33.0 RDW-18.4* Plt Ct-45* [**2200-12-19**] 03:39AM BLOOD WBC-21.2* RBC-2.56* Hgb-8.3* Hct-26.2* MCV-102* MCH-32.5* MCHC-31.8 RDW-17.2* Plt Ct-39* [**2200-12-18**] 06:00AM BLOOD WBC-15.8* RBC-2.76* Hgb-9.1* Hct-29.5* MCV-107* MCH-33.2* MCHC-31.0 RDW-18.7* Plt Ct-53* [**2200-12-17**] 11:02AM BLOOD WBC-18.3* RBC-2.98* Hgb-9.8* Hct-33.8* MCV-113* MCH-32.9* MCHC-29.1* RDW-18.8* Plt Ct-65* [**2200-12-17**] 06:35AM BLOOD WBC-18.0* RBC-3.22* Hgb-10.3* Hct-34.5* MCV-107* MCH-32.0 MCHC-29.8* RDW-16.7* Plt Ct-72* [**2200-12-16**] 05:14AM BLOOD WBC-13.5* RBC-3.12* Hgb-10.4* Hct-34.1* MCV-109* MCH-33.2* MCHC-30.4* RDW-18.5* Plt Ct-104* [**2200-12-15**] 02:57AM BLOOD WBC-11.9* RBC-2.94* Hgb-9.6* Hct-30.2* MCV-103* MCH-32.5* MCHC-31.7 RDW-16.9* Plt Ct-109* [**2200-12-14**] 02:36AM BLOOD WBC-8.9 RBC-3.06* Hgb-10.1* Hct-32.2* MCV-105* MCH-33.0* MCHC-31.3 RDW-18.3* Plt Ct-167 [**2200-12-13**] 06:35AM BLOOD WBC-10.0 RBC-3.22* Hgb-10.5* Hct-34.2* MCV-106* MCH-32.7* MCHC-30.8* RDW-18.1* Plt Ct-208 [**2200-12-12**] 03:30AM BLOOD WBC-13.5* RBC-2.98* Hgb-9.6* Hct-31.1* MCV-104* MCH-32.2* MCHC-30.9* RDW-16.8* Plt Ct-201 [**2200-12-20**] 03:27AM BLOOD Neuts-97.1* Bands-0 Lymphs-1.0* Monos-1.6* Eos-0.2 Baso-0 [**2200-12-17**] 11:02AM BLOOD Neuts-95* Bands-0 Lymphs-1* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2200-12-17**] 06:35AM BLOOD Neuts-88.5* Bands-0 Lymphs-10.6* Monos-0.7* Eos-0.1 Baso-0 [**2200-12-16**] 05:14AM BLOOD Neuts-88.9* Lymphs-9.7* Monos-1.0* Eos-0.2 Baso-0.2 [**2200-12-14**] 02:36AM BLOOD Neuts-93.4* Bands-0 Lymphs-4.6* Monos-1.7* Eos-0.3 Baso-0.1 [**2200-12-12**] 03:30AM BLOOD Neuts-96.1* Lymphs-2.2* Monos-1.6* Eos-0.1 Baso-0 [**2200-12-20**] 03:27AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL Stipple-OCCASIONAL [**2200-12-17**] 11:02AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-1+ Stipple-1+ [**2200-12-17**] 06:35AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+ [**2200-12-14**] 02:36AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+ [**2200-12-22**] 03:56AM BLOOD Plt Ct-57* LPlt-1+ [**2200-12-22**] 03:56AM BLOOD PT-22.6* PTT-64.7* INR(PT)-2.2* [**2200-12-21**] 06:19PM BLOOD Plt Ct-54* [**2200-12-21**] 10:59AM BLOOD Plt Ct-49* [**2200-12-21**] 03:50AM BLOOD Plt Ct-43* [**2200-12-21**] 03:50AM BLOOD PT-26.2* PTT-72.3* INR(PT)-2.6* [**2200-12-20**] 03:27AM BLOOD Plt Ct-45* [**2200-12-20**] 03:27AM BLOOD PT-29.7* PTT-79.8* INR(PT)-3.0* [**2200-12-19**] 03:39AM BLOOD Plt Ct-39* [**2200-12-19**] 03:39AM BLOOD PT-26.1* PTT-74.1* INR(PT)-2.6* [**2200-12-18**] 04:08PM BLOOD PTT-54.5* [**2200-12-18**] 06:00AM BLOOD Plt Ct-53* [**2200-12-18**] 06:00AM BLOOD PT-24.0* PTT-150* INR(PT)-2.3* [**2200-12-18**] 12:04AM BLOOD PTT-76.7* [**2200-12-17**] 11:02AM BLOOD Plt Ct-65* [**2200-12-17**] 11:02AM BLOOD PT-14.9* PTT-34.9 INR(PT)-1.3* [**2200-12-17**] 06:35AM BLOOD Plt Smr-VERY LOW Plt Ct-72* [**2200-12-16**] 05:14AM BLOOD Plt Ct-104* [**2200-12-15**] 02:57AM BLOOD Plt Ct-109* [**2200-12-15**] 02:57AM BLOOD PT-16.8* PTT-34.1 INR(PT)-1.5* [**2200-12-14**] 02:36AM BLOOD Plt Smr-NORMAL Plt Ct-167 [**2200-12-14**] 02:36AM BLOOD PT-20.5* PTT-31.0 INR(PT)-1.9* [**2200-12-13**] 06:35AM BLOOD Plt Ct-208 [**2200-12-12**] 03:30AM BLOOD Plt Ct-201 [**2200-12-12**] 03:30AM BLOOD PT-14.4* PTT-29.5 INR(PT)-1.2* [**2200-12-20**] 03:27AM BLOOD Fibrino-313# [**2200-12-17**] 11:02AM BLOOD Fibrino-157 [**2200-12-12**] 12:10PM BLOOD ESR-15 [**2200-12-12**] 11:30AM BLOOD ESR-21* [**2200-12-17**] 06:35AM BLOOD Ret Aut-2.6 [**2200-12-14**] 02:36AM BLOOD Ret Aut-2.2 [**2200-12-22**] 03:56AM BLOOD Glucose-182* UreaN-88* Creat-2.0* Na-134 K-3.9 Cl-100 HCO3-24 AnGap-14 [**2200-12-21**] 03:50AM BLOOD Glucose-193* UreaN-56* Creat-1.5* Na-138 K-3.7 Cl-104 HCO3-26 AnGap-12 [**2200-12-20**] 03:27AM BLOOD Glucose-219* UreaN-69* Creat-2.0* Na-138 K-3.6 Cl-105 HCO3-24 AnGap-13 [**2200-12-19**] 03:39AM BLOOD Glucose-202* UreaN-91* Creat-2.5* Na-141 K-4.2 Cl-110* HCO3-23 AnGap-12 [**2200-12-18**] 06:00AM BLOOD Glucose-202* UreaN-110* Creat-2.9* Na-148* K-4.6 Cl-118* HCO3-20* AnGap-15 [**2200-12-17**] 06:35AM BLOOD Glucose-172* UreaN-122* Creat-3.1* Na-149* K-4.0 Cl-118* HCO3-21* AnGap-14 [**2200-12-16**] 11:53PM BLOOD Glucose-177* UreaN-120* Creat-3.2* Na-151* K-4.1 Cl-118* HCO3-23 AnGap-14 [**2200-12-16**] 08:00PM BLOOD Glucose-189* UreaN-118* Creat-3.3* Na-147* K-4.3 Cl-120* HCO3-11* AnGap-20 [**2200-12-16**] 05:14AM BLOOD Glucose-225* UreaN-113* Creat-3.3* Na-150* K-4.1 Cl-117* HCO3-21* AnGap-16 [**2200-12-15**] 04:48PM BLOOD Glucose-239* UreaN-109* Creat-3.2* Na-152* K-3.7 Cl-120* HCO3-22 AnGap-14 [**2200-12-15**] 02:57AM BLOOD Glucose-111* UreaN-99* Creat-3.3* Na-154* K-4.0 Cl-120* HCO3-21* AnGap-17 [**2200-12-14**] 11:39AM BLOOD Glucose-208* UreaN-93* Creat-3.4* Na-150* K-5.4* Cl-118* HCO3-19* AnGap-18 [**2200-12-14**] 02:36AM BLOOD Glucose-179* UreaN-88* Creat-3.2* Na-152* K-5.4* Cl-117* HCO3-19* AnGap-21* [**2200-12-13**] 09:03PM BLOOD Glucose-184* UreaN-84* Creat-3.2* Na-152* K-5.9* Cl-119* HCO3-16* AnGap-23* [**2200-12-13**] 06:35AM BLOOD Glucose-109* UreaN-74* Creat-2.9* Na-151* K-5.0 Cl-114* HCO3-18* AnGap-24* [**2200-12-12**] 03:30AM BLOOD Glucose-107* UreaN-59* Creat-2.7* Na-145 K-4.9 Cl-113* HCO3-21* AnGap-16 [**2200-12-20**] 03:27AM BLOOD ALT-3 AST-12 LD(LDH)-211 AlkPhos-37* TotBili-0.2 [**2200-12-17**] 12:15PM BLOOD CK(CPK)-36* [**2200-12-17**] 06:35AM BLOOD LD(LDH)-217 [**2200-12-12**] 11:30AM BLOOD ALT-7 AST-9 LD(LDH)-176 AlkPhos-36* TotBili-0.3 [**2200-12-12**] 03:30AM BLOOD ALT-5 AST-10 LD(LDH)-145 AlkPhos-31* Amylase-11 TotBili-0.3 [**2200-12-12**] 03:30AM BLOOD Lipase-13 [**2200-12-17**] 12:15PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2200-12-22**] 03:56AM BLOOD Calcium-7.6* Phos-3.3 Mg-1.6 [**2200-12-21**] 03:50AM BLOOD Calcium-7.4* Phos-3.2 Mg-1.6 [**2200-12-20**] 03:27AM BLOOD Albumin-2.0* Calcium-7.3* Phos-3.3 Mg-1.7 [**2200-12-19**] 03:39AM BLOOD Calcium-8.0* Phos-4.7* Mg-2.1 [**2200-12-18**] 06:00AM BLOOD Calcium-8.9 Phos-5.1* Mg-2.4 [**2200-12-17**] 06:35AM BLOOD Calcium-7.9* Phos-5.8* Mg-2.1 [**2200-12-16**] 11:53PM BLOOD Calcium-7.4* Phos-6.6* Mg-2.2 [**2200-12-16**] 05:14AM BLOOD Calcium-7.6* Phos-6.8* Mg-2.2 [**2200-12-15**] 02:57AM BLOOD Calcium-7.9* Phos-6.5* Mg-2.3 [**2200-12-14**] 02:36AM BLOOD Calcium-8.4 Phos-6.3* Mg-2.2 [**2200-12-13**] 06:35AM BLOOD Calcium-8.9 Phos-5.4* Mg-2.1 [**2200-12-12**] 12:10PM BLOOD Iron-67 [**2200-12-12**] 11:30AM BLOOD TotProt-5.5* Albumin-2.9* Globuln-2.6 Iron-74 [**2200-12-12**] 03:30AM BLOOD Albumin-2.7* Calcium-8.4 Phos-5.3* Mg-2.1 [**2200-12-20**] 03:27AM BLOOD Hapto-140 [**2200-12-17**] 06:35AM BLOOD Hapto-77 [**2200-12-13**] 01:23PM BLOOD Cryoglb-NO CRYOGLO [**2200-12-12**] 12:10PM BLOOD calTIBC-86* VitB12-213* Folate-7.2 Ferritn-997* TRF-66* [**2200-12-12**] 11:30AM BLOOD calTIBC-94* VitB12-241 Folate-7.3 Ferritn-1074* TRF-72* [**2200-12-12**] 12:10PM BLOOD TSH-3.2 [**2200-12-12**] 11:30AM BLOOD TSH-3.3 [**2200-12-12**] 12:10PM BLOOD T4-5.9 [**2200-12-12**] 11:30AM BLOOD T4-6.5 [**2200-12-13**] 01:23PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2200-12-16**] 10:27AM BLOOD ANCA-PND [**2200-12-13**] 01:23PM BLOOD Smooth-POSITIVE [**2200-12-12**] 12:24PM BLOOD ANCA-NEGATIVE [**2200-12-12**] 12:24PM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE [**2200-12-12**] 12:10PM BLOOD CRP-42.2* [**2200-12-12**] 11:30AM BLOOD RheuFac-10 CRP-46.6* [**2200-12-12**] 11:30AM BLOOD PEP-NO SPECIFI IgG-1123 IgA-592* IgM-35* [**2200-12-15**] 02:57AM BLOOD C3-41* C4-10 [**2200-12-12**] 11:30AM BLOOD C3-64* C4-15 [**2200-12-13**] 01:23PM BLOOD HCV Ab-NEGATIVE [**2200-12-22**] 04:10AM BLOOD Type-ART pO2-85 pCO2-45 pH-7.43 calTCO2-31* Base XS-4 [**2200-12-20**] 04:13PM BLOOD Type-ART pO2-113* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 [**2200-12-19**] 11:43AM BLOOD Type-ART Temp-36.6 pO2-95 pCO2-50* pH-7.31* calTCO2-26 Base XS--1 [**2200-12-18**] 12:50PM BLOOD Type-ART Temp-37.2 O2 Flow-2 pO2-94 pCO2-51* pH-7.34* calTCO2-29 Base XS-0 [**2200-12-18**] 06:34AM BLOOD Type-ART pO2-125* pCO2-55* pH-7.21* calTCO2-23 Base XS--6 [**2200-12-18**] 12:13AM BLOOD Type-ART pO2-95 pCO2-46* pH-7.29* calTCO2-23 Base XS--4 [**2200-12-17**] 08:54PM BLOOD Type-ART pO2-119* pCO2-47* pH-7.25* calTCO2-22 Base XS--6 [**2200-12-17**] 06:44PM BLOOD Type-ART pO2-110* pCO2-45 pH-7.26* calTCO2-21 Base XS--6 Intubat-NOT INTUBA [**2200-12-17**] 04:26PM BLOOD Type-ART pO2-123* pCO2-49* pH-7.25* calTCO2-23 Base XS--5 [**2200-12-17**] 12:18PM BLOOD Type-ART pO2-115* pCO2-61* pH-7.15* calTCO2-22 Base XS--8 [**2200-12-17**] 08:09AM BLOOD Type-ART pO2-86 pCO2-65* pH-7.14* calTCO2-23 Base XS--8 [**2200-12-17**] 03:40AM BLOOD Type-ART pO2-103 pCO2-53* pH-7.21* calTCO2-22 Base XS--7 [**2200-12-17**] 01:31AM BLOOD Type-ART pO2-86 pCO2-70* pH-7.13* calTCO2-25 Base XS--7 [**2200-12-17**] 01:12AM BLOOD Type-ART pO2-42* pCO2-72* pH-7.12* calTCO2-25 Base XS--7 [**2200-12-16**] 11:15PM BLOOD Type-ART FiO2-4 pO2-77* pCO2-58* pH-7.16* calTCO2-22 Base XS--8 [**2200-12-16**] 10:31PM BLOOD Type-ART pO2-44* pCO2-73* pH-7.09* calTCO2-23 Base XS--10 [**2200-12-19**] 11:43AM BLOOD Lactate-1.3 [**2200-12-17**] 04:26PM BLOOD Lactate-1.0 [**2200-12-17**] 12:18PM BLOOD K-4.1 [**2200-12-17**] 01:31AM BLOOD Lactate-1.1 [**2200-12-17**] 01:12AM BLOOD Lactate-1.8 [**2200-12-16**] 10:31PM BLOOD Lactate-2.0 [**2200-12-12**] 12:24PM BLOOD CONFIRMATORY ANCA- [**2200-12-15**] 02:57AM BLOOD ANTI-GBM-Test [**2200-12-12**] 12:24PM BLOOD RO & [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **] . [**2200-12-12**]: Successful fluoroscopic-guided lumbar puncture. . [**2200-12-12**] AXR: No definite evidence for intra-abdominal free air. Bilateral small-to-moderate pleural effusions, unchanged. Chest radiograph reported separately . [**2200-12-12**] CXR: Bilateral moderate-sized pleural effusions. Difficult to exclude a retrocardiac atelectasis or pneumonia. . [**2200-12-13**] CXR: No significant change in pulmonary findings. . [**2200-12-14**] CT Chest without contrast: 1. Large left-sided pleural effusion and left lower lobe collapse with nonaeerated LLL bronhi. Bronchoscopy could be helpful for further evaluation if clinically indicated. 2. Scattered airspace opacities seen throughout the right lung with evidence of spirated material in right lower lobe. Small right pleural effusion. 3. Nodular densities in the right lung. Followup imaging following treatment would be recommended to document resolution. 3. Mildly enlarged, nonspecific mediastinal lymph nodes. . [**2200-12-14**] CXR: Nasogastric tube with the proximal side port at the level of the GE junction. The nasogastric tube should be advanced for optimal positioning. Bibasilar atelectasis and bilateral pleural effusions, worse on the left than the right. The findings are better seen on subsequent CT examination. . [**2200-12-15**] Renal Ultrasound: No evidence for hydronephrosis. . [**2200-12-15**] EEG: This is an abnormal portable EEG in the waking and drowsy states due to the slow and disorganized background intermixed with bursts of mixed theta and delta frequency slowing consistent with a mild encephalopathy. This suggests dysfunction of deep midline or bilateral subcortical structures. Medications, metabolic disturbances, and infections are among the common causes of encephalopathy but there are others. There are no areas of prominent focal slowing although encephalopathic patterns can sometimes obscure focal findings. There were no epileptiform features. No electrographic seizures were noted. . [**2200-12-17**] CXR: 1. Large left pleural effusion. 2. Newly placed right PICC line with tip projected over the upper to mid SVC. . [**2200-12-16**] Pleural fluid cytology: NEGATIVE FOR MALIGNANT CELLS. . [**2200-12-18**] CXR: Slight mediastinal shift and nonvisualization of the contour of the left hemidiaphragm suggests the presence of remaining air in the left pleura. Additionally, there should be mild-to-moderate left-sided pleural effusion. Patchy atelectasis at the right lung base. The cardiac silhouette is unchanged. . [**2200-12-19**] CXR: Interval increase in bilateral pleural effusions with worsening of bibasilar retrocardiac atelectasis. No pulmonary edema, no consolidations worrisome for pneumonia. . [**2200-12-20**] MRI Brain: 1. Study limited due to significant motion artifacts. 2. Acute infarcts in the right cerebellar hemisphere (at the junction of the superior-inferior portions); small acute infarct in the left medulla superiorly. 3. Nonvisualization of the posterior inferior cerebellar arteries, unclear if this represents disease versus related to the field of view and artifacts on the technique. 4. Limited assessment on the MR angiogram and the MR venogram. Patent V4 segments of the vertebral arteries, basilar, and internal carotid arteries. Brief Hospital Course: 75 y/o M with CKD, HTN, bladder/prostrate [**Hospital 4699**] transferred from outside hospital altered mental status and VRE/Proteus UTI now with altered mental status of unclear etiology. During his stay, an extensive workup for his altered mental status was performed in addition to the workup performed at the outside hospital. EEG showed no active seizures, LP showed no meningitis or other infection. Both neurology and rheumatology were consulted to help determine the causes for encephalopathy, but no clear etiology was determined. After discussion with his family and review of his living will, which indicated that he didn't want any life-prolonging measures in the event of a poor prognosis, treatment was withdrawn and feeding tube removed. He expired approximately three days after this decision was made. . Other issues during the hospitalization: . # Resp acidosis: Data was not entirely consistent with initial bicarb 11 and repeat was 23. Repeat ABG confirms resp acidosis with gas 7.13/70/86, and lactate 1.1. Unclear etiology, but may be related to CNS disease and low respiratory drive. Of note recently was treated for aspiration pneumonia with levo/flagyl. No evidence of aspiration event. . # CKD. Required HD during a septic episode last fall. Kidney biopsy revealed focal active glomerulitis. Had stable Cr to 2.6 at OSH; unclear baseline. Recently started on prednisone in middle of [**Month (only) 1096**]. Renal team was following and all medications were dosed for low creatinine clearance. He received 4 cycles of hemodialysis with resolution of his uremia but no improvement in mental status. . # Aspiration pneumonitis/pneumonia. Given O2 as needed and completed course of levofloxacin/metronidazole for aspiration pneumonitis/pneumonia. . # Hypernatremia. Multiple etiologies, including decreased PO intake, decreased free water intake, low intravascular volume. Given boluses and free water with resolution of hypernatremia. . # VRE/Proteus UTI. Developed a pan-resistant VRE UTI at OSH and had not yet been started on treatment (was on Levo/Clinda/Flagl). Completed course of levofloxacin and daptomycin for Proteus and VRE, respectively. . # HTN. Continued metoprolol 50mg [**Hospital1 **]. . # Anemia. Unclear baseline. Hct stable 30-34 as it was at OSH. Medications on Admission: Home meds: Flagyl 500mg QID Lopressor 50mg PO BID Protonix 40mg Daily Reglan 5mg QID Remeron 15mg Daily Bactrim 800mg [**Hospital1 **] Bicitra 30ml [**Hospital1 **] Procrit 10,000 units SC qWeek (thursday) Thorazine 25mg po BID prn Tylenol #3, 1 tab PO Q6H prn Ensure 1 can [**Hospital1 **] . Meds on transfer from OSH(although not taking PO meds) Daptomycin 300mg IV Q48H Heparin 5000U subQ TID Insulin SC Methylprednisolone 40mg IV Q12H Acetaminophen 650mg PR Q6H:PRN Metoprolol 50mg PO BID Dulcolax 10mg PR QHS: PRN Pantoprazole 40mg IV Q24H Sarna Lotion Cyanocobalamin 50mcg PO daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]

[ "285.21", "518.81", "578.9", "287.4", "V10.51", "041.04", "349.82", "585.6", "276.0", "V10.46", "403.91", "V66.7", "511.9", "V09.80", "041.6", "458.9", "V44.6", "599.0", "434.91", "584.9", "507.0" ]

icd9cm

[ [ [] ] ]

[ "03.31", "34.91", "38.93", "38.95", "93.90", "99.04", "39.95", "96.6" ]

icd9pcs

[ [ [] ] ]

19335, 19344

16373, 18668

310, 371

19395, 19404

2776, 16350

19460, 19582

2398, 2429

19307, 19312

19365, 19374

18694, 19284

19428, 19437

2444, 2757

249, 272

399, 1903

1925, 2183

2199, 2382

77,927

177,095

49339

Discharge summary

report

Admission Date: [**2150-12-30**] Discharge Date: [**2151-1-20**] Service: MEDICINE Allergies: Morphine / Bactrim / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 689**] Chief Complaint: Syncope, shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 89 F with history of breast cancer s/p lumpectomy in [**2145**], dementia, atrial fibrillation, PSVT, orthostatic hypotension and history of syncopal episodes and multiple falls with recent C2/3 spinous process fractures in [**10-5**], who presents after a syncopal episode with C2 spinous process fracture on CT. Patient was in USOH at rehab (where she has had several falls), when to the bathroom to urinate, became dizzy, syncopized and "hit the floor" quickly. She landed on her left side, and is not sure whether she actually lost consciousness. (event not witnessed). She cannot recall any prodromal symptoms other than dizziness. She was brought to [**Hospital1 **] [**Location (un) 620**], where she was found to be hypoxic to 87% on RA, Head CT neg, CXR showed fluffy bilateral infiltrates read as pulmonary edema, shoulder and pelvic XRay without fracture, and CT neck showed "subacute C2 fracture." She received Ceftriaxone and was sent to [**Hospital1 18**] [**Location (un) 86**] for further management. . The patient has had prior admissions for syncope, which is thought to be secondary to orthostatic hypotension. She has had a 24 hour holter monitor during a symptomatic episode, which showed sinus bradycardia in the 50s. She is followed by Dr. [**Last Name (STitle) **] of gerontology for her othostatic hypotension, who recently increased her florinef to 0.1 mg daily in [**Month (only) 1096**] [**2149**]. Past Medical History: Atrial fibrillation Hypothyroidism Breast cancer s/p lumpectomy [**2145**] Anemia s/p CCY s/p shoulder surgery Social History: widow of [**Hospital1 **] pediatrician Dr [**Known lastname 6174**], No ETOH, smoked for ~10 years, quit ~60 years ago, no illicit drugs. lives alone, functionally independent, no cane or walker Family History: Noncontributory - Mother died of MI in 80s. Father died of unknown type of cancer. Physical Exam: On admission: VS - Temp 96.5 F, BP 184/76, HR 76, R 20, O2-sat 97% 3L orthostatics neg per nursing GENERAL - well-appearing elderly female in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - fine crackles midway up b/l, with anterior rales b/l 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) SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, decreased strength throughout, gait not assessed Rectal: stool guaiac + Pertinent Results: LABS ON ADMISSION: [**2150-12-30**] 09:35AM BLOOD WBC-10.8 RBC-3.73* Hgb-10.0* Hct-31.2* MCV-84 MCH-26.8* MCHC-32.1 RDW-15.2 Plt Ct-329 [**2150-12-31**] 06:30AM BLOOD WBC-9.6 RBC-3.34* Hgb-9.2* Hct-28.0* MCV-84 MCH-27.7 MCHC-33.0 RDW-15.1 Plt Ct-292 [**2150-12-31**] 03:20PM BLOOD Hct-31.1* [**2151-1-1**] 06:00AM BLOOD WBC-12.3* RBC-3.54* Hgb-9.8* Hct-30.2* MCV-85 MCH-27.7 MCHC-32.4 RDW-15.2 Plt Ct-355 [**2150-12-30**] 09:35AM BLOOD Neuts-84.3* Lymphs-9.5* Monos-5.4 Eos-0.6 Baso-0.3 [**2150-12-30**] 09:35AM BLOOD PT-11.9 PTT-23.6 INR(PT)-1.0 [**2151-1-1**] 06:00AM BLOOD Glucose-132* UreaN-17 Creat-0.9 Na-134 K-4.0 Cl-97 HCO3-25 AnGap-16 [**2151-1-1**] 06:00AM BLOOD ALT-39 AST-31 LD(LDH)-354* AlkPhos-87 TotBili-0.5 [**2150-12-30**] 09:35AM BLOOD CK-MB-3 proBNP-4668* [**2150-12-30**] 09:35AM BLOOD cTropnT-<0.01 [**2150-12-30**] 07:20PM BLOOD CK-MB-2 cTropnT-<0.01 [**2151-1-1**] 06:00AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1 [**2150-12-30**] 09:35AM BLOOD D-Dimer-2920* [**2150-12-30**] 09:35AM BLOOD TSH-6.1* [**2151-1-1**] 06:00AM BLOOD T3-42* MICRO: [**2150-12-31**] URINE CULTURE - NO GROWTH IMAGING: -EKG [**2150-12-30**]: Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2150-10-4**] there is no significant diagnostic change. -CXR [**2150-12-30**]: Diffuse bilateral opacities may represent pulmonary edema or ARDS, although infectious process not excluded. -C-SPINE (AP, FLEX & EXT): No significant interval change. Unchanged, grade 1 anterolisthesis of C4 on C5 which normalizes with extension. Unchanged severe degenerative changes. -CTA CHEST W&W/O C&RECONS, NON-CORONARY: 1. No evidence of pulmonary embolus. 2. Diffuse bilateral ground glass and interstitial pulmonary opacities. Differential includes ARDS or pulmonary edema. Superimposed infectious process not excluded. Recommend chest radiograph after diuresis for further evaluation. 3. Bilateral small pleural effusions. 4. Mild mediastinal lymphadenopathy may be reactive. -ECHO: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60-70%). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**11-28**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2149-9-5**], the apparent pulmonary artery systolic pressure is markedly increased. CXR [**2150-12-31**]: AP chest compared to [**12-30**] and baseline examination [**5-15**]: Symmetrically distributed coarse peribronchial opacification is probably pulmonary edema worsening in some areas of the lungs, relatively sparing others because of emphysema and relatively mild pulmonary fibrosis. Moderate cardiomegaly with particularly severe left atrial enlargement is longstanding. Pleural effusion is small if any. An alternative to atypical pulmonary edema would be multifocal interstitial pneumonia and particularly viral. Brief Hospital Course: Upon admission to the medicine team, she was afebrile, but had a chest xray concerning for multilobular pneumonia, and possibly also for changes consistent with pulmomnary fibrosis from Amiodarone, which she had been taking since [**2144**] for A Fib. She was started on antibiotics (Cefepime, Cipro and Vancomycin for HAP), and methylprednisolone 80mg q8h for treatment of amiodarone toxicity, as well as albuterol and ipratropium nebulizers for symptomatic treatment. Over a period of four days her oxygen requirement improved from 6 liters to 3 liters and she seemed to be markedly improving. . On [**1-4**], the patient became tachypneic, began grasping at her throat, and was unresponsive to commands. A code blue was called. Upon the ICU team's arrival to the patient she was being intubated. She continued to have a pulse, but was bradycardic to low 30s, with BP 60/palp. Pulse became weak. She was given Atropine 0.5mg x2, and started on a Dopamine gtt. About 1 minute into the drip, HR was >100 and SBP rose to 210. Doapmine was stopped and she was transfered to the MICU, placed on the ventilator and sedated on Versed and Fentanyl. Her post-arrest lactate was 7.2, but by midnight it was 1.7. On [**1-5**] she was bronchoscoped, and her steroids were continued for presumed Amiodarone pulmonary toxicity. She could not be immediately weaned from the vent, and in fact on [**1-6**] required an increase in FiO2 from 50% to 60% and PEEP of 8. Of note, she had a BNP of 9540. On [**1-7**], tube feeds were started, and a CT of her chest was interpreted as an acute CHF exacerbation superimposed on chronic Amiodarone lung toxicity processes. Weaning from the vent remained [**Name (NI) 2480**], and discussions were held with the patient's son and family meetings arranged. On [**1-9**], she was still intubated, and her Cefepime and Vancomycin completed a 7-day course for HAP and were discontinued. She did spike a temp of 100.9 and had cultures and C Diff studies sent, all of which were ultimately negative. On [**1-10**] for elevated potassiums (with normal EKGs) she received kayexalate, and on [**1-11**] she was diursed with Lasix. She became hypernatremic at 150, received D5W and free water tube feed flushes, and her hypernatremia resolved back into normal ranges by [**1-12**]. On [**1-13**] she was extubated successfully, and her steroid dosing was changed to 1 mg/kg/day. Upon extubation she was withdrawn and at times difficult, for example refusing all nursing attention on [**1-14**]. Tube feeds were begun. On [**1-15**], after a family meeting, she was made a DNR/DNI. The patient was subsequently transferred out of the ICU to the regular medicine floor. Over the next several days, the patient's oxygen requirement and her work of breathing increased. On [**1-18**], after several family meetings with the primary medical team and the palliative care team, the patient was made CMO and a dilaudid drip initiated for comfort. The patient died on the evening of [**2151-1-20**]. Medications on Admission: -ALENDRONATE 70 mg PO weekly -AMIODARONE HCL - 200MG PO daily -Tylenol 1000 mg q6h prn -FLUDROCORTISONE [FLORINEF] - 0.1 mg daily (increased [**11-4**]) -Levothyroxane - 100MCG daily -phenylephrine 10 mg daily (started in [**Month (only) **]) -ASPIRIN - 325 mg daily -Niferex 150 mg daily -Vit D 1000 U PO daily -Prilosec 20 mg daily -Oscal 600/vit D [**Hospital1 **] -Prozac 10 mg daily Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired

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icd9cm

[ [ [] ] ]

[ "38.93", "33.24", "96.6", "96.72", "96.04" ]

icd9pcs

[ [ [] ] ]

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179,992

50639

Discharge summary

report

Admission Date: [**2121-1-21**] Discharge Date: [**2121-1-24**] Date of Birth: [**2036-2-24**] Sex: F Service: MEDICINE Allergies: Zestril Attending:[**First Name3 (LF) 689**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: None. History of Present Illness: Mrs. [**Known lastname **] is a 84-year-old woman with history of obesity, hypertension, diabetes, type II, coronary artery disease, heart failure (LVEF 26%), COPD, atrial fibrillation, dementia, HTN and multiple myeloma presented from [**Hospital3 2558**] with shortness of breath for several days and worsened lower extremity edema. [**Known firstname 4248**] is responsive, pleasant and interactive, but dementia is evident. She does not know why she is here and denies shortness of breath. Shortnessof breath was noted for several days at [**Hospital3 2558**] with some increased work of breathing. Hypoxia to 85% O2Sat on was noted on the day of admission. EMS were called. She received furosemide 80 mg IV x 1 and nitroglycerin by EMS en route. In the ED, initial VS: T 96.8, HR 82, BP 121/73, RR 20, 100%4LNC. Her BNP was 12 511 (baseline 4000s). Cr was 2.3. ABG was 7.35/57/61/33. CXR showed L base atelectasis and no infiltrate. Head CT was negative. Patient was somnolent and had altered mental status in ED, very similar to her known baseline. But ED team was concerned and wanted MICU admission. On transfer to the ICU, her vitals T 96.9, HR 69, BP 90/47, RR 16, O2 sat 99%2L. She had put out 500 cc of urine. In the MICU her mental status was observed to wax and [**Last Name (un) **] with periods of near unresponsiveness. Fluid balance in the MICU was -240 cc net. BiPAP was not needed. She is now saturating to high 90s % on room air, without nasal cannula. Hematocrit was noted to drop between the ED and MICU, but the patient has not yet stooled, nor has guaiac been performed. There is a tinge of blood in her urine, but a Foley was either placed or replaced on admission (not clear if she has at baseline). In the MICU her blood pressure has been around 100 systolic. She has been afebrile. 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 of 35-40% in echo in [**6-25**], 3+ MR. 7. Atrial Fib with adm in [**7-31**] for RVR (anticoagulated) 8. Chronic kidney disease with baseline creatinine of 1.4 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: Used to live with daughter until recent hospitalization at NEBH with CHF exaccerbation. Currently living at [**Hospital3 2558**]. Now patient requires wheel chair for mobility, per daughter. Denies tobacco/alcohol. Family History: Sister with coronary artery disease. Physical Exam: Physical Exam on Transfer from the MICU (similar to status at admission to MICU): General: Elderly woman, slightly overweight, Alert, oriented, apparently greater than normal work of breating with unclear baseline. Hunched posture sitting leaning to right in bed. HEENT: Sclera anicteric but with some injection, MMM, oropharynx clear.. Neck: Supple, JVP not elevated when at 30 degrees (actually flat), no LAD. Lungs: Clear to auscultation bilaterally, trivial crackles in the bases, some transmitted upper airway sounds, impression of some COPD based on cardiac auscultation and slightly slow exhalation. CV: Distant sounds, normal S1 with quiet S2, no murmurs, rubs, gallops appreciated. 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. No pitting edema, some venous stasis dermatitis. Skin: Some venous stasis dermatitis. Neuro: Difficult arouse, but then to alertness, responsive. Oriented to hospital, self, but not context. Appears deconditioned and impression is that she likely does not walk at baseline - gait not tested. Moving all limbs spontaneously. Pertinent Results: [**2121-1-21**] 06:59PM WBC-4.5 RBC-2.58* HGB-8.1* HCT-25.2* MCV-98 MCH-31.3 MCHC-32.0 RDW-14.6 [**2121-1-21**] 06:59PM NEUTS-68.1 LYMPHS-20.4 MONOS-2.8 EOS-8.4* BASOS-0.4 [**2121-1-21**] 06:59PM PLT COUNT-302 [**2121-1-21**] 06:59PM PT-31.5* PTT-37.1* INR(PT)-3.2* [**2121-1-21**] 06:59PM GLUCOSE-89 UREA N-36* CREAT-2.3* SODIUM-146* POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-26 ANION GAP-14 [**2121-1-21**] 06:59PM cTropnT-0.02* [**2121-1-21**] 06:59PM CK-MB-3 proBNP-[**Numeric Identifier 105371**]* [**2121-1-21**] 06:59PM CALCIUM-8.0* PHOSPHATE-3.7 MAGNESIUM-2.0 CXR: There is moderate cardiomegaly, unchanged. There are low lung volumes. There is no focal consolidation, pleural effusion or pneumothorax. There is left basilar atelectasis. The pulmonary arteries are prominent bilaterally and there is mild increased interstitial markings. Multilevel degenerative changes of the thoracic spine, including compression deformities are noted. Severe degenerative changes of the left shoulder are unchanged. Head CT: There is no acute intracranial hemorrhage, major vascular territorial infarction, mass effect, or edema. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Periventricular white matter hypodensity is unchanged and consistent with chronic small vessel ischemic disease. Age-appropriate prominence of ventricles and sulci is consistent with diffuse parenchymal volume loss, unchanged from prior. There may be mild mucosal thickening in the ethmoid sinuses, but evaluation is limited due to patient motion. The remainder of visualized paranasal sinuses and mastoid air cells are well aerated. No osseous abnormality is identified. Globes and lenses are intact. There is calcification of the bilateral cavernous carotids. Urine [**2121-1-23**] 09:50AM URINE Color-Pink Appear-Hazy Sp [**Last Name (un) **]-1.010 [**2121-1-23**] 09:50AM URINE Blood-LG Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2121-1-23**] 09:50AM URINE RBC->50 WBC-[**5-1**]* Bacteri-FEW Yeast-NONE Epi-0-2 Cardiology Report ECG Study Date of [**2121-1-21**] 6:44:08 PM Sinus rhythm. Right bundle-branch block. Compared to the previous tracing of [**2120-11-27**] variation in precordial lead placement. Otherwise, no diagnostic interim change. Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 81 [**Telephone/Fax (3) 105372**]/466 1 -140 27 Brief Hospital Course: This 84-year-old woman had an episode of desaturation on several days of more labored breathing. Likely CHF exacerbation. Mental status appears to be at baseline, with dramatic variation in level of arousal (see below), worse than typical baseline per her daughter. Breathing improved with diuresis and mental status also seemed improved over the course of the admission. She will return to [**Hospital3 2558**]. Shortness of Breath and Desaturation Likely CHF exacerbation. BNP elevated at [**Numeric Identifier 890**] from 4800 in [**2120-11-22**]. Respiratory status rapidly improved after furosemide 80 mg IV x 1 by EMS. Also with evidence of COPD exacerbation on exam. No evidence of pneumonia, ACS, tachyarrhthmias. Stable oxygen saturation on 2L NC then room air at admission at then to 99% on room air at transfer to the floor (the next day). Patient had no respiratory distress by the time she was transferred to the floor. For her COPD, she was given nebulizers prn. Restarted home Lasix dose (although IV - gave 20 mg) today. Home Lasix dose is not clear based on records from admission (not in admission note, but 40 mg and 60 mg doses hand written on [**Hospital3 2558**] notes). Given wheeze, is likely that COPD is also present. Albuterol and ipratropium nebulizer treatements were given in-house. Altered Mental Status and Functional Status Actually appears to be at baseline per [**Hospital3 2558**] and more difficult to rouse per daughter. [**Name (NI) 650**] dementia, with very high arousal threshold. Numerous etiologies were considered: Reversible causes of dementia, dementia/neurodegenerative disorder, medication toxicity. Reversible causes in this case primary inlude B12 deficiency and hypothyroidism. TSH and B12 were checked: TSH was 5.0 suggesting the need for likely supplemental thyroxine. B12 was high normal. T3, T3 uptake and T4 are pending at the time of discharge. This may require further outpatient work-up or the addition of levothyroxine if T4 is found to be low. Without the rest of the panel, it is not possible to interpret her high TSH and start treatment, although the most likely cause is hypothyroidism at the level of the thyroid (rather than central hyperthyroid). Difficulty in arousing the patient from sleep may relate to dementia and hypothyroidism. However, primary disorders of the arousal system, rather than cortical dementia are worth considering. Our research in Dr. [**First Name4 (NamePattern1) 5699**] [**Last Name (NamePattern1) **] lab is suggestive of the parabrachial area as important in arousal and awakening from sleep, so it would be of academic interest to see how this area appears on MRI, but would unlikely be of clinical import. Given that it is unlikely that the patient would feel comfortable during MRI, we did not perform this. CT is not adequate for evaluation of the various components of the arousal system. Another contributor that was considered was supratherapeutic phenytoin level (due to present renal insufficiency, although this degree of renal insufficiency is unlikely to require dose adjustment being mostly hepatically metabolized). The target dose for an elderly patient is at the bottom or even slightly below the typical therapeutic range. The result was 9.7 and the typical therapeutic range is [**9-10**] for an adult, but this level is likely appropriate for an elderly patient. Seizure Disorder No seizures during admission. Dilantin (phenytoin) was continued. Supratherapeutic INR and Atrial Fibrillation Continue outpatient medications: Amiodarone. Allow INR to drift down. Peaked at 3.6 yesterday, so we did not restart coumadin before discharge. This will need to be restarted when her INR is less than 3.0 and likely at a dose of about 5 mg per day (she was on 6 mg previously). Hypertension Presently not active problem. Unclear why not on ACE/[**Last Name (un) **] at home, given ejection fraction of 26%. We did not start this here given renal failure. Acute Renal Failure Cr 2.2 on admission. Most likely a combination of poor forward flow in context of CHF exacerbation effect of furosemide. Evidence for this is improvement with diuresis. Despite giving furosemide, creatinine fell. Another likely contributor is multpile myeloma. This is supported by previous electrophoresis and protein in urine. Hypernatremia Possible salt load as etiology, but not obvious cause. Na is actually similar to level when she was discharged in [**Month (only) 404**] [**2120**]. Gradually and carefully adjust given possible CHF exacerbation, with sodium restriction only (rather than giving additional hypotonic fluid). Urinanalysis with WBC and Blood Not impressive enough to treat, but should be followed. Hematuria has been a chronic problem and may warrant further work-up at the discretion of her PCP. [**Name10 (NameIs) **] was not futher investigated while an inpatient. Multiple Myeloma Appears stable at present. Nothing to do. Followed by Hem.-Onc. Diabetes Only one supplemental dose of two units of regular insulin was given on one evening. Glucose was otherwise normal during the admission. Medications on Admission: Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: 12 hours on, 12 hours off. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (SA) as needed for Saturday. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Phenytoin 50 mg Tablet, Chewable Sig: Five (5) Tablet, Chewable PO Q12H (every 12 hours). Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). warfarin 6 mg Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (SA). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Phenytoin 50 mg Tablet, Chewable Sig: Five (5) Tablet, Chewable PO BID (2 times a day). 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day: Please hold until INR < 3.0. Dose may need to be adjusted downward. 12. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once a day. 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H:PRN as needed for shortness of breath or wheezing. 16. Epogen 10,000 unit/mL Solution Sig: One (1) Injection once a week. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] Discharge Diagnosis: Primary Exacerbation of congestive heart failure (systolic dysfunction with LVEF of 26%). Wheeze consistent with COPD. Secondary Dementia Renal Failure Hematuria Discharge Condition: Level of Consciousness: Lethargic but arousable Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You came to the hospital after a few days of more difficulty with breathing and increased sleepiness. We found that you were slightly volume overloaded here, secondary to your heart failure, and diuresis of this fluid had already commenced at the nursing and during the trip here. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: SURGICAL SPECIALTIES When: FRIDAY [**2121-1-31**] at 1:30 PM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/BMT When: WEDNESDAY [**2121-3-5**] at 10:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2121-3-19**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14542, 14589

6903, 10441

288, 295

14796, 14914

4367, 5392

15333, 16279

3102, 3140

13183, 14519

14610, 14775

12074, 13160

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3155, 4348

10465, 12048

228, 250

323, 2141

5401, 6878

2163, 2854

2870, 3086

44,018

113,295

42199

Discharge summary

report

Admission Date: [**2155-10-21**] Discharge Date: [**2155-11-27**] Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 371**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2155-10-21**] ERCP for stent placment [**2155-10-26**] PICC line placement [**2155-11-5**] exploratory laparotomy, lysis of adhesions History of Present Illness: Ms. [**Known lastname **] is an 88 year old woman with h/o HTN, who presented to [**Hospital3 **] with abdominal pain and fevers, transferred to [**Hospital1 18**] for management of cholangitis. . Patient presented to [**Hospital3 **] today with abdominal pain and fevers x1 day. ASA 325mg PO x1 given by EMS. At the OSH ED, VS: T 99.0 BP 120/44 HR 140 RR 21 O2sat 92% 2LNC, 95% 4LNC. She was given 1LNS, Lopressor 25mg PO x1, Nitro 0.4mg SL x1, Zofran 4mg IV x1, Morphine 2mg IV x1, Tylenol 625mg PO x1, Imipenem 500mg IV x1, Flagyl 500mg IV x1. CT abd/pelvis concerning for cholangitis vs pancreatitis, so the patient was transferred to [**Hospital1 18**] for possible ERCP. . In the ED, initial vs were: 96.7 50 86/44 19 96% 4L Nasal Cannula. Patient was AOx3 initially, complaining of severe abdominal pain. Per ED report, patient wanted everything to be done at that time. Given bradycardia and hypotension, patient was intubated, sedated with Fentanyl/Versed, CVL was placed. HR improved to the 70s with a dose of Atropine. She was started on Dopamine and Levophed. Given a dose of Vanc and Zosyn, 4L IVF. Surgery and ERCP were notified. Surgery recommends decompression by ERCP. ERCP planning to intervene around 6am in the ICU. Given concern for ?CCB/BB overdose, patient was given a dose of Calcium chloride in the ED. Bedside ECHO showed poor contractility. Vital prior to transfer: P 97 BP 133/60 RR 16 O2sat 100%. Patient has PIVs and CVL. . On the floor, patient is intubated and sedated. . Review of sytems: unable to assess Past Medical History: HTN Depression COPD MGUS Osteopenia GERD, treated for Hpylori in the past Cardiac cath [**2151**] - minimal, non-obstructive disease Social History: No tobacco/EtOH. Lives alone in her home. Husband and son are deceased. Friend [**Name (NI) 5969**] is HCP. Only family is nephew in [**Name (NI) 2784**]. Family History: unknown Physical Exam: On admission: Vitals: T: 98.4 BP: 154/65 P: 108 R: 20 O2: 100% Vent: FiO2 50%, TV 470, RR 20, PEEP 5 General: intubated, sedated HEENT: Sclera anicteric, ETT in place Neck: supple, no LAD Lungs: Clear to auscultation anteriorly CV: tachy, then brady, S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, bowel sounds present, tender abdomen GU: foley Ext: cool extremities, + distal pulses, no clubbing, cyanosis or edema Neuro: intubated, sedated On discharge: General: A&O, flat affect, speech clear and coherent Lungs: bilateral wheezes occasionally CV: normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, slightly distended, bowel sounds present, mildly tender to palpation Ext: + distal pulses, no clubbing or cyanosis, mild LE edema Pertinent Results: [**2155-11-16**] 05:00AM BLOOD WBC-8.5 RBC-3.01* Hgb-9.0* Hct-28.7* MCV-96 MCH-29.9 MCHC-31.2 RDW-15.3 Plt Ct-168 [**2155-11-15**] 07:00AM BLOOD WBC-7.1 RBC-2.94*# Hgb-8.8*# Hct-27.4* MCV-93 MCH-29.8 MCHC-32.0 RDW-15.1 Plt Ct-158 [**2155-11-15**] 04:59AM BLOOD WBC-5.7 RBC-2.35*# Hgb-7.0*# Hct-22.4* MCV-95 MCH-29.9 MCHC-31.4 RDW-15.4 Plt Ct-122* [**2155-10-21**] 02:53PM BLOOD WBC-26.9* RBC-2.73* Hgb-8.4* Hct-25.6* MCV-94 MCH-30.9 MCHC-32.9 RDW-17.6* Plt Ct-235 [**2155-10-21**] 04:15AM BLOOD WBC-32.1* RBC-2.77* Hgb-8.6* Hct-25.7* MCV-93 MCH-31.0 MCHC-33.4 RDW-16.9* Plt Ct-311 [**2155-10-20**] 11:20PM BLOOD WBC-33.9* RBC-3.06* Hgb-9.4* Hct-28.2* MCV-92 MCH-30.8 MCHC-33.5 RDW-16.9* Plt Ct-304 [**2155-11-5**] 04:01PM BLOOD Neuts-86.5* Lymphs-7.5* Monos-5.5 Eos-0.3 Baso-0.3 [**2155-11-16**] 05:00AM BLOOD Plt Ct-168 [**2155-11-15**] 07:00AM BLOOD Plt Ct-158 [**2155-11-12**] 04:48AM BLOOD Plt Ct-72* [**2155-11-11**] 09:47AM BLOOD Plt Ct-60* [**2155-11-17**] 05:21AM BLOOD Glucose-119* UreaN-31* Creat-0.7 Na-139 K-4.1 Cl-103 HCO3-34* AnGap-6* [**2155-11-16**] 05:00AM BLOOD Glucose-124* UreaN-28* Creat-0.7 Na-139 K-3.7 Cl-101 HCO3-34* AnGap-8 [**2155-10-23**] 04:51PM BLOOD Glucose-179* UreaN-39* Creat-2.0* Na-142 K-3.5 Cl-109* HCO3-19* AnGap-18 [**2155-10-23**] 04:07AM BLOOD Glucose-74 UreaN-36* Creat-1.8* Na-141 K-3.5 Cl-110* HCO3-20* AnGap-15 [**2155-10-20**] 11:20PM BLOOD Glucose-150* UreaN-24* Creat-1.3* Na-137 K-4.1 Cl-101 HCO3-26 AnGap-14 [**2155-11-4**] 05:50AM BLOOD ALT-6 AST-15 LD(LDH)-191 AlkPhos-90 TotBili-0.7 [**2155-11-2**] 05:52AM BLOOD ALT-10 AST-17 LD(LDH)-169 AlkPhos-69 TotBili-0.6 [**2155-10-21**] 04:15AM BLOOD CK-MB-3 cTropnT-<0.01 [**2155-10-20**] 11:20PM BLOOD cTropnT-<0.01 [**2155-11-16**] 05:00AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.1 [**2155-10-31**] 05:49AM BLOOD calTIBC-185* VitB12->[**2143**] Folate-12.9 Ferritn-448* TRF-142* [**2155-10-31**] 05:49AM BLOOD Triglyc-167* [**2155-10-21**] 04:15AM BLOOD TSH-0.79 [**2155-11-6**] 02:52AM BLOOD Glucose-97 [**2155-11-5**] 02:46PM BLOOD Glucose-145* Lactate-2.4* Na-134 K-4.1 Cl-101 [**2155-11-6**] 02:52AM BLOOD freeCa-1.10* [**2155-11-5**] 02:46PM BLOOD freeCa-1.10* [**2155-10-20**]: EKG: Baseline artifact. Probable atrial fibrillation with a controlled ventricular response. Left axis deviation. Consider left anterior fascicular block. No previous tracing available for comparison. Clinical correlation is suggested. [**2155-10-21**]: ERCP; A periampullary diverticulum was seen and the papilla was inverted within the diverticulum. Multiple attempts were made to cannulate with the patient in the supine position, however, it was not possible to approach the ampulla en-face. The patient was then rotated onto the left side. Successful cannulation was achieved after manipulating the diverticulum with the sphincterotome. The procedure was highly difficult. Fluoroscopic views were limited due to the portal C-arm and patient positioning, so aspiration was performed to confirm biliary location. Pus was aspirated from the bile duct. Contrast medium was injected resulting in partial opacification. The wire could not pass beyond the mid-CBD. A 5cm by 10FR biliary stent was placed successfully in the bile duct, with immediate passage of pus and small stone fragments Otherwise normal ERCP to 3rd part of duodenum [**2155-10-24**]: ECHO: The left atrium is dilated. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is lipomatous hypertrophy of the interatrial septum. No mass is seen in the left atrium. The prior study of [**2155-10-22**] was also reviewed. Based on review of both studies, the echodense region in the left atrium is consistent with artifact. [**2155-10-25**]: X-ray of the abdomen: FINDINGS: Technically limited radiograph. No safe evidence of free air. Upper abdominal endo-drain in situ. No pathological calcifications. Moderate distention of bowel loops with multiple air-fluid levels on the left lateral decubitus view. No bowel wall thickening. CT [**11-12**]- layering pleural effusions, atelectasis, PO contrast through small and large bowel to rectum, normal bowel loops, mesenteric haziness, perihepatic ascites, postERCP pneumobilia, cbd stent, trace free fluid in pelvis [**2155-11-20**]: x-ray of the abdomen: Impression: No ileus or obstruction Brief Hospital Course: Ms. [**Known lastname **] is an 88 year old woman with h/o HTN, who presented with acute cholangitis s/p ERCP with stent, whose course has been complicated by sepsis, with improving pressures throughout the hospitalization. Her course has also been complicated by respiratory failure, ARF, delirium, and partial SBO/ileus. Medical course ([**Date range (3) 91498**]): . #. cholangitis/sepsis: ERCP was performed and stent placed in biliary duct. Biliary tree was incompletely visualized however stones and pus were released following stent placement. LFTs downtrended and patient was treated with Zosyn, switched to cefazolin when sensitivities returned with pan-sensitive e.coli from OSH cxs, no further cxs positive at [**Hospital1 18**]. Pt did require pressor support for a short amount of time initially while in the ICU. . # Atrial fibrillation: New diagnosis during her stay. She was initially managed with IV diltiazem drip in the ICU and then shifted to diltiazem 90 mg four times a day. She was called out of the ICU in stable condition. While on the medical floor, NG tube was replaced given worsening of her abdominal pain and distension. During relpacement, she went into Aflutter with RVR at rate of 180's but remained hemodynamically stable and asymptomatic. She was given diltiazem 10mg and rate decreased to low 100's, then up to 150's and received another 10mg dilt. Cardiology was consulted who recommended diltiazem 20mg IV, given with HR into 90's however her HR went back to 150's. Her BP was in the 140-150's. She was transferred to inpatient cardiology floor for further management. There, she was initiated on diltiazem drip along with iv metoprolol 5 mg every six hours. The next day her rhythm was sinus in rate of 70's-80's with occasional bursts into Afib. IV diltiazem was discontinued and metoprolol IV was resumed. Given she had bowel movements and her residual after NG tube clamping was only 100 cc, She was given carvedilol 12.5 mg through the NG tube and transferred back to the medical floor for further management of her other comorbidities. . #. Respiratory failure: Patient intubated for airway protection, as she was bradycardic and hypotensive in the ED. CXR with bibasilar opacities c/w atelectasis and pleural effusion. Initial ABG 7.27/48/114. She was extubated on [**10-22**] with minimal difficutly; agitation controlled with seroquel/haldol. She did desat after extubation, sats improved with diuresis. . #. Bradycardia/tachycardia: Likely [**1-8**] to BB - takes Bisoprolol at home and given Lopressor at OSH. She subsequently became tachycardic with new afib with RVR, requiring dilt drip and eventually transitioned PO dilt. CHADs score of 2, risk/benefit of anticoagulation to be discussed with PCP. . #. Acute renal failure: peaked at 2.1, however now downtrending, likely pre-renal in the setting of hypotension. Cr now stable at 1.2-1.3. . # HTN: BP elevated later in the admission. Initially her HCTZ was restarted. While on the inpatient cardiology floor, this was held. Amlodipine 5 mg daily was given for 2 days ([**10-29**] and [**10-30**]) through NG tube. Carvedilol PO 12.5 mg x1 was given [**10-30**] morning for SBP of 150's-180. Can consider initiating ACEi or [**Last Name (un) **] given her Cr is stable now at 1.2-1.3. . #. COPD: concern for exacerbation given wheezing post-extubation, treated with prednisone x5 days . #. Depression: She expressed her wishes to die but no active plans. home paroxetene which was held initially was restarted while on the cardiology floor. She expressed her misery that her husband and son are dead. Social work was consulted. . #. Concern for L atrial mass: seen on initial ECHO performed to r/o cardiogenic cause of hypotension, not present on repeat ECHO, likely lipomatous hypertrophy of the interatrial septum. . # Partial SBO/ileus: Pt with increasing abd pain on day 6 of the admission. CT showed possible partial SBO, also concerning for ileus secondary to cholangitis. Improved with NG tube with suctioning and supportive care. She was treated conservatively for approximately two weeks. On HD16 was then taken to the OR for failure of conservative management. She underwent exploratory laparotomy with extensive lysis of adhesions. Postoperatively, her care was transferred to the Acute Care Surgical service. Please see section below for hospital course following this transfer. The following describes the patients surgical course and postoperative management up until [**2155-11-23**]. On [**11-23**], after discussion with the patient and family, the decision was made to withdraw medical interventions and transfer the patient to hospice. On [**11-24**], paliative care became involved and she was officially made CMO status. On HD16 she was then taken to the OR for failure of conservative management of her partial SBO. She underwent exploratory laparotomy with extensive lysis of adhesions. Postoperatively, she remained intubated and was thus admitted to the ICU. She was successfully extubated on POD 1. She developed Afib, which was rate-controlled with IV lopressor. She was additionally hyperkalemic, which improved with continued fluid administration. She was transferred to the floor in stable conditon NPO, with an NGT to suction, and on TPN [**2155-11-6**]. On the floor her vital signs were monitored routinely along with her oxygen saturations through until [**11-24**]. Prior to being made CMO, she remained afebrile and hemodynamically stable with intermittent hypertension in the 170s systolic and HR in the 90s. Her pain level was routinely assessed and she was given analgesics as needed thoughout her entire hospitalization. On [**2155-11-7**], her NG tube was removed and her diet was advanced as tolerated. However, on [**2155-11-10**] she developed hypertension, tachycardia and had bilious emesis. Her abdomen was distended and an NG tube was replaced. Her NG output remained high over the following few days, and she was repleted with IV fluids along with the continuing TPN. On [**11-14**] her NG output decreased and the tube was removed. On [**11-17**] she was started on regular diet and her TPN was stopped. She was started on a bowel regimen and also given fleets enemas as needed. She continued to have evidence of bowel function, including passing flatus and stool (also see abd xray from [**11-20**] under results section). However, she displayed poor PO intake. Calorie counts were performed for three days during her posoperative course, in which she did not have adequate intake. The possibility of a PEG tube placement was discussed with the patient, her nephew and her health care proxy, all of whom decided that the patient did not want a PEG tube (see last paragraph for details). A foley was replaced perioperatively for urine output monitoring. It was removed on POD2. However, she was incontinent after and it was difficult to monitor her urine output, so it was replaced on [**11-11**]. On [**11-24**], her foley was removed as her care was transitioned to comfort measures only. Her hematocrit was monitored throughout her postoperative course and she was given blood transfusions in the initial postoperative phase as needed, to which she responded appropriately. Her electrolytes were also monitored and repleted as needed. However, after being made CMO, all lab draws were stopped. Throughout her postoperative course she had evidence of pleural effusions, atelectasis and pulmonary edema. She was diuresed as appropriate and pulmonary toileting was encouraged. Her intake and output was monitored closely. Her labs were continually monitored, and she showed evidence of a metabolic alkalosis, and diamox was used as a means of diuresis during this phase. She continued to have an oxygen requirement however, and on [**2155-11-18**] she was transferred back to the ICU for tachypnea and concern for her respiratory status. In the ICU, diuresis was continued with a lasix drip as her bicarb had normalized. On [**11-20**], her pulmonary edema on chest xray showed improvement and she was transferred back to the floor, where diuresis was continued with PO lasix. Her respiratory status is currently stable on supplemental oxygen via nasal cannula. However, at present she is refusing most oral medications, including lasix. Physical therapy was consulted postoperatively and she was encouraged to mobilize out of bed as tolerated. However, aggressive PT measures have been withdrawn at this time. She began to develop thrombocytopenia on heparin postoperatively, which was thought to be due to HITT, as her platelets trended back upward to normal after discontinuing heparin. Therefore, she was placed on fondaparinux and pneumoboots for DVT prophylaxis. This has also been discontinued at this time. Postoperatively, geripsych was involved in the patient's care as the patient continued to expresses her wishes to die, but was also exhibiting signs of delirium. Initially upon evaluation, the psychiatry team deemed her without capacity to make medical decisions. Her health care proxy was [**Name (NI) 653**] who stated to proceed with medical treatment in the initial postoperative phase. However, as the patient became more stable and her bowel obstruction cleared (see above), she continued to express her wishes to die and refused to eat or take oral medications. Social work was involved throughout the hospitalization. The patient's nephew who lives in [**Name (NI) 2784**] was [**Name (NI) 653**] who came to [**Name (NI) 86**] to see the patient. A meeting was held with a member of the surgical team, the social worker and the nephew, after the nephew had a chance to meet with the [**Hospital 228**] health care proxy. The proxy was involved in the meeting via telephone. The decision was made at that time to honor the patient's wishes and cease further medical interventions. Therefore, palliative care was consulted and care was changed to comfort measures only and admitted to hospice. The patient is being discharged to a facility to pursue end of life care. Medications on Admission: Medications (per OSH records): Bisoprolol/HCTZ 5mg/6.25mg PO daily Hydrocodone/Acetaminophen 1tab PO BID Mupirocin 2% cream TP [**Hospital1 **] Paroxetine 30mg PO daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 7. hydromorphone (PF) 1 mg/mL Syringe Sig: 0.25-0.5 mg Injection Q1H (every hour) as needed for pain. 8. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 0.25-0.5 mL PO Q1H (every hour) as needed for pain or dyspnea. 9. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: [**1-10**] mL Injection Q8H (every 8 hours) as needed for nausea. 10. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal at bedtime as needed for constipation. 11. haloperidol 1 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Expired Discharge Diagnosis: 1. pancreatitis 2. small bowel obstruction 3. postoperative ileus 4. atrial fibrillation 5. sepsis 6. acute renal failure 7. delirium Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Confused - sometimes. Discharge Instructions: You were admitted to the hospital with abdominal pain. You had a CT scan of the abdomen done which showed pancreatitis. You underwent an ERCP and placement of a stent into the bile duct. Once the stent was placed you passed a few stones as well as pus. You were started on antibiotics. During this time you dropped your blood pressure and developed signs suggestive of infection. Despite this procedure, your abdominal pain continued and you were taken to the operating room for an exploratory laparotomy and lysis of adhesions for a bowel obstruction. Your bowel function has returned after this procedure. After discussion with you, your family and your health care proxy, the decision was made to transfer you to a facility to pursue end of life care. Followup Instructions: none- comfort measures only Completed by:[**2156-10-27**]

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icd9cm

[ [ [] ] ]

[ "54.59", "38.93", "51.85", "51.87", "99.15", "46.73", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

18983, 18992

7591, 17655

254, 393

19170, 19285

3110, 7568

20133, 20193

2307, 2316

17875, 18960

19013, 19149

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1943, 1962

421, 1925

2345, 2792

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2135, 2291

3,621

191,818

7254

Discharge summary

report

Admission Date: [**2110-3-26**] Discharge Date: [**2110-4-3**] Date of Birth: [**2053-6-3**] Sex: F Service: SURGERY Allergies: Erythromycin Base / Sulfa (Sulfonamides) Attending:[**Last Name (NamePattern1) 4659**] Chief Complaint: colovaginal fistula Major Surgical or Invasive Procedure: loop colostomy History of Present Illness: Ms. [**Known lastname 26825**] is a 56-year-old woman who is status post a total abdominal hysterectomy and oophorectomy for endometrial cancer with postoperative radiation therapy. She subsequently developed hepatic metastases and some thickness in her posterior bladder wall on CT scan. The liver metastases were confirmed by biopsy. Six days ago, she developed stool from her vagina and in her urine along with pneumaturia. She presented to [**Hospital **] [**Hospital **] Medical Center on [**3-26**], and general surgery was consulted. Her pelvic tumor is considered unresectable, and she is currently considered a palliative care candidate. She has significant symptoms from the perineal erosion from the colovaginal fistula. She is now taken to the operating room for a diverting colostomy. Past Medical History: Endometrial Cancer s/p XRT Depression COPD Cor pulmonale morbid obesity PSH: s/p TAH/BSO s/p radial repair of L arm s/p ex-lap/appendiceal abscess Social History: Social / Occupational History: lives alone, sisters / brothers live in same apt building, employed at [**Hospital3 26826**] as telecom manager Living Environment: [**Location (un) **] apt Prior Functional Status / Activity Level: fully independent PTA w/o assistive device, denies falls, has home O2 that uses PRN Physical Exam: T 98.4, HR 84, BP 140/80, R 20 95%RA NAD RRR CTA-B obese, s/nt/nd pt declined pelvic exam, peripad with greenish fluid and fecal matter Brief Hospital Course: Ms. [**Known lastname 26825**] was admitted to the GYN onc service under the care of Dr. [**First Name (STitle) 1022**]. Given a presumed colovaginal fistula, a general surgery consult was obtained for evaluation of surgical management. Given the course of her cancer, it was felt that any procedure would be palliative in nature. A Urology consult was also obtained and agreed that the colovaginal fistula should not be repaired but the patient's symptoms would be best managed with a diverting colostomy. On HD#3, Ms. [**Known lastname 26825**] was taken to the OR by Dr. [**Last Name (STitle) **] for a diverting loop colostomy. She tolerated the procedure well, please see Dr.[**Name (NI) 6218**] Operative Note for detail. She was transferred to the Purple Surgery service under the care of Dr. [**Last Name (STitle) **]. On POD#3, some erythema was noted around the stoma site. The stoma was pink and patent. She was started on Keflex for empiric coverage for a presumed wound infection. By POD #4, Ms. [**Known lastname 26825**] had stool and liquid output from her [**Known lastname 9341**]; the erythema was signifcantly less than the day before. Over the next 24 hours, however, Ms. [**Known lastname 26825**] was noted to have high [**Known lastname 9341**] output. She was checked for C. Difficile on POD #5, but these results were negative. By POD #6, Ms. [**Known lastname 26825**] felt well and was discharged home with services. Medications on Admission: Combivent Albuterol Paxil Unasyn Discharge Medications: 1. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 weeks. Disp:*56 Capsule(s)* Refills:*0* 6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: colovesicular fistula s/p loop colostomy [**2110-3-28**] endometrial cancer depression COPD Discharge Condition: Stable Discharge Instructions: If you have nausea/vomiting, fevers/chills, belly pain, difficulty breathing, seek medical attention. Any increasing redness around stoma site, please seek medical attention. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks, call for an appointment [**Telephone/Fax (1) 26827**] Follow up with Dr. [**Last Name (STitle) 4427**] as needed: [**Telephone/Fax (1) 26828**] Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 26829**]CC3 [**Doctor First Name 147**] SPEC [**Hospital **] CLINIC-CC3 [**Doctor First Name 147**] SPEC Where: CLINICAL CENTER/7TH FL. [**Doctor First Name 147**]. SPEC. CLINICAL CENTER 7 S.SPEC. Phone:[**Pager number 26830**] Date/Time:[**2110-4-6**] 4:20 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]

[ "V10.42", "401.9", "619.1", "197.7", "V15.3", "596.1", "416.9", "278.01", "496", "311" ]

icd9cm

[ [ [] ] ]

[ "46.03" ]

icd9pcs

[ [ [] ] ]

4114, 4173

1852, 3311

326, 343

4309, 4317

4542, 5206

3394, 4091

4194, 4288

3337, 3371

4341, 4519

1692, 1829

267, 288

371, 1172

1194, 1343

1359, 1677

7,449

135,044

52489

Discharge summary

report

Admission Date: [**2138-11-3**] Discharge Date: [**2138-11-13**] Date of Birth: [**2072-8-31**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest pain with exertion Major Surgical or Invasive Procedure: [**2138-11-9**] - Exploration of right groin with thrombectomy of right iliac artery, stenting and bovine patch angioplasty of common femoral artery. [**2138-11-7**] - Coronary bypass graft x4 (saphenous vein graft to obtuse marginal branch, saphenous vein graft to right coronary artery sequential saphenous vein graft to diagonal branch of left anterior descending artery). [**2138-11-3**] - Cardiac Catheterization, coronary angiography History of Present Illness: 66 year old man with progressive chest pain with exertion over the past 6 months. An ETT was performed which was strongly positive. A cardiac catheterization was performed which revealed severe three vessel disease. He was referred for revascularization. Past Medical History: coronary artery disease Status post myocardial infarction in [**9-/2116**] Status post coronary stents to Lcx in [**2118**] and RCA congestive heart failure status post right carotid endarterectomy and stent Hypertension Hyperlipidemia Nephrolithiasis Gout s/p renal artery angioplasty/Stenting bilaterally Colonic polyps Social History: Design draftsman for [**Company 2676**]. Ex-smoker- quit 8 years ago. - approximately 1-2 drinks per day. Family History: Family history positive for CAD: father had MI and died at age 75. Mother died of an MI at age 65. One brother s/p CABG in his 60s. Physical Exam: At the time of discharge Mr. [**Known lastname **] was found to be awake, alert, and oriented times three. His heart was of regular rate and rhythm. His lungs were clear to ausculation bilaterally. His sternal incision was clean, dry, and intact. His abdomen was soft, non-tender, and non-distended. His extremities were warm with 1+ edema (right greater than left). His left sided endovascular site was clean, dry, and intact. Pertinent Results: [**2138-11-3**] 09:00AM PLT COUNT-191 [**2138-11-3**] 09:00AM WBC-6.0 RBC-3.76* HGB-12.3* HCT-35.4* MCV-94 MCH-32.7* MCHC-34.7 [**2138-11-3**] 09:00AM TRIGLYCER-86 HDL CHOL-48 CHOL/HDL-3.2 LDL(CALC)-87 [**2138-11-3**] 09:00AM ALT(SGPT)-23 AST(SGOT)-24 CK(CPK)-138 ALK PHOS-41 AMYLASE-30 TOT BILI-0.3 [**2138-11-3**] 09:00AM GLUCOSE-128* UREA N-23* CREAT-1.0 SODIUM-137 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-23 ANION GAP-11 [**2138-11-3**] 02:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2138-11-3**] Cardiac Catheterization 1. Coronary angiography of this right dominant system revealed three vessel coronary disease. The LMCA was short and without significant disease. The LAD had 2 serial 70% stenoses proximal and mid-segment with a 90% ostial D1 stenosis as well. The LCX had a 99% stenosis at the previous POBA site. The RCA had a 90% stenosis in the mid-segment. 2. Resting hemodynamics revealed mildly elevated systemic arterial pressure with an SBP of 148 mm Hg. The LVEDP was elevated at 20 mm Hg. There was no aortic stenosis will pullback across the aortic valve. 3. Left ventriculography was not performed. [**2138-11-3**] Carotid U/S 1. Patent right internal carotid artery stent with no evidence of stenosis. 2. 60-69% stenosis of the left internal carotid artery. [**2138-11-4**] ECHO 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 is moderately dilated. There is moderate regional left ventricular systolic dysfunction with inferior, inferolateral and lateral akinesis. The remaining segments contract normally. Quantitative (biplane) LVEF = 31%. Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. [**2138-11-8**] CTA 1. Right lower extremity: Thrombosis of the right external iliac artery at its origin at the level of the bifurcation of the right common iliac artery. The right common femoral artery reconstitutes via collateral branches from the right obturator artery, and deep iliac circulflex arteries. Multifocal atherosclerotic disease is seen in the widely patent right common femoral, superficial femoral and popliteal arteries. There is one vessel runoff to the right foot via the diminutive right posterior tibial artery. 2. Left lower extremity: Multifocal atherosclerotic disease is seen throughout the left iliac arterial system, left common femoral, superficial femoral and popliteal arteries. These vessels remain widely patent. There is one vessel runoff to the left foot via the left posterior tibial artery. 3. Note is made of bilateral renal artery stents. The kidneys enhance symmetrically, implying patency of the stents. [**2138-11-5**] Chest CTA Minimal centrilobular emphysema. No lung nodule identified. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2138-11-3**] for a cardiac catheterization. As this revealed severe three vessel disease, the cardiac surgical service was consulted for surgical revascularization. He was worked-up in the usual preoperative manner including a carotid duplex ultrasound which showed a patent right and a 60-69% stenosis of the left internal carotid artery. There was a question of a lung nodule on chest x-ray however a follow-up CT scan showed no evidence of any lung nodules. On [**2138-11-7**], Mr. [**Known lastname **] was taken to the operating room where he underwent coronary artery bypass grafting to four vessels. Please see operative note for details. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, he awoke neurologically intact and was extubated. On postoperative day one he complained of pain and his right leg pulses were absent and a vascular surgery consult was obtained. A CTA of his aorta and lower extremities was performed which showed a thrombosed right external iliac artery from its origin at the bifurcation of the right common iliac artery. He was taken to the operating room where he underwent exploration of right groin with thrombectomy of right iliac artery followed by angiogram and stenting of right common into the external iliac artery, bovine patch angioplasty of common femoral artery. Postoperatively he was returned to the intensive care unit. Bicarbonate was administered for 6 hours following his surgery to prevent acidosis. He did well and was transferred to the step down unit on [**2138-11-11**] for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. By post-operative day 6 he was ready for discharge to home with physical therapy. Medications on Admission: Allpurinol 100', ASA 81, Lipitor 20, Lopressor 50", Isordil 10", Plavix 75' Discharge Medications: 1. Influen Tr-Split [**2138**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One (1) ML Intramuscular ASDIR (AS DIRECTED). 2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 8. 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* 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: Coronary artery disease Status post myocardial infarction [**9-/2116**] Status post coronary stents Hypertension Hyperlipidemia Nephrolithiasis s/p carotid endarterectomy and stent Gout Renal artery stenosis -s/p angioplasty/Stenting bilaterally Colonic polyps Acute right iliac thrombosis Discharge Condition: good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 month.([**Telephone/Fax (1) 170**]. Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.([**Telephone/Fax (1) 108408**]. Follow-up with Dr. [**Last Name (STitle) 108409**] in [**3-3**] weeks.([**Telephone/Fax (1) 108410**]. Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 1 month. ([**Telephone/Fax (1) 39970**] Staples (both sternal and groin) can be removed in 1 week. Completed by:[**2138-11-13**]

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32286

Discharge summary

report

Admission Date: [**2155-12-25**] Discharge Date: [**2156-1-9**] Date of Birth: [**2080-1-23**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 4052**] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: Intubation History of Present Illness: 75 year old male with a history of a cerebral vascular accident, chronic back pain and sarcoidosis who was found down by his son [**2155-1-3**] in his living room. The patient does not recall how he fell. He states he does not recall what parts of his body hit the floor. He recalls trying to pull himself up and being unable. He remembers hearing acceptance speeches from the NH primary. When he woke up he found he was soiled with feces. He does believe he lost consciousness. He denies any prior similar episodes. Brought in by family because of continued generalized weakness. He states that since wednesday afternoon he has had a dry productive cough and had trouble "getting a deep breath". Of note of the day he fell, he went to his pain doctor after the fall and was told it may have been vasovagal. . In ED, 95.8, 81, 121/63, 18 96%RA. His spine was noted to be diffusely tender. Imaging of CT cervical spine indicative of C3-C4 ligamentous injury, and C7 ? acute fracture for which patient has been placed in a c-collar. Patient noted to have a mildly elevated BUN, and anemia. He was admitted for further work-up of this event. . Review of Systems: + constipation, +cough, +shortness of breath, +dysphagia, +weight loss (40 lbs, 8 months), +chronic lower back pain. Patient denies fevers, chills, nausea, vomiting, headache, vision changes. Past Medical History: Sarcoid, on chronic prednisone GERD, on omeprazole Dyspagea, on limited diet, but refuses any of the thickened liquids CVA, 1 yr ago, residual left foot drop, memory difficulty Hypertension Anemia Chronic Back Pain, on fentanyl patch Social History: retired physician, [**Name Initial (NameIs) **], 2 grandchildren. Son-in-law [**Name (NI) **] very supportive. Divorced from wife, who recently died. Patient does not/has never smoked. Patient rarely consumes alcohol. Patient lives alone at [**Hospital1 100**] Senior Life. His meals are provided for him, he does go shopping on his own and is quite active. He ambulates without a cane. Family History: NC, no family history of sarcoid Physical Exam: Gen Alert and Oriented *3 Skin: rash, left macular-papular irregular areas (6)of hyperpigmentation roughly oval with center darkening HEENT: PERRL, EOMI, CN II-XII intact, no nystagmus CV: RRR, nl S1, S2, no m/r/g Pulm: CTA b/l, no w/r/r Back: kyphotic, tender diffusely in t-spine. No l spine tenderness. Abd: s/nt/nd +bs no hepatosplenomegaly Ext: no c/c/e, 2+ DP Neurological: UE biceps [**4-19**], triceps [**4-19**], deltoids 5-/5, LE: hamstrings [**4-19**], hip flexors [**4-19**], knee flexors 5-/5, knee extensors 5-/5, plantarflexion [**4-19**], dorsiflexion L [**3-20**] R [**4-19**]. DTRs 1+, no clonus. able to stand and balance. Rectal tone good per ED. Pertinent Results: STUDIES MRI C SPINE: 1. Ligamentous injury adjacent to an old C7 spinous process fracture. 2. Tiny abnormality of the ligament anterior to C3-4, without findings suggestive of acute disruption. 3. Degenerative disease of the cervical spine as detailed above. Diffuse idiopathic skeletal hyperostosis (DISH). . CT L SPINE:1. No evidence of acute fracture of the lumbar spine. 2. Multilevel degenerative changes, most severe at L4-5 and L5-S1, with central canal encroachment by a disc osteophyte complex at L4-5. . CT T SPINE 1. No evidence of fracture within the thoracic spine with preservation of vertebral body height throughout. 2. Findings compatible with diffuse idiopathic skeletal hyperostosis (DISH). 3. Right adrenal myelolipoma. . CT C SPINE:1. Widening of the anterior disc space at C3-4 which may be chronic; however, ligamentous injury cannot be excluded. Recommend MRI for further evaluation. 2. Irregularity and disruption of the spinous process at C7 which could represent an acute fracture. An underlying lytic lesion cannot be excluded. 3. Diffuse idiopathic skeletal hyperostosis (DISH) and multilevel degenerative changes. 4. Right upper lobe pneumonia. . CXR: Focal, increased parenchymal opacities involving the right upper lobe which may represent aspiration and/or pneumonia. . CT HEAD: No evidence of intracranial hemorrhage or edema. . BILATERAL HIPS: 1. Degenerative changes of both hips which are mild, as well as moderate degenerative changes of the lumbar spine. 2. No signs for acute bony injury. . CTA CHEST [**2156-1-5**] . TECHNIQUE: Axial volumetric images have been obtained through the chest, abdomen and pelvis. IV contrast was administered according to the PE protocol. COMPARISON: There is a [**2155-12-28**] chest CT for comparison. FINDINGS: The main pulmonary artery is enlarged measuring 4 cm.This is highly suggestive of pulmonary hypertension. The segmental and subsegmental arteries appear to be prominent, which is unchanged compared to previous. Again noted are the airspace changes within the right upper lobe as well as within the left lower lobe, which appear unchanged, compared to previous.There is a soft tissue density associated with atelectasis around the right hilum which is unchanged compared to previous. Right basal atlectasis is also present. There are bilateral pleural effusions. The airway is patent with no evidence of significant lymphadenopathy. ABDOMINAL AND PELVIC CT: There are no suspicious hepatic lesions. The spleen appears unremarkable. There is evidence of cholelithiasis and the CBD is prominent measuring 1.5 cm. No evidence of intrahepatic biliary duct dilatation. The pancreas appears unremarkable. Within the right adrenal gland, there is a rounded hypodense fatty lesion measuring 3.5 x 4 cm, most likely in keeping with adrenal myelolipoma. The left adrenal appears unremarkable. There is a left upper pole renal cyst. Otherwise, the bilateral kidneys appear unremarkable with no evidence of hydronephrosis. The small and large bowel appear unremarkable with no evidence of dilatation or wall thickening. There is no evidence of pneumatosis, free air or free fluid. There is no significant retroperitoneal lymphadenopathy. The abdominal aorta is atherosclerotic. The bladder appears unremarkable with evidence of Foley catheter in place. There are multilevel degenerative changes within the lumbosacral spine. There are no suspicious bony lesions. IMPRESSION: 1. No evidence for pulmonary embolism. Evidence for pulmonary arterial hypertension with prominent peripheral pulmonary vessels, especially on the left, which is unchanged from previous. 2. No significant change in the airspace disease within the bilateral lungs with persistent soft tissue density within the right hilum, which is concerning for an underlying mass lesion obscured by the airspace disease or resulting in obstructive airway changes and thus followup is recommended. 3. Cholelithiasis. 4. Left adrenal myelolipoma. Findings were discussed with Dr. [**Last Name (STitle) **] from team medicine on the same day. . ON ADMIT: [**2155-12-25**] 11:30AM BLOOD WBC-6.4 RBC-3.79* Hgb-11.8* Hct-34.7* MCV-91 MCH-31.2 MCHC-34.1 RDW-13.2 Plt Ct-304 [**2155-12-25**] 11:30AM BLOOD Neuts-88.0* Bands-0 Lymphs-6.9* Monos-4.4 Eos-0.4 Baso-0.4 [**2155-12-25**] 11:30AM BLOOD PT-13.1 PTT-26.8 INR(PT)-1.1 [**2155-12-25**] 11:30AM BLOOD Glucose-99 UreaN-27* Creat-1.2 Na-140 K-4.4 Cl-100 HCO3-30 AnGap-14 [**2155-12-26**] 07:05AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1 Iron-12* [**2155-12-26**] 07:05AM BLOOD calTIBC-182* VitB12-304 Folate-8.0 Ferritn-1122* TRF-140* . AT DISCHARGE . COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2156-1-9**] 06:45AM 12.0* 3.52* 11.3* 32.5* 92 32.1* 34.8 13.7 354 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2156-1-5**] 08:28AM 86.2* 0 10.3* 2.9 0.5 0.1 Source: Line-picc RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr [**2156-1-5**] 08:28AM NORMAL 1+ NORMAL NORMAL NORMAL 1+ Source: Line-picc BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2156-1-9**] 06:45AM 354 [**2156-1-9**] 06:45AM 13.11 30.2 1.1 1 NOTE NEW REFERENCE RANGE AS OF [**2155-10-29**] 12:00A MISCELLANEOUS HEMATOLOGY ESR [**2156-1-7**] 12:40PM 55* [**2156-1-7**] 05:46AM 22* ESR ADDED 12:20PM Brief Hospital Course: 75 year old male with past medical history significant for sarcoid on chronic low dose predisone was brought by son to [**Name (NI) **] for generalized weakness following a syncopal episode with loss of consciousness. The patient's syncope was felt to be in the setting of the patient self regulating his pain medications including starting neurotin. He woke up surrounded by feces. . 1) Syncope: It is unclear if the patient lost bowel or bladder function during the event or if it was a result of his prolonged immobility. He has a history of chronic back pain and degenerative disk disease. CT imaging done in emergency department revealed no evidence of acute event. His neurological examination was benign. No disturbances in electrolytes noted. The patient was monitored on telemetry and was noted to have 18 beats of atrial tachycardia which spontaneously resolved. The patient was restarted on his hydrochlorothiazide every other day, then transitioned to daily. He had no syncopal or seizure episodes in house. He did become quite delirious with visual hallucinations a few days into his admission. He refused to be examined. thought doctors [**First Name (Titles) **] [**Last Name (Titles) 75467**], and said he would not do anything until the government issued a report. A psychiatry consultation was obtained. He was felt by the psy team not to be psychotic, but delirious in the setting of prolonged hospital stay, and narcotics. RPR and B12 were ordered to complete the labs, results pending at time of discharge. However, within 48 hours he returned to baseline, where he is conversant with some logic but has obvious obsessions, reiterations, a monotone speech, flat affect and lack of eye contact and insight. He is otherwise very cooperative, with his thought content focused on his pain control and his ability to handle thin liquids. His cultures remained negative. However, he had findings of PNA for which he is on a 14 day course of aztreonam and vancomycin, 3 days left. . 2) Fall: When the patient syncopized, he fell to the floor. Apparently he remained on the floor for a significant period of time. He was treated for mildly elevated BUN with fluids. Multiple imaging modalities were used to evaluate him status post fall and he was noted to have a C 7 ligamentous injury by MRI and several old cervical spinal fractures. Ortho was consulted, with the recommendation to wear a cervical collar for one month. . 3) Pulmonary Infiltrate: In the MICU the patient had persistent hypercarbic hypoxia. By chest x-ray the patient had a question of a RUL PNA. The patient had a nonproductive cough. He is a known aspiration risk and this may represent an aspiration event and pneumonitis, although infection could not be excluded. The patient cough likely also occured after he spent likely >7 hours on the floor and he could have aspirated while unconscious. He was noted to have a mild left shift in his white blood cell count with no leukocytosis. Patient was also noted to have no fever. On the morning after admission, the patient was noted to have development of diffuse rhonchi with a need for 2 liters of nasal cannula oxygen to keep oxygenation at >95%. Patient at this time was presumed to have pneumonia. He was given the pneumovax vaccine and continued on Levofloxacin/Flagyl for therapy, then switched to aztreonam and vancomycin as stated above. Subsequently, his oxygen requirements increased to 5 L while on antibiotics with lung exam significant for rhonchi. A sarcoid flare was suspected and his dose of prednisone was increased to 40 mg daily. Within two days of this regimen, with chest PT and nebulizers, he was able to completely wean off oxygen, satting in the high 90s on room air. He also benefitted from gentle diuresis although edema was felt to be a small contributor to his hypoxia. . 4) Chronic Back Pain: Patient was restarted on his home pain medication per his primary care physician, [**Name10 (NameIs) **] [**Last Name (STitle) 1266**]. Overnight post admission, he developed acute pain. This was felt to be due to his recent fall and due to the fact that he was liberally self medicating at home. The patient threatened to leave against medical advice. After a detailed discussion with the patient and his daughter, the patient made clear his preference for improved pain control, even if this means he will be very sleepy. After consultation with the pain service the patient was started on PCA morphine pain control. He was eventually transitioned to a fentanyl patch, initially 50 micrograms with percocet for breakthrough. At discharge, he is on a fentanyl patch 100 micrograms with which his patient seems to be well controlled, on no other narcotics. . 5) Sarcoid: As stated above, his sarcoid was felt to be contributing to his hypercarbic hypoxia, as his oxygenation improved dramatically on increased steroids. It is unclear if he has a component of neurosarcoid which is affecting his mental status. He is reiterative at baseline, with obsessive thoughts and tangential. . 6)Cerebral Vascular Accident: Thombotic event. Patient notes residual left foot drop. Unclear if dysphagia result of CVA but patient has noted difficulty since CVA. He was kept on ASA. . 7) Dysphagia: The patient had significant dyspagia which has been evaluated by ENT and revealed aspiration, perhaps a residual deficit from stroke. In the setting of this dysphagia he has lost weight. Speech and swallow evaluations were challenging for the patient, who insisted to be placed on thin liquids. He initially did not collaborate with speech and swallow evaluations, but was placed on thickened liquids, nectar diet with crushed pills. On the day of discharged, he agreed to a speech and swallow evaluation given that his sensorium was clearer. The recommendations are to keep him on thick liquids, nectar pureed foods, and crush his pills. . 8) DISH: disease of spine/bones which results in osteophytes. This may be causing esophageal compression/tortuousness seen by EGD. This might be contributing to his dysphagia and his pain. . FULL CODE . FEN: he was kept on special diet as above, repleted lytes as needed . CONTACT: [**Name (NI) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27772**] -- his daught and son-in-law, live in [**Name (NI) 5176**], recently moved Mr. [**Known lastname **] to be nearer to family. Cell #s [**Telephone/Fax (1) 75468**] or [**Telephone/Fax (1) 75469**] Medications on Admission: Metoprolol 25 mg PO BID Aspirin 325 mg PO DAILY Miralax *NF* 17 gram (100 %)HS Benefiber Clear 3 gram/3.5 [**12-17**] tbsp by mouth at bedtime mixed with water Donepezil 5 mg PO HS OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain Docusate Sodium 100 mg PO BID Pantoprazole 40 mg PO Q24H Fentanyl Patch 50 mcg/hr TP Q72H Start: SAT [**12-27**] AM Potassium Chloride 10 mEq PO BID Duration: 24 Hours Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **] Gabapentin 300 mg PO 1-4 tablets DAILY: patient has been taking more than once a day Hydrochlorothiazide 12.5 mg PO EVERY OTHER DAY: patient has been taking daily Simvastatin 20 mg PO DAILY Losartan Potassium 50 mg PO DAILY Thiamine 100 mg PO DAILY Methylprednisolone 4 mg PO 1-3 tablets DAILY : patient had been varying dose and taking more than prescribed Discharge Medications: 1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Psyllium Packet Sig: [**12-17**] Packets PO TID (3 times a day) as needed for constipation. 5. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day) as needed for constipation. 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual ASDIR (AS DIRECTED). 9. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation [**Hospital1 **] (2 times a day). 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twenty-four(24) hours. 18. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 19. Aztreonam 1 gram Recon Soln Sig: Two (2) grams Injection Q8H (every 8 hours) for 3 days. 20. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 3 days. 21. Sliding scale insulin as needed while on steroids Discharge Disposition: Extended Care Facility: [**Hospital 100**] Rehab Discharge Diagnosis: Hypercarbic respiratory failure Syncope Chest pain Aspiration Pneumonia Sarcoidosis C7 ligamentous injury Dysphagia Discharge Condition: Breathing well on room air Discharge Instructions: Admitted with syncope and cervical ligament injury, developed respiratory failure and pneumonia. Had to be intubated in the MICU. The pneumonia was treated with antibiotics (still needs two more days) and the sarcoidosis with prednisone. You need to discuss when to stop the prednisone with your doctors. There was also some fluid in your lungs which we treated with lasix. . Your speech and swallow evaluation has concluded that you need to continue on the thick liquids, as you run the risk of a pneumonia otherwise. You can be reevaluated again. Please discuss with Dr [**Last Name (STitle) 1266**]. . Take the medications in the list below and return to the ED if you experience any concerning symptoms. Followup Instructions: CT chest [**2-9**] at 10:45 ([**Hospital Ward Name 23**] building) Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 5376**] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2156-1-12**] 8:30 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2156-1-19**] 10:40 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2156-1-19**] 11:00 With Dr [**Last Name (STitle) 1266**] within 2-3 weeks. PLease call [**Telephone/Fax (1) 10688**] Orthopedics: [**1-30**] at 2: 25 pm. [**Hospital Ward Name 23**] building [**Location (un) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]

[ "780.2", "401.9", "507.0", "707.05", "285.9", "250.02", "952.05", "518.81", "E888.9", "135" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

17881, 17932

8505, 14960

280, 293

18092, 18121

3089, 4410

18877, 19687

2353, 2387

15828, 17858

17953, 18071

14986, 15805

18145, 18854

2402, 3070

1483, 1676

233, 242

321, 1464

4419, 8482

1698, 1933

1949, 2337

48,821

149,079

43238

Discharge summary

report

Admission Date: [**2148-4-29**] Discharge Date: [**2148-5-10**] Date of Birth: [**2073-7-6**] Sex: M Service: CARDIOTHORACIC Allergies: Amiodarone Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2148-4-30**] CABG x3(LIMA-LAD, SVG-Diag, SVG-PDA) History of Present Illness: Mr. [**Known lastname 31823**] is a 74-year-old gentleman with a complex medical history that is relevant for known coronary artery disease. His last coronary angiogram in [**2145-12-24**] showed a total occlusion of the right coronary artery, a 50% stenosis of the left circumflex artery with significant left anterior descending disease. A past attempt in [**2126**] was made to intervene on the left anterior decending artery however the intervention was unsuccessful. Of note, he has a heavily calcified aorta and his last cardiac catheterization was complicated by embolic disease to his kidneys and lower extremities. Recently he has been having worsening episodes of angina which occur daily and require daily nitroglycerin. He is also dyspneic with minimal activity. His chest pain is always relieved with 1-2 nitroglycerin however it can occur at rest. He has not had a recent cardiac cathterization given the risk associated with the procedure in regards to his aortic atherosclerotic disease. He presents today to discuss high risk surgical options versus percutaneous intervention given his decompensated state and poor quality of life. Past Medical History: Past Medical History: -Coronary Artery disease -Peripheral vascular disease (Significant claudication) -Carotid disease with occluded left carotid artery -Renal artery stenosis s/p prior left renal artery stent in [**Location (un) 24402**] in [**2146-5-24**] -End-stage renal disease on hemodialysis (Tuesdays/Fridays)- Creat 2.8 -Complex aortic atheroma -Hyperlipidemia -Atrial fibrillation with sick sinus syndrome status post permanent pacemaker in [**2137**] complicated by subsequent amiodarone toxicity -history of cholesterol embolization syndrome -Hypothyroid -Congestive heart failure -Pneumonia -Currently uses oxygen to sleep and as needed during day -Likely diabetes in setting of elevated triglycerides and fasting glucose. Past Surgical History: - PPM placement [**1-1**] for sick sinus syndrome - Abdominal port placement - AV fistula placement with history of multiple peritoneal dialysis procedures - Renal artery stent [**2145**] - Cholecystectomy [**10-30**] - Cataract surgery - Partial right toe amputation - Failed angioplasty in [**2126**] Social History: Race: Caucasian Last Dental Exam: Once yearly Lives with: his family Occupation: Retired Tobacco: Denies tobacco use, though significant second-hand smoke from his wife's chronic smoking history ETOH: occasional alcohol Family History: Family History: Significant for both brother and sister having coronary artery disease. Sister with CABG in her 40's Physical Exam: Pulse: 63 Resp: 18 O2 sat: 94% RA B/P Right: 134/68 Left: AV Fistula Height: 66" Weight: 170 General: WDWN in NAD. Mildly pale. Skin: Warm, Dry and intact. No clubbing or cyanosis. HEENT: PERRLA [X] EOMI [X] Sclera anicteric, oropharynx benign. Teeth in fair repair. Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: No M/R/G, II/VI systolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Well healed abdominal incisions Extremities: Warm [X], well-perfused [X] Trace LE Edema. Left upper extremity AV fistula with good thrill. Left upper chest well healed pacer pocket. Varicosities: slight varicosities noted below knee bilaterally along GSV tract. Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 DP/PT [**Name (NI) 167**]: weak palp Left: weakly palp Radial Right: Left: Carotid Bruit Right: None appreciated Left: + High pitched bruit Pertinent Results: Admission: [**2148-4-29**] 10:52AM URINE RBC-0-2 WBC-0-2 BACTERIA-0 YEAST-NONE EPI-0-2 [**2148-4-29**] 10:52AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2148-4-29**] 10:52AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2148-4-29**] 11:00AM PT-14.5* PTT-26.8 INR(PT)-1.3* [**2148-4-29**] 11:00AM PLT COUNT-251 [**2148-4-29**] 11:00AM WBC-9.9 RBC-4.06* HGB-11.3* HCT-34.4* MCV-85 MCH-27.9 MCHC-32.9 RDW-16.0* [**2148-4-29**] 11:00AM %HbA1c-8.2* eAG-189* [**2148-4-29**] 11:00AM ALBUMIN-3.7 CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.8 [**2148-4-29**] 11:00AM LIPASE-86* [**2148-4-29**] 11:00AM ALT(SGPT)-47* AST(SGOT)-58* LD(LDH)-206 ALK PHOS-108 AMYLASE-42 TOT BILI-0.4 [**2148-4-29**] 11:00AM GLUCOSE-188* UREA N-54* CREAT-4.4* SODIUM-138 POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-31 ANION GAP-13 Discharge: [**2148-5-10**] 06:06AM BLOOD WBC-13.7* RBC-3.87* Hgb-11.3* Hct-33.7* MCV-87 MCH-29.3 MCHC-33.7 RDW-17.1* Plt Ct-371 [**2148-5-10**] 06:06AM BLOOD Plt Ct-371 [**2148-5-10**] 06:06AM BLOOD PT-28.4* INR(PT)-2.8* [**2148-5-9**] 05:25AM BLOOD PT-26.1* PTT-31.4 INR(PT)-2.5* [**2148-5-8**] 04:19AM BLOOD PT-19.8* INR(PT)-1.8* [**2148-5-10**] 06:06AM BLOOD Glucose-162* UreaN-88* Creat-4.9* Na-137 K-3.5 Cl-95* HCO3-27 AnGap-19 Date/Time: [**2148-5-7**] at 16:02 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm Right Atrium - Four Chamber Length: *6.2 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Left Ventricle - Stroke Volume: 40 ml/beat Left Ventricle - Cardiac Output: 4.37 L/min Left Ventricle - Cardiac Index: 2.31 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *16 < 15 Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 14 Aortic Valve - LVOT diam: 1.9 cm Mitral Valve - E Wave: 1.3 m/sec Mitral Valve - E Wave deceleration time: 191 ms 140-250 ms Pulmonic Valve - Peak Velocity: 1.0 m/sec <= 1.5 m/sec Findings Left pleural effusion seen. LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Mild global LV hypokinesis. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: RV not well seen. Paradoxic septal motion consistent with prior cardiac surgery. AORTA: Normal aortic diameter at the sinus level. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Mild to moderate ([**11-25**]+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Moderate [2+] TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: Very small pericardial effusion. No echocardiographic signs of tamponade. GENERAL COMMENTS: Resting tachycardia (HR>100bpm). Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis (LVEF = 45-50 %). There is no ventricular septal defect. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**11-25**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2148-5-7**] 16:14 Radiology Report CHEST (PA & LAT) Study Date of [**2148-5-9**] 3:17 PM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 93147**] [**Hospital 93**] MEDICAL CONDITION: 74 year old man with CABG Final Report PA AND LATERAL CHEST: Right IJ line tip ends in the lower SVC. Intact pacemaker leads terminate in the right atrium and in the right ventricle. Mediastinal wires are intact. Bilateral pleural effusion is unchanged, moderate on the left and small on the right. Mild perihilar haziness and fluid in the minor fissure is consistent with mild fluid overload, unchanged from prior study ([**2148-5-4**]). Retrocardiac opacity on the left is unchanged. There is no pneumothorax. Moderate cardiomegaly is stable. The mediastinal and hilar contours are stable. IMPRESSION: 1. Unchanged bilateral pleural effusion, moderate on the left and small on the right. 2. Moderate cardiomegaly and mild fluid overload are stable. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] Brief Hospital Course: Mr [**Known lastname 31823**] was admitted to [**Hospital1 18**] for coronary bypass grafting. He is a renal failure patient and was therefore admitted one day pre-operatively for hemodialysis prior to his scheduled surgery. On [**4-30**] he was brought to the operating room where he had coronary bypass grafting x3, please see operative report for details. In summary he had Coronary artery bypass grafting x3; left internal mammary artery grafted to the left anterior descending; reverse saphenous vein graft to the posterior descending artery and diagonal branch. his bypass time was 73 minutes with a crossclamp time of 53 minutes. He tolerated the operation well and was transferred to the cardiac surgery ICU in stable condition. He remained hemodynamically stable in the immediate post-operative period and was extubated on the day of surgery. He stayed in the cardiac surgery ICU for an additional 2 days for hemodynamica monitoring and pulmonary support. On POD3 he was transferred to the floor for continued care. Once on the floor he worked with the nursing and physical therapy staff to advance his physical activity. He was progressing nicely until POD 6 when he had an episode of rapid atrial fibrillation associated with mild hypotension during his hemodialysis run. He was treated with increased Bblockers. Amiodarone was not used due to previous episode of Amiodarone toxicity, additionally he was restarted on his coumadin at his pre-op dose. He was brought back to the ICU for observation overnight where he remained hemodynamically stable and the following day he returned to the stepdown floor. The remainder of his hospital stay was uneventful. On POD 10 he was discharged home with visiting nurses. He is to have followup with Dr [**Last Name (STitle) **] and with dr [**Last Name (STitle) 3407**] of vascular surgery. Medications on Admission: Medications at home: Vitamin D 400 mg daily Fish oil 1000 mg daily Imdur 60 mg daily Synthroid 50 mcg daily Lorazepam 0.5 (3)p.r.n. Protonix 40 mg b.i.d. Atenolol 25 mg one-half tablet b.i.d. Diovan 40 mg q.a.m. Sublingual nitroglycerin 0.3 mg p.r.n. Lipitor 10 mg daily ***Coumadin 2.5 mg as directed*** [**State 1727**] Cardiology follows coumadin. Aspirin 81 mg daily Norvasc 2.5 mg daily Zolpidem 10mg qHS prn NTG 0.3 SL prn Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 8. Warfarin 2.5 mg Tablet Sig: as directed to keep INR 2-2.5 Tablets PO once a day: INR 2.0-2.5 for Afib dose as directed by cardiologist [**Telephone/Fax (1) 93148**]. Disp:*30 Tablet(s)* Refills:*2* 9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: [**5-10**], [**5-11**], [**5-12**] doses then as directed by cardiologist. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital6 **] of s [**State **] Discharge Diagnosis: s/p Coronary artery bypass grafting x3; left internal mammary artery grafted to the left anterior descending; reverse saphenous vein graft to the posterior descending artery and diagonal branch. PMH:Coronary artery disease, Peripheral Vascular Disease, occluded left carotid artery, Renal artery stenosis s/p prior left renal artery stent([**Location (un) 24402**] [**5-30**]),Hemodialysis, (Tuesdays/Fridays)Creat 2.8, Complex aortic atheroma, Hyperlipidemia, SSS/PAF- status post permanent pacemaker in [**2137**] complicated by subsequent amiodarone toxicity, history of cholesterol embolization syndrome, Hypothyroid, CHF, Pneumonia, Currently uses oxygen to sleep and as needed during day ,NIDDM,Abdominal port placement,AV fistula placement with history of multiple peritoneal dialysis procedures, Cholecystectomy [**10-30**], Cataract surgery, Partial right toe amputation Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right- Large area of eschar 3x1.5cm, dopplerable pulse. Followed by vascular surgery, dressing with Adaptic. 1+ edema in right leg, no edema in left leg Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **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: Cardiac Surgeon: Dr [**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2148-6-6**] 1:15 vascular Surgeon: Dr [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2148-5-24**] 11:30 You have a wound check on [**Hospital Ward Name 121**] 6 in one week - the [**Hospital Ward Name 121**] 6 nurse will advise you as to the date and time Please call and schedule the following appointments Your primary care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17437**] [**Telephone/Fax (1) 61751**] in 2 weeks Your cardiologist Dr. [**Last Name (STitle) 83788**] in 2 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:[**2148-5-10**]

[ "250.00", "427.31", "458.21", "426.4", "285.21", "440.0", "433.10", "244.9", "443.9", "585.6", "276.6", "V45.11", "424.0", "V53.31", "428.0", "272.4", "411.1", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.95", "39.61", "36.12", "36.15" ]

icd9pcs

[ [ [] ] ]

13137, 13202

9642, 11486

287, 344

14127, 14443

3937, 8612

15202, 16152

2881, 2983

11966, 13114

8652, 9619

13223, 14106

11512, 11512

14467, 15179

11533, 11943

2305, 2610

2998, 3918

237, 249

372, 1523

1567, 2282

2626, 2849

8,506

139,647

19097

Discharge summary

report

Admission Date: [**2128-7-30**] Discharge Date: [**2128-8-3**] Date of Birth: [**2109-4-14**] Sex: F Service: TRAUMA SURGERY HISTORY OF PRESENT ILLNESS: This is a 19-year-old female transferred from [**Hospital 1263**] Hospital. At 4 am on the day of admission, was lying in the back of a car which was hit from behind at approximately 40 miles per hour. Positive loss of consciousness with head trauma. At [**Hospital 1263**] Hospital, presented at approximately 3 pm after going home after the accident complaining of left upper quadrant pain. The patient was found to have splenic laceration and a left renal laceration with gross hematuria. The patient was hemodynamically stable with a hematocrit of 36, and transferred to [**Hospital1 **] Emergency Department around 10 pm. On arrival, the patient was hemodynamically stable complaining of mild left upper quadrant pain without other complaints and without any C spine precautions. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Smokes 1.5 pack per day. PHYSICAL EXAMINATION: [**Location (un) 2611**] coma score 15. Vital signs: 127/58, pulse 81, respirations 18, O2 saturation 98% on room air, temperature 99.8. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Tympanic membranes clear. Face was stable. Trachea was midline. No crepitus in the neck. Heart regular, rate, and rhythm. Lungs are clear to auscultation bilaterally. Abdomen is soft, tender to palpation diffusely, no peritoneal signs. Pelvis was stable. Extremities: Was moving freely cool and dry. Pulses 2+, normal capillary refill. Neurologic examination: No focal deficits. Rectal examination: Tone was normal. No gross blood. Was guaiac negative. Back: Slightly tender to palpation in the lower T spine. No tenderness to palpation of the C spine. No step-offs. Was moving her neck freely without pain. There is a small ecchymosis noted over the left flank, which was approximately 2 x 2 cm round. LABORATORIES: At [**Hospital 1263**] Hospital, the patient had a hematocrit of 36.2. Coags were normal. No other abnormal laboratory abnormalities except for large blood and many red blood cells in the urinalysis. Also from the outside hospital, she had a negative head CT scan. At [**Hospital1 **], the patient's hematocrit was 32.8 on presentation with normal coags and normal platelet count. She had a negative tox screen. Her other laboratories were normal. Radiology: Chest x-ray was normal with no pneumothorax and no widening of the mediastinal. Pelvic x-ray showed no fracture. The lateral C spine showed no fractures or dislocations. CT scan of abdomen and pelvis demonstrated a minimally displaced fracture of the transverse process of L1. It also showed a laceration of the spleen to the hilum without involvement of hilar vessels. There is also a left renal laceration with small amount of perirenal fluid, and there was subacute blood in the pelvis, a large amount of free fluid within the pelvis. The T, L, S plain films showed no fractures or dislocations. HOSPITAL COURSE: The patient was admitted to the Trauma SICU overnight for observation, serial hematocrits, and serial abdominal examinations. The hematocrit stayed stable on serial examinations, and her abdominal examinations were unremarkable for change in her pain, distention, or tenderness to palpation. Since the patient remained stable without a change in her hematocrit or abdominal examination throughout the evening in the Trauma SICU, the patient was transferred to the floor on hospital day #2. We continued to observe the patient and on the floor, slowly increasing her activity level, diet. The patient tolerated each of these advancements without any complications, and was discharged from the hospital on hospital day #5. Orthopedic Spine Surgery was consulted for the transverse process fracture. They recommended nonoperative intervention and no brace needed. Their recommendation was that logroll precautions could be discontinued, and the patient would be on limited activity, but no other precautions need to be taken. They also recommended that the patient would receive followup for Orthopedic Spine Surgery. On hospital day two, the patient had one temperature spike to 101.4 degrees and noted an increase in her white blood cell count to 21. The temperature spikes noted was believed to be due to atelectasis. No blood cultures were drawn at the time. The increasing in white blood cell count was thought to be due to her splenic injury. White blood cell count did progressively decrease over her hospital stay without any further temperature spikes. Therefore, the patient was subtle for discharge on hospital day #5. Overall, the patient tolerated the hospital stay without any change in her hematocrit, or abdominal examination, or any other symptoms of bleeding or worsening abdominal pain. The patient was suitable for discharge on hospital day #5. FINAL DISCHARGE DIAGNOSES: 1. Status post motor vehicle collision. 2. Splenic laceration Class III. 3. Left renal laceration. 4. Transverse process fracture of the L1 vertebrae. MEDICATIONS: 1. Vicodin 1-2 tablets po q4-6h prn pain. 2. Colace 100 mg [**Hospital1 **] prn constipation. FOLLOW-UP PLANS: 1. Patient will receive followup with Orthopedics in clinic in [**1-12**] weeks. The patient was given information as far as making follow-up appointment. 2. Patient will make an appointment to be seen in the Trauma Clinic within two weeks. Patient was also given information to make follow-up appointment for Trauma Clinic. 3. Patient was given instructions if any worrisome symptoms of worsening abdominal symptoms that might be related to increasing in bleeding. It is unlikely that patient will have any worsening in her status given the examination in the hospital, but the patient was given instructions for limited activity and close observation at home for the next several weeks along with any instructions for followup to the Emergency Department. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Last Name (NamePattern1) 13389**] MEDQUIST36 D: [**2128-8-3**] 12:44 T: [**2128-8-3**] 12:56 JOB#: [**Job Number 52124**]

[ "805.4", "305.1", "599.7", "866.00", "780.09", "518.0", "865.00", "E816.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3205, 5084

1021, 1087

1153, 3187

5388, 6427

5111, 5371

175, 967

990, 997

1104, 1130

27,726

156,290

27484

Discharge summary

report

Admission Date: [**2188-6-16**] Discharge Date: [**2188-6-25**] Date of Birth: [**2116-10-30**] Sex: F Service: MEDICINE Allergies: Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: septic shock Major Surgical or Invasive Procedure: tunnelled line placement by IR History of Present Illness: 71 yo F with dementia, ESRD on HD, respiratory failure s/p trach, s/p PEG, COPD, recurrent aspiration PNA, and hx of C.diff colitis is transferred from the [**Hospital 100**] Rehab MACU after having two hypotensive/unresponsive episodes during HD. Rather than take fluid off, they gave the patient 500 cc. Per the patient's son, the patient has been having difficulties for the past nine weeks, with delerium that finally resolved after adding phosphate binders, correcting lyte (hypercalcemia, hyperpphos) abnormalities, and d/c'ing sedating medications. Per rehab records, she recently had recurrent C diff, and was treated with Zosyn for PNA with cxs + for Providencia stuartii, Psuedomonas, and Citrobacter. She appeared to recover when she was noted about 1 week prior to admission be increasingly hypotensive with altered mental status. She had blood and C diff cxs from [**6-11**] which were negative. Sputum cultures again grew Citrobacter and Pseudomonas. She was started on Levaquin for Citrobacter (Pseudomonas was presumed to be a colonizer) but she was noted to have worsening resp status with increasingly purulent sputum. On [**6-15**] her antibiotics were changed to Tobramycin and Cefepime. Her WBC has continued to rise, she had an episode of atrial fibrillation, and then the above mentioned episodes at HD. . In the ED, Patient's blood pressures were initially in the 90's - 100's and the patient's mental status was at baseline per her son. [**Name (NI) **] [**Name2 (NI) **] count returned at 20.1 and her CXR came back as having BL infiltrates concerning for multifocal PNA vs aspiration. She then began to drop her pressures into the 60's systolic. A code sepsis was called. She received 2 liters of fluid and was started on peripheral levophed. A central lines was placed and her initial CVP was 13 and her lactate was 1.5. She appeared to be having significant oral secretions and de-satting down to the 80's so she was placed on the ventilator. She was started on Vancomycin, Zosyn, Azithromycin and admitted to MICU for further work-up and management. . Per her son, at baseline she is able to hold a coherent conversation although she has some chronic deficits from her previous CVA's including frequent altered mental status with infections or lyte abnormalities, finding it difficult to explain where her pain is in her body, and being easily overstimulated (lights, sounds.) She had some diarrhea at [**Hospital 100**] Rehab today, and again in the ED, and one episode of vomiting this AM. Her baseline temp is 97.8 and she rarely gets fevers when infected. Past Medical History: #. ESRD on HD of unclear etiology. ? d/t chronic pyelo and uncontrolled HTN. #. Respiratory failure s/p trach in [**2-11**], vent dependent until [**2188-1-5**] when she was successfully weaned off #. COPD #chronic pleural effusions #. Recurrent aspiration PNA #. PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of toew bilaterally and autoamputating #. HTN #. Hypothyroidism #. h/o GI bleeding #. CHF no previous echo here, so unclear [**Name2 (NI) **] #. h/o Cholesterol emboli syndrome #. Paroxysmal AF # Anemia # s/p multiple embolic CVA # Dementia # Adenocarcinoma of the colon s/p resection in [**2186**] # s/p PEG # h/o MRSA colonization # hx of pseudomonas colonization # h/o VRE infection # C.diff colitis Social History: # Personal: Lives at [**Hospital 100**] Rehab. Divorced. Three adult children. # Tobacco: Former smoker. 3 packs per day x 13 years. # Alcohol: Occasional past use. Family History: # Siblings: MI in 60s. Schizophrenia. Physical Exam: VS: T: BP: 114/54 P: 66 RR: O2 sat: 100% GEN: Lying in bed, NAD HEENT: PERRL, cloudy cornea, Mouth open with dry tongue. no obvious OP lesions NECK: trach in place CV: RRR, nl S1 and S2, no m/r/g PULM: CTA bilaterally, no wheezes/rhonchi/crackles. ABD: Soft, grimaces on palpation, mildly distended, active bowel sounds. No hepatosplenomegaly EXT: warm, no edema of LEs, no rashes, lidoderm patch on feet bilaterally, dry gangrenous toes bilaterally and auto-amputated toes on L. R great toe looks dry and auto-amputating. No signs of infection in any toes, however. NEURO: awake, opens eyes spontaneously, but does not follow any commands. Uncooperative with exam. Pertinent Results: FINDINGS: A single frontal view of the chest labeled "PCXR upright at 15:00 p.m." excludes the uppermost portion of the left lung apex. A tracheostomy tube is in unchanged position. The left-sided hemodialysis catheter again terminates at the cavoatrial junction. Cardiomegaly is unchanged. Perihilar opacities, probable small bilateral pleural effusions, and Kerley B lines are consistent with mild CHF. In addition, airspace opacities in the right upper lobe abutting the major fissure and opacity in the right lower lung field may represent pneumonia or aspiration. No pneumothorax is evident. Atherosclerotic calcifications are again noted along the thoracic aorta. A tube overlying the left upper abdomen is again seen. No rib fractures are seen. IMPRESSION: Right-sided opacities may represent multifocal pneumonia versus aspiration. These findings are superimposed on underlying mild CHF. Brief Hospital Course: A/P: 71 yo F with dementia, CVAs, ESRD on HD, chronic respiratory failure s/p trach, s/p PEG, COPD, recurrent aspiration PNA, and recent hx of C diff colitis transferred from [**Hospital 100**] Rehab MACU with septic shock. . 1) Septic shock: Patient has infiltrates on CXR concerning for PNA, infectious vs recurrent aspiration PNA. At [**Hospital 100**] Rehab grew out resistant Pseudomonas and Citrobacter in her sputum. She was being treated for Citrobacter and Pseudomonas pneumonia with Vancomycin, Zosyn, and Gentamycin. When her cultures from [**Hospital 100**] Rehab returned, the Pseudomonas was only intermediate sensitive to the gentamycin and she was switched to Vanc, Zosyn, and Amikacin which were dosed at various levels as her kidney function fluctuated. A sputum sample sent here grew out Pseudomonas which was sensitive to gentamycin and Amikacin. Patient was left on the Amikacin, dosed by level. Additonal possible sources for infection included her multiple lines. She had a PICC lines placed at [**Hospital 100**] Rehab on [**6-15**] and a tunneled line catheter, which proved to be non-functioning and was removed. Cultures were sent from all her lines and were all negative. She is anuric. She had no other localizing signs or symptoms. She initially required levophed and vasopressin, titrated to systolic blood pressure rather than MAPs given her chronically low diastolic blood pressure. She was extremely difficult to wean so she was started on stress dose steroids on [**6-18**]. She came off both pressors by [**6-21**] and stress dose steroids were d/c'd on [**6-22**]. Given her obvious pneumonia, lack of signs of local infection, and negative blood cultures from her lines, her PICC line was left in place. She recovered from her shock and tolerated fluid removal by intermittent HD prior to discharge. Her antibiotics will be continued until [**2188-7-1**]. . 2) Respiratory failure: Patient has chronic trach but has not been vent dependent since [**2188-1-5**] prior to this admission. As noted above she was vented in the ED for thick yellow secretions and hypoxia to the 80's. She continued to have thick pale yellow secretions while on the vent. She was placed on standing albuterol and atrovent nebs, and QVAR for her history of COPD. She received aggressive pulmonary toilet. . 3) ESRD: Pt is on M-W-F HD schedule but was not able to receive HD given her pressor-dependent septic shock. Renal was consulted. CVVH was schedule to be initiated on but was post-poned when it was discovered that her tunneled dialysis catheter was not working. The old line was removed and a new one was placed by IR on [**6-19**]. The line placement was complicated by some bleeding at the insertion site. That day, patient's PTT was greater than 150 depite not receiving any systemic heparin. The draw was repeated three times, two line draws and a peripheral stick with peristently elevated PTT. The patient received a one time dose of DDAVP and the bleeding at the line site eventually resolved with additional sutures and a fibrin injection. CVVH was initiated late in the evening of [**6-19**]. After her shock improved, she tolerated intermittent HD last on [**2188-6-24**]. She will resume her prior M-W-F schedule. She was discharged above her dry weight however she was requiring minimal ventilatory support. She can be re-assessed daily should she need additional ultra-filtration sessions. . 4) Bradycardia/Atrial Fibrillation: Previous ECG from [**12-12**] shows normal rate. ECG shows sinus brady with 1st degree block. Her dignoxin level was checked multiple times and remained sub-therapeutic. Nevertheless, it was held given her bradycardia with rates in the 40's but dipping transiently as low as the 30's. An Echocardiogram was performed which showed preserved EF. The etiology of her bradycardia was unclear. On [**6-21**] she was noted to be in atrial fibrillation with rates to the 80's. Her ASA was increased from 81 mg to 325 mg PO daily. Her digoxin was discontinued as she remained rate controlled without it. . 5) G-tube fell out: On arrival to the unit patient's G-tibe was noted to be out and lying at her side. A foley catheter was placed and surgery was consulted. Patient received her tube feedings and PO medications through the foley cathter without complication. The G-tube was changed during her admission. . 6) Anemia: Patient has chronic macrocytic anemia. B12 and folate levels were normal. Her Hct drifted downwards until on [**6-20**] it had trended down to 22.7. As the patient was actively oozing from the site of her new HD catheter, she received one unit of PRBC with an appropriate rise in her HCT. She has been relatively stable at ~ 26 since that time with no further signs of active bleeding. . 7) Hypothyroidism: continue synthroid which was changed to IV. This can be converted to G-tube administration once her Mid-line is removed. . 8) PVD: Followed by vascular surgery at rehab. Patient has dry gangrene of toes and auto-amputating. Per son, [**Last Name **] problem with infection. Lidoderm patches were applied to her feet. . 9) FEN: - TF via G-tube - replete lytes PRN . 10) PPX: - heparin SC for DVT prophylaxis - PPI . 11) COMMUNICATIONS: [**Name (NI) **], [**First Name3 (LF) **] and HCP, [**Telephone/Fax (1) 67244**] (cell) . 12) CODE: No compressions, no shocks. Chemical code okay. - confirmed with son [**Name (NI) **] (HCP)on [**6-16**] . 13) Access: Midline (placed at HR [**6-15**]), tunnelled HD cath (placed [**6-20**]) . 14) Dispo: transfered to MACU at [**Hospital1 100**] Senior Life 15) Ethical considerations: Pt seems very uncomfortable, resists nursing care, usually noncommunicative during hospital course but did mouth words to the nurses and doctors. Her only communications were clearly mouthing "I want to die" and "help me." [**Name (NI) 1094**] son argues that she doesn't mean that, or that she only says those things when she is sick. Discussed with ethics and social work. Medications on Admission: 1. Hydromophone 0.75mg q2h/prn during HD sessions only 2. Vancomycin 125mg QID GT 3. Oxycodone 2.5mg q6h/prn GT 4. Benadryl 25mg [**Hospital1 **]/prn GT 5. Benadryl 25mg qhs GT 6. Tums 650mg po QID 7. colace 100mg [**Hospital1 **]/prn GT 8. Digoxin 0.125mg every other day GT, last dose given today at the rehab 9. Mucomyst 200mg TId inh 10 Tylenol Q6h/prn GT 11. Albuterol 2 puffs q6h/prn inh 12. Synthroid 125 mcg daily GT 13. Aspirin 81mg qday Gt 14. Combivent 6 puffs q6h inh 15. Lactinex 1 tab [**Hospital1 **] GT 16. Prilosec 20mg GT 17. Reglan 10mg TID GT 18. Lidoderm patch top daily 19. Lactobacillus 1 tab [**Hospital1 **] 20. Epogen at HD Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mL PO BID (2 times a day) as needed. 3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff Inhalation QID (4 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) mL Injection [**Hospital1 **] (2 times a day). 5. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID (4 times a day) as needed: apply to perineal area. 10. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 2-15 Puffs Inhalation Q6H (every 6 hours). 11. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 2-15 Puffs Inhalation Q2H (every 2 hours) as needed for SOB, wheeze. 12. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Last Name (STitle) **]: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical 3X/WEEK (TU,TH,SA): apply to intact skin of right foot. 14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical 3X/WEEK (TU,TH,SA): apply to intact skin of left foot. 15. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 16. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: 0-10 units Injection ASDIR (AS DIRECTED). 17. Levothyroxine 200 mcg Recon Soln [**Hospital1 **]: One (1) Recon Soln Injection DAILY (Daily). 18. Fentanyl Citrate (PF) 50 mcg/mL Solution [**Hospital1 **]: 0.5-1 mL Injection Q4H (every 4 hours) as needed for pain. 19. Amikacin 250 mg/mL Solution [**Hospital1 **]: 1.6 mL Injection QHD (each hemodialysis): last dose on [**2188-7-1**]. 20. Piperacillin-Tazobactam 2.25 gram Recon Soln [**Date Range **]: One (1) Recon Soln Intravenous Q12H (every 12 hours): last dose on [**2188-7-1**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary diagnoses: 1)Sepsis secondary to Ventilator associated pneumonia 2)Respiratory failure 3)End stage renal disease Secondary diagnoses: 1)Atrial fibrillation 2)Anemia 3)Hypothyroidism 4)Peripheral vascular disease Discharge Condition: Stable. mouthing words. moving all 4 extremities. Discharge Instructions: 1)You were admitted to the hospital with an infection, likely in your lungs. You are currently on antibiotics for 2 weeks. 2)Please take all medications as listed in the discharge instructions. 3)Please attend all appointments as listed below. Please schedule an appointment with your primary care physician within [**Name Initial (PRE) **] few weeks after being discharged from the hospital. 4)If you experience any fevers, chills, chest pain, shortness of breath, dizziness, or any other concerning symptoms please return to the emergency room. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 610**] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2188-7-4**] 2:00

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icd9cm

[ [ [] ] ]

[ "38.95", "99.21", "96.72", "38.91", "39.95", "38.93", "97.02", "96.6" ]

icd9pcs

[ [ [] ] ]

14822, 14888

5640, 11669

359, 391

15153, 15205

4718, 5617

15803, 15960

3976, 4015

12370, 14799

14909, 15031

11695, 12347

15229, 15780

4030, 4699

15052, 15132

307, 321

419, 3028

3050, 3774

3790, 3960

41,627

179,626

11500

Discharge summary

report

Admission Date: [**2171-2-13**] Discharge Date: [**2171-2-16**] Date of Birth: [**2136-9-5**] Sex: F Service: NEUROSURGERY Allergies: sunflower oil-parsley seed oil / Oxcarbazepine Attending:[**First Name3 (LF) 1835**] Chief Complaint: seizure Major Surgical or Invasive Procedure: [**2-13**]: Left temporal craniotomy and mass resection History of Present Illness: 34yo F with new onset seizure in [**Month (only) 404**] while in Aruba who was found to have a left temporal cavernoma. She recently started trileptal by her Neurologist Dr. [**Last Name (STitle) **] after EEG on [**1-10**] showed epileptiform activity in left fronto-temporal region. She presents to clinic today after undergoing CTA to evaluate the vasculature surround the cavernoma. She continues to have 2 episodes a day of mild disorientation that may be related to seizure activity. She is no longer experiencing difficulty with her speech. She has no otehr active medical issues. Past Medical History: none Social History: mother of 2 children Social EthOH; Occasional marijuana Family History: non-contributory Physical Exam: PHYSICAL EXAM UPON DISCHARGE: nonfocal Pertinent Results: [**2-13**]: Head CT- Postoperative pneumocephalus, status post left temporal cavernoma resection. [**2-14**]: Head MRI- The patient is status post small left temporal lobe mass resection. Postoperative changes and air are present. Expected postoperative blood products are seen in the left temporal lobe. There is no residual enhancement. Evaluation of the remainder of the brain parenchyma demonstrates no suspicious lesions or restricted diffusion to suggest ischemia. Brief Hospital Course: Electively admitted and underwent craniotomy and mass resection. She tolerated this well and was transferred to the ICU for close neurological monitoring. Post operative head CT revealed no hemorrhage and post op changes. On [**2-14**] she remained neurologically stable and was cleared for transfer to the floor. She was ambulating independently and tolerating a soft diet. Post op MRI was obtained which revealed good resection. On [**2-15**] she was again stable and her wound was C/D/I. She was cleared for discharge home, however, she continued to have nausea throughout the day. As a result, patient was discharged home on [**2-16**] and will follow up with Dr. [**Last Name (STitle) **] in [**12-28**] weeks. Medications on Admission: Keppra 750mg PO BID Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever >38.5. 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. Reglan 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea for 3 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Brain Lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Keppra (Levetiracetam) for seizures, you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? 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. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**6-2**] days (from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ?????? Please call [**Telephone/Fax (1) 1669**] to make a follow up appointment with Dr. [**Last Name (STitle) **] in 3 months. You will need an MRI of the brain before this appointment. Completed by:[**2171-2-16**]

[ "225.0", "787.02", "345.90", "348.89" ]

icd9cm

[ [ [] ] ]

[ "01.59", "02.12" ]

icd9pcs

[ [ [] ] ]

3202, 3208

1705, 2425

318, 376

3265, 3265

1208, 1682

4882, 5507

1116, 1134

2496, 3179

3229, 3244

2451, 2473

3416, 4859

1149, 1149

271, 280

1179, 1189

404, 998

3280, 3392

1020, 1026

1043, 1100

463

197,296

43664+58650

Discharge summary

report+addendum

Admission Date: [**2198-10-5**] Discharge Date: [**2198-10-9**] Date of Birth: [**2136-9-25**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old female with nonsmall cell lung cancer metastatic to pleura, paracardium and ocular stage four disease diagnosed in [**2198-9-4**] with increasing shortness of breath and was status post her second therapeutic thoracentesis on [**2198-10-5**] when outpatient echocardiogram revealed tamponade. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Doctor Last Name 32868**] MEDQUIST36 D: [**2198-10-11**] 11:33 T: [**2198-10-12**] 06:20 JOB#: [**Job Number **] Name: [**Known lastname 14848**], [**Known firstname 14849**] Unit No: [**Numeric Identifier 14850**] Admission Date: [**2198-10-5**] Discharge Date: [**2198-10-9**] Date of Birth: [**2136-9-25**] Sex: F Service: [**Hospital1 1098**] MEDICINE ADDENDUM: HISTORY OF THE PRESENT ILLNESS: The patient is a 62-year-old female with metastatic non-small cell lung cancer to the pleura, pericardium, and ocular, stage IV, diagnosed in [**2198-9-4**], who is status post her second therapeutic thoracentesis on [**2198-10-5**] when an outpatient echocardiogram revealed tamponade. The patient had a history of increasing shortness of breath and dyspnea on exertion for the past month. She had two therapeutic thoracentesis to her right side as an outpatient and once again on [**2198-10-5**] was found to have pericardial tamponade by an outpatient echocardiogram. She was admitted to the CCU on [**2198-10-5**] for treatment. PHYSICAL EXAMINATION ON ADMISSION TO THE CCU: Temperature 98.8, oxygen saturations around 98% on room air, pulse 117, blood pressure 130/84, weight 133 pounds. She had pulses of [**9-18**], no JVD and [**12-6**]+ lower extremity edema. PERTINENT LABORATORY DATA AND X-RAYS ON ADMISSION: EKG revealed sinus rhythm but diffuse low voltages and increased rate with new electrical alternans consistent with pericardial effusion. An echocardiogram performed at that time revealed a normal left atrium, normal left ventricle, left ventricle ejection fraction greater than 55%, right ventricle systolic function was normal. There was a large pericardial effusion of 4.2 cm which appeared circumferential. There was evidence of right ventricular diastolic collapse which was consistent with impaired filling and tamponade physiology. HOSPITAL COURSE: After admission to the CCU, the patient underwent a pericardial tap which revealed around 800 cc of serosanguinous fluid from the pericardium. A repeat echocardiogram was performed which once again showed normal left atrium, normal left ventricle. There was only a small pericardial effusion measuring about 1 cm inferior to the basal left ventricle and about 0.5 cm lateral to the left ventricle around the left ventricle apex and anterior to the right ventricle. There was no evidence of diastolic collapse. Overnight, the drain put out about 200 cc of material with fibrin clots. The patient was also started on oxygen 2 liters for sats in the low to mid 90s. The patient continued to have dull pressure over her chest on inspiration and with movement. A portable chest x-ray obtained on [**2198-10-6**] revealed interval increase in pleural fluid on the right. An EKG obtained on [**2198-10-6**] revealed sinus rhythm, diffuse low voltages but no electrical alternans. An ultrasound of the right lower extremity was performed for right lower extremity edema, greater than left, but revealed no evidence of DVT. Throughout the day, the pericardial drain put out 500 cc of fluid. On [**2198-10-7**], the patient continued to be stable. An echocardiogram revealed normal left ventricle again with left ventricular ejection fraction greater than 55%, normal RV, and a small pericardial effusion with no evidence of compromise. A right pleural effusion was again noted. Also, during this stay, the patient was taken off her Premarin due to the increased risk of clot with her malignancy. On [**2198-10-8**], an AP and lateral chest x-ray were again obtained which revealed a stable right pleural effusion and a slight increase in a small left-sided effusion. An EKG again revealed diffuse low voltages and sinus tachycardia. The pericardial drain was pulled that morning and the patient was called out to the floor. An echocardiogram performed later that day revealed a small loculated pericardial effusion with fibrin or thrombus on the surface of the heart. No echogenic signs of tamponade and no significant change from prior study. The patient was saturating 92-95% on room air, had a blood pressure in the 100-120s/60-70s. That evening, the patient's blood pressure was about 80/50. She was asymptomatic and her examination unchanged. She was monitored closely and her blood pressure increased to 100s/70s without intervention. On [**2198-10-9**], the patient continued to be stable with a blood pressure in the 100-110s/50s-70s. She was tachycardiac to about 100. Her oxygen saturations in room air and walking were 92-95%. She did experience some hot flashes, presumably from the discontinuance of her Premarin. The patient was afebrile. The patient was discharged to home with a prescription for Ativan 0.5 mg one to two tablets t.i.d. p.r.n. anxiety. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Pericardial tamponade. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**], M.D. [**MD Number(1) 225**] Dictated By:[**Name8 (MD) 2450**] MEDQUIST36 D: [**2198-10-11**] 14:04 T: [**2198-10-12**] 06:43 JOB#: [**Job Number 14851**]

[ "197.2", "198.4", "162.9", "198.89" ]

icd9cm

[ [ [] ] ]

[ "37.0", "34.91" ]

icd9pcs

[ [ [] ] ]

5538, 5826

2566, 5453

156, 1990

2005, 2548

5478, 5516

63,914

106,614

36887

Discharge summary

report

Admission Date: [**2185-7-19**] Discharge Date: [**2185-8-12**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Intracranial hemorrhage - transfer from [**Hospital3 1280**] Hospital in [**Location (un) 47**] Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 85 yo Russian speaking only man w/ PAF, HTN, chronic anemia, recent E. coli sepsis presenting with ICH in the setting of altered mental status earlier today. Pt was admitted to [**Hospital6 1109**] [**7-14**] with fever and found to be septic w/ E-coli. He was treated with Ceftriaxone and was improving. He transferred to the floor 2 days prior. This afternoon he had a change in MS from being completely alert and oriented to starting to talk to himself. Before the transfer, he was more confused and agitated, requiring medical intervention for sedation. Per EMS report, he was given 0.5 of Haldol IV. Non-contrast head CT was done at 3pm to assess the change in mental status and found intracranial hemorrhage in the R hemisphere measuring 3.7 x 6.6 cm with associated midline shift at the OSH. Neurosurgery here was called and recommended neurology consultation there and admission to the neuro ICU. He is on Arixta and Trental at home. PTT 26 INR 1.6. For the past 2 days he's been back on Arixtra. On admission to [**Hospital1 **] they noted him to be thrombocytopenic to 86. This has improved gradually to 163. He had a normal UA. During his work up for a source of bacteremia he had an abdominal CT w/ possible air behind duodenum. His abdominal exam remained benign by report. He was planned for EGD today and then discharge home but this was delayed by altered mental status. No source for sepsis has been found but given possible GI source, his ABX was switched to Unasyn as of [**7-18**]. Past Medical History: 1. Paroxysmal Atrial fib - in sinus whole hospitalization - Not on Coumadin for unclear reasons 2. Hypertension 3. Chronic anemia 4. BPH 5. s/p Pacemaker 6. L knee replacement 7. Dementia 8. s/p appendectomy Social History: Lives at home with wife. Denies tobacco, drug use but occasional EtOH use. HCP listed as [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 83293**] or [**Telephone/Fax (1) 83294**] Family History: Father had breast cancer. Physical Exam: Physical Exam: T C HR /min, RR/min BP / mmHg Pulse ox 100%RA Gen: Awake - talks to himself but unclear if dysarthria present or fluent given only in Russian. Neck: Supple, no meningismus. CVR: RRR, no murmurs, rubs, or gallops Lung: Clear Abd: +BS, soft, non-tender, non-distended. Extrem: No edema Neuro: MS - Awake and continually talks to self but unclear if speech coherent, fluent or dysarthric since only in Russian. Does seem oriented to self. Cranial Nerves ?????? Keeps eyes closed - difficult to pry them open, +Bell's phenomenon more on R than L. Face appears symmetric and does appear to blink to threat on both sides. Both pupils small but reactive. Difficult to assess EOM given that its difficult to pry eyes open. +Gag. Motor: Tone ?????? Does appear to move all extremities but LE not antigravity and moves both UEs spontaneously and anti-gravity. Increased tone in both lower extremities but LUE>RUE. Reflexes - [**Hospital1 **] Tri BR Pat Ach Toes R 2 2 2 0 0 up L 2+ 2+ 2+ 2- 0 up Sensation - Appears intact to noxious stim. Impression: Patient is a 85 yo Russian-speaking man initially admitted to [**Hospital1 **] with fever and found to be septic who was improving with IV ABX but found to have change in ME with NCHCT revealing R tempo-occipital hemorrhage. On exam, patient appears confused and does not follow commands although there is a severe language barrier. He is moving all extremities but only UEs are anti-gravity. No clear difference in tone but L side reflexes > R. Pertinent Results: CT CNS w/o contrast: 06/ 30 There is a very large lobar-type hematoma spanning the right parietal, temporal and occipital lobes, with internal layering of blood products suggesting a hematocrit effect. It is not significantly changed since the previous study. Surrounding edema is relatively mild, given the size of the hematoma. There is associated 2-mm left shift of the third ventricle and inferior anterior falx, as well as mild narrowing of the right limb of the quadrigeminal plate cistern. The posterior right lateral ventricle is effaced. While the third ventricle is partially compressed, the left lateral ventricle is normal in size. Extracranial soft tissue structures and bones are unremarkable. Repeat Ct CNS on 07/ 01: unchanged. CT abd/pelvis [**2185-7-21**]; A 6 x 7 mm ground-glass nodule in the right lower lobe. [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] guidelines, recommend chest CT followup in [**7-1**] months or if high risk (for example, a smoker) in three to six months. 2. Bilateral pleural effusions and associated atelectasis. 3. Sigmoidal colonic wall thickening without signs of acute inflammation indicative of circular muscle hypertrophy associated with diverticulosis. 4. Sigmoidal diverticulosis without evidence of diverticulitis. No abscess. 5. Gas in the bladder likely secondary to Foley instrumentation. EEG [**2185-7-26**] BACKGROUND: There is a localized posterior quadrant polymorphic delta slowing of [**2-23**] Hz on the right that seems to obliterate the occipital region on the right. There is a 10 Hz posterior predominant rhythm seen in the left hemisphere. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Produced no activation of the record. SLEEP: No normal waking or sleeping morphologies were seen. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: This is an abnormal EEG due to the localized posterior quadrant slowing on the right with associated obliteration of the occipital rhythm which suggests cortical involvement. There was no seizure activity detected. [**2185-7-19**] 09:59PM GLUCOSE-95 UREA N-13 CREAT-0.7 SODIUM-141 POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-22 ANION GAP-13 [**2185-7-19**] 09:59PM ALT(SGPT)-18 AST(SGOT)-32 ALK PHOS-66 TOT BILI-0.6 [**2185-7-19**] 09:59PM ALBUMIN-3.2* CALCIUM-7.6* PHOSPHATE-2.2* MAGNESIUM-1.7 [**2185-7-19**] 09:59PM WBC-14.6* RBC-4.62 HGB-13.4* HCT-40.0 MCV-87 MCH-29.0 MCHC-33.5 RDW-13.7 [**2185-7-19**] 09:59PM PLT COUNT-216 [**2185-7-19**] 09:59PM PT-14.3* PTT-22.6 INR(PT)-1.2* BCx [**7-19**], [**7-21**] x2 negative to date Urine culture [**7-21**] negative. LDL 93, HDL 45, trig 80 HbAlc 5.9 Brief Hospital Course: The patient was asssessed by neurosurgery (Dr. [**First Name (STitle) **] who feels there is no current benefit from a possible surgical intervention. The neuro-ICU team (Dr. [**Last Name (STitle) 1794**] has discussed the situation and prognosis with the family (daughter) and patient was transferred to the Neurology floor [**7-20**]. A CT of the head was obtained on [**2185-7-19**], which revealed a large lobar hematoma in the right cerebral hemisphere. Given the patient's age, it was felt to be most likely secondary to amyloid angiopathy. In addition to this underlying potential etiology, Mr. [**Known lastname 83295**] was also noted to be on both Arixtra and Trental at home both of which are antiplatelet agents. Of note, he had been thrombocytopenic actually at the outside hospital, his platelets were down to 86. This was of unclear etiology and had actually gradually improved. Since admission in the ICU, Mr. [**Known lastname 83295**] has remained stable. He was initially treated with Dilantin empirically, although did not have a history of seizures. This was, however, discontinued. A CT of the head was repeated [**7-20**] for further comparison. This unfortunately revealed significant motion artifact. There was, however, noted again blood in the third ventricle. His platelet count also improved after admission when compared to the previous hospitalization. Aspirin 81 mg was resumed [**7-23**]. In regards to further evaluation for his etiology of bleed, MRI brain could not be obtained due to his pacemaker. He is not being anticoagulated for his paroxysmal afib, but has been in sinus rhythm since he has been here. On [**7-21**] patient was found to have temp of 100.6, leukocytosis, worsening mental status, and possible nuchal rigity on examination. He had been completing a course of unasyn for e coli bacteremia noted from outside hospital. He was empirically treated with ceftriaxone, vancomycin, and ampicillin due to suspicion of meningitis. An LP was not performed due to the large hemorrhage and mass effect on CT head. Blood cultures, urine culture, and CXR, as well as CT abd/pelvis showed no obvious infectious source. Clinically patient improved over the next several days, leukocytosis continued to resolve and was afebrile. Therefore antibiotics were narrowed and unasyn was resumed [**7-25**]. It is anticipated this can be discontinued [**7-29**]. Patient had an NG tube placed and was receiving tube feeds during hospitalization. Speech/swallow re-eval [**7-25**] recommended ground diet with thin liquids. Patient is tolerating this well. On [**7-26**] AM patient was noted to have brief episode (20 seconds) of left gaze deviation, decreased responsiveness and rhythmic eye blinking. Given size and location of hemorrhage, EEG was performed with results reported above. The patient was also started on keppra for seizure prophylaxis. This will be continued upon discharge but may be re-evaluated in outpatient follow up. He has not shown any further activity concerning for seizure since this episode. Also, on [**8-8**], patient was found by RN on floor next to bed. He had a repeat CT head which showed no new hemorrhage and x-ray of rib and R shoulder which did not show a fracture. His pain has resolved with tylenol, and he is currently pain-free. Patient will be discharged home on aspirin and keppra for seizure prophylaxis. The family has arranged elder services for support at home and arrange for physical therapy at home. He will follow up with Dr. [**Last Name (STitle) **] (neurology) as well as his PCP. Medications on Admission: 1. Trental 400 [**Hospital1 **] 2. Flomax 0.4 qhs 3. Folate 1 daily 4. Simvastatin 20 daily 5. Lisinopril 15mg daily 6. Aricept 10mg daily 7. Atenolol 25mg daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Tablet(s) 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily) as needed for stroke. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 5. Ampicillin-Sulbactam 1.5 gram Recon Soln Sig: One (1) 1.5 g Injection Q6H (every 6 hours): To be completed [**7-29**]. 6. Aricpet 10 mg daily 7. Simvastatin 20 mg qhs 8. Folate 1 mg daily 9. Keppra 500 mg b.i.d. 10. Hospital Bed Diagnosis; right-sided temporal occipital stroke Reason for hospital bed; the patient has very limited movement of his left arm and leg. Necessary for patient safety, mobility and transfers. Discharge Disposition: Home Discharge Diagnosis: 1) R temporal occipital hemorrhage, likely secondary to amyloid angiopathy. 2) HTN 3) Dementia Discharge Condition: Awake, arousable to voice, follows commands and verbalizes. Pinpoint pupils, moves all extremities against gravity (but minimally on left), increased tone L > R, mild left sided neglect. Discharge Instructions: Please continue your medications as prescribed. Please return to the emergency department immediately for any changes in mental status, speech, or motor function. Follow up with Dr. [**Last Name (STitle) **] (neurology) as instructed below. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2185-8-26**] 1:30. [**Hospital1 18**], [**Hospital Ward Name 23**] 8.

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icd9cm

[ [ [] ] ]

[ "99.15" ]

icd9pcs

[ [ [] ] ]

11352, 11358

6728, 10334

368, 374

11497, 11686

4023, 6705

11978, 12217

2388, 2415

10547, 11329

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10360, 10524

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190,204

50020

Discharge summary

report

Admission Date: [**2102-3-5**] Discharge Date: [**2102-3-28**] Date of Birth: [**2021-1-14**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain with exertion Major Surgical or Invasive Procedure: Cardiac Catheterization [**2102-3-9**] Coronary bypass grafting x4 with the left internal mammary artery to the left anterior descending artery and reverse saphenous vein graft to the posterior descending artery, distal left circumflex artery and obtuse marginal artery History of Present Illness: 81 y/o spanish-speaking woman with Diabetes Mellitus, class I chronic diastolic Congestive Heart Failure, Chronic Kidney Disease, Hypertension, hyperlipidemia presents with chest pain and shortness of breath. Of note, the patient was recently seen by her PCP [**Last Name (NamePattern4) **] [**2-21**] with the complaint of right sided chest pressure and shortness of breath, worsened by exertion. An EKG performed in the office showed TWI in leads V1-V4, and an outpatient stress test was ordered. The patient states that she has been having tightness and pressure in her chest that has been present for the last 2 weeks. She states that since her visit to her PCP that her symptoms have become progressively worse with exertion, to the point that she develops symptoms while getting up to go to the bathroom. She admits that she feels fatigued throughout the day, which is worse from her baseline. She stated that last night she became markedly dyspneic while getting up to go to the bathroom, with associated R chest pressure which migrated to the substernal region. Her daughter was concerned about this development and decided to bring the patient into the emergency department. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. She was admitted for further evaluation. Past Medical History: - DMII c/b retinopathy and peripheral neuropathy - hypertension - hyperlipidemia - osteoporosis - nocturnal leg cramps - asthma (mild intermittent, not on any meds) - low back pain - ECHO ([**1-/2095**]) - EF 60%, impaired LV relaxation, borderline - pulmonary systolic hypertension - Dobutamine Stress ECHO ([**4-/2093**]) - no evidence of ischemia - Multinodular goiter - s/p CCY - s/p back surgery at NBH ~[**2098**] Social History: Lives alone, has a woman who helps to cook and clean. Six children, at least 3 of whom live in area. Denies EtOH or tobacco use, no recreational drug use. States she doesn't move around much. Family History: Two children have died, two children with cancer (prostate, liver). +HTN, +DM type II Physical Exam: GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Coarse inspiratory rales heard in all lung fields. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ LE edema to the mid shins bl. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP dopplerable Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP dopplerable Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 104434**] (Complete) Done [**2102-3-9**] at 9:52:03 AM FINAL GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is mildly depressed (LVEF= 40 - 45 %). with mild global free wall hypokinesis. The apex is hypokinetic, while base and mid segments all work well. 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 moderately thickened. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is AV-Paced, on no inotropes. Preserved biventricular systolic fxn. No AI. MR is now mild. Aorta intact. SGC tip is at the PA bifurcation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2102-3-9**] 15:15 ?????? [**2094**] CareGroup IS. All rights reserved. [**2102-3-28**] 05:09AM BLOOD WBC-7.4 RBC-3.02* Hgb-9.0* Hct-27.0* MCV-89 MCH-29.7 MCHC-33.3 RDW-14.2 Plt Ct-375 [**2102-3-27**] 06:30AM BLOOD WBC-7.8 RBC-3.16* Hgb-9.3* Hct-28.1* MCV-89 MCH-29.4 MCHC-33.0 RDW-14.3 Plt Ct-404 [**2102-3-28**] 05:09AM BLOOD Glucose-64* UreaN-92* Creat-2.8* Na-138 K-4.7 Cl-100 HCO3-29 AnGap-14 [**2102-3-28**] 01:33AM BLOOD Na-137 K-5.1 Cl-99 Brief Hospital Course: On [**3-9**] Ms.[**Known lastname 3234**] was taken to the operating room and underwent Coronary bypass grafting x4 (left->internal mammary artery to the left anterior descending artery and reverse saphenous vein graft to the posterior descending artery, distal left circumflex artery and obtuse marginal artery) with Dr.[**Last Name (STitle) **]. Please refer to operative report for further surgical details. CROSS-CLAMP TIME:74 minutes. PUMP TIME:89 minutes. She tolerated the procedure well and was transferred to the CVICU in stable but critical condition, intubated and sedated. She remained intubated with progressive oliguric renal failure and subsequent volume overload. Renal consulted and CVVH was initiated. Fluid was removed and on POD# 6 she was extubated without difficulty. CVVH was discontinued. Renal advised no further lasix. The following day she demonstrated markedly diminished mental status and a head CT scan per Radiology revealed scattered hypodense foci in the right frontal lobe and left frontal and temporal lobes are indeterminate but may represent small vessel ischemic changes/volume averaging. Ultimately her mental status improved, her urine output was adequate with resolving postoperative ARF. She continued to slowly progress and on POD# 12 she was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. The remainder of her hospital course was essentially uneventful. On POD19 she was cleared for discharge to [**Hospital 100**] Rehab. All follow up appointments were advised. Electrolytes will be checked frequently at rehab. Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled every six (6) hours as needed CANDESARTAN [ATACAND] - (Prescribed by Other Provider) - 32 mg Tablet - 1 Tablet(s) by mouth once a day FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 2 puffs oral twice daily GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times a day INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 100 unit/mL Solution - 25 units every am daily LATANOPROST [XALATAN] - 0.005 % Drops - 1 drop(s) both eyes at bedtime LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1 patch twice a day METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily SIMVASTATIN - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day ASPIRIN [ADULT LOW DOSE ASPIRIN] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 81 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - 500 mg (1,250 mg)-200 unit Tablet - 1 Tablet(s) by mouth daily GUAIFENESIN - 400 mg Tablet - 3 Tablet(s) by mouth twice a day GUAIFENESIN [MUCINEX] - 1,200 mg Tablet, ER Multiphase 12 hr - 1 Tab(s) by mouth twice a day GUAR GUM [BENEFIBER (GUAR GUM)] - (OTC; Dose adjustment - no new Rx) - Packet - 1 (One) Packet(s) by mouth once a day as needed LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day MULTIVITAMIN - (OTC) - Capsule - Capsule(s) by mouth once a day Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 4. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 10. ipratropium bromide 0.02 % Solution Sig: [**1-15**] Inhalation Q6H (every 6 hours) as needed for wheezing. 11. guaifenesin 600 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO BID (2 times a day). 12. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 13. multivitamin Tablet Sig: 1-2 Tablets PO DAILY (Daily). 14. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 15. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 16. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 17. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 18. Insulin Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Breakfast Glargine 25 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-140 mg/dL 2 Units 2 Units 2 Units 0 Units 141-199 mg/dL 4 Units 4 Units 4 Units 1 Units 200-239 mg/dL 6 Units 6 Units 6 Units 2 Units 240-280 mg/dL 8 Units 8 Units 8 Units 3 Units > 280 mg/dL Notify M.D. 19. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 20. Outpatient Lab Work Electrolytes daily x 3 days then 3x/week to monitor hyperkalemia and renal insufficiency 21. insulin glargine 100 unit/mL Solution Sig: Twenty Five (25) Subcutaneous once a day: 25 units Glargine daily am. 22. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 4 PAst medical history: -Chronic diastolic CHF, class I by TTE [**2101-11-10**] - Insulin-dependent diabetes complicated by retinopathy and peripheral neuropathy -hypertension, difficult to control -Hyperlipidemia -Osteoporosis -Nocturnal leg cramps -Mild intermittent asthma -Mild diastolic dysfunction -Multinodular goiter -Chronic Kidney Disease (baseline Cr 1.5) Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema LLE [**1-15**]+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on [**2102-4-12**] at 1:30PM Cardiologist: Dr. [**First Name (STitle) 437**] on [**2102-5-10**] at 9AM Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**4-18**] 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:[**2102-3-28**]

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icd9cm

[ [ [] ] ]

[ "36.15", "37.23", "34.04", "38.97", "36.13", "88.56", "39.95", "96.72", "96.6", "39.61" ]

icd9pcs

[ [ [] ] ]

11690, 11756

5690, 7339

334, 605

12226, 12453

3687, 5667

13376, 13912

2717, 2805

8998, 11667

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7365, 8975

12477, 13353

2820, 3668

270, 296

633, 2044

11860, 12205

2504, 2701

76,494

158,374

46330+58901+58902

Discharge summary

report+addendum+addendum

Admission Date: [**2130-2-3**] Discharge Date: [**2130-2-7**] Date of Birth: [**2061-7-28**] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Shellfish Attending:[**First Name3 (LF) 1271**] Chief Complaint: status post fall Major Surgical or Invasive Procedure: none History of Present Illness: This is a 68 year old male who fell backwards at home on [**2130-2-2**] and presented to the mergency department.There was no loss of conciousness. At the time of admission he complained of pain in his neck and back after this fall. He came to the emergency [**Hospital1 **] and was evaluated with a head CT and Cspine CT. A intercranial hemorhage was ruled out. A cervical spine CT showed pre-vertebral swelling. He was completely neurologically intact, and has no pain to palpation of his c-spine, he denied difficulty breathing,and was saturating appropriately on room air. Of note, he had spine surgery in [**Month (only) 1096**](1 year ago) at [**Hospital6 **] hopsital. The patientdoes not remember what type of surgery he had, however, based onthe MRI and scar in posterior neck, he must have had posterior laminectomies. MRI cspine was done to evaluate this injury and it just re-confirmed the pre-vertebral swelling. Past Medical History: DM2 with neuropathy Prostate cancer s/p prostatectomy IgA gammopathy Carcinoid s/p colectomy Cervical spondylosis s/p C4-5 fusion and posterior laminectomies. Social History: The patient is retired auto worker. He says he does use alcohol. He has four children and four grandchildren. Family History: non contributory Physical Exam: 99.3 80 159/80 16 100% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils:PERLLA EOMs Intact Neck: No murmurs heard. Posterior neck scar is clean dry and intact 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. Motor: 5/5 strength BUE: deltoid, biceps, triceps, ECR,FCR,intrinsic hand muscles. 5/5 strength BLE: hip flexors/extensors, knee flexors/extensors, ankle plantarflexio/dorsiflexion. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Propioception intact Toes downgoing bilaterally Rectal exam normal sphincter control exam upon discharge: Pertinent Results: [**2130-2-3**] 08:19PM CRP-17.2* [**2130-2-3**] 08:19PM SED RATE-20* [**2130-2-3**] 03:37PM COMMENTS-GREEN TOP [**2130-2-3**] 03:37PM GLUCOSE-131* LACTATE-1.2 NA+-141 K+-4.3 CL--99* TCO2-28 [**2130-2-3**] 03:20PM UREA N-19 CREAT-1.1 [**2130-2-3**] 03:20PM WBC-5.4 RBC-4.40* HGB-13.3* HCT-38.3* MCV-87 MCH-30.2 MCHC-34.7 RDW-13.7 [**2130-2-3**] 03:20PM NEUTS-53.9 LYMPHS-38.1 MONOS-5.9 EOS-1.5 BASOS-0.6 [**2130-2-3**] 03:20PM PLT COUNT-168 [**2130-2-2**] 10:30AM GLUCOSE-145* UREA N-21* CREAT-1.1 SODIUM-136 POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-23 ANION GAP-18 [**2130-2-2**] 10:30AM estGFR-Using this [**2130-2-2**] 10:30AM WBC-7.1# RBC-4.86 HGB-14.3 HCT-41.8 MCV-86# MCH-29.4 MCHC-34.2 RDW-13.6 [**2130-2-2**] 10:30AM NEUTS-72.7* LYMPHS-21.2 MONOS-4.8 EOS-1.0 BASOS-0.2 [**2130-2-2**] 10:30AM PLT COUNT-146* [**2130-2-2**] 10:30AM PT-12.8 PTT-25.7 INR(PT)-1.1 CT C-SPINE W/O CONTRAST Study Date of [**2130-2-2**] 10:17 AM IMPRESSION: 1. Abnormal prevertebral soft tissue swelling extending from C2 through C7-T1. There is also soft tissue stranding of the right neck with associated loss of fat planes. Recommend further evaluation of the neck with MR. 2. Multilevel degenerative changes of the cervical spine including moderate-to-severe narrowing of the spinal canal at C5-6 secondary to a bulging disc. Narrowing of the canal is also seen at C3-4 and C6-7. In the setting of trauma, narrowing of the central spinal canal can predispose to spinal cord injury. 3. Slight rotation of the C1 vertebral body on the C2 vertebral body is likely positional, although rotatory subluxation cannot be excluded. 4. No evidence of fracture. CT HEAD W/O CONTRAST Study Date of [**2130-2-2**] 10:17 AM IMPRESSION: No acute intracranial process. CHEST (PA & LAT) Study Date of [**2130-2-2**] 10:38 AM IMPRESSION: No acute cardiopulmonary process. MR CERVICAL SPINE W/O CONTRAST Study Date of [**2130-2-2**] 4:12 PM IMPRESSION: 1. Extensive fluid signal and edema in the prevertebral space, and involving the right greater than left soft tissues of the neck, extending inferiorly below the level covered by this MRI. These findings are concerning for an acute process, such as infection or hematoma. The ALL is not well seen (artifact from the plate and screws limits evaluation) and may be torn. CT chest with contrast is suggested to assess the inferior extent of this process. 2. Interval increase in kyphotic angulation at C5-C6 with moderate spinal canal narrowing, worse compared to [**2128-11-14**]. This could represent interval worsening of degenerative disease, or acute injury. 3. Interval (when compared to [**2128-11-14**]) C3 and C4 laminectomy. The posterior paraspinal edematous changes could be residual post-operative changes, although acute traumatic injury to the structure is possible as well. 4. Remote anterior fusion of C4 and C5, with underlying degenerative changes with a chronic myelomalacia changes at that level. CTA NECK W&W/OC & RECONS Study Date of [**2130-2-3**] 5:23 PM IMPRESSION: 1. No change in the size of the prevertebral soft tissue swelling since the previous cervical spine CT. 2. Compression of the left jugular vein with a small thrombus identified as described above. 3. No evidence of arterial injury seen or extravasation of contrast in relation with the veins identified. 4. Small metallic fragment is seen in the cervical spine, of uncertain significance, likely from previous surgical instrumentation. 5. Post-surgical changes in the region of cervical spondylosis. CT CHEST W/CONTRAST Study Date of [**2130-2-3**] 5:23 PMIMPRESSION: Soft tissue stranding and fluid of intermediate density extending from prevertebral space of the neck into the upper mediastinum and right supraclavicular fat. This is likely edema and hemorrhage tracking inferiorly from the cervical surgery but infection of it cannot be excluded, though there is no abnormal enhancement to suggest it. Multiple lung nodules unchanged from [**2123**], benign. MR THORACIC SPINE W/O CONTRAST Study Date of [**2130-2-4**] 12:18 AM IMPRESSION: No evidence of fracture or intraspinal hematoma in the thoracic region. No abnormal signal is seen within the spinal cord. Upper thoracic prevertebral soft tissue swelling, likely from extension from the cervical region. Brief Hospital Course: This is a 68 year old male who fell backwards at home on [**2130-2-3**]. There was no loss of consiousness. He initially complained of pain in his neck and back after this fall. He came to the emergency [**Hospital1 **] and was evaluated with a head CT and Cspine CT. Head bleed was ruled out. Cspine CT showed pre-vertebral swelling. On [**2-3**] he was admitted to the trauma SICU with a hard cervical collar to be worn at all times. A CTA of the neck was performed which revealed compression of the left jugular vein with a small thrombus.After discussion with vascular surgery and trauma surgery, it was decided that you did not need anticoagulation was not needed for this clot. You had a repeat CT done that showed interval improvement in the pre-vertebral swelling. Your condition is at baseline now and your vitals are stable. Medications on Admission: dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). niacin 100 mg Tablet Sig: Five (5) Tablet PO BID (2 times a day). bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 3. dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. niacin 100 mg Tablet Sig: Five (5) Tablet PO BID (2 times a day). 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 86**] Discharge Diagnosis: prevertebral edema left internal jugular thrombus Discharge Condition: AAO X 3 regular diet baseline ambulation Discharge Instructions: ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Wear your cervical collar at all times as instructed. ?????? You may shower briefly without the collar or back brace; unless you have been instructed otherwise. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ??????CALL 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 change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow Up Instructions/Appointments ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**] to be seen in 4 weeks. ??????You will/will not need x-rays/CT-scan prior to your appointment. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2130-2-7**] Name: [**Known lastname 1923**],[**Known firstname 672**] Unit No: [**Numeric Identifier 15724**] Admission Date: [**2130-2-3**] Discharge Date: [**2130-2-7**] Date of Birth: [**2061-7-28**] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Shellfish Attending:[**First Name3 (LF) 1698**] Addendum: Please call [**Telephone/Fax (1) 10038**] to schedule an appointment with ENT in two weeks for further follow up. Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 42**] [**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**] Completed by:[**2130-2-7**] Name: [**Known lastname 1923**],[**Known firstname 672**] Unit No: [**Numeric Identifier 15724**] Admission Date: [**2130-2-3**] Discharge Date: [**2130-2-7**] Date of Birth: [**2061-7-28**] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Shellfish Attending:[**First Name3 (LF) 1698**] Addendum: Patient was discharged home with services. Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 42**] [**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**] Completed by:[**2130-2-7**]

[ "453.86", "E880.9", "V45.77", "V45.4", "952.05", "952.00", "357.2", "V45.72", "250.60", "V10.46" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11749, 11933

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303, 310

9243, 9286

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10275, 11116

1595, 1613

8255, 9066

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247, 265

338, 1266

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1288, 1449

1465, 1579

2457, 2457

80,534

159,568

8433+55945

Discharge summary

report+addendum

Admission Date: [**2151-8-13**] Discharge Date: [**2151-8-20**] Date of Birth: [**2094-10-18**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 13256**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 56M homeless with history of hepatocellular carcinoma s/p resections, Hep C cirrhosis, HTN, psoriasis, and psych history significant for chronic alcohol dependence, polysubstance abuse, and depression who came in after being observed to have a seizure. Per report patient started seizing and then fell to the ground. Reports h/o seizures in past in setting of EtOH withdrawal. When EMS arrived on scene he was awake but not oriented. SBPs en route in 90s. On arrival SBPs 70s, febrile to 102.7, lactate at 11.9, creatinine 3 from 0.7. Patient was noted to be tachycardic, rigid and agitated but moving all extremities and able to answer basic questions. Shortly after arrival SBPs fell to 50s. BPs not responsive to 2L IVS. Started on vanc/zosyn and levophed. CXR without e/o PNA, UA relatively [**Name2 (NI) 29734**]. Blood and urine cultures pending. CVL placed. CVP ~10 after 3-4L. Aggressive IVF, lactate trending down s/p 3-4L. Head CT without acute cranial process. Films showed C1 fracture which was [**Name2 (NI) 6349**] by spine. Bedside U/S showed plump IVC and no pericardial effusion. Transferred to ICU for further management. BP prior to transfer 120/90. On arrival to the MICU he was agitated and shaking. Oriented to place. Requesting to be left alone to sleep. Past Medical History: hepatocellular carcinoma s/p resections Hep C cirrhosis HTN psoriasis alcohol dependence polysubstance abuse depression seizures in setting of EtOH withdrawal Social History: Currently homeless, has been at Rosscommon for rehab/shelter needs, has been [**Street Address(1) 29735**] Inn as well. Reports has 3 children, no contact with them, has a sister who is listed as his HCP. Family History: Noncontributory Physical Exam: ADMISSION PE: Vitals: T: 100.7 BP: 144/65 P: 107 R: 22 O2: 99/2L. UOP ~2L General: Alert but severely agitated, oriented to place HEENT: Sclera anicteric, dry MM Neck: C collar CV: tachycardic, no murmur Lungs: scattered sparse crackles, no wheeze, decent air movement Abdomen: soft, non-tender, slightly-distended, +bs GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: tremor, moving all extremities, unable to cooperate with remainder of exam Discharge PE: General: Sleeping peacefully. No acute distress. Oriented x3. Lethargic HEENT: Sclera anicteric, MMM. Large laceration with staples in place over left parietal area appears non-infected. Neck: C collar in place. CV: RRR. NS1&S2. NMRG Lungs: B/l crackles improved from yesterday. Good air flow. Poor inspiratory effort Abdomen: Soft. Mild RUQ TTP with rebound guarding. No rebound, or rigidity. Liver palpable ~2cm below costal margin Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: No tremor. Moving all extremities. No asterixis Skin: Psoriatic lesion on b/l hands, kneecaps. Abrasion on R. elbow dressed. Pertinent Results: ADMISSION LABS: [**2151-8-13**] 07:45PM BLOOD WBC-9.5# RBC-3.93* Hgb-10.8* Hct-34.1* MCV-87 MCH-27.6 MCHC-31.8 RDW-17.2* Plt Ct-138*# [**2151-8-13**] 07:45PM BLOOD Glucose-79 UreaN-18 Creat-3.0*# Na-133 K-5.1 Cl-105 HCO3-10* AnGap-23* [**2151-8-13**] 07:45PM BLOOD CK(CPK)-1456* [**2151-8-13**] 11:39PM BLOOD Type-ART Temp-38.3 O2 Flow-4 pO2-142* pCO2-34* pH-7.32* calTCO2-18* Base XS--7 Intubat-NOT INTUBA [**2151-8-13**] 08:11PM BLOOD Lactate-11.2* [**2151-8-13**] 09:47PM BLOOD Lactate-3.4* [**2151-8-13**] 11:39PM BLOOD Lactate-2.4* [**2151-8-14**] 03:36AM BLOOD Lactate-0.8 . Discharge Labs: [**2151-8-20**] 05:55AM BLOOD WBC-5.9 RBC-3.24* Hgb-9.3* Hct-28.3* MCV-87 MCH-28.6 MCHC-32.8 RDW-18.1* Plt Ct-124* [**2151-8-20**] 05:55AM BLOOD PT-12.0 PTT-31.6 INR(PT)-1.1 [**2151-8-20**] 05:55AM BLOOD Glucose-97 UreaN-11 Creat-0.5 Na-138 K-3.9 Cl-107 HCO3-23 AnGap-12 [**2151-8-20**] 05:55AM BLOOD ALT-40 AST-57* AlkPhos-98 TotBili-0.7 [**2151-8-20**] 05:55AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.8 . Micro: [**2151-8-18**] Blood Culture, Routine-PENDING [**2151-8-17**] Blood Culture, Routine-PENDING [**2151-8-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-Contaminated [**2151-8-16**] URINE CULTURE-Neg [**2151-8-16**] Blood Culture, Routine-PENDING [**2151-8-16**] Blood Culture, Routine-PENDING [**2151-8-13**] URINE CULTURE-Neg [**2151-8-13**] Blood Culture, Routine-Neg [**2151-8-13**] Blood Culture, Routine-Neg Brief Hospital Course: 56 yo homeless M w/PMH significant for HCV cirrhosis and HCC that presented to the ED in septic state following witnessed tonic clonic seizure. Volume resuscitated with NS and started on broad spectrum abx. Stabilized and transferred to floor. Treated for aspiration PNA with resolution of fevers by time of discharge. . Active Issues: #SIRS: Pt was hypotensive with SBP in 70's and fever to 102.7 when presenting to the ICU. BP responded well to volume resuscitation and pressures stabilized on first day of admission. Pt had no recollection of events leading up to admission. Fever resolved while on vancomycin and zosyn, but returned on the floor (see below). Thought to be caused by aspiration pneumonia, however, initial chest xray unrevealing. Patient was pan-cultured, however, all cultures remained negative. Although fever recurred, no hypotension, tachycardia, or leukocytosis while on the floor. . #Fever: Developed recurring fevers to 101-102 despite being on broad spectrum antibiotics vancomycin and zosyn. Wide differential included infection, medications, collagen vascular disease, and neoplasm. Switched to PO levofloxacin and metronidazole to treat for aspiration pneumonia after CXR positive for BLL infiltrates and physical exam significant for productive cough and b/l dense crackles. Despite this fevers persisted, so he received a CT torso to evaluate for HCC metastases vs. occult abscess. This was unrevealing. At time of discharge, he had been fever free for >24 hours, and had completed 3 days of a 10 course of metronidazole and flagyl. . #Aspiration PNA: See above. Treated with empiric vancomycin and zosyn, then switched to levofloxacin/flagyl for aspiration pneumonia. Received 3 days of 8 day course, and given prescription for outpatient meds. . #EtOH Withdrawal/Abuse: Patient seizure likely [**1-28**] EtOH withdrawal as head CT negative and no documented history of seizure in the past. Seizure resulted in L. parietal scalp laceration, that was closed with staples. Although patient states that he has not had alcohol in months, his BAL was 64 in the ED. Patient did not initially score on CIWA in MICU, however, did so for several days on the floor. Had not scored in >48 hours prior to discharge. Pt ad no recollection of events prior to admission. This is consistent with Korsakoff's dementia, though no ataxia, opthalmoplegia or confabulation. Patient was started on thiamine and folate in-house, and discharged on these medications. . #C1 Fracture: CT at time of admission significant for C1 fracture. [**Month/Day (2) **] by neurosurgery in ICU, and instructed to wear neck collar for no less than 3 months. If he takes this off prior to this, there is chance of subluxation, paralysis, and death. . #[**Last Name (un) **]: Patient Cr on admission was 3.0. Resolved immediately after administration of IVF. Back to baseline of 0.5-0.7 for several days prior to discharge. . Chronic Issues: #Hypertension: Patient BP was difficult to control. Started on lisinopril 20mg qday per note in WebOMR, however, increased to 40mg qday at time of discharge. SBP 117 on discharge. . #HCC: He is known to have hepatocellular carcinoma. RUQ U/S at time of floor transfer significant for enlarging lesion from prior exam suspicious for HCC. AFP increased to 944 from 326 in [**Month (only) 116**]. Patient is being followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Hospital 2082**]. Outside records were obtained, which showed that they were aware of his liver lesion, and that it was last [**Hospital 6349**] with MRI on [**2151-7-27**]. He was discharged with a follow-up with Dr. [**Last Name (STitle) **] on [**2151-9-2**]. . #HCV Cirrhosis: Well compensated HCV cirrhosis with no known hepatic encephalopathy, esophageal varices, SBP, or ascites. . Transitional: #Follow-up with Dr. [**Last Name (STitle) **] and PCP [**Name Initial (PRE) 176**] 2 weeks #Will need to go to homeless shelter #Staples in scalp need to be removed in 2 weeks ([**2151-9-3**]) Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from Past note at Dr. [**Last Name (STitle) **] office. 1. Multivitamins 1 TAB PO DAILY 2. Fluocinonide 0.05% Cream 1 Appl TP QID 3. Tamsulosin 0.4 mg PO HS 4. Lisinopril 20 mg PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Fish Oil (Omega 3) 1000 mg PO DAILY 7. Gabapentin 800 mg PO DAILY 8. OLANZapine (Disintegrating Tablet) 10 mg PO DAILY 9. MethylPHENIDATE (Ritalin) 10 mg PO BID 10. MethylPHENIDATE (Ritalin) 20 mg PO BID 11. Zolpidem Tartrate 10 mg PO HS 12. BuPROPion (Sustained Release) 150 mg PO BID 13. HydrOXYzine 25 mg PO Q6H:PRN anxiety Discharge Medications: 1. Bacitracin Ointment 1 Appl TP [**Hospital1 **] Apply to affected areas on scalp RX *bacitracin zinc 500 unit/gram Apply to affected area twice a day Disp #*1 Tube Refills:*0 2. Levofloxacin 750 mg PO DAILY RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*5 Tablet Refills:*0 3. Lidocaine 5% Patch 1 PTCH TD DAILY RX *lidocaine 5 % (700 mg/patch) Apply to affected area Daily Disp #*14 Unit Refills:*0 4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*15 Tablet Refills:*0 5. BuPROPion (Sustained Release) 150 mg PO BID 6. Fish Oil (Omega 3) 1000 mg PO DAILY 7. Fluocinonide 0.05% Cream 1 Appl TP QID 8. Gabapentin 800 mg PO DAILY 9. HydrOXYzine 25 mg PO Q6H:PRN anxiety 10. MethylPHENIDATE (Ritalin) 10 mg PO BID 11. MethylPHENIDATE (Ritalin) 20 mg PO BID 12. Multivitamins 1 TAB PO DAILY 13. OLANZapine (Disintegrating Tablet) 10 mg PO DAILY 14. Omeprazole 40 mg PO DAILY 15. Tamsulosin 0.4 mg PO HS 16. Zolpidem Tartrate 10 mg PO HS 17. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 18. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 19. Lisinopril 40 mg PO DAILY hold for SBP <100 RX *lisinopril 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Aspiration pneumonia Community Acquired Pneumonia Alcoholic hepatitis Alcohol withdrawal seizures C1 vertebral fracture Secondary Diagnosis: Hepatitis C virus cirrhosis Hepatocellular carcinoma Alcohol Abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], It was a pleasure caring for you at [**Hospital1 18**]. You were admitted after having a seizure. Your blood pressure was very low and temperature was very high, so you were seen in the intensive care unit. Your seizure was related to alcohol withdrawl. We believe you also have an infection of your lung called pneumonia. They treated you in the ICU and your blood pressure improved, so you were transferred to the Liver service. Here you were continued on antibiotics for pneumonia, but you continued to have fevers. After switching the antibiotics, your fevers stopped, and you remained fever free for 24 hours prior to discharge. Please continue taking the antibiotics by mouth through [**2151-8-25**]. You fractured a vertebrae during your seizure. The brain doctors [**Name5 (PTitle) 6349**] [**Name5 (PTitle) **] and placed a neck collar on you. This must be left in place for the next 3 months to avoid further injury. If you remove this collar it could result in paralysis or death. Your seizure is likely from alcohol withdrawal. You were treated with medication to prevent further withdrawal, and at time of discharge you displayed no symptoms of withdrawal. Your liver function tests were elevated, indicating damage to your liver from alcohol. This is referred to as alocholic hepatitis. The only way to treat this is to stop all future alcohol intake. We looked at your liver with a machine that uses soundwaves to image, called an ultrasound. There is an area on your liver that is suspicious for recurrence of your hepatocellular carcinoma. We [**Name (NI) 653**] [**Hospital6 **], who follows your condition, and made them aware you were here. They have recent imaging that shows the same thing we found. Medications to START: START Levofloxacin 750mg daily for 5 days (continue through [**2069-8-23**]) START Flagyl 500mg three times a day for 5 days (through [**2069-8-23**]) START Bacitracin: This should be applied to the scalp laceration to prevent infection INCREASE Lisinopril to 40mg Daily Followup Instructions: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Hepatology Appointment [**2151-9-2**] 8:30am [**Telephone/Fax (1) 29736**] Name: [**Last Name (LF) **],[**First Name3 (LF) 488**] I. Location: [**Hospital 29737**] HEALTHCARE FOR THE HOMELESS Address: [**Location (un) 5137**], [**Location (un) **],[**Numeric Identifier 5138**] Phone: [**Telephone/Fax (1) 5139**] Appointment: Wednesday [**2151-9-1**] 9:00am *If you need to be seen sooner please walk in to your PCPs office anytime on Monday [**2151-8-23**]. Name: [**Known lastname 796**],[**Known firstname 133**] Unit No: [**Numeric Identifier 5195**] Admission Date: [**2151-8-13**] Discharge Date: [**2151-8-20**] Date of Birth: [**2094-10-18**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5196**] Addendum: Studies: [**2151-8-13**] CT Head: No evidence of acute intracranial process. Soft tissue laceration at the left vertex with no underlying fracture. Dense atherosclerotic vascular calcifications. Cerebellar atrophy out of proportion to the cerebrum. . [**2151-8-13**] CT C-spine: Minimally distracted fracture through the right anterior arch of C1 with extension to the right lateral mass. Fracture lines extend to the right transverse foramen. Multilevel degenerative changes with severe spinal stenosis at C5/C6 and C6/C7. . [**2151-8-14**] Portable CXR: No evidence of aspiration pneumonia. . [**2151-8-15**] CXR PA/Lat: Bibasilar opacities consistent with clinical diagnosis ofpneumonia. . [**2151-8-16**] RUQ U/S: Findings consistent with hepatic cirrhosis. Prior RFA sites in segment VII and III identified and appear stable. Interval enlargement of a lesion in segment VII adjacent to the RFA site is concerning for HCC. This now measures 1.9 cm. New lesion superior to RFA site in segment III, is also potentially concerning for HCC. Targeted son[**Name (NI) 5197**] imaging of previously seen indeterminate lesions on MRI in segments V and III was performed. The segment V lesion did not show a son[**Name (NI) 5197**] correlate. The segment III lesion was possibly visualized and unchanged in size. Right pleural effusion. . [**2151-8-19**] CT Torso w&w/o: Small bilateral pleural effusions with overlying atelectasis; however, superinfection cannot be excluded. Ill-defined hypodense lesion in segment VII concerning for recurrent HCC corresponding to finding on recent ultrasound). Marked increase in heterogeneity of the left lateral segment adjacent to the segment III RFA site is concerning for infiltrative HCC. This appears more extensive than what was evident on recent prior ultrasound. Recommend further evaluation with MRI or multiphase CT. Slightly enlarged retroperitoneal lymphadenopathy compared to [**2150-9-26**]. Atherosclerotic disease involving the aorta. Mild thickening of the bladder wall, correlate clinically. Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5198**] MD [**MD Number(2) 5199**] Completed by:[**2151-8-20**]

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icd9cm

[ [ [] ] ]

[ "86.59" ]

icd9pcs

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318, 324

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45989+58877

Discharge summary

report+addendum

Admission Date: [**2176-10-16**] Discharge Date: [**2176-11-4**] Date of Birth: [**2115-11-19**] Sex: F Service: [**Hospital Unit Name 196**] Allergies: Penicillins Attending:[**First Name3 (LF) 2704**] Chief Complaint: Chest pain, shortness of breath and increased lower extremity edema. Major Surgical or Invasive Procedure: Cardiac catheterization. History of Present Illness: The pt. is a 60 year-old female with multiple medical problems including right heart failure, obstructive sleep apnea and COPD who presented with a one day history of progressive shortness of breath, chest "tightness" and increased lower extremity edema. As per the pt., the VNA nurses were at her home yesterday and commented on how her legs appeared more swollen. In addition, she stated that she did become somewhat more short of breath over her baseline yesterday. She added that she was eventually unable to take more than 2 or 3 steps without becoming dyspneic. This morning, the pt. stated that she also developed a "tight" feeling in the center of her chest which radiated to her back. The pain is made worse with deep breathing. She stated that the pain was a [**5-11**] at its worst. She also noted [**Month/Year (2) 9140**] dyspnea and diaphoresis associated with this chest tightness and occasional episodes of lightheadedness and palpitations. She denied nausea or vomiting. She did admit to increasing lower extremity edema, PND and orthopnea. On arrival to the ED, she was noted to be tachycardic with a heart rate in the 120s. It was felt that she was in MAT. She was given 50mg of IV diltiazem, followed by 30mg po diltiazem with effect and the pt's. heart rate decreased to the 90's and was noted to be in sinus rhythm. Her chest pain resolved with a nitroglycerin IV drip and 2mg morphine sulfate IV times two. Her first set of cardiac enzymes were negative. She had a CXR performed which showed cardiomegaly and mild CHF. She received 40mg of IV lasix with a good response, as the pt. became less dyspneic. She was ordered for a V/Q scan to rule out PE in light of dyspnea and an elevated Ddimer. Currently, the pt. complains of minor persistent shortness of breath. She added that her chest pain has resolved. Past Medical History: -Right heart failure -Obstructive sleep apnea -Type II Diabetes Mellitus -Chronic obstructive pulmonary disease -Hypertension -BPPV -h/o leiomyomata -chronic venous insufficiency -depression. Social History: Pt lives on a [**Location (un) 10043**] apartment. She denied tobacco use or illicit drug use. She drinks one glass of alcohol (usually wine) once per month. Family History: Remarkable for diabetes mellitus in a number of family members. Sister with breast and ovarian cancer. Physical Exam: Vitals: T:97.3F P: 110 R: 20 BP: 91/58 SaO2: 97% on 3L via NC General: awake, alert, NAD HEENT: PERRL, EOMI, MMM, no lesions noted in oropharynx Neck: supple, JVD to approximately 14-15 cm Pulmonary: bibasilar rales noted Cardiac: tachycardic, regular rate, S1S2, II/VI HSM at LUSB radiating to apex Abdomen: obese, soft, NT/ND, active BS, no masses appreciated Extremities: no c/c, chronic venous stasis changes over BLE, [**3-5**]+ BLE edema. Neurologic: pt. alert and oriented in all 3 spheres, no focal deficits noted. Skin: venous stasis changes over BLE Pertinent Results: CXR: remarkable for cardiomegaly, mild CHF EKG: sinus tachycardia, rate 124, q waves in inferior leads, no change from previous EKG [**2176-10-16**] 10:02PM URINE COLOR-LtAmb APPEAR-SlCldy SP [**Last Name (un) 155**]-1.020 [**2176-10-16**] 10:02PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-MOD [**2176-10-16**] 10:02PM URINE RBC-262* WBC-157* BACTERIA-MANY YEAST-NONE EPI-<1 [**2176-10-16**] 10:02PM URINE CA OXAL-OCC [**2176-10-16**] 10:01PM CK(CPK)-80 [**2176-10-16**] 10:01PM CK-MB-NotDone cTropnT-0.02* [**2176-10-16**] 04:40PM CK(CPK)-71 [**2176-10-16**] 04:40PM CK-MB-NotDone cTropnT-0.02* [**2176-10-16**] 10:20AM GLUCOSE-146* UREA N-26* CREAT-1.6* SODIUM-138 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18 [**2176-10-16**] 10:20AM CK(CPK)-94 [**2176-10-16**] 10:20AM cTropnT-<0.01 [**2176-10-16**] 10:20AM CK-MB-NotDone [**2176-10-16**] 10:20AM WBC-7.8 RBC-4.08* HGB-12.5 HCT-38.1 MCV-94 MCH-30.6 MCHC-32.7 RDW-16.2* [**2176-10-16**] 10:20AM NEUTS-84.7* LYMPHS-9.4* MONOS-4.8 EOS-0.8 BASOS-0.3 [**2176-10-16**] 10:20AM HYPOCHROM-1+ ANISOCYT-1+ MACROCYT-1+ [**2176-10-16**] 10:20AM PLT COUNT-278 [**2176-10-16**] 10:20AM PT-15.3* PTT-34.4 INR(PT)-1.5 [**2176-10-16**] 10:20AM D-DIMER-1736* PATIENT/TEST INFORMATION: Indication: Congestive heart failure. Pulmonary hypertension. Height: (in) 61 Weight (lb): 380 BSA (m2): 2.48 m2 BP (mm Hg): 107/69 HR (bpm): 106 Status: Inpatient Date/Time: [**2176-10-28**] at 13:43 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Tape Number: 2004W401-0:00 Test Location: West CCU Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MEASUREMENTS: TR Gradient (+ RA = PASP): *73 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is dilated. LEFT VENTRICLE: The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF>55%). RIGHT VENTRICLE: The right ventricular cavity is markedly dilated. Right ventricular systolic function appears depressed. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. AORTIC VALVE: There is no aortic valve stenosis. No aortic regurgitation is seen. MITRAL VALVE: The mitral valve leaflets are moderately thickened. No mitral regurgitation is seen. TRICUSPID VALVE: Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. GENERAL COMMENTS: Suboptimal image quality due to poor echo windows. Suboptimal image quality due to body habitus. Conclusions: The right atrium is dilated. The left ventricular cavity is unusually small due to compression from the dilated right ventricle. Overall left ventricular systolic function appears normal but focal/regional wall motion abnormality cannot be excluded due to suboptimal image quality. The right ventricular cavity is markedly dilated. Right ventricular systolic function appears depressed. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. No mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. Compared with the findings of the prior report (tape unavailable for review) of [**2176-10-26**] no significant change. Brief Hospital Course: 1. Atypical chest pain: The pt. had cardiac enzymes which were negative times three, ruling out an acute myocardial infarction as cause for her chest pain. Her nitroglycerin drip was titrated off by the morning of the second hospital day and she remained chest-pain free for the remainder of the hospital stay. Telemetry showed only sinus tachycardia. 2. CHF: The pt. appeared to be suffering from an exacerbation of CHF on admission. She was aggressively diuresed with IV lasix with improvement in her shortness of breath and mild improvement in her lower extremity edema over the first four hospital days. A TTE was performed on the third hospital day which revealed the following: The left atrium is markedly dilated. The right atrium is dilated. The left ventricular cavity is unusually small. Overall left ventricular systolic function is probably preserved. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is markedly dilated. Right ventricular systolic function appears depressed. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate thickening of the mitral valve chordae. Trivial mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. On hospital day number five, the pt. was noted to be very lethargic and had minimal urine output over the previous night despite treatment with lasix. Her blood pressure was noted to be 80-85 systolic which was a signficant decrease from her baseline. On examination, she had very cold extremities. It was felt that she was experiencing cardiogenic shock. She was transferred to the CCU. While in the CCU, she was aggressively diuresed with nesiritide and was noted to have improved breathing and less peripheral edema over the four day course in the CCU. While in the CCU, a cardiac catheterization was performed. This showed the following: Severely elevated right sided filling pressures (mean RA pressure was 34 mm Hg and RVEDP was 38 mmHg). Severe pulmonary hypertension was noted (PA pressure was 90/48 mm Hg). Mildly elevated left sided filling pressures were present (mean PCW pressure was 20 mm Hg). Severe tricuspid regurgitation was suggested by prominant ventricular waves on the RA tracing and catheter fling from the right ventricle throughout the whole procedure. Cardiac index was low (at 1.7 L.min/m2). After a four day stay in the CCU, she was transferred back to the floor on a nesiritide drip. As the pt. had minimal urine output on a nesiritide drip alone, a dopamine drip was begun. on [**10-26**], patient was found to be unresponsive with a rhythym that was originally thought to be vfib, and the patient was shocked (EP evaluation of the tele strips at a later time indicated that the patient seemed to be in afib arrest). She was shocked with 200J x 1--> PEA arrest--> epi x 2--> NSR with BP 120's on dopamine and natrecor shut off. Patient was then transferred back to the CCU. A work up for PEA at the time indicated no evidence of a tamponade(assessed by using echo) and started in heparin drip prohylactically for ?PE, however V?Q scan with low probability for PE, Doppler imaging showed no evidence of a DVT. On [**10-27**], patient then had a swan ganz catheter under ultrasound placed. First set of numbers indicated CVP of 34, RV 95/30, PA 95/45 PCWP mean 40, CO/CI 5.3/1.82 with SVR 775. Patient continued to be oliguric with a positive fluid status despite bring placed in nesiritide and lasix. Patient also had a lower GI bleed (most likely hemoorhoids) and heparin was dc'ed. Repeat echo on [**10-28**] showed no significant change from [**10-26**] (see reports section). Patient continued to have positive fluid status, therefore, the decision to perform ultrafiltration to remove excess fluid. on day 2 of UF patient had negative fluid balance. Patient was also maintained on nestiride. Patient was continued on amiodarone and digoxin for her afib. Eventually patient had decreased platelets and HITs was of a concern, heparin (used to keep CVVHD from clotting off) was dc'ed and the CVVHD machine clotted off. UF was not restated. 3. Pulmonary Hypertension: Please refer to the cardiac catheterization results cited under #2. It was felt that the cause of the pulmonary hypertension was likely related to the combination of obstructive sleep apnea for which the pt. only intermittently uses her CPAP machine, morbid obesity and long-standing COPD. Nevertheless, a workup for causes of secondary pulmonary hypertension was performed and included lower extremity duplex doppler ultrasonography which was negative for DVT, a lung scan which was not suggestive of pulmonary emboli. The pt. was scheduled for an outpatient sleep study on [**2176-11-11**]. Severe pulm HTN not reversible with 100% O2. Non-compliant with CPAP and not candidate for Flolan. Therefore, nasal CPAP was continued at night, supplemental O2 PRN and MDIs. Throughout the hospital stay pulmonary htn remained high, and patient was dc'ed home with hospice with a diagnosis of pulm HTN and CHF 3. COPD: The pt. was maintained on albuterol and ipratropium nebulizers for the duration of the hospitalization. 4. DM2: The pt. was maintained on a sliding scale of regular insulin. Her fingersticks were noted to be within acceptable ranges. 5. CRF: The pt. was noted to have a baseline creatinine of 1.3 to 1.4. The etiology is uncertain, but may be related to long-standing HTN and diabetes mellitus. Her creatinine was noted to be 1.6 on admission, but slowly rose to a peak of 3.0. It was felt that she was suffering from acute on chronic renal failure with a prerenal etiology secondary to renal hypoperfusion resulting from severe CHF. Her serum creatinine responded well once aggressive diuresis was undertaken beginning in the CCU, however patient became less responsive to diuresis and BUn and CR rose to 77/3.7 on [**10-28**]. CR decreased with UF and rose to 3.7 after UF was stopped. Patient also developed hyponatremia while on UF and dialyste was adjusted appropriately 6: ID- patient was also treated for a UTI (urine grew out Klebsiella sensitive to bactrim) - patient txed with bactrim, but on fourth day of bactrim ([**10-28**])- noted to have white count of 17.6, patient pan cultured (blood cultured, sputum cultures), chest x-ray showed no evidence of pneumonia. Patient received three days of vanc while final blood cultures were pending- the final culture indicated 1/2 bottles of coag negative staph, most likely a contaminant so vanco was stopped. 7: Psych: Patient has an extensive history of physical and sexual abuse from husband, SW addressed these issues with patient 8: MSK: on [**10-31**] patient developed wrist pain and was found to have a wrist fracture with cortical interruption of fifth metatarsal- wrist was splinted 9: Dispo: once patient had maximal medical therapy with minimal results, condition was discussed with patient and family. In according with her wishes, she was made DNR/DNI and CMO and sent home with hospice care. Medications on Admission: -lasix 80mg po bid -zolpidem 5mg po qhs prn -albuterol nebs -lipitor 10mg po once daily -pantoprazole 40mg po once daily -atrovent nebs -meclizine 25mg po bid -amitryptiline 25mg po qhs -humalog 75/25 units once daily Discharge Medications: 1. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) for 3 months. Disp:*90 Tablet(s)* Refills:*0* 2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day) for 3 months. Disp:*qS mdi* Refills:*2* 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for 3 months. Disp:*qS mdi* Refills:*2* 4. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for 3 months. Disp:*90 Tablet(s)* Refills:*0* 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QOD (every other day) for 3 months. Disp:*45 Tablet(s)* Refills:*0* 6. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 2 months. Disp:*240 Tablet(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 months. Disp:*120 Capsule(s)* Refills:*0* Scripts given for MSIR, Ativan, Scopolamine, and Levsin Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: Congestive Heart Failure Pulmonary Hypertesion, severe Chronic Obstructive Pulmonary disease Chronic renal failure Obstructive sleep apnea Hypertension Congestive Heart Failure Pulmonary Hypertesion, severe Chronic Obstructive Pulmonary disease Chronic renal failure Obstructive sleep apnea Hypertension Discharge Condition: Stable. Discharge Instructions: Please follow the instructions given to you by your Hospice nurse. Please continue to take all of your prescribed medications. Followup Instructions: Please follow the recommendations of hospice care Completed by:[**2176-11-4**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 15642**] Admission Date: [**2176-10-16**] Discharge Date: [**2176-11-4**] Date of Birth: [**2115-11-19**] Sex: F Service: [**Hospital Unit Name 319**] Allergies: Penicillins Attending:[**First Name3 (LF) 2129**] Chief Complaint: pulmonary htn Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: see previous summary Past Medical History: -Right heart failure -Obstructive sleep apnea -Type II Diabetes Mellitus -Chronic obstructive pulmonary disease -Hypertension -BPPV -h/o leiomyomata -chronic venous insufficiency -depression. Social History: Pt lives on a [**Location (un) **] apartment. She denied tobacco use or illicit drug use. She drinks one glass of alcohol (usually wine) once per month. Family History: Remarkable for diabetes mellitus in a number of family members. Sister with breast and ovarian cancer. Physical Exam: see previous dc summary Pertinent Results: see previous dc summary Brief Hospital Course: Patient is HIT antibody posititive, this has been noted on her discharge worksheet Discharge Disposition: Home With Service Facility: [**Location (un) 15504**] Discharge Diagnosis: Congestive Heart Failure Pulmonary Hypertesion, severe Chronic Obstructive Pulmonary disease Chronic renal failure Obstructive sleep apnea Hypertension Discharge Condition: Stable Discharge Instructions: Please follow the instructions given to you by your Hospice nurse. Please continue to take all of your prescribed medications. Followup Instructions: Please follow the recommendations of hospice care [**First Name11 (Name Pattern1) 448**] [**Last Name (NamePattern4) 2130**] MD [**MD Number(1) 2131**] Completed by:[**2176-11-4**]

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icd9cm

[ [ [] ] ]

[ "37.21", "99.62", "89.64", "38.93", "93.90", "38.95", "00.13", "39.95" ]

icd9pcs

[ [ [] ] ]

17617, 17673

17509, 17594

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44927

Discharge summary

report

Admission Date: [**2142-4-3**] Discharge Date: [**2142-5-8**] Service: SURGERY Allergies: Penicillins / Codeine / Clindamycin / Zestril / Ciprofloxacin / Ivp Dye, Iodine Containing / Milk Attending:[**First Name3 (LF) 2777**] Chief Complaint: Ischemic right foot. Major Surgical or Invasive Procedure: 1. Abdominopelvic arteriogram and selective right lower extremity arteriogram. 2. Right saphenofemoral artery to plantar bypass using left greater saphenous vein, angioscopy. 3. a Exploration of bypass graft. b Thrombectomy of bypass graft. c Angioscopy vein graft. d Patch angioplasty of graft using greater saphenous vein x4. 4. Ligation of the right lower extremity vein graft. History of Present Illness: This 87-year-old lady has previously had a right superficial femoral angioplasty and stent. She has had recurrent ischemic ulceration of her right foot and is undergoing a diagnostic arteriogram. Past Medical History: 1. Type 2 diabetes mellitus. 2. Total right hip replacement in [**2131**]. 3. Total abdominal hysterectomy and bilateral salpingo- oophorectomy. 4. Cholecystectomy. 5. Appendectomy. 6. DDD pacer status post Type II AV block. 7. Spinal stenosis. 8. Chronic lower back pain. 9. Hypothyroidism. 10. Orthostatic hypotension. 11. Recurrent Malignant External Otitis 12. Bell's Palsy Social History: She is a nonsmoker, and denies alcohol use. The patient is a retired nurse [**First Name (Titles) 767**] [**Hospital1 69**]. Family History: She has a family history pertinent for diabetes mellitus, coronary artery disease Physical Exam: 99.5 61 132/50 18 97% No apparent distress, alert and oriented x3 Perrla, EOMI MMM, slight droop lt droop noted RRR, S1 S2 Clear to auscultation Soft abdomen, non-tender, non distended Left DP palpable, Left PT biphasic, Right PT and BP monophasic Erythema of right foot on dorsal surface extending to ankle Ulceration of rt 4th digit Pertinent Results: [**2142-5-7**] 04:00AM BLOOD WBC-8.9 RBC-3.05* Hgb-9.3* Hct-26.4* MCV-87 MCH-30.4 MCHC-35.0 RDW-14.3 Plt Ct-173 [**2142-5-7**] 04:00AM BLOOD PT-18.5* PTT-37.2* INR(PT)-1.7* [**2142-5-7**] 04:00AM BLOOD Glucose-97 UreaN-24* Creat-1.1 Na-142 K-3.8 Cl-101 HCO3-34* AnGap-1106/19/06 Calcium-8.5 Phos-3.0 Mg-1.8 [**2142-5-1**] URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG URINE Hours-RANDOM UreaN-268 Creat-44 Na-73 K-34 URINE Osmolal-331 [**2142-5-6**] 7:00 pm STOOL CONSISTENCY: SOFT Source: Stool. FINAL REPORT [**2142-5-7**]** CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2142-5-7**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. [**2142-5-1**] Probable atrial sensed and ventricular paced rhythm with occasional atrial premature beats. Since the previous tracing of [**2142-4-25**] ventricular premature beats are no longer seen. Intervals Axes Rate PR QRS QT/QTc P QRS T 82 0 136 400/438.42 0 -83 -167 [**2142-4-26**] 1:15 PM CHEST (PORTABLE AP) HISTORY: Congestive heart failure. UPRIGHT AP VIEW OF THE CHEST: Increasing moderate bilateral pleural effusions, right greater than left are present. Additionally, bibasilar opacities reflecting atelectasis persists. Rounded opacity within the medial aspect of the right base also may represent right middle lobe collapse. The cardiac contours are obscured by the basilar atelectasis. The mediastinal and hilar contours are unchanged, and there is no evidence of pulmonary vascular engorgement. Calcifications of the mitral annulus and aortic knob are unchanged. There is no pneumothorax. Right-sided dual chamber pacemaker with leads overlying the right atrium and right ventricle, unchanged. Right internal jugular central venous catheter with tip overlying the SVC is stable. Severe degenerative changes are present within both shoulders. IMPRESSION: Increasing moderate-sized bilateral pleural effusions, right greater than left. Bibasilar atelectasis persists. Possible right middle lobe collapse. Cardiology Report ECHO Study Date of [**2142-4-13**] REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.5 cm (nl <= 4.0 cm) Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%) Aorta - Valve Level: 1.9 cm (nl <= 3.6 cm) Aorta - Ascending: 3.0 cm (nl <= 3.4 cm) Aortic Valve - Valve Area: *1.3 cm2 (nl >= 3.0 cm2) INTERPRETATION: Findings: mild diastolic dysfunction with Vp velocity is 28cm/sec. LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast in the body of the LA. Mild spontaneous echo contrast in the body of the LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Depressed LAA emptying velocity (<0.2m/s) All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast in the body of the RA. A catheter or pacing wire is seen in the RA and extending into the RV. No spontaneous echo contrast in the RAA. No ASD by 2D or color Doppler. The IVC is normal in diameter with appropriate phasic respirator variation. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Normal LV cavity size. Moderately depressed LVEF. No LV mass/thrombus. LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Normal aortic root diameter. Simple atheroma in aortic root. Simple atheroma in ascending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mild AS. Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral annular calcification. Moderate thickening of mitral valve chordae. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is normal in size. No spontaneous echo contrast is seen in the body of the left atrium. Mild spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. No masses or thrombi are seen in the left ventricle. R. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is mild aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. [**2142-4-7**] 7:01 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS TECHNIQUE: Routine noncontrast head CT was followed by MDCT imaging of the head and neck following the administration of 90 cc of intravenous Optiray. Nonionic contrast was administered per protocol. Coronal and sagittal reformatted images were obtained. NONCONTRAST HEAD CT: There is no intra- or extra-axial hemorrhage, mass effect, or shift of normally midline structures. There is no specific evidence of major vascular territorial infarction. Patchy and confluent hypodensity in bihemispheric subcortical and periventricular white matter, representing chronic micro-ischemic change; the appearance is not significantly changed from prior study dated [**2140-7-26**]. The [**Doctor Last Name 352**]-white matter differentiation is otherwise preserved. The surrounding soft tissue and osseous structures are unremarkable. The imaged paranasal sinuses and mastoid air cells are appropriately aerated. CT ANGIOGRAM HEAD: The major vessels of the circle of [**Location (un) 431**] and their major branches are patent. There is no hemodynamically significant stenosis or aneurysmal. Within the limits of coverage of this study, no sign of AV malformation is apparent. There are moderate mural calcifications of the cavernous and supraclinoid segments of both intracranial internal carotid arteries. CT ANGIOGRAM NECK: There is no evidence of significant stenosis or ulceration, particularly with reference to the carotid bifurcation bilaterally. The left jugular vein is asymmetrically enhancing compared with the right. While this maybe related to the phase of contrast injection, right internal jugular thrombus cannot be excluded. There are large bilateral pleural effusions, reaching the level of the right lung apex, and diffuse atherosclerosis with dense mural calcifications along the aortic arch. IMPRESSION: 1. No intracranial hemorrhage or major vascular territorial infarction. 2. Unremarkable CTA of the neck and circle of [**Location (un) 431**]. 3. Asymmetric enhancement of the left internal jugular vein compared with the right. While this may be related to the phase of contrast injection, a right internal jugular thrombus cannot be excluded. 4. Large bilateral pleural effusions. 5. Atherosclerosis. Brief Hospital Course: 86 Female admitted with right 4th toe ischemia and was placed on antibiotics for cellulitis. After resolution of the cellulitis she underwent a right SFA->plantar BPG w/ left NRSVG ([**4-13**]) and tolerated the procedure well and had a strongly palpable graft pulse. Approximately one week later she underwent a toe amputation by the podiatry service. She was noted to be hypotensive to the 80s post-operatively after receiving a dose of morphine and it was noted that her graft had lost its palpable signal and was weakly dopplerable. She was emergently taken back to the OR and underwent a graft thrombectomy and patch angioplasties. She had a palpable graft post-operatively. She was progressing well until [**4-27**] when she was noted to have a small amount of serous fluid draining from her thigh (medial) incision and some underlying induration and erythema. The wound was opened on [**4-28**] and drained of seropurulent fluid. Culture revealed E. Coli. She was treated with antibiotics accordingly and the wound was packed with wet-to-dry dressings. A vac was placed on [**4-30**]. later that evening she was noted to have brisk bleeding from her thigh wound. She was taken immediately to the OR where the bleeding vessel was ligated. She bled again in the PACU, this time dropping her pressures. She went again to the OR where the vein graft was noted to be macerated from the infection and frankly bleeding. This was ligated and the wound left open. She was transfused multiple units of blood and 2units of FFP. She recovered well with a notably cool right lower leg. She was eventually diuresed and her hematocrit remained stable. A vac was placed on her wound on [**5-4**]. She is tolerating a regular diet, out of bed with assist, and continued on IV antibiotics with a right IJ central line. She has underlying CHF and reactive airway disease which have required diuresis and nebulizer treatments but have remained stable. She currently has RLE pain but is refusing an amputation at this time. Her blood supply to her right lower leg is poor and her leg should be protected from trauma and pressure ulceration. Please follow up with Dr. [**Last Name (STitle) **] for any antibiotic changes or major changes in her care. Medications on Admission: coumadin 2'/4'Sundays (for PAF), lasix 20/10QOD, lantus, lisinopril 10', quinine 25', synthroid 75mcg', colchicine 0.6', asa 81' Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO three times a day. 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): INR goal 2. 13. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 14. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 16. Insulin Insulin SC Fixed Dose Orders Bedtime lantus 20 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 0-55 mg/dL 4 oz. Juice and 15 gm crackers 56-160 mg/dL 0 Units 161-200 mg/dL 2 Units 201-240 mg/dL 4 Units 241-280 mg/dL 6 Units 281-320 mg/dL 8 Units 321-360 mg/dL 10 Units 361-400 mg/dL 12 Units > 401 mg/dL Notify M.D. 17. Potassium Oral 18. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 19. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 20. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**11-20**] Tablets PO Q6H (every 6 hours) as needed. 21. Ceftriaxone 1 gm IV Q24H 22. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for breakthru pain. 23. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Ischemic ulceration of the right foot. Acute occlusion of right superficial femoral artery to posterior tibial bypass graft. Hemorrhage from the right lower extremity vein graft. Discharge Condition: Stable Discharge Instructions: routine wound care checks / fevers / chills / discharge from wound/ pain management. Please keep right lower extremity clean, dry, moisturized. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2142-6-20**] 1:30. Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 2625**]. Schedule an appointment for 2 weeks. Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2142-6-20**] 1:30. Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 2625**]. Schedule an appointment in 2 weeks. Completed by:[**2142-5-9**]

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icd9cm

[ [ [] ] ]

[ "39.49", "93.59", "86.22", "39.29", "38.89", "88.72", "00.14", "38.91", "88.42", "99.07", "88.48", "84.11", "99.04", "80.98", "39.56", "77.88", "39.98" ]

icd9pcs

[ [ [] ] ]

15074, 15140

10402, 12663

324, 719

15365, 15374

1968, 8421

15567, 16133

1509, 1592

12842, 15051

15161, 15344

12689, 12819

15398, 15544

1607, 1949

263, 286

747, 945

8430, 10379

967, 1349

1365, 1493

51,020

112,893

40933

Discharge summary

report

Admission Date: [**2191-3-30**] Discharge Date: [**2191-4-4**] Date of Birth: [**2138-8-5**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2751**] Chief Complaint: Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 1005**] is a 52yo F with history of leukocytoclastic vasculitis recently diagnosed and completed steroid taper about a week ago who presented to her PCP's office complaining of fatigue, vomiting and subjective fevers for the past 3 days. She was found to be hypotensive with systolics in the 90s and hyponatremic and received 2 liters of NS before being referred to the ER. . In the ED, initial vs were: 99, 95, 96/46, 16, 100% RA. She was febrile to 101 and received tylenol. CXR was negative for infection, and urinalysis was benign. She received stress dose steroids for concern for adrenal insufficiency and ceftriaxone. Given her continued borderline blood pressures of systolics in the 80s-90s despite total of 4 liters of NS, she was admitted to the MICU for further monitoring. . In the ICU, she complains of generalized fatigue and malaise for the past few weeks and nightly fevers at home for the past couple weeks. Patient has had decreased PO intake for the past week in the setting of this fatigue and malaise. She has had intermittent headaches, occasional blurry vision, frequent nausea and morning diarrhea. She had some non-bloody, non-bilious emesis yesterday and has had persistant pruritis. She feels her rash has progressively worsened to cover more of her body surface now. No sick contacts. . Review of systems: (+) Per HPI (-) Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, dysuria, frequency, or urgency. Past Medical History: # Leukocytoclastic Vasculitis -- diagnosed in [**2191-2-15**] with skin biopsy -- presented with rash # DM Type 2 -- last A1C 6.7 # Hypertension # Hyperlipidemia # Scoliosis # Fatty liver -- mild on US in [**2188**] # OSA -- denies needing CPAP # Major Depressive Disorder # Appendectomy # C-section # Osteoarthritis Social History: She was born in the [**Country 13622**] Republic and moved to the US in the early [**2159**]. She was vaccinated with BCG as in grade school and has had a positive PPD since. Last travel to DR [**Last Name (STitle) **] [**Name (STitle) **] and has not travelled since. She has never smoked and drinks 2 margaritas/week. No illicit drug use. Family History: MI, CVA and stomach cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.7 BP: 95/54 P: 94 R: 19 O2: 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, PERRL, MM dry, oropharynx clear without lesions Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Diffuse, blanching, macular, erythematous rash covering chest, scattered across back, arms and legs. Bilateral lower cheeks and neck with macular erythema. Hyperpigmented plaque across upper back consistent with acanthosis nigricans. DISCHARGE PHYSICAL EXAM: VS: T 98.9, BP 146/96, HR 91, RR 20, SpO2 94 on RA Gen: NAD. Alert and oriented x3. Mood and affect appropriate. Pleasant and cooperative. Resting in bed. HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP benign. Neck: Supple. JVP not elevated. No cervical lymphadenopathy. CV: RRR. Normal S1, S2. No M/R/G appreciated. Chest: Respiration unlabored, no accessory muscle use. Bibasilar crackles right>left. No wheezes or rhonchi. Abd: BS present. Soft, NT, ND. Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+. Skin: Flat, erythematous rash worst over chest Neuro: Moving all four limbs. Pertinent Results: ADMISSION LABS: [**2191-3-30**] 05:26PM BLOOD WBC-7.6 RBC-3.26* Hgb-10.5* Hct-30.1* MCV-93 MCH-32.4* MCHC-35.0 RDW-13.4 Plt Ct-280 [**2191-3-30**] 05:26PM BLOOD Neuts-79.3* Lymphs-13.1* Monos-1.8* Eos-5.6* Baso-0.2 [**2191-3-30**] 05:26PM BLOOD Glucose-113* UreaN-49* Creat-2.3* Na-131* K-4.3 Cl-98 HCO3-20* AnGap-17 [**2191-3-30**] 05:26PM BLOOD ALT-54* AST-72* AlkPhos-74 TotBili-0.3 [**2191-3-30**] 05:24PM BLOOD Lactate-1.9 Na-132* K-4.2 Cl-99* DISCHARGE LABS: [**2191-4-4**] 05:35AM BLOOD WBC-13.1* RBC-2.69* Hgb-8.9* Hct-25.2* MCV-94 MCH-33.1* MCHC-35.3* RDW-13.6 Plt Ct-390 [**2191-4-4**] 05:35AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-141 K-4.3 Cl-106 HCO3-26 AnGap-13 [**2191-4-4**] 05:35AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.1 STUDIES: # CXR ([**2191-3-30**]): IMPRESSION: No acute intrathoracic process. # ECHO ([**2191-3-31**]): The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality due to body habitus. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. Mild mitral regurgitation. Mildly elevated pulmonary artery systolic pressures. # CXR ([**2191-4-1**]): IMPRESSION: 1. New mild-to-moderate volume overload. 2. Bibasilar opacities may represent atelectasis, although infection cannot be excluded. Brief Hospital Course: Ms. [**Known lastname 1005**] is a 52yo F with history of leukocytoclastic vasculitis presenting with malaise, hypotension, fever, and hyponatremia. . # Hypotension: Appeared dry on admission exam with history consistent with decreased PO intake and suspected dehydration. She also likely had insensible losses due to her rash, fevers and AM loose stools. Adrenal insufficiency was also a concern given her history of steroid use and development of fevers, malaise, hyponatremia and vague abdominal discomfort after steroid d/c. However, her cosyntropin stim test was WNL (although on the low end of normal). We felt that sepsis was also a possibility but no clear source or concerning leukocytosis (at least initially - see below). She was given IVF and stress dose steroids for 1 day and improved. . # Fever: She reported nightly subjective fevers at home and was febrile to 101 in the ER on admission. No leukocytosis or clear localizing symptoms on exam or by history to suggest infection on admission. Initial CXR and urinalysis were reassuring. Blood cultures on [**2191-3-30**] grew Strep viridans in one set, and urine culture grew coag negative staph. CXR on [**2191-4-1**] showed bibasilar opacities and could not exclude pneumonia. Fever could also be due to underlying inflammation from her vasculitis. Drug fever was also a possibility given that she started Plaquenil the day PTA but this did not fit the time course she had suggested. Later in the admission she developed leukocytosis but based on clinical improvement and time course this was felt to be [**1-19**] steroids. She remained afebrile for the remainder of her stay. She was treated with Vancomycin and Cefepime during her stay and discharged on Levofloxacin 750 mg PO for three days to complete a 7 day course of antibiotics. . # Acute kidney injury: Her baseline creatinine is 0.6 according to Atrius records and was elevated to 3.4 at her PCP's office. Creatinine improved to 2.3 by admission to [**Hospital1 18**] ER after receiving 2L of NS at PCP's office which was reassuring for pre-renal etiology that improved with fluids. However, intrinsic renal disease was also a possibility given her vasculitis, but less likely, given Cr trended down to 0.8 with more IVF. . # Volume Overload: On exam she had bibasilar crackles which likely represented volume overload. She was initially hypovolemic, but received significant IV fluids early in her stay. Her CXR on [**2191-4-1**] showed new mild-to-moderate volume overload with bibasliar atelectasis and effusions, and an infectious process could not be excluded. TTE showed normal LVEF and diastolic function. She was given Furosemide 20 mg IV once prior to discharge and prescribed Furosemide 20 mg PO daily for 4 days after discharge. . # Rash: Her current rash appears almost confluent and erythrodermic across her chest with some scattered areas on the back and extremities. Although this may be her underlying leukocytoclastic vasculitis, drug rash from Plaquenil was also a possibility (new med started the day PTA). We held Plaquenil and there was clinical improvement. . # Leukocytoclastic vasculitis: We continued sarna and hydroxyine for itch, held Plaquenil. After her low-normal response to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test, steroids were held for several days. She was restarted on Prednisone 10 mg PO daily on [**2191-4-3**]. . Medications on Admission: Hydroxychloroquine 200 mg Oral Tablet 1 tablet twice daily Clobetasol (TEMOVATE) 0.05 % Topical Cream apply to itchy areas [**Hospital1 **] prn Hydroxyzine HCl 25 mg Oral Tablet Take 1 tablet three times daily as needed Desonide 0.05 % Topical Lotion apply to affected area Prednisone 10 mg Oral Tablet take 5 pills tues-wed-thurs, then 4 pills friday-sat, decrease by one pill every 2 days 5-5-5-4-4-3-3-2-2-1-1 Lisinopril-Hydrochlorothiazide (ZESTORETIC) 20-25 mg Oral Tablet 1 by mouth once daily Propranolol (INDERAL LA) 120 mg daily Omeprazole 20 mg daily Citalopram 20 mg Oral Tablet 1 and [**12-19**] tablet daily Simvastatin 40 mg Oral Tablet 1 TABLET PO DAILY Discharge Medications: 1. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO three times a day as needed for itching. Disp:*60 Tablet(s)* Refills:*0* 2. desonide 0.05 % Lotion Sig: One (1) Topical once a day: Apply to affected area. 3. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*10 Tablet(s)* Refills:*0* 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:*4 Tablet(s)* Refills:*0* 9. clobetasol 0.05 % Cream Sig: One (1) Topical twice a day as needed for itching: Apply to affected areas. Do not apply to face, underarms, or groin. . Discharge Disposition: Home Discharge Diagnosis: Primary: Hypotension, Vomiting, Fevers Secondary: Leukocytoclastic Vasculitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen in the hospital for vomiting, fevers, and low blood pressure. You were initially sent to the ICU to help stabilize your blood pressure. Your symptoms improved and you were transferred to a regular medical floor after receiving IV fluids, antibiotics, and steroids. Your chest X-ray was concerning for possible pneumonia, and you will need to complete a course of antibiotics after discharge. You were also started on a short course of Furosemide to help remove excess fluid from your body. Since it may have been contributing to your rash, your Plaquenil was stopped. Because of your low blood pressure on admission, you have not been receiving your usual blood pressure medications. You should stop taking them until restarted by your PCP. We made the following changes to your medications: START: Levofloxacin 750 mg once a day for 3 days START: Furosemide 20 mg once a day for 4 days START: Prednisone 10 mg once a day STOP: Plaquenil (Hydroxychloroquine) STOP: Lisinopril-Hydrochlorothiazide (ZESTORETIC) until restarted by your PCP [**Name Initial (PRE) **]: Propranolol (INDERAL) until restarted by your PCP Please continue to take your other medications as prescribed. If you experience any of the below listed Danger Signs please call your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: Please see your PCP, [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Name (STitle) **], for followup at the appointment you have scheduled this week. The office can be reached at [**Telephone/Fax (1) 2261**]. You should also see your Dermatologist and Rheumatologist for followup at the appointments you have scheduled this week.

[ "999.9", "780.57", "787.01", "715.90", "584.9", "250.00", "296.30", "276.1", "571.8", "401.9", "458.9", "486", "446.29", "E879.8", "272.4", "276.69", "780.60", "737.30" ]

icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

11406, 11412

6308, 9746

311, 317

11534, 11534

4149, 4149

13088, 13435

2594, 2623

10466, 11383

11433, 11513

9772, 10443

11685, 12470

4615, 6285

2663, 3447

12499, 13065

1707, 1875

263, 273

345, 1688

4165, 4599

11549, 11661

1897, 2216

2232, 2578

3472, 4130

82,159

103,208

16798

Discharge summary

report

Admission Date: [**2103-5-6**] Discharge Date: [**2103-5-18**] Date of Birth: [**2021-2-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 633**] Chief Complaint: fevers, leukocytosis Major Surgical or Invasive Procedure: IR percutaneous drainage of left perinephric fluid collection _____ History of Present Illness: 82M with multiple medical comorbidities s/p sigmoid colectomy with end transverse [**Hospital 47427**] transfered from OSH for further management of a retroperitoneal abscess. Pt initially presented from his nursing home to [**Hospital3 **] [**2103-5-4**] with fever to 102.6 and increasing leukocytosis. He was found to be hypotensive to SBP 85, which improved with resuscitation, and WBC 33. CXR revealed a LLL pneumonia and UA was consistent with a UTI, for which he was started on empiric Vanc/Zosyn and admitted to the ICU. He underwent CT A/P which was interpreted as showing left hydronephrosis with a 16x10x8cm peri-nephric / retroperitoneal abscess with air, along with a LLL pneumonia. Given the lack of interventional radiology capabilities at the OSH, the pt was directly transfered to [**Hospital1 18**] TSICU for anticipated percutaneous drainage pf the per-nephric abscess. Past Medical History: Past Medical History: -Hypertension, GERD, Atrial fibrillation, Hx positive PPD, Urinary retention, BPH, Hx basal cell CA, SIADH, Hypothyroidism, glaucoma, Insomnia, Constipation Past Surgical History: -Sigmoid colectomy w/ Hartmann's / end transverse colostomy -Cataract surgery -Total thyroidectory [**2091**] Social History: Lives in a nursing home. Denies tobacco, EtOH, illicits. Family History: NC Physical Exam: GEN: elderly male, frail appearing, shovel mask w/ humidified air in place, oriented to self and medical center, intermittent weak cough with thick secretions HEENT: oropharynx clear CV: S1, S2 regular rhythm, normal rate, no murmurs LUNG: rhonchi bibasilarly, decreased BS right base ABD: soft, non-tender, non-distended, drain w/ yellow fluid, ostomy with brown stool EXT: warm, distal pulses intact, [**1-15**]+ edema, RUE > LUE, picc in place in RUE Neuro: face w/ right sided droop, asymmetry w/ smile, tongue midline, EOMI, moves toes bilaterally Pertinent Results: Laboratory: 10.2 21.9 >------< 425 34.0 PT: 14.6 PTT: 29.5 INR: 1.4 154 123 31 -------------< 102 3.6 21 0.5 Ca: 7.7 Mg: 2.3 P: 2.9 Imaging: CT A/P (OSH [**2103-5-6**]): 1. Obstructed left kidney with a large perirenal/RP abscess (16x10x8cm) with air, involving psoas muscle and extending to the lower pelvis to just above the acetabulum. 2. RLL consolidation with air bronchograms 3. Extensive atherosclerotic disease of the abdominal aorta without aneurysm 4. Aneurysmal dilitationof the common left iliac artery with the lumen narrowed. 5. Bladder calculi Brief Hospital Course: This is an 82 M who initially presented to [**Hospital3 **] [**2103-5-4**] with fever, leukocytosis, and hypotension found to have 16x10x8cm peri-nephric / retroperitoneal fluid collection and pneumonia he was started on vancomycin and zosyn and transferred to [**Hospital1 18**] surgery service for further management . #PSOAS / PERINEPHRIC ABSCESS: The etiology was unclear although most likely from complication of GU infection in patient with chronic indwellling foley catheter. He was initially admitted to surgery service but was not a surgical candidate. Patient underwent IR guided drainage on [**2103-5-8**] with removal of 400cc of fluid resulting in partial decompression of hydronephrosis. There was evidence that the collecting system was communicating with the fluid collection during the procedure. Subsequently fluid from the drain was found to have elevated creatinine c/w urine. Likely he developed GU infection with nephric/ureter abscess with loss of collecting system integrity and spread to perinephric/psoas. Unclear if calculi (bladder calculi seen on imaging) or ureter mass (not found on imaging) predisposed to rupture. He was startd on vancomycin and zosyn. Urine culture and fluid collection culture returned with no growth (although had already been on antibiotics for several days. Urine and drain cytology returned without evidence of malignant cells. Infectious disease was consulted. Repeat abdominal imaging on [**5-15**] showed a well placed drain and signficant improvement in fluid collection. Plan for percutaneous nephrostomy tube and eventual removal of abdominal drain was was discussed with the son [**Name (NI) 382**]. However, the patient continued to slowly decline and there was concern about his ability to tolerate the procedure and whether it was consistent with his overall goals of care given his poor overall prognosis. In coordination with the son, it was decided to not pursue further procedures, such as nephrostomy tube placement. At [**Doctor First Name 391**] Bay, in discussion with the son, if the abdominal drain were to accidentally come out the, then he would not be rehospitalized to replace it. Zosyn was stopped on [**2103-5-17**] as, in consultation with the son, it was felt to not aid in patient comfort. . #HYPERNATREMIA: Patient's sodium was 137 at OSH and on admission to [**Hospital1 18**] was found to be 154. The most likely etiology is over-resuscitation with normal saline in setting of reduced access to free H20. His sodium continued to remain slighly elevated in the setting of decreased access to free water. He was given D5W at a rate of 75-125cc/hr while he was NPO. Per discussion with the son, he wants to continue the PICC line and continue D5W (rate of 75cc/hr) for hydration at this time to have family members the opportunity to come in this weekend and see the patient. . #HCAP: Patient is nursing home resident found to have fever, increased secretions and cough, and radiographic evidence with opacity in the right lung base of pneumonia with differential icluding aspiration vs HCAP. During his hospital stay he was noted to have a weak cough with difficulty managing secretions. He completed an 8 day course of vanc/zosyn on [**5-15**]. Legionella negative. . #NUTRITION: The patient has failed several speech/swallow evaluations and was determined to be high risk of aspiration. This was discussed with the HCP, who was not interested in NG tube placement. We held off on oral nutrition initially in the hope that his condition may improve. At discharge, the risk of aspiration was again addressed with the HCP and the options to either continue NPO status or have the patient be allowed to have nectar thick liquids for comfort if he verbalizes. The HCP felt that it could be ok for him to eat/drink for comfort knowing that this might lead to the patient's demise. Please continue aspiration precautions. . #RUE SWELLING: He was found to have a PICC associated non-occlusive subacute-to-chronic right subclavian thrombus. PICC functining appropriately. He was discharged with the PICC line given his healthcare proxy wanted the pt to continue hydration during the weekend so family could come and see him. . #HEMATOCRIT DROP: His hematocrit trended down on [**5-16**] from mid twenties to 18. He was transfused four units of blood with improvement up to 26. His hematocrit trended down to 23 on [**5-17**] and he was given another unit of blood. The etiology of blood loss was unclear. GI bleed considered, particularly stress ulcer, although no melana or bright red blood in ostomy. He was evaluated by the GI service. RP bleed considered but CT abdomen negative. No evidence of hemolysis on labs. . GOALS OF CARE: Addressed with [**Doctor Last Name **], the healthcare proxy, [**Name (NI) 6028**] the hospitalization. We discussed that even with standard medical care in this situation that he has a poor prognosis. The HCP informed us that his father would not want extraordinary measures and would want to focus more on comfort in this situation. [**Doctor Last Name **] agreed with stopping antibiotics at discharge, as well as no additional transfusions, or further lab testing, or re-hospitalization. If the abdominal drain were to fall out he would not want his father rehospitalized for more procedures. He wanted to keep the PICC line in place and continue IV hydration over the weekend so that family members could visit him. Would readdress whether continuing IVF after this weekend is c/w goals of care. . . CHRONIC ISSUES: . #HYPERTENSION: Blood pressure ranged from 100-130. His home antihypertensives were held during this hospitalization. . #ATRIAL FIBRILLATION: He has a history of atrial fibrillation, managed with rate control with beta blocker. His beta blocker was changed to IV during the hospitalization given he was NPO. Aspirin was held. Beta blocker not continued due to goals of care. . #FACIAL DROOP: Patient noted to have facial droop on admission with garbled speech and right sided weakness. The [**Hospital1 2519**] note also reported that his speech was not clear. I spoke w / [**Doctor First Name 391**] Bay Skilled Nursing who confirmed that the unclear [**Name2 (NI) 16019**] was chronic. . #INSOMNIA: His ambien was held . #GLAUCOMA: His Methazolamid 25mg [**Hospital1 **] (hold while NPO) was held. . #HYPOTHYROID: The levothyroxine daily was changed from PO to IV while hospitalized and NPO. It was stopped at discharge as not c/w goals of care change to comfort focused care. . #URINE RETENTION: The oxybutynin was held . This was prepared by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D.(cell phone [**Telephone/Fax (1) 47428**] if any questions) Medications on Admission: Brimonidine Tartrate 5ml solution 0.15% OP Protonix 40mg daily Amlodipine 5mg daily Levothyroxine 0.1mg daily Artificial tear solution 2 gtt [**Hospital1 **] PRN tylenol 650mg Q6H PRN pain ambien 5mg HS PRN insomnia Vitamin B-12 Inj 1000 mcg IM q3 months Methazolamid 25mg [**Hospital1 **] ASA 325mg daily Lactulose 30ml daily Metoprolol Tartrate 25mg [**Hospital1 **] Oxybutynin Chloride 5mg TID Levofloxacin 500mg daily Flagyl 250mg TID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. 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. 3. Senna 1 TAB PO BID:PRN constipation 4. Intravenous fluid order -> D5W at 75cc per hour for three days Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**] Discharge Diagnosis: Psoas / Perinephric abscess Healthcare Associated Pneumonia Discharge Condition: Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Mental Status: Confused - sometimes. Discharge Instructions: It was a pleasure to participate in your care Mr. [**Known lastname **]. You were admitted with a fluid collection near your kidney and a pneumonia. For the fluid collection, a drain was placed to remove the fluid. The fluid appears to be urine from a rupture in your kidney or ureter. You were treated for an infection with antibiotics. You were followed by the urology and infectious disease services. For the pneumonia, you were treated with antibiotics and your condition improved. Your blood counts were low and you were given a transfusion. Followup Instructions: -

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icd9cm

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Discharge summary

report

Admission Date: [**2199-7-10**] Discharge Date: [**2199-7-12**] Service: MEDICINE HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 71329**] is a 76-year-old gentlemen with a history of coronary artery disease, hypertension, hypercholesterolemia, status post recent L3-S1 laminectomy who was in his usual state of health until the night of admission when he had an episode of emesis after taking his OxyContin medication. Initially, his emesis consisted only of food and there was no evidence of blood. However, over the next couple of hours, he had a couple of additional episodes of emesis now with bright red blood. He also described feeling somewhat dizzy, as well as cold and clammy. He therefore presented to the [**Hospital6 649**] Emergency Room. REVIEW OF SYSTEMS: Negative for any history of prior melena or hematochezia. He denied any chest pain, shortness of breath, palpitations, abdominal pain. He denied any prior history of gastrointestinal bleeding in the past. He denied any history of known liver disease. He does take enteric coated aspirin at home but denied any other nonsteroidal agents. He denied any history of alcohol use. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [**2180**], status post four vessel coronary artery bypass graft in [**2194**]. 2. Hypercholesterolemia. 3. Hypertension. 4. Hypothyroidism. 5. Status post L3-S1 laminectomy [**5-19**]. 6. Nephrolithiasis. 7. Status post septoplasty. ALLERGIES: Tetanus shot. MEDICATIONS ON ADMISSION: 1. Levoxyl. 2. Lipitor 10 mg po q.h.s. 3. OxyContin. 4. Zantac. 5. Enteric coated aspirin 325 mg po q.d. SOCIAL HISTORY: The patient has a remote history of tobacco. He drinks about two martinis per week. He is married. PHYSICAL EXAMINATION: He was in no acute distress. Temperature 97.9. Heart rate 77. Blood pressure 156/81. Respiratory rate 18. Oxygen saturation 98% on room air. On head, eyes, ears, nose and throat exam, his mucous membranes were moist. Her sclera were anicteric. His oropharynx was clear. He had no lymphadenopathy. His lungs were clear to auscultation. His heart had a regular rate and rhythm with a soft 1/6 systolic murmur. His abdomen had normal active bowel sounds with soft, nontender and nondistended. He had no hepatosplenomegaly. His rectal exam was guaiac negative with no masses. On his extremities, there was no edema. He had a scar from an old gunshot wound on his left arm. LABORATORIES: White blood cell count 5.4, hematocrit 33.1 (down from 34.8 one month ago), immune cell volume 90, RDW 14, platelets 227,000, PT 12.6, INR 1.1, PTT 31.7. Sodium 140, potassium 4.4, chloride 106, bicarbonate 21, BUN 27, creatinine 1.5, glucose 121. Electrocardiogram: Normal sinus rhythm, rate 75, normal axis, prolonged PR interval at 234 milliseconds, other intervals normal. Q wave in III and aVF, T wave inversions in III, aVL, aVF. There was no change from his baseline electrocardiogram from [**2199-5-22**]. HOSPITAL COURSE: In the Emergency Department, the patient underwent an nasogastric lavage which revealed bright red blood which did not clear with one liter of normal saline. He underwent emergent upper endoscopy which revealed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear which was oozing blood at the GE junction. He underwent a successful ejection with epinephrine and BICAP electrocautery with good hemostasis. He was transfused with a total of two units of packed red blood cells. His hematocrit subsequently remained stable in the 30-33 range over the next 48 hours. His aspirin was held and it was recommended by the Gastrointestinal Service that this continue to be held for one week after discharge. He was started on Protonix 40 mg intravenous b.i.d. which was then switched over to 40 mg po q.d. for discharge. He was started on clears on hospital day two and his diet was advanced and he was tolerating full cardiac diet by the day of discharge. DISPOSITION: The patient was discharged to home in stable condition. DISCHARGE INSTRUCTIONS AND FOLLOW-UP: 1. The patient will hold on taking his aspirin for one week after discharge and then resume his prior dose. 2. His Zantac will be discontinued and he will be discharged on Protonix (see below). 3. He will follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**], within a couple of weeks after discharge. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po q.d. 2. Levoxyl. 3. Lipitor 10 mg po q.d. 4. OxyContin. 5. He will hold on taking his aspirin for one week after discharge, then he will resume enteric coated aspirin 325 mg po q.d. DISCHARGE DIAGNOSIS: Upper gastrointestinal bleed secondary to [**Doctor First Name **]-[**Doctor Last Name **] tear. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Name8 (MD) 13249**] MEDQUIST36 D: [**2199-7-16**] 21:10 T: [**2199-7-16**] 21:10 JOB#: [**Job Number 109121**] cc:[**Last Name (NamePattern1) 109122**]

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icd9cm

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Discharge summary

report

Admission Date: [**2195-3-15**] Discharge Date: [**2195-4-26**] Date of Birth: [**2116-2-18**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 695**] Chief Complaint: Elevated LFT's, admitted for PTC Major Surgical or Invasive Procedure: - [**3-16**]: IR biliary drainage / PTC placement - [**3-21**]: IR removal of R biliary drains after balloon angioplasting stents, tracts plugged with gelfoam, angioplasty of L drain with replacement of L biliary drain, placement of R pleural pigtail drain - [**3-30**]: L chest pigtail placed at bedside - [**4-4**]: Open Tracheostomy History of Present Illness: Mr. [**Known lastname **] is a 79 M s/p Whipple [**2186**] for low grade ampullary adenoCA c/b biliary strictures s/p stenting recently found to have now w/ elevated LFTs. Pt had an excision of subcutaneous nodule in R posterior chest wall [**2195-2-12**] which showed adenoCA. He was planned for systemic chemotherapy (gemcitabine/cisplatin). On [**2195-2-24**] a PET CT demonstrated multiple FDG avid liver masses as well as an enlarged FDG avid gastrosplenic lymph node and uptake in the left adrenal gland. A follow up MRI did not show any discrete hepatic masses but a mass could not be exclude. There are areas of peripheral peribiliary enhancement within the liver which correspond to the areas of FDG avidity more suggestive of inflammation or infection. There is severe atrophy of the R hepatic lobe with severe biliary dilation and moderate biliary dilation of the L hepatic lobe. The MRI again demonstrated the enlarged 2.1-cm gastrosplenic lymph node, concerning for metastasis as well as a 11-mm subcu nodule within the anterior abdominal wall along the previously placed left biliary catheter which may represent scar tissue or metastasis. On [**2195-3-13**] the patient had elevated LFT's (Bili 5) and he was jaundiced. He was planned to be directly admitted to the West 1 Surgical Service (Dr. [**Last Name (STitle) **] for PTC, brushings and biopsy. The patient reports intermittent fevers/chills over the past 2 weeks with a decrease in energy level over the past 3 months. He has had no new nausea or emesis, but reports [**1-22**] loose stools per day. He denies BRBPR or melena. His appetite and weight have been stable. Past Medical History: pylorus-preserving pancreaticoduodenectomy on [**2187-5-3**] for a well-differentiated adenocarcinoma of the ampulla benign prostatic hypertrophy, schistosomiasis, Past surgical hx: pylorus-preserving pancreaticoduodenectomy and cholecystectomy [**2194-9-12**] L biliary duct dilation and stent placement Social History: He has an occasional social alcoholic beverage. He has no history of smoking, IV drug use, marijuana use, tattoos, hepatitis, or piercing. He does have a history of blood transfusions. His social history is significant for the fact that he has some college courses. He is Mandarin and does not speak English. He is married and has two children, ages 45 and 49. He is a retired accountant. Family History: Mother who died of ? GI cancer. Father also died of ? GI cancer. He had a brother who died of pancreatitis in his 40s and a sister who died of liver cancer in her 60s. Physical Exam: On admission Vitals: Afebrile, vital signs stable Gen: NAD, AOx3, Jaundiced HEENT: Icteric sclera. MMM, neck supple, non-tender, trachea midline. + R anterior cervical LAD, no supraclavicular LAD CVS: RRR Pulm: CTAB, no resp distress Abd: Softly distended, non-tender. Well healed incision c/w surgical history. LE: no edema Pertinent Results: [**2195-3-15**]: 8.2>29.6<149 132 102 9 AGap=11 -------------< 156 3.9 23 0.8 Ca: 8.0 Mg: 2.1 P: 2.8 ALT: 44 AP: 311 Tbili: 8.2 Alb: 2.3 AST: 102 LDH: 150 Dbili: 6.9 TProt: [**Doctor First Name **]: 27 Lip: 6 PT: 19.8 PTT: 37.2 INR: 1.8 Labs from [**2195-3-13**]: ALT: 40 AP: 318 Tbili: 5.3 Alb: 2.5 AST: 101 LDH: 168 Gran-Ct: 6030 TSH:1.4 Vit-B12:1113 %HbA1c: 5.9 [**2195-2-24**] PET Scan: IMPRESSION: 1. Multiple mass-like areas of FDG uptake in the liver, highly concerning for metastases. Biliary dilation and vessel patency cannot be assessed on this noncontrast study. 2. 2.3 cm FDG avid gastrosplenic lymph node,concerning for metastasis. 3. Non-FDG avid 8mm right lower lobe nodule, probable 4mm left upper lobe nodule and small left pleural effusion. 4. FDG uptake of the left adrenal gland without definite mass. Attention on follow-up studies is recommended. 5. Focal right posterolateral chest wall FDG uptake, likely corresponding to the site of chest wall nodule excision. [**3-10**] MRI Abdomen: 1. Areas of peripheral peribiliary enhancement within the liver correspond to the areas FDG avidity and are more suggestive of inflammation/infection rather than tumor. No discrete hepatic masses are seen though cannot be excluded. The area of FDG avidity within the right lobe corresponds to the region of severe biliary dilation and more [**Location (un) 21851**] is not excluded, though no mass is discretely visualized. 2. Severe atrophy of the right hepatic lobe with severe biliary dilation and right metallic hepatic biliary stent in place. Moderate biliary dilation of the left hepatic lobe. 3. Enlarged 2.1-cm gastrosplenic lymph node, concerning for metastasis. 4. 11-mm subcutaneous nodule within the anterior abdominal wall along the previously placed left biliary catheter. This focus is nonspecific and may represent scar tissue, but is concerning for metastasis, particularly given that the right lateral subcutaneous nodule (which also appears likely to have been along a prior right PTBD course) is biopsy proven adenocarcinoma. 5. 9-mm hypoenhancing focus within the interpolar region of the right kidney which may represent a small focus of inflammation or infection. Brief Hospital Course: Mr. [**Known lastname **] returned to oncology clinic (Dr. [**Last Name (STitle) 1852**] on [**2195-3-12**] in anticipation of beginning systemic chemotherapy with gemcitabine/cisplatin. He was found to have elevated bilirunbin (5.3). Patient was then admitted to hepatobiliary service (Dr. [**Last Name (STitle) **] on [**2195-3-15**] for planned PTC on [**2195-3-16**]. Patient was afebrile with normal vital signs on admission. However, later that evening, patient became febrile with elevated WBC (18.7K, from 8.2K). Patient then was transferred to the ICU resuscitation. IV Vanco/Zosyn was emperically started. On [**2195-3-16**], patient was given FFPs for INR 1.8 and underwent PTC with placement of R anterior, posterior and L biliary drains. Patient remained hypotensive after the procedure. He was briefly weaned off Levophed on the next day, however, his bilirubin continued to increase and patient returned to IR for cholangiogram, which showed hemobilia and obstruction of the drains that was resolved with aspiration/flushing. The drained was also advanced centrally. Patient was then weaned off Levophed on the next day. His drains continued to put out ~200-250ml of bilious material. However, his bilirubin continued to be elevated. What follows is a summary of this patient's complicated SICU course: [**3-17**]: lactate trending down, weaning levophed, weaning vent, switch to D5W [**3-18**]: Rec'd 25g albumin, weaned off pressors, biliary drains checked & cleared of clots by IR [**3-19**]: 1 U PRBC's, start TPN [**3-20**] :started on 25g albumin q8h,continued advancing TPN,laxix 10mgiv, us liver shows patent vessels, cx swann to triple lumen; failed decreasing PEEP fto 8 (desatted) & failed decreasing PS to 8 (desatted) [**3-21**]: R PTC began pouring out serosanguinous fluid, hct stable, thought to be pleural effusion through sidehole. Tbili continuing to rise. Pt went to IR for removal of R drains, replacement of L drain and placement of R pleural pigtail catheter. Bp somewhat labile with fluid shifts requiring some levo intermittently. Given albumin bolus in early AM as patient significantly negative over day. [**3-22**]: persisting abd distension, bladder pressure 14-15; pleural fluid cultured, start TPN w/ lipids on [**3-23**], pigtail to suction [**3-23**]: Biliary fluid from ET - F/U serum and sputum Tbili. Added Flagyl for c. perfringens in bile, d/c'd zosyn & started meropenem. Added Fluconozole. sputum from [**3-21**] grew 2 types of GNR & sparse growth of yeast. Episode of hypotension: 1x albumin 12.5 g. Started NICOM. [**3-24**]: Increased sedation to help with vent compliance as changed over to pressure control ventilation. Required increasing pressors due to propofol. Started cisatricurium drip to improve vent synchrony and decreased sedation. Continued on vanc/[**Last Name (un) 2830**]/fluc/flagyl. [**3-25**]: d/c'd flagyl (adequate anaerobic coverage w/ [**Last Name (un) 2830**]). US shows large pleural effusion but primary team does not want to tap. Concentrating fluids (e.g., abx) to reduce Inputs. continued on CMV. NO AM CXR per primary team. Ecoli, yeast in sputum from [**3-21**] [**3-26**]: vanc trough 27.6, held today's dose and redosed q24hrs. Continue PCV.,surv bl cx sent. At 4pm acute desat, improved w/ suctioning. CXR showed RUL collapse (mucous plug). Bronch done & BAL sent. repeat CXR showed improved lung fields but required 100% FiO2 for 3 hrs before being able to wean slowly to 70%. Cisatrocurum stopped and propofol increased slightly to 50. SQH started, slight increase in norepi to 0.12. [**3-27**]: Persistent b/l plueral effusions. Continue PCV. Cr trending up from 1.4 to 1.7. Meropenem decreased to 500 mg IV q6h. Coags trending up. On ARDS rotator bed, with some improvement in pulmonary function over day. Intermittently dropping blood pressures upon turning but recovers quickly. Levo adjusted up and down prn. [**3-28**]: episode of hypotension when levophed decreased 0.09; increased, then BP stablized at 0.1; hyperK - tx w/ insulin/glucose x2 and bicarb; renal to eval for CVVH - per their recs, can start when hyperK worsens; no ST changes [**3-29**]: K 6.3 - more ins/glucose, HCO3; albumin 12.5g TID, lasix 40mg x1=400 urine above baseline but pt also turned in am so actually decreased in pO2 & cxr, creatinine bump to 2.1; repeat dose lasix yielded another 440 urine above baseline. Continued discussion re: CVVH; discussed w/ T-plant CT chest to look for loculations (right pleural pigtail not draining for ~ 24 hrs but overnight started draining for total 200cc), not agreed upon. Added albuterol MDI q6h prn. AM gas much improved [**3-30**]: HCT 24 --> txf 2U PRBC. d/c albumin. IV lasix 40mg IV twice today. Holding off on CVVH. IP placed pigtail to L chest. [**3-31**]: Slowly weaning vent settings. L and R chest tubes continue to drain. - 700 over day. CXR improving [**4-1**]: No longer on propofol, requiring lower dose of norepi; penile ulcer/necrosis noted, wound consult requested. Diuresed to negative 1.9L as of midnight from the am dose of 40 iv lasix. Pt has withdrawl to pain response now that propofol off for 18 hours. Off norepinephrine. [**4-3**]: Went to IR for drain study, drain patent. Also attempted to advance Dobhoff tube to post-pyloric position, however unable to pass despite multiple attempts. Left in stomach. Started D5W for sodium of 150. On recheck, trending down 149->148. [**4-4**]: s/p open trach. Urology c/s w/wound recs for penile necrosis. [**4-5**]: did well on trach collar. Still needs jejunal dobhoff. [**4-6**]: dubhoff still gastric after reglan x2; GI to advance at bedside on [**4-7**] [**4-7**]: Endoscopy guided advancement of DHT by GI, however, DHT still coiled in stomach. Likely J-tube will be needed. [**4-8**]: Successful endoscopic advancement of NJ tube-->tube feeds started [**4-9**]: increasing TF 10cc q8h to a goal of 65 mL/hr. Cont'd TPN. [**4-10**]: fluids to 50cc/hr NS per transplant [**4-11**]: chest tube replacement cc:cc w/ 1/2NS [**4-12**]: CT output replacement held o/n for + fluid balance [**4-13**]: RUQ US shows mild-mod right but not left biliary dilatation. Cholangiogram shows left biliary duct is patent, R not patent. Two units RBC's given for decreasing SBP & decreasing crit. In evening pt had acute desat to 80%, brady to 40, hypotension to 60 SBP. Resolving w/ bagging. EKG shows afib. Pt later developed hypotension, sinus rhythm. Given fluid boluses. Vanc/[**Last Name (un) 2830**] started for sepsis. Finally levophed started. Overnight insulin given for hyperkalemia. Developed bleeding from central line site, so coags and fibrinogen sent. Consider d/c central line. Bicarb given for 7.26, repeated insulin, D50 for repeat K=6.1. [**4-14**]: R pigtail output dropped off, likely clogged. R sided whiteout. pigtail stripped. Both pigtails put to 20mmHg sxn per tranplant. D/c'd cipro. 3amps bicarb; bili/amylase/cytology for pleural fluid sent [**4-15**]: GPCs in blood cx from RIJ, R SC TLC placed; D10 @ 20ml/hr for hypoglycemia; 1:1 fluid replacement for increased CT output which then decreased over the day, sputum cx for green sputum. Weaned vent to CPAP Fio2 40% and [**4-23**]. Could not wean levo to off but down to 0.03. [**4-16**]: tolerating trach collar. Bicarb decreasing, so given 1 amp bicarb. [**4-17**]: tolerating trach collar, still on 0.03 levophed, d/c D10, ordered flexiseal, TFs to goal at 35ml/hr; started NaHCO3 in NS @ 75ml/hr; decreasing UOP - gave 500ml NS, increasing Cr 3.3 [**4-18**]: 1 amp bicarb [**4-19**]: Gave 2 amps bicarb. Consulted renal - ATN vs prerenal vs obtruction from mets. FeNA 0.35. Recs include urine lytes, osms, sediment; salt poor albumin with lasix to decrease K if needed. Minimal UOP, but Cr and BUN mildly improved. No HD per primary team. Low albumin - started 25g 25% albumin TID. Also started TPN. Started cipro for PTC prophylaxis and dosed vancomycin. [**4-20**]: renal US showed no hydronephrosis or stone. renal reconsulted:no HD indicated [**4-21**]: recomendation to consider palliative care consult, TPN d/ced [**4-22**]: Renal agrees HD is not indicated, albumin given x 3, 2 amps bicarb for level of 14, put back on vent. Restarted levo and placed R radial Aline. BP did not respond to last albumin [**4-23**]: family meeting planned for [**4-24**], [**Last Name (un) 2830**] spaced to Q24H secondary to renal failure [**4-24**]: Moving towards CMO, DNR/DNI confirmed. No further lab tests or blood draws. [**4-25**]: Removed Aline and d/c'd abx. started morphine gtt for agonal breathing. Medications on Admission: Creon [**12-21**] capsule PO TID w/ meals & snacks, Omeprazole 20mg PO daily Ondansetron 8mg prn nausea Prochloroperazine maleate 10 mg Q6H prn nausea Ursodiol 300mg PO BID Calcium MVI 1 tab po daily Omega-3-FA's Discharge Medications: None, pt expired. Discharge Disposition: Expired Discharge Diagnosis: Cholangitis Sepsis Metastatic Cholangiocarcinoma Liver Failure Acute Renal Failure Respiratory Failure Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2195-4-29**]

[ "605", "518.81", "607.83", "511.9", "196.2", "576.1", "286.7", "995.92", "197.7", "584.5", "287.5", "198.7", "276.0", "607.89", "576.2", "933.1", "E879.8", "112.89", "V10.09", "276.69", "427.31", "198.89", "997.31", "038.8", "E915", "785.51", "482.82", "785.52", "570" ]

icd9cm

[ [ [] ] ]

[ "87.54", "99.15", "33.24", "96.72", "64.91", "45.13", "31.1", "51.98", "34.91", "34.04", "96.6" ]

icd9pcs

[ [ [] ] ]

14759, 14768

5887, 14452

336, 673

14915, 14925

3642, 5864

14978, 15141

3109, 3281

14717, 14736

14789, 14894

14478, 14694

14949, 14955

3296, 3623

263, 298

701, 2353

2375, 2681

2697, 3093

13,068

192,842

27520

Discharge summary

report

Admission Date: [**2107-5-21**] Discharge Date: [**2107-5-28**] Date of Birth: [**2050-12-12**] Sex: F Service: CARDIOTHORACIC Allergies: Atorvastatin Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x 4 on [**5-23**] (LIMA to LAD, SVG to RCA, SVG to OM1> OM2) History of Present Illness: 56 y/o female with recent chest pain for few weeks. Underwent cardiac cath which revealed three vessel disease. She was stable without chest pain and was referred for surgery within the next week. In the mean time she again developed chest pain and was advised to return to the hospital by her PCP. [**Name10 (NameIs) **] transferred to [**Hospital1 18**] for CABG. Past Medical History: Hypertension Hypercholesterolemia Diverticulosis Social History: Does not smoke, Rare Alcohol. Denies ilicit drug use. Family History: Mother denied after CABG at 72 y/o. Father with CAD, died in late 50's. Physical Exam: Unremarkable upon admission Pertinent Results: Echo [**5-23**]: PRE-BYPASS: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). There are simple atheroma in the descending thoracic aorta. 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. Post-bypass: Overall LVEF 55%. Ascending aorta is similar to prebypass. Trivial MR, TR. CXR [**5-27**]: [**2107-5-21**] 07:30PM BLOOD WBC-6.3 RBC-4.96 Hgb-13.6 Hct-39.5 MCV-80* MCH-27.4 MCHC-34.4 RDW-13.9 Plt Ct-218 [**2107-5-26**] 08:40AM BLOOD WBC-7.8 RBC-3.22* Hgb-8.9* Hct-26.2* MCV-82 MCH-27.6 MCHC-33.9 RDW-14.2 Plt Ct-194 [**2107-5-27**] 06:24AM BLOOD Hct-22.6* [**2107-5-21**] 07:30PM BLOOD PT-12.2 PTT-23.7 INR(PT)-1.0 [**2107-5-25**] 03:04AM BLOOD PT-12.7 PTT-24.9 INR(PT)-1.1 [**2107-5-21**] 07:30PM BLOOD Glucose-144* UreaN-28* Creat-1.1 Na-141 K-4.6 Cl-104 HCO3-25 AnGap-17 [**2107-5-26**] 08:40AM BLOOD Glucose-107* UreaN-17 Creat-0.7 Na-136 K-4.1 Cl-101 HCO3-27 AnGap-12 [**2107-5-26**] 08:40AM BLOOD Calcium-7.5* Phos-2.1* Mg-1.7 [**2107-5-22**] 03:00PM URINE RBC-3* WBC-8* Bacteri-MANY Yeast-NONE Epi-5 Brief Hospital Course: As mentioned in the HPI, Ms. [**Known lastname **] is a 56 y/o female who was transferred here from [**Hospital1 **] d/t chest pain and recently found to have severe three vessel disease. She underwent usual pre-operative testing and was cleared for surgery. She was brought to the operating room on [**5-23**] and underwent a coronary artery bypass graft x 4 by Dr. [**Last Name (STitle) 914**]. Please see operative report for surgical details. Following surgery she was transferred to the CSRU for invasive monitoring in stable condition on minimal Inotropic support. Later on operative day she was weaned from sedation, awoke neurologically intact and was extubated. Chest tubes were removed on post-op day two. She was weaned off of Neo-Synephrine also on this day and was transferred to the cardiac surgery step-down floor. Beta blockers and diuretics were initiated per protocol. She was gently diuresed towards her pre-operative weight. On post-op day three her epicardial pacing wires were removed. Physical therapy followed patient during entire post-op course for strength and mobility. She appeared to be recovering well with a heart rate of 86, blood pressure 101/69 and a oxygen saturation of 98% at room air on day of discharge. She was discharged home with visiting nurse and appropriate follow-up appointments on post-op day five. Medications on Admission: Atenolol 12.5mg qd Lescol 80mg qd Fosamax 70 qwkly Aspirin 81mg 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:*2* 3. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*1* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 6. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 10 days. Disp:*20 Packet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 5871**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Hypertension Hypercholesterolemia Diverticulosis Discharge Condition: Good Discharge Instructions: no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 101, redness, or drainage from incisions may shower over incisions and pat dry no lotions, creams or powders on any incision Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks Dr. [**Last Name (STitle) 20764**] in [**1-24**] weeks Cardiologist (at [**Hospital1 **]) in [**2-25**] weeks Completed by:[**2107-5-28**]

[ "414.01", "794.31", "272.0", "562.10", "401.9", "V17.3" ]

icd9cm

[ [ [] ] ]

[ "38.91", "36.13", "34.04", "39.61", "39.64", "36.15" ]

icd9pcs

[ [ [] ] ]

4649, 4712

2293, 3642

291, 383

4865, 4871

1074, 2270

5144, 5328

938, 1011

3759, 4626

4733, 4844

3668, 3736

4895, 5121

1026, 1055

241, 253

411, 779

801, 851

867, 922

28,695

191,815

33195

Discharge summary

report

Admission Date: [**2159-12-22**] Discharge Date: [**2160-1-1**] Service: NEUROLOGY Allergies: Aspirin Attending:[**First Name3 (LF) 2518**] Chief Complaint: left sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: 88 year old right handed woman hx atrial fibrillation, left shoulder fracture, left hip fracture, who had a fall at 2:45am on [**2159-12-22**] and was found to have left face, arm, and leg weakness. A nurse at the [**Hospital3 5277**] (her nursing home) said that she was last known to be normal at 11pm on [**2159-12-21**]. When she awoke that morning, she was not aware of any deficits. She walked to the bathroom with her walker. After she had a bowel movement, she returned to her bedroom. The patient does not remember falling. She is unsure if she lost consciousness or not. At 2:45am she was discovered by the staff. She was lying near her roomate's bed. Patient had left face, arm, and leg weakness. She had dysarthria. Patient denies any headache, vertigo, numbness, incoordination. She was taken to [**Hospital 18**] [**Location (un) **] campus at 3:25am. CT brain showed chronic left MCA, right frontal, and right parieto-occipital infarcts. No acute infarct or bleed was seen. She was transferred to [**Location (un) 77139**] Campus. Patient was seen by Neurology Stroke fellow at 8:10am. Her NIHSS was 6 (-2 dysarthria, -1 left lower facial droop, -1 left arm drift, -1 left leg drift, and -1 extinction to light touch on the left. She was not a candidate for iv TPA due to uncertain time of onset. Patient was placed on a Diltiazem drip due to rapid ventricular rate in the 120's. This drip was tapered off. Patient was admitted to the neuro stepdown unit. Past Medical History: Atrial fibrillation Osteoporosis Left hip fracture Left shoulder fracture UTI Rhinitis Social History: Patient does not smoke, use Etoh, or illegal drugs. She lives at the [**Hospital3 5277**] nursing home Family History: Her father had a stroke. Physical Exam: VS: BP 99-119/41-71 P 119 (afib) R 18 02 97-100% Gen: thin Heent: supple neck, no carotid bruits, no lymphadenopathy Chest: lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi Heart: irregularly irregular, no murmurs, Abd: soft, non-distended, non-tender, no mass, positive bowel sounds Ext: no cyanosis, clubbing, or edema Skin: no erythema Neuro: MS: alert and oriented x3 (knows that she is in hospital but does not know the name), fluent, intact comprehension, intact naming, repetition, knowledge, can spell world forwards, immediate recall [**2-18**] short term recall [**12-20**] (with prompting), follows crossed body commands, no neglect CN: moderate dysarthria, visual fields full to confrontation, no papilledema, pupils equal, round, and reactive, extraocular movements intact, intact light touch, mild left lower nasolabial fold effacement, intact t/u/p, [**4-21**] SCM and trapezius Motor: normal tone and bulk of all four extremities, no tremor D B T WE WF FE FF Left 4- 4+ 4+ 4 4+ 4 4+ Right 4+ 5 5 5 5 5 5 IP Q H DF PF Left 4+ 5 5 5 5 Right 4+ 5 5 5 5 Sensory: intact light touch and pinprick of all four extremities intact proprioception of LE extinction to light touch of the left arm and leg Romberg not assess Reflex: T BR B K A toes Left 2 2 2 2 2 up Right 2 2 2 2 2 down Coord: Intact finger-nose-finger, heel-shin, and rapid alternating movements bilaterally Gait: deferred The patient was reexamined at 1:30pm. At this time, her dysarthria had improved. Her left nasolabial fold effacement was only mild. She still had left arm weakness. Her left leg weakness was not appreciably worse than the right leg weakness. She did not have extinction to light touch on the left arm and leg. Pertinent Results: CBC 14.0 10.9 294 40.5 Chem 7 137 101 12 124 6.5 27 0.8 Ca Mag Phos pending PT 13.0 PTT 25.2 INR 1.1 CK CK-MB Trop pending EKG irregularly irregular, rate 112, axis 0 degrees, twi in V1-V2 A1c: 6.0 FLP: LDL 144, HDL 59, Tot chol 221, Trig 89 Imaging: CXR: no acute cardiopulmonary process Head CT: Chronic infarcts of the left MCA, right frontal lobe, and right parieto-occipital region. No acute signs of infarct or bleed. MRI Head: Acute infarction in the inferior division of the right middle cerebral artery. Evidence of old infarction in the left frontal and right occipital lobes. Incomplete examination due to the patient's inability to remain motionless. Carotid U/S: Bilateral less than 40% carotid stenosis. Video Swallow Study: Penetration with straw sips of thin liquids. No aspiration was detected during the exam. TTE: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. Mild to moderate ([**12-19**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Preserved regional and global biventricular function. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. No evidence of left atrial thrombus - however a trans-thoracic echocardiogram is not accurate enough to exclude the presence of thrombus in the left atrium or left atrial appendage. Brief Hospital Course: Ms. [**Known lastname 77140**] is an 88-year-old woman with a history of atrial fibrillation and multiple prior strokes who presented with dysarthria and left sided face, arm, and leg weakness. She was admitted to the neurology stroke service and found on MRI to have had a right MCA inferior division infarct. The mechanism was presumed to be clot from atrial fibrillation, as she was not on anticoagulation. Heparin drip and Coumadin were started, with goal INR [**1-20**]. Carotid ultrasound showed no significant stenosis. Hemoglobin A1c was 6.0; TSH was 3.2; lipid panel showed ldl 144, hdl 59, tchol 221, trig 89 - she was started on statin therapy. Her atrial fibrillation had several episdoes of rapid ventricular response. This was responsive to IV diltiazem, and her oral diltiazem dose was increased. Metoprolol was ineffective. She was also found to have a urinary tract infection, and was treated initially with Bactrim, then cipro when she was persistently febrile on Bactrim. She will have a 7-day course given the association with an indwelling Foley catheter. She had some signs of inattention consistent with encephalopathy related to the infection, which cleared as the infection was treated further. She remained in the hospital several days pending therapeutic INR; initially, her INR increased to over 6, and she received vitamin K, after which heparin drip was re-initiated and after holding coumadin for two days, this was resumed as well. Her INR at time of discharge was 2.1. She will require daily PT/INR until off Cipro and on stable dose of coumadin. Medications on Admission: All: ASA causes anaphylaxis NSAIDS bacon Meds: Fosamax 70mg qweek Nasacort 55mcg 2sprays each nostril daily Senna Diltiazem SR 120mg daily Multivitamin Vitamin D 400units [**Hospital1 **] Os-Cal 500mg [**Hospital1 **] Colace Tylenol Fluticasone 2 sprays each nostril qhs Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 4. Nasacort AQ 55 mcg Aerosol, Spray Sig: [**12-19**] Nasal twice a day as needed. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days: Two days of 7 day course remaining at time of discharge for catheter assoc UTI. 12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QHS (once a day (at bedtime)) as needed. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 14. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16): Check PT/INR daily. Will likely need to increase once off cipro. Discharge Disposition: Extended Care Facility: [**Hospital3 5277**] - [**Location (un) 745**] Discharge Diagnosis: Stroke - (Acute infarction in the inferior division of the right middle cerebral artery, likely embolic) Atrial fibrillation with rapid ventricular response Urinary tract infection Discharge Condition: Good - dysarthria improved, mental status improved, left-sided weakness very mild (5-/5, upper motor neuron pattern) Discharge Instructions: Please return if you have new symptoms suggestive of a new stroke. [**Name8 (MD) **] MD if you have any bleeding while on coumadin. Please check INR at nursing facility DAILY and make adjustments to coumadin as appropriate, for target INR [**1-20**]. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**3-25**] weeks after discharge from hospital - call ([**Telephone/Fax (1) 7394**] for appointment. Please follow up with PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18376**] ([**Telephone/Fax (1) 18377**]) in [**2-21**] weeks. You should have your PT/INR checked in 24-48 hours and your coumadin dose should be adjusted accordingly (you are taking cipro and this may elevate your INR). [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]

[ "401.9", "V43.64", "790.92", "E888.9", "V45.77", "E879.6", "427.31", "996.64", "434.11", "438.20", "438.11", "348.30", "733.00", "788.20", "V15.88", "599.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9307, 9380

5914, 7502

237, 244

9605, 9724

4043, 4428

10024, 10642

1994, 2021

7836, 9284

9401, 9584

7528, 7813

9748, 10001

2036, 4024

177, 199

272, 1746

4437, 5891

1768, 1857

1873, 1978

23,357

122,444

47308

Discharge summary

report

Admission Date: [**2109-5-13**] Discharge Date: [**2109-5-14**] Date of Birth: [**2050-7-21**] Sex: F Service: MICU GREEN HISTORY OF THE PRESENT ILLNESS: The patient is a 58-year-old woman transferred from [**Hospital 8**] Hospital after presenting status post a fall with abdominal distention, acute fulminant hepatic failure and pancreatitis. CT of the abdomen at the outside hospital showed significant hepatomegaly, gallbladder not visualized, and became lethargic and acidotic with hypercapnic respiratory failure. The patient was intubated and transferred over the [**Hospital6 2018**]. On arrival, the patient was hemodynamically stable. HOSPITAL COURSE: She was started on Unasyn for presumed intra-abdominal infection. Over the next 24 hours, the patient became progressively septic, hypotensive despite the addition of three pressors. An emergent family meeting was held 24 hours after admission and the decision was made to make the patient comfort measures. The pressors were discontinued. The patient's blood pressure fell and she became asystolic at around 8:35 on the morning of [**2109-5-14**]. The ventilator was temporarily turned off. There were no spontaneous respirations and no spontaneous heart sounds. The patient was pronounced dead at 8:35 in the morning of [**2109-5-14**]. DISCHARGE DIAGNOSIS: 1. Fulminant hepatic failure. 2. Sepsis. FOLLOW-UP: The patient is to have post mortem to further determine the etiology of her fulminant hepatic failure and sepsis. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AEW Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2109-5-15**] 08:25 T: [**2109-5-17**] 22:42 JOB#: [**Job Number 100150**]

[ "570", "038.9", "250.00", "584.9", "577.0", "E888.9", "518.81", "452", "491.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

1352, 1754

685, 1331

23,463

131,647

7863

Discharge summary

report

Admission Date: [**2157-6-11**] Discharge Date: [**2157-7-20**] Date of Birth: [**2085-9-5**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: 72 y/o male transferred from the [**Location (un) **] emergency room to our facility with free air after repair of a perf'd duodenal ulcer 10 days prior and 5 days prior an operation for secondary closure of wound dehiscence. He presented with severe abdominal pain which quickly progressed to shock. Major Surgical or Invasive Procedure: [**6-11**] - ex-lap and loop colostomy [**6-28**] - trach placed History of Present Illness: 72 y/o male transferred from the [**Location (un) **] emergency room to our facility with free air after repair of a perf'd duodenal ulcer 10 days prior and surgery 5 days prior an operation for secondary closure of wound dehiscence. He presented with severe abdominal pain which quickly progressed to shock. The patient was found to have free air on the CT scan and was taken to the OR and found to have a transverse colon perforation. Past Medical History: Paroxysmal atrial fibrillation on coumadin. Gastroesophageal reflux disease. Hypercholesterolemia. Chronic obstructive pulmonary disease. Steroid dependent. Hypertension. Non-insulin-dependent diabetes mellitus. Coronary artery disease as mentioned above. Coronary artery bypass grafting times six in [**2146**]. Catheterization on [**2153-10-10**], showed no new disease AAA, obesity. Physical Exam: NAD, AAOx3 Afib, tachycardic, no m/r/g Coarse breath sounds bilaterally, no wheezes trach collar in place Abd. soft, mildy tender, mildly distended Open wound covered by wound vac 1+ edema bilateral LE's Midline Line in place left arm Pertinent Results: [**2157-7-15**] 05:00PM BLOOD WBC-6.9 RBC-3.56* Hgb-10.5* Hct-30.9* MCV-87 MCH-29.5 MCHC-34.0 RDW-19.4* Plt Ct-310 [**2157-6-11**] 12:15PM BLOOD Neuts-51 Bands-36* Lymphs-5* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1* NRBC-1* [**2157-7-15**] 05:00PM BLOOD Plt Ct-310 [**2157-7-19**] 09:36AM BLOOD Glucose-183* UreaN-24* Creat-0.8 Na-131* K-6.0* Cl-96 HCO3-26 AnGap-15 [**2157-7-16**] 01:24AM BLOOD CK(CPK)-9* [**2157-6-16**] 02:55AM BLOOD ALT-61* AST-51* AlkPhos-66 Amylase-63 TotBili-0.9 [**2157-7-16**] 01:24AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2157-7-19**] 09:36AM BLOOD Calcium-9.1 Phos-4.3 Mg-1.9 [**2157-7-19**] 06:26AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0 Brief Hospital Course: 72 y/o male transferred from the [**Location (un) **] emergency room to [**Hospital1 18**] with free air after repair of a perf'd duodenal ulcer 10 days prior and 5 days prior an operation for secondary closure of wound dehiscence. He had just been discharged when he presented with severe abdominal pain which quickly progressed to shock. A CT scan revealed free air in the abdomen and the patient ws taken to the OR for an ex-lap where he was found to have a perforated transverse colon. He was washed out and given a colostomy. Post operatively he was admitted to the SICU where he required pressors and was intubated. He was started on vanc/levo/flagyl/fluc and maintained on a neo and epi drip. On POD #6 a dobhoff was placed and he was started on tube feeds which were increased to goal. His blood cultures grew vanc resistant enterococcus and so he was switched from vanc to linezolid. On POD # 10 the drainage from his wound had increased and he developed an enterocutaneous fistula. On POD 12 a fluid collection was drained and 125cc of fluid was removed from his abdomen. Pt. began tolerating trach trials on POD #15 and on POD #18 a percutaneous tracheostomy was performed. It was decided to manage his low output fistula with conservative meausures. On POD #21 the patient was weaned and remained on trach collar for 24 hours. On POD 26, while off the vent and pressors, the patient failed a speech and swallow eval and failed a passt-muir valve test. On POD #29 the patient was transferred to the floor. His dressing over his fistula were changed to a wound vac, which has been changed every 3 days. Since being on the floor the patient has remained stable. He continues to live in Afib chronically, his 02 sats have been good, and he is tolerating his trach collar and tube feeds well. His fistula has decreased output and on POD #38 he failed his sppech and swallow once again. He was seen by ENT who recommened keeping HOB > 45%, start nexium, and speech/swallow eval later on this month. All antibiotics were stopped on [**2157-7-19**]. THe patient will be transferred in stable condition to rehab. Medications on Admission: prednisone, paxil, digoxin, carvedilol, ezetemibe, gemfibrozil, glipizide, metformin, lisinopril, rosiglitazone, zocor, terazosin, omeprazole, lasix, nitro patch, nitroglycerin, fluticasone, combivent, ?coumadin, Discharge Medications: 1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day). 3. Oxycodone 5 mg/5 mL Solution Sig: [**1-3**] PO Q4H (every 4 hours) as needed. 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): per tube. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscell. Q4-6H (every 4 to 6 hours) as needed. 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for pulm toilet. 8. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Paxil 30 mg Tablet Sig: One (1) Tablet PO once a day. 11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO once a day. 14. Terazosin 5 mg Tablet Sig: One (1) Tablet PO once a day. 15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual prn as needed for chest pain. 16. Combivent 103-18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day. 17. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Inhalation twice a day. 18. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime: Please check INR. 19. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 20. Outpatient Lab Work Check INR daily x 1 week. Check Chem-7 with firts INR. Discharge Disposition: Extended Care Facility: St [**Hospital **] Hospital Rehabilitation Unit - [**Location (un) 8117**], NH Discharge Diagnosis: Pt. s/p ex-lap and loop colostomy for transverse colon perforation 10 days after repair of a perforated duodenal ulcer. Long postoperative ICU stay including the development of an enterocutaneous fistula. Discharge Condition: Stable Discharge Instructions: To Rehab: Please continue tube feeds for patient until pt can be reevaluated by speech and swallow. NPO until then. PT: Pt. OOB, continue chest PT. Increase activity slowly as tolerated Meds: Pt. to be restarted on Coumadin. Please check INR daily for first week and adjust dose according to maintain a therapuetic level for his Afib. Wound vac on abdominal wound to be changed every 3 days. Followup Instructions: Please call Dr.[**Name (NI) 28329**] office to schedule a followup appointment. [**Telephone/Fax (1) 1483**] Please followup with PCP [**Name Initial (PRE) 176**] 1 week to adjust home meds dose. Completed by:[**2157-7-20**]

[ "584.5", "569.81", "272.0", "569.83", "038.11", "998.59", "V45.81", "567.29", "V58.61", "996.62", "530.81", "427.31", "998.83", "V58.65", "995.92", "278.00", "785.52", "997.4", "V53.32", "518.5", "428.0", "250.00", "496" ]

icd9cm

[ [ [] ] ]

[ "99.07", "93.59", "99.04", "86.28", "54.91", "31.42", "96.6", "31.1", "38.93", "46.75", "96.72", "46.03", "99.15", "00.17", "00.14" ]

icd9pcs

[ [ [] ] ]

6464, 6569

2516, 4633

614, 680

6817, 6825

1825, 2493

7265, 7491

4896, 6441

6590, 6796

4659, 4873

6849, 7242

1570, 1806

274, 576

708, 1146

1168, 1555

10,019

177,759

24500

Discharge summary

report

Admission Date: [**2163-5-14**] Discharge Date: [**2163-5-15**] Date of Birth: [**2114-6-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: none History of Present Illness: 48 y/o M w/hx of EtOH abuse who presented to [**Hospital3 **] on [**2163-5-13**] c/o hematemesis. He was a somewhat vague historian, but c/o persistent n/v of bright red blood. Denied melena. Noted decreased UOP. Drinks daily, with last drink at midnight on day of admission. In [**12-29**], he was admitted to [**Hospital **] with CP, noted to have Hct 28, and had an EGD that revealed mild reflux esophagitis, no varices, and small gastric ulcerations. On [**5-13**], he called EMS c/o hematemesis. At that time he was hypotensive to 80/40, pulse 67. Labs revealed ABG 6.97/41/141, Hct 20, plt 39, INR 1.6, creatinine 12.1, bicarb 11, calcium 5, bili 8.3, AST 587, ALT 158, alk phos 433. He had an EGD which revealed fresh large clot traveling down the entire length of the esophagus. No varices. Large fresh thrombus in fundus. There was concern that some of the bleeding was from his nasopharynx, and ENT visualized a laceration in his right nasopharynx that they packed extensively. He was begun on octreotide and protonix, given 9 units PRBC and 12 pk of platelets. Placed on levophed and neo. Given IVF w/sodium bicarb but remained anuric. They placed a subclavian dialysis catheter and emergently dialyzed him on [**5-14**]. Later that day he was transferred to [**Hospital1 18**]. During the [**Location (un) 7622**], he became hypotensive and was begun on vasopressin. He was bleeding from his eyes, nose, and ETT. Past Medical History: HTN Anemia GI bleed [**12-29**] (small gastric antral ulcers, ? due to NSAIDs) Bilateral OA of hips EtOH abuse Social History: lives with his brother. used to work as a welder and was exposed to benzene per family. currently on disability [**1-26**] OA. Drank heavily between [**12-28**] and 1/05 per family, but they do not believe he had been drinking since [**12-29**] although pt reported that he had been upon admission. Family denies tobacco or other drugs. Family History: sister died during PTCA at 37 y/o, mother died of CVA Physical Exam: T: 96 P: 77 BP: 100/57 Vent 500 x 16, PEEP 5, FiO2 60% Gen: intubated/sedation HEENT: dried bloodon eyes, nasal packing, mouth Lungs: coarse anteriorly, diminished breath sounds at bilateral bases CV: RRR, no m/r/g Abd: distended, nontender, hypoactive bowel sounds Ext: trace pedal edema, 1+ dp pulses bilaterally Skin: cool extremities, poor capillary refill Pertinent Results: [**2163-5-14**] 08:53PM BLOOD WBC-3.7* RBC-3.73* Hgb-12.1* Hct-33.2* MCV-89 MCH-32.5* MCHC-36.5* RDW-18.0* Plt Ct-68* [**2163-5-15**] 12:23AM BLOOD Hct-30.6* [**2163-5-15**] 04:09AM BLOOD WBC-4.8 RBC-3.53* Hgb-11.2* Hct-30.9* MCV-87 MCH-31.7 MCHC-36.3* RDW-17.5* Plt Ct-49* [**2163-5-15**] 08:04AM BLOOD WBC-6.8 RBC-4.03* Hgb-12.5* Hct-36.0* MCV-89 MCH-31.0 MCHC-34.7 RDW-17.2* Plt Ct-38* [**2163-5-15**] 02:48PM BLOOD Hct-31.5* Plt Ct-85*# [**2163-5-14**] 08:53PM BLOOD PT-32.2* PTT-150* INR(PT)-6.8 [**2163-5-15**] 12:23AM BLOOD PT-17.6* PTT-76.5* INR(PT)-2.1 [**2163-5-15**] 08:04AM BLOOD PT-15.6* PTT-51.5* INR(PT)-1.6 [**2163-5-14**] 08:53PM BLOOD Fibrino-418* [**2163-5-14**] 09:52PM BLOOD FDP-40-80 [**2163-5-15**] 04:09AM BLOOD Fibrino-398 [**2163-5-14**] 08:53PM BLOOD Glucose-155* UreaN-53* Creat-7.2* Na-137 K-3.3 Cl-104 HCO3-16* AnGap-20 [**2163-5-15**] 04:09AM BLOOD Glucose-95 UreaN-48* Creat-6.4* Na-141 K-3.6 Cl-99 HCO3-14* AnGap-32* [**2163-5-15**] 08:04AM BLOOD Glucose-85 UreaN-42* Creat-5.6* Na-136 K-6.3* Cl-95* HCO3-10* AnGap-37* [**2163-5-15**] 11:20AM BLOOD Glucose-360* UreaN-36* Na-138 K-3.6 Cl-89* HCO3-18* AnGap-35* [**2163-5-15**] 07:10PM BLOOD Glucose-279* UreaN-31* Creat-4.0*# Na-136 K-5.2* Cl-83* HCO3-12* AnGap-46* [**2163-5-14**] 08:53PM BLOOD ALT-176* AST-747* LD(LDH)-1120* AlkPhos-487* Amylase-51 TotBili-14.0* [**2163-5-14**] 09:52PM BLOOD CK(CPK)-68 DirBili-0.2 [**2163-5-15**] 04:09AM BLOOD ALT-155* AST-682* AlkPhos-434* TotBili-12.8* [**2163-5-14**] 08:53PM BLOOD Lipase-1260* [**2163-5-15**] 11:20AM BLOOD CK-MB-15* cTropnT-<0.01 [**2163-5-14**] 08:53PM BLOOD Ammonia-507* [**2163-5-14**] 09:52PM BLOOD Acetone-NEGATIVE Osmolal-308 [**2163-5-14**] 09:52PM BLOOD Cortsol-151.4* [**2163-5-14**] 09:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5.5 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2163-5-14**] 09:07PM BLOOD Type-ART pO2-123* pCO2-46* pH-7.20* calHCO3-19* Base XS--9 [**2163-5-14**] 11:12PM BLOOD Type-ART pO2-61* pCO2-36 pH-7.33* calHCO3-20* Base XS--6 [**2163-5-15**] 12:11AM BLOOD Type-ART pO2-69* pCO2-35 pH-7.29* calHCO3-18* Base XS--8 [**2163-5-15**] 01:00AM BLOOD Type-ART pO2-74* pCO2-35 pH-7.30* calHCO3-18* Base XS--7 [**2163-5-15**] 05:32PM BLOOD Type-ART Temp-35.0 Rates-36/ Tidal V-450 PEEP-15 FiO2-80 pO2-78* pCO2-31* pH-7.34* calHCO3-17* Base XS--7 AADO2-469 REQ O2-79 -ASSIST/CON Intubat-INTUBATED [**2163-5-14**] 09:07PM BLOOD Glucose-146* Lactate-6.8* [**2163-5-15**] 02:04AM BLOOD Lactate-10.8* [**2163-5-15**] 04:23AM BLOOD Lactate-12.6* [**2163-5-15**] 08:29AM BLOOD Glucose-80 Lactate-15* [**2163-5-15**] 03:07PM BLOOD Lactate-19.2* [**2163-5-15**] 07:20PM BLOOD Glucose-287* Lactate-26.3* CXR: IMPRESSION: 1) ET tube in satisfactory position. 2) Right central line tip approximately at SVC/RA junction. 3) Feeding tube tip high, probably in region of GE junction. This was called to the nurse caring for this patient. 4) Patchy increased density right perihilar and left retrocardiac region. Brief Hospital Course: He was admitted to the MICU service. He was felt to have alcoholic hepatitis and pancreatitis, with a GI bleed of unclear source, and ARF. His respiratory failure was felt due to anasarca from the massive amt of fluids and blood products he required. He was given levofloxacin, empiric decadron, and continued on pressors. He was placed on CVVH on admission because he was anuric, acidemic, and difficult to oxygenate/ventilate. Bladder pressure was checked at was elevated at 28, but he had no ascites on abdominal ultrasound. Surgery was called re: abdominal compartment syndrome but did not feel he had any indications for surgery. He was placed on paralytics, resulting in decreased abd pressure. He was transfused 3 add'l units of PRBCs and 9 of FFP. He continued to require additional pressors, including dopamine, levophed, and vasopressin. Because of his multi-organ system failure and grim prognosis, a family meeting was held. He had worsening acidosis and hypotension despite maximum pressors. The family decided to change goals of care to comfort measures only, and he died on [**2163-5-15**]. Medications on Admission: Meds at home: lovastatin atenolol lisinopril combivent lactulose Meds on transfer: levophed neosynephrine vasopressin octreotide protonix Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: GI bleed Hepatitis Lactic Acidosis Acute Renal Failure Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

[ "401.9", "518.81", "303.90", "584.5", "571.1", "284.8", "493.90", "995.92", "785.59", "578.1", "572.2", "729.9", "038.9", "577.0" ]

icd9cm

[ [ [] ] ]

[ "00.17", "96.71", "99.04", "39.95" ]

icd9pcs

[ [ [] ] ]

7084, 7093

5747, 6866

326, 332

7191, 7200

2765, 5724

7253, 7260

2311, 2366

7055, 7061

7114, 7170

6892, 6958

7224, 7230

2381, 2746

275, 288

360, 1804

1826, 1938

1954, 2295

6976, 7032

65,569

120,640

35059

Discharge summary

report

Admission Date: [**2199-4-23**] Discharge Date: [**2199-5-1**] Date of Birth: [**2124-1-21**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3645**] Chief Complaint: Back and left leg pain. Major Surgical or Invasive Procedure: L2-3 AND L3-4 ANTERIOR DECOMPRESSION AND FUSION; L1-L5 POSTERIOR DECOMPRESSION; L2-4 POSTERIOR INSTRUMENTATION/FUSION WITH ALLOGRAFT, ILIAC CREST BONE GRAFT. History of Present Illness: Mr [**Known lastname 80089**] is a pleasant 75 year old gentleman with an approximate 10 month history of lumbar spine and left anterior thigh pain. His pain is aggravated by walking and lifting. He has had some conservative treatment which included tylenol and some physical therapy. He continues to find his back and leg pain bothersome. For these reasons and after informed consent he wishes to proceed with surgery. Past Medical History: 1. Hypertension 2. Scarlet fever induced renal failure s/p allograft renal transplant in [**2182**]. 3. COPD 4. Osteoporosis 5. Gout 6. s/p corneal transplant Social History: He does not smoke. Originally from [**Location (un) **], now lives in Montreal. Worked as a physics professor [**First Name (Titles) 5001**] [**Last Name (Titles) 80090**] several years ago. Sister is a physician. Family History: NC Physical Exam: On physical examination, this is an elderly appearing male who has an obvious scoliosis. He is unable to stand in an upright position. In his lower extremities, he has good strength in bilateral lower extremities, except that his quad is quite weak on the left side. He has significant atrophy. He has no quad reflex on that side. No clonus. He has decreased sensation in his anterior thigh on the left. His upper extremities: No trouble with fine hand or motor function. No atrophy. Full range of motion of his neck. His back is without previous scars. No skin lesions noted. Pertinent Results: [**2199-4-23**] 10:57PM BLOOD WBC-9.5 RBC-3.75* Hgb-10.3* Hct-30.2* MCV-81* MCH-27.4 MCHC-33.9 RDW-15.0 Plt Ct-129* [**2199-4-24**] 12:50AM BLOOD WBC-8.4 RBC-3.53* Hgb-9.8* Hct-28.7* MCV-81* MCH-27.7 MCHC-34.1 RDW-14.9 Plt Ct-111* [**2199-4-24**] 04:12AM BLOOD WBC-8.5 RBC-3.29* Hgb-8.9* Hct-26.9* MCV-82 MCH-27.1 MCHC-33.1 RDW-15.0 Plt Ct-123* [**2199-4-24**] 10:52AM BLOOD Hct-26.9* [**2199-4-25**] 08:10AM BLOOD WBC-11.0 RBC-3.15* Hgb-8.6* Hct-25.8* MCV-82 MCH-27.2 MCHC-33.3 RDW-15.0 Plt Ct-84* [**2199-4-25**] 09:35PM BLOOD Hct-29.0* [**2199-4-26**] 07:50AM BLOOD WBC-8.8 RBC-3.26* Hgb-9.0* Hct-27.5* MCV-85 MCH-27.7 MCHC-32.7 RDW-14.6 Plt Ct-89* [**2199-4-27**] 06:40AM BLOOD WBC-8.3 RBC-3.44* Hgb-9.4* Hct-29.0* MCV-84 MCH-27.4 MCHC-32.5 RDW-14.7 Plt Ct-100* [**2199-4-28**] 06:45AM BLOOD WBC-5.4 RBC-3.16* Hgb-8.8* Hct-26.4* MCV-84 MCH-27.8 MCHC-33.3 RDW-14.7 Plt Ct-141* [**2199-4-23**] 10:57PM BLOOD Plt Ct-129* [**2199-4-23**] 10:57PM BLOOD Glucose-138* UreaN-22* Creat-1.1 Na-142 K-4.8 Cl-110* HCO3-23 AnGap-14 [**2199-4-24**] 12:50AM BLOOD Glucose-162* UreaN-23* Creat-1.1 Na-141 K-4.8 Cl-110* HCO3-24 AnGap-12 [**2199-4-24**] 04:12AM BLOOD Glucose-153* UreaN-21* Creat-1.0 Na-140 K-4.4 Cl-110* HCO3-25 AnGap-9 [**2199-4-25**] 08:10AM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-135 K-4.6 Cl-106 HCO3-24 AnGap-10 [**2199-4-26**] 07:50AM BLOOD Glucose-126* UreaN-21* Creat-1.1 Na-133 K-4.6 Cl-105 HCO3-23 AnGap-10 [**2199-4-27**] 06:40AM BLOOD Glucose-91 UreaN-22* Creat-1.1 Na-135 K-4.5 Cl-103 HCO3-25 AnGap-12 [**2199-4-28**] 06:45AM BLOOD Glucose-98 UreaN-21* Creat-1.0 Na-138 K-4.4 Cl-106 HCO3-24 AnGap-12 [**2199-4-23**] 10:57PM BLOOD Calcium-7.7* Phos-4.1 Mg-1.7 [**2199-4-24**] 12:50AM BLOOD Calcium-7.7* Phos-4.2 Mg-1.7 [**2199-4-24**] 04:12AM BLOOD Calcium-7.4* Phos-3.9 Mg-2.4 [**2199-4-25**] 08:10AM BLOOD Calcium-7.5* Phos-3.0 Mg-1.9 [**2199-4-26**] 07:50AM BLOOD Calcium-7.4* Phos-2.5* Mg-2.0 [**2199-4-27**] 06:40AM BLOOD Calcium-7.9* Phos-2.7 Mg-2.1 [**2199-4-28**] 06:45AM BLOOD Calcium-7.7* Phos-2.8 Mg-2.1 Brief Hospital Course: Mr. [**Name13 (STitle) **] was admitted to the [**Hospital1 18**] Spine Surgery Service on [**2199-4-23**] and taken to the Operating Room for the above procedure performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] & Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]. During the procedure he sustained a small dural tear that was repaired primarily. Surgical EBL was 1000cc, he received 4L of crystalloid and urine output was 1460cc. Dark red hematuria was noted during the case and was presumed secondary to traumatic foley insertion in the setting of baseline BPH. Please refer to the dictated operative note for further details. The surgery was otherwise without complication however due to the long duration under anesthesia and his significant EBL the decision was made to keep him intubated after surgery. He was transferred to the SICU overnight. He was placed on a HOB<30 restriction for the first 48hrs postop due to his dural tear. Pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. He became transiently hypotensive overnight with SBPs in the 70s and required pressor support. Other vital signs remained stable. The following morning he was extubated without incident. He was transfused 1U RBC for HCT 26.9 and his hypotension improved. He remained stable throughout the day POD#1 and was transferred to the regular Orthopaedic floor in the evening of POD#1. His foley was put on traction and irrigated for treatment of his hematuria. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. On POD#2 his activity restrictions were lifted and he had no headache or symptoms of dural leak when upright. Physical therapy was consulted for mobilization OOB to ambulate. He was transfused a further 2U RBCs for dropping HCT (HCT 25.8) in the setting of his hematuria and postop Hemovac output. His postop transfusion HCT was appropriately elevated at HCT 29.0. Urology was consulted and performed foley irrigation and replacement. His hematuria resolved by POD#3. On POD#3 he was noted to have a distended abdomen. A KUB was performed that was consistent with postop ileus and he was made NPO for bowel rest. Suppository was given to encourage bowel movement and IVF were restarted while he remained NPO. Daily KUBs were checked until his symptoms resolved. On POD#6 his diet resumed and he was advanced from clear liquids to regular diet as tolerated. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: 1. Prednisone 5 mg DAILY 2. Flarex 0.1 % Drops 3. Pindolol 10 mg [**Hospital1 **] 4. Cyclosporine 25 mg PO Q12H 5. Combigan 0.2-0.5 % Drops 6. Valsartan 80 mg PO DAILY 7. Travoprost 0.004 % Drops Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Flarex 0.1 % Drops, Suspension Sig: One (1) DROPS Ophthalmic daily (). 3. Pindolol 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 5. Combigan 0.2-0.5 % Drops Sig: One (1) DROP Ophthalmic [**Hospital1 **] (2 times a day). 6. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic QD (). 8. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 12. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for spasms. Disp:*60 Tablet(s)* Refills:*0* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: LUMBAR STENOSIS Discharge Condition: Stable Discharge Instructions: You have undergone the following operation: Lumbar Decompression With Fusion Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Limit any kind of lifting. - Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. - Brace: You do not need a brace - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Followup Instructions: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. [**Telephone/Fax (1) 3736**]. You have a previously scheduled appointment or a ORTHO XRAY on [**2199-5-8**] at 9:40 please call Phone:[**Telephone/Fax (1) 1228**] with questions. You also have an appointment on the same day with DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] on [**2199-5-8**] at 10:00. Please call [**Telephone/Fax (1) 3736**] with questions. Completed by:[**2199-4-29**]

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icd9cm

[ [ [] ] ]

[ "84.52", "84.51", "03.59", "81.06", "77.79", "81.08", "81.62" ]

icd9pcs

[ [ [] ] ]

8374, 8380

4075, 6866

342, 502

8440, 8449

2018, 4052

10277, 10856

1391, 1395

7113, 8351

8401, 8419

6892, 7090

8473, 8551

1410, 1999

8813, 9148

8585, 8795

279, 304

9160, 10254

530, 956

978, 1144

1160, 1375

30,204

172,114

33679

Discharge summary

report

Admission Date: [**2128-7-8**] Discharge Date: [**2128-7-14**] Date of Birth: [**2063-7-24**] Sex: F Service: MEDICINE Allergies: Etomidate / Norpace / Quinidine / Demerol / Penicillins / Lipitor Attending:[**Doctor First Name 1402**] Chief Complaint: Cardiac Tamponade s/p Pulmonary vein isolation Major Surgical or Invasive Procedure: Attempted pulmonary vein isolation Pericardiocentesis History of Present Illness: 64 year-old woman with a long history of paroxysmal atrial fibrillation refractory to mulitple pharmacologic interventions and multiple cardioversions, who presents to the CCU with cardiac tamponade s/p pulmonary vein isolation procedure Past Medical History: Dyslipidemia -Paroxysmal atrial fibrillation -->diagnosed at age 47, has a few episodes per year, which are highly symptomatic: palpitations, flushing & SOB. She has tried quinidine w/o success and disopyramide, which caused polymorphic ventricular tachycardia. -Urethrocele repair in the 60??????s -D&C in [**2120**] -S/P Ganglion cyst repair [**2090**] -Tonsillectomy -Sciatica -S/P L4-L5 fracture approximately 5 years ago Social History: Married. Multiple grown children. Lives in [**Location **]--[**Doctor First Name 77967**]. Retired RN, though still working 1day/wk in [**Hospital **] clinic. Family History: NA Physical Exam: 97.1, 72, 91/66, 15, 100% on RA. Generally, the patient was well developed, well nourished and well groomed. She was oriented to person, place and time. The patient's mood and affect were appropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. Nml JVP. The pericardial drain was in place and draining bloody fluid. The respirations were not labored and there were no use of accessory muscles. The lungs were clear to ascultation bilaterally anteriorly with normal breath sounds. The heart sounds revealed a normal S1 and the S2 was normal. There were no clear rubs, murmurs, or gallops. . There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, clubbing or edema. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [**Known lastname 77968**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77969**]Portable TTE (Focused views) Done [**2128-7-8**] at 1:10:41 PM FINAL Findings PERICARDIUM: Moderate pericardial effusion. RV diastolic collapse, c/w impaired fillling/tamponade physiology. Conclusions There is a moderate sized pericardial effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. C.CATH COMMENTS: 1. Limited resting hemodynamics revealed equalization of RA, RVEDP and pericardial pressure (mean of 19 mmHg). 2. A pericardiocenthesis was performed: 260 cc of bloody fluid was drained with a separation of RA and pericardial pressure (PP down to zero). Pericardial drain was left to gravity. A bedside echocardiogram revealed no residual pericardial effusion. FINAL DIAGNOSIS: 1. Bloody pericardial effusion with tamponade physiology. 2. Successful pericardiocenthesis. ECHO: Overall left ventricular systolic function is normal (LVEF>55%). There is normal right ventricular free wall contractility. The mitral valve leaflets are structurally normal. There is a small loculated pericardial effusion, primarily anterior to the distal RV (with the patient supine). No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Small loculated pericardial effusion without echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2128-7-8**], there has been some, albeit minimal, reaccumulation of the pericardial fluid. RIGHT UPPER QUADRANT ULTRASOUND. COMPARISON: [**2128-7-9**]. HISTORY: Abdominal pain. FINDINGS: The liver demonstrates normal echotexture. There are no focal liver lesions identified. There is no intrahepatic or extrahepatic biliary dilatation. The portal vein is patent with normal hepatopetal flow. The common bile duct measures 3 mm. The gallbladder appears contracted, with extensive gallbladder wall thickening and edema. There is no pericholecystic fluid identified. There is no free fluid. The pancreas is unremarkable. The tail is obscured by the overlying bowel gas. There is no evidence of gallbladder stones. IMPRESSION: 1. Contracted gallbladder with extensive gallbladder wall edema. No evidence of gallbladder stones or pericholecystic fluid. These findings are non specific but may represent chronic cholecystitis. HIDA could be performed for further evaluation. 2. Small right pleural effusion. The study and the report were reviewed by the staff radiologist. ECHO [**7-13**] Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.4 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.2 cm <= 5.0 cm Left Ventricle - Ejection Fraction: >= 60% >= 55% Pericardium - Effusion Size: 0.5 cm Findings Left pleural effusion. This study was compared to the prior study of [**2128-7-12**]. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Increased IVC diameter (>2.1cm) with <35% decrease during respiration (estimated RAP (10-20mmHg). LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Moderate [2+] TR. PERICARDIUM: Small pericardial effusion. No echocardiographic signs of tamponade. Conclusions The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The mitral valve appears structurally normal with trivial mitral regurgitation. Moderate [2+] tricuspid regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2128-7-12**], there is no change in the size of pericardial effusion. Brief Hospital Course: 64 year-old woman with a long history of paroxysmal atrial fibrillation refractory to mulitple pharmacologic interventions and multiple cardioversions, who presents to the CCU with cardiac tamponade s/p pulmonary vein isolation procedure. She underwent an elective PVI procedure using a double transeptal approach to treat her afib on the AM of admission. She seemed to tolerate the procedure well, until the end of it, when she became hypotensive to systolic of 60s (baseline reportedly 90-100s). At the time, her heart rate was in the 60-70s. Pt became nauseous & developed CP. A stat echo showed RV collapsed. HD monitoring showed equilization of pressures and an absent y-descent. [Mean right atrial pressure was 19, RVEDP 20.] She was brought to the cath [**Year (4 digits) **], where 260cc of frank blood was drained from the pericardial space and a drain was placed. The pericardial space was reportedly drained "dry" (pericardial pressure 10-->0-5)and the post-procedure echo showed no significant fluid in the space. Following drain placement, her BP improved to the 90s-100s systolic. Of note, as part of the PVI procedure, the patient was heparinized. Following the procedure, she received protamine 20mg x2. Pt was monitored in the CCU post procedure. Her drain was removed. She was subsequently transitioned back to the general floor and monitored on telemetry and had serial ECHOs. She had some mild epigastric/RUQ pain and RUQ U/S showed gallbladder wall edema, but no gallstones. It was felt this was likely hepatic congestion [**2-28**] volume overload. She was give lasix to diurese her with improvement in her symtoms. In terms of rate control, she was continued on metoprolol at 25mg [**Hospital1 **] and started on Propafenone 225mg sustained release [**Hospital1 **]. In addition, she was anti-coagulated with coumadin. SHe was bridged with heparin initially but discharged with a lovenox bridge and follow up with Dr [**Last Name (STitle) **] for INR check 2 days post discharge. She was also sent home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor and a follow up cardiac MR for 1 month post discharge. Medications on Admission: Toprol XL 50 mg 1 tab in ??????tab in pm ASA 81 mg 1 tab daily Pravastatin 20 mg 1 tab daily MVI 1 tab daily Milk of Magnesia prn Discharge Medications: 1. Outpatient [**Name (NI) **] Work Pt needs INR and electrolytes checked Friday [**7-16**] 2. Coumadin 1 mg Tablet Sig: Five (5) Tablet PO once a day: You will take 5mg per day until you have your labs checked and this may be adjusted accordingly. Disp:*100 Tablet(s)* Refills:*2* 3. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) PO once a day as needed for constipation. 4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Aldactazide 25-25 mg Tablet Sig: one half tablet Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe Subcutaneous [**Hospital1 **] (2 times a day): Continue to take one injection twice daily until your INR is therapeutic; as directed by your cardiologist. Disp:*30 syringe* Refills:*2* 8. Propafenone 225 mg Capsule, Sust. Release 12 hr Sig: One (1) Capsule, Sust. Release 12 hr PO twice a day. Disp:*60 Capsule, Sust. Release 12 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. atrial fibrillaion 2. pericarial effusion/cardiac tamponade s/p complication pulmonary vein isolation . Secondary: -Dyslipidemia -Paroxysmal atrial fibrillation -->diagnosed at age 47, has a few episodes per year, which are highly symptomatic: palpitations, flushing & SOB. She has tried quinidine w/o success and disopyramide, which caused polymorphic ventricular tachycardia. -Urethrocele repair in the 60??????s -D&C in [**2120**] -S/P Ganglion cyst repair [**2090**] -Tonsillectomy -Sciatica -S/P L4-L5 fracture approximately 5 years ago Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for pulmonary vein isolation, which was complicated by cardiac tamponade from possible atrial perforation vs. laceration. You underwent a pericardiocentesis with drain placement. Patient was monitored in the cardiac care unit for two days, echocardiograms were performed, which showed a stable pericardium. The drain was then removed. You were started on a number of new medications. You will take Propafenone 150mg twice daily to control the rhythm of your heart. You were started on aldactazide [**1-28**] tablet daily. You were started on Metoprolol 25mg twice daily You were started on coumadin to thin your blood. You will continue this medication and have your blood checked frequently to monitor the level. In the meantime, you will need to take Lovenox shots until the level of coumadin is therapeutic, as discussed with you during your stay. You will be seen on Friday [**7-16**] to have your [**Month/Year (2) **] values checked. . Please see below for follow up. You will need to see Dr [**Last Name (STitle) **] on Friday in his office. You will have your blood drawn at that visit. In addition, you will wear [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor for 3 weeks. You will then see Dr [**Last Name (STitle) **] back in his office in one month and have an MRI done at that time. You should receive a phone call with the scheduled date of the MRI. . If you acquire chest pain, shortness of breath, nausea, vomiting, or any other concern that is out of the ordinary for you, please call 911 or go to an emergency room. Specifically, if you feel lightheaded, dizzy, or you are showing signs of bleeding, please seek medical attention. Followup Instructions: As agreed upon with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], you are to see him on Friday [**7-16**] and have your labs checked as well. You will also need to see him in 1 months time. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2128-7-16**] 2:20

[ "573.0", "423.9", "276.6", "423.3", "427.31", "998.2", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "37.0", "37.34", "37.21", "37.27" ]

icd9pcs

[ [ [] ] ]

9852, 9858

6399, 8577

373, 429

10458, 10467

2345, 3192

12243, 12595

1338, 1342

8758, 9829

9879, 10437

8603, 8735

3209, 6376

10491, 12220

1357, 2326

287, 335

457, 696

718, 1146

1162, 1322

58,995

195,846

51221

Discharge summary

report

Admission Date: [**2168-3-31**] Discharge Date: [**2168-4-4**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2291**] Chief Complaint: Hypoxemia Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: Mr. [**Known lastname 106273**] is a [**Age over 90 **] yo M with h/o metastatic prostate cancer, hypothyroidism, and diastolic CHF, who was recently discharged from [**Hospital1 18**] in [**2-/2168**] s/p fall and with concern for C1 and C7 fractures, who now presents from [**Hospital1 **] [**Location (un) 620**] with hypoxia and evidence of R-sided pleural effusion on CXR. . The patient was discharged to [**Location (un) **] Independent Living [**2168-2-17**], a skilled nursing facility, and reports that he has had significant difficulty carrying out his activities of daily living, and even taking part in his leisure activities as well. Last night, the patient endorses that his breathing became significantly more difficult, and due to this noticeable shortness of breath, the patient's nurses called an ambulance and had him taken to the [**Hospital1 **] [**Location (un) 620**] ED. . At [**Hospital1 **] [**Location (un) 620**], Mr. [**Known lastname 106273**] had an O2 Sat in the 80s and underwent imaging that showed a large right-sided pleural effusion. The patient was then placed on 2L oxygen by NC and was transferred to [**Hospital1 18**] for further care. . In the [**Hospital1 18**] ED, initial VS were: T 98.4 HR: 88 BP: 97/61 RR: 22 O2Sat: 97 on 3L NC. Due to findings on CXR, the patient was admitted to the MICU for management of his pleural effusions (which have shown to be malignant effusions in the past), given that the Interventional Pulmonart team was unable to perform the procedure this evening. . On arrival to the MICU, patient's VS were: T 98.3 HR: 90 BP: 110/57 RR: 22 O2Sat: 97 on 3L NC. The patient had no other concerns or complaints. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1) Prostate cancer w known metastases to ribs and lungs, s/p prostatectomy and XRT to ribs ([**2163**]) 2) Recent C1 and C7 Fractures in [**2-/2168**] 3) Diastolic CHF (EF >50% per recent echo at DCFI) 5) HTN 6) Hypothyroidism 7) BPV 8) H/O cataract surgery 9) H/O shoulder pain 10) Appendectomy Social History: He lives at [**Location (un) **] Independent Living. He quit smoking 20 years ago; prior to that 2 packs a day for 30 years. Occasional social drinker. Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== . Vitals: T 98.3 HR: 90 BP: 110/57 RR: 22 O2Sat: 97 on 3L NC Constitutional: AOx3, Comfortable HEENT: Normocephalic, atraumatic Chest: Decreased breath sounds at the right base compared to the left, crackles on the left Cardiovascular: Regular Rate and Rhythm, [**1-18**] Ejection Murmur appreciated in the RUSB, [**1-18**] Holosystolic Murmur at the Apex Abdominal: Soft, ND, Tender to Deep Palpation in the RUQ GU/Flank: No costovertebral angle tenderness Extr/Back: Warm, Well-Perfused, Trace Pitting in the Lower Extremities Skin: No rash . DISCHARGE PHYSICAL EXAM: ======================== . Pertinent Results: ADMISSION LABS: =============== . [**2168-3-31**] 10:27PM BLOOD WBC-4.5# RBC-3.08* Hgb-9.9* Hct-30.5* MCV-99* MCH-32.2* MCHC-32.5 RDW-16.2* Plt Ct-140* [**2168-3-31**] 10:27PM BLOOD Neuts-62 Bands-11* Lymphs-14* Monos-10 Eos-1 Baso-1 Atyps-1* Metas-0 Myelos-0 [**2168-3-31**] 10:27PM BLOOD PT-13.8* PTT-27.8 INR(PT)-1.3* [**2168-3-31**] 10:27PM BLOOD Glucose-93 UreaN-26* Creat-0.8 Na-136 K-3.8 Cl-95* HCO3-37* AnGap-8 [**2168-3-31**] 10:27PM BLOOD Calcium-8.8 Phos-3.1 Mg-1.7 . DISCHARGE LABS: =============== . . MICRO/PATH: =========== . [**2168-4-2**] SPUTUM GRAM STAIN: Inadequate sample [**2168-4-1**] GRAM STAIN (Final [**2168-4-1**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [**2168-4-1**] BLOOD CULTURE: NGTD [**2168-4-1**] BLOOD CULTURE: NGTD [**2168-4-1**] Cytology PLEURAL FLUID pending . IMAGING/STUDIES: ================ . [**2168-4-3**] Radiology CHEST (PORTABLE AP: IMPRESSION: Compared with [**2168-4-1**] at 19:17 p.m., a tiny curvilinear density at the right lung apex is again noted. I doubt, but cannot entirely exclude, a tiny right apical pneumothorax. No interval change is identified. Otherwise, no significant change is detected. Again seen is prominent cardiomediastinal silhouette; R>L effusions with underlying collapse and/or consolidation; unusual appearance to the right posterior ribs and right chest wall, unchanged. Bilateral effusions are grossly stable in size. . [**2168-4-1**] Radiology CHEST (PORTABLE AP): IMPRESSION: 1. Bilateral effusions and parenchymal changes essentially unchanged compared with earlier the same day. 2. Possible tiny right apical pneumothorax. 3. Abnormal increased density along right chest wall is unchanged, but of uncertain etiology. If clinically indicated, CT could help to further characterize this abnormality. 4. Poor visualization of the right posterior fifth and sixth ribs. Has there been prior surgical resection? Otherwise, rib lesions would be suspected. . [**2168-4-1**] Radiology LIVER OR GALLBLADDER US: IMPRESSION: -No biliary dilatation is seen. Cholelithiasis. There are no specific signs of cholecystitis or other sources of infection -Bilateral pleural effusions and trace ascites -Splenomegaly -Simple right renal cysts . [**2168-4-1**] Radiology CHEST (PORTABLE AP): IMPRESSION: Moderate right pleural effusion has markedly decreased in amount. There is no evident pneumothorax. There are persistent low lung volumes. A small left pleural effusion has increased. Left lower lobe and left mid perihilar opacities have increased since [**2-14**], unchanged from the prior study, could be worsening atelectasis and pleural effusion, but superimposed infection cannot be excluded. Opacity in the right lower lobe is a combination of pleural effusion and adjacent consolidation, could be atelectasis and/or pneumonia. The patient has known osseous mets. . [**2168-3-31**] CHEST (PORTABLE AP): IMPRESSION: Large right pleural effusion has recurred, displacing the mediastinum slightly to the left of midline. Osseous metastasis involving right ribs are longstanding. Heart is at least mildly enlarged and there is some engorgement of the vessels in the left lung. . Brief Hospital Course: Mr. [**Known lastname 106273**] is a [**Age over 90 **] yo M with h/o metastatic prostate cancer, hypothyroidism, and diastolic CHF, who was recently discharged from [**Hospital1 18**] in [**2-/2168**] s/p fall and with concern for C1 and C7 fractures, who now presents from [**Hospital1 **] [**Location (un) 620**] with hypoxia and evidence of R-sided pleural effusion on CXR now s/p thoracentisis with possible HCAP. ACTIVE DIAGNOSES: ================= #) HYPOXEMIA/PLEURAL EFFUSION/CONCERN FOR HCAP: Patient was admitted to the MICU with recurrent R-sided pleural effusion with hypoxia requiring no more than 4LNC. Thoracentesis was performed at bedside with drainage of 1.5L of fluid with negative gram stain, exudative chemistry, and lymphocyte predominance with cytology pending at the time of discharge though overall felt to be c/w prior malignant pleural effusion. His breathing improved and he felt clinically well but was occasionally hypotensive to as low as the 70's systolically, asymptomatic the whole time. Additionally, despite not having fevers, elevated lactate or a white count, he had a significant bandemia which was new for him and not felt to be related to his chemotherapy drug (not a listed side effect) or his steroids which generally cause demargination of mature neutrophils. As a result, he was started on vanc/zosyn/azithro for HCAP coverage for a plan of 8 total days. As part of the infectious workup, he underwent RUQ U/S which showed no evidence of cholecytitis. After discussion with [**Female First Name (un) **], his daughter/HCP, the decision was made not to escalate care and to avoid invasive procedures such as PICC placement for IV antibiotics or initiation of pressors. As his blood, urine, and sputum studies were negative, and pulmonary was the only organ system that could possibly be involved, he was discharged with four more days of PO levaquin to finish an 8 day course. The plan was to forego further thoracentesis in the future if and when these effusions recur and to instead treat them symptomatically with diuretics and opiates. # ASYMPTOMATIC HYPOTENSION: Patient was intermittently hypotensive to as low as the 70's systolically without tachycardia and without symptoms. On discussion with his daughter, it was determined that he has blood pressures that are this low and asymptomatic at rehab. He was administered albumin following his thoracentesis with improvement in his pressures. As the patient is a chronic prednisone patient an AM cortisol was checked and 15 and he was continued on his 5mg prednisone daily. Home antihypertensives were initially held but were restarted at discharge. # Goals of Care: The patient and his HCP/daughter expressed their desire not to escalate care with invasive procedures such as central lines, picc lines, or pressors as patient is in the process of transitioning to hospice. He also expressed a wish to no longer be hospitalized. He is a DNR/DNI/DNH and should be provided care that is only oriented towards comfort. CHRONIC DIAGNOSES: ================== #) DIASTOLIC CHF: The patient was diagnosed from an ECHO in [**2163**], but also had an ECHO at DCFI for concern that his chemotherapy regimen was causing cardiomyopathy, however there was no evidence of cardiomyopathy and his EF was > 50%. Furosemide was held for hypotension while in the MICU, and restarted at discharge when his pressures could tolerate it for symptomatic management of his effusions. #) PROSTATE CANCER: Pt has known prostate cancer metastatic to ribs and lungs, with documented malignant effusion on [**6-22**] and [**2-22**]. He has been off chemotherapy since [**3-28**] with no plans to resume. He is on prednisone as per his oncologist's recommendations for appetite and bony pain. #) INSOMNIA: Patient had problems with insomnia during his stay. Trazodone was added to his current regimen of oxycodone and mirtazapine. #) HYPOTHYROIDISM: Continued home Levoxyl 100mg PO daily. TRANSITIONAL ISSUES: ==================== Patient and family are interested in focusing on symptom management and avoiding future hospitalization. He will be followed by the palliative care service at his [**Hospital1 1501**]. He is a DNR/DNI and DNH at this point forward with comfort measures only. . Blood cultures and pleural fluid cultures are still pending final results at time of discharge, although there is no growth to date. Medications on Admission: 1) Zytiga 4 pills daily (chemo) ****stopped [**3-28**] 2) Prednisone 5 mg daily 3) Levothyroxine 100 mcg daily 4) ASA 81 mg every other day 5) Furosemide 20 mg daily 6) Mirtazipine 15 mg daily 7) Vit D3 Senacot 8) Sorbitol 70% 30mL [**Hospital1 **] 9) Multivitamin 10) Acetaminophen 650 [**Hospital1 **] 11) Senna 2 tabs [**Hospital1 **] 12) Bisacodyl 10mg suppository daily 12) Oxycodone 2.5mg Daily 13) Oxycodone 2.5mg Q4H PRN 14) Milk of mag 30ml daily PRN Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 5. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO twice a day. 6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)). 9. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. 11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every other day. 12. Vitamin D3 400 unit Tablet Sig: Two (2) Tablet PO once a day. 13. sorbitol 70 % Solution Sig: Thirty (30) mL Miscellaneous twice a day as needed for constipation. 14. multivitamin Tablet Sig: One (1) Tablet PO once a day. 15. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO once a day as needed for constipation. 16. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Tablet(s) Discharge Disposition: Extended Care Facility: [**Location (un) **] - [**Location (un) 620**] Discharge Diagnosis: PRIMARY Pleural effusion, likely malignant Metastatic prostate cancer SECONDARY Hypertension Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 106273**], You were admitted to [**Hospital1 18**] for shortness of breath and were found to have fluid around your lung. The fluid was removed and your breathing improved. You were initially started on antibiotics but as samples of the fluid did not grow any bacteria we stopped these at the time of discharge. You will be going back to your facility to focus on controlling your pain and shortness of breath. The following medications were changed during this hospitalization: START Trazodone 50mg every night to help you sleep. You can take this in addition to your nighttime dose of oxycodone. Levoquin 750mg by mouth once per day for 4 more days (last day [**4-8**]) Followup Instructions: You will follow-up with the doctors at your facility who will continue to manage your pain, shortness of breath, and insomnia.

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icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

13270, 13343

7047, 7467

261, 276

13495, 13495

3612, 3612

14404, 14533

2912, 2930

11966, 13247

13364, 13474

11481, 11943

13677, 14381

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2970, 3540

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211, 223

304, 1986

3628, 4091

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13510, 13653

7485, 11017

2427, 2724

2740, 2896

4497, 4508

3565, 3593

81,443

122,727

16771

Discharge summary

report

Admission Date: [**2111-2-11**] Discharge Date: [**2111-2-13**] Date of Birth: [**2056-9-21**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5606**] Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 54M with insulin dependent DM and h/o DKA presented to [**Hospital1 **] after two days of vomiting, transferred to MICU in setting of persistent anion gap. . Per report patient presented to [**Hospital3 4107**] with chief complaint to nausea/vomiting x2 days. He reported flu like symptoms 2 weeks prior to admission and general malaise since that time. There FS 460, AG 31, Lactate 11, K 3.8. Started IVFs and insulin gtt. LFTs elevated (300s/400s, T bili 3).RUQ U/S which was negative for acute process. Patient had transient CP on arrival at [**Hospital1 **], but resolved w/o intervntion. Referral states patient was hypoxic to 68% when sleeping. On arrival here, removed from O2 and pt c/o SOB but )2 sat 98%. HR initially 130s --> 105 with IVFs. . In the ED, 99.1 114 115/62 16 100% 4L. EKG: sinus tach at 124, NA, NI, QTc 456, diffuse ST depression c/w rate related ST changes. CBC: 8.5/31.2/108; Chem: 136/3/96/22/0.9/80; AG 18/ Lactate 2.6. Patient continued on IV insulin as well as IVF. FS in 90s so started on D50. Repeat FS: 70s; ordered to D10W with 20mEq of K. Concern for reversion to DKA prompted presentation to the MICU. . Of note patient has h/o alcoholic hepatitis, - patient denies h/o alcohol related liver disease, states he used to drink more heavily (2 or 3 times per week) but did become tremulous when he stopped drinking. Last drink Friday. On arrival to the MICU, pt is still complaining of nausea. Past Medical History: hx B/L SDHs hx EtOH withdrawl seizures hx EtOH cirrhosis IDDM c/b hypoglycemia HTN HLD Intention tremors Social History: Mr. [**Known lastname 47374**] moved to the US from [**Location (un) 4708**] 14 years ago. He attended college but never obtained a degree and currently owns and works in a Lil Peach store. He has prior hx smoking and quit in [**2078**]. Previously he drank 3-4 beers 3-4 times a week. Has prior hx drinking daily since [**2101**]. Reports he had stopped drinking x4 months, but recently has been drinking 1-1.5L vodka daily. He has two children (daughter is [**Name (NI) **] and next of [**Doctor First Name **]) and lives with his son and wife [**Name (NI) 47375**]. Denies any illicit drug use or history of IVDU. Family History: Mr. [**Known lastname 47376**] mother had HTN and his father had DM. No family history of cancer. Physical Exam: Physical Exam on admission: Vitals: T: Afebrile BP: 130/58 P: 75 R: 18 O2: 98% on RA General: Alert, oriented, 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, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Labs on admission: [**2111-2-11**] 01:35AM BLOOD WBC-8.5 RBC-3.53* Hgb-11.4* Hct-31.8* MCV-90 MCH-32.4* MCHC-36.0*# RDW-13.6 Plt Ct-102*# [**2111-2-11**] 05:02AM BLOOD PT-12.0 PTT-27.5 INR(PT)-1.1 [**2111-2-11**] 01:35AM BLOOD Glucose-80 UreaN-10 Creat-0.9 Na-136 K-3.0* Cl-96 HCO3-22 AnGap-21* [**2111-2-12**] 02:36AM BLOOD ALT-112* AST-147* AlkPhos-214* TotBili-1.8* [**2111-2-13**] 06:50AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8 [**2111-2-12**] 02:36AM BLOOD Calcium-7.4* Phos-2.1* Mg-1.8 [**2111-2-11**] 01:35AM BLOOD ALT-165* AST-259* AlkPhos-275* TotBili-2.4* [**2111-2-11**] 01:35AM BLOOD cTropnT-<0.01 [**2111-2-11**] 01:48AM BLOOD Lactate-2.6* [**2111-2-11**] 05:06AM BLOOD Glucose-93 Lactate-2.2* K-3.2* Labs on discharge: Microbiology: [**2111-2-11**] 4:43 am URINE Source: CVS. **FINAL REPORT [**2111-2-12**]** URINE CULTURE (Final [**2111-2-12**]): <10,000 organisms/ml Blood cx [**1-/2028**]: Negative Brief Hospital Course: 54 yo M with insulin dependent DM and a h/o DKA who presented to [**Hospital3 **] after two days of vomiting, admitted for treatment of DKA. # Diabetic Ketoacidosis: Pt presented with AG of 31, lactate of 11 in the settting of nausea/vomiting and hyperglycemia. Both lactic acidosis and DKA were potential etiologies of his elevated anion gap. His anion gap closed with IVF and IV insulin adminsitration by time he was admitted to the MICU. Once his glucose was below 200 D5W was started along with the insulin gtt. His insulin gtt was weaned on his first day in the MICU and he was restarted on his insulin pump by [**Last Name (un) **]. The most likely etiology of his DKA was a viral infection leading to nausea and vomiting as there was no clear source of urinary or pulm infection and no cardiac ischemia was present. #Alcohol withdrawal prophylaxis: Pt with a h/o alcohol withdrawal seizures, last reported drink was 4 days prior to admission. He was placed on po lorazepam q2h prn CIWA>10 on arrival to the ICU and was administered thiamine, folate and multivitamin. He did not show signs of withdrawl during his hospitalization. He was counseled to abstain from alcohol given his history. #HTN: pt is normotensive on arrival. We continued lisiniopril #HLD: continued simvastatin 20 mg daily. Held on discharge due to elevated LFTs. TRANSITIONAL -- Simvastatin was held on discharge due to elevated LFTs but can be restarted if LFTs normalize. Medications on Admission: insulin lispro [Humalog] 100 unit/mL Cartridge 0.8 units basal rate sliding scale (Prescribed by Other Provider) [**2110-4-16**] lisinopril Dosage uncertain omeprazole 40 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by mouth once daily simvastatin Dosage uncertain nr subcutaneous insulin pump [Insulin Pump IR1250] aspirin 81 mg Tablet, Delayed Release (E.C.) 1 (One) Tablet(s) by mouth once a day cyanocobalamin (vitamin B-12) [Vitamin B-12] folic acid potassium Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. insulin lispro 100 unit/mL Cartridge Sig: Subcutaneous once a day: per insulin pump instructions. 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 9. potassium chloride Oral Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 47374**] You were admitted to the hospital with high blood sugars, which lead to a condition called Diabetic Ketoacidosis. It is important that you monitor your sugars regularly, and be particularly careful when you feel you are getting sick. Followup Instructions: Department: Primary Care Name: Dr. [**Last Name (STitle) 47377**] [**Name (STitle) **] When: Please call the office number listed below to schedule a hospital follow up appointment 4-8 days after your hospital discharge. Location: [**Hospital3 **] MEDICAL ASSOCIATES Address: [**Street Address(2) 17502**], [**Location (un) **],[**Numeric Identifier 17464**] Phone: [**Telephone/Fax (1) 17503**] Department: Endocrinology- [**Last Name (un) **] Diabetes Center Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11712**], Nurse Practitioner When: Tueaday [**2111-2-17**] at 4:00 PM Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3402**] The above appointment is with [**Last Name (un) **] in [**Location (un) 86**]. If you would like to transition your care to closer to home, please call: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47378**] (Endocrinology) Phone: [**Apartment Address(1) 47379**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**Numeric Identifier 2876**] You can say Dr. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 818**] recommended you follow there.

[ "250.13", "303.90", "V58.67", "333.1", "571.2", "401.9", "272.4", "287.5", "571.1", "487.1", "V15.82", "284.19", "V45.85" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7036, 7042

4368, 5832

324, 331

7107, 7107

3387, 3392

7547, 8823

2574, 2673

6349, 7013

7063, 7086

5858, 6326

7257, 7524

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265, 286

4118, 4345

359, 1792

3407, 4098

7122, 7233

1814, 1921

1937, 2558

6,772

146,435

7923

Discharge summary

report

Admission Date: [**2121-3-8**] Discharge Date: [**2121-3-14**] Date of Birth: [**2056-8-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: change in mental status Major Surgical or Invasive Procedure: Intubation Central line placement History of Present Illness: 64F with breast CA s/p mastectomy 17y ago with local recurrence leading to paralysis of L arm ~5-6y ago. Now declining gradually since [**Month (only) 404**] (30 lbs weight loss, becoming more confused, decreased appetite). Patient declined workup/imaging for mets as outpatient. Moving toward home hospice. Over the last 2 weeks, husband reports patient becoming increasingly weak, unable to leave bed, confused, unable to feed herself. Seen by VNA and noted to be tachycardic and sent to [**Hospital3 7571**]for evaluation. Now sent in to [**Location (un) **] by VNA because of asymptomatic sinus tachycardia. Transferred here for workup for CNS mets and admission. . In ED, VS - 99.6, 135, 122/65, 20. Neurology evaluated pt and felt to have intact brainstem reflexes but poor prognosis. Neurosurg evaluated pt and felt to not be surgical candidate; recommended dilantin load and decadron. Received lorazepam prior to CT scan. Intubated for MS changes and lethargy and concern for airway protection. Post intubation, hypotensive and started on dopamine and transitioned to levophed. Received vancomycin/levafloxacin at OSH. Received metronidazole at ED in [**Hospital1 18**]. . In MICU, pt. responsive to noxious stimuli only. History obtained from husband as above. . . Past Medical History: PMHx: 1. Left breast status post radical mastectomy in [**2102**] with adjuvant Tamoxifen for five years. This was followed by later development of lymphedema and left arm (distal>proximal) weakness due to metastatic disease in left axilla ensheathing nerve plexus. Treated with course of local XRT in [**Hospital1 189**] and Tamoxifen. Switched to Arimedex in [**11/2119**] due to vaginal bleeding on Tamoxifen. Self discontinued Arimedex last month. No prior history of intracranial disease. 2. Metastatic disease in left arm, brachial plexus resulting in left arm paresis, as above Social History: Married, lives with husband. [**Name (NI) **]'t worked since [**2108**], prior to that worked in a school cafeteria. +children (husband [**Name (NI) 15598**]'t quantify). Social smoker in her youth. Distant smoking history. Occasional alcohol use. Family History: Maternal aunt with breast cancer. Mother aged 85, alive and well. Three healthy siblings. Father deceased from complications from MS. . Physical Exam: T 99.8 HR 124 SBP 135/58 RR 16 Ox 100 Gen: Cachectic, lays with eyes closed. HEENT: Temporal wasting. NC/AT. Anicteric. Mucosa dry. Neck: Supple. Lungs: Clear anterolaterally. No R/R/W. Cardiac: Tachycardic, regular. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Wasted. Legs are rigid. Pertinent Results: Head CT There is diffuse metastatic disease. Three discrete lesions are seen within the left frontal, right occipital, and left parietal lobes with significant surrounding vasogenic edema. The largest single lesion measures 3.7 x 3.4 cm. There is moderate surrounding edema with 10 mm rightward shift of the normally midline structures with associated mass effect on the lateral ventricles. The basilar cistern is preserved and there is no uncal herniation. The osseous structures are unremarkable. The paranasal sinuses and mastoid air cells are well aerated. . CT torso 1. Right middle lobe lung nodule, suspicious for metastatic disease. 2. Right upper lobe lung opacities which appear confluent, most suggestive of infectious etiology, however, cannot entirely exclude metastatic lesions. Recommend follow up CT to ensure resolution. 3. Multiple hypodense liver lesions which are mildly enhancing, most consistent with metastatic disease. 4. Bilateral small pleural effusion, which certainly could be malignant given today's findings and history of breast cancer. 5. No evidence of bony metastases. 6. Uterine cavity fluid of unclear etiology. . Brief Hospital Course: Metastatic breast CA - Large brain mets with midline shift. Intubated for airway protection. Treated with IV dilantin and decadron. Patient mental status improved slightly. After discussion with primary oncologist goals of care where change to comfort. Dilantin was stopped. Will go home with prn morphine, ativan, and PR decadron. . Pnuemonia - Possible aspiration. Completed a 7 day course of vancomycin and levofloxacin. Medications on Admission: none Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-20 mg PO Q1-2H () as needed for pain. Disp:*30 ml* Refills:*0* 2. Lorazepam 0.5 mg Tablet Sig: 0.5-2 mg PO Q4-6H (every 4 to 6 hours) as needed for aggitation/seizure: Please dispense liquid. Disp:*50 ml* Refills:*0* 3. Dexamethasone 4 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours): please give 8mg suppository. Disp:*90 suppository* Refills:*0* Discharge Disposition: Home With Service Facility: Home Health Hospice Discharge Diagnosis: Breast cancer Discharge Condition: Stable Discharge Instructions: Please call hospice for questions. Followup Instructions: as needed Completed by:[**2121-3-14**]

[ "198.3", "344.40", "197.0", "V10.3", "276.52", "790.7", "507.0", "198.89", "197.7", "263.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "96.71", "00.17" ]

icd9pcs

[ [ [] ] ]

5160, 5210

4251, 4676

337, 373

5268, 5277

3074, 4228

5360, 5401

2576, 2714

4731, 5137

5231, 5247

4702, 4708

5301, 5337

2729, 3055

274, 299

402, 1685

1708, 2295

2311, 2560

68,870

111,943

1837

Discharge summary

report

Admission Date: [**2158-10-6**] Discharge Date: [**2158-10-19**] Date of Birth: [**2089-11-8**] Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3645**] Chief Complaint: lower back pain and hip pain Major Surgical or Invasive Procedure: Posterior surgical fusion T9-L1 with anterior column reconstruction at T11 level History of Present Illness: A 68 year-old female with history of bilateral breast cancer and metastatic kidney cancer, with extensive osseous and pulmonary metastases presented with chronic and acute lower back pain and hip pain. She has chronic lower pain and b/l hip pain for 2 years. The pain has gotten worse over the past one month. The pain was constant and [**10-23**] in intensity. Any movement would aggravate the pain and only pain med would relieve the pain. Because of the pain, she underwent a CT of abd and pelvis on [**2158-10-4**], which found that dramatic increase in overall tumor burden and metastatic disease at T11/T12 results in focal spinal instability with a invasion of the spinal canal with nearly 50% canal narrowing and greater than 50% vertebral body involvement. She denied focalized weakness, numbness, fecal or urine incontinence, buttock area numbness, or urine retention. However, she has constipated over the past one week. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: ONCOLOGIC HISTORY: [**2142-6-26**]: left nephrectomy for 11 cm clear cell renal cell carcinoma [**2155-3-15**]: diagnosted with bilateral breast cancer (node-positive on left, ER/PR positive, HER-2 negative). Treated with neoadjuvant dose-dense AC and weekly taxol ending [**2155-10-3**], bilateral mastectomy [**2155-12-25**] (after lumpectomy with positive margins), radiation ending [**3-22**]. On arimidex since completion of chemotherapy. [**2156-7-14**]: CT torso (done because of elevated alk phos) showed 1.5 and 0.6 cm left upper lobe nodules. [**2156-8-26**]: Left upper lobectomy showed two foci of clear cell renal cell carcinoma. [**2157-5-4**]: MRI of T/L spine with disease at T10, T11 vertebral bodies, soft tissues T10-T12, and L3 body. CT-guided biopsy consistent with renal cell carcinoma. Bone scan [**2157-4-18**] also showed involvement of several left ribs. Subsequently received XRT to thoracic spine. [**5-/2157**]: Began sunitinib; dose reduced over time to 25 mg because of toxicities. Sutent ended in [**2158-1-14**] because of disease progression. [**2158-2-7**]: MRI L-spine with T11 disease with persistent mass effect on thecal sac but no significant cord compression, and T9 and T10 disease, all likely unchanged. New T12 compression fracture. Significant progression of L3 vertebral body lesion with pathologic fracture and retropulsion of posterior cortex. [**2158-2-13**]: CT torso with interval marked progression of innumerable pulmonary mets since [**2157-8-2**]. Destructive lytic lesion within left femoral head. [**2158-2-14**]: XRT to lumbar spine [**2158-4-12**]: signed consent for 08-184 trial of avastin and temsirolimus. CT torso showed osseous mets in spine and left ribs, with interva lincrease in size in soft tissue component at T11 encasing thecal sac, invading cord, and invading more than 50% of the spinal canal. At L3, compression fracture with soft tissue component extending into spinal canal. Increase in number and size of numerous pulmonary mets bilaterally. Destructive lytic lesion within left femoral head. [**2158-4-19**]: C1D1 08-184 (avastin/temsirolimus) [**2158-6-7**]: CT torso with significant decrease in size of bilateral pulmonary lesions and stable osseous disease with decrease in soft tissue mass at T11 - [**Date range (3) 10263**]: admitted for PNA, mental status changes, found to have frontal CVA, taken off study - [**2158-8-9**] CT TORSO: stable disease Other Past Med Hx: - Hypertension - Breast Cancer s/p resection - gout Social History: She lives with her 3 sons who assist with her medical care. She used to work at [**Hospital3 2568**] in the GI division. She is a non-smoker, no alcohol or other drugs. Family History: Father had esophageal cancer. Her maternal grandmother had breast cancer in her 70s. Physical Exam: Vitals: 98.2 99 132/73 18 97% General: AAOX3 NAD HEENT: NC/AT, EOMI, anicteric, slightly dry MM, chin-to-chest normal motion and not painful CV: RRR, nl s1/s2, no m/r/g Lungs: clear to auscultation bilaterally without rales or rhonchi Abdomen: + bowel sounds, nondistended, no tenderness to palpation, no organomegaly appreciated Extremities: no edema or rash Neurologic: A&OX3, CN II-XII grossly intact. However, due to the pain, other neurologic exam wa sunable to performed Psych: appropriate, pleasant, cooperative Pertinent Results: [**2158-10-6**] 09:29PM GLUCOSE-100 K+-3.9 [**2158-10-6**] 09:20PM GLUCOSE-105* UREA N-10 CREAT-1.0 SODIUM-134 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-15 [**2158-10-6**] 09:20PM estGFR-Using this [**2158-10-6**] 09:20PM WBC-5.6 RBC-3.99* HGB-11.6* HCT-34.0* MCV-85 MCH-29.0 MCHC-34.0 RDW-17.4* [**2158-10-6**] 09:20PM NEUTS-83.9* LYMPHS-8.4* MONOS-6.2 EOS-1.0 BASOS-0.5 Ct of the abd on [**2158-10-4**]: Dramatic increase in overall tumor burden, including increase in size and number of numerous pulmonary nodules, and increased size of destructive bony lesion and soft tissue metastases. Metastatic disease at T11/T12 results in focal spinal instability with a invasion of the spinal canal with nearly 50% canal narrowing and greater than 50% vertebral body involvement, placing the patient at high neurological and pathologic fracture risk. A large right femoral head mass is at increased risk for pathologic fracture as well. [**2158-10-8**] skeletal survey:[**10-9**]: MRI shows cord compression. ortho spine will pursue surgery on wednesday. pt states pain control improved but not optimal. pall care came by and meds adjusted. toradol stopped, deemed not safe for pt with one kidney. stopped ASA in prep for surgery. [**10-10**]: pall care came by again in AM and uptitrated pain meds. pt reports in PM it is better. surgery plan for tomorrow. Final MRI read in and shows cord compression. neuro exam stable. [**2158-10-8**] MRI T- and L-spine:1. Heterogenous expansile lesion invlolving T11 vertebral body and posterior elements. There is posterior epidural soft tissue noted at this level which along with retropulsion of vertebral body causes compression of the spinal cord at this level. There is increase in the amount of compression of the vertebra as compared to the prior study, with increased epidural soft tissue and increased spinal canal stenosis. 2. Hyperintense signal in the spinal cord extending from T3-T12, which likely represent syrinx and is unchanged since the prior study. 3. Heterogenous lesion in the posterior elements of T12 vertebra on the left side with associated periosseous soft tissue. Hypointense lesion in C6 vertebral body. These are new since the prior study. 4. Decreased height of L3 vertebral body with biconcave shape. There is retropulsion of the vertebral body causing moderate spinal canal stenosis and indentation of the ventral thecal sac. 5. Multiple nodules in bilateral lung fields suggestive of metastases. Brief Hospital Course: A 68 year-old female with history of bilateral breast cancer and metastatic kidney cancer, with extensive osseous and pulmonary metastases presented with chronic and acute lower back pain and hip pain found to have metastatic bone disease. # Bony Mets: pt was admitted for pain crisis and found to have extensive bony lesions in the spine and femur, likely secondary to known renal carcinoma. No focal neurologic deficits. MRI and skeletal survey were ordered and pt was found to have cord compression near T11-T12. Skeletal survey also showed metastatic disease in T11, T12, L3 and lungs bilaterally. Pt was started on dexamethasone for cord compression protocol. Sliding scale insulin and GI prophylaxis with raniditine were also started. Ortho spine and rad/onc were consulted consulted and decision was made to pursue surgery of spine for decompression. Ortho Spine team wanted embolization of tumor prior to procedure so pt underwent Angio on [**2158-10-11**]..... # Pain Crisis: palliative care was consulted to assist in pain control after several days of difficulty controlling pain. Pt was satisfied with regimen of neurontin and oxycontin standing, with oxycodone for breakthrough and dilaudid for refractory pain. # HTN: continued home valsartan # Anemia: likely secondary to underlying cancer. Hct was near baseline and remained stable. Medications on Admission: anastrozole 1 mg Tab 1 Tablet(s) by mouth once a day Diovan 160 mg Tab 1 Tablet(s) by mouth once a day hold for bp < 110 ondansetron 4 mg Tab, Rapid Dissolve 1 Tablet(s) by mouth every 8 hours as needed for nausea aspirin 81 mg Chewable Tab 1 Tablet(s) by mouth daily acetaminophen 325 mg Tab 1 Tablet(s) by mouth every 6 hours Ativan 0.5 mg Tab [**1-15**] Tablet(s) by mouth three times a day as needed for anxiety do not drive while taking this medication simvastatin 10 mg Tab 1 Tablet(s) by mouth once a day prochlorperazine maleate 10 mg Tab 1 Tablet(s) by mouth every six (6) hours as needed for nausea/vomiting docusate sodium 100 mg Cap 1 Capsule(s) by mouth levothyroxine 50 mcg Tab 1 Tablet(s) by mouth once a day OxyContin 10 mg 12 hr Tab 2 Tablet(s) by mouth twice a day oxycodone 5 mg Tab 1 Tablet(s) by mouth every 4 hours as needed for pain Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: Unstable T11 Spinal metastasis 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 have undergone the following operation: Thoracic/Lumbar Decompression With Fusion Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Limit any kind of lifting. - Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. - Brace: You may have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. o We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity: Activity: Activity as tolerated tid Pneumatic boots per pt Treatments Frequency: dressing can be changed PRN when wet to dry sterile dressing Followup Instructions: Brain [**Hospital 341**] Clinic Date: [**2158-10-30**] Phone: ([**Telephone/Fax (1) 6574**] Please call the Spine Care Clinic and make a follow up appointment for two weeks at [**Telephone/Fax (1) 3736**] Completed by:[**2158-10-19**]

[ "336.3", "338.3", "E870.0", "285.22", "338.19", "997.09", "V49.86", "V10.3", "198.5", "733.13", "293.0", "349.31", "274.9", "V10.52", "244.9", "724.01", "401.9", "564.00", "197.0" ]

icd9cm

[ [ [] ] ]

[ "80.99", "84.51", "83.21", "88.48", "88.44", "81.04", "81.63", "03.59", "39.79", "81.05" ]

icd9pcs

[ [ [] ] ]

10101, 10201

7820, 9182

338, 421

10276, 10276

5303, 7797

13090, 13327

4654, 4741

10222, 10255

9208, 10078

10452, 10541

4756, 5284

12909, 12983

13005, 13067

12382, 12891

10577, 10807

1408, 1917

270, 300

11344, 12370

449, 1389

10291, 10428

1939, 4450

4466, 4638

82,320

192,604

37606

Discharge summary

report

Admission Date: [**2176-1-23**] Discharge Date: [**2176-1-26**] Date of Birth: [**2134-1-13**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 348**] Chief Complaint: EtOH withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: 42M with PMH of ETOH and klonopin abuse, h/o of severe withdrawls DTs, self reported seizures admitted from the ED secondary to frequent triggering of CIWA. Last drink at 6PM on [**2176-1-22**]. Last Klonopin one week ago. Drinks 2 pints of vodka daily for last 1.5 years prior to that drank slightly less. Reports worsening N/V over last week preventing him from drinking his usual 2 pints. Billous, non bloody. . Of note patient endorses recent self limited BRBPR three weeks ago. No Blood/melena currently. No Abdominal pain or fullness. . . In the ED, initial vs were 97.4 100 161/76 16 100%. The patient was asking for help getting alcohol detox. He was noted to be hypertensive and tremulous. He briefly responded to 10MG IV valium Q 1.5 hours. However triggered too frequently for the floor. His mental status remained pristine throughout. He also received zofran and compazine for nausea and protonix for unclear reasons. It is unclear if the patient received a banana bag. . On the floor, pt is alert and oriented but notably tremulous. No c/o pain/SOB/CP. Reports nausea is under control with compazine. He endorses recent excedrin use last night, however denies chronic use or use of other pain/cold meds. Past Medical History: # Stroke in [**2168**] # HCV # EtOH abuse - Since age 12. Currently drinking [**1-28**] to 1 liter of vodka daily. # history of seizure "10 or 15 when I quit drinking" # Polysubstance abuse - per [**Hospital1 **] admit note, pt is s/p inpt detox at BayRidge in [**Location (un) **] in [**9-4**], relapsed nearly immediately with percocet and EtOH. Remote history of IVDU and Cocaine. Currently denying any use of any illicits. # BRBPR in the setting of Detox in [**10-5**] with polyp and internal hemerhoids Social History: See above with substance abuse details. Completed 11th grade. Currently unemployed living in shelter in [**Location (un) **] Family History: Bipolar d/o in mother, colon cancer diagnosis in brother at age 40 Physical Exam: On admission to the MICU: 95.8 (post cold water) T: BP: 125/70 P: 81 R:24 O2: 96% General: Somewhat sedated bu AAOX3. NAD. Visibly tremulous HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, No Hepatosplenomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: On admission: [**2176-1-23**] 09:20AM BLOOD WBC-8.1 RBC-4.87 Hgb-15.2 Hct-43.8 MCV-90 MCH-31.2 MCHC-34.7 RDW-13.0 Plt Ct-204 [**2176-1-23**] 06:08PM BLOOD PT-14.3* PTT-31.1 INR(PT)-1.2* [**2176-1-23**] 09:20AM BLOOD Glucose-108* UreaN-13 Creat-0.9 Na-134 K-4.6 Cl-103 HCO3-23 AnGap-13 [**2176-1-23**] 09:20AM BLOOD ALT-165* AST-116* LD(LDH)-292* AlkPhos-75 TotBili-0.4 [**2176-1-23**] 09:20AM BLOOD Lipase-97* [**2176-1-23**] 09:20AM BLOOD Albumin-4.6 [**2176-1-23**] 06:08PM BLOOD Calcium-8.4 Phos-3.3 Mg-1.8 Iron-140 [**2176-1-23**] 06:08PM BLOOD Ferritn-140 [**2176-1-23**] 06:08PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2176-1-23**] 06:08PM BLOOD HCV Ab-POSITIVE* [**2176-1-23**] 09:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-10 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2176-1-23**] 05:17PM URINE bnzodzp-POS barbitr-POS opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Brief Hospital Course: 42 YOM with long history of polysubstance abuse admitted from ED for alcohol withdrawal . # ETOH withdrawal: Pt was initially admitted to the ICU for frequent CIWA scale. He had significant history of long-standing EtOH abuse - 2 pints per day. Last drink was night prior to admission. He also reported history of DTs. The patient was kept on a q2h CIWA scale and triggered every 2-3 hours the first 24 hours of admission. He was also given compazine for nausea. A banana bag and thiamine/folate/MTV were also started. By HD #2 he was [**Doctor Last Name **] less than 5 on his CIWA although still quite nauseous. He was tolerating bland diet and was called out to floor. A social work consult was initiated in the unit. Patient also made repeated requests to leave AMA however was easily redirected. On the floor, he remained hemodynamically stable and was able to tolerate a regular diet. He declined all outpatient programs such as rehabilitation, detox programs, and AA meetings. He was given passes for the T by social work to help him travel around [**Location (un) 86**]. We will discharge him with instructions to stop all alcohol consumption, to f/u with his primary care physician, [**Name10 (NameIs) **] to re-consider attending AA meetings or enrolling in other outpatient programs for alcohol abuse. We reinforced the dangers of consumping alcohol - he expressed understanding of the consequences and a committment to quit. . # Transaminitis: ALT 165 and AST 116 on admission with normal coags. Thought to be secondary to HepC and chronic EtOH abuse. Repeat LFTs trended downward. He will need outpatient f/u with a hepatologist. . # H/O BRBPB: Had been asymptomatic for several weeks with stable Hct. Hematocrit was stable as inpatient. . # HCV: No signs or sequelae of cirrhosis currently. Will need to follow up with hepatology as outpatient. Medications on Admission: None Had been taking Klonopin Discharge Disposition: Home Discharge Diagnosis: Primary Alcohol withdrawal Secondary # Stroke in [**2168**] # HCV # EtOH abuse - Since age 12. Currently drinking [**1-28**] to 1 liter of vodka daily. # history of seizure "10 or 15 when I quit drinking" # Polysubstance abuse - per [**Hospital1 **] admit note, pt is s/p inpt detox at BayRidge in [**Location (un) **] in [**9-4**], relapsed nearly immediately with percocet and EtOH. Remote history of IVDU and Cocaine. Currently denying any use of any illicits. # BRBPR in the setting of Detox in [**10-5**] with polyp and internal hemerhoids Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 **] for alcohol withdrawal. You were monitored in the intensive care unit. You were treated with a medication called valium and with anti-nausea medications. You were seen by social workers and you were offered detoxification, rehabilitation, and other alcohol abuse programs which you declined. If you change your mind at any time, these options are still available to you. We also recommend attending Alcoholics Anonymous (AA) meetings - you can contact their main office at ([**Telephone/Fax (1) 24644**] or you can look on-line for meeting locations. Our social workers provided you with passes for the T to help you travel throughout [**Location (un) 86**]. It is imperative that you STOP any and all alcohol intake. No changes were made to your home medications. Followup Instructions: Please see your primary care physician [**Name Initial (PRE) 176**] 1 week. Please see your liver doctor in [**1-28**] weeks. If you have any concerns, please contact your primary care physician: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) 488**] Y Location: [**Location (un) **] FAMILY DOCTORS [**Name5 (PTitle) **]: [**Location (un) 84383**], [**Location (un) **],[**Numeric Identifier 26335**] Phone: [**Telephone/Fax (1) 32367**] Fax: [**Telephone/Fax (1) 72726**]

[ "291.81", "345.90", "295.70", "070.70", "303.91", "305.40", "455.0", "V12.54", "V12.72" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5742, 5748

3796, 5662

287, 293

6338, 6338

2874, 2874

7322, 7828

2236, 2304

5769, 6317

5688, 5719

6488, 7299

2319, 2855

232, 249

321, 1547

2888, 3773

6353, 6464

1569, 2078

2094, 2220

41,854

139,909

39010

Discharge summary

report

Admission Date: [**2176-3-27**] Discharge Date: [**2176-3-31**] Date of Birth: [**2153-4-13**] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 5608**] Chief Complaint: Respiratory Distress. Major Surgical or Invasive Procedure: Transferred with ETT and L IJ CVL ([**3-27**]). Bronchosopy ([**3-27**]) with BAL. Esophageal balloon study ([**3-29**]). Terminal extubation ([**3-31**]). History of Present Illness: 22 yo woman with history of Rubinstein Taybi disease (with associated kyphoscoliosis, small lung volumes and chronic right lung compression, obesity, mental retardation, and short stature) who presents from OSH with CC of respiratory distress. History was obtained from her mother. Pt was reportedly in her USOH until morning of transfer, when she developed acute onset shortness of breath. Per her mother she was being treated with prolonged prednisone taper after URI approx one month ago. She received about one week of antibiotics (cipro + cephalosporin) and was treated with prolonged prednisone taper, down to 5 mg on the day prior to admission. She was in her USOH until this morning, when she became acutely hypoxic to 50s. Her mother thumped on her chest a few times after which she coughed up a large mucus plug. However, she continued to have increasing oxygen requirements which prompted her mother to bring her to [**Name (NI) 1562**] Hospital ED. At OSH ED, she was noted to have initial BP 146/93, HR 118, RR 32, with sats 88-91% on NRB 15L. EKG showed sinus tachycardia with RAD and RBBB. Cardiac enzymes were negative. White count was noted to be 24K. CXR showed complete white-out both lung fields although this was difficult to interpret in the setting of severe kyphoscoliosis. Patient was intubated for hypoxemic respiratory failure. Left IJ placed. She underwent bronchoscopy that showed moderate thick yellowish mucus plug in the RLL with clot. There were no visible neoplasms. Patient was given Rocephin, vancomycin, and azithromycin and transferred to [**Hospital1 18**] for further care. At time of transfer patient was hypoxic to 60s on 100% FiO2. HR was 130s and regular with stable blood pressure. ABGs were consistent with respiratory acidosis and hypoxemia. Patient underwent bronchoscopy that showed scant secretions, most prominent in the left lingula. Secretions were suctioned and washed without incident. BAL was then performed after which there was frank bleeding, after which small amount of iced saline was applied with resulting cessation of bleeding. After the bronch her vent settings were adjusted to pressure control, 30/15, FiO2 100% and RR 28 with resulting increase in O2 sat to 90%. **Of note pt is on chronic oxygen therapy at home with CPAP at night. Per report she uses 2-4L oxygen by NC to maintain sats in the low 90s. She is ambulatory at baseline. REVIEW OF SYSTEMS: unable to attain. Past Medical History: #Rubinstein Taybe disease, complicated by mental retardation, short stature, severe kyphoscoliosis, restrictive and obstructive lung physiology #tachycardia thought to be related to underlying lung disease for which patient takes Cardizem Social History: patient lives with mother and father on [**Hospital3 **]. Per report she is ambulatory at baseline and attends school. Of note, pt with multiple sick contacts recently (including visiting nurses and multiple family members). Family History: Non-contributory. Physical Exam: BP 96/59, HR 118, sat 91%, RR 28 Ventilation: pressure control 30/15, FiO2 100%, RR 28 General: intubated and sedated HEENT: small indurated, raised eythematous lesion on left jaw (per mother this lesion is not new) Neck: supple Heart: RRR, normal s1/s2, tachycardic Lungs: coarse breath sounds bilaterally Abdomen: obese, soft, non-tender Extremities: warm, well-perfused, non-edematous Pertinent Results: [**2176-3-27**] 04:00PM BLOOD WBC-32.0* RBC-4.51 Hgb-11.0* Hct-37.1 MCV-82 MCH-24.5* MCHC-29.8* RDW-16.8* Plt Ct-134* [**2176-3-27**] 06:29PM BLOOD WBC-26.8* RBC-4.13* Hgb-10.2* Hct-33.5* MCV-81* MCH-24.7* MCHC-30.4* RDW-16.9* Plt Ct-127* [**2176-3-30**] 04:01AM BLOOD WBC-16.9* RBC-3.27* Hgb-8.3* Hct-26.7* MCV-82 MCH-25.5* MCHC-31.2 RDW-16.7* Plt Ct-139* [**2176-3-30**] 04:01AM BLOOD PT-16.3* PTT-24.4 INR(PT)-1.4* [**2176-3-27**] 04:00PM BLOOD Glucose-169* UreaN-15 Creat-0.6 Na-146* K-3.4 Cl-98 HCO3-41* AnGap-10 [**2176-3-28**] 04:48AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.8 Iron-16* [**2176-3-27**] 06:29PM BLOOD ANCA-NEGATIVE B [**2176-3-27**] 06:29PM BLOOD [**Doctor First Name **]-NEGATIVE [**2176-3-29**] 11:08PM BLOOD Lactate-0.9 Studies/Images: Transthoracic echocardiogram ([**3-28**]): The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Dilated right ventricle with evidence of right ventricular pressure and volume over load. If clinically indicated, a cardiac MR ([**Telephone/Fax (1) 5098**]) is recommended to further assess biventricular structure and function. Lower extremity doppler ultrasound ([**3-27**]): IMPRESSION: No evidence of lower extremity DVT. Limited study due to patient's body habitus. Brief Hospital Course: # Respiratory distress, hypoxemia, hypercarbia, and hemoptysis. Differential includes infectious etiologies (viral, bacterial, fungal), autoimmune/inflammatory disorders (Goodpasture's, Wegeners)- resulting in ARDS or diffuse alveolar hemorrhage. INR slightly elevated at 1.2 with platelets of 134 (no baseline available). Patient with no h/o exposure to antiplatelet agents or anticoagulants. She underwent bronchoscopy and BAL fluid was sent for microbial analysis. She was treated with broad-spectrum antibiotics (vancomycin, levofloacin, cefepime) for pneumonia, given her tenuous status. She was also started on high dose steroids because she had just completed a prolonged steroid taper and there was concern of airway inflammation/obstructive lung disease. In addition, because she was so difficult to oxygenate, she underwent esophageal balloon study to help assess and adjust her ventilator settings. With increasing the PEEP and driving pressure, her oxygenation improved significantly and we were able to wean down on the FiO2. Clinically, she appeared stable to slightly improved, though still ventilated with high peak expiratory and inspiratory pressures. Due to her recurrent admissions, high liklihood of prolonged ventilator-dependence, and overall poor prognosis, her family decided (over the course of several days) to withdraw care. She was extubated on [**3-31**] and passed away shortly thereafter # Tachycardia. Patient has chronic tachycardia which is felt to be related to chronic hypoxemia from underlying lung disease. Other considerations include intravascular volume depletion, anemia from blood loss, and pulmonary embolism. Her hct dropped slightly from 37 at admission to 33, although after discussion with her family it seemed this was consistent with her baseline. She underwent lower extremity doppler that showed no evidence of DVT. She also underwent transthoracic echocardiogram that showed right ventricular dilation and mild pulmonary hypertension, although both were unchanged from a study one year prior (making acute PE less likely). When her oxygenation improved (see above), the tachycardia likewise improved. Thus the tachycardia was likely a compensatory response to the hypoxemia. # Leukocytosis. We suspect this is secondary to pulmonary infection versus acute inflammatory response. There was no bandemia, and currently patient is afebrile. Antibiotics and steroids were initiated as above. # Thrombocytopenia. Platelets ranging from 120-130s, which was consistent with her baseline. # Goals of care. Her family, including her parents who are also her health care proxies, were aware that she would likely be ventilator-dependent for several days, possibly well-over one week. With this in mind, and believing that her quality of life would be significantly impaired were she to become ventilator-dependent, they decided to withdraw care on the fifth hospital day. Her medications were stopped, morphine was started and titrated to comfort, and she was extubated. She passed away shortly thereafter. Medications on Admission: -Nexium 40 mg daily -Cardizem 60 mg qid -Albuterol inh -Pulmicort inh Discharge Medications: Deceased. Discharge Disposition: Expired Discharge Diagnosis: Deceased. Discharge Condition: Deceased. Discharge Instructions: Deceased. Followup Instructions: Deceased. Completed by:[**2176-4-1**]

[ "756.19", "518.89", "319", "783.43", "518.81", "785.0", "276.2", "V46.2", "287.5", "327.23", "759.89", "288.60", "416.8" ]

icd9cm

[ [ [] ] ]

[ "33.24", "88.72", "96.71" ]

icd9pcs

[ [ [] ] ]

9133, 9142

5924, 8979

318, 475

9195, 9206

3915, 5901

9264, 9303

3472, 3491

9099, 9110

9163, 9174

9005, 9076

9230, 9241

3506, 3896

2930, 2950

257, 280

503, 2911

2972, 3213

3229, 3456

29,999

196,534

32473

Discharge summary

report

Admission Date: [**2138-10-30**] Discharge Date: [**2138-11-2**] Date of Birth: [**2081-5-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Coronary catheterization History of Present Illness: Patient is a 57 year old male with past medical history of idet controlled hypertension who presented to [**Hospital1 **] ER with 7/10 chest pain located mid-sternal starting about 2 hours prior to admission with radiation to the jaw. Patient was working at a paint store when this started and he began to feel diaphortic. Denies any nausea, vomiting, parastheias in his arm or radiation to the back. Patient denied any shortness of breath, palpitations, syncope, or presyncope. The pain gradualy worsened and he drove himself to the hospital. Patient recieved an EKG showing ST elevations in the inferior leads and sinus bradycardia to 55 bpm. He recieved three (3) sublingual nitroglycerine and pain improved to [**5-15**]. He recieved 325mg of aspirin, 600mg Plavix, Heparin 4000 unit bolus followed by Heparin drip. He recieved an integrillin bolus of 6.2cc followed by a drip and 1mg of ativan. He was given 80mg of Atorvastatin and transfered to [**Hospital1 18**] for emergent cardiac cath. Patient was taken to the cath lab and was found to have a right dominant system with 95% stenosis to the mid RCA with TIMI 2 flow and 50% distal RCA stenosis. LAD 50% proximal and 60% mid. Left Circumflex had 60% OM1. Patient was given a 3.0 33 Cypher tot he RCA. An acute marginal branch which had 80% stenosis and TIMI 2 flow became occluded after stenting and could not be reopened. Patient had transient hypotension during the procedure requiring Dopamine IV for approximatly 20 minutes. During and after the procedure in recovery the patient had 9 beat runs of VT and multiple PVCs consistant with reperfusion. Patient remained hemodynamically stable and was transfered to the CCU. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, excessive bleeding, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: HTN which normalised with lifestyle changes Social History: Social history is significant for the absence of current tobacco use with a 40 pack year history. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death, DM, HTN. Physical Exam: VS: T 98.1, BP 119/88, HR 50, RR 15, O2 99% on 2L NC Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with no appreciable JVP. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Audible S4, no m/r/g Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Dressing to the right groin is clean dry and intact. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2138-10-30**] 11:29PM POTASSIUM-3.8 [**2138-10-30**] 11:29PM CK(CPK)-1367* [**2138-10-30**] 11:29PM CK-MB-215* MB INDX-15.7* [**2138-10-30**] 10:22PM POTASSIUM-7.4* [**2138-10-30**] 10:22PM CK(CPK)-1424* [**2138-10-30**] 10:22PM CK-MB-226* MB INDX-15.9* [**2138-10-30**] 10:22PM PLT COUNT-211 [**2138-10-30**] 05:15PM GLUCOSE-111* UREA N-12 CREAT-0.8 SODIUM-138 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12 [**2138-10-30**] 05:15PM estGFR-Using this [**2138-10-30**] 05:15PM estGFR-Using this [**2138-10-30**] 05:15PM HCT-36.8* [**2138-10-30**] 05:15PM HCT-36.8* . Coronary catheterization ([**2138-10-30**]): 1. Selective coronary angiography of this right dominant system demonstrated multivessel coronary artery disease. The left main demonstrated no angiographically apparent dissection with normal flow throughout. The left anterior descending artery had minor disease throughout including a 50% proximal and 60% mid vessel lesion. The left cirucmflex demonstrated an OM1 with a 60% lesion. The right coronary artery demonstrated a mid 95% ulcerated lesion with TIMI II flow distal to the lesion. 2. LV ventriculography was deferred. 3. Limited resting hemodynamics demonstrated normal left (mean PCWP 14 atm) and right (RVEDP 10 atm) heart filling pressures. The cardiac index measured via the FICK method was preserved at 2.6 L/min/m2. 4. Rhythm throughout the procedure was sinus rhythm and AVIR. The patient was hypotensive requiring transient dopamine infustion during periods of AVIR. 5. Successful PTCA and stenting of the mid RCA with a Cypher (3x33mm) drug eluting stent postdilated with a 3.25 mm balloon. Final angiography demonstrated a jailed acute marginal with no flow that could not be rescued. No angiographically apparent dissection and TIMI III flow throughout the native right coronary artery (see PTCA comments). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Acute inferior ST elevation myocardial infarction. 3. Preserved cardiac index. 4. Successful PTCA and stenting of the mid RCA with a Cypher drug eluting stent postdilated with a 3.25mm balloon. Jailed acute marginal with no flow. . Echo ([**2138-10-31**]): The left atrium is normal in size. The estimated right atrial pressure is 0-5mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal half of the inferior wall. The remaining segments contract normally (LVEF = 45-50 %). 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.The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction c/w CAD.Mildly dilated aortic root. CLINICAL IMPLICATIONS: Based on [**2138**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: Pt was admitted to [**Hospital1 18**] and taken straight to the cath lab and was found to have a right dominant system with 95% stenosis to the mid RCA with TIMI 2 flow and 50% distal RCA stenosis. LAD 50% proximal and 60% mid. Left Circumflex had 60% OM1. Patient was given a 3.0 33 Cypher to the RCA. An acute marginal branch which had 80% stenosis and TIMI 2 flow became occluded after stenting and could not be reopened. Patient had transient hypotension during the procedure requiring Dopamine IV for approximatly 20 minutes. During and after the procedure in recovery the patient had 9 beat runs of VT and multiple PVCs consistant with reperfusion. Patient remained hemodynamically stable and was transfered to the CCU. In the CCU pt did weel without any further arrhythmias. He was monitored on telemetry and cardiac enzymes were trended initially, peaking at CK-MB 226 and MB index 15.9. Cholesterol panel was checked with the following results: LDL 97, HDL 47, total chol 167. His medical managment was optimized with ASA 325mg, lisinopril 2.5mg, metoprolol 12.5 [**Hospital1 **], atorvastatin 80mg, and plavix 75 mg. Pt was instructed to not take the metoprolol if the systolic blood pressure was less than <90. Pt remained cp free and without other symptoms, saturating well on room air, voiding on own, taking good po. The plan was for folllow-up care with PCP and dr.[**Doctor Last Name 3733**] within [**1-7**] weeks. Medications on Admission: aspirin 162 Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day: PLEASE DO NOT TAKE IF SYSTOLIC BLOOD PRESSURE IS BELOW 90. Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Tartrate 25 mg Tablet Sig: [**1-7**] Tablet PO twice a day: please do not take if systolic blood pressure <90. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: ST elevation myocardial infarction Discharge Condition: Stable Discharge Instructions: You were admitted to [**Hospital1 18**] with an ST elevation myocardial infarction. Please take your previous medications as prescribed. The following changes has been made to your medications: - please start taking aspirin 325mg daily for secondary cardiovascular prevention (to prevent another heart attack) instead of the lower dose of aspirin - Please start taking atorvastatin 80mg daily for your heart and for your cholesterol. - Please start taking lisinopril 2.5 mg daily for your heart and blood pressure (prevents remodelling of the heart) - Please start taking metoprolol 12.5mg daily for your heart and blood pressure (prevents remodelling of the heart) ***BUT PLEASE MEASURE YOUR BLOOD PRESSURE EVERY DAY FOR THE FIRST 2 WEEKS AND STOP TAKING IF SYSTOLIC BLOOD PRESSURE IS LESS THAN 90*** - Please start taking clopidogrel (Plavix) 75 mg daily. If you develop chest pain, jaw pain, or chest pressure with pain radiating into arm, or if you for any reason become concerned about your medical condition please call 911 or present to nearest ED. **DO NOT STOP TAKING THE ASPIRIN OR PLAVIX UNLESS INSTRUCTED TO DO SO BY YOUR CARDIOLOGIST EVEN IF ANOTHER DOCTOR TELLS YOU TO** Followup Instructions: Please call your PCP for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment to be seen within 1-2 weeks Please schedule and appointment with Dr.[**Doctor Last Name 3733**] within [**1-7**] weeks

[ "V15.82", "427.89", "401.9", "410.41", "458.29", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.07", "88.56", "99.20", "00.17", "37.23", "00.45", "00.40", "00.66" ]

icd9pcs

[ [ [] ] ]

9177, 9183

6976, 8415

327, 354

9262, 9271

3651, 5537

10505, 10730

2643, 2734

8477, 9154

9204, 9241

8441, 8454

5554, 6693

9295, 10482

2749, 3632

6716, 6953

277, 289

382, 2407

2429, 2474

2490, 2627

23,568

107,367

54175

Discharge summary

report

Admission Date: [**2113-5-18**] Discharge Date: [**2113-5-30**] Date of Birth: [**2047-6-23**] Sex: F Service: CARDIOTHORACIC Allergies: Influenza Virus Vaccine Attending:[**First Name3 (LF) 1505**] Chief Complaint: sternal wound dehiscence Major Surgical or Invasive Procedure: [**5-19**] sternal debridement [**5-23**] sternal debridement/omental flap History of Present Illness: 65 yo F with severe MR s/p Major Surgical or Invasive Procedure: [**4-5**] Coronary Artery Bypass Graft x 2 (Left internal mammary artery to left anterior descending artery, Saphenous vein graft to posterior descending artery), Mitral valve repair. Readmitted w/ falls at home and head CT revealed new frontal lobe meningioma. Past Medical History: -[**4-5**] Coronary Artery Bypass Graft x 2 (Left internal mammary artery to left anterior descending artery, Saphenous vein graft to posterior descending artery), Mitral valve repair -Severe Mitral regurgitation -Coronary artery disease s/p prior RCA stenting c/b ISR x 2, most recently with Cypher stenting in [**2107-4-24**] for NSTEMI -Hypertension -Dyslipidemia -'[**05**]: post cath large retroperitoneal hematoma extending from the right groin superiorly to the level of the lower pole of the right kidney-->required 7 units PRBCs -Non sustained polymorphic VT s/p ICD [**2-24**] -Depression -History of panic attacks/anxiety, prior psychiatric admission within the past several years -Gastroesophageal reflux disease -Osteopenia -History of pulmonary nodules, followed by serial imaging -Glucose intolerance -History of H. pylori Social History: Retired, worked as hairdresser. Husband died in [**12-2**] from MI. Lives at home with 18 yo son. Pt smoked cigarettes x many years, reports on-off history most recently in setting of CABG quit. Denies ETOH abuse. Family History: Father died at age 50 of an MI and "enlarged heart." Brother with drug abuse. Mother had depression and panic attacks Physical Exam: Pulse: Resp: O2 sat: B/P Right: Left: Height: Weight: General: Skin: Dry [] intact []- moist yeast under both breasts. open draining sternal wound 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 Pulses: Femoral Right: Left: DP Right: +2 Left:+2 PT [**Name (NI) 167**]: +2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit none Right: +2 Left:+2 Pertinent Results: [**2113-5-30**] 06:10AM BLOOD WBC-15.0* RBC-3.50* Hgb-10.3* Hct-31.1* MCV-89 MCH-29.4 MCHC-33.1 RDW-14.7 Plt Ct-215 [**2113-5-29**] 05:09AM BLOOD Glucose-172* UreaN-32* Creat-0.8 Na-137 K-4.3 Cl-99 HCO3-27 AnGap-15 [**2113-5-25**] 04:00AM BLOOD ALT-47* AST-26 LD(LDH)-563* AlkPhos-75 Amylase-155* TotBili-0.4 Brief Hospital Course: Ms. [**Known lastname 7958**] was admitted on [**5-18**] to cardiac surgery. Infectious disease was consulted and she was started on Vancomycin, ciprofloxacin, and diflucan. On [**5-19**] she underwent a sternal debridement in the operating room. No gross pus was detected intra-operatively. She then returned to the operating room on [**5-23**] for a second sternal debridement and closure with an omental flap. She tolerated both procedures well and was transferred to the surgical intensive care unit post-operatively on both occasions. She was extubated and weaned from drips. Her diet was advanced as tolerated. Cornebacterium grew from her operative cultures. Neurosurgery was consulted regarding weaning her steroids. Her JP drains were continued per the plastics surgery service. A PICC was placed for her antibiotics. By post-operative day 11 and 8 she was ready for discharge to rehab with continued JP drain care, IV Vancomcin, and neurosurgery follow-up. Medications on Admission: Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 3. 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* 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. Disp:*2 inhaler* Refills:*0* 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*0* 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 10. 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* 11. Lorazepam 0.5 mg Tablet Sig: 0.5-1 Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:*45 Tablet(s)* Refills:*0* 12. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*0* 13. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). Disp:*30 Tablet(s)* Refills:*0* 14. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*0* 18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 19. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Medications: 1. Outpatient Lab Work Weekly CBC with differential, BUN/Creatinine, LFTs, Vanco trough with results sent to the Infectious disease nurses or to on [**Name8 (MD) 138**] MD [**First Name (Titles) 10139**] [**Last Name (Titles) **] is closed at ([**Telephone/Fax (1) 6313**]. 2. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750) mg Intravenous Q 12H (Every 12 Hours): until [**2113-6-24**]. Disp:*[**Numeric Identifier 17451**] mg* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. JP drain care Please record and dispose of daily JP output. Bring these records to your plastic surgery appointment 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days: evaluate for need for further lasix at end of course. Disp:*10 Tablet(s)* Refills:*2* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 9. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 10. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 11. Hydrocortisone 20 mg Tablet Sig: 2.5 Tablets PO Q12H (every 12 hours): wean by halving the dose every other day. Disp:*150 Tablet(s)* Refills:*0* 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). Disp:*90 injection* Refills:*2* 13. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for eye care. Disp:*30 * Refills:*0* 14. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*qs Patch 24 hr(s)* Refills:*2* 15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-25**] Drops Ophthalmic PRN (as needed) as needed for eye care. Disp:*qs * Refills:*0* 16. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply under breasts for yeast infection. Disp:*qs * Refills:*2* 17. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 18. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs * Refills:*2* 19. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: sternal wound infection Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2113-6-27**] 9:00 Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (plastic surgery) in [**11-25**] weeks ([**Telephone/Fax (1) 1429**]. please call for an appointment Please record and dispose of daily JP drain output. Bring these records to your plastic surgery appointment. Dr. [**First Name (STitle) **] [**Name (STitle) 739**] (neurosurgery) ([**Telephone/Fax (1) 88**] in 4 weeks. Please call for an appointment. Completed by:[**2113-5-30**]

[ "530.81", "250.00", "998.59", "V45.02", "518.89", "V15.82", "V58.67", "225.2", "E878.2", "414.00", "733.00", "V15.88", "401.1", "998.31", "288.60", "V45.81", "041.84", "300.4", "E885.9" ]

icd9cm

[ [ [] ] ]

[ "96.72", "83.82", "77.61", "38.93" ]

icd9pcs

[ [ [] ] ]

9136, 9236

2993, 3971

315, 392

9304, 9311

2660, 2970

9822, 10429

1862, 1981

6357, 9113

9257, 9283

3997, 6334

9335, 9799

1996, 2641

251, 277

420, 750

772, 1613

1629, 1846

19,620

165,701

49815

Discharge summary

report

Admission Date: [**2164-9-24**] Discharge Date: [**2164-9-30**] Date of Birth: [**2120-9-25**] Sex: F Service: [**Location (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old female with a history of type 1 diabetes mellitus since the age of 10, on hemodialysis times one year, who presented to the [**Hospital1 69**] Emergency Department from an outside hospital in likely diabetic ketoacidosis with a potassium of 8 and massive volume overload. The patient was recently discharged from rehabilitation five days prior to admission. She states that she developed a respiratory tract infection and had difficulty controlling her sugars. At this time, she was living with her mother. She states that although she was checking her blood sugars regularly, she was unable to keep them within the normal range. She reports blood sugars above 400. At the outside hospital, the patient was treated with intravenous fluids. She was noted to have an anion gap and a potassium of 8. She received calcium chloride and bicarbonate. She also received insulin. She became agitated and was treated with Ativan. She was given one dose of vancomycin. She was transferred to the [**Hospital1 190**] Medical Intensive Care Unit. In the Medical Intensive Care Unit, the patient was treated with an insulin drip and hemodialysis. On the day of admission, she was noted to be disoriented. However, by day one of her hospitalization the patient's mental status had markedly improved. She was transferred to the floor on [**2164-9-27**]. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus since the age of 10. 2. End-stage renal disease (on hemodialysis). 3. Depression/personality disorder. 4. Severe neuropathy. 5. Chronic heel ulcerations with osteomyelitis; status post subtotal calcanectomy. 6. Diabetic ketoacidosis. 7. Retinopathy with blindness in her right eye and reduced vision in the left eye. 8. Gastropathy. 9. Autonomic dysfunction. 10. Chronic constipation. 11. Failed renal transplant; the patient received a living donor transplant; her sister was the donor, this transplant lasted approximately 12 to 14 years. 12. Hypercholesterolemia. 13. History of arteriovenous fistula infections. 14. Hypothyroidism. 15. Osteoporosis. 16. Squamous cell vulvar carcinoma. 17. History of methicillin-resistant Staphylococcus aureus. ALLERGIES: SULFA. MEDICATIONS ON ADMISSION: 1. Ultram 25 mg to 50 mg by mouth q.4h. as needed. 2. Nephrocaps. 3. Levoxyl 0.25 mcg by mouth once per day. 4. Phos-Lo. 5. Questran. 6. Lantus 14 unit subcutaneously at hour of sleep. 7. Alprazolam. 8. Ambien 10 mg by mouth as needed. 9. Cholestyramine. 10. Neurontin 300 mg by mouth three times per week; given with dialysis. 11. Tylenol. 12. Fludrocortisone 0.1 mg by mouth once per day. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories upon transfer to the floor revealed the patient's complete blood count was stable. Her sodium and potassium were within normal limits. Vancomycin level was 41.6. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed the patient's temperature was 98 degrees Fahrenheit, her blood pressure was 150/85, her heart rate was 88, her respiratory rate was 18, and her oxygen saturation was 100% on room air. Head, eyes, ears, nose, and throat examination revealed the oropharynx was clear. Pupils were equal, round, and reactive to light. Extraocular movements were intact. The mucous membranes were moist. No jugular venous distention was appreciated. No lymphadenopathy was appreciated. Cardiovascular examination revealed a 3/6 systolic murmur heard best at the left sternal border. Chest examination revealed the lungs were clear to auscultation bilaterally. No wheezes or crackles were appreciated on examination. The abdomen was soft, nontender, and nondistended. Extremity examination revealed no clubbing, cyanosis, or edema. Neurologic examination revealed the patient was alert and oriented times three. She had markedly reduced sensation in her lower extremities. She had 5/5 strength in all extremities. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted originally to the Medical Intensive Care Unit as described in the History of Present Illness. On the floor, the patient's blood sugars were relatively well controlled. She was on a regimen which consisted of Glargine 14 units subcutaneously at night and then an insulin sliding-scale before and two hours after meals. This regimen was designed by the [**Last Name (un) **] Service in consultation. The patient continued with her Monday, Wednesday, and Friday dialysis schedule. The patient was seen by Podiatry who performed an ulceration excision and closure around her left partial calcanectomy. The patient tolerated the procedure well. She was left with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain. This drained serosanguineous fluid. The patient was continued on her vancomycin therapy for her history of methicillin-resistant Staphylococcus aureus and osteomyelitis. In addition, she was continued on her levofloxacin therapy which had been started in the Medical Intensive Care Unit because a chest x-ray was consistent with right lower lobe pneumonia. On the Medicine floor, the patient continued to saturate well on room air and was relatively asymptomatic with respect to her right lower lobe pneumonia. After her Podiatry surgery and after remaining stable on the floor, it was the consensus of the medical team that the patient was stable enough to return to her mother's house. Thus, the patient was discharged to home with services. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge status was to home. DISCHARGE DIAGNOSES: 1. End-stage renal disease. 2. Osteomyelitis. 3. Diabetes mellitus. 4. Peripheral neuropathy. 5. Retinopathy. 6. Autonomic neuropathy. 7. Squamous cell carcinoma. MEDICATIONS ON DISCHARGE: 1. Ultram 25 mg to 50 mg by mouth q.4h. as needed. 2. Nephrocaps. 3. Levoxyl 0.25 mcg by mouth once per day. 4. Phos-Lo. 5. Questran. 6. Lantus 14 unit subcutaneously at hour of sleep. 7. Alprazolam. 8. Ambien 10 mg by mouth as needed. 9. Cholestyramine. 10. Neurontin 300 mg by mouth three times per week; given with dialysis. 11. Tylenol. 12. Fludrocortisone 0.1 mg by mouth once per day. 13. Levofloxacin. 14. Vancomycin. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 6280**] Dictated By:[**Name8 (MD) 9719**] MEDQUIST36 D: [**2164-9-28**] 21:38 T: [**2164-10-1**] 09:24 JOB#: [**Job Number 104102**]

[ "585", "707.14", "276.7", "250.63", "996.81", "337.1", "250.13", "486", "276.6" ]

icd9cm

[ [ [] ] ]

[ "39.95", "77.68" ]

icd9pcs

[ [ [] ] ]

5855, 6026

6053, 6747

2435, 4155

4184, 5733

5748, 5834

178, 1561

1584, 2408

27,799

147,861

34726

Discharge summary

report

Admission Date: [**2183-7-25**] Discharge Date: [**2183-7-29**] Date of Birth: [**2150-5-11**] Sex: M Service: MEDICINE Allergies: Aspirin / Haldol Attending:[**First Name3 (LF) 10593**] Chief Complaint: Admitted for abnormal labs following PCP [**Name Initial (PRE) **] Major Surgical or Invasive Procedure: - CT Abd w/ contrast [**2183-7-25**] History of Present Illness: 33-year-old male with EtOH abuse who is admitted for abnormal labs. . He presented for a routine visit to his primary care physician [**Last Name (NamePattern4) **] [**2183-7-24**]. He had no acute complaints and labs were checked at that visit. He had abnormal electrolytes (Na 124, K 2.4, Cl 64, HCO3 40, lipase 187) and was told to report to the ED for further evaluation. Of note, he drinks 1 pint of vodka per night. In the ICU, the patient states his last drink was ~1 week ago on Tuesday, however in the clinic note, it states he continues to drink 1 pint daily. He denies all ingestions. He reported NB/NB vomiting 2x daily for the past few weeks, mostly after eating something (told another resident that he has not had any nausea or vomiting). He says he has had much decreased appetite recently, but has been drinking POs. Has had change in bowel habits to "specks" of stool rather than either formed stools or diarrhea. . In the EW, initial vitals were: T 98.8 P 89 BP 123/76 R 19 O2 sat 100% RA. Repeat labs were done which showed Na 123, K 2, Cl 69, lactate 3.2. ABG showed 7.57/43/79. He was given 2L NS, 60 mEq potassium chloride, 2 grams of magnesium. UTox was negative. He got a CT abdomen for concern of pancreatitis given his elevated lipase. He was admitted to the ICU for further evaluation and management. 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. Denies diarrhea, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies penile discharge, ulcers. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - EtOH abuse with history of severe withdrawals and DTs and seizures. - Bipolar depression/?schizophrenia per notes and patient. ALso reports ADHD. History of suicide attempt as teenager. Not currently on meds and no psychiatrist currently. - Hypertension - Reports history MI from cocaine use in [**State 531**] Social History: Pt. born in [**Country 13622**] Republic and moved to United States at the age of 1. Denies tobacco use. +EtOH abuse. History of polysubstance abuse/ recreational drug use (including cocaine and remote use of marijuana, heroin, LSD, crystal meth) - denies any x 4 years. Has been recently unemployed. Patient has seen numerous therapists since the age of twelve. He reports being abused and raped when he was younger. Currently living with 3 roomates. Mother and brother in the [**Name (NI) 86**] area. Family History: No history of MI, cancer, or depression in his first degree relatives. There is a history of high cholesterol, hypertension, and alcohol use in his father's side of his family. Physical Exam: Admission PE: Vitals: T: 99.8 BP: 121/85 P: 91 R: 15 SaO2: 100% RA General: Alert, oriented, no acute distress, diaphoretic HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Psych: Flat affect Neuro: CNII-XII grossly intact. 5/5 strength, Normal gait. Discharge PE: Vitals: T: 99.8 BP: 106/76 P: 80 R: 12 SaO2: 100% RA General: Alert, oriented, no acute distress, diaphoretic HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Psych: Not assessed Neuro: Gross neurological examination normal Pertinent Results: [**2183-7-26**] 04:12AM BLOOD WBC-5.8 RBC-3.94* Hgb-12.1*# Hct-32.7* MCV-83 MCH-30.6 MCHC-36.9* RDW-13.6 Plt Ct-378 [**2183-7-24**] 03:16PM BLOOD WBC-8.5 RBC-5.12 Hgb-16.0 Hct-42.7 MCV-83# MCH-31.2 MCHC-37.4* RDW-13.6 Plt Ct-478* [**2183-7-25**] 12:15PM BLOOD Neuts-71* Bands-0 Lymphs-16* Monos-13* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2183-7-25**] 12:15PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2183-7-26**] 09:50AM BLOOD Na-136 K-3.3 Cl-92* [**2183-7-24**] 03:16PM BLOOD UreaN-15 Creat-1.2 Na-124* K-2.4* Cl-62* HCO3-40* AnGap-24* [**2183-7-25**] 12:15PM BLOOD ALT-77* AST-84* AlkPhos-140* [**2183-7-24**] 03:16PM BLOOD ALT-94* AST-85* AlkPhos-137* TotBili-1.0 [**2183-7-26**] 04:12AM BLOOD Calcium-8.4 Phos-2.1* Mg-2.3 [**2183-7-24**] 03:16PM BLOOD VitB12-575 Folate-13.8 [**2183-7-24**] 03:16PM BLOOD Triglyc-108 HDL-94 CHOL/HD-2.4 LDLcalc-108 [**2183-7-24**] 03:16PM BLOOD TSH-2.0 [**2183-7-25**] 11:50PM BLOOD ASA-NEG Ethanol-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2183-7-25**] 04:04PM BLOOD Type-ART pO2-79* pCO2-43 pH-7.57* calTCO2-41* Base XS-15 [**2183-7-26**] 12:19AM BLOOD Lactate-2.0 [**2183-7-25**] 02:52PM BLOOD Lactate-3.2* Micro: [**2183-7-25**]: Blood + Urine cultures pending Imaging: [**2183-7-25**]: CT Abdomen w/contrast: (Preliminary Read): No peri-pancreatic stranding, necrosis, pseudocyst or other evidence/complication of pancreatitis. No other acute abdominal process. Brief Hospital Course: Assessment and Plan: 33-year-old male with bipolar disorder, ?schizophrenia, EtOH abuse who presents with multiple abnormal laboratory abnormalities, most consistent with vomiting, dehydration and alcohol use. He was initially admitted to the ICU. Metabolic abnormalities improved with IVF. He was transferred to the general medical [**Hospital1 **]. . # Fever # Pleural effusion Had low-grade fever on general medical [**Hospital1 **]. Also noted mild dyspnea and cough. U/A without evidence of UTI. CXR small L pleural effusion. D-dimer was negative. Repeat CXR the following day showed decrease in the small L pleural effusion; did not suspect pneumonia or empyema. He remained afebrile for 24 hours prior to discharge. His dyspnea and cough had resolved on the day of discharge. He was not treated with antibiotics. Suspect that the fever could have been due to a viral upper respiratory tract infection. Repeat CXR can be done in the outpatient settting to assess for resolution of tiny L pleural effusion. . # Vomiting: Etiology was unclear. Differential includes GERD, ketoacidosis, gastroparesis, ingestions, and induced emesis. Patient was able to tolerate PO while in hospital. Resolved with correction of electrolyte imbalance making a combination of these etiologies likely. . # Hypokalemia: Of unknown chronicity, but patient had previously documented normal K. Questionable history of vomiting which could explain hypokalemia; also, potassium levels would decrease with metabolic alkalosis (see below). He was given IV and PO potassium in the ED. EKG showed no evidence of cardiovascular changes due to hypokalemia. His potassium levels have now returned to a normal level following aggressive repletion and administration of IVF. . # Hyponatremia: Was likely due to hypovolemia with component of poor nutrition from alcohol ingestion (patient had not eaten any food in few days prior to admission; was dependent on PO liquids only). Received 2 units of NS in ED with a further 1 L NS bolus in the ICU leading to complete resolution of sodium status. No symptoms of acute hyponatremia at any time during stay in ICU. . # Metabolic alkalosis: Likely secondary to vomiting given history. Low urine Cl (<20) consistent with this history. Also considered hyperaldosteronism, although patient was not hypertensive, making it unlikely. Denied use of diuretics, laxitives. Contraction alkalosis likely played a role, even though BUN/Cr ratio was not elevated. Resolved with administration of IVF as above. Bicarbonate levels continue to drop and should be monitored. . # Elevated lipase: Originally cause of concern for pancreatitis, most likely cause of which is alcohol abuse. CT abdomen done but wet read not c/w pancreatitis. In addition, patient does not have abdominal pain or clinical signs of pancreatitis. Was able to eat solids without difficulty. Lipase levels can be re-checked if the patient develops abdominal pain or other signs of pancreatitis; also, follow-up of CT abdomen recommended. . # Elevated Lactate: Suggested some hypoperfusion, possibly secondary to hypovolemia. Corrected with IVF administration to a level of 2.2. . # EtOH history: Will need valium CIWA scale and close monitoring for evidence of withdrawal given history of seizures and DTs. No signs of DTs during admission in ICU. # Bipolar disorder: home meds were continued. . # Anemia - acute on chronic. Lowish MCV. B12 and folate were normal. Fe a bit low, but ferritin OK. Suspect IVF contributed to lowering of Hct here. Fe and CBC can be followed as outpatient. . He was seen by Social Work. He expressed a desire to cut back on alcohol. He preferred to seek outpatient treatment/alcohol rehab rather than inpatient alcohol rehab. Medications on Admission: Medications (per OMR): (per patient, only taking aripiprazole, fluoxetine, gabapentin, trazodone) - aripiprazole 15 mg PO daily - fluoxetine 20 mg PO daily - folic acid 1 mg PO daily - gabapentin 800 mg PO TID - levetiracetam 500 mg PO BID - trazodone 100 mg PO qHS - cholecalciferol 5,000 unit PO daily - thiamine HCl 50 mg PO daily Discharge Disposition: Home Discharge Diagnosis: Hyponatremia Hypokalemia Hypophosphatemia Alcohol abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for electrolyte abnormalities (including low sodium and low potassium). This was probably related to alcohol use and poor diet. You should avoid alcohol, and eat a well-rounded diet in order to prevent further electrolyte abnormalities. You had a very small pleural effusion (fluid outside the left lung), which improved on a repeat chest x-ray. Followup Instructions: Department: [**Hospital3 249**] When: WEDNESDAY [**2183-8-6**] at 9:20 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10137, 10143

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345, 383

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10164, 10222

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239, 307

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2210, 2525

2541, 3046

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133,835

12887

Discharge summary

report

Admission Date: [**2162-11-14**] Discharge Date: [**2162-11-24**] Date of Birth: [**2094-12-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name8 (NamePattern2) 812**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Endotracheal Intubation Arterial Line Placement History of Present Illness: 67 year old male with COPD, atrial fibrillation, history of stroke, CAD, SCLC s/p chemo and XRT in [**2155**]; presenting with dyspnea. He appeared to be more dyspneic at [**Hospital1 1501**] and today was noted to have a low sat (upper 80s on RA). He was put on 4L O2 with sat increase to 91% only. Per one note had a fever to 101 at [**Hospital1 1501**]. History from patient somewhat limited by expressive aphasia. He is unable to report on further details regarding his dyspnea. Does deny headache, chest pain. Unclear if has been coughing. Does point out that he has been having some tongue discomfort. Denies abdominal pain. In the ED, initial vs were: 99.6 126 115/69 38. O2 sats into 80s on RA. Temp spike to 103.4 associated with HRs in 120s and RR as high as 46. Mildly increased work of breathing. CXR concerning for R sided pneumonia. Elevated LFTs for unclear reasons. Patient was given levofloxacin and vancomycin and PR tylenol. 1L NS given. Review of systems: (+) Per HPI (-) difficult to obtain given aphasia Past Medical History: - left MCA stroke, felt to be cardio-embolic, on [**2162-3-6**] - CAD s/p MI and angioplasty [**2145**] - Paroxysmal atrial fibrillation - RUL SCLC s/p chemo and radiation [**2155**], in remission - COPD - no home O2 - Hyperlipidemia - DM Social History: Former heavy smoker, [**2-9**] ppd for 20-30 years, but quit in [**2155**] years ago with lung cancer diagnosis. Family History: His mother died from a heart disease at the age of 75. His father died from a throat cancer at the age of 52. Physical Exam: General: Alert, speech mostly not understandable, mildly tachypneic HEENT: R facial droop. Sclera anicteric, Pupils 3->2, MM slightly dry, oropharynx clear Neck: supple, JVP does not appear elevated, no LAD Lungs: R mid and lower posterior lung fields with +crackles; L clear with exception of occ end expiratory wheezes. CV: Distant heart sounds, irregular, no m/r/g Abdomen: soft, non-distended, bowel sounds present, mild RUQ TTP, no rebound tenderness or guarding, no organomegaly, no murphys Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: alert, orientation difficult to assess. Follows complex commands. R facial droop present (central 7th). No movement of RUE. R foot with weak dorsiflexion. L side with 5/5 strength. Difficulty assessing sensation. Pertinent Results: Hematology: [**2162-11-14**] 06:30PM BLOOD WBC-12.8* RBC-4.27* Hgb-13.3* Hct-38.3* MCV-90 MCH-31.0 MCHC-34.7 RDW-13.3 Plt Ct-282 [**2162-11-18**] 02:59AM BLOOD WBC-8.9 RBC-3.73* Hgb-11.2* Hct-33.5* MCV-90 MCH-30.0 MCHC-33.3 RDW-13.5 Plt Ct-284 [**2162-11-14**] 06:30PM BLOOD Neuts-87.6* Lymphs-7.3* Monos-4.9 Eos-0.1 Baso-0.1 [**2162-11-14**] 06:30PM BLOOD PT-25.3* PTT-37.6* INR(PT)-2.4* [**2162-11-18**] 02:59AM BLOOD PT-32.8* PTT-34.6 INR(PT)-3.3* Chemistries: [**2162-11-14**] 06:30PM BLOOD Glucose-182* UreaN-24* Creat-0.8 Na-139 K-3.3 Cl-100 HCO3-26 AnGap-16 [**2162-11-18**] 02:59AM BLOOD Glucose-113* UreaN-17 Creat-0.5 Na-140 K-3.3 Cl-103 HCO3-36* AnGap-4* [**2162-11-14**] 06:30PM BLOOD ALT-300* AST-463* CK(CPK)-71 AlkPhos-110 TotBili-0.9 [**2162-11-18**] 02:59AM BLOOD ALT-211* AST-82* [**2162-11-14**] 06:30PM BLOOD Lipase-14 [**2162-11-17**] 02:52AM BLOOD Lipase-34 [**2162-11-15**] 04:11AM BLOOD Albumin-3.4 Calcium-8.2* Phos-2.6* Mg-2.7* [**2162-11-16**] 07:56AM BLOOD Vanco-6.9* [**2162-11-14**] 06:36PM BLOOD Lactate-2.4* [**2162-11-16**] 03:38AM BLOOD Glucose-148* Lactate-1.2 Cardiac Enzymes: [**2162-11-14**] 06:30PM BLOOD cTropnT-<0.01 [**2162-11-14**] 06:30PM BLOOD CK-MB-2 proBNP-1164* [**2162-11-15**] 04:11AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2162-11-15**] 12:40PM BLOOD CK-MB-2 cTropnT-<0.01 EKG [**2162-11-14**]: sinus tach at 101. Borderline PR prolongation. Borderline RAD. RBBB. Low limb lead voltage. Compared to prior, complete RBBB new (had IVCD with R bundle pattern), low limb lead voltage slightly more prominent. CXR [**2162-11-14**]: Limited study with increased conspicuity of right perihilar opacity, which likely in part reflects chronic radiation-related changes. Subtle superimposed pneumonia cannot be excluded. Consider dedicated PA and lateral view for more thorough evaluation. RUQ ultrasound [**2162-11-15**]: 1. Cholelithiasis with no sign of cholecystitis. 2. Echogenic liver consistent with mild fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. No biliary dilatation. 3. Borderline splenomegaly. CT Chest [**2162-11-15**]: 1. Multifocal consolidative opacification with air bronchograms most pronounced in the right upper and right lower lobes is concerning for multifocal pneumonia. 2. Unchanged appearance to post-radiation changes, cholelithiasis, right pleural effusion, and splenomegaly. Microbiology: Blood cultures x 2 [**2162-11-14**] - negative Urine culture [**2162-11-14**], [**2162-11-15**] - negative Urine Legionalle [**2162-11-14**]- negative Influenza DFA [**2162-11-15**] - negative GRAM STAIN (Final [**2162-11-15**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. BAL [**2162-11-16**]: GRAM STAIN (Final [**2162-11-16**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2162-11-18**]): NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2162-11-16**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [**2162-11-17**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Virus isolated so far. [**11-20**] Blood cultures- negative to date Brief Hospital Course: 67 year old male with COPD, CAD, history of SCLC, prior CVA, presenting with tachypnea, hypoxia, and found to have pneumonia. Respiratory distress/tachypnea/hypoxemia: Patient has expressive aphasia and was unable to fully describe characteristics of onset, etc. CXR and chest CT consistent with multifocal pneumonia. He was started on vancomycin, zosyn and levofloxacin for coverage of health care associated pneumonia. He was also started on oseltamavir for cover of influenza until his nasopharyngeal aspirate came back as negative. Patient received IV steroids initially out of concerning that his COPD might be contributing which were tapered. Sputum samples were inconclusive. He underwent bronchoscopy without significant secretions, BAL was unrevealing. Viral culture for influenza from the broncoscopy was negative. He was initially intubated for respiratory distress but was able to be extubated without difficulty on [**2162-11-17**]. He was transitioned to oxygen via NC and later stable on room air. His pneumonia was treated with an eight day course of antibiotics. Fever, leukocytosis: Patient was initially febrile to 103 degrees in the emergency room. He was hemodynamically stable. This was likely secondary to pneumonia versus influenza which is being treated as above. Blood and urine cultures have been negative to date. Elevated LFTs: On presentation his transaminases were elevated to ALT 300 and AST 463, and he was noted to have mild RUQ tenderness on exam. Patient underwent right upper quadrant ultrasound which was negative for cholecystitis but showed fatty infiltration of his liver. At discharge, ALT 93 and AST 45. His transaminases have trended down without further intervention but this should be followed up by his PCP. Atrial Fibrillation: As above, history of embolic stroke. INR was 2.4 on presentation. His INR trended up with initiation of antibiotics and was held in this setting. Once his INR trended down, he was bridged with heparin until discharge when he was switched to lovenox for bridging until therapeutic INR will be obtained at rehab. Type II Diabetes: He was continued on his home insulin dosing. Medications on Admission: Coumadin - unknown dosage ASA 81 mg daily omeprazole 40 mg daily lopressor 37.5 mg TID simvastatin 40 mg daily Multivitamin 5 ml daily robitussin prn senna [**Hospital1 **] colace 100 mg [**Hospital1 **] miralax 17 grams daily albuterol Q6H prn ipratropium nebs Q6H NAC inhaled 600 mg Q12H regular insulin sliding scale plus 36 units glargine daily HS prn: MOM, maalox, dulcolax, fleet, APAP Water by PEG 400cc QID Diet - NAS, low sugar, regular solids with thin liquids, plus ensure plus with meals. Discharge Medications: 1. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 3. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Senna 8.8 mg/5 mL Syrup [**Hospital1 **]: Ten (10) milliliters PO BID (2 times a day) as needed for constipation. 5. Omeprazole-Sodium Bicarbonate 40-1.1 mg-gram Capsule [**Hospital1 **]: One (1) Capsule PO once a day. 6. Robitussin Chest Congestion 100 mg/5 mL Liquid [**Hospital1 **]: Ten (10) milliliter PO every four (4) hours as needed for cough. 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) unit Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 8. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Thirty Six (36) units Subcutaneous at bedtime. 9. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) unit Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 10. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: Three (3) milliliters Miscellaneous twice a day. 11. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) milliliters PO BID (2 times a day). 12. Polyethylene Glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) dose PO DAILY (Daily). 13. Maalox 200-200-20 mg/5 mL Suspension [**Hospital1 **]: Five (5) milliliters PO every six (6) hours as needed for indigestion. 14. Milk of Magnesia 400 mg/5 mL Suspension [**Hospital1 **]: Five (5) milliliters PO once a day as needed for constipation. 15. Acetaminophen 650 mg Tablet [**Hospital1 **]: One (1) Tablet PO every [**4-12**] hours as needed for fever or pain: Do not exceed 2 grams daily. 16. Insulin Please follow humalog insulin sliding scale as attached. Check fingerstick blood glucose four times daily. 17. Warfarin 2 mg Tablet [**Month/Day (3) **]: Three (3) Tablet PO once a day. 18. Metoprolol Tartrate 25 mg Tablet [**Month/Day (3) **]: 0.5 Tablet PO TID (3 times a day): Hold for SBP<95, HR<60. 19. Enoxaparin 100 mg/mL Syringe [**Month/Day (3) **]: One (1) milliliter Subcutaneous [**Hospital1 **] (2 times a day): Continue until INR between [**2-9**]. Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Primary: 1. Respiratory Failure 2. Pneumonia (health care associated) 3. Anticoagulation for Paroxysmal atrial fibrillation Secondary: 1. Diabetes Mellitus 2. COPD Discharge Condition: stable, breathing improved Discharge Instructions: You were admitted to the hospital after you were found to have a fever and difficulty breathing. You required a breathing tube to support your breathing while you were in the intensive care unit. You were found to have pneumonia which likely caused most of your symptoms. You had tests to look for the flu which were negative. After receiving antibiotics and breathing treatments, you improved and were ready to go back to your nursing facility. Please follow up with your PCP. The following changes were made to your medications: 1. Decreased your metoprolol tartrate to 12.5mg TID 2. Continue lovenox 100mg [**Hospital1 **] until your INR is between [**2-9**] on Coumadin If you experience difficulty breathing, chest pain, or fever and chills, please call your doctor or come to the ED. Followup Instructions: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2162-12-29**] 1:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2162-12-29**] 3:20 [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]

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icd9cm

[ [ [] ] ]

[ "38.91", "33.24", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

11478, 11519

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334, 383

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20499

Discharge summary

report

Admission Date: [**2113-6-12**] Discharge Date: [**2113-6-21**] Date of Birth: [**2046-3-5**] Sex: F Service: CSU HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: The patient is a 66 year old, Hispanic female with known mitral stenosis. She had been referred to Dr. [**Last Name (Prefixes) **] for mitral valve replacement as she has had a recent increase in dyspnea on exertion. The patient underwent cardiac catheterization which showed an ejection fraction of 55 percent, elevated pulmonary artery pressures of 57/25 with LVEDP of 11 and pulmonary capillary wedge pressure of 25. She had severe mitral stenosis with mean gradient of 16 mmHg, valve area 0.84 cm squared with no significant coronary artery disease. PAST MEDICAL HISTORY: 1. Mitral stenosis. 2. Hypertension. 3. Hypercholesterolemia. 4. GERD. 5. Asthma. 6. Hypothyroidism. ALLERGIES: NKDA. MEDICATIONS: 1. Lopressor 50 mg p.o. b.i.d. 2. Celexa 40 mg p.o. q.day. 3. Prilosec 20 mg p.o. q.day. 4. Lorazepam 1 mg p.o. q.day. 5. Crestor 10 mg p.o. q.day. 6. Synthroid 75 mcg p.o. q.day. 7. Lasix 80 mg p.o. q.day. 8. Potassium chloride 80 mEq p.o. q.day. 9. Zestril 40 mg p.o. q.day. 10. Aspirin 81 mg p.o. q.day. 11. Albuterol MDI p.r.n. HO[**Last Name (STitle) **] COURSE: The patient was admitted to [**Hospital1 346**] on [**2113-6-12**]. She was taken to the operating room with Dr. [**Last Name (Prefixes) **] for mitral valve replacement with a 25 mm [**Company 1543**] Mosaic porcine valve. Please see operative note for full details. The patient was transported to the intensive care unit in stable condition. The patient was weaned and extubated from mechanical ventilation on the first postoperative day. The patient was on low dose epinephrine. She had good cardiac indices. The patient was weaned off epinephrine on postoperative day one and was started on Lasix and captopril. The chest tubes were removed without incident. On postoperative day two the patient was noted to have mild right hand and arm weakness. Neurology consult was obtained. The weakness subsequently resolved. The patient underwent a CT scan of her head which was negative for any acute event. Subsequently neurology felt that the incident was due to effects of anesthesia and narcotics. On postoperative day two as well the patient developed atrial fibrillation, rate controlled with rates in the 80s. The patient was started on amiodarone and Lopressor with continued rate control. The patient continued in atrial fibrillation. By postoperative day four the decision was made to cardiovert. She was cardioverted successfully to sinus bradycardia which she remained in until postoperative day eight when she again had another episode of atrial fibrillation. The electrophysiology service was consulted for possible repeat cardioversion, however, the patient converted into sinus rhythm on her own. On postoperative day four the patient had a low grade fever of 101. The patient had UA and urine culture sent which were significant for less than 10,000 gram negative rods. The patient was started on empiric levofloxacin times five days. The patient had no further fever. The patient began working with physical therapy and it was subsequently determined that the patient would benefit from a stay at short term rehab. On postoperative day six the patient was transferred from the intensive care unit to the regular part of the hospital. When the patient had the second episode of atrial fibrillation, the decision was made that the patient needed to be anticoagulated for continued atrial fibrillation. Heparin infusion and Coumadin were started. On postoperative day nine the patient was cleared for discharge to rehab. CONDITION ON DISCHARGE: T-max 98.4, pulse 66 in sinus rhythm, blood pressure 117/56, respiratory rate 18, room air oxygen saturation 97 percent. Laboratory data white blood cell count 8.7, hematocrit 30.5, platelet count 243. Sodium 139, potassium 5.2, chloride 99, bicarb 33, BUN 17, creatinine 1.2, glucose 86. The patient's weight on [**6-21**] was 80.2. Preoperatively the patient weighed 77 kg. Neurologically the patient is awake, alert and oriented times three. Strength in upper and lower extremities is equal bilaterally. cardiovascular regular rate and rhythm without rub or murmur. Respiratory breath sounds are clear bilaterally. GI positive bowel sounds, soft, nondistended, nontender. The patient is tolerating a regular diet. Sternal incision is clean, dry and intact. Sternum is stable. Lower extremities have trace to 1+ edema. They are warm and well perfused. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. 2. Synthroid 75 mcg p.o. q.day. 3. Dilaudid 2 mg p.o. q.four to six hours p.r.n. 4. Lipitor 10 mg p.o. q.day. 5. Lasix 20 mg p.o. b.i.d. times seven days. 6. Enteric coated aspirin 81 mg p.o. q.day. 7. Protonix 40 mg p.o. q.day. 8. Lopressor 25 mg p.o. b.i.d. 9. Amiodarone 400 mg p.o. b.i.d. times five days, then 400 mg p.o. q.d. times one month. 10. Lorazepam 1 mg p.o. q.h.s. p.r.n. 11. Celexa 40 mg p.o. q.day. 12. Coumadin 2 mg p.o. on [**6-21**]. The patient is to have PT/INR checked on [**6-22**] and Coumadin titrated for goal INR of 2.0 to 2.5. 13. Heparin infusion 900 units per hour with goal PTT of 50 to 60. The patient is to continue on heparin infusion until her INR is greater than 2.0. DISCHARGE DIAGNOSIS: 1. Mitral stenosis. 2. Status post mitral valve replacement. 3. Postoperative atrial fibrillation. 4. Postoperative right hand weakness. Th[**Last Name (STitle) 1050**] is to be discharged to rehab and she should follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17887**], in one to two weeks. The patient is to follow up with Dr. [**Last Name (STitle) 7047**], cardiologist, in one to two weeks. She is to follow up with Dr. [**Last Name (Prefixes) **] in three to four weeks. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**Numeric Identifier 54860**] Dictated By:[**Last Name (NamePattern4) 8524**] MEDQUIST36 D: [**2113-6-21**] 10:36:41 T: [**2113-6-21**] 11:40:26 Job#: [**Job Number 54861**]

[ "997.99", "997.1", "729.89", "E878.8", "998.89", "401.9", "780.6", "427.31", "391.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "89.68", "88.72", "35.23", "38.93" ]

icd9pcs

[ [ [] ] ]

4652, 5425

5446, 6280

767, 3737

3762, 4629

1,381

181,430

29931

Discharge summary

report

Admission Date: [**2189-1-2**] Discharge Date: [**2189-1-2**] Date of Birth: [**2107-7-15**] Sex: F Service: NEUROLOGY Allergies: Codeine / Morphine / Darvocet-N 50 / Ambien Attending:[**First Name3 (LF) 5018**] Chief Complaint: L sided weakness and L gaze deviation Major Surgical or Invasive Procedure: CT head History of Present Illness: 81 y.o. woman seen to be well at 0830 am. Began to complain of pain at this time and received Vicodin at 0830. At 0900 patient became somnolent and was noted to have L sided weakness and L gaze deviation. Received Narcan with no change in mental status. Became progressively more somnolent and transferred to [**Hospital1 18**] for further evaluation. Intubated in ER here for decreased LOC. Patient was recently admitted to ICU at [**Hospital 1562**] Hospital on [**12-26**]/06 after having a fall at home with pelvic bone #, fractures of both pubic rami and pelvic hematoma with retroperitoneal bleed. There was no operative intervention. She required blood transfusion for dropping Hct from 30 to 20 with hypotension. Transferred to NH on [**12-28**]/06. Past Medical History: - pelvic bone #, pelvic hematoma and retroperitoneal bleed -diabetes -Carcinoma of the rectum -hypothyroidism -chronic Atrial fibrillation with sick sinus syndrome; has pacemaker -CAD -bilateral hip replacement surgeries done in the past -lumbar laminectomy in [**2122**] and [**2152**] -coronary stent Social History: Retired. Has children. Family History: Non-contributory Physical Exam: BP 200/60 HR 80 Intubated Afebrile CVS - S1, S2 Chest - clear [**Last Name (un) **] - soft, nontender MS - recently administered paralytics and sedatives; -not opening eyes, not following commands CN - PERRL (2mm), no Doll's eye movements seen, no corneals, with nasal tickle will withdraw both L/E Motor - contracture and increased tone in L arm; will withdraw L arm; -moves R arm spontaneously -withdrawal of both L/E -Both toes upgoing Pertinent Results: Trop-T: 0.01 SLIGHTLY HEMOLYZED 135 101 15 176 AGap=13 4.8 26 0.7 Comments: Hemolysis Falsely Increases This Result estGFR: >75 (click for details) CK: 29 MB: Notdone 91 14.1 11.7 354 34.0 N:Pnd L:Pnd M:Pnd E:Pnd Bas:Pnd PT: 11.5 PTT: 27.3 INR: 1.0 CT head - old L MCA and R occipital infarcts; nil acute seen EEG: This is an abnormal EEG due to the slow and disorganized background with bursts of generalized slowing. ECG: Baseline artifact. Sinus rhythm. Borderline low limb lead voltage. Left bundle-branch block. Q-T interval prolongation. No previous tracing available for comparison. CXR: Perihilar edema. Brief Hospital Course: 81 y.o. woman with decreased LOC and witnessed L eye deviation and L arm weakness localizing to R hemisphere. Differential diagnosis included seizure from infarct in R hemisphere, hemorrhage, brain stem event. Head CT showed no ICH, large old right MCA and left PCA infarcts, and hyperdense MCAs and basilar arteries. CXR showed perihilar edema. The reported history of left-sided weakness and eye deviation to the left was more suggestive of focal seizures, rather than stroke. The patient was not a candidate for IV thrombolysis given recent retroperitoneal hemorrhage and pubic rami fractures, and concern for possible seizures. The impression was discussed with family who indicated that she was DNR/DNI, and that they would likely consider extubation if the patient was not in active status. STAT EEG showed generalised slowing without seizure activity. Brain CTA to r/o basilar occlusion (given a hyperdense basilar sign on CT), was planned, although the latter seemed less likely. Given a lack of clinical improvement, the family strongly indicated their wish to avoid further investigation and intervention, and to optimise comfort care. Medications on Admission: ASA Plavix Vicodin Discharge Medications: EXPIRED Discharge Disposition: Expired Discharge Diagnosis: EXPIRED Discharge Condition: EXPIRED Discharge Instructions: EXPIRED Followup Instructions: EXPIRED [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "V10.06", "433.00", "V45.82", "427.31", "427.81", "V43.64", "244.9", "414.01", "V45.01", "250.00", "V66.7" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

3940, 3949

2683, 3839

341, 350

4000, 4009

2021, 2660

4065, 4190

1526, 1544

3908, 3917

3970, 3979

3865, 3885

4033, 4042

1559, 2001

264, 303

378, 1143

1165, 1470

1486, 1510

53,470

181,975

4207

Discharge summary

report

Admission Date: [**2181-5-12**] Discharge Date: [**2181-5-20**] Date of Birth: [**2100-6-30**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: hypoxic respiratory distress Major Surgical or Invasive Procedure: none History of Present Illness: 80 yo W w/ end stage frontotemporal dementia, OSA, HTN, depression and an unprovoked PE dx in [**2-22**] on coumadin, who developed hypoxic respiratory distress, diagnosed with new PEs on CTA and admitted to MICU for monitoring. Of note, pt. was admitted to [**Hospital1 18**] [**Date range (1) 2820**] for diagnosis of submassive PE and dishcarged to [**Hospital1 1501**] on lovenox/coumadin. While at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **], has done will until the morning of admission, when patient was found to be SOB, unable to ambulate and weak while going to the bathroom. HR 110s and O2 sats in 70s on RA and 84-86% on 6L. Of note last INR was 1.3 on [**5-9**], last dose of coumadin at 4mg. INR was 2.4 on [**4-25**], when last checked (on 3mg at that time). No events noted by [**Hospital1 1501**] and they are unsure as to why INR may have decreased. No medication changes other decr. of risperidone dose and having been started on [**4-26**] on Carnation instant breakfast 120ml daily. In the ED, initial VS were: 97.7F 123/83 90 20 96% NRB. She underwent CTA that showed a new PE in addition to the prior. ECG was not done. Labs showed 11K, Trop < 0.01, lactate of 1.9. UA w/ pyuria, bacteriuria, positie nitrates w/ 57 epis. She received 650mg of APAP, CFTX 1g, Heprain gtt was started at 1300. Pt. is DNR/I from prior admission, family was not contact[**Name (NI) **] at time of admission. . On arrival to the MICU, pt. in NAD on 50% face mask. No acute complaints. She is unable to provide any reproducible history, her responses are incongruent. . Review of systems: unable to obtain reproducibly. Past Medical History: -Pulmonary embolism, Dx [**2-/2181**] on coumadin, 84% on RA with ambulation on d/c. -Frontal-temporal dementia: Neurocognitive decline has been tested at least three times consistent findings with frontal lobe "dementia." -Spinal stenosis: arthritis of lumbar spine with sciatica diagnosed in [**2172**]. -Depression: currently on Fluoxetine -Mild sleep apnea, although patient refuses to use equipment. -Hypertension in past: subsequently had "low blood pressure" treated with Florinef. -Bilateral cataract surgeries in [**2170**]. -Surgery on both feet foot for bunions. Chronic foot pain. Social History: Lives now in [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. In the past, lived [**Street Address(1) 18292**] Senior Living Center (adult [**Doctor Last Name **] day care). Per prior d/c summary, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], the program director at Bishop St., knows the patient well (contact #: [**Telephone/Fax (1) 18294**]; [**Telephone/Fax (1) 18295**]). Divorced, no kids, former violinist. Hcp/[**Telephone/Fax (1) 18297**] [**First Name4 (NamePattern1) **] [**Name (NI) 18298**] [**Telephone/Fax (1) 18299**] home, [**Telephone/Fax (1) 18300**] cell Tobacco - denies, long standing history prior to this. EtOH - denies Drug [**Doctor Last Name **] - denies. Family History: NC Physical Exam: ADMISSION EXAM General: Alert, disoriented, inattentive HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no JVD, no LAD CV: RR, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTA Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Awake, alert, inattentive. EOMI, VFF, Face symmetric, tongue midline. UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]-resistance. Toes down. . DISCHARGE EXAM VS - 97.5, BP 119/69 (98/56-135/71) , HR 85, R 20 , O2-sat 95% 4L GENERAL - well-appearing female in NAD, comfortable, appropriate HEENT - NC/AT, MMM, OP clear LUNGS - CTAB on the anterior chest HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, EXTREMITIES - WWP,no edema SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: ADMISSION LABS [**2181-5-12**] 10:35AM BLOOD WBC-11.1* RBC-4.22# Hgb-12.9 Hct-40.8# MCV-97 MCH-30.6 MCHC-31.6 RDW-13.7 Plt Ct-419 [**2181-5-12**] 10:35AM BLOOD Neuts-76.1* Lymphs-14.6* Monos-6.7 Eos-0.8 Baso-1.8 [**2181-5-12**] 10:35AM BLOOD PT-15.7* PTT-30.8 INR(PT)-1.5* [**2181-5-12**] 10:35AM BLOOD Glucose-110* UreaN-15 Creat-0.7 Na-137 K-4.8 Cl-103 HCO3-22 AnGap-17 [**2181-5-12**] 10:35AM BLOOD Calcium-8.8 Phos-4.8* Mg-1.9 [**2181-5-12**] 10:35AM BLOOD cTropnT-<0.01 proBNP-PND [**2181-5-12**] 10:54AM BLOOD Lactate-1.9 [**2181-5-12**] 11:00AM URINE RBC-0 WBC->182* Bacteri-MANY Yeast-NONE Epi-57 [**2181-5-12**] 11:00AM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG [**2181-5-12**] 11:00AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.017 . DISCHARGE LABS [**2181-5-17**] 07:02AM BLOOD WBC-10.0 RBC-3.95* Hgb-11.8* Hct-38.2 MCV-97 MCH-30.0 MCHC-31.0 RDW-14.2 Plt Ct-388 [**2181-5-17**] 07:02AM BLOOD PT-29.3* PTT-34.9 INR(PT)-2.8* [**2181-5-17**] 07:02AM BLOOD Glucose-129* UreaN-24* Creat-0.8 Na-144 K-4.4 Cl-110* HCO3-23 AnGap-15 [**2181-5-12**] 10:35AM BLOOD cTropnT-<0.01 proBNP-[**Numeric Identifier **]* [**2181-5-17**] 07:02AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.2 . MICROBIOLOGY [**2181-5-12**] 11:31 am URINE ADDED TO SPECIMEN 67639B. **FINAL REPORT [**2181-5-14**]** URINE CULTURE (Final [**2181-5-14**]): 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------------ 8 S AMPICILLIN/SULBACTAM-- 4 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 TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . Blood cultures [**2181-5-12**]- No growth x 2 . CTA [**2181-5-12**]: FINDINGS: There are curvilinear filling defects in the main pulmonary artery extending into the right main pulmonary artery and left main pulmonary artery. The left upper lobe artery appears patent but just distal to the bifurcation, there appears to be additional thrombus completely occluding one arterial branch. There is a large thrombus within the right main pulmonary artery extending into the right middle lobe artery and right lower lobe artery, some of which branches appear to be patent. There is flattening and perhaps mild bowing of the interventricular septum and reflux of contrast into the hepatic veins, as seen previously. The aorta and branch vessels demonstrate calcifications but are otherwise unremarkable. Trace pericardial fluid is within physiologic range and appears unchanged compared to recent prior exam. Diffuse patchy ground-glass opacity persists and is nonspecific. No pleural effusion or pneumothorax is detected. A 1-cm subcarinal lymph node is again noted. No other lymphadenopathy is detected. The visualized portion of the thyroid appears homogeneous. This study is not optimized for evaluation of subdiaphragmatic structures. Small hiatal hernia is again noted. No acute subdiaphragmatic process is detected. A 12-mm soft tissue density subcutaneous nodule in the left anterior chest wall is again noted. No concerning lytic or sclerotic osseous lesions are detected. IMPRESSION: Increased clot burden within the central and bilateral main pulmonary arteries. . Chest Xray [**2181-5-17**] FINDINGS: As compared to the previous radiograph, there is no relevant change. Borderline size of the cardiac silhouette without evidence of pulmonary edema. No pleural effusions. No focal parenchymal opacity suggesting pneumonia. Normal hilar and mediastinal structures . CTA [**2181-5-17**] Extensive pulmonary emboli with increased clot burden in the left descending and lower lobe pulmonary artery with associated right heart strain and enlargement of pulmonary artery. . TTE [**2181-5-19**] The left atrium is elongated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Severe pulmonary hypertension. Dilated and hypertrophied right ventricle with mild global systolic dysfunction. Normal global and regional left ventricular systolic function. Moderate tricuspid regurgitation. Compared with the prior study (images reviewed) of [**2181-3-1**], estimated pulmonary pressures have further increased. Brief Hospital Course: Primary Reason for Admission 80 yo W w/ end stage frontotemporal dementia, OSA, HTN, depression and an unprovoked PE dx in [**2-22**] on coumadin, who developed hypoxic respiratory distress, diagnosed with new PEs on CTA and admitted to MICU for monitoring. . # Hypoxic respiratory distress/ Submassive Acute Pulmonary Embolism- As above the patient presented in respiratory distress from her nursing facility. CTA demonstrated increased clot burden. which was felt to be the most likely etiology of her symptoms. Clot burden was significantly increased and appears to have saddle configuration. Etiology of orignal PE in [**2-22**] is unclear, but this current event is likely due to subtherapeutic INR in the setting of initiation of a vitamin K containing meal supplement (carnation instant breakfast). She was currently hemodynamically stable. Other etiologies such as PNA and cardiac ischemia were on the differential, but there was evidence of this clinically and troponins were negative x 2. During her ICU stay, the patient did not have increasing oxygen requirements and only required nasal cannula. She was started on heparin drip, then Lovenox until her INR could reach therapeutic levels. Lovenox was discontinued when INR was therapeutic. Her coumadin dose was decreased from her home dose of 4 mg daily given antibiotic treatment (see below). She remained hypoxic and had one acute desaturation to an oxygen saturation of 82% on 4 L NC. Repeat CTA was performed and showed increased clot burden despite therapeutic INR, in addition to evidence of right heart strain. She was restarted on lovenox and coumadin was discontinued. Both pulmonary and hemetology were consulted and recommended continuation of lovenox. Though it was felt presentation may be suggestive of an underlying malignancy. In discussion with her HCP the decision was made to forgo further work-up given her age and comorbities. The patient remained hemodynamically stable with was weaned to 4L nasal cannula. The patient was discharged back to [**Hospital3 **] after discussing her clinical status with the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] nurse practitioner. . # Aspiration risk- There was some some concern for risk of aspiration raised by nursing. She was evalutated by speech and swallow who recommended a diet of thin liquids and regular solids. . # UTI- Patient was noted to have a positive UA on admission with > 182 WBC. Urine culture grew E. coli. She was initally started on IV ceftriaxone which she received for 3 days. When sensitivities returned she was transitioned to oral nitrofurantoin 100 mg twice a day to complete a 7 day course. The patient was afebrile throughout admission without suprapubic tenderness on exam. Blood cultures were drawn on admission and were pending at the time of discharge. . STABLE ISSUES # Frontotemporal dementia- Patient has end state dementia. She was A+O x1 throughout this hospitalization which per report is her baseline. The patient was continued on risperdal, valproic acid. . # HTN: She has a documented history of hypertension but was not on anti-hypertensives as an outpatient. Patient was normotensive throughout this hospitalization. . # OSA. Has not tolerated CPAP in the past, therefore CPAP was not done while the patient was in house. . # Depression/anxiety- Patient was continued on her home celexa and buspar. . # GERD- Patient was continued on her home PPI . TRANSITIONAL ISSUES - DNR/DNI Medications on Admission: - Coumadin 4mg daily - omeprazole 20mg daily - citalopram 10mg daily - MVI - Risperdal 0.25mg 4PM - Buspar 10mg [**Hospital1 **] - VPA sprinkles 125mg [**Hospital1 **] - Docusate 100mg [**Hospital1 **] - Senna 8.6mg daily - aPAP prn - Ca/D 500/200 tid Discharge Medications: 1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO daily at 4 pm: . 4. divalproex 125 mg Capsule, Sprinkle Sig: One (1) Capsule, Sprinkle PO BID (2 times a day). 5. buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO three times a day. 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO three times a day as needed for pain/fever: Do not exceed 4 grams in 24 hours . 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Primary Diagnosis Acute Pulmonary Embolism Secondary Diagnosis Frontotemporal Dementia Depression Obstructive sleep apnea 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: Ms [**Known lastname **], It was a pleasure participating in your care while you were admitted to [**Hospital1 69**]. As you know you were admitted because you were having difficulty breathing. You had a CT scan which showed the clots in your lungs have gotten worse. This is most likely because the test we use to monitor your coumadin level was low. The clots continued to worse and we needed to switch you a new blood thinner. You were also found to have a urinary tract infection for which you were given antibiotics. We made the following changes to your medications 1. STOP Coumadin 2. START lovenox 70 mg twice a day Followup Instructions: You will be seen by your doctor at the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]

[ "294.10", "429.9", "041.49", "416.8", "V12.55", "276.0", "V58.61", "518.82", "401.1", "599.0", "724.02", "530.81", "331.19", "327.23", "415.19" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14504, 14626

9710, 13198

334, 340

14793, 14793

4348, 9687

15621, 15733

3407, 3411

13500, 14481

14647, 14772

13224, 13477

14969, 15598

3426, 4329

1995, 2028

266, 296

368, 1976

14808, 14944

2050, 2646

2662, 3391

52,077

163,736

35523

Discharge summary

report

Admission Date: [**2160-9-15**] Discharge Date: [**2160-9-22**] Date of Birth: [**2095-10-21**] Sex: M Service: MEDICINE Allergies: Adhesive Tape Attending:[**First Name3 (LF) 7651**] Chief Complaint: Right renal mass Major Surgical or Invasive Procedure: Right radical nephrectomy, caval extraction, Dr. [**Last Name (STitle) **], [**2160-9-15**]. History of Present Illness: From [**Hospital1 1516**] Service Accept Note: 64 M with h/o CAD, prior MI, non-ichemic Dilated Cardiomyopathy (EF 12%), Gout, TIAs x2, Empyema s/p Thoracotomy, s/p Right Radical Nephrectomy w/ resection & primary repair of IVC on [**2160-9-15**] for Renal Cell Carcinoma with IVC invasion. The patient is being transferred from T-SICU given his cardiac history. He had an uneventful recovery course thus far. Currently extubated, off pressors, on Pivoicaine (epidural) and Toradol for pain control. At this time, he denies SOB, CP, palpitations. He gets episodes of sharp pain at incision site lasting a few seconds, but otherwise his pain is under control. The patient also complains of gout fare in his right knee and left foot. His outpatient antihypertensives (Carvedilol, Lisinopril) and Aspirin are being held. The patient received Kefzol x 3 doses, which has been d/c'd. The patient is currently afebrile. . On review of systems, he denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. Reports TIAs in [**2155**] and [**2157**]. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Dilated cardiomyopathy (EF~10%) Prior MI (age unknown), incidental finding during workup for his TIAs x 2 Gout Empyema s/p Thoracotomy, VATS TIAs x 2 ([**2155**], [**2157**]) Social History: Lives in Senior Housing. Divorced. Retired plumber. -Tobacco history: Quit smoking in [**2148**]. 30 years x [**2-26**] ppd prior to that. -ETOH: The patient drinks 3-4 beers / day -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Father with [**Name2 (NI) **] Cancer, died at 86. Mother with Breast cancer and Colon Cancer, died at 73. Maternal uncle with cancer history as well. Physical Exam: From [**Hospital1 1516**] service Accept Note: VS: T=afebrile BP=153/90 HR=100 RR= 18 O2 sat= 98% RA GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of *** cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. Lungs clear to auscultation anteriorly. ABDOMEN: Soft, NTND. No abdominial bruits. Surgical site c/d/i. EXTREMITIES: No c/c/e. No femoral bruits. Swollen, erythematous toes L>R, tophi on fingers. Knees swollen and warm. SKIN: Multiple tophi on fingers. 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: Labs on Admission: Blood: [**2160-9-15**] 01:50PM BLOOD WBC-9.6 RBC-3.27* Hgb-9.8*# Hct-30.9* MCV-94 MCH-30.1 MCHC-31.9 RDW-12.9 Plt Ct-235 [**2160-9-15**] 01:50PM BLOOD Neuts-88.2* Lymphs-8.3* Monos-2.9 Eos-0.3 Baso-0.3 [**2160-9-15**] 01:50PM BLOOD PT-12.4 PTT-31.7 INR(PT)-1.0 [**2160-9-15**] 01:50PM BLOOD Glucose-149* UreaN-34* Creat-1.6* Na-136 K-4.5 Cl-107 HCO3-22 AnGap-12 [**2160-9-15**] 01:50PM BLOOD Calcium-8.5 Phos-3.8 Mg-1.8 [**2160-9-15**] 09:35AM BLOOD Type-ART Tidal V-600 FiO2-100 pO2-406* pCO2-45 pH-7.33* calTCO2-25 Base XS--2 AADO2-279 REQ O2-52 Intubat-INTUBATED Vent-CONTROLLED [**2160-9-15**] 09:35AM BLOOD Glucose-137* Lactate-0.8 Na-136 K-4.8 Cl-105 [**2160-9-15**] 09:35AM BLOOD Hgb-11.6* calcHCT-35 [**2160-9-15**] 09:35AM BLOOD freeCa-1.16 Urine: [**2160-9-16**] 08:54PM URINE CastGr-0-2 [**2160-9-16**] 08:54PM URINE RBC-0-2 WBC-[**3-27**] Bacteri-NONE Yeast-NONE Epi-0-2 RenalEp-0-2 [**2160-9-16**] 08:54PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2160-9-16**] 08:54PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 MRSA screen ([**2160-9-15**]): [**2160-9-15**] 1:50 pm MRSA SCREEN No MRSA isolated. [**2160-9-16**] 8:54 pm URINE CULTURE Source: Catheter. NO GROWTH. [**2160-9-16**] 11:15 pm BLOOD CULTURE x 2 Source: Venipuncture. NO GROWTH. [**2160-9-21**] 12:27PM JOINT FLUID WBC-[**2176**]* RBC-2700* Polys-92* Lymphs-0 Monos-8 [**2160-9-21**] 12:27 pm JOINT FLUID Source: Knee. GRAM STAIN (Final [**2160-9-21**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2160-9-24**]): NO GROWTH. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2160-9-22**]): Feces negative for C.difficile toxin A & B by EIA. RENAL PATHOLOGY ([**2160-9-15**]): Macroscopic extent of tumor: Tumor extension into major veins. MICROSCOPIC Histologic Type: Conventional (clear cell) renal cell carcinoma. Histologic Grade: G3: Nuclei very irregular, approximately 20 microns;nucleoli large and prominent. EXTENT OF INVASION Primary Tumor: pT3b: Tumor grossly extends into the renal vein or its segmental (muscle-containing) branches, or vena cava below the diaphragm. Regional Lymph Nodes: pN0: No regional lymph node metastasis. Lymph Nodes Number examined: 6. Number involved: 0. Distant metastasis: pMX: Cannot be assessed. Margins Margin(s) involved by invasive carcinoma: Renal vein margin only. Adrenal gland: Uninvolved by tumor. Venous invasion: Present. Additional Pathologic Findings: None identified. ADDENDUM: Additional sections (P-R) were submitted. There is no definite invasion of the renal sinus or perinephric fat. ECHO ([**2160-9-15**]): The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis with overall left ventricular systolic function being severely depressed (LVEF= [**11-6**] %). There is preservation of the basal rim of myocardium. The mid to distal anterior, inferior, anterolateral and inferolateral walls are severely hypokinetic. The mid to distal infero and antero septal walls are dyskinetic. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. Mild to moderate ([**1-25**]+) mitral regurgitation is seen. There is no pericardial effusion. ECG ([**2160-9-15**]): Sinus rhythm. Left bundle branch block. Compared to the previous tracing of [**2160-9-5**] multiple abnormalities persist without major change. CXR ([**2160-9-15**]): The ET tube tip is 6.7 cm above the carina, just at the level of the clavicular head. The NG tube tip is in the stomach. The Swan-Ganz catheter tip is at the right ventricle outflow tracts/main pulmonary artery. Cardiomediastinal silhouette is stable. Free air below the right hemidiaphragm is seen most likely related to recent nephrectomy and should be closely followed. There is no pleural effusion or pneumothorax. CXR ([**2160-9-16**]): Persistent large volume of free air under the diaphragm with bilateral lower lobe atelectasis. CXR ([**2160-9-18**]): Right subdiaphragmatic air (pneumoperitoneum) has decreased compared to [**2160-9-16**]. There is unchanged mild cardiomegaly without evidence of CHF. XRAY OF KNEE (AP, LAT, OBLIQUE, [**2160-9-20**]): There is some narrowing of the medial joint space compartment bilaterally, right greater than left. Both knees show suprapatellar fluid. However, no erosive changes are visualized and there is no evidence for fracture or dislocation. Brief Hospital Course: The patient is a 64 M with h/o Gout, TIAs x2, Empyema, Dilated Cardiomyopathy (EF~10%) s/p Right Radical Nephrectomy w/ resection & primary repair of IVC on [**2160-9-15**] for Renal Cell Carcinoma with IVC invasion. Each of the problems addressed during this hospitalization are described in detail below. Renal Cell Carcinoma: Patient was admitted to Dr.[**Doctor Last Name **] Urology service after undergoing right radical nephrectomy, IVC thrombectomy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the ICU from the OR in stable condition. The patient was successfully extubated in the ICU. The patient's post-operative course was uneventful. The patient's pain was initially controlled with PCA Morphine, epidural and Toradol. The patient was subsequently switched to PO regimen for pain control with PO Dilaudid [**4-28**] q3hrs PRN; IV Dilaudid for breakthrough pain. PCA, Epidural and Toradol were discontinued. On discharge, the patient's pain is well controlled with Oxycodone and Tylenol PRN, which he will continue to take as outpatient. The patient maintained good UOP, and Foley was discontinued. Post-operatively, Incentive Spirometry was encouraged 10X/hr. The patient was given Ondansetron 4-8 mg IV Q8H:PRN for nausea. The patient was initially held NPO, and diet was gradually advanced to regular, which the patient tolerated well. The patient received Physical Therapy throughout post-operative course. Ambulation was encouraged. Hematocrit remained stable throughout post-operative course. There were no signs of bleed, and the patient remained hemodynamically stable. The patient's creatinine initially bumped to 2.2, which was attributed to expected exacerbation of renal function s/p nephrectomy. However, on discharge Cr is down to 1.2, which an improvement from patient's pre-operative baseline of 1.4-1.5. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient has a follow-up appointment to with his urologist Dr. [**Last Name (STitle) **] in 3 weeks as outpatient. He will also follow up with his PCP. CAD: The patient with a history of prior MI, age undertermined as well as DCM (EF 12%). Last catheterization in [**2158**] per patient with no intervention. Recent ETT was not interpretable in the setting of LBBB and poor exercise tolerance. However, there was a noted patially reversible moderate defect of the apical -inferior wall on MIBI. Post-operatively, outpatient aspirin was held. The patient was instructed to hold Aspirin and avoid NSAID use until he is seen by Urology as outpatient. Outpatient Carvedilol was continued postoperatively. Lisinopril was initially held given acute creatinine bump from nephrectomy, but was re-started prior to discharge. The patient was closely monitored on Telemetry, which recorded no concenrning events. EKGs showed no acute changes. CHF: Dilated Cardiomyopathy with EF of 12% per recent perfusion scan. The patient does not have ICD, but states that he was evaluated for it recently. Post-operatively, volume status was closely monitored to assure that the patient remains euvolemic despite anticipated fluid shifts. Diuresis and fluid rescucitation were performed as necessary to maintain euvolemia. I&Os, urine output and Cr were monitored closely. The patient showed no signs of CHF exacerbation postoperatively. He has an appointment to follow-up with his cardiologist Dr.[**Name (NI) 3733**] upon discharge. Gout: Post-operative course was complicated by significant pain in knees and feet bilaterally c/w acute gout flare. X-ray of the knees was significant for b/l knee effusions, Uric Acid level was measured to be 10.4. The patient was seen by Rheumatology service, who aspirated left knee and performed bilateral gluocoritcoid injections. The patient received a single systemic dose of 20mg IV Methylprednisone. Pain was controlled as above. The patient was atrted on 0.6mg of colchicine daily, which he will continue as outpatient. The patient reported symptomatic improvement prior to discharge. He was able to ambulate with the assistance of a rolling walker. He will schedule an appointment to follow-up with Rheumatology service as outpatient. Medications on Admission: Lisinopril Carvedilol 25mg [**Hospital1 **] Aspirin 81mg daily Indomethacin Alleve and Tylenol PRN Discharge Medications: 1. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain: Do not drink or drive with this medication. . Disp:*36 Tablet(s)* Refills:*0* 5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. rolling walker 8. 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 With Service Facility: Visiting Nurse and Health [**State 2748**] Discharge Diagnosis: Primary: Right renal mass status post right radical nephrectomy, caval extraction, Gout, Dilated Cardiomyopathy. Secondary: Chronic Renal Disease, Hypertension, Hyperlipidemia Discharge Condition: Vitals stable, pain under control, able to ambulate Discharge Instructions: You were admitted to the hospital for surgery to remove your kidney and repair of your Inferior Vena Cava after you were noted to have a large mass. You tolerated the surgery well. During your recovery period, you were amditted to Cardiology service and we monitored you closely due to your prior history of a heart condition known as Dilated Cardiomyopathy. During this time, you also had a flare of gout, and were seen by Rheumatology team, who injected your knees with corticosteroids to reduce inflammation. You were also given a short course of systemic corticosteroids. At this time, your gout flare is under control and you are able to walk with the assistance of a rolling walker. We made several changes to your medications as follows: -Tylenol should be your first line pain medication. The maximum daily Tylenol dose is 4gm. A narcotic pain medication has been prescribed for breakthough pain as needed every 6 hours. Do not drive or drink alcohol while taking narcotics -We decreased your dose of Carvedilol (Coreg) to 6.25mg twice a day. - Please take colchicine 0.6 mg every day for your gout exacerbation. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. - Do not take NSAID (aspirin, and ibuprofen containing products such as advil & motrin) until you see your urologist in follow-up. Please ask Dr. [**Last Name (STitle) 261**] when you can restart your aspirin. -Resume all of your other home medications You also have the following instructions from your Urology team: -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 You have several follow-up appointments (see below). If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, cheat pain, palpitations, shortness of breath, nausea, vomiting, excessive sweating, chills, or any other concerning symptoms, call your doctor or go to the nearest ER -Call Dr. [**Last Name (STitle) **] if you have any urological questions. [**Telephone/Fax (1) 80892**] Followup Instructions: 1. You have an appointment with your Urologist Dr. [**Last Name (STitle) 261**] as follows: Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**] Date/Time:[**2160-10-1**] 10:00 Location: [**Hospital6 29**], [**Location (un) **] UROLOGY CC3 (NHB) You may call Dr.[**Doctor Last Name **] office ([**Telephone/Fax (1) 80892**]), if you have any urological questions prior to that. 2. You also have an appointment with your cardiologist Dr. [**Doctor Last Name 11723**] as follows: [**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2160-10-7**] Location: [**Hospital6 29**], [**Location (un) **] CC7 CARDIOLOGY (SB) 3. You also need to call to set up an appointment with a rheumatologist for follow up of your gout in [**1-25**] weeks. Please call [**Telephone/Fax (1) 2226**] to schedule appointment. 4. You also need to set up an appointment with your primary care doctor [**Last Name (Titles) 80893**],[**First Name3 (LF) **] S. Call to schedule appointment within 2 weeks at [**Telephone/Fax (1) 80894**]. Completed by:[**2161-2-25**]

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icd9cm

[ [ [] ] ]

[ "81.92", "38.67", "55.51", "38.07", "99.23" ]

icd9pcs

[ [ [] ] ]

13873, 13946

8449, 12968

292, 387

14167, 14221

3668, 3673

16578, 17750

2492, 2758

13118, 13850

13967, 14146

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188,364

11532

Discharge summary

report

Admission Date: [**2175-12-3**] Discharge Date: [**2175-12-7**] Date of Birth: [**2120-6-2**] Sex: M Service: ACOVE HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 9700**] is a 55-year-old male who denies any past medical history, who was found down status post assault and intoxicated in the [**Location (un) 14927**]on the day of admission. Patient was transferred via EMS to the [**Hospital3 **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] Emergency Department. Per records, patient smelled of ethanol, and was very combative in the Emergency Department. The patient had a questionable episode of hypotension with systolic blood pressure in the 80s, and in addition was combative on arrival in the Emergency Department. The patient was then sedated/paralyzed/intubated in the Emergency Department. Of note, patient's serum/urine toxicology screen was significant for an ethanol level of 297. In addition, in the Emergency Department, the patient became hypotensive plus questionable bradycardia in the setting intubation, morphine, versed, succinylcholine. The patient was given a fluid challenge, intravenous atropine with a subsequent return to normal pressure and normal heart rate. The patient was then admitted to the Intensive Care Unit for observation given the patient's intubation and ethanol level. On the second day of hospital admission, the patient was extubated without any problems and he was transferred to the floor. Trauma series of radiographs was negative as was CT abdomen/pelvis/head, C spine, CT thorax. After the patient was extubated on hospital day number two, he was hemodynamically stable. He showed no signs and symptoms of withdrawal, and was transferred to the floor for observation for ethanol withdrawal, as well as left lower extremity edema after assault. When the patient was awake, he was better able to describe his assault. Patient states he was in [**Location (un) 5069**], and "someone" assaulted him with a baseball bat to his left lower extremity. PAST MEDICAL HISTORY: The patient denies any past medical problems. SOCIAL HISTORY: Smokes one half to one pack of cigarettes per day. Drinks "one half pint" of Vodka every few days. Patient specifically denies daily ethanol use. Denies cocaine, heroin, or any other intravenous drug use. Patient has a girlfriend, lives with his mother, has several children. He works at [**Hospital6 256**] in "animal research" laboratory. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: None. PHYSICAL EXAMINATION: Vital signs on transfer to the floor: Temperature 99.7. Blood pressure 166/80. Pulse 82. Respiratory rate 20. Oxygen saturation 98% on room air. Physical examination: In general, this is a middle-aged African American male, laying in bed, no distress. Head, eyes, ears, nose and throat: Oropharynx pink. Mucous membranes slightly dry. Upper and lower teeth intact. Cardiovascular: Regular rate and rhythm, no murmurs. Chest: Good inspiratory effort, coarse breath sounds bilaterally, right-sided rhonchi/crackles. No wheezing. Abdomen: Soft, nontender, nondistended, bowel sounds present. No guarding. Extremities: Warm, no obvious fracture, right calf diameter 32 cm, left calf diameter 38 cm, left calf is tense, firm, but not tender to palpation. Genitourinary: Foley is intact. Neurological: Awake, alert, oriented, to person, place, time and situation. Cranial nerves are intact. Extraocular movements are intact. LABORATORY DATA ON TRANSFER TO THE FLOOR: White blood cell count 6.6, hematocrit 37.9, platelet count 257,000. Sodium 140, potassium 4.3, chloride 108, bicarbonate 27, BUN 8, creatinine 0.9, glucose 96, calcium 8.1, phosphorus 3.3, magnesium 1.7. Ethanol level 59. CK 3690 (this is increased from the previous value of 3349). CK-MB 115, troponin I less than 0.3. IMPRESSION: This is a 55-year-old male status post intubation/extubation after being found down after ethanol intoxication and assault on his left lower extremity. He is currently doing well, with no signs or symptoms of delirium tremens on second day of hospital admission. HOSPITAL COURSE: 1. Ethanol abuse: Patient was placed on DT precautions on a CIWA protocol. During the [**Hospital 228**] hospital admission, the patient did not have a temperature greater than 100. He was not tachycardic. Systolic blood pressure was not greater than 160, and he showed no signs of agitation or confusion, and no hallucinations. Patient did not experience any signs or symptoms of withdrawal during this period. In addition, the patient refused counseling for ethanol use/abuse. 2. Pulmonary: Patient had coarse rhonchi after extubation, however, within two days, he had cleared his secretions. The patient had an incentive spirometry at bedside for treatment of his atelectasis. 3. Nutrition: The patient tolerated a regular diet well. 4. Musculoskeletal: The patient had a left lower extremity swelling, but was not tender to palpation. Distal pulses were palpable. X-rays of his left tibia/fibula were obtained which showed well mineralized bones, no bone lesion, no radiopaque foreign bodies. There were also no apparent fractures. Because of the swelling, left lower extremity noninvasive vascular were obtained (Doppler), which showed normal color and wave forms. There was no thrombus seen and there was normal compressibility, which implied that there was no deep vein thrombosis. The left common femoral, superficial femoral, and popliteal veins were normal and no intraluminal thrombus was seen. When patient attempted to ambulate, the patient had severe pain with ambulation. An Orthopedic Consult was obtained to evaluate for compartment syndrome. Orthopedic Consult: Positive left calf swelling, but with an intact neurological examination to left calf/foot, as well as light touch. His left calf had a negative [**Last Name (un) 5813**] sign. Vascular exam revealed palpable dorsalis pedis and posterior tibial pulses. X-rays showed no fractures, no dislocations. IMPRESSION: This is a 55-year-old male, status post trauma to his left calf, but with no signs of compartment syndrome. Recommendations included decreased weight bearing in his left lower extremity secondary to pain, and providing the patient with crutches if necessary for assistance with gait. Also of note, the patient's CK continued to rise during patient's admission, and there was concern over rhabdomyolysis. The patient's CKs trended upwards and the patient was aggressively hydrated. On hospital day number three, the patient, after aggressive hydration, the patient's CK began to trend downwards, and on hospital day number four, the trend continued downwards as well. The maximum CK during his admission was 3690, on hospital day three, it had decreased to 2630, and on the day of discharge, had decreased to 1884. The patient's renal function remained within normal limits, and his BUN and creatinine were at 7 and 0.7 respectively on the day before discharge. The patient was instructed to drink copious amounts of nonalcoholic fluids after discharge. DISCHARGE DISPOSITION: Discharged to home. DISCHARGE CONDITION: On the day of discharge, patient's CK continued to decrease. Patient was ambulating without assistance, and patient's left lower extremity swelling had decreased slightly. Patient was afebrile and his blood pressure was within normal range, 130/72, and was able to ambulate without difficulty. Patient stated that he did not need crutches, and was walking "fine." Patient denied any pain/tenderness with ambulation. Observation of his gait revealed a grossly normal gait, and patient was able to stand on his left foot without support, bearing the weight of his full body without any pain. Since the patient declined crutches, he was given the phone number to the Orthopedics/[**Hospital 36721**] Clinic to follow-up if his signs or symptoms worsened or pain occurred. DISCHARGE DIAGNOSES: 1. Rhabdomyolysis, status post trauma to left lower extremity. 2. Ethanol abuse. 3. Hypertension ? episodic; may be secondary to pain, status post trauma. Should be followed as an outpatient. DISCHARGE MEDICATIONS: Patient was not discharged with any medications. Patient was instructed to drink greater than three liters of water or juice everyday. DISCHARGE FOLLOW-UP: Discharge follow-up was scheduled with the [**Hospital6 733**] Clinic, with his new primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Patient was to follow-up with his new primary care physician for [**Name Initial (PRE) **] recheck of CK, BUN, creatinine, as well as evaluation for left lower extremity swelling, and questionable hypertension. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern1) 14484**] MEDQUIST36 D: [**2176-3-20**] 04:31 T: [**2176-3-23**] 13:17 JOB#:[**Job Number 36722**]

[ "728.89", "518.82", "924.10", "458.9", "E968.2", "401.9", "305.00" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

7187, 7208

7230, 8005

8026, 8223

8247, 9067

2549, 2556

4184, 7163

2750, 4166

161, 2051

2074, 2121

2138, 2522

2,092

105,566

26061+26062

Discharge summary

report+report

Admission Date: [**2187-9-19**] Discharge Date: [**2187-10-5**] Date of Birth: [**2134-1-7**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Altered mental status, fever Major Surgical or Invasive Procedure: [**9-23**]: CT guided drainage of RUQ fluid collection and drain placement History of Present Illness: 53M quadraplegic s/p MVA in [**2180**]. He is chronically vent dependent through trach, has neurogenic bladder, SVC filter on coumadin, and pacemaker for episodes of bradycardia/asystole with suctioning or laying flat per his wife. [**Name (NI) **] began to experience malaise, fevers to 100 at home starting [**9-1**]. Wife and son with URI preceding symptoms. On morning of admission to OSH, noted to have dark urine from suprapubic catheter. At OSH found to have leukocytosis and complete left lung opacification on CXR. Admitted to ICU. Waxing and [**Doctor Last Name 688**] mental status beginning hospital day 4 with intermittent episodes of tongue thrashing, head deviations, and grimacing. At baseline, patient alert, oriented, very interactive with family. Neurology did 20 min EEG on [**9-10**] showing slow back ground with no Sz focus. He was started on keppra around [**9-10**] for prophylaxis. Wife notes that pt missed several doses of baclofen during admission. His course was notable for multiple bronchs which revealed thick mucous plugs that were not able to fully remove to reairate. [**9-6**] BAL grew ecoli and klebsiella (no sensitivities reported), TB negative. [**9-10**] BAL grew acinetobacter sensitive to zosyn and klebsiella sensitive to cefepime, ctx, imipenem. Blood Cx [**9-5**] grew staph epidermidis sensitive to oxacillin, cefazolin, vancomycin and clindamycin, repeat cx [**9-14**] showed no growth. Stool cx [**9-9**] C diff negative.Urine culture with Enterococcus sensitive to vanco, levo, linezolid. Pt was treated initially w/ vanc and zosyn starting [**9-5**]. Of note, HCT drop 29.7 to 22.6 and pt was transfused 4 units RBCs, no bleeding source identified. On [**9-18**], he was transferred out of the ICU and found to have fevers to 102, switched to vanc and cefepime. He has a CVL since [**9-5**]. CT chest on [**9-9**] showed air bronchograms, partial collapse on left lung. Head CT showed no acute process. CXR [**9-18**] showed no change in left opacity w/ new opacities on the right. Abdominal CT showed "inflammation of the hepatic flexure," colonoscopy not performed. His vent settings are AC 450, 15, 50%. His sats were 96% and last ABG was 7.44, 43, 77 from [**9-18**]. Transferred to [**Hospital1 18**] for continuous EEG monitoring and further evaluation. Labs prior to transfer were INR 4.37 (holding coumadin), WBC 12.9, hematocrit 32, platelet 500, Na 145, K 4.5, BUN 13, Creat 0.5. Review of systems: (+) Per HPI, Per wife and daughter: no HA, no diarrhea, no bloody or tarry stools, no nausea/vomiting prior to admission Past Medical History: -MVA [**2180**] resulting in C2/C3 fracture and quadriplegia -respiratory failure, ventilator dependent with tracheostomy placed [**2181**] -Neurogenic bladder with suprapubic catheter changed every 3 weeks, most recently [**2187-9-5**] at OSH -DVT s/p IVC, on warfarin -Anxiety, depression on Lexapro -Obesity Social History: Lives at home with wife. Chronically on vent but able to eat, talks when cuff deflated. Usees wheelchair with family assistance. Normal mental status at baseline. Patient is as former police officer. Family History: Father CVA x2, deceased age 78. No h/o seizure or neurological disorders. No MI. No CA. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 98.7 P78 151/95 99% on FiO2 33 General: somnolent, opens eyes to voice Skin: 1x1.5cm sacral decubitus ulcer without surrounding erythema or exudate; R subclavian line in place, no erythema or induration of site HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: trach in place, tracheostomy without erythema or dischargeCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Diffuse rhonchi bilaterally, exam limited to anterior chest Abdomen: moderately distended, soft, loud BS throughout, suprapubic catheter in place with slight erythema, no discharge Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis, +edema bilateral feet and lower legs (@baseline per wife) Neuro: somnolent, opens eyes to voice, unable to follow commands Discharge Physical Exam: Vitals: 97.6 P 60 100/46 R 17 100% (FiO2 40%) General: awake and alert, nodding head appropriately to questions HEENT: Sclera anicteric, MM dry Neck: trach in place, tracheostomy without erythema or discharge CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: clear to auscultation anteriorly Abdomen: soft, nontender, nondistended, RUQ dressing clean/dry/intact Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis, 3+ edema bilateral feet and lower legs Pertinent Results: ADMISSION LABS [**2187-9-19**] 11:19PM WBC-15.2* RBC-4.05* HGB-11.5* HCT-35.7* MCV-88 MCH-28.4 MCHC-32.2 RDW-15.2 [**2187-9-19**] 11:19PM PLT COUNT-456*# [**2187-9-19**] 11:19PM NEUTS-90.0* LYMPHS-5.7* MONOS-4.0 EOS-0.2 BASOS-0.1 [**2187-9-19**] 11:19PM PT-60.3* PTT-57.2* INR(PT)-6.0* [**2187-9-19**] 11:19PM ALT(SGPT)-15 AST(SGOT)-11 CK(CPK)-31* ALK PHOS-150* TOT BILI-0.5 [**2187-9-19**] 11:19PM ALBUMIN-3.7 CALCIUM-9.0 PHOSPHATE-2.6*# MAGNESIUM-2.3 [**2187-9-19**] 11:19PM GLUCOSE-188* UREA N-20 CREAT-0.4* SODIUM-148* POTASSIUM-3.1* CHLORIDE-107 TOTAL CO2-30 ANION GAP-14 [**2187-9-19**] 11:20PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018 [**2187-9-19**] 11:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR [**2187-9-19**] 11:20PM URINE RBC-16* WBC-4 BACTERIA-FEW YEAST-NONE EPI-1 MICRO [**2187-9-23**] 3:43 pm ABSCESS Source: RUQ fluid collection. GRAM STAIN (Final [**2187-9-23**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2187-9-26**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2187-9-29**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2187-9-22**] 2:34 pm BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2187-9-26**]** GRAM STAIN (Final [**2187-9-22**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2187-9-25**]): Commensal Respiratory Flora Absent. IDENTIFICATION AND Susceptibility testing requested by [**Last Name (LF) 13210**],[**First Name3 (LF) **] ([**Numeric Identifier 13211**]) [**2187-9-24**]. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. 10,000-100,000 ORGANISMS/ML.. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. KLEBSIELLA PNEUMONIAE. ~6OOO/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA | PSEUDOMONAS AERUGINOSA | | KLEBSIELLA PNEUMONIAE | | | AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- 4 S <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- <=0.25 S <=0.25 S GENTAMICIN------------ 4 S <=1 S MEROPENEM------------- 1 S <=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S [**2187-9-21**] 8:00 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2187-9-21**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2187-9-24**]): 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. GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML.. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. GRAM NEGATIVE ROD #3. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 4 S MEROPENEM------------- 1 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S LEGIONELLA CULTURE (Final [**2187-9-28**]): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): YEAST. IMAGING CXR [**2187-9-19**]: COMPARISON: [**2180-12-24**]. FINDINGS: Tracheostomy tube in situ. The patient also has a right subclavian vein catheter, the tip of the catheter projects over the upper SVC. The patient has received a left pectoral pacemaker, the course and position of the leads is unremarkable. In the interval, the patient has developed a volume loss of the left lung, associated to a diffuse fibrotic process and pleural thickening. In addition, a parenchymal opacity at the right upper lobe base is seen. This opacity might be more recent and infectious in origin. The heart continues to be mildly enlarged. Mild fluid overload is present. The parenchymal processes, if clinically relevant, could be further evaluated by CT. Continuous EEG [**2187-9-20**]: IMPRESSION: This is an abnormal continuous ICU monitoring study. The background showed mixed theta and delta activity, suggesting a moderate encephalopathy, which is etiologically nonspecific. There are no epileptiform discharges or seizures recorded CT Guided Drainage of RUQ fluid collection [**2187-9-23**]: IMPRESSION: Technically successful CT-guided drainage of the right upper abdominal fluid collection yielding black fluid, uncertain whether this is bilious or represents old blood products. Fluid analysis is recommended. A colonic etiology should be considered given the imaging findings. However if the fluid is bilious consideration could be given to a perforated gallbladder. Microbiology is pending. CXR [**2187-9-24**]:Left lower lobe collapse is persistent. Peripheral consolidation in the left upper lobe is unchanged. There has been worsening of aeration in the left upper lobe likely new atelectasis in the lingula. Right lower lobe atelectasis is grossly unchanged. Cardiomediastinum is shifted towards the left. Tracheostomy is in a standard position. Pacer leads are in the standard position. NG tube tip is out of view below the diaphragm. Right pigtail catheter tip is at the cavoatrial junction. CT Abd/Pelvis [**2187-10-2**]:IMPRESSION: 1. Significant improvement in the right pericolonic fluid collection adjacent to the hepatic flexure of the colon. Pigtail catheter remains in place. There is only minimal residual phlegmon within this region. 2. Stable bibasilar airspace consolidation with atelectasis and small bilateral pleural effusions, greater on the left. Persistent left pleural thickening and enhancement suggestive of underlying chronic inflammation versus underlying infection as previously mentioned. 3. Persistent soft tissue stranding in the right flank without identifiable fluid collection. The above findings were discussed with the resident in charge of patient, Erina [**Last Name (un) **] at 5:50 p.m. on [**2187-10-2**]. The resident was notified about the significant improvement of the fluid collection since [**2187-9-21**]. Discussion was underway as to possible removal of the right sided drainage catheter. Brief Hospital Course: Brief Course: Mr. [**Known lastname **] is a 53 yo quadraplegic man s/p MVA in [**11/2180**], chronically vent-dependent, who presented to an outside hospital with fevers and AMS found to have fluid collection in colon near hepatic flexure. Active Issues: # Altered Mental Status: Mr. [**Known lastname 64705**] altered mental status on admission was likely delirium secondary to multiple factors, possibly toxic metabolic encephalopathy from infection in the setting of recent fevers and elevated WBC. Levetiracetam started at the OSH was continued and continuous EEG monitoring was performed given reported jerking movements of his face and head. No seizure activity was shown on EEG and prophylactic levetiracetam was continued until 2 days prior to discharge with no recurrence of involuntary movements. Pt became increasingly more alert and was able to communicate verbally with the trach cuff deflated. # Right upper quadrant fluid collection: Pt was found to have a peri-colonic fluid collection adjacent to the hepatic flexure of unclear etiology and underwent percutaneous drainage by IR on [**2187-9-23**] with placement of a pigtail catheter in the area of the fluid collection. The fluid was determined to be bilious (bilirubin 31.5, gastro-occult negative) and thought to be related to a gall bladder perforation, but HIDA scan did not show evidence of acute cholecystitis. Fluid cultures showed no growth. Bilious fluid drained continuously until [**10-2**] when there was concern that the catheter was damaged. Repeat CT abd/pelvis on [**2187-10-2**] showed significant improvement of the fluid collection with minimal residual phlegmon and the drain was removed at the bedside on [**10-3**]. Since the exact origin of the fluid collection remains unclear, he will need to follow-up for a colonoscopy after discharge. Because he is ventilator dependent, the procedure is scheduled to be performed in the [**Hospital1 18**] [**Hospital Unit Name 153**] on [**2187-11-13**]. Coumadin should be held 1 week prior to colonoscopy. # Respiratory failure: Patient has what appears to be chronic left lung collapse. IP performed bronchoscopy on [**9-22**] which did not show significant secretions to warrant treatments such as cryotherapy to break up secretions and recruitment maneuvers have not been able to open up airways. Left pleural effusing was not thought to be large enough to warrent US/CT guided drainage. A BAL grew Pseudomonas and Klebsiella for which he completed a 10 day course of meropenem on [**9-28**]. BAL also grew Stenotrophomonas which was questionable for colonization rather than infection, but he completed 8 day course of Bactrim on [**10-2**]. He does not require further ID follow-up. # Constipation: Patient was constipated for several days while he was on tube feeds and dilated loops of small bowel seen on KUB were suggestive of ileus. He began to have bowel movements again after his bowel regimen was optimized and he was started on a regular diet once his mental status improved. # Edema: Patient has edema at baseline. Home furosemide dose was started after confirmation of his home meds but patient was net positive 13L at time of discharge. He had brisk diuresis to IV lasix, but not to his PO regimen, possible to to bowel edema. On discharge, his lasix was changed to torsemide 20mg PO BID. He will need follow-up of his electrolyte panel after discharge. # Repetitive facial movements: Mr. [**Known lastname **] had repetitive facial movements early during admission which resolved after restarting baclofen. 24 hour EEG was negative and prophylactic Keppra was discontinued 2 days prior to discharge. # Hypertension: Pt experienced intermittent episodes of HTN with systolic blood pressures >180. These episodes seemed to correlate with agitation and discomfort. Pain control was optimized and hydralazine boluses were used to treat sustained sbp >180. At the time of discharge, his blood pressures were at his baseline with SBP in the 100s. # Pain: Patient was monitored for pain control and treated with his home dose of methadone 15mg [**Hospital1 **] prn. # Coagulopathy. Likely due to poor nutrition and prolonged antibiotics. Coumadin was held due to supratherapeutic INR (6) on admission but home dose was restarted at discharge. He will need to have a repeat INR as an outpatient. # Anemia: Per OSH report, he received 4 units PRBCs prior to transfer to [**Hospital1 18**], but the circumstances were unclear. His HCT during admission decreased from 35.7 to 25.2 with no signs of active bleeding. Workup for hemolysis and DIC was negative. He had no signs of active bleeding and remained hemodynamically stable without transfusion. This may be related to hemodilution as his fluid balance was net positive as noted above. Inactive Issues: # Quadraplegia: Pt has been quadriplegic following remote MVA in 11/[**2180**]. Routine care was continued throughout admission. Transitional Care Issues: 1. Code staus: DNR/DNI 2. Contact: Wife 3. Medication changes: - START Torsemide 20mg [**Hospital1 **] - STOP Furosemide 40mg [**Hospital1 **] - RESTART Warfarin as you were taking it prior to this admission 4. Follow up: -PCP [**Name10 (NameIs) 64706**] readmit to [**Hospital Unit Name 153**] on [**11-13**] for colonoscopy 5. Pending labs: None Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Coumadin 3 mg PO 2X/WEEK (MO,FR) Monday and Friday 2. Coumadin 2.5 mg PO 5X/WEEK ([**Doctor First Name **],TU,WE,TH,SA) Sun, Tue, Wed, Thurs, Sat 3. glimepiride *NF* 2 mg Oral daily 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Juven *NF* (arginine-glutamine-calcium Hmb) 7-7-1.5 gram Oral [**Hospital1 **] 6. Dantrolene Sodium 50 mg PO TID 7. Multivitamins 1 TAB PO DAILY 8. Furosemide 40 mg PO BID 9. BuPROPion 200 mg PO BID 10. Guaifenesin ER 600 mg PO Q12H 11. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Hold for K >5 12. Escitalopram Oxalate 20 mg PO DAILY 13. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation [**Hospital1 **] 14. Lyrica 100 mg PO TID 15. Methadone 15 mg PO BID 16. Ascorbic Acid 500 mg PO TID 17. Baclofen 20 mg PO TID 18. Baclofen 40 mg PO QHS 19. BusPIRone 10 mg PO QID 20. Tizanidine 2 mg PO QID 21. Omeprazole 20 mg PO DAILY 22. Methadone 5 mg PO QHS:PRN pain 23. Tums 500 mg PO X2 PRN indigestion 24. Magic Bullets *NF* (bisacodyl) 10 mg Rectal Daily:PRN constipation 25. Acetaminophen 650 mg PO Q4H:PRN pain 26. Miralax 17 g PO TID:PRN constipation 27. Colace 100 mg PO BID constipation 28. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing 29. Neosporin 1 Appl TP QID 30. Povidone Iodine Full Strength Dose is Unknown TP ASDIR 31. Ibuprofen 600 mg PO Q8H:PRN pain 32. Magnesium Citrate 300 mL PO PRN DAILY constipation 33. Diazepam 5 mg PO Q6H:PRN spasms 34. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 35. Triple Antibiotic *NF* ( n eomycin-bacitracin-polymyxin;<br>neomycin-bacitracnZn-polymyxin) 3.5-400-5,000 mg-unit-unit/g Topical PRN rash/skin breakdown 36. Fentanyl Patch 25 mcg/h TP Q3DAYS PRN pain 37. ALPRAZolam 0.25 mg PO Q4H:PRN anxiety Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. ALPRAZolam 0.25 mg PO Q4H:PRN anxiety 3. Baclofen 20 mg PO TID 4. BuPROPion 200 mg PO BID 5. Escitalopram Oxalate 20 mg PO DAILY 6. Diazepam 5 mg PO Q6H:PRN spasms 7. BusPIRone 10 mg PO QID 8. Guaifenesin ER 600 mg PO Q12H 9. Ibuprofen 600 mg PO Q8H:PRN pain 10. Lyrica 100 mg PO TID 11. Tums 500 mg PO X2 PRN indigestion 12. Methadone 15 mg PO BID 13. Miralax 17 g PO TID:PRN constipation 14. Tizanidine 2 mg PO QID 15. Magic Bullets *NF* (bisacodyl) 10 mg Rectal Daily:PRN constipation 16. Magnesium Citrate 300 mL PO PRN DAILY constipation 17. Colace 100 mg PO BID constipation 18. Coumadin 3 mg PO 2X/WEEK (MO,FR) Monday and Friday 19. Coumadin 2.5 mg PO 5X/WEEK ([**Doctor First Name **],TU,WE,TH,SA) Sun, Tue, Wed, Thurs, Sat 20. Dantrolene Sodium 50 mg PO TID 21. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation [**Hospital1 **] 22. Fentanyl Patch 25 mcg/h TP Q3DAYS PRN pain 23. glimepiride *NF* 2 mg ORAL DAILY 24. Juven *NF* (arginine-glutamine-calcium Hmb) 7-7-1.5 gram Oral [**Hospital1 **] 25. MetFORMIN (Glucophage) 500 mg PO BID 26. Multivitamins 1 TAB PO DAILY 27. Neosporin 1 Appl TP QID 28. Omeprazole 20 mg PO DAILY 29. Triple Antibiotic *NF* ( n eomycin-bacitracin-polymyxin;<br>neomycin-bacitracnZn-polymyxin) 3.5-400-5,000 mg-unit-unit/g Topical PRN rash/skin breakdown 30. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 31. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Hold for K >5 32. Torsemide 20 mg PO BID RX *torsemide 20 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 33. Ascorbic Acid 500 mg PO TID 34. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing Discharge Disposition: Home With Service Facility: Centrus Home Care Discharge Diagnosis: Primary: 1. Right upper quadrant fluid collection 2. Respiratory failure Secondary; 1. Quadraplegia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 18**]. You were transferred here with fevers and delirium and were found to have a fluid pocket in your abdomen which was drained. You also had difficulty with your breathing for which we increased your ventilation support and treated you for a lung infection. You will be readmitted to the ICU for a colonoscopy on [**11-13**] to further evaluate the cause of this abdominal fluid collection. The following changes were made to your medications; 1. START Torsemide 20mg [**Hospital1 **] 2. STOP Furosemide 40mg [**Hospital1 **] 3. RESTART Warfarin as you were taking it prior to this admission Followup Instructions: You will be directly readmitted to the [**Hospital Unit Name 153**] at [**Hospital1 18**] on [**11-13**], [**2187**], for your colonoscopy. Please stop taking your warfarin 1 week prior to this date. Also, please call your PCP to schedule [**Name Initial (PRE) **] follow up appointment for next week. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2187-10-6**] Admission Date: [**2187-10-8**] Discharge Date: [**2187-10-26**] Date of Birth: [**2134-1-7**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3984**] Chief Complaint: AMS, Fever Major Surgical or Invasive Procedure: Percutaneous abdominal drainage History of Present Illness: 53M quadraplegic s/p MVA in [**2180**], chronically vent dependent through trach, neurogenic bladder, SVC filter on coumadin, and pacemaker for episodes of bradycardia/asystole who presents after a recent hospitalization for sepsis with lethargy, a fever, and inability to speak or eat. He was discharged from the hospital on [**Last Name (LF) **], [**10-5**] and was near his baseline at home over the weekend. On the day of admission his wife noted that he was agitated, speaking in nonsense words, was febrile and speaking in nonsense words. He was reportedly swearing at the VNAs, which is uncharacteristic for him. He endorses ongoing abdominal pain which predates his previous admission, loose stools since a bowel prep was attempted during his previous admission, and nausea. His blood glucose was elevated in the 200s today. He did not have any changes in his secretions and no blood in his secretions. Loss of appetite today whereas he usually eats a regular diet. On [**9-14**] the patient presented to an OSH with a fever x 2 days. Work up there demonstrated vent associated pneumonia and mucus plug of L lung, and transaminitis. He was started on broad spectrum antibiotics. During his hospitalization at the OSH, the patient had a CT abdomen demonstrating colonic thickening at the hepatic flexure. He required 4 units of blood (circumstances unclear from the OSH documentation).The patient had continued fevers and leukocytosis despite antibiotics so the family requested transfer patient care to [**Hospital1 18**] on [**9-19**]. During his work-up for leukocytosis here, the patient was found to have a fluid collection in the RUQ. An IR placed drain produced bilious fluid. Drain was removed prior to discharge. Also during this admission he was found to have a partially collapsed left lung likely secondary to mucous plugging. Multiple bronchoscopies were done to relieve the obstruction without clinical benefit. He was also noted to have seizure activie in the setting of missing several doses of his baclofen and he was started on keppra. A colonoscopy was scheduled for [**11-13**] in follow up of the hepatic flexure inflammation. In the ED, initial VS were: Tmax 102.9 HR 86 BP 140/80 RR 18. He received Morphine 5 mg, ondansetron 4mg ODT, Acetaminophen 650 mg. Attempts were made at bilateral femoral lines and may have gotten artery on the left. Pressure was held for 15-20 minutes. Was hemodynamically stable in the ED. CXR is unchanged and UA does not show evidence of infection. In ED was more alert and able to converse and answer questions. On arrival to the MICU, he is alert and appropriately responsive to questions. Wife is with the patient and provided much of the history above. BAL:[**9-6**]: E.coli, Klebsiella (no sensitivities, TB negative) [**9-10**]: Acinetobacter sensitive to zosyn, klebsiella sensitive to cefepime, ctx, impipenem BCx:[**9-5**]: Staph epidermidis sensitive to oxacillin, cefazolin, vanc, clindamycin [**9-14**]: No growth Stool: [**9-9**], C. diff negative Urine: Enterococcus sensitive to vanco,levo, linezolid. History of VRE. Review of systems: per wife (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies, shortness of breath, or changes in sputum. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, diarrhea, abdominal pain, or changes in bowel habits. Denies rashes or skin changes. Past Medical History: -MVA [**2180**] resulting in C2/C3 fracture and quadriplegia -Respiratory failure, chronic, ventilator dependent with tracheostomy placed [**2181**] -Left lung atalectasis, subtotal, chronic: unresponsive to repeated bronchoscopies -Neurogenic bladder with suprapubic catheter changed every 3 weeks, most recently [**2187-9-5**] at OSH -DVT s/p IVC, on warfarin -Anxiety, depression on Lexapro -Obesity Social History: Lives at home with wife. Chronically on ventilator at home, and able to eat, talks when cuff deflated. Usees wheelchair with family assistance. Normal mental status at baseline. Patient is as former police officer. Family History: Father CVA x2, deceased age 78. No h/o seizure or neurological disorders. No MI. No CA. Physical Exam: ADMISSION PHYSICAL EXAM: General: awake and alert, nodding head appropriately to questions HEENT: Sclera anicteric, MM dry. Neck: trach in place, tracheostomy without erythema or discharge CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: clear to auscultation anteriorly Abdomen: soft, mildy tender diffusely, nondistended, RUQ dressing. Suprapubic catheter in place. clean/dry/intact Ext: Warm, well perfused, no clubbing or cyanosis, 3+ edema bilateral feet and lower legs. Left femoral access site with minimal bleeding on dressing. Right femoral site without any bleeding. *Skin breakdown on coccyx, stage II DISCHARGE PHYSICAL EXAM: VS- 99 84 110/51 100% RA General: Pt a&ox3 with trach in place HEENT: Sclera anicteric, MM dry. Neck: trach in place, tracheostomy without erythema or discharge. Right PICC. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bilateral rhonchi Abdomen: Slightly worsening distention (likely bowel gas). Soft, non-tender. RUQ dressing. Suprapubic catheter in place. RUQ catheter draining scant cloudy brown fluid. clean/dry/intact. +BS Rectal: Rectal tube in place draining green stool. Ext: Warm, well perfused, no clubbing or cyanosis, 3+ edema bilateral feet and lower legs. Pertinent Results: Admission: [**2187-10-8**] 07:25PM URINE RBC-6* WBC-9* BACTERIA-NONE YEAST-RARE EPI-0 [**2187-10-8**] 07:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-8.5* LEUK-TR [**2187-10-8**] 07:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2187-10-8**] 07:25PM URINE GR HOLD-HOLD [**2187-10-8**] 07:25PM URINE HOURS-RANDOM Discharge: [**2187-10-26**] 04:15AM BLOOD WBC-7.7 RBC-3.05* Hgb-9.0* Hct-27.4* MCV-90 MCH-29.5 MCHC-32.9 RDW-18.2* Plt Ct-220 [**2187-10-26**] 04:15AM BLOOD PT-12.7* INR(PT)-1.2* [**2187-10-26**] 04:15AM BLOOD Glucose-187* UreaN-26* Creat-0.3* Na-140 K-4.5 Cl-110* HCO3-19* AnGap-16 [**2187-10-24**] 04:21AM BLOOD ALT-72* AST-55* AlkPhos-256* TotBili-0.8 [**2187-10-26**] 04:15AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.3 CT Abd [**10-11**] 1.Interval development of air-fluid level in the previously seen extraluminal pericolonic fluid collection near the hepatic flexure of the colon. New pneumobilia and moderate amount of air within the gallbladder and common hepatic/common bile duct. Suspect fistulous communication with an adjacent hollow viscus, either enteric or colonnic, with exact location unknown. If there is no recent history of intervention within the biliary system. Additional small pockets of air extend above and below this hepatic flexure colonic air-fluid collection. 2.No evidence of retroperitoneal hematoma. 3.Incompletely characterized hypodense lesions in the left mid kidney. Probably benign adrenal adenoma. HIDA scan [**10-15**] IMPRESSION: Normal hepatobiliary scan. No choledocho-colonic fistula was detected during the course of the scan. CT Scan [**10-24**]: IMPRESSION: 1. Significantly improved extraluminal air and fluid in the right paracolic gutter region with pigtail catheter in place. However, there is a questionable small amount of rounded fluid collection abutting or within the right ascending colon which may represent a short segment loop of bowel versus a residual loculated fluid collection. Recommend CT sinogram before catheter removal to ensure absent communication with hollow viscus. 2. Resolution of pneumobilia and air in the gallbladder with mild amount of debris within the gallbladder. 3. Improved but persistent right basilar subsegmental atelectasis. Chronic left basilar atelectasis/consolidation with chronic left basilar pleural effusion with mild pleural thickening. 4. Stable splenomegaly. 5. Stable compression deformities in the upper lumbar spine. MICRO: Negative stool cx x2 within last week Negative c diff assay within last week Pending blood cx with nothing growing Brief Hospital Course: 53m with quadraplegia [**2-22**] MVC [**2180**] with vent dependent trach at home who is found to have an intraabdominal abscess and colonic fistula. #Colonic Fistula: Recurrent. On admission, patient was febrile to 102.9, WBC 19.3 no bands, lactate 1.3.Intraabdominal collection found on CT abdomen [**10-10**]. Pt went for interventional radiology percutaneous drainage which brought up possibility of colonic-biliary fistula. A drain was placed and put out dark brown, purulant fluid. He was made NPO and started on TPN. CT scan also concerning new pneumobilia and moderate amount of air within the gallbladder and common hepatic/common bile duct. Pt was started on zosyn and daptomycin per ID consult recommendations. GI and Surgery were consulted. Both teams recommended a HIDA scan to better assess which showed no cholonic-biliary fistula with normal biliary filling. Patient improved on antibiotics as WBC trended down from 19.6 and normalized with treatment. Pt remained afebrile and normotensive following MICU admission with treatment. On [**10-23**], Mr. [**Known lastname **] developed straw colored stool and there was concern for new abdominal infection. A cdiff study was negative and his stool returned to [**Location 213**] after several days. He was transiently febrile to 101 on [**10-24**]. A repeat CT scan showed stable abdominal collection with no signs of infection. Surgery saw patient and decided to hold off on intervention at this time. They will see him as an outpatient and he will receive a follow up abdominal CT at this time. He will continue taking cipro and flagyl until surigcal outpatient follow up on [**2187-11-8**]. RUQ drain will also be left in until surgical outpatient follow up. He will be continued on TPN but can have a PO diet as tolerated. #PNA: Patient with tracheotomy tube and mechanical ventilatr-dependent at home. Chronic left lung collapse. On previous admission bronch did not show increased secretions warranting therapy (ie cryotherapy to break up secretion, recruitment maneuvers). CXR is unchanged from previous- still has chronic left lobe collapse likely secondary to mucous plugging. O2 saturations have been near 100% on vent. He completed a 8 day course for ventilator associated PNA on [**10-23**]. # Altered mental status: Fever and altered mental status at home (decreased resonsiveness, nonsense words, yelling at VNA). Improved in ED and was waxing and [**Doctor Last Name 688**] on floor. Likely secondary to infectious process given leukocytosis and fever. No evidence of seizure activity. A&Ox3 for over a week and on discharge. # Edema: Patient has edema at baseline. Had brisk diuresis last admission to IV lasix but not to home PO regimen. On discharge was changed to Torsemide 20 mg PO BID. Torsemide held during admission and not being restarted at this time. KCl held on admission and potassium was repleted as needed. #DVTs: Has IVC filter. INR has been stable at home per wife. [**Name (NI) 64707**] held on admission because of anticipated drainage of RUQ accumulation. Coumadin restarted on [**10-23**] and increased to 3mg daily. # Anemia: On HD2 Hct dropped from 26 to 20. He received 3 units of pRBCs and Hct improved appropriately. CT scan did not show evidence of a retroperitoneal bleed. # Hypertension: On last admission had hypertension to SBP>180 that responded to pain control and hydralazine boluses. He became hypertensive and was started on metoprolol 25 [**Hospital1 **]. Home toresimide had been restarted but pt became hypotensive transiently and it was held for rest of admission. # Pain: Takes pain medication at home. Continued on home methadone and Lyrica for pain. # Diabetes: Held home metformin and glimipirid in the hospital. Was on a regular insulin sliding scale while in the hospital and receives insulin in TPN. # Depression/Anxiety: Continued home Alprazolam, Escitalopram Oxalate, buproprion, buspirone. In addition, added olanzapine 2.5mg for sleep and increased anxiety, # Quadraplegia: s/p MVA in [**2180**]. Continued home baclofen, diazepam, tizanidine, dantrolene for spasticity. Used home bowel regimen PRN constipation (miralax, Tums, bisacodyl, magnesium citrate, Colace). CT showed chronically distended small and large bowel consistent with pseudo-obstruction. Transitional Issues: 1. Patient will follow up with surgery on [**11-8**]. He will go for a CT scan prior to appointment. Antibiotics should be continued until this visit. Drain will also be evaluated at this visit 2. Pt is DNR/DNI 3. Patient needs a PT/INR drawn on [**2187-10-28**] 4. Drain should be draining to gravity with no flushes into the cavity 5. Continue TPN as prescribed Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver[**Name (NI) 581**] discharge summary. 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. ALPRAZolam 0.25 mg PO Q4H:PRN anxiety 3. Baclofen 20 mg PO TID 4. BuPROPion 200 mg PO BID 5. Escitalopram Oxalate 20 mg PO DAILY 6. Diazepam 5 mg PO Q6H:PRN spasms 7. BusPIRone 10 mg PO QID:PRN anxiety 8. Guaifenesin ER 600 mg PO Q12H 9. ibuprofen *NF* 600 mg Oral q8hr:PRN pain 10. Lyrica 100 mg PO TID 11. Calcium Carbonate 500 mg PO X2 PRN indigestion 12. Methadone 15 mg PO BID 13. Polyethylene Glycol 17 g PO TID:PRN constipation 14. Tizanidine 2 mg PO QID 15. Bisacodyl 10 mg PR DAILY:PRN constipation 16. Magnesium Citrate 300 mL PO DAILY:PRN constipation 17. Docusate Sodium 100 mg PO BID:PRN constipation 18. Warfarin 3 mg PO 2X/WEEK (MO,FR) Monday, [**Name (NI) 2974**] 19. Warfarin 2.5 mg PO 5X/WEEK ([**Doctor First Name **],TU,WE,TH,SA) 20. Dantrolene Sodium 50 mg PO TID 21. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation [**Hospital1 **] 22. glimepiride *NF* 2 mg Oral Daily 23. arginine-glutamine-calcium Hmb *NF* 7-7-1.5 gram Oral [**Hospital1 **] 24. MetFORMIN (Glucophage) 500 mg PO BID 25. Multivitamins 1 TAB PO DAILY 26. Omeprazole 20 mg PO DAILY 27. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN skin rash 28. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain hold for SBP <100 29. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Hold for K >5 30. Torsemide 20 mg PO BID 31. ascorbic acid *NF* 500 mg Oral TID 32. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing Discharge Medications: 1. Baclofen 20 mg PO TID 2. BuPROPion 200 mg PO BID 3. BusPIRone 10 mg PO QID:PRN anxiety 4. Calcium Carbonate 500 mg PO X2 PRN indigestion 5. Diazepam 5 mg PO Q6H:PRN spasms 6. Docusate Sodium 100 mg PO BID:PRN constipation 7. Warfarin 3 mg PO 2X/WEEK (MO,FR) Monday, [**Hospital1 2974**] 8. Polyethylene Glycol 17 g PO TID:PRN constipation 9. Magnesium Citrate 300 mL PO DAILY:PRN constipation 10. Lyrica 100 mg PO TID 11. Escitalopram Oxalate 20 mg PO DAILY 12. Guaifenesin ER 600 mg PO Q12H 13. Dantrolene Sodium 50 mg PO TID 14. Acetaminophen IV 1000 mg IV Q6H:PRN pain less than 4 g per day 15. Ciprofloxacin HCl 500 mg PO Q12H until pt sees surgery as outpt 16. Loperamide 2 mg PO QID 17. Metoprolol Tartrate 25 mg PO BID hold for HR<60, SBP<100 18. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H until pt sees surgery as outpt 19. OLANZapine 2.5 mg PO HS:PRN insomnia 20. Pantoprazole 40 mg PO Q24H 21. Ondansetron 4 mg IV Q8H:PRN nausea 22. Multivitamins 1 TAB PO DAILY 23. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation [**Hospital1 **] 24. Ibuprofen *NF* 600 mg ORAL Q8HR:PRN pain 25. Bisacodyl 10 mg PR DAILY:PRN constipation 26. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing 27. arginine-glutamine-calcium Hmb *NF* 7-7-1.5 gram Oral [**Hospital1 **] 28. ascorbic acid *NF* 500 mg Oral TID 29. Cyclobenzaprine 10 mg PO TID Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: 1) Colonic Fistula 2) Ventilator Associated Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you during your stay at [**Hospital1 18**]. You came in with a fever and signs of infection on blood work. On CT scan we found a leak in your colon and bacteria in your abdomen. A drain was placed and you were started on antibiotics. We also believe you had a pneumonia and treated you with antibiotics. Your fever resolved and on discharge there is are no signs of infection on your blood work. You will follow up with surgery as an outpatient on [**11-8**]. You will continue antibiotics and leave the drain in place until you see the surgeon on [**2187-11-8**]. Followup Instructions: Department: RADIOLOGY When: THURSDAY [**2187-11-8**] at 11:45 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2187-11-8**] at 1:15 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

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icd9cm

[ [ [] ] ]

[ "38.93", "89.19", "33.24", "54.91", "96.72", "96.04", "33.21", "99.15", "96.6" ]

icd9pcs

[ [ [] ] ]

39283, 39354

31560, 33842

23291, 23325

39452, 39452

28893, 31537

40243, 40986

27497, 27586

37906, 39260

39375, 39431

36273, 37883

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27626, 28244

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17688, 17816

35882, 36247

26471, 26823

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23241, 23253

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17466, 17509

23353, 26452

17310, 17440

39467, 39563

26845, 27249

27265, 27481

28269, 28874

47,667

140,010

42471

Discharge summary

report

Admission Date: [**2110-6-9**] Discharge Date: [**2110-6-18**] Date of Birth: [**2058-4-20**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: -Mitral Valve Repair (30mm [**Last Name (un) 3843**]-[**Doctor Last Name **] Ring) [**2110-6-9**] -Redo sternotomy, Mitral Valve Replacement (#27mm St.[**Male First Name (un) 923**] Mechanical)[**2110-6-13**] History of Present Illness: 51 year old male who has a history of a heart murmur for his entire life. Has had echocardiograms the last couple of years after increasing intensity of his mitral regurgitation murmur was noted. Recent echocardiograms have shown severe mirtral regurgitation with a flail P2 and torn chordae. He is currently asymptomatic but given state of his regurgitation along with dilated left atrium he was referred to Dr. [**Last Name (STitle) **] for evaluation in [**2110-1-19**]. He returns now for preadmission testing for surgery on [**2110-6-9**]. Past Medical History: Mitral Regurgitation Hypertension Hypercholesterolemia Past Surgical History s/p Left ACL surgery Social History: Lives with: Wife Contact: Wife Phone # Occupation: Firefighter Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx: Other Tobacco use: Denies ETOH: < 1 drink/week [] [**2-25**] drinks/week [X] >8 drinks/week [] Illicit drug use: Denies Family History: +Premature coronary artery disease Father MI < 55 [] Mother < 65 [X] CABG in 50's Father with CABG in 60's. Uncles with CABGs. Physical Exam: Admission Physical Exam Pulse: 80 Resp: 18 O2 sat: 99% B/P Right: 144/77 Left: 150/82 Height: 5'[**09**]" Weight: 185 lbs General: Well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR, III/VI systolic murmur best heard at apex 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 [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: [**2110-6-9**] Intra-op TEE: PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are myxomatous. There is moderate/severe P2 leaflet mitral valve prolapse. There is partial P3 mitral leaflet flail. An eccentric, anteriorly directed jet of severe (4+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time of surgery. POST-BYPASS: Biventricular systolic function remains normal. There is a ring prosthesis in the mitral position. With initial post bypass loading conditions there was significant [**Male First Name (un) **] with LVOT velocities >3 m/sec. With volume and increase of SBP from 80 to 110 the [**Male First Name (un) **] decreased, with LVOT gradient ~15 mm Hg. No early closure of the AV, LVOT patent on 3D images. Trace residual MR. The study is otherwise unchanged from prebypass I [**Male First Name (un) 91932**] that I was present for this procedure in compliance with HCFA regulations. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 91933**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 91934**] (Complete) Done [**2110-6-13**] at 9:16:45 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2058-4-20**] Age (years): 52 M Hgt (in): 70 BP (mm Hg): / Wgt (lb): 187 HR (bpm): BSA (m2): 2.03 m2 Indication: H/O cardiac surgery. Left ventricular function. Mitral valve disease. Preoperative assessment. Shortness of breath. ICD-9 Codes: 424.0 Test Information Date/Time: [**2110-6-13**] at 09:16 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16164**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2012AW-:1 Machine: us6 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Left Ventricle - Stroke Volume: 330 ml/beat Left Ventricle - Peak Resting LVOT gradient: *43 mm Hg <= 10 mm Hg Aorta - Annulus: 2.6 cm <= 3.0 cm Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm Aorta - Ascending: 2.5 cm <= 3.4 cm Aorta - Arch: 2.8 cm <= 3.0 cm Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm Aortic Valve - Peak Velocity: *4.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *64 mm Hg < 20 mm Hg Aortic Valve - LVOT pk vel: 3.37 m/sec Aortic Valve - LVOT VTI: 73 Aortic Valve - LVOT diam: 2.4 cm Mitral Valve - Peak Velocity: 1.7 m/sec Mitral Valve - Mean Gradient: 6 mm Hg Findings LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. No atheroma in ascending aorta. Normal aortic arch diameter. No atheroma in aortic arch. Normal descending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AR. MITRAL VALVE: Mitral valve annuloplasty ring. [**Male First Name (un) **] of mitral valve leaflets. No MS. [**Name13 (STitle) 650**] (4+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the patient. 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. See Conclusions for post-bypass data Conclusions PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mean LVOT gradient is 16 mmHg. No aortic regurgitation is seen. A mitral valve annuloplasty ring is present. There is systolic anterior motion of the mitral valve leaflets. Severe (4+) mitral regurgitation is seen at a systolic blood pressure of 100 to 120 mmHg.. Mitral regurgitation is mild (1+) at a blood pressure of 174/84 achieved by phenylephrine with continued systolic anterior motion of the mitral valve. There is a trivial/physiologic pericardial effusion. There is a left pleural effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time of surgery. POST-BYPASS #1: Patient is in sinus rhythm. The patient is on a norepinephrine infusion. Left ventricular function is unchanged. Right ventricular function appears mildly depressed. There is a well-seated mitral annuloplasty ring in place. The height of the posterior leaflet of the mitral valve appears smaller compared to pre-bypass. There is still moderate to severe (3+) mitral regurgitation at a blood pressure of 95/54. There is still significant systolic anterior motion of the mitral valve with turbulent flow through the LVOT suggesting LVOT obstruction. POST-BYPASS #2: Patient is in sinus rhythm. The patient is on norepinephrine. Left ventricular function remains unchanged. Right ventricular function is normal. There is a well-seated mechanical prosthetic valve in the mitral position. Characteristic washing jets are seen. No mitral regurgitation is seen. There is a mean gradient of 2 mmHg at a cardiac output of 4.8 L/min. There is no resting LVOT gradient. The aorta is intact post-decannulation. Prebypass exam and post bypass exam #1 reviewed by Dr [**First Name (STitle) 6507**], [**Doctor Last Name 4901**], [**Last Name (un) 16164**] and [**Location (un) **]. Post #2 reviewed by Dr [**Last Name (STitle) 16164**] and [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 91932**] that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16164**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2110-6-13**] 12:05 ?????? [**2101**] CareGroup IS. All rights reserved. [**2110-6-17**] 04:40AM BLOOD WBC-7.8 RBC-2.67* Hgb-8.0* Hct-25.2* MCV-94 MCH-30.1 MCHC-31.9 RDW-13.8 Plt Ct-240 [**2110-6-9**] 11:52AM BLOOD WBC-15.4*# RBC-3.72* Hgb-11.5*# Hct-34.5*# MCV-93 MCH-30.9 MCHC-33.3 RDW-12.9 Plt Ct-115* [**2110-6-17**] 04:40AM BLOOD PT-23.1* INR(PT)-2.2* [**2110-6-9**] 11:52AM BLOOD PT-12.5 PTT-26.5 INR(PT)-1.2* [**2110-6-17**] 04:40AM BLOOD Glucose-102* UreaN-21* Creat-0.8 Na-140 K-5.4* Cl-104 HCO3-31 AnGap-10 [**2110-6-9**] 11:52AM BLOOD UreaN-15 Creat-0.7 Na-139 K-4.7 Cl-108 HCO3-23 AnGap-13 [**2110-6-18**] 04:45AM BLOOD Hct-28.5* [**2110-6-18**] 12:45PM BLOOD PT-25.8* PTT-66.2* INR(PT)-2.5* [**2110-6-18**] 04:45AM BLOOD UreaN-19 Creat-0.8 Na-138 K-5.4* Cl-101 Brief Hospital Course: Mr.[**Known lastname **] was brought to the Operating Room on [**2110-6-9**] where he underwent Mitral Valve Repair (#30mm CE ring)with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. He awoke neurologically intact. He remained on Neo for hemodynamic support and was slow to wean off. On POD 2, Mr.[**Known lastname **] had increasing oxygen requirements and continued to require pressor support. Trans thoracic Echo per Cardiology revealed well seated mitral valve annuloplasty ring. Hyperdynamic left ventricular systolic function with at least moderate resting left ventricular outflow tract obstruction secondary to systolic anterior motion of the mitral valve leaflets. Moderate to severe mitral regurgitation. He was volume resuscitated for [**Male First Name (un) **] and beta-blockade optimized as BP tolerated. Mr.[**Known lastname **] did not progress. Repeat trans thoracic echo [**2110-6-12**] compared with the prior study of [**2110-6-11**] per Cardiology, the LVOT obstruction was minimally decreased (from 56 mmHg to 46 mmHg). Severe mitral regurgitation now readily apparent; previously it was moderate to severe. Dr.[**Last Name (STitle) **] discussed with Mr.[**Known lastname **] the need for reoperation in the AM to address this, and the likelihood of a mitral valve replacement. On [**2110-6-13**] he was taken to the operating room and underwent a mitral valve replacement with #27mm mechanical valve. Please see operative report for further surgical details. He tolerated the procedure well and was transferred to the CVICU for hemodynamic monitoring and recovery. He required pressor support and was ultimately weaned off. [**6-14**] he awoke neurologically intact and was extubated. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Anticoagulation was initiated for his mechanical valve. All lines and drains were discontinued per protocol. He made progress and was transferred to the telemetry floor for further recovery. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #9 and #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 services. All follow up appointments were advised. Medications on Admission: Pravastatin 40mg daily Lisinopril 5mg daily Discharge Medications: 1. aspirin 81 mg [**Month/Year (2) 8426**], Delayed Release (E.C.) Sig: One (1) [**Month/Year (2) 8426**], Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 [**Month/Year (2) 8426**], Delayed Release (E.C.)(s)* Refills:*2* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. pravastatin 20 mg [**Month/Year (2) 8426**] Sig: Two (2) [**Month/Year (2) 8426**] PO DAILY (Daily). Disp:*60 [**Month/Year (2) 8426**](s)* Refills:*2* 4. ranitidine HCl 150 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO BID (2 times a day). Disp:*60 [**Month/Year (2) 8426**](s)* Refills:*2* 5. metoprolol tartrate 25 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO TID (3 times a day). Disp:*90 [**Month/Year (2) 8426**](s)* Refills:*2* 6. potassium chloride 10 mEq [**Month/Year (2) 8426**] Extended Release Sig: One (1) [**Month/Year (2) 8426**] Extended Release PO BID (2 times a day) for 10 days. Disp:*20 [**Month/Year (2) 8426**] Extended Release(s)* Refills:*0* 7. Lasix 40 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO twice a day for 10 days. Disp:*20 [**Month/Year (2) 8426**](s)* Refills:*0* 8. hydromorphone 2 mg [**Month/Year (2) 8426**] Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 [**Month/Year (2) 8426**](s)* Refills:*0* 9. ibuprofen 600 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO Q6H (every 6 hours) as needed for pain. Disp:*50 [**Month/Year (2) 8426**](s)* Refills:*0* 10. warfarin 5 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO ONCE (Once) for 1 doses. Disp:*1 [**Month/Year (2) 8426**](s)* Refills:*0* 11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 12. tramadol 50 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO Q4H (every 4 hours) as needed for pain. Disp:*50 [**Month/Year (2) 8426**](s)* Refills:*0* 13. warfarin 2.5 mg [**Month/Year (2) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a day: at 4 pm. Disp:*180 [**Last Name (Titles) 8426**](s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 11485**] VNA Discharge Diagnosis: Mitral Regurgitation Hypertension Hypercholesterolemia Past Surgical History s/p Left ACL surgery 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: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2110-7-16**] at 1:30 Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2110-8-18**] at 3:45 PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 91935**],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] follow INR/Coumadin dosing. INR indication: Mechanical MVR (#27mm St.[**Male First Name (un) 923**]) INR goal: 2.5-3.5 Please fax results to: Attention Dr.[**Last Name (STitle) **], fax# [**Telephone/Fax (1) 91936**] phone# [**Telephone/Fax (1) 86343**] **First draw [**2110-6-19**] Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 91935**],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 86343**] in [**4-24**] 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:[**2110-6-18**]

[ "429.5", "458.29", "401.9", "V17.3", "424.0", "276.50", "E878.2", "285.9", "996.02", "429.3", "272.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.24", "35.32", "35.12" ]

icd9pcs

[ [ [] ] ]

15657, 15713

10762, 13327

290, 500

15855, 16011

2360, 10739

16799, 17936

1484, 1619

13422, 15634

15734, 15834

13353, 13399

16035, 16776

1634, 2341

238, 252

528, 1075

1097, 1196

1212, 1468

4,454

134,657

10299

Discharge summary

report

Admission Date: [**2183-8-18**] Discharge Date: [**2183-8-21**] Date of Birth: [**2111-6-23**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 72-year-old male resident of the [**Hospital3 6560**] Home who was transferred to the Emergency Department at [**Hospital6 1760**] for evaluation of possible aspiration pneumonia. Triage note from the emergency room mentions a possible apneic episode. At the nursing home his temperature was noted to be 99.6, pulse in the 120s, blood pressure 140/70, respiratory rate 18-22. In the emergency room he was hypotensive to systolic blood pressure of 73 and diastolic blood pressure of 49, tachycardic to 127, febrile to 100.9 by axillary thermometer. The patient is reported to be mostly nonverbal at baseline. Laboratory studies drawn in the emergency room showed a blood glucose level in the 700s, serum sodium 167, and a highly concentrated urine with specific gravity of 1.036. His blood pressure increased to a systolic blood pressure in the 100s with two liters of normal saline intravenously. An insulin drip was started in the emergency room for the hyperglycemia. He was transferred to the MICU for further evaluation and treatment. PAST MEDICAL HISTORY: 1. Multiple urinary tract infections, including infection with methicillin-resistant Staphylococcus aureus, E. coli, and Enterococcus. He has a chronic suprapubic catheter. 2. Multiple CVAs. 3. Gastrojejunostomy tube. 4. Benign prostatic hyperplasia. 5. Hypertension. 6. The patient is reportedly nonverbal at baseline. MEDICATIONS: Zantac, aspirin, Colace, tube feeds at 100 cc/hour. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Mr. [**Known lastname **] moved from [**State 19827**] to [**Location (un) 86**] earlier in [**2183**]. He lives at the [**Hospital3 6560**] Home. Per old discharge summary, he has no history of tobacco or alcohol use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 100.0, heart rate 114, blood pressure 91/56, oxygen saturation 94% on two liters nasal cannula. GENERAL: The patient was nonverbal, thin, and in no acute distress. He tracked with his eyes occasionally. Otherwise he was not interactive. HEENT: The pupils were equal and reactive to light. His oropharynx was dry. NECK: His neck was stiff with no lymphadenopathy. LUNGS: Clear to auscultation anteriorly. HEART: Rate was slightly tachycardic and the rhythm was regular; no murmur, rub, or gallop appreciated. ABDOMEN: Soft and nontender with decreased bowel sounds. He had a nasogastric tube and suprapubic catheter. He had a large sacral decubitus ulcer extending down to the coccyx. EXTREMITIES: He did not move any of his four extremities. There was no peripheral edema. The extremities were warm without cyanosis. LABORATORY DATA: In the emergency room sodium was 167, potassium 4.3, chloride 128, bicarbonate 20, BUN 76, creatinine 1.1, glucose 736. WBC 14.6 with 89 neutrophils and no bands. Hematocrit 48. Platelet count 226. A second SMA-7 showed a sodium of 167 and glucose 724. Arterial blood gases on two liters nasal cannula showed pH 7.40, PCO2 37, PO2 67. His urinalysis revealed slightly hazy urine with a specific gravity of 1.036. The urine was nitrite negative, ketone negative, with 14 red blood cells and six white blood cells, and moderate bacteria. Chest x-ray showed patchy air space disease in the left lower lung zone, consistent with a possible aspiration pneumonia. HOSPITAL COURSE: The patient was transferred to the medical intensive care unit for management of his hypernatremia and hyperglycemia. The patient's free water deficit was calculated to be greater than 10 liters when the serum sodium was corrected for the hyperglycemia. He was started initially on normal saline until his blood pressure returned to [**Location 213**] levels. Once the blood pressure was stable, his intravenous fluid was changed to half normal saline, with an aim of decreasing his serum sodium at a rate of 0.5 mEq per liter per hour. He was also started on free water boluses per his G-tube. His sodium declined gradually. His hyperglycemia was of unclear etiology. He was treated with an insulin drip in the MICU until his serum glucose dropped below 200. At that time the insulin drip was discontinued and he was placed on sliding scale coverage with fingerstick glucose checks every four hours. Since his insulin drip was discontinued he has not required any supplemental insulin. His fever and elevated white blood cell count were thought to be secondary to either a urinary tract infection or an aspiration pneumonia. He was started on vancomycin and ceftriaxone for coverage of his possible pneumonia and urinary tract infection. His oxygenation improved with supplemental oxygen and he had copious white sputum production. Because of this, it was assumed that his infection was due to an aspiration pneumonia. After two days of intravenous antibiotics, his antibiotic regimen was changed to oral levofloxacin. Blood cultures remained negative. Urine cultures grew Pseudomonas and Enterococcus. These were thought to be urine colonizers and not a source of infection. His hypotension and acute renal insufficiency were thought to be secondary to massive intravascular volume depletion, which in turn was thought secondary to decreased p.o. intake and osmotic diuresis from the hyperglycemia. The hypotension and acute renal insufficiency resolved with intravenous fluid administration. As his serum sodium corrected and his free water deficit declined, Mr. [**Known lastname **] mental status improved slightly. At the time of discharge he was at his baseline. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Mr. [**Known lastname **] will return to the [**Hospital3 **] Home. He will follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He will have an SMA-7 drawn on [**2183-8-23**] to check his serum sodium level. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg per G-tube x six days (last dose on [**2183-8-27**]), water 250 cc per G-tube q. six hours. 2. Tube feeds via G-tube at 100 cc per hour. 3. Zantac 150 mg per G-tube q. day. 4. Proscar 5 mg per G-tube q. day. 5. Multivitamin per G-tube q. day. 6. Aspirin 81 mg per G-tube q. day. 7. Albuterol nebulizer q. six hours. 8. Serax 10 mg per G-tube q.h.s. DISCHARGE DIAGNOSES: 1. Hypernatremia. 2. Hyperglycemia of unknown etiology. 3. Pneumonia. 4. Acute renal failure secondary to intravascular volume depletion. 5. Hypotension secondary to intravascular volume depletion. 6. Benign prostatic hyperplasia. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Last Name (NamePattern1) 7787**] MEDQUIST36 D: [**2183-8-21**] 09:54 T: [**2183-8-21**] 12:00 JOB#: [**Job Number 34247**] rp [**2183-8-21**]

[ "584.9", "600.0", "507.0", "276.0", "344.00", "707.0", "290.40", "437.0", "276.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

1954, 1972

6524, 7068

6130, 6503

3561, 5752

1995, 3543

166, 1244

1267, 1699

1716, 1937

5777, 6107

8,900

196,620

8509

Discharge summary

report

Admission Date: [**2191-4-7**] Discharge Date: [**2191-4-13**] Date of Birth: [**2113-1-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 18988**] Chief Complaint: Melena 1 day after ERCP Major Surgical or Invasive Procedure: EGD with cauterization History of Present Illness: 78 year old male with history of atrial fibrillation, CHF, Parkinsons disease, and cholangitis for which he underwent an ERCP with stent placement in the common bile duct in 3/[**2190**]. He underwent repeat ERCP [**2191-4-6**] for choledocholithiasis at which time the stent was removed, stones/sludge extracted, and sphincterotomy performed. He was admitted for observation overnight and discharged [**2191-4-7**] AM. That evening, he returned to the emergency department with melena, at which time he was noted to be hypotensive (sbp 70s). His hematocrit was 30 from 35 post-ERCP. He was admitted to the [**Hospital Unit Name 153**] for upper endoscopy, receiving 1 unit of PRBC in the emergency department. Of note, he had been off coumadin for 5 days. Past Medical History: 1. Atrial fibrillation- on Coumadin, followed by Dr. [**Last Name (STitle) 73**]; off coumadin for ERCP. 2. CHF - EF 35-40%, RWMA suggesting ischemic cardiomyopathy 2. Parkinson's disease - on Sinemet and mirapex, followed by Dr. [**Doctor Last Name **] of Neurology 3. Prostate cancer - s/p XRT 4. L hip replacement 5. ? Sleep disorder 6. LE edema 7. Cervical myelopathy - wears C-collar 8. Myasthenia [**Last Name (un) 2902**] - diplopia, on pyridostigmine 9. s/p ERCP with CBD stent placement for cholangitis [**1-31**]; E coli/Klebs bacteremia Social History: Married, has 4 children and 5 grandchildren. Used to work in sales, in a showroom. Denies present tobacco (sm quantity in past, quit 30y ago, more pipes than cigarettes); drinks 1 glass wine/day, denies IVDU. At [**Hospital **] rehab right now. Family History: No family history of Parkinsons. Mother died of [**Name (NI) 2481**] at 86 years of age. Father died of esophageal cancer at 65 years. Physical Exam: Physical Exam on admission VS - 97.1, 97-104, 83-105/68-90, 12, 99% RA HEENT - pale conjunctivae, MMM, OP clear LUNGS - CTA HEART - irreg irreg, S1, S2 ABD - soft, NT, ND, RUQ cholecystectomy scar. EXT - wwp, 2+ DP pulses. + chronic venous stasis changes NEURO - + cogwheeling b/l Pertinent Results: Laboratory studies on admission [**2191-4-7**] WBC-6.8 RBC-3.42 HGB-9.9 HCT-30.0 MCV-88 RDW-17.4 NEUTS-82.1 LYMPHS-11.1 MONOS-4.9 EOS-1.5 BASOS-0.4 GLUCOSE-115 UREA N-24*CREAT-1.1 SODIUM-140 POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-24 PT-17.9 PTT-36.1 INR(PT)-1.7 U/A (-) [**4-7**] EKG: Atrial fibrillation. Non-specific ST-T wave changes. Compared to the previous tracing no significant change. Brief Hospital Course: 78 year old male w/ h/o CHF, Parkinsons disease presents with melena s/p ERCP/sphincterotomy. 1. GI bleed: The patient was admitted to the MICU. He underwent an EGD [**2191-4-8**] which showed large blood clots with small amount of fresh blood in the second portion of the duodenum. After irrigation with sterile water, the bleeding was identified to the recent sphincterotomy site. BICAP cauterization and epinephrine injection was applied at the sphincterotomy site with resolution of active bleeding. The patient was initially kept NPO, and received 8 units of PRBC in the ICU. He was transferred to the general floor, after which time he remained hemodynamically stable with a stable hematocrit (on discharge 28.9). His coumadin and aspirin were initially held, but were gradually restarted (aspirin on [**2191-4-11**], coumadin on [**2191-4-13**]). He was continued on a proton pump inhibitor. He will follow-up with gastroenterology as previously scheduled. 2. Atrial Fibrillation: The patient was maintained on his home dose of amiodarone. As mentioned above, his coumadin was restarted on day of discharge. His INR will need to be closely monitored as an outpatient, with a goal INR 2-2.5. 3. Ichemic cardiomyopathy (EF 35-40% on TTE [**1-31**]): Given the patient continued to be orthostatic throughout his hospital stay, his furosemide and spironolactone were held. At time of discharge, the patient appeared euvolemic. He will need to adhere to a low sodium diet and weigh himself daily. His diuretics will be restarted at the discretion of his primary care physician. 4. Hypertension: Although the patient has a history of hypertension, his losartan, furosemide, and spironolactone were held during his hospital stay given orthostasis and systolic blood pressures 100s-110s. These medications will be restarted as needed at the discretion of his primary care physician. 5. Parkinson's disease: The patient was continued on his home doses of Sinemet and Mirapex. Physical therapy evaluated him while in-house and, given risk of fall, recommended rehabilitation center placement. The patient and wife, however, declined this option in favor of home physical therapy. 6. Myasthenia [**Last Name (un) 2902**]: The patient was continued on his home dose of pyridostigmine with good effect. 7. Full Code. Medications on Admission: MEDS: Pyridostigmine Bromide 60 mg tid Carbidopa-Levodopa 25-100 mg tid Amiodarone 200 mg qd Tamsulosin 0.4 mg qhs Oxybutynin Chloride 5 mg tid Aspirin 81 mg qd Losartan 25 mg qd Pantoprazole 40 mg qd Sertraline 100 mg qd Oxycodone 5 mg q4-6 PRN Lasix 10 mg qd Spironolactone 25 mg qd Coumadin 3 mg qhs Mirapex 5 mg tid Discharge Medications: 1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 2. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*2* 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Pramipexole 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 7. 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* 8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Caregroup Solutions Discharge Diagnosis: GIB from sphincterotomy site, s/p repeat EGD with cauterization Atrial fibrillation Ischemic cardiomyopathy Hypertension Discharge Condition: The patient's hematocrit remains stable Discharge Instructions: Please follow up with appointment as below. . Take your medications as below. Given your blood pressure was low in the hospital, your furosemide (Lasix), Losartan, and spironolactone (Aldactone) were held. Please do not restart these medications unless directed to do so by your doctor. . Your coumadin has been restarted at 2.5 mg daily. Your INR will need to be closely monitored as an outpatient and adjusted at the discretion of your primary care physician for [**Name Initial (PRE) **] goal INR 2-2.5 If you develop bleeding from below, black tarry stools, lightheadedness or dizziness, fainting or passing out, chest pain, shortness of breath, or any other symptoms, please call Dr. [**Last Name (STitle) 1683**] or report to the nearest ER. Please also weigh yourself daily and call Dr. [**Last Name (STitle) 1683**] if you are gaining more than 3lb. Followup Instructions: 1) Primary Care: Please call Dr. [**Last Name (STitle) 1683**] ([**Telephone/Fax (1) 19968**]) to schedule an appointment to be seen early next week - your INR will be checked by VNA; these results will need to be communicated to Dr. [**Last Name (STitle) 1683**] for adjustment of your coumadin dose. - your furosemide, spironolactone, and Losartan are being held for low blood pressure in the hospital. These may be restarted at the discretion of your primary care physician 2) Gastroenterology Please follow up with Dr. [**Last Name (STitle) 12590**] in the [**Hospital **] clinic on Monday, [**5-2**] at 8 am. Completed by:[**2191-4-18**]

[ "E878.8", "V10.46", "332.0", "358.00", "428.0", "V43.64", "998.11", "414.8", "427.31", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

6729, 6779

2880, 5200

340, 365

6944, 6986

2462, 2857

7892, 8537

2007, 2146

5570, 6706

6800, 6923

5226, 5547

7010, 7869

2161, 2443

277, 302

393, 1153

1175, 1725

1741, 1991

80,752

180,665

41145

Discharge summary

report

Admission Date: [**2120-3-12**] Discharge Date: [**2120-4-8**] Date of Birth: [**2066-2-15**] Sex: M Service: MEDICINE Allergies: Nafcillin Attending:[**First Name3 (LF) 4891**] Chief Complaint: knee pain, drainage Major Surgical or Invasive Procedure: left knee total knee replacement resection with antibiotic spacer, left knee Irrigation and Debridement paracentesis, endotracheal intubation, mechanical ventilation, bronchoscopy, bronchoalveolar lavage History of Present Illness: 54yo male referred in to [**Hospital1 18**] ED from [**Hospital3 **] for evaluation of reported increase in pain and drainage from knee surgical incision site. Patient reports surgical incision staples were removed late last week and he noticed fluid dripping down his leg intermittently since [**2120-3-10**], while ambulating with physical therapy. He states no increase in pain during this time. Patient reports increase in activity with physical therapy on [**2120-3-12**], leading to some increased diffuse knee pain that completely resolved at rest. He denies any recent fevers, chills, or diaphoresis. He notes development of significant knee swelling which is similar to in the past. His recent medical course is notable for septic left TKA and left shoulder s/p I&D on [**2-25**] and [**2-26**]. Past Medical History: - Alcoholic Cirrhosis - GIB [**1-/2120**], found to have gastric ulcers on EGD, no varices - EtOH Abuse - Left rotator cuff tear Social History: EtOH abuse for many years, 8-10 beers per day, refers he quit 3 wks ago. No illicits drugs. Previous smoker, quit a couple of yrs ago. Lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] with his wife. [**Name (NI) **] is retired prision officer. Family History: Diabetes-father Physical Exam: ADMISSION EXAM: VS: 96.0 122 134/77 27 99% on 15% FM General: awake, oriented to person, hospital setting, year but not month, uncomfortable appearing in mild respiratory distress HEENT: PERRL, EOMI, sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD, JVP difficult to assess given accessory muscle use Lungs: bibasilar rales with rhonchi in upper air fields, no wheezing, labored breathing with accessory muscle use CV: tachycardic but regular, normal S1 S2, no r/m/g appreciated Abdomen: hypoactive bowel sounds, moderately distended, tympanitic, mildly tender to palpation, no rebound tenderness or guarding GU: foley draining dark yellow urine Ext: 2+ DP/PT on RLE, faint DP/PT [**Name (NI) **], 3+ edema bilaterally to knees, left knee with dressing and brace in place C/D/I Neuro: awake, oriented to person, hospital setting, and year only, +asterixis, PERRL, moving all four extremities Pertinent Results: ADMISSION LABS: [**2120-3-12**] 10:45PM BLOOD WBC-8.1 RBC-2.58* Hgb-8.7* Hct-25.2* MCV-98 MCH-33.6* MCHC-34.4 RDW-16.8* Plt Ct-266 [**2120-3-12**] 10:45PM BLOOD Neuts-76.8* Lymphs-15.1* Monos-5.3 Eos-2.3 Baso-0.5 [**2120-3-12**] 10:45PM BLOOD PT-17.1* PTT-33.8 INR(PT)-1.5* [**2120-3-12**] 10:45PM BLOOD Glucose-104* UreaN-18 Creat-1.0 Na-130* K-3.6 Cl-97 HCO3-25 AnGap-12 [**2120-3-13**] 04:47AM BLOOD ALT-5 AST-30 AlkPhos-92 TotBili-1.2 [**2120-3-13**] 04:47AM BLOOD Albumin-1.9* Calcium-7.9* Phos-3.5 Mg-1.5* [**2120-3-12**] 11:01PM BLOOD Lactate-1.3 . MICROBIOLOGY: [**4-4**] Sputum culture: --gram stain: no microorganisms --culture: sparse yeast; commensal flora [**4-3**] Peritoneal fluid: 90 WBC, 105 RBC, 62 PMN, 22L, 16M, total protein 1, glucose 185, LDH 51, albumin 0.5 --culture: negative [**4-3**] Urine culture: yeast [**4-3**] Blood culture: negative [**3-31**] Peritoneal fluid culture: --gram stain: 1+ polys, no microorganisms --fluid culture: no growth --anaerobic culture: no growth [**3-31**] Blood cultures x2: pending [**3-30**] Urine culture: yeast [**3-29**] Urine culture: yeast [**3-29**] Stool: negative for C. diff [**3-27**] Sputum: --gram stain: no microorganisms --fungal culture (prelim): yeast --legionella culture (prelim): no legionella isolated --no PCP [**Name9 (PRE) 89637**] culture: rare growth yeast [**3-27**] Mycolytic blood culture: pending [**3-27**] Sputum: --gram stain: no microorganisms --respiratory culture: sparse growth yeast [**3-25**] Sputum: --gram stain: no microorganisms --respiratory culture: sparse growth yeast [**3-25**] Left Knee joint fluid: --no microorganisms [**3-24**] Blood culture: negative [**3-23**] Blood culture: negative [**3-18**] Peritoneal fluid: negative . IMAGING: [**2120-3-12**] Knee xray: No radiographic evidence of osteomyelitis. Status post total knee arthroplasty without evidence of hardware failure. . [**2120-3-12**] [**Month/Day/Year **] U/S: No left lower extremity DVT. . [**2120-3-15**] Knee xray: The left knee arthroplasty has been removed and there is a methyl methacrylate spacer in the knee joint. Smooth periosteal reaction about the distal shaft of the femur is unchanged and likely reactive to the recent infection. HPOA could have a similar appearance and note is made of the recent chest radiograph dated [**2120-4-4**]. Expected post surgical changes including soft tissue swelling as well as a surgical drain are noted. . [**2120-3-18**] CTA chest: 1. Mild multifocal pneumonia. 2. No pulmonary emboli. Possible pulmonary hypertension. 3. Mild dependent atelectasis. Small bilateral pleural effusions. 4. Severe ascites. 5. Atherosclerotic coronary calcification, right, left, and left anterior descending segments. . [**2120-3-23**] Bilataral LE U/S: Complete thrombosis of the left anterior gastrocnemius vein (communicating vein/perforator vein) of the left calf. . [**2120-3-26**] CT Chest w/o con: Newly occurred massive consolidations and opacities, predominating in the upper lobes but also visualized in the peribronchial areas of the middle lobe and both lower lobes. The changes are suspicious of non-recent pneumonia, combined to atelectasis, which has already been suspected on previous chest films. Newly appeared moderate right pleural effusion, increased left pleural effusion. Numerous mucus accumulations in the tracheobronchial tree. Mild decrease in extent of the pre-existing ascites. . [**2120-3-28**] CT Abdomen/Pelvis: 1. Extensive ascites with mesenteric edema and anasarca, findings consistent with decompensated cirrhosis. No discrete loculated fluid collection to suggest abscess, though evaluation is limited due to the free fluid and non-contrast technique. 2. Multifocal consolidations within the lung bases consistent with pneumonia. Bilateral pleural effusions, left greater than right. 3. Stable appearance of the IVC filter, post-pyloric NG tube, rectal tube, and Foley catheter. 4. No definite evidence of colitis, though evaluation is limited due to extensive free fluid and non-contrast technique. . [**2120-4-2**] CT Head w/o con: Moderately motion limited study without evidence of an acute intracranial process. . [**2120-4-3**] Bilateral UE U/S: Occlusion of the distal segment of the right radial artery, without evidence of flow. Brief Hospital Course: 54 year old man with EtOH cirrhosis, recent MSSA bacteremia with left septic prosthetic knee and left septic shoulder, initially admitted to the ortho service with increased drainage from the left knee, s/p L TKA resection, with course complicated by development of hypoxemic respiratory distress requiring transfer to the MICU. . # GOALS OF CARE: After discussions between the MICU team and the patient's wife and family members, the decision was made to focus on comfort measures. The patient was extubated and pain was controlled with morphine. He passed several hours later. . # HYPOXEMIC RESPIRATORY DISTRESS: On [**3-18**], patient became hypoxic with sat of 90% on 6L NC. CTA negative for PE, but showed multifocal PNA. Was concern patient may have aspirated in setting of AMS [**2-14**] hepatic encephalopathy, and also concern for volume overload in setting of multiple recent transfusions given elevated JVP. Patient briefly improved following administration of lasix, though given continued decline in respiratory status patient transferred to MICU for further monitoring. Started on broad spectrum antibiotics with vanc/cefepime given concern for HCAP. Was already on cipro for L knee infection, with ID following, though ID felt cipro could be stopped [**3-20**] given broader coverage with vanc/cefepime. Restrictive physiology from worsening ascites and abdominal distension was also felt to be contributing, though diuresis initially limited secondary to [**Last Name (un) **]. Once renal function initially improved, patient started back on lasix, was weaned to 2L NC, and underwent paracentesis with removal of 3L peritoneal fluid on [**3-21**]. Patient was electively intubated for return to OR on [**3-25**] and remained intubated post-operatively. Abx changed to vanc/meropenem on [**3-27**] per ID recs given persistent/worsening leukocytosis. Had repeat CT chest, which showed worsening of multifocal PNA with bilateral patchy consolidations. Antibiotic course continued through [**3-30**], for total of 13 day course of treatment for presumed HCAP. Was also thought that PNA may have been chemical insult from aspiration, as patient did not significantly improve on broad spectrum abx. Sputum cultures sent, but only positive for rare yeast, and all blood cultures remained negative. Ongoing respiratory distress again thought to be multifactorial from PNA, restriction from significant ascites, and volume overload in setting of repeated transfusions and worsening renal function with near anuria. As below, patient started on CRRT on [**4-3**], and chest imaging did show improvement in bilateral pulmonary congestion. Patient's vent settings were changed from assist control to pressure support, and patient did well, though extubation was limited by patient's mental status. Patient also had repeated paracenteses, with 2-3L fluid removed each time as below. . # ALTERED MENTAL STATUS: Patient initially with AMS secondary to hepatic encephalopathy prior to ICU transfer, in setting of refusing [**Month/Year (2) 89638**]. Had some improvement in MS [**First Name (Titles) **] [**Last Name (Titles) 89638**] dosing increased, though developed increasing confusion in ICU most likely secondary to delirium in setting of post-op pain and infection. Patient was intubated on [**3-25**] for return to OR, and given initial sedation with propofol, and later with fent/midaz, was difficult to fully assess mental status. However, patient weaned off all sedation, but remained unresponsive to voice and was not following commands. Was though to have persistent encephalopathy, and also AMS secondary to uremia in setting of worsening renal function. CT head [**4-2**] was negative for acute intracranial process. . # HYPOTENSION: Patient was on phenylephrine following intubation on [**3-25**], though this was weaned off within several days with stabilization of BP. Hypotension felt to be multifactorial in setting of underlying cirrhosis, acute blood loss peri-operatively, infection, and sedation. Patient had recurrent hypotension when starting on HD; was switched to CRRT and had arterial line placed for closer monitoring on [**4-3**]. Also received small fluid boluses as needed for recurrent hypotension. . # [**Last Name (un) **]: At time of transfer to ICU, Cr noted to have trended up from 1.0 to 1.7. Patient had h/o recent AIN from nafcillin, and urinalysis still revealed rare eosinophils. However, was more concern for pre-renal azotemia/transient ischemia causing acute worsening of renal function. Renal consulted, and felt presentation most c/w ischemic injury based on presence of granular casts and sheets of hyaline casts in urine. Was some concern for HRS, given low urine Na, though patient was responsive to albumin challenge and maintained good urine output initially. However, again developed worsening renal function with significant rise in Cr, and renal re-consulted on [**3-28**] and felt [**Last Name (un) **] secondary to ischemic ATN. Urine output continued to decline, and patient became nearly anuric with ~100cc urine output daily. Decreased urine output was also exacerbated by increased bladder pressures, noted to be as high as 28 in setting of worsening ascites and abdominal distension on [**3-31**]. Had repeat para [**3-31**] with 3L removed, and resultant decrease in bladder pressure to 12. Went to IR for placement of temp HD line on [**4-1**], and was started on HD later that day with about 500cc volume removed. Given hypotension occurring during HD, but desire to remove volume given persistent respiratory distress, patient started on CRRT on [**4-2**] to allow removal of greater volume. Goal was for removal of 100-200cc/hr if BP would tolerate, and arterial line placed for closer BP monitoring. HD line clogged on [**4-4**], though became patent again after administration of TPA. CRRT was discontinued on [**4-7**] when the patient was transitioned to CMO. . # LEFT KNEE DRAINAGE: Initially admitted to ortho service. Was on daptomycin and cefazolin, which had been started for MSSA bacteremia and VRE bacteremia during previous admission. Dapto course completed [**3-15**], cefazolin was continued initially. Patient taken to OR and all hardware was removed on [**3-15**]. The surgery was c/b EBL ~4L and he was given 6 units PRBC, 4 units FFP, 3 units albumin, 1 unit platelets, and 2 units cryoprecipitate intra-operatively. On the floor, he received another 3 U pRBC. Joint fluid culture did grow pseudomonas, and patient started on cipro. All other cultures remained negative, and cipro later d/c'd as this was felt to be contaminant and not true infection by ID consulting team. Patient's JP drain removed while patient in ICU, though patient continued to have oozing from left knee given underlying coagulopathy from his liver disease. Patient transfused additional 2 units pRBCs in ICU, and also given vitamin K given elevated INR. Oozing from surgical site slowed. Patient's knee kept immobilized. Given concern about developing fluid pocket in right knee, with rise in patient's WBC, patient taken back to OR on [**3-25**] for I&D of left knee via arthrotomy, removal of antibiotic spacer and insertion of new spacer. Patient electively intubated for procedure, and remained intubated post-op. Had about 1.5L blood loss during operation, requiring additional transfusions of pRBCS and FFP. Fluid pocket felt to be hematoma and not infection, and cultures sent from OR [**3-25**] negative. Patient continued on antibiotics throughout his hospital course (see below), though when antibiotic course for multifocal PNA completed on [**3-30**], patient switched back to cefazolin for planned 6 week course of treatment of L septic knee, scheduled to end [**4-27**]. . # ETOH CIRRHOSIS: Patient with decompensated cirrhosis this admission. Increased ascites noted intraoperatively on [**3-15**]. Patient initially continued on home regimen of spironolactone and lasix, as well as [**Month/Day (4) 89638**], though spironolactone and lasix later stopped in setting of worsening renal function. Had therapeutic thoracentesis on [**3-18**] during which 2 L of fluid were removed, chemistries were unremarkable. [**Month/Day (4) **] was increased to 45 mg QID because patient was not having bowel movements and was felt to be developing hepatic encephalopathy. Patient followed by liver service. Had repeat paracentesis [**3-21**] with removal of 3L fluid, and another paracentesis on [**3-25**] which was also negative for SBP. Started on rifaximin. Dobhoff placed in OR on [**3-25**] for increased nutritional support, and patient continued on thiamine and folate. Had additional paracentesis on [**4-15**] (3L fluid removed each time). The patient was not a transplant candidate. . # DVT: Patient found to have DVT in left gastrocnemius [**Last Name (un) **] via LENIs performed [**3-23**]. Started on heparin gtt, though drip stopped prior to patient's return to OR on [**3-25**] for I&D of left knee and replacement of antibiotic spacer. Given surgery and concern for ongoing blood loss post-operatively, patient could not be anticoagulated and therefore had IVC filter placed. He was continued on prophylactic heparin. . # RIGHT RADIAL ARTERY THROMBUS: Patient found to have clot in R radial artery on [**4-3**] ultrasound. Right ulnar artery was patent. Patient did not have any arterial cannulation or ABGs obtained from right side. . # DIARRHEA: Patient noted to have increased stool output on [**3-23**], and which was felt to be multifactorial from increased [**Month/Year (2) 89638**] dosing and antibiotic course. Was concern for C. diff given hospital course and antibiotic administration, and patient was started empirically on IV flagyl. Several stool samples negative for C. diff, and flagyl eventually stopped [**3-29**] after C. diff PCR came back negative. . # UTI: Patient noted to have yeast persistently in urine, and completed a 7-day course of fluconazole. Foley replaced, and eventually removed [**4-5**] as patient anuric. Medications on Admission: Lasix 40mg po daily Spironolactone 100mg daily [**Month/Year (2) **] 30ml po qid Cefazolin 2g Q8 Daptomycin 600mg Q24 Pantoprazole 40mg po q12h Enoxaparin 40mg daily until [**2120-3-25**] Thiamine 100mg daily Folic acid 1 tab daily Multivitamin daily Docusate [**Hospital1 **] Senna prn Miralax prn Tylenol prn Discharge Disposition: Expired Discharge Diagnosis: During the patient's ICU stay, the patient was transitioned to comfort-focused care based on extensive discussion with the family/HCP. The patient died overnight after transfer out of the ICU, with family at the bedside. Discharge Condition: Deceased Completed by:[**2120-4-9**]

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icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "96.04", "54.91", "77.67", "38.91", "38.95", "96.6", "38.7", "80.06", "84.56", "96.72" ]

icd9pcs

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289, 495

17751, 17789

2742, 2742

1785, 1803

17508, 17730

17142, 17455

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77,836

136,762

41777

Discharge summary

report

Admission Date: [**2184-1-14**] Discharge Date: [**2184-2-4**] Date of Birth: [**2156-2-6**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 598**] Chief Complaint: Trauma: Post C2 body fx w/ C2-3 flex-distraction bilat preseptal hemorrhage small bilateral PTX splenic injury s/p splenectomy L sqaumous temporal bone fx bilat anterior acetabular fx R inferior pubic ramus fx laceration x2 R anterior shin/knee Shallow impaction fx ant tibial cortex RLL contusion Carotid->cav sinus fistula s/p embol. Annular tear C2/3 disk Prevertebral hematoma, skull base -> C4 Major Surgical or Invasive Procedure: [**2184-1-24**] open trach/PEG [**2184-1-21**] C2-3 ant fusion w/ iliac bone graft; halo application [**2184-1-15**] coil/gel foam embolization multiple splenic branches [**2184-1-15**] splenectomy [**2184-1-15**] Embolization of superior ophthalmic vein History of Present Illness: 27 y/o F w/ history of opiate abuse s/p MVA [**2184-1-14**] w/ another vehicle: unrestrained driver, trapped requiring extrication +LOC; s/p 1U PRBCs in the field; 2U PRBCs in ED. Positive FAST. Intubated for decline in mental status. Past Medical History: Unknown Social History: UK Family History: UK Physical Exam: PHYSICAL EXAMINATION HR: 145 BP: 90/70 Resp: 29 O(2)Sat: 100 Normal Constitutional: appears altered, GCS 14 HEENT: bilateral periorbital ecchymosis, perrla dilated pupils with nystagmus 5mm-->4mm blood from mouth, lax lower jaw, mid face stable, teeth intact, no hemotympanum, + gag Chest: Clear to auscultation, ecchymosis L chest Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, tender diffusely, guarding + FAST, grossly, mildly distended Pelvic: pelvis stable Rectal: brown stool, no gross blood, normal rectal tone GU/Flank: no hematuria Extr/Back: Multiple large lacerations to LE, along tib fib on R Neuro: moving all ext Psych: altered Physical examination upon discharge [**2184-2-4**] vital signs: 98.5, hr=93, bp=106/93, resp. rate 18, oxygen sat 97% RA General: NAD, talking valve in place, Halo CV: ns1, s2, -s3, -s4 LUNGS: Diminshed throughout ABDOMEN: Soft, non-tender EXT: Mild erythema right lower leg suture line, no exudate, +dp bil., no pedal edema bil NEURO: alert and oriented x3, speech clear, no tremors, right eye conjunctival edema and injection, limited right lat. movement, full upward, and downward gaze Pertinent Results: [**2184-1-29**] 05:06AM BLOOD WBC-15.5* RBC-3.23* Hgb-9.6* Hct-30.2* MCV-93 MCH-29.8 MCHC-32.0 RDW-14.9 Plt Ct-1033* [**2184-1-28**] 05:06AM BLOOD WBC-22.8* RBC-3.20* Hgb-9.7* Hct-29.8* MCV-93 MCH-30.2 MCHC-32.4 RDW-14.8 Plt Ct-964* [**2184-1-27**] 02:53AM BLOOD WBC-22.1* RBC-3.16* Hgb-9.3* Hct-29.1* MCV-92 MCH-29.5 MCHC-32.1 RDW-15.0 Plt Ct-840* [**2184-1-14**] 06:05PM BLOOD WBC-46.6* RBC-4.02* Hgb-12.0 Hct-37.6 MCV-94 MCH-29.9 MCHC-32.0 RDW-12.3 Plt Ct-354 [**2184-1-29**] 05:06AM BLOOD Neuts-59 Bands-0 Lymphs-12* Monos-11 Eos-15* Baso-3* Atyps-0 Metas-0 Myelos-0 [**2184-1-29**] 05:06AM BLOOD Plt Smr-VERY HIGH Plt Ct-1033* [**2184-1-24**] 11:07AM BLOOD PT-13.0* PTT-25.2 INR(PT)-1.2* [**2184-1-14**] 11:13PM BLOOD Fibrino-116*# [**2184-1-28**] 05:06AM BLOOD Glucose-118* UreaN-12 Creat-0.4 Na-138 K-4.5 Cl-97 HCO3-35* AnGap-11 [**2184-1-27**] 02:53AM BLOOD Glucose-129* UreaN-10 Creat-0.3* Na-139 K-4.4 Cl-98 HCO3-33* AnGap-12 [**2184-1-26**] 01:46AM BLOOD ALT-42* AST-31 AlkPhos-161* [**2184-1-14**] 08:21PM BLOOD ALT-80* AST-155* LD(LDH)-454* AlkPhos-50 Amylase-62 TotBili-0.6 [**2184-1-28**] 05:06AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.1 [**2184-1-23**] 03:36AM BLOOD Vanco-12.6 [**2184-1-15**] 01:50PM BLOOD HCG-<5 [**2184-1-26**] 02:04AM BLOOD freeCa-1.20 [**2184-1-14**]: cat scan of c-spine: IMPRESSION: 1. C2-3 flexion-distraction with comminuted fractures of posterior C2 body and bilateral transverse processes ("hangman's fracture"). Due to involvementof the transverse foramina, CT angiography should be considered because of the potential for vertebral artery injury. 2. Right thyroid nodule can be evaluated by ultrasound when clinically appropriate. [**2184-1-14**]: cat scan of the head: 1. Comminuted fractures of both temporomandibular joints, with subluxation on the right and complete dislocation on the left. 2. Fracture of the left squamous temporal bone, with trace pneumocephalus in the middle cranial fossa. 3. Bilateral preseptal hemorrhages and right retroorbital contusion/hemorrhage. [**2184-1-14**]: cat scan of abdomen/pelvis: 1. Shattered spleen (grade 5 injury,) with extensive active arterial extravasation arising from the superior pole, and massive hemoperitoneum. Additional foci of active bleeding in the left upper quadrant are also not excluded noting extensive pooling of the extravasated contrast. 2. Suspected focal dissection and potentiallly partially occlusive thrombus of the suprahepatic IVC, although flow is patent. 3. Tiny bilateral pneumothoraces, without displaced rib fractures. 4. Right lower lobe contusions and/or aspiration. 5. Bilateral anterior acetabulum and right inferior pubic ramus fractures. [**2184-1-14**]: right tib/fib x-ray: IMPRESSION: Shin laceration, with shallow impaction fracture of the anterior tibial cortex; correlation with physical findings is suggested as the appearance raises concern for an open fracture. [**2184-1-14**]: cat scan of sinus and mandible: IMPRESSION: 1. Comminuted fractures of the bilateral temporal bones and mandibular condyles, with subluxation on the right mandibular condyle and complete dislocation on the left with a displace angulated fracture. 2. Fracture through the left squamous temporal bone with associated nearby intracranial pneumocephalus along the floor of the middle cranial fossa. 3. Bilateral preseptal hemorrhages and right retroorbital fat stranding suggesting contusion with suspected hemorrhage. [**2184-1-14**]: tran-cath. embolization: IMPRESSION: 1. Uncomplicated splenic arteriogram with coil and Gelfoam embolization of the upper pole branch distribution. 2. Uncomplicated IVC-gram. [**2184-1-15**]: ct of the sinuses: IMPRESSION: 1. Right greater than left proptosis, with interval increase in dense fluid collection posterior to the globe. The optic nerve appears stretched and thinned. There is enlargement of the superior ophthalmic veins and cavernous sinuses,right more than left, increased compared with the prior study concerning for carotid-cavernous fistula. Please correlate for presence of bruit. 2. Multiple fractures, described previously [**2184-1-15**]: CTA head: IMPRESSION: 1. Bilateral enlargement of the cavernous sinus, dilatation of the superior ophthalmic veins and proptosis with definite right-sided prominence of pathology. Altogether, these findings are consistent with the diagnosis of right-sided carotid cavernous sinus fistula, which in the meantime has been also identified by conventional angiography. 2. Multiple fractures of the facial skull as previously reported. 3. No acute intracranial abnormality [**2184-1-15**]: trans. cath embollization: IMPRESSION: Successful embolization of the superior ophthalmic vein on the right. Unsuccessful embolization of the carotid cavernous fistula. Further treatment will be attempted at a later time when the patient stabilizes [**2184-1-15**]: car./[**Last Name (un) **]. angio: IMPRESSION: Successful embolization of the superior ophthalmic vein on the right. Unsuccessful embolization of the carotid cavernous fistula. Further treatment will be attempted at a later time when the patient stabilizes. The following coils were used to place into the superior ophthalmic vein. GDC 18 4 mm x 10 cm coil. GDC 18 2D 7 mm x 30 cm coil: 8 mm x 20 cm Cashmere 14 coil. 9 mm x 22 cm Cashmere 14 coil. 10 mm x 25 cm Cashmere 14 coil. 8 mm x 20 cm Cashmere 14 coil. GDC 18 2D 8 mm x 30 cm coil. [**2184-1-16**]: MR cervical spine: IMPRESSION: 1. C2/C3 flexion distraction with fracture of the posterior C2 body and transverse processes, better demonstrated on CT C-spine. 2. Posttraumatic annular tear of the C2/C3 intervertebral disc as well as a tear of the posterior longitudinal ligament. 3. Questionable mild injury to the posterior ligamentous complex at the C2/C3 level. 4. Extensive prevertebral hematoma from skull base to C4 as well as diffuse hemorrhage involving the suboccipital soft tissues. 5. No evidence of cord contusion. [**2184-1-21**]: x-ray of c-spine: FINDINGS AND IMPRESSION: Endotracheal tube and temperature probe are present. Surgical instrument is seen within the anterior disc space of C2-C3. Subsequently ACDF of C2-C3 with anterior instrumentation at intervertebral cage. Normal alignment. Please see operative report for further details. [**2184-1-22**]: chest x-ray: FINDINGS: In comparison with the study of [**1-21**], there is little overall change. Monitoring and support devices remain in place. Hazy opacification bilaterally is consistent with pleural effusion with some basilar atelectasis. Engorgement of pulmonary vessels is consistent with elevated pulmonary venous pressure. [**2184-1-24**]: chest x-ray: FINDINGS: As compared to the previous radiograph, the patient has been extubated. The lung volumes are unchanged. The presence of bilateral mild-to-moderate pleural effusions cannot be excluded. Unchanged borderline size of the cardiac silhouette, mild fluid overload. Retrocardiac atelectasis of constant extent. [**2184-1-25**]: chest x-ray: FINDINGS: As compared to the previous radiograph, the patient has received a tracheostomy tube. The tip of the tube projects 2.8 cm above the carina. There is no evidence of complications. Unchanged position of left subclavian catheter. Unchanged moderate cardiomegaly. The bilateral parenchymal opacities show a decreasing trend. After splenectomy, free intra-abdominal air is now visible under the right hemidiaphragm [**2184-1-27**]: ct of the head: IMPRESSION: 1. Interval embolization of the right superior ophthalmic vein. Persistent right-sided proptosis and preseptal soft tissue swelling. 2. No evidence of intracranial hemorrhage. 3. Limited examination secondary to artifact from the halo. No gross territorial infarction. [**2184-1-27**]: cat scan of the c-spine: IMPRESSION: 1. Fracture lines involving the body of C2 extending to the bilateral transverse processes, compatible with a "Hangman's fracture" are still evident though the previously noted distraction of C2 on C3 is improved status post anterior C2-C3 fusion with intervertebral disc spacer placement. 2. Known associated prevertebral hematoma and swelling. Brief Hospital Course: 27 year old female who was involved in a car/car MVC. She was brought to [**Hospital1 18**] ED as trauma activation [**2184-1-14**]. Following trauma evaluation patient was admitted to ACS trauma service for further care in TSICU intubated/sedated. Systems based hospital course as follows: INJURIES: - bilateral comminuted mandibular fx (OMFS non-operative) - basilar skull fx (non-operative) - L squamous temporal bone fx (non-operative) - Post C2 body fx w/ C2-3 flex-distraction (s/p ant fusion ortho-spine) - bilat preseptal hemorrhage (s/p neuro IR coiling/optho following/stable IOP) - tiny bilateral PTX (stable) - splenic injury (s/p splenectomy) - bilat anterior acetabular fx (stable, WB as tol) - R inferior pubic ramus fx (stable, WB as tol) - laceration x2 R anterior shin/knee (stable, WB as tol) - Shallow impaction fx ant tibial cortex (stable, WB as tol) - RLL contusion (stable, WB as tol) Neuro: Patient was intubated in trauma bay for altered mental status. CT head showed no TBI. Sedation was administered as needed for patient comfort. Followed commands when sedation lightened throughout. Sedation weaned as appropriate. Given hx opiate abuse chronic pain service was contact[**Name (NI) **] [**1-23**] to assist w pain control issues. Methadone was started [**1-25**] in combination w dilaudid combination long/short acting analgesia. Mental status noted to be markedly improved [**1-25**]. CT of the head and c-spine were completed as part of trauma evaluation revealing likely carotid-cavernous sinus fistula as well as C2 hangman's fracture. [**1-15**] patient went to neuro IR for embolization of carotid-cavernous fistula. Type I CC fistula w enlarged superior ophtalmic vein was seen and embolized. Unable to embolize cavernal sinus. [**1-16**] b/l femoral sheaths were removed. Neurosurgery cleared patient for c-spine repair [**1-18**]. Repair was initially deferred secondary to presumed pulmonary infection and hesitance to insert ortho spine hardware in setting of active infection. [**1-21**] patient went to OR with ortho spine for C2-3 anterior fusion w/ iliac BG and halo application. Per ortho/Nsurg, CT head/c-spine performed [**1-27**] revealed interval placement of multiple embolization coils within the right superior ophthalmic vein. No coils are demonstrated in the region of the right cavernous sinus. There is persistent right-sided proptosis and preseptal soft tissue swelling. No evidence of intracranial hemorrhage. On [**2184-2-3**] she underwent a repeat cartoid angiogram and had placment of 3 coils to the right carotid sinus fistula. Right ophthalmologic injury noted with ophtho consult obtained on [**1-14**]. Bedside evaluation [**1-15**] was notable for bedside periorbital blood evacuation by opthalmology. Drops/ointments were applied per ophtho recs. [**1-16**] optho exam was notable for pressures as follows: R eye pressure 18,23,21. L eye pressure 18,22,19. Opthalmologic evaluation continued on ongoing basis. [**1-19**] pressures were approaching normal limits. CV: Patient was resuscitated per trauma protocol with adequate/appropriate response. The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: Patient was intubated in trauma bay for altered mental status/agitation. Noted to have small B/L PTX though chest tubes not required. Remained intubated for procedures as well as likely VAP (see ID). [**1-19**] patient made progress weaning ventilatory support. [**1-20**] bronch with BAL was repeated but was not terribly impressive. Respiratory status improved [**1-22**]. Trajectory of pulmonary progress improved such that patient met criteria for extubation [**1-24**]. Patient proceeded to decompensate from respiratory standpoint [**1-24**] requiring urgent nasotracheal intubation (given halo). With difficult airway and tenuous respiratory status patient was taken to OR for trach/PEG [**1-24**]. Speculated that poor gag at this time may be related to superior laryngeal nerve stress in setting of recent neck instrumentation. Bronch repeated [**1-25**] with clearing secretions. [**1-26**] patient weaned off of ventilatory support. [**1-27**] tolerated trach mask throughout day. Patient also noted to cough well with good clearance of respiratory secretions. S&S tried PMV eval [**1-27**] which patient did not tolerate due to coughing and increase secretions. Concern for laryngeal edema. Vital signs were routinely monitored. GI/GU: Trauma scan revealed splenic laceration for which patient was brought to IR for attempted embolization. Adequate hemostasis required coil/gel foam embolization multiple splenic branches. Given likelihood of subsequent splenic infarct patient was taken to OR for splenectomy [**1-15**]. Patient tolerated this well and was brought to TSICU for further management intubated/sedated. Patient was given IV fluids on arrival per trauma resuscitation protocol. Dobhoff was placed [**1-16**] and TFs initiated which were tolerated well. PEG was placed [**1-24**] without incident and TFs resumed [**1-25**]. She was also started on a bowel regimen [**1-16**] to encourage bowel movement. Patient had bowel function per normal with flatus and BMs. Foley was placed as part of trauma evaluation. Urine output was adequate and patient resuscitated accordingly. Intake and output were closely monitored. ID: Patient noted to be febrile [**1-17**]. Tylenol and cooling measures were initiated. 4+GNR on sputum were found on gram stain and cipro/zosyn started for antipseudomonal coverage. [**1-18**] abx were changed to Vanc/Cefepime/Cipro for broad coverage on PNA. Bronch performed for desat to 89 with large amount of thick secretions demonstrated. BAL specimen was sent showing 3+PMNs, no orgs on gram stain. Bronchs were repeated as needed with specimens sent accordingly. Nystatin was started [**1-22**]. Abx d/c'd [**1-22**] as all cultures remained negative. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. MSK: See neuro for mgmt of C2 fx. OMFS consult requested for mandibular fx. Noted that evaluation should take place when patient awake/cooperative so formal evaluation deferred through [**1-26**]. On eval for mandibular fx OMFS stated no indication for operative intervention. Rec chlorhexidine rinse x 1month. Pelvic fractures as above injury list. Eval by ortho notable for non-op management. HEME: Patient required massive transfusion protocol initiation at time of arrival for hypotension. [**2088-1-13**] patient received 7 pRBC, 4 FFP, 1 pack platelets. Hct throughout remainder of admit remained stable. No further transfusions required as of [**1-28**]. DISPO: Remained in ICU from [**1-14**] - [**1-27**] for recovery. PT consult was placed [**1-22**]. [**1-26**] central line and a-line d/c'd with expectation that patient would go to floor [**1-27**]. Transferred to the surgical floor on [**2184-1-27**]. She was evaluated for placement of a speaking valve in hopes of allowing her to speak and to assess her ability to manage her secretions. She was reported to have severe coughing with the cuff deflated and recommendations made to down-size trach tube before attempts made to allow oral intake. Her trach tube was down-sized to a #7 non-cuffed fenestrated trach tube on [**1-30**]. Tube feedings continued as per order. She was evaluated by Opthamology for further assessement of visual acuity, but exam deferred related to patient's mental status, but recommendations made for lacrilube to right eye every 2 hours. She was re-evaluated by speech and swallow on [**2-4**] to assess her ability to tolerate a speaking valve. A Sheily speaking valve was placed and patient was able to vocalize. She did experience coughing after swallowing thick nectar and pain with chewing. In order to better assess her swallowing, she underwent a video swallow and was found to continue to aspirate with liquids, but did tolerate pureed foods. She will need to be evaluated again by Speech/Swallow prior to increasing her diet (see note Speech/Swallow) The patient was found to be making good progress with ambulation, and balance, but continues to have require trach care and tube feedings and for this reason was evaluated for a rehabilitation facility where she can further regain her strength and mobility. She did receive her post-splenectomy vaccines on [**2184-1-30**] Of note: she will need follow-up for repeat angio on [**2-9**]. Neuro. is aware and will call facility regarding time and place. Medications on Admission: none Discharge Medications: 1. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q8H (every 8 hours): apply to rigth eye. 2. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): right eye. 3. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for yeast . 4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 5. methadone 10 mg Tablet Sig: Ten (10) mg PO BID (2 times a day). 6. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). 7. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) cc PO BID (2 times a day): hold for loose stools. 8. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 9. acetaminophen 650 mg/20.3 mL Solution Sig: 20.3 ml PO Q6H (every 6 hours). 10. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 3 hours: as needed for pain, may cause increased drowsiness. 11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic Q2H (every 2 hours): right eye. 13. lorazepam 0.5 mg Tablet Sig: 0.5 mg PO Q4H (every 4 hours) as needed for anxiety . 14. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal at bedtime as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Trauma: bilateral comminuted mandibular fx basilar skull fx Post C2 body fx w/ C2-3 flex-distraction bilat preseptal hemorrhage small bilateral PTX splenic injury s/p splenectomy L sqaumous temporal bone fx bilat anterior acetabular fx R inferior pubic ramus fx laceration x2 R anterior shin/knee Shallow impaction fx ant tibial cortex RLL contusion Carotid->cav sinus fistula s/p embol. Annular tear C2/3 disk Prevertebral hematoma, skull base -> C4 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive( pt has trach) Activity Status: non-op pelvic fx WBAT; Spine-s/p C2-3 fusion with Halo Discharge Instructions: You were admitted to the hospital after you were involved in a motor vehicle accident in which you sustained a cervical spine fracture, facial fracture, and a laceration to your spleen. To stabilize your cervical spine, you had a bone graft and halo brace for additional stability. You sustained a lacertation to your spleen and had your spleen removed. Because of your injuries and your neck instability, you had a trach performed and a feeding tube placed for nutrition. You were monitored in the intensive care unit for 2 weeks. Once your vital signs stabilized, you were transferred Your vital signs have stabilized and you are now preparing for discharge to an extended care facility where you can further regain your strength. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 54446**] when discharge. OMFS will call you.(they have been informed of discharge) You follow-up appointment will be at Yawkey Ambulatory Care Center at [**Hospital6 **] in the oral surgery clinic on the [**Location (un) 90746**]. Address is [**Last Name (NamePattern1) **]. Phone number is [**Telephone/Fax (1) 68463**]. Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Location: DEPT OF ORTHOPAEDIC SURGERY/SPINE CENTER Address: [**Location (un) **], [**Hospital Ward Name **] 2, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3736**] We are working on a follow up appointment with Dr. [**Last Name (STitle) 1352**] in the next 2 weeks. You will be called at the facility with the appointment. If you have not heard within 2 business days or have questions, please call the number listed above. Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2184-2-17**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage You will need a chest x-ray prior to this appointment. Please go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **] Radiology 30 minutes prior to your appointment. Please arrive there at 1:30pm. Department: ORTHOPEDICS When: TUESDAY [**2184-3-2**] at 10:00 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2184-3-2**] at 10:20 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please follow with Mass Eye/Ear Oculoplastics in 1 week. You can schedule an appointment by calling # [**Telephone/Fax (1) 32768**]. Please follow up with the [**Hospital1 69**] eye clinic in [**3-5**] weeks. You can schedule your appointment by calling # [**Telephone/Fax (1) 253**] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2184-2-4**]

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icd9cm

[ [ [] ] ]

[ "81.62", "77.79", "33.23", "41.5", "31.1", "96.6", "39.76", "39.79", "43.11", "08.51", "96.72", "84.51", "03.53", "86.59", "81.02", "33.24", "93.41", "84.52", "02.94" ]

icd9pcs

[ [ [] ] ]

20854, 20920

10772, 19433

701, 958

21416, 21416

2518, 10749

22370, 24874

1289, 1293

19488, 20831

20941, 21395

19459, 19465

21610, 22347

1308, 2499

261, 663

986, 1222

21431, 21586

1244, 1253

1269, 1273

40,461

118,931

37384

Discharge summary

report

Admission Date: [**2113-3-12**] Discharge Date: [**2113-3-24**] Date of Birth: [**2063-6-7**] Sex: M Service: SURGERY Allergies: Penicillin G Attending:[**First Name3 (LF) 3223**] Chief Complaint: headache and neck pain Major Surgical or Invasive Procedure: none History of Present Illness: This is a 49 year old male on Coumadin with INR 3.9 who presents today from Rehabilitation Center with reports that he was attempting to get up and fell to the floor striking his head. This fall was unwitnessed and there is unknown loss of consciousness. The patient had a Head CT at an outside hospital which was consistent with possible depressed anterior frontal sinus and possibly some hemorrhage located in the inferior temporal occipital region in the location of infarcted tissue. This patient takes Coumadin for a Mitral Valve Replacement([**Street Address(2) 84052**]. [**Male First Name (un) 923**] Mechanical Valve)which he had on [**2113-1-27**] with Debridement of Aortic Valve. Past Medical History: PMH 1. Hypertension 2. Hypercholesterolemia 3. Diabetes 4. MSSA endocarditis 5. Multiple septic embolic CVA's 6. Chronic draining right bursa PSH 1. S/P MVR with #29 St. Jude valve and aortic valve debridement12/09 2. S/P Multiple dental extractions [**1-25**] 3. S/P Right elbow bursectomy Social History: Lives with wife -[**Name (NI) 1139**] history: 1.5-2 PPD for last 30 years -ETOH: 3-4 beers daily -Illicit drugs: none Family History: Brother had myocardial infarct in 50s. Physical Exam: O: T: 98 BP: 153/95 HR:92 R: 16 O2Sats: 100% Gen: comfortable, NAD. HEENT: erythema over right forehead Pupils:3.5-3 EOMs:pt unable to complete on right side- unable to follow examiners finger secondary to visual deficit post CVA Neck: hard cervical collar in place Chest clear, well healed sternal scar COR RRR Abd soft, some tenderness over LLQ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert with complaints of headache,pt appears to have right sided neglect, right sided paresis and right eye blindness and left eye impaired vision which impairs neurological exam. Patient is inattentive and agitated with exam. Orientation: Oriented to person-first name only, place "[**Location (un) 86**]", and not date. Recall: pt unable to perform this task Language: Speech fluent. Pt agitated and unable to perform good comprehension exam. Intermittently following commands, able to repeat phrases. Naming not intact-pt unable to identify a pen or watch, but has servere visual deficit. Possibly some receptive dysphasia noted in exam. Pt becoming frustrated throughout exam stating "I do not know what you mean- what are you asking me to do" Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,3.5 to 3 mm bilaterally. Visual fields deficit bilaterally. III, IV, VI: Extraocular movements unable to perform due to visual field deficit. V, VII: Facial strength and sensation grossly intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius pt does not participate. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full on left power [**6-21**] throughout. Right upper extremity exam limited due to subluxed shoulder-triceps/grip appear [**6-21**]. Right IP, quad [**6-21**]. R hamstrings [**5-22**], R dorsiflex/plantar flex, [**Last Name (un) 938**] [**3-24**] Pronator drift-pt not compliant with exam Sensation:pt non compliant with exam. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements slower on right upper extremity. no clonus Pertinent Results: [**2113-3-12**] 11:00AM WBC-8.3 RBC-3.16* HGB-9.5* HCT-29.3* MCV-93 MCH-30.2 MCHC-32.6 RDW-17.9* [**2113-3-12**] 11:00AM NEUTS-77.8* LYMPHS-15.2* MONOS-4.8 EOS-1.9 BASOS-0.3 [**2113-3-12**] 11:00AM PLT COUNT-551* [**2113-3-12**] 11:00AM PT-37.5* PTT-35.1* INR(PT)-3.9* [**2113-3-12**] 11:00AM GLUCOSE-98 UREA N-21* CREAT-1.0 SODIUM-135 POTASSIUM-6.3* CHLORIDE-100 TOTAL CO2-26 ANION GAP-15 [**2113-3-12**] 11:00AM ALT(SGPT)-26 AST(SGOT)-58* LD(LDH)-743* ALK PHOS-76 TOT BILI-0.3 [**2113-3-12**] Head CT : 1. Interval increase in size of parenchymal hemorrhage within the infarcted tissue of the left temporo-occipital lobe, now measuring 12 x 8 mm. No associated mass effect. 2. No other intracranial hemorrhage. 3. Stable appearance of multifocal hypodensities corresponding to prior infarcts. 4. Redemonstration of anterior wall of right frontal sinus fracture. [**2113-3-12**] CT C spine : 1. Minimally depressed fracture of the anterior wall of the right frontal sinus, with blood layering dependently in the sinus. Fracture does not appear to extend to the posterior wall. There is no pneumocephalus or intracranial hemorrhage at this site. 2. Tiny amount of high-density material in the infarcted tissue of the inferior left temporo-occipital lobe, likely reflecting small amount of acute bleeding. 3. No evidence of new infarct. 4. No fracture or malalignment of the cervical spine. [**2113-3-12**] CT Mandible : 1. Re-demonstration of minimally depressed fracture of the anterior wall of the right frontal sinus, not extending through the posterior wall into the cranial vault. 2. Extension of fracture through the superior wall of the right orbit, without intraorbital fluid collection. 3. Interval decrease in blood within the right frontal sinus. 4. Mucosal thickening of the right maxillary sinus. 5. Atherosclerotic calcifications. [**2113-3-13**] Head CT : 1. Again continued interval increase in size of parenchymal hemorrhage within the infarcted tissues of the left temporo-occipital lobe. No associated mass effect. No new focus of intracranial hemorrhage nor intraventricular extension. 2. Unchanged appearance of multiple foci of hypodensities corresponding to prior infarcts. 3. Redemonstration of depressed anterior wall of right frontal sinus fracture. [**2113-3-15**] Head CT : 1. Stable appearance of area of intraparenchymal hemorrhage with associated intraventricular extension. 2. Stable appearance of encephalomalacic change from known chronic infarction. 3. Stable subacute right subdural hemorrhage with associated leftward 5 mm midline shift. [**2113-3-17**] Head CT : 1. Slight decrease in left occipital lobe hemorrhage. 2. Gradually decreasing thin right subdural hygroma. 3. Chronic cerebral and lacunar infarcts. Brief Hospital Course: Mr. [**Known lastname 84050**] was evaluated by the Trauma service in the Emergency Room and admitted to the Trauma ICU for frequent neuro checks. A CT scan was done 5 hours after admission and showed an increase in the left temporo-occipital region from 8mm/2mm to 12mm/8mm. He had no change in his neurological exam. His INR remained elevated and he received multiple units of fresh frozen plasma ( no Vit. K ) to gradually decrease his INR. The neurosurgical service as well as the neurology service followed closely. He had Head CT's every 24-48 hours and his INR was corrected gingerly as his mechanical valve needed protection. His baseline confusion was from his prior embolic stroke but he remained alert and interactive. His highest INR was 6.4 and as he approached 2.0 he was started on a heparin infusion. His last CT scan was [**2113-3-17**] which showed a decrease in his left occipital hemorrhage. Over the last week he was transferred to the Trauma floor for titration of heparin and Coumadin. He was started on only 0.5 mg for 3 days and had no activity on his INR. The dose was increased to 1 mg for 3 days and again his INR was 1.2. Finally after giving 5 mg his INR rose to 1.5 today. The plan is to give him 2 mg. of Coumadin tonight and to resume his Heparin drip at 1750 units/hr. without a bolus. The goal INR is 2.5-3.0. During his hospital stay the Orthopedic service evaluated his right bursectomy site which had previously had a VAC dressing in place. The VAC dressing was eventually removed on [**2113-3-18**] and saline wet to dry dressings were instituted [**Hospital1 **]. This is working out well and there is good granulation tissue at the base. He has had continued Physical Therapy and Occupational Therapy during his stay and he is making good progress. He is being transferred back to rehab with the hopes of increasing his independence and returning home. Medications on Admission: !. Atorvastin 20 mg PO Daily 2. Coumadin 1 mg PO Daily 3. Aspirin 81 mg PO Daily 4. Haldol 1 mg PO BID 5. MVI 1 tab Po Daily 6. Tamsulosin 0.4 mg PO qhs 7. Lopressor 50 mg PO TID 8. Zantac 150 mg PO daily 9. Nafcillin 2 GM IV q4hrs to continue until [**Hospital **] clinic F/U [**3-3**] 10. Lasix 10 mg IV BID 11. Albuterol Nebs q4hrs prn wheezing 12. Ipratropium nebs [**Hospital1 **] prn whezing Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO 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. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: 1750 (1750) units per hour Intravenous ASDIR (AS DIRECTED): Keep PTT 65-85 DC when INR less than 2.0. 9. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Give 2 mg on [**2113-3-24**]. 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Insulin Regular Human 100 unit/mL Solution Sig: 2-8 units Injection four times a day: per sliding scale. 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for PRN. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Primary diagnosis S/P Fall 1. Depressed frontal sinus fracture 2. Temporoccipital hemmorrhage Secondary diagnoses 1. Hypertension 2. Hypercholesterolemia 3. Diabetes 4. MSSA endocarditis 5. Multiple septic embolic CVA's 6. S/P MVR with #29 St. Jude valve and aortic valve debridement and repair [**1-25**] 7. S/P Multiple dental extractions [**1-25**] 8. Right elbow bursectomy [**1-25**] for chronic draining bursa 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: ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. Keep right arm elevated when not walking. ?????? Increase your intake of fluids, food and fiber. Nutrition is very important in healing. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? Your Coumadin has been difficult to regulate and you'll need close follow up after your discharge from rehab. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Orthopedics, for your elbow. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in 4 weeks with Dr. [**Last Name (STitle) 548**], Neurosurgery for a rpeat non-contrast head CT scan. Call [**Telephone/Fax (1) 2992**] for an appointment. Call Dr. [**Last Name (STitle) 84051**] for a follow up appointment after your discharge from rehab. The following appointment was previously scheduled for you: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2113-3-21**] 1:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2113-3-24**]

[ "V45.89", "438.83", "272.0", "438.22", "438.11", "E888.1", "E849.7", "V58.61", "305.1", "V12.51", "V43.3", "V17.3", "801.30", "401.9", "250.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10114, 10161

6578, 8489

294, 301

10621, 10621

3782, 6555

11682, 12466

1491, 1532

8938, 10091

10182, 10600

8515, 8915

10798, 11659

1547, 1936

232, 256

329, 1024

2730, 3763

10635, 10774

1046, 1338

1354, 1475

7,478

168,872

45279

Discharge summary

report

Admission Date: [**2104-11-26**] Discharge Date: [**2104-12-8**] Date of Birth: [**2028-5-12**] Sex: F Service: GYN/OB HISTORY OF PRESENT ILLNESS: This is a 76 year-old G4, P2 who was admitted on [**2104-11-26**] for preoperative evaluation. The patient was scheduled for a debulking procedure for advanced ovarian cancer on [**2104-11-27**]. The patient was given the diagnosis of likely ovarian cancer on [**2104-11-22**]. She had had two to three months of decreased appetite and increased weight loss with distention of her abdomen, fatigue and insomnia. The patient denies abdominal pain or vaginal bleeding. PAST GYN HISTORY: No abnormal PAPS, STDs or fibroids. Menarche was at age 12, 25 day cycles two to three days of bleeding. The patient is currently postmenopausal. PAST OB HISTORY: The patient had two spontaneous vaginal deliveries and two abortions. PAST SURGICAL HISTORY: 1. Appendectomy in [**2072**]. 2. Left breast lumpectomy with XRT for breast cancer. PAST MEDICAL HISTORY: 1. Breast cancer. 2. High blood pressure. 3. GERD. MEDICATIONS: 1. Atenolol 25 milligrams q day. 2. Pepcid q day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives independently. She denies tobacco and alcohol use. She is very active. FAMILY HISTORY: The patient had a mother with breast cancer at age 72 with a mastectomy. The patient's father died of cirrhosis at age 83. PHYSICAL EXAMINATION ON ADMISSION: The patient was well appearing, pleasant white female in no apparent distress. She was afebrile with stable vital signs. Her cardiovascular exam revealed regular rate and rhythm, no murmurs. Her chest was clear to auscultation bilaterally without crackles. Her breast exam showed a right scar from mastitis and a left scar from lumpectomy. Her abdominal exam was soft, extended with a fluid wave. It was tender to deep palpation in the right lower quadrant, no hepatosplenomegaly or rebound appreciated. Vaginal exam was deferred. Extremities showed no cyanosis, clubbing or edema. LABORATORY ON ADMISSION: [**2104-11-26**] white count 9.1, hematocrit 32.3, platelet count 459,000, normal differential. Urinalysis on [**2104-11-22**] was negative. Electrolytes on admission showed sodium 138, potassium 4.0, chloride 101, bicarb 22, BUN 29, creatinine 1.3, glucose 71. On [**2104-11-23**] the patient had a CA125 of 5,324 and a CEA of less than 1. The patient also had a cancer antigen 27.29 that was 695 which is elevated and a CA199 that was 9 which was within normal limits. On [**2104-11-22**] the patient had a CT scan of the abdomen and pelvis which showed massive ascites with omental caking compatible with metastatic disease. Given the solid and cystic masses seen on the left adnexa this was felt to represent ovarian carcinoma less likely consideration would include metastatic breast cancer and bilateral Krukenberg tumors. 1. Pulmonary nodule seen in the right lung base worrisome for metastatic disease. 2. Left renal cyst. 3. Sigmoid diverticulitis. A chest CT scan obtained [**2104-11-26**] showed: 1. 5 mm nodule in lateral right lower lung. 2. Large amount of ascites associated with omental thickening consistent with abdominal carcinomatosis. A preoperative chest x-ray showed heart size within normal limits, mild degenerative changes, no evidence of CHF or infiltrates. HOSPITAL COURSE: On [**2104-11-27**] the patient underwent an exam under anesthesia, exploratory laparotomy, total omentectomy, mobilization of the splenic flexure, supracervical hysterectomy with bilateral salpingo-oophorectomy, resection of the rectosigmoid colon, creation of a colostomy, creation of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3379**] pouch. Intraoperative the patient had 3 liters of ascites, 1200 cc blood loss and received 6500 cc of IV fluids plus 1000 cc of Hespan 3 units packed red blood cells as well as 2 grams of Cefzil. The findings intraoperative showed a large omental caking extending from splenic flexure to hepatic flexure, frozen pelvis with large tumor encasing the rectosigmoid colon and a duplication of the right ureter. For further detailed operative note. Postoperative course - The patient was initially admitted to the Surgery ICU postoperative given her extensive surgery and need for blood products. The patient was kept intubated until postoperative day one and then was transferred to the regular GYN Oncology floor. 1. NEUROLOGICAL - The patient was initially maintained on a Dilaudid PCA for pain relief. When the patient was tolerating po this was changed to po Dilaudid. The patient did receive three days of Toradol between postoperative day six to nine for additional pain relief. The patient also given Tylenol for breakthrough pain. 2. PSYCHIATRIC - The patient had a very negative affect and was extremely frustrated with her large surgery and diagnosis of the ovarian cancer as well as the need for an ostomy which she was not prepared for. During her hospital course the patient was seen by social work and was started on Paxil. Prior to discharge on postoperative day nine the patient refused Paxil, admitted she did not need it and would rather wait to have outpatient psychiatry consult when she went to rehab. Throughout her admission the patient's affect did improve although per nursing report she was frequently teary and frustrated. Prior to her admission the patient had been diagnosed with mild depression and had not started any medical therapy. 3. FLUIDS, ELECTROLYTES AND NUTRITION - The patient had a central line placed intraoperative. She was then started on TPN on postoperative day one. The patient remained on TPN for her full admission. Her electrolytes were initially hard to manage with low potassium requiring a lot of potassium in her TPN but then her electrolytes stabilized and remained stable for the rest of her admission. On postoperative day 10 the patient did tolerate po and had an appetite for the first time. She took in 550 cc without nausea or vomiting. By the time of discharge the patient is currently still on TPN with daily electrolytes being checked and found to be within normal limits. 4. GASTROINTESTINAL - The patient was kept NPO and had an NG tube placed intraoperatively. The NG tube was discontinued on postoperative day three. The patient had occasional vomiting in the beginning of her postoperative course which resolved spontaneously. The patient did complain of abdominal fullness and had an ileus for several days postoperative which resolved. The patient's ostomy was working with positive gas and stool by postoperative day six. The ET nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] and followed the patient for ostomy care. Her ostomy did look very dark and eventually some of the superficial epithelial layer did slough off. At the current time the ostomy is pink with positive liters and stool but is more flush with the abdominal wall than had been previously. 5. GENITOURINARY - The patient had a Foley placed intraoperatively. The Foley was discontinued on postoperative day nine after the patient was found to have a urinary tract infection also leaking around her Foley catheter. The patient was initially incontinent after removal of the catheter. This resolved over the next three days. The patient still loses urine when she is unable to make it to the toilet but reports that she does have control of her bladder and this appears to be a functional incontinence. The patient's urinary tract infection grew out pseudomonal as well as enterococcus which were sensitive to Ciprofloxacin and Levofloxacin therefore she was started on Levofloxacin po. Before the enterococcus was isolated the patient had been on Ceftazidine for the pseudomonas for three days. The Levofloxacin was started on [**2103-12-9**] and will continue for a full 10 days course. 6. POSTOPERATIVE - The patient's incision remained intact without any signs of erythema or drainage. The lower edge of the incision did have a small tear from one of the staples which was slightly wet with serous fluid but no evidence of infection or collection. The patient does have staples in and will need those removed on postoperative day 14 which is [**2104-12-12**]. 7. PHYSICAL THERAPY - The patient was initially very hard to move after the surgery. She was having difficulty holding herself up secondary to abdominal pain. After we got the pain under control the patient was more ambulatory and prior to discharge she was able to walk 50 feet independently with the aid of a walker or the IV pole. Physical therapy did visit patient throughout the second half of her hospital admission and although the patient is behind in her strength and physical activity she is improving daily. 8. CARDIOVASCULAR - The patient remained cardiovascularly stable throughout the surgery. She was not on any pressor medications during her ICU course. Her Atenolol was re-started when the patient was tolerating po because her blood pressure did begin to rise. On postoperative day eight and nine the patient did have some elevated blood pressures to 210/70 this was treated with 5 milligrams of IV Lopressor and her Atenolol was increased to 50 milligrams po q day. The patient's blood pressure remained high and her hydrochlorothiazide was re-added on postoperative day nine with good results. 9. HEMATOLOGY - The patient's preoperative hematocrit was 29.7 intraoperative she received 3 units of packed red blood cells and postoperatively her hematocrit was 26.2. The patient received an additional 4 units of packed red blood cells over the next three postoperative days with settling of her hematocrit at approximately 33 which remained stable throughout the rest of her hospital course. The patient also developed a coagulopathy postoperative with an increased INR of 1.9 and an elevated PTT in the high 30s. The patient was treated with fresh frozen plasma on postoperative day one and received again fresh frozen plasma on postoperative day two. After that her coagulopathy settled out with an INR of 1.5 and then eventually went to 1.1. The patient received no further fresh frozen plasma. 10. LINES - The patient had a central line placed postoperative day 0 in the ICU which she has upon discharge. 11. DVT PROPHYLAXIS - The patient was maintained on pneumo-boots throughout her hospitalization. She did have the mild coagulopathy and therefore was not given subcutaneous Heparin. The patient was given IV Protonix through most of her hospital admission. This was changed to Zantac in the TPN which could be changed to po after the TPN is weaned. DISCHARGE STATUS: The patient is stable. She is afebrile with stable vital signs. Her blood pressure is well controlled on her Atenolol and hydrochlorothiazide. Her pain is well controlled on po Dilaudid. She is ambulating approximately 50 feet twice a day with assistance of walker / IV pole. The patient's ostomy is working with positive gas and stool although slightly flush as some sloughing of epithelium. The patient is continent of urine although has a functional incontinence if she cannot get to the toilet in time. She is currently being treated for a urinary tract infection on levofloxacin. DISCHARGE MEDICATIONS: 1. Timolol 5% one drop each eye q hs. 2. Dilaudid 1 to 4 milligrams po q four to six prn. 3. Mycostatin cream or powder to perineal area tid started on [**2104-12-5**]. 4. Hydrochlorothiazide 25 milligrams po q day. 5. Atenolol 50 milligrams po q day. 6. Levofloxacin 500 milligrams po q day times 10 days for urinary tract infection started on [**2104-12-8**]. 7. Serax 15 milligrams po q hs prn. 8. Tylenol prn. 9. Paxil which the patient has been refusing to take. DISCHARGE DIET: Clear as well as toast and pudding and may be advanced as tolerated. DISCHARGE NEEDS: The patient will need intensive physical therapy at an outside rehab as well as tapering of her TPN, ostomy care and staple removal on [**2104-12-12**]. DISCHARGE FOLLOW UP: The patient will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5166**]. She should call the office for a follow up appointment. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 26060**] Dictated By:[**Name8 (MD) 6269**] MEDQUIST36 D: [**2104-12-8**] 09:05 T: [**2104-12-8**] 10:13 JOB#: [**Job Number **]

[ "197.6", "789.5", "530.81", "560.1", "286.9", "183.0", "V10.3", "599.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "68.3", "45.76", "65.61", "54.4", "99.15", "99.07", "46.10", "48.63" ]

icd9pcs

[ [ [] ] ]

1312, 1458

11333, 12080

3401, 11310

917, 1005

12092, 12512

169, 894

2086, 3383

1027, 1186

1204, 1295

16,536

108,445

11799

Discharge summary

report

Admission Date: [**2143-4-11**] Discharge Date: [**2143-4-15**] Date of Birth: [**2090-5-29**] Sex: M Service: MEDICINE Allergies: Lipitor / Gemfibrozil / Zosyn Attending:[**First Name3 (LF) 3507**] Chief Complaint: Fever and Hypotension Major Surgical or Invasive Procedure: Central Line placement Left Nephrostogram History of Present Illness: 52M with h/o BPH, markedly elevated PSA (>200) and outlet obstruction, presents with fever and hypotension. He presented to the ED with confusion, fever and abdominal pain on [**4-11**]. In the ED, he was found to have a positive UA with CT Abdomen revealing bilateral hydronephrosis with pyeloneprhosis. He was hypotensive requiring vaspressors 5L NS. Foley was placed and he was initially treated with levofloxacin. . On admission to the MICU he was treated with vancomycin and zosyn with vasopressors weaned off on day of admission. On [**4-12**] urine culture grew enterococcus so Linezolid was started for concern for VRE. Due to concern of ureteral obstruction as well as bladder outlet obstruction, IR atempted placement left perc nephrostomy tube, but ureterogram did not reveal obstruction or hydroureter and therefore no tube placed. On [**4-13**] he developed acute SOB and CT chest/abd showed small RP bleed at site of prior procedure with no PE. There was concern for anaphylaxis to zosyn (as SOB was temporally related to infusion) so he was given steroids, Epi, H1 and H2 blockers. . [**Hospital **] transferred to floor for further care. Past Medical History: 1. S/P hemorrhagic CVA [**2127**] with residual partial right hemiparesis, homonymous hemianopsia and partial aphasia. Etiology of CVA thought to be thrombotic; MRA at that time showed no vascular abnormality. High homocysteine resolved with B complex. 2. Reactive depression, never suicidal, improved. 3. GERD, nearly resolved after rx for H. pylori, now uses ranitidine only prn. 4. Hypertension. 5. Chronic headaches, improved. 5. Hyperlipidemia / hyperuricemia. Triglycerides greatly improved with strict diet but then patient regained weight. 6. Abnormal lfts - noted [**6-/2140**]; unclear if related to lipitor or hyperlipidemia or other etiology, resolved. Hepatitis A Ab+, Hepatitis B and C neg. 7. Sexual dysfunction. did not try cialis and is not currently having sexual relations. 8. HTN 9. left hydronephrosis . PAST SURGICAL HISTORY: 1. S/P circumcision 2. S/P shrapnel wound upper back. 3. s/p ccy [**10/2142**] Social History: Cambodian immigrant (came to US at age 27). Disabled. Lives with wife and 2 daughters. Resumed smoking up to 1 PPD, no alcohol, no history drug abuse. Family History: Resumed smoking up to 1 PPD, no alcohol, no history drug abuse. Physical Exam: T 97.1 HR 70 RR 34 BP 118/70 99%% on RA (on floor) Gen: NAD HEENT: PERRLA, OP clear Neck: R IJ in place. Lung: crackles at bases, no wheeze Cor: RRR, nml S1S2 no MRG Abd: NABS, soft NT, mod distended, no CVA tenderness Ext: trace bilat LE edema, contracted on the R upper ext. Back: mild Left CVA tenderness Pertinent Results: [**2143-4-11**] CT ABD: 1. Perinephric stranding with thickening of Gerota's fascia on the left not identified on previous study dated [**2143-2-18**]. The differential includes an inflammatory process versus a slow forniceal leak. The renal parenchyma cannot be well evaluated given lack of IV contrast administration. No stones are identified within the genitourinary system. There is mild increase in left hydroureter since previous study. 2. There is a suggestion of a small bladder diverticulum at the insertion of the left ureter. No definite bladder mass identified to explain hematuria, although full evaluation is limited secondary to lack of IV contrast administration. 3. Bibasilar airspace opacity representing either atelectasis or pneumonia. 4. Trace bilateral pleural effusions, greater on the left. 5. Diffuse fatty infiltration of the liver. . [**2143-4-12**] NEPHROSTOGRAM: Uncomplicated ultrasound and fluoroscopically-guided left nephrostogram. No evidence of left hydronephrosis or hydroureter or urinary obstruction. . [**2143-4-13**] CT PELVIS/ABD/CHEST: 1. New high-density material surrounding the left ureter and tracking within the retroperitoneum consistent with hemorrhage. 2. Abnormal perfusion of the left kidney, most severe at the upper pole. Findings are consistent with pyelonephritis. Edema and abnormal perfusion at the upper pole and interpolar region medially with multiple peripheral hypoenhancing wedge- shaped regions likely represent ischemia and a component of infarction. 3. Limited examination for pulmonary embolism due to suboptimal contrast bolus with no large central embolus seen. Evaluation of distal segmental and subsegmental branches is limited. 4. Small bilateral layering pleural effusions with associated compressive atelectasis. Patchy predominantly ground-glass opacities in both lower lobes, left worse than right could represent pneumonia or pneumonitis. 5. 5mm cystic lesion in the head of the pancreas. Recommend 1 year follow up. . [**2143-4-13**] CXR: Questionable small right pleural effusion, vague indistinct linear opacity in the right infrahilar region, likely atelectasis. . [**2143-4-11**] 05:01AM BLOOD Lactate-4.3* [**2143-4-11**] 08:54PM BLOOD Lactate-1.6 [**2143-4-10**] 08:35PM BLOOD CRP-118.7* [**2143-4-11**] 01:58PM BLOOD Cortsol-32.8* [**2143-4-11**] 02:43AM BLOOD CK-MB-5 cTropnT-<0.01 [**2143-4-13**] 01:46PM BLOOD cTropnT-0.07* [**2143-4-11**] 02:43AM BLOOD CK(CPK)-548* [**2143-4-13**] 01:46PM BLOOD ALT-20 AST-18 CK(CPK)-139 AlkPhos-78 [**2143-4-14**] 04:12AM BLOOD ALT-18 AST-17 LD(LDH)-243 AlkPhos-71 Amylase-56 TotBili-0.8 [**2143-4-10**] 08:35PM BLOOD Glucose-116* UreaN-20 Creat-1.9* Na-133 K-3.5 Cl-96 HCO3-22 AnGap-19 [**2143-4-15**] 05:00AM BLOOD Glucose-222* UreaN-23* Creat-1.1 Na-141 K-3.6 Cl-109* HCO3-23 AnGap-13 [**2143-4-10**] 08:35PM BLOOD Neuts-88* Bands-4 Lymphs-2* Monos-5 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2143-4-11**] 05:05AM BLOOD Neuts-71.0* Bands-16.0* Lymphs-1.0* Monos-2.0 Eos-0 Baso-0 Metas-9.0* Myelos-1.0* [**2143-4-13**] 05:25AM BLOOD Neuts-76* Bands-9* Lymphs-9* Monos-2 Eos-1 Baso-0 Atyps-3* Metas-0 Myelos-0 [**2143-4-10**] 08:35PM BLOOD WBC-17.3*# RBC-5.55# Hgb-15.3# Hct-45.3# MCV-82 MCH-27.5 MCHC-33.6 RDW-13.7 Plt Ct-202 [**2143-4-15**] 05:00AM BLOOD WBC-12.9* RBC-3.96* Hgb-10.8* Hct-32.0* MCV-81* MCH-27.2 MCHC-33.6 RDW-14.0 Plt Ct-218 . URINE CULTURE (Final [**2143-4-12**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S Brief Hospital Course: #Enterococcus Pyelonephritis/Urosepsis: initially treated with Vanco/Zosyn---> Linezolid. Enterococcus isolate pan-S; pt switched to Doxycycline on discharge given concern for ?Zosyn allergy. Will complete a total of 14 days of abx. Lopressor and Flomax held on d/c until pt follows up with PCP. . #?Anaphylaxis to Zosyn: episode of acute SOB in ICU that was thought to be temporally related to Zosyn. Resolved with treatment for anaphylaxis. CTA negative for large PE, CXR without overt volume overload. Will complete a total of 4 days of steroids to prevent possible late anaphylaxis. 02 sats/Lung exam normal on floor. . #Enlarged Prostate, ?Prostate Cancer: to f/u with urology as an outpatient for bx. . #Urinary Retention: No Hydronephrosis noted on Nephrostogram (after Foley placed). Per Urology, pt to leave Foley catheter in place until f/u as outpatient. . #Acute Renal Failure: resolved after IVF. Likely secondary to prerenal causes/sepsis. . #Retroperitoneal Bleed: likely secondary to Nephrostogram (IR procedure). Serial HCTs stable. . #5mm cystic lesion in the head of the pancreas: Noted on imaging. Per radiology, needs 1 year follow up. Medications on Admission: 1. FLOMAX 0.4 mg--2 capsule(s) by mouth at bedtime 2. METOPROLOL TARTRATE 25 mg--1 tablet(s) by mouth twice a day - blood pressure 3. OMEPRAZOLE 20 mg--1 capsule(s) by mouth once a day - reflux, gastritis Discharge Medications: 1. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day for 1 days. Disp:*3 Tablet(s)* Refills:*0* 2. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days. Disp:*20 Capsule(s)* Refills:*0* 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Capsule, Delayed Release(E.C.)(s) Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: 1. Enterococcus Pyelonephritis/Urosepsis 2. ?Anaphylaxis to Zosyn 3. Enlarged Prostate, ?Prostate Cancer 4. Urinary Retention/Hydronephrosis secondary to above 5. Acute Renal Failure, resolved 6. Retroperitoneal Bleed, likely secondary to Nephrostogram Discharge Condition: stable Discharge Instructions: Please come back to the emergency room should you develop any fevers, chills, sweats, nausea, vomiting, diarrhea, burning with urination, or any other complaints. Do not take your "Flomax" or "Metoprolol" medications until you see Dr. [**Last Name (STitle) 1683**]. Followup Instructions: Please call to make an appoinment with Dr. [**Last Name (STitle) 770**] in two weeks ([**Telephone/Fax (1) 5727**]). Please call to be seen by Dr. [**Last Name (STitle) 1683**] within 1-2 weeks.

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icd9cm

[ [ [] ] ]

[ "38.93", "99.21", "87.73" ]

icd9pcs

[ [ [] ] ]

8730, 8778

6906, 8077

312, 356

9081, 9090

3088, 6883

9406, 9605

2677, 2743

8335, 8707

8799, 9060

8103, 8312

9114, 9383

2411, 2492

2758, 3069

251, 274

384, 1540

1562, 2388

2508, 2661

24,759

146,694

44492

Discharge summary

report

Admission Date: [**2106-3-10**] Discharge Date: [**2106-3-18**] Date of Birth: [**2027-2-16**] Sex: M Service: CARDIOTHORACIC Allergies: Procardia / Isosorbide Attending:[**First Name3 (LF) 1267**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2106-3-10**] Three Vessel Coronary Artery Bypass Grafting utilizing left internal mammary to left anterior descending, and vein grafts to ramus intermedius and posterior descending artery History of Present Illness: This 79 year old man has a history of emphysema and an IMI in [**2085**]. He has never undergone cardiac catheterization and through the years has been managed on medication only without any symptoms. He denies any recent chest pain or change in activity tolerance but does note stable shortness of breath with moderate exertion which he attributes to his pulmonary disease. This can occur with climbing two to three flights of stairs, bending down to pick something up or walking up an incline. The patient is very hard of hearing and was recently scheduled to have a right cochlear implant at the [**Location (un) 10866**]. In preparation for surgery, he was referred for cardiovascular preoperative testing as noted below. Because of the results of his testing, his surgery has been cancelled and the patient has elected to come back to [**Location (un) 86**] for further cardiology care. Patient denies PND, orthopnea, edema. He does note some bilateral calf discomfort with walking approximately five minutes at a fast pace. The left leg is worse than the right. Cardiac catheterization on [**2106-3-5**] revealed severe three vessel disease. Left ventriculography showed a depressed ejection fraction(46%) with posterobasal akinesis. Coronary angiography was notable for a right dominant system; the LAD had an 80% ostial lesion; the ramus had an 80% stenosis; while the circumflex and right coronary arteries were totally occluded. Based on the above results, he was referred for cardiac surgical intervention. Past Medical History: Coronary Artery Disease, Prior IMI, Congestive Heart Failure, Mild to moderate aortic insufficiency, Mild mitral regurgitation, Emphysema, Hypertension, Hyperlipidemia, Peripheral Vascular Disease with claudication, Vertigo, Gout, GERD, Deafness - s/p Cochlear implant, s/p Labyrinthectomy, s/p Discectomy, Varicocele, s/p Shoulder surgery Social History: Patient is married with six children. He lives half of the year in [**State 108**] and half the year in [**Hospital1 392**]. He previously worked as an elevator mechanic. Patient's hearing is extremely poor and he is quite dependent on his wife for communication. He requires that you speak in a very loud, slow voice as words sound garbled to him. He does rely on lip [**Location (un) 1131**] to assist in his communication. Family History: Uncle with angina his 60's. Physical Exam: Vitals: BP 165/76, HR 64, RR 16, SAT 98% on room air General: pleasant, well developed male in no acute distress HEENT: oropharynx benign, upper dentures Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal, hard of hearing Pertinent Results: [**2106-2-2**] ETT: 4 minutes 27 seconds [**Doctor First Name **] protocol, 85% max PHR, stopping due to shortness of breath and fatigue. Immediately post exercise the patient was noted to have diffuse pulmonary wheezing. EKG did not reveal evidence of ischemia with stress. Imaging was notable for an inferior lateral perfusion defect that was moderately reversible. EF noted at 55%. [**2106-2-2**] echo: Mild concentric LVH with an LVEF of 50-55%. Moderate MR, moderate AI, mild TR, mild pulmonary hypertension. [**2106-2-8**] carotid u/s: no significant disease noted. [**2106-2-8**] ABI's: moderate to severe stenosis of the superficial femoral and popliteal arteries bilaterally. ABI's 1.0. Echo [**2106-3-10**]:PRE-CPB: There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis. Overall left ventricular systolic function is low normal (LVEF 50-55%). The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild to moderate ([**1-18**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is slight retraction of both mitral valve leaflets. Moderate (2+) central mitral regurgitation is seen with systolic blood pressures of around 150 mmHg. At lower SBP (around 110) the MR is mild to moderate. POST-CPB Normal biventricular systolic function. Valvular abnormalities noted in pre-CPB study remain. CXR [**3-17**]: No CHF with stable left pleural effusion. Sternal wires in unchanged position. [**2106-3-10**] 01:13PM BLOOD WBC-11.0# RBC-2.57*# Hgb-8.4*# Hct-23.1*# MCV-90 MCH-32.9* MCHC-36.5* RDW-13.3 Plt Ct-106*# [**2106-3-12**] 02:14AM BLOOD WBC-11.5* RBC-3.42* Hgb-10.8* Hct-31.2* MCV-91 MCH-31.6 MCHC-34.6 RDW-13.5 Plt Ct-148* [**2106-3-18**] 06:25AM BLOOD WBC-9.8 RBC-3.70* Hgb-11.9* Hct-34.5* MCV-93 MCH-32.1* MCHC-34.5 RDW-13.7 Plt Ct-450* [**2106-3-10**] 01:13PM BLOOD PT-16.7* PTT-36.8* INR(PT)-1.5* [**2106-3-12**] 08:30PM BLOOD PT-13.4* PTT-27.9 INR(PT)-1.2* [**2106-3-10**] 02:40PM BLOOD UreaN-17 Creat-1.0 Cl-112* HCO3-22 [**2106-3-12**] 08:30PM BLOOD Glucose-128* UreaN-22* Creat-1.3* Na-137 K-4.4 Cl-101 HCO3-27 AnGap-13 [**2106-3-18**] 06:25AM BLOOD UreaN-22* Creat-1.5* K-3.6 [**2106-3-12**] 02:14AM BLOOD Calcium-8.4 Phos-4.6*# Mg-2.0 [**2106-3-11**] 04:03AM BLOOD freeCa-1.29 Brief Hospital Course: On the day of admission, Mr. [**Known lastname 32793**] [**Last Name (Titles) 1834**] three vessel coronary artery bypass grafting by Dr. [**Last Name (STitle) **]. The operation was uneventful - see operative note for further details. Following the operation, he was brought to the CSRU. Within 24 hours, he awoke neurologically intact and was extubated. He maintained stable hemodynamics and transferred to the SDU on postoperative day two. He experienced bouts of paroxysmal atrial fibrillation which was treated with Amiodarone. He remained mostly in a normal sinus rhythm and did not require Warfarin anticoagulation. On postoperative day five, he displayed new onset paranoia with visual hallucinations. The timing of his symptoms did raise the possibility of adverse reaction to Percocet. He intermittently required Haldol and was assigned to a one on one sitter for safety. The psych service was consulted and felt this event was related to narcotic analgesia. Opiates, benzos and anticholinergics were avoided. Over the next 24 hours, his mental status improved and by discharge, returned to baseline. Over several days, he continued to make clinical improvements. Because of some mild sternal drainage, he was empirically placed on antibiotics. He was eventually cleared for discharge to home with VNA services on postoperative day 8. At discharge, his BP was 132/65 with a HR of 88. He will follow-up with Dr. [**Last Name (STitle) **] and his Cardiologist and PCP. Medications on Admission: Lopressor 50 [**Hospital1 **], Zocor 40 qd, Aspirin 325 qd, Albuterol MDI, Glucosamine, Zantac, MVI, Coenzyme Q10 Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Postoperative Narcotic Induced Delirium Sternal Drainage Prior IMI Congestive Heart Failure Mild to moderate aortic insufficiency Mild mitral regurgitation Emphysema Hypertension Hyperlipidemia Peripheral Vascular Disease Vertigo Gout GERD Deafness - s/p Cochlear implant s/p Labyrinthectomy, s/p Discectomy, Varicocele, s/p Shoulder surgery Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**4-21**] weeks. Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**2-19**] weeks. Local cardiologist, Dr. [**Last Name (STitle) **] in [**2-19**] weeks. Completed by:[**2106-4-16**]

[ "396.3", "443.9", "272.4", "414.01", "530.81", "492.8", "274.9", "412", "401.9", "398.91" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.12", "36.15" ]

icd9pcs

[ [ [] ] ]

7415, 7472

5773, 7251

297, 489

7918, 7924

3317, 5750

8242, 8502

2859, 2888

7493, 7897

7277, 7392

7948, 8219

2903, 3298

250, 259

517, 2037

2059, 2400

2416, 2843

73,139

167,401

27824

Discharge summary

report

Admission Date: [**2106-11-18**] Discharge Date: [**2106-11-21**] Date of Birth: [**2037-10-2**] Sex: M Service: SURGERY Allergies: Avandia Attending:[**First Name3 (LF) 4691**] Chief Complaint: Motor Vehicle Collision Major Surgical or Invasive Procedure: none History of Present Illness: 69 yM restrained driver in MVC with airbag depoloyment. The damage to the vehicle is unknown. He was first seen at an outside hospital where CT scan showed that he had a subdural hemorrhage as well as a chest x-ray which showed multiple rib fractures left 5, 6, 8, 9. The patient also had what appeared to be an old t7 compression fracture. Past Medical History: HTN, CHF gout, cad, dm, crf, right leg bypass, CABG, penile implant Social History: No smoking, occasional alcohol, no IVDU Family History: Non-contributory Physical Exam: VS: 98.7 69 181/88 16 94 on 2L AAOx3, NAD EOMI, PERRL no hemotypidum, no blood in mouth soft, supple neck, no midline c-spine tenderness LF CTA RRR no GMR soft, NT, ND, normal bowel sounds normal TLS spine, no tenderness, step offs or deformities of vertebrae, otherwise good rectal tone, no gross blood, ecchymosis on L scapulae and flank II-XII intact, moving all for extremities with symmetric strength Pertinent Results: [**2106-11-18**] 09:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2106-11-18**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2106-11-18**] 09:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 [**2106-11-18**] 09:30PM URINE HYALINE-[**4-16**]* [**2106-11-18**] 09:10PM COMMENTS-GREEN TOP [**2106-11-18**] 09:00PM UREA N-54* CREAT-1.6* [**2106-11-18**] 09:10PM GLUCOSE-187* LACTATE-2.0 NA+-143 K+-4.2 CL--101 TCO2-27 [**2106-11-18**] 09:00PM estGFR-Using this [**2106-11-18**] 09:00PM LIPASE-56 [**2106-11-18**] 09:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2106-11-18**] 09:00PM WBC-14.2* RBC-4.60 HGB-14.3 HCT-41.8 MCV-91 MCH-31.1 MCHC-34.3 RDW-14.5 [**2106-11-18**] 09:00PM NEUTS-85.4* LYMPHS-10.5* MONOS-3.4 EOS-0.2 BASOS-0.5 [**2106-11-18**] 09:00PM PT-12.1 PTT-25.8 INR(PT)-1.0 [**2106-11-18**] 09:00PM PLT COUNT-182 [**2106-11-18**] 09:00PM FIBRINOGE-402* Brief Hospital Course: The patient was admitted after being transferred. His hospital course by systems is as follows. Neuro- the patient had a small suddural hemorrhage which was again seen on repeat head CT. Neurosurgery was consulted and said that without shift or evidence of hernia this was a non-operative situation. They recommended to give platelets for reversing anticoagulation however this was not done as plavix would render any blood product useless without first plasmaphoresing the patient. Repeat CT imaging of the head did not show any further progression of the suddural hemorrhage. Clinically the patient had a normal neurologic exam and remained unchanged during his hospital course. Cards- the patient had his aspirin and plavix held as these were through to potentially worsen the subdural hemorrhage. Upon discharge the patient was instructed to hold these until follow up in the acute care surgery clinic in [**2-13**] weeks. Otherwise the patient did not have any chest pain throughout the admission. Musculoskeletal- the patient's rib fracture did not present as flail chest. Chest rise on inspiration was symmetric without any discordant segments. The patient's pain was controlled at first with IV pain medication which were then switched to PO pain medication. He was given incentive spirometry and performed it adequately at his bed side. He was discharged home with pain meds and incentive spirometry. The T7 compression fracture was felt by both the Truama surgery attending and the spine service to be chronic in nature and thus not needing any acute intervention. GI- the patient was restarted on the diet and took it without any issues. Renal- no issues GU- a foley was placed originally which was subsequently discontinued neither with any complications or issues Medications on Admission: allopruinol 100mg' amaryl/glimipeiridie 2mg' ecotrin 325mg' fisl oil 1200mg'' hectorol 0.5 mcg every other day hydralazine 10 mg ''' imdor 30mg' lasix 80mg'' plavix 75mg' lopressor 25mg'' simvastatin 20 mg' zolpidem 10'prn Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. doxercalciferol 2.5 mcg Capsule Sig: Two (2) Capsule PO 3X/WEEK ([**Doctor First Name **],TU,TH,SA). 4. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day as needed for pain. Disp:*12 patches* Refills:*0* 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*25 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: S/P MVC 1. left rib fractures 5 thru 9 2. Right subdural hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital after your motor vehicle accident with rib fractures and a small area of bleeding in the brain. * Your second head CT shows the area of bleeding is even smaller than on admission and you have not had any neurologic changes. * Your injury caused left rib fractures 5 thru 9 which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). Followup Instructions: Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**3-17**] weeks.

[ "V45.81", "E849.5", "403.90", "E812.0", "274.9", "852.26", "585.9", "807.04", "414.00", "733.13", "807.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5289, 5295

2361, 4146

293, 300

5405, 5405

1302, 2338

7268, 7387

835, 853

4419, 5266

5316, 5384

4172, 4396

5556, 7245

868, 1283

230, 255

328, 671

5420, 5532

693, 762

778, 819

41,345

197,418

37977

Discharge summary

report

Admission Date: [**2164-12-31**] Discharge Date: [**2165-1-9**] Date of Birth: [**2096-7-29**] Sex: M Service: CARDIOTHORACIC Allergies: Shellfish Attending:[**First Name3 (LF) 1406**] Chief Complaint: Exercise intolerance and fatigue Major Surgical or Invasive Procedure: [**2165-1-1**] 1. Coronary bypass grafting x3 with the left internal mammary artery to left anterior descending artery and reversed saphenous vein graft to the right coronary artery and the obtuse marginal artery. 2. Aortic valve replacement with an [**Doctor Last Name **] Perimount Magna Ease 23-mm pericardial valve, model #3300 TFX. History of Present Illness: 68 year old male of with severe aortic stenosis and a decline in his activity tolerance referred for cardiac catheterization. Cath revealed severe coronary artery disease and he was admitted for planned surgery on [**1-1**]. Past Medical History: Hypertension Hyperlipidemia Diabetes Type 2 Severe aortic stenosis Remote bowel obstruction Possible TIA approximately 25 years ago Past Surgical History: Vasectomy Social History: Race:Caucasian Last Dental Exam:1 month ago Lives with:wife Occupation:retired, part-time at a print and design company Tobacco:quit 40 years ago ETOH: 2 drinks per day Family History: Mitral valve replacement and CVA, Mother had a CVA in her 60's Physical Exam: VS (pre): 182/102, 182/89, 94, 14, 97% RA FS 203 (post): 159/83, 87, 20, 95% RA Gen: A+Ox3, pleasant and cooperative, NAD Neck: 2+ carotids, no bruits appreciated CV: RRR, NL S1S2 3/6 systolic murmur noted Resp: LS clear throughout Abd: Soft, nontender, + BS EXT: Right radial approach-cath, hemoband in place, no bleeding/ hematoma/ ecchymosis noted, 2+ radial and ulnar pulses, + CSM right hand. DP/PT per doppler, no pedal edema EKG: SR, HR 93 Labs: [**2164-12-21**]: WBC 7.2, Hct 41.6, plt 241, INR 1.1, Na 142, K 4.4, BUN 24, Cr 1.2 Pertinent Results: [**12-31**] Cath: 1. Coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had no angiographically apparent disease. There was a calcified 70% stenosis in the proximal LAD. The LAD was not a large vessel in distribution. The diagonal branches were small. There was a large OM1/Ramus that was free of disease. There was a tubular 80% stenosis in the mid-LCx leading to a large OM2. The RCA was a large vessel in its distribution. There was no disease in the distal RCA or its PDA or PL branches. 2. Resting hemodynamics revealed normal blood pressures with an aortic pressure of 121/75 mmHg. [**12-31**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis <40%. [**1-1**] Echo: Prebypass: No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 65-70%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Postbypass (#1) There is a new bioprosthetic valve in the aortic position. There is good leaflet excursion but there is at least moderate aortic regurgitation which appears to be paravalvular. Postbypass (#2) The same bioprosthetic aortic valve continues to have some regurgitation but it now appears to be mild. However, it still appears perivalvular. After protamine and FFP, the leak is now trace. The peak/mean gradients are 14/7 mmHg at a CO of 5.0 L/min. Left ventricular function continues to be normal. Trace mitral and tricuspid regurgitation persist. The thoracic aorta is intact. Pre-op labs: [**2164-12-31**] 09:30AM PT-14.6* PTT-91.5* INR(PT)-1.3* [**2164-12-31**] 09:30AM PLT COUNT-197 [**2164-12-31**] 09:30AM WBC-5.7 RBC-3.79* HGB-13.0* HCT-36.2* MCV-96 MCH-34.3* MCHC-35.9* RDW-13.5 [**2164-12-31**] 09:30AM %HbA1c-6.8* eAG-148* [**2164-12-31**] 09:30AM ALBUMIN-3.9 [**2164-12-31**] 09:30AM ALT(SGPT)-34 AST(SGOT)-26 ALK PHOS-31* AMYLASE-39 TOT BILI-0.2 [**2164-12-31**] 09:30AM GLUCOSE-160* UREA N-26* CREAT-1.0 SODIUM-136 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-15 [**2164-12-31**] 11:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2164-12-31**] 11:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Discharge labs: [**2165-1-8**] 04:55AM BLOOD WBC-10.3 RBC-3.31* Hgb-10.6* Hct-31.6* MCV-96 MCH-32.1* MCHC-33.6 RDW-14.5 Plt Ct-315 [**2165-1-9**] 04:55AM BLOOD PT-17.4* INR(PT)-1.6* [**2165-1-9**] 04:55AM BLOOD UreaN-35* Creat-1.5* Na-137 K-3.6 Cl-96 [**2165-1-8**] 04:55AM BLOOD Glucose-150* UreaN-36* Creat-1.5* Na-134 K-4.1 Cl-94* HCO3-29 AnGap-15 Radiology Report CHEST (PA & LAT) Study Date of [**2165-1-8**] 9:41 AM [**Hospital 93**] MEDICAL CONDITION: 68 year old man with s/p cardiac surgery Final Report: PA and lateral chest compared to [**12-31**] through 24: Small right pleural effusion has increased, small left pleural effusion stable since [**1-4**]. No appreciable atelectasis. Mild-to-moderate postoperative enlargement of the cardiac silhouette is stable. No pneumothorax or pulmonary edema. Left PIC line ends in the mid SVC. Brief Hospital Course: Mr. [**Known lastname 44979**] was admitted following his cardiac cath and underwent usual pre-operative testing. On [**1-1**] he was brought to the operating room for coronary artery bypass grafting and aortic valve replacement. Please see operative report for surgical details. In summary he had: 1. Coronary bypass grafting x3 with the left internal mammary artery to left anterior descending artery and reversed saphenous vein graft to the right coronary artery and the obtuse marginal artery. 2. Aortic valve replacement with an [**Doctor Last Name **] Perimount Magna Ease 23-mm pericardial valve, model #3300 TFX. His bypass time was 135 minutes with a crossclamp of 117 minutes. He tolerated the operation well and following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one beta blockers and diuretics were started and he was diuresed towards his pre-op weight. On post-op day 3 he was transferred to step-down floor for further care and post-operative recovery. Chest tubes were removed per protocol. Ventricular pericardial pacing wires were removed but atrial epicardial wires were cut at the skin, as resistance was met on attempted removal. He did develop post-op a-fib and was started on amiodarone and coumadin. He converted to sinus rhythm and the coumadin was stopped. He also developed erythema at the EVH site on his left knee and was started on keflex. On the stepdown floor he worked with physical therapy and nursing to increase activity and endurance. On POD 8 he was ready for discharge home with visiting nurses. He is to followup with Dr [**Last Name (STitle) **] in 3 weeks Medications on Admission: ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth every morning GLIMEPIRIDE - (Prescribed by Other Provider) - 4 mg Tablet - 2 Tablet(s) by mouth every morning HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth every morning METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet Sustained Release 24 hr - 2 Tablet(s) by mouth twice a day SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth every evening VALSARTAN [DIOVAN] - (Prescribed by Other Provider) - 160 mg Tablet - 1 Tablet(s) by mouth every morning Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth every morning CALCIUM CARBONATE [OYST-CAL-500] - (Prescribed by Other Provider) - 500 mg (1,250 mg) Tablet - 1 Tablet(s) by mouth daily GLUCOSAMINE-CHONDROIT-VIT C-MN [GLUCOSAMINE 1500 COMPLEX] - (Prescribed by Other Provider) - 500 mg-400 mg Capsule - 1 Capsule(s) by mouth twice a day MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 7. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x7 days then 400mg QD x7 days then 200mg QD. Disp:*65 Tablet(s)* Refills:*1* 8. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 10 days. Disp:*30 Capsule(s)* Refills:*0* 9. glimepiride 4 mg Tablet Sig: Two (2) Tablet PO once a day. 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 11. potassium chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day for 2 weeks. Disp:*14 Tablet Sustained Release(s)* Refills:*0* 12. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day: do not resume until after BUN/Cr and K+ checked on [**1-11**]. If Cr normalized will resume at that time. Otherwise hold until directed to resume. Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Coronary artery disease and Aortic stenosis s/p Coronary bypass grafting x3 and Aortic valve replacement Past medical history: Hypertension Hyperlipidemia Diabetes Type 2 Severe aortic stenosis Remote bowel obstruction Possible TIA approximately 25 years ago s/p Vasectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema- 1+ pedal bilat Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on [**1-31**] at 1:30PM Cardiologist: Dr.[**Name (NI) 3733**] on [**2-9**] at 1:40PM Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] 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** Labs: please check BUN/Cr/K+ on [**1-11**] call results to cardiac surgery office @[**Telephone/Fax (1) 1504**] Completed by:[**2165-1-9**]

[ "250.00", "E878.2", "V12.54", "458.29", "278.00", "518.5", "401.9", "E849.7", "272.4", "V15.82", "997.1", "287.5", "998.59", "414.01", "427.31", "682.6", "424.1" ]

icd9cm

[ [ [] ] ]

[ "36.12", "35.21", "88.56", "37.22", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

10101, 10164

5635, 7382

309, 647

10480, 10714

1934, 4762

11637, 12227

1291, 1355

8531, 10078

5223, 5612

10185, 10290

7408, 8508

10738, 11614

4778, 5186

1078, 1089

1370, 1915

237, 271

675, 901

10312, 10459

1105, 1275

71,848

166,514

54659

Discharge summary

report

Admission Date: [**2198-5-31**] Discharge Date: [**2198-6-25**] Date of Birth: [**2155-4-24**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 598**] Chief Complaint: MVC Major Surgical or Invasive Procedure: [**2198-5-31**]: Exploratory laparotomy, washout of hemoperitoneum, debridement of laceration of the liver, ileocecectomy, ileocolostomy. [**2198-5-31**]: Take back for Exploratory laparotomy, ileocectomy [**2198-6-8**]: IR-guided drainage of subhepatic/ right paracolic gutter collection History of Present Illness: 42M car vs pole, ejected ~30ft, garbled speech at scene, +[**Hospital 76954**] transfer from OSH with C6 fracture, free fluid in abd/pelvis, hypotension peri-RSI. Per EMS was moving all 4 extremities at OSH. Taken to OR upon admission, found liver lacs and performed ileocecectomy. Brought to TICU intubated. Taken to OR for re-exploration on [**5-31**], evacuated ~1L old blood. Past Medical History: s/p Left ankle ORIF s/p removal of adenoids Social History: Supportive wife, works in construction building houses +ETOH, unknown tobacco/IVDU Family History: Noncontributory Physical Exam: On admission: Constitutional: Intubated and sedated HEENT: Pupils equal, round and reactive to light Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nondistended, Nontender GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Moves all extremities Pertinent Results: [**2198-5-31**] 12:00AM BLOOD WBC-10.8 RBC-4.50* Hgb-13.5* Hct-41.0 MCV-91 MCH-30.1 MCHC-33.0 RDW-14.1 Plt Ct-214 [**2198-5-31**] 12:00AM BLOOD PT-11.4 PTT-24.9* INR(PT)-1.1 [**2198-5-31**] 01:16AM BLOOD Glucose-138* UreaN-14 Creat-1.2 Na-136 K-4.8 Cl-106 HCO3-16* AnGap-19 CT Head: No acute intracranial process with small left subgaleal hematoma. CT Cspine: 1. Comminuted fracture of the left facet of the C6 vertebral body with extension into the lamina, pedicle and posterosuperior left-sided aspect of the C6 vertebral body. 2. Right-sided C6 pedicular fracture extending into the facet and right lateral C6 vertebral body. 3. Assessment of fracture extension into the transverse foramina is limited and as a result cannot fully be excluded. Thus, need for CTA to assess vertebral arteries is unclear. These findings were discussed with Dr. [**First Name (STitle) **] by phone at 01:40. Initial findings were also discussed with Dr. [**Last Name (STitle) 54156**] and [**Doctor Last Name 2819**] at 23:45 on [**2198-5-30**]. CT Sinus: Limited study due to motion without evidence of fracture. CT Torso: 1. Subcapsular hepatic hematoma with 1 or 2 segment VI, 4-5 cm lacerations, though others may be masked due to fatty liver and bolus timing 2. 3.2 cm right adrenal hematoma and stranding about the left adrenal gland. 3. Stranding and free fluid in the mesentery as well as dependently in the pelvis suspicious for mesenteric and/or bowel injury, though no additional CT signs of bowel injury are identified. 4. Non-specific stranding about the aorta and IVC without evidence of frank extravasation. 5. Right sixth and seventh lateral rib fractures, right fifth rib anterior chondral fracture, left fifth through eighth anterolateral costochondral fracture-dislocations, and transverse process fractures at T6 and T12 through L5 as described above. 6. No evidence pulmonary contusion with atelectasis felt more likely. 7. Right axillary soft tissue contusion. MRI Cspine: 1. Mild STIR hyperintensity in bilateral C6 pedicles and facets. There is mal-alignment of bilateral C5-C6 facet joints, left more than right which is likely secondary to rotatory subluxation. The fractures of C6 facets are better seen on the CT cervical spine. No evidence of ligamentous injury. Increased mobility at this level can be assessed by flexion/extension views when patient is stable if clinically indicated. 2. A T1 and T2 hypointense soft tissue in the anterior epidural space extending from C6-C7 disc posterior to C7 body. This likely represents an extruded disc with inferior migration. This causes deformity of the ventral surface of the spinal cord. 3. No focal signal abnormality in the spinal cord. 4. Degenerative changes in the cervical spine with multilevel neural foraminal stenosis. Brief Hospital Course: Mr. [**Known lastname 9450**] was admitted to the trauma ICU on [**2198-5-31**] with the following injuries: Bilateral pulmonary contusions Right rib fractures [**6-21**] Left rib fractures [**5-22**] Fracture of C-spine at C6 Transverse process fracture T12-L5 Subcapsular liver hematoma Segment 6 liver laceration (4cm) Ileal mesenteric tear with small bowel ischemia Blunt cardiac injury Adrenal hematoma In brief, he was taken to the operating room on admission from the ED. There was a large mesenteric tear and associated small bowel ischemia. This was resected; he had a ileo cecectomy with primary anastomosis. He also was noted to have a liver laceration with associated liver ischemia, this was debrided. Post-op he was monitored in the ICU and was noted to be persistently tachycardic with an increasing pressor requirement. His lactate was elevated and rising and he was taken back to the OR for a 2nd look laparotomy, also on [**2198-5-31**]. Approximately 1 liter of blood was found and an internal hernia. He was hemostatic at the end of the case and he was returned to the ICU. The rest of his hospital course by systems below, but in brief was characterized by a prolonged wean from the ventilator, finally extubated on [**2198-6-14**] and liver necrosis and eventual fluid collection which was drained by IR. His course is described below by system: Neuro: He was initially sedated while intubated with a combination of propofol, fentanyl and versed but this was weaned as appropriate and after extubation he was treated with Dilaudid for pain. Orthopedic Spine evaluation was requested for the cervical spine fracture- this was treated non operatively with a cervical collar. He will follow up in approx 4 weeks with Dr. [**Last Name (STitle) 363**] where he will have repeat spine films done. He was alert and oriented x 3 and neurologically intact with some bilateral upper extremity weakness that had improved during his admission. Cardiac: Patient was hypotensive during the initial days postop and required pressors. He was weaned off Levophed on POD#3. Echo was performed to evaluate for blunt cardiac injury and the heart appeared hyperdynamic with no wall motion abnormalities. Patient was resuscitated with PRBC and albumin. He remained hemodynamically stable throughout the rest of his hospital course. Resp: He was intubated initially on scene then remained intubated post-operatively through two trips to the OR. Initially requiring high PEEPs this was eventually weaned though he continued to struggle with poor oxygenation and inability to wean from the vent, likely due to a combination of [**Last Name (STitle) 1064**] (noted on CXR, BAL after bronch on [**2198-6-6**] grew MSSA) and fluid overload. He was placed on a Lasix drip to remove excess fluid and treated with levofloxacin (started on [**6-7**]) for the [**Month/Year (2) 1064**]; he was eventually weaned to extubation on [**2198-6-14**]. He remained on 40mg PO Lasix daily while on the floor and continued to diurese well. He was changed to diamox on [**6-21**] to avoid hypercarbia. His supplemental oxygen was weaned and his oxygen saturation remained stable on room air. Continued pulmonary toileting and incentive spirometry were encouraged. On [**6-24**] he underwent diagnostic and therapeutic thoracentesis for 1.5L and he symptomatically improved with saturations remaining in the mid to high 90's. Follow up CXR showed interval decrease in right pleural effusion with no evidence of pneumothorax after thoracentesis. GI: Patient was taken for emergent laparotomy on the night of admission. Postop, patient had persistent lactic acidosis and hypotension. Patient was taken back to OR for re-exploration, also on [**5-31**], as noted above. He started to spike temperatures on [**4-19**]. In combination with his downtrending Hct (to 24), a CT scan was obtained on [**6-7**]; it showed a fluid collection near a necrotic portion of the liver with fluid in the right paracolic gutter. Hepatobiliary surgery was consulted and recommended a triple phase CT to assess progression of the liver ischemia/necrosis one week later (this was done on [**6-14**]) to aid in surgical planning regarding debridement. He was taken by IR on [**6-8**] for drainage of the fluid collection near the drain. Cultures grew mixed bacteria as well as b. fragilis (he was started on Flagyl on [**6-7**] along with levofloxacin). He had a triple phase CT on [**6-14**] which demonstrated progression of necrosis with expected walling off/organization of the liver necrosis. Also of note on [**6-14**], the drainage from his liver collection drain (placed [**6-8**] by IR) changed from serosanguinous/yellow to thicker brown. There was concern that this was stool from a leak in his anastomosis, so he was sent down urgently for a CT scan with contrast injected through the drain. The contrast did not enter the bowel which was reassuring. The drainage color change was attributed to additional necrosis of the liver which was now sloughing off and draining through the drain. On transfer to the floor on [**6-15**] his tube feeds were discontinued and he was started on a regular diet. Nutritional supplements were added. He tolerated a regular diet and was started on a bowel regimen. He was discharged to home with the drainage catheter in place, teaching was provided to patient and his wife on the care and monitoring of the drainage catheter system. GU: On admission, patient was in acute renal failure with rhabdomyolysis. He was aggressively hydrated and his creatinine improved with downtrend in his CK from 12,0000 to 700 after which the level was no longer checked as his urine output was excellent and his creatinine normalized. His urine output was normal throughout his stay. On the floor he was diuresed as discussed above under respiratory. A Foley catheter remained in place for urine output monitoring until [**6-16**], at which time it was removed and he voided without difficulty. He was noted with scrotal edema primarily related to fluid overload; this did eventually improve significantly with intermittent diuresis using Lasix which was later changed to Diamox. ID: Patient began to spike fevers on POD#4. He was started on levofloxacin, as noted above, for an MSSA [**Month/Day (2) 1064**] and completed a 7 day course that was dc'd on [**6-14**]. The Flagyl was also started on [**6-7**] due to the cultures from the drain growing bacteroides. This was continued until [**2198-6-21**]. At time of discharge he was afebrile with a normal white count of 8.2. MSK: He was evaluated by Physical ad Occupational therapy and at time of discharge he was supervision level with the walker. Dispo: He was discharged home with his wife and was provided with follow up appointments with his PCP, [**Name10 (NameIs) 4289**] [**Name11 (NameIs) **] surgery and Orthopedic Spine. Medications on Admission: Multivitamin, Vitamin D Discharge Medications: 1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* 4. multivitamin Capsule Sig: One (1) Capsule PO once a day. 5. Vitamin D3 4,000 unit Capsule Sig: One (1) Capsule PO once a day. 6. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. 7. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*30 GM* Refills:*2* 8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Polytrauma s/p motor vehicle crash: Bilateral pulmonary contusions Right rib fractures [**6-21**] Left rib fractures [**5-22**] Fracture of C-spine at C6 Transverse process fracture T12-L5 Subcapsular liver hematoma Segment 6 liver laceration (4cm) Ileal mesenteric tear with small bowel ischemia Blunt cardiac injury Adrenal hematoma 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 hospital after a motor vehicle crash. You sustained multiple injuries including fractures in your neck, spine, ribs and an injury to your bowel and liver. You required an operation to repair your abdominal injury. You required a stay in the intensive care unit and were transferred to the surgical floor when stable. You are continuing to recover well from your accident and are now being discharged home with the following instructions: You should remain in the cervical collar until follow up with Orthopedic Spine Surgery. Please follow up with Dr. [**Last Name (STitle) 363**] at the appointment scheduled below. You sustained rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. You should take your pain medicine as as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating, take half the dose and notify your physician. [**Name10 (NameIs) **] is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. Symptomatic relief with ice packs or heating pads for short periods may ease the pain. Do NOT smoke. Return to the ED right away for any acute shortness of breath, increased pain or crackling sensation around your rips (crepitus). Narcotic pain medication can cause constipation. Thefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. If your doctor allows, non steriodal anti-inflammatory drugs are very effective in controlling pain (i.e. Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. General Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Measure and record the output from the draiange catheter every day and be sure to bring a log/diary of this information with you to your Acute Care Surgery Clinic follow up. *Wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. You sustained rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. You should take your pain medicine as as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating, take half the dose and notify your physician. [**Name10 (NameIs) **] is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. Symptomatic relief with ice packs or heating pads for short periods may ease the pain. Do NOT smoke. Return to the ED right away for any acute shortness of breath, increased pain or crackling sensation around your rips (crepitus). Narcotic pain medication can cause constipation. Thefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. 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 [**Name10 (NameIs) 5059**] at your next visit. Don't lift more than 20-25 lbs for 4-6 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. 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 of 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: 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 that's okay. Your incision may be slightly red around the stitches. This is normal. You may gently wash away dried material around your incision. 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. Ove 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 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your [**Month (only) 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 to take this medicine as directied. 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 don't take any other pain medicine, including non-prescription pain medicine, unless your [**Name2 (NI) 5059**] has said its okay. If you are experiencing no pain, it is okay to skip a dose of pain medicine. 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 folloiwng, 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 DANGER SIGNS: Please call your [**Name2 (NI) 5059**] 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: Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 111789**] NP Location: [**Hospital1 **]-[**Location (un) **] When: Wednesday [**7-4**] at 12pm Address: [**Street Address(2) 87814**], [**Location (un) **],[**Numeric Identifier 76341**] Phone: [**Telephone/Fax (1) 30738**] Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2198-7-12**] at 1:15 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage *You will need a chest x-ray prior to this appointment. Please go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **] Radiology 30 minutes prior to your appointment. Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] When: Friday [**7-20**] at 11 am Location: [**Hospital1 **] Address: [**Location (un) **], [**Hospital Ward Name 23**] [**Location (un) 551**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3573**] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2198-6-25**]

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26388

Discharge summary

report

Admission Date: [**2132-4-9**] Discharge Date: [**2132-4-16**] Date of Birth: [**2058-10-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 800**] Chief Complaint: - altered mental status, hypoxia, fever Major Surgical or Invasive Procedure: - none History of Present Illness: On admission: 72 year old female with CAD, CHF, COPD presenting with altered mental status, hypoxia and fever. Recurrent admissions for hypercarbic resp failure and PNA. last admission early late [**Month (only) **]/early [**Month (only) 956**], and has been home from rehab x approx 3 weeks. . On the day of admission, the patient was noted to be more lethargic than usual by her health aide, afebrile, no cough. Per daughter, using nasal bipap at night, NC oxygen 3.5L all day (baseline sats 86-92%). By report, not her self yesterday, walking with walker and slumped to ground witnessed, no head strike. Today more lethargic. Pt presented to the ED initially afebrile, but later spiked to 102.8. She received CTX 1 g and Levaquin 750, Solumedrol 125. An initial VBG showed 7.34/72/45. She was placed on CPAP 10/5 with a sat of 95% and an ABG: 7.26/78/89/37. Pt is DNR/DNI. . Upon arrival to the MICU, pt was somnolent, on CPAP, no complaints via daughter who interprets for her. Past Medical History: - CAD; s/p 4 vessel CABG in [**2119**] - CHF; EF 55%, mild AS - obesity hypoventilation syndrome - obstructive sleep apnea - DM2 - ventricular tachycardia; s/p ICD in [**2127**] - hypothyroidism - schizophrenia Social History: - lives in [**Hospital3 **] alone w/home health aide - daily visits from daughter - smoked 1.5 ppd X 30 years, quit in [**2123**] - at baseline can do most ADLs (wash face, comb hair, etc) Family History: - mother died of MI (age unknown) Physical Exam: On transfer to the Medicine floor from the ICU: Vitals (floor): T:97.5 BP:119/50 HR:80 RR:35 O2:88% 3.5L FS:424 (exam limited by lack of cooperation) Gen: alert, vocalizing loudly in Farsi HEENT: EOMI, nasal cannula CV: RRR, 2+ distal pulses Resp: moderate air flow, clear to auscultation of frontal fields Abd: soft, obese, tympanic, no TTP Ext: no edema Neuro/Psych: alert, mildly agitated, responds to questions but no direct answers, perseverating on blood draws, people trying to kill her, etc. Pertinent Results: [**2132-4-9**] WBC-11.8 Hgb-10.5 Hct-31.4 Plt Ct-207 [**2132-4-9**] Neuts-87.7 Lymphs-7.6 Monos-3.2 Eos-1.3 Baso-0.3 [**2132-4-10**] WBC-8.9 Hgb-9.5 Hct-28.8 Plt Ct-191 [**2132-4-15**] WBC-6.8 Hgb-10.4 Hct-31.5 Plt Ct-195 . [**2132-4-9**] Glucose-300 UreaN-33 Creat-1.3 Na-137 K-3.9 Cl-90 HCO3-38 [**2132-4-11**] Glucose-88 UreaN-28 Creat-0.9 Na-145 K-3.2 Cl-103 HCO3-35 [**2132-4-15**] Glucose-204 UreaN-27 Creat-1.0 Na-136 K-4.0 Cl-93 HCO3-35 . [**2132-4-9**] ALT-12 AST-15 LD(LDH)-190 CK(CPK)-18* AlkPhos-71 TotBili-0.3 [**2132-4-9**] Lipase-24 . [**2132-4-9**] proBNP-380 [**2132-4-9**] cTropnT-<0.01 [**2132-4-10**] cTropnT-<0.01 . [**2132-4-9**] Type-MIX FiO2-20 pO2-45 pCO2-72 pH-7.34 calTCO2-41 Base XS-9 [**2132-4-10**] Type-ART Temp-36.3 Rates-/20 FiO2-30 pO2-80 pCO2-56 pH-7.33 calTCO2-31 Base XS-1 Intubat-NOT INTUBA . CXR ([**4-9**]): Markedly limited study due to motion artifact. [**Month/Year (2) **] left basilar atelectasis, cardiomegaly, prominent hilar vessels. Recommend repeat radiograph for further evaluation if needed . CXR: IMPRESSION: AP and lateral chest compared to [**4-9**]: Severe enlargement of the cardiac silhouette has worsened consistent with progressive cardiomegaly and/or pericardial effusion. Pulmonary vascular congestion is moderate, not appreciably changed since [**4-9**] and mediastinal veins are only mildly dilated. No appreciable pleural effusion is present and there is no consolidation to suggest pneumonia. Transvenous right ventricular pacer defibrillator lead is continuous from the left axillary pacemaker. . ECHOCARDIOGRAM: 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 top normal/borderline dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2132-3-5**], LV systolic funciton has improved. If clinically indicated, a repeat study with echo contrast (Definity) may aid in a more accurate assessment of regional and global LV function. Brief Hospital Course: MICU Course: She was initially admitted to the medical ICU due to hypoxia and an increased oxygen requirement in the ED. Sedating medications were held due to her sedation and lethargy, and she was given steroids and started on antibiotics (vancomycin/Zosyn/Levaquin) for a possible healthcare associated pneumonia and COPD exacerbation, since she was at risk due to her underlying pulmonary status and recent prolonged stay in a rehabilitation facility. She was placed on CPAP overnight. The following day, her oxygenation had improved, as had her sedation/lethargy. However, she became quite agitated; this was thought to be due to having had her usual anti-psychotic medications held, as well as the administration of steroids. At that time, she was deemed medically stable for transfer to the regular Medicine floor. . . Hospital Course: *)Fever/hypoxia - initial CXR was sub-optimal due to her body habitus and movement during the exam. Repeat imaging showed a possible retrocardiac infiltrate vs. increased pulmonary congestion. As she remained afebrile during her hospital course, antibiotics were narrowed to levofloxacin only, and she had completed an 8-day course prior to discharge. . *)Altered mental status - likely related to fever, dehydration, and a possible shift in acid-base balance due to recently added medications (diuretics). Mental status improved with CPAP and improved oxygenation. Recently added medications were initially held, although furosemide was later re-started at a lower dose once her mental status had improved and stabilized. . *)COPD/OSA - she is a chronic CO2 retainer, but her oxygenation improved after maintenance with CPAP at night and supplemental oxygen during the day. On discharge she was maintaining her baseline oxygen saturation on her usual level of supplemental oxygen. . *)CHF - diuretics were initially held due to concern that a derangement of her acid/base balance was contributing to her altered mental status. A later CXR was concerning for possible increase in fluid, and as her mental status had normalized, she was re-started on furosemide at a lower dose than prior, which she tolerated well. An echocardiogram was performed to evaluate possibly increased cardiomegaly on CXR, and showed improved function from her prior echo. . *)ARF - creatinine on admission was 1.3, which normalized to her baseline of 1.0 after gentle IV fluids in the ICU. This was likely due to pre-renal azotemia/dehydration in the setting of infection. . *)Schizophrenia - after recovery of her mental status, was initially quite agitated, with an increase in paranoid delusions. Was re-started on the anti-psychotic medications that had been held due to her sedation. Over the following few days, her agitation decreased and on discharge she was at her baseline. This was confirmed by her daughter, who was a daily visitor. [**Name (NI) **] medication regimen was discussed with her outpatient psychiatrist, and he will follow up with her. . *)CAD - she had one episode of chest pain during her hospitalization, but based on her symptoms and the physical exam at that time (with tenderness to palpation over the chest wall) this was thought to be more likely musculoskeletal and/or respiratory in nature. An ECG did not show any significant changes from prior. Her symptoms improved with a nebulizer treatment and medications for her chronic musculoskeletal pain. She was otherwise kept on her home medication regimen. . *)DM - FS were quite elevated during her hospital course, up to the low 400's in the morning on several occasions. She was given insulin glargine and a sliding scale while hospitalized, due to better titration of insulin while initially NPO and with possible underlying infection. However, she has not used insulin at home and already has a lengthy list of medications, so she was discharged on her home oral hypoglycemic and will follow up shortly with her primary care doctor. . *)Chronic neck/back pain/headache - has been a longstanding issue for her. Of note, she does have a sizeable (5-6cm) lipoma at her right posterior neck, but it is quite soft and not clearly compressing anything. Her pain was reasonably controlled with Tylenol and ibuprofen around-the-clock, Ultram, and a lidocaine patch. She was started on Zonegran to help manage her chronic headaches; this may be titrated up. A limited course of ibuprofen was discussed with her daughter, as this can cause problems if used long-term. . *)Hypothyroidism her home dose of levothyroxine was continued. Medications on Admission: - risperdal 2 mg po qhs --> changed to Invega ER 3mg qAM - atorvastatin 10 mg po qhs - Advair - Abilify 40 mg qhs - Spiriva qam - duoneb prn - aspirin 81 mg daily - Lasix 100 mg qam - spirolocatone 25 q AM - acetazolamide 250mg q AM - medroxyprogesterone 10 mg daily - glyburide 5 mg [**Hospital1 **] - levothyroxine 125 mcg daily - Zoloft 75 mg daily - Phoslo 2 cap qac - metoprolol SR 25 mg qam - Zyprexa when restless - nitroglycerin prn Discharge Medications: 1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours). 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: [**2-1**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 6. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Aripiprazole 10 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 9. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed. 12. Zonisamide 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 18. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 4 days. Disp:*16 Tablet(s)* Refills:*0* 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 21. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: - pneumonia - chronic obstructive pulmonary disease - obstructive sleep apnea - schizophrenia . - coronary artery disease - congestive heart failure - diabetes mellitus - hypothyroidism Discharge Condition: - improved/stable Discharge Instructions: You were hospitalized for difficulty breathing and sleepiness/lethargy. This improved when you were given help with breathing (CPAP) and treated for pneumonia. You were also given medications to help with your chronic headache and neck pain. Please follow up with your primary care doctor, as well as with your psychiatrist. Please use your CPAP machine every night. . Medication Changes: - you were given insulin instead of glyburide for your diabetes - you may resume your usual dose of glyburide when you go home - you completed a full course of antibiotics - Risperdal was given instead of Invega --> please continue this - Zonegran was started - Lasix was reduced from 100 mg to 80 mg daily . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases by more than 3 lbs. Adhere to a 2 gram sodium diet. Please call your doctor for the following: fever, increased difficulty breathing, chest pain, confusion, lethargy, severe or increasing pain, numbness/weakness of your arms or legs, new or concerning symptoms. Followup Instructions: 1) Primary Care [**Name6 (MD) **] [**Name8 (MD) 65266**], MD Phone:[**Telephone/Fax (1) 2205**] Date/Time:[**2132-4-18**] 1:15pm . Please go to this appointment as follow up from your hospitalization. If you are planning to change your primary care doctor, you may call [**Hospital3 **] at [**Telephone/Fax (1) 250**]. . Please also make a follow up appointment with your psychiatrist, Dr. [**Last Name (STitle) **] [**Name (STitle) 12696**] at [**Telephone/Fax (1) 65267**]. A message has been left with him, but you will need to call to make an appointment within the next month. . Addendum --> has a f/u appointment with Dr. [**Last Name (STitle) 12696**] on [**4-23**]; app't. date/time/contact information printed out and given to her daughter. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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41128

Discharge summary

report

Admission Date: [**2163-5-9**] Discharge Date: [**2163-5-13**] Date of Birth: [**2078-7-12**] Sex: M Service: MEDICINE Allergies: Penicillins / Dilantin Attending:[**Doctor First Name 2080**] Chief Complaint: Altered mental status, hyponatremia Major Surgical or Invasive Procedure: Arterial line History of Present Illness: Mr. [**Known lastname **] is an 84 year old right handed male with PMH of HTN and recent SAH s/p external ventricular drain placement who presents with worsening mental status, hyponatremia and hypertension. . He was recently admitted to the neurosurgical service on [**2163-3-22**] with severe HA and hypertension with a Head CT revealing extensive, bilateral SAH. CTA showed AComm aneurysm. He underwent emergent external ventricular drain placement and Acomm aneurysm coiling. His hospital course was complicated by lethargy on [**3-26**] and he was noted to have bilateral cerebellar infarcts. CTA and TCDs were negative for vasospam. His drain was clamped but needed to be reopened. It was eventually clamped successfully and pulled on [**4-6**]. He was discharged to rehab on [**2163-4-11**]. . At the nursing facility, he had been doing until 4-5 days ago when he developed progressive lethargy. He had previously been walking and doing well with PT. He was able to recognize and interact with his family members and friends. His son went to visit him 5 days ago and patient reported a [**10-3**] headache but he was able to continue with his regular activities. His daughter visited him the next day and noted that he was sleepy, lethargic and nodding off during his PT sessions. He began to refuse several of his medications and was refusing his labetalol- normally dosed at 200 mg po TID. Due to his AMS, several labs were checked including sodium, which was found to be 122. They were initially planning to treat with 1 L fluid restriction. Neurosurgery was contact[**Name (NI) **] and recommended he be referred to the [**Hospital1 18**] ED for further evaluation of hypnonatremia, hypertension and progressive AMS. . In the ED, his initial VS were T 97.8 HR 67 BP 194/67 (patient activly contracting biceps however) RR: 16 O2 sat 99%. On exam, he responds to verbal stimuli by opening his eyes but with mumbled speech. He appeared hypovolemic on exam. He also had symmetric upper extremity contractions, which was thought unlikely to be decorticate posturing but questionable seizure activity but no other signs. His neuro exam was limited but showed PERRL, not oriented, moving all 4 extremities. Serum osm 248. K 5.1. The EKG was unchanged from baseline. Normal Bun/cr. EF of 40%. Head CT showed no evidence of hydrocephalus or herniation. Patient was given NS at 60 cc/hr. . Review of sytems: unable to obtain fully [**1-26**] AMS (+) Per HPI, + mild headache currently, patient not answering other question. Per daughter, he has occasional cough but she does not know of any localizing symptoms- including fever, chills, n/v/d. Past Medical History: - Bilateral subarchnoid hemorrhage and ACOMM Aneurysm(admit from [**Date range (1) 89614**])- s/p coiling of Anterior communicating artery coiling and right external ventricular [**Last Name (un) **] placement - HTN - CAD - s/p triple bypass in [**2158**] - Vertigo - BPH s/p TURP in [**2152**] - Low back surgery to remove a synovial cyst in [**2154**] Social History: Remote smoking history. Full code and next of [**Doctor First Name **] is his wife, [**Name (NI) **] [**Name (NI) **]. Contact information includes [**Telephone/Fax (1) 89613**]. Family History: No hx of no FH of aneurysms or ICH. Physical Exam: On admission: General: lethargic, arousable to voice, NAD, AAO to person, not time (year 200) or place HEENT: Sclera anicteric, sl. dry mm, 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, hypoactive bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: somewhat limited by lethargy, inattentiveness. opens eyes to name, follows simple commands, 4+/5 strength in bilateral upper ext, patient not following commands with leg strength but no focal deficits. 2+ biceps/ patellar reflexes. unable to test light touch as patient would not answer questions, but responds to pain. downgoing toes bilaterally. Pertinent Results: ADMISSION LABS -------------- [**2163-5-9**] 06:20PM BLOOD WBC-6.9 RBC-3.33* Hgb-10.3* Hct-28.9* MCV-87 MCH-30.9 MCHC-35.5* RDW-13.6 Plt Ct-269 [**2163-5-9**] 06:20PM BLOOD Neuts-61.1 Lymphs-24.6 Monos-6.3 Eos-7.3* Baso-0.7 [**2163-5-9**] 11:16PM BLOOD PT-12.7 PTT-27.7 INR(PT)-1.1 [**2163-5-9**] 06:20PM BLOOD Glucose-94 UreaN-16 Creat-1.2 Na-119* K-5.3* Cl-88* HCO3-21* AnGap-15 [**2163-5-9**] 06:20PM BLOOD Calcium-8.6 Phos-4.0 Mg-1.7 [**2163-5-9**] 08:50PM BLOOD Osmolal-255* [**2163-5-9**] 08:47PM BLOOD K-4.6 [**2163-5-9**] 09:03PM BLOOD Lactate-0.9 . DISCHARGE LABS -------------- . MICROBIOLOGY ------------ [**2163-5-9**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2163-5-9**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT . [**2163-5-9**] 8:00 pm URINE Site: NOT SPECIFIED CHM S# [**Serial Number 89615**]B UCU ADDED [**5-10**]. URINE CULTURE (Pending): . IMAGING ------- Chest X-ray on admission: FINDINGS: As compared to the previous radiograph, the signs suggestive of pulmonary edema have completely resolved. Borderline size of the cardiac silhouette. Status post CABG. No evidence of pneumonia. No pleural effusions. Borderline size of the cardiac silhouette. . CT head on admission: IMPRESSION: No acute intracranial process. Stable ventricular size. [**2163-5-12**] 05:05AM BLOOD WBC-7.7 RBC-3.14* Hgb-9.8* Hct-28.6* MCV-91 MCH-31.3 MCHC-34.3 RDW-13.4 Plt Ct-233 [**2163-5-13**] 05:00AM BLOOD Glucose-86 UreaN-21* Creat-1.2 Na-133 K-4.4 Cl-99 HCO3-23 AnGap-15 [**2163-5-13**] 05:00AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.9 [**2163-5-12**] 05:05AM BLOOD calTIBC-216* VitB12-516 Folate-9.8 Ferritn-586* TRF-166* [**2163-5-10**] 03:09AM BLOOD Cortsol-6.0 [**2163-5-10**] 03:09AM BLOOD TSH-3.6 Brief Hospital Course: Mr. [**Known lastname **] is an 84 year old right handed male with PMH of HTN and recent SAH s/p ventriculoperitoneal shunt who presents with worsening mental status, hyponatremia and hypertension. # Acute encephalopathy: Patient's altered mental status is likely multifactorial, likely related to his hyponatremia, underlying brain pathology, including his previous subarachnoid hemorrhage, neurosurgical interventions and hypertension. His hyponatremia is likely the most significant factor. His CT head was unchanged from prior in [**4-4**]. He had also been refusing his oral labelatol and this may have caused an mild increase in intracranial pressure - though finding suggestive of PRES were not seen on head CT. Hypertension may be causing PRES - BP has been as high as the 220s. EEG was obtained and was non-specific Mental status improved with normalization of blood pressure and sodium level. HS seroquel continued - Close monitoring is required # Hyponatremia: Etiology of hyponatremia is not completely known, though thought [**Last Name (un) **] from cerebral salt wasting and SIADH. Urine osm was ~340, higher than would be expected if ADH were responding only to serum osmolality. Patient may have had a component of SIADH, particularly in the setting of neurological pathology. Patient was fluid restricted and was administered salt tabs, to which sodium level normalized. - Cont 1g [**Hospital1 **] NaCl, adjust as needed - 1 Liter fluid restriction # Hypertension, malignant: Patient with has history of hypertension and is on oral labetalol and lisinopril at home. Patient had been refusing labetalol at the nursing facility. His elevated blood pressure was likely secondary to his missed doses of medications. He was briefly placed on a labetalol drip briefly for blood pressure control. He was then placed on oral labetalol at increased dose 200mg [**Hospital1 **], and patient's lisinopril was increased to 5 mg daily. # Anemia: patient was noted to be anemic, but did not require and blood transfusions. Hematocrit was trended daily. Patient's home dose of iron and folate were held during time in the ICU. Restarted at discharge #SAH: Follow up with neurosurgery as already scheduled #CAD s/p CABG: unclear treatment - readdress with PCP/ family. Code: Full Medications on Admission: Acetaminophen 650 mg po q4h prn T >100.8 Famotidine 20 mg Tablet po BID Lansoprazole 30 mg po daily Labetalol 100 mg Tablet PO BID Docusate sodium 100 mg PO BID Heparin 5,000 unit/mL Injection TID Senna 8.6 mg PO BID prn constipation Lisinopril 2.5 mg po daily Modafinil 100 mg po BID Bisacodyl 10 mg po qD prn constipation Quetiapine 12.5 mg po qHs PRN insomnia Ferrous sulfate 325 mg PO DAILY Albuterol sulfate Inhalation Q6H prn wheezing Guafenisin 200 mg po q4h prn cough Bactrim DS tab po BID x 3 days (started [**5-9**]) Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. docusate sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: One (1) dose PO BID (2 times a day). 3. heparin (porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) injection Injection TID (3 times a day). 4. acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain . 5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. labetalol 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 7. sodium chloride 1 gram Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 8. lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 9. modafinil 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 10. quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime) as needed for agitation. 11. ferrous sulfate 300 mg (60 mg iron) Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. folic acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 13. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Discharge Disposition: Extended Care Facility: [**Hospital 671**] HealthCare Center at [**Location (un) 4047**] Discharge Diagnosis: Acute encephalopathy Hyponatremia Cerebral salt wasting/SIADH Hypertension, malignany GERD Anemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Patient was admitted with confusion and high blood pressure. His confusion was caused by hyponatremia due to cerebral salt wasting and SIADH. His blood pressure was controlled with increased doses of his medications. Please monitor his sodium going forward and adhere to 1 liter fluid restriction. Please continue all medications as prescribed Followup Instructions: Department: RADIOLOGY When: THURSDAY [**2163-5-26**] at 10:00 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: THURSDAY [**2163-5-26**] at 11:00 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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11,785

171,760

10587

Discharge summary

report

Admission Date: [**2150-10-31**] Discharge Date: [**2150-11-7**] Date of Birth: [**2093-3-23**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 57 year old male resident of nursing home with a history of chronic obstructive pulmonary disease on supplemental oxygen at four liters nasal cannula, insulin dependent diabetes mellitus, status post left below the knee amputation and right above the knee amputation, who presents with worsening shortness of breath times nine hours. The patient is a very poor historian but denies any fever, chills, sweats, chest pain, nausea, vomiting, diarrhea, dysuria or urgency. He denied any new cough and no sputum production. In the Emergency Department, he was noted to have oxygen saturation of 50% in room air which improved to 70% on five liters, 87% on 100% nonrebreather mask. His shortness of breath symptomatically improved with the oxygen. He was given Lasix 40 mg intravenous in the Emergency Department with 1800 ccs of urine output and decreased FIO2 to 10 liters with oxygen saturation to 90%. He was additionally given Solu-Medrol 125 mg intravenous and Levaquin in the Emergency Department. Chest angiogram showed no evidence of pulmonary embolus. He was transferred to the Medical Intensive Care Unit for further care. PAST MEDICAL HISTORY: 1. Interstitial lung disease. 2. Chronic obstructive pulmonary disease on home oxygen at four liters. 3. Coronary artery disease, status post myocardial infarction with right bundle branch block. 4. Anal cell cancer, status post resection, chemotherapy and radiation therapy. 5. Left below the knee amputation, right above the knee amputation. 6. Gastroesophageal reflux disease. 7. Schizophrenia. 8. Diabetes mellitus times twenty years. MEDICATIONS ON ADMISSION: 1. Potassium Chloride 20 meq p.o. q.d. 2. Prednisone 5 mg p.o. q.d. 3. Vitamin D, Vitamin C, multivitamin and Calcium. 4. Singulair 10 mg p.o. q.d. 5. Paxil 10 mg p.o. q.d. 6. Prilosec 20 mg p.o. q.d. 7 Aspirin 325 mg p.o. q.d. 8. Lasix 40 mg p.o. q.d. 9. Lipitor 10 mg p.o. q.d. 10. Novolin sliding scale. 11. Dulcolax. 12. Guanethidine 1200 mg p.o. b.i.d. 13. Acetylcysteine nebulizer. 14. Ativan p.r.n. 15. Albuterol and Atrovent nebulizers q4hours p.r.n. ALLERGIES: No known drug allergies. FAMILY HISTORY: Unknown. SOCIAL HISTORY: He is a resident of a nursing home. Positive forty pack year history of tobacco. He denies any alcohol use. PHYSICAL EXAMINATION: Vital signs on admission revealed temperature 99.0, blood pressure 104/69, pulse 102, respiratory rate 24, oxygen saturation 87% on 100% nonrebreather mask. Generally, he is a middle age man in moderate respiratory distress. Head, eyes, ears, nose and throat - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Mucous membranes are slightly dry. Sclera anicteric. Neck - There is no jugular venous distention, no lymphadenopathy. The neck is supple without any palpable masses. The lungs revealed distant breath sounds bilaterally, no crackles, no wheezes or rales. Cardiovascular examination - regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. The abdomen is soft, nontender, nondistended with normoactive bowel sounds. There is no hepatomegaly. Extremities - right above the knee amputation and a left below the knee amputation with no edema and moves all four extremities spontaneously. Neurologically, he is alert and oriented times three. Cranial nerves II through XII are intact. Motor examination is grossly normal. LABORATORY DATA: White blood cell count is 7.6, hematocrit 44.0, platelets 199,000. Sodium 134, potassium 3.8, chloride 102, bicarbonate 20, blood urea nitrogen 16, creatinine 0.7, glucose 249. INR 1.1, prothrombin time 13.1, partial thromboplastin time 26.3. Urinalysis showed moderate blood, no nitrites, trace protein, negative glucose, negative ketone, 3 red blood cells, 20 white blood cells, few bacteria and no yeast. Arterial blood gases was done with pH 7.44, pCO2 34, pO2 66. CT angiogram of the chest revealed no evidence of pulmonary embolism, diffuse increased interstitial markings with patchy areas of ground glass opacifications most pronounced at the bases. Compared to the prior study, it appears to be somewhat accentuated. The patient has a baseline chronic lung disease likely consistent with an emphysematous pattern as well as possible fibrotic changes at the lung bases. Line with reflux into the inferior vena cava. Most likely diagnosis is congestive heart failure. Electrocardiogram showed normal sinus rhythm at 105 beats per minute, left axis deviation, right bundle branch block, normal intervals, no ST segment changes, no Q waves and there were no changes from his electrocardiogram from [**2150-3-26**]. The patient had a blood culture from [**2150-11-1**], that showed enterococcus as well as coagulase positive Staphylococcus aureus that was Methicillin resistant. Enterococcus was sensitive to Vancomycin. There were four out of four blood cultures that were positive including two that were drawn from his port-a-cath and two that were drawn peripherally. Urine culture was negative. Chest x-ray showed bilateral coarse interstitial pattern, mild progression since [**3-26**], no consolidation or effusion, stable cardiac and mediastinal contours. Lower extremity Doppler showed normal evaluation in the common femoral, superficial femoral vessels bilaterally. No evidence of a deep vein thrombosis although the popliteal vein on the left was not visualized. HOSPITAL COURSE: This is a 57 year old male with a history of severe lung disease, chronic obstructive pulmonary disease and interstitial lung disease, diabetes mellitus, who presents with hypoxic respiratory distress and initially admitted to the Medical Intensive Care Unit. 1. Pulmonary - The patient was admitted to the Medical Intensive Care Unit from the Emergency Department for further care. The patient was felt to be in hypoxic respiratory distress secondary to chronic obstructive pulmonary disease exacerbation. Pulmonary embolus was ruled out in the Emergency Department with a chest CT angiogram. In the Medical Intensive Care Unit, he was continued on Solu-Medrol at 125 mg intravenous q6hours and was continued at that dose for the first 72 hours. In the Medical Intensive Care Unit, he continued to receive Albuterol and Atrovent nebulizers q2hours. He was also initially started on Levaquin for coverage of a possible pneumonia associated with his chronic obstructive pulmonary disease as his chest x-ray showed increased interstitial infiltrate. On hospital day two, however, the patient became tachycardic, tachypneic and hypotensive with decreasing oxygen saturation. This was thought to be due to sepsis as his blood cultures came back four out of four bottles positive for Methicillin resistant Staphylococcus aureus and Vancomycin. His respiratory status improved and he was gradually weaned off the 100% nonrebreather to face mask and then transferred to the Medicine floor on hospital day five. While on the Medicine floor, he has continued to receive Albuterol and Atrovent nebulizers q4hours and his Solu-Medrol was switched to p.o. Prednisone with plans to taper gradually over three weeks to his regular dose of 5 mg Prednisone q.d. The patient has a baseline oxygen requirement and while he was on the Medicine floor, his oxygen requirement was titrated to keep his oxygen saturation around the high 80s to low 90s. On discharge, the patient was on five liters of nasal cannula oxygen with oxygen saturation in the low 90s. 2. Cardiovascular - The patient has a history of coronary artery disease and previous inferior myocardial infarction. He initially denied any chest pain on admission and electrocardiogram was similar to his prior electrocardiogram in [**2150-3-26**]. He was continued on his Aspirin and Lipitor on admission. However, on hospital day, he became hypotensive, tachycardic and tachypneic with decreasing oxygen saturation. He was initiated on Levophed to keep his blood pressure elevated. His hypotension was thought to be secondary to sepsis and he was gradually weaned off Levophed and transferred to the Medicine floor when his blood pressure was stable off pressors for more than 48 hours. On the Medicine floor, he did have one episode of transient hypotension to systolic of 60s to 70s that responded to intravenous fluid boluses of 500 ccs. His blood pressure has been stable over the last 36 hours at 110/70, and this is likely his baseline. 3. Infectious disease - The patient was initially started on Levofloxacin for coverage of pneumonia and received five days of the antibiotic. However, on hospital day two, the patient became tachypneic, tachycardic and hypotensive with decreased oxygen saturation. This was presumed to be secondary to sepsis and he was pancultured and started on Vancomycin and Gentamicin in addition to the Levaquin for more broad spectrum coverage. Blood cultures, four out of four bottles, cultured from his port-a-cath and peripherally, grew out Methicillin resistant Staphylococcus aureus and Vancomycin sensitive Enterococcus. The Levaquin was subsequently discontinued. In addition, when the sensitivities returned, Gentamicin was also discontinued. The port-a-cath was removed when it was decided the line was the source of his bacteremia. A PICC line was placed for intravenous antibiotic. The patient will need to complete a fourteen day course of Vancomycin antibiotic for his bacteremia. 4. Endocrine - The patient has a history of diabetes mellitus. His blood sugar was stable throughout his hospital course and he was continued on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet. He had no further endocrine issues. 5. Access - The patient has a PICC line placed for intravenous antibiotic. 6. Disposition - The plan is to discharge the patient to [**Hospital 13698**] Rehabilitation Center for a short term stay for acute rehabilitation need. At that facility, he will also need physical therapy. 7. Code Status - The patient's condition was explained to him in great detail and he did not wish to be intubated if he had further respiratory distress. He also did not wish to receive any CPR or shock should he become unstable. MEDICATIONS ON DISCHARGE: 1. Albuterol and Atrovent nebulizers q4hours. 2. Protonix 40 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Regular insulin sliding scale. 5. Albuterol MDI two puffs q4hours p.r.n. 6. Serevent two puffs b.i.d. 7. Ativan 1 mg p.o. q6hours p.r.n. 8. Dulcolax suppository 10 mg per rectum p.r.n. 9. Vancomycin one gram intravenous q12hours. The patient will need to continue Vancomycin through [**2150-11-14**]. 10. Prednisone 60 mg p.o. q.d., please decrease dose to 40 mg p.o. q.d. on [**2150-11-9**], times four days, then decrease to 30 mg times four days, then 20 mg times four days and then 10 mg times four days. Then the patient will need to be continued on Prednisone at 5 mg p.o. q.d. 11. Lipitor 10 mg p.o. q.h.s. 12. Paxil 10 mg p.o. q.h.s. 13. Potassium Chloride 20 meq p.o. q.d. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Diabetes mellitus. 3. Bacteremia. 4. Schizophrenia. 5. Anal cell cancer. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Name8 (MD) 17311**] MEDQUIST36 D: [**2150-11-7**] 11:58 T: [**2150-11-7**] 12:12 JOB#: [**Job Number 34820**]

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Discharge summary

report

Admission Date: [**2139-9-27**] Discharge Date: [**2139-12-10**] Date of Birth: [**2084-9-19**] Sex: M Service: SURGERY Allergies: Plasma Expander Classifier / Valium / Mercaptopurine / Remicade / Shellfish Derived Attending:[**First Name3 (LF) 3376**] Chief Complaint: Low back pain and inability to care for himself, fungating tumor growing from enterocutaneous fistula Major Surgical or Invasive Procedure: 1. Exploratory laparotomy and extensive lysis of adhesions. 2. Choledochojejunostomy dictated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 3. En bloc resection of involved small bowel, abdominal wall and mass of tumor with primary jejunoileal anastomosis. 4. Veritas patch closure of abdominal wall defect. . [**2139-11-20**]: Pt with SVC syndrome, went through R IJ CVC access site and baloon dilated svc/RBCV with improved flow. Pt placed on heparin and is to have an MRV. Possible re-intervention at later date. . [**11-26**] Angio: LIJ & RSC occluded, IVC severely stenosed with collaterals, angioplastied SVC to 5-7 mm, could not get wire across from L to R . [**2139-11-28**]: had line replaced due to one of the Tunneled port not working. History of Present Illness: Patient is 55 yo male with h/o Crohn's disease and hypercoagulable condition s/p multiple amputations as a complication of this who presents for increasing low back pain and failure to care for himself at home. Pt was recently admitted to [**Hospital1 2177**] for [**Hospital1 **] and found to have line sepsis and new dx of stage IV mucinous adenocarcinoma from fungating mass originating from enterocutaneous fistula. (Admitted to [**Hospital1 2177**] from [**9-10**]) His tunnel line was replaced at [**Hospital1 2177**] on the contralateral side after removing the previous line. The patient also had multiple episodes of anemia characterized by a HCT drop from 24-25. Abdominal CT scan negative for bleeding. He required 4 units PRBCs but a source of the bleeding was never found. Patient was d/c'd 2 days ago with intent of presenting to [**Hospital1 18**]. Patient went home instead to care for himself and was unable to do this with increased ostomy output and increasing low back pain. GEN: {X]WNL, no fevers, chills, night sweats, fatigue, weightloss/weight gain HEENT: [X ]WNL, no vision changes, tinnitus, loss of hearing, dysphagia headache, sinus tenderness, rhinorrhea or congestion. CV: [X ]WNL - no chest pain - RESP: [ X]WNL- no cough, +shortness of breath, no orthopnea, PND GI: copious drainage of stool and gastric contents through fistula. GU: [X] WNL- no dysuria, hematuria, hesitancy, or change in frequency, change in bladder habits, vaginal discharge SKIN: []WNL no rashes, lesions, - healing stage II pressure ulcer NEURO:[X] WNL no weakness, paresthesias, numbness, headaches, dizziness MUSCULOSKELETAL: []WNL, chronic arthralgias- back pain in good control, myalgias PSYCH: [X]WNL No sadness or hallucinations. All other review of systems negative. Past Medical History: 1.Crohn??????s disease: diagnosed at age 21, followed by Dr. [**Last Name (STitle) 1940**]. Has involvement of his mouth, proximal small bowel, ampulla of Vater and biliary system. Had small bowel resection and cholecystectomy at same surgery in past. Treated with Remicade in late [**2133**], though course was stopped due to burning pain in his legs and joint pains. Has also had 6-MP therapy (as above) and did not respond to budesonide (Entocort). Currently treated with pentasa and intermittent prednisone. Most recent steroid course completed 1 month ago. 2.Antiphospholipid antibody syndrome: Diagnosed with hypercoagulable state at age 29. In the past has been told that he also had antithrombin III deficiency. Per Dr. [**Last Name (STitle) 410**]??????s notes, he did not have antithrombin III deficiency in [**2125**], but had high levels of anticardiolipin IgG antibody (normal IgM) and positive lupus anticoagulant at that time. Repeat tests in [**2130**] revealed very high levels of both IgG and IgM anticardiolipin antibody. On chronic anticoagulation with coumadin, INR goal 3.0-4.0. 3.[**Doctor Last Name **]??????s syndrome: known to have mild case per Dr. [**Last Name (STitle) 1940**]??????s notes. 4.Pulmonary embolism: History of at least 2 PE??????s in distant past, had IVC filter placed. 5.L AKA and R BKA: s/p multiple bilateral amputations secondary to clotting, status post right below-knee amputation in [**5-/2114**], s/p revision in 09/84, s/p left above-knee amputation in 05/95, s/p revision in 05/[**2132**]. 6. Small bowel resection and cholecystectomy: as above. 7. Reversible pancytopenia of unclear etiology. 8. Iron deficiency anemia. 9. Lactose intolerance. 10. Osteoarthritis. 11. Status post vascular bypass surgery of his right groin. Social History: The patient does not smoke or drink alcohol. He was using recreational drugs including marijuana in the 60s but not recently. He denies ever using intravenous drugs. He is single and has no children. He has been on disability since [**2108**]. Lives in subsidized housing. HCP = niece [**Name (NI) **] Di [**Name (NI) 25912**] [**Telephone/Fax (1) 25913**]/[**Numeric Identifier 25914**] Family History: His mother had hypercoagulability and was on Coumadin as well. She also had lung cancer. His father was an alcoholic, he had [**Name (NI) 4522**] disease, and he died secondary to cirrhosis. Physical Exam: VS: 98.6, 124/78, 18, 96% on RA GENERAL: Thin male who looks his stated age Nourishment: At risk Grooming: Good Mentation: Alert, conversant, completely up to date about his medical diagnoses. Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: Lungs CTA bilaterally without R/R/W Cardiovascular: RRR, nl. S1S2, no M/R/G noted Gastrointestinal: Large polypoid fungating abdominal wall mass and enterocutaneous fistula. Genitourinary: wnl. Skin: Stage II sacral decubitus ulcer. Extremities: 2+ radial, DP and PT pulses b/l. 2+ edema of UEs b/l. Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. Psychiatric: WNL - remarkably after all that he has been through. . At Discharge: Vitals:__________ GEN: A/Ox3, somnolent/withdrawn on occasion. Depressed. CV: RRR, no M/R/G. Face/Upper extremities: Moderate Edema, + radial & brachial pulses. + cap refill. R & L arm broken skin weeping serous fluid. Neck: distended, edematous, +JVD RESP: RR-20-24, SOB/DOE, occasional wheeze. ABD: +BS, +flatus, +BM-liquid, brown stool, ND, appropriately TTP, central incision with vacuum dressing appliance-wound bed: Beefy red granulation tissue, close to skin level, fistula LLQ lateral wound bed wall. Lower Extrem: Mild edema. B/L LE amputee. Skin: generalized maculo-papular rash Upper extremities, trunk, back. Coccyx stage II ulcer, pink tissue, blanching. Duoderm applied. Pertinent Results: CXR: No acute intrathoracic pathology. IVC filter appears high in position though unchanged. Recommend clinical correlation L-S Spine: INDICATION: 55-year-old man with history of Crohn's disease and back pain. LUMBAR SPINE, TWO VIEWS: The osseous structures are intact and in normal alignment. Mild loss of disc space is noted at the level of L4-L3 and L2-L3. Diffuse calcification of the aorta and high position of the IVC filter is noted. The bowel gas pattern is nonobstructive. THORACIC SPINE, TWO VIEWS: The osseous structures are intact and in normal alignment. No paravertebral soft tissue prominence is noted. IMPRESSION: No fracture or malalignment in the thoracic and lumbar spine. CT SCAN CHEST/ABD/PELVIS IMPRESSION: 1. Mass involving the anterior abdominal wall and adjacent small bowel loops increased in size 2. No definite evidence of metastatic disease. Heterogeneous enhancement of segment 4 of the liver likely represents perfusion abnormality, no focal liver lesions are seen. 3. Ovoid lesion in the splenic hilum is of uncertain etiology but stable in size. . [**2139-11-30**] 06:15AM BLOOD WBC-3.2* RBC-2.72* Hgb-7.8* Hct-23.0* MCV-85 MCH-28.7 MCHC-34.0 RDW-16.8* Plt Ct-62* [**2139-11-29**] 04:57AM BLOOD WBC-3.9* RBC-2.82* Hgb-8.1* Hct-23.6* MCV-84 MCH-28.8 MCHC-34.5 RDW-16.8* Plt Ct-71* [**2139-11-28**] 04:20AM BLOOD WBC-3.3* RBC-2.84* Hgb-8.2* Hct-23.9* MCV-84 MCH-28.8 MCHC-34.4 RDW-16.8* Plt Ct-64* [**2139-11-27**] 03:13AM BLOOD WBC-3.3* RBC-2.76* Hgb-7.9* Hct-23.1* MCV-84 MCH-28.5 MCHC-34.1 RDW-16.6* Plt Ct-47* [**2139-10-28**] 05:28AM BLOOD WBC-5.9 RBC-3.43* Hgb-9.8* Hct-27.9* MCV-81* MCH-28.5 MCHC-35.1* RDW-17.3* Plt Ct-151 [**2139-10-27**] 07:45AM BLOOD WBC-6.9 RBC-3.66* Hgb-10.5* Hct-31.2* MCV-85 MCH-28.6 MCHC-33.6 RDW-17.2* Plt Ct-149* [**2139-10-26**] 04:55AM BLOOD WBC-7.5 RBC-3.65* Hgb-10.5* Hct-29.6* MCV-81* MCH-28.7 MCHC-35.3* RDW-17.7* Plt Ct-134* [**2139-10-19**] 12:24PM BLOOD WBC-16.9*# RBC-2.79* Hgb-7.7* Hct-23.7* MCV-85 MCH-27.5 MCHC-32.4 RDW-19.3* Plt Ct-64*# [**2139-10-14**] 03:06AM BLOOD WBC-9.5 RBC-3.04* Hgb-8.5* Hct-24.1* MCV-79* MCH-28.0 MCHC-35.3* RDW-17.9* Plt Ct-79* [**2139-10-13**] 04:17PM BLOOD WBC-12.7* RBC-3.63* Hgb-9.7* Hct-28.7* MCV-79* MCH-26.8* MCHC-33.9 RDW-18.1* Plt Ct-83* [**2139-9-27**] 06:45PM BLOOD WBC-9.0 RBC-4.56* Hgb-11.1*# Hct-33.7* MCV-74* MCH-24.4*# MCHC-33.0# RDW-17.8* Plt Ct-119*# [**2139-12-7**] 10:45AM BLOOD PT-19.6* INR(PT)-1.8* [**2139-12-3**] 05:08AM BLOOD PT-19.4* PTT-113.4* INR(PT)-1.8* [**2139-11-25**] 04:43AM BLOOD Fibrino-360# D-Dimer-As of [**11-24**] [**2139-10-19**] 09:10AM BLOOD Fibrino-633*# [**2139-10-13**] 03:10AM BLOOD Fibrino-344# [**2139-11-21**] 03:18PM BLOOD Ret Aut-3.5* [**2139-12-8**] 06:00AM BLOOD Glucose-78 UreaN-47* Creat-0.9 Na-141 K-3.7 Cl-109* HCO3-22 AnGap-14 [**2139-12-7**] 05:56AM BLOOD Glucose-93 UreaN-47* Creat-0.9 Na-139 K-3.6 Cl-108 HCO3-22 AnGap-13 [**2139-12-6**] 04:52AM BLOOD Glucose-111* UreaN-48* Creat-0.9 Na-135 K-3.7 Cl-105 HCO3-22 AnGap-12 [**2139-12-5**] 05:18AM BLOOD Glucose-94 UreaN-45* Creat-0.9 Na-132* K-4.0 Cl-105 HCO3-22 AnGap-9 [**2139-12-4**] 06:28AM BLOOD Glucose-103 UreaN-42* Creat-0.8 Na-134 K-4.1 Cl-105 HCO3-22 AnGap-11 [**2139-12-3**] 05:08AM BLOOD Glucose-94 UreaN-41* Creat-0.8 Na-131* K-4.0 Cl-102 HCO3-23 AnGap-10 [**2139-11-22**] 04:44AM BLOOD ALT-11 AST-17 AlkPhos-202* [**2139-11-21**] 03:18PM BLOOD LD(LDH)-186 TotBili-0.8 DirBili-0.3 IndBili-0.5 [**2139-11-17**] 06:15AM BLOOD ALT-19 AST-17 AlkPhos-207* Amylase-51 TotBili-0.4 DirBili-0.2 IndBili-0.2 [**2139-11-6**] 06:26AM BLOOD ALT-13 AST-18 AlkPhos-185* Amylase-66 TotBili-0.6 DirBili-0.2 IndBili-0.4 [**2139-12-8**] 06:00AM BLOOD Calcium-7.6* Phos-3.1 Mg-2.2 [**2139-12-7**] 05:56AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.2 [**2139-12-6**] 04:52AM BLOOD Calcium-7.5* Phos-3.6 Mg-2.4 [**2139-12-5**] 05:18AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1 [**2139-12-4**] 06:28AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.1 [**2139-11-22**] 04:44AM BLOOD Albumin-2.5* Calcium-8.6 Phos-2.8 Mg-2.2 Iron-33* [**2139-11-15**] 12:29PM BLOOD Albumin-2.7* Iron-25* [**2139-11-3**] 05:41AM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.5 Mg-1.9 Iron-36* [**2139-11-2**] 04:43AM BLOOD Albumin-3.0* Calcium-8.4 Phos-3.2# Mg-1.6 Iron-40* [**2139-11-25**] 05:09AM BLOOD D-Dimer-1627* [**2139-11-22**] 04:44AM BLOOD calTIBC-217* Ferritn-402* TRF-167* [**2139-11-21**] 03:18PM BLOOD VitB12-492 Folate-12.1 Hapto-156 [**2139-11-9**] 04:52AM BLOOD Triglyc-79 [**2139-10-19**] 04:36AM BLOOD Triglyc-97 [**2139-9-29**] 06:24AM BLOOD Triglyc-59 [**2139-12-6**] 09:23AM BLOOD Vanco-21.0* [**2139-12-5**] 04:04PM BLOOD Vanco-40.7* [**2139-11-22**] 04:44AM BLOOD Vanco-27.9* [**2139-10-29**] 05:34AM BLOOD Vanco-22.4* . Studies: [**9-29**] EGD: Crohn's disease of the duodneum. No gastric lesion found [**10-1**] PET/CT: No definite metastatic disease. [**10-6**] stress test: LVEF 63%, normal perfusion [**11-18**] CXR: little change, bilat pleural eff and bibasilar atelectasis, no vascular congestion or acute PNA [**11-19**] CT abd: Increased pleural effusion, now moderate bilaterally, with adjacent compressive atelectasis. New moderate pericardial effusion. New anasarca. [**11-23**] MRV: Thrombosis of left SV, IJ, right IJ, right BC, stenosis of superior SVC, b/l pleural effusions IR - SVC venoplasty 5-7 mm diameter, right subclavian and left IJ 100% occlusion, highly occluded IVC [**12-5**] CXR: L basilar atelectasis, L pleural effusion . Micro: [**10-21**] Sputum cx: Klebsiella pneumoniae (sparse growth) [**Last Name (un) 36**] to ceftaz, ceftriax, cefurox, cipro, gent, [**Last Name (un) 2830**], tobra, bactrim 10/29,30,31 C.diff: Neg x3 [**11-7**] Stool: C.diff negative; negative for other bacteria [**11-12**] BCx: no growth [**11-12**] UCx: Klebsiella ([**Last Name (un) 36**] to Cipro) [**11-14**] - [**11-19**] BCx/UCx: no growth [**11-20**] pleural fluid: no growth [**11-20**] cath tip: no growth Brief Hospital Course: The pt was admitted for inability to care for himself as well as his low back pain. Pt was started on oxycodone for his low back pain which was likely due to old L4 compression fracture. Pt was afebrile on admission but then spiked [**Month/Year (2) **] on [**9-29**]. Cx were drawn and given hx of recent line bacteremia(no + blood cx) which was empirically treated at [**Hospital1 2177**] w Vanc which finished on [**9-25**], pt was started empirically on IV Vanc. Pt initially defervesced but then spiked again on [**10-3**] and was empirically started on Ceftaz with suspicion for abdominal wall cellulitis as there was noted to be increased redness around fistula site. Pt remained afebrile and antibiotics were discontinued on [**10-7**]. Pt was continued on steriods for his Crohn's disease and remained on Lovenox anticoagulation for his antiphospholipid antibody syndrome. . The plan was for surgical treatment of his cancer. CT of the chest/abdomen/pelvis and PET scan had been negative for metastatic disease. Pt had pre-op stress test on [**10-6**] which was negative. On [**10-12**], the pt was taken to the OR for an exploratory laparotomy and extensive lysis of adhesions, choledochojejunostomy, en bloc resection of involved small bowel, abdominal wall and mass of tumor with primary jejunoileal anastomosis, and veritas patch closure of abdominal wall defect. Post-op, the pt was transferred to the ICU in stable condition. He did require multiple fluid boluses for oliguria following surgery. The pt was able to be extubated the following day. He returned to the OR on [**10-15**] for VAC dressing change. Pt remained stable from a hemodynamic and respiratory standpoint and was transferred to the floor on [**10-16**]. The pt was kept on TPN for nutrition and remained on his steroids for Crohn's disease. On [**10-18**], the pt had return of bowel function, his NG tube was pulled, and his diet was advanced. However, it was noticed that the pt then began having bilious output from his surgical drain. He was made NPO and was scheduled to have a CT scan to rule out a leak. While being prepped for a CT scan, the pt was found to be unresponsive with agonal breathing and decrease in oxygen saturations. A code was called and the pt was intubated emergently and transferred to the ICU. The pt had a head CT which was negative for stroke or hemorrhage. An abd CT scan showed thrombosis in the superior mesenteric artery and the right common iliac artery, unchanged since [**2139-9-29**], post-surgical changes following small bowel resection, and prominent small and large bowel loops consistent with ileus. A chest CTA was negative for PE. The pt did require pressor support for a brief period in the ICU. He was ruled out for MI, pancultured, and started on broad spectrum abx. His Hct was discovered to be 17.5 and the pt was transfused for this. It remained unclear as to cause for the pt's unresponsiveness. . The pt was soon weaned off pressors. His mental status improved and he was able to be extubated. The pt was started on a clear liquid diet and started having increased drainage from his abdominal wound. It was soon discovered that the cause of this increased drainage was a recurrence of an enterocutaneous fistula. The VAC dressing was discontinued and the pt had a wound appliance applied to his wound. The pt was draining a few liters of fluid daily from this wound and pt was given crystalloid for his wound losses. Eventually, the fistula output did slow down as the pt decreased his liquid intake and increased his solid food intake. The pt's surgical drain that was kept in in order to drain the bile leak fell out on [**10-27**]. It was not replaced as a cholangiography performed on [**10-28**] did not show bile leak. . On [**2139-11-2**], the pt was transferred to the floor. . While on the floor, the patient was stable. His VAC was changed 2-3 days as needed. Granulation tissue appeared healthy and his overall abdominal wound size decreased significantly. His fistula continued to put out green colored fluid throughout his entire admission requiring frequent dressing changes. . On [**11-17**], the surgical team started to notice that the patient's right arm, neck, and face was becoming increasingly swollen. His right subclavian CVL continued to function correctly though. The decision was to continue to watch the swelling to see if it improves or gets worse by measuring upper extremities and neck daily. . On [**11-19**], the patient's swelling appeared worse. In addition, the patient became more dyspenic and required 2-4 Liters of supplemental oxygen to maintain his O2 saturation above 93% (he was saturating at 98-100% on [**1-26**] L). He became febrile at 101.3. Blood and urine cultures were taken which were negative. A CXR was performed which suggested bilateral effusions versus atelectasis. A trial of Lasix was started. The patient diuresed appropriately, however was still requiring 2-4 Liters of oxygen to maintain his saturation. A limited venogram was obtained which revealed stenosis of the right subclavian and right IJ vein and low flow distally, suggestive of a possible brachieocephalic vein stenosis/SVC syndrome. No thrombosis was seen. in light of this, a vascular sugery consult to Dr. [**Last Name (STitle) **] and his team was made. Dr. [**Last Name (STitle) **] wanted to pull the right subclavian CVL to see if the swelling would resolve itself. Dr. [**Last Name (STitle) 1120**] agreed upon this only if further access could be done before the right line was discontinued. Therefore a request to IR to place a left IJ and discontinue the right CVL. In addition IR stated that they would try to perform a venoplasty in the area of stenosis in order to relieve the obstruction. . When the patient went down for the venogram, imaging of his chest and abdomen was performed as well. His chest CT reveals moderate sized bilateral effusions. His abdomen did not reveal any fluid collections/abscesses. Body CT was consulted for thoracocentesis of these collections. . On [**11-20**], before the patient was to go to IR and body CT for such procedures, he received 2 units of PRBCs (Hct of 19) and 1 bag of platelets (plt=50). Body CT was able to take off approximately 1 liter of fluid from his lungs which they sent for cytology and culture which were negative. IR was able to perform a venoplasty and exchange his old right line with a new line over a wire. They sent the old tip for culture which was negative. After arriving back on the floor, his heparin gtt was restarted. . Through the subsequent days, the patient's swelling did not improve. A MR venogram was obtained which showed thrombosis of left SV, IJ, right IJ, right BC, stenosis of superior SVC, and persistent b/l pleural effusions. . On [**11-26**], the patient was taken to IR and a SVC venoplasty was performed. According to the radiologist, the maximal diamater post-plasty was 5-7 mm. . On [**11-27**], one of his subclavian CVL lines clotted off. TPA was successful temporarily, however the line still remained unaccessible. IR was called to manage the line. Given the patient's poor prognosis, a palliative care consult was obtained. Dr. [**Last Name (STitle) 1120**], the surgical team, & patient met with the palliative staff and the decision was made to make the patient DNR/DNI. . On [**11-28**], the patient was taken down to IR and a new line was inserted, this time further distally into the right atrium. . On [**11-30**], vascular surgery was consulted and discussed the possiblity of further surgical intervention for Mr. [**Known lastname 25894**]. Dr. [**Last Name (STitle) 1120**] and Dr. [**Last Name (STitle) **] decided further intervention was possible in the case of Mr. [**Known lastname 25894**]. He was informed of the possible outcomes/prognosis. Once again, Palliative Care met with Mr. [**Known lastname 25894**], and patient felt he was not ready to transfer to Hospice. He wants to continue with current treatment (ie) TPN. Patient understands that if his current central access for TPN clots off, then he will no longer have access for supplemental nutrition. . On [**12-7**], patient went to Interventational Pulmonology for possible thoracentesis, and pleurex catheter for draining any possible fluid. Ultrasound of lungs did not reveal any drainable fluid. CXR noted LLL effusion which has been persistent. Mr. [**Known lastname 25894**] decline insertion of Pleurax catheter for interval drainage of lungs. . [**12-16**] medical/surgical condition remains stable. He continues on TPN, Lovenox SC, IV Lasix, & IV Vanco. He should continue on IV Vanco while his central line is in place. His respiratory status remains stable. He continues to have RR in low 20's, O2 sats >95%. He is ready for transfer to Rehab for continued care. Discussion regarding need for Hospice will continue per patient and family. . [**12-9**]-His line pulled out a few centimeters later in day. He was taken to IR for replacement of line over a wire. He received cycled TPN overnight. Line remains patent. Vacuum dressing replaced [**Name6 (MD) **] Ostomy RN. Please refer to Note for detailed intruction on wound care. Dressing continues to leak on a daily basis, and requires frequent reinforcement. Per REHAB policy, the vacuum dressing will be taken down right before patient is transferred to REHAB. Moist dressing will be applied to keep wound bed from drying. Wound will be assessed, and vacuum dressing will be re-applied upon arrival to facility. Medications on Admission: Lovenox 60 mg Dilaudid 2 mg 1-2 tabs Folic acid 1 mg Pantoprazole 40 mg qd Hydroxycholoroquine 200 mg [**Hospital1 **] and 100 mg [**Hospital1 **] Vitamin D [**Numeric Identifier 1871**] IU q T/T/S Iron sulfate 325 mg Prednisone 15 mg qd Calcium - vitammin 500-125 mg tid Humira 40 mg /0.8 l SQ each saturday' Forte injection 20 mcg qd Mesalamine cr cap [**2130**] mg [**Hospital1 **] Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed): Apply to affected areas. 2. Teriparatide 20 mcg/dose (750 mcg/3 mL) Pen Injector Sig: One (1) Subcutaneous DAILY (Daily). 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-24**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day) as needed. 6. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed: Do not exceed 4000mg in 24hours. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 9. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed: To affected areas of groin/buttocks. 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours): Do not exceed 16mg in 24hrs . 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze/SOB. 15. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 16. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for itching. 17. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 18. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 19. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO PRN (as needed). 20. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO PRN (as needed) as needed for diarrhea: please stagger from loperamide dosing . 21. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day): Check Serum potassium 2-3 times per week. 22. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection PRN (as needed). 23. Prochlorperazine Edisylate 5 mg/mL Solution Sig: [**12-24**] Injection Q6H (every 6 hours) as needed for nausea. 24. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours): Check Vanco trough after every 3rd dose. 25. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection four times a day: Please refer to sliding scale . 26. Regular insulin Sliding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-50 mg/dL [**12-24**] amp D50 51-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-160 mg/dL 2 Units 2 Units 2 Units 2 Units 161-200 mg/dL 5 Units 5 Units 5 Units 5 Units 201-240 mg/dL 8 Units 8 Units 8 Units 8 Units 241-280 mg/dL 11 Units 11 Units 11 Units 11 Units 27. Outpatient [**Month/Day (2) **] Work Please check weekly LFT's, and Chem 10. **Contact [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 11475**](Home Hyperal Service Coordinator), [**Telephone/Fax (1) 11476**], FAX: [**Telephone/Fax (1) 11477**] for instruction with TPN formulation titration. 28. Outpatient [**Telephone/Fax (1) **] Work Please check Vanco trough after every 3rd dose. **Please fax results to Dr. [**Last Name (STitle) 1120**] at ([**Telephone/Fax (1) 25915**]. **Call [**Telephone/Fax (1) 160**] with questions/concerns. 29. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 30. Dilaudid 2 mg/mL Solution Sig: 0.5-1 Injection Prior to Vacuum dressing changes as needed for pain. 31. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for anxiety: Hold for somnolence . Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: Adenocarcinoma of the small bowel invading abdominal wall, creating fistulas Short gut syndrome-[**1-25**] feet of bowel remains post-op (TPN dependent) Malnutrition Enterocutaneous fistula-abdominal incision Crohn's disease Pancytopenia Post-op pleural effusions Post-op SVC syndrome Post-op Thrombosis of left SV, IJ, right IJ, right BC, stenosis of superior SVC. Post-op anasarca Post-op Klebsiella Pneumonia Post-op UTI-Klebsiella Post-op Stage II coccyx pressure ulcer . Secondary: Crohn's w/mult intest strictures, SBO/jejunal perf/sepsis 2^ to adhesions S/P LOA, repair perf jej [**9-/2137**] c/b chronic EC fistula S/P mult skin grafts, [**Doctor Last Name 9376**], Antiphospholipid syndrome S/P b/l LE DVT, PE, S/P IVC filter s/p R fem bypass, s/p b/l amp; Anemia, iron/B12 defic, Recurrent L parotitis/sialolithiasis in [**2136**] and [**2138**] Discharge Condition: Stable Tolerating regular diet, small amounts. TPN for major nutritional requirements. Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a [**Year (4 digits) **] 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 care: Please refer to Wound Care Nurse for detailed instruction. Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) 1120**] [**Telephone/Fax (1) 160**] in 2 weeks. . Previous appointments: 1. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2140-8-18**] 2:00 SUMMARY NEITHER DICTATED NOR READ BY ME Completed by:[**2139-12-10**]

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icd9cm

[ [ [] ] ]

[ "88.72", "51.37", "00.41", "86.3", "88.67", "45.13", "99.21", "99.04", "39.50", "54.59", "45.62", "93.59", "99.05", "87.51", "96.71", "99.10", "96.04", "54.3", "34.91", "88.51", "99.07", "99.15", "89.44" ]

icd9pcs

[ [ [] ] ]

27242, 27321

13185, 22761

446, 1231

28230, 28361

7259, 13162

29483, 29823

5286, 5479

23197, 27219

27342, 28209

22787, 23174

28385, 29388

6377, 6539

5494, 6281

6553, 7240

305, 408

29400, 29460

1259, 3047

6296, 6360

3069, 4864

4880, 5270

4,714

108,055

7380

Discharge summary

report

Admission Date: [**2170-12-3**] Discharge Date: [**2170-12-7**] Date of Birth: [**2108-4-19**] Sex: M Service: MEDICINE Allergies: Penicillins / Vasotec / Iodine; Iodine Containing / Hydrochlorothiazide / Sulfonamides / Trilafon / Elavil / Tegaderm / Tegretol / Verapamil / Nitrofurantoin / Fentanyl / Levofloxacin Attending:[**First Name3 (LF) 30**] Chief Complaint: CC: lethargy Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Mr. [**Known lastname 1968**] is a 62 yo wheelchair bound male with h/o HIV, CRI, HTN, CVA with residual L-sided hemiparesis and ? seizure disorder who presented from a Senior Center with lethargy on [**2170-12-3**]. Patient does not remember the events prior to his admission. The last thing he remembers is waiting to get on the bus prior to going to work yesterday. He doesn't remember anything from that time until ~3 hours ago today. He recalls feeling fine the night before and just a little more tired prior to this event. Per report of [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3077**], the co-worker who called the ambulance yesterday, the patient appeared disoriented when he arrived at work yesterday. He first rode his wheelchair into a door and then into a table. He was unable to sit up in his chair and kept slumping down. He was less responsive than he normally is and had slow (but not slurred) speech. She stated it sounded as if he was having "difficulty finding his words". He was able to understand her when she spoke to him. He did not voice any complaints to her, except that he "had a bad weekend and needed something to eat." His face also appeared a little more flushed to her. He had no episodes of shaking, no loss of consciousness and no bowel or bladder incontinence. He may have had one episode of emesis. Ms. [**Name13 (STitle) 3077**] states the patient became more disoriented and less responsive over the course of 45 minutes. By the time he reached the ambulance he was barely able to keep his eyes open. Per report he was given narcan in the field with little effect. Past Medical History: Past Medical History: 1. HIV/?AIDS- most recent VL undetectable; CD4 336 2. CKD (baseline Cr 1.9-2.0) 3. Hypertension 4. Gerd 5. h/o RTA 6. CVA [**2161**] with residual L-sided hemiparesis 7.? seizure disorder that resolved per the patient. Patient describes occasional shaking with his seizures in the past, with some lethargy and no bowel or bladder incontinence 8. s/p colectomy for C. difficile colitis in [**2153**] with colostomy. 9. h/o recurrent LLE cellulitis 10. s/p L hip replacement [**2167**] 11. Depression 12. h/o memory loss evaluated by Dr. [**Last Name (STitle) 2340**] in neurology clinic Social History: SH: Denies Tob or Illicit drug use. H/o heavy EtOH use in the past. Last drink 3 days ago (3 vodka tonics). Works at [**Company 27162**] for united people with disability. Lives in his own apartment at a Senior Home. Has a home aide and nurses that help him 3 times per week. Family History: father d. CVA, mother d. MI, ages unknown Physical Exam: Gen: awake and alert, NAD HENNT: MMM, anicteric, PERRL, EOMI Neck: right IJ line, no significant JVP CV: RRR, nl S1S2, No M/R/G Lungs: CTA B Abd: soft, NT/ND, +BS, ostomy intact with soft green stool in bag Ext: LLE trace edema compared to right, Left LE with ulcer on lateral aspect of leg with no purulent drainage. Granulation tissue around medial malleoulus with erythema, but does not feel significantly more hot than right side. Neuro: A&Ox3, CN2-12 intact Right UE/LE muscle strength 5/5, Left UE/LE strength decreased Pertinent Results: [**2170-12-3**] 12:33PM BLOOD WBC-5.2 RBC-4.15* Hgb-12.3* Hct-37.6* MCV-91# MCH-29.6 MCHC-32.6 RDW-17.9* Plt Ct-227 [**2170-12-5**] 06:40AM BLOOD WBC-5.2 RBC-4.01* Hgb-11.7* Hct-35.5* MCV-88 MCH-29.2 MCHC-33.0 RDW-17.5* Plt Ct-214 [**2170-12-6**] 07:00AM BLOOD WBC-4.6 RBC-4.03* Hgb-12.3* Hct-36.1* MCV-90 MCH-30.6 MCHC-34.1 RDW-18.8* Plt Ct-216 [**2170-12-7**] 07:00AM BLOOD WBC-5.3 RBC-4.60 Hgb-13.4* Hct-40.7 MCV-88 MCH-29.0 MCHC-32.8 RDW-17.4* Plt Ct-239 [**2170-12-3**] 12:33PM BLOOD Neuts-63.0 Lymphs-27.6 Monos-5.8 Eos-2.8 Baso-0.9 [**2170-12-6**] 07:00AM BLOOD Neuts-55.6 Lymphs-34.1 Monos-5.6 Eos-3.8 Baso-0.8 [**2170-12-3**] 12:33PM BLOOD PT-12.7 PTT-24.9 INR(PT)-1.1 [**2170-12-3**] 12:33PM BLOOD Glucose-107* UreaN-16 Creat-1.7* Na-141 K-4.0 Cl-110* HCO3-21* AnGap-14 [**2170-12-7**] 07:00AM BLOOD Glucose-105 UreaN-28* Creat-1.9* Na-137 K-5.1 Cl-104 HCO3-18* AnGap-20 [**2170-12-3**] 12:33PM BLOOD ALT-13 AST-17 CK(CPK)-78 Amylase-106* TotBili-0.3 [**2170-12-3**] 12:33PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2170-12-3**] 12:33PM BLOOD Albumin-3.5 Calcium-8.6 Phos-4.1 Mg-2.0 [**2170-12-3**] 12:33PM BLOOD VitB12-436 Folate-GREATER TH [**2170-12-3**] 12:33PM BLOOD Osmolal-289 [**2170-12-6**] 06:50PM BLOOD Vanco-20.9* [**2170-12-3**] 12:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2170-12-3**] 01:47PM BLOOD Lactate-1.6. . [**2170-12-3**] 02:15PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2170-12-3**] 02:15PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2170-12-3**] 02:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . [**2170-12-3**] 1:35 pm BLOOD CULTURE LINE OR SITE NOT NOTED. AEROBIC BOTTLE (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON REQUEST.. ANAEROBIC BOTTLE (Final [**2170-12-7**]): REPORTED BY PHONE TO [**Female First Name (un) 10561**] O. 11R [**2170-12-5**] AT 0915. PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES. . URINE CULTURE ([**2170-12-3**]): NO GROWTH. . [**2170-12-4**]: GRAM STAIN (Final [**2170-12-5**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). [**2170-12-5**]: WOUND CULTURE (Preliminary): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). PROTEUS SPECIES. HEAVY GROWTH. GRAM NEGATIVE ROD(S). MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. GRAM POSITIVE BACTERIA. QUANTITATION NOT AVAILABLE. ? OF TWO COLONIAL MORPHOLOGIES. BEING ISOLATED FURTHER IDENTIFICATION TO FOLLOW. ANAEROBIC CULTURE (Final [**2170-12-7**]): UNABLE TO R/O PATHOGENS DUE TO OVERGROWTH OF SWARMING PROTEUS SPP.. . Bcx [**12-5**], [**12-6**], [**12-7**] NGTD . CT head [**12-3**]: No intracranial hemorrhage or mass effect. . CXR [**12-3**]:Limited study due to marked patient rotation. No gross evidence of pneumonia. Dedicated PA and lateral chest radiograph suggested for more complete assessment when the patient's condition permits. . EKG [**12-3**]:Baseline artifact. Sinus bradycardia. Early precordial QRS transition is non-specific and probably within normal limits. Since the previous tracing of [**2169-1-2**] sinus bradycardia is present. . CXR [**12-4**]:IMPRESSION: AP chest compared to [**12-3**]. Heart size top normal. Lungs clear. . left foot x-ray [**12-5**]: Three views of the left ankle were obtained. There is diffuse demineralization. There has been interval removal of the previously identified distal fibula metallic fixation plate and screws. Defects are noted in the areas of the prior screws. Two fixation screws are redemonstrated, extending from the medial malleolus into the distal tibia. No fractures or destructive changes are present to suggest osteomyelitis. Soft tissue swelling is noted. Brief Hospital Course: * Lethargy: The patient presented with lethargy and slow speech. Upon arrival to the ED the patient was noted to have SBPs in the 80s. He was given 3 liters of normal saline, Aztreonam, Vanco, and Decadron. Tox screen was negative. He initially admited to taking 2 tabs of MS Contin prior to arrival, however, later denied taking any extra meds. CT in ER showed no acute changes. . He was transferred to the [**Hospital Unit Name 153**] where he was A&Ox3 and answering questions appropriately. He denied CP, SOB, fever, chills, HA, photophobia, neck stiffness, belly pain, nausea, vomiting, increased ostomy output. He did report going to a pub two nights prior to his admission, where he drank 3 vodka tonics. He had no memory problems the next day. He was a heavy drinker in the past, however, he denied binge drinking for the past 12 yrs. He denied other drug abuse or recent changes in medication. He reported his last seizure was 4-6 months ago. As per OMR notes, pt had a similar episode of altered mental status thought to be secondary to EtOH intoxication in [**7-17**]. He was being evaluated in neurology clinic by Dr. [**Last Name (STitle) 2340**] for memory loss. Of note, B12, Folate, and TSH were unremarkable in [**6-17**]. . In the [**Hospital Unit Name 153**] the patient was observed and his mental status improved. He was then transferred to the floor where he was A&Ox3. His PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11412**] was [**Name (NI) 653**], as well has his neurologist Dr. [**Last Name (STitle) 2340**]. Per his PCP, [**Name10 (NameIs) **] patient had several episodes like this in the past and often this was thought to be secondary to ETOH intoxication or dehydration after drinking. Patient's last drink prior to this episode was ~36 hours prior. It was possible this was secondary to dehydration and this was the working diagnosis. DDx also included: Sedative effect from medications including ultram, trazodone and remeron, seizures, TIA, depression, ETOH abuse with dehydration or infectious source. Remeron, Trazodone and loratidine were stopped because of their possible sedating effects. He was ready to be discharged when blood cultures that were drawn while the patient was in the ER grew out G+ cocci in pairs and chains in an anaerobic bottle. Patient had been afebrile with normal WBC throughout admission. It was possible this could have been a contaminant, but the patient was kept and started on Vancomycin until speciation and sensitivities could come back. Plastics and podiatry were consulted to look at his left foot ulcer, as this could have been a possible source for bacteremia. Surveillance blood cultures were drawn and negative at d/c. Several days later the initial blood cultures were found to be growing coagulase negative staph and peptostreptococcus. It was thought these were a contaminant and the patient was discharged without antibiotics. He was to follow-up with Dr. [**Last Name (STitle) 11412**], who stated he would take care of the f/u appt and with Dr. [**Last Name (STitle) 2340**]. . Foot ulcer: Patient stated he had a chronic left lower extremity ulcer x 7 years. He had numerous surgeries on his foot and had a skin graft placed over the ulcer at [**Hospital1 756**] by plastics. The ulcer looked erythematous, but not infected during his stay. He was seen by plastics and podiatry since the ulcer was thought to be the possible site for the bacteremia. They did not think the patient required debridement at this time. Foot x-ray was done and was negative for osteo. Wound swab was done and grew out GNR, g+ cocci in pairs and clusters and G+ rods. Final speciation was pending at discharge. He was not treated for the GNR because they were not growing in his blood and he had a h/o anaphylactic reactions to levaquin and PCN. He had wet to dry dressing changes qd and the wound was packed. . * Anion Gap metabolic acidosis with metabolic alkalosis: Patient had an anion gap metabolic acidosis with metabolic alkalosis. The acidosis was likely secondary to renal failure with increased bicarb secondary to bicitra. He was continued on bicitra for his h/o RTA. . * CKD. Baseline Cr was noted to be 1.9-2. Creatinine was followed and was between 1.5-1.9 during his admission and all medications were renally dosed. . * HTN: BPs were stable and he was continued on Norvasc. . *HIV:Last known CD4 was 336 and VL was undetectable. His HAART regimen was clarified with his pharmacy and he was continued on Epivir,Levixa and Ziagen. . * Depression: He was continued on Celexa. His Trazodone was used for sleep and this was discontinued to reduce sedating medications in his regimen. His Remeron was used as an appetite stimulant but did not work for him, so this was discontinued as well. . * FEN: He was continued on a regular diet and lytes were repleted PRN. . * PPX: For prophylaxis he was on SC heparin, PPI, bowel regimen and Celexa. Medications on Admission: Home Meds: - Bicitra 15-30 mL TID - Celexa 40 mg daily - Depo Testosterone 200 mg/1mL taken every 2 weeks - quinine 325 daily - ASA 325 qd - Ziagen 300 [**Hospital1 **] - Levixa 700 [**Hospital1 **] - Norvasc 10 daily - Ultram 50 mg 1-2 tabs q 6 hours PRN - Remeron 30 qhs - Prilosec 20 daily - Flomax 0.8 qhs - Trazodone 50 mq qhs - Epivir 300 mg qhs - Loratidine 10 mg qd - Panafil Ointment PRN for leg wound. Discharge Medications: 1. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig: 15-30 MLs PO TID (3 times a day). 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Fosamprenavir 700 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Depo-Testosterone 200 mg/mL Oil Sig: One (1) injection Intramuscular q 2 weeks. 10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO at bedtime. Discharge Disposition: Home With Service Facility: Physician [**Name9 (PRE) **] [**Name9 (PRE) **] Discharge Diagnosis: Primary Diagnosis: 1. Lethargy likely secondary to dehydration 2. Chronic leg ulcer . Secondary Diagnosis: 1. HIV 2. Chronic Renal Insufficiency 3. Hypertension 4. GERD Discharge Condition: Patient was stable, afebrile with a normal WBC. He was alert and oriented to person, place and time. Discharge Instructions: Please take your medications as prescribed. . Please call your primary care doctor or return to the emergency department if you develop fevers, chills, dizziness, confusion, increased redness or pain in your left foot or difficulty breathing. . Followup Instructions: Please follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 11412**], in [**1-14**] weeks. His phone number is [**Telephone/Fax (1) 27157**]. . Please follow-up with Dr. [**Last Name (STitle) 27163**] in Plastic surgery in [**1-14**] weeks. If you are not able to get an appointment with him, you may follow-up with the plastic surgeons at [**Hospital1 **]. The phone number for them is [**Telephone/Fax (1) 6331**]. . The following appointment has already been made for you: Provider: [**Name10 (NameIs) 2341**] [**Last Name (NamePattern4) 2342**], M.D. Phone:[**Telephone/Fax (1) 2343**] Date/Time:[**2170-12-12**] 2:30

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14312, 14390

8009, 12953

456, 463

14603, 14706

3669, 6177

15000, 15686

3064, 3107

13416, 14289

14411, 14411

12979, 13393

14730, 14977

3122, 3650

403, 418

6212, 7986

491, 2123

14518, 14582

14430, 14497

2167, 2755

2771, 3048

2,211

175,696

48179

Discharge summary

report

Admission Date: [**2176-1-12**] Discharge Date: [**2176-1-19**] Date of Birth: [**2122-9-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: left foot redness/swelling Major Surgical or Invasive Procedure: Left foot debridement, right PICC line placement History of Present Illness: 53 year old male w/ CAD s/p MI [**2171**], poorly controlled type I DM and prior DKA presented to ED [**2176-1-12**] with left foot pain/swelling. He was last hospitalized [**6-6**] with left foot infection s/p debridement by podiatry and in mild DKA. Patient had noted increased swelling/warmth of left foot over the last month 2 months. Over the 5 days prior to admission, he noted increased pain, associated with fevers, chills, generalized fatigue, and anorexia. Pt does not check fingersticks. He reports polyuria and N/V x 1 day. In the ED, his T 102.6, bp 183/70, HR 103, 987%RA. Blood cultures and urine cultures were sent and the patient received vancomycin, levo, and flagyl. Given that his blood sugar was >600 with a gap of 14, he received Humalog 12 u and was started on an insulin drip. Despite this, his blood sugars were persistently in the mid 400s although AG closed to 10. ROS: Denies URI/cough. CP, SOB, abdominal pain, dysuria, BRBPR Past Medical History: 1) Type I DM: poorly controlled, history of prior DKA 2) CAD s/p MI [**2171**] 3) HTN 4) GERD 5) h/o MRSA (left foot wound) Social History: Works in sales. Denies ethanol, tobacco, or other drug use. Lives with an aunt in [**Name (NI) 583**] Family History: Noncontributory Physical Exam: Tc 102.6, HR 88, bp 119/65, resp 18, 98% RA Gen: well appearing middle-aged male in NAD HEENT: PERRL, EOMI, anicteric, OMMM, OP clear Neck: supp[le, no LAD, no JVD Cardiac: RRR, no M/R/G Pulm: CTA bilaterally Abd: NABS, soft, NT/ND Ext: Left foot and left lower extremity with erythema/edema, mildly tender to palpation with fluctuance. Neuro: CN II-XII grossly intact and symmetric bilaterally, A&OX3, decreased sensation to light touch in lower extremities to mid calves bilaterally Pertinent Results: At Time of Admission wbc 10.6 (86% PMN, 5% bands, 5 lymph, 3 mono), HCT 39.6 Na 134, K 4.0, Cl 99, HCO3 25, BUN 18, Cr 1.1 AG 10, glucose 397 CK 73, TnT <0.01 U/A: 1000 glc, 150 ketones, small blood [**4-7**] rbc, 0 wbc 0 epi serum tox (-) [**1-12**] foot x-ray: extensive deformity, of lateral foot c/w DM arthropathy. No fracture or evidence of osteomyelitis [**1-12**] EKG NSR @ 97, LAD, LVH, IVCD, no ST/TW changes from [**6-6**] [**3-/2171**] ETT MIBI: fixed moderate inferolateral perfusion defect with apical hypokinesis Brief Hospital Course: 1) DKA: This was likely precipitated by re-infection of left foot. Although patient's initial anion gap closed while in the emergency room, given persistant hyperglycemia >400 despite insulin drip, he was admitted to the ICU. He was transitioned to a subcutaneous NPH/Humalog regimen and transferred to the floor. His hemoglobin A1C on [**1-12**] was 9.1, consistent with his known poor glycemic control. The [**Last Name (un) **] service was consulted for assistance with management of blood sugars and his standing humalog and NPH as well as his Humalog sliding scale titrated up. He will require close diabetes follow-up as an outpatient and follow-up with his former [**Last Name (un) **] physician ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**]) was arranged. 2) Left foot abscess/cellulitis: Initially covered with vancomycin, levofloxacin, and Flagyl given history of MRSA, which was changed to vancomycin and Unasyn. Blood cultures from [**1-12**] remained negative at time of discharge. A swab culture of his left foot wound from [**2176-1-12**] grew >3 colony types; Heavy beta strep group B, sparse MRSA, and sparse diphtheroids. He underwent debridement of the area by podiatry (including bone) on [**2176-1-15**]. Follow-up foot X-ray showed findings consistent with debridement of fifth metatarsal. There was a lucency deep to the deepest area of debridement, however the Podiatry service was confident that they had removed all of the infected material. The pathology was pending at time of discharge, however, tissue cultures grew sparse group B beta strep and sparse gram positive organism (being further identified), indicating contiguous polymicrobial osteomyelitis. He will continue on 4 weeks of antibiotics from day of debridement (to complete [**2176-2-12**]). He will remain non-weight bearing with dry dressing changes QD. On [**2176-1-18**], increased erythema was noted over dorsolateral foot, concerning for cellulitis. This was improving at discharge, but will need to be closely followed as an outpatient to ensure resolution. 3) CAD: No evidence of ischemia on admission EKG; one set of CE (-). Pt continued on ASA and beta blocker. Given lipid panel from [**6-7**] (LDL 54, HDL 46, total chol 135), a statin was not initiated. His lipid panel will need to be followed closely as an outpatient to ensure optimal control. In order to optimize blood pressure control, low dose ACEI (lisinopril 10 mg PO daily) was initiated, which can be titrated up as an outpatient. 4) Prophylaxis: Given his relative immobility, the patient received Heparin SC TID throughout hospital stay. Medications on Admission: 1) NPH 70 units SC QAM, 40 units SCqPM 2) Humalog 15 units SC QAM, 15 units SC qPM 3) Metoprolol 25 mg PO BID 4) ASA 325 mg PO daily 5) Tums prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold sbp <100, HR <55. Tablet(s) 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 4. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Injection TID (3 times a day). 6. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifty (50) units Subcutaneous qAM: and 40 u qhs . 8. Humalog 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous qAM (with breakfast): and 15 units qPM (with dinner). 9. Humalog 100 unit/mL Solution Sig: sliding scale units Subcutaneous qAC and qhs: see attached sliding scale. 10. Ampicillin-Sulbactam Sodium [**3-5**] g Recon Soln Sig: Three (3) grams Injection Q8H (every 8 hours): through [**2175-2-11**] (total 28 day course). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Vancomycin HCl 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q12H (every 12 hours): through [**2176-2-12**] (total 28 days of therapy). Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: Primary: osteomyelitis Secondary: cellulitis, diabetic ketoacidosis, type II diabetes, coronary artery disease, hypertension Discharge Condition: Good Discharge Instructions: Please take all of your medications as prescribed. You will be on the antibiotics Unasyn and Vancomycin for 4 weeks (completing the course on [**2176-2-12**]). You have been started on lisinopril for your high blood pressure. Please follow-up as indicated a below. It is very important in order to ensure healing that your diabetes be well-controlled; this requires close physician [**Last Name (NamePattern4) 702**]. Followup Instructions: 1) Primary Care -- Dr [**Last Name (STitle) 1256**] (in place of Dr. [**Last Name (STitle) 2539**] secondary to availability of appointments [**Telephone/Fax (1) 3070**]) [**2176-2-7**] 10 a.m. 2) [**Last Name (un) **]: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**] ([**Telephone/Fax (1) 2378**]) on [**2176-2-6**] at 8 a.m. 3) Podiatry: DR. [**First Name8 (NamePattern2) 23305**] [**Name (STitle) **] Where: CC-2 PODIATRY UNIT Phone: [**Telephone/Fax (1) 25274**] Date/Time:[**2176-1-22**] 2:30 p.m. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2176-5-8**]

[ "250.11", "707.14", "682.7", "731.8", "730.07", "285.9", "401.9", "250.81", "412", "276.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "77.68" ]

icd9pcs

[ [ [] ] ]

6879, 6956

2759, 5394

341, 392

7125, 7131

2203, 2736

7598, 8275

1666, 1683

5589, 6856

6977, 7104

5420, 5566

7155, 7575

1698, 2184

275, 303

427, 1384

1406, 1531

1547, 1650

23,401

146,420

51750

Discharge summary

report

Unit No: [**Numeric Identifier 107191**] Admission Date: [**2109-1-31**] Discharge Date: [**2109-2-10**] Date of Birth: Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient was 69-year-old male with a history of chronic obstructive pulmonary disease, coronary artery disease, and peripheral vascular disease who presented with respiratory failure to the Intensive Care Unit. The patient was originally admitted on [**2109-1-30**] to the Neurology Service after presenting with left hand numbness, fevers, and chills. The patient's chest x-ray on admission was negative, and a magnetic resonance imaging/magnetic resonance angiography done showed no acute infarction and no flow changes in the arteries. On [**1-31**], the patient had a temperature spike to 101.8 degrees, and then in the early evening complained of chest pain. Approximately one to two hours later, the patient had respiratory failure with an arterial blood gas of 7.04/112/84, with a blood pressure of 220/100, and a pulse of 110. The patient was intubated. Then, secondary to hypotension (with a systolic blood pressure drop to 70) was transiently placed on dopamine and transferred to the Intensive Care Unit. PAST MEDICAL HISTORY: Coronary artery disease; status post stent in [**2107-4-25**]. Chronic obstructive pulmonary disease (on home oxygen). Hypercholesterolemia. Hypertension. Peripheral vascular disease. Bilateral aortoiliac occlusion. Cerebrovascular accident in occipital area after a right internal carotid artery stent. A right internal carotid artery stent placed in [**2108-4-24**]. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON TRANSFER TO INTENSIVE CARE UNIT: [**Unit Number **]. Aspirin. 2. Plavix. 3. Lopressor. 4. Salmeterol. 5. Maxair. 6. Combivent. 7. Diltiazem 240 mg by mouth once per day (which was held). FAMILY HISTORY: The patient's family history included coronary artery disease. SOCIAL HISTORY: A 120-pack-year history of smoking; quitting three years prior to admission. No history of alcohol use. No history of intravenous drug use. The patient has two daughters and lives alone. he is divorced. PHYSICAL EXAMINATION ON TRANSFER: Vital signs revealed a temperature of 98.3, his pulse was 110, his blood pressure was 150/70, and he was saturating 100 percent on assist control 750 X 12, a positive end-expiratory pressure of 5, and an FiO2 of 50 percent. In general, the patient appeared to be in no apparent distress and was intubated. Head, eyes, ears, nose, and throat examination showed anicteric sclerae. The oropharynx was clear. The patient's cardiac examination showed that he was tachycardic. Normal first and second heart sounds. No murmurs, rubs, or gallops. Pulmonary examination showed diffuse wheezes with some rhonchi. The abdomen was soft, nontender, and nondistended. There were normal active bowel sounds. The patient's extremities showed no edema and no calf tenderness. The patient's neurologic examination showed that he was sedated; although, even with decreased sedation he did respond. LABORATORY STUDIES ON TRANSFER: White blood cell count was 17.7 (which was an increase from his baseline of 7.8 on admission), his hematocrit was 34.8, and his platelets were 230. The patient's sodium was 142, potassium was 5.1, chloride was 105, bicarbonate was 29, blood urea nitrogen was 20, creatinine was 1.4 (with a baseline of 1.1), and blood glucose was 126. The patient's creatine kinase was 213. His calcium was 8.7, his magnesium was 1.8, and his phosphorous was 4.9. PERTINENT RADIOLOGY-IMAGING: The patient's electrocardiogram showed sinus tachycardia at 132 beats per minute with no acute changes compared to prior electrocardiograms. The patient's echocardiogram done on [**1-31**] showed an ejection fraction of 40 percent with severe pulmonary hypertension and severe mitral regurgitation. There was no atrial septal defect or patent foramen ovale noted on the Doppler. SUMMARY OF HOSPITAL COURSE: RESPIRATORY FAILURE: The patient had been intubated secondary to respiratory failure, and after eight days of intubation had repeated unsuccessful attempts at extubated and a failure to wean. After long discussions with the patient, the family, and the Intensive Care Unit team, it was decided that the patient would be made do not resuscitate and do not intubate. After repeated attempts to maximize the patient's extubated conditions, the patient was still unable to be weaned or extubated. After further discussions with the patient's daughters - including the healthcare proxy - the patient was made comfort measures only and extubated. The patient was then called out to the floor where the patient passed away on [**2109-2-10**]. The patient's family was notified, and they declined an autopsy. Both the attending and the admitting offices were also notified of the patient's passing. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 6648**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2109-7-5**] 14:56:39 T: [**2109-7-5**] 16:29:08 Job#: [**Job Number **]

[ "518.81", "458.9", "428.0", "276.5", "491.21", "584.9", "401.9", "443.9", "486" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.91", "96.04", "89.64" ]

icd9pcs

[ [ [] ] ]

1898, 1962

4037, 5160

197, 1223

1246, 1881

1979, 4008

74,954

130,688

36618

Discharge summary

report

Admission Date: [**2165-8-13**] Discharge Date: [**2165-8-21**] Date of Birth: [**2140-2-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: blurred vision, ataxia, confusion, hallucination, incontinence Major Surgical or Invasive Procedure: lumbar puncture X2 History of Present Illness: [**Known firstname **] [**Known lastname 82855**] is a 25 [**University/College **] PhD student with a history of anorexia and anxiety who was transfered to [**Hospital1 18**] from [**Hospital3 2568**] with multiple neurologic complaints. History obtained from chart, and boyfriend [**Name (NI) 82856**] [**Name (NI) 82857**] as pt is minimally able to contribute to history. Initial symptoms began with blurry vision and dizziness approximately 2 weeks ago. She presented to her optometrist for a new prescription for her glasses, after correction when she still complained of visual disturbance he referred her to [**Hospital3 2568**] ED on [**7-31**]. There she had a CT head which was negative and a reportedly normal MRI. The recommendation was made to stay for admission, which the patient declined. Over the following 10 days the patient had progressive anxiety and ataxia and continued visual deficits. She became weaker and weaker with frequent falls, unable to [**Known lastname **] 2 flights of stairs to her apartment. Boyfriend had to walk to support her and cites inability to leave apartment as reason that various medical follow up appointments were not attended. Due to concern for her boredom and homebound status, her boyfriend brought her multiple bottles of wine and estimate that for the past 10-14 days she had been consuming approximately 1 bottle of wine per day. 3-4 days prior to admission she began having fecal incontinence, insomnia and visual hallucinations. He also notes that she has always struggled with an eating disorder and estimates that she consumes approximately 400-500 calories per day. On day of admission the patient/her boyfriend [**Name (NI) 653**] her new PCP who suggested that as they were unable to leave the apartment for an appointment with her that they call an ambulance and present to the ED, at which point she was again brought to [**Hospital3 **]. She had a negative non-contrast CT, was evaluated by psych and neurology, given acyclovir and benzodiazepines and was transferred to [**Hospital1 18**] for further evaluation. Her boyfriend notes that he thought the ativan made her hallucinations worse. . In the ED, initial vs were: T 98.7 P 132 BP 131/92 R16 O2 sat 99% RA. Patient was given 3L NS, ativan total 4mg IV, magnesium 2mg IV, D5W with MVI, folate, thiamine, and ceftriaxone. Acyclovir 600mg IV had been initiated at [**Hospital3 2568**] and was completed at [**Hospital1 18**] ED. She had an LP which was unremarkable. She was evaluated by neurology in the ED and recommendation was made for EEG, MRI, and monitoring in ICU. . Upon arrival to the MICU the patient was pleasant and cooperative but confused, slightly anxious, with confabulations and some paranoia. She was easily redirectible, although meaningful ROS was difficult to obtain. Denied pain. Stated mood was good. Denied depression or SI. Denied recent overdose or ingestion. Denied new sexual contacts, recent travel, tick bites, denied restrictive or purging type behaviors. Reports feeling safe at home; hesitates when discussing her relationship, but denies violence. . Past Medical History: Anxiety Occasional headaches Recent traumatic lower extremity while skiing last winter Eating disorder Social History: Lives alone, in a relationship with her boyfriend. 3 years into [**University/College **] PhD program in Renassaisance poetry. Father and step mother live in [**Name (NI) 30285**] and travelled to [**Location (un) 86**] to see her during the admission. Mother passed away from cancer of unknown primary. Pantient reports mother had history of eating disorder but no clear additional history of psychiatric disease in the family. Non-smoker. Denies illicit drug use. Admits to [**4-3**] glasses of wine per day. Sexually active. Denies ever being pregnant. Family History: Mother died [**2161**] of cancer, unknown primary; had anorexia ? autoimmune arthritis in maternal grandmother Physical Exam: Vitals: T: 97.7 BP:144/97 P:129 R: 16 O2: 100% RA General: Pleasant young thin female, no acute distress, occasinal jerking movements. Confused. HEENT: Sclera anicteric, MM dry. Neck: supple. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rhythm, tachycardic. normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Slight lateral nystagmus and subtle disconjugate gaze. EOMI. PERRL. CNII-XII intact. Decreased visual acuity. Abnormal limb random limb jerking. UE strength: proximal muscles [**4-4**], distal muscles 2+/5. + pronator drift LE strength: [**3-7**] downgoing toes. Proprioception dampened L>R. Marked cerebellar dysmetria on finger to nose and RHMs. Psych: Alert. Oriented with prompting to year, month, not date or day. Not to town. Poor attention, short term memory. Confabulation as well as tangential speech. Easily redirectible. Mild anxiety. Pertinent Results: [**2165-8-12**] 09:55PM BLOOD WBC-5.4 RBC-3.53* Hgb-11.8* Hct-36.4 MCV-103* MCH-33.4* MCHC-32.4 RDW-14.2 Plt Ct-417 [**2165-8-12**] 09:55PM BLOOD Neuts-67.0 Lymphs-23.8 Monos-5.9 Eos-2.7 Baso-0.5 [**2165-8-20**] 06:35AM BLOOD WBC-4.0 RBC-3.07* Hgb-10.4* Hct-30.7* MCV-100* MCH-33.8* MCHC-33.7 RDW-14.1 Plt Ct-373 [**2165-8-17**] 08:15AM BLOOD Ret Aut-1.9 [**2165-8-17**] 08:15AM BLOOD calTIBC-150* Ferritn-556* TRF-115* [**2165-8-16**] 05:17AM BLOOD PT-12.3 PTT-32.2 INR(PT)-1.0 [**2165-8-12**] 09:55PM BLOOD Glucose-90 UreaN-5* Creat-0.5 Na-142 K-3.8 Cl-109* HCO3-18* AnGap-19 [**2165-8-20**] 06:35AM BLOOD Glucose-94 UreaN-6 Creat-0.4 Na-138 K-4.0 Cl-104 HCO3-27 AnGap-11 [**2165-8-20**] 06:35AM BLOOD Calcium-9.3 Phos-5.3* Mg-1.7 [**2165-8-12**] 09:55PM BLOOD ALT-52* AST-108* AlkPhos-122* TotBili-0.8 [**2165-8-20**] 06:35AM BLOOD ALT-27 AST-66* AlkPhos-101 TotBili-0.3 [**2165-8-13**] 05:52AM BLOOD Ammonia-53* [**2165-8-12**] 09:55PM BLOOD TSH-12* [**2165-8-13**] 05:52AM BLOOD T3-107 Free T4-0.94 [**2165-8-12**] 09:55PM BLOOD CRP-0.9 [**2165-8-12**] 09:55PM BLOOD ESR-12 [**2165-8-12**] 11:35PM URINE RBC-[**12-20**]* WBC-[**12-20**]* Bacteri-MOD Yeast-NONE Epi-0 [**2165-8-12**] 11:35PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-15 Bilirub-SM Urobiln-NEG pH-6.5 Leuks-MOD [**2165-8-12**] 09:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr- NEG Tricycl-NEG [**2165-8-12**] 11:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2165-8-12**] 11:00PM CEREBROSPINAL FLUID (CSF) WBC-25 RBC-1700* Polys-0 Lymphs-100 Monos-0 [**2165-8-12**] 11:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-12* Polys-0 Lymphs-100 Monos-0 [**2165-8-12**] 11:00PM CEREBROSPINAL FLUID (CSF) TotProt-50* Glucose-63 MICRO CSF Herpes Simplex virus PCR negative RPR negative Lyme serologies NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA. MRSA Screen: No MRSA isolated. Urine culture: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. IMAGINE Head MRI/MRA/MRV 1. No evidence for acute infarction or hemorrhage. 2. No neurovascular abnormality identified. No evidence for venous sinus thrombosis MRI: Cervical, thoracic, lumbar Minimal straightening of the cervical lordosis, mild posterior disc bulge noted at C5/C6 without evidence of central spinal canal stenosis or neural foraminal narrowing. There is no evidence of spinal canal stenosis or neural foraminal narrowing at any intervertebral disc space. There is no evidence of abnormal enhancement. The signal intensity throughout the cervical and thoracic spinal cord appears normal, the lumbar spine appears within normal limits. Lower extremity ultrasound (bilateral): No evidence of DVT. EEG: This is an abnormal portable routine EEG due to a slight slowing of the background rhythm. These findings suggest a mild encephalopathy affecting both cortical and subcortical structures. Medications, metabolic disturbances, and infection are among the most common causes. Nevertheless, there were no areas of prominent focal slowing although encephalopathies can obscure focal findings. There were no clearly epilptiform features. . EKG: Sinus tach at 130, normal axis. QTc 440. Other intervals normal. No ST wave changes. . CXR: Normal . Echocardiogram: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. The inferior vena cava is probably small (views suboptimal) consistent with low right atrial pressure. Brief Hospital Course: The patient is a 25 year-old female with a history of heavy EtOH use and restrictive type eating disorder presenting with multiple neurologic complaints including visual disturbances, weakness, incontinence, altered mental status, and cerebellar ataxia. 1) Altered mental status When the patient presented to the ED from an outside hospital, she was awake and alert, but inattentive, confabulating, and having visual hallucinations. In the ED, she received normal saline, D5W, magnesium, folate, thiamine, ceftriaxone. She was continued on acyclovir that was started at the outside hospital. She was admitted to the ICU, where she was treated with thiamine, vitamin B complex, ascorbic acid, niacin, folic acid, and multivitamins. Work-up revealed negative RPR, lyme serologies. CSF analysis showed 1 WBC (lymphocyte), 25 RBC and negative HSV-1 and -2 PCR; acyclovir was discontinued. T3 and free T4 were normal. EEG was consistent with mild encephalopathy but not seizure activity. MR, MRA, and MRV of the head showed normal signal intensities (although motion artifact was present) and no vascular abnormalities. Neurology consult and ICU staff noted she had diplopia, mental status changes, and ataxia in the setting of excessive EtOH intake and poor nutritional status and in light of the above data determined Wernicke's encephalopathy was the most likely diagnosis. As the history of fecal incontinence did not fit with this diagnosis, an MRI of the cervical, thoracic, and lumbar spine was ordered; the results were within normal limits with no cord compression. Syphillis, thyroid disorders, subacute combined degeneration, Lyme disease, alcohol withdrawal, and [**Last Name (un) **]-[**Location (un) **] were also considered in the differential and were excluded because of negative laboratory data and incongruent symptoms. During her ICU course, the patient's mental status improved as did her short-term memory (although not back to baseline). She had intermittent periods of hallucinations and confusion. On hospital day 4, the patient was transfered to the general medicine service. At the time of transfer, her mental status was normal. Over the next 4 days, she had at least 2 short (~1 hour) episodes of confusion during which she did not recall why she was in the hospital and did not recall that she had profound weakness. She also had intermittent anxiety which was relieved by lorazepam. The episodes of confusion were not temporally associated with the administration of lorzepam. She was continued on vitamin therapy as above. She was followed by neurology, psychiatry and nutrition. At discharge, she was continued on thiamine therapy x3 months, as well as multivitamins. 2) Motor dysfunction: weakness and ataxia The patient had profound weakness upon presentation and was unable to stand. Most notably, on exam she could not perform hip flexion against gravity. Her wrist and finger flexors and extensors were also profoundly weak and she was unable to hold a pen. Through her stay, her strength improved. Although her hands were still weak, she was able to feed herself at discharge. She was still unable to stand. Occupational therapy and physical therapy worked with her during her stay. Her ataxia was exhibited by dysmetria on finger-nose-finger testing. This improved during her admission, although she still had ataxia at discharge. These findings and symptoms are consistent with the cerebellar dysfunction and peripheral neuropathy components of Wernicke's Encephalopathy. 3) Pain The patient experienced bilateral tingling pain in her hands and feet. This was consistent with the peripheral neuropathy of Wernicke's Encephalopathy and Beriberi. She has also has bilateral knee pain at baseline (which she reports is from overuse from long-distance running) which was worse during her stay. She was treated with PRN ibuprofen, tylenol, and tramadol. She was administered lidocaine patches for her hands. She received percocet in the ICU, which her family feels exacerbated her visual hallucinations and therefore was stopped. 4) Excessive alcohol intake In the ICU, the patient was started on lorazepam according to the CIWA scale initially for concern of alcohol withdrawal. This was discontinued as her presentation was not consistent with withdrawal. Social work provided support to the patient and family and encouraged open discussion about the reasons for excessive intake. Possible contributing factors include recent death of patient's mother. 5) Anorexia BMI was approximately 18.7, despite low caloric intake from food. Increased caloric intake from alcohol may have prevented her BMI from being below normal. Nutrition service was consulted and provided calorie counts to monitor the patient's intake The patient's vegetarian diet was supplemented by Ensure with each meal. Psychiatry was consulted and advised outpatient follow-up with a psychiatrist. 6) Urinary tract infection The patient had a positive urinalysis and was treated with double strength bactrim x3 days. 7) Tachycardia The patient had sinus tachycardia which did not respond to fluids. Her heart rate was in the 130s in the ED, decreased to low 100s in the ICU, and remained 90-110 on the medicine service. Tachycardia and increased cardiac output can be seen in Wernicke's Encephalopathy without frank beriberi. Pain and anxiety likely contributed to the tachycardia. 8) Anemia The patient's hematocrit stabilized near 30. The anemia was slightly macrocytic, with evidence of hypoproduction (reticulocyte index was < 2). There is likely a component of bone marrow suppression by alcohol. B12 and folate were normal. While TIBC and ferritin were consistent with anemia of chronic disease, her iron levels were normal. Disposition: inpatient rehabilitation in [**Location (un) 30285**] (where the patient's father and step-mother live). She should been see by a psychiatrist, a neurologist, and an ophthalmologist. The patient and family are aware that physical rehabilitation will be long and that her symptoms may not completely resolve. Medications on Admission: None Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day for 3 months. 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*8 Tablet(s)* Refills:*0* 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24 (): Each day, apply 1 patch to each hand for 12 hours; then use no patches for 12 hours. Disp:*4 Adhesive Patch, Medicated(s)* Refills:*0* 5. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for pain. 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 245**] Rehab Hospital Discharge Diagnosis: Primary diagnosis: 1) Wernicke's encephalopathy 2) Anemia 3) Urinary tract infection Secondary diagnosis: 2) Anorexia nervosa Discharge Condition: Hemodynamically stable. Maintaing normal oxygen saturations on room air. Patient is currently not ambulatory due to weakness. Discharge Instructions: You were admitted to the hospital with confusion, weakness, and problems with coordination. It was found that your symptoms were most likely due to thiamine deficiency (causing a disorder called Wernicke's Encephalopathy and beriberi). We found no infectious cause of your symptoms. For these symptoms, you were treated with vitamins. You were also found to have a urinary tract infection and you were treated with antibiotics. Your medication regimen has changed. Please take the follow medications: Multivitamin, once a day Thiamine 100 mg one a day for 3 months Lidocaine patches for your hands while you have pain: 12 hours on, 12 hours off. Tramadol 50 mg every 6 hours as needed for pain. Ativan 0.5 mg as needed for anxiety while you travel to your rehabilitation facility. Please wait at least 6 hours between doses. Please avoid alcohol intake as this could worsen your condition. Please call your primary care physician or go to an emergency department if you develop confusion or worsening of your weakness or for any other symptoms that are concerning to you. Followup Instructions: Please follow up with a ophthalmologist, psychiatrist and neurologist at your rehabilitation facility. Completed by:[**2165-8-21**]

[ "427.89", "285.9", "300.00", "787.6", "265.0", "305.01", "V85.0", "307.1", "599.0", "356.9", "265.1", "334.3" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

16442, 16503

9486, 15552

376, 396

16672, 16800

5495, 9463

17923, 18057

4270, 4382

15607, 16419

16524, 16524

15578, 15584

16824, 17900

4397, 5476

274, 338

424, 3549

16630, 16651

16543, 16609

3571, 3676

3692, 4254

78,100

149,085

35798

Discharge summary

report

Admission Date: [**2143-9-10**] Discharge Date: [**2143-9-18**] Date of Birth: [**2078-2-10**] Sex: M Service: MEDICINE Allergies: Pravachol / Levaquin / Bactrim / Zyvox Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Worsening dyspnea on exertion Major Surgical or Invasive Procedure: Right heart catheterization PICC line placement History of Present Illness: The patient is a 65 yo M with PMH significant for ischemic cardiomyopathy with EF 15%, cardiac cirrhosis, s/p CABG [**2115**] & [**2127**], [**Hospital1 **]-ventricular ICD, s/p VT ablation, h/o CVA, s/p right CEA presents with volume overload with planned right heart cath in the AM and possible milrinone initiation. The patient has been having worsening fatigue, lower ext swelling, SOB and increasing weights at home. His lasix was increased to 80mg daily and also started on metolazone 5mg on Mondays and Fridays. The patient continued to have worsening a symptoms of volume overload and it was decided to admit him for a right heart cath and possible initiation of milrinone. . On arrive to the floor the patient feels well, but reports continued fatigue and volume overloaded. . On review of systems, he denied deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. Past Medical History: Dyslipidemia Hypertension Severe ischemic cardiomyopathy with LVEF of 15% status post biventricular pacer ICD ([**2127**]) status post VT ablation x 3 ([**2137**], [**2130**], ?) AF Fib on coumadin s/p CABG: [**2115**] and again in [**2127**] Cerebrovascular accident ([**2127**]) with no residual neuro deficits s/p Carotid endarterectomy, right, in [**2127**] Appendiceal perforation with colostomy Cardiac Cirrhosis Gout Hypothyroidism Social History: He is married with 3 children. He is a retired business man. He previously drank 1 glass a wine per week, but no longer does. He never drank more than 1-2 drinks per day. He does not smoke, but has a history of pipe smoking, quit in [**2127**]. Family History: His father developed a CVA at age 88 and also had lung cancer. His mother is alive and well at [**Age over 90 **] years of age Physical Exam: On admission: VS: T=97.1 BP=94/62 HR=66 RR=20 O2 sat= 100% RA GENERAL: Appears chronically ill, in no acute distress. Oriented x3. Mood, affect appropriate. HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, JVD elevated at approx 9-10cm. No carotid bruits. CHEST: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. HEART: RR, nl S1/S2, no S3/S4. Apical holosystolic murmur @ LLSB. No thrills, lift. PMI displaced laterally. ABDOMEN: Soft, protuberant and distended with a fluid wave. No HSM noted, BS present. EXTREMITIES: 2+ bilateral pitting edema. There is no cyanosis or clubbing. SKIN: Diffuse purpura and discoloration; evidence of venous stasis in LE bilaterally. No open lesions, ulcers. PULSES: Right: Carotid 1+ Radial 1+ DP 1+ PT 1+ Left: Carotid 1+ Radial 1+ DP 1+ PT 1+ Discharge Physical Exam: Pertinent Results: Labs on Admission: [**2143-9-10**] 09:25PM GLUCOSE-133* UREA N-116* CREAT-3.1* SODIUM-130* POTASSIUM-3.7 CHLORIDE-90* TOTAL CO2-25 ANION GAP-19 [**2143-9-10**] 09:25PM estGFR-Using this [**2143-9-10**] 09:25PM ALT(SGPT)-22 AST(SGOT)-30 LD(LDH)-232 ALK PHOS-242* AMYLASE-74 TOT BILI-1.7* [**2143-9-10**] 09:25PM LIPASE-63* [**2143-9-10**] 09:25PM ALBUMIN-3.9 CALCIUM-9.4 PHOSPHATE-4.4 MAGNESIUM-2.8* [**2143-9-10**] 09:25PM WBC-5.1 RBC-3.37* HGB-10.3* HCT-32.1* MCV-95 MCH-30.4 MCHC-32.0 RDW-19.1* [**2143-9-10**] 09:25PM PLT COUNT-80* [**2143-9-10**] 09:25PM PT-32.6* PTT-40.9* INR(PT)-3.3* [**2143-9-12**] Right heart cathterization: COMMENTS: 1. Resting hemodynamics revealed elevated right and left heart filling pressures with RVEDP 21 mmHg and PCWP (mean) 25 mmHg. The cardiac index was depressed at 1.64 l/min/m2. FINAL DIAGNOSIS: 1. Elevated right and left heart filling pressures. 2. Depressed cardiac index. Brief Hospital Course: 65M with ischemic cardiomyopathy (chronic systolic CHF, EF 15%), cardiac cirrhosis, s/p CABG [**2115**] & [**2127**], [**Hospital1 **]-ventricular ICD, s/p VT ablation, h/o CVA, s/p right CEA presents with volume overload with planned right heart cath and milrinone initiation. # Decompensated Systolic Heart Failure of Ischemic Etiology: Ischemic cardiomyopathy (chronic systolic CHF, EF 15%), fluid overloaded on exam. He was admitted for aggressive diuresis with lasix gtt and metolazone. Milrinone gtt initiated after right heart catheterization on [**2143-9-12**]. The patient was transferred to the CCU for invasive hemodynamic monitoring to trial and titrate Milrinone. After starting IV Milrinone, the patient's hemodynamics improved markedly, with CI improving from 1.6 to 2.3 l/min/m2; on Milrinone 0.25 mcg/kg/hr, CI was 2.3 l/min/m2, on 0.5 mcg/kg/hr, CI was 2 l/min/m2. Concomitant with the Milrinone trial, the patient was volume optimized with aggressive diuresed on Metolazone, a Lasix GTT, and Eplerenone; the patient was transitioned from carvedilol to metoprolol while being diuresed to help maintain mean arterial pressures and he was eventually transitioned to PO Torsemide from Lasix. Preload was also optimized with reprogramming of the patient's BV-Pacer to lengthen the PR interval; after this was done, CI was 2.9 l/min/m2. No changes were made to the patient's antiarrhtymic medications dofetilide and quinine. The patient remained hemodynamically stable throughout admission without requiring pressure support. Discharged on Metolozone, Torsemide, Metoprolol Succinate, Eplerenone, Dofetilide, and Milrinone as detailed below. Coumadin was held upon discharge due to INR 3.7, with plans for the patient follow-up as detailed below. . # History of AF: Remained stably paced w/[**Hospital1 **]-ventricular ICD, s/p VT ablation, anticoagulated on coumadin. Continued dofetilide and quinine. . # Congestive cirrhosis: Followed by hepatology; continue regimen of rifaxamin, lactulose (dosed for [**2-7**] BM daily) to improve encephalopathy. . # Renal insufficiency: Secondary to poor cardiac output, continued to monitor, renally dose medications. . # Gout: Well controlled. Patient was continued on renally dosed allopurinol, prednisone. . # Hypothyroidism: Last TSH 13, FT4 1.1 ([**1-7**]). Continued levothyroxine. Medications on Admission: Prednisone 5mg daily ASA 81mg daily Carvedilol 12.5mg [**Hospital1 **] Alprazolam 0.25mg qhs Synthroid 50mcg qam Vit C Metolazone 5mg daily Quinine 324mg qhs Lactulose 45ml [**Hospital1 **] (titrate to 3 BM per day) Allopurinol 100mg daily Dofetilide 0.25mg [**Hospital1 **] Inspra 25mg [**Hospital1 **] Lasix 80mg daily Rifaximin 550mg [**Hospital1 **] Tramadol prn pain Coumadin 4mg daily Discharge Medications: 1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Vitamin C Oral 6. quinine sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. lactulose 10 gram/15 mL Solution Sig: Forty Five (45) ML PO twice a day: Titrate to 3 BM per day. 8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. dofetilide 125 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*2* 13. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 14. milrinone in D5W 200 mcg/mL Piggyback Sig: One (1) Intravenous INFUSION (continuous infusion). Disp:*1 drip* Refills:*0* 15. Milrinone Infusion milrinone 1 mg/mL solution;Give 0.25 mcg/kg/min continuous Weight is 73.7 kg.; Please compound to 400 mcg/ml; Disp# *** 30*** (Thirty) Bag; Refills: **11** 16. Outpatient Lab Work Please check Chem 7, INR/PT and CBC on Friday [**9-20**] and call results to Dr. [**First Name (STitle) 437**]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 62**] 17. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 18. 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* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Primary diagnosis: ischemic cardiomyopathy Secondary diagnoses: Cardiac cirrhosis, Dyslipidemia, Hypertension, s/p biventricular pacer ICD ([**2127**]), s/p VT ablation x 3 ([**2137**], [**2130**], ?), atrial fibrillation, s/p CABG ([**2115**], [**2127**]), Cerebrovascular accident ([**2127**]) with no residual neuro deficits, R carotid endarterectomy ([**2127**]), Gout, Hypothyroidism 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 during your admission. You were admitted for fluid overload. You were given diuretics and underwent a right heart catheterization. You were then transferred to the cardiac intensive care unit for monitoring while you were given milrinone to help increased your cardiac output. . The following changes were made with your medications: 1. Decrease Metolozone to 2.5 mg daily 2. STOP Carvedilol, Start Metoprolol Succinate 25mg daily instead 3. STOP taking Furosemide (lasix), take Torsemide instead to remove excess fluid 4. STOP taking Warfarin (coumadin) 5. Decrease Eplerenone to once daily only 6. Decrease Dofetalide to .125 mg ([**12-8**] previous dose) because of your worsened kidney function. 7. Start Milrinone intravenously to help your heart beat more effectively. . Please continue all other home medications as prescribed. . Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2143-10-14**] at 9:00 AM With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**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: MONDAY [**2143-10-14**] at 9:20 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**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: WEDNESDAY [**2143-11-27**] at 11:00 AM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "276.1", "585.9", "414.8", "996.1", "244.9", "428.0", "414.01", "403.90", "E879.8", "V58.61", "V45.02", "572.2", "428.23", "427.31", "E849.7" ]

icd9cm

[ [ [] ] ]

[ "89.64", "37.21", "38.93", "38.97", "88.56" ]

icd9pcs

[ [ [] ] ]

9061, 9144

4462, 6811

337, 387

9577, 9577

3500, 3505

10835, 11806

2364, 2492

7252, 9038

9165, 9165

6837, 7229

4357, 4439

9728, 10812

2507, 2507

9229, 9556

268, 299

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9184, 9208

3520, 4340

9592, 9704

1645, 2085

2101, 2348

3481, 3481

81,146

168,839

39668

Discharge summary

report

Admission Date: [**2188-7-22**] Discharge Date: [**2188-7-30**] Date of Birth: [**2110-2-13**] Sex: M Service: MEDICINE Allergies: Cardura Attending:[**First Name3 (LF) 5810**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Colonoscopy with clipping of diverticular bleeding sites History of Present Illness: 78 yo male DM, HTN, HLD, prior diverticular bleed presented to [**Hospital6 19155**] on [**7-19**] complaining of bright red blood per rectum. . Patient states the he was in his normal state of health until [**7-19**] when he had a bowel movement which filled the toliet bowel with bright red blood. A few minutes later he passed another bowel movement which filled the toliet bowel with darker blood. During this time he only noted mild cramping in the abdomen. Denied any abdominal pain prior to this bleed. During this time patient notes no chest pain, lightheadedness, fever, chills, nausea, or vomiting. After the episode of bleeding the patient presented to the [**Hospital6 19155**] where he was monitored in the ICU. . At [**Hospital3 **]the patients initial Hematocrit was 34 and patient was hemodynamically stable. EGD was performed without site of bleeding. On [**7-21**] underwent a colonoscopy showing a site of active diverticular bleeding estimated at 45cm. No other active sites were identified to the level of the cecum. 5 clips were placed at the site of diverticular bleeding and epinephrine was injected. Reportedly, pt also had a bleeding scan which was negative however I have not seen this report. From [**7-20**] - [**7-21**] patient was transfused total 6 units PRBCs and one unit platelets given concern for platelet dysfunction given ASA use. Patient was evaluated by . During colonoscopy patient was thought to have aspirated with desats to med 70s. CXR with concern for worsening left lung opacity and right hilar opacity. Patient was started on Clindamycin, zosyn sp colonoscopy with concern for aspiration event. Also on levaquin for a short time which was dc'd [**7-21**]. After event patient has required . On the floor, patient is hemodynamically stable, denies abdominal pain. Patient states that the last time he moved his bowels was on Sunday. At that time stool was bloody. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, 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: CAD Type II DM HTN HLD Obesity Distal Adominal Aortic Dissection on CT scan ([**2187-5-23**]) Thoracic Aortic Aneurysm measuring 4.8cm on CT Scan ([**2187-5-23**]) RAS Bladder Cancer GERD Barrett's esophagus (endoscopy [**2180**]) Diverticular disease Chronic Anemia Lumbar disc Disorder Social History: Lives with wife. Two Children. Retired from the paper business - Tobacco: Quit 20 years prior - Alcohol: Occasional EtOH - Illicits: None Family History: Father - MI. Mother with diabetes. Physical Exam: Vitals: T: BP: 170/38 P: 95 R: 20 O2: 97% - 3L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, Mucous Membranes Dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Rales bilateral bases, with scant exp wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2188-7-22**] 11:38PM BLOOD WBC-6.0 RBC-2.82* Hgb-8.6* Hct-24.3* MCV-86 MCH-30.5 MCHC-35.5* RDW-15.8* Plt Ct-142* [**2188-7-23**] 04:46AM BLOOD WBC-5.1 RBC-2.74* Hgb-8.3* Hct-23.6* MCV-86 MCH-30.3 MCHC-35.2* RDW-15.7* Plt Ct-116* [**2188-7-23**] 11:07AM BLOOD Hct-28.4* [**2188-7-23**] 03:55PM BLOOD Hct-25.9* [**2188-7-23**] 08:41PM BLOOD Hct-26.4* . . [**2188-7-22**] 07:46PM BLOOD Glucose-283* UreaN-23* Creat-1.5* Na-141 K-3.1* Cl-105 HCO3-28 AnGap-11 [**2188-7-23**] 04:46AM BLOOD Glucose-184* UreaN-20 Creat-1.1 Na-141 K-6.6* Cl-107 HCO3-27 AnGap-14 [**2188-7-23**] 05:35AM BLOOD Glucose-222* UreaN-20 Creat-1.2 Na-143 K-3.0* Cl-107 HCO3-29 AnGap-10 [**2188-7-23**] 11:12AM BLOOD Glucose-179* UreaN-19 Creat-1.0 Na-142 K-3.4 Cl-107 HCO3-27 AnGap-11 [**2188-7-23**] 03:54PM BLOOD Glucose-303* UreaN-19 Creat-1.0 Na-140 K-3.4 Cl-107 HCO3-27 AnGap-9 . . [**2188-7-22**] 07:46PM BLOOD CK-MB-2 cTropnT-0.01 [**2188-7-23**] 05:35AM BLOOD CK-MB-2 cTropnT-0.01 . Discharge Labs [**2188-7-29**] 05:20AM BLOOD WBC-4.6 RBC-3.12* Hgb-9.4* Hct-27.7* MCV-89 MCH-29.9 MCHC-33.8 RDW-15.6* Plt Ct-230 [**2188-7-28**] 05:45AM BLOOD WBC-4.5 RBC-3.21* Hgb-9.7* Hct-28.8* MCV-90 MCH-30.3 MCHC-33.8 RDW-15.6* Plt Ct-191 [**2188-7-29**] 05:20AM BLOOD PT-14.0* PTT-29.6 INR(PT)-1.2* [**2188-7-28**] 05:45AM BLOOD Plt Ct-191 [**2188-7-27**] 06:20AM BLOOD Plt Ct-154 [**2188-7-29**] 05:20AM BLOOD Glucose-164* UreaN-12 Creat-1.0 Na-144 K-3.6 Cl-107 HCO3-28 AnGap-13 [**2188-7-28**] 05:45AM BLOOD Glucose-217* UreaN-10 Creat-1.0 Na-140 K-3.8 Cl-104 HCO3-28 AnGap-12 [**2188-7-28**] 12:05AM BLOOD CK(CPK)-66 [**2188-7-27**] 02:55PM BLOOD CK(CPK)-71 [**2188-7-28**] 12:05AM BLOOD CK-MB-2 [**2188-7-27**] 02:55PM BLOOD CK-MB-2 [**2188-7-27**] 08:05AM BLOOD CK-MB-3 cTropnT-<0.01 [**2188-7-23**] 05:35AM BLOOD CK-MB-2 cTropnT-0.01 [**2188-7-29**] 05:20AM BLOOD Calcium-7.9* Phos-4.0 Mg-1.8 [**2188-7-28**] 05:45AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.0 [**2188-7-27**] 08:05AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.6 [**2188-7-23**] 04:51AM BLOOD Lactate-1.2 [**2188-7-23**] 12:09AM BLOOD Lactate-1.4 . Micro: Sputum [**7-24**] and [**7-27**] were both contaminated MRSA negative Blood and urine cultures=no growth to date . Reports [**7-22**] EKG Sinus rhythm. Left atrial abnormality. Occasional atrial ectopy. Downsloping ST segment depression and T wave inversion in leads I and aVL. Biphasic to inverted T waves in leads V2-V6 with slight Q-T interval prolongation. Left axis deviation. Non-specific ST-T wave flattening in the inferior leads. These findings are consistent with active anterolateral ischmeic process. No previous tracing available for comparison. Followup and clinical correlation are suggested. Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 89 178 114 408/458 34 -31 154 . [**7-22**] CXR REASON FOR EXAM: Question aspiration event. Assess also for volume overload. There are no prior studies available for comparison. There is mild cardiomegaly. Very large left lung consolidation could be due to aspiration/pneumonia. Left pleural effusion is small. There is no evident pneumothorax. . [**7-28**] HISTORY: 78-year-old male with COPD, CAD, presenting with GI bleeding, now with aspiration versus hospital-acquired pneumonia versus pulmonary edema. COMPARISON: Chest radiograph from [**2188-7-22**], [**2188-7-23**], and [**2188-7-27**]. CHEST RADIOGRAPHS, PA AND LATERAL VIEWS: The heart size remains mildly enlarged, but there is no evidence for new pulmonary edema. Large consolidation in the left lung, now predominantly lingular and lower lobe, is only subtly improved from one day prior but is again noted to be substantially improved, especially in the left upper lung, compared to [**2188-7-22**] and [**2188-7-23**]. There is mild opacity remaining in the right lower lobe. There is no pneumothorax. There is probable small unchanged left pleural effusion. Degenerative changes are noted in the spine, as well as vascular calcifications and cholecystectomy clips. IMPRESSIONS: Left lung consolidation subtly improved from 1 day prior, but substantially improved since [**2188-7-22**]. . EKG [**7-25**] Sinus rhythm. QS deflections in leads VI-V2 and Q waves in lead V3. Compared to the previous tracing of [**2188-7-22**] atrial ectopy is absent. There may be variation in precordial lead placement. However, the Q wave before the transition remains and the ischemic appearing T wave abnormalities previously recorded have resolved. Rule out interim myocardial injury. Followup and clinical correlation are suggested. Intervals Axes Rate PR QRS QT/QTc P QRS T 80 98 104 404/439 18 -21 80 Brief Hospital Course: Mr. [**Known lastname 87434**] is a 78 yo man with a PMH of DM, HTN, HLD, and prior diverticular bleed who presented to [**Hospital3 12594**] on [**7-19**] complaining of bright red blood per rectum. Colonoscopy there revealed bleeding diverticulum and 5 clips and epinephrine were applied with control of bleeding. . #Diverticular bleed- His bleeding was likely related to the bleeding diverticulum identified on colonoscopy. The EGD did not reveal bleeding from above. Throughout his admission he remained hemodynamically stable and HCT also remained stable. He was monitored on telemetry and PRBCs were typed and screened actively. He was transfused total 2u PRBCs during admission. . #. Aspiration Pneumonia vs. Pneumonitis: His aspiration event with subsequent fever is most likely attributable to aspiration pneumonitis given the history and documented desat. He was sating well in the ICU with sats in the mid 90s on room air. He was placed on Flagyl and Levaquin pending sputum cultures initially. He was later switched to Zosyn and completed the full regimen. His breathing and cough improved and he tolerated room air very well. His chest X rays also improved though he still had a opacity of the right lower lobe still present on CXR [**7-28**]. . #. Diabetes: Held Metformin and start ISS with standing PM 16 units Lantus. . #. Acute Kidney Injury: Creatinine to 1.5 rapidly returned to baseline of 1.0 with gentle hydration. . #. Hypertension: Currently hypertensive SBP's 140-160. Was on metoprolol succinate, HCTZ, Lisinopril with blood pressures which have remained elevated. Kept all medications the same except for discontinuing HCTZ and starting chlorthalidone on the first day after discharge. . #. GERD/Barretts: EGD at [**Location (un) **] without evidence of upper origin for bleeding. - Pantoprazole 40mg IV q24hours; changed to omeprazole at discharge . # Tachycardia-Transient SVT: Noted in MICU for seconds and on [**7-27**] lasting approx 2 min which was associated with ambulation, diaphoresis and palpitations. Blood pressure remmained stable in this time and converted to normal sinus spontaneously before any intervention. On [**7-28**] he had another episode associated with bowel movement where his HR went to the 130's, however on telemetry it showed as sinus tachycardia. During this episode his vitals remained stable and he only complained of palpitations. We started metoprolol succinate, and monitored electrolytes. Medications on Admission: Ferrous Sulfate 325mg TID Metoprolool Succinate 100mg Daily Clonidine 0.2mg PO QHS Omeprazole 20mg Daily Zocor 40mg Daily Aspirin 325mg Daily Omega-3 Fatty Acids 1200mg Po Daily Metformin 1000mg PO BID Lisinopril 20/HCTZ 12.5mg Daily Glyburide 5mg po daily Furosemide 20mg Daily Symbicort 1 aer daily Albuteral inhaler 2 puffs QID Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO daily . 3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0* 4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation twice a day. 8. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: Two (2) Inhalation four times a day as needed for shortness of breath or wheezing. 9. Chlorthalidone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO three times a day. 12. Omega-3 Fatty Acids 1,250 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Diverticular bleed Aspiration Pneumonia Superventricular tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to care for you as your doctor. You were brought to the hospital because of bleeding from your colon and a pneumonia which you developed while at another hospital. The bleeding was treated at the other hospital with diverticular clipping. During this admission you experienced no further bleeding and were treated with antibiotics for your pneumonia. Your blood pressure was high so your medications were adjusted. . We made the following changes to your home medications list: Increased Lisinopril from 20 to 40mg Stopped hydrochlorthiazide. Started chlorthalidone for high blood pressure. Increased your Metoprolol Succinate from 100mg to 150mg daily Stopped clonidine. Stopped furosemide. Aspirine decreased from 325mg to 81mg. Please go over your medications with your primary care physician. We discontinued your Furosemide which you were on before. Please go over with your primary care physician if you should restart this medication. . Please weigh yourself daily and if you gain more than 3 pounds in one day contact your primary care physician. Followup Instructions: Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Location: [**Hospital **] MEDICAL ASSOCIATES Date: 3:30PM [**2188-8-7**] Address: [**Street Address(2) 75551**] [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 87435**] Phone: [**Telephone/Fax (1) 65542**] Fax: [**Telephone/Fax (1) 87436**] .

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12579, 12585

8544, 11004

277, 335

12698, 12698

3817, 8521

13949, 14313

3221, 3258

11385, 12556

12606, 12677

11030, 11362

12849, 13926

3273, 3798

2308, 2735

229, 239

363, 2288

12713, 12825

2757, 3046

3062, 3205

27,311

159,547

16745

Discharge summary

report

Admission Date: [**2144-1-29**] Discharge Date: [**2144-2-7**] Date of Birth: [**2077-7-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: Fevers, diarrhea, vomitting, bleeding AV fistula Major Surgical or Invasive Procedure: AV Fistulogram History of Present Illness: 66 year-old female with a history of ESRD on HD who presents with diarrhea until monday, vomiting x 3 days, and fever at presentation. She was unable to keep PO down for the past 3 days. After hemodialysis today, she developed bleeding from the fistula site. The bleeding was intractable and required clamping for 6 hours, which resulted in adequate hemostasis. She states that this has happened before when they stick her AV fistula distally rather than proximally. She was seen in the ED by transplant surgery who requested CT venogram to ensure that the fistula did not thrombose from the clamping. . Regarding her GI symptoms, patient noted diarrhea and nausea with vomiting 4 days. She had [**4-14**] loose bowel movements until Monday(normally has 0-1 well-formed daily) and 3-4 episodes of vomitting since. She also did complain of abdominal pain at the time. She says she ate "Cheese-Its" before this started. Denies any sick contacts. [**Name (NI) **] recent antibiotic use. Denies any diarrhea episodes today, and has not has a bowel movement because she has not eaten in 3 days. She skipped hemodialysis on Monday due to illness, but went on Tuesday for short course, and had a full session of dialysis on Wednesday, the day of admission. Says she has been hungry all day today but just has not eaten because she was in the ED. . In the ED, patient was noted to be febrile to 101. Blood cultures were sent, and no other data to suggest a localized source of infection, with unchanged chest x-ray. IV access was difficult, but was obtained with ultrasound guidance. Patient required femoral stick for lab draws. . ROS: The patient denies any weight change, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: IDDM2 (dx ~15 yrs ago), mult admissions for uncontrolled DM ESRD on hemodialysis (M, W, F) HTN Hypercholestolemia Social History: Lives with 18 yr old nephew in [**Location (un) 686**]; unemployed; Occasional ETOH. Never drugs. ~40 pack year hx, actively smoking [**7-19**] cigarettes per day. Occasionally sexually active with x-husband, no protection. 6 children. Seemingly very supportive family. Family History: father died of etoh-induced cirrhosis 64 y/o mother died of pna at 35 y/o grandmother had DM 5 siblings w/o DM Physical Exam: VS: Tm 102.6 Tc99.7 129/58 (129-135) 84 (72-84) 24 95%RA GEN: Overweight female, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry MM, OP Clear; no erythema, no exudate. no sinus tenderness NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, obese, NT, ND, +BS, no HSM, no masses EXT: + Charcot joint changes of ankles. + thrill and bruit over right arm AV fistula. No C/C/E, no palpable cords. NEURO: alert, oriented to person, place, and time. CN II - XII grossly intact. moves all 4 extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. no ulcer lesions between toes Pertinent Results: . LABS ON ADMISSION: [**2144-1-30**] 12:35AM BLOOD WBC-13.2 Hgb-10.0 Hct-32.2 Plt Ct-156 [**2144-1-30**] 12:35AM BLOOD Neuts-88.2 Bands-0 Lymphs-6.3 Monos-3.3 Eos-1.7 Baso-0.5 [**2144-1-30**] 12:35AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+ Macrocy-OCCASIONAL Microcy-2+ Polychr-NORMAL Ovalocy-1+ Tear Dr[**Last Name (STitle) 833**] [**2144-1-30**] 12:35AM BLOOD PT-14.7 PTT-30.2 INR(PT)-1.3 [**2144-1-30**] 12:35AM BLOOD Glucose-87 UreaN-15 Creat-4.1 Na-135 K-3.7 Cl-94 HCO3-33 [**2144-1-30**] 12:35AM BLOOD Albumin-2.8 Calcium-7.8 Phos-2.2 Mg-1.4 [**2144-1-30**] 12:35AM BLOOD Triglyc-176 HDL-25 CHOL/HD-4.6 LDLcalc-56 . IRON STUDIES [**2144-2-5**] 05:55AM BLOOD calTIBC-108 Ferritn-GREATER TH TRF-83 . LABS ON DISCHARGE [**2144-2-7**] 06:15AM BLOOD WBC-12.4 Hgb-7.9 Hct-27.1 Plt Ct-304 [**2144-2-7**] 06:15AM BLOOD Glucose-105 UreaN-23 Creat-5.4 Na-138 K-4.3 Cl-101 HCO3-25 [**2144-2-7**] 06:15AM BLOOD Calcium-7.9 Phos-4.5 Mg-2.1 . IMAGING [**2144-1-29**] CXR: IMPRESSION: No focal consolidation. . [**2144-1-30**] AV FISTULOGRAM: IMPRESSION: AV Fistulogram demonstrated 2 moderate stenoses within the graft, 1 outflow vein stenosis, and a severe stenosis at the venous anastomosis. All 4 were successfully dilated with 6-mm cutting and 8-mm regular PTA balloons. . [**2144-1-31**] BILATERAL LOWER EXTREMITY ULTRASOUND IMPRESSION: No deep vein thrombosis seen in either lower extremity. Edematous right calf subcutaneous tissues with no fluid collection. . [**2144-1-31**] UNILAT UP EXT VEINS US RIGHT No deep vein thrombosis identified in the right arm. No evidence of abscess. . [**2144-1-31**] PORTABLE ABDOMEN IMPRESSION: Normal study. Specifically, no evidence of obstruction. . [**2144-1-31**] CT HEAD W/O CONTRAST Limited examination by motion artifact, but no hemorrhage or mass effect. . [**2144-2-4**] CHEST (PA & LAT) FINDINGS: The PICC line has been removed. The heart continues to be moderately enlarged and there is pulmonary vascular redistribution with increased interstitial markings suggesting mild CHF. Otherwise there is no focal infiltrate. Brief Hospital Course: IMP: 66 year-old diabetic female with ESRD on HD who presenting with fevers, diarrhea, vomitting, and bleeding from fistula. . # Fever/Leukocytosis due to Lower Extremity Cellulitis: On the first day of admission, the patient had a fever to 102.5 which quickly resolved by that afternoon. The initial differential diagnosis included gastroenteritis, UTI, bacteremia/AV fistula infection, enteric pathogen vs c.diff, and pulmonary infection. She had a fistulogram performed which did not show any thrombosis. On the evening of HD2 ([**1-30**]), the pt became confused in the setting of T 103.5. Blood cultures were drawn. A urinalysis was sent, which looked infected, but there was not enough urine to send for culture since she does not make much urine. A chest x-ray was negative. Head CT was negative. Unilateral upper extremity U/S was checked at graft site and was negative for abscess. The patient had bilateral lower extremity swelling concerning for DVT vs. cellullitis. Bilateral lower extremity ultrasounds were checked and were negative for DVT. The patient was started on vancomycin and zosyn empirically. . Given persistent mental status changes as well as systolic blood pressures in the 90s (from baseline 110s-130s), the patient was transferred to the MICU on [**1-31**] for the possibility of emerging sepsis. In the MICU, the patient's blood pressure remained stable and came up to baseline with minimal IVF and without the need for pressors. The patient's mental status resolved. In the MICU the patient continued to spike temperatures as high as 101.3. Her WBC peaked at 20.7 yesterday. The patient was transferred to the regular floor and her fever curve trended down and normalized. Her WBC trended down as well. None of her culture data was revealing. The patient's GI symptoms resolved, though she had persistent warmth and swelling in her right lower extremity. Given this, the most likely source of the patient's infection was felt to be right lower extremity cellulitis. She was initially treated with a course of vancomycin and zosyn; however, zosyn was switced to ceftazadime which could be dosed with dialysis. She was discharged on a continued course of vancomycin IV and ceftazadime to be administered at dialysis to complete a 2 week course. . # Nausea/Vomiting due to Probable Gastroenteritis - This was felt to possibly be secondary to gastroenteritis. An abdominal film showed no evidence of obstruction. Her symptoms were controlled with anti-emetics and resolved in the MICU and she had no further occurences. At the time of discharge she tolerated POs without difficulty. . # Diarrhea: This resolved by the time of the patient's discharge from the MICU. C diff toxin was negative times two. . #. AV Fistula bleeding: On admission transplant surgery was consulted. An AV fistulogram on HD 2 demonstrated 2 areas of moderate stenoses, successfully dilated with PTA balloons. The patient was continued on ASA 325 mg daily given her history of AV fistula thrombosis. Renal had no difficulty accessing her AVF during HD; she has no further bleeding complications. . #. ESRD: The patient was placed on dialysis per renal and had no difficulty accessing her fistula. . #. Diabetes mellitus Type II Controlled with complications: The patient was continued on NPH and a regular insulin sliding scale. . #. Benign Hypertension: Because of the patient's relative hypotension as described above, the patient's home amlodipine and clonidine were stopped. She remained well controlled on metoprolol 12.5 [**Hospital1 **]. Dehydration secondary to gastroenteritis was thought to contribute to her hypotension which resolved with fluids. She was well-controlled on metoprolol tartrate solely during this hospitalization with maximum SBP 130-140s. Her metoprolol dosage was changed upon discharge; she was discharged on metoprolol succinate 25 mg daily. She became slightly hypertensive upon discharge (systolic BP in the 140s). She was instructed to begin her home amlodipine dosage upon discharge. She was told to restart usage of her clonidine patch in one week on discharge and to followup with her PCP regarding optimization of her blood pressure control. . #.Hypercholesterolemia: The patient was continued on pravastatin 20 mg daily. . # GERD: THe patient was continued on her daily famotidine. . # FEN: The patient was continued on a renal/diabetic diet. . # PPx: The patient was placed on Heparin SQ. . # Code: full code Medications on Admission: #. Insulin NPH 30 Units qAM #. Amlodipine 10mg PO DAILY #. Clonidine 0.2 mg/24 hr Patch qMonday #. Metoprolol Tartrate 50 mg po bid #. Pravastatin 20 mg PO DAILY #. Aspirin 325 mg PO DAILY #. Sevelamer 800 mg PO TID #. B-Complex with Vitamin C 1 tab po qday #. Folic Acid 1 mg PO DAILY #. Sodium Bicarbonate 650 mg PO DAILY #. Ascorbic Acid 500 mg PO DAILY #. Famotidine 20mg PO DAILY PRN #. Docusate Sodium 100 mg po bid Discharge Medications: 1. Ceftazidime-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) Intravenous QHD (each hemodialysis) for 1 weeks: Day one of antibiotics: [**1-31**]; planned 2 week course to be completed on [**2-13**]. 2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol): Day one of antibiotics: [**1-31**]; planned 2 week course to be completed on [**2-13**]. 9. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirty (30) units Subcutaneous every morning. 11. 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* Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: 1. Cellulitis 2. Gastroenteritis . Secondary diagnoses: Diabetes Renal failure Discharge Condition: Hemodyanically stable, afebrile. Discharge Instructions: You were admitted to [**Hospital3 **] [**Hospital 1225**] Medical Center with a fever which was likely due to an infection in your right leg called cellulitis. You have been treated with intravenous (IV) antibiotics while in the hospital; these will be continued at hemodialysis sessions to complete a two week course. All the antibiotics that you need will be given to you at hemodialysis. . Please keep all followup appointments as below. . Your blood pressure was low during the hospital admission but normalized upon discharge. You low blood pressure was thought to be due to dehydration and responded to fluids. You were likely dehydrated due to a gastrointestinal infection which resolved shortly after your admission. Some of your blood pressure medications were changed during this admission. The following changes were made in your medications: 1. Please take metoprolol 25mg daily. Note that this is a lower dosage than when you were admitted. 2. Please wait to apply the clonidine patch one week after discharge. . Otherwise, resume your all your home medications. . Please call your doctor or return to the emergency room if you experience chest pain, shortness of breath, dizziness, nausea, vomiting, diarrhea, or any other symptoms which are concerning to you. Followup Instructions: 1. Please followup with your PCP [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 11616**], MD, in [**2-12**] weeks of hospital discharge for followup. Dr. [**Last Name (STitle) 11616**] may be reached at [**Telephone/Fax (1) 7976**]. . 2. Please continue your regular outpatient hemodialysis schedule on Monday, Wednesday, and Friday.

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icd9cm

[ [ [] ] ]

[ "39.50", "39.95", "00.40", "88.49", "38.93" ]

icd9pcs

[ [ [] ] ]

11886, 11892

5774, 10235

363, 379

12034, 12069

3685, 3692

13400, 13760

2771, 2884

10708, 11863

11913, 11967

10261, 10685

12093, 13377

2899, 3666

11988, 12013

275, 325

407, 2330

3706, 5751

2352, 2467

2483, 2755

22,847

138,715

12192

Discharge summary

report

Admission Date: [**2194-10-6**] Discharge Date: [**2194-10-14**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 13386**] Chief Complaint: Delirium Major Surgical or Invasive Procedure: elective intubation for LP and MRI s/p extubation lumbar puncture History of Present Illness: Patient is an 81 year-old gentleman with past medical history including HTN who was referred to the Emergency Department by his PCP after contacting her with complaint of sudden loss of memory. Per report, patient was at his baseline state of health until noon, when his partner noted him to be sitting in a chair, confused. He was speaking in Portuguese, which was unusual as he generally communicates in English; speech was not slurred. He did not know his partner's name but was aware of his own name. No obvious facial droop, unilateral weakness, complaints of headache, gait unsteadiness during this time according to his partner. Episode lasted approximately 45 minutes, patient then returned to baseline without intervention. EMS was called, patient refused transport, and patient's partner brought him to [**Name (NI) **]. VS in ED at 3:37 PM were T 98.8; BP 234/114; HR 51; 95% RA. . In the ED, patient received hyralazine for his BP. Patient developed HA and was given morphine for pain control. He complaiend of itchign and was given benadryl 25mg IV and later Solumedrol 125mg IV for his rash?. Patient then became paranoid and combative, and was given total of 10mg Haldol. At 7 PM, patient spiked temp to 101.6. Neurology was consulted in ED, and they suspected mental state was secondary to medications, but given fever, there was some concern for underlying infectious process and recommended LP and MRI, with broad spectrum antibiotics coverage. Prior to transfer to ICU, he was given 2mg Versed. . Diagnostic studies included chem 10, UA, CBC, LFTs, cardiac enzymes, all of which were within normal limits. Serum tox screen was negative, and urine tox was positive for opiates (patient known to take oramorph) but otherwise negative. Head CT showed no evidence of intracranial hemorrhage; white matter disease and prior lacunar infarcts were unchanged. Past Medical History: 1. HTN 2. GERD 3. hyperlipidemia 4. arthritis (possibly RA) 5. h/o prostate CA s/p XRT and chronic pain 6. h/o colon CA s/p partial colectomy in [**2147**] Social History: Patient emigrated from [**Country 4194**] approximately 50 years ago. Homosexual male who lives with his partner, [**Name (NI) 3065**]. [**Name2 (NI) **] tobacco use. Occasional alcohol consumption. No illicit drugs. Family History: NC Physical Exam: VITALS: T 98.6; HR 88; BP 184/83; RR 20; 98% RA GEN: mildly agitated, follows commands, in restraints, responds to name and orients to voice HEENT: MMM. Sclerae anicteric. OP clear. NECK: No JVD. Supple CHEST: CTA B/L. HEART: Tachycardic, RRR. No MRG ABD: soft, NT/ND. +BS. No organomegaly EXT: Erythematous rash on R shoulder with area of central hyperpigmentation but no vesicles or crusted lesions. NEURO: Agitated, but re-orientable. Responds to name. Does not follow commands, likley [**1-16**] agitation. No myoclonus. Unable to test all reflexes, but biceps 2+. Unable to assess gait, strength, sensation, proprioception [**1-16**] cooperation issues. Pertinent Results: [**2194-10-6**] 09:28PM COMMENTS-GREEN TOP [**2194-10-6**] 09:28PM LACTATE-2.7* [**2194-10-6**] 07:42PM URINE HOURS-RANDOM [**2194-10-6**] 07:42PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2194-10-6**] 05:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2194-10-6**] 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-7.5 LEUK-NEG [**2194-10-6**] 04:15PM GLUCOSE-91 UREA N-24* CREAT-1.0 SODIUM-139 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-30 ANION GAP-12 [**2194-10-6**] 04:15PM ALT(SGPT)-15 AST(SGOT)-31 CK(CPK)-111 ALK PHOS-88 AMYLASE-88 TOT BILI-0.6 [**2194-10-6**] 04:15PM CK-MB-5 cTropnT-<0.01 [**2194-10-6**] 04:15PM ALBUMIN-4.4 CALCIUM-9.3 PHOSPHATE-3.3 MAGNESIUM-2.2 [**2194-10-6**] 04:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2194-10-6**] 04:15PM WBC-5.7 RBC-4.51* HGB-14.3 HCT-40.4 MCV-90 MCH-31.6 MCHC-35.3* RDW-13.4 [**2194-10-6**] 04:15PM NEUTS-62.2 LYMPHS-28.8 MONOS-3.1 EOS-5.4* BASOS-0.6 [**2194-10-6**] 04:15PM PLT COUNT-205 [**2194-10-6**] 04:15PM PT-12.4 PTT-27.2 INR(PT)-1.1 . CSF [**2194-10-7**] 2 WBC, 0 RBC 34 TotProt 91 Glucose Gram Stain negative Cryptococcal Ag negative . MRI IMPRESSION: 1. There is no change from [**2193-10-25**]. 2. No recent infarct is seen on the diffusion-weighted images. 3. There are fairly extensive microvascular changes in the cerebral white matter and there is an old right pontine infarct. . CT HEAD IMPRESSION: Stable appearance of the brain, without evidence of intracranial hemorrhage or acute territorial infarction by CT. Stable evidence of white matter hypodensity, suggestive of chronic small vessel ischemic disease, as well as prior small lacunar infarcts. . PORTABLE CXR: IMPRESSION: New medial biapical opacities which are nonspecific. Infection cannot be excluded. As this appearance could be seen in radiation pneumonitis, correlation with a history of radiation therapy is suggested. . Carotid dopplers: Brief Hospital Course: 81M with hx HTN p/w word-finding difficulty, hypertensive urgency, later developing agitation, ? headache, and fever. . # CONFUSION/AGITATION Initial presenting complaint was confusion (patient speaking in Portuguese) which resolved on arrival to ED. Patient later became combative in the ED and received several CNS-active medications including Benadryl, Morphone, Haldol, Versed, and Ativan. Head CT negative for acute bleed, but with possible area of encephalomalacia in the left sylvian fissure. Patient was covered broadly with Vancomycin, Ceftriaxone, Ampicillin, and Acyclovir for empiric meningitis treatment given ? headache and rash on arm. - LP negative for meningitis or encephalitis picture - Stroke on differential, MRI/MRA done which was negative for ischemic changes or encephalitic changes. - Neurology was consulted, initially thought findings were consistent with TIA but MRI/MRA not suggestive. Seizure moved higher on differential, symptoms at presentation could have been post-ictal state, EEG showed no epileptiform activity. - Patient's mental status improved significantly over 36 hours, and was communicating appropriately, AOx3 at time of discharge - Carotid dopplers showed <40% stenosis bilaterally - He will follow up with Neurology in clinic. . # FEVER - Source unclear; no localizing exam findings except rash on R arm/shoulder (which is several days old), but no weeping lesions or crusting to suggest infection. UA negative. Blood and urine cultures pending. CXR with [**Hospital1 **]-apical opacities which could be infection, but no pulmonary symptoms. No leukocytosis or bandemia. Empiric Vancomycin, Ceftriaxone, Ampicillin were discontinued once LP was negative. Acyclovir was continued empirically for VZV encephalitis. Fever could be acounted for by seizure, although EEG showed no epileptiform activity. . # HYPERTENSION - Patient is intermittently compliant with medications at home, and appears to live in 180s-190s at home based on OMR notes. Initially maintained BP < 180-200 and allowed autoregulation given concerns for stroke. Once MRI/MRA was negative, goal SBP of 160 was pursued. When it was determined that he did not have a stroke, we aggressively attempted to manage his BP, and it was eventually well-controlled on lisinopril 40 and atenolol 75 qd. Please titrate meds as necessary. . # RASH Not in dermatomal distribution suggestive of shingles. Patient with bilateral itching history, could be dermatitis secondary to pruritus. Given no other localizing source of infection, dermatology was consulted for assistance with rash and ? VZV/HSV. Suspicion for the latter was low. Derm felt it was [**1-16**] changes from scratching the area. The rash resolved during the admission. . # DEPRESSION - On Celexa as outpatient. This was held until his MS [**First Name (Titles) 4245**] [**Last Name (Titles) 38154**]d. . # GERD - On Prilosec at home, Protonix here . # Prostate Cancer - On Casodex, Lupron injections, Proscar as outpatient Medications on Admission: ASA 81 Casodex 50 daily Celexa 20 Calcium +D 600-125 Lupron q3 months Mirapex .125 hs prn MVI Nasonex Oramorph SR 15 daily Prilosec 20 Proscar 5 [**Hospital1 **] [**Last Name (un) **] Forte 500 [**Hospital1 **] B12 1000 qweek Zestril 20 daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 2. Mupirocin Calcium 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 3. Triamcinolone Acetonide 0.1 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 2 weeks. 4. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for pruritus. 5. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 6. Finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Atenolol 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY (Daily). 12. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed for cramping. 13. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 14. Ursodiol 300 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO BID (2 times a day). 15. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8 hours) as needed for abd pain. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Delirium, unknown etiology Discharge Condition: Stable. At cognitive baseline. Discharge Instructions: Please take all your medicines as prescribed. . Please return to the hospital if you experience fevers, chills, night sweats, vomiting, chest pain or shortness of breath. . Please keep all of your follow-up appointments. Followup Instructions: Please call [**Telephone/Fax (1) 541**] to make an appointment with Dr. [**Last Name (STitle) 20764**] in neurology as soon as possible. . Please make a follow-up appointment with your primary care doctor as soon as possible.

[ "530.81", "585.9", "437.2", "V10.05", "435.9", "403.90", "272.4", "692.9", "V10.46" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

10357, 10427

5451, 8441

273, 341

10498, 10531

3372, 5428

10800, 11029

2673, 2677

8735, 10334

10448, 10477

8467, 8712

10555, 10777

2692, 3353

225, 235

369, 2243

2265, 2423

2439, 2657

21,350

195,316

51276

Discharge summary

report

Admission Date: [**2164-11-15**] Discharge Date: [**2164-11-22**] Service: ACOVE DISCHARGE DIAGNOSIS: Cholangitis. CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year-old man with a history of sick sinus syndrome, cerebrovascular accident, hypertension who presented with epigastric and lower chest pain. The sensation was described as heavy, but was without shortness of breath, nausea, vomiting or radiation. The patient was ruled out for myocardial infarction and had a troponin peak of 15.4, but CKMB was within normal limits and cardiology reviewed the electrocardiogram concluding that it was not an myocardial infarction. Lumbar puncture was negative. Liver function tests were found to be negative with AST equalling 359, ALT equaling 258. The patient underwent endoscopic retrograde cholangiopancreatography, but became hypoxic and hypoventilated during the procedure. The procedure was aborted and the patient went to the Intensive Care Unit for monitoring and respiratory support on a nonrebreather mask. The patient was also found to be anemic with a hematocrit of 25.6 and so received 1 unit of packed red blood cells. The patient was found on chest x-ray to have pneumonia. Given both the cholangitis and the pneumonia the patient was started on Levaquin and Flagyl as well as Ampicillin. Subsequently the patient's vital signs remained stable and transferred to [**Hospital **] Medical Service for further medical management. PAST MEDICAL HISTORY: Cerebrovascular accident in [**2161**], atrial fibrillation on Coumadin and bradycardia status post pacer placement in [**2144**] as well as hypertension. FAMILY HISTORY: Notable for no coronary artery disease. SOCIAL HISTORY: No alcohol or tobacco. The patient is Bulgarian born. He speaks Bulgarian, Russian and English. ALLERGIES: No known drug allergies. OUTPATIENT MEDICATIONS: Metoprolol 25 mg po b.i.d., Coumadin 50 mg po t.i.d. taken on Monday, Wednesday and Friday and 12.5 mg taken on Sunday, Tuesday, Thursday and Saturday. HOSPITAL COURSE ON THE ACOVE SERVICE: The patient was medically managed. Bowel rest was obtained by having the patient first NPO and then on clears and thick liquids only as well as supportive management with intravenous fluid hydration prn and gentle diuresis to maintain fluid balance for maintaining clear lungs. Tachycardia was noted so the patient was put back on a beta blocker. The patient continued to improve clinically with decreased abdominal pain, normalized liver function tests. Blood cultures came back positive for Enterobacter cloacae that was Levaquin sensitivity, so Ampicillin and Flagyl were discontinued. The decision was made to then hold off repeating the endoscopic retrograde cholangiopancreatography for at least another month to allow the patient to recover and compensate and then to arrange an endoscopic retrograde cholangiopancreatography as an outpatient. The plan, therefore is to discharge the patient to a rehab facility and follow up endoscopic retrograde cholangiopancreatography in about a month. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg po q day for seven more days, net fourteen days treatment with weekly surveillance cultures for the next four weeks. 2. Coumadin 50 mg po q.h.s. on Monday, Wednesday and Friday and then 12.5 mg po q.h.s. on Sunday, Tuesday, Thursday and Saturday. INR should be checked daily starting on [**11-23**] and readjusting dosing with target INR goal of 2.5. Once the goal is reached INR should be checked at least weekly. 3. Tylenol 650 mg po q 6 hours prn. 4. Metoprolol 75 mg po b.i.d. 5. Furosemide 20 mg po q day. Potassium, BUN and creatinine should be checked every three to four days. Hold doses until values normalize if potassium level is replete. 4. Captopril 37.5 mg po t.i.d. holding for systolic blood pressures of less then 100. 5. Albuterol nebulizers one nebulizer every four hours prn. 6. Enoxaparin 50 mg subQ q 12 hours until INR is 12.5. 7. Protonix 40 mg po q day. DIET: Start with thick liquids and then advance as tolerated. DISCHARGE STATUS: The patient will be discharged at [**Location (un) 2716**] [**Last Name (un) **] in [**Location (un) 55**], telephone number [**Telephone/Fax (1) 106382**]. The patient has a follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on Tuesday [**1-8**], at 3:30 p.m., [**Hospital **] Clinic at 4:00 p.m. with Dr. [**Last Name (STitle) **]. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Last Name (NamePattern1) 8562**] MEDQUIST36 D: [**2164-11-22**] 14:18 T: [**2164-11-23**] 07:09 JOB#: [**Job Number 106383**]

[ "276.2", "402.91", "427.31", "507.0", "518.5", "411.89", "428.31", "790.7", "576.1" ]

icd9cm

[ [ [] ] ]

[ "03.31", "45.13" ]

icd9pcs

[ [ [] ] ]

1701, 1742

3142, 4767

112, 126

1921, 3118

144, 157

186, 1505

1528, 1684

1759, 1896

46,429

165,719

48594

Discharge summary

report

Admission Date: [**2151-10-10**] Discharge Date: [**2151-11-1**] Date of Birth: [**2069-12-16**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1390**] Chief Complaint: increased diarrhea Major Surgical or Invasive Procedure: Total abdominal colectomy and ileostomy History of Present Illness: 81 yoF who was admitted from nursing home [**10-10**] with UTI to medical service, and found to have a second bout of c-diff. Was doing well until this morning when urine output began to drop. She progressively became anuric and her creatinine increased from 0.8 to 1.6. Additionally her WBC rose from 12.8 to 21. No fevers. Patient is demented and her exam suffers because of this. She denies any pain at baseline. No SOB, chest pain. Past Medical History: - C Diff colitis -Alzheimer's dementia -CAD s/p LAD stent [**6-/2141**] & PTCA and beta brachytherapy of ISR [**12-15**] -CHF: severe systolic dysfxn with EF 25%, diastolic dysfxn, LVH ([**2149**]) -DM on insulin, last A1c 7.7 in [**9-20**] -HTN -Hyperlipidemia -Dementia -Urinary incontinence -PVD [**1-23**]: stenting of left popliteal artery stenoses, balloon angioplasty of left superficial femoral artery. [**7-24**]: R great toe amputation [**7-24**]: balloon angioplasty and stenting of R superficial femoral and popliteal arteries, completed 1 month Plavix and 10 days Augmentin Social History: She grew up in the [**Hospital3 4414**] of [**Location (un) 86**]. She is married, lives with her husband who is primary care giver. They have two grown daughters. She is a retired secretary. No tobacco use, no alcohol use, no drug use. Family History: Positive for diabetes and CAD. No family history of hypertension or malignancies. Physical Exam: VS: 98.2 142/61 90 20 96% on RA AAO x2, NAD but demented and affect blunted Tachycardic to 130's B/L rales distended, ?able guarding, tender, tympanitic + 2 edema B/L Pertinent Results: [**2151-10-10**] 12:15PM WBC-13.0*# RBC-3.27* HGB-11.6* HCT-34.5* MCV-105* MCH-35.5* MCHC-33.7 RDW-19.7* [**2151-10-10**] 12:15PM NEUTS-70 BANDS-3 LYMPHS-16* MONOS-8 EOS-0 BASOS-1 ATYPS-0 METAS-1* MYELOS-1* [**2151-10-10**] 12:15PM PLT SMR-NORMAL PLT COUNT-313 [**2151-10-10**] 12:15PM PT-12.0 PTT-19.9* INR(PT)-1.0 [**2151-10-10**] 12:15PM GLUCOSE-260* UREA N-28* CREAT-1.1 SODIUM-139 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-24 ANION GAP-19 [**2151-10-10**] 12:15PM ALT(SGPT)-21 AST(SGOT)-48* ALK PHOS-41 TOT BILI-0.9 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2151-10-29**] 09:45 13.1* 2.48* 8.6* 26.4* 107* 34.8* 32.6 22.0* 426 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos NRBC [**2151-10-29**] 09:45 87.6* 8.7* 3.2 0.2 0.3 125*1 14 0.5 134 4.6 105 23 11 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2151-10-24**] 07:40 15 44* 322* 1.8* OTHER ENZYMES & BILIRUBINS Lipase [**2151-10-21**] 05:05 34 CHEMS ADDED 2:52PM CPK ISOENZYMES CK-MB cTropnT proBNP [**2151-10-12**] 20:35 4 0.04*1 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2151-10-29**] 05:15 2.4* 2.3 PITUITARY TSH [**2151-10-12**] 08:10 5.8* TSH ADDED 3:39PM ANTIBIOTICS Vanco [**2151-10-15**] 04:26 12.5 [**2151-10-10**] CT Abd/pelvis : 1. Severe pancolitis in keeping with the history of underlying C. difficile colitis. No findings of pneumatosis or pneumoperitoneum. Mild-to-moderate amount of intra-abdominal pelvic ascites. 2. Dense atherosclerotic calcification without aneurysmal dilatation. 3. Small type 1 hiatal hernia. [**2151-10-13**] CXR : The right at least moderate-sized pneumothorax is seen after insertion of right central venous line with the tip terminates at the level of cavoatrial junction. The ET tube tip is 3.5 cm above the carina. Tube tip is in the stomach. There is no change in the cardiomediastinal silhouette. Subsequent studies have demonstrated a chest tube placement for the treatment of pneumothorax. Note is made of extensive amount of subcutaneous air that potentially may be related to insertion of the central line [**2151-10-22**]: cat scan of abdomen and pelvis: IMPRESSION: 1. Marked wall edema and mural hyperenhancement involving the [**Doctor Last Name **] pouch consistent with proctitis, presumably related to persistent C. difficile involvement, although other etiologies remain possible. 2. Moderate amount of simple ascites within the abdomen and pelvis. No organized or enhancing collection. 3. Interval development of moderate left and small right pleural effusion with regions of adjacent compression atelectasis. Small nonspecific pulmonary nodules may be infectious or inflammatory. 4. Interval worsening of diffuse soft tissue anasarca and marked subcutaneous emphysema involving the visualized lower chest wall and breasts [**2151-10-29**]: Chest x-ray: INDICATION: 81-year-old female with fever. Evaluate for pulmonary etiology. TECHNIQUE: AP portable upright chest radiograph from [**2151-10-27**]. FINDINGS: There is no relevant change compared to the prior radiograph. There is no focal consolidation. There are unchanged bilateral small pleural effusions. There is unchanged prominence of the ascending aorta and otherwise unremarkable cardiomediastinal silhouette. There are low lung volumes and the pulmonary vasculature is unremarkable. IMPRESSION: 1. No focal infiltrate. No relevant change from prior radiograph [**2151-10-21**]: Blood culture: no growth [**2151-10-22**] 12:50 pm STOOL CONSISTENCY: WATERY Source: Stool. **FINAL REPORT [**2151-10-23**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2151-10-23**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative) [**2151-10-12**] 8:35 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2151-10-14**]** MRSA SCREEN (Final [**2151-10-14**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS Brief Hospital Course: Mrs. [**Known lastname **] was admitted to the medical service for hyperglycemia and significant diarrhea while recovering in rehab post her right toe amputation. She was rehydrated and placed on antibiotics for a proteus UTI. She continued to have diarrhea, developed abdominal distention with an elevated WBC of 21K and became anuric with a creatinine of 2.1. An abdominal CT was done which demonstrated pan colitis prompting a surgical consult. She was transferred to the MICU for further management as she became hemodynamically unstable requiring fluid resuscitation, pressors and intubation. She was taken to the Operating Room on [**2151-10-13**] and underwent a total colectomy with ileostomy for toxic megacolon. She tolerated the procedure well and returned to the ICU in stable condition. She remained intubated and had a chest xray done for tube placement which demonstrated a large right pneumothorax prompting placement of a pigtail catheter. Unfortunately the right lung did not expand after pigtail placement and a regular chest tube was placed on [**2151-10-14**]. She was oxygenating well and subsequently able to be weaned and extubated from the ventilator later that day. Following transfer to the Surgical floor she continued to make good progress. Her ostomy was active and she gradually started a liquid diet. She was seen by the speech and swallow service for evaluation and seemed to have some trouble with aspirating thin liquids. She then remained NPO for another day and was reevaluated. This time there was no evidence of aspiration and she began soft solids and thin liquids and was progressing very well. After multiple water seal trials her chest tube was removed on [**2151-10-20**] and a post pull film showed a tiny apical pneumothorax which resolved the following day. She was oxygenating well on room air and remained free of any other pulmonary complications. Her renal function improved dramatically after surgery and her creatinine was back to baseline 48 hours post op. Her abdominal wound was healing well and her ostomy was pink and functioning well. Recommendations from the ostomy nurse can be found in the page 1 . Her staples were removed on [**11-1**]. Blood sugars were variable and she was initially covered with sliding scale insulin alone however, as her appetite improved her blood sugars were in the low 200 range. Her Humalog 75/25 was resumed at a lower dose on [**2151-10-21**]. She has required intermittent IV Lasix for failure on exam and by chest radiograph. Her home Lasix 20 mg po daily dose was restarted and eventually was increased to 40 mg daily. Her electrolytes have been followed closely, she had been noted to be slightly hyponatremic down to as low as 130; her last Na was 133 on day of discharge. She was transfused on [**10-30**] for a hemaotcrit of 24; post transfusion Hct on [**10-31**] was 27.4. She was evaluated by the Physical Therapy service as her mobility has markedly decreased from a few months ago when she was walking independently. She was screened by several rehab facilities and will likely be discharged to a skilled nursing facility once accepted. Medications on Admission: alendronate 70 mg qSat -donepezil 50 mg daily -Santyl 250 unit/gram Ointment -Econazole 1 % Cream apply to rash twice a day -Insulin Lispro Protam & Lispro [Humalog Mix 75-25] 28 units in am and 30 units before dinner -memantine 10 mg [**Hospital1 **] -metoprolol 25 mg [**Hospital1 **] -simvastatin 20 mg daily -ASA 650mg q6h prn -calcium carbonate - vit d3 - min 1 Tablet(s) by mouth twice a day -Loperamide [Imodium A-D] 2 mg by mouth daily x 5 days -furosemide 20mg daily -oxybutynin 10mg daily Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP < 110. 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 12. trazodone 50 mg Tablet Sig: 1/2-1 Tablet PO HS (at bedtime) as needed for insomina. 13. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous QID (4 times a day) as needed for CDiff for 1 days: Give per rectum. Please give enemas GENTLY as there is a new anastomosis . 14. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical three times a day: apply t oaffected areas as directed. Discharge Disposition: Extended Care Facility: [**Hospital 3137**] Care Center - [**Location (un) 1468**] Discharge Diagnosis: 1. Fulminant Clostridium difficile colitis. 2. Renal failure 3. Respiratory failure 4. Right pneumothorax 5. MRSA nasal swab positive 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: *DISCHARGE WITH SPECIAL NOTICE* Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-24**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at rehab on [**2151-10-27**] Monitoring Ostomy output/Prevention of Dehydration: *Keep well hydrated. *Replace fluid loss from ostomy daily. *Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. *Try to maintain ostomy output between 1000mL to 1500mL per day. *If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Followup Instructions: Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment in [**2-17**] weeks. You also have appoitnments withthe following providers that were made prior to this hospital stay: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2151-11-3**] 2:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2151-12-2**] 3:30 Completed by:[**2151-11-1**]

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icd9cm

[ [ [] ] ]

[ "45.82", "46.21", "34.04" ]

icd9pcs

[ [ [] ] ]

11287, 11372

6131, 9292

335, 377

11550, 11550

2018, 6108

14027, 14579

1731, 1814

9841, 11264

11393, 11529

9318, 9818

11726, 13216

13232, 14004

1829, 1999

277, 297

405, 849

11565, 11702

871, 1459

1475, 1715

7,999

144,083

21948

Discharge summary

report

Admission Date: [**2196-9-25**] Discharge Date: [**2196-9-29**] Date of Birth: [**2151-8-25**] Sex: M Service: TRA ADMISSION DIAGNOSIS: Status post attempted suicide by hanging. DISCHARGE DIAGNOSIS: Cardiac death, status post anoxic encephalopathy. HISTORY OF PRESENT ILLNESS: The patient was a 45-year-old gentleman who was found by his family after attempting to hang himself. EMS was activated and the patient was resuscitated, although he was found in PEA arrest. He was intubated at the scene and transported to [**Hospital1 346**] via Life Flight. Evidently, the patient had had a DUI charge and was pending a jail sentence and had attempted to hang himself earlier today. PAST MEDICAL HISTORY: Significant for depression and alcohol abuse. ALLERGIES: No known drug allergies. MEDICATIONS: None. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient was afebrile with stable hemodynamics. Setting of 100 percent on the ventilator machine. Neuro examination demonstrated no activity other than spontaneous breaths. Chest was clear to auscultation bilaterally. Cardiovascular showed regular rate and rhythm without murmur, rub, or gallop. Abdomen was soft, nontender, and nondistended. Extremities were warm and well perfused with 2 plus peripheral pulses. Although, the patient was resuscitated from his apneic and PEA state, he had imaging including a CT scan, which demonstrated essentially massive anoxic encephalopathy. The patient was supported with maximal medical therapy including Dilantin and mannitol to decrease intracranial pressures. Neurosurgical and neurology services were consulted upon the patient's arrival and deemed the patient essentially to be a nonoperative candidate and have a very poor prognosis and minimal chance for recovery. The patient was assessed for brain death using perfusion scan. The perfusion scan was not consistent with brain death. Hypercapnic apnea test was performed, but the patient did have spontaneous breaths over the ventilator machine. After extensive discussion with the patient's wife and family, decision was made to make the patient DNR and DNI. After further supportive care over the next couple of days, further discussions with the family led to making the patient comfort measures only. The [**Location (un) 511**] Organ Bank was involved and discussed with the patient possibility of organ donation. The patient's family agreed and the patient donated organs after cardiac death. Shortly after making the patient CMO, the patent expired at approximately 8 in the night on [**2196-9-29**]. [**Location (un) 511**] Organ Bank, [**Hospital1 69**] Admitting Office, and [**Hospital3 **] Examiners office were all contact[**Name (NI) **] according to the protocol. DISPOSITION: Death, organ donation after cardiac death. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13137**] Dictated By:[**Last Name (NamePattern1) 23688**] MEDQUIST36 D: [**2196-11-11**] 12:31:16 T: [**2196-11-12**] 06:53:39 Job#: [**Job Number 57486**]

[ "780.6", "786.06", "E953.0", "994.7", "348.1", "303.90", "311", "276.2" ]

icd9cm

[ [ [] ] ]

[ "93.96", "96.71", "38.91" ]

icd9pcs

[ [ [] ] ]

223, 274

158, 201

303, 709

874, 3114

732, 859

19,296

181,850

18923

Discharge summary

report

Admission Date: [**2155-5-27**] Discharge Date: [**2155-6-17**] Date of Birth: [**2080-11-20**] Sex: F Service: NEUROLOGY Allergies: Codeine / Tetracyclines / Aspirin Attending:[**First Name3 (LF) 5378**] Chief Complaint: weakness Major Surgical or Invasive Procedure: Right PICC line Sural nerve biopsy CT-guided liver biopsy Lumbar puncture History of Present Illness: The patient is a 74 yo R-handed woman with paroxysmal Afibb, CAD, and recently diagnosed adenoma of the ampulla of Vater, who was transferred from an OSH for further workup and management of weakness. The patient looks very tired when interviewed. She is not able to provide exact information with respect to time of onset and progression. Family is not available to provide further details. According to the patient, her symptoms started around the same time that she was diagnosed with her adenoma, which was at the end of [**Month (only) 547**]. Given her medical problems, she was not a suitable surgical candidate and a stent was placed. It not exactly clear, where she resided after this procedure. She was admitted to [**Hospital3 4107**] on [**5-19**] where she was diagnosed with constipation and diverticulitis. She says that the weakness progressed slowly over weeks. She felt tired all the time and she was told to rest some more. The weakness involved both sides evenly according to the patient. Her legs feel somewhat weaker than her arms. She is still able to comb her hair. Standing up and walking stairs was one of the first things that was difficult for her. Currently (according to the patient since about 3 weeks), she is not able to stand or walk on her own. She denies any tingling or numbness. She also says she has not been incontinent, with no urgency or frequency (but she does have a Foley in). She had a Bell's palsy on the R many years ago (when she gave birth to twins), but this seems to have become more prominent over the last weeks. Hospital course at OSH: [**Date range (1) 51738**]: afebrile; she had some abdominal pain thought to be due to diverticulitis and constipation. She has been on long term dicloxacillin for chronic osteomyelitis in her R-knee. The disease is not active. KUB: fecal impaction, no SBO; CXR: mild CHF; plain films knees: osteochondromatosis, no acute active disease. During the admission, her weakness was noted, but no clear etiology was found (MRI C- and spine). She does have a compression fracture of T11 vertebra, but no cord compression was seen. ROS: poor appetite since onset of her symptoms; denies any fever, chills, weight loss, visual changes, hearing changes, headache, neckpain, nausea, vomiting, dysphagia, chest pain, shortness of breath, abdominal pain, dysuria, hematuria, or bright red blood per rectum. No rash; no itch. No back or neckpain today. Appetite decreased. Past Medical History: - adenoma of the ampulla of Vater; cholangitis - s/p stent placement in biliary tract - MI, s/p CABG, 3 yrs ago? - CHF; EF 45% - hyperlipidemia - DVT - paroxismal Afibb - s/p bilateral knee replacements - s/p partial colon resection with recurrent strictures and adhesions - left ovarian surgery (reason?) - diverticulitis, resulting in intraabdominal abces - s/p cholecystectomy - osteomyelitis R-knee; long term Abx since 6 months - lumbar spinal stenosis, s/p spinal fusion L3-5 2 yrs ago - Bells palsy R-facial (when she gave Social History: Occupation: was a homemaker for many years; also did some office work. No travel outside USA. Smoking: no; EthOH: no; drug abuse: no. Level of activity: active prior to onset of disease Married: yes; children: 8 children, all healthy. No tick exposure. Family History: -CAD Physical Exam: VITALS: T97.9 HR76 BP145/58 RR12 sO298% GEN: tired HEENT: mmm, no sleral icterus NECK: no LAD; no carotid bruits; no paraspinal tenderness LUNGS: Clear to auscultation bilaterally HEART: Regular rate and rhythm, normal S1 and S2, soft systolic murmurs ABDOMEN: normal bowel sounds, soft, diffusely tender periumbilical and RLQ, nondistended. Liver not palpable. EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema; pulses +/+; R-knee not swollen or red. Both knees somewhat tender. Contractures of the Achilles tendons bilaterally. MENTAL STATUS: Awake and alert, cooperative with exam, normal affect; tired. Oriented to person, place, month, not day, and not date. Attention: DOWbw very slowly. Memory: Registration: [**3-7**] items; Recall [**1-7**] at 5 min. Language: fluent; repetition: intact; Naming intact for high frequency object; Comprehension intact; no dysarthria, no paraphasic errors. [**Location (un) **]: intact; Prosody: normal. No Apraxia. No Neglect. . CRANIAL NERVES: II: Patient did not have her glasses with her. Visual fields are full to confrontation, pupils equally round and reactive to light both directly and consensually, 4-->3 mm bilaterally. III, IV, VI: Extraocular movements intact without nystagmus. Fixation and saccades are normal. No ptosis. V: Facial sensation intact to light touch and pinprick. VII: Facial asymmetrical; R-facial droop. VIII: Hearing intact to finger rub bilaterally. IX: Palate elevates in midline. XII: Tongue protrudes in midline, no fasciculations; somewhat weaker upon moving it to the right. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. MOTOR SYSTEM: Decreased bulk in deltoids, interossei, lower extremities (distal), all bilaterally. No adventitious movements, no tremor, no clear asterixis. Tone in upper extremities normal. In lower extremities mildly increased R>L. R-leg exorotated. D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE Right 4 4 4 5- 5- 4+ 4 4- 4 4+ 4 4 3 3 3 Left 4 4 4 5- 5- 4 4 4- 4 4+ 4 4 4- 3 3 No pronator drift. No rebound. Neck flexors 4; neck extensors 5. No fasciculations tongue. Few fasciculations R-triceps. No muscle tenderness/myalgia. SENSORY SYSTEM: Sensory exam unreliable due to inattention. Sensation intact to light touch. Pin prick/temperature decreased distal to halfway the shines, vibration mildly decreased in both LE; proprioception mildely decreased in LE. Inconsistent repsonses throughout the sensory exam. REFLEXES: B T Br Pa Pl Right 2 1 1 0 1 Left 2 1 1 0 1 Grasp reflex absent; snout, glabellar, palmomental absent. Toes: mute bilaterally. COORDINATION: Normal FNF; [**Doctor First Name **] slow bilaterally; HTS unable. No dysmetria or pastpointing. GAIT: unable. Pertinent Results: RADIOLOGY Final Report MR CONTRAST GADOLIN [**2155-5-29**] 1:07 AM MR [**Name13 (STitle) **] W& W/O CONTRAST; MR CONTRAST GADOLIN Reason: MRI C-spine with contrast; signal abnormality; neoplastic pr Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with adenoma of pappilla of Vater; severe weakness with increased tone in LE; inattentive on exam REASON FOR THIS EXAMINATION: MRI C-spine with contrast; signal abnormality; neoplastic process MR CERVICAL SPINE WITHOUT AND WITH CONTRAST, [**2155-5-29**] HISTORY: Severe weakness and increased tone in lower extremities. Sagittal imaging was performed with long TR, long TE fast spin echo and short TR, short TE spin echo technique. Axial imaging was performed with long TR, long TE fast spin echo and with gradient echo technique. After administration of gadolinium intravenous contrast, sagittal short TR, short TE spin echo imaging was repeated. No prior cervical spine imaging studies are available for comparison. FINDINGS: Alignment of the cervical spine is normal. There is a focus of hyperintensity on the short TR images in the C6 vertebral body, perhaps reflecting focal fat deposition or a small hemangioma. Vertebral body signal intensity is otherwise normal. There are degenerative changes of the intervertebral discs with loss of signal and loss of height, most prominent from C4 through C7. There are small intervertebral osteophytes at C5-6 and C6-7. These narrow the spinal canal but do not appear to encroach upon the spinal cord. The axial images are severely degraded by motion artifact and are nondiagnostic. Specifically, I cannot evaluate the neural foramina on this examination. There is no abnormal enhancement after contrast administration. CONCLUSION: Limited study due to motion artifact. There is degenerative disc disease with mild encroachment on the spinal canal. The suboptimal study prevents evaluation of the neural foramina. There is no abnormal enhancement after contrast administration. RADIOLOGY Final Report MR [**Name13 (STitle) **] W &W/O CONTRAST [**2155-5-29**] 1:14 AM MR [**Name13 (STitle) **] W &W/O CONTRAST Reason: please with gad!!!! indication of carnomatous meningitis? Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with profound weakness; suspect paraneoplastic REASON FOR THIS EXAMINATION: please with gad!!!! indication of carnomatous meningitis? CONTRAINDICATIONS for IV CONTRAST: None. MRI THORACIC SPINE WITHOUT AND WITH CONTRAST, [**2155-5-29**]. HISTORY: Profound weakness. Is there paraneoplastic syndrome versus carcinomatous meningitis? Sagittal and axial imaging was performed with long TR, long TE fast spin echo and short TR, short TE spin echo technique. After administration of gadolinium intravenous contrast, sagittal short TR, short TE spin echo imaging was repeated. No prior thoracic spine imaging studies are available for comparison. FINDINGS: There is a wedged T11 vertebral body. This maintains high signal intensity on the short TR images suggesting that it is not acute. It is only faintly hyperintense on the long TR images. However, this may represent a subacute or chronic fracture. There is deformity of the posterior margin of the vertebral body with bone protruding into the spinal canal. However, this does not contact the spinal cord. There is no abnormal enhancement after contrast administration. Specifically, there are no imaging findings to suggest carcinomatous meningitis. CONCLUSION: Subacute to chronic T11 compression fracture. Degenerative changes. No evidence of carcinomatous meningitis. MR HEAD W & W/O CONTRAST [**2155-5-30**] 2:46 PM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Reason: ? intracranial neoplastic process? Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with pancreatic cancer; severe weakness; inattentive on exam. Rule out malignancy REASON FOR THIS EXAMINATION: ? intracranial neoplastic process? EXAM: MRI of brain and MRA of the head. CLINICAL INFORMATION: Patient with pancreatic cancer, severe weakness. Rule out malignancy or intracranial neoplastic process. TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were obtained before gadolinium. T1 axial, sagittal and coronal images were obtained following gadolinium. 3D time-of-flight MRA of the circle of [**Location (un) 431**] was acquired. FINDINGS: BRAIN MRI: The diffusion images demonstrate no evidence of slow diffusion to indicate acute infarct. There is mild prominence of ventricles and sulci. Mild periventricular hyperintensities indicate small vessel disease. There is no midline shift or hydrocephalus. Following gadolinium administration, no evidence of abnormal parenchymal, vascular or meningeal enhancement identified. Mild changes of small vessel disease are also seen within the brain stem. IMPRESSION: Mild changes of small vessel disease. No evidence of acute infarct. No enhancing brain lesions. MRA OF THE HEAD: Head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. The distal left vertebral artery appears to be ending in posterior inferior cerebellar artery, a normal variation. The MRA is slightly limited by motion. IMPRESSION: Slightly limited MRA of the head demonstrate no significant abnormalities. CT HEAD W/O CONTRAST [**2155-5-29**] 8:39 AM CT HEAD W/O CONTRAST Reason: Intracranial bleed? mass? [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with somnolence, fatigue; INR 5; REASON FOR THIS EXAMINATION: Intracranial bleed? mass? CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Somnolence, fatigue, high INR. COMPARISON: None. TECHNIQUE: Non-contrast axial head CT. FINDINGS: There is no evidence for intracranial hemorrhage. There is no mass effect or shift of normally midline structures. Periventricular white matter hypodensities as a sequelae of chronic small vessel infarction. There are bilateral lacunar infarcts within the basal ganglia. There is mild mucosal thickening of the visualized portions of the maxillary sinus. The mastoid air cells are well pneumatized. The osseous structures are unremarkable. IMPRESSION: No evidence for intracranial hemorrhage. Cytology Report SPINAL FLUID Procedure Date of [**2155-5-30**] REPORT APPROVED DATE: [**2155-6-4**] SPECIMEN RECEIVED: [**2155-6-3**] [**-6/2059**] SPINAL FLUID SPECIMEN DESCRIPTION: Received specimen in Cytolyt. Prepared 1 ThinPrep slide. CLINICAL DATA: 74 y/o woman with pancreatic adenocarcinoma, diffuse weakness and inability to walk x 6 weeks, concern for carcinomatous meningitis. PREVIOUS BIOPSIES: [**2155-4-28**] 06-[**Numeric Identifier 51739**] COMMON BILE DUCT BRUSHINGS . . . . . . . . . ................................................................ CSF CYTOLOGY REPORT TO: DR. [**First Name11 (Name Pattern1) 539**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 540**] DIAGNOSIS: CSF: NEGATIVE FOR MALIGNANT CELLS. . . . . . . . . . ................................................................ SURAL NERVE BIOPSY DIAGNOSIS: Preliminary neuropathologic diagnosis: -Peripheral nerve, with no evidence of vasculitis on H&E stained sections. -Special stains (Bodian, modified trichrome, iron, [**Country 7018**] red, one micron toluidine blue) and electron microscopy are pending and will be reported in an addendum. . . . . . . . . . ................................................................ RADIOLOGY Final Report CT CHEST W/CONTRAST [**2155-6-2**] 3:30 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: Please eval for any underlying occult malignancy Field of view: 36 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with new severe generalized weakness of unclear etiology REASON FOR THIS EXAMINATION: Please eval for any underlying occult malignancy CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 74-year-old female with severe generalized weakness. Rule out malignancy. COMPARISONS: No comparisons are available. TECHNIQUE: 64-MDCT axial images of the chest, abdomen and pelvis were obtained with IV contrast. Oral contrast was also administered. CT OF THE CHEST WITH IV CONTRAST: There is no significant axillary lymphadenopathy. There are small mediastinal lymph nodes that do not meet CT criteria for pathology. The largest lymph node measures 6 mm. The patient is status post median sternotomy and CABG. The right lobe of the thyroid is mildly enlarged and contains several nodules. The largest nodule measures 1 cm. Correlation with ultrasound could be performed. Examination of the lung windows demonstrate no lung nodules or masses. There are mild atelectatic changes of the lungs. CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: There are 2 hypodense areas within segment [**Doctor First Name 690**] of the liver that were not well characterized in this study. The largest one measures 2.0 x 1.6 cm (image2, 46). A smaller one measures 6 mm and is too small to characterize (image 2, 47). There is pneumobilia and dilatation of the intra and extra hepatic ducts. There is a stent within the biliary tree. Correlate with prior ERCP. The portal vein is patent. The spleen, adrenal glands are within normal limits. There is a small hypodense area in the upper pole of the right kidney measuring 6 mm and is too small to characterize. The left kidney is normal. The pancreatic duct is dilated measuring up to 7 mm. However, no definite pancreatic masses identified in this study. No obvious retroperitoneal lymphadenopathy is seen. CT OF THE PELVIS WITH ORAL AND IV CONTRAST: There are postoperative changes status post hernia repair in the right anterior pelvis. There is a Foley catheter within the urinary bladder. The uterus and adnexa are unremarkable. There is no free fluid in the pelvis. Moderate amount of stool in the colon and rectum. BONE WINDOWS: Patient is status post median sternotomy. The patient is also status post posterior fixation of the spine. No suspicious destructive lesions are seen. IMPRESSION: 1. Two hypodense liver lesions concerning for metastatic disease. This could be confirmed with ultrasound. 2. Biliary and pancreatic duct dilatation with a stent. No definite pancreatic mass is identified in this study. 3. Nodular thyroid with multiple nodules, the largest one measuring 10 mm. Ultrasound could be performed if indicated. 4. Diverticulosis, without evidence of diverticulitis. RADIOLOGY Final Report CT ABDOMEN W/CONTRAST [**2155-6-2**] 3:30 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: Please eval for any underlying occult malignancy Field of view: 36 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with new severe generalized weakness of unclear etiology REASON FOR THIS EXAMINATION: Please eval for any underlying occult malignancy CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 74-year-old female with severe generalized weakness. Rule out malignancy. COMPARISONS: No comparisons are available. TECHNIQUE: 64-MDCT axial images of the chest, abdomen and pelvis were obtained with IV contrast. Oral contrast was also administered. CT OF THE CHEST WITH IV CONTRAST: There is no significant axillary lymphadenopathy. There are small mediastinal lymph nodes that do not meet CT criteria for pathology. The largest lymph node measures 6 mm. The patient is status post median sternotomy and CABG. The right lobe of the thyroid is mildly enlarged and contains several nodules. The largest nodule measures 1 cm. Correlation with ultrasound could be performed. Examination of the lung windows demonstrate no lung nodules or masses. There are mild atelectatic changes of the lungs. CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: There are 2 hypodense areas within segment [**Doctor First Name 690**] of the liver that were not well characterized in this study. The largest one measures 2.0 x 1.6 cm (image2, 46). A smaller one measures 6 mm and is too small to characterize (image 2, 47). There is pneumobilia and dilatation of the intra and extra hepatic ducts. There is a stent within the biliary tree. Correlate with prior ERCP. The portal vein is patent. The spleen, adrenal glands are within normal limits. There is a small hypodense area in the upper pole of the right kidney measuring 6 mm and is too small to characterize. The left kidney is normal. The pancreatic duct is dilated measuring up to 7 mm. However, no definite pancreatic masses identified in this study. No obvious retroperitoneal lymphadenopathy is seen. CT OF THE PELVIS WITH ORAL AND IV CONTRAST: There are postoperative changes status post hernia repair in the right anterior pelvis. There is a Foley catheter within the urinary bladder. The uterus and adnexa are unremarkable. There is no free fluid in the pelvis. Moderate amount of stool in the colon and rectum. BONE WINDOWS: Patient is status post median sternotomy. The patient is also status post posterior fixation of the spine. No suspicious destructive lesions are seen. IMPRESSION: 1. Two hypodense liver lesions concerning for metastatic disease. This could be confirmed with ultrasound. 2. Biliary and pancreatic duct dilatation with a stent. No definite pancreatic mass is identified in this study. 3. Nodular thyroid with multiple nodules, the largest one measuring 10 mm. Ultrasound could be performed if indicated. 4. Diverticulosis, without evidence of diverticulitis. . . . . . . . . ................................................................ RADIOLOGY Final Report CT 150CC NONIONIC CONTRAST [**2155-6-11**] 5:54 PM CTA ABD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST Reason: please eval for pancreatic mass Field of view: 40 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with pancreatic mass, biopsied, suspected to be carcinoma-- for surgical eval? REASON FOR THIS EXAMINATION: please eval for pancreatic mass CONTRAINDICATIONS for IV CONTRAST: None. CLINICAL HISTORY: Patient with pancreatic mass that was biopsied and suspected to be carcinoma. Surgical evaluation for extent of disease and resectability. STUDY: Pancreatic CTA. TECHNIQUE: Axial multidetector CT of the abdomen was performed before and twice after the uneventful intravenous administration of 150 cc Optiray. Single pass through the pelvis was made after contrast administration. Axial and coronal reformats were made as well as 3D reformats. COMPARISON: [**2155-6-2**]. CT ABDOMEN WITHOUT AND WITH CONTRAST: There is atelectasis of the lung bases dependently, as before. No effusions. The two hypodense lesions within segment IV of the liver are unchanged in size and appearance. The larger lesion shows mild enhancement and may represnet focal hepatic edema from cholangitis or a metastatic focus. The smaller lesion is too small to characterize. No new liver lesions. Intrahepatic biliary ductal dilatation is unchanged as is pneumobilia. The extrahepatic bile ducts remain dilated to a similar extent down to the level of the distal intrapancreatic portion near the papilla where the extent is in unchanged position. No definite pancreatic mass is seen, though one is suspected with the common bile duct and pancreatic duct dilation. The pancreatic duct measures up to 11 mm in caliber within the body slightly less dilated in the tail. This appears mildly increased since the prior study. Within the pancreatic tail, there is a 5 mm round fluid attenuation lesion that could represent side branch IPMT or another pancreatic cystic lesion. The spleen, bilateral adrenal glands and bowel within the abdomen are normal in appearance. There are focal low attenuation lesions within the kidneys bilaterally that likely represent cysts. Otherwise, the kidneys appear normal. No lymphadenopathy within the abdomen by CT size criteria, though there are sub-cm lymph nodes within the portacaval space and retroperitoneum. There is descending colon and sigmoid diverticulosis without evidence of acute diverticulitis. BONE WINDOWS: There is an old compression fracture at T11 with focal kyphosis. There is L3- L5 fusion, as before. There is grade I-II anterolisthesis of L4 on L5, as before. No suspicious lytic or sclerotic bone lesions. IMPRESSION: 1) No pancreatic mass seen, though one is suspected with the biliary and pancreatic duct dilation. The pancreatic duct dilation is slightly increased from the prior study with unchanged biliary duct dilation with stent in place. 2) Two hypodense liver lesions within segment 4, with the larger 2 cm lesion showing mild enhancement. This raises the question that this is a metastasis, though edema from cholangitis is a consideration. Even though the biopsy was negative, a short term follow up of this lesion is recommended in [**4-10**] weeks to assess for interval change in case there was biopsy sampling error. . . . . . . . . . ................................................................ RADIOLOGY Final Report C1769 GUID WIRES INCL INF [**2155-6-3**] 7:41 AM Reason: Please place PICC, already eval by PICC nursing [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with generalized weakness, w/u in progress REASON FOR THIS EXAMINATION: Please place PICC, already eval by PICC nursing INDICATION: 74y/o female with generalized weakness of unclear [**Name2 (NI) 51740**]. The patient requires IV for medications. RADIOLOGISTS: This procedure was performed by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 380**]. Dr. [**Last Name (STitle) 380**], the attending radiologist, was present during the entire procedure supervising. PROCEDURE/FINDINGS: The patient was brought to the angiography table and placed in supine position. The right upper arm was prepped and draped in the standard sterile fashion. Since no suitable superficial veins were available, ultrasound was used for location of a suitable vein. The right brachial vein was patent and compressible. Under ultrasonographic guidance, the right brachial vein was entered using a micropuncture sheath. Under fluoroscopic guidance, a 0.018 guide wire was advanced into the SVC. Hard copy ultrasound images were obtained before and after venous access documenting vessel patency. Based on the markers on the guide wire, it was decided that the length of 36 cm would be suitable. The PICC line was then trimmed to length and advanced over a 4 French introducer sheath under fluoroscopic guidance. The tip of the line was placed in the superior SVC just above the right atrium. A final chest x- ray was obtained and demonstrated good position of the catheter. The line was flushed and secured to the skin with a StatLock device. IMPRESSION: Successful placement of 36 cm double lumen PICC line with the tip in the superior vena cava just above the right atrium. The line is ready for use. . . . . ................................................................ RADIOLOGY Final Report THYROID U.S. [**2155-6-4**] 1:42 PM THYROID U.S. Reason: BIOPSY/PT HAD CT THAT SHOWED THYROID NODULES [**Hospital 93**] MEDICAL CONDITION: 74 year old woman with thyroid nodules. REASON FOR THIS EXAMINATION: Biopsy? INDICATION: 74-year-old with thyroid nodules. No prior studies for comparison. THYROID ULTRASOUND: The right lobe measures 2.1 x 2.4 x 5.3 cm. The left lobe measures 1.9 x 2.1 x 5.3 cm. Both lobes are heterogeneous with multiple masses. There is a large 1.2 x 1.0 x 1.4 cm right colloid cyst. There is a dominant 1.1 x 1.0 x 2.1 cm heterogeneous nodule in the mid pole of the left lobe. IMPRESSION: Multinodular goiter. Procedure date Tissue received Report Date Diagnosed by [**2155-6-4**] [**2155-6-4**] [**2155-6-9**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/kg Previous biopsies: [**Numeric Identifier 51741**] GI BX 1: DISTAL. Liver Biopsy Results DIAGNOSIS: Liver, needle core biopsy: 1. Focal mild portal mononuclear cell inflammation, see note 2. Rare atypical degenerated cell of uncertain significance. 3. No steatosis or increased fibrosis (on trichrome stain). 4. No iron deposition on iron stain. Neurophysiology REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 539**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 540**] CLINICAL HISTORY: 74-year-old woman with a diagnosis of adenoma of the papilla of Vater 2 months ago. Since that time, she has had progressive weakness of her legs greater than her arms. She has been unable to walk or get out of bed for approximately 2 weeks. She does not report any arm weakness. She has not noted any diplopia, dysarthria, dysphagia, or dyspnea. She has not had difficulty with bowel or bladder. She has no pain or sensory loss. Directed neurological examination shows moderate wasting of distal muscles in the lower extremities. Muscle tone is decreased. There is mild-to-moderate proximal and distal weakness in bilateral upper extremities, worse in the left arm than the right arm. There is moderate-to-severe weakness in bilateral lower extremities, both proximally and distally. Reflexes are preserved in bilateral upper extremities and decreased at the knees and ankles. Toes are downgoing. Sensation is preserved throughout. This study was requested to evaluate for [**Location (un) **]-[**Location (un) **] myasthenic syndrome, myopathy, and motor neuron disease. FINDINGS: Motor nerve conduction studies (NCSs) of the left ulnar nerve were normal, including F responses. Motor NCSs of the left tibial nerve showed mild-to-moderate prolongation of distal latency, increased temporal dispersion, moderately reduced response amplitudes, and normal conduction velocity. Left tibial F responses were absent. . Neurophysiology Report EMG Study Date of [**2155-6-6**] REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CLINICAL HISTORY: 74-year-old woman with a diagnosis of adenoma of the ampulla of Vater 2 months ago. Since that time, she has had progressive weakness of her legs greater than her arms. She has been unable to walk or get out of bed for approximately 3 weeks. She does not report any arm weakness. She has not noted any diplopia, dysarthria, dysphagia, or dyspnea. She has not had difficulty with bowel or bladder. She reports pain in both legs, which has improved since her hospital admission. She does not report sensory loss. Directed neurological examination shows moderate wasting of distal muscles in the lower extremities. Muscle tone is decreased. There is mild-to-moderate proximal and distal weakness in bilateral upper extremities, worse in the left arm than the right arm. There is moderate-to-severe weakness in bilateral lower extremities, both proximally and distally. She has bilateral foot drops, worse on the right than the left. Reflexes are decreased in bilateral upper extremities and absent at the knees and ankles. Toes are downgoing. Sensation is reduced to large and small-fiber modalities distally in the legs. This study was requested to evaluate for polyneuropathy and motor neuron disease. FINDINGS: Motor NCSs of the left median nerve showed borderline normal response amplitude, mildly reduced conduction velocity, and normal F responses. Motor NCSs of the left ulnar nerve showed mildly reduced response amplitude and mildly reduced conduction velocities. Left ulnar F responses were normal. Motor NCSs of the left deep peroneal nerve showed normal distal latency, moderately reduced response amplitudes, normal conduction velocity in the leg, and markedly reduced conduction velocity across the fibular neck. Motor NCSs of the right deep peroneal nerve showed moderately reduced response amplitudes and markedly reduced conduction velocities. Motor nerve conduction studies (NCSs) of the left tibial nerve showed normal distal latency, markedly reduced response amplitudes, and mildly reduced conduction velocity. Motor NCSs of the right tibial nerve showed moderately prolonged distal latency, moderately reduced response amplitudes, and moderately reduced conduction velocity. Motor NCSs of the left common peroneal nerve recording tibialis anterior showed moderately reduced response amplitudes and normal conduction velocity. Ten seconds of exercise failed to produce an incremental response upon stimulation of the left deep peroneal nerve. Sensory responses of bilateral sural nerves were absent. Sensory NCS of the left ulnar nerve showed normal response amplitude and mildly reduced conduction velocity. Concentric needle electromyography (EMG) of selected muscles representing the left L2-S1 myotomes was performed. There was marked, ongoing denervation in tibialis anterior with moderate polyphasia and poor activation. EMG of left gastrocnemius and long head of biceps femoris was normal with the exception of fair activation. EMG of vastus lateralis showed poor activation of long duration, markedly polyphasic units. EMG of gluteus medius showed mild, ongoing denervation with poor activation. EMG of iliopsoas showed mild, ongoing denervation with moderately polyphasic units. EMG of right tibialis anterior showed marked, ongoing denervation with fair activation and markedly reduced recruitment. EMG of left first dorsal interosseous showed moderate, ongoing denervation with fair activation. EMG of left triceps showed mild polyphasia and slightly reduced recruitment. EMG of left deltoid was normal. EMG was terminated prematurely at the patient's request. IMPRESSION: Complex, abnormal study. The electrophysiologic findings are most consistent with a moderately severe, subacute (between 3 weeks and 3 months duration) neurogenic disorder, which is motor > sensory and non-length dependent in distribution. This is a predominantly axonal process, with minor demyelinating features, not suggestive of an acute, acquired demyelinating polyradiculoneuropathy. Similar to the study of [**2155-5-28**], activation is fair to poor throughout, suggesting a central nervous system contribution to the patient's weakness. Compared with this prior study, there has been progression of the neurogenic process. [**2155-5-27**] 09:45PM %HbA1c-6.4* [Hgb]-DONE [A1c]-DONE [**2155-5-27**] 09:45PM HOMOCYSTN-13.3* [**2155-5-27**] 09:45PM TSH-2.5 Brief Hospital Course: The patient is a 74 yo R-handed woman with paroxysmal Afibb, CAD, CHF, chronic osteomylelitis of the R-knee and recently diagnosed adenoma of the ampulla of Vater, who was transferred from an OSH for further workup and management of weakness. Her weakness started around the time that her adenoma was diagnosed, and slowly progressed. It involved lower somewhat more than her upper extremities. On exam, she is somewhat inattentive. Her strength is decreased distally as well as proximally. Neck flexors are weak as well. In addition, PP, vibration sense and proprioception was decreased, but this part of the exam was limited due to inattention and not reliable. The tone in her LE was increased, especially on the R. DTR were present. Few fasciculation R-triceps (not in tongue). She already has shortening of the achilles tendons due to her weakness. DDx: ALS, polyradiculopathy; paraneoplastic #. Neuro: MRI head, C/T spine showed no evidence of disease aside from some small vessel changes and some degenrative bony changes. EMG most consistent with a moderately severe, subacute (between 3 weeks and 3 months duration) neurogenic disorder, which is motor > sensory and non-length dependent in distribution. This is a predominantly axonal process, with minor demyelinating features, not suggestive of an acute, acquired demyelinating polyradiculoneuropathy (e.g. not [**Last Name (un) 4584**]-[**Location (un) **]). A sural nerve biopsy was recommended and performed by neurosurgery. Sural nerve biopsy showed no pathological feature. [**Country 7018**] red staining and electon microscopy are pending. CSF and liver cytology negative. The patient's weakness has thus, not been diagnosed, yet. There are features of her weakness consistent with both peripheral and central involvement and while a paraneoplastic process is still suspected, there is no objective evidence for this diagnosis. Oncologic workup hs yielded only suggestive evidence of malignancy (pancreatic duct dilatation). Mononeuritis multiplex has also been suggested. The team elected not to empirically treat the patient with steroids, without a clear diagnosis and with clinical improvement in the absence of treatment. . #. Pulm: NIF and VC were monitored. SHe required BiPAP for a few days but her NIFs steadily improved and then normalized without acute intervention. . #. CV: Pt has history of PAF, has been maintained on coumadin as an outpatient. Reversed on admission for LP. Has now been maintained on heparin gtt given possible need for further procedures. Antihypertensive regimen continued per outpatient regimen. Currently on heparin drip, coumadin started [**2155-6-17**]. Goal INR [**2-7**]. Goal PTT in interim 40-60 prior to achieving therapeutic INR. Last PTT 41.1. . #. GI/Oncologic: Pt with mildly elevated amylase and lipase after her biliary stent placement. CT abdomen performed earlier this admission, with evidence of 2 hypodense foci, may be c/w metastasis. Case discussed with Dr. [**Last Name (STitle) **]. Patient underwent CT-guided biopsy of lesion. Pathology was unrevealing, not demonstrating malignancy. Pathology: 1. Focal mild portal mononuclear cell inflammation, see note. 2. Rare atypical degenerated cell of uncertain significance. 3. No steatosis or increased fibrosis (on trichrome stain). 4. No iron deposition on iron stain. UPEP: negative for Bence-[**Doctor Last Name **] protein. CEA 1.4 (normal) Pt continued on pancrease. She is tolerating an oral diet. s/p hepatic bx [**2155-6-4**] - pathology shows normal liver. s/p ampulla bx [**4-10**] - adenoma . #. Endo: adequate blood sugar control on current regimen. Will continue for now. -- FSBS, ISS . #. Chronic osteomyelitis: Pt with chronic osteo of the knee s/p TKR. Now on chronic suppression therapy with dicloxacillin. -- continue dicloxacillin 500mg PO BID . #. Proph: -- bowel regimen. Pepcid as above for GI ppx. . #. FEN: Pt appears euvolemic on exam this AM. -- Regular DM diet -- Replete K PRN Medications on Admission: - coumadin 5 mg daily - lipitor 10mg daily - pepcid 20mg [**Hospital1 **] - colace 100mg [**Hospital1 **] - MOM PRN - pancrease one caps with meals; one qHS - nysstatin Swish and swallo 4 times daily - dicloxacillin 500mg [**Hospital1 **] - lactulose 30ml PRN daily - mycolog II triamcenolone apply to lower back - tylenol PRN - lopressor 25mg [**Hospital1 **] PO - flonase 2 sprays at bedtime Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:*100 ML(s)* Refills:*0* 3. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day (with meals and at bedtime)). Disp:*120 Cap(s)* Refills:*2* 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. Disp:*100 ML(s)* Refills:*0* 5. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. Disp:*1 tube* Refills:*0* 6. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal QHS (once a day (at bedtime)). Disp:*1 MDI* Refills:*2* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for high homocysteine. Disp:*30 Tablet(s)* Refills:*0* 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 11. Polyethylene Glycol 3350 17 g (100%) Packet Sig: One (1) Packet PO daily (). Disp:*30 Packet(s)* Refills:*2* 12. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp:*50 Tablet, Chewable(s)* Refills:*0* 14. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 15. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: Nine Hundred (900) units Intravenous ASDIR (AS DIRECTED): Please use with PTT goal 40-60 until INR [**2-7**] on coumadin. Disp:*1000 units* Refills:*2* 16. Dicloxacillin 250 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Weakness Mixed Peripheral Neuropathy ?Myelopathy Dilatated Common [**Last Name (un) **] Duct s/p stenting Hepatic adenomas Hyperhomocysteneimia Atrial Fibrillation Diverticulosis Chronic Osteomyelitis Discharge Condition: Stable Discharge Instructions: Please take your medications If you develop severe chest pain, difficulty breathing, new weakness or numbness, trouble swallowing or speaking, please [**Name6 (MD) 138**] your MD or report to the ED Followup Instructions: Provider: [**Name Initial (NameIs) **]/[**Last Name (NamePattern4) 11683**], MD Phone:[**Telephone/Fax (1) 558**] Date/Time:[**2155-7-14**] 9:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**]

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31,586

102,261

1858

Discharge summary

report

Admission Date: [**2134-9-20**] Discharge Date: [**2134-9-24**] Date of Birth: [**2066-10-21**] Sex: F Service: MEDICINE Allergies: Compazine / Phenobarbital Attending:[**First Name3 (LF) 2704**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Cardiac Catheterization with Stent placement History of Present Illness: Ms. [**Known lastname 7518**] is a 67 year old woman with known CAD who presented to [**Hospital3 10377**] Hospital on [**2134-9-14**] with worsening shortness of breath x 2 days. At time of presentation, her HR was 120, RR 30's, and BP 210/136. She had a CXR and elevated BNP of 660, felt to be consistent with congestive heart failure. She received Lasix 60 mg IV and was started on a nitroglycerin drip as well as NIPPV. Patient ruled in for an NSTEMI at OSH with troponin increase from 0.12 to 3.4. Cardiac cath was receommended at this time, but the patient refused. Patient agreed to a Myoview stress test, which demonstrated an apical myocardial defect with an EF of 28%. No c/o chest pain or dyspnea. Hospital course was complicated by UTI for which she has been treated with Levofloxacin since [**9-15**]. . In cath lab, all vein grafts from her CABG were down. Patient's left subclavian was occluded. LIMA was attempted to be reached via right brachial then right radial approach. 2 stents were deployed to right subclavian, proximal and distal. Catheter perforated branch of left radial artery. Heparin was stopped. While arm was being compressed, patient became bradycardic to 30's, BP unknown. CPR was initiated x 20 seconds. Atropine was given and heart rate to 150's. Hand Surgery was consulted for perforation of radial artery. . Pt was transfered to the floor on [**9-21**]. She underwent an additional cardiac cath on [**9-22**] with placement of 5 stents. Past Medical History: 1) CAD s/p 4-V CABG at [**Hospital1 18**] in [**2125**], with LIMA to the LAD, SVG sequential to [**Last Name (LF) **], [**First Name3 (LF) **], SVG to PDA. 2) Hypertension 3) Hyperlipidemia 4) PVD 5) s/p right carotid endarterectomy [**10-10**] 6) s/p right carotid stent in [**6-/2134**] 7) TIAs due to r/t left carotid occlusion (Patient has known occlusion of left internal carotid artery intracranially at the level of the opthalmic artery, and she has had multiple TIAs from this occlusion. Patient develops TIAs when her BP becomes too low, and thus she requires SBPs ~130s to maintain perfusion. Patient is on Florinef due to low BP causing TIA symptoms r/t carotid occlusion and CHF was felt to be related to the Florinef.) 8) [**3-12**] intracranial hemorrhage [**3-12**] while on asa, plavix and coumadin (coumadin subsequently stopped) 9) Diabetes 10) Peripheral neuropathy Social History: Patient lives with her husband. She has a 40 pack-year smoking history, and she quit in [**2125**]. Patient drinks alcohol occasionally. Family History: Patient has five surviving children. Two of her sons have diabetes. Brother died of CAD in his 50s. One of her sisters has DM2. Father died in his mid-70s from alcoholic cirrhosis. Mother was diabetic and died in her mid-50s. Physical Exam: VS: T 97.6, BP 144/72, HR 93, SpO2 97% on RA Gen: WDWN elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple without JVD. 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 in supine position, no accessory muscle use. Trace basilar crackles. No wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: Ecchomyosis over Left wrist with palpable radial pulse from mid forearm. Ulnar pulse present. Slight edema. Left hand warm with 3 second capillary refill in all digits. No c/c/e. No femoral hematomas. Stable Right femoral bruit present prior to cath. warm extremities Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT nonattainable with doppler Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [**2134-9-20**] 12:45PM HGB-11.5* calcHCT-35 O2 SAT-98 [**2134-9-20**] 06:17PM WBC-10.4 RBC-4.04* HGB-10.8* HCT-33.3* MCV-83# MCH-26.7*# MCHC-32.3 RDW-13.9 [**2134-9-20**] 06:17PM BLOOD WBC-10.4 RBC-4.04* Hgb-10.8* Hct-33.3* MCV-83# MCH-26.7*# MCHC-32.3 RDW-13.9 Plt Ct-231 [**2134-9-24**] 09:15AM BLOOD WBC-9.3 RBC-3.41* Hgb-9.2* Hct-28.4* MCV-83 MCH-27.0 MCHC-32.4 RDW-13.9 Plt Ct-229 [**2134-9-23**] 06:15AM BLOOD PT-14.1* PTT-27.9 INR(PT)-1.2* [**2134-9-23**] 06:15AM BLOOD Plt Ct-222 [**2134-9-24**] 09:15AM BLOOD Plt Ct-229 [**2134-9-20**] 06:17PM BLOOD PT-15.5* PTT-33.7 INR(PT)-1.4* [**2134-9-20**] 06:17PM BLOOD Plt Ct-231 [**2134-9-24**] 09:15AM BLOOD Glucose-272* UreaN-18 Creat-0.8 Na-139 K-4.0 Cl-102 HCO3-29 AnGap-12 [**2134-9-20**] 06:17PM BLOOD Glucose-235* UreaN-27* Creat-0.9 Na-138 K-3.5 Cl-97 HCO3-33* AnGap-12 [**2134-9-20**] 10:38PM BLOOD CK(CPK)-18* [**2134-9-21**] 05:44AM BLOOD CK(CPK)-26 [**2134-9-22**] 05:43PM BLOOD CK(CPK)-40 [**2134-9-23**] 06:15AM BLOOD CK(CPK)-219* [**2134-9-23**] 03:52PM BLOOD CK(CPK)-175* [**2134-9-20**] 10:38PM BLOOD CK-MB-NotDone cTropnT-0.18* [**2134-9-21**] 05:44AM BLOOD CK-MB-3 cTropnT-0.26* [**2134-9-22**] 05:43PM BLOOD CK-MB-NotDone [**2134-9-23**] 06:15AM BLOOD CK-MB-26* MB Indx-11.9* [**2134-9-23**] 03:52PM BLOOD CK-MB-17* MB Indx-9.7* [**2134-9-23**] 06:15AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 [**2134-9-24**] 09:15AM BLOOD Mg-2.3 [**2134-9-20**] 12:45PM BLOOD Type-ART pO2-125* pCO2-46* pH-7.45 calTCO2-33* Base XS-7 . [**9-21**] Urine cult no growth . [**9-20**] Cath: 1. Selective coronary angiography of this right dominant system revealed severe diffuse coronary artery disease. The LMCA had diffuse calcification. The LAD was diffusely diseased, and was occluded mid segment. The LCx had severe diffuse disease with a 90% stenosis of the OM. The RCA was a dominant vessle with severe diffuse disease througout. 2. Coronary angiography of the bypass grafts revealed an occluded SVG to D1 and an occluded SVG to RPDA. The LIMA to LAD graft was patent. 3. The left subclavian artery was occluded proximal to the LIMA. 4. Resting hemodynamics were performed. The right sided filling pressures were normal (Mean RA pressure was 5 mm Hg and RVEDP was 7 mm Hg). The pulmonary atery pressures were within the normal range, measuring 30/9 mm Hg. The left sided pressures were normal, with a mean PCW pressure of 12 mm Hg. The systemic arterial pressures were elevated with a systolic pressure of 150-170mm Hg. The cardiac index was calculated using FIck's principle with an assumed oxygen consumption index of 125 ml O2/min/m2, and was mildly decreased at 2.2 L/min/m2. 5. Left ventriculography revealed a depressed ejection fraction of 36%. There was no gradient across the aorta on pullback of the catheter from the left ventricular into the ascending aorta. 6. Successful PTA and stenting of the left subclavian artery with two overlapping stents. Final angiography revealed 0% residual stenosis and normal LIMA flow. 7. Arterial extravasation at the forearm without hand ischemia. Normal radial and ulnar pulses and no evidence of compartment syndrome. FINAL DIAGNOSIS: 1. Diffuse three vessel coronary artery disease with occluded SVG to D1, occluded SVG to RPDA and patent LIMA to LAD 2. Left subclavian artery occlusion with PTA/stent x 2. 3. Systolic ventricular dysfunction with a depressed ejection fraction of 36%. 4. Successful stenting of the left subclavian artery with two overlapping stents and normal LIMA flow. . Cardiac cath [**9-22**]: COMMENTS: 1. Selective angiography of the left subclavian demonstrated two widely patent stents with normal flow throughout. Angiography of the left upper extremity demonstrated a an ulnar artery that filled the left hand and backfilled the proximal portion of the occluded radial artery. 2. Selective angiography of the native coronary arteries demonstrated diffusely diseased three (3) vessel disease. The left anterior descending artery was occluded proximally and was known to fill by a patent LIMA-LAD graft. The right coronary artery was diffusely diseased with a tight 95% proximal - ostial lesion. The left circumflex demonstrated a diffusely diseased artery with a 99% lesion in the second obtuse marginal. 3. We did engage the saphenous vein grafts - the graft to the RCA was known to be occluded and the graft to the LCX was also known to be occluded proximally. 4. Successful PTCA and stenting of the 2nd obtuse marginal from the site of the SVG anastomosis to the bifurcation with the native LCX proximally with three overlapping Xience drug eluting stents (2.5x12mm; 2.5x18mm; 2.5x18mm). Final angiography demonstrated no angiographically apparent dissection; no residual stenosis and TIMI III flow throughout the vessel (See PTCA comments). 5. Successful PTCA and stenting of the ostial-mid RCA with four overlapping Xience drug eluting stents (2.5x18mm; 2.5x23mm; 2.5x23mm; and 2.5x8mm). Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel (See PTCA comments). FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful PTCA and stenting of the RCA with multiple drug eluting stents. 3. Successful PTCA and stenting of the LCX with multiple drug eluting stents. 4. Widely patent left subclavian stents. An occluded left brachial-radial artery with a widely patent ulnar artery supplying the hand and backfilling the proximal portion of the radial artery. . Brief Hospital Course: A+P [**2134-9-23**]: 67 y/o with CAD s/p CABG and PCI to subclavian, PVD, CHF who presented to OSH with CHF exacerbation, NSTEMI. Course complicated by left raidal artery perf, UTI, TIA symptoms at SBP < 130. Triggered for TIA like symptoms in setting of SBP of 90s #. CAD: Patient is s/p CABG with severe multi-vessel disease. Patient ruled in for NSTEMI at OSH and was transferred for intervention. Trigger of CHF exacerbation was likely ischemic in the setting of graft found down. CABG graft was revascularized by angioplasty and stents x 2 to the proximal and distal subclavian vein. Final resisual s/p stenting was 0% with normal flow returned to [**Female First Name (un) 899**] and LBA. On [**9-22**] a total of 7 stents to LCx and RCA were placed, see full report above. After the [**9-22**] cath the patient had [**8-12**] Left should pain without rad, N/V, mild right shoulder pain. Prior to CABG presented with upper back pain. This pain is different, and responded to vicodin and repositioning. No EKG changes. The patient becamde orthostatic at times after cath, this improved with fluid bolus. On the day of discharge the pt was no longer orthostatic and able to ambulate without TIA symptoms On discharge she was continued on Plavix 75 mg PO x 12 months, ASA 325 mg daily, beta-blocker, high dose statin. . #. Pump: Acute on chronic systolic congestive heart failure: Patient presented with CHF exacerbation and found to have depressed ejection fraction in the setting of cardiac ischemia. Symptoms improved after multiple cardiac cath interventions. During cath EF measured at 36%. Patient may need echo as outpt to access for functional status and change in EF. During hosptialization the patient was continued on beta-blocker. The patient is likely to benefit from addition of AceI; however, BP will not tolerate at this time. With blood pressure's less than 130/90 patient is at risk of TIA symptoms and actually requires Florinef to assure her BP is maintained near this range. The patient did not require diuresis during this hospitalization. On discharged she was continued on her beta blocker. ACE inhibitor should be added to the outpt regimen if possible. . # Rhythm: During the first cardiac cath the catheter perforated a branch of left radial artery. Heparin was stopped. While arm was being compressed, patient became bradycardic to 30's, BP unknown. CPR was initiated x 20 seconds. Atropine was given and heart rate to 150's. This episode is likely secondary to vagal episode, with return of perfusing rhythm after atropine. On transfer to the floor she was closely monitored on telemetry. The patient did not have any further bradycardia and remained in NSR. . # Left radial artery performation: Resulted as a complication to the first cardiac cath. Hand Surgery was consulted in house. They stated no indication for extremity vascular reconstruction at present given multiple comorbidities. The patient underwent serial exams of left upper extremity to monitor for compartment syndrome. In the days following catheterization the Left Radial pulse returned, up to 1+, although it was felt strongest in the mid forearm. She continued to have mild forearm swelling, but FROM without evidence of compartment syndrome. She maintained a ulnar pulse with normal capillary refill in all fingers. She received warm compresses to forearm for comfort. Hand surgery signed off saying she could f/u as an outpatient on an as needed basis. . # h/o TIA: Patient has a history of TIAs due to r/t left carotid occlusion (Patient has known occlusion of left internal carotid artery intracranially at the level of the opthalmic artery, and she has had multiple TIAs from this occlusion. Patient develops TIAs when her BP becomes too low, and thus she requires SBPs ~130s to maintain perfusion. Patient is on Florinef due to low BP causing TIA symptoms r/t carotid. During time on floor the patient triggered for TIA symptoms, R sided facial weakness/droop and slurred speeh, in setting of SBP 90. Resolved with trendelenburg and IVF bolus which improved the BP to the 130s. Neurology saw the patient and suggested non-con CT head and Carotid US, but decided against since episode same as previously documented and Carotids patent on cath 2 days prior to TIA. Continue to Maintain SBP>130, per outpatient Neurology recs. Continue Florinef .2 qpm, to maintain BP. On day of discharge patient was no longer orthostatic with SBP stable in 130s to 140s. Pt was able to ambulate without large drop in BP and was free of her TIA symptoms. As an outpatient the need to continue florinef at .2 dosage should be discussed. The patient previously became hypertensive to 170s on this dosage. . # UTI: Patient diagnosed at OSH with UTI, s/p 3 days of levofloxacin prior to transfer. [**9-21**] UA showed large blood, 1000 glucose, leuk neg, nitrate neg and urine culture [**9-21**] showed no growth. The patient was without symptoms of UTI and no further treatment was given. . #. Diabetes: Treated with SSI, held glyburide in house. Restarted glyburide on discharge. . #. FEN: DM, cardiac diet . #. PPx: pneumoboots, no heparin SQ [**3-6**] heparin "alergy" [**3-6**] Intracranial hemmorage. Continued PPI per home regimen. . #. Code status: Full code, confirmed with patient and husband at time of admission to CCU. Medications on Admission: Neurontin 200 mg TID Asa 325 mg daily Plavix 75 mg daily 40mg of nexium Levaquin 500 mg (for UTI) Lopressor 12.5 mg [**Hospital1 **] 1 inch of nitro paste Glyburide 10 mg [**Hospital1 **] Florinef 0.1 mg daily Simvastatin 10 mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed): take one pill at onset of chest pain, may repeat in five minutes for a total of 3 NTG. Please call your doctor or go to the ED if you need to take this medicine. Disp:*1 bottle* Refills:*2* 5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY AT 8 P.M. (). Disp:*60 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: VNA of Southeastern MA Discharge Diagnosis: Primary Diagnoses: NSTEMI Acute on chronic systolic heart failure TIA [**3-6**] left internal carotid stenosis and hypotension orthostatic hypotension peripheral vascular disease Secondary Diagnoses: Diabetes Mellitus Discharge Condition: good Discharge Instructions: You were transfered to [**Hospital1 18**] for management of your heart attack (NSTEMI) and heart failure (CHF). You underwent 2 separate catheterzations in which 2 stents were placed in an artery in your left arm, and 7 additional stents were placed in the arteries in your heart. These procedures were successful in improving the blood flow through your heart. Your heart failure improved with diuresis at the outside hospital. You had injury to your left radial artery during one of the cathiterzation. However it is improving and your pulse has returned. You should follow up with Dr [**First Name (STitle) 10378**] for this and your TIAs. You had a episode of symptoms consistant with TIA following a low blood pressure. If you experience a return of Right sided weakness or slurred speech you should call your doctor or return to the emergency room. You should discuss you florinef dose with your PCP. Medications: 1) Your Florinef was increased to 0.2mg daily to help maintain your blood pressure. 2) Your simvastatin was increased to 80mg daily. All other medicines are the same as prior to admission. As you know it is very important for you to continue to take your Plavix every day to prevent your heart stents from closing which could cause another heart attack and even death. Please follow up as below. For arm or back pain take 2 extra strengh tylenol every [**5-9**] hours. Call your PCP if the pain is severe. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases > 3 lbs. Adhere to 2 gm sodium diet Please call your doctor or return to the hospital if you experience any concerning symptoms including chest pain, light headedness, dizziness, persistance of your TIA symptoms or any other new symptoms. Followup Instructions: You have a follow up appointment with The nurse [**First Name (Titles) 3525**] [**Last Name (Titles) 10379**]n at Dr[**Name (NI) 10380**] office [**2134-10-7**] at 11am ([**Telephone/Fax (1) 10381**]) You need to make an appointment with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for cardiology follow up ([**Telephone/Fax (1) 3183**]) within two weeks of discharge You have an appointment with Dr [**First Name (STitle) 10378**] (vascular)([**Telephone/Fax (1) 10382**]) [**2134-10-12**] at 11:15am for follow up of your TIA and left radial artery. Completed by:[**2134-10-4**]

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icd9cm

[ [ [] ] ]

[ "88.55", "88.52", "00.41", "88.53", "00.48", "36.07", "00.66", "37.22", "39.50", "88.49", "39.90", "00.40", "00.46" ]

icd9pcs

[ [ [] ] ]

16516, 16569

9840, 15184

307, 353

16832, 16839

4304, 7432

18636, 19246

2937, 3165

15469, 16493

16590, 16770

15210, 15446

9419, 9817

16863, 18613

3180, 4285

16791, 16811

248, 269

381, 1857

1879, 2767

2783, 2921

78,419

193,119

6765

Discharge summary

report

Admission Date: [**2179-5-7**] Discharge Date: [**2179-5-18**] Date of Birth: [**2120-3-16**] Sex: F Service: SURGERY Allergies: Penicillins / Iodine / Talwin Attending:[**First Name3 (LF) 695**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: Transvaginal biopsy of pelvic mass PICC placement Diagnostic Paracentesis History of Present Illness: 59 y/o F with history of HCV and EtOH cirrhosis presented to at an outpatient clinic for LLE redness and swelling and was treated with Keflex for cellulitis for one week. She presented to [**Hospital3 **] on [**2179-5-5**] with fever 101.6 and BP of 79/40 and admitted to the ICU with sepsis [**12-23**] LLE cellulitis. She was started on Vanco and Ceftriaxone empirically. A diagnostic paracentesis was neg for SBP. Blood cultures grew Pseudomonas and and Cefepime was added to her antibiotic regimen. She was transferred to [**Hospital1 18**] for further management and at that time her MELD was 31. Past Medical History: Group B streptococcal cellulitis/ left leg cellulitis in [**2177**].; alcoholic hepatitis, hepatitis C with cirrhosis, portal hypertension, hepatic encephalopathy, COPD, previous IV drug abuse Past Surgical History:vaginal hysterectomy [**2168**] Social History: married, smokes. Previous heavy alcohol use,. Stopped 1 1/2 years back. Previous cocaine use. Family History: non contributory Brief Hospital Course: Ms. [**Known lastname **] was transferred from [**Hospital3 2737**] on [**2179-5-7**] to the [**Hospital1 18**] SICU for further evaluation and treatment of her presumed septic shock. Cultures from [**Hospital3 2737**] yielded Pseudomonas in the blood and GNR in the urine and peritoneal fluid. She was continued on her Vanco/Cefepime antibiotic regimen and initially required norepinephrine to maintain perfusing blood pressures. She was in renal failure with Cr 2.8 and she was started on midodrine, octreotide and albumin for treatment of possible hepatorenal syndrome. She experienced brief episodes of desaturation to the 80%s, and her mental status was declined initially such that she was arousable to voice but disoriented and somnolent. [**5-7**] U Cx was + for yeast and was started on Fluconazole. Further w/u included CT scan of the chest, abdomen and pelvis revealed evidence of pneumonia. Cultures obtained at this facility were notable UCx+ for yeast. A chest CT was obtained showing grand glass opacities concerning for PNA with small bilateral pleural effusions. She was weaned off pressors. On [**5-11**] she had negative diagnostic paracentesis and culture was negative. She was transferred to the floor. On [**5-10**] she had CT scan for transplant w/u and findings were notable for a pelvic mass (9.1x5.4x0.7cm). She had further workup for this mass with an abdominal MRI. Gyn was consulted for this mass and given with her overall condition and pending transplant, a transvaginal bx was done. Prior to the bx she received numerous units of FFP/Platelets/Cryo for her coagulopathy. Pathology demonstrated benign uterine fibroid tissue. She had repeat diagnostic paracentesis on [**5-17**] which remained negative. A f/u UCx on [**5-15**] detected VRE sensitive to Linezolid and Tetracycline and was started on Tetracycline for 2 days which was d/c'd as patient was unable to tolerate. A repeat UA was sent on [**5-18**] which was neg and culture is pending at time of discharge. She was discharged to [**Hospital1 **] rehab for PT and abx treatment. She will receive PO Fluconazole and IV Levo ending [**5-20**] and IV Vancomycin ending [**5-21**], per ID recs. PT evaluated the patient and recommended rehab. She tolerated regular diet and ambulates with assist. She had perineal skin breakdown requiring commercial cleanser and criticaid. Her lower extremities were wrapped with ACE bandages. A bed became available at [**Hospital1 **]. She will f/u with outpatient hepatology service and she remains on the liver transplant wait list. Medications on Admission: Folic acid 1', rifaximin 550', omeprazole 20'', Seroquel 25'', iron 325'', B complex, Mag-OX 400'', Duo Neb, lactulose 30'''', levalbuterol 2puffs '''' Discharge Medications: 1. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for sob,wheeze. 6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for sob, wheeze. 7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for peri area. 9. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Aldactone 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for Nausea/heartburn. 14. vancomycin 1,000 mg Recon Soln Sig: 1250 (1250) mg Intravenous once a day for 3 days. 15. levofloxacin 25 mg/mL Solution Sig: Seven [**Age over 90 1230**]y (750) mg Intravenous once a day for 2 days. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Pelvic mass-benign fibroid Pseduomanas bacteremia and periotnitis UTI (yeast, VRE) Pnemonia Septic Shock Venous stasis dermatitis Perineal/thigh excoriation 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 will be transferred to [**Hospital1 **] Rehab in [**Location (un) 701**] Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any of the following: fever (101 or greater), chills, nausea, vomiting, vaginal bleeding, abdominal pain, painful or frequent urination, worsening lower extremity redness/swelling/pain/drainage, confusion, excessive sleepiness Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2179-5-26**] 10:20 Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2179-8-25**] 8:30 Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2179-8-25**] 8:55 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2179-5-18**]

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icd9cm

[ [ [] ] ]

[ "54.91", "38.93", "38.97", "65.11" ]

icd9pcs

[ [ [] ] ]

5667, 5739

1443, 4008

294, 370

5940, 5940

6525, 7025

1401, 1420

4210, 5644

5760, 5919

4034, 4187

6123, 6502

1239, 1273

248, 256

398, 1001

5955, 6099

1023, 1217

1289, 1385